The Intersystem Model supplanted Chrisman and Riehl’s (1974, 1989) systems model at the School of Nursing at Azusa Pacific University. Several works were used in developing the components of the model. For example, sense of coherence(SOC), a social science construct proposed by Antonofsky, provided grounding for the concept situational sense of coherence(SSOC). The SSOC serves as a measure of the integrative potential of clients within the context of situations (Artinian, 1997a) (see Table 8-2 and Figure 8-1).
TABLE 8-2Relationship Between SOC and SSOC in Artinian’s Model
Term Definition
SOC (sense of coherence) The progenitor to the SSOC.
SSOC (situational sense The analytic structure for evaluating the effectiveness of interventions in of coherence) the plan of care, and the current level of health.
Comprehensibility The extent to which one perceives the stimuli present in the situational environment deriving from the internal and external environments as making cognitive sense, in that information is ordered, consistent, structured, and clear, versus disordered random or inexplicable.
Meaningfulness The extent to which one feels that the problem demands posed by the situation are worth investing energy in, and are challenges for which meaning or purpose is sought rather than burdens.
Manageability The extent to which one perceives that resources at one’s disposal are adequate to meet the demands posed by stimuli present in the situation.
Source: Antonofski (1987) as cited in Artinian (1991, p. 199); Erdmann (2003, p. 336).
Additionally, the model of intrasystem analysis and intersystem interaction devel- oped by Alfred Kuhn was refined by Artinian to explain client–nurse interaction pro- cesses in health care situations and for use in developing the nursing plan of care.
Finally, the work of Maturana and Varela provided the conceptualization of the per- son as a perceiving, self-determining, self-regulating human system and explains the patient/client concept of the model (Artinian, 1997a).
(Knowledge) Detector
(Attitudes and values) Selector
(Behaviors) Effector
(Knowledge) Detector
(Attitudes and values) Selector
(Behaviors) Effector Communicating information
Assess intrasystems and environment
Score on situational sense of coherence (SSOC)
State nursing diagnosis
Negotiating values
Develop goals and plan of care
Implement plan Organizing behaviors
Evaluate plan:
Rescore on SSOC Intrasystem
(Patient/Client)
Intrasystem (Nurse)
FIGURE 8-1The Intersystem Model. (Source: Artinian, B. M. (1991). Journal of Advanced Nursing, p. 201 [Reprinted with permission].)
MAJOR ASSUMPTIONS, CONCEPTS, AND RELATIONSHIPS
In the Intersystem Model, there is a differentiation between the human as a system (the intrasystem) and the interactive systems of individuals or groups, known as the intersystem. The language of the Intersystem Model is scholarly English, and non- sexist language is used throughout.
Assumptions
A number of major assumptions of the model (Artinian, 1997a) are listed in Box 8-1.
Concepts
The Intersystem Model incorporates nursing’s metaparadigm concepts of person, en- vironment, and health, and specifies the concept nursing action. Definitions for these concepts are presented in Table 8-3. Person is viewed as a “coherent being who con- tinually strives to make sense of his or her world” (Artinian, 1991, p. 3). The person as an individual has biological, psychosocial, and spiritual subsystems (Artinian, 1997a). Person may also be an aggregate meaning a group of people, such as a fam- ily, community, or other aggregates. Environment includes internal and external environments and specifies developmental environment and situational environment as important to the interaction.
Health is viewed on a multidimensional continuum involving health/disease. The focus is on stability and adaptation, and Artinian developed the concept of SSOC, to measure adaptation. Health is considered to be “a dynamic state of functioning within the limitations of the person” (Artinian, 1991, p. 10), and includes the element of effective adaptation that occurs through strengthening the SSOC. As a result, the model defines health as “a strong SSOC.”
Nursing is specified as “nursing action,” which is identified by the mutual commu- nication, negotiation, organization, and priorities of both the client and nurse in- trasystems. This is accomplished through intersystem interaction; feedback loops are necessary to produce a mutually determined plan of care (Artinian, 1991). One major innovation of this model is that client spirituality and values are important in the as- sessment of client needs and within the resulting nursing process.
1. The human being exists within a framework of development and change, which is inherent to life
2. The human’s life is a unit of interrelated systems that is viewed as past and potential future
3. Persons interact with the environment on the biological level, and the senses are the mode of input from the environment; bodily functions are the mode for output
4. The person’s present can be seen in terms of his past and future 5. The human spirit is at the center of the person’s being, transcend-
ing time and affecting all aspects of life
6. The nurse focuses on all aspects of the total person, systemati- cally noting the interrelations of the systems and the relationships of the systems to time and environment
7. The nursing process can take place only in the present Source: Artinian (1997a).
BOX 8-1
Assumptions of Artinian’s Intersystem Model
TABLE 8-3Concepts of the Intersystem Model
Relationships
The Intersystem Model consists of two levels: the intrasystemand the intersystem.
The intrasystem applies both to the client and to the nurse, and focuses on the indi- vidual. The intersystem, by contrast, focuses on the interactions between the nurse and client.
In the intrasystem model, three basic components comprise each intrasystem: the detector, selector, and effector. The detector processes information, the selector com- pares the situation with the attitudes and values of the individual, and the effector identifies behaviors relevant to the situation (Artinian, 1991, 1997a).
The first step in an interaction in the intrasystem is to evaluate the detector domain, each person’s knowledge of the problem. The detector incorporates knowledge about the internal environment (physical symptoms), social situations, the condition, treat- ment, and available resources. The selector allows the client and nurse to examine their attitudes and values in choosing a course of action that fits both patient/client and nurse. The effector is the behavioral level in which a response is selected from the reper- toire of the behaviors available. This intrasystem level of the model provides the nurse with the capability of progressively clarifying with the client to bring about a mutual plan of care (Artinian, 1997a).
The intersystem (Artinian, 1991, 1997a) is seen when client and nurse interact, which occurs when nursing assistance is required. Communication and negotiation between nurse and client lead to development of a plan of care. If the planned intervention is not effective, the determination is made that further assessment is necessary.
SOC and SSOC are the concepts that relate to health. In the intervention phase of the process, “input is the nurse–client interaction to change the SSOC if it is judged
Concept Definition
Person A coherent being who continually strives to make sense of his or her world. The person is a system, the subsystems of which are biological, psychosocial, and spiritual. Subsystem configuration is such that “transactions among the subsystems result in emergent properties at the systemic level” (Artinian, 1997a, p. 3).
Environment The environment has two dimensions, developmental and situational. The developmental environment is “all the events, factors, and influences that affect the system as it passes through its developmental stages” (p. 8). This developmental environment provides the context for other developmental arenas such as the healing environment. Situational environment occurs when the nurse and client interact, and this includes all the details of the encounter.
Health Health is considered to be a multidimensional continuum. The client’s situational sense of coherence (SSOC) is a reflection of the client’s adaptation to crisis and is the factor that the nurse assesses, and to which the nurse ministers, in assisting the client to adapt. In the Intersystem Model health is defined as having a strong SSOC, illness has a low SSOC, and adaptation moves the SSOC toward a higher level.
Nursing Those actions (interventions) that are needed when the client enters the hospital
environment. It is the goal of both the nurse and client to move the client to a higher SSOC.
The nurse assesses the client’s knowledge (comprehensibility of the problem), the available resources needed to manage the problem (manageability), and the client’s motivation to meet the challenges posed by the problem (meaningfulness).
Source: Artinian (1997a).
to be low” (Artinian, 1997a, p. 13). Outcomes are scored on the SSOC by changes in knowledge, values and beliefs, and behaviors.
USEFULNESS
The Intersystem Model is relatively new; examples in nursing literature describing its use in practice and education are available. Online searches indicate that Artinian’s qualitative research method is being used in Europe and the United States. A recent investigation by Giske and Artinian (2008) used classical grounded theory and stud- ied adults aged 80 and older in a Norwegian hospital who were undergoing gastro- enterologic studies. Findings indicate that participants were concerned with preparing themselves for life after their diagnosis, a difficult period for the participants.
Research on educational issues includes that by Cason et al. (2008), who studied perceived barriers and supports for nursing students as seen by successful Hispanic health care professionals. They found that multiple barriers deter Hispanic students from success. Bond et al. (2008), followed up with a study of Hispanic students in bac- calaureate nursing programs, and found multiple barriers and supports. Critchley and Ball (2007) studied rheumatology patients using Artinian’s (1998) descriptive qualita- tive method. Dover and Pfieffer (2006) studied spiritual care of Christian clients of parish nurses. They developed a theory of spirituality for work in parish nursing.
Vukovitch and Artinian (2005) investigated mental health nurses who administered medications to psychiatric patients and their methods of avoiding coercion.
TESTABILITY
The Intersystem Model has not been fully tested. Research studies applying the model primarily involve using grounded theory methodology to examine the meanings of events and the person’s reactions to those events in the effort to formulate theories and hypotheses (Artinian, personal communication, May 30, 2003).
The SSOC instrument has been used in research as a self-report instrument (Artinian, 1997b). Major themes that emerged from a study of patients with chronic obstructive pulmonary disease (COPD) by Milligan-Hecox (Artinian, 1997c) were “pacing, depend- ing on others, clarifying values, maintaining independence, maintaining the struggle and accepting ambiguity” (p. 259). Other research efforts using the model included caring for cancer patients, COPD patients, and patients experiencing difficulties in managing illness situations (Artinian, 1997d).
PARSIMONY
The model developed by Artinian (1997a) is parsimonious and is explained in a logi- cal and coherent way using two simple diagrams. It is not simplistic, however, and has multiple interacting elements.
VALUE IN EXTENDING NURSING SCIENCE
The Intersystem Model has value in guiding education and in implementing practice.
Its innovation is attention to the spirituality, goals, and values of both the client and nurse. Nurses use it in diverse clinical settings, such as psychiatric, acute care, and community nursing. Several chapters, a book by the author, and numerous journal articles have been generated by this model (Artinian, 1998; Giske & Artinian, 2008;
Treolar & Artinian, 2001; Vukovitch & Artinian, 2005).
Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain:
Modeling and Role-Modeling
Modeling and role-modeling (MRM) is considered by its authors to be a theory and a paradigm. They constructed the theory from a multiplicity of resources that explain nurses’ interactions with clients.