Orlando

Whither Nursing Models?

Niall McCrae RCN Nurse Education Conference, Harrogate

February 2012

Florence Nightingale School of Nursing & Midwifery

McCrae N (2011): Whither nursing models? The value of nursing theory in

the context of evidence-based practice and multidisciplinary health care.

Journal of Advanced Nursing, 68: 222-229

Professional Development of Nursing

Basic care

(‘handmaiden’)

Training in

anatomy and

physiology

Professional

certificate

and register

Nursing

theory

Diploma /

degree

qualification

Apprenticeship Higher education

Vocation Profession

Nursing has improved academic status, expansion

of roles (e.g. prescribing), more autonomy, but...

• has not developed a specialised knowledge base

• lacks infrastructure to conduct research

• professionalisation not fully recognised / desired

Nursing as Interpersonal Relationship

• First theory of nursing, published 1952

• Based on interpersonal relations theory of Harry Stack Sullivan

• Relationship is medium for all nursing care

• Shift from ‘doing things to people’ to therapeutic partnership

• Highlighted nurse’s attitude and need for self-awareness

Overlapping stages of therapeutic relationship

ORIENTATION

IDENTIFICATION

EXPLOITATION

RESOLUTION

Hildegard Peplau (1909-1999)

Psychodynamic nursing is being able to understand one’s own behaviour

to help others identify felt recoveries, and to apply principles of human

relations to the problems that arise at all levels of experience

H Peplau

Dorothea Orem (1914-2007)

Nursing: Concepts of Practice (1971)

• Self-care is human regulatory function

• Unlike physiological processes, it must be learned

• Influenced by individual motivation and social norms

• Illness may impede self-care capacity

• Factors in self-care capacity: age, gender,

developmental state, family, culture and resources

• Nursing directed at self-care deficit, helping patient to

regain ability and knowledge to perform self-care

• Most cited model in nursing research

Theory of Self-Care Deficit

Nursing Process

• ‘Nursing process’ introduced by psychiatric nurse Ida Orlando

(The Dynamic Nurse-Patient Relationship, 1961)

• Orlando concerned that nursing activity was prompted by medical

direction and procedural rules rather than patient needs

• Nursing described as interpersonal process: behaviour of patient,

reaction of nurse, nursing actions for patient’s benefit

Developed as problem-solving approach: -

1. Assessment

2. Planning

3. Implementation

4. Evaluation

Roper, Logan & Tierney Model of Nursing

Nursing process applied comprehensively to activities of daily

living (building on Virginia Henderson’s work in 1950s)

1. maintaining a safe environment

2. communicating

3. breathing

4. eating and drinking

5. eliminating

6. personal cleansing and dressing

7. controlling body temperature

8. mobilising

9. working and playing

10. expressing sexuality

11. sleeping

12. dying

Diversification of Nursing Models

NEEDS-ORIENTATED (Henderson, Orem, Roper-Logan-Tierney)

• Rationale: biopsychosocial needs covered comprehensively with

clear plan for nursing intervention

• Criticism: compartmentalisation, mechanistic, prioritising of needs

lower in hierarchy to neglect of individual preferences, needs

determined by nurse rather than by patient

INTERACTIONIST (Peplau, Barker)

• Rationale: nursing is interpersonal process between patient and

nurse, therapeutic use of self, focus on meanings and motives

• Criticism: neglect of physical health, denial of environmental

constraints

HOLISTIC (Roy, Rogers)

• Rationale: based on systems theory, patient to regain equilibrium

and harmony with environment

• Criticism: complexity of concepts beyond ‘common sense’

Meleis (1985)

Demise of Nursing Models

• Despite featuring prominently in training in 1970s and 1980s,

models of nursing have faded from nursing discourse

• Major criticism was failure of models to bridge theory-practice

gap, as demonstrated in comparative study by Griffiths (1998)

• Holistic, patient-centred intent lost in rigid application, jargon

and documentation

• Opposition to nursing models initially a postmodern response

(Reed, 1995): nursing is intuitive and cannot be reduced to

determinist theory

• Later opposition from empiricists (Gournay, 2001): nursing

theory has not satisfied doctrine of evidence-based practice

• Pursuit of esoteric theoretical framework for nursing seen as

futile and irrelevant endeavour in context of multidisciplinary

healthcare

Arguments against Nursing Theory

1. Nursing eludes definition

2. Lack of prescription for practice

3. Limited professional demarcation and autonomy

4. Incompatibility with evidence-based practice

5. Irrelevance to modern healthcare

Arguments and Counterarguments

1. Definition of Nursing

• Generation of theory arose from search for definition of nursing

• Key stage in development of discipline: enabled nursing to

create curricula independent of medical direction

• Broad principles such as holistic ethos have constancy, but

detail of nursing practice evolves with flux in healthcare systems

and society

• Theory is iterative process: while it grows it adapts

• Conceptual clarity necessary but pursuit of scientific precision

may be unrealistic: inflexibility leads to redundancy

A rigorous and exact delineation of nursing as a role and as a

scientific discipline is necessary specifically when it is used

as the conceptual basis for the development of nursing’s

theoretical knowledge Kim (2000)


2. Prescription for Practice

• Theory should guide practice, but utilisation limited

• Too discursive: Newman’s ‘expanding consciousness’ and Rogers’

‘dynamic energy fields’ deviate from contemporary nursing discourse

• Or too mechanistic: Roper, Logan & Tierney model was good training

tool, but in practice tended to be applied ritualistically (McCrae, 1992)

• However, faults may be in application rather than in design

• Applying theory requires judgment as well as action: nursing needs

‘knowledgeable doers’ to integrate theory and practice

(McCaugherty, 1992)

• Ability of nurses to use theory may be boosted by development of

graduate profession and advanced practice

When I see models, I see documentation Nurse interviewee (Wimpenny, 2002)


3. Professional Demarcation and Autonomy

• Nursing lacks autonomy of more powerful professions

• Professional and societal prejudice: traditional (and lingering) idea

that nurses merely follow doctors’ instructions and provide basic care

• What is value of theory if nursing is under de facto medical and

administrative control?

• Nursing-specific theory may be perceived as counteracting

multidisciplinary ethos

• Each discipline has own training, culture and outlook, thus makes

unique contribution to healthcare

• Multidisciplinary system is argument for nursing theory

• Nursing should have theoretical rationale for its specific function (not

simply filling gaps left by other disciplines)

• Most nursing care occurs in one-to-one relationship: this provides

context for theoretical framework

• What are nurses thinking and doing in interaction: is there a purpose?

• Nursing borrows heavily from knowledge of other disciplines, e.g.

psychology in understanding interpersonal relations

• CBT is standardised intervention: but do psychologist and nurse

bring something different to therapeutic table?

Deferent Knowledge

On a visceral level there seems something

wrong (if not blasphemous) about a nursing

article constructing relationship elements

from a psychology text

Perraud et al (2006)


4. Compatibility with Evidence-Based Practice

• Evidence-based practice is moral, professional and ethical imperative

(Cameron et al, 2005)

• But whose evidence?

• Reductionism dismantles human complexity into measurable concepts

• Emphasis on causal relationships and predictive outcomes rather than

humanistic process of caring

• Empathy has been much studied and categorised, but to engage in

patient’s world requires intuitive, humanistic approach honed by

professional training and experience

• Essence of nursing devalued by empiricist dogma

The evidence-based movement in health sciences is

outrageously exclusionary and dangerously normative Holmes et al (2006)

• So many models, so little testing

• Barnum (1998) appealed for systematic intervention, but difficult to

do this at broader level of theory

• Nursing theories fail Karl Popper’s test of falsifiability

• Theories emphasising interpersonal function of nursing (e.g. Peplau)

are durable and applicable to diverse practice situations

• Caring is phenomenological whole greater than sum of parts

• Comprehensive theory encompasses art and science of nursing, with

humanistic principles at core

• Beware notion that practices with best evidence are best practices!

Nursing Models and Evidence The art of nursing has been characterised by a humanistic

philosophy which values personal meaning, subjectivity and

understanding. At the same time, in attempts to become scientific,

there has been an acceptance of notions of science which are

primarily based in a positivistic, empirico-analytical paradigm.

JF Playle (1995)

Theory Development

Theory development is progression

through four functions of theory

(Walker & Avant, 1995): -

1. Describe

2. Explain

3. Predict

4. Control

However, prediction and control not

always feasible or desirable

Empiricist tendency to regard process

as descriptive and outcomes as

explanatory – but this could be

reversed

Theory in the humanities may be

likened to the growth of a tree. It

first appears as a perishable

sapling, but if the soil is fertile and

the surroundings accommodating,

and it is not eaten away or

ravaged by frost or drought, it

develops a hardy stem and

gradually becomes a young tree.

As it branches ever outwards from

a solid trunk, it attracts nesting

birds and becomes a prominent

feature of the environment. No

structure is permanent, but must

evolve with a changing world.

Barbara Carper (1978) described four domains of nursing

knowledge: -

1. Empirics

2. Aesthetics

3. Personal

4. Ethics

Jacobs-Kramer and Chinn (1988) developed this typology into a

model of nursing knowledge, with three dimensions of how

knowledge is: -

1. Created

2. Expressed

3. Assessed

Nurses should be able to articulate how knowledge is attained,

applied and evaluated (not all-or-nothing empiricism)

Different Ways of Knowing


5. Relevance to Modern Healthcare

• Common criticisms of nursing in media and society: trainees spending

too long studying and not enough time at bedside; nurses parked in

office on computer

• Ever-increasing amount of research and policy to master: a theoretical

framework for nursing may help to make sense of new knowledge

• Theory may provide rationale for more frequent and meaningful

engagement with patients (not just a chat, but therapeutic support or

problem-solving)

• Potentially, theory could guide nursing response to sociopolitical

controversies that cannot be resolved by scientific evidence alone (e.g.

assisted dying)

• Theory may contribute to greater input by nurses in research,

particularly on nursing interventions

• Magnet accreditation programme has encouraged fresh thinking on

theoretical foundations for nursing

Conclusions

Professional development requires differentiation of knowledge

and skills from other disciplines

Specific nursing theory may become more important in

multidisciplinary system where nurses must articulate and justify

their role

To bridge theory-practice gap, lessons must be learned from

previous experience with nursing models

As a corrective to doctrine of evidence-based practice, theory

should encompass caring (art) and technique (science) of nursing

Orlando

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