Nursing theory concepts and frameworks

Nursing

In the pantheon of nursing theories, borrowed theories are those that derive from other disciplines and have been adapted to the nursing context. Many such borrowed theories come from the different social sciences, such as psychology or sociology, because they directly reflect critical issues in care such as human nature and the role of human interactions in well-being. One could apply religious theories to care for religious people, and it is possible even to consider things like motivational theories as well, if the nurse is trying to motivate the patient (for example, to change behavior as a means of changing health outcomes). Borrowed theories have perhaps received less study than either grand theories or mid-level theories, but they are nevertheless an important source of insight for the nursing educator, and it is important to understand the theory, where it comes from, and how it has been adapted to apply specifically to the nursing context. There is still debate within the nursing community about the usefulness of borrowed theories, because they may not adapt perfectly to the nursing context (Villarruel, et al., 2001), but that is what makes them so interesting -- they are in common use yet may not be perfectly applicable. For the nursing educator, this is important because choosing what to teach requires understanding the nature of borrowed theories, and their pros and cons alike.

Maslow's Hierarchy of Needs

Maslow's hierarchy of needs derives from psychology and was developed in the 1950s by Abraham Maslow. This theory, which outlines five different strata of human needs and proposes that they exist in hierarchical form, has been widely applied in many fields where human motivation is being studied. It has become important not only in psychology but is taught in the human resources section of business schools and of course in nursing schools (McLeod, 2014). The five strata of needs are, in order of importance, physiological, safety, social, esteem and self-actualization. At the heart of the theory is that the lower-order needs need to be satisfied in order to progress to higher-order needs. In other words, people who are hungry cannot worry about their social lives until they have acquired food, then shelter. Only then can they worry about their social needs. If their social needs are met, then they will worry about the higher-order needs. While there are people who can be held up as exceptions -- the starving artist archetype is pursuing self-actualization at the expense of basic physiological need -- for the most part people stick to these needs. Over the years, Maslow's hierarchy has been subject to scrutiny, but its simplicity and broad applicability has allowed it to remain common in education and practical use across many different disciplines.

Maslow

Abraham Maslow sought to study the characteristics of successful people, and what motivated them. It was through these studies that he developed his theory. His approach was both typical of the time and unconventional. The typical element of his approach was that there was little scientific method used in the early 20th century in psychology. He developed his theory more through observation and quasi-academic study than anything else. His approach was unconventional in that at the time apparently most psychological study was done on the mentally ill, rather than the highly successful. Psychology was more about understanding and helping those with psychological difficulty, whereas Maslow was more interested in learning how to help people succeed. His hierarchy was the output of that, and was published in book form in 1954. He spent the rest of his career working on this theory, both refining it and defending it.

Key Components

The key components of Maslow's hierarchy are the five different types of needs. People have all of these needs, but the hierarchical element of these needs holds that most people tend to prefer to satisfy the basic needs first, and then progress. Self-actualization, for example, is a luxury for those who have satisfied the other needs. The hierarchical nature in particular has been criticized, and it does appear that it reflects a more individualistic culture where self-actualization is considered more important than the social group. A counter that argument is that people from cultures where social needs are primary are simply people who stop at that level, and do not worry about the higher-level needs. Individuals within those cultures -- artists for example -- tend to place esteem and actualization needs above the social needs even within those societies.

In nursing practice, esteem and actualization are often not the focus when Maslow's hierarchy is applied to the nursing context. Instead, the focus is on meeting the other needs. So much of the application is centered around the three lower order needs, the physiological, the safety and the social needs. Nurses typically deal with physiological needs as caregivers, and sometimes they also deal with safety needs (especially where physical health in concerned) and social needs.

Application

There are many ways that Maslow's hierarchy has been applied to nursing practice. And there are ways that the hierarchy has been challenged. There are many middle-range theories, for example, that emphasize the role that the social group plays in physical health. Such theories contradict the hierarchical nature of Maslow's theory, proposing that where these needs exist, there is a two-way flow of benefit from meeting the needs. Where one's family and friends can help to improve their motivation, that can spur improvements in physiological health. Maslow never really seemed to consider the possibility, yet it is something that is found in many middle-range theories.

However, other nursing theories do seem to incorporate many of the principles found in Maslow's hierarchy. They understand the role that physical health plays in a person's well-being. For example, theories that are oriented towards proactive interventions are typically built on a Maslow base. When a nurse intervenes to improve the health of a patient by changing their habits, this is done because doing so will usually bring about better outcomes for the other elements of the hierarchy. A basic example would be that of a drug addict. The nurse seeks to get the addict off of the drugs, because that basic level of health is a precursor to the restoration of safety (home, reliable food supply) and social needs (family relationships, a job).

There are several examples of the application of Maslow's hierarchy to the nursing setting. Benson and Dundis (2003) applies Maslow's hierarchy to training in nursing. They note that it is a key framework for understanding motivation in the workplace, something that is at least of importance to health care administrators. Nurses are only likely to be motivated if the basic human needs are being met.

Zalenski & Raspa (2006) apply the hierarchy of needs to the hospice setting. They adapted the five hierarchical needs to palliative care as follows. The first order is the distressing symptoms, the second is fears for physical safety, of dying or abandonment. The third is affection, love and acceptance in the face of devastating illness. The fourth is esteem, respect and appreciation for the person. The fifth remains as self-actualization. The authors argue that the first needs are those immediate health needs, such as active pain, breathing troubles, hydration or other basic physiological needs. The first priority should therefore be focused on meeting those needs above all else. Only when those needs are met, should practitioners in the hospice setting focus on other issues -- fear and the state of mind of the patient is important. Then, the next two needs are basically affection and esteem, two things that important for a dying person to better accept their situation. Knowing that theirs was a life well-lived and that they had a meaningful impact on people allows for them to feel better, and have an improved palliative situation.

Practical Application

Resnick's theory was applied to getting people to motivate to healthier behaviors in order to improve their health. Clearly, Maslow is useful here, because it is a motivation theory. Understanding the ways that people are motivated will in particular help the nursing practitioner understand some of the potential obstacles. For example, it might be important for someone to change their eating habits in order to avoid diabetes, but developing that motivation can be tricky when the only food in their area is junk food -- this problem is common in some parts of the U.S., but it makes it difficult to convince somebody to change their habits when they can barely afford the food they eat already -- when money gets in the way, that reflects the safety need. Appealing to a lower order need can work though -- pointing out that the patient will be unable to provide even their most basic needs if they get sick might help convince them to take the needed steps to avoid getting sick in the first place.

Conclusion

The simplicity of Maslow's hierarchy makes it easy to apply to a wide range of studies relating to people. It was developed in psychology back before scientific practice was part of that discipline, but has remained vital in psychology and a number of other fields as well. The theory has proven surprisingly robust, but it does still need to be adapted for use in nursing. As a human resources tool for nursing administrators, Maslow's hierarchy works the same as it would in any other business, but for nurses dealing with patients, some adaptations need to be made. Many nursing theorists have been able to make such adaptations in order to help nurse practitioners better understand the motivations that patients have. These generally fall along the lines of immediate pain and discomfort issues, followed by bigger health issues, and finally to the social and esteem dimensions.

Some of the critics of the hierarchy specifically take issue with the hierarchical structure, and such criticisms can be found embedded in a number of middle-range theories as well. For example, where the human is taken as a holistic system, meeting social needs can affect positive change in the patient's physical condition, indicating linkages that are not part of Maslow's hierarchy. So the application of Maslow's hierarchy in nursing theory and practice is by no means universal, and it does not align well with many nursing theories.