NURS 502 Week 4 Written Responses to Questions 2 on Grand Nursing Theories Example

Written Responses to Questions 2: Needs and Interaction in Grand Nursing Theory, Compared at One Bedside

Question 1: How Are Grand Nursing Theories Grouped?

Grand theories are often grouped by the idea that organizes them, and McEwen and Wills (2014) describe groups centered on human needs, on interactive processes and on unitary processes. Theories in the needs group describe the person as having needs that, when unmet, call for nursing, and the nurse's role is to help meet them until the person can do so independently. Theories in the interactive group describe nursing as a relationship between nurse and patient, and they focus on perception, communication and shared goals. The grouping is useful because it tells a reader what a theory will ask the nurse to look at first. It also explains why two well-prepared nurses can describe the same patient so differently: each has been trained, often without noticing, to begin from a different question.

Question 2: What Is the Central Idea of Orem's Self-Care Deficit Theory?

Orem's theory, a needs theory, holds that adults normally look after their own self-care requisites, and that a nurse steps in only where what a person can manage falls short of what the situation demands. It combines three linked theories: self-care, describing what people do to maintain life and health; self-care deficit, describing when and why nursing is required; and nursing systems, describing how much of the care the nurse provides, from doing it all to teaching and supporting (Orem, 2001). The theory directs the nurse to measure the gap between demand and ability and to close it.

Question 3: What Is the Central Idea of King's Theory of Goal Attainment?

King's theory, an interactive theory, describes nursing as a process in which nurse and patient perceive each other and the situation, make judgments, act, react and interact until they reach a transaction, an agreed goal and the means to reach it. King set the theory within personal, interpersonal and social systems, and she proposed that when perceptions are accurate and goals are mutual, goals are more often attained (King, 1981). The theory directs the nurse's attention to communication and agreement rather than to deficits.

Question 4: How Would Each Theory Guide Care for the Same Patient?

Consider a composite patient, 78 years old, two days after surgery for a hip fracture, who lives alone and is reluctant to get out of bed. Through Orem's theory, the nurse would assess the patient's self-care demands, including mobility, hygiene, nutrition and preventing complications, against the patient's current abilities, decide that a partly compensatory system is needed for now, and plan to move toward a supportive-educative system as strength returns. The plan would be organized around what the patient cannot yet do.

Through King's theory, the nurse would begin by learning how the patient perceives the situation. Perhaps the patient fears falling again and believes rest is safest. The nurse would share a different perception, that early walking prevents complications and speeds the return home, and the two would negotiate a goal, such as walking to the doorway twice today with a walker and a nurse beside the patient. The plan would be organized around a goal both have agreed to. The same patient becomes a set of deficits in one theory and a partner in a negotiation in the other, and an advanced practice nurse can draw on both. In practice the most effective plan probably uses Orem's structure to identify what must be done and King's process to secure the patient's agreement to do it.

Question 5: What Are the Limits of Grand Theories for Advanced Practice?

Grand theories are broad enough to apply to almost any patient, but that breadth is also their limit. Their concepts, such as self-care agency or transaction, are abstract and cannot be measured directly, which makes the theories hard to test and hard to translate into specific clinical decisions (McEwen & Wills, 2014). An advanced practice nurse choosing an intervention for heart failure self-care, for example, needs more specific guidance than either theory provides. That need is one reason middle-range theories developed. Some grew directly from grand theories, such as theories of self-care in chronic illness that narrow Orem's concepts to measurable behaviors, and they can be tested in research and used to design programs. Grand theories remain valuable as lenses that shape how nurses see patients, while middle-range theories do most of the work in research and in evidence-based practice.

The two theories also suggest different measures of success. Under Orem's theory, progress for the hip fracture patient would be measured by tasks the patient can now perform, such as transferring to a chair or managing hygiene without help. Under King's theory, progress would be measured by goals attained, such as the agreed walk to the doorway, and by whether the patient and nurse continue to set new goals together. An advanced practice nurse designing a rehabilitation pathway could combine both, tracking functional tasks for safety and documenting mutual goals for engagement, since a patient who has agreed to a goal is more likely to keep working toward it after discharge.

A further limit is fit with particular populations. Both theories were developed mainly with adult, Western patients in mind, and the assumption in Orem's theory that independence is the goal of self-care, or the assumption in King's theory that patient and nurse can negotiate as equals, may fit poorly with patients from cultures that value family decision-making or deference to professionals. An advanced practice nurse should hold any grand theory loosely enough to notice when a patient's world does not match its assumptions.

References

King, I. M. (1981). A theory for nursing: Systems, concepts, process. Wiley.

McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing (4th ed.). Wolters Kluwer Health.

Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). Mosby.