A Developmental Model of Health and Nursing
Identifieur interne : 001524 ( Istex/Corpus ); précédent : 001523; suivant : 001525A Developmental Model of Health and Nursing
Auteurs : F. Moyra Allen ; Marguerite WarnerSource :
- Journal of Family Nursing [ 1074-8407 ] ; 2002-05.
Abstract
This is the last article written by Moyra Allen prior to her death in 1996. Allen believed that nursing has a vital role to play in reorienting the Canadian health care system to goals more appropriate to our rapidly changing society—the development of healthful living styles, healthy families, and healthy communities. First, she argued, we must separate the ideas of health and illness. Health is fundamentally a social phenomenon, a way of living or behaving that is readily communicated within such institutions as the family and across groups through the media and community life. She asked: What are the resources that families/groups require to recognize and develop their potential for healthful living? How can professionals work with families in this process? In this article, she lays out an organizing plan or model with which to seek answers to these questions and the inquiry process through which the model-building process evolved.
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DOI: 10.1177/107484070200800202
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Moyra Allen</name><affiliation><mods:affiliation>McGill University</mods:affiliation></affiliation><affiliation><mods:affiliation>McGill University</mods:affiliation></affiliation></author><author><name sortKey="Warner, Marguerite" sort="Warner, Marguerite" uniqKey="Warner M" first="Marguerite" last="Warner">Marguerite Warner</name><affiliation><mods:affiliation></mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: mwarner@mb.sympatico.ca</mods:affiliation></affiliation><affiliation><mods:affiliation>McGill University, mwarner@mb.sympatico.ca</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Journal of Family Nursing</title><idno type="ISSN">1074-8407</idno><idno type="eISSN">1552-549X</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="2002-05">2002-05</date><biblScope unit="volume">8</biblScope><biblScope unit="issue">2</biblScope><biblScope unit="page" from="96">96</biblScope><biblScope unit="page" to="135">135</biblScope></imprint><idno type="ISSN">1074-8407</idno></series><idno type="istex">201735C412BB7AA4C9FD50889CFF7893B54136F9</idno><idno type="DOI">10.1177/107484070200800202</idno><idno type="ArticleID">10.1177_107484070200800202</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1074-8407</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">This is the last article written by Moyra Allen prior to her death in 1996. Allen believed that nursing has a vital role to play in reorienting the Canadian health care system to goals more appropriate to our rapidly changing society—the development of healthful living styles, healthy families, and healthy communities. First, she argued, we must separate the ideas of health and illness. Health is fundamentally a social phenomenon, a way of living or behaving that is readily communicated within such institutions as the family and across groups through the media and community life. She asked: What are the resources that families/groups require to recognize and develop their potential for healthful living? How can professionals work with families in this process? In this article, she lays out an organizing plan or model with which to seek answers to these questions and the inquiry process through which the model-building process evolved.</div></front></TEI><istex><corpusName>sage</corpusName><author><json:item><name>F. 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Health is fundamentally a social phenomenon, a way of living or behaving that is readily communicated within such institutions as the family and across groups through the media and community life. She asked: What are the resources that families/groups require to recognize and develop their potential for healthful living? How can professionals work with families in this process? 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Moyra</forename><surname>Allen</surname></persName><affiliation>McGill University</affiliation><affiliation>McGill University</affiliation></author><author xml:id="author-2"><persName><forename type="first">Marguerite</forename><surname>Warner</surname></persName><email>mwarner@mb.sympatico.ca</email><affiliation></affiliation><affiliation>McGill University, mwarner@mb.sympatico.ca</affiliation></author></analytic><monogr><title level="j">Journal of Family Nursing</title><idno type="pISSN">1074-8407</idno><idno type="eISSN">1552-549X</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="2002-05"></date><biblScope unit="volume">8</biblScope><biblScope unit="issue">2</biblScope><biblScope unit="page" from="96">96</biblScope><biblScope unit="page" to="135">135</biblScope></imprint></monogr><idno type="istex">201735C412BB7AA4C9FD50889CFF7893B54136F9</idno><idno type="DOI">10.1177/107484070200800202</idno><idno type="ArticleID">10.1177_107484070200800202</idno></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2002</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>This is the last article written by Moyra Allen prior to her death in 1996. Allen believed that nursing has a vital role to play in reorienting the Canadian health care system to goals more appropriate to our rapidly changing society—the development of healthful living styles, healthy families, and healthy communities. First, she argued, we must separate the ideas of health and illness. Health is fundamentally a social phenomenon, a way of living or behaving that is readily communicated within such institutions as the family and across groups through the media and community life. She asked: What are the resources that families/groups require to recognize and develop their potential for healthful living? How can professionals work with families in this process? 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Moyra</given-names></name><aff>McGill University</aff></contrib><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Warner</surname><given-names>Marguerite</given-names></name><aff>McGill University, <email xlink:type="simple">mwarner@mb.sympatico.ca</email></aff></contrib></contrib-group><pub-date pub-type="ppub"><month>05</month><year>2002</year></pub-date><volume>8</volume><issue>2</issue><fpage>96</fpage><lpage>135</lpage><abstract><p><italic>This is the last article written by Moyra Allen prior to her death in 1996. Allen believed that nursing has a vital role to play in reorienting the Canadian health care system to goals more appropriate to our rapidly changing society—the development of healthful living styles, healthy families, and healthy communities. First, she argued, we must separate the ideas of health and illness. Health is fundamentally a social phenomenon, a way of living or behaving that is readily communicated within such institutions as the family and across groups through the media and community life. She asked: What are the resources that families/groups require to recognize and develop their potential for healthful living? How can professionals work with families in this process? In this article, she lays out an organizing plan or model with which to seek answers to these questions and the inquiry process through which the model-building process evolved.</italic></p></abstract><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value> JFN, May 2002, Vol. 8 No. 2Allen, Warner / A Developmental Model A Developmental Model of Health and Nursing F. Moyra Allen, R.N., Ph.D. Marguerite Warner, R.N., Ph.D. McGill University This is the last article written by Moyra Allen prior to her death in 1996. Allen believed that nursing has a vital role to play in reorienting the Cana- dian health care system to goals more appropriate to our rapidly changing society--the development of healthful living styles, healthy families, and healthy communities. First, she argued, we must separate the ideas of health and illness. Health is fundamentally a social phenomenon, a way of living or behaving that is readily communicated within such institutions as the family and across groups through the media and community life. She asked: What are the resources that families/groups require to recognize and develop their potential for healthful living? How can professionals work with families in this process? In this article, she lays out an organizing plan or model with which to seek answers to these questions and the inquiry process through which the model-building process evolved. Ahealth care system functions within the sociopolitical system of the country in which it is situated. In this sense, the health care system stands as an exemplar of the culture and philosophy of that country. The same holds true for nursing, a significant component of health care. Therefore, any model of nursing that structures independent nursing practice must itself reflect the dominant values of that culture This article develops ideas presented by Allen at the Rosella M. Schlotfeldt Lecture in Cleveland (1982) and the Nursing Theory Congress in Toronto (1986). Address correspondence to Marguerite Warner, D-711 Niagara Street, Winnipeg, MB, R3N 0W2; e-mail: mwarner@mb.sympatico.ca. JOURNAL OF FAMILY NURSING, 2002, 8(2), 96-135 2002 Sage Publications 96 and its health care system. This concern with social-cultural relevance was a precipitating factor in the decision to outline and describe a newly emergent model of nursing at McGill University (Montral, Quebec, Canada), to evaluate it in demonstration, and to investigate it further through research. Health Care and Nursing in Canada In Canada, legislation for a relatively complete system of govern- ment health insurance was in place in 1968. The national health insur- ance program changed the way people pay for health services. It did not explicitly redefine the goals of health care or reorganize the way services are provided. Nevertheless, the underlying principles of uni- versality, comprehensiveness, portability, and accessibility implied greater emphasis on care directed toward health and well-being (not simply illness and disease) and provision of services at the commu- nity level. These directives translated into a much fuller role for nurs- ing for many in the health care field. In the mid-1970s, two models of an expanded nursing role emerged in Canada. The two models are based on very different points of view as to the way nursing should respond to the health needs of the Cana- dian public and to the needs of the changing health care system (Allen, 1974, 1977a). The proponents of one model promoted expan- sion of nursing into physician-type services. The physician-assistant or physician-replacement mode of the expanded role of the nurse holds that more of the same type of health care services is required and that, with preparation, nurses can perform some of the assess- ment, prevention, and treatment procedures traditionally part of the physician's repertoire (Spitzer et al., 1975; Spitzer & Kergin, 1975). This stance propelled McGill University's nursing faculty into action to demonstrate the expansion of nursing within the field of health promotion. Allen referred to this alternative model of the expanded role of the nurse as the "complemental model," the inten- tion of which is to fill a gap evidenced by the lack of community resources directly concerned with the healthy development of fami- lies throughout their life span (Allen, 1979; Allen, Frasure-Smith, & Gottlieb, 1980a, chap. 1). Not only was the emphasis on health promo- tion consistent with federal health policy (Health and Welfare Can- ada, 1974), it was also clearly supported by the Qubec government's plans to establish local community health centers throughout the province (Gouvernement du Qubec, 1970-1972). Furthermore, con- Allen, Warner / A Developmental Model 97 cern with health goals has been the legitimate field for nursing since Florence Nightingale's treatises on the subject. In today's society, nursing has a vital role to play in reorienting the system to the impor- tant goals of family and community health. Contrasting Models of Nursing Practice The complemental model of nursing that was gaining strength in McGill's educational programs was eventually put to paper. In the early stage, it was named situation-responsive nursing to describe an approach to situations that are relatively unknown and require responses evolving from the situation. In Table 1, the components of this model are outlined in contrast with the more traditional a priori approach, in which the situation is defined in terms of expert knowledge and the applicationofknownsolutionstoknownproblemsmaybewarranted. With the situation-responsive approach, the nurse focuses on the health aspects of a client situation. The health aspects of life situations include how the person/family copes with the problems at hand and how they go about living and developing as a person/family (elabo- rated later in the section entitled "Nature of Health"). The nurse per- ceives the situation as evolving and complex in nature, as a product of and a reflection of the family/primary group, and as part of a lifelong process of becoming healthy. In making an assessment, the nurse uses an open-ended, exploratory approach to gathering information with the person/family, seeking to understand their concerns and behav- iors within a broader context. The plan of care makes use of the individual's/family's potential: that is, what they have going for them, such as their goals, strengths, resources. The nurse assesses the readiness of the client and times the implementation of the plan accordingly. In evaluation, the nurse looks to the client's responses to both the plan and the outcomes of the plan and then modifies the plan as required. With the a priori approach, the nurse focuses on the illness aspects of a client situation. The term "illness aspects" refers to the manifest problem, or ill, such as the client's complaint, medically defined con- dition, and/or the demands of the medical regimen. It also includes real or imagined "lacks" (e.g., knowledge) or "risks" (e.g., for injury, chronic disease) in the client's situation for which there are standard teaching and/or prevention protocols. The nurse perceives the prob- lem to be a phenomenon of the individual or individuals and episodic in nature. In making an assessment, the nurse generally uses a stan- 98 JFN, May 2002, Vol. 8 No. 2 dard structure or guide for collecting information from each client, along with professional knowledge related to diagnosis, treatment, and prevention. The plan for care focuses on remedying or preventing deficiencies and is implemented according to the professional's time frame. Evaluation is based on the extent to which the nurse's objec- tives have been accomplished and, to the extent they are not, the plan is reinforced and/or repeated. Allen, Warner / A Developmental Model 99 Table 1: Contrasting Models of Nursing Practice Situation-Responsive A Priori Problem What is the focus of the Health Illness nurse in a particular individual/family situation? Unit of concern What is the size of the unit Family/Primary Individual (persons involved) within group which the nurse perceives the problem to be? Perspective What is the extent and Evolving over Discrete and complexity of the time episodic problem as perceived by the nurse? Assessment What sources of information Exploratory A priori and knowledge does the nurse draw on to identify the problem of the individual/family? Plan On which attributes within Strengths Deficits the individual/family does the nurse formulate a plan? Time frame How are interventions for Wait Zoom the individual/family timed? Evaluation What is the nurse's approach Client responses Professional to identifying outcomes objectives of the plan as feedback for further assessment and planning? Trying Out the Situation-Responsive Model The first task was to try out the situation-responsive model in prac- tice and to evaluate it in comparison with other modes of nursing. In the mid-1970s, this was accomplished in a new family medicine unit in which McGill nursing faculty were able to shape the development of nursing (Allen et al., 1980a). Throughout the project, a faculty member worked with the nurses in the demonstration setting, help- ing them to implement the model and, at the same time, to describe, examine, and analyze their practice. The major purpose here was to gather data about the nature of health. Although we were committed to health promotion and the development of healthy ways of living, our world as yet knew very little about health. We had certain ques- tions in mind as we implemented the model in practice. What are healthy families like? How did they get that way? How did they start out? What are the signs of a family starting out in a healthy way? What sort of health behavior and health practices do children learn in healthy families, in less healthy families, and how? Although other disciplines in addition to nursing contribute to answer- ing questions on the nature of health, nursing must assume major responsibility for answering questions about nursing practice. How does nursing work with individuals and families to increase their competence in health matters and to augment their health status? What interventions and what ways of working with the family actually improve their health behavior and their health status? NATURE OF HEALTH In the situation-responsive model, health is the central concept and the focus of nursing practice. For this reason, it was necessary to find a definition of health and to describe healthy behaviors and how they develop in order to propose a framework for nurses to use to promote health. Through observation, literature searches, reflection, and dis- cussion, we came to a number of ideas on the subject of health. Health is usually defined in terms of disease or illness; if one has no disease and is not ill, then one is healthy. According to this definition, health is located at one end of a continuum and disease/illness/death 100 JFN, May 2002, Vol. 8 No. 2 at the other. In this sense, health is a negative concept. It means "not illness"; it has no meaning of its own. For this reason, it cannot be elab- orated as an idea or serve as a goal toward which to work. One cannot work for or toward something that can only exist as not something else. This prevailing notion of health provides us with a logical dilemma. It is possibly the major philosophical problem facing the nursing profession. How can a profession legitimize a search for a sci- entific base when the effectiveness of its practice is measured by out- comes indicative of the absence of something else? The dilemma we face in nursing owing to the lack of a definition of health was well-stated by Chinn (1980): "Nursing groups . . . speak of health with great effort, struggling to differentiate 'health' out of the pools of nonhealth or illness concepts with which they have been immersed in their education and in most of their nursing experience" (p. xvii). It is critical that we find a definition of health that points to a field of practice that can be recognized as nursing. Second, we should search for a definition of sufficient scope and depth to give direction to all of nursing, whether it be in hospital or the larger community with peo- ple in all states of illness and wellness. In other words, the meaning of health in illness should have the same qualities and be described in the same way as the meaning of health when illness is not present. Withthis type of definition, amodelofnursing stands forallnursing. We came to the conclusion that "health is not an entity that is lost or gained" but rather "a developmental process involving multilevel responses to a total environment" (Hoke, 1968, p. 270). Thus, we required an understanding of health in process terms rather than in static, ontological terms. As Hoke (1974, p. 171) suggested, health encompasses a number of "life-enhancing" behaviors and processes that are complexly related within a person's/family's overall pattern of living and developing. This life-enhancing quality of health is com- posed of different attributes or properties, two of which are particu- larly salient in this model--coping and development. Audy (1971) describedthefirst attribute, copingability,asfollows: Health is a continuing property, potentially measurable by the individ- ual's ability to rally from insults, whether chemical, physical, infec- tious, psychological, or social. Rallying is measured by completeness and speed. Any insult may have a "training function," and recovery will often be to a slightly higher level. The person or body learns something. (p. 142) Allen, Warner / A Developmental Model 101 Rallying, Audy explains, is the coping process. When activated, it sig- nals that the measurable ability to rally (a property of health) is being challenged. Important here is the idea that the act of coping is a learn- ing experience; one learns how to be healthy. The second attribute of health refers to the person's/ family's abil- ity to actively shape the direction of their life by making choices and patterning their lifestyle in view of their goals and circumstances. Bruhn and Cordova (1977) described this attribute of the health pro- cess as The development of an individual's ability to actively seek to change his life situation so that he can function at his perceived maximum capacity and satisfaction. The criteria for determining capacity and sat- isfaction should be established by each individual . . . the experience of which would be similar to Pratt's [1976] "energized" family. (p. 248) Here again, acts of development are capacity-building or learning experiences; one learns how to become healthy. In short, people dem- onstrate health in their coping behavior and growth-seeking or devel- opment activity. Valued Health Behaviors After further work, we constructed a tentative outline of valued coping and development behaviors drawn from the literature (Bransford & Stein, 1984; Bruhn & Cordova, 1977; Bruhn, Cordova, Williams, & Fuentes, 1977; Dewey, 1916/1966, 1938/1968; Dubos, 1965, 1979; Hoke,1968,1974;Jourard,1974;Klein&Hill,1979;Lazarus&Folkman, 1984; Perlman, 1975; Pratt, 1976). These include 1. coping with the events of daily living as reflected in problem-solving activities such as observing and gathering data; seeking additional knowledge and information; discussing, sharing; examining, analyzing, assessing; identifying alternatives, options, and priorities; goal setting, planning; practicing, testing out, evaluating; and transferring learning from one situation to another; 102 JFN, May 2002, Vol. 8 No. 2 2. developmental or growth-seeking activities in daily life such as setting realistic goals for development and present circumstances, mobilizing resources and potentials within the individual/family and from the larger social context, modifying behavior and making lifestyle choices to function at max- imum capacity, linking achievements with life goals, and assuming responsibility for personal/family development. Thus, valued health behaviors for individuals and families are viewed as coping with problematic events in a problem-solving fashion and actively shaping personal/family development. These are the goals nursing is endeavoring to achieve with clients; these are the goals of health promotion. Theoretically, the person's/family's repertoire of coping skills and growth-seeking behavior should increase and expand over time with experience. Nursing is attempting to foster health behaviors in individuals and families that will increase their compe- tencyindealingwithlifeeventsanddevelopinginahealthfulfashion. Learning to be Healthy Through Life Experiences Life events become the experiences through which people learn to cope and develop. These learning experiences begin in early child- hood, and few institutions rival the power of the family in the social- ization process. It is society's most basic educational institution. As children are introduced to the macro world, parents and other family members monitor their exploration. They try to regulate and define what children see and experience in the world outside. Thus, children acquire their first ideas about healthy living and development within the micro world of family interaction and influence. These primary impressions are lasting and very difficult to modify. For this reason, we view the family as the primary social unit in which the process of learning to be healthy goes on. In addition, the types of situations that people encounter and undertake, such as having a baby, going to school, coping with illness, and aging, are not solely personal matters but also matters of the family/primary group. In other words, one family member's situation influences and in turn is influenced by all family members. Accordingly, the health aspects of any situation-- that is, coping and developing--are viewed as being a product of and a reflection of the family/primary group. Allen, Warner / A Developmental Model 103 During the aforementioned demonstration project in a family medicine unit, the research team recorded and categorized the types of life-change events people brought to nurses (Allen, Frasure-Smith & Gottlieb, 1980b). This early classification system provided a tem- plate that has been refined and elaborated throughout subsequent demonstrations and in a variety of education, research, and practice protocols. (See Appendix A for a current version of the classification system.) Health and Illness To further clarify and elaborate a positive concept of health, it is necessary to separate the ideas of health and illness; they are different ideas and different variables. This view is portrayed in Table 2, which provides a way of thinking about health and illness as separate con- tinua, each of which varies both qualitatively and quantitatively (Allen, 1981). This conceptualization allows us to explore such ques- tions as: Can a person have a disease and be healthy? Can a person have no disease and yet be unhealthy? If we accept the premise that health and illness can coexist, then one approach to exploring states of health-illness coexistence across situations is to look for interplay of the two variableswhereintheybecomerelatedinthepersonorfamily. Hypothetically, the optimum state is a high level of health (as dis- played in coping and growth-seeking behaviors) and no illness. Less satisfactory states exist when there is no illness but the level of health is low or when there is illness and a high level of health. The least satis- factory state exists when there is illness and the level of health is low. An important idea in this conception is that health is always present. As Audy (1971) explained, "Health is a continuing property . . . It does not disappear during an illness to return on recovery but continues, even though it may drop in level while the [person/family] is adapting to the current insult" (p. 142). The Meaning of Health in Illness Let us think about the meaning of health and illness by focusing on the health aspects in cancer, an important illness in our time. Besides the medical aspects of diagnosis and treatment of this illness, what else is involved for the individual and his or her family? To begin with, the person has to cope with the cancer, the disease, and the ill- ness. He has to cope with the diagnostic process, with the diagnosis, 104 JFN, May 2002, Vol. 8 No. 2 Table 2: Health Continuum and Illness Continuum No Signs and Illness Minor Major Terminal illness symptoms episodes disability disability state Illness Continuum a Seeking Knowledge Examining, Goal Attending, and Analyzing, Discussing, Setting and Testing out/ Ignoring Observing information Assessing Sharing planning Evaluating Health Behavior Continuum b a. Other views of the illness continuum are possible, such as stages in the body's ability to adapt. b. Level of health measured by the number and quality of problem solving activities that favor person/family development. Although a logical sequence is suggested, neither linear learning nor linear functioning is implied. 105 with the treatment, with his physiological functioning and bodily changes, with his family, with his work situation, and with the health care professionals who care for him. He has to cope with the way he is coping with all of these things and with the way everyone else is cop- ing with themselves as well as with him. The meaning of health in illness is, in part, the ability to cope with the illness. In addition, the person has to live and develop as an indi- vidual, as a member of a family or group, and as a member of groups, such as work, school, community, and other groups. How does the ill person manifest health in his day-to-day living and in his develop- ment as a person? Some tentative answers are as follows: by viewing the illness as an event in his life, in the life of his family or group, and within his/their priorities; by incorporating the illness with its demands and exigencies realisti- cally into the ways he and his family/group function or operate to achieve goals at work, play, school, and so forth; and by seeking and trying out more practical approaches to living and devel- opment if the degree of illness and disease compromise his earlier cop- ing methods. If we consider health as the sum total of the person's/family's coping skills and growth-seeking behavior at any point in time, we can view subsequent life events as having a training function--as opportuni- ties to augment the health of the person or family. Health profession- als tend to identify with the vulnerability of the person who is ill and therebymisstheopportunitytoparticipateinthegrowthpossibilities. At some point, for all people, disease and illness are novel experi- ences, bringing a wealth of opportunity for learning and acquiring new knowledge and skills in dealing with what are thought of as adverse events of life. When people become ill, they and their families enter into the situation with various amounts of health. Some have remarkable coping ability and growth potential, and others have less. Theoretically, one can gain more and more understanding and skill in being healthy, in learning to cope, and in harnessing one's strengths and resources to achieving life goals and objectives. In summary, in any group of patients with cancer there are features of the disease process, including its diagnosis and treatment, which are similar across patients; however, the level of health of these same individuals varies in both quality and quantity. Disease is a feature of some part(s) of the body or person; health is a feature of the whole 106 JFN, May 2002, Vol. 8 No. 2 human being. Illness and disease tend to exist in individuals and, therefore, can be diagnosed and treated as a phenomenon of the indi- vidual at a point in time. On the other hand, health--ways of coping, living, and developing--is more a social phenomenon. These ways of behaving have a social-historical context--a family of origin in which they have been learned and acquired, and a contemporary social envi- ronment, such as peers, the community, and the media. For this rea- son, the assessment of health is a much more complex task than the assessment of illness or disease. Possibly, this explains why the pre- vention, diagnosis, and treatment of disease are so much further advanced than the assessment and promotion of health. RESEARCH ACROSS DEMONSTRATION AND COMPARISON SETTINGS In the early 1970s, the Faculty of Medicine, McGill University, estab- lished family medicine units in some of the teaching hospitals affiliated with the university. In only one hospital did the nursing in the new unit come within the real purview of the director of nursing; in the others, nursing was placed under the supervision of the physician director of the family medicine unit. It was in this one hospital that the opportu- nity existed to mount a demonstration of a model of nursing comple- mental to the practice of other health professionals and responsive to families. (Allen et al., 1980a, chap. 1, p. 011). The starting date for this demonstration was January 1974, when three nurses with some experience in community health nursing were hired in the demonstration setting. As required by the design for eval- uation of the situation-responsive model of nursing, two other family medicine units were selected for purposes of comparison. All of the nurses in both the demonstration setting and in the Comparison Set- ting A had university degrees in nursing; the nurses in Comparison Setting B had hospital school of nursing diplomas. Nurses in the dem- onstration setting and Comparison Setting A had their own patient caseloads; those in Comparison Setting B did not. A faculty member of McGill's School of Nursing worked with the nurses in the demon- stration unit to monitor and facilitate the implementation of the situation-responsive model of nursing. No educational intervention was undertaken with nurses in the comparison units. Allen, Warner / A Developmental Model 107 The Research Project The research was directed toward determining the value of the model of nursing in practice vis--vis the health outcomes for individuals/families. The major questions studied were as follows: 1. To what extent are the demonstration nurses really nursing according to the aims of situation-responsive nursing? 2. Are the theoretically relevant outcomes for patients 1 any different in the demonstration setting than in the comparison settings? 3. What is the relationship between nursing differences and patient out- come differences? In designing the evaluation phase, the aim was to 1. develop a set of measurable nursing process variables based on the theory of situation-responsive nursing, 2. developreliableandvalidmeasuresforassessingtheseprocessvariables, 3. develop a set of measurable outcome variables related to the theory of situation-responsive nursing, 4. develop reliable and valid measures for assessing these outcome vari- ables, and 5. testthenursingprocessvariablesinrelationtopatientoutcomevariables. Data were collected over a period of 14 months. The primary meth- ods of data collection were tape-recorded observations of nurse- patient interactions, interviews with the nurses, interviews with the patients, and a mail-back questionnaire for patients. Table 3 summa- rizes the study variables and the instruments used to collect data. An extensive description of the operationalization and measurement of key variables may be found in the full research report (Allen et al., 1980a, 1980b). Selected Results A few of the results of this intensive study are presented here to enable the reader to understand the nature of the research and the direction of the findings in view of the research questions. 1. To what extent are the nurses in the demonstration setting really nurs- ing according to the aims of situation responsive nursing? 108 JFN, May 2002, Vol. 8 No. 2 Reliable and valid measures were developed for five of the seven nursing process variables listed in Table 3. These measures were based in a detailed coding scheme constructed for each of the two types of unstructured data, the tape-recorded nurse-patient interac- tions, and the nurse interviews. For example, a set of speech codes was used to analyze nurses' verbal activity during interaction with patients. The resultsonthreeofthenursing variableswereasfollows: a. Focus on health. The average number of verbal units of nursing practice speaking/listening focusing on health was 25.90 in the demonstration setting, 21.82 in Comparison Setting A, and 15.95 in Comparison Set- Allen, Warner / A Developmental Model 109 Table 3: Summary of Study Variables and Instruments Used to Collect Data Variable Instrument Nursing variables a A. Type of problem (HealthIllness) 1. Tape recordings of nurse-patient interactions 2. Nurse interviews 3. Mail-back questionnaire for patients B. Unit of concern (FamilyIndividual) 1. Tape recordings of nurse-patient interactions 2. Nurse interviews C. Perspective 1. Nurse interviews (Long-termEpisodic) D. Assessment (ExploratoryA priori) 1. Tape recordings of nurse-patient interactions E. Evaluation (Patient/family response 1. Nurse interviews Professional objectives) Outcome variables A. Patients' perceptions of helpfulness 1. Mail-back questionnaire for of nurses for health problems patients B. Nurses' perceptions of their 1. Nurse interviews success in helping patients with their health problems a. Two variables included in the original theory of Situation Responsive Nursing were not evaluated: Plan of Care (PotentialDeficiency) and Time Frame (WaitZoom). Although attempts were made to measure both variables, the data collected proved to be too inadequate in terms of sample size to be considered valid measures of these vari- ables. Therefore, these variables were not included in the evaluation (Allen, Frasure- Smith, & Gottlieb, 1980a, Ch. II, p. 006). ting B. These differences were statistically significant at p = .01 (Allen et al., 1980a, chap. III, p. 054). b. Focus on family. The average number of verbal units of nursing practice focusing on family was 14.56 in the demonstration setting, 10.85 in Comparison Setting A, and 7.26 in Comparison Setting B. The differ- ences were statistically significant only between the demonstration setting and Comparison Setting B, at p = .05 (Allen et al., 1980a, chap. III, p. 054). c. Exploratory approach to assessment. The average number of verbal units of nursing practice using an exploratory approach to assessment was 53.26 in the demonstration setting, 42.91 in Comparison Setting A, and 29.91 in Comparison Setting B; all differences were significant at p = .01 (Allen et al., 1980a, chap. III, p. 054). 2. Are the theoretically relevant outcomes for patients any different in the demonstration setting than in the comparison settings? For the outcome measure, patients were presented with a modified version of the Life Events Scale developed by Holmes and Rahe (1967). Item by item, the patients were asked to indicate if the event had occurred during the previous year and who had helped them with it. In accord with situation-responsive nursing, it was expected that the demonstrationnurseswouldhelpmorewithhealthproblems-- that is, problems of coping with illness and/or other events of daily living--than would other nurses. As may be seen below, patients in the demonstration unit felt that their nurses had tried to help them cope with a significantly greater percentage of health problems than did patients in each of the two comparison units. a. The percentage of patients who felt that the nurse had attempted to help with at least one stressful life event occurring in the previous year was 43.7% in the demonstration setting, 26.19% in Comparison Setting A, and 18.02% in Comparison Setting B. The differences were signifi- cant at p = .01 (Allen et al., 1980a, chap. VII, p. 028). b. The percentage of stressful events for which patients reported receiv- ing nurses' help during the previous year was 23.56% in the demon- stration setting, 9.30% in Comparison Setting A, and 6.33% in Compar- ison Setting B. The differences were significant at p = .01 (Allen et al., 1980a, chap. VII, p. 027). In a later study in a second demonstration set- ting, The Health Workshop, the percentage of events for which patients said they received nurses' help increased to 28.65%, possibly suggest- ing a growing capability on the part of the nurses (Allen, 1983). 110 JFN, May 2002, Vol. 8 No. 2 3. What is the relationship between nursing differences and patient out- come differences? In a sense, this is a test of the internal consistency of the model because it examines the relationship between each nursing process variable and the desired outcome of the model independent of set- ting. Twenty-eight separate correlations between measures of nurs- ing process and patient outcome were conducted. As the reader shall see in the small sample of findings provided below, the theoretical link between key nursing process variables and the main outcome variable, perceivedhelpfulness ofnurses, stood upremarkably well. a. Focus on health (two measures based in nurse interview data). Astrong posi- tive relationship (r = .80) was found between the percentage of patients for whom the nurse identified at least one health problem and the per- centage of events for which patients reported receiving nurses' help. In contrast, a strong negative relationship (r = .70) was found between the percentage of all problems the nurse identified that were illness problems and the percentage of events for which patients reported receiving nurses' help. Both correlations were significant at p = .05 (Allen et al., 1980a, chap. VIII, p. 004). b. Exploratory approach to assessment (four measures based in tape-recorded interaction data). Astrong positive relationship was found between the percentage of client speech units to which the nurse listened and the percentage of events for which patients reported receiving nurses' help (r = .71) and between the percentage of client expressions of emo- tion to which the nurse listened and the percentage of events for which patients reported receiving nurses' help (r = .63). These correlations were significant at p = .01 and p = .05, respectively. In contrast, a nega- tive relationship was found between the nurse asking questions and perceived helpfulness of the nurse (r = .70) and between the nurse giving directives or suggestions and perceived helpfulness of the nurse (r = .59). The correlations were significant at p = .05 and p = .01, respectively (Allen et al., 1980a, chap. VIII, pp. 004-005). Armed with a positive response to the model, based on the initial results of this evaluation project, we established a second and eventu- ally a third demonstration as a testing ground to elaborate the model more fully. The second demonstration was mounted in an affluent, suburban Montral community and the third in a less advantaged rural area of Qubec comprising two towns--one French and one English--plus the surrounding farms and small villages. These were Allen, Warner / A Developmental Model 111 nurse-managed community health centers that we and the people of the communities came to speak of as The Health Workshop and of what went on as "The Health Workshop way." A DEVELOPMENTAL MODEL OF HEALTH AND NURSING Having clarified some of the concepts of the model--valuable health behavior and how it is acquired in the family and through life events--we were ready to outline a framework for designing settings for the learning of health behavior. This framework is directed toward the development of nursing as the science of health-promoting inter- actions. We sometimes speak of the model as a competency model as opposed to a deficiency model, a process model as opposed to a con- tent model, and a developmental model as opposed to a closed or static model. In each case, the terminology refers to a focus on health as a way of living everyday life situations, the result of which is devel- opment to a slightly higher level of competence in coping with events and in actively shaping the direction of personal/family life or development. Health-Promoting Interactions The basic element of a social context or setting is the interaction of persons and situations. Thus, a conceptual framework for structuring environments to support the learning of health behavior must com- prise both the key processes of a learning interaction and the principal dimensions of the content of the situation, in this case, health behav- ior. Table 4 outlines the characteristics of a developmental model of health and nursing that define the participation of both the nurse and the client in health-promoting interactions. The work agenda of these interactions has a content aspect (what they will work on) and a method or process aspect (how they will work on it). In approaching a situation, the nurse and client share a common cognitive orientation in which the family or primary group is the par- ticular unit of concern; health is the focus of work, learning is the pro- cess through which health behaviors are acquired and developed, and life experiences, which are de facto health situations, are the con- text of learning. With a shared orientation to content, the nurse and individual/family assume a collaborative relationship in working on health situations. Their collaboration features periods of assessment, 112 JFN, May 2002, Vol. 8 No. 2 planning, implementation, and evaluation. The work proceeds through cycles of exploring, experimenting, and valuing in view of client responses and outcomes. Content of Nurse and Client Health Work Health focus. As implied by the results of our inquiry into the nature of health, the nurse and individual/family focus on the health aspects of situations. These include the coping, accommodating, and adap- tive behaviors in response to occurrences in daily life and the devel- opmental or capacity-building behaviors that support the individual/ family in modifying and changing their approach to life situations in search of optimum functioning. Family system. Based on the premise that health (behavior) is learned within a family/social system of interaction and influence, the unit of concern is the family or primary group. Even though only one person or member of the family may be involved, the nurse per- ceives the individual through a "family/group filter." This perspec- tive reflects a systems approach (e.g., Bronfenbrenner, 1979), with the individual/family as an open system in constant interaction with Allen, Warner / A Developmental Model 113 Table 4: Nurses and Client Health Work Agenda Content: Health Developing Over Time Focus Health System Family Process Learning Context Life events a Method: Collaborative Relationship Assessment Exploratory Planning Capacity-building Attributes Strengths, potential Implementation Experimental Activity Problem solving Time frame Wait Shape Tailored to client Evaluation Client outcomes a. Life experiences through which people learn to be healthy, also called health situations. other systems in their environment. Behaviors, including health behaviors, are not isolated but rather are part of a larger pattern of behavior in the family/primary group. Perspective on learning. The perspective on learning that guides the structuring of environments for learning required in this model of nursing is Bandura's social cognitive learning theory (Bandura, 1977a, 1986). Social cognitive learning theory approaches the explanation of human behavior in terms of continuous reciprocal interaction between cognitive, behavioral, and environmental determinants. Bandura (1977a) focuses on the capacity of people to learn by observation aided by modeling when novel forms of behavior can be conveyed effectively only by social cues. From the sociological view- point, Bucher and Stelling's (1977) research on becoming professional provides almost irrefutable evidence that people select out of the array of behaviors of their models those behaviors that they will incorporate into their own professional behavior. This finding sug- gests that clients also may select to incorporate those behaviors that fit with their own ways and have outcomes that are valuable to them. In a similar vein, Bandura believes that response patterns learned obser- vationally are further refined through self-corrective adjustments based on information feedback from performance (Bandura, 1977b). In Bandura's conceptual system, expectations of one's capability to master particular skills (perceived self-efficacy) affect both the initia- tion and persistence of coping behavior, that is, how much effort will be spent and how long this effort will be sustained in dealing with a situation. Bandura found that once established, enhanced self- efficacy tends to generalize to other situations. Social learning theory suggests the conditions of health-promoting interactions. These include an informal and welcoming social and physical setting; involvement and participation of clients; knowledge and information resources; and opportunities to develop problem- solving skills such as observing, gathering information, weighing evi- dence, generating options, planning, and noting outcomes of action. It also implies provision for acquiring skills particular to the situation at hand, such as the physical care of an ill person in the home, time management, or negotiating the support of a child's teacher. Needless to say, the presence of models who can observe, examine, assess, focus on the health aspects in the family system, find health potential in families, and demonstrate management and technical skills are of paramount importance in environments that are health promoting. 114 JFN, May 2002, Vol. 8 No. 2 Here are some of the features of the environment for learning that were set up at The Health Workshop. 1. Families require a place where all the ordinary concerns and happen- ings in life are viewed as appropriate to the work of the health resource--a place where families can come over time, either individu- ally or collectively. 2. Families require up-to-date information and knowledge resources, such as books, journals, videos, Internet access, and so on--a health library. 3. Families require professionals with whom to talk over situations, the issues and problems involved--people who have experience and a body of knowledge, who can discuss and explore ideas, approaches, and plans. 4. Families require other families and individuals with similar interests, concerns, and experiences with whom to discuss, compare, and work to develop plans or programs relevant to the particular situation. 5. At times, families require direct assistance in dealing with situations (e.g., demonstration and guidance in the care of a member who has recently been diagnosed as having a disabling disease). Sometimes families require consultation with and/or referral to other profession- als or community agencies. 6. Families require a place where they can keep perspective on the total health of the family, not just diet, exercise, or self-awareness but a gen- eralized type of service that in its efforts is multifaceted in approach to family health. Families require opportunities to see health as an inte- gral part of family life in all its endeavors. 7. Families require a setting in which to try out new and different modes of expression and behavior. They require assistance in recognizing resources within their own family and neighbor group and in using these resources as the basis for healthy lifestyles. Method of Nurse and Client Health Work Assessment. The basic idea of assessment is to place the specific con- cerns of the individual/family within a broader context so as to derive an overall profile of the health situation (events, behavior, knowledge, attitudes) with which the nurse and individual/family are dealing. It is this perspective that allows the nurse and individual/ family to focus more sharply on the critical realities of the situation. In turn, there is greater opportunity for them to plan action that is practi- cal and relevant to the situation. There can be no doubt that the effec- tiveness of interventions depends on the quality of the assessment. Allen, Warner / A Developmental Model 115 The broader context that one seeks to comprehend in any individual/ family situation would identify the family system: its patterns of interaction and key relationships, functions, and roles over time; its learning and developmental styles vis--vis health and well-being; and the nature and quantity of resources available to the individual/ family--strengths such as goals, interests, skills, motivation, readi- ness for health work within the family, and various financial and social supports. This long-term view of assessment gives shape to the concept of nursing as continuous inquiry. The evaluation of this pro- cess is determined by the outcomes of nursing interventions that serve to test the quality of assessment, its accuracy, and its validity. During assessment, the nurse enters into negotiation with the cli- ent, sharing, testing out, and validating throughout the process. With a supportive milieu as background, the nurse identifies the central role of the client in the health-promoting process by acknowledging the client as the primary source of information relevant to the situa- tion and the direction it is taking. As negotiation proceeds, both nurse and client attempt to clarify their goals and the tasks of each in the process. Implementation. The way in which a person/family becomes active in health work varies. For example, a person who has suffered a myo- cardial infarction is already engaged in health work when she arrives in a coronary care unit: physiologically, the body is responding to the insult of the infarct on the myocardial tissue and on the circulatory system; psychologically, the person is coping with pain, fear, and many other manifestations of the infarct as well as with machines, new faces, lack of rest and sleep, and so forth. In this situation, it is critical that the person-as-patient learn to give herself over to the care of others and to become an active collaborator with this goal so that the medical regime has every opportunity of success. Initially, the brevity of the nurse-patient relationship and the higher degree of nonverbal communication from the patient compli- cate the processes of negotiation and collaboration in achieving the goal. Efforts to validate perceptions and verify information being received from the patient add to the complexity of creating an envi- ronment characterized by support, caring, expertise, and safety. Yet the outcomes rest to some extent on the collaboration of the patient. What is accomplished at this point sets the stage for further health work whether it is toward rehabilitation or in dying. Examples of cli- ent factors other than physical illness that may complicate the process 116 JFN, May 2002, Vol. 8 No. 2 of collaboration include severe emotional distress, sensory deficits, lack of fluency in the dominant language of the health care setting, and authoritarian beliefs about the respective roles of the client and the health professional, to name a few. In assuming a collaborative approach to the situation, the nurse and individual/family share responsibility for planning and for test- ing out or implementing the plan in view of client outcomes and the client's responses to these outcomes. Planning builds on client strengths and capacities--goals, motivation, time, knowledge and skills, social supports, and so forth. The nurse assists the individual/family to build on their potential for problem solving and goal attainment through active participation and personal discovery. The nurse waits for the individual/family to try out the plan within their own time frame and in their own way. This is not passive waiting but rather a kind of participation that involves "tolerance of a certain amount of confusion and floundering," appreciation for the "free play that char- acterizes growth" (Mayeroff, 1971, p. 18), and is alert to cues suggest- ing nursing roles that support learning in the situation at hand. Evaluation. The Developmental Model of Health and Nursing espouses an open (situation-responsive) approach to evaluation. The nurse gathers evidence on individual/family responses and out- comes but does not assign value. Together and/or independently, the nurse and client note tentative linkages between activity and out- come. This permits ample emphasis on the process of learning and provides opportunities to identify factors that appear to influence the process. In this way, both the nurse and the individual/family are better able to select and tailor subsequent steps in their work together. Ultimately, the individual/family validates the health work process according to outcomes in the situation and their satisfaction with these outcomes. THE HEALTH WORKSHOP As previously mentioned, a second demonstration of the model of nursing was established following evaluation and elaboration of the model in a family medicine unit. This research was a funded demon- stration of a freestanding, nurse-managed community health center located in a middle-income suburb of Montral (funded by Health and Welfare Canada, Health Programs Branch). The center was called Allen, Warner / A Developmental Model 117 The Workshop: A Health Resource or, more familiarly, The Health Workshop. The project employed a service team and a research team. The service staff included nine nurses, a community development officer, an information officer, and administrative and clerical person- nel. The five-member research team was comprised of health and social scientists. With the help of an architect, the staff designed a nonclinical, open, welcoming, multiresource setting. The design aimed to promote dif- ferent types of interaction and activity, such as community meetings, small interest group meetings, nurse-client visits, physical examina- tion and treatment, classes, children's play, and solitary reading. It provided for varying privacy needs and was equipped with a library, audiovisual technology, and a variety of other materials to support performance of tasks and activities. A local artist created six large poster drawings, each depicting a different situation of family and community life. The posters were hung as a group under a banner that pulled the display together to depict families in the community learning to be healthy through life experiences. The display became a popular orienting device, a declaration, so to speak, of the orientation to health matters taken in this setting. Observations of Nursing at The Health Workshop For both nurses and the community, learning to use The Health Workshop setting was a critical factor in its development. In fact, the nature of a health resource is, in large part, a function of the way both the staff and the community use the setting. For nurses, learning to use the innovative interior design; becoming accustomed to working in a nonclinical, open setting; observing the effects of interior design on client behaviors; experimenting with the use of various types of space; and discovering ways of using the setting to support nursing are all part of a situation-responsive approach to practice. Marketing a model of nursing to clients, community, and society. During the hiring of nursing staff for The Health Workshop, concern with the applicant's potential for nursing according to the Developmental Model of Health and Nursing was paramount. Consequently, as each nurse was hired, the type and quality of nursing she2 personally could provide was emphasized. That she should participate in cultivating and promoting a setting that might be even more instrumental in improving the health of the community was not a part of the early dis- 118 JFN, May 2002, Vol. 8 No. 2 cussion. In actual practice, however, the latter took precedence, because continued financial support was tied to use of the facility. Clearly, in the beginning, increased use depended less on the quality of an indi- vidual's nursing than on the capability of the staff to market the con- cept of The Health Workshop and its resources. Later, the quality of nursing was expected to play a major role in continued utilization of the health center by the community. Marketing results in people buying a product or, in this case, using The Health Workshop. Nursing results in improved health of clien- tele; to achieve this, clients must use The Health Workshop. For some nurses, the line between marketing and nursing was blurred. Mar- keting nursing for health promotion was viewed as a step in the pro- cess of nursing, differing only in strategies, depending on whether one was responding to an individual, a group, or a community. Some nurses, experienced in working with families and groups, displayed the art of intriguing, enticing, and challenging people in the search for healthy ways of living. They seized opportunities in various media to portray their concept of health and healthful living. In fact, they tended to view all of their activities as within the practice of nursing. In this way, competency in nursing marketed the product success- fully and solved the problem of utilization. Other nurses made a clear distinction between marketing and nursing and balked at employing marketing strategies that they labeled, at best, not nursing and, at worst, unethical. For these nurses, the success of the other nurses was unethical, because in their percep- tion, it created needs where, heretofore, there had been none. In this situation, we were faced with a clash between opposing philosophical positions in nursing: one related to the medical model and elimina- tion of deficits or needs and the other, to a developmental model and a process of search and growth. So, the question of how to involve peo- ple in health work, either as individuals or as communities, may become an ethical issue, on the one hand, or a competency issue, on the other. The setting as a facility in demonstration. The Health Workshop was not merely the setting or context of the demonstration: It was the dem- onstration. To go around this emphasis on the facility, some nurses carried out as much of their work as possible in the client's home, explaining with such comments as "I don't need any backup center to nurse my clients." These nurses tended to keep their clients to them- selves and concentrate on the problems they presented. Other nurses Allen, Warner / A Developmental Model 119 explored and experimented with activities and materials that support learning. They routinely solicited the participation of community res- idents to develop the center as a health facility. It would seem that if nursing is to enter the field of health promotion successfully, it must forfeititsstrongattachmenttotheone-to-onerelationshipandbroaden its scope: to include families and community groups on the "client dimension"; and to include coworkers, settings, and other resources that support and promote health work on the "nurse" dimension. Admission of people to The Health Workshop. When The Health Work- shop began, new clients were asked to complete a detailed demo- graphic information form at the point of entry. Clients were then seen by a nurse who responded to their concern or problem, thereby elimi- nating the usual waiting so common in clinics and emergency rooms. In a short time, however, it became clear that the immediate attention and taking of information, the referral of a client to a particular nurse, and the focusing on client concerns were ineffective in conveying and promoting the concept of a health facility and The Health Workshop method. These admission procedures were modified so as to enroll people as members instead of registering them as clients. The term "recep- tion" was explored and elaborated to generate alternatives to the more familiar clinical model of admission. Reception meant taking time to welcome newcomers to the setting, to describe the idea of the facility and The Health Workshop while taking them on a tour, and to stop to make introductions and chat with other members of the staff. At an appropriate time, the person/family was linked with a nurse who then followed through to identify their interests in The Health Workshop, those aspects that had intrigued them, and their particular concern or reason for visiting. In this way, newcomers were presented with a variety of stimuli relative to the health facility--its purposes, goals, programs, and resources--and the nurse had the opportunity to capitalize on their interests as well as identify the concerns they brought to the visit. Sometime before the end of the first visit, new- comers were invited to enroll as client-members of The Health Work- shop and given a small packet of information about the facility to share with family and friends. Information relative to the individual/ family was recorded as it was gathered over time. One had to make a trade-off here between accuracy and completeness of data and the type of health resource one wished to establish. 120 JFN, May 2002, Vol. 8 No. 2 The nature of family. In this approach to nursing, great ambiguity surrounded the concept of health and, secondarily, that of family. One theme of the developmental concept of health is that health is socially constructed. More specifically, health is a product of family/primary group interaction and influence over time. The health behavior of one family member is a reflection of the health behavior of the whole family/primary group. Therefore, one has a biased and/or inade- quate assessment of a person's health to the extent that the data on which it is based derive from a unitary source. Consequently, it was expected that nurses endeavor to meet other family members, engage them in exploring their ways of living and developing as a family, and eventually get in step with the family's pace and style. In The Health Workshop, some nurses obtained most of their fam- ily data from one family member; they failed to entice other members to the center or the client came only a few times. Other nurses com- piled family data by separately gathering similar information from each family member; they employed an a priori format and/or fol- lowed a medical history "problem" approach. Still other nurses derived family data with the whole family gathered together for the purpose of "family therapy"; they tended to focus on the therapy structure and less on collaborative health work. These positions may seen extreme but variations of them exist and greatly influence the assessments nurses make. It was usual for new members to come alone or in family pairs such as mother and child, husband and wife, or daughter and elderly par- ent. Various techniques emerged to involve family members and to engage them in the process of health work. One such ploy described by Warner (personal communication, May 1978) was to give "home- work." A few examples of how homework was introduced follow. Talk this over with ___, and let's discuss it next time. Here is an article on ___; let's talk about it on your next visit. Try ___ out at home and see if it makes any difference in the situation. Keep track of ___ and then we'll know more about it on your next visit, when ___ seems to happen, how long it lasts, who was there, and so on. I could make a home visit sometime when everyone is at home to talk about ___ together. Why don't you propose that and let me know what they suggest. Allen, Warner / A Developmental Model 121 Research Findings at The Health Workshop Nursing functions. In The Health Workshop, we wished to deter- mine the functions that nurses were carrying out in noncritical situa- tions. The researchers gathered data from observation of nurse-client encounters followed by interviews with both the nurse and the client. Based on these observational and interview data, the following analy- sis details the roles and activities of the nurse in structuring a learning experience. Focuser, stimulator, resource provider who devises projects to involve client in such tasks as clarifying concerns and goals, thinking about his/her learning style, gathering information. Examples include (a) design an observation guide that client can use to gather objective data on a particular concern, look at patterns of family interaction or coping strategies and resources; (b) ask provocative or rhetorical questions for the purpose of having the client consider a situation from another point of view; and (c) provide information resources and invite discussion of same. Integrator and awareness raiser who assists client with analyzing the sit- uation, identifying additional resources, and seeking potential solu- tions. Examples include (a) point out relationships between events and patterns of behavior; (b) help client to transfer knowledge from previous experience to the present; (c) point out networking possibilities within family or group or with an external resource and assist access to addi- tional resources; and (d) review and summarize what has been learned and how (e.g., changes in coping behavior, how observation led to a better understanding of the problem). Role model, instructor, coach, guide, and encourager as client makes a decision on alternatives and tries new behavior. Examples include (a) model approaches to problem solving; (b) set up role playing to allow client to experience and practice ways of interacting and responding; (c) provide opportunity for practice of new skills, such as first aid, bathing, feeding, instillation of eye drops, leading a family discussion, speaking to the doctor, and so on. Pacer, reinforcer, and reviewer as client looks at and evaluates out- comes. Examples include (a) reinforce orientation to process; (b) note cli- ent's use of strengths and resources; and (c) share observations of appar- ent links between activity, outcomes, and next steps. In a sequence of nurse-client interactions, these functions of the nurse clustered into what appeared to be the phases of a cyclical, 122 JFN, May 2002, Vol. 8 No. 2 Table 5: Interaction Between Client and Nurse in Health Work Health Work I II III IV Client's a task Clarifying concerns Analyzing situation Deciding on alternatives Noting outcomes and goals Displaying strengths Identifying resources Testing new behavior Valuing and preferences Gathering information Culling options Nurse's b role Focuser Integrator Role model Pacer Stimulator Awareness raiser Instructor Reinforcer Resource provider Identify additional Coach, Guide Reviewer resources Encourager Make linkages Mobilizer a. Client may be an individual, a family, group, or community. b. Nurse may be an individual, a team, facility, or service. 123 forward-moving process. Table 5 depicts these phases, including the client's tasks and the roles of the nurse in structuring a learning experience. Styles of nursing at The Health Workshop. Gottlieb (1982) summa- rized the differences in nursing observed by the researchers3 and described three patterns: a learning style, a teaching style, and a mixed style. The situation-responsive approach to nursing, as described throughout this article, is reflected in the learning style. Some of its critical aspects were as follows: 1. Nurse devotes considerable time to assessment in the form of continu- ous inquiry. 2. Nurse is always trying to maintain a broader context, placing specific concerns and events within a pattern of experience. 3. Nurse views situations as emergent and evolving over time. 4. Nurse takes an inductive approach to assessment, validating hunches and hypotheses through observation and consultation with client. 5. Nurse designs "projects" or experiential types of situations to involve client, which is creative. 6. Nurse consults readily, uses the available setting or structure, tries things, and is open with other professionals and groups--a process model. The most outstanding feature of the teaching style of nursing is that the nurse assumes the major role of directing the nurse-client work and the client is the recipient of the nurse's knowledge, advice, coordination, and so forth. The underlying modus operandi is an a priori framework. Given this framework, the assessment and plan- ning phases of the nursing process are relatively short in time and less subject to revision. The scope of the nurse's assessment is limited to the actual problem and it is seen as limited in scope. The focus is on what the client needs to learn or do: that is, the content as opposed to the process. With little use of consultation, the nurse begins to imple- ment her plan of action in her role as expert and coordinator. When this approach founders and/or when the amount of data presented to her is overwhelming, the nurse seems to drift within, as well as between, encounters. Instead of moving along in the health work pro- cess, the nurse and client go around and around. The major effort of nursing is expended in the intervention phase. 124 JFN, May 2002, Vol. 8 No. 2 Health potential--An emerging concept. The Developmental Model of Health and Nursing suggests that we de-emphasize teaching (de-emphasize content) and pay more attention to the tasks involved in learning (problem solving or what we also refer to as health work) and to our role in creating situations and structuring environments that support learning. Of considerable importance is the nurse's abil- ity to assess individual/family health potential in the situation at hand: that is, the probability for change. Health potential is mani- fested in displays of (a) readiness to spend time and effort on thinking about and working on health and (b) capability to perform the tasks and master the skills of health work. Among nurses involved in The Health Workshop, much effort has been directed toward describing the nature of health potential. The significance of this variable for the role of nursing in marketing the ideas of healthful living and health work to prepare people to use a community health resource cannot be overemphasized. In our work, we quickly discovered that many individuals and families are not at a point when they are willing to spend time and effort on being and becoming healthy. They simply are not ready. Limited resources can also affect the potential for learning (change). In addition, our obser- vations suggest that family organization prior to a problem-solving situation is a key factor in the makeup of health potential. Thus far, we have identified several indicators of each of these three factors, as follows: 1. Motivation Request for assistance is consultative as opposed to advice- or directive-seeking Participation demonstrates a tendency to initiate and collaborate Follow-through is active, mindful 2. Resources Access to knowledge and information Economic sufficiency Network of family, neighbors, and friends Access to community services Sense of personal/family efficacy (experiences of success in key areas, such as school, work, social life, family life) Allen, Warner / A Developmental Model 125 3. Family functioning style Sees life events as situations to be dealt with as part of family life Invests in situations proportionally in terms of time and people involved Uses different approaches to situations of different levels of complexity Members participate in defining situations, goals, and expectations Members attracted to family and to each other At the Economic Conference on Health Care in Winnipeg in May 1986, it was stated that 80% of health care is provided by nonprofessionals, such as family, friends, and neighbors. This finding emphasizes the need for nursing to assume a much more active lead- ership role in supporting the development of the health potential of people. To begin, this emerging description of health potential, with its key aspects, provides us with a working, although tentative, struc- ture to use and explore further with client families. A well-grounded description of health potential can then serve as a reference point against which to test the relevance and usefulness of related concepts and measures available in the social science and health literature. Through this line of inquiry, we seek answers to such questions as: What motivates people to work on health? What aspect of family/pri- mary group structure and functioning are most closely related to motivation for health work and capacity for learning or change? What resources do people require to support and augment their capacity for learning? CONCLUSION The conditions of modern life--the weakening of concrete and rel- atively cohesive communities of meaning and support, the orienta- tion to the future that means endless striving and a mounting incapac- ity for repose, and the greater freedom and responsibility associated with progressive separation of the individual self from collective entities--tax traditional modes of living. This is especially true for the family, the most significant primary group in our society. The model of nursing presented in this article aims to locate the practice of nurs- ing within the mainstream of services directed toward assisting peo- ple to find healthy ways of coping with these conditions of modernity as they are experienced in everyday life. It is especially concerned 126 JFN, May 2002, Vol. 8 No. 2 with the development of healthy families--not with illness and dis- ease, not with real or imagined deficiencies but with the capacity of all families to learn through experience to cope with problems and develop in a healthful fashion. The main components of the model structure an inquiry process through which nurses, individuals, families, and communities accu- mulate knowledge about the nature of health and the resources peo- ple require to develop their health potential. Perhaps this will be its most important contribution to health care reform. In an essay on evaluation of the model (see Appendix B), Allen employs three criteria--relevance, relatedness, and accountability--to critically examine its value for nursing practice, education, administration, and research. As this essay suggests, the model provides a blueprint for demonstrating what nursing can be and for mapping its territory. Clearly, the Developmental Model of Health and Nursing provides an alternative to the deficit model that continues to dominate the health care system. Without question, it attempts to cause a revolution in nursing and, ultimately, in health care. APPENDIX A Health Situations Health situations are life events that appear to be closely related to health and around which interest in and concern for health is frequently manifested. Some of these events are common experiences; others are uncommon. Life events are viewed as the primary experiences through which individuals and families learn to behealthy. Therefore, they fall within the domain of nursing. 1. Customary changes in family size, composition, roles, and relationships Adjusting to married life/learning to live together Preparing for a new baby Incorporating a new member into the family/household Acquiring skills and knowledge of infant care, parent-child interaction Assisting children to develop and get along in their world Adjusting to a family member's transition to a new stage of development Coping with death of parent/spouse/child/close friend or relative Managing issue-specific conflicts Allen, Warner / A Developmental Model 127 Coping with conflictive and abusive relationships Terminating a relationship that is no longer satisfying Coping with loss of spouse/partner/parent through separation or divorce Adjusting to remarriage/blended family 2. Entering, functioning in, and exiting from a social system Relocating to a new house/nursing home/community/country Seeking employment, entering or returning to employment Planning for and adjusting to retirement Balancing the demands of work and family life Entering and using the education system Entering and using the welfare/social assistance system 3. Interaction between lifestyle and health practices Examining and altering lifestyle as it affects health and health habits Acquiring health habits (sleep, relaxation, recreation, physical activ- ity, nutrition practices, etc.) to improve energy level, mood, role per- formance, weight control Making time for family interaction Modifying erratic or destructive habits such as smoking, alcohol consumption, drug use, overeating Acquiring and evaluating information and ideas about health and factors that affect personal/family health Establishing and/or regulating links with the broader community Deciding when and how to utilize health processionals and facilities for periodic physical assessment, screening procedures, immuniza- tion, medical treatment 4. Biophysiological changes (characteristic physical, physiological changes accompanying new stages of growth and development) Understanding human sexuality and developing standards of sex- ual practice Clarifying/accepting one's sexual identity Coping with gender stereotypes and prejudice Deciding on methods of birth control and safe sexual practice Coping with problems of sexual functioning Coping with physical and physiological changes or discomforts of puberty, pregnancy, menopause, aging Coping with possible or actual infertility Coping with fears of growing up physically and socially Coping with fears of getting old physically and socially Coping with social pressures coming from peers, family, media 128 JFN, May 2002, Vol. 8 No. 2 5. Chronic disease, disability, or other long-term conditions Caring for an ill, frail, or disabled person in the home Coping with children's reactions to a family member's illness, dis- ability, pain, irritability, disorientation Shaping family living and development in view of family goals while incorporating the realities of a chronic physical disease or dis- ability, mental illness (e.g., schizophrenia, depression), or behav- ioral syndrome (e.g., autism) Coping with multiple services and professionals 6. Acute illness, injury, or uncertain health Caring for an ill, injured, or recuperating person in the home Coping with medical intervention and prescriptions such as diag- nostic testing, medication regimen, hospitalization, surgery, func- tional aids/appliances Acquiring knowledge and skills necessary for assessment of signs and symptoms of common illnesses (e.g., colds and flu, fever in chil- dren, skin rashes, digestive upsets) Learning specific skills of sick care--administering medications, coaxing a finicky eater, alleviating symptoms, making a person com- fortable, caring for a wound or cast, lifting, and so forth Learning appropriate first aid techniques 7. Financial insufficiency and economic reverses Coping with unemployment, reduced income, or unpredictable job situation Accommodating to a period of increased financial expense (e.g., buying a home or a car, costly medical care, children's education fees) Learning to live within a budget, manage money 8. Catastrophic or severely adverse events Coping with the immediate hurts, losses, dislocation of a natural disaster, fire, burglary/home invasion, social upheaval, physical violence Coping with the psychological and physical sequela of catastrophic events 9. Community development, environmental, and social policy issues Becoming informed about health and social policy, changes in the social and physical environment, public health issues Conducting surveys of community interests, assets, and needs Allen, Warner / A Developmental Model 129 Initiating and/or participating in neighborhood and community action projects Learning how "the system" works, where to go to deal with issues Acquiring skills of participatory decision making, group process, publicspeaking,fund-raising,lobbyinggovernmentandcorporations Adapted through ongoing refinement and elaboration from Allen et al., 1980b. APPENDIX B Evaluation of a Developmental Model of Health and Nursing 4 This essay discusses evaluation of the developmental health model as a framework for nursing practice, education, administration, and research. The criteria for evaluation are those presented initially in a publication on evalua- tion of educational programs in nursing (Allen, 1977b) and later utilized by the Canadian Association of University Schools of Nursing to develop an accreditation program for university schools of nursing in Canada. Briefly, the criteria as related to a model of health and nursing are as follows: the relevance of the model to the society and communities it serves, the relatedness of the concepts or parts of the model to each other and to the overall goals, and the accountability of the model in its responsiveness to clients. Relevance. Are the nursing, education, and research implied by the model relevant to the society and the communities it serves? In the broadest sense, health work as defined by the model outlines the parameters of nursing. In contrast to the prevailing a priori approach result- ing in consensus about nursing, this model looks at what nursing is at this point in time and what it can be. Its major ideas encourage and provoke debate, even conflict, thus setting the stage for pinning evidence to proposi- tions about health and healthful living. From the perspective of society, this model of nursing aims to fill a gap: to provide a service to promote the development of healthy families from their beginning and over time in such a way as to augment health competence, responsibility, and accountability. In the time of enlightened social concern and sophisticated consumers, the elitism of the traditional professional-client relationship can no longer prevail. In its stead, an egalitarian quality between professional and client has emerged, heralding the onset of collaborative rela- tionships between these participants. 130 JFN, May 2002, Vol. 8 No. 2 In a collaborative search for health, as in this model, the professional is actively engaged in identifying the attributes of health-promoting interac- tionsineveryclientsituation.Thispracticeservestheepidemiologicalfunction by gathering data on the order and sequence of factors that characterize healthy development. The search is on for competence models, not deficiency models. Both basic and applied research emanating from the model are directed toward providing answers where real gaps in knowledge exist. In general, the model dictates a way of responding to major health service debates: for example, the differential health outcomes for clients when using a health focus versus an illness focus, working with a family versus with an individual, having a long-term versus an episodic perspective. Although epi- demiology of health studies concentrate on the incidence and prevalence of coping-type situations, other critical investigations suggested by the model seek to identify the enabling qualities and behaviors that are productive of health, such as health potential. The model is also of significance to the emerging field of population health research. Although few would argue with the assertion that society needs healthy families, minimal attention has been paid to the role of the family in explaining the relationship of the "determinants of health" to rates of morbid- ity and mortality, the principal indicators of health in the population health model. With the family as its unit of concern, the developmental health model introduces a plausible theoretical link among various social and behavioral health determinants and, in turn, to the traditional health indicators reported in the population health literature. Relatedness. Are the concepts and parts of the model related to each other and to its goals? It is through actual practice in implementing this model of nursing that legitimate questions are raised about the learning of health behavior and related health-promoting practices. Concomitantly, students learn to nurse by working alongside faculty in practice and in the examination of practice. This model augments the potential relatedness of practice, research, educa- tion, and administration, thereby maximizing interaction and the flow of knowledge and ideas. In concentrating on that which is nursing as implied by the model, it decreases functional compartmentalization and de-emphasizes specialization. Families learning health are part of a system in the real world. These concepts-- family, learning, health--each with a knowledge field derived from the humanities and the social and biological sciences, constitute a theoretical sys- tem of social import. In their multiple manifestations, these concepts com- prise the situations that confront nurses. This theoretical system orients the nurse who collects data in a client situation and serves to organize the result- ing data as the nurse moves toward assessment. Allen, Warner / A Developmental Model 131 The model espouses a goal-free open system that is developmental for health and supportive of the search for health as opposed to discrepancy eval- uation of a closed system that aims to maintain the status quo by remedying limitations and weaknesses. In many instances in nursing, theorists perceive the nurse's role as promoting client productivity, and they use a social pro- ductivity criterion to evaluate progress. The model of nursing presented in this article gathers evidence on client-family outcomes and responses but does not affix value. Rather, tentative linkages are noted as possible relation- ships between activity and outcome. It is in this fashion that evidence relative to the research endeavor of nursing to promote health is garnered in everyday practice. Accountability. Is the nursing implied by the model a response to the partic- ular client? As noted in an earlier study of students learning to nurse (Allen & Reidy, 1971), nurses operate at two levels. In one, knowledge is research-based and can be directly applied, often referred to as solving problems to which there are known solutions (Bruner, 1961). In such circumstances, an a priori approach is warranted. However, in the learning of health behavior in fami- lies, evidence as to what one should do is tenuous. In such circumstances, it is improper for nurses to operate as though the knowledge were known. In fact, it is unethical to assume there is knowledge when there is not. It is here that the method implied in this model is most critical--exploration, experimenta- tion, and valuation of response outcomes. Similar to the stance toward inde- terminate situations described by Schn (1983), the nurse and individual/ family assume the scientist's role and, as coinvestigators, search for informa- tion and make decisions about what to do. This systematic gathering of data, followed by analysis and synthesis, trains the individual/family in the pro- cess of healthy development, a situation about which knowledge is scarce. Espousing goal-free evaluation, as this model proposes, permits ample emphasis on the process of health work and the consideration of factors that influence process such as wait time, recognition of potential, and so forth. As the evidence accumulates on these factors, both nurse and client are better able to shape and fine tune subsequent steps in the process. According to Dewey's theory of valuation (1939/1972), "learning from experience" entails reflecting on and appraising actions in view of where the situation at hand is going. By looking at where our actions are taking us, we learn what works in view of desired or intended ends. It is in this way that the individual/family is able to validate the purpose and value of their responses in view of healthy development. The criterion of accountability is met through participation, collaboration, and validation by the client. Values hinge on the health responses in the client. 132 JFN, May 2002, Vol. 8 No. 2 NOTES 1. Clients are called patients in these family medicine units. 2. All staff members of The Health Workshop were female. 3. These findings were derived from data collected at The Health Workshop by Adele Carrier and Kent Farrell under the direction of Charles Bourgeois from May through August 1978. 4. This essay is an excerpt from the Rosella M. Schlotfeldt lecture presented by Allen in May 1982 at Case Western Reserve University, Cleveland, OH. The title of her presen- tation was "Shaping Health Potential. The Cutting Edge of Nursing Practice." REFERENCES Allen, M. (1974). The expanding role of the nurse: Her preparation and practice [Edito- rial]. Nursing Papers, 6(2), 2-4. Allen, M. (1977a). Comparative theories of the expanded role in nursing and implica- tions for nursing practice: A working paper. Nursing Papers, 9, 38-45. Allen, M. (1977b). Evaluation of educational programmes in nursing. Geneva, Switzerland: World Health Organization. Allen, M. (1979). Notes on the contribution of nursing to health care. Nursing Papers, 11, 56-60. Allen, M. (1981). The health dimension in nursing practice: Notes on nursing in pri- mary health care. Journal of Advanced Nursing, 6, 153-154. Allen, M. (1982, May). Shaping health potential: The cutting edge of practice in nursing. Paper presented at the Rozella M. 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Montreal, Canada: McGill University, School of Nursing. Allen, M., & Reidy, M. (1971). Learning to nurse: The first 5 years of the Ryerson Nursing Pro- gram. Toronto, Canada: Registered Nurses Association of Ontario. Audy, J. R. (1971). Measurement and diagnosis of health. In P. Shepard & D. McKinley (Eds.), Environmental essays on the planet as home (pp. 140-162). Boston: Houghton Mifflin. Bandura, A. (1977a). Social learning theory. Englewood Cliffs, NJ: Prentice Hall. Allen, Warner / A Developmental Model 133 Bandura, A. (1977b). Self-efficacy: Toward a unifying theory of behavioral change. Psy- chological Review, 84, 191-215. Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall. Bransford, J. D., & Stein, B. S. (1984). The ideal problem solver. New York: Freeman. Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press. Bruhn, J. G., & Cordova, F. D. (1977). 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Healthy personality: An approach from the viewpoint of humanistic psy- chology. New York: Macmillan. Klein, D. M., & Hill, R. (1979). Determinants of family problem-solving effectiveness. In W. Burr, R. Hill, F. I. Nye, & I. L. Reiss (Eds.), Contemporary theories about the family. Vol. I (pp. 493-548). New York: Free Press. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Mayeroff, M. (1971). On caring. New York: Harper & Row. Perlman, H. (1975). In quest of coping. Social Casework, 56, 213-225. Pratt, L. (1976). Family structure and effective health behavior. The energized family. Boston: Houghton Mifflin. Schn, D. (1983). The reflective practitioner. New York: Basic Books. Spitzer, W. O., & Kergin, D. J. (1975, Spring). Nurse practitioners in primary care: The McMaster University educational program. Health Care Dimensions, pp. 95-103. 134 JFN, May 2002, Vol. 8 No. 2 Spitzer, W. O., Kergin, D. J., Yoshida, M. A., Russell, W. A., Hackett, B. C., & Goldsmith, C. H. (1975, Spring). Nurse practitioners in primary care: The Southern Ontario ran- domized trial. Health Care Dimensions, pp. 105-199. F. Moyra Allen, R.N., Ph.D., (1921-1996) was Emeritus Professor of Nursing at McGill University when she wrote the article in this issue. For a portrait of Allen's early life and the highlights of her career in nursing, see Meryn Stuart's biography (in this issue). Marguerite Warner, R.N., Ph.D., is a health promotion specialist in Winnipeg, Man- itoba, Canada. F. Moyra Allen supervised her research project in 1975 for the master of science (applied) degree at McGill University. Recent publications include (with M. Ford-Gilboe, Y. Laforet-Fliesser, J. Olson, & C. Ward-Griffin) "The Teamwork Project: A Collaborative Approach to Learning to Nurse Families" in Journal of Nursing Education (1994). Allen, Warner / A Developmental Model 135 </meta-value></custom-meta></custom-meta-wrap></article-meta></front><back><notes><p><list list-type="order"><list-item><p>1. Clients are called patients in these family medicine units.</p></list-item><list-item><p>2. All staff members of The Health Workshop were female.</p></list-item><list-item><p>3. These findings were derived from data collected at The Health Workshop by Adele Carrier and Kent Farrell under the direction of Charles Bourgeois from May through August 1978.</p></list-item><list-item><p>4. This essay is an excerpt from the Rosella M. Schlotfeldt lecture presented by Allen in May 1982 at Case Western Reserve University, Cleveland, OH. The title of her presentation was “Shaping Health Potential. The Cutting Edge of Nursing Practice.”</p></list-item></list></p></notes><ref-list><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Allen, M.</surname></name> (<year>1974</year>). <article-title>The expanding role of the nurse: Her preparation and practice [Editorial]</article-title>. <source>Nursing Papers</source>, <volume>6</volume>(<issue>2</issue>), <fpage>2</fpage>-<lpage>4</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Allen, M.</surname></name> (<year>1977a</year>). <article-title>Comparative theories of the expanded role in nursing and implications for nursing practice: A working paper</article-title>. <source>Nursing Papers</source>, <volume>9</volume>, <fpage>38</fpage>-<lpage>45</lpage>.</citation></ref><ref><citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Allen, M.</surname></name> (<year>1977b</year>). <source>Evaluation of educational programmes in nursing</source>. <publisher-loc>Geneva, Switzerland</publisher-loc>: <publisher-name>World Health Organization</publisher-name>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Allen, M.</surname></name> (<year>1979</year>). <article-title>Notes on the contribution of nursing to health care</article-title>. <source>Nursing Papers</source>, <volume>11</volume>, <fpage>56</fpage>-<lpage>60</lpage>.</citation></ref><ref><citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Allen, M.</surname></name> (<year>1981</year>). <article-title>The health dimension in nursing practice: Notes on nursing in primary health care</article-title>. <source>Journal of Advanced Nursing</source>, <volume>6</volume>, <fpage>153</fpage>-<lpage>154</lpage>.</citation></ref><ref><citation citation-type="confproc" xlink:type="simple"><name name-style="western"><surname>Allen, M.</surname></name> (1982, May). <article-title>Shaping health potential: The cutting edge of practice in nursing</article-title>. 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O.</surname></name> , <name name-style="western"><surname>Kergin, D. J.</surname></name>, <name name-style="western"><surname>Yoshida, M. A.</surname></name>, <name name-style="western"><surname>Russell, W. A.</surname></name>, <name name-style="western"><surname>Hackett, B. C.</surname></name>, & <name name-style="western"><surname>Goldsmith, C. H.</surname></name> (<year>1975</year>, Spring). <article-title>Nurse practitioners in primary care: The Southern Ontario randomized trial</article-title>. <source>Health Care Dimensions</source>, pp. <fpage>105</fpage>-<lpage>199</lpage>.</citation></ref></ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>A Developmental Model of Health and Nursing</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>A Developmental Model of Health and Nursing</title></titleInfo><name type="personal"><namePart type="given">F. Moyra</namePart><namePart type="family">Allen</namePart><affiliation>McGill University</affiliation><affiliation>McGill University</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Marguerite</namePart><namePart type="family">Warner</namePart><affiliation></affiliation><affiliation>E-mail: mwarner@mb.sympatico.ca</affiliation><affiliation>McGill University, mwarner@mb.sympatico.ca</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article"></genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">2002-05</dateIssued><copyrightDate encoding="w3cdtf">2002</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">This is the last article written by Moyra Allen prior to her death in 1996. Allen believed that nursing has a vital role to play in reorienting the Canadian health care system to goals more appropriate to our rapidly changing society—the development of healthful living styles, healthy families, and healthy communities. First, she argued, we must separate the ideas of health and illness. Health is fundamentally a social phenomenon, a way of living or behaving that is readily communicated within such institutions as the family and across groups through the media and community life. She asked: What are the resources that families/groups require to recognize and develop their potential for healthful living? How can professionals work with families in this process? In this article, she lays out an organizing plan or model with which to seek answers to these questions and the inquiry process through which the model-building process evolved.</abstract><relatedItem type="host"><titleInfo><title>Journal of Family Nursing</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1074-8407</identifier><identifier type="eISSN">1552-549X</identifier><identifier type="PublisherID">JFN</identifier><identifier type="PublisherID-hwp">spjfn</identifier><part><date>2002</date><detail type="volume"><caption>vol.</caption><number>8</number></detail><detail type="issue"><caption>no.</caption><number>2</number></detail><extent unit="pages"><start>96</start><end>135</end></extent></part></relatedItem><identifier type="istex">201735C412BB7AA4C9FD50889CFF7893B54136F9</identifier><identifier type="DOI">10.1177/107484070200800202</identifier><identifier type="ArticleID">10.1177_107484070200800202</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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