BY: PATRICK GAUGHAN, RN, M.H.A., M.B.A., CARL MIDDLETON, D.MIN., M.DIV., M.A., M.R.E. and PAT PATTON, RN, M.S.N., F.C.N.
At its most fundamental, the term "nursing theory" involves the type of care provided at the hospital bedside — in other words, how individual nurses interact with and treat their patients. While often misunderstood in the abstract, nursing theory encompasses the practices and policies in patient care that spring from the basic values and principles of a health care organization.
Of course, this is especially needed in the Catholic health care ministry at a time when the entire health care industry is changing so rapidly — and so dramatically.
Two years ago, Catholic Health Initiatives, based in Englewood, Colo., began system-wide discussions about ways to ensure that the key aspects of a nursing theory matched in every respect the nursing care provided at its hospitals and other health care facilities.
At the time, more than a dozen nursing theories were either in use or being considered across CHI's system of more than 70 hospitals. To ensure consistency, leaders from several key functional areas — including mission and clinical services — created a task force to review nursing theories and provide guidance to local facilities.
Nursing theories are used to describe, develop, disseminate and employ present knowledge in nursing. They are critical to excellent, consistent care because they provide a framework for nurses to systematize their nursing actions and focus on best practices: what to ask, what to observe, what to focus on and what to think about. They also provide a framework to develop new knowledge and validate current knowledge. Nursing theories are also used to define commonalities of the variables in a stated field of inquiry, guide nursing research and actions, forecast practice outcomes and predict client response. They are especially important as roles and responsibilities shift in the ever-evolving environment of health care.
"As health care organizations prepare for unprecedented change, nurses are also facing major shifts in their professional practice," said Kathleen Sanford, RN, CHI's senior vice president and chief nursing officer. "Fewer nurses will work inside the hospital walls as they move into community sites and to roles that may not even have a physical site — such as virtual nursing. This transformation for nursing and the individual nurse makes nursing theory even more important as a framework that organizes concepts — and a body of knowledge — in a manner that guides practice."
The group charged with reviewing nursing theories, which included four mission leaders and about a dozen nurses from across the system, set out on a painstaking process, starting with a wide-ranging initial list of almost 30 theories — everything from the "Core, Care and Cure Model" to the "Theory of Comfort" to the "Theory of Cultural Care, Diversity and Universality." The group pared the list, eventually to nine, based on a series of questions to determine how well each one met the attributes of Catholic health care — that is, its principles and its identity, derived from the Ethical and Religious Directives for Catholic Health Care Services (ERDs) and, more broadly, the church's moral theology and social teachings.
The process was unique because it provided strong guidance to local hospitals but allowed them to be fairly autonomous in their selection of a particular nursing theory. With hospitals in all four continental U.S. time zones, CHI leaders believed it was essential that local clinicians were allowed leeway in the way they practiced nursing. The philosophy, grounded in the recognition that different regions of the country will have different needs, also reflects the fact that CHI was created in 1996 in collaboration with 10 different congregations of women religious. One of the first steps in the process was providing each of the nursing leaders with a copy of the ERDs, followed by a robust dialogue regarding alignment of the values inherent in the ERDs with the nursing theories.
"This work was so important because it helps us to better understand and carry on the legacy and the work that the sisters started," said Julie Weldon, RN, a nurse and education coordinator at Mercy Medical Center in Des Moines, Iowa, who teaches nursing theory to colleagues and served on the CHI national committee. "Today, we're relying on lay people more and more for the work that used to be done by nuns, the sisters.
"When I think of the sisters — and I went to a Catholic elementary school where there were more sisters than lay teachers — I think of certain characteristics: someone who is disciplined, who you can rely on, who can be trusted, a counselor. As nurse-leaders we have to preserve the sisters' legacy even as we continue to lead change. Nurses have to fill that same role. And the work we have done with nursing theory really underscores that."
The decision to examine nursing theories also stemmed from the organization's focus on the Magnet Recognition Program, a national certification of the strength, quality and service of nursing programs at hospitals. One CHI facility has attained that status, and seven others are currently undergoing the accreditation process, which requires a well-stated expression of how the particular facility is practicing nursing. Magnet hospitals attest to a particular nursing theory, known as a "professional practice model," and this was a key consideration in CHI's decision to review these practices. CHI's goal is that all of its facilities ultimately achieve Magnet status.
The Magnet program recognizes that nurses need meaningful accomplishment in their work, which means they must be able to practice according to professional standards. They must be able to make decisions based on their expertise and professional judgment, and to be involved in decisions that affect their working conditions. That includes the ability to work toward a consensus on a theory that underpins their professional practice. Kristin Powell, RN, a nurse for 20 years who is the manager for clinical education at Memorial Hospital in Chattanooga, Tenn., describes nursing theory as a road map for clinicians to best serve their patients. "There are different ways to get to the same outcome, in many cases," said Powell. "But you need to pick the route that best fits your culture, your goal and your values."
At Memorial, Powell explained, clinicians selected as their nursing theory Patricia Brenner's "Novice to Expert," a conceptual model that does precisely what the name suggests, moving nurses along a continuum of transformational development. The model fits perfectly with CHI's focus on social justice and community health, Powell said. "It also fosters the notion that nurses should be critical thinkers, to really reflect on the way they practice and to ask questions like, ‘Why are we doing it this way?' and ‘Will this provide the best outcomes for our patients?' This helps us to find the best ways of doing things and to pass this along to the next generation," she said.
Weldon said, "It was enlightening to assess the nursing theories based on compatibility with CHI's mission, vision and core values. The work reinforced the need to promote the important use of theory at the bedside to ground nurses for delivery of excellent, person-centered patient care for our Catholic ministry."
HISTORY AND EVOLUTION
The origins of nursing theory date to the 19th century, when the concepts were developed by the most recognized name in nursing — Florence Nightingale, who advocated for a corps of nurses to tend to British troops during the Crimean War. She started the first school of nursing in England.
Nightingale, widely credited with establishing the modern practice of nursing, developed an environmental theory of nursing that helped nurses develop practices that saved countless lives. She looked at the way nurses practiced and focused on items such as fresh air, cleanliness, communication and environment. Her theory was grounded in the notion that everything about the patient's surroundings, both inside and outside the hospital — water, air, appropriate food and nutrition, sunlight and cleanliness — has an impact on recovery. She recognized that patients did not want to smell the odors of bedpans and chamber pots, common in rooms during that time, and that fresh air played a vital role. Every hospital or hospital room should have windows as well as attractive colors to help patients recover more quickly, she determined.
Nightingale's views on communication with patients were radical for her time. She suggested that visitors not give their family or friends false hopes or uninformed medical suggestions, since patients needed to know the truth about their condition and their care.
The development of other theories continued through the mid 1800s and 1900s, when nursing practice was based on hierarchy, rules, principles and traditional practices. Theories were rooted in conceptual models and philosophies of practice such as the nature of nursing and the purposes for which nursing exists. Theories were deliberate, reflective, critical and self-correcting and encouraged nurses to cultivate basic inquiry skills.
The evolution went on to the development of philosophies of nursing theories, with an emphasis on knowledge associated with aesthetic, ethical and personal issues.
Nursing theories in the 1960s and 1970s focused on a functional view of nursing. These described what nursing is and how nursing functions, given the many variables influencing health and illness. Then, in the 1970s and 1980s, theorists started developing the essence or definition of nursing. This was done by developing mid-range, practice-linked theory, which provided specific guidance for nursing practice and tended to cluster around a concept of interest.
In its evaluation of nursing theories, CHI's mission leaders and clinicians agreed on a key part of the process: A tool, composed of eight key questions and areas, designed to objectively evaluate the compatibility of nursing theorists and nursing theories with the Catholic identity of its affiliated hospitals. (See sidebar.)
Overall, the selection process, which reduced the list of acceptable nursing theories to nine (including Nightingale's), helped develop a deeper understanding of why nursing theory is so important in daily practice.
CAREFUL NURSING: A PERFECT FIT
As CHI reviewed nursing theories, one known as Careful Nursing scored a perfect "5" on each of the questions used in scoring. Careful Nursing was developed in Dublin, Ireland, by Sr. Catherine McAuley, who founded the Sisters of Mercy in 1831, and Mother Mary Aikenhead, who founded the Irish Sisters of Charity in 1816.
Nursing as a social service had been effectively wiped out by the effects of the Reformation, but Sr. McAuley was deeply involved in nursing family, friends and eventually her Irish community. She was one of a number of women who sought to re-establish nursing services for the sick and poor during this time. Careful Nursing was further developed by Therese Meehan, Ph.D., a senior lecturer on nursing at the University College Dublin in Ireland. Meehan's work comprises five central tenets: person, environment, health, nursing and transcendence. It first included 10 key concepts: disinterested love, contagious calmness, creation of a restorative environment, "perfect" skill in fostering safety and comfort, nursing interventions, health education, participatory-authoritative management, trustworthy collaboration, power derived from service and the notion of nurses caring for themselves. It has now been expanded and revised to 18 practice concepts, including intellectual engagement; clinical reasoning and decision-making; interventions; patient engagement in self-care; and professional visibility.
"Nurses, especially for a faith-based organization, essentially represent the ministry at the bedside," said Mercy Medical Center's Weldon, who teaches the 18 different practice concepts of the Careful Nursing Theory to fellow nurses at her facility. "Nursing is both an art and a science. We use science to find out what's wrong with our patients — and how to correct it. The art is more the human element we bring to the bedside."
"Obviously, both are important," she added. "But nurses spend the most time with the patients. If you understand theory, it helps ground you, and helps to put context to the work you do. It helps organize your thinking and gives you language to describe what you do, every day, as a nurse at the bedside. Nursing theory is foundation for us."
In the future, any CHI hospital that wants to use a theory not on the newly approved list will need to go through the same exercise in evaluating and analyzing its compatibility.
CARRYING LEADERSHIP FORWARD
The "grading" of the important criteria associated with each of the nursing theories also aligned with another key priority at CHI: ensuring the integrity of the ministry and the credibility of future leaders, an objective as important in the executive suite as it is at the bedside.
In work that complements the effort to highlight nursing theory, CHI has identified four key expectations of all its leaders: managing the organization's legacy of care, managing relationships, managing results and managing the common good. These four key expectations must be embedded in every facet of the leadership experience. Those fundamental expectations helped inform the leaders who reviewed, analyzed and ultimately chose nursing theories for the system.
As a result, CHI strengthened its ability to sustain the ministry far into the future by intentionally and explicitly connecting how ordinary leadership practices, business processes, and care delivery protocols help to manage the legacy of care, relationships, results and the common good.
"For nurses in Catholic systems, the theories we subscribe to will serve as the foundation for maintaining our faith-based identity," said CHI's Sanford. "Bringing the legacy of our founding sisters forward will depend on an adherence to a framework that guides our practice — however and wherever it evolves. Adherence to a theory which supports respect for the dignity of all persons, emphasizes service to all of God's people with a special concern for the most vulnerable among us, and which is based on love, will be our North Star."
This integration of Catholic identity in all areas, including nursing theory, is vitally important as the ministry begins preparing a new generation of leaders to face issues such as emerging markets and the changes wrought by health reform. What's more, it's another effort to maintain that centuries-long connection with the founding women religious.
"We must ensure that the sisters' history is known and understood by every new Catholic Health Initiatives nurse from his or her first day of orientation," said Weldon. "And we must ensure that each patient encounter and each work experience is seen through the lens of faith-based nursing."
Nursing is designed to foster optimum health and to bring comfort in suffering and death for anyone in need, in any stage of life. It is a ministry of compassionate care for the whole person, a response to God's love and grace in the world today.
"Nursing theory," said Weldon, "helps us use our faith to guide our work. It helps us keep in mind what we are doing — and why we are doing it. Every nurse is entrusted to provide holistic care to patients, just as we look to our religious leaders to provide us with faith-based resources to enrich our own lives."
PATRICK GAUGHAN is vice president, Center for Formation; CARL MIDDLETON is vice president, theology and ethics; PAT PATTON is vice president, clinical innovation and leadership development, all at Catholic Health Initiatives, Englewood, Colo.
EVALUATING NURSING THEORIES
In order to effectively evaluate a nursing theory, the CHI task force essentially graded each based on how they:
- Honor the dignity of the human person and the sanctity of life in all of its dimensions and stages
- Foster a relationship-centered philosophy of mind/body/spirit care
- Encourage service to and advocacy for those people whose socio-economic condition will not allow them access to health care
- Promote a co-responsible partnership based on mutual respect between caregivers, patients and families in achieving the goals of healing
- Espouse compassionate care of the dying, relief of pain and suffering, and ethical reflection upon the use of life-sustaining technology in light of the benefit/burden or proportionate/disproportionate means analysis
- Affirm CHI's mission, vision, core values and cultural attributes
- Complement the ministry culture of CHI
- Complement the local culture of the hospital or health facility
Confident that these principles would help determine that a theory and a theorist were compatible with the church's teaching and CHI's culture, the group divided into smaller teams to review the questions, scoring each proposed theory on a 5-point scale. After each theory was reviewed, the entire group reconvened to look at all of the theories together and to justify answers. After considerable discussion and debate, the group omitted one theory from the list and provided further focus on nursing theories that the group believed align with and support CHI's mission, vision and values.
Although the group felt that each question was equal in value, the last was vital because local clinicians were being called upon the make a final decision. Thus, a good match with the local culture was essential.
"Instead of changing our culture to fit a nursing theory, we picked a nursing theory that fit our culture as patient advocates focused on evidence-based practices," said Kristin Powell, RN, manager for clinical education at Memorial Hospital in Chattanooga, Tenn. "The power of healing fit very well with environmental outreach, creating and nurturing healthy communities — and truly being involved with patients. These are caring powers."