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Nursing needs new model reflecting changing relationship
President's message
Nursing needs new model reflecting changing relationship A model is a diagram of a system. It depicts the relationships of the components within that system. As a symbol, a model uses words, numbers, or pictures, rather than physical representations to depict potentially relevant aspects of a process. One often thinks of a model as a miniature replica of some larger object or set of objects such as an airplane or car or a frontier fort. These models are usually identical replicas of the original. For example, hobby kits have models of gasoline engines that are identical, part by part, to a larger engine differing only in size. Regardless of the size of the parts, the relationship is always the same. The process denoted by the model is ever present. Models vary in their sophisticationdepending largely on how much is known about the particular phenomenon demonstrated by the model. In some instances, models function as fully developed and formalized theories from which a number of specific outcomes may be deduced. Some authors believe that the terms “model” and “theory” are synonymous. Kaplan contends this belief is not entirely justified and that only certain types of theories should be labeled as models.’ Many representations called models do not meet the tests of a coherent scientific theory. In a sense, these models are little more than useful visual aids. Given these two extremes, ie, a developed formalized theory or a visual aid, the nursing models of
a
which I will speak fall closer to visual aids. Even so, such models serve a useful purpose. Specifically, let us think of a model for nursing process as a kind of component system enabling us to abstract and categorize potentially relevant relationships within the process.
E
u sibling Fig 1
For example, one basic model shows the relationship between parent and child (Fig 1). This relationship is one of invariance where the mother and father are always the natural parents of the child and the reverse. The relationship never varies. The child or parent may be legally disclaimed; however, the natural relationship remains a fact. Understanding models and invariance of relationship will help in my discussion of nursing models and what I believe to be invariant relationships between patient and nurse and between physician and nurse. I contend a dichotomy exists between the invariant relationship of nurse and patient and the process of the model. I believe that we in nursing have failed to change the model as the process has changed in the nurse-patient relationship. We talk about, seek to imple-
AORN Journal, December 1976, Vol.24, No 6
1031
ment, and generally espouse the “extended role” theory without effectively communicating what we perceive the extended role to be. To be of value, a model should serve three functions: an organizational function; a heuristic, or research-generating, function; and an anticipatory, or predictive, function. Each of these is important to us as we view the model for nursing in the past, present, and future. With the visual aid of the model, perhaps we can understand where we are in the process, why we are there, and how we can best affect change for the betterment of nursing and ultimately patient care.
n n 1
I
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Fig 2 Let us first look at what I see as the foundation or basic model-a model that is really the “medical” model (Fig 2). Note that the physician initiates the process of patient care. All activities and communications are funneled through and controlled by the physician. He or she is the prime mover and alone assesses, plans, implements, or orders the care of the patient. The nurse in this model carries out direct orders and reports the reactions, behavior, and activities of the patient to the physician. This nurse is said to do an excellent job because she or he performs all duties well. She or he charts the patient’s condition extremely well and sees that the patient has a hypo “q 4 h” regardless of the needs of the patient. Drainage is described in a noncommittal manner, eg, pink-tinged rather than bloody, or yellowish thick rather than purulent. She or he never makes a direct statement relative to the condition even though it is within her realm of
1032
knowledge as a nurse. The patient and his family are never given direct information as to the well being of the patient. Instead, the nurse defers to “ask your doctor,” or “I can’t answer that, but doctor will be in soon.” This nurse never institutes patient or family teaching without a direct order from the physician. In the OR, the nurse may be a wizard with the instruments, knows Drs X, Y, Zs preferences and may refuse to do needle and instrument counts because “Dr X doesn’t like us to count.” She may allow Dr Y to wear his favorite shoes in the OR even though they are rejects from the trash. This nurse will have five patients in the waiting area for Dr Z “because he likes to see them all down at once.” The examples are endless, but this model in figure 2 gives some idea of the process and the nurse’s relationship to the patient, the physician, and the family. Each example has to do with what I call patient care discount, ie, patient care is less due to an intervening variable, in this case the physician. First, the patient’s and family’s rights are possibly being denied, and then the patient’s welfare regarding safety and emotional status was being discounted in deference to the physician’s wants and temperament. In my estimation, this model is the handmaiden system, which unfortunately exists in far too many institutions. Prior to 1965, most students were trained to use and follow this model or process. It was the traditional model then, but as nursing education became influenced by the independentthinking movement, nursing education came into being and nurse training ceased to be. A new and different process evolved. The process changed, but the relationship of the
c3 2
AORN Journal, December 1976, Val 24, No 6
Fig 3
3
nurse to the patient and the physician has not changed, in other words, the relationship remains invariant. In this new model, which is much freer, the physician-nurse-patientfamily articulation is complete (Fig 3). The concentration of articulation is not equal, but the process can move in all directions. The physician plans for the care of his patient; however, the nurse also observes, plans, and implements nursing care in accordance with the medical regimen set forth by the physician. The nurse still sees that the orders are carried out, in fact more efficiently and effectively due to the process. She or he actually enhances the medical regimen with the plan of nursing care. This plan of care is based on a sound body of knowledge in nursing science and related fields and enables the nurse to actively practice nursing in every aspect. The nurse in this model makes nursing diagnoses and plans the actions necessary to maintain or improve the patient’s health status relative to the diagnosis. This nurse is directly involved with the family as necessary and often makes recommendations to the attending physician based on information received from the family. In the OR, this nurse respects the surgeon’s wishes but not at the expense of the patient. The patient is first and foremost. The instruments are selected primarily with the patient as an individual in mind. The special clamp or retractor Dr X needs is, of course, added but to be efficient and patient-oriented, one must be aware of the many intervening variables influencing instrument selection such as patient size, medical history, etc. It would be futile to have the surgeon’s favorite clamp but not the necessary length and size of instruments for the procedure and the patient. As you know, time taken to find or bring forgotten or unplanned items to the OR room during the procedure prolongs anesthesia time and is not in the best interest of the patient. Many times this delay is not due to the nurse’s lack of knowledge about the patient or procedure but to indecision by the “can’t-make up-hismind surgeon.” Also, we all know the “don’t-second-guess-me surgeon” who changes suture or something just because the nurse has anticipated what is needed and has it ready.
1034
Obstacles can be dealt with if you constantly and consciously keep the patient’s welfare foremost in your mind and let logic and “uncommon common” sense guide your actions. The process in this model shows that nurses articulate freely with all the components, that we have the knowledge and skills to function on a colleague basis with the physician as well as the other professionals within the field, and that we are not simply “order takers” as the traditional model denotes. As the models show, nurses are invariably related with the patient and the physician. Without the patient or the physician, she does not function as a nurse. Note I place the patient first. But what of the future model for nursing? I see the future model to be the same as the “now” model, the difference being a stronger connection from nurse to patientlfamily and a weaker connection between nurse and physician (Fig 4). In the future, the nurse practitioner will see patients 1
Fig 4
2
initially and refer them to a physician. I predict a greater amount of this type of practice. As soon as nurses follow the process of the “now” model, I see the dichotomy ceasing to be. Presently, however, dichotomy remains if you profess one model and, in fact, practice another.
Barba J Edwards, RN, MA President Notes 1. Abraham Kaplan, The Conduct of Inquiry: Methodology for Behavioral Science (San Francisco: Chandler, 1964).
AORN Journal, December 1976,Vol24, No 6
Nursing needs new model reflecting changing relationship A model is a diagram of a system. It depicts the relationships of the components within that system. As a symbol, a model uses words, numbers, or pictures, rather than physical representations to depict potentially relevant aspects of a process. One often thinks of a model as a miniature replica of some larger object or set of objects such as an airplane or car or a frontier fort. These models are usually identical replicas of the original. For example, hobby kits have models of gasoline engines that are identical, part by part, to a larger engine differing only in size. Regardless of the size of the parts, the relationship is always the same. The process denoted by the model is ever present. Models vary in their sophisticationdepending largely on how much is known about the particular phenomenon demonstrated by the model. In some instances, models function as fully developed and formalized theories from which a number of specific outcomes may be deduced. Some authors believe that the terms “model” and “theory” are synonymous. Kaplan contends this belief is not entirely justified and that only certain types of theories should be labeled as models.’ Many representations called models do not meet the tests of a coherent scientific theory. In a sense, these models are little more than useful visual aids. Given these two extremes, ie, a developed formalized theory or a visual aid, the nursing models of
a
which I will speak fall closer to visual aids. Even so, such models serve a useful purpose. Specifically, let us think of a model for nursing process as a kind of component system enabling us to abstract and categorize potentially relevant relationships within the process.
E
u sibling Fig 1
For example, one basic model shows the relationship between parent and child (Fig 1). This relationship is one of invariance where the mother and father are always the natural parents of the child and the reverse. The relationship never varies. The child or parent may be legally disclaimed; however, the natural relationship remains a fact. Understanding models and invariance of relationship will help in my discussion of nursing models and what I believe to be invariant relationships between patient and nurse and between physician and nurse. I contend a dichotomy exists between the invariant relationship of nurse and patient and the process of the model. I believe that we in nursing have failed to change the model as the process has changed in the nurse-patient relationship. We talk about, seek to imple-
AORN Journal, December 1976, Vol.24, No 6
1031
ment, and generally espouse the “extended role” theory without effectively communicating what we perceive the extended role to be. To be of value, a model should serve three functions: an organizational function; a heuristic, or research-generating, function; and an anticipatory, or predictive, function. Each of these is important to us as we view the model for nursing in the past, present, and future. With the visual aid of the model, perhaps we can understand where we are in the process, why we are there, and how we can best affect change for the betterment of nursing and ultimately patient care.
n n 1
I
n
Fig 2 Let us first look at what I see as the foundation or basic model-a model that is really the “medical” model (Fig 2). Note that the physician initiates the process of patient care. All activities and communications are funneled through and controlled by the physician. He or she is the prime mover and alone assesses, plans, implements, or orders the care of the patient. The nurse in this model carries out direct orders and reports the reactions, behavior, and activities of the patient to the physician. This nurse is said to do an excellent job because she or he performs all duties well. She or he charts the patient’s condition extremely well and sees that the patient has a hypo “q 4 h” regardless of the needs of the patient. Drainage is described in a noncommittal manner, eg, pink-tinged rather than bloody, or yellowish thick rather than purulent. She or he never makes a direct statement relative to the condition even though it is within her realm of
1032
knowledge as a nurse. The patient and his family are never given direct information as to the well being of the patient. Instead, the nurse defers to “ask your doctor,” or “I can’t answer that, but doctor will be in soon.” This nurse never institutes patient or family teaching without a direct order from the physician. In the OR, the nurse may be a wizard with the instruments, knows Drs X, Y, Zs preferences and may refuse to do needle and instrument counts because “Dr X doesn’t like us to count.” She may allow Dr Y to wear his favorite shoes in the OR even though they are rejects from the trash. This nurse will have five patients in the waiting area for Dr Z “because he likes to see them all down at once.” The examples are endless, but this model in figure 2 gives some idea of the process and the nurse’s relationship to the patient, the physician, and the family. Each example has to do with what I call patient care discount, ie, patient care is less due to an intervening variable, in this case the physician. First, the patient’s and family’s rights are possibly being denied, and then the patient’s welfare regarding safety and emotional status was being discounted in deference to the physician’s wants and temperament. In my estimation, this model is the handmaiden system, which unfortunately exists in far too many institutions. Prior to 1965, most students were trained to use and follow this model or process. It was the traditional model then, but as nursing education became influenced by the independentthinking movement, nursing education came into being and nurse training ceased to be. A new and different process evolved. The process changed, but the relationship of the
c3 2
AORN Journal, December 1976, Val 24, No 6
Fig 3
3
nurse to the patient and the physician has not changed, in other words, the relationship remains invariant. In this new model, which is much freer, the physician-nurse-patientfamily articulation is complete (Fig 3). The concentration of articulation is not equal, but the process can move in all directions. The physician plans for the care of his patient; however, the nurse also observes, plans, and implements nursing care in accordance with the medical regimen set forth by the physician. The nurse still sees that the orders are carried out, in fact more efficiently and effectively due to the process. She or he actually enhances the medical regimen with the plan of nursing care. This plan of care is based on a sound body of knowledge in nursing science and related fields and enables the nurse to actively practice nursing in every aspect. The nurse in this model makes nursing diagnoses and plans the actions necessary to maintain or improve the patient’s health status relative to the diagnosis. This nurse is directly involved with the family as necessary and often makes recommendations to the attending physician based on information received from the family. In the OR, this nurse respects the surgeon’s wishes but not at the expense of the patient. The patient is first and foremost. The instruments are selected primarily with the patient as an individual in mind. The special clamp or retractor Dr X needs is, of course, added but to be efficient and patient-oriented, one must be aware of the many intervening variables influencing instrument selection such as patient size, medical history, etc. It would be futile to have the surgeon’s favorite clamp but not the necessary length and size of instruments for the procedure and the patient. As you know, time taken to find or bring forgotten or unplanned items to the OR room during the procedure prolongs anesthesia time and is not in the best interest of the patient. Many times this delay is not due to the nurse’s lack of knowledge about the patient or procedure but to indecision by the “can’t-make up-hismind surgeon.” Also, we all know the “don’t-second-guess-me surgeon” who changes suture or something just because the nurse has anticipated what is needed and has it ready.
1034
Obstacles can be dealt with if you constantly and consciously keep the patient’s welfare foremost in your mind and let logic and “uncommon common” sense guide your actions. The process in this model shows that nurses articulate freely with all the components, that we have the knowledge and skills to function on a colleague basis with the physician as well as the other professionals within the field, and that we are not simply “order takers” as the traditional model denotes. As the models show, nurses are invariably related with the patient and the physician. Without the patient or the physician, she does not function as a nurse. Note I place the patient first. But what of the future model for nursing? I see the future model to be the same as the “now” model, the difference being a stronger connection from nurse to patientlfamily and a weaker connection between nurse and physician (Fig 4). In the future, the nurse practitioner will see patients 1
Fig 4
2
initially and refer them to a physician. I predict a greater amount of this type of practice. As soon as nurses follow the process of the “now” model, I see the dichotomy ceasing to be. Presently, however, dichotomy remains if you profess one model and, in fact, practice another.
Barba J Edwards, RN, MA President Notes 1. Abraham Kaplan, The Conduct of Inquiry: Methodology for Behavioral Science (San Francisco: Chandler, 1964).
AORN Journal, December 1976,Vol24, No 6