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CHAPTER II THEORETICAL FRAMEWORK Review of Related Literature Tell me, I might forget; Teach me and I might remember; Involve

me and I learn! -Benjamin Franklin Nursing as a profession is the integration of the theoretical basis of its distinguished body of knowledge in the actual delivery of care to patients. In nursing education, learning takes place in various settings, in the classroom or in the affiliated hospitals of the institution. In addition, as identified by Dr Benjamin S. Bloom (1956), there are three learning domains, namely the cognitive, affective, and the psychomotor domain which are essential in the acquisition and application of new bodies of knowledge. Therefore, lectures, demonstrations, and various skills cultivation is important in the pursuit of the professional nursing practice. NURSING Nursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from birth to the end of life. The authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. In almost all countries, nursing practice is defined and governed by law, and entrance to the profession is regulated at national or state level. The aim of the nursing community worldwide is for its professionals to ensure quality care for all, while maintaining their credentials, code of ethics, standards, and competencies, and continuing their education. NURSING EDUCATION Nursing education consists of the theoretical and practical training provided to nurses with the purpose to prepare them for their duties as nursing care professionals. This education is provided to nursing students by experienced nurses and other medical professionals who have qualified or experienced for educational tasks. Courses leading to autonomous registration as a nurse typically last for four years. There are a number of educational paths to becoming a professional nurse, which vary greatly worldwide, but all involve extensive study of nursing theory and practice and training in clinical skills.

NURSING THEORIES

Nursing theory is the term given to the body of knowledge that is used to support nursing practice. In their professional education nurses will study a range of interconnected subjects which can be applied to the practice setting. This knowledge may be derived from experiential learning, from formal sources such as nursing research or from non-nursing sources. Nursing models are conceptual models, constructed of theories and concepts. They are used to help nurses assess, plan, and implement patient care by providing a framework within which to work. They also help nurses achieve uniformity and seamless care. Unlike most sciences, Nursing theories seem primarily concerned with what "Nursing" is or should do, rather than a phenomenon of "Nursing". All nursing models involve some method of assessing a patient's individual needs and implementing appropriate patient care. An essential portion of each nursing model is measurable goals in order that the process can be evaluated in order to provide better, is used to determine a patient's treatment by nurses, doctors and other healthcare professionals and auxiliary workers. These documents are considered to be living documents they are changed and evaluated on a daily basis as the patients condition and abilities change. A good theory must have the following characteristics: 1. Theories can interrelate concepts in such a way as to create a different perspective in looking at a particular phenomenon. 2. Theories must be logical in nature. 3. Theories can be simple yet generalized. 4. Theories can be bases for hypotheses that can be tested or for theory to be regenerated; and 5. Theories can contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them. 6. theories can be used by practitioners to guide and improve their practice 7. Theories must be consistent with other validated theories, laws and principles but will serve open unanswered questions that need to be investigated. Common Concepts in Nursing Theories. Four concepts common in nursing theory that influence & determine nursing practice are: 1. The person (patient). 2. The environment 3. Health 4. Nursing (goals, roles, functions) Each of these concepts is usually defined & described by a nursing theorist, often uniquely; although these concepts are common to all nursing theories. Of the four concepts, the most important is that of the person. The focus of nursing, regardless of definition or theory, is the person. Purposes of nursing theories In Practice: 1. Assist nurses to describe, explain, and predict everyday experiences.

2. Serve to guide assessment, interventions, and evaluation of nursing care. 3. Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. 4. Help to describe criteria to measure the quality of nursing care. 5. Help build a common nursing terminology to use in communicating with other health professionals. 6. Ideas are developed and words are defined. 7. Enhance autonomy (independence and self-governance) of nursing through defining its own independent functions. In Education: 1. Provide a general focus for curriculum design 2. Guide curricular decision making. In Research: 1. Offer a framework for generating knowledge and new ideas. 2. Assist in discovering knowledge gaps in the specific field of study. 3. Offer a systematic approach to identify questions for study; select variables, interpret findings, and validate nursing interventions. Nightingales Environmental Theory. Florence Nightingale (1820-1910), considered the founder of educated and scientific nursing and widely known as "The Lady with the Lamp", wrote the first nursing notes that became the basis of nursing practice and research. The notes, entitled Notes on Nursing: What it is, What is not (1860), listed some of her theories that have served as foundations of nursing practice in various settings, including the succeeding conceptual frameworks and theories in the field of nursing. Nightingale is considered the first nursing theorist. Her theory was the Environmental Theory, which incorporated the restoration of the usual health status of the nurse's clients into the delivery of health careit is still practiced today. She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969), that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development. Defined in her environmental theory are the following factors present in the patient's environment: 1. Pure or fresh air 2. Pure water 3. Sufficient food supplies 4. Efficient drainage 5. Cleanliness 6. Light (especially direct sunlight)

Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. Hendersons Need Theory (14 Fundamental Needs). Virginia Avenel Henderson (November 30, 1897 March 19, 1996) was an American nurse, researcher, theorist and author. She was born in Kansas City, Missouri, the fifth of eight children of Lucy Abbot Henderson and Daniel B. Henderson. She graduated from the Army School of Nursing, Washington, D.C. in 1921. She graduated from Teachers College, Columbia University with a M.A. degree in nursing education. Henderson is famous for a definition of nursing: "The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge" Henderson's focus on individual care is evident in that she stressed assisting individuals with essential activities to maintain health, to recover, or to achieve peaceful death. She proposed 14 components of basic nursing care to augment her definition: 1. Breathe normally. 2. Eat and drink adequately. 3. Eliminate body wastes. 4. 5. 6. 7. Move and maintain desirable postures. Sleep and rest. Select suitable clothes-dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying environment 8. Keep the body clean and well groomed and protect the integument 9. Avoid dangers in the environment and avoid injuring others. 10. Communicate with others in expressing emotions, needs, fears, or opinions. 11. Worship according to ones faith. 12. Work in such a way that there is a sense of accomplishment. 13. Play or participate in various forms of recreation. 14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities. The first 9 components are physiological. The tenth and fourteenth are psychological aspects of communicating and learning. The eleventh component is spiritual and moral. The twelfth and thirteenth components are sociologically oriented to occupation and recreation The major assumption of the theory is that:

1. Nurses care for patients until patient can care for themselves once again. 2. Patients desire to return to health, but this assumption is not explicitly stated. 3. Nurses are willing to serve and that nurses will devote themselves to the patient day and night 4. A final assumption is that nurses should be educated at the university level in both arts and sciences. Hendersons Theory and the Four Metaparadigms Individual 1. Have basic needs that are component of health. 2. Requiring assistance to achieve health and independence or a peaceful death. 3. Mind and body are inseparable and interrelated. 4. Considers the biological, psychological, sociological, and spiritual components. 5. The theory presents the patient as a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer. Environment 1. Settings in which an individual learns unique pattern for living. 2. All external conditions and influences that affect life and development. 3. Individuals in relation to families 4. Minimally discusses the impact of the community on the individual and family. 5. Supports tasks of private and public agencies 6. Society wants and expects nurses to act for individuals who are unable to function independently. 7. In return she expects society to contribute to nursing education. 8. Basic nursing care involves providing conditions under which the patient can perform the 14 activities unaided Health 1. Definition based on individuals ability to function independently as outlined in the 14 components. 2. Nurses need to stress promotion of health and prevention and cure of disease. 3. Good health is a challenge. 4. Affected by age, cultural background, physical, and intellectual capacities, and emotional balance 5. Is the individuals ability to meet these needs independently? Nursing 1. Temporarily assisting an individual who lacks the necessary strength, will and knowledge to satisfy 1 or more of 14 basic needs. 2. Assists and supports the individual in life activities and the attainment of independence.

3. Nurse serves to make patient complete whole", or "independent." 4. The nurse is expected to carry out physicians therapeutic plan 5. Individualized care is the result of the nurses creativity in planning for care. 6. Use nursing research 7. Categorized i. Nursing : nursing care ii. Non nursing: ordering supplies, cleanliness and serving food. 8. In the Nature of Nursing that the nurse is and should be legally, an independent practitioner and able to make independent judgments as long as s/he is not diagnosing, prescribing treatment for disease, or making a prognosis, for these are the physicians function. 9. Nurse should have knowledge to practice individualized and human care and should be a scientific problem solver. 10. In the Nature of Nursing i. Nurses Role is, to get inside the patients skin and supplement his strength will or knowledge according to his needs. ii. And nurse has responsibility to assess the needs of the individual patient, help individual meet their health need, and or provide an environment in which the individual can perform activity unaided. Abdellahs Typology of 21 Nursing Problems. Faye Glenn Abdellah (born March 13, 1919) is a pioneer in nursing research that has been recognized with 77 professional and academic honors. She was the first nurse officer to receive the rank of a two-star rear admiral. Her more than 150 publications, including her seminal works, Better Nursing Care through Nursing Research and Patient-Centered Approaches to Nursing, changed the focus of nursing theory from a diseasecentered to a patient-centered approach and moved nursing practice beyond the patient to include care of families and the elderly. Abdellahs patient-centred approach to nursing was developed inductively from her practice and is considered a human needs theory. The theory was created to assist with nursing education and is most applicable to the education of nurses. Although it was intended to guide care of those in the hospital, it also has relevance for nursing care in community settings. Major Assumptions, Concepts & Relationships. The language of Abdellahs framework is readable and clear. Consistent with the decade in which she was writing, she uses the term she for nurses, he for doctors and patients, and refers to the object of nursing as patient rather than client or consumer. She referred to Nursing diagnosis during a time when nurses were taught that diagnosis was not a nurses prerogative. Assumptions were related to: 1. change and anticipated changes that affect nursing; 2. The need to appreciate the interconnectedness of social enterprises and social problems;

3. the impact of problems such as poverty, racism, pollution, education, and so forth on health care delivery; 4. changing nursing education 5. continuing education for professional nurses 6. development of nursing leaders from under reserved groups Abdellah and colleagues developed a list of 21 nursing problems. They also identified 10 steps to identify the clients problems and 11 nursing skills to be used in developing a treatment typology. 10 Steps To Identify the Clients Problems 1. Learn to know the patient 2. Sort out relevant and significant data 3. Make generalizations about available data in relation to similar nursing problems presented by other patients 4. Identify the therapeutic plan 5. Test generalizations with the patient and make additional generalizations 6. Validate the patients conclusions about his nursing problems 7. Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting his behavior 8. Explore the patients and familys reaction to the therapeutic plan and involve them in the plan 9. Identify how the nurses feels about the patients nursing problems 10. Discuss and develop a comprehensive nursing care plan 11 Nursing Skills 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 8. Problem-solving 9. Direction of work of others 10. Therapeutic use of the self 11. Nursing procedures The Twenty One Nursing Problems. There are three major categories. Physical, sociological, and emotional needs of clients; Types of interpersonal relationships between the nurse and patient; and common elements of client care. BASIC TO ALL PATIENTS 1. To maintain good hygiene and physical comfort 2. To promote optimal activity: exercise, rest and sleep 3. To promote safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 4. To maintain good body mechanics and prevent and correct deformities

SUSTENAL CARE NEEDS 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 10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory function REMEDIAL CARE NEEDS 12. To identify and accept positive and negative expressions, feelings, and reactions 13. To identify and accept the interrelatedness of emotions and organic illness 14. To facilitate the maintenance of effective verbal and non verbal 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 RESTORATIVE CARE 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 case of illness Abdellah's 21 problems are actually a model describing the "arenas" or concerns of nursing, rather than a theory describing relationships among phenomena. In this way, the theory distinguished the practice of nursing, with a focus on the 21 nursing problems, from the practice of medicine, with a focus on disease and cure. Abdellahs Theory and the Four Metaparadigm Nursing 1. Nursing is a helping profession. In Abdellahs model, nursing care is doing something to or for the person or providing information to the person with the goals of meeting needs, increasing or restoring self-help ability, or alleviating impairment. 2. Nursing is broadly grouped into the 21 problem areas to guide care and promote use of nursing judgment. 3. She considers nursing to be comprehensive service that is based on art and science and aims to help people, sick or well, cope with their health needs.

Person 1. Abdellah describes people as having physical, emotional, and sociological needs. These needs may overt, consisting of largely physical needs, or covert, such as emotional and social needs. 2. Patient is described as the only justification for the existence of nursing. 3. Individuals (and families) are the recipients of nursing 4. Health, or achieving of it, is the purpose of nursing services. Health 1. In Patient Centered Approaches to Nursing, Abdellah describes health as a state mutually exclusive of illness. 2. 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. Society/Environment 1. Society is included in planning for optimum health on local, state, national, and international levels. However, as she further delineated her ideas, the focus of nursing service is clearly the individual. 2. The environment is the home or community from which patient comes. Watsons Theory of Human Caring / Transpersonal Theory. Jean Watson was born in a small, close-knit town in the Appalachian Mountains of West Virginia in the 1940s. Watson graduated from the Lewis Gale School of Nursing in Roanoke, Virginia, in 1961. She continued her nursing studies at the University of Colorado at Boulder, earning a B.S. in 1964, an M.S. in psychiatric and mental health nursing in 1966, and a Ph.D. in educational psychology and counseling in 1973. Watson proposes even assumptions about the science of caring. The basic assumptions are: 1. Caring can be effectively demonstrated and practiced only interpersonally. 2. Caring consists of carative factors that result in the satisfaction of certain human needs. 3. Effective caring promotes health and individual or family growth. 4. Caring responses accept person not only as he or she is now but as what he or she may become. 5. A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time. 6. Caring is more healthogenic than is curing. A science of caring is complementary to the science of curing. 7. The practice of caring is central to nursing. The Ten Primary Carative Factors. The structure for the science of caring is built upon ten carative factors. These are: 1. The formation of a humanistic-altruistic system of values. 2. The installation of faith-hope. 3. The cultivation of sensitivity to ones self and to others.

4. The development of a helping-trust relationship 5. The promotion and acceptance of the expression of positive and negative feelings. 6. The systematic use of the scientific problem-solving method for decision making 7. The promotion of interpersonal teaching-learning. 8. The provision for a supportive, protective and /or corrective mental, physical, socio-cultural and spiritual environment. 9. Assistance with the gratification of human needs. 10. The allowance for existential-phenomenological forces. The first three carative factors form the philosophical foundation for the science of caring. The remaining seven carative factors spring from the foundation laid by these first three. 1. The formation of a humanistic- altruistic system of values Begins developmentally at an early age with values shared with the parents. Mediated through ones own life experiences, the learning one gains and exposure to the humanities. Is perceived as necessary to the nurses own maturation which then promotes altruistic behavior towards others. 2. Faith-hope Is essential to both the carative and the curative processes. When modern science has nothing further to offer the person, the nurse can continue to use faith-hope to provide a sense of well-being through beliefs which are meaningful to the individual. 3. Cultivation of sensitivity to ones self and to others Explores the need of the nurse to begin to feel an emotion as it presents itself. Development of ones own feeling is needed to interact genuinely and sensitively with others. Striving to become sensitive, makes the nurse more authentic, which encourages self-growth and self-actualization, in both the nurse and those with whom the nurse interacts. The nurses promote health and higher level functioning only when they form person to person relationship. 4. Establishing a helping-trust relationship Strongest tool is the mode of communication, which establishes rapport and caring. She has defined the characteristics needed to in the helping-trust relationship. These are: Congruence Empathy Warmth Communication includes verbal, nonverbal and listening in a manner which connotes empathetic understanding.

5. The expression of feelings, both positive and negative According to Watson, feelings alter thoughts and behavior, and they need to be considered and allowed for in a caring relationship. According to her such expression improves ones level of awareness. Awareness of the feelings helps to understand the behavior it engenders. 6. The systematic use of the scientific problem-solving method for decision making According to Watson, the scientific problem- solving method is the only method that allows for control and prediction, and that permits selfcorrection. She also values the relative nature of nursing and supports the need to examine and develop the other methods of knowing to provide an holistic perspective. The science of caring should not be always neutral and objective. 7. Promotion of interpersonal teaching-learning The caring nurse must focus on the learning process as much as the teaching process. Understanding the persons perception of the situation assist the nurse to prepare a cognitive plan. 8. Provision for a supportive, protective and /or corrective mental, physical, sociocultural and spiritual environment Watson divides these into eternal and internal variables, which the nurse manipulates in order to provide support and protection for the persons mental and physical well-being. The external and internal environments are interdependent. Watson suggests that the nurse also must provide comfort, privacy and safety as a part of this carative factor. 9. Assistance with the gratification of human needs It is grounded in a hierarchy of need similar to that of the Maslows. She has created a hierarchy which she believes is relevant to the science of caring in nursing. According to her each need is equally important for quality nursing care and the promotion of optimal health. All the needs deserve to be attended to and valued. Watsons ordering of needs o Lower order needs (biophysical needs) a) The need for food and fluid b) The need for elimination c) The need for ventilation o Lower order needs (psychophysical needs) a) The need for activity-inactivity b) The need for sexuality c) Watsons ordering of needs o Higher order needs (psychosocial needs) a) The need for achievement b) The need for affiliation

o Higher order need (intrapersonal-interpersonal need) a) The need for self-actualization Research findings have established a correlation between emotional distress and illness. According to Watson, the current thinking of holistic care emphasizes that: Factors of the etiological component interact and produce change through complex neuro-physiological and neuro-chemical pathways Each psychological function has a physiological correlate Each physiological component has a psychological correlate 10. Allowance for existential-phenomenological forces Phenomenology is a way of understanding people from the way things appear to them, from their frame of reference. Existential psychology is the study of human existence using phenomenological analysis. This factor helps the nurse to reconcile and mediate the incongruity of viewing the person holistically while at the same time attending to the hierarchical ordering of needs. Thus the nurse assists the person to find the strength or courage to confront life or death. Watsons Theory and the Four Metaparadigm Human being 1. She adopts a view of the human being as: a valued person in and of him or herself to be cared for, respected, nurtured, understood and assisted; in general a philosophical view of a person as a fully functional integrated self. He, human is viewed as greater than and different from, the sum of his or her parts.

Health 1. Watson believes that there are other factors that are needed to be included in the WHO definition of health. She adds the following three elements: A high level of overall physical, mental and social functioning A general adaptive-maintenance level of daily functioning The absence of illness (or the presence of efforts that leads its absence) Environment/society 1. According to Watson caring (and nursing) has existed in every society. A caring attitude is not transmitted from generation to generation. It is transmitted by the culture of the profession as a unique way of coping with its environment. Nursing

1. According to Watson nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health. 2. It focuses on health promotion and treatment of disease. She believes that holistic health care is central to the practice of caring in nursing. 3. She defines nursing as A human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human transactions. Peplaus Psychodynamic Theory. Hildegard Peplau, Ed.D (September 1, 1909, Reading, Pennsylvania 17 March 1999) was a nursing theorist whose seminal work Interpersonal Relations in Nursing was published in 1952.Dr. Peplau emphasized the nurse-client relationship as the foundation of nursing practice. At the time, her research and emphasis on the give-and-take of nurse-client relationships was seen by many as revolutionary. Peplau went on to form an interpersonal model emphasizing the need for a partnership between nurse and client as opposed to the client passively receiving treatment (and the nurse passively acting out doctor's orders).The essence of Peplau's theories is the creation of a shared experience. Nurses, she thought, could facilitate this through observation, description, formulation, interpretation, validation, and intervention. Peplau's Six Nursing Roles illustrate the dynamic character roles typical to clinical nursing. 1. Stranger role: Receives the client the same way one meets a stranger in other life situations; provides an accepting climate that builds trust. 2. Resource role: Answers questions, interprets clinical treatment data, gives information. 3. Teaching role: Gives instructions and provides training; involves analysis and synthesis of the learner's experience. 4. Counseling role: Helps client understand and integrate the meaning of current life circumstances; provides guidance and encouragement to make changes. 5. Surrogate role: Helps client clarify domains of dependence, interdependence, and independence and acts on clients behalf as advocate. 6. Active leadership: Helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way. Specific roles are variable with-in each nurse-client situation being limited only by the imagination and skill of the nurse. The four phases of nurse-patient relationships are: 1. Orientation: During this phase, the individual has a felt need and seeks professional assistance. The nurse helps the individual to recognize and understand his/ her problem and determine the need for help. 2. Identification: The patient identifies with those who can help him/ her. The nurse permits exploration of feelings to aid the patient in undergoing illness as an experience that reorients feelings and strengthens positive forces in the personality and provides needed satisfaction.

3. Exploitation: During this phase, the patient attempts to derive full value from what he/ she are offered through the relationship. The nurse can project new goals to be achieved through personal effort and power shifts from the nurse to the patient as the patient delays gratification to achieve the newly formed goals. 4. Resolution: The patient gradually puts aside old goals and adopts new goals. This is a process in which the patient frees himself from identification with the nurse. Peplaus Theory and the Four Metaparadigm Person 1. A developing organism that tries to reduce anxiety caused by needs Environment 1. Existing forces outside the organism and in the context of culture Health 1. A word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living. Nursing 1. A significant therapeutic interpersonal process. It functions cooperatively with other human process that makes health possible for individuals in communities. LEARNING Is the process of acquiring knowledge, skills, and attitude through study, experience, or teaching, which causes a change of behavior that is persistent, measurable, and specified or allows an individual to formulate new mental construct or revise a prior mental construct. According to Hirni and Craven (2003), learning is the acquisition of a skill or knowledge by practice or instruction. Moreover, as stated by Bailey (2005), learning is a development of the individuals capacities. It motivates and shows the maximum potential of knowledge, skill, talent, and to mention the other area of multiple intelligence. In addition, according to Illeris (2002), a common definition of learning is a process that brings together cognitive, emotional, and environmental influences and experiences for acquiring, enhancing, or making changes in one's knowledge, skills, values, and world views. DOMAINS OF LEARNING Humans are lifelong learners. From birth onward humans learn and assimilate what man has just learned into what man already know. There is more than one type of learning. The domains of learning are used to classify learning. These classifications allow teaching to be able to organize instruction and therefore provide better structure and improve clarity.

There are three basic domains of learning that are adapted from Benjamin Bloom. Cognitive Domain. This domain deals with the recognition of knowledge and the development of intellectual abilities and skills. This is the domain in which most of the work in curriculum development has taken place. There are six major categories, starting from the simplest behavior (recalling facts) to the most complex (Evaluation). The six Educational Objectives is discussed as follows; 1. Knowledge of terminology & specific facts; ways and means of dealing with specifics (conventions, trends and sequences, classifications and categories, criteria, methodology); universals and abstractions in a field (principles and generalizations, theories and structures): Knowledge is defined as the remembering (recalling) of appropriate, previously learned information. Key Words: defines, describes, identifies, knows, labels, lists, matches, names, outlines, recalls, recognizes, reproduces, selects, states. 2. Comprehension: Grasping (understanding) the meaning of informational materials. Understand the meaning, translation, interpolation, and interpretation of instructions and problems. State a problem in one's own words. Keywords: classifies; cites; converts; describes; discusses; estimates; explains; generalizes; gives examples; illustrates; makes sense out of; paraphrases; restates (in own words); summarizes; traces; understands. 3. Application: The use of previously learned information in new and concrete situations to solve problems that have single or best answers. Applies what was learned in the classroom into novel situations in the workplace. Keywords: acts; administers; applies; articulates; assesses; charts; collects; computes; constructs; contributes; controls; demonstrates; determines; develops; discovers; establishes; extends; implements; includes; informs; instructs; operationalizes; participates; predicts; prepares; preserves; produces; projects; provides; relates; reports; shows; solves; teaches; transfers; uses; utilizes. 4. Analysis: The breaking down of informational materials into their component parts, examining (and trying to understand the organizational structure of) such information to develop divergent conclusions by identifying motives or causes, making inferences, and/or finding evidence to support generalizations. Distinguishes between facts and inferences. Keywords: analyzes; breaks down; categorizes; compares; contrasts; correlates; diagrams; differentiates; discriminates; distinguishes; focuses;

illustrates; infers; limits; separates; subdivides.

outlines;

points

out;

prioritizes;

recognizes;

5. Synthesis: Builds a structure or pattern from diverse elements. Put parts together to form a whole, with emphasis on creating a new meaning or structure. Creatively or divergently applying prior knowledge and skills to produce a new or original whole. Keywords: adapts; anticipates; collaborates; combines; communicates; compiles; composes; creates; designs; develops; devises; expresses; facilitates; formulates; generates; hypothesizes; incorporates; individualizes; initiates; integrates; intervenes; invents; models; modifies; negotiates; plans; progresses; rearranges; reconstructs; reinforces; reorganizes; revises; structures; substitutes; validates. 6. Evaluation: Judging the value of material based on personal values/opinions, resulting in an end product, with a given purpose, without real right or wrong answers. Keywords: appraises; compares & contrasts; concludes; criticizes; critiques; decides; defends; interprets; judges; justifies; reframes; supports. Affective Domain. This domain is concerned with attitude, beliefs, and the entire spectrum of the value and value systems. This area is often considered the more difficult domain to structure instruction. The five major categories listed in order are: 1. Receiving phenomena: Awareness, willingness to hear, selected attention. Keywords: asks, chooses, describes, follows, gives, holds, identifies, locates, names, points to, selects, sits, erects, replies, uses. 2. Responding to phenomena: Active participation on the part of the learners. Attends and reacts to a particular phenomenon. Learning outcomes may emphasize compliance in responding, willingness to respond, or satisfaction in responding (motivation). Keywords: answers, assists, aids, complies, conforms, discusses, greets, helps, labels, performs, practices, presents, reads, recites, reports, selects, tells, writes. 3. Valuing: The worth or value a person attaches to a particular object, phenomenon, or behavior. This ranges from simple acceptance to the more complex state of commitment. Valuing is based on the internalization of a set of specified values, while clues to these values are expressed in the learners overt behavior and are often identifiable.

Keywords: completes, demonstrates, differentiates, explains, follows, forms, initiates, invites, joins, justifies, proposes, reads, reports, selects, shares, studies, works. 4. Conceptualizing Vvalues: completes, demonstrates, differentiates, explains, follows, forms, initiates, invites, joins, justifies, proposes, reads, reports, selects, shares, studies, works. Keywords: adheres, alters, arranges, combines, compares, completes, defends, explains, formulates, generalizes, identifies, integrates, modifies, orders, organizes, prepares, relates, synthesizes. 5. Internalizing values (characterization): Has a value system that controls their behavior. The behavior is pervasive, consistent, predictable, and most importantly, characteristic of the learner. Instructional objectives are concerned with the student's general patterns of adjustment (personal, social, emotional). Keywords: acts, discriminates, displays, influences, listens, modifies, performs, practices, proposes, qualifies, questions, revises, serves, solves, verifies. Psychomotor Domain. This domain attempts to classify the coordination aspects associated with movements and integrate cognitive and affective outlay with bodily actions and performance. The psychomotor domain includes physical movement, coordination, and use of the motor-skill areas. Development of these skills requires practice and is measured in terms of speed, precision, distance, procedures, or techniques in execution. The seven major categories listed in order are: 1. Perception: The ability to use sensory cues to guide motor activity. This ranges from sensory stimulation, through cue selection, to translation. Keywords: chooses, describes, detects, identifies, isolates, relates, selects. differentiates, distinguishes,

2. Set: Readiness to act. It includes mental, physical, and emotional sets. These three sets are dispositions that predetermine a persons response to different situations (sometimes called mindsets). Keywords: begins, displays, explains, moves, proceeds, reacts, shows, states, volunteers. 3. Guided response: The early stages in learning a complex skill that includes imitation and trial and error. Adequacy of performance is achieved by practicing Keywords: copies, traces, follows, react, reproduce, responds

4. Mechanism: This is the intermediate stage in learning a complex skill. Learned responses have become habitual and the movements can be performed with some confidence and proficiency. Keywords: assembles, calibrates, constructs, dismantles, displays, fastens, fixes, grinds, heats, manipulates, measures, mends, mixes, organizes, sketches. 5. Complex Overt Response: The skillful performance of motor acts that involve complex movement patterns. Proficiency is indicated by a quick, accurate, and highly coordinated performance, requiring a minimum of energy. This category includes performing without hesitation, and automatic performance. For example, players are often utter sounds of satisfaction or expletives as soon as they hit a tennis ball or throw a football, because they can tell by the feel of the act what the result will produce. Keywords: assembles, builds, calibrates, constructs, dismantles, displays, fastens, fixes, grinds, heats, manipulates, measures, mends, mixes, organizes, sketches. NOTE: The key words are the same as Mechanism, but will have adverbs or adjectives that indicate that the performance is quicker, better, more accurate, etc. 6. Adaptation: Skills are well developed and the individual can modify movement patterns to fit special requirements. Keywords: adapts, alters, changes, rearranges, reorganizes, revises, varies. 7. Origination: Creating new movement patterns to fit a particular situation or specific problem. Learning outcomes emphasize creativity based upon highly developed skills. Keywords: arranges, builds, combines, composes, constructs, creates, designs, initiate, makes, originates. RELATED LEARNING EXPERIENCE Clinical experience is recognized as the core of nursing education. Quality clinical placements across a variety of venues are vital to the development of capable and competent professionals. Clinical placements are essential to becoming a competent professional nurse. Although a theoretical and research-based education is essential for contemporary nursing, on its own it is not enough. Learning in the clinical setting provides the real world context where nursing students develop the knowledge, skills, attitudes and values of a registered nurse. Students have experiences on clinical placements that cannot be realistically provided in a classroom or laboratory setting. They communicate with patients and their families, interact with and learn from the health-care team, practice skills under supervision and learn to

deal with the complexity of competing priorities. When students are on clinical placements they receive feedback on their real world performance and are guided to reflect on their lived experiences as individuals and nurses (Clare et al. 2003; Madjar et al. 1997). The Importance of Training The significance and value of training has long been recognized. Consider the popular and often repeated quotation, Give a person a fish and you feed him for a day. Teach a person to fish and you feed him for a lifetime. This simple but profound saying is attributed to the wisdom of Confusius who lived in the 5th century BC. Given todays business climate and the exponential growth in technology with its effect on the economy and society at large, the need for training is more pronounced than ever. Training, in the most simplistic definition, is an activity that changes peoples behavior. Increased productivity is often said to be the most important reason for training. But it is only one of the benefits. Training is essential not only to increase productivity but also to motivate and inspire workers by letting them know how important their jobs are and giving them all the information they need to perform those jobs (Anonymous, 1998). McNamara (n.d.) lists the following as general benefits from employee training: increased job satisfaction and morale increased motivation increased efficiencies in processes, resulting in financial gain increased capacity to adopt new technologies and methods increased innovation in strategies and products reduced employee turnover Benefits to Students How do students benefit from work-based learning experiences? It has been argued (Ashworth, Saxton & Buckle, 1989) that the following are principal motivators, from a teaching and learning perspective, of placing students in the workplace: (1) linking theory and practice; (2) gaining work experience generally, and within a particular function; (3) gaining personal insight -- including job preferences; (4) entering into a professional role; (5) gaining knowledge of the working of the particular organization; (6) acquiring knowledge and attitudes relevant to future learning; (7) exercising skills of thinking in a practical context; and (8) developing personal maturity. According to Knowles (1970), growth in personal maturity implies more autonomy, broader awareness, extended capacities, more ability to take on responsibilities, greater clarity of self in work role, more self acceptance, and greater tolerance for ambiguity. There is empirical evidence (Hopkins, J. R. Stone, Stern & McMillion, 1990) to support the contention that well-designed formal school-to-work transition programs can contribute to enhancing many of these factors. Stern, J. R. Stone, Hopkins, McMillion, and Cagampang (1992) compared typical teenage work experiences (with no connection to school) with school-supervised work experiences, concluding that school-supervised work better developed some of these crucial factors which contribute to adult success in the workplace.

Benefits to Employers How do employers benefit from participating with schools in providing workbased learning opportunities? According to the National Alliance of Business (1992) , employers who provide youth apprenticeship opportunities can expect to experience the following benefits: o Obtain an expanded pool of qualified applicants o Gain a direct chance to recruit and screen potential employees o Evaluate potential employees in work settings prior to hiring o Develop a quick, reliable source of skilled labor o Meet contractual and legal obligations for affirmative action and equal employment o Improve the quality of life and skills in the community o Reduce turnover of entry-level employees o Influence curriculum development to meet industry requirements M. A. Hamilton and S. H. Hamilton (1993) describe the learning process of an apprentice as follows: (1) attend coaching and mentoring; (2) try out in practice what is taught; (3) process learning to comprehend, apply and transform it; (4) produce, or get work done; (5) initiate learning by seeking out people who can teach and by noticing opportunities for learning; and (6) reflect on work experiences. It can thus be argued that, through mentor involvement and observation of and exposure to the apprentice learning process, employees and organizations may recognize that the improved training and development efforts represent an investment in learning for the entire workforce in the organization. Initial observations of a youth apprenticeship program in Broome County, New York add to our belief that youth apprenticeship brings in tools and examples for human resource development. Starting in the sixth month of that program's existence, employees were demanding to receive the same type of training and cross-training that was provided to apprentices (S. H. Hamilton, 1993). Similar initial findings in a recent study of six youth apprenticeship sites by the National Center for Research in Vocational Education (NCRVE) also support this conclusion CHED MEMORANDUM ORDER NUMBER 5, SERIES OF 2008 A person is a unique bio-psycho-socio-cultural and spiritual being, always in constant interaction with the environment. These interactions affect individuals, families, population groups and societal health status. The nurse assumes the caring role in the promotion of health, prevention of diseases, restoration of health, alleviation of suffering and, when recovery is not possible, in assisting patients towards peaceful death. The nurse collaborates with other members of the health team and other sectors to achieve quality healthcare. Moreover, the nurse works with the individuals, families, population groups, community and society in ensuring active participation in the delivery of holistic healthcare. Within the context of the Philippine society, nursing education with caring as its foundation, subscribes to the following core values which are vital components in the development of a professional nurse and are emphasized in the BSN program:

1.1 Love of God 1.2 Caring as the core of nursing a. Compassion b. Competence c. Confidence d. Conscience e. Commitment (commitment to a culture of excellence, discipline, integrity and professionalism) 1.3 Love of People a. Respect for the dignity of each person regardless of creed, color, gender and political affiliation. 1.4 Love of Country a. Patriotism (Civic duty, social responsibility and good governance) b. Preservation and enrichment of the environment and culture heritage A strong liberal arts and sciences education with a transdisciplinary approach, enhances this belief. The BSN program therefore, aims to prepare a nurse who, upon completion of the program, demonstrates beginning professional competencies and shall continue to assume responsibility for professional development and utilizes research findings in the practice of the profession. The following are the Key Areas of Responsibility for which the nurse should demonstrate competence: 1. Safe and quality nursing care 2. Management of resources and environment 3. Health education 4. Legal responsibility 5. Ethico-moral responsibility 6. Personal and professional development 7. Quality improvement 8. Research 9. Record Management 10. Communication 11. Collaboration and teamwork Section 8. Curriculum Outline A. Outline of Total Units of General Education (GE) Courses: 87 Units Language and Humanities 21 English 1 & 2 (Communication Skills) 6 English 3 (Speech and Communication) 3 Filipino 1 & 2 6 Philosophy of the Human Person 3 Logic and Critical Thinking 3 Mathematics, Natural Sciences & Information Technology 22 Mathematics (College Algebra) 3 Biostatistics 3

General Chemistry 3/2 5 Biochemistry 3/2 5 Physics 2/1 3 Nursing Informatics 2/1 3 Health Sciences 9 Anatomy & Physiology 3/2 5 Microbiology & Parasitology 3/1 4 * Science, Technology and Society course could be integrated in any professional courses Social Sciences 15 General Psychology 3 Sociology/Anthropology 3 Humanities [ World Civilization & Literature] 3 Health Economics with Taxation & Land Reform 3 Bioethics 3 Mandated Subjects 6 Life, Works and Writings of Rizal 3 Philippine History with Governance and Constitution 3 Physical Education & NSTP 14 PE 1 to 4 8 National Service Training Program 1& 2 6 B. Outline and Units of Professional Courses 125 Units Theoretical Foundations in Nursing 3 Health Assessment (2/1) 3 Community Health Nursing (3/2) 5 Nutrition and Diet Therapy (3/1) 4 Teaching Strategies in Health Education 3 Pharmacology 3 Nursing Research 1 3 Nursing Research 2 2 Competency Appraisal I 3 Competency Appraisal 2 3 NCM 100 Fundamentals of Nursing Practice (3/2) 5 NCM 101 Care of Individuals and Family with Maternal and Child Health (6/6) 12 NCM 102 Care of Clients Across the Lifespan with Mother, Child and Family/Population Group -atrisk or With Problems (6/6) 12 NCM 103 Care of Clients Across the Lifespan with Problems in Oxygenation, Fluid & Electrolyte Balance, Metabolism and Endocrine (8/6) 14 NCM 104 Care of Clients Across the Lifespan with Problems in Perception and Coordination, Adjustment and Maladaptive Behaviors (8/6) 14

NCM 105 Related Learning Experiences (4 RLE) 4 NCM 106 Care of Clients Across the Lifespan and Population Group with Problems in Inflammatory and Immunologic Reactions, Cellular Aberrations,Acute Biologic Crisis, Including Emergency and Disaster Nursing (8/8) 16 NCM 107 Nursing Leadership and Management (8/8) 16 Total Number of Units = 212 At the end of the B. S. Nursing program, the total number of exposure/contact hours in the clinical laboratory is as follows: RLE RLE Contact Credit Hours (1 credit Courses Unit unit =51hours) Health Assessment 1 1 51 Community Health Nursing 2 2 102 Nursing Care Management 100 2 2 102 Nursing Care Management 101 6 6 306 Nursing Care Management 102 6 6 306 Nursing Care Management 103 6 6 306 Nursing Care Management 104 6 6 306 Nursing Care Management 105 4 4 204 Nursing Care Management 106 8 8 408 Nursing Care Management 107 8 8 408 Total 49 2499 Section 13. Facilities and Equipment 13.4. Clinical Facilities and Resources: Related Learning Experiences (RLEs) are teaching-learning opportunities that are designed to develop the competencies of students utilizing processes in various health situations. These could be sourced from, but not limited to lyingin clinics, schools, industrial establishments, community, out-patient clinics and general and specialty hospitals. Base Hospital. The base hospital is a health facility being utilized by a higher education institution with nursing program offering as a source of basic or primary related learning experiences. The hospital maybe independent or

owned or operated by the institution or utilized by the institution in accordance with an effective and duly notarized Memorandum of Agreement between the institution and the base hospital which clearly specifies the responsibilities of each party. The base hospital of a nursing school should meet the following requirements: a. Has current accreditation by the DOH-Bureau of Licensing and Regulation as Level IV Hospital (Tertiary Care/Teaching/Training Hospital). However, Level III Hospitals (Secondary Care Hospitals) may be considered provided that the hospital can provide the following: a.1 adequate case load for the number of students enrolled as stipulated in Article VII, Section 15-f. 9. a.2 adequate facilities for the teaching and learning needs of the students. b. Should be accessible and located within the region where the nursing school is situated. In the case of nursing schools located in Metro Manila, the base hospital should be located within Metro Manila. c. Sixty per cent (60%) of the total bed capacity of the base hospital shall be used for the RLEs of students. Affiliation Hospital is a health facility being utilized by the higher education institution in specialized areas for supplementary clinical learning of students such as mental, orthopedics and communicable diseases. A Contract of Affiliation shall be used as a legal document to show the terms of references among involved parties. Parties to the contract of affiliation should provide and maintain an environment conducive to the attainment of the teaching-learning objectives. The nursing school and the hospital agency should establish effective coordination and cooperation. Open communication should exist among the medical staff and the school personnel. Cross regional affiliations will not be allowed unless in cases where specialty areas cannot be found in the region. The base hospital/s, affiliation hospital/s and community health agency/ies being used by the students for RLEs either conducted in urban or rural community should have the following facilities: a. classroom for conference b. library c. comfort room d. dressing room e. lounge f. locker

Provision should be made for adequate physical facilities, supplies and equipment for effective nursing care and learning experiences of students. The nursing service should be provided with a designated training coordinator and the required staffing composed of qualified professional and nonprofessional personnel. The faculty and the nursing service personnel of the affiliation agency should work together in the planning, implementation and evaluation of the related learning experiences of students. There should be an adequate number of patients varying in age, sex, level/acuity and types of illness desired for teaching-learning experience of different curricular levels. 13.5. Virtual Nursing Skills Laboratory: Higher education institutions are encouraged to put up Virtual Skills Laboratory to supplement and complement the related learning experiences prior to actual experience. Section 14. The institution must maintain a high standard of instruction, utilizing appropriate and updated course syllabi/references and instructional methods/strategies taking into consideration the key areas of responsibility (Safe Quality Care, Communication, Collaboration & Teamwork, Legal Responsibility, Ethico-Moral, Personal & Professional Development, Research, Quality Improvement, Records Management and Environmental Management) that contribute to quality nursing education. The following should be strictly observed: a. The offering of professional nursing subjects with the corresponding RLEs must be strictly adhered to, taking into consideration the prerequisites, sequencing, continuity and integration requirements. b. Credit for the completion of the course is based on the fulfillment of curricular requirements. c. The Related Learning Experiences are organized around the objectives and competencies set forth by the course which all students must be able to achieve. RLE requirements must conform to PRC Policies and Guidelines. d. The ratio of faculty to student in science laboratory class is 1:25 while regular classroom is 1:50. The institution shall provide for a systematic and continuing plan of evaluation of the students progress through a marking system that is consistent and congruent to set objectives.

Section 15. The Related Learning Experiences (RLEs) are carefully selected to develop competencies utilizing the nursing process in varying health situations. The following conditions must be observed: a. There shall be close correlation of theoretical knowledge to related learning experience. Classroom and RLE activities must be congruent. b. Classroom and RLE is a continuous process. Faculty teaching in the classroom shall continue to teach the students in their RLE. c. Letters of intent to utilize affiliation agencies shall be available at the initial year of operation. d. A documented RLE rotation plan showing distribution of students and faculty supervision in each clinical area of base hospital and affiliation agencies shall be made available. e. Faculty compensation shall be based on the computation that one (1) hour RLE is equivalent to one (1) lecture hour. f. Effectiveness and efficiency of the related learning experience, shall consider the following factors: f.1 Quality of supervision of clinical instructors and teaching-learning process f.2 Readiness and capability of the learner f.3 Quality of the learning resources both in institutions and communities f.4 Adequate number and variety of clientele f.5 Utilization of appropriate feedback mechanism f.6 Adequate number of qualified nursing staff and other personnel f.7 Quality of nursing care services f.8 Compliance with the required equivalence of fifty one (51) hours to to one (1) unit RLE f.9 Ratio of student to clientele depends upon the objectives and the capacity of the student. The ratio of student to clientele shall be: 1st Semeste r 1:1 1:2-3 1:5 2nd Semeste r 1:2 1:3-4 1:6

Level II III IV

The ratio of faculty to student ratio shall be:

Level II III IV

1st Semeste r 1:8 1:10-12 1:12-15

2nd Semeste r 1:8 1:10-12 1:12-15

g. For government recognition, an increase in student population shall be subject to proportionate increase of resources both in classroom and clinical area subject to CHED approval. For this purpose, CHED Regional Offices shall strictly monitor compliance herein. h. Nursing schools that are in existence for a period of five (5) years are encouraged to undergo program accreditation.

Conceptual Framework

The conceptual framework above shows the interconnection between the BSN Students together with their PLE exposures and the learning of their nursing theories. It also shows two arrows presenting the importance and impact of RLE and Nursing Theories learned to one another. This correlation can be seen in the students performance and application of Nursing theories in their area of exposure and how their RLEs can maximize the learning of these theories.