Nursing Theories

1. Nursing Theories Dr. Belal M. Hijji, RN, PhD 19.09.2010

2. Learning Outcomes • At the end of this lecture, students will be able to: • Define the working terms and theory • Recognise the four metaparadigms for nursing • Discuss some of the selected nursing theories 2

3. Defining Relevant Working Terms • Phenomenon: Is a thing, event or activity that we perceive through our senses. The phenomenon represents the subject matter of a discipline. When experience and sensory and intuitive data become coherent as a whole, we have a phenomenon. For example, when a patient, preoperatively, is noted restless in bed, biting fingernails, and sighing, this is a phenomenon. • Concept: Is a label used to describe a phenomenon. Therefore, when we put a name to a phenomenon, we are identifying a concept. In the example provided above, the phenomenon may be labelled as ‘anxiety’. • As a mental image, a concept is a view of reality tinted [colored] with our perceptions and experience. Therefore, a phenomenon could be given a different conceptual label by two different nurses. Therefore, a concept is a tool not a reality – it facilitates observation of a real phenomenon. Concepts are also the building blocks of theory. • Construct: If the phenomenon is very abstract and the resultant concept is not directly observable or measurable, it is often referred to as a construct (‘self-esteem’). 3

4. A construct is a type of highly complex concept whose reality base can only be inferred. Therefore, imagining a continuum of concepts from concrete (thermometre) to abstract (caring, compassion), constructs would be placed at the abstract end. All constructs are concepts but not all concepts are constructs. • The following example illustrates the continuum of abstraction of concepts. A cow is a very concrete conceptualisation and we move toward more abstract levels of conceptualisation. • Cow - Bessie - livestock - farm asset - wealth • Two things are noted as the concepts become more abstract; more of the characteristics of the concept ‘cow’ are being omitted and the ability to directly observe and measure the concept is becoming more difficult. • Constructs could be made measurable by identifying variables. For example, if ‘marital status’ is a construct, it could be made measurable by breaking it into the variables ‘single’, ‘widowed’, ‘divorced’, ‘married’. 4

5. What is a Theory? • ‘Theory’ is often defined in relation to ‘practice’. For example, a teacher describes the process of giving an injection, as opposed to students actually giving the injection to patient. Theory in this sense means dealing with a topic (administration of an injection). • Theory has several definitions. At basic level, theory explains the occurrence of phenomena. To do this, it has to explain the relationship between variables or concepts. For example, ‘an expansion in a bar of metal occurs when it is heated’. The phenomenon of expansion is explained by the relationship between the variable ‘metal’ and the variable ‘heat’. • The theory must also predict that each time the variables happen to be in the same relationship, the same results will be obtained. • Another definition of theory is that it ‘is a set of interrelated constructs (concepts) definitions and propositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explanation and prediction’. 5

6. From the above example on the theory of metal expansion, a number of propositions exist: • Metals are made up of atoms • The structure of atom is changed by heat • Heat causes atoms to expand 6

7. The Metaparadigm For Nursing • Paradigm: refers to a pattern of shared understandings and assumptions about reality and the world. We become aware of paradigms when realities clash. In nursing we refer to qualitative vs quantitative research paradigms. • Person, environment, health, and nursing are collectively referred to as metaparadigm for nursing. Meta means ‘with’, while paradigm means ‘pattern’. These four concepts are central to nursing. • Person: The recipient of nursing care. • Environment: The internal and external surroundings that affect the person. • Health: the degree of wellness or well-being that the person experiences. • Nursing: The attributes, characteristics, and actions of the nurse providing care to person. • What we need to know about these four major concepts is that their definitions vary from one theorist to another 7

8. Overview of Selected Nursing Theories • Nightingale Environmental Theory: Nightingale (1860) defined nursing as ‘the act of utilising the environment to assist the patient in his recovery’. She linked health with five environmental factors: “fresh air”, “pure water”, “efficient drainage”, “cleanliness” and “light, especially direct sunlight”. • Nightingale concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care today. 8

9. Orem’s General Theory of Nursing • Consists of three related theories collectively referred to as “Orem’s General Theory of Nursing”: • Self-care Theory: 3 types of self-care requisites (needs) • Self-care Deficit Theory: 5 Methods of Assistance • Nursing Systems Theory: 3 types 9

10. Orem’s Self-care Theory • Based on the concepts of: • SELF-CARE • SELF-CARE AGENCY • SELF-CARE REQUISITES • THERAPEUTIC SELF-CARE DEMAND 10

11. Self-care Definition • Self-care comprises those activities performed independently by an individual to promote and maintain personal well-being throughout life. Self-care Agency • Definition: the individual’s ability to perform self-care activities • Consists of TWO agents: • Self-care Agent - person who provides the self-care • Dependent Care Agent - person other than the individual who provides the care (such as a parent) 11

12. Self-care Requisites (Needs) • Definition: the actions or measures used to provide self-care. A need is also a requirement within an individual or group which stimulates a response to maintain integrity. • Consists of THREE categories: • Universal - requisites/needs that are common to all individuals. These include maintaining intake and elimination of air, water, and food. • Developmental - needs resulting from maturation or develop due to a condition or event, such as adjusting to a change in body image or to loss of spouse. • Health Deviation - needs resulting from illness, injury & disease or its treatment. These include actions such as seeking health care assistance and taking prescribed medications

13. Orem’s Self-care Deficit Theory • Is the central focus of Orem’s Grand Theory of Nursing • Explains when nursing is needed • Describes and explains how people can be helped through nursing • Results when the Self-care Agency (patient) can’t meet her/his self-care needs or administer self-care • Nursing meets these self-care needs through five methods of helping. These are: • Acting or doing for • Guiding • Teaching • Supporting • Providing an environment to promote the patient’s ability to meet current or future demands

14. Orem’s Nursing Systems Theory Describes... • Nursing responsibilities • Roles of the nurse and patient • Rationales for the nurse-patient relationship • Types of actions needed to meet the patient’s demands Orem’s Nursing Systems Theory • Refers to a series of actions a nurse takes to meet a patient’s self-care needs • Is determined by the patient’s self-care needs • Is composed of THREE types of nursing systems: • Wholly compensatory: a patient’s self-care agency is so limited that s/he depends on others for well-being. • Partly compensatory: a patient can meet some self-care requisites but needs a nurse to help meet others • Supportive-educative: a patient can meet self-care requisites but needs help in decision-making, behavior control, or knowledge acquisition

15. Henderson Definition of Nursing “It is my contention that the nurse is, and should be legally, an independent practitioner [as long as she is not performing the doctor’s duties.] But the nurse is the authority on basic nursing care. Perhaps I should explain that by basic nursing care I mean helping the patient with the following activities…” “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.”

16. 14 Fundamental Needs • Breathing normally • Eating and drinking adequately • Eliminating body wastes • Moving and maintaining a desirable position • Sleeping and resting • Selecting suitable clothes • Maintaining body temperature… by adjusting cothing and modifying the environment • Keeping the body clean and well-groomed… • Avoiding dangers in the environment and avoiding injuring others • Communicating with others in expressing emotions, needs, fears, or opinions • Worshipping according to one’s faith • Working in such a way that one feels a sense of accomplishment • Playing or participating in various forms of recreation • Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities

17. Nurse’s Role • Substitutive : acting for a person • Supplementary : assisting a person • Complementary : working with the person • “…with the goal of helping the person become as independent as possible.” • “Today I see the role of nurses as givers of ‘primary health care,’ as • those who diagnose and treat when a doctor is unavailable… Nurses • may be the general (medical) practitioners of tomorrow…”

18. Neuman’s Systems Model • Neuman’s model is based on the individual’s relationship to stress, reaction to it, and reconstitution factors. Reconstitution is the state of adaptation to stressors. • In this model, the client is an open system composed of a central core of energy sources (physiologic, psychologic, sociocultural, developmental, and spiritual) surrounded by two rings referred to as lines of resistance. These lines represent internal factors that help the client defend against a stressor; for example an increase in the body white cells count to fight an infection. • Outside the lines of resistance are two lines of defense. The normal line of defense represents the person’s state of equilibrium or the state of adaptation developed and maintained over time and considered normal for the person. The flexible line of defense is dynamic and can be rapidly altered over a short period of time. It prevents stressors from penetrating the normal line of defense.

19. Stressors in Neuman’s model are: • Intrapersonal: Occur within an individual (infection) • Interpersonal: Occur between individuals (Unrealistic role expectation) • Extrapersonal: Occur outside the person (financial concerns) • The individual’s reaction to stress depends on the strength of lines of defense. When these lines fail, the resulting reaction depends on the lines of resistance. • Nursing interventions focus on retaining or maintaining system stability. The intervention are carried out on three preventive levels: • Primary prevention: Focuses on protecting the normal line of defense and strengthening the flexible line of defense. • Secondary prevention: Focuses on strengthening internal lines of resistance, reducing the reaction, and increases resistance factors. • Tertiary prevention: Focuses on readaptation and stability and protects reconstitution or return to wellness after treatment.

21. Roy Adaptation Model • Roy sees the person as "a biopsychosocial being in constant interaction with a changing environment“. • The person is an open, adaptive system who uses coping skills to deal with stressors. • The environment is "all conditions, circumstances and influences that surround and affect the development and behaviour of the person". • Stressors are stimuli that influence the person. • Three types of stimuli influence an individual’s ability to cope with the environment. • Focal stimuli are those that immediately confront the individual in a particular situation. Focal stimuli for a family include individual needs. • Contextual stimuli are those other stimuli that influence the situation. • Residual stimuli include the individual’s beliefs or attitudes that may influence the situation. • Contextual and residual stimuli for a family system include nurturance, socialization, and support.

22. Roy Four Modes of Adaptation The physiologic mode. Adaptation involves the maintenance of physical integrity. Basic human needs such as nutrition, oxygen, fluids, and temperature regulation are identified with this mode. The self-concept mode. A function of this mode is the need for maintenance of psychic integrity. Perceptions of one’s physical and personal self are included in this mode. The role function mode. The need for social integrity is emphasized in this mode in which human beings adapt to various role changes that occur throughout a lifetime. The interdependence mode. The need for social integrity is also emphasized in the interdependence mode. Interdependence involves maintaining a balance between independence and dependence in one’s relationships with others. 22

23. Spiritual Caring individuals are holistic beings = physical, mental, spiritual, emotional “Considering a light bulb analogous to a human, think of the glass, aluminum, and other tangible materials that comprise it as representing the physical dimension; think of the light and warmth the bulb elicits as the psychological; and the electrical current that energizes and ultimately provides the meaning and function for the bulb as the spiritual dimension.” Stallwood & Stoll 1975 as cited by Taylor, E. F. (2002).

24. Case Study Mr. Elder works at the zoo. He has a large open wound on his forehead from a tiger attack. Mr. Elder was referred to a home health agency for wound management. The wound extends to the skull. Mr. Elder was out of work as a result of this wound, saw friends infrequently, and was somewhat depressed. His wife spent hours each day fixing him goodies to help cheer him up because she liked to cook and found it was a good way to release her own anxiety about her husband’s condition. After three weeks the wound showed no improvement in healing, although had not become infected. During the agency visit, Mrs. Elder confides in the nurse that her husband was drinking “tons of water” and seemed to be urinating frequently. She was worried that he might hurt himself getting up so often in the middle of the night. She was wondering if there was a pill to help him sleep through the night. Using theories models, what would the nurse do to help Mr. Elder’s healing problems? Case study adapted from Chitty, 2003.

25. Neuman’s Nurse: Nancy If Nancy were the nurse dispatched from the home health agency, she would use Neuman’s theory to solve the problem. Nancy knows that stressors attack the normal and flexible lines of defense. There must be an imbalance in Mr. Elder’s stability because his wound is not healing. The responses to his stressor are polyuria, polydipsia, both of which are physiological variables. This leads Nancy to believe the stressor is diabetes, and tertiary interventions need to be implemented in order to bring about reconstitution.

26. Roy’s Nurse: Roberta If Roberta were the nurse dispatched from the home health agency, she would use Roy’s theory to solve the problem. Roberta would assess Mr. Elder’s physical adaptive modes and identify his maladaptive behaviors: • Eating too many sweets • Drinking too much water • Urinating too frequently • Being socially isolated Roberta would modify the environment (both the internal and external) to create adaptive behaviors and enhance coping: • Internal: insulin administration • External: change in diet

27. Mr. Elder’s wound started healing almost immediately after his diabetes was identified and controlled. He was able to go back to work and to meet with his friends again. Mrs. Elder learned fun, new diabetic-friendly foods to cook for herself and Mr. Elder. The advantage of applying both theories to clinical practice is that it will lead to appropriate client-based nursing care.