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Theoretical Foundation in Nursing

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    Professional roles of nurses

    Caregiver – provide care and comfort for persons together with preserving the dignity of a human being. Communicator – Communication facilitates understanding and collaboration of nursing action with their clients and other members of the health team. Teacher–nurses help the clients learn the state of their well-being and the therapies that will be done to alleviate their conditions. Counselor – help the clients to cope with stress brought about by their health condition. Client Advocate – promoting what is best for the patient, ensuring that his needs are met and protecting his rights. Change Advocate – as a change agent, the nurse can identify the problem, assess the client’s motivation and capacities for change and others.

    Leader – the process of influencing helps the client in making decisions to establish and achieve their goals towards alleviating their conditions. Manager – involves “planning, giving direction, developing staff, monitoring operations, giving rewards fairly, and representing both staff members and administration as needed.” Researcher – investigative role of nurses which further improves the nursing practice

    The expanded role of nurses

    Nurse Generalist Nurse Clinician Nurse Practitioner Nurse Specialist

    Scope of theories and analysis

    Theories – known to have a relative system of ideas that is intended to explain a given phenomenon or fact.

    Nursing theories – reflect particular views of a person, health, environment, nursing and other concepts that contribute to the development of a body of knowledge specific to nursing concerns.

    Categories related to the scope of the theory

    Grand theories – are simply known to speak about a broad range of important relationships among concepts and discipline. An example of the grand theory is Orem’s Self-care theory of nursing and Neuman Systems Model theory.

    Middle-Range Theories – are the least abstract level of theoretical knowledge because they include details specific to nursing practice. 3. Micro-range theories – known to be the most concrete and narrow in scope.

    Different ways in analysing and evaluating nsg theory

    Clarity Simplicity Generality Empirical precision Derivable consequences Nursing theorist Florence nightingale: The matriarch of modern nursing born on May 12, 1820, in Florence, Italy. Lives in Derbyshire(Orig. home) and Hampshire (Embley Park) in London. In 1851 she complete her training at Kaiserworth, Germany. 1853- she completed her training and became superintendent for invalid women. During the Crimean war, she took care of the wounded soldiers. She was called “Lady of the Lamp” because she made rounds at night time. She addresses the environmental problems that existed. Established St. Thomas Hospital and King’s College Hospital in London. Died in her sleep on Aug. 13, 1910 at age of 90. Theoretical sources: Individual, societal and professional values were an integral part of her theory development.

    As a Unitarian, her belief in God serves as her foundation in her work as a nurse. Empirical evidence: Uses her reports describing the sanitary and health conditions in Crimea. As a statistician, she generated reports of varied subjects of health care, nursing and social reform. Accdg. to Cohen, she invented a polar diagram to dramatically represent the extent of needless death in the British Military Hospital in Crimea. Cohen summarizes the work of Nightingale as researcher and statistician Metaparadigm in nursing: Nursing – That nursing is very essential for everybody’s well-being.

    Person – Essence of a person as a patient; Nightingale emphasizes the nurse who is in control of the patient’s environment. Health – Nightingale’s statement regarding health is “being well using every power that the person has to the fullest extent. ” Environment – Stressed that nurses could have a special role in uplifting the social status of the poor by improving their living situations. Acceptance by the nursing community practice – The environmental aspects of her theory (ventilation, warmth, quiet, diet, and cleanliness) are integral components in nsg.

    Care; Her essay “Cassandra” – concept in feminism. Research- Scientific inquiry and statistics -inquiry used in her research. If analyzed as a theory, they lack complexity and testability found in modern nursing. Analysis Simplicity – Her theory contains 3 major relationships:

    1. environment to the patient
    2. nurse to environment
    3. nurse to patient.

    Generality – Used to provide guidelines for all nurses for the last 150 years. Empirical precision – She advised nurses that their practice be based on observations and experiences rather than systemic empirical research.

    System Theory

    Hildegard Peplau’s “Interpersonal relationship” She is known as the “Psychiatric Nurse of the Century”. Born on Sept. 1, 1909 in Reading, Pennsylvania. 1931- she graduated from Pottstown, Pennsylvania Hospital School of Nsg. 1943- graduated in Interpersonal Psychology from Bennington College, Vermont 1947 – MAN in Psychiatric Nursing from Teacher’s College Columbia, New York. 1953 – Doctor of Education in Curriculum Development. 1930- started her works in advanced education and practice and saved the ANA from the point of bankruptcy by moving the nursing profession towards scientific recognition.

    She worked with renowned psychiatrists Freida Fromm-Riechman and Harry Stack Sullivan. Her nursing writings are research are featured in the American Journal of Nursing from 1951- 1960. Interpersonal Relations in Nursing – her first book published in 1952 states the need to emphasize the importance of the nurse-patient relationship in providing health care. An awardee of The Christian Reimann Prize and a fellow of the American Academy of Nursing. March 7, 1999- died peacefully in Sherman Oaks, California at age 89. Metaparadigm in Nursing:

    Person: Defines person as a man who is an organism that lives in an unstable balance of a given system. Health: symbolizes the movement of the personality and other ongoing process human processes that directs the person towards creative, constructive, productive and community living. Believed that one’s health is maintained and achieved by meeting the psychological demands and interpersonal conditions. Environment: Defined that they are forces outside the organism and in context with the socially approved way of living from which vital social processes are derived such as norms, customs and beliefs.

    Nursing: Defines nursing as a significant therapeutic interpersonal process; Considers the socio-economic, spiritual, emotional and physical aspects of a person.
    Phases of nurse-patient relationship:

    1. Orientation- meeting and winning patient’s trust (on admission) nurse-patient first interaction.
    2. Identification- During the intensive treatment period
    3.  Exploitation- Convalescence and rehabilitation. The client derives full value from what the nurse offers through a relationship
    4. Resolution- Discharge. Old needs and goals are set aside and new ones are adopted.

    Once older needs are resolved, newer and more mature ones become evident. Nursing Roles:

    1. Role Of A Stranger – the patient and nurse as strangers to each other. The nurse must treat her patient with utmost courtesy with respect for his individuality.
    2. Roles of the resource person – The nurse provides answers to the patient’s queries which include health information, advices and a simple explanation of his health care.
    3. leadership role – The nurse must act on behalf of his patient’s interest to enable him to make decisions of his plan of care. It is achieved through cooperation and active participation.

    Surrogate Role – The nurse serves as a temporary caregiver to the patient. Counselling Role – It strengthens the relationship of the nurse-patient. The nurse is a listening friend, understanding family members and giving emphatic advice. Analysis Simplicity: It is easily understood; It was taken from specific observations and applied in general also called inductive reasoning. Generality: This can be used only in situations that communication between nurse and patient can occur. The evaluative standard is not met.

    Empirical Precision: Provides a theory based on reality; Her theory can be tested and observed by using pure observation; Precise in work but still needs continued research and development. Derivable Consequence: Her work has provided a significant contribution to the nursing profession. Virginia Henderson “14 Fundamentals of Basic Human Needs” Born on March 19, 1897 Died on November 30, 1996 1921 Graduated at Army School of Nursing Graduated at Columbia University M. A. Degree in Nursing Education She wrote and edited several editions of the “Principles and Practice of Nursing” & Basic Principles of Nursing Care.

    Metaparadigm Nursing – 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. (of to a peaceful death that he would perform unaided if he had a necessary strength, will or knowledge and to do this in such way as to help him gain independence as rapidly as possible) Health – The quality of health rather than life itself, that margin of mental, physical vigor that allows a person to work most effectively and to reach his highest potential level of life satisfaction.

    Environment – The aggregate of all the external conditions and influences affecting the life and development of an organism. Person – is an individual who requires independence or peaceful death. The mind and body are inseparable The patient and his or she are viewed as a unit. 14 Components of Basic Human Needs

    1. Breathing- fresh air
    2. Eating and Drinking- right nutrition
    3.  Elimination- eliminate body waste
    4.  Movement- maintain desirable posture
    5.  Rest and Sleep- enough rest
    6. Suitable Clothing- proper clothing (dress and undress)
    7. Body Temperature- normal range by adjusting & modifying the environment
    8. Clean body and protected integument – well-groomed and clean body
    9. Safe Environment- avoid danger & injuries in the environment
    10. Communication- expressing emotions, needs fears, or opinions
    11. Worship- faith
    12. Work- work with a sense of accomplishment
    13. Play – participate in various activities
    14. Learning- discover or satisfy the curiosity that leads to development and health.

    3 levels of Nurse – patient relationship

    1. The nurse is a substitute for the patient. – doing for the patient (substitutive)
    2. The nurse is a helper to the patient. – helping the patient (supplementary).

    The nurse partner with the patient. – working with the patient (complementary) Goal of Nursing

    1. 1To work independently with other health care workers.
    2. Assisting client in gaining independence as quickly as possible
    3.  To help the client gain lacking strength.
    4.  Keep the patient’s day as normal as possible.
    5.  Promotion of health.

    Major Assumptions Nursing The nurse has a unique function to help sick or well individuals. The nurse functions as a member of a medical team The nurse function independently of the physician in attendance. The nurse is knowledgeable in both biological and social sciences.

    The nurse can assess basic human needs. The 14 components of nursing care encompass all possible functions of nursing. Person (Patient) The person must maintain physiological and emotional balance The mind and body of the person are inseparable. The patient requires help toward independence. The patient and his or her family are units. The patient’s needs are encompassed by the 14 components of nursing. Health Health is quality of life. Health is basic to human functioning Health requires independence and interdependence. The promotion of health is more important than the care of the sick.

    The individual will achieve or maintain health if they have the necessary strength, will, or knowledge. Environment Healthy individuals may be able to control their environment, but illness may interfere with that ability. Nurses should have safety education. Nurses should protect patients from mechanical injury. Nurses should minimize the chances of injury through recommendations regarding the construction of buildings, purchase of equipment and maintenance. Acceptance of the Nursing Community: Practice:  She focuses on decision-making. The nursing process – is a problem-solving process that could be used to answer the patient’s need.

    Steps in Nursing Process:

    1.  Assessment Phase – assess the 14 basic human needs and check which one is lacking.
    2. The planning phase – involves giving a plan of care to meet the needs and personality of the patient.
    3.  Implementation Phase – the nurses use 14 basic needs in answering factors that contribute to the illness of the patient.
    4.  Evaluation Phase – the nurse and patient review the relationships and decide whether the goals are met.

    Education: Developed 3 phases of curriculum development:

    1. First Phase – the emphasis is made on helping patients perform activities of daily living.
    2. Second Phase – importance is placed on assisting patients to achieve their needs in times of illness.
    3. The third phase – is centered on the patient and his family together with the dynamics affecting the relationship inside the unit.

    Research: Uses research to improve the nursing practice; Developed baccalaureate level and use of library research. Analysis Simplicity: It is complex in nature. Her interpretation of 14 basic needs had too many variables and several interpretations can be derived and other explanatory relationships can be seen.

    Generality: It is broad in scope and can be applied in any setting. Derivable Consequences – Emphasizes the importance of independence and interdependence on the different health care professions; Her definition of the unique function of the nurse is widely read and accepted. Joyce Travelbee “Human to Human Relationship Model” Born in 1926, a psychiatric nurse, educator and writer. 1956 – completed her Bachelor of Science degree in nursing education at Louisiana State University and her Master of Science degree in Nursing from Yale University in 1959.

    1973- started her doctoral program in Florida but was unable to finish it because she died later that year at the age of 47 after a brief sickness. 1952 – started as instructor focusing in Psychiatric Nursing at Depaul Hospital Affiliate School, New Orleans while working on her baccalaureate degree. She was the director of Graduate Education at Louisiana State University Scholl of Nursing until her death. Interpersonal Aspects of Nursing – her first book was published in 1966 and 1971. Intervention in Psychiatric Nursing: Process in the One to One Relationship – her second book published in 1969.

    Metaparadigm in Nursing:

    Person: Defined as a human being – is a unique, irreplaceable individual who is in the continuous process of becoming, evolving and changing. Health: This is measured by subjective and objective health. Environment: She defined human conditions and life experiences encountered by all men as suffering, hope, pain and illness associated with the environment. Nursing: Define as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experiences of illness and suffering and if necessary to find meaning in these experiences.

    The Interactional Phases of Human to Human Relationship Model are:

    1. Original encounter – described as the first impression by the nurse of the sick person and vice versa. The nurse and patient are in stereotyped or traditional roles.
    2. Emerging identities – the nurse and patient perceiving each other as unique individuals.
    3. Empathy – the ability to share in the person’s experience. Two qualities that enhance empathy: similarities of experiences; desire to understand another person
    4. Sympathy –happens when the nurse lessens the cause of the patient’s suffering.“When one sympathizes, one is involved but not incapacitated by the involvement”. The nurse uses therapeutic use of self or helpful nursing actions.
    5. Rapport – described as nursing interventions that lessen patient’s suffering. “ A nurse establishes rapport because she possesses the necessary knowledge and skills required to assist ill persons and because she can perceive, respond to, and appreciate the uniqueness of the ill human being. Acceptance by the Nursing Community: Practice: She stated that understanding illness enables the patient not only to accept illness but also to use it as a self-actualizing life experience.

    The hospice nurse believes that a dying person must find meaning in his/her death before he/she can accept reality so just her family or loved ones must find meaning in death before they can complete the grieving process. Education: It served as better assistance for nurses to help individuals in the meaning of illness and suffering. Accdg. to Travelbee model course in philosophy and religion helps the nursing student to fulfill the purpose of nursing efficiently. Research: The researchers acknowledged nursing interventions that would support her theory.

    Analysis Clarity: They are not consistent in clarity and origin. She also uses different terms for the same definition. She only dealt with family not in communities. Simplicity: Simplicity is not evident because it contains different variables thus was not able to meet the criteria. Generality: It has a wide scope of application. It seems useful in chronically ill patients, undergoing long-term rehabilitation and the dying or terminally ill. Empirical Precision: It has low measures of empirical soundness due to a lack of simplicity.

    Derivable Consequences: The theory is useful because it can describe, explain, predict and control phenomena. Lack of empirical precision creates a lack of usefulness. Her theory focuses on the development of the quality of care. Betty Neuman “Systems Model in Nursing Practice” 1924 – born Lowell, Ohio 1947 – Received RN Diploma from Peoples Hospital School of Nursing, Akron, Ohio; Moved to California and gained experience as a hospital, staff, and head nurse; school nurse and industrial nurse; and as a clinical instructor in medical-surgical, critical care and communicable disease nursing.

    1957 – Attended the University of California at Los Angeles (UCLA) with a double major in psychology and public health; Received BS in nursing from UCLA. 1966 – she received her Master’s Degree in Mental Health, Public Health Consultation from UCLA. 1971 – her first book publication, Consultation and Community Organization in Community Heath Nursing 1985 – Received doctorate in Clinical Psychology from Pacific Western University. 1998 – Received second honorary doctorate this one from Grand Valley State University, Allendale, Michigan. Major concepts and definitions:

    The major concepts in her model are: Wholistic Client Approach– it is a dynamic, open, systems approach to client care and was developed to focus on nursing problem definition and understanding the client interaction with the environment. Wholistic Concept – clients have viewed wholes whose parts are in dynamic interaction. It affects the whole system of the client in physiological, psychological, sociocultural, developmental and spiritual. Open System – its elements are exchanging information energy within its complex organization. Stress and reaction to stress are elements of the open system.

    Environment: Internal and external forces affecting and being affected by the client. Created Environment – the client’s unconscious mobilization of all system variables toward integration, stability and integrity. Content – The five variables (psychological, physiological, socio-cultural, developmental and spiritual) of interaction with the environment comprise the whole system of the client. Basic structure – basic factors of survival such as innate(energy sources) or genetic features. Stressors – are tension-producing stimuli. They may be: Intrapersonal forces – occurring within individual such as responses.

    Interpersonal forces – occurring between one or more individuals such as role expectations. Extrapersonal forces – occurring outside the individual such as financial circumstances. Degree of reaction – the amount of energy required for the client to adjust to stress. Prevention as intervention – are purposeful actions to help the client retain, attain and/or maintain stability. There are three (3) levels of prevention: Primary prevention- a stressor is suspected or identified ( wala pang sakit) Secondary Prevention- stress has already occurred ( 1st stage or early findings) Tertiary prevention- occurs after the active treatment.

    (rehabilitation/readaptation) Reconstitution– occurs following the treatment of stressor reactions. (the result of the intervention, and ang nangyari) Line of Defense or Resistance Normal Line of Defense – is the model’s outer solid circle. It represents the stable state of the individual. Flexible Line of Defense – the model’s outer broken ring. It is perceived as a protective buffer for preventing stressors. Lines of Resistance – a series of broken rings surrounding the basic core structure. They are the resource factors that help clients defend against stressors.

    Process or Function –a system adjusting to the environment. Input and Output – matter, energy, and information that is exchanged between the client system. Feedback – system output in form of matter, energy and information. Negentropy – process of energy utilization for stability or wellness. Entropy – a process of energy depletion and disorganization that moves toward illness or possible death. Stability– it is able to maintain an adequate level of health. Wellness – systems needs are met. Illness – disharmony among parts of the system. Metaparadigm in Nursing or Major Assumptions:

    Nursing: Concerned with the whole person. She views nursing as a unique profession in that it is concerned with all the variables affecting an individual’s response to stress. PERSON: client/client system that may be an individual, family, group, community or social issue. Health: It is a continuum of wellness to illness that is dynamic in nature and constantly subject to change. The total system needs are being met. Environment: Defined as being all internal and external factors that surround or interact with person and client. Acceptance by the Nursing Community:

    Practice: The model facilitates the nurses to be goal-oriented, unified, holistic approaches to client care yet serves as multidisciplinary use to prevent fragmentation of client’s care. It is used in community-based practice in public health nursing. Education: Widely used as curriculum guide oriented toward wellness. Research: It is widely used to advance the scientific discipline. It is used to enhance the nursing care of patients with psychological stressors. Dorothy Johnson “Behavioral System Model” Born on August 21, 1919 in Savannah, Georgia Youngest in a family of seven.

    She obtained her Bachelor of Science in Nursing Degree from Vanderbilt University, Nashville, Tennessee, and her Master in Public Health from Harvard University in Boston, Massachusetts. Most of her career was in Pediatric Nursing at the University of California. From 1949 till retirement in 1978 she was an assistant professor of pediatric nursing, an associate professor of nursing, and a professor of nursing at the University of California in Los Angeles. Johnson stressed the importance of research-based knowledge about the effect of nursing care on clients.

    Died in February 1999 at the age of 80. Metaparadigm Nursing- This is an external force acting to preserve the organization of the patient’s behavior using the imposing regulatory mechanism or by providing resources while the patient is under the stress. Person – a behavioral system with a patterned, repetitive and purposeful way of behaving that link the person to the environment. Health – an elusive, dynamic state influence by biological, psychological and social factors. Environment – can be manipulated by the nurse to achieve the health goal of the patient.

    Seven Behavioral Subsystems:

    1.  The Attachment or Affiliative Subsystem – is well known as the earliest response system to expand in the individual. The most favorable functioning of the affiliative subsystem allows social inclusion, closeness and the pattern and continuance of a strong public bond.
    2.  The Dependency Subsystem – are actions that trigger nurturing behaviors from other individuals in the environment. The product is consent, interest or appreciation and physical support.
    3.  The Ingestive Subsystem – relates to the behaviors surrounding the ingestion of food. Behaviors related to ingestion of food may relate more to what is satisfactory in a specified culture than to the biological necessities of the person.
    4.  The Eliminative subsystem – relate to behaviors surrounding the secretion of waste products from the body. Human cultures have defined different socially acceptable behaviors for the excretion of waste, but the continuation of such an outline remains from culture to culture.
    5. The Sexual Subsystem – imitates behaviors related to procreation or reproduction. The goal in all societies has the same outcome-behaviors suitable to the society at large.
    6. The Aggressive Subsystem – relates to behaviors concerned with defense and self-preservation. It is a defensive response of the individual in life-threatening events.
    7. The Achievement Subsystem – contains behaviors that attempt to control the environment. It is composed of intellectual, physical, imaginative, mechanical and communal skills. Acceptance by the Nursing Community Practice: It is used to develop a self-report and observational instrument to be carried out in the nursing process. The theory was used as a model to develop an assessment tool when caring for children.

    Education: A core curriculum based on a person as a behavioral system would have definite goals and a clear course of planning. The study centered on the patient behavioral system and dysfunction, which would necessitate the use of the nursing process. The student would need knowledge from the social and behavioral disciplines and the physical and biological sciences. Research: It explains and identifies the behavioral system disorders which arise about illness and develops good reasoning as means of management. Analysis

    Simplicity: Johnson’s theory is somewhat straightforward with some concepts. The theory is somewhat complex because of some interrelationships among behavioral systems. Generality: The theory is relatively limitless when applied to sick individuals, but it has not been used with well individuals or groups. Empirical Precision: The models contain abstract concepts and need improvement. Derivable Consequences: The model guides nursing practice, education and research and generates new ideas about nursing and differentiates nursing from other professions.

    Imogene King “Goal Attainment Theory ” Born January 30,1923, West Point, Iowa 1945 – Graduated from St. John’s Hospital of Nursing in St. Louis, Missouri. 1948 – graduated with Bachelor of Science in Nursing in St. Louis University. 1947-1958 – she worked as instructor for Medical Surg. Nsg. and assistant director at St. John’s Hospital. 1957 – finished her MSN Died December 14,2007, St Petersburg Florida 1961- she became the Doctor of Education from Teacher’s College Columbia University, New York. 1980 – awarded an honorary Ph.D. from Southern Illinois University.

    1964 – her first theory appeared in journal of Nursing Science and was edited by Martha Rogers. 1968 – Her article “A Conceptual Frame of Reference for Nursing” was published in nursing research. 1968 – 1972 – works as director of the School of Nursing at Ohio State University where she wrote her book Toward a Theory for Nursing: General Concepts of Human Behavior Metaparadigm in Nursing: King’s model is composed of three interacting systems:

    1. Personal – These are used to
    2. Interpersonal – establish nurse
    3. Social Communication – client relationship Accrdg.

    to King there are three needs of human beings:

    1. Need for information
    2. Need for care for illness prevention
    3. Need for total care when a person doesn’t have the capacity to help themselves.

    Person: Describe as an open system as a spiritual being and rational thinker who makes choices, selects alternative courses of action and has the ability to record their history through their own language and symbols, unique, holistic and have different needs, wants and goals. Health: The ability of a person to adjust to the stressors that the internal and external environment exposes to the client.

    Environment: The process of balance involving internal and external interactions inside the social system. Reactions from the external and internal environment can be biological, psychological, physical, social or spiritual. Nursing: An act wherein the nurse interacts and communicates with the client. The goal of the nurse is to help the client maintain health through health promotion and maintenance, restoration and caring for the sick and dying. Interacting Framework: Personal – how the nurse views and integrates self-based from personal goals and beliefs.

    Body Image – includes both the way one perceives one’s body and other reactions to one’s appearance. Growth & Development – processes in people’s lives through with their move from a potential (physiological/psychological)achievement Perception – data obtained through the senses & from memory, organized, interpreted & transformed. Self – made up of thoughts & feelings Space – Interval between two events that is experienced differently by each person. Interpersonal – how the nurse interrelates with co-workers or patients, particularly in the nurse-patient relationship.

    Communication – verbal & non-verbal

    Interaction – are observable behaviors of two or more persons in mutual presence Transaction – series of exchange between human beings & the environment Role – characterized by reciprocity in that of a person may be a giver or a taker. Stress – ever-changing conditions in which an individual seeks to keep equilibrium Social – how the nurse interacts with co-workers, superiors, subordinates and the client environment in general; comprehensive interacting system is comprised of groups that make up a society Organization – made up of individuals who have prescribed role.

    Authority – refers to active reciprocal process transactions. Status – a relationship of one’s place in a group to others in a group. Decision-making – changing and orderly process through which choices related to goals are made among identified. Goal Attainment Theory: Action – is means of behavior or activities that are towards the accomplishment of a certain act. It is both physical and mental. It aims toward setting of goals through communication.

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