AN INTRODUCTION TO NURSING THEORY

Chapter 1, George, Kozier et.al.

Why is there a need to understand nursing theory?

• Understanding nursing theory is the prerequisite to choosing and using a theory to guide one’s nursing practice.

Theory
• It is a supposition or system of ideas that is proposed to explain a given phenomenon.
• No scientific theory is purely objective since each is developed in cultures and expressed in language.
• It is a creative and rigorous structuring of ideas that project a tentative, purposeful, and systematic view of the phenomena.
Creative -underscores the role human imagination and vision in theory development.
Tentative -open to revision as new evidence emerges.

Nursing Theory
• A conceptualization of some aspect of reality (invented or discovered) that pertains to nursing.

Complete Nursing Theory

a. Context – the environment in which the nursing act takes place
b. Content – subject of the theory
c. Process – the method the nurse uses in applying the theory

What is a concept?
• It is an idea, thought, or notion conceived in the mind.
a. Empirical concept-they can be observed or experienced through the senses.
b. Abstract concept-not observable (eg caring, hope, infinity)
• All concepts become abstractions in the absence of the object.
• Building blocks of theories

What is a paradigm?
• A pattern of shared understanding and assumptions about reality and the world.
• It includes our notions of reality that are largely unconscious or taken for granted.

What is a metaparadigm?
It is defined as the core content of a discipline, stated in the most global or abstract of terms.
These concepts can be superimposed on almost any work in nursing.

What is the function of a metaparadigm?

To summarize the intellectual and social missions of a discipline and place a boundary on the subject matter of that discipline.

Four major concepts:

1. Person -it may represent an individual, a family, a community, or all of humanity.
-it is the focus of nursing practice.
-the recipient of nursing care
2. Health -a state of well-being mutually decided on by the client and the nurse.
3. Environment -the immediate person’s immediate physical surroundings, the community, or the universe and all that it
contains.
-the internal and external surroundings that affect the client. This includes people in the physical environment, such as
families, friends, and significant others.
4. Nursing -the practice of the science and art of the discipline.
-the attributes, characteristics, and actions of the nurse providing care on behalf, or in conjunction with, the client.

What is practice discipline?

Practice discipline
A term used for fields of study in which the central focus is the performance of a professional role (nursing, teaching,
management, music), contrary to the practice of physics which is theory and research.
The main function of theory (and research) is to provide new possibilities for understanding the discipline’s focus.
The relationship between the theory of physics and the practice of physics is strong.

Did Nightingale envision a unique body of theoretical knowledge?

No. in the 19th century, Nightingale thought that the people of Great Britain needed to know more about how to maintain
healthy homes and to care for the sick and family members.
-to her, knowledge to provide good nursing was neither unique nor specialized.
-she viewed nursing as central human activity grounded in observation, reason, and commonsense health practices.
Notes on Nursing: What It Is, and What It Is Not (1860/1969)
-First textbook on home care and community health.
-audience: public at large, not a separate discipline or profession.

What is soft versus hard disciplines?

Soft disciplines are those that o not have strong theory and research base. Hard disciplines include natural sciences.

The purpose of nursing theory in:

a. Education – nursing theory was used primarily to establish the profession’s place in the university.
b. Research – nursing research identifies the philosophical assumptions or theoretical frameworks from which it proceeds.
-new theoretical perspectives provide an essential service by identifying gasps in the way we approach specific fields of study
such as symptom management or quality of life.
c. Practice – the primary contribution of nursing theory when employed in a clinical setting is the facilitation of reflection,
questioning, and thinking about what nurses do.
-nursing theory is a useful tool for reasoning, critical thinking, and decision making in nursing practice.

NURSING THEORY IN CLINICAL PRACTICE

TRADITIONAL THEORETICAL VIEW

The power or control in the relationship is with the nurse; the nurse is the expert and patient receives nursing care.
e.g. Henderson, Abdellah

“EQUAL PARTNERS IN PROCESS “ Relationship

Emphasizes an equal view of power or control and emphasizes caring.
e.g. Parse, Boykin and Schoenhofer, Newman

FACTORS T THAT HAVE INFLUENCED CHANGES IN NURSING THEORYAND ITS USE IN PRACTICE
1. Diverse clientele
2. The move from hospital-based to community-based care.
Change in setting.
How useful is a nursing theory for various settings and types of clients?
3. More opportunities for interdisciplinary practice

THE NURSING PROCESS

• Two basic assumptions
a. Nursing is interpersonal in nature
b. Human beings are holistic

What is Holism?
Holism when applied to nursing emphasizes that nurses must keep the whole person in mind and strive to understand how
one area of concern relates to the whole person. The nurse must also consider the relationship of the individual to the external
environment and to others (Kozier).
The term holism was coined by Jan Smuts, a South African statesman, in his book Holism and Evolution (1926). He theorized
that nature tends to bring things together to form whole organisms and that the determining factors in nature and evolution
are wholes, not their constituent parts. In holistic theory, all living organisms are seen as interacting, unified wholes that are
more than the mere sum of their parts.
Viewed in this light, any disturbance in one part is a disturbance of the whole system; in other words the disturbance affects
the whole being.
Holistic theories maintain that health requires that the forces of nature be kept in balance or harmony. Human life is one
aspect of nature that must be in harmony with the rest of the nature. When the natural balance or harmony is disturbed,
illness results.
Holistic health, then, involves the total person: the whole of the person’s being and the overall quality of lifestyle.
Holistic health care includes health education, health promotion, health maintenance, illness prevention, and restorative-
rehabilitative care.
The goal of holistic nursing as described by the American Holistic Nurses’ Association (AHNA) is to enhance healing of the
whole person from birth to death.

What is nursing process?

• A planning and decision-making process, provides the structure for nursing care.
• It is a part of the movement towards making nursing as a profession.
• The nursing process deals with problems specific to nurses and their clients/patients (individual, family, or community).
• A means for evaluating the quality of nursing care given. (accountability and responsibility)
• This process, however, has been simplified over the years by the use of generic care plans, charting by exception, and the
use of computerized records.

Phases
ANA’s revised Standards of clinical nursing practice, 1998
1. Assessment
2. Nursing diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation

Assessment
• is the systematic and orderly collection and analysis of data about the past and present health status of the client for the
purpose of making nursing diagnosis.
• Garbage in, garbage out.
• Systematic and orderly manner
• See Table 2-1 for example
• Components
Biographical and demographic data
Health history, including family members
Current health status (P.E., reasons for contact, medical diagnoses, diagnostics)
Generic or folk treatments and/ or other treatments for the problem
Social, cultural, spiritual, and environmental data
Behavioral risks
• Organization[clustering] and Analysis of data come next (Analysis-identifying, comparing[compared with the societal norms],
and contrasting each piece of data with the others).

Nursing diagnosis
• A clinical judgment about individual, family, or community responses to actual or potential health problems /life processes
(NANDA).
• Provide the basis for selection of nursing interventions
• Diagnoses are derived from the assessment data and are validated with the patient, family, and other healthcare providers,
when appropriate and possible.
• The statement of nursing diagnosis identifies an actual or potential health problem, deficit, or area of concern that may be
amenable to nursing actions.
• NANDA system is not amenable to family diagnoses. Omaha system may be used for diagnostic categorization when working
with families as the client.
• Each diagnosis is based on client behaviors and an area of need which may be actual or potential.
This is relevant to the definition of nursing by ANA which is the diagnosis and treatment of human responses to actual or
potential health problems.
• Prioritization. As the nursing diagnoses are identified, they should be ranked in order of priority, based on the input from
both the client and the nurse.
Basis for Prioritizing
a. The greatest impact on the client, the family, or both / degree of threat to wellness
b. client’s willingness

Outcome Identification
• Specific, Measurable, Attainable, Realistic, and Time-bound
• Culturally appropriate
• Outcome criteria should provide the information needed to evaluate attainment of the identified outcome. They should
include who will take what actions under what conditions, how well it will be done, and a specified time frame for completing
the actions. Outcome criteria specify the data needed for evaluating the results of nursing action.
-must be stated in observable behaviors (may be end-behaviors or step-by-step progress toward the desired outcome)
-stated concisely in an “act-of-being” phrase containing the performer (the client), a performance (action), and a change in
behavior (objective).
-end behaviors must be placed in a time-frame. Time frames should be specific enough to provide for evaluation purposes but
should be flexible enough that needed changes can be made.

Where do these changes come from? From reassessment of priorities and desired outcomes.

• Outcomes can pertain to a.) rehabilitation b.) prevention of complications associated with stressors, c.) the ability of the
client to adapt to these stressors, or all three.
• Four Categories of Outcome Indicators
a. Patient-focused
1. Diagnosis-focused outcome indicators
Typically quantitative like laboratory values and signs and symptoms (e.g.CBC, Apgar scores, vital signs, dyspnea, or weight
changes).
*Vital signs include temperature, pulse rate, respiratory rate and blood pressure.
2. Holistically focused outcome indicators
Are overall measures of health status or quality of life areas related to health.
Measured through self-reports or performance on objective tests (e.g. mobility, ability to carry ADLs, patient knowledge,
patient satisfaction, symptom management).
b. Provider-focused
Professional provider or a family or a significant other caregiver
e.g. complication rates, interventions, or profiles of providers
e.g. when a nurse supervisor makes it a requirement that nurses be sufficiently trained before working in a special ward like
ICU.
c. Organization-focused
e.g. access to care cost of care; mortality and morbidity data; rate-based information like infections, falls, medication errors,
and readmissions.
*before you could understand this, it is in order that you know what is meant by mortality and morbidity rate. This is your
home work.
d. Population-focused

*when trying to ascertain whether an outcome indicator is patient-focused, provider-focused, organization-focused, or

population-focused, ask: who is being improved? For instance, a client who agrees with a nurse to improve (decrease) his
blood pressure may be an example of patient-focused outcome indicator since the improvement is on the client’s part.

Planning
• The determination of what can be done to assist the client, and reflects nursing actions.
• Strategies/action to attain the outcomes
• Each nursing action is based on scientific rationale
• Should be spelled out precisely
• Clients’ actions are included
• It is a continuous process based on reassessment and evaluation
• The NURSING CARE PLAN
-means for reaching identified outcomes in an orderly fashion
-a means for organization, giving direction and meaning to the nursing actions used in helping the client resolve problems
-for efficient use of time
-the written plan is the most efficient way to keep all individuals involved in the client’s care informed of modifications in the
plan of nursing care

Implementation
• Putting the plan into action
• Implementation is more proper since intervention speaks to involvement in the affairs of another
• The implementation phase begins when the nurse selects those actions most suitable to achieve the identified outcomes. It
ends when the nursing actions are finished and the results are recorded against each diagnosis.
• Broad categories of nursing actions
a. Counseling
b. Teaching
c. Providing physical care
d. Carrying out delegated medical therapy
e. Coordinating resources
f. Referral
g. Therapeutic communication (verbal, nonverbal)
h. Serving as client advocate
• 7 Categories of Nursing Action according to Campbell
a. Assertive
b. Hygienic
c. Rehabilitative
d. Supportive
e. Preventive
f. Observational
g. Educative
• Roles/Roles
a. Independent
b. Dependent- an example would be when you need to administer a drug. It’s dependent because you need the physician’s
prescription.
c. Interdependent

Evaluation
• The appraisal of the client’s behavioral changes that are a result of the actions of the nurse.
• Five steps in evaluation
a. Review the stated (predicted) outcomes. GOAL
b. Collect data about the client’s responses to nursing interventions. OUTCOMES
c. Compare actual outcomes to predicted outcomes and decide if goals have been met. COMPARE GOALS WITH OUTCOMES
d. Record the conclusion
e. Relate nursing plans and interventions to client outcomes. COMPARE PLANS AND INTERVENTIONS WITH OUTCOMES
• Who’s responsible for carrying outcome evaluation? The nurse and the client.
• How about for structure and process evaluations? The nurse, nursing administrators, or both.
• Outcome evaluation – evaluation based on behavioral changes
Structure evaluation – relates to such things as appropriate equipment to assess the client or to carry out the plan ant to
record evaluation conclusions.
e.g. weighing scales
It may also relate to organization within which the nurse works.
e.g. agency-created limitation on time
Process evaluation – focuses on the activities of the nurse, can be done during each phase of the nursing process, or it may be
carried out at the end of the process.
P. 36 There are questions to be asked to evaluate each phase of the nursing process.

Criteria of a Profession
a. Utilizes in its practice a well defined and well-organized body of specialized knowledge that is on the intellectual level of the
higher learning.
b. Constantly enlarges the body of knowledge it uses and improves its techniques of education and service by the use of the
scientific method.
c. Entrusts the education of its practitioners to institutions of higher education.
d. Applies its body of knowledge to practical services vital to human and social welfare.
e. Functions autonomously in the formulation of professional policy and in the control of professional activity thereby
f. Attracts individuals of intellectual and personal qualities who exalt service above personal gain and who recognize their
chosen occupation as a life work
g. Strives to compensate its practitioners by providing freedom of action, opportunity for professional growth, and economic
security.