Nursing Theories: lý thuyết điều dưỡng hiện đại

Phenomenon: Is a thing, event or activity that we perceive through our senses. The phenomenon represents the subject matter of a discipline. When experience and sensory and intuitive data become coherent as a whole, we have a phenomenon. For example, when a patient, preoperatively, is noted restless in bed, biting fingernails, and sighing, this is a phenomenon. Concept: Is a label used to describe a phenomenon. Therefore, when we put a name to a phenomenon, we are identifying a concept. In the example provided above, the phenomenon may be labelled as ‘anxiety’. As a mental image, a concept is a view of reality tinted colored with our perceptions and experience. Therefore, a phenomenon could be given a different conceptual label by two different nurses. Therefore, a concept is a tool not a reality – it facilitates observation of a real phenomenon. Concepts are also the building blocks of theory. Construct: If the phenomenon is very abstract and the resultant concept is not directly observable or measurable, it is often referred to as a construct (‘selfesteem’).

Nursing Theories

Dr Belal M Hijji, RN, PhD

19.09.2010

Learning Outcomes

At the end of this lecture, students will be able to:

• Define the working terms and theory

• Recognise the four metaparadigms for nursing

• Discuss some of the selected nursing theories

Defining Relevant Working Terms

• Phenomenon: Is a thing, event or activity that we perceive through our senses The phenomenon represents the subject matter of a

discipline When experience and sensory and intuitive data become coherent as a whole, we have a phenomenon For example, when a patient, preoperatively, is noted restless in bed, biting fingernails,

and sighing, this is a phenomenon

• Concept: Is a label used to describe a phenomenon Therefore,

when we put a name to a phenomenon, we are identifying a

concept In the example provided above, the phenomenon may be labelled as ‘anxiety’

– As a mental image, a concept is a view of reality tinted [colored] with our perceptions and experience Therefore, a phenomenon could be given

a different conceptual label by two different nurses Therefore, a

concept is a tool not a reality – it facilitates observation of a real

phenomenon Concepts are also the building blocks of theory

• Construct: If the phenomenon is very abstract and the resultant

concept is not directly observable or measurable, it is often referred

– A construct is a type of highly complex concept whose reality base can only be inferred Therefore, imagining a continuum of concepts from

concrete (thermometre) to abstract (caring, compassion), constructs would

be placed at the abstract end All constructs are concepts but not all

concepts are constructs.

– The following example illustrates the continuum of abstraction of concepts

A cow is a very concrete conceptualisation and we move toward more

abstract levels of conceptualisation

– Cow - Bessie - livestock - farm asset - wealth – Two things are noted as the concepts become more abstract; more of the characteristics of the concept ‘cow’ are being omitted and the ability to

directly observe and measure the concept is becoming more difficult.

– Constructs could be made measurable by identifying variables For

example, if ‘marital status’ is a construct, it could be made measurable by breaking it into the variables ‘single’, ‘widowed’, ‘divorced’, ‘married’

What is a Theory?

• ‘Theory’ is often defined in relation to ‘practice’ For example, a

teacher describes the process of giving an injection, as opposed to students actually giving the injection to patient Theory in this sense means dealing with a topic (administration of an injection)

• Theory has several definitions At basic level, theory explains the occurrence of phenomena To do this, it has to explain the

relationship between variables or concepts For example, ‘an

expansion in a bar of metal occurs when it is heated’ The

phenomenon of expansion is explained by the relationship between the variable ‘metal’ and the variable ‘heat’

• The theory must also predict that each time the variables happen to

be in the same relationship, the same results will be obtained

• Another definition of theory is that it ‘is a set of interrelated

constructs (concepts) definitions and propositions that present a

systematic view of phenomena by specifying relations among

variables, with the purpose of explanation and prediction’

• From the above example on the theory of metal expansion, a

number of propositions exist:

– Metals are made up of atoms

– The structure of atom is changed by heat

– Heat causes atoms to expand

The Metaparadigm For Nursing

• Paradigm: refers to a pattern of shared understandings and

assumptions about reality and the world We become aware of

paradigms when realities clash In nursing we refer to qualitative vs quantitative research paradigms

• Person, environment, health, and nursing are collectively referred to

as metaparadigm for nursing Meta means ‘with’, while paradigm

means ‘pattern’ These four concepts are central to nursing

– Person: The recipient of nursing care.

– Environment: The internal and external surroundings that affect the

person.

– Health: the degree of wellness or well-being that the person

experiences.

– Nursing: The attributes, characteristics, and actions of the nurse

providing care to person.

• What we need to know about these four major concepts is that their definitions vary from one theorist to another

Overview of Selected Nursing Theories

• Nightingale Environmental Theory: Nightingale (1860) defined

nursing as ‘the act of utilising the environment to assist the patient in his recovery’ She linked health with five environmental factors:

“fresh air”, “pure water”, “efficient drainage”, “cleanliness” and “light, especially direct sunlight”

– Nightingale concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care today.

Orem’s General Theory of Nursing

• Consists of three related theories collectively referred to

as “Orem’s General Theory of Nursing”:

1 Self-care Theory: 3 types of self-care requisites (needs)

2 Self-care Deficit Theory: 5 Methods of Assistance

3 Nursing Systems Theory: 3 types

Orem’s Self-care Theory

• Based on the concepts of:

Self-care Definition

• Self-care comprises those activities performed independently by an individual to promote and maintain personal well-being throughout life

Self-care Agency

• Definition: the individual’s ability to perform self-care activities

• Consists of TWO agents:

– Self-care Agent - person who provides the self-care

– Dependent Care Agent - person other than the individual who

provides the care (such as a parent)

Self-care Requisites (Needs)

• Definition: the actions or measures used to provide self-care A need is

also a requirement within an individual or group which stimulates a

response to maintain integrity

• Consists of THREE categories:

– Universal - requisites/needs that are common to all individuals

These include maintaining intake and elimination of air, water, and food

– Developmental - needs resulting from maturation or develop due to

a condition or event, such as adjusting to a change in body image or

to loss of spouse

– Health Deviation - needs resulting from illness, injury & disease or

its treatment These include actions such as seeking health care

assistance and taking prescribed medications

Orem’s Self-care Deficit Theory

• Is the central focus of Orem’s Grand Theory of Nursing

• Explains when nursing is needed

• Describes and explains how people can be helped through nursing

• Results when the Self-care Agency (patient) can’t meet her/his self-care needs or administer self-care

• Nursing meets these self-care needs through five methods of helping These are:

- Acting or doing for

Orem’s Nursing Systems Theory Describes

• Nursing responsibilities

• Roles of the nurse and patient

• Rationales for the nurse-patient relationship

• Types of actions needed to meet the patient’s demands

Orem’s Nursing Systems Theory

• Refers to a series of actions a nurse takes to meet a patient’s self-care needs

• Is determined by the patient’s self-care needs

• Is composed of THREE types of nursing systems:

– Wholly compensatory: a patient’s self-care agency is so limited that s/he depends on others for well-being

– Partly compensatory: a patient can meet some self-care requisites but needs a nurse to help meet others

– Supportive-educative: a patient can meet self-care requisites but needs help in decision-making, behavior control, or knowledge

acquisition

Henderson Definition of 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 (or to peaceful death) that he would perform unaided if

he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.”

“It is my contention that the nurse is, and should be legally, an

independent practitioner [as long as she is not performing the doctor’s duties.] But the nurse is the authority on basic nursing care Perhaps I

should explain that by basic nursing care I mean helping the patient

with the following activities…”

14 Fundamental Needs

1 Breathing normally

2 Eating and drinking adequately

3 Eliminating body wastes

4 Moving and maintaining a desirable position

5 Sleeping and resting

6 Selecting suitable clothes

7 Maintaining body temperature… by adjusting cothing and

modifying the environment

8 Keeping the body clean and well-groomed…

9 Avoiding dangers in the environment and avoiding injuring others

10 Communicating with others in expressing emotions, needs, fears,

or opinions

11 Worshipping according to one’s faith

12 Working in such a way that one feels a sense of accomplishment

13 Playing or participating in various forms of recreation

14 Learning, discovering, or satisfying the curiosity that leads to

normal development and health, and using available health

facilities

Nurse’s Role

• Substitutive : acting for a person

• Supplementary : assisting a person

• Complementary : working with the person

“…with the goal of helping the person become as independent as

possible.”

“Today I see the role of nurses as givers of ‘primary health care,’ as

those who diagnose and treat when a doctor is unavailable… Nursesmay be the general (medical) practitioners of tomorrow…”

Neuman’s Systems Model

• Neuman’s model is based on the individual’s relationship to stress, reaction to it, and reconstitution factors Reconstitution is the state of adaptation to stressors

• In this model, the client is an open system composed of a central core of energy sources (physiologic, psychologic, sociocultural,

developmental, and spiritual) surrounded by two rings referred to as lines of resistance These lines represent internal factors that help the client defend against a stressor; for example an increase in the body white cells count to fight an infection

• Outside the lines of resistance are two lines of defense The normal line of defense represents the person’s state of equilibrium or the state of adaptation developed and maintained over time and

considered normal for the person The flexible line of defense is

dynamic and can be rapidly altered over a short period of time It

prevents stressors from penetrating the normal line of defense

• Stressors in Neuman’s model are:

 Intrapersonal: Occur within an individual (infection)

 Interpersonal: Occur between individuals (Unrealistic role

expectation)

 Extrapersonal: Occur outside the person (financial concerns)

• The individual’s reaction to stress depends on the strength of lines

of defense When these lines fail, the resulting reaction depends on the lines of resistance

• Nursing interventions focus on retaining or maintaining system

stability The intervention are carried out on three preventive levels:

Primary prevention: Focuses on protecting the normal line of defense and strengthening the flexible line of defense

Secondary prevention: Focuses on strengthening internal lines of resistance, reducing the reaction, and increases resistance factors

Tertiary prevention: Focuses on readaptation and stability and protects reconstitution or return to wellness after

Roy Adaptation Model

• Roy sees the person as "a biopsychosocial being in constant

interaction with a changing environment“

• The person is an open, adaptive system who uses coping skills to deal with stressors

• The environment is "all conditions, circumstances and influences that surround and affect the development and behaviour of the person"

• Stressors are stimuli that influence the person

• Three types of stimuli influence an individual’s ability to cope with the environment

• Focal stimuli are those that immediately confront the individual in a particular situation Focal stimuli for a family include individual

needs

• Contextual stimuli are those other stimuli that influence the situation

• Residual stimuli include the individual’s beliefs or attitudes that may influence the situation

• Contextual and residual stimuli for a family system include

nurturance, socialization, and support

Roy Four Modes of Adaptation

• The physiologic mode Adaptation involves the maintenance of

physical integrity Basic human needs such as nutrition, oxygen, fluids, and temperature regulation are identified with this mode

• The self-concept mode A function of this mode is the need for

maintenance of psychic integrity Perceptions of one’s physical and personal self are included in this mode

• The role function mode The need for social integrity is emphasized

in this mode in which human beings adapt to various role changes that occur throughout a lifetime

• The interdependence mode The need for social integrity is also

emphasized in the interdependence mode Interdependence

involves maintaining a balance between independence and

dependence in one’s relationships with others

Spiritual Caring

individuals are holistic beings = physical, mental, spiritual, emotional “Considering a light bulb analogous to a human, think of the glass, aluminum, and other tangible materials that comprise it as

representing the physical dimension; think of the light and warmth the bulb elicits as the psychological; and the electrical current that

energizes and ultimately provides the meaning and function for the bulb as the spiritual dimension.” Stallwood & Stoll 1975 as cited by Taylor, E F (2002)

Case Study

Mr Elder works at the zoo He has a large open wound on his forehead from a tiger attack Mr Elder was referred to a home health agency for wound management The wound extends to the skull Mr Elder was out of work as a result of this wound, saw friends infrequently, and was somewhat depressed His wife spent hours each day

fixing him goodies to help cheer him up because she liked to cook and found it was a good way to release her own anxiety about her husband’s condition

After three weeks the wound showed no improvement in healing,

although had not become infected During the agency visit, Mrs

Elder confides in the nurse that her husband was drinking “tons of water” and seemed to be urinating frequently She was worried that

he might hurt himself getting up so often in the middle of the night She was wondering if there was a pill to help him sleep through the night Using theories models, what would the nurse do to help Mr Elder’s healing problems?

Case study adapted from Chitty, 2003.

Neuman’s Nurse: Nancy

If Nancy were the nurse dispatched from the home health agency, she

would use Neuman’s theory to solve the problem

Nancy knows that stressors attack the normal and flexible lines of

defense There must be an imbalance in Mr Elder’s stability

because his wound is not healing The responses to his stressor are polyuria, polydipsia, both of which are physiological variables This leads Nancy to believe the stressor is diabetes, and tertiary interventions need to be implemented in order to bring about

reconstitution