Middle_Range_Theory_Paper

Smith and Liehr’s Story Theory Cecilia C. Singson Olivet Nazarene University Theoretical and Professional Foundations of Nursing MSN 38 Deborah Raley December 4, 2011 Abstract This paper is about Smith and Liehr’s Story Theory, classified as a middle-range theory. It will give an overview and description of the theory, a plan of implementation in this author’s area of work and discuss potential barriers that may be encountered during implementation as well as a critique of the theory. Smith and Liehr’s Story Theory Every patient has a story and almost everyone wants to share it. A person’s story is a fundamental dimension of the human experience. Although nursing has evolved into a science requiring a large knowledge base and skill set, it becomes an art when the nurse integrates caring, compassion and empathy into his/her care of the patient. From the get go, as nursing students, we have always been taught to care for the “whole” person- that the patient’s psychosocial and spiritual needs are not to be neglected or forgotten even when the disruption of the physical continuum is what brings the patient to the hospital. Nursing theories allow the nurse to vary her care according to the patient’s specific needs. Two patients might be admitted for the same diagnosis but their stories differ. Each person is unique, therefore, each care plan is also unique and well suited to the needs of the patient taking into consideration his/her whole self. As nurses, this writer believe it is integral to our jobs to value our patients’ stories to care for them holistically. This is why I chose Smith and Liehr’s Story Theory. Overview Middle range theories are narrow in scope than grand theories and offer an effective bridge between the grand theories and the description and explanation of specific nursing phenomena ( Parker & Smith, 2010). Nursing scholars proposed using this level of theory because of the difficulty in testing grand theory (Jacox, 1974). They present concepts and propositions at a lower level of abstraction and hold great promise for increasing theory-based research and nursing practice strategies (Smith & Liehr, 2008). Middle-range theories may have their foundations in a particular paradigmatic perspective or may be derived from a grand theory or conceptual model (Parker & Smith, 2010). This paper will focus on Smith and Liehr’s Story Theory. It was previously named “attentively embracing story” theory. There are three concepts to the Story Theory: intentional dialogue, connecting with self-in-relation and creating ease. When we say true presence, there is intentional dialogue and purposeful engagement by a nurse to a patient to summon a story. The nurse allows for time to listen to the patient’s story in a non-judgmental manner and allows the patient to tell his/her health story. This could be achieved by simply sitting with the patient and allowing them to know that you have time to listen to their story. When people are allowed to tell their health stories to a truly present nurse, the road to healing, change and recovery are possible. In connecting to self-in-relation, the nurse is aware of the patient’s feelings, respect the storyteller and what is important to them and at the same time, being sensitive to their verbal and bodily expressions. To create ease, the nurse must act as the facilitator and gently urge the patient toward solutions to resolving the health challenge they are experiencing. When a seemingly achievable solution is reached, the patient is put at ease. In the Story Theory, the nurse understands what matters most to the patient living through a health challenge and respects the person as the expert in his health story. Some examples of health challenges may be newly diagnosed cancer, teen or unexpected pregnancy, undergoing a life changing surgical intervention to name a few. These can all be traumatic experiences and how the patient reacts vary depending on age, life experiences and/or support system and even socio-economic background. There are seven phases of inquiry in Smith & Liehr’s Story Theory: 1) gathering the story about a complicating health challenge, 2) composing the reconstructed story, 3) connecting existing literature to the health challenge, 4) naming the complicating health challenge, 5)describing the developing story plot , 6) identifying movement toward resolution and 7) collecting additional stories about the complicating health challenge. The Story Theory has been used in many different settings. Mittender (2011) utilized this theory working with a Guatemalan Mayan patient to provide a culturally sensitive plan of care. Walter, Davis & Glass (1999) applied the Story Theory examining the nurses’ self-knowledge and self-actualization in relation to self-concept and nursing practice. Payne (2010) used the Story Theory while working with women recovering from addiction. Clearly, it has a place in many different areas of nursing practice. Implementation/ Discussion/Barriers/ Critique This nurse believes the Story Theory can be put to practice in her current work in the Cardiac Intermediate care Unit. This project will start unit-based. This project aligns with the mission, values and philosophy of my current employer so I believe I will gain the support of my nurse manager to implement this project. The plan will be presented to the Shared Governance Council and this RN foresees that it will be approved. The Story Theory will be presented and described in our shift huddles. There will be an outline or script for the nurses to follow. It will ask the nurse to sit with the patient for 5 minutes in an intentional dialogue at the beginning of his/her shift and establish goals for the day. This allows the nurse to summon the story of the patient’s health challenge and allow the patient to feel involved in their care. The nurse has to abandon assumptions relating to the patient or the disease diagnosis to be truly present and non-judgmental. He/she will also involve the family if they are present at that time. The nurse should not only be sensitive to the patient’s verbal cues but also the bodily expressions. He/she is also responsible for anchoring flow of the conversation and establishing health goals for the shift moving towards a resolution of a health crisis. Our goal as nurses is to provide the best care always. Patient satisfaction is a major quality indicator if we achieved this goal. In my present work, surveys are sent to every patient upon discharge. Follow up discharge phone calls are also made 48-72 hours after the patient leaves the hospital. One key question asked in these surveys and phone calls is if the patient feels that they were involved in their care. By implementing the Story Theory, we can address this area of achieving patient satisfaction. More importantly, we connect with another human being and become a catalyst toward the resolution of a health problem. I believe its implementation will achieve several goals: my personal goal, the patient’s goal and my hospital’s goal. As an example, I will refer to a patient who just had a myocardial infarction requiring angioplasty. The day nurse at the beginning of her shift will allow for time to sit with the patient and allow him to tell her his health story. She will be truly present and compassionate and ask the patient key questions during this interaction. Leihr explains, “When I am truly present as a nurse, it enables the patient to feel stronger, take positions and move on.” Questions may include the patient’s lifestyle, job, diet, family history, support system and his willingness to modify those factors that can be changed. Together, the nurse and patient will decide on an achievable goal that they will both evaluate at the end of an eight hour shift. For this example, we will say that the patient picked the goal of being able to identify his medications, a beta-blocker and an anti-coagulant and to repeat to the nurse why it is imperative that he takes them. At this point, this is of utmost importance to the patient. The nurse then provides the patient with printed literature as well as a discussion of the classification, simple pharmacology and most common side-effects of the medications. A pharmacist can also be called to provide more teachings to the patient. It may sound simple but it if the patient himself picked this goal, he feels empowered and involved in decisions for his care. A log of topics taught to the patient that day can also be kept at the patient’s bedside which will provide a tangible reminder for the patient. At the end of the shift, the nurse returns to the patient’s room and asks him if he he has any further questions on the day’s topic. This patient may have been admitted with a MI but while the nurse was drawing out the patient’s story, she found out that the patient recently lost his wife and expressing feelings of depression. To truly take care of this patient holistically, the nurse will refer this problem to the primary care doctor and may suggest a psych evaluation. Often times, we learn of other problems the patient may have besides their actual diagnosis when we listen to their story. This gives us the opportunity to give care to the “whole” person. The goal is to provide patients the tools that they need once the acute phase of hospitalization is done and give them self-management skills. My personal goal of making a difference will also be achieved. And when that survey returns to my administrator, I would have hopefully gotten us the best scores possible and played a part in living our mission and philosophy. It is truly a rewarding experience for all involved and all it took was to listen to someone’s story. Having a theory in mind and a plan for implementation is not all it takes for a plan to be successful. The greatest barrier to the implementation of this project is time constraint. A typical patient load for a nurse in our unit is 4 to 5. The Story Theory emphasizes sitting with the patient to be truly present. It does not encourage incorporating it to our other duties and functions of the nurse. I do believe that it is not impossible. Time management is of essence here and it is hard to teach that. Support for this project may also be hard to win from the staff nurses. If they have 4 patients, that would mean twenty minutes would be spent sitting with the patient to draw out their story. They might argue that this task could be done simultaneously with other nursing duties such as passing medications. This would require educating the nurses and providing them with articles on how the Story Theory was used at other similar hospitals and how it has worked. Support from the Shared Governance Council as well as the nurse manager would also be key for successful implementation. To evaluate if this project worked, this RN will track daily Hospital Consumer Assessment of Health Care Provider and Systems (HCAHPS) scores and pull out several surveys to measure if this project has truly impacted how the patients feel about the nurses’ responsiveness as well as their being allowed to participate in their care. This is a measurable and objective evaluation and provide insight on whether the project is successful or not. Smith and Liehr (1999) explain that “The following descriptions of middle-range theory as found in the nursing literature; testable and immediate in scope, adequate in empirical foundation, neither too broad nor too narrow.... and more circumscribed than grand theory but not as concrete as practice theory.” I chose this theory for this particular reason. Being a nurse in the 21st century, I can relate to the middle-range Story Theory. I believe it is relevant to my practice today and could easily be applied to my everyday work as a nurse. Being the permanent charge nurse of the Cardiac Intermediate Care Unit, I am presented with countless opportunities to summon a patient’s health story. Having no patient load, I would have the time to sit with a patient and draw out their story in a compassionate way. I will be able to help a person feel that they are involved in their care and that we, as nurses, are available not only to give them their medications or give them a sponge bath but are truly interested in them as a person with a story. In closing, I would like to quote Liehr and Smith The challenge is to move nursing theory forward by spinning research and practice in the creation of middle-range theory congruent with the current historical context. It is the forward movement that will give substance and direction to the discipline. Middle- range theory will create the disciplinary fabric of the new millennium as nurse theorists spin and twist fibers from the past-present into the future. ( Liehr & Smith, 1999) References Liehr, P. (2005). Looking at symptoms with a middle-range theory lens. Advanced Studies in Nursing. 3(5), p.152-157. Liehr,P. & Smith, M. (1999). Middle-range theory: spinning research and practice to create knowledge for the new millennium. Advances in Nursing Science. 21(4), p.81-91. Mittender, E. (2011). Using stories to bridge cultural disparities, one culture at a time. Journal of Continuing Education in Nursing. 42(1), p.37-42. doi:10.3128/00220124-20100901-01. Parker, M. & Smith, M. (2010). Nursing theories and nursing practice. Philadelphia: F.A. Davis Company. Payne, L. (2010). Self-acceptance and its role in women’s recovery from addiction. Journal of Addictions Nursing.21(4), p.207-14. doi:103109/10884602.2010.515693. Smith,M. & Liehr, P. (2008). Middle range theory for nursing (2nd ed.). New York, NY: Springer Publishing Company, LLC. Smith, M. & Liehr, P. (2005). Story theory: advanced nursing practice scholarship. Holistic Nursing Practice. 19(6), p. 272-6, ISSN 0887-9311. Walter, R., Davis, K. & Glass, N.(1999). Discovery of self: exploring, interconnecting self (concept). Nursing Collegian. 6(2), p.12.