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Nursing Theory
At the Heart of Practice
by Maureen Habel, RN, MA
CE632 | 1.00 contact hrs
Course Objectives
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A nurse is applying for a position in a healthcare organization that has been designated as a Magnet hospital by the American Nurses Credentialing Center. What differences might the nurse notice? What makes Magnet organizations different?
 
Magnet status recognizes healthcare organizations that foster nursing excellence, encourage nursing staff growth and development and provide an environment that supports professional nursing practice. Increasingly, healthcare organizations are selecting theoretical nursing models on which to base nursing practice. Organizations that are applying for or have achieved Magnet status must identify a theoretical framework that guides nursing practice. When a healthcare organization uses a theoretical model to design care, it strengthens nursing’s focus of care and recognizes nurses as members of a scholarly discipline that improves the health of society.1
 
Florence Nightingale was the first person to clearly describe a distinct nursing role. The basis of her nursing philosophy was that nurses, by providing a sanitary and healthy environment, could allow nature to help patients recover health.2 Nightingale published her views on nursing in Notes on Nursing: What It Is, and What It Is Not in 1859.
 
In the late 19th and early 20th centuries, nurses received a vocational education referred to as “nurses training” that focused on mastering functional tasks. Until the mid-1950s, most students participated in a hospital-based apprenticeship program that taught them to carry out physician orders while also providing patient comfort measures. The diagnostic and treatment model of the medical profession is based on an understanding of disease pathophysiology and altered homeostasis. In contrast, nursing’s caring and wellness model views humans in a holistic way, assisting people with actual and potential health problems by taking into account factors such as culture, economic status and social support.
 
Nursing leaders in the 20th century believed that improving nursing care and gaining recognition of nursing as a profession depended on developing a body of nursing practice knowledge that reflects nursing’s holistic nature.1 As a result of their efforts, nursing began a transition from a vocation to a profession.1 The latter part of the 20th century saw rapid development of nursing scholarship and theory.
 
“Nursing theory” refers to the body of knowledge that supports nursing practice. In practical terms, nursing theory helps nurses think about what they do and why they do it. Without a theoretical framework to guide practice, a profession is like a ship without a rudder, randomly changing course and not always reaching its destination. Most importantly, individual members of a profession need to have a unified view of what comprises the heart of their practice. A theoretical framework provides nurses with clarity of purpose, strengthens professional identity and guides research and professional development. Nursing research studies that continue to build an evidence base for nursing practice are designed using a nursing theoretical model. Many nursing theories have been developed in the past several decades, and today’s nursing scholars continue to propose new models that promote nursing practice excellence.1 Theory development helps nurses view their practice in a deeper and more insightful way, organizes nursing knowledge, and results in discovering important new ways to advance nursing practice.3
 
Learning the Lingo
 
First, let’s define a few terms: metaparadigm, person, environment, health and nursing. A metaparadigm describes the broadest view of and essential parameters of a profession. Nursing views human health and health deviation from a holistic physical, psychological, spiritual and sociocultural perspective.3,4 The metaparadigm for nursing, distinguishing nursing from other healthcare professions, consists of four concepts and the relationships between them: person, health, environment and nursing.4 Person refers to the individual, family or community receiving nursing care. Environment includes all internal and external factors influencing an individual, family or community. Health describes not just the absence of disease, but the degree of wellness. Nursing includes the actions, characteristics and attributes of the person giving care, the nurse.4
 
Theoretical works in nursing can be classified as philosophies, grand theories or conceptual models, middle-range theories and practice theories.1,3 The conceptual hierarchy is from the most abstract; i.e., philosophies, to the least abstract; i.e., practice theories.
 
A nursing philosophy describes personal beliefs or a worldview. Examples of nursing philosophies include Jean Watson’s Philosophy and Theory of Transpersonal Caring and Patricia Benner’s Philosophy of Caring, Clinical Wisdom and Ethics in Nursing Practice. Grand theories consist of conceptual frameworks that provide broad practice perspectives.3
 
A theory can have a specific focus or be used in a broad range of practice settings. For example, Madeleine Leininger’s Culture Care Theory of Diversity and Universality focuses on human cultural care and has broad applicability to all nursing practice settings.
 
Middle-range theories are concerned with an area of interest within a discipline. A middle-range theory is not as broad as that of a grand theory.3 Middle-range theory fills the gaps between abstract grand theories and nursing practice.3 Examples of middle-range nursing theories include Ramona Mercer’s Theory of Maternal Role Attainment, which focuses on the maternal role through pregnancy, and Katherine Kolcaba’s Theory of Comfort.5
 
Practice theories that nurses use to address specific patient problems are the least abstract of nursing’s theoretical works. Practice theories can focus on specific elements of specialty practice (e.g., pediatric nursing).3 The development of additional theories at the middle-range and practice level that can be readily incorporated into practice is a challenge facing the profession of nursing today.
 
Examples of Grand Nursing Theoretical Works
 
Adaptation models:
Sister Callista Roy’s Adaptation Model
 
Anthropological models:
Madeleine Leininger’s Theory of Transcultural Care Diversity and Universality 
 
Self-care models:
Dorothea Orem’s Self-Care Deficit Nursing Theory
 
 
Self-Care Deficit Nursing Theory
 
Dorothea Orem’s Self-Care Deficit Nursing Theory consists of three interrelated theories, the theory of self-care, the theory of self-care deficit and the theory of nursing systems.6,7 Self-care comprises activities performed independently by a person to sustain life, health and well-being.6,7 Self-care agency refers to a person’s ability to perform self-care activities. Self-care deficit occurs when the person is unable to perform self-care activities. The nurse then meets self-care needs by acting or doing for, guiding, teaching, supporting or providing an environment to promote patient self-care abilities. Self-care deficit is the basic reason people need nursing care.6,7 The theory of nursing systems describes a composite of the nurse’s actions on behalf of the patient, ranging from total care to education and advocacy. In a wholly compensatory system, the patient is dependent on the nurse to meet all self-care needs. In a partially compensatory mode, the patient can meet some of his or her needs for self-care agency, but needs assistance from the nurse to maintain health and well-being. As the patient regains more ability to engage in self-care activities, the nurse functions in a supportive-educative mode.4,6,7
 
For example, when a patient has a large burn injury, he or she may be unable to perform any of the self-care activities necessary for health. The level of care and type and extent of injury can be correlated to Orem’s systems. When nurses provide total self-care to a patient in an intensive burn care environment, the nurse is functioning from within Orem’s wholly compensatory framework.6,8 Minor burns are treated with less intense nursing intervention. As the patient and family members, as appropriate, are encouraged to take part in dressing changes and other care activities, the nurse is functioning in a partially compensatory mode.8 Nurses who care for patients who have experienced burns may also follow the care of patients after hospital discharge through wound centers and support groups. Some burn nurses provide post-burn education to schools and industry as patients return to pre-burn activities. This level of care is consistent with the educative-development system within Orem’s framework.6,8
 
Orem’s Self-Care Model is useful for patients with multiple chronic health conditions and has been used in many practice settings. Her theory can help the nurse focus on the strengths and challenges of the self-care agent rather than on the disease process.7 For more information on Orem’s theory, go to the International Orem Society for Nursing Science and Scholarship.
 
Transcultural Care Theory
 
Madeleine Leininger is the founder of transcultural nursing and an influential leader in transcultural care.10 Transcultural nursing refers to humanistic and scientific knowledge and practices that focus on assisting individuals, families and communities to maintain or regain health and to deal with disability, dying or other human conditions in a culturally respectful and beneficial manner.9,10 Leininger’s Theory of Transcultural Care Diversity and Universality is derived from the disciplines of anthropology and nursing.9,10 Key concepts in this theory include cultural diversity — differences between and among different cultures — and cultural universality — commonalities or similarities in different cultures.9,10 When using this theory, nurses can recognize and understand cultural similarities and differences to influence the person’s health status.3 Because Leininger’s theory includes multiple holistic factors common to many cultures, it has practical application in both Western and non-Western cultures.9,10 In an era of globalization and an increasing emphasis on cultural competence to meet human needs, Leininger’s theory is significant.9,10 More information on Leininger’s theory can be found at the website for the Transcultural Nursing Society or at www.Madeleine-leininger.com.
 
Adaptation Model
 
Sister Callista Roy’s Adaptation Model views a person as comprising interrelated biological, psychological and social systems. The person continuously seeks to maintain a balance between each of these systems and the external environment. The person is an open, adaptive system who uses coping skills to deal with stressors. The goal of nursing is to promote the person’s adaptation during health and illness using four adaptation modes: the physiological mode, the self-concept mode, the role function mode and the interdependence mode.11,12
 
The focus of the physiological mode is on basic survival needs such as nutrition, oxygen, fluids and temperature regulation. The self-concept mode includes psychological integrity, including perceptions of the physical and personal self. The nurse assesses the degree to which patient and family actions in each mode are leading to positive adaptation to the focal stimuli.11-13 Three types of stimuli — focal, contextual and residual — influence a person’s ability to cope with environmental demands. Focal stimuli are those that immediately confront the individual in a particular situation. Contextual stimuli are those that influence the situation. Residual stimuli include the individual’s beliefs or attitudes that may influence the situation.11,12 Adaptation occurs when the total stimuli falls within the person’s/family’s adaptive capabilities. The nurse assesses the contextual and residual stimuli associated with the focal stimulus to evaluate whether positive coping can occur and to predict when the nurse needs to intervene to promote adaptation.11-13 Roy also proposes two types of coping mechanisms, known as regulator and cognator subsystems. The regulator subsystem responds through automatic physiological processes while the cognator subsystem responds through innate and acquired processes, including cognitive and emotional reactions such as perceptual and information processing, learning, judgment and emotion.11-13 If coping and adaptation are inadequate to achieve and maintain health, the nurse assesses the types of stimuli and the effectiveness of the regulator subsystems in order to plan nursing interventions that increase adaptation. The Roy Adaptation Model has had a great influence on nursing.1,12 For more information, visit http://www.nursingtheoryandtheoristsroyorem.weebly.com/about-sr-callista-roy.html.

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