NCM 100: Theoretical Foundations of Nursing PDF

NCM 100: Theoretical Foundations of Nursing SUBTOPIC 1A; HISTORY OF NURSING THEORY 4. Theory Emphasis was placed on middle range Nursing Utilization Era theory for theory-base...

NCM 100: Theoretical Foundations of Nursing SUBTOPIC 1A; HISTORY OF NURSING THEORY 4. Theory Emphasis was placed on middle range Nursing Utilization Era theory for theory-based nursing practice, as - The history of professional nursing began with Florence well as on theory development. Nightingale. - It was Nightingale who envisioned nurses as a body of educated women at a time when women were neither C. MID 1970s educated nor employed in public service. - An evaluation of the first 25 years of the journal Nursing - Nursing began with a strong emphasis on practice, but Research revealed that nursing studies lacked conceptual throughout the century, nurses worked toward the connections and theoretical frameworks. development of nursing as a profession through successive - An awareness of the need for concept and theory development periods recognized as historical eras. coincided with two other significant milestones in the evolution of nursing theory (1) standardization of curricula for nursing master’s Mid 1800s education and (2) decision that doctoral education for nurses should - Nightingale wrote that nursing knowledge is distinct from be in nursing. medical knowledge. She described a nurse’s proper - In the 1970s, nursing continued to make the transition from function as putting the patient in the best condition for vocation to profession as more and more nurses asked, “Will nursing nature (God) to act upon him or her. She proposed that care be other-discipline based or be nursing based?” The history records of the sick is based on knowledge of persons and their the answer, “Nursing practice needs to be based on nursing science” surroundings – a different knowledge base than that used is as noted, “theory is not a luxury in the discipline of nursing … but by physicians in their practice. an integral part of the nursing lexicon in education, administration, - Nursing practice was based on principles and traditions and practice”. that had been passed on through an apprenticeship model of education and hospital-kept procedure manuals. D. 1980s Although some nursing leaders aspired for nursing to be recognized as - It was a period of major developments in nursing theory a profession and become an academic discipline, nursing practice characterized as a transition from the pre-paradigm to the paradigm continued to reflect its vocational heritage more than a professional period. vision. - It provides perspectives for nursing practice, administration, education, research and further theory development. B. HISTORICAL ERAS 1. Curriculum Era Addressed the question of what prospective nurses should study to learn how to be a nurse, the emphasis was on what courses nursing students should take, with the goal of arriving at a standardized curriculum. 2. Research Era This era came about as more and more nurses embraced higher education and arrived at a common understanding of the scientific age, that is, that research is the path to new nursing knowledge. Nurses began to participate in research, and research courses began to be included in the SIGNIFICANCE OF THEORY FOR THE DISCIPLINE AND nursing curricula of many developing PROFESSION graduate programs. Discipline - The significance of theory for the discipline of nursing is that 3. Theory Era Natural outgrowth of the research and the discipline is dependent upon theory for its continued graduate education eras. As our existence, that is, we can be a vocation, or we can be a understanding of research and knowledge discipline with a professional style of theory-based practice. development increased, it soon became - Knowledge of persons, health, and environment forms the obvious that research without theory basis of recognition of nursing as a discipline, and this produced isolated information, and that it knowledge is taught to those who enter this profession was research and theory together that - Every discipline or field of knowledge includes theoretical produced nursing science. knowledge. Therefore, nursing as an academic discipline depends on the existence of nursing knowledge. For those In the early years of the theory era, doctoral entering the profession, this knowledge is basic for their education in nursing flourished with an practice. emphasis on theory development. 1|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing Profession - As a nursing theory is essential for the existence of nursing For example, research revealed gaps between the pain management as an academic discipline, it is also vital to the practice of needs of patients and the information communicated by patients and professional nursing. clinicians during office visits. Although many older adults have painful but not readily visible conditions (e.g., symptomatic osteoarthritis), Nursing is recognized as a profession today because its development little research has examined how the style or format of a health care was guided by the criteria for a profession. practitioner’s questions influence the quality and amount of diagnostic information obtained from older adults. A recent study - Body of knowledge is important, the theories and research tested the theory that a certain type of question would elicit the most are vital to the discipline and profession, so that new response. The theory was confirmed when findings supported that the knowledge continues to be generated. open-ended questions prompted patients to provide a larger amount of diagnostically useful pain information than did the closed-ended Criteria for development of the professional status of nursing: questions. While this study is one example of nursing science, advance 1. Utilized in the practice a well-defined and well-organized practice nurses should be familiar with the long history of the science knowledge [that] is on the intellectual level of the higher of nursing. learning 2. Constantly enlarges the body of knowledge it uses and HISTORICAL VIEWS OF THE NATURE OF SCIENCE improves its techniques of education and service through Let us consider these philosophical questions to know more about use of the scientific method what is the science of nursing. 3. Entrusts the education of its practitioners to institutions of 1. What is science, knowledge, and truth? higher education 2. What methods produce scientific knowledge? 4. Applies its body of knowledge in practical services vital to human and social welfare Note: Remember that science is a logical, systematic, and coherent 5. Functions autonomously in the formulation of professional way to solve problems and answer questions. It is a collection of activity facts known in an area and the process used to obtain that 6. Attracts individuals with intellectual and professional knowledge. qualities of exalting service above personal gain who recognize their chosen occupation as a life work Two competing philosophical foundations of science, rationalism and 7. Strives to compensate its practitioners by providing empiricism, have evolved in the era of modern science with several freedom of action, opportunity for continuous professional variations. Gale (1979) labeled these alternative epistemologies as growth, and economic security. centrally concerned with the power of reason and the power of sensory experience. Gale noted similarity in the divergent views of A discipline is a specific to A profession refers to a science in the time of the classical Greeks. For example, Aristotle academia and refers to a branch specialized field of practice. believed that advances in biological science would develop through of education, a department of systematic observation of objects and events in the natural world, learning, or a domain of whereas Pythagoras believed that knowledge of the natural world knowledge. would develop from mathematical reasoning. Nursing science has been characterized by two branching B. HISTORY AND PHILOSOPHY OF SCIENCES philosophies of knowledge as the discipline developed. Various terms Why is it important? are utilized to describe these two stances: empiricist and - The history and philosophy of science is important as a interpretive, mechanistic and holistic, quantitative and qualitative, foundation for exploring whether scientific results are and deductive and inductive forms of science. Understanding the actually truth. As nurses our practice should be based upon nature of these philosophical stances facilitates appreciation for what truth and we need the ability to interpret the results of each form contributes to nursing knowledge. science. Nursing science provides us with knowledge to describe, explain and predict outcomes. The legitimacy of 1. Rationalism any profession is built on its ability to generate and apply Rationalist epistemology (scope of knowledge) theory. emphasizes the importance of a priori reasoning as the appropriate method for advancing The development of nursing science has evolved since the 1960s as a knowledge. A priori reasoning utilizes deductive pursuit to be understood as a scientific discipline. Being a scientific logic by reasoning from the cause to an effect or discipline means identifying nursing’s unique contribution to the from a generalization to a particular instance. An care of patients, families, and communities. It means that nurses can example in nursing is to reason that a lack of social conduct clinical and basic nursing research to establish the scientific support (cause) will result in hospital readmission base for the care of individuals across the life span. (effect). This causal reasoning is a theory until disproven. The traditional approach proceeds by explaining hospitalization with a systematic explanation (theory) of a given phenomenon (Gale, 1979). 2|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing 2. Empiricism - At present many theories in nursing are focused on The empiricist view is based on the central idea relationships among four major concepts that scientific knowledge can be derived only Note: Metaparadigm: Greek “meta” – with and “paradigm” – pattern from sensory experience (i.e., seeing, feeling, hearing facts). - A metaparadigm is the most general statement of discipline Best example to demonstrate: formulating and functions as a framework in the more restricted differential diagnoses structures of conceptual models. Highly important in the assessment of patients all throughout the entire nursing process NURSING METAPARADIGM Formulating different diagnoses. This requires Person Person is the recipient of nursing care and many collecting the facts and devising a list of possible include individuals, patients, groups, families, and theories to explain the fact. Also, the use of communities empiricism is highly important in the assessment Health Health is defined as the degree of wellness or well- of patients all throughout the entire nursing being that the client experiences process. Environment Environment (for situation) is defined as the internal and external surrounds that affect the In summary, deductive inquiry uses the theory-then-research client approach, and inductive inquiry uses the research-then-theory Place or community where care is provided approach. Both approaches are utilized in the field of nursing. Nursing The attributes, characteristics, and actions of the nurse providing care on behalf of or conjunction Early 20th Century Views of Science and Theory with, the client - Philosophers focused on the analysis of theory structure, Action; interaction of the nurse with the person whereas scientists focused on the empirical research. There was minimal interest in the history of science, the nature of CONCEPTUAL MODELS scientific discovery, or the similarities between the philosophical view What are conceptual models? of science and the scientific methods (Brown, 1977). - Defined as a set of concepts and statements that integrate - Positivism, a term first used by Comte, emerged as the the concepts into a meaningful configuration dominant view of modern science (Gale, 1979). Modern - Is a set of general and abstract concepts and propositions logical positivists believed that empirical research and integrated into the meaningful configuration; these are logical analysis (deductive and inductive) were two global concepts of individuals, groups of people, situations, approaches that would produce scientific knowledge events and phenomena which are the focus of a particular (Brown, 1977). scientific discipline. Emergent Views of Science and Theory in the Late 20 th Century What are nursing concept models? - Empiricists view phenomena objectively, collect data, and - In nursing there are dozens of conceptual models which analyze it to inductively proposed theory (Brown, 1977). are created by induction or deduction. This position is based upon objective truth existing in the - Representatives of various models interpret the same world, waiting to be discovered. Brown (1977) set forth a phenomenon in different ways, ex: an individual in models king (open new epistemology challenging the empiricist view system) an Orem (self-caring individual). They interpret the four proposing that theories play a significant role in determining metaparadigmatic concepts and their relation differently. what the scientist observes and how it is interpreted. The following story illustrates Brown’s premise that What is the relationship of conceptual models and theories to observations are concept laden; that is, an observation is nursing care? influenced by values and ideas in the mind of the observer: - Nursing conceptual models are abstractions which are applied to practice in the nursing process. “An elderly patient has been in a trauma and appears to be crying. The - A nursing process is a conceptual problem-solving nurse on admission observes that the patient has marks on her body approach used to identify actual and potential health problems. and believes that she has been abused; the orthopedist has viewed an Guides. It guides nursing practice implementation of comprehensive, x-ray and believes that the crying patient is in pain due to a fractured safe, effective, and intervention. femur that will not require surgery only a closed reduction; the chaplain observes the patient crying and believes the patient needs Strengths of the Nursing Process spiritual support. Each observation is concept laden.” - Applicable in all levels of nursing practice - A scientific, holistic, problem solving method. STRUCTURE OF NURSING KNOWLEDGE - Referred to as a blueprint or plan for client care A. METAPARADIGM - Nurses apply the nursing process as a competency when What ae nursing metaparadigms? delivering client care. - Are patterns or models used to show a clear relationship among the existing theoretical works in nursing NURSING PROCESS Assessment Collect client health data PARADIGM: refers to a pattern of shared understanding and Nursing Diagnosis Analyze assessment data to determine assumption about reality, the word; worldview or accepted value diagnoses system. 3|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing Outcome Identification Identities expected outcomes of client To walk from one place to Taking 6 steps without for nursing diagnoses another or to move about assistance Planning Develops plan of care and prescribe interventions to the attain expected outcomes Implementation Implement the interventions (action types) in the plan of care Evaluation Evaluates client’s attainment of outcomes Proposition - Explains the relationships of different concepts Assessment Diagnoses Assumption Planning, Outcome Identification - Specifies the relationship or connection of factual concepts Implementation of phenomena Evaluation The following diagram explains the relationship of concept, THEORY propositions, assumptions and definitions with theory and What is Theory? phenomenon - A set of concepts, propositions, definitions, and assumptions that project a systemic view of a phenomenon. Concepts Propositions Assumptions CONCEPTS Definitions - Building blocks of a theory Systematic Organization - Labels or names for phenomena/ observable facts - Assist us in formulating a mental image about an object or Theory situation View Phenomenon 2 TYPES OF CONCEPT: 1. Abstract Concept: Are indirectly observed or intangible How our authors define theory: Ex. Love, Care, Freedom HOW OTHER AUTHORS DEFINE THEORY: Parker (2001) “A theory, by traditional definition, is an 2. Concrete Concept: Are directly observed or tangible organized coherent set of concepts and Ex. Nurse, Mother, Pain their relationship to each other that offers descriptions, explanations and predictions Definition about a phenomena” - Composed of various descriptions which convey a general meaning and reduce the vagueness in understanding a set Potter (2004) “A theory is a set of concepts, definitions, of concepts relationships and assumptions that project a systematic view of phenomena” CONCEPTUAL DEFINITIONS: are the meaning of a word based on how a certain theory or relevant literature perceives it to be Blackwell (2005) “(It is) a reasoned proposed explanation of an occurrence, or of something that will OPERATIONAL DEFINITIONS: are the meaning of a word based on the occur or be produced, for which absolute method of how it was measured or how the person came up with the proof is lacking” perception Delaune and Ladner “A theory is a set of concepts and TYPES OF DEFINITION OF CONCEPTS (2006) propositions that provide an early way to CONCEPTUAL OPERATIONAL view phenomena” Compares to definition from a Specifies exactly how the literature such as a dictionary, concept will be determined and Mosby (2006) “(It is) an abstract statement formulated to encyclopedia, and journals assess. It also identifies predict, explain or describe the procedures and operations relationships among concepts, constructs significant to determine or events. It is tested by observation and concepts. research using factual data” Example 1: Hospital Stay Kozier (2008) “A theory is a supposition or system of The time during which a person The total days as patient, ideas that is proposed to explain a given is a registered patient in a beginning with admission day phenomenon” certain hospital and finishing with discharge Example 2: Ambulation 4|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing NURSING THEORY recognize what should set the foundation of practice by What about a nursing theory? explicitly describing nursing. - Nursing theory is a group of interrelated concepts that are - By proving a definition of nursing, nursing theory also helps developed from various studies of discipline and related the nurses to understand their purpose and role in the experiences. healthcare setting. - This aims to view the essence of nursing care. Theorists are - Theories serve as a rationale scientific reason for nursing specifically contributed by different times and ages interventions and give nurses the knowledge base - For instance, in the 19th century, Florence Nightingale necessary for acting and responding appropriately in projected a valuable relationship between health and nursing care situations. environment factors like fresh air, sunlight, and ventilation. THEORY Purposes of Nursing Theories 1. Describes - The primary purpose of theory is to improve practice by 2. Explains positively influencing the health and quality of life and 3. Predicts patients. 4. Prescribes - Nursing theories are also developed to define nursing care, guide nursing practice, and provide a basis for clinical NURSING CARE decision making. E. Middle – Range Theory Education - They are the least abstract level of theoretical knowledge - Used to develop and guide nursing education in universities because this includes details specific to nursing practice. and institutions. - Descriptions, explanations, and predictions are made with - They were once known to be more strongly established in the purpose of answering questions about different nursing the field of academics rather than in clinical practice. phenomena. - They specify such things as the health condition, the patient Studying nursing theories develop analysis skills and critical thinking population (age group), the location of practice, and the ability for the purpose of safe and effective nursing practice. different interventions of the nurse. Example: Application of Leininger’s transcultural nursing theory for developing culturally similar strategies is useful to nurses working with suspected child maltreatment cases In Research - Development of theory is fundamental to the research process where it is necessary to use theory framework to provide perspective and guidance to the research study. - Theory can also be used to guide the research process by creating a testing phenomena of interest - Theory can improve nursing profession’s ability to meet societal duties and responsibilities, there need to be a continuous reciprocal and cyclical connection with theory, practice, and research. - This will help connect the perceived “gap” between theory and practice and promote the theory-guided practice. In Profession - Clinical practice generates research questions and knowledge for theory. - In a clinical setting, its primary contribution has been the facilitation of reflection, question, and thinking about what Let us learn deeper the importance of nursing theories and its nurses do. purpose to out discipline, research, and profession - Because nurses and nursing practice are often subordinate to power institutional forces and traditions, the introduction Why are nursing theories important? of any framework that encourages nurses to reflect on, - Nursing theories are the basis of nursing practice today. In question, and think about what they do provides an many cases, nursing theory guides knowledge development individual service and directs education, research, and practice. - - Historically, nursing was not recognized as an academic CLASSIFICATION OF NURSING THEORIES discipline or as a profession. Before nursing was developed - There are different ways to categorize nursing theories. and recognized, nursing was considered to be a task- They are classified depending on their function, levels of oriented occupation. abstraction, or goal orientation - The training and function of nurses were under the direction and control of the medical profession. Theories help 5|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing Descriptive theories are the first level of theory development. They describe the phenomena and identify its properties and components in which it occurs. Descriptive theories are not action-oriented or attempt to produce or change a situation. There are two types of descriptive theories: factor-isolating theory and explanatory theory. II. 1. Factor – Isolating Theory Also known as category-formulating or labeling theory. Theories under this category describe the properties and BY ABSTRACTION dimensions of phenomena. - There are three major categories when classifying nursing II. 2. Explanatory Theory theories based on their level of abstraction: grand theory, Explanatory theories describe and explain the nature of middle-range theory, and practice-level theory. relationships of certain phenomena to other phenomena. I.1 Grand Nursing Theories Prescriptive Theories Grand theories are abstract, broad in scope, and - Address the nursing interventions for a phenomenon, guide complex, therefore requiring further research for practice change, and predict consequences. clarification. - Includes propositions that call for change. Grand nursing theories do not guide specific - In nursing, prescriptive theories are used to anticipate the nursing interventions but rather provide a general outcomes of nursing interventions. framework and nursing ideas. Grand nursing theorists develop their works OTHER WAYS OF CLASSIFYING NURSING THEORIES based on their own experiences and their time, Classification According to Meleis explaining why there is so much variation among - Afaf Ibrahim Meleis (2011), in her book Theoretical Nursing: theories. Development and Progress, organizes the major nurse Address the nursing metaparadigm components theories and models using the following headings: needs of person, nursing, health, and environment. theories, interaction theories, and outcome theories. These categories indicate the basic philosophical underpinnings of I.2 Middle – Range Nursing Theories the theories. More limited in scope (compared to grand theories) and present concepts and propositions Needs – Based The needs theorists were the first group of at a lower level of abstraction. They address a Theories nurses who thought of giving nursing care a specific phenomenon in nursing. conceptual order. Theories under this group Due to the difficulty of testing grand theories, are based on helping individuals to fulfill nursing scholars proposed using this level of their physical and mental needs. Theories of theory. Orem, Henderson, and Abdella are Most middle-range theories are based on a grand categorized under this group. Need theories theorist’s works, but they can be conceived from are criticized for relying too much on the research, nursing practice, or the theories of medical model of health and placing the other disciplines. patient in an overtly dependent position. I.3 Practice – Level Nursing Theories Interaction These theories emphasized nursing on the Practice nursing theories are situation-specific theories Theories establishment and maintenance of that are narrow in scope and focuses on a specific relationships. They highlighted the impact of patient population at a specific time. nursing on patients and how they interact Practice-level nursing theories provide frameworks for with the environment, people, and nursing interventions and suggest outcomes or the situations. Theories of King, Orlando, and effect of nursing practice. Travelbee are grouped under this category. Theories developed at this level have a more direct effect on nursing practice than more abstract theories. Outcome These theories describe the nurse as These theories are interrelated with concepts from Theories controlling and directing patient care using middle-range theories or grand theories. their knowledge of the human physiological and behavioral systems. The nursing theories BY GOAL ORIENTATION of Johnson, Levine, Rogers, and Roy belong - Theories can also be classified based on their goals. They to this group. can be descriptive or prescriptive. II. Descriptive Theories 6|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing CLASSIFICATION ACCORDING TO ALLIGOOD - She was able to complete her nursing training in 1851 (at In her book, Nursing Theorists and Their Work, Raile Alligood (2017) age 31) at Kaiserwerth, Germany, a protestant religious categorized nursing theories into four headings: nursing philosophy, community with a hospital facility. She was there for nursing conceptual models, nursing theories and grand theories, and approximately 3 months; at the end of that time, her middle-range nursing theories. teachers declared her trained as a nurse - She died on August 13, 1910 Nursing Philosophy It is the most abstract type and sets forth the meaning of nursing phenomena CRIMEAN WAR (1845 – 1856) through analysis, reasoning, and logical RUSSIA VS TURKEY presentation. Works of Nightingale, - Nightingale received a request from Sidney Herbert (a Watson, Ray, and Benner are categorized family friend and the secretary of war) to travel to Scutari, under this group. Turkey, with a group of nurses to care for wounded British soldiers; at that time, the mortality rate of wounded Nursing Conceptual These are comprehensive nursing soldiers was incredibly high. Models theories that are regarded by some as - She arrived there in November 1854 (age 34) accompanied pioneers in nursing. These theories by 34 newly recruited nurses who met her criteria for address the nursing metaparadigm and professional nursing—young, middle-class women with a explain the relationship between them. basic general education (not the usual type of women who Conceptual models of Levine, Rogers, were identified as nurses in England). Roy, King, and Orem are under this group. - She was called The Lady of the Lamp, as immortalized in the poem “Santa Filomena” (Henry Wadsworth Longfellow, Grand Nursing Are works derived from nursing 1857), because she made ward rounds during the night, Theories philosophies, conceptual models, and providing emotional comfort to the soldiers. other grand theories that are generally - Her writings, Notes on Matters Affecting the Health, not as specific as middle-range theories. Efficiency, and Hospital Administration of the British Army Works of Levine, Rogers, Orem, and King Founded Chiefly on the Experience of the Late War are some of the theories under this (Nightingale, 1858b), Notes on Hospitals (Nightingale, category. 1858a), and Report on Measures Adopted for Sanitary Improvements in India, from June 1869 to June 1870 Middle – Range Are precise and answer specific nursing (Nightingale, 1871), reflect her continuing concern about Theories practice questions. They address the these issues. specifics of nursing situations within the model’s perspective or theory from Published a notes on nursing: “What it is and what it is not” and which they are derived. Examples of “Notes in Hospital Middle-Range theories are that of Mercer, Reed, Mishel, and Barker. MAJOR CONCEPTS AND DEFINITIONS - Nightingale’s theory focused on environment; however, Nightingale used the term surroundings in her writing. - She defined and described the concepts of ventilation, warmth, light, diet, cleanliness, and noise—components of surroundings usually referred to as environment in discussions of her work. - When reading Notes on Nursing (Nightingale, 1969), one can easily identify an emphasis on the physical environment. - Her concern about healthy surroundings involved hospital settings in Crimea and England, and also extended to the public in their private homes and to the physical living conditions of the poor. - She believed that healthy surroundings were necessary for proper nursing care and the restoration and maintenance of health. 1. PURE AIR: - Proper ventilation for the patient seemed to be of greatest concern to Nightingale; - Her charge to nurses was to “keep the air he breathes as FLORENCE NIGHTINGALE pure as the external air, without chilling him “ENVIRONMENTAL THEORY” - Nightingale’s emphasis on proper ventilation indicates that she recognized the surroundings as a source of disease and - Born on May 12, 1820, in Florence, Italy while her parents recovery. were on an extended European tour; she was named after her birthplace 7|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing In addition to discussing ventilation in the room or home, Nightingale provided a description for measuring the patient’s 1. Health of - Cleanliness outside the house body temperature through palpation of extremities to check for Houses affected the inside heat loss (Nightingale, 1969). The nurse was instructed to - Badly constructed houses do for the manipulate the surroundings to maintain ventilation and healthy what badly constructed patient warmth by using a good fire, opening windows, and hospitals do for the sick properly positioning the patient in the room. - Bad environment = Bad Health 2. LIGHT: 2. Ventilation - Keep the air he/she breathes as pure - She identified direct sunlight as a particular need of and Warming as the external air without chilling him patients. - (Fresh air) (By opening the windows - She noted that “light has quite as real and tangible effects and properly positioning the patient in upon the human body.... Who has not observed the the room) (Don’t let the patient slouch purifying effect of light, and especially of direct sunlight, since that patient will not be able to upon the air of a room” breathe properly) To achieve the beneficial effects of sunlight, nurses were - Maintain ventilation and patience instructed to move and position patients to expose them to warmth sunlight. 3. Light - Direct sunlight was what patients 3. CLEANLINESS: wanted - In this regard, she specifically addressed the patient, the - If the patients need stimulation: we nurse, and the physical environment. She noted that a dirty need to dim the lights environment (floors, carpets, walls, and bed linens) was a - Achieve the beneficial effects of source of infection through the organic matter it contained. sunlight 4. EFFICIENT DRAINAGE: 4. Noise - Patients should never be waked - Even if the environment was well ventilated, the presence intentionally or accidentally during of organic material created a dirty area; therefore the first part of sleep appropriate handling and disposal of bodily excretions and - Assess the need for quiet sewage were required to prevent contamination of the surroundings environment. 5. Variety - The need for changes in color and form in the environment can improve 5. PURE WATER: patient’s recovery - Finally, Nightingale advocated bathing patients on a - Bring the patients in bright lighted frequent, even daily, basis at a time when this practice was scenery not the norm. She required that nurses also bathe daily, that - Need for changes in color and form; their clothing be clean, and that they wash their hands excrement frequently (Nightingale, 1969). This concept held special significance for individual patient care, and it was critically 6. Bed and - The nurse to keep bedding clean, neat, important in improving the health status of the poor who Bedding and dry and to position the patient for were living in crowded, environmentally inferior conditions maximum comfort with inadequate sewage and limited access to pure water - If the patient is feeling really ill it will lead to poor circulation NIGHTINGALE’S ENVIRONMENTAL THEORY - One cause of: Bed sore CONCEPTUAL FRAMEWORK - Changed and aired frequently; avoid contact with the patient’s bed 7. Personal - Bathing and drying the skin provides Cleanliness comfort to the client - Dirty environment = source of infection through organic matter 8. Nutrition and - Variety of food should be presented to Taking Food the patient - Assess the dietary intake and effect of meal schedule; intelligent nurses successfully meet patient’s nutritional needs 9. Chattering - Falsely cheer the sick by making light Hopes and of their illness and its danger is not Advices helpful 8|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing - Communicate with the patients - Her treatise on rural hygiene includes an incredibly specific - Good news = benefit to becoming description of environmental problems and their results, as well healthier as practical solutions to these problems for households and communities (Halsall, 1997). 10. Social - Looking beyond the individual to the - She believed that sick poor people would benefit from Considerations social environment in which he or she environmental improvements that would affect both their bodies lived and their minds. She believed that nurses could be instrumental - We will be encountering different in changing the social status of the poor by improving their patients with different concerns physical living conditions. - Nightingale’s understandings of physical surroundings and their effect on health were acquired through first-hand observation and experience beyond her own comfortable living situation. MAJOR ASSUMPTIONS Nursing - Nightingale believed that every woman, at one time in her life, THE EFFECT ON NURSING PRACTICE would be a nurse in the sense that nursing is being responsible - Stressed the importance of hygiene and believed that it aided in for someone else’s health. the prevention of disease spreading - Nightingale wrote Notes on Nursing, published originally in 1859, - Focused on a holistic caring perspective (Environmental Theory: to provide women with guidelines for caring for their loved ones Conceptual Framework) at home and to give advice on how to “think like a nurse” - Aseptic practices Trained nurses, however, were to learn additional scientific principles - Nursing is continuous learning process because new and better to be applied in their work and were to be more skilled in observing practices are always being developed and reporting patients’ health status while providing care as the patient recovered. NURSING METAPARADIGMS 1. Nursing Person - “What nursing has to do… is to put the patient in the best - Nightingale referred to the person as a patient. condition for nature to act upon him.” - Nurses performed tasks to and for the patient and controlled the patient’s environment to enhance recovery. 2. Human Beings - For the most part, Nightingale described a passive patient in this - Relationship to their environment and the impact of the relationship. environment upon them However, specific references are made to the patient performing self- - In relation with the conceptual framework care when possible and, in particular, being involved in the timing and substance of meals. The nurse was to ask the patient about his or her 3. Environment preferences, which reveals the belief that Nightingale saw each - Focused on the ventilation, warmth, noise, light and cleanliness patient as an individual. However, Nightingale (1969) emphasized that - all that surrounds human beings is considered in relation to the nurse was in control of and responsible for the patient’s their state of health environmental surroundings. Nightingale had respect for persons of various backgrounds and was not judgmental about social worth. 4. Health - “Nature alone cures” Health - Nightingale defined health as being well and using every power THE NIGHTINGALE PLEDGE (resource) to the fullest extent in living life. I solemnly pledge myself before God and in the presence of this - In addition, she saw disease and illness as a reparative process assembly, to pass my life in purity and to practice my profession that nature instituted when a person did not attend to health faithfully. I will abstain from whatever is deleterious and mischievous concerns. and will not take or knowingly administer any harmful drug. I will do - Nightingale envisioned the maintenance of health through all in my power to maintain and elevate the standard of my profession prevention of disease by environmental control and social and will hold in confidence all personal matters committed to my responsibility. keeping and all family affairs coming to my knowledge in the practice - What she described led to public health nursing and the more of my calling. With loyalty with will I endeavor to aid the physician in modern concept of health promotion. She distinguished the his work and devote myself to the welfare of those committed to my concept of health nursing as different from nursing a sick patient care. to enhance recovery, and from living better until peaceful death. Environment MARGARET JEAN HARMAN WATSON - Nightingale’s concept of environment emphasized that nursing “WATSON’S PHILOSOPHY AND THEORY OF was to assist nature in healing the patient. Little, if anything, in TRANSPERSONAL CARING” the patient’s world is excluded from her definition of The disease might be cured, but illness would remain because without environment. caring, health is not attained. Caring is the essence of nursing and - Her admonition to nurses, both those providing care in the home connotes responsiveness between the nurse and the person; the and trained nurses in hospitals, was to create and maintain a nurse co-participates with the person. She contends that caring assists therapeutic environment that would enhance the comfort and the person to gain control, become knowledgeable, and prompt recovery of the patient. health changes. 9|N C M 1 0 0 : AT H E N A R I Z  NCM 100: Theoretical Foundations of Nursing TEN CARITAS PROCESSES - Born: West Virginia - Educated: BSN, University of Colorado, 1964, MS, University of TEN CARITAS PROCESSES Colorado, 1966, PhD 1. Cultivating the Humanistic and altruistic values are Practice of Loving – learned early in life but can be The theory was developed during 1979 when curing disease is the Kindness and influenced greatly by nurse domain of medicine. Watson asserted that the caring stance that Equanimity Toward educators and clinical experience. nursing has always held is being threatened by the tasks and Self and Other as This process can be defined as technology demands of the curative factors. Foundational to satisfaction through giving and Caritas extension of the sense of self and an THEORETICAL SOURCES Consciousness increased understanding of the - Watson’s work has been called a philosophy, blueprint, ethic, impact of love and caring on self and paradigm, worldview, treatise, conceptual model, framework, Formation of Human other. and theory. Altruistic System of Values - Watson (1988) defines theory as “an imaginative grouping of knowledge, ideas, and experience that are represented 2. Being Authentically This process, incorporating symbolically and seek to illuminate a given phenomenon” Present: Enabling, humanistic and altruistic values, - She draws on the Latin meaning of theory “to see” and Sustaining, and facilitates the promotion of holistic concludes, “It (Human Science) is a theory because it helps me Honoring the Faith, nursing care and positive health ‘to see’ more broadly (clearly)” Hope, and Deep within the patient population. It also - Watson points out that Carl Rogers’s phenomenological Belief System and describes the nurse’s role in approach, with his view that nurses are not here to manipulate the Inner – developing effective nurse-patient and control others but rather to understand, was profoundly Subjective World of interrelationships and in promoting influential at a time when “clinicalization” (therapeutic control Self/Other wellness by helping the patient adopt and manipulation of the patient) was considered the norm. health-seeking behaviors. Instillation of Faith-Hope 3. Cultivation of One’s The recognition of feelings leads to Own Spiritual self-actualization through self- Practices and acceptance for both the nurse and Transpersonal Self, patient. As nurses acknowledge their Going Beyond Ego - sensitivity and feelings, they become Self more genuine, authentic, and sensitive to others. The nurse also Cultivation of sensitivity of goes beyond feelings in a lifelong self and others exploration of personal values and belief systems with the goal of increased mindfulness in caring actions. 4. Development and The development of a helping-trust Sustaining a relationship between the nurse and Helping-Trust Caring patient is crucial for transpersonal Relationship caring. A trusting relationship THE SEVEN ASSUMPTIONS/PROPOSITIONS OF promotes and accepts the expression SCIENCE OF CARING: Development of Helping – of both positive and negative Trust Relationship feelings. It involves congruence, 1. Caring can be effectively demonstrated and practiced only empathy, nonpossessive warmth, interpersonally and effective communication. 2. Caring consists of carative factors that result in the satisfaction of Congruence involves being real, certain human needs. honest, genuine, and authentic. 3. Effective caring promotes health and individual or family growth Empathy is the ability to experience 4. Caring responses accept person not only as he or she is now but and thereby understand the other as what he or she may become person’s perceptions and feelings 5. A caring environment is one that offers the development of and to communicate those potential whole allowing the person to choose the best action for understandings. Nonpossessive himself or herself at a given point in time. warmth is demonstrated by a 6. Caring is more “healthogenic” that is curing. moderate speaking volume, a 7. The practice of caring is central in nursing. relaxed open posture, and facial expressions that are congruent with other communications. Effective communication has cognitive, 10 | N C M 1 0 0 : A T H E N A R I Z  NCM 100: Theoretical Foundations of Nursing affective, and behavior response examples of lower-order biophysical components. needs, whereas activity, inactivity, and sexuality are considered lower- 5. Being Present to, The sharing of feelings is a risk-taking order psychophysical needs. and Supportive of, experience for both nurse and Achievement and affiliation are the Expression of patient. The nurse must be prepared higher-order psychosocial needs. Positive and for either positive or negative Self-actualization is a higher-order Negative Feelings feelings. The nurse must recognize intrapersonal-interpersonal need. that intellectual and emotional Systematic Use of the understandings of a situation differ. Scientific Problem – Solving Methods for Decision Making 6. Creative Use of Self The process of nursing requires and All Ways of application of various ways of 10. Opening and Watson considers this process the Knowing as Part of knowing, including “creative, Attending to most difficult to understand and can the Caring Process; intuitive, aesthetic, ethical, personal Spiritual/Mysterious be best understood through her own Engage in the and even spiritual”. This process and Existential words. Artistry of Caritas moves most significantly away from a Unknowns of Life Nursing singular perspective on scientific Death “Our rational minds and modern knowledge as essential for nursing science do not have all the answers Systematic Use of the practice and calls upon the nurse to Allowance for Existential – to life and death and all the human Scientific Problem – use knowledge creatively in Phenomenological Forces conditions we face: thus, we have to Solving Methods for practicing caritas nursing. be open to unknowns we cannot Decision Making control, even allowing for what we may consider a ‘miracle’ to enter our 7. Engage in Genuine This factor is an important concept life and work. This process also Teaching – Learning for nursing in that it separates caring acknowledges that the subjective Experience that from curing. It allows the patient to world of the inner-life experiences of Attends to Unity of be informed and shifts the self and other is ultimately a Being and Subjective responsibility for wellness and phenomenon, an ineffable mystery, Meaning – health to the patient. The nurse affected by many, many factors that Attempting to Stay facilitates this process with teaching- can never be fully explained.” Within the Other’s learning techniques that are Frame of Reference designed to enable patients to provide self-care, determine NURSING METAPARADIGMS Promotion of personal needs, and provide Nursing Interpersonal Teaching- opportunities for their personal - Nursing is concerned with promoting health, preventing illness, Learning growth. caring for the sick, and restoring health - A human science of persons and human health-illness 8. Creating a Healing Nurses must recognize the influence experiences that are mediated by professional, personal, Environment at All that internal and external scientific, esthetic, and ethical human care transactions. Levels environments have on the health - Nursing’s goal, through the caring process, is to help people gain and illness of individuals. Concepts a high degree of harmony within the self in order to promote self- Provision for a Supportive, relevant to the internal environment knowledge and self healing, or to gain insight into the meaning Protective, and Corrective include the mental and spiritual well- of the happenings in life Mental, Physical, being and sociocultural beliefs of an Sociocultural, and individual. In addition to Human Being Spiritual Environment epidemiological variables, other - A valued person in and of him or herself to be cared for, external variables include comfort, respected, nurtured, understood, and assisted in general a privacy, safety, and clean, esthetic philosophical view of a person as a fully functional integrated surroundings. self. - The human is viewed greater than, and different from, the sum 9. Administering The nurse recognizes the biophysical, of his or her parts. Sacred Nursing Acts psychophysical, psychosocial, and - Humans are best viewed in a developmental conflicts, frame and of Caring – Healing intrapersonal needs of self and that systematic attention to developmental conflicts of by Tending to Basic patient. individuals and their families is necessary for health care Human Needs Patients must satisfy lower-order Health Assistance with needs before attempting to attain Gratification of Human higher-order needs. Food, Needs elimination, and ventilation are 11 | N C M 1 0 0 : A T H E N A R I Z  NCM 100: Theoretical Foundations of Nursing - The positive state of physical, mental, and social well-being MAJOR CONCEPTS AND DEFINITIONS (WHO definition) Novice - Has limited experience with tasks and needs - A high level of of overall physical, mental, and social functioning. rules to guide actions or rule-based reasoning - A general adaptive-maintenance of daily functioning - Is a time of using the theory and translating the - Unity and harmony within the mind, body, and soul lessons of nursing program into the real-life - Degree of congruence between the self as perceived and the self patient care environment as experienced - Beginner with no experience - Watson also states that the diagnosing of disease, treatment of - Taught general rules to help perform tasks illness, and prescriptions of drugs is medical care while health - Rule-governed behavior is limited and care focuses on lifestyle, social conditions and environment inflexible - Tell me what I need to do and I will do it Environment - Provides the values that determine how one should behave and Student Nurse what goals one should strive forward Working to acquire nursing knowledge & skills Advanced - Professional performance improves to become WATSON’S ORDERING OF NEEDS Beginner marginally acceptable Lower Order Needs - The need for food and fluid - The nurse knows the rules that govern care in (Biophysical Needs) - The need for elimination a situation but begins to understand how and - The need for ventilation when the rules can be applied based upon the patient’s condition, desire, and needs Lower Order Needs - The need for activity – inactivity - Has enough experience to recognize patterns (Psychophysical Needs) - The need for sexuality of work - Continues to need help setting priorities and Higher Order Needs - The need for achievement relies on rules and protocols (Psychosocial Needs) - The need for affiliation - Beginning to discern the situational elements to clinical decision making - Has gained prior experience in actual situations Higher Order Needs - The need for self – actualization (Intrapersonal – to recognized recurring meaningful Interpersonal Need) components - Principles, based on experiences, begin to be formulated to guide actions PATRICIA BENNER - Have the knowledge and the know-how but “CARING, CLINICAL WISDOM, AND ETHICS IN not enough in-depth experience NURSING PRACTICE” Newly Qualified Nurse - “Knowing how” and “knowing that” 6 months experience - Born: August 1942 at Hampton, Virginia; Nationality: American; Reliance on protocol & oversight from colleagues University of California - Notable Awards: Living Legend of the American Academy of Nursing Competent - Number of elements in clinical situation which - Novice to Expert is relevant is still overwhelming - Development of Knowledge in applied disciplines such as - Adopts and understand rules according to medicine and nursing is composed of the extension of practical relevance and set priorities knowledge (know how) through research and the - Recognize decisions that affect outcome and characterization and understanding of the “know how” of clinical becomes emotionally involved experience - Has been practicing 2-3 years - She conceptualizes in her writing about nursing skills as - Can prioritize and cope with various experience is a prerequisite for becoming an expert contingencies - Requires assistance working through situations not yet experienced CLINICAL CONTEXT Two years experience Able to provide independent care Assumes greater responsibility Proficient - Hallmark involves approaching a care situation with both concern and involvement and knowing intuitively what the priorities are and being able to perform the required procedures with proficiency, speed and confidence - Action becomes easier and less stressful as the nurse simply sees what needs to be achieved - Has enough experience to see the “big picture” rather than series of individual actions 12 | N C M 1 0 0 : A T H E N A R I Z  NCM 100: Theoretical Foundations of Nursing - Decision-making is more efficient and accurate KATIE ERIKSSON - Able to prioritize and plan even challenging patient care “THEORY OF CARITATIVE CARING” “Caritative caring means that we take “caritas' ' into use when caring for the human being in health and suffering… Caritative caring is a 3+ years experience Able to recognize and respond rapidly changing manifestation of the love that “just exists”... Caring communion, true clinical situations e.g. unstable patients caring, occurs when the one caring in a spirit of caritas alleviates the suffering of the patient” Expert - Can handle complex and unique situations - Born: November 18, 1943 at Jakobstad, Finland - Ability to discriminate and set priorities among - 1984 - appointed as Docent of CAring Science (part time) at situations all seen as important and to know University of Kuopio how to achieve goals once a decision has been - 1992 - appointed as Professor of caring science at Abo Akademi made University - Focus quickly on variable solutions - 1997 - Eriksson’s caritative theory of caring is known - No longer relies on rules to understand a internationally situation or to act appropriately - 1999 to 2002 - Chairperson of the Nordic Academy of Caring - Able to lead a teams efficiently, can organize Science other’s work and supervise them effectively 5+ years experience MAJOR CONCEPTS AND DEFINITIONS Expert Nurse Caritas Intuitive management of complex cases - Caritas means “love and charity.” In caritas, eros and agapé are Patient advocate united, and caritas is by nature unconditional love. Caritas, which is the fundamental motive of caring science, also constitutes the motive for all caring. It means that caring is an endeavor to MAJOR CONCEPTS AND DEFINITIONS – CONT’D mediate faith, hope, and love through tending, playing, and learning. Caring Communion - Caring communion constitutes the context of the meaning of caring and is the structure that determines caring reality. - It is a form of intimate connection that characterizes caring. - Caring communion requires meeting in time and space, an absolute, lasting presence. - Caring communion is characterized by intensity and vitality, and by warmth, closeness, rest, respect, honesty, and tolerance. It cannot be taken for granted but presupposes a conscious effort to be with the other. - Caring communion is seen as the source of strength and meaning in caring. The Act of Caring - The act of caring contains the caring elements (faith, hope, love, tending, playing, and learning), involves the categories of infinity