Theoretical Perspectives and Contemporary Issues

Theoretical Perspectives and Contemporary issues

Ns. Heni Dwi Windarwati, MKep.,SpKepJ

Outline• Basic Concepts

– Definition of theory– Theory as a guide to practice– Nursing knowledge

• Applications– Nursing theory in the nurse-client

relationship – Communication theory– Contemporary Issues

Objectives

• Describe the nature and purpose of nursing theory

• Identify the historical development of nursing theory

• Compare and contrast different levels of nursing knowledge

• Describe the implications of Peplau’s nursing theory for the nurse-client relationship

• Analyze psychological models relevant to nurse-client relationship

• Specify the use of communication theory in nursing practice

What is a theory?

• A set of concepts, definitions, relationships, and assumptions that project a systematic view of a phenomena

• It may consist of one or more relatively specific and concrete concepts and propositions that purport to account for, or organize some phenomenon (Barnum, 1988)

What are the components of a theory?

• Concepts – ideas and mental images that help to describe phenomena (Alligood and Marriner-Tomey, 2002)

• Definitions – convey the general meaning of the concepts

• Assumptions – statements that describe concepts

• Phenomenon – aspect of reality that can be consciously sensed or experienced (Meleis, 1997).

THEORY DEVELOPMENT

How does a theory develop?

Four strategies of theory development1. Theory practice theory (theory

developed in other discipline and used in nursing situations)

2. Practice – theory evolved from clinical practice

How does a theory develop?

3. Research theory or inductive method Must evolve from research findings or empirical evidence.

4. Theory research theory theories developed by other

disciplines are utilized but given unique nursing perspective. Original theory examined and given a new research findings.

What is a paradigm?

• A model that explains the linkages of science, philosophy, and theory accepted and applied by the discipline (Alligood and Marriner – Tomey, 2002)

What is a domain?

• The view or perspective of the discipline

• It contains the subject, central concepts, values and beliefs, phenomena of interest, and the central problems of the discipline

How does domain relate to nursing theory?

• Nursing has identified its domain in a paradigm that includes four linkages:

1) person/client 2) health 3) environment 4) nursing

Purposes of nursing theory

What are the purposes of nursing theory?

• It guides nursing practice and generates knowledge

• It helps to describe or explain nursing

• Enables nurses to know WHY they are doing WHAT they are doing

Patterns of Knowing

• Empirical ways of knowing – Are grounded in science of nursing and evidenced in

the scientific principle a nurse consistenly incorporates in all phases of the nursing process

• Personal ways of knowing– Help nurses understand and acknowledge the

humanness of another

Patterns of Knowing

• Aesthetic ways of knowing– Allow for creative applications in the relationship

designed to connect with clients in a different and more meaningful way

• Ethical ways of knowing– Refers to the moral aspect of nursing

Evidence Based Nursing Practice

• Is informed, collaborative and patient-centered

• Four components are:– Best practice– Evidence from scientific findings in

research-based studies– Clinical nursing expertise of professional

nurse– Preference and values of client and family

members

Applications:

Nursing Theory in the nurse-client relationship

Nurse-Client RelationshipWhat is the nurse-client relationship?

– Main tool of psychiatric nursing–Safe–Confidential–Reliable–Consistent–With clear boundaries

Social Relationships

• Initiated for the purpose of friendship, socialization or task accomplishment.

• Mutual needs are met during interaction.

• Communication includes giving advice and ask for or provide help with jobs.

• Content of communication may be superficial, roles may shift.

• No evaluation

Intimate Relationships• Individuals have an emotional commitment• Often a partnership where mutual needs are

met• Short and long term goals are mutual • Personal and intimate information are shared• Emotional satisfaction, security, sex,

procreation, etc.

Therapeutic Relationships

• Relationship consistently focused on the client's problems and needs

• Potential solutions to problems discussed

• Client chooses and implements plans• New coping skills develop• Behavioral change encouraged

Nurse’s Behaviors that Facilitated Growth and Change in Clients

• Genuineness “Being yourself”– Self-awareness of one's feelings– Ability to communicate one's feelings when appropriate– Key ingredient in building trust

• Empathy– Understanding the client’s feelings and ideas accurately – Accurate understanding of client's communication– Communicating understanding to the client and check for

accuracy– Acting on “this understanding” in a helpful way

Nurse’s Behaviors that Facilitated Growth and Change in Clients

• Positive self-regard– Respect communicated indirectly by actions– Help client to develop own personal resources and actualize

his living potential– Nonjudgmental focus on client's thoughts, feelings to

understand behaviors– Cultural sensitivity

Goals of Therapeutic Communication

• To obtain or provide information• To develop trust• To show caring• To explore feelings

HILDEGARD PEPLAU

Peplau

• Hildegard Peplau– Describe the nurse-client relationship as a

foundation of nursing practice– Four developmental phases of the

relationship • The orientation phase• Working phase

– Identification– exploitation

• Termination (resolution) phase

Hildegard Peplau

• Mother of psychiatric nursing• Infuences

– First nursing theory to borrow concept from other disciplines

– Freud, Maslow, Sullivan’s interpersonal relationship theories and the psychological model

• The purpose is– To facilitate the developmental of

problem solving skill, within the context of the interpersonal relationship between nurse and client, using education and therapeutic interaction

• Psychodynamic nursing facilitates– Understanding of one’s own behavior– Helping others identify felt difficulties– Nurse-patient relationship as partners– Application of human relations to

problems at all levels of experience

• Concept and definition – Role of nurse

• Stranger• Teacher• Resource person• Counselor• Leader• Advocate• Additional role

Peplau’s model and four concepts

• Person– A developing organism that tries to

reduce anxiety caused by needs– An individual is made of physiological,

psychological and social spheres striving towards equilibrium in life

– Live is an unstable equilibrium

• Environment– Not specifically defined– Being and occurring in the context of

the nurse client relationship– Existing forces outside of the

individual

• Health– Peplau didn’t include an exact definition of health

whitin her model– Peplau viewed health as “a word symbol that implied

forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living (Peplau, 1992)

– Consisting of interacting physiologic and interpersonal conditions

– Promoting throught interpersonal process

• Nursing– Is a signified, therapeutic, interpersonal process that

functions cooperatively with other human processes that make health possible.

– Is a human relationship between an individual who is sick or who has a felt need and a nurse who is educated to recognize and respond to the need for help

– Achieves its goal by promoting the patient’s development of skills to deal with problems and achieve health, this is a mutual and collaboration process that attempt to resolve the problem

– Views the nursing process as having sequential steps that focus on therapeutic interactions.

– Involves the use of problem solving techniques by he nurse and patient; according the Peplau both the nurse and patient learn the problem solving process from the relationship.

• Contribution from other disciplines– Therapeutic conversations with client

• Sigmund freud• Carl jung • Harry stock Sullivan• Martin buber• Carl rogers• Aaron beck

• Sigmund freud– Transference

» In which the client project irrational attitude and feelings from the past onto people in the present

» Are useful in understanding difficult behaviors in nurse-client relationship.

– Countertransference» Refer to unconscious attitudes or aaggerated a

nurse may develop toward a client.

• Carl Jung– Help nurses examine the complex

dimensions of a person• Gender roles• Acceptance of each individual just as they are• Our universal heritage as human beings

• Harry Stack Sullivan – Introduced the concept that people cannot

always relate easily to a helping person and may need ongoing, compassionate, supportive encouragement to make use of the therapeutic relationship

• Martin Burber– Captured the essence of the equal partner

connection desired in the nurse-client relationship

– Each individual responds to the other as a unique person in a mutually respectful manner.

• Carl Rogers– Identified three helper characteristic

essential to the development of client-centered relationship • Unconditional positive regard• Empathetic understanding• genuineness

• Aaron Beck– Aaron Beck focused his work on depression

• Concludes that psychological disturbances frequently stem from automatic thoughts

• Automatic thoughts reflect habitual errors in thinking

• Therapy is structured & interactive• Uses “Socratic dialogue” to get clients to

arrive at own conclusions• Begins with identifying problems or “agendas”• Includes setting goals, operationally defining

problems, testing hypotheses, and assigning homework.

– Developmental theories• Erik erikson• Abraham maslow

Erikson’s Theory

Erikson’s view was that the social environment combined with biological maturation provides each individual with a set of “crises” that must be resolved.

The individual is provided with a "sensitive period" in which to successfully resolve each crisis before a new crisis is presented.

Erikson’s Theory

The results of the resolution, whether successful or not, are carried forward to the next crisis and provide the foundation for its resolution.

Erikson’s Eight Stages

Trust vs. Mistrust

Infancy

Child develops a belief that the environment can be counted on to meet his or her basic physiological and social needs.


Autonomy vs. Shame &

Doubt Toddlerhood

Child learns what he/she can control and develops a sense of free will and corresponding sense of regret and sorrow for inappropriate use of self-control.


Initiative vs. Guilt

Early Childhood

Child learns to begin action, to explore, to imagine as well as feeling remorse for actions.


Industry vs. Inferiority Middle

Childhood

Child learns to do things well or correctly in comparison to a standard or to others


Identity vs. Role

Confusion

Adolescence

Develops a sense of self in relationship to others and to own internal thoughts and desires

• social identity • personal identity


Intimacy vs.

IsolationYoung Adulthood

Develops ability to give and receive love; begins to make long-term commitment to relationships


Generativity vs.

StagnationMiddle Adulthood

Develops interest in guiding the development of the next generation


Ego-integrity

vs. Despair

Later Adulthood

Develops a sense of acceptance of life as it was lived and the importance of the people and relationships that individual developed over the lifespan

Maslow, a humanistic psychologist

1. Humanist do not believe that human being are pushed and pulled by mechanical forces, either of stimuli and reinforcements (behaviorism) or of unconscious instinctual impulses (psychoanalysis).

2. Humanist focus upon potentials.3. They believe that humans strive for an upper

level of capabilities.4. Humans seek the frontiers of creativity, the

highest reaches of consciousness and wisdom.

• Physiological needs-also known as biological needs. Consists of oxygen, food, water, constant body temperature.

• Physiological are the strongest needs

• Safety Needs-Security and Protection from physical and emotional harm

• Adults have little awareness for safety needs except in times of emergency

• Belongingness & Love needs- people seek to overcome feelings of loneliness and alienation.

• Involves giving and receiving love affection and a sense of belonging

• Needs for esteem-involves both self-esteem and esteem a person gets from others

• Humans need self-respect and respect of others• When these needs are satisfied person feels self-

confident and valuable• When not met people feel inferior, weak, helpless,

and worthless

• Needs to Achieve Self-Actualization– Cognitive – to know, to understand, to

explore– Aesthetic-to find symmetry, order and

beauty

• Self actualization characteristics– Problem focused– Incorporate an ongoing freshness of

appreciation of life– Concerned about personal growth– Ability to have peak experiences

• Transcendence – to help others find self-fulfillment and realize their potential

• Maslow recognized that not all personality types followed this hierarchy

• Suggested that flow through the heirarchy can occur at any level at any time and many times simultaneously.

• Communication theory– Linier theory– Circular transactional theoretical

models– Therapeutic communication

• Contemporary issues

Linier theory

• Claude Shannon developed a model that reduced the communication process to a set of seven basic elements: – sender, receiver, encode, decode, message,

channel, and noise• These early models depicted

communication as a linear, one-way process where messages were transmitted in a straightforward manner from one person to another

Continue….

sender encodes decodesreceivesmassage

noiseOpportunity for interference

channel

Sender sends a massage ; receiver receives massage passively

Figur: Linier model of communication

Interactional Model

• The model introduced the element of feedback to reflect the two-way flow of communication between people

• this model also introduced the element of fields of experience

Field of experience

Field of experience

EncodesSender

Decodes

DecodesSenderEncodes

feedback

channel

feedbackchannel

noise noisenoise

More opportunities for interference factors

Sender and receivers each contribut toexchanging created and interpreted messages

Circular transactional theoretical models

• described the communication process as a reciprocal, simultaneous flow of messages and feedback between individuals

• Senders and receivers were redefined as communicators to reflect the simultaneous flow of messages and feedback during conversations

• a process of negotiating and creating common meaning

• Encoding and decoding were mutually interdependent actions of the communicators, each contributing to the shared meaning they were building together

• The element of context was introduced, which expanded the original element of fields of experience in the interactional model

• The transactional model acknowledged that creation and interpretation of messages evolves from the past, is influenced by the present, and is affected by visions of the future

Context Contextmassage

feedback

encodes

decodes

communicator communicator

decodes

encodes

channel channel

noise noise noise

noise noise noise

Greater opportunities

for interference factors

Context includes fields of

experience and the situational factors

that influence communication

Communicators create and send messages simultaneously and are equally responsible for creating common meaning

Figure :Transactional model of communication

The element of noise evolved to include

• Psychological noise: the emotional state of the communicators, their personalities and preconceived ideas and judgments.

• Physical noise: external factors that distract communicators like loud music in the background or being unfamiliar with the physical setting.

• Physiological noise: the biological factors that interfere with communications such as fatigue, illness, or altered cognitive function.

• Semantic noise: the way people speak, their use of terms, and any dialect or literacy issues.

THERAPEUTIC COMMUNICATION

In a therapeutic relationship…

• There are specific goals• The patient’s needs are the focus

(relationship is client centered)• The nurse makes use of specific

communication and relationship skills

Contemporary Issues

• Perubahan Demografik– Culture– Gender

• Teknologi• Posisi Perawat Sebagai Pemain

Kunci

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Therapeutic N-P Relationship

• Definition:– a series of goal-directed interactions

• Peplau: – nursing as a significant, therapeutic,

interpersonal process

• Characteristics - goals, stages, specific time and place. It is different from a social relationship

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N-Pt Relationship

• Communication skills• Respect and a desire to help• Trust is based on confidentiality• Understanding

– mental mechanisms– adaptation styles– coping strategies– therapeutic intervention skills

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Communication

• In-born nature• Happened at anytime, anyplace,• Multi-level• Verbal & Nonverbal

– Proxemics - environmental, social, and personal space

– Kinesics - body movement• Can be learned

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Therapeutic Communication

• Def: – It is an interpersonal interaction in

which the nurse used the self to focus on the client’s emotional issues, establish a therapeutic relationships, identify client’ issues, discern the most important topic at that time, and guide the client toward identifying his/her own solutions to problems

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Therapeutic Communication Techniques (I)

• Broad opening - start the conversation• Offering self - available, concern,

interest• Active listening - content, emotion• Using silence - respect, anxiety• Asking questions - what, when, who…• General leads - go on, Mm... • Restating - repeating

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Thera. Commu. Tech (II)• Making observation - comment on what

have been seen• Verbalizing the implies - rephrasing,

reflecting• Clarification - restate, elaborate• Focusing - single, important topic • Exploring - getting more information• Interpreting -• Consensual validation - mutual agreement

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Thera. Commu. Tech (III)• Giving information - decision making• Presenting reality - but no argument• Voicing doubt - uncertainty about pt’s

interpretation/conclusion• Placing an event in time or sequence - R

among events• Encouraging comparison - similarity &

difference• Summarizing - review the main points

Contemporary Issues

• Perubahan Demografik– Culture– Gender

• Teknologi• Posisi Perawat Sebagai Pemain

Kunci

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Theoretical Perspectives and Contemporary Issues