Evaluating nursing practice through theories and models - Essay Example

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EVALUATING NURSING PRACTICE THROUGH THEORIES AND MODELS TABLE OF CONTENTS TABLE OF CONTENTS 2 LIST OF TABLES 3 1.0INTRODUCTION 4 2.0NURSING MODELS AND THEORIES 5 2.1Florence Nightingales Legacy Of Caring 6 2.2Orem’s Theory of self-care deficit 7 2.3Paplau’s Theory 8 3.0CASE STUDY: How to Take Care Of Peripherally Inserted Central Catheter Paediatric Patients for Chemo Therapy Purpose Long Term Care 10 3.1Infection Control 13 3.2Orem’s Theory of self-care deficit, areas and priority 13 3.3Therapeutic Self Care Demand- the areas of deficient identified 15 3.4Outcomes and Plan 15 3.4.1Outcomes 15 3.4.2Nursing goals and objectives will be: 15 3.5Education 16 3.6Health 16 3.7Environment 17 3.8Nursing 17 4.0CONCLUSION 17 REFERENCES 18 APPENDIX 20 LIST OF TABLES Table 1: Basic Conditioning Factors 10 Table 2: Universal Self-Care Requisites 11 Table 3: Developmental Self-Care Requisites 12 Table 4: Health Deviation Self Care Requisites 12 Table 5: Nursing care plan as per the Orem's Theory of Self-care and Deficit 13 1.0 INTRODUCTION The safety and quality of initiatives of patients and their magnet status does call upon the nurses to carry their work in a professional platform putting in mind an evidence-based healthcare practice that does propagate an overall nursing administration. When nurses are armed with a conceptualized practice, they are able to transform the medical practice. As has been outlined, theories form a set of concepts which are interrelated giving a very systematic perception of various phenomena. The phenomenon must be explanatory and predictive in its approach (Craven & Hirnle, 2007, pp.4-18). These nursing theories are made of some concepts, models, definitions, propositions and are entrenched in certain informed assumptions. This paper discusses some of the nursing theories that have been applied in the nursing profession and form the basis of some of the best evidence-based practices. In professional practice, models and theories provide planners with relevant tools to help them go beyond intuition and as such enables them to design and carry out an evaluation of health behaviour and the interventions meant to promote health as regards the best understanding of that behaviour in question. Models become necessary when representations of various interactions among different concepts needs to be shown and patterns established. Theories should be able to give nursing practice the foundation it needs in order to develop more knowledge in the area and provide the direction such a nursing professional practice needs to take (Alligood & Tomey, 2002, pp.56-78). The paper looks at these nursing models and theories and in particular addresses the Florence Nightingales Legacy of Caring; Orem Theory and Paplau's Theory and points out their underlying theoretical and evidence base for each of them. The strengths and weakness of each of these theories are also discussed. A case study will be carried out on one of these models and theories to help illustrate its application further. This case study involves how to take care of peripherally inserted central catheter paediatric patients for chemo therapy purpose long term care. The peripheral IV devises are those cannula that are inserted into a peripheral vein that is small for purposes of therapy in cases where medications, blood products or fluids need to be administered to patients. The peripherally inserted central catheter devices or PICC are usually inserted into brachial veins or basilica or cephalic veins and do get into the large vein or superior vena cava. Little is however known regarding the risk of complications in applying these devices to paediatric patients with cancer who are under chemotherapy (Callaghan, et al., 2002, pp.256-64). This will be further illustrated by taking into account the metaparadigms in nursing application such as infection Control of this condition, relevant education that is needed, health situation, the environmental setting, and the kind of nursing required. A critical reflection of this process of study will be given at the end of my discussion in order to give my personal view of the study and what I have learnt throughout the process. Nursing models and theories in nursing profession have a greater importance because they assist in the evidence-based nursing practice. 2.0 NURSING MODELS AND THEORIES The conceptual frameworks within the models and theories of nursing give professional nurses the much needed foundation in the individual practice and its development. There are various models that have been put forward in the nursing profession to help in the evidence based practices. Some of these models and theories include, but not limited to, Florence Nightingales Legacy of Caring, Orem’s Theory, Paplau's Theory, Neumans’s Health Care System Model, Myra Estrin Levine’s: The conservation model, and Patricia Benner’s Primacy of caring, among others. However, for the sake of this discussion, I am going to evaluate the first three models as explained below (McQuiston & Webb, 1995, pp.107-118; Tomey & Alligood, 2002): 2.1 Florence Nightingales Legacy Of Caring This theory focuses its practice on the aspect of nursing and the relationship with patient environment. The major concepts that are presented in this theory are ventilation and warming of the environment; light and noise; cleanliness of the walls and the rooms; health of the houses; bed and bedding; personal cleanliness; variety; chattering the hopes and advices; taking food; and, petty observation and management of the patient. The theory assumes that mankind is able to achieve perfection; nature has laws; nursing is a calling; nursing is an art and a science at the same time; nursing can be achieved by altering the environment; nursing needs provision of specific educational base; and that, nursing is quite distinct and separate from the field of medicine (Selanders, 2010, pp.81-8). The theory advocates for promoting health of patients and preventing people from getting diseases. The avenues for propagating this theory are decent housing, accessing clean water and breathing clean air, improvement in the nutrition levels, safe births, and good care for children. Immediate needs of patients have to be met if healing is to be achieved. The theory outlines that people are naturally multidimensional and are made up of biological, social, spiritual and psychological parts. health is achieved when we can use all the power we possess and as such, absence of comfort in life defines what a disease is. poor environment and difficult situations is a recipe for poor health status and diseases and as such, it is important to alter the environment in order to let nature laws allow healing to be realized (Wills & McEwen, 2002). The strength of this theory lies in the ability to apply a holistic and comprehensive approach to healthcare through provision of settings that allow prevention of diseases. It addresses the weaknesses that poor environment poses for diseases to emerge. However, this theoretical model has some weaknesses one of them being the fact that she put much emphasis on subservience to doctors and the other being her focus on physical factors more than the psychological factors that are needed by the patient. She seemed to have been overwhelmed by environmental and spiritual matters in her formulation of this theoretical model (Alligood & Tomey, 2002, pp.56-78). 2.2 Orem’s Theory of self-care deficit This theory combines three theories namely the theory of self-care which are those activities done by the individual patients in maintaining their personal health status, theory of self-care deficit, and the theory of nursing systems. There arises a self-care agency which is that ability that is acquired by the patient in his or her performance of self-care. This performance is subject to some basic conditioning factors like gender, age, family system, and health care system among others. There is the therapeutic demand of self-care and this he defines it as the totality of measures related to the self-care which is required in the process. Performing these self-care is aimed at meeting certain self-care requisites that could take the form of universal, health deviation, and developmental and these requisites form the basis for need creation. Absence of one of these requisites means that the patient creates a need due to the deficit. The nurse is in a position to identify the need by conducting a thorough assessment of the patient. The choice of care will be determined by the degree of deficit faced by the patient. Nursing systems for care provision are then selected and these include wholly compensatory, supportive or partly compensatory, and educative systems. After care has been given, nursing activities and systems are evaluated in order to find out whether those initially established mutual goals have been met or failed to do so (Wills & McEwen, 2002). The strength of this theory and model lies in the fact that it has the ability to identify the self-care requisites by the nursing professional and enable provision of a comprehensive healthcare to the patient. The model is also both supportive and educative to the patient and the nursing practitioner. Self-agency is very useful when an explanation of various pathological and individual factors is attributed to personal neglect. Self-care requisites give very important heuristic devices that help in the differentiation of self-neglect image (Lauder, 1999, pp.48-57). The major weakness of this theory and model is the fact that it rejects the objective reality and instead does accept multiple realities considered to be social constructions of someone’s mind. This deviates from the norm of identifying self-neglect by the patient. It takes a relativist epistemology. These judgments do not reach to an objective conclusion of one having gone through self-neglect to require self-care. It also fails to address the anomalies that are normally experienced in relation to the hierarchy of requisites. 2.3 Paplau’s Theory This theory puts much of its emphasis on the interpersonal and therapy relationships arising between the nurse and his or her patient/client. The interpersonal bit demands that the nurse must be able to give service to the processes of interpersonal nature that do occur between them. The interpersonal process could be seen as that maturing force related to personality. These interpersonal processes do incorporate nurse-client relationship, pattern integration, communication, and the roles that the given nurse plays. This process involves some form of psychodynamic nursing concepts which encompasses the ability of the nurse to understand personal behaviour that is exhibited in a bid to assisting other people figure out some difficulties and help apply the human relations concepts and principles to those problems emanating from all experiential levels. The theory does stress on the need for a nurse to understand his or her own individual behaviour so that he or she can be in a position to help others, in this case patients, find out their own perceived difficulties (George, 2002, pp.80-97). This theory takes on a model that is carried out in four phases. These phases include orientation whereby the individual feels the need to seek professional help and ends up doing so. The nurses are in a position to assist this person recognize and comprehend personal difficulties and determine the necessity of getting help. This phase is in parallel with the assessment phase in which case the patient and the nurse are first strangers; identification is the second phase and the patient does identify with the people that can offer assistance where exploration of personal feelings of the patient is permitted by the nurse to help the patient reorient feelings and add strength to positive forces with the aim of giving required satisfaction and personality; exploitation phase where the patient tries to get enough value by means of individual efforts and the subsequent shift in power from the nursing professional to the patient. At this point, the patient needs to delay gratification with the aim of reaching the new targets; and finally, resolution phase entails the patient departing from old goals and acquiring new ones in a very gradual manner. The patient is thus able to set him or herself free from the identity that had been formed with the nurse. Peplau argued that the nursing process is a deliberate intellectual activity able to guide professional practice of nurses in their bid to give care in a very orderly and systematic manner. The strength of this model and theory is the full participation of both patient and nurse (Potter & Perry, 1992, 56-66). This is because the model bases its success on the conjoined efforts of the nurse and the patient to work together, make clarifications and collect required information. Formulations of the nursing diagnostics are done on the background of the assessment process, outcomes are predicted and the goals set for achievement. The other strength is the ability to bring out a holistic approach to patient care. The weakness of this model and theory lies in the fact that it is 100% reliant on the patient. In cases where patients are not able to give required signals and communicate effectively, there might be problems in both diagnosis and care (Meleis, 1997, pp.24-31; Reed, 2006, pp.22-24). 3.0 CASE STUDY: How to Take Care Of Peripherally Inserted Central Catheter Paediatric Patients for Chemo Therapy Purpose Long Term Care Therapy of outpatients is becoming more common currently since hospitals are trying to shorten the inpatient numbers and on the other hand patients needing long term care by way of intravenous antibiotics, analgesia, chemotherapy or even nutrition has also increased. PICC has been seen to be a better alternative when compared to indwelling CVCs and other devices. Patient X is a child who came to the hospital with complications resulting from PICC use. The patient is on chemotherapy for long term care purposes. The following data pertains to the X as per the Orem’s Theory of Self-Care Deficit. Table 1: Basic Conditioning Factors Age 11 years Gender Female Health State Cancer patient Development State Pain due to complications of PICC use and despair Sociocultural Orientation Basic primary education, American, African-American decent, Christian Health Care System Institutional health care Family System Child with both parents, not separated Patterns Of Living At home with parents Environment Stays in rural area where items for PICC are not easily reachable. There have not been any special precautions meant to prevent injuries Resources Parent’s and brother’s Table 2: Universal Self-Care Requisites Air Has no difficulties in breathing and exhibits no pallor cyanosis Water She has sufficient fluid intake. Mild malnutrition Food Food intake is somehow sufficient and basic nutrition value is present Elimination She does void and removes bowel with no much difficulty Activity/ rest She needs frequent rest based on the pain she feels on the PICC location and the general chemotherapy treatment pains.  Pain is not fully relieved,  the activity level is going down There is hematomas leading to skin necrosis at the location of the PICC insertion Social interaction She does communicate well with people around her especially parents and can make calls when she needs something. When she needs medicine, she most of the time communicates to the mother. Prevention of hazards She needs further instructions on how to control PICC when sleeping and avoid falling off the bed. She also needs instructions on improvement of nutritional status through parents and advice on foods she could eat given her condition since she likes snacks and fizzy drinks to other foods considered more nutritional. Promotion of normalcy She has very cordial relationships with both mother and father Table 3: Developmental Self-Care Requisites Maintenance of   environment for development She is able to feed herself, experiences difficult in performing some activities such as dressing Prevention and management of the conditions that threaten the normal development She feels that her health problems come from her behaviours and is free to discuss them with the nurse and parents Table 4: Health Deviation Self Care Requisites Adherence to the prescribed medical regimen She is able to report the problem to the healthcare provider when she is taken to hospital by her parents She also cooperates with the nurse giving her medication but she has no information regarding its use and effects on her health. She thus asks many questions like if the medicine will cure her hematomas and skin necrosis or if she will not go for chemotherapy again Awareness of the possible problem related to the regimen She is not aware of the process of the disease that is affecting her she is not fully adhering to the recommended diet and the required prevention of hazards She also doesn’t know the side effects that come with the use of PICC. Modification of personal picture to include various changes in the status of health She has got used to being limited to movement Adjustment of the patient’s lifestyle in order to accommodate the changes in her health status, including her medical regimen She adjusted to the changes required in her lifestyle according to the instructions given. Still maintains accuracy with her medical regimen Medical Problem and Its Plan 3.1 Infection Control The perspective of the physician regarding X’s condition: she has been diagnosed with hematomas leading to skin necrosis and put on relevant medications. Medical diagnosis: hematomas and skin necrosis Treatment: a combination of medication and physical therapy is required 3.2 Orem’s Theory of self-care deficit, areas and priority Air; water; food; elimination; activity reduction and rest; solitude and in interaction; hazards prevention; normalcy promotion; maintenance of an environment for development; prevent and manage threats to good development; maintain a good health status; be aware and able to manage the disease process or condition; follow the medical regimen provided; be aware of the possible problem; modify personal image; and make changes to the lifestyle in order to accommodate good health status changes (Croyle, 2005). Table 5: Nursing care plan as per the Orem's Theory of Self-care and Deficit Nursing diagnosis   or diagnostic operations Outcome and plan  or Prescriptive operations Implementation  or control operations Evaluation  or regulatory operations This is based on self-care deficits Outcome  Nursing goal and objectives  Design the system for  nursing devise appropriate method of assisting the patient Propagate nurse and patient actions in order to:  achieve the needs of self-care; be able to decrease the self-care deficit that has been identified; Try and promote the patient as a self-care agent for easier control of the process  a) Consider the effectiveness of the nurse and patient interactive actions to:  Work on the reduction of the self-care deficit Enhance the ability of the patient to act as self-care agent  Be able to achieve the individual needs for self-care b) establish the effectiveness of the chosen nursing system in realizing the needs of the patient in this process From the above analysis, the areas that needed attention and assistance from the nurse to patient X were: Air; water; food; elimination; activity reduction and rest (2); solitude and in interaction; hazards prevention (2); normalcy promotion; maintenance of an environment for development; prevent and manage threats to good development; maintain a good health status; be aware and able to manage the disease process or condition; follow the medical regimen provided; be aware of the possible problem; modify personal image; and make changes to the lifestyle in order to accommodate good health status changes. 3.3 Therapeutic Self Care Demand- the areas of deficient identified Good nutrition, rest and reduction of activity, prevention of hazards and reduction of pain Self-care agency’s adequacy levels: inadequate Nursing diagnosis established: Incapacity to manage nutritious diet due to favouring low nutrient foods such as snacks and fizzy drinks; dressing problems due to complications of hematomas and skin necrosis; less effective control for pain due to low use of measures of pain relief; and availability of possibilities for fall and interference with insertions. 3.4 Outcomes and Plan 3.4.1 Outcomes High levels of nutrition and maintenance of good diet by avoiding snacks and fizzy drinks; Improved levels of self-care; Maintain the needed ability to personal dressing; Improve on self-control of pain and manage pain reduction; and finally, Eliminate all possible falls and subsequent injuries to insertion areas. 3.4.2 Nursing goals and objectives will be: Goals: Realize highest levels of nutrition; Be able to self-care; Get pain relief; and finally, Prevent any fall and injury at the insertions. Objectives: Indicate to the patient the importance of sticking to a balanced diet and list the foods that are nutritious and accessible at the locality; Perform her activities of dressing in the possible limits and perform other activities necessary for her living with less assistance; Establish and describe the overall plan of both pharmacological and non-pharmacological measures to relieving pain and be able to demonstrate a reduction in the behaviours of pain while verbalizing these to a scale of 7-4; Stick to conditions without injury and this should be evidenced by lack of signs of having fallen or injured and explaining the necessary methods to be able to prevent injury; and finally, Keep integrity of normal skin and list measures to prevent hematomas 3.5 Education Support the patients knowledge by teaching her how to avoid falling, sticking to the meals given by parents to enhance good diet, means of personal dressing with less struggles, measures to maintain good skin by avoiding disruptions at the PICC site, and teach her how to avoid hazards. 3.6 Health Give her adequate information she needs to know about the health status; Ensure her comfort by observing good health measures; Help her stick to the medication regimen provided by the physician; and, Make her verbalize what she has learnt about her condition and how to manage it to maintain good health. 3.7 Environment A developmental environment should be promoted at all times during the process; Eliminate all the threats to development; be able to modify her self-image; promote a normal environment, serene enough to ensure healing; and interact well with the patient. 3.8 Nursing Nurse patient X with necessary caution and required theoretical procedures. Help the patient meet her set goals at the end of the process. Evaluate and assess her level of development to ensure that goals and objectives have been met. Failure of having met the goals and objectives mean that she has to repeat the process from the stage where she started going wrong (Vandemark, 2006, pp. 605-15). 4.0 CONCLUSION Indeed the importance of models and theories in nursing profession cannot be overemphasized because they hold a critical point in the evidence-based nursing practice which cannot be ignored if professional practice is to be upheld. These concepts are very useful in the success of any nursing professional in providing healthcare to his or her patients. The theoretical models discussed above have been used in various medical settings in assisting patients cope and deal with their conditions (Taylor & Lillis, 2001) Paediatric patients on chemotherapy need special care. PICCs are a choice for patients who need long-term IV access and many practitioners would choose PICCs due to the fact that they are durable and pose fewer problems when it comes to insertion and their removal after use. There is however a high rate of complication with cancer patients when PICCs are used, especially during chemotherapy. But that aside, the fact that these PICCs do not require a surgical procedure, less pain experienced during insertion, and ease of removing them after use, make PICCs preferred for patients especially paediatric patients under chemotherapy (Callaghan, et al., 2002, pp.256-64). Knowing the theories and models in nursing is one thing and applying them in practice is another serious challenge that nurses do face in their profession. The application of the theory of self-care deficit has the capacity to point out self-care requisites for patients such as X in the case study. It is a comprehensive approach to helping the patient meet her health needs. This is important in the field of nursing practice and should further be developed in order to fully address the identified weaknesses of this theoretical model (Reed, 2006, pp.22-24). REFERENCES Alligood M R, & Tomey A M. (2002), Nursing Theory: Utilization &Application .3rd ed. Missouri: Elsevier Mosby Publications, 56-78 Callaghan S. Copnell B. & Johnston L. (2002), Comparison of Two Methods of Peripheral Intravenous Cannula Securement in the Paediatric Setting, Journal of Infusion Nursing, 25(4):256-64, Craven R. F. & Hirnle C. J. (2007). Fundamentals of nursing – human health and function, 5th edition, Philadelphia: Lippincott Williams and Wilkins, 4-18 George JB (2002). Nursing Theories: The Base for Professional Nursing Practice .5th Ed. New Jersey: Prentice Hall, 80-97 Lauder W. (1999) Constructions of self-neglect: a multiple case study design. Nursing Inquiry 6, 48-57 McQuiston CM & Webb A. A. (1995), Foundations of nursing theory- Contributions of 12 key theorists. New Delhi: Sage Publications, 107-118 Meleis Ibrahim Afaf (1997), Theoretical Nursing: Development & Progress 3rd ed. Philadelphia, Lippincott, 24-31 Potter A. Patricia, & Perry G Anne (1992) Fundamentals of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book, 56-66 Reed PG, (2006) The force of nursing theory guided- practice. Nurs Sci Q.; 19(3):22-24 Croyle Robert T. (2005). Theory at a Glance: Application to Health Promotion and Health Behaviour (Second Edition). U.S. Department of Health and Human Services, National Institutes of Health. Selanders LC. (2010), The power of environmental adaptation: Florence Nightingale's original theory for nursing practice. .J Holist Nurs.; 28(1):81-8 Taylor Carol, Lillis Carol (2001), The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott. Tomey AM, Alligood. MR. (2002), Nursing theorists and their work, (5th ed.) Mosby, Philadelphia, Vandemark L.M. (2006), Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs.; 27(6): 605-15 Wills Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& Wilkins. APPENDIX What I Have Learned From Doing This Assignment I have learnt that the nursing models and theories are the foundations to evidence-based practice in the nursing profession. They are essential in giving directions of practice and behaviour to nurses. The application of these models and theories to real life scenarios is necessary in order to arm oneself with necessary skills and knowledge required in the field. I also learnt that there are many theories and models within the nursing profession which can be applied in various areas. Proper management of relationships between the patient and nurse is critical if healing of the patient is to be realized. Care of peripherally inserted central catheter paediatric patients for chemo therapy purpose long term care can be done within the models and theories of nursing. Care must be taken when handling such patients since they are sensitive to any form of external factors including the PICCs. Finally, in learnt that caution is important in the care for patients and that issues to do with time management while making a study are required if the deadline is to be met. I hope to apply these lessons in both my research study and career. Read More