Nursing theory: the 21st century.

On September 21, 1990, at the University of California, Los Angeles, Neuropsychiatric Institute and Hospital, six nurse theorists participated in a panel discussion on theory development for the 21st century. The theorists included Dorothy Johnson, Betty Neuman, Dorothea E. Orem, Rosemarie Rizzo Parse, Martha E. Rogers and Callista Roy. The panel provided the participants the opportunity to speculate on the course for future development of nursing knowledge. Three questions were posed to the panel relating to the development of their models, the direction nursing theory will take in the 21st century, and current research emerging from the extant theories. The panel also addressed questions from the audience.     

Perspectives on health

On May 12, 1989, in Pittsburgh, six nurse leaders participated in a panel discussion on health at Discovery International, Inc.'s Nurse Theorist Conference. The participants were Imogene King, Nola Pender, Betty Neuman, Martha E. Rogers, Afaf Meleis and Rosemarie Rizzo Parse. The goal of the conferences was to present views on the meaning of health from different perspectives. The panel discussion provided the nurse leaders with an opportunity to engage in a dialogue about health. Five of the participants answered the questions posed and the conference keynote speaker Afaf Meleis responded. Four questions were posed to the panel relating to the meaning of health, the uniqueness of nursing, and nurse-person relationships. The dialogue of the panel discussion follows.     

Conceptual models of nursing: international in scope and substance? The case of the Roy adaptation model

This column focuses on exploration of the international applicability of conceptual models of nursing developed by nurse theorists from the United States. Viewpoints put forward by Marilyn E. Parker and William K. Cody are presented. Then, nurse scholars from Colombia and Japan discuss their experiences with use of the Roy adaptation model in their countries.     

A multidimensional analysis of the epistemic origins of nursing theories, models, and frameworks

The purpose of this article is to introduce our notion of epistemic space and to demonstrate its utility for understanding the origins and trajectories of nursing theory in the 20th century using multidimensional scaling (MDS). A literature review was conducted on primary and secondary sources written by and about 20 nurse theorists to investigate whether or not they cited 129 different scholars in the fields of anthropology, biology, nursing, philosophy, psychology, and sociology. Seventy-four scholars were identified as having been cited by at least two nurse theorists (319 citations total). Proximity scores, quantifying the similarity among nurse theorists based on proportions of shared citations, were calculated and analyzed using MDS. The emergent model of epistemic space that accommodated these similarities among nurse theorists revealed the systematic influence of scholars from various fields, notably psychology, biology, and philosophy. We believe that this schema and resulting taxonomy will prove useful for furthering our understanding of the relationships among nursing theories and theories in other fields of science.     

Nursing models and research - a restricting view?

The question is asked, Do some nursing models present a restricting view? If so, then the type of research in nursing may be restricted also. The author examines the writings of several nurse theorists to demonstrate the development of a singular focus, the patient. This consideration is followed by an introduction to the thoughts of critics on the narrow perspective embraced by some nurses. Blind acceptance of any nursing model is questioned. The use of a model must be accompanied by discussion, exploration and adaptation. No one model provides a true picture for all nursing situations.     

Caring in an environment of change and casemix funding

Caring has been defined by nurses and consumers of health care as an integral component of nursing. Florence Nightingale was the first nurse to describe an ethos of caring, and since then other theorists and clinicians have continued to support and develop a philosophy of care. Studies have highlighted that patients and their families also value care. However, concerns have been expressed that the current health care ideology is making caring practices more difficult to enact. The new priorities in health care award financial management a place that has the potential to overtake the importance of caring in nursing. This discussion examines the options that nurses have to defend and promote a philosophy of care.     

Maintaining competence for first-line nurse managers: an evaluation of the use of the literature

The use of nursing literature is frequently advocated as a means of maintaining competence. The purpose of this study was to compare the frequency of references to competencies in the literature with those retained for the role of first-line nurse managers by an expert panel involved in the Delphi technique. In this way, the use of literature in maintaining managerial competence for first-line nurse managers was evaluated. When the 20 most frequently mentioned competencies in the literature were compared with the highest mean scores and those ranked as most important by the expert panel, only two competencies appeared on all three lists. Fifteen competencies were frequently mentioned in the literature but were not identified by the expert panel as important to the role of first-line nurse managers. A further three competencies identified in the literature were excluded by the expert panel, indicating they were not perceived to be a function of first-line nurse managers.     

Use of reflective practice in introducing change on the management of pain in a paediatric setting

AIM: The paper describes the application of a reflective model devised by the author, in the management of paediatric pain within a district hospital. BACKGROUND: The issue of bridging the theory-practice gap in nursing has encapsulated the workings of both nurse practitioners and theorists for many years, not least in the management of paediatric pain. METHODS: The reflective model, divided into seven stages, demonstrates the way in which reflective practice and management of change can be integrated. FINDINGS: Applying this model highlighted nurses' concern themselves with a theory-practice gap, but was also evident of a theory (practice knowledge)-theory (official scientific knowledge) gap that needs to be acknowledged. CONCLUSION: It is predicted that the integration of reflective practice with management of change will be useful to nurse practitioners and theorists alike who have sought to address the issue of a theory-practice gap in nursing by embracing the concept of reflective practice.     

Evaluation of MicroScan ESBL confirmation panel for Enterobacteriaceae-producing,extended-spectrum beta-lactamases isolated in Japan

We assessed use of the MicroScan ESBL confirmation panel (Dade Behring, Tokyo, Japan) for the detection of eight Enterobacteriaceae-producing extended-spectrum beta-lactamases (ESBL) species. Of 137 bacterial strains isolated from patients in 32 hospitals in the Kinki area of Japan, 91 produced ESBL and comprised 60 bacteria (of E. coli, K. oxytoca, and K. pneumoniae) targeted by the NCCLS ESBL test and 31 non-target bacteria such as chromosomal AmpC-producing bacteria (e.g., Serratia marcescens, Enterobacter spp.). Sensitivity and specificity of the MicroScan panel for the target bacteria were 92% and 93%, respectively; sensitivity and specificity for non-target bacteria were 52% and 100%, respectively. There were 20 ESBL-positive strains that were not inhibited by clavulanic acid in the MicroScan panel (3 of 32 ESBL-producing E. coli strains, 1 of 24 K. pneumoniae, 1 of 4 K. oxytoca, 8 of 13 E. cloacae, and 7 of 14 S. marcescens), and most of them were bacteria not targeted by the NCCLS test. In 19 of the 20 strains, the synergy effect of clavulanic acid was observed in the modified-double-disk synergy test using only the cefepime-disk. Because these strains had high MICs of > or = 16 microg/ml for cephamycins such as cefoxitin and cefmetazole, these strains might produce high levels of AmpC in addition to ESBL. The MicroScan ESBL confirmation panel showed excellent performance in detecting target, but not other bacteria. Addition of cefepime and clavulanic acid to the MicroScan panel may significantly improve detection of non-target bacteria.     

Communicating with children in A & E: what skills does the nurse need?

It is well recognized in the UK that up to 30% of annual attendances to Accident & Emergency (A & E) departments will be from children aged 16 years and under. Whilst much of the available literature relating to the care of children in A & E focuses upon the need for specially trained nurses and environmental improvements, there is little evidence provided as to the skills required by the A & E nurse when caring for this group of patients. This paper investigates some of the communication skills that may be needed by A & E nurses if they are to communicate effectively with pre-school children. The discussion focuses upon how these skills may be developed and the nature of the underpinning knowledge and experience required by the nurse in this context.     

Transforming healthcare with a unitary view of the human

The purpose of this article is to explicate the meaning of unitary from a historical perspective. The term was first used in ancient Greece, and its meaning has been transformed over time. The article explicates the similarities and differences among the nurse theorists who use the term unitary. It also specifies a different approach to healthcare when a unitary perspective of the human guides practice.     

Academic group practice. The physicians' view

In order to evaluate physician response to the reorganization of a traditional medical clinic into a group practice model, a randomized controlled trial was conducted using equivalent groups of patients and physicians. The group practice model, unlike the traditional clinic, provided decentralized registration, 5 days/week clinic coverage, and night/weekend phone coverage. Residents worked in small groups with an attending physician, nurse practitioner, staff nurse, and receptionist. A panel of 50 medical residents was interviewed prior to the reorganization and 1 year later. Residents in the experimental groups perceived improvements in the ancillary staff, placed a higher value on informal discussion of patient management problems, and were more satisfied with the outpatient experience. Moreover, residents in the group practices were more likely to voluntarily schedule additional clinic sessions to accommodate their patients. No change was noted in their career choices. We conclude that reorganization of a traditional medical clinic into a group practice model can result in increased physician satisfaction although it may not have a major impact on long-term career goals.     

Nursing as an emerging academic discipline

During the past decade nurse theorists and educationalists have been attempting to establish nursing as an academic discipline Nurse education is rapidly moving away from monotechnic colleges of nursing into institutes of higher education This paper presents a discussion of some of the issues associated with the emergence of nursing as an academic discipline The definition of a discipline is ambiguous and, although nursing may be said to exhibit some of the desired elements required to be classified as a discipline, it is apparent that many of these elements have not been developed sufficiently Many attempts have been made to classify nursing as 'art' or 'science' or a combination of the two Nursing epistemologists, educationalists and practitioners appear unable to determine the essence and uniqueness of nursing in order to inform practice, which is still heavily weighted toward the established academic disciplines If nursing is to survive in the echelons of higher education and gain respect as an emerging academic discipline, these recurring arguments need to be resolved     

Web-based networking in CNS education

PURPOSE: An important component of the clinical nurse specialist (CNS) educational program involves anticipatory guidance for students assimilating the CNS role. This article describes a strategy for facilitating this transition through online discussion about CNS practice among students and experienced CNSs. DESCRIPTION OF THE PROCESS: Six students in the final semester of their CNS program and 5 CNSs from across the country used the WebCT platform to participate in an online learning experience. This article outlines the process of structuring an online discussion, soliciting an expert panel, and preparing the participants. Students' concerns and panelists' responses are presented. CONCLUSIONS: Themes that emerged from students' questions to the panelists were certification and title protection; developing a career trajectory, including tips for interviewing and negotiation; and current and future trends in CNS practice. Benefits to participants are described, as well as suggestions for using Web-based discussion in other applications.     

The essential elements of a practitioners' nursing model: a survey of psychiatric nurse managers

Most of the existing models of nursing have been formulated by academic theorists rather than practising nurses. According to the literature, the template used by these theorists is their perception of what the essential elements 'nursing', 'health', 'person' and 'environment' are: the so-called 'metaparadigm' of professional nursing. However it is also generally accepted in the literature that all nurse practitioners have their own 'personal model' of nursing, invariably based upon the individual nurse's values and beliefs concerning the same elements! Within this study it was possible to enable 95 ward managers to make their views on the four elements explicit, thereby forming a basis for a practitioners' model of nursing.     

A Delphi study to determine baseline informatics competencies for nurse managers

The objective of this research study was to produce a job-specific list of informatics competencies for generic nurse manager positions. In 2002, Staggers et al (Nurs Res. 2002;51(6):383-390) identified a list of core nursing informatics competencies at four levels of nursing practice but concluded that job-specific competencies still needed to be developed. An expert panel utilized the Master List of Nursing Informatics Competencies produced in the 2002 study by Staggers et al to define the job-specific informatics competencies appropriate for generic nurse manager positions. A three-round Delphi study was utilized to establish the core competencies appropriate for this job-specific position. Participants were expert informatics nurses in the US Veterans' Healthcare System. Based on the Four Levels of Practice defined in the 2002 study by Staggers et al, the panel identified the level 2 experienced nurse as most appropriate for generic nurse manager positions. For the purposes of review, each practice level was considered to include the competencies of the levels below it. Therefore, having selected level 2 experienced nurse, this necessitated the review of levels 1 and 2, which totaled 69 competencies. From the available 69 competencies, the panel selected a total of 49 core competencies appropriate for generic nurse manager positions. This Delphi research study chose to focus on a single job-specific position to take one small step toward the recommendation of Staggers et al to identify job-specific competencies. The generic nurse manager position was selected as it is a vital position in providing leadership and support within all institutions. While the study raises several questions about how the panel elected some competencies over others, it also begins to define which levels of competencies and categories are most appropriate. With this information at hand, the next logical step would be to establish associated tools for competency development and evaluation, which could then be used to properly prepare and review individuals for the associated nurse manager responsibilities.     

Awareness of self and expanding consciousness: using nursing theories to prepare nurse-therapists

Psychotherapy is an accepted role of the advanced practice psychiatric nurse. Nursing theorists, notably Hildegard Peplau and Margaret Newman, offer guidance on the psychological and professional development of the nurse. This paper examines Newman's theory of health as expanding consciousness and the concept of awareness of self in Peplau's theory, and suggests that psychiatric advanced practice nursing programs consider the need for nurses to develop self-knowledge to facilitate the nurse-patient relationship and to improve outcomes of patient care in psychotherapy.     

Identifying nurse sensitive indicators specific to haemodialysis nursing: A Delphi approach

BackgroundNurse sensitive indicators measure the quality of care that is specific to the practice of nurses. There are currently few indicators suitable to measure haemodialysis nursing practice.AimTo identify haemodialysis nurse sensitive indicators.MethodsThe Delphi technique, an iterative process, was used to attain consensus from a national expert panel of haemodialysis registered nurses. The panel rated their level of agreement, importance and frequency of nurse sensitive indicators using online surveys that included qualitative feedback. Results of each round shaped subsequent rounds. Consensus was set at greater than 70.0%.FindingsThe 38-member expert panel had a median haemodialysis experience of 17 years (IQR 8.5–22) and 89% had attained a specialist post-registration renal qualification. Round 1 assessed the suitability of 38 nurse sensitive indicators. Those indicators failing to achieve consensus were retested and removed after round 2 (n = 12). Round 3 assessed a modified list of 26 nurse sensitive indicators with all achieving consensus. The fourth and final round was used to both provide feedback to the expert panel and to elicit further qualitative feedback.DiscussionA comprehensive set of quality indicators to measure nursing-sensitive activities in the specialised context of haemodialysis have been developed.ConclusionThese 26 haemodialysis nurse sensitive indicators capture the structures, processes and outcomes which could measure the quality of nursing care provided to people receiving haemodialysis.     

The desired competence of the Swedish ambulance nurse according to the professionals – A Delphi study

Nursing is evolving into new fields of health care including ambulance care, where a branch of specialist nursing is growing. Various views exist on the desired competence for the ambulance nurse and valid guidelines are lacking in Sweden. To increase knowledge of the field, professionals were asked to describe what competences an ambulance nurse should possess. The aim of this study was therefore to elucidate the desired professional competence of the specialist ambulance nurse, according to the professionals. A modified Delphi technique was used, where a panel of professional experts expressed their views on the desired competence of the ambulance nurse. This study reports, at a high level of agreement among the panel experts, that the desired competence of the specialist ambulance nurse consist of forty-four separate competences creating ten areas of competences: execute leadership, generic abilities, interpersonal communication, institutional collaboration, pedagogic skills, possession of relevant knowledge, professional judgement, professional skills, research activities, and technical skills. The high level of agreement among the professionals as well as the large number of competences reflects the high demands placed on the ambulance nurse by the professionals themselves.