Self-Care Requirements, Self-Care Capabilities, and Nursing Systems in the Diabetic Nurse Management Clinic

JOAN E. BACKSCHEIDER, RN, MSN, PhD

Assessment of patient capacities in relation to health care requirements of a diabetic therapeutic regime establishes the need for initiating a system of nursing assistance and identifying the type of nursing system required.

Introduction
Do ambulatory diabetic patients require nursing? The answer to this question, viewed from the perspective of nursing staffing in diabetic outpatient clinics, has usually been affirmative. Most frequently, however, reference is made to the assignment of nurses to the clinic, and emphasis is placed on service to the geographic area rather than to patients. The emergence of nurse management clinics and nurse practitioner positions in recent years has placed new emphasis on the organization of nursing services to patients. This paper is one of a set of papers which explore the conceptual framework of nursing used in the Diabetic Nurse Management Clinic at The Johns Hopkins Hospital to determine the factors which validate the use of nursing in the setting and establish the speciflc nature of these

services.1

The concept of nursing utilized in this setting is that of Dorothea Orem,2 and it has been stated more extensively in the related articles. The three constituent elements within The late Joan E. Backscheider was a Staff Member, Center for Experimentation and Development in Nursing, and Assistant Director of Nursing, Pediatric Ambulatory Services, The Johns Hopkins Hospital, Baltimore, Maryland 21205. This article was written in December, 1971.
1138 AJPH DECEMBER, 1974, Vol. 64, No. 12

this concept which must have a dynamic identity in a nursing situation are3: * Self-care agency: the capacity of the patient to engage in health-related actions for self, the product of the exercise being the self-care system; * Therapeutic self-care demand: a representational element which is (1) a summation of action to be taken, work to be done, (2) a standard for assessment of the adequacy of self-care agency at a point in time, and (3) a standard for deliberate change in self-care agency or nursing agency; * Nursing agency: the prime regulatory mechanism for the nursing system, the capacity of the nurse to perceive and interpret data from the patient, the nurse, and the environments of both and to initiate and maintain as needed a set of assisting actions which compensate for the deflcit between a patient's self-care agency and the therapeutic self-care demand. A relationship between these elements has been identified which, if accepted, influences the design of nursing for the clinic and the specific nursing systems for patients within it. The relationship is: the therapeutic self-care demand sets the requirements for the patient's self-care agency; a deficit in the self-care agency (agencyrequirements) establishes a need for nursing agency; and the

quantity and form of nursing assisting actions is determined by the nature of the deficit. Inherent in this approach is the position that the nursing system and the self-care system are action systems and that they are open, self-organizing systems, in the sense described by Ashby4 and Buckley.5 These systems have the qualities of conditionality, constraint, and freedom of variation.
. . . as open systems become more complex there develop within them more and more complex mediating processes that intervene between external forces and behavior.... They come to perform the operations of: (1) temporarily adjusting the system to external contingencies; (2) directing the system toward more congenial environments; and (3) permanently reorganizing aspects of the system itself to deal perhaps more effectively with the environment. The "self" in "self-regulation," "self-direction," and "self-organizing" points, of course, to these mediating processes, though we tend to use the term "self" in its full sense only on the human level.*

demand or in a permanent reorganization of aspects of the system which once may have been therapeutic. There are several sources of the therapeutic requirements: the condition, effects of the condition, the therapy, and effects of the therapy. The requirements flowing from the condition are discernible through an understanding of the pathophysiology involved. Those related to the therapy are discernible through an understanding of medical therapeutics as it is practiced in the particular setting. To describe the therapeutic self-care demand, some of the components of the therapeutic regimes utilized in the Diabetic Nurse Management Clinic at The Johns Hopkins Hospital are examined. The Clinic treats moderate to severe diabetics, many of whom have other health complications which are also treated at the clinic. The regime is described from the perspective of action responsibilities which may be assigned to the patient.

Patient Responsibilities Related to the Condition The patient is responsible for monitoring for symptoms of hypoglycemia and hyperglycemia; urine testing for glycosuria on a daily or more frequent basis; urine testing for acetone on a selective basis; adjustment of activity level and intake level to each other and establishment of regularity in daily personal living; development of acceptable standards to identify or regulate the above activities; and maintenance of good general hygiene and good health habits.

Since nursing as assistance is a mediating system which has its effect on an action system (the self-care system), its success is dependent on the accuracy of the nature of the relationship between self-care system and therapeutic self-care demand. In practice, this assessment focuses on a specific patient from two perspectives: Which dimensions of the therapeutic plan of care for this patient might involve the patient and in what ways? What are the capabilities of the patient in relation to those required by the therapeutic plan of care? The relationship between the two sets of answers provides the dimensions to which the system of nursing for this patient must address itself. The purpose of this paper is to examine one component of self-care agency, the patient capabilties which are essential to that portion of the therapeutic self-care demand associated with diabetes. In a specific clinical setting, judgments must be made about the reciprocal effect of these two factors on each other. A second purpose of the paper, therefore, is to assess the potential effect of limitations of patient capabilities on the diabetic-related component of the demand on the patient and on the type of nursing system which would be established. The focus of the paper is the presentation of a framework for assessment of individual capacities in relation to components of the therapeutic regime, an assessment which would establish the conditions for initiation of a nursing system.

Patient Responsibilities Related to Effects of the Condition

The patient is responsible for good skin care to maintain excretory capacity and to remove any glucose secreted through these surfaces; additional skin care measures if infection is present; monitoring for infections, skin lesions, and retinopathy; and compensatory mechanisms for protection and maintenance of function when sensory deficit is present in the extremities or in the eyes. Patient Responsibilities Related to Therapy The patient is responsible for use of control agentsoral or insulin, including measurement and administration; use of diet as an agent of control-comprehension of the system of dietary exchanges or of calorie values; planning and selection of foods; and sterilization and maintenance of a sterile operation for injection of insulin.
Patient Responsibilities Related to the Effects of Therapy The patient is responsible for monitoring of the skin at injection sites; monitoring the glycemic and glycosuric state after administration of control agents; monitoring effects of medication, activity, and diet and of changes in each; and maintaining written records of urine test results and dietary intake between clinic visits.
SELF-CARE IN DIABETES 1139

The Diabetic-Related Component of Therapeutic

Self-Care
The presence of a disturbance in the health state, such as diabetes mellitus, usually results in a new stream of requirements within the individual's therapeutic self-care
*

Reprinted by permission of Prentice-Hall, Inc.'

Patient Adjustments

Some of the components in the therapeutic regime involve learning new practices and incorporating these into the self-care system (e.g., administration of medications and monitoring the glycemic state). Others involve continuation of parts of the ongoing practical system (e.g., activity level) but modification in understanding the relationships of those parts to the health state. Still others require change in portions of the self-care system which have been established to meet some universal requirement (e.g., food intake). Permanent adjustment may be necessary in these practices, often culturally derived, if self-care is to be therapeutic. The cumulative effects of diabetes and the regimes necessary to manage it are described in a recent article by a nurse who is a diabetic.6 From her account, too, there is evidence that requirements arise because of the condition and its effects, the results of having the condition over time, the regime of medical therapy, and the effects of therapy. Permanent reorganization of the self-care system is essential. Temporary adaptations are necessary during certain variations in the health state. In addition, the well-being of the whole person must continue to move toward "congenial environments."

Self-Care Action Capabilities Required by the Therapeutic Regime for Diabetes

The action requirements deriving from the therapeutic regime for diabetes may or may not be met in the self-care systems of patients. The translation of action requirements into action calls for the coordination of specific human capabilities. Absence of a portion of these capabilities results in a limitation in meeting these requirements. The art of nursing has rested on the intuitive identification by nurses of such capacities and limitations in patients and the use of assisting actions by the nurse to complement the existing state in the patient. The science of nursing requires that the foundations of these intuitive actions be articulated and assessed against scientific criteria. Review of nursing literature revealed an absence of material describing action requirements in this manner. There is a body of literature which does focus on errors in compliance. These data give some perspective on the nature of the self-care system, but without sound detennination of the factors which resulted in this product. Studies of compliance with medical regime among diabetics indicate that errors in performance are common.7'8 Some of the types of errors which have been reported are: incorrect matching of syringe calibration to insulin type; selection of inappropriate reading gauge for urine testing; miscalculation of diet plan in relation to daily eating habits; misunderstanding the purpose of sterilization of equipment, urine testing, and dietary prescription; misunderstanding of diabetes as a condition; and failure to perform aspects of the regime despite verbalized understanding.
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During the first 2 years of our operation, one direction of our conceptual effort was toward a description of the types of capabilities required by the therapeutic regime we used for management of diabetes. Tables 1 through 4 contain the result of our efforts in its present state of development. Much of the material is self-explanatory, but some comments from our experiences may be helpful. Tables 1 and 2 identify the physical and mental capabilities necessary to perform various tasks involved in the regime. Limitation of these capabilities would pose a deficit in relation to the therapeutic self-care, and nursing assistance would be directed toward overcoming the deficit and accomplishing the task. In relation to Tables 3 and 4, motivational and orientational capabilities, the effect is less upon the perfornance of specific procedures and more upon the general disposition to engage in aspects of therapeutic self-care consistently. I will comment briefly on the meaning of one or more of the capabilities listed under each table. In relation to Table 1, vision plays a vital role in many components of the management regime for diabetes. It is essential in measurement processes (used in urine testing and timing during specific procedures) used to assess control status. Image and color perception are needed for several procedures such as administration of insulin and reading results of urine test for sugar. Clinical and general health monitoring also require obtaining certain data through visual channels, such as observation of skin state and of condition of the feet. The fact that retinopathy is a frequent complication of diabetes has implications for the types of compensatory actions necessary to intervene between the extemal force of the condition and the behavior necessary as adjustment to it. An outstanding fact made evident by Table 2 is the number of mental capabilities required by the procedures in diabetic management. In a control regime which of necessity is as time-oriented as the clinical management of diabetes must be, memory and attention span are critical factors. Memory and learning (defined as the capacity of the nervous system to store memories9) must cover a broad range of items, from the specific (such as preparation steps, amounts, terms, times, and classes of food) to the general (purposes for various procedures and knowledge of the condition itself). Memory and learning must also endure over time; attention span is essential to support learning and also to provide for execution of procedures to the point of completion. The aging process and the vascular complications associated with diabetes may result, over time, in changes in the individual's health state (i.e., his environment) and may affect his action capacity. Observation for symptoms, introduced as a repeated experience each day, is intended to provide data which require repeated judgments about current health status and adequacy of management. A positive signal on symptoms and a negative one on management (failure to adhere to diet, for example) ideally are intended to communicate to the patient that he should do something about his condition. Whether the message carries that meaning and

TABLE 1-Physical Capabilities Essential to Therapeutic Self-care for Diabetes

General Capability
Sensation

Specific Capability
Touch

Aspect of the Regime

Feel skin surfaces-at injection sites; for dryness; for foot care Sense obstacles or sharp objects when walking Estimate water temperature for foot care, bathing, household chores, to avoid burns Handling syringes (especially Vim), utensils for home care (cooking) Assess needle for burring

Vision

Accuracy in measurement for insulin, urine testing Color-sightedness to read results of urine testing For reading: number labels for colors on urine test, labels of medication bottles, syringe level; diet exchange Noting presence of blood in syringe Observation of skin appearance, status of abnormalities of skin on feet; length of toenails Watch time

Dexterity

Hands

Manipulate small objects: syringe, eye dropper, draw up injection Maintain sterile conditions during injection Use utensils to prepare food
Activity level consistent with food intake and medication

Movement and general energy

what the patient decides to do are affected by the amount and quality of what the patient has learned and by the status of the operative knowing processes which the individual uses to handle the existing content and input.* The operative knowing processes most frequently required are the abilities to discriminate and classify items, associate these into correct clusters, evaluate the cluster, and engage in some action. This is influenced by the number of factors that the individual can take into account and by the level of understanding that he has of the glucose metabolism system. Accurate identification of states of
* Operative knowing and its states are used in the sense defined by Piaget.1 0

hypo- and hyperglycemia cannot be made unless one can label symptoms and then cluster them into states. In this case, the problem is complicated by the number of symptoms which overlap both states. Patients who have limited backgrounds in healthrelated matters and limitations in intellectual processing often go from classification of specific items to a corrective or maintaining action, without any intervening steps. It is common to have patients say that they "eat a piece of candy for weakness"; in this case, the action probably suits the state. Less satisfactory is the decision not to do anything after seeing "blue" (i.e., negative) results on the urine test (Clinitest) because "blue is nornal." Distinguishing normality from hypoglycemia is impossible when a blue
SELF-CARE IN DIABETES 1141

TABLE 2-Mental Capabilities Essential to Therapeutic Self-care for Diabetics

General Capability
Learned skills

Specific Capability
Reading

Aspect of Regime

Use diet exchange Use literature to understand

condition
Check accuracy of labels, dates Check prescription label, dosage Counting
Measure drops for urine Hours for peak time Observing clock or estimating time Knowledge of purpose of each activity or procedure Steps of procedures Dosage of medication Amounts: food in diet, diet exchange, urine and water, frequencies for procedures or medicines Classification of food substances Terms-language Times for medications, procedures

Functions of the cerebral cortex

Memory and learning

Functions of the reticular activating system

Attention span

Following through to completion of procedures (e.g., urine testing, injection of insulin) Learning parts of diabetic

regime
Planning diet

Operative knowing

Discriminating and classifying specific

events

Internal sensations (dizziness, confusion) Outcomes of tests (blue = 0; orange = 4+) Foods-by type, by calorie quantity Effects of medicationfollow sensation over time Skin condition-type of problem

Discriminating and classifying clusters of events

Cluster certain internal sensations into states (hypoglycemia, hyperglycemia) Relate hypoglycemia, normal, hyperglycemia on continuum Relate internal and external sensations (normal, infection,

ulcer)
Making judgments
about a cluster Present state versus normal Cause of the state

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TABLE 2-Continued

General Capability Operative knowing

Specific Capability
Conceptualizing a system on basis of empirical conditions on basis of nonperceptual condition

Aspect of Regime

Glucose manufacture, glucose metabolism, glucose utilization Learning Use norms Planning diet for time period What to do about state When to call clinic Ways to adjust intake (direction, means) Ways to adjust activity level (direction, means)

Decision making about action on the basis of judgment

color indicates normality and when the variety of feelings which the individual may be experiencing cannot be clustered into a definition of abnormal glucose state. Tables 3 and 4, motivational and orientational capabilities, are obviously the most underdeveloped at this point. Essentially, the major emotional demands come in the form of placing value on oneself, directing concern to oneself, and placing regulations on oneself to produce consistency and order in daily living. The amount of demand for consistency (the extent or limitations of freedom to cheat a little without precipitating glucose imbalance) places the patient in a position which may be difficult or relatively easy in relation to his life situation. The demand for habit and time orientation may place on the patient very different and perhaps conflicting expectations from that held by his most immediate social relations. Orientationally, the time priority and health awareness dimensions are critical. If a patient's own background does not provide him with these, he has the option of learning them. Learning alone is not the issue. The organization of living around these dimensions may be difficult or impossible to achieve in a household which has other needs or in living with others who rank them differently. In a large clinic, especially among an older and less educated population, it is a false assumption to design a sXstem which expects nearly equal capacities in all patients. In the Diabetic Nurse Management Clinic, about 30 per cent of our patients cannot read. This factor in itself necessitates the design of a nursing system in which much of the information and teaching is exchanged through verbal contact. We have not as yet come up with estimates of the percentage of patients with other types of limitations, but we are in the process of attempting to accumulate this information. Our increased awareness of the effect of these limitations on certain components in the diabetic regime has resulted in revision or omission of

certain components from the specific regime prescribed for certain patients.

Self-Care Deficits and the Nursing System in Diabetes

A self-care deficit exists when a limitation in the

patient's capacity for self-care results in a failure to meet a

therapeutic requirement for self-care. The identification of
a self-care deficit is the factor which conditions the movement of nursing action from that of assessment to that of design and initiation of a system of nursing assistance. Taking capabilities as the point of departure, four general types of relationships between patient limitations in diabetic management and nursing systems can be identified: (1) some self-care limitations may give rise to additional self-care demands in areas where a capacity for self-care exists and can be developed in a supportive, educative nursing system; (2) some limitations may require supportive developmental assisting actions on a temporary basis but may not eliminate the patient's capacity to perform the task; (3) some limitations may require that permanent compensatory assistances be provided to the patient in order to accomplish the requirement for therapeutic self-care; responsibility for doing the action could fall to nurses or to a family member, friend, or paid health care agent; (4) some limitations may stem from the personal environment in which the person exists and may require environmental developmental assisting actions or possible referral to another type of assisting service. An example of the first type of nursing system would exist with loss of some sensory capacities in the extremities, which can decrease the effectiveness or eliminate the use of hands in skin protection. As this occurs, the patient needs
SELF-CARE IN DIABETES 1143

TABLE 3-Motivational and Emotional Capabilities Essential to Therapeutic Self -care for Diabetics
Attention to own internal body Self-value (see self independently of others and experience other than during
as being of value)

crises

Willingness to modify usual if

necessary Willingness to remain within normal to degree possible Ability to act differently from group Acceptance of being patient Management of feeling about genetic transmission of diabetes

Self-image and self-concern

Consistent attention to health, self Acceptance of need for therapeutic routines Willingness to learn about condition and care

Emotional control sufficient to make judgments and carry out actions

Quality of management Consistency in management Reduction in energy utilization during stress Execution of care in certain emotionally charged areas (self-injection; collection of urine)
Care plan designed Consistency in management Quality of management Learning interest

Willingness to engage in
care

Self-discipline

Establishment of habits conducive to self-care Selection of stress-relieving mechanisms (amount of eating and drinking) Selection of foods (preference
versus needs)

Ability to work with body and its parts

Collecting and testing

urine

Injecting self with insulin

to use more caution during skin care and to protect the feet while walking. Given no other limitation, the patient could incorporate into the regime compensatory actions such as more visual observation, use of more protective footwear, and use of thermometer to assess water temperature. The action of the nurse would be assistance in the form of guidance or teaching, possibly on a one-time basis. The second type of system described above requires that the nurse initiate and maintain a supportive developmental system of assistance to patients. Urine testing itself is one of the less complex procedures in diabetic management. Its technique and the interpretation of results are standardized, and in reality it is usually fairly well done
1144 AJPH DECEMBER, 1974, Vol. 64, No. 12

by those individuals who are consistent and orderiy and have the requisite physical capabilities. In the area of judgments and action, however, patient performance is often lower. The nurse often finds that it is at this point that she must design a system of compensatory actions. Dependent on her judgment of the patient's capacities, that action might consist of "Call me at the clinic whenever the result of your urine test is any color but blue," or it may be the development of a plan to teach this patient how to assess related factors when positive results occur. In the latter case, a system of supportive assistance in the form of review of judgment through telephone contact may be included.

In the area of intellectual functioning, inability to count is a limitation which poses a deficit in use of urine testing. Some compensatory choices still exist for the nurse, as long as fairly gross measures are satisfactory. Words of 10-second, 20-second, etc., length can be substituted for counts during procedures, and meal times may be useful as markers for peak action times for insulin or antidiabetic agents. The compensatory system should include periodic review or demonstration to make provision for the maintenance of accuracy over time. Emotional lability or difficulties in emotional control must be evaluated in relation to the competencies of the clinic staff to deal with them. From the viewpoint of the diabetic clinic, a network of supportive counseling nursing actions are necessary to help the patient perform at maximal level in relation to management of his condition. Utilization of other resources such as social service and psychiatry may be indicated as additional resources to deal with the emotional component of the problem more directly. Examples of the third type of nursing system can be seen in relation to limitations in vision and in memory. Color blindness is a permanent deficit, and its compensatory mechanism would have to go in the direction of seeking assistance of another person. Inability to delineate visually sharp lines or boundaries or blurring of vision affects several procedures directly related to management of blood sugar level. Compensatory measures might be a Vim syringe which the patient could use himself or superb fine muscle control, but most safely it is a substitute pair of eyes. To acquire these, the nurse incorporates another person-a family member or a friend-into the system established to meet the patient's self-care requirements. In this case, performance of the task is transferred to someone other than the patient. Deficits in memory and attention span, especially when organic and irreversible, pose major limitations to the whole regime. Supervision in the home on a continual or intermittent basis may need to be planned for. An example of the fourth type of nursing system would exist in a situation in which a patient had inadequate

income to obtain the foods essential for the diabetic diet or in which the patient was faced with the problem of providing and preparing several types of diets on limited income. The nursing system for the patient might be directed toward educational assistance for home management or food management. It might involve referral to another agency, such as a social work organization.

The Nursing System as Self-Organizing System

In the concept of nursing which provides the framework for this clinical operation, nursing is viewed as an action system the purpose of which is mediation. The object system toward which its effects are directed is the patient self-care system; the external contingencies or guidelines for the mediation are the therapeutic self-care demand which arises from the environment of the patient health state and from the personal environment of the patient. The separate but related purposes of the patient self-care system and the nursing system are apparent if the four types of nursing cases described above are examined in light of the operations they perform, as described by Buckley.5 The patient self-care system in types I to III is incorporating processes which will permanently reorganize aspects of itself to deal more effectively with its environments, the physical and psychological state. During periods of temporary variation in health state, temporary readjustments in the self-care system may be necessary in addition to the more permanent ones. The patient self-care system in type IV is directed toward incorporating processes which will move the system toward more congenial environments, whether these be financial, residential, or sociocultural. The nursing system has different purposes arising from variations in the status of the patient self-care system and the self-care agency status. In types I and II, the nursing system exists for a temporary period to adjust the patient self-care system to external contingencies. The adjustment in the nursing system is temporary because of the capabilities in the patient to carry on his own reorganized

TABLE 4-Orientations Essential to Therapeutic Self-care for Diabetics

Time and priority habit

Organization of activities
into daily regime Daily management based on order and priority

(predictability)
Predictable ranges of energy utilization and energy provision Acceptance of body functioning and self-care

Ongoing system to maintain

general health Concern about general hygiene As stimulus for learning about condition

SELF-CARE IN DIABETES

1145

process. The nursing system in type III is an ongoing one, involving permanent reorganization of aspects of the actions of a nurse to assist the patient self-care system to deal permanently more effectively with the environment. The permanent reorganization of nursing actions may involve participation with the patient in meeting the self-care requirements or ongoing supervision of a permanent assistant such as a family member. The nursing system in type IV is directed toward linking the patient with a more congenial environment. The function of the nursing mediating system, however, is a linkage operation; the function of the patient self-care system is a movement operation. The quantification of these systems for caseloads of patients and for specific patients in a setting provides a description of nursing in the setting, a mechanism for deflnition of the qualities which nurses need to operate in the setting, and an estimation of the quantity of nursing personnel needed.

overcomes self-care incapacities. Our work has suggested that we have available materials defining essential or potential requirements for self-care related to various health conditions. More nursing knowledge needs to be structured around the description of self-care capacities and limitations and around the mechanisms for objective derivation of the therapeutic self-care demand for specific patients or categories of patients.

References
1. Allison, S. E. A Framework for Nursing Action in a Nurse-Conducted Diabetic Management Clinic. J. Nurs. Admin. 3:53-60, 1973. 2. Orem, D. Nursing: Concepts of Practice. McGraw-Hill Book Company, New York, 1971. 3. Nursing Development Conference Group. Concept Formalization in Nursing: Process and Product. Little, Brown and Company, Boston, 1973. 4. Ashby, W. R. Principles of the Self-Organizing System. In Modern Systems Research for the Behavioral Scientist, edited by Buckley, W., pp. 108-118. Aldine Publishing Company, Chicago, 1968. 5. Buckley, W. Sociology and Modern Systems Theory. Prentice-Hall, Englewood Cliffs, NJ, 1967. 6. Stuart, S. Day to Day Living with Diabetes. Am. J. Nurs. 71:1548-1550, 1971. 7. Anderson, R. S., Gunter, L. M., and Kennedy, E. J. Evaluation of Clinical, Cultural, and Psychosomatic Influences in the Teaching and Management of Diabetic Patients: A Study of Medically Indigent Negro Patients. Am. J. Med. Sci. 245:682-690, 1963. 8. Watkins, J. D., and Moss, F. T. Confusion in the Management of Diabetes. Am. J. Nurs. 69:521-524, 1969. 9. Guyton, A. C. Textbook of Medical Physiology, p. 854. W. B. Saunders Company, Philadelphia, 1966. 10. Inhelder, B., and Piaget, J. The Growth of Logical Processes from Childhood to Adolescence. Basic Books, New York, 1958.

Summary
This paper presents a framework for assessing patient self-care capacities and an example of a use of the framework in relation to requirements for self-care related to diabetes mellitus. Given condition of patient health state and given the patient residential environment, the definition of patient self-care capacities establishes a value which must be assessed in relation to the therapeutic self-care demand. The definition of patient self-care capacities may, in fact, influence the definition of what the demand might be. Based on the definition of the present self-care system and its capacities in relation to the therapeutic self-care demand, nursing assistance is considered as a mediating system which complements or

AAAS ANNUAL MEETING TO HOLD SESSION ON WOMEN

A session on the "Occupational Health Status of Women" will be part of the annual meeting of the American Association for the Advancement of Science to be held January 28, 1975, in New York City. Speakers will consider patterns of female employment, hazards in the workplace, the adequacy of data on morbidity and mortality of the working woman, and the effects of social and technological changes as they impinge on women's right to work. For further information write: Vilma R. Hunt, Associate Professor of Environmental Health, College of Human Development, The Pennsylvania State University, University Park, PA 16802.

ERRATUM
In the article "Hemoglobinopathy Screening: Approaches to Diagnosis, Education, and Counseling," by Robert M. Schmidt, MD, which was published in the August, 1974, issue of this Journal, two errors appeared on page 802. These errors are corrected as follows: "At a recent symposium, F. Clarke Fraser (not Frazier) mentioned three things that must be done in a good counseling program . . ." and "Thus, counseling for genetic disease requires an unusually perceptive (not perspective), empathetic person with a wide range of knowledge and training. . ."
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