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Castledine (1994a) reiterates this point sug-gesting that a definitive and unified theory of nursing can never exist and we should accept that there are multiple views about the ways in which nursing is perceived and described. He also believes that nursing is a complex concept that is so intricate in its constitution that it may not be possible to encompass its full meaning in any definition.

Meleis (1985) categorizes the major nurse theorists and their models using the fol-lowing headings:

● Needs theories ● Interaction theories ● Outcome theories.

This framework provides a structure for the examination of nursing models and ideas when attempting to identify how the role of the nurse is described.

NEEDS-BASED THEORY

The difficulty in describing and defining nurs-ing was identified by Florence Nightnurs-ingale (1952) in her work Notes on Nursing. She suggests that nursing is complex and mul-tifaceted and that its full meaning needs exploration:

‘I use the word nursing for want of a better…the very elements of nursing are all but unknown.’

Roper (1994a) summarizes Florence Nightingale’s ideas about nursing in the fol-lowing way:

● The requirements and needs of sick and healthy people are central to nursing ● The environment of people is a legitimate

concern

● Skill of observation does not make a good nurse but without it a nurse would be ineffective.

Roper (1994b) suggests that Nightingale’s ideas remain an important part of nursing and underpin much of the present role of the nurse. She states:

F

rom the literature available it is apparent that the role of the nurse is not easily defined with theorists from within the profession failing to agree on the exact nature of nursing (Antrobus, 1993). Some place the emphasis of the role on the concept of caring (Kitson, 1987) and therapy (McMahon, 1991; Pearson, 1992), while oth-ers indicate that the role is more diagnostic and technical, remaining disease-centred rather than person-centred (Bortoff and D’Cruz, 1984). Antrobus (1993) believes that the way forward is to develop the body of nursing knowledge as this will enable nurses to articulate what they are and what they do. The use of nursing models as a base for the practice and development of nursing knowl-edge is being increasingly criticized and ques-tioned by nurse scholars for not providing realistic descriptions of nursing (Robinson, 1990; Draper, 1992; Kenny, 1993). However, in terms of defining the role of the nurse, examining the contents of these models pro-vides a useful challenge. Smith (1982) states:

‘…a general theory of nursing or a general model of nursing which encompasses the entire profession is to be rejected. This statement is justified on the basis that the diversity in nursing precludes the emergence of a general theory of nursing.’

Role of the nurse: introducing

theories and concepts

Frank Crossan, Alna Robb

Abstract

This article is a descriptive analysis of the work of nurse theorists in relation to the role of the nurse. It is clear from the literature that nursing is difficult to define but it is possible to identify the core values of nursing and the commonalities that run through the profession. The core components identified by an examination of the literature are the development of systems for the delivery of care, coordinating care, teaching, defending the frail and vulnerable, caring for the ill and the well, and providing technical care. This article aims to provide a baseline picture of what nursing is and how it is described in nursing models allowing readers to examine and compare their own values and image of nursing with what the theorists have written.

Frank Crossan is Clinical Services Manager, Surgical Directorate, Falkirk and District Royal Infirmary and Alna Robb is Lecturer, Department of Nursing Studies, University of Glasgow

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‘Today over a hundred years later, observing has become part of the assessing, implementing, and evaluation phases of the process of nursing. To use this method nurses can select from a variety of conceptual models of nursing. In current nursing curricula there is an emphasis on promoting health and preventing ill health, and on the sociocultural and politicoeconomic context pertaining to the environment in which nursing takes place.’

One of the most widely quoted descriptions of the nurse’s role is that of Virginia Henderson (1966):

‘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 a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do so in such a way as to enable him to gain independence as rapidly as possible.’ Henderson’s work is described as the water-shed between the past and the future of mod-ern nursing (Marks-Maran, 1992). Henderson describes the nurse as an independent practi-tioner but she emphasizes that nursing care is carried out as part of the wider medical plan. Aggleton and Chalmers (1988) suggest that these two nursing functions do not fit easily together and result in a confused image of nursing. However, it could be argued that these two roles are complimentary and essen-tial if the nurse is to play a significant part in the multidisciplinary team.

Roper et al (1980) describe the role of the nurse in terms of independent practice, but point out that at times the nurse may fulfil a dependent role (e.g. assisting doctors), and an interdependent role as part of the multidisciplinary care team with the emphasis being on assisting and enabling individuals to carry out activities associated with living. Orem (1991) also subscribes to the view that a major part of the nurse’s role is enabling individuals to care for themselves and describes five aspects of nursing: acting and doing for the patient; guid-ing; providing physical and psychological sup-port; providing an environment to promote development; and teaching people to care effectively for themselves.

McFarlane and Castledine (1982) propose that nursing involves prescriptive activities but point out that the major role of the nurse is to assist the individual, or community, in the maintenance of health and wellbeing, with particular reference to basic human physiological, psychological and social needs. The ‘needs-based’ models of nursing are criticized for their dependence on the med-ical, physical and curative aspects of care (Cavanagh, 1991) with others (Melnyk, 1983) indicating that the description of the nurse’s role contained in some models (e.g. Orem’s, 1991) suggests that the function of the nurse is guided by the prescriptive activities of others, such as medical staff. Wright (1990), however, argues that the help-ing and assisthelp-ing aspect of the role described by such theorists is essential and basic to the nursing function.

Roper (1994b) reaffirms her ideas about the role of the nurse when she states:

‘…I am still convinced that there is a nurse-initiated core of nursing that concerns patients’ problems with every day living activities. Many patients also require derived nursing interventions.’ She suggests that if nurses accept this they will be able to conceptualize nursing more realistically.

INTERACTION THEORY

Interaction theorists place the emphasis of nursing on the establishment and maintenance of relationships. Crucial to these theories is the impact of nursing on patients and how they interact with the environment, people and the situations in which they find themselves. Nurse theorists as diverse as King, Orlando, Travelbee and Weichanbach can be grouped under this heading (Kitson, 1992).

Orlando (1961) asserts:

‘The function of professional nursing is conceptualized as finding out and meeting the patient’s immediate need for help.’

This is achieved by using the nursing process which, according to Orlando, comprises three major elements: the behaviour of the patient; the reaction of the nurse; and the nursing actions that are designed for the patient’s bene-fit. The interaction of these elements is, in

The

“needs-based” models

of nursing are

criticized for

their dependence

on the medical,

physical and

curative aspects of

care...with

others...indicating

that the

description of the

nurse’s role

contained in some

models...suggests

that the function

of the nurse is

guided by the

prescriptive

activities of

others, such as

medical staff.

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and directing patient care by using their knowledge of the human physiological and behavioural systems. Roy’s (1980) adaptation theory suggests that the role of the nurse is to enable individuals, through nursing interven-tion, to adapt to the environmental stimuli around them. The nurse is seen primarily as a change agent who can manipulate the stimuli affecting the individual or help the individual to adapt so that he/she can cope (Roy and Roberts, 1981).

Neuman (1982) suggests that the role of the nurse is concerned with caring for the individ-ual as a whole. She describes nursing as:

‘A unique profession in that it is concerned with all the variables in an individual’s responses to stress.’

This holistic caring role extends to the well individual in terms of health promotion. According to Rogers (1970), the major role of the nurse is to:

‘Promote symphonic interaction between man and environment, to strengthen the coherence and integrity of the human field, and to direct and redirect patterning of the human and

environmental fields for the realization of maximum health potential.’

These theorists are often criticized for their abstract and complicated ideas about nursing (Aggleton and Chalmers, 1988). While their ideas are intellectually challenging they are often difficult to implement and use opera-tionally. However, they provide key indica-tors as to what constitutes the nursing role and this depth of thought is useful in that it stimulates others to explore and question what is written about nursing.

NURSING CARE

Traditionally, the concept of caring is closely linked with the role of the nurse. However, actually defining the role of the nurse as a carer is difficult.

Orem (1991) sees the focus of caring, and therefore the role of nursing, as the return of the patient to self-care as opposed to the formation of a reciprocal caring relationship. Kitson (1987) expands this idea and suggests that the nurse committed to care must be able to provide sustained and continuous care for as long as the individual needs it, have the essence, nursing. The emphasis on the

relation-ship as the cornerstone of the nursing role (Orlando, 1961) is also supported by the work of Travelbee (1971), who describes nursing as:

‘...an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering and, if necessary, to find meaning in these experiences.’ King (1981), in her systems model, states that the primary function of the nurse is to help individuals maintain their health in order that they can function in their roles. She views nursing as a process of action, reaction, interaction and transaction.

Peplau (1988) states that the nurse’s role cannot be considered in isolation as it will change in relation to interactions with others and suggests the roles listed in Table 1. Peplau feels that the relationships within which these roles are enacted should be the focus of nurs-ing. Salvage (1990), however, suggests that this may not be what patients need or want. In general hospitals, for example, the sick person’s priority is more likely to be relief of physical symptoms as opposed to expres-sion of understanding or learning about the symptoms in an all-embracing, caring rela-tionship with a nurse. In addition, Webb (1994) warns that:

‘The traditional emphasis on physical care and comfort must not be lost in the struggle to humanize care.’

OUTCOME THEORY

According to Meleis (1985), outcome or holistic theories describe nurses as controlling

In general

hospitals...

the sick person’s

priority is more

likely to be

relief of physical

symptoms as

opposed to

expression of

understanding or

learning about

the symptoms

in an all-embracing,

caring

relationship

with a nurse.

Stranger who initiates relationships Teacher Resource person Leader Counsellor Surrogate Source: Peplau (1988)

Table 1. Peplau’s nursing

roles

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CONCLUSION

In summary, it is clear that there is no straight-forward description, or definition, of the nurse’s role. It is complex and multifaceted and, according to some, is based in the competent completion of technical/diagnostic treatment closely linked to medical care. According to others, the nurse is a profession-al caregiver who is able to deliver nursing as a therapy in its own right (Antrobus, 1993).

There is a continued need for nurses to develop their knowledge base and demonstrate the benefits of nursing in real terms so as to clarify the concept of nursing. The report The Challenges of Nursing and Midwifery in the 21st Century (Department of Health, 1994), otherwise known as the Heathrow debate, identified a concept in the nurse’s role which it refers to as the ‘nursing constant’. This comprises the core skills and values of the nursing role, i.e. coordinat-ing, teachcoordinat-ing, defending the frail and vulnera-ble, developing systems of care, concern for the ill and the well and technical expertise. Castledine (1994b) suggests that nurses should concentrate their energies on the development of this ‘nursing constant’ if the true value of nursing is to be demonstrated. He states:

‘We live in a world that pays little attention to the value of caring and necessary level of knowledge and skills to

meet the needs of the patient and ensure that care is provided in such a way that maintains the integrity of those in receipt of the care.

Watson (1979) states that caring, as a nursing term, represents all the factors that the nurse employs to deliver care. She identi-fies 10 caring factors which relate to the dynamics between individuals in a nursing relationship, e.g. trust and respect, and believes that these can only effectively be used interpersonally by a skilled and knowledge-able practitioner. These factors are identified by Leininger (1978) as comfort measures and include the attributes listed in Table 2. Pearson (1992) insists that the need to place caring as the central part of the nursing role has never been greater and is concerned that the caring components have:

‘…become decentralized and seen as the least sophisticated and subordinate to the therapeutic interventions of doctors and paramedical therapists.’

McFarlane’s (1977) view of caring in nurs-ing suggests that nursnurs-ing activities will only become meaningful in a relationship based on respect for an individual’s dignity and autonomy. This definition of nursing as an ethically based phenomenon is supported by Benner (1985):

‘Nursing offers crucial services that require high intelligence, a thorough and sound educational base, and firm grounding in the ethics of both rights and justice and care and responsibility.’

Benner suggests that while the nurse’s caring role will require an involved stance it should not:

‘…seek to control or master but to facilitate and uncover the possibilities inherent in the situation and the person. Caring provides empowerment.’

Gaut (1986) agrees and believes that the concepts related to caring and nursing must be taken beyond the observable behaviours of nurses to mechanisms such as decision making and scientific problem-solving which underpin the more obvious aspects of the role.

...it is clear that

there is no

straightforward

description, or

definition, of the

nurse’s role. It is

complex and

multifaceted and,

according to some,

is based in the

competent

completion of

technical/diagnostic

treatment

closely linked to

medical care...

Compassion Empathy

Helping and coping behaviours Stress alleviating measures Touching (hand and body contact) Nur turance

Succourance

Protective, restorative and stimulative behaviours

Health maintenance Instruction

Consultation

Source: Leininger (1978)

Table 2. Leininger’s comfort

measures

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sharing. It is important therefore that nurses continue to advocate and champion the cause of nursing as quality in living well and dying free from stress and pain.’

Nursing is complex and difficult to describe, but it is an exciting profession which is rich in theory and practice. As nurs-es we must continue to build and expand the ideas and concepts that underpin what we are and what we do.

Aggleton P, Chalmers H (1988) Nursing Models and the Nursing Process. Macmillan, London

Antrobus S (1993) Nursing’s nature and bound-aries. Sen Nurse13(2): 46–50

Benner P (1985) From Novice to Expert. Addison-Wesley, Menlo Park

Bortoff JL, D’Cruz JV (1984) Towards inclusive notions of patients and nurse. J Adv Nurs 9: 549–53

Castledine G (1994a) Nursing can never have a unified theory. Br J Nurs3(4): 180–1

Castledine G (1994b) The role of the nurse in the 21st century. Br J Nurs3(12): 621–2

Cavanagh SJ (1991) Orem’s Model in Action. Macmillan Education, London

Department of Health (1994) The Challenges of Nursing and Midwifery in the 21st Century — A Report on the ‘Heathrow Debate’ held in May 1993. HMSO, London

Draper J (1992) The impact of nursing models. Sen Nurse12(3): 38–9

Gaut DA (1986) Evaluating caring competencies in nursing practice. Top Clin Nurs8(2): 77–83 Henderson V (1966) The Nature of Nursing:

A Definition and its Implication for Practice, Research, and Education. Macmillan, New York

Kenny T (1993) Nursing models fail in practice. Br J Nurs2(2): 133–5

KEY POINTS

■ Nursing models provide a vast array of information in relation to the role of the nurse.

■ Developing a single general description of nursing is not possible as a result of the complex and wide range of work carried out by nurses.

■ The nursing process is common to most models as the system for planning and developing their work.

■ There is a need for nurses to promote and develop these core values and to communicate them to others.

King IM (1981) A Theory for Nursing: Systems, Concepts and Process. Wiley and Sons, New York

Kitson A (1992) Formalizing concepts related to nursing and caring. In: Kitson A, ed. Nursing, Art and Science.Chapman and Hall, London: 24–45

Kitson A (1987) A comparative analysis of lay caring and professional (nursing) caring relationships. Int J Nurs Stud 24(2): 155– 65

Leininger M (1978) Transcultural Nursing Concepts, Theories and Practices. John Wiley, New York

Marks-Maran D (1992) Rethinking the nursing process. In: Jolley M, Brykczyska G, eds.

Nursing Care: The Challenge to Change. Arnold, London: 91–103

McFarlane JK (1977) Developing a theory of nursing: the relationship of theory to practice, education and practice. J Adv Nurs2:

261–72

McFarlane JK, Castledine G (1982) The Practice of Nursing: Using the Nursing Process.CV Mosby, London

McMahon R (1991) Therapeutic nursing: theory, issues, and practice. In: McMahon R, Pearson A, eds. Nursing as Therapy. Chapman and Hall, London: 2–25

Meleis A (1985) Theoretical Nursing: Development and Progress.Lippincott, Philadelphia

Melnyk KAM (1983) The process of theory analy-sis: an examination of the nursing theory of Dorothea E Orem. Nurs Res32(3): 170–4 Nightingale F (1952) (original 1859) Notes on

Nursing. What it is and What it is Not.

Duckworth, London

Neuman B (1982) The Neuman Systems Model: Application to Nursing, Education and Practice.

Appleton-Century-Crofts, Norwark

Orem DE (1991) Nursing Concepts of Practice.4th edn. Mosby Year Book, St Louis

Orlando I (1961) The Dynamic Nurse– Patient Relationship. GP Putnam’s and Sons, New York

Pearson A (1992) Taking up the challenge: the future of therapeutic nursing. In: McMahon R, Pearson A, eds. Nursing as Therapy. Chapman and Hall, London: 192–210

Peplau HE (1988) Interpersonal Relations in Nursing. 2nd edn. Macmillan, Basingstoke Robinson D (1990) Two decades of ‘The Process’.

Sen Nurse10(2): 4–6

Rogers ME (1970) An Introduction to the Theoretical Basis of Nursing. Davis, Philadelphia

Roper N (1994a) Definition of nursing: 1. Br J Nurs3(7): 355–7

Roper N (1994b) Definition of nursing: 2. Br J Nurs3(9): 460–2

Roper L, Logan W, Teirney A (1980) The Elements of Nursing.Churchill-Livingstone, Edinburgh Roy C (1980) The Roy Adaptation Model. In:

Reihl JP, Roy C, eds. Conceptual Models for Nursing. Appleton-Century-Crofts, Norwark: 179–89

Roy C, Roberts S (1981) Theory Construction in Nursing: An Adaptation Model. Prentice Hall, Englewood Cliffs, New Jersey

Salvage J (1990) The theory and practice of new nursing. Nurs Times84(4): 42–5

Smith L (1982) Models of nursing as the basis for curriculum development: some rationales and implications. J Adv Nurs8:117–27

Travelbee J (1971) Interpersonal Aspects of Nursing.FA Davis, Philadelphia

Watson J (1979) Nursing: The Philosophy and Science of Caring.Little Browne, Boston Webb C (1994) What is nursing? Br J Nurs1(11):

567–8

Wright SG (1990) Building and Using a Model of Nursing.2nd edn. Edward Arnold, London

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