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Nursing Theory: The Basis for Professional Nursing
Nursing TheoryLatin “a viewing”; Greek “contemplating”A body of knowledge shaped by how nurses
see the worldA group of related concepts, definitions &
statements that propose a view of nursing phenomena from which to describe, explain or predict outcomes
Abstract ideas
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
Theory Guides the Professional Nurse in….
Organizing and analyzing patient dataUnderstanding connections between
pieces of dataDiscriminating between important and
less pertinent dataMaking sound clinical judgments based
on evidencePlanning effective nursing interventionsPredicting and evaluating outcomes of
interventions
Definition of TermsMetaparadigm = the major
concepts or abstract ideas of the discipline; most important to practice and researchPersonEnvironmentHealthNursing
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
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
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 patientsFocused on the relationship of patients to their
surroundingsImportance of observing the patient and
recording informationImportance of cleanlinessHealth and recovery from illness is related to
environment
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)
Jean Watson
Studied at CUThe Philosophy and Science of Caring (1979)Emphasized the caring aspects of nursing10 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
Watson ContinuedProposed that nursing be
concerned with spiritual matters and the inner knowledge of nurse and patient as they participate together in the transpersonal caring processNurses share their genuine selfPatient’s spiritual strength is
recognized, supported, encouragedRN encourages openness to
understanding of self and othersLeads to trusting, accepting
relationships where feelings are shared and confidence is inspired
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 assessedSystems of care
Wholly compensatoryPartially compensatorySupportive-educative
Imogene King
A Theory for Nursing: Systems, Concepts, Process (1981)
Focused on persons, their interpersonal relationships, and social contexts with three interacting systemsPersonalInterpersonal Social
Emphasizes goal attainment and patient’s involvement in setting goals (Goal Attainment Model)
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
Hildegard Peplau
Interpersonal Relations in Nursing (1952 & 1988)Relationship between patient and nurse is the
focus of attentionTherapeutic interpersonal relationship
Survival of the patientPatient’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
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
Madeleine Leininger
Theory of cultural careFounder of Transcultural nursingPatients 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
Theory-Based EducationPhD: a research degree that generates
new, discipline-specific knowledgeMaster’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
Theory-Based PracticeOccurs 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
BenefitsExplain practice to othersPasses on knowledge to
studentsContributes to
professional autonomyDevelops analytical skills,
challenges thinking, and clarifies your values and assumptions
Theory-Based ResearchGreat strides have been made in the
last 25 years in nursing research Nursing research tests and refines the
knowledge base of nursingResearch 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
Health Care DeliveryThe four basic types of
services provide by the health care delivery systemHealth Promotion: remain
healthyIllness prevention: reduce risk
factorsDiagnosis & treatment:
refined methods of diagnosis allow for more effective treatment
Rehabilitation & LTC: restore function & independence; disease management
Health Care AgenciesGovernment: 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
Level of Health Care ServicesPrimary 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
Organizational Structures of Health Care AgenciesBoard of Directors: carry responsibility
for mission, quality of services, financesChief Executive Officer (CEO): overall
daily operationMedical Staff: physicians granted
privileges; organized by service/dept.Chief of staff work with CEO to make
important decisions about medical policyNursing Staff: RNs, LPNs, NAs and clerical
staff; organized according to unitsChief Nurse Executive (CNE) or Chief Nursing
Officer (CNO) today on Board of Directors, oversee nursing care
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
Maintaining Quality Accreditation: accrediting bodies approved by
CMS; to improve pt. outcomes; institution wide initiativesJCAHO (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
Health Care DisparitiesDefined as differences in the quality of health
care provided to different populationsCan 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
Health Care TeamPhysiciansPhysician AssistantsPatient Care TechniciansDietitiansPharmacistsTechnologistsRespiratory TherapistsSocial WorkersTherapistsAdministrative Support Personnel:
admissions, medical records, billing, etc.
Nurse’s Role on TeamProvider of Care: direct hands on careEducator: teaching pt., family, new staff,
community, etc.Counselor: emotional support & problem solvingManager: organizes careResearcher: investigates how nursing
interventions impact patient outcomes Collaborator: works with patients, families &
team on agreed patient outcomesPatient Advocate: stands up for patient rights;
advocates for patient’s best interests at all times
Types of Nursing Care DeliveryFunctional 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
Financing Health CareIn 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
Economics of Nursing CareNursing accounted for 20-28% of the costs
of hospitalizations in 1980sTo 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
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)
MedicarePart A = Hospital InsurancePart B = Medical Insurance (20% co-
pay, deductiblePart C = Managed care optionPart D = Prescription drug coverage
MedicaidFederal government contributes 50-
76.8%Personal (out-of-pocket) paymentWorker’s Compensation
Forces Changing Health CareManaged Care attempts to control
healthcare costs; health promotion not illness treatment
Health Maintenance Organization (HMO): health care services provided for a predetermined fixed feeCapitation: same amount paid to provider each
month regardless of whether services were provided or how much the services cost
Gatekeeper: PCP, responsible for referralsPreferred Provider Organization (PPO):
contracts with provider for discounted rate
Forces Changing Health CarePoint-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
Nurse’s Role in Managed Care
Advanced Practice Nurses: ambulatory and community settings
Case ManagerTriageUtilization reviewers to determine most appropriate and cost-efficient level of care
Change in Consumer’s ExpectationsBecame 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
Health Care’s Response Reengineering: rethinking & redesigningPatient-centered care: patient at center of
activity and designing outcomesDecentralization: staff exercise own
judgmentCross-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
New Organizational ModelsFunctional 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
Continued Escalation of Health Care Costs
InflationNew Technology and DrugsIncreased 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
Cost Containment MeasuresCenters 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
Health Care Finance ChallengesContinuing Crisis: Uninsured
AmericansQuality of CareLimits on Choice and
ServicesProvider Restrictions &
Financial Incentives to Limit Services
Cost of Prescription DrugsMalpractice Costs & Impact
of Access to Care
Health Care ReformThe 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