Nursing Metaparadigm Analysis
Exploration into Nursing: A Personal Framework
The University of Texas at Arlington School of Nursing
In Partial Fulfillment of the Requirements of
N5327 Analysis of Theories in Nursing
Ronda Mintz-Binder, DNP, RN,CNE
Exploration into Nursing: A Personal Framework
Upon graduation from nursing school, I started working on a telemetry/oncology unit at Memorial Herman Hospital in Houston, Texas. Because the unit was also oncology we had to take care of patients who were enrolled in hospice. As a brand new nurse, it was so much I had to learn. Five years later, I have the privilege of working in the Palliative Care Clinic at MD Anderson Cancer Center. I am an outpatient palliative nurse, pain …show more content…
resource nurse, and clinical coach. As a palliative care clinic nurse, I believe in treating all patients with respect and to treat not just one symptom instead consider the patient as a whole. As a palliative care clinic nurse, pain resource nurse and clinic coach, it is vital to assess the holistic aspect of the patient and treat, mind, body and spirit. There are times we have to deal with patients that are at the end of life and refuse hospice, having never been educated about end of life care. I have learned that I do not always have to agree with some of the decisions patients make, but I always have to respect them. My job is to educate the patient about their quality of life, and end of life, keeping in mind the wishes and plan they present. I see myself as a patient advocate, I am there to assist the patient or be the patients’ voice if their symptoms have not been taken care. My interpersonal approach to patients is holistic. My expectations and goals are for every patient that comes to the clinic be treated as an individual and focus on the care tailored to them. I will be exploring my personal values, beliefs, and philosophy in nursing related to my outpatient clinic nursing, pain resource nurse, and clinic coach duties. I will describe Ruland and Moore theory, End-of-Life Care, the nursing metaparadigm, and how it applies in my practice. I will compare my beliefs and Roland and Moore theory, apply the model to my framework, and show a situation where my framework was useful.
Philosophy
My personal philosophy most closely resembles that of Jean Watson. “The nurse guided by Watson’s work is responsible for creating and maintaining an environment that support human caring while recognizing and providing for patient’s primary human requirements” (Chitty &Black, 2007, p.335). The Merriam-Webster dictionary (n.d) defines palliative as “something that is intended to make a bad situation seem better but that does not improve the situation” and “something that reduces the effects or symptoms of a medical condition without curing it”. It is my philosophy of nursing practice that every patient should be introduced to palliative care from the beginning of diagnoses, preparing them to manage their symptom burden. We are our own person, and we live in this world with different experiences and I believe that is what makes us react different. Palliative care is an area where nurses have to give more supportive care. Nurses in palliative care practice active listening to the patient and family. There are times when you feel spirituality drain and have no more to give, however you continue, knowing their time to say goodbye to this world is near. My priority is always the patient but must consider the family especially if they have young children. My goal is to help with symptom burden, assessing for spiritual pain, and help the patient to enjoy their life.
Taylor (2013) identifies beneficence as one of the principles that takes in consideration the interest of the patients. I respect the patients’ decisions when enrolled in hospice. As I precept nurses I teach them to have respect for the decision selected by the patient. Taylor (2013) describes the principle of justice as having two components: equitability and distributive. Every patient that comes to the clinic is treated as an individual, with respect, regardless of who they are. Pugh (2014) describes the ethical principle of autonomy an individual can make informed decision and make choices for themselves. Patients have the right to be given all information regarding their treatment plan, in order to decide if they will continue fighting for a cure. They also have the right to decide how they want to spend the last days of their lives. My clinical focus regardless of their decision is to promote quality of life.
Usefulness of Nursing Theory
Peaceful End of Life theory developed by Cornelia Ruland & Shirley Moore (1998) this theory was the derivative of standards of care. The theory was progressed for the terminally ill patient, for end of life care therapy. Ruland & Moore (1998) stated “the main focus for standard development is not on the final instance of dying itself, but on contributing to peaceful and meaningful living in the time that remained for patients and their significant others” (p.171). The development of this theory has five outcomes for peace end of life: “not being in pain, experience of comfort, experience of dignity/respect, being at peace, and closeness to significant others/person who care” (Ruland & Moore, 1998). Patients have a right to not be in pain. Patients also have the right to be treated with respect and dignity. Ruland & Moore (1998) studied the importance of making sure of living in peace with a meaningful life span. Ruland & Moore (1998) placed emphasis on clinical knowledge for nurse practitioners who choose to specialize in end of life care.
Domain Concepts
The nursing metaparadigm consists of four elements called domain concepts (McEwen & Willis, 2007). These are person, health, environment, and nursing. In the following section, Ruland and Moore nursing metaparadigm will be discussed as I evaluate, explore, and define my own domain concepts. McEwen & Willis, 2007 defines a person as the center and a holistic existence. They also say life is connecting the needs of the physical, intellectual, biochemical, and psychosocial. Ruland & Moore (1998) studied the person as the patient experiencing an illness that should be free of symptoms and experience the optimal comfort. A person should not be in pain, person should experience comfort, dignity and respect. The person should be at peace with themselves having a close relationship with others. Every day we see many patients come to the clinic with so many bothersome symptoms, my aim is to make them feel better so they have good quality of life and continue with the treatment or prepare for the end of life. McEwen & Willis (2007) defines health as being independent and operational. They also say working with and managing daily stressors which living to full potential. In Ruland & Moore (1998) theory health is seen as a preventing to manage their symptoms. An example, providing patients with pain medication, they are functioning better. When dealing with terminal ill patients, we should always be aware of and educate on being proactive. Health can be determined individually as to what the patient classifies as health. McEwen & Willis (2007) defines the external boundaries of external conditions as exchange of energy and information with the self. In Ruland & Moore (1998) the environment is implied as having closeness to significant and others. The patients’ environment with where they clam comfort and define their space. The environment to me is subject to be modified for care and necessities. McEwen & Willis (2007) educate and define nursing as one in a trade and provides care. Nursing also focus towards helping the sick, education, promoting health and seeking prevention. In, Ruland & Moore (1998) they studied saying the nurses help the patient to stay at peace and remain respectful of the patient’s wishes toward the end of life. The elimination of pain is also part of the care from the nurse. Nurses advocate for their patient by providing care, empathy, respect and dignity. The nurse to be is the coordinator for prevention, education, gathers data and manages the patients care. Nurses function by gaining the trust from the patient, and coordinates services from other discipline services.
Applicability of Definition
According to the World Health Organization (2009), palliative care is set up and designed for everybody with a terminal illness. As a nurse practitioners, I would be able treat the patient longer with follow up care then help make the transition into end of life. In my current metaparadigm all the domains work together to capture any maladjustment at the end of life. The patients have complete autonomy of decisions make for their care. The goal is to introduce palliative care earlier, maintaining quality of life, and a smoother time period for end of life. Walker & Breitsameter (2014) believe that the patients’ wishes are the central focus of the nurses’ work every day. I view health with a holistic approach to help service the patient physical and mental wellbeing. The environment is composed of the patient’s family and life situations. I strongly believe that a patient’s family plays an important role in the recuperation of the patient. Family is there for emotional support and to assist in the care. The socioeconomic conditions of the patient and the stressors and cultural beliefs has to consider when providing care to any patient. “The nurse promotes, advocates for, and strives to protect the health, safety, and right of the patient” (ANA Code of Ethics, 2001). The nurse by being there displays compassion and caring. The nurse is the one that brings all of them together. As I advance in my nursing practice, my domain concept definition will mature and progress.
Philosophy and Approach
I believe that palliative care should be introduced early at time of a life changing illness. My personal framework educates on the benefits of making a patient’s life better towards the end of life. My personal theory is of peace and preparedness. In comparison to Ruland and Moore’s theory having respect, autonomy and dignity at the end of life bring harmony. Another comparison is similar management of bothersome symptoms striving for comfort. In contrast, it differentiates in the early intervention of palliative care for support. Hui, Roquemore, Dev & Bruera (2014) reports in their study that if the patient gets referred to palliative care earlier and as outpatient their quality of care would improve. My personal framework theory is for patients who are newly diagnosed to patient who is at the end of their lives. This prepares the patient and their families better as they deal with a terminal illness, and progresses of disease. My theory will assist in my practice as I grow and educate myself to continue to treat all patients as individuals. My theory lacks how to make terminal patients aware of the palliative care services.
Personal Framework Model
The four components of the nursing metaparadigm are entwined with each other. The person, health, environment, and nursing are all functions that work together and cannot be separated (see Figure 1). The person domain remains at the top representing the most important concept but all domains have equal significance. The double sided arrows links each domain concept to one another. The bisector arrow shows the relationship of the domain to the concept of the theory uniting each domain to represent a whole. The square with the arrow pointing to the domain defines the domain concept. This model explains how each domain introduces early intervention for Palliative end of life theory.
Application in Practice
Patient J.T. female with stage IV Breast Cancer metastatic to the bones, lungs, and a small lesion in the brain. Patient came to our clinic having failed a Phase I clinical trial, with progression of a disease. Patient was told to go see Palliative Care, with no other explanation given or explained. She was in pain, nauseated, vomiting, depressed, and having anxiety. She also had not slept for days with high spiritual pain. She was the mother of three children ages ranging from four to ten years old. The Patient was referred Palliative care to transition her into hospice. Patient J. T would have benefit from palliative care sooner to receive counselling, child life specialist for her kids, and been relieved of her bothersome symptoms that she presents to the palliative care. Palliative care has a team approach, and she would have a different outcome for her quality of life.
Conclusion
In this personal framework, I have discover how valuable nursing is to me. I have learned that every day we have the opportunity to learn. I reviewed the ethical values of beneficence, justice and autonomy in my theory of practice. I compared Ruland & Moore peaceful end of life theory. I learn that we all use their theory when faced with patients who are in their last days of life. I discussed in detail the domain concepts of the nursing metaparadigm; Ruland & Moore definition, my definitions, and the applicability of each domain concept. I was able to create a model to my personal framework and give examples of how my framework was useful. Theory helps us gain a better understanding of nursing practice in the clinical setting, improving patient outcomes. When I first started this class I was so overcome with all the different concepts and papers that we had to write, I was ready to give up. Most importantly, I learned, that one step leads to another step and soon you get to the end point. I know there is still so much to learn as I advance in my profession. My personal framework will change as I continue learning different theories. I will use them to help guide me to provide better care for my patients.
References
American Nurses Association. Code of Ethics (2001). Nursing World Journal Provision 3. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe1115.htm.
Chitty, K.K., and Black, B.P. (2007). Nursing theory: The basis for professional nursing Professional Nursing: Concepts and challenges. (pp.328-347). St Louis, Mo: Saunders. Retrieved July 2014, from CINAHL database.
Hui D, Kim S.,H, Roquemore J,R., Dev R, Chisholm G, Bruera E. (2014). Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer, 120, 1743-1749.doi:10.1002/cncr.28628
McEwen, M., & Willis, E.M. (2011). Theoretical basis for nursing (4th ed.) Philadelphia: Lippincott Williams & Wilkins.
Merriam-Webster dictionary. Palliative. (n.d.). Retrieved July 27, 2014, from http://www.merriam-webster.com/dictionary/palliative
Pugh, D.M. (2014). Ethics at the End of Life. Clinical Nurse Specialist, 28, 201-204. doi:10.1097/NUR.0000000000000058
Ruland C, M., Moore S, M. (1998). Theory construction based on standards of care: a proposed theory of the peaceful end of life. Nurse Outlook. (46):169-175 doi: 10.1016/S0029-6554(98)90069-0
Taylor, R.M. (2013). Ethical Principles and concepts in medicine. Ethical and legal issues in neurology, 118:1-9. doi: 10.1016/B978-0-444-53501-6.00001-9
Walker, A., & Breitsameter, C. (2014) Ethical decision-making in hospice care. Nursing Ethics. Jun 29. pii: 0969733014534873. [Epub ahead of print] doi:10.1177/0969733014534873
World Health Organization. (2009). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en
Exploration into Nursing: A Personal Framework
The University of Texas at Arlington School of Nursing
In Partial Fulfillment of the Requirements of
N5327 Analysis of Theories in Nursing
Ronda Mintz-Binder, DNP, RN,CNE
Exploration into Nursing: A Personal Framework
Upon graduation from nursing school, I started working on a telemetry/oncology unit at Memorial Herman Hospital in Houston, Texas. Because the unit was also oncology we had to take care of patients who were enrolled in hospice. As a brand new nurse, it was so much I had to learn. Five years later, I have the privilege of working in the Palliative Care Clinic at MD Anderson Cancer Center. I am an outpatient palliative nurse, pain resource nurse, and clinical coach. As a palliative care clinic nurse, I believe in treating all patients with respect and to treat not just one symptom instead consider the patient as a whole. As a palliative care clinic nurse, pain resource nurse and clinic coach, it is vital to assess the holistic aspect of the patient and treat, mind, body and spirit. There are times we have to deal with patients that are at the end of life and refuse hospice, having never been educated about end of life care. I have learned that I do not always have to agree with some of the decisions patients make, but I always have to respect them. My job is to educate the patient about their quality of life, and end of life, keeping in mind the wishes and plan they present. I see myself as a patient advocate, I am there to assist the patient or be the patients’ voice if their symptoms have not been taken care. My interpersonal approach to patients is holistic. My expectations and goals are for every patient that comes to the clinic be treated as an individual and focus on the care tailored to them. I will be exploring my personal values, beliefs, and philosophy in nursing related to my outpatient clinic nursing, pain resource nurse, and clinic coach duties. I will describe Ruland and Moore theory, End-of-Life Care, the nursing metaparadigm, and how it applies in my practice. I will compare my beliefs and Roland and Moore theory, apply the model to my framework, and show a situation where my framework was useful.
Philosophy
My personal philosophy most closely resembles that of Jean Watson. “The nurse guided by Watson’s work is responsible for creating and maintaining an environment that support human caring while recognizing and providing for patient’s primary human requirements” (Chitty &Black, 2007, p.335). The Merriam-Webster dictionary (n.d) defines palliative as “something that is intended to make a bad situation seem better but that does not improve the situation” and “something that reduces the effects or symptoms of a medical condition without curing it”. It is my philosophy of nursing practice that every patient should be introduced to palliative care from the beginning of diagnoses, preparing them to manage their symptom burden. We are our own person, and we live in this world with different experiences and I believe that is what makes us react different. Palliative care is an area where nurses have to give more supportive care. Nurses in palliative care practice active listening to the patient and family. There are times when you feel spirituality drain and have no more to give, however you continue, knowing their time to say goodbye to this world is near. My priority is always the patient but must consider the family especially if they have young children. My goal is to help with symptom burden, assessing for spiritual pain, and help the patient to enjoy their life.
Taylor (2013) identifies beneficence as one of the principles that takes in consideration the interest of the patients. I respect the patients’ decisions when enrolled in hospice. As I precept nurses I teach them to have respect for the decision selected by the patient. Taylor (2013) describes the principle of justice as having two components: equitability and distributive. Every patient that comes to the clinic is treated as an individual, with respect, regardless of who they are. Pugh (2014) describes the ethical principle of autonomy an individual can make informed decision and make choices for themselves. Patients have the right to be given all information regarding their treatment plan, in order to decide if they will continue fighting for a cure. They also have the right to decide how they want to spend the last days of their lives. My clinical focus regardless of their decision is to promote quality of life.
Usefulness of Nursing Theory
Peaceful End of Life theory developed by Cornelia Ruland & Shirley Moore (1998) this theory was the derivative of standards of care. The theory was progressed for the terminally ill patient, for end of life care therapy. Ruland & Moore (1998) stated “the main focus for standard development is not on the final instance of dying itself, but on contributing to peaceful and meaningful living in the time that remained for patients and their significant others” (p.171). The development of this theory has five outcomes for peace end of life: “not being in pain, experience of comfort, experience of dignity/respect, being at peace, and closeness to significant others/person who care” (Ruland & Moore, 1998). Patients have a right to not be in pain. Patients also have the right to be treated with respect and dignity. Ruland & Moore (1998) studied the importance of making sure of living in peace with a meaningful life span. Ruland & Moore (1998) placed emphasis on clinical knowledge for nurse practitioners who choose to specialize in end of life care.
Domain Concepts
The nursing metaparadigm consists of four elements called domain concepts (McEwen & Willis, 2007).
These are person, health, environment, and nursing. In the following section, Ruland and Moore nursing metaparadigm will be discussed as I evaluate, explore, and define my own domain concepts. McEwen & Willis, 2007 defines a person as the center and a holistic existence. They also say life is connecting the needs of the physical, intellectual, biochemical, and psychosocial. Ruland & Moore (1998) studied the person as the patient experiencing an illness that should be free of symptoms and experience the optimal comfort. A person should not be in pain, person should experience comfort, dignity and respect. The person should be at peace with themselves having a close relationship with others. Every day we see many patients come to the clinic with so many bothersome symptoms, my aim is to make them feel better so they have good quality of life and continue with the treatment or prepare for the end of life. McEwen & Willis (2007) defines health as being independent and operational. They also say working with and managing daily stressors which living to full potential. In Ruland & Moore (1998) theory health is seen as a preventing to manage their symptoms. An example, providing patients with pain medication, they are functioning better. When dealing with terminal ill patients, we should always be aware of and educate on being proactive. Health can be determined individually as to …show more content…
what the patient classifies as health. McEwen & Willis (2007) defines the external boundaries of external conditions as exchange of energy and information with the self. In Ruland & Moore (1998) the environment is implied as having closeness to significant and others. The patients’ environment with where they clam comfort and define their space. The environment to me is subject to be modified for care and necessities. McEwen & Willis (2007) educate and define nursing as one in a trade and provides care. Nursing also focus towards helping the sick, education, promoting health and seeking prevention. In, Ruland & Moore (1998) they studied saying the nurses help the patient to stay at peace and remain respectful of the patient’s wishes toward the end of life. The elimination of pain is also part of the care from the nurse. Nurses advocate for their patient by providing care, empathy, respect and dignity. The nurse to be is the coordinator for prevention, education, gathers data and manages the patients care. Nurses function by gaining the trust from the patient, and coordinates services from other discipline services.
Applicability of Definition
According to the World Health Organization (2009), palliative care is set up and designed for everybody with a terminal illness. As a nurse practitioners, I would be able treat the patient longer with follow up care then help make the transition into end of life. In my current metaparadigm all the domains work together to capture any maladjustment at the end of life. The patients have complete autonomy of decisions make for their care. The goal is to introduce palliative care earlier, maintaining quality of life, and a smoother time period for end of life. Walker & Breitsameter (2014) believe that the patients’ wishes are the central focus of the nurses’ work every day. I view health with a holistic approach to help service the patient physical and mental wellbeing. The environment is composed of the patient’s family and life situations. I strongly believe that a patient’s family plays an important role in the recuperation of the patient. Family is there for emotional support and to assist in the care. The socioeconomic conditions of the patient and the stressors and cultural beliefs has to consider when providing care to any patient. “The nurse promotes, advocates for, and strives to protect the health, safety, and right of the patient” (ANA Code of Ethics, 2001). The nurse by being there displays compassion and caring. The nurse is the one that brings all of them together. As I advance in my nursing practice, my domain concept definition will mature and progress.
Philosophy and Approach
I believe that palliative care should be introduced early at time of a life changing illness. My personal framework educates on the benefits of making a patient’s life better towards the end of life. My personal theory is of peace and preparedness. In comparison to Ruland and Moore’s theory having respect, autonomy and dignity at the end of life bring harmony. Another comparison is similar management of bothersome symptoms striving for comfort. In contrast, it differentiates in the early intervention of palliative care for support. Hui, Roquemore, Dev & Bruera (2014) reports in their study that if the patient gets referred to palliative care earlier and as outpatient their quality of care would improve. My personal framework theory is for patients who are newly diagnosed to patient who is at the end of their lives. This prepares the patient and their families better as they deal with a terminal illness, and progresses of disease. My theory will assist in my practice as I grow and educate myself to continue to treat all patients as individuals. My theory lacks how to make terminal patients aware of the palliative care services.
Personal Framework Model
The four components of the nursing metaparadigm are entwined with each other. The person, health, environment, and nursing are all functions that work together and cannot be separated (see Figure 1). The person domain remains at the top representing the most important concept but all domains have equal significance. The double sided arrows links each domain concept to one another. The bisector arrow shows the relationship of the domain to the concept of the theory uniting each domain to represent a whole. The square with the arrow pointing to the domain defines the domain concept. This model explains how each domain introduces early intervention for Palliative end of life theory.
Application in Practice
Patient J.T. female with stage IV Breast Cancer metastatic to the bones, lungs, and a small lesion in the brain. Patient came to our clinic having failed a Phase I clinical trial, with progression of a disease. Patient was told to go see Palliative Care, with no other explanation given or explained. She was in pain, nauseated, vomiting, depressed, and having anxiety. She also had not slept for days with high spiritual pain. She was the mother of three children ages ranging from four to ten years old. The Patient was referred Palliative care to transition her into hospice. Patient J. T would have benefit from palliative care sooner to receive counselling, child life specialist for her kids, and been relieved of her bothersome symptoms that she presents to the palliative care. Palliative care has a team approach, and she would have a different outcome for her quality of life.
Conclusion
In this personal framework, I have discover how valuable nursing is to me. I have learned that every day we have the opportunity to learn. I reviewed the ethical values of beneficence, justice and autonomy in my theory of practice. I compared Ruland & Moore peaceful end of life theory. I learn that we all use their theory when faced with patients who are in their last days of life. I discussed in detail the domain concepts of the nursing metaparadigm; Ruland & Moore definition, my definitions, and the applicability of each domain concept. I was able to create a model to my personal framework and give examples of how my framework was useful. Theory helps us gain a better understanding of nursing practice in the clinical setting, improving patient outcomes. When I first started this class I was so overcome with all the different concepts and papers that we had to write, I was ready to give up. Most importantly, I learned, that one step leads to another step and soon you get to the end point. I know there is still so much to learn as I advance in my profession. My personal framework will change as I continue learning different theories. I will use them to help guide me to provide better care for my patients.
References
American Nurses Association. Code of Ethics (2001). Nursing World Journal Provision 3. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe1115.htm.
Chitty, K.K., and Black, B.P.
(2007). Nursing theory: The basis for professional nursing Professional Nursing: Concepts and challenges. (pp.328-347). St Louis, Mo: Saunders. Retrieved July 2014, from CINAHL database.
Hui D, Kim S.,H, Roquemore J,R., Dev R, Chisholm G, Bruera E. (2014). Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer, 120, 1743-1749.doi:10.1002/cncr.28628
McEwen, M., & Willis, E.M. (2011). Theoretical basis for nursing (4th ed.) Philadelphia: Lippincott Williams & Wilkins.
Merriam-Webster dictionary. Palliative. (n.d.). Retrieved July 27, 2014, from http://www.merriam-webster.com/dictionary/palliative
Pugh, D.M. (2014). Ethics at the End of Life. Clinical Nurse Specialist, 28, 201-204. doi:10.1097/NUR.0000000000000058
Ruland C, M., Moore S, M. (1998). Theory construction based on standards of care: a proposed theory of the peaceful end of life. Nurse Outlook. (46):169-175 doi: 10.1016/S0029-6554(98)90069-0
Taylor, R.M. (2013). Ethical Principles and concepts in medicine. Ethical and legal issues in neurology, 118:1-9. doi: 10.1016/B978-0-444-53501-6.00001-9
Walker, A., & Breitsameter, C. (2014) Ethical decision-making in hospice care. Nursing Ethics. Jun 29. pii: 0969733014534873. [Epub ahead of print]
doi:10.1177/0969733014534873
World Health Organization. (2009). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en
Exploration into Nursing: A Personal Framework
The University of Texas at Arlington School of Nursing
In Partial Fulfillment of the Requirements of
N5327 Analysis of Theories in Nursing
Ronda Mintz-Binder, DNP, RN,CNE
Exploration into Nursing: A Personal Framework
Upon graduation from nursing school, I started working on a telemetry/oncology unit at Memorial Herman Hospital in Houston, Texas. Because the unit was also oncology we had to take care of patients who were enrolled in hospice. As a brand new nurse, it was so much I had to learn. Five years later, I have the privilege of working in the Palliative Care Clinic at MD Anderson Cancer Center. I am an outpatient palliative nurse, pain resource nurse, and clinical coach. As a palliative care clinic nurse, I believe in treating all patients with respect and to treat not just one symptom instead consider the patient as a whole. As a palliative care clinic nurse, pain resource nurse and clinic coach, it is vital to assess the holistic aspect of the patient and treat, mind, body and spirit. There are times we have to deal with patients that are at the end of life and refuse hospice, having never been educated about end of life care. I have learned that I do not always have to agree with some of the decisions patients make, but I always have to respect them. My job is to educate the patient about their quality of life, and end of life, keeping in mind the wishes and plan they present. I see myself as a patient advocate, I am there to assist the patient or be the patients’ voice if their symptoms have not been taken care. My interpersonal approach to patients is holistic. My expectations and goals are for every patient that comes to the clinic be treated as an individual and focus on the care tailored to them. I will be exploring my personal values, beliefs, and philosophy in nursing related to my outpatient clinic nursing, pain resource nurse, and clinic coach duties. I will describe Ruland and Moore theory, End-of-Life Care, the nursing metaparadigm, and how it applies in my practice. I will compare my beliefs and Roland and Moore theory, apply the model to my framework, and show a situation where my framework was useful.
Philosophy
My personal philosophy most closely resembles that of Jean Watson. “The nurse guided by Watson’s work is responsible for creating and maintaining an environment that support human caring while recognizing and providing for patient’s primary human requirements” (Chitty &Black, 2007, p.335). The Merriam-Webster dictionary (n.d) defines palliative as “something that is intended to make a bad situation seem better but that does not improve the situation” and “something that reduces the effects or symptoms of a medical condition without curing it”. It is my philosophy of nursing practice that every patient should be introduced to palliative care from the beginning of diagnoses, preparing them to manage their symptom burden. We are our own person, and we live in this world with different experiences and I believe that is what makes us react different. Palliative care is an area where nurses have to give more supportive care. Nurses in palliative care practice active listening to the patient and family. There are times when you feel spirituality drain and have no more to give, however you continue, knowing their time to say goodbye to this world is near. My priority is always the patient but must consider the family especially if they have young children. My goal is to help with symptom burden, assessing for spiritual pain, and help the patient to enjoy their life.
Taylor (2013) identifies beneficence as one of the principles that takes in consideration the interest of the patients. I respect the patients’ decisions when enrolled in hospice. As I precept nurses I teach them to have respect for the decision selected by the patient. Taylor (2013) describes the principle of justice as having two components: equitability and distributive. Every patient that comes to the clinic is treated as an individual, with respect, regardless of who they are. Pugh (2014) describes the ethical principle of autonomy an individual can make informed decision and make choices for themselves. Patients have the right to be given all information regarding their treatment plan, in order to decide if they will continue fighting for a cure. They also have the right to decide how they want to spend the last days of their lives. My clinical focus regardless of their decision is to promote quality of life.
Usefulness of Nursing Theory
Peaceful End of Life theory developed by Cornelia Ruland & Shirley Moore (1998) this theory was the derivative of standards of care. The theory was progressed for the terminally ill patient, for end of life care therapy. Ruland & Moore (1998) stated “the main focus for standard development is not on the final instance of dying itself, but on contributing to peaceful and meaningful living in the time that remained for patients and their significant others” (p.171). The development of this theory has five outcomes for peace end of life: “not being in pain, experience of comfort, experience of dignity/respect, being at peace, and closeness to significant others/person who care” (Ruland & Moore, 1998). Patients have a right to not be in pain. Patients also have the right to be treated with respect and dignity. Ruland & Moore (1998) studied the importance of making sure of living in peace with a meaningful life span. Ruland & Moore (1998) placed emphasis on clinical knowledge for nurse practitioners who choose to specialize in end of life care.
Domain Concepts
The nursing metaparadigm consists of four elements called domain concepts (McEwen & Willis, 2007). These are person, health, environment, and nursing. In the following section, Ruland and Moore nursing metaparadigm will be discussed as I evaluate, explore, and define my own domain concepts. McEwen & Willis, 2007 defines a person as the center and a holistic existence. They also say life is connecting the needs of the physical, intellectual, biochemical, and psychosocial. Ruland & Moore (1998) studied the person as the patient experiencing an illness that should be free of symptoms and experience the optimal comfort. A person should not be in pain, person should experience comfort, dignity and respect. The person should be at peace with themselves having a close relationship with others. Every day we see many patients come to the clinic with so many bothersome symptoms, my aim is to make them feel better so they have good quality of life and continue with the treatment or prepare for the end of life. McEwen & Willis (2007) defines health as being independent and operational. They also say working with and managing daily stressors which living to full potential. In Ruland & Moore (1998) theory health is seen as a preventing to manage their symptoms. An example, providing patients with pain medication, they are functioning better. When dealing with terminal ill patients, we should always be aware of and educate on being proactive. Health can be determined individually as to what the patient classifies as health. McEwen & Willis (2007) defines the external boundaries of external conditions as exchange of energy and information with the self. In Ruland & Moore (1998) the environment is implied as having closeness to significant and others. The patients’ environment with where they clam comfort and define their space. The environment to me is subject to be modified for care and necessities. McEwen & Willis (2007) educate and define nursing as one in a trade and provides care. Nursing also focus towards helping the sick, education, promoting health and seeking prevention. In, Ruland & Moore (1998) they studied saying the nurses help the patient to stay at peace and remain respectful of the patient’s wishes toward the end of life. The elimination of pain is also part of the care from the nurse. Nurses advocate for their patient by providing care, empathy, respect and dignity. The nurse to be is the coordinator for prevention, education, gathers data and manages the patients care. Nurses function by gaining the trust from the patient, and coordinates services from other discipline services.
Applicability of Definition
According to the World Health Organization (2009), palliative care is set up and designed for everybody with a terminal illness. As a nurse practitioners, I would be able treat the patient longer with follow up care then help make the transition into end of life. In my current metaparadigm all the domains work together to capture any maladjustment at the end of life. The patients have complete autonomy of decisions make for their care. The goal is to introduce palliative care earlier, maintaining quality of life, and a smoother time period for end of life. Walker & Breitsameter (2014) believe that the patients’ wishes are the central focus of the nurses’ work every day. I view health with a holistic approach to help service the patient physical and mental wellbeing. The environment is composed of the patient’s family and life situations. I strongly believe that a patient’s family plays an important role in the recuperation of the patient. Family is there for emotional support and to assist in the care. The socioeconomic conditions of the patient and the stressors and cultural beliefs has to consider when providing care to any patient. “The nurse promotes, advocates for, and strives to protect the health, safety, and right of the patient” (ANA Code of Ethics, 2001). The nurse by being there displays compassion and caring. The nurse is the one that brings all of them together. As I advance in my nursing practice, my domain concept definition will mature and progress.
Philosophy and Approach
I believe that palliative care should be introduced early at time of a life changing illness. My personal framework educates on the benefits of making a patient’s life better towards the end of life. My personal theory is of peace and preparedness. In comparison to Ruland and Moore’s theory having respect, autonomy and dignity at the end of life bring harmony. Another comparison is similar management of bothersome symptoms striving for comfort. In contrast, it differentiates in the early intervention of palliative care for support. Hui, Roquemore, Dev & Bruera (2014) reports in their study that if the patient gets referred to palliative care earlier and as outpatient their quality of care would improve. My personal framework theory is for patients who are newly diagnosed to patient who is at the end of their lives. This prepares the patient and their families better as they deal with a terminal illness, and progresses of disease. My theory will assist in my practice as I grow and educate myself to continue to treat all patients as individuals. My theory lacks how to make terminal patients aware of the palliative care services.
Personal Framework Model
The four components of the nursing metaparadigm are entwined with each other. The person, health, environment, and nursing are all functions that work together and cannot be separated (see Figure 1). The person domain remains at the top representing the most important concept but all domains have equal significance. The double sided arrows links each domain concept to one another. The bisector arrow shows the relationship of the domain to the concept of the theory uniting each domain to represent a whole. The square with the arrow pointing to the domain defines the domain concept. This model explains how each domain introduces early intervention for Palliative end of life theory.
Application in Practice
Patient J.T. female with stage IV Breast Cancer metastatic to the bones, lungs, and a small lesion in the brain. Patient came to our clinic having failed a Phase I clinical trial, with progression of a disease. Patient was told to go see Palliative Care, with no other explanation given or explained. She was in pain, nauseated, vomiting, depressed, and having anxiety. She also had not slept for days with high spiritual pain. She was the mother of three children ages ranging from four to ten years old. The Patient was referred Palliative care to transition her into hospice. Patient J. T would have benefit from palliative care sooner to receive counselling, child life specialist for her kids, and been relieved of her bothersome symptoms that she presents to the palliative care. Palliative care has a team approach, and she would have a different outcome for her quality of life.
Conclusion
In this personal framework, I have discover how valuable nursing is to me. I have learned that every day we have the opportunity to learn. I reviewed the ethical values of beneficence, justice and autonomy in my theory of practice. I compared Ruland & Moore peaceful end of life theory. I learn that we all use their theory when faced with patients who are in their last days of life. I discussed in detail the domain concepts of the nursing metaparadigm; Ruland & Moore definition, my definitions, and the applicability of each domain concept. I was able to create a model to my personal framework and give examples of how my framework was useful. Theory helps us gain a better understanding of nursing practice in the clinical setting, improving patient outcomes. When I first started this class I was so overcome with all the different concepts and papers that we had to write, I was ready to give up. Most importantly, I learned, that one step leads to another step and soon you get to the end point. I know there is still so much to learn as I advance in my profession. My personal framework will change as I continue learning different theories. I will use them to help guide me to provide better care for my patients.
References
American Nurses Association. Code of Ethics (2001). Nursing World Journal Provision 3. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe1115.htm.
Chitty, K.K., and Black, B.P. (2007). Nursing theory: The basis for professional nursing Professional Nursing: Concepts and challenges. (pp.328-347). St Louis, Mo: Saunders. Retrieved July 2014, from CINAHL database.
Hui D, Kim S.,H, Roquemore J,R., Dev R, Chisholm G, Bruera E. (2014). Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer, 120, 1743-1749.doi:10.1002/cncr.28628
McEwen, M., & Willis, E.M. (2011). Theoretical basis for nursing (4th ed.) Philadelphia: Lippincott Williams & Wilkins.
Merriam-Webster dictionary. Palliative. (n.d.). Retrieved July 27, 2014, from http://www.merriam-webster.com/dictionary/palliative
Pugh, D.M. (2014). Ethics at the End of Life. Clinical Nurse Specialist, 28, 201-204. doi:10.1097/NUR.0000000000000058
Ruland C, M., Moore S, M. (1998). Theory construction based on standards of care: a proposed theory of the peaceful end of life. Nurse Outlook. (46):169-175 doi: 10.1016/S0029-6554(98)90069-0
Taylor, R.M. (2013). Ethical Principles and concepts in medicine. Ethical and legal issues in neurology, 118:1-9. doi: 10.1016/B978-0-444-53501-6.00001-9
Walker, A., & Breitsameter, C. (2014) Ethical decision-making in hospice care. Nursing Ethics. Jun 29. pii: 0969733014534873. [Epub ahead of print] doi:10.1177/0969733014534873
World Health Organization. (2009). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en
The University of Texas at Arlington School of Nursing
In Partial Fulfillment of the Requirements of
N5327 Analysis of Theories in Nursing
Ronda Mintz-Binder, DNP, RN,CNE
Exploration into Nursing: A Personal Framework
Upon graduation from nursing school, I started working on a telemetry/oncology unit at Memorial Herman Hospital in Houston, Texas. Because the unit was also oncology we had to take care of patients who were enrolled in hospice. As a brand new nurse, it was so much I had to learn. Five years later, I have the privilege of working in the Palliative Care Clinic at MD Anderson Cancer Center. I am an outpatient palliative nurse, pain …show more content…
resource nurse, and clinical coach. As a palliative care clinic nurse, I believe in treating all patients with respect and to treat not just one symptom instead consider the patient as a whole. As a palliative care clinic nurse, pain resource nurse and clinic coach, it is vital to assess the holistic aspect of the patient and treat, mind, body and spirit. There are times we have to deal with patients that are at the end of life and refuse hospice, having never been educated about end of life care. I have learned that I do not always have to agree with some of the decisions patients make, but I always have to respect them. My job is to educate the patient about their quality of life, and end of life, keeping in mind the wishes and plan they present. I see myself as a patient advocate, I am there to assist the patient or be the patients’ voice if their symptoms have not been taken care. My interpersonal approach to patients is holistic. My expectations and goals are for every patient that comes to the clinic be treated as an individual and focus on the care tailored to them. I will be exploring my personal values, beliefs, and philosophy in nursing related to my outpatient clinic nursing, pain resource nurse, and clinic coach duties. I will describe Ruland and Moore theory, End-of-Life Care, the nursing metaparadigm, and how it applies in my practice. I will compare my beliefs and Roland and Moore theory, apply the model to my framework, and show a situation where my framework was useful.
Philosophy
My personal philosophy most closely resembles that of Jean Watson. “The nurse guided by Watson’s work is responsible for creating and maintaining an environment that support human caring while recognizing and providing for patient’s primary human requirements” (Chitty &Black, 2007, p.335). The Merriam-Webster dictionary (n.d) defines palliative as “something that is intended to make a bad situation seem better but that does not improve the situation” and “something that reduces the effects or symptoms of a medical condition without curing it”. It is my philosophy of nursing practice that every patient should be introduced to palliative care from the beginning of diagnoses, preparing them to manage their symptom burden. We are our own person, and we live in this world with different experiences and I believe that is what makes us react different. Palliative care is an area where nurses have to give more supportive care. Nurses in palliative care practice active listening to the patient and family. There are times when you feel spirituality drain and have no more to give, however you continue, knowing their time to say goodbye to this world is near. My priority is always the patient but must consider the family especially if they have young children. My goal is to help with symptom burden, assessing for spiritual pain, and help the patient to enjoy their life.
Taylor (2013) identifies beneficence as one of the principles that takes in consideration the interest of the patients. I respect the patients’ decisions when enrolled in hospice. As I precept nurses I teach them to have respect for the decision selected by the patient. Taylor (2013) describes the principle of justice as having two components: equitability and distributive. Every patient that comes to the clinic is treated as an individual, with respect, regardless of who they are. Pugh (2014) describes the ethical principle of autonomy an individual can make informed decision and make choices for themselves. Patients have the right to be given all information regarding their treatment plan, in order to decide if they will continue fighting for a cure. They also have the right to decide how they want to spend the last days of their lives. My clinical focus regardless of their decision is to promote quality of life.
Usefulness of Nursing Theory
Peaceful End of Life theory developed by Cornelia Ruland & Shirley Moore (1998) this theory was the derivative of standards of care. The theory was progressed for the terminally ill patient, for end of life care therapy. Ruland & Moore (1998) stated “the main focus for standard development is not on the final instance of dying itself, but on contributing to peaceful and meaningful living in the time that remained for patients and their significant others” (p.171). The development of this theory has five outcomes for peace end of life: “not being in pain, experience of comfort, experience of dignity/respect, being at peace, and closeness to significant others/person who care” (Ruland & Moore, 1998). Patients have a right to not be in pain. Patients also have the right to be treated with respect and dignity. Ruland & Moore (1998) studied the importance of making sure of living in peace with a meaningful life span. Ruland & Moore (1998) placed emphasis on clinical knowledge for nurse practitioners who choose to specialize in end of life care.
Domain Concepts
The nursing metaparadigm consists of four elements called domain concepts (McEwen & Willis, 2007). These are person, health, environment, and nursing. In the following section, Ruland and Moore nursing metaparadigm will be discussed as I evaluate, explore, and define my own domain concepts. McEwen & Willis, 2007 defines a person as the center and a holistic existence. They also say life is connecting the needs of the physical, intellectual, biochemical, and psychosocial. Ruland & Moore (1998) studied the person as the patient experiencing an illness that should be free of symptoms and experience the optimal comfort. A person should not be in pain, person should experience comfort, dignity and respect. The person should be at peace with themselves having a close relationship with others. Every day we see many patients come to the clinic with so many bothersome symptoms, my aim is to make them feel better so they have good quality of life and continue with the treatment or prepare for the end of life. McEwen & Willis (2007) defines health as being independent and operational. They also say working with and managing daily stressors which living to full potential. In Ruland & Moore (1998) theory health is seen as a preventing to manage their symptoms. An example, providing patients with pain medication, they are functioning better. When dealing with terminal ill patients, we should always be aware of and educate on being proactive. Health can be determined individually as to what the patient classifies as health. McEwen & Willis (2007) defines the external boundaries of external conditions as exchange of energy and information with the self. In Ruland & Moore (1998) the environment is implied as having closeness to significant and others. The patients’ environment with where they clam comfort and define their space. The environment to me is subject to be modified for care and necessities. McEwen & Willis (2007) educate and define nursing as one in a trade and provides care. Nursing also focus towards helping the sick, education, promoting health and seeking prevention. In, Ruland & Moore (1998) they studied saying the nurses help the patient to stay at peace and remain respectful of the patient’s wishes toward the end of life. The elimination of pain is also part of the care from the nurse. Nurses advocate for their patient by providing care, empathy, respect and dignity. The nurse to be is the coordinator for prevention, education, gathers data and manages the patients care. Nurses function by gaining the trust from the patient, and coordinates services from other discipline services.
Applicability of Definition
According to the World Health Organization (2009), palliative care is set up and designed for everybody with a terminal illness. As a nurse practitioners, I would be able treat the patient longer with follow up care then help make the transition into end of life. In my current metaparadigm all the domains work together to capture any maladjustment at the end of life. The patients have complete autonomy of decisions make for their care. The goal is to introduce palliative care earlier, maintaining quality of life, and a smoother time period for end of life. Walker & Breitsameter (2014) believe that the patients’ wishes are the central focus of the nurses’ work every day. I view health with a holistic approach to help service the patient physical and mental wellbeing. The environment is composed of the patient’s family and life situations. I strongly believe that a patient’s family plays an important role in the recuperation of the patient. Family is there for emotional support and to assist in the care. The socioeconomic conditions of the patient and the stressors and cultural beliefs has to consider when providing care to any patient. “The nurse promotes, advocates for, and strives to protect the health, safety, and right of the patient” (ANA Code of Ethics, 2001). The nurse by being there displays compassion and caring. The nurse is the one that brings all of them together. As I advance in my nursing practice, my domain concept definition will mature and progress.
Philosophy and Approach
I believe that palliative care should be introduced early at time of a life changing illness. My personal framework educates on the benefits of making a patient’s life better towards the end of life. My personal theory is of peace and preparedness. In comparison to Ruland and Moore’s theory having respect, autonomy and dignity at the end of life bring harmony. Another comparison is similar management of bothersome symptoms striving for comfort. In contrast, it differentiates in the early intervention of palliative care for support. Hui, Roquemore, Dev & Bruera (2014) reports in their study that if the patient gets referred to palliative care earlier and as outpatient their quality of care would improve. My personal framework theory is for patients who are newly diagnosed to patient who is at the end of their lives. This prepares the patient and their families better as they deal with a terminal illness, and progresses of disease. My theory will assist in my practice as I grow and educate myself to continue to treat all patients as individuals. My theory lacks how to make terminal patients aware of the palliative care services.
Personal Framework Model
The four components of the nursing metaparadigm are entwined with each other. The person, health, environment, and nursing are all functions that work together and cannot be separated (see Figure 1). The person domain remains at the top representing the most important concept but all domains have equal significance. The double sided arrows links each domain concept to one another. The bisector arrow shows the relationship of the domain to the concept of the theory uniting each domain to represent a whole. The square with the arrow pointing to the domain defines the domain concept. This model explains how each domain introduces early intervention for Palliative end of life theory.
Application in Practice
Patient J.T. female with stage IV Breast Cancer metastatic to the bones, lungs, and a small lesion in the brain. Patient came to our clinic having failed a Phase I clinical trial, with progression of a disease. Patient was told to go see Palliative Care, with no other explanation given or explained. She was in pain, nauseated, vomiting, depressed, and having anxiety. She also had not slept for days with high spiritual pain. She was the mother of three children ages ranging from four to ten years old. The Patient was referred Palliative care to transition her into hospice. Patient J. T would have benefit from palliative care sooner to receive counselling, child life specialist for her kids, and been relieved of her bothersome symptoms that she presents to the palliative care. Palliative care has a team approach, and she would have a different outcome for her quality of life.
Conclusion
In this personal framework, I have discover how valuable nursing is to me. I have learned that every day we have the opportunity to learn. I reviewed the ethical values of beneficence, justice and autonomy in my theory of practice. I compared Ruland & Moore peaceful end of life theory. I learn that we all use their theory when faced with patients who are in their last days of life. I discussed in detail the domain concepts of the nursing metaparadigm; Ruland & Moore definition, my definitions, and the applicability of each domain concept. I was able to create a model to my personal framework and give examples of how my framework was useful. Theory helps us gain a better understanding of nursing practice in the clinical setting, improving patient outcomes. When I first started this class I was so overcome with all the different concepts and papers that we had to write, I was ready to give up. Most importantly, I learned, that one step leads to another step and soon you get to the end point. I know there is still so much to learn as I advance in my profession. My personal framework will change as I continue learning different theories. I will use them to help guide me to provide better care for my patients.
References
American Nurses Association. Code of Ethics (2001). Nursing World Journal Provision 3. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe1115.htm.
Chitty, K.K., and Black, B.P. (2007). Nursing theory: The basis for professional nursing Professional Nursing: Concepts and challenges. (pp.328-347). St Louis, Mo: Saunders. Retrieved July 2014, from CINAHL database.
Hui D, Kim S.,H, Roquemore J,R., Dev R, Chisholm G, Bruera E. (2014). Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer, 120, 1743-1749.doi:10.1002/cncr.28628
McEwen, M., & Willis, E.M. (2011). Theoretical basis for nursing (4th ed.) Philadelphia: Lippincott Williams & Wilkins.
Merriam-Webster dictionary. Palliative. (n.d.). Retrieved July 27, 2014, from http://www.merriam-webster.com/dictionary/palliative
Pugh, D.M. (2014). Ethics at the End of Life. Clinical Nurse Specialist, 28, 201-204. doi:10.1097/NUR.0000000000000058
Ruland C, M., Moore S, M. (1998). Theory construction based on standards of care: a proposed theory of the peaceful end of life. Nurse Outlook. (46):169-175 doi: 10.1016/S0029-6554(98)90069-0
Taylor, R.M. (2013). Ethical Principles and concepts in medicine. Ethical and legal issues in neurology, 118:1-9. doi: 10.1016/B978-0-444-53501-6.00001-9
Walker, A., & Breitsameter, C. (2014) Ethical decision-making in hospice care. Nursing Ethics. Jun 29. pii: 0969733014534873. [Epub ahead of print] doi:10.1177/0969733014534873
World Health Organization. (2009). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en
Exploration into Nursing: A Personal Framework
The University of Texas at Arlington School of Nursing
In Partial Fulfillment of the Requirements of
N5327 Analysis of Theories in Nursing
Ronda Mintz-Binder, DNP, RN,CNE
Exploration into Nursing: A Personal Framework
Upon graduation from nursing school, I started working on a telemetry/oncology unit at Memorial Herman Hospital in Houston, Texas. Because the unit was also oncology we had to take care of patients who were enrolled in hospice. As a brand new nurse, it was so much I had to learn. Five years later, I have the privilege of working in the Palliative Care Clinic at MD Anderson Cancer Center. I am an outpatient palliative nurse, pain resource nurse, and clinical coach. As a palliative care clinic nurse, I believe in treating all patients with respect and to treat not just one symptom instead consider the patient as a whole. As a palliative care clinic nurse, pain resource nurse and clinic coach, it is vital to assess the holistic aspect of the patient and treat, mind, body and spirit. There are times we have to deal with patients that are at the end of life and refuse hospice, having never been educated about end of life care. I have learned that I do not always have to agree with some of the decisions patients make, but I always have to respect them. My job is to educate the patient about their quality of life, and end of life, keeping in mind the wishes and plan they present. I see myself as a patient advocate, I am there to assist the patient or be the patients’ voice if their symptoms have not been taken care. My interpersonal approach to patients is holistic. My expectations and goals are for every patient that comes to the clinic be treated as an individual and focus on the care tailored to them. I will be exploring my personal values, beliefs, and philosophy in nursing related to my outpatient clinic nursing, pain resource nurse, and clinic coach duties. I will describe Ruland and Moore theory, End-of-Life Care, the nursing metaparadigm, and how it applies in my practice. I will compare my beliefs and Roland and Moore theory, apply the model to my framework, and show a situation where my framework was useful.
Philosophy
My personal philosophy most closely resembles that of Jean Watson. “The nurse guided by Watson’s work is responsible for creating and maintaining an environment that support human caring while recognizing and providing for patient’s primary human requirements” (Chitty &Black, 2007, p.335). The Merriam-Webster dictionary (n.d) defines palliative as “something that is intended to make a bad situation seem better but that does not improve the situation” and “something that reduces the effects or symptoms of a medical condition without curing it”. It is my philosophy of nursing practice that every patient should be introduced to palliative care from the beginning of diagnoses, preparing them to manage their symptom burden. We are our own person, and we live in this world with different experiences and I believe that is what makes us react different. Palliative care is an area where nurses have to give more supportive care. Nurses in palliative care practice active listening to the patient and family. There are times when you feel spirituality drain and have no more to give, however you continue, knowing their time to say goodbye to this world is near. My priority is always the patient but must consider the family especially if they have young children. My goal is to help with symptom burden, assessing for spiritual pain, and help the patient to enjoy their life.
Taylor (2013) identifies beneficence as one of the principles that takes in consideration the interest of the patients. I respect the patients’ decisions when enrolled in hospice. As I precept nurses I teach them to have respect for the decision selected by the patient. Taylor (2013) describes the principle of justice as having two components: equitability and distributive. Every patient that comes to the clinic is treated as an individual, with respect, regardless of who they are. Pugh (2014) describes the ethical principle of autonomy an individual can make informed decision and make choices for themselves. Patients have the right to be given all information regarding their treatment plan, in order to decide if they will continue fighting for a cure. They also have the right to decide how they want to spend the last days of their lives. My clinical focus regardless of their decision is to promote quality of life.
Usefulness of Nursing Theory
Peaceful End of Life theory developed by Cornelia Ruland & Shirley Moore (1998) this theory was the derivative of standards of care. The theory was progressed for the terminally ill patient, for end of life care therapy. Ruland & Moore (1998) stated “the main focus for standard development is not on the final instance of dying itself, but on contributing to peaceful and meaningful living in the time that remained for patients and their significant others” (p.171). The development of this theory has five outcomes for peace end of life: “not being in pain, experience of comfort, experience of dignity/respect, being at peace, and closeness to significant others/person who care” (Ruland & Moore, 1998). Patients have a right to not be in pain. Patients also have the right to be treated with respect and dignity. Ruland & Moore (1998) studied the importance of making sure of living in peace with a meaningful life span. Ruland & Moore (1998) placed emphasis on clinical knowledge for nurse practitioners who choose to specialize in end of life care.
Domain Concepts
The nursing metaparadigm consists of four elements called domain concepts (McEwen & Willis, 2007).
These are person, health, environment, and nursing. In the following section, Ruland and Moore nursing metaparadigm will be discussed as I evaluate, explore, and define my own domain concepts. McEwen & Willis, 2007 defines a person as the center and a holistic existence. They also say life is connecting the needs of the physical, intellectual, biochemical, and psychosocial. Ruland & Moore (1998) studied the person as the patient experiencing an illness that should be free of symptoms and experience the optimal comfort. A person should not be in pain, person should experience comfort, dignity and respect. The person should be at peace with themselves having a close relationship with others. Every day we see many patients come to the clinic with so many bothersome symptoms, my aim is to make them feel better so they have good quality of life and continue with the treatment or prepare for the end of life. McEwen & Willis (2007) defines health as being independent and operational. They also say working with and managing daily stressors which living to full potential. In Ruland & Moore (1998) theory health is seen as a preventing to manage their symptoms. An example, providing patients with pain medication, they are functioning better. When dealing with terminal ill patients, we should always be aware of and educate on being proactive. Health can be determined individually as to …show more content…
what the patient classifies as health. McEwen & Willis (2007) defines the external boundaries of external conditions as exchange of energy and information with the self. In Ruland & Moore (1998) the environment is implied as having closeness to significant and others. The patients’ environment with where they clam comfort and define their space. The environment to me is subject to be modified for care and necessities. McEwen & Willis (2007) educate and define nursing as one in a trade and provides care. Nursing also focus towards helping the sick, education, promoting health and seeking prevention. In, Ruland & Moore (1998) they studied saying the nurses help the patient to stay at peace and remain respectful of the patient’s wishes toward the end of life. The elimination of pain is also part of the care from the nurse. Nurses advocate for their patient by providing care, empathy, respect and dignity. The nurse to be is the coordinator for prevention, education, gathers data and manages the patients care. Nurses function by gaining the trust from the patient, and coordinates services from other discipline services.
Applicability of Definition
According to the World Health Organization (2009), palliative care is set up and designed for everybody with a terminal illness. As a nurse practitioners, I would be able treat the patient longer with follow up care then help make the transition into end of life. In my current metaparadigm all the domains work together to capture any maladjustment at the end of life. The patients have complete autonomy of decisions make for their care. The goal is to introduce palliative care earlier, maintaining quality of life, and a smoother time period for end of life. Walker & Breitsameter (2014) believe that the patients’ wishes are the central focus of the nurses’ work every day. I view health with a holistic approach to help service the patient physical and mental wellbeing. The environment is composed of the patient’s family and life situations. I strongly believe that a patient’s family plays an important role in the recuperation of the patient. Family is there for emotional support and to assist in the care. The socioeconomic conditions of the patient and the stressors and cultural beliefs has to consider when providing care to any patient. “The nurse promotes, advocates for, and strives to protect the health, safety, and right of the patient” (ANA Code of Ethics, 2001). The nurse by being there displays compassion and caring. The nurse is the one that brings all of them together. As I advance in my nursing practice, my domain concept definition will mature and progress.
Philosophy and Approach
I believe that palliative care should be introduced early at time of a life changing illness. My personal framework educates on the benefits of making a patient’s life better towards the end of life. My personal theory is of peace and preparedness. In comparison to Ruland and Moore’s theory having respect, autonomy and dignity at the end of life bring harmony. Another comparison is similar management of bothersome symptoms striving for comfort. In contrast, it differentiates in the early intervention of palliative care for support. Hui, Roquemore, Dev & Bruera (2014) reports in their study that if the patient gets referred to palliative care earlier and as outpatient their quality of care would improve. My personal framework theory is for patients who are newly diagnosed to patient who is at the end of their lives. This prepares the patient and their families better as they deal with a terminal illness, and progresses of disease. My theory will assist in my practice as I grow and educate myself to continue to treat all patients as individuals. My theory lacks how to make terminal patients aware of the palliative care services.
Personal Framework Model
The four components of the nursing metaparadigm are entwined with each other. The person, health, environment, and nursing are all functions that work together and cannot be separated (see Figure 1). The person domain remains at the top representing the most important concept but all domains have equal significance. The double sided arrows links each domain concept to one another. The bisector arrow shows the relationship of the domain to the concept of the theory uniting each domain to represent a whole. The square with the arrow pointing to the domain defines the domain concept. This model explains how each domain introduces early intervention for Palliative end of life theory.
Application in Practice
Patient J.T. female with stage IV Breast Cancer metastatic to the bones, lungs, and a small lesion in the brain. Patient came to our clinic having failed a Phase I clinical trial, with progression of a disease. Patient was told to go see Palliative Care, with no other explanation given or explained. She was in pain, nauseated, vomiting, depressed, and having anxiety. She also had not slept for days with high spiritual pain. She was the mother of three children ages ranging from four to ten years old. The Patient was referred Palliative care to transition her into hospice. Patient J. T would have benefit from palliative care sooner to receive counselling, child life specialist for her kids, and been relieved of her bothersome symptoms that she presents to the palliative care. Palliative care has a team approach, and she would have a different outcome for her quality of life.
Conclusion
In this personal framework, I have discover how valuable nursing is to me. I have learned that every day we have the opportunity to learn. I reviewed the ethical values of beneficence, justice and autonomy in my theory of practice. I compared Ruland & Moore peaceful end of life theory. I learn that we all use their theory when faced with patients who are in their last days of life. I discussed in detail the domain concepts of the nursing metaparadigm; Ruland & Moore definition, my definitions, and the applicability of each domain concept. I was able to create a model to my personal framework and give examples of how my framework was useful. Theory helps us gain a better understanding of nursing practice in the clinical setting, improving patient outcomes. When I first started this class I was so overcome with all the different concepts and papers that we had to write, I was ready to give up. Most importantly, I learned, that one step leads to another step and soon you get to the end point. I know there is still so much to learn as I advance in my profession. My personal framework will change as I continue learning different theories. I will use them to help guide me to provide better care for my patients.
References
American Nurses Association. Code of Ethics (2001). Nursing World Journal Provision 3. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe1115.htm.
Chitty, K.K., and Black, B.P.
(2007). Nursing theory: The basis for professional nursing Professional Nursing: Concepts and challenges. (pp.328-347). St Louis, Mo: Saunders. Retrieved July 2014, from CINAHL database.
Hui D, Kim S.,H, Roquemore J,R., Dev R, Chisholm G, Bruera E. (2014). Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer, 120, 1743-1749.doi:10.1002/cncr.28628
McEwen, M., & Willis, E.M. (2011). Theoretical basis for nursing (4th ed.) Philadelphia: Lippincott Williams & Wilkins.
Merriam-Webster dictionary. Palliative. (n.d.). Retrieved July 27, 2014, from http://www.merriam-webster.com/dictionary/palliative
Pugh, D.M. (2014). Ethics at the End of Life. Clinical Nurse Specialist, 28, 201-204. doi:10.1097/NUR.0000000000000058
Ruland C, M., Moore S, M. (1998). Theory construction based on standards of care: a proposed theory of the peaceful end of life. Nurse Outlook. (46):169-175 doi: 10.1016/S0029-6554(98)90069-0
Taylor, R.M. (2013). Ethical Principles and concepts in medicine. Ethical and legal issues in neurology, 118:1-9. doi: 10.1016/B978-0-444-53501-6.00001-9
Walker, A., & Breitsameter, C. (2014) Ethical decision-making in hospice care. Nursing Ethics. Jun 29. pii: 0969733014534873. [Epub ahead of print]
doi:10.1177/0969733014534873
World Health Organization. (2009). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en
Exploration into Nursing: A Personal Framework
The University of Texas at Arlington School of Nursing
In Partial Fulfillment of the Requirements of
N5327 Analysis of Theories in Nursing
Ronda Mintz-Binder, DNP, RN,CNE
Exploration into Nursing: A Personal Framework
Upon graduation from nursing school, I started working on a telemetry/oncology unit at Memorial Herman Hospital in Houston, Texas. Because the unit was also oncology we had to take care of patients who were enrolled in hospice. As a brand new nurse, it was so much I had to learn. Five years later, I have the privilege of working in the Palliative Care Clinic at MD Anderson Cancer Center. I am an outpatient palliative nurse, pain resource nurse, and clinical coach. As a palliative care clinic nurse, I believe in treating all patients with respect and to treat not just one symptom instead consider the patient as a whole. As a palliative care clinic nurse, pain resource nurse and clinic coach, it is vital to assess the holistic aspect of the patient and treat, mind, body and spirit. There are times we have to deal with patients that are at the end of life and refuse hospice, having never been educated about end of life care. I have learned that I do not always have to agree with some of the decisions patients make, but I always have to respect them. My job is to educate the patient about their quality of life, and end of life, keeping in mind the wishes and plan they present. I see myself as a patient advocate, I am there to assist the patient or be the patients’ voice if their symptoms have not been taken care. My interpersonal approach to patients is holistic. My expectations and goals are for every patient that comes to the clinic be treated as an individual and focus on the care tailored to them. I will be exploring my personal values, beliefs, and philosophy in nursing related to my outpatient clinic nursing, pain resource nurse, and clinic coach duties. I will describe Ruland and Moore theory, End-of-Life Care, the nursing metaparadigm, and how it applies in my practice. I will compare my beliefs and Roland and Moore theory, apply the model to my framework, and show a situation where my framework was useful.
Philosophy
My personal philosophy most closely resembles that of Jean Watson. “The nurse guided by Watson’s work is responsible for creating and maintaining an environment that support human caring while recognizing and providing for patient’s primary human requirements” (Chitty &Black, 2007, p.335). The Merriam-Webster dictionary (n.d) defines palliative as “something that is intended to make a bad situation seem better but that does not improve the situation” and “something that reduces the effects or symptoms of a medical condition without curing it”. It is my philosophy of nursing practice that every patient should be introduced to palliative care from the beginning of diagnoses, preparing them to manage their symptom burden. We are our own person, and we live in this world with different experiences and I believe that is what makes us react different. Palliative care is an area where nurses have to give more supportive care. Nurses in palliative care practice active listening to the patient and family. There are times when you feel spirituality drain and have no more to give, however you continue, knowing their time to say goodbye to this world is near. My priority is always the patient but must consider the family especially if they have young children. My goal is to help with symptom burden, assessing for spiritual pain, and help the patient to enjoy their life.
Taylor (2013) identifies beneficence as one of the principles that takes in consideration the interest of the patients. I respect the patients’ decisions when enrolled in hospice. As I precept nurses I teach them to have respect for the decision selected by the patient. Taylor (2013) describes the principle of justice as having two components: equitability and distributive. Every patient that comes to the clinic is treated as an individual, with respect, regardless of who they are. Pugh (2014) describes the ethical principle of autonomy an individual can make informed decision and make choices for themselves. Patients have the right to be given all information regarding their treatment plan, in order to decide if they will continue fighting for a cure. They also have the right to decide how they want to spend the last days of their lives. My clinical focus regardless of their decision is to promote quality of life.
Usefulness of Nursing Theory
Peaceful End of Life theory developed by Cornelia Ruland & Shirley Moore (1998) this theory was the derivative of standards of care. The theory was progressed for the terminally ill patient, for end of life care therapy. Ruland & Moore (1998) stated “the main focus for standard development is not on the final instance of dying itself, but on contributing to peaceful and meaningful living in the time that remained for patients and their significant others” (p.171). The development of this theory has five outcomes for peace end of life: “not being in pain, experience of comfort, experience of dignity/respect, being at peace, and closeness to significant others/person who care” (Ruland & Moore, 1998). Patients have a right to not be in pain. Patients also have the right to be treated with respect and dignity. Ruland & Moore (1998) studied the importance of making sure of living in peace with a meaningful life span. Ruland & Moore (1998) placed emphasis on clinical knowledge for nurse practitioners who choose to specialize in end of life care.
Domain Concepts
The nursing metaparadigm consists of four elements called domain concepts (McEwen & Willis, 2007). These are person, health, environment, and nursing. In the following section, Ruland and Moore nursing metaparadigm will be discussed as I evaluate, explore, and define my own domain concepts. McEwen & Willis, 2007 defines a person as the center and a holistic existence. They also say life is connecting the needs of the physical, intellectual, biochemical, and psychosocial. Ruland & Moore (1998) studied the person as the patient experiencing an illness that should be free of symptoms and experience the optimal comfort. A person should not be in pain, person should experience comfort, dignity and respect. The person should be at peace with themselves having a close relationship with others. Every day we see many patients come to the clinic with so many bothersome symptoms, my aim is to make them feel better so they have good quality of life and continue with the treatment or prepare for the end of life. McEwen & Willis (2007) defines health as being independent and operational. They also say working with and managing daily stressors which living to full potential. In Ruland & Moore (1998) theory health is seen as a preventing to manage their symptoms. An example, providing patients with pain medication, they are functioning better. When dealing with terminal ill patients, we should always be aware of and educate on being proactive. Health can be determined individually as to what the patient classifies as health. McEwen & Willis (2007) defines the external boundaries of external conditions as exchange of energy and information with the self. In Ruland & Moore (1998) the environment is implied as having closeness to significant and others. The patients’ environment with where they clam comfort and define their space. The environment to me is subject to be modified for care and necessities. McEwen & Willis (2007) educate and define nursing as one in a trade and provides care. Nursing also focus towards helping the sick, education, promoting health and seeking prevention. In, Ruland & Moore (1998) they studied saying the nurses help the patient to stay at peace and remain respectful of the patient’s wishes toward the end of life. The elimination of pain is also part of the care from the nurse. Nurses advocate for their patient by providing care, empathy, respect and dignity. The nurse to be is the coordinator for prevention, education, gathers data and manages the patients care. Nurses function by gaining the trust from the patient, and coordinates services from other discipline services.
Applicability of Definition
According to the World Health Organization (2009), palliative care is set up and designed for everybody with a terminal illness. As a nurse practitioners, I would be able treat the patient longer with follow up care then help make the transition into end of life. In my current metaparadigm all the domains work together to capture any maladjustment at the end of life. The patients have complete autonomy of decisions make for their care. The goal is to introduce palliative care earlier, maintaining quality of life, and a smoother time period for end of life. Walker & Breitsameter (2014) believe that the patients’ wishes are the central focus of the nurses’ work every day. I view health with a holistic approach to help service the patient physical and mental wellbeing. The environment is composed of the patient’s family and life situations. I strongly believe that a patient’s family plays an important role in the recuperation of the patient. Family is there for emotional support and to assist in the care. The socioeconomic conditions of the patient and the stressors and cultural beliefs has to consider when providing care to any patient. “The nurse promotes, advocates for, and strives to protect the health, safety, and right of the patient” (ANA Code of Ethics, 2001). The nurse by being there displays compassion and caring. The nurse is the one that brings all of them together. As I advance in my nursing practice, my domain concept definition will mature and progress.
Philosophy and Approach
I believe that palliative care should be introduced early at time of a life changing illness. My personal framework educates on the benefits of making a patient’s life better towards the end of life. My personal theory is of peace and preparedness. In comparison to Ruland and Moore’s theory having respect, autonomy and dignity at the end of life bring harmony. Another comparison is similar management of bothersome symptoms striving for comfort. In contrast, it differentiates in the early intervention of palliative care for support. Hui, Roquemore, Dev & Bruera (2014) reports in their study that if the patient gets referred to palliative care earlier and as outpatient their quality of care would improve. My personal framework theory is for patients who are newly diagnosed to patient who is at the end of their lives. This prepares the patient and their families better as they deal with a terminal illness, and progresses of disease. My theory will assist in my practice as I grow and educate myself to continue to treat all patients as individuals. My theory lacks how to make terminal patients aware of the palliative care services.
Personal Framework Model
The four components of the nursing metaparadigm are entwined with each other. The person, health, environment, and nursing are all functions that work together and cannot be separated (see Figure 1). The person domain remains at the top representing the most important concept but all domains have equal significance. The double sided arrows links each domain concept to one another. The bisector arrow shows the relationship of the domain to the concept of the theory uniting each domain to represent a whole. The square with the arrow pointing to the domain defines the domain concept. This model explains how each domain introduces early intervention for Palliative end of life theory.
Application in Practice
Patient J.T. female with stage IV Breast Cancer metastatic to the bones, lungs, and a small lesion in the brain. Patient came to our clinic having failed a Phase I clinical trial, with progression of a disease. Patient was told to go see Palliative Care, with no other explanation given or explained. She was in pain, nauseated, vomiting, depressed, and having anxiety. She also had not slept for days with high spiritual pain. She was the mother of three children ages ranging from four to ten years old. The Patient was referred Palliative care to transition her into hospice. Patient J. T would have benefit from palliative care sooner to receive counselling, child life specialist for her kids, and been relieved of her bothersome symptoms that she presents to the palliative care. Palliative care has a team approach, and she would have a different outcome for her quality of life.
Conclusion
In this personal framework, I have discover how valuable nursing is to me. I have learned that every day we have the opportunity to learn. I reviewed the ethical values of beneficence, justice and autonomy in my theory of practice. I compared Ruland & Moore peaceful end of life theory. I learn that we all use their theory when faced with patients who are in their last days of life. I discussed in detail the domain concepts of the nursing metaparadigm; Ruland & Moore definition, my definitions, and the applicability of each domain concept. I was able to create a model to my personal framework and give examples of how my framework was useful. Theory helps us gain a better understanding of nursing practice in the clinical setting, improving patient outcomes. When I first started this class I was so overcome with all the different concepts and papers that we had to write, I was ready to give up. Most importantly, I learned, that one step leads to another step and soon you get to the end point. I know there is still so much to learn as I advance in my profession. My personal framework will change as I continue learning different theories. I will use them to help guide me to provide better care for my patients.
References
American Nurses Association. Code of Ethics (2001). Nursing World Journal Provision 3. Retrieved from http://nursingworld.org/ethics/code/protected_nwcoe1115.htm.
Chitty, K.K., and Black, B.P. (2007). Nursing theory: The basis for professional nursing Professional Nursing: Concepts and challenges. (pp.328-347). St Louis, Mo: Saunders. Retrieved July 2014, from CINAHL database.
Hui D, Kim S.,H, Roquemore J,R., Dev R, Chisholm G, Bruera E. (2014). Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer, 120, 1743-1749.doi:10.1002/cncr.28628
McEwen, M., & Willis, E.M. (2011). Theoretical basis for nursing (4th ed.) Philadelphia: Lippincott Williams & Wilkins.
Merriam-Webster dictionary. Palliative. (n.d.). Retrieved July 27, 2014, from http://www.merriam-webster.com/dictionary/palliative
Pugh, D.M. (2014). Ethics at the End of Life. Clinical Nurse Specialist, 28, 201-204. doi:10.1097/NUR.0000000000000058
Ruland C, M., Moore S, M. (1998). Theory construction based on standards of care: a proposed theory of the peaceful end of life. Nurse Outlook. (46):169-175 doi: 10.1016/S0029-6554(98)90069-0
Taylor, R.M. (2013). Ethical Principles and concepts in medicine. Ethical and legal issues in neurology, 118:1-9. doi: 10.1016/B978-0-444-53501-6.00001-9
Walker, A., & Breitsameter, C. (2014) Ethical decision-making in hospice care. Nursing Ethics. Jun 29. pii: 0969733014534873. [Epub ahead of print] doi:10.1177/0969733014534873
World Health Organization. (2009). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en