CH. 8 Theory

practice

the first puzzle piece, initially, a nurse has an idea, which usually comes out of experiences in practice. ex: an idea could be "why don't I slow down and spend some time with the patients' families? That would really help them"

research

the second puzzle piece, after seriously considering the idea the nurse may decide it is worth investigating with research. ex: "how does spending more time with family members affect the quality of care the patient receives?"

Theory

the third puzzle piece, if the research supports the nurse's idea she could use the research findings to develop a theory. Then it could even be turned into a policy, practice, or standardized care plan.

Dr. Patricia Benner's novice to expert theory

- describes progression of a beginning nurse to increasing levels of expertise. - this theory provides info necessary to understand how you learn and perform your nursing responsibilities - 5 levels--> novice, advanced beginner, competent, proficient, and expert

developmental theory

- Erikson's psychological developmental theory - theories of family development - Kohlberg and Gilligan's theories of moral development - these theories are useful in nursing b/c they identify norms and expectations at various stages of development to help you identify activities and intervention appropriate for the patient

statements

- describes the linkages and interactions among the concepts of a theory - the statements taken as a whole, makes up the theory ex: Maslow's theory--2 concepts, physiological needs and self-esteem needs statement "physiological needs must be met to an acceptable degree before a person can attempt to meet his/her self-esteem needs".

system theory

- Ludwig Von Bertalanffy created system theory in 1940s - intended to be abstract enough to use for theory and research in any discipline - evolved to a point where it is part of our everyday system--healthcare, body, family, info, etc. - a system is made up of separate components or subsystems which constantly interact with each other or other systems ex: cardiovascular and renal systems are subsystems to the body and the cells are a subsystem to those systems--all these exhange info with each other and other systems - goal is to process input for use within the system or environment

conceptual model (aka conceptual framework)

- a model that is expressed in words/language - symbols=words - all models are conceptual b/c they all represent ideas

3. transpersonal caring moments

- a moral idea rather than a task-oriented behavior - such moments occur when an actual caring occasion or caring relationship exists between the nurse and the person - make a commitment to be a caring nurse, go to work with the commitment ex: "today I will be genuine with people in my care"

conceptual framework (aka theoretical framework)

- a set of concepts that are related to form a whole or pattern - tend to be broader and more philosophical than theories - are not developed using research processes and not been tested in practice

model

- a symbolic representation of a framework or concepts - a diagram, graph, picture, drawing or physical model

What is theory?

- a theory is an organized set of related ideas and concepts that helps us find meaning in our experiences (nursing) - organize our thinking around an idea (caring) - develop new ideas and insights into the work we do - a theory answers "what is this?" and "how does it work?" - a theory is based on observations of facts but is not a fact itself - merely a way of viewing phenomena (reality) - defines and illustrates concepts and explains how they are related or linked - theories can be and are usually revised

6. listening

- active listening - quiet your mind and truly listen with your mind and heart - listening from within yourself (your intuition)

validation theory

- arises from social work and provides for a way to communicate with older people with dementia - theory asks the caregiver to go where the demented person is in her/his own mind

Phenomena

- aspects of reality that you can observe and experience - subject matter of discipline (phenomena of concern) ex: pharmacists phenomena of concern are medications b/c of chemical composition and side effects for nurses: human beings--their body-mind-spirit responses to health, illness, disease, or injury

Virginia Henderson

- began her career as a U.S. Army nurse in 1918 - also a visiting nurse in NYC and a teacher of nursing - nursing student at Walter Reed Army hospital - questioned the mechanistic nursing care she was taught to give and how she was expected to be the doctor's handmaiden - first nurse to identify that there was no clear description of the purpose and function of nursing - her idea was that nurses deserve to know what it means to be a nurse - she identified 14 basic needs that are addressed by nursing care - she defined what nursing was in the 20th century

Dr. Imogene Rigdon theory

- bereavement of older women after noticing that older women handled grief differently from men and younger women - hospice organizations all over the country now use this theory to work with older women who have lost a significant other

Patricia Benner & J. Wrubel

- caring is central concept of their primacy of caring model - their idea was that the nurse's caring helps the client cope - opportunity for the nurse to connect with others and to receive as well as give help - caring involves personal concern for persons, events, projects, and things. - reveals what is stressful for a person and provides motivation b/c if something does not matter then it will not create stress - each person is unique so caring is always specific and relational for each nurse-person encounter

Grand theory

- covers broad areas of concern within a discipline - usually abstract and doesn't outline specific nursing interventions - deals with relationships among nurse, person, health, and environment - often used to guide program and curriculum planning in schools of nursing ex: Watson's theory of caring or Roger's science of unitary human beings

Dr. Jean Watson's Science of human caring

- developed nursing theory called science of human caring (1988) - this theory describes what caring means from a nursing perspective - before "caring theorists" nurses were mechanistic in their work/care ex: getting tasks done, not putting holistic care effect in completing tasks. Checking things off a list only and not doing "something more" - the point of this caring theory changes the focus of nursing - demonstrates the value of non-task-oriented aspects of nursing

Florence Nightingale

- during the Crimean war @ Scutari hospital she transformed nursing, is the founder of modern nursing - her idea was that more men would survive if they had a clean and healthy environment and nutritious food so that the body could heal itself - kept detailed records of what was happening at the hospital before and after she introduced her ideas - a clean environment would improve the health of patients - she dramatically reduced the death rate of soldiers and changed the way British army hospital system was managed

Nightingale's theory

- emphasize the importance of the environment in the care of patients - her work affected the design and building of hospitals for decades

practice theory

- focuses on a particular situation, defining explicit goals and interventions to address the situation

Madeleine Leininger

- founder of transcultural nursing - 1st nurse in U.S. to earn doctors degree in cultural and social anthropology - theory focuses on caring as cultural competence using knowledge of cultures and of nursing to provide culturally congruent and responsible care - approach came from working with children from diverse cultures who were under her care in a psych hospital - her idea was would psychotherapy for children be more effective if delivered within framework of the child's culture? - proved her theory to be true - meets all criteria of puzzle pieces - person: way of caring vary across cultures and an individual with cultural beliefs that are specific to herself and differ from others - nurse: the professional who values the cultural diversity of person and is willing to make cultural accommodations for the health benefit of the person required specialized cultural knowledge - environment: wherever the nurse and person is/are together in the healthcare system - health: defined by person and may be culturally specific in its definition

Nola Pender theory

- health promotion is the basis for most health promotion teaching done by nurses

Components of a theory: Assumptions

- ideas that we take for granted - presumes to be true--does not test with research ex: Watson presumed that nursing had its own professional concept-->caring and many theorists assume that human beings are complex but do not state it

feedback

- info about aspect of processing used to monitor system to make it better--how patient responded to intervention

definitions

- is a statement of the meaning of a term or concept that sets forth the concepts characteristics or indicators the things that allow you to identify the concept

Mid-range theory (or practice theory)

- is narrower and more specific - can be used to create nursing protocols and procedures and design educational programs ex: theory about comfort by an in-service education director in a residential care facility

deductive reasoning

- is the opposite of inductive reasoning - receive a call stating you will be getting a patient with kidney infection, you know what is involved in the general premise of kidney infection, so you deduce that the patient will probably have a fever and back pain - deduction starts with general premise & moves to a specific conclusion (big picture)

paradigm

- is the worldview or ideology of a discipline - the broadest, most global conceptual framework of a discipline - it includes and guides the values, philosophy, knowledge, theories, and research processes of the discipline - paradigms are NOT theories, they are just "how we see things"

The Framingham heart study

- long, multidisciplinary research project - several studies done over 50 years (1948-1998) - to identify the health & healthcare practices in one community--Framingham, Massachusetts - this project influenced many healthcare practices ex: mammography to screen for breast cancer became commonly accepted b/c mammography was once considered unimportant and unreliable.

5. comfort

- much more than just relief of pain - comfort occurs in four contexts - physical, psycho-spiritual, social, and environmental - is the person comfortable with you as the caregiver? - room temp - need more rest periods to heal - too much or too little environmental stimuli - patient's modesty is being respected

7. spiritual care

- need to know what an individual's spiritual needs are make appropriate plans to meet them - if the person does not want to talk about it then you will listen and respect their choices - BUT the opposite is true b/c people who are sick generally want to talk about their spiritual needs, but may be uncomfortable doing so - call a clergy member or simply pray with the person

how nurses use theories

- nursing theories try to describe, explain, and predict human behavior - the theory you use influences what you look for, what you notice, what you perceive as a problem, what outcomes you want, and what interventions you will choose - serve as a guide for assessment, problem, identification, and choice of nursing interventions

inductive reasoning

- often used in nursing practice/process - walk into patients room and see that temp is 101 degrees, pulse is 104 bpm, respiration rate of 20 then you could induce (conclude) that the patient is ill/sick - induction moves from the specific to the general - IN-duction: I have specific data out there and I bring the data "IN" to make the generalization

Full spectrum nursing (puzzle)

- practice - research - theory

output

- product or service that results from syystem's throughput ex: documents, money, cars, diagnoses, etc.

Hildegard Peplau

- psychiatric nurse from early 20th century - influenced the advancement of standards in nursing education, promoted self-regulation thru credentialing and was a strong advocate for advanced nursing practice - her idea was that health could be improved for psychiatric patients if there was more effective way to communicate with them - developed theory of interpersonal relations to focus on relationship between nurse and patient - theory of interpersonal communication can improve mental health

8. caring for the family

- recognize the importance of involving and respecting the family of the person who is receiving care - nontraditional family structure--blended families, single-parent, same sec or transgendered partners, polygamist

9. cultural competence

- refer to Leininger's cultural care theory - using knowledge of cultures and of nursing to provide culturally congruent and responsible care

in nursing research

- researchers use theories and models as a framework for structuring a study - theories provide a way to define the questions for study, identify variables to measure and interpret findings ex: Kolcaba tested her statement that comfort interventions would improve the health of the whole person

9 key concepts of Watson's caring theory to describe important nursing activities and approaches 1. Holistic nursing care

- the basis of modern nursing - allows nurses to examine the entire person and the person world when making healthcare decisions - goes beyond just giving medications or dressing a wound - cares for the entire person and all that it entails (family, friends, fears, cultural beliefs)

4. personal presence

- the nurse are emotionally and physically with the person for the time you are there - you are not thinking about a medication you need to give or medical orders you need to get - if the person in bed if fearful you should be fully present and recognize the fear and support the person experiencing it - Can do so by simply answering questions, providing more in-depth education or staying with the person for 2-3 minutes, quietly listening and or holding the person's hand

2. honoring personhood

- the patient is someone who deserves to be honored for individuality in behavior as we as needs - learn names of people in your care and refer to them by name and not by room number - requires you to control the fast pace of nursing and hurried care and take time with your patients - need to look at and talk to and touch the person to understand his/her personhood

How are theories developed?

- thru logical reasoning which is connecting ideas in a way that makes sense - purpose of this is to develop an argument or statement based on evidence that will result in logical conclusion - 2 types of logical reasoning (up next)

Nursing theories

Florence Nightingale stated that nursing theories describe and explain what is and what is not nursing

Stress and Adaptation Theory

Hans Selye (1993) developed the stress and adaptation theory. Some stress is good, but too much stress, called distress, results in physiological symptoms and eventual illness

clinical practice theory

a theory that is immediately applicable in the patient care setting

Concepts

ex: Watson's 10 caring processes - a mental image or symbol of phenomenon - formed by generalizing observations or experiences - used to draw similarities and differences among objects or idea (organize them) ex: the word "fever"--> a symbol for all the ideas and images you get when you hear the word fever - simple, concrete concepts are those you can observe directly--like height, weight, gender - abstract and complex concepts are those observed indirectly--like hematocrit, brain activity, nutritional status

open systems

exchange info and energy freely with environment and capable of growth, adaptation, etc. ex: hospitals, people, body systems, etc.

closed systems

fixed automated relationships among their components little give and take with environment ex: rock, or family isolated from community and resist outside influence

Dr. Katherine Kolcaba theory

holistic comfort in nursing which provides a more holistic view than earlier theories of pain and anxiety

essential concepts of a nursing theory

person, environment, health, nursing - these concepts represent the phenomena (reality) of concern for nursing

throughput

processes the system uses to convert input into output ex: thinking, planning, sorting, cutting, etc.

theoretical definition

refers to the conceptual meaning of a term (ex: pain) = an unpleasant sensory, emotional experience associated with actual or potential tissue damage.

operational definition

specifies how you would observe or measure the concept (ex: when doing research on pain--pain is the patient's verbal statement that he/she is in pain)

The caring theorists

top 3 are - Dr. Jean Watson - Dr. Patricia Benner - Dr. Madeleine Leininger

clinical practice theories

very specifically guide you what to do each day and they are limited in scope--meaning they do not attempt to explain all of nursing

medical paradigm

views a person thru lens that focuses on identifying and treating disease ex: looking into body parts only--cells, organs, etc.

nursing paradigm

views person thru lens with a broader perspective on entire person and how they respond to changes in physical, psychological, social, and spiritual health

Benner's other theory

what makes an expert nurse? ex: ICU nurse, b/c they know exactly when to extubate a critical patient - this theory meets the criteria of the four components of a theory, although some are emphasized more than others - person & nurse: (points of focus)--knowing the nurse's skill level provides a logical way to match nurse's skill with patient's acuity - health as a criterion is met b/c the nurse contributes to the person's health according to her skill level - environment is clearly stated as ICU