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The Importance of Nursing Theory in Nursing Practice

Using Nursing Theory in Daily Practice

Nurse scholars agree that nurses utilize some form of nursing theory,or conceptual model  in  daily  practice  and  they  propose that nursing theory is vital to nursing existence. Meleis(1985) defined theory as "an articulated and communicated conceptualization of invented or discovered  reality in or pertaining to nursin for the purpose of describing, explaining, predicting or prescribing nursing care".Through theory analysis,nurses gain power through knowledge and understanding of  the  phenomena that characterize the nursing situation Fawcett (2010) stated that conceptual models of nursing and nursing theories are a starting point for nursing practice instead of other points of view,such as the medical model.She believed nurses need to adopt the conceptual-theoretic empirical system to acquire  knowledge  in nursing to guide nursing practice.


In terms of advocating evidencedbased nursing practice,it is essential that nursing theories are developed,tested,and disseminated for practical use.Polit and  Beck described conceptual models as ideas assembled in terms of their  relevance to a common theme.Conceptual models are more broad and abstract than theories. Fawcett(2010)delineated  nursing  theory and nursing conceptual model in the different contexts for which each is used.One  example of a nursing  theory  is  the  middle-range theory. Middle-range theories focus on a portion of reality or human experience,involving a selected number of concepts.Mariner-Tomey and Alligood added that nursing theory provides autonomy by reinforcing nursing practice,education and research.Nursing research findings from rigorous studies provide a robust basis for nursing decisions and actions and help guide nursing practice.


Quantitative as well as qualitative research is the foundation of evidence-based nursing practice.Qualitative research cannot be disregarded  since  this  research  includes human experiences such as love,happiness,hope,and despair.It seems logical to utilize middle-range theories for testing nursing theory in order to differentiate nurse’s contributions to the health and well-being of human beings from contributions  by other disciplines.Conceptual models may lead to middles-range theory development, which can generate empirical esearch findings to validate nursing actions and practice.Nursing theory leads to the further development of nursing knowledge through its research potential.Most theories described in the literature relate to the metaparadigm of nursing .


In  practice,thoughtful,effective,communication,and interpersonal skills can produce positive health outcomes whether it is in an emergency department or a public health setting. According to Fawcett (2010),nurses assess and intervene  in  the  context  of  the metaparadigm to produce the desired outcome.The nurse-patient relationship fosters trust and  understanding  between nurse and patient.Through this relationship, goals for the patient are set and can be achieved.Peplau’s Theory of Interpersonal Relations Peplau developed the theory of interpersonal  relations.She was a staff nurse,researcher,and educator.Peplau urged nurses to use nursing situations as a source ofobservation from which concepts could be derived that were unique to nursing Her primary concerns were the conditions in  patient  wards,particularly psychiatric patients in asylums during the 1940s and 1950s Ironically,as Peplau worked as a young nurse in hospitals,she was told she  should  not  talk  to  the  patients. She referred to an earlier version of her theory as talking to patients,which would be transformed as a therapeutic interpersonal relation theory that would not only be used in treating psychiatric patients but all patients.This includes areas of clinical practice,research,nursing administration,and nursing education.Today,Peplau’s theory is widely taught as a component  of the psychiatric nursing curriculum in nursing programs.

The Significance of Middle-Range Theories in Nursing Theory Testing


Peplau’s (1952) theory evolved through educational endeavors and desire to achieve better outcomes for patients.Her  techniques  and  theory  are  still  practiced  today.Peden said that,“Peplau’s work introduced a woman ahead of her time,and today her theory keeps in pace  with postmodern nursing influences that have reinforced nurses’awareness of the knowledge-rich context of practice, at the level of the patient”.Peplau’s theory can be classified as a middle-range theory.  She  defined  nursing  as  the  therapeutic relationship between both individuals; therefore,it necessitated that the nurse interact with the patient purposefully. Peplau believed that:  “through  the  devise  of  the  therapeutic  nurse-patient relationship,the nurse could be most  beneficial  to human beings” .Peplau  admitted that her theory focused on psychological and interpersonal phenomena and did not include most  aspects of  the physiological phenomenon (Fawcett, 2010). Peplau’s (1952) theory is not applicable to patients with severely altered mental states or for infants and young  children.Despite  this,the nurse can collect pertinent data and facilitate a plan of care by establishing  relationships with parents of infants and children and through the relationships with the families of mentallycompromised patients.


Peplau’s theory is abstract with a one-dimensional concept, unlike some other nursing theories.The dimension of  nursing  here  is  achieved  through  the  nurse-patient relationship.The theorist  emphasized  that  the  terms  relations and  relationships should  not  be  used  as  one  in  the  same.This  implies  that  the  study of what  goes on between  two people  or  their  relations  can  be  quite  elusive.The nursepatient relationship can be expressed as a process with overlapping phases.The three identifiable phases in this process the orientation  phase,the  working  phase,  and the termination phase.According to Peplau (1952), her process of communication was a means to promote  favorable changes  in  patient behaviors. Her model defined health in a broad sense,as the forward movement of the personality and human processes.In each of these  phases the  nurse-patient relationship has certain  nurse  and  patient  behaviors andpurpose.The nurse uses the nurse-patient relationship  to assess the patient’s psychological,emotional,and spiritual needs with learned communication skills,personal strengths,and an understanding  of  human  behavior.  The  result is to produce desirable goals that benefit the patient. In any patient setting,trust occurs when the patient is confident in the nurse’s conveyance of integrity and reliability. It is through the nurse-patient  relationship  that  the  nurse  can  express empathy toward the patient.From this perspective empathy is  the  ability to perceive  the  meaning  and  feelings  of  the patient and to communicate that understanding to the patient.The initial phase of Peplau’s theory is orientation.During this time the patient has health-seeking behaviors.

Peplau’s Theory of Interpersonal Relations


The nurse is identified as someone who is qualified to help the patient.This period sets the stage for a more trusting relationship. In the  orientation  phase  the  nurse collects  data,makes initial assessments of  the  patient’s  needs,  potential,  interests,  and the patient’s inclination to experience fear or anxiety Fawcett.It is importan for the nurse to establish boundaries and maintain these during all phases of the process.Phase  two  of  Peplau’s  theory  is  the  working  phase,which is appropriately named because most  of  the  work  of the relat on the patient’s reactions  and the work that  the  patient  needs  to accomplish.During the identification stage, the nurse may assume  various  roles.  For  example,the nurse may be the care provider,the surrogate parent, the educator or the counselor.It is here where the nurse uses professional knowledge, education, and skill to solve a particular health problem.This is an important  period  where  the patient identifies the nurse as consistently helping, providing unconditional care, and providing empathy.Initially in the nurse-patient relationship, the nurse may act as a surrogate parent if the patient is in a developmental stage of infancy or adolescence.During the working phase power shifts away from the nurse  to  the  patient as the patient becomes more independent  with  personal  care.  During  this  time, the nurse starts  activating the discharge plan and acts primarily an educator and leader.The final phase of the theory is the termination phase. This phase allows the nurse and patient to disngage from the nurse-patient relationship altogether.


During this time, the nurse summarizes the discharge plan and helps the patient organize actions to progress toward new socially interdependent relationships. According to Peplau, the termination of the nurse-patient relationship enhances the patient’s ability  to  become  more  self-reliant in leading a productive healthier lifeImplications of Peplau’s Theory in Emergency Nursing Emergency nursing requires skillful and tactful communication between  nurses  and  patients.The interactions  between nurses  and  patients  in  the  emergency  setting  may  be  brief,but should have meaning for the patients.Emergency nurse are cross-trained in many  aspects  of nursing that include,traumatic  injuries,  psychiatric  illnesses,  substance  abuse,cardiopulmonary emergencies,pediatrics,and obstetrics.Hines and Fraze found that one out of eight emergency department visits were related to mental illness and/or substance  abuse.  It  is  essential  for  the  emergency nurse to communicate proactively with the patients and their families utilizing empathy,assertiveness,and active listening.

Emergency nurses can use the components of Peplau’s theory particularly  when  applying the principlesof the hases in the nurse-patient  relationship.The  process used by the triage nurse in an emergency department is similar to the process described in the initial orientation phase of the theory.During the initial meeting the stage is set during the interaction between the nurse and the patient.The type and quality of interaction either facilitates or hinders further communication.For instance,referring to a patient as a frequent flyer may have extremely negative effects on the outcome.The triage nurse has now set the entire tone for the experience and the patient may have a negative perception that leads to mistrust.

The Three Phases of the Nurse-Patient Relationship in Peplau’s Theory


Sometimes patients will describe their emergency room experience solely based on the interaction  with  the  triage nurse.In general,triage nurses should have good interpersonal skills along with sound clinical knowledge.When patients arrive in an emergency department with a problem should use a non-judgmental,calm approach with an understanding of cultural diversity.In the event that the patient cannot  pinpoint the immediate  problem,the nurse needs touse skills to extract the information through an effective and timely interview processAn Emergency Department Case Study and Use of Peplau’s Nursing Theory.


A 32 year-old  woman  runs into the emergency  department screaming, “I can’t breathe!” She has tears streaming down her face and has a strong odor of alcohol on her breath.Her respiratory rate  is 26 per minute and her pulse oximetry reading is 99%. The nurse introduces herself to the patient. Here is where orientation occurs as the  patient displays health-seeking  behavior,and the emergency  triage  nurse is identified  as someone qualified to intervene and help.She watches her non-verbal cues and body language and deals with the patient with empathy.This behavior facilitates inicompletes the initial vital signs,she notices an odor of alco-hol on the patient’s breath and she realizes that the patient is hyperventilating due to anxiety. At this time, the nurse need to explore her own feelings and beliefs  when  dealing  with the patient,whether negative or neutral.


According to Fawcett the importance of this comes from the philosophical  claim  that  in  each interpersonal relationship,the behaviors tend to be organized around how each person thinks  of  self.In this case,the nurse realizes  through her interview process  that this  patient has a history of panic attacks and she has recently been dismissed from her job. In this sub phase of identification,the patient may feel helplessand the nurse provides reassurance.The nurse actively listens to the patient as the  patient explores similar previous episodes and reveals  methods in which she dealt  with past experiences.When the nurse allows the patient to  express feelings,the patient’s experience may strengthen positive forces in personality.Peplau was responsible for developing a protocol for use in nursing practice for patients experiencing severe anxiety. 


The anxiety protocol identifies a specific criterion that was derived  from  her  theory.The nurse observes for anxiety-related behaviors such as crying, yelling or hyperventilating as displayed by the patient. Consequently, the nurse should focus  efforts on maintaining the patient’s awareness of the anxiety and connect it to the  anxiety-relieving  behaviors.The emergency nurse continues to interact with the patient in the working phase through counseling and clarifying information.The patient realizes through the nurse-patient relationship and self-examination  that  she  is having a panic attack. She also recalls she has medicine prescribed in the event of reoccurrences. The patient discloses that the reason she was fired from her job was that she was intoxicated  and  did  not show  up  for  work.  She  assumes responsibility for this and makes an outpatient appointment for the substance abuse program that she had attended in the past.She remembers  how  this  was  helpful  for  her.The patient also makes an appointment with her therapist on her own before  she  is  discharged  from  the  emergency department. The  exploitation  phase  is seen  here  when  the  patient takes responsibility and acts on her own without the nurse.Finally,  the  nurse and  patient review  the  discharge  plan including: feelings that led to panic attacks, medications,and follow-up appointments.They reviewed signs and symptoms requiring  return  to  the  emergency  department.  This  is  the phase of in the nurse-patient relationship where termination occurs and the relationship ends.



In the emergency department setting,the  nurse  uses  the phases  of the nurse-patient  relationship  in  briefer  periods since the average emergency room visit is usually less than four  hours.Nurses  are  generally  excellent multi-taskers in that they can talk to patients therapeutically,while performing tasks such as starting an intravenous line, or changing a dressing. In this case, the nurse used the nurse patient relationship with skill and empathy,and she developed a mutual trust facilitating the patient’s independence  with  positive health behaviors.

Peplau’s theory is appropriately used in the context of emergency nursing practice.Rural Nursin Rural nursing is now taught in some community health Rural Nursing.Rural nursing is now taught in some community health nursing curriculums  and  graduate  nursing  programs.Long  and Weinert(1989)were the  first  nurse scholars to recognize rural nursing and highlighted that the needs of rural dwellers were  not  adequately  met  through  existing  models  and unique approach was needed to emphasize the needs of rural patients. In 1989,the researchers gave a broad definition of rural  nursing"as the provisio nof nursing to persons living in sparsely populated areas".It is important to update the term rural in terms of the nursing populations served.Rural populations in the  United States are areas that are not urbanized and usually consist of country towns or smaller cities.The United States Census Bureau defined geographical areas that have sparse population densities where much of the land is used for agriculture.


In recent years,urban clusters have been included in the definition of rural.These are subdivisions within a rural area,which is defined as an area with 2,500 to 5,000 persons.The purpose of expanding the definition was for the purposes of economic development and access to resources.The  Office of Rural  Health Policy identified  over 16% of the individuals in the United States are characteristic of rural populations.The definition of rural can vary depending on whichgovernment agency is defining it.Low income and isolated rural populations in large  metropolitan area can be considered  rural populations  when it relates to access to healthcare.In the United States,rural is also defined by each individual state and its properties of land and residents.Individuals residing in remote Alaska have quite different characteristics than individuals residing in remote Appalachia in North Carolina.


The initial studies on rural nursing were from qualitative and quantitative data based on rural individuals’ health perceptions and needs (Long & Weinert, 1989). The participants in the qualitative study were individuals working as farmers,ranchers,and loggers  in  rural  Montana.Rural nursing was initially defined by a set of relational statements about how people in rural areas define health and how they  access healthcare.Winters and Lee admit that continued research  is  needed  to provide a more solid foundation  for rural nursing.Rural nursing is multidimensional,unlike Peplau’s onedimensional theory of interaction.Winters and Lee described concepts of rural nursing practice.The first dimension of rural nursing is health,which is defined by the patient and as the ability to work and maintain activities of daily living.Nurses,who practice in rural settings, need to approach nurse-patient interactions with rural concepts in mind.


The rural nurse needs to understand the rural dweller’s belief systems in order to promote positive interactions that lead to healthy outcomes. Health to a farmer probably may mean that he can continue plowing the farm for the crop due tomorrow.A trip to the emergency department for an illness or injury would be delayed if he could perform his activities.A second concept in rural nursing is isolation and distance.Rural people are often isolated from clinics,doctors’offices,hospitals,and even  pharmacies.A third concept of rural nursing is self-reliance and use of informal healthcare. Conclusion It is critical that nurses have the ability to skillfully inter-act with patients in any setting.This fosters trust,mutualgoal-setting,therapeutic interventions, and improved learning experiences for the patient and the nurse. More often than not,nurses use a combination of nursing theories and conceptual frameworks in daily nursing practice.


Theories such as Peplau’s (1952) and concepts from rural nursing  continue to evolve to guide nursing  practice in the future.The information acquired through the development of nursing theory and research,providesincreased validity and substance to the unique science of nursing.It is important for nurses to utilize nursing theory and conceptual models in the context of their appro-priate settings and populations. In evidence-based practice,nursing theories provide strong building blocks to  produce  research specific to nursing  interventions,which is essential to increase health promotion and health prevention behaviors for patients.The evidence produced through research helps to validate nursing activities  that  can  be  directly responsible for positive health outcomes.

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