Nightingale’s principles

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NUR3500

Nursing Theory: The Basis for Professional Nursing

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Nursing Theory

  • Latin “a viewing”; Greek “contemplating”
  • A body of knowledge shaped by how nurses see the world
  • A group of related concepts, definitions & statements that propose a view of nursing phenomena from which to describe, explain or predict outcomes
  • Abstract ideas

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Why is Theory Important?

  • Nursing is strengthened when knowledge is built on sound theory
  • Criteria to be a profession: distinct body of knowledge as the basis for practice
  • Nursing must be viewed as a scholarly academic discipline hat contributes to society
  • Ultimate goal is to support excellence in practice

Theory Guides the Professional
Nurse in….

  • Organizing and analyzing patient data
  • Understanding connections between pieces of data
  • Discriminating between important and less pertinent data
  • Making sound clinical judgments based on evidence
  • Planning effective nursing interventions
  • Predicting and evaluating outcomes of interventions

Definition of Terms

  • Metaparadigm = the major concepts or abstract ideas of the discipline; most important to practice and research
  • Person
  • Environment
  • Health
  • Nursing
  • Philosophy = a set of beliefs about the nature of how things work and how the world should be viewed; begins to put together some or all concepts of the metaparadigm

Definition of Terms Cont’d.

  • Conceptual Model or Framework = a more specific organization of nursing phenomena than philosophies; provide an organizational structure that makes clearer connections between concepts
  • Propositions = statements that describe linkages between concepts and are more prescriptive; they propose an outcome that is testable in practice and research

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Florence Nightingale

  • Notes on Nursing: What It Is and What It Is Not (1969, originally published in 1859)
  • Her philosophy of health, illness, and the nurse’s role in caring for patients
  • Focused on the relationship of patients to their surroundings
  • Importance of observing the patient and recording information
  • Importance of cleanliness
  • Health and recovery from illness is related to environment

Virginia Henderson

  • The “Unique function of he nurse… is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.”
  • Nurse’s role = substitute for the patient, a helper to the patient or a partner with the patient
  • 14 basic needs of the patient (see Box 13-3 on pg. 308)

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Jean Watson

  • Studied at CU
  • The Philosophy and Science of Caring (1979)
  • Emphasized the caring aspects of nursing
  • 10 Carative factors (see Box 13-4 on pg. 309); these factors differentiate nursing from medicine (curative)
  • Illness or disease equated with lack of harmony within the mind, body, and soul
  • RN responsible for creating and maintaining an environment supporting human caring while recognizing and providing for patient’s primary human requirements

Watson Continued

  • Proposed that nursing be concerned with spiritual matters and the inner knowledge of nurse and patient as they participate together in the transpersonal caring process
  • Nurses share their genuine self
  • Patient’s spiritual strength is recognized, supported, encouraged
  • RN encourages openness to understanding of self and others
  • Leads to trusting, accepting relationships where feelings are shared and confidence is inspired

Dorothea Orem

  • Concept of self-care
  • “Ordinary people in contemporary society want to be in control of their lives.”
  • Patient’s baseline ability to provide adequate self-care is assessed
  • Systems of care
  • Wholly compensatory
  • Partially compensatory
  • Supportive-educative

Imogene King

  • A Theory for Nursing: Systems, Concepts, Process (1981)
  • Focused on persons, their interpersonal relationships, and social contexts with three interacting systems
  • Personal
  • Interpersonal
  • Social
  • Emphasizes goal attainment and patient’s involvement in setting goals (Goal Attainment Model)

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Sister Callista Roy

  • Introduction of Nursing: An Adaptation Model (second edition 1984)
  • Individual as a biopsychosocial adaptive system
  • Nursing is a humanistic discipline that emphasizes the person’s adaptive and coping abilities
  • The environment can be manipulated by the RN to further patient’s adaptation

Hildegard Peplau

  • Interpersonal Relations in Nursing (1952 & 1988)
  • Relationship between patient and nurse is the focus of attention
  • Therapeutic interpersonal relationship
  • Survival of the patient
  • Patient’s understand his or her health problems and learn from them as they develop new behavior patterns
  • 6 roles of the nurse: counselor, resource, teacher, technical expert, surrogate, and leader

Ida Orlando

  • The Dynamic Nurse-Patient Relationship: Function, Process and Principles (1961)
  • Observation and confirmation of patients’ verbal and non-verbal behavior, which identify patient needs
  • Goal of the nurse is to determine and meet patients’ immediate needs and improve their situation by relieving distress or discomfort
  • Individualize care by attending to behavior

Madeleine Leininger

  • Theory of cultural care
  • Founder of Transcultural nursing
  • Patients viewed in the context of their cultures
  • Nursing care should be culturally congruent
  • “Sunrise Model” (Figure 13-2, pg. 317) guides the assessment of cultural data for an understanding of its influence on the patient’s life

Theory-Based Education

  • PhD: a research degree that generates new, discipline-specific knowledge
  • Master’s: use theoretical perspectives focused on the patient for specific nursing outcomes; base practice on evidence from research & experience
  • BSN: introduced to research process & the use of theory to guide it
  • ADN: find middle range theories useful as they are specific to patient care

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Theory-Based Practice

  • Occurs when nurses intentionally structure their practice around a particular nursing theory and use it to guide them in their care of the patient
  • Provides a systematic way of thinking about nursing that is consistent and guides the decision-making process
  • Challenges conventional views of patients, illness, the health care delivery system, and traditional nursing interventions

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Benefits

  • Explain practice to others
  • Passes on knowledge to students
  • Contributes to professional autonomy
  • Develops analytical skills, challenges thinking, and clarifies your values and assumptions

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Theory-Based Research

  • Great strides have been made in the last 25 years in nursing research
  • Nursing research tests and refines the knowledge base of nursing
  • Research findings enable nurses to improve the quality of care and understand how evidence-based nursing influences patient outcomes
  • Research is vital to the future of nursing and theory is integral to research

The Health Care Delivery System

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Health Care Delivery

  • The four basic types of services provide by the health care delivery system
  • Health Promotion: remain healthy
  • Illness prevention: reduce risk factors
  • Diagnosis & treatment: refined methods of diagnosis allow for more effective treatment
  • Rehabilitation & LTC: restore function & independence; disease management

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Health Care Agencies

  • Government: Contribute to health of all U.S. citizens; supported by taxes; Federal, State, Local
  • Voluntary (Private): Support via private donations, government grants
  • Not-for-profit: Profits used on behalf of agency
  • For-profit: Profits distributed to partners or shareholders

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Level of Health Care Services

  • Primary Care Services: first entry into system, emergency care, health maintenance, LTC, chronic care, temporary health problems
  • Secondary Care: prevent complications from disease; home health, ambulatory care, skilled nursing agencies, and surgery centers; disease management via electronics
  • Tertiary Care: acutely ill to LTC to rehab to terminally ill; interdisciplinary; specialized hospitals: trauma centers, burn centers, specialized peds centers; LTC facilities that offer skilled nursing, intermediate care and supportive care; rehab centers; hospice
  • Subacute Care: Inpatient care between hospital and long-term care

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Organizational Structures of Health Care Agencies

  • Board of Directors: carry responsibility for mission, quality of services, finances
  • Chief Executive Officer (CEO): overall daily operation
  • Medical Staff: physicians granted privileges; organized by service/dept.
  • Chief of staff work with CEO to make important decisions about medical policy
  • Nursing Staff: RNs, LPNs, NAs and clerical staff; organized according to units
  • Chief Nurse Executive (CNE) or Chief Nursing Officer (CNO) today on Board of Directors, oversee nursing care

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Nursing Organization Governance

  • Nurses govern themselves though the organization
  • Shared governance = founded on the philosophy that employees have both a right and a responsibility to govern their own work and time within a financially secure, patient-centered system
  • Promotes decentralization and participation at all levels of nursing

Maintaining Quality

  • Accreditation: accrediting bodies approved by CMS; to improve pt. outcomes; institution wide initiatives
  • JCAHO (Joint Commission): not-for-profit that serves as the nation’s predominant standards-setting and accrediting body in health care
  • HFOP (Healthcare Facilities Accreditation Program): Standards met in all depts.
  • Continuous Quality Improvement (CQI)/Total Quality Management (TQM): examine processes to look for ways to improve services before mistakes occur; anticipate potential problems and prevent their occurrence
  • Performance Improvement (PI): organizational efforts to improve corporate performance; focuses efforts on increasing individual and group competence and productivity

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Health Care Disparities

  • Defined as differences in the quality of health care provided to different populations
  • Can be due to race, ethnicity, gender, age, income, education, disability, sexual orientation, and place of residence
  • Little progress has been made in narrowing disparities
  • Provider bias possible contributing factor

Health Care Team

  • Physicians
  • Physician Assistants
  • Patient Care Technicians
  • Dietitians
  • Pharmacists
  • Technologists
  • Respiratory Therapists
  • Social Workers
  • Therapists
  • Administrative Support Personnel: admissions, medical records, billing, etc.

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Nurse’s Role on Team

  • Provider of Care: direct hands on care
  • Educator: teaching pt., family, new staff, community, etc.
  • Counselor: emotional support & problem solving
  • Manager: organizes care
  • Researcher: investigates how nursing interventions impact patient outcomes
  • Collaborator: works with patients, families & team on agreed patient outcomes
  • Patient Advocate: stands up for patient rights; advocates for patient’s best interests at all times

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Types of Nursing Care Delivery

  • Functional Nursing: focuses on functions/tasks; personnel work side by side each performing an assigned task
  • Team Nursing: RN is team leader, oversees, assesses, documents; LPN direct care, treatments, procedures; NA personal care
  • Primary Nursing: one nurse accountable for nursing care of patient during stay on unit; delegates care while off duty
  • Case Management Nursing: oversees pt. care and manages the delivery of services from entire health care team throughout patient’s illness
  • Patient-centered Care: contemporary model focusing on patient’s rights to individualized care

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Financing Health Care

  • In 2007 the nation’s health care expenditures reached $2.2 trillion and consumed 16.2% of the gross domestic product
  • By 2018 health care costs are expected to reach $4.4 Trillion
  • Basic Economic Theory: supply/demand; Does it relate to health care?
  • Free-Market economy: consumption determined by an individual’s ability to pay
  • Price sensitivity in health care: third party payers (employer, insurance company, or government) removed price sensitivity from the concern of most health care consumers because they pay only a portion of the actual costs
  • Additional influences: can’t delay care

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Economics of Nursing Care

  • Nursing accounted for 20-28% of the costs of hospitalizations in 1980s
  • To stay in business, hospitals must make at least enough money to pay personnel, maintain buildings and equipment, and pay suppliers
  • ANA: overzealous cost-containment efforts have led to lower quality hospital care
  • Aiken, Clark, Sloane et al, 2006 research links nursing and quality of care; increased patient death rate with higher nurse:patient ratios

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History of Health Care Finance

  • Before 1945, 90% paid out of pocket or charity care
  • Growth of Private Insurance → tax exempt
  • Rise of Public Insurance Programs (1965)
  • Medicare
  • Part A = Hospital Insurance
  • Part B = Medical Insurance (20% co-pay, deductible
  • Part C = Managed care option
  • Part D = Prescription drug coverage
  • Medicaid
  • Federal government contributes 50-76.8%
  • Personal (out-of-pocket) payment
  • Worker’s Compensation

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Forces Changing Health Care

  • Managed Care attempts to control healthcare costs; health promotion not illness treatment
  • Health Maintenance Organization (HMO): health care services provided for a predetermined fixed fee
  • Capitation: same amount paid to provider each month regardless of whether services were provided or how much the services cost
  • Gatekeeper: PCP, responsible for referrals
  • Preferred Provider Organization (PPO): contracts with provider for discounted rate

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Forces Changing Health Care

  • Point-of Service Organization (POS): choice of service within network; or outside network pay higher $
  • Physician Hospital Organization (PHO): corporation formed by hospital/physician to contract with managed care organization

Nurse’s Role in Managed Care

  • Advanced Practice Nurses: ambulatory and community settings
  • Case Manager
  • Triage
  • Utilization reviewers to determine most appropriate and cost-efficient level of care

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Change in Consumer’s Expectations

  • Became more educated and fight for rights to health care through political reform and the legal system
  • Proliferation of internet websites has dramatically affected the knowledge and expectations of consumers

Health Care’s Response

  • Reengineering: rethinking & redesigning
  • Patient-centered care: patient at center of activity and designing outcomes
  • Decentralization: staff exercise own judgment
  • Cross-functional teams: people form all areas of the organization who contribute to a particular process
  • Multi-skilled workers: single worker cross-trained to do different tasks

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New Organizational Models

  • Functional Model: defines each major function of the organization and establishes clear lines of managerial authority
  • Service Line Model: establishes management responsibilities around specific types of services wherever they occur in the hospital
  • Matrix Model: complex with multiple authority and support systems
  • Process Model: organizes management of care around phases in the process of healthcare delivery
  • Regional Model: complex health care systems that grew from acquisitions; organized by type of service provider

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Continued Escalation of
Health Care Costs

  • Inflation
  • New Technology and Drugs
  • Increased Demand for Healthcare Services – more elderly & uninsured
  • Fraud and Abuse of Payment Systems - $75 billion of US annual health expenditures may be attributable to fraud

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Cost Containment Measures

  • Centers for Medicare & Medicaid Services – contracts private insurance agencies to service the Medicare program
  • Professional Review Organizations (PROs) – monitor the quality of care received
  • Diagnosis-Related Groups (DRGs) – diagnoses with similar resources consumptions and LOS patterns into a single category; 495 DRGs
  • Block Grants – state given set amount of money based on caseload, etc.
  • Continued Expansion of Managed Care – largest provider; limits consumer choices but not intended to reduce quality of care

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Health Care Finance Challenges

  • Continuing Crisis: Uninsured Americans
  • Quality of Care
  • Limits on Choice and Services
  • Provider Restrictions & Financial Incentives to Limit Services
  • Cost of Prescription Drugs
  • Malpractice Costs & Impact of Access to Care

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Health Care Reform

  • The US and South Africa are the only two industrialized nations that do not provide universal access to health care
  • System-wide health reform efforts were supported by public opinion but failed to pass congress

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