Nursing Administration in the 21st Century: A Self-Care Theory Approach
Publication Year: 1999
Subject: Nursing Administration & Management
This book seeks to define nursing at a management or administrative level. Using the widely regarded Orem self-care deficit model to provide a nursing focus, the authors explore the nursing needs of populations, the roles and functions of advanced practice nursing administration, and the administrative structures, processes and outcomes that facilitate nursing practice.
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Health Care Service Organization: Trends as We Move toward the 21st Century
- Chapter 2: The Domain of Nursing
- Chapter 3: Models for Nursing Administration
- Chapter 4: Describing Populations for Purposes of Providing Nursing Services
- Appendix 4A: A Structure for Categorizing Data in Describing a Population for Nursing Purposes
- Appendix 4B: A Population Description
- Chapter 5: The Processes of Administration
- Chapter 6: Design as a Function of the Nursing Professional
- Appendix 6A: A General Nursing System Design for New Spinal Cord Injury Patients
- Appendix 6B: Program Design in a Community Setting
- Chapter 7: The Clinical Communication System
- Appendix 7A: Nursing Documentation Forms from a Rehabilitation Setting
- Appendix 7B: Philosophical Statements, Standards, and Forms from a Community Health Setting
- Appendix 7C: Materials from Acute Care Settings
- Chapter 8: Quality Control: Patient Outcomes
- Appendix 8A: Responses about Rehabilitation Outcomes Organized from the Self-Care Deficit Nursing Theory Perspective
- Appendix 8B: Patient Self-Care Classification
- Appendix 8C: Excerpt from a Classification System Developed in an Acute Care Setting
- Chapter 9: Quality Control: Nursing Standards
- Appendix 9A: Excerpt from Nursing Standards for Bowel Management for Patients with Spinal Cord Injury
- Appendix 9B: Excerpt from Nursing Assessment Standards
- Chapter 10: Fiscal Management and Delivery of Safe, Effective Nursing
- Chapter 11: Utilization of Nursing Personnel
- Appendix 11A: Extracts from Minutes Describing a Patient Population, a Nursing System for it, and Organizational Problems
- Chapter 12: Strategies for Theory-Based Nursing
- Appendix 12A: Excerpt from Inservice Program—Nursing System for Patients with Acute Renal Failure
Copyright © 1999 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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Library of Congress Cataloging-in-Publication Data
Allison, Sarah E.
Nursing administration in the 21st century: A self-care theory approach/ by Sarah E.
Allison and Katherine E. McLaughlin-Renpenning.
Includes bibliographical references (p.) and index.
ISBN 0-7619-1455-2 (cloth: acid-free paper)
ISBN 0-7619-1456-0 (pbk.: acide-free paper)
1. Nursing services—Administration. 2. Nursing services—Forecasting. 3. Nursing—Philosophy. I. Renpenning, Kathie McLaughlin. II. Title. III. Title: Nursing administration in the twenty-first century
99 00 01 02 03 04 8 7 6 5 4 3 2 1
Acquiring Editor: Dan Ruth
Production Editor: Astrid Virding
Editorial Assistant: Denise Santoyo
Typesetter/Designer: Danielle Dillahunt
Indexer: Paul Corrington
Cover Designer: Candice Harman
This book is Sarah Allison's and Kathie Renpenning's response to the repeated request, “Tell us how to use a general theoretical position about nursing, specifically self-care deficit nursing theory, in the day-to-day operation of our nursing service. Both writers brought to their task a background of experiences in the study and the development of constructs of self-care deficit nursing theory, a general theory that is descriptively explanatory of nursing. They also brought to their task convictions, based on practical experiences about the value of the use of self-care deficit nursing theory in nursing practice, in the organization and operation of nursing services, and in the structuring and development of curricula for nursing educational programs.
The development of self-care deficit nursing theory during the period from 1965 to 1979 provided the basic structure for the continuing development and organization of nursing knowledge. The work of development included formulation, expression, naming, and validation of the broad conceptual elements and their relationship that were used to express the theory. The conceptual elements included self-care, self-care agency, self-care deficit, nursing agency, and nursing system. Developments during this period also included the identification of the substantive structure of each broad conceptual element named above. Substantive elements of a concept are the more narrow concepts and named features [Page x]of concrete entities that constitute the structure of a broad concept such as self-care agency. The substantive elements of broad concepts identify or point to the concrete entities and relationships of nursing practice situations that nurses must know about and deal with as professionals.
The writers indicate their use of two major primary sources that address self-care deficit nursing theory and its fit within the broader framework of the nursing profession and health care services. These are the Nursing Development Conference Group's 1979 edition of Concept Formalization in Nursing: Process and Product and Orem's 1995 edition of Nursing: Concepts of Practice. Other developments of the theory expressed by the writers have some foundations in the initially developed concepts.
In the development of the book, the writers look to the future of nursing but they do not make predictions about what nursing will be. They tell us, however, what nursing can be, for nursing is something designed and produced by nurses. If nursing is the product made through the work that nurses do for and with persons under their care, then nurses' knowing what they can and should produce, why they produce it, and how to produce it in concrete life situations is critical for the continuing existence of the human health service of nursing. The content of the book should be of value to nurses and nursing students in their efforts to become experienced in thinking within a nursing frame of reference, in communicating nursing, and in practicing nursing and articulating it with broader human and health care frames of reference.
The writers use the first two chapters and Chapter 4 to discuss the settings and the features of situations where nursing is produced. Chapters 3 and 5 describe the responsibilities and work operations of nursing practitioners and nursing administrators. Chapters 6 through 12 describe specific and critical features of the work of producing nursing within health care enterprises. The content of the book is oriented to both the theoretical and the practical features of nursing and its administration.
The practical work of producing nursing or medicine or any human service is always done within a specific concrete situation of practice. For example, a surgeon at work sees and knows anatomically and physiologically the characteristics of the tissues, organs, and organ systems of the person for whom he or she is performing a surgical procedure for an agreed-on reason. As work proceeds, the surgeon makes judgments and decisions about what can and should be done in each existent but changing situation to achieve results that contribute to the human integrity of the individual for whom the surgical procedure is performed. Before and during surgery, the surgeon is aware of the health state and environmental factors that condition the patient's need for and ability to [Page xi]undergo surgery and the factors that condition the process of surgery. The design and plan for performance of the surgical procedure therefore not only incorporate a valid technological design of the surgical procedure but also identify and describe specific conditioning factors that affect both the patient and the surgeon's performance of the procedure.
Nurses must know the existent features of nursing practice situations where they are working. They must know the features of each situation that can be controlled or regulated and how the control or regulation can be exerted by their work for and with patients. When factors cannot be controlled or regulated, nurses act to minimize deleterious occurrences. Nursing professionals know the human and environmental factors that condition their own work and the work of their patients. They know that action based on vague impressions and generalizations is not behavior engaged in by professionals.
Sarah Allison and Kathie Renpenning have produced a book that brings to bear the nursing knowledge structured within the theoretical frame of reference of self-care deficit nursing theory on the work operations of nursing professionals and nursing administrators. These initiated developments can be taken further by interested and creative nurses. The work operations of nursing practice and nursing administration can be formalized for specific health care settings, and essential positions and units of organization can be created. Comprehensive views of populations requiring nursing, of health care enterprises, and of nursing and nurses are requisites for performance of the work of ensuring the continuing effective presence of the work of nursing in societies.
Dorothea E. Orem[Page xii]
First and foremost, we want to recognize Dorothea E. Orem for her significant contribution to nursing knowledge and to nursing as a practice discipline. We want to express our profound appreciation to her for sharing her conceptualizations of nursing, for her encouragement and direct assistance with this book, and most of all for her constant admonition that development of an understanding of nursing occurs in the practice setting.
To do justice in acknowledging the many nurse colleagues, friends, and family members who either directly or indirectly contributed to our thinking and work with self-care deficit nursing theory is impossible. Their help, guidance, and support are deeply appreciated. Practicing nurses who seek ways to improve care to patients and the practice of nursing provided a stimulus for this book.
We want to thank, among those who have shared their work with us, the many nurses past and present of the Mississippi Methodist Hospital and Rehabilitation Center in Jackson, Mississippi, particularly Patricia Hilkert, Irma David, Ellen Lee, and Janice McGee.
We want to thank Kathryn Long and Angela Rayborn, who have taken time to share their clinical experiences with us, helping us to validate some of the categorizations that we have derived from the theory and their usefulness to the administrator.
[Page xiv]Dale Walker and members of the Orem Development Group and the nurses of the Vancouver Health Department, Vancouver, Canada, have made significant contributions to nursing through their work in extending the application of self-care deficit nursing theory in the community. They have generously shared their clinical experiences in several conferences and workshops providing a forum for advancing conceptualizations of nursing. We thank them for sharing the materials they have developed for client services and education of nurses.
The discussions with nurses at the Self-Care Deficit Nursing Theory Institutes sponsored by the Sinclair School of Nursing at the University of Missouri—Columbia have been invaluable. In particular, appreciation is extended to Dr. Susan Taylor, who has been instrumental in organizing those workshops and providing a vehicle for sharing thoughts, ideas, successes, and failures related to implementing theory-based nursing. Lynne Nickle has always been available for discussion and clarification as the work of the book has proceeded.
The work done under the auspices of Reuben Fernandez at Newark Beth Israel Medical Center in Newark, New Jersey, the conferences sponsored by the institution, and the contributions of the staff there as they worked to improve their practice with the assistance of nursing theory have been an impetus for writing this book and providing a guide for nursing administration.
Appreciation is extended also to the many nurses who participated in various projects of the former Center for Experimentation and Development in Nursing of the Johns Hopkins Hospital, Baltimore, Maryland, particularly the late Joan E. Backscheider.
Finally, thanks to Megan McLaughlin, who so diligently proofread versions of the manuscript at varying stages, and to Hans Renpenning, who encouraged us and put up with the confusion during the production process.
Introduction[Page xv]Purpose of the Book
Ensuring the provision of nursing to individuals and patient populations now and in the future is the responsibility of professional nursing practitioners and nursing administrators. With the vast changes in the health care field, nursing leaders more than ever must have a clear vision—a mental model for nursing. Being able to conceptualize and think from a definitive nursing frame of reference provides a sound basis on which to structure and develop nursing practice in a variety of health care settings and organizations to ascertain that nursing is a visible, productive, and qualitative service. In this book, we demonstrate that a theory of nursing practice, the self-care deficit theory of nursing (Orem, 1995), facilitates developing and implementing such a mental model. A variety of conceptual structures are proposed to guide nurse administrators and nursing professionals to “think” nursing and enable them to design and develop nursing systems for a variety of patient populations. Examples of practical application are given. When nurses understand the product of nursing and the outcomes of nursing, they are in a strong position to describe the articulation of nursing with other health care professions and to communicate about nursing to the community at large. In short, the purpose of this book is to [Page xvi]present both theoretical and practical considerations for ensuring the provision of nursing in the 21st century.
Changes in health care pose both challenges and demands for nurses and nursing as a practice discipline and a discipline of knowledge. Because nurses have diverse knowledge, skills, availability, and willingness to serve others, they are often called on and often expected to fulfill many functions, some of which are nursing and some of which are not. Maintaining the nursing focus of assisting people to manage their self-care and/or dependent care systems is essential if nursing is to survive as a profession and as an organized distinctive service to people in society. This book is not about nursing administration or nursing management per se. Other textbooks provide this information. Orem, in her foreword to this book, identifies the textbooks that set forth and explain the self-care deficit theory of nursing to which readers can refer to learn more about this theory of nursing. In this book, we show how a mental model of nursing provides a means by which nursing administration can structure and develop nursing practice and the delivery of nursing services. Examples illustrate structures and processes through which nursing administration can communicate with health care administrators, physicians, other health care members, third-party payers, and the public about patient/client requirements for nursing, nursing needs and programs, and the results to be expected from nursing. Nursing's role and contribution to health care and the benefits to be derived from nursing must be made clear to all. An adequate, comprehensive theory of nursing practice provides the means to achieve these ends.Organization of the Book
The first chapter of this book reviews the current health care environment from which future trends must be projected and examines nursing in light of these trends. In the second chapter, the purpose of nursing and the nature of the particular service provided by nurses are described, and that service is differentiated from the services of other health care professions. In the next chapter, a view of nursing as an entity and its dimensions within the broader organizational structure is presented. A model of administration is proposed. In it, the variables of concern to nursing as revealed by self-care deficit nursing theory are utilized for forecasting nursing requirements of patient populations and projecting from these requirements the types of nurses needed to meet them and the processes that need to be in place to provide the required service. Subsequent chapters [Page xvii]examine selected aspects of nursing administration. Overall, three major themes are explored: (a) describing nursing needs of populations; (b) specifying the knowledge and capabilities for nursing action utilizing various levels of nursing workers, with particular attention to the roles and functions of the advanced nursing practitioner and the nurse administrator; and (c) specifying administrative structures, processes, and outcomes to facilitate nursing practice. In each of these areas, models to guide thinking and practical examples are given.Need for Nursing Theory in Nursing Administration
Without a clear theoretical basis for “thinking nursing,” one reasonably might ask whether anyone, nurse or non-nurse, can fulfill the executive and managerial functions of planning and administering nursing as a service. If the administrator, whether a nurse or a non-nurse, has no formal knowledge of nursing and no basis for conceptualizing nursing, his or her approach will be strictly managerial. There will be little understanding of the product to be produced by nursing. The non-nurse manager must depend on designated nurse leaders in the organization to know and demonstrate what nursing can and should produce for the benefit of patients/clients and the organization.
Historically, management of nursing services has largely focused on the utilization of nursing resources: staffing, scheduling, assignments, and management of personnel in performing nursing activities and procedures in a humane, caring way to meet patient needs. Without a clear and consistent way to define those needs and to define and describe what nursing does and why, nursing is assumed because it is there. Too often, the contract for nursing services by health care organizations, particularly hospitals, is implied but not explicitly set forth when persons are admitted to the service. Consequently, health care providers feel free to use nonlicensed health care personnel to offer less expensive services without having a clear concept of the service nursing has to offer. Efforts to control costs associated with delivery of the nursing have resulted in using tools to measure time on task. Nursing still has not found adequate systems to accurately define nursing costs. Until recent years, no need has been felt to explain and justify nursing's particular contribution to essential operations in a health care enterprise other than to attempt to maximize the utilization of nursing resources at least cost and to coordinate nursing services with those of other health care personnel. In today's health care system, priorities have to be set and limitations in resources addressed.
[Page xviii]How can nursing safely and effectively be provided, and to what extent can provision of nursing be ensured now and in the future? One approach to address this problem is for nursing administrators as well as nursing practitioners to have a clear focus on the domain and boundaries of nursing and the best way to utilize nursing resources to meet health goals of the populations served and goals of the organization. This requires nurses to have a clear understanding of the nature of nursing and its product—service—and involves close communication, coordination, and collaboration among nurses, other health care disciplines, administration, patients/clients, and the public.
Consideration of nursing theory as potentially useful in nursing administration began to emerge in the literature during the 1980s (Allison, McLaughlin, & Walker, 1991). In the 1990s, greater attention has been given to nursing theory in nursing administration (Fernandez & Wheeler, 1990; Huckaby, 1991; Manthey, 1991; Young & Hayne, 1988). Over the past 15 years, many health care agencies, such as hospitals, nursing homes, home health, and community health services, have adopted nursing theories such as Orem's as the basis for practice (Fawcett et al., 1990; Kerstra, Castelein, & Philipsin, 1991; Laurie-Shaw & Ives, 1988; Park, 1989; Perras & Zappacosta, 1982; Walborn, 1980; Walker, 1993). Huckaby (1991) noted the significance of nursing theory for nursing administration as a means for explaining and directing nursing practice. Barnum and Kerfoot (1995) stated that nursing theory is “the intellectual framework for patient care”; it provides “a sound basis” on which to set the “mind frame.” According to them, theorizing, whether formal or informal, “is inevitable” (p. 23). Young and Hayne (1988) briefly described various valuable roles that nursing theory plays in nursing administration (pp. 67–70) but did not discuss in depth how any one theory fulfills these roles.
With the focus today on promoting people's responsibility for their own health care and a healthier lifestyle to reduce the high cost of “sick” care, the self-care deficit nursing theory is highly relevant and provides a definitive guide for designing nursing systems for patient populations for the future. The theory provides an explanation of what is required to promote and protect people's abilities for self/dependent care and to overcome self-care deficits at every stage of the health care process. Corollary to this, the nurse administrator must perceive how nursing from the self-care perspective articulates and coordinates with services provided by other health care disciplines. The nurse administrator must be visionary to foresee and conceive what can and should be done for nursing to help persons to achieve health goals, collaborate with other health care disciplines as necessary to achieve them, and reduce health care costs. Broad vision is needed to perceive and demonstrate how nursing fits into a health [Page xix]service organization for a particular population but also into the larger framework of health care services.Nursing Administrative Leadership
A premise of this book is that leadership from nursing administration is essential if substantive changes in nursing practice are to be made. A nursing conceptual basis for making decisions enables development of nursing practice to achieve nursing outcomes and can provide evidence as to the particular contribution and benefits of nursing. If nursing administration or nursing management at whatever level does not take a leadership role, employed nurses will tend to be absorbed by the dominant culture—organizational, medical, or some other. An adequate conceptualization of nursing provides the basis for making decisions that support the development of nursing practice to achieve nursing outcomes and can provide evidence as to the particular contribution and benefits of nursing. Consequently, nursing administration must lead the way to demonstrate the what, how, and why of nursing by making clear nursing's purpose, focus, and boundaries—the nursing domain—and its contribution to health care. This does not preclude the collaboration of nursing in other spheres of endeavor but should make clear where nursing fits in and where it is expending effort to provide other services.
In the past, studies to advance nursing practice frequently borrowed knowledge and skills from other disciplines such as medicine. An example of this is the early work at the University of Colorado in the mid-1960s on developing the nurse practitioner role in ambulatory well-child care. This proved so successful that the role today is well established, not only in primary care for children and adults but in acute care as well. Today, this role and related functions are incorporated into both undergraduate and graduate nursing education programs. Known, validated, and standardized medical diagnostic and treatment knowledge and skills are taught to nurses and nursing students as a means of expanding the role of the nurse. But this is not nursing knowledge. It is medical knowledge. It does, however, help the nurse to understand the medical conditioning factors that establish and influence self-care demands and self-care capabilities in a nursing situation and to know more accurately when medical assistance is needed beyond what the nurse knows and can do. Advanced nursing knowledge about self-care/dependent care limitations, helping persons to meet complex self-care demands, and dealing with the factors influencing both is lacking. [Page xx]Knowledge about managing self/dependent care systems needs to be developed. Knowledge borrowed from other disciplines is useful when articulated from a nursing frame of reference and can help to advance nursing knowledge.
Organizations are created and operate through the collective activities of individuals working in them toward a common purpose and having a shared vision. This requires extensive and intensive communication, cooperation, and collaboration. Nursing administration must be able to articulate and communicate the nursing perspective, how nursing can (or cannot) and does contribute to the purposes of the organization, and how nursing relates to other components in the organization. This requires the ability to clearly describe and explain nursing as a form of care required by and provided for individuals in the populations to be served, whether they are in their homes or in health care settings, based on their status as sick or healthy.
The nurse administrator's beliefs, values, concerns, and commitment to nursing, to its safe, effective delivery, and to the professional growth and development of nursing personnel are essential if the service is to be dynamic and adaptable to meet changes in health care. The leader should inspire and empower nurses to use all of their knowledge and skills and give their best for patients. Management concerns should be less in the sense of controlling relationships or the environment, asserted Morath and Manthey (1993), and more in terms of promoting the intellect and creativity of nurses. “Thinking” nursing from a theoretical perspective engages these faculties. Being able to conceptualize nursing provides a basis for developing and improving nursing practice. In this way, nursing administration becomes more than guiding and managing people. Nurse administrators or managers as leaders are responsible for examining nursing situations involving patient populations, designing and developing nursing systems of care, and planning to ensure that the essential and preferably desirable operations of nursing practice are carried out.References[Page xxii]1991). Nursing theory: A tool to put nursing back into nursing administration. Nursing Administration Quarterly, 15(3), 72–78., , & (1995). The nurse as executive. Gaithersburg, MD: Aspen., & (1990). The effect of Orem's self-care model on nursing care in a nursing home setting. Journal of Advanced Nursing, 15, 659–666., , , et al. ([Page xxi]1990). Organizing a nursing system through theory-based practice. In G. G.Mayes, M. J.Madden, & E.Lawrenz (Eds.), Patient delivery models (pp. 63–83). Rockville, MD: Aspen., & (1991). The role of conceptual frameworks in nursing practice, administration, education, and research. Nursing Administration Quarterly, 15(3), 17–28.(1991). Preventive home visits to elderly people by community nurses in the Netherlands. Journal of Advanced Nursing, 16, 631–637., , & (1988, March-April). Implementing Orem's self-care deficit nursing theory, part 1: Selecting a framework and planning for implementation. Canadian Journal of Nursing Administration, 1, 9–12., & (1991). Delivery systems and practice models: A dynamic balance. Nursing Management, 22, 28–29.(1993). An environment for care and service leadership: The nurse administrator's impact. Nursing Administration Quarterly, 17(2), 75–80., & (1995). Nursing: Concepts of practice ((5th ed.). St. Louis, MO: Mosby Year-Book.1989). Health care for the homeless: A self-care approach. Clinical Nurse Specialist, 3, 171–174.(1982). The application of Orem's theory in promoting self-care in a peritoneal dialysis facility. American Association of Nephrology Nurses and Technologists [AANNT] Journal, 9, 3, 37–38, 55., & (1980). A nursing model for hospice: Primary and self-care nursing. Nursing Clinics of North America, 15, 205–217.(1993). A nursing administration perspective on use of Orem's self-care deficit nursing theory. In M.Parker (Ed.), Patterns of nursing theories in practice (pp. 253–263). New York: National League for Nursing.(1988). Nursing administration: From concepts to practice. Philadelphia: W. B. Saunders., & (
Ensuring the Provision of Nursing in the Future: A Summation[Page 283]
In this book, we seek to provide a way to conceptualize nursing and nursing administration as the basis for ensuring the provision of nursing now and in the future. Nurse administrators and nursing practice leaders need mental models through which to think about their work, to structure nursing practice, and to develop ways to ensure that nursing is provided to populations of persons requiring personal assistance with their health care. A definitive comprehensive general theory of nursing such as the self-care deficit nursing theory provides such a model. It speaks to the reality of nursing practice and is simple, yet it reveals the complexities of nursing that need to be explored, studied, and explained. This theory defines the focus and the boundaries of nursing in terms of helping people to manage self and/or dependent care systems—that is, to deal with and overcome actual or potential self-care deficits, enhance, promote, and protect self-care capabilities, and monitor and regulate factors that affect both. The focus of nursing is distinct from that of other health care disciplines, but nursing must be articulated with them to help people reach general goals of life, health, well-being, and effective living. In other words, nursing can be viewed [Page 284]as the medium through which self-care is accomplished and people are helped to maintain and increase their capabilities for self-care. With this focus clear, the limits or boundaries of nursing are known and understood. With this understanding, knowledge developed by other disciplines can be used and/or incorporated into nursing. Overlap and gaps in services between health care disciplines can be seen more clearly. From this perspective, nursing practice and services to patient populations can be structured and developed to meet health care requirements that are appropriate to nursing's domain and complementary to the services and contributions of other health care disciplines, all for the benefit of patients/clients.
The major premise of this book is that the nurse administrator, as the leader for nursing in any nursing organization, big or small, must know and “think” nursing to ensure that nursing is truly provided cost-effectively and efficiently for the benefit of populations served, the profession, the organization, and the community. Nursing administrative leadership is key to making this happen because nurse administrators, at whatever level in the organization, are the ones ultimately responsible for nursing. Nursing leaders in practice and those with designated managerial responsibilities must have a mental model for nursing to structure nursing organizations and their processes if they are to achieve nursing outcomes and be definitively able to say what these are. This means the nurse leader must have a mental model for nursing. The nurse leader, as an advanced nursing practitioner or administrator, must clearly know the nature of the service to be provided and the results to be expected from it. The nurse administrator must be able to conceptualize the dimensions of nursing and have a model for nursing administration. The latter, consistent with self-care deficit nursing theory, addresses the various components or variables of concern in providing nursing for patient populations. The theory provides a guide for structuring nursing practice. The remainder of the book describes what conceptualizations might be put into practice and how, giving practical examples of ways in which to develop administrative processes to ensure the delivery of quality nursing care.
The model for nursing administration mentioned above, found in Figure 3.3, gives direction for development of nursing practice for patient populations, the characteristics of which are described in Chapter 4 's Appendix 4A. Particular attention is drawn to the function of design by the nursing professional, a too often neglected function. To date, the notion of design of nursing systems has been given little or no attention in the profession of nursing. A model for design of nursing systems for patient populations is proposed. Figure 6.4 shows the dimensions and conceptualizations of nursing as derived from self-care deficit nursing theory, laid out in flowchart fashion. The factors addressed in this model [Page 285]provide a basis for designing and planning for nursing services for patient populations in relation to general nursing and health goals to be achieved.
A categorization scheme for identifying outcomes of nursing based on the self-care deficit nursing theory is proposed. The categorization model needs to be studied and tested for validity and reliability. But such studies will depend on nurses' practical knowing of the variables in the theory and the development and maintenance of adequate documentation systems. These categories, based on components of the theory, provide a logical, comprehensive framework for evaluating the outcomes of nursing. Figure 10.1 shows the fiscal aspects of nursing administration in relationship to the nursing focus as a basis for examining costs and budgets for nursing, a consideration when looking at nursing productivity in relation to financial outcomes.
When it comes to utilization of nurses, the differences in focus of the basic nurse and the advanced nurse are identified on the basis of a conceptual approach to nursing practice. The nursing theory thus helps to clarify issues related to delivery of nursing services and nursing practice (see Table 11.2). A model (Table 11.3) for delivery of nursing across the continuum of care is proposed. Listed are criteria for decision making about placement of persons in a health care environment on the basis of needs for nursing as defined by the theory. If nursing is the major health service provided by many of these organizations, then the nursing case manager, an advanced nursing practitioner, should play a definitive role in planning and providing nursing across the continuum of care. This nursing role has financial implications and potential for revenue generation for nursing as well.
Finally, the book suggests some strategies for implementing practice from a particular perspective or mental model in an organization. Because nurses employed in an organization may or may not have any knowledge of the particular mental model for nursing that has been adopted by the organization as the basis for practice, it is incumbent on the organization to ensure that these nurses learn the theoretical basis for nursing practice, work from that perspective, and communicate it orally and in written documentation. This ensures commonality of purpose and consistency in practice and communication about patients/clients.
At this stage of development in professional nursing, when no one conceptual framework or mental model for nursing is commonly accepted, valid and reliable nursing theories must be tested in the reality of the nursing work world. The nurse administrator ultimately is the one to promote and support the establishment of a theoretical perspective for nursing practice and must substantiate its effectiveness or ineffectiveness in terms of the purposes and goals of the [Page 286]organization providing the service and the populations being served. Evidence of productivity and effectiveness in results from theory-based nursing, when shared with others through demonstration and publication, can bring about a change in how nursing is practiced in the future. This book proposes an approach to that future and places the responsibility on nursing administration, aided by advanced nursing practitioners, to make that future happen.
About the Authors[Page 297]
Sarah E. Allison, RN, MSN, EdD, was a member of the Nursing Development Conference Group, which did pioneer work in the development of self-care deficit nursing theory. She has been involved as a nursing administrator in the integration of nursing theory and nursing administration for more than 30 years. She is frequently sought out as a consultant and speaker on this topic at national and international nursing conferences and has taught nursing theory at several university schools of nursing. She was formerly Vice President of the International Orem Society and Vice President of Nursing Administration at the Mississippi Methodist Rehabilitation Hospital and Center in Jackson, Mississippi. Her recent publications include “Nursing Theory: A Tool to Put Nursing Back Into Nursing Administration” (with Kathie McLaughlin and Dale Walker) in Nursing Administration Quarterly (1991), “Historical Development of the Self-Care Deficit Nursing Theory in Education Practice” in the International Orem Society Newsletter (1993), and “Continuing Education for Theory-Based Nursing in a Service Agency” (with Lynne Nickle) in the International Orem Society Newsletter (1995).
Katherine E. McLaughlin-Renpenning, RN, MScN, has had experience as a nursing educator as well as a nursing administrator. She has provided consul [Page 298]tation services relating to the use of nursing theory to provide direction for nursing practice, education, research, and administration over the past 15 years in Canada and internationally. She is currently President and Chief Nursing Consultant of MCL Educational Services, Inc., and McLaughlin Associates. She has been involved in the development of computer applications using nursing theory as a component of the information-processing model. She is a member of the Self-Care Deficit Nursing Theory Study Group and the Editor of the International Orem Society Newsletter. She has also been a speaker nationally and internationally. Recent publications include coauthorship of “The Practice of Nursing in Multiperson Situations, Family and Community” in D. E. Orem's Nursing: Concepts of Practice (5th ed.) and authorship of “Implementing Self-Care Deficit Nursing Theory: A Process of Staff Development” in Marilyn Parker's Patterns of Nursing Theories in Practice, as well as coauthorship of several articles on computer applications and nursing theory.