Nursing Theories And Conceptual Frameworks

Nursing Theories and Conceptual Frameworks NURS (201). SPRING 2020-2021 1 Outline  Introduction to Nursing Theories  Purpose of Nursing Theories  Overview of Selected Nursing Theories  Addressing Basic Human Needs of clients/patients and families  Patient and Family-Centered Care 2 Learning Outcome After completing of this lecture the students will be able to : 3 1. Differentiate the terms theory, concept, conceptual framework, paradigm, and metaparadigm for nursing. 2. Explain relationship of philosophy – metaparadigm – conceptual model – theory 3. Identify the components of the metaparadigm for nursing 4. Describe the major purpose & role of nursing theory in the sciences: nursing education, research, and clinical practice. 5. Identify the main concepts for selected Nursing theories 6. Summarize non-nursing theories and Explain the human needs theory (Maslow’s hierarchy of human needs) and their use in nursing. INTRODUCTION TO THEORIES In the 19th century Florence Nightingale (Great Britain) thought that the people of needed to know more about how to maintain healthy homes and how to care for sick family members 4 INTRODUCTION TO THEORIES In the 20th century  Nursing education in the United States took a different path than Great Britain.  They establish nursing departments in colleges and universities 5 INTRODUCTION TO THEORIES  It provide a foundation and direction for research.  Research in these disciplines often produced tangible results: knowledge that could be used in our efforts to control nature, disease, and foreign threats.  In practice disciplines, guide us to interpret things (like human mind, pain, and suffering).  It help us interpret phenomena from unique perspectives, building new understandings, relationships, and possibilities. 6 Defining Terms A phenomenon  is the term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations. A philosophy  is a belief system, often an early effort to define nursing phenomena, and serves as the basis for later theoretical formulations.  a statement about the beliefs and values of nursing  Examples: philosophies of Nightingale, Henderson, and Watson. 7 Defining Terms  Theory  contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon.  defined as a system of ideas that is presumed to explain a given phenomenon  Theories guide the design of nursing interventions  A conceptual framework or Model  is a group of related ideas, statements, or concepts  Model is a scientific construction, an image, a notion, a conception or a description of an examined phenomenon or an object.  Conceptual model is a collection of interrelated concepts that provides direction for nursing practice, research, and education 8 Components of a Theory 9 Defining Terms A paradigm  Refers to a pattern of shared understandings and assumptions about reality and the world.  Links science, philosophy, and theories accepted and applied by a discipline  Nursing paradigm links person, health, environment/situation, & nursing Metaparadigm  The term originates from two Greek words: meta, meaning “with,” and paradigm, meaning “pattern.”  A global set of concepts that identify and describe the central phenomena of the discipline  the most abstract level of knowledge  The metaparadigm four concepts central to nursing are Client , Environment, Health , Nursing 10 Relation Between Terms Nursing practice (experience, knowledge, training, skill) is the lowest hierarchic level of the vertical dimension of the epistemic structure of nursing. It serves to verify (test) valid theories Philosophy 11 Paradigm Theory Structure of nursing science as knowledge system Nursing Practice Relation Between Terms A metaparadigm, as the most abstract level of knowledge Metaparadigm Philosophy Conceptual model Theory 12 Relation of theory – conceptual model – metaparadigm Metaparadigm 13 1. Client are the recipients of nursing care (Ex: individuals, families, groups, and communities). 2. ENVIRONMENT is the internal and external surroundings that affect the client. (Ex: people in the physical environment, such as families, friends, and significant others). 3. HEALTH is the degree of wellness or well-being that the client experiences. 4. NURSING is the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with, the client. Metaparadigm of nursing 14 Nursing theorists have built on the metaparadigm and on the work of Nightingale 15 ROLE OF NURSING THEORY  Direct links exist among theory, education, research, and clinical practice.  Nursing theory :  guides knowledge development  directs education, research, and practice 16 ROLE OF NURSING THEORY 1. In Education  many nursing programs identified the major concepts in one or two nursing models, and:  organized these concepts into a conceptual framework & built the entire curriculum around that framework.  Introduced them into program objectives, course objectives, course descriptions, and clinical performance criteria. 17 ROLE OF NURSING THEORY 2. In Research Theories identify gaps in the way we approach specific fields of study (Ex: symptom management or quality of life). Help generate new ideas, research questions, and interpretations Grand theories only occasionally direct nursing research because of their breadth Midlevel (or middle range) theories focus on the exploration of concepts such as pain, self-esteem, learning In Qualitative research, theory to help select the phenomenon, frame the philosophical underpinnings of the study, and guide data analysis and interpretation. 18 ROLE OF NURSING THEORY 3. In Clinical Practice  Nursing theory employed in a clinical setting, its primary contribution has been the facilitation of reflecting, questioning, and thinking about what nurses do.  Example  School nurses used Orem’s self-care deficit theory to work with children with special health care needs (Green, 2012).  Theory of postpartum depression are important contributors to effective evidence-based practice  Recognizes organizations that demonstrate excellence in nursing practice used a professional practice model. 19 ROLE OF NURSING THEORY Relationship of Theory to Nursing Process  The theories & models can seen as part of the nursing process. They help in :  Guide assessment & organize patient data  Understand analysis of patient data  Support decision making related to nursing intervention  Help in the plan of patient care (embeds Goals &outcome)  Add to evidence based practice  Explain & predict outcome of care  Evaluate patient outcome 20 Nursing theory  represents a group of concepts that can be tested in practice and can be derived from a conceptual model Some theories are :  Philosophies (Ex: Florence Nightingale)  Nursing models (Ex: Neuman, Orem, Rogers, Roy, and King)  Nursing theories (Ex: Peplau, Leininger, and Parse) 21 1. Grand theory: a global conceptual framework that defines broad perspectives for nursing practice and provides ways of looking at nursing phenomena from a distinct nursing perspective (Ex: Neuman’s systems model) 2. Middle-range theory: moderately abstract theory with a limited number of variables & more limited in scope and less abstract. They address a specific phenomenon and reflect practice (Ex: Mishel’s theory of uncertainty in illness ) 3. Practice theory (situational theory) focuses on the way in which nursing is practiced (Ex:Norton’s theory of nursing elderly people) 22 23 Florence Nightingale Concept of balance between environment and patient: emphasized prevention; clean air, water, and housing Hildegard Peplau Interpersonal process between nurse and patient: 1. orientation, 2. working (ID and exploitation), 3. resolution Virginia Henderson 14 components based on Maslow’s hierarchy of needs; defined nursing: assisting individuals to gain independence in relation to the performance of activities Martha Rogers Science of Unitary Human Beings; four dimensions are used in developing principles of resonancy Dorothea Orem Self-care Deficit Theory of Nursing: self care, selfcare deficit, nursing systems Imogene King Three level of systems: individual/personal, group/interpersonal, society/social Betty Neuman Systems Model: holistic concept with open-system approach Sister Callista Roy Leininger Adaptation Model: humans as adaptive open system Jean Watson Parse 24 Cultural Care Diversity and Universality Theory. health and care are influenced by elements of the social structure Based on caring, with nurses dedicated to health and healing Humanbecoming Theory. focus on meaning, rhythmicity, and cotranscendence Nightingale’s Environmental Theory  first nurse theorist (Nightingale, 1860/1969). Concept of balance between environment and patient:  linked health with five environmental factors:  (1) pure or fresh air,  (2) pure water,  (3) efficient drainage,  (4) cleanliness,  (5) light, especially direct sunlight.  General concepts about ventilation, cleanliness, quiet, warmth, and diet  She stressed the importance of (1) keeping the client warm, (2) maintaining a noise- free environment, (3) and attending to the client’s diet in terms of assessing intake, (4) timeliness of the food, and its effect on the person 25 Peplau’s Interpersonal Relations Model  Theory emphasis on the existence of a therapeutic relationship between the nurse and the client  nurses assume many roles: stranger, teacher, resource person, surrogate, leader, and counselor  The nurse–client relationship evolves in four phases: 1. Orientation 2. Identification 3. Exploitation. 4. Resolution. 26 Orem’s General Theory of Nursing (Self-care theory)  Dorothea Orem’s theory (Self-care theory ), published in 1971  includes three related concepts: 1. self-care 2) self-care deficit 3) A nursing systems. • It is based on four concepts: 1. self-care, 2. self-care agency, 3. self-care requisites (self care need) 4. Therapeutic self-care demand. • 27 Goal: Help the patient perform self-care and manage his or her health problems. Self - care: Activities performed by the individual independently throughout life. Self - care agency: Individual’s ability to perform self-care activities Therapeutic self-care: Demands means actions to maintain health and well-being. Nursing agency: Actions done by the nurse for the patient 28 • Self care: practice of activities that individual initiates and perform on their own behalf in maintaining life , •health and well being •Self care agency: is a human ability which is •"the ability for engaging in self care" -conditioned by age developmental state, •life experience sociocultural orientation health and available resources •Therapeutic self care demand: •"totality of self care actions to be performed for some duration in order to meet self care requisites by using valid methods and related sets of operations and actions" •Self care requisites: action directed towards provision of self care. • 3 categories of self care requisites are• Universal self care requisites • Developmental self care requisites • Health deviation self care requisites 29 Orem’s General Theory of Nursing (Self-care theory) • I) Self-care (activities an individual performs independently throughout life to promote and maintain personal well-being). • II) Self-care agency (individual’s ability to perform self-care activities).  self-care agent (an individual who performs self-care independently)  dependent care agent (a person other than the individual who provides the care).  III) Self-care requisites /self-care needs (measures or actions taken to provide self- care).  IV) Therapeutic self-care demand (all self-care activities required to meet existing self-care requisites, or in other words, actions to maintain health and well-being) 30 Orem’s General Theory of Nursing (Self-care theory) Five methods of nursing to help individual through: 1) Acting or doing for 2) Guiding 3) Teaching 4) Supporting 5) Providing environment promotes individual’s abilities to 31 meet demands. Orem’s General Theory of Nursing  There are three categories of self care requisites:  1. Universal requisites are common to all people  Ex: maintaining intake and elimination of air, water, and food; balancing rest, solitude, and social interaction; preventing hazards to life and well-being; and promoting normal human functioning.  2. Developmental requisites result from maturation or are associated with conditions or events  (Ex: adjusting to a change in body image or to the loss of a spouse).  3. Health deviation requisites result from illness, injury, or disease or its treatment.  (Ex: seeking health care assistance, carrying out prescribed therapies, & learn to live with 32 effects of illness or treatment). Orem’s General Theory of Nursing  Orem identifies three types of nursing systems.  1. Wholly compensatory systems  are required for individuals who are unable to control & monitor their environment and process information.  2. Partly compensatory systems  are designed for individuals who are unable to perform some, but not all, self-care activities.  3. Supportive-educative (developmental) systems  are designed for persons who need to learn to perform self-care measures and need assistance to do so. 33 Roy’s Adaptation Model  Callista Roy (2009) defines adaptation as:  “the process and outcome whereby the thinking and feeling person uses conscious awareness and choice to create human and environmental integration”  Adaptive responses :  defines as the process of being and becoming integrated; ineffective or maladaptive responses do not contribute to health.  Each person’s adaptation level is unique and constantly changing 34 Roy’s Adaptation Model  Roy focuses on the individual as a biopsychosocial adaptive system that employs a feedback cycle of input (stimuli), throughput (control processes), and output (behaviors or adaptive responses).  Both the individual and the environment are sources of stimuli that require modification to promote adaptation 35 Roy’s Adaptation Model  The goal of Roy’s model is to enhance life processes through adaptation in four adaptive modes. Individuals respond stimuli in one of the four modes: 1. Physiological mode (basic physiological needs and ways of adapting) 2. Self-concept mode (1) Physical self (2) Personal self 3. Role function mode (performance of duties based on given positions within society). 4. Interdependence mode (involves one’s relations and support systems ) 36 Watson’s Human Caring Theory  Jean Watson , 2013, believes the practice of caring is central to nursing; (unifying focus for practice)  Nursing interventions related to human care (10 carative factors ) 'Core of Nursing' 37 Watson’s Human Caring Theory 10 clinical caritas processes (Nursing interventions) 1. Values and practice loving kindness 2. faith and hope and honor others. 3. Be sensitive to self and others 4. Develop helping–trusting, human caring relationships. 5. Promote and accept positive and negative feelings 6. Use problem-solving methods for caring decision making. 7. Share teaching & learning that addresses individual needs 8. Create a healing environment which respects human dignity. 9. Assist basic physical, emotional, and spiritual human needs. 3810. Open to mystery and allow miracles to enter 39  The first 4 levels are deficiency needs (D-needs), & the top level is growth or being needs (Bneeds). 1. Physiologic needs 2. Safety needs 3. Love needs 4. Esteem needs 5. Self-actualization needs individuals must satisfy lower level deficit needs before 40 progressing on to meet higher level growth needs. Self-Actualization recognition and realization of one’s potential, growth, health, and autonomy Self-Esteem self-worth, self-respect, independence, privacy, status, dignity, and self-reliance Love and Belonging affection, intimacy, support, and reassurance Safety and Security from a physiologic and psychological threat; protection, stability, and lack of danger, secure environment Physiologic needs oxygen, water, food, elimination, temperature control, sex, sleep, movement, rest, and comfort 41  Individuals must satisfy lower level deficit needs before progressing on to meet higher level growth needs.  When a deficit need has been 'more or less' satisfied it will go away (salient needs), and our activities become habitually directed towards meeting the next set of needs that we have yet to satisfy.  However, growth needs continue to be felt and may even become stronger once they have been engaged.  Growth needs do not stem from a lack of something, but rather from a desire to grow as a person.  Once these growth needs have been reasonably satisfied, one may be able to reach the highest level called self-actualization. 42  Maslow (1987) proposed that the order in the hierarchy “is not nearly as rigid” (p. 68)  Flexibility based on external circumstances or individual differences.  Example: some individuals, the need for self-esteem is more important than the need for love. others, the need for creative fulfillment may supersede even the most basic needs. 43  Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families 44 Goal:  To create partnerships among health care practitioners, patients and families that will lead to the best outcomes and enhance the quality and safety of health care. 45 Four Core Concepts: 1. Dignity And Respect listen & honor patient and family perspectives & choices. consider their knowledge, values, beliefs & cultural backgrounds in planning & care. 2. Information Sharing Practitioners communicate and share complete information with patients and families 3. Participation  Patients and families are encouraged and supported in participating in care and decision-making. 4. Collaboration  Patients, families, health care practitioners, and hospital leaders collaborate 46 in policy and program development, implementation and evaluation, education, as well as in the delivery of care. • Respect for patients’ values, preference, and expressed needs; • Coordination and integration of care;  Information, communication, and education; • Physical comfort; emotional support; and 47 • The involvement of family and friends. Summary 48 Summary  Terms theory, concept, conceptual framework, paradigm, and metaparadigm  Components of the metaparadigm for nursing  Role of nursing theory  Main concepts for selected nursing theories & non nursing theory 49 Summary  Nightingale (mid-1800s)  Environment as the focus of nursing care  Descriptive theory  Peplau (1952)  Focus on interpersonal relations between nurse, patient, and patient’s family  Development of nurse-patient relationship  Orem (2001)  Focuses on patient’s self-care needs  Goal is for patient to manage his or her health problems. 50 Summary (cont’d)  Roy (1989)  Views the patient as an adaptive system  When patient cannot adapt to stressors, nursing is needed.  Watson (1996)  Defines the outcome of nursing activity with regard to the humanistic aspects of life  Purpose is to understand the interrelationships among health, illness, and human behavior.  Maslow (1943, 1954)(non Nursing)  Physiological needs, safety & security, love & belong, self esteem, and self actualization 51