theoretical perspectives and contemporary issues
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Theoretical Perspectives and Contemporary issues
Ns. Heni Dwi Windarwati, MKep.,SpKepJ
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Outline• Basic Concepts
– Definition of theory– Theory as a guide to practice– Nursing knowledge
• Applications– Nursing theory in the nurse-client
relationship – Communication theory– Contemporary Issues
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Objectives
• Describe the nature and purpose of nursing theory
• Identify the historical development of nursing theory
• Compare and contrast different levels of nursing knowledge
• Describe the implications of Peplau’s nursing theory for the nurse-client relationship
• Analyze psychological models relevant to nurse-client relationship
• Specify the use of communication theory in nursing practice
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What is a theory?
• A set of concepts, definitions, relationships, and assumptions that project a systematic view of a phenomena
• It may consist of one or more relatively specific and concrete concepts and propositions that purport to account for, or organize some phenomenon (Barnum, 1988)
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What are the components of a theory?
• Concepts – ideas and mental images that help to describe phenomena (Alligood and Marriner-Tomey, 2002)
• Definitions – convey the general meaning of the concepts
• Assumptions – statements that describe concepts
• Phenomenon – aspect of reality that can be consciously sensed or experienced (Meleis, 1997).
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THEORY DEVELOPMENT
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How does a theory develop?
Four strategies of theory development1. Theory practice theory (theory
developed in other discipline and used in nursing situations)
2. Practice – theory evolved from clinical practice
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How does a theory develop?
3. Research theory or inductive method Must evolve from research findings or empirical evidence.
4. Theory research theory theories developed by other
disciplines are utilized but given unique nursing perspective. Original theory examined and given a new research findings.
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What is a paradigm?
• A model that explains the linkages of science, philosophy, and theory accepted and applied by the discipline (Alligood and Marriner – Tomey, 2002)
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What is a domain?
• The view or perspective of the discipline
• It contains the subject, central concepts, values and beliefs, phenomena of interest, and the central problems of the discipline
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How does domain relate to nursing theory?
• Nursing has identified its domain in a paradigm that includes four linkages:
1) person/client 2) health 3) environment 4) nursing
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Purposes of nursing theory
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What are the purposes of nursing theory?
• It guides nursing practice and generates knowledge
• It helps to describe or explain nursing
• Enables nurses to know WHY they are doing WHAT they are doing
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Patterns of Knowing
• Empirical ways of knowing – Are grounded in science of nursing and evidenced in
the scientific principle a nurse consistenly incorporates in all phases of the nursing process
• Personal ways of knowing– Help nurses understand and acknowledge the
humanness of another
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Patterns of Knowing
• Aesthetic ways of knowing– Allow for creative applications in the relationship
designed to connect with clients in a different and more meaningful way
• Ethical ways of knowing– Refers to the moral aspect of nursing
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Evidence Based Nursing Practice
• Is informed, collaborative and patient-centered
• Four components are:– Best practice– Evidence from scientific findings in
research-based studies– Clinical nursing expertise of professional
nurse– Preference and values of client and family
members
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Applications:
Nursing Theory in the nurse-client relationship
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Nurse-Client RelationshipWhat is the nurse-client relationship?
– Main tool of psychiatric nursing–Safe–Confidential–Reliable–Consistent–With clear boundaries
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Social Relationships
• Initiated for the purpose of friendship, socialization or task accomplishment.
• Mutual needs are met during interaction.
• Communication includes giving advice and ask for or provide help with jobs.
• Content of communication may be superficial, roles may shift.
• No evaluation
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Intimate Relationships• Individuals have an emotional commitment• Often a partnership where mutual needs are
met• Short and long term goals are mutual • Personal and intimate information are shared• Emotional satisfaction, security, sex,
procreation, etc.
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Therapeutic Relationships
• Relationship consistently focused on the client's problems and needs
• Potential solutions to problems discussed
• Client chooses and implements plans• New coping skills develop• Behavioral change encouraged
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Nurse’s Behaviors that Facilitated Growth and Change in Clients
• Genuineness “Being yourself”– Self-awareness of one's feelings– Ability to communicate one's feelings when appropriate– Key ingredient in building trust
• Empathy– Understanding the client’s feelings and ideas accurately – Accurate understanding of client's communication– Communicating understanding to the client and check for
accuracy– Acting on “this understanding” in a helpful way
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Nurse’s Behaviors that Facilitated Growth and Change in Clients
• Positive self-regard– Respect communicated indirectly by actions– Help client to develop own personal resources and actualize
his living potential– Nonjudgmental focus on client's thoughts, feelings to
understand behaviors– Cultural sensitivity
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Goals of Therapeutic Communication
• To obtain or provide information• To develop trust• To show caring• To explore feelings
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HILDEGARD PEPLAU
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Peplau
• Hildegard Peplau– Describe the nurse-client relationship as a
foundation of nursing practice– Four developmental phases of the
relationship • The orientation phase• Working phase
– Identification– exploitation
• Termination (resolution) phase
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Hildegard Peplau
• Mother of psychiatric nursing• Infuences
– First nursing theory to borrow concept from other disciplines
– Freud, Maslow, Sullivan’s interpersonal relationship theories and the psychological model
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• The purpose is– To facilitate the developmental of
problem solving skill, within the context of the interpersonal relationship between nurse and client, using education and therapeutic interaction
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• Psychodynamic nursing facilitates– Understanding of one’s own behavior– Helping others identify felt difficulties– Nurse-patient relationship as partners– Application of human relations to
problems at all levels of experience
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• Concept and definition – Role of nurse
• Stranger• Teacher• Resource person• Counselor• Leader• Advocate• Additional role
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Peplau’s model and four concepts
• Person– A developing organism that tries to
reduce anxiety caused by needs– An individual is made of physiological,
psychological and social spheres striving towards equilibrium in life
– Live is an unstable equilibrium
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• Environment– Not specifically defined– Being and occurring in the context of
the nurse client relationship– Existing forces outside of the
individual
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• Health– Peplau didn’t include an exact definition of health
whitin her model– Peplau viewed health as “a word symbol that implied
forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living (Peplau, 1992)
– Consisting of interacting physiologic and interpersonal conditions
– Promoting throught interpersonal process
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• Nursing– Is a signified, therapeutic, interpersonal process that
functions cooperatively with other human processes that make health possible.
– Is a human relationship between an individual who is sick or who has a felt need and a nurse who is educated to recognize and respond to the need for help
– Achieves its goal by promoting the patient’s development of skills to deal with problems and achieve health, this is a mutual and collaboration process that attempt to resolve the problem
– Views the nursing process as having sequential steps that focus on therapeutic interactions.
– Involves the use of problem solving techniques by he nurse and patient; according the Peplau both the nurse and patient learn the problem solving process from the relationship.
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• Contribution from other disciplines– Therapeutic conversations with client
• Sigmund freud• Carl jung • Harry stock Sullivan• Martin buber• Carl rogers• Aaron beck
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• Sigmund freud– Transference
» In which the client project irrational attitude and feelings from the past onto people in the present
» Are useful in understanding difficult behaviors in nurse-client relationship.
– Countertransference» Refer to unconscious attitudes or aaggerated a
nurse may develop toward a client.
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• Carl Jung– Help nurses examine the complex
dimensions of a person• Gender roles• Acceptance of each individual just as they are• Our universal heritage as human beings
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• Harry Stack Sullivan – Introduced the concept that people cannot
always relate easily to a helping person and may need ongoing, compassionate, supportive encouragement to make use of the therapeutic relationship
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• Martin Burber– Captured the essence of the equal partner
connection desired in the nurse-client relationship
– Each individual responds to the other as a unique person in a mutually respectful manner.
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• Carl Rogers– Identified three helper characteristic
essential to the development of client-centered relationship • Unconditional positive regard• Empathetic understanding• genuineness
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• Aaron Beck– Aaron Beck focused his work on depression
• Concludes that psychological disturbances frequently stem from automatic thoughts
• Automatic thoughts reflect habitual errors in thinking
• Therapy is structured & interactive• Uses “Socratic dialogue” to get clients to
arrive at own conclusions• Begins with identifying problems or “agendas”• Includes setting goals, operationally defining
problems, testing hypotheses, and assigning homework.
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– Developmental theories• Erik erikson• Abraham maslow
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Erikson’s Theory
Erikson’s view was that the social environment combined with biological maturation provides each individual with a set of “crises” that must be resolved.
The individual is provided with a "sensitive period" in which to successfully resolve each crisis before a new crisis is presented.
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Erikson’s Theory
The results of the resolution, whether successful or not, are carried forward to the next crisis and provide the foundation for its resolution.
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Erikson’s Eight Stages
Trust vs. Mistrust
Infancy
Child develops a belief that the environment can be counted on to meet his or her basic physiological and social needs.
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Erikson’s Eight Stages
Autonomy vs. Shame &
Doubt Toddlerhood
Child learns what he/she can control and develops a sense of free will and corresponding sense of regret and sorrow for inappropriate use of self-control.
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Erikson’s Eight Stages
Initiative vs. Guilt
Early Childhood
Child learns to begin action, to explore, to imagine as well as feeling remorse for actions.
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Erikson’s Eight Stages
Industry vs. Inferiority Middle
Childhood
Child learns to do things well or correctly in comparison to a standard or to others
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Erikson’s Eight Stages
Identity vs. Role
Confusion
Adolescence
Develops a sense of self in relationship to others and to own internal thoughts and desires
• social identity • personal identity
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Erikson’s Eight Stages
Intimacy vs.
IsolationYoung Adulthood
Develops ability to give and receive love; begins to make long-term commitment to relationships
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Erikson’s Eight Stages
Generativity vs.
StagnationMiddle Adulthood
Develops interest in guiding the development of the next generation
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Erikson’s Eight Stages
Ego-integrity
vs. Despair
Later Adulthood
Develops a sense of acceptance of life as it was lived and the importance of the people and relationships that individual developed over the lifespan
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Maslow, a humanistic psychologist
1. Humanist do not believe that human being are pushed and pulled by mechanical forces, either of stimuli and reinforcements (behaviorism) or of unconscious instinctual impulses (psychoanalysis).
2. Humanist focus upon potentials.3. They believe that humans strive for an upper
level of capabilities.4. Humans seek the frontiers of creativity, the
highest reaches of consciousness and wisdom.
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• Physiological needs-also known as biological needs. Consists of oxygen, food, water, constant body temperature.
• Physiological are the strongest needs
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• Safety Needs-Security and Protection from physical and emotional harm
• Adults have little awareness for safety needs except in times of emergency
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• Belongingness & Love needs- people seek to overcome feelings of loneliness and alienation.
• Involves giving and receiving love affection and a sense of belonging
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• Needs for esteem-involves both self-esteem and esteem a person gets from others
• Humans need self-respect and respect of others• When these needs are satisfied person feels self-
confident and valuable• When not met people feel inferior, weak, helpless,
and worthless
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• Needs to Achieve Self-Actualization– Cognitive – to know, to understand, to
explore– Aesthetic-to find symmetry, order and
beauty
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• Self actualization characteristics– Problem focused– Incorporate an ongoing freshness of
appreciation of life– Concerned about personal growth– Ability to have peak experiences
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• Transcendence – to help others find self-fulfillment and realize their potential
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• Maslow recognized that not all personality types followed this hierarchy
• Suggested that flow through the heirarchy can occur at any level at any time and many times simultaneously.
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• Communication theory– Linier theory– Circular transactional theoretical
models– Therapeutic communication
• Contemporary issues
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Linier theory
• Claude Shannon developed a model that reduced the communication process to a set of seven basic elements: – sender, receiver, encode, decode, message,
channel, and noise• These early models depicted
communication as a linear, one-way process where messages were transmitted in a straightforward manner from one person to another
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Continue….
sender encodes decodesreceivesmassage
noiseOpportunity for interference
channel
Sender sends a massage ; receiver receives massage passively
Figur: Linier model of communication
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Interactional Model
• The model introduced the element of feedback to reflect the two-way flow of communication between people
• this model also introduced the element of fields of experience
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Field of experience
Field of experience
EncodesSender
Decodes
DecodesSenderEncodes
feedback
channel
feedbackchannel
noise noisenoise
More opportunities for interference factors
Sender and receivers each contribut toexchanging created and interpreted messages
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Circular transactional theoretical models
• described the communication process as a reciprocal, simultaneous flow of messages and feedback between individuals
• Senders and receivers were redefined as communicators to reflect the simultaneous flow of messages and feedback during conversations
• a process of negotiating and creating common meaning
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• Encoding and decoding were mutually interdependent actions of the communicators, each contributing to the shared meaning they were building together
• The element of context was introduced, which expanded the original element of fields of experience in the interactional model
• The transactional model acknowledged that creation and interpretation of messages evolves from the past, is influenced by the present, and is affected by visions of the future
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Context Contextmassage
feedback
encodes
decodes
communicator communicator
decodes
encodes
channel channel
noise noise noise
noise noise noise
Greater opportunities
for interference factors
Context includes fields of
experience and the situational factors
that influence communication
Communicators create and send messages simultaneously and are equally responsible for creating common meaning
Figure :Transactional model of communication
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The element of noise evolved to include
• Psychological noise: the emotional state of the communicators, their personalities and preconceived ideas and judgments.
• Physical noise: external factors that distract communicators like loud music in the background or being unfamiliar with the physical setting.
• Physiological noise: the biological factors that interfere with communications such as fatigue, illness, or altered cognitive function.
• Semantic noise: the way people speak, their use of terms, and any dialect or literacy issues.
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THERAPEUTIC COMMUNICATION
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In a therapeutic relationship…
• There are specific goals• The patient’s needs are the focus
(relationship is client centered)• The nurse makes use of specific
communication and relationship skills
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Contemporary Issues
• Perubahan Demografik– Culture– Gender
• Teknologi• Posisi Perawat Sebagai Pemain
Kunci
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Therapeutic N-P Relationship
• Definition:– a series of goal-directed interactions
• Peplau: – nursing as a significant, therapeutic,
interpersonal process
• Characteristics - goals, stages, specific time and place. It is different from a social relationship
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N-Pt Relationship
• Communication skills• Respect and a desire to help• Trust is based on confidentiality• Understanding
– mental mechanisms– adaptation styles– coping strategies– therapeutic intervention skills
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Communication
• In-born nature• Happened at anytime, anyplace,• Multi-level• Verbal & Nonverbal
– Proxemics - environmental, social, and personal space
– Kinesics - body movement• Can be learned
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Therapeutic Communication
• Def: – It is an interpersonal interaction in
which the nurse used the self to focus on the client’s emotional issues, establish a therapeutic relationships, identify client’ issues, discern the most important topic at that time, and guide the client toward identifying his/her own solutions to problems
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Therapeutic Communication Techniques (I)
• Broad opening - start the conversation• Offering self - available, concern,
interest• Active listening - content, emotion• Using silence - respect, anxiety• Asking questions - what, when, who…• General leads - go on, Mm... • Restating - repeating
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Thera. Commu. Tech (II)• Making observation - comment on what
have been seen• Verbalizing the implies - rephrasing,
reflecting• Clarification - restate, elaborate• Focusing - single, important topic • Exploring - getting more information• Interpreting -• Consensual validation - mutual agreement
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Thera. Commu. Tech (III)• Giving information - decision making• Presenting reality - but no argument• Voicing doubt - uncertainty about pt’s
interpretation/conclusion• Placing an event in time or sequence - R
among events• Encouraging comparison - similarity &
difference• Summarizing - review the main points
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Contemporary Issues
• Perubahan Demografik– Culture– Gender
• Teknologi• Posisi Perawat Sebagai Pemain
Kunci