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Nursing Theory in CLABSI Prevention and APN Practice

Central line associated bloodstream infections (CLABSIs) are responsible for an

estimated 28,000 death a year (Reynolds et al., 2021). Every hospital has CLABSI prevention

protocols in place, but CLABSIs still cause approximately 80,000 infections a year (Reynolds et

al., 2021). While current CLABSI prevention methods are effective in decreasing CLABSI rates,

prevention methods can be improved with the use of nursing theory. Nursing theory is an

extremely important component of nursing, both at the Registered Nurse and Advanced Practice

Nurse (APN) level, because theory allows nurses to explain the “why” behind everything nurses

do. The purpose of this paper is to explore the use of nursing theory in the prevention of

CLABSIs and the implications nursing theory has for APNs.

Nursing Theories

Environmental Model of Nursing

The Environmental Model of Nursing (EMN), created by Florence Nightingale, is a

patient centered nursing theory which emphasizes how a healthy environment positively affects

patient outcomes (Gilbert, 2020; Masters, 2022). EMN states the job of the nurse is to manage

physical and social factors to encourage patient healing (Masters, 2022). Nightingale taught how

hospitals are unsanitary places and how nurses are responsible for creating and maintaining clean

environments to protect patients. The ideas of EMN laid the foundation for infection control

practices used today, such as in current CLABSI prevention methods (Gilbert, 2020). EMN can

be used in the prevention of CLABSIs through the utilization of infection control measures and

by keeping patient environments clean. Frequent disinfection of high touch surfaces, daily CHG

baths for patients, central venous catheter (CVC) dressing monitoring, hand hygiene, and proper

mediation administration techniques are ways EMN can be used to prevent CLABSI occurrence.
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By maintaining a clean environment for the patient, nurses can decrease CLABSI risk. Another

nursing theory which places importance on patient environment is the Roy Adaptation Model.

Roy Adaptation Model

The Roy Adaptation Model (RAM) is a nursing theory which claims the individual is

continually adapting to the surrounding environment using a set of interrelated systems, which

are the biological system, the psychological system, and the social system. RAM claims the

individual is continuously working to keep balance between the three systems and the

environment, and an individual’s behavior is dependent on stimuli received from the

environment (Whetsell et al., 2022). By using RAM, nurses can examine how patients are

responding and adapting to stimuli, and then form nursing diagnoses and treatments if necessary

(Whetsell et al., 2022). The ICU is a challenging environment for patients, often taking away

patients’ feelings of autonomy or control, and patients can have a difficult time adapting to the

ICU environment (Burns et al., 2020). Difficulty with adaption can cause patients to refuse

certain aspects of care, such as CLABSI prevention protocols. CLABSI prevention methods

require the patient to comply with care, such as with daily CHG baths and frequent CVC

dressing changes. RAM gives nurses to tools necessary to encourage patients and to promote

adaptation to the ICU environment through communication, compassion, goal setting, and

encouragement (Burns et al., 2020; Whetsell et al., 2022). Through aiding with the patient

adaptation process, nurses can encourage the patient to comply with CLABSI prevention

protocols and therefore prevent CLABSI occurrence (Burns et al., 2020). RAM is a nursing

theory which encourages positive nurse-patient interactions, much like the Relationship Based

Care theory.

Relationship Based Care

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Relationship Based Care (RBC) is a nursing theory which claims healthy relationships

are the foundation of high-quality nursing care (Stewart, 2022). RBC is centered around three

relationships, which are the nurse’s relationship with the patient, the nurse’s relationship with

self, and the nurse’s relationship with colleagues (Stewart, 2022). While each relationship is

important, RBC claims the nurse and patient relationship is fundamental and is key to creating a

healing atmosphere for patients (Kristoffersen & Friberg, 2016; Stewart, 2022). Research shows

how when the nurse-patient relationship is not prioritized and nurses provide solely necessary

care, patients can feel like a burden (Kristoffersen & Friberg, 2016). Nurses can improve the

nurse-patient relationship through behavior such as kind acts, comforting touch, listening to the

patient, and meeting the patient’s true needs (Stewart, 2022). RBC can be used in preventing

CLABSIs through the creation of strong relationships and mutual goals between nurses and

patients. RBC is based on the elements of inspiration and education. Through inspiring and

educating patients, nurses can not only improve the nurse-patient relationship, but also cultivate

patient confidence and educate patients on health promotion, such as the dangers of CLABSIs

and CLABSI prevention methods (Stewart, 2022). By using RBC to increase patient confidence

and knowledge, patients can be empowered to pursue positive health behaviors and will be more

likely to comply with CLABSI prevention protocols and participate in CLABSI prevention care.

Another nursing theory which focuses on the importance of relationships in healthcare is the

Quality Caring Model.

Quality Caring Model

The Quality Care Model (QCM) is a nursing theory with the overarching goal of making

the patient feel cared for. The QCM emphasizes the importance of relationships by claiming

when patients feel cared for by healthcare professionals, patients are more likely to have positive
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outcomes and improved health (Duffy, 2022). The goal of the nurse in the QCM is to make each

patient feel cared for through the provision of caring behaviors. Caring behaviors are behaviors

such as listening to patient concerns, giving each patient autonomy, providing respect, being

encouraging, and mutually solving problems (Duffy, 2022; Salinas et al., 2022). Current research

shows how through the implementation of caring behaviors, patient’s feelings of confidence,

comfort, and self-worth improve, which in turn causes patients to be more engaged and involved

in care and treatment (Salinas et al., 2022). Through engagement and involvement, patients can

become more educated and empowered to purse positive health behaviors, such as with CLABSI

prevention practices. By having the nurse-patient relationship centered around caring behaviors,

nurses can empower patients to improve health through educating on CLABSIs and encouraging

CLABSI prevention methods, such as not touching or removing CVC dressings, complying with

daily CHG bathing protocols, and allowing for necessary CVC dressing changes (Salinas et al.,

2022). Cultivating positive nurse-patient relationships is necessary to provide high-quality

nursing care and in the use of many nursing theories, such as when utilizing the Praxis Theory of

Suffering.

Praxis Theory of Suffering

The Praxis Theory of Suffering (PTS) was created to aid nurses in helping patients and

families through the suffering process. PTS states suffering is a basic human reaction to any type

of danger which could harm an individual’s physical or psychosocial integrity (Morse, 2022).

PTS claims suffering has two parts, which are enduring and emotional suffering. An individual is

enduring when the individual is holding in emotions and attempting to live in the present, while

emotional suffering is when the patients finally release all emotions and attempts to accept what

is happening (Morse, 2022). PTS gives nurses the understanding and tools to help guide patients
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and families through suffering by implementing comforting practices. When enduring, patients

become aware of the emotions which will eventually be released in emotional suffering, and

knowledge of such emotions can cause fear. Enduring is a highly recognizable phase of

suffering, and once a nurse is taught to see the signs and read enduring behaviors, the nurse can

respond and provide comfort (Morse, 2018). Suffering often occurs in ICU settings because

patients are extremely ill or in critical condition. When the patient is critical, CLABSI prevention

remains extremely important, though the importance is often not seen by patients and family

members. Due to enduring and emotional suffering, patients and families can often refuse any

care for the patient which does not seem necessary. To educate patients and families on the

dangers of CLABSIs and the importance of CLABSI prevention protocols, the nurse must first

help patients and families through the suffering process. In PTS, hope cannot be found until

patients and families understand and accept what is happening (Morse, 2022). In guiding the

patient and families through the suffering process by providing comfort and aiding in coping

strategies, nurses can help provide a pathway to hope. Once hopeful, patients and families will be

more inclined to comply with protocols in place, such as with CLABSI prevention practices.

Implications of Nursing Theory for APNs

Many skills learned as a Registered Nurse can be applied when transitioning to the APN

role, the use of nursing theory being one of those skills. APNs can implement the Environmental

Model of Nursing to ensure clean environments for patients and to prevent infections, such as

CLABSIs. In the provider role, APNs can use leadership to educate and encourage nurses to

continually strive for clean environments to protect patients from CLABSIs. APNs can also

protect patients from CLABSIs by use of the Roy Adaptation Model (RAM). When patients do

not appropriately adapt to the ICU setting, patients often refuse to listen to bedside nurses and
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wish to speak with providers, such as APNs. APNs can aid patients in the adaptation process by

reassuring patients, listening to patients, and changing patient perceptions (Whetsell et al., 2022).

In aiding in adaption, APNs can encourage patient participation in CLABSI prevention

protocols. When interacting with patients, APNs can also use Relationship Based Care (RBC)

and the Quality Caring Model (QCM) to encourage patients to participate in CLABSI

prevention. Through RBC and QCM, APNs can create relationships with patients and help the

nurse to make each patient feel cared for. In fostering the APN-patient relationship, APNs can

use leadership role to educate patients on the dangers of CLABSIs and how to prevent CLABSIs.

APNs can also use the Praxis Theory of Suffering when working on relationships with patients

and families. Patients and families tend to respect and look to providers during times of

suffering. APNs can step in to work with patients and families through enduring and emotional

suffering. After helping patients and families navigate through the suffering process, APNs can

then encourage participation in CLABSI prevention methods.

Conclusion

Nursing theory allows nurses to treat with much more than medicine. The utilization of

nursing theory in practice encourages strong nurse-patient relationships and shows the

importance of going on beyond what is solely necessary of the nurse. In using theory, nurses can

see the patient as a whole and improve patient outcomes, such as in the prevention of CLABSIs.

CLABSI prevention practices require the participation of patients, and the use of nursing theory

can help foster strong nurse-patient relationships and create a pathway of communication. More

research into the use of nursing theory in healthcare is needed for nursing theory to be efficiently

used by nurses in CLABSI prevention.

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References

Burns, M., Bally, J., Burles, M., Holtslander, L., & Peacock, S. (2020). Influences of the culture

of science on nursing knowledge development: Using conceptual frameworks as nursing

philosophy in Critical Care Nursing. Nursing Philosophy, 21(4).

https://doi.org/10.1111/nup.12310

Duffy, J. R. (2022). Theories Focused on Caring. In J. B. Butts & K. L. Rich (Eds.),

Philosophies and theories for Advanced Nursing Practice (4th ed., pp. 447–464). Jones &

Bartlett Learning.

Gilbert, H. A. (2020). Florence Nightingale's environmental theory and its influence on

contemporary infection control. Collegian, 27(6), 626–633.

https://doi.org/10.1016/j.colegn.2020.09.006

Kristoffersen, M., & Friberg, F. (2016). Relationship-based nursing care and destructive

demands. Nursing Ethics, 24(6), 663–674. https://doi.org/10.1177/0969733015623097

Masters, K. (2022). Models and Theories Focused on Nursing Goals and Functions. In J. B.

Butts & K. L. Rich (Eds.), Philosophies and theories for Advanced Nursing Practice (4th

ed., pp. 349–372). Jones & Bartlett Learning.

Morse, J. M. (2018). Theoretical coalescence. Nursing Research, 67(2), 177–187.

https://doi.org/10.1097/nnr.0000000000000263

Morse, J. M. (2022). The Praxis Theory of Suffering. In J. B. Butts & K. L. Rich (Eds.),

Philosophies and theories for Advanced Nursing Practice (4th ed., pp. 489–516). Jones &

Bartlett Learning.

Reynolds, S. S., Woltz, P., Keating, E., Neff, J., Elliott, J., Hatch, D., Yang, Q., & Granger, B. B.

(2021). Results of the chlorhexidine gluconate bathing implementation intervention to

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improve evidence-based nursing practices for prevention of Central Line Associated

Bloodstream Infections Study (changing baths): A stepped wedge cluster randomized

trial. Implementation Science, 16(1). https://doi.org/10.1186/s13012-021-01112-4

Salinas, M., Salinas, N., Duffy, J. R., & Davidson, J. (2020). Do caring behaviors in the quality

caring model promote the human emotion of feeling cared for in hospitalized stroke

patients and their families? Applied Nursing Research, 55, 151299.

https://doi.org/10.1016/j.apnr.2020.151299

Stewart, M. W. (2022). Models and Theories Focused on Competencies and Skills. In J. B. Butts

& K. L. Rich (Eds.), Philosophies and theories for Advanced Nursing Practice (4th ed.,

pp. 429–446). Jones & Bartlett Learning.

Whetsell, M. V., Gonzalez, Y. M., & Moreno-Fergusson, M. E. (2022). Models and Theories

Focused on a Systems Approach. In J. B. Butts & K. L. Rich (Eds.), Philosophies and

theories for Advanced Nursing Practice (4th ed., pp. 373–394). Jones & Bartlett