Copyright ©2011 by Pearson Education, Inc. All rights reserved. Professional Nursing Practice:...

Copyright ©2011 by Pearson Education, Inc.All rights reserved.

Professional Nursing Practice: Concepts and Perspectives, Sixth EditionBlais • Hayes

CHAPTERCHAPTER

Professional Nursing PracticeConcepts and Perspectives

Sixth Edition

Socialization to Professional Nursing Roles

2

Hallmark FeaturesHallmark Features

• A focus on foundational knowledge A focus on foundational knowledge related to professional nursingrelated to professional nursing– Includes nursing history, nursing theory, Includes nursing history, nursing theory,

ethics, and legal aspects, etc.ethics, and legal aspects, etc.

• An overview of professional nursing roles, An overview of professional nursing roles, issues, and changes in the professionissues, and changes in the profession– Discusses nurses as healthcare providers, Discusses nurses as healthcare providers,

learners and teachers, and leaders.learners and teachers, and leaders.

Learning Objective 2.1Learning Objective 2.1

Discuss professionalism and nursing.Discuss professionalism and nursing.

Common Mistakes (cont’d)Common Mistakes (cont’d)

• writing an unattainable, unrealistic writing an unattainable, unrealistic objectiveobjective

• writing objectives unrelated to stated goalwriting objectives unrelated to stated goal

• cluttering an objective with unnecessary cluttering an objective with unnecessary informationinformation

• making an objective too general so that making an objective too general so that the outcome is not clearthe outcome is not clear

Nursing as a ProfessionNursing as a Profession

• A profession is distinguished from other A profession is distinguished from other kinds of occupations bykinds of occupations by– Requirement of specialized trainingRequirement of specialized training– Orientation toward service, either to a Orientation toward service, either to a

community or an organizationcommunity or an organization

• The standards are determined by its The standards are determined by its membersmembers

Nursing as a ProfessionNursing as a Profession

• The education involves a complete The education involves a complete socialization processsocialization process

• Debates about whether nursing is a Debates about whether nursing is a professionprofession

Challenges for the Nursing Challenges for the Nursing ProfessionProfession

• Level of entry into practiceLevel of entry into practice– Multiple levelsMultiple levels

• Associate degreeAssociate degree• DiplomaDiploma• Baccalaureate degreeBaccalaureate degree

• Gaps between education and practiceGaps between education and practice

• Professional identity: job versus careerProfessional identity: job versus career

Nursing as a Discipline and Nursing as a Discipline and ProfessionProfession

• History and trends in the education of History and trends in the education of nursingnursing– Earliest type of education was in hospitalsEarliest type of education was in hospitals– Emergence of baccalaureate and Emergence of baccalaureate and

associate degree programsassociate degree programs– Shift from diploma (hospital-based) Shift from diploma (hospital-based)

programs to associate and baccalaureateprograms to associate and baccalaureate

Nursing as a Discipline and Nursing as a Discipline and ProfessionProfession

• ANA 1965 position paperANA 1965 position paper– Proposing master’s degree as minimum Proposing master’s degree as minimum

education for entry level nurseeducation for entry level nurse

• Definition of profession, six Definition of profession, six conceptualizationsconceptualizations– A discipline is a branch of knowledgeA discipline is a branch of knowledge– Disciplines are dividedDisciplines are divided

• Academic–research and educationAcademic–research and education

Professional–Component of Professional–Component of Clinical PracticeClinical Practice

• Standards of clinical nursing practiceStandards of clinical nursing practice– Reflect values and prioritiesReflect values and priorities– Provide direction for professional nursing Provide direction for professional nursing

practicepractice– Provide a framework for evaluationProvide a framework for evaluation

Define the Professions Define the Professions AccountabilityAccountability

• ANA established standards of clinical ANA established standards of clinical nursing practicenursing practice– Six standards of practice known as nursing Six standards of practice known as nursing

processprocess– Nine standards of professional Nine standards of professional

performanceperformance


Describe socialization to professional Describe socialization to professional nursing.nursing.

Professional SocializationProfessional Socialization

• Socialization is a learned processSocialization is a learned process

• Professional socialization is to internalize a Professional socialization is to internalize a professional identityprofessional identity

• Social control is intrinsicSocial control is intrinsic– Capacity of a social group to regulate itself Capacity of a social group to regulate itself

through conformity and adherence to group through conformity and adherence to group normsnorms• Sanctions are used to enforce normsSanctions are used to enforce norms• Norms become internalized standardsNorms become internalized standards

Professional SocializationProfessional Socialization

• Agents of socialization are the people Agents of socialization are the people who initiate the socialization processwho initiate the socialization process– Children Children –– family, teachers, peers, media family, teachers, peers, media– Adults Adults –– superiors, subordinates in the superiors, subordinates in the

workplace, peers, people of other social workplace, peers, people of other social groupsgroups

– Nursing students Nursing students –– clients, faculty, health clients, faculty, health professionals, and professional colleaguesprofessionals, and professional colleagues

– Nursing Nursing –– preceptors, mentors, staff preceptors, mentors, staff development on the jobdevelopment on the job


Compare socialization models.Compare socialization models.

Process of Professional Process of Professional SocializationSocialization

• Models that describe the process of Models that describe the process of socialization socialization – SimpsonSimpson– HinshawHinshaw– DavisDavis


• Simpson ModelSimpson Model– Three phasesThree phases

• ProficiencyProficiency• AttachmentAttachment• InternalizationInternalization


• Hinshaw ModelHinshaw Model– Three phasesThree phases

• TransitionTransition• AttachmentAttachment• InternalizationInternalization

– Value and standardsValue and standards


• Davis ModelDavis Model– Six stagesSix stages

• Initial innocenceInitial innocence• Labeled recognition of incongruityLabeled recognition of incongruity• ““Psyching out”Psyching out”• Role simulationRole simulation• Provisional internalizationProvisional internalization• Stable internalizationStable internalization


• Ongoing professional socialization and Ongoing professional socialization and resocializationresocialization– Process does not terminate with Process does not terminate with

graduation or start of a new jobgraduation or start of a new job


• Three models of career stages or Three models of career stages or developmentdevelopment– Kramer’s Postgraduate Resocialization ModelKramer’s Postgraduate Resocialization Model

• Reality shockReality shock

– Dalton’s Career Stages ModelDalton’s Career Stages Model• Development of competencies derived from Development of competencies derived from

experienceexperience

– Benner’s Stages from Novice to ExpertBenner’s Stages from Novice to Expert• Implications of teaching and learningImplications of teaching and learning


Analyze elements of and boundaries for Analyze elements of and boundaries for nursing roles.nursing roles.

Role TheoryRole Theory

• Role theory emerged from sociologyRole theory emerged from sociology

• A role is a set of expectations A role is a set of expectations associated with a position in societyassociated with a position in society


• Elements of rolesElements of roles– IdealIdeal

• The socially prescribed or agreed-upon rights The socially prescribed or agreed-upon rights and responsibilities associated with the roleand responsibilities associated with the role

– PerceivedPerceived• How a person believes he or she should How a person believes he or she should

behave in this rolebehave in this role

– PerformedPerformed• What the person actually doesWhat the person actually does


• Role performance factors includeRole performance factors include– Health statusHealth status– Personal and professional valuesPersonal and professional values– Needs of clients and support personNeeds of clients and support person– Politics of employing agencyPolitics of employing agency


• Role transition is the process by which Role transition is the process by which a person assumes or develops a new a person assumes or develops a new rolerole

• Two components associated with role Two components associated with role behaviorsbehaviors– NormsNorms– ValuesValues


• Role transition is influenced by many Role transition is influenced by many factorsfactors– IndividualIndividual– InterpersonalInterpersonal– OrganizationalOrganizational

Boundaries for Nursing RolesBoundaries for Nursing Roles

• Five determinants form boundaries for Five determinants form boundaries for nursing rolesnursing roles– Theoretical and conceptual frameworksTheoretical and conceptual frameworks– The nursing processThe nursing process– Standards of nursing practiceStandards of nursing practice– Nursing practice actsNursing practice acts– National and international codes of ethicsNational and international codes of ethics


Discuss ways to manage role stress and Discuss ways to manage role stress and strain while enhancing professional strain while enhancing professional

identity.identity.

Role Stress and Role StrainRole Stress and Role Strain

• Factors associated with role stress for Factors associated with role stress for nursesnurses– Little control in the jobLittle control in the job– High demandsHigh demands– Few supportive relationshipsFew supportive relationships


• Role stress may create role strainRole stress may create role strain– Common role stress problemsCommon role stress problems– Role ambiguityRole ambiguity– Role conflictRole conflict– Role incongruityRole incongruity– Role overload or underloadRole overload or underload– Role over-qualification or under-Role over-qualification or under-

qualificationqualification


• Four major causes for role conflict for Four major causes for role conflict for nursesnurses– Professional bureaucratic work conflictProfessional bureaucratic work conflict– Different views concerning what nursing is Different views concerning what nursing is

and should beand should be– Discrepancy between the nursing and Discrepancy between the nursing and

medical view of what the nurse’s role medical view of what the nurse’s role should beshould be


• Strategies for relieving role stressStrategies for relieving role stress– Priority setting and time managementPriority setting and time management– Rewriting job descriptions for clarityRewriting job descriptions for clarity– Integrating multiple roles into a larger Integrating multiple roles into a larger

wholewhole

Characteristics of a Positive Characteristics of a Positive Self-ConceptSelf-Concept

• Characteristics of a person with a positive Characteristics of a person with a positive self-conceptself-concept– Future orientationFuture orientation– Copes with life’s problems and Copes with life’s problems and

disappointmentsdisappointments– Helps others and accepts helpHelps others and accepts help– Can see and value uniqueness in all Can see and value uniqueness in all

individualsindividuals– Feels emotion but does not allow feelings to Feels emotion but does not allow feelings to

affect behavioraffect behavior

Characteristics of a Positive Characteristics of a Positive Self-ConceptSelf-Concept

• To develop a positive self-conceptTo develop a positive self-concept– Accept your present self but have a better Accept your present self but have a better

self in mindself in mind– Set attainable goalsSet attainable goals– Develop expertiseDevelop expertise

Preventing BurnoutPreventing Burnout

• Personal goal settingPersonal goal setting– Long- and short-term goalsLong- and short-term goals

• Problem identificationProblem identification– What is causing the stressWhat is causing the stress

• Problem-solving strategiesProblem-solving strategies– See Table 2–3 See Table 2–3

• Time management skillsTime management skills– DelegationDelegation

Overcoming ProcrastinationOvercoming Procrastination

• Caring for one’s selfCaring for one’s self



CHAPTERCHAPTER


Sixth Edition

Historical Foundations of Professional Nursing

3

Learning Objective 3.1

Discuss the historical development of nursing from ancient times to the present.

Primitive societies Traditional female roles

History of Nursing

Ancient civilizations Midwives, wet nurses Belief about disease imbedded in superstition

and magic Earliest recording of healing practice is a 4,000

year old tablet Earliest documentation of law governing

medicine is Code of Hammurabi dating to 1900 B.C.

History of Nursing

Egyptian culture Ebers papyrus oldest medical text,

approximately from 1550 B.C. Mummification or embalming

Hebrew culture Mosiac Health Code

Christian culture The Bible mentions nurses in Old Testament Ancient civilizations

History of Nursing

African culture Midwife, herbalist, wet nurses, caregivers

Indian culture Male nurses

China Acupuncture Herbal remedies

History of Nursing

Greece Mythology Hippocrates, father of medicine

Rome Public sanitation

History of Nursing


Discuss the role of religion in the development of nursing.

Role of religion Benevolence as a Christian value Parabolani Brotherhood Knighthoods

Knights Hospitallers of St. John of Jerusalam Teutonic Knights Knights of Lazarus

Specialized institutions supported by the church

History of Nursing

Other groups Military and secular orders Islamic women Sisters of Charity Deaconess groups

History of Nursing


Discuss the influence of war on the development of nursing.

Deaconess Institute at Kaiserwerth, Germany Recognized the need for services of women in

caring for the sick, poor, children, and female prisoners

Developed a training school for nurses at Kaiserwerth

Deaconess movement spread to 4 continents

Development of Modern Nursing

Florence Nightingale Kaiserwerth pupil Recruited during the Crimean War to care for

soldiers Transformed the environment by setting

standards Used the honorarium to develop the

Nightingale Training School for Nurses

Development of Modern Nursing

Augustinian Sisters in Canada – first hospital in Canada, 1639

Sisters of Charity of St. Joseph’s in Maryland – Mother Elizabeth Seton

Religious orders developed nursing education and nursing services

Catholic and Protestant churches developed hospitals across the country

Development of Nursing in America


Describe the contributions of selected nurses to nursing and society.

Related to the need to care for sick and injured soldiers Civil War

Dorothea Dix Louisa May Alcott Harriet Tubman Sojourner Truth


Related to the need to care for sick and injured soldiers World War I

Vassar Training Camp combined university and hospital training – Isabel Stewart

Army School of Nursing – Annie Goodrich World War II

United States Cadet Nurse Corps


Nursing Image

• The following job description was given to floor nurses by a hospital in 1887:

• In addition to caring for your 50 patients, each nurse will follow these regulations:

• see 1887 Job Description 1887 Job Description

1903: North Carolina, New Jersey, New York, Virginia enacted voluntary licensure laws Regulated the use of the title Registered Nurse

(RN) 1915: American Nurses Association draft of a

model nurse practice act 1923: All 48 states had nursing licensure

laws or registration


1935: Mandatory licensure act passed in New York that went into effect in 1949

1971: Idaho became the first state to recognize advanced practice

1992: Eddie Bernice Johnson was the first nurse to be elected to the United States House of Representatives



Analyze the contributions of selected nurses and the nursing profession to society from a historical

perspective.

The founders Rufida Jeanne Mance Florence Nightingale Mary Seacole Clara Barton Lucy Osborne Linda (Melinda) Richards

Historical Leaders in Nursing

The founders Mary Mahoney Ceclia Makiwane Lillian Wald Mary Breckinridge Loretta C. Ford


The men John Ciudad St. Camillus de Lellis James Derham Walt Whitman Luther Christman Richard Henry Carmona


The risk takers Clara Maass Edith Cavell Sharon Lane Barbara Fassbinder


The social reformers Sojourner Truth Dorothea Lynde Dix Harriet Tubman Lavinia Dock Margaret Sanger Mary Elizabeth Carnegie Mabel Staupers


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.

Hallmark Features


Compare and contrast the history of nursing and the history of caring.

“Modern” history is the idea of caring Symbiotic relationship between the history of

Nursing Caring Women & Feminist Movement

Nursing: A History of Caring

Learning Objective 3.7Discuss the development of professional nursing

organizations and their role in advocating for nurses and healthcare.

Nursing organizations are divided into three types Those that represent all nurses Those that meet the needs of nurses within

specialties Those that represent special interests

Professional Nursing Organizations

American Nurses Association (ANA) National professional organization for all

registered nurses in the United States Headquarters – Washington, D.C. The name Nurses Associated Alumnae was

changed to ANA in 1911 Became a federation of state nurses’

associations in 1982


American Nurses Association (ANA) Mission: To foster high standards of nursing,

promote the rights for nurse in the workplace, project positive view and lobby Congress on healthcare issues

Official publication: American Journal of Nursing and American Nurse


National Student Nurses’ Association (NSNA)

Established in 1952 Mission: To organize, represent, and mentor

students preparing for initial licensure as registered nurses

Official publication: Imprint


National League of Nursing (NLN) Mission: To promote excellence in nursing

education to build a strong and diverse nursing workforce

Began in 1893 as the American Society of Superintendents of Training Schools for Nurses, later the National League for Nursing Education (NLNE)


National League of Nursing (NLN) In 1952, the NLNE and the Association for

Collegiate Schools of Nursing and the National Organization for Public Health Nursing combined to form the NLN

Official publication: Nursing Education Perspectives


American Association of Colleges of Nursing (AACN) National voice for baccalaureate and higher-

degree nursing education programs Official publication: Journal of Professional

Nursing


International Council of Nurses (ICN) Founded in 1899 as the world’s first and widest

international organization for health professionals

Mission: To represent nursing worldwide, advancing the profession and influencing health policy


International Council of Nurses (ICN) Five core values of ICN

Visionary leadership Inclusiveness Flexibility Partnership Achievement

Official publication: International Nursing Review


Sigma Theta Tau International Founded in 1922 as an international honor

society for nursing Member of the Association of College Honor

Societies


Sigma Theta Tau International Mission: To support learning, knowledge, and

professional development of nurses committed to make a difference in health worldwide

Official publication: Journal of Nursing Scholarship


Specialty Nursing Organizations Represent special interests of nurses from a

practice perspective Provide educational opportunities for members

Special-Interest Organizations Address special needs of nurses from minority

groups


Chapter 1The Professional Nurse

Chapter 1The Professional Nurse

Leddy & Pepper’s Conceptual Bases of Professional Nursing

Introduction

Nurse, nourish, nurture: all come from Latin root nutrire

Professional nurses Assume ultimate accountability for client

outcomes Supervise, educate LPN/LVNs, UAP Use science as basis for professional practice,

art when modifying care approaches

Introduction (cont’d)

Six essential features of professional nursing: Provide caring relationship that promotes

health, healing Assess, attend to full range of human

responses, experiences Integrate subjective, objective data

Introduction (cont’d)

Six essential features of professional nursing: Use professional judgment, critical thinking Use scholarly inquiry Strive for social justice by influencing social,

public policy

Characteristics of Professional Nursing Practice: The Hood

Professional Nurse Contributions Model Nurses: members of interdisciplinary team

Circular form of model designates how interprofessional health care team surrounds health care consumers

Outer circle emphasizes importance of all team members working cohesively for benefit of care recipients

Characteristics of Professional Nursing

Practice: The Hood (cont’d)

Professional Nurse Contributions Model Outer circle of model

Altruistic attitude Caring Compassion Commitment Competence Confidence

Characteristics of Professional Nursing

Practice: The Hood (cont’d)

Professional Nurse Contributions Model Innermost circle depicts

Clinical skills Cognitive skills Communication skills

The Multiple Roles of the Professional Nurse

Caregivers Client advocate Teacher Change agent Coordinator Counselor Colleague Lifelong learner

Challenges to the Returning Professional Nursing

Student

Nurses who return to school assume role of student, resulting in many lifestyle changes: Chaos, personal sacrifices Increased expenses for school needs Decreased time with family Lack of support from work environment Entering unfamiliar learning situations

Skills for Educational Success

In ideal educational situations, students and faculty interact with each other as colleagues Traditional education or Authoritarian expert Educative-caring education or Egalitarian

interactions Nurses

Focus educational efforts on refining previously learned skills while establishing theoretical foundations for professional practice

Skills for Educational Success (cont’d)

Reading Reading assigned material

Listening, speaking Effective speaking, listening Asking questions to avoid making errors in

education, health care settings

Skills for Educational Success (cont’d)

Writing Essential mode of communication for nurses Must use critical, reflective thinking Learning to evaluate information, especially

from world wide web. Effective writing, appropriate writing style

Question A diploma graduate who has been a practicing RN

for 5 years is considering returning to school for a BSN. The nurse says she’s not sure it is worth the money to return to school. What emotion is this nurse possibly experiencing?

A.Discomfort, chaosB.Fear, angerC.Acceptance, certaintyD.Jealousy, resentment

Answer

A. Discomfort, chaos Rationale: Nurses who return to school

assume the role of student, which results in many lifestyle changes. The added responsibilities of returning to school may result in chaos and personal sacrifices.

Professional Image and Physical Appearance

Nursing caps became obsolete in 1970s White uniforms abandoned for colorful scrub

suits, dresses Cartoons, other distracting designs in scrub

attire fail to project professional image

Professional Image and Physical Appearance

(cont’d)

Cleanliness, safety are priorities: Clean clothing, well-manicured natural nails Clean shoes decrease spread of infections Avoid dangling earrings, necklaces to prevent

injury Tongue piercing impairs clarity of nurse’s

speech Visible body piercing, extensive tattooing

might create distress for some clients

Organizational Skills for Educational and

Professional Success

Key organizational skills for success: Managing information

Setting priorities to meet deadlines Organizing personal libraries, files Staying abreast of latest information

Organizational Skills for Educational and

Professional Success (cont’d)

Key organizational skills for success: Refine test-taking skills

Prepare for tests ahead of time Alleviate test anxiety

Managing personal time Keep schedule or calendar Learn to say no, ask for help

Socialization and Resocialization into the

Nursing Profession

Socialization: process of making someone ready for particular societal role Professional socialization

Formation, internalization of professional identity congruent with professional role


Nursing Profession (cont’d)

Resocialization: occurs when someone adapts role to new setting Significant environmental changes (changing

job, moving to different practice setting, returning to school) stimulate resocialization



Role Theory Role contains three key pieces: values,

attitudes, behaviors Students must adjust how they meet all

current life roles to avoid role conflict Role conflict: arises when roles assumed by

person compete with each other for time, attention



Shane’s Returning-to-School Syndrome Honeymoon - nurses feel energetic about

learning new things Conflict - turbulent negative emotions (anger,

helplessness, depression) Reintegration - nurses question why they

decided to pursue higher degree Integration - ability to blend original culture of

work with new culture of school


Nursing Profession (cont’d) Bridge’s Managing Transitions

People undergo transitions (psychological adaptations to changes) whenever exposed to changes

Three-step process to facilitate transitions: starts with ending, finishes with beginning: Letting go The neutral zone The new beginning

Development of a Professional Self-Concept

Encompasses Beliefs about oneself, personal interpretations

about past, present, future Development of professional self-concept (how

person perceives oneself as a nurse) follows same path as development of personal self

Personal self-concept cannot be separated from professional self-concept

Development of a Professional

Self-Concept (cont’d)

Encompasses Professional self-system emerges from

personal self Benner’s Novice-to-Expert Model

Describes stages in progression of patient care expertise that can result from practice nursing experience



Professional Nursing Roles Helping, teaching-coping Diagnostic, patient monitoring Effective management of rapidly changing

situations Administration, monitoring of therapeutic

interventions, regimens



Professional Nursing Roles Monitoring of, ensuring quality of health care

practices Organizational, work role competencies

Characteristics of a Profession

Authority to control its own work Exclusively unique body of knowledge Extensive period of formal training Specialized competence Control over work performance Service to society Self-regulation

Characteristics of a Profession (cont’d)

Credentialing systems to certify competence Legal reinforcement of professional

standards Ethical practice Creation of collegial subculture Intrinsic rewards Public acceptance


Three levels of education qualify people to take licensing exam: Associate’s Degree in Nursing (ADN) Diploma Nursing Program Baccalaureate Degree in Nursing (BSN)


Intellectual Characteristics Body of knowledge on which professional

practice is based Specialized education to transmit body of

knowledge to others Ability to use knowledge in critical, creative

thinking


Body of Knowledge Professional practice based on body of

knowledge derived from Experience (leading to expertise) Research (leading to theoretical foundations for

knowledge, practice) Liberal arts education serves as hallmark of

professional education


Specialized Education National Council of State Boards of Nursing

(NCSBN) coordinates efforts to license registered, practical nurses

Graduate nursing education programs offer advanced education

Postgraduate nursing education leads to doctorate in nursing

Using Knowledge by Critical Thinking

Nurses as critical thinkers exhibit these habits of mind: Confidence Contextual perspective Creativity Flexibility Inquisitiveness

Using Knowledge by Critical Thinking (cont’d)

Nurses as critical thinkers exhibit these habits of mind: Intellectual integrity Intuition Open-mindedness Perseverance Reflection


Creative Thinking Ability to think outside what usually is done Results in novel approaches to client care Must be tempered by critical thinking to avoid

hazardous solutions


Reflective Thinking Purposeful analysis about what one is currently

doing, what one has done Reflection on action a retrospective analysis of

action taken

Independent Clinical Decision Making

Independent decisions to solve problems in clinical practice

Nurses act prematurely because of inadequate information, insufficient time to generate alternative approaches

Nursing Process

Systematic thinking method to process information about specific client-care situations

Problem-solving approach that consists of five steps: Assessment Diagnosis Planning Implementation Evaluation

Nursing Process (cont’d)

Effective use of nursing process requires critical, creative, reflective thinking

Question To avoid hazardous solutions, the professional nurse

must temper creative thinking with_________.A.Contextual perspective B.Reflective thinkingC.Reflective actionD.Critical thinking

Answer

D. Critical thinking Rationale: Creative thinking is the ability to

think outside what usually is done and results in novel approaches to client care. It must be tempered with critical thinking to avoid hazardous solutions.

Service to Society

Students still enter nursing to help people or to care for people

Five conceptualizations of caring: Caring as human trait Caring as moral imperative Caring as affect Caring as interpersonal interaction Caring as therapeutic intervention

Service to Society (cont’d)

International Council of Nurses (ICN), American Nurses Association (ANA)

State boards of nursing provides copies of Nurse Practice Act (NPA) upon initial licensure Provide legal reinforcement against incompetence Specifies legal definition of nursing practice,

minimal education preparation for licensure Imposes penalties for illegal, unethical, negligent

practice

Autonomy and Self-Regulation

Autonomy Independence, willingness to take risks,

accountability for one’s actions, self-determination, self-regulation.

State Boards of Nursing (SBN) Regulates professional nursing practice by

issuing professional licenses to qualified individuals

Autonomy and Self-Regulation (cont’d)

National Council of State Boards of Nursing (NCSBN) Developed licensure examinations for

professional, practical nursing

A Collegial Subculture (Accrediting, Professional,

and Student Nursing Organizations)

Professional nursing organizations: two categories: General-purpose nursing organizations Specialized nursing organizations

Participation in specialty nursing organization links nurses who practice in particular area Creates subcultures of nurses with common interests

within nursing profession

A Collegial Subculture (Accrediting, Professional,

and Student Nursing Organizations) (cont’d)

National League for Nursing American Association of Colleges of Nursing National Council of State Boards of Nursing American Nurses Association The International Council of Nurses Sigma Theta Tau International National Student Nurses’ Association

Question

What is the purpose for nurses to participate in professional organizations?

A.Links to other nurses in specific area of practiceB.Creates sense of moral belonging, imperativeC.To have regulation of professional nursing

practiceD.Boost ability to make ethical practice decision

Answer

A. Links to other nurses in specific area of practice

Rationale: Professional nursing organizations foster the development of collegial relationships among nurses. Participation in a specialty nursing organization links nurses who practice in a particular area and creates subcultures of nurses with common interests within the nursing profession.

Ethical Practice

Guiding principles: Respect for human dignity, uniqueness Protection of confidential information Acts to safeguard persons Responsibility, accountability for nursing

actions Maintenance of nursing competence

Ethical Practice (cont’d)

Guiding principles: Use of informed judgment Participation in research, other activities Participation in activities to improve,

implement nursing standards Integrity to profession Collaboration with other health care

professionals, consumers

Societal Acceptance: Legal Reinforcement of

Professional Standards

Emerging profession because of barriers to fulfilling all criteria for professional stature Multiple levels of education for entry to

practice Specialists in particular area of practice Failure to unite, lack of working collectively Nurses viewed as hired help Disparity in salary related to multiple levels of

education

Summary and Significance to Practice

Professional nursing: Involves change, growth throughout various

stages of career Moral, ethical practice needed to provide what is

best for clients

Summary and Significance to Practice (cont’d)

Effective implementation of roles for professional nursing requires: Deep commitment, authentic caring Genuine compassion, technical competence Self-confidence, cognitive, clinical,

communication skills Ability to work in, cope with non-stop change,

highly complex systems, chaos



CHAPTERCHAPTER


Sixth Edition

Ethical Foundations of Professional Nursing

4



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,





Explain how nurses can help clients clarify their values to facilitate ethical decision

making.



Challenges and Opportunities

• Values Conflicts – Nurses’ established values and beliefs may

conflict with clients’

• Ethical-Legal Conflicts – “Right” thing to do versus what is legal



Values

• Highly personal• Freely chosen • Enduring beliefs or attitudes about the

worth of a– Person – Object – Idea – Action



Values

• Derived from– Cultural, ethnic, religious background – Societal traditions– Peer group – Family

• Form the basis for behavior, guide choices and decisions– Moral– Nonmoral



Values

• Exist within a person and affect the person’s relationship with others

• Awareness of one’s values is necessary to make ethical decisions



Values Transmission

• Learned through observation and experience

• Family, community, cultural and society influences

• Values are acquired gradually



Values Transmission

• Professional values of the nurse are acquired during socialization into nursing from– Nursing experience – Teachers – Peers



Values Transmission

• Nurses hold values that relate to competence and compassion

• Nurses need to be– Value-neutral– Nonjudgmental



Values Clarification

• Process by which individual values are identified, examined, and developed – No one set of values is right for everyone – Identified values can be retained or changed

• Act on free choice• Fosters personal growth



Values Clarification

• “Valuing process” components include– Cognitive– Affective– Behavioral



Identifying Personal Values

• Nurses need to understand their values about– Life– Health– Illness– Death

• Ability to identify personal values leads to better understanding of situations that may affect care



Helping Clients Identify Values

• Help identify how values influence and relate to a particular health problem – List alternatives– Examine possible consequences of choices – Choose freely– Feel good about the choice – Affirm the choice– Act on the choice – Act with a pattern




Explain the uses and limitations of professional codes of ethics.



Morals and Ethical Behavior

• Morals are personal ethics guiding behavior and choice

• Ethics beliefs of a particular group• Similar to ethics • Individual’s personal standards of what is

right and wrong in conduct, character, and attitude

• Ethics refers to the moral standards of a particular group




Discuss how cognitive development, values, moral frameworks, and codes of ethics

affect decision making.



Moral Development

• Process of learning what ought to be done and what ought not to be done – Morality – Moral behavior – Moral development



Theories of Moral Development

• Lawrence Kohlberg – Theory focuses on structure of thought about

moral issues – Moral development progresses through three

levels and six stages – Not always linked to age or growth and

development




• Lawrence Kohlberg – People progress to different level of moral

development, ranging from Egocentric actions Concern for society




• Kohlberg’s Levels and Stages – Level I premoral or preconventional

Stage 1: Punishment and obedience orientation Stage 2: Instrumental-relativist orientation

– Level II conventional Stage 3: Interpersonal concordance Stage 4: Law and order orientation

– Level III postconventional, autonomous or principled Stage 5: Social contract, legalistic orientation Stage 6: Universal-ethical principles




• Defining Issues Test (DIT)– Carol Gilligan – Challenged Kohlberg’s theory in

Its application to females Absence of concepts of caring, compassion,

relationships, and responsibility




• Gilligan’s care perspective is organized around– Responsibility– Compassion (care)– Relationships




• Justice or fairness based on idea of equality– Typically followed by men

• Ethic of care– Typically followed by women

• Gilligan’s stages – Stage 1: Caring for oneself – Stage 2: Caring for others – Stage 3: Caring for oneself and others



Moral and Ethical Theories or Frameworks

• Two classifications of theories of ethics– Consequential: Teleology – Nonconsequential: Deontology

• Virtue ethics • Caring



Moral and Ethical Principles

• Ethical principles that help guide decision making– Autonomy – Respect for person– Nonmaleficence – Beneficence– Justice – Fidelity– Veracity




Discuss common bioethical issues currently facing healthcare professionals.



Ethics in Nursing

• Ethics– Is a study of morality and an activity– Refers to practices, beliefs, and standards of

behavior

• Bioethics – Applies to life sciences and healthcare in an

in disciplinary settings



Ethics in Nursing

• Nurses are accountable for their ethical conduct

• Scopes and Standards of Practice




Analyze ways in which nurses can enhance their ethical decision making abilities.



Nursing Codes of Ethics

• Formal statement of a group’s ideal and values

• Higher than legal standards • Established by the International Council of

Nurses – First adopted in 1953, revised 1973



Nursing Codes of Ethics

• ANA adopted Code of Ethics in 1950, revised 2001 – Code of Ethics for Nurses with Interpretive

Statements



ANA Nursing Code of Ethics

• Purpose – Succinct statement of ethical obligations and

duties – Nonnegotiable ethical standard – Expression of nursing’s commitment to

society



Canadian and Australian Nurses Code of Ethics

• Purposes – Inform the public of minimum standards – Professional commitment – Outline ethical considerations – Guidelines for professional behavior – Guide for self-regulation – Responsibility when assuming care for clients



Types of Ethical Problems

• Decision-focused – What should I do?

• Action-focused – Moral distress. What can I do?



Making Ethical Decisions

• Catalano’s five step ethical decision-making algorithm for the nurse – Identification of potential ethical dilemma – Collect, analyze, and interpret data – State the dilemma – Can be resolved – Cannot be resolved




Identify the moral principles involved in ethical decision making.




• Questions to ask – For whom is the decision being made? – Who should be involved in making the

decision, and why? – What criteria should be used in determining

who makes the decision? – What degree of consent is needed by the

subject?




• When compromise is necessary, the desirable outcome is preservation of each person’s integrity



Strategies to Enhance Ethical Decision Making

• Become aware of one’s own values and ethical aspects of nursing situations.

• Be familiar with nursing code of ethics. • Understand the values of other health care

professionals.



Strategies to Enhance Ethical Decision Making

• Participate on ethics committees. • Participate in or establish a nursing ethics

group. • Participate in or establish educational

ethics rounds.




Describe the advocacy role of the nurse.



Advocacy

• Advocacy = providing support for a patient’s rights/best interests

• Three models of nurse advocacy– Rights protection – Values-based – Respect-for-persons



Advocacy

• To be an advocate a nurse needs– Self-knowledge – Professional knowledge

• Advocacy encompasses range of approaches– Legal– Self– Collective– Citizen



Advocacy

• Defining attributes of patient advocacy include – A therapeutic nurse-patient relationship in

which to secure patient’s freedom and self-determination

– Promoting and protecting patients’ rights to be involved in decision making and informed consent

– Acting as an intermediary between patients and their families or significant others, and between them and health care providers



Advocacy

• An advocate support clients decisions can involve– Action– Nonaction



Advocacy

• Underlying client advocacy are clients individual rights– To select values deemed necessary to save

own life– To decide which course of action will best

achieve the chosen values– To dispose of values in a way they choose

without coercion by others



Advocacy

• To be a client advocate involves– Being assertive– Recognizing that the rights and values of their

clients and families must take precedence when they conflict with those of health care providers

– Ensuring that clients and families are adequately informed to make decisions about their own health and healthcare



Advocacy

• To be a client advocate involves– Being aware that personal conflicts may arise

over issues that require consultation, confrontation, or negotiation between the nurses and administrative personnel or between the nurse and physician

– Working with unfamiliar community agencies or lay practitioners

– Political action

Legal Foundations of Professional Nursing

5

Hallmark FeaturesHallmark Features

• A focus on foundational knowledge A focus on foundational knowledge related to professional nursingrelated to professional nursing– Includes nursing history, nursing theory, Includes nursing history, nursing theory,

ethics, and legal aspects, etc.ethics, and legal aspects, etc.

• An overview of professional nursing roles, An overview of professional nursing roles, issues, and changes in the professionissues, and changes in the profession– Discusses nurses as healthcare providers, Discusses nurses as healthcare providers,

learners and teachers, and leaders.learners and teachers, and leaders.


Identify primary sources of law and Identify primary sources of law and

types of legal actions.types of legal actions.

Challenges and Opportunities Challenges and Opportunities

• Scientific development and new Scientific development and new technological advances technological advances – Critical care units – Surgical technologies Critical care units – Surgical technologies

• Genetic engineering and the Genetic engineering and the identification of disease-carrying genesidentification of disease-carrying genes

Challenges and OpportunitiesChallenges and Opportunities

• Changes in the health care system Changes in the health care system – Providing new roles for nursing Providing new roles for nursing

• Advanced practice nurse (APN)Advanced practice nurse (APN)

• Expanded roles = added responsibilitiesExpanded roles = added responsibilities

The Judicial System The Judicial System

• Four primary sources of lawFour primary sources of law– ConstitutionsConstitutions– StatutesStatutes– Administrative lawsAdministrative laws– Decisions of court (common law)Decisions of court (common law)

Types of Legal Actions Types of Legal Actions

• Civil (private) Civil (private) – Between individualsBetween individuals

• Criminal Criminal – Disputes between an individual and societyDisputes between an individual and society


Describe the nurse practice act as Describe the nurse practice act as

the legal boundary of nursing.the legal boundary of nursing.

Safeguarding the Public Safeguarding the Public

• Permissive laws, first laws applicable to Permissive laws, first laws applicable to nursing in the United Statesnursing in the United States– No restrictions on nursing practiceNo restrictions on nursing practice

• 1923 all states had nurse registration 1923 all states had nurse registration laws laws

Safeguarding the Public Safeguarding the Public

• State authority responsible for nursing State authority responsible for nursing practice within the state is the state practice within the state is the state board of nursing board of nursing

• National Council of State Boards of National Council of State Boards of Nursing (NCSBN)Nursing (NCSBN)

Nurse Practice Acts Nurse Practice Acts

• Guides for states in developing their Guides for states in developing their nurse practice actsnurse practice acts

• State board of nursing is the governing State board of nursing is the governing body for regulationbody for regulation

• State boards of nursing and state State boards of nursing and state nurses association collaborate with nurses association collaborate with nurse practice actsnurse practice acts

Nurse Practice Acts Nurse Practice Acts

• Nurse Practice acts includeNurse Practice acts include– Authority of board of nursingAuthority of board of nursing– Scope of Practice Scope of Practice – Licenses and titlesLicenses and titles– Requirements for licensure Requirements for licensure – Protects titlesProtects titles– Identifies grounds for disciplinary actionIdentifies grounds for disciplinary action

Credentialing Credentialing

• Determines and maintains competenceDetermines and maintains competence

Licensure Licensure

• Process by which state government Process by which state government agency grants permission to an agency grants permission to an individual to engage in a given individual to engage in a given profession who has proven competency profession who has proven competency

• Types of licensure Types of licensure – Mandatory Mandatory – Permissive Permissive

Licensure Licensure

• Licenses may be revoked for just causeLicenses may be revoked for just cause– Nurse may appeal decision Nurse may appeal decision

• One state licensure vs. practices across One state licensure vs. practices across state linesstate lines– Nurse Licensure Compact Model Nurse Licensure Compact Model

Legislation provides information Legislation provides information

• Advanced practice Advanced practice – Many states require different license Many states require different license

Controversy Regarding Controversy Regarding LicensureLicensure

• ANA’s position ANA’s position – licensing is function of professional association, licensing is function of professional association,

not the lawnot the law

• Registration Registration – Listing an individual’s name and other Listing an individual’s name and other

information on an official roster information on an official roster

• Certification Certification – Validation that a nurse has met minimum Validation that a nurse has met minimum

standards of competencestandards of competence


• Accreditation Accreditation – Accredited status given by an organization to Accredited status given by an organization to

institutions, programs, or services that meet institutions, programs, or services that meet predetermined standards and criteria predetermined standards and criteria

• Standards of care Standards of care – Used to evaluate quality of care Used to evaluate quality of care – Derived from multiple sources Derived from multiple sources – Developed from ANA standards of nursing Developed from ANA standards of nursing

practice practice


Entry to practiceEntry to practice

•BSNBSN

•ANDAND

•Hospital DiplomaHospital Diploma

Potential Liability Areas Potential Liability Areas

• NegligenceNegligence– Conduct lacking due careConduct lacking due care

• Malpractice Malpractice – Professional misconduct or the failure to Professional misconduct or the failure to

meet the requisite standard of care meet the requisite standard of care

• May be intentional or unintentionalMay be intentional or unintentional• Five elements of proof of nursing Five elements of proof of nursing

malpractice malpractice

Potential Liability Areas Potential Liability Areas

• Nursing negligent actions may occur Nursing negligent actions may occur with with – Medication errors Medication errors – Burning a client Burning a client – Client falls Client falls – Failure to assess and take appropriate Failure to assess and take appropriate

actionaction

Strategies to Reduce Medical Strategies to Reduce Medical Errors Errors

• Increase staff Increase staff

• Experienced nurses Experienced nurses

• Reduce interruptions and distractions Reduce interruptions and distractions

• Improve information exchangeImprove information exchange

• Nurses obtain their own liability Nurses obtain their own liability insurance coverageinsurance coverage– Available through the ANA or private Available through the ANA or private

companiescompanies


• Documentation Documentation – Medical record is legal source of Medical record is legal source of

information about patientinformation about patient

• Credible document must be Credible document must be – Comtemporaneous Comtemporaneous – Accurate Accurate – Truthful Truthful – AppropriateAppropriate


• Delegation Delegation – Process of a nurse to direct another person Process of a nurse to direct another person

to perform nursing taskto perform nursing task

• Nurse is accountable and responsible Nurse is accountable and responsible for the care given his or her clientsfor the care given his or her clients

• NCSBN developed Decision Tree for NCSBN developed Decision Tree for DelegationDelegation


• AACN five factors affecting delegationAACN five factors affecting delegation– Potential for harmPotential for harm– Complexity of taskComplexity of task– Problem solving and necessary Problem solving and necessary

innovationsinnovations– Unpredictability of outcomeUnpredictability of outcome– Level of interaction with client requiredLevel of interaction with client required


Discuss essential legal aspects of Discuss essential legal aspects of malpractice, informed consent, adverse malpractice, informed consent, adverse

event reports, DNR orders, euthanasia, and event reports, DNR orders, euthanasia, and death-related issues.death-related issues.

RestraintsRestraints

• Limit activity of clientLimit activity of client– ChemicalChemical– PhysicalPhysical– Only used with physician’s written orderOnly used with physician’s written order

Informed ConsentInformed Consent

• An agreement when client accepts An agreement when client accepts treatment/proceduretreatment/procedure

• Nurse’s roleNurse’s role– Witness exchange between client and Witness exchange between client and

physician physician – Establish that client understands Establish that client understands – Witness client signatureWitness client signature


• Three major elements of informed Three major elements of informed consentconsent– Voluntarily given Voluntarily given – Client must be competent to understand Client must be competent to understand – Client receives adequate information to be Client receives adequate information to be

ultimate decision makerultimate decision maker


• Three groups who cannot provide Three groups who cannot provide consent consent – Minors Minors – Unconscious or injured Unconscious or injured – Mentally ill or incompetentMentally ill or incompetent

• Adverse events and risk management Adverse events and risk management – Record of an adverse or unusual Record of an adverse or unusual

occuranceoccurance

Adverse Events and Risk Adverse Events and Risk ManagementManagement

• Adverse event or incident report should Adverse event or incident report should make all facts knownmake all facts known– Adverse event reports are not part of Adverse event reports are not part of

client’s medical record, but should be client’s medical record, but should be noted noted

Adverse Events and Risk Adverse Events and Risk ManagementManagement

• Risk-management department Risk-management department – Reviews all adverse event reports Reviews all adverse event reports – Identifies risks Identifies risks – Controls occurrences Controls occurrences – Prevents damage Prevents damage – Controls legal liabilityControls legal liability– Determines need for further investigationDetermines need for further investigation

WILLSWILLS • A declaration by a person about how the A declaration by a person about how the

person’s property is to be disposed after person’s property is to be disposed after death death

• A valid will mustA valid will must– Be made by person of sound mind Be made by person of sound mind – Not be unduly influenced by anyone else Not be unduly influenced by anyone else

• Nurse may act as witnessNurse may act as witness

• Do-not-resuscitate orders (DNR) “no-code”Do-not-resuscitate orders (DNR) “no-code”

ANA Recommendations ANA Recommendations

• Client’s values and choices highest Client’s values and choices highest prioritypriority

• Advanced directive or surrogate makes Advanced directive or surrogate makes decisions for incompetent clientdecisions for incompetent client

• DNR discussed with client, family, and DNR discussed with client, family, and designated decision makerdesignated decision maker

• Clear documentation Clear documentation


• Separate from other aspects of a Separate from other aspects of a client’s careclient’s care

• Request change in assignment if Request change in assignment if conflicts with nurse’s beliefsconflicts with nurse’s beliefs

• Advance healthcare directive Advance healthcare directive – Statement made before receiving Statement made before receiving

healthcare specifying the client’s wishes healthcare specifying the client’s wishes


• Three types Three types – Living will Living will – Durable power of attorney for healthcareDurable power of attorney for healthcare– Medical or physician directiveMedical or physician directive

ANA RecommendationsANA Recommendations

• Questions to ask on admission Questions to ask on admission – Does the client have basic information on Does the client have basic information on

advanced healthcare directives? advanced healthcare directives? – Does the client wish to initiate an advance Does the client wish to initiate an advance

healthcare directive? healthcare directive? – Did the client bring one that was prepared in Did the client bring one that was prepared in

advance? advance? – Has the client discussed end-of-life-choices?Has the client discussed end-of-life-choices?

EuthanasiaEuthanasia

• The act of painlessly putting to death The act of painlessly putting to death persons suffering persons suffering

• Legally wrong in Canada and the United Legally wrong in Canada and the United States States

• Voluntary euthanasia/assisted suicide Voluntary euthanasia/assisted suicide

• Dying individual desires control over Dying individual desires control over time and manner of deathtime and manner of death

Death and Related Issues Death and Related Issues

• Legal issues surrounding deathLegal issues surrounding death– Death certificate Death certificate – Labeling of deceased Labeling of deceased – Autopsy Autopsy – Organ donation Organ donation – Inquest into the cause or manner of a Inquest into the cause or manner of a

deathdeath


Examine the nurse’s role in identifying Examine the nurse’s role in identifying

and assisting the impaired nurse.and assisting the impaired nurse.

The Impaired Nurse The Impaired Nurse

• One whose practice is deteriorated One whose practice is deteriorated because of substance abuse because of substance abuse

• Three victims of the impaired nurse Three victims of the impaired nurse – Client Client – Colleagues Colleagues – Impaired nurseImpaired nurse

The Impaired Nurse The Impaired Nurse • Actions to take when a nurse suspects an Actions to take when a nurse suspects an

impaired colleague impaired colleague – Do not let them care for clients Do not let them care for clients – Report unsafe practicesReport unsafe practices– Document suspicious behaviors or incidentsDocument suspicious behaviors or incidents– Confront individual with another person Confront individual with another person – Respect nurse’s right to confidentiality and Respect nurse’s right to confidentiality and

privacyprivacy– Avoid being judgmentalAvoid being judgmental

Learning Objective 5.5Learning Objective 5.5Examine the problem of sexual harassment Examine the problem of sexual harassment

in nursing.in nursing.

Sexual Harassment Sexual Harassment

• Unwelcome sexual advances of any Unwelcome sexual advances of any kind occurringkind occurring– As a condition of employment As a condition of employment – As the basis for employment decisions As the basis for employment decisions – At a work place where work is interfered or At a work place where work is interfered or

creates an intimidating, hostile, or offensive creates an intimidating, hostile, or offensive working environmentworking environment

Nurses as Witnesses Nurses as Witnesses

• Called to testify as a defendant in a Called to testify as a defendant in a malpractice or negligence action malpractice or negligence action – Provide testimony about care provided to Provide testimony about care provided to

the plaintiff the plaintiff – Provide testimony as an expert witnessProvide testimony as an expert witness


Consider how the collective bargaining Consider how the collective bargaining process is used to improve nursing process is used to improve nursing

practice.practice.

Collective Bargaining Collective Bargaining

• Formalized decision making process Formalized decision making process between management and labor to between management and labor to negotiate negotiate – WagesWages– Conditions of employment Conditions of employment – Work hoursWork hours– Work environment Work environment – Fringe benefits of employmentFringe benefits of employment


• Written contractWritten contract

• Controversial among nurses Controversial among nurses – Necessary to obtain control of nursing Necessary to obtain control of nursing

practice and economic security practice and economic security – Moral dilemma in the event of a strikeMoral dilemma in the event of a strike

• Process includes Process includes – recognition of a certified bargaining agent recognition of a certified bargaining agent


• Collective bargaining agentCollective bargaining agent– Union Union – Trade association Trade association – Professional organizationProfessional organization

• United American Nurses United American Nurses – Largest labor union for registered nurses in Largest labor union for registered nurses in

the United States the United States – Established in 1999 by ANA Established in 1999 by ANA


• Grievances Grievances – Any dispute, difference, controversy, or Any dispute, difference, controversy, or

disagreement arising out of the terms and disagreement arising out of the terms and conditions of employment conditions of employment

– Four main categories Four main categories • Contract violations Contract violations • Violations of federal and state law Violations of federal and state law • Management responsibilities Management responsibilities • Violation of agency rulesViolation of agency rules



CHAPTERCHAPTER


Sixth Edition

Theoretical Foundations of Professional Nursing

6



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,





Describe the nature of knowledge development.



Challenges and Opportunities

• Traditional gap between academia and practice – Nursing theory considered ethereal and

unrelated to the “real world” of nursing by practicing nurses

• One theory or many – Multiple and diverse approaches – Allows application to what is the “best fit” – Does this best serve the profession?



Worldviews and Knowledge Development

• Theory – A system of ideas proposed to explain

something – Provide knowledge to improve practice – Guides practice, education, and research – Provides professional autonomy – Study helps develop analytical skills




• Nursing theory – Not formally integrated at an everyday level – Not part of nursing education when first

developed – 1950s’ practice based on principles and

traditions




• Florence Nightingale first proposed nursing knowledge as different and distinct from medical knowledge




• Worldviews – Different theories represent different

worldviews – Individuals who think and see the world in

different ways create them – Provide contrasting paradigms– Provide different traditions and approaches to

science and knowledge development




• Worldviews – One paradigm: Positivist approach

Nineteenth-century Age of Enlightenment Natural law Linear Cause and effect using experimental research

methods General to specific




• Worldviews – Second paradigm: Constructivist

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




• Categories of theories – Philosophy

Nature of things, aims to provide broad understanding

– Nursing conceptual models Form interrelationships among concepts and

definitions to provide organized perspective




• Categories of theories – Grand theory

General, broad, and complex

– Middle-range theory Narrower focus, refined through series of studies

– See Table 6−1




Differentiate among the terms concept, conceptual framework, conceptual model,

theory, construct, proposition, and hypothesis.



Defining Terms

• Concepts – 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 – 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 testing– Deductive approach– Compares outcomes with relationship

predicted by hypothesis drawn from theory and linked to concept

• Theory generation– Inductive approach use




• Five kinds of knowledge– Revealed – Intuitive – Rational – Empirical – Authoritative




• Ways of knowing framework – Empirical – Esthetic – Personal – Ethical




Analyze the development of theory in nursing.



Nursing Theory Development

• Source of discussion and debate regarding uniqueness

• Borrowed or shared • Result in diversity of theories




Compare the theoretical approach of selected nurse theorists.



Nightingale’s Environmental Theory

• Florence Nightingale, first nurse theorist



Nightingale’s Environmental Theory

• Five environmental factors – Pure or fresh air – Pure water – Efficient drainage – Cleanliness – Light, especially direct sunlight

• Deficiencies in these factors result in poor health



Peplau’s Interpersonal Relations Model

• Hildegard Peplau was a psychiatric nurse• Based on psychoanalytic theory, principles

of social learning, concepts of human motivation and personality development



Henderson’s Definition of Nursing

• Virginia Henderson, known for Textbook of the Principles and Practices of Nursing

• Formulated a definition of the unique function of nursing

• Basic to definition are assumptions about the individual




• 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




• Maintain physiological and emotional balance– Nurses focus to help individuals and families

in Breathing Eating and drinking adequately Eliminating body wastes Moving and maintaining a desirable position Sleeping and resting





in Selecting suitable clothing Maintaining body temperature within normal range

by adjusting clothing and modifying the environment

Keeping the body clean and well groomed to protect the integument





in Avoiding dangers in the environment and avoiding

injuring others Communicating with others in expressing emotions,

needs, fears, or opinions





in 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





in Learning, discovering, or satisfying the curiosity

that leads to normal development and health, and using available heath facilities



Rogers’ Science of Unitary Human Beings

• Martha Rogers theory presented in 1970• Views person as a irreducible whole • The whole is greater than the sum of its

parts• Humans are dynamic energy fields in

continuous exchange with environmental fields

• Behaves as a totality



Rogers’ Science of Unitary Human Beings

• Rogers’ theory applied to nursing practice – Focus on the person’s wholeness– Seek to promote symphonic interaction

between the two energy fields to strengthen the coherence and integrity of the person

– Coordinate the human field with rhythmicities of the environmental field

– Direct and redirect 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




• 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




• 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




• 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– Interpersonal – Social




• Transactions are purposeful interactions that lead to goal attainment, characteristics are – Social exchange, bargaining, and negotiating– Perceptual accuracy in nurse-client interaction– Goal attainment




• 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 seven hypotheses in goal-attainment theory– Role conflict decreases transactions– Congruence in role expectations and

performance increases transactions



Neuman Systems Model

• Betty Neuman based on Gestalt theory and others

• Focus on the wellness of the client in relation to environmental stressors and reactions to stressors




• Five client system variables– Physiological– Psychological– Sociocultural– Developmental– Spiritual




• 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




• Stressor is any environmental force that alters the system’s stability– Internal stressors– Interpersonal; stressors– Extrapersonal stressors– Created stressors




• 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

• Patrica Benner’s thinking was influenced by Virginia Henderson and Herbert Dreyfus

• Adapted Dreyfus and Dreyfus model of skill acquisition and skill development to clinical practice nursing




• Five levels – Novice – Advanced beginner – Competent – Proficient – Expert




• As one moves through the levels, four aspects of performance change – Movement toward abstraction– Shift from analytical to intuition – Viewing the situation from relevant bits to

complex whole – Detached observer to fully engaged in the

situation



The Caring Theories

• Provide a link between generic caring and the uniqueness of nursing

• Caring is a central concept to the practice of professional nursing



The Caring Theories

• Core value encompassing – Altruism– Autonomy – Human dignity– Integrity – Social justice



The Caring Theories

• The caring theorists, see Table 6−2 – Jean Watson – Madeleine Leininger – Roach, Boykin, and Schoenhofer



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

• Comfort is 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– Psycho-spiritual– 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.




• Assumption 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 moves from

uncertainty to adaptation




• Assumption of this theory are– People function in far-from-equilibrium states– Major fluctuations in far-from-equilibrium

enhance receptivity to change– Fluctuations result in repatterning



One Model Versus Several Models

• Advantages to a single, universal model – Further development of the profession– Common framework – Promotes understanding about nurse’s role in

nontraditional settings



One Model Versus Several Models

• Advantages to a single, universal model– Other disciplines have several models, which

allows exploration of phenomena in different ways and viewpoints

– Increase an understanding of the nature and scope of nursing

– Fosters full scope and potential of discipline




Identify the relationship between nursing process and nursing theory.



Relationship to Theories to the Nursing Process and Research

• Assessing • Diagnosing • Planning • Implementing • Evaluating

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