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Nursing theories are important to the practice of nursing. More importantly, theory-guided practice is important, as a nurse in any role, particularly in the role as an advanced practice registered nurse. It enables the nurse to deliver effective, efficient, and holistic care (Saleh, 2018). Theory guided practice is becomingly increasingly important in nursing that it was suggested that it should become the future of nursing (Saleh, 2018).There are numerous theories in nursing practice taught in nursing school. Some of the numerous examples of major nursing theories include: Watson’s theory of caring, Orem’s Self-Care Theory, Madeline Leiniger’s Transcultural Nursing theory, or Patricia Benner’s Novice to Expert theory. These theories are designed to help guide each individual nurse in his/her practice. In practice, each nurse chooses the theorist that best fits his/her practice based on how he/she views the four paradigms of nursing- the patient, the nurse, the client’s health, and the environment. The purpose of this paper is to introduce the author as a nurse, describe the four meta paradigms of nursing contained in each nursing philosophy/theory, and describe two practice-specific concepts unique to the author.
The author is a 52-year-old woman, married for over 33 years, mother of three sons and grandmother of two. She began her nursing career in an emergency department setting in Atlanta, Georgia for five years. She worked in a level 1 trauma center as a staff nurse for the clinical decision unit, emergency and trauma department. In collaboration with physicians with various specialties, the author provided care for a diverse population of patients with both acute and chronic illnesses and trauma. The author was also employed with the DeKalb Board of Health for a year as a public health nurse, where her responsibilities included: visiting Spanish and English speaking patients in their homes to assess their living environment and provide resources needed to families to properly care for patients in the home setting and assist with arranging for transportation to health care appointments. In addition to home visits, the author coordinated setting up health fairs in local communities with an effort to deliver primary prevention through administering vaccinations to various populations- pediatrics, adults, and the elderly patient or engage in secondary prevention through offering blood pressure screenings or glucose and cholesterol checks. The author is currently working at the Veterans Affair (VA) hospital, a federal facility where she cares for adult patients that are in active duty in the United States Military and veterans from all branches or the military that ranges in ages 18 and up with acute or chronic health issues. Patients present to the emergency room with a wide range health issues to include: medication refills, mental health evaluations, suicidal and or homicidal ideations, post-traumatic stress disorder, chronic and acute pain, strokes, cancer, exacerbation of chronic conditions (i.e.- asthma, congestive heart failure, etc.) and more. In collaboration with the emergency room team and other specialties, we stabilize and care for these patients. These patients will either be admitted to the hospital, referred to specialty units or transferred out for advance services or trauma care.
Metaparadigm is defined as the global concepts specific to a discipline and the global propositions that define and relate the concepts (Peterson & Bredow,2017, p. 4). Each metaparadigm has to have several domains. These domains are a classification system to identify the constructs or phenomena that are the focus of any discipline. Specific to the discipline of nursing, the four paradigms most commonly cited in most nursing theories include: man/person, health, society/environment, and nursing. According to Fawcett, a major nursing theorist cited in Peterson & Bredow (2017), he offers the following definition for the four metaparadigms of nursing:
The patient as individuals, families, communities, and other groups who are involved in nursing. Environment refers to the person’s social network and physical surroundings and to the setting in which nursing is taking place. It also includes all local, regional, national, cultural, social, political, and economic conditions that might have an impact on a person’s health. Health refers to a person’s state of well-being at the time of engagement with nursing. It exists on a continuum from high-level wellness to terminal illness. Nursing refers to the definition of the discipline, the actions taken by nurses on behalf of and/or with the person, and the goals or outcomes of those actions (Fawcett, 2000, p.7).
The author views the patient as a client coming to seek care for an alteration in health pattern or prevent an alteration in health pattern. For example, when a client comes in to the VA to seek treatment, there is an active alteration in health pattern that exists to bring the client there. However, when working at the health department, the nurse was providing preventive care through measures of early detection (i.e.-glucose monitoring) or prevention through providing immunizations and teaching.
The author views the nurse as not only having the role of providing immediate care to the client that she interacts with but also providing teaching to prevent complications from occurring as a result of that health alteration. The author views her role in this client-nurse relationship as being a resource to help her client understand better about his/her condition, ways to manage their condition, and preventive measures needed to be taken to prevent complications in the future.
The author views the client’s health as not optimal at the time of interaction because there has to be an alteration in health pattern in order for the client to seek care at an emergency department. For example, the author sees patients in acute exacerbations of certain conditions (i.e.- heart failure, diabetes, asthma, etc.), trauma, or acute pain. Furthermore, the author sees this as opportunities for education to improve a client’s overall health status.
The author views the environment as where care is being tendered to the patient. This setting is not limited to the hospital. It could be where the patient desires for care to be delivered at. For some patients, this may be outpatient (i.e.- rehabilitation center) or at home (i.e.- home health services). Furthermore, Fawcett defines the environment as the client’s social networks and physical surroundings. To this aspect, the author views the environment as being a contributor to the patient’s overall well-being and health status. For example, if the patient is surrounded by a supportive environment with limited exposure to toxins and carcinogens (i.e.- second-hand smoke or alcohol exposure), the client is healthier as compared to one who is exposed to this type of environment. Additionally, clients in a low socioeconomic setting has a variety of barriers present to attaining good physical health. Some of these barriers includes lack of access to a primary care provider, a good grocery store that sells nutritious foods, and lack of clean environmental water.
Two practice-specific concepts that are specific to this author’s day-to-day nursing practice includes: transcultural nursing care and caring. Transcultural nursing practice is defined as: “The delivery of culturally congruent, meaningful, high-quality, and safe healthcare to patients of similar or diverse cultures” (Albougami, Pounds & Alotaibi, 2016). The Meriam-Webster dictionary defines caring as “the act of feeling or showing concern for or kindness to others (2019). Narayanasamy ACCESS model and Watson's theory of human caring will help elaborate on these two specific concepts.
Nurses from all specialties encounter patients from all walks of life, cultures and ethnicity in their practice. Cultural competency training is integrated throughout nursing school and hospitals to enrich nurse’s knowledge of various cultures and help nurses deliver culturally sensitive care to patients. As an emergency room nurse at a large public hospital and level one trauma center in the city of Atlanta, the author encounters patients from numerous ethnicities, cultural groups, and patients with a variety of socioeconomic status, ranging from rich to homeless patients. The author is a Catholic female of Mexican origin with very strong cultural ties to her cultural background. The author provides culturally competent care for all patients she encounters in practice in a non-bias manner.
Narayanasamy ACCESS model was chosen to help explain the delivery of transcultural nursing care. This was a model formulated by Narayanasamy that can be used as guidance to aid nurses in providing acceptable transcultural care (Vogel, 2016). In this model, “A” stands for assessment. With assessment, the nurse should determine the patient’s cultural upbringing, health beliefs and health practices. The “C” stands for communication. With communication, the nurse needs to be aware of both verbal and non-verbal cues as she is communicating with the patient. The other “C” stands for cultural negotiation and compromise. This means that the nurse should be aware of patient’s cultures and views on holistic care and be able to negotiate with patient to keep patient safe from harm and assist healing. The “E” in this model stands for establishing respect and rapport. By listening and displaying caring and respect for the patient’s cultural values, the nurse is not only showing respect for the patient but also helps establish a rapport that is essential to establishing trust at the beginning of the patient’s care. The “S” in this model stands for sensitivity. The nurse should be able to deliver culturally sensitive care to all patients. The final “S” in this model stands for safety. Through establishing a trusting relationship with his/her patient, the nurse is allowing the patient to have a sense of safety in which their cultural practices is honored (Vogel, 2016).
The second concept specific to this author’s nursing practice is caring. As a professional nurse, the author cares for patients with compassion and understanding. She creates a trusting relationship and listens to her patients and understands their fears and concerns. She addresses patients fears and concerns and advocates to create a safe and healing environment. Opinionated, the author believes that caring is a quality that is not taught in textbooks rather is an inherited quality a person is born with and chooses to use in nursing.
Watson's Theory of Human Caring is a theory in nursing that is used to help explain the concept of caring in nursing practice. This theory was developed by Dr. Jean Watson in an attempt to define nursing as a blend between science and human caring (Watson Caring Science Institute, 2019). There are three major elements to this theory. These three elements includes: carative factors, transpersonal caring relationship, and caring occasion/caring moments (Watson Caring Institute, 2019).
The first element of this theory is the ten carative factors. The ten carative factors core to this theory includes: 1) sustaining humanistic-altruistic values by practice of loving-kindness, compassion and equanimity with self/others. 2) being authentically present, enabling faith/hope/belief system; honoring subjective inner, life-world of self/others 3) being sensitive to self and others by cultivating own spiritual practice, 4) developing and sustaining loving, trusting-caring relationships, 5) allowing for expression of positive and negative feelings through authentically listening to another person’s story, 6) creatively problem-solving-‘solution-seeking’ through caring process 7) engaging in transpersonal teaching and learning within context of caring relationship, 8) creating a healing environment at all levels; subtle environment for energetic authentic caring presence, 9) Reverentially assisting with basic needs as sacred acts, touching mind body and spirit of others; sustaining human dignity and 10) being open to spiritual, mysteries, allowing for miracles (Watson Caring Institute, 2019).
The second element of this theory is a transpersonal caring relationship. This is a relationship characterized by a special kind of human care relationship. In describing this kind of relationship, Watson describes it as going beyond an objective assessment, with the nursing showing more concern towards the patient’s own subjective assessment of their own health care situation (Watson Caring Institute, 2019).
The third essential element of this theory is a caring occasion/caring moment. This describes a moment when there is an opportunity for the nurse and patient to interact in a caring manner (Watson Caring Institute, 2019).
In conclusion, theory guides practice in nursing. The two practice-specific concepts this author uses most common in practice includes: transcultural nursing and caring. Narayanasamy ACCESS model and Watson’s caring theory further elaborate on these two concepts. Becoming a culturally competent nurse in a diverse community helps the author deliver proper health care to patients from multiple ethnicities and cultural groups. As a nurse, it is essential to deliver care that goes beyond the physical symptoms to the patient and rather focus on caring for the individual holistically.
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