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Theory-Based Nursing Practice
Theory plays a pivotal role in nursing since it helps in differentiating what is already known and what nurses need to know. Theory also forms the basis of nursing practice through describing, predicting and explaining nursing phenomena. According to Paley (2001), nursing theory helps in the generation of further knowledge and suggesting the future direction of nursing. There are numerous benefits associated with having a clear body of nursing theory such as improved patient care, guiding education and research, enhancing communication between nurses, and improving the professional status of nursing and nurses. It is impossible to measure caring, which is the main aspect of nursing; therefore, theory is needed for the purposes of explaining and analyzing the actions of nurses. With the medical profession gradually moving towards embracing a multidisciplinary approach, nursing should attempt to build a distinctive body of knowledge, which is evident by the nursing profession trying to establish and uphold its professional limits (Fawcett & Desanto-Madeya, 2013). Owing to the importance of theory in nursing, the purpose of this paper is to discuss the theory-driven advanced nursing practice. To this end, this paper discusses how Jean Watson’s theory of human caring and Marlaine Smith’s theory of unitary caring embodies globalization, healthcare disparity and cultural relevance. The paper also provides an example of a nursing situation in which the identified frameworks could be used, and provides a description of a specific example of how this role will be used in guiding advanced nursing practice.
A metaparadigm refers to a set of ideas or theories outlining the structure that determines the functioning of a particular discipline. In the context of the nursing discipline, there are four basic components of metaparadigm, which include the patient as a whole, the patient’s environment, the patient’s wellbeing and health, and nursing responsibilities. Despite the fact that numerous nursing theories exist, the aforementioned four nursing paradigms offer a holistic approach to care characterized by the patient’s health and well-being being interconnected to the four components (Fawcett & Desanto-Madeya, 2013). The person component of the nursing metaparadigm places emphasis on the individual receiving care. Nevertheless, the person component also encompasses family members as well as other people who are important to individual receiving care. The structure of care takes into consideration the social, spiritual and healthcare needs. The subsequent health outcome depends on how interactions between the patient and the social and physical needs (Masters, 2012). The underlying presumption is that the patient is empowered to be able to manage his/her wellbeing and health with dignity as well as self-preservation using positive personal relationships. Acuity is part of the person component of the nursing metaparadigm. In this respect, acuity, specifically, patient acuity can be used to denote the extent of needs of the person receiving care including the health, spiritual and social needs (Abualrub, 2007). The magnitude of these needs (patient requirements) will determine the amount of nursing care required for the patient, and the intensity of care required. In addition, acuity in the person component of the nursing paradigm could be used to denote the level of patient dependency on nurses to meet their needs (Arling, Kane, Mueller, & Lewis, 2007).
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The environment component of the nursing metaparadigm places emphasis in the surroundings having an effect on the person receiving care (Paley, 2001). The environment comprises of both external and internal influences. The manner in which the person interacts with his/her environmental influences determines his/her wellness and health. In addition, interactions with friends, families and other people are also considered part of the environment. Other aspects of the environment include technology, social connections, culture, geographic location and economic conditions – all of these comprise of social and physical factors. The environment component of the nursing metaparadigm assumes that an individual has the capability of modifying his/her environmental factors in order to enhance his/her health and wellness status (Watson & Smith, 2002). Acuity is not a component of the environment domain of the nursing metaparadigm. From the concept analysis of acuity, there is no attribute of the concept that has is directly or indirectly related to the environment of the patient. The concept analysis of “acuity” showed that the concept could be applied in various settings including patient-related acuity, non-patient related acuity, provider-related acuity, and system-related acuity (Habasevich, 2012). However, in all these settings and uses, there is reference to the environment of the patient; therefore, it can be inferred that acuity is not related to the environment component of the nursing metaparadigm.
The health element of the nursing metaparadigm denotes the degree of wellness of the patient and his/her access to healthcare (Watson & Smith, 2002). The health aspect is often typified with manifold dimensions that are dynamic. The underlying assumption is that these factors have an effect on the state of wellbeing of an individual. Health and wellbeing is needed for existence in one’s environment. In addition, health various throughout one’s lifespan through the interaction between environmental factors and genetic factors, and is determined by the ability of an individual to access care and meet his/her healthcare needs (Fawcett & Desanto-Madeya, 2013). Acuity is related to the health aspect of the nursing paradigm, especially the provider-related acuity, which denotes the intensity of care required for a patient (Rischbieth, 2006). In this respect, acuity can be used to represent the magnitude of the health needs of the patient. It can also be used to refer to the seriousness of the illness, which determine the state of health and wellness of the patient. Therefore, the degree of health represents acuity such as the functional status of the patient.
The nursing aspect in the metaparadigm focuses on delivering optimal patient outcomes in a caring and safe environment (Parker & Smith, 2010). The nursing component makes use of the principles of communication, professional judgment, collaborations, technology, skills and knowledge in executing responsibilities and duties in order to achieve the most optimal patient outcome. The nursing component emphasizes on high degree of care service and integration with other components of the nursing metaparadigm in order to enhance patient wellbeing. In addition, nursing is considered both a practice profession and an academic discipline. Nursing has been defined as the science and art associated with offering holistic healthcare based on the values of human responsibility, choice and freedom. Nursing science composes of the vast body of knowledge obtained via development of theories, logical analysis and research. Therefore, nursing theories are considered essential in guiding and advancing nursing practice (Paley, 2001). Nursing practice involves the creative application of the nursing knowledge to enhance human care. As a result, nursing makes use of clinical judgment as well as critical thinking in offering evidence-based healthcare to people, families, groups and communities with the aim of achieving optimal client wellness in various nursing contexts. As a result, clinical judgment skills are considered a crucial requirement for professional nursing practice. Acuity is related to the nursing component aspect of metaparadigm. In this respect, acuity is used in determining the intensity and type of clinical care required by the patient, which requires the use of clinical judgment. Acuity in the context of the nursing element of the paradigm can also be used in representing the care burden that a patient imposes on nursing, the complexity of the care needs, the difficulty of the medical and nursing care needs of the patient, and the intensity and severity of care needs. In this respect, nurses are supposed to make use of clinical judgments based on acuity in order to determine aspects such as surveillance, mental concentration, skills needed in satisfying the needs of the patient. Acuity has direct implications for nursing practice in the sense that high acuity requires more nursing care, increased workload, and complex patient needs; the case is opposite for low acuity patients (Abualrub, 2007).
The central theme of nursing is human caring. As a result, nursing actions should focus on showing empathy and concern as well as being committed to the lived experience of the patient regarding human health, and how it relates to disease, illness and wellness (Fawcett & Desanto-Madeya, 2013). In such a case, the nurse is perceived to be a person who plays an active role in human care transactions with patients throughout their lifespan. In addition, human care transactions have the main objective of protecting, enhancing and preserving human dignity and worth. Therefore, human caring entails commitment and will to healthcare, values, caring actions, and their resulting outcomes. Moreover, human care is considered an endeavor that needs action, reflection and research. Moreover, human caring depends on context and is individual specific (Parker & Smith, 2010). Essentially, caring is the centerpiece of nursing. To this end, nurses work independently and utilize power in shaping the profession and empowering patients using caring relationships. In addition, nurses should use up-to-date scientific research and critical thinking in order to be able to translate technologies, skills and knowledge into nursing practice. Other pertinent nursing actions and behaviors include evaluation and selection of alternative course of actions, communication, empowering, reflection, intuition and observation. With respect to the client outcomes pertinent to nursing practice, nursing should focus on enhancing the health potential and caring for all people including those who are all, those who are all, and those who are dying.
The ethical principles used in guiding the nursing practice comprise of beneficence, justice and autonomy. The principle of beneficence focuses on promoting what the nurse deems best for the client. As aforementioned, the central theme in nursing is human caring; therefore, the principle of beneficence focuses on doing well to other people, which is underpinned by developing a professional caring relationship (Fawcett & Desanto-Madeya, 2013). Defining “what is best” for the patient depends on the professional judgment of the nurse or the wishes of the client. In most cases, nurses’ judgment and patient wishes are often consistent, although cases of divergent views are likely to be witnessed. During cases whereby the patient and nurse have differing opinions, nurses should decide to act in a manner that they deem is for the “own good” of the patient” instead of allowing patients to use their autonomy. The intentional superseding of the client’s autonomy (paternalism) is consistent with the earlier assertion that clinical judgment and critical analysis skills are important for nursing practice (Masters, 2012).
The principle of autonomy denotes the capacity to act, decide and think based on free will. As a result, family members and caregivers have the obligation of helping the patient make their own decisions by ensuring that patients are provided with full information. In addition, this principle asserts that medical practitioners must uphold the adult patient’s competent decision even when the decision seems medically wrong. Nevertheless, based on the human caring principle, nurses might embark on paternalistic actions (Paley, 2001). In such a case, it is imperative for nurses to carefully evaluate the value associated with such paternalistic actions and establish whether they are genuinely in the best interest of the patient. Paternalistic actions can be justified when it is concerned with patient safety, which is also one of the important aspects of human caring (Fawcett & Desanto-Madeya, 2013).
With respect to justice, there is no doubt that resources are often limited, which implies that nurses are not in a position to cure every patient. In such cases, it is important set priorities. During the allocation of care resources and service, the principle of justice maintains that patients under the same conditions must be provided access to the same care. In addition, the principle of justice states that, when allocating healthcare resources to a given patient group, it is important to evaluate the impact of the allocation to others. This entails determining if the decision is fair and whether it will burden others (Paley, 2001). The fair distribution of burdens and benefits by nurses require the use of professional judgment and critical analysis skills. Overall, owing to the potential conflicts between the principles of autonomy, beneficence and justice, nurses have to rely significantly on their professional and clinical judgment as well as critical analysis skills in order to result in the most optimal patient outcomes. Such an approach to nursing practice requires nurse to embrace human caring as the central theme in practice (Fawcett & Desanto-Madeya, 2013).
The mid-range theory selected to guide advanced nursing practice is Marlaine Smith’s theory of unitary caring. The assumptions of this theory are based on a number of concepts including Roger’s science unitary human beings, Watson’s Theory of Transpersonal Caring, and Newman’s theory of health as expanding consciousness (Watson & Smith, 2002).
In addition, it is imperative to note that this mid-range theory is not sufficient in defining advanced registered nurse practice; as a result, there is the need to pair it with another theory (Jean Watson’s theory of human caring) in order to fully guide the practice. The theory of human caring is based on the beliefs and philosophical understandings associated with the meanings of being human, meaning of care, and meaning of healing. The theory of human caring outlines ten carative factors (clinical caritas processes) (Paley, 2001).
Caritas relate to cherishing, appreciating and giving specialized attention. (Masters, 2012)
Being open to and attending to the unknown, mysterious and spiritual aspects of suffering, death and life – believing the possibility of a miracle.
According to the theory of human caring, the clinical caritas processes are considered central to nursing practice, which draws upon the art, science and philosophy of caring. Other aspects associated with nursing practice such as nursing techniques, technology, clinical disease focus, functional tasks, procedures and practice setting are important; however, they are not the heart of nursing practice. Based on the value system embedded in the 10 clinical caritas, human caring needs extreme respect and regard for human life and person. In this respect, nursing should emphasize on the subjective internal world of the patient and the nurse, and how they perceive and experience health and illness conditions (Watson & Smith, 2002). Therefore, the nurse has the role of helping the patient to acquire more self-knowledge, self-knowledge and be ready for self-healing. It is evident that the theory of human caring outline the guidelines regarding nurse-client interactions; nevertheless, this framework does not outline the details of achieving the authentic caring relationships. In addition, this theory focuses more on being instead of doing; overall, it offers a helpful framework that can be used in delivering patient-centered care.
Model shows a representation of the nursing concepts and domains with the frameworks of Smith and Watson. The model is based on the interaction between the elements of the nursing of nursing paradigm within the frameworks of Smith Marlaine theory of unitary care and Jean Watson theory of human caring. There is no predefined boundaries regarding the interactions of the nursing actions in the model. For instance, instillation of hope can span various elements of the nursing metaparadigm including the person component, the environment and health domains. For instance, in the person component, the nurse can instil feelings of hope and faith in the person receiving the care. In the environment component, the nurse can instil feelings of hope and faith among families and friends of the person receiving care. In the nursing environment, faith and hope can be incorporated in nursing practice. Essentially, the various nursing actions such as appreciating diversity, being present in the moment, manifesting intentions, being open, and creating and nurturing a healing environment interact with one another irrespective of the metaparadigm components to result in human wholeness, hope and faith, sense of wellbeing and culturally competent caring. In other words, the nursing actions in the model can be helpful in all domains of nursing.
The following situation is presents the application of the nursing of the Watson and Smith framework with respect to globalization, healthcare disparity and cultural relevance. Cardiovascular disease (CVD) has been identified as one of the leading factors contributing to hospitalization and death in the US and other regions of the world (Cossette, Frasure-Smith, Dupuis, Juneau, & Guertin, 2012). Coronary heart disease (CHD) is one of the most prevalent CVDs accounting of a considerable fraction of cardiac-related deaths and hospitalizations. For instance, in the US, CHD causes about 6000 deaths per year (Heidenreich et al., 2011). Moreover, it has been forecasted that an approximated 50% and 30% of 40-year olds women and men are at risk of developing CHD in future (Heran et al., 2011). Owing to the high prevalence of the disease, preventing secondary cardiac occurrences has been considered an important aspect of care for patients with CVD. Other treatment options like medication and surgery have also played a crucial role in helping patients to survive CVD; however, they are considered treatment-oriented and not preventive-oriented. The most effective approach is the cardiac rehabilitation, which entails the use of medically supervised programs having the main objective of promoting quick recovery for patients with CVD (Manzoni et al., 2011). In addition, cardiac rehabilitation plays a crucial role in ensuring that CVD patients stay healthy. The option to enroll in a cardiac rehabilitation program is accessible in the United States and globally (Heidenreich et al., 2011).
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In other regions, cardiac rehabilitation is often tailored to suit the cultural needs of those specific regions. In the US, the choice to enroll in a cardiac rehabilitation program is accessible because of insurance coverage plans and the increase in the number of hospitals offering such services (Manzoni et al., 2011). In addition, cardiac rehabilitation is being offered in non-hospital settings such as home in order to increase accessibility. Eligibility for enrollment in cardiac rehabilitation program include heart valve repair; heart transplant; stable angina and heart attack occurring during the last one year. Before being considered eligible, patients are also subjected to cardiovascular screening before being eligible to enroll. The prospect of enrolling in a cardiovascular rehabilitation program is often characterized by feelings of hope and faith. However, the components of the actual rehabilitation require commitment and dedication from the patient to continue living a healthy lifestyle even after the completion of the program.
A patient had enrolled in a cardiovascular training and was nearing the completion of his program. However, the risk factors for the patient for CVD had not reduced significantly despite the fact that the program was nearing completion. The patient expressed frustration that the cardiac rehabilitation program was a waste of his time and money. The patient had expectations that the program would improve his health conditions in terms of body mass index, weight and other health-related outcomes. Essentially, the patient had lost all the hope that she had in the program and any other remedy to his heart disease. I explained the concerns of the patient to the administrator of the program, who asserted that overall responsibility lies with the patient in following the guidelines of the program. The nurse had the sole responsibility of issuing guidelines and conducting regular checkups for changes. I felt like the program was not taking into account and responding to the needs of the patient.
I had a feeling that the cardiac rehabilitation program at the hospital was not offering an individualized approach to care. In addition, the program did not make use of a multidimensional approach goes beyond exercise and diet programs. It is impossible to enhance physical wellbeing when the wellbeing of the mind and spirit were not guaranteed. Following a conversation with the patient, the solution to the issue seemed rather simple. The social and spiritual needs of the patient were not incorporated in the program. Simply stated, the program was not caring. I believe that cardiac rehabilitation programs should not focus on diet and exercise (physical needs), but also social, mental and physical functioning and reinforcing healthy lifestyles (spiritual needs).
Conclusion
In the Watson and Smith framework, the central theme of nursing is human caring; therefore, nursing actions should emphasize on showing empathy and concern for patients as well as commitment to the lived experience of the patient in respect to human health and how it is related to disease, illness and wellness. In such a nursing framework, nursing has the responsibility of empowering patients by use of caring relationships. In line with the assertion that caring is the centerpiece of nursing, nursing actions should focus on creating intentions using images, thoughts and feelings and articulating them through actions; seeing diversity; ensuring presence in the moment; having an open mind; establishing a healing environment; and the development of a transpersonal caring relationship.
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