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Nursing is an evolving discipline in the development of science i.e. th

In this project, the innovation proposed is a continuous patient satisfaction improvement process and is planed to be promoted in the local Public hospital’s haemodialysis unit.

The particular unit offers haemodialysis treatment to almost 120 patients suffering from End Stage Renal Disease (ESRD). All the patients are undergoing haemodialysis treatment which is last four hours per session, three times a week. Treatment is governed by the adequacy and mode of dialysis. Haemodialysis requires an access to patient’s circulatory system that will sustain a blood flow of 300 to 500 millilitres per minute per treatment session. The blood must be able to pass through the dialyser for a prescribed amount of time in order to guarantee dialysis adequacy. This is usually expressed as a Kt/V value which is a standard measurement of urea clearance during a specified time.

In order to manage all those patients the unit has 14 haemodialysis stations that are working 18 hours per day, every day including weekends. The dialysis program is spread in three shifts (morning, afternoon, and evening) with the majority of the patients coming in morning and afternoon shifts. The unit delivers approximately 300 haemodialysis sessions per week. In order to carry out all this workload the unit occupies 30 first grade nurses, two sisters in charge, and one nurse supervisor. Furthermore, along with the nursing staff there are 3 doctors specialized in nephrology contributing to the care of those patients.

With the growing changes due to the emergence of advance technology, globalization and other economic aspects, different organisations, particularly healthcare organisations are considering changes through the context of innovation (Shelton & Davila, 2005). Accordingly, innovation can be regarded as the creative and resourceful approaches as well as duties resulting to the effective and efficient function of a firm or organisation. It is essential for health care organisations to ensure high levels of their client satisfaction – in this case the patients- their personnel and the entire organisation. It can be noted that innovation focus on thorough management of the approaches involving the deliberation of the services or even products (Amsden, 2001).

Consequently, like any other firms and organisations, the healthcare industry should also adhere in having the knowledge of considering changes and innovation to ensure that the organisation always adapt to the newest trends and developments in providing quality healthcare, it may be in the facilities used or the knowledge of the personnel.

The context of innovation is very crucial in enabling the organisation to analyse its current situation and status so as to reduce costs, increase income, spot healthcare trends rapidly, and communicate efficiently with the target market. Nonetheless, to be able to complete such purpose, innovation approaches are required to be relevant, precise, thorough and timely. It is essential that the innovation team should be able to determine what part of the organisation needs change and how they are going to initiate such innovation activities. For instance, in healthcare institutions, it is important that the organisation should constantly adapt to the changes in providing quality health care.

The innovation opportunity

The importance of providing quality healthcare services has long been recognized by the health care providers. But, such has been influenced by the consideration of the quality assurance, improvement programs and also the participation of the patients (Darby, 1998). Quality assurance in the healthcare services has long been studied as one of the driving forces of innovation in these institutions. Quality is referred to as the creation as well as maintenance of a competent edge has been widely considered by different institutions. (Frangou et al., 1999). In line with the health care practice, recent decades have researched and noticed remarkable innovation even an evolution in the quality supervision in the health care organisation, (Millenson, 1997). Prior to these changes, the context of the quality assurance for patient care had been analysed thoroughly by professionals, frequently this is conducted a subjective approach for the patients and individuals (Iglehart, 1996). But the obligations for quality in this system are no longer considered as exclusive realm of the health care providers. Healthcare authorities, governmental institutions and also the accrediting sectors have to innovate for the improvement of health care system in quality assurance.

Nowadays in my country, an overhaul reconstruction of the entire health system is in progress therefore, major important changes are due to take place. Among these anticipated changes is public hospitals’ status. Until now these hospitals are totally dependent for financial support from the Government and particularly from the Ministry of Health. With the new plans, they will transform into autonomous organisations leading to independence from their current state. The implication of this transformation is that once independence is granted, each institution will have to seek for its own sources of funding and other facilities, as are necessary to maintain their services, just as is the case in the private sector. This means that, they will have to compete equally for their resources with other organisations existing in the private sector. However, to be successful competitors, public hospitals have to identify their present quality status and where necessary, to enhance their care provision in all areas. Therefore, all hospitals have to adopt quality assurance programs, even before they transform to autonomous organisations.

The new healthcare reformation which will come into effect in the near future, aims to give patients, wherever they lived in the country, better health care and greater choice of service. Therefore the concepts of the internal market will be introduced, according to which, the ‘providers’ of healthcare will be separated from the ‘purchasers’ of healthcare. The idea is that by giving the purchasers the freedom to choose where to buy the best care, including the private sector, the system would place competitive pressure on the providers to offer greater quality, efficiency and value for money. Therefore, measurements of patient satisfaction have to play an increasingly important role in the growing demand towards accountability among health care providers. Overshadowed by measures of clinical processes and outcomes in the quality of care equation, patient satisfaction measurement has traditionally been downgraded to service improvement efforts by hospitals.

However, in today’s hyper-competitive environment, how much satisfied the patients are can determine whether a healthcare provider become preferred provider and retain that status. Therefore, continuous monitoring of patients’ satisfaction level it is expected to have a positive outcome not only on how the patients perceive the care they receive but also on the quality of delivered care in general.

Finally, as quality matters are in a primitive stage in my country such a venture will be the first of its kind especially in haemodialysis settings and probably will open the doors for others to follow.

C. The innovation planned

The project’s aim.

The aim of the propose project is to establish a Continuous Patient Satisfaction Improvement (CPSI) process within the Local General Hospital’s haemodialysis unit by utilizing the PDCA circle (Plan Do Check Act) or as differently known by many as `the Deming Wheel’ along with having Patient Satisfaction Index (PSI).

Relevant objectives.

The major objectives of the proposed project are:

To establish the current levels of patients’ satisfaction towards specific aspects of the care they receive.

Caring and communication.

Quality of haemodialysis unit care and procedures.

Information dissemination.

To recognize and report on the patient perceived strengths and weaknesses of the health care service provided.

To report the results to haemodialysis unit’s authorities to assist them to integrate patient understanding of good health care into the provided services.

Establish benchmarks to allow unit’s authorities to compare their results with those of other units either domestic or international.

Individuals that you might consult or ask to support the project in question.

To be able to have an efficient and proficient initiation of the proposed innovation it is essential to recognize the stakeholders who will have specific participation in the proposed innovation. The intention of such analysis is to recognize who among the stakeholders will have a high interest on the innovation, which will have the highest effect and effect on others for the initiation and establishment of continuous patient satisfaction improvement process. Further, this stakeholder analysis also aims on recognizing who will be subjects, players, spectators and actors concerned in the said innovation. The stakeholder analysis will be discussed through the consideration of the stakeholders’ grid.

In this proposed innovation the potential stakeholders composes of the haemodialysis unit’s authorities (as they will have the main responsibility for the process, interpreting the results and promote and implement changes), the patients receiving haemodialysis treatment and medication (as they will provide the information and they will have a direct impact from the changes), the unit’s personnel (as they will be asked to apply the changes), the hospital’s authorities and of course the Ministry of Health as the hospital’s and consequently the unit’s funders. The different participants for this innovation have varying amounts and classification of power, and those with the greatest effect shape approach and methods from a number of precise decisions (Shafritz & Ott, 2001). Participants for innovation are provided with the utmost authority in any organisational setting, like in this situation the initiation of the innovation of the continuous patient satisfaction improvement process. Their power and significance is beginning to expand slighter advantage when compared to an institution’s management team. The innovation participants will give diverse effect to both kinds of institutions and authorities and they guide the people in the health care organisation that the innovation aims and purposes will be met.

Innovation plan

The following is an outline of initiation plan for the innovation of Continuous Patient Satisfaction Improvement through the process of PDCA circle.

Carry out research to establish the current situation on patients’ satisfaction.

The first stage is to consider a research study to identify the current situation regarding patients’ satisfaction in this unit.

Team Organisation

The innovation process will not be able to attain its purpose if the tasks rendered were not appointed to efficient individuals to implement CPSI. Task allocation is not merely a situation of handing out the various tasks on final lists to the individual healthcare personnel you have available; it is far more delicate as well as powerful than such context. Hence, the unit’s authorities should consider what each member of the team is capable to provide sufficient complexity of tasks to match that.

Identify the weaknesses or problems regarding patient satisfaction

The next thing to consider is the identification of the weaknesses and issues relating to patient satisfaction to know what specific approach needed to satisfy them in the future.

Plan the changes that will promote the patients’ satisfaction with the care they receive.

The management should elaborate and disseminate information regarding the modification needed to promote the satisfaction of the patients with the care that they receive. For this matter, the change will include the enhancements of communication process and healthcare provision in the unit.

Changes implementation.

Changes evaluation.

Report writing. A results report will be produced at the end of the cycle describing the methodology and the results of the first cycle. The report will be disseminated to the haemodialysis unit’s authorities, to the hospital administrators as well as to ministry of health.

Finally in this project, the time limit estimated to be about 9 months, however the exact time that will be requested will be decided by the innovation team after discussions with the unit’s authorities.

Conclusion.

In this paper the Continuous patient satisfaction process had been presented as an innovation opportunity. Implementing such a process within the haemodialysis unit of the Local General Hospital it is expected that the overall quality of the services provided there will be promoted and change in such a way that will meet its clients/patients expectations on the higher possible level. In the light of the forthcoming changes of the entire health system in the country where every healthcare institution will have to compete in equal terms with other institutions the concept of keeping the client/patient satisfy is imperative. Utilizing established and effective processes like PDCA and PSI to monitor the patients satisfaction levels the unit’s authorities will be in position to early identify any possible weaknesses and proceed to the necessary changes so that to keep its clients/patients as satisfy as possible which in return will become “loyal customers”.

eory and research and in professional practice. We have a rich history of thought from Florence Nightingale to the recent nurse researchers, theorists and clinicians. Moreover, nursing professional practice includes integration of knowledge from the broad conceptualizations of models to the level of practice theory. The nursing theoretical frameworks serve in powerful ways as guides for articulating, reporting, recording nursing thought and action. Nurses must know what they are doing, why they are doing, what may be the range of outcomes of nursing, and indicators for measuring nursing impact (Parker, 2001). The aim of this paper is to study, compare and contrast two nursing models given by two nursing theorists who have made major contributions in the field of nursing practice. These models are; Roy adaptation model and Orem’s Self-care model.

Introduction to the theorists, Sister Callista Roy and Dorothea E. Orem

Sister Callista Roy received a bachelor’s degree in nursing in 1963 from Mount Saint Mary’s College as master’s degree in pediatric nursing in 1966, a master’s degree in sociology in 1975 and a doctorate degree in sociology in 1977, all from the University of California, Los Angeles. Roy first proposed her model while studying for her master’s degree, where she was challenged by Dorothy Johnson to develop conceptual models of nursing. Therefore, the development of the adaptation model for nursing has been influenced by Roy’s personal and professional background. She had her experience as a pediatric staff nurse where she mainly noticed the children and their ability to adapt in response to major physical and psychological changes.

Dorothea E. Orem was born in Baltimore, Maryland. She received her diploma in nursing from Providence Hospital School of Nursing in Washington, DC, baccalaureate in nursing from Catholic University in 1939 and master’s degree in 1945 from the same university. She decided to develop her theory after she and her colleagues were given an assignment to produce a nursing curricula for practical nursing for the department of Health, Education and Welfare in Washington, DC. Between 1971 and the 1995 editions, there have been some changes in Orem’s theory, notably in the concept of an individual and the idea of the nursing system. Orem delineates three theories; self-care, self-care deficit, and nursing system.

Focus of Roy’s and Orem’s Model

Roy’s model was initially developed for education; however, it continued to work in research and practice settings. Roy’s model focuses on the concept of adaptation of man. Her concepts of nursing, person, health and environment are all interrelated to this central concept. According to her model, the person receives inputs or stimuli from both the environment and the self. Adaptation occurs when the person responds positively to environmental changes. This adaptive response promotes the integrity of the person which leads to health. Ineffective responses to stimuli lead to disruption of the integrity of the person.

Self-care model was given by Dorothea Elizabeth Orem in 1970. The focus of the model is self-care, self-care agency, self-care demand, self-care deficit, nursing agency and nursing system. Self-care is a requirement of every person, man, woman and child. Self-care is viewed as function and the capability of an individual which means that the things an individual can do and able to do. When self-care is not maintained, illness, disease or death will occur. Self-care requisites result in the regulation of structural and functional integrity and human development. There are three categories of self-care requisites; universal, developmental and health deviation self-care requisites. According to Orem, there are various basic conditioning factors (age, gender, developmental state, health state and health care system, sociocultural orientation, and family system, patterns of living, environment and available resources) that can influence the categories of self-care requisites. The essence of Orem’s model is entirely the nurse-patient relationship.

Metaparadigm of both the Models

The Person:

Roy described the person in terms of system and adaptation, a biopsychosocial being in constant interaction with a changing environment. She defines person as a recipient of nursing care, as a living complex, adaptive system with internal processes (the cognator and regulator) acting to maintain adaptation in the four adaptive modes: physiological (biologic), self-concept (psychological), role function and interdependence (social). The cognator controls processes related to perception, learning, judgment, and emotion i.e. psychological adjustments. The regulator functions primarily through the use of the autonomic nervous system in making physiologic adjustments.

On the other hand, Orem expressed that the individual person is the primary focus in the model. People are basically rational beings who assess situations, reflect and understand them. Based on this person as agent or having agency that chooses to perform specific actions and goal directed. Moreover, in comparison to Roy’s model, she also indicated that empowering person helps to cope with the causes and effects which ultimately progress to the positive adaptation of an individual.

Nursing:

Roy’s goal of nursing is to help individual adapt to changes in his psychological needs, self-concept, role function and interdependent relations during health and illness. Nursing fills a unique role as a facilitator of adaptation by assessing behavior in each of these four adaptive modes and intervening by managing the influencing stimuli (George, 1995).

Similarly, Orem defines nursing as a human service and facilitates that nursing special concern is a person’s physiological needs for the provision and management of self-care action on a continuous basis in order to sustain life and health. However, the goal of nursing in both the theories is to overcome the patient’s limitation whether it is psychological or physiological needs.

Health:

According to Roy and Andrews (1999) health is a state and process of being and becoming an integrated and whole person. Likewise Orem (1985) sees health as an ideal when living things are structurally and functionally whole. Health can be viewed as a human adaptive system within a changing environment. Lack of integration represents lack of health. Adaptation is a process of promoting this integration i.e. maintaining physiological, psychological and social integrity. Similarly, according to Horsburgh (1999), Orem views health state as the basic conditioning factor also comprises on physiological, psychological and social imbalances most likely to influence adult self-care abilities and behaviors.

Environment:

According to Roy (1999), environment is all the conditions, circumstances that influences surrounding and affect the development and behavior of persons or groups. Environment is the input into the person as an adaptive system involving both internal and external factors. Any environmental change demands increasing energy to adapt to the situation. Factors in the environment that affect the person are categorized as focal, contextual and residual stimuli. Focal stimulus mostly confronts the person that precipitates the behavior. Contextual stimuli are all other stimuli present that contribute to the behavior caused or precipitated by the focal stimuli. Residual stimuli are factors that may be affecting behavior but whose affects are not validated.

Orem acknowledges self-care requisites to have their origins in human beings and the environmental factors, elements, conditions, etc. Environmental factors influences health care abilities of a person and are shaped within a person’s sociocultural context. Furthermore, she proposed the similar concept of Roy’s theory that man and environment interact as self-care system. If the system of man and environment gets change, the adaptation of self-care system will be affected.

Compare & Contrast of both the Models with Literature Support

Identification of the underlying assumptions is necessary to internal and external evaluation of the theory which deals with logic, consistency and congruence with the practical world (Barnum, 1998). The concept of person, health, nursing and environment are well defined however there are some similarities and differences among the two models. Firstly, Roy’s model focuses mainly on psychological aspects of a person. She discusses about the adaptation of a man and stresses on ways of adaptation and coping mechanisms whereas Orem’s model focuses greatly on physiological and sociological aspects of a person and lacks psychological aspects. She talks about individualism, autonomy, self-directed and self-reliance. Moustafa (1999) also noted that Orem’s theory is generally accorded to the physiological and sociological wellbeing of the person, undermining the importance of mental health. For e.g., a person who is a paranoid schizophrenic will not admit that he needs help regarding his self-care demands and without acceptance of the self-care deficit, it will be difficult to care for the person using Orem’s theory concepts.

Secondly, according to Roy (1999) environment is internal and external stimuli and the person receives inputs from the external and internal environments. In her earlier writing (1981) that environment is different from internal stimuli and now she viewed internal stimuli is a part of environment. However, the question arises if internal stimuli are a part of environment than how it is different from the person’s adaptation level? Moreover, Roy’s model of nursing management specify that the manipulation of the stimuli is different from the manipulation of people however the question still remains the same can internal stimuli be manipulated without manipulating the person? It seems that the relationships of adaptation to person, health and nursing are clear however the person-environment interaction is less clear. In contrast, Orem simply proposed that the change in person-environment system will ultimately change the entire self-care system. Both the models highlight similar factors but the objective of both the theorists differ as in case of Orem, it is self-care whereas Roy as adaptation. Nevertheless, both the models can be interrelated as for e.g., in order to perform self-care successfully, a person needs to adapt to the internal and external stimuli or the environment. The person needs to be stress free and comfortable both physically and psychologically. Both adaptation and self-care is a behavior of a person that are influenced by various factors such as culture, personality, socioeconomic status, education, age, gender and available resources etc.

Thirdly, both of these models primarily focus on individualism. None of them takes the viewpoint of family, society, or a community as a whole. However, with certain modification, the models are seen empirically tested on various age groups such as among student’s community, elderly, various disease specific groups etc. Roy sees person as a living complex, adaptive system acting to maintain adaptation in four adaptive models (physiological needs, self-concept, role function and interdependence) whereas according to Orem, person as rational beings who has mastery over their destiny. In other words, the individual as a person is independent to choose and select whatever they want. It is normal for the person who wants to attain optimum levels of self-care. However, this is not true at all the time; a person looking for a secondary gain from the illness may not give importance to his/her wellness. Regarding health, both of them believe that health is a state and a process for becoming an integrated and whole person. However, these models lack the spiritual and existentialist aspects of a person. These models describe nurse as a facilitator. The aim of the nurse in Roy’s model is to help man adapt to changes brought about during the health illness continuum whereas according to Orem’s model, nurse facilitates the self-care abilities of a person which is more towards the physiological needs of a person.

Lastly, Orem’s model is somehow culturally biased. In scientifically advance culture, people believe that sickness is because of natural reason. However, some cultures believe on traditional and folk premises. Therefore, these perceptions are still failing to recognize the variety of health related cultural belief and practices. Orem’s theory does not explain the traditional and folk health believes even she called a scientifically advanced culture (Orem, 1991). On the contrary, Roy’s model talks about the person’s relationship with the world and God on philosophical premises. Persons use human creative abilities of awareness, enlightenment and faith. In my judgment I feel that as an external stimuli or factor, cultural and religious believes can hinder in adaptation process.

Furthermore, both the theories are very complex and have broad concepts for the practical implication. Roy’s model is difficult to categorize the behaviors of the person in the four adaptive modes (George, 1995). In addition, there is an overlapping of concepts definitions. Similarly, Orem’s self-care model is used with numerous configurations; this multitude of terms such as self-care agency, self-care demand, self-care deficit, requisites can be very confusing to the reader. Abdul (2002) also noted that Orem’s work is easy to explain but difficult to differentiate among numerous terminologies and hypothesis. The holistic approach of these models helps prevent putting too much emphasis on aspects of illness and allows for the inclusion of health promotion. In addition, they are easy to apply as a family center model. Both have been found very useful in inpatient and outpatient settings as well as in work settings and in the community. However, it is difficult to apply Roy’s model in intensive care units where situations change rapidly (George, 1995). Moreover, the clinical research generating from these theories have health promotion application also. Nursing, when define in terms of focus ( for knowledge and practice), is a specialized health service necessitated by an adults inability to maintain the amount and quality of self-care i.e. therapeutic in sustaining life and health , even in recovering from disease or injury, or in coping with their effects through adaptation.

Application of models in clinical Practice & Conclusion

Roy’s ad Orem’s model have greatly influenced nursing profession. The integration of both the models is not only applicable in clinical practice but also in nursing education, administration and research. These models guide nurses to use observations and interviewing skills in doing an individualized assessment of each person. It is a useful guide in nursing assessment and formulating nursing diagnosis. Therefore, apparently both the models are valuable in nursing clinical practice. Alligood and Marriner-Tomey (2002) state that conceptual or theoretical models of nurse practice are significant to the field, providing the profession with a guide to patient care and with a general frame of reference that connects the structural environment to the patterns of behavior and relationships within the organization. Nurses have a unique role to promote health in majority of the setting by utilizing these theory in acute healthcare settings, community settings, rehabilitation nursing, palliative care, in learning disability nursing etc. The goal of both the theories is giving assistance adapted to specific human needs and limitations. I suggest that the concept development of different models and analysis will contribute to further identification of functional theories in nursing. Thus, we need to continue our efforts to develop diverse types of theories and consider the advancement of the nursing discipline.