Trilogy Course -Part 2

Theories

Welcome to Part 2.

What are theories?  And of what value are they to the 21st century nurse?

In general terms, a theory refers to a group of related concepts, definitions, and statements that attempt to describe, explain, or predict the activities and behaviors of nurses in practice that might elicit patient responses or outcomes.  They are abstract ideas, not concrete facts and are tenable, or subject to change as new discoveries in science and human behavior are made.  Actually, they are propositions that suggest new ways of thinking and paradoxically, may sustain beliefs for centuries.  Nightingale’s theories about hygiene and environmental health are an example.

Theories are important for: (1) a repository of the body of knowledge upon which nursing practice develops, (2) it contributes to the integrity of the nursing profession because of its scholarly characteristics and the respect it builds in the scientific community, and (3) it is a  useful tool for developing reasoning, critical thinking, and decision making.

Are concepts the same as theory?

Concepts are frameworks, or organizing structures, similar to theory of broader and more comprehensive implication. Theory may be formed from concepts.  Models are even more abstract and may display concepts and theories within them.  Levine’s Conservation Model in this course is one example.  Theory, conceptual constructs, and models have guided the development of nursing research, education, and practice in ways that have facilitated the quality of health care we now experience.

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We will begin with a scenario with which we will manipulate the theories of Watson and Levine so that we can feel the texture of practical nursing care implemented through the topics of this course.  Questions will be asked of you regarding these theories in later modules so that you may contribute to our learning together.

CLAIRE

Claire sits by her bed, hearing the irregular rhythm and declining quality of Victoria’s breathing.  An adult son and his wife huddle around the makeshift bed in the humble living room where she has been lingering between life and death for 3 days, suffering in the unfortunate final stage of a battle with AIDS complicated by pneumonia, comforted and cared for by the community-based hospice staff.  Claire has been her case manager and now she is remembering when she first met Victoria in this same community 25 years ago . . .

Claire began her career on a Med-Surgical unit in a general hospital of a middle-size town.  She worked 2 years full time, during that time she married and she and Jason began working toward the purchase of their own home. Claire had many challenging and interesting patients over this time (the mid ‘80s).  One of whom was Victoria, who was 22 years of age.

Six days before Victoria was discharged to home after a cholescystectomy with a 4-inch incision and an adjacent stab wound with a T-tube draining into a grenade-like collection unit (this was before laparoscopy procedures). She returned in 3 days with a fever of 1040 and abdominal pain.  Her surgical wound had eviscerated 10 cms producing foul drainage.   She was assigned to Claire.

In the immediate hours cultures were taken, IV antibiotics begun, pain med ordered and given, diet limited to clear liquids, and activity restricted to bedrest for 24 hours.  A male visitor from a different ethnicity from the patient had accompanied her to the Emergency Department, but never returned throughout her hospitalization.  It was 3 days before Victoria gained the courage to relate what brought about this setback: a male “friend” had handled her roughly and punched her in the abdomen.  Claire learned more about the environmental and social aspects of her living circumstances and, with her permission, arranged for the Social Worker to meet with her.  Today she was discharged with new living arrangements made and continuance of the SW support.

Discussion . . .

Today, what assessment measures are in place to discover need for intervention earlier?
What support structure do you have in your community to assist a person like Victoria?

Theory Overview:  Transformational Caring

JEAN WATSON – Caring
(Refer to the Bibliography page for reference sources)

Her Background: Psychiatric Nursing; Education-Psychology Doctorate; Taught at Univ. Colo. 27 yrs.

A theory demanding use of qualitative research.

Presented in her book “Nursing: Human Science and Human Care: A Theory of Nursing” (1985).

She wrote it following 6 years of study into what she perceived as the problem of a lack of explanation of the work of nurses.  It is meant to bring new meaning and dignity and broadens the conceptual scope of nursing.  Rejects people as “objects.”

Also called the Theory of Transpersonal Caring.

A middle range, explanatory theory—a world view.

Continues to evolve . . . In spite of her promotion of wholism, she often describes dualism.

The promise and scope of the theory:

  • Recognition each individual is a being inseparable from self, others, nature, and the universe.
  • There is healing potential for both caregiver and care recipient in a caring relationship

Admittedly, she draws on a range of dimensions:

  • Humanitarian
  • Metaphysical
  • Spiritual—existential
  • Phenomenological
  • Eastern philosophy

Refer to:

Her extensive philosophical claims on value  (Fawcett, p. 659)

Her elaboration on human life (Fawcett, p. 661)

She defines Health: “Health refers to unity and harmony within the mind, body, and soul.  Health is also associated with the degree of congruence between the self as perceived and the self as experienced.”  (p. 661)

Caring is a moral ideal of nursing.  Protecting, enhancing, preserving human dignity.  Seek ways to enable individuals to reach a higher degree of harmony in the spheres of wholeness—body, mind, soul.

She purposely merges Christianity (Western thought) with Eastern beliefs (Buddhism).

Concepts:

  • Transpersonal caring relationship
  • Caring occasion/moment
  • Care (Healing) consciousness
  • Carative factors – 10 Dimensions  (Fawcett, p. 663)
  • Which are behavior guides for nurses  (Core of nursing)
    • Are hierarchical in nature, with each level contributing to the next
    • They are also interactive—holistic

“Caring and love are the most universal, the most tremendous, the most mysterious of cosmic forces . . .”  (Alligood and Tomey, p. 102)

Caring–“the ethical principle or standard by which caring interventions are measured.”  (p. 103)

She refers to technical nursing procedures/protocols as sacred acts conducted with a caring consciousness in a way that honors the person as an “embodied spirit.”  (p. 103)

Carative Factors (Caring-Healing Modalities) employ intention, conscious use of implements which appeal to imagination, senses, cognition, body movement (kinesis), and presence.  Also employed are comfort measures; emotional, expressive, and relational work; and teaching and learning.  To be implemented they need on the part of the nurse:

Intention
Caring values
Knowledge
A will to engage
A relationship
Actions
Commitment

Theory Overview: Levine’s Conservation Model

LEVINE’S CONSERVATION MODEL OF NURSING PRACTICE

Primary Sources:  Fawcett (2000), p. 190; Alligood & Tomey (2002); Mefford article; Mock, et al article

Her purpose in developing the model:  provide an organizing framework for teaching undergraduate nursing students.  It illustrates a rationale for nursing behaviors/activities—the why’s of procedures and activities of care.

Conservation—a natural law common to basic sciences.

Enables students and practicing nurses to understand the scientific nature of what they do.

The underlying purpose of the theory design/structure, in practice, is to “keep together,” or maintain a well-considered balance between the intentional activities of nursing interventions coupled with the patient’s participation and safe limits of the patient’s abilities.  Examples:

  • a 65 year-old male with severe CHF at home with ambulation, strict fluid and nutrition intake   in his care plan
  • a 28 year-old male war veteran with RLE amputation adapting to a prosthesis and experiencing PTSD
  • a 12 year-old female in the Republic of Congo recently orphaned, caring for a 5 year-old injured brother, receiving instructions for his aftercare

What makes this theory compatible with the concepts of this trilogy is the set of philosophical claims of her perceived value system (selected):

1 a.  Regard for the sanctity of life.

1b.  Motivation to prevent/alleviate suffering   [The fundamental principles of all moral systems]

2.  Healing sciences are founded on the belief in the wholeness of man – restoration, well-being. Unction is conferred on the caregiver to bring dignity and compassion in care rendered.

3.  The role of the caregiver, and by extension the health system, is to prevent/alleviate suffering.

4.   The patient should have ultimate decisionmaking about his care; the nurse reserves his/her personal values and avoids influencing those decisions.

5.   The nurse-patient relationship is built on mutual trust, maintenance of integrity, encouragement to self-care, avoidance of judgmental contingency care.  The nurse must accept the patient the way he/she is.

6.   Nursing behaviors must demonstrate a respect for patient rights and privileges.

7.   “The wholeness which is part of our awareness of ourselves is hared best with others when no act diminishes another person, and no moment of indifference leaves him with less of himself. Every moment of moral injustice extracts a price from both patient and nurse, just as every moment of moral responsibility gives each strength to grow in his wholeness” (Levine, 1967, p. 54)

Why the term “conservation”?

Answer:  Nursing activity is conserving in nature, joining the best science (best practices) with the most devoted human acts.  Bringing those to the patient elicits a reciprocal relationship.

The primary/ultimate goal of Conservation:  To defend, sustain, maintain, define, the integrity of the system.  It acknowledges the effort the individual makes to receive recognition, respect, self-awareness, humanness, holiness, independence, freedom, self-hood, and self-determination. (Alligood & Toomey, p. 201)

Conservation measures the effectiveness of nursing care and the patient’s adaptiveness.

Adaptation:  “The ongoing process of change wherein individuals retain their integrity without the realities of their environment” (Alligood & Toomey, p. 199).

Concepts:

  • System
  • Wholeness     Dimensions of a holistic being (Person)
  • Integrity

Conservation Dimensions Principles:

  • Conservation of Energy
  • Conservation of Structural Integrity
  • Conservation of Personal Integrity (Sense of Self-Worth)
  • Conservation of Social Integrity

The interface of Integrity and Environment is where nursing care begins.

Environmental Influences:

Internal Homeostasis (stable state)

Homeorrhesis (stabilized flow, fluidity of change within space-time continuum)

External Perceptual Environment

Operational Environment (all aspects of life-space forms not identified by the senses)

Conceptual Environment (language, ideas, symbols, etc.)

[Wholeness is the desired state where these two influences come together and have the best fit—a smooth interface.]

Adaptation (change)

Historicity – evolution of species – information conveyed by the genes through generations

Specificity – synchronicity of physiological activities in the whole being

Redundancy – “fail-safe” options in anatomy, physiology, and psychology.  Its failure brings on aging.

Organismic Responses:

Fight/flight
Inflammatory – Immune
Stress
Perceptual Awareness

[Please continue to Part 3

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