Nursing Models

1 The case for nursing theory Fundamentals of Nursing Models, Theories and Practice, Second Edition. Hugh P. McKenna, Majda Pajnkihar and Fiona A. Murphy. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wileyfundamentalseries.com/nursingmodels Outline of content This chapter covers the following: the case for theory; the argument that all intentional and rational actions, including nursing actions, by definition must have an underlying theory; an initial definition of theory; how theory and practice become integrated in nursing praxis. Learning outcomes At the end of this chapter you should be able to: 1. Understand what nursing theory is 2. Define theory 3. Understand the construction/development of a theory 4. Discuss the relationship between nursing theory and science 5. Evaluate the relationship between nursing theory and practice 6. Know the limitations of the nursing theory 7. Understand the importance of nursing theory for contemporary nursing Introduction Before nursing students and registered nurses recognise the content and function of theory, they often ask themselves question such as the following. What are nursing theories? Why study them? What has this got to do with nursing? How can something that is divorced from action, that is by definition abstract and conjectural, be of value to something like nursing, which is one of the most practical of activities? This book will help to answer these questions. Theories exist everywhere in society. There are numerous theories of the family, of the internal combustion engine, of how cancer cells multiply, of changes in the weather. There are even lots of theories as to who killed President John F. Kennedy or Marilyn Monroe. The world is full of theories, some tested as accurate, some untested and some speculative. It is no surprise, then, that there are theories of nursing. But what do theories do? In essence, they are simply used to describe, explain or predict phenomena (see Reflective Exercise 1.1). This will be explored in detail later. Reflective Exercise 1.1: Theory Write down or discuss with other people two different theories for one of the following: • the break-up of the Beatles • the assassination of John F. Kennedy • global warming • newborn babies smiling when spoken to Consider if there is the basis of truth in any of these theories. Now, none of the theories that you outlined for any of the topics in Reflective Exercise 1.1 may be true. In fact, they may be erroneous or downright preposterous. The point is that we all use theories to explain what goes on in our lives or in the world. But if you wanted to, you could probably test or find out whether your theories are true. Later on in this chapter we will outline what theories are made of and how they are formed. In many ways, theories are like maps. Maps are used to give us directions or to help us find our way in a complicated landscape or terrain. Maps often make simple what is a very complex picture. At their best, nursing theories also give us directions as to how to best care for patients. But why have we got so many nursing theories (over 50 at last count)? If you take any large city, there are many maps. For instance, in London, there are street maps, underground maps, electricity supply maps, Ordinance Survey maps and so on. Consider the London Underground map or the Moscow or Paris Metro maps – they are simple and easy to follow but they do not look anything like the complex reality of the underground networks they represent. In other words, they make a complex system understandable. Similarly, nursing is highly complex and we need different theories to help us understand what is going on. A theory that can be used in emergency care may not be much use in mental health care, and a theory that can be used to help nurses in a busy surgical ward may be of little use in community care. Nursing theories can provide frameworks for practice and in many clinical settings they have been used in the assessment of patients’ needs. For instance, in the UK one of the most popular nursing theories was designed by three nurses who worked at Edinburgh University – Nancy Roper, Winifred Logan and Alison Tierney. They based their theory on the work of an American nurse called Virginia Henderson. Her theory outlined how nurses should be focused on encouraging patients to be independent in certain activities of daily living (ADLs) such as sleeping, eating, mobilising etc. Roper et al. took this a step further by identifying 12 ADLs. They stressed that it was the nurses’ role to prevent people having problems with these ADLs. If this could not be achieved then nurses should help the patients to be independent in the ADLs. If this was not possible then nurses should give the patient and/or the patient’s family the knowledge and skills to cope with their dependence on the ADLs. Many clinical nurses used the ADL theory to assess patients. They simply see how independent the patient is for each ADL and then focus their care on those for which the patient is dependent. Therefore, theory can help us to carry out an individual patient’s care and can contribute to better observation and recognition of specific patient needs, be they biological, social or psychological. Nursing theories are often derived from practice. In other words, nursing theorists have constructed their theories based on what they have experienced when working with patients and their families. Understanding the basic elements of a theory and its role, as well as taking a critical view of it, can help to develop a body of knowledge that nurses need for everyday work. In this book we want to highlight the need for and use of nursing theory and its function. We will try to convince you of the importance of nursing theories to the nursing profession, to nursing education and especially to practice. This first chapter will introduce you to new words and ideas and it will take some concentration to understand the terminology. You may decide to read it in small doses, rather than all of it in one sitting. However, once you have mastered this first chapter, the rest of the book will be relatively easy to understand and, believe it or not, enjoyable. Several aspects of nursing theory are discussed in later chapters, and when reading those, dipping back into this first chapter will be helpful. Have a look at Reflective Exercise 1.2. Reflective Exercise 1.2: Terminology When you get involved in a new subject, you often have to learn new words to understand the topic. If you are a nursing student, you have had to learn many new anatomical or psychological words and phrases. Also, think of all the new words you would have to learn to take on any of the following hobbies: • photography • astronomy • music • gardening See how many more you can think of. People accept learning new terms as part of understanding something in which they have an interest. The same is true in nursing theory. The necessity and meaning of theory Some people argue that in the real world of practice most nurses are not concerned with theories and that they are of interest only to nursing academics. However, our position is that there is no such thing as nursing without theory, because there is no such thing as atheoretical nursing. Nursing is theory in action and every nursing act finds its basis in some theory. For instance, if a nurse is talking to a patient, she may be using communication theory. At its simplest, a communication theory would include a speaker, a listener, a message and understanding between the speaker and the listener. Similarly, if she is putting a dressing on a patient, she may be using a theory of asepsis from the field of microbiology. Nurses may not always have a named theory in mind or they may even reject the notion that they are using a theory at all. Yet nurses do what they do for a reason and where there is a reason or purpose in mind, there is, more often than not, a theory. When providing care to a patient, we are doing something in a purposeful manner. While doing it, we are seeking to understand, to uncover meaning, to determine how we should act on the basis of our understanding. This process describes theorising or theory construction. In this sense, theory is not some rarefied academic pursuit, but something that every nurse employs many times a day. From the moment we start to think about something intentionally, we are constructing a theory. When we speak of construction, we are referring to how something is built or how the parts are put together to form a whole structure. Frequently we are referring to a building that has been constructed, such as a house or a bridge. When we bring thoughts together to form some understanding, we are also constructing. In this instance we are producing a mental building that has about it a sense of wholeness, which can be explained and shared with others through language. This draws attention to another significant aspect of this process: when we think, we do so in language. A set of symbols that label the mental images are constructed, made up of our thoughts and the connections we make between them. In daily life too, people use different words and symbols to express meaning. In the same way, all theorists constructing their own theory use their own language and symbols to express and describe the theory. For example, an American nurse theorist, Jean Watson (1979), developed a theory that differentiates nursing from medicine, and advocates a moral stance on caring and nursing as a service driven by specific value systems regarding human caring. According to this theory, the purpose of nursing is to preserve the dignity of clients. Similarly, another American theorist, Dorothy Orem (1991) began to see that most people are self-caring, e.g. they feed themselves, they get themselves out of bed and they wash themselves. This is a normal way of living for most of the population. Orem saw that self-caring is very important for the preservation of dignity and independence. How would you feel if someone started feeding you or helping you to walk when you could do these things very well yourself? Her theory focused on encouraging patients and helping them towards as much self-caring as possible (Pajnkihar 2003). Therefore, theory involves thinking (describing) and seeking meanings and connections (explaining), and often leads to actions (predicting). Such knowledge included in different nursing theories can help not only to describe and explain what is significant about patient care, but also to assist with the prediction of what would work with different patients’ problems (Pajnkihar 2003). As we outlined earlier, there are many nursing theories to help us describe, explain or predict caring practices. However, we need to be selective in the use of theories and this will be dealt with in a later chapter. We can, of course, adopt, adapt or develop our own theories, but many of the existing ones have been researched and found to be useful guides for practice and so might be more useful than simply constructing our own. But as with the map analogy discussed earlier, we need to consider them as guides that inform our actions (Meleis 1997, 2007). It has been said that there is nothing as practical as a good theory, so theories only have value if they can be applied in practice. Theory defined The issue of what theory actually is will be returned to frequently in this and subsequent chapters. There are almost as many definitions of theory as there are nursing theories. Various definitions are offered here with the intention of showing differences in describing and defining what a nursing theory is. To best understand the various definitions of theory, it would be useful to describe the bits that make up a theory – the working parts of a theory. We have already alluded to some of these. For instance, theories describe, explain or predict phenomena. The singular of phenomena is phenomenon. But what, you may ask, are phenomena? Put simply, phenomena are things we witness through our senses. So a patient falling is a phenomenon, a dog barking is a phenomenon and a wet floor is a phenomenon. Kennedy’s assassination was a phenomenon and wound healing is a phenomenon (see Reflective Exercise 1.3). Reflective Exercise 1.3: Phenomena Consider your average day in class or at work. Identify five phenomena that you have seen, heard, smelled, touched or tasted. As you have read, theories seek to explain, describe or predict these phenomena. When we put a name to a phenomenon, it becomes a concept. To take the examples discussed earlier of a patient falling, a dog barking, a wet floor and an assassination are all concepts. They tend to encapsulate what the phenomenon is. If we can define the concepts, they help clarify our view of the phenomena. So, concepts are the building blocks of a theory (see Reflective Exercise 1.4). Reflective Exercise 1.4: Concepts See if you can put a label or name to the five phenomena you identified in Reflective Exercise 1.3. If you can provide a name such that any other person hearing it would know what the phenomenon is then so much the better. Try to define each of the concepts in one sentence. When two or more concepts are linked, this is called a proposition. The obvious proposition from one of the concepts introduced earlier would be the link between a wet floor and a patient falling. So a proposition would be that the patient fell because of the wet floor. This would be termed a causal proposition. There are different types of propositions and, as you will see in the following, they can be seen as the cement or mortar that binds the concepts (bricks) together to form the structure (a theory) (see Reflective Exercise 1.5). Reflective Exercise 1.5: Proposition Consider the names (concepts) you gave to your five phenomena in Reflective Exercise 1.4. Think of other possible concepts they could be linked to. For example, let’s say one of your phenomena was seeing a car crash on your way to work or to class. The name you put on this to make it a concept was ‘road traffic accident’. Anyone seeing this concept would know what the phenomenon was. What other concepts in the situation could be linked to this concept? Let’s say that the traffic lights were not working at that junction or the road was wet and slippery. These are also phenomena and can be expressed as concepts. When you form linkages or relationships between different phenomena, you are developing propositions. Another term that you will find when you study nursing theory is assumption. An assumption is something that you accept as true even though it has not been tested. For instance, I think readers can assume that people are composed of biological, psychological and social dimensions. If you take the example of the car crash, you may assume that the driver did not want to crash (see Key Concepts 1.1). Key Concepts 1.1 Phenomenon: something that you experience through your senses Concept: a name given to a phenomenon Proposition: a statement that links concepts together different types of relationships Assumption: something that you take for granted even though it has not been proved or tested From these exercises you will hopefully be able to understand some of the definitions that exist to explain nursing theory. For example, Dickoff and James (1968: 105) defined nursing theory as a ‘conceptual system or framework’ whereas Chinn and Jacobs (1979: 2) saw theory as ‘an internally consistent body of relational statements about phenomena which is useful for prediction and control’. Chinn & Jacobs later developed the definition further. The more recent definition is more complex (Chinn & Jacobs 1987), but you should understand its meaning: ‘a set of concepts, definitions and propositions that project a systematic view of phenomena by designating specific interrelationships among concepts for the purpose of describing, explaining, predicting or controlling the phenomenon’. The definition highlights the content, context and function of the theory, pointing to the construction of a theory (concepts, definitions and propositions) and the interrelationships between theory elements and functions of a theory (describing, explaining and predicting). It is important to note here that this description is close to the original meaning of the term ‘theory’. It is derived from the Ancient Greek term theoria, meaning a spectacle, i.e. something that is witnessed – in other words, a phenomenon! Another definition, this time by Im and Meleis (1999: 11), drew attention to a theory as something that is purposefully structured: ‘an organised, coherent and systematic articulation of a set of statements related to significant questions in a discipline that are communicated in a meaningful whole to describe or explain a phenomenon or a set of phenomena’. This clearly states that the theory is a body of knowledge of nursing, and provides answers to questions that are of interest to nursing. However, more recently, Chinn and Kramer (2008: 219) defined theory as ‘a creative and rigorous structuring of ideas that project a tentative, purposeful, and systematic view of phenomena’. Earlier in this chapter, we wrote that theories may reflect fact or, indeed, be totally untrue. When a theory is tested many times and stands up to that test, in theoretical language it is beginning to take on the shape of a law. Theofanidis and Fountouki (2008: 16) stated that a theory can be defined as ‘a statement representing a law waiting to happen’. For example, let us say a theory of skin integrity led nurses to turn bed-bound patients once every two hours to prevent pressure ulcers. If this was consistently tested through research and found to be true then the theory could be taking on law-like properties. According to these various definitions, a nursing theory is constructed out of specific nursing phenomena represented as concepts, definitions, assumptions and propositions that help describe, explain or predict how nursing may support and help patients, families or society (see Key Concepts 1.2 and Reflective Exercise 1.6). Key Concepts 1.2 A priori knowledge: knowledge that arises before experience or, more accurately, without the need for experience A posteriori knowledge: sometimes called propositional knowledge, this is where knowledge emerges from experience, and we make deductions arising from this. In this instance, it is termed a posteriori to denote that it is derived from empirical experience, which, in all instances, precedes it and is its source Reflective Exercise 1.6: Defining theory Using your learning and library resources, look up the definitions for phenomena, concepts, propositions, description, explanation and prediction. See if you can find six different definitions of a theory. They do not have to be from the nursing literature. You should find that most of the definitions are composed of the words in the list. To summarise, the definitions point out that: • Theory consists of an organised and coherent set of concepts (two or more), definitions and propositions (two or more) that encapsulate specific phenomena in a purposeful and systematic way. • The proposition(s) must claim a relationship or relationships between the concepts contained in the statement. • It is a purposeful process and demands creative and rigorous structuring and tentative description of phenomena. • The purpose of a theory is to describe, explain and/or predict. • Theories use specific language, ideas or sometimes symbols to give answers to practice-based nursing problems. • Theories are made up of mental building blocks and they can be explained and shared with others through language. Some of the definitions proposed here are rather complex. In one sense, they are certainly comprehensive, but in attempting to achieve this, they run the risk of being difficult to understand. It is important, therefore, to spend some time reflecting on the definitions and the various terms used. Reflection on the definition Theory often means different things to different people. For example, we have emphasised in our definition above the notion that theory requires concepts (two or more) linked by propositions (one or more) (Figure 1.1). Nevertheless, not everyone agrees with this, and in completing Reflective Exercise 1.6, you will already be aware that there is no shortage of differing definitions. We must at least be aware that there are these differences; that there are in fact various ways in which people use the term ‘theory’. Figure 1.1 The links between theory and practice. Theory or model There is also some confusion about the terms theory and model. These are often used interchangeably. Some authors, such as Jacqueline Fawcett (2005a), see them as very different, whereas others, like Afaf Meleis, see them all as theories, with models simply being a theory at an earlier stage of development or not as advanced – but a theory nevertheless. Therefore, the differences between a theory and a model lie in the level of abstractedness and the level of development. Models are more abstract and are associated with notions of something practical that illustrate real situations. For example, toys (cars), anatomical models (bodies), nursing practice simulators and diagrammatic representations are all models. This difference will be explained in more detail in Chapter 5. Construction of theory As we saw earlier, theory consists of concepts linked by statements that propose particular types of connections that join these concepts together (propositions). Another way of expressing this is that concepts are linked by propositions that demonstrate their relationships. Extending the notion of theory as construction, we might view this in terms of the concepts (bricks) and statements (mortar or cement) metaphor shown in Figure 1.2. Figure 1.2 Theory as construction. The concepts (bricks) may be of different forms and levels of abstraction, from concrete to abstract (of different shapes and sizes, and made of different materials). They may be ‘people’ bricks, ‘object’ bricks or even bricks consisting of more abstract concepts such as ‘love’ or ‘care’. They may be joined together to make descriptive, explanatory or predictive propositional statements (mortar/cement). Additional concepts (bricks) may be added, but they must not look out of place and must adhere in a meaningful way to the propositions (mortar/cement). The journey to theoretical understanding starts with seeing and trying to interpret phenomena. Some examples of directly observing and describing a phenomenon in practice are seen to underpin the theories of Florence Nightingale (1859) and Hildegard Peplau (1952). Nightingale described her time in the Barrack Hospital during the Crimean War: she saw the unsanitary environment as the main cause of soldiers dying unnecessarily. The old barracks across the Bosphorus from Constantinople had been set up as a hospital; it had poor ventilation and a dead horse was found in the water supply. It is not surprising that most of the soldiers died from infections rather than from the wounds of battle. Nightingale believed that such infections were caused by a ‘miasma’ that travelled through the air. Therefore, the phenomena she saw in her physical environment were related to better cleanliness and better ventilation. Her theory, not surprisingly, focuses mainly on getting the environment right (Figure 1.3). She wrote that the nurse’s role was to place the patients in the best position to let nature cure them (Nightingale 1859). Figure 1.3 Nightingale theory of nursing. Peplau’s (1952) theory was constructed from the years she spent working as a nurse in psychiatric hospitals. She began to be convinced that the main cause of mental illness was the lack of interpersonal communications between nurses and patients; she described how nurses failed to talk to patients. Therefore, Peplau’s theory is mainly centred on how to establish and sustain interpersonal relations with patients. Roper et al. (1983) observed how patients often lost independence in some of their ADLs (e.g. walking, eating or sleeping). Their theory provides nurses with knowledge on how to change dependence to independence in the ADLs (see Reflective Exercise 1.7). Reflective Exercise 1.7: Building theory A cancer nurse notices that patients often become sick when a nurse is giving them chemotherapy. This is a phenomenon that the nurse observes. Her conceptual name for this phenomenon is ‘chemotherapy-induced nausea’. The proposition is the link between the two concepts of nausea and chemotherapy. The theory that describes this phenomenon is that every time the patient received chemotherapy he became nauseated. Think about your work in practice, choose one event and discuss what the phenomenon is and identify the related concepts and propositions. Theory and science of nursing In this section, the relationship between the theory and science of nursing will be described (Figure 1.4). The starting point is that a theory represents knowledge developed by a systematic process, with the purpose of being useful and helping to improve practice. This is new knowledge, which still has to be tested (Pajnkihar 2003). Theory is best tested by research and once this has been undertaken the theory becomes part of nursing science. Therefore, Figure 1.4 Correlation: education, science and practice. Science = Theory + Research where theory is the knowledge and research refers to the methods used to test the theory. Karl Popper (1989) famously said the theory was like a paper boat that you placed into a pond to see if it floats or sinks. If it continued to float under different circumstances (e.g. wind or waves), then you could be confident that it was a good paper boat (theory). However, if it sank after many successes then there was a question over the soundness of the design. This can be also seen with nursing theory. If nurses were to research a new theory of oral hygiene for cancer patients and find it effective every time, then such a theory would enter nursing science and become standardised practice. However, if at a later date some researchers found that it did not work or was not effective with people who had a particular form of cancer then the theory would have failed and its position in nursing science would have to be re-evaluated. From this explanation of what science is and what theory is, we can assert the following: when a nursing theory is developed, it forms a body of knowledge that describes, explains and/or predicts phenomena from practice and that gives nursing professional meaning and relevance. Once research shows that theory does what it should do and does so consistently – the end product contributed to nursing science. For Meleis (2012: 28) science is ‘a unified body of knowledge about phenomena that is supported by agreed-on evidence. Science includes disciplinary questions and provides answers to questions that are central to the discipline.’ For Keck (1998: 16) science is both a ‘unified body of knowledge concerned with specific subject matter and the skills and methodologies necessary to provide such knowledge’. Jacox (1974: 406) explained that science as a process incorporates ‘methods or research strategies by which knowledge is developed and tested’, whereas science as a product is referred to as ‘a body of accumulated knowledge that purports to describe some selected aspects of the universe’ (Pajnkihar 2003). Within nursing, science is defined as ‘the process, and the result of ordering and patterning the events and phenomena of concern to nursing’ (Jacobs & Heuther, 1978: 66). Nursing science, therefore, can be described as a body of knowledge, developed by different methods and approaches that nurses can use to describe, explain and/or predict phenomena. When described as a product it means a theory; when described as a process it means the way (research methods used and research process) in which a theory is developed (Pajnkihar 2003). Therefore, nursing science is simply nursing theory that has been tested. How nurses practise and how they use this knowledge in their practice to treat patients can be said to be the art of nursing. It is obvious that nursing as a science and as an art are both related to nursing research. The purpose of the science of nursing is to develop knowledge that is applicable and useful in nursing practice (Pajnkihar 2003). There is no doubt about the worth of having reliable scientific knowledge to underpin nursing practice.

 

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