Chapter 9: Nursing Theory, the basis for professional nursing – Flashcards

Leininger specified caring as the essence of nursing, and nurses who use Leininger's theory of cultural care in their practices view patients in the context of their cultures. Practice from a cultural perspective begins by respecting the culture of the patient and recognizing the importance of its relationship to nursing care. Use of the "sunrise model" (Figure 9-1) guides the assessment of cultural data for an understanding of its influence on the patient's life (Leininger, 1991). The nurse plans nursing care, recognizing the health beliefs and folk practices of the patient's culture, as well as the culture of traditional health services. To this end, nursing care is then focused on culture care preservation, accommodations, or repatterning, depending on the patient's need. The nursing outcome of culturally congruent nursing care is health and well-being for the patient.

A general explanation scholars use to explain, predict, control, and understand commonly occurring events -Theories represent abstract ideas rather than concrete facts -New theories are always being generated, although some theories are useful for many years -when new knowledge becomes available, theories that are no longer useful are modified or discarded -Why is theory important? Because nursing as a profession is strengthened when nursing knowledge is built on a sound theory -In today's research environment where theory is developed and tested, interdisciplinary collaboration is now considered to be a critical approach to the development of knowledge -Secondly, theory is useful tool for reasoning, critical thinking, and decision making >the ultimate goal of nursing practice is to support excellence in practice

from the most to least abstract, these include metaparadigm, philosophy, conceptual model or framework, and theory

The metaparadigm of nursing consists of the major concepts of the discipline- person, environment, health and nursing -In the past two decades, caring has been added as a major concept of the discipline central to nursing knowledge development and practice.

metaparadigm of nursing, or also called the CONCEPTS (abstract notions or ideas) of most important to nursing practice and research

a set of beliefs about the nature of how the world works -For example: Florence Nightingale, wrote Notes on Nursing: What is it and what it is not, in which her basic philosophy of nursing is described in detail

more specific organization of nursing phenomena than philosophies -as the words "model" or "framework" imply, models provide an organizational structure that makes clearer connections between concepts

are statements that describe linkages between concepts and are more prescriptive; that is, they propose an outcome that is tesable in practice and research -For example: Peplau's book Interpersonal Relations in Nursing contains a theory that describes very specific elements of effective interaction between the nurse and patient -Peplau created a theory delineating elements of excellent and effective practice in psychiatric nursing. She linked abstract concepts such as health and nursing to create a concrete, useful theory for practice

is the original writings of the theorist- is the best source for in-depth understanding of the theory. -In the original writings, the theorist will describe exactly what he or she is thinking and how the concepts go together -criteria means (standard)

general understanding of nursing theory and theoretical developments in nursing in a unique but complimentary way

1. philosophies 2. conceptual models 3. theories 4. middle-range theories

-Her persistence in the face of her parents' opposition proved to be a sustained characteristic over the course of her life >This trait enabled her to accomplish work that most women of the time would not have had the education or willingness to achieve Nightingale explained her philosophy of health, illness, and the nurse's role in caring for patients in Notes on Nursing: What It Is & What it is not (1969) -Importantly, she made a distinction between the work of nursing and the work of physicians by identifying health rather than illness as the major concern of nursing -Nightingale's unique perspective on nursing practice focused on the relationship of patients to their surroundings. She set fourth principles that were foundational to nursing and remain relevant to nursing practice today -Nightingale focused the profession on what has become known as metaparadigm of nursing: person (patient), health (as opposed to illness), environment (how the environment affects health and recovery from illness), and nursing (as opposed to medicine)

-health of patients was related to their environment (open system) -she recognized importance of clean air & water & ventilation and sunlight -encourage arrangement of patients' bed so that they were in sunlight -people need balanced diet, nurse's responsibility to find out what the patients' ate -Nightingale recognized problem of loud noise is hospital room and that rest is important for recovery -she believed that sudden disruption of sleep was a serious problem -Nightingale's work was radically different -Nightingale recognized nursing's role in protecting patients -Nurses were newly responsible for shielding patients from possible harm by well-meaning visitors who may provide false hope, discuss upsetting news, or tire the patient with social conversation -Nurse off duty? doesn't matter, still have to take care of patient -she thought small pet visits may help patients.. long term and acute care settings -This philosophy provided the foundational work for theory development that proposed changing patients' environments to effect positive changes in their health -she promoted view that nurses' primary responsibility was to protect patients by careful management of their surroundings

-the "Florence Nightingale" of the 20th century -100 yrs after Nightingale, Virginia Henderson's work first was published, emerging at a time when efforts to clarify nursing as a profession emphasized the need to define nursing -Her definition of nursing, "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 that he would perform unaided if he had the necessary strength, will or knowledge" (1966) -Her early work remains noteworthy and relevant, defining nursing and specifying the role of the nurse in relation to the patient -Attempted to answer, like Nightingale, "What is the nursing profession?", "What do nurses do?" -Henderson described the nurse's role as that of a substitute for the patient, a helper to the patient, or a partner with the patient -Henderson identified 14 basic neds as a general focus for patient care

1. breathe normally 2. eat and drink adequately 3. eliminate body wastes 4. move and maintain desirable postures 5. sleep and rest 6. select suitable clothes—dress and undress 7. maintain body temperature within normal range by adjusting clothing and modifying the 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 one's 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 function of nurses was to assist patients if they were unable to perform any of these 14 functions themselves -although these needs can be categorized as physical, psychological, emotional, sociological, spiritual, or developmental, thoughtful analysis reveals a holistic view of human development and health

-Nurses whose practice is consistent with Henderson's philosophy adopt an orientation to care from the perspective of the 14 basic needs. -Henderson used her definition of nursing and the basic needs approach in her definition of nursing and the basic needs approach in her well-known case study of a young patient who had undergone a leg amputation. Using this case, Henderson demonstrated how the nurse's role changes on a day-to-day, week-to-week, and month-to-month basis in relation to the patient's changing needs and the contributions of other health care providers

-Watson is a more recent contributor to the evolving philosophy of nursing -She published the book "Philosophy and Science of Caring" -Within this book, she called for a return to the earlier values of nursing and emphasized the caring aspects of nursing. Watson's work is recognized as human science -Caring as a theme is reflected in her other professional accomplishments, such as the center for Human Caring at the University of Colorado in Denver

1. Embrace altruistic values and practice loving kindness with self and others. 2. Instill faith and hope and honor others. 3. Be sensitive to self and others by nurturing individual beliefs and practices. 4. Develop helping - trusting caring relationships. 5. Promote and accept positive and negative feelings as you authentically listen to another's story. 6. Use creative scientific problem-solving methods for caring decision making. 7. Share teaching and learning that addresses the individual needs and comprehension styles. 8. Create a healing environment for the physical and spiritual self which respects human dignity. 9. Assist with basic physical, emotional and spiritual human needs. 10. Open to mystery and allow miracles to enter.

philosophical question of the nature of nursing as viewed as a human-to-human relationship. -She focused on the relationship of the nurse and the patient, drawing on philosophical sources for a new approach that emphasized how the nurse and patient change together through transpersonal caring process -She equated health with harmony, resulting from unity of body, mind, and soul, for which the patient is primarily responsible. Illness or disease with equated with lack of harmony within the mind, body, and soul experienced in internal or external environments -Nursing is based on human values and interest in the welfare of others and is concerned with health promotion, health restoration, and illness prevention

-Watson's caritas processes guide nurses who use transpersonal caring in practice -Caritas processes specify the meaning of the relationship of nurse and patient as human being. Nurses are encouraged to share their genuine selves with patients -Patient's spiritual strength is recognized, supported, and encouraged for its contribution to health -In the process of transpersonal relationships, nurses develop and encourage openness to understanding of self and others. This leads to the development of trusting, accepting relationships in which feelings are shared freely and confidence is inspired. -Even a core element of practice such as patient teaching can be carried out in an interpersonal manner true to the philosophy and nature of the caring relationship -the nurse guided by Watson's work has responsibility for creating and maintaining an environment supporting human caring while recognizing and providing for patient's primary human requirements -Key aspects of nursing's metaparadigm evident in Watson's work are environment, person, health, and nursing. -Watson's work on caring has contributed to another aspect to the metaparadigm of nursing, bc caring itself is now considered by many scholars to be a central concept of the discipline of nursing

Anna, a hospice nurse, was working with a patient who was very ill with lung cancer and who had received both chemotherapy and radiation with the hope of achieving a long remission. The patient, a 60-year-old woman named Mavis, was what some people would refer to as a "character"—full of opinions that she would share with anyone who came close, still smoking, still cursing. 182Mavis' cancer did not respond to the various therapies, and metastases developed in her brain, causing occasional seizures. Mavis was terminally ill. Her abrasive personality did not allow many people to get near her, but she was very fond of Anna, who understood Mavis in a way that few did. They connected on a deep level, and, although they never talked in great depth about Mavis' impending death, Mavis revealed that one of her unfulfilled plans was to be baptized. She did not remember her baptism from childhood and did not want to die without having that memory. Although nothing in the nursing texts says it is a good idea to take a terminally ill patient into the cold of January to church for an immersion baptism, it was Anna's human-to-human caring approach that allowed her to respect the meaning of this event from Mavis' point of view. On a bitterly cold night with a howling wind, Mavis was baptized by a friend who was a minister, her family in attendance, her turban covering her bald head. Mavis told Anna that she was free to die now. Within days she took to her bed. On one of her final days, the family called Anna frantically because Mavis had called for her all day. The on-call nurse covering the weekend simply could not console her, and Mavis' cries for her hospice nurse made the family muster the courage to call Anna on her day off. Anna, knowing Mavis as she did, responded, and when she arrived at the bedside, she asked Mavis what she could do to help her. Mavis' response was what Anna knew as "vintage Mavis": "I just wanted to see if you would come." Anna said simply, "I am here." Mavis lapsed into a peaceful coma that evening. Her last words had been to Anna. Anna practiced nursing with the philosophy that human-to-human relationships are primary in professional practice. In the confines of this deeply caring relationship, Mavis found acceptance and peace from her nurse and was guided into a calm death. Although the nurse whose guiding philosophy is based on human relationships must set clear professional boundaries, this philosophical approach to the practice of nursing raises the possibility of exquisite experiences between humans that transcend the nurse-patient relationship, just as Anna and Mavis experienced.

(or conceptual frameworks) are the second type of theoretical work that provides organizational structures for critical thinking about the processes of nursing -These are broad conceptual structures that provide comprehensive, holistic perspectives of nursing by describing the relationships of specific concepts -Models are less abstract and more formalized than the philosophies. Models are more abstract than theories of nursing. Theories are built from conceptual models much as buildings are constructed from blueprints -Conceptual models provide a preliminary view of the relationship between concepts of nursing that can be used to build theory

Dorothea Orem, Imogene King, and Sister Callista Roy

Over the years, Orem formalized three interrelated theories: the theory of self-care, theory of self-care 183deficit, and theory of nursing system. Her model focuses on the patient's self-care capacities and the process of designing nursing actions to meet the patient's self-care needs. In this model, the nurse prescribes and regulates the nursing system on the basis of the patient's self-care deficit, which is the extent to which a patient is incapable of providing effective self-care. An underlying assumption of Orem's model is that "ordinary people in contemporary society want to be in control of their lives" (Pearson, Vaughan, and FitzGerald, 2005, p. 104). Nursing is needed in the presence of an actual or potential self-care deficit (Orem, 2001) when patients cannot provide their own care adequately. Orem's work is widely used in nursing education and practice, providing a comprehensive system for nursing practice in a variety of clinical settings.

In Orem's model, appropriate care for the patient is developed through a series of three operations: diagnostic, prescriptive, and regulatory. To determine the patient's ability to provide effective self-care, the nurse initiates a diagnostic operation that begins with the establishment of the nurse-patient relationship. This includes contracting with the patient to explore current and potential self-care demands. Factors such as age, gender, and developmental status, as well as sociocultural and environmental factors, are examined in relation to universal, developmental, and health requirements and related self-care actions of the patient. In other words, the patient's baseline ability to provide adequate self-care is assessed by the nurse to determine the extent to which the patient is limited in providing his or her own effective care. These limitations are self-care deficits. Prescriptive operations occur when therapeutic self-care requisites (based on deficits) are determined and the nurse reviews various methods, actions, and priorities with the patient. This is a planning stage in which the nurse confirms with the patient the nurse's assessment of the patient's needs and begins to formulate a plan of care. In regulatory operations, the nurse designs, plans, and produces a system for care (Berbiglia, 2002). Systems of care range from wholly compensatory, which is the most comprehensive form of care for patients with few (if any) abilities to provide care for self, to supportive-educative, in which the patient has the ability to provide effective self-care, but needs to work with the nurse to further develop these abilities or acquire additional information to promote self-care (George, 2002).

-Roy's work is based on adaptation and adaptive behavior, which is produced by altering the environment. -According to Roy, the individual and the environment are sources of stimuli that require modification to promote adaptation in the patient -Roy viewed the person as an adaptive system, with physiologic, self-concept, role function, and interdependent modes -Roy's model provides a comprehensive understanding of nursing from the perspective of adaptation. When the demands of environmental stimuli are too high or the person's adaptive mechanisms are too low, the person's behavioral responses are ineffective for coping. Effective adaptive responses promote the integrity of the individual by conserving energy and promoting the survival, growth, reproduction, and mastery of the human system. Nursing promotes the patient's adaptation and coping, with progress toward integration as the goal (Phillips, 2002).

The nurse using Roy's model focuses on the adaptation of the patient and on the environment. Adaptation, specifically patients' adaptation behavior and stimuli in the internal and external environments, is assessed and facilitated. Based on these assessments, the nurse develops nursing diagnoses to guide goal setting and interventions aimed at promoting adaptation. Simply stated, the nurse modifies the environment to facilitate patient adaptation. Observable behavior is recognized and understood in the context of Roy's physiologic, self-concept, role function, and interdependent modes. Descriptions of the behaviors included in each mode provide the nurse with a means of making evaluative judgments about the patient's progress toward the goal of adaptation (Phillips, 2002). Roy's model is extensively used in nursing practice and has been described comprehensively in the literature

Mr. Elderd was referred to a home health agency for wound management. He had a very large open wound on his forehead as a result of a wide excision of several 185deep basal cell carcinomas, a form of skin cancer. Dean, his nurse, was surprised to see that the wound extended completely to Mr. Elderd's skull. Mr. Elderd was out of work as a result of this wound, saw friends infrequently, and was somewhat depressed. His wife, although well meaning, spent hours each day fixing him high-calorie "treats" because she liked to cook and found it was a good way to release her own anxiety about her husband's condition. Dean's nursing practice was shaped by Roy's adaptation model. In his initial assessment of the home environment, he noticed the cleanliness of the home, the evidence of supportive family and social ties, adequacy of income, availability of good nutrition, and other indicators of health. What Dean did not understand was why Mr. Elderd's wound was not healing. After Dean's assessment, he believed that there was some "missing link" in Mr. Elderd's adaptive abilities, but he was not sure whether the ineffective coping was psychological, environmental, or physiologic. Dean visited Mr. Elderd daily for 3 weeks and, although the wound did not become infected, it showed little evidence of closure. Dean expressed his concern to Mr. Elderd and decided to ask Mr. Elderd again some questions related to his basic health practices, including nutrition, activity, sleep, and elimination. Mr. Elderd commented almost off-handedly that he was sleeping fine except that he had to get up to go to the bathroom several times each night. His wife chimed in from the kitchen, "But that's no different than from the day. He is always going to the bathroom. I told him to quit drinking so much water all the time!" Dean, being an experienced nurse and seeking ways to assist patients with all forms of adaptation, realized the likely problem. He called Mr. Elderd's physician and asked for an order to draw a blood chemistry, including glucose. Sure enough, Mr. Elderd had undiagnosed diabetes. Mrs. Elderd's stream of cookies and other treats from the kitchen aggravated the problem to the point that Mr. Elderd was experiencing polyuria and polydipsia, both signs of diabetes. With aggressive blood glucose level management with insulin, a change in diet, and increasing exercise, Mr. Elderd's wound began to heal almost immediately. He did not require a skin graft as had been feared. The use of Roy's adaptation model allowed Dean to see Mr. Elderd's situation as a function of a variety of maladaptive coping efforts. Correcting the diabetic problem became the foundation for Mr. Elderd's eventual healing and resumption of his usual life activities.

Peplau, born in 1909, was one of the earliest nurse theorists who recognized the importance of the work of nursing rather than continuing to define and delineate nursing (Pearson et al., 2005, p. 179). Although Peplau's first book, Interpersonal Relations in Nursing, was published in 1952, it was published again in 1988, reflecting both the value of her work and nursing's continuing focus on interpersonal relationships. Peplau drew from developmental, interactionist, and human needs theories in developing her 186work (Pearson et al., 2005, p. 179), which grew from her interest in nursing care of psychiatric patients. Peplau believed, however, that all nursing is based on the interpersonal process and the nurse-patient relationship (Forchuk, 1993). -Peplau's theory is based on the premise that the relationship between patient and nurse is the focus of attention, rather than the patient only as the unit of attention (Forchuk, 1993, p. 7). Nursing care occurs within the context of the patient-nurse relationship. The goals of a therapeutic interpersonal relationship are twofold: first is the survival of the patient; second is the patient's understanding of his or her health problems and learning from these problems as he or she develops new behavior patterns. As the nurse assists the patient in developing new behavior patterns, the nurse also grows and develops a greater understanding of the effect of universal stressors on the lives and behaviors of individual patients

Hildegard Peplau: Within the relationship with my patient, how can I best help him or her understand his or her health problems and develop new, healthier behaviors? Ida Orlando: How can I best figure out what my patient needs through my interaction with him or her? Madeleine Leininger- What are the best ways to provide care to my patient that are culturally congruent?

Although Peplau's theory grew from her experience as a psychiatric nurse, her work is applicable to a wide variety of practice settings. Peplau describes a four-pronged process similar to the nursing process by which the nurse assists the patient in achieving personal growth. Completion of this process involves six roles by the nurse: counselor, resource, teacher, technical expert, surrogate, and leader (Pearson et al., 2005, p. 184). Depending on the setting, the nurse will spend more or less time in each of these roles. For instance, a nurse in a critical care unit will likely spend more time as a technical expert and less time as a counselor, whereas a nurse on a postpartum unit may act as a surrogate, guiding a new mother into independent care of her newborn infant, with less time spent as a leader. Peplau's theory is complex. Its importance lies in the focus on what happens between the nurse and patient in a therapeutic relationship. Furthermore, Peplau was visionary in recognizing the importance of the relationship between nurse and patient, publishing her ideas early and continuing to refine and expand her work over several decades.

The work of Madeleine Leininger (1978, 1991) in cultural care grew out of her early nursing experiences. She observed that children of different cultures had widely varying behaviors and needs. After discussing the parallels between nursing and anthropology with the noted anthropologist Margaret Mead, Leininger pursued doctoral study in cultural anthropology. Through her doctoral work she became more convinced about the relationship of cultural differences and health practices. This led her to begin developing a theory of cultural care for nursing. Leininger's work is formalized as a theory rather than as a conceptual model. It has stimulated the formation of the Transcultural Nursing Society, transcultural nursing conferences, newsletters, and the Journal of Transpersonal Nursing, as well as the awarding of master's degrees in the specialty area known as transcultural nursing. The goal of transcultural nursing involves more than simply being aware of different cultures. It involves planning nursing care based on knowledge that is culturally defined, classified, and tested—and then used to provide care that is culturally congruent (Leininger, 1978). Leininger described theory as a creative and systematic way of discovering new knowledge or accounting for phenomena in a more complete way (Leininger, 1991). She encouraged nurses to use creativity to discover cultural aspects of human needs and to use these findings to make culturally congruent therapeutic decisions. Her theory is broad because it considers the impact of culture on all aspects of human life, with particular attention to health and caring practices. Leininger's theory has become increasingly relevant as global migration continues and societies become more diverse.

Jan, a nurse with many years of experience providing care for patients with human immunodeficiency virus (HIV) in a large urban hospital, decided that she would move to a less chaotic environment. Jan applied for a job with an agency providing nursing care in the homes of low-income rural women with HIV. Jan had grown up and gone to college in a city in the northeast; her new home was in a rural county in the Deep South. Almost immediately Jan ran into some unanticipated situations that posed problems for her. She complained at team meetings that her patients were always late for their appointments. Members of the team, each of whom had grown up nearby, explained to her that this was not unusual behavior and that she should plan "waiting time" into her daily schedule. Jan was always surprised when the rest of the team reported good visits and outcomes with their patients, and almost all seemed to be caught up with their work consistently. Jan always felt like she was running behind. She began to question her nursing skills, her knowledge, and time management behaviors that had served her well in her previous work. Jan described herself as a "fish out of water." She decided that she would spend her "waiting time" by sitting in her car and catching up on paperwork until the patient arrived home. One day she was invited by the patient's grandmother to wait inside but she declined, saying that she would wait in the car and "get some work done." Her patient arrived home after 20 minutes or so and Jan met with her, reporting to the team later that day that she had a productive visit with the patient in which several care goals were addressed. Jan's satisfaction with the visit was short-lived. Her patient called, demanding that she be assigned another nurse because "Jan insulted my grandma." In this community where being invited into the home was considered an honor, Jan's decision to wait instead in the car was interpreted as rude and uncaring. No amount of discussion dissuaded the patient from her insistence that she have a new nurse who "knew how to act." The care team met with Jan, but they too, as products of the culture, did not understand at first that Jan did not mean to be insulting or rude. 188Because the other members of the team were deeply acculturated, they knew the meaning behind the grandmother's invitation: Jan was an honored, trusted guest who was welcomed in their home.