32 U n i t 1 The Growth of Nursing Issues Now Travel Nursing as a Career As a nursing student, you may have heard of travel nursing or traveling nurses but not really know what they are or if it might be something you would be interested in as a career. Much like the recruitment posters for the armed services, “See the World” seems to be an attrac- tive slogan for those looking for new experiences and adventure. However, there may be some drawbacks to travel nursing. In general, travel nurse staffing companies require a BSN or higher degree. This stan- dard allows the nurses to meet any staffing requirements of individual facilities. Research has demonstrated improved client outcomes with the use of BSN staffing, so it is impor- tant to health-care organizations. Travel nurses differ from agency nurses in several ways. Travel nurses are usually committed to working for a facility for a predetermined length of time, usually about 3 months. To allow preparation for travel to the facility, they are scheduled for their time about 2 months before their start date. Agency nurses generally work on a per diem (by the day) basis and live near the facility. They work a few days at a time to meet a short-term staffing need. Travel nurses provide more continuity of care and fill in for long-term needs, such as extended illness, maternity leave, or even sabbati- cal leave. Travel nurses can select where they want to work and the time period of the work schedule. They usually follow the schedule required by the facility but have scheduled days off like other nurses. Their salaries tend to be higher; and, depending on the com- pany, the benefits may range from “bare bones” to what regular staffers would receive at a large health-care facility. Some staffing agencies also pay for the nurse’s license and housing costs. Staffing agencies have a group of employees who support the nurse and act as liaisons with the facilities to resolve any problems that may arise. Salaries are a bit complicated to calculate, depending on benefits, but usually work out to a range of $40.00 to $50.00 or more per hour ($80,000 to $105,000 or more per year). Tax-free benefits can include stipends for incidentals such as laundry, Wi-Fi use, phone, and free, private, quality housing located conveniently near the work facility. Because these sti- pends do not qualify as income, they are not taxed as part of the salary of a travel nurse. Even better, stipends are not performance or hours based, so nurses keep their stipend no matter what happens; however, stipends are usually calculated as a fixed sum on the initial contract. A nurse must be careful when selecting a travel nurse staffing company. The nurse should investigate the company carefully, talk to other nurses it employs, and examine the benefits closely. Generally, the larger the firm, the more locations it serves and the better the benefits and support services. Some nurses use travel nurse employment to research locations in which they may be interned and then permanently relocate when they find the ideal location. Requirements: • At least 1 year of experience • For specialty areas (obstetrics, intensive care, emergency, etc.), an additional year in that area • BSN preferred but not required • Basic life support (BLS), advanced cardiovascular life support (ACLS), certification in spe- cialty area (e.g., critical care registered nurse (CCRN) for intensive care unit)
C h a p t e r 2 Historical Perspectives 33 I s s u e s N o w (continued) • Belong to Nurse Compact Licensure state or obtain nursing license in the state you are going to practice • Remain current in competency with continuing education units (CEUs) or other requirements So, if you want to be a travel nurse, the opportunities are out there. Travel nursing cer- tainly provides a high degree of autonomy and control of your schedule and career. One of the key elements reported by nurses for career satisfaction is quality of life. The freedom of choice provided by travel nursing would certainly fulfill that need. Source: What is a travel nurse? American Traveler, 2018. Retrieved from https://www.americantraveler.com/ what-is-a-travel-nurse Traveling nurses see the world. Conclusion and made massive changes in health outcomes. She singlehandedly reworked the education system for Nursing and the modern health-care system are in nurses in the face of a physician-run and highly a time of transition. How will the various health- resistant health-care system. Hampton Robb pushed care professions address the challenges posed by for nursing education at the university level at a shrinking health-care budgets, increasing insurance time when there were hardly any women in college. and medical costs, and a large population of aging Loretta Ford conceived and nurtured the role of baby boomers? Nurses at all levels can find creative advanced practice nurse despite strong objections solutions to meet these challenges with profession- from her physician colleagues. alism and empowerment, just as nursing’s fore- mothers did. Although many of the difficulties with today’s health-care system, and those of nursing in Nightingale invaded the hospital run by the British Army with 37 of her best educated nurses
34 U n i t 1 The Growth of Nursing they can sometimes move mountains (sometimes particular, can be traced back to the historical devel- called legislators, physicians, and administrators). opment of the profession, they cannot stop creative, strong-willed, and persistent nurses from moving the There are untold opportunities for today’s nurses profession forward. Knowledge of nursing’s histori- to be change agents in defining the role of the nurse cal roots can help us understand these current dif- and empowering nurses to have a strong voice in the ficulties. That same historical knowledge can point 21st-century health-care system. Those who belong to the way to innovative solutions. For example, nurses the nursing profession have a responsibility not only today still typically have a high level of responsibility to learn from the past but also to use those lessons to but a low level of power; however, when nurses unite, make nursing the premier profession for the future. Critical-Thinking Exercises • Trace the history of your nursing school. Who were the leaders in the foun- dation of the school? Write a short biography for each one, listing their accomplishments. • If you know any retired nurses, contact them and ask if they would be willing to talk to you about their practice. Develop an oral history of what they experi- enced and compare it to nursing practice today. • Start a journal of your own experiences as a nursing student. Maintain this journal throughout your career. Make sure to include interesting instructors and clients with whom you are in contact. NCLEX-STYLE QUESTIONS 3. Place the events in the development of nursing in the Christian church in the order in which they 1. Which of these nursing leaders helped develop the occurred. American Journal of Nursing? 1. Monks and nuns, often with little training, cared 1. Florence Nightingale for the poor and the sick. 2. Isabel Adams Hampton Robb 2. After the Protestant Reformation, nursing care 3. Lillian Wald in countries that broke away from the Catholic 4. Lavinia Lloyd Dock Church fell into disarray. 3. During the Crusades, Knights Hospitallers cared 2. In what way did Hippocrates’ beliefs about illness for those who became sick or were wounded in and medicine differ from those of other ancient battle. Greek physician-priests? 4. Wealthy Roman women who had converted 1. Hippocrates believed in treating the whole cli- to Christianity established hospital-like ent, not just in appeasing the gods. institutions. 2. Hippocrates believed in diagnosis through mys- tical visions. 3. Hippocrates believed that the physician was never to be questioned. 4. Hippocrates believed in treating the body, not the spirit.
C h a p t e r 2 Historical Perspectives 35 4. Which historical thread explains the evolution of 3. Nursing became more secular, and faith in the health-care providers from shamans and priests to teachings of the Catholic Church waivered. nurses and physicians? 1. The value place in individual life 4. Nursing in countries that broke away from the 2. The role of women in society Catholic Church advanced swiftly. 3. The beliefs about the causes of illness 4. The effects of large-scale war on society 8. What does the nursing lamp symbolize? Select all that apply. 5. What effect did World War II have on the devel- 1. Life opment of U.S. nursing? Select all that apply. 2. Learning 1. The U.S. government commissioned nurses and 3. Fire paid them the same as men with the same rank. 4. Sacrifice 2. Working with physicians and untrained person- 5. Caring nel, nurses initiated the concept of the health- care team. 9. What was the status of organized medical care in 3. The nursing shortage immediately after World the American colonies before they gained their War II led to ADNs outnumbering BSNs by the independence? 1960s. 1. People were cared for at home; only five hos- 4. The number of BSN and graduate nursing pro- pitals existed for the homeless and poor before grams exploded. the Revolutionary War. 5. The image of the nursing profession was espe- 2. Nurses trained in religious orders in Europe cially positive, in part because of the heroic immigrated to the colonies in large numbers. portrayal of nurses in movies produced during 3. Hospitals were well known for their success in the war. treating a variety of serious illnesses. 4. Benjamin Franklin organized and trained 6. Which of the following nursing leaders is best medical volunteers to aid the injured and sick known for her work outside the field of nursing? during the Revolutionary War. 1. Annie W. Goodrich 2. Loretta C. Ford 10. In addition to their development of central heat- 3. Lavinia Lloyd Dock ing, baths, and advanced systems for sewage dis- 4. Lillian Wald posal, the ancient Romans maintained the good health of citizens with ___________, which sup- 7. What effect did the Renaissance have on the role plied clean water. of nursing? 1. Nursing care fell to female religious orders as the number of male nursing orders decreased. 2. Nursing became more scientific because of the invention of the microscope and the thermometer. References title/lavinia-lloyd-dock-an-activist-in-nursing-and-social-reform/ oclc/51048335 1. Magner L, Kim O. A History of Medicine (3rd ed.). Boca Raton, 7. Annie Warburton Goodrich (1866–1954), 1976 Inductee, FL: CRC Press, 2017. American Nurses Association. Retrieved from http://www .nursingworld.org/AnnieWarburtonGoodrich 2. Keeling A, Hehman M, Kirchgessner J. History of Professional 8. Ridgway S. Loretta Ford, founded nurse practitioner movement. Nursing in the United States. New York, NY: Springer, 2017. Profiles in Nursing. Retrieved from http://www.workingnurse .com/articles/Loretta-Ford-Founded-Nurse-Practitioner- 3. Judd D, Sitzman S. A History of American Nursing. Burlington, Movement MA: Jones & Bartlett Learning, 2015. 9. Ligenza D. Loretta Ford: The “mother” of the nurse practitioner movement. Working Nurse, 2015. Barton Associates. Retrieved 4. Isabel Hampton Robb—Nursing theorist. Retrieved from http:// from https://www.bartonassociates.com/blog/throwback- nursing-theory.org/nursing-theorists/Isabel-Hampton-Robb.php thursday-loretta-ford-the-mother-of-the-nurse-practitioner- movement-2 5. Lillian Wald: The Henry Street Settlement. Retrieved from https://www.henrystreet.org/about/our-history/lillian-wald 6. Burnam-Bradfir MA. Lavinia Lloyd Dock: An activist in nursing and social reform. Retrieved from https://www.worldcat.org/
Theories and Models 3 of Nursing Joseph T. Catalano Learning Objectives CARING FOR REAL PEOPLE After completing this chapter, the reader will be able to: For many nurses, and for most nursing students, the terms theory and model evoke images of textbooks filled with abstract, • Explain why theories and obscure words and convoluted sentences. The visceral response models are important to the is often, “Why is this important? I want to take care of real people!” profession of nursing The simple answer is that understanding and using practice models, especially the middle-range theories and models, will help you be a • Analyze the four key concepts better nurse and provide better care to real people. Nurses and insti- found in nursing theories and tutions that use professional practice models find that the quality of models patient care improves with the knowledge and use of practice models, and nurses have more satisfaction with their careers and remain cur- • Interrelate systems theory as rent with trends and changes in technology. an important element in under- standing nursing theories and DIFFERENCES BETWEEN THEORIES AND MODELS models What Is a Theory? • Evaluate how the four parts of Although the terms theory and model are not synonymous, in nurs- all systems interact ing practice they are often used interchangeably. Strictly speaking, a theory refers to a speculative statement involving some element • Synthesize three nursing theo- of reality that has not been proved. For example, the theory of rela- ries, identifying how the differ- tivity has never been proved, although the results have often been ent nursing theorists define the observed. key concepts in their theories The nursing profession tends to use the term theory when • Compare and contrast a attempting to explain apparent relationships between observed middle-range theory with a behaviors and their effects on a client’s health. In this nursing con- grand nursing theory text, the goal of a theory is to describe and explain a particular 36
C h a p t e r 3 Theories and Models of Nursing 37 nursing action to make a hypothesis, which predicts What Do Nurses Do? the effect on a client’s outcome, such as improved Although a model tends to be more concrete than health or recovery from illness. For example, the a theory, they both help explain and direct nurs- action of turning an unresponsive client from side ing actions. This use of a systematic and structured to side every 2 hours should help to prevent skin approach is one of the key elements that raises nurs- breakdown and improve respiratory function. ing from a task-oriented job to the level of a profes- In the early days of the practice of nursing, theo- sion that requires judgment and knowledge to make ries were very simple and reflected the knowledge informed decisions about client care. With the use of base of the time. With the rapid growth in health- a conceptual model, nurses can provide intelligent care knowledge and technology, nursing theory also and thoughtful answers to the question, “What do has expanded and evolved to help nurses provide nurses do?” Consider the quoted scenario below. higher-quality care in increasingly complex patient Without an understanding of the underlying conditions. Nursing theories provide a framework to dynamics involved, the nurses might themselves plan for decision-making when new patient needs are become sarcastic and scold the client about his encountered. They also provide a method for nurses behavior or simply minimize their contact with to communicate with each other and with other him. This type of response will not improve Mr. X’s members of the health-care team. Guiding the devel- health status. If, however, the nurses knew about and opment of research and understood the dynam- “helping to formulate a ics of grief theory, they Mr. X had surgery for intestinal cancer would realize that Mr. X nurse’s values and goals, 4 days ago. He has a colostomy and needs is probably in the anger nursing theories are one to learn how to take care of it at home stage of the grief pro- of the key elements in because he is going to be discharged cess. This understand- nursing’s development as ing would direct the a profession. nurses to allow, or even In recent years, nurs- from the hospital in 2 days. When the ”ing has been moving to encourage, Mr. X to nurses attempt to teach him colostomy express his anger and toward using research care, he looks away, makes sarcastic aggressiveness without findings to guide nursing personal comments about the nurses, and condemnation and to practice. This approach, generally displays a belligerent and hostile help him deal with his called evidence-based attitude. practice, is an important feelings in a constructive element in improving manner. Once Mr. X nursing care and proving gets past the anger stage, many of the long-standing theories that the nursing he can move on to taking a more active part in his profession has developed over the years.1 care and thus improve his health status. The client goals would then be achieved. What Is a Model? If a researcher were to stop 10 people at random on A model is a hypothetical representation of some- the street and ask the question, “What do nurses do?” thing that exists in reality. The purpose of a model is to explain a complex reality in a systematic and he or she would likely get 10 different answers, but the confusion about nurses’ activities extends far beyond organized manner that is more easily understood. the public at large. What if the researcher asked 10 hos- For example, a hospital organizational chart is a model that attempts to demonstrate the inter- pital administrators, 10 physicians, or even 10 nurses the same question? The answers would probably vary relationships of the various levels of the hospital’s almost as much as the answers from laypersons. administration. What Do You Think? Professional Practice Model With the development of the Magnet Recognition Do you consider yourself to be healthy? What factors Program whereby health-care organizations can make you healthy? What factors are indicators of illness? earn Magnet status by meeting requisite criteria, the American Nurses Credentialing Center reinforced
38 U n i t 1 The Growth of Nursing The Iowa Project (Nursing Interventions the need for professional practice models (PPM). For Classification) an institution seeking Magnet status, the PPM needs In an attempt to identify exactly what it is that nurses to provide an “overarching conceptual framework do, J. C. McCloskey and G. M. Bulechek, two nurse for nurses, nursing care and interprofessional patient researchers at the University of Iowa, have been care.” The PPM is a way to describe in a pictorial way conducting an ongoing research project since 1990 all the iterations, values, beliefs, and activities that to develop a taxonomy of the interventions that go into producing high-quality patient outcomes. nurses use in their practice (Box 3.1). This project is It must be evaluated annually to ensure that it is now called the Nursing Interventions Classification current with the institution’s practices.2 Box 3.1 What Constitutes Care? At first glance, it would seem that everybody knows that nurses take care of clients. But what constitutes care? A study conducted by the faculty of the University of Iowa, called the Nursing Interventions Classifica- tion (NIC), has identified 554 tasks or interventions for which nurses are responsible in their care of patients. Not all nurses carry out all 554 of these tasks all the time, but during an average career, a nurse would likely be involved in the majority of these tasks. Although this project was undertaken in the mid-1990s, it remains the benchmark study. Since the original study, several additional studies have been conducted that reaffirm the findings of the initial Iowa Project, and researchers have undertaken projects to use the data generated by the NIC in actual client-care situations. It now forms the basis for the classification of patients in health- care institutions. This project is an excellent example of how a nursing theory led to a research project that developed information that can be used by nurses in their daily practice. On the principle that nursing interventions are specific actions that a nurse can perform to bring about the resolution of a potential or actual health-care problem, the NIC identifies and classifies nursing interventions. It also ranks those interventions according to the number of times a nurse was likely to perform one during a working day. The goal was to develop a nurs- ing information system that could be incorporated into the current information systems of all clinical facilities. By using the NIC system, hospital administrators, physicians, nurses, and even the public should be better able to recognize and evaluate the multiple interventions that nurses are responsible for in their daily work. It is a generally acknowledged fact that nurses, as the largest single group of health-care providers, are essential to the welfare and care of most clients. Yet, in an age of health-care reform, nurses are finding it increasingly difficult to delineate the specific contributions they make to health care. If nurses are unable to define the care they provide, how are the reformers, politicians, and the public going to be able to identify the unique contribution made by nursing? Unfortunately, many of the contributions that nurses make to health care are currently invisible because there is no method of classification for them in the computerized database systems now in use. Commonly used nursing interventions such as active listening, emotional support, touch, skin surveillance, and even family support cannot be measured and quantified by most current information systems. The large number of interventions used daily by nurses demonstrates the complex and demanding nature of the profession. The breadth and depth of knowledge and skills demanded of nurses on a daily basis are much greater than are found in many other health-care professions. One study found that nurses working in general medical-surgical units during a 6-month period were likely to care for 500 clients with more than 600 individual diagnoses (many clients have multiple diagnoses). These researchers also found that the physical demands of the work were actually less difficult and tiring than dealing with the emotional and technical demands of handling the huge amounts of information generated by the care given. Sources: G. M. Bulechek, H. K. Butcher, and J. M. Dochterman, Nursing Interventions Classification (NIC) (6th ed.), St. Louis, MO: Mosby Elsevier, 2016; K. Kleber, Nursing interventions you use every single shift, NRSSG, 2017, retrieved from https://www.nrsng.com/7-nursing-interventions- every-single-shift-written-nurse; R. Bernstine, Categorizing care: A guide to nursing interventions [blog post]. Husson Education Online, 2017, retrieved November 2017 from https://online.husson.edu/nursing-interventions-nic-system.
C h a p t e r 3 Theories and Models of Nursing 39 (NIC).3–5 It has been totally computerized and can be routinely perform for various client populations. accessed from a nurse’s phone on a number of apps. Taking the process one step further, the Nursing NIC’s focus has shifted from attempting to iden- Outcomes Classification system closes the loop by tify what nurses do to a system of communication providing a means for nurses to evaluate whether the between nurses, other nurses, and health-care team outcomes were achieved.6 members. It has become an important element in Although initially used to help nurses with the health-care informatics. delegation of duties to unlicensed personnel by link- “ ”ttartaftaccltIibnbcTmAcicn(inniihhhhtiaoaoaibrreesuurnh.aCueentgeeeaerttnnmhslrrgeleeaeeayt.tlnkissoawdu,rcirasgb,zsmneeNleritevvuw.pupssoailattossedrsstiseeeFhyrrhtcoIrs.oeeseitndiriocC)itfdoiusy3ntrRsoanrazeiesotovvpercsaa3rlblnegniwdeantityianvcesolno6dyadssio.yt;dtphnhtedenaned,iuieIlasiedleneaeoesatboaesnpndoasiriapcdn3rrctnnrnogeofuaptewuisceca0e2edecditusandSbhhsphcrcito0irwoaltysfc,syl5etaaritvdbe0fyireshsalyea;a2tsl4srewayeat8tps:clairnnhfsae2ontstbsn,oybebeaesaymnekedsetaete-mnkrlacneddietadhelceaosli-cssd.iloeiriotoineelqlcosnamsyrn4nsu;fxin;a3gnt1paetoifhs3oh9nnvhftn.eeoeia9ettyiAnvoareirnts4sfelmgrtitytt,nhnifvohhegocnuyiewrlegaamloesrvnlCfe2acohtthysoeogoeetealo0fce-dasianweirdgrqorhrsct1tsiemtroeeg-eafeunhiwiu0teomurolivenhasae:enisi.rhpenv.lzAsceeesnacaiEnienIesuy;teocslalwtncydvuatttdhumsdsdstuehnherkhttusaoo.wdn(suhtpnde-eneemcT.eoAycunddelayidcseIcamhlrylaCniemxolbtsteernihs;o-mnyboAleoscesrefsr-)pmuete,arlatweohobsnvheuaatiiqapnctibvoawldnstcenciholbecfurriolneahshgesinoinloiabworrnTeeeynftlntmsotosw,ngeniirfhkh.patoetfiasi tytihtinatnbdersnenhslsrooilsuusossdeotsieatAnvahtmcrfyionbtpwiiisvlmhptepnodcofi.eapiaeieeeanuemssuotnlosbnylhifsrsytosrsadrautuestuhedtnfmipaiti,ccamrrndsnahdrtaeanttsesaeregtorihpribe,etdiosasfonednrcmoteelcettw,nhoestaogatsrhhmubvremreioeaetaeeyciyannlhan.ahlinuidiklnmtgWnnnyosdehucretccpsltehhaerroahoolstweeerporieirfanreumntioccidbwIonehsktnnits.eiloqaafnonunog aaemeniaggvaanmsudtardntlurnuiftitllhtscilpipndesosoe-rthepfrryetsee.ohbnsrryrearesshesylteosoUenepiteetmop,ihescdtfnsuivriyfsxchoaftduflsneeegereveiwyenuiayrotbdsemagemnnma-hhnssnwdhnntlocbrtgniiioehoeoaedaassitdccoahawofmosfel,nntrc,iensnyaalauetdtWlcherttsoatiziut.eahn.hhsmtlsddernanoeaisMrrtneWsemeCestidsasafsapptaunyaniiaunntnnhuAitfanlroCeertnnthlirudhdeuadcnessyvrcsg-Adeichriraea.tradecsntsa-tssvi-nah-i-legnecyrestee recent NIC list, 554 interventions are identified. Research into nursing intervention classification Nursing Competencies systems is ongoing and, in addition to providing a One way in which the nursing profession identifies system of communication, has served as the founda- what nurses do is by looking at competencies. In tion of several methods to define nursing practice nursing, the word competence is often defined as the and measure the outcomes of client care. The need combination of skills, knowledge, attitudes, values, to increase client satisfaction and achieve success- and abilities that support the safe and effective prac- ful outcomes of nursing care is a key element in the tice of the nurse. A nurse practices competently when Affordable Care Act (ACA), which was passed in he or she has mastered a range of skills and decision- 2010. Even more than in the past, these elements making processes demonstrated in the care of clients. will be the basis of reimbursement for health-care All the major nursing organizations have developed providers. lists of competencies for nurses. These are usually Using the NIC as a starting point, the Work general, broad statements rather than catalogs of spe- Complexity Assessment (WCA) was developed so cific skills. (See “Issues Now: The Pew Commission that nurses could identify specific interventions they Final Report” in this chapter.)
40 U n i t 1 The Growth of Nursing Nursing competencies first came under close scru- A Complex Relationship tiny because of the large number of medication and The concept of client has changed over the years as other types of errors in the health-care setting that knowledge and understanding of human nature have have led to numerous clients being injured or killed. developed and increased. A client constitutes more The Institute of Medicine’s (IOM, now the Health than a person who simply needs restorative care and Medicine Division of the National Academies of and comes to a health-care facility with a disease Sciences, Engineering, and Medicine) document on to be cured. Clients are now seen as complex enti- the future of nursing contains recommendations and ties affected by various interrelating factors, such lists of competencies for nursing school graduates to as the mind and body, the individual and the help improve the quality of care. The Quality and environment, and the person and the person’s Safe Education for Nurses (QSEN) project, built family. When nurses talk about clients, the term upon the IOM recommendations, is in the process biopsychosocial is often used to express the complex of developing a framework for nursing schools’ cur- relationship between the body, mind, and environ- ricula (see more about IOM competencies and QSEN ment. These elements are at the heart of preven- in Chapter 4). tive care that has been an emphasis of professional Nursing researchers have attempted to develop nursing since the time of Florence Nightingale. The specific lists of skills based on the general compe- prevention of disease and promotion of health are tency statements from the various nursing organiza- key provisions in the health-care reform bill passed tions. These skills lists help differentiate the various in 2010 that opened the door for nurses to practice levels of nursing practice. to the full extent of their One such list of skills is “ Although nursing models vary in licenses. presented in Table 3.1. terminology and approach to health care, there are four concepts that are Modeling a Healthy KEY CONCEPTS common to almost all of them: client or Client COMMON TO A client, in many of the nursing models, is patient (individual or collective), health, not required to have an ”NURSING MODELS environment, and nursing. illness to be the central Although nursing models element of the model. vary in terminology and This is another reason approach to health care, four concepts are common some prefer using the term client over the term to almost all of them: client or patient (individual or patient. This is also one of the clearest distinc- collective), health, environment, and nursing. Each tions between medical models and nursing models. nursing model has its own specific definition of these Medical models tend to be restrictive and reactive, terms, but the underlying definitions of the concepts focusing almost exclusively on curing diseases and are similar. restoring health after the client becomes ill. Nurs- ing models tend to be proactive and holistic. Like Client medical models, they are certainly concerned with The concept of client (or patient) is central to all curing disease and restoring a client’s health, but nursing models because it is the client who is the they also focus on preventing disease and main- primary recipient of nursing care. Although the taining health. A healthy person is just as impor- term client usually refers to a single individual, it can tant to many nursing models as the person with also refer to small groups or to a large collective of a disease. individuals (e.g., for community health nurses, the community is the client). The use of the term patient Health became unpopular for a number of years because of Like the concept of client, the concept of health has its origin from the Latin word pati, which means to undergone much development and change over “suffer.” However, it seems to be making a return to the years as knowledge has increased. Tradition- usage in professional publications. ally, health was thought of as an absence of disease. (text continues on page 51)
C h a p t e r 3 Theories and Models of Nursing 41 Table 3.1 Competencies for Nursing Skills Associate Degree RN Baccalaureate Degree RN Administering Blood Products Obtain and document baseline vital signs according to Same agency policies and procedures. Same Obtain blood transfusion history. Initiate administration Same of blood products according to agency policies and procedures. Evaluate and document client response to administration of blood products. Admission, Transfer, Discharge Admit client to a health-care facility, following facility’s Same policies and procedures. Same Transfer client within a health-care facility, following facility’s policies and procedures. Manage the discharge planning process. Assist client in exiting a health-care facility, following Same facility’s policies and guidelines. Same Assess client to determine readiness for discharge. Facilitate the continuity of care within and across health- care settings. Assessment of Vital Signs Monitor and assess oral, rectal, and axillary temperature. Same Measure and record temperature using an electronic or Same tympanic thermometer. Same Monitor and assess peripheral pulses. Same Monitor and assess apical pulse. Same Monitor and assess apical-radial pulse. Same Monitor and assess blood pressure. Same Monitor and assess respiratory rate and character. Bowel Elimination Document characteristics of feces. Same Perform test for occult blood. Same Administer enemas for cleansing or retention. Same Remove a fecal impaction. Same Provide and teach colostomy and ileostomy care. Same Administer a rectal suppository. Same Administer a rectal tube. Same Develop client’s bowel retraining protocol. Same (continued)
42 U n i t 1 The Growth of Nursing Table 3.1 Competencies for Nursing Skills (continued) Baccalaureate Degree RN Associate Degree RN Care of the Dying Client During the dying process, provide measures to decrease Same client’s physical and emotional discomfort. Same Evaluate final progress note on client’s chart to determine completeness of information. Same Notify appropriate people and departments, according Develop services that support dying clients to agency’s policies and procedures. and their families. Evaluate family’s response to client’s death and make Same referrals as appropriate. Provide care for the body after client’s death, according to agency’s policies and procedures. Circulatory Maintenance Evaluate fetal heart rate pattern. Same Apply antiembolism stockings. Same Obtain cardiopulmonary resuscitation certification. Same Client Teaching Assess and document client’s and/or family member’s Assess client’s readiness to learn. knowledge of specific procedure or health problem. Develop materials to provide client and/ Assess client and significant support person(s) for or family member with information learning strengths, capabilities, barriers, and concerning procedure or health problem. educational needs. Same Develop an individualized teaching plan based on assessed needs. Same Modify teaching plan based on evaluation of progress Same toward meeting identified learning outcomes. Same Provide client and significant support person(s) with the information to make choices regarding health. Using multiple teaching strategies, teach heterogeneous groups of clients, Teach client and significant support person(s) the accounting for individual differences. information and skills needed to achieve desired learning outcomes. Implement teaching plan using individualized teaching and learning Evaluate progress of client and significant support strategies with clients and/or groups in person(s) toward achievement of identified learning structured settings. outcomes. Implement teaching plan using individualized teaching and learning strategies with clients and/or groups in unstructured settings. Communication Effectively use communication skills during assessment, Same intervention, evaluation, and teaching. Same Express oneself effectively using a variety of media in different contexts.
C h a p t e r 3 Theories and Models of Nursing 43 Associate Degree RN Baccalaureate Degree RN Adapt communication methods to clients with special Same needs (e.g., sensory or psychological disabilities). Same Produce clear, accurate, and relevant writing. Same Use therapeutic communication within the nurse–client Same relationship. Evaluate effectiveness of communication Maintain confidentiality of nurse–client interactions. Appropriately, accurately, and effectively communicate patterns. with diverse groups and disciplines using a variety of Same strategies. Same Elicit and clarify client preferences and values. Same Evaluate dynamics of family interactions. Evaluate data concerning coping mechanisms of client/ Same family/support system. Same Provide emotional support to client/family/support system. Same Evaluate strengths of client and family/significant other. Evaluate need for alternative methods of communicating Teach assertive communication skills to with client. clients, unlicensed assistive nursing Use assertive communication skills in interactions with personnel, and other licensed nurses. clients and other health-care providers. Same Communicate data concerning client to appropriate members of the health-care team. Identify and plan for services to ensure continuity in meeting health-care needs Communicate the need for consultation/referral to during transition from one setting to interdisciplinary care team. another. Collaborate with other health-care team members to Collaborate with community members in provide nursing care. planning care for the community. Critical Thinking Within acquired knowledge base, create alternative Same courses of action, develop reasonable hypotheses, and develop new solutions to problems. Same Develop an awareness of personal values and feelings Same and examine basis for them. Same Use critical thinking to further develop Evaluate credibility of sources used to justify beliefs. working hypotheses, using patterns and Examine assumptions that underlie thoughts and behaviors. inconsistencies in data. Seek out evidence and give rationale when questioned. Delegation and Supervision Provide assistive personnel with relevant instruction to Specify aspects of nursing care that support achievement of client outcomes. can appropriately be delegated to unlicensed health-care providers and assistive personnel. (continued)
44 U n i t 1 The Growth of Nursing Table 3.1 Competencies for Nursing Skills (continued) Baccalaureate Degree RN Associate Degree RN Coordinate the implementation of an individualized plan Coordinate and/or implement plan of of care for clients and significant support person(s). care for clients with multiple nursing diagnoses, especially both physiological Delegate aspects of client care to qualified assistive and psychosocial diagnoses. personnel. Delegate performance of nursing Supervise and evaluate activities of assistive personnel. interventions. Delegate nursing care given by others while retaining accountability for the quality of care given to the client. Supervise performance of nursing interventions. Supervise nursing care given by others while retaining accountability for the quality of care given to the client. Manage community-based care for a group of clients. Direct care for clients whose conditions are changing. Direct care for clients in situations with a potential for variation in client condition. Supervise implementation of a comprehensive client-teaching plan. Documentation Maintain privacy of client’s record. Same Same Accurately document data according to agency’s policies and procedures. Same Use common abbreviations and nomenclature for Establish a reporting and recording recording information in the client’s record. system to provide for continuity and accountability of programs in designated structured and unstructured settings (e.g., school health, occupational health, community). Health Assessment Using a systematic process, perform a head-to-toe Perform a holistic assessment of the assessment. individual across the life span. Assess physical, cognitive, and psychosocial abilities of Same individuals in all developmental stages. Perform a risk assessment of the Assess family structure, roles of family members, and individual and family, including family’s strengths and weaknesses. lifestyle, family and genetic history, and other risk factors.
C h a p t e r 3 Theories and Models of Nursing 45 Associate Degree RN Baccalaureate Degree RN Evaluate an individual’s capacity to assume Same responsibilities for self-care. Perform assessment of using a family Assess community resources to determine possible genogram. referral sources. Perform a community assessment for Use assessment findings to diagnose and evaluate diverse populations. quality of care and to deliver high-quality care. Perform an assessment of the environment Evaluate family’s emotional reaction to client’s illness in which health care is being provided. (e.g., chronic disorder, terminal illness). Establish processes to identify health Evaluate client’s emotional response to treatment. risks in designated structured and Evaluate adequacy of client’s support systems. unstructured settings (e.g., school Assist in diagnostic procedures used to determine health, occupational health, community). client’s health status. Integrate data from client, other health- care personnel, and other systems to which client is linked (e.g., work, church, neighborhood). Modify data collection tools to make them appropriate to client’s situation (e.g., language and culture, literacy level, sensory deficit). Perform family assessment. Same Same Same Same Health Promotion Facilitate parental attachment with newborn. Same Determine the need for a health promotion program. Develop and implement a health promotion Evaluate risk factors related to client’s potential for program. accident/injury/disease. Same Evaluate client’s knowledge of disease prevention. Same Evaluate client’s knowledge of lifestyle choices (e.g., Same smoking, diet, exercise). Heat and Cold Therapy Evaluate client’s response to heat therapy. Same Same Evaluate client’s response to cold therapy. Same Same Evaluate client’s response to sitz bath. Same Monitor and evaluate client’s response to hypothermia blanket. Monitor and evaluate infant’s response to radiant warmer. (continued)
46 U n i t 1 The Growth of Nursing Table 3.1 Competencies for Nursing Skills (continued) Baccalaureate Degree RN Associate Degree RN Home Care Management Evaluate ability of family/support system to provide care Same for client. Develop criteria to evaluate client’s home Evaluate client’s home environment for self-care environment for self-care modifications modifications (e.g., doorway width, accessibility for (e.g., doorway width, accessibility for wheelchair, safety bars). wheelchair, safety bars). Infection Control Use aseptic practices: hand washing, donning and Same removing a face mask, gowning, donning and removing disposable gloves, bagging articles, Same managing equipment use for isolation clients, Same assessing vital signs. Same Same Use universal precautions. Same Use body substances isolation procedures. Evaluate client’s immunization status. Use surgical aseptic practices: scrubbing hands, donning and removing a sterile gown, donning and removing sterile gloves, preparing and maintaining a sterile field. Assist with a sterile procedure. Information and Health Care Technology Use technology, synthesize information, and select Use technology, analyze information, and resources effectively. select resources effectively. Demonstrate competence with current technologies. Same Same Use computers for record-keeping and documentation in health-care facilities. Use data-management system to evaluate a comprehensive program for monitoring health of populations in designated structured and unstructured settings (e.g., school, occupational, community). IV Therapy Perform venipuncture to obtain blood specimens. Same Perform venipuncture with an over-the-needle device. Same Prime tubing and hang IV fluids. Same Load and discontinue a PCA pump. Same Administer and document IV piggyback medications. Same Administer and document IV push medications. Same
C h a p t e r 3 Theories and Models of Nursing 47 Associate Degree RN Baccalaureate Degree RN Calculate IV flow rates. Same Document medications administered through IV. Same Discontinue an IV and document procedure. Same Monitor and maintain an IV site and infusion. Same Change IV tubing and container. Same Prime tubing and hang IV fluids. Same Determine amount of IV fluid infused and left-to-count Same each shift Same Assess implanted infusion devices. Same Maintain implanted infusion devices. Medication Administration Assess family members’ knowledge of medication Same therapy: reasons for taking medication, daily dosages, side effects. Same Same Instruct clients and their families in the proper Same administration of medications. Same Accurately calculate medication dosages. Same Same Gather information pertinent to the medication(s) Same ordered: actions, purpose, normal dosage and route, common side effects, time of onset and peak action, nursing implications. Administer and document administration of enteral and parenteral medications per order. Administer and document administration of topical medications per order. Evaluate client’s response to medication. Perform eye and/or ear irrigation according to agency guidelines. Meeting Mobility Needs Evaluate client’s need for range-of-motion exercises. Same Same Evaluate client’s level of mobility. Same Evaluate client’s need for range-of-motion Manage care of client who uses assistive devices. exercises. Provide client or family member with list of resources to Evaluate client’s level of mobility. contact when mobility or body alignment is impaired. Manage care of client who uses assistive Evaluate client and/or family members’ ability to perform devices. range-of-motion exercises. Provide client or family member with list of resources to contact when mobility or body alignment is impaired. (continued)
48 U n i t 1 The Growth of Nursing Baccalaureate Degree RN Table 3.1 Competencies for Nursing Skills (continued) Evaluate client and/or family members’ ability to perform range-of-motion Associate Degree RN exercises. Nursing Process Perform comprehensive assessment to Analyze collected data to establish a database for client. determine client’s ability to manage self-care, including physiological, Identify client health-care needs to select nursing psychosocial, developmental, and diagnostic statements. cognitive factors and their interaction with each other. Consider complex interactions of actual and potential nursing diagnoses. Formulate individualized nursing diagnoses, based on a synthesis of knowledge Identify client goals and appropriate nursing from nursing, biological and behavioral interventions. sciences, and humanities, that reflect a health problem and its etiology. Develop and communicate nursing care plan. Implement and document planned nursing interventions. Consider complex interactions of actual and potential nursing diagnoses Establish priorities for nursing care needs of clients. (e.g., two or more physiological and/or Evaluate and document the extent to which goals of psychosocial nursing diagnoses). nursing care have been achieved. Same Same Develop comprehensive plan of care in collaboration with client. Same Implement a care plan for individuals, families, and communities with complex health problems that have unpredictable outcomes. Use preventive, supportive, and restorative measures to promote client comfort, optimum physiological functioning, and emotional well-being. Base care planning on knowledge of primary, secondary, and tertiary levels of prevention. Same Participate in obtaining collective data concerning client outcomes. Deliver care that reflects an understanding of interactions among potentially conflicting nursing interventions. Initiate a comprehensive plan for discharge of client at time of admission.
C h a p t e r 3 Theories and Models of Nursing 49 Associate Degree RN Baccalaureate Degree RN Care for clients in an environment that may not have established protocols. Care for clients in situations requiring independent decision-making (e.g., community-based practice settings). Pain Management Evaluate data from comprehensive pain history. Same Evaluate and document client’s response to Same pharmacological and nonpharmacological Same interventions. Document client’s response to interventions used to Collaborate with other members of prevent or reduce pain. health-care team to identify alternative Assess client when pain is not relieved through ordered interventions. pharmacological and nonpharmacological methods. Same Evaluate appropriateness of any pain medication taken by clients. Same Same Educate clients on correct use of medications. Same Manage and monitor client receiving epidural analgesia. Teach client to use a PCA device. Perioperative Care Preoperatively, assess client’s risk for postoperative Same respiratory complications. Same Same Postoperatively, assess client’s ability to perform Same respiratory exercises. Same Same Preoperatively, assess client’s risk for postoperative Same thrombus formation. Postoperatively, assess client’s ability to perform passive range-of-motion exercises. Preoperatively, assess client’s willingness and capability to learn exercises. Preoperatively, assess family members’ willingness to learn and to support client postoperatively. Postoperatively, assess client’s condition during operative procedure, including range of vital signs, blood volume or fluid loss, fluid replacement, type of anesthesia, type of airway, and size and extent of surgical wound. Personal Hygiene of Clients Provide or assist with personal hygiene on Same developmental and/or chronological age basis. Same Provide or assist with personal hygiene needs as determined by physical limitations and/or diagnosis. (continued)
50 U n i t 1 The Growth of Nursing Table 3.1 Competencies for Nursing Skills (continued) Baccalaureate Degree RN Associate Degree RN Provide or assist with personal hygiene needs with Same respect to client’s culture and/or religious values. Same Same Provide or assist with personal hygiene care in hospital, nursing home, or client’s home. Assess and maintain chest tubes. Safety and Comfort Implement measures to protect the immunosuppressed Same client. Same Protect the client from injury. Same Verify identity of the client. Same Implement agency policies and procedures in the event Same of client injury. Follow policies and procedures for agency fires and Same Develop protocols for use of restraints safety measures. Follow procedures for handling biohazardous materials. or other safety devices. Assess need for restraints or other safety devices. Same Implement nursing measures to reduce the risk for falls, Same poisoning, and electrical hazards. Same Prepare for internal and external disasters. Same Develop a plan for reducing environmental stressors Same (e.g., noise, temperature, pollution). Evaluate client’s orientation to reality. Evaluate need for measures to maintain client’s skin integrity. Vascular Access Devices Assist with insertion of central venous catheters. Same Change a central venous catheter dressing. Same Monitor administration of medications/nutrients via a Same vascular access device. Same Measure and monitor central venous pressure. Same Maintain central vein infusions in adults and children. Same Change parenteral nutrition dressing and tubing. Wound Care and Dressings Assess and manage wounds, including irrigation, Same application of dressings, and suture/staple removal. PCA = patient-controlled analgesia. Sources: Nursing Skills Competency Program, American Nurses Credentialing Center, 2017, retrieved from https:// www.nursingworld.org/~4b0c0f/globalassets/organizational-programs/accreditation/nursing-skills-competency/ nursing-skills-competency-program-application/nscp-handbook-20170412.pdf; N. Merrifield, Draft list of over 90 skills, Nursing Times, 2018, retrieved from https://www.nursingtimes.net/news/professional-regulation/nmc-releases-draft- skills-list-for-nursing-associate-training/7023309.article.
A more current, realistic view is that of health as a C h a p t e r 3 Theories and Models of Nursing 51 continuum, ranging from a completely healthy state alterations in the environment will improve the cli- in which there is no disease to a completely unhealthy ent’s health status. state, which results in death. At any given time in our lives, we are located somewhere along the health con- Nursing tinuum and may move closer to one side or the other, The culminating concept in all the various nursing depending on circumstances and health status.7 models is nursing itself. After consideration of what it means to be a client, what it means to be healthy, Health is difficult to define because it varies so and how the environment influences the client’s much from one individual to another. For example, a health status (either positively or negatively), the 22-year-old bodybuilder who has no chronic diseases concept of nursing delineates the function and role perceives health differently than does an 85-year-old of nurses in their relationships with clients that affect who has diabetes, congestive heart failure, and vision the client’s health. problems. The perception of health also varies from one culture to another and at different historical Historically, the profession of nursing has been periods within the same culture. In some past cul- interested in providing basic physical care (i.e., tures, a sign of health was pale white skin, whereas hygiene, activity, and nourishment), psychological in recent American culture, a dark bronze tan was support, and relief of discomfort. Modern nursing, considered a sign of health—although research has although still including these basic elements of client shown how harmful ultraviolet light is to the skin. care, has expanded into areas of health care that were only imagined a generation ago. Environment Client as Partner The concept of environment is another element in In the modern nurse–client relationship, the client most current nursing models. Nursing models often is no longer the passive recipient of nursing care. broaden the concept of environment from the simple The relationship has been expanded to include physical environment to elements such as living con- clients as key partners in curing and in the health- ditions, public sanitation, and air and water quality. maintenance process. In conjunction with the Factors such as interpersonal relationships and social nurse, clients set goals for care and recovery, take interactions are also included. an active part in achieving those goals, and help in evaluating whether those actions have achieved Some internal environmental factors that affect the goals.8 health include personal psychological processes, religious beliefs, sexual orientation, personality, and Partnerships with patients emotional responses. It has long been known that equal successful recoveries. individuals who are highly self-motivated and inter- nally goal directed (i.e., type A personality) tend to develop ulcers and have myocardial infarctions at a higher rate than the general population. Medical models, which are primarily illness oriented, may not consider personality types treatable. Nursing models that consider personality as one of the environmental factors affecting health are more likely to attempt to modify the individual’s behavior (internal environ- ment) to decrease the risk for disease. Like the other key concepts found in nursing models, the concept of environment is consistent within a particular model’s overall structure. Nurs- ing models try to show how various aspects of environment interrelate and how they affect the client’s health status. In addition, nursing mod- els treat environment as an active element in the overall health-care system and assert that positive
52 U n i t 1 The Growth of Nursing What Do You Think? and almost anything that exists can be viewed as a system. How do you define nursing? What competencies are important for you to practice safely when you graduate? A Basis in Thought Although general systems theory in its pure form is rarely, if ever, used as a nursing model, its process Because of the broadened understanding of envi- and much of its terminology underlie many nursing ronment, several nursing models include manipula- tion of environmental elements that affect health as models. Elements of general systems theory in one form or another have found their way into many an important part of the nurse’s role. The environ- textbooks and much of the professional literature. ment may be directly altered by the nurse with little General systems theory often acts as the unacknowl- or no input from the client, or the client may be taught by the nurse to alter the environment in ways edged conceptual framework for many educational that will contribute to curing disease, increasing programs. An understanding of the mechanisms and terminology of general systems theory is helpful in comfort, or improving the client’s health status.9 providing an orientation to understanding nursing Four Key Concepts models. To analyze and under- stand any nursing model, Manageable “it is important to look for Fragments e culminating concept in all the various General systems theory, these four key concepts: nursing models is nursing itself. A er sometimes referred client, health, environ- consideration of what it means to be a to simply as systems ment, and nursing. client, what it means to be healthy, and theory, is an outgrowth These concepts should how the environment in uences the of an innate intellectual be clearly defined, closely client’s health status (either positively process. The human interrelated, and mutu- mind has difficulty ally supportive. Depend- ing on the particular or negatively), the concept of nursing comprehending a large, nursing model, one ele- complex entity as a ment may be emphasized delineates the function and role of nurses single unit, so it auto- more than the others. matically divides that The resultant role and ”in their relationships with clients that entity into smaller, more function of the nurse manageable fragments depend on which ele- a ects the client’s health. and then examines each ment is given greatest emphasis. fragment separately. This is similar to the process of deductive reasoning in which a single complex thought or theory is broken down into smaller, inter- GENERAL SYSTEMS THEORY related pieces. All scientific disciplines, from physics to biology and the social sciences (e.g., sociology and psychology), use this method of analysis. A widely accepted method for conceptualizing and understanding the world and what is in it derives from a systems viewpoint. Generally understood Reassembling the Fragments as an organized unit with a set of components that Systems theory takes the process a step further. After interact and affect each other, a system acts as a analyzing or breaking down the entity, systems the- whole because of the interdependence of its parts.10 ory attempts to put it back together by showing how As a result, when part of the system malfunctions or the parts work individually and together within the fails, it interrupts the function of the whole system system. This interrelationship of the parts makes the rather than affecting merely one part. The termi- system function as a unit. Often, particularly when nology and principles of systems theory pervade the system involves biological or sociological enti- U.S. society. Humans, plants, cars, governments, ties, the system that results is greater than the sum the health-care system, the nursing profession, of its parts.
For example, a human can be considered to be a C h a p t e r 3 Theories and Models of Nursing 53 complex biosocial system. Humans are made up of many smaller systems, such as the endocrine system, moves in and out of the system, thus making its neurological system, gastrointestinal system, urinary boundaries difficult to identify. Most systems have system, and so forth. Although each of these systems some control over the movement of information, is important, in and of themselves they do not make energy, and matter around them. This control is a human. Many animals have the same systems, yet maintained through the semipermeable nature of the human is more than the animal and more than their boundaries, which allows some things in and the sum of the systems. keeps some things out, as well as allowing some out while keeping others in. This control of input and A Set of Interacting Parts output leads to the dynamic equilibrium found in Although the early roots of general systems theory most well-functioning systems. can be traced as far back as the 1930s, Ludwig von Bertalanffy is usually credited with the formal devel- Closed Systems opment and publication of general systems theory Theoretically, a closed system prevents any move- around 1950.11 His major achievement was to stan- ment into and out of the system. In this case, the dardize the definitions of the terms used in systems system would be totally static and unchanging. Prob- theory and make the concept useful to a wide range ably no absolutely closed systems exist in the real of disciplines. Systems theory is so widely applicable world, although some systems may tend to be closed because it reflects the reality that underlies basic to outside elements. A stone, for example, considered human thought processes. as a system, seems to be almost perfectly closed. It does not take anything in or put anything out. It does Very simply, a system is defined as a set of inter- not change very much over long periods. In reality, acting parts. The parts that compose a system may though, it is affected by several elements in nature. be similar or may vary a great deal from each other, It absorbs moisture when it is damp, freezes when but they all have the common function of making the cold, and becomes hot in the summer. Over long system work well to achieve its overall purpose. periods, these factors may cause the stone to crack, break down, and eventually become topsoil. A school is a good example of how the dynam- ics and connections of a system work. A school as a Systems with which nurses deal frequently are rela- system consists of several units, including buildings, tively open. Primarily, the client can be categorized as a administrators, teachers, students, and various other highly open system that requires certain input elements individuals (e.g., counselors, financial aid personnel, and has output elements too. Other systems that nurses bookkeepers, and maintenance persons). Each of commonly work with (e.g., hospital administrators these individuals has a unique job but also contrib- and physicians) are generally considered to be open, utes to the overall goal of the school, which is to pro- although their degree of openness may vary widely. vide an education for the students and to further the development of knowledge through research. Input and Output The processes by which a system interacts with All systems consist of four key parts: the system elements in its environment are called input and itself (whether it is open or closed), input and output, output. Input is defined as any type of information, throughput, and a feedback loop. energy, or material that enters the system from the environment through its boundaries. Conversely, Open and Closed Systems output is defined as any information, energy, or A system is categorized as being either open or material that leaves the system and enters the envi- closed. Very few systems are completely open or ronment through the system’s boundaries. The end completely closed. Rather, they are usually a combi- product of a system is a type of output that is not nation of both. reusable as input. Open systems require relatively large amounts of input and output. Open Systems Open systems are those in which relatively free Throughput movement of information, matter, and energy into A third term sometimes used in relationship to the and out of the system exists. In a completely open system’s dynamic exchange with the environment is system, there would be no restrictions on what
54 U n i t 1 The Growth of Nursing Negative Feedback Negative feedback maintains stability—that is, it throughput. Throughput is a process that allows the does not produce change. Negative feedback is not input to be changed so that it is useful to the system. necessarily bad for a system. Rather, when a system has reached its peak level of functioning, negative For example, most automobiles operate on some feedback helps it maintain that level. For example, form of liquid fossil fuel (input) such as gasoline or if a person on a weight-loss regimen has reached diesel fuel. However, going to the gas station and the target weight, he or she knows what type of diet pouring liquid fuel on the roof of the car will not and exercise is needed to stay at the ideal weight. produce the desired effects. If the fuel is put into the Negative feedback—in the form of numbers on the gas tank, it can be transformed by the carburetor or bathroom scale—indicates that no changes in diet or fuel-injection system into a fine mist, which when exercise patterns are required. mixed with air and ignited by a spark plug burns rap- idly to produce the force necessary to propel the car. The feedback loop is an important element in sys- Without this internal process (throughput), liquid tems theory. It makes the process circular and links fuel is not a useful form of energy. the various elements of the system together. Without a feedback loop, it is virtually impossible for the sys- Feedback Loop tem to have any meaningful control over its input The fourth key element of a system is the feed- and output. back loop. The feedback loop allows the system to monitor its internal functioning so that it can either Feedback loops are used at all levels in a hospital. restrict or increase its input and its output and main- Nurses get feedback about the care they provide from tain the highest level of functioning. both clients and supervisors. The hospital admin- istration gets feedback from clients and accredit- Positive Feedback ing agencies. Physicians get feedback from clients, Two basic types of feedback exist. Positive feedback nurses, and the hospital administration. Since the leads to change within the system, with the goal of passage of the ACA with its emphasis on quality improving the system. For example, students in the of care, feedback from clients about the care they classroom receive feedback from the teacher in sev- received while in health-care facilities is an impor- eral ways; it may be through direct verbal statements tant part of the facilities’ economic survival. Systems such as “Good work on this assignment” or through theory is present, if sometimes unseen, in almost examination and homework grades. Feedback is con- all health-care settings. Professional nurses need to sidered positive if it produces a change in a student’s be able to understand and identify the components behavior, such as motivating him or her to study of systems theory when they are encountered to more, spend more time on assignments, or prepare improve their nursing practice and quality of care. more thoroughly for class. Improve test scores by learning NURSING THEORIES AND MODELS the test-taking tips. A Hierarchy Nursing theories and models are arranged into a hierarchical system. At the top are the grand theories and models, which are highly theoretical and contain broad general concepts and suppositions that dem- onstrate and mirror what the author has observed in his or her own experience of nursing care. These provide a broad way of conceptualizing nursing care and practice in almost all setting and situations. The abstract nature of these theories or models make them difficult to test through empirical nursing research, so they are difficult to translate into daily nursing care without significant modification.
C h a p t e r 3 Theories and Models of Nursing 55 The second level of nursing theories or mod- elements, then the theory or model is usually deemed els are referred to as middle-range nursing theo- a valuable contribution to nursing.12 ries or models. They differ from the grand models in that their scope is much narrower and they are much more concrete. Consequently, they are GRAND THEORIES OR MODELS easier to translate into a theory-based daily nurs- At least 15 published nursing models (or theories) ing practice. Because they are less complex, they usually deal with a limited number of variables, are considered grand and are used to direct nursing and more to the point, they are more amenable education and nursing care.12 The nursing models to scientific research testing. They serve as a discussed here (Table 3.2) were selected because way to connect some of the high-level abstract they are the most widely accepted and are good thinking found in grand models with the nurse’s examples of how the concepts of client, health, envi- everyday practice. ronment, and nursing are used to explain and guide Third are the nursing practice theories or models. nursing actions. Discussion of these theories is not These have an even narrower scope and less abstrac- intended to be comprehensive but rather to provide tion than the middle-range theories and are generally an overview of the main concepts of the nurse theo- limited to a particular situation or set of circum- rist. It is important to understand the terms used in stances. They provide the rationales for specific the theories as defined by their authors and to see nursing interventions and help guide the nurse in the interrelationship between the elements in each developing goals and outcomes for a specific patient theory as well as the similarities and differences or community. Nursing among the various students almost always models. use practice theories e feedback loop is an important element when they are develop- in systems theory. It makes the process The Roy ing care plans for their Adaptation assigned patients. “ circular and links the various elements of Model ”the system together. As developed by Sister Borrowed or shared Callista Roy, the Roy nursing theories or mod- adaptation model of els use knowledge from nursing is very closely other sciences and disci- plines and incorporate it into a theory or model that related to systems theory.13 The main goal of this focuses primarily on nursing. The borrowed knowl- model is to allow the client to reach his or her edge may come from psychology, medicine, systems highest level of functioning through the process of analysis, and so forth. These borrowed or shared adaptation. theories can be found at all three levels of nursing theories or models. Some borrowed theories include Client Nightingale, Roy, and Orem. Some nursing theories The central element in the Roy adaptation model is that do not borrow from others include Neuman, man (a generic term referring to humans in general, Watson, Parse, and Peplau. or the client in particular, collectively or individu- Nursing is always striving to develop a unique ally). Man is viewed as a dynamic entity with both body of knowledge. Does that fact make borrowed or input and output. As derived from the context of the shared theories less valuable than original theories? four modes in the Roy adaptation model, the client is Not necessarily. The key factors to look for are as defined as a biopsychosocial being who is affected by follows: (1) Is the knowledge being used harmoni- various stimuli and displays behaviors to help adapt ous with nursing knowledge? (2) Can the knowledge to the stimuli. Because the client is constantly being be placed in a nursing context where it becomes a affected by stimuli, adaptation is a continual process.13 part of a nursing framework? (3) Has the knowledge Inputs are called stimuli and include internal been modified or used in a way that can guide nurs- stimuli that arise from within the client and stimuli ing practice? and (4) Does the knowledge advance coming from external environmental factors such nursing knowledge? If the answer is yes to all four as physical surroundings, family, and society.
56 U n i t 1 The Growth of Nursing Table 3.2 Comparison of Selected Nursing Models Nursing Theory Client Health Environment Nursing Roy adaptation Human being—a A continuum with the Both internal Multistep process model dynamic system ability to adapt and external that helps the with input and successfully to stimuli client adapt Orem self-care output illness that affect and reach the model behaviors highest level of Human being— Able to live life to functioning King model biological, the fullest through The medium of goal psychological, self-care through which Assistance in self- attainment social being with the client care activities the ability for Dynamic process moves to help the Watson model self-care to achieve the client achieve of human highest level of Personal, health caring Person—exchanges functioning interpersonal, energy and and social Dynamic process Johnson information with Dynamic state systems and that identifies behavioral the environment to of growth and the external and meets the system meet needs development physical world client’s health- model leading to full care needs Individual—has potential as a The client must Neuman health- needs, grows, and human being overcome Science of caring care systems develops to reach certain factors that helps model a state of inner A behavioral system to achieve clients reach harmony able to achieve a health their greatest balanced, steady potential Person—a behavioral state All the internal system; an and external Activities that organized, An individual elements that manipulate the integrated whole with relatively affect client environment composed of stable internal behavior and help clients seven subsystems functioning of achieve the a high state of Internal and balanced state An open system that wellness (stability) external of health constantly interacts stressors with internal that produce Identifies and external change in the boundary environment client disruption and helps clients in activities to restore stability The output in the Roy adaptation model is the internal attempts to adapt to the input, or stimuli. Roy behavior that the client demonstrates as a result of identifies four internal adaptational activities that cli- stimuli that are affecting him or her. ents use, called the four adaptation modes: 1. The physiological mode (using internal physiologi- Output, or behavior, is a very important element in the Roy adaptation model because it provides the cal process) baseline data about the client that the nurse obtains 2. The self-concept mode (developed throughout life through assessment techniques. In this model, the output (behavior) is always modified by the client’s by experience)
3. The role function mode (dependent on the client’s C h a p t e r 3 Theories and Models of Nursing 57 relative place in society) Assessment 4. The interdependence mode (indicating how the The primary nursing assessments are of the client’s client relates to others) behavior (output). Basically, the nurse should try to determine whether the client’s behavior is adap- Health tive or maladaptive in each of the four adaptational In the Roy adaptation model, the concept of health modes previously defined. Some first-level assess- is defined as the location of the client along a con- ments of the client with pneumonia might include tinuum between perfect health and complete illness. a temperature of 104°F, a cough productive of thick In this model, health is rarely an absolute. Rather, green sputum, chest pain on inspiration, and signs of “a person’s ability to adapt to stimuli, such as weakness or physical debility, such as the inability to injury, disease, or even psychological stress, deter- bring in wood for the fireplace or to visit friends. mines the level of that person’s health status.”13 For example, a client who broke her neck in an automo- A second-level assessment should also be made bile accident and was paralyzed but who eventually to determine what type of stimuli (input) is affect- went back to college, obtained a law degree, and ing the client’s health-care status. In the case of the became a practicing lawyer would, in the Roy adap- pneumonia client, this might include a culture and tation model, be considered to have a high degree of sensitivity test of the sputum to identify the invasive health because of the ability to adapt to the stimuli bacteria, assessment of the client’s clothes to deter- imposed. mine whether they were adequate for the weather outside, and an investigation to find out whether any Environment neighbors could help the client upon discharge from The Roy adaptation model’s definition of environ- the hospital. ment is synonymous with the concept of stimuli. The environment consists of all those factors that Analysis influence the client’s behavior, both internally and After performing the assessment, the nurse analyzes externally. This model categorizes these environmen- the data and arranges them in such a way as to be tal elements, or stimuli, into three groups: (1) focal, able to make a statement about the client’s adaptive (2) contextual, and (3) residual. or maladaptive behaviors—that is, the nurse identi- fies the problem. In current terminology, this identi- Focal stimuli are environmental factors that most fication of the problem is called a nursing diagnosis. directly affect the client’s behavior and require most The problem statement is the first part of the three- of his or her attention. Contextual stimuli form the part PES (problem–etiology–signs and symptoms) general physical, social, and psychological environ- formulation that completes the nursing diagnosis ment from which the client emerges. Residual stimuli (Fig. 3.1). are factors in the client’s past, such as personality characteristics, past experiences, religious beliefs, Setting Goals and social norms, that have an indirect effect on the After the problem is identified, goals for optimal client’s health status. Residual stimuli are often very adaptation are established. Ideally, these goals should difficult to identify because they may remain hidden be a collaborative effort between the nurse and the in the person’s memory or may be an integral part of client. A determination of the actions needed to the client’s personality. achieve the goals is the next step in the process. The focus should be on manipulation of the stimuli to Nursing promote optimal adaptation. Finally, an evaluation is In the Roy adaptation model, nursing becomes a made of the whole process to determine whether the multistep process, similar to the nursing process, goals have been met. If the goals have not been met, to aid and support the client’s attempt to adapt to the nurse must determine why, not how, the activi- stimuli in one or more of the four adaptive modes. ties should be modified to achieve the goals.11 To determine what type of help is required to promote adaptation, the nurse must first assess The Orem Self-Care Model the client. Dorothea E. Orem’s model of nursing is based on the belief that health care is each individual’s own responsibility. The aim of this model is to help
pSruopblpeormt the58 U n i t 1 The Growth of Nursing Health In the Orem self-care model, health is defined as the PES StatementmanAifsested by person’s ability to live fully within a particular physi- cal, biological, and social environment, achieving a Problem higher level of functioning that distinguishes the per- son from lower life forms. Any problem or risk, either stated by the Quality of life is an extremely important element patient, or identified in this model of nursing. A person who is healthy is living life to the fullest and has the capacity to con- by the nurse tinue that life through self-care. According to Orem, an unhealthy person is an individual who has a self- Related to Etiology care deficit. Based on this definition, not only adults with diseases and injuries but also children, elderly Suggests a possible persons, and people with disabilities could be consid- cause of the stated ered unhealthy if they are not able to carry out one or more of the key health-care activities. These activities problem have been categorized into six groups: • Air, water, and food Signs and • Excretion of waste Symptoms • Activity and rest • Solitude and social interactions Subjective and objective • Avoiding hazards to life and well-being clues that indicate and • Maintaining healthy mental status while practicing support the presence of universal self-care the problem Self-Care Together, these components make up the PES In the Orem model, self-care is a two-part con- (Problem, Etiology, Signs/symptoms) statement, which cept. The first type of self-care is called universal is demonstrated below. self-care and includes those elements commonly found in everyday life that support and encour- Pain, acute, may be related to surgical wound, as age normal human growth, development, and manifested by facial grimacing, increased heart rate, functioning. Individuals who are healthy, accord- and verbal complaints of pain at the incision site. ing to the Orem model, carry out the activities listed in order to maintain a state of health. To Fi g u re 3 . 1 Together, these components make up the some degree, all of these elements are neces- PES (problem–etiology–signs and symptoms) statement: sary activities in maintaining health through Pain, acute, may be related to surgical wound, as manifested self-care.15 by facial grimacing, increased heart rate, and verbal complaints of pain at the incision site. The second type of self-care comes into play when the individual is unable to conduct one or more clients direct and carry out activities that maintain or of the six self-care activities. This second type of improve their health. Orem’s model is also referred self-care is called health deviation self-care. Health to as the self-care deficit model or theory because it deviation self-care includes those activities carried focuses on identifying and remediating where the out by individuals who have diseases, injuries, physi- client falls short in his or her self-care.14 ological or psychological stress, or other health-care concerns. Activities such as seeking health care at Client an emergency department or clinic, entering a drug As with most other nursing models, the central rehabilitation unit, joining a health club or weight- element of the Orem model is the client, who is a control program, or going to a physician’s office fall biological, psychological, and social being with the into this category. capacity for self-care. Self-care is defined as the prac- tice of activities that individuals initiate and perform on their own behalf to maintain life, health, and well- being. Self-care is a requirement for maintenance of life and for optimal functioning.
C h a p t e r 3 Theories and Models of Nursing 59 Environment who have not yet learned the technique of self- Environment, in the self-care model, is the medium administered insulin injections. through which clients move as they conduct their daily activities. Although less emphasized in this Supportive Developmental Care model, the environment is generally viewed as a neg- Clients who are able to meet all of their basic self-care ative factor in a person’s health status because many needs require very few or no nursing interventions. environmental factors detract from the ability to These clients fall in the supportive developmental cat- provide self-care. Environment includes social inter- egory of nursing care in which the nurse’s main func- actions with others, situations that must be resolved, tions are to teach the client how to maintain or improve and physical elements that affect health. health and to offer guidance in self-care activities and provide emotional support and encouragement. Nursing The primary goal of nursing in the Orem model is to What Do You Think? help the client conduct self-care activities in such a way as to reach the highest level of human function- Based on your experiences with the health-care system, write your own definition of a client (patient). What fac- ing. Because there is a range of levels of self-care abil- tors led you to this definition? ity, three distinct levels, or systems, of nursing care are delineated and are based on the individual’s abil- ity to undertake self-care activities. As clients become Also, the nurse may adjust the environment to sup- less able to care for themselves, their nursing care port the client’s growth and development toward needs increase. self-care or may identify community resources Wholly Compensated Care A person who is able to to help in the self-care carry out few or no self- process.15 Conducting care activities falls into “the wholly compensated nursing care category in which the nurse must provide for most or all ”of the client’s self-care needs. who require this level of care e primary goal of nursing in the Orem model is to help the client conduct self-care prenatal classes, arrang- activities in such a way as to reach the ing for discharge plan- ning, providing child highest level of human functioning. screening programs through a community health agency, and organizing aerobic exercise classes Examples of clients for postcoronary clients all are nursing actions that include comatose and belong in the supportive developmental category ventilator-dependent clients in an intensive care unit, of care. clients in surgery and the immediate recovery period, women in the labor and delivery phases of childbirth, and clients with emotional and psychological prob- A Three-Step Process lems so severe as to render them unable to conduct In the Orem model, nursing care is carried out through a three-step process. Step 1 determines normal activities of daily living (ADLs). whether nursing care is necessary. This step includes a basic assessment of the client and identification of Partially Compensated Care self-care problems and needs. Step 2 determines the Clients in the partially compensated category of appropriate nursing care system category and plans nursing care can meet some to most of their self- nursing care according to that category. Step 3 pro- care needs but still have certain self-care deficits vides the indicated nursing care or actions to meet that require nursing intervention. The nurse’s role the client’s self-care needs. becomes one of identifying these needs and carrying out activities to meet them until the client reaches a Step 3—the provision of nursing care (implementa- state of health and is able to meet the needs person- tion phase)—is carried out by helping the client through ally. Examples of this level of nursing care include one or a combination of five nursing methods:12 postoperative clients who can feed themselves and do basic ADLs but are unable to care for a catheter and • Acting for or doing for another person dressing and clients with newly diagnosed diabetes • Guiding another person
60 U n i t 1 The Growth of Nursing Environment Environment is an important concept in the King • Supporting another person (physically or model and encompasses a number of interrelated psychologically) elements. The personal and interpersonal systems or groups are central to King’s conception of environ- • Providing an environment that promotes personal ment. They are formed at various levels according to development internal goals established by the client. • Teaching another person Personal Systems Orem, by focusing on the individual’s ability to At the most basic level are the personal systems, where an interchange takes place between two indi- perform self-care, was many years ahead of her time. viduals who share similar goals. An example of such Current trends in health care reinforce her belief that a personal system is a client–nurse relationship. individuals can take responsibility for care of them- selves and others. The capacity for self-care is a key Interpersonal Systems premise of the ACA and the more than 8000 apps At the intermediate level are the interpersonal sys- that are available that deal with self-care. It might tems that involve relatively small groups of indi- even be referred to as “Digital Orem.” viduals who share like goals, for example, a formal weight-loss program in which the members have the The King Model of Goal Attainment common goal of losing weight. Human interactions, The current widely accepted practice of establish- communications, role delineation, and stress reduc- ing health-care goals for clients, and directing tion are essential factors at this level. client care to meet these goals, has its origins in the King model of goal attainment developed by Social Systems Imogene M. King. It is also called the King inter- At the highest level are social systems, which include vention model.16 the large, relatively homogeneous elements of society. The health-care system, government, and society in The King model also notes that nursing must general are some important social systems. Com- function in all three systems levels found in the mon goals of these social systems are organization, environment: personal, interactional, and social. authority, power, status, and decision. Although the The primary function of nursing is at the personal client may not be in direct interaction with the social systems level, where care of the individual is the systems, these systems are important because the main focus. However, nurses can effectively pro- personal and interpersonal systems necessarily func- vide care at the interactional systems level, where tion within larger social systems. they deal with small to moderate-sized groups in activities such as group therapy and health- Invoking the principle of nonsummativity, when- promotion classes. Finally, nurses can provide care ever one part of an open system is changed, all the at the social systems level through such activities other parts of the system feel the effect. For example, as community health programs. In addition, the a decision made at the governmental level to reduce role of nursing at the social systems level can be Medicare or Medicaid payments may affect when expanded to include involvement in policy deci- and how often a client can use health-care services sions that have an effect on the health-care system such as doctor’s office visits, group therapy, or emer- as a whole. gency department care. The King model also includes the external physical environment that affects a Client person’s health and well-being. As the person moves As in other nursing models, the focal point of care through the world, the physical setting interacts with in the King model is the person or client. The client the personal systems to either improve or degrade is viewed as an open system that exchanges energy the client’s health-care status. and information with the environment—a personal system with physical, emotional, and intellectual Health needs that change and grow during the course of life. Viewed as a dynamic process that involves a range of Because these needs cannot be met completely by human life experiences, health exists in people when the client alone, interpersonal systems are developed they can achieve their highest level of functioning. through interactions with others, depending on the Health is the primary goal of the client in the King client’s perceptions of reality, communications with others, and transactions to reduce stress and tension in the environment.
model. It is achieved by continually adjusting to C h a p t e r 3 Theories and Models of Nursing 61 environmental stressors, maximizing the use of avail- able resources, and setting and achieving goals for theory approach seen in many other nursing models. one’s role in life. Anything that disrupts or interferes Her main concern in the development of this model with people’s ability to function normally in their was to balance the impersonal aspects of nursing chosen roles is considered to be a state of illness. care that are found in the technological and scientific aspects of practice with the personal and interper- Nursing sonal elements of care that grow from a humanistic The King model considers nursing to be a dynamic belief in life. Watson is also one of the very few theo- process and a type of personal system based on rists who openly recognizes the client’s and family’s interactions between the nurse and the client. Dur- spiritual beliefs as an essential element of health.17 ing these interactions, the nurse and the client jointly evaluate and identify the health-care needs, set goals Client for fulfillment of the needs, and consider actions to The concept of client or patient in the Watson model take in achieving those goals. Nursing is a multifac- is developed closely with the concept of nursing. The eted process that includes a range of activities such individuality of the client is a key concern. “The Wat- as the promotion and maintenance of health through son model views the client as someone who has needs, education, the restoration of health through care who grows and develops throughout life, and who of the sick and injured, and preparation for death eventually reaches a state of internal harmony.”17 through care of the dying.16 The client is also seen as a gestalt, or a whole entity, The process of nursing in the King model includes who has value because of inherent goodness and five key elements considered central to all human capacity to develop. This gestalt, or holistic, view of interactions: the human being is a recurring theme in the Watson • Action: A sequence of behaviors involving mental model; it emphasizes that the total person is more important to nursing care than the individual injury or and physical activities disease process that produced the need for care. • Reaction: The resulting behaviors produced by the Environment process of action Environment in the Watson model is a concept • Interaction: The client and nurse communicating that is also closely intertwined with the concept of nursing. Viewed primarily as a negative element in together to establish goals the health-care process, the environment consists • Transaction: A life situation in which perceivers of those factors that the client must overcome to achieve a state of health. The environment can be and things perceived are encountered and entered both external (physical and social elements) and into as active participants internal (psychological reactions that affect health). • Feedback: Change that occurs as a result of the interaction and transaction process. Health To be healthy, according to the Watson model, the With some modifications, the King model has individual must be in a dynamic state of growth and been successfully implemented in a variety of health- development that leads to reaching full potential as a care settings ranging from rural clinics to acute human. As with other nursing models, health is viewed urban care centers. Its focus on the one-on-one inter- as a continuum along which a person at any point may action between the nurse and the client is at the heart tend more toward health or more toward illness. of all nursing practice. Establishing goals with the client rather than for the client raises the success level Illness, in the Watson model, is the client’s of the interventions and promotes better outcomes. inability to integrate life experiences and the failure to achieve full potential or inner harmony. In this The Watson Model of Human Caring model, the state of illness is not necessarily synony- Although the concept of caring has always been an mous with the disease process. If the person reacts to important, if somewhat obscure, element in the prac- the disease process in such a way as to find meaning, tice of nursing, the Watson model of human caring that response is considered to be healthy. A failure defines caring in a detailed and systematic manner. to find meaning in the disease experience leads to a In the development of her model, Jean Watson used state of illness. a philosophical approach rather than the systems
62 U n i t 1 The Growth of Nursing Issues Now The Pew Commission Final Report Projected estimates of the nursing shortage based on data collected by the U.S. Bureau of the Census Current Population Survey, Division of Nursing, the Pew Commission, and the Buerhaus and Staiger data collection agency in 1998 are now considered woefully inad- equate. According to the Bureau of Labor Statistics (2017), by 2022 the nursing shortage could be much worse, with as many as 1 million nursing positions unfilled. Some say the worst shortage may be regional in nature. The Pew Commission’s final report addresses the competencies that nurses in the future will need. Twenty-One Competencies for the 21st Century 1. Embrace a personal ethic of social responsibility and service. 2. Exhibit ethical behavior in all professional activities. 3. Provide evidence-based, clinically competent care. 4. Incorporate the multiple determinants of health in clinical care. 5. Apply knowledge of the new sciences. 6. Demonstrate critical thinking, reflection, and problem-solving skills. 7. Understand the role of primary care. 8. Rigorously practice preventive health care. 9. Integrate population-based care and services into practice. 10. Improve access to health care for those with unmet health needs. 11. Practice relationship-centered care with individuals and families. 12. Provide culturally sensitive care to a diverse society. 13. Partner with communities in health-care decisions. 14. Use communication and information technology effectively and appropriately. 15. Work in interdisciplinary teams. 16. Ensure care that balances individual, professional, system, and social needs. 17. Practice leadership. 18. Take responsibility for quality of care and health outcomes at all levels. 19. Contribute to continuous improvement of the health-care system. 20. Advocate for public policy that promotes and protects the health of the public. 21. Continue to learn and help others to learn. The Pew Commission also identified five key areas for professional education: 1. Change professional training to meet the demands of the new health-care system. 2. Ensure that the health profession workforce reflects the diversity of the nation’s population. 3. Require interdisciplinary competence in all health professionals. 4. Continue to move education into ambulatory practice. 5. Encourage public service of all health-professional students and graduates. The changes that will occur over the next decade may take some health-care pro- fessionals out of their comfort zone, but they will also open a vista of opportunities for those willing to look creatively into the future. Nursing has to recognize that it will
Chapter 3 Theories and Models of Nursing 63 I s s u e s N o w (continued) grow only to the extent that it is able to contribute to the needs of an evolving health- care system. These needs will change with time. The Pew Report, although broad in scope, provides the nursing profession with a blueprint for dealing with these changes as they occur. It is a call to action that nurses and the nursing profession need to hear. Sources: NURSE.com, US still headed for a nurse shortage, 2017, retrieved from https://www.nurse .com/blog/2016/02/16/u-s-still-headed-for-nurse-shortage; J. P. Bellack and E. H. O’Neil, Recreating nursing practice for a new century: Recommendations of the Pew Health Professions Commission’s Final Report, Nursing and Health Care Perspectives, 21(1):14–21, 2000; U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analy- sis, National and regional supply and demand projections of the nursing workforce: 2014–2030, 2017; B. Donaho, The Pew Commission Report: Nursing’s challenge to address it, ANNA Journal, 24(5): 507–512, 1997. Nursing help and trust between the nurse and the client; Watson makes a clear distinction between the sci- encouraging the client to express both positive and ence of nursing and the practice of curing (medi- negative feelings with acceptance; manipulating cine).12 She defined nursing as the science of caring the environment to make it more supportive, pro- in which the primary goal is to assist the client to tective, or corrective for the client with any type reach the greatest level of personal potential. The of disease process; and assisting in whatever way practice of curing involves the conduct of activities is deemed appropriate to meet the basic human that have the goal of treatment and elimination of needs of the client.17 disease. The Johnson Behavioral System Model The process of nursing in the Watson model is By integrating systems theory with behavioral theory, based on the systematic use of the scientific problem- Dorothy E. Johnson developed a model of nursing solving method for decision-making. To best under- that considers client behavior to be the key to pre- stand nursing as a science of caring, the nurse should venting illness and to restoring health when illness hold certain beliefs and be able to initiate certain occurs. Johnson holds that human behavior is a type caring activities. of system in itself that is influenced by input factors from the environment and has output that in turn Values affects the environment.18 Basic to the beliefs necessary for the successful practice of nursing in the Watson model is the for- Client mation of a humanistic, altruistic system of values Drawing directly on the terminology of systems based on the tenet that all people are inherently theory, the Johnson model describes the person, valuable because they are human. In addition, the or client, as a behavioral system that is an orga- nurse should have a strong sense of faith and hope nized and integrated whole. The whole is greater in people and their condition because of the human than the sum of its parts because of the integration potential for development. and functioning of its subsystems. In the Johnson model, the client as a behavioral system is com- Caring posed of seven distinct behavioral subsystems. According to Watson’s caring model, several activities are important in the practice of nurs- ing. These include establishing a relationship of
64 U n i t 1 The Growth of Nursing In turn, each of these seven behavioral subsystems themselves from harm, either internal or exter- contains four structural elements that guide and nal, derive from this subsystem and are shown shape the subsystem. in actions toward others and the environment in general. Security The first behavioral subsystem is the attachment, or Achievement affiliate, subsystem. Its driving force is security. For the most part, the type of activity that this subsys- The seventh, and final, behavioral subsystem is achievement. Exploration and manipulation of the tem undertakes is inclusion in social functions, and environment are the objectives of this subsystem. the behavior that is observed from this subsystem is Gaining mastery and control over the environ- social interaction. ment is the primary activity; it can be demonstrated externally when the individual shows that learning Dependency has occurred and higher-level accomplishments are The second behavioral subsystem is dependency; being produced.18 its main goal is to help others. The primary type of activity involved is nurturing and promoting self- As with all open systems, the behavioral sys- image. The observable behaviors that are a result of tem that makes up the person seeks to maintain a this activity include approval, attention, and physical dynamic balance by regulating input and output. assistance of the person. This regulation process takes the form of adapting to the environment and responding to others. However, the Johnson model sees human behavior as being Taking In goal oriented, which leads The third behavioral the person to constant subsystem is the ingestive growth and development subsystem. Its motive is beyond the maintenance to meet the body’s basic of a mere steady state. physiological needs of “food and nutrient intake. Correspondingly, its pri- mary activity is seeking and eating food. ”Eliminative Behavior e Johnson model sees human behavior as being goal directed, which leads the person to constant growth and development beyond the maintenance of a mere steady state. Health According to the John- son model, a state of health is achieved when balance and a steady state exist within the behav- The fourth behavioral subsystem is the elimina- ioral systems of the client. Under normal circum- tive; its goal is removing waste products from the stances, the human system has enough inherent system. Its primary activity is means of elimination, flexibility to maintain this balance without external which is observed as the behavior of expelling waste intervention. At times, however, the system’s bal- products. ance may be disturbed to such a degree by physical Sexual Behavior disease, injury, or emotional crisis as to require The fifth behavioral subsystem is sexual behavior, external assistance. This out-of-balance state is the which is found in the Johnson model’s description state of illness. of the person. The sexual subsystem has gratification Environment and procreation of the species as its goals. It involves In the Johnson model, the environment is defined as the complex activities of identifying gender roles, all those internal and external elements that have an undergoing sexual development, and participating effect on the behavioral system. These environmental in sexual activity. It manifests itself in courting and elements include obvious external factors, such as mating behaviors. air temperature and relative humidity; sociological Self-Protection factors, such as family, neighborhood, and society in The sixth behavioral subsystem is the aggressive general; and the internal environment, such as bodily subsystem; its main goal is self-preservation. All of processes, psychological states, religious beliefs, and the actions that individuals undertake to protect political orientation.
C h a p t e r 3 Theories and Models of Nursing 65 All seven behavioral subsystems are involved with health-care disciplines apart from nursing. Draw- the client’s relationship to the environment through ing from systems theory, the Neuman model also the regulation of input and output. The client is includes elements from stress theory with an overall continually interacting with the environment in an holistic view of humanity and health care.19 attempt to remain healthy by maintaining an internal dynamic balance. Client In this model, the client is viewed as an open system that interacts constantly with internal and external Nursing environments through the system’s boundaries. The In the Johnson model, nursing is an activity that client-system’s boundaries are called lines of defense helps the individual achieve and maintain an opti- mal level of behavior (state of health) through the and resistance in the Neuman model and may be represented graphically as a series of concentric manipulation and regulation of the environment.18 circles that surround the basic core of the indi- Nursing has functions in both health and illness. Nursing interventions to either maintain or restore vidual. The goal of these boundaries is to keep the basic core system stable by controlling system input health involve four activities in the regulation of the and output. environment: Neuman classifies these defensive boundaries • Restricting harmful environmental factors according to their various functions. The internal • Defending the client from negativeenvironmental lines of resistance are the boundaries that are closest influences to the basic core and thus protect the basic inter- • Inhibiting adverse elements nal structure of the system. The from occurring normal lines of • Facilitating positive internal In the Johnson model, nursing is an defense are outside activity that helps the individual achieve the internal lines environmental factors in the and maintain an optimal level of behavior of resistance; they recovery process (state of health) through the manipulation protect the system and regulation of the environment. from common, “As a professional, the nurse in the Johnson model provides direct services to the ”multiple subsystems that are found in the client’s everyday environ- client. By interacting with, and mental stressors. sometimes intervening in, the The flexible line of defense surrounds the normal line environment, the nurse acts as an external regulatory of defense and protects it from extreme environmen- force. The goal of nursing is to promote the highest tal stressors. The general goal of all these protective level of functioning and development in the client at boundaries is to maintain the internal stability of the all times. individual. Nursing actions include helping the client act in a socially acceptable manner, monitoring and aiding Health biological processes that are necessary for maintain- ing a dynamic balance, demonstrating support for Health, then, in the Neuman model is defined as the medical care and treatment during illness, and tak- relatively stable internal functioning of the client. ing actions to prevent illness from recurring. In this Optimal health exists when the client is maintained model, nursing makes its own unique contribution to in a high state of wellness or stability. the health and well-being of individuals and provides a service that is complementary to those provided by As in other nursing models, health is not consid- other health-care professionals. ered an absolute state but rather a continuum that reflects the client’s internal stability while moving from wellness to illness and back. It takes a consider- able amount of physical and psychological energy to The Neuman Health-Care Systems Model maintain the stability of the person who is in good As envisioned by Betty Neuman, the health-care health. systems model focuses on the individual and his or The opposite of a healthy state, illness, exists when her environment and is applicable to a variety of the client’s core structure becomes unstable through
66 U n i t 1 The Growth of Nursing A secondary intervention is aimed at treat- ing symptoms that have already been produced by the effects of environmental factors that overwhelm stressors. Many of the actions that nurses perform in and defeat the lines of defense and resistance. These the hospital or clinic (e.g., giving pain medications environmental factors, whether internal or external, or teaching a client with cardiac disease about the are called stressors in this model. benefits of a low-sodium diet) fall into this secondary intervention category. Environment The environment is composed of internal and A tertiary intervention seeks to restore the cli- external forces, or stressors, that produce change or ent’s system to an optimal state of balance by adapt- response in the client. Stressors may be helpful or ing to negative environmental stressors. Teaching harmful, strong or weak. a client how to care for a colostomy bag at home after discharge from the hospital is an example of a Stressors are also classified according to their rela- nursing activity at the tertiary level. It occurs after tionship to the basic core of the client-system. Stress- the client has received a secondary intervention and ors that are completely outside the basic core are offers support to the client so that he or she can termed extrapersonal and are either physical, such continue to recover or prevent further deterioration as atmospheric temperature, or sociological, such in health. as living in either a rural or an urban setting. Inter- personal stressors arise from interactions with other What Do You Think? human beings. Marital relationships, career expecta- tions, and friendships are included in this group of Which of these grand theories appeals to you most? interpersonal stressors. Those stressors that occur Why? How would you apply it to an actual client you within the client are called intrapersonal and include have seen in the clinical setting or to a sick family involuntary physiological responses, psychological member? reactions, and internal thought processes. TRENDS FOR THE FUTURE Nursing IN NURSING THEORY The nurse’s role in the Neuman model is to identify at what level or in which boundary a disruption in Although the search for the perfect nursing model the client’s internal stability has taken place and continues, the emphasis in recent years has shifted then to aid the client in activities that strengthen or from developing new theories to applying existing restore the integrity of that particular boundary.19 theories to nursing practice. Also, modern theorists The Neuman model expands the concept of client seem to be more interested in expanding existing from the individual to include families, small groups, nursing theories by including such concepts as cul- the community, or even society in general. tural diversity, spirituality, family, and social change Identifying Stressors rather than starting over from the beginning. A good Nursing’s main concern in this model is either to example of this trend is the cultural meaning–cen- identify stressors that will disrupt a defensive bound- tered theory that was published by Mendyka and ary in the future (prevention) or to identify a stressor Bloom.20 This theory expands the King model by that has already disrupted a defensive boundary, adding a cultural perspective. thereby producing instability (illness).19 The Neuman model is based on the nursing process and identifies A More Recent Theory three levels of intervention: primary, secondary, and One of the more recent of the established nursing tertiary. theories is the human becoming theory proposed by Types of Intervention Rosemary Rizzo Parse. Although her original work The main goal of a primary intervention is to pre- started in 1981, a more developed form of her theory vent possible symptoms that could be caused by was published in 1987.20–22 Parse’s theory stresses the environmental stressors. Teaching clients about elements of experience, personal values, and lifestyle stress management, giving immunizations, and choices in the maintenance of health. encouraging aerobic exercise to prevent heart disease are examples of primary interventions.
A Matter of Choice C h a p t e r 3 Theories and Models of Nursing 67 In this theory, the client can be any person or family who is concerned with the quality of their or nursing. They are less abstract than the grand life situation. The client is viewed as an open, theories and are much more easily applied to practice whole being who is influenced by past and present hypotheses. However, when several middle-range life experiences. The ability to make free choices theories are used to investigate the same or similar is essential in this theory. The client, through concepts over a period of time, they can be woven choices he or she makes, interacts with the envi- together to reinforce or even form the fabric of a new ronment to influence health either positively or grand nursing theory.24 negatively. Middle-range theories should be socially signifi- For Parse, health is an ongoing process. Because cant, meaning that they deal with people or popula- clients make free choices, their health status is con- tions with health-care conditions. They should also tinually unfolding. In addition, health is determined have theoretical significance, meaning that they by lived experiences, synthesis of values, and the way develop a new set of facts or data that adds to the the client lives.23 theoretical knowledge base of nursing. The whole movement toward evidence-based practice (EBP) Finding Meaning depends on this type of research. Middle-range The main role of nursing in the Parse model is to theories often form the theoretical framework for a guide clients in finding and understanding the mean- research project. ing of their lives. Once the client chooses a healthy life situation, the nurse can further increase the qual- Two Middle-Range Nursing Theories ity of the client’s life and improve his or her health Formulated in 1987, Dr. Nola Pender’s health status. The ability to change the client’s health- promotion model is widely used as the theoreti- related values is an important skill for nurses to mas- cal framework for research on prenatal care and ter in this model. pregnancy. It is based on her conceptualizations of Orem’s self-care model. Pender proposes that sev- Parse does not specifically define the concept of eral key factors provide the primary motivation for environment in relationship to her theory. It seems individuals to adopt behaviors that maintain and to be any health-related setting, but it can also be improve their health.25 These factors include the expanded to include past and present experiences. person’s perception of • How important it is to be healthy. MIDDLE-RANGE THEORIES AND MODELS • How much control they have over their health. • How much control they have over the health-care Middle-range theories and models have been pres- ent in nursing research for many years. More than 50 system. have identified themselves as middle range, although • What it means to them to be healthy. many more fit into the category.24 A middle-range • What their current health status is. theory is a set of relatively concrete concepts or propo- • What the benefits and barriers are to health sitions that lie between a minor working hypothesis found in everyday nursing practice theories and a improvement. well-developed grand nursing theory, like those previ- The goal of the individual is to move toward a bal- ously discussed.24 Middle-range models develop from middle-range theories, although not all middle-range anced state of positive health and well-being.26 Health theories have a model. is up to the individual, not the health-care system; although the health-care system can be an important Middle-range theories generally contain only part, it will always be secondary to the individual. a few basic ideas or concepts that researchers are attempting to prove or illustrate. They do not have Swanson’s theory of caring, first published in a large number of variables and tend to focus on 1991, was inspired by the writings of Jean Watson one or two problems that are linked, like the grand and by Kristen M. Swanson’s own experiences as a theories, to human beings, environment, health care, nurse providing care for clients and families. As she observed how clients used their internal strengths to overcome their illnesses and transition to a state of health, Swanson began to see a pattern of how clients who successfully made the transition to wellness
68 U n i t 1 The Growth of Nursing related to other individuals and how those individu- care, mental health, public health, hospice, gerontol- als affected the final health status of the client.27 ogy, and oncology. As the elements of the theory became more Some other middle-range theories that are defined, Swanson conducted three studies that rein- commonly used in nursing research include forced the underlying assumptions of her theory. Mishel’s uncertainty in illness theory, Reed’s self- The data from these three studies were used to bet- transcendence theory, Thomas’s women’s anger ter clarify the key concepts of her theory: person, theory, Jezewski’s cultural brokering theory, Auvil- environment, health/well-being, and caring actions. Novak’s chemotherapeutic intervention for post- Based on additional research, Swanson was able to surgical pain theory, Good and Moore’s balance develop instruments to measure key concepts and between analgesia and side effects theory, and Huth identify concrete interventions to use in implement- and Moore’s acute pain management theory.29 ing her theory of caring.28 She identified five “caring processes” that were essential to the successful tran- New Challenges to Nursing Theory sition to health experienced by clients: knowing, As with any developing science, nursing will con- being with, doing for, enabling, and maintaining tinue to change and respond to the dynamic trends belief.29 of society. Older nursing models will be either The role of the nurse in the theory of caring replaced by new ones or modified to include devel- is to guide the client through discussions of their oping concepts. Indeed, one of the hallmarks of a experiences so that they believe their problems sound nursing theory or model is its flexibility and are understood by the ability to adapt to new nurse. Through these discoveries. discussions, clients are “ When several middle-range theories are An increasing num- kept informed with key used to investigate the same or similar information, their needs concepts over a period of time, they can ber of independent are met, their lives are be woven together to reinforce or even nurse practitioners and validated, and the nurse’s other advanced prac- ”form the fabric of a new grand nursing tice nurses are testing belief in the client’s abil- nursing theories as they ity to move toward well- theory. have never been tested ness is expressed. The before. The theories that anticipated outcome is are flexible, realistic, that the clients are better and usable in practice able to integrate their sufferings and losses into their will survive and remain as the pillars of professional lives.27 Although originally studied in the perinatal nursing.23 Those that are too theoretical or rigid will setting, the theory of caring has been adopted to fall by the wayside and become mere footnotes in many other health-care settings, including critical nursing texts. Conclusion The development of nursing theory and mod- els indicates a maturing of the profession. As As nursing takes its rightful place among the other the knowledge associated with the profession helping professions, nursing theory will take on addi- increases and becomes unique, more complex, tional importance. Nursing theories and models are and better organized, the general body of nurs- the systematic conceptualizations of nursing practice ing science knowledge also increases and EBP and how they fit into the health-care system. Nursing becomes a reality. When nursing becomes a theories help describe, explain, predict, and control well-developed body of specialized knowledge, nursing activities to achieve the goals of client care. By it will be fully recognized as a separate scientific understanding and using nursing theory, nurses will discipline and take its rightful place as a true be better able to incorporate theoretical information profession. into their practice to provide new ways of approaching nursing care and improving nursing practice.
C h a p t e r 3 Theories and Models of Nursing 69 Critical-Thinking Exercises Mrs. M is an 88-year-old woman who has been a resident of St. Martin’s Village, a lifetime care community, since her husband died 8 years ago. Her health status is fair. She has adult-onset diabetes controlled by oral medication and a scar from a tumor behind her left ear that was removed surgically. The wound from this tumor removal has never healed completely, and it has continuously oozed a serous fluid, requiring a dressing. At St. Martin’s Village, Mrs. M has her own apartment, which she maintains with minimal assistance. She receives one hot meal each day in a common dining room and has access to a full range of services such as a beauty shop, recreational facilities, and a chapel. She is generally happy in this setting. She has no immediate family nearby, and the cost of the facility was covered by a large, one-time gift from her now-deceased husband. Recently, she is becoming increasingly weak and has difficulty walking; attending activities, including meals; and changing the dressing on her ear. The nurse at St. Martin’s Village is sent to evaluate this client. • Select two nursing models and apply their principles to this case study. Make sure you include the concepts of client, health, environment, and nursing. NCLEX-STYLE QUESTIONS 4. General systems theory is the theoretical basis for many nursing theories and models. What 1. Why are theories and models important to the aspect of general systems theory is most compa- profession of nursing? rable to the key concept of nursing in nursing 1. They describe the interventions nurses use to theory? care for patients. 1. Input 2. They provide a conceptual structure for under- 2. Output standing nursing care and practice. 3. Throughput 3. They help nonmedical people understand what 4. Feedback loop nurses do. 4. They distinguish between the competencies 5. According to the Sister Callista Roy’s model, required of ADNs and BSNs. what is the best measure of a person’s health status? 2. What key concepts are commonly found in nurs- 1. The person’s ability to care for himself or ing theories and models? Select all that apply. herself. 1. Client 2. The person’s ability to adapt to the stimuli 2. Environment imposed on him or her. 3. Health 3. The person’s ability to engage in the dynamic 4. Nursing process of the nurse–client relationship. 5. Feedback 4. The person’s ability to integrate life experiences and achieve his or her full potential. 3. ___________ theories or models have a narrow scope, are concrete rather than abstract, and pro- vide rationales for specific nursing interventions.
70 U n i t 1 The Growth of Nursing 6. What distinguishes a middle-range theory from a 3. Changing one’s environment is an act of grand theory of nursing? self-care. 1. Middle-range theories have a large number of variables, while grand theories have only a few. 4. Nursing interventions include helping the cli- 2. Grand theories should be socially significant, ent change his or her environment. while middle-range theories have theoretical significance. 9. In what way is the human body a system, accord- 3. Middle-range theories, not grand theories, form ing general systems theory? the theoretical framework for EBP research 1. The human body takes in food (input) and projects. excretes waste (output). 4. There are fewer middle-range theories than 2. The human body is an open system, which is there are grand theories. why pathogens can make us ill. 3. The human body has a feedback loop that sig- 7. What is the goal of Orem’s self-care model of nals when we have had enough to eat. nursing? 4. The human body functions as a set of inter- 1. To return the client to a disease- or illness-free acting parts that work together to achieve an state overall purpose. 2. To allow the client to reach his or her full potential as a human 10. Which factor has had the greatest effect on the 3. To return the client to a state of balance that rise of middle-range nursing theories? does not require external intervention 1. The increasing numbers of research-focused 4. To help the client direct and carry out activities PhD-level nurses. that maintain or improve his or her health 2. The rise of EBP as the gold standard for care. 3. The rejection of the grand theories for being 8. One key concept of nursing theories is that of out of touch with bedside care. environment. What theme related to environment 4. The changing requirements of graduate is present across several grand nursing theories? schools of nursing. 1. Environment, both internal and external, can negatively affect a person’s health. 2. Environment cannot be changed and must be adapted to. References 6. Bernstine R. Categorizing Care: A guide to nursing inter- ventions [blog post]. Husson Education Online, 2017. 1. Karnick P. Evidence-based practice and nursing theory. Retrieved November 2017 from https://online.husson.edu/ Nursing Science Quarterly, 29(4):283–284, 2016. https://doi nursing-interventions-nic-system .org/10.1177/0894318416661107 7. Dupree D. Four basic metaparadigm concepts in nursing. 2. Glassman K. Developing and implementing a professional Career Trend, 2017. Retrieved from https://careertrend. practice model. Nursing Science Quarterly, 29(4):336–339, 2016. com/13373959/four-basic-metaparadigm-concepts-in-nursing https://doi.org/10.1177/0894318416662928 8. The practicality of nursing theory in the future. Nurse Journal, 3. Struwdik G, Hardiker N. Understanding the use of standardized 2017. Retrieved from https://nursejournal.org/community/ nursing terminology and classification systems in published the-practicality-of-nursing-theory-in-the-future research: A case study using the International Classification for Nursing Practice. Health Advance, 94(10): 215–221, 2016. 9. Benner P. Florence Nightingale environmental theory of nurs- https://doi.erg/10.1016/j.ijmedinf.2016.06.012 ing explained. HealthResearchFunding.org, 2017. Retrieved from https://healthresearchfunding.org/florence-nightingale- 4. Bulechek GM, Butcher HK, Dochterman JM. Nursing Interventions environmental-theory-of-nursing-explained Classification (NIC) (6th ed.). St. Louis, MO: Mosby Elsevier, 2016. 10. Thompson C. Borrowed theory in nursing theory development. 5. Kleber K. 7 Nursing interventions you use every single shift CJT Consulting & Education, 2017. Retrieved from https:// [blog post]. NRSNG, 2017. Retrieved November 2017 from nursingeducationexpert.com/borrowed-theory https://www.nrsng.com/7-nursing-interventions-every-single- shift-written-nurse 11. Rodgers B. The evolution of nursing science. In JB Butts & KL Rich (Eds.), Philosophies and Theories for Advanced Nursing
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The Process 4 of Educating Nurses Joseph T. Catalano Learning Objectives EDUCATIONAL PATHWAYS After completing this chapter, Unlike many other professions, nursing has several related the reader will be able to: but unique educational pathways that lead to licensure and professional status. Indeed, the current system of nursing • Explain why the Institute of education creates confusion about nursing not only among the public Medicine (IOM) competencies but also among nurses. Perhaps the belief that “a nurse is a nurse is a are important to nursing educa- nurse” developed because, even though registered nurses (RNs) may tion and how they improve qual- be trained in educational programs that vary in length, orientation, ity of care and content, the graduates all take the same licensing examination and, superficially, all seem able to provide the same level of care. • List the six Quality and Safety Education for Nurses (QSEN) PARADIGM SHIFTING competencies and their relation- ship to nursing education The current profession of nursing faces many difficult challenges and extraordinary opportunities. Future trends in health care are being • Compare the major differences driven by several powerful government and societal forces that are among the diploma, associate producing an inevitable reshaping of health-care delivery. Tradition- degree nursing, and bachelor of ally somewhat insulated from the forces of change, nursing educators science in nursing educational have been made to recognize that graduates need to be prepared with programs knowledge and skills that are in tune with a rapidly evolving health- care system. The most powerful of these forces of change are • Discuss at least three types of • Health-care reform that will increase the availability of health care to advanced nursing degrees more diverse clients who previously were shut out of the health-care • Distinguish between the different market. types of doctoral degrees avail- • The wider use of capitated managed care for financing coverage and able to nurses a market-driven system. • Explain the concept of advanced practice for nurses • Discuss the significance of the doctorate in nursing practice for advanced practice nurses • Identify and explain the importance of interprofessional education for nurses and future nursing practice 72
C h a p t e r 4 The Process of Educating Nurses 73 • The increasing age and diversity of the U.S. In this regard, the consumers of the products of population. nursing education—that is, the health-care entities • The shortage of nurses. that hire nursing school graduates—have had an • The shortage of qualified nursing faculty. important if somewhat unstructured role in deter- • The rapid leaps forward in health care and infor- mining curricular content. mation technology. • The government’s attempts to increase health-care The Pew Study coverage for uninsured citizens. The Pew Health Professions Commission Study, or Pew Report, was published in the late 1990s. It was In the 2016 report of the Bureau of Labor Statics, the first comprehensive study to systematically 60.5 percent of RNs were employed in acute care address which competencies nursing students should hospitals, and that trend appears likely to continue possess upon graduation.3 A few of the 21 recom- well into the future.1 Hospitals have attempted to mendations for all schools preparing health-care slow the drain of nurses to other employment set- professionals are tings by seeking Magnet status certification, which identifies the facility as being “nurse friendly” and • Expanding the scientific basis of the programs. a place where the nurse turnover rate is low.2 The • Promoting interdisciplinary education. other 40 percent of nurses are employed in a wide • Developing cultural sensitivity. variety of settings, including private practice, public • Establishing new alliances with managed-care health agencies, home health care, primary nurs- companies and government. ing, school-operated nurs- • Increasing the use of com- ing centers, ambulatory care centers, insurance and Nursing educators are continually puter technology and managed-care companies, challenged to evaluate whether the interactive software. education, and health-care The Pew Report also research. There is also an “ graduates of their programs are ever-growing group of adequately prepared to meet the recommends a differenti- emerging health occupa- demands of all areas of care. ated practice structure to tions that have not yet been simplify and consolidate the officially recognized by pro- titles that are used for the fessional organizations. ”for each level. While the Pew study was in its final different practitioner levels so that there is just one title What Do You Think? stages, the Institute of Medicine (IOM) became interested in the data it was producing and began its Is there a Magnet hospital in your area? If you have own parallel study, which is one of today’s driving clinical rotations there, is there any difference between forces for quality health care. the care at the Magnet and a non-Magnet facility? How about the attitude of the nurses and the overall facility Nursing educators are continually challenged to atmosphere? evaluate whether the graduates of their programs are adequately prepared to meet the demands of all areas of care. Nursing educators also need to evaluate whether their own educational and skills preparation What Nursing School Graduates Must is sufficient to meet the needs of diverse health-care Know and Be Able to Do settings. It has always been a challenge for nursing educa- tors to decide how much and what nursing students Required Skills and Knowledge need to learn before they graduate. Some of the cur- In an attempt to structure the input from the hos- ricular content is dictated by the licensure examina- pitals and other facilities who hire new graduate tion, but high-quality nursing programs recognize nurses, a study was conducted to survey adminis- that this test knowledge is the minimum required trators who worked at hospitals, home health-care for safe practice at an entry level. The health-care agencies, and nursing homes. They were asked to marketplace demands more than the minimum. rank 45 skills or knowledge-based competencies they
74 U n i t 1 The Growth of Nursing expected to see in the baccalaureate-level graduate • Nurses should achieve higher levels of education nurses they hired. The results showed a mix of skills and training through an improved education sys- and knowledge competencies that were most sought tem that promotes seamless academic progression. after. Those that ranked the highest included Fundamental to this message are the goals of increasing the number of RNs with baccalaureate • Teaching clients health promotion and prevention. degrees to at least 80 percent by 2020 (up from • Teaching clients about how lifestyle affects health. the current 50 percent), doubling the number of • Effectively supervising less-educated staff. nurses with doctorates by 2020, and having nurses • Effectively delegating and monitoring staff. commit to lifelong learning. Another goal is to • Efficiently organizing routine daily tasks. increase the diversity of nurses to better meet the • Safely administering medications. needs of an increasingly diverse U.S. population. • Having competency using computer databases and Expanded residency programs, focused on easing the transition into practice, are fundamental to the charting. progression of newly licensed nurses into success- • Having the ability to organize nursing care for 6 to ful professionals. 10 clients at the same time. Overall, the expectations for new graduates cluster • Nurses should be full partners with physicians and around the ability to initiate and adapt to change, use critical thinking in problem-solving, attain a basic other health professionals in redesigning health care in the United States. For a long time, nurses have level of skills, and be able to communicate with clients needed expanded opportunities to demonstrate and staff. It is interesting to note that the basic compe- tencies have not changed their leadership and management skills as key mem- bers of the health-care “much since Florence team. In collaboration Health-care technology has advanced so with physicians and Nightingale organized her rapidly in recent years that it has put a other team members, first nursing school. Like strain on both the faculty teaching nursing nurses need to be her students, current stu- involved in redesigning dents still need to master ”basic skills, communicate students and the students attempting to the health-care system master it. through such activities effectively, and solve cli- as conducting research, ent care issues. improving practice envi- The IOM Competencies ronments, developing and the Future of Nursing care systems, and improving quality of care. In 2010, a report by the American Nurses Associa- • Effective workforce planning and policy-making tion (ANA) and the Constituent Member Associa- require better data collection and an improved tions (CMA) moved the discussion to a new level by information infrastructure. Collaboration between outlining the key messages from the IOM’s report national, state, and local initiatives in collecting and on the future of nursing. This report is part of an analyzing data can make the data more useful to all ongoing project aimed at using evidence-based prac- health-care providers. tice (EBP) to advance the nursing profession so that • Nursing education has long strived to be relevant nursing can keep pace with health-care reform activi- and vibrant in a rapidly changing health-care sys- ties. Although not entirely new, the four key mes- tem. The shift in recent years to a consumer-driven sages from the report are the following: health-care system is shaping what nurses need to • Nurses should practice to the full extent of their be able to accomplish in their practice. education and training. A fundamental element of this goal is to revise states’ nurse practice acts by Out of these guiding principles, the IOM devel- removing unnecessary scope-of-practice restric- oped five key competencies that nursing students tions. The 111th Congress promoted this issue in must be able to achieve upon graduation: various health-care settings, but it seems to have • Client-centered care fallen by the wayside since the Trump administra- • Interdisciplinary teamwork tion took over in 2017. • EBP
C h a p t e r 4 The Process of Educating Nurses 75 • Quality improvement (QI) students and developing QSEN-based curricula in • Informatics 15 selected schools. The 15 pilot schools explored the difficulties in implementing QSEN in their programs. Because of society’s demands for an increased Phase III began in 2009 and is ongoing. The goals level of safety and high-quality nursing care, nursing education institutions began using the IOM compe- of Phase III are tencies to develop the Quality and Safety Education • Developing nursing faculty knowledge and skills in for Nurses (QSEN) competency model for nursing teaching QSEN competencies. curricula.4,5 • Writing textbooks that include the six competencies. QSEN Competencies Guide for Nursing Curriculum • Working with licensing, accreditation, and certi- Current leaders in nursing education have built on the Nightingale, Pew, and IOM principles and developed fication agencies to develop standards that reflect the QSEN competencies to help guide what is being QSEN competencies. taught in nursing programs. However, health-care • Developing ongoing innovative methods to imple- technology has advanced so rapidly in recent years that ment QSEN. it has put a strain on both the faculty teaching nursing The overarching goal of Phase III is to develop students and the students attempting to master it. a “culture of safety” in the health-care system that The push for an improved nursing curriculum is so ingrained in health-care providers that they began with recognition of the large numbers of will practice safety without even thinking about it. medication and medi- It will be in develop- cal errors that occur in “ Nurses of the future will need to practice ment for many years to today’s health-care sys- with self-reliance, independence, and come. Many of the pilot tem. These errors lead to exibility. ey will be required to have schools have published the injury and death of well-developed decision-making skills on the information about their as many as 90,000 clients basis of critical-thinking ability, a working experiences implement- per year. Driven by com- knowledge of community resources, and ing QSEN as their cur- munity and professional ricular model. Overall, concerns, the Robert the conversion seems to ”the quality and safety of client care by focusing Wood Johnson Founda- computer and technical competencies. be going smoothly and tion undertook a three- successfully.6 phase project to improve One issue troubling some nursing leaders is that the QSEN competencies nursing education on student competency. The are based on a model developed by the IOM (i.e., project, QSEN, is built on the five competencies a medical model). All agree on the need for quality developed initially by the IOM. and safety measures to reduce harm to clients, and Phase I began in 2005 with a $590,000 grant to the QSEN certainly meets that need. However, for many University of North Carolina at Chapel Hill School years, the American Association of Colleges of Nurs- of Nursing. The goal of Phase I was to develop the ing (AACN)’s Essentials of Baccalaureate Education theoretical foundations for QSEN, including student for Professional Nursing Practice has been the gold competencies; the knowledge, skills, and abilities standard for nursing program outcomes. Is there a (KSAs) necessary to maintain a safe health-care sys- clearcut advantage in using the QSEN competencies tem; and measurable outcomes for graduates of nurs- over the Essentials as a curricular model? ing programs. Some nursing leaders believe that by conform- A thorough and extensive set of KSAs was devel- ing to QSEN-based curricula, they will transform oped for each competency for undergraduate stu- the professional identity of nursing into something dents. In addition, Phase I established an electronic other than nursing. What about the competencies of resources center, supported by the grant, which con- caring, integrity, and client advocacy? What about tains materials on client safety and quality initiatives. research and scholarship? Where does prevention—a With Phase I still ongoing, Phase II kicked off in key nursing role since the time of Florence 2007 with the goals of developing KSAs for graduate Nightingale—fit in? Those who support QSEN
76 U n i t 1 The Growth of Nursing schools. It can be used in both schools of nursing believe that if a nurse is providing safe, high-quality that have competency-based curricula and schools care, then caring and integrity are already included. that have more traditional curricula to enhance stu- Others believe that a seventh competency, “profes- dent learning and make curricular revisions appro- sional person,” should be added to include those priate for the demands of the health-care system of aspects of nursing that make it unique and separate today and of the future. from the medical profession7 (see Box 4.1). NURSES OF THE FUTURE It has always been a challenge to measure com- petency in the health-care professions. The current Nurses of the future will need to practice with self- interest in positive client outcomes as a measure of reliance, independence, and flexibility. They will be performance reinforces the need to better measure required to have well-developed decision-making competency. It is by no means a new issue. The skills on the basis of critical-thinking ability, a work- Competency Outcomes Performance Assessment ing knowledge of community resources, and com- (COPA) model, developed in the early 1990s, has puter and technical competencies. Just as important, been used by medical schools and some schools of they will need to deliver high-quality care and client nursing to validate the skills and knowledge of their education while working within the constraints of a graduates. It is designed to promote competency for managed-care system with tight cost-control measures. clinical practice at all levels. With a few modifica- tions, the COPA model fits well with QSEN and can be used as the evaluation tool for graduates of these Box 4.1 Competency/Outcome Comparison: IOM, QSEN, AACN Essentials IOM Competencies QSEN Competencies AACN Essentials Client-centered care Client-centered care Liberal education for baccalaureate generalist nursing practice Interdisciplinary Teamwork and teamwork collaboration Basic organizational and systems leadership for high-quality care and client safety EBP EBP QI QI Scholarship for EBP Informatics Safety informatics Information management and application of client-care technology Health-care policy, finance, and regulatory environments Interprofessional communication and collaboration for improving health outcomes Clinical prevention and population health Professionalism and professional values Baccalaureate generalist nursing practice AACN = American Association of Colleges of Nursing; EBP = evidence-based practice; IOM = Institute of Medicine; QI = quality improvement; QSEN = Quality and Safety Education for Nurses. Sources: American Association of Colleges of Nursing. Essentials of baccalaureate education for professional nursing practice: Faculty tool kit, 2018, retrieved from http://www.AACN.nche.edu; Competencies for nursing education, National League for Nursing, 2018, retrieved from http:// www.nln.org/professional-development-programs/competencies-for-nursing-education; Bickford C, Affirmation of focused practice competencies, American Nurse Today, 12(10):22, 2017.
Will nursing education ever be able to prepare C h a p t e r 4 The Process of Educating Nurses 77 a graduate who fulfills all the qualities required of nurses of the future? Nursing education responds felt that nursing education is either acute care with a yes, but only with curricular revisions that focused or community focused. Nursing education provide graduates with the tools to continue to learn needs to combine the two so that the graduate can as they advance in their careers. practice with competence in either or both settings. The skills are similar, but the emphasis may be dif- A holodeck is coming soon to your school. ferent. Although some hospital skills are being done by non-nurses at a cheaper cost, nursing education Hospital Skills and More must still teach such important skills as critical think- Hospital-based acute care nursing practice will ing, therapeutic relationship, primary care, and case always have an important place in any health-care management, as well as how to be comfortable with system. Highly skilled acute care nurses will always a consumer-driven health-care system. find a place to practice. It is generally accepted that the older population requires more health care of Critical Thinking all types—acute, chronic, and community based. Critical thinking has been an important element in Although the current system experienced a decrease nursing practice for many years. It is generally recog- in the use of acute care beds, a gradual reverse in nized as the ability to use basic core knowledge and this trend is beginning as the baby boomers become decision-making skills in resolving situations with a the senior citizens who require more care for acute relatively small amount of data and a high degree of problems. risk and ambiguity. Critical thinking is the basis for clinical judgment used by nurses in making decisions Paradigm shifting in nursing education does not about client care and is a key part of the nursing need to be an either/or proposition. It is sometimes licensure examination. Nursing has long been con- cerned with the ability to make good judgments and decisions about client care. At a fundamental level, the nursing process is a type of critical thinking. Unfortunately, in the health-care system of the future, a nurse’s critical- thinking skills will have to go far beyond those of the basic nursing process. Nursing education will need to prepare students for more advanced critical thinking by exposing them to real-life situations that require the use of creativity, intuition, analysis, and deductive and inductive reasoning. These situations are introduced in the classroom as case studies and are reinforced in the clinical setting through guided experiences and mentoring. The Therapeutic Relationship Therapeutic relationship skills have long been stressed by mental health nursing faculty as a key element in the treatment of psychiatric problems. In reality, therapeutic relationship skills are essen- tial for all nurses to fulfill their roles as health-care providers and healers. Although these skills are cur- rently being taught in a limited and focused way in most nursing schools, they need to be expanded to involve directed services and relationship-centered nursing care.
78 U n i t 1 The Growth of Nursing Issues Now e-Nursing Education The nursing shortage is expected to get worse. Projected shortages for nurses range from 200,000 to 800,000 over a 10-year period from 2012 to 2022. Compounding the nursing shortage is a lack of nursing faculty qualified to educate new nurses. Many faculty are past retirement age, and it is difficult to attract new staff due to the relative low wages in educa- tion as compared to hospitals and the private sector for nurses with similar degrees. How- ever, a current trend viewed by some as a possible solution to the lack of nursing faculty is e-nursing education. Most nursing schools are steadily increasing their online learning opportunities. However, full immersion into e-nursing education requires not only a total acceptance of technology but also a shift in fundamental thought processes and teaching. Both nursing students and nursing instructors can look forward to several key technologies in the not-too-distant future. “Intelligent” assistive health-care devices have spurred the growth of new industries that did not exist even 5 years ago. Artificial limbs that respond to computer-mediated signals from the brain are being used by those with amputations. Elderly people and those with mobil- ity problems are being helped by intelligent walkers to ambulate and to change position from sitting to standing and vice versa. Nursing education needs to keep pace with these developments by teaching students how to use these devices and how to educate clients in their use. All nursing faculty are aware that current nursing students are not like students of the past, even the recent past. Referred to as “generation E” or “millennials” and raised with computers, cell phones, and a myriad of wireless devices, these students do not respond well to sitting in lecture classes. They like to be more interactive, and they adapt readily to new technologies. They are masters at electronic multitasking and are nonlinear in their thought processes. The challenge for nursing educators is to develop and use technologies that keep these students engaged while ensuring that they master the vast amount of material required to practice nursing safely in today’s complex health-care environment. Several educational software companies are begin- ning to develop simulators and electronic learning games that address this need. One example is the Interactive Community Simulation Environment for Community Health Nursing, otherwise known as the Community Health Nursing Serious Game, which is based on the modular Synthetic Training Research Evaluation and Extrapolation Tool (mSTREET) platform to deliver computerized virtual training. In the game, students can investigate and respond to a variety of settings as they walk through the streets of a virtual city. The same mSTREET platform can be used for other health-care settings. Students will be able to walk into the room of an intensive care client and observe and manipulate the machines connected to the client, such as a ventilator, cardiac monitor, cooling blanket, and other commonly used devices. Serious games technology uses virtual reality to take learning one step beyond sim- ulation. Although it is still developing as a learning methodology, it has great potential for education. It would allow students total participation in health-care scenarios, ranging from counseling sessions for clients with psychiatric disorders to advanced life support resuscitation of a client in cardiac arrest. Combined with simulation tech- nology, virtual reality would allow students to use the equipment they will see in the work setting.
Chapter 4 The Process of Educating Nurses 79 I s s u e s N o w (continued) Wireless technology also has the potential to provide new learning opportunities and techniques. Access to the Internet is no longer tied to hardwired devices. Through the cellu- lar networks, anyone can access a whole world of information, from e-mail to video stream- ing. Students enrolled in online programs can now access them from almost any place where they can make a cell phone call. Publishing companies offer textbooks in electronic form (e-texts). Incorporated into these books are interactive exercises, videos, and simula- tion activities. Students can now read their textbooks on one of the many tablets available on the market today. What will the nursing classroom of the future look like? It is a sure bet that the whole experience will be different. In reality, there may be no centrally located classrooms at all. Classroom lectures and interactive discussions will be conducted electronically over wire- less devices. The way students learn will not be as important as what they learn, and learn- ing will be measured through outcome testing. Nursing education will be asynchronous and available to anyone anywhere. It has been proposed that sometime in the future there may be only one nursing program for the whole country that is located in the cloud and totally online. That possibility certainly requires major paradigm shifting! Sources: K. Lilleburg, New nursing students and online education, NursingLink, 2018, retrieved from http:// nursinglink.monster.com/education/articles/181-new-nursing-students-and-online-education; B. Siwicki, 12 Defining healthcare issues of 2018, Health Care IT News, 2017, retrieved from http://www.healthcareit- news.com/news/here-are-12-healthcare-issues-will-define-2018-according-pwc; Spies K. et. al. C. Sipes, K. Hunter, D. McGonigle, K. West, T. Hill, and T. Hebda, The health information technology tool: Does it trans- late for nursing informatics in the United States? Computer Informatics Nursing, 35(12):609–614, 2017. Trust Is Essential must be able to develop learning experiences for Relationship-centered nursing care is client focused students that involve care for selected individu- and revolves around the client’s trust in, value of, als or families over extended periods of time, and understanding of the nurse’s skills and role in perhaps ranging from several weeks to several the healing process. The client must be able to feel semesters. comfortable with the nurse and share his or her understanding of both illness and health. Case Management Care management is a general term that refers Follow-up Care to a method of coordinating care either with an Currently, in some licensed practical nurse and individual client or on a systemwide basis. Case licensed vocational nurse (LPN/LVN) programs management in a health-care system driven by offering the associate degree in nursing, clinical expe- the demand for better-quality, cost-effective care riences consist of one-time, 8-hour provision of care usually is associated with coordinating care for for an acutely or chronically ill client. Little time is individual clients as they move from one level to spent in follow-up care. However, many bachelor of another through the health-care system. Case man- science in nursing (BSN) programs and some associ- agement is now a certified specialty; however, there ate degree nursing (ADN) programs have expanded is a lack of qualified nurses trained in case manage- clinical experiences to include discharge planning ment. Almost all the proposals for revisions in the and follow-up home health-care experiences. health-care system include the case manager as an important element in the overall management of To meet the demands of the future health- care (see Chapter 27). care system, all nursing education programs (text continues on page 84)
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