Nursing Theory: Did we throw the baby out with the bathwater?

[james2309]

Hi fellow nurses. I'm a Clinical Nurse Educator (CNE) in Mental Health in a major Australian hospital in Melbourne. For many years now I have felt frustrated by what seems to me to be a loss of direction for nurses. I completed my degree course in New Zealand around the year 2000 and was taught about several different nursing theories/models (the terms seem to be faily interchangeable for the most part...) Peplau was the most significant for the mental health nurses (of course), but there were Orem's Self-Care Deficit, there was Callista Roy, Jean Watson, Newman, Neuman, Leininger, Erikson - so the list goes on.

There's a lot of talk about Evidence Based Practice, these days. But I'm wondering, how do we instil the value of this in our nursing colleagues, especially the beginner practitioners, if we don't give them somewhere to ground their practice? Maybe I'm getting it wrong, but it seems to me if you're not basing (aka grounding) your practice in a nursing model, then you're practising medical model, by default!

I'm wondering how others feel? Is it just me that feels this loss? Do we need to bring some sense of ownership of our nursing practice back? If not, how do we regain and retain our professionalism and sense of who we are and what we do as nurses, if we can't articulate this in some form of framework or structure? Why has it disappeared? What have we replaced it with (if anything) and is this working?

Please share your thoughts and feelings on this subject. Sometimes I feel like a lost voice in the wilderness and wonder if there's some giant factor that I'm completely missing...???

James

[ukstudent]

@ UKstudent: I'm not going to slam you - I hope nobody will, eveyone's entitled to their opinion - which is what's so great about these forums... But I'm not sure where you're looking to see nurses (or nursing) hating themselves (itself) - I certainly don't see it in my area of clinical practice. And to acknowledge that you might be speaking metaphorically, to me the idea that we are advancing the practice of nursing through academia is evidence that we ARE loving ourselves and our practice. Let me put it this way... If you were accused of murder and your freedom and total liberty were in the hands of a legal representative, wouldn't you want the best qualified, most experienced person you could possibly get your hands on (and afford) arguing your case and defending your rights? If you needed heart or brain surgery wouldn't you want the best qualified, most experienced person handling the scalpel? If your car needed major work and it was make or break - you might be up for a new one if you can't fix it - wouldn't you want the best qualified, most experienced mechanic (that you could afford

:->) doing the repairs? I'm going to assume you answered yes to these questions and so my next question is this, why is nursing any different? I don't see my extra learning, my additional qualifications or my drive to improve and enhance my skills as taking me away from basic patient care. I see it more as improving my skills so that I can do the basic care much more easily and include ADVANCED patient care - thus improving the overall health outcomes for the person (people) I'm looking after.

I say nursing hates itself because since I have been alive the ANA has had as a position that LPN's and ADN's should not be considered nurses. And now that there are so many direct entry MSN programs around maybe even a BSN is not good enough to be considered a nurse. Now they don't want to do the work that LPN's do, they just don't want them to be allowed to cal themselves nurses. Well they are nurses, they are more of a nurse than someone that has sat in a office for the last 20 years and has not touched a pt since.

You asked if I would want the most qualified and experienced nurse looking after me if I were sick. As I work in a Level 1 trauma center in as a surgical ICU nurse we do very advanced nursing care. Now if I was a pt in my ICU would I want a nurse that,

1) is an ACNP but had not done bedside care for 10 years - No

2) a fresh out of school MSN - No

3) an ASN with several years of direct SICU care current in knowing how to monitor and use RVADS, LVADS, Balloon pumps, CRRT, etc - Yes

4) is a diploma grad that has worked in the ICU for the last 20 years - Yes

You want to know why nursing is different from Lawyers, Doctors, Mechanics. It's different because as students go to school to become a lawyer they are not bombarded with the talk that if the stay a lawyer they are are somehow a failure, that they need to go on and become judges. Student doctors are not bombarded with the idea that being a practicing doctor is beneath them, that they need to all go into research. Student mechanics are not bombarded with the idea that having grease beneath there nails is too lowering, that they need to all become garage owners and get to the office level. They all except what they are, nursing does not.

Now if I was a pt in a nursing home I would want that experienced LPN, the one that would notice the subtle signs of me getting in trouble and needing to go to a hospital. In other words a good bedside nurse.

[MissBrahmsRN]

amen UK student!!

i've been out of school around a year and what i get are people (fellow nurses among them) asking me "so when are you gonna grow up and get the job you want?" um, this is the job i want. this is the job i went to school for. it's tough, messy smelly but i love it. i love hanging IVs, messing with the pumps, holding someone's hand the night before that surgery, explaining what the med i'm giving them does, helping with turns, seeing 2 & 2 add up and paging the doc because i can see them beginning to circle the drain. i'm a bedside nurse through and through.

my dad once told me: "managers are a dime a dozen" why do i want to be a manager? my manager is nice enough but frankly she hardly uses her RN. the stuff she does she could do at many other companies, nonmedical ones. it's all payroll, budget, supply.. yet she is praised for being a "good nurse" while the bedside nurses are asked, "when are you gonna grow up?"

[RNperdiem, RN]

Nursing theory. There are a few true believers,but lots more of non-believers and agnostics on nursing theory out there.

Reaching them is not always possible.

[INLPN93]

I say nursing hates itself because since I have been alive the ANA has had as a position that LPN's and ADN's should not be considered nurses. And now that there are so many direct entry MSN programs around maybe even a BSN is not good enough to be considered a nurse. Now they don't want to do the work that LPN's do, they just don't want them to be allowed to cal themselves nurses. Well they are nurses, they are more of a nurse than someone that has sat in a office for the last 20 years and has not touched a pt since.

You asked if I would want the most qualified and experienced nurse looking after me if I were sick. As I work in a Level 1 trauma center in as a surgical ICU nurse we do very advanced nursing care. Now if I was a pt in my ICU would I want a nurse that,

1) is an ACNP but had not done bedside care for 10 years - No

2) a fresh out of school MSN - No

3) an ASN with several years of direct SICU care current in knowing how to monitor and use RVADS, LVADS, Balloon pumps, CRRT, etc - Yes

4) is a diploma grad that has worked in the ICU for the last 20 years - Yes

You want to know why nursing is different from Lawyers, Doctors, Mechanics. It's different because as students go to school to become a lawyer they are not bombarded with the talk that if the stay a lawyer they are are somehow a failure, that they need to go on and become judges. Student doctors are not bombarded with the idea that being a practicing doctor is beneath them, that they need to all go into research. Student mechanics are not bombarded with the idea that having grease beneath there nails is too lowering, that they need to all become garage owners and get to the office level. They all except what they are, nursing does not.

Now if I was a pt in a nursing home I would want that experienced LPN, the one that would notice the subtle signs of me getting in trouble and needing to go to a hospital. In other words a good bedside nurse.

:yeah::yeah::yeah::yeah::yeah:

I wish I could give this more than one kudos!!!!

AMEN.

Thank You from the bottom of a LPNs heart :redpinkhe

[netglow, ASN, RN]

Nursing theory. There are a few true believers,but lots more of non-believers and agnostics on nursing theory out there.

Reaching them is not always possible.

What an insightful comment!

For me all that stuff is just the "politically correct BS" game I might play only if it looks like it's required for me to get something I want.

I've said often that I am a part of a medical team, my role is a nurse on that team. I follow clinical pathways that the team constructs and also follows.

[BluegrassRN]

Nursing theory is such absolute crap. Most of it is worthless, unimaginative drivel. Theorist seem to have their masters degrees in the bloody obvious, and their PhDs in "let's see if I can rephrase this old, common knowledge with new words, some of which I made up, and call it a doctoral dissertation *and* a new theory!"

I am so disgusted by nursing theory, and how much time and useless energy is spent on it in schools, that if I go back to get a degree for advanced practice, I'm going to PA school.

[ZippyGBR, BSN, RN]

one of the problems is that nursing theories are sold as a cre-all for all the problems that the author percieves with Nursing care in that location at that time,

All the nursing models have situations which they applicable into , part of the Art of nursing is knowing which model and when - no one model suits every nurses and every patient, the best model of care for a patient also depends on their presenting condition and in enduring and relapsing - remitting conditions what part of the 'journey' they are at ...

In my recently adopted speciality of Spinal Cord Injury Nursing the model of care you use with a 'fresh' acute injury I very different to the model of care you'd use with the same patient 3 - 6 months down the line when the acute injury is old news and teheir current needs are around maximising they ability to self care and function outside of the in-patient environment.

As for the medical model , some specialities are very poor at the holistic view of the patient an d rely on the Nursing team to provide this ( e.g. the old joke about the definition of 'holistic orthopaedics being treating the whole bone ) , but there is no need to swerve around common terminology which many nursing models and NANDA seems to take great pleasure in ...

[james2309]

quote]

i say nursing hates itself because since i have been alive the ana has had as a position that lpn's and adn's should not be considered nurses. and now that there are so many direct entry msn programs around maybe even a bsn is not good enough to be considered a nurse. now they don't want to do the work that lpn's do, they just don't want them to be allowed to cal themselves nurses. well they are nurses, they are more of a nurse than someone that has sat in a office for the last 20 years and has not touched a pt since.

i guess i can't comment on this, since i live and work in australia, i'm not that familiar with terms such as ana, lpn, adn etc...

you asked if i would want the most qualified and experienced nurse looking after me if i were sick. as i work in a level 1 trauma center in as a surgical icu nurse we do very advanced nursing care. now if i was a pt in my icu would i want a nurse that,

1) is an acnp but had not done bedside care for 10 years - no - clearly there is a difference between nurses who stay on the floor and nurses who head to management and have no experience - here in australia we have an expectation that in any nursing role, we keep our practice current and no nurse is allowed to stay registered without doing a minimum amount of clinical work every year - so this would never happen

2) a fresh out of school msn - no - kinda obvious, fresh out of school lawyers, doctors and mechanics aren't that popular either because of the potential for errors!

3) an asn with several years of direct sicu care current in knowing how to monitor and use rvads, lvads, balloon pumps, crrt, etc - yes

4) is a diploma grad that has worked in the icu for the last 20 years - yes

you want to know why nursing is different from lawyers, doctors, mechanics. it's different because as students go to school to become a lawyer they are not bombarded with the talk that if the stay a lawyer they are are somehow a failure - i'm sad that you've had this experience, but here in australia we have developed and officially scoped and sanctioned the role of nurse practitioner to deal with the need to keep senior nurses on the floor, that they need to go on and become judges - i think a major difference in the analogy here is that good lawyers can earn s***loads of money by staying lawyers, whereas nurses cannot, but do you not think they aspire to owning the company? why are they so keen to become partners? so they can determine their own futures!. student doctors are not bombarded with the idea that being a practicing doctor is beneath them, that they need to all go into research - i think you're missing my point - i'm not advocating that all nurses need to become managers or academics - simply that there are some very clever and informed nurses who have developed structure and framework to 'hang' our practice on - just saying that "we do what we do because we do" is nonsensical. student mechanics are not bombarded with the idea that having grease beneath there nails is too lowering, that they need to all become garage owners and get to the office level - again, do you seriously believe that all good mechanics really want to stay just doing the job for someone else and being paid wages????? that mechanics don't dream of being their own boss, owning the company one day? it seems to me that you're deliberately missing the point. they all except what they are, nursing does not. i dispute this. in my experience nursing does accept what it is - that does not mean that we shouldn't be constantly striving to improve our standing, raise our standards and be better at what we do... and taking our practice into the realm of academia and continuing to improve our hands-on clinical skills is evidence that so many nurses do really love what they do!

now if i was a pt in a nursing home i would want that experienced lpn, the one that would notice the subtle signs of me getting in trouble and needing to go to a hospital. in other words a good bedside nurse.i agree with this comment wholeheartedly - but that doesn't mean that a good bedside nurse should remain ignorant of what current research is telling us... without research and without people committed to searching for new knowledge, we'd still be holding people down, with a face full of ether while we saw their gangrenous legs off... good bedside nursing by itself can't lessen this pain...

[james2309]

i agree, ukstudent has expressed to a t many of my opinions about the way nursing is going....

i think that, in order to become a nurse, you first need to have some desire to serve your fellow human beings; there are many threads about "nurses who are only in it for the money", and to that you can add status. i have no problem with nurses being paid highly for their services, or the almost-awe with which nurses are viewed, at least in my country; but i do have a problem with nurses who regard basic care as being beneath them, and who regard patients as being nuisances.

science is an inextricable part of nursing. without knowledge of disease processes and developments in treatment of disease, the nurse is not equipped to function as the central point of the health care team-the interface between the patient and the other disciplines involved. however, nurses should always remember that their profession is also a humanity.

the bulk of patient care is basic care. once nurses forget that simple fact, they are in danger of losing the spirit of nursing. once the spirit is gone, only the science remains, and the art of nursing is lost. i agree wholeheartedly with this final statement but believe that inherent in the art of nursing is the constant search to improve the quality of that basic care, which is frequently compromised by the limitations of finances - but this is a political issue, not new, and will never go away... and i believe the understanding and application of a specific nursing theory helps me hone and improve my practice...

[GHGoonette, BSN, RN]

i agree wholeheartedly with this final statement but believe that inherent in the art of nursing is the constant search to improve the quality of that basic care, which is frequently compromised by the limitations of finances - but this is a political issue, not new, and will never go away... and i believe the understanding and application of a specific nursing theory helps me hone and improve my practice...

a comment i made in another thread refers to nursing theory application as "something we do automatically without even thinking about it." when i first did nursing in the 1970s, i didn't do any "nursing theory", and the "nursing process" had not yet been developed. these were concepts that i only learned about in the 80s, which is when i finally returned to the profession and completed my training. however, i did a diploma course, which, as you will remember, consisted predominantly of "hands on" training, so students not only learned nursing theory at college, but saw the theories applied during patient care. thus, as the training progresses, the "recognition of nursing needs" and the "nursing diagnosis", resulting in the appropriate action being taken, becomes second nature.

you refer to political and financial limitations. to me, the most disturbing of these is the trend to employ "cheap" caregivers or aides to perform basic care, which previously fell into the category of "nursing". allied to that is the movement away from training enrolled nurses/lpns. reading many posts on this forum, it would appear that cnas are not regarded as "nurses", and lpns will eventually not be referred to as "nurses" either. in fact, only rns or higher will be entitled to refer to themselves as such. so if rns "don't go to nursing school for 3 years (or more) to learn how to wipe butts", which category of health care worker will be designated to perform such tasks? and how trained will they be to observe and deduce while performing such care? to what extent are we prepared to allow the politicians and economists to take us away from the bedside? if this trend continues, the art of nursing will truly be lost.

this post https://allnurses.com/general-nursing-discussion/new-style-education-528223.html illustrates exactly the problems being created by politicians and administrators... and the means to combat them (thanks, eriksoln!) if we as nurses, and the councils and boards which govern our profession, don't start fighting back, the art of patient care will be buried under a mass of paperwork, the spirit will be crushed, and the science will become irrelevant-because nurses won't be there to observe and care for their patients....

[lxpatterson]

I think this thread has kind of derailed...But the main point that is being made is the feeling that nursing theory is really about promoting the profession rather than being especially helpful for bedside practice; to promote nurses to partake in roles more "advanced" than bedside care.

As an accelerated second-degree BSN student, I can see where that is coming from what I've read, many of the theorists like Porifice or Rogers never did actual clinical work. I have not spoken to any classmates who are interested in nursing theory or would consider doing research based on theory. In fact, most of us mock these theorists as weird hippies or women who trained as nurses when really they should have been philosophy or humanities academics. These theories are then exploited by nursing associations and colleges to promote autonomy and increase the profile of the nursing profession. Of course, we students don't mind that part, since it means better pay and more opportunities for us...but we don't lose sight of the fact that it's all just part of the game. And that's exactly how we treat our theory courses in school: it's all part of the nursing school game and we play it to get an A (especially with those super-earnest nursing theory profs).

Of course I'm ashamed to tell my doc friends about nursing theory courses, and sometimes I will read an especially incomprehensible Porifice sentence to my non-healthcare friends for a laugh. But I think it is helpful in that it makes us realize that nursing is a diverse practice with all sorts of people in it. I guess it makes a person more tolerant to how weird people are. Like for instance, if I see a colleague practicing therapeutic touch (based on Rogerian energy fields), I can rest assured that this old hippy dippy nurse will likely retire in a couple of years.

Which brings me to my last point, which is that I don't think this all this theory ******** will last. I can tell that the younger nursing faculty spout that crap just to play the game and it's only the older ones who are really militant about theory. Most of my classmates, and myself, got into nursing to practice, whether as an administrator, NP or bedside nurse. Without young blood to perpetuate nursing theory, I think it will die within the next 10-20 years...good riddance!

[MunoRN, RN]

... and I believe the understanding and application of a specific nursing theory helps me hone and improve my practice...

I've never seen the light when it comes to Nursing theory, although it's great that you get some benefit from them, can you give some examples of how your practice has been effected by Nursing theory?

For me it's hard to critique Nursing theory because it's hard to evaluate the effectiveness of something when you don't even understand it's purpose in the first place. Nursing theory supposedly helps to define Nursing as the independent profession that it is, which makes no sense since it is not an independent profession; never will be, and we need to learn to be OK with that.

Second, it's not "theory", it's philosophy/ideology/priniciples/values/etc, but it's not theory. As a group with some connection to Science let's have some respect for the term "theory" and use it appropriately. I realize the term gets muddled by folks like Freud, although Freud was in no way a scientist. We should hold ourselves to a higher standard.

If Nursing theory is supposed to help define Nursing for those outside of Nursing, I don't think that a thesis project that appears to have been written while on way too much acid that completely fails to capture that majority of what Nurses do accurately is the best way sell ourselves to the Public.