|Fundamentals of Nursing Practice||© Rhodora Cruz|
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Nursing Theories and the Practice of Nursing
The nursing practice must be based on nursing theories. This is what makes the nursing discipline a profession. The nursing theories provide direction and guidance for structuring professional nursing practice, education, and research. It also differentiates the focus of nursing from other professions. They serve to guide assessment, intervention, and evaluation of nursing care. They provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. They help to establish criteria to measure the quality of nursing care. They help build a common nursing terminology to use in communicating with other health professionals. Finally, nursing theories enhance the autonomy of nursing by defining its own independent functions.
In nursing education, nursing theories provide a general focus for curriculum design. They guide the curricular decision making.
In nursing research, nursing theories offer a framework for generating knowledge and new ideas. They assist in discovering knowledge gaps in the specific field of study. Finally, they offer a systematic approach to identify questions for study, select variables, interpret findings, and validate nursing interventions.
To understand nursing theories, a theory, concept, conceptual frameworks, and conceptual model must first be defined. A theory is a supposition or system of ideas that is proposed to explain a given phenomena. Concepts are the building blocks of theory, are abstract ideas or mental images of phenomena. A conceptual framework is a group of related concepts. It provides an overall view or orientation to focus thoughts. A conceptual model is a graphic illustration or diagram of a conceptual framework.
Nursing has four basic concepts, called metaparadigms. You can call this conceptual framework of nursing theories in general since a metaparadigm consists of a group of related concepts. The four metaparadigms of nursing are person or client, environment, health, and nursing. A person or client is the recipient of nursing care. Environment is the internal or external surroundings that affect the client. Health is the degree of wellness or well-being that the client experiences. Nursing are the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with, the client (Kozier, Erb, Berman, and Burke, 2000).
Nightingale’s Environmental Theory
Florence Nightingale is recognized as founder of modern-day nursing. Her environmental model is based on the idea that the impetus for healing lies within the individual human being and the focus of care is to place the individual in an environment that is supportive to that healing process. Her 13 canons speak to areas that require the attention of the nurse, such as cleanliness, ventilation, warming, light, noise, variety, nutrition, ®chattering hopes and advices,¯and observation of the sick. To utilize this theory in the nursing practice, the nurse would provide clean environment to prevent infection.
Peplau’s Interpersonal Relations Model
Hildegard E. Peplau, in addition to her other accomplishments, presented the first published theoretical development in nursing in the twentieth century. Her focus is on the interpersonal process between a nurse and a client and the roles played by the nurse in this process. The interpersonal process occurs in three phases: orientation, working, and termination. In the orientation phase, the client seeks help, and the nurse assists the client to understand the problem and the extent of the need for help. In the identification phase, the client assumes a posture of dependence, interdependence, or independence in relation to the nurse. In the exploitation phase, the client derives full value from what the nurse offers through the relationship. The client uses available services on the basis of self-interest and needs. Power shifts from the nurse to the client. To utilize this theory in the nursing practice, the nurse recognizes that the client move from one phase of dependence to independence during the nurse-patient interaction for the provision of health care.
Henderson’s Definition of Nursing
Virginia Henderson presented her definition of nursing as part of her effort to regulate nursing practice through licensure. Although all states now have licensure regulations for the practice of nursing, her definition has had far greater impact. Her 14 components of basic nursing care augment the definition to provide an overall guide to the practice of nursing. The following are the 14 fundamental needs that Henderson conceptualized for the nurse’s role:
1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
4. Moving and maintaining a desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal range by adjusting clothing and
modifying the environment
8. Keeping the body clean and well-groomed to protect the integument
9. Avoiding dangers in the environment and avoiding injuring others.
10. Communicating with others in expressing emotions, needs, fears, or opinions
11. Worshipping according to one’s faith
12. Working in such a way that one feels a sense of accomplishment
13. Playing or participating in various forms of recreation
14. Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities
To utilize this in the nursing practice, the nurse would see whether the client has all of these basic needs. If not, then, a problem exists. The nursing process must be then formulated, which will be discussed in Chapter 4.
Roger’s Science of Unitary Human Beings
Martha E. Rogers developed the Science of Unitary Human Beings as nursing’s unique body of knowledge. Human beings and their environments are infinite energy fields in continuous motion. They produce patterns and are unitary. Rogers’ three principles are the principles of resonancy (continuous change from lower to higher frequency), helicy (increasing diversity), and integrality (continuous process of the human and environmental fields). Roger states that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. Nurses trained in noncontact therapeutic touch claim they can assess and feel the energy field and manipulate it to enhance the healing process of people who are ill or injured. This nursing theory can be utilized in the nursing practice in many ways. For example, just being present most of the time in the room of a patient may help them recover quicker because of the energy transferred from the nurse to the patient. To utilize this in the nursing practice, the nurse would realize that visitors may help the patient recover quicker due to the energy fields of the visitors being transferred.
Orem’s General Theory of Nursing
Dorothea E. Orem’s general theory of nursing is made up of the three interrelated theories of self-care, self-care deficit, and nursing systems. A peripheral concept, basic conditioning factors, applies to all of the theories. The major concepts of self-care are self-care, self-care agency, self-care requisites (universal, developmental, and health deviation), and therapeutic self-care demand. A self-care deficit exists when the therapeutic self-care demand exceeds self-care agency. Nursing systems involve nursing agency and the design of nursing systems for care (wholly compensatory, partly compensatory, and supportive-educative). Orem’s nursing process is a three-step process (diagnosis and prescription, nursing system design, production and management of nursing systems). Orem’s theory of self care can be utilized in the nursing practice by being aware that individuals should be able to perform self-care duties to promote and maintain well-being.
King’s Goal Attainment Theory
Imogene M. King developed a general systems framework and a theory of goal attainment. The framework speaks to three levels of systems—individual or personal, group or interpersonal, and society or social. The theory of goal attainment speaks to the importance of interaction, perception, communication, transaction, self, role, stress, growth and development, time, and personal space. King emphasizes that both the nurse and the client bring important knowledge and information to the relationship and that they work together to achieve goals. Research has supported that when the nurse and client communicate and work together toward mutually selected goals, the goals are more likely to be attained. This theory can be utilized in the practice by being aware that goals are attained by the nurse and the client after they interact and this interaction is affected by perception, judgment, stress, growth and development, time, and personal space. Goals are likely to be attained once the nurse and clients interact and addressed these factors that affect the goals to be attained.
Neuman’s System’s Model
Betty Neuman developed the Neuman Systems Model to provide a structure for integrating information about humans in a holistic manner. The model consists of a core or basic structure and energy resources that provide for basic survival. Surrounding the core are the lines of resistance that are activated when a stressor invades the system. Outside of the lines of resistance is the normal line of defense, the system’s usual level of wellness that protects from the negative impact of stressors. Finally, the flexible line of defense is the outer boundary and provides the initial response to stressors. Each of these levels also incorporates the five client variables—physiological, psychological, sociocultural, developmental, and spiritual. There are three environments—internal, external, and created—and three levels of prevention—primary, secondary, and tertiary. Less clearly defined are reaction and reconstitution. Neuman presents her own process, which is compatible with the nursing process. Nursing interventions focus on retaining or maintaining system stability through primary, secondary, and tertiary prevention. Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction, and increasing the resistance factors. Tertiary prevention focuses on readaptation and stability and protects reconstitution or return to wellness following treatment.
Roy’s Adaptation Model
Sister Callista Roy developed the Roy Adaptation Model, which is based on the belief that the human being is an open system. The system responds to environmental stimuli through the cognator and regulator coping mechanisms for individuals and the stabilizer and innovator control mechanisms for groups. The responses occur through at least one of four modes—physiological-physical, self-concept-group identity, role function, and interdependence. The responses in these modes are usually visible to others and can be identified as adaptive or ineffective. Adaptive behaviors that need support and ineffective behaviors are then analyzed to identify the associated stimuli. The major stimulus leading to one of these behaviors is the focal stimulus; other stimuli that are verified as being involved are contextual, and stimuli that might be involved but have not been verified are residual. Nursing care focuses on altering stimuli or strengthening adaptive processes to result in adaptive behaviors.
Watson’s Human Caring Theory
Jean Watson (1979) believes the practice of caring is central to nursing; it is the unifying focus for practice. Caring science encompasses a humanitarian, human science orientation to human caring processes, phenomena and experiences. Caring science includes arts and humanities as well as science. A caring science perspective is grounded in a relational ontology of being-in-relation, and a world view of unity and connectedness of All. Transpersonal Caring acknowledges unity of life and connections that move in concentric circles of caring - from individual, to others, to community, to world, to Planet Earth, to the universe. Caring science investigations embrace inquiries that are reflective, subjective and interpretative as well as objective-empirical. Caring science inquiry includes ontological, philosophical, ethical, historical inquiry and studies. In addition, caring science includes multiple epistemological approaches to inquiry including clinical and empirical, but is open to moving into new areas of inquiry that explore other ways of knowing, for example, aesthetic, poetic, narrative, personal, intuitive, kinesthetic, evolving consciousness, intentionality, metaphysical - spiritual, as well as moral-ethical knowing. This is the theory nurses can utilized that caring is central to nursing. Hildegard E. Peplau, in addition to her other accomplishments, presented the first published theoretical development in nursing in the twentieth century. Her focus is on the interpersonal process between a nurse and a client and the roles played by the nurse in this process. The interpersonal process occurs in three phases: orientation, working, and termination.
Parse’s Human Becoming Theory
Rosemarie Rizzo Parse developed the Theory of Human Becoming (now known as the Human Becoming School of Thought) through a combination of concepts from Martha Rogers and from existential-phenomenological thought. Her nine assumptions are based on the three main themes of meaning, rhythmicity, and transcendence. Each theme leads to a principle: meaning relates to imagining, valuing, and languaging; rhythmicity relates to revealing-concealing, enabling-limiting, and connecting-separating; transcendence relates to powering, originating, and transforming. Each of the principles has a practice dimension and process. Parse’s model of human becoming emphasizes how individuals choose and bear responsibility for patterns of personal health. For example, a client who smokes cannot be instructed to just stop smoking because the client is the authority figure and decision maker. The nurse’s role involves helping him or her in choosing the possibilities for changing the health process.
Leininger’s Cultural Care Diversity and Universality Theory
Madeleine M. Leininger recognized the importance of an understanding of culture—both the nurse’s and the client’s—to effective nursing practice. She believes that all cultures have practices related to caring. Those practices that are common across cultures are culture care universalities, and those that are specific to a given culture are culture care diversities. Research findings indicate there is more diversity than universality. Leininger’s Sunrise Model depicts the dimensions of Culture Care Diversity and Universality.
The cultural and social structure dimensions include technological, religious, philosophic, kinship, social, value and lifeway, political, legal, economic, and educational factors. These factors influence the patterns and expressions of caring in relation to the health of individuals, families, groups, and communities. The involved health systems include folk systems, nursing, and other professional systems. To achieve culture congruent care, nursing actions are to be planned in one of three modes: culture care preservation/maintenance, culture care accommodation/negotiation, or culture care repatterning/restructuring. This theory can easily be applied in the nursing practice. For example, the nurse needs to be aware that caring is common to all cultures. However, there are more differences than similarities in the practice related to caring. Therefore, becoming familiar of ones culture is of utmost importance to provide the ultimate nursing care (Kozier, Erb, Berman, Burke, 2000).
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