Chapter 13: Nursing Theory: The
Basis for Professional Nursing
Bonnie M. Wivell, MS, RN, CNS
Nursing Theory
 Latin “a viewing”; Greek “contemplating”
 A body of knowledge shaped by how nurses see
the world
 A group of related concepts, definitions &
statements that propose a view of nursing
phenomena from which to describe, explain or
predict outcomes
 Abstract ideas
Why is Theory Important?
 Nursing is strengthened when knowledge is built on
sound theory
 Criteria to be a profession: distinct body of
knowledge as the basis for practice
 Nursing must be viewed as a scholarly academic
discipline hat contributes to society
 Ultimate goal is to support excellence in practice
Theory Guides the Professional
Nurse in….
 Organizing and analyzing patient data
 Understanding connections between pieces of data
 Discriminating between important and less pertinent
data
 Making sound clinical judgments based on evidence
 Planning effective nursing interventions
 Predicting and evaluating outcomes of interventions
Definition of Terms
 Metaparadigm = the major concepts or abstract ideas of the
discipline; most important to practice and research
 Person
 Environment
 Health
 Nursing
 Philosophy = a set of beliefs about the nature of how things
work and how the world should be viewed; begins to put
together some or all concepts of the metaparadigm
Definition of Terms Cont’d.
 Conceptual Model or Framework = a more
specific organization of nursing phenomena than
philosophies; provide an organizational structure
that makes clearer connections between concepts
 Propositions = statements that describe linkages
between concepts and are more prescriptive; they
propose an outcome that is testable in practice
and research
Florence Nightingale
 Notes on Nursing:What It Is and What It Is Not (1969, originally
published in 1859)
 Her philosophy of health, illness, and the nurse’s role in caring for
patients
 Focused on the relationship of patients to their surroundings
 Importance of observing the patient and recording
information
 Importance of cleanliness
 Health and recovery from illness is related to environment
Virginia Henderson
 The “Unique function of he nurse… is to assist the
individual, sick or well, in the performance of those
activities contributing to health or its recovery (or a
peaceful death) that he would perform unaided if he
had the necessary strength, will or knowledge.”
 Nurse’s role = substitute for the patient, a helper to
the patient or a partner with the patient
 14 basic needs of the patient (see Box 13-3 on pg.
308)
Jean Watson
Studied at CU
The Philosophy and Science of Caring (1979)
Emphasized the caring aspects of nursing
10 Carative factors (see Box 13-4 on pg. 309); these factors
differentiate nursing from medicine (curative)
 Illness or disease equated with lack of harmony within the
mind, body, and soul
 RN responsible for creating and maintaining an environment
supporting human caring while recognizing and providing
for patient’s primary human requirements
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Watson Continued
 Proposed that nursing be concerned with spiritual
matters and the inner knowledge of nurse and patient as
they participate together in the transpersonal caring
process
 Nurses share their genuine self
 Patient’s spiritual strength is recognized, supported, encouraged
 RN encourages openness to understanding of self and others
 Leads to trusting, accepting relationships where feelings are
shared and confidence is inspired
Dorothea Orem
 Concept of self-care
 “Ordinary people in contemporary society want to be in
control of their lives.”
 Patient’s baseline ability to provide adequate self-care is
assessed
 Systems of care
 Wholly compensatory
 Partially compensatory
 Supportive-educative
Imogene King
 A Theory for Nursing: Systems, Concepts, Process (1981)
 Focused on persons, their interpersonal relationships, and
social contexts with three interacting systems
 Personal
 Interpersonal
 Social
 Emphasizes goal attainment and patient’s involvement in
setting goals (Goal Attainment Model)
Sister Callista Roy
 Introduction of Nursing: An Adaptation Model (second edition
1984)
 Individual as a biopsychosocial adaptive system
 Nursing is a humanistic discipline that emphasizes the
person’s adaptive and coping abilities
 The environment can be manipulated by the RN to further
patient’s adaptation
Hildegard Peplau
 Interpersonal Relations in Nursing (1952 & 1988)
 Relationship between patient and nurse is the focus of
attention
 Therapeutic interpersonal relationship
 Survival of the patient
 Patient’s understand his or her health problems and learn from them
as they develop new behavior patterns
 6 roles of the nurse: counselor, resource, teacher, technical
expert, surrogate, and leader
Ida Orlando
 The Dynamic Nurse-Patient Relationship: Function, Process and
Principles (1961)
 Observation and confirmation of patients’ verbal and nonverbal behavior, which identify patient needs
 Goal of the nurse is to determine and meet patients’
immediate needs and improve their situation by relieving
distress or discomfort
 Individualize care by attending to behavior
Madeleine Leininger
 Theory of cultural care
 Founder of Transcultural nursing
 Patients viewed in the context of their cultures
 Nursing care should be culturally congruent
 “Sunrise Model” (Figure 13-2, pg. 317) guides the
assessment of cultural data for an understanding of
its influence on the patient’s life
Theory-Based Education
 PhD: a research degree that generates new, discipline-
specific knowledge
 Master’s: use theoretical perspectives focused on the
patient for specific nursing outcomes; base practice on
evidence from research & experience
 BSN: introduced to research process & the use of theory
to guide it
 ADN: find middle range theories useful as they are
specific to patient care
Theory-Based Practice
 Occurs when nurses intentionally structure their practice
around a particular nursing theory and use it to guide them
in their care of the patient
 Provides a systematic way of thinking about nursing that is
consistent and guides the decision-making process
 Challenges conventional views of patients, illness, the health
care delivery system, and traditional nursing interventions
Benefits
 Explain practice to others
 Passes on knowledge to students
 Contributes to professional autonomy
 Develops analytical skills, challenges thinking,
and clarifies your values and assumptions
Theory-Based Research
 Great strides have been made in the last 25 years in
nursing research
 Nursing research tests and refines the knowledge base of
nursing
 Research findings enable nurses to improve the quality of
care and understand how evidence-based nursing
influences patient outcomes
 Research is vital to the future of nursing and theory is
integral to research
Chapter 14: The Health Care
Delivery System
Bonnie M. Wivell, MS, RN, CNS
Health Care Delivery
 The four basic types of services provide by the
health care delivery system
 Health Promotion: remain healthy
 Illness prevention: reduce risk factors
 Diagnosis & treatment: refined methods of diagnosis
allow for more effective treatment
 Rehabilitation & LTC: restore function &
independence; disease management
Health Care Agencies
 Government: Contribute to health of all U.S.
citizens; supported by taxes; Federal, State, Local
 Voluntary (Private): Support via private
donations, government grants
 Not-for-profit: Profits used on behalf of agency
 For-profit: Profits distributed to partners or
shareholders
Level of Health Care Services
 Primary Care Services: first entry into system, emergency
care, health maintenance, LTC, chronic care, temporary
health problems
 Secondary Care: prevent complications from disease; home
health, ambulatory care, skilled nursing agencies, and surgery
centers; disease management via electronics
 Tertiary Care: acutely ill to LTC to rehab to terminally ill;
interdisciplinary; specialized hospitals: trauma centers, burn
centers, specialized peds centers; LTC facilities that offer
skilled nursing, intermediate care and supportive care; rehab
centers; hospice
 Subacute Care: Inpatient care between hospital and longterm care
Organizational Structures of Health
Care Agencies
 Board of Directors: carry responsibility for mission,
quality of services, finances
 Chief Executive Officer (CEO): overall daily operation
 Medical Staff: physicians granted privileges; organized by
service/dept.
 Chief of staff work with CEO to make important decisions
about medical policy
 Nursing Staff: RNs, LPNs, NAs and clerical staff;
organized according to units
 Chief Nurse Executive (CNE) or Chief Nursing Officer (CNO)
today on Board of Directors, oversee nursing care
Nursing Organization Governance
 Nurses govern themselves though the organization
 Shared governance = founded on the philosophy that
employees have both a right and a responsibility to govern
their own work and time within a financially secure, patientcentered system
 Promotes decentralization and participation at all levels of
nursing
Maintaining Quality
 Accreditation: accrediting bodies approved by CMS; to
improve pt. outcomes; institution wide initiatives
 JCAHO (Joint Commission): not-for-profit that serves as the
nation’s predominant standards-setting and accrediting body in
health care
 HFOP (Healthcare Facilities Accreditation Program): Standards
met in all depts.
 Continuous Quality Improvement (CQI)/Total
Quality Management (TQM): examine processes to look for
ways to improve services before mistakes occur; anticipate
potential problems and prevent their occurrence
 Performance Improvement (PI): organizational efforts
to improve corporate performance; focuses efforts on
increasing individual and group competence and productivity
Health Care Disparities
 Defined as differences in the quality of health care provided to
different populations
 Can be due to race, ethnicity, gender, age, income, education,
disability, sexual orientation, and place of residence
 Little progress has been made in narrowing disparities
 Provider bias possible contributing factor
Health Care Team
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Physicians
Physician Assistants
Patient Care Technicians
Dietitians
Pharmacists
Technologists
Respiratory Therapists
Social Workers
Therapists
Administrative Support Personnel: admissions, medical
records, billing, etc.
Nurse’s Role on Team
 Provider of Care: direct hands on care
 Educator: teaching pt., family, new staff, community, etc.
 Counselor: emotional support & problem solving
 Manager: organizes care
 Researcher: investigates how nursing interventions impact
patient outcomes
 Collaborator: works with patients, families & team on agreed
patient outcomes
 Patient Advocate: stands up for patient rights; advocates for
patient’s best interests at all times
Types of Nursing Care Delivery
 Functional Nursing: focuses on functions/tasks; personnel
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work side by side each performing an assigned task
Team Nursing: RN is team leader, oversees, assesses,
documents; LPN direct care, treatments, procedures; NA
personal care
Primary Nursing: one nurse accountable for nursing care of
patient during stay on unit; delegates care while off duty
Case Management Nursing: oversees pt. care and manages
the delivery of services from entire health care team
throughout patient’s illness
Patient-centered Care: contemporary model focusing on
patient’s rights to individualized care
Financing Health Care
 In 2007 the nation’s health care expenditures reached $2.2
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trillion and consumed 16.2% of the gross domestic product
By 2018 health care costs are expected to reach $4.4 Trillion
Basic Economic Theory: supply/demand; Does it relate to
health care?
Free-Market economy: consumption determined by an
individual’s ability to pay
Price sensitivity in health care: third party payers (employer,
insurance company, or government) removed price
sensitivity from the concern of most health care consumers
because they pay only a portion of the actual costs
Additional influences: can’t delay care
Economics of Nursing Care
 Nursing accounted for 20-28% of the costs of
hospitalizations in 1980s
 To stay in business, hospitals must make at least enough
money to pay personnel, maintain buildings and
equipment, and pay suppliers
 ANA: overzealous cost-containment efforts have led to
lower quality hospital care
 Aiken, Clark, Sloane et al, 2006 research links nursing
and quality of care; increased patient death rate with
higher nurse:patient ratios
History of Health Care Finance
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Before 1945, 90% paid out of pocket or charity care
Growth of Private Insurance → tax exempt
Rise of Public Insurance Programs (1965)
Medicare
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Part A = Hospital Insurance
Part B = Medical Insurance (20% co-pay, deductible
Part C = Managed care option
Part D = Prescription drug coverage
 Medicaid
 Federal government contributes 50-76.8%
 Personal (out-of-pocket) payment
 Worker’s Compensation
Forces Changing Health Care
 Managed Care attempts to control healthcare costs;
health promotion not illness treatment
 Health Maintenance Organization (HMO): health care
services provided for a predetermined fixed fee
 Capitation: same amount paid to provider each month
regardless of whether services were provided or how much the
services cost
 Gatekeeper: PCP, responsible for referrals
 Preferred Provider Organization (PPO): contracts with
provider for discounted rate
Forces Changing Health Care
 Point-of Service Organization (POS): choice of service
within network; or outside network pay higher $
 Physician Hospital Organization (PHO): corporation formed
by hospital/physician to contract with managed care
organization
Nurse’s Role in Managed Care
 Advanced Practice Nurses: ambulatory and
community settings
 Case Manager
 Triage
 Utilization reviewers to determine most
appropriate and cost-efficient level of care
Change in Consumer’s Expectations
 Became more educated and fight for rights to
health care through political reform and the
legal system
 Proliferation of internet websites has
dramatically affected the knowledge and
expectations of consumers
Health Care’s Response
 Reengineering: rethinking & redesigning
 Patient-centered care: patient at center of activity and
designing outcomes
 Decentralization: staff exercise own judgment
 Cross-functional teams: people form all areas of the
organization who contribute to a particular process
 Multi-skilled workers: single worker cross-trained to do
different tasks
New Organizational Models
 Functional Model: defines each major function of the
organization and establishes clear lines of managerial
authority
 Service Line Model: establishes management
responsibilities around specific types of services
wherever they occur in the hospital
 Matrix Model: complex with multiple authority and
support systems
 Process Model: organizes management of care around
phases in the process of healthcare delivery
 Regional Model: complex health care systems that grew
from acquisitions; organized by type of service provider
Continued Escalation of
Health Care Costs
 Inflation
 New Technology and Drugs
 Increased Demand for Healthcare Services – more elderly &
uninsured
 Fraud and Abuse of Payment Systems - $75 billion of US annual
health expenditures may be attributable to fraud
Cost Containment Measures
 Centers for Medicare & Medicaid Services – contracts private
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insurance agencies to service the Medicare program
Professional Review Organizations (PROs) – monitor the quality
of care received
Diagnosis-Related Groups (DRGs) – diagnoses with similar
resources consumptions and LOS patterns into a single category;
495 DRGs
Block Grants – state given set amount of money based on
caseload, etc.
Continued Expansion of Managed Care – largest provider; limits
consumer choices but not intended to reduce quality of care
Health Care Finance Challenges
 Continuing Crisis: Uninsured Americans
 Quality of Care
 Limits on Choice and Services
 Provider Restrictions & Financial Incentives to
Limit Services
 Cost of Prescription Drugs
 Malpractice Costs & Impact of Access to Care
Health Care Reform
 The US and South Africa are the only two
industrialized nations that do not provide
universal access to health care
 System-wide health reform efforts were
supported by public opinion but failed to pass
congress