NGR5800: Theory Guiding Practice
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NGR5800 Paper 3: Theory Guiding Practice
Lorraine Babcock
UCF
Fall 2013
NGR5800: Theory Guiding Practice
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Abstract
As previously discussed, cognitive adult patients who have had stoma surgery present
multifaceted challenges for nursing. The objective of nursing is to enhance a safe and quick
recovery, with assurance of the patient’s ability to perform self-care once discharged. Although
an inpatient nurse may not be a comprehensive expert regarding stoma patients, they have
expertise on the subjects of coping interventions and stress reduction. Inflammatory bowel
disease is estimated to affect as many as 1.4 million people in the United States. Both the patient
and surgeon are dependent upon the nurse to achieve positive outcomes. Coping and education
may be impaired in this patient population (Babcock, 2013). Through application of the Theory
of Self-Efficacy, nurses can reduce the patient’s stress and anxiety to facilitate effective
education of self-care for discharge home.
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Background
Cognitive adult patients who have had stoma surgery present multifaceted challenges for
nursing. Many colorectal surgeons are now practicing an enhanced recovery program of
standardized post-operative orders designed to reduce recovery time (Aasa, Hovbäck , &
Berterö, 2013). The optimal length of stay is two to three days, but high stress and anxiety levels
often hinder the patient’s self-care and education. The nurse must develop a plan of care that
addresses coping and health maintenance while also being mindful of the financial implications
regarding extended lengths of stay (Babcock, 2013).
McEwen and Wills advocate that in order “to provide comprehensive, holistic, and
effective interventions, nurses should rely on sound theoretical principles to develop and
implement the plan of care” (2011, p. 390). In the case of the stoma population, the nurse can
use multidisciplinary concepts as theory is applied to practice (McEwen & Wills, 2011). This
patient population will likely be apprehensive about how they will live their life after discharge
(Readding, 2005). The role of inpatient nursing is to make sure the patient possesses basic selfcare skills, knowledge, and knows how to access resources to prevent future complications
and/or readmission (Readding, 2005). Pre-hospitalization initiation of patient education is
advantageous (Readding, 2005).
Inpatient nurses may not have extensive knowledge regarding stoma patients, but they do
have expertise on the subjects of coping interventions and stress reduction. Stoma patients have
feelings of uncertainty and feelings of not being in control. Emphasis should be placed on
teaching the patient coping strategies (Danielson, Soerensen, Burcharth, & Rosenberg, 2013).
To achieve positive, optimal outcomes, the surgeons and patients rely upon nursing.
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Statement of the Clinical Problem
Adult stoma patients with normal intellect experience ineffective health maintenance
related to impaired knowledge regarding integration of stoma care into their lifestyle (Ackley &
Ladwig, 2006). The essence of this problem is motivation and changing behavior.
Significance of the Problem
As stated in my previous paper, Crohn’s disease and ulcerative colitis are inflammatory
bowel diseases (IBD) that can cause pain, cramping, altered elimination, fatigue, and
malnutrition (Mayo Clinic, 1998-2013). Patients usually require healthcare throughout their life;
there is no medical cure (CDC, 2012). Inflammatory bowel disease affects as many as 1.4
million people in the United States (CDC, 2012). Ten percent of patients are under the age of
18; peak onset of IBD usually occurs between 15-30 years of age (CDC, 2012). In both adults
and children, a focus on education and coping is beneficial (Borkowski, 1998). Colorectal
surgical intervention is necessary when symptoms of IBD are no longer controlled by medical
management (Allison, Lindsay, Gould, & Kelly, 2013). IBD has “an overall health care cost of
more than $1.7 billion” (CDC, 2012). Over 100,000 hospitalizations per year are due to IBD
(CDC, 2012).
“In order for a patient to comprehend and retain information, they must be at low levels
of stress and anxiety” (Babcock, 2013). Because nurses know how to help patients cope and
because they are skilled at education, they are the key to success where this patient population is
concerned. To verify effective patient education and comprehension, return demonstration and
the teach-back methods have been used (Peter & Robinson, 2011). Mindfulness training may
also be helpful. Trunnell states mindfulness is “being nonjudging, having a beginner’s mind,
NGR5800: Theory Guiding Practice
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being trusting, nonstriving, accepting, and letting go” (Trunnell, 1996). Research also supports
that active coping strategies used to change self-efficacy are healthier than avoidant coping
strategies (Krouse, et al., 2009).
Specific Aims
Nurses have an opportunity to help improve patient outcomes by applying the middle
range theory of self-efficacy to get the patient prepared for discharge. The Theory of SelfEfficacy will address the core problems of motivation and changing behaviors. The goal is to
use the critical elements of shared decision making, teamwork, and communication to design
successful plans of care for integrating stoma care into the life of the patient. The patient,
family, providers, and nursing should be involved. Specific examples of how to accomplish this
goal will be further explored in the theory application section below.
Theory / Conceptual Framework / Model
Self-efficacy is the individual’s own recognition of his or her ability to take action (Smith
& Liehr, 2014). The Theory of Self-Efficacy is based on the social cognitive theory (Smith &
Liehr, 2014). The two vital concepts of the theory are self-efficacy expectations and outcome
expectations (Smith & Liehr, 2014). In other words, the individual has to believe they are
capable of causing a certain outcome. The environment and the interaction with others in the
environment are influential as well.
The Theory of Self-Efficacy is a middle range theory of nursing as it meets the evaluation
framework of substantive foundations, structural integrity, and functional adequacy. The theory
is within the discipline of nursing and the concepts are clearly defined. There are no more
NGR5800: Theory Guiding Practice
concepts than needed to explain the phenomenon and they are logically represented with a
model. The theory is applicable in a variety of environments and settings (Smith & Liehr, 2014).
Application of the Theory to the Problem
Self-efficacy conclusions are based on four sources: enactive attainment, vicarious
experience, verbal persuasion, and physiological feedback during a behavior (Smith & Liehr,
2014, p. 201). To apply the Theory of Self-Efficacy to the problem of integrating stoma care
into the patient’s lifestyle, nursing can focus on each of the informational sources. Examples of
enactive attainment, otherwise described as the performance of a behavior, is the most influential
source (Smith & Liehr, 2014). A specific action towards enactive attainment would be to set a
goal that the patient and family will be able to return demonstrate care of the stoma or incision
by postoperative day two. Another way to encourage enactive attainment would be to have the
patient and family participate in developing the plan of care; this can begin before
hospitalization. Multidisciplinary participation in the plan of care should include the patient and
family and is accomplished with shared decision making; it also helps to decrease patient anxiety
(Singh, Butow, Charles, & Tattersall, 2010).
Through the informational source of vicarious experience, the patient and family can
visualize others performing the same behavior identified in the goals. The patient and family
should be given resources (via networking and/or literature) so they can see how others have
dealt with the same situation. Case management, nursing, and providers may all be in the
position to offer resources before and during hospitalization. Another source of information is
mentoring and motivating; otherwise considered verbal persuasion (Smith & Liehr, 2014).
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NGR5800: Theory Guiding Practice
Verbal persuasion can be achieved when nursing staff and providers give verbal encouragement
and support the patient’s efforts.
Physiological feedback during a behavior is when individuals consider how they feel
physically; if they feel ill or are in pain, they may decide not to display the desired behavior
(Smith & Liehr, 2014). Nursing must establish goals related to physical function. An example
would be the goal to maintain pain at an acceptable level through the use of relaxation techniques
and non-opioid medications. Additional goals would be for the patient to comply with a walking
schedule and early nutrition schedule. Research has shown improved self-efficacy, reduced pain,
and reduced anxiety the earlier the patient is provided education (Wong, Chan, & Chair, 2010).
A goal for nursing would be to maintain an even or euvolemic fluid balance throughout the
hospitalization.
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Summary and Conclusions
Adult stoma patients with normal intellect or cognition often have difficulty
incorporating their stoma care into their lifestyle after discharge. Stress and anxiety may hinder
how quickly the patient retains knowledge as well as how effectively they are able to cope with
the changes they are experiencing, resulting in problems with motivation and changing behavior.
With the increased implementation of enhanced recovery programs, the objective is discharge on
post-operative day two or three; often it is difficult to meet this objective due to the complexities
of the patient population. The goal is to ready the patient and family for a safe discharge home.
Although every nurse may not be proficient in the care of stoma patients, they are very skilled at
assisting with coping strategies and patient education. Through the application of the Theory of
Self-Efficacy, the actions of the nurse can effect positive outcomes, where the patient is
motivated and able to change behaviors.
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References
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Babcock, L. (2013, October 25). NGR5800: Paper 2 Analysis of a Nursing Problem.
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NGR5800: Theory Guiding Practice
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