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A Personal Practice Framework Based on Caring and Compassion
Nurses face daunting challenges in the modern healthcare system, creating both opportunities and challenges for professional practice. In order to address these challenges, nursing professionals often rely on personal frameworks of nursing practice which are rooted in basic concepts of nursing care and the synthesis of nursing theory to guide practice. Even though these nursing practice frameworks can be useful, it is imperative for professionals to first conceptualize these frameworks so that they can be effectively operationalized and placed into every day practice. Since early childhood, I have been interested in a profession where I could help those in need in a caring and compassionate manner. Following is a review of my personal practice framework focusing on the specific theories and nursing concepts, which are personally important for developing my nursing practice.
In developing my personal practice framework, ideas and concepts from nursing theorists including Orem and Watson were used as a foundation for understanding the nursing role. These theories were augmented by the theory of self-efficacy as a means to motivate patient behavior and the use of Lewin's change theory as a means to improve outcomes for the patient. With careful consideration of these theories and their synthesis through the four nursing paradigms, my personal practice framework is provided. Through the application of this framework, it should be possible to provide a solid foundation in developing my practice as a family nurse practitioner. A review of this position is provided to demonstrate how the personal framework can be effective for developing this specific practice role.
Definition of the Four Paradigms of Nursing
In order for one to understand the foundation of my personal practice framework, it is first necessary to provide a review of the definition of the four paradigms of nursing: person, environment, health and nursing. Considering first the paradigm of nursing, Orem's theory of self-care has been selected as a foundation for understanding the importance and role of the person. Libster (2008) reviews Orem's theory noting that this theorist believed in the ability of all persons to engage in self-care or practices which would allow for the development and maintenance of health. Libster goes on to argue that Orem's theory of self-care places the person at the center of care, prompting the need for the nurse to understand the patient and the specific barriers which exist regarding self-care. Placing the person at the center of care creates an environment in which the person and his or her specific needs are the focus of health. This is pertinent to my personal practice framework.
Orem's conception of the environment is also used in the current practice framework. As described by Zrinyi and Zekanyne (2007) Orem believed that the environment encompassed the individual and included all aspects of the individual's life. The environment could be both a support for improving self-care and a detriment to supporting self-care behaviors. Identification of these elements in the environment are critical to providing the support needed by patients to improve their health. By reducing barriers in the environment, the family nurse practitioner can effectively augment the ability of the patient to engage in self-care. This should have implications for both health outcomes of the patient and for building a strong and formidable foundation for long-term patient/practitioner partnerships.
Nursing for this practice framework is conceptualized using Watson's theory of human caring. Sitzman and Eichelberger (2004) provide a review of the theory noting that Watson believed in the caring relationship which developed between the nurse and the patient. Specifically, the nurses caring practices could serve as the foundation for the development of true healing for the patient. By providing these caring practices to the patient, the nurse could effectively engage the patient, create an environment for healing and enable the patient to be present in the caring moment (p. 50). This process is one which has considerable implications for improving patient care and one which is fundamental to the current framework. The essence of caring noted by Watson in her theory is the foundation for nursing practice which should address the patient and environment to create improved health outcomes.
The final paradigm of nursing is health. In developing my current practice framework, health is viewed as something that is possessed by the patient and can be changed with the right support and action on the part of the nurse. Self-efficacy and Lewin's change model are integral to improving health. In this process, Lewin's three stages of change-unfreezing, moving and refreezing-are supported as the foundation for improving health behavior (Levasseur, 2001). In this change process, the nurse would engage in carative behaviors which allow for the development of self-efficacy to improve the health of the patient. Self-efficacy would focus on improving the patient's perceived capabilities in performing a task or improving some aspect of health (Young & Bippus, 2008).
Other Concepts for the Practice Framework
Although a review of the four paradigms of nursing provide a solid foundation for building my current practice framework, there are other concepts which are also important to develop in this process. Because the specific practice area for nursing practice will be as a family nurse practitioner, it is important to consider the concept and definition of family which will be used for the practice framework. Developing a clear understanding of the family will provide more focus in directing care and comprehensively understanding the needs of the patient seeking care.
In defining the family, Corbett (2004) argues that efforts must be made to include a wide range of models in this definition. Specifically, Corbett argues that families include all individuals that live together and work cooperatively to improve outcomes in everyday life. These individuals are typically related biologically in some manner or through marriages in the family; however, it is important to note that some individuals included as family may not fit either of these criteria (p. 5). Approaching the conceptualization of family in this manner allows for a more integral understanding of relationships and for determining the influence that individuals in the environment have on a specific person.
Placing this definition of family into the context of the practice framework it is evident that family will be integrally tied to the environment of the patient. With this in mind, the clinical professional will need to have an integral understanding of the family so that the care provided is reflective of this environment. Further, expanding the definition of family to include all individuals that impact that patient in a significant manner could provide additional supports for improving and changing health behavior. The family will be an essential component of understanding the patient and the specific barriers/assets to care which can be accessed for health promotion.
Putting It All Together
Although the current research provides a basic foundation for the concepts and ideas which will be used in my practice framework, it is pertinent to operationalize the concepts to provide a clear understanding of how the practice framework will work in clinical discourse. The central focus of my practice framework will be the patient and the specific self-care deficits which exist. The patient will present for treatment and the family nurse practitioner will be charged with providing a comprehensive evaluation of the patient to understand the impact of the environment, the role of the family and the specific assets and barriers in the environment which are contributing to the current health status of the patient. This process will include carative nursing practices which will allow me to engage the patient in a positive and meaningful manner.
As the patient progresses through the care process, I will be able to identify critical areas for improvement of the patient which will focus on change to improve health behavior. For instance, a patient with diabetes may be provided with medical support to control diabetes but the nurse practitioner must go beyond this support to provide education and interpersonal change in a caring manner which will facilitate improved health. This will require the nurse practitioner to consider the needs of the patient, the strengths and weaknesses of the environment and the particular carative practices which can enhance the relationship between the patient and the healthcare provider.
Once the nurse practitioner identifies these critical issues, a plan of action for improving health can be put in place. This plan will include the development of specific steps to create health change for the patient-using Lewin's change model-and the utilization of self-efficacy to create the needed health changes. In this process, the family nurse practitioner will be able to continue to use carative interactions and practices which will connect the patient to their health and, over time, create an important bond between the practitioner and the patient which will further facilitate health care exchanges. In this process, healing for the patient will occur that will allow the patient to achieve the highest level of health possible given the specific conditions and needs of the patient.
The Framework and the Family Nurse Practitioner Role
With a basic understanding of how the practice framework will be opertionalized provided, it is now possible to consider how the framework will be applied to the family nurse practitioner role. Novotny, Lippman and Sanders (2003) provide a review of the definition of family nurse practitioners reporting that "family nurse practitioners are advanced practice nurses who specialize in providing health promotion and care to patients in primary care settings" (p. 46). Novotny and coworkers go on to report that the family nurse practitioner focuses on health promotion and disease prevention as central tools for ensuring the health of the patient. This practice occurs across the lifespan and seeks to provide a protective means to improve the patient's health over the long-term. Novotny and colleagues also note the need for strong communication skills in this role and the need for the nurse practitioner to take an active interest in promoting the needs of the patient over the long-term.
Application of this clinical environment to the practice framework noted here, it becomes evident that the practice framework has notable implications for improving the role of the family nurse practitioner. Specifically, the practice framework focuses on the development of the patient as a means to ensure the best possible outcomes for care. The nurse acquires a clear understanding of the patient and his or her environment, engaging with the patient in a carative manner which fosters a positive bond with the nurse practitioner. This process enables the nurse practitioner to provide the patient with the support needed to make critical health changes and improvements through both directing the change process and building the self-efficacy of the patient. Given that family nurse practitioners provide care to patients over the course of the lifespan, the development of care and relationships proposed in the practice framework are commensurate with the specific foundations of nursing roles in family practice.
Practice Framework and Nursing Process
Although there is considerable congruity between the practice framework and the role of the family nurse practitioner, it is pertinent to consider how the practice framework will be used in everyday practice for diagnosis, evaluation and measuring patient outcomes. In reviewing the proposed practice framework, it becomes evident that the focus of practice will be on long-term care and improvement of health practices to promote the comprehensive healing and well being of the patient. With this in mind, it seems reasonable to argue that evaluation of the practice framework will need to include a long-term review of the patient and the changes that have been possible for fostering health. Incremental change which occurs over the course of the relationship with the patient is important not only for indicating the efficacy of the practice framework but also for using these improvements for building self-efficacy.
Diagnosis of the patient will occur through a comprehensive review of the patient's environment and needs. There is a recognition that these issues will change. As such, the nurse practitioner must not only consider initial data presented by the patient, but also the nurse practitioner must review historical data on the patient to identify trends and changes in behavior and needs. This process will require ongoing and consistent review of the patient and the information provided during all clinical visits.
Application of the Framework to Different Patient Groups
The final issue which must be addressed is a review of the application of the practice framework to different patient groups-i.e. age and illness-in the family practice environment. As noted at the outset of this paper, the patient (person) is the central focus of the practice framework. What this effectively suggests is that all other aspects of practice are built on the needs of the patient, the environment of the patient and the specific conditions which exist for the patient. For this reason, it seems feasible to argue that the practice framework could be adapted to meet the needs of any patient in the family practice setting. By making the patient the central focus of practice, the nurse practitioner is able to develop practice based on the uniqueness of each individual.
The practice framework articulated here incorporates a number of nursing and non-nursing theories to support the comprehensive improvement of patient health. The nursing professional clearly has an obligation to address the patient's needs through this process; one which will allow for a complete understanding of patient needs and issues. The current practice framework is flexible enough to be used with a wide range of patients and should facilitate a true connection between the patient and the nurse practitioner.