Role of the Nurse

PROFESSIONAL ISSUES
Castledine (1994a) reiterates this point sug-
gesting that a definitive and unified theory of
nursing can never exist and we should accept
that there are multiple views about the ways
in which nursing is perceived and described.
He also believes that nursing is a complex
concept that is so intricate in its constitution
that it may not be possible to encompass its
full meaning in any definition.
Meleis (1985) categorizes the major
nurse theorists and their models using the fol-
lowing headings:
G Needs theories
G Interaction theories
G Outcome theories.
This framework provides a structure for
the examination of nursing models and ideas
when attempting to identify how the role of
the nurse is described.
NEEDS-BASED THEORY
The difficulty in describing and defining nurs-
ing was identified by Florence Nightingale
(1952) in her work Notes on Nursing.
She suggests that nursing is complex and mul-
tifaceted and that its full meaning needs
exploration:
‘I use the word nursing for want of a
better…the very elements of nursing are
all but unknown.’
Roper (1994a) summarizes Florence
Nightingale’s ideas about nursing in the fol-
lowing way:
G The requirements and needs of sick and
healthy people are central to nursing
G The environment of people is a legitimate
concern
G Skill of observation does not make a good
nurse but without it a nurse would be
ineffective.
Roper (1994b) suggests that Nightingale’s
ideas remain an important part of nursing
and underpin much of the present role of the
nurse. She states:
F
rom the literature available it is
apparent that the role of the nurse is
not easily defined with theorists from
within the profession failing to agree on the
exact nature of nursing (Antrobus, 1993).
Some place the emphasis of the role on the
concept of caring (Kitson, 1987) and therapy
(McMahon, 1991; Pearson, 1992), while oth-
ers indicate that the role is more diagnostic
and technical, remaining disease-centred
rather than person-centred (Bortoff and
D’Cruz, 1984). Antrobus (1993) believes that
the way forward is to develop the body of
nursing knowledge as this will enable nurses
to articulate what they are and what they do.
The use of nursing models as a base for the
practice and development of nursing knowl-
edge is being increasingly criticized and ques-
tioned by nurse scholars for not providing
realistic descriptions of nursing (Robinson,
1990; Draper, 1992; Kenny, 1993). However,
in terms of defining the role of the nurse,
examining the contents of these models pro-
vides a useful challenge. Smith (1982) states:
‘…a general theory of nursing or a
general model of nursing which
encompasses the entire profession is to
be rejected. This statement is justified on
the basis that the diversity in nursing
precludes the emergence of a general
theory of nursing.’
Role of the nurse: introducing
theories and concepts
Frank Crossan, Alna Robb
Abstract
This article is a descriptive analysis of the work of nurse theorists in
relation to the role of the nurse. It is clear from the literature that
nursing is difficult to define but it is possible to identify the core values
of nursing and the commonalities that run through the profession. The
core components identified by an examination of the literature are the
development of systems for the delivery of care, coordinating care,
teaching, defending the frail and vulnerable, caring for the ill and the
well, and providing technical care. This article aims to provide a baseline
picture of what nursing is and how it is described in nursing models
allowing readers to examine and compare their own values and image of
nursing with what the theorists have written.
608 BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10
Frank Crossan is Clinical
Services Manager, Surgical
Directorate, Falkirk and
District Royal Infirmary and
Alna Robb is Lecturer,
Department of Nursing
Studies, University of
Glasgow
BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10 609
‘Today over a hundred years later,
observing has become part of the
assessing, implementing, and evaluation
phases of the process of nursing. To use
this method nurses can select from a
variety of conceptual models of nursing.
In current nursing curricula there is an
emphasis on promoting health and
preventing ill health, and on the
sociocultural and politicoeconomic
context pertaining to the environment in
which nursing takes place.’
One of the most widely quoted descriptions
of the nurse’s role is that of Virginia
Henderson (1966):
‘The unique function of the nurse is to
assist the individual, sick or well, in the
performance of those activities
contributing to health or its recovery (or
to a peaceful death) that he would
perform unaided if he had the necessary
strength, will or knowledge. And to do
so in such a way as to enable him to gain
independence as rapidly as possible.’
Henderson’s work is described as the water-
shed between the past and the future of mod-
ern nursing (Marks-Maran, 1992). Henderson
describes the nurse as an independent practi-
tioner but she emphasizes that nursing care is
carried out as part of the wider medical plan.
Aggleton and Chalmers (1988) suggest that
these two nursing functions do not fit easily
together and result in a confused image of
nursing. However, it could be argued that
these two roles are complimentary and essen-
tial if the nurse is to play a significant part in
the multidisciplinary team.
Roper et al (1980) describe the role of the
nurse in terms of independent practice, but
point out that at times the nurse may fulfil a
dependent role (e.g. assisting doctors), and an
interdependent role as part of the
multidisciplinary care team with the emphasis
being on assisting and enabling individuals to
carry out activities associated with living. Orem
(1991) also subscribes to the view that a major
part of the nurse’s role is enabling individuals to
care for themselves and describes five aspects of
nursing: acting and doing for the patient; guid-
ing; providing physical and psychological sup-
port; providing an environment to promote
development; and teaching people to care
effectively for themselves.
McFarlane and Castledine (1982) propose
that nursing involves prescriptive activities
but point out that the major role of the nurse
is to assist the individual, or community, in
the maintenance of health and wellbeing,
with particular reference to basic human
physiological, psychological and social needs.
The ‘needs-based’ models of nursing are
criticized for their dependence on the med-
ical, physical and curative aspects of care
(Cavanagh, 1991) with others (Melnyk,
1983) indicating that the description of the
nurse’s role contained in some models (e.g.
Orem’s, 1991) suggests that the function of
the nurse is guided by the prescriptive
activities of others, such as medical staff.
Wright (1990), however, argues that the help-
ing and assisting aspect of the role described
by such theorists is essential and basic to the
nursing function.
Roper (1994b) reaffirms her ideas about
the role of the nurse when she states:
‘…I am still convinced that there is a
nurse-initiated core of nursing that
concerns patients’ problems with every
day living activities. Many patients also
require derived nursing interventions.’
She suggests that if nurses accept this they
will be able to conceptualize nursing more
realistically.
INTERACTION THEORY
Interaction theorists place the emphasis of
nursing on the establishment and maintenance
of relationships. Crucial to these theories is the
impact of nursing on patients and how they
interact with the environment, people and the
situations in which they find themselves. Nurse
theorists as diverse as King, Orlando,
Travelbee and Weichanbach can be grouped
under this heading (Kitson, 1992).
Orlando (1961) asserts:
‘The function of professional nursing is
conceptualized as finding out and
meeting the patient’s immediate need for
help.’
This is achieved by using the nursing process
which, according to Orlando, comprises three
major elements: the behaviour of the patient;
the reaction of the nurse; and the nursing
actions that are designed for the patient’s bene-
fit. The interaction of these elements is, in
The “needs-
based” models
of nursing are
criticized for
their dependence
on the medical,
physical and
curative aspects of
care...with
others...indicating
that the
description of the
nurse’s role
contained in some
models...suggests
that the function
of the nurse is
guided by the
prescriptive
activities of
others, such as
medical staff.
‘
’
ROLE OF THE NURSE: INTRODUCING THEORIES AND CONCEPTS
and directing patient care by using their
knowledge of the human physiological and
behavioural systems. Roy’s (1980) adaptation
theory suggests that the role of the nurse is to
enable individuals, through nursing interven-
tion, to adapt to the environmental stimuli
around them. The nurse is seen primarily as a
change agent who can manipulate the stimuli
affecting the individual or help the individual
to adapt so that he/she can cope (Roy and
Roberts, 1981).
Neuman (1982) suggests that the role of the
nurse is concerned with caring for the individ-
ual as a whole. She describes nursing as:
‘A unique profession in that it is
concerned with all the variables in an
individual’s responses to stress.’
This holistic caring role extends to the well
individual in terms of health promotion.
According to Rogers (1970), the major role of
the nurse is to:
‘Promote symphonic interaction between
man and environment, to strengthen the
coherence and integrity of the human
field, and to direct and redirect
patterning of the human and
environmental fields for the realization
of maximum health potential.’
These theorists are often criticized for their
abstract and complicated ideas about nursing
(Aggleton and Chalmers, 1988). While their
ideas are intellectually challenging they are
often difficult to implement and use opera-
tionally. However, they provide key indica-
tors as to what constitutes the nursing role
and this depth of thought is useful in that it
stimulates others to explore and question
what is written about nursing.
NURSING CARE
Traditionally, the concept of caring is closely
linked with the role of the nurse. However,
actually defining the role of the nurse as a
carer is difficult.
Orem (1991) sees the focus of caring, and
therefore the role of nursing, as the return of
the patient to self-care as opposed to the
formation of a reciprocal caring relationship.
Kitson (1987) expands this idea and suggests
that the nurse committed to care must be able
to provide sustained and continuous care for
as long as the individual needs it, have the
essence, nursing. The emphasis on the relation-
ship as the cornerstone of the nursing role
(Orlando, 1961) is also supported by the work
of Travelbee (1971), who describes nursing as:
‘...an interpersonal process whereby the
professional nurse practitioner assists
an individual, family, or community to
prevent or cope with the experience of
illness and suffering and, if necessary,
to find meaning in these experiences.’
King (1981), in her systems model, states
that the primary function of the nurse is to
help individuals maintain their health in
order that they can function in their roles. She
views nursing as a process of action, reaction,
interaction and transaction.
Peplau (1988) states that the nurse’s role
cannot be considered in isolation as it will
change in relation to interactions with others
and suggests the roles listed in Table 1. Peplau
feels that the relationships within which these
roles are enacted should be the focus of nurs-
ing. Salvage (1990), however, suggests that
this may not be what patients need or want.
In general hospitals, for example, the sick
person’s priority is more likely to be relief
of physical symptoms as opposed to expres-
sion of understanding or learning about the
symptoms in an all-embracing, caring rela-
tionship with a nurse. In addition, Webb
(1994) warns that:
‘The traditional emphasis on physical
care and comfort must not be lost in the
struggle to humanize care.’
OUTCOME THEORY
According to Meleis (1985), outcome or
holistic theories describe nurses as controlling
610 BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10
In general
hospitals...
the sick person’s
priority is more
likely to be
relief of physical
symptoms as
opposed to
expression of
understanding or
learning about
the symptoms
in an all-embracing,
caring
relationship
with a nurse.
‘
’
Stranger who initiates
relationships
Teacher
Resource person
Leader
Counsellor
Surrogate
Source: Peplau (1988)
Table 1. Peplau’s nursing
roles
PROFESSIONAL ISSUES
CONCLUSION
In summary, it is clear that there is no straight-
forward description, or definition, of the
nurse’s role. It is complex and multifaceted
and, according to some, is based in the
competent completion of technical/diagnostic
treatment closely linked to medical care.
According to others, the nurse is a profession-
al caregiver who is able to deliver nursing as a
therapy in its own right (Antrobus, 1993).
There is a continued need for nurses to
develop their knowledge base and
demonstrate the benefits of nursing in real
terms so as to clarify the concept of nursing.
The report The Challenges of Nursing and
Midwifery in the 21st Century (Department
of Health, 1994), otherwise known as the
Heathrow debate, identified a concept in the
nurse’s role which it refers to as the ‘nursing
constant’. This comprises the core skills
and values of the nursing role, i.e. coordinat-
ing, teaching, defending the frail and vulnera-
ble, developing systems of care, concern
for the ill and the well and technical expertise.
Castledine (1994b) suggests that nurses
should concentrate their energies on the
development of this ‘nursing constant’ if the
true value of nursing is to be demonstrated.
He states:
‘We live in a world that pays little
attention to the value of caring and
necessary level of knowledge and skills to
meet the needs of the patient and ensure
that care is provided in such a way that
maintains the integrity of those in receipt
of the care.
Watson (1979) states that caring, as a
nursing term, represents all the factors that
the nurse employs to deliver care. She identi-
fies 10 caring factors which relate to the
dynamics between individuals in a nursing
relationship, e.g. trust and respect, and
believes that these can only effectively be used
interpersonally by a skilled and knowledge-
able practitioner. These factors are identified
by Leininger (1978) as comfort measures and
include the attributes listed in Table 2.
Pearson (1992) insists that the need to place
caring as the central part of the nursing role
has never been greater and is concerned that
the caring components have:
‘…become decentralized and seen as the
least sophisticated and subordinate to
the therapeutic interventions of doctors
and paramedical therapists.’
McFarlane’s (1977) view of caring in nurs-
ing suggests that nursing activities will only
become meaningful in a relationship based on
respect for an individual’s dignity and
autonomy. This definition of nursing as an
ethically based phenomenon is supported by
Benner (1985):
‘Nursing offers crucial services that
require high intelligence, a thorough
and sound educational base, and
firm grounding in the ethics of both
rights and justice and care and
responsibility.’
Benner suggests that while the nurse’s caring
role will require an involved stance it
should not:
‘…seek to control or master but to
facilitate and uncover the possibilities
inherent in the situation and the
person. Caring provides
empowerment.’
Gaut (1986) agrees and believes that the
concepts related to caring and nursing must be
taken beyond the observable behaviours of
nurses to mechanisms such as decision making
and scientific problem-solving which underpin
the more obvious aspects of the role.
BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10 611
...it is clear that
there is no
straightforward
description, or
definition, of the
nurse’s role. It is
complex and
multifaceted and,
according to some,
is based in the
competent
completion of
technical/diagnostic
treatment
closely linked to
medical care...
‘
’
Compassion
Empathy
Helping and coping behaviours
Stress alleviating measures
Touching (hand and body contact)
Nurturance
Succourance
Protective, restorative and stimulative
behaviours
Health maintenance
Instruction
Consultation
Source: Leininger (1978)
Table 2. Leininger’s comfort
measures
ROLE OF THE NURSE: INTRODUCING THEORIES AND CONCEPTS
sharing. It is important therefore that
nurses continue to advocate and
champion the cause of nursing as quality
in living well and dying free from stress
and pain.’
Nursing is complex and difficult to
describe, but it is an exciting profession
which is rich in theory and practice. As nurs-
es we must continue to build and expand the
ideas and concepts that underpin what we are
and what we do.
Aggleton P, Chalmers H (1988) Nursing Models
and the Nursing Process. Macmillan,
London
Antrobus S (1993) Nursing’s nature and bound-
aries. Sen Nurse 13(2): 46–50
Benner P (1985) From Novice to Expert. Addison-
Wesley, Menlo Park
Bortoff JL, D’Cruz JV (1984) Towards inclusive
notions of patients and nurse. J Adv Nurs 9:
549–53
Castledine G (1994a) Nursing can never have a
unified theory. Br J Nurs 3(4): 180–1
Castledine G (1994b) The role of the nurse in the
21st century. Br J Nurs 3(12): 621–2
Cavanagh SJ (1991) Orem’s Model in Action.
Macmillan Education, London
Department of Health (1994) The Challenges of
Nursing and Midwifery in the 21st Century — A
Report on the ‘Heathrow Debate’ held in May
1993. HMSO, London
Draper J (1992) The impact of nursing models. Sen
Nurse 12(3): 38–9
Gaut DA (1986) Evaluating caring competencies in
nursing practice. Top Clin Nurs 8(2): 77–83
Henderson V (1966) The Nature of Nursing:
A Definition and its Implication for
Practice, Research, and Education. Macmillan,
New York
Kenny T (1993) Nursing models fail in practice. Br
J Nurs 2(2): 133–5
612 BRITISH JOURNAL OF NURSING, 1998, VOL 7, NO 10
KEY POINTS
I Nursing models provide a vast array of information in relation to
the role of the nurse.
I Developing a single general description of nursing is not possible
as a result of the complex and wide range of work carried out
by nurses.
I The nursing process is common to most models as the system for
planning and developing their work.
I There is a need for nurses to promote and develop these core values
and to communicate them to others.
King IM (1981) A Theory for Nursing: Systems,
Concepts and Process. Wiley and Sons, New
York
Kitson A (1992) Formalizing concepts related to
nursing and caring. In: Kitson A, ed. Nursing,
Art and Science. Chapman and Hall, London:
24–45
Kitson A (1987) A comparative analysis of lay
caring and professional (nursing) caring
relationships. Int J Nurs Stud 24(2): 155–
65
Leininger M (1978) Transcultural Nursing
Concepts, Theories and Practices. John Wiley,
New York
Marks-Maran D (1992) Rethinking the nursing
process. In: Jolley M, Brykczyska G, eds.
Nursing Care: The Challenge to Change. Arnold,
London: 91–103
McFarlane JK (1977) Developing a theory of
nursing: the relationship of theory to
practice, education and practice. J Adv Nurs 2:
261–72
McFarlane JK, Castledine G (1982) The Practice of
Nursing: Using the Nursing Process. CV Mosby,
London
McMahon R (1991) Therapeutic nursing: theory,
issues, and practice. In: McMahon R, Pearson A,
eds. Nursing as Therapy. Chapman and Hall,
London: 2–25
Meleis A (1985) Theoretical Nursing: Development
and Progress. Lippincott, Philadelphia
Melnyk KAM (1983) The process of theory analy-
sis: an examination of the nursing theory of
Dorothea E Orem. Nurs Res 32(3): 170–4
Nightingale F (1952) (original 1859) Notes on
Nursing. What it is and What it is Not.
Duckworth, London
Neuman B (1982) The Neuman Systems Model:
Application to Nursing, Education and Practice.
Appleton-Century-Crofts, Norwark
Orem DE (1991) Nursing Concepts of Practice. 4th
edn. Mosby Year Book, St Louis
Orlando I (1961) The Dynamic Nurse–
Patient Relationship. GP Putnam’s and Sons,
New York
Pearson A (1992) Taking up the challenge: the
future of therapeutic nursing. In: McMahon R,
Pearson A, eds. Nursing as Therapy. Chapman
and Hall, London: 192–210
Peplau HE (1988) Interpersonal Relations in
Nursing. 2nd edn. Macmillan, Basingstoke
Robinson D (1990) Two decades of ‘The Process’.
Sen Nurse 10(2): 4–6
Rogers ME (1970) An Introduction to the
Theoretical Basis of Nursing. Davis,
Philadelphia
Roper N (1994a) Definition of nursing: 1. Br J
Nurs 3(7): 355–7
Roper N (1994b) Definition of nursing: 2. Br J
Nurs 3(9): 460–2
Roper L, Logan W, Teirney A (1980) The Elements
of Nursing. Churchill-Livingstone, Edinburgh
Roy C (1980) The Roy Adaptation Model. In:
Reihl JP, Roy C, eds. Conceptual Models for
Nursing. Appleton-Century-Crofts, Norwark:
179–89
Roy C, Roberts S (1981) Theory Construction in
Nursing: An Adaptation Model. Prentice Hall,
Englewood Cliffs, New Jersey
Salvage J (1990) The theory and practice of new
nursing. Nurs Times 84(4): 42–5
Smith L (1982) Models of nursing as the basis for
curriculum development: some rationales and
implications. J Adv Nurs 8: 117–27
Travelbee J (1971) Interpersonal Aspects of
Nursing. FA Davis, Philadelphia
Watson J (1979) Nursing: The Philosophy and
Science of Caring. Little Browne, Boston
Webb C (1994) What is nursing? Br J Nurs 1(11):
567–8
Wright SG (1990) Building and Using a Model of
Nursing. 2nd edn. Edward Arnold, London
BJN
PROFESSIONAL ISSUES