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Critical care nursing in the 21st century
Original article
Critical care nursing in the 21st century Fiona Timmins
Introduction
Fiona Timmins RGN, BNS, RNT, FFNRSCI, NFESC, MSc, Lecturer, School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland (Requests for offprints to FT) Manuscript accepted: 26/11/01
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Nursing as a scientific discipline is in the early stages of development. The nursing profession requires knowledge developed through the systematic study and development of ‘theories in nursing’ (application of theories and knowledge from other disciplines) and ‘theories of nursing’ (definition and differentiation of nursing phenomena as distinct from other disciplines) (Kim 1983). Nurse theorists have focused on the development of ‘theories of nursing,’ but ‘theories in nursing’ are less well developed; both types of knowledge are required to develop in-depth understanding of nursing situations (Kim 1983). ‘Models’ of nursing have developed from theories of nursing, describe the patient condition and inform nurse activities (Kim 1983). When considering theoretical domains of nursing, models of nursing can be categorized under the domain ‘nursing action’ (Kim 1983). This domain, Kim (1983) contends, is the central tenet of nursing as it embraces all the elements of nursing and concerns the ‘how to do’ and ‘what to do’ of the profession. However, nursing action is not fully described in many models of nursing (Kim 1983). Several contemporary authors contend that theories of nursing and models of nursing are inadequate to inform the complexity of healthcare situations (Marks-Maran 1998; Spitzer 1998a). The use of the Nursing Process, although neither a theory nor a model, but merely a framework to assist with nursing decision-making and operationalization of many nursing models, has also yielded similar criticism (Marks-Maran 1998; Spitzer 1998a). This criticism of traditional notions of nursing, and of nursing care delivery, has emanated
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doi:10.1016/S0964-3397(02)00006-X, available online at http://www.idealibrary.com on
from theorists who subscribe to postmodern ideology. Postmodern rejection of theories of nursing, models of nursing and the use of the Nursing Process stem from the postmodern rejection of ‘grand theories’ to inform practice. Postmodernism challenges the modernist idea of a single transcendent meaning of reality and the importance of the search for empirical patterns that correspond to and represent ultimate meaning. (Reed 1995, p. 3)
The concern lies with the individual meaning and context of each situation rather than the notion of ‘one model fits all.’ With words akin to a ‘conspiracy theory,’ Spitzer (1998b) suggests that conceptual models of nursing and the Nursing Process were developed in an attempt to excel in the ‘positivist paradigm’ rather than for the benefit of the profession (Spitzer 1998b). Marks-Maran (1998) and Spitzer (1998b) both contend that current theories of nursing are not capable of solving central issues to nurses or addressing the complex nature of health and healthcare situations. Under the current, mainly positivistic paradigm, Spitzer (1998b) suggests that, ‘nursing has difficulties in highlighting to both patients and the system where nursing can and does make a difference.’ Spitzer (1998b) suggests that it is obvious that the current paradigm within nursing is a ‘misfit’ and a new paradigm is required. Marks-Maran (1998) and Spitzer (1998b) suggest that, as nursing occupies a central role in an ever-changing, complex healthcare system, nurses should begin to examine the philosophical perspectives that inform their practice, and critically examine current theories of nursing. Reed (1995, p. 2) acknowledges that postmodernism presents a challenge to nursing:
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For the past several years, nurses have been feeling the ground shift with the reforming of philosophic ideas that launched nursing as a science. Not since the advent of modernism and the birth of modern nursing at the end of the 19th century has nursing science been faced with such a wealth of possibilities for knowledge development. These possibilities . . . are nurtured by the current dialogue postmodern thought has precipitated. (sic)
However, Reed (1995) also cautions against losing sight of the rich knowledge of the past. Reed (1995) suggests that the gap should be bridged between modern and postmodern philosophies to allow nursing to develop and clarify contemporary approaches to knowledge development. Reed (1995) calls to current theorists and practitioners to ‘build on the accomplishments of modernist nursing while exploiting opportunities of the postmodern context.’ Western society is undergoing tremendous change. The changes that have taken place during the last 30 years are more far-reaching and significant than in the 100 years prior to this time (Marks-Maran 1998). Critical care units have become highly complex technological environments requiring nursing staff with a high degree of knowledge and skill (Adam & Osborne 1997). Clinicians are accountable and responsible for their own practice; they are also accountable to the law, patients, to their professional regulatory bodies and to the organization in which they operate. It is time now for critical examination of the theory that informs their practice. It is likely that the 21st century, with its inherent complexity and constant change, will require that nurses operate from a postmodern perspective, where complexity and unpredictability are recognized aspects of nursing care delivery. To ensure that critical care nurses remain responsive to the challenges of the 21st century, it is essential that they examine the philosophical perspectives that inform their practice, and critically examine current nursing theory and practice. The aim of this paper is to examine philosophical perspectives of nursing and to explore the development of nursing knowledge as articulated in ‘theories of
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nursing,’ models and the Nursing Process in order to explore possibilities for their continued use in a postmodern era.
Philosophical perspectives of nursing Philosophy is the study of abstract problems concerned with nature of existence, knowledge, morality, reason and human purpose (Teichman & Evans 1995). Philosophies of nursing have been in existence for over a century (Rutty 1998). The 1950s and 1960s saw nursing striving to form a science base for the discipline, and positivism became the underlying paradigm. Positivism, which developed during the 18th century, still profoundly influences many disciplines including medicine and nursing (Marks-Maran 1998). It has been valuable for the progression of medicine, the explanation of diseases, their causes and treatments and has contributed to major improvements in world health. This scientific paradigm or positivism, which still dominates both medicine and nursing, is founded on the belief that reality is orderly and predictable. Positivism attempts to understand a phenomenon through breaking it down into its component parts, subjecting it to analysis and applying understanding (Spitzer 1998b). Throughout the western world, positivism is no longer seen as the dominant world view and a paradigm shift is taking place among all disciplines, including nursing (Watson 1995). This paradigm shift, termed postmodernism, has occurred because previous philosophical perspectives are no longer wholly applicable. Positivism, which subscribes to the view that everything operates in a mechanical way, that can be determined, controlled and predicted is no longer sufficient to explain the inherent complexity of the world (Marks-Maran 1998; Spitzer 1998b; Watson 1995). This criticism of the positivistic paradigm is particularly relevant in nursing situations, where nursing interventions and outcomes are often context-dependent. However, despite this new awareness, the positivistic paradigm remains dominant within medicine and nursing. Spitzer (1998b) supports this notion and suggests that positivism underpins many of the theories of nursing used in nursing today. This
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theory informs nursing practice and is often operationalized through the use of ‘models.’ Silva and Rothbart (1984) reveal that positivism underpinned almost all theories of nursing until 1969 and that, since then, although there has been a steady progress away from positivism as the dominant philosophy, positivism remains explicit in most theory. Recent approaches to theory development include the incorporation of humanistic psychology, which considers the notion of man as a person rather than espousing a mechanistic view. Humanistic psychology supports the notion of the mind and soul, which are redundant in a positivistic view of man (Lister 1997). However, Mitchell (1996) contends that both humanism and positivism are based on assumptions of objectivity, truth and certainty, all factors that are rejected by the more recent philosophical position of ‘poststructuralism.’ Poststructuralism emphasizes the dynamism of language and meaning. It aims to challenge established knowledge by ‘deconstructing’ the linguistic organization of the subjective self (Lister 1991). Deconstruction refers to an ongoing analytical procedure that aims to draw out inconsistencies (Lister 1991). Poststructuralism has been interpreted as a subset of postmodernism. However, there is no all-embracing postmodernist philosophical position (Lister 1991). A postmodern era is characterized by pluralism, variety and contingency where positivistic beliefs in science, truths, objectivity and certainty are undermined (Mitchell 1996). Lay knowledge emerges as an important concept (Mitchell 1996). From a nursing perspective, this implies that patients need greater involvement in their care, including patient assistance in the use and selection of models of nursing (Graeme 2000). It could also include eclectic choice of nursing model (Lister 1997) or building on established theory using the ideas and views of nurses locally towards developing a model for use (Graeme 2000; Mitchell 1996). A further notion is the development and exploration of nursing knowledge using interpretive approaches (Benner 1984; Benner et al. 1999; Parton 1994). Complexity is another postmodern phenomenon (Spitzer 1998b). Spitzer (1998b) suggests that the healthcare system is one of the most complex systems known to society,
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comprising many complex internal and external interactions. Healthcare too is becoming increasingly complex, with the advent of competition, technology and the changing nature of health and illness. Patients are also inherently complex systems. Complex systems such as this must be viewed as a whole; any attempt to deal with these in a positivistic manner, through their component parts is futile (Spitzer 1998b). In complex systems, a change in any one part has implications for many other parts. These changes and their effects are unpredictable. The idea that one theory or model of nursing fits all situations becomes redundant in the postmodern context. Although uniformity is needed to a certain extent in healthcare settings, prescribing one model of nursing for use in practice is futile (Lister 1997; Robinson 1993).
The development of nursing knowledge The first period of nursing knowledge and practice development took place during the late 19th century and early 20th century and was based largely on women’s contributions. Because of their place in society and the predominance of the biomedical model, the mainly intuitive and experiential knowledge remained ‘silent’ (Rutty 1998). From 1950 to 1970, nursing theorists began to articulate nursing knowledge and practice, often through the use of theory from other disciplines such as psychology. Theories of nursing developed and from these, models of nursing emerged to inform nursing actions (Rutty 1998). Carper (1978) examined early nursing literature and identified four patterns of knowing that nurses have valued and used in practice. One of the patterns is empirics—the science of nursing. In addition, she identified ethics—the component of moral knowledge in nursing; aesthetics—the art of nursing; and personal knowing in nursing. These patterns have endured as essential aspects of nursing knowledge for more than a century. The science of empirics emerged during the late 1950s (Carper 1978). Empirics as a pattern of knowing yields from the philosophical perspective of positivism. During the 1950s and 1960s there was an emphasis on the use of
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empirical knowledge in nursing which resulted in the development of the Nursing Process. The Nursing Process incorporates a series of systematic steps in planning individualized patient care, assessment, planning, implementation and evaluation. This concept was recommended to the Department of Health for use in Ireland, by the Working Party on General Nursing in 1980 (Department of Health 1980). It has been adopted generally by the nursing profession and remains the major framework for nursing practice today (Deloughery 1998). Since the 1950s there has been a steady increase in the development of theories of nursing, and models of nursing have evolved from this theory to inform nursing practice (Rutty 1998). The Nursing Process was developed in the 1950s in response to the scientific movement, which had a profound influence on nursing practice (Clark 1998). Both the Nursing Process and nursing models are in widespread use in nursing situations today, and nurses educated in the UK have been encouraged to use the Nursing Process to assess, plan, deliver and record nursing care since the 1970s (General Nursing Council 1977, cited in Griffiths 1998). The introduction and use of the Nursing Process resulted in a need to establish a knowledge base specifically related to nursing. As a result, nursing theorists advocated the use of specific theories of nursing (Aggleton & Chalmers 2000). Theory development was viewed as a means of clearly establishing nursing as a profession and also emerged from the belief in the intrinsic value of theory for nursing (Walker & Avant 1995). Grand theories of nursing are described in the theory development literature, and consist of global conceptual frameworks defining broad perspectives for nursing and ways of viewing nursing. Grand theory has attempted to make conceptual distinctions between nursing and medicine, by highlighting the presence of distinct nursing perspectives. Contributors to grand theory include Orem (1971) and Roy (1976). The term ‘conceptual models’ is also used to describe grand theory (Fawcett 1989). Theories are often graphically represented by the use of models of nursing, which correspond directly to the theory.
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Kim (1983) suggests that theory development within nursing requires further progress. Theory needs to be tested in practice and extensive conceptual clarification is required. Kim (1983) also suggests that a gap exists between theory development and use of theory in practice. This is in part due to a lack of dialogue between practitioners and theorists as well as the structural spread of practitioners in various fields. One way of narrowing this gap is for practitioners to examine the usefulness of theories of nursing at a practice level. This examination should provide areas for further research, which would further enhance theory development (Kim 1983). Kim (1983) also suggests that a diversity of techniques of inquiry would aid reformulation of theories of nursing ‘‘the theme of nursing science has to be ‘discovery’ and ‘expansion.’’’ Hence, theory development may be informed by both qualitative and quantitative methodologies, rather than an over-reliance on the latter, which was a feature of early theories of nursing. It is also clear that the practical application of theories of nursing, which is often operationalized through models of nursing, requires some work in order to bridge the gap, real or hypothesized that exists between theory and practice. Kim (1983) highlights that many models of nursing fail to inform practitioners about ‘how to’ perform nursing actions. This may explain why, in practice, nurses often express difficulty with the use of models of nursing (Mason & Chandley 1992). From a postmodern perspective, difficulty with application of theories of nursing, models of nursing and the Nursing Process is due to the subscription of these concepts to positivism, which no longer ‘fits’ nursing situations. These concepts all suggest to the practitioner that the world (and the individual) is ‘orderly’ and ‘predictable.’ Postmodern thought emphasizes that reality is not ordered and mechanistic and there are multiple positions from which it is possible to view reality. Postmodern thought rejects the notion of ‘grand’ theories of nursing. However, the development, absorption and utilization of theories of nursing, mainly through the use of models of nursing and the Nursing Process in practice, has resulted in a commitment to the positivistic paradigm by the nursing profession (Clark 1998).
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Despite the concerns of postmodern advocates, theory development in nursing has undoubtedly contributed to the professional development of nursing and its development as a scientific discipline. Theories of nursing, models of nursing and the Nursing Process have informed the education of nurses for many years, and although ultimate effects on patient outcome are not empirically tested, benefits such as clear documentation and ease of translation of nursing practice to students clearly contribute to the progression of nursing (Tierney 1998).
The suitability of models of nursing and the Nursing Process to the postmodern era Abstract models derived form theories of nursing are commonly used in practice situations, often in conjunction with the Nursing Process and documented using a ‘care plan.’ Both the Nursing Process and nursing models reflect positivistic philosophies, whereby patients, patients’ conditions and nursing situations are broken down into component parts and analyzed (Clark 1998; Marks-Maran 1999). This approach to complex healthcare situations may not be entirely suitable in a postmodern era, where patient participation and dialogue is important and where the complexity of the world is acknowledged. There is also growing awareness that science does not have all the answers and it is postulated that nursing decisions do not necessarily follow a linear pathway. In practice, nurses often express difficulty with the use of models and the Nursing Process, there is often a feeling of powerlessness as nurses feel unable to attain change in this area (Mason & Chandley 1992). In addition, the use of the Nursing Process and nursing models has often come about due to a ‘top-down’ approach by management, with little consultation with nurses, further contributing to the difficulty with assimilating this change (Mason & Chandley 1992). Models of nursing usually include a set of beliefs about nursing, health, society, the environment and the individual, and suggest how these can be put into action through assessing, planning, implementing and
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evaluating care. Examples of nursing models in current use include Orem’s self-care model (Orem 1971) and the Roper–Logan–Tierney (1990) activities model. This latter is one of the most widely used in both Ireland and Britain. It has been widely adopted in the UK in the field of general nursing and nurse education (Lister 1991). It was developed in 1980, and is based on the assumption that individuals carry out 12 basic activities in everyday living. Breathing, eating, drinking and eliminating are examples of these. The Roper–Logan–Tierney (1990) activities model, although widely taught in schools of nursing (Tierney 1998), underestimates the complexity of the individual and the healthcare situation and fails to address the wider issues of family, society and context that also affect health. Lister (1997) uses the postmodernist strategy of deconstruction to critique this model. Through the analysis, this author questions the model’s usefulness as a model of nursing. It is suggested that the model has its basis in positivism and offers little by way of providing nurses with new perspectives on nursing. This point is endorsed in Mason and Chandley’s (1992) study of the use of unspecified nursing models in a hospital using 40 semi-structured interviews with nurses. Two major themes emerged from the data. Firstly, there was reference to the models as concrete entities, consisting of paperwork. This reliance on the concrete aspect of the model in use, led to a stagnated nursing situation. There appeared to be definitive perception of patients and reduced interactive dialogue to inform nursing care. The second theme to emerge was the adherence to the model as the focal point and not the individuality of the patient or the specific contextual nature of the setting. However, the contextual nature of this study and small sample size needs to be considered when generalizing from these findings. Griffiths (1998) investigated how nurses describe patients’ problems and the possible effects of an espoused model of nursing on these descriptions. A descriptive study that involved observation and audiotape of ward reports and recording of identified problems from care plans was carried out on one particular day on a medical ward. Ward A used the Roper–Logan–Tierney (1990)
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activities model to inform practice and ward B used Orem’s (1971) self-care model. Twenty-six patients were included in the study. Findings revealed that, when describing patient problems, nurses frequently used medical terminology and there was little evidence of application of the two models. Although there was a failure to refer to patients’ psychosocial needs on the written care plan, these were referred to in oral reports, but still ‘relatively sparse.’ Nurses often excluded important areas such as elimination and sexuality. The writing of the care plan appeared to be a ‘routine’ on both wards, with little changes made to plans after initial assessment. Information was not committed to written record but rather stored ‘in the memory of the nurses,’ which Griffiths (1998, p. 978) suggested was problematic as ‘essential information was often only lodged in the nurse’s head, and thus subject to loss.’ Griffiths (1998) concluded that the models of nursing did little to inform nursing practice. However, the study mainly concerned documentation and nurse reporting as a reflection of the use of models of nursing, further information may have been gleamed through a longitudinal observation study or interviews with individual nurses. The author acknowledged the limitations of the study that were due to the small sample size. Assessment and problem identification are crucial stages in the Nursing Process. The Nursing Process is based on the assumption that decision-making in nursing is linear and ordered and that if the process is followed this will result in ‘good patient care and good documentation of that care’ (Marks-Maran 1998; Spitzer 1998a). While these concepts have been valuable for documentation purposes, they may be inadequate in describing nursing actions, as the complex decision-making process, that is so central to nursing is oversimplified (Spitzer 1998a). In addition, there is little empirical evidence suggesting an overall benefit in either patient satisfaction or outcomes with the use of the Nursing Process. It is suggested that nurses should reconsider the Nursing Process, as the ‘current central paradigm’ (Spitzer 1998a) that informs practice as it limits nursing’s ability to deal with complex nursing situations. The Nursing Process—the framework often used in
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conjunction with models of nursing to guide nurses’ decision-making regarding patient care—is likely to become redundant in today’s ‘postmodern era’ (Marks-Maran 1998; Spitzer 1998b). Richards (1987) explored the effect of the use of the Nursing Process on patient satisfaction with nursing care. The study commenced 18 months after the introduction of the Nursing Process into the ward. A 28-item questionnaire was used to evaluate patient satisfaction. Results indicated that the introduction of the Nursing Process had little impact of patients’ perception of nursing care. Patients did not view nurses as more therapeutic nor were they more satisfied with their care. Spitzer (1998b) suggests that the process is deficient in informing modern nursing practice. Criticism of the process fall into two categories: firstly, that it is nurse-centered rather than patient-centered and, secondly, that it focuses on identification of individual nursing problems, rather than patient problems. Spitzer (1998b) contends that nursing must confront the limitations in the application of the Nursing Process. For critical care nurses, it comes as no surprise that models of nursing and the Nursing Process are not entirely suitable instruments through which to view nursing situations. On a practical level, in critical care units, the care and treatment of patients involves more complex and subtle processes which are difficult to categorize within these frameworks. Expert nurses can recognize signs of impending shock before documentable changes in vital signs are apparent and can discriminate the need for imminent resuscitation efforts prior to vascular collapse or dramatic vital sign change (Benner 1984). These finely tuned abilities have come from many hours of direct patient observation and care and not easily be predicted or guided by the use of models of nursing or the Nursing Process (Benner 1984). Indeed, Heath (1998) contends that the use of such structured frameworks can inhibit the expert nurse, although they may be useful for guiding junior members of staff. One example of where models may inhibit the expert nurse in critical care is in the area of pain assessment for patients with cardiac chest
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pain. This is a crucial role of the nurse in this area, and nurses’ commitment to this aspect of care is reflected in the abundance of studies in the literature (Bondestam et al. 1987; Willets 1989; Jacavonne & Dostal 1992; Thompson et al. 1994; O’Connor 1995a,b). However, pain assessment does not form a component part of nursing models in current use (O’Connor 1995a). O’Connor (1995a, p. 185) concludes that ‘pain assessment in nursing models was not considered a priority (sic).’ O’Connor (1995a) went on to explore the Roper–Logan–Tierney (1990) model ‘with respect to pain assessment’ and stated that, while a section regarding pain exists under the heading of ‘activity of communicating,’ it is sufficiently discrete, in O’Connor’s (1995a) opinion, to raise concern that pain may be overlooked by nurses during assessment. Benner et al. (1999) suggest that the practice of critical care nursing should expand the boundaries of nursing theory, and that articulation of that theory in the domain of nursing action, using models of nursing is difficult because of the inherent complexity of the environment. Interventions are instantaneous and highly context-dependent. Frameworks, which involve listing diagnoses and matching interventions, are ‘static models’ that are not suited to the dynamic of expert practice (Benner et al. 1999). As an alternative, these authors suggest that critical care nurses should focus on six aspects of clinical judgment and skillful behavior: (1) reasoning-in-transition; (2) skilled knowledge; (3) response-based practice; (4) agency; (5) perceptual ability and the skill of involvement; and (6) the links between clinical and ethical reasoning. These aspects of practice may serve as a guide for use within each of the domains of practice that they identify, to articulate nursing care for documentation and teaching and improving practice (Benner et al. 1999). Nine domains of practice were identified and these tend to reflect the complexity of critical care nursing practice; diagnosing and managing life-sustaining physiologic functions in unstable patients, the skilled know-how of managing a crisis, providing comfort measures for the critically ill, caring for patients’ families, preventing hazards in a technological environment, facing death-end of life-care and
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decision-making, communicating and negotiating multiple perspectives, monitoring quality and managing breakdown and the skilled know-how of clinical leadership and the coaching and mentoring of others. These domains of practice reflect the inherent complexity of the practice of critical care nurses. Ultimately, practicing nurses must assess the value and contribution of current nursing theory, models of nursing and the Nursing Process to practice. Mason and Chandley (1992) emphasize that clinicians who use nursing models must critique and develop them. One study that analyzed the practice of eight critical care nurses from an intensive care unit (Walters 1995) identified two main themes from the study: ‘being busy’ and ‘balancing.’ Being busy recognizes the concentration of these nurses on the important technical aspects of critical care and the fast pace of nursing in the unit. Balancing is where the participating nurses bridge the gap between the patients’ comfort needs and the coldness of the technological environment that exists which concur with the domains of practice identified by Benner et al. (1999). This type of uncovering of the ‘work’ that critical care nurses perform is essential to the development of local narratives to inform good practice, and also to ‘build on’ current theories of nursing that exist as is suggested by Mitchell (1996). Practicing nurses may face pressure from both academics and managers to adopt a model of nursing for practice (Lister 1997). Lister (1997) suggests that the quest to find one ‘true’ model of nursing, to suit one area or one establishment should be abandoned. This latter strategy, subscribes to the notion of positivism, through the presupposition that one true model exists. Rather, an eclectic use of models is suggested, where clinicians themselves may draw on multiple models, combined with their own experience, to formulate a model for use in practice in their own specific context (Lister 1997). One clinician in the UK (Graeme 2000), influenced by the writings of Marks-Maran (1999) and postmodern thought, outlined the formation of a ‘postmodern model’ for nursing in an newly opened 18-bedded palliative care unit. The whole nursing team were involved
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in devising the model, and although patients were not initially involved, their contribution to evaluation of the model was valued. The staff initially decided on their collective philosophy of care, based on the beliefs and values of the nursing team. Then they began a search for a suitable model but ‘no off the shelf model seemed to fit.’ They opted for an eclectic selection model and devised the ‘Shipley Model’ (Graeme 2000). Use of this model allowed for the collection of both qualitative and quantitative data during assessment and evaluation. Patients and family were actively involved in both assessment and evaluation of care. This patient and family participation in evaluation, together with the use of qualitative assessment, led Graeme (2000) to suggest that this model is based on postmodern thought, although the author acknowledges that the use of the Nursing Process does not reflect the complex decision-making processes that the expert practitioners on the unit may possess. This adaptation of nursing models is not, however, a new idea, although the notion that this reflects postmodern thinking certainly is. Similar work has been undertaken in critical care in the past, notably the Mead model, an adaptation of the Roper–Logan–Tierney (1990) activities model (McClune & Franklin 1987) that was further adapted for use in the Brompton Hospital, London by Sutcliffe (1994). Of particular interest in Sutcliffe’s (1994) work is the collaborative approach used to identify a model for use in the unit. All staff were initially involved in devising a unit philosophy, which inspired confidence with regard to model usage. Initially, there appeared to be a negative attitude towards the development of a model for practice as they were perceived to be ‘. . . not for nurses working in a busy clinical area’ (Sutcliffe 1994, p. 220). However, once the philosophy was devised, individual nurses began to ‘search for, critique and present various different models’ (Sutcliffe 1994, p. 217). The Mead model was chosen, and adapted to include the family in the centrality of the model and specific areas for assessment were also identified. Robb (1997) concurs with the view that models of nursing need to be adapted locally in intensive care units to suit the beliefs, practices and needs of the group. He
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highlights that models have a place in nursing practice however he states that ‘a models is not a static structure . . . there will often be a need to adapt it to fit a particular area’ (Robb 1997, p. 96). To this end, nurses must be involved locally in model selection and development. Robinson (1993) suggests the only way to generate nursing knowledge is through the process of clarifying concepts or ideas of what nursing practice means to those who deliver it and to the recipients of care. Walker and Avant (1995) suggest that nurses frequently encounter new situations in which little conceptual work has been done or where existing concepts have become outmoded, requiring new ways of classifying phenomena in nursing situations. In order to generate new knowledge and theory of nursing, from which models of nursing may derive, generation of new concepts in critical care settings may be required. ‘Concept derivation’ after Walker and Avant (1995) is useful in areas where no concept development has taken place or where extant concepts exist but have contributed little to practical or theoretical development in the field. Four steps are involved in ‘concept derivation’: sourcing the existing literature on the topic; searching for new ways of looking at the topic; selecting a parent set of concepts from another field to use in the derivation process; and redefining the concept or set of concepts. This process involves building on existing nursing theory, and may be suitable for the critical care setting. Using an interpretative approach to knowledge development, clinicians could draw on their own insights and understandings, as the main tools for development (Parton 1994). In addition, concepts could be borrowed from other fields to develop ‘theories in nursing’ that are essential for comprehensive understanding of nursing practice (Kim 1983). Mitchell (1996) highlights the need for new forms of inquiry to be based on practical and contextual information rather than an overreliance on grand theories of nursing, while acknowledging that the latter may still be useful, but as building blocks to which local narratives may be added. This supports Benner’s (1984) view that adequate description of practical knowledge in the critical care area is essential to the development and extension of nursing theory.
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Within a transforming healthcare system, it is essential that critical care nurses examine their unique contribution to the healthcare system. Such an evaluation should examine the use of the Nursing Process and consider appropriate methods of developing theory of nursing and models of nursing (Marks-Maran 1999). ‘Concept derivation’ (Walker & Avant 1995) may be necessary to develop existing ‘theories of nursing’ and ‘theories in nursing.’ Nursing actions within critical care settings need to be examined and documented using observation techniques incorporating both qualitative and quantitative methodologies to contribute to theory development in this area. Critical care nurses also need to critically analyze their expert knowledge, personal knowledge and experience, and the contribution of this evidence to practice and theory development within the profession. Eclectic models, also termed ‘theoretical pluralism’ by Dickoff and James (1982) and patient involvement in selection and development may also enable a move away from positivistic notions of nursing. However, this does not mean that there is no place for science in nursing care delivery Cheek (1999). Cheek (1999) suggests that this proposal would be absurd as many lives have been enhanced and saved by scientific and medical principles. However, it is important to examine the belief that the scientific framework is not the only way of viewing or understanding contemporary nursing care. Kim (1983) highlights the need for diversity and expansion in the science of nursing. Theory development is an essential component of the development of the nursing profession. However, over-reliance on frameworks that have emerged to articulate grand theories of nursing such as the Nursing Process and models of nursing must not be adopted blindly. Kim (1983, p. 118) describes nursing action as the ‘core’ and central concern of nursing ‘. . . for this domain embraces the elements that nursing as a discipline is made of. It involves what we do and how we perform those actions we call nursing.’ It is important, therefore, that the chosen model of nursing does embrace all the elements that define critical care nursing.
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Conclusion The scientific paradigm and positivistic notions of objectivity and truth dominated the 19th century. Nursing’s response to the scientific era led to the development of theories of nursing, the Nursing Process and models of nursing. Practitioners very often are exposed to the Nursing Process and models of nursing in the clinical area, and may have a limited understanding of the theoretical propositions that support these frameworks. Furthermore, where models of nursing are utilized they may be of limited value to practitioners or patients (Mason & Chandley 1992; Griffiths 1998; Lister 1997). While these concepts have been useful teaching tools and have also assisted with documentation, postmodern nurse theorists are concerned that these frameworks are inadequate to inform nursing actions in today’s complex healthcare environment. This is particularly true of critical care situations, where nurses are performing highly skilled duties and making astute observations of patients that may not be captured in current theories of nursing or models of nursing (Benner 1984). A paradigm shift is taking place in many disciplines, including nursing. The scientific reductionistic view of nursing no longer suffices. Nursing in the 21st century is searching for new meaning and understanding of what it means to care and of the value of critically analyzing personal experience. It is essential that nurses within critical care value their unique contribution to nursing practice and produce evidence that is credible and derived in rigorous ways. They must enter the 21st century confident, and prepared to develop theories of nursing and models of nursing, and they must exercise caution when adopting positivistic ideology imparted from those outside this specialist field. To this end it is essential that nurses develop both professionally and academically to be able to meet the challenge of redefining critical care nursing in the 21st century. References Adam SK, Osborne S 1997 Critical Care Nursing Science and Practice. Oxford University Press, Oxford Aggleton P, Chalmers 2000 Nursing Models and Nursing Practice, 2nd ed. Macmillan Press, London
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Benner P 1984 From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, London Benner P, Hooper-Kyriakidis P, Stannard D 1999 Clinical Wisdom and Interventions in Critical care. A Thinking in Action Approach. W.B. Saunders, London Bondestam E, Hovgren K, Johansson FG, Jern S, Hertlitz J, Holmberg S 1987 Pain assessment in the early phase of acute myocardial infarction. Journal of Advanced Nursing 12: 677–682 Carper BA 1978 Fundamental patterns of knowing in nursing. Advanced Nursing Science 1: 13 Cheek J 1999 Postmodern and Poststructuralist Approaches to Nursing Research. Sage, London Clark AM 1998 The qualitative–quantitative debate: moving from positivism and confrontation to post-positivism and reconciliation. Journal of Advanced Nursing 27: 1242–1249 Deloughery G 1998 Issues and Trends in Nursing, 3rd ed. CV Mosby, London Department of Health 1980 Working Party Report on General Nursing. The Stationery Office, Dublin Dickoff J, James P 1982 Towards a cultivated but decisive pluralism in nursing. In: McGee M (ed) Theoretical Pluralism in Nursing Science. University of Ottawa Press, Ottawa, pp 9–83 Fawcett J 1989 Analysis and Evaluation of Conceptual Models of Nursing, 2nd ed. Davies, USA Graeme A 2000 A post-modern nursing model. Nursing Standard 14(34): 40–42 Griffiths P 1998 An investigation into the description of patients’ problems by nurses using two different needs-based nursing models. Journal of Advanced Nursing 28(5): 969–977 Heath H 1998 Paradigm dialogues and dogma: finding a place for research, nursing models and reflective practice. Journal of Advanced Nursing 28(2): 228–294 Jacavonne J, Dostal M 1992 A descriptive study of nursing judgement in the assessment and management of cardiac pain. Advances in Nursing Science 15(1): 54–63 Kim HS 1983 The Nature of Theoretical Thinking in Nursing. Appleton-Century Crofts, Norwalk, CT Lister P 1991 Approaching models of nursing from a postmodernist perspective. Journal of Advanced Nursing 16: 206–212 Lister P 1997 The art of nursing in a ‘postmodern’ context. Journal of Advanced Nursing 25: 38–44 Marks-Maran D 1998 Reconstructing Nursing: Evidence, Artistry and the Curriculum. Conference Presentation, Nurse Education Tomorrow Conference, 12th September, Durham, UK Marks-Maran D 1999 Reconstructing nursing: evidence, artistry and the curriculum. Nurse Education Today 19(1): 3–11 Mason T, Chandley M 1992 Nursing models in a special hospital: cybernetics, hyperreality and beyond. Journal of advanced Nursing 17: 1350–1354 McClune B, Franklin M 1987 The Mead model for nursing—adapted from the Roper/Logan/Tierney model for nursing. Intensive Care Nursing 3(3): 97–103 Mitchell DP 1996 Postmodernism, health and illness. Journal of Advanced Nursing 23: 201–205
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O’Connor L 1995a Pain assessment by patients and nurses, and nurses’ notes on it, in early acute myocardial infarction. Part 1. Intensive and Critical Care Nursing 11(4): 183–191 O’Connor L 1995b Pain assessment by patients and nurses, and nurses’ notes on it, in early acute myocardial infarction. Part 2. Intensive and Critical Care Nursing 11(5): 283–291 Orem DE 1971 Nursing: Concepts of Practice. McGraw-Hill, New York Parton N 1994 Problematics of government post modernity and social work. British Journal of Social Work 24(1): 9–32 Reed PG 1995 A treatise on nursing knowledge development for the 21st century: beyond postmodernism. Advances in Nursing Science 17(3): 70–84 Richards DA 1987 The Nursing Process: the effects on patients’ satisfaction with nursing care. Journal of Advanced Nursing 12: 559–562 Robb Y 1997 Have nursing models a place in intensive care units? Intensive and Critical Care Nursing 13: 93–98 Robinson J 1993 Problems with paradigms in a caring profession. In: Kitson A (ed) Nursing: Art and Science. Chapman Hall, London Roper N, Logan W, Tierney A 1990 The Elements of Nursing. Churchill Livingstone, Edinburgh Roy C 1976 Introduction to Nursing: An Adaptation Model. Prentice-Hall, Englewood Cliffs, NJ Rutty JE 1998 The nature of science, theory and knowledge relating to nursing and professionalism. Journal of Advanced Nursing 28(2): 243–250 Silva MC, Rothbart D 1984 An analysis of changing trends in philosophies of science on nursing theory and development and testing. Advances in Nursing Science 6(2): 1–13 Spitzer A 1998a Nursing in the health care system of the postmodern world: crossroads, paradoxes and complexity. Journal of Advanced Nursing 28(1): 164–171 Spitzer A 1998b Moving into the information era: does the current nursing paradigm still hold? Journal of Advanced Nursing 28(4): 786–793 Sutcliffe L 1994 Philosophy and models in critical care nursing. Intensive and Critical Care Nursing 10: 212–221 Thompson DR, Webster RA, Sutton TW 1994 Coronary care unit patients’ and nurses’ ratings of intensity of chest pain. Intensive and Critical Care Nursing 10: 83–88 Teichman J, Evans KC 1995 Philosophy—A Beginner’s Guide. Blackwell Scientific, London Tierney AJ 1998 Nursing models: extant or extinct? Journal of Advanced Nursing 28(1): 77–85 Walker OL, Avant CK 1995 Strategies for Theory Construction in Nursing, 3rd ed. Appleton and Lange, Norwalk, CT Watson J 1995 Postmodernism and knowledge development in nursing. Nursing Science Quarterly 8(2): 60–64 Willets K 1989 Assessing cardiac pain. Nursing Times 22(85): 52–54
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Critical care nursing in the 21st century Fiona Timmins
Introduction
Fiona Timmins RGN, BNS, RNT, FFNRSCI, NFESC, MSc, Lecturer, School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland (Requests for offprints to FT) Manuscript accepted: 26/11/01
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Nursing as a scientific discipline is in the early stages of development. The nursing profession requires knowledge developed through the systematic study and development of ‘theories in nursing’ (application of theories and knowledge from other disciplines) and ‘theories of nursing’ (definition and differentiation of nursing phenomena as distinct from other disciplines) (Kim 1983). Nurse theorists have focused on the development of ‘theories of nursing,’ but ‘theories in nursing’ are less well developed; both types of knowledge are required to develop in-depth understanding of nursing situations (Kim 1983). ‘Models’ of nursing have developed from theories of nursing, describe the patient condition and inform nurse activities (Kim 1983). When considering theoretical domains of nursing, models of nursing can be categorized under the domain ‘nursing action’ (Kim 1983). This domain, Kim (1983) contends, is the central tenet of nursing as it embraces all the elements of nursing and concerns the ‘how to do’ and ‘what to do’ of the profession. However, nursing action is not fully described in many models of nursing (Kim 1983). Several contemporary authors contend that theories of nursing and models of nursing are inadequate to inform the complexity of healthcare situations (Marks-Maran 1998; Spitzer 1998a). The use of the Nursing Process, although neither a theory nor a model, but merely a framework to assist with nursing decision-making and operationalization of many nursing models, has also yielded similar criticism (Marks-Maran 1998; Spitzer 1998a). This criticism of traditional notions of nursing, and of nursing care delivery, has emanated
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doi:10.1016/S0964-3397(02)00006-X, available online at http://www.idealibrary.com on
from theorists who subscribe to postmodern ideology. Postmodern rejection of theories of nursing, models of nursing and the use of the Nursing Process stem from the postmodern rejection of ‘grand theories’ to inform practice. Postmodernism challenges the modernist idea of a single transcendent meaning of reality and the importance of the search for empirical patterns that correspond to and represent ultimate meaning. (Reed 1995, p. 3)
The concern lies with the individual meaning and context of each situation rather than the notion of ‘one model fits all.’ With words akin to a ‘conspiracy theory,’ Spitzer (1998b) suggests that conceptual models of nursing and the Nursing Process were developed in an attempt to excel in the ‘positivist paradigm’ rather than for the benefit of the profession (Spitzer 1998b). Marks-Maran (1998) and Spitzer (1998b) both contend that current theories of nursing are not capable of solving central issues to nurses or addressing the complex nature of health and healthcare situations. Under the current, mainly positivistic paradigm, Spitzer (1998b) suggests that, ‘nursing has difficulties in highlighting to both patients and the system where nursing can and does make a difference.’ Spitzer (1998b) suggests that it is obvious that the current paradigm within nursing is a ‘misfit’ and a new paradigm is required. Marks-Maran (1998) and Spitzer (1998b) suggest that, as nursing occupies a central role in an ever-changing, complex healthcare system, nurses should begin to examine the philosophical perspectives that inform their practice, and critically examine current theories of nursing. Reed (1995, p. 2) acknowledges that postmodernism presents a challenge to nursing:
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For the past several years, nurses have been feeling the ground shift with the reforming of philosophic ideas that launched nursing as a science. Not since the advent of modernism and the birth of modern nursing at the end of the 19th century has nursing science been faced with such a wealth of possibilities for knowledge development. These possibilities . . . are nurtured by the current dialogue postmodern thought has precipitated. (sic)
However, Reed (1995) also cautions against losing sight of the rich knowledge of the past. Reed (1995) suggests that the gap should be bridged between modern and postmodern philosophies to allow nursing to develop and clarify contemporary approaches to knowledge development. Reed (1995) calls to current theorists and practitioners to ‘build on the accomplishments of modernist nursing while exploiting opportunities of the postmodern context.’ Western society is undergoing tremendous change. The changes that have taken place during the last 30 years are more far-reaching and significant than in the 100 years prior to this time (Marks-Maran 1998). Critical care units have become highly complex technological environments requiring nursing staff with a high degree of knowledge and skill (Adam & Osborne 1997). Clinicians are accountable and responsible for their own practice; they are also accountable to the law, patients, to their professional regulatory bodies and to the organization in which they operate. It is time now for critical examination of the theory that informs their practice. It is likely that the 21st century, with its inherent complexity and constant change, will require that nurses operate from a postmodern perspective, where complexity and unpredictability are recognized aspects of nursing care delivery. To ensure that critical care nurses remain responsive to the challenges of the 21st century, it is essential that they examine the philosophical perspectives that inform their practice, and critically examine current nursing theory and practice. The aim of this paper is to examine philosophical perspectives of nursing and to explore the development of nursing knowledge as articulated in ‘theories of
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nursing,’ models and the Nursing Process in order to explore possibilities for their continued use in a postmodern era.
Philosophical perspectives of nursing Philosophy is the study of abstract problems concerned with nature of existence, knowledge, morality, reason and human purpose (Teichman & Evans 1995). Philosophies of nursing have been in existence for over a century (Rutty 1998). The 1950s and 1960s saw nursing striving to form a science base for the discipline, and positivism became the underlying paradigm. Positivism, which developed during the 18th century, still profoundly influences many disciplines including medicine and nursing (Marks-Maran 1998). It has been valuable for the progression of medicine, the explanation of diseases, their causes and treatments and has contributed to major improvements in world health. This scientific paradigm or positivism, which still dominates both medicine and nursing, is founded on the belief that reality is orderly and predictable. Positivism attempts to understand a phenomenon through breaking it down into its component parts, subjecting it to analysis and applying understanding (Spitzer 1998b). Throughout the western world, positivism is no longer seen as the dominant world view and a paradigm shift is taking place among all disciplines, including nursing (Watson 1995). This paradigm shift, termed postmodernism, has occurred because previous philosophical perspectives are no longer wholly applicable. Positivism, which subscribes to the view that everything operates in a mechanical way, that can be determined, controlled and predicted is no longer sufficient to explain the inherent complexity of the world (Marks-Maran 1998; Spitzer 1998b; Watson 1995). This criticism of the positivistic paradigm is particularly relevant in nursing situations, where nursing interventions and outcomes are often context-dependent. However, despite this new awareness, the positivistic paradigm remains dominant within medicine and nursing. Spitzer (1998b) supports this notion and suggests that positivism underpins many of the theories of nursing used in nursing today. This
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theory informs nursing practice and is often operationalized through the use of ‘models.’ Silva and Rothbart (1984) reveal that positivism underpinned almost all theories of nursing until 1969 and that, since then, although there has been a steady progress away from positivism as the dominant philosophy, positivism remains explicit in most theory. Recent approaches to theory development include the incorporation of humanistic psychology, which considers the notion of man as a person rather than espousing a mechanistic view. Humanistic psychology supports the notion of the mind and soul, which are redundant in a positivistic view of man (Lister 1997). However, Mitchell (1996) contends that both humanism and positivism are based on assumptions of objectivity, truth and certainty, all factors that are rejected by the more recent philosophical position of ‘poststructuralism.’ Poststructuralism emphasizes the dynamism of language and meaning. It aims to challenge established knowledge by ‘deconstructing’ the linguistic organization of the subjective self (Lister 1991). Deconstruction refers to an ongoing analytical procedure that aims to draw out inconsistencies (Lister 1991). Poststructuralism has been interpreted as a subset of postmodernism. However, there is no all-embracing postmodernist philosophical position (Lister 1991). A postmodern era is characterized by pluralism, variety and contingency where positivistic beliefs in science, truths, objectivity and certainty are undermined (Mitchell 1996). Lay knowledge emerges as an important concept (Mitchell 1996). From a nursing perspective, this implies that patients need greater involvement in their care, including patient assistance in the use and selection of models of nursing (Graeme 2000). It could also include eclectic choice of nursing model (Lister 1997) or building on established theory using the ideas and views of nurses locally towards developing a model for use (Graeme 2000; Mitchell 1996). A further notion is the development and exploration of nursing knowledge using interpretive approaches (Benner 1984; Benner et al. 1999; Parton 1994). Complexity is another postmodern phenomenon (Spitzer 1998b). Spitzer (1998b) suggests that the healthcare system is one of the most complex systems known to society,
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comprising many complex internal and external interactions. Healthcare too is becoming increasingly complex, with the advent of competition, technology and the changing nature of health and illness. Patients are also inherently complex systems. Complex systems such as this must be viewed as a whole; any attempt to deal with these in a positivistic manner, through their component parts is futile (Spitzer 1998b). In complex systems, a change in any one part has implications for many other parts. These changes and their effects are unpredictable. The idea that one theory or model of nursing fits all situations becomes redundant in the postmodern context. Although uniformity is needed to a certain extent in healthcare settings, prescribing one model of nursing for use in practice is futile (Lister 1997; Robinson 1993).
The development of nursing knowledge The first period of nursing knowledge and practice development took place during the late 19th century and early 20th century and was based largely on women’s contributions. Because of their place in society and the predominance of the biomedical model, the mainly intuitive and experiential knowledge remained ‘silent’ (Rutty 1998). From 1950 to 1970, nursing theorists began to articulate nursing knowledge and practice, often through the use of theory from other disciplines such as psychology. Theories of nursing developed and from these, models of nursing emerged to inform nursing actions (Rutty 1998). Carper (1978) examined early nursing literature and identified four patterns of knowing that nurses have valued and used in practice. One of the patterns is empirics—the science of nursing. In addition, she identified ethics—the component of moral knowledge in nursing; aesthetics—the art of nursing; and personal knowing in nursing. These patterns have endured as essential aspects of nursing knowledge for more than a century. The science of empirics emerged during the late 1950s (Carper 1978). Empirics as a pattern of knowing yields from the philosophical perspective of positivism. During the 1950s and 1960s there was an emphasis on the use of
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empirical knowledge in nursing which resulted in the development of the Nursing Process. The Nursing Process incorporates a series of systematic steps in planning individualized patient care, assessment, planning, implementation and evaluation. This concept was recommended to the Department of Health for use in Ireland, by the Working Party on General Nursing in 1980 (Department of Health 1980). It has been adopted generally by the nursing profession and remains the major framework for nursing practice today (Deloughery 1998). Since the 1950s there has been a steady increase in the development of theories of nursing, and models of nursing have evolved from this theory to inform nursing practice (Rutty 1998). The Nursing Process was developed in the 1950s in response to the scientific movement, which had a profound influence on nursing practice (Clark 1998). Both the Nursing Process and nursing models are in widespread use in nursing situations today, and nurses educated in the UK have been encouraged to use the Nursing Process to assess, plan, deliver and record nursing care since the 1970s (General Nursing Council 1977, cited in Griffiths 1998). The introduction and use of the Nursing Process resulted in a need to establish a knowledge base specifically related to nursing. As a result, nursing theorists advocated the use of specific theories of nursing (Aggleton & Chalmers 2000). Theory development was viewed as a means of clearly establishing nursing as a profession and also emerged from the belief in the intrinsic value of theory for nursing (Walker & Avant 1995). Grand theories of nursing are described in the theory development literature, and consist of global conceptual frameworks defining broad perspectives for nursing and ways of viewing nursing. Grand theory has attempted to make conceptual distinctions between nursing and medicine, by highlighting the presence of distinct nursing perspectives. Contributors to grand theory include Orem (1971) and Roy (1976). The term ‘conceptual models’ is also used to describe grand theory (Fawcett 1989). Theories are often graphically represented by the use of models of nursing, which correspond directly to the theory.
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Kim (1983) suggests that theory development within nursing requires further progress. Theory needs to be tested in practice and extensive conceptual clarification is required. Kim (1983) also suggests that a gap exists between theory development and use of theory in practice. This is in part due to a lack of dialogue between practitioners and theorists as well as the structural spread of practitioners in various fields. One way of narrowing this gap is for practitioners to examine the usefulness of theories of nursing at a practice level. This examination should provide areas for further research, which would further enhance theory development (Kim 1983). Kim (1983) also suggests that a diversity of techniques of inquiry would aid reformulation of theories of nursing ‘‘the theme of nursing science has to be ‘discovery’ and ‘expansion.’’’ Hence, theory development may be informed by both qualitative and quantitative methodologies, rather than an over-reliance on the latter, which was a feature of early theories of nursing. It is also clear that the practical application of theories of nursing, which is often operationalized through models of nursing, requires some work in order to bridge the gap, real or hypothesized that exists between theory and practice. Kim (1983) highlights that many models of nursing fail to inform practitioners about ‘how to’ perform nursing actions. This may explain why, in practice, nurses often express difficulty with the use of models of nursing (Mason & Chandley 1992). From a postmodern perspective, difficulty with application of theories of nursing, models of nursing and the Nursing Process is due to the subscription of these concepts to positivism, which no longer ‘fits’ nursing situations. These concepts all suggest to the practitioner that the world (and the individual) is ‘orderly’ and ‘predictable.’ Postmodern thought emphasizes that reality is not ordered and mechanistic and there are multiple positions from which it is possible to view reality. Postmodern thought rejects the notion of ‘grand’ theories of nursing. However, the development, absorption and utilization of theories of nursing, mainly through the use of models of nursing and the Nursing Process in practice, has resulted in a commitment to the positivistic paradigm by the nursing profession (Clark 1998).
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Despite the concerns of postmodern advocates, theory development in nursing has undoubtedly contributed to the professional development of nursing and its development as a scientific discipline. Theories of nursing, models of nursing and the Nursing Process have informed the education of nurses for many years, and although ultimate effects on patient outcome are not empirically tested, benefits such as clear documentation and ease of translation of nursing practice to students clearly contribute to the progression of nursing (Tierney 1998).
The suitability of models of nursing and the Nursing Process to the postmodern era Abstract models derived form theories of nursing are commonly used in practice situations, often in conjunction with the Nursing Process and documented using a ‘care plan.’ Both the Nursing Process and nursing models reflect positivistic philosophies, whereby patients, patients’ conditions and nursing situations are broken down into component parts and analyzed (Clark 1998; Marks-Maran 1999). This approach to complex healthcare situations may not be entirely suitable in a postmodern era, where patient participation and dialogue is important and where the complexity of the world is acknowledged. There is also growing awareness that science does not have all the answers and it is postulated that nursing decisions do not necessarily follow a linear pathway. In practice, nurses often express difficulty with the use of models and the Nursing Process, there is often a feeling of powerlessness as nurses feel unable to attain change in this area (Mason & Chandley 1992). In addition, the use of the Nursing Process and nursing models has often come about due to a ‘top-down’ approach by management, with little consultation with nurses, further contributing to the difficulty with assimilating this change (Mason & Chandley 1992). Models of nursing usually include a set of beliefs about nursing, health, society, the environment and the individual, and suggest how these can be put into action through assessing, planning, implementing and
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evaluating care. Examples of nursing models in current use include Orem’s self-care model (Orem 1971) and the Roper–Logan–Tierney (1990) activities model. This latter is one of the most widely used in both Ireland and Britain. It has been widely adopted in the UK in the field of general nursing and nurse education (Lister 1991). It was developed in 1980, and is based on the assumption that individuals carry out 12 basic activities in everyday living. Breathing, eating, drinking and eliminating are examples of these. The Roper–Logan–Tierney (1990) activities model, although widely taught in schools of nursing (Tierney 1998), underestimates the complexity of the individual and the healthcare situation and fails to address the wider issues of family, society and context that also affect health. Lister (1997) uses the postmodernist strategy of deconstruction to critique this model. Through the analysis, this author questions the model’s usefulness as a model of nursing. It is suggested that the model has its basis in positivism and offers little by way of providing nurses with new perspectives on nursing. This point is endorsed in Mason and Chandley’s (1992) study of the use of unspecified nursing models in a hospital using 40 semi-structured interviews with nurses. Two major themes emerged from the data. Firstly, there was reference to the models as concrete entities, consisting of paperwork. This reliance on the concrete aspect of the model in use, led to a stagnated nursing situation. There appeared to be definitive perception of patients and reduced interactive dialogue to inform nursing care. The second theme to emerge was the adherence to the model as the focal point and not the individuality of the patient or the specific contextual nature of the setting. However, the contextual nature of this study and small sample size needs to be considered when generalizing from these findings. Griffiths (1998) investigated how nurses describe patients’ problems and the possible effects of an espoused model of nursing on these descriptions. A descriptive study that involved observation and audiotape of ward reports and recording of identified problems from care plans was carried out on one particular day on a medical ward. Ward A used the Roper–Logan–Tierney (1990)
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activities model to inform practice and ward B used Orem’s (1971) self-care model. Twenty-six patients were included in the study. Findings revealed that, when describing patient problems, nurses frequently used medical terminology and there was little evidence of application of the two models. Although there was a failure to refer to patients’ psychosocial needs on the written care plan, these were referred to in oral reports, but still ‘relatively sparse.’ Nurses often excluded important areas such as elimination and sexuality. The writing of the care plan appeared to be a ‘routine’ on both wards, with little changes made to plans after initial assessment. Information was not committed to written record but rather stored ‘in the memory of the nurses,’ which Griffiths (1998, p. 978) suggested was problematic as ‘essential information was often only lodged in the nurse’s head, and thus subject to loss.’ Griffiths (1998) concluded that the models of nursing did little to inform nursing practice. However, the study mainly concerned documentation and nurse reporting as a reflection of the use of models of nursing, further information may have been gleamed through a longitudinal observation study or interviews with individual nurses. The author acknowledged the limitations of the study that were due to the small sample size. Assessment and problem identification are crucial stages in the Nursing Process. The Nursing Process is based on the assumption that decision-making in nursing is linear and ordered and that if the process is followed this will result in ‘good patient care and good documentation of that care’ (Marks-Maran 1998; Spitzer 1998a). While these concepts have been valuable for documentation purposes, they may be inadequate in describing nursing actions, as the complex decision-making process, that is so central to nursing is oversimplified (Spitzer 1998a). In addition, there is little empirical evidence suggesting an overall benefit in either patient satisfaction or outcomes with the use of the Nursing Process. It is suggested that nurses should reconsider the Nursing Process, as the ‘current central paradigm’ (Spitzer 1998a) that informs practice as it limits nursing’s ability to deal with complex nursing situations. The Nursing Process—the framework often used in
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conjunction with models of nursing to guide nurses’ decision-making regarding patient care—is likely to become redundant in today’s ‘postmodern era’ (Marks-Maran 1998; Spitzer 1998b). Richards (1987) explored the effect of the use of the Nursing Process on patient satisfaction with nursing care. The study commenced 18 months after the introduction of the Nursing Process into the ward. A 28-item questionnaire was used to evaluate patient satisfaction. Results indicated that the introduction of the Nursing Process had little impact of patients’ perception of nursing care. Patients did not view nurses as more therapeutic nor were they more satisfied with their care. Spitzer (1998b) suggests that the process is deficient in informing modern nursing practice. Criticism of the process fall into two categories: firstly, that it is nurse-centered rather than patient-centered and, secondly, that it focuses on identification of individual nursing problems, rather than patient problems. Spitzer (1998b) contends that nursing must confront the limitations in the application of the Nursing Process. For critical care nurses, it comes as no surprise that models of nursing and the Nursing Process are not entirely suitable instruments through which to view nursing situations. On a practical level, in critical care units, the care and treatment of patients involves more complex and subtle processes which are difficult to categorize within these frameworks. Expert nurses can recognize signs of impending shock before documentable changes in vital signs are apparent and can discriminate the need for imminent resuscitation efforts prior to vascular collapse or dramatic vital sign change (Benner 1984). These finely tuned abilities have come from many hours of direct patient observation and care and not easily be predicted or guided by the use of models of nursing or the Nursing Process (Benner 1984). Indeed, Heath (1998) contends that the use of such structured frameworks can inhibit the expert nurse, although they may be useful for guiding junior members of staff. One example of where models may inhibit the expert nurse in critical care is in the area of pain assessment for patients with cardiac chest
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pain. This is a crucial role of the nurse in this area, and nurses’ commitment to this aspect of care is reflected in the abundance of studies in the literature (Bondestam et al. 1987; Willets 1989; Jacavonne & Dostal 1992; Thompson et al. 1994; O’Connor 1995a,b). However, pain assessment does not form a component part of nursing models in current use (O’Connor 1995a). O’Connor (1995a, p. 185) concludes that ‘pain assessment in nursing models was not considered a priority (sic).’ O’Connor (1995a) went on to explore the Roper–Logan–Tierney (1990) model ‘with respect to pain assessment’ and stated that, while a section regarding pain exists under the heading of ‘activity of communicating,’ it is sufficiently discrete, in O’Connor’s (1995a) opinion, to raise concern that pain may be overlooked by nurses during assessment. Benner et al. (1999) suggest that the practice of critical care nursing should expand the boundaries of nursing theory, and that articulation of that theory in the domain of nursing action, using models of nursing is difficult because of the inherent complexity of the environment. Interventions are instantaneous and highly context-dependent. Frameworks, which involve listing diagnoses and matching interventions, are ‘static models’ that are not suited to the dynamic of expert practice (Benner et al. 1999). As an alternative, these authors suggest that critical care nurses should focus on six aspects of clinical judgment and skillful behavior: (1) reasoning-in-transition; (2) skilled knowledge; (3) response-based practice; (4) agency; (5) perceptual ability and the skill of involvement; and (6) the links between clinical and ethical reasoning. These aspects of practice may serve as a guide for use within each of the domains of practice that they identify, to articulate nursing care for documentation and teaching and improving practice (Benner et al. 1999). Nine domains of practice were identified and these tend to reflect the complexity of critical care nursing practice; diagnosing and managing life-sustaining physiologic functions in unstable patients, the skilled know-how of managing a crisis, providing comfort measures for the critically ill, caring for patients’ families, preventing hazards in a technological environment, facing death-end of life-care and
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decision-making, communicating and negotiating multiple perspectives, monitoring quality and managing breakdown and the skilled know-how of clinical leadership and the coaching and mentoring of others. These domains of practice reflect the inherent complexity of the practice of critical care nurses. Ultimately, practicing nurses must assess the value and contribution of current nursing theory, models of nursing and the Nursing Process to practice. Mason and Chandley (1992) emphasize that clinicians who use nursing models must critique and develop them. One study that analyzed the practice of eight critical care nurses from an intensive care unit (Walters 1995) identified two main themes from the study: ‘being busy’ and ‘balancing.’ Being busy recognizes the concentration of these nurses on the important technical aspects of critical care and the fast pace of nursing in the unit. Balancing is where the participating nurses bridge the gap between the patients’ comfort needs and the coldness of the technological environment that exists which concur with the domains of practice identified by Benner et al. (1999). This type of uncovering of the ‘work’ that critical care nurses perform is essential to the development of local narratives to inform good practice, and also to ‘build on’ current theories of nursing that exist as is suggested by Mitchell (1996). Practicing nurses may face pressure from both academics and managers to adopt a model of nursing for practice (Lister 1997). Lister (1997) suggests that the quest to find one ‘true’ model of nursing, to suit one area or one establishment should be abandoned. This latter strategy, subscribes to the notion of positivism, through the presupposition that one true model exists. Rather, an eclectic use of models is suggested, where clinicians themselves may draw on multiple models, combined with their own experience, to formulate a model for use in practice in their own specific context (Lister 1997). One clinician in the UK (Graeme 2000), influenced by the writings of Marks-Maran (1999) and postmodern thought, outlined the formation of a ‘postmodern model’ for nursing in an newly opened 18-bedded palliative care unit. The whole nursing team were involved
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in devising the model, and although patients were not initially involved, their contribution to evaluation of the model was valued. The staff initially decided on their collective philosophy of care, based on the beliefs and values of the nursing team. Then they began a search for a suitable model but ‘no off the shelf model seemed to fit.’ They opted for an eclectic selection model and devised the ‘Shipley Model’ (Graeme 2000). Use of this model allowed for the collection of both qualitative and quantitative data during assessment and evaluation. Patients and family were actively involved in both assessment and evaluation of care. This patient and family participation in evaluation, together with the use of qualitative assessment, led Graeme (2000) to suggest that this model is based on postmodern thought, although the author acknowledges that the use of the Nursing Process does not reflect the complex decision-making processes that the expert practitioners on the unit may possess. This adaptation of nursing models is not, however, a new idea, although the notion that this reflects postmodern thinking certainly is. Similar work has been undertaken in critical care in the past, notably the Mead model, an adaptation of the Roper–Logan–Tierney (1990) activities model (McClune & Franklin 1987) that was further adapted for use in the Brompton Hospital, London by Sutcliffe (1994). Of particular interest in Sutcliffe’s (1994) work is the collaborative approach used to identify a model for use in the unit. All staff were initially involved in devising a unit philosophy, which inspired confidence with regard to model usage. Initially, there appeared to be a negative attitude towards the development of a model for practice as they were perceived to be ‘. . . not for nurses working in a busy clinical area’ (Sutcliffe 1994, p. 220). However, once the philosophy was devised, individual nurses began to ‘search for, critique and present various different models’ (Sutcliffe 1994, p. 217). The Mead model was chosen, and adapted to include the family in the centrality of the model and specific areas for assessment were also identified. Robb (1997) concurs with the view that models of nursing need to be adapted locally in intensive care units to suit the beliefs, practices and needs of the group. He
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highlights that models have a place in nursing practice however he states that ‘a models is not a static structure . . . there will often be a need to adapt it to fit a particular area’ (Robb 1997, p. 96). To this end, nurses must be involved locally in model selection and development. Robinson (1993) suggests the only way to generate nursing knowledge is through the process of clarifying concepts or ideas of what nursing practice means to those who deliver it and to the recipients of care. Walker and Avant (1995) suggest that nurses frequently encounter new situations in which little conceptual work has been done or where existing concepts have become outmoded, requiring new ways of classifying phenomena in nursing situations. In order to generate new knowledge and theory of nursing, from which models of nursing may derive, generation of new concepts in critical care settings may be required. ‘Concept derivation’ after Walker and Avant (1995) is useful in areas where no concept development has taken place or where extant concepts exist but have contributed little to practical or theoretical development in the field. Four steps are involved in ‘concept derivation’: sourcing the existing literature on the topic; searching for new ways of looking at the topic; selecting a parent set of concepts from another field to use in the derivation process; and redefining the concept or set of concepts. This process involves building on existing nursing theory, and may be suitable for the critical care setting. Using an interpretative approach to knowledge development, clinicians could draw on their own insights and understandings, as the main tools for development (Parton 1994). In addition, concepts could be borrowed from other fields to develop ‘theories in nursing’ that are essential for comprehensive understanding of nursing practice (Kim 1983). Mitchell (1996) highlights the need for new forms of inquiry to be based on practical and contextual information rather than an overreliance on grand theories of nursing, while acknowledging that the latter may still be useful, but as building blocks to which local narratives may be added. This supports Benner’s (1984) view that adequate description of practical knowledge in the critical care area is essential to the development and extension of nursing theory.
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Within a transforming healthcare system, it is essential that critical care nurses examine their unique contribution to the healthcare system. Such an evaluation should examine the use of the Nursing Process and consider appropriate methods of developing theory of nursing and models of nursing (Marks-Maran 1999). ‘Concept derivation’ (Walker & Avant 1995) may be necessary to develop existing ‘theories of nursing’ and ‘theories in nursing.’ Nursing actions within critical care settings need to be examined and documented using observation techniques incorporating both qualitative and quantitative methodologies to contribute to theory development in this area. Critical care nurses also need to critically analyze their expert knowledge, personal knowledge and experience, and the contribution of this evidence to practice and theory development within the profession. Eclectic models, also termed ‘theoretical pluralism’ by Dickoff and James (1982) and patient involvement in selection and development may also enable a move away from positivistic notions of nursing. However, this does not mean that there is no place for science in nursing care delivery Cheek (1999). Cheek (1999) suggests that this proposal would be absurd as many lives have been enhanced and saved by scientific and medical principles. However, it is important to examine the belief that the scientific framework is not the only way of viewing or understanding contemporary nursing care. Kim (1983) highlights the need for diversity and expansion in the science of nursing. Theory development is an essential component of the development of the nursing profession. However, over-reliance on frameworks that have emerged to articulate grand theories of nursing such as the Nursing Process and models of nursing must not be adopted blindly. Kim (1983, p. 118) describes nursing action as the ‘core’ and central concern of nursing ‘. . . for this domain embraces the elements that nursing as a discipline is made of. It involves what we do and how we perform those actions we call nursing.’ It is important, therefore, that the chosen model of nursing does embrace all the elements that define critical care nursing.
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Conclusion The scientific paradigm and positivistic notions of objectivity and truth dominated the 19th century. Nursing’s response to the scientific era led to the development of theories of nursing, the Nursing Process and models of nursing. Practitioners very often are exposed to the Nursing Process and models of nursing in the clinical area, and may have a limited understanding of the theoretical propositions that support these frameworks. Furthermore, where models of nursing are utilized they may be of limited value to practitioners or patients (Mason & Chandley 1992; Griffiths 1998; Lister 1997). While these concepts have been useful teaching tools and have also assisted with documentation, postmodern nurse theorists are concerned that these frameworks are inadequate to inform nursing actions in today’s complex healthcare environment. This is particularly true of critical care situations, where nurses are performing highly skilled duties and making astute observations of patients that may not be captured in current theories of nursing or models of nursing (Benner 1984). A paradigm shift is taking place in many disciplines, including nursing. The scientific reductionistic view of nursing no longer suffices. Nursing in the 21st century is searching for new meaning and understanding of what it means to care and of the value of critically analyzing personal experience. It is essential that nurses within critical care value their unique contribution to nursing practice and produce evidence that is credible and derived in rigorous ways. They must enter the 21st century confident, and prepared to develop theories of nursing and models of nursing, and they must exercise caution when adopting positivistic ideology imparted from those outside this specialist field. To this end it is essential that nurses develop both professionally and academically to be able to meet the challenge of redefining critical care nursing in the 21st century. References Adam SK, Osborne S 1997 Critical Care Nursing Science and Practice. Oxford University Press, Oxford Aggleton P, Chalmers 2000 Nursing Models and Nursing Practice, 2nd ed. Macmillan Press, London
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