Developing the Skills of a Nurse Theorist: Case of Mark O’Brien

Abstract

Caring for handicapped individuals is a challenging task because this group of vulnerable patients is characterized by a range of special needs that sometimes can be hardly addressed. Delivering care to disabled patients requires considerable financial expenditure, social tolerance and involvement, and an ethical attitude towards their needs. The discussed case study is Breathing Lessons: The Life of Mark O’Brien, a short documentary movie in which Yu (1996) draws attention to the problems of Mark O’Brien. A permanently handicapped man who lives in an iron machine (artificial lungs) reveals the problems of misaddressed/neglected needs for quality care of his biological, cognitive, psychological, social, and spiritual needs. The present research paper aims to partly resolve the issues of Mark O’Brien being neglected by a nurse when providing holistic care to him. The reviewed concepts are caring, self-efficacy, and holistic health. The reviewed theoretical frameworks are Kolcaba’s Comfort Theory and Pender’s Health Promotion Model.

Introduction

Despite the significant development of medicine, a modern healthcare setting contains a lot of issues that need to be addressed. A short documentary movie Breathing Lessons: The Life of Mark O’Brien by Yu (1996) draws public attention to the problems of physically disabled individuals. The main character is Mark O’Brien whose body is paralyzed starting from his head (a complication of poliovirus that the man has got as a child). O’Brien has been living in an iron lung machine since childhood because he could not breathe by himself. The life of this man depicts significant medical, financial, psychological, ethical, and social problems that a moral society should acknowledge and address. The main idea of Mark O’Brien’s revelation is that disabled individuals should not necessarily feel handicapped (Yu, 1996). The term handicapped is inversely proportional to the notions of independence and capability. In other words, disabled individuals need to be assisted in gaining as much self-efficacy as possible in terms of satisfying their physical, emotional, cognitive, and spiritual needs. Endeavoring to address the problems of disabled individuals, healthcare professionals should incorporate theoretical knowledge in advocacy and caring activities.

The Purpose of Study

The purpose of this paper is to identify the concepts revealed in Breathing Lessons: The Life of Mark O’Brien and discuss in detail three essential concepts, which are caring, self-efficacy, and holistic health. The aim of exploring these notions is to increase understanding of how to provide the best possible care to disabled patients. Besides, the connection created between these concepts can be used in nurse advocacy activities. Moreover, the goal is to relate the discussed concepts to 1 nursing theory and to 1 nursing middle-range theory to suggest a framework within which the concepts of addressing the needs of disabled individuals may be put into practice. Finally, the aim of this study is to provide self-reflection on the experience obtained in regard to nursing science.

The List of Concepts

The four meta-paradigm concepts: person, nursing, environment, health.

• Caring;
• Advocacy;
• Self-efficacy;
• Holistic (being/needs/health);
• Behavior-specific cognitions;
• Activity-related affect;
• Interpersonal relations.

Concept 1: Caring

Antecedents

Care is one of the main concepts in the nursing sector. The concept ‘caring’ is defined as ”feeling and exhibiting concern and empathy for others; showing or having compassion” (Lavdaniti, 2014). This notion has emerged in the middle of the 20th century (Lavdaniti, 2014). The antecedents of caring can be observed in the concept of nursing. The latter is referred to ”as care of individuals of all ages, families, groups, and communities, sick or well and in all settings” (Lavdaniti, 2014). Consequently, caring is a central concept of nursing. The notion ‘caring’ is being developed and constantly shaped simultaneously with the concept of nursing. In regard to nursing science a breakthrough of care/caring occured with the emergence of Watson’s theory of Ten Carative Factors and Caritas Processes (Masters, 2015). According to this theory, ‘caring’ consists of ”carative factors that result in the satisfaction of human needs” (Lavdaniti, 2014). In this way, caring is related to holistic health (satisfaction of patients’ diverse needs).

Characteristics

Discussing the characteristics of caring, it is important to understand that this concept is quite broad and universal. Therefore, in one way or another, it is present in each nursing theory. To describe this concept Lavdaniti (2014) reveals that care/caring is perceived from five different perspectives. Specifically, ‘caring’ is referred to ”as a human trait, as a moral imperative, as an effect, as an interpersonal interaction, and as a therapeutic intervention” (Lavdaniti, 2014). Each of these sub-concepts is addressed in the process of caring.

Consequences (Relevant to the Discussed Case Study)

Caring as an effect is thoroughly discussed by O’Brien. The man claims that he did not receive adequate care in a nursing home (Yu, 1996). In spite of the fact that the clinicians used to describe it as quality care, the patient reports being humiliated and even injured. This highly negative attitude is probably connected to the fact that the life expectancy is quite short in this healthcare establishment (Yu, 1996). Unfortunately, the example of Mark O’Brien stresses the negative effects of care and points to the absence of nurses’ intentions to provide quality care to patients. This example illustrates how care/caring can be referred to as an effect.

Moreover, linking the concept of caring to the discussed case study, in particular, and nursing practice, in general, one should comprehend that this term goes beyond the habitual frames of daily assistance. For instance, Yu (1996) reveals that moral imperative, interpersonal relations, and a therapeutic intervention resonate with assisted suicide and sexual surrogate. Without a doubt, both approaches are highly controversial but frequently discussed ethical dilemmas.

Mark O’Brien reports having suicidal ideation, recurrent suicidal intentions, and even attempts to commit suicide. This information is in compliance with the already known fact that the overall population of people with disabilities is at risk of suicide. This premise implies that the psychological (cognitive and emotional needs) of patients are scarcely addressed. This issue is closely related to the nursing area because it is obvious that the patients do not receive holistic care. Besides, the issue has also financial, social, and ethical considerations. The former is caused by a financial burden. The latter two are the result of a dilemma whether a society has to spend resources on handicapped people and if yes, what is the appropriate amount of such input. Both of these questions are vocalized by Mark O’Brien (Yu, 1996). This scrutiny emphasizes that caring is a multidimensional concept and, for that matter, it is a holistic concept. Thus, one may rightfully deduce that quality care is a synonym of holistic care. In this way, the concepts of holistic health and caring are interwoven.

According to the American Nurses Association (ANA) (2017) assisted suicide is forbidden. This option is considered to be unethical and unacceptable. Thus, healthcare professionals are discouraged from helping patients (even those with a severe permanent disability, or the dying ones) commit suicide. Hence, the clinical practice of withdrawing or withholding treatment is legally and ethically justified (ANA, 2017). Connecting this insight to the case of Mark O’Brien, it is possible to deduce that his will to withhold from an iron lung may be fulfilled. Despite the fact that this aspect of caring is disturbing and ambivalent for most caregivers, it is a frequent part of caring for severely disabled or dying individuals. Therefore, it is important to know what options may or may not be considered.

Another controversial matter of caring is sexual surrogate. A sexual surrogate is a specialist who is trained to assist an individual in gaining sexual experiences to develop an adequate and positive self-image (Weeks, Gambescia & Hertlein, 2016). In other words, the main goal of a sexual surrogate is to address the physical and psychological intimate issues of a person. More specifically, ”surrogate partners work to help clients build communication skills and self-confidence, and assist clients in becoming more comfortable with physical and emotional intimacy” (Weeks et al., 2016, p. 227). Generally, a sexual; surrogate is required to help disabled patients, and/or those who have sex-related disorders.

Mark O’Brien reveals that his experience with a sexual surrogate was positive but expensive; his revelation points to financial considerations related to addressing this kind of need. Hence, there are also legal, social, and ethical dilemmas associated with a sexual surrogate. In particular, according to Weeks et al. (2016), such therapy is legally forbidden in most states. Besides, since this kind of care is rather controversial, there is no much empirical data available about its effectiveness. Despite the fact that surrogate partner therapy is a controversial approach in caring for disabled individuals, it stresses the significance of holistic care. Moreover, considering the function of such a therapy it is natural to assume that it serves to increase a patient’s self-efficacy.

Concept 2: Self-Efficacy

Antecedents

The concept of self-efficacy was brought to the nursing area from psycho-social sciences. In particular, self-efficacy stems from the Social Cognitive Theory that was developed by Alberta Bandura (AIPPG, 2012). Self-efficacy is defined as ”belief that one has the power to produce that effect by completing a given task or activity related to that competency” (AIPPG, 2012). In other words, self-efficacy is a variable that indicates a person’s belief in the likelihood of successful goal completion. Taking this fact into consideration, self-efficacy depends on one’s cognitions. Moreover, cognitions affect behaviors and vice versa. Self-efficacy becomes one of the central concepts in the nursing area. Let’s consider an example of a patient who has certain health issues that prevent his/her from reaching health goals. In this respect, the level of this person’s self-efficacy may be observed in behavioral patterns as well as in cognition. Helping patients increase their self-efficacy is an essential task of healthcare professionals. Without a doubt, self-efficacy is also common for clinicians, as it affects their work performance, and thus, indirectly, impacts nurse-patient relations, quality of care, and health outcomes. Hence, this paper focuses on the importance of self-efficacy in patients.

Characteristics

According to Social Cognitive Theory, self-efficacy is affected by three domains: behavior, environment, and individual cognitions (AIPPG, 2012). These factors are interrelated and shape one another. Cognitive factors are central to this theory. Consider the fact that ”motivation, performance, and feelings of frustration associated with repeated failures determine affect and behavior relations” (AIPPG, 2012). Taking this into consideration, the issue with self-efficacy is especially prominent in patients with permanent disabilities. Thus, this concept is relevant to the case of Mark O’Brien and other similar situations.

Consequences (Relevant to the Discussed Case Study)

Mark O’Brien has limited self-efficacy. The man reveals that he suffers from the expectations of society towards handicapped people. In particular, they are expected to be able to overcome their psychical limitations. Nevertheless, in real life this task is much more complicated and disabled individuals (O’Brien refers to himself) are not capable of fulfilling those expectations (Yu, 1996). This example illustrates how maladaptive cognition affects the life quality of this disabled man. As a result, his self-efficacy is negatively affected. O’Brien believes that society forces handicapped people to make extreme efforts to recover and that these forced expectations are unreal. The fact is that the truth may not concise with a patient’s subjective opinion. To help Mark O’Brien gain self-efficacy, a nurse should strive to alter this maladaptive cognition replacing it with a belief that the patient should be proud of his inner power to survive so long and so effectively despite the circumstances. This intervention would increase the patient’s self-efficacy as cognition, and it is likely that behaviors would be positively altered as well.

Establishing the connection between self-efficacy and caring, one may rightfully suggest that the former is linked to the latter as a human trait and as a healing effect. The division of self-efficacy on thinking and acting, both influenced by environmental factors, points out that a person should be perceived as a holistic being. In this respect, discussing the matter of holistic health, it is appropriate to define it as a bio-psycho-social unit. All aspects of a holistic being, and thus, holistic health should be addressed in nursing care. Thus, it is possible to deduce that quality care is holistic care. In this way, a strong relation between such concepts as holistic health and care/caring can be emphasized.

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Concept 3: Holistic Health

Antecedents

Holistic health implies an equally high level of functioning of all systems of a person. The word ‘holistic’ ”comes from the Greek word holos, meaning ”entire” or ”all”(Flanagan, 2015). In this respect, holistic health is predefined by the fact that humans are holistic beings and consists of physical, cognitive, and emotional domains. Besides, as a part of society, every person is a reflection of his/her social ecology. Thus, interpersonal relations and social layers should be also included in holistic care.

Characteristics

Holistic human functioning underlines many nursing theories (Masters, 2015). This fact is not surprising because an individual has various needs, and the task of the health care industry is to fulfill all health-related needs of a patient. This approach is called holistic care.

Consequences (Relevant to the Discussed Case Study)

The case study of Mark O’Brien is a vivid example of a holistic approach towards addressing a patient’s needs. For example, apart from physical needs, the man has psychological needs, such as the need for communication with other people, the need to be a part of society (he is a journalist and a writer, and communicates with the rest of the world in this way). Besides, O’Brien has intimate needs (affection, love, desire for intimacy, etc.). In addition, the patient has spiritual needs (he talks to God, and believes that he has a soul). Addressing every aspect of these needs is important because this holistic treatment is the way to increase O’Brien’s self-efficacy and, thus, ensure that the care provided to him is of high quality.

Middle-Ranged Theory: Kolcaba`s Theory of Comfort

When addressing the needs of severely and permanently disabled individuals healthcare professionals should refer to the Theory of Comfort developed by Katharine Kolcaba. According to this theory, patients possess needs for relief, and the task of a nurse is to deliver care that satisfies these needs timely and effectively (Peterson & Bredow, 2017; Masters, n. d.). Needs for comfort are holistic because a patient needs to feel comfort (as a health goal) within all physiological and psychological systems. This insight implies that nurses are expected to provide holistic care. In this regard, holistic care consists of physical, psychospiritual, sociocultural, and environmental contexts (Masters, n. d., p. 73).

Furthermore, an important concept of Kolcaba’s Comfort Theory is a concept of ‘health-seeking behaviors’ (Masters, n. d.). According to Kolcaba, these behaviors can be either conscious or unconscious, but they necessary emerge during the treatment process and move to health goals (even if the ultimate health goal is to die peacefully). The concept of health-seeking behaviors of patients (and their significant others if there are such people) resonates with the above-discussed concept of self-efficacy. In particular, it is natural to assume that the health-seeking behaviors of patients are the external result of their internal self-efficacy. At the same time, addressing these behaviors with holistic treatment is equated to quality nursing care. Finally, reaching comfort within all systems resonates with the concept of holistic health.

Conceptual Map

Nursing Health Assessment Questions

1. In what way patients’ self-efficacy relates to their health-seeking behaviors?
2. In what ways patient’s cognition shape (limits/enhances) his/her health-seeking behaviors?
3. What caring approach should be deployed to reach the goals of comfort?
4. How a nurse’s caring and a patient’s health-seeking intentions are related?
5. What is the role of external stimuli (environment, interpersonal relations with significant others) in forming a patient’s health-seeking behaviors?
6. How a nurse can deploy external factors (environment, significant others) to reach health goals?

A Published Theory: The Health Promotion Model by Nola J. Pender

Apart from the above-discussed middle-ranged theory, nurses may use Pender’s Health Promotion Model. This theory is based on the concepts of caring, self-efficacy, and holistic human functioning. In particular, Masters (n. d.) explains that the Health Promotion Model incorporates the following:

multidimensionality of persons interacting with their interpersonal and physical environments as they pursue health while integrating constructs from expectancy-value theory and social cognitive theory with a nursing perspective of holistic human functioning (p. 70).

Establishing the connection between this theory and the concepts discussed above, one emphasizes a critical role of patients’ self-efficacy in the process of addressing their health needs. Just as the concept of ‘self-efficacy’, Pender’s model is based on the Social Cognitive theory. Thus, the role of a patient’s cognition is emphasized. At the same time, given that cognition stipulates the emergence of particular behavioral outcomes, the latter is an important category of the present model. Moreover, dividing a man’s system into biological, cognitive, behavioral, and social spheres, Pender encourages healthcare professionals to acknowledge the holistic nature of a human being and provide holistic care (Masters, n. d.).

Linking the theoretic insights of Pender’s Health Promotion Model to the case of Mark O’Brien, it is necessary to derive a number of practical guidelines that can be implemented by nurses who care for this patient. Masters (n. d.) states that behavior-specific cognitions are characterized by motivational significance. Consequently, it is important to work on O’Brien’s cognition ensuring the development and maintenance of a positive outlook. Undoubtedly, this task is extremely difficult to achieve when working with severely disabled patients; however, it is possible to increase O’Brien’s self-efficacy by refining his social interactions. This aspect of his personality seems to be strong, and there is a prominent need for its fulfillment. Besides, holistic treatment should be conducted to improve care for the patient’s basic needs. Finally, the theory of Pender may be used in nurses’ advocacy activity to draw public and government attention to the holistic needs of patients like Mark O’Brien.

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Being a Nurse Theorist

First of all, being a nurse theorist presumes collecting evidence to set up new logical connections between the already existing concepts. In addition, while studying a particular phenomenon a nurse theorist may establish a new concept and/or add new features to the already existing ones. Besides, presence of a purpose is an essential aspect of developing new concepts and steady logical connections between those concepts. In other words, practical usability and applicability are the main triggers of theoretical researches. The present study is aimed to synthesize theoretical insights from nursing science to make them applicable to the case of Mark O’Brien. The intention to find a practical solution for theoretical insights is an indicator of a nurse theorist.

Conclusion

Summing up the facts mentioned above it is appropriate to emphasize that provision of care to disabled individuals requires knowledge on how to provide quality care while increasing patients’ self-efficacy. Besides, the diverse biological needs of a patient have to be addressed to ensure holistic human functioning. In this respect, healthcare professionals are able to refer to Katherine Kolcaba’s Comfort Theory and Nola Pender’s Health Promotion Model. Both of these theoretical frameworks emphasize the importance of a patient’s cognitions (in part, those that are related to self-efficacy) and behavioral patterns and effects. In a word, the approaches should be aimed at reducing limitations and increasing self-efficacy. Apart from that, a nurse should comprehend that caring for severely handicapped individuals is complicated as there is a possibility they may face such controversial matters of caring as suicide ideation and surrogate partner therapy. Besides, nurses need to be ready to advocate the needs of such vulnerable patients in society to decrease the amount of financial, social, and ethical stumbling blocks in caring.