Professional Nursing Practice Concepts and Perspectives Seventh Edition Chapter 6 Knowledge Development in Nursing

Learning Objectives 6.1 Describe the nature of knowledge development. 6.2 Differentiate among the terms concept, conceptual framework, and conceptual model. 6.3 Analyze the development of knowledge in nursing. 6.4 Compare the theoretical approach of selected nurse theorists. 6.5 Identify the relationship between nursing process and nursing theory.

Hallmark Features A focus on foundational knowledge related to professional nursing Includes nursing history, nursing theory, ethics, and legal aspects, etc. An overview of professional nursing roles, issues, and changes in the profession Discusses nurses as healthcare providers, learners and teachers, and leaders

Challenges and Opportunities Traditional gap between academia and practice Nursing theory considered ethereal and unrelated to the real world of nursing by practicing nurses Theory development is foundation for knowledge development Drawn from multiple and diverse approaches Allows application to what is the best fit Does this best serve the profession?

Learning Objective 6.1 Describe the nature of knowledge development.

Worldviews and Knowledge Development Theory A system of ideas proposed to explain something Improves practice by describing, explaining, predicting, and controlling phenomena Guides practice, education, and research Provides professional autonomy Study helps develop analytical skills

Worldviews and Knowledge Development Nursing theory Not part of nursing education when first developed Until the 1950s, practice based on principles and traditions Florence Nightingale first proposed nursing knowledge as different and distinct from medical knowledge

Worldviews and Knowledge Development Different theories represent different worldviews Individuals who think and see the world in different ways create theories Provide contrasting paradigms (structures for organizing theory) Provide different traditions and approaches to science and knowledge development

Worldviews and Knowledge Development Positivist approach paradigm 18th-century Age of Enlightenment Natural law Linear Cause and effect using experimental research methods General to specific

Worldviews and Knowledge Development Constructivist paradigm Science is embedded in time because truth is dynamic Reality not fixed Truth is found in one’s experiences Research uses naturalistic settings and observational methods Specific to general

Worldviews and Knowledge Development Categories of theories Philosophy Nature of things, aims to provide broad understanding Nursing models Form interrelationships among concepts and definitions to provide organized perspective

Worldviews and Knowledge Development Categories of theories Grand theory (nursing theories) General, broad, and complex Middle-range theory Narrower focus, refined through series of studies See Table 6−1

Table 6-1 Nursing Theorists and Their Theoretical Scope Philosophies Nursing Models Nursing Theories Middle-Range Theories Jean Watson’s philosophy and science of caring Martha Rogers’s unitary human beings Madeleine Leininger’s culture care theory of diversity and universality Merle Mishel’s uncertainty in illness theory Marilyn Ray’s theory of bureaucratic caring Dorothea Orem’s self-care deficit theory Margaret Newman’s health as expanding consciousness Katherine Kolcaba’s theory of comfort Patricia Benner’s novice to expert Betty Neuman’s systems model Rosemarie Parse’s human becoming theory Cheryl Beck’s postpartum depression theory Sister Callista Roy’s adaptation model Afaf Meleis’s transition theory Kristen Swanson’s theory of caring Imogene King’s theory of goal attainment Anne Boykin and Savina Schoenhofer’s theory of nursing as caring Ramona Mercer’s maternal role attainment Source: Based on Nursing Theorists and Their Work (7th ed.), by A. M. Tomey and M. R. Alligood, 2010, St. Louis, MO: Mosby.

Learning Objective 6.2 Differentiate among the terms concept, conceptual framework, and conceptual model.

Defining Terms Concepts Concepts may be Building blocks of theory Abstract ideas or mental images Concepts may be Readily observable, or concrete Indirectly observable, or inferential Nonobservable, or abstract

Defining Terms Four concepts of the metaparadigm of nursing Person or client Environment Health Nursing

Theory Development in Nursing Theory and conceptual framework differ in levels of abstraction Conceptual framework more abstract Provides overall view to focus thoughts Umbrella under which concepts exist Conceptual model/conceptual framework A graphic illustration of a conceptual framework

Theory Development in Nursing Supposition or system of ideas to explain a given phenomenon Relates concepts by using definitions that state significant relationships between concepts Knowledge development Deductive or inductive approach

Theory Development in Nursing Theory testing Deductive approach Compares outcomes with relationship predicted by hypothesis drawn from theory and linked to concept Theory generation Inductive approach

Theory Development in Nursing Five kinds of knowledge Revealed Intuitive Rational Empirical Authoritative

Theory Development in Nursing Ways-of-knowing framework Empirical Aesthetic Personal Ethical

Learning Objective 6.3 Analyze the development of knowledge in nursing.

Theory Development in Nursing Source of discussion and debate regarding uniqueness Borrowed or shared Result is diversity of theories

Learning Objective 6.4 Compare the theoretical approach of selected nurse theorists.

Nightingale’s Environmental Theory Florence Nightingale, first nurse theorist Five environmental factors; deficiencies in these result in poor health Pure or fresh air Pure water Efficient drainage Cleanliness Light, especially direct sunlight

Peplau’s Interpersonal Relations Model Hildegard Peplau, psychiatric nurse Based on psychoanalytic theory, principles of social learning, concepts of human motivation and personality development

Peplau’s Interpersonal Relations Model Psychodynamic nursing Nurse-client relationship evolves in four phases Orientation Identification Exploitation Resolution

Henderson’s Definition of Nursing Virginia Henderson, known for Textbook on the Principles and Practices of Nursing Formulated a definition of the unique function of nursing Basic to definition are assumptions about the individual

Henderson’s Definition of Nursing The individual needs To maintain physiological and emotional balance Assistance to achieve health and independence or a peaceful death Necessary strength, will, or knowledge to achieve or maintain health

Henderson’s Definition of Nursing Nurse’s focus to help individuals and families in 14 fundamental needs Breathing normally Eating and drinking adequately Eliminating body wastes Moving and maintaining a desirable position Sleeping and resting Selecting suitable clothing

Henderson’s Definition of Nursing Nurse’s focus to help individuals and families in 14 fundamental needs Maintaining body temperature within normal range by adjusting clothing and modifying the environment Keeping the body clean and well groomed to protect the integument Avoiding dangers in the environment and avoiding injuring others Communicating with others in expressing emotions, needs, fears, or opinions

Henderson’s Definition of Nursing Nurse’s focus to help individuals and families in 14 fundamental needs Worshipping according to one’s faith Working in such a way that one feels a sense of accomplishment Playing or participating in various forms of recreation Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available heath facilities

Rogers’s Science of Unitary Human Beings Martha Rogers’s theory presented in 1970 Humans are dynamic energy fields in continuous exchange with environmental fields Unitary human beings Irreducible energy field identified by patterns Manifest characteristics different from sum of parts Interacts continuously and creatively with environment Behave as totality Sentient, participate creatively in change

Rogers’s Science of Unitary Human Beings Individuals and the environment are characterized as Energy fields Open systems Uniquely patterned and organized Pandimensional

Rogers’s Science of Unitary Human Beings Three principles of homeodynamics Integrality Resonancy Helicy

Rogers’s Science of Unitary Human Beings Rogers’s theory applied to nursing practice Focuses on the person’s wholeness Seeks to promote symphonic interaction between the two energy fields to strengthen the coherence and integrity of the person Coordinates the human field with rhythmicities of the environmental field Directs patterns of interactions between the two energy fields to promote maximum health potential

Orem’s Self-Care Deficit Theory of Nursing Dorothea Orem’s theory published in 1971 Referred to as the self-care deficit theory of nursing Based on theories of self-care, self-care deficit, and nursing systems

Orem’s Self-Care Deficit Theory of Nursing Self-care theory based on four concepts Self-care Self-care agency Self-care agent Dependent-care agent Self-care requisites Universal requisites Developmental requisites Health deviation requisites Therapeutic self-care demand

Orem’s Self-Care Deficit Theory of Nursing Self-care deficit theory, five methods of helping Acting or doing for Guiding Teaching Supporting Providing an environment promoting individual’s abilities to meet current and future demands

Orem’s Self-Care Deficit Theory of Nursing Three types of nursing systems Wholly compensatory Partly compensatory Supportive-educative

King’s Goal-Attainment Theory Imogene King’s theory based on mutual goal setting of the nurse and patient Three dynamic interacting systems Personal (individuals) Interpersonal (groups) Social (society)

King’s Goal-Attainment Theory Transactions Purposeful interactions that lead to goal attainment Characteristics of transactions Social exchange, bargaining, and negotiating Perceptual accuracy in nurse-client interaction Lead to goal attainment

King’s Goal-Attainment Theory King’s seven hypotheses in goal-attainment theory Perceptual congruence Communication increases mutual goal setting Satisfaction in nurses and clients increases goal attainment Goal attainment decreases stress and anxiety Goal attainment increases learning and coping

King’s Goal-Attainment Theory King’s seven hypotheses in goal-attainment theory Role conflict decreases transactions Congruence in role expectations and performance increases transactions

Neuman’s Systems Model Betty Neuman’s theory based on Gestalt theory and others Focuses on the wellness of the client in relation to environmental stressors and reactions to stressors

Neuman’s Systems Model Five client system variables Physiological Psychological Sociocultural Developmental Spiritual

Neuman’s Systems Model Client is a basic structure with central core of energy surrounded by two lines of resistance Inner or normal line of defense Flexible line of defense

Neuman’s Systems Model Stressor is any environmental force that alters the system’s stability Internal stressors Interpersonal stressors Extrapersonal stressors Created stressors

Neuman’s Systems Model Adapting to stressor is known as reconstitution Nursing interventions focus on three preventive levels Primary prevention Secondary prevention Tertiary prevention

Roy’s Adaptation Model Callista Roy’s theory is based on Harry Helson’s work in psychophysics Focuses on individuals as a biopsychosocial adaptive system Employs a feedback cycle Input Throughput Output

Roy’s Adaptation Model Adaptive responses contribute to health Each person’s adaptive level is unique and constantly changes Classes of stimuli Focal stimuli Contextual stimuli Residual stimuli

Benner’s Novice to Expert Patricia Benner’s thinking was influenced by Virginia Henderson and Hubert Dreyfus Adapted Dreyfus and Dreyfus model of skill acquisition and skill development to clinical practice nursing

Benner’s Novice to Expert Five levels Novice Advanced beginner Competent Proficient Expert

Benner’s Novice to Expert As one moves through the levels, four aspects of performance change Movement from abstraction to use of past concrete experiences Shift from analytical to intuitive Viewing the situation from relevant bits to complex whole Detached observer to fully engaged in the situation

The Caring Theorists Provide a link between generic caring and the uniqueness of nursing Caring is a central concept to the practice of professional nursing

The Caring Theorists Core value encompassing Altruism Autonomy Human dignity Integrity Social justice

The Caring Theorists The caring theorists; see Table 6−2 Milton Mayeroff Jean Watson Madeleine Leininger Simone Roach Anne Boykin and Savina Schoenhofer

Table 6-2 Comparison of Caring Models and Theories Mayeroff Leininger Roach Watson Boykin and Schoenhofer Perspective on caring To care for another person is to help that person grow and actualize. Care is the essence of nursing. Caring is the human mode of being. Individual healing processes can be strengthened through authentic caring relationships. Caring is an essential feature and expression of being human. Unique focus Major ingredients of caring are knowing, alternating rhythms, patience, honesty, trust, humility, hope, and courage. Caring is inextricably linked with culture. Caring is not unique to nursing but is unique in nursing. Caritas processes are based on the carative factors. A transpersonal caring relationship is established through the processes of caring and healing and being in an authentic relationship, in the moment. Nurturing involves persons living and growing in caring.

Table 6-2 (Continued) Expression in nursing It assists the nurse in developing a sense of self as a caring person. Provide culturally acceptable care. Professionalization of caring is expressed through the 5 C's of caring: Compassion Competence Confidence Conscience Commitment Watson's theory stresses the importance of the lived experience not only of the client but of the nurse. Both the nurse and the client come together in a caring moment. Caring is the intentional and authentic presence of the nurse with another who is recognized as a person living and growing in caring. Discipline of origin Philosophy Anthropology Humanism and metaphysics Philosophy, human science, and nursing Source: Based on “Caring: Theoretical Perspectives of Relevance to Nursing,” by T. V. McCance, H. P. McKenna, and J.R.P. Boore, 1999, Journal of Advanced Nursing, 30(6), pp. 1388–1395; On Caring, by M. Maycroff, 1971, New York, NY: Harper Perennial; Nursing as Caring: A Model for Transforming Nursing Practice, by A. Boykin and S. Schoenhofer, 1993, National League for Nursing Press. Boston, MA: Jones & Bartlett; Theory of Human Caring, by J. Watson, in Nursing Theories and Nursing Practice (pp. 351–369), by M. Parker (Ed.), 2010, Philadelphia, PA: F. A. Davis.

Mayeroff On Caring Milton Mayeroff’s conception of caring Helping others to grow Caring consists of Knowing, alternating rhythms, patience Honesty, trust, tumility Hope, courage

Watson’s Human Caring Theory Jean Watson believes that caring is central to nursing Two major assumptions Care and love constitute the primal and universal psychic energy Care and love are requisite for our survival and the nourishment of humanity

Watson’s Human Caring Theory Major elements Carative factors Transpersonal caring relationship Caring moment/caring occasion

Leininger’s Culture Care Diversity and Universality Theory Madeleine Leininger’s sunrise model depicts her theory Caring and culture are inextricably linked

Leininger’s Culture Care Diversity and Universality Theory Transcultural nursing focuses on comparative study and analysis of different cultures and subcultures Goal of transcultural nursing is to develop a scientific body of knowledge to provide culture-specific and culture-universal nursing practices Focuses on diversity and universality

Kolcaba’s Theory of Comfort Katherine Kolcaba’s theory defines comfort as the immediate and holistic experience of being strengthened through having the needs met for three types of comfort Relief Ease Transcendence

Kolcaba’s Theory of Comfort Four contexts of experience Physical Psychospiritual Social Environmental With this theory nurses identify unmet comfort needs of clients

Mishel’s Uncertainty in Illness Theory Theory developed from information-processing model used by psychology Uncertainty is the inability to determine meaning of illness-related events when decision maker can’t assign value to objects or events

Mishel’s Uncertainty in Illness Theory Assumptions of this theory are Uncertainty is a cognitive state Uncertainty is neutral until interpreted as desirable or aversive Adaptation is the desired outcome The relationships among illness move from uncertainty to adaptation

Mishel’s Uncertainty in Illness Theory Assumptions of this theory are People function in far-from-equilibrium states Major fluctuations in far-from-equilibrium states enhance receptivity to change Fluctuations result in repatterning

Learning Objective 6.5 Identify the relationship between nursing process and nursing theory.

Relationship of Theories to the Nursing Process and Research Different from set of concepts Relate concepts in a logical, testable way Provide clarity Create foundation Developed through research

Relationship of Theories to the Nursing Process and Research Conceptual models for nursing, abstractions that are operationalized by use of nursing process Assessing Diagnosing Planning Implementing Evaluating