Theory-Guided Practice 1,050- to 1,225 word paper APAf ormat

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Theory-Guided Practice

Use the six criteria from this week's readings from Fundamentals of Nursing Models, Theories, and Practice as a guide for this assignment. If you need to review the criteria, click the Presentation tab for a link to Fundamentals of Nursing Models, Theories, and Practice.

Select a practice/clinical setting.

Use the following six criteria to select a theory appropriate for the setting you chose:

• Clinical setting

• Origin of the theory

• Paradigms as a basis for choice

• Simplicity

• Patient's needs

• Understandability

Explain what practice or clinical setting you chose, how the six criteria helped you choose, and why the selected theory is well suited to it.

Cite a minimum of two sources in text and include a page or slide with APA-formatted references.

Format your assignment as one of the following:

• 1,050- to 1,225-word paper

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Theory-Guided Practice Use the six criteria from this week's readings from Fundamentals of Nursing Models, Theories, and Practice as a guide for this assignment. If you need to review the criteria, click the Presentation tab for a link to Fundamentals of Nursing Models, Theories, and Practice. Select a practice/clinical setting. Use the following six criteria to select a theory appropriate for the setting you chose: • • • • • • Clinical setting Origin of the theory Paradigms as a basis for choice Simplicity Patient's needs Understandability Explain what practice or clinical setting you chose, how the six criteria helped you choose, and why the selected theory is well suited to it. Cite a minimum of two sources in text and include a page or slide with APA-formatted references. Format your assignment as one of the following: • 1,050- to 1,225-word paper 7 How to select a suitable model or theory Fundamentals of Nursing Models, Theories and Practice, Second Edition. Hugh P. McKenna, Majda Pajnkihar and Fiona A. Murphy. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website: Outline of content Imagine you are a clinical nurse who has been asked by her unit manager to select a suitable theory for application in the unit. Your immediate thought is that it is a great honour to be asked to do this and you set about the task with enthusiasm. You soon discover that there are around 50 grand nursing theories and almost as many mid-range nursing theories. How do you decide which one to choose? This chapter will help you do this. It will start off by describing how the selection process was done in the UK. It will then progress to identifying criteria that you could use to select an appropriate nursing theory. Along the way, it will deal with the problems you might come across and how the process will be viewed by other nurses and health professionals. Learning outcomes At the end of this chapter you should be able to: • • • • • • • 1. Describe how nursing theories were introduced in clinical settings 2. Outline the 12 potential problems when selecting a nursing theory 3. Understand the roles of grand and mid-range theories in theory selection 4. Identify the criteria used to select a suitable theory 5. Discuss the role of the metaparadigm in theory selection 6. Understand who are the best people to select a theory for practice 7. Explain the advantages and disadvantages of borrowed theory. Introduction You will recall from Chapter 1 that we all use theories in our daily life, either knowingly or unknowingly. Our conversations will be underpinned by communication theories or interpersonal theories. Our choice of what to purchase in a shop may be influenced by financial theory or decision theory. Even when climbing a ladder or boarding a plane, we will take account of the theory of gravity! It is surprising, then, that UK nurses in the late 20th century did not accept nursing theories more readily. With hindsight, it is perhaps not surprising; after all, they were mainly imposed on practising nurses by nurse educators and nurse managers. Nursing theories (at that time they were mostly called nursing models) were the new fashion to hit UK nursing; there were dozens of books written about them, and most nursing journals and professional magazines published articles about them (see Key Concepts 7.1). Being so popular, they were obviously perceived as good. Invariably, clinical settings were perceived as not being up to date unless the nurses were using a nursing theory to guide their practice. If the hospital in the next town was using one, we were behind the times if we weren’t doing so. Nurse managers returned from nursing theory conferences loaded down with templates of care plans for one theory or another. Key Concepts 7.1 Nursing theories: assist nurses in using the nursing process to assess needs, plan care, intervene and evaluate the outcomes of care In addition, and several years previously, the ‘nursing process’ had been introduced. By all accounts, it too was the great saviour for patient care. It seemed simple enough: you assessed your patient’s needs, planned the care, implemented the care plan and evaluated whether the patient’s need had been met. But for some reason it, too, was having difficulty taking root in most clinical settings. Then the proponents of nursing theories spotted what was wrong. In order to make the nursing process work, a theory was required to give it structure. In fact, it had been argued that the implementation of the nursing process without a theory to underpin it was an empty approach, often described as ‘practising in the dark’ (Aggleton and Chalmers 2000: 22). As a result, nursing theories were perceived as the saviour of good care planning and they were imposed uncritically onto hard-pressed clinical nurses. Reflective Exercise 7.1: Change If you wish to change someone’s behaviour, you need to change their beliefs and attitudes. Otherwise they will not enthusiastically adopt a new way of working. Consider how you would implement a new evidence-based procedure to change the way nurses in a clinical setting practised. How would you approach the problem? You will get some ideas if you read the seminal work of Everett M. Rogers (1962), The Diffusion of Innovations. See also and Innovations. It was not unusual for clinical nurses to be informed by managers that they were to introduce a nursing theory to guide their practice by the following week. A common motive for imposing a theory on an unsuspecting workforce was that nurse teachers in the local school of nursing were teaching the specific theory to their students or it underpinned the curriculum. Clinical nurses soon realised that if they were going to have to use nursing theories, it would be better if they could select one that was appropriate for their type of clinical setting. Selecting an appropriate nursing theory It is surprising that the choice of a nursing theory took little account of patient needs and views or the clinical specialism (see Reflective Exercise 7.2). You will recall from the previous chapter that the theories selected most often had more than a passing resemblance to the biomedical model. For instance, Henderson’s (1966) and Roper et al.’s (2000) theories were the most popular choices. This was the case regardless whether the patient population comprised people with mental health problems, women in labour, sick children or older people. Peter Wimpenny (2002) rightfully criticised this, pointing to the advantage in matching particular theories to particular clinical specialities. After all, he argued, different theories had been developed from particular experiential perspectives. Reflective Exercise 7.2 It is interesting that nurses did not involve patients or patient pressure groups in the selection of nursing theories. Think about this and try to understand why. Your answer may reflect the fact that this was the 1980s and 1990s. Why? McKenna and Slevin (2008) noted that there were over 50 grand theories of nursing and a growing number of mid-range theories. Since assessments of patient need, planning care, interventions and evaluation of care differ depending on what nursing theory is being used, a new awareness exists as to the necessity of making the right choice. The alternative is to have a nursing theory that moulds practice to fit it, rather than the other way around. However, there is a dearth of research evidence available to help practising nurses decide which theory is best suited for which clinical speciality. For instance, in a psychiatric unit, where the development of interpersonal relationships is important, would Peplau’s theory (1992) be most appropriate? But the theories of Orlando (1961), Travelbee (1966), King (1968), Wiedenbach (1964) and Paterson and Zderad (1976) also focus on interpersonal relationships. As a result, choosing the most relevant theory is a daunting task and must be carried out with care. You will recall from Chapter 3 that grand theories are broad conceptualisations of a discipline. In nursing, they deal with everything from self-care to adaptation, and nurse-patient interaction to activities of daily living. It could be argued that grand theories are so all-encompassing in their scope, they should be applicable in any setting where nursing is taking place. For instance, Orem’s self-care theory (Denyes et al. 2001) could be used in any setting where the patients were being encouraged to be independent. This would give it wide applicability. So, is sorting through theories to find a suitable one a waste of your valuable time? Barbara Stevens Barnum (2006) did not think so; she asserted that there was a need to employ different theories to suit different patient settings. We would concur with this view and argue that the choice of one theory for application throughout a hospital is imprudent and perhaps even dangerous. Should patients and staff have to put up with a theory that has a less desirable ‘fit’ for the sake of conformity to management or educational dictates? Fitting the patient’s problems to a theory rather than the theory fitting the patient’s problems is a foolish and labour-intensive exercise. As stated many times in this book, grand theories are broad frameworks and are often well recognised and publicised (e.g. self-care, adaptation, activities of living etc.). By contrast, mid-range theories are those that have more limited scope and less abstraction, address specific phenomena or concepts and reflect best practice (see Key Concepts 7.2). Invariably, they are based on evidence that emerges out of research studies. Examples of mid-range theories were given in Chapter 3. Others include mid-range theories of information-seeking behaviour of newly diagnosed cancer patients (McCaughan and McKenna 2007), comfort (Kolcaba 2001), quality caring (Duffy 2008) and self-transcendence (Runquist and Reed 2007). You should refer back to Chapter 3 if you need to update yourself on the difference between grand and mid-range theories. However, regardless of whether we are dealing with grand or mid-range theories, we believe that there are 11 potential problems to acknowledge when selecting an appropriate one for your practice. Some of these reflect the limitations of theory outlined in Table 5.2 (p. 004). Key Concepts 7.2 Grand theories: broad frameworks that may be widely applicable Mid-range theories: these are very specific and are appropriate for a more focused area of care Potential problems when selecting a nursing theory American or UK nursing theories? • England and America are two countries separated by a common language. (George Bernard Shaw, 1856-1950) Although Florence Nightingale (1859) can be credited with being the first nurse theorist, most modern nurse theorists are based in the United States (see Reflective Exercise 7.3). A question has been posed as to whether their nursing theories are transferable to nursing practice in the Europe (Cutcliffe et al. 2009). There is nothing wrong with nurses from different countries exchanging ideas, but the application of one group’s practices to another group may not always be appropriate. After all, as has been pointed out in earlier chapters, the UK has a different health care system from the US, a different nurse education system and a different culture (see Key Concepts 7.3). Therefore, it is understandable that American theories may not always be the best choice for nursing care in other parts of the world. If nurses in different countries continually look towards the America for conceptual guidance, any selected theory will have to be manipulated so as to fit their health services. Of the 50 or so well-known grand nursing theories, about 12 were formulated in the UK. By far the most popular of these is that of Roper et al. (Holland et al. 2008). Reflective Exercise 7.3: Why America? It is a truism that even though the first nursing theory by Nightingale was British, US nurse theorists have taken the lead in the development of modern nurse theories. Most of the 50 grand theories and many of the 40 or so mid-range theories are American in origin. In addition, Peplau developed her interpersonal nursing theory in the 1950s in the US; this was followed by many other US theories in the 1960s, 1970s and 1980s. By contrast, nursing theories only emerged in the UK in the 1980s and 1990s. Think about why this might be the case and why UK nurse theorists were less willing to call their work theory - preferring the word model. Discuss your conclusions with other students and compare views. Some of the content in Chapter 5 may be helpful for this exercise. Key Concepts 7.3 Nurses in various parts of the world are attracted to American nursing theories. This may be because they view US nursing as being more advanced. However, it may be inappropriate to impose a US theory on a non-US health care system. Ethical and moral issues The selection of a nursing theory is value-laden. It follows, therefore, that the choice will be influenced by a nurse’s beliefs about and attitude towards the nature of patients, people and health care. For instance, Orem’s (1995) self-care theory would not be a nurse’s first choice if he or she held the view that patients are dependent and should adopt the sick role and do as little for themselves as possible. On the other hand, if a nurse were to select a theory that encourages dependency, this could do a great deal of damage to the patient’s rehabilitation and self-esteem. Over a number of years, the psychologist Richard Lynn (2010) wrote that black people were less intelligent than white people and that men were more intelligent that women. The selection of Lynn’s theory to frame policy would have implications for hiring employees, providing educational opportunities and for the self-esteem of many people. This would be highly unethical. Similarly, the rigid application of the theories that the Earth was flat and the Sun orbited the Earth led to people like Galileo Galilei (1564-1642) being imprisoned and victimised (see Reflective Exercise 7.4). Reflective Exercise 7.4: Ethical considerations In Chapter 6, you will recall, we discussed the barriers to the use of interactional theories to build interpersonal relationships. Among other things, we mentioned the fast pace of modern health care and the increasing use of technology. Later on in this chapter, we will show that when using a nursing theory, a nurse undertakes a comprehensive and detailed assessment and identifies many actual and potential physical, social and psychological problems. However, in the modern health care system, the patient will only be in hospital for a short length of stay. Write a one-page account of the ethical implications of these issues for nursing care. Length of patient stay Time is an important factor when selecting a theory. For example, a theory used in a long-stay ward for the care of older people would not work in a very rushed emergency room setting. In the former, a human needs theory like that of Minshull et al. (1986) would be appropriate, whereas the FANCAP theory (fluids, aeration, nutrition, communication, activity, and pain) would be more appropriate in the emergency room. To implement Roy’s theory correctly it has been calculated that 16 A4 pages of a care plan would be required (McKenna & Slevin, 2008). It was noted in Chapter 6 that the pace of hospital treatment has increased and that these days patients are often discharged home once they are over the acute phase of their illness. This has implications for the choice of nursing theory. We should ask ourselves if it is morally correct to put patients through a comprehensive assessment and set goals for nursing interventions when they may not be in the clinical setting long enough to receive the interventions or have the goals of their care plan met. One obvious way to address this is to ensure there is a good discharge plan so that community nurses can pick up the care once the patient has returned home. Of course, this raises another potential complication - if community nursing staff are using a different theory from that used in hospital, the opportunities for confusion and misunderstanding are increased. You were asked to consider the ethical aspects of this example in Reflective Exercise 7.4. Nurses’ knowledge of nursing theories While the level of knowledge about different theories will influence the selection process, readers will spot the obvious flaw with this method of selection. Considering that there are over 50 nursing grand theories available, is it realistic to expect busy practising nurses to be familiar with any more than a few of the most popular ones. Their level of knowledge about theories is also biased according to which ones they were taught as students and which ones have the highest profile in the journals and books they have read. Further bias is introduced according to the journals the nurse reads and, as alluded to earlier, the predilections of her nurse educators and managers. The growth in mid-range theories complicates the selection process. At last count there were 40 of these (see the link in the useful web links at the end of the chapter). It is difficult enough to be up to date on the vast number of grand theories, but there are almost as many mid-range theories and the number is growing (Fawcett 2005b; Smith & Liehr 2008). The implications of a wrong choice Cutcliffe et al. (2009) maintained that the quality of care would be adversely affected by an inappropriate choice of a nursing theory, while McKenna and Slevin (2008) maintained that an early decision on an unsuitable theory may stifle creativity. Therefore, mistakenly selecting an incompatible theory may have undesirable consequences. In Chapter 1 we used the analogy of a map. A map will help to direct you to where you want to go and there are different maps according to your specific needs. An underground rail map is different from a street map, which is also different from a map used by airline pilots. An incorrect choice of map can get you lost; the same applies to the incorrect choice of theory. Of course, the map might be the right one but you have simply read it incorrectly. Similarly, the nursing theory may be the right one for your clinical setting but you may have misunderstood it or implemented it incorrectly. However, although an unsuitable choice is regrettable, it is not an insoluble situation: as with an incorrect map, an incorrect theory can be changed (see Reflective Exercise 7.5). Reflective Exercise 7.5 Think of the city or town in which you live and identify 10 different maps that could be used to understand the terrain. This should make you appreciate why there are so many different nursing theories looking at the same thing - nursing. Hybrid nursing theories The idea that different concepts can be chosen from several different theories and applied in the clinical area as one amalgamated theory is supported by some (Fawcett 2004), but is seen as totally untenable by others. However, there is a danger that such a strategy could lead to the loss of coherence and rigour, to the introduction of contradiction, and to the theoretical status being compromised. More research is being carried out on nursing theories and many of these studies show that particular theories are valid for guiding practice. For example, Anderson (2001) showed the effectiveness of using Orem’s (1995) theory with homeless adults and 25 years of research on Roy’s theory has shown the positive outcomes of encouraging adaptation (Yeh, 2001). Similarly, McKenna (1997) showed that Minsh ...
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