Role of the nurse: introducing theories and concepts Frank Crossan, Alna Robb Abstract This article is a descriptive analysis of the work of nurse theorists in relation to the role of the nurse. It is clear from the literature that nursing is difficult to define but it is possible to identify the core values of nursing and the commonalities that run through the profession. The core components identified by an examination of the literature are the development of systems for the delivery of care, coordinating care, teaching, defending the frail and vulnerable, caring for the ill and the well, and providing technical care. This article aims to provide a baseline picture of what nursing is and how it is described in nursing models allowing readers to examine and compare their own values and image of nursing with what the theorists have written. Frank Crossan is Clinical Services Manager, Surgical Directorate, Falkirk and District Royal Infirmary and Alna Robb is Lecturer, Department of Nursing Studies, University of Glasgow From the literature available it is apparent that the role of the nurse is not easily defined with theorists from within the profession failing to agree on the exact nature of nursing (Antrobus, 1993). Some place the emphasis of the role on the concept of caring (Kitson, 1987) and therapy (McMahon, 1991; Pearson, 1992), while others indicate that the role is more diagnostic and technical, remaining disease-centred rather than person-centred (Bortoff and DCruz, 1984). Antrobus (1993) believes that the way forward is to develop the body of nursing knowledge as this will enable nurses to articulate what they are and what they do. The use of nursing models as a base for the practice and development of nursing knowledge is being increasingly criticized and questioned by nurse scholars for not providing realistic descriptions of nursing (Robinson, 1990; Draper, 1992; Kenny, 1993). However, in terms of defining the role of the nurse, examining the contents of these models provides a useful challenge. Smith (1982) states: a general theory of nursing or a general model of nursing which encompasses the entire profession is to be rejected. This statement is justified on the basis that the diversity in nursing precludes the emergence of a general theory of nursing. Castledine (1994a) reiterates this point suggesting that a definitive and unified theory of nursing can never exist and we should accept that there are multiple views about the ways in which nursing is perceived and described. He also believes that nursing is a complex concept that is so intricate in its constitution that it may not be possible to encompass its full meaning in any definition. Meleis (1985) categorizes the major nurse theorists and their models using the following headings: Needs theories Interaction theories Outcome theories. This framework provides a structure for the examination of nursing models and ideas when attempting to identify how the role of the nurse is described. NEEDS-BASED THEORY The difficulty in describing and defining nursing was identified by Florence Nightingale (1952) in her work Notes on Nursing. She suggests that nursing is complex and multifaceted and that its full meaning needs exploration: I use the word nursing for want of a better the very elements of nursing are all but unknown. Roper (1994a) summarizes Florence Nightingales ideas about nursing in the following way: The requirements and needs of sick and healthy people are central to nursing The environment of people is a legitimate concern Skill of observation does not make a good nurse but without it a nurse would be ineffective. Roper (1994b) suggests that Nightingales ideas remain an important part of nursing and underpin much of the present role of the nurse. She states: 608 BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10
ROLE OF THE NURSE: INTRODUCING THEORIES AND CONCEPTS Today over a hundred years later, observing has become part of the assessing, implementing, and evaluation phases of the process of nursing. To use this method nurses can select from a variety of conceptual models of nursing. In current nursing curricula there is an emphasis on promoting health and preventing ill health, and on the sociocultural and politicoeconomic context pertaining to the environment in which nursing takes place. One of the most widely quoted descriptions of the nurses role is that of Virginia Henderson (1966): The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do so in such a way as to enable him to gain independence as rapidly as possible. Hendersons work is described as the watershed between the past and the future of modern nursing (Marks-Maran, 1992). Henderson describes the nurse as an independent practitioner but she emphasizes that nursing care is carried out as part of the wider medical plan. Aggleton and Chalmers (1988) suggest that these two nursing functions do not fit easily together and result in a confused image of nursing. However, it could be argued that these two roles are complimentary and essential if the nurse is to play a significant part in the multidisciplinary team. Roper et al (1980) describe the role of the nurse in terms of independent practice, but point out that at times the nurse may fulfil a dependent role (e.g. assisting doctors), and an interdependent role as part of the multidisciplinary care team with the emphasis being on assisting and enabling individuals to carry out activities associated with living. Orem (1991) also subscribes to the view that a major part of the nurses role is enabling individuals to care for themselves and describes five aspects of nursing: acting and doing for the patient; guiding; providing physical and psychological support; providing an environment to promote development; and teaching people to care effectively for themselves. McFarlane and Castledine (1982) propose that nursing involves prescriptive activities but point out that the major role of the nurse is to assist the individual, or community, in the maintenance of health and wellbeing, with particular reference to basic human physiological, psychological and social needs. The needs-based models of nursing are criticized for their dependence on the medical, physical and curative aspects of care (Cavanagh, 1991) with others (Melnyk, 1983) indicating that the description of the nurses role contained in some models (e.g. Orems, 1991) suggests that the function of the nurse is guided by the prescriptive activities of others, such as medical staff. Wright (1990), however, argues that the helping and assisting aspect of the role described by such theorists is essential and basic to the nursing function. Roper (1994b) reaffirms her ideas about the role of the nurse when she states: I am still convinced that there is a nurse-initiated core of nursing that concerns patients problems with every day living activities. Many patients also require derived nursing interventions. She suggests that if nurses accept this they will be able to conceptualize nursing more realistically. INTERACTION THEORY Interaction theorists place the emphasis of nursing on the establishment and maintenance of relationships. Crucial to these theories is the impact of nursing on patients and how they interact with the environment, people and the situations in which they find themselves. Nurse theorists as diverse as King, Orlando, Travelbee and Weichanbach can be grouped under this heading (Kitson, 1992). Orlando (1961) asserts: The function of professional nursing is conceptualized as finding out and meeting the patients immediate need for help. This is achieved by using the nursing process which, according to Orlando, comprises three major elements: the behaviour of the patient; the reaction of the nurse; and the nursing actions that are designed for the patients benefit. The interaction of these elements is, in The needsbased models of nursing are criticized for their dependence on the medical, physical and curative aspects of care...with others...indicating that the description of the nurses role contained in some models...suggests that the function of the nurse is guided by the prescriptive activities of others, such as medical staff. BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10 609
In general hospitals... the sick persons priority is more likely to be relief of physical symptoms as opposed to expression of understanding or learning about the symptoms in an all-embracing, caring relationship with a nurse. essence, nursing. The emphasis on the relationship as the cornerstone of the nursing role (Orlando, 1961) is also supported by the work of Travelbee (1971), who describes nursing as:...an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering and, if necessary, to find meaning in these experiences. King (1981), in her systems model, states that the primary function of the nurse is to help individuals maintain their health in order that they can function in their roles. She views nursing as a process of action, reaction, interaction and transaction. Peplau (1988) states that the nurses role cannot be considered in isolation as it will change in relation to interactions with others and suggests the roles listed in Table 1. Peplau feels that the relationships within which these roles are enacted should be the focus of nursing. Salvage (1990), however, suggests that this may not be what patients need or want. In general hospitals, for example, the sick persons priority is more likely to be relief of physical symptoms as opposed to expression of understanding or learning about the symptoms in an all-embracing, caring relationship with a nurse. In addition, Webb (1994) warns that: The traditional emphasis on physical care and comfort must not be lost in the struggle to humanize care. OUTCOME THEORY According to Meleis (1985), outcome or holistic theories describe nurses as controlling Table 1. Peplaus nursing roles Stranger who initiates relationships Teacher Resource person Leader Counsellor Surrogate Source: Peplau (1988) and directing patient care by using their knowledge of the human physiological and behavioural systems. Roys (1980) adaptation theory suggests that the role of the nurse is to enable individuals, through nursing intervention, to adapt to the environmental stimuli around them. The nurse is seen primarily as a change agent who can manipulate the stimuli affecting the individual or help the individual to adapt so that he/she can cope (Roy and Roberts, 1981). Neuman (1982) suggests that the role of the nurse is concerned with caring for the individual as a whole. She describes nursing as: A unique profession in that it is concerned with all the variables in an individuals responses to stress. This holistic caring role extends to the well individual in terms of health promotion. According to Rogers (1970), the major role of the nurse is to: Promote symphonic interaction between man and environment, to strengthen the coherence and integrity of the human field, and to direct and redirect patterning of the human and environmental fields for the realization of maximum health potential. These theorists are often criticized for their abstract and complicated ideas about nursing (Aggleton and Chalmers, 1988). While their ideas are intellectually challenging they are often difficult to implement and use operationally. However, they provide key indicators as to what constitutes the nursing role and this depth of thought is useful in that it stimulates others to explore and question what is written about nursing. NURSING CARE Traditionally, the concept of caring is closely linked with the role of the nurse. However, actually defining the role of the nurse as a carer is difficult. Orem (1991) sees the focus of caring, and therefore the role of nursing, as the return of the patient to self-care as opposed to the formation of a reciprocal caring relationship. Kitson (1987) expands this idea and suggests that the nurse committed to care must be able to provide sustained and continuous care for as long as the individual needs it, have the 610 BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10
ROLE OF THE NURSE: INTRODUCING THEORIES AND CONCEPTS necessary level of knowledge and skills to meet the needs of the patient and ensure that care is provided in such a way that maintains the integrity of those in receipt of the care. Watson (1979) states that caring, as a nursing term, represents all the factors that the nurse employs to deliver care. She identifies 10 caring factors which relate to the dynamics between individuals in a nursing relationship, e.g. trust and respect, and believes that these can only effectively be used interpersonally by a skilled and knowledgeable practitioner. These factors are identified by Leininger (1978) as comfort measures and include the attributes listed in Table 2. Pearson (1992) insists that the need to place caring as the central part of the nursing role has never been greater and is concerned that the caring components have: become decentralized and seen as the least sophisticated and subordinate to the therapeutic interventions of doctors and paramedical therapists. McFarlanes (1977) view of caring in nursing suggests that nursing activities will only become meaningful in a relationship based on respect for an individuals dignity and autonomy. This definition of nursing as an ethically based phenomenon is supported by Benner (1985): Nursing offers crucial services that require high intelligence, a thorough and sound educational base, and firm grounding in the ethics of both rights and justice and care and responsibility. Benner suggests that while the nurses caring role will require an involved stance it should not: seek to control or master but to facilitate and uncover the possibilities inherent in the situation and the person. Caring provides empowerment. Gaut (1986) agrees and believes that the concepts related to caring and nursing must be taken beyond the observable behaviours of nurses to mechanisms such as decision making and scientific problem-solving which underpin the more obvious aspects of the role. Table 2. Leiningers comfort measures Compassion Empathy Helping and coping behaviours Stress alleviating measures Touching (hand and body contact) Nurturance Succourance Protective, restorative and stimulative behaviours Health maintenance Instruction Consultation Source: Leininger (1978) CONCLUSION In summary, it is clear that there is no straightforward description, or definition, of the nurses role. It is complex and multifaceted and, according to some, is based in the competent completion of technical/diagnostic treatment closely linked to medical care. According to others, the nurse is a professional caregiver who is able to deliver nursing as a therapy in its own right (Antrobus, 1993). There is a continued need for nurses to develop their knowledge base and demonstrate the benefits of nursing in real terms so as to clarify the concept of nursing. The report The Challenges of Nursing and Midwifery in the 21st Century (Department of Health, 1994), otherwise known as the Heathrow debate, identified a concept in the nurses role which it refers to as the nursing constant. This comprises the core skills and values of the nursing role, i.e. coordinating, teaching, defending the frail and vulnerable, developing systems of care, concern for the ill and the well and technical expertise. Castledine (1994b) suggests that nurses should concentrate their energies on the development of this nursing constant if the true value of nursing is to be demonstrated. He states: We live in a world that pays little attention to the value of caring and...it is clear that there is no straightforward description, or definition, of the nurses role. It is complex and multifaceted and, according to some, is based in the competent completion of technical/diagnostic treatment closely linked to medical care... BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10 611
sharing. It is important therefore that nurses continue to advocate and champion the cause of nursing as quality in living well and dying free from stress and pain. Nursing is complex and difficult to describe, but it is an exciting profession which is rich in theory and practice. As nurses we must continue to build and expand the ideas and concepts that underpin what we are and what we do. BJN Aggleton P, Chalmers H (1988) Nursing Models and the Nursing Process. Macmillan, London Antrobus S (1993) Nursings nature and boundaries. Sen Nurse 13(2): 46 50 Benner P (1985) From Novice to Expert. Addison- Wesley, Menlo Park Bortoff JL, DCruz JV (1984) Towards inclusive notions of patients and nurse. J Adv Nurs 9: 549 53 Castledine G (1994a) Nursing can never have a unified theory. Br J Nurs 3(4): 180 1 Castledine G (1994b) The role of the nurse in the 21st century. Br J Nurs 3(12): 621 2 Cavanagh SJ (1991) Orems Model in Action. Macmillan Education, London Department of Health (1994) The Challenges of Nursing and Midwifery in the 21st Century A Report on the Heathrow Debate held in May 1993. HMSO, London Draper J (1992) The impact of nursing models. Sen Nurse 12(3): 38 9 Gaut DA (1986) Evaluating caring competencies in nursing practice. Top Clin Nurs 8(2): 77 83 Henderson V (1966) The Nature of Nursing: A Definition and its Implication for Practice, Research, and Education. Macmillan, Kenny T (1993) Nursing models fail in practice. Br J Nurs 2(2): 133 5 KEY POINTS Nursing models provide a vast array of information in relation to the role of the nurse. Developing a single general description of nursing is not possible as a result of the complex and wide range of work carried out by nurses. The nursing process is common to most models as the system for planning and developing their work. There is a need for nurses to promote and develop these core values and to communicate them to others. King IM (1981) A Theory for Nursing: Systems, Concepts and Process. Wiley and Sons, New York Kitson A (1992) Formalizing concepts related to nursing and caring. In: Kitson A, ed. Nursing, Art and Science. Chapman and Hall, London: 24 45 Kitson A (1987) A comparative analysis of lay caring and professional (nursing) caring relationships. Int J Nurs Stud 24(2): 155 65 Leininger M (1978) Transcultural Nursing Concepts, Theories and Practices. John Wiley, Marks-Maran D (1992) Rethinking the nursing process. In: Jolley M, Brykczyska G, eds. Nursing Care: The Challenge to Change. Arnold, London: 91 103 McFarlane JK (1977) Developing a theory of nursing: the relationship of theory to practice, education and practice. J Adv Nurs 2: 261 72 McFarlane JK, Castledine G (1982) The Practice of Nursing: Using the Nursing Process. CV Mosby, London McMahon R (1991) Therapeutic nursing: theory, issues, and practice. In: McMahon R, Pearson A, eds. Nursing as Therapy. Chapman and Hall, London: 2 25 Meleis A (1985) Theoretical Nursing: Development and Progress. Lippincott, Philadelphia Melnyk KAM (1983) The process of theory analysis: an examination of the nursing theory of Dorothea E Orem. Nurs Res 32(3): 170 4 Nightingale F (1952) (original 1859) Notes on Nursing. What it is and What it is Not. Duckworth, London Neuman B (1982) The Neuman Systems Model: Application to Nursing, Education and Practice. Appleton-Century-Crofts, Norwark Orem DE (1991) Nursing Concepts of Practice. 4th edn. Mosby Year Book, St Louis Orlando I (1961) The Dynamic Nurse Patient Relationship. GP Putnams and Sons, Pearson A (1992) Taking up the challenge: the future of therapeutic nursing. In: McMahon R, Pearson A, eds. Nursing as Therapy. Chapman and Hall, London: 192 210 Peplau HE (1988) Interpersonal Relations in Nursing. 2nd edn. Macmillan, Basingstoke Robinson D (1990) Two decades of The Process. Sen Nurse 10(2): 4 6 Rogers ME (1970) An Introduction to the Theoretical Basis of Nursing. Davis, Philadelphia Roper N (1994a) Definition of nursing: 1. Br J Nurs 3(7): 355 7 Roper N (1994b) Definition of nursing: 2. Br J Nurs 3(9): 460 2 Roper L, Logan W, Teirney A (1980) The Elements of Nursing. Churchill-Livingstone, Edinburgh Roy C (1980) The Roy Adaptation Model. In: Reihl JP, Roy C, eds. Conceptual Models for Nursing. Appleton-Century-Crofts, Norwark: 179 89 Roy C, Roberts S (1981) Theory Construction in Nursing: An Adaptation Model. Prentice Hall, Englewood Cliffs, New Jersey Salvage J (1990) The theory and practice of new nursing. Nurs Times 84(4): 42 5 Smith L (1982) Models of nursing as the basis for curriculum development: some rationales and implications. J Adv Nurs 8: 117 27 Travelbee J (1971) Interpersonal Aspects of Nursing. FA Davis, Philadelphia Watson J (1979) Nursing: The Philosophy and Science of Caring. Little Browne, Boston Webb C (1994) What is nursing? Br J Nurs 1(11): 567 8 Wright SG (1990) Building and Using a Model of Nursing. 2nd edn. Edward Arnold, London 612 BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10