Bonnie M. Wivell, MS, RN, CNS

Chapter 13: Nursing Theory: The Basis for Professional

Nursing

Nursing TheoryLatin “a viewing”; Greek

“contemplating”A body of knowledge shaped by how

nurses see the worldA group of related concepts, definitions

& statements that propose a view of nursing phenomena from which to describe, explain or predict outcomes

Abstract ideas

Why is Theory Important?Nursing is strengthened when

knowledge is built on sound theoryCriteria to be a profession: distinct body

of knowledge as the basis for practiceNursing 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 dataUnderstanding connections between

pieces of dataDiscriminating between important and less

pertinent dataMaking sound clinical judgments based on

evidencePlanning effective nursing interventionsPredicting and evaluating outcomes of

interventions

Definition of TermsMetaparadigm = the major concepts or

abstract ideas of the discipline; most important to practice and researchPersonEnvironmentHealthNursing

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

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 patientsFocused on the relationship of patients to their

surroundingsImportance of observing the patient and

recording informationImportance of cleanlinessHealth 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)

Jean Watson

Studied at CUThe Philosophy and Science of Caring (1979)Emphasized the caring aspects of nursing10 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 ContinuedProposed that nursing be concerned with

spiritual matters and the inner knowledge of nurse and patient as they participate together in the transpersonal caring processNurses share their genuine selfPatient’s spiritual strength is recognized,

supported, encouragedRN encourages openness to understanding of self

and othersLeads 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 assessedSystems of care

Wholly compensatoryPartially compensatorySupportive-educative

Imogene King

A Theory for Nursing: Systems, Concepts, Process (1981)

Focused on persons, their interpersonal relationships, and social contexts with three interacting systemsPersonalInterpersonal Social

Emphasizes goal attainment and patient’s involvement in setting goals (Goal Attainment Model)

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 attentionTherapeutic interpersonal relationship

Survival of the patientPatient’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 careFounder of Transcultural nursingPatients 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

Theory-Based PracticeOccurs 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

Benefits

Explain practice to othersPasses on knowledge to studentsContributes to professional

autonomyDevelops analytical skills,

challenges thinking, and clarifies your values and assumptions

Theory-Based ResearchGreat strides have been made in the

last 25 years in nursing research Nursing research tests and refines the

knowledge base of nursingResearch 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

Bonnie M. Wivell, MS, RN, CNS

Chapter 14: The Health Care Delivery System

Health Care DeliveryThe four basic types of services

provide by the health care delivery systemHealth Promotion: remain healthyIllness prevention: reduce risk factorsDiagnosis & treatment: refined

methods of diagnosis allow for more effective treatment

Rehabilitation & LTC: restore function & independence; disease management

Health Care AgenciesGovernment: 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

Level of Health Care ServicesPrimary 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

Organizational Structures of Health Care AgenciesBoard of Directors: carry responsibility

for mission, quality of services, financesChief Executive Officer (CEO): overall

daily operationMedical Staff: physicians granted

privileges; organized by service/dept.Chief of staff work with CEO to make

important decisions about medical policyNursing Staff: RNs, LPNs, NAs and clerical

staff; organized according to unitsChief Nurse Executive (CNE) or Chief Nursing

Officer (CNO) today on Board of Directors, oversee nursing care

Nursing Organization GovernanceNurses govern themselves though the

organizationShared 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 initiativesJCAHO (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

Health Care DisparitiesDefined as differences in the quality of health

care provided to different populationsCan 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 TeamPhysiciansPhysician AssistantsPatient Care TechniciansDietitiansPharmacistsTechnologistsRespiratory TherapistsSocial WorkersTherapistsAdministrative Support Personnel:

admissions, medical records, billing, etc.

Nurse’s Role on TeamProvider of Care: direct hands on careEducator: teaching pt., family, new staff,

community, etc.Counselor: emotional support & problem solvingManager: organizes careResearcher: investigates how nursing

interventions impact patient outcomes Collaborator: works with patients, families &

team on agreed patient outcomesPatient Advocate: stands up for patient rights;

advocates for patient’s best interests at all times

Types of Nursing Care DeliveryFunctional 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

Financing Health CareIn 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

Economics of Nursing CareNursing accounted for 20-28% of the costs

of hospitalizations in 1980sTo 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

History of Health Care FinanceBefore 1945, 90% paid out of pocket or

charity careGrowth of Private Insurance → tax exemptRise of Public Insurance Programs (1965)Medicare

Part A = Hospital InsurancePart B = Medical Insurance (20% co-pay,

deductiblePart C = Managed care optionPart D = Prescription drug coverage

MedicaidFederal government contributes 50-76.8%

Personal (out-of-pocket) paymentWorker’s Compensation

Forces Changing Health CareManaged Care attempts to control

healthcare costs; health promotion not illness treatment

Health Maintenance Organization (HMO): health care services provided for a predetermined fixed feeCapitation: same amount paid to provider each

month regardless of whether services were provided or how much the services cost

Gatekeeper: PCP, responsible for referralsPreferred Provider Organization (PPO):

contracts with provider for discounted rate

Forces Changing Health CarePoint-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 CareAdvanced Practice Nurses: ambulatory and community settings

Case ManagerTriageUtilization reviewers to determine most appropriate and cost-efficient level of care

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 & redesigningPatient-centered care: patient at center of

activity and designing outcomesDecentralization: staff exercise own

judgmentCross-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

New Organizational ModelsFunctional 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

Continued Escalation of Health Care Costs

InflationNew Technology and DrugsIncreased Demand for Healthcare Services –

more elderly & uninsuredFraud and Abuse of Payment Systems - $75

billion of US annual health expenditures may be attributable to fraud

Cost Containment MeasuresCenters 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

Health Care Finance ChallengesContinuing Crisis: Uninsured

AmericansQuality of CareLimits on Choice and ServicesProvider Restrictions & Financial

Incentives to Limit ServicesCost of Prescription DrugsMalpractice Costs & Impact of

Access to Care

Health Care ReformThe 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