Theory of Nursing – MidTerm Exam

What is important about 1750
1st hospital established
Penn Hospital

What happened in 1790s?
US Marine Hospital Service
Act of Congress for Public Health

Who is Clara Barton
Angel of the battlefield
Established the Red Cross

What are the four metaparadigms in nursing theories?
person
health
environment
nursing

PHEN (Paradigm = Phen)

What are the six criteria for theory acceptance?
simplicity
consistency
accuracy
relevance
fruitfulness
inclusiveness

SCARFI (need a scarf-I in order to be accepted)

Who is Florence Nightingale?
Cannons of Nursing
1860
“Lady with the lamp”
Investigates the effect of environment on healing
Ventilation, warming, noise, variety, diet, light, cleanliness

Florence Nightingale’s Contributions
Hygeine/cleanliness

Documentation of everything!
– use of statistics to improve health
– early research
– Founded 1st training school for nurses at St. Thomas’s hospital in London

Influential in training some nurses that helped in Civil War

Jean Watson: Theory of Human Caring 1971
Holistic outlook addresses the impact and importance of altruism, sensitivity, and trust (& interpersonal skills)
** Living Legend

Dorthea Orem: Self-Care Deficit Model 1979
Nurse implements appropriate measures to assist the client in meeting self-care needs

Hildegard E. Peplau: Interpersonal Relations as a Nursing Process 1952
Identified the client’s feelings as a predictor of positive outcomes related to health
“Peplau Predicts Positive outcomes”

Sister Callista Roy: Adaptation Model 1974
Adaptation will occur by assisting the “biopsychosocial” client in modifying external stimuli
6 physiological needs…
(nurse is the change agent that modifies whatever is going wrong so that it is more conducive to the patient)

Martha E. Rogers: Science of Unitary Human Beings 1970
Nurse promotes synchronicity between human beings and their universe/environment
“Energy Fields/Openess”

Ida Orlando 1960
Developed Nursing Process
ANOPIE (ADOPIE)
(assess, nursing diagnosis, outcome identification, planning, implementation, evaluation)

Virginia Henderson
Definition of Nursing! Modern day Flo Nightingale
14 essential functions towards independence –
(don’t overhelp patient, let them work towards ADLs)

Myra Levine: Conservation Model
Four principles of conservation of inpatient client resources:
Energy & Personal/Structural/Social Integrity
(PESSi =)
** Lamonica’s favorite

Betty Neuman: Systems Model
Wellness-illness continuum = supports the notion of prevention through appropriate intervention

Primary – prevention

Secondary – Early detection of illness and effort it prevent for escalating

Tertiary – Treating illness

(“Neuman”salad dressing where primary is fat free dressing, secondary light dressing, teriary is full fat dressing)

Imogene King
Goal Attainment Theory: Collaboration for goal
Nurse-client transactions to set and obtain goals

(nurse & patient have to have the same “IMAGE”to attain goal and be the KING of recovery)

Madeline Leininger
Theory of Cultural Care Diversity & Universality
Values & beliefs within a culture impact health practices
Ethnohistory are essential to four concepts: care, caring, health & nursing

Rosemarie Parse
Theory of Human Becoming
Quality of Life – nurse works with patient’s perceived quality of life in order to set goals
– Not fixing what is wrong, just working with patient on their goals.

Patricia Benner
Primacy of caring; the practice of nurses depends on the experience absorbed by engaging in five areas/levels (novice, advnced beginner, competent, proficient, expert) within the seven domains of nursing practice.

(Patricia = Practice skills
Benner = Better nurse)

Faye Abdellah
Better Nursing Care thru Research
Better patient-centered care through nursing research making the nurse the “problem-solver”

(abDELLah =RESEARCH on dell computer)

Ernestine Wiedenbach
Best known for Theory Development:
Family-centered maternity care

– got expelled from John’s Hopkins but later put back in program by Adelaide Nutting

Fruitful Nursing
Generates new direction for future research

Phenomena
Observable fact or event

complex and dynamic conceptual building blocks, are the basis of our nursing language

Theory
Group of related concepts (at least 2) that explains the phenomena that predicts future events
– abstract generalization
– Presents a systematic explanation

Concept Models
aka= framework

Common theme
Conceptual framework/model
More loosely structured than theories

Nursing Science related to Nursing Theory
Collection of Data
Related to nursing
Applied to nursing practice
Guides nursing practice
Goal is better client outcomes
Guides nursing research

Which events led to the first recognition of African Americans in nursing?
Mary Seacoyle efforts in the Crimean War

– She improved health conditions for British soldiers

Health Contributions – Early Civilizations
PREHISTORIC
• Evil spirits make illness
• Thought that you got sick because there was curse on the body/person
• Guided magic
• Religion
• Superstition
• Tribal rituals
• Evil spirits dispelled

Health Contributions – Early Civilizations
EGYPT
Preventive measures – created laws to promote cleanliness in order to prevent disease
Documentation (calendar & writing)
Pharmacopeia: 700 drugs
First to use sutures
Early midwives (saved baby Moses)

Health Contributions – Early Civilizations
PALESTINE
Created by Moses = Mosaic Law
Cause and Effect:
– laws to prohibit eating animals more than 3 days old
– Isolate those with communicable disease

Health Contributions – Early Civilizations
GREECE
Created the wisdom & immortality symbol

Gods controlled the illnesses

Paved way for scientific method

Hippocrates: Father of Medicine

Health Contributions – Early Civilizations
INDIA
Male staffed nurses

Importance of prenatal care

Surgery

Health Contributions – Early Civilizations
CHINA
Confucius

Moral Obligation to Society was basis for education & gov’t
– family unit, community

Yin & Yang
– balance = good health

Ancient Chinese Medicine
– Acupuncture
– hydrotherapy
– herbs
– massage
– exercise

Health Contributions – Early Civilizations
ROME
1st Military Hospital

Adapted medical practices from those they enslaved
– Galen (Greek) made important medical contributions as a slave

Both male & female took care of sick

Health Contributions – Early Civilizations
MIDDLE AGES
Women of nobility took care of sick
Use of purging (leeches and mercury to cause bleeding done by barbers)
Female nurses had limits in how they could care for male patients (even male babies)
Use of Christian concepts in charity and sanctity in Nursing

Health Contributions – Early Civilizations
RENAISSANCE
Major advances in medicine
– medical education, not nursing education
– use of cadavers
– pharmacy/chemistry/surgery/A&P

Health Contributions – Early Civilizations
COLONIAL PERIOD (Americas)
First Hospital in the Americas – Medical School of Mexico

Plagues – yellow fever, typhoid, small pox

Still used purging (bleeding)

Impact of war on nursing:
More women became nurses when their economic opportunities were scarce.

Dr. Jonathan Letterman
Father of modern military medicine

Created field hospitals to improve response time

Antietam Battle of Civil War
Bloodiest battle

Triage & early response

North had better care and were more organized with supplies and training.

Clara Barton assisted = “Angel of the Battlefield”

African-Americans Union Nurses
Harriet Tubman – established underground railroad

Sojourner Truth – insisted on better sanitation & cleanliness

Susie King Taylor – taught soldiers to read and write

Dorthea DIX during Civil War
Started volunteer training programs (for both sides of war)

No pay, no formal title

Required that nurses be over 35, plain, no jewelry, no hoopskirts

Organized for the North

Civil War in the South
Sallie Thompkins – only woman to hold military rank in Confederacy

Phoebe Pember – matron at Chimborazo Hospital in Richmond
– Documentation! Records now kept on patients
– hospital for the Confederacy
– now a museum

Other Civil War Nurse Leaders
Louisa May Alcott – nurse for 6 week, got ill, became author

Civil War Field Hospitals
Male nurses = assist in surgery/amputations
Female nurses = cooks/laundry/ only helped in nursing when wounded patients ↑

more than 6 million hospitalized

What is true about Crimean War & Civil War
History repeats itself…
They both had epidemics (small pox, thyphoid fever)

Post Civil War
First nursing text

Atlanta Baptist Seminary (later called Spellman College) – 1st nursing school for African-Am female nurses

North segregated by custom, south segregated by law

World War I
US Army Corps Nurses
– most were non-commissioned
– 1st nurse to go before a firing squad (from Belgium)

Need for Nurses
– add campaigns
– 1:3

World War II
Army & Navy Nurses
– 2 year cadet program
– Nurses as military officers
* 1st participated in combat at mobile field hospitals
* “Angels of Bataan”

Nurses during Korean War
Early M*A*S*H units
– launched trauma & critical care

Nurses during Vietnam War
Navy nurse
Corpsmen
Medics

Nurses during War in Iraq
More modern
?

Lessons learned from Civil War
Triage
First Responders
Coordinated, progressive system of response
Surgical field units

Trends in nursing
2nd highest demand for employment
– nurses are the highest # of health care workers

Nursing Shortage
– Pres Bush created nursing scholarships

Lacking nurse educators

Increased workload in hospitals

Nursing Research
Systematic approach used to examine phenomena important to nursing and nurses.

This clinical practice must be based on scientific knowledge = use of scientific method

Evidence generated by nursing research provides support for the quality and cost-effectiveness of nursing interventions.

Nursing Science
The collection and organization of data related to nursing and its associated components.

The purpose of this data collection is to provide a body of scientific knowledge, which provides the basis for nursing practice.

Who was the first Nurse Researcher?
Florence Nightingale

What is researched?
Study of nurses helps us to understand how to improve patient care.

Recent focus is on patient outcomes

Why do we need research in nursing?
Provide descriptions

Explanations

Predictions

Useful to improve nursing care

What does it mean by, “Nursing research is related to and informed by nursing theory and nursing in turn influences them?”
Nursing theory as the abstract generalization of phenomena

Nursing research is the systematic approach to scientifically explain/support the theory

Nursing practices are influenced by results of research and research is fueled by practice

Deductive Reasoning in Research
Researcher works from the more general information to the more specific.

A.k.a, “top down” Researcher starts at the top with a very broad spectrum of information and they work their way down to a specific conclusion.

Begin with a theory about topic of interest & then narrow that down into more specific hypotheses that can be tested. The hypotheses are then narrowed down even further when observations are collected to test the hypotheses. This ultimately leads the researcher to be able to test the hypotheses with specific data, leading to a confirmation (or not) of the original theory and arriving at a conclusion.

Inductive Reasoning in Nursing Research
Moves from specific observations to broader generalizations and theories.

AKA= a “bottom up” approach. The researcher begins with specific observations and measures, begins to then detect patterns and regularities, formulate some tentative hypotheses to explore, and finally ends up developing some general conclusions or theories.

Research with Human Beings
IRB must approve research proposals
– Main goal is to protect the research participants
– Strenuous research guidelines mandated

* Stems form past problems of abuse to research subjects

Steps in the Research Process
PROBLEM identification
Define PURPOSE of study
REVIEW OF LITERATURE
Formulating RESEARCH QUESTION or HYPOTHESIS
STUDY DESIGN – METHOD
Selecting a SAMPLE & SETTING
PILOT STUDY

(Problem, purpose, literature, hypothesis. design-method, sample, pilot) pplhdsp

Steps to Carry out and Analyze Research
DATA COLLECTION
DATA ANALYSIS
MAKING SENSE OF DATA
Discussion of FINDINGS
DISSEMINATION OF FINDINGS

Study Design Methods
Quantitative
(statistical analysis of numerical data, knowledge of very precise topics)

Qualitative
(research designed for discovery rather than verification, looking to explain phenomena or process rather than to verify a cause & effect)
Ex: one on one interviews

Mixed: Triangulation
(The use of various research methods or different data collection techniques in the same study)

Evidence-based Nursing
The process of systematically finding, appraising, and using research findings as the basis for clinical practice

Evidence-based practice challenges nurses to look at the “why” behind existing methods and processes in the search for improvement.

Why is evidence-based nursing important (to practicing nurses and student nurses)?
Uses research for nursing practice

Improves standards of care

Critical awareness or research

Helps in learning to critique research articles

What questions can be asked to make better practices as a result of more research?
Asking ‘Why?’
Asking ‘Why Not?’
Asking ‘How this can be made better?’
Asking ‘Does this make a difference?’

What does ethic in research involve?
Prevention of violations

Protections in place IRB
– self-determination
– privacy
– confidentiality (anonymous)
– fair treatment
– protection from discomfort and harm

Concerns for vulnerable populations

Magnet Status
Nursing-based research!

This encourages the nurse to flourish as a professional, focuses on professional autonomy, decision making at the bedside, involves nursing in determining the nurse work environment, provides professional education and promotes leadership. Magnet recognition means that collaborative working relationships are fostered. Teamwork and positive relationships among different departments and disciplines are demonstrated.

Historical Ethical Abuses in Research
Nazi Germany

Tuskegee Syphilis Study

Protection of Human Subjects
Nuremberg Code
Set of research principle for human experimentation as a result of Nuremberg Trials at end WWII

Declaration of Helsinki
Applicable principles regarding human experimentation developed by the world medical association. Regarded as cornerstone document of human research ethics

NIH Guidelines

IRB (institutional review board)

Once research is done, how do you evaluate it?
Findings
– include statistical significance

What were study limitations

What would you do different next time

Nursing Image
Angel of Mercy/Alleviation of Suffering

o Varied historically: prostitutes, women of wealthy nobility, religious orders.

o Victorian: women innately sensitive- high morals/ sensitivity, breeding, intelligence, and ladylike behavior, including submission to authority

o Current: Professional

How has the nurses image changed over time?
Caps have disappeared
Uniforms have changed
Nurses are generally seen as honest and ethical
Truth is most important

What initiatives are there to improve the image of nursing?
Woodhull study on nursing and media- nurses are essentially invisible to media and consequently to American public
Johnson and Johnson campaign- recruiting efforts
Center for nursing advocacy- to encourage accurate portrayal of nurses in media
Professional, caring, competent

Traditional View of Women and its effects on nursing
Traditional Role of women: western culture- passive, dependent, affectionate, emotional, expressive

Expected to avoid risk raking and conflict; to give in to authority, to seek careers suitable for females

Stereotype of intellectual inferiority

Effects on status and pay

Men in Nursing
Provided care- 11th, 12th, 13th centuries- military religious orders – 1st male commissioned as a nurse 1955

Separate educational programs- up until GI Bill
• GI Bill- post WWII- more funding for education of military corpsmen

6-8% men in nursing today

Special concerns for males in nursing
• Role strain
• Discrimination from practicing nurses, MDs, and the public – “why are they still called “male nurses”??
• Physical strength may be emphasized
• May not be welcomed in some settings
• Hiring preference given to men?
• Seen as having more leadership potential?
• Given preferential treatment by male MDs?
• Earn more money?

Nursing Education
o Hospital Based practical training programs
o University based: 4 year traditional/ 2nd degree programs
o 1869-1900: formal education and training schools for nurses
civil war prompted formal nursing training schools
early schools used Nightingale model

Which Schools Opened in 1873?
• Bellevue Training school for nurses
• Connecticut training school for nurses in New Haven
• Boston Training school for nurses as Mass General
o Linda Richards is first trained nurse in US
• Schools remained segregated

What are the different levels/types of Nursing Education
Licensed Practical Nurse (LPN/LVN) – mainly technical skills, supervised by RN
Hospital – Diploma / On-the-job Experience
Associate Degree – 2 years / Nursing License
Baccalaureate – 1st Yale (1924)
1st 4-year (1923-24) Western Reserve
Arts & Science Foundation
Masters (MSN) – education / administration
1960’s – Focus changed – Clinical Expertise
Role of Advanced Practice Nurse (NP)
Doctoral Programs (Education/Pracitce/Research)
DNSc
PhD
DNP – advanced clinical practice
New focus on Education: Online/Distant Learning

First Professional Organizations
o nurse leaders from US, Canada, UK – met at Chicago World’s Fair (1893)—nursing education

o concerns: lack of uniformity of nursing education programs and need for scientific training

o formed American society for superintendents of training schools for nurses—later, national league for nursing (NLN)

Roots of Nursing Organizations
Isabel Hampton Robb (1896) founded Nurses’ Associated Alumnae of US – later American Nurses Association (ANA).

Bedford Fenwick – founded International Council of Nurses (1899).

National Association for Colored Graduate Nurses (1908) to raise standards & eliminate discriminatory practices.

African American nurses no full participation in ANA till 1950’s.

Other Nursing Leaders
Lavinia Dock: formalized public health nursing @ Henry Street Settlement (NY).

Jessie Sleet Scales: African American nurse established Stillman House – community health services to African Americans in NY

The impact of the Great Depression & Social Legislation on Nursing
In 1920s and 1930s, trained nurses were employed primarily as private duty nurses.

1929 -Depression – no longer funds for private duty

Civil Works Administration (1933) provided nursing employment in rural & school settings.

Hospitals forced to close schools of nursing, & began to hire trained nurses as staff.

Why was the Social Security Act (1935) important?
Public health money for care to mothers, children, & blind

Encouraged the evolution of public health nursing.

Social Security Amendments in 1965
Medicare & Medicaid – access to health care for elderly, poor, & disabled.

Much of hospital care funded by Medicare and Medicaid.

Nurses stayed primarily in hospital settings.

Specialties in nursing – 1960s (psychiatry, critical care, coronary care, nurse practitioners)

What is the Hill Burton Act of 1946
Federal funds to construct hospitals.

Rapid expansion of facilities resulted in nursing shortage (Larger buildings but less staff – as today?)

Traditionalist (Veterans) Generation
[Differences in work ethic/learning]
• Born: 1922-1945
• Nursing School in 40s-50s / early 60s
• Most diploma school / later BSN
• “Greatest Generation” (born betw. 1922-1945 / Nursing career began in 1940’s – 1950’s)
• Built their reputation -WWII; war effort
• Did as they were told
• Did not question authority
• Learned “on the job” and books
• Strong country and work values
• Loyalty – same hospital or company
• **Have earned respect – more formal

Baby Boomers Generation
[Differences in work ethic/learning]
• Born 1945 – 1960 (most faculty):
• Nursing School in late 60’s / 70′ / early 80’s (“hands-on” and textbooks)
• Most BSN / some started with Associate
• Grew up in time of economic prosperity & societal changes (civil rights; marches)
• Value collective action, organizational involvement, causes, &social justice / loyal to cause or an institution
• Highly competitive; sacrifice for success
• Recognition; value respect but “non-traditionalists”
• More relaxed – personal style
• 1970s- still the white dress, hose, shoes, and caps

Gen X Generation
[Differences in work ethic/learning]
• Born 1960 – 1980’s
• Nursing School in late 80’s / 90’s / present
• Nursing in 21st Century
• Commitment to profession BUT within degree
• (Loyalty to one institution is over-valued)
• Value alternative work environment, flexibility, accelerated career mobility
• “Instant gratification” – dynamic work & learning environment; online – instant feedback – emphasis on outcomes not process (hate meetings)
• Task: seeking balance and perspective in lives (they have watched on parents “work themselves to death”, divorce, etc…)

What can we learn from the Generational Differences?
Conflicting values
Different ways of learning
Communication

Discussion—bridging the gap:
• Creating better communication
• Interactive strategies
• Working together

What does the phrase, “not your Mama’s nursing” mean?
• In Past
o Formality – uniforms – starched white with cap
o Stand up when Doctor comes in
o Less decision-making
o Limited men in nursing
o Limited technology – paper documentation
o Limited roles for nurses

Describe Nursing Today
o Professional but less formal (colorful scrubs; name tags)
o Collaboration with Doctors – most of the time….
o More men in profession
o More technology (sometimes complex; sometimes a burden) E-charting
o More decision-making
o More nursing advancement

What has and has not changed in 21st Century Nursing?
What has changed:
• More drugs
• Complex technology
• Teaching methods

What has not changed:
• Patient centered
• Respect for patient
• Striving for best care
• Making patients comfortable / caring!!

What are the employment trends in nursing?
58%- full time nursing

5.7 – Employed RNs are males

Largest number of health care workers in US

Average age (2004)- 46.8 y.o.
• 8.1% of newly licensed RN were under 30

What is the educational preparation of practicing nurses today?
• 17.1% diploma
• 33.7% associate
• 34.2 % bachelors
• 13% master’s or doctorate

What is outlook for employment in nursing?
• Highest growth will be in community settings, and specific hospital sectors: same day surgery, rehabilitation, outpatient cancer centers.
• Home health and long term care have great growth potentials.**
o Clinics, Schools, Home, Daycare, Nursing Homes
• Hospitals: 56.2%
• Community health/Public health: 14.9%
• Ambulatory care: 11.5%
• Nursing homes: 6.3%

What is the Nursing Process
(definition)
o Organizing framework for professional nursing practice
o Given to us by Ida Jean Orlando
o Scientific Problem- Solving Approach
o Deliberate
o Applicable to all Client-Nurse Situations
o May be used with any Nursing theory
o Steps of Nursing Process- nursing care plan developed from these steps
Assessment-

What is SUBJECTIVE data?
Process in which data relating to the patient’s problem are elicited from a patient or a patient’s family. The data are retrieved from the patient’s description of an event rather than from a physical examination, which provides objective data. The interviewer encourages a full description of the onset, the course, and the character of the problem and any factors that aggravate or ameliorate it

o History from patient
o From family members
“my baby had a fever yesterday”- subjective- this is what she is telling you
o Medical records
o Other professionals
o History of present illness
How long has this been happening?
Does anything help?
Has this happened before?
o Past Medical history
What medications are they on?
Any other health problems?

What is OBJECTIVE data?
The process in which data relating to the client’s problem are obtained through direct physical examination, including observation, palpation, percussion, and auscultation, and by laboratory analyses and radiologic and other studies

o Anything that you observe
o Vital signs, height, weight, physical assessment, labs, x-rays, other diagnostic tests

What is the Nursing Diagnosis?
• Information (subjective and objective) collected from patient assessment used to identify a problem/concern/area of interest
• A standardized listing of diagnoses developed by north American nursing diagnosis association (NANDA)
• Developed by analyzing collected information (data)
o A clinical judgment about individual, family or community responses to actual or potential health problems or life processes

How does the nursing diagnosis relate to nursing care?
o Helps determine appropriate nursing actions (interventions)
o Collection of symptoms or behaviors
o Unique to a particular patient care situation
o Nursing diagnosis- not medical diagnosis
o Should be individualized
o Note: not one size fits all!

What are nursing diagnosis statements?
o Standards from north American nursing diagnosis association (NANDA)
o Others may fit better
o Individualize according to each patient situation, age, etc.

Outcome Identification
• NIC= Nursing intervention Classification
• NOC= Nursing Outcome

o IE: nursing Dx: ineffective breathing pattern
NIC: encourage slow, deep breathing; turning; coughing
NOC: client will report that he can breathe comfortably within 20 minutes

Planning Interventions
• Plan is based on:
o Data from assessment (subjective/objective data)
o Nursing diagnosis
o Priority of the patient problems identified
o Age and condition of the patient

Maslow’s Hierarchy of Needs
useful for setting patient priorities
o Self actualization
o Self-esteem
o Love and belonging
o Safety and security- physical and psychological
o Physiological- oxygen, fluids, nutrition, body temperature, elimination, shelter, sex

NANDA
(North American Nursing Diagnosis Association)
Developed standardized interventions and outcomes that complement the nursing diagnoses
o These are called NICS and NOCS

Implementation
• Care is given as planned

Evaluation
do those steps, if something changes start over
• Outcomes that were hoped for are reviewed
• To determine if they have been achieved
• Sometimes re-evaluation of plan is necessary

Important events in nursing in the 1800’s
1850 – Crimean war
1860 – 1st nursing school in London created by Flo
1860’s – Civil war
1880’s – post civil war
1890’s – nurses assoc. established

Important dates in the 1900’s in nursing
– 1st nursing journal published
– WW I advances in nurse care
1920’s – Shepard-Townes act gives federal aid to maternal & child health care
– sigma theta tau founded
1929 – Great Depression
1935 – 1st social security act passed
– changes in WW II
1940’s – nurse trainee bill
1950’s – Korean War
– code for prof. Nurses
1960’s – Medicare/Medicaid
– advance practice nurses
1970’s – Vietnam war
– bill of patient rights
– roe v. Wade (legalize abortion)
1980’s – AIDS increasing epidemic

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