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associate what you have learned about theory in comparison to the case study and reflect on it.

 

·       A comparison of what you have learned from the case study to related theories you have studied. Make sure to cite these theories in APA format.

·       A comparison of the case study to your nursing practice, giving one or two examples from your nursing experience in which you might have applied a particular theory covered.

Your reflection should be a minimum of five to six paragraphs

Below are the theories


CHAPTER 15: Theories From the Biomedical Sciences

Melanie McEwen

Maria Leon is in her final year of a graduate program preparing to become a certified registered nurse anesthetist (CRNA). During the course of her graduate education, Maria observed that most people reported a burning sensation as propofol (a drug used to induce general anesthesia) was administered intravenously (IV). In conducting a review of the literature and discussing her observations with other CRNAs, Maria found several techniques used to minimize the injection pain. Based on this information, Maria decided that she would like to conduct a research study to examine the effectiveness of using lidocaine to reduce the injection pain of propofol. This project would fulfill the capstone requirement for her master’s degree.

A literature review of pain management led Maria to the gate control theory, which posits that there is a gating mechanism in the spinal cord. When pain impulses are transmitted from the periphery of the body by nerve fibers, the impulses travel to the dorsal horns of the spinal cord, specifically to the area of the cord called the substantia gelatinosa. According to the theory, when the gate is open, pain impulses ascend to the brain; when the gate is partially open, only some of the pain impulses can pass through. Pain medication has an effect on the gate, and if pain medication is administered before the onset of pain, it will help keep the gate closed, allowing fewer pain impulses to pass through.

In planning her research project, Maria used the gate control theory to guide the design and structure of the study. For the study, she decided to compare two techniques for pain prevention. One technique involved mixing 20 ml of a 1% propofol solution with 5 ml of a 2% lidocaine solution and injecting 1 ml of the mixture immediately before administration of the propofol. The second technique involved the placement of a tourniquet inflated to 50 mmHg on the arm in which the IV access device was placed. Then, 5 ml of 2% lidocaine would be injected and the tourniquet would be removed 1 minute later; propofol would then be injected. A time frame of 20 seconds would allow the clients to report pain in the arm before the propofol took effect. Maria also planned to have a control group that did not have either of the pain prevention interventions.

If the theory was correct, Maria hypothesized that both experimental groups would have less pain from the injection because the gate that allowed pain sensations would not open or would only partially open. She did not know which of the two experimental procedures would be more effective in preventing pain but was enthusiastic about conducting the study and adding to the body of knowledge on pain prevention in anesthesia.

Theories from the biomedical sciences (e.g., biology, medicine, public health, physiology, pharmacology) have had a tremendous impact on nursing practice since Nightingale’s time. Indeed, many of these theories are so integral to nursing practice that they are overlooked or taken for granted. For example, at the beginning of the 21st century, the germ theory seems almost too elemental to mention because even kindergarten children are taught the basic concept of germs and how to prevent infection. But nurses should recognize the relatively recent discovery of this revolutionary theory (late 1800s) and understand that a significant amount of nursing care is based on it. Other theories, concepts, and principles are similarly ingrained within nursing practice.

Biomedical theories have been the basis for research efforts of physiologists, physicians, and laboratory-based scientists for many years. Nurses have also been involved in research of this type and are increasingly directing studies that have a physiologic or biologic basis. As with any study, the underlying theories or conceptual frameworks may be broad (e.g., germ theory) or very narrow (e.g., gate control theory).

This chapter presents some of the most commonly used theories and principles from the biomedical sciences to illustrate how they are being used in studies conducted by nurses and applied in nursing practice. The number of these theories is staggering; thus, space allows for discussion of only a few. Although there is some overlap, the theories will be grouped into two large categories: theories of disease causation (e.g., germ theory, natural history of disease) and theories related to physiology (e.g., stress and adaptation, cancer causation, pain).

Theories and Models of Disease Causation

On a day-to-day, moment-to-moment basis, nurses in practice use any one of a number of concepts, principles, and theories from biology and public health. These theories are often related to disease causation and progression. This includes pathogenesis and infection, as well as multiple epidemiologic concepts and principles (e.g., risk factor, exposure, prevention). This section provides a review of a few of these principles, theories, and models and shows how they are used in nursing practice and nursing research.

Evolution of Theories of Disease Causation

Disease refers to any condition that disturbs the normal functioning of an organism, whether it affects one organ or several systems. The term has also been defined as the failure of an organism to respond or adapt to its environment. The concept has changed dramatically over the course of time, however, and ideas about the cause of disease have been influenced by the prevailing culture and scientific thought.

In ancient times, disease was frequently viewed as a divine intervention or punishment. Early human beings attributed diseases to the influence of demons or spirits, and magic was a large part of treatment and prevention. As time passed, other interventions or treatments, such as the use of plant extracts, became more common.

As humans formed into societies and distinct cultural groups, two trends, or approaches, to medicine evolved. Sorcerers and priests embraced a magico-religious approach, whereas early physicians and scientists developed an empirico-rational approach. The empirico-rational approach was based on experience and observation and was practiced at first by priests but was adapted by nonclerical physicians. Modern medicine arose primarily from the empirico-rational approach as the human body and its functions became better known and as science led medical practice away from superstition and focus on the spiritual realm to include scientific processes and reasoning.

In the 17th century, William Harvey, an English physician and anatomist, demonstrated the dynamics of blood circulation (Donahue, 2011). Detailed studies of the organs, diseases, and processes, such as physiology and respiration, quickly followed, conducted by eminent physicians and scientists of the time. Medical debates focused on minute features of the body and how to treat particular diseases. Philosophies and theories developed that were largely reductionistic and deductive, focusing on cause and effect; the medical model quickly evolved.

In the latter part of the 19th century, scientists began to unravel the basic causes of infectious disease. Modern medicine began with the advent of Pasteur’s germ theory, which posited that a specific microorganism was capable of causing an infectious disease (Black & Hawks, 2009). The focus on single-agent or single-organism cause for disease persisted for a number of decades and resulted in multiple successes in both treating and preventing communicable diseases. Today, however, the predominant general model of disease causation is multicausal, involving invasive agents, immune responses, genetics, environment, and behavior.

A number of theories and models describe disease causation and the properties that relate to disease processes and prevention. Some of the most frequently encountered models in nursing practice and research are discussed in the following sections.

Germ Theory and Principles of Infection

Louis Pasteur first proposed the germ theory in 1858. He theorized that a specific organism (i.e., a germ) was capable of causing an infectious disease (Kalisch & Kalisch, 2004). Today, this seems like a simple theory, but it is one that was critical to the development of modern medical care. Its impact has been phenomenal and has helped to radically reduce the number of deaths from infection.

At the beginning of the 21st century, theories of infection are most often applied to prevent infection (e.g., practicing strict hand washing, cleansing a scrape and applying antibiotic ointment, or prophylactically treating a surgery client with antibiotics) or to describe the process that seeks to identify, understand, and manage infectious diseases. This process initiates the search for the causative agent of an infection and method(s) of transmission. Once this has been accomplished, the focus can shift to the development of ways to prevent and treat the disease.

One of the most recent and dramatic examples of this process was the outbreak of AIDS. The syndrome was first identified by the Centers for Disease Control and Prevention in September of 1982, but months passed before it was determined that the causative agent was a retrovirus, later termed HIV (Shi & Singh, 2012). Early in the process, even before the virus was isolated, methods of transmission (e.g., sexual, transplacental, via blood products) were recognized and interventions for prevention proposed. Research on treatment has produced somewhat successful results in recent years and is ongoing.


CHAPTER 15: Theories From the Biomedical Sciences

Melanie McEwen

Maria Leon is in her final year of a graduate program preparing to become a certified registered nurse anesthetist (CRNA). During the course of her graduate education, Maria observed that most people reported a burning sensation as propofol (a drug used to induce general anesthesia) was administered intravenously (IV). In conducting a review of the literature and discussing her observations with other CRNAs, Maria found several techniques used to minimize the injection pain. Based on this information, Maria decided that she would like to conduct a research study to examine the effectiveness of using lidocaine to reduce the injection pain of propofol. This project would fulfill the capstone requirement for her master’s degree.

A literature review of pain management led Maria to the gate control theory, which posits that there is a gating mechanism in the spinal cord. When pain impulses are transmitted from the periphery of the body by nerve fibers, the impulses travel to the dorsal horns of the spinal cord, specifically to the area of the cord called the substantia gelatinosa. According to the theory, when the gate is open, pain impulses ascend to the brain; when the gate is partially open, only some of the pain impulses can pass through. Pain medication has an effect on the gate, and if pain medication is administered before the onset of pain, it will help keep the gate closed, allowing fewer pain impulses to pass through.

In planning her research project, Maria used the gate control theory to guide the design and structure of the study. For the study, she decided to compare two techniques for pain prevention. One technique involved mixing 20 ml of a 1% propofol solution with 5 ml of a 2% lidocaine solution and injecting 1 ml of the mixture immediately before administration of the propofol. The second technique involved the placement of a tourniquet inflated to 50 mmHg on the arm in which the IV access device was placed. Then, 5 ml of 2% lidocaine would be injected and the tourniquet would be removed 1 minute later; propofol would then be injected. A time frame of 20 seconds would allow the clients to report pain in the arm before the propofol took effect. Maria also planned to have a control group that did not have either of the pain prevention interventions.

If the theory was correct, Maria hypothesized that both experimental groups would have less pain from the injection because the gate that allowed pain sensations would not open or would only partially open. She did not know which of the two experimental procedures would be more effective in preventing pain but was enthusiastic about conducting the study and adding to the body of knowledge on pain prevention in anesthesia.

Theories from the biomedical sciences (e.g., biology, medicine, public health, physiology, pharmacology) have had a tremendous impact on nursing practice since Nightingale’s time. Indeed, many of these theories are so integral to nursing practice that they are overlooked or taken for granted. For example, at the beginning of the 21st century, the germ theory seems almost too elemental to mention because even kindergarten children are taught the basic concept of germs and how to prevent infection. But nurses should recognize the relatively recent discovery of this revolutionary theory (late 1800s) and understand that a significant amount of nursing care is based on it. Other theories, concepts, and principles are similarly ingrained within nursing practice.

Biomedical theories have been the basis for research efforts of physiologists, physicians, and laboratory-based scientists for many years. Nurses have also been involved in research of this type and are increasingly directing studies that have a physiologic or biologic basis. As with any study, the underlying theories or conceptual frameworks may be broad (e.g., germ theory) or very narrow (e.g., gate control theory).

This chapter presents some of the most commonly used theories and principles from the biomedical sciences to illustrate how they are being used in studies conducted by nurses and applied in nursing practice. The number of these theories is staggering; thus, space allows for discussion of only a few. Although there is some overlap, the theories will be grouped into two large categories: theories of disease causation (e.g., germ theory, natural history of disease) and theories related to physiology (e.g., stress and adaptation, cancer causation, pain).

Theories and Models of Disease Causation

On a day-to-day, moment-to-moment basis, nurses in practice use any one of a number of concepts, principles, and theories from biology and public health. These theories are often related to disease causation and progression. This includes pathogenesis and infection, as well as multiple epidemiologic concepts and principles (e.g., risk factor, exposure, prevention). This section provides a review of a few of these principles, theories, and models and shows how they are used in nursing practice and nursing research.

Evolution of Theories of Disease Causation

Disease refers to any condition that disturbs the normal functioning of an organism, whether it affects one organ or several systems. The term has also been defined as the failure of an organism to respond or adapt to its environment. The concept has changed dramatically over the course of time, however, and ideas about the cause of disease have been influenced by the prevailing culture and scientific thought.

In ancient times, disease was frequently viewed as a divine intervention or punishment. Early human beings attributed diseases to the influence of demons or spirits, and magic was a large part of treatment and prevention. As time passed, other interventions or treatments, such as the use of plant extracts, became more common.

As humans formed into societies and distinct cultural groups, two trends, or approaches, to medicine evolved. Sorcerers and priests embraced a magico-religious approach, whereas early physicians and scientists developed an empirico-rational approach. The empirico-rational approach was based on experience and observation and was practiced at first by priests but was adapted by nonclerical physicians. Modern medicine arose primarily from the empirico-rational approach as the human body and its functions became better known and as science led medical practice away from superstition and focus on the spiritual realm to include scientific processes and reasoning.

In the 17th century, William Harvey, an English physician and anatomist, demonstrated the dynamics of blood circulation (Donahue, 2011). Detailed studies of the organs, diseases, and processes, such as physiology and respiration, quickly followed, conducted by eminent physicians and scientists of the time. Medical debates focused on minute features of the body and how to treat particular diseases. Philosophies and theories developed that were largely reductionistic and deductive, focusing on cause and effect; the medical model quickly evolved.

In the latter part of the 19th century, scientists began to unravel the basic causes of infectious disease. Modern medicine began with the advent of Pasteur’s germ theory, which posited that a specific microorganism was capable of causing an infectious disease (Black & Hawks, 2009). The focus on single-agent or single-organism cause for disease persisted for a number of decades and resulted in multiple successes in both treating and preventing communicable diseases. Today, however, the predominant general model of disease causation is multicausal, involving invasive agents, immune responses, genetics, environment, and behavior.

A number of theories and models describe disease causation and the properties that relate to disease processes and prevention. Some of the most frequently encountered models in nursing practice and research are discussed in the following sections.

Germ Theory and Principles of Infection

Louis Pasteur first proposed the germ theory in 1858. He theorized that a specific organism (i.e., a germ) was capable of causing an infectious disease (Kalisch & Kalisch, 2004). Today, this seems like a simple theory, but it is one that was critical to the development of modern medical care. Its impact has been phenomenal and has helped to radically reduce the number of deaths from infection.

At the beginning of the 21st century, theories of infection are most often applied to prevent infection (e.g., practicing strict hand washing, cleansing a scrape and applying antibiotic ointment, or prophylactically treating a surgery client with antibiotics) or to describe the process that seeks to identify, understand, and manage infectious diseases. This process initiates the search for the causative agent of an infection and method(s) of transmission. Once this has been accomplished, the focus can shift to the development of ways to prevent and treat the disease.

One of the most recent and dramatic examples of this process was the outbreak of AIDS. The syndrome was first identified by the Centers for Disease Control and Prevention in September of 1982, but months passed before it was determined that the causative agent was a retrovirus, later termed HIV (Shi & Singh, 2012). Early in the process, even before the virus was isolated, methods of transmission (e.g., sexual, transplacental, via blood products) were recognized and interventions for prevention proposed. Research on treatment has produced somewhat successful results in recent years and is ongoing.

 


CHAPTER 17: Learning Theories

Evelyn M. Wills

Melanie McEwen

Barbara Davis is a family nurse practitioner working in a community clinic. Recently, she cared for Frank Young, a 65-year-old African American who came to the clinic at his wife’s insistence because of recurring, severe headaches. Mr. Young reported that his headaches started about 6 months ago; he attributed them to stress caused by his recent retirement.

Mr. Young’s physical findings indicated that he was about 50 lbs overweight and that his blood pressure while sitting was 204/110 mmHg. His lower legs and feet were slightly edematous, and laboratory tests revealed a total cholesterol reading of 290 mg/dl. All other laboratory blood and urine results were normal.

Barbara explained to Mr. Young that he has high blood pressure and asked to discuss the problem with both him and his wife. She led the Youngs to a room in which they sat in comfortable chairs around a small table. Barbara began the discussion by asking if the couple had any experience with hypertension (HTN). She explained the relationship among HTN, race, age, gender, and weight and described its prevalence among various groups. She showed the Youngs a short video that used nonmedical terms to describe HTN, visually illustrated the physiologic changes that cause HTN, and then explained some of the possible complications.

After the video, Barbara questioned the Youngs to evaluate their level of understanding. A 15-minute discussion followed in which Barbara described management strategies. She gave Mr. Young two prescriptions and explained what they were for and how to take them. Following the explanation, she had him repeat the information to her. They also discussed the importance of limiting sodium intake, and Barbara gave the Youngs a booklet with pictures to show the exact types, varieties, and amounts of foods available in their region and whether the sodium content was safe, high, or too high to consume. It included condiments, with the allowed amounts, on a full-color poster that could be placed on the side of the refrigerator or attached to the door of a cabinet. There were recipes for variations on favorite foods with lowered sodium content, and the booklet also had removable shopping lists to assist Mrs. Young when she had to make quick decisions in grocery stores. Learning that both Mrs. and Mr. Young enjoyed working and gaming on the computer, Barbara included websites with helpful hints on limiting sodium and fats, and the URLs for “say NAYtoNA,” a local Facebook support group page and Twitter site for social support.

At the end of the appointment, they reviewed the ways to lower Mr. Young’s blood pressure and they set up an appointment with the clinic’s dietitian to go over ways the Youngs could reduce the amount of fat and salt in their diet. Finally, Barbara made a follow-up appointment for the next week and encouraged Mrs. Young to accompany her husband to that meeting.

One of the most important roles of professional registered nurses (RNs) and advanced practice nurses (APNs) is teaching. Teaching performed by nurses at all levels is usually more informal than formal. That is, the nurse teaches clients and their families, or students and colleagues, more often on a one-to-one basis as the need arises than in a formal, planned teaching session in a classroom setting. But teaching includes more than just providing clients with information. Because someone has been told something does not mean that learning has occurred. Many factors are involved for learning to be successful, and providing information is only one of them.

Health information is usually foreign and difficult to understand for patients and families; the idea of health literacy as a component of health teaching is important in teaching patients/clients. Health literacy is defined as “the degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions” (Bastable, Myers, & Poitevent, 2014, p. 261). Although health literacy is not an educational theory, health teaching depends on the abilities of nurses to bring information and education to individuals and groups regardless of their educational level and ability to learn. Because many patients depend on someone else to help or to care for them, the caregivers must also be taught to provide assistance so that the patient may heal or live with chronic diseases or the effects of illness and trauma.

This chapter provides professional nurses with tools to facilitate learning for patients, families, and staff. Basic theories of learning can serve as a framework for the nurse in all teaching endeavors. Theories provide a way to organize thinking for what will be communicated to other people. They may offer a mechanism whereby the instructor can look at a situation in a different way when current methods are not working, or they may provide a map for charting unfamiliar territory. In any event, facilitating learning is an essential objective of the professional nurse, and application of theories helps ensure that learning is optimized.

What Is Learning?

Learning has been defined as “a relatively permanent change in behavior or in behavioral potentiality that results from experience and cannot be attributed to temporary body states such as those induced by illness, fatigue, or drugs” (Olson & Hergenhahn, 2012, p. 6). Learning occurs as individuals interact with their environment, incorporating new information into what they already know (Braungart, Braungart, & Gramet, 2014; Candela, 2012). Further, if learning is to be permanent, it must be treated as a process that occurs over time rather than an isolated event. Often, time and repeated contacts are required for an individual to acquire new knowledge that is meaningful and significant (Forrest, 2004).

Learning can be grouped into three categories: psychomotor learning (the acquisition and performance of skills), affective learning (a change in feelings, values, or beliefs), and cognitive learning (acquiring information). Examples of psychomotor learning would include a nursing student mastering certain patient care procedures (e.g., inserting an IV line or changing a sterile dressing) and a patient learning to self-inject insulin. Illustrations of affective learning include an alcoholic acquiring strategies to overcome addiction and a nurse developing cultural sensitivity when caring for immigrants. Cognitive learning generally involves the addition of new information, as when a new mother learns how to care for her infant or a novice nurse learns to recognize the signs and symptoms of heart failure. Although not always recognized, psychomotor learning tends to be more easily accomplished and measured than affective and cognitive learning (Rankin & Stallings, 2005). Nurses must understand all three types of learning and know how to facilitate each in patients and their families as well as among other nurses and ancillary staff.

The process of assimilating new knowledge into our daily lives makes all humans constant learners, because learning is necessary for survival. Although all animals can learn, humans are capable of using their knowledge to be creative, predict the future, explain the past, or deal with the present. Indeed, learning is such an important human experience that it has created the desire or curiosity to discover how people learn. This search to understand how people learn has led to the development and formalization of learning theories.

What Is Teaching?

It must be recognized that although teaching and learning are interrelated, learning occurs as a separate and individual process apart from teaching. Teaching refers to the intentional act of communicating information and is often defined as the facilitation of learning (Bastable & Alt, 2008). To accomplish this, teachers must be aware of the learning styles and learning needs of the individual and how capable that individual is of responding to the demands of instruction.

It is a common assumption that teaching is helping one to gain knowledge. While that is certainly an important component of teaching, knowledge is seldom enough to elicit a change in behavior or thinking. Knowing what should be done and acting on that knowledge are two different things. For example, a patient with chronic renal failure may know that salt and potassium are to be avoided in the diet, but learning has not occurred until that knowledge has been incorporated as a change in behavior.

Anyone who teaches, including a mother or father teaching a child how to put away toys, or a woman teaching a friend to crochet, has some belief regarding how learning occurs. Unfortunately, sometimes the knowledge the teacher possesses about learning is simplistic: “I told you; therefore, you should know.” An individual’s beliefs about learning can influence that person’s behavior regarding what should happen to make learning occur. By understanding basic theories of learning, the professional nurse will be better prepared to help the learner make the transition from acquiring knowledge to learning. This chapter presents some of the many theories of learning and describes how they are used to solve problems encountered in the teaching–learning process. These theories may be used by nurses in practice or education, as well as for designing, implementing, and evaluating research projects that involved education.

Categorization of Learning Theories

Some nurses might question why it is important to understand the process of learning and to know about some of the theories of learning. Learning theories describe the processes used to bring about changes in the ways individuals understand information and changes in the ways they perform a task or skill. Further, learning theories can help provide a focus for creating an environment and conditions in which teaching can occur more effectively (Candela, 2012). Kurt Lewin is credited with the adage: “There is nothing so practical as 

 

 

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