Original article Jobin et al., Intersensory Model

Inter-sensory perception model: Integrating the sixth in providing nursing care Ponnambily Jobin*, Rajeswari Siva, Sudha R, Hema V H Email: [email protected] Abstract

Introduction: In 21st century, nursing profession is enriched with many theories. However, there exists a wide gap between knowledge and implementation of nursing care. Aim: The paper explains causes of this gap and addresses a solution using a conceptual model titled “Intersensory perception in nursing care ‘under empirical concept’ open your sixth sense in addition to five traditional .” Methods: A qualitative case study design was used for testing the conceptual model. Results: The paper classifies the different modalities of sensing, adds one more nontraditional sense (auto thermoception) to five traditional senses and depicts how general sensory perception can be upgraded to inter-sensory perception among nurses through nursing education process, which is pictured as nursing foundry lab model. It also explains that how nurses can identify homeostatic imbalance among beings using inter- sensory perception and help the patient to retain homeostasis. Further, a comparative analysis is done with Florence Nightingale’s environmental theory and criterion based critique model is used to evaluate the role of inter-sensory perception in nursing care. Conclusion: Hopefully, these concepts pave the way to implement an effective nursing care using inter-sensory perception and reduce unintentional torts by overcoming ‘numbness’ of senses.

Key words: Conceptual model, inter-sensory perception, nursing theory, sensing, sixth sense

Introduction counselling, food and others (Nightingale, 1860). Until In 1860, Florence Nightingale defined nursing on 1970, nursing was considered as a semiprofessional “Nursing: What it is, what it is not” as a patient care career and a female dominant job (Adams & Miller, service requires education and training to maintain 2001). During those periods, lack of theories and ventilation, comfortable room temperature, light researches are considered as barriers to meet professional and noise, cleaned rooms, proper bedding, hygiene, standards (Etzioni, 1969). Since 1980, development of educational standards dispersed all over the world. Ponnambily Jobin Many theorists have discussed the concept of nursing Assistant Lecturer, M A Chidambaram College of Nursing, in a unique way. However, the definition of nursing by Tamilnadu Dr MGR Medical University, Chennai, Tamilnadu, India. (Virginia Henderson, 1966) was widely accepted and it says; “The unique function of a nurse is to assist the Rajeswari Siva Professor and Head of the Department, College of Nursing, individual, sick or well, in the performance of those Christian Medical College, Tamilnadu Dr MGR Medical University, activities contributing to health or its recovery (or to Vellore, Tamil Nadu peaceful death) that he would perform unaided if he Sudha R Principal had the necessary strength, will or knowledge and to M A Chidambaram College of Nursing, Tamilnadu Dr MGR do this in such a way as to help him gain independence Medical University, Chennai, Tamilnadu as rapidly as possible.” (Henderson, 1966) In order to Hema V H cope with the fast changing and competitive nature of Principal, Faculty of Nursing, Dr MGR Educational and Research Institute University, Chennai, Tamilnadu the world, the nurses are forced to face more ethical and philosophical challenges to provide care. These changes *Corresponding Author also created new revised education and training system in

How to cite this article: Jobin , P., Siva, R., Sudha, R., & Hema, V.H. (2018). Intersensory Perception Model: Integrating the sixth sense in providing Nursing care. Manipal Journal of Nursing and Health Sciences, 4(1), 8-17.

8 Manipal Journal of Nursing and Health Sciences | January 2018 | Volume 4 | Issue 1 Jobin et al., Intersensory Perception Model the nursing profession (Ghadirian, Salsali & Cheraghi, smell). Nursing foundry lab model depicts how general 2014). There are many theorists, who have explained sensory perception can be upgraded to inter-sensory about metaparadigm of nursing. Nonetheless, there perception among nurses through nursing education is a wide gap between knowledge and practice, which process. It also explains that how nurses can identify directly shows errors in the implementation of nursing homeostatic imbalance among human beings using care in the form of unintentional torts. Therefore, it is inter-sensory perception and help the patient to retain high time to think about the chain of concepts, which homeostasis. ‘Inter-sensory perception in nursing care’ can fill the gap in nursing care. would help nurses deliver effective care to individual, family, and community. Review of literature If one looks at the ample literature in nursing, then Data source it may raise the question ‘why does nursing need a A review of literature was done to understand existing theory?’ which has already been adequately addressed. theoretical concepts and to develop a conceptual model Nonetheless, highly defined Indian nursing programs on inter-sensory perception in nursing care. The key take nursing into upgraded realms of higher education words used are sense, care, perception, theories and (Ingram, 1991). Despite these programs, nursing conceptual models. The data is obtained from Pubmed, frequently witnesses issues that reflect theory-practice Ovid technologies, CINAHL, Researchgate, MedIND, gap (Miller, 1985). One may raise a question ‘should and dissertations from 1860 to 2014. A total of 38 we borrow theories from other fields or must a new articles were reviewed for literature related to sensing, theory be developed?’ Nursing theories (Ingram, 1991), nursing care, and nursing theories. help nurses to practice quality patient care. However, Development of concepts literature may disagree on many theories and has forced many nurses to reject useful theories, which might be Sensing useful in clinical practice later (Colley, 2003). Theories Aristotle (390 BCE-350 BCE), a Greek philosopher, help to develop a sense of identity among nurses, viewed reality as physical world and knowledge comes paves the way to achieve satisfied patient care services through observation and perception by five sensory (Draper, 1990). organs - eye, nose, tongue, , and skin with five senses - vision, smell, , hear, and touch (Postgate, 1995). Theories can influence patient care directly or Sensory perception is defined as the physiological indirectly. The main issue in patient care is lack of capacity of organisms to identify and interpret the autonomy in decision making by nurses versus doctors. sensory information to understand the environment In such a scenario, theories provide a common or (Schacter, 2011). It is also considered as a cognitive specified framework to identify the care needed by function, (Myers, Isabel Briggs, & Myers, 1995) which each patient and work along with patient’s family and focuses on tangible, concrete and empirical over other professionals (Ingram, 1991). Theories ease abstract and theoretical concepts. The paper describes the communication between nurses by providing a sense as an ability of a human being to identify and platform of theoretical knowledge and thoughts, upon interpret the from the external environment which practices could be implemented. Further, theory through five sensory organs- eye, nose, ear, tongue, can enhance communication between theorists and and skin with six senses- vision, smell, , taste, other professionals to practice an effective patient care touch, and auto thermoception. The paper categorizes (Chinn & Jacobs, 1987). sensing into three:

The paper throws light on three concepts: On sight sensing Classification of sensing, nursing foundry model, and It is an ability of a human being to see and interpret inter-sensory perception in nursing care. The paper the surrounding environment in the visible light classifies the different modalities of sensing, adds one through sensory organs (eyes) called on sight sensing. more nontraditional sense (auto thermoception) to The sensory response of the eyes is known as five traditional senses (hear, vision, taste, touch, and ophthalmoception (Puro, 2012).

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Abut sensing Remote sensing The word “abut” is Anglo-Latin origin which means Remote sensing is an ability of a human being to “touch”. It is an ability of a human being to identify acquire and interpret the surrounding environment and interpret the surrounding environment with without physical contact and out of sight through physical contact through skin and tongue (Francis, ear, nose, and skin. The sensory response of the ear Ladher, & Schoenwolf, 2002). The sensory response known as audioception (hearing-ability of the human of the tongue is called as gustaoception (taste-ability to to acquire the sound waves from the surrounding) interpret taste with contact between tongue and food) (Jan Schnupp, Israel Nelken, & Andrew King, 2011) and skin is called as thermoception (temperature- and nose is olfacception (smell-ability of the human ability to differentiate the high and low temperature nose to acquire the smell of the particles from the with contact between skin and thermal conductor), surrounding) (de March, Claire, Ryu, SangEun, Sicard, (-ability to respond to pain with contact Gilles, Moon, Cheil, Golebiowski, & Jérôme, 2015). between skin and sharp object), and mechanoreception The is normally sensitive to heat and cold. (vibration-ability to identify the vibration with contact The ability of the skin to identify the level of room between skin and vibrating material) (Darian-Smith, temperature in the surrounding environment without Johnson, LaMotte, Shigenaga, Kenins, & Champness, touching is called auto thermoception. 1979; Dubin, & Patapoutian, 2010; Adrian & Umrath, 1929).

Figure 1: Classification of sensing

Figure 1 explains the three modalities of sensing and appropriate environmental modification of individual, highlights five sensory organs and six senses. family, and community through nursing education, practice, and research’. The paper depicts the nursing Nursing Foundry Model education process as a nursing foundry model, where The paper defines nursing as a ‘profession with unique body of knowledge, attitude, and practice aimed to the general sensory perception of student nurse is mould the sensory modalities of a learner of nursing, to moulded into inter-sensory perception. Here, a human enable him/her to provide care to patients using inter- being with general sensory perception is transformed sensory perception during health to illness continuum into a nurse through a period of education process or till death by assisting them to meet physical, and is enabled to identify and provide care using inter- psychological, social, and spiritual needs through sensory perception.

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Figure 2: Nursing foundry model

The nursing foundry model (Figure 2), explains three attitude and skills. Nursing foundry lab helps to instill transition phases. unique body of knowledge, attitude, and practice 1. Human being with six senses towards nursing among the students by reinforcing the 2. Nursing foundry lab nursing care behaviours through persistent instructions 3. Nurse having nursing care behaviour with inter- (Omari, AbuAlRub, & Ayasreh, 2013). According sensory perception to Jean Watson’s theory (1988) on ‘Nursing: Human In Phase I, it is showed that a human being is the one science and care,’ nursing care behaviour has ten who can identify and interpret general information carative factors to satisfy the human needs (Suliman, from the external environment using six senses. Welmann, Omer, & Thomas, 2009).

In Phase II, nursing profession is compared to foundry In Phase III, the output of nursing foundry lab is a lab, where transition of human being (Phase I) to nurse nurse, who is equipped to provide care to patients (Phase III) happens. During this phase, the human using six senses with inter-sensory perception. Inter- being is identified as a student for a period of time sensory perception means using one or more senses and sensory modalities (Small, Dana, Prescott, & John, together to identify, compare to self and patient, and 2005) of student are moulded to enable him/her to interpret the alterations in the physical, psychological, provide care through teaching and learning process and environmental subzones of the patients. in the nursing curriculum (Mitchell, & Batty, 2009). Inter-sensory perception in nursing care Nursing curriculum (Veenema, 2001) is implemented The paper describes about transformation of a human through three modes; being with general sensory perception into a nurse with 1. Theory sessions inter-sensory perception. Here, a nurse, who is enabled 2. Prio practical sessions to provide care using inter-sensory perception with six 3. Clinical sessions senses, comes into a scenario to identify, compare and interpret alterations in the zones of human being. The theory sessions are delivered through class room teaching to develop knowledge and favourable attitude The concept of human being in this paper is an towards patient, family, and community. Prio practical individual, seeking constant adjustment between sessions are conducted through lab demonstrations. internal and external zones to maintain homeostasis The clinical field experiences help him/her to (Figure 3). Homeostasis is the property of human strengthen the knowledge, develop and reaffirm caring being to maintain balance between internal and

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Figure 3: Conceptual framework on inter-sensory perception in nursing care external zones or to return the body to function within The nurse, who is enabled to provide care using inter- normal range. Homeostatic imbalance is an inability of sensory perception, is able to identify, compare to self a patient to maintain homeostasis that leads to further and patient, and interpret any alterations in the subsets complications or death (Marieb, Elaine, Hoehn, & of elements of human being. If the nurse identifies any Katja, 2007). alterations, he/she has to take action immediately (Act), evaluate the effectiveness of his/her action (Assess) and The internal zone of human being is divided into affirm (3 A’s) the homeostasis of the patient. Nursing two subzones; physical and psychological subzones. care can be redefined as the process of activities done Physical subzone contains four subsets of elements by the nurse using inter-sensory perception, aiming such as respiration, nutrition, elimination, and sleep/ to help the patient to maintain homeostasis between rest (Maslow, 1943), which are vital to maintain internal and external environment. homeostasis in the human being. Numbness is a situation in which the nurse identifies Intrapsychological and interpsychological are the stimulus through senses but fails to compare and subsects in psychological subzone (Vygotsky, 1978). Intrapsychological subset focuses on an ability to interpret the sensory information. This results in the perceive own identity and ability to maintain balance failure to identify the alterations in the subsets of between the perception of self and to others in the elements, which leads to further complications and society. death of the patient.

External zone consists of environmental subzone. It Methods and materials comprises of four elements such as air, light, noise, and A qualitative blinded case study design was selected effluvia (Nightingale, 1860), which influence on internal to test the inter-sensory perception as a nursing care zone to maintain homeostasis. Any alterations in one model. The purpose of the design was capturing or more subsets of elements of human being and in the phenomena in a real-life context, where the the environment will result in homeostatic imbalance, researchers have minimal control over events (Yin, which may lead to further complications and/or death 2003). According to Yin (2003), six evidences could be of patient. used such as documentation, records, interviews, direct

12 Manipal Journal of Nursing and Health Sciences | January 2018 | Volume 4 | Issue 1 Jobin et al., Intersensory Perception Model observations, participant observation, and physical Sensing Nursing Time Events modalities of artifacts in a case study. Authors appointed non- process medical personnel to record the events related to nurse- nurse (SM) patient care in the natural setting to avoid observational 8.15 am Patient is sweating 8.19 am Alarm rings bias. Authors selected eight case studies, which are She identifies the Hearing, applicable to the concepts in different hospital settings 8.22 am alarm and quickly Assessment Vision such as emergency department, outpatient department, rushes to patient. intensive care unit, and general wards with above- She switches off the alarm and records the mentioned sources. vital signs as heart rate 36/min and 8.23 am Vision Assessment Inter-sensory perception in nursing care and respiration rate 26/ nursing process min. The American Nurses Association (2004) identifies She starts oxygen 4 litres/min. six standards of practice: Assessment, diagnosis, She identifies the outcome identification, planning, implementation, and sweating by the Vision evaluation. These practices are identified as nursing 8.25 am patient in room Auto Assessment temperature 20.0 thermoception process. Assessment means collection of information, Degree Celsius. diagnosis is the identification of problem, outcome She touches the identification involves identifying what goal to be patient to assess the achieved, planning is what to do to reach outcome, body temperature and perceives it implementation is carrying out activities, and evaluation as below normal. is assessing the success of activities. 8.27 am She checks the Touch, Vision Assessment temperature with The model is applied to clinical practice with the thermometer and following case study; Mr X came to Emergency reads the body temperature as 35.0 Department (ED) on feet with colleague at 8.00 am Degree Celsius. with the complaint of chest pain after having breakfast. She attaches the He is 64 years old and does not have any history of non- patient to ECG monitor, interprets Nursing communicable/communicable diseases. The assigned 8.29 am Vision the reading and diagnosis nurse to care for Mr X is a registered nurse, who had identifies as three years of nursing education and had been working myocardial infarction. for the past two years in the emergency department. She discusses the patient status with Outcome Table 1: Hearing, 8.31 am the physician through planning and Application of inter-sensory perception in nursing care in clinical Vision practice telephone and writes plan of action the verbal order. Sensing Nursing Time Events modalities of She gives medications process to the patient and Vision, nurse (SM) 8.35 am Implementation Nurse receives reinforces the patient Hearing the patient from and attender. Vision, 8.00 am reception and assists Hearing She informs the the patient to lie cardiac unit regarding 8.41 am Hearing Implementation down on bed. transfer of the Patient is attached patient. to cardiac monitor She transfers the and records the vital Vision, Vision, 8.06 am 8.50 am patient to cardiac Implementation signs. Collects a brief Hearing Assessment Hearing history from the unit. patient. She makes a call Informs physician to cardiac unit and 9.15 am Hearing Evaluation 8.13 am and waiting for the Hearing inquires about the physician. patient status.

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Table 1 shows the application of ‘Inter-sensory the individual to meet physical, psychological, social, perception in nursing care model’ in clinical practice. and spiritual needs with appropriate modification of It shows that the nurse did assessment through history environment of individual, family, and community collection and recorded vital signs (Sensory Modalities through nursing education, practice, and research.” (S.M.): Vision and Hearing). Patient started sweating Nurse at 8.15 am. After seven minutes, she recognized the Florence Nightingale (1860) viewed nurses, who assist alterations in the physical subzone of the patient. One can easily identify the two aspects of numbness of the physician in patient care. Peplau (1988) considered senses of the nurse for seven minutes; either it may nurse, who assists the patient in therapeutic process. lead to complications and/or death of patient or able The nurse is especially “educated to recognize and to bring the patient back to homeostasis by sudden respond to the need for help.” (George, 2011) The and effective interventions. She perceived the room paper explains nurse, who is enabled to provide care temperature by herself (S.M.: Auto thermoception) to patients using inter-sensory perception. The nurse as very cool but, patient is sweating in the cool is able to use one or more senses together to identify, environment (S.M.: Vision). To confirm, she touched compare to self and patient, and interpret the alterations the patient to assess body temperature (S.M.: Touch). in the physical, psychological, and environmental She continued her assessment by reading ECG (S.M.: subzones of the patients. Vision) and formulated nursing diagnosis as risk for cardiovascular disease. She planned the outcomes and Human being plan of actions with the physician. She reinforced the Sister Callista Roy (1984) proposed human being as patient and attender to avoid alterations in the intra a person, who responds to stimuli from internal and and inter psychological zones. She implemented plan external environment through coping mechanisms. The of action within six minutes and evaluated the success coping mechanisms are one of the four modes such of action after 20 minutes. as physiological-physical mode, identity mode, role function mode, and interdependence mode (George, Discussion 2011). In this paper, human being is an individual, Inter-sensory perception in nursing care and seeking constant adjustment between internal and nursing metaparadigm external zones to maintain homeostasis. Any alterations The discipline of nursing has four concepts such in one or more subsets of elements of human being as person, health, environment, and nursing. The will result in homeostatic imbalance, which may lead to metaparadigms are abstract concepts, which help to further complications and/or death. summarize missions of a discipline and place boundaries on the discipline (Kim, 1989; George, 2011). The paper Patient considers six metaparadigms to explain inter-sensory The paper refers patient to human being, who seeks perception in nursing care such as nursing, nurse, help to retain homeostasis between internal and human being, patient, health, and environment. external zones through identification and action on alterations in the subsets of elements. Nursing Florence Nightingale (1860) considered nursing is Health to put the patient in best condition for nature to act Henderson’s belief about health was related to human upon him. In twentieth century, Hall (1966) explained function. It was based on the individual’s ability to nursing is the process of participation in the care, core, function independently (Henderson, 1977). The paper and cure aspects with other members of the health explains health as a complete state of homeostasis team (George, 2011). The paper explains nursing as a of an individual between physical, psychological, and “Profession with unique body of knowledge, attitude, environmental zones. and practice, aimed to mould the sensory modalities of a learner of nursing, to enable him/her to provide Environment care to patients using inter-sensory perception during Nightingale (1974) stressed physical environment illness to health continuum or till death by helping consists of ventilation, warmth, noise, light, and

14 Manipal Journal of Nursing and Health Sciences | January 2018 | Volume 4 | Issue 1 Jobin et al., Intersensory Perception Model cleanliness that play an important role. Peplau (1980) Florence does not directly address environment. However, Nightingale’s Inter-sensory perception in nursing environmental care she advocated the nurses to consider patient’s theory External Vision, Smell, cultural background. Henderson (1966) considered Ventilation and environment: Air, and Auto environment as an individual in relation to families warming light, and effluvia thermoception (George, 2011). The paper classifies environment into External Vision, Smell, environment: Air, Hearing, Touch, internal and external zones. Internal zone comprises Healthy houses noise, light, and and Auto physical and psychological subzones. External zone effluvia thermoception consists of four subsets of elements such as air, light, Maintain noise, and effluvia. balance between Petty intrapsychological Vision, Hearing, management and and Touch Inter-sensory perception in nursing care and interpsychological nursing theory subzones Theory in nursing is conceptualizing various aspects of External Noise environment: Hearing nursing, communicated for the purpose of describing Noise phenomena, explaining the relationship between Maintain balance between physical, Vision, Smell, phenomena, predicting possible errors, and suggesting psychological, Hearing, Touch, Variety nursing care services. Theory comprises of concepts and and Auto environmental thermoception (and its definitions) and propositions that explain zones relationship between the concepts (George, 2011). Physical subzone: Vision, Smell, Taking food Barnum (1998) stated that a complete nursing theory Nutrition Taste, and Touch Physical subzone: Touch, Smell, and Bed consists of context, content, and process. Context Sleep/rest Vision means the environment in which nursing care is given. External Vision and Auto- Light environment: Process is the method by which nurse acts on (Barnum, thermoception Light 1998; George, 2011). The paper describes the context External Vision, Smell, Cleanliness of environment: Air, Touch, and Auto as the environment, which is a natural setting, in which the rooms patient seeks help to act on him to retain homeostasis. light, and effluvia thermoception Maintain balance Vision, Smell, The content elements are senses of nurse and subsets Personal between physical Touch, and Auto- cleanliness and psychological of elements of human being. The process is a series of thermoception zones activities such as identification of alterations in subsets Maintain of elements in the human being, comparison to self balance between and patient, interpretation, action, assessment, and Chattering intrapsychological Vision, Hearing, hopes and and Touch affirmation of retention of homeostasis done by the interpsychological nurse. subzones

Table 2: Table 2 shows the comparison of inter-sensory Comparative analysis of inter-sensory perception in nursing care perception in nursing care with Florence Nightingale’s with Florence Nightingale’s environmental theory environmental theory. Florence Nightingale’s Inter-sensory perception in nursing Critiquing inter-sensory perception in nursing environmental care care theory The authors used Johnson and Weber (2005) (George, Sensory Human being modalities of 2011) criterion based critique model to evaluate the nurse inter-sensory perception in nursing care. Assist the human Preface: Nursing being to retain Vision, Smell, Phase I: Intent of the theory ought to assist homeostasis Hearing, Touch, The meaning of the concepts is clear and easy to reparative from alterations Taste, and Auto process in the subsets of thermoception understand. The boundaries of the model are consistent elements with nursing care standards.

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Phase II: Concepts and propositions Colley, S. (2003). Nursing theory: its importance to Major concepts such as sensing, nursing foundry model practice. Nursing Standard, 17(46), 33-37. Retrieved and a nurse with inter-sensory perception are clearly July 19, 2017, from http://journals.rcni.com/doi/ identified and defined. The propositions like transition abs/10.7748/ns.17.46.33.s56 of human being into a nurse, human being into a Chin, P.L., & Jacobs, M.K. (1987). Theory and nursing: patient, and patient into a human being by retaining a systematic approach, 2nd ed., C.V. Mosby, St. Louis. homeostasis are interpreted. Darian-Smith, Ian., Johnson.K.O., LaMotte.C., Shigenaga.Y., Kenins.P., & Champness.P. (1979). Phase III: Usefulness in nursing practice Warm fibers innervating palmar and digital skin of Conceptual knowledge regarding “inter-sensory the monkey: responses to thermal stimuli, perception in nursing care” influences the nurses to Journal of Neurophysiology, 42 (5), 1297–1315. reduce unintentional torts. de March., Claire A., Ryu, SangEun., Sicard, Gilles., Strengths Moon, Cheil., Golebiowski., & Jérôme. The description of inter-sensory perception in nursing (2015). Structure–odour relationships reviewed in care is uncomplicated and self-explanatory. It explains the postgenomic era, Flavour and Fragrance Journal, holistic nature of human being and nurse. The relations 30 (5), 342–361. among the concepts are clear and explain the significant Draper, P. (1990). The development of theory in British role of nurses in giving care. It seems to be easy to nursing: current position and future prospects. apply in practice by nurses. Journal of Advanced Nursing.15, 1, 12-15. http:// journals.rcni.com/doi/abs/10.7748/ns.17.46.33. Conclusion s56 The paper provides an essence of what is nursing, nurse, Dubin, A.E., & Patapoutian. A. (2010). : human being, and patient in practice. Additionally, the the sensors of the pain pathway, Journal of Clinical paper was able to throw light on sixth sense (Auto Investigation, 120(11), 3760–72. thermoception) in addition to five traditional senses, Etzioni, A. (1969). New York, McMillan, The Semi-Professions which was unmarked in nursing practice. This model and Their Organizations. NY: London, Free press. calls nurses to implement the approach ‘inter-sensory George, B.J. (2011). Nursing theories: The base for professional perception’ in nursing practice with the empirical practice (6th ed.). California State University, concept of ‘open your six senses,’ which paves the way Fullerton: Pearson. P. 3-189. for reduction of unintentional torts in the nursing care. Ghadirian, F., Salsali, M., & Cheraghi, M. A. (2014). Nursing professionalism: An evolutionary concept Sources of support: None analysis. Iranian Journal of Nursing and Midwifery Conflict of interest: None declared Research, 19(1), 1–10. Source of support in form of grants: None Hall,L.E. (1966). Another view of nursing care and quality. References In K.M.Straub & K.S.Parker (Eds.), Community Adams, D., & Miller, B. (2001). Professionalism in in patient care; the role of nursing, Washington, nursing behaviors of nurse practitioners, Journal of DC: Catholic University Express. Professional Nursing, 17, 203-210. Henderson,V. (1966). The Nature of Nursing: A Definition Adrian, E.D., & Umrath, K. (1929). The impulse and its Implications for Practice, Research, and Education. discharge from the , Journal of New York: Macmillan Publishing. p. 15. Physiology, 68 (2), 139–154. Henderson, V. (1977). Reference resource for research American Nurses Association. (2004). Nursing: Scope and continuing education in nursing, Kansas City, and standards of practice, Washington, MO: American Nurses Association Publication DC: American Nurses Publishing. No.6125. Barnum, B.J.S. (1998). Nursing theory: Analysis, Application Ingram, R. (1991). Why does nursing need theory? and Evaluation (5thed.). Philadelphia: Lippincott. Journal of Advanced Nursing, 16, 350-353.

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