Tuesday, July 21, 2009
Saturday, July 18, 2009
The nursing profession is continuously evolving and dynamic. Ever since Florence Nightingale started writing her notes on nursing, more theories and models about the nursing profession flourished during the last decade; one of these is Myra Levine’s Conservational Theory which was completed on 1973.
Myra Estrin Levine (1920-1996) was born in Chicago, Illinois. She was the oldest of three children. She had one sister and one brother. Levine developed an interest in nursing because her father (who had gastrointestinal problems) was frequently ill and required nursing care on many occasions. Levine graduated from the Cook County School of Nursing in 1944 and obtained her BS in nursing from the University of Chicago in 1949. Following graduation, Levine worked as a private duty nurse, as a civilian nurse for the US Army, as a surgical nursing supervisor, and in nursing administration. After earning an MS in nursing at Wayne State University in 1962, she taught nursing at many different institutions (George, 2002) such as the University of Illinois at Chicago and Tel Aviv University in Israel. She authored 77 published articles which included “An Introduction to Clinical Nursing” with multiple publication years on 1969, 1973 & 1989. She also received an honorary doctorate from Loyola University in 1992. She died on 1996.
Levine told others that she did not set out to develop a “nursing theory” but had wanted to find a way to teach the major concepts in medical-surgical nursing and attempt to teach associate degree students a new approach for daily nursing activities. Levine also wished to move away from nursing education practices that were strongly procedurally oriented and refocus on active problem solving and individualized patient care (George, 2002).
Levine’s Conservation Model is focused in promoting adaptation and maintaining wholeness using the principles of conservation. The model guides the nurse to focus on the influences and responses at the organismic level. The nurse accomplishes the goals of the model through the conservation of energy, structure, and personal and social integrity (Levine, 1967). Although conservation is fundamental to the outcomes expected when the model is used, Levine also discussed two other important concepts critical to the use of her model – adaptation and wholeness.
Adaptation is the process of change, and conservation is the outcome of adaptation. Adaptation is the process whereby the patient maintains integrity within the realities of the environment (Levine, 1966, 1989a). Adaptation is achieved through the “frugal, economic, contained, and controlled use of environmental resources by the individual in his or her best interest” (Levine, 1991, p. 5).
Wholeness is based on Erikson’s (1964, p. 63) description of wholeness as an open system: “Wholeness emphasizes a sound, organic, progressive mutuality between diversified functions and parts within an entirety, the boundaries of which are open and fluid.” Levine (1973, p. 11) stated that “the unceasing interaction of the individual organism with its environment does represent an ‘open and fluid’ system, and a condition of health, wholeness, exists when the interaction or constant adaptations to the environment, permit ease—the assurance of integrity…in all the dimensions of life.” This continuous dynamic, open interaction between the internal and external environment provides the basis for holistic thought, the view of the individual as whole.
Conservation, on the other hand, is the product of adaptation. Conservation is from the Latin word conservatio, meaning “to keep together” (Levine, 1973). “Conservation describes the way complex systems are able to continue to function even when severely challenged.” (Levine, 1990, p. 192). Through conservation, individuals are able to confront obstacles, adapt accordingly, and maintain their uniqueness. “The goal of conservation is health and the strength to confront disability” as “... the rules of conservation and integrity hold” in all situation in which nursing is requires” (Levine, 1973, pp. 193- 195). The primary focus of conservation is keeping together of the wholeness of the individual. Although nursing interventions may deal with one particualr conservation principle, nurses must also recognize the influence of other conservation principles (Levine, 1990).
Over the years, nurses (like Myra Levine) have developed various theories that provide different explanations of the nursing discipline. Like her Conservation Model, all theories share four central or major concepts: person, environment, nursing and health. In addition to this, Levine’s Model also discussed that person and environment merge or become congruent over time, as it will be discussed below.
I. The person is a holistic being who constantly strives to preserve wholeness and integrity and one “who is sentient, thinking, future-oriented, and past-aware.” The wholeness (integrity) of the individual demands that the “individual life has meaning only in the context of social life” (Levine, 1973, p. 17). The person is also described as a unique individual in unity and integrity, feeling, believing, thinking and whole system of system.
II. The environment completes the wholeness of the individual. The individual has both an internal and external environment.
The internal environment combines the physiological and pathophysiological aspects of the individual and is constantly challenged by the external environment. The internal environment also is the integration of bodily functions that resembles homeorrhesis rather than homeostasis and is subject to challenges of the external environment, which always are a form of energy.
Homeostasis is a state of energy sparing that also provides the necessary baselines for a multitude of synchronized physiological and psychological factors, while homeorrhesis is a stabilized flow rather than a static state. The internal environment emphasizes the fluidity of change within a space-time continuum. It describe the pattern of adaptation, which permit the individual’s body to sustain its well being with the vast changes which encroach upon it from the environment.
The external environment is divided into the perceptual, operational, and conceptual environments. The perceptual environment is that portion of the external environment which individuals respond to with their sense organs and includes light, sound, touch, temperature, chemical change that is smelled or tasted, and position sense and balance. The operational environment is that portion of the external environment which interacts with living tissue even though the individual does not possess sensory organs that can record the presence of these factors and includes all forms of radiation, microorganisms, and pollutants. In other words, these elements may physically affect individuals but are not perceived by the latter. The conceptual environment is that portion of the external environment that consists of language, ideas, symbols, and concepts and inventions and encompasses the exchange of language, the ability to think and experience emotion, value systems, religious beliefs, ethnic and cultural traditions, and individual psychological patterns that come from life experiences.
III. Health and disease are patterns of adaptive change. Health is implied to mean unity and integrity and “is a wholeness and successful adaptation”. The goal of nursing is to promote health. Levine (1991, p. 4) clarified what she meant by health as: “… the avenue of return to the daily activities compromised by ill health. It is not only the insult or the injury that is repaired but the person himself or herself… It is not merely the healing of an afflicted part. It is rather a return to self hood, where the encroachment of the disability can be set aside entirely, and the individual is free to pursue once more his or her own interests without constraint.” On the other hand, disease is “unregulated and undisciplined change and must be stopped or death will ensue”.
IV. Nursing involves engaging in “human interactions” (Levine, 1973, p.1). “The nurse enters into a partnership of human experience where sharing moments in time—some trivial, some dramatic—leaves its mark forever on each patient” (Levine, 1977, p. 845). The goal of nursing is to promote adaptation and maintain wholeness (health).
The goal of nursing is to promote wholeness, realizing that every individual requires a unique and separate cluster of activities. The individual’s integrity is his/her abiding concern and it is the nurse’s responsibility to assist the patient to defend and to seek its realization. The goal of nursing is accomplished through the use of the conservation principles: energy, structure, personal, and social integrity.
V. As it was mentioned above, Levine’s Conservation Model discussed that the way in which the person and the environment become congruent over time. It is the fit of the person with his or her predicament of time and space. The specific adaptive responses make conservation possible occur on many levels; molecular, physiologic, emotional, psychologic, and social. These responses are based on three factors (Levine, 1989): historicity, specificity and redundancy.
1. Historicity refers to the notion that adaptive responses are partially based on personal and genetic past history. Each individual is made up of a combination of personal and genetic history, and adaptive responses are the result of both.
2. Specificity refers the fact that each system that makes up a human being has unique stimulus-response pathways. Responses are stimulated by specific stressors and are task oriented. Responses that are stimulated in multiple pathways tend to be synchronized and occur in a cascade of complimentary (or detrimental in some cases) reactions.
3. Redundancy describes the notion that if one system or pathway, is unable to ensure adaptation, then another pathway may be able to take over and complete the job. This may be helpful when the response is corrective (e.g., the use of allergy shots over a lengthy period of time to diminish the effects of severe allergies by gradually desensitizing the immune system). However, redundancy may be detrimental, such as when previously failed responses are reestablished (e.g., when autoimmune conditions cause a person’s own immune system to attack previously healthy tissue in the body).
A change in behavior of an individual during an attempt to adapt to the environment is called an organismic response. It helps individual to protect and maintain their integrity. There are four types, namely (1) Flight or fight: An instantaneous response to real or imagined threat, most primitive response; (2) Inflammatory: response intended to provide for structural integrity and the promotion of healing; (3) Stress: Response developed over time and influenced by each stressful experience encountered by person; and (4) Perceptual: Involves gathering information from the environment and converting it in to a meaning experience.
The core, or central concept, of Levine’s theory is conservation (Levine, 1989). When a person is in a state of conservation, it means that individual adaptive responses conform change productively, and with the least expenditure of effort, while preserving optimal function and identity. Conservation is achieved through successful activation of adaptive pathways and behaviors that are appropriate for the wide range of responses required by functioning human beings.
Myra Levine described the Four Conservation Principles. These principles focus on conserving an individual's wholeness. She advocated that nursing is a human interaction and proposed four conservation principles of nursing which are concerned with the unity and integrity of individuals. Her framework includes: energy, structural integrity, personal integrity, and social integrity.
I. Conservation of energy: Refers to balancing energy input and output to avoid excessive fatigue. It includes adequate rest, nutrition and exercise.
Conservation of structural integrity: Refers to maintaining or restoring the structure of body preventing physical breakdown and promoting healing.
Examples: Assist patient in ROM exercise; Maintenance of patient’s personal hygiene
III. Conservation of personal integrity: Recognizes the individual as one who strives for recognition, respect, self awareness, selfhood and self determination.
Example: Recognize and protect patient’s space needs
IV. Conservation of social integrity: An individual is recognized as some one who resides with in a family, a community, a religious group, an ethnic group, a political system and a nation.
Example: Help the individual to preserve his or her place in a family, community, and society.
- The nurse creates an environment in which healing could occur
- A human being is more than the sum of the part
- Human being respond in a predictable way
- Human being are unique in their responses
- Human being know and appraise objects ,condition and situation
- Human being sense ,reflects, reason and understand
- Human being action are self determined even when emotional
- Human being are capable of prolonging reflection through such strategists raising questions
- Human being make decision through prioritizing course of action
- Human being must be aware and able to contemplate objects, condition and situation
- Human being are agents who act deliberately to attain goal
- Adaptive changes involve the whole individual
- A human being has unity in his response to the environment
- Every person possesses a unique adaptive ability based on one’s life experience which creates a unique message
- There is an order and continuity to life change is not random
- A human being respond organismically in an ever changing manner
- A theory of nursing must recognized the importance of detail of care for a single patient with in an empiric framework that successfully describe the requirement of the all patient
- A human being is a social animal
- A human being is an constant interaction with an ever changing society
- Change is inevitable in life
- Nursing needs existing and emerging demands of self care and dependant care
- Nursing is associated with condition of regulation of exercise or development of capabilities of providing care
Furthermore, the nurse has the responsibility for determining the patient ability to participate in the care, and if the perception of nurse and patient about the patient ability to participate in care don’t match, this mismatch will be an area of conflict.
There are a number of limitations when it comes to the four principles. On conservation of energy, Levine’s goal is to avoid fatigue or excessive use of energy. This is manageable in the bedside care of ill clients. In cases where energy needs to be utilized rather than conserved like in manic patients, ADHD in children or those with limited movements such as paralyzed clients, Levine’s theory does not apply. On conservation of structural integrity, the focus is to preserve the anatomical structure of the body as well as to prevent damage to the anatomical structure. This, again, has limitations. In cases where the anatomical structure is not so perfect but without identified disfigurement or problems as in plastic surgeries, procedures like breast enhancements and liposuctions; the person's structural integrity is compromised but it is the patient's choice seeking physical beauty and psychological satisfaction that is taken into consideration. Otherwise such, procedures should not be promoted. On conservation of personal integrity, the nurse is expected to provide knowledge and the patient need to be respected, provided with privacy, encouraged and psychologically s supported. The limitations here will center on clients who are psychologically impaired and incapacitated and cannot comprehend and absorb knowledge, i.e. comatose patients, suicidal individuals or clients. Lastly, conservation of social integrity’s aim is to preserve and recognition of human interaction, particularly with the clients, significant others who comprise his support system. The limitation specific for this, is when the client has no significant others like family members. Abandoned children, psychiatric patients who are unable to interact, unresponsive clients like unconscious individuals, the focus here is no longer the patient himself but the people involved in his/her health care.
- Principles of conservation have been used for data collection in various researches
- Conservational model was used by Hanson et al.in their study of incidence and prevalence of pressure ulcers in hospice patient
- Newport (n.d.) used principle of conservation of energy and social integrity for comparing the body temperature of infant’s who had been placed on mother’s chest immediately after birth with those who were placed in warmer
- Conservational model was used as guidelines for curriculum development
- It was used to develop nursing undergraduate program at Allentown college of St. Francis de Sales, Pennsylvania
- Used in nursing education program sponsored by Kapat Holim in Israel
- Nursing administration
- Taylor (n.d.) described an assessment guide for data collection of neurological patients which forms basis for development of comprehensive nursing care plan and thus evaluate nursing care
- McCall (n.d.) developed an assessment tool for data collection on the basis of four conservational principles to identify nursing care needs of epileptic patients
- Family assessment tool was designed by Lynn-Mchale and Smith (n.d.) for families of patient in critical care setting
- Conservational model has been used for nursing practice in different settings
- Bayley (n.d.) discussed the care of a severely burned teenagers on the basis of four conservational principles and discussed patient’s perceptual, operational and conceptual environment
- Pond (n.d.) used conservation model for guiding the nursing care of homeless at a clinic, shelters or streets
- Collection of provocative facts through observation and interview of challenges to the internal and external environment using four conservation principles
- Nurses observes patient for organismic responses to illness, reads medical reports. talks to patient and family
- Assesses factors which challenges the individual
- Nursing diagnosis-gives provocative facts meaning
- A nursing care judgment arrived at through the use of the scientific process
- Judgment is made about patient’s needs for assistance
- Nurse proposes hypothesis about the problems and the solutions which becomes the plan of care
- Goal is to maintain wholeness and promoting adaptation
- Testing the hypothesis
- Interventions are designed based on the conservation principles
- Mutually acceptable
- Goal is to maintain wholeness and promoting adaptation
- Observation of organismic response to interventions
- It is assesses whether hypothesis is supported or not supported
- If not supported, plan is revised, new hypothesis is proposed
To summarize, Levine expressed the view that within the nurse-patient relationship a patient’s state of health is dependent on the nurse-supported process of adaptation. This guides nurses to focus on the influences and responses of a client to promote wholeness through the Conservation Principles. The goal of this model is to accomplish this through the conservation of energy, structural, personal and social integrity. The goal of nursing is to recognize, assist, promote, and support adaptive processes that benefit the patient.
Current Nursing. (n.d.). Nursing theories: Levine’s four conservation principles. Retrieved from http://currentnursing.com/nursing_theory/Levin_four_conservation_principles.htm on July 2009.
Leach, M.J. (n.d.) Wound management: Using Levine’s Conservation Model to guide practice. Vol. 52, Issue No. 8. Retrieved from: http://www.o-wm.com/article/6024 on July 2009.
Sitzman, K. & Eichelberger, L.W. (2009). Understanding the work of nurse theorists: A creative beginning. Retrieved from http://nursing.jbpub.com/sitzman/artGallery.cfm on July 2009. Jones and Bartlett Publishers.
Yeager, S. (2002). Overview of nurse theorist: Myra Levine’s conservation model. Retrieved from: http://www4.desales.edu/~sey0/levine.html on July 2009.
Añonuevo, C. A., et al. (2005). Theoretical foundations of nursing. University of the Philippines Open University: Quezon City, Philippines.
George, J. B. (2001). Nursing theories: Base for professional nursing. (5th ed). Pearson Education.
Levine, M. E. (1973). Introduction to clinical nursing. F. A. Davis Company: Philadelphia, PA.
Parker, M. E. (2001). Nursing theories and nursing practice. F. A. Davis Company: Philadelphia, PA.
Schaefer, K. M., Pond, J. B., et al. (1991). Levine’s conservation model: A framework of nursing practice. F.A. Davis Company: Philadelphia, PA.
Tomey, A. M. & Alligood, M. R. (2006). Nursing theorists and their work. (6th ed.). Elsevier Health Sciences.
Nurses in Action
Florin, Mae Kristine
Francisco, Abigail Kristine
Gamat, Melanie Jel
Garcia, Jet Lorenz
Gaspar, Aldin D.
Gochuico, Alfred Joseph
Guirjen, Jhune Huyo
Jaro, Maria Elvira
Click here for a short quiz. Enjoy!
-Margaret Newman was born on October 10, 1933 in Memphis Tennessee.
In 1954 She earned her first Bachelors degree in Home Economics and English from Baylor University in Waco, Texas
-Margaret Newman felt a call to nursing for a number of years prior to her decision to enter the field.
-During that time she became the primary caregiver for her mother, who became ill with Lou Gehrig's Disease.
-Upon entering nursing at the University of Tennessee, Memphis, Dr. Newman knew almost immediately that nursing was right for her
• In 1962 she received her Bachelors degree in Nursing from the University of Tennessee, Memphis.
• In 1964 she received her Masters Degree of Medical-Surgical Nursing and Teaching at the University of California in San Francisco.
• In 1971 she completed her Doctorate of Nursing Science and Rehabilitation at New York University
Ø 1971 to 1976- She completed her graduate studies at New York University. She also worked and taught alongside nursing theorist Martha Rogers.
Ø Rehabilitation Nursing stemmed her interest in health, movement & time.
Ø 1977- Professor in charge of graduate study in nursing at Pennsylvania State.
Ø 1984- Nurse theorist at the University of Minnesota.
Ø 1996- Retired from teaching.
HEALTH AS AN EXPANDING CONSCIOUSNESS
Newman's Health as Expanding Consciousness was influenced by Martha Rogers. Newman (2003) writes:
Newman’s theory of pattern recognition provides the basis for the process of nurse-client interaction. Newman suggested that the task in intervention is a pattern recognition accomplished by the health professional becoming aware of the pattern of the other person by becoming in touch with their own pattern. Newman suggested that the professional should focus on the pattern of the other person , acting as the “reference beam in a hologram”.
Relationship to the Metaparadigm Concepts
Newman has designated “caring in the human health experience” as the focus of nursing discipline and has specified the focus as the metaparadigm of the discipline.
-to help clients get in touch with the meaning of their lives by the identification of their patterns of relating
-Intervention is a form of non intervention whereby the nurse’s presence assists clients to recognize their own patterns of interacting with the environment.
-facilitates pattern recognition in clients by forming relationships with them at critical points n their lives and connecting with them in an authentic way.
-The nurse-client relationship is characterized by “a rhythmic coming together and moving apart as clients encounter disruption of their organized predictable state.”
-Nurses are seen as partners in the process of expanding consciousness.
-Person as individuals are identified by their individual patterns of consciousness.
-Persons are further defined as “centers of consciousness” within an overall pattern of expanding consciousness”
-The definition of person has also been expanded to include family and community.
-Environment is not explicitly defined but is described as being the larger whole, which is beyond the consciousness of the individual.
-A fusion of disease and non-disease creates a synthesis that is regarded as health.
-Disease and non-disease are each reflections of the larger whole; therefore a new concept “pattern of the whole” is formed.
-Newman has stated that pattern recognition is the essence of the emerging health. Manifest health, encompassing disease and non-disease can be regarded as the explication of the underlying pattern of person-environment.
Essence of Margaret Newman's Theory:
• An individual person in each situation, no matter how disordered and hopeless, is part of the universal process of expanding consciousness.
• The expanding consciousness is a process wherein an individual becomes more of his real self, as he finds greater meaning in his life and the lives of those people around him.
• In his/her search for his/her real self, the individual's awareness expands to include the interests of those people around him and the rest of the world.
• Self-awareness may eventually lead to acceptance of one's self and one's circumstances and limitations.
• With self-awareness and self-acceptance, an in-depth understanding of one's condition may pave the way for a person to engage into activities leading to positive progression transcending
• The health of a human being is a unitary phenomenon, an evolving pattern of human-environment (Rogers, 1970).
• Life is a process of expanding consciousness. Consciousness is the informational capacity of the system and can be seen in the quality of interaction of the system with the environment (Bentov, 1978).
• The explicate order is a manifestation of the implicate order (Bohm, 1980).
1. Health encompasses conditions heretofore described as illness, or, in medical terms, pathology
2. These pathological conditions can be considered a manifestation of the total pattern of the individual
3. The pattern of the individual that eventually manifests itself as pathology is primary and exists prior to structural or functional changes
4. Removal of the pathology in itself will not change the pattern of the indivdual
5. If becoming ill is the only way an individual's pattern can manifest itself, then that is health for that person
6. Health is an expansion of consciousness.
Semantic clarity is evident in the definitions, descriptions, and dimensions of the concepts of the theory.
The deeper meaning of the theory of health as expending consciousness is complex. The theory as a whole must be understood, nut just the isolated concepts. If an individual wanted to use a positivist approach, Newman’s original propositions would serve as guides for hypothesis development. However, researchers who tried that approach have concluded that it is inadequate to study the theory. As Newman have advocated in the 1994 edition of her book, Health as Expanding Consciousness, the holistic approach of the hermeneutic dialectic method is consistent with the theory and requires a high level of understanding the theory in praxis research.
The concepts in Newman’s theory are broad in scope because they all relate to health. The theory has been applied in several different cultures and is applicable across the spectrum of nursing care situations. This renders her theory generalizable.
In the early stages of development, aspects of the theory were operationalized and tested within a traditional scientific method. However, quantitative methods are inadequate in capturing the dynamic, changing nature of this theory.
The focus of Newman’s theory of health as expanding consciousness provides an evolving guide for all health-related disciplines. In the quest for understanding the phenomenon of health, this unique view of health challenges nurses to make a difference in nursing practice by the application of this theory.
Margaret Newman UPOU N207_09_groupF
Case Study/ Application
Alice admits that she hardly knows or speaks to her neighbours despite having lived there for 8 years, and she still feels like a stranger and doesn’t want to “push myself in.” She says that she hates to bother people and “won’t hardly unless I just have to.” She says that sometimes she gets lonely for “her people” who are all deceased.
The visiting nurse, in working with Alice, recognized the current situation as a choice point, with potential for increased interaction with other and increased interaction with others and increased consciousness. The old ways no longer work for Alice and new ways relating are necessary. The nurse incorporates the elements of Newman’s method to assist Alice in pattern recognition for the purpose of discovering new potentials for action. As the nurse has Alice relate her story, through dialogue and interacting with Alice, she helps Alice recognize past patterns of relating and how present circumstances have changed those patterns. Alice talks about how she and her husband lived for 56 years in a rural mountain cabin with few neighbours except for two sisters and their sole daughter. They were very self-sufficient, grew large gardens, had their own livestock, and rarely went to town. All these family members are now deceased except the granddaughter, who insisted that Alice leave the cabin and move into town after the death of her husband. It is apparent that Alice’s past patterns have been those of independence and limiting social contact mainly to family members.
The nurse shares her perceptions with Alice and verifies the pattern identification. Alice states, “I just don’t know long I am going to manage by myself anymore.” The nurse helps her explore sources of help, besides the granddaughter, that will help Alice remain in her apartment as independently as possible. Alice relates that there is one man, a few doors away who has stopped several times to ask if she needed anything from the grocery store, but she hadn’t asked him because she hates to bother him and doesn’t want to be “beholden.”
After further discussion, she decides that she will ask him to pick up staples and medications for her and pay him back by baking some bread saying, “I just love to bake anyway and haven’t had anyone much to bake for.”
In subsequent weekly visits, Alice and the nurse explore the possibility of getting medications at a reduced price through the local nurse-managed clinic. Alice states that she might try getting to know some of her neighbours. The nurse helps Alice make arrangements to be picked up by the Senior Van for physician appointments. As Alice begins to build her own support system, she finds that she relies on the nurse less for help with maintain her independence and they resume their previous pattern of simply checking her BP and giving her injections weekly.
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Maria Helen Villacorte
Novelynne Joy Yap
And she couldn’t have said it any better. Let us get to know this extraordinary theorist by understanding her theory, appreciating how her life story influenced her scientific pursuit, and discerning how her theory can be applied in the ever-dynamic field of nursing.
Faye Glenn Abdellah was born on March 13, 1919, in New York City. Years later, on May 6, 1937, the German hydrogen-fueled airship Hindenburg exploded over Lakehurst, New Jersey, where 18-year-old Abdellah and her family then lived, and Abdellah and her brother ran to the scene to help. In an interview with a writer for Advance for Nurses, Abdellah recalled: "I could see people jumping from the zeppelin and I didn't know how to take care of them, so it was then that I vowed that I would learn nursing."
In 1942, Abdellah earned a nursing diploma and is magna cum laude from Fitkin Memorial Hospital's School of Nursing New Jersey (now Ann May School of Nursing).
She received her Bachelor of Science Degree in 1945, a Master of Arts degree in 1947 and Doctor of Education in Teacher’s College, Columbia University. In 1947 she also took Master of Arts Degree in Physiology. With her advanced education, Abdellah could have chosen to become a doctor. However, as she explained in her Advance for Nurses interview, "I never wanted to be an M.D. because I could do all I wanted to do in nursing, which is a caring profession.”
As an Educator and Researcher
Abdellah went on to become a nursing instructor and researcher and helped transform the focus of the profession from disease centered to patient centered. She expanded the role of nurses to include care of families and the elderly.
In 1957 Abdellah headed a research team in Manchester, Connecticut, that established the groundwork for what became known as progressive patient care. In this framework, critical care patients were treated in an intensive care unit, followed by a transition to immediate care, and then home care. Abdellah is credited with developing the first nationally tested coronary care unit as an outgrowth of her work in Manchester.
Abdellah's first teaching job was at Yale University School of Nursing. At that time she was required to teach a class called "120 Principles of Nursing Practice," using a standard nursing textbook published by the National League for Nursing that included guidelines that had no scientific basis. After a year Abdellah became so frustrated that she gathered her colleagues in the Yale courtyard and burned the textbooks. As she told Image: "Of the 120 principles I was required to teach, I really spent the rest of my life undoing that teaching, because it started me on the long road in pursuit of the scientific basis of our practice."
Established Nursing Standards
In another innovation within her field, Abdellah developed the Patient Assessment of Care Evaluation (PACE), a system of standards used to measure the relative quality of individual health-care facilities that was still used in the health care industry into the 21st century. She was also one of the first people in the health care industry to develop a classification system for patient care and patient-oriented records.
Military Nursing Service
Abdellah served for 40 years in the U.S. Public Health Service (PHS) Commissioned Corps, a branch of the military. In 1981 she was named deputy surgeon general, making her the first nurse and the first woman to hold the position and hold the position for eight years. As deputy surgeon general, it was Abdellah's responsibility to educate Americans about public-health issues, and she worked diligently in the areas of AIDS, hospice care, smoking, alcohol and drug addiction, the mentally handicapped, and violence.
She was also the former Chief Nurse Officer for the U.S. Public Health Service, Department of Health and Human Services, Washington D.C. She was one of the first to talk about gerontological nursing, to conduct research in that area, and to influence public policy regarding nursing homes. She was responsible for establishing nursing-home standards in the United States.
Abdellah has frequently stated that she believes nurses should be more involved in public-policy discussions. In her government position, Abdellah also continued her efforts to improve the health and safety of America's elderly.
What has influenced Faye Abdellah in the development her own model of nursing?
1937 – She wanted to be a nurse on the day she saw Hindenburg explode. In this time she was 18 years old on an outing with her family in New Jersey. The fire and injuries that resulted from this horrific event inspired in her wish to never again be helpless when people needed assistance.
1949 – She spent 40 years in Public Health Service where she first became involved in research, being assigned to perform studies to improve nursing practices.
1960 – She was influenced by the desire to promote client-centered comprehensive nursing care. Abdellah described nursing as a service to individuals, to families and therefore to, to society. Acknowledging the influence of Henderson, expanded Henderson's 14 needs into 21 problems that she believed would serve as a knowledge base for nursing. Throughout her career, she strongly supported the idea that nursing research would be the key factor in helping nursing to emerge as a true profession. The research done regarding these common needs and problems has served as a foundation for the development of what is now known as nursing diagnosis.
Now that we have learned her influences, let’s get to know her concepts on the nursing concepts of man, health, environment, and nursing:
Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largely physical needs, or covert, such as emotional, sociological and interpersonal needs- which are often missed and perceived incorrectly. The patient is described as the only justification for the existence of nursing. The individuals (and families) are the recipients of nursing, and health, or achieving of it, is the purpose of nursing services
Abdellah’s concept of health maybe defined as the dynamic pattern of functioning whereby there is a continued interaction with internal and external forces that results in the optimal use of necessary resources that serve to minimize vulnerabilities (George, 1990).
In Patient–Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness. Emphasis should be placed upon prevention and rehabilitation with wellness as a lifetime goal. Holistic approach must be taken by the nurse to help the client achieve state of health (George, 1990). However in order to effectively perform these services, the nurse must accurately identify the lacks or deficits regarding health that the client is experiencing. These lacks or deficits are the client’s health needs.
Although Abdellah does not give a definition of health, she speaks to “total health needs” and “a healthy state of mind and body” in her description of nursing as a comprehensive service.
The environment is implicitly defined by Abdellah as the home or community from which patient comes. Society is included in “planning for optimum health on local, state, national and international levels.” However, as Abdellah further delineated her ideas, the focus of nursing service is clearly the individual. Society is integrated when she discusses the implementation.
GOAL OF NURSING:
To Abdellah, nursing is a service to individuals, to families and therefore to society. The goal of nursing according to Abdellah is the fullest physical, emotional, intellectual, social and spiritual functioning of the client which pertains to holistic care.
She stated that nursing is based on an art and science that molds the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people, sick or well, cope with their health needs (George, 1990). These would mean a comprehensive nursing service, this would include:
1. Recognizing the nursing problems of the patient.
2. Deciding the appropriate actions to take in terms of relevant nursing principles.
3. Providing continuous care of the individual’s total health needs.
4. Providing continuous care to relieve pain and discomfort and provide immediate security for the individual.
5. Adjusting total nursing care plan to meet the patient’s individual needs.
6. Helping the individual to become more self directing in attaining or maintaining a healthy state of mind and body.
7. Instructing nursing personnel and family to help the individual do for himself that which he can with his limitations.
8. Helping the individual to adjust to his limitations and emotional problems.
9. Working with allied health professional in planning for optimum health on local, state, national and international needs.
10. Carrying out continuous evaluation and research to improve nursing techniques and to develop new techniques to meet all the health needs of the people.
Nursing care for Abdellah is doing something to or for the person or providing information to the person with the goals of meeting needs, increase or restoring self-help ability or alleviating impairment.
Her theory also stated that the nurse needs knowledge on basic science and specific nursing skills, as well as knowledge skills in the communication, psychology, sociology, growth and development and interpersonal relations. These 11 nursing skills that a nurse must possess includes the following:
1. Observation of health status
2. Skills of communication
3. Application of knowledge
4. Teaching of patients and families
5. Planning and organization of work
6. Use of resource materials
7. Use of personnel resources
9. Direction of work of others
10. Therapeutic use of the self
11. Nursing procedures
Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment. These deals with biological, psychological, and social areas of individuals.
KEY CONCEPTS AND MODEL
Faye Abdellah proposed a classificatory framework for identifying nursing problems, based on her idea that nursing is basically oriented to meeting an individual client’s total health needs. Her major effort was to differentiate nursing from medicine and disease orientation.
Abdellah’s patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory. Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings. Abdellah was clearly promoting the image of the nurse who was not only kind and caring, but also intelligent, competent, and technically well prepared to provide service to the patient.
ABDELLAH'S TYPOLOGY OF 21 NURSING PROBLEMS
1. To maintain good hygiene and physical comfort.
2. To promote optimal activity: exercise, rest, and sleep.
3. To promote safety through prevention of accident, injury, or other trauma and through the prevention of the spread of infection.
4. To maintain good body mechanics and prevent and correct deformity.
5. To facilitate the maintenance of a supply of oxygen to all body cells.
6. To facilitate the maintenance of nutrition of all body cells.
7. To facilitate the maintenance of elimination.
8. To facilitate the maintenance of fluid and electrolyte balance.
9. To recognize the physiological responses of the body to disease conditions—pathological, physiological, and compensatory.
10. To facilitate the maintenance of regulatory mechanisms and functions.
11. To facilitate the maintenance of sensory function.
12. To identify and accept positive and negative expressions, feelings, and reactions.
13. To identify and accept interrelatedness of emotions and organic illness.
14. To facilitate the maintenance of effective verbal and nonverbal communication.
15. To promote the development of productive interpersonal relationships.
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and/or maintain a therapeutic environment.
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs.
19. To accept the optimum possible goals in the light of limitations, physical, and emotional.
20. To use community resources as an aid in resolving problems arising from illness.
21. To understand the role of social problems as influencing factors in the cause of illness.
Abdellah's typology was divided into three areas:
1. Physical, sociological,and emotional needs of the patients;
2. Types of interpersonal relationship between the nurse and the patient;
3. Common elements of patient care.
Several assertions were repeatedly stated by Abdellah although they were not labeled as such. These assertions are:
1. The nursing problem and nursing treatment typologies are the principles of nursing practice and constitute the unique body of knowledge that is nursing.
2. Correct identification of the nursing problem influences the nurse's judgment in selecting steps in solving the patient's problem.
3. The core of nursing is patient/client problems that focus on the patient and his/her problems.
With this knowledge, how, then, can we apply Abdellah’s theory in our field of practice?
First and foremost, Abdellah’s main goal is the improvement of the nursing education. She believed that as the education of nurses improves, nursing practice improves as well.
The most important impact of Abdellah’s theory to the nursing practice is that it helped transform the focus of the profession from being “disease-centered” to “patient-centered.” The patient-centered approach was constructed to be useful to nursing practice as it helped bring structure and organization to what was often been a disorganized collection of nursing care experiences. She categorized nursing problems based on the individual’s needs and developed a typology of nursing treatment and nursing goals which served as a basis for determining and organizing nursing care.
Her twenty one nursing problems made nurses look at patients’ problems and come up with nursing plan of care in a thorough and organized way. Abdellah’s identification of health needs as overt and covert assists nurses in exploring unmasked conditions about the client and plan appropriate interventions to address them. Client centered care emphasizes the principle that every nursing goal should be geared towards treating the patient and not just the mere illness. It has been viewed that if all 21 problems are investigated, the patient would be likely to be thoroughly assessed and thus will aid the nurse organize appropriate nursing strategies. Currently, the 21 nursing problems have been updated to focus on the patient and nursing diagnosis. It has ultimately helped nurses develop their individual critical-thinking skills leading to increase in job satisfaction and more productive nurse-patient and nurse-family interaction.
The application of Abdellah’s theory in nursing practice is greatly attributed to its strong influence to a patient-centered nurse-focused problem-solving approach. Abdellah’s problem-solving process of identifying the problem, selecting pertinent data, formulating hypotheses through collection of data, and revising hypotheses on the basis of conclusions obtained from the data parallels the steps of the nursing process of assessment, diagnosis, planning, implementation and evaluation (Abdellah and Levine, 1986; George, 1995). Because of the strong nurse-centered orientation in the 21 nursing problems, their use in the nursing process is primarily to direct the nurse; indirectly, the client benefits (George, 1995). If the nurse assists the client in meeting the goals states in the nursing problems, then the client will be moved toward good, optimum health.
In the end, Abdellah’s theory helps the practicing nurse organize the administration of care, nursing strategies and provides a scientific base for making decisions. As a theorist who was actively involved on nursing and health care internationally, Abdellah gave credence to the use of the model and is an advocate of applying new knowledge to improve practice.
Abdellah’s theories and concepts were developed in the 1950’s to present a comprehensive clinical record for nursing students, thus, providing structure to the nursing curriculum. The patient-centered approach that was based from her concepts supported and facilitated the move from the medical model that was used at the time to a nursing model. The major focus of her book, Patient-Centered Approaches (Abdellah, et al., 1960), was on the implementation of the model in baccalaureate, associate degree and diploma nursing programs. Abdellah’s extraordinary researches, publications and other works and her worldwide reputation have been instrumental in disseminating the patient-centered approach to educational programs around the world.
Abdellah’s typology of twenty one nursing problems was an awakening call for revisions and amendments of the nursing educational system in her era. Professors and educators realized the importance of client centered care rather than focusing on medical interventions. Nursing education then slowly deviated its concentration from the complex, medical concepts, into exercising better attention to the client as the primary concern.
One of Abdellah’s theory’s major limitation—it’s very strong nurse-centered orientation—is, on the other hand, it’s major contribution to nursing education. With this orientation, the theory can be used to organize teaching contents for nursing students, to evaluate a student’s performance in a clinical area, or both (George, 1995).
Research played a great part in the selection of the 21 problem classifications. Her researches were actually the major strengths of her works. In fact, her framework continues to stimulate research about the role and responsibilities of the nurse. The broad nature of the concepts in her framework offers opportunities to identify directional relationships in nursing interventions. Her theories continue to guide researchers to focus on the body of nursing knowledge itself, the identification of patient problems, the organization of nursing interventions, the improvement of nursing education, and the structure of the curriculum.
Abdellah strongly believed the idea that nursing research would be the key factor in helping nursing emerge as a true profession. The extensive research done regarding the patient’s needs and problems has served as a foundation for the development of what is now known as nursing diagnoses.
Her Typology gave birth to more nursing research and studies. The concepts are very precise and straight forward, making it simple and applicable, thus, stimulating similar disciplines and researches. Her typology was also utilized by some clinical institutions in establishing their staffing outline, namely, the intensive care, intermediate care, long term care, self care and home care units. These were identified according to how Abdellah ideates patient’s needs in her concept of care. Now patients in varied medical institutions are categorized with similar client needs, than by their medical diagnosis and diseases. Also it helped nurses provide better patient care and improve critical thinking skills.
Let us see how nurses in various settings can use Abdellah’s Typology of Needs Theory in their own work settings.
From an ICU nurse:
Ruff Joseph Cajanding, RN
As an ICU nurse, Abdellah's model of nursing care equips me with specific guidelines as to how I can better manage various patient conditions with adeptness and grace. The spectrum of cases I have and will handle in the ICU is diverse and multidimensional, ranging from the extremely common myocardial infarction, up until the most devastating Stevens-Johnson Syndrome, or porphyria, and their management could not get any more complicated. However, in planning for their care, I could utilize the principles underlying Abdellah's Typology inasmuch as it is synonymous to Maslow's hierarchy of needs. I will be guided by the fact that the basic needs should be met first (oxygenation, hydration, nutrition, etc.) before proceeding to higher level needs. Moreover, I will utilize the principle of treating patients in holistic manner, minding their psychosocio-spiritual needs inasmuch as I cater to their physical needs. Ultimately, Abdellah's typology provides nurses a framework as to how we can better organize our work in order to deliver quality nursing care to our clientele—the individual, the family, and the community in general.
From an OR nurse:
Francis Lloyd Borcelas, RN
“As an OR suite nurse, my responsibilities are not only confined on being a scrub, circulating, or anesthetist nurse in the PACU. Managing the OR is a big responsibility, and we do function similarly to the bedside nurses in the ward. Once the patient is scheduled for a procedure, an hour should be rendered for pre-operative preparation including giving of pre-operative medications, performing physical as well as emotional, psychological and spiritual assessment, and reviewing the patient’s history and laboratory results, referrals and co-management needed. In this manner, we learn more about the patient through our review of relevant data and consequently uncover nursing problems presented by the patient. Through this, we will be able to identify the therapeutic plan of care that needs to be delivered pre-operative, intra-operative and post-operatively. The applicability of Abdellah’s nursing theory is of valuable to patient care and management, and this allows nurses to manage patients in a holistic manner.
From a medical-surgical nurse:
Mae Claire N. Cabatania, RN
I would like to cite a case of my client (a stroke patient) in the medical-surgical ward. He is 45 year old male patient diagnosed with CVA and was a trans-out from ICU. He is receiving oxygen therapy via nasal cannula and hooked to NGT for feeding, and there are times when the client would be restless. Upon receiving the client during endorsement I have identified the possible nursing problems of my client. First thing on the line is the performance of self care needs and safety. Self care needs such as personal hygiene is very important for client to maintain their integrity and enhance their recovery. Another nursing problem identified is the risk for injury. At times the patient is restless, raising of side rails is very important to prevent falls and injuries. Stroke patients are at risk for falls due to altered level of consciousness. To maintain my client’s nutrition to support his recovery, he is fed via nasogastric tube as prescribed by physician. Also, my patient is at risk for aspiration that is why before feeding it is a must to check for the placement of nasogastric tube to avoid aspiration during feeding.
From a medical-surgical nurse ward:
Patricia Cornejo, RN
In this setting where clients receive direct nursing care, nurses provide a variety of measures to maintain good hygiene and physical comfort. For clients who are totally dependent and require total hygiene care such as clients with alteration in level of sensorium, a complete bed bath is rendered. While bathing the client, exposing only the areas being bathed, closing the door or pulling room curtains around the bathing area promote physical comfort. Clients in a hospital setting have their normal rest and sleep routine disrupted, which generally leads to sleep problems. The nurse can control the hospital environment in several ways. As an example, the nurse can close the curtains between clients in semiprivate rooms. Lights on the nurse’s station and client’s room can be dimmed at night. To reduce noise, nurses can conduct conversations and reports in a private area away from the client’s rooms and keep necessary conversations to a minimum, especially at night. Keeping bed clean and dry and in a comfortable position may help clients relax. Some clients suffer painful illnesses requiring special comfort measures such as application of dry or moist heat, use of supportive dressings or sprints, and proper positioning before retiring. In the rehabilitation unit, the nurse, in collaboration with other health care professionals such as physical therapists, promotes activity and exercise by teaching the use of canes, walkers, or crutches, depending on the assistive device most appropriate for the client’s condition. Nursing interventions to facilitate supply of oxygen to all body cells include positioning and coughing techniques. Initially placing a dyspneic client in high-fowlers position can relieve dyspnea whereas deep breathing and coughing techniques for postoperative client prevent further complications such as pneumonia. To create and/or maintain a therapeutic environment, a nurse can allow relatives to remain at client’s bedside during hospitalization. To facilitate the maintenance of sensory function in the older adult clients, it helps to reduce any background noise by turning off or lowering the volume of any TV, appliance, or radio during a conversation. Since bedridden clients are at risk for sensory deprivation, a nurse routinely stimulates them through range-of-motion exercises, positioning, and self-care activities (as appropriate). To prevent the spread of infection, nurses can teach aseptic practices. Medical asepsis, which includes hand hygiene and environmental cleanliness, reduces the transfer of microorganisms. Proper disposal of body secretions such as sputum should be taught as well. Safety bars on toilets, locks on beds and wheelchairs, and call lights are examples of safety features found in the hospital to prevent accident, injury, or other trauma.
To further examine how Abdellah’s Typology of 21 Nursing Problems can individually be applied in a specific nursing area, the following scenario is presented:
In my experience as a staff nurse in the endoscopy unit, Faye Abdellah's 21 nursing problems were applied in the following ways:
Katherine D, RN
1. To maintain good hygiene and physical comfort – After colonoscopy, patients are usually soiled from the procedure. It is therefore important to clean them properly and change their diapers if applicable. Physical comfort through proper positioning in bed, adjusting the air-conditioning unit, as well as proper lighting are also provided to the patient, especially if they were sedated and have to stay in the unit.
2. To promote optimal activity: exercise, rest, and sleep – Patients who were sedated during the procedure stay in the unit until the effect of the sedation has decreased to a safe level. During this time, patients are allowed to stay in the room and rest. As a nurse, I make sure the patients are able to rest and sleep well by providing a conducive environment for rest, such as decreasing environmental noise and dimming the light if necessary.
3. To promote safety through prevention of accident, injury, or other trauma and through the prevention of the spread of infection – Making sure the siderails are always up when leaving the patient keeps them from fall accidents. In our unit, one way we prevent the spread of infection is through proper disinfection of the equipments we use. We use products such as Cidezime to disinfect the instruments.
4. To maintain good body mechanics and prevent and correct deformity – Positioning the patient properly, allowing for the normal anatomical position of body parts.
5. To facilitate the maintenance of a supply of oxygen to all body cells – when patients manifest breathing problems, oxygen is attached to them, usually via nasal cannula. Sedated patients are attached to cardiac monitor and pulse oximeter while having the oxygen delivered. When the oxygen saturation falls below the normal levels, the rate of oxygen is increased accordingly, as per physician's order.
6. To facilitate the maintenance of nutrition of all body cells – patients undergoing endoscopic procedures are on NPO. For this reason it is important to monitor the blood glucose level through HGT. When the patient's blood glucose falls from the normal value, we inject D50W to the patient or we change the patient's IVF to a dextrose containing fluid.
7. To facilitate the maintenance of elimination – Providing bedpans or urinals to patients and at times, insertion of foley catheter when the patient is not able to void
8. To facilitate the maintenance of fluid and electrolyte balance – Proper regulation of the intravenous solutions as well as proper incorporations it may have. An example is when patients have low serum potassium, KCl is incorporated in the solution
9. To recognize the physiological responses of the body to disease conditions—pathological, physiological, and compensatory – it is important to check the patients for signs of internal gastrointestinal bleeding by monitoring the blood pressure and cardiac rate.
10. To facilitate the maintenance of regulatory mechanisms and functions – When a patient has a difficulty in breathing and is showing an increase respiratory rate, elevating the head part of the bed is done to facilitate the respiratory function.
11. To facilitate the maintenance of sensory function – Sometimes there are semi-conscious patients, in these cases, it is still necessary to talk to them while performing nursing interventions to maintain their auditory sense
12. To identify and accept positive and negative expressions, feelings, and reactions – most patients feel anxious before undergoing the procedures. It is necessary to listen to the patients' expressions and allow them to ask questions. To decrease their anxiety, proper instructions are given, what they are to expect, how long the procedure will take, what they should do during and after the procedure as well as other concerns.
13. To identify and accept interrelatedness of emotions and organic illness – Encourage patients to verbalize their feelings and allow them to cry when they have the need to do so will help them emotionally. Some patients are diagnosed with malignancy after the procedure and during this time the emotional needs of the patient is a priority.
14. To facilitate the maintenance of effective verbal and nonverbal communication – when patients are not able to express themselves verbally, it is important to assess for nonverbal cues. For instance when patients are in pain, assessing for facial grimacing. Touch and eye contact are also done for a good patient care.
15. To promote the development of productive interpersonal relationships – allow the patient's significant others to stay with the patient before and after the procedure. This allows for bonding and promotes interpersonal relationship.
16. To facilitate progress toward achievement of personal spiritual goals – our supervisor is a nun and she usually visits the patients in the unit. Catholic patients may benefit from this, allowing them time to practice their faith
17. To create and/or maintain a therapeutic environment - providing proper lighting, proper room temperature, a quiet environment are done to patients staying in the unit.
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs – care to patients vary according to their developmental needs. Allowing the parents to stay during the procedure help the pediatric patients in their emotional and developmental needs.
19. To accept the optimum possible goals in the light of limitations, physical, and emotional – The goals for each patient vary depending on the capability of the patient. The nutritional goal for a patient with a PEG tube for instance will be different, knowing that the patient has limited feeding options.
20. To use community resources as an aid in resolving problems arising from illness – Some patients live far from the city and thus referral to health centers is sometimes done
21. To understand the role of social problems as influencing factors in the cause of illness – Some patients who are diagnosed with amoebic colitis for instance are advised to avoid buying street foods to which the preparation they are not sure of, and also avoid drinking water that are not safe.
In conclusion, using Abdellah’s concepts of health, nursing problems, and problem solving, the theoretical statement of nursing that can be derived is the use of the problem-solving approach with key nursing problems related to the health needs of people. From this framework, 21 nursing problems, which are comparable to Henderson’s 14 components of nursing and Maslow’s hierarchy of needs, are developed. Her theory and framework provides a basis for determining and organizing nursing care. It is anticipated that by solving the nursing problems through appropriate and organized nursing strategies, the client will be moved towards ultimate health.
Isn’t health everything that we all aspire for?
Abdellah, F. G. & Levine, E. (1965). Better patient care through nursing research. New York: Macmillan.
George, J. (2002). Nursing Theories: The Base for Professional Nursing Practice. Upper Saddle River, NJ: Prentice-Hall, Inc.
George, J. (1995). Nursing theories: The base for professional nursing practice, 4th ed. USA: Prentice-Hall Intl.
George, J.B. (1990). Nursing theories: The base for professional nursing practice 3rd edition. Norwalk, CN: Appleton and Lange.
_____________. (1998). Image. USA: ____________.
Johnson, B. & Webber, P. (2005). An Introduction to Theory and Reasoning in Nursing 2nd Ed. Philadelphia, PA: Lippincott Williams and Wilkins.
Octaviano, O. & Balita, C. (2000). Theoretical Foundations of Nursing: The Philippine Perspective. Philippines: ___________.
_____________. (2000). Advance for Nurses. USA: ___________.
Parascandola, J (1994). "Women in the Public Health Service". Leadership in Public Health. Chicago: Illinois Public Health Leadership Institute.
Submitted by Group B: UPOU N207 batch 2009 group B.