CHAPTER 7: Grand Nursing Theories Based on Human Needs

CHAPTER 7: Grand Nursing Theories Based on Human Needs

CHAPTER 7: Grand Nursing Theories Based on Human Needs

Donald Crawford is an intensive care unit (ICU) clinical nurse specialist (CNS) who has just completed his graduate degree. Donald strongly believes that evidence guiding nursing practice should be experiential and measurable, and during his master’s program, he derived a system for evaluation of the needs of the seriously ill individuals for whom he cared. He also devised a way to diagram the disease pathophysiology for many of his patients based on the Neuman Systems Model (Neuman & Fawcett, 2009).

During his graduate studies, Donald began to apply concepts and principles from Neuman’s model in his practice with encouraging results. He observed that the model helped predict what would happen next with some patients and helped him define patient’s needs, predict outcomes, and prescribe nursing interventions more accurately. In particular, he appreciated how Neuman focused on identification and reduction of stressors through nursing interventions and liked the construct of prevention as intervention. Using his position as CNS, he is developing a proposal to implement his methods throughout the ICU to help other nurses apply Neuman’s model in managing patient care.

The earliest theorists in nursing drew from the dominant worldviews of their time, which were largely related to the medical discoveries from the scientific era of the 1850s through 1940s (Artinian, 1991). During those years, nurses in the United States were seen as handmaidens to doctors, and their practice was guided by disease theories of medical science. Even today, much of nursing science remains based in the positivist era with its focus on disease causality and a desire to produce measurable outcome data. Evidence-based medicine is the current means of enacting the positivist focus on research outcomes for effective clinical therapeutics (Cody, 2013).

In an effort to define the uniqueness of nursing and to distinguish it from medicine, nursing scholars from the 1950s through the 1970s developed a number of nursing theories. In addition to medicine, the majority of these early works were strongly influenced by the needs theories of social scientists (e.g., Maslow). In needs-based theories, clients are typically considered biopsychosocial beings who are the sum of their parts, who are experiencing disease or trauma, and who need nursing care. Further, clients are thought of as mechanistic beings, and if the correct information can be gathered, the cause or source of their problems can be discerned and measured. At that point, interventions can be prescribed that will be effective in meeting their needs (Dickoff, James, & Wiedenbach, 1968). Evidence-based nursing fits with these theories completely and comfortably.

The grand theories and models of nursing described in this chapter focus on meeting clients’ needs for nursing care. These theories and models, like all personal statements of scholars, have continued to grow and develop over the years; therefore, several sources were consulted for each model. The latest writings of and about the theories were consulted and are presented. As much as possible, the description of the model is either quoted or paraphrased from the original texts. Some needs theorists may have maintained their theories over the years with little change; others have updated and adapted theirs to later ideas and methods. Nevertheless, new research has often extended the original work. Students are advised to consult the literature for the newest research using the needs theory of interest.

It should be noted that a concerted attempt was made in this book to ensure that the presentation of the works of all theorists is balanced. Some theories (e.g., Orem and Neuman) are more complex than others, and the body of information is greater for some than for others. As a result, the sections dealing with some theorists are a little longer than others. This does not imply that shorter works are inferior or less important to the discipline.

Finally, all theory analysts, whether novice or expert, will comprehend theories and models from their own perspectives. If the reader is interested in using a model, the most recent edition of the work of the theorist should be obtained and used as the primary source for any projects. All further works using the theory or model should come from researchers using the theory in their work. Current research writings are one of the best ways to understand the development of the needs theories.

Florence Nightingale: Nursing: What It Is and What It Is Not

Nightingale’s model of nursing was developed before the general acceptance of modern disease theories (i.e., the germ theory) and other theories of medical science. Nightingale knew the germ theory (Beck, 2005), and prior to its wide publication she had deduced that cleanliness, fresh air, sanitation, comfort, and socialization were necessary to healing. She used her experiences in the Scutari Army Hospital in Turkey and in other hospitals in which she worked to document her ideas on nursing (Beck, 2005; Dossey, 2000; Selanders, 1993; Small, 1998).

Nightingale was from a wealthy family, yet she chose to work in the field of nursing, although it was considered a “lowly” occupation. She believed nursing was her call from God, and she determined that the sick deserved civilized care, regardless of their station in life (Nightingale, 1860/1957/1969).

Through her extensive body of work, she changed nursing and health care dramatically. Nightingale’s record of letters is voluminous, and several books have been written analyzing them (Attewell, 2012; Dossey, Selanders, Beck, & Attewell, 2005). She wrote many books and reports to federal and worldwide agencies. Books she wrote that are especially important to nurses and nursing include Notes on Nursing: What It Is and What It Is Not (original publication in 1860; reprinted in 1957 and 1969), Notes on Hospitals (published in 1863), and Sick-Nursing and Health-Nursing, originally published in Hampton’s Nursing of the Sick, 1893) (Reed & Zurakowski, 1996) and reprinted in toto in Dossey et al. (2005a), to name but a small portion of her great body of works. Much of her work is now available, where once it was kept out of circulation; perhaps because of the sheer volume and perhaps because she originally asked that her papers all be destroyed at her death. She later recanted that request (Bostridge, 2011; Cromwell, 2013).

Background of the Theorist

Nightingale was born on May 12, 1820, in Florence, Italy; her birthday is still honored in many places. She was privately educated in the classical tradition of her time by her father, and from an early age, she was inclined to care for the sick and injured (Bostridge, 2011; Dossey, 2000, 2005a; Selanders, 1993). Although her mother wished her to lead a life of social grace, Nightingale preferred productivity, choosing to school herself in the care of the sick. She attended nursing programs in Kaiserswerth, Germany, in 1850 and 1851 (Bostridge, 2011; Dossey et al., 2010; Small, 1998), where she completed what was at that time the only formal nursing education available. She worked as the nursing superintendent at the Institution for Care of Sick Gentlewomen in Distressed Circumstances, where she instituted many changes to improve patient care (Cromwell, 2013; Dossey, 2000; Selanders, 1993; Small, 1998).

During the Crimean War, she was urged by Sidney Herbert, Secretary of War for Great Britain, to assist in providing care for wounded soldiers. The dire conditions of British servicemen had resulted in a public outcry that prompted the government to institute changes in the system of medical care (Small, 1998). At Herbert’s request, Nightingale and a group of 38 skilled nurses were transported to Turkey to provide nursing care to the soldiers in the hospital at Scutari Army Barracks. There, despite daunting opposition by army physicians, Nightingale instituted a system of care that reportedly cut casualties from 48% to 2% within approximately 2 years (Bostridge, 2011; Dossey, 2000, 2005a; Selanders, 1993; Zurakowski, 2005).

Early in her work at the army hospital, Nightingale noted that the majority of soldiers’ deaths was caused by transport to the hospital and conditions in the hospital itself. Nightingale found that open sewers and lack of cleanliness, pure water, fresh air, and wholesome food were more often the causes of soldiers’ deaths than their wounds; she implemented changes to address these problems (Small, 1998). Although her recommendations were known to be those that would benefit the soldiers, physicians in charge of the hospitals in the Crimea blocked her efforts. Despite this, by her third trip to the Crimea, Nightingale had been appointed the supervisor of all the nurses (Bostridge, 2011; Dossey, 2000).

At Scutari, she became known as the “lady with the lamp” from her nightly excursions through the wards to review the care of the soldiers (Audain, 1998; Bostridge, 2011). To prove the value of the work she and the nurses were doing, Nightingale instituted a system of record keeping and adapted a statistical reporting method known as the polar area diagram (Audain, 2007; O’Connor & Robertson, 2003), or Cock’s Comb model, to analyze the data she so rigorously collected (Small, 1998). Thus, Nightingale was the first nurse to collect and analyze evidence that her methods were working.

On her return to England from Turkey, Nightingale worked to reform the Army Medical School, instituted a program of record keeping for government health statistics and assisted with the public health system in India. The effort for which she is most remembered, however, is the Nightingale School for Nurses at St. Thomas’

n Based on Scope

One of the most logical ways to categorize grand nursing theories is by scope. For example, Alligood and Tomey (2010) organized theories according to the scope of

CHAPTER 7: Grand Nursing Theories Based on Human Needs.CHAPTER 7: Grand Nursing Theories Based on Human Needs.CHAPTER 7: Grand Nursing Theories Based on Human Needs.