A second set of questions was then beginning to be formulated, based on a view of nursing as supporting and promoting interactions with patients. The theorists in this group did not totally ignore the first set of questions; rather, the new sets of questions complemented the first. Whereas the first questions that guided earlier theorists were related to the central one—“What do nurses do?”—the second set of questions evolved from the Yale University School of Nursing and was related to another central question—“How do nurses do whatever it is they do?” Answers to the
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TABLE 9-7 NEEDS THEORISTS—A SUMMARY
Concepts Defining Properties
Focus Problems
Nurses’ function
Human being A set of needs or problems A developmental being
Patient Needs deficit
Orientation Illness, disease
Role of nurse Dependent on medical practice Beginnings of independent functions Fulfill needs requisites
Decision making Primarily health care professional
TABLE 9-6 NEEDS THEORISTS—NURSING THERAPEUTICS
Theorists Nursing Therapeutics
Abdellah Preventive care (hygiene, safety, exercise, rest, sleep, body mechanics) Sustenal care (psychosocial care)
Remedial care (provision of oxygen, fluid, nutrition, elimination) Restorative care (coping with illness and life adjustment)
Henderson Complementing and supplementing knowledge, will, and strength of patient to perform 14 daily activities and to carry out his medical prescriptions
Orem Wholly compensatory system (nurse performs all self-care for patient) Partly compensatory system (nurse and patient perform patient self-care) Supportive-educative system (nurse helps in overcoming any self-care limitations)
TABLE 9-4 NEEDS THEORISTS—GOALS OF NURSING
Theorists Goals of Nursing
Abdellah Help individual meet health needs and adjust to health problems
Henderson Completeness or wholeness and independence of patient to perform daily activities Orem Eliminate deficit between self-care capabilities and demand
TABLE 9-5 NEEDS THEORISTS—NURSING PROBLEMS
Theorists Nursing Problems
Abdellah Condition faced by patient for which a nurse can assist, overtly and covertly (21 problems) Henderson Patient’s lack of knowledge, strength, or will to carry out 14 activities
Orem Deficiency in eight universal, two developmental, and six health deviation requisites/needs
CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 165
“how” question focused on the interaction process. Peplau was the pioneer in that group (1952);
yet, her answer was more congruent with the prevailing interest at the time in psychoanalytic the- ory and closer to the biomedical model. It is significant when studying the history of ideas to note the connection between the first school of thought at Teachers College and the second one at Yale.
The Yale or interactionist school of thought grew out of the needs approach, with some of the con- cepts still prevailing in both; this will be demonstrated in the following discussion. The conceptu- alization of Imogene King (1968), also a graduate of Teachers College, evolved out of interest in the “hows” of making decisions about nursing care.
Interaction theories were conceived in the late 1950s and early 1960s by theorists who viewed nursing as an interaction process with a focus on the development of a relationship between patients and nurses. These theories grew out of a social milieu in the United States that included the following:
• This was the post-Sputnik era.
• There was a focus on such values as human integrity, as promoted by President Kennedy.
• The Cuban missile crisis may have promoted a return to focus on humanity and relation- ships against the fear of outside invasion.
• The beginning formation of hippie groups, communal living, and the flower children indicated a definite need for intimacy and human relations.
• Technological advances continued, but with a growing distaste for mechanization and dehumanization.
Interaction theories also reflected several changes that were ongoing within the profession of nursing. Among them were two that had a direct impact on the development of interactional theories:
• Federal grant support was designated to improve the curricula and education of nurse researchers.
• A pioneering effort to develop an integrated curricula arose, freeing psychiatric nurses to identify core concepts and to integrate these concepts throughout nursing curricula, and allowing them to observe and reflect on the processes of utilizing mental health concepts in all nursing subspecialties.
Tables 9-8 through 9-12 present theories that focused on interaction. Although some of the interaction theorists continued to address the needs of the patient, all the interactionist theorists
TABLE 9-8 INTERACTION THEORISTS—A VIEW OF NURSING
Theorists Definitions
King A process of action, reaction, and interaction whereby nurse and client share information about their perceptions of the nursing situation and agree on goals
Orlando Interaction with patients who have a need or response to suffering individuals or those anticipating helplessness
Assistance to individual to avoid, relieve, diminish, or cure sense of helplessness Paterson and Zderad A human dialogue, intersubjective transaction, a shared situation, a transactional
process, a presence of both patient and nurse Peplau Therapeutic interpersonal, serial, goal-oriented process
A health-focused human relationship
Travelbee An interpersonal process, an assistance to prevent, cope with experiences of illness and suffering, and to find meaning in these experiences
Wiedenbach Sensing, perceiving, validating patients need for help, ministering help needed in a deliberate, goal-oriented way
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focused on the processes of care and on the various interaction episodes between nurses and clients. Their theories were based on interactionism, phenomenology, and existentialist philosophy.
See Table 9-13 on page 168 for a summary of the major components of the interaction theories.
What did we learn from the interactionists?
• Nurse–patient interaction is fundamental to providing care.
• Nursing is a deliberate process that can be elucidated.
• Nursing encompasses help and assistance.
• Nursing is an interpersonal process occurring between a person in need of help and a per- son capable of giving help.
• The nurse, to be able to give help, should clarify her own values, use the self in a therapeu- tic way, and be involved in the care.
TABLE 9-10 INTERACTION THEORISTS—GOALS OF NURSING
Theorists Goals of Nursing
King Help individuals maintain their health so they can function in their role Orlando Relieve distress, physical and mental discomfort
Improve sense of well-being
Paterson and Zderad Develop human potential, more well-being for both patient and nurse Peplau Develop personality, making illness an eventful experience
Forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive personal and community living
Travelbee Cope with an illness situation and find meaning in the experience Assist patient to accept humanness
Wiedenbach Meet the needs of an individual experiencing need for help
TABLE 9-9 INTERACTION THEORISTS—FOCUS OF NURSING
Theorists Focus of Nursing
King Nurse–patient interactions that lead to goal attainment in a natural environment Orlando Care for the needs of the patients who are distressed, with consideration for perception,
thought, and feeling through deliberate action Paterson and Zderad Patient is a unique being
Patient’s perception of events Both patient and nurse are the focus Peplau Nurse–patient relationship and its phases
Orientation, identification, exploitation, and resolution
Harnessing energy from anxiety and tension to positively defining understanding, and meeting productively the problem at hand
Travelbee Interpersonal relations, finding meaning in suffering, pain, and illness Self-actualization
Wiedenbach Patient’s perception of condition, care, action
CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 167
• Care is not a mechanistic act but a humanistic act.
• The humanistic interactionist nurses used existential philosophy, symbolic interaction, and developmental theories to develop their conceptions of nursing.
• Patient-centered care is based on developing a relationship with patients.
• Illness is defined as an inevitable human experience; if one learns to find meaning in it, it will become a growing experience. In this, these theorists differ from the previous group of theorists who defined illness as a deviation that must be corrected.
• Nursing is defined as caring, assisting (all other health care professionals), and helping patients to find meaning and actions that increase human potential and improve well- being.
• Nurses need systematic knowledge to help them in assessing, diagnosing, and intervening.
• The nursing process is well developed by these theorists.
• Properties, antecedents, and consequences of interactions are advanced by this group of theorists, and all the theories reflect the relationships that are formed to relieve distress, as well as those formed to enhance trust.
TABLE 9-11 INTERACTION THEORISTS—NURSING PROBLEMS
Theorists Nursing Problems
King When nurse and patient do not perceive each other, the situation, or communicate information, transactions are not made, goals are not attained
Orlando Distress due to unmet needs
Paterson and Zderad Persons with perceived needs related to the health/illness quality of living Peplau Unsuccessful or incomplete learning of life tasks
Energy used in tensions and frustrations due to unmet needs, opposing goals—giving rise to conflict, aggression, anxiety
Discomfort, anxiety, doubt, guilt, obsession, compulsion Travelbee Lack of support in nurse–patient relationship
Not finding meaning in illness, transitory discomfort, anguish, malignant despair, apathetic indifference
Wiedenbach Person with need for help (unmet needs due to physical or inadequate environment)
TABLE 9-12 INTERACTION THEORISTS—NURSING THERAPEUTICS
Theorists Nursing Therapeutics
King Goal attainment, transaction, perceptual validation Orlando Deliberate nursing process not automatic
Paterson and Zderad Humanness—use of nurse’s self, existential nurturing, being, relating, meeting, maximum participation
Peplau Development of problem-solving skills through the interpersonal process (educational, therapeutic, and collaborative)
Travelbee Use of nurse’s self, original encounter, emerging identities, empathy, sympathy, rapport Wiedenbach Ministration of help, validation, rational, reactional, and deliberate
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• These theories mark the beginning of a movement that led toward the patient becoming an equal partner in the nursing process.
• The interactionist nurse considers uniqueness, dignity, and worth values of patients as important in the development of wellness. The view of an autonomous individual with individually established norms was beginning to emerge. Help, it was emphasized, was to be tailored to individual needs.
• Properties of interaction as validation (Wiedenbach), as meeting the needs of patients (Orlando), as being totally present, and as relating to others (Paterson and Zderad) are delineated and defined by this group of theorists.
• The theories concede that perceptions of the patient are important in assessing illness and its meaning.
• The major nurse–patient interaction relationship goal is derived from their observation that the person in need of help becomes distressed; the purpose is to prevent or deal with this distress.
• The interactionist theorists remind us that nurses are human beings who need to participate in self-reflection to understand their own values. Without such understanding, nurses will not be able to care, give care, establish connections, and help patients relieve their distress.
• The theorists tentatively introduced the notion of effect of environment on patients. To them, unmet needs of the patient develop because of:
~ Physical limitations (from incomplete development, temporary or permanent disability, or restrictions in environment)
~ Adverse reactions to inadequate environment (Orlando)
• This group of theorists reintroduced the significance of nurses’ intuition and subjectivity in the nursing act.
• Some common assumptions guided the development of the interactionist theories. These are:
~ The integrity of an individual has to be maintained.
~ Individuals have self-awareness and are therefore able to identify their needs.
~ Individuals strive toward actualization.
~ Events in life are human experiences inevitable and essential in helping to move to the next stage in development.
TABLE 9-13 INTERACTION THEORISTS—A SUMMARY
Concepts Defining Properties
Focus Nurse–patient interactions
Illness as an experience Human being Interacting being
A set of needs Can validate needs
Human experience with meanings
Patient Helpless being
A human experience with meaning Orientation Illness/disease
Role of nurse Deliberate helping process Self as a therapeutic agent Use of the nursing process Decision making Primarily health care professional
Validated by clients
CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 169
~ The nurse cannot separate herself as an individual from the act of care—the nurse is an integral part of care.
~ Within the historical context of the discipline’s development interaction theorists pro- vided nursing with a new perspective on viewing the nursing care act:
~ There is a reciprocal assessment process.
~ Patient perspective is significant in health care.
~ Situation determines needs and care.
~ Patients are helpless and suffer due to illness.
A number of concepts were identified by the interaction theorists as central to nursing. These concepts continue to be significant components of the discipline of nursing. These concepts are integral to nurses’ roles and actions in planning, providing, and evaluating care:
Sensing Perceiving Validating
Existential transactions Goal orientation of interaction Nurses’ self-development
Interaction theories neither addressed nor focused on:
A more complete view of a human being (human beings are interacting beings with a minimal focus on biopsychocultural focus) as a biophysiological and a genetic being A view of the environment, although the centrality of environment was tangential in some
of the theories