EVIDENCE - BASED THEORETICAL

NURSING

Basis for Professional Nursing

OBJECTIVES: to show the relationship and importance of

evidenced-based theoretical nursing in developing the curriculum and activities of nursing schools here in the Philippines.

To discuss the application of nursing theories in academic and clinical management .

JOURNEY TO NURSING THEORIES (Activity)

By Pairs: Interview Method

Ask your partner these questions:

1. As an undergraduate student, can you easily recall 5 nursing theorists and their theories?

2. Choose 1, describe the concepts.

3. Were you able to use this theory either personally or professionally?

4. If yes, please describe the occasion.

NURSING THEORIES THAT CAN BE APPLIED IN THE ACADEME

Background: First reaction to Theoretical Foundations in

Nursing:

UGH!

Why? The Journey is Long and Winding STAGES IN NURSING PROGRESS

STA

GE

1

PRACTICE

STA

GE

2

EDUCATION ADMINISTRATION

STA

GE

3

RESEARCH

STA

GE

4

THEORY

Stage 1: PRACTICEWhat DEVELOPMENT THEORIST ho?

• Aimed to define nursing and identify goals • Organization of women to take care of wounded soldiers

• establishment of formal education and training for nurses, code of ethics, advocated for alleviation of suffering and promotion of healing

FLORENCE NIGHTINGALE (WESTERN WORLD)

RUFAIDA SAAD AL-ASLAMIYA(EASTERN WORLD)

Stage 2: EDUCATION AND ADMINISTRATION

What ? Who?

• Aimed to IMPROVE definition of nursing and added HOW TO practice nursing • Definition of the different levels of nursing education • different from medical profession

VIRIGINIA HENDERSON (1966)14 Nursing Needs

Stage 3: RESEARCHWhat ? Who?

• Overlapped with the first two stages • started as case studies (1920)• Objectives of research were focused on: a. Improving nursing education b. Embracing research productivity c. Raising quality of graduates

1948: Division of Nursing Research1952: First Nursing Research Journal1970: Commission and Council of Nurse Researchers1977: Research on how to teach, administer, and lead schools Gortner and Nahon, 1977)1980: Focus on scientific syntax (influenced by Kuhn)

Stage 4: THEORYWhat ? Who?

• Aimed at finding essence and mission of nursing in an organized way•Acceptance of the following: 1. nursing is complex that requires body of knowledge (theories) 2. Nursing is an autonomous profession. Concepts/ theories needed to support practice. 3. acceptance of need to test major hypothesis

(1979) Theory Think Tank

(1980) Overwhelming and too abstract Example: Martha Rogers“Science of Unitary Human Being” (1971) Simplistic and reductionist Dorothea Orem (1971) “Nursing Care Deficit Nursing Theory”

Why? Milestones in Theory Development in Nursing

PERIOD DESCRIPTION

BEFORE 1955 From FN to Research Stages

1955 – 1960 Birth of Nursing TheoryColumbia University Teachers College Abdellah, Peplau, Rogers, Henderson, Hall, Wiedenbach

1961 - 1965 Theory: A National Goal for Nursing

1966 - 1970 Theory Development: A Tangible Goal for Academics

1971 - 1975 Theory Syntax: Metaparadigm of Nursing

1976 - 1980 A Time to Reflect

1981 - 1985 Nursing Theories Revival : Emergence of DomainConcepts

1986 - 1990 From meta theory to concept development

1991 – 1995 Mid-Range and Situational Theories

1996 - 2000 Evidence Based Research

2001 – 2005 Diversity in thought: Linking Theory and Practice

Furthermore, the Journey is Complicated. Survey of McEwen (2000) :

1. books were dated

2. too focused on Grand Theories

3. too theoretical

In Practice, many questions remain unanswered. Uncomfortable.

In the academe, the noise competes with acquisition of knowledge. How will they relate?

McEwen (2006) Recommendations: 1. emphasis on Middle Range Theories

and more modern ones. Grand Nursing

Theories as knowledge foundation

2. teach and practice evidence –based

nursing linked to research

3. organize text according to Nursing

language

4. complement nursing theories with

borrowed theories used in Nursing

1. FOCUS ON MRT AND MODERN THEORIES Use the classification as guide

COMPARISON DIAGRAM

THEORY Level of Abstraction

Meta theory MOST

Grand Theories

Mid-range theories

Practice theories LEAST

CLASSIFICATION OF THEORIES IN NURSING Tomey and Alligood (2002)

Scope of THEORETICAL WORKS:

1. Philosophies: based on analysis,

reasoning, and logical arguments

Nightingale, Wiedenbach, Henderson,

Abdellah, Hall, Watson, Benner

CLASSIFICATION OF THEORIES IN NURSING Tomey and Alligood (2002)

Scope of THEORETICAL WORKS

2. Grand Theory – comprehensive and include their perspectives, usually developing from their own model

Example: Person as An Adaptive System Theory from Adaptation Model by Roy

GRAND NURSING THEORIES Historical Background Focus on greatest contribution to nursing Just enough knowledge to whet readers’

appetite, unless the students’ will

pursue studies

FOCUS: THEORIES IN NURSING Tomey and Alligood (2002)

Scope of THEORETICAL WORKS:

3. Middle –Range Theories focus on

specific phenomena in the middle

of a continuum between GNT and

SITUATION BASED THEORIES

Example: Kolcaba

CLASSIFICATION OF THEORIES BASED ON RANGE, SCOPE AND

ABSTRACTNESS

Peterson (2004)

1. Meta theory, Philosophy, or Worldview

2. Grand Theory or Macro theory

3. Middle Range or Mid-range*

4. Micro theory, situation-specific theory or

practice theory*

5. Partial Theory or in the development stage

RELATIONSHIP AMONG LEVELS OF THEORY

CLARIFIES

•META THEORY LEVEL

GUIDES

•GRAND THEORY LEVEL

•MIDDLE RANGE LEVEL

DIRECTS

•PRACTICE THEORY

SUPPORTS

REFINES

TESTSINPRACTICE

Walker and Avant (2005) Strategies for Theory Construction

CLASSIFICATION OF THEORIES IN NURSING

3 Major Groups:

1. human needs

Nightingale, Henderson, Abdellah,

Orem, Johnson, Neuman

2. interactive process

Levine, Artinian, Erickson, Tomlin, Swain

King, Roper, Logan, Tierney, Roy, Watson

3. unitary process

Rogers, Newman, Parse

CLASSIFICATION BASED ON PURPOSE Dickoff and James (1968)

1. descriptive (factor –isolating)

2. explanatory (factor-relating)

3. predictive (situation relating )

4. prescriptive (situation producing)

Note: level of development is progressive.

CLASSIFICATION BASED ON PURPOSE

DESCRIPTIVE (Factor Isolating)

EXPLANATORY (Factor relating)

PREDICTIVE (Situation relating)

PRESCRIPTIVE (Situation Producing)

DESCRIPTIVE –Factor Isolating PURPOSE: DESCRIPTION AND EXAMPLES:

OBSERVE, DESCRIBE, NAMECONCEPTS, PROPERTIES, ANDDESCRIPTIONS

PURPOSE: TO PROVIDE MEANINGAND OBSERVATIONS

GENERATED AND TESTED BY DESCRIPTIVE RESEARCH TECHNIQUES INCLUDING:1. CONCEPT ANALYSIS2. 2. CASE STUDIES3. ETHNOGRAPHY Fawcett (1999)

IT DOES NOT EXPLAIN HOW OR WHY THE CONCEPTS ARE RELATED

Examples: KIDNER, FLANDERS-STEPANS(2004)Descriptive model of mothers whose pregnancies were complicated with HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)

CAROLL (2003):Theory of Personal Preservation for End Stage Renal Disease.

EXPLANATORY (FACTOR RELATING )It does DESCRIPTION AND EXAMPLES

Relates concepts with one another

Describe interrelationships

Cause and Effect and correlations Developed by Correlational ResearchFawcett(1999)

Examples:

Mc Carley (1999) Chronic Dyspnea

Haight, Barba, Tesh, Courts (2002) Thriving Model (Failure to Thrive in elderly)

These models need additional research and developments

PREDICTIVE OR SITUATION RELATING It does: Description and examples

Conditions under which concepts are related, and the relational statements are able to describe future outcomes consistently

Prediction of precise relationships between concepts

Relatively difficult to find in nursing literatures

Dirksen (2000) Prediction of Well being among Breast Cancer Survivors(Reosurcefulness, Social Support, Self Esteem)

Smith et al (2002) Caregiving Effectiveness Model (Characteristic of caregiver, interpersonal interactions between patient and caregiver, educational preparenedness, and adaptive factors such as economic stability, coping mechanism etc)

PRESCRIPTIVE OR SITUATION PRODUCING It does: Description and Examples

Precribe activities necessary to reach defined goals

Address nursing therapeutics and consequences of interventions

They describe the type of client, the conditions, the prescription and the consequences Meleis ( 2005)

THE MOST DIFFICULT TO IDENTIFY IN NURSING LITERATURES.

Novak (1997). Middle Range Theory on CHRONOTHERAPEUTIC INTERVENTION FOR POST SURGICAL PAIN. It used a time dependent approach to pain assessment and provides directed nursing interventions to address post op pain.

CATEGORIZATION BASED ON NURSING DOMAINS Meleis (2004)

1. Nursing clients: Johnson, Roy, Newman

2. Human being-environment interactions

Rogers

3. Interactions : King, Orlando, Travelbee

4. Nursing therapeutics: Levin , Orem

. II. Teach and practice according to evidence –based research

PRINCIPLES:

1. Clinical experience

2. Experiences

3. Conceptualization about KNOWLEDGE

patients’ responses and

experiences

4. KNOWLEDGE is existing and needs to be discovered.

THE EVIDENCE BASED JOURNEY IS DAUNTING… BUT WORTHWHILE

1. HUMAN BARRIERS

“Nurses as Nurses” Service orientation vs professionalization Today, financial potential and career

growth overshadows the goals of nurses to make a difference in nursing profession

THE EVIDENCE BASED JOURNEY IS DAUNTING… BUT WORTHWHILE

Cont. 1. HUMAN BARRIERS

“Nurses are Nurses” Attitudes of students are changing as

changes occur in the spheres of life More nurses seeking Graduate Degrees More male joining nursing

THEORIES AND NURSING EDUCATION Before: Nurses are trained to be passive

handmaidens of physicians, executors of

Doctor’s orders, implementers of hospital

policy Today: Nurses plays a major role in

training the mind to think beyond immediate action, to question situations, to link events, to generalize and conceptualize.

THEORIES AND NURSING EDUCATION

Before Present

Nurses are dependent on hospital and medical system

Nurses do procedures and train as “socialized intellectual subordinates” in the hospital setting. Hospitals improve patient care and increase savings.

HOWEVER:REWARDS are given in clinical practice and teaching, but not in research.

Autonomous, uses own problem solving, critical thinking, uses own theory, debate on nursing issues

Nurses are trained in universities using its own standards, base of knowledge, competencies and skills

However:No standards of rewards which may be due to lack of competitive spirit among nurses. We are still overly compliant

THE EVIDENCE BASED JOURNEY IS DAUNTING… BUT WORTHWHILE

2. KNOWLEDGE BARRIER

Our discipline status is based on scientific foundations. THE THEORIES! (Meleis, 2005)

However, discipline cannot be installed only academically with the use of theories in curricula (Fawcett, 1999)

Theories must be developed through asking and answering significant questions of profession and discipline (Tomey and Alligood, 2006)

2. KNOWLEDGE BARRIER What is the central goal of nursing related

to the use of the theories?

KNOWLEDGE BARRIERS CONCLUSION:

There is a need for nursing theories to drive development of knowledge in daily responses, activities, lives of patients such as eating, sleeping, mobility, relating etc.

This can be supplemented by borrowed theories.

THE EVIDENCE BASED JOURNEY IS DAUNTING… BUT WORTHWHILE

3. CONCEPTUAL BARRIERS

In the past, there seems to be a close gate

that prevent nurses from developing and

perceiving nursing phenomena. This is referred to as PERCEPTUAL BLOCKS (Adams 1974)

FORMS OF CONCEPTUAL BARRIERS1. Difficulty delineating a phenomenon that is

worthy of pursuance theoretically

a. Unable to perceive meaningful clues

b. Focus on tangential issues

2. Use of comfortable boundaries on a phenomenon

a. Societal expectations

b. Non-compliance/ Lack of diagnostics

3. Lack of experience. Seeing the world in medical models.

III. Organize text according to Nursing language

Nursing practice

Nursing

Research

Nursing

Theory

CATEGORIZATION BASED ON PARADIGMS

PARADIGM is a worldview or an over all way of looking at a discipline and its science

PARADIGM is a view of life and not just a principle or theory

Sources of Knowledge Traditional — passed down from generation

to generation Authoritative — comes from an expert Scientific — arrived at through the scientific

method

Types of Knowledge Science — knowledge in and of nursing Philosophy — the study of wisdom Process — conceptual frameworks and

theories Historical influences — Florence

Nightingale, societal changes Societal influences — schools of nursing

Framework of Nursing Theory Theory — group of concepts that describe a

pattern of reality Can be tested, changed, or used to guide

research Concepts — abstract impressions

organized into symbols of reality Conceptual framework or model

Types of Reasoning Deductive reasoning — examines general

ideas and considers specific actions or ideas

Inductive reasoning — builds from specific ideas or action to conclusions about general ideas

Retroductive reasoning

Interdisciplinary Base for Nursing Theories General systems theory — theory for

universal application Adaptation theory — adjustment of living

matter to other living things and environment

Developmental theory — orderly and predictable growth and development

Benefits of Nursing Theory

Directs nurses toward common goal Leads to improved patient care Provides rational and knowledgeable

reasons for nursing actions

Benefits of Nursing Theory

Gives nurses knowledge base necessary for appropriate actions

Helps resolve current nursing issues Prepares nurses to question assumptions

and values Serves research, education, and practice

Goal of Theoretical Frameworks Holistic patient care Individualized care to meet needs of

patients Promotion of health Prevention or treatment of illness

METAPARADIGM OF Nursing Theories Person (patient) Environment Health Nursing

IV. Complement nursing theories with borrowed theories used in Nursing

Kuhn (1970)

Science of Scientific revolution

a. Paradigm

b. Paradigm shift

Nursing developed its own paradigm and meta paradigm

Four Principles of Learning Prior Knowledge: What we know affects what we learn Social Interaction: Learning is enhanced when learners talk to each other Use of Strategies: Successful learning involves use of numerous strategies Particular Situations: Learning is situational and not readily transferred to other

situations

Learner-centered teaching in Education

Piaget: Knowledge constructed through assimilation/accommodation Dewey: Active learningBruner: Developing thinkingAusubel: Rote and discovery learning

Learner-centered teaching in EducationVygotsky: Metacognition/Zone of Proximal DevelopmentSternberg: Learning stylesGardener: Multiple IntelligencesWiggins: Performance based Assessment

Learning and Psychology Affective Cognitive Psycho-motor

PSYCHOMOTOR (Dave 1975)

Juxtaposition with Benner’s “From Novice to Expert” will be useful development of Nursing Curriculum

AFFECTIVE LEARNING (Kratwohl, Bloom and Masia (1964))

Affective domain has received less attention, and is less intuitive than the Cognitive. It is concerned with values, or perception of value issues, and ranges from mere awareness (Receiving), through to analyzing values.

Bloom’s Taxonomy (1956)

Cognitive: the most-used of the domains, refers to knowledge structures (although sheer “knowing the facts” is its bottom level). It can be viewed as a sequence of progressive contextualisation of the material.

Knowledge

Anderson and Krathwohl (2001)

Later version

Side by Side: Bloom’s and Schultz

Caption: Terminology changes "The graphic is a representation of the NEW verbage associated with the long familiar Bloom's Taxonomy. Note the change from Nouns to Verbs [e.g., Application to Applying] to describe the different levels of the taxonomy. Note that the top two levels are essentially exchanged from the Old to the New version." (Schultz, 2005) (Evaluation moved from the top to Evaluating in the second from the top, Synthesis moved from second on top to the top as Creating.) Source: http://www.odu.edu/educ/llschult/blooms_taxonomy.htm

Journey :Year 2010 onwards! Nurses are now on the land of the “CAN “

and not anymore in the land of the “CAN’T”

Knowledge depends on experience; experience on observation; but observation by themselves do not form experience. Observations have to be organized as prioritized by the mind to develop into knowledge (Kant, 1800).

ASSIGNMENT Week 4: Thursday

Reporting by Pair: MANAGEMENT THEORIES

Scientific Management (Frederick Taylor)

Management Functions (Henri Fayol)

Participative Management ( Follet)

Weber (Bureaucratic Organizations)

Hawthorne Effect (Mayo)

Theory Y and X (McGregor

Employee Participation (Argyris)

Activities of Management (Gulick)

ASSIGNMENT Week 5: Thursday Reporting by Pair: LEADERSHIP THEORIES

The Great Man/ Trait Theory

Leadership Styles

Organizational Structure

Integrated Leader –Manager

Behavioral Theories

Situational and Contingency Leadership

Interactional Leadership

Transactional and Transformational Leadership

Quantum Leadership and Thought Leadership

Servant Leadership

Emotional Intelligence

Cultural Bridging

References:

Meleis, A.I. (2007). Theoretical Nursing Development and Progress. 4 th ed. Lippincott Williams and Wilkins. Philadelphia, PA.

McEwen, M., Wills, E. (2007). Theoretical Basis for Nursing. 2nd ed. Lippincott Williams and Wilkins. Philippine Edition.

Fawcett, J. (1995). Analysis and Evaluation of Conceptual Models of Nursing. 3 rd ed. Philadelphia. F.A. Davis Company.

Peterson , S., Bredow, T. (2009). Middle Range Theory. Application to Research . 2nd ed. Lippincott, williams, and Wilkins. Philadelphia, PA.

Tomey, A., Alligood, M. (2008). Nursing Theories and their Works. 6 th ed. El Sevier Singapore Pte Ltd. Singpaore.