Bonnie M. Wivell, MS, RN, CNS

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Chapter 13 Nursing Theory The Basis for
Professional Nursing

• Bonnie M. Wivell, MS, RN, CNS

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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

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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

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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

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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

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Definition of Terms Contd.

• 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

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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
  nurses 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

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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.
• Nurses 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)

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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 patients primary
  human requirements

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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
• Patients 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

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Dorothea Orem

• Concept of self-care
• Ordinary people in contemporary society want to
  be in control of their lives.
• Patients baseline ability to provide adequate
  self-care is assessed
• Systems of care
• Wholly compensatory
• Partially compensatory
• Supportive-educative

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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 patients
  involvement in setting goals (Goal Attainment
  Model)

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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 persons adaptive and coping
  abilities
• The environment can be manipulated by the RN to
  further patients adaptation

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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
• Patients 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

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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

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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 patients life

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Theory-Based Education

• PhD a research degree that generates new,
  discipline-specific knowledge
• Masters 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

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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

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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

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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

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Chapter 14 The Health Care Delivery System

• Bonnie M. Wivell, MS, RN, CNS

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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

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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

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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

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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

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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

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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 nations 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

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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

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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.

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Nurses 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 patients best interests at all
  times

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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 patients illness
• Patient-centered Care contemporary model
  focusing on patients rights to individualized
  care

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Financing Health Care

• In 2007 the nations 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
  individuals 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 cant delay care

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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 nursepatient ratios

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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
• Workers Compensation

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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

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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

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Nurses 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

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Change in Consumers 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

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Health Cares 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

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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

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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

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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

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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

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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