Fundamentals of Nursing Kozier

FUNDAMENTALS OF NURSING HISTORICAL AND CONTEMPORARY NURSING PRACTICE Women’s Roles – traditional female roles of wife, mother, daughter and sister have always included the care and nurturing of the other family members. Nursing could be said to have its roots in “the home.” Religion – the Christian value of ‘love thy neighbor as thyself’ and Christ’s parable of the Good Samaritan had a significant impact on the development of Western Nursing. 3rd and 4th centuries – several wealthy matrons of Roman empire, such as Fabiola, converted to Christianity and used their wealth to provide houses of care and healing for the poor and the sick and the homeless. The crusade saw the formation of several orders of Knights that provide nursing care to their sick and injured comrades. These orders built hospital, organization and management of which set standard for the administration of hospitals through Europe. E.g. Knights of Saint Lazarus dedicated themselves to the care of people with leprosy, syphilis and chronic skin conditions. War – Wars have accentuated the need for nurses. During the Crimean War – inadequacy of soldiers led to a public outcry in Great Britain. The role of Florence Nightingale played in addressing this problem. She was asked to recruit a contingent of female nurses to provide care to the sick and injured in the Crimea. She was credited for creating miracles by reducing the mortality rate in the barracks by setting up sanitation through hand wash and washing clothing regularly. During the American Civil War – Harriet Tubman and Sojourner Truth provided care and safety to the slaves fleeing to the north on the Underground Railroad. Mother Biekerdyke and Clara Barton searched the battlefields and gave care to injured and dying soldiers. Dorothea Dix – responsible for recruiting nurses and supervising nursing care of all women nurses working in an army hospital. World War 1 – American, British and French women rushing to volunteer their nursing services. These nurses endured harsh environments and treated injuries not seen before. A monument entitiled ‘ The Spirit of Nursing,” stands in the Arlington Cemetery which honors the nurses who served in the US Armed Services in WW1. World War 2 – created an acute shortage of caregivers. The Cadet Nurse Corps was established in response to a marked shortage of nurses. Vietnam War – 90% of the American military women stationed in Vietnam were nurses. Societal Attitudes: Before 1800’s nursing was without organization, education or social status. The prevailing attitude was that, a woman’s place is in the home and that no respectable woman should have a career. Society’s attitude towards nursing was reflected in book. Sairy Gamp, a character in Dicken’s book Martin

Chuzzlewit represented the negative image of nurses. “She cared for the sick by neglecting them, stealing from them and physically abusing them. In contrast, the rise of the “Guardian Angel or angel of mercy” in the late part of 19th century because of the work of Florence Nightingale during the Crimean war brought respectability of nursing profession. Nurses were viewed as noble, compassionate, moral, religious, dedicated and self-sacrificing. Leaders: Florence Nightingale – Lady with the Lamp, her efforts in reforming hospitals and in producing and implementing public health policies also made her an accomplished political nurse. Through her contribution to nursing education, she is also recognized as the first scientist-theorist for her work: Notes on Nursing: What it is and what it is not. She developed the Nightingale Training School for Nurses which opened in 1860. The school served as the model for other training schools. Clara Barton – was a schoolteacher who volunteered as a nurse during the American Civil War and she was noted for her role in establishing the American Red Cross. Linda Richards – was America’s first trained nurse. She was known for introducing nurses’ notes nad doctor’s orders. She also initiated the practice of nurses wearing uniforms. She is credited for her pioneer work in psychiatric and industrial nursing. Mary Mahoney – was the first African American professional nurse. She constantly worked on the acceptance of African American nurses and for the promotion of equal opportunities. Lillian Wald – considered the founder of public health nursing. Wald and Brewster were the first to offer trained nursing services to the poor in the New York slums. Lavinia Dock – was a feminist. Joined protest movements for women’s rights resulted in the 1920 passage of the Amendment which granted women the right to vote. She also campaigned for a legislation to allow nurses rather than physicians to control their profession. Margaret Higgins Sanger – considered the founder of the Planned parenthood, she was imprisoned for opening the first birth control information clinic in America. Breckinridge – started the first midwifery training schools in the US. She was a notable pioneer nurse, established the Frontier Nursing Service.

CONTEMPORARY NURISNG PRACTICE Definition of Nursing: Florence Nightingale – “the act of utilizing the environment of the patient to assist him in his recovery” she considered a clean, well ventilated, and quiet environment essential for the recovery.

Virginia Henderson – “the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.” ANA – “direct, goal-oriented and adaptable to the needs of the individual, the family, and the community during health and illness.” 1973 1980 ANA – Nursing is a diagnosis and treatment of human responses to actual and potential health problems. 2003 ANA – Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of the individuals, families, communities and population.

Scope of Nursing: 1. Promoting health and wellness – wellness is a process that engages in activities and behaviors that enhance quality of life and maximize personal potential 2. Prevention of Illness – maintain optimal health by preventing disease. Nursing activities include: immunization, prenatal and infant care, prevention of STD. 3. Restoring Health – focuses on the ill client. Extends from early detection of disease through helping the client during the recovery period. Activities include: providing direct care, perform diagnostic and assessment procedures, teaching clients about recovery activities and rehabilitation. 4. Caring for the Dying – involves comforting and caring for the people of all ages who are dying, helping clients live as comfortable as possible until death and helping support persons cope with death. Benner’s Stages of Nursing Expertise Stage 1 – Novice No experience, (nursing student). Performance is limited, inflexible, and governed by context-free rules and regulations rather than experience. Stage 2 – Advanced Beginner Demonstrates marginally acceptable performance, recognizes the meaningful aspects of a real situation. Has experienced enough real situations to make judgments about them Stage 3- Competent Have 2 -3 years of experience, demonstrates organizational and planning abilities. Differentiates important factors from less important aspects of care; coordinates multiple complex care demands. Stage 4 – Proficient Have 3-5 years of experience. Perceives situations as wholes rather than terms of parts, as in Stage 2; uses maxims as guide for what to consider in a situation. It has a holistic understanding of the client, which improves decision making. It focuses also on long term goals.

Stage 5 – Expert Performance is fluid, flexible, and highly proficient. No longer requires rules, guidelines, or maxims to connect an understanding of the situation to appropriate action. Demonstrates highly skilled intuitive and analytic ability in new situation; It is inclined to take certain action because ‘it felt right’.

Canadian Nurses Association (CNA) – is the national nursing association in Canada. Nurses do not join CNA independently but obtain membership by paying a fee to the provincial chapters. The CAN has developed standards and a code of ethics and it offers support to all provincial association. The CAN prepares licensure exam and offers research grants, fellowships and scholarships to Canadian Nurses.

NURSING THEORIES Theory – is a supposition or a system of ideas that proposed to explain a phenomenon. Concepts – building blocks of theories Conceptual Framework – group of related ideas, statements or concepts Example: Freud’s theory of the structure of the mind (id, ego, superego) Paradigm – refers to a pattern of shared understandings and assumptions about reality and the world. Metaparadigm of Nursing – much of the theoretical work in nursing focused on articulating relationships among 4 major concepts: person, environment, health and nursing. Because of this, 4 concepts can be superimposed on almost any work in nursing; thus called Metaparadigm. 1. Person – or client, the recipient of nursing care 2. Environment – the internal and external surroundings that affect the client. This includes people in the physical environment 3. Health – the degree of wellness or well-being that the client experiences 4. Nursing – the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with the client

Overview of Nursing Theories Nightingale’s Environmental Theory – the act of utilizing the environment of the patient to assist him in his recovery. 5 factors include: 1. Pure or fresh air 2. Pure water 3. Efficient drainage 4. Cleanliness 5. Light – especially direct sunlight. Deficiencies in these five factors produced lack of health or illness

Peplau’s Interpersonal Relations Model – Hildegard Peplau, a psychiatric nurse, introduced her interpersonal concepts in 1952. Central to this theory is the use of a therapeutic relationship between the nurse and the client. 4 phases: 1. Orientation – client seeks help, and the nurse assists the client to understand the problem and the extent of the need for help 2. Identification – client assumes a posture of dependence, interdependence, or independence in relation to the nurse. The nurse’s focus is to assure the client that nurse understands interpersonal meaning of the client’s situation 3. Exploitation – client derives full value from what the nurse offers through the relationship. The client uses available services based on self-interest and needs. Power shifts from the nurse to the client 4. Resolution – old needs and goal are put aside and new ones adopted. Once older needs are resolved, newer and more mature ones emerged. Henderson’s Definition of Nursing  Same with Nightingale which tackles environment but unlike Nightingale, Virginia Henderson sees the nurse as concerned with both healthy and ill individuals.  Conceptualizes the nurses’ role as assisting sick or healthy individuals to gain independence in meeting 14 fundamental needs: 1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining a desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining a body temperature within normal range by adjusting clothing and modifying the environment 8. Keeping the body clean and well groomed to protect the integument 9. Avoiding dangers in the environment and avoiding injuring others 10. Communicating with others in expressing emotions, needs, fears, or opinions 11. Worshipping according to one’s faith 12. Working in such a way that one feels a sense of accomplishment 13. Playing or participating in various forms of recreation 14. Learning and discovering or satisfying curiosity that leads to normal development of health, and using available health facilities Roger’s Science of Unitary Beings  Martha Rogers views the person as an irreducible whole, the whole being greater than the sum of its parts. Whole is differentiated from holistic.

Orem’s General Theory of Nursing  Dorothea Orem’s theory includes 3 related concepts: 1. Self-care 2. Self-care deficit 3. Nursing system

Watson’s Human Caring theory Jean Watson believes the practice of caring is central to nursing; it is the unifying focus for practice. Watson’s assumption of Caring  Human caring in nursing is not just an emotion, concern or attitude or benevolent desire, caring connotes a personal response.  Caring is an intersubjective human process and is the moral ideal of nursing  Caring can be effectively demonstrated only interpersonally  Effective caring promotes health and individual or family growth  Caring promotes health more than does curing  Caring responses accept a person not only as they are now, but also for what the person may become  A caring environment offers the development of potential while allowing the person to choose the best action for the self at a given point in time  Caring occasions involve action and choice by the nurse and client. If the caring occasion is transpersonal, the limits of openness expands as do human capacities  The most abstract characteristic of a caring person is that the person is somehow responsive to another person as a unique individual, perceives the other’s feelings and sets one person apart from another.  Human caring involves values, and will and a commitment to care, knowledge, caring actions, and consequences  The ideal value of caring is a starting point, a stance and an attitude that has to become a will, an intention, a commitment, and a conscious judgment that manifest itself in concrete acts. Neuman’s Systems Model  Betty Neuman, a community health nurse and clinical psychologist, developed a model based on the individual’s relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. Reconstitution is the state of adaptation to stressors.  Neuman views the client as an open system consisting of a basic structure ore central core of energy resources (physiologic, psychologic, sociocultural, developmental and spiritual) surrounded by two concentric boundaries or rings referred to as lines of resistance.  The lines of resistance represent internal factors that help the client defend against stressors; one example is an increase in the body’s leukocyte cunt t combat infection.  Outside the lines of resistance are two lines of defense. The inner or normal line of defense is depicted in solid line, represents the person’s state of equilibrium or the state of adaptation developed and maintained over time and considered normal for that person.  The flexible line of defense, depicted as the broken line, is dynamic and can be rapidly altered over a short period of time. It is a protective buffer that prevents stressors from penetration into the line of defense. Certain variables can create rapid changes in the flexible line of defense. Example: Lack of sleep

Roy’s Adaptation Model  Sister Callista Roy defines adaptation as “the process and outcome whereby the thinking and feeling person uses conscious awareness and choice to create human and environmental integration.

 Focuses on the increasing complexity of person and environment self- organization, and on the relationship between and among persons, universe, and what can be considered as Supreme Being or God.  Focuses on the individual as a biopsychosocial adaptive system that employs a feedback cycle of input throughput and output. Leininger’s Cultural Care Diversity and Universality theory  Madeline Leininger, a nurse anthropologist, put her views on transcultural nursing. She stated that care is the essence of nursing and the dominant, distinctive, and unifying features of nursing. She emphasized that human caring, although universal phenomenon, varies among cultures in its expressions, processes and patterns; it is largely culturally derived. 3 intervention modes: 1. Culture care preservation and maintenance 2. Culture care accommodation, negotiation or both 3. Culture care restructuring and repatterning Parse’s Human Becoming Theory Parse proposes three assumptions on Human becoming: 1. Human becoming is freely choosing personal meaning in situations in the intersubjective process of relating value priorities 2. Human becoming is cocreating rhythmic patterns or relating in mutual process with the universe 3. Human becoming is cotranscending multidimensionally with the emerging possible. These three assumptions focus on meaning, rhythmicity and cotranscendence. 1. Meaning arises from a person’s interrelationship with the world and it refers to happenings to which the person attaches to varying degrees of significance 2. Rhythmicity is the movement towards greater diversity 3. Cotranscendence is the process of reaching out beyond the self.  Parse’s model of human becoming emphasizes how individuals choose and bear responsibility for patterns of personal health.  Parse contends that the client, not the nurse, is the authority figure and the decision maker. The nurse’s role involves helping individuals and families in choosing the possibilities for changing the health process.