EMERGENCE of CONCEPT, THEORY AND MODELS in

NURSING

Presented by: LAIDEE CAMILLE B. ACACIO, R.N.

On the way to Theoretical Nursing:

Stages and Milestones

ROGERS (1970)

Offered a conception of nursing that focused on the constant human interaction with the environment.

JOHNSON (1980)

Developed the notion that a human being- a biological system- is also an abstract system of behavior centered on innate needs.

LEVINE (1967) & OREM (1971)

Proposed guidelines for nursing therapeutics that preserve the integrity of the human being, the psychology, the community affiliation.

TOULMIN (1977)

Proposed that “human behavior in general represents too broad a domain to be encompassed within a single body of theory.”

3 Themes in Nursing evolved:

Acceptance of the complexity of nursing and the inevitability of multiple paradigms.

Acceptance of the need to test and corroborate major propositions of differing theories before dismissing any of them.

The idea that concepts or theories remaining in the field, through a cumulative effect, become the basis of the development of perspective.

Dualism and pluralism were the norms of this stage. In this stage, nursing developed the boundaries to focus its

flexibility to allow expansion through creative endeavor.

MILESTONES in THEORY DEVELOPMENT

Prior to 1955: From Florence Nightingale to Nursing Research

This period was otherwise uneventful for nursing theory, except that the establishment of nursing research publications provided the framework for a questioning attitude that has inquiries into theoretical nursing.

Establishment of the journal, Nursing Research, with the goal of reporting on scientific investigations for nursing by nurses.

1955-1960 The Birth of Nursing Theory: The Columbia University Teachers College Approach

They offered graduate programs that focused on educational and administration theories. Nurses are being prepared in the functional roles and experiencing a sense of competency in preparing syllabi, staffing patterns and so on.

1961-1965 Theory: A National Goal in Nursing

Nursing was considered a process rather than an end, an interaction between unrelated nurse and patient.

Availability of time and resources was significant in providing the necessary push and the environment to reflect on nursing’s mission and goals.

American Nurses’ Association

Defined nursing and articulated the position that one of the most significant goals of nursing was theory development.

Thereby, supporting the need for an articulate theoretical mission to guide the further development of nursing knowledge (ANA, 1965)

It was a confirmation that nursing is an evolving science with theoretical principles and underpinnings.

2 Significant developments occurred in this stage

1. Federal support was provided to nurses wishing to pursue doctoral education in one of the basic sciences.

2. The inauguration of the journal, NURSING SCIENCE, it was a medium for exchange of ideas on theory and science in nursing.

1966-1970 Theory Development: A Tangible Goal for Academics

Three symposia

1. Nursing Research2. Definition of Nursing Theory3. Theories used in conjunction

Nursing Research

Considered as perceptions and conceptions of theoretical nursing from an isolated number of theorists.

Nursing Theory

It was defined, goals for theory development were set and the confirmation of outsiders was productive.

Theories used in conjunction It was used in conjunction with education and not in

practice. Debates existed as to whether the theories should be basic

or borrowed, pure or applied, descriptive or prescriptive.

Accomplishments at this stage can be summarized as:

Nursing is a field amenable to theorizing. Nurses can develop theories. Practice is a rich area for theory. Practice theory should be the goal for theory development

in nursing.

Nurses’ highest theory goal should be prescriptive theory, but it is all right to develop descriptive and explanatory theories.

1971-1975 Theory Syntax

The emphasis of this period was on the components of theory and the process of theory analysis and critque.

Education of nurses in basic, natural, and social sciences through the federally supported nurse-scientist programs produced who shared common goal.

Discussions of what constituted theory and identification of theory syntax seemed to be the means in achieving the goal.

American Nurses’ Association

Acknowledged the significance of theory development.

National League for Nursing

Made theory-based curriculum a requirement for accreditation. It increased the use of theory and discussions about theory and prompted more writing about the syntax of theory.

1976-1980 A Time to Reflect

This was the time for nurse academicians to utilize nursing theories as guiding frameworks for curriculum.

Advances in Nursing Science

It focuses on the full range of activities involved in the development of science.

Journal Theory & Theory Development

To add support to the significance of theoretical nursing and give nurses medium to present their ideas.

This period is characterized by questioning if nursing’s progress would benefit from the single paradigm and a single theory of truth.

1981-1985 Nursing Theories’ Revival:

Emergence of the Domain Concepts

This period is characterized by the nursing theory advocates who pleaded for the use of nursing perspective in general or specific utilization of nursing theory.

This period is characterized by a greater clarity in the relationship between theory and research than theory and practice.

Advocates

Promote nursing theory and demonstrate its use in one research project or in a limited practice arena.

Synthesizers

Limited use to describe and analyze how nursing theory may have influenced nursing practice, education, research, and administration.

THEORY

Chinn and Jacobs, 1987:70

Is a set of concepts, definitions and propositions that project s systematic view of phenomena by designating specific interrelationships among concepts for the purpose of describing, explaining, predicting and/or controlling phenomena.

Duldt and Griffin (1985:5)

A system of interrelated propositions which should enable phenomena to be described, explained, predicted and controlled.

Chinn and Kramer 1995: 20

A careful and rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenomena.

Barnum (1990: 16)

A theory is a statement that purports to account for or characterize some phenomenon.

Types of Theory Definitions

Chinn and Jacobs (1983)

1. Definitions focusing on structure.2. Definitions focusing on practice goals.3. Definitions focusing on tentativeness.4. Definitions focusing on reseach.

Meleis (1985)

1. Definitions focusing on multiple uses.2. Definitions focusing on one or more of the specified domain

concepts.3. Definitions focusing on any of the domain concepts and

health.

Theory

Logically interrelated sets of confirmed hypotheses. A conceptual system invented for some purpose. A statement that purports to account for the

characterization of some phenomenon. A coherent set of hypothetical, conceptual, and pragmatic

principles forming a general frame of reference for a field of inquiry.

Made up of concepts and propositions. Phenomena with much greater specificity than do

conceptual models. The metaparadigm phenomenon of person, environment,

health, and nursing by specifying relationships among variables derived from these phenomena.

Nursing Theory

Is defined as an articulated and communicated conceptualization of invented or discovered reality in or pertaining to nursing care.

Examples of phenomena and relationships depicted in nursing theories are:

A nursing client is conceptualized as self-care agent. A nursing client is biopsychological being. A nursing client is a system with a number of behavioral

subsytems.

Concept

Meleis (1991: 12)

A label used to describe a phenomenon or a group of phenomena.

A concept is a tool and not a real entity- it merely facilitates observation of a real phenomenon.

It refers to the properties of a phenomenon; the concept is not the phenomenon itself, rather it is a name one gives to a phenomenon.

Concepts give meaning for filing purposes, enabling us to categorize, interpret and structure the phenomenon.

Concepts are also the building blocks of theory, they convey the ideas within the theory.

Fawcett and Downs (1992)

The concepts of a theory are its special vocabulary.

Model

McFarlane, 1986a

A representation of reality.

Stockwell, 1985

A simplified way of organizing a complex phenomenon.

Fawcett,1992

Is a set of concepts and the assumptions that integrate them into a meaningful configuration.

Rambo, 1984

Is a way of representing a situation in logical terms in order to show the structure of the original idea or object.

McKenna, 1994b: 16

A diagrammatic representation of care which is systematically constructed and which assists practitioners in organizing their thinking about what they do in and in the transfer of their thinking into practice for the benefit of the client and the profession.

Chapman, 1985, used three dimensions to describe them.

One-dimensional models

1. Presented in one-dimensional format take the form of verbal statements or philosophical beliefs about the phenomena.

2. It tends to be at a high level of abstraction. They cannot be taken apart or explicitly observed, but they can be thought about mentally manipulated.

Two-dimensional modelsIncludes diagrams, drawings, graphs or pictures.

Three-dimensional models 1. Refers to as “physical models”2. These are scale models or structural replicas of things.

Paradigm

Derives from the Greek word “paradeigma”, meaning pattern.

Fawcett, 1992:66

Maintains that a paradigm represents “global ideas about the individuals, groups, situations and events of interest to a discipline”.

4 Main Paradigms used in Nursing Theories

Systems paradigm Is a collection of parts that function as a whole entity for a

particular purpose.

These interrelationships may form “sub-systems” within the parent system.

Interactional Paradigm It emphasizes the relationships between people and the roles they

play in society.

Developmental Paradigm The central themes are growth, development, maturation and

change.

Behavioral Paradigm Assumes that individuals normally exist and survive by meeting

their won needs.

REFERENCES:

Theoretical Nursing Development and Progress 4th Edition, Afaf Ibratim Meleis RT 84.5 M482 2007

Nursing Theorist and Their Works 6th Edition, Ann Marriner Tomey; Martha Raie Alligood, RT 84.5 N948 n 2006

Fundamentals of Nursing; Barbara Kozier

COMPARATIVE ANALYSIS OF CONCEPT, THEORY AND

MODEL

PRESENTED BY:

JINKY RIVERA, RN

DEFINITION OF TERMS

Assumptions – statements supposed to be true without proof or demonstration

Borrowed or shared Theory - a theory developed in another discipline that is not adopted to the worldview and practice of nursing.

Conceptual model/ Framework - set of interrelated concepts that symbolically represents and conveys a mental image of phenomenon.

Construct - comprised of more than one concept and typically constructed by the theorist to fit a purpose. Concept is a more general term- all constructs are concept but not all concept are constructs

Empirical Indicator - instructions, experimental conditions and procedures used to observe/ measure the concepts of a theory.

Epistemology - theories of knowledge or how people come to have knowledge.

Hypotheses - tentative suggestions that a specific relationship exist between two concepts

Knowledge - awareness of reality acquired through insight, learning or investigation.

Laws - proposition about the relationship between concepts in a theory that has been repeatedly validated.

Metaparadigm - represents the worldview of a discipline. Nursing’s metaparadigm is generally thought to consist of the concepts of person, environment, health and nursing.

Paradigm - organizing framework that contains concepts, theories, assumptions, beliefs, values and principles that form the way a discipline interprets the subject matter with which it is concerned. It describes work to be done and frames an orientation within which the work will be accomplished.

Praxis- application of a theory to cases encountered in experience Model - graphic or symbolic representations of phenomena that present

certain perspectives or point of view about nature or function or both. Models may be:

Theoretical- something not directly observable expressed in language or symbol

Empirical- observable reality, example model of an eye

Phenomena - designation of an aspect of reality

Practice/ microtheory- discrete phenomena that are not expanded to include their link with the boad concerns of a discipline.

OVERVIEW OF THEORY

Theory is a systematic explanation of event in which constructs and concepts are identified and relationships are proposed and predictions made.(Streubert- Speziale, 2006)

It is a creative and rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenomena. (Chinn and Kramer, 2008)

A set of interpretative assumptions, principles or propositions that help explain or guide actions. ( Young, Taylor and Renpenning, 2001)

Theory is invented rather than found in or discovered from reality. (Dickoff and James, 1968)

Offers structure and organization to nursing knowledge and provides a systematic means of collecting data to describe, explain and predict nursing practice.

Theories make nursing practice more overtly purposeful by stating not only the focus of practice but specific goals and outcome.

Promotes rational and systematic practice by challenging and validating intuition.

Theories define and clarify nursing and the purpose of nursing practice to distinguished it from other caring professions by setting professional boundaries

Use of theory in nursing lead to coordinated and less fragmented care.

THEORY DEVELOPMENT IN NURSING

Florence nightingale

First modern nursing theorist

First to delineate what she considered nursing’s goal and practice domain

Postulated that “to nurse” meant having charge of the personal health of someone

Believed that role of the nurse was seen as placing the client “in the best condition for nature to act upon him”

Stressed the significance of trained powers of observation and reflection

Notes on Nursing, 1859

Notes on nursing, 1859

basic premises for nursing practice

In her view, nurses must make astute observations of the sick and their environment, record observations and develop knowledge about factors that promoted healing.

STAGES OF THEORY DEVELOPMENT

Silent Knowledge Stage

American Medical Association advocated the formal training of Nurses and suggested that schools of Nursing be attached to hospitals with instructions being provided by medical staff and resident physician.

Education practice were based on rules, principles, and traditions that were passed along through an apprenticeship form of education.

By 1909 there were 1006 such programs, a meager amount of theory was taught by physicians and practice was taught by experienced nurses.

Few nursing books were available and the emphasis was on carrying out doctor’s order.

Nursing education and practice focused on the performance of technical skills and application of a few basic principles, such as aseptic technique and principles of mobility

Largely adhered to the medical model which views body and mind separately and focuses on cure and treatment of pathologic problems.

Hospital admin. view nurses as inexpensive labor.

Nurses were exploited. They were taught to be submissive and obedient and they learned to fulfill their responsibilities to physicians without question.

This model of nursing education persisted for 80 years.

Yale University started the first autonomous school of nursing in 1924. Professional training was strengthened by in depth exposure to underlying theory of disease as well as the social, psychological and physical aspects of client welfare.

the growth of collegiate programs lagged, however due to opposition from many physicians who argued the university-educated nurses were over trained.

Hospital schools continued to insist that nursing education meant acquisition of technical skills and knowledge of theory was unnecessary and might actually handicapped the nurse.

RECEIVED KNOWLEDGE STAGE

After World War II substantive changes were made in nursing education.

1948 report, Nursing for the Future, by Esther Brown, PhD, compared nursing with teaching. She said that the current model of nursing education was central to the problems of the profession and recommended that efforts be made to focus nursing education in universities , with formal education, as opposed to the apprenticeship system that existed in most hospital programs.

Professional org. for nurses were restructured and began to grow

State Licensure testing for registration took effect and by 1949, 41 states required testing. The registration requirement necessitated that education programs review the content matter they were teaching to determine minimum criteria and some degree of uniformity.

In 1950, the journal Nursing Research was first published .

American Nurses Association began a program to encourage nurses to pursue graduate education to study nursing functions and practice

Books on research methods and explicit theories of nursing began to appear.

1856, the Health Amendments Act authorized funds for financial aid to promote graduate education for full time study to prepare nurses for administration, supervision and teaching. These resulted in slow but steady increase in graduate nursing education programs.

First Doctoral programs in nursing – Teacher’s College, Columbia University (1933) and New York University ( 1934).

By 2007, there were 107 doctoral programs granting PhD OR DNS and 73 doctorate of nursing practice (DNP)

Graduate nursing education allowed nurse scholars to debate ideas that were taken for granted in nursing and the traditional basis in which nursing was practiced.

SUBJECTIVE KNOWLEDGE STAGE

James Dickoff, Patricia James and Ernestine Weidenbach – described theory development and the nature of theory for a practice discipline.

Approaches to Theory development combined direct observations of practice, insights derived from existing theories and other literature sources and insights derived from explicit philosophical perspectives about nursing and the nature of health and human experience.

1960s a number of nurse leaders developed and published their views of nursing. Their definition of nursing evolved from personal, professional and educational experiences and reflect their perception of ideal nursing practice.

Theorist during this period:

PROCEDURAL KNOWLEDGE STAGE

By the 1970s, the nursing profession viewed itself as a scientific discipline evolving toward a theoretically based practice focusing on the client.

Late 1960s and early 1970s, several nursing theory conferences were held.

1972- National League for Nursing implemented a requirement that nursing curricula be based on conceptual frameworks.

Many nursing theorists published their beliefs and ideas in nursing and some developed conceptual models.

1970’s, a consensus developed among nursing leaders regarding common elements of nursing. These were the nature of nursing (roles/ actions), the individual recipient of care (client), the context of nurse-client interactions (environment) and health.

Nurses debated whether there should be one conceptual model for nursing or several models to describe the relationships among the nurse, client, environment and health.

Graduate School developed courses on analysis and application of theory.

Researchers identified nursing theories as conceptual frameworks for their studies.

Late 1970s and early 1980s – theories moved to characterizing nursing’s role from what they do to what nursing is. This moved nursing from context-dependent, reactive position to context independent, proactive arena.

CONSTRUCTE KNOWLEDGE STAGE

Late 1980’s scholars began to concentrate on the need to develop substantive theory that provides meaningful foundation for nursing practice.

A call to develop substance in theory and to focus on nursing concepts grounded in practice and linked to research.

1990s and early 21st century saw an increasing emphasis on philosophy and philosophy of science in nursing

Attention shifted from grand theories to middle range and practice or situation specific theories as well as application of theory in research and practice.

This is the current stage of theory development in nursing.

It is anticipated that the importance of application of middle range and practice theories in research and practice will continue to be stressed. Correspondingly, less attention will be given to grand theories and conceptual frameworks.

CLASSIFICATION OF THEORIES IN NURSING

Classification Based in Scope

refers to complexity and degree of abstraction.

to describe philosophical basis of the discipline: Metatheory, Philosophy or worldview

grand theory or macrotheory to describe the comprehensive conceptual frameworks.

Middle range / midrange theory to describe frameworks that are relatively more focused than grand theories

Microtheory, situation-specific theory or practiced theory to describe those smallest in scope

1. METATHEORY it refers to theory about theory Focuses on broad issues such as the process of generating new

knowledge and theory development Philosophical and methodological issues at the metatheory or

worldview level include: identifying the purposes and kinds of theory needed for

nursing, developing and analyzing methods for creating nursing theory proposing criteria for evaluating theory.

Walker and Avant (2005) Historical Trends in Nursing Metatheory

1960s- discussions involve nursing as an academic discipline and the relationship of nursing to basic sciences

Later discussions addressed the predominant philosophical worldviews ( received vs perceived view) and methodological issues related to research

Recent issues relate to the philosophy of nursing and address what levels of theory development are needed to nursing practice, research and education.

2. GRAND THEORIES the most complex and broadest in scope Explain broad areas within the discipline and may incorporate numerous

other theories Macrotheory- used to describe a theory that is broadly conceptualized and

is usually applied to general area of specific discipline. Comprised of relatively of abstract concepts that lack operational

definition The majority of conceptual frameworks ( Orem, Roy, Rogers) are

considered to be grand theories. OREM, ROY, HALL, NEUMAN, KING

3. Middle Range Theories lies within the nursing models and are more circumscribed, concrete ideas

(practice theories) PEPLAU,

Comprised of relatively concrete concepts that are operationally defined and relatively concrete propositions that may be empirically tested.

Fawcett (2000) states that a middle theory may be

description of a particular phenomenon Explanation of the relationship between phenomena Prediction of effects of one phenomenon or another

Provide the basis for generating testable hypotheses related to particular nursing phenomena and to particular client populations. Examples: social support, quality of life and health promotion

4. Practice Theories also called as microtheories, prescriptive theories or situation specific

theories and are the least complex

Produce specific directions for practice

Contain fewest concepts and refer to specific; easily defined phenomena, narrow in scope, explain a small aspect of reality and tend to be prescriptive.

Limited to specific populations or fields of practice theories developed and used by nurses are theories of infant bonding and oncology pain management.

5. Partial Theories theories that are in the development stage

Some concepts have been identified, some relationships between them have been identified but the theory is not complete

Keck (1998) states that theories derived from the social sciences, including nursing, are probably exclusively partial theories because they are few, if any, phenomena that have been totally and completely explained.

Comparison of the scope of nursing theories

TYPE OR PURPOSE OF THEORY

Factor-isolating theories

Describe, observe and name concepts, properties and dimensions

Descriptive theory identifies and describes the major concepts of phenomena but does not explain how or why the concepts are related.

Purpose: to provide observation and meaning regarding the phenomena.

Generated and tested by descriptive research techniques including concept analysis, case studies, literature review phenomenology, ethnography and grounded theory.

EXAMPLES

Robles-Silva (2008)

used ethnography to construct a theory explaining the multiple phases that caregivers experience while working with poor, chronically ill adults in Mexico.

Register and Herman (2008)

Used comprehensive literature review to develop a middle range theory for generative quality of life for elders

Factor-Relating theories

also known as Explanatory Theories, are those that relate concepts to one another, describe the interrelationships among concepts or propositions and specify the associations or relationships among some concepts.

“how or why” the concepts are related and may deal with cause and effect and correlations and rules that regulate interactions.

Developed by Correlational Research

EXAMPLES

Hastings-Tolsma, 2006

proposed Theory of Diversity of Human Field Pattern. It was developed from descriptive corelational study that examined the relationships between risk-taking behavior and time movement, within the context of energy flow and field patterns.

Haight, Barba, Tesh & Courts, 2002

Thriving Model, which builds in previous work related to failure to thrive in elders by defining the constructs thriving and failure to thrive.

SITUATION-Relating theories

Also known as Predictive Theories

achieved when the conditions under which concepts are related are stated and the relational statements are able to describe future outcomes consistently.

Move to prediction of precise relationships between concepts

Experimental Research is used to generate and test them

EXAMPLES

Auvil- Noval 1997

presented the development of middle range theory of chronotherapeutic intervention for post surgical pain based on three experimental studies of pain relief among postsurgical clients. The theory uses a time-dependent approach of pain assessment and provides directed nursing interventions to address postoperative pain.

ISSUES IN THEORY DEVELOPMENT IN NURSING

Borrowed vs. unique theory

Opponents of Using Borrowed Theory

Proponents of Using Borrowed Theory

only theories that are grounded in nursing should guide the actions of the discipline

They believe borrowing requires returning and that the theory is not in essence nursing if concepts are borrowed

knowledge belongs to the scientific community and to society at large and it is not the property of individuals or disciplines.

knowledge is not a private domain of one discipline and the use of knowledge generated by other discipline is not borrowed but shared.

NURSING’S METAPARADIGM

Metaparadigm is the global perspective of a discipline that identifies the primary phenomena of interest to that discipline and explains how the discipline deals with those phenomena in a unique manner.

Purpose: to summarize the intellectual and social missions of the discipline and place boundaries on the subject matter of that discipline.

Requirements for a metaparadigm (Fawcett and Malinski, 1996)

Must identify a domain that is distinctive from the domain of other disciplines

Must encompass all phenomena of interest to the discipline in a parsimonious manner

Must be perspective-neutral

Must be international in scope and substance

1970s and early 1980s- growing consensus that the dominant phenomena within the science of nursing revolved around the concepts of man (person) , health, environment and nursing

Wagner (1986)

Examined the nursing metaparadigm in depth. Her sample of 160 doctorate-prepared chairpersons, deans or directors of programs for bachelor’s of science in nursing revealed that between 94% and 98% of the respondents agreed that the concepts that comprise the nursing metaparadigm are person, health, nursing and environment. She concluded that this findings indicated a consensus within the discipline of nursing that these are the dominant phenomena within the science.

Person

refers to a being composed of physical, intellectual, biochemical psychosocial needs; a human energy field; a holistic being in the world; an open system; an integrated whole; an adaptive system; a being who is greater than the sum of his parts

Health

ability to function independently; successful adaptation to life’s stressors ; achievement of ones full life potential; and unity of mind, body and soul.

Environment

the external elements that affect the person; internal and external conditions that influence the organisms; significant others with whom the person interacts and an open system with boundaries that permit the exchange of matter, energy and information with human beings

Nursing

is a science, an art and a practice of discipline and involves caring.

Goals: Care of the well, the sick, assisting with self-care activities, helping individuals attain their human potential and discovering and using nature’s law of health.

Kim (1987, 1989)

Identified four domains (client, client-nurse, practice and environment) as an organizing framework or typology of nursing. The most significant difference appears to be in placing health issues (i.e. health care expenses) within the client domain and differentiating the nursing practice domain from the client-nurse domain.

Meleis, 2005

Maintained that nursing encompasses seven central concepts: interaction, nursing client, transitions, nursing process, environment, nursing therapeutics and health. Addition of the concepts of interaction, transition and nursing process denotes the greatest difference between this framework and the more commonly described person/ health/ environment/ nursing framework.

Concept of caring in nursing

Caring as the essence of nursing

Thorne and Colleagues cited three major areas of contention in the debate about caring in nursing.

Diverse views on the nature of caring

Use of caring terminology to conceptualize a specialize role

Implication for the future development of the profession should nursing espouse caring as its unique mandate

Fawcett and Maliniski (1996)

Argued that although caring is included in several conceptualizations of the discipline of nursing, it is not a dominant term in every conceptualizations of the discipline-wide viewpoint. Furthermore caring is not uniquely a nursing phenomenon and caring behaviors may not be generalizable across national and cultural boundaries.

CONCEPT DEVELOPMENT

Abstract term derived from particular attributes.

A symbolic statement describing a phenomenon or a class of phenomena.

Formulated in words that enable people to communicate their meanings about realities in the world and give meaning to phenomena that can directly or indirectly be seen, tasted, smelled or touch.

Compared to bricks in a wall that lend structure to science

Concept Characteristics Examples

Enumerative concepts Are always present and universal Age, height, weight

Associative concepts Exist only in some conditions within a phenomenon; may have a zero value

Income, presence of disease, anxiety

Relational concepts Can be understood only through the combination or interaction of two or more enumerative or associative concepts

Elderly (must combine concepts of age and longevity)

Mother (must combine man, woman, and birth)

Statistical concepts Relate the property of one thing in terms of its distribution in the population rate

Average blood pressure HIV/AIDS prevalence rate

Summative concepts Represent an entire complex entity of a phenomenon; are complex and not measurable

Nursing, health, and environment

ABSTRACT VERSUS CONCRETE CONCEPTS

DISCRETE VERSUS CONTINUOUS

THEORETICALLY VS. OPERATIONALLY DEFINED CONCEPTS

EXAMPLE: THE CONCEPT OF COPING

Vinson J. A. (2002)

Children with Asthma : Initial Developing of the Child Resilience Model

Theoretical Definition: Cognitive and behavioral efforts to manage specific external and/ or internal demands that are appraised as taxing and exceeding the resources of the person

Operational Definition: Score on the Coping Health Inventory for Children

SOURCES OF CONCEPTS

Concept Source Characteristics Examples from NursingLiterature

Naturalistic concepts

Present in nursing practice

May be defined and developed for use in research and theory development. Often have medical implications as well as nursing use

Body weight, pain, thermoregulation, depression, hematologic complications, circadian dysregulation

Research-based concepts

Developed through a qualitative research processes (i.e., grounded theory or existential phenomenology)

Often relate to a nursing specialty

Hope, grief, cultural competence, chronic pain

Existing concepts

Borrowed from other disciplines

Developed for nursing practice, but are useful in research and theory

Job satisfaction, quality of life, abuse, adaptation, stress

CONCEPT ANALYSIS AND DEVELOPMENT

Process of inquiry that examines concept for their level of development as revealed by their internal structure, use, representativeness and relationship to other concepts.

Explores the meaning of concepts to promote understanding

PURPOSES OF CONCEPT DEVELOPMENT

Clarifying, recognizing and defining concepts that describe phenomena

Identifying gaps in nursing knowledge

Determine the need to refine and clarify a concept when it appears to have multiple meanings

Evaluating the adequacy of competing concepts in their relation to other phenomena

Examining the congruence between the definition of the concept and the way it has been operationalized

Determining the fit between the definition of the concept and its clinical application.

CONTEXT FOR CONCEPT DEVELOPMENT

Example: before we had a concept labeled “burnout”, we did not see burnout never though the syndrome may have existed in one form or another. Because we do not have a label to give to that constellation of behaviors; we did not have a reservoir in which we could connect and deposit those seemingly discrete feelings and responses of apathy, irritability, impatience and the urge to flee and change one’s life. Therefore, describing the varied behaviors and actions related to them may have been limited and somewhat ineffective.

CONCEPT DEVELOPMENT AND RESEARCH

STRATEGIES USED IN NURSING LITERATURE FOR ANALYZING CONCEPTS

Wilson Method of Concept Analysis

1. Identify and isolate the questions of the concept

Facts - answered by existing knowledge about the concept

Values- answered based on moral principles of “should” and “should nots”

Meanings- best considered in terms of concepts

2. Consider the possible answers to the questions and identify the essential elements of these questions

3. Identify and describe exemplars to reflect the different critical and essential characteristics of the concept.

4. . Identify “contrary cases”, that is, those exemplars that do not include any of the properties of the concept.

5. Identify describe and use some related cases in which the concept may be connected or similar in some way or as it occurs in similar texts.

6. Provide borderline cases as exemplars

7. Develop and present invented cases

8. Identify and define the social contexts and analyze concepts as to who may use it, why it may be used and how it could be used.

9. Beware of underlying anxiety related to concepts or generated by the concepts.

10. Define and explain the potential practical results related to the concept.

11. Choose the language for describing the results and the label carefully.

WALKER AND AVANT METHOD OF CONCEPT ANALYSIS

1. Concept Analysis

It is an approach to clarify the meanings of terms and to define terms so that writers and readers share a common language.

Conducted when concepts require classification or further development to define them for a nurse scholar’s purposes, whether that is research, theory development or practice

Steps in Concept Analysis

Step 1: select the concept of interest   

A concept may be selected which originates from an intuitive feeling or an area of concern. The best concept analyses tend to have their roots in clinical

phenomena. This helps to bridge the theory practice gap in that the end result has more credibility and relevance for practice. The concept can also lead to the development of theory which can be more easily used and tested in practice.

Meleis (1991) suggest that while giving care a practitioner’s attention may be attracted to a particular phenomenon. She refers to this as ‘attention grabbing’ and states that can occur concurrently during the care episode or retrospectively when the nurse is reflecting about the care given. The attention-grabbing phase is followed by the ‘attention-giving’ phase. This is a more active and deliberate process. Answers to the following attention-giving questions may help to clarify the hunch that the nurse has about the phenomenon of interest.

Example. The nurse may ask;’ why do patients get angry with their spouse during visiting time?’, or what is it happens when patients decide not to attend a clinic?’, or ‘what are the properties of pre-operative anxiety?’

Meleis urges the nurse to persist with probing questions:

How is the phenomenon related to nursing’s body of knowledge?

Would understanding the phenomenon contribute to better understanding of a patient care issue?

How would questions relating to the phenomenon be significant for nursing?

Once these questions have been answered, the nurse labels the phenomenon with a word or a short phrase. Labels should be precise, used consistently when referring to phenomenon, contain one cardinal idea and be fundamental to the definition/description of the phenomenon (Meleis, 1991).

Example:  In your everyday clinical work, you may notice that ward sisters are able to predict client mishaps before they occur and without knowing precisely how they are able to do this. The concept ‘intuition’ is the term you should select to describe this phenomenon.

From other clinical experiences  you may also be interested in clarifying what the concepts ‘loss’, ‘loneliness’, ‘compassion’ or ‘spirituality’ really mean.

Moody (1990) suggest that it may be helpful to categorize the concept requiring analysis within the metaparadigm. For instance, the concept ‘well-being’ maybe subsumed under health; ’identity’ or ‘body image’ under person; ’caring’ or ‘empathy’ under nursing; and ‘energy field’ under environment.

avoid broad concepts: if you were to select ‘communications’ as a concept you would find it extremely difficult to identify manageable indicators which are representative of this concept.

Step 2: define the aims of the analysis

Step 2 should provide a good rationale as to why you are undertaking the process at all.

may provide a research-based justification for selecting a particular concept.

Government reports and health care strategies may highlight old concepts being used in new ways (quality of care) or new concepts being used to denote old ideas (nursing diagnosis).

It is recommended that a short rationale is constructed to justify why a particular concepts should be analyzed.

In most cases, the prime purpose for undertaking an analysis is to elucidate and to create conceptual meaning for a clinical phenomenon. For instance, the term ‘caring’ is often used in many confusing ways, and an analysis of this concept would tell you what it is and what it is not.

Step 2 will set the parameters for later steps in process. For instance, if the purpose was to investigate fear or hopelessness among

coronary care patients then this will guide you towards those indicators and attributes identified as an aid to recognizing and investigating these concepts.

Step 3: identify meaning of the concepts

This step involves trawling the literature to find as many pertinent meanings of the concept as possible.

The search will provide a range of different ways in which the concept is thought about and used.

Walker and Avant (1995) suggest that you should cast your net as wide as possible in seeking meanings for the concepts.

Rodgers (1994) also recommends sampling a range of uses, stating that this increases the rigor of the analysis.

Example:  If the concept was ‘caring’, you will note that it could be perceived as a noun or an adjective, whereas ‘care’ could be a verb. ‘Care’ could also mean caution or attention or protection. It is a good idea to keep searching until you reach the stage of `diminishing returns’, where no new meanings are being uncovered. Dictionaries will give you information on the Latin or Greek origins of the concept of the interest. Thesauri will provide you with a range of similar concepts. However, definitions are often unclear and ambiguous, so simply providing a list of definitions of a concept should not be construed as undertaking an analysis.

It is also recommended that you examine what theorist or researchers have said about the concept. You do not have to confine your search to nursing, but may include all those who have attempted to use the concept within their theory or study.

There are other sources that may give an insight into the use of the concept. These include professional, popular, classical and philosophical literature, poetry, books of quotations, music, paintings, cartoons and photographs.

Example: The film Philadelphia may be an excellent source of information on the concept `loss’, Schindler’s list may provide a unique view of the concept `sorrow’; and The Silence of the Lambs may give a different perspective on the concept `fear’.

it must be remembered that the objective is to uncover meaning, not to describe, explain or predict relationships between the concept of interest and other similar or dissimilar concepts.

Step 4: determine the defining attributes

the defining attributes distinguish the concept (as envisaged in Step2) from similar or related concepts.

By isolating the defining attributes, the `semantic space’ that the concept shares with similar concepts is reduced (Moody, 1990).

For each concept there may be a list of several defining attributes, but extra superfluous defining attributes should not be added just because the list appears too short. It is better to have three or four defining attributes that really characterize the concept well, than to have many that are only tangentially related to the concept.

Example: A defining attribute of caring may be `providing for another’, a defining attribute for empathy may be ‘demonstrating concern’, and defining attribute for attachment may be `visual contact’.

Kim (1983) argues that when nurses are undertaking conceptual analysis they should ensure that the defining attributes are examined for their degree of consistency with nursing’s perspective. She argues that such an approach will help focus the analysis on the phenomena of specific concern to the discipline.

The defining attributes play a key role in differentiating the concept being analyzed from dissimilar concepts.

Moody (1990) calls this `test for necessity’, where failure to pass means that more work has to be done to identify the defining attributes.

The ‘test of sufficiency’ should also be applied. Here, the entire list of defining attributes is considered and, if a contrary case can be identified that meets all the attributes, then an essential attribute has been omitted.

Moody (1990) gives the example of an analysis of a right-angled triangle (a concrete concept). She identified the following thee defining attributes:

1. Two-dimensional geometric figure;2. Composed of three sides;3. The sum of the internal angles equals 180 degrees

Since Attribute 1 could be applied to any geometric figure, the ‘test of necessity’ indicates that it is not necessary attribute for defining a right-angled triangle: this attribute can be removed from the list. The other two attributes pass the `test of necessity’.Applying the `test of sufficiency’ to the remaining two attributes it is noted that other types of triangle meet this criteria (e.g., an equilateral triangle). It is obvious that some key attributes which differentiate this concept from other similar concepts are missing. Clearly, attributes indicating that one of the angles must be 90 degrees and the other two angles must be 45 degrees each should be included as defining attributes. While the test of necessity and sufficiency help in the identification of defining attributes, it must be remembered that the concepts of interest to nurses are not concrete as right-angled triangles.

Therefore, the identification of defining attributes is an inexact science, but it is valuable in that it does yield important information for the clarification of concepts for clinical and research purposes.

McCance (1996) undertook a concept analysis of caring. From a wealth of literature (Step 3 above) she identified the following defining attributes of caring:

Serious attention Concern Providing for Regard, respect, or linking

 Step 5: identify a model case

A model case is a pure example of the concept being use and should include all defining attributes. It may be written in one or two paragraphs indicating a hypothetical case, an extract from literature illustrating a real-life event or, preferably, a clinical example that accurately describes the concept.

Rodgers (1994) argues that by providing a real-life example that includes defining attributes, a model case enhances the degree of clarification and credibility of the concept.

A rule of thumb is that there must be no contradictions between the model case and the defining attributes. In other words, a model case must include all defining attributes.

 McCance (1996) presented the model case to illustrate the concept `caring’:

Case model: ‘caring’

Mr Cook was in the terminal stages of congestive heart failure. He had two myocardial infarctions. He was alone, his family were out of town. We knew he wasn’t doing well . . . When I touched his hand and introduced myself . . . he squeezed my hand and began to talk . . . I sat on his bed, and he reached out and held my hand. He talked to me about his life, about his family, the things he wanted to do but wasn’t able to . . . I ignored everything else that was going on in the unit at that time: and it was busy. I pulled the curtains around one side of the bed because there was some activity coming from that side. I just sat and listened as he spoke.                                                (Ford, 1990: 160, cited in McCance, 1996)

Each of the four defining attributes identified by McCance above were included in this model case.

Step 6: identify alternative cases

Alternative cases are identified to provide examples of what is not the concept.

To do this often helps clarify with certainty what is the concept. Alternative cases includes:

Contrary cases, Related cases, Borderline cases, Invented cases and

Illegitimate cases.

Contrary case

This case represents what is not the concept being analyzed. When examining the concept of `caring’, a contrary case would be an

example of an interaction where a nurse was consciously harming a client. With some of the more nebulous concept in nursing, a contrary case may be

easier to identify than a model case and may subsequently help in the identification of a model case.

McCance (1996) presents the contrary case shown in Box 3.2 in her analysis of ‘caring’.

It is description of a nurse given by a patient with lupus erythematosis.

 Contrary case: ’caring’

She was always in hurry, she didn’t have time to talk or even she had time she didn’t really seem to want to talk. Her body languages let me know she wasn’t interested in what I had to say. All she was here to do was to perform her duty and go home. She stood at a distance, she didn’t even come close. She made me feel I have some kind of illness and it may rub off on her. When I was talking to her she wouldn’t look at me directly. When I ask her a question she would be snappy – even on defensive side. She wasn’t interested in the person as a whole. She would cut me off short and she talked in such a rush. She never would say when she’d be back. I was not at ease. I was uncomfortable. I became depressed by not being able to talk. I felt I had to keep my mouth shut.

The nurse in the above case shows no concern, provides no help or comfort to the patient, is in no way present or attentive and makes no attempt to get to know this patient and what is important to them .

Within McCance’s analysis, the defining attributes are missing here, this is a clear example of what caring is not.   

Related case In a related case all the defining attribute are missing but the concept

is still seen as similar in meaning to the concept being analyzed. Related cases may represent concepts that are often confused with the

concept under study. For instance, ‘innovation’ is sometimes misconstrued with change, the

concept `stress’ with burnout, ’fear with anxiety, ‘adaptation’ with coping, and the concept ‘comfort’ is often confused with care.

Using these concepts as related cases demonstrates examples that are similar to the concept of interest but differ from it when you examine them closely.

Borderline case This example is very similar to a model case but some of the defining

attributes are missing. This inclusion of some of the defining attributes in a borderline case

also differentiates it from a related case. Identifying borderline cases helps to clarify the attributes which are an

essential perquisite of the model case and helps to reduce the blurring of the boundaries between cases.

Meleis (1991) recommends what she calls ‘analogising’. Here the concept is compared to similar concepts which have been reached well and studied more extensively so that the examination of the better understood concept may shed more light on what the new concept is.

Box 3.3 Borderline case: ‘caring’

Jim Smith was forty-five years old when i met him...he was admitted to the cardiopulmonary unit where I was working. The patient had an eight-hour history of slurred speech and blurred vision. The symptoms had cleared up prior to his admission and he was now admitted for a diagnostic workup...He was worked for transitory ischemic arterial spasm. Four days later he went home with a negative work up. Two days after he was readmitted after having a seizure at home, I was on holiday the time, and by the time I had returned he had a diagnosis of metatistic lung cancer.

I do not how he responded to the initial diagnosis when I returned; I didn’t go to see him for a couple of days. I was really frightened about seeing him because I did not know what to say or do. He made it easy for me, and I did begin working with him again, concentrating on teaching him about chemotherapy and radiotherapy. I felt I was teaching him a lot, but actually he taught me. One day he said to me, “you are doing OK job Mary, but i can tell that every time you walk in that door are walking out”.

He was right. He had developed so much meaning in his illness and life that i was relating to. This man had really expanded the context of his life into areas where I could have been effective, had I had some understanding. (Benner  and Wrubel,1989: 16, cited in McCance, 1996)

McCance (1996) presents the example of a borderline case of ‘caring’ in It can be seen that two of the defining attributes identified by McCance above are missing from this case.

Defining attributes ‘serious attention’ and ‘regard for’ are missing in this case while ‘providing for’ and ‘concern’ are present.

Invented case This refers to a case that takes the concept out of its normal context

and places it in an invented, out-of-the-ordinary situation. For instance, subterranean humanoids for aging in the pit of a volcano

gathering sustaining food for their offspring may be an example of the concept ‘caring’.

According to Moody (1990), invented cases are particularly useful when a concept describes an unfamiliar phenomenon or when clarity is needed for a familiar concept whose existence is often overlooked under normal circumstances.

The analyst may also identify an invented alternative case, in other words, an invented case that is not caring.

Illegitimate Case This type of case is a real-life example of the concept being used

inappropriately for the purpose of the analysis.

For example, if the concept being analysed was “attachment”, an illegitimate case could be an attachment for a portable drill or saw.

Similarly, if the concept was ‘curing’, an illegitimate case may involve a butcher curing bacon.

 

Step 7: Identify Antecedents and Consequences

This type is useful in that it gives an indication of the purpose of the analysis and the clinical arena in which the concept is normally used.

Antecedents are those events that precede the occurrence of the concept. Antecedents is not synonymous with causality.

An antecedent may contribute to the occurrence of the concept, it may be associated with its occurrence or it may need to be present for the concept to be present.

Walker and Avant (1995) maintain that something cannot be antecedent and a defining attribute at the same time.

McCance (1996) identified the following antecedents of caring: ‘a respect for persons’, ‘an amount of time’ and ‘the intention to care’.

You can see that ‘respect for persons’ could be confused as a defining attribute for caring. However, in order to be a defining attribute it would have to be respect for the person(s) being cared for rather than respect for persons in general.

Consequences are those events or outcomes that happen after the occurrence of the concept.

If the concept was anxiety, an antecedent may be bad news or a request to go to the chief executive’s office. Consequences of anxiety may be physiological changes and avoidance behaviour. Once more, care must be taken that the consequences are not seen as defining attributes for the concept.

Well –being, both physical and mental, was seen as one of the consequences of caring as analysed by McCance (1996).

 

Step 8: Identify Empirical Indicators

These are explicit referents for measuring or appraising the existence of the concept.

This step is often referred to as the operationalization of a concept. In other words, armed with these indicators, it would be possible to see

‘beyond a shadow of a doubt’ if the concept was present. In some cases, the empirical indicators will be the same as the defining

attributes identified in step 4 above. However, according to Walker and Avant (1995) sometimes the concept is so abstract that the defining attributes are also abstract, and therefore would not make good empirical indicators.

For instance, a defining attribute for care would be ‘providing for’, while an empirical indicator for care may be actually physically interacting with someone.

Such indicators are useful in research and practice because they can provide criteria by which a concept can be measured.

Chin and Kramer (1995), for instance, analysed ‘mothering’.

They identified several empirical indicators two of which are: The persons who receive mothering must be physically touched

by the mothering person; Some positive feeling must be experienced by the mothering

person and by the person who receives the mothering. 

2. Concept Synthesis used when concepts require development based on observation or

other forms of evidence Methods of synthesizing concepts: Qualitative Synthesis – sensory data Quantitative Synthesis- numerical data Literary Synthesis – review of literature

3. Concept Derivation Necessary when there are few concepts currently available to a

nurse that explain a problem area When a comparison or analogy can be made between one field or

area that is conceptually defined and another that is not Helpful in generating new ways of thinking about a phenomenon of

interest.

Steps in Concept Derivation Become thoroughly familiar with the existing literature Search other fields of interest for new ways of viewing the

topic Search a parent concept that gives an insightful view of topic Redefine the concepts in terms of the topic of interest

RODGER’S METHOD OF CONCEPT ANALYSIS,1989

Concept analysis is necessary because concepts are dynamic , it must be continually refined and variations introduced to achieve a clearer and more useful meaning.

Steps:

1. Identify the concept and associated terms

2. Select an appropriate realm (a setting or a sample) for a data collection

3. Collect data to identify the attributes of the concept and the contextual basis of the concept

4. Analyze the data regarding the characteristics of the concept

5. Identify an exemplar of the concept, if appropriate

6. Identify hypotheses and implications for further development.

The Hybrid Strategy by Schwartz-Barcott and Kim

Phase Activities

Theoretical phase Select a concept Review the literatureDetermining meaning and measurementChoose a working definition

Fieldwork phase Set the stageNegotiate entry into a settingSelect casesCollect and analyze data

Final analytical phase Weight findingsWrite report

Example: Review of Withdrawal by Schwartz-Barcott,

They began with the review of pervasiveness of the concept in nursing and discovered that it is relatively underdeveloped. They then defined the concept as flight response that is used as defense to an actual or anticipated threat. They described it in terms of biological adaptation an instinctive physical response.

Then they discussed how it is measured in research through a literature review. Subsequently, they observed it clinically, developed a set of key questions related to observations, developed case studies to reflect the different responses and validated earlier notions about withdrawal . It is through this process that common factors were identified to describe and refine withdrawal.

MELEIS STRATEGY OF CONCEPT DEVELOPMENT, 2007

1. Concept Exploration

Used when concepts are new and ambiguous in a discipline or when a concept from another discipline is being redesigned for use in nursing.

Steps in Concept Exploration

1. Identifying the major components and dimensions of the concept

2. Raising appropriate questions about the concept

3. Proposing triggers for continuing the exploration

4. Identifying and defining the advantages to the discipline of continuing the exploration of the concept.

2. Concept Clarification Is used to refine concepts that have been used in nursing without a clear,

shared, and conscious agreement on the properties of meanings attributed to the concept.

It is a way to refine existing concepts when they lack clarity for a specific nursing endeavor.

3. Concept Analysis This process implies that the concept will be broken down to its essentials

and then reconstructed for its contribution to the nursing lexicon.

The goal of the analysis is to bring the concept close to use in research or clinical practice and to ultimately contribute to instrument development and theory testing.

Focused on an integrated approach to concept development, which includes defining, differentiating, delineating antecedents, and consequences, modeling, and analogizing, and synthesizing.

Process Task or Activity

Defining Creating theoretical and operational definitions that clarify ambiguities, enhance precision, and relate concepts to empirical referents

Differentiating Sorting in and out similarities and differences between the concept being developed and other like concepts

Delineating antecedents

Defining the contextual conditions under which the concept is perceived and expected to occur

Delineating consequences

Defining events, situations, or conditions that may result from the concept

Modeling Defining and identifying exemplars (i.e., clinical referents or research referents) to illustrate some aspect of the concept. Models may be same or like models, or contrary models

Analogizing Describing the concept through another concept or phenomenon that is similar and has been studied more extensively

Synthesizing Bringing together findings, meanings, and properties that have been discovered and describing future steps in theorizing

MORSE STRATEGY OF CONCEPT DEVELOPMENT, 1995

Advance Techniques of Concept Analysis

1. Concept Delineation

Is a strategy that requires an extensive literature search and assists in separating two terms that seem closely linked

Concepts compared and contrasted to identify commonalities, similarities, and differences

2. Concept Comparison

It clarifies competing concepts, again using a extensive literature review and keeping the literature for each concept separate.

Phases in comparison are:

o Preconditions - the status of the concept in nursing and its use in teaching or clinical practice

o Proces s- the type of nursing response to the concept, at what level of consciousness it occurs, and, if it is identified with the client, at what level

o Outcomes - whether the concept was used to identify process or product, its accuracy in prediction, the client’s condition, and the client’s experience with the concept

3. Concept Clarification

Is used with concepts that are “mature” and have a large body of literature identifying and using them.

It requires a “literature review to identify the underlying values and to identify, describe and compare and contrast the attributes of each”

Examples:

o Olson and Morse (2005) delineated the concept of fatigue using a system of analytic questions;

o Whitehead (2004) used Morse’s method to analyze health promotion and health education;

o Fanacht (2003) used Morse’ method to refine the concept of creativity;

PENROD AND HUPCEY STRATEGY OF CONCEPT DEVELOPMENT, 2005

They termed their method “principle- based concept analysis” explaining the intent to “determine and evaluate the state of science surrounding the concept” and produce evidence that reveals scholars best estimate of ‘probable truth’ in the scientific literature”(2005)\

Four principles for their method are: epistemological, pragmatic, linguistic, and logical

Findings “are summarized as a theoretical definition that integrates an evaluative summary of each of the criteria posed by the four over- reaching principles.” Researchers consider three issues:

Selection of appropriate disciplinary literature for review

assurance of the adequacy and appropriateness of the sample derived from the literature, and

employment of “within- and across- discipline analytic techniques”

Four Principles of Concept Analysis

Epistemological principle

“Is the concept clearly defined and well differentiated from other concepts?”

Pragmatic principle ‘Is the concept applicable and useful within the scientific realm or inquiry? Has it been operationalized?

In this principle they believe that an operationalized concept has achieved a level of maturity

Epistemological principle

“Is the concept clearly defined and well differentiated from other concepts?”

Pragmatic principle ‘Is the concept applicable and useful within the scientific realm or inquiry? Has it been operationalized? In this principle they believe that an operationalized concept has achieved a level of maturity

CONCEPT ANALYSIS EXEMPLAR USING RODGERS’ EVOLUTIONARY METHOD

1. Identify the concept and associated terms

 

Concept: Chronic pain 9noncacerous pain in adults)

Associated terms: Chronic pain, persistent pain. Intractable pain, and continuous pain

 

2. Select an appropriate realm (setting) for data collection

 

The realm for study was nursing, psychology, and neurophysiology professional journal publications between the year 1969 and 1999. Included were case studies, qualitative and quantitative studies, review articles, and meta- analysis.

3. Identify the attributes of the concept and the contextual basis of the concept

 

Attributes of chronic pain: Their primary dimensions (physical, behavioral, and psychological)

Physical dimension is characterized by quantity, intensity (level or severity), and neurological transmission. And anatomic patterns and chronic pain

Behavioral dimension is characterized by expressive, movement, and functional behaviors.

Psychological dimension is characterized by effective and evaluative components.

4. Specify the characteristic of the concept

Characteristic of the chronic pain include:

Relative language (e.g.; “ache”) and modifiers (e.g.; “annoying” or “dull”)

Behaviors:

Expressive behaviors (moaning and use of pain words);

Movement behaviors (grimacing, massaging, protective movements, rhythmic movements);

Functional behaviors (used of socially defined sick-role behaviors such as decreased mobility, inactivity, and bed rest

Time dimensions: include onset and frequency or rhythm of pain episodes.

Antecedents: no specific or physical psychological characteristics were noted that were antecedents of chronic pain. Although trauma sometimes precedes chronic pain, trauma is not necessary or sufficient to cause chronic pain. Chronic pain may be

related to alterations in the production and regulation of cortisol, serotonin, and endogenous opioids and in the synthesis and release of sensory neuropeptides.

Consequences: two themes:

living with chronic pain results in alterations of psychological life patterns including depression, anger, anxiety, grief, hopelessness, and helplessness, social pattern alterations may result in isolation and loneliness; loss of work, and loss of insurance and money to pay for medical expenses.

Coping with chronic pain-effective coping-decreases the adverse effects of chronic pain by reducing stress and thereby pain intensity. Strategies include distraction, meditation, positive thinking, counseling, and use of alternative treatments (e.g.; acupuncture, massage, herbal medications, meditation, and imagery)

5. Identify an exemplar of the concept

Chronic pain is a subjective, multidimensional, bio/psychological syndrome that can be recognized by physical, psychological, and behavioral patterns. It results in physical, psychological, and social alterations of function to varying degrees. There is no known purpose and there is no single explanation of the symptoms.

6. Identify hypotheses and implications for development

Research is needed to understand the relationship between intensity, quality, and duration of pain, and central nervous system function.

Research is needed to explore body-brain-mind interactions in the development, persistent, and, consequences of chronic pain.

Research is needed to identify the subjective symptoms that may differentiate chronic pain from acute pain. If early symptoms can be identified, studies can be conducted to determine interventions that may stop the development of chronic pain.

THEORY DEVELOPMENT

OVERVIEW OF THEORY DEVELOPMENT

It is used as the global term to refer to the process and methods used to create, modify, or refine a theory.

complex, time- consuming process that covers a number of stages or phases from inception of concepts to testing theoretical propositions through research

the process of theory development begins with one or more concepts that are derived from within a discipline’s metatheory or philosophy. These concepts are further refined and relate to one another in propositions or statements that can be submitted to empirical testing

CATEGORIZATIONS OF THEORY

CATEGORIZATION BASED ON SOURCE OR DISCIPLINE

Shared Theory Used in Nursing practice and Research

Disciplines Examples of Theories Used by Nurses

Theories from sociological sciences Family systems theoryFeminist theoryRole theoryCritical social theory

Theories from behavioral sciences Attachment theoryTheories of self- determinationLazrus and Folkman’s theory of stress, coping, and adaptationTheory of planned behavior

  Theories from biomedical sciences Pain

Self-regulation theory Immune function Symptomology Germ theory

Theories from administration and management

Donabedian’s quality framework Theories of organizational behavior Models of conflict and conflict resolution Job satisfaction

Learning theories Bandura’s social codnitive learning theory Developmental learning theory Prospect theory

COMPONENTS OF A THEORY

TYPES OF RELATIONSHIP STATEMENTS

Type of Statement Characteristics

Axioms Consist of a basic set of statements or propositions that state the general relationship between concepts. Axioms are relatively abstracts; therefore, they are not directly observed or measured.

Empirical generalizations Summarize empirical evidence. It provides some confidence that the same pattern will be repeated in concrete situations in the future under the same conditions.

Hypotheses Statements that lack support from empirical research but are selected for study. The source may be a variation of a law or derivation from an axiomatic theory, or they may be generated by a scientist’s nutrition (a hunch). All concepts in a hypothesis must be measurable, with operational definitions in concrete situations.

Laws Well-grounded with strong empirical support and evidence of empirical regulatory. It contains concepts that can measure or identified in concrete settings.

Propositions Statements of a constant relationship between two or more concepts or facts

Theoretical statements can be classified into two groups

Existence Statement

Consists of statement that claim the existence of phenomena referred to by concepts. (e.g., that chair is brown or that man is nurse).

Relational Statement

Assert that a relationship exists between the properties of two or more concepts. This relationship is basic to development of theory and is expressed in terms of relational statements that explain, predict, understand, or control.

Associational/ Correlational - concepts that occur or exist together

Causal Relationship- one concept is considered to cause the occurrence of a second concept

APPROACHES TO THEORY DEVELOPMENT

PROCESS OF THEORY DEVELOPMENT

1. CONCEPT DEVELOPMENT: CREATION OF CONCEPTUAL MEANING

This provides the foundation for theory development and includes specifying, defining, and clarifying the concepts used to described the phenomenon of interest

2. STATEMENT DEVELOPMENT: FORMULATION AND VALIDATION OF RELATIONAL STATEMENTS

Relational statements are the skeletons of theory; they are the means by which the theory comes together. The process of formulation and validation of relational statements involves developing the relational statements and determining empirical referents that can validate them.

STEPS IN STATEMENT ANALYSIS

Select the statement to be analyzed. Simplify the statement. Classify the statement. Examine concepts within the statement for definition and validity. Specify relationship between concepts. Determine stability.

3. THEORY CONSTRUCTION: SYSTEMATIC ORGANIZATION OF THE LINKAGES

This includes formulating systematic linkages between and among concepts, which results in formal, coherent theoretical structure.

Aspects of theory construction include identifying and defining the concepts, identifying assumptions, clarifying the context within which the theory is placed, or relationship among the components.

4 VALIDATING AND CONFIRMING THEORETICAL RELATIONSHIPS IN RESEARCH

Validating theoretical relationships through empirical testing

the focus is on correlating the theory with demonstrable experiences and designing research to validate the relationships, additionally, explanations are considered, based on the empirical evidence.

5. VALIDATION AND APPLICATION OF THEORY IN PRACTICE

research methods are used to assess how the theory can be applied in practice.

The theoretical relationships are examined in the practice setting and results are recorded to determine how well the theory achieves the desired outcomes.

. Questions to be considered in this step include: are the theory’s goals congruent with the practice situation are explanations of the theory sufficient for use in the nursing situation is there research evidence supporting use of the theory.

THEORY DEVELOPMENT EXEMPLAR

Smith and colleagues developed the “Caregiving Effectiveness Model” to be applied to home care situations in which the patient requires “technologically based treatment.”

Scope of theory: Middle range

Purpose: “To explain and predict outcomes of technology- based home caregiving provided by family members. Outcomes of the model are “to help nurses develop relevant nursing interventions to support positive patient and caregiver outcomes.”

Concept Definition Empirical Indicator

Caregiving effectiveness

The provision of technical, physical, and emotional care by family members that results in outcomes of optimal patient condition, yet maintain the well-being of caregiver

Caregiving Context Concepts Measures + Adaptive Context Concepts Measures=

Caregiving Effectiveness Outcomes

Caregiving characteristics

Caregiving Context Concepts

Personal characteristics potentially affecting caregiving

Age, gender, educational level

Caregiving/care- receiving interactions

Quality of relationships between caregivers and patients (mutuality) and motivation to provide home care

Mutuality scale Motivation to Help

Home care management strategies

Educational preparation; health care services use

Preparedness scale efficient use of resources (DEA coefficient)

Family economic stability

Adaptive Context Concepts Income adequacy; degree of health care services use

Health care services use/cost

Caregiver health status

Mental health status (presence or absence of depression); physical health status

Quality of life indexDepression Score (CES-D Scale)

Family adaptation

Family coping and problem-solving skills

Family Coping Scale

Reactions to caregiving

Caregiving system Caregiver Reactions Scale

Theoretical Statement and Linkages

Caregiving Effectiveness outcomes are the result of the variables in the Caregiving Context being mediated by adaptive Context Variables.

Caregiving characteristics mediated by the caregiver mental health status (depression) affect Caregiving Effectiveness Outcomes.

Home-care management strategies 9preparedness) mediated by reactions to caregiving influence patient condition.

Caregiving Effectiveness Outcome of Efficient Use of Resources is influenced by caregiving and adaptive context variables.

ASSUMPTIONS

Caregiving with complex technological home care is stressful and disruptive to usual family activities.

Families prefer home technological care as opposed to institutional care.

Model concepts are clinically relevant for nursing practice with patients and their caregivers.

Models about caregiving of terminally ill and frail or cognitively impaired older persons are not directly applicable to technology-dependent patients.

THEORY EVALUATION

Presented by: DANICA JESSA SANCHEZ, RN

*** 12 REASONS WHY THEORY EVALUATION IS ESSENTIAL (Meleis, 2007) ***

1. to decide which theory is more appropriate to use as framework for research, teaching, administration or consultation

2. to identify effective theories in exploring some aspect of practice or in guiding a research project

3. to compare and contrast different explanations of the same phenomenon

4. to enhance the potential of constructive changes and further theory development

5. to identify approaches of a discipline through attention to the sociocultural context of the theory and theorist

6. to critically examine and question the beliefs in a discipline

7. to identify competing and complementary schools of thought in a discipline

8. to effect changes in clinical practice, define research priorities and identify content for teaching and guidelines for nursing administration

9. to utilize coherent and integrative frameworks to communicate to the public the rationales and goals of nursing practice

10. to identify strategies that could be used to advance the development of theories

11. to define and articulate the discipline’s demand and perspective

12. to be a critical consumer of theories as well as critical consumer of evidence-based practice

Theory Evaluation - process of systematically examining a theory

- 1968: first method to describe, analyze and critique theory

Was published

*Criteria for theory evaluation:*

1. Examination of theory’s origin

2. meaning

3. logical adequacy

4. usefulness

5. generalizability

6. testability

*addl summary: theory evaluation identifies a theory’s degree of usefulness to guide practice, research and education.

-assisit in identifying a need for theory development or refinement

-provides a systematic, objective way of examining a theory that may lead to new insights and new formulations that will add to the body of knowledge or research (Walker & Avant 2005 )

-ultimate goal of theory evaluation: to determine the potential contribution of the theory to scientific knowledge

*addl use :

-in nursing practice, it helps to identify which theoretical relationships are supported by research and provides guidelines for the choice of appropriate interventions and gives some indication of their efficacy.

-in research, it helps clarify form and structure of a theory being tested or will allow the researcher to determine the relevance of the content of theory for use as a conceptual framework

-it will also identify inconsistencies and gaps in the thory used in practice or research ( Walker & Avant 2005)

Theory evaluation has been dscribed as:

1. As a single-phase process (theory analysis)- Tomey & Alligood,2002; Hardy, 1974

2. As a two-phase process( theory analysis and theory critique/evaluation)- Fawcett, 2000; Duffey and Muhlenkamp, 1974

3. As a three-phase process (theory description, theory analysis and theory critique/evaluation)- Meleis, 2005; Moody,1990

*Theory description- initial step in the evaluation process

-review of theorist’s works with focus on the historical content of the

History (Hickman, 2002)

*Theory Analysis- second phase of evaluation process

-systematic process of objectively examining the content, structure and

function of a theory

*Theory Critique/Evaluation- final step of the evaluation process

-assess theory’s potential contribution to the discipline’s

knowledge base (Fawcett,2000)

***THEORY EVALUTION BY DIFFERENT NURSING SCHOLARS: ***

1. Rosemary Ellis

- first nursing scholar to document criteria for analyzing theories for use by nurses, 1968

-Ellis’s characteristics os a significant theory:

1. scope

2. complexity

3. testability

4.usefulness

5.implicit values of theorist

6. information generation

7. meaningful terminology

2. Margaret Hardy, 1974,1978

– theory should be evaluated using the 7 universal standards:

a. meaning & logical adequacy

b. operational and empirical adequacy

***for Hardy, EMPIRICAL ADEQUACY, is the single most important criterion for evaluating a theory applied in practice…it involves review of related literature and relevant research***

c. testability

d. generality

e. contribution to understanding

f. predictability

g. pragmatic adequacy

3. Mary Duffey & Ann Muhlenkamp, 1974

- used the 2-phase approach

3.1 SETS OF QUESTIONS FOR THEORY ANALYSIS (PHASE ONE)

3.1.1 What is the origin of the problem/s with which the theory is concerned?3.1.2 What methods were used in the theory development?3.1.3 What is the character of the subject matter dealth with by the theory?3.1.4 What kind of outcomes of testing propositions are generated by the

theory?

3.2 SETS OF QUESTIONS FOR THEORY EVALUATION (PHASE TWO)

3.2.1 Does the theory generate testable hypotheses?3.2.2 Does the theory guide practice?3.2.3 Is it complete in terms of subject matter and perspective?3.2.4 Are biases and underlying values made explicit?3.2.5 Are relationships among propositions made explicit?3.2.6 Is the theory parsimonious/concise?

4. Barbara Barnum (Stevens), 1979,1998

USE OF: Internal and external criticism

4.1 Internal criticism- examines how components of theory fit with each other

4.1.1 Clarity4.1.2 Consistency4.1.3 Adequacy4.1.4 Logical development4.1.5 Level of theory development

4.2 External criticism- examines how a theory relates to the extant world4.2.1 Reality convergence (how theory relates to the real world)

4.2.2 Utility

4.2.3 Significance

4.2.4 Discrimination (differentiation between nursing and other profession)

4.2.5 Scope

4.2.6 Complexity

5. Lorraine Walker and Kay Avant, 1983,2005

-one-phase process

CRITERIA:

5.1 Origin of theory5.2 Examine meaning of theory5.3 Logical Adequacy5.4 Usefulness5.5Generalizability5.6 Parsimony/ Briefness5.7Testability

6. Jacqueline Fawcett, 1980, 2000

-two-phase process evaluation

6.1 PHASE ONE: ANALYSIS

6.1.1 theory’s origin6.1.2 unique focus6.1.3 content

6.2 PHASE TWO: CRITIQUE/ EVALUATION

6.2.1 explication of theory’s origin6.2.2 comprehensiveness of content6.2.3 logical congruence6.2.4 how can it lead to generation of new theory?6.2.5 Credibility6.2.6 How has it contributed to nursing?

7. Peggy Chinn and Maenoa Kramer (Jacobs), 1983, 2004

-two-phase process

7.1 PHASE ONE: THEORY DESCRIPTION

7.1.2 7.1.2 Concepts7.1.3 Definitions7.1.4 Relationships7.1.5 Structure7.1.6 Assumptions

*ASSUMPTIONS are underlying truths that determine the nature of concepts, definitions, purpose, relationships and structure.

7.2 PHASE TWO: CRITICAL REFLECTION

*How a theory serves its purpose*

7.2.1 Clarity & Consistency7.2.2 Complexity7.2.3 Generality7.2.4 Accessibility7.2.5 Importance

8. Afaf Meleis, 1985, 2005

-three-phase process

8.1 PHASE ONE: THEORY DESCRIPTION

8.1.1 Examination of theory’s STRUCTURAL components:

8.1.1.1 assumptions 8.1.1.2 concepts 8.1.1.3 propositiions

8.1.2 Examination of theory’s FUNCTIONAL components:

8.1.2.1 anticipated consequence of theory8.1.2.2 purpose of theory

8.2 PHASE TWO: THEORY ANALYSIS

8.2.1 Theorist

-educational background, employment history, sociocultural influences

8.2.2 origin of theory

-is it influence of other theorists?

8.2.3 internal dimensions of theory

-theory’s rationale, goal, scope

8.3 PHASE THREE: THEORY CRITIQUE/EVALUATION

8.3.1 Clarity & Consistency8.3.2 Level of simplicity/ complexity8.3.3 Tautology/teleology

*TAUTOLOGY- assess needless repetition of ideas which can decrease clarity

*TELEOLOGY- occurs when definitions of concepts, conditions and events are described by consequences

9. Ann Whall, 1989, 2005

-3,3,3

- 3 THREE-PHASE PROCESS, THREE LEVELS OF NURSING THEORY, THREE CRITERIA

9.1 THREE-PHASE PROCESS

9.1.1 THEORY DESCRIPTION9.1.2 THEORY ANALYSIS9.1.3 THEORY CRITIQUE/ EVALUATION

9.2 THREE LEVELS OF NURSING THEORY

9.2.1 PRACTICE THEORY9.2.2 MIDDLE RANGE THEORY9.2.3 NURSING MODELS

9.3 THREE CRITERIA OF EVALUATION

9.3.1 BASIC CONSIDERATIONS9.3.2 INTERNAL ANALYSIS AND EVALUATION9.3.3 EXTERNAL ANALYSIS AND EVALUATION

LEVEL OF THEORY

BASIC CONSIDERATIONS

INTERNAL ANALYSIS AND EVALUATION

EXTERNAL ANALYSIS AND EVALUATION

PRACTICE THEORY

-Can concepts be organized?

-Are concepts congruent with empirical data?

-Do statements lead to directives for nursing care?

-Are statements sufficient and not contradictory?

-gaps/inconsistencies

-Are assumptions congruent to :

historical perspective?Ethical standards?Social policies

-conflicts with cultural groups

-Is theory produced and consistent with existing nursing standards?

-Is theory related to nursing diagnoses, interventions and practice?

-Is it supported by research?

MIDDLE-RANGE

-What definitions and importance of major concepts?

-What are theory’s assumpyions?

-Relationship of concepts

-congruency with related theory and research internal and external to nursing

THEORY -What is the type and

importance of theoretical statements?

-consistency and congruency

-empirical adequacy

-Has theory been examined to practice and research?

-relation to ethical,social policy issues and cultural aspects

NURSING MODELS

-What are definitions of metaparadigm: person, nursing, health and environment?

-What are relationships among metaparadigm?

-Descriptions of other concepts in the model?

-assumptions-definitions of components

-importance

-analyses of internal and external consistency

-analyses of adequacy

-Is nursing research, education and practice based on the model or related to model?

-What is the relationship to existing nursing diagnoses and interventions system?

10.Sharon Dudley- Brown, 1997

10.1 CRITERIA:

10.1.1 Accuracy10.1.2 Consistency10.1.3 Fruitfulness10.1.4 Simplicity/ Complexity10.1.5 Scope10.1.6 Accessibility10.1.7 Sociocultural Utility

***SUMMARY:***COMMON CRITERIA FOR THEORY EVALUATION:

1ST ( 7 OUT 9)

-COMPLEXITY/SIMPLICITY -SCOPE/ GENERALITY

2ND (6 OUT OF 9)

-MEANINGFUL TERMINOLOGY-DEFINITION OF CONCEPTS-CONSISTENCY-USEFULNESS

3RD (5 OUT OF 9)

-CONTRIBUTION TO UNDERSTANDING

4TH (4 OUT OF 9)

-TESTABILITY-LOGICAL ADEQUACY-VALIDITY

RELATIONSHIP OF THEORY WITH THE FOLLOWING ACCORDING TO DIFFERENT NURSING SCHOLARS:

A. NURSING PRACTICE

B. EDUCATION

C. RESEARCH

A. NURSING PRACTICE

-“Nursing theory should lend itself to research testing, and research testing should lead to knowledge that guides practice.” (Chinn & Kramer, 2004)  -“Nurse’s professional power is increased when using theoretical knowledge, because systematically developed methods guides critical thinking and decision making.” (Tomey&Alligood, 2006)

-”in nursing practice, it helps to identify which theoretical relationships are supported by research and provides guidelines for the choice of appropriate interventions and gives some indication of their efficacy.” (McEwen & Wills, 2007)

- “Through interaction with practice, theory is shaped and guidelines for practice evolves. Research validates, refutes, and/or modifies theory as well as new theory. Theory then guides practice.”(Meleis, 2007)

 

-“Through interaction with practice, theory is shaped and guidelines for practice evolves. Research validates, refutes, and/or modifies theory as well as new theory. Theory then guides practice.”(Meleis, 2007)

-“Theory provides nurses with framework and goals for assessment, diagnosis and intervention. Nurses focus on aspects of care that are described theoretically for a more effective judgment of patient’s situations and conditions.” (Meleis, 2007) 

B. EDUCATION

-“Theories guide the critical thinking of nurses.” (Cody, 1997)

-“Theory contributes to the achievement of professional autonomy by guiding practice, education and research within the profession.” (Tomey&Alligood, 2006)

-theory evaluation identifies a theory’s degree of usefulness to guide practice, research and education. (McEwen & Wills, 2007)

-ultimate goal of theory evaluation: to determine the potential contribution of the theory to scientific knowledge. (McEwen & Wills, 2007)

-“Theories are important content for teaching nurses.” (Meleis, 2007)

-“Nurses utilize theories to develop nursing curricula and programs.” (Meleis, 2007)

C. RESEARCH

-“Because of theory, nurses can define the focus and means to achieve that focus…and being able to predict consequences increase nurses’ control of nursing practice and therefore increases nurses’ autonomy.” (Fuller, 1978)

-”it will also identify inconsistencies and gaps in the theory used in practice or research” ( Walker & Avant 2005)

-assistS in identifying a need for theory development or refinement;-provides a systematic, objective way of examining a theory that may lead to new insights and new formulations that will add to the body of knowledge or research (Walker & Avant 2005 )

-”in research, it helps clarify form and structure of a theory being tested or will allow the researcher to determine the relevance of the content of theory for use as a conceptual framework” (McEwen & Wills, 2007)

-“Nursing theories stimulate nurse scientists to explore significant responses in the field of nursing and in doing so the potential for the development of knowledge that informs daily activities of clients and nurses increases.” (Meleis, 2007) -“Results of research can be used to verify, modify, disprove or support a theoretical proposition.” (Meleis, 2007)

THEORY EVALUATION EXAMPLE

EVALUATION OF: MYRA ESTRINE LEVINE: THE CONSERVATION MODEL

A. BRIEF BACKGROUND OF THE THEORIST:

MYRA LEVINE earned her diploma in nursing from Cook County School of Nursing, Chicago, Illinois in 1944., a bachelor’s degree in science at University of Chicago in 1949 and MAN from Wayne State University in Detroit, Michigan in 1962.

She held numerous clinical and education positions during her long productive career (Schaefer, 2002).

She published “An Introduction to Clinical Nursing” in 1969, revised it in 1973 and revised it again in 1989.

She died in 1996 at age 75, leaving a legacy to nursing administration, practice, and scholarship.

B. PHILOSOPHICAL UNDERPINNINGS OF THE THEORY

LEVINE (1973) based the Conservation Model on the ff:

B.1 Nightingale’s idea that “the nurse created an environment in which healing could occur.”

B.2 Tillich’s unity principle of life

B.3 Bernard’s principle on internal environment

B.4 Cannon’s Theory of Homeostasis

B.5 Waddington’s Concept of Homeorrhesis

Homeorrhesis describes the tendency of developing or changing organisms to continue development or change towards a given state, even if disturbed in development.

C. MAJOR ASSUMPTIONS, CONCEPTS AND RELATIONSHIPS

The 4 conservation MAJOR principles:

1. The principle of conservation of energy.

2. The principle of conservation of structural integrity.

3. The principle of conservation of personal integrity.

4. The principle of conservation of social integrity.

According to Levine’s theory of Conservation:

-nursing interventions are based on conservation of client’s integrity in each of the conservation domains.

-nurse is seen as part of environment and shares the repertoire of skills, knowledge and compassion, assisting each cliet to confront environmental challenges in resolving the problems encountered in client’s unique way.

-effectiveness of interventions is measured by the maintenance of client’s integrity

ASSUMPTIONS:

A. ASSUMPTIONS ABOUT INDIVIDUALS

-Each individual is an active participant in interaction with environment…constantly seeking information from it.

-Individual “is a sentient/conscious being and the ability to interact with environment seems ineluctably tied to his sensory organs.

-”Change is the essence of life and it is unceasing as long as life goes on. Change is characteristic of life.

B. ASSUMPTIONS ABOUT NURSING

-”Ultimate decisions for nursing intervention must be based on the unique behavior of the individual patient.”

-“Patient-centered nursing care means individualized nursing care. It is predicated on the reality of common experience: every man is a unique individual, and as such he requires a unique constellation of skills techniques and ideas designed specifically for him.”

CONCEPTS

CONCEPT DEFINITIONENVIRONMENT Includes both internal and external

environment

HEALTH Patterns of adaptive change of the whole being

NURSING Human interaction relying on communication, rooted in the organic dependency of the individual human being in his relationships with other human beings

ADAPTATION Process of change and integration of the organism in which the individual retains integrity/wholeness

CONCEPTUAL ENVIRONMENT Part of person’s environment that includes ideas, symbolic exchange, belief, tradition and judgment

CONSERVATION Includes joining together and is the product of adaptation including

nursing intervention & patient participation to maintain a safe balance

ENERGY CONSERVATION Nursing conservation based on the conservation of patient’s energy

HOLISM Singular yet integrated response of individual to forces in environment

HOMEOSTASIS Stable state normal alterations in physiologic parameters in response to environmental changes; energy saving state; a state of conservation

MODES OF COMMUNICATION Many ways in w/c information, needs and feelings are transmitted among the patient, family, nurses and other health care workers

PERSONAL INTEGRITY Person’s sense of identity & self-definition wherein nursing interventions are based

STRUCTURAL INTEGRITY Healing is a process of restoring structural integrity through nursing interventions that promote healing and maintain structural integrity

SOCIAL INTEGRITY Life’s meaning gained through interactions w/ others. Nurses intervene to maintain relationships.

THERAPEUTIC INTERVENTIONS Interventions that influence adaptation in a favorable way, enhancing the adaptive response available to the person

D. RELATIONSHIPS

Relationships are not specifically stated but can be extracted from the descriptions given by Levine(1973). The relationships serve as the basis for nursing interventions and include

1. Conservation of energy is based on nursing intervations to conserve energy through a deliberate decision as to the balance between activity and person’s available energy.

2. Conservation of personal integrity is based on nursing interventions that permit the individual to make decisions for himself or participate in the decisions.

3. Conservation of social integrity is based on nursing interventions to preserve the client’s interactions with family and the social system to which they belong.

4. All nursing interventions are based on careful and continued observation over time.

E. USEFULNESS

E.1 EDUCATION:

-It was used to develop a nursing undergraduate program at Allentown College of St. Francis de Sales in Center Valley, Pennsylvania, where it deemed to be compatible with the mission and philosophy of the college.( Grindley & Paradowski, 1991).

-It was also used in the undergraduate of the same school as the framework for development of the content of graduate nursing courses. (Schaefer, 1991).

E.2 CLINICAL SETTING

-The Emergency Department at the Hospital of the University of Pennsylvania used the 4 conservation principles for organizing framework for nursing practice. It was believed that because of this, communication was strengthened and nursing care was improved (Pond & Taney, 1991).

-This was useful in directing nursing care practice for children, especially the ill child (Dever, 1991)

-Mefford (2004) based her theory of health promotion for preterm infants thru using Levine’s conservation model.

-Taylor (1989) implemented Levine’s model for nursing diagnoses in a neurologic setting. She devised an extensive assessment guide and a nursing care plan diagnostic template.

-Neswick(1997) suggested levine’s model as theoretical basis for Enterostomal Therapy (ET) nursing. She integrated the 4 principles into wound & ostomy care

F. TESTABILITY

-Roberts, Fleming & Giese (1991) used the conservation principles in maternity practice to study perineal integrity. It provided framework for episiotomy in preserving maternal or fetal well-being. They also used levine’s model to compare women with diff. perineal conditions on post-partum that allowed physical and physiologic consequences of these conditions.

-(Foreman,1991) did a research on conserving the cognitive integrity of the hospitalized elderly

-(Hanson, Langmo, Olson, Hunter, Sauvage, Burd et al, 1991) used levine’s theory in the study comparing 2 methods for prevention of pressure ulcers in a hospice setting

-In 3 qualitative case studies, Levine’s model was used :

a. By Pasco & Halupa in 1991, with patients who were experiencing chronic pain and found it assisted subjects to fully adapt.

b. By Schaefer in 1991, with patients with CHF

c. By Schaefer & Potylycki in 1993, to study fatigue in patients with CHF with focus on client adaptation

G. PARSIMONY

-Levine’s model is fairly parsimonious; however, there are a great many concepts w/ comparatively unspecified relationships and unstated assumptions.(McEwen & Wills, 2007).

-According to Levine (1991), redundancy of the domains allows multiple means of configuring interventions.

H. VALUES IN EXTENDING NURSING SCIENCE

Levine’s (1973) Conservation Model has made an impact in the discipline of nursing in education and in research, providing 4 defining principles that are sufficiently universal to allow research and practice in a large number of situations.

The concept of holism, although not unique to this model, was proposed at an early stage in nursing’s scientific history and has made an important difference in the care of clients.