Nursing Theory???

[k123456]

Message deleted. No response necessary.

[kmchugh]

My .02:

When I studied nursing theory back in my undergrad program, I formulated my own theory about nursing theory. It is:

Nursing theory can generally fall into two classifications. The first are theories that are essentially restatements of known fact, intermingled with pretty prose, and statements of the obvious. The second (of which Martha Rogers is the leader) are theories that are so far out there, they either only apply in alternate universes, where the laws of physics as we know them are fundamentally different or they were written on a serious, week long acid trip.

Let us all face facts. As "theories," nursing "theories" hardly are on a par with, oh, say the "theory" of general relativity. Einstein developed his theory through long years of study and research, and the theory was founded on hard science, and was testable.

I graduated from my BSN program in 1996, and have since then, completed my Master's in Nurse Anesthesia, and have found nothing to change my mind. Essentially, I have found most nursing theory to be a desperate attempt to separate nursing from medical practice. There are, however, unfortunate downsides to this. The first is that as nurses have more nursing theory classes, there is less time for the real fundamentals of nursing (i.e. anatomy, physiology, pathophysiology, biochemistry, pharmacology, etc). Next, as we stray farther afield from the sciences (as listed above) on which we base our treatment of patients, we become less able to think critically about what we are doing, and why. Hence, we become a greater danger to our patients. An example: Where I live, a few years ago, a nurse read an order to give a patient a 10 mEq bolus of potassium. So, she took out the vial, drew up the 10 mEq, and gave it. Bolus. Over about five seconds. Fortunately, the patient had a few arrhythmias, and was otherwise fine. But, it could have ended much differently, like, in cardiac arrest. During the review of the incident, the nurse was questioned about why she did what she did, and her response was "I'm very busy. I don't have time to know about every drug I give." Certainly, that is not in keeping with accepted nursing practice. But, perhaps in her degree program, instead of teaching this nurse the theory of unitary human beings, we could have taught her electrolyte balance in the human body. Then she would have understood, at a physiological level, why she was being told to give a potassium bolus, and what the outcome could have been to her giving that bolus IV push.

As for nursing diagnoses, they are an extension of that pitiful attempt at validation. I know of no health care facility that actually uses them. They have no value. Particularly when we allow such nonsense as "energy field disturbance" into NANDA, for which the only approved "therapy" is therapeutic touch (another load, but this is getting long). Adequate proof that much of nursing has strayed way to far afield from the basic sciences that underlie what we do.

My advice is simple. If you want to be a nurse, go for it. I applaud you, and frankly, we need you. K123456, just remember thi. As you go through your nursing program, like any other program, you will learn things that are necessary, like the sciences I mentioned above. Study those hard, immediately put that knowledge into long term memory, and keep it fresh. There will be other things that are less useful. Don't ignore those things. One great value I found in nursing theory was a better understanding of nusing history. Knowing where your profession came from is always valuable. But, as you learn these things, think about them critically. As you perform in the clinical arena, ask yourself whether some of these things, such as theory and nursing diagnosis have any real application. Look at the nurses you find whom you admire, and see whether they use these things. You will find in nursing, as in many other things, there are areas that you can put in short term memory, get through the tests and the semester, then do a brain dump.

I have personally used my knowledge of physical science to benefit patients. As a nurse anesthetist, like most other advanced practice nurses, I put my knowledge of these sciences to work every day. Without this knowledge, I would be a severe danger to my patients. Nursing theory? Nursing diagnoses? They are good for a chuckle, and not much else.

One other quick point. Psych is not everyone's cup of tea. Its not mine, either. But, it IS valuable, in that even if you don't work on a psych unit, it gives you an understanding of why some people do what they do, and an ability to interact with your patients and their families in a manner that helps them. So, be careful. There will be things you may not enjoy in nursing school, but not enjoying them does not equate to their being useless. As a CRNA, I still use my lessons in basic psych nursing every day.

Kevin McHugh

[Q.]

Since the discussion seemed to have moved toward the nursing process in particular, I'd like to comment, seeing as I just wrote a paper on that very theory.

As I've stated, and Kevin stated, nursing theory, just like any theory, has it's useful ones and it's not so useful (and almost embarassing ones). But that is not to dismiss why having a theory or theories is important. Like Adrie, I too wasn't terribly concerned with them in undergrad, but speaking from a semi-experienced RN currently in grad school, I see things from a little different perspective. Oddly enough, my experience as an RN and my grad school education made me realize some of the problems with nursing today, and how we can fix it.

To Kevin's point, comparing the theory of relativity to nursing theory; a good nursing theory is indeed, testable. Most of the theories nurses learn and know about are the "grand theories" like Orem, Watson, and Rogers. "Grand theories" are considered more abstract and are therefore only testable indirectly through what's called "middle range theories" and those are theories spawned from the grand ones.

Here's an example. Kristen Swanson wrote and developed a theory on caring in perinatal nursing. Sounds obvious, doesn't it? And why would caring really be any different perinatally? Well don't let the title fool you. Swanson worked off of the seemingly "obvious" beliefs of Watson related to caring, and found patterns of behavior within patients who experienced miscarriage. Again, obvious? Sure..NOW. Was this obvious in Nightengale's era? No. So I think to dismiss most theories as "restating the obvious" might be a bit of an overstatement. They are obvious now because these theories are 46 years old. But SOMEONE needed to write them.

Anyway, back to Swanson. Her theory is used in the development and implementation of Resolve Through Sharing, a national based program that helps nurses help parents recover from perinatal loss. Resolve Through Sharing has had a very positive effect, from patient feedback, on coping with this kind of loss. So here, theory was useful in someone taking those concepts and making a useful,applicable program for nurses to use out of it.

There are more...but the point I am trying to make is that, to me anyway, theories can be generated from the top down, meaning, you have an academic who hasn't touched a patient in years or has no clue on current nursing issues write a theory and attempt to implement it in practice, or, you can generate from the bottom up (like Swanson and Orlando) who observed nurses and patients and studied behavior, to write a theory based on repeated patterns. I'd prefer the latter myself. But there are many instances where theory has shaped, and can continue to shape, nursing.

[Peeps Mcarthur]

Adrienurse,

I don't know if you were talking about something I wrote, but I want to be clear.

I don't think assessment skills are useless. I think that it is essential for a nurse to constantly use the five senses in collecting data, both when in contact with the patient and in comparison to reported data from the outgoing shift. Physical assessment is critical, it is what nurses do, but psychosocial assessment is useless.

Psychology is conected to patient behaviors. Patient behaviors are an important component of the tx course in the area of compliance. It is essential to have agreement and cooperation between patient and any caregiver, so psychology is necesscary, but not to the extent that it is taught in schools and utilized in forming nursing "diagnosis".

Nursing diagnosis should be used to teach an SN how to physicaly assess. That skill is at the top of the list when it comes to what the patient, the hospital, the doctor, the BON, really expect a nurse to be skilled in.

I really have to get to the books today. I'm enjoying talking to all of you and reading what you all think. I don't feel so alone now. Talking to nurses that believe theory and all the nonmedical stuff is useful gives me a chance to tell somebody what I really think. Until someone can articulate thier thoughts in contrast to an opposing view it's all just frustration.

I hope everyone will continue this unusualy civil discussion. I'm enjoying how we're making our responses to eachother even more than making my own oppinions known.

:)

[adrienurse, LPN]

Peeps, its alright. You want to see psychosocial assessment, I'll take you to work with me one day. I couldn't do my job without it.

[WashYaHands]

I think understanding and applying theoretical concepts is difficult and confusing unless you've practiced as a nurse and have that as a base to apply theory. Using an analogy of music. You learn to play the instrument and read the music before you can apply music theory. In my undergrad program I didn't fully understand theory and it's applicability either. As Adriene said, once I had some experience and went back to study it again with a different perspective, it makes more sense to me. Do I agree with every nursing theory developed? No, but some make more sense to me than others.

In reference to psychosocial assessment, I think it is an important component of the whole patient assessment. A few examples that come to mind are the 30 year old brain injury or stroke patient who loses bowel and bladder control. The fact that he has to wear an attends and I have to assist him with his elimination function as a result of a medical condition is certainly going to effect him psychosocially. Here's another scenario......you take report on a female patient at 7:00 am, her admitting diagnosis is lyme disease. The doctor comes in at 7:05 am and explains to the lady that they unexpectedly found another problem, she's been diagnosed with breast cancer, he leaves and she's alone. You'll do your physical assessment, but you are her nurse and you'll need to be prepared for some psychosocial aspects of that medical diagnosis during your shift. Nursing is more than a medical diagnosis, nursing is caring for a person in their wholeness, all body systems, including the mind. Science and Art....2 equally important aspects of nursing.

I don't expect everyone to agree with me, but this is my nursing style. Everyone has their own.

Linda

[Peeps Mcarthur]

The patients you describe may have psychological needs, so what are you going to use psychosocial theory for?

What would be some actions you would take that would be unique to nursing diagnosis that would preclude the need for psych consult?

In other words, why use nursing DX when there is already a medical way of treating these possible roadblocks to the acceptance stage?

See, now I said I was studying and I just couldn't help clicking over.

[Q.]

Originally posted by Peeps Mcarthur

The patients you describe may have psychological needs, so what are you going to use psychosocial theory for?

Swanson's caring in perinatal nursing is completely psychologically based. As I've stated, Resolve Through Sharing is a way of implementing it.

Also Peeps, the patients WashYaHands described will, not may, have those needs. To address them and utilize theories that have studied women's responses to losing a breast will make you more likely to actually help her through all her needs, rather than assuming you know what to say.

Your other question, why bother using nursing dx when you have a perfectly legit MEDICAL way of treating her; well...to the recently dx breast CA patient, or the patient who suffers perinatal loss...do you really think they need therapy? Or antidepressants? Not necessarily. Sometimes just understanding, as best as possible, their situation is enough therapy they need, rather than referring them to yet another physician who will really only serve to increase their medical bills.

[WashYaHands]

Nursing diagnosis and nursing theory are not the same. Learning nursing diagnosis and the nursing process in school is a systematic tool used to help students learn to think in a systematic and critical way. Those lengthly care plans and NANDA diagnosis teach students a thinking process...over and over and over, so when you're done, this "way of thinking" will become second nature. Eventually, this thought process will occur moreso in your mind than on paper. That would be Patricia Benner's theory called Novice to Expert.

To answer your question, Peeps, using my example, an action that I would take with the BC patient would depend on her needs at that moment. She may have questions that I could answer for her, she may just want to vent anger, she may cry, we may both sit there in silence and say nothing, but having someone present with her validating her feelings may be what she needs. It depends on the assessment. Grieving is not a psychological disorder, so a psych consult probably wouldn't be appropriate at this point. There is a theory that would support this type of nursing interaction --- Wiedenbach, The Helping Art of Clinical Nursing.

You mention the acceptance stage, which is based on Kubler-Ross Stages of Grief.. a theory, not necessarily a nursing theory, but a theory based on practice. We are not always cognitively aware that we use theories, but we do.

Linda

[Peeps Mcarthur]

Grieving is a psych disorder if they are ineffectual in the process isn't it?. If they were not stuck at some point in the process, then they would be coping and following a normal course all by themselves. How did people get well before nurses became quasi-psychologists?

The theory of grieving is what I was referring to. How nice that we have some common ground. Perhapse that could be used to be put into a nursing diagnosis, but it is not a nursing theory. It is quite clear in its statement and can be used to give a pt foresight into the process but not if they are dysfunctional or unwilling. Diagnosing and treating a psychological pathology or dysfunction is a job for a specialist. Observing the need for the specialist is the nurses realm I think, but certainly not a priority.

Perinatal nursing?.....................:chuckle That's all yours. I won't be fighting for a seat on that bus! Homeostatic levels of a woman's hormones are disturbing enough thank you.:kiss

Now I've been writting care plans for 4 months, so I'm no expert or anything, but they go so far out of the medical framework as to make it difficult to see the point, since the plan is to come back to the medical track at discharge and take credit for it.

I can't see why we can't just say COPD instead of quite a few Nursing DX that try to butt in and make it look original..................like/insufficiant clearance of secretions(very vague) insufficient ventillation(hallmark of COPD, but still many differentials). It seems that nursing DX..........this is just me, seems kind of simplistic to be teaching preprofessionals how to assess potentialy serious pathophysiologies, pathopsychology, and lumping them all into psychosocial disorders.

With practicly no medical training whatsoever and being encouraged not to use medical DX in one's thinking to boot.

[Q.]

Peeps,

You sound so...discouraged with nursing, and it seems almost like something that can't be fixed. I agree that it would seem somewhat "easier" per se to use COPD instead of "insuffcient clearance of secretions" however, as a nurse, we can't diagnose a patient medically. We don't have the knowledge or training to do so.

I can't quite explain this very well in such a format as this; this is one of those discussions best had in person. I will say, however, that discussing this here is challenging to me. Being immersed in this way of thinking, and now having the challenge of explaining it to you, a nursing student, is great mental exercise for me. That is not meant to be derogatory by any means . I mean that in the best way possible.

The only way I can describe this is what Linda (WashYaHands) stated. The nursing process and nursing dx are not theories. And nsg dx are not really used in practice much; they are a basis for novice nurses to organize thoughts and prioritize.

Yes, grieving can turn pathological, but chances are at the point in the scenario above with the breast CA patient, there isn't much time for it to BECOME a pathology enough to warrant a referral or medication. As a nurse, you can possibly help her avoid it becoming a pathology.

It seems that you are disenchanted with the wholistic view that nursing holds and that your focus is much more medically based. The only thing perhaps I can offer is maybe nursing isn't for you. Nursing works in concert with medicine; it is not medicine, though. It almost sounds as if you should've gone to medical school or PA school. I don't know, Peeps, but it just sounds as if you really weren't sure what nursing was when you entered.

[Peeps Mcarthur]

Suzy,

I really did know what nursing was about before I went to nursing school. The problem I'm having is that I never would have imagined the nurses that I knew could come from such a curicculum, and now I feel trapped. I saw nurses taking vitals, conferring with doctors, reading rythms and treating arrythmias, recommending holding meds based on labs, that kind of stuff. I never overheard them talking about or witnessed anything in 5 years of observing thier duties that would lead me to believe that they had anything less than a premedical degree. I guess they just learned medicine on the job because , as we can agree, they did not learn it in school. I guess the reason they talked about how hard learning the drug cards was and pathophysiology, was because they felt more comfortable with communication and psychology, psychosocial developmental................stuff.

I think we can say that nursing is still very femminine. I think you would find that psychology, human development, therapeutic communication/touch, are subjects that would peak interest in your average female. I know there are men that make fine nurses, but I think you'll find that women will excel at these subjects more often than men if both samples are random.

I think you are right about not being a good fit for nursing. There are few reasons for me to persue a degree in psychosocial psychology, I haven't quit on it because I have seen what a real nurse does and I wonder why the programs have strayed so far. There must be some patho, pharm, or something resembling what I've seen.

I don't think you were talking down to me. We will both have a hard time presenting our points of view from two such far away places. I think I am not willing to deeply understand something that seems so impractical to physical science and you are perhapse too imersed, as you say, in it to be able to see it any other way.

If I thought for a second that I could stand 5 years without a real paycheck, I would be in a PA program tommorow. I have no doubt that I would excel at the medical model(I'm too old for med school). I daydream about it all the time. I even think in a whole different world from my peers. I cannot discuss any of my ideas, even with my instructor. She just crinkles her brow, her mind racing for a solution that will make me believe that she knows the answer but just forgot. Maybe she doesn't know what "refractory to thiazides" means because she works in a diferrent mind-set than I do.

I think knowing Furosemide(I refuse to make using trade names habit) being refractory to thiazides is important, but I don't think using trade names or knowing those kinds of things about drugs and other medical facts is important to academic nurses.

I wonder if I had asked that of those nurses back when I was an RT, if they would have known.

[Roland]

nursing or medical model. The goal of a Dr. or Nurse is (or should be) to facilitate the recovery of their patients. Everything has a definitive answer even when we cannot absolutely ASCERTAIN that answer (perhaps Hesenburg would spin in his grave but even the exact location and speed of an electron does have a solution, it's just that we cannot measure one property without distorting the other). Thus, our task as professionals is to use SCIENCE in order to elucidate to the best of our abilities exactly WHAT the best interventions are for our patients. In addition, if we are to proclaim an intervention as beneficial we must document according to the scientific method how it is so.

There is not a "gray" area here except with regard to what is and what is not helpful. Thus, both doctors and nurses would agree that antibiotics are often helpful to patients suffering from infection because their efficacy has been demonstrated beyond dispute. Now if nurses wish to proclaim an intervention as beneficial to a patient (I avoid the term medical because to me it is simply not relevent) such as massage therapy perhaps, it is incumbent upon them to demonstrate this fact in a scientific fashion. We have seen many "alternative" therapies such as acupuncture gain greater acceptence in this manner. However, it has only been AFTER their efficacy has been scientifically proved and explained.