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June Larrabees Quality of Nursing Care Theory Corinne Bradley, Theresa Connors, Amy Herrington, and Katie Tiesworth Ferris State University

QUALITY OF NURSING CARE Abstract This paper critiques June Larrabees Quality of Nursing Care Theory. It examines the origins of the theory and describes the unique focus of this theory as compared to other quality theories. The comprehensiveness, clarity, and simplicity of this theory are explored. The four nursing metaparadigm concepts of this theory are also analyzed. The impact on future theory generation is discussed, as well as its contribution to nursing practice. The credibility and generality of the scope of Larrabees concepts are explored. Also, the testability and usability of the theory is analyzed, as well as the derivable consequences from this theory.

QUALITY OF NURSING CARE June Larrabees Quality of Nursing Care Theory The purpose of this writing is to investigate and critique Larrabee's Quality of Nursing Care Theory. The origins of the theory will be analyzed, as well as the focus of the theory and what makes it unique from others. This will be followed by an analysis of the comprehensiveness of the theory, including both clarity and simplicity. Next, the ability of this theory to contribute to further theory generation will be explored, as well as the generality and credibility of the theory. Last, the contributions of this theory to the nursing profession will be considered, including its empirical use and the derivable consequences gained. Origins Larrabees Quality of Nursing Care Theory provides a framework for understanding healthcare quality that includes not only the providers perception but also the patient and his/her family. The theory involves both ethical and economic concepts and identifies patients and families as equally important partners collaborating with providers to achieve quality healthcare. Value, beneficence, prudence, and justice are the four identified ethical and economic concepts in the theory (Larrabee, 1996). Aristotles philosophies, linguistic analysis of quality, professional experience, a holistic worldview, and healthcare economics were all integrated in the development of this theory (Larrabee, 1996). Aristotles ethical philosophy is focused on the good and the poor, which includes examining the meaning, as well as the principles of the good (Larrabee, 1996). The four concepts used in Larrabees theory were partially derived from Aristotles ethical philosophy. Aristotles philosophy also identified a way to assess quality and influenced the meaning of quality (Larrabee, 1996).

QUALITY OF NURSING CARE Value is one concept within the theory that was identified in the linguistic analysis. The linguistic analysis was performed to examine the meaning of quality (Larrabee, 1996). The analysis involved how quality is used linguistically, as well as the concepts of quality. It was identified that quality has two meanings; one is value-laden while the other is value-neutral. Aristotles definition of quality is value-laden (Larrabee, 1996). Excellence and virtue are related concepts, as well as synonyms of quality. As synonyms of quality, both excellence and virtue involve attaining desired attributes. Through the linguistic analysis, Larrabee (1996) recognized that quality means a value-laden attribute that can be used for comparison (p. 355). This definition recognizes that value is an inherent concept of the Quality of Nursing Care Theory. Through professional experience, Larrabee was able to identify perceptions that influenced this theory. Larrabee (1996) recognized that most interventions were influenced by the benefit it would provide to the patient. Second, providers were not convinced patients were capable of defining and assessing quality. This led to patient satisfaction data not being used for quality improvement. Quality decisions rarely considered cost to the patient or society. Finally, in the past, quality assessment has been reserved for facets of healthcare that were selected by providers or were discipline specific (Larrabee, 1996). Historical and current literature about healthcare quality was utilized in the development of the Quality of Nursing Care Theory. Larrabee (1996) notes healthcare quality has been associated with value by various authors. The usage of value in a quality model has been supported significantly (Larrabee, 1996). There has also been widespread support of the use of benefits or beneficence in a quality model (Larrabee, 1996). The use of prudence and justice in a quality model has limited support (Larrabee, 1996).

QUALITY OF NURSING CARE The origins of the theory are derived from Larrabees personal and professional experience, as well as Aristotles philosophy, healthcare economics, and current and historical theoretical findings. Larrabee examined many authors ideals and definitions regarding quality and the concepts of value, beneficence, prudence, and justice. Though Larrabee (1996) did not discover extensive support of prudence and justice in a quality model, Larrabee was able to identify the importance of the inclusion of prudence and justice, particularly in regards to healthcare economics. Unique Focus While many quality models involve the concepts of value and beneficence, most lack the concepts of justice and prudence. The unique focus of Larrabees (1996) theory is the inclusion of justice and prudence, as well as the patient and family. Influenced by healthcare economics and Aristotles ethical philosophy, justice and prudence became concepts of the Quality of Nursing Care Theory (Larrabee, 1996). There are three healthcare economics principles relevant to a quality model. The first principle is scarce resources (Larrabee, 1996). There is competition for resources and when resources are utilized they must be equal to the benefits attained (Larrabee, 1996). It is important to consider these principles to cut cost and manage healthcare financing. Justice and prudence highlight how individuals and families can affect healthcare economics. Aristotle believed that the good of the group is more important than individual good, which is believed because if the group suffers, then the individual will suffer (Larrabee, 1996). In relation to Aristotles philosophy and economics, prudence is represented at the individual level and justice at the group level. Prudence involves self-sufficiency and utilizing goods and services appropriately to meet ones objectives. While the prudent individual seeks out what is

QUALITY OF NURSING CARE best for the individual, he or she does it while also considering what is best for the group (Larrabee, 1996). Justice involves how others treat one another while in pursuit of resources. Justice is comprised of two elements, fairness and voluntary obedience. Fairness is the pertinent element of justice to the quality model (Larrabee, 1996). Fairness is taking only the resources that are truly needed. When focusing on prudence and fairness, it is easy to see how the individual and family play a key role in quality of care. If an individual is prudent with healthcare resources, uses the resources appropriately, and considers the groups greater good before abusing the use of resources, then the quality of healthcare can improve. In addition, if the group focuses on fairness and justice, it uses only the resources that are needed and justly their own, which impacts both the cost and quality of healthcare. Comprehensiveness Larrabees Quality of Nursing Care Theory focuses on four concepts that are interrelated: value, beneficence, prudence and justice (Larrabee, 1996). These four concepts are proposed to influence each other and how quality is perceived (Larrabee, Engle & Tolley, 1995). Value and quality are found to be linked (Larrabee, 1996). Within this theory, patient-perceived quality is influenced to some extent by each of these four quality concepts. Within this theory, quality is defined as the presence of socially acceptable, desired attributes within the multifaceted holistic experience of being and doing (Larrabee, 1996, p. 356). Larrabee further defines each of the four interrelated concepts of this theory. Larrabee clearly defines each of these four concepts. Value is being intrinsically desirable, of fair worth, and offers a fair return in goods or services (Larrabee, 1996). Beneficence likely produces something good or promotes well-being (Larrabee, 1996). Prudence

QUALITY OF NURSING CARE is having good judgment in both setting goals that are realistic and utilizing personal resources to achieve goals (Larrabee, 1996). Justice is being fair which includes both distributive justice and corrective justice. Distributive justice involves using common resources proportionately to each persons contribution. Corrective justice is correcting an injustice by finding the mean between profit and loss (Larrabee, 1996, p. 356). Within this theory, quality has three distinct characteristics. First, quality is a value-laden or desirable attribute (Larrabee, 1996). Second, quality has degrees of desirability which is influenced by social and cultural values and changes based on circumstances (Larrabee, 1996). Third, quality meets the appropriateness criteria which involve having the right thing, person, or way (Larrabee, 1996). There are several propositions within the Quality of Nursing Care Theory. Quality is proposed to be influenced by beneficence, value, prudence, and justice (Larrabee, 1996). Beneficence, prudence, value, and justice are all proposed to influence one another. Also, value is seen as a weighting concept between quality and prudence, justice and beneficence. The role of the nurse is not clearly defined but implied when it states that providers need to find out what a patients goals are (Larrabee, 1996). Larrabee, Ferri, and Hartig (1997) also discuss that nurse practitioners can have an effect on patient satisfaction. In this study, it was found that patients were satisfied with the care they received from nurse practitioners. In 1995, a study was conducted that identified interventions of patient-perceived quality of nursing care (Larrabee, Engle & Tolley, 1995). It is clear in the Quality of Nursing Care Theory the nursing profession influences patients perception of quality. The concept of human being although not clearly defined is discussed at great length in regards to the patients goal in quality. This theory focuses on the well-being of individuals

QUALITY OF NURSING CARE (Larrabee, 1996). It also discusses that patients have goals for healthcare. Larrabee et. al (1995) also provides a framework by which patient-perceived quality can be measured in relationship to value. Clarity Larrabees theory of quality has consistent terminology and structure. The four main terms utilized throughout this theory are value, beneficence, prudence, and justice. This theory is structured around the relationship between these four concepts (Larrabee, 1995). Larrabee provides an excellent diagram (Appendix A) of her theory and how each of the four concepts of health care quality inter-relate and affect one another (Larrabee, 1996). Simplicity The quality of nursing theory has eight propositions that are somewhat complex and require some thought to understand each of the relationships between the four concepts that Larrabee proposes. The four concepts of value, beneficence, prudence, and justice all influence one another in this model (Larrabee, 1996). For example, beneficence is influenced by value, prudence, justice, and quality, while prudence is influenced by value and beneficence (Larrabee, 1996). With some thought and effort, the relationship between these concepts can be understood and applied to the practice of nursing. Further Theory Generation A theory should have the ability to elicit new (a) feelings, (b) phenomena, and (c) relationships which have yet to be discovered amongst existing phenomena (Dudley-Brown, 1996). Theory should also contain ideas to encourage new research and allow for the generation of new hypothesis (Dudley-Brown, 1996). Dudley-Brown (1996) further promotes new hypothesis generation from existing theory with the idea that even a hypothesis with low

QUALITY OF NURSING CARE probability, or one in which is difficult to test, will further contribute to the understanding of the original theory. As defined by Larrabee (1996), quality is "the presence of socially acceptable, desired attributes within the multifaceted holistic experience of being and doing" (p. 356). This definition of quality is abstract in that its attributes are not clearly observable with concrete concepts and cannot be directly measured with empirical data (McEwen & Wills, 2007). This thought could be extended to the four concepts included in Larrabee's Quality of Nursing Care Theory: (a) value, (b) beneficence, (c) prudence, and (d) justice. Due to the abstract nature of Larrabee's Quality of Nursing Care Theory, it has the ability to lead to further middle range theories for both nursing and healthcare (Larrabee, 1996). A middle range theory proposed by Larrabee (1996) which could be based from her Quality of Nursing Care Theory considers patient prudence and how this could affect patient participation in healthcare and patient outcomes. In 1998, a phenomenological study was conducted by Larrabee, Bolden, and Knight with the purpose of identifying the fundamental structure of patient prudence in health care from the patient's perspective (Larrabee, Bolden, & Knight, 1998). Though Larrabee had already described prudence as a concept in her Quality of Nursing Care Theory, this model had not considered what prudence meant to the patient. Though this study of patient prudence did not lead to additional theory generation, this study did help to expand the definition of prudence as it pertains to Larrabee's Quality of Nursing Care Theory (Larrabee, Bolden, & Knight, 1998). In 1999, Larrabee partnered with Mary Ann Rosswurm to create a model to guide change in evidence based practice. This model guides changes of practice to evidence based care by utilizing seven steps which stem from assessing the need for a change, to integrating and

QUALITY OF NURSING CARE maintaining the change (Rosswurm & Larrabee, 1999). Throughout these steps, concepts similar to those utilized in Larrabee's Quality of Nursing Care Theory are mentioned and utilized (Rosswurm & Larrabee, 1999), which leads to the belief that the Quality of Nursing Care Theory may have aided in the generation of the Evidence Based Practice Model. However, the Quality of Nursing Care Theory was not mentioned as one of the contributing frameworks for this model (Rosswurm & Larrabee, 1999). Although Larrabee feels that additional middle range theories could be developed from the Quality of Nursing Care Theory, upon investigation no theories were found which were directly based form her model. Although many studies have been conducted using Larrabee's theory as a theoretical base and similar concepts have been mentioned in her later works, no direct theory generation has occurred. Additionally, though Larrabee also proposed further theory generation from her model as related to healthcare justice (Larrabee, 1996), no further work was found on this subject. Credibility and Generality According to Masters (2012), when considering the generality of a theory, one must consider the scope of the theories concepts and the theories purpose. In relation, the broader the scope of a theory, the more significance it will hold. This belief leads to the assumption that a theory which is more general will be more useful (Dudley-Brown, 1996). Fawcett (2005) describes the generality of a theory under the concept of pragmatic adequacy. Under pragmatic adequacy one must consider a theories use and if it would be feasible in real world situations, as well as one's ability to base practice from the theory (Fawcett, 2005). Prior to Larrabee's Quality of Nursing Care Theory, the existing models which examined healthcare quality and value were of limited scope and lacked consistency. The scope of


QUALITY OF NURSING CARE Larrabee's theory investigates a variety of aspects including (a) patient behavior, (b) cost, (c) quality of care and its influence on outcomes, and (d) patient perceptions of quality (Larrabee, 1996). This theory also considers the quality of healthcare from the perspectives of both providers and patients and their families (Larrabee, Engle, & Tolley, 1995). According to Larrabee (1996), example subjects which could be examined with this theory include (a) individual wellness, (b) the general welfare of society, (c) the perceptions of suppliers and consumers of products or services, or (d) policy makers decisions about the use of public funds. Larrabee's theory not only covers multiple content areas, but can also be used on both a small and large scale. For example, this theory could help examine the cost to benefit ratio of available treatments for an individual, or it could be used on a larger scale to judge the cost to benefit ratio of a public health program on society (Larrabee, 1996). When considering the scope of a theory, one must ask the question of how many problems in nursing could be considered under the umbrella of the theory (Meleis, 2007). When considering that Larrabee's Quality of Nursing Care Theory has the ability to cover multiple content areas in nursing as well as varying scales, one could consider this model to have a wide scope. In return, one can assume Larrabee's Quality of Nursing Care Theory to be very general (Masters, 2012) and useful to the practice of nursing (Dudley-Brown, 1996). Contribution to Nursing Discipline Nursing theories must be applicable to the nursing profession by being able to be replicated and applied to practice (Fawcett, 2005). June Larrabees Quality of Nursing Care Theory has been tested by multiple researchers including Rosswurm and Larrabee (1999); Larrabee, Engle, and Tolley (1995); and Long, Burkett, and McGee (2009). These researchers have applied the concepts of the Quality of Nursing Care Theory to different modalities of


QUALITY OF NURSING CARE practice, including patient perceived quality, and evidence-base practice (EBP), including the utilization of EBP to develop and review policies and procedures. Empirical Use The concepts used by Larrabee are both broad and narrow with adequate definition to explain the pertinence to the theoretical model. These terms include quality, value, beneficence, prudence, justice, ethics, and health care economics (Larrabee, 1996). These key terms are then incorporated into a diagram to give even better understanding of the significance and relationship it has to quality (Appendix A). Larrabee based this theory on multiple relevant research articles, Aristotles ethical principles, as well as statistical data, proving the data to be accurate (Larrabee, 1996). As has been proven by the number of research studies conducted based on the Quality of Nursing Care Theory, replication and testability are demonstrated as well (Fawcett, 2005). Larrabee partnered with Veronica Engle and Elizabeth Tolley in 1995 to further implement the Quality of Nursing Care Theory to predict patient perceived quality. The researchers focused on the importance of patients being part of the assessment and planning process to ensure that mutual goals were agreed upon resulting in more positive outcomes and cost-effectiveness (Larrabee et. al, 1995). The concepts of the original theory were introduced into the implementation of integrating clients into care planning and then assessing the perceived quality of care after hospitalization (see Appendix B). Larrabee also partnered with Mary Ann Rosswurm in 1999 to further develop the concepts of the Quality of Nursing Care Theory into a model for change which developed evidence based practice. The theorys concepts were integrated into the implementation of framework for the study with the focus remaining around quality of care, while putting more emphasis on the importance of healthcare providers to remain up to date on the most recent


QUALITY OF NURSING CARE evidence to provide excellent care. This model involved multiple steps including assessment, linking, synthesizing, design, implementation, evaluation, and integration and maintenance (Rosswurm & Larrabee, 1999). In 2009, Long, Burkett, and McGee used the research done by Rosswurm and Larrabee, to develop a more specific focus on how evidence based information should be implemented into policies and procedures. These researchers utilized the same seven step model of Rosswurm and Larrabee to evaluate the importance of evidence-based research for policy and procedure development (Long, et. al, 2009). This model allowed for an empirical based study to be performed as the model had been previously researched, tested, and successful. In conclusion there are three further studies that are mentioned based on June Larrabees Quality of Nursing Care Theory. Same or similar concepts were utilized and developed into evidence-based practice focusing on the changing needs of healthcare. This supports the fact that Larrabees theory provides empirical use contributing to the nursing discipline in a favorable way. The fact that the theory was utilized for further research also supports the empirical use demonstrating the theory to be testable by other researchers. Derivable Consequences To know the derivable consequences of the theory, it is important to question the theorys importance to the nursing profession (Chinn & Kramer, 1995). June Larrabee created a theory that has proven important to the nursing profession in multiple ways. The theory and research conducted can influence nursing care and actions and has proven successful in different areas. Larrabee also succeeded in implementing the metaparadigms of nursing in the theory validating that it coincides with nursing philosophy (Chinn & Kramer, 1995). Finally the theory is broad


QUALITY OF NURSING CARE enough that it can be utilized for future research to improve quality of care as healthcare and patient needs change. Larrabee, Engle, and Tolley (1995) proved that not only was the theory the basis for the model of perceived patient satisfaction, but also that it would be able to meet the needs of multicultural situations due to the flexibility of local, national, and international utilization. The relationship between value and quality as far as patients perceptions was proven during the research project, supporting the key concepts of Larrabees theory. This study also will have an impact on the care provided by the nurses conforming practice to ensure patient satisfaction. This will be accomplished by valuing patients as holistic individuals desiring to be part of the assessment and planning process, and then collaborating on mutual goals increasing compliance (Larrabee, et. al, 1995). Rosswurm and Larrabee (1999) also proved the importance of this theory to the nursing discipline by implementing the concepts to develop a model for evidence-based practice as the need was seen in the changing healthcare environment. The importance of EBP had already been established. This model gave a method for nurses to use, in order to ensure that the practice they provided was based on evidence and to also impact his/her cohorts to recognize the importance of EBP (Rosswurm & Larrabee, 1999). This study is yet another solid example of the importance of Larrabees Quality of Nursing Care theory to the nursing discipline as it aided with the development of a model needed to continue nursing being viewed as a profession with independent thinking based on research. Long, Burkett, and McGee (2009) enhanced the concepts of Larrabees theory combined with the model of Rosswurm and Larrabee to demonstrate the importance of EBP on the review and development of the policies and procedures that nursing uses. By using EBP in policy and


QUALITY OF NURSING CARE procedure development, it promotes continuity in care increasing patient safety and thus, quality of care (Long, et. al, 2009). This supports the practicality of the theory as well as the flexibility to be utilized in future research to meet the ever changing health care needs. In conclusion, the derivable consequences of Larrabees Quality of Nursing Care Theory support the importance the theory holds to nursing as a discipline. The basic concepts of the theory were utilized to further develop future research, providing influence over nursing practice in multiple arenas. The theories concepts have already been utilized in different research models that have developed with changing healthcare needs, and will continue to be valuable for future researchers. Conclusion In critiquing June Larrabees Quality of Nursing Care Theory the authors found that the theory was general with applicability to the nursing profession. The theory was based on empirical evidence, however due to the broad terminology and definitions the theory would be hard to test with empirical data without further clarification. The Quality of Nursing Care Theory has been influential to further research projects and model development; however no additional theories have been created using this theory thus far. Quality is a constant process in healthcare, and by establishing the concepts of value, beneficence, prudence, and justice Larrabee has given some structure to quality measurements. Another important contribution of the Quality of Nursing Care Theory is the expressed importance of collaborating with patients and his/her loved ones to ensure that quality care is given to improve long term outcomes.


QUALITY OF NURSING CARE References Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work (7th ed.). Maryland Heights, MO: Mosby/Elsevier. Chinn, P. L., & Kramer, M. K. (1995). Theory and nursing systemic approach (4th ed.). Saint Louis, MO: Mosby. Dudley-Brown, S. L. (1996). The evaluation of nursing theory: A method for our madness. International Journal of Student Nurses, 34(1), 76-83. Long, L., Burkett, K., & McGee, S. (2009). Promotion of safe outcomes: incorporating evidence into policies and procedures. Nursing Clinics of North America, 44(1), 57-70. doi:10.1016/j.cnur.2008.10.013 Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quaterly, 18(2), 131-135. doi:10.1177/0894318405274823 Hunter, M. A., & Larrabee, J. H. (1998). Womens perceptions of quality and benefits of postpartum care. Journal of Nursing Care Quality, 13(2), 21-30. Larrabee, J. H. (1996). Emerging model of quality. Image: Journal of Nursing Scholarship, 28(4), 353-358. Larrabee, J., Bolden, L., & Knight, M. (1998). The lived experience of patient prudence in health care. Journal Of Advanced Nursing, 28(4), 802-808. doi:10.1046/j.13652648.1998.00723.x Larrabee, J., Engle, V., & Tolley, E. (1995). Predictors of patient-perceived quality. Image: Scandinavian Journal of Caring Sciences, 9(3), 153-164. Larrabee, J. H., Ferri, J. A., & Hartig, M. T. (1997). Patient satisfaction with nurse practitioner care in primary care. Journal of Nursing Care Quality, 11(5), 9-14.


QUALITY OF NURSING CARE Masters, K. (2012). Nursing theories: A framework for professional practice. Sudbury, MA: Jones & Bartlett Learning. Retrieved from McEwen, M., & Wills, E. M. (2007). Theoretical basis for nursing (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Meleis, A. I. (2007). Theoretical nursing: Development and progress (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Rosswurm, M., & Larrabee, J. (1999). Clinical scholarship: A model for change to evidencebased practice. Image: Journal of Nursing Scholarship, 31(4), 317-322.




Larrabees Theory of Quality








(Larrabee, et. al, 1995, p. 155)