Development of Nursing Theories

Development of Nursing Theories

This page was last updated on November 4, 2010

============================================

Introduction Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory & predictive in nature. Theories are composed of concepts, definitions, models, propositions & are based on assumptions. Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior.[Robert T. Croyle (2005)]. They are derived through two principal methods; deductive reasoning and inductive reasoning. Nursing theorists use both of these methods. Theory is “a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena”. A theory makes it possible to “organize the relationship among the concepts to describe, explain, predict, and control practice” Definition Concepts are basically vehicles of thought that involve images. Concepts are words that describe objects, properties, or events & are basic components of theory. Types: Empirical concepts Inferential concepts Abstract concepts Definitions Models are representations of the interaction among and between the concepts showing patterns. Propositions are statements that explain the relationship between the concepts. Process it is a series of actions, changes or functions intended to bring about a desired result. During a process one takes systemic & continuous steps to meet a goal & uses both assessments & feedback to direct actions to the goal. A particular theory or conceptual frame work directs how these actions are carried out. The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks & theories define the person (patient), the environment, health & nursing. The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which further confounds matters. In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981). They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment. Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981). Their main limitation is that they are only as accurate or useful as the underlying theory. Importance of nursing theories Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978). It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964). Theory is important because it helps us to decide what we know and what we need to know (Parsons1949). It helps to distinguish what should form the basis of practice by explicitly describing nursing. The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education (Nolan 1996). The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do. As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge. This can be seen as an attempt by the nursing profession to maintain its professional boundaries. The characteristics of theories Theories are: interrelating concepts in such a way as to create a different way of looking at a particular phenomenon. logical in nature. generalizable. bases for hypotheses that can be tested. increasing the general body of knowledge within the discipline through the research implemented to validate them. used by the practitioners to guide and improve their practice. consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated. Basic processes in the development of nursing theories Nursing theories are often based on & influenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts. General System Theory It describes how to break whole things into parts & then to learn how the parts work together in “systems”. These concepts may be applied to different kinds of systems, e.g. Molecules in chemistry, cultures in sociology, and organs in Anatomy & Health in Nursing. Adaptation Theory It defines adaptation as the adjustment of living matter to other living things & to environmental conditions. Adaptation is a continuously occurring process that effects change & involves interaction & response. Human adaptation occurs on three levels : 1. The internal (self) 2. The social (others) & 3. the physical (biochemical reactions) Developmental Theory It outlines the process of growth & development of humans as orderly & predictable, beginning with conception & ending with death. The progress & behaviors of an individual within each stage are unique. The growth & development of an individual are influenced by heredity, temperament, emotional, & physical environment, life experiences & health status. Common concepts in nursing theories Four concepts common in nursing theory that influence & determine nursing practice are: The person (patient). The environment Health Nursing (goals, roles, functions) Each of these concepts is usually defined & described by a nursing theorist, often uniquely; although these concepts are common to all nursing theories. Of the four concepts, the most important is that of the person. The focus of nursing, regardless of definition or theory, is the person. Historical perspectives and key concepts Nightingale (1860): To facilitate “the body’s reparative processes” by manipulating client’s environment Peplau 1952: Nursing is; therapeutic interpersonal process. Henderson 1955: The needs often called Henderson’s 14 basic needs Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960) emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family. Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being. Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery. Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through “humanistic science of nursing” Orem1971: This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs. King 1971: To use communication to help client reestablish positive adaptation to environment. Neuman 1972: Stress reduction is goal of system model of nursing practice. Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes. Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life. Classification of nursing theories A. Depending On Function (Polit et al 2001) Descriptive-to identify the properties and workings of a discipline Explanatory-to examine how properties relate and thus affect the discipline Predictive-to calculate relationships between properties and how they occur Prescriptive -to identify under which conditions relationships occur B. Depending on the Generalisability of their principles Metatheory: the theory of theory. Identifies specific phenomena through abstract concepts. Grand theory: provides a conceptual framework under which the key concepts and C. Principles of the discipline can be identified. Middle range theory: is more precise and only analyses a particular situation with a limited number of variables. Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved. D. Based on the philosophical underpinnings of the theories “Needs “theories. “Interaction” theories. “Outcome “theories. Humanistic theories. 1. “Needs” theories These theories are based around helping individuals to fulfill their physical and mental needs. Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position. 2.“Interaction” theories As described by Peplau (1988), these theories revolve around the relationships nurses form with patients. Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs. 3. “Outcome” theories" Oucome theories portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health. Outcome theories have been criticized as too abstract and difficult to implement in practice. 4. “Humanistic” Theories Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life. Humanistic theories emphasize a person’s capacity for self-actualization. Humanists believe that the person contains within himself the potential for healthy & creative growth. Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual. The major contribution that Rogers added to nursing practice is the understandings that each client is a unique individual, so, person-centered approach now practice in nursing. Models of nursing A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking. A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions. According to Fawcett (2000), A conceptual model “gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems” Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursinghealth. These four concepts form a metaparadigm of nursing. (goals, roles, functions); and The term metaparadigm comes from the Greek prefix “meta,” which means more comprehensive or transcending, and the word Greek word “paradigm,” which means a philosophical or theoretical framework of a discipline upon which all theories, laws, and generalizations are formulated (Merriam-Webster’s Collegiate Dictionary, 1994). Categories of Conceptual Models Ten conceptual models of nursing have been classified according to two criteria: the world view of change reflected by the model (growth or stability); and the major theoretical conceptual classification with which the model seems most consistent (systems, stress/adaptation, caring, or growth/development). 1.Systems Theory as a Framework Systems theory is concerned with changes caused by interactions among all the factors (variables) General systems theory states A system is defined as “a whole with interrelated parts, in which the parts have a function and the system as a totality has a function”. A general systems approach allows for consideration of the subsystems levels of the human being, as a total human being, and as a social creature who networks himself with others in hierarchically arranged human systems of increasing complexity. Thus the human being, from the level of the individual to the level of society, can be conceptualized as the client and becomes the target system for nursing intervention (Sills & Hall, 1977). An example of systems interaction Input (Diet teaching) Throughput (Assimilation of information) Output (Food intake) Feedback (Weight record, Hb estimation etc.) Two nursing models based on systems theory: Imogene King’s systems interaction model, and Betty Neuman’s health care systems model. Major Concepts as Defined in King’s Model Person (Human Being) A personal system that interacts with interpersonal and social systems Environment A context “within which human beings grow, develop, and perform daily activities” Health dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” Nursing A process of human interaction Imogene King’s Systems Interaction Model In interaction model, the purpose of nursing is to help people attain, maintain, or restore health. King’s model conceptualizes three levels of dynamic interacting systems. 1. Individuals are called “personal systems.” 2. Groups (two or more persons) form “interpersonal systems.” 3. Society is composed of “social systems.” As the person interacts with the environment, he or she must continuously adjust to stressors in the internal and external environment (King, 1981). Health assumes achievement of maximum potential for daily living and an ability to function in social roles. It is the “dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” (King, 1981,). “Illness is a deviation from normal, that is, an imbalance in a person’s biological structure or in his psychological makeup, or a conflict in a person’s social relationships” (King, 1989). “The goal of nursing is to help individuals and groups attain, maintain, and restore health” Stress: “a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance” Betty Neuman’s Health Care Systems Model Betty Neuman specifies that the purpose of nursing is to facilitate optimal client system stability. Normal line of defense: an adaptational level of health considered normal for an individual Lines of resistance: protection factors activated when stressors have penetrated the normal line of defense Neuman’s model, organized around stress reduction, is concerned primarily with how stress and the reactions to stress affect the development and maintenance of health. The person is a composite of physiologic, psychological, sociocultural, developmental, and spiritual variables considered simultaneously. “Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences” (Neuman, 2002). A person is constantly affected by stressors from the internal, external, or created environment. Stressors are tension-producing stimuli that have the potential to disturb a person’s equilibrium or normal line of defense. This normal line of defense is the person’s “usual steady state.” It is the way in which an individual usually deals with stressors. Stressors may be of three types: Intrapersonal: forces arising from within the person Interpersonal: forces arising between persons Extrapersonal: forces arising from outside the person Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person’s resistance to any given stressor or stressors. If the flexible line of defense is no longer able to protect the person against a stressor, the stressor breaks through, disturbs the person’s equilibrium, and triggers a reaction. The reaction may lead toward restoration of balance or toward death. Neuman intends for the nurse to “assist clients to retain, attain, or maintain optimal system stability” (Neuman, 1996). Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense. Neuman defines illness as “a state of insufficiency with disrupting needs unsatisfied” (Neuman, 2002). Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person’s lines of resistance. Stress/Adaptation Theory as a Framework In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect. The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand both how the balance is maintained and the possible effects of disturbed equilibrium. This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological) phenomenon. Criticisms of nursing theories To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice. Summarization Definition Importance of Nursing Theories The characteristics of theories: Basic Processes in the Development Of Nursing Theories: Nursing theories are often based on & influenced ANA definition of Nursing Practice Common concepts in Nursing Theories: Historical Perspectives & Key Concepts Clasification of Nursing Theories Models Of Nursing Growth and Stability Models of Change Betty Neuman’s Health Care Systems Model Stress/Adaptation Theory as a Framework A unique body of knowledge Criticisms of nursing theories Conclusion Theory and practice are related. A theory presents a systematic way of understanding events or situations.It is a set of concepts, definitions, and propositions that explain or predict these events or situations by illustrating the relationships between variables.Theories must be applicable to a broad variety of situations. They are, by nature, abstract, and don’t have a specified content or topic area. Like empty coffee cups, theories have shapes and boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems. [Robert T. Croyle (2005)] Reference Robert T. Croyle (2005). Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition). U.S. Department of Health and Human Services, National Institutes of Health. Available at www.thecommunityguide.org. George B. Julia , Nursing Theories- The base for professional Nursing Practice , 3rd ed. Norwalk, Appleton & Lange. Wills M.Evelyn, McEwen Melanie (2002). Theoretical Basis for Nursing Philadelphia. Lippincott Williams& wilkins. Meleis Ibrahim Afaf (1997) , Theoretical Nursing : Development & Progress 3rd ed. Philadelphia, Lippincott. Taylor Carol,Lillis Carol (2001)The Art & Science Of Nursing Care 4th ed. Philadelphia, Lippincott. Potter A Patricia, Perry G Anne (1992) Fundamentals Of Nursing –Concepts Process & Practice 3rd ed. London Mosby Year Book. Vandemark L.M. Awareness of self & expanding consciousness: using Nursing theories to prepare nurse –therapists Ment Health Nurs. 2006 Jul; 27(6) : 605-15 Reed PG, The force of nursing theory guided- practice. Nurs Sci Q. 2006 Jul;19(3):22