Nursing theory and clinical practice: how three nursing models can be incorporated into the care of patients with end stage kidney disease.
Patients with end stage kidney disease require complex care regardless of where they are within the disease continuum. Although not often recognized by clinical nurses, the incorporation of nursing theory into the clinical care of patients with end stage kidney disease can enhance the overall care that is administered. This paper will endeavour to demonstrate how the three nursing models/theories of Orem, Neuman and Peplau can assist renal nurses to articulate their practice and to incorporate these theories into the nursing practice required to care for patients with end stage kidney disease.
Key words: theoretical models, self-care, end stage kidney disease
To the disappointment of nursing academics throughout the world, the words nursing theory are not ones that are heard routinely during conversations with clinical nurses. Not only observed through clinical experience, but also described in the literature, is the fact that clinical nurses do not recognize a relationship between nursing theory and everyday clinical nursing practice. Greenwood (2000) describes nursing theory as "among the least-loved subjects in the undergraduate curriculum"(p.77). There may be many reasons why practising nurses and nursing students dislike nursing theory, but one of the key reasons may, in fact, be one that has been described by Greenwood (2000).
Greenwood (2000) explains how the apparent division between nursing theory and nursing practice are the result of nursing theory and nursing practice being taught by different instructors. Undergraduate nurses begin to believe that nursing theory is learned only from nursing academics and nursing literature and that nursing practice, or clinical nursing skills, are learned through their experience while working alongside more experienced clinical nurses. She points out that nursing theory is also learned from the experience of working with senior clinical nurses, but that this theory is somewhat different from what is taught in university and has an influence on even routine procedures (Greenwood, 2000).
The development of nursing practice from nursing theory is not clearly understood among clinical nurses. Theory helps to provide the knowledge that is needed to improve nursing practice. This theoretical knowledge increases nursing's power and provides professional autonomy through its ability to guide practice, education and research (Marriner-Tomey, 1994).
Theory and a professional discipline
Dickoff and James (1997) define theory as "a conceptual system or framework invented to some purpose"(p. 104). They explain that as the purpose changes so must the structure and complexity of the system. Theory is something that is discussed verbally and can be communicated to others. It is the guide that shapes reality, but is not reality. How a theory relates to reality is how the theory is validated. To be valid, a theory must fulfill the purpose for which it was invented. In order to decide what theory is best for a specific professional discipline, the purpose of the discipline must first be articulated. Dickoff and James (1997) describe that a true professional is action-oriented rather than someone who just observes or comments and actually initiates realistic change.
The purpose or focus of nursing has been defined differently throughout the literature. Florence Nightingale identified the focus of nursing in relation to providing an optimal environment in which to foster health promotion and healing (Meleis, 1991). The work of Newman, Sime and Corcoran-Perry (1991) described nursing as "the study of caring in the human health experience" (p. 3). Although the purpose of nursing may vary somewhat depending on the theorist or academic, the common thread within much of the literature is the provision of care in a caring manner. The theories of Orem, Neuman and Peplau can easily be integrated into the care of patients with end stage kidney disease.
The care of patients with end stage kidney disease and nursing theory
Orem's Self-Care Model
While examining the nursing theories of Orem, Neuman and Peplau, it becomes obvious that the care of patients with end stage kidney disease can be enhanced using a number of different nursing models. Orem's Self-Care Model is one that is particularly well-suited to this nursing specialty.
Dorothea Orem began publishing her early work in 1959. The purpose of this work was to develop curriculum for practical nurses. These practical roots may explain why Orem's nursing model has been openly accepted among American and British nursing groups and is used extensively by health care practitioners (Pearson et al., 2005). Orem's work evolved throughout the 1960s, 1970s and 1980s. During these times, health care consumers had become more inquisitive about their health and health care needs, as well as developing an increased desire to become more involved in their care. Although today there still remain patients who simply want to be taken care of and provide little or no input into their plan of care, the trend toward increased health and illness awareness continues. The concept of self-care has stood the test of time, especially with an increased emphasis on health promotion and illness prevention. Orem (1985) defines self-care as "the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being" (p. 392).
Although the focus may appear to be on caring for one's self, Orem does not limit self-care to the individual. Self-care also includes the care that is given by health care workers, family or friends when an individual cannot provide aspects of, or complete care to themselves in the short or long term.
The care of patients with end stage kidney disease is complex and may begin anywhere along the disease continuum from early recognition of renal impairment to very late detection that requires the urgent initiation of life-saving dialysis treatments. Although kidney disease may strike at any age, the vast majority of patients are elderly with multiple co-morbidities. These patients require complex care that is often difficult to provide without the assistance of the patient's family and/or friends. Advanced kidney disease impacts multiple aspects of an individual's life. There must be modifications to what an individual eats and drinks, sleeping patterns are affected, energy levels are diminished, and complex medication regimens are required, as well as the ongoing treatment with some form of renal replacement therapy. The three types of renal replacement therapies are hemodialysis, continuous ambulatory peritoneal dialysis (CAPD) and renal transplantation. The majority of patients with end stage kidney disease are on hemodialysis. This requires that they come to a dialysis centre three times per week and receive four hours of dialysis treatment. Peritoneal dialysis requires that an individual performs dialysis exchanges five times per day or that they connect themselves to a cycler overnight. Renal transplantation is the preferred method of renal replacement therapy, but it is not an option for all patients for a number of reasons. The most common of these reasons is advanced age combined with multiple co-morbidities.
From the early days of diagnosis of kidney disease, patients are encouraged to be active participants in their own care. This includes participation in the decision-making that requires the selection of a treatment modality, compliance with strict dietary and fluid restrictions, compliance with complex medication regimens, and compliance with their prescribed dialysis treatment. Ricka et al. (2002) have examined how Orem's (1985) theory of self-care is "characterized by patient's deliberate actions regulating his/her functioning and development for health and well-being. The self-care theory claims that self-regulation is necessary for life itself, for health, for human development, and for general well-being". Because Orem's theory describes self-care as a learned behaviour and nurses believe that self-care will improve the well-being of the patient, nurses have the opportunity to teach patients to help control the impact that kidney disease can have on their lives.
Ricka et al. (2002) describe six categories of health-related self-care requirements that are relevant to patients with end stage kidney disease. The first four categories are "1) seeking and securing appropriate medical assistance, 2) being aware of and attending to the effects of pathological conditions, 3) effectively carrying out medically prescribed measures with respect to regulating or preventing pathological processes, and 4) compensating for disabilities and being aware of and attending to or regulating discomfort"(Orem 1985, p. 225). All of these categories relate to compliance with alterations in dietary and fluid intake, changes in elimination patterns, and compliance with medications and renal replacement therapies that are required in order to survive with end stage kidney disease.
The final two categories of health-related self-care are: 1) modifying the self-care in accepting oneself as being in a particular state of health and in need of a specific form of health care and learning to live with the effect of pathological conditions, and 2) the effects of medical diagnostic and treatment measures in a lifestyle that promotes continued personal development (Orem, 1985). These two categories relate to the psychological impact of chronic kidney disease. The acceptance of this life-threatening disease and its devastating effects on almost every aspect of a patient's life is very difficult. Denial is common among this patient population. Kubler-Ross (1984) describes denial as a positive protective mechanism used by patients initially to cope with the diagnosis of a disease process. Although this is a normal response, denial can complicate the delivery of care by both family members and the health care team. A number of researchers have examined the impact chronic kidney disease can have on family members including changes in roles and issues with sexuality (Brunier & Taylor McKeever, 1993; Dingwall, 1997; Woods et al., 1989).
Neuman's System Model
Although Neuman's System Model has been utilized extensively in the development of nursing curricula and administrative practice, it has also been adapted to many clinical areas. This model can be used to facilitate nurses to practise with a goal-directed and holistic approach to patient care (Beckman et al., 1994). As previously described, chronic kidney disease has a significant impact on almost every aspect of a patient's life. Although there are a number of disciplines involved in a patient's care, the nurse is the nucleus and constant presence in their care. Even though there are significant technical aspects to the care that is delivered to these patients, nurses are often involved in a number of situations where critical decision-making is required by the patients and their families. These situations include having to decide what type of renal replacement therapy to begin, or the even more difficult decision of whether or not to begin or continue any form of renal replacement therapy.
Beckman et al. (1994, p. 276) state that "Neuman has developed several instruments to facilitate the utilization of the systems model". This model has also been used extensively in a variety of nursing research. Neuman's Systems Model "directs researchers to study patient's perceptions"(Breckenridge, 1997, p. 314). This model can be utilized as a framework when examining decision-making in chronic kidney disease. Breckenridge (1997) has used this model and the life-death decisions framework (Degner & Beaton, 1987) to examine why in-centre hemodialysis is chosen more often by patients as their preferred form of renal replacement therapy despite research (Bremer et al., 1989; Deniston et al., 1989; Evans et al., 1985) that has demonstrated that patients on continuous ambulatory peritoneal dialysis report a higher quality of life. This group was able to identify the value that patients place on having a choice of treatment modality. They also identified the need for further study of the many factors affecting this choice. Breckenridge (1997) has described the application of theory in practice as a way of testing the validity of the theory. This study was able to demonstrate how Neuman's System's Model can be used to examine decision-making in this patient population.
Peplau's Theory of Interpersonal Relationships
Pearson et al. (2005, p. 179) describe Hildegard Peplau as "one of the earliest American theorists to recognize and respond to the need for changes in nursing practice". Peplau's primary area of interest was psychiatric nursing, but her work can also be applied to other fields (Pearson et al., 2005). When discussing Peplau's work, Sills (1978) describes how the ideas of this theorist have provided an architectural design for the practice of a discipline. Peplau's focus on professional behaviour and accountability is the foundation to establishing nursing as a professional discipline. She describes not only accountability to the patient and society, but also accountability to oneself. There is an emphasis on the need for nurses to remain current and recognize the need for ongoing education to maintain their skills and improve patient care.
Peplau visualized nursing as a healing art (Belcher & Fish, 1995). The need for mutual respect between the nurse and the patient is an important part of the therapeutic process (Belcher & Fish, 1995). Peplau identified the possibility of discrepancy between what an individual needs and what they may want when it comes to care and treatment. The professional expertise that is required to ensure that the patient understands the need for appropriate care and to ensure that this is provided can be obtained through ongoing education and revision of theory (Pearson et al., 2005). Although more formal education is required as part of this ongoing education, she also identifies the ongoing learning process that is nursing itself. Peplau recognizes the individual as unique and capable of learning and changing.
Peplau has described that "the essence of nursing is in the relationship between the nurse and the client"(Pearson et al., 2005, p. 182). In nephrology nursing, there is a unique opportunity to develop long-term relationships with patients. Although nurses may care for patients with other chronic illnesses over the long term, a nurse who is caring for patients on any form of renal replacement therapy may have contact with that patient for many, many years. Sometimes this means until the patient dies or the nurse moves on to another clinical area. This is not the case in most other clinical environments. Although this gives ample time to develop a therapeutic relationship, there are other issues to consider. Peplau's approach to establishing this nurse-client relationship is by having the nurse manage her own behaviour rather than that of the patients. This is particularly important in an environment like hemodialysis where that patient returns three times per week for potentially the rest of their life. Peplau has described "the danger of nurses behaving in such a way as to meet their own personal needs through seeking patient approval. For example doing something for a patient may give satisfaction to the nurse and gain thanks from the patient, but may not achieve movement towards a goal of development for the patient" (Pearson et al., 2005, p. 182). This behaviour is commonly seen throughout hemodialysis units. An example of this is when a nurse cannulates a patient's vascular access in the same site that has been suggested by the patient over and over again despite knowing that the rotation of cannulation sites will help to ensure the long-term patency of the access. Although this brings praise to the nurse from the patient because it is less painful, it will, indeed, shorten the life of the access. This may also create difficulty for the nurses who adhere to the cannulation policy. They may be subjected to criticism by patients and thus be perceived as less competent than their peers. Some nurses seek the approval and praise of patients to enhance their own self-esteem.
Another situation that may occur when caring for patients on renal replacement therapy is the development of inappropriate professional closeness. In Peplau's theory, nurses need to always demonstrate interest, concern and competence toward their clients' situation, but may need to learn to control their own reactions in order to achieve this (Pearson et al., 2005). Pearson (2005) describes the need for nurses to understand their own personal reactions to situations and to also recognize the risks of becoming either over-involved at a personal level or under-involved through a focus on the clinical or technical components of their work. All of these risks are seen in environments where patients are cared for on some form of renal replacement therapy. Hemodialysis units, in particular, are most vulnerable. Nurses may become too personally involved with their patients, which may, in turn, adversely affect their professional judgment. By examining Peplau's Theory of Interpersonal Relations, nephrology nurses can learn to better understand themselves and, in turn, develop more appropriate therapeutic patient relationships. This theory can also assist the nurse with the recognition of the six roles that will emerge during the care of patients as they move through Peplau's four phases towards health.
Although the relevance of nursing theory to clinical practice may not be evident to all practicing nurses, it is clear that Orem's Self-Care Model, Neuman's System Model and Peplau's Theory of Interpersonal Relations can assist nursing to articulate its practice. Pearson et al. (2005) describes how all human practices are based on some form of theoretical premise and that theory is, in fact, practical in nature. Theories have been described as "theoretical models of reality, often a reality that is not directly observable"(Marriner-Tomey 1994, p. 24). Marriner-Tomey (1994) explains how models can be useful in theory development because they can aid in the selection of relevant concepts that are necessary to represent a specific area of interest and to assist in the determination of the relationships among the many concepts. Although not all nursing theories/models are appropriate to every clinical area of nursing, through careful selection, an appropriate theory or model can be used to assist in the improvement of patient care. Although the models of Orem, Neuman and Peplau can be incorporated into some aspect of caring for patients with chronic kidney disease, it is Orem's Self-Care Model that can be incorporated into all aspects of care of this patient population from the early identification of renal impairment to end stage kidney disease requiring renal replacement therapy. The concept of self-care is a key component to meeting the overwhelming needs of these patients and their families in order to ensure quality of life and optimal life expectancy.
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By Janet Graham, RN, BHScN, Cneph(C)
Janet Graham, RN, BHScN, CNeph(C), is Regional Nephrology Access Coordinator, The Ottawa Hospital, Ottawa, Ontario.
Address correspondence to Janet Graham at: firstname.lastname@example.org
Submitted for publication: May 7, 2006.
Accepted for publication in revised form: October 15, 2006.
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|Date:||Oct 1, 2006|
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