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Case Study
Integrating Nursing Theory and Process into Practice; Virginia’s Henderson Need Theory
Younas Ahtisham, BScN Jr. Lecturer, Shifa College of Nursing, ShifaTameer-e-Millat University, Islamabad, Pakistan Sommer Jacoline, RN, BScN Sr. Lecturer, Shifa College of Nursing, ShifaTameer-e-Millat University, Islamabad, Pakistan Correspondence: AhtishamYounas, Shifa College of Nursing, Sector H8/4 Pitras Bukhari Road, Islamabad, Pakistan e-mail:[email protected]
Abstract
Introduction: The application of nursing theories into clinical practice varies from context to context. But addressing the needs of patient is crucial in providing quality care, across the globe. There is hardly any local literature regarding theory application into practice in our setting. Aim: The aim of the paper is to elaborate the application of nursing theory into clinical setting for deliverance of nursing care and to address gap between theory and practice in Pakistani context. Methodology: This document illustrates a case study integrating Virginia Henderson’s need theory and nursing theory process. Conclusion: This paper is an example of theory based nursing care that can enhance the human health.Virginia Henderson’s need theory is considered close to realism and is applicable in Pakistanicontext.Therefore, it will enable nurses to improve the standard of caring by assessing patient needs and developing a pragmatic plan of care.
Keywords: Client assistance, clinical practice, health promotion, Henderson’s need theory, nursing theory process, theory – practice gap
Introduction
One of the most contentious and enduring problems in nursing is the poor clinical observation and least integration of theoretical concepts into clinical practice. Although theories has been taught in many nursing institutions of Pakistan, but the theory integration into nursing practice has not been tested yet. There is barely any literature about utilization of these theories into nursing practice. Moreover these theories are considered to be abstract in nature and least applicable in clinical environment. However, nursing students are forced to assess the application of theory into clinical without an experienced faculty .Therefore, nursing students may find themselves torn between the demands of their tutors to implement what they have learnt in theory, and pressure from practicing nurses to conform to the constraints of real life clinical situations (Rolfe, 1993).
Clinical situations could become very daunting to students without theoretical knowledge of the practical situations, they would encounter. In such situations, the students became passive rather than active learners, and this could lead to poor understanding of integrating theory and practice.(Maselesele,2001).A nurse increases professional power while using theoretical research as systematic evidence for critical thinking and decision making. When nurses use theory and theory-based evidence to structure their practice, it improves the quality of care.
Considering nursing practice in a theory context helps students to develop analytical skills and critical thinking ability and to clarify their values and assumptions. (Alligood 2014, Chinn& Kramer, 2011; Fawcett, 2005; Meleis, 2007).This paper elaborates the utilization of Virginia Henderson’s need theory into
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clinical practice by incorporating the nursing theory process in Pakistani context.
Literature Review
Biography of Theorist
Virginia Henderson was born in Kansas City, Missouri and was titled with the Nightingale of modern nursing; she earned her Diploma in nursing from the Army School of Nursing at Walter Reed Hospital, Washington, D.C. in 1921 and worked at the Henry Street Visiting Nurse Service for two years after graduation. In 1923, she started teaching nursing at the Norfolk Protestant Hospital in Virginia.
In 1929, she entered Teachers College at Columbia University for Bachelor’s Degree in 1932and Master’s Degree in 1934 respectively.Later shejoined Columbia as a member of the faculty, remained there until 1948 and then became a part of Yale University School of Nursing as a research associate.
She received numerous recognitions:Honorary doctoral degrees from the Catholic University of America, Pace University, University of Rochester, University of Western Ontario, and Yale University.In 1939, she revised: Harmer’s classic textbook of nursing for its 4th edition, and later wrote the 5th; edition, incorporating her personal definition of nursing in 1991.
Henderson died on March 19, 1996 (George, 2011; Timber, ng; Wills 2002).
The Need Theory
Henderson called her definition of nursing her “concept” and emphasized the importance of increasing the patient’s independence so that progress after hospitalization would not be delayed. She categorized nursing activities into fourteen components, based on human needs. She described the nurse’s role as substitutive (doing for the person), supplementary (helping the person), complementary (working with the person), with the goal of helping the person become as independent as possible.
Her definition of nursing was: “The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible” (Henderson, 1966).Virginia
Henderson focused on individual care. She described nursing role as assisting individuals with essential activities to maintain health, to recover, or to achieve peaceful death. She proposed fourteen components required for effective nursing care (Table I).
The first nine components are physiological. The tenth and fourteenth are psychological aspects of communicating and learning. The eleventh component is spiritual and moral. The twelfth and thirteenth components are sociologically oriented to occupation and recreation (Meleis, 2007; George, 2011)
Discussion
Case Scenario:
Ms.X25 years old female client was admitted in the surgical unit, with attempted suicide. Two weeks ago, she ingested toilet cleaner because of a family dispute. Ms. X lived a rural life and had studied till 8th standard. Upon history taking, her mother informed that her marriage was planned two days before the incident. She was reluctant to share the reason for her suicide but stated that she was stressed out and tried to kill herself.Later on,her mother reported that she was impulsiveand emotional person and was in live with someone but the family was willing for her marriage.
Her physical assessment revealed alert, oriented but depressed female. Her chief complaints were difficulty in breathing and mood swings. Her CT scan and endoscopy showed damaged larynx, mouth and stomach ulcers respectively.
The dietician advised liquid diet but Ms. X showed dislike and resisted eating. Due to her limited intake, Foley’s catheter was passed for accurate record of her daily intake and output .She was noncompliance towards her intake and developed dehydration, irritability and insomnia as evidenced by dry mouth, sunken eyes with dark circles around.
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Table 1 Fourteen components required for effective nursing care
1 Breathe normally.
2 Eat and drink adequately.
3 Eliminate body wastes
4 Move and maintain desirable postures
5 Sleep and rest.
6 Select suitable clothes-dress and undress
7 Maintain body temperature within normal range by adjusting clothing and modifying
environment
8 Keep the body clean and well groomed and protect the integument
9 Avoid dangers in the environment and avoid injuring others
10 Communicate with others in expressing emotions, needs, fears, or opinions
11 Worship according to one’s faith
12 Work in such a way that there is a sense of accomplishment
13 Play or participate in various forms of recreation
14 Learn, discover, or satisfy the curiosity that leads to normal development and health and use
the available health facilities
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Table 2 Nursing Assessment of Ms.X
Henderson’s 14 Components Assessment Findings
1 Breathing normally She was experiencing difficulty in breathing; Respiratory rate-16 irregular, Oxygen saturation 87%
2 Eat and drink adequately. Height 153 cm; weight 45kg; skin turgor good, She was advised liquid diet but she resisted taking any liquid.
3 Elimination of body wastes Foley’s catheter was in placed
4 Movement and Posturing Reports fatigue , Feeble to walk, Gait imbalance
5 Sleep and Rest Experiencing insomnia for three days, Dark circles around eyes
6 Select suitable clothes-dress and undress
Wearing loose fitted dirty dress.
7 Maintain body temperature No signs of hyperthermia or hypothermia;Temperature 37 C
8 Keep the body clean and well groomed Mother reported that she was very conscious of her physical appearance and hygiene but was not well groomed at that time.
9 Avoid dangers in the environment Fatigue, feeble walk and history of attempted suicide.
10 Communication She had damaged larynx and had speech difficulty
11 Worship according to one’s faith Religion; Islam, mother reported that she was not spiritual.
12 Work accomplishment Lost interest in self-care and inability to perform ADLs since her marriage was planned as reported by mother
13 Play or participate in various forms of recreation
Mother reported that she used to spend time with family but had lost active participation in home activities.
14 Learn, discover, or satisfy the curiosity Finding difficult to cope with her stress and present illness
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Table 3 Possible Nursing Diagnoses for Ms.X
Breathing Activity intolerance related to dyspnea
Nutrition Nutritional Imbalance less than body requirement related to less desire to eat
Elimination Altered Elimination Pattern related to catheter in-placement
Movement and Posturing
Impaired physical mobility related to fatigue and weakness
Sleep and Rest Disturbed Sleep pattern related to external factors i.e hospitalization
Safety High risk of Injury related to stress
Communication Impaired Verbal Communication related to larynx injury
Hygiene Self-Care deficit related to stress and fatigue
Spirituality Spiritual distress related to inability to participate in religious activities
Learning Ineffective coping related to situational crisis and inadequate psychological resources
Table 4 Planning
1 Address all the physiological needs and provide respective nursing care.
2 Encourage client to identify her strengths and limitations, share her concerns, and participate in activities of daily living
3 Discuss effective coping strategies and impulse control like talking, drawing any pictures, asking questions for exploring her stress factors.
4 Encourage family support by asking mother why she was upset due to her marriage? What were the domestic problems leading to suicidal attempt? Did she have any suicidal thoughts before attempting suicide?
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Table 5 Interventions
1 Observe for strengths such as the ability to relate the facts and to recognize the source of stressors.
2 Monitor risk of harming self or others.
3 Help client set realistic goals and identify personal skills and knowledge
4 Use empathetic communication, and encourage client/family to verbalize fears, express emotions, and set goals.
5 Encourage client to make choices and participate in planning of care and scheduled activities
6 Encourage use of cognitive behavioral relaxation (e.g., music therapy, guided imagery).
7 Involve patient in spiritual activities
8 Discuss coping and stress management techniques like mind distraction, self-control and effective decision making and recreation (watch tv, listen music, outing)
9 Involve in daily life activities of hygiene and exercise.
10 Maintain airway and pain management (medication, relaxation techniques)
She was too feeble to walk with imbalance gait, lost interest in self-care and refused to participate in hygiene care such as dressing, hair brushing and face washing. She was not willing to interact and discuss her feelings with the nurse. The case was managed by employing Virginia Henderson’s theory into nursing theory process.
Nursing Theory Process
Henderson viewed the nursing process as an application of the logical approach to the solution of the problem. The nursing theory process comprises of six elements; Assessment, Nursing Diagnose, Outcome, Planning, Implementation and Evaluation (George, 2011).
Nursing Assessment
A nurse uses a systematic and dynamic way to collect and analyze data about a client; the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. (American Nurses Association,2015). Nursing Assessment of Ms. X (Table II), in accordance with Henderson’s caring components serve as basis for formulation of a nursing diagnose and care plan.
Analysis
Ms. X was in the intimacy stage of Erikson’s (1963) developmental theory. Her mother reported that she experienced social isolation and lost her ability to get involved in the family functions, gatherings and activities .She was not happy with the family decision of her marriage. She was in fear of losing her love and thus experienced social isolation and tried to commit suicide. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression (Erikson, 1963).
Nursing Diagnosis
Based on Ms. X’s assessment findings, a number of nursing diagnoses were developed (Table III).These diagnoses addressed her clinical condition in a comprehensive manner, but in-depth analysis in accordance with need theory emphasized the prioritized nursing diagnose to be; Ineffective coping related to situational crisis and inadequate psychological resources as evidenced by attempted suicide.
Outcome
The intended outcome for her was helpful in planning a short and long term plan of care.It was expected that
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she would be able to; verbalize ability to cope and asks for help when needed; demonstrate ability to solve problems and participate at usual level in society; remained free of destructive behavior toward self or others and communicate needs and negotiate with others to meet needs. Keeping in view the outcome, Ms. X’s caring goals were set which assisted her to cope with her stress and meet all the felt needs (Table IV).
Implementation
Ms. X was provided care by intervening, in accordance with the outcome. The interventions (Table V) helped her to surmount her troubles and regain the lost value in her life. She dealt with the tribulations in an effectual manner.
Evaluation
The outcome of the care plan was successfully achieved by the client. At the end of hospitalization, Ms. X verbalized her concerns with the nurse and showed willingness for family decision. She talked to her mother and decided to be a part of all family activities. She was able to; walk on her own and perform all the daily life activities independently; narrated the coping strategies like relaxation, recreational and spiritual activity and family involvement.
Theory concept and relationship
Henderson used the concepts of fundamental human needs, bio physiology, culture and interaction- communication, which give the theory a dynamic coverage regarding patients need. (Geroge, 2011). Her division of the fourteen component well address patient need in different domains yet simple to apply in clinical setting. Moreover it is more concise as compare to other models like unitary human beings by Martha Rogers which is difficult to address and lacks applicability into practice (Mackenna, 2005). It is applicable to different dimensions of client- nurse relationship. It can effectively address patient need and elaborate nurses’ role. It’s design successfully wrap the components of nursing process. Henderson’s need theory is relevant to Maslow’s hierarchy of human needs.(George,2011).In general this theory is well suited and adoptable for nursing care and practice in various clinical settings.
Conclusion
The case scenario of Ms. X illustrates the utilization of nursing theory into clinical practice by making use of nursing theory process in a broader aspect. The need theory is relevant to clinical setting and can serve as a framework to recognize caring needs, deliver and evaluate holistic nursing care. In addition it was relevant to our settings as well and can help experienced nurses to collect reliable and valid data about the health status of clients, which sequentially enhance the quality of nursing care provided to the patients. The relevancy of various other nursing theories in our setting is still open to discussion and need to be address.
Reference
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