Ateneo de Davao University

Graduate School

Name: Dennis N. Muñoz, LPT, RM, RN Course: Theoretical Foundation of Nursing

Student Number: 22017001253391 Professor: Dr. Patria V. Manalaysay

Degree: Master’s in Nursing

FINAL COURSE REQUIREMENT

1. Use a Nursing theory in nursing practice, nursing education, nursing research
and nursing administration.

A. Nursing Practice

Introduction:

Last September 21, 2020, I was formally hired as Staff Nurse assigned in the Adult
Intensive Care Unit here at Tagum Doctor’s Hospital. Way back from 2009 to 2012,
I was also assigned in the intensive care however, I handled babies in the NICU,
Now I am working at the Adult ICU. As a nurse, I worked hard for the whole night
to save the patient’s life. Since, the patient was in life threatening situation, i.e.,
maximum inotropic and vasopressors support with increasing ventilator’s
requirement; the lifesaving part became the priority. Towards the end of the ten
hours shift, I realized that the room appeared all messed and so does the patient.
The patient’s mouth was stained with blood and yellow plaque like substance.
The floor had dried pyodine splotch which splashed during catheterization, and
also some dried blood drops. The bed sheets and linen were spattered with the
yellowish seepage which probably was stool. The dressing of his central venous
catheter (CVC), which was in placed in right femoral artery, was also soaked with
that seepage. Somehow, I managed time to redress the patient and clean the
room before the new shift begun. In the next shift, the patient developed fever,
and his pan cultures were sent. The blood culture showed growth of some
pseudomonas specie. Hence, the patient was put on contact isolation in the ICU.

Application of the Nursing Theory

Nursing care in the intensive therapy unit has tended to follow a medical model
and has concentrated on the physical needs of the patient. With the emergence of
nursing models intensive care nurses are beginning to question more than previously
the care that they are giving. The use of a structured model gives direction to patient
care and potentially benefits both the patient and the nurse. However, it is necessary to
examine closely the relevance of the model to the area of nursing, the needs of the
individual patient and the philosophy held by the nurses in that area.
 Over recent years Orem's self-care model has become popular. The major
concepts of the model in relation to the intensive therapy unit and the possible benefits
and difficulties of applying the model to this area has a great importance in the nursing
practice. It is concluded that although the possibilities of achieving self-care for the
critically ill patient are limited the use of the model encourages an individualized
approach to care and heightens awareness of the patient as a whole.

Nightingale also explored 13 cannons, also known as the sub concepts, in her
theory which can be related to the aforesaid scenario. These are “Ventilation and
warming, Light, Cleanliness of rooms and walls, Health of houses, Noise, Bed and
bedding, Personal cleanliness, Variety, Chattering hopes and advices, Taking food,
What food, Petty management and Observation of the sick.”

The environmental theory explains seven important assumptions. These are

“Nursing is a calling; natural laws; nursing is achieved through environmental alteration;
mankind can achieve perfection; nursing is an art and a science; nursing is distinct and
separate from medicine and nursing requires a specific educational base.” According to
Florence, the disease occurrence i.e., asthma exacerbation is a natural law. This could
had been prevented with her another assumption i.e., environmental alteration.
Nightingale believes that a nurse can do her right (calling) by manipulating the
environment in harmony with the natural laws to achieve healing by attaining perfection
in health. In the scenario, nurses could have facilitated in the patient’s prompt recovery.
The nurse used her knowledge of medicine education in keeping patient alive and out of
danger in the ICU. Yet, she left the aesthetic part of nursing which distinguishes the
profession from medicine.

At ICU though, the nurse made out time and provide hygiene care to the patient,
she somehow got late. By the time, the patient developed infection in his body. In the
situation, both the ward and ICU nurses kept using their reflective and critical skills to
help the patient. There were many drawbacks in the environment which worsened the
patient’s health. Reflecting the scenario, it was found that the problems were started, in
the ward, prior to the patient’s collapse. Florence nicely explains the status quo in her
theory through the canons. Firstly, ventilation being the integral component was
overlooked in both the ICU and the ward. In the ward, though the patient was cleaned
for stool timely, but the dustbin was not changed. Instead, a room freshener was used.
The nurse could have used her observational skills and knowledge. She could have
either opened the windows or removed the dustbin. Since both were not done, asthma
trigger due to improper ventilation alongside the vomiting deteriorated the patient’s
condition. Similarly, ICU being a closed setup not only hindered ventilation but also
warmth (sunlight). There are isolated rooms for every patient with only a door to enter
and exit. Thus, there remains no access to direct sunlight. There is only a central air
conditioner which serves for ventilation. Moreover, the former facts also reflect the
diminished concept of cleanliness of room and walls in both the settings. As discussed
in the scenario, the presence of the soiled dustbin in the ward contaminated the air and
ultimately the environment. Likewise, in the ICU the room was again polluted due to the
liquid seepage of stool, the pyodine splash, and the blood drops specks. Florence
summarized this as “a pool of polluted air”.
The idea is further supported by the germ theory of diseases. It says that environmental
contamination gives birth to microorganisms which harm health. The similar happened
in the scenario. The soiled and tainted environment led to the growth of pseudomonas
specie giving another blow to the patient’s health and also prolonging his hospital stay.

Moreover, in ICU patients have many invasive lines including arterial lines, swan-
Ganz catheters, and central venous catheters (CVCs) etc. Reflecting to the scenario,
growth of pseudomonas could also be also a possible consequence of the fecal
seepage in the CVC since the dressing was soaked. The scenario also highlights that
bed and bedding was neglected too. Persistent dampness and friction due to crinkled
bed-sheets irritate skin integrity and result in the development of pressure sores.
Therefore, in the long run patient could also have developed an ulcer. The scenario also
describes the violation of another important canon, personal hygiene. ICU patients are
completely dependent upon nurses for care.

Intensive care unit encounters nurses with different kinds of stressors, which can
result in nurses’ psychological traumas; one of these disorders is PTSD (post-traumatic
stress disorder). Three roles are considered for the nurses in traumatic incidents; they
can be as the observer of the incident, the victim, and finally they may suffer from the
stress related to background. Nurses are suffering from high pressure due to large
number of patients and high workload; they are also under high pressure by the
patients’ family and relatives. Applying Neuman systematic theory by using three levels
of prevention is amazingly effective in reducing injuries in nurses. These actions are
divided into two organizational and individual levels. Regarding the organizational level,
a cooperative supportive system, educational and simulated emergency situations can
be effective in decreasing injuries. Regarding the individual level, increasing nursing
knowledge about stressful factors and factors influencing the increase of flexibility and
endurance, as well as strengthening the ability of coping with stressful factors are
among other outcomes of applying Neuman theory on nurses.

Neuman model is trying to consider family as the care center through a family-
centered approach since family is counted as a client/client system in this model.
Evidence indicates that family has an important role in protecting patient’s health in
critical or intensive care situations; spousal support is especially important in such
situations which is not specified to a special patient and can be effective in different
situations. According to the results of the studies conducted by using NSM approach,
the following points can be considered:

1. Considering differences in assessing requirements: necessary understanding of the

nurses to compare the difference of the stressors perceived by the nurses with those
perceived by the patients’ families in intensive care units under critical conditions.
2. Nurses’ ability to develop accurate knowledge about stressful factors in the patients’
family since family partnership is especially important in the treatment process.
3. Nurse’s inability to identify stressful factors in the patients’ family that can lead to the
worsening of patient and family conditions.
4. Patients’ needs cannot be separated from their family needs; patients and their
family should be considered as a client system.
5. This theory makes a framework for helping nurses control critical conditions and
work with families.
6. According to this theory, nurse’s role is to create appropriate strategies for families
to cope with stressful factors.
7. Changing in the family members’ role or losing one member of the family in intensive
care units are among the stressful conditions for the patients’ family.
8. Patients’ family is considered as a member of the health care team.
9. Nurses’ cooperation with the patients’ family results in a strong defense wall and
reduced recovery duration after intensive and critical conditions.
10. Using this model in the cooperative care of nurses and families reduces the length of
hospitalization in ICU significantly.
11. Using evidence-based care according to Neuman theory can decrease delirium in
patients of intensive care units (18).
12. Nurses’ understanding of the stressful factors and conditions can have a great
influence on setting-up care plan which can lead to high quality care
B. Nursing Education

Prior to the development of nursing theories, nursing was seen as a task-oriented

occupation, and nurses were trained by doctors. Today, nursing theory serves as the
foundation of nursing. It is shaping the field in important ways because it:

1. Helps nurses to understand their purpose and role in the healthcare setting
2. Guides knowledge development
3. Directs education, research, and practice
4. Recognizes what should set the foundation of practice by explicitly describing
nursing
5. Serves as a rationale or scientific reason for nursing interventions and give nurses
the knowledge base necessary for acting and responding appropriately in nursing
care situations
6. Provides the foundations of nursing practice
7. Indicates in which direction nursing should develop in the future
8. Gives nurses a sense of identity
9. Helps patients, managers, and other healthcare professionals to acknowledge and
understand the unique contribution that nurses make to healthcare service
10. Prepares the nurses to reflect on the assumptions and question the values in
nursing, thus further defining nursing and increasing knowledge base
11. Allows the nursing profession to maintain and preserve its professional limits and
boundaries

Nurse educators use nursing theories, which are developed from scientific evidence
and valid data, to create supportive frameworks for patient care. These theories offer
strategies and approaches that play a vital role in educating the next generation of
healthcare providers.

Nurse educators design curricula based on sound educational principles, research,

and theory to help student nurses develop the knowledge and skill they need to provide
care. Nursing theory permeates almost every component of nursing education,
particularly for registered nurses (RNs) who are moving into the next phase of their
careers as advanced practice registered nurses (APRNs).

Nursing theories can be applied to many different circumstances. However, the

leading nursing programs, including the program at Duquesne University, incorporate
the grand theories into the master’s in nursing curriculum. Grand theories are
considered the theoretical framework that supports the principles and key concepts of
nursing.
Self-Care Nursing Theory

Introduced by Dorothea Orem, the Self-Care Nursing Theory (also known as the
Self-Care Deficit Nursing Theory) focuses on the nurses’ role in supporting the patients’
ability to be self-sufficient and responsible for their own care. The theory is based on the
idea that people must be knowledgeable about their health problems to provide
adequate self-care. The theory is made up of three interconnected theories: the theory
of self-care, the theory of self-care deficit, and the theory of nursing systems.
Orem said she based her theory on her practice as a nurse and contemporary nursing
literature and thought. During her career, she published several books that explored and
expanded her theory, including Guides for Developing Curricula for the Education of
Practical Nurses and Nursing: Concepts of Practice.

Culture Care Theory

As a nurse, Madeleine Leininger recognized a lack of cultural and care

knowledge as a missing component in nursing and patient care. From her experiences,
she developed transcultural nursing and the Cultural Care Theory to study and explain
the outcomes of transcultural nursing.

Leininger’s theory is focused on providing care that is in harmony with a patient’s

cultural beliefs, practices, and values. In the 1960s, she coined the phrase “culturally
congruent care,” which is the primary goal of transcultural nursing. Some of the basic
tenets of transcultural nursing include an understanding of the following:
 Cultural care diversity and universality, which refers to the differences and
commonalities between different cultures.
 Cultural and social structure dimensions, which include factors that include
religion, social structures, and economics that set cultures apart.
 Cultural care preservation or maintenance, which relates to nursing care
activities that help specific cultures to retain the core cultural values related to
healthcare.

Humanistic Nursing Theory

Also called the holistic approach, the Humanistic Theory looks to meld mental
and emotional health with physical health. The theory is based on the idea that patients
grow in healthy and creative ways. This approach to nursing, created by APRNs
Josephine Paterson and Loretta Zderad, looks at each patient as an individual who
needs personalized care.

Paterson and Zderad developed five phases of nursing, called phenomenological

nursing, to accompany the Humanistic Theory:
 Nurses prepare for “coming to know” or start investigating a case.
 Nurses create an “I-You” relationship so they can understand their patients and
use their intuitive knowledge.
  Nurses apply scientific knowledge and begin a subject-object or “I-It” relationship,
which allows nurses to reflect on their own experiences and put them into context
for the current situation.
 Nurses synthesize their knowledge to become a source of continually evolving
information.
 Nurses transform from the “many to the paradoxical one” to apply knowledge to a
practical clinical setting.
Theory of Interpersonal Relations

The Interpersonal Relations Theory, developed in 1952 by Hildegard Peplau,

focuses on the importance of the nurse-patient relationship. Nurses are able to prove
better care to their patients if they build a strong relationship based on mutual respect.
Peplau’s theory evolves in three phases:
1. Orientation: The nurse-patient relationship is initiated by a patient’s needs. The
nurse helps the patient get acquainted with the treatment process and answers
questions.
2. Working: As the nurse-patient relationship develops, the patient concentrates on
expressing reactions to the illness and becomes an active participant in care.
3. Termination: The nurse helps the patient follow through on care that has been
provided and return to a normal productive life.

During the different phases, the nurses take on many roles, including resource
person, teacher, surrogate, and counselor.

Need Theory

Developed by Virginia Henderson, an RN who was inducted into the American

Nurses Association’s Hall of Fame, the nursing Need Theory focuses on a nurse’s role
in assisting patients to maintain health, recover from injuries or achieve a peaceful
death. In her work, she continually stressed nursing’s duty to focus on helping the
patient rather than the doctor.

Henderson, considered the mother of modern nursing care, outlined four basic
needs—psychological, physiological, social, and spiritual — that are required for
patients to live independently:
 Psychological needs including communicating and handling fears.
 Physiological needs including eating and sleeping.
 Spiritual needs including worship and faith.
 Social needs including recreational activities.

In the Philippine Nursing Curriculum as per CMO no. 14, series of 2009, the nursing
theory imbedded within the context of the Philippine society, where nursing education
with caring as its foundation, subscribes to the following core values which are vital
components in the development of a professional nurse and are emphasized in the BSN
program:
1.1 Love of God
1.2 Caring as the core of nursing
a. Compassion
b. Competence
c. Confidence
d. Conscience
e. Commitment (commitment to a culture of excellence, discipline, integrity, and
professionalism)
1.3 Love of People
a. Respect for the dignity of each person regardless of creed, color, gender, and
political affiliation.
1.4 Love of Country
a. Patriotism (Civic duty, social responsibility, and good governance)
b. Preservation and enrichment of the environment and culture heritage

Comment:
The concept of Caring as the core of nursing was actually lifted from the
nursing theory of Sister Simone Roach’s 5 C’s of caring – commitment, conscience,
competence, compassion, and confidence - are universally applicable to the nursing
profession. It is fairly straightforward to grasp the meaning of the 5 C’s, but it takes time
and effort to ensure they are consistently applied in the workplace particularly in the
Philippine nursing education context.
C. Nursing Research

Introduction

Practice research, and theory are the cornerstones of the nursing

profession. The relationship of these three cornerstones are reciprocal and
cyclical. Clinical practice generates research questions and knowledge for
theory. Research guides our practice and build knowledge through theory
development. Theory guides research and improve practice.

Effective nursing practice requires the application of knowledge, skills,

caring, and art to care for patients in an effective, efficient, and considerate way.
An important part of the knowledge used in making nursing clinical decisions is
produced by research findings. Ideally, all patient care decisions should be based
on research-evidence. Research findings are used to develop a protocol and the
protocol is followed in daily nursing practice.

Theory and Research

The primary purpose of theory in the profession of nursing is to improve practice

by positively influence the health and quality of life of patients. The relationship between
theory and practice is reciprocal. Practice is the basis for the development of nursing
theory whereas nursing theory must be validated in practice.

Theory guided practice, in the form of practice theory, is the future of nursing.
Practice theories are narrow, circumscribed theories proposed for a specific type of
practice. As we progress into the 21st century, nurse scholars, scientists, researchers,
and practitioners must place theory-guided practice at the core of nursing. To provide
effective, efficient, and holistic care, nurses must rely on sound theoretical principles to
develop and implement the plan of car

Theories can be useful to nurse-researchers as guides for conducting research

(Bartholomew & Mullen, 2011; Rodgers, 2005). A theory offers a set of concepts and
propositions that can be applied consistently and examined systematically across
studies of clinical problems (Meleis, 2012). Admittedly, not all research should be theory
guided; some research is conducted to generate theory about new phenomena
(Goldkuhl, 2012). When authors explain in sufficient detail how they planned their aims
and methods, guided by theory, in sufficient detail, then readers can perceive
conceptual parallels or differences across studies (Bartholomew & Mullen, 2011; Meleis,
2012; Rodgers, 2005). Ultimately, when nurse researchers conduct theory-guided
research carefully and delineate how they did so in their publications, then their
research could inform nursing practice efficiently as well as add to our existing
knowledge of describing, explaining, and predicting clinical problems.

D. Nursing Administration

The requisite theoretical base of nursing administration has been defined as a

synthesis of knowledge from nursing and other disciplines. The value of nursing theory
to administration practice is articulated as well as levels of theory development and their
relationship to the knowledge base of nursing administration practice.

Orem’s Theory of Self-Care Deficit Nursing Theory (SCDNT) Orem (2001) defined
nursing administration as “the body of persons who function in situational contexts to
collectively manage courses of affairs enabling for the provision of nursing to the
population currently served by an organized health service institution or agency and to
populations to be served at future times” (Fawcett, 2005). Orem's theory is used in
several clinics and hospitals in order to increase the self-care functions of individuals
and to educate patients, to evaluate nursing practices and to distinguish nursing
practices from medical practices (Fawcett, 2005; McEwen & Wills, 2007). The utility of
the Self Care Framework is clear for the administration of nursing services. A
particularly innovative application of the Self-Care Framework in nursing management
was the Professional Care System, a software package for nursing documentation
(Bliss-Holtz et al., 1992). The software can also generate personalized critical paths and
maintenance maps. Various paper and pen application tools have been developed to
document nursing practices, to measure the quality of practices based on the Personal
Care Framework, and to evaluate nurses themselves. Calhoun and Casey’s (2002)
developed innovative ambulatory case management model, which they based on
Orem’s Self-Care Framework, to apply at the New Mexico Presbyterian Health Plan. In
this study, model provide to cost savings, but the result was that the reduction in
costs was due to a personality reduction rather than the use of the model.
Within the framework of the administrative and management guidance of healthcare
organizations in the United States, Canada, the United Kingdom and Australia is used
this model (Fawcett, 2005).

Neuman Systems Model Neuman Systems is a suitable model for guiding

nursing applications because it has five major varieties of physiological,
psychological, sociocultural, spiritual and developmental aspects of the individual
with modeled well-adapted, holistic approach and open system features (Ume-
Nwagbo et al., 2006). Guidelines for the use of the model in clinical nursing practice
and in the management of health care services have been published (Neuman and
Fawcet, 2011; Lawson, 2014). The breadth of the Neuman model has led to its
implementation and adaptation in a variety of nursing practice environments
including community-based services such as hospitals, nursing homes, rehabilitation
centers, hospitals, mental health units, birth centers and communal nursing
practices.

The model works well for multidisciplinary use (Kain, 2000). The focus of
healthcare services guidelines for the administration of health-care services based on
Neuman’s Systems Model is to make primary, secondary, and tertiary protection
interventions that best help customers achieve, acquire, and retain customer systems.
So guidelines determine of organization of healthcare services, characteristics of health-
care personnel including administrators and practitioners and settings for health-care
services (Fawcett, 2005). It has also been proven to be beneficial in the field of hospital-
based staffing in various Kansas hospitals; development of case management teams,
social workers, and nursing staff (Lawson, 2014).

The use of the Neuman Systems Model in clinical practice agencies has been as
pervasive in other countries as in the United States. Published reports indicate that the
model has been implemented successfully at the unit or organization level in the
United States, Canada, Iceland, England, Wales, Holland, Slovenia, and Sweden
(Parker, 2005).

Watson’s Theory of Human Caring. Watson argues that the model takes part in the
interpersonal process between caregiver and care-recipient and emphasizes the whole
of nursing. According to Watson, the nursing process is the process of human-man
care (Fawcett, 2005). The need and importance for caring in patient care environments
demand that nurses apply the concepts of care in the human resources
management process (Minnaar, 2002). Watson’s theory requires administrative
practices and business models to adopt care. It has been reported that the theory can
be applied to hospital admissions, technological complexities (Watson, 2005). In these
issues, ethical reforms in the health care system require nurses to use their own
professional practice model rather than short-term solutions. Many hospitals are
trying to acquire Magnet status. For example; The Lexington Central Baptist Hospital in
America uses the Watson ‘s Human Care Theory in administrative changes to
overcome the challenges. In many hospitals, professional care is defined, which
defines the basics of patient care (Jesse and Alligood, 2014). Although there is
more work to be done, some efforts include inclusion of a nursing goal in the
nursing strategic plan; rewriting policies and procedures, career ladder models,
and job descriptions that impact performance appraisals (and pay); adding a
section-level requirement for a Healing Community initiative that is reflected in
department ciphers; and revising orientation and leadership curricula to include
caring-relevant concepts (Watson, 2002). When the theory is systematically
incorporated into nursing services, nurses and others have become more introspective
about the nature of their rehabilitation work. The magnet hospital in the system took
interest in our adventure and adopted Watson's theory. The theory that resonates
within the institution gives a magnetic shine that patients and caregiver know (Birk,
2007). There are also many clinics that use Watson’s studies. For example, Some of
the hospitals in Miami, Chicago, Denver, Virginia, Kentucky, New York, Florida,
California and New Jersy; some of them (Jesse and Alligood, 2014). Reports of the
implementation projects have made some comparisons between the results before
and after the implementation of the Human Caring Theory. The results of various
projects show that when the theory is guided by nursing practice, the job
satisfaction of the staff is increased, the length of stay in the hospital is reduced and the
cost of health care is reduced (Fawcett, 2005).

Roy Adaptation Model. The Roy Adaptation Model is a model that is widely used in
nurses and focuses on the adaptive system of the human and environmental change
system, which creates a structure for determining the adaptation needs of people,
families and groups. The focus of RAM is on changes in and around the human
adaptive system (Roy, 2009). The Roy Adaptation Model has been used to guide the
management of nursing services in hospitals and medical centers in the United
States and Canada, England and Sweden. In addition, practice tools that are
particularly relevant to the administration of nursing services, including standards of
nursing practice, nursing job descriptions, quality assessment tools, a
performance appraisal system, and a format for intershot reports (Fawcett, 2005). As
hospitals in the United States work towards the Magnet Status certificate, more nurses
want information on the implementation of the Roy Adaptation Model in institutional
health care (Parker, 2005). Clinical setting managers attempted to make the theory
more active in various situations. In each case, each of the modes provided a
framework for assessing patient needs and provided a convenient, convenient
classification system for stimulants. Recording of patient care needs has been made
more regular and simple and there have been indications that increased patient
satisfaction and dissemination of professional practices (Meleis, 2012).

Patricia Benner's From Novice to Expert Model. Benner’s model is situational and
defines winning and developing five levels of skill: (1) beginner, (2) advanced
beginner, (3) competent, (4) competent and (5) expert. The model posits that changes
in four aspects of performance occur in movement through the levels of skill acquisition:
(1) movement from a reliance on abstract principles and rules to the use of past,
concrete experience,(2) shift from reliance on analytical, rule-based thinking to
intuition, (3) change in the learner’s perception of the situation from viewing it as a
compilation of equally relevant bits to viewing it as an increasingly complex whole, in
which certain parts stand out as more or less relevant, and (4) a separate
observer would switch from one position of participation fully engaged to the situation to
one out of the state (Benner, Tanner, & Chesla, 1992). Benner (1992) describes
clinical nursing practice using an interpreting phenomenological approach. Benner’s
approach continues to be used to help develop clinical promotion ladders, new
graduation orientation programs, and clinical information development seminars
(Brykczynski, 2014).
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