Nursing Practice. Theoretical Basis.

Introduction

Nursing theories are the creative products of nurses. They thoughtfully describe relationships and interactions within their nursing practice. Several theories have been propounded but there is no single theory which is more correct than the others. Theories have been classified into philosophies, grand theories and middle range. They aim at facilitating the nursing practice and equipping nurses to become experts in their field.

Commitment to health (CTH) is a theory derived from Prochaska and DiClemente’s (1983) Transtheoretical Model of Behavior Change. Commitment can be defined as an internal resolve of ones own choice to perform health behaviors when faced with difficulties or hindrances, where health is the optimal level of well being (Kelly, 2008). The transtheoretical model has the “stages of change, the decisional balance scale, the strong and weak principle, self-efficacy and the processes of change”. It was one of the more popular theories.

Main Text

Promoting health implies that sufficient behavioral interventions are provided to encourage healthy eating, participation in daily physical activity, and the elimination of tobacco smoking as defined by the Centers for Disease Control [CDC] (Kelly, 2008). Precontemplation, contemplation, preparation, action and maintenance are the five stages involved in behavioral change following the interventions. In the precontemplative sage, the person is not yet thinking about a behavior change. The person then starts thinking about a change in the contemplative stage and prepares for it. It could take some months before he really goes through the change. Next comes the stage of maintenance whereby his change becomes permanent. At this point his behavior becomes part of his daily activities. When the patient has reached the maintenance stage, he no longer wishes to revert to the old behavior. The triggers that used to initiate his old behavior no longer influence him.

The patient goes through the stages weighing the pros and cons of the change which is termed ‘decisional balance scale’ (Kelly, 2008). Prochaska called this the strong and weak principle on which the changes occur. The patient would recognize the behavior change as a positive activity and his old behavior as a negative one. The self efficacy is the patient’s growing confidence in the ability to overcome his old behavior and the processes of change further strengthen the behavior change (Kelly, 2008).

A set of 10 cognitive processes are used for determining how far the client has reached and how the clinician must act to promote behavior change (Kelly, 2008). The main intention is to prevent a relapse causing the client to go backwards to an earlier stage. A table by Prochaska and Velicer shows the stage of change range, the processes corresponding to that stage change and the determination of the change (Kelly, 2008).

The concepts, assumptions, and statements are well defined in the transtheoretical

model leading to its being accepted widely for clinical practice (Kelly, 2008). This has the disadvantages of being applicable to only one unhealthy behavior at a time; the social, biological and environmental issues are not addressed and there is no differentiation between a person who has undergone the change and one who has not. This led to the development of the CTH theory (Kelly, 2008). Here commitment is a variable. The person who is highly committed is expected to perform his health behaviors on more than one behavior. The one who is moderately committed is inconsistent and needs to be prodded on by the clinician to maintain the changes for at least 6 months. The one who is least committed is inconsistent faster, maybe even in a month (Kelly, 2008).

Anne Bradshaw and Kate Erikkson have both propounded nursing theories based on theology. These permit a vocational understanding of nursing (Lundmark, 2007).

Femininity and motherhood are related to the ‘ideals of altruism, service, caring and nurturing’ (Lundmark, 2007). They are therefore seen as a limiting force to nursing and are considered to be the central factors for the exploitation of nurses.

One study on newly recruited nurses identified several reasons for their joining nursing. Their reasons for selecting nursing were to ‘focus on others, focus on self, people and experiences, God, and nursing as a default choice’ (Lundmark, 2007). Intrinsicality and extrinsicality are the two concepts considered here. A person who is very close to God and religion will be described as having intrinsicality and his goals in the health movement would be sincerely achieved without expecting rewards. The main feature of extrinsicality would be goals other than the health of the clients and nursing would be just a means of securing other goals.

Bradshaw presented a meta-theory of nursing based on the work of the Swiss theologian, Karl Barth (Lundmark, 2007). She identified the relationship between God and human beings as a covenant where mutual giving and sharing occurred. Five principles related to the covenant notion were described by her: ‘the image of God in people; the absolute value of human life; freedom and love; relationality; and hope and peace.’(Lundmark, 2007). Nurses who believe in the vocation aspect would be close to the needs and problems of people. There would be a primary responsibility that will not exhibit ‘autonomous self interest, career achievements or other personal benefits’ (Lundmark, 2007). They would be motivated to the ethical idea of giving selfless service in response to patients’ requirements.

Eriksson’s theory, as translated by Lundmark defines ‘caring theology as’ a scientific investigation of and a serious or philosophical reflection on the importance of theological, religious and spiritual or existential questions for caring and nursing’ (Lundmark, 2007). She has described the fundamental ‘caritas’ model in nursing.

‘Caritas’ in Latin means human love and charity. Eriksson’s model allows us to understand the intrinsic and extrinsic motivational factors for nursing. This model however has a fault whereby the intrinsic could overshadow the extrinsic and convey the impression that the intrinsic is more significant which is not always the case.

Benner’s model of skill acquisition (from novice to expert) Benner (1984) believed that nursing care involves risks for both nurse and patient and that well planned educational programs provide skilled nursing (Waldner, 2007). She further pointed out that ‘Experience-based skill acquisition is safer and quicker when it rests upon a sound educational base”. Benner identified 5 levels of competency. The first item requiring attention is the measurable parameters like weight and vital signs. At the second level she is able to recognize clinical vital signs. At the third level, she focuses on the patient care issues which are long term goals. At the fourth level she is able to notice the changing relevance of clinical signs. At the fifth level, she is an expert who has a deep understanding of the situation due to her experience.

Kolb describes a process of learning where the nurse has an experience which she utilizes in her practice “The learner learns both through and from the experience: through the experience by doing and from the experience by reflection” (Waldner, 2007). She conceptualizes her learning experience into the recognized cognitive frame works. This experiential learning theory has 4 learning styles.

Accomodating learners learn from experience and actively experiment to internalize the learning. Divergent learners also learn from experience but they internalize by reflection.

Converging learners learn from abstract ideas and internalize them through active experimentation. Assimilating learners also learn from abstract ides but they internalize through reflection (Waldner, 2007). Kolb believed that the nursing profession consisted of these varieties of learners and they gained their experience from nursing practice through these different methods.

Theories with caring as a central concept within nursing has been adopted by many theorists, the most well known being Madeleine Leininger’s Theory of Culture Care and Jean Watson’s Theory of Human Caring. Both were established in the 1970s. Two newer theories have been presented by Simone Roach developed in the 1980s and recently by Boykin & Schoenhofer. A similar theory is the comfort theory of Katherine Kolcaba.

The concept of comfort has been considered in nursing practice since the time of Florence Nightingale as a desirable outcome or goal nursing care (Kolcaba and Kolcaba, 1991). Various meanings have been ascribed to comfort. In 1991, Katherine Kolcaba , a nurse theorist, developed the comfort theory. Nurses are the best people to confront the isolation of patients and bring comfort to these suffering ones (Kolcaba, 1992). It is difficult to define how one achieves it. It involves a multidimensional personal experience with different intensities. Nurses understand that a holistic assessment is necessary to totally identify the physical, psychological and spiritual positive result on any need affects the whole patient positively. Assuming that comfort is the desirable outcome for patient care, the concept of observation becomes significant (Kolcaba, 1992). Comfort should be pleasant , positive, multidimensional and the result of purposive action by the nurse. Gerontologic nursing and palliative care nursing are two applications which employ this technique of maintaining life in dignity and comfort till death. This would mean that the patient is kept free from pain, nausea and fatigue (Kolcaba, 1992). In the modern concept of comfort three senses of state, relief and renewal which facilitate precise communication and provide the conceptual resources for assessing comfort needs, designing measurement tools and determining comfort outcomes (Kolcaba and Kolcaba, 1991).

Leadership and change

Leadership is the process of influencing others through personal trustworthiness and self confidence, by communicating a vision that turns self –interest into commitment to the job. The primary tasks of a nurse leader are to set a direction towards a mission, goals and vision; to build commitment by motivating and inspiring and confront challenges by innovation, dealing with change, facing turbulence and taking risks. Various theories have been established for leadership qualities: traits, behavioral theories

(leadership styles), situational theories (understanding all the factors) and transformational theories (providing inspiration and meaning). An effective leader thinks critically, solves problems, respects people, communicates skillfully, sets goals, shares a vision and develops self and others.

Three styles of leadership have been described. The democratic or transformational leader moves the group towards its goals. The goal of transformational leadership is to change people and organizations in mind and heart, expanding their vision, insight and understanding; clarifying purpose, make behaviors congruent with beliefs, principles or values and bringing about changes that are permanent, self-perpetuating and momentum-building. This leader carries with her all her patients, her nurse colleagues, the doctors, other health care providers, employers, families of patients. She would be looked up to in times of crises… Transactional or autocratic leaders are better followers and move the group towards the leader’s goals. The laissez faire group makes no attempt to move the group they are in. The transformational nurse leader would be the sought after nurse.

‘Portable skills’ are the key qualities of the qualified nurse (Cadman and Brewer, 2001). She must have the capacity to be an efficient member of a team. The ability to recognize and respond appropriately to one’s own and others’ feelings is another skill. She must also be a good motivator to herself and to others. These skills are known as emotional intelligence. Many nurse theorists believe that selection processes for nurses should be able to determine the emotional intelligence of a candidate as this factor would be a predictor of success in clinical nursing and study (Cadman and Brewer, 2001).

Emotional intelligence is not a quality that can be built up. The emotionally intelligent nurse excels with relationships. Qualities which are central to effective clinical practice like empathy, motivation, self awareness and adeptness in relationships would be strong in an emotionally intelligent nurse leader (Cadman and Brewer, 2001). An emotionally intelligent nurse leader would elicit the best outcome for a patient. She exhibits the features of an effective leader through her ability to motivate others, communicate effectively and manage conflict resolution. Women leaders are known to encourage participation, share power and information, enhance other peoples’ self worth and they have the quality of getting others to be excited too. Here is another reason that the nurses who are women make good nurse leaders.

. Nursing leaders usually form part of a large organization in the new era. In this setup, processes would be acting to ensure precision, consistency and efficiency. There would be a division of tasks, hierarchial supervision and detailed rules and regulations (Weston, 2008). Due to the demands of the healthcare system, the nurses who are the transformational leaders must be efficient enough to respond to the changes. Innovative leadership becomes mandatory due to the rapidly changing healthcare environment. It has been noticed that maximum satisfaction and nurse retention are seen in magnet hospitals A nurse leader should be an advocate for quality care, collaborator, article communicator, mentor, risk taker, role model and visionary (CNA, 2002). Leadership is a shared responsibility. Safe, competent and ethical nursing care must be provided. A quality professional practice incorporates nurse leaders as middle managers, for decision making in boards, in organizational strategic planning activities, for accountability for high nursing care standards, for determining resource utilization and giving opinions in quality improvement activities. Appropriate staff development if encouraged, an optimum work design can be established (CNA, 2002).

With the expanding healthcare system to nearly $200 billion dollars of healthcare construction by 2015, the nurse leaders are having to take responsibility for millions or billions of dollars (Stichler, 2007). Their roles could include interaction with boards for getting acceptance for design concepts and approval of funding. They may have to communicate with affluent or highly influential people to obtain financial and political support. Networking with nurse leaders of other organizations is another new responsibility in order to identify best practice examples and successful completed projects. The healthcare expansion is now including interdisciplinary teams (IDTs) to help in the running of the organization. The leadership of the nurse leaders would extend to involving the IDTs too (Stichler, 2007). These once-in-a-lifetime opportunities for leadership extend from the planning stage to the post-occupancy evaluation stage. Nurse leaders are highly dependable leaders “for their group process and facilitation skills, abilities to lead diverse groups and manage conflicting opinions, insight into facility needs to support clinical functions, and commitment to a patient-first philosophy as a guide to decision making”.

The sphere of involvement and influence has obviously expanded for nurse leaders. As a part of the steering committee, the nurse leader gets the opportunity to remind the committee about the significance of ‘philosophies and values that must be preserved to achieve the vision for the project’. The nurse becomes an important personality who has a critical role in ensuring the visions and strategic goals of the organization. Summarizing, the nurse leadership has involvement in the steering committee, strategy decision making, selecting the nursing philosophy and model of care delivery, space planning process, leadership of the interdisciplinary teams, leadership in research and evidence based design efforts, managing of budgets and mega-sized projects (Stichler, 2007).

Succession planning happens to be a major role for nurse leaders. Effective succession planning is essential to maintain an organization’s culture. Predictability should be cultivated. Chaos or last minute scrambling should never be done. Candidates may be selected for an acceleration pool system (Byham, 2002). This would mean more numbers are in the pool. Opportunities are offered to the pool members to attend planning processes, development sessions, conferences and focus group discussions (Byham, 2002).

My experience of leadership

I first had such an experience when there was a fire in my ward. It occurred due to a short circuit. The lady patients were all ambulant and could be led away fairly quickly. There were six babies in the incubator in the neonatal ICU close by. They were not under my charge.However, the staff nurse on duty appeared confused. I advised her and together we solicited the help of a few of the other staff to carry the babies safely to the other ICU room which was next to the labor room. Thankfully the babies were not harmed.

I had another occasion when I had to participate in a labor case which could not be shifted to the labor room. I quickly washed up and delivered the baby on the ward cot. My presence of mind was appreciated by the mother and her family.

When a baby who just had immunization developed convulsions, I intervened with resuscitative measures and saved the baby.

Change

When I was working in the psychiatry ward, I was able to calm a patient who had suicidal tendencies. Through many interactions, I was able to become her confidante and get to the root of her problems. She slowly came out of her depression and now is well on the way to a satisfactory outcome.

I could persuade my elder brother to quit smoking. He is now a different person altogether and has a steady job.

Research Knowledge

Evidence based practice is the providing of high quality cost effective care with favorable outcomes. Learning to systematically locate, evaluate and select the best available research in order to use the best evidence based practice (Meeker, 2008) is important for nursing practice. Nurses must understand the value of research, evidence based practice and clinical guidelines in their daily practice. Innovative techniques are being designed to project the value of research in the nursing students (Meeker, 2008).

However it would be apt to comment that more time is spent on demonstration of evidence based practice. I believe that this is to increase student interest. This could also be due to the fact that all nursing students hope to become registered nurses and so concentrate more on the practice side. Clinical practice is inevitably more exciting and students have a sense of purpose where practice is concerned.

What I have learned

There are two main kinds of research: qualitative and quantitative. Qualitative research studies experiences, behaviors and perspectives in relation to circumstances and settings. New theories could be established. The aim of this research is to study previously unexplained situations or behaviors. The questions what, how and why would be answered in the process. Different philosophies are attached. The methods of research are observation, exploratory interviews, focus groups, discourse, narrative, documentary and video analysis and analysis of documents and materials Finally analysis is done from the accumulated data. Computers also are resorted to for data analysis through usage of specific software. A target population makes up the participants.

In the assessment of health care, there are two current models; the enhancement model and the difference models. There are six types of qualitative studies associated with nursing: phenomenological, ethnographic, grounded theory, historical, case study, and action research (Nieswadomy, 2008). Ethnography is very commonly used and it is useful in nursing because nurse researchers can view nursing and health care in the context in which it occurs. In grounded theory, data is collected and a theory is conceived. Grounded theory is excellent for understanding the processes through which patients learn to manage new or chronic health problems (Nieswadomy, 2008). This method can be used to study the emotional comfort of hospital patients. Historical studies concern the identification, location, evaluation, and synthesis of data from the past. Leininger wrote “Without a past, there is no meaning to the present, nor can we develop a sense of ourselves as individuals and as members of groups” (Nieswadomy, 2008). Case studies are used when real clinical situations are to be studied. Solutions are sought to practice problems in one particular hospital or health care setting in action research. Participatory action research is resorted to when a large community is researched. Quantitative research classifies features and counts them. The researcher knows what he is looking for. He uses tools like questionnaires to collect numerical data. There will be precise measurement and analysis. Researcher is objectively separate from the research. Theories may be conceived and utilized for future purposes.

I have participated in a qualitative research conducted during the first year of nursing where we were taken to a community to evaluate the number of smokers and how motivated they are for quitting.

In our class we had to prepare posters and development of proposals for research. Each of us had to present them in class. My classmates commented on my piece of work. I had to do the same for their presentations too. Our tutor guided us and participated in the interactions.

I have had the opportunity to read up research articles related to evidence based practice during my course and critique two research studies for my class. We had great fun finding others’ faults but learned in the process, much more than what we would have gained by reading alone.

My senior was doing a quantitative research to compare intravenous and epidural anaesthesia for patients undergoing total knee replacement. The assessments of analgesia’s side effects were made to see whether they influence patient satisfaction. She found that there was nothing to suggest that epidural offered more consistent analgesia. I noticed that the question of ethics is important in any research. It was an experience for me.

References

Byham, W,C,; (2002), “A new look at succession management”, Ivey Business Journal, Vol 66, issue 5, pgs 10-12.

Cadman. and Brewer J. (2001), “Emotional intelligence: a vital prerequisite for recruitment in nursing”, Journal of Nursing Management 9, 321±324. Blackwell Science Ltd.

Kelly, Cynthia W., “Commitment to health theory”, Research and Theory for Nursing Practice: An International Journal, Vol. 22, No. 2, 2008, Springer Publishing Company.

Kolcaba, K.Y.and Kolcaba, R.J.; (1991), Journal of Advanced Nursing, Vol 16, Pgs 1301-1310.

Kolcaba, Katherine Y.; (1992), “Holistic comfort: operationalizing the construct as a nurse-sensitive outcome, Advances in Nursing Science, Vol 15, Issue 1, pgs 1-10, Aspen Publishers.

Lundmark, Mikael; “Vocation in theology-based nursing theories”, Nursing Ethics 2007, Vol.14 (6) SAGE Publications.

Meeker, Mary Ann et al, “Teaching Undergraduate Nursing Research from an Evidence-Based Practice Perspective”, Journal of Nursing Education, Vol 47, No.8, 2008.

Rose Marie Nieswiadomy, (2008), Foundations of Nursing Research, 5th Ed., Pearson Education Inc., Chapter 10.

Stichler, Jaynelle F.; (2007), “Leadership Roles for Nurses in Healthcare Design”, Journal of Nursing Administration, Vol 37, Issue 12, Pgs 527-530, Lippincott Williams & Wilkins, Inc.

Waldner, Magda H. and Olson, K.Joanne; (2007), “Taking the Patient to the Classroom: Applying Theoretical Frameworks to Simulation in Nursing Education”, International Journal of Nursing Education Scholarship, Vol.4, Issue 1, Article 18, Berkeley Electronic Press.