Theoretical Foundations of Nursing: Nursing Can Be

Theoretical Foundations of Nursing:

Nursing can be described as a science and practice that enlarges adaptive capabilities and improves the transformation of an individual and the environment. This profession focuses on promoting health, improving the quality of life, and facilitating dying with dignity. The nursing profession has certain theoretical foundations that govern the nurses in promoting adaptation for individuals and groups. These theoretical foundations include theories, theory integration, reflection, research and practice, and assimilation.

Grand Nursing Theory:

There are several grand nursing theories that were developed by various theorists including the Science of Unitary Human Beings by Martha Rogers, Sister Callista Roy's Adaptation Model, and Systems Model by Betty Neuman. Sister Callista Roy's Adaptation Model is based on the consideration of the human being as an open system. She argues that the system reacts to environmental stimuli via cognator and regulator coping techniques for individuals. On the other hand, the stabilizer and innovator control mechanisms are the means with which the system responds to environmental stimuli for groups (George, 2009).

Sister Callista Roy developed this grand nursing theory while she was a graduate student at the University of California -- Los Angeles. The major factor that prompted her to develop this theory was the challenge she received to build a conceptual nursing model by Dorothy Johnson in a seminar. During this process, she examined Harry Helson's adaptation theory and obtained concepts from Seyle and Lazarus. The development of the adaptation model was also influenced by her 17-year work with the faculty at St. Mary's College in Los Angeles, where it became the framework for a nursing-based integrated curriculum.

One of the central values and beliefs established by the theorist is that nursing focuses on transforming stimuli or fostering adaptive procedures to lead to adaptive behaviors. In essence, nursing practice focuses on promoting adaptation for individuals and groups throughout the four adaptive modes in order to improve health, enhance quality of life, and contribute to dying with dignity ("The Roy Adaptation Model," 2013). Secondly, this model presents an individual as a holistic adaptive system that constantly interacts with both the internal and external environments. As nursing focuses on promoting successful adaptation, the major responsibility of the human system is to maintain integrity when faced with environmental stimuli.

Roy's Adaptation Model is adequate and useful for nursing education since it incorporates the four metaparadigm concepts. Its use in nursing education is evident in its integration as a framework for nursing-based curriculum. The person metaparadigm is included in the model through its definition of the human system while environment is included through consideration of environmental stimuli. The concept also defines health and states the major goal of nursing practice in relation to individuals and groups. However, this model can be more useful in nursing practice because it enables the nurse to follow the six stages in the nursing process (Masters, 2011).

Nursing Theory and Recommendations for the Future of Nursing:

The Institute of Medicine recently published a report on the future of health care in the United States. One of the major concepts highlighted in the report is the critical role nurses will have in that future with regards to promoting safe, quality care, and coverage for every patient in the health care system ("IOM Recommendations," 2011). The basis for these recommendations includes the need for nurses to practice to the total extent of their education and training and need for improved education system to facilitate seamless academic progression.

The other factors are need for improved data collection and information infrastructure and fostering partnerships between nurses and other health care professionals.

Since nursing theory has usually played an important role in nursing practice, it will play a crucial role in supporting IOM recommendations for the future of nursing. However, the role of nursing theory in the future of nursing will require further theoretical development, which will be fueled with the needs of the population. Further theoretical development in the nursing field will also be characterized with attempts to meet the needs of patients from an interdisciplinary and integrative measure of perspective (Meleis, 1995, p.112). In order to support IOM recommendations, the nursing profession will be based on phenomenon-driven theories.

Nursing theory can support the future of nursing through focusing on three major areas, which are the basis for IOM recommendations i.e. education, research, and practice. Under education, nursing theory should offer a general emphasis for designing curriculum and directing curricular decision-making. In research, nursing theory should provide the basis for producing knowledge and new ideas, facilitate the identification of knowledge gaps in the field of study, and provide a systematic framework to identify study questions, interpret findings, and ratify nursing interventions ("Application of Theory in Nursing Process," 2012). Under practice, nursing theory should govern assessment and intervention of nursing care, develop the means to evaluate quality of nursing care, and provide a framework for data collection.

Middle Range Theories:

One of major middle range theories is Watson's Theory of Human Caring, which focuses on how nurses provide care to patients and the translation of that caring into improved health plans that promote the patients' well-being. Jean Watson states that people enter the profession because of the opportunity it provides to care about individuals. Based on Watson's Philosophy and Science of Caring, nursing practice is founded on caring and promotes improved health as compared to mere medical cure. Therefore, caring promotes growth since a caring environment accepts an individual as he/she is and works toward making he/she become better ("Jean Watson -- Nursing Theorist," 2011). Watson's development of the theory and philosophy is attributed to her rich history and background in the nursing field, which can be traced to graduation from Lewis Gale School of Nursing in 1961. She holds a Bachelor's Degree in Nursing, a Master's Degree in Psychiatric and Mental Health Nursing, and a Doctorate Degree in Educational Psychology and Counseling.

A good model case for applying Watson's theory is in delivery of care to older adults in order to promote successful aging. For instance, a 59-year-old patient has been admitted to a hospital for acute abdominal pain caused by excessive drinking. The patient asks for pain medications more often than other patients suffering from the same condition. In addition to requiring a higher level of analgesia, the patient is provided with more morphine dose due to conflicts with the physician.

The current measures and views of successful aging originate from the medical model and primarily focus on behavioral determinants of health (McCarthy, 2011, p.22). However, successful aging requires combination of biomedical and psychosocial perspectives, which can be achieved through caring. Watson's Theory of Caring can be used in this scenario to address the patient's biophysical, psychophysical, and psychosocial needs. This can be achieved through attentiveness, responsibility, competence, and responsiveness. It implies recognizing the patient's need, determining the scope and extent of care, developing effective intervention strategies, and evaluating whether the patient's caring needs are met (Lachman, 2012, p.114).

In an advanced nursing role, the application of the theory would follow the same procedure, which is similar to the scientific process i.e. assessment of the problem, development of a nursing care plan, implementation of the developed plan, and evaluation of the results. Notably, the assessment of the problem may involve formulating a hypothesis while the evaluation of results may contribute to formulation of another hypothesis. The strength of Watson's theory is that it helps to develop a generalized framework for practice that is applicable to various patients and situations. However, the theory is not useful in situations that need more structured approach to patient care.

Research and Practice:

While middle range theories are quite different from grand nursing theories, grand nursing theories provide the basis for some of the middle range theories like Self-Care Deficit. As compared to grand theories, middle range theories are more constrained though not as solid as situation-specific practice theories. In the past few years, these theories have attracted huge scientific interest because of their high levels of construction (Andershed & Olsson, 2009, p.598). However, there is need to continue examining and promoting the use of middle range theories in nursing research and practice.

One of the major reasons for ongoing evaluation and promoting the use of middle range theories is the fact that these theories have a high explanatory value in understanding varying phenomena and easy application in practice. Through assessing these theories, researchers will not only examine the relevance of the theories but they will also develop measurement tools and practical models. This will also enable assessment of the effectiveness of these theories and how they can guide nursing research and practice.

Secondly, these theories provide valuable management mechanisms to facts being evaluated by interdisciplinary teams. There is a huge need to continue using middle range theories in research and practice because they are beneficial to nurses and professionals from other disciplines with formulating common phenomena (Smith & Liehr, 2008). The use of these theories in research and practice elevates nurses' work through theory-guided practice. Thirdly, examining middle range theories should be promoted because their use to individual health behaviors has not been well assessed in several instances (McDonald, Graham & Grimshaw, 2004, p.32). The evaluation will help in developing a complete scientific rationale for nursing intervention to enhance quality of care.

Ethical Dilemma:

Ethical issues and dilemmas have become common in the nursing profession because of global developments and changes in the modern health care system. These issues and dilemmas require guidance in making ethical decisions in nurses' daily experiences and practice. Since the development of this field necessitates practice to be based on theory, nursing theory is usually used to enable nurses in ethical decision-making (Noureddine, 2001, p.2).

An example of an ethical dilemma recently faced in nursing practice involves a patient who asked for some paracetamol tablets because of pain in his legs. However, the patient does not have any pain but is attempting to collect enough tablets to commit suicide. The patient had received more tablets from another health practitioner and from the market. After unsuccessfully trying to commit suicide by swallowing the tablets, the patient accuses the nurse for being incompetent while concealing his attempt to commit suicide.

Ethical decision-making process in this scenario should be based on four major obligations i.e. protecting privacy and confidentiality, honest communication, carrying out an ethically informed-consent procedure, and promoting the patient's best interests (Lachman, 2008, p.44). The most suitable nursing theory that could be used to resolve the issue is Kristen Swanson's middle-range theory of caring. The theory encompasses five inter-related procedures i.e. maintaining belief, knowing, being with, doing for, and enabling. While the theory does not contain a specific ethical framework, the client's well-being is usually emphasized. Some of the major ethical concepts included in the theory include self-determination, beneficence, autonomy, justice, and nonmaleficence.

Through this theory, the most appropriate course of action would be to seek help from an experienced health practitioner to not only support the patient but also work towards clearing her name. In this case, the nurse will demonstrate nonmaleficence by attempts not to harm the patient and beneficence by seeking to keep her job and continue helping the community. As previously mentioned, Swanson's theory of caring emphasizes on patient's rights, provides clear directions for ethical decision-making, and focuses on ethical codes for practice. Moreover, the theory incorporates every aspect of four component model for ethical practitioner i.e. ethical sensitivity, ethical judgment, ethical motivation, and ethical action (Robichaux, 2012, p.66).

Global Perspective:

Mishel's theory of uncertainty in illness is a nursing theory that is relevant today because uncertainty remains a shared aspect of the modern illness experience. The uncertainty of the illness experience is attributed to the disruption illness cause to stability in life and its unprecedented outcomes. Through her theory, Mishel states that adaptation is the eventual goal and that nurses play a crucial role in influencing the adaptation process. During the process of promoting achievement, nurses not only serve as credible authorities but they also provide social support for patients as they cope with changes originating from illness (Mishel, 1998, p.227).

A clear example of the use of Mishel's theory of uncertainty in illness is its use in meningioma diagnosis. The ability of nurses to provide necessary support to patients for informed decision making regarding treatment options and interventions is dependent on understanding patients' response to uncertainty surrounding meningioma diagnosis (Guadalupe, 2010, p.77). The relevance of Mishel's theory in today's health care is evident in the factors that lead to uncertainty i.e. lack of information, doubt about the situation, complexity of care delivery, and unpredictability of disease prognosis and progression (Guadalupe, 2010, p.79). Generally, these are the most common challenges that healthcare workers experience in delivery of care to patients. The ability of these professionals to promote adaptability to illness-related conditions requires development of care plans that deal with these factors.

For Mishel's theory to better support the ethical and social issues that nurses face in healthcare, there is need to incorporate the most suitable approach nurses can use to have substantial impact on the illness experience. Mishel basically describes nurse as credible authorities and social support professionals but does not explain the approach nurse should take in dealing with patient's uncertainty in illness. The best possible approach I would include in the theory to better support ethical and social issues faced by nurses is a presence-centered approach to care in which nurses do their best to attune with patients (Klaver & Baart, 2011, p.687). This approach enables nurses to provide professional loving care through the use of professional knowledge and experience.

Theory Integration:

Nursing is an educational practice that is guided by various principles including respect for the patient's lifestyle and autonomy. The delivery of improved patient care in this field requires competence, which is described as a combination of experience, professional attitudes, and knowledge (Paganini & Egry, 2011, p.578). I believe that nursing is a field that focuses on promoting patient's well being, health, and adaptation to illness-related changes. Nurses carry out their respective care duties in an environment that promotes and fosters a patient's well-being and health regardless of his/her condition. Patient care delivery is a process that is geared towards improving a patient's health condition through appropriate care plans, treatment options, and interventions. However, nurses usually experience changes in the health care environment that necessitates the development of culturally-relevant patient care to meet the diverse needs of individuals, families, and groups.

Leininger's Culture Care Theory described advanced practice nursing as a process that is based on educational preparation, primary care contextual practice, and outcome-centered research initiatives (McFarland & Eipperle, 2008, p.48). The theory ascertains that provision of culturally-relevant care to meet diverse healthcare needs is based on education, research, and practice. Therefore, nurses should competently and sensitively assimilate culture care into clinical techniques, relative schedules, and approaches. This theory is congruent with my personal values that the nursing process should be based on competence while nursing care and environment is characterized with different challenges that require culturally-relevant care. Actually, the nursing environment is faced with increased cultural diversity that requires delivery of culturally-relevant care to meet the populations' needs (Bernal, 1993, p.228).

Global View:

Modernism is a global view that identifies to my overall outlook of life and is considered as one model for research and practice. Unlike other global perspectives, this view promotes individual constructions or the notion of the self as a coherent agent. With regards to evidence-based practice, modernism is associated with truth, reason, and scientific improvements. Therefore, the best possible research is one that identifies the objective truth of occurrences in therapy, determination of informal relationships between techniques and outcomes, and removal of other casual relationships (Ramey & Grubb, 2009, p.76). One of the major arguments by modernist practitioners and researchers is that research processes and findings contribute to the improvement of evidence-based practice.

As the world continues to experience numerous changes across various settings and societies, there is need for ongoing research to improve delivery of care and evidence-based practice. This perspective resonates with my overall outlook in life because changes in the modern societies and settings require the development and use of new processes and measures to meet the needs of populations. Unlike post-modernism perspective, the modernism global view is dependent on rationalism and naturalism, which have proven to be beneficial for the nursing profession throughout its history (Salladay, 2000, p.42).

The improvement of the modern society is dependent on promoting the understanding and use of science though modernism (Esade & McKelvey, 2010, p.418). The modernist perspective has been the basis of the huge technological advancements and industrialization that have characterized today's society. These technological advancements have affected every facet of society including nursing, which implies that processes in this field require the use of a modernist perspective to improve outcomes. The modernist perspective provides objectivity in understanding and improving processes across various fields, especially the health care field because of the consideration of people as the basis of representation and interpretations.

Reflection:

This course has played a crucial role in my development as a nurse in an advanced role by promoting understanding of conceptual knowledge in advanced nurse roles, application of nursing theories and conceptual frameworks, and development of a professional nursing philosophy. In addition to this, the other learning outcome for the course was formulating a conceptual framework to direct advance nurse roles. The course has enabled to understand that nursing practice is based on conceptual knowledge and the significance of competence in patient care delivery. In advanced nursing roles, conceptual knowledge is not only important in guiding nursing practice but it also helps in governing research initiatives. The conceptual knowledge is presented in models, which represent abstract and complex conditions as a means of reflecting reality (Murphy, Williams & Pridmore, 2010).

Secondly, the course has demonstrated how nursing theories and concepts are the basis for developing nursing models, formulating a professional nursing philosophy, and creating a conceptual framework to guide advanced nurse roles. The effectiveness of nursing practice procedures and the efficiency and effectiveness of healthcare delivery systems are dependent on nursing concepts developed from conceptual knowledge (Fawcett & Russell, 2001, p.108). These nursing concepts basically focus on two general propositions i.e. theory and practice as represented in Dr. Fawcett's questions. Nursing practice is guided by theory and conceptual knowledge because theory originates from practice in a similar manner as it guides practice (Fawcett, 2003, p.225). This implies that success and effectiveness in advanced nurse roles is dependent on theory that guides practice.

The course has also demonstrated how nursing theory is significant in guiding nursing education, practice, and research. This is primarily because nursing theory consists of the necessary models, concepts, and knowledge that are needed to guide practice and improve patient care delivery. Therefore, advanced nursing roles require education, practice, and research in order to improve the quality of patient care.

Assimilation:

Currently, global communities of nursing scholars are sharing nursing theoretical works and playing a crucial role in the development of nursing knowledge. While there are still numerous unresolved issues with care and healthcare delivery systems, extensive growth of nursing knowledge has occurred since the beginning of the 21st Century (Roy & Jones, 2007). The growth of nursing knowledge is associated with ongoing evaluation and use of nursing theories in nursing education, nursing practice, and nursing research. This has contributed to the development of nursing theory, which has significant impact on current practice and in future.

The main impact of development of nursing knowledge upon theory development is that it contributes to evolution of nursing theories based on a view of ideal nursing practice (Masters, 2011, p.6). This results in the development of various nursing theories that represent varying aspects of reality while dealing with different aspects of the nursing profession. In the future, the impact of growth in nursing knowledge upon theory development is the potential emergence of new models and concepts for nursing practice. Since nursing practice is guided by theory, theory development due to growth in nursing knowledge will lead to new practices because of the probable development of new concepts and models to guide nursing practice.