Nightingale’s principles
NUR3500
Nursing Theory: The Basis for Professional Nursing
*
Nursing Theory
Latin “a viewing”; Greek “contemplating”
A body of knowledge shaped by how nurses see the world
A group of related concepts, definitions & statements that propose a view of nursing phenomena from which to describe, explain or predict outcomes
Abstract ideas
*
Why is Theory Important?
Nursing is strengthened when knowledge is built on sound theory
Criteria to be a profession: distinct body of knowledge as the basis for practice
Nursing must be viewed as a scholarly academic discipline hat contributes to society
Ultimate goal is to support excellence in practice
Theory Guides the Professional
Nurse in….
Organizing and analyzing patient data
Understanding connections between pieces of data
Discriminating between important and less pertinent data
Making sound clinical judgments based on evidence
Planning effective nursing interventions
Predicting and evaluating outcomes of interventions
Definition of Terms
Metaparadigm = the major concepts or abstract ideas of the discipline; most important to practice and research
Person
Environment
Health
Nursing
Philosophy = a set of beliefs about the nature of how things work and how the world should be viewed; begins to put together some or all concepts of the metaparadigm
Definition of Terms Cont’d.
Conceptual Model or Framework = a more specific organization of nursing phenomena than philosophies; provide an organizational structure that makes clearer connections between concepts
Propositions = statements that describe linkages between concepts and are more prescriptive; they propose an outcome that is testable in practice and research
*
Florence Nightingale
Notes on Nursing: What It Is and What It Is Not (1969, originally published in 1859)
Her philosophy of health, illness, and the nurse’s role in caring for patients
Focused on the relationship of patients to their surroundings
Importance of observing the patient and recording information
Importance of cleanliness
Health and recovery from illness is related to environment
Virginia Henderson
The “Unique function of he nurse… is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge.”
Nurse’s role = substitute for the patient, a helper to the patient or a partner with the patient
14 basic needs of the patient (see Box 13-3 on pg. 308)
*
Jean Watson
Studied at CU
The Philosophy and Science of Caring (1979)
Emphasized the caring aspects of nursing
10 Carative factors (see Box 13-4 on pg. 309); these factors differentiate nursing from medicine (curative)
Illness or disease equated with lack of harmony within the mind, body, and soul
RN responsible for creating and maintaining an environment supporting human caring while recognizing and providing for patient’s primary human requirements
Watson Continued
Proposed that nursing be concerned with spiritual matters and the inner knowledge of nurse and patient as they participate together in the transpersonal caring process
Nurses share their genuine self
Patient’s spiritual strength is recognized, supported, encouraged
RN encourages openness to understanding of self and others
Leads to trusting, accepting relationships where feelings are shared and confidence is inspired
Dorothea Orem
Concept of self-care
“Ordinary people in contemporary society want to be in control of their lives.”
Patient’s baseline ability to provide adequate self-care is assessed
Systems of care
Wholly compensatory
Partially compensatory
Supportive-educative
Imogene King
A Theory for Nursing: Systems, Concepts, Process (1981)
Focused on persons, their interpersonal relationships, and social contexts with three interacting systems
Personal
Interpersonal
Social
Emphasizes goal attainment and patient’s involvement in setting goals (Goal Attainment Model)
*
Sister Callista Roy
Introduction of Nursing: An Adaptation Model (second edition 1984)
Individual as a biopsychosocial adaptive system
Nursing is a humanistic discipline that emphasizes the person’s adaptive and coping abilities
The environment can be manipulated by the RN to further patient’s adaptation
Hildegard Peplau
Interpersonal Relations in Nursing (1952 & 1988)
Relationship between patient and nurse is the focus of attention
Therapeutic interpersonal relationship
Survival of the patient
Patient’s understand his or her health problems and learn from them as they develop new behavior patterns
6 roles of the nurse: counselor, resource, teacher, technical expert, surrogate, and leader
Ida Orlando
The Dynamic Nurse-Patient Relationship: Function, Process and Principles (1961)
Observation and confirmation of patients’ verbal and non-verbal behavior, which identify patient needs
Goal of the nurse is to determine and meet patients’ immediate needs and improve their situation by relieving distress or discomfort
Individualize care by attending to behavior
Madeleine Leininger
Theory of cultural care
Founder of Transcultural nursing
Patients viewed in the context of their cultures
Nursing care should be culturally congruent
“Sunrise Model” (Figure 13-2, pg. 317) guides the assessment of cultural data for an understanding of its influence on the patient’s life
Theory-Based Education
PhD: a research degree that generates new, discipline-specific knowledge
Master’s: use theoretical perspectives focused on the patient for specific nursing outcomes; base practice on evidence from research & experience
BSN: introduced to research process & the use of theory to guide it
ADN: find middle range theories useful as they are specific to patient care
*
Theory-Based Practice
Occurs when nurses intentionally structure their practice around a particular nursing theory and use it to guide them in their care of the patient
Provides a systematic way of thinking about nursing that is consistent and guides the decision-making process
Challenges conventional views of patients, illness, the health care delivery system, and traditional nursing interventions
*
Benefits
Explain practice to others
Passes on knowledge to students
Contributes to professional autonomy
Develops analytical skills, challenges thinking, and clarifies your values and assumptions
*
Theory-Based Research
Great strides have been made in the last 25 years in nursing research
Nursing research tests and refines the knowledge base of nursing
Research findings enable nurses to improve the quality of care and understand how evidence-based nursing influences patient outcomes
Research is vital to the future of nursing and theory is integral to research
The Health Care Delivery System
*
Health Care Delivery
The four basic types of services provide by the health care delivery system
Health Promotion: remain healthy
Illness prevention: reduce risk factors
Diagnosis & treatment: refined methods of diagnosis allow for more effective treatment
Rehabilitation & LTC: restore function & independence; disease management
*
Health Care Agencies
Government: Contribute to health of all U.S. citizens; supported by taxes; Federal, State, Local
Voluntary (Private): Support via private donations, government grants
Not-for-profit: Profits used on behalf of agency
For-profit: Profits distributed to partners or shareholders
*
Level of Health Care Services
Primary Care Services: first entry into system, emergency care, health maintenance, LTC, chronic care, temporary health problems
Secondary Care: prevent complications from disease; home health, ambulatory care, skilled nursing agencies, and surgery centers; disease management via electronics
Tertiary Care: acutely ill to LTC to rehab to terminally ill; interdisciplinary; specialized hospitals: trauma centers, burn centers, specialized peds centers; LTC facilities that offer skilled nursing, intermediate care and supportive care; rehab centers; hospice
Subacute Care: Inpatient care between hospital and long-term care
*
Organizational Structures of Health Care Agencies
Board of Directors: carry responsibility for mission, quality of services, finances
Chief Executive Officer (CEO): overall daily operation
Medical Staff: physicians granted privileges; organized by service/dept.
Chief of staff work with CEO to make important decisions about medical policy
Nursing Staff: RNs, LPNs, NAs and clerical staff; organized according to units
Chief Nurse Executive (CNE) or Chief Nursing Officer (CNO) today on Board of Directors, oversee nursing care
*
Nursing Organization Governance
Nurses govern themselves though the organization
Shared governance = founded on the philosophy that employees have both a right and a responsibility to govern their own work and time within a financially secure, patient-centered system
Promotes decentralization and participation at all levels of nursing
Maintaining Quality
Accreditation: accrediting bodies approved by CMS; to improve pt. outcomes; institution wide initiatives
JCAHO (Joint Commission): not-for-profit that serves as the nation’s predominant standards-setting and accrediting body in health care
HFOP (Healthcare Facilities Accreditation Program): Standards met in all depts.
Continuous Quality Improvement (CQI)/Total Quality Management (TQM): examine processes to look for ways to improve services before mistakes occur; anticipate potential problems and prevent their occurrence
Performance Improvement (PI): organizational efforts to improve corporate performance; focuses efforts on increasing individual and group competence and productivity
*
Health Care Disparities
Defined as differences in the quality of health care provided to different populations
Can be due to race, ethnicity, gender, age, income, education, disability, sexual orientation, and place of residence
Little progress has been made in narrowing disparities
Provider bias possible contributing factor
Health Care Team
Physicians
Physician Assistants
Patient Care Technicians
Dietitians
Pharmacists
Technologists
Respiratory Therapists
Social Workers
Therapists
Administrative Support Personnel: admissions, medical records, billing, etc.
*
Nurse’s Role on Team
Provider of Care: direct hands on care
Educator: teaching pt., family, new staff, community, etc.
Counselor: emotional support & problem solving
Manager: organizes care
Researcher: investigates how nursing interventions impact patient outcomes
Collaborator: works with patients, families & team on agreed patient outcomes
Patient Advocate: stands up for patient rights; advocates for patient’s best interests at all times
*
Types of Nursing Care Delivery
Functional Nursing: focuses on functions/tasks; personnel work side by side each performing an assigned task
Team Nursing: RN is team leader, oversees, assesses, documents; LPN direct care, treatments, procedures; NA personal care
Primary Nursing: one nurse accountable for nursing care of patient during stay on unit; delegates care while off duty
Case Management Nursing: oversees pt. care and manages the delivery of services from entire health care team throughout patient’s illness
Patient-centered Care: contemporary model focusing on patient’s rights to individualized care
*
Financing Health Care
In 2007 the nation’s health care expenditures reached $2.2 trillion and consumed 16.2% of the gross domestic product
By 2018 health care costs are expected to reach $4.4 Trillion
Basic Economic Theory: supply/demand; Does it relate to health care?
Free-Market economy: consumption determined by an individual’s ability to pay
Price sensitivity in health care: third party payers (employer, insurance company, or government) removed price sensitivity from the concern of most health care consumers because they pay only a portion of the actual costs
Additional influences: can’t delay care
*
Economics of Nursing Care
Nursing accounted for 20-28% of the costs of hospitalizations in 1980s
To stay in business, hospitals must make at least enough money to pay personnel, maintain buildings and equipment, and pay suppliers
ANA: overzealous cost-containment efforts have led to lower quality hospital care
Aiken, Clark, Sloane et al, 2006 research links nursing and quality of care; increased patient death rate with higher nurse:patient ratios
*
History of Health Care Finance
Before 1945, 90% paid out of pocket or charity care
Growth of Private Insurance → tax exempt
Rise of Public Insurance Programs (1965)
Medicare
Part A = Hospital Insurance
Part B = Medical Insurance (20% co-pay, deductible
Part C = Managed care option
Part D = Prescription drug coverage
Medicaid
Federal government contributes 50-76.8%
Personal (out-of-pocket) payment
Worker’s Compensation
*
Forces Changing Health Care
Managed Care attempts to control healthcare costs; health promotion not illness treatment
Health Maintenance Organization (HMO): health care services provided for a predetermined fixed fee
Capitation: same amount paid to provider each month regardless of whether services were provided or how much the services cost
Gatekeeper: PCP, responsible for referrals
Preferred Provider Organization (PPO): contracts with provider for discounted rate
*
Forces Changing Health Care
Point-of Service Organization (POS): choice of service within network; or outside network pay higher $
Physician Hospital Organization (PHO): corporation formed by hospital/physician to contract with managed care organization
Nurse’s Role in Managed Care
Advanced Practice Nurses: ambulatory and community settings
Case Manager
Triage
Utilization reviewers to determine most appropriate and cost-efficient level of care
*
Change in Consumer’s Expectations
Became more educated and fight for rights to health care through political reform and the legal system
Proliferation of internet websites has dramatically affected the knowledge and expectations of consumers
Health Care’s Response
Reengineering: rethinking & redesigning
Patient-centered care: patient at center of activity and designing outcomes
Decentralization: staff exercise own judgment
Cross-functional teams: people form all areas of the organization who contribute to a particular process
Multi-skilled workers: single worker cross-trained to do different tasks
*
New Organizational Models
Functional Model: defines each major function of the organization and establishes clear lines of managerial authority
Service Line Model: establishes management responsibilities around specific types of services wherever they occur in the hospital
Matrix Model: complex with multiple authority and support systems
Process Model: organizes management of care around phases in the process of healthcare delivery
Regional Model: complex health care systems that grew from acquisitions; organized by type of service provider
*
Continued Escalation of
Health Care Costs
Inflation
New Technology and Drugs
Increased Demand for Healthcare Services – more elderly & uninsured
Fraud and Abuse of Payment Systems – $75 billion of US annual health expenditures may be attributable to fraud
*
Cost Containment Measures
Centers for Medicare & Medicaid Services – contracts private insurance agencies to service the Medicare program
Professional Review Organizations (PROs) – monitor the quality of care received
Diagnosis-Related Groups (DRGs) – diagnoses with similar resources consumptions and LOS patterns into a single category; 495 DRGs
Block Grants – state given set amount of money based on caseload, etc.
Continued Expansion of Managed Care – largest provider; limits consumer choices but not intended to reduce quality of care
*
Health Care Finance Challenges
Continuing Crisis: Uninsured Americans
Quality of Care
Limits on Choice and Services
Provider Restrictions & Financial Incentives to Limit Services
Cost of Prescription Drugs
Malpractice Costs & Impact of Access to Care
*
Health Care Reform
The US and South Africa are the only two industrialized nations that do not provide universal access to health care
System-wide health reform efforts were supported by public opinion but failed to pass congress
*