Class 7: Nursing Theory

Classification of Theory by Scope or Purpose

- By scope: o Grand theory: abstract o Middle range: less abstract and applies across settings and populations o Practice: specific to populations and settings. o Partial: a combination - By purpose: o Descriptive o Explanatory o Predictive o Perscriptive

Nursing Theory Purpose

- To Guide Research: o Setting limits on questions o Drives method to answer questions - To Guide Practice: o Provide insight o Common language o Improve efficiency and effectiveness o Enhanced professional autonomy and accountability • the idea of questioning • implementing new theory to improve the practice, to improve patient outcomes • *it enhances our professionalism * • gives us a common language to communicate with one another and other HCPs

ontological questions

what is the nature of nursing practice?

Unknowing

• "is an awareness that the nurse does not and cannot know or understand the client when they first meet, and by recognizing this unknowing, the nurse remains alert to the client's perspective of the situation" • "knowing that one does not know something, that one does not understand someone who stand before them and that perhaps this process does not fit into some preexisting paradigm or theory is critical to the evolution and development of knowledge" • suggests need for nurse to approach each new encounter with an openness and readiness for all possible types and sources of knowledge

Systems theories

• (Dorothy Johnson, UBC model, Betty Neuman, Sister Callista Roy) • during 1970s/80s, based on general systems theory for guidance in conceptualizing the complexity of human health • accounted for the whole of an entity (system) and its component parts (subsystems), as well as the complex interactions between the parts and the whole • enabled an expanded conceptualization of nursing practice through structure and process, where the individual was viewed as an open system in constant interaction with their environment • emphasized that intervention in any one part of a system produces consequent reactions in other parts, as well as the system as a whole

Practice-Based theories:

• (Florence Nightingale, The McGill Model) • conceptual models of nursing are designed to guide and shape practice • theoretical inspiration is derived directly from practice setting, h/w cannot capture all of what may influence that practice (ex societal and demographic changes, health care belief models, political struggles) • theories can be dated: reflect issues that were shaping the role and context of nursing during those specific times

Interactionist theories

• (Hidegard Peplau, Joyce Travelbee, Evelyn Adam) • focused on the relationships between the nurses and their clients • defined more clearly the specific human communicative and behavioural patterns by which practitioners met their patients' needs • reframed definitions of the nursing profession, drew from the work of psychologists and psychoanalysts such as Harry Stack Sullivan, Abraham Maslow, and Sigmund Frued

Simultaneity theories:

• (Martha Rogers, Rosemarie Parse, Jean Watson) • considered fundamentally distinct from practice, needs, interactionist, and system theories • characteristic feature is Rogers "unitary human being" • view the individual as an entirely irreducible whole, inherently and "holographically" connected with the universal environment • represent a distinct approach to articulating an understanding of the client of nursing as well as nursing's role in relation to that client

Needs theories:

• (Virginia Henderson, Dorothea Orem) • conceptualized the patient as representing a collection of needs • common theory in 1960s, in which needs, drives, and competencies were thought to hold potential for explaining human behaviour • Henderson defined nursing practice as assisting the individual in the performance of these basic needs to contribute to health, recovery, or a peaceful death • Orem considered role of the nurse to act temporarily for the patient until they could resume a more independent role

the context of early nursing theorizing

• *Florence Nightingale*: discipline's early theorists, rejected traditional social role of women, created systems for education of nurses and delivery of nursing care, active in massive reform of health care delivery system • feminist movements: nursing work rendered invisible and formal authority within health care decision making was eroded • during wartime: nurses elevated and contributions highly regarded, practice developed and expanded nursing knowledge and practice to benefit of patients and society • 1950s and 1960s: explosion of health sciences knowledge, nurses theorized and conceptualized the scientific basis of their practice and distinguished from more dominant health disciplines

concepts

• A mental formation of objects or events. Denotes some degree of classification or categorization. • A term to describe a phenomenon or group of phenomenon. - Example: Jet Lag. Grouped tired, irritability, sleep deprivation together. - Concepts of Interest to Nurses: Quality of life in long term care.

Central Aims of Nursing Theorists

• Foster self-caring behaviour that leads to individual health • Optimize human environments for health • A study of caring in the human health experience • Facilitate transitions to enhance a sense of well-being

Historical Evolution of Nursing Theory

• Nightingale: very passive, silent knowledge, very observational • Postwar science: logical positivism, very scientific, causality focused, appreciating context was irrelevant at the time • 1960s/70s: began to realize that meaning behind the human experience is relevant, as a result nurses lacked autonomy (broke away from physician assistants with this revelation); models of theory began to break out • 1970s - Metaparadigm thinking (person, environment, nursing, health); models were rigid, a disconnect between theory and practice • 1980s and 1990s: Blackish era • now: appreciating value of model as a guidelines, shaping the practice, profession is being eroded without theory to shape it

assumptions

• Statements that describe concepts or connect two concepts that are factual, accepted as truths and represent values beliefs or goals • Taken for granted statements that are generally accepted as probably true. • reserving assumptions fits intp the Unknowing pattern of knowing.

Summary

• Theory is a mental image and conception of reality. • Nursing theory is developed to answer central domain questions. • Central goal is the provision of effective nursing care of clients in any society. • qualities needed for theory development are thinking, reflecting, questioning, and perceiving the self as being capable of developing knowledge

theory

• a purposeful set of assumptions or propositions about concepts; shows relationships between concepts and thereby provides a systematic view of phenomena so that they may be explained predicted, or prescribed

Nursing Theory

• a way to structure what we are doing and why <-> Theory <-> Practice <-> Research • A conceptualized aspect of nursing reality communicated for the purpose of describing phenomena, explaining relationships between phenomena, predicting consequences or prescribing nursing care.

4) nursing (relationships)

• actions taken by the nurse on behalf of (or in conjunction with) the client • nursing enhances the relationship between the person and environment to achieve the goal of health. o ex: Health promotion, Educating people and clients

prescriptive theory

• addresses nursing interventions and helps predict the consequences of a specific intervention • designates the prescription (ie nursing interventions), the conditions under which the prescription should occur, and the consequences • are action oriented, which tests the validity and predictability of a nursing intervention • guide nursing research to develop and test specific nursing interventions

phenomena

• aspect of reality that can be consciously sensed or experienced, viewed from a variety of perspectives (a physician's, a nurse's, a psychologist's, an anthropologist's perspective varies)

3) health (goal)

• client's state of wellness/illness o It's holistic; there are different factors that determine one's health. o Physical, Spiritual, Mental, Emotional

conceptual frameworks

• conceptual framework builders of the late 1960s and after are usually referred to as the nursing theorists • four types of theory: grand theory, middle-range theory, descriptive theory, prescriptive theory

descriptive theory

• describes phenomena (ex responding to illness through patterns of coping), speculates on why phenomena occur, describes the consequences of phenomena • explain, relate, and in some situations predict phenomena of concern to nursing • designed not to direct specific nursing activities but rather to help explain client assessments as well as guide future nursing research

sense based phenomenon

• emotions that we experience, things we can think, feel, and discuss these experiences

middle-range theory

• encompasses a more limited scope and is less abstract • address specific phenomena or concepts and reflect practice (administration, clinical, or teaching) • phenomena or concepts tend to cross different nursing fields and reflect a variety of nursing care situations

metaparadigm concepts in nursing theory

• four concepts recognized as essential building blocks for any theoretical representation of nursing: 1) *person*, 2) *environment*, 3) *health*, or 4) *nursing* • refer to "client" rather patient to signify wide range of health states, a less patriarchal relationship between the care and the individual, and less individualistic - to families, groups or communities

early theoretical challenges

• fundamental clinical decision-making structure upon which all nursing theory was built was the "nursing process" • *nursing process*: systematic process of assessing, planning, intervening, and evaluating • became essential problem-solving approach nurses applied general knowledge into specific clinical situations • attempted to capture complexity of nursing reasoning in nonlinear, intellectual way forms basis of more recent theory, which uses terms like "clinical judgement," "critical thinking," and multiple ways of knowing"

grand theory

• global, conceptual framework that provides insight into abstract phenomena, such as human behaviour or nursing science • broad in scope and require further application through research before the ideas can be fully tested • intended to provide structural framework for broad, abstract ideas about nursing • aka paradigms: represent distinct world views about those phenomena and provide structural framework within which narrower-range theories can be developed and tested

1) client/person (object of concern):

• individual, family, group, or community that is the recipient of nursing care o goes across the lifespan and involves all groups of people o Interactions are important for healthy development o Each client is unique; they want to be defined as a person, not by their problem.

discipline

• is a body or a sphere of knowledge • is a field of inquiry characterized by a unique perspective and a distinct way of viewing phenomena • defines limitations and scope of practice that is unique to nursing

aesthetic knowing

• is a process of "perceiving or grasping the nature of a clinical situation; interpreting this information in order to understand its meaning for those involved, while envisioning desired outcomes in order to respond with appropriate skilled action; and subsequently reflecting on whether the outcomes were effectively achieved" • comes from the nurse's ability to grasp and interpret the meaning of a situation • makes use of nurse's intuition and empathy • involves the nurse's skills in imagining a desired and practical outcome in the actual situation and responding based on an interpretation of the whole situation, analyzing the interrelationships of its various aspects

personal knowing

• is knowledge of the concrete, individual self; it is not knowledge about the self • enables the nurse to transcend the notion of other individuals as objects but instead to engage with others in authentic personal relationships • these relationships result in an increasing willingness to accept ambiguity, vagueness, and discrepancy in oneself and others • involves three interrelated factors: l. Perceiving the self's feelings and prejudices within the situation 2. Managing the self's feelings and prejudices in order to respond appropriately (to the other) 3. Managing anxiety and sustaining the self

ethical knowing

• is knowledge of what is right or wrong and the commitment to act on the basis of that knowledge • involves "judgments of moral value in relation to motives, intentions and traits of character" and focuses on obligations, on what ought to be done related to those judgments • sources include nursing's ethical codes and professional standards

Ontology (wikipedia)

• is the philosophical study of the nature of being, becoming, existence, or reality, as well as the basic categories of being and their relations. • Traditionally listed as a part of the major branch of philosophy known as metaphysics, ontology deals with questions concerning what entities exist or can be said to exist, and how such entities can be grouped, related within a hierarchy, and subdivided according to similarities and differences. • In the broadest sense, ontologists investigate what makes a human human, relying on institutional, social, and technical conventions representing a nexus of intellectual activities.

praxis

• is the process by which a theory, lesson, or skill is enacted, practiced, embodied, or realized • may also refer to the act of engaging, applying, exercising, realizing, or practicing ideas.

theoretical model

• mental representation of how things work

nursing knowledge

• nurses are fundamentally "knowledge workers" in that they synthesize "a broad array of information and knowledge from a wide variety of sources and bring that synthesis to bear on nursing work" • four distinct patterns: (a) *empirics*: the science of nursing; (b) *aesthetics*: the art of nursing; (c) *personal knowing*: the intra- and interpersonal nature of nursing; (d) *ethics*: the moral component of nursing • each of the ways of knowing represents a necessary but incomplete representation of the discipline of nursing • there is also an inherent interrelationship between the four patterns

phenomena / conept

• phenomena: is an aspect of reality • concept: mental formulation of phenomena

empirical knowing

• positivistic science, i.e, it is logically determined and based on observable phenomenon • observable phenomenon. It is knowledge that is systematically organized into general laws and theories that serve to describe, explain, and/or predict the phenomena of interest to nursing • sources are research and theory and model development • for the practicing nurse must always be interpreted within the context of specific clinical situations

Sociopolitical Knowing

• situates nursing practice in the world of society, community life, culture, economics, and politics, all of which impact human health • central questions "Whose voice is heard? Whose voice is silenced?" • Nightingale emphasized deep concern and sympathy for the intense social deprivation and suffering outside of privileged society, within the labouring classes, as well as her interest in feminsim

2) environment (context)

• social environment (client's family, friends, significant others) and the physical environment (surroundings) o ex: Physical, Family, Political, Community

nursing praxis

• the dynamic interaction between theorizing and clinical practice • does *not* seek static truths about nursing practice • seeks to create a coherent foundation upon which nurses can build, challenge, and integrate an infinite range of new ideas, new forms of knowledge, and new path toward action • represents a blend of the art and science of nursing • engages knowledge in a reflexive manner that invokes emancipation and fuels action

phenomenology

• the lived experience • a philosophy and research method that explores meaning • what does it feel like?

conceptualization

• the process of formulating concepts

conceptual framework

• theoretical structure that links concepts together for a specific purpose • when its purpose is to show how something works, it can also be a theoretical model • nursing conceptual frameworks link major nursing concepts and phenomena to direct nursing decisions • aka nursing models or nursing theories

Nightingale

• very individualistic perspective, move towards holistic view with promotion of emotional state, focus on physical health primarily • environment: focus on hygiene to aid care and recovery, putting pt in best position to improve health via nature • nurses interaction with clients was to manipulate the environment to allow the pt to achieve better health; pt had to actively participate