34 U n i t 1 The Growth of Nursing the role of the nurse in the health-care community.9 interpreting diagnostic tests. They can diagnose and It was so effective that they published their findings, treat acute and chronic conditions such as diabetes, which later became the blueprint for an educational high blood pressure, infections, and injuries. In some curriculum for NPs. states they are legally permitted to prescribe medica- tions independently. Although still receiving some Soon after the pilot project was completed, resistance from physicians’ groups, NPs have trans- the University of Colorado started the first formal formed both the health-care system and the profession NP program in the country. Initially, it was a cer- of nursing.8 tificate program for nurses with a baccalaureate in nursing degree. Ford believed that the nurse Ford became the founding dean of the practitioner philosophy should be to provide a University of Rochester School of Nursing and di- holistic approach to the client’s health. Nurse prac- rector of the Nursing Service at the University Hos- titioners should focus on health, functionality, and pital in 1972. The school now has nine specialty daily living, as well as give the client feedback on NP programs, including child psychiatry, which how they are progressing.8 helps fill a need for mental health services in rural upstate New York.9 In 2003, she was awarded the At first, the NP program prepared nurses Blackwell Award (named for the first female doctor in child and family care, educating clients in preven- in America) from Hobart and William Smith Col- tive health. The program became extremely popular leges, which is given to a woman whose life exempli- and moved up to a master’s degree program. It also fies outstanding service to humanity. Among many expanded its focus to a broader population as it other accolades, she was inducted into the National grew, including caring for adults. Ford’s program Women’s Hall of Fame in 2011 for being recognized educated NPs to integrate the traditional role of the as an internationally renowned nursing leader nurse with advanced medical training and commu- who has transformed the profession of nursing and nity health, thereby providing clients with high- made health care more accessible to the general quality care and education not found in the traditional public. Ford is now retired and living in Florida; health-care setting. however, she has remained involved with the University of Rochester School of Nursing. She still NPs are found in every corner of the health- consults and lectures on the historical development care system today. There are over 150,000 NPs working of the nurse practitioner along with issues in ad- within the United States, and the number grows daily. vanced nursing practice and health-care policy. In many states, NPs can function independently and provide services such as ordering, performing, and Conclusion How did this situation develop? What can be done about it? A great deal of confusion exists about Many of the problems and difficulties with today’s the education of nurses, unlike the situation in other health-care system, and those of nursing in particular, health-care professions. Why does nursing have this are based in the historical development of the profes- problem, and how can this confusion be addressed? sion. Knowledge of these historical roots can help us Those who belong to the nursing profession have a understand why the profession of nursing is the way responsibility not only to learn how these and other it is and even suggest solutions to problems that may conditions developed but also to relate that knowl- seem unsolvable. For example, nursing today appears edge to nursing’s possibility for growth in the future. to be a profession with a high level of responsibility but a low level of power.
C h a p t e r 2 Historical Perspectives 35 Issues in Practice: Case Study Mrs. Lee, a 56-year-old high school teacher, had been “feeling something in her eye” for 3 days. She visited the retail optometry store where she had purchased her last pair of glasses. The optometrist at the store examined her and did not find any foreign objects in her eye or scratches on her cornea. However, he felt that the symptoms were serious enough to have Mrs. Lee visit the emergency depart- ment (ED) at a local hospital. At the hospital, the ED triage nurse assessed Mrs. Lee’s vital signs, which were normal, and also gave her a basic eye examination for visual acuity. The exam revealed 20/200 vision in the right eye and 20/30 vision in the left eye (20/20 is normal). The triage nurse had a second-year ophthalmology resident from the hospital’s outpatient vision clinic examine Mrs. Lee. The resident examined both eyes but extensively examined the right eye, which had the worse vision. He could find no irregularities and sent Mrs. Lee home with eyedrops and an appointment to see an ophthalmologist the next day. The ophthalmologist ordered a computed tomography (CT) scan, which was taken the same day. He also sent Mrs. Lee home with an appointment to see a neurologist the next day. Mrs. Lee went home after the CT scan. She collapsed and died from a ruptured cerebral aneurysm before the scan was read by the hospital radiology department and before she could see the neurologist. The family filed a malprac- tice law suit against the triage nurse, the physicians, and the hospital. After a lengthy trial, the jury in the Supreme Court of Kings County, New York, concluded that ED personnel committed negligence by failing to have the client examined by a neurologist at admission to the ED. Expert witness testimony convinced the jury that the great disparity in the vision between the two eyes was a primary indicator of some type of brain problem. This should have been recog- nized immediately by the nurse and ED staff, and a neurologist should have been part of the team from the beginning. The jury awarded $2.15 million to the family. Questions for Thought 1. Do you think there was any malpractice involved in this case? If yes, what is its nature? 2. Should the triage nurse have noticed any abnormalities that might suggest the condition was worse than an eye problem? 3. What would you have done differently in this case if you were the triage nurse? Source: Collazo v. NY Eye and Ear Infirmary, 2009 WL 1199357. Superior County Kings Court, New York, March 18, 2009.
36 U n i t 1 The Growth of Nursing Critical Thinking Exercises 1. Trace the history of your nursing school. Who were the leaders in the foundation of the school? Write a short biography for each one, listing their accomplishments. 2. If you know any elderly nurses, contact them and ask them if they would be willing to talk to you about their practice. Develop an oral history of what they experienced and compare it to nursing practice today. 3. Start a journal of your own experiences as a nursing student. Maintain this jour- nal throughout your career. Make sure to include interesting instructors and clients with whom you are in contact.
References C h a p t e r 2 Historical Perspectives 37 1. Griffin GJ, King J. History and Trends in Professional Nursing. 6. Burtram MAB. Lavinia Lloyd Dock: An activist in nursing and St. Louis: CV Mosby, 2003. social reform. Retrieved April 2013 from http://etd.ohiolink. edu/view.cgi?acc_num=osu1269373366 2. Judd D. History of American Nursing: Trends and Eras (10th ed.). Burlington, MA: Jones & Bartlett Publishers, 2009. 7. Annie Warburton Goodrich (1866–1954) 1976 Inductee, American Nurses Association. Retrieved April 2013 from http://www.nursing 3. Florence Nightingale: A Biography. Retrieved April 2013 from world.org/AnnieWarburtonGoodrich http://www.biography.com/people/florence-nightingale-9423539 8. Ridgway S. Loretta Ford, Founded Nurse Practitioner Movement. 4. Isabel Hampton Robb—Nursing Theorist. Retrieved April 2013 Profiles in Nursing. Retrieved April 2013 from http://www.working from http://nursing-theory.org/nursing-theorists/Isabel-Hampton- nurse.com/articles/Loretta-Ford-Founded-Nurse-Practitioner- Robb.php Movement 5. Lilian Wald: The Henry Street Settlement. Retrieved April 9. Loretta Ford, 91, Started Nurse Practitioner Movement. Senior 2013 from http://www.henrystreet.org/about/history/lillian- Spirit. 2012. Retrieved April 2013 from http://www.csa.us/email/ wald.html spirit/ssarticles/1012SeniorSpotlight.html
3 Theories and Models of Nursing Joseph T. Catalano Learning Objectives FCARING FOR REAL PEOPLE After completing this chapter, or many nurses, and for most nursing students, the terms theory the reader will be able to: and model evoke images of textbooks filled with abstract, obscure words and convoluted sentences. The visceral response is often, “Why is this • Explain why theories and mod- els are important to the profes- sion of nursing important? I want to take care of real people!” The simple answer is that • Analyze the four key concepts understanding and using nursing theories or models will help you be a found in nursing theories and better nurse and provide better care to real people. models • Interrelate systems theory as an important element in under- DIFFERENCES BETWEEN THEORIES AND MODELS standing nursing theories and models What Is a Theory? • Evaluate how the four parts of Although the terms theory and model are not synonymous, in nursing practice they are often used interchangeably. Strictly speaking, a theory all systems interact refers to a speculative statement involving some element of reality that • Synthesize three nursing theories, identifying how the different nurs- ing theorists define the key con- has not been proved. For example, the theory of relativity has never cepts in their theories been proved, although the results have often been observed. • Compare and contrast a mid- The nursing profession tends to use the term theory when dle-range theory with a major attempting to explain apparent relationships between observed behaviors nursing theory and their effects on a client’s health. In this nursing context, the goal of a theory is to describe and explain a particular nursing action to make a hypothesis, which predicts the effect on a client’s outcome, such as im- proved health or recovery from illness. For example, the action of turning an unresponsive client from side to side every 2 hours should help to pre- vent skin breakdown and improve respiratory function. In recent years, nursing has been moving toward using research findings to guide nursing practice. This approach, called evidence-based practice, is an important element in improving nursing care and proving 38
C h a p t e r 3 Theories and Models of Nursing 39 many of the long-standing theories that the nursing thus improve his health status. The client goals would profession has developed over the years.1 then be achieved. What Is a Model? If a researcher were to stop 10 people at ran- A model is a hypothetical representation of some- dom on the street and ask the question, “What do thing that exists in reality. The purpose of a model is nurses do,” he or she would likely get 10 different to explain a complex reality in a systematic and or- answers, but the confusion about nurses’ activities ganized manner. For example, a hospital organiza- extends far beyond the public at large. What if the tional chart is a model that attempts to demonstrate researcher asked 10 hospital administrators, 10 physi- the interrelationships of the various levels of the cians, or even 10 nurses the same question? The an- hospital’s administration. swers would probably vary almost as much as the answers from laypersons. What Do You Think? The Iowa Project Do you consider yourself to be healthy? What factors make In an attempt to identify what exactly it is that nurses ?you healthy? What factors are indicators of illness? do, J. C. McCloskey and G. M. Bulechek, two nurse researchers at the University of Iowa, have been con- ducting a research project since 1990 to develop a taxonomy of the interventions that nurses use in What Do Nurses Do? their practice (Box 3.1). This research has been called Although a model tends to be more concrete than a Nursing Interventions Classification (NIC), the Iowa theory, they both help ex- Interventions Project, or “plain and direct nursing Mr. X had surgery for intestinal cancer simply the Iowa Project.2–5 4 days ago. He has a colostomy and actions. This ability, using needs to learn how to take care of it at A Classification System a systematic and structured home because he is going to be dis- The Iowa Project addresses approach, is one of the key an ongoing need for elements that raises nurs- charged from the hospital in 2 days. ing from a task-oriented nurses to be able to iden- job to the level of a profes- When the nurses attempt to teach him tify and quantify what they sion that uses judgment colostomy care, he looks away, makes do. In the current era of and knowledge to make in- sarcastic personal comments about the concern for high-quality ”formed decisions about health care, this need has become even more acute. client care. With the use of a conceptual model, nurses, and generally displays a belliger- ent and hostile attitude. The first results, published nurses can provide intelli- in 1994, categorized and gent and thoughtful answers to the question, “What do ranked 336 interventions that nurses use when they nurses do?” Consider the quoted scenario above. provide care to clients. A follow-up study was con- Without an understanding of the underlying ducted about 2 years after the original study catego- dynamics involved, the nurses might themselves be- rized and ranked 433 interventions used by nurses. come sarcastic and scold the client about his behavior McCloskey and Bulechek6 also investigated which or simply minimize their contact with him. This type nursing interventions were commonly used by nurses of response will not improve Mr. X’s health status. in specialty settings. Forty specialty areas responded, If, however, the nurses knew about and understood and the researchers were able to develop a table that the dynamics of grief theory, they would realize that lists what core skills are used by each organization. Mr. X was probably in the anger stage of the grief In 2008, the list was again updated. It now contains process. This understanding would direct the nurses 542 interventions within a taxonomy of seven do- to allow, or even to encourage, Mr. X to express his mains (i.e., physiological: basic; physiological: com- anger and aggressiveness without condemnation and plex; behavioral; safety; family; health systems; and to help him deal with his feelings in a constructive community) and 30 classes of interventions. manner. Once Mr. X gets past the anger stage, he can Research into nursing intervention classifi- move on to taking a more active part in his care and cation systems is ongoing and has served as the
40 U n i t 1 The Growth of Nursing 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 Classification (NIC) or simply the Iowa Project, has identified 336 tasks or interventions for which nurses are responsible in their care of patients. Not all nurses carry out all 336 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 Iowa Project, and several researchers have undertaken projects to use the data generated by the Iowa Project in actual client-care situations. This project is an excellent example of how a nursing theory led to a research project that developed in- formation 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 attempted to identify and classify nursing interventions. It also attempted to rank those inter- ventions according to the number of times a nurse was likely to perform one during a working day. The goal of the project was to develop a nursing information system that could be incorporated into the current informa- tion 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 re- sponsible 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 in- creasingly difficult to delineate the specific contributions they make to health care. If nurses are unable to de- fine the care they provide, how are the reformers, politicians, and 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 techni- cal demands of handling the huge amounts of information generated by the care given. Sources: Bulechek GM, Butcher HK, Dochterman JM. Nursing Interventions Classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier, 2008; Moorhead S, et al. Nursing Outcomes Classification (NOC): Iowa Outcomes Project (3rd ed.). St. Louis, MO: Mosby, 2004; Scherb CA, Weydt AP. Work complexity assessment, nursing interventions classification, and nursing outcomes classification: Making connections. Creative Nursing, 15(1):16–22, 2009. foundation of new methods to define nursing prac- routinely perform for various client populations. tice and measure the outcomes of client care. The Taking the process one step further, the Nursing Out- need to increase client satisfaction and achieve comes Classification system closes the loop by pro- successful outcomes of nursing care is a key element viding a means for nurses to evaluate whether the in the Affordable Care Act (ACA), which was outcomes were achieved.2 passed in 2010. Even more than in the past, these elements will be the basis of reimbursement for Although initially used primarily to help health-care providers. nurses with the delegation of duties to unlicensed personnel by linking skills with performance re- Using the NIC as a starting point, the Work quirements, WCA is now an important tool in the Complexity Assessment (WCA) was developed so improvement of the quality of nursing care. When that nurses could identify specific interventions they nurses analyze the care they provide and actually
C h a p t e r 3 Theories and Models of Nursing 41 look at the various interventions they use, they in- competency statements from the various nursing crease their understanding of both the methods and organizations. These skills lists help differentiate the rationales for care. WCA also fits nicely into the use various levels of nursing practice. One such list of of evidence-based practice when nurses share with skills is presented in Table 3.1. other nurses what they have learned about improv- ing care. KEY CONCEPTS COMMON TO NURSING MODELS This type of research helps identify the im- portant contributions made by nursing to the health and well-being of clients. It also demonstrates the Although nursing models vary in terminology and complex and demanding nature of the nursing pro- approach to health care, four concepts are common fession. Much of the public, and even many physi- to almost all of them: Client or patient (individual or cians and nurses, do not really understand what collective), health, environment, and nursing. Each nurses do for clients on a daily basis. Using classifica- nursing model has its own specific definition of these tion systems aids in clarifying what nurses bring to terms, but the underlying definitions of the concepts client care, makes what they do measurable, and are similar. validates the importance of the nursing profession. Client Nursing Competencies The concept of client (or patient) is central to all One way in which the nursing profession identifies nursing models because it is the client who is the what nurses do is by looking at competencies. In primary recipient of nursing care. Although the nursing, the word compe- “The need to increase client satisfaction term client usually refers tence is often defined as and achieve successful outcomes of nurs- to a single individual, it the combination of skills, ing care is a key element in the Health can also refer to small knowledge, attitudes, val- Care Reform Act, which was passed in groups or to a large col- ues, and abilities that sup- 2010. Even more than in the past, these lective of individuals port the safe and effective (e.g., for community practice of the nurse. A health nurses, the com- nurse practices compe- elements will be a basis of reimbursement munity is the client). tently when he or she has mastered a range of skills ”processes demonstrated in the care of clients. All the has changed over the years as knowledge and for health-care providers. A Complex Relationship and decision-making The concept of client major nursing organizations have developed lists of understanding of human nature have developed competencies for nurses. These are usually general, and increased. A client constitutes more than a broad statements rather than catalogues of specific person who simply needs restorative care and skills. (See “Issues Now: The Pew Commission Final comes to a health-care facility with a disease to Report” in this chapter.) be cured. Clients are now seen as complex entities Nursing competencies are currently under affected by various interrelating factors, such as close scrutiny due to the large number of medication the mind and body, the individual and the and other types of errors in the health-care setting environment, and the person and the person’s that have led to numerous clients being injured or family. When nurses talk about clients, the term killed. The Institute of Medicine’s (IOM) document biopsychosocial is often used to express the complex on the future of nursing contains recommendations relationship between the body, mind, and environ- and lists of competencies for nursing school gradu- ment. These elements are at the heart of preventive ates to help improve the quality of care. The Quality care that has been an emphasis of professional and Safe Education for Nurses (QSEN) project, built nursing since the time of Florence Nightingale. upon the IOM recommendations, is in the process of The prevention of disease and promotion of health developing a framework for nursing schools’ curric- are key provisions in the health-care reform bill ula (see IOM and QSEN in Chapter 4). passed in 2010 and open the door for nurses to Nursing researchers have attempted to practice what has always been a part of their develop specific lists of skills based on the general educational history. (Text continued on page 51)
42 U n i t 1 The Growth of Nursing Baccalaureate Degree RN Table 3.1 Competencies for Nursing Skills Same Associate Degree RN Same Administering Blood Products Same Obtain and document baseline vital signs according to Same agency policies and procedures. Obtain blood transfusion history. Initiate administration Same of blood products according to agency policies and Manage the discharge planning process. procedures. Evaluate and document client response to administration Same of blood products. Same 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. Same Assist client in exiting a health-care facility, following Same facility’s policies and guidelines. Same Assess client to determine readiness for discharge. Same Facilitate the continuity of care within and across Same health-care settings. Assessment of Vital Signs Same 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 Same Document characteristics of feces. Perform test for occult blood. Same Administer enemas for cleansing or retention. Remove a fecal impaction. Same Provide and teach colostomy and ileostomy care. Administer a rectal suppository. Administer a rectal tube. Develop client’s bowel retraining protocol. Care of the Dying Client During the dying process, provide measures to decrease client’s physical and emotional discomfort. Evaluate final progress note on client’s chart to determine completeness of information. Notify appropriate people and departments, according to agency’s policies and procedures.
C h a p t e r 3 Theories and Models of Nursing 43 Table 3.1 Competencies for Nursing Skills—cont’d Baccalaureate Degree RN Associate Degree RN Develop services that support dying clients and their families. Evaluate family’s response to client’s death and make referrals as appropriate. Same Provide care for the body after client’s death, according Same to agency’s policies and procedures. Same Same Circulatory Maintenance Evaluate fetal heart rate pattern. Assess client’s readiness to learn. Apply antiembolism stockings. Develop materials to provide client and/or family member with information Obtain cardiopulmonary resuscitation certification. concerning procedure or health problem. Client Teaching Same Assess and document client’s and/or family member’s Same knowledge of specific procedure or health problem. Same Assess client and significant support person(s) for learning strengths, capabilities, barriers, and Same educational needs. Using multiple teaching strategies, teach Develop an individualized teaching plan based on heterogeneous groups of clients, assessed needs. accounting for individual differences. Modify teaching plan based on evaluation of progress Implement teaching plan using individualized toward meeting identified learning outcomes. teaching and learning strategies with clients and/or groups in structured Provide client and significant support person(s) with settings. the information to make choices regarding health. Same Teach client and significant support person(s) the information and skills needed to achieve desired Same learning outcomes. Same Evaluate progress of client and significant support person(s) toward achievement of identified Same learning outcomes. Same Implement teaching plan using individualized Same teaching and learning strategies with clients Evaluate effectiveness of communication and/or groups in unstructured settings. patterns. Communication Effectively use communication skills during assessment, (continued) intervention, evaluation, and teaching. Express oneself effectively using a variety of media in different contexts. Adapt communication methods to clients with special needs (e.g., sensory or psychological disabilities). Produce clear, accurate, and relevant writing. Use therapeutic communication within the nurse–client relationship. Maintain confidentiality of nurse–client interactions. Appropriately, accurately, and effectively communicate with diverse groups and disciplines using a variety of strategies.
44 U n i t 1 The Growth of Nursing Baccalaureate Degree RN Table 3.1 Competencies for Nursing Skills—cont’d Same Same Associate Degree RN Same Elicit and clarify client preferences and values. Same Evaluate dynamics of family interactions. Same Evaluate data concerning coping mechanisms of Same client/family/support system. Teach assertive communication skills to Provide emotional support to client/family/support system. clients, unlicensed assistive nursing Evaluate strengths of client and family/significant other. personnel, and other licensed nurses. Evaluate need for alternative methods of communicating Same with client. Use assertive communication skills in interactions with Identify and plan for services to ensure continuity in meeting health-care needs clients and other health-care providers. during transition from one setting to another. Communicate data concerning client to appropriate members of the health-care team. Collaborate with community members in planning care for the community. Communicate the need for consultation/referral to interdisciplinary care team. Same Collaborate with other health-care team members to Same provide nursing care. Same Critical Thinking Same Within acquired knowledge base, create alternative Use critical thinking to further develop courses of action, develop reasonable hypotheses, working hypotheses, using patterns and and develop new solutions to problems. inconsistencies in data. Develop an awareness of personal values and feelings and examine basis for them. Specify aspects of nursing care that can Evaluate credibility of sources used to justify beliefs. appropriately be delegated to unlicensed Examine assumptions that underlie thoughts and health-care providers and assistive behaviors. personnel. Seek out evidence and give rationale when questioned. Coordinate and/or implement plan of care for clients with multiple nursing diagnoses, Delegation and Supervision especially both physiological and Provide assistive personnel with relevant instruction psychosocial diagnoses. to support achievement of client outcomes. Delegate performance of nursing interventions. Coordinate the implementation of an individualized plan of care for clients and significant support Delegate nursing care given by others while person(s). retaining accountability for the quality of care given to the client. Delegate aspects of client care to qualified assistive personnel. Supervise performance of nursing interventions. Supervise and evaluate activities of assistive personnel.
Table 3.1 Competencies for Nursing Skills—cont’d C h a p t e r 3 Theories and Models of Nursing 45 Associate Degree RN Baccalaureate Degree RN Documentation Supervise nursing care given by others while Maintain privacy of client’s record. retaining accountability for the quality of Accurately document data according to agency’s care given to the client. policies and procedures. Manage community-based care for a group Use common abbreviations and nomenclature for of clients. recording information in the client’s record. Direct care for clients whose conditions are changing. Health Assessment Using a systematic process, perform a Direct care for clients in situations with a potential for variation in client condition. head-to-toe assessment. Assess physical, cognitive, and psychosocial abilities Supervise implementation of a comprehensive client-teaching plan. of individuals in all developmental stages. Assess family structure, roles of family members, Same Same and family’s strengths and weaknesses. Evaluate an individual’s capacity to assume Same responsibilities for self-care. Establish a reporting and recording system to provide for continuity and accountability of Assess community resources to determine possible programs in designated structured and referral sources. unstructured settings (e.g., school health, occupational health, community). Perform a holistic assessment of the individual across the life span. Perform a risk assessment of the individual and family, including lifestyle, family and genetic history, and other risk factors. Same Perform assessment of using a family genogram. Perform a community assessment for diverse populations. Perform an assessment of the environment in which health care is being provided. Establish processes to identify health risks in designated structured and unstructured settings (e.g., school health, occupational health, community). Integrate data from client, other health-care personnel, and other systems to which client is linked (e.g., work, church, neighborhood). (continued)
46 U n i t 1 The Growth of Nursing Baccalaureate Degree RN Modify data collection tools to make them Table 3.1 Competencies for Nursing Skills—cont’d appropriate to client’s situation (e.g., Associate Degree RN language and culture, literacy level, sensory deficit). Use assessment findings to diagnose and evaluate Perform family assessment. quality of care and to deliver high-quality care. Same Evaluate family’s emotional reaction to client’s illness (e.g., chronic disorder, terminal illness). Same Same Evaluate client’s emotional response to treatment. Same Evaluate adequacy of client’s support systems. Assist in diagnostic procedures used to determine Same Develop and implement a health promotion client’s health status. Health Promotion program. Facilitate parental attachment with newborn. Same Determine the need for a health promotion program. Same Evaluate risk factors related to client’s potential for Same accident/injury/disease. Same Evaluate client’s knowledge of disease prevention. Same Evaluate client’s knowledge of lifestyle choices Same Same (e.g., smoking, diet, exercise). Heat and Cold Therapy Same Evaluate client’s response to heat therapy. Evaluate client’s response to cold therapy. Same Evaluate client’s response to sitz bath. Monitor and evaluate client’s response to hypothermia Develop criteria to evaluate client’s home environment for self-care modifications blanket. (e.g., doorway width, accessibility for Monitor and evaluate infant’s response to radiant wheelchair, safety bars). warmer. Same Home Care Management Evaluate ability of family/support system to provide Same Same care for client. Evaluate client’s home environment for self-care modifications (e.g., doorway width, accessibility for wheelchair, safety bars). Infection Control Use aseptic practices: Hand washing, donning and removing a face mask, gowning, donning and removing disposable gloves, bagging articles, managing equipment use for isolation clients, assessing vital signs. Use universal precautions. Use body substances isolation procedures.
C h a p t e r 3 Theories and Models of Nursing 47 Table 3.1 Competencies for Nursing Skills—cont’d Baccalaureate Degree RN Associate Degree RN Same Same Evaluate client’s immunization status. Use surgical aseptic practices: scrubbing hands, Same donning and removing a sterile gown, donning and Use technology, analyze information, and removing sterile gloves, preparing and maintaining a select resources effectively. sterile field. Assist with a sterile procedure. Same Information and Health Care Technology Same Use technology, synthesize information, and select resources effectively. Use data-management system to evaluate a Demonstrate competence with current technologies. comprehensive program for monitoring Use computers for record-keeping and documentation in health of populations in designated health-care facilities. structured and unstructured settings (e.g., school health, occupational health, IV Therapy community). Perform venipuncture to obtain blood specimens. 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 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 Same each shift Assess implanted infusion devices. Same Maintain implanted infusion devices. Same Medication Administration Assess family members’ knowledge of medication Same therapy: reasons for taking medication, daily Same dosages, side effects. Same Instruct clients and their families in the proper administration of medications. Accurately calculate medication dosages. (continued)
48 U n i t 1 The Growth of Nursing Baccalaureate Degree RN Table 3.1 Competencies for Nursing Skills—cont’d Same Associate Degree RN Same Gather information pertinent to the medication(s) Same ordered: actions, purpose, normal dosage and route, common side effects, time of onset and Same peak action, nursing implications. Same Administer and document administration of enteral and parenteral medications per order. Same Administer and document administration of topical Same medications per order. Same Evaluate client’s response to medication. Evaluate client’s need for range-of-motion Perform eye and/or ear irrigation according to agency guidelines. exercises. Meeting Mobility Needs Evaluate client’s need for range-of-motion exercises. Evaluate client’s level of mobility. Evaluate client’s level of mobility. Manage care of client who uses assistive devices. Manage care of client who uses assistive Provide client or family member with list of resources to devices. contact when mobility or body alignment is impaired. Evaluate client and/or family members’ ability to perform Provide client or family member with list of range-of-motion exercises. resources to contact when mobility or body alignment is impaired. Nursing Process Analyze collected data to establish a database for client. Evaluate client and/or family members’ ability to perform range-of-motion exercises. Identify client health-care needs to select nursing diagnostic statements. Perform comprehensive assessment to determine client’s ability to manage Consider complex interactions of actual and potential self-care, including physiological, nursing diagnoses. psychosocial, developmental, and cognitive factors and their interaction Identify client goals and appropriate nursing interventions. with each other. Develop and communicate nursing care plan. Formulate individualized nursing diagnoses, based on a synthesis of knowledge from nursing, biological and behavioral sciences, and humanities, that reflect a health problem and its etiology. Consider complex interactions of actual and potential nursing diagnoses (e.g., two or more physiological and/or psychosocial nursing diagnoses). Same Same Develop comprehensive plan of care in collaboration with client.
C h a p t e r 3 Theories and Models of Nursing 49 Table 3.1 Competencies for Nursing Skills—cont’d Baccalaureate Degree RN Associate Degree RN Same Implement and document planned nursing interventions. Implement a care plan for individuals, Establish priorities for nursing care needs of clients. families, and communities with complex Evaluate and document the extent to which goals of health problems that have unpredictable outcomes. nursing care have been achieved. Use preventive, supportive, and restorative Pain Management measures to promote client comfort, Evaluate data from comprehensive pain history. optimum physiological functioning, and Evaluate and document client’s response to emotional well-being. pharmacological and nonpharmacological Base care planning on knowledge of primary, interventions. secondary, and tertiary levels of Document client’s response to interventions used to prevention. prevent or reduce pain. Assess client when pain is not relieved through ordered Same pharmacological and nonpharmacological methods. Evaluate appropriateness of any pain medication taken Participate in obtaining collective data by clients. concerning client outcomes. Educate clients on correct use of medications. Manage and monitor client receiving epidural analgesia. Deliver care that reflects an understanding of Teach client to use a PCA device. interactions among potentially conflicting Perioperative Care nursing interventions. Preoperatively, assess client’s risk for postoperative respiratory complications. Initiate a comprehensive plan for discharge of Postoperatively, assess client’s ability to perform client at time of admission. respiratory exercises. 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). Same Same Same Collaborate with other members of health- care team to identify alternative interventions. Same Same Same Same Same Same (continued)
50 U n i t 1 The Growth of Nursing Table 3.1 Competencies for Nursing Skills—cont’d Baccalaureate Degree RN Associate Degree RN Preoperatively, assess client’s risk for postoperative Same thrombus formation. Same Same Postoperatively, assess client’s ability to perform passive Same range-of-motion exercises. Same Preoperatively, assess client’s willingness and capability to Same learn exercises. Same Same Preoperatively, assess family members’ willingness to Same learn and to support client postoperatively. Same Same Postoperatively, assess client’s condition during Same operative procedure, including range of vital signs, Same blood volume or fluid loss, fluid replacement, type of Same anesthesia, type of airway, and size and extent of Same surgical wound. Same Develop protocols for use of restraints or Personal Hygiene of Clients Provide or assist with personal hygiene on developmental other safety devices. Same and/or chronological age basis. Same Same Provide or assist with personal hygiene needs as Same determined by physical limitations and/or diagnosis. Same Provide or assist with personal hygiene needs with Same respect to client’s culture and/or religious values. 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 client. Protect the client from injury. Verify identity of the client. Implement agency policies and procedures in the event of client injury. Follow policies and procedures for agency fires and safety measures. Follow procedures for handling biohazardous materials. Assess need for restraints or other safety devices. Implement nursing measures to reduce the risk for falls, poisoning, and electrical hazards. Prepare for internal and external disasters. Develop a plan for reducing environmental stressors (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.
C h a p t e r 3 Theories and Models of Nursing 51 Table 3.1 Competencies for Nursing Skills—cont’d Baccalaureate Degree RN Associate Degree RN Same Same Change a central venous catheter dressing. Monitor administration of medications/nutrients via a Same Same vascular access device. Same Measure and monitor central venous pressure. Maintain central vein infusions in adults and children. Same Change parenteral hyperalimentation dressing and tubing. Wound Care and Dressings Assess and manage wounds, including irrigation, application of dressings, and suture/staple removal. PCA = patient-controlled analgesia. Sources: Cowan DT. Competence in nursing practice: A controversial concept—a focused review of literature. Accident & Emergency Nursing, 151(1):20–26, 2007; Dickey C, et al. Nursing Skills Identified as Required Competencies. Helene Fuld Educational Mobility Grant. Oklahoma Nursing Articulation Consortium, Kramer School of Nursing, Oklahoma City University; Levett-Jones TL. Facilitating reflective practice and self-assessment of competence through the use of narratives. Nurse Education in Practice, 7(2):112–119, 2007. Modeling a Healthy Client “Although nursing models vary in time in our lives, we are A client, in many of the terminology and approach to health located somewhere along nursing models, does not care, there are four concepts that are the health continuum and have to have an illness to common to almost all of them: Client may move closer to one be the central element of or patient (individual or collective), side or the other, depend- the model (this explains health, environment, and nursing. ing on circumstances and the preference for using health status.7 ”term patient). This is also one of the clearest distinc- to define because it varies so much from one individual the term client over the Health is difficult tions between medical models and nursing models. to another. For example, a 22-year-old bodybuilder Medical models tend to be restrictive and reactive, fo- who has no chronic diseases perceives health differently cusing almost exclusively on curing diseases and than an 85-year-old who has diabetes, congestive heart restoring health after the client becomes ill. Nursing failure, and vision problems. The perception of health models tend to be proactive and holistic. Like med- also varies from one culture to another and at different ical models, they are certainly concerned with curing historical periods within the same culture. In some past disease and restoring a client’s health, but they also cultures, a sign of health was pure white skin, whereas focus on preventing disease and maintaining health. in the modern American culture, a dark bronze tan has A healthy person is just as important to many nursing been more desirable as a sign of health—although re- models as the person with a disease. search has shown how harmful ultraviolet light is to the skin. Health Like the concept of client, the concept of health has Environment undergone much development and change over the The concept of environment is another element in years as knowledge has increased. Traditionally, most current nursing models. Nursing models often health was originally thought of as an absence of dis- broaden the concept of environment from the simple ease. A more current realistic view is that of health as physical environment to elements such as living con- a continuum, ranging from a completely healthy ditions, public sanitation, and air and water quality. state in which there is no disease to a completely un- Factors such as interpersonal relationships and social healthy state, which results in death. At any given interactions are also included.
52 U n i t 1 The Growth of Nursing ?What Do You Think? Some internal environmental factors that af- How do you define nursing? What competencies are impor- fect health include personal psychological processes, tant for you to practice safely when you graduate? religious beliefs, sexual orientation, personality, and emotional responses. It has long been known that in- Because of the broadened understanding of dividuals who are highly self-motivated and inter- environment, several nursing models include manip- nally goal directed (i.e., type A personality) tend to ulation of environmental elements that affect health develop ulcers and have myocardial infarctions at a as an important part of the nurse’s role. The environ- higher rate than the general population. Medical ment may be directly altered by the nurse with little models, which are primarily illness oriented, may not or no input from the client, or the client may be taught consider it to be treatable. Nursing models that con- by the nurse to alter the environment in ways that will sider personality as one of the environmental factors contribute to curing disease, increasing comfort, or affecting health are more likely to attempt to modify improving the client’s health status.9 the individual’s behavior (internal environment) to decrease the risk for disease. Four Key Concepts To analyze and understand any nursing model, it is Like the other key concepts found in nursing important to look for these four key concepts: client, models, the concept of environment is used so that it is health, environment, and nursing. These concepts consistent within a particular model’s overall context. should be clearly defined, closely interrelated, and Nursing models try to show how various aspects of en- mutually supportive. Depending on the particular vironment interrelate and how they affect the client’s nursing model, one element may be emphasized health status. In addition, nursing models treat envi- more than another. The resultant role and function ronment as an active element in the overall health-care of the nurse depend on which element is given system and assert that positive alterations in the envi- greater emphasis. ronment will improve the client’s health status. GENERAL SYSTEMS THEORY Nursing The culminating concept in all the various nursing A widely accepted method for conceptualizing and models is nursing itself. After consideration of what understanding the world and what is in it derives it means to be a client, what it means to be healthy, and how the environment influences the client’s health status (either positively or negatively), the concept of nursing delineates the function and role of nurses in their relationships with clients that affect the client’s health. Historically, the profession of nursing has been interested in providing basic physical care (i.e., hygiene, activity, and nourishment), psychological support, and relief of discomfort. Modern nursing, although still including these basic elements of client care, has expanded into areas of health care that were only imagined a generation ago. Client as Partner In the modern nurse–client relationship, the client is no longer the passive recipient of nursing care. The relationship has been expanded to include clients as key partners in curing and in the health-maintenance process. In conjunction with the nurse, clients set goals for care and recovery, take an active part in achieving those goals, and help in evaluating whether those actions have achieved the goals.8
C h a p t e r 3 Theories and Models of Nursing 53 from a systems viewpoint. Generally understood as attempts to put it back together by showing how the an organized unit with a set of components that in- parts work individually and together within the sys- teract and affect each other, a system acts as a whole tem. This interrelationship of the parts makes the sys- because of the interdependence of its parts.10 As a tem function as a unit. Often, particularly when the result, when part of the system malfunctions or fails, system involves biological or sociological entities, the it interrupts the function of the whole system rather system that results is greater than the sum of its parts. than affecting merely one part. The terminology and For example, a human can be considered to principles of systems theory pervade U.S. society. be a complex, biosocial system. Humans are made Humans, plants, cars, governments, the health-care up of many smaller systems such as the endocrine system, the profession of nursing, and almost any- system, neurological system, gastrointestinal system, thing that exists can be viewed as a system. urinary system, and so forth. Although each of these systems is important, in and of themselves they do A Basis in Thought not make a human. Many animals have the same sys- Although general systems theory in its pure form is tems, yet the human is more than the animal and rarely, if ever, used as a nursing model, its process more than the sum of the systems. and much of its terminology underlie many nursing models. Elements of general systems theory in one A Set of Interacting Parts form or another have found their way into many Although the early roots of general systems theory textbooks and much of can be traced as far back as “the professional litera- The culminating concept in all the vari- the 1930s, Ludwig von ous nursing models is nursing itself. Bertalanffy is usually cred- ture. General systems the- After consideration of what it means to ited with the formal devel- ory often acts as the opment and publication of unacknowledged concep- tual framework for many be a client, what it means to be healthy, general systems theory educational programs. An and how the environment influences the around 1950.11 His major understanding of the client’s health status (either positively or achievement was to stan- mechanisms and termi- negatively), the concept of nursing delin- dardize the definitions of nology of general systems eates the function and role of nurses in the terms used in systems theory is helpful in pro- their relationships with clients that theory and make the con- viding an orientation to cept useful to a wide range understanding nursing ”affects the client’s health. of disciplines. Systems the- models. ory is so widely applicable Manageable Fragments because it reflects the reality that underlies basic human thought processes. General systems theory, sometimes referred to simply Very simply, a system is defined as a set of as systems theory, is an outgrowth of an innate interacting parts. The parts that compose a system may intellectual process. The human mind has difficulty be similar or may vary a great deal from each other, comprehending a large, complex entity as a single but they all have the common function of making the unit, so it automatically divides that entity into system work well to achieve its overall purpose. smaller, more manageable fragments and then exam- A school is a good example of how the ines each fragment separately. This is similar to the dynamics and connections of a system work. A process of deductive reasoning in which a single com- school as a system consists of several units, includ- plex thought or theory is broken down into smaller, ing buildings, administrators, teachers, students, interrelated pieces. All scientific disciplines, from and various other individuals (e.g., counselors, physics to biology and the social sciences (e.g., sociol- financial aid personnel, bookkeepers, and mainte- ogy and psychology), use this method of analysis. nance persons). Each of these individuals has a unique job but also contributes to the overall goal Reassembling the Fragments of the school, which is to provide an education for Systems theory takes the process a step further. After the students and to further the development of analyzing or breaking down the entity, systems theory knowledge through research.
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