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Theoretical Foundations of Nursing Practice in Poland

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Science Quarterly

Theoretical Foundations of Nursing Practice in Poland

Danuta Zarzycka, Beata Dobrowolska, Barbara slusarska, Irena Wronska, Tomasz Cuber and Majda Pajnkihar
Nurs Sci Q 2013 26: 80
DOI: 10.1177/0894318412466736

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6736
rzycka et al.
NSQXXX10.1177/08943184124667
Theoretical Foundations of Nursing
Practice in Poland
Danuta Zarzycka, RN; PhD1, Beata Dobrowolska, RN; PhD1,
Barbara S'lusarska, RN; PhD1, Irena Wron' ska, RN; PhD2, Tomasz Cuber, PhD1,
and Majda Pajnkihar, RN; PhD3
Abstract
This authors of this column explore the use of nursing theory in Poland. A quasi-experimental pretest-posttest study was
conducted to explore what, if any nursing theories were used by nurses in Poland, and if an education program on nursing
theory increased the use of nursing theory. The study found that while there were discrepancies between the nurses’
theoretical knowledge base and their use of these theories in practice, there is evidence of the use of the ideas and theory
of Nightingale, Orem, and Henderson in nursing practice in Poland.
Keywords
Henderson, Neuman, Nightingale, nursing practice, nursing theory, Orem, Poland
Nursing theories are used to improve the quality of nursing
care (Fawcett, Newman, & McAllister, 2004). Their devel-
opment in the United States and elsewhere dates back to the
1950’s. Their adoption in many places has been slow; they
have been criticized as being mutually incoherent and too
often developed in isolation from practice (Bond et al.,
2011). An analysis of research in nursing shows that many
nurses find it difficult to use theory in practice because of the
diversity of theories or the level of their generality and com-
plexity (Parse, 2005). Theory, research, and practice should
interact in cyclical ways and it is important for nurses to
understand theory as a basis for practice (Pajnkihar & But-
terworth, 2005).
Fawcett (2004) pointed out that the application of theory
in practice needs to be contextual. In Poland for example,
nursing practice may be more family-focused and may take
into consideration the influence of the Roman Catholic
Church, more than in other countries. It is also recom-
mended that nurses should not be uncritical of nursing the-
ories they use, but rather seek theories that will underpin
their practice and enhance nursing in their country
(Pajnkihar & Butterworth, 2005).
In nursing, as in other theoretical-practical disciplines, it
is important to ground occupational activities in theoretical
foundations, which also enhances the distinctiveness of that
discipline. The level of attainment of this objective is evolv-
ing and changing. The effectiveness of basing occupational
operations on relevant theories and reliable research findings
is demonstrated in reports, research lists and the quality of
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Nursing Science Quarterly
26(1) 80­–84
© The Author(s) 2013
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DOI: 10.1177/0894318412466736
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nursing care as perceived by both patients and nurses. In the
United Kingdom (UK) for example there are data that sug-
gest supporting self-care can improve health outcomes,
increase patients’ satisfaction, and help in developing coop-
eration between the patient, family, and environment (UK
Department of Health, 2007). At the same time, it is also pro-
vides evidence of the usefulness of Orem’s theory and con-
cepts in that context.
Background
In a World Health Organization/EURO document from 1986,
the assessment of almost all European countries including
Poland was presented regarding the use of nursing theory.
The Polish nurses primarily reported that they followed the
biomedical model, as well as principles of illness prevention
and rehabilitation (Górajek - Jóźwik, 1988). Other authors
have asserted that nurses in Poland also use theoretical con-
structs by Nightingale and Henderson (Górajek - Jóźwik,
2007). In Poland there are very few healthcare workplaces
1
Faculty of Nursing and Health Sciences, Medical University of Lublin,
Poland
2
Chair of Nursing Development, Medical University of Lublin, Poland
3
Faculty of Health Sciences, University of Maribor, Slovenia
Contributing Editor:
Steven L. Baumann, RN, PhD, Professor, Hunter College, City University of
New York, 82 Sherman Avenue, Williston Park, New York 11596
Email: sbaumann@hunter.cuny.edu
Zarzycka et al. 81
that invest in theoretical foundations for practice. However,
an analysis of nursing documentation and research reveals
that elements of theories are present in the practice of nursing
in Poland (Górajek - Jóźwik, 2007). Nightingale has been
described as the starting point, trunk of the nursing theory
tree, from which others nursing theories grew (Tourville &
Ingalls, 2003).
Aim of this Study
The aim of this study was to explore the importance of
selected theories in shaping nursing practice in Poland. The
research question is; What nursing theory is identified in
nursing practice in Poland? To answer this question the
following sub-questions were formulated:
1. Which nursing theories are recognized as signifi-
cant for the development of contemporary Polish
nursing?
2. What impact has the implemented educational
program had on the respondents’ opinions?
3. Is there coherence in the respondents’ opinions in
the empirically examined area of the nursing reality?
Design
The design was quasi-experimental with a one-group pre-
test-posttest conducted in Poland in the first half year of
2009. The participants were recruited from a postgraduate
course in surgical nursing. One hundred nurses were asked
twice, with a 4-week interval, to indicate the basic assump-
tions of nursing theory and to indicate those nursing theories
that were relevant in their practice. After the first survey, an
educational program was presented to the participants that
included content on the works of Nightingale, Henderson,
Orem, Roy, Neuman, Maslow, and Taylor. The educational
program’s goal was to enhance the theoretical knowledge
base of the participants. The program included 15 hours of
didactic learning activities on the philosophy of nursing,
selected nursing theories, the nursing process, and the practi-
cal applications of nursing theory.
Data Collection
A questionnaire included 25 statements grouped into five
topic areas (surnames of theory founders, the aim of nursing,
the essence of nursing, the perception of the patient, the
perception of the nurse’s role) in which some of the state-
ments were true and reflected the assumptions of selected
theories, while others were false. The participants were
asked to list statements in a hierarchical order within a par-
ticular topic area starting from the most important matters
(ranked 1) to the least important (ranked 5 or 6). If an ele-
ment was not ranked at all it was given a zero. The study
included one open-ended question regarding the nurse’s
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perception of the patient’s health. The questionnaire was
administered twice (one group pretest-posttest design). The
Ethics Committee of the Medical University in Lublin
approved this study. Verbal consent was given by all nurses
who participated and their identity was kept confidential.
Data Analysis
The data were checked and entered in a database and ana-
lyzed with SPSS 12.0. Descriptive analysis was completed
to report the participants’ use of nursing theories and aspects
of nursing practice. Their ranking of the items was reflected
as a percentage. Spearman’s rank order correlation was used
to search for the coherence of opinions in the tested area.
Results
Demographic
The participants were nurses working in a variety of places
and levels of job seniority. Most of the 100 participants
(n = 83) worked on surgical floors; 16 participants worked
in surgically-oriented outpatient clinics. Most participants
had worked as nurses for more than a decade.
Theoretical Foundations of Nursing Practice
The results of the study indicated that Nightingale’s ideas and
concepts remain very important to nurses in Poland and her
influence was unchanged by the educational program (82%
before the program and 83% after). Orem’s ideas and con-
cepts were initially ranked at 53% of the nurses before the
program, but only 20% afterwards. Henderson’s ideas and
concepts were ranked higher after the educational program
(from 23% to 62%). Neuman’s ideas were also ranked higher
after the program (18% to 31%). The other theories received
fewer responses; Maslow’s theory was ranked 6% before and
32% afterward, as did Taylor, which went from 8% to 43%.
These findings suggest that the most significant person in
creating contemporary nursing in Poland remains Nightingale
(5.45 mean importance weight before the program and 5.63
mean importance weight after program) and this result was
independent of the educational program. The change of
opinion on the work of Orem (4.17 mean importance weight
before the program and 4.26 mean importance weight after
the program) between the first and second inquiry was small.
The change of opinion of the participants on the work of
Henderson (2.52 mean importance weight before the pro-
gram and 4.52 mean importance weight after the program)
demonstrated a dramatic increase of nurses ascribing greater
theoretical meaning to contemporary nursing after the edu-
cation program.
The second finding of the study was in regard to the range
of occupational duties of nurses according to their opinions
—mean frequency weight and importance rank. This also
82 Nursing Science Quarterly 26(1)
was examined before and after the program. The opinions of
the nurses regarding the scope of their duties included deter-
mining the most common forms of activities. Before the edu-
cational program, the dominant nursing action was identified
by the participants as fulfilling medical directives (41%
before the program and 36% after the program). This item
dropped to a tie for second place after the education pro-
gram. “Assisting in self-care activities” went from only 18%
before the program to 38% after the program, making it the
first ranked item. “Supportive conversation” went from 28%
before the program to 36% after the program. Educating
patients went from 17% before the program to 35% after the
program. The following activities in the last position:
“replacing the patient in self-care activities” and “influenc-
ing the patient through changes in the environment” (26%
before the program and 47% after the program, and 39%
choices before the program and 22% choices after the pro-
gram, respectively). Some respondents did not express opin-
ions regarding the rank (the number of indications in the
zero-rank column ranges from 1 to 6). The role of the nurse
indicated by the ranking of the activities, shown by mean
frequency weights, was perceived as fulfilling medical direc-
tives in the first place (4.68 mean weight before the program;
4.49 mean weight after the program), next came assisting
the patient in self-care activities (3.73 mean weight before
the program; 4.49 mean weight after the program) and sup-
portive conversation (3.86 mean weight before the program;
4.10 mean weight after the program). Also this indicator
confirmed that the rarest and lowest ranked are activities
involving replacing the patients in their daily activities (3.10
mean weight before the program; 1.94 mean weight after the
program) and influencing the patient by environmental fac-
tors (2.19 mean weight before the program; 2.62 mean
weight after the program).
Spearman’s rank correlation coefficient was completed
for the variables of theorists’ surname and nursing aim, and
scope of nursing activities. The results of the analysis show
that the nurses who took part in the survey related Orem and
Neuman to the nursing goal of “help in self-care activities”
(r = 0.205, p = 0.039; r = 0.201, p = 0.044). When they chose
Neuman, they were most likely to select “decreasing stress”
as the aim (r = -0.258, p = 0.009). The presented negative
correlations show lack of coherence in the factual knowledge
of the respondents, which was reflected in their opinions.
In the search for the relations of the scope of the nurse’s
duties as the operational indicator in practicing nursing, it
was revealed that Orem was associated with the activity
of “replacing the patient in self-care activities” (r = 0.288,
p = 0.003) and Neuman was related to “assisting in self-
care” (r = 0.339, p = 0.000). These results indicate that
self-care appears to be essential in nursing practice. Three
items which were close to statistical significance where the
association of “educating the patient” with Orem, “assisting
in self-care” with Nightingale, and “fulfilling medical direc-
tives” with Henderson.
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Discussion
The complexity of nursing theories and other factors require
careful interpretation of these findings. To complicate mat-
ters elements of non-nursing theories are integrated into
several nursing theories (Bond et al., 2011; Torres, 1986).
Therefore, in the research findings, opinions regarding
names of nurse theoreticians, aims of nursing care, and
scope of nursing duties are convergent and not coherent with
each other. This lack of coherence may arise from insuffi-
cient general knowledge by the respondents and little under-
standing of this knowledge.
At the same time it is difficult for nurses to name what
they do in daily practice. One of the reasons for this, accord-
ing to Clark (2006), is that the nurses themselves find it dif-
ficult to express what they do theoretically. Having said that,
this study supports Torres’s (1986) view that “nursing care
requires both knowledge of some matters and processing
those matters” (p. 21). Therefore, the content provides
frames of reference that create a view of nursing. Processing
the content, on the other hand, facilitates the application of
known matters in the practice of nursing care (Torres, 1986).
Among nurse theoreticians and practicing nurses, it is widely
acknowledged that the theoretical bases, regardless of the
amount of content, are tested and used in practice to deter-
mine usefulness (Górajek-Jóźwik, 2007). According to this
statement, it would be an over-simplification to draw a theo-
retical image of contemporary Polish nursing on the basis of
the study results.
The respondents assessed their ability to meet the self-
care needs of their patient as rather high. This conception of
compensatory nursing focuses on team-work through
which nurses help dependant patients in meeting basic
needs and in adapting to living conditions changed by sick-
ness and disability. This study suggested that nurses’ per-
spective of health and consequently nursing practice in
Poland closely follows the biomedical model. The theories
and ideas of Nightingale and Henderson are still the most
popular in nursing practice in Poland. Similarly, nurses in
Slovenia reportedly prefer Henderson’s conceptual model
because of its simplicity, but they do criticize it as being too
narrow and not holistic (Pajnkihar & Butterworth, 2005).
Similar to the findings in this study, Kolcaba (1994) said
that meeting the basic needs of patients is significant and
specific for the nursing discipline.
Applying nursing theories in nursing practice in Poland
remains as infrequent as using nursing theories to guide
research. Nevertheless, Bond and colleagues (2011) identi-
fied a gradual increase in the number of studies based on
nursing theories. Research conducted in a Community
Nursing Center using on Neuman’s systems model, shows
the effectiveness of the use of her theoretical model in nurs-
ing practice, especially in the domain of assessment, diagno-
sis, planning, and nursing care realization. Neuman’s model
has also been seen as exerting positive influences on
Zarzycka et al. 83
communication in the therapeutic team, which is relevant for
future management of information in the healthcare centre
(Newman, 2005).
Difficulties in linking theoretical knowledge and nursing
practice remain a concern in nursing. At the same time, theo-
ries should be treated as ideal foundations and, thus, their
practical use supported, because the future of nursing lies in
transferring theoretical knowledge into practice (Barker,
2008). Among elements of critique of theoretical concepts in
nursing and difficulties of their use in practice, there is also
language that is criticized for being abstract and, hence, lack-
ing explanatory adequacy. In addition, it is sometimes
claimed that theories constitute the idealized conceptions of
nurse educators or researchers who do not have much in
common with nurses in practice (Graham, 2006). It is also
believed that some of the theories were created for the devel-
opment of critical thinking in nursing rather than for practice
in this domain (McKenna, 1997). Moreover, theories are
criticized for encompassing domains wider than nursing, or
for being locally/regionally-oriented (Fawcett & Cody,
2003).
Fawcett (2003) wrote about the importance of nursing
theory “if we were to discard this foundation, we would
have no right to expect recognition as fellow professionals
by physicians, social workers, therapists and health care
administrators” (p. 229). Hence, it is recommended that
more extensive studies be done to present the structure of
theoretical nursing in Poland. Within the framework of
such an empirical project it is essential to define the most
significant nursing theories used in nursing practice by test-
ing a greater number of practicing nurses.
Studies of nursing theory, even in a very limited dimen-
sion, help in the development of analytical abilities, change
ways of thinking, clarify assumptions and values, and indi-
cate suggestions for nursing practice, education, and man-
agement, which will contribute to the development of
nursing. This paper contributes the knowledge that:
•• In Polish nursing practice, theoretical assumptions
in the form of selected classical theories of nurs-
ing (Nightingale, Henderson, Orem, Neuman) are
increasing in cognitive interpretation but it is not
the same in the practice of nursing.
•• Nursing theories do not function as a basic substan-
tial interpretation for nursing practice, but are more
like a structure that organizes the main directions of
nurses’ professional activities.
The implications of this study for practice and policy
include:
•• Identifying the extent of incorporation of nursing
theories in Polish nursing practice, regardless of
professional experience and forms of the nurses’
professional education;
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•• Identifying existing discrepancies between theo-
retical knowledge about nursing theories and their
application in the process of caring; and
•• Defining strategic directions of the development of
nursing considering nursing practice, education and
management, based on the implementation of the
assumptions of classical nursing theories.
Conclusions
The most frequently indicated theoretician in Polish nursing
was Nightingale followed by Orem and Henderson. An edu-
cational program has, to a limited extent, influenced the
change of the respondents’ opinions. The findings of this
study showed a moderate amount of coherence of opinions
of the respondents in the area of nursing theories and their
use in practice in Poland. It can be reasonably claimed that
only theoretical grounding in nursing will be a reliable factor
in assuring optimal quality of nursing care.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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