Chapter 13: Nursing Theory: The Basis for Professional Nursing

1. Chapter 13: Nursing Theory: The Basis for Professional Nursing Bonnie M. Wivell, MS, RN, CNS

2. Nursing Theory • Latin “a viewing”; Greek “contemplating” • A body of knowledge shaped by how nurses see the world • A group of related concepts, definitions & statements that propose a view of nursing phenomena from which to describe, explain or predict outcomes • Abstract ideas

3. Why is Theory Important? • Nursing is strengthened when knowledge is built on sound theory • Criteria to be a profession: distinct body of knowledge as the basis for practice • Nursing must be viewed as a scholarly academic discipline hat contributes to society • Ultimate goal is to support excellence in practice

4. Theory Guides the Professional Nurse in…. • Organizing and analyzing patient data • Understanding connections between pieces of data • Discriminating between important and less pertinent data • Making sound clinical judgments based on evidence • Planning effective nursing interventions • Predicting and evaluating outcomes of interventions

5. Definition of Terms • Metaparadigm = the major concepts or abstract ideas of the discipline; most important to practice and research • Person • Environment • Health • Nursing • Philosophy = a set of beliefs about the nature of how things work and how the world should be viewed; begins to put together some or all concepts of the metaparadigm

6. Definition of Terms Cont’d. • Conceptual Model or Framework = a more specific organization of nursing phenomena than philosophies; provide an organizational structure that makes clearer connections between concepts • Propositions = statements that describe linkages between concepts and are more prescriptive; they propose an outcome that is testable in practice and research

7. Florence Nightingale • Notes on Nursing: What It Is and What It Is Not (1969, originally published in 1859) • Her philosophy of health, illness, and the nurse’s role in caring for patients • Focused on the relationship of patients to their surroundings • Importance of observing the patient and recording information • Importance of cleanliness • Health and recovery from illness is related to environment

8. Virginia Henderson • The “Unique function of he nurse… is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.” • Nurse’s role = substitute for the patient, a helper to the patient or a partner with the patient • 14 basic needs of the patient (see Box 13-3 on pg. 308)

9. Jean Watson • Studied at CU • The Philosophy and Science of Caring (1979) • Emphasized the caring aspects of nursing • 10 Carative factors (see Box 13-4 on pg. 309); these factors differentiate nursing from medicine (curative) • Illness or disease equated with lack of harmony within the mind, body, and soul • RN responsible for creating and maintaining an environment supporting human caring while recognizing and providing for patient’s primary human requirements

10. Watson Continued • Proposed that nursing be concerned with spiritual matters and the inner knowledge of nurse and patient as they participate together in the transpersonal caring process • Nurses share their genuine self • Patient’s spiritual strength is recognized, supported, encouraged • RN encourages openness to understanding of self and others • Leads to trusting, accepting relationships where feelings are shared and confidence is inspired

11. Dorothea Orem • Concept of self-care • “Ordinary people in contemporary society want to be in control of their lives.” • Patient’s baseline ability to provide adequate self-care is assessed • Systems of care • Wholly compensatory • Partially compensatory • Supportive-educative

12. Imogene King • A Theory for Nursing: Systems, Concepts, Process (1981) • Focused on persons, their interpersonal relationships, and social contexts with three interacting systems • Personal • Interpersonal • Social • Emphasizes goal attainment and patient’s involvement in setting goals (Goal Attainment Model)

13. Sister Callista Roy • Introduction of Nursing: An Adaptation Model (second edition 1984) • Individual as a biopsychosocial adaptive system • Nursing is a humanistic discipline that emphasizes the person’s adaptive and coping abilities • The environment can be manipulated by the RN to further patient’s adaptation

14. Hildegard Peplau • Interpersonal Relations in Nursing (1952 & 1988) • Relationship between patient and nurse is the focus of attention • Therapeutic interpersonal relationship • Survival of the patient • Patient’s understand his or her health problems and learn from them as they develop new behavior patterns • 6 roles of the nurse: counselor, resource, teacher, technical expert, surrogate, and leader

15. Ida Orlando • The Dynamic Nurse-Patient Relationship: Function, Process and Principles (1961) • Observation and confirmation of patients’ verbal and non-verbal behavior, which identify patient needs • Goal of the nurse is to determine and meet patients’ immediate needs and improve their situation by relieving distress or discomfort • Individualize care by attending to behavior

16. Madeleine Leininger • Theory of cultural care • Founder of Transcultural nursing • Patients viewed in the context of their cultures • Nursing care should be culturally congruent • “Sunrise Model” (Figure 13-2, pg. 317) guides the assessment of cultural data for an understanding of its influence on the patient’s life

17. Theory-Based Education • PhD: a research degree that generates new, discipline-specific knowledge • Master’s: use theoretical perspectives focused on the patient for specific nursing outcomes; base practice on evidence from research & experience • BSN: introduced to research process & the use of theory to guide it • ADN: find middle range theories useful as they are specific to patient care

18. Theory-Based Practice • Occurs when nurses intentionally structure their practice around a particular nursing theory and use it to guide them in their care of the patient • Provides a systematic way of thinking about nursing that is consistent and guides the decision-making process • Challenges conventional views of patients, illness, the health care delivery system, and traditional nursing interventions

19. Benefits • Explain practice to others • Passes on knowledge to students • Contributes to professional autonomy • Develops analytical skills, challenges thinking, and clarifies your values and assumptions

20. Theory-Based Research • Great strides have been made in the last 25 years in nursing research • Nursing research tests and refines the knowledge base of nursing • Research findings enable nurses to improve the quality of care and understand how evidence-based nursing influences patient outcomes • Research is vital to the future of nursing and theory is integral to research

21. Chapter 14: The Health Care Delivery System Bonnie M. Wivell, MS, RN, CNS

22. Health Care Delivery • The four basic types of services provide by the health care delivery system • Health Promotion: remain healthy • Illness prevention: reduce risk factors • Diagnosis & treatment: refined methods of diagnosis allow for more effective treatment • Rehabilitation & LTC: restore function & independence; disease management

23. Health Care Agencies • Government: Contribute to health of all U.S. citizens; supported by taxes; Federal, State, Local • Voluntary (Private): Support via private donations, government grants • Not-for-profit: Profits used on behalf of agency • For-profit: Profits distributed to partners or shareholders

24. Level of Health Care Services • Primary Care Services: first entry into system, emergency care, health maintenance, LTC, chronic care, temporary health problems • Secondary Care: prevent complications from disease; home health, ambulatory care, skilled nursing agencies, and surgery centers; disease management via electronics • Tertiary Care: acutely ill to LTC to rehab to terminally ill; interdisciplinary; specialized hospitals: trauma centers, burn centers, specialized peds centers; LTC facilities that offer skilled nursing, intermediate care and supportive care; rehab centers; hospice • Subacute Care: Inpatient care between hospital and long-term care

25. Organizational Structures of Health Care Agencies • Board of Directors: carry responsibility for mission, quality of services, finances • Chief Executive Officer (CEO): overall daily operation • Medical Staff: physicians granted privileges; organized by service/dept. • Chief of staff work with CEO to make important decisions about medical policy • Nursing Staff: RNs, LPNs, NAs and clerical staff; organized according to units • Chief Nurse Executive (CNE) or Chief Nursing Officer (CNO) today on Board of Directors, oversee nursing care

26. Nursing Organization Governance • Nurses govern themselves though the organization • Shared governance = founded on the philosophy that employees have both a right and a responsibility to govern their own work and time within a financially secure, patient-centered system • Promotes decentralization and participation at all levels of nursing

27. Maintaining Quality • Accreditation: accrediting bodies approved by CMS; to improve pt. outcomes; institution wide initiatives • JCAHO (Joint Commission): not-for-profit that serves as the nation’s predominant standards-setting and accrediting body in health care • HFOP (Healthcare Facilities Accreditation Program): Standards met in all depts. • Continuous Quality Improvement (CQI)/Total Quality Management (TQM): examine processes to look for ways to improve services before mistakes occur; anticipate potential problems and prevent their occurrence • Performance Improvement (PI): organizational efforts to improve corporate performance; focuses efforts on increasing individual and group competence and productivity

28. Health Care Disparities • Defined as differences in the quality of health care provided to different populations • Can be due to race, ethnicity, gender, age, income, education, disability, sexual orientation, and place of residence • Little progress has been made in narrowing disparities • Provider bias possible contributing factor

29. Health Care Team • Physicians • Physician Assistants • Patient Care Technicians • Dietitians • Pharmacists • Technologists • Respiratory Therapists • Social Workers • Therapists • Administrative Support Personnel: admissions, medical records, billing, etc.

30. Nurse’s Role on Team • Provider of Care: direct hands on care • Educator: teaching pt., family, new staff, community, etc. • Counselor: emotional support & problem solving • Manager: organizes care • Researcher: investigates how nursing interventions impact patient outcomes • Collaborator: works with patients, families & team on agreed patient outcomes • Patient Advocate: stands up for patient rights; advocates for patient’s best interests at all times

31. Types of Nursing Care Delivery • Functional Nursing: focuses on functions/tasks; personnel work side by side each performing an assigned task • Team Nursing: RN is team leader, oversees, assesses, documents; LPN direct care, treatments, procedures; NA personal care • Primary Nursing: one nurse accountable for nursing care of patient during stay on unit; delegates care while off duty • Case Management Nursing: oversees pt. care and manages the delivery of services from entire health care team throughout patient’s illness • Patient-centered Care: contemporary model focusing on patient’s rights to individualized care

32. Financing Health Care • In 2007 the nation’s health care expenditures reached $2.2 trillion and consumed 16.2% of the gross domestic product • By 2018 health care costs are expected to reach $4.4 Trillion • Basic Economic Theory: supply/demand; Does it relate to health care? • Free-Market economy: consumption determined by an individual’s ability to pay • Price sensitivity in health care: third party payers (employer, insurance company, or government) removed price sensitivity from the concern of most health care consumers because they pay only a portion of the actual costs • Additional influences: can’t delay care

33. Economics of Nursing Care • Nursing accounted for 20-28% of the costs of hospitalizations in 1980s • To stay in business, hospitals must make at least enough money to pay personnel, maintain buildings and equipment, and pay suppliers • ANA: overzealous cost-containment efforts have led to lower quality hospital care • Aiken, Clark, Sloane et al, 2006 research links nursing and quality of care; increased patient death rate with higher nurse:patient ratios

34. History of Health Care Finance • Before 1945, 90% paid out of pocket or charity care • Growth of Private Insurance → tax exempt • Rise of Public Insurance Programs (1965) • Medicare • Part A = Hospital Insurance • Part B = Medical Insurance (20% co-pay, deductible • Part C = Managed care option • Part D = Prescription drug coverage • Medicaid • Federal government contributes 50-76.8% • Personal (out-of-pocket) payment • Worker’s Compensation

35. Forces Changing Health Care • Managed Care attempts to control healthcare costs; health promotion not illness treatment • Health Maintenance Organization (HMO): health care services provided for a predetermined fixed fee • Capitation: same amount paid to provider each month regardless of whether services were provided or how much the services cost • Gatekeeper: PCP, responsible for referrals • Preferred Provider Organization (PPO): contracts with provider for discounted rate

36. Forces Changing Health Care • Point-of Service Organization (POS): choice of service within network; or outside network pay higher $ • Physician Hospital Organization (PHO): corporation formed by hospital/physician to contract with managed care organization

37. Nurse’s Role in Managed Care • Advanced Practice Nurses: ambulatory and community settings • Case Manager • Triage • Utilization reviewers to determine most appropriate and cost-efficient level of care

38. Change in Consumer’s Expectations • Became more educated and fight for rights to health care through political reform and the legal system • Proliferation of internet websites has dramatically affected the knowledge and expectations of consumers

39. Health Care’s Response • Reengineering: rethinking & redesigning • Patient-centered care: patient at center of activity and designing outcomes • Decentralization: staff exercise own judgment • Cross-functional teams: people form all areas of the organization who contribute to a particular process • Multi-skilled workers: single worker cross-trained to do different tasks

40. New Organizational Models • Functional Model: defines each major function of the organization and establishes clear lines of managerial authority • Service Line Model: establishes management responsibilities around specific types of services wherever they occur in the hospital • Matrix Model: complex with multiple authority and support systems • Process Model: organizes management of care around phases in the process of healthcare delivery • Regional Model: complex health care systems that grew from acquisitions; organized by type of service provider

41. Continued Escalation of Health Care Costs Inflation New Technology and Drugs Increased Demand for Healthcare Services – more elderly & uninsured Fraud and Abuse of Payment Systems - $75 billion of US annual health expenditures may be attributable to fraud

42. Cost Containment Measures • Centers for Medicare & Medicaid Services – contracts private insurance agencies to service the Medicare program • Professional Review Organizations (PROs) – monitor the quality of care received • Diagnosis-Related Groups (DRGs) – diagnoses with similar resources consumptions and LOS patterns into a single category; 495 DRGs • Block Grants – state given set amount of money based on caseload, etc. • Continued Expansion of Managed Care – largest provider; limits consumer choices but not intended to reduce quality of care

43. Health Care Finance Challenges • Continuing Crisis: Uninsured Americans • Quality of Care • Limits on Choice and Services • Provider Restrictions & Financial Incentives to Limit Services • Cost of Prescription Drugs • Malpractice Costs & Impact of Access to Care

44. Health Care Reform • The US and South Africa are the only two industrialized nations that do not provide universal access to health care • System-wide health reform efforts were supported by public opinion but failed to pass congress