Debate the utility of the knowledge of nursing theories and associated theoretical concepts in the process of assessing patient’s needs and implementing appropriate care.

Many textbooks and journal articles were written to explain what the models were and how they could be used. However, they were heavily criticised and, in the past 10 years, they seem to have fallen out of favour.

In very simple terms, a model can be thought of as a way of representing reality. For example, model cars or aeroplanes are scaled representations that allow people to familiarise themselves with an object, understand it, and take it apart to see how it works. Models can also represent abstract and complex situations such as models of the economy, health beliefs, or grief and bereavement.

Initially, formal models of nursing were considered as ways of representing what nursing is, what it aimed to achieve and the different components of nursing that could then be taken apart, analysed and understood. The components of nursing – however it may be defined – are complex and, as a result, several models were developed. Each offered a different way of thinking about nursing and each presented a different way of guiding nursing practice.

So, a nursing model could be defined as “a picture or representation of what nursing actually is” (Pearson et al, 1996).

The development of nursing models

Nursing models originally came from the US in the 1960s, where several important social, technological, and cultural events were occurring at the time.

The 1960s was a time of staggering technological development, the most prime example of which was the Apollo space programme. This was a very visible example of the power of science and technology to transform lives. Some of this expertise and achievement spilled over into healthcare, with the advancement of medical technology.

Alongside these technological advances came the civil rights movement in the US, which included women’s rights. The consequences of this included the drive to ensure that more women – and therefore nurses – were educated in universities and an awareness and desire to develop nursing as a separate occupation and as a profession distinct from medicine.

At that time, the idea of what defined a “profession” was heavily influenced by Freidson (1988), who believed that one of the hallmarks was the possession of a unique body of knowledge. The early nurse theorists felt it was very necessary for nurses to be able to show that they had a body of knowledge specific to nursing, and models were one way of achieving this.

Historically, both the theory and practice of nursing had been heavily influenced and dictated by the goals of medicine (Pearson et al, 1996), a position perpetuated through the apprentice-style approach to nurse education.

The “medical model” focused on diagnosis, treatment, and cure of physical disease. Growing concerns among nurses about the suitability of the medical model added impetus to the development of models for nursing (Pearson et al, 1996).

It was anticipated that models of nursing would capture, represent, and articulate the particular concerns and purpose of nursing and develop that all important knowledge base characteristic of professional status (Hodgson, 1992). However, there were several difficulties in the development of such a model, not least of which was an apparent lack of a definition of nursing. This led to Henderson’s definition (Henderson, 1966) being frequently cited, and it formed the cornerstone of the debates at that time. Interestingly, there was also a return to the ideas of Florence Nightingale, one of the earliest and most influential writers on nursing.

In the endeavour to identify and build a body of knowledge unique to nursing, the early nurse theorists and model builders were highly influenced by conventional science. They used “scientific” techniques and shared the goal of trying to develop theories about, or for, nursing that could be “tested” by research. There was also an interest in systematically describing and analysing key concepts considered to be important in nursing practice, which can be seen in the work on the concept of care by Leininger (1988) and Watson (1988).

The arrival of nursing models and the nursing process in the UK can be seen from around the mid 1970s with the publication of influential texts on the nursing process and models (MacFarlane and Castledine, 1982; Aggleton and Chalmers, 1986).

The introduction in the 1970s of the idea of the nursing process as a four stage problem solving method to enhance the delivery of care to the individual was an important vehicle in the application of nursing models to clinical practice (Aggleton and Chalmers, 1986). The values, beliefs and theories for care within a given model of nursing could be used to guide the assessment, planning, implementation and evaluation of nursing care.

The nursing process, like nursing models, was not without its critics. Increasingly, it was questioned whether the proposed linear problem-solving approach to care delivery was a valid reflection of the nature of clinical decision-making, particularly for experienced nurses (Walsh, 1998).

The introduction of care pathways to the UK healthcare setting heralded a significant move away from the nursing process and a potential threat to the ideals of individualised care. However, the concept of a planned, standardised, multidisciplinary approach to care for groups of patients with the same health problem proved popular (Walsh, 1998) and continues to support the current emphasis on quality in healthcare provision (Currie and Harvey, 2000).

Components of nursing models

At a basic level, there are three key components to a nursing model:

• A set of beliefs and values;
• A statement of the goal the nurse is trying to achieve;
• The knowledge and skills the nurse needs to practise (Pearson et al, 1996).

An important first step in the development of ideas about nursing was to try and identify the core concepts central to nursing, then to identify the beliefs and values around those. After extensive debate, there was some favour shown to the idea that nursing consists of four key concepts: person; health; environment; and nursing (see Box 1).

 

 

Nursing models may have these four concepts as their cornerstones but each describes them a little differently. For example, the sets of beliefs and values might be different and hence the goal of nursing and the knowledge and skills required might vary (Table 1).

The early theorists drew substantially on other disciplines to develop their ideas and to give their model a different perspective. For example, Neuman (1995) drew extensively on systems theories in thinking about people as a system that strives for stability. Illness is therefore a stressor which can destabilise an individual, and people then need help from nurses to regain stability.

Peplau (1988) drew on psychological theories to conceptualise nursing as an interpersonal process to help patients with mental health problems. In doing so, she contributed to the recognition of the therapeutic potential of nursing.

Arguably, the most influential and most commonly adopted model in the UK was that developed by Roper at al (1990). This described the person as being capable of performing activities of living along an independence/dependence continuum throughout their lifespan. In this model, the role of the nurse is to assist the individual if necessary to achieve as much independence as possible in these activities. Individuality is an important concept in carrying out the activities of living but this is set in the context of biological, psychological, sociocultural, environmental and politicoeconomic considerations.

There was no attempt to prescribe one model that would fit all of nursing, but each model offered a different picture of nursing. Practising nurses could select – and modify if necessary – a model to serve their needs and those of their patients.

Benefits of nursing models

The introduction and use of nursing models was thought to bring substantial benefits to nursing, nurses and patients. In terms of nursing, it was a serious and committed attempt to develop a knowledge base that would make it unique from other disciplines, in particular medicine. The hope was that, in devising models of and for nursing, theories of and for nursing could be generated, tested and, ultimately, added to the profession’s knowledge base.

Part of this knowledge base would be a set of clear ideas about what nursing is, what its values are, and what contribution it makes to healthcare (Draper, 1990).

While it might not be possible to come up with some kind of grand theory of nursing, it was hoped that there would be a working consensus of what nursing was. It was also hoped that these models would lead to the development of very practical theoretical tools to help nurses in their everyday practice.

Another benefit of nursing models was that they could offer a useful set of frameworks to guide practice and education. When teamed with the nursing process, a model could give shape and a structure to the nursing assessment, enabling a focus on the patient and allowing clear identification of the nursing problems and hence the nursing care the patient required. Such a framework would also guide the planning, implementation and evaluation phases of the process.

For example, using Orem’s model, nurses would assess patients for their individual self-care deficits and plan an appropriate set of interventions to help them to overcome and restore their self-care deficits as much as possible. In this example, the process of nursing would be clearly focused on the concerns of nursing and not other disciplines such as medicine.

Such was the importance of nursing models in the 1980s and 1990s that clinical areas had to be seen to be using a nursing model and some educational institutions structured their whole pre-registration curriculum around one. This was partly because the selection of a nursing model gave some guidance on the knowledge and skills required to deliver care.

For example, the use of Peplau’s model in a mental health programme would emphasise that nursing is potentially a therapeutic, interpersonal process; the curriculum would focus on the knowledge and skills needed by the nurse to provide that kind of nursing care. A general nurse training programme based on Neuman’s system model would emphasise the need to assess the patient for the stressors affecting them and provide appropriate interventions to offset the effects of these stressors. The use of a model would also potentially lead to a common language to allow nurses to discuss nursing practice.

Finally, for patients, it was considered that they would receive systematic nursing care, clearly focused on their needs, and in which the unique nursing contribution was clearly articulated and demarcated.

Criticisms of nursing models

Initially, nursing models such as the nursing process were vigorously endorsed in the UK (Aggleton and Chalmers, 1986; UKCC, 1986). However, despite the early enthusiasm associated with their development, models of nursing receive some significant criticism from a number of sources (Miller, 1984; Draper, 1990).

These criticisms can be categorised into intrinsic and extrinsic, depending on the nature of the criticism. Intrinsic criticisms relate to the model itself, which may include factors such as the language used in the model or the beliefs and values. Extrinsic criticisms are related to factors that are external to the model, such as the approach to implementation, attitudes to change, and the motives for developing nursing models.

Intrinsic factors

Nursing models received criticism for their frequent use of jargon and complex concepts, which did little to endear them to UK nurses (Kenny, 1993; Hodgson, 1992). As an example, Neuman (1995) uses the terms intra, inter and extra-personal stressors which have the potential to affect the system (or the person) which has a central core, lines of resistance and two lines of defence. In addition, Orem (1991) includes a number of complex terms such as health deviation, universal and developmental self-care requisites, self-care deficit, dependent-care deficit, and wholly, partly compensatory and supportive-educative nursing systems.

Such complex concepts and terminology had to be grasped and understood before the models could be used effectively in practice. Yet Hodgson (1992) concluded a significant problem was that models “leave us puzzling over the ridiculous use of English and ideas so embedded in terminology as to be inaccessible”.

Another criticism of nursing models was related to their origin in the US. Questions were raised about their underpinning philosophical beliefs and values, and their applicability and transferability to British nursing (Kenny, 1993; Draper, 1990). For example, the concept of self care in Orem’s model assumed a willingness and motivation on the part of individual patients to manage their healthcare needs to an extent, which sat well in the US healthcare system at that time.

However, the NHS historically has a less individually centred approach, with explicit financial responsibility for care costs and a greater emphasis on state or government responsibility for health. This meant the notion of self care as described by Orem was alien to British nurses and patients in the 1980s and 1990s.

Nursing models represented specific values and beliefs about nursing held by individual authors. Subsequent critical analyses have suggested these to be rather narrow perspectives that fail to capture what nursing is (Hardy, 1982).

The irony here is that one of the main reasons for the development of nursing models was to capture and articulate the nature and contribution of nursing as a discipline (Tierney, 1998). Yet Miller (1984) argued that models were idealised, lacked relevance to the reality of nursing practice and, as such, increased the gap between theory and practice.

Models of nursing also received criticism for the lack of research underpinning and supporting the relationships between the concepts and the effects on patient care (Fraser, 1996). As a result, models remained at a descriptive and explanatory level at best and failed to serve a practice-based discipline like nursing (Dickoff and James, 1968).

Draper (1990) also suggested that the application of theories from other disciplines undertaken by academic nurses to explain nursing was inadequate.

He and others argued for inductive theory generation derived from the practice of British nurses and the reality of contemporary British practice (Miller, 1985; Draper, 1990). Following this logic, the end theory would be more useful, valuable, and readily embraced by practitioners.

Extrinsic factors

While some of the criticisms focused on the nature of models themselves, the approach to implementation in the UK also received critical attention. Kenny (1993) highlighted the “top-down” strategy used to introduce nursing models, which prevented a sense of ownership by nurses and created a significant barrier to success.

Another contributing factor was the lack of educational preparation and in service training for practitioners in the use of models, which, together with resistance to change, posed significant barriers to their successful implementation (Kenny, 1993). Reflecting on the nature, approach, and attitude towards change and the bureaucratic environment of the NHS, Kenny (1993) also questioned whether nursing models stood any real chance of success.

Further scepticism of nursing models was derived from the perception that their purpose was primarily to advance the professionalisation of nursing (Hodgson, 1992) rather than improve patient care.

Conclusion

Models of nursing represented an important stage in the development of nursing theory and the development of nursing as a discipline.

The criticisms they generated were an important part of the professional debate and advancement of nurses and nursing. It could be argued that some of this criticism arose from a lack of clarity as to the aim and purpose of nursing models and their implementation, rather than the concepts and ideas within them.

Nursing models may therefore incorporate fundamental concepts, values and beliefs about nursing that are pertinent to contemporary nurses and the next article in the series examines this further.