Contemporary Issues in Coronary Care Nursing

Fiona Timmins

• Publisher: Routledge
• Year: 2005
• Print ISBN: 9780415309714
• eBook ISBN: 9781134391332
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

In this text, Fiona Timmins integrates the findings of recent nursing research with key aspects of the nurse's role. She provides an evidence-based rationale for the best ways of improving cardiac care (in general and for specific conditions), describes important nursing initiatives to reduce the risk factors and presents a needs-based approach to patient education. Concerned with the need to bridge the current research-practice gap in coronary care, she knows how nurses can make the best use of available research and describes the advances that are being made in nurse-led services in this area. Contemporary Issues in Coronary Care Nursing offers a non-medical approach to coronary care and is informed throughout by the latest nursing theory and research.

Chapter 1
Nursing theory in coronary care

KEY POINTS

• The utilisation of nursing theory and conceptual models of nursing is necessary for the advancement of nursing.
• The implementation of conceptual-model-based practice requires a rigorous, systematic and collegial approach.
• The selection of a conceptual model for practice is dependent upon the beliefs and values held by the organisation or department.
• Critical appraisal of conceptual models is an essential component of the utilisation process.

Introduction to nursing theory

Nurses are responsible for the care they provide for their patient. They have to be active, competent and autonomous in providing this care and be able to justify what they do. It is no longer acceptable for nurses to base care on ritual and tradition—they must be able to justify the decisions they have made about appropriate care and treatment on the basis of professional expertise.

(McSherry et al. 2002: 1)

Stewart (2002) suggested that cardiac nursing is ‘at a crossroads of an important moment in its history’. Having abandoned what he terms ‘archaic’ rituals such as confining patients to bed following myocardial infarction, he suggests that nursing ‘can be proud of its efforts to create new ways of caring for patients’. However, the extent to which nursing has abandoned these rituals and adopted new practices is unclear. This notion of ritualistic or task-oriented care, although perceived as predominantly a feature of the past, is a potential feature of new nursing roles. The expanding cardiovascular nurse roles (Riley et al. 2003) within Europe, although welcome, are often not standardised and are unregulated. As a result some of these roles involve little more than the performance of junior doctors tasks.

This point was highlighted by a leading cardiac nurse/academic, Thompson (2002), who stated that many new roles of cardiac nurses ‘have developed organically…without any systematic planning or evaluation’. He also highlighted that ‘there is a danger that [in these roles] nurses focus solely on particular aspects of medical treatment rather than focus on the totality of patient care’. He suggests that current evaluation of many of these roles indicates that they pay little attention to the ‘important contextual factors’ such as the person and environment.

Nursing has long been associated with the use of rituals and tradition, and although these have declined in many areas of nursing they still prevail (Riegel et al. 1996, Jacobson 2000, Strange 2001). There are a variety of reasons for this—lack of autonomy, lack of knowledge, hierarchical systems and avoidance measures, to name but a few. Little consensus exists regarding their exact origin, however, there is consensus that nursing needs to move away from these traditional operating frameworks towards evidence-informed nursing.

Evidence-informed nursing is ‘the integration of professional judgement and research evidence’ (McSherry et al. 2002:3). It requires nurses to be ‘knowledgeable doers’ and have a ‘systematic approach to providing nursing care’ (McSherry et al. 2002:3). Nurse theorists have long advocated for the use of nursing theory to inform a systematic approach to nursing care. Nursing theory offers researchderived evidence to inform the nursing knowledge base (Fawcett 2003). Stewart (2002) suggests that nurses in general and cardiovascular nurses in particular need to begin to generate new theory to inform practice.

Nursing theory offers nursing a distinct scientific knowledge base to guide practice. Without the use of nursing theory to guide practice, the work of the nurse may be oversimplified. In addition, nursing in some situations may appear as a discrete set of tasks or orders, thus under-estimating the complexity of the role. Given the increasingly medical aspects of some cardiac nursing roles as described by Thompson (2002), it is time therefore to consider the potential contribution of nursing theory to coronary care nursing.

There is considerable discussion and debate, within the nursing literature with regard to the usefulness of nursing theory to inform nursing practice. Fawcett (1999) expressed concern with today’s nursing practice, suggesting that there is little evidence of nursing theory occupying what she describes as its true position as the central tenet of nursing practice. The fact is supported anecdotally in coronary care practice, where there is lack of consistency of both use and application of nursing theory.

Fawcett (1999) and Alligood (2002a) both strongly advocate that nurses base their practice upon nursing theory. Fawcett (1999) suggests that ‘It has become increasingly clear to [her] that the discipline of nursing can survive if, and only if, we end our romance with medical science and the conceptual frameworks and theories of non-nursing disciplines’.

Fawcett (1999) would like all nurses to ‘embrace’ nursing theory and conceptual models to ensure survival of the discipline. The author recommends that all nurses must ‘fall in love with nursing science now and develop a passion for the destiny of the discipline of nursing’. Conversely, Cormack and Reynolds (1992:1473) suggested that the use of conceptual models and theory ‘provides no more than a pseudoscientific respectability’.

Despite Fawcett’s (1999) and Alligood’s (2002a) commitment to the development of nursing practice through nursing theory and conceptual model use, there is opposition within nursing to this view. Rawnsley (1999) in response to Fawcett’s paper, rejected the notion of a purist knowledge base for nursing in favour of a more inclusive approach to nursing that draws on many areas of knowledge other than nursing. Similarly, Heath (1998) highlighted that many theorists have become preoccupied with the role of theory development in raising nursing’s professional status rather than concentrating on what is best for the patient. Heath (1998) dismissed Fawcett’s views regarding the need for a distinct body of knowledge to guide nursing and develop the discipline, as extreme. Much criticism of nursing theory and conceptual models of nursing also emanates from scholars who hold post-modern views (Timmins 2002).

The debate continues, however, from a practising nurse’s perspective. Current evidence suggests that the use of theories and conceptual models of nursing may be a useful adjunct to practice and therefore should be embraced. Their development and use for cardiac nursing is also advocated (Fawcett et al. 1992, Stewart 2002, Timmins 2002).

The development of nursing knowledge has been a prevalent theme in the nursing literature for the past 30 years. Prior to the gradual development of nursing theory and conceptual models in the USA in the 1950s, Alligood (2002a) suggests that nursing practice was based on principles and traditions passed on through apprenticeship education and common-sense wisdom that came with years of experience. Although some nurse leaders aspired for nursing to develop as a profession and an academic discipline, ‘nursing practice continued to reflect vocational heritage more than professional vision’ (Alligood and Marriner-Tomey 2002a: 5). The latter have suggested that theory development in the USA has contributed to the transition of nursing from vocation to profession.

Although the USA has been largely responsible for theory development within nursing, it is recognised that scholarly work came from within Europe as evidenced by the plethora of nursing journals disseminating the research endeavours of many countries. Alligood (2002a) suggested that it is difficult to compare theory development within Europe to the USA. From an academic perspective, Europe has integrated nurse education into university settings less universally and at a slower pace than in the USA. As nursing schools within Europe began to formalise links with third-level institutes from the 1960s, nurses holding doctorate degrees were in the minority. This embryonic nature of postgraduate development of the profession as a whole has the effect of limiting scholarly activity (Treacy and Hyde 1999). The slow development of nursing science within Europe was highlighted by Evers (2002) suggesting difficulty with transference of American knowledge due to language and lack of empirical testing of American theories of nursing.

Despite the relative naivety of European nurses in theoretical and empirical development and the difficulties noted by Evers (2002), the American perspective on the profession of nursing and its theoretical base has been readily embraced in many areas. The work of many American theorists has been translated into several languages, and theories emanating from the USA are widely used throughout Europe (Fawcett 1995).

One theory of nursing developed in Edinburgh and forming the basis for the Roper-Logan-Tierney (RLT) model of nursing (Roper et al. 1980, 1985, 1990, 1996) is widely used throughout the UK and Ireland. Its recognition and inclusion in one recent text (Alligood and Marriner-Tomey 2002b) may indicate growing recognition by the USA of the presence of theory emanating from outside.

What is nursing theory?

Florence Nightingale (1820–1910), who laid the foundations of theoretical development in nursing, suggested that ‘the most important practical lesson that can be given to nurses is to teach them what to observe, how to observe, [and] what symptoms indicate improvement’ (Nightingale 1992:59), thus indicating the importance then, as now, of a systematic and methodical approach to nursing care. She described how patients who had a lot of information to give would provide little to the nurse if the questioning technique was poor and unfocused. She went on to describe ‘how few there are who, by five or six pointed questions, can elicit the whole case and get accurately to know and to be able to report where the patient is’ (Nightingale 1992:61). Observation features highly in her writings and she suggests careful and detailed observation with use of directive questioning can lead to appropriate diagnosis. This notion of guiding nurses’ observation towards accurate diagnosis underpins much of today’s nursing theory.

Nightingale (1992) also argued that nursing had a distinct function outside of medicine in the observation and treatment of patients, prevention of disease and evaluation of care. These words were written in a less sophisticated healthcare environment; however, discerning what constitutes nursing and the notion that nursing is more than the administration of medical orders are themes that permeate the text, and have occupied nurse theorists for decades.

One prime motivator for the development of nursing theory in recent decades is the belief that, although nurses work in parallel with many other healthcare professionals, they assess, plan, implement and evaluate care in their own right. Using nursing theory to guide this process provides a suitable theoretical framework with which to conceptualise, describe and inform the unique contribution of the nurse in healthcare settings.

The complexity of contemporary nursing practice requires a systematic approach that complies with current trends of patient-centred care. Application of theoretical works to nursing practice serves to clarify the nurse’s function in nursing situations and provides a rationale for nursing actions. It also offers a unique perspective of the patient that is holistic and not disease focused. The use of a conceptual model prescribes a systematic approach to care based on sound theoretical principles, with particular emphasis on assessment, planning, implementing and evaluation of care. However, there are difficulties with the understanding and application of these concepts in practice.

Confusion exists with regard to differentiating between conceptual models and theory (Fawcett 1995). The terms are often used interchangeably, and while many theorists outline both a theory and a conceptual model, significant differences exist in the definition and understanding of both (Fawcett 1995).

Practising nurses are most familiar with the use of conceptual models. These are one component of what Fawcett (1995) termed a structural hierarchy of nursing knowledge. Fawcett’s (1989, 1993, 1995) work was pivotal in developing nursing’s understanding of conceptual models. This important contribution was acknowledged by Alligood who suggested that Fawcett developed ‘a paradigm explanation of the interconnectedness of the various nursing theoretical works…which began to clarify different levels of abstraction…’ (2002a: 8).

Fawcett (1995) stated that conceptual models form the fourth component in a hierarchy; the first component is the metaparadigm, the second is philosophy, the third is theory and the fourth is conceptual models (Box 1.1). The metaparadigm outlines global concepts that identify what phenomena are of interest to any discipline. This is the most abstract level of knowledge in the hierarchy. It specifies the main concepts that encompass the subject matter and the scope of the discipline. In nursing, these are the person, the environment, health and nursing (Alligood and Marriner-Tomey 2002c).

These concepts form the four central areas of interest to nursing (Fawcett 1995). The person is the receiver of care, including individuals, families and communities. The environment is the person’s family, physical surroundings and the healthcare setting. Health is the ‘person’s state of well being…’ (Fawcett 1995:7). Nursing is that which is done by nurses for the patient.

The concepts of a metaparadigm are extremely broad. They serve to represent the views within a discipline, and distinguish a domain which is very different from that of other disciplines, but its purpose is not to provide direct guidance to practice (Fawcett 1995).

Philosophy is the second component in the structural hierarchy of contemporary nursing knowledge (Fawcett 1995). It may be defined as a statement of beliefs and values (Kim 1983). The path from the metaparadigm of the discipline to philosophy is non-linear, i.e. philosophy does not follow directly in line from the metaparadigm, and does not directly precede conceptual models. Rather a cyclical relationship exists. The metaparadigm identifies areas about which philosophical claims are made. The unique focus and context of each conceptual model then reflects the underlying philosophy (Fawcett 1995).

The next component in the structural hierarchy of nursing knowledge is theory. Theory is a concept devised for a particular purpose. In nursing this purpose goes beyond description to theory that informs the nursing situation. Theory, although abstract, is capable of being translated into reality. Theory is a proposed structure that shapes and guides reality. This structure is made up of things and situations that constitute the theory (Dickoff and James 1968).

Theories that are broadest in scope are called grand theories. These are made up of rather abstract and general concepts and propositions that cannot be generated or tested empirically. Middle-range theories are narrower in scope and contain a limited number of concepts which are empi...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• Foreword
• Chapter 1 Nursing theory in coronary care
• Chapter 2 Planning nursing care
• Chapter 3 Care plans for specific cardiac conditions
• Chapter 4 Role of the nurse in risk factor management
• Chapter 5 Patient education in coronary care
• Chapter 6 Research utilisation in coronary care
• Chapter 7 Nurse-led services in coronary care