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As health care professionals it is essential that Registered Nurses use well developed and tested theories to guide their practice. As put by McEwen (2011, p.375) "Theory provides the basis of understanding the reality of nursing; it enables the nurse to understand why an event happens." Utilizing the research and theory of nurses is what makes us unique and an in disposable resource to the health care team. In fact, there is a two part study, the first by Murphy et al. (2010) and the second by Pridmore et al. (2010) in which the team analyzed the use of nursing models in contemporary nursing practice. In the first section the team talked about the use of theory in past and present nursing and determined that as nurses we are moving away from the use of nursing theory and simply completing skills for patient care. After careful research into the use of theory the study concluded that using nursing theory guides the nurse to use holistic assessments and approach their care in a systematic way. They also said the nursing models make the profession unique and distinct from other disciplines. Therefore, the purpose of this paper is to give the writer an opportunity to apply the Conceptual- Theoretical- Empirical (CTE) process to practice through a hypothetical case study. This will make the writer think about how to apply theory to their own practice and realize the importance of nursing theory. The paper will introduce the topic of the CTE process then introduce a case study that will incorporate the PEI Conceptual Model (PEICM). Following this, will be an analysis of the Theory of Community Empowerment and how it is currently being used in nursing practice as well as how it applies to the case study. To conclude the CTE process will be critiqued including a discussion of the strengths and weaknesses of using the CTE process for practice settings.
Introduction to the CTE Process
The CTE process is simply a way for the nurse to apply a conceptual model, middle range theory, and empirical indicator to their practice in an organized way. The nurse uses the process to guide their practice and in time the process should become second nature to the nurse. The process does not have to follow a certain sequential path such as CTE, if needed the process could be TCE or any other sequence. (Murnaghan, 2010) To begin we will look at what CM, MRT, and EI will be used throughout the paper.
When selecting the proper CM for the setting you are working in it is important to assess certain factors, such as, does the content (concepts) of the model match with the mission statement of the setting and is the philosophical background of the model congruent with the setting (Murnaghan, 2010). For the purpose of this paper the Prince Edward Island Conceptual Model for Nursing (PEICM) will be used. This model has its roots at the UPEI School of Nursing and was developed passed on the principles and philosophy of primary health care (PHC). Like all true nursing theories the PEICM defines the four metaparadigm concepts of nursing, but what makes it unique is that they are defined based on PHC. (Munro et al, 2000).
Person. When practicing under the PEICM person can be an individual, family, group, or a community. The individual is seen as being a holistic being that is unique biologically, psychologically, socioculturally, spiritually, and developmentally. Family is two or more people brought together by birth, placement, or mutual consent and have unique characteristics. A group is two or more individuals that are brought together by a certain purpose. Finally a community is a large number of individuals that live in the same geographical location. However it is not simple location that makes a community, a community is brought together by a shared age, religion, culture, or occupation. Communities range from groups of families living together to a world community. (Munro et al, 2000).
Health. In the PEICM health is viewed as a wellness and illness in a dynamic relationship in which the two can co-exist. This means that even if an individual is seen as ill they can still be well in other areas. For example after a successful surgery a person could be physically in pain but emotionally they could be fine, even happy. (Munro et al, 2000).
Environment. The environment of an individual is directly linked to the influence of the determinants of health. In other words the environment is the socio-political factors that affect where an individual lives, works, plays, and learns. (Munro et al, 2000).
Nursing. Nursing is the promotion of wellness and the prevention of disease by following the five principles of primary health care. Which are accessibility, public participation, appropriate technology, wellness promotion and illness prevention, and intersectoral collaboration. Nursing care is providing in a process beginning with assessing, followed by identifying the health concern, planning, implementation, and evaluation. (Munro et al, 2000).
Key Assumption of the PEICM. The PEICM outlines 16 key assumptions; there are a few however that are important to the application of the setting outlined later. They are; "Clients have the potential to become active participants in problem-solving on behalf of themselves or others" (Munro et al, 2000, pp.42 (Munro et al, 2000, pp.42), and "Clients are partners in their own health care." (Munro et al, 2000, pp.42) For a list of all the assumptions of the PEICM refer to Appendix A. (Munro et al, 2000). As you will see the reason these assumptions are of particular interest is because they are all assumptions associated with empowerment.
Middle Range Theory
The MRT theory that will be used is The Theory of Community Empowerment, developed by Cynthia Armstrong Persily and Eugenie Hildebrandt. The theory was developed in hopes to aid communities in increasing their health care knowledge and decision making skills (Smith & Liehr, 2008). The theory originated when Persily approached Hildebrandt to discuss the possibility of developing a middle range theory based on the study by Hildebrandt (1996). In the study Hildebrandt used the Community Involvement in Health model to build community participation in an African community. In the conclusion of the study Hildebrandt states that empowerment was an effective way to increase participation however the model was too broad and a practice model may be needed (Hildebrandt, 1996). Since then they have developed the MRT and are currently working on expanding the theory through research and application to practice. Empowerment has many definitions and depending on the context it can be a complex concept. As far as community empowerment there are a few definitions in the literature. An older definition taken from Hildebrandt's 1996 study stated that community empowerment is when the health care professional shares control with the community to make members effective managers of their own health. In a more recent study by Hildebrandt (2002) empowerment was explained in terms of the PHC principle of community participation, which is working with the community to develop skills that will allow them to gain mastery over their own health. It is also important to note that empowerment has been a key aspect of community health nursing in the literature and one text in particular outlined the barriers to empowerment. Some examples include, past intervention in a community that were not successful could hinder participation, cultural differences between community and health care workers could cause a lack of trust, resistance to change, and difficulty of measuring progress or outcomes (Israel et al., 2004).
To reach the goal of empowerment the theory is based on three major concepts, the use of community lay-workers in increasing health, community involvement, and reciprocal health. Community lay-workers are trained to work with members of the community to help the nurse increase self-care and participation in health care. Community involvement is the identification of health concerns by the community with assistance from the nurse. It also includes the planning, implementation, and intervening to overcome health concerns and reach goals. Reciprocal health is when a community reaches its full wellness potential their active participation. (Smith & Liehr, 2008)
The empirical indicator (EI) that will be used is the REALM-R developed by Bass et al. (2003). This health education tool asses the health literacy of an individual in as little as 2-3 minutes making it a very quick and effective tool.
As a public health nurse you have been assigned to a population health project focused on reducing the incidence of high blood pressure with your community. Through a community needs assessment completed it was determined that the community you are working in has a large population diagnosed with high blood pressure. As a nurse it is your job to work in partnership with the community as a whole to reduce the incidence of high blood pressure through empowerment. To complete this goal you will use the Theory of Community Empowerment and the PEICM to guide your practice. You will start your planning by setting up focus groups in the community to work with the members to determine what they feel is the best plan of action. Through the focus groups it was determined that more education was needed around the risk factors of high blood pressure as well as was to reduce blood pressure. Your first goal is to find members of the community that you can train as lay-workers. These lay-workers will be aimed with the task of determining what level of health literacy the community is at. Therefore you must train the workers to use the REALM-R screening tool. Then from the results of the screening tool the nurse will be aware as to what type of education tool will best fit the community's needs.
The Rapid Estimate of Adult Literacy in Medicine (REALM-R) is a short screening tool that is clinical tested and displays the potential to identify health illiteracy in patients (Bass, Wilson, and Griffith, 2003). Some strengths of the screening tool are that it is quick and easy to administer, can take as little as 2-3 minutes to explain and complete. This makes it easy to train the lay-workers to use the tool because no extensive training would be required. Also because it is quickly completed lay-workers can spend more time talking to the client about their health concerns and educating them about those concerns. The major limitation of this assessment tool is the fact that it only assess the patients health literacy level, it does not assess their comprehension level. One study suggested that a more in-depth assessment tool should be used such as the Test of Functional Health Literacy in Adults (TOFHLA) (Gannon, & Hildebrandt, 2002). Using a more elaborate test such as this would allow the nurse to assess the literacy of the individual as well as their reading comprehension. The downfall however is that due to the increased comprehensiveness of this tool it would take longer to complete and it would be harder to teach the lay-workers how to use it. This EI fits with the MRT because education is an excellent way to empower patients. In order to educate patients with the best possible outcomes it is important to have an understanding of their literacy level. This will determine what kind of educational material you provide as well as how you deliver your education. Also due to the simplicity of the screening tool it would be easy to train lay-workers to use the tool in the community, again linking the EI to the MRT. The EI also allows for community involvement which is another concept of the MRT as outline above. The information gathered from this screening tool will be used in the development of an intervention making the community involved in the planning process of the health promotion project.
Applying the CTE Process to Case Study
The first step that the public health nurse would take is to determine if the CM they have chosen is congruent with the mission statement of their practice setting. As a public health nurse one of the main goals of your facility is health promotion through education. This is congruent with the PEICM which has a strong emphasizes on wellness promotion. In fact wellness promotion is the act creating an environment in which the client can reach their full potential through gaining control over their health care (Munro et al., 2000). This then links the MRT to the practice setting as well due to the fact that wellness promotion is an act of empowerment.
So to tie it all together we will go through the steps of the nursing process outlined in the PEICM. First is your assessment. In this case a needs assessment was completed in the community and it was determined that high blood pressure was of concern to the community. This takes care of identifying the health concern which is the second step. The third step is planning and this is where the MRT comes in. In the planning phase the nurse needed to determine what the community felt was the greatest need to lower blood pressure. Focus groups would allow the nurse to get input from a large population in a short amount of time. This also allows the community to have some control as to what kind of intervention should be planned. As we learned giving control back to the community is key to empowerment. Next is implementing know that the community has decided that more education is needed the nurse can get started planning and implementing an educational tool. However before she can do this it is important to know the literacy level of the community. Using lay-workers at this point incorporates the MRT. Lay-workers can use the EI to quickly gain data as to the health literacy level of the community. After the data is collected the nurse can implement the intervention at the appropriate literacy level. Then when the program needs to be evaluated (the final step of the nursing process) the nurse can once again use the lay-workers to go into the community to determine if the community found the intervention helpful.
Analysis of MRT
There are several reasons as to why this MRT is congruent with the PEICM; first the main goal of the MRT is to empower the community to reach their full potential (Smith & Liehr, 2008). This concept is congruent with the PEICM and the underlying framework of PHC which has a philosophy of guiding individual, groups, and communities to control their own health (Munro et al., 2000). Also the MRT is focused on the health of the community and treats the community as a whole. The PEICM defines person as an individual, group, or community, person does not have to be a single being.
Like all things there are strengths to using the CTE process to guide nursing are and there are limitations. For this case example some of the strengths would include the strong congruence between the MRT and the PEICM. For a public health nurse working on PEI that has completed their education at UPEI it would be easy to utilize the MRT of Community Empowerment. The nurse would have used the PEICM throughout their education therefore; they would have a strong understanding of the CM and could easily apply the MRT to their practice because of this. However like all things there are also limitations to using theory to guide practice. Some nurses just don't believe that theory should guide their practice therefore it would be difficult to apply the CTE process to that setting. Also if the nurse is not trained in the PEICM it would be difficult to implement the CTE process in this case example. Literature has shown that a significant barrier to application of theory is lack of training in the use of nursing models and resistance to change (Kenny, 1993). Another barrier to applying nursing theory is that some nurses believe that nursing theory is used largely to enhance the professionalism of nurse and is not really of benefit to patient care (Hodgson, 1992).
In the end the most important question a nurse needs to ask themselves is, what is best way to care for my patient? As this paper shows the answer to that question is through tested, researched, and sound nursing knowledge based on nursing theory and models. It really is common sense that the best way to provide "nursing" should be through the use of "nursing knowledge". The CTE process is an excellent way for the nurse to determine what model, theory and empirical indicator would work best or their practice setting. At first it may seem like a lot of work to apply this process to every patient you care for, but, like nursing skills such as intramuscular injection or IV therapy the CTE process will be become instinctual. For example when a school of nursing utilizes a CM to guide the education of their students, the students start to use the CM in their everyday practice without much thought. As for the application of the theory of community empowerment there is still some work to be done. The theory has a great foundation and could be utilized in many practice settings in particular the public health sector of nursing. However, because the theory is relatively new there is not enough theory to back it up. In the future this theory would be an excellent choice to guide the practice of public health nurses. So what is the best way to care for your client? Well, just apply the CTE process to your situation and you will have your answer.