Nursing Theory The Basis for Professional Nursing

Nursing Theory The Basis for Professional Nursing

INTRODUCTION

The nursing profession, in addition to other professions, has faced and still faces the consequences of fast technological and scientific advancement in the last decades. As a result of this advance, the first nursing theoreticians appeared in the 1950s, represented by professionals who were concerned about understanding and describing their functions and roles, thus enabling the nursing practice to be understood. These nurses sought to identify a unique conceptual field for this profession, independent from the medical model in particular, seeking greater professional autonomy.

Theory constitutes a systematic form of perception of the world with the purpose of understanding it, becoming the way to characterize a phenomenon and to point the aspects that identify it.

The application of a theory to the nursing practice seems to represent a growing interest among nurses. The use of theory supports nurses in the definition of their roles, better knowledge of reality and the resulting adequacy and quality of professional development, enabling clients to undergo the least harmful procedures and types of care possible, challenging current practices, creating new approaches and remodeling the structure of norms and existing principles.

Nursing theory can be described as an instrument of work that emphasizes scientific knowledge, showing the trends of views of the health-disease process and the experience of therapeutic care. Thus, Nursing, as science, includes a set of theories based on the practice of care, conceptualizing health, man, the environment and nursing itself. Its definitions are influenced by both theoreticians and its social, political and philosophical context, so that nursing theory and practice can be complementary moments of the praxis.

·         Theories are composed of concepts, definitions, models, propositions & are based on assumptions.

·         They are derived through two principal methods; deductive reasoning and inductive reasoning.

Objectives

·         to assess the patient condition by the various methods explained by the nursing theory

·         to identify the needs of the patient

·         to demonstrate an effective communication and interaction with the patient.

·         to select a theory for the application according to the need of the patient

·         to apply the theory to solve the identified problems of the patient

·         to evaluate the extent to which the process was fruitful.

Definition

·         Nursing theory is an organized and systematic articulation of a set of statements related to questions in the discipline of nursing.

·         "A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and /or prescribing."

Characteristics of a Useful Theory [Robert T. Croyle (2005)]

A useful theory makes assumptions about a behavior, health problem, target population, or environment that are:

·         Logical

·         Consistent with everyday observations

·         Similar to those used in previous successful programs and

·         Supported by past research in the same area or related ideas.

Importance of nursing theories

·         Nursing theory aims to describe, predict and explain the phenomenon of nursing

·         It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future. Theory is important because it helps us to decide what we know and what we need to know

·         It helps to distinguish what should form the basis of practice by explicitly describing nursing. The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education

·         The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do

·         As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge

·         This can be seen as an attempt by the nursing profession to maintain its professional boundaries

Evolution of Nursing Theories & Application

·         The history of professional nursing begins with Florence nightingale.

·         Later in last century nursing began with a strong emphasis on practice.

·         Following that came the curriculum era which addressed the questions about what the nursing students should study in order to achieve the required standard of nursing.

·         As more and more nurses began to pursue higher degrees in nursing, there emerged the research era.

·         Later graduate education and masters education was given much importance.

·         The development of the theory era was a natural outgrowth of the research era.

·         With an increased number of researches it became obvious that the research without theory produced isolated information; however research and theory produced the nursing sciences.

·         Within the contemporary phase there is an emphasis on theory use and theory based nursing practice and lead to the continued development of the theories.

Characteristics of theories

Theories are

·         Interrelating concepts in such a way as to create a different way of looking at a particular phenomenon.

·         Logical in nature.

·         Generalizable.

·         Bases for hypotheses that can be tested.

·         Increasing the general body of knowledge within the discipline through the research implemented to validate them.

·         Used by the practitioners to guide and improve their practice.

·         Consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.

Purposes of theory in practice

·         Assist nurses to describe, explain, and predict everyday experiences.

·         Serve to guide assessment, intervention, and evaluation of nursing care.

·         Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation.

·         Help to establish criteria to measure the quality of nursing care

·         Help build a common nursing terminology to use in communicating with other health professionals. Ideas are developed and words defined.

·         Enhance autonomy (independence and self-governance) of nursing by defining its own independent functions.

PURPOSES OF NURSING THEORIES
In Practice:

  • Assist nurses to describe, explain, and predict everyday experiences.
  • Serve to guide assessment, interventions, and evaluation of nursing care.
  • Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation.
  • Help to describe criteria to measure the quality of nursing care.
  • Help build a common nursing terminology to use in communicating with other health professionals. 
  • Ideas are developed and words are defined.
  • Enhance autonomy (independence and self-governance) of nursing through defining its own independent functions. 

In Education:

  • Provide a general focus for curriculum design
  • Guide curricular decision making.

In Research:

  • Offer a framework for generating knowledge and new ideas.
  • Assist in discovering knowledge gaps in the specific field of study.
  • Offer a systematic approach to identify questions for study; select variables, interpret findings, and validate nursing interventions.
  • Approaches to developing nursing theory
  • Borrowing conceptual frameworks from other disciplines.
  • Inductively looking at nursing practice to discover theories/concepts to explain phenomena.
  • Deductively looking for the compatibility of a general nursing theory with nursing practice.
  • Questions from practicing Nurse about using Nursing theory

Practice

  • Does this theory reflect nursing practice as I know it?
  • Will it support what I believe to be excellent nursing practice?
  • Can this theory be considered in relation to a wide range of nursing situation?
  • Personal Interests, Abilities and Experiences
  • What will it be like to think about nursing theory in nursing practice?
  • Will my work with nursing theory be worth the effort?

Conclusion

·         If theory is expected to benefit practice, it must be developed co- operatively with people who practice nursing.

·         People who do research and develop theories think differently about theory when they perceive the reality of practice.

·         Theories do not provide the same type of procedural guidelines for practice as do situation- specific principles and procedures or rules.

·         Procedural rules or principles help to standardize nursing practice and can also be useful in achieving minimum goals of quality of care.

·         Theory is ought to improve the nursing practice.

·         One of the most common ways theory has been organized in practice is in the nursing process of analyzing assessment data.

Virginia Henderson

The Principles and Practice of Nursing

“I believe that the function the nurse performs is primarily an independent one – that of acting for the patient when he lacks knowledge , physical strength, or the will to act for himself as he would ordinarily act in health, or in carrying out prescribed therapy. This function is seen as complex and creative, as offering unlimited opportunity for the application of the physical, biological, and social sciences and the development of skills based on them.”
(Henderson, 1960) 

Major Concepts

Human or Individual
Henderson considers the biological, psychological, sociological, and spiritual components.
She defined the patient as someone who needs nursing care, but did not limit nursing to illness care.
Society or Environment
She did not define environment, but maintaining a supportive environment is one of the elements of her 14 activities.
She sees individuals in relation to their families but minimally discusses the impact of the community on the individual and family.
She supports the tasks of private and public health agencies keeping people healthy.
She believes that society wants and expects the nurse’s service of acting for individuals who are unable to function independently.
Health
Health was not explicitly defined, but it is taken to mean balance in all realms of human life.
Nursing
Henderson believed that “the 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 (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”
(Henderson, 1991)

 

Subconcepts

Activities for Client Assistance
Physiological
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 environment
8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others
Psychological Aspects of Communicating and Learning
10. Communicate with others in expressing emotions, needs, fears, or opinions
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities
Spiritual and Moral
11. Worship according to one’s faith
Sociologically Oriented to Occupation and Recreation
12. Work in such a way that there is sense of accomplishment
13. Play or participate in various forms of recreation
“It is equally important to realize that these needs are satisfied by infinitely varied pattern of living, no two of which are alike.” (Henderson, 1960)

 

Assumptions

Nurses care for patients until patients can care for themselves once again.
Patients desire to return to health.
Nurses are willing to serve and that “nurses will devote themselves to the patient day and night.” (Henderson, 1991)
Nurses should be educated at the university level in both arts and sciences.
Henderson also believes that mind and body are inseparable. It is implied that the mind and body are interrelated.
(Henderson, 1966, 1991)

 

Strengths/Weaknesses
Henderson’s work is relatively simple yet generalizable with some limitations. Her work can be applied to the health of individuals of all ages. Limited in a way that it can generally be applied to fully functional individuals.
Each of the 14 activities can be the basis for research. Although the statements are not written in testable terms, they may be reformulated into researchable questions.
Strength
The concept of nursing formulated by Henderson in her definition of nursing and the 14 components of basic nursing is uncomplicated and self-explanatory. Therefore, it can be used without difficulty as a guide for nursing practice by most nurses.
Weakness
A major shortcoming in her work is the lack of a conceptual linkage between physiological and other human characteristics.

 

Analysis

One cannot say that every individual who has similar needs indicated in the 14 activities by Henderson are the only things that human beings need in attaining health and for survival. With the progress of today’s time, there may be added needs that humans are entitled to be provided with by nurses.
The prioritization of the 14 Activities was not clearly explained whether the first one is prerequisite to the other. But still, it is remarkable that Henderson was able to specify and characterize some of the needs of individuals based on Abraham Maslow’s hierarchy of needs.
Some of the activities listed in Henderson’s concepts can only be applied to fully functional individuals indicating that there would always be patients who always require aided care which is in contrary to the goal of nursing indicated in the definition of nursing by Henderson.
Because of the absence of a conceptual diagram, interconnections between the concepts and subconcepts of Henderson’s principle are not clearly delineated.

Jean Watson

Caring Science as Sacred Science

In today’s world, nursing seems to be responding to the various demands of the machinery with less consideration of the needs of the person attached to the machine. In Watson’s view, the disease might be cured, but illness would remain because without caring, health is not attained. Caring is the essence of nursing and connotes responsiveness between the nurse and the person; the nurse co-participates with the person. Watson contends that caring can assist the person to gain control, become knowledgeable, and promote health changes.

 

Major Concepts

Society provides the values that determine how one should behave and what goals one should strive toward. Watson (1979) states:
“Caring (and nursing) has existed in every society. Every society has had some people who have cared for others. A caring attitude is not transmitted from generation to generation by genes. It is transmitted by the culture of the profession as a unique way of coping with its environment.”
Human being is a valued person to be cared for, respected, nurtured, understood, and assisted.
Health is the unity and harmony within the mind, body, and soul; health is associated with the degree of congruence between the self as perceived and the self as experienced.
Nursing is a human science of persons and human health – illness experiences that are mediated by professional, personal, scientific, esthetic, and ethical human care transactions.
Actual caring occasion involves actions and choices by the nurse and the individual. The moment of coming together in a caring occasion presents the two persons with the opportunity to decide how to be in the relationship – what to do with the moment.
The transpersonal concept is an intersubjective human-to-human relationship in which the nurse affects and is affected by the person of the other. Both are fully present in the moment and feel a union with the other; they share a phenomenal field that becomes part of the life story of both. (Watson, 1999)

Subconcepts

Phenomenal field

The totality of human experience of one’s being in the world. This refers to the individual’s frame of reference that can only be known to that person.
Self

The organized conceptual gestalt composed of perceptions of the characteristics of the “I” or “ME” and the perceptions of the relationship of the “I” and “ME” to others and to various aspects of life.

Time

The present is more subjectively real and the past is more objectively real. The past is prior to, or in a different mode of being than the present, but it is not clearly distinguishable. Past, present, and future incidents merge and fuse. (Watson, 1999)

Nursing interventions related to human care originally referred to as carative factors have now been translated into clinical caritas processes(Watson, 2006):

1. The formation of a humanistic-altruistic system of values, becomes: “practice of loving-kindness and equanimity within context of caring consciousness.”

2. The instillation of faith-hope becomes: “being authentically present, and enabling and sustaining the deep belief system and subjective life world of self and one-being-cared-for.”

3. The cultivation of sensitivity to one’s self and to others becomes: “cultivation of one’s own spiritual practices and transpersonal self, going beyond ego self.”

4. The development of a helping-trusting relationship becomes: “developing and sustaining a helping-trusting authentic caring relationship.”

5. The promotion and acceptance of the expression of positive and negative feelings becomes: “being present to, and supportive of the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for.”

6. The systematic use of the scientific problem-solving method for decision making becomes: “creative use of self and all ways of knowing as part of the caring process; to engage in artistry of caring-healing practices.”

7. The promotion of interpersonal teaching-learning becomes: “engaging in genuine teaching-learning experience that attends to unity of being and meaning attempting to stay within other’s frame of reference.”

8. The provision for a supportive, protective, and(or) corrective mental, physical, sociocultural, and spiritual environment becomes: “creating healing environment at all levels (physical as well as non-physical), subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and peace are potentiated.”

9. Assistance with the gratification of human needs becomes: assisting with basic needs, with an intentional caring consciousness, administering ‘human care essentials,’ which potentiate alignment of mindbodyspirit, wholeness, and unity of being in all aspects of care,” tending to both embodied spirit and evolving spiritual emergence.

Watson’s (1979) ordering of needs:

Lower Order Needs (Biophysical Needs)

Survival Needs

The need for food and fluid

The need for elimination

The need for ventilation

b. Lower Order Needs (Psychophysical Needs)

Functional Needs

The need for activity-inactivity

The need for sexuality

c. Higher Order Needs (Psychosocial Needs)

Integrative Needs

The need for achievement

The need for affiliation

d. Higher Order Need (Intrapersonal-Interpersonal Need)

Growth-seeking Need

The need for self-actualization.

10. The allowance for existential-phenomenological forces becomes: “opening and attending to spiritual-mysterious and existential dimensions of one’s own life-death; soul care for self and the one-being-cared-for.”

 

Assumptions

Caring can be effectively demonstrated and practiced only interpersonally.

Caring consists of carative factors that result in the satisfaction of certain human needs.

Effective caring promotes health and individual or family growth.

Caring responses accept a person not only as he or she is now but as what he or she may become.

A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time.

Caring is more “healthogenic” than is curing. The practice of caring integrates biophysical knowledge with knowledge of human behavior to generate or promote health and to provide ministrations to those who are ill. A science of caring is therefore complementary to the science of curing.

The practice of caring is central to nursing. (Watson, 1979).

Relationships

Transpersonal caring field resides within a unitary field of consciousness and energy that transcend time, space and physicality.

A transpersonal caring relationship connotes a spirit-to-spirit unitary connection within a caring moment, honoring the embodied spirit of both practitioner and patient, within a unitary field of consciousness.

A transpersonal caring relationship transcends the ego level of both practitioner and patient, creating a caring field with new possibilities for how to be in the moment.

The practitioner’s authentic intentionality and consciousness of caring has a higher frequency of energy than noncaring consciousness, opening up connections to the universal field of consciousness and greater access to one’s inner healer.

Transpersonal caring is communicated via the practitioner’s energetic patterns of consciousness, intentionality, and authentic presence in a caring relationship.

Caring-healing modalities are often noninvasive, nonintrusive, natural-human, energetic environmental field modalities.

Transpersonal caring promotes self-knowledge, self-control, and self-healing patterns and possibilities.

Advanced transpersonal caring modalities draw upon multiple ways of knowing and being; they encompass ethical and relational caring, along with those intentional consciousness modalities that are energetic in nature that honors wholeness, healing, comfort, balance, harmony, and well-being. (Watson, 2005)

 

Strengths/Weaknesses

Strengths:

Watson’s work can be used to guide and improve practice. It can provide the nurse with the most satisfying aspects of practice and can provide the client with holistic care.

The theory is relatively simple

Watson’s work is logical in that the carative factors are based on broad assumptions that provide a supportive framework. The carative factors are logically derived from the assumptions and related to the hierarchy of needs.

The carative factors delineate nursing from medicine.

Weakness:

Watson’s theory becomes more complex when entering the area of existential-phenomenology, for many nurses may not have the liberal arts background to provide the proper foundation for this area.

 

Analysis

It is undeniable that technology has already been part of nursing’s whole paradigm with the evolving era of development. Watson’s suggestion of purely “caring” without giving much attention to technological machineries cannot be solely applied but then her statement is praiseworthy because she dealt with the importance of the nurse patient interaction rather than a practice confined with technology.

Watson stated the term “soul-satisying” when giving out care for the clients. Her concepts guide the nurse to an ideal quality nursing care provided for the patient. This would further increase the involvement of both the patient and the nurse when the experience is satisfying.

In providing the enumerated clinical caritas processes, the nurse becomes an active co-participant with the patient. Thus, quality of care offered by the nurse is enhanced.