Concept of caring in nursing theory practice gap

Introduction

Caring starts from childhood and grows with us till we become an adult, it is a behavior that can be felt, taught and practiced, if the person has intention to perceive it. For instance the child learns it from his mother in the way she talks, touch and handle. On the other hand caring is considered as an important behavior and a key aspect in promoting patient’s health and accelerating the healing process.

Caring in the nursing profession happens when a nurse have contact with a patient with hope and commitment as the important parts. According to Watson’s theory the goal of nursing is helping a patient to achieve harmony within the mind, body, and soul.

As contrast we can’t expect everybody to care for us. We can ask ourselves what is the relation between learning how to care and practicing it. In fact it’s a conflict between theoretical concept of caring and vocational practice of it.

In the following essay I will explore the important facts about caring.

Definition of caring

Caring is a difficult subject to define as it’s the feeling which exhibit concern, empathy in satisfying the physical, psychological, spiritual, cultural, social and emotional needs. This can be achieved by being compassionate, loving, kind, warm, sensitive, sympathetic, responsive, and considerate to others.

We have a variety of different theories of caring, Leininger (1991) who considered caring is a world wide phenomenon originates from the cultures and affects the individual response. Based on the needs of an individual, she also stated “care as the essence of nursing and the central, dominant, and unifying focus of nursing”. Others think that” caring is an art as well as a science that embrace a humanitarian, science based, process and experience with medicine for mind, body and soul, commitment to patients and families, defined by beliefs and morals. Regardless of illnesses or diseases patients are having, they should be seen as a whole and complete transpersonal Caring allows unity of life and connect to move caring from one individual to another” (Watson, 2003).

Bearing in mind the Nursing theories integrates the caring concept in nursing practice and considered the nurse as the main key point in the whole process. Therefore the “Nursing has distinctive views of persons and strong commitments to compassionate and knowledgeable care of persons through nursing” (Parker, 2001).

Side by side the patient care, not cure, should be addressed in a holistic framework and not in particularistic method. The care should grant the use of the nursing process (to assess, plan, implement and evaluate patient care), clinical, ethical and practical experience followed by evidence based practice to maximize patient’s outcome.

The Nursing caring theory is based on practical, educational and research aspects and the “nurses reflective-critical practice models” are increasingly adhering to caring ethic and ethos (Watson, 2008).

Relevance of the caring

In 1987 the World Health Organization improved the quality of health care by publishing aims that help to gain health and promote it, Hood (2010). Florence Nightingale is considered as the first person involved in improving the quality of care, similarly the quality of care defined” as a concept that is at its most meaningful when applied to the individual user of health care” (Campbell,2000). Appendix (1)

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Watson (2007) listed steps used to achieve the Human caring theory as the following: First combining the value, practice and beliefs with self and others, then placing faith and hope to honor others, followed by improving the helping – trusting – caring relationship and promoting, developing and acknowledging optimistic and pessimistic feelings to listen to other people. Problem-solving methods should be used in decision making, besides focusing on teaching and learning individual requirements to generate an environment that respects human dignity, supports physical, emotional and spiritual requirements, and finally offers the chance for miracles to happen.

Nevertheless “Between 2002 and 2026, the number of older people who will require care is likely to rise by 50 per cent, and costs per head will also rise, unless the Government increases its own contribution, the extra costs will fall on care users” (Royal collage of Nurses, 2008).

It seems that caring can be threatened by an economic wedge between doctors and patients that will weaken and finally destroy the commitment for caring and ultimately the great calling. Health care providers should not be too fascinated and preoccupied by modern science and technology and then neglect caring for the human person who has the disease.

Lots of institutions started to focus on better care for everyone in a hospital, care home and at home (The Care Quality Commission, 2010).

Palliative Care for terminally sick people is a good example; that shows the importance of caring in nursing. Health care providers handles the situation in a holistic method, by offering the dying patient the dignity and the support, but also to his family, friends and caregivers in both psychological, emotional and spiritually aspects, which help them to cope with the journey.

However the Palliative care is also defined as “a therapy that focuses on decreasing pain and suffering by providing treatment for relief of symptoms along with comfort and support for patients of all ages It is also. to have apprehension for each human life, having inner peace with own mortality and know and accept all cycles of life (Watson 2002).

Palliative care uses a team approach that involves the treating doctor, the family, other health care professionals and social services” (Journal of the American Medical Association, 2006) and assist the patient and his family to make informed decision for the desire treatment.

High quality palliative care can differentiate between a comfortable existence and one that involves much suffering. Besides, it aim to relieve the suffering, improve quality of life for people facing serious and complex illness, treating the pain and other distressing symptoms, provides psychological and spiritual care and a support system to help the individual live as actively as possible and aim to sustain and rehabilitate the individual’s family and enable them to deal with the issues of grief and bereavement.

Caring is an important behavior, that disciplining a nurse’s act and teach them commitment to win the patient and his family’s trust. As a result it promotes the healing process, prevents further illness and saves lives. It also offers him value and a death in dignity along with allowing the patient and the nurse to choose the suitable action to a certain extent.

Care -Q instrument is a widely used assessment tool to measure the level of care provided. The “Care -Q instrument” consists of 50 behavior items ordered in six subscales of caring: accessible; explains and facilitates; comforts; anticipates; trusting relationship; monitors and follows through. This tool is used to investigate the qualitative and quantitative method of the caring concept (Cutcliffe , 2005).

Other topics to focus on are the level of patient satisfaction by also measuring the connection or relationship between the care provider and the patient, not only in terms of interpersonal treatment, but also in the effectiveness of communication, comprehensiveness and continuity of care.

Defining the Theory Practice gap

After looking in literature I realize the theory practice gap is a world wide dilemma and every nation tries to resolve it by creating different measures. However the theory practice gap dilemma rose up based on the hypothesis of applying the nursing theory in to the direct practice. The theory practice gap can be due to the presence of lack in integration of theory into clinical practice which affects the patient satisfaction. “The patient satisfaction is used as an important indicator of quality of care and often integrated in planning and evaluation of healthcare” (Zavare, 2010).

“The theory practice gap occurs between the knowledge and practical application that can affect professional competence and contribute to difficulties in progressing from student to a novice professional” (Michau et al, 2009).

Both Maben (2006) and Vedam (2007) experienced the differences between

The ideal practice values in theory and the actual daily practice. Thus “The values and beliefs are expressed in the philosophies of nursing that are essential underpinnings of theoretical developments in the discipline” (Parker, 2001).

Consequently the presence of theory practice gap affects “the  Patient’s satisfaction and was reported as the most important predictor of the overall satisfaction in hospital care and this is a very important goal to reflect on health organization care ” (Mrayyan, 2006).

Although knowledge is power, the student nurses learns the rationalized care based on theories, but the controversy starts once they starts working in the clinical areas, facing the real situation and facts. Consequently it would be beneficial to them if the content studied correlates with the clinical practice, to minimize the theory practice gap. They should utilize their clinical experience, modifies the theory, applying and facilitating it in the patient healing process. As contrast the students should identify the strategic facts of performing the theory and try to justify the practice.

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Relevance of the theory gap practice

All the nursing practitioners and theorists putting their effort in narrowing the theory practice gap by inspiring a new attractive theory model derived from clinical experience to influences the future of nursing practice. This explains the importance to customize the individual care according to the patient’s needs. Therefore the clinical nurse is not only a practitioner, but a researcher and theorist who responds to patients needs by reflecting their past experience in their action of caring.

Julia Unwin “many older people and careers feel unsupported by a system that too often seems to be working against them, rather than giving them essential support at a time of their life when they are at their most vulnerable.” (Joseph Rowntree Foundation, 2010).

World wide facts:

United state of America

The Institute of Medicine (2001) provided their health care as an art they brush and redesign the entire health system and close the health care gap by prepared a new health system for the 21st Century by the committee on the quality of health care in America and released in March 2001.

Saudi Arabia

A research conducted and showed a gap in nursing performance and highlighted the effect of national culture attitudes between Saudi nurses. The finding shows the “nurse’s attitudes towards their jobs; and commitment to their employing organizations have been compelling to researchers due to the impact of their behavior at work and on quality of patient care”(Al-Ahmadi,2008).

United Kingdom

Alexis et al (2006) conducted a study that reported the different experience of UK nurses working overseas and the gap that they are facing in implementing the policies while caring for patient, inaddition to the unequal opportunities for training and the chance for developing their skill.

Bahrain

In Bahrain we have a huge theory practice gap, unfortunately this fact is not backed up by a research; it’s only based on individual clinical practice. For example most students experiencing shortage in hospital material and supplies, like gloves. They were taught to use gloves while doing a procedure and to use it once only, but due to the shortage of gloves in the hospital, the nurses were advised to use them more than once. This creates a theory practice conflict and only assertiveness of the students will solve the problem.

Both Cutcliffe (2005) and Wilson (2008) listed some factors that hinder the nursing practice from being accomplished and provide the theory practice gap, for example poor knowledge and skill provide chances of making errors. In addition to the lack of interpersonal communication between the nurses and patients, this causes attitudes responses. Irrelevant patient nurse ratio and limited time to finish assigned tasks, along with peer pressure on each other hand, can either motivate or discourage their enthusiasm.

To be effective in caring, communication to a patient or family should be comforting and create trust which can be a powerful therapeutic tool that provides consolation and a feeling of wellbeing. In nursing caring needs effective communication that validates the patient as well as the nurse as human.

Chiang (2008) focused on organizational factors like downsizing or reducing the employee numbers and discrimination between domestic and foreign employees in the facilities. Distinguishing between maintaining the standard of quality care in the hospital and bridging the theory practice gap depends on reporting and investigating those factors to be able to solve it.

Although the Ministry of Health in the Kingdom of Bahrain set up a good strategy (2002) by offering an “open communication approach, staff empowerment in discussion making, provide rewards and appropriate training ” to achieve the commitment and best staff performance, this strategy is only considered on paper as it’s not completely applied by hospitals in the Kingdom of Bahrain.

Conclusion

Caring is a behavior which varies from simplicity to complexity in understanding, and perceiving it. On the other hand it’s the way to deliver safe support and efficient care to all. For instance the American Nurses Association stated that the evolution between “health care and managed care has significantly changed practice settings and has brought expanded practice opportunities”.

Others like Florence Nightingale International Foundation visualize the importance of the care behavior by designing a nice Caring Symbol which illustrated four elements together such as a flame, hand, heart and globe. The flame represents the light of nursing knowledge and caring.  It also reflects back to the lamp Florence Nightingale carried while caring for the wounded during the Crimean War. The hand illustrates nurses reaching out to help and comfort others. The white heart characterizes the knowledge and humanity that infuse the work and spirit of nursing, and finally the globe shape illustrates the universality of the Foundation and the world in which each nurse provides care. Appendix

Nevertheless the Florence Nightingale International Foundation awarded scholarships and fellowships to enable nurses to undertake projects in several areas including advocacy, leadership, new models of patient care and new roles for nurses.

On the other hand merging nursing theories with practice will always be on the top of our list as “The community will require a fundamental, sweeping redesign of the entire health system” to suit the action needed (Institute of Medicine, 2009).

Pryjmachunk (1996) and Fealy (1997) cited in Cronin (2004) agreed that research, theories and practice are interdependent of each other. Developing the nursing practice and providing the best quality of care, nurses should apply the nursing process in such a way that a nurse can use her discretion in dealing with a patient’s situation instead of applying the nursing theory as it is. Appendix (3)

Skills maximizes by theory, guide and influence practice which should be applied artfully and scientifically.

Recommendation

Having the concept of improve the nursing practice and reduce the theory practice gap I listed some recommendation as the following: First nurses must have access to updated information, learning resources, and continuous educational opportunities. Second availability of job-related materials and supplies needed to improve and facilitate better patient care. Third the health Organization should encourage the professional employee to conduct researches to indicate the factors affecting the theory-practice gap. Fourth apply the related theory objective in to practice. Fifth the nurses should build in self interest to adapt to hospital environment change. Sixth emphasis to be on staff reflection, revise and indicate mal practice and observation and assessment of patient care. Seventh keep a list of multiple tasks to be accomplished. Eighth document all care activities to minimize errors. Ninth find a smooth measure to maintain a good nurse patient communication skill to promote the patient healing process. Tenth use the appreciating or incentive rewards to encourage the staff adherence to hospital policies.