Human Theory of Caring

Theory guides practice. This is true of many things, but is especially true of nursing. While many processes, actions, and rules are involved in becoming a great nurse, understanding and applying theory must be the most important aspect. Nursing theory allows for one to examine concepts and then attempt practical application of these concepts when theories are tested. Evidence-based practice for example, is the wonderful lovechild of theory and application in that when theories are constructed, they are then tested, and if they work, are applied to standard practice via modification. This essay aims to provide a deeper synthesis of nursing theory by examining two important nursing theories: Orem's Self-care Theory and Watsons Nursing Theory. Additionally, one will see how nursing theory has evolved since its beginnings.

Many say nursing is as old as humankind. If there was someone sick, there was someone willing to take care of that person and nurse them back to health. The word ‘nurse’ comes from the Anglo French nurice as well as the Latin nutrica. Both words mean nourish. Nurses nourish the patient emotionally, mentally, and physically and provide for them the means of getting back to good health (Parker & Smith, 2015). When looking at nursing theory, the purpose of it, is to help one comprehend the process of nursing and improve one’s own thinking related to nursing. “The purpose of nursing theory goes beyond its study within courses. Nursing theory becomes alive when the ideas are brought to practice. The usefulness of theory in practice is one way that we judge its value and worth” (Parker & Smith, 2015, p. 27).

Many theories exist out there in various fields. Nursing is no different. It is up to the person to decide which theory to apply to one’s own thinking and practice. It is helpful to examine theories via primary sources or the work of prominent scholars that have studies selected theories. Back then theory was the only thing that kept nursing going in the sense that nursing and healthcare in general demanded constant improvement, innovation.

Improvement and innovation cannot be done unless theory is involved. Even now, there are constant new nursing theories surfacing that could one day end up responsible for standard practice and care. For example, emergency nursing, this is something that requires quick thinking and a plethora of knowledge of various ailments. Without theory, one has no direction to take to explore the different avenues of what it is to be a nurse.

William K. Cody is a respected and well-known contributor to Nursing Science Quarterly. In one of his articles he discusses nursing theory. Cody opens with stating how convinced he is theory guides practice. This is significant to note because some people may say that practice guides theory. But, as Cody and others before him suggested, it is the opposite.
To assert the alternative, that theory arises from practice to an equal or greater extent than theory guides practice, would be a misrepresentation of the contemporary art and science of nursing theory development. In actuality, this assertion has been made widely and, I would venture to say, that is to the detriment of theory development in nursing (Cody, 2003, p. 225).
Practice comes from thought, process of thought is the foundation of theory. This is not a chicken or egg scenario. One thinks something and then it becomes real through practice. Sure, theories are tested and then people implement sound theories into nursing. But the first is always the initial thought.

Nursing theory has evolved more than ever before in recent times and has become a main way to provide better patient care. What also come about from theory is a new mode of thinking that is based on theory, evidence-based practice. One article stated that nurse educators and nurses must embrace both theory-based practice and evidence-based practice because they have their benefits when it comes to improvement and innovation (McCrae, 2012). In fact, one can consider evidence-based practice a step further from theory-based practice in that, one must cultivate a theory and then implement, and gain evidence of its usefulness and effectiveness in practice. Practice does not exist without theory and people are beginning to truly see that now.
They may see that through Carr’s four principal approaches that explain the nature of theory. “Carr terms these approaches the 'common-sense' approach, the 'applied-science' approach, the 'practical' approach and the 'critical' approach. Each approach is recoverable from the explicit and implicit content of scholarly literature” (Fealy, 1999, p. 74). The common-sense approach is a way to locate or ground theory within commonsense and is articulated in the world of practice. Practice allows it to be refined, reconstructed, and then validated (Ghaye & Lillyman, 2014).

An applied science approach means conforming to standards of validity, reliability, and vigor as it is laid down by ‘science’. The practical approach allows for nourishing of practical clinical wisdom. This approach is used to support and inform clinical decisions (Ghaye & Lillyman, 2014). A critical approach allows one to see through theory, why a practice is the way it is. This approach takes into consideration how political, social, and historical forces serve to constrain or liberate what is done. Seeing theory from these perspectives, one can see how nursing theory is integral to everything, especially evidence-based practice.

Orem’s self-care theory or Self-care deficit nursing theory or Orem’s Model of Nursing, is a grand nursing theory developed by Dorothea Orem between 1959 and 2001. The theory stems from totality paradigm based on adaptation to one’s environment (Masters, 2014). Thanks to this theory there has been improved quality of care from numerous randomized controlled trials carried out in the nursing discipline. Many use this theory especially in primary care and rehabilitation settings where patients are encouraged to strive for independence.
That is one of the main caveats of the theory when applied to primary care or rehabilitative settings. To have patients achieve independence as soon as possible part of the adaptation aspect of the theory. Human beings have the amazing ability to adapt to their surroundings. Therefore, creating an environment where they can achieve independence quickly may produce better results, better outcomes.

Orem herself, described the model as a general theory consisting of three related theories. “The three inter-related theories include the theory of self-care, the theory of self-care deficit, and the theory of nursing systems” (Masters, 2014, p. 154). These three parts of theory focus not on the individual, rather on persons in relations. The emphasis is on the ‘I’, the ‘you and me’, and the ‘we’. When applying these three theories together, it generates Orem’s personal theory. Meaning, if there is no one there to care for the patient, there is a model that exists for self-care.
Imagining how this can be applied to my practice as an emergency department nurse, there are patients often that must wait hours to be seen. In their state of pain and anxiety, a nurse can come over and help them get over such a frazzled state. The nurse can teach the patient for example, to elevate a leg if it is in pain, or take deep breaths if one is anxious. These things teach the patient independence and allows them to adapt to the current situation.
There is the expectation in the theory that patients want to take care of themselves. When they are permitted to take care of themselves to the best of their ability, the assumption is that they recover quicker and holistically. Orem in her theory, identified self-care requisites and are classified as either:

· Developmental self-care requisites that are 1 of 2 things, maturational: progress toward higher levels of maturation and situational: aversion of deleterious effects associated with development
· Universal self-care requisites: those needs everyone has
· Health deviation requisites: needs arising from a patient’s condition (Parker, 1993).

There are also self-care deficits that mean a person cannot meet his or her own self-care requisites. This is when the nurse determines these deficits and defines support modalities.

Bringing this back to my practice, there can be patient who is obese and needs his blood pressure measured. He is writhing in pain and cannot sit still to take the reading. Now because of the person’s weight, a regular pressure cuff cannot fit, so a larger one can be used. The nurse has to determine if the patient can sit still or not. If not due to pain, the nurse can give the patient a pain killer to then take the reading.

Some recent literature points to a long time before patients receive pain relief for injuries in the emergency department. “The median time to pain medication administration for patients presenting to our ED with extremity fractures was 72.5 minutes” (Heilman, Tanski, Burns, Lin, & Ma, 2016, p. 1). If the patient is suffering an extremity fracture, there should be a shorter window of time to administer pain medication. While theoretically, this seems viable, practicality may lend to a different interpretation. But that is the point of nurse theory and theories like Orem’s. It is to think differently and see where it leads.
At times patients cannot support themselves and experience self-care deficits. That is where Orem’s theory includes support modalities. Meaning, nurses are encouraged to recognize and rate a patient’s dependency or any of identified self-care deficits on the following scale:

1. Partial Compensation
2. Total Compensation
3. Education/Supportive (Meleis, 2012).

Total compensation is when there is an utter lack of independence on the part of the patient. This means the nurse needs to assist the patient in everything. Partial Compensatory, means a patient can do some things like for example, go to the bathroom on their own, but needs help to walk. Educative/Supportive, in this system, means a patient is independent, but needs assistance in behavior control, decision-making, as well as getting hold of information (Meleis, 2012) (Abotalebidariasari, Memarian, Vanaki, Kazemnejad, & Naderi, 2016).

If this were to be seen through my practice, three patients could be in the emergency department. One is bedridden and cannot move because of recent surgery. This person needs complete help in everything. Another person, who underwent minor surgery needs help with bathing but can take his or her own medication. And the last one, a patient experiencing an infection, that just needs an education on proper antibiotics.

Orem described a nurse in terms of a counselor, advocator, educator and teacher. This is true. Orem included the concept of inductive and deductive thinking in this theory and provided the stage from which to understand the various complexities of patient recovery (Dickson, Buck, & Riegel, 2011). Overall, one can understand how important theory is in relating to patients, in recognizing the need to assist patients and so forth. Without theories like Orem’s there is little that can be done to understand context. Patients need a higher level of understanding to recover and to communicate effectively.

Some may argue Watson’s nursing theory as eclectic. “Watson's theory is eclectic, that is, she has pulled ideas from several sources in building her theoretical expositions. In addition to those already mentioned, major thoughts from pragmatism are evident, such as seeing humans as experiencing subjects in ongoing change” (Kim, Kollak, IG Publishing, & Springer Publishing Company, 2006, p. 175). However, it is a popular theory that promotes the notion that people care. Otherwise known as Theory of Human Caring, Watson feels that the main concern of nursing is the promotion of health, prevention of illness, restoring health, and caring for the sick (Clark, 2016). The theory places a focus on health promotion along with treatment of illness. According to Watson, when nurses care, they are adhering to essential principles and in turn promote better health outcomes versus a simple medical cure (Clark, 2016).

Putting this in the perspective of my practice, patients respond better when nurses act like they care. Showing sincere interest in the person’s wellbeing promotes a desire for the patient to get better. I personally experienced enthusiastic patients come back and tell me that my care of them during their time ill helped them and allowed them to understand what they needed to do to get better. Caring is such an integral part of nursing that without it, nursing would not be what it is regarding patient care and patient satisfaction.

While caring can be difficult with long shift and multiple patients throughout the day, making that extra effort can and does lead to positive health outcomes. Ultimately, that is what is needed in healthcare. To get nurses to care, this may be an interesting area of research. Nurses may need additional support or higher pay to be able to remove some of the stress of emotionally investing in so many patients all the time.
When it comes to unique contribution, the theory of human caring is a means of uniquely contributing to my clinical practice. How is this? It can be found in Watson’s model and how she makes seven assumptions:

1. Caring can be successfully shown as well as practiced only interpersonally.
2. Caring is comprised of carative aspects resulting in satisfaction of particular human needs.
3. Successful caring allows for the promotion of health plus individual or family growth.
4. Caring responses accept patients as they are now and what they may become.
5. A caring environment is one that provides growth of potential while permitting patients to elect the best action at any given point in time.
6. Science of curing and science of caring are complementary.
7. The practice of caring remains a central part of nursing (Butts & Rich, 2017).

These assumptions demonstrate that caring is not only pivotal but exists within a certain structure. Watson’s theory also brings up four major concepts: health, nursing, environment or society, and human being. Society offers the values that help determine how a person behaves and what objectives they should aim toward. The concept of the human being is one of respect, nurture, understanding, and assistance. Patients are human beings and deserve compassion, respect, help, and nurturance. Without these fundamental ideas, there can be no cultivation of genuine connection.
Health is the harmony and unit in the soul, body and mind. Health is connected with the degree of congruence among the self as experienced and the self as perceived. Nursing is human health and a human science of persons where they mediate by personal, esthetic, ethical, personal, and human care transactions. All of this amounts to a complex narrative of compassion and nurturing for the human soul and the human experience.

Several studies have noted that caring behaviors are an integral aspect of patient care.
“Patients rated overall caring behaviors as important (97.2%) and frequently experienced (73.7%)” (Suliman, Welmann, Omer, & Thomas, 2009). Patients notice when nurses show that they care and respond accordingly. When I treat my patients, I show that they care, and it motivates them to get better. They may feel afraid or anxious because of surgery and I provide them with relief and humor and they tell me it makes all the difference.

In a randomized controlled trial, the theory of human caring model promoted a better health outcome for women who experienced infertility. “Nursing care based on the Theory of Human Caring decreased the negative impact of infertility in women receiving infertility treatment and increased self-efficacy and adjustment” (Arslan-Özkan, Okumu?, & Bulduko?lu, 2013, p. 1801). Working in an emergency environment, some people come in dead or dying. This is when the theory can be best applied because it allows development of emotional intelligence that can lead to a better overall outcome for patients or patients’ relatives. By nurses demonstrating they care and are concerned with the wellbeing of the patient or even the relatives of the patient, it shows vested interest and promotes healing. Sometimes emotional healing is the most significant aspect to patient care. This cannot be done without some level of sincere caring for the individual.

Nursing theory has contributed greatly to the evolution of nursing. Recent innovations seem centered on a customer service model where patient satisfaction is emphasized. “Corporate and commercial values are inducing some healthcare organizations to prescribe a customer service model that reframes the provision of nursing care” (Austin, 2011, p. 158). Patient satisfaction is of utmost priority in hospitals and clinics as reputation and popularity are integral to the maintenance of these establishments. Satisfied patients are more likely to come back if needed and recommend friends to go there for treatment. While the ideal scenario in healthcare is minimal chronic illness, the reality is many people suffer from chronic ailments and several hospitals and clinics are often full. Therefore, to keep them satisfied and keep these places going, there needs to be a change in how patients are treated. This means going back to theory.

Theory-based practice has in recent years been pushed to the side in favor of evidence-based practice. Although evidence-based practice is integral to the various aspects of nursing, its roots are theoretical. To begin something, one must think of it and formulate a theory. For example, there is a growing need to instill in nurses how to be effective leaders. Clinical leadership development has become a focus for some researchers. “Clinical leadership development should emphasize the development of all nurses as clinical leaders in the context of the delineation, clarification and articulation of their distinctive contribution in multidisciplinary care settings” (McNamara et al., 2011, p. 3502). My position as emergency department nurse often requires taking on the responsibility of a leader. That means communicating effectively with others and so forth.
There is a constant inundation of information and situations that needs to be examined and looked at from a theoretical perspective. For example, why isn’t leadership being instilled in nurses? Nurses are often taking on the role of the doctor. Their greater responsibilities mean they need additional training to handle additional stresses. Theory helps pave the way for what to look for to train the nurses of the future on how to become effective leaders.

Moss (2004), shares that there is a level of emotional intelligence nurse leaders must possess. Speaking for nurses in the emergency department, some patients come in close to death with loved ones in need of assistance. There is a need to acknowledge the various emotional processes that happen in this scenario. “Increasingly, leaders in all fields acknowledge emotional processing, which was once left to instinct and intuition, as a vital component of executive ability” (Moss, 2005, p. 5). In an age where people may be more prone to pursue legal action against healthcare professionals they feel did not handle an emotional situation correctly, there arises the need to know how to correctly handle such scenarios.
Theory is for lack of a better word, a floodgate where people can open it and try to access knowledge or keep it close and let information remain hidden, locked away. To pursue theoretical-based practice is to pursue a new way of thinking in situations that require it.

In nursing, the progress of theories has taken place on countless levels.
Meta-theory refers to the theory of theory and is focused at the “big” philosophical and methodological level. Grand theories provide a conceptual framework that emphasizes broad perspectives on practice, but these are abstract and difficult to test. Middle-range theories are the bridge between grand theories and practice theories (Moyle, Rickard, Chambers, & Chaboyer, 2015, p. 252).

These levels not only make for greater examination and exploration of nursing topics, but continued evolution of nursing itself.
Theory-based and evidence-based practice have a common goalmouth of making the correct choice and creating the most effective answer for an issue. The two, though have some core philosophical differences. The difference among evidence-based practice and theory-based practice can be appended to an antiquated divide existing in science and philosophy. Such a divide is that of rationalism versus empiricism. Rationalists possess a perspective that one’s senses are inadequate and place their trust in reason (Polifroni & Welch, 1999). This is in disparity with empiricists who state sense experience is the source of all information and ideas. Theory guided practice tails a rationalist viewpoint while evidence based practice shadows empirical knowledge.