1. Theoretical Foundations of Nursing Practice
Chapter 4
Theoretical Foundations of Nursing Practice
Theories help to describe, explain, and/or predict nursing care measures. Well-developed theories are an important basis for your approach to nursing care.
To address individual and family responses to health problems, theory-based nursing practice is important for designing and implementing nursing interventions.

2. The Domain of Nursing Domain
Is the perspective of a profession
Provides the subject, central concepts, values and beliefs, phenomena of interest, and central problems of a discipline
Domain of nursing provides both practical and theoretical aspects of the discipline.
Nursing is a profession that draws from many areas: nursing history, nursing theory, education, practice, and research.
The domain of nursing is the knowledge of nursing practice, as well as the knowledge of nursing history, nursing theory, education, and research. The domain of nursing gives nurses a comprehensive perspective that allows you to identify and treat patients’ health care needs at all levels and in all health care settings.
In nursing, you will use critical thinking skills to integrate knowledge, experience, attitudes, and standards into the individualized plan of care for each patient.

3. Paradigm Paradigm Nursing paradigm
Links science, philosophy, and theories accepted and applied by a discipline
Nursing paradigm
Links person, health, environment/situation, and nursing
A paradigm is useful in describing the domain of a discipline.
The elements of the nursing paradigm, including knowledge development, philosophy, theory, educational experience, research, and practice, direct the activity of the nursing profession.
To differentiate:
In medicine, physicians diagnose and treat disease.
In nursing, nurses diagnose and treat human responses to actual or potential health problems.
In nursing, you will use critical thinking skills to integrate knowledge, experience, attitudes, and standards into the individualized plan of care for each patient.

4. Terminology Person Health Environment/situation Nursing
Nursing process: Method of applying the theory or knowledge
Integration of theory and nursing process is the basis for professional nursing.
Person is the recipient of nursing care, including individual patients, groups, families, and communities.
Health has different meanings for each patient, the clinical setting, and the health care profession. It is dynamic and continuously changing. Your challenge as a nurse is to provide the best possible care based on the patient’s level of health and health care needs at the time of care delivery.
Environment/situation includes all possible conditions affecting patients and the settings in which their health care needs occur. A continuous interaction can be observed between a patient and the environment, which has positive and negative effects on the person’s level of health and health care needs.
Nursing is the “… diagnosis and treatment of human responses to actual or potential health problems …” (American Nurses Association, 2010). The scope of nursing is broad. From these nursing diagnoses, the nurse creates a patient-centered plan of care for each of the patient’s health problems. Use critical thinking skills to integrate knowledge, experience, attitudes, and standards into the individualized plan of care for each of your patients.

5. Theory
A theory contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon.
Theories guide the design of nursing interventions.
Nursing theory
Is a conceptualization of some aspect of nursing
Describes, explains, predicts, and/or prescribes nursing care
Theories constitute much of the knowledge of a discipline.
Nursing theories provide nurses with (1) a perspective from which to view patient situations, (2) a way to organize data, and (3) a method for analyzing and interpreting information.
Theory is the generation of nursing knowledge used for practice.

6. Components of a Theory
The theory explains how these elements are uniquely related in the phenomenon.
A phenomenon is an aspect of reality that people consciously sense or experience. In nursing, phenomena include caring, self-care, and patient response to stress.
A theory consists of interrelated concepts. Concepts help to describe or label phenomena.
The definitions within a theory communicate the general meaning of the concepts. These definitions describe the activity necessary to measure the concepts within a theory.
Assumptions are taken-for-granted statements that explain the nature of the concepts, definitions, purposes, relationships, and structure of a theory.
[Fig. 4-1 is on text p. 41.]

7. Types of Theory Grand Middle-range Descriptive Prescriptive
Broad in scope, complex, require specification
Middle-range
More limited in scope and less abstract
Descriptive
Describe phenomena, speculate on why phenomena occur, and describe the consequences of phenomena.
Prescriptive
Address nursing interventions for a phenomenon, and predict the consequence of a specific nursing intervention.
Theories have different purposes and sometimes are classified by levels of abstraction.
See Box 4-1 (on text p. 42) for goals of theoretical nursing models.
A grand theory does not provide guidelines for specific nursing interventions but provides the structural framework for broad and abstract ideas related to nursing.
Middle-range theories address a specific phenomenon and reflect practices of administration, clinical interventions, or teaching.
These types of theories cross different nursing fields and reflect a wide variety of nursing care situations such as uncertainty, incontinence, social support, quality of life, and caring.
Descriptive theories do not direct specific nursing activities but help to explain patient assumptions.
In nursing, prescriptive theories designate the nursing intervention, the condition under which the nursing intervention occurs, and the consequences of the intervention. These theories guide nursing research to develop and test specific nursing interventions.

8. Theory-Based Nursing Practice
Theories
Generate nursing knowledge for use in practice
Can direct how to use nursing process
Are adaptable to different patients and all care settings
The goal of nursing knowledge is to explain the practice of nursing as different and distinct from the practice of medicine, psychology, and other health care disciplines.
Nursing is a practice-oriented discipline. Nursing process is not a theory. It is a systematic set of steps for the delivery of nursing care, not the knowledge component of our discipline.
Remember that a theory can direct how a nurse uses the nursing process.
Theory generates nursing knowledge for use in practice, thus supporting evidence-based practice. Integration of theory into practice is
the basis for professional nursing.
Theories from nursing and other disciplines help explain how the roles and actions of nurses fit together in nursing.

9. Interdisciplinary Theories
Explain systematic views of phenomena specific to the discipline of inquiry:
Basic human needs
Developmental
Psychosocial
Systems
From developmental psychology, you remember the basic human needs. Maslow’s hierarchy of needs is an interdisciplinary theory.
[Ask students if they can recall the five needs: (1) physiological, (2) safety and security, (3) love and belonging, (4) esteem and self-esteem, and (5) self-actualization.]
Developmental theories help determine whether patients are adapting during their specific developmental stage in life.
Psychosocial theories help us to predict patient responses to their physiological, psychological, sociocultural, developmental, and spiritual needs.
Systems theories are discussed on the next slide.

10. Quick Quiz!
1. Nursing theories provide nurses with perspectives from which to A. Analyze patient data. B. Predict phenomena. C. Formulate legislation. D. Link science to nursing.
Answer: A

11. Systems Theories
Systems have three components: input, output, and feedback (Fig. 4-2 on text p. 43).
The systems theory can be open or closed.
Open theory interacts with the environment, exchanging information between the system and the environment. Examples of an open system include the human organism and the nursing process.
A closed system does not interact with the environment.
Let’s look at this in relationship to the nursing process. Input for the nursing process consists of the data or information obtained through assessment. Output is the end product, which indicates whether the patient’s health status improves or remains stable as a result of nursing care rendered. Feedback is reflected by outcomes, which occur as the patient’s response to nursing interventions.

12. Case Study
Susan is a new nurse who tutors a nursing student, Bill, who has difficulty mastering good study habits and prioritizing school assignments. Susan is helping Bill learn the theoretical foundations of nursing practice.
After Susan and Bill review interdisciplinary theories such as Maslow’s hierarchy of needs and the developmental theories, they move on to the topic of nursing theories.
[Ask students: How will you remember interdisciplinary theories? What study techniques do you need to develop?]

13. Selected Nursing Theories
Nightingale
Peplau
Henderson
Orem
Leininger
Neuman
Roy
Watson
Benner and Wrubel
Application of nursing theory in practice depends on nurses having knowledge of the theories and an understanding of how they relate to one another. Theories are the organizing frameworks for the science of nursing and substantive approaches for nursing care. They provide critical thinking structures to guide clinical reasoning and problem solving.
[See subsequent slides for each theory’s discussion. Explain how the nursing theorist you use in your nursing program guides nursing care planning and perhaps the way you evaluate students in the clinical area using a clinical evaluation tool.]
Table 4-1 (on text p. 45) presents a summary of nursing theories.
Remember that application of nursing theory in practice depends on nurses having knowledge of theory. This is the organizing framework for the science of nursing and approaches to nursing care. .

14. Selected Nursing Theories (cont’d)
Nightingale (mid-1800s)
Environment as the focus of nursing care
Descriptive theory
Peplau (1952)
Focus on interpersonal relations between nurse, patient, and patient’s family
Development of nurse-patient relationship
Henderson (1955, 1966)
14 basic needs of the whole person
Framing nursing care are the needs of the individual.
Nightingale was one of the first to develop a nursing theory (1860) that is still in use today. Her concept of the environment was the focus of nursing care, and her suggestion that nurses need not know all about the disease process differentiated nursing from medicine. The focus of nursing is on caring through the environment and helping the patient deal with the symptoms and changes in function related to an illness.
Nightingale did not view nursing as limited to the administration of medications and treatments, but rather, it is oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. Through observation and data collection, she linked the patient’s health status with environmental factors and initiated improved hygiene and sanitary conditions during the Crimean War. Nightingale’s “descriptive theory” provides nurses with a way to think about patients and their environment.
Peplau’s theory focuses on interpersonal relations between the nurse, the patient, and the patient’s family and developing the nurse-patient relationship. The patient is an individual with a need, and nursing is an interpersonal and therapeutic process. In developing a nurse-patient relationship, the nurse can serve as a resource person, counselor, and surrogate.
The patient gains from this relationship by using available services to meet needs, and the nurse helps the patient reduce anxiety related to health care problems.
Peplau’s theory is unique: The collaborative nurse-patient relationship creates a “maturing force” through which interpersonal effectiveness meets the patient’s needs.
Henderson defines nursing as “assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death, and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge.” Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the patient: physiological, psychological, sociocultural, spiritual, and developmental.
Framing nursing care around the needs of the individual allows you to use Henderson’s theory for a variety of patients across the life span and in multiple settings along the health care continuum.

15. Selected Nursing Theories (cont’d)
Orem (2001)
Focuses on patient’s self-care needs
Goal is for patient to manage his or her health problems.
Leininger (2010)
Theory of cultural care diversity and universality
Considers social structure factors
Neuman (2010)
Based on stress and the patient’s reaction to the stressor
Role of nursing is to stabilize the patient or situation.
Orem defines self-care as a learned, goal-oriented activity directed toward the self in the interest of maintaining life, health, development, and well-being. Nursing care is necessary when the patient is unable to fulfill biological, psychological, developmental, or societal needs. The nurse assesses and determines why a patient is unable to meet these needs, identifies goals to assist the patient, intervenes to help the patient perform self-care, and evaluates how much self-care the patient is able to perform.
According to Orem’s theory, the goal of nursing is to enhance the patient’s ability to independently meet these needs.
Leininger’s background in anthropology informed her theory. Human caring varies among cultures in its expressions, processes, and patterns. Societal structure factors such as the patient’s religion, politics, culture, and traditions are significant forces affecting care and influencing the patient’s health and illness patterns.
The major concept of Leininger’s theory is cultural diversity, and the goal of nursing care is to provide the patient with culturally specific nursing care. To provide care to patients of unique cultures, the nurse safely integrates the patient’s cultural traditions, values, and beliefs into the plan of care. Leininger’s theory recognizes the importance of culture and its influence on everything that involves the patient and providers of nursing care.
In addition, symptom expression differs among cultures.
In the Neuman model, the patient is the individual, group, family, or community. The system is composed of five concepts that interact: physiological, psychological, sociocultural, developmental, and spiritual. These concepts interact with both internal and external environmental factors and all levels of prevention (primary, secondary, and tertiary) to achieve optimal wellness. Neuman considers any internal and external factors as stressors that affect the patient’s stability and any or all of the five system concepts.
When you apply the Neuman systems model, you assess the stressor and the patient’s response to the stressor, identify nursing diagnoses, plan patient-centered care, implement interventions, evaluate the patient’s response, and determine whether the stressor is resolved.

16. Case Study (cont’d)
Susan and Bill review the history of nursing theories. Rank the following nursing theories in chronological order of their acceptance into nursing practice.
Leininger’s theory
Henderson’s theory
Peplau’s theory
Nightingale’s theory
Orem’s theory
Rationale: The chronological order of acceptance into nursing practice of the nursing theories listed here is as follows: Nightingale’s, Peplau’s, Henderson’s, Orem’s, and Leininger’s.

17. Selected Nursing Theories (cont’d)
Roy (1989)
Views the patient as an adaptive system
When patient cannot adapt to stressors, nursing is needed.
Watson (1996)
Defines the outcome of nursing activity with regard to the humanistic aspects of life
Purpose is to understand the interrelationships among health, illness, and human behavior.
Benner and Wrubel (1989)
Caring is central.
According to Roy’s model, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. The need for nursing care occurs when the patient cannot adapt to internal and external environmental demands. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.
The nurse determines which demands are causing problems for a patient and assesses how well the patient is adapting to them. Nurses direct care at helping the patient adapt to changes.
Box 4-2 (on text p. 46) reviews Theory-Based Practice in the Management of Heart Failure.
In Watson’s theory, nursing is concerned with promoting and restoring health and preventing illness. Watson designed the model around the caring process—assisting patients in attaining or maintaining health or dying peacefully. This caring process requires the nurse to be knowledgeable about human behavior and human responses to actual or potential health problems. The nurse also needs to know individual patient needs, how to respond to others, and strengths and limitations of the patient and family and those of the nurse. In addition, the nurse comforts and offers compassion and empathy to patients and their families.
With Benner and Wrubel’s theory, caring is central to nursing and creates possibilities for coping, enables possibilities for connecting with and concern for others, and allows for giving and receiving help. Caring means that persons, events, projects, and things matter to people. It presents a connection and represents a wide range of involvement. This theory sees personal concern as an inherent feature of nursing practice. In caring for one’s patients, nurses help patients recover by noticing interventions that are successful and that guide future caregiving.

18. Case Study (cont’d)
Bill reads about the concept of people’s responses and adaptation to change. The theory that views the patient as an adaptive system is ______________.
Answer: Roy’s theory
Rationale: According to Roy’s model, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness.

19. The Link Between Theory and Knowledge Development
Nursing knowledge is theoretical and practical.
The goals of theoretical knowledge are to stimulate thinking and create a broad understanding of the “science” and practices of the nursing discipline.
Experiential knowledge, or the “art” of nursing, is based on nurses’ experiences in providing care to patients.
Nursing theories help direct nursing practice. When using theory-based nursing practice, you apply the principles of the theory in delivering nursing interventions in your practice.
Theory-based nursing practice improves nurse satisfaction and patient outcomes. The reason for this is that the basic values, guiding principles, and elements from the foundation of a particular nursing theory give meaning to the practice and influence how patient care is provided.

20. Quick Quiz!
2. Nursing process is central to nursing practice. Nursing practice A. Is a theory. B. Is derived from a theory. C. Is not adaptable to all patients. D. Generates knowledge for use in practice.
Answer: B

21. Case Study (cont’d)
Susan quizzes Bill about the core concept of Benner and Wrubel’s theory. Benner and Wrubel’s theory is based on the premise that persons, events, projects, and things matter to people.
True
False
Rationale: True. Benner and Wrubel’s theory is based on caring. Caring means that persons, events, projects, and things matter to people.

22. The Link Between Theory and Knowledge Development
Theories provide direction for nursing research.
Nursing theory and nursing research build the knowledge base for nursing, which is then applied to practice.
Theory-generating or theory-testing research refines the knowledge base of nursing.
Nurses incorporate research-based interventions into theory-based practice.
As more research is conducted, the discipline learns to what extent a given theory is useful in providing information to improve patient care. The relationships of components in a theory often help drive the research questions.
Theory-generating research tries to discover and describe relationships of phenomena without imposing preconceived notions of what the phenomena under study mean. In theory-generating research, the investigator makes observations to view a phenomenon in a new way.
Theory-testing research determines how accurately a theory describes a nursing phenomenon. Testing helps to develop evidence for describing or predicting patient outcomes.
As research activities continue, not only do the knowledge and science of nursing increase, but patients are the recipients of the best evidence-based nursing practice.