Nursing…..The word brings to mind the true embodiment of compassion, structure and devotion. Deep within the heart of every nurse lays an unfathomable sense of commitment and caring for others. Along with this profound sense of loyalty, comes an unbridled passion for upholding a strong, ethical standard of practice and the ability to be a formidable leader among peers. As the basis for a nursing conceptual framework, the question of what nursing means to me hopes to be answered in the following manuscript.
Background
As the youngest of eight children, after 12 years of working as a cosmetologist, I decided to change careers. Seeking to realize goals that could not be accomplished through cosmetology, I pursued an associate’s degree in nursing. To further my knowledge and clinical practice, a baccalaureate degree became my next challenge, in hopes to fulfill my life-long dream of higher education. During my recent clinical practice in a long term geriatric facility, I have been precepted by the director of nursing and my dream of receiving my bachelor’s degree in the field of nursing is almost at fruition.
My clinical course work includes nursing ethics, leadership, management, community health, research, health assessment and pathophysiology. Through my clinical studies, I have developed a structural framework on which to build my own nursing practice. As with any structure, however, the framework must be substantial in order to provide adequate support. With further review of the literature and a well-thought out formula based on present nursing concepts, my nursing conceptual framework has manifested itself into a practical format.
Review of Literature to Formulate a Conceptual Framework
When developing the basis for a nursing framework, if we take the concept of nursing ethics, leadership and management and combine it with a mixture of nursing theory, we have the recipe for a nursing conceptual framework that gives rise to a steadfast nursing practice.
Polit and Hungler (as cited in Chitty, 1993) claim that both nursing theories and nursing conceptual frameworks overlap to a certain degree, since they both utilize concepts as developmental components. Furthermore, Fawcett (as cited in Chitty, 1993) defined a conceptual framework as “a set of concepts and those assumptions that integrate them into a meaningful configuration” (p. 194). It is important to note that a conceptual framework is not a theory and includes a less formal and more abstract explanation (Chitty, 1993). According to Fawcett (as cited in Chitty, 1993) what differentiates the two, is the degree of abstractness and formality that is used to describe the concept.
Relative to nursing ethics, Andrist, Nicholas and Wolf (2006) make the bold statement that “it is now more accurate to describe the ethical core of nursing as being part of it’s intellectual heritage” (p. 434). Since the foundation of modern day nursing was built in the early 19th century, the moral nature of the discipline has devoted considerable thought to ethical standards. Brief reviews of nursing ethics include writings of early leaders in the field such as Florence Nightingale. Her unwavering efforts attempted to encourage a high number of quality applicants to enter into the field. In 2000, Dossey (as cited in Andrist, Nicholas & Wolf, 2006) implied that the ethical common denominator for nurses included those who were sober, honest, trustworthy and truthful. While this implication may have been based on a strong desire to keep the nursing profession free from scandal, the strain of changing times has, in certain instances, caused the profession to falter under scrutiny. In efforts to survive the ever-increasing stress imposed upon nurses from a health care system in transition, the nursing profession has suffered some moderate bruising but continues to progress onward with the highest degree of moral standards.
An effective leader is not only a picture painter, but one who builds commitment and loyalty among others. A good leader not only assists others in idealizing the corporate mission statement but encourages creativity in developing ways to carry it out. He also has a strong ability to influence and motivate others. All nurses, whether administrative or clinical practitioners, are leaders (Rocchiccioli & Tilbury, 1998).
Being a leader is an essential part of the nursing profession. A nurse who has weak leadership abilities should look for to ways to improve them. Nurses, as leaders, develop stronger leadership skills through patient teaching. As role models, nurses further impart their value system to patients and other staff members as they communicate their vision in the way that they practice their nursing skills on a daily basis.
“If leaders are picture painters, managers are problem solvers whose energies are directed toward goals, resources, structures and the management of people” (Rocchiccioli & Tilbury, 1998, p. 101). While leaders focus on doing things right, managers’ focus on getting things done (Rocchiccioli & Tilbury, 1998). Being a manager not only requires natural leadership abilities but strong organizational and negotiating skills. While leaders create change, managers facilitate it! In a perfect world, each embraces similar qualities (Rocchiccioli & Tilbury, 1998). The aptitude for leadership and management skills make the role of the nurse in the health care system, of two-fold importance.
In her book, Notes on Nursing, What It Is and What It Is Not, Florence Nightingale states that “every woman is a nurse” (Nightingale, 1860, preface). Though rudimentary in example, as the profession has grown to include men, her fundamental framework set the pace for nursing theorists of the future.
Nursing theory “provides a specific structure for interpreting and/or modifying a situation or behavior (Leddy, 2006. p. 76). Theories, therefore, are similar to hypotheses in that they explain to us what might be rather than what is. Different theories are usually supported by specific research and typically co-exist within the discipline of nursing (Leddy, 2006).
Identification and Application of Theorist Hildegard Peplau
In addition to her many other accomplishments, Hildegard E. Peplau developed the first theoretical compilation of works published in the twentieth century. Her focus was on the interpersonal relationship between a nurse and a patient and the process that occurs during four phases of the relationship: orientation, identification, exploitation and resolution (Peplau, 1988).
During the orientation phase, the nurse, using the nursing process, assesses the patient’s physical and psychological needs and then the needs of the patient’s family. Using the information he discovers in this phase, the nurse attempts to develop a relationship with the patient and the family members through open communication. This step is used to begin a working relationship based on trust where the patient becomes an active participant, asking questions and establishing a comfort level with the nurse (Andrist, Nicholas ; Wolf, 2006).
In the identification phase of the process the patient will adopt one of three modes of interaction as he grows accustomed to the nurse: one of passivity and dependence, autonomy or independence or one of interdependence whereby he will work and communicate with the nurse as part of a collaborative team. The goal of this step is to increase the patient’s capacity to develop better coping skills to deal with their current health care problems (Andrist, Nicholas & Wolf, 2006).
As the patient moves into the exploitation phase, he begins to fully utilize the services offered by the nurse. There is a power shift from nurse to patient as he begins to assume more control. During this time, he often focuses on future goals, which usually include being discharged from the hospital. It is the nurse’s job to support the patient during this phase, according to Peplau (as cited in Andrist, Nicholas ; Wolf, 2006) and allow them to move spontaneously towards independence.
The final phase sees the patient with all of his needs being met via this mutual nurse-patient relationship. The patient now takes the lead in the relationship and severs the bond, stepping out of the hospital to re-start his journey without any further assistance from the nurse. The therapeutic bond has thus effectively been broken through a collaborative effort (Andrist, Nicholas ; Wolf, 2006),
Application of Peplau’s Theory
The development of the Interpersonal Relationship Theory by Hildegard Peplau began after her own experience in which she neglected a patient’s psychological needs and the patient subsequently died. After this she vowed never again, out of ignorance, would she make the same mistake. Hence the basis for her important contribution to the nursing field.
During one of my more recent clinical experiences, I was assigned to a unit where most patients were suffering from chronic illness. As I took report from the night nurse, I was told about Mr. B, an elderly gentleman who had been admitted to the hospital for respiratory distress secondary to Chronic Obstructive Pulmonary Disease. The last thing that the night nurse said to me was that the patient had a flat affect and seemed very angry. She further stated that the patient did not make eye contact with people, spoke in a very gruff tone and many times shrugged the nurses off, while refusing to get out of bed.
Prior to entering the room, I reviewed his chart and noted that he had recently lost his wife of 55 years and was facing homelessness, as his son did not want to take care of him anymore. He was also being asked to make a decision about his code status, in the event of cardiac or respiratory arrest.
When I first entered the room, I introduced myself to Mr. B. and tried to establish a rapport. Mr. B., however, refused to make eye contact with me and provided a curt “yes” or “no” answer to the questions I imposed. Each time I presented myself to the room, I continued to try to get Mr. B. to open up and be more expressive about his feelings.
Finally, towards the middle of the day, after multiple demands and angry outbursts, he realized that I was not going to react, and started to open up to me. He told me of the intense pain he had felt after losing his wife. He said he thought that he would rather see the end than go through another day without her. He further explained that he wanted to make himself a “no-code” that he had led a long and trying life and was now ready to accept his dreary fate.
Guiding him through the process, I used active listening skills that offered frequent restatements to let him know that, while I heard what he was saying, I too felt his pain! The shift ended and when I went home that night, my thoughts resided with Mr. B.
The next day I was back in the same unit and as it is our policy to provide continuity of care, I had Mr. B. as a patient again. Much to my surprise, he had a smile on his face and was much friendlier than he had been the day before. He went so far as to ask me to help him out of bed so that he could sit in the chair. This was something that he had not done in weeks!
There came a day when Mr. B. was finally ready to be discharged on hospice to a local nursing home. On the day that he left, although not my patient, he reached for my hand while being wheeled out by the ambulance and with a warm smile, said “thank you”! I was so overwhelmed I had to turn my head so that he would not see the tears that were welling up inside my eyes. Peplau’s theory made it possible for this nurse and that patient to connect in a way that was never thought possible!
Progression of Practice from the Associate to Baccalaureate Level Nurse
Associate degree nursing (ADN) programs have long been a vital part of the health care system. The question remains, however, about distinguishing between a “professional” or baccalaureate (BSN) degree nurse and a “technical” or associate degree nurse (Haase, 1990).
While associate degree educators agree that those who obtain their two year degree should continue their education, it becomes difficult for the adult learner who has already established himself as an ADN nurse to venture onward to obtain his bachelor’s (Andrist, Nicholas ; Wolf, 2006).
Luckily, many options exist today for achieving higher education in nursing. Online degree programs and accelerated baccalaureate programs make it easier than ever to attain an advanced degree, should that be the nurse’s ultimate goal.
According to Delaney and Piscopo (as cited in Andrist, Nicholas & Wolf, 2006), BSN nurses help to transform nursing practice and improve patient outcomes by utilizing advanced knowledge gained through further education.
ADN nurses must be aware that when entering into a BSN program, critical thinking skills must become fine tuned as nurses start to think “outside the box” when it comes to patient care. No longer are ADN nurses just using their technical skills in practice, but they must now assume the role of being an integral part of the health care team.
To create a smooth transition, it becomes important for nurse educators to assist the ADN nurse during the process by helping them to build confidence and rely on their own nursing instinct. This not only assists nurses to thrive in a new level of professionalism, but improves the health care system as a whole.
Identified Strengths and Weaknesses of Framework
As every structure has its faults, so does a nursing framework. Ethical dilemmas exist when the patient’s belief system conflicts with that of the nurse. Culturally competent care should be devoid of judgment and discrimination. This only creates bias and prejudice that can cause the patient cultural pain. Cultural competence means the ability of the nurse to give care to a diverse group of people, regardless of their cultural beliefs (Potter ; Perry, 2003).
Flaws in the leadership-management aspect of the job can be found within the different leadership styles. There are times when an autocratic leader may be inappropriate when dealing with patients. A democratic style may better serve them. It may be more relevant for the nurse to use a situational leadership style that is based on the needs of his patient (Potter ; Perry, 1997).
On the other hand, in applying nursing theory to patient care, the strength of Peplau’s work gives the nurse a framework on which to base therapeutic interactions with the patient. Peplau’s model encourages the nurse to develop an attitude that gives a strong, conceptual framework to his practice (Fowler, 1995). Using nursing theory, then, is a fundamental part of any framework.
While nursing ethics, leadership, management and theory play a vital role in the nurse’s development as a professional, an ever-growing need exists to emphasize patient care and not hospital bureaucracy. The clever nurse knows how to assertively maintain the delicate balance between what is necessary for the patient, and what is necessary for the paperwork! As the nursing profession evolves, the nursing conceptual framework remains the basic foundation for every nurse’s clinical practice.
References
Andrist, L., Nicholas, P. ; Wolf, K. (2006). A History of Nursing Ideas. Sudberry, MA: Jones ; Bartlett Publishers Inc.
Chitty, K. (1993). Professional Nursing Concepts and Challenges. Philadelphia, PA: W.B. Saunders Company.
Fowler, J. (1995). Taking Theory into Practice Using Peplau’s Model in the Care of a Patient. Professional Nurse Journal, 10 (4) 226-30.
Haase, P. (1990). The Origins & Rise of Associate Degree Nursing Education. Durham, NC: Duke University Press.
Leddy, S. (2006). Integrative Health Promotion: Conceptual Bases for Nursing Practice. Sudbury, MA: Jones & Bartlett Publishers
Nightingale, F. (1969). Notes on Nursing: What It Is and What It Isn’t. Mineola, NY: Dover Publications, Inc.
Peplau, H. (1988). Interpersonal Relations in Nursing. London, England: Macmillan Publishing Inc.
Potter, P. ; Perry, G. (2007). Basic Nursing: Essentials for Practice (6th edition). Philadelphia, PA: Mosby Inc., an affiliate of Elsevier Inc.
Potter, P. ; Perry, G. (1997). Fundamentals of Nursing: Concepts, Process ; Practice (4th edition). St. Louis, MO: Mosby Year Book Inc.
Rocchiccioli, J. ; Tilbury, M. (1998). Clinical Leadership in Nursing. Philadelphia, PA: W.B. Saunders Company.
