PRIMARY HEALTH CARE RE-ENGINEERING

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CHAPTER 2 THEORETICAL FRAMEWORK

INTRODUCTION

This chapter describes the theoretical framework used to guide this study. Theoretical assumptions are assumptions concerning knowledge. According to King’s systems theory, knowledge is based on personal systems, interpersonal systems and social systems, which are dynamic and which interact, and within which transactions occur (George 2011:234). Nursing involves helping the patient get healthy. In order to do that, it is necessary to set health goals with the patient and then take steps to achieve those goals. When the nurse and patient communicate and work together toward mutually selected goals, the goals are more likely to be attained. Kings concepts focus on these methods to help nurses in the nurse-patient relationship therefore Kings System theory has been utilised to guide the researcher to evaluate how the individual, interpersonal and social systems are put together to achieve health goals of the MDR-TB patient. The provision of a supportive environment may improve the quality of nursing care

EPISTEMOLOGY

Epistemology is the research of philosophy concerned with how individuals determine what is true (Streubert Speziale & Carpenter 2003:362). Mouton (1998:47) states that research done in the epistemological dimension is regarded as the pursuit of valid knowledge (truth). Epistemology is the relationship of researchers to reality and the road that they will follow in the search for truth (De Vos 2002:214). This study explored the “truth” of working in an MIT. The researcher was committed to “search for truth” in the epistemic imperative. A close relationship exists between epistemology, intentionality and ontology. The focus or definition of intentionality forms the basis for epistemology. Intentionality is a way of knowing reality – an epistemology. It carries the meaning of reality (ontology) as we know it. Ontology is essentially part of the process of constituting a life-world (ontology) (Van der Wal 1999:77). Linguistic epistemology refers to the way of knowing reality (truth) through the spoken word (linguistic or lingual), i.e.
using words to describe an experience. The present study required that the MIT describe their experiences of nursing MDR-TB outpatients. Linguistic epistemology made the researcher opt for the open unstructured qualitative interview to investigate the lived experiences of the MIT. This choice was also based on the assumption that what people experience, they experience in terms of language.
Bracketing refers to the process of holding assumptions and presuppositions in suspension to improve the rigour of the research (Holloway 2005:289). This means that Researchers explore their own assumptions and preconceptions in order to set them aside or keep them in suspension, rather than conceal them, so that they do not interfere with the information given by the participants. The bracketing process is crucial throughout the research process, especially during data analysis. Bracketing requires the researcher to remain neutral with respect to belief or disbelief in the existence of the phenomenon (Streubert Speziale & Carpenter 2003:55).
The researcher thus had to first identify any preconceived ideas about the MIT (Streubert Speziale & Carpenter 2003:22). Then the researcher had to suspend any knowledge she might have about the MIT’s experiences to prevent this information from interfering with the recovery of a pure description of the phenomenon (experiences of the MIT). This would allow the “truth” to show itself and would determine the trustworthiness of the results

KING’S SYSTEM THEORY

Imogene King used a “systems” approach in the development of a dynamic interacting systems framework and in her subsequent theory of goal attainment (George 2011:234). King’s general systems framework involves three interacting systems (individual or personal, group or interpersonal, and society or social), and her theory of goal attainment pertains to the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space. King emphasises that both the nurse and the client bring important knowledge and information to the relationship, and that they work together to achieve goals

King’s open systems framework

The three interacting systems that led to King’s theory of goal attainment are the personal system (individual), the interpersonal system (nurse-patient interaction), and the social system (the family). Each system involves different concepts (George 2011:234)

The personal system

The concepts related to the personal system are perception, self, growth and development, body image, space and time. These are fundamental concepts for understanding human beings because they refer to how a nurse views and integrates herself, based on her personal goals and beliefs. Of all these concepts, the most important is perception, because it influences behaviour. King summarises the connections between these concepts as follows:
“An individual’s perception of self, of body image, of time, of space influences the way he or she responds to objects and events in his/her life. As individuals grow and develop through the lifespan, experiences with changes in the structure and function of their bodies over time influence their perceptions of self” (King 1981:19).
Personal systems are constructed by all individuals who are regarded as rational, sentient, social beings. The concepts related to the personal system are described as follows (George 2011:236):

• Perception — a process of organising, interpreting and transforming information from sense data and memory that gives meaning to one’s experience, represents one’s image of reality, and influences one’s behaviour.
• Self — a composite of thoughts and feelings that constitute a person’s awareness of their individual existence, i.e. of who and what he or she is.
• Growth and development — cellular, molecular and behavioural changes in human beings that are a function of their genetic endowment, of meaningful and satisfying experiences, and of an environment conducive to helping individuals move towards maturity.
• Body image — a person’s perceptions of his or her body.
• Time — the duration between the occurrence of one event and the occurrence of another event.
• Space — the physical area called territory that exists in all directions.
• Learning — gaining knowledge.

In this study the ENs and the TBAs attended to MDR-TB patients in the community. They learned a great deal through their interactions with the patients, which helped them to grow and develop as individuals. The experiences helped them to become more knowledgeable staff, and helped them to assist their clients when faced with diverse situations

The interpersonal system

The concepts associated with the interpersonal system are interaction, communication, transaction, role and stress. King refers to two individuals as dyads, three as triads, and four or more individuals as a small group or large group (King 1981:140). The interpersonal system explains how nurses interrelate with co-workers or patients, and is particularly useful in examining the nurse-patient relationship. For example, communication between the nurse and the patient can be verbal or non-verbal, and collaboration within the nurse-patient dyad is very important for the attainment of the goal.
The concepts related to the interpersonal system are described as follows (George 2011:237-238):

• Interaction — the acts of two or more persons in mutual presence; a sequence of verbal and non-verbal behaviours that are goal directed.
• Communication — the mechanism by means of which human relations are developed and maintained; encompasses intrapersonal, interpersonal, verbal and non-verbal communication.
• Transaction — a process of interaction in which human beings communicate with the environment to achieve goals that are valued; goal-directed human behaviours.
• Role — a set of behaviours expected of a person occupying a position in a social system.
• Stress — a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development and performance, and which involves an exchange of energy and information between the person and the environment for the regulation and control of stressors.
• Coping — a way of dealing with stress.

In this study the ENs and the TBAs shared information about their interactions and how they communicate with the MDR-TB patients. They were sometimes faced with stressful situations with the MDR-TB patients in the community, and they shared how they coped in such stressful situations

The social system

The final interacting system is the social system, which describes how a nurse interacts with colleagues, superiors, subordinates and the client environment in general. The social system comprises of groups of people within the community or society that share a common goal, values and interests. This system provides a framework for social interaction and relationships, and establishes rules of behaviour and courses of action. Social systems are organised boundary systems of social roles, behaviours and practices that are developed to maintain specific values and that function as a mechanism to regulate practices and roles. The concepts related to social systems are described as follows (George 2011:239):

• Organisation — composed of human beings with prescribed roles and positions who use resources to accomplish personal and organisational goals.
• Authority — a transactional process characterised by active, reciprocal relations in which members’ values, backgrounds and perceptions play a role in defining, validating and accepting the authority of individuals within an organisation.
• Power — the process whereby one or more people influence other people in a situation.
• Status — the position of an individual in a group, or of a group in relation to other groups in an organisation.
• Decision making — a dynamic and systematic process by which goal-directed choices between perceived alternatives are made and acted upon by individuals or groups in order to answer a question and attain a goal.
• Control — being in charge.

Of the three systems, the conceptual framework of the interpersonal system has the greatest influence on the development of King’s theory of goal attainment. King states that “although personal systems and social systems influence quality of care, the major elements in a theory of goal attainment are discovered in the interpersonal systems in which two people, who are usually strangers, come together in a health care organisation to help and to be helped to maintain a state of health that permits functioning in roles” (King 1981:142)

King’s theory of goal attainment

The elements of King’s theory of goal attainment are developed from the elements or concepts in her framework of interacting systems. However, her theory of goal attainment focuses on the interpersonal system, and the interaction, communications and transactions between two individuals: the nurse and the patient. The essence of this theory is that the nurse and the patient come together, communicate and transact; they set goals and work to achieve the goals set. They each have a purpose, and they perceive, judge, act and react upon each other. At the end of their communication a goal is set, and with this certain transactions occur. King states that the goal of nursing “is to help individuals maintain their health so that they can function in their roles (King 1981:142). Transactions thus occur to formulate and achieve goals related to the health of the patient.

RELEVANCE OF KING’S THEORY TO THE STUDY

In this study the lived experiences of ENs and TBAs with MDR-TB patients show how health care practitioners interact with patients, they indicate whether the patient or the health care practitioner is in control, and they show how decisions are made. The patients and the nurse both bring perceptions, judgements and actions to the interaction, and together experience reactions to each other, interactions with each other and transactions that can help achieve the treatment goals of the patient (see Figure 2.1). The interactions and transactions that take place have a cumulative effect. The nurse assists and guides the patient to move forward towards positive treatment outcomes, and aims for patient satisfaction as a result of quality nursing care. A patient will feel a sense of satisfaction when they are taking their treatment and are able to maintain control during the entire treatment process. Nurses can help the patient achieve control by involving them in decision making, listening to their concerns, and offering them health education to aid their decision making. Education about medication, about when the injections will be given, and about why they will be given, provides opportunities for reinforcing patients’ sense of self-efficacy. The patient contributes personal, emotional and subjective information while the nurse contributes medical and technical information.

CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION.
1.2 BACKGROUND TO THE RESEARCH PROBLEM
1.3 RESEARCH PROBLEM
1.4 PURPOSE OF THE STUDY.
1.5 SIGNIFICANCE OF THE STUDY.
1.6 DEFINITIONS OF KEY CONCEPTS
1.7 THEORETICAL FOUNDATION OF THE STUDY.
1.8 RESEARCH DESIGN AND METHODS
1.9 SCOPE OF THE STUDY
1.10 STRUCTURE OF THE THESIS
1.11 CONCLUSION
CHAPTER 2  THEORETICAL FRAMEWORK
2.1 INTRODUCTION.
2.2 EPISTEMOLOGY..
2.3 RELEVANCE OF KING’S THEORY TO THE STUDY
2.4 CONCLUSION
CHAPTER 3 LITERATURE REVIEW.
3.1 INTRODUCTION.
3.2 TUBERCULOSIS
3.3 PRIMARY HEALTH CARE RE-ENGINEERING
3.4 THE CONCEPT OF MOBILE CLINIC SERVICES
3.5 OLD METHODS OF MDR-TB TREATMENT
3.6 MDR-TB INJECTION TEAM.
3.7 PREPARATION OF STAFF FOR THE MDR-TB MOBILE INJECTION TEAM
3.8 MANAGEMENT OF MULTI DRUG RESISTANT-TB
3.9 MDR-TB MOBILE INJECTION TEAMS AS PART OF COMPREHENSIVE HEALTH SERVICES
3.10 CONCLUSION
CHAPTER 4 RESEARCH DESIGN AND METHODOLOGY
4.1 INTRODUCTION
4.2 RESEARCH DESIGN
4.3 RESEARCH METHODOLOGY
4.4 MEASURES TO ENSURE TRUSTWORTHINESS
4.5 CONCLUSION
CHAPTER 5 nANALYSIS, PRESENTATION AND DESCRIPTION OF THE RESEARCH FINDINGS
5.1 INTRODUCTION
5.2 DATA MANAGEMENT.
5.3 DATA ANALYSIS
5.4 RESEARCH RESULTS
5.5 PRESENTATION AND DESCRIPTION OF RESEARCH FINDINGS
5.6 CONCLUSION
CHAPTER 6 DEVELOPMENT OF GUIDELINES TO ENHANCE THE UTILISATION OF MOBILE MDR-TB INJECTION TEAMS
6.1 INTRODUCTION.
6.2 THE PURPOSE OF THE GUIDELINES
6.3 THE DEVELOPMENT OF THE GUIDELINES.
6.4 THE PRESENTATION OF THE GUIDELINES.
6.5 CONCLUSION.
CHAPTER 7. CONCLUSIONS AND RECOMMENDATIONS 
7.1 INTRODUCTION.
7.2 RESEARCH DESIGN AND METHOD
7.3 SUMMARY AND INTERPRETATION OF THE RESEARCH FINDINGS OF THE STUDY.
7.4 CONCLUSIONS
7.5 RECOMMENDATIONS FOR FUTURE RESEARCH
7.6 CONTRIBUTIONS OF THE STUDY.
7.7 LIMITATIONS OF THE STUDY.
7.8 CONCLUDING REMARKS
ANNEXURES
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