The philosophy of nursing
The philosophy of nursing, which underlies all nursing and non-nursing theories, describes a system of views on the relationship between a nurse, a patient, society, and the environment. The philosophy of nursing is a theoretical foundation of the nursing profession, revealing the main provisions that determine its meaning, direction, and role in society.
The Theory of Elisabeth Kubler-Ross: Brief History
For example, many people know the theory according to which grief goes through several stages when a person receives unbearable information. Its scope is wide: from hospices to company boards of directors (da Maia et al., 2017). When the Swiss psychiatrist Elisabeth Kubler-Ross began working in American hospitals in 1958, she was struck by the lack of methods of psychological assistance to the dying patient. Kubler-Ross graduated from the Faculty of Medicine at the University of Zurich, after which she left for the United States in 1958. She has worked extensively in hospitals in New York, Chicago, and Colorado, deeply resenting the treatment of dying patients by doctors. Unlike her colleagues, she communicated with the dying, listened to their stories about the emotions they felt. This is how her course of lectures on near-death experiences came about. She began teaching workshops with medical students at Colorado State University based on her conversations with cancer patients about how they thought and felt (Alligood, 2018). Later, based on the results of her observations and conversations, in 1969, she published a book On Death and Dying, in which she cited typical statements of her patients, and then moved on to a discussion of how to help doomed people leave life without fear and torment.
The Theory of Elisabeth Kubler-Ross: Conceptual Description
Kübler-Ross described in detail the five emotional states that a person goes through after knowing a fatal diagnosis: denial, anger, bargaining, depression, acceptance. She considered all five stages to be protective mechanisms of the psyche, which are triggered in an extremely difficult situation (Newman, 2004). A separate chapter of her book is devoted to each of the stages. In addition to the five main ones, the author singled out intermediate states – the first shock, preliminary grief, hope – in total, from 10 to 13 types. Below, there is a detailed description of each of the five main stages (Alligood, 2018):
The first stage is denial and isolation. Usually, shock and denial arise in patients who were told a fatal diagnosis at the very beginning of the development of the disease, or in those who guessed it themselves. Too strong shock is present in patients to whom this news was prematurely and unexpectedly reported by a person who does not know the patient well or who was not prepared. Denial and shock are common in almost all patients and not only in the early stages of the disease. Shock, according to Kübler-Ross, acts as a form of protection; it softens unexpected strikes and allows the patient to arrange his/her thoughts, and later use other, less radical forms of protection. After the shock comes the stage of denial, which later transforms into the stage of partial denial.
The second stage is anger. When the patient is unable to deny the obvious, he is overwhelmed with rage, irritation, envy, and resentment. He asks the question: “Why me?” In this case, it is difficult for the patient’s family and hospital staff to communicate with the patient. The patient suddenly throws out his indignation on others; he scolds the doctors for keeping him in the hospital for too long, the nurses for being either too annoying or indifferent, and visiting relatives cause only irritation and anger in the patient, which leads relatives to a state of grief.
The third stage is bargaining. This stage is rather short; during it, the patient is trying to “negotiate” with the disease. He/she knows that good behavior is rewarded; at first, the patient desires to prolong life, and later they are replaced by hope for at least a few days without pain and inconvenience, or hope for the fulfillment of a cherished desire. In essence, the deal is an attempt to delay the inevitable. It not only defines the award for “good behavior,” but also establishes a certain “final line”. If the dream comes true, the patient promises not to ask for anything else. At the same time, usually, no one keeps his words.
The fourth stage is depression. Numbness, irritability, and resentment soon give way to a feeling of great loss, and depression arises. Kubler-Ross distinguishes two types of depression: reactive and preparatory grief. Reactive depression is often accompanied by a feeling of guilt that the person has changed due to illness, that is, regret about the past. A person in this state cannot face their illness and the threat of death, but, at the same time, he/she is prone to verbose communication, since he/she wants to share his worries. The stage of depression, which Kubler-Ross called “preparatory grief” is characterized by the fact that it is caused by inevitable losses in the future, that is, the patient is aware of the inevitability of the end; at this stage, usually the person mostly keeps silence.
However, many researchers point to the problems of this model (Bonanno & Boerner, 2007):
- According to observations, patients do not go through all stages, and the order of their sequence is not followed.
- Kubler-Ross did not use data collection and analysis methodologies; she identified the stages after conducting interviews with patients, which were subjective.
- Stages tell patients how to feel rather than describe how they feel. Patients and their relatives adapt to a well-known stage program.
- The strong dependence of the patient’s condition on the environment does not give grounds to believe that they will go through the same stages.
The Theory of Hildegard Peplau: Brief History
It should be noted that early theorists of nursing in the 1950s viewed primarily the tasks of a nurse from a rather mechanistic perspective. Namely because of this, the emphasis on the foundation of nursing – the value of care, aspects of interpersonal relations, the aesthetics of nursing practice – has been leveled. The early writers of nursing theories did not attempt to address metaparadigmatic concepts, since there was no consensus about this at the time (Haber, 2000). However, Hildegard Peplau, a psychiatric nurse who combined her research work with experience, developed the theory of psycho-dynamic nursing care.
Hildegard Peplau was considered the “nurse of the century” and the “mother of psychiatric nursing care” for her remarkable theoretical contributions to medicine. Since 1952, her theories have served as a contribution to the development of modern nursing, as well as a training base for professionals and potential research in the field of psychotherapy and mental health (Haber, 2000). It was a middle theory that focused on both nursing and the patient. The author has defined the concept and stages of development of the nurse-patient relationship.
The Theory of Hildegard Peplau: Conceptual Description
Peplau defined patient care as the human relationship between a sick person and a nurse trained to recognize and respond to a need for help. The primary goal of a nurse is to help sick persons identify their perceived difficulties and then use the principles of human relations to resolve them (Alligood, 2018). In general, Peplau presented nursing as a complex process of interpersonal and therapeutic interaction between a nurse and a patient, where the nurse acts as an assistant, advisor, and guardian for the patient, and the process of their interpersonal interaction includes several sequential stages: orientation, identification, explanation, and resolution. (Alligood, 2018). She defined nursing as the art of healing: the nurse and the patient work together, during which they both mature and gain new knowledge.
Theories Comparison
Thus, while the Elisabeth Kubler-Ross model is intended for use in the dying process, aimed at palliative care, the Hildegard Peplau model is aimed at speedy recovery of the patient. However, both models are based on the principle of human relations and apply some elements of behaviorism (although its application is not declared in any of these models).
The behaviorist approach provides more opportunities for studying the role of heredity and the history of the development of the environment about the effect on the formation of biosocial systems than mentalism, which deals with unraveling, interpreting the logic of already committed and future actions, as well as the thoughts and feelings that arise during this process. The logic of behavior is determined by a system of current needs, formalized as motivation that gives meaning and emotional tone to behavior and activities aimed at changing the environment; the environment, in turn, affects our feelings. Understanding these processes allows restoring the system of cause-and-effect relationships between the actions that took place, behavioral reactions, and creating their imitation model, which was done both in the theory of Elisabeth Kubler-Ross and Hildegard Peplau.
References
Alligood, M. A. (2018). Nursing theorists and their work (9th ed.). Mosby/Elsevier.
Bonanno, G., & Boerner, K. (2007). The stage theory of grief. JAMA, 297(24), 2692-2694.
da Maia, B., Seiler, L., Futami, A., & de Oliveira, M. (2017). The phases of dying in organizations – a case study for new business. European Journal of Business and Management, 9(23), 46-52.
Haber, J. (2000). Hildegard E. Peplau: The psychiatric nursing legacy of a legend. Journal of American Psychiatric Nurses Association, 6(2), 56-62.
Newman, L. (2004). Elisabeth Kübler-Ross. BMJ, 329(7466), 627-628.