THEORIES

Theory-Nursing theory is a framework designed to organize knowledge and explain phenomena in nursing, at a more concrete and specific level. The word theory is derived from the Latin word theoria meaning 'vision'.

Theories-

According to Kerlinger,-Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory & predictive in nature.
Theory is “a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena”. (Chinn and Kramer 1999)
Theories are composed of concepts, definitions, models, propositions & are based on assumptions.

Nursing Theory

Defined as a belief, policy, or procedure proposed or followed as the basis of action. It is an organized framework of concepts and purposes designed to guide the practice of nursing.

Characteristics of Theories

Theories can interrelate concepts in such a way as to create a different way of looking at a particular phenomenon.
Theories must be logical in nature.
Theories should be relatively simple yet generalizable.
Theories can be the bases for hypotheses that can be tested.
Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.
Theories can be used by the practitioners to guide and improve their practice.
Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.

Scope of Nursing theories

A. In practice

Assist nurses to describe, explain and predict everyday experiences.
Serve to guide assessment, intervention and evaluation of nursing care.
Provide a rationale for collecting reliable and valid data about the heath status of clients, which are essential for effective decision making and implementation.
Help to establish criteria to measure the quality of nursing care
Help build a common nursing terminology to use in communication with other health professionals.
Enhance autonomy of nursing by defining its own independent function

B. In Education

Provide a general focus for generating knowledge and new ideas.
Guide curricular decision making.

C. In Research

Offer a framework for generating knowledge and new ideas
Assist in discovering knowledge gaps in specific field of study
Offer systematic approach to identify question for study, select variables, interpret findings and validate nursing intervention.

D. In Management

As there is more specific and practical approach in nursing, management becomes more efficient and effective
Helps to study, assess and control various aspect of nursing.

A. Types of Nurisng theores

According to Scope,Functions and Philosophy

Speculative – yet to be tested through research and found to be consistently true, valid and reliable in answering questions, solving problems and exploring phenomenon.
Established – Accumulation of facts, principles and laws that have been repeatedly tested through research over time and found to be consistently valid and reliable.

B. According to Scope

Grand Theory - It is the broadest in scope, represents the most abstract level of development, and addresses the broad phenomena of concern within the discipline.
Middle-Range Theory - Theory that addresses more concrete and more narrowly defined phenomena. It is intended to answer questions about nursing phenomena, yet they do not cover the full range of phenomena of concern to the discipline.Are precise and answer specific nursing practice questions.
Micro-Range Theory - Concrete and narrow in scope. It explains a specific phenomenon of concern to the discipline.

C. Types According to Knowledge base and Characteristics

1. Nursing Philosophy

Meaning of nursing phenomenon through analysis, reasoning and logical argument.
Includes works which predate or introduce the nursing theory era and have contributed to the knowledge development in nursing.

2. Nursing Conceptual Models

Works of grand theorists or pioneers in Nursing.
“Provides a distinct frame of reference for its adherents that tells them how to observe and interpret the phenomena of interest to the discipline.”

3. Nursing Theories and Middle-Range Theories

Addresses the specifics of nursing situations within the perspective of the model or theory from which they are derived.

D. Types According to Function

Descriptive-Theories are the first level of theory developmen.To identify the properties and workings of a discipline. descriptive theories are not action-oriented.
Explanatory-Explanatory theories describe and explain the nature of relationships of certain phenomena to other phenomena.
Predictive-To calculate relationships between properties and how they occur.
Prescriptive -Address the nursing interventions for a phenomenon, guide practice change, and predict consequences.

E. Based on the Philosophical Underpinnings of the Theories

“Needs” theories-Are based around helping individuals to fulfill their physical and mental needs.
“Interaction” theories-As described by Peplau (1988), these theories revolve around the relationships nurses form with patients.
Outcome” theories"-Outcome theories portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health.
“Humanistic” Theories -Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life.Humanistic theories emphasize a person’s capacity for self-actualization.

Nursing Metaparadigm

Person :- Person is the recipient of nursing care, People are multidimensional, composed of biological, psychological, social and spiritual components.
Environment :- Environment can be external as well as internal, poor or difficult leads to poor heath and disease.
Health:- Health is “not only to be well but maintaining well being by using a person’s power to the fullest extend” Health is maintained by controlling the environmental factors to prevent disease. Disease is considered as dys-ease or the absence of disease.
Nursing :- Nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969)

Background of the Nightingale's Theorist

The goal of nursing is “to put the patient in the best condition for nature to act upon him”. - Nightingale
Born- 12 May 1820 in Florence, Italy.
Privately educated by father
Inclined to care for sick.
In 1837 at the age of 17 she confined in her dairy, “GOD SPOKE TO ME AND CALLED TO SERVICE”
She attended nursing programs in KaiserWerth, Germany in 1850 and 1851.
She worked as the Nursing superintendent at the Institution for care of sick gentlewomen in distressed circumstances, where she instituted many changes to improve patient care.
Called to Turkey, during Crimean war.
Her work proved successful in decreasing the mortality rate in the war.
She reduced the mortality rate of the wounded soldiers from 42.7% to 2.2% because of her intervention in the environment.
Lady with the lamp.
Begin the Nightingale school of nursing at St. Thomas hospital, King’s College in London
Founder of modern nursing and the first nursing theorist.
Books:

Notes on Nursing: What it is, what it is not (1860)
Notes on hospitals (1863)
Sick-Nursing and Health-Nursing (1893)

Died-she died in her sleep on August 13, 1910,in London at age 90.

Nightingale's Thirteen Canons

Ventilation and warmth
Health of houses
Petty management
Noise
Variety
Food intake
Food
Bed and bedding
Light
Cleanliness of rooms/walls
Personal cleanliness
Chattering hopes and advices
Observation of the sick

1.Ventilation and warmth

Keeping patient, patient’s room warm
Keeping patient’s room well ventilated and free of odors.
Keep the air within as pure as the air external air/without noxious smells.

2. Health of houses

This canon includes five essentials of- Pure air, Pure water, Efficient drainage, Cleanliness, Light
Examples include-

Removing garbage or standing water
Ensuring clean air and water and free from odour and that there is plenty of light.

3. Petty management

Continuity of the care, when the nurse is absent
Documentation of the plan of care and all evaluation will ensure others give the same care to the client in your absence.

4. Noise

Avoidance of sudden/startling noises.
Keeping noise in general to a minimum.
Refrain from whispering outside the door.

5. Variety

Provide variety in the patient’s room to help him/her avoid boredom and depression.
This is accomplished by cards, flowers, pictures, books or puzzles (presently known as diversional therapy)
Encourage significant others to engage with the client.

6. Food intake

Assess the diet of the client.
Documentation of amount of foods and liquids ingested at every meal.

7. Food

Instructions include trying to include patient’s food preferences.
Attempt to ensure that the client always has some food or drink available that he/she enjoys.

8. Bed and Bedding

Comfort measures related to keeping the bed dry, wrinkle-free and at the lowest height to ensure the client’s comfort.

9. Light

Assess the room for adequate light.
Sunlight works best.
Develop and implement adequate light without placing the client in direct light.

10. Cleanliness of rooms/walls

Assess the room for dampness, darkness and dust or mildew.
Keeping the environment clean (free from dust, dirt, mildew and dampness)

11. Personal cleanliness

Keeping the patient clean and dry at all times
Frequent assessment of client’s skin is needed to maintain adequate moisture.

12. Chattering hopes and advices

Avoidance of talking without reason or giving advice that is without fact.
Continue to talk to the client as a person. And to stimulate the client’s mind
Avoid personal talks.

13. Observation of the sick

Making and documenting observations.
Continue to observe the client’s surrounding environment.

Nursing Metaparadigm according to Nightingale -

There are four metaparadigms-

Person
Environment
Heath
Nursing

1. Person

Recipient of nursing care.

People are multidimensional, composed of biological, psychological, social and spiritual components.

2. Environment-

Environment can be external as well as internal.
Poor or difficult environments led to poor health and disease.
Environment could be altered to improve conditions so that the natural laws would allow healing to occur.

3. Health

For nightingale, health is “not only to be well, but to be able to use well every power we have”.

Disease is considered as dys-ease or the absence of comfort. [Six D’s of Dys-ease are: Dirt, Drink (need clean drinking water), Diet, Damp, Draughts and Drains (need proper drainage and sewer systems)]

4. Nursing

Nursing to nightingale was above all, “Service to God in the relief of man”
To alter or manage the environment to implement the natural laws of health.
Nursing is different from, medicine and the goal of nursing is to place the patient in the best possible condition for nature to act.
Nursing is the activities that promote health (as outlined in canons) which occur in any caregiving situation.

Application of Nightingale's Theory in Practice:-

"Patients are to be put in the best condition for nature to act on them, it is the responsibility of nurses to reduce noise, to relieve patients' anxieties, and to help them sleep."
As per most of the nursing theories, environmental adaptation remains the basis of holistic nursing care.

Criticisms:-

Simplicity - Simple and logical; tends toward description and explanation rather than prediction
Generality - Provides general guidelines for all nurses
Empirical Precision - Little or no provision is made for empirical examination; individual observation rather than systematic research
Derivable Consequences - To extraordinary degree, direct the nurse to action on behalf of patient and herself. These directives encompass the areas of practice, research and education.

Dorothea Orem's Theory

Introduction

Theorist : Dorothea Orem (1914-2007)
Born 1914 in Baltimore, US
Received her diploma at Providence Hospital Washington, DC in 1934
1939 – BSN Ed.
Master of science in nursing education (1945) from Catholic University of America, Washington D.C.
Her clinical practice included staff nurse in the operating room, paediatrics and adult medical surgical units.
She also did private-duty nursing in private homes and the hospital and was an emergency room supervisor.
She taught biological sciences and later served as director of nursing service and director of the school of nursing at Providence Hospital, Michigan.
Received several honorary degrees.
Orem’s concept of nursing as the provision of self- care was first published in 1959.
Orem continued to develop her nursing concepts and her self-care deficit theory of nursing. In 1971 she published Nursing Concepts of practice.
The second, third, fourth, fifth and sixth editions of this book were published in 1980, 1985, 1991, 1995 and 2001 respectively.

Orem’s general theory of nursing

Orem’s general theory of nursing in three related parts:-

Theory of self care
Theory of self care deficit
Theory of nursing system

Relationship of Orem’s concept to the three theories

Theory of self - care	Theory of self- care deficit	Theory of nursing system
Self-care Self-care agency Self care requisites Universal Developmental Health Deviation Therapeutic self- care demand	When therapeutic self-care demand exceeds self-care agency, a self-care deficit exists and nursing is needed.	Nursing agency Nursing systems Wholly compensatory Partly compensatory Supportive education

1. Theory of self-care-This theory include-

a. Self care

Self care is the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health and well- being.
When self-care is effectively performed, it helps to maintain structural integrity and human functioning and contributes to human development.

b. Self care agency

Self-care agency is the human’s acquired powers and capabilities to engage in self care. The ability to engage in self-care is affected by basic conditioning factors.
The basic conditioning factors are age, gender, developmental stat, health state, socio-cultural orientations, health care system factors, pattern of living etc.

c. Therapeutic self-care demand

Total of care activities needed, either at an identified moment or over a period of time, to meet a person’s known requirements for self-care.
Self-care requisites - Actions directed towards provision of self- care.

Three categories of self-care requisites are

Universal self care requisites
Developmental self care requisites
Health deviation self care requisites

1. Universal self care requisites -

Associated with life processes and the maintenance of the integrity of human structure and functioning.
A common term for these requisites is activities of daily living.

Universal self care requisites Orem identifies self-care requisites as follows-

The maintenance of a sufficient intake of air.
The maintenance of a sufficient intake of water.
The maintenance of a sufficient intake of food.
The provision of care associated with elimination processes and excrements
The maintenance of a balance between activity and rest.
The promotion of human functioning.

2. Developmental self-care requisites

More specific to the processes of growth and development and are influenced by what is happening during the life cycle stages; such influence may be positive or negative.

Ex: Adjusting to new job or adjusting to body changes.

3. Health deviation self-care requisites

Changes in human structure and function, out of the range of normal, and may be associated with genetic variations or other defects.
May deal with the effects of defects or deviations and the effects of efforts to diagnose and treat them.
The health deviation self-care requisites are as follows-
Seeking and securing appropriate medical assistance
Being aware of and attending to the effects and results of pathologic condition and states
Effectively carrying out medically prescribed diagnostic, therapeutic and rehabilitative measures
Modifying the self-concept in accepting oneself as being in a particular state of health and in need of specific forms of health care.
Learning to live with the effects of pathologic conditions and states and the effect of medical diagnostic and treatment measures in a life-style that promotes continued personal development.

2. Theory of self care deficit

It is the central focus of Orem’s general theory of nursing.
It describes how people can be helped through nursing.
Orem identifies 5 methods of helping: –

Acting for and doing for others
Guiding and directing
Providing physical or psychological support
Providing an environment promoting personal development
Teaching

3. Theory of Nursing System.

Orem has identified work operations of nurses in clinical nursing practice-

Entering into and maintaining nurse-patient relationships with individuals, families, or groups
Designing, planning for, instituting, and managing systems of nursing care
Responding to patients’ requests, desires and needs for nurse contact and assistance.

Theory of Nursing Systems

This theory describes how the patient’s self care needs will be met by the nurse, the patient, or both.
If there is a self-care deficit- that is, if there is a difference between what the individual can do (self-care agency) and what needs to be done to maintain optimum functioning (therapeutic self- care demand)- nursing is required.

Classification of nursing system It identifies 3 classifications of nursing system to meet the self care requisites of the patient:-

Wholly compensatory system
Partly compensatory system
Supportive – educative system

Wholly compensatory system

Represented by a situation in which the individual is unable to carry out needed self-care actions, either through inability to be self-directed or due to medical prescription.

Those who have such limitations are dependent upon others for their well-being and even their very existence.
Subtypes of this system are-

Unable to engage in self care(person in coma).
Aware but could not engage in self-care(person with C3-C4 vertebral fracture)
Include persons who are severely mentally impaired (senile persons, some forms of mental retardation).

Partly compensatory system

It is used when a patient can meet some self-care requisites but needs a nurse to help meet other needs; the nurse and the patient play major role in performing self- care.
For example: a patient undergone abdominal surgery.

Supportive – educative system

It is used when a patient can meet self- care requisites but needs assistance with decision making, behavior control, or knowledge acquisition skills.
For e.g, patient with controlled HTN who seeks additional diet information from the nurse: in this system, the nurse attempts to promote the self-care agency.

Major Assumptions

All patients wish to care for themselves.
Humans are capable and willing to engage in self-care and care for dependent members of the family.
Self-care and dependent care are learned behaviors through human communication and interaction with each other.
Nursing is a deliberate helping actions performed by nurses for the benefits of others over a certain period of time.
Humans are supposed to be self-reliant and responsible for their self-care needs and care needs for dependent members of the family.
Humans are unique individuals that are separated from each other and from their environment.

Major Concepts of Orem’s Theory

Person
Health
Environment
Nursing

Person

Person is defined by Orem as the patient (a recipient of nursing care)- a being who functions biologically, symbolically, and socially and who has the potential for learning and development.
Person is an individual, who is with the capacity for self knowledge, who can engage in deliberate action, interpret experiences, and perform beneficial actions

Health

A state characterized by soundness or wholeness of bodily structure and function; illness is its opposite.
It consists of physical, psychological, interpersonal and social aspects; these aspects are inseparable.
Health includes promotion and maintenance of health, treatment of illness, and prevention of complications.

Environment

Environment consists of environmental factors, environment elements, environmental conditions (external physical and psychological surrounding), and developmental environment.
Environment can positively or negatively affects the person’s ability to provide self care.

Nursing

Orem defines the art of nursing as an intellectual quality of the individual nurse; this quality is related to creativity as well as analysis and synthesis of information, all of which contribute to development of nursing systems to assist individuals or multiperson units.
Orem further defines nursing as a human service.
Nursing is distinguished from other human services by its focus on persons with inabilities to maintain the continuous provision of health care.

Strengths of Orem's theory

Provides a comprehensive base to nursing practice
It has utility for professional nursing in the areas of nursing practice, curricula, education, administration, and research
Specifies when nursing is needed
Her self-care approach is contemporary with the concepts of health promotion and health maintenance
Expanded her focus of individual self-care to include multiperson units

Limitations of Orem's theory

In general system theory, a system is viewed as a single whole thing while Orem defines a system as a single whole, thing.
Appears that the theory is illness oriented rather with no indication of its use in wellness settings.

Roy's Adaptation Model

Introduction:-

Sr. Callista Roy- nurse theorist, writer, lecturer, researcher and teacher.
Professor and Nurse Theorist at the Boston college of Nursing in Chestnut Hill.
Born at Los Angeles on October 14, 1939, 2nd child of Mr. & Mrs. Fabien Roy.
Bachelor of Arts with a major in nursing - Mount St. Mary's College, Los Angeles in 1963.
Master's degree program in paediatric nursing - University of California, Los Angeles in 1966.
Master's and PhD in Sociology in 1973 and 1977.
Worked with Dorothy E. Johnson.
Worked as faculty of Mount St. Mary's College in 1966.
Organized course content according to a view of person and family as adaptive systems.
In 1970- The model was implemented in Mount St. Mary's school.
1971-She was made the chairperson of the nursing department.

Metaparadigm Of RAM

Human being
Environment
Health
Nursing

1. Human being-

The Person viewed as a adaptive system, their health, and their environment
Interchanging with the environment
Person also refers to families, groups, communities and the whole society.

2. Environment-

All conditions, circumstances and influences that surround and affect the development and behavior of the person.
A change acts as a stimulating and causes adaptive responses.

3. Health-

It is a process where he or she is striving to achieve their maximum potential.

4. Nursing-

Nursing acts to enhance the interaction of the person with the environment to promote adaptation.