Nursing Theories

A companion to nursing theories

Development of Nursing Theories

Introduction

Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory & predictive in nature. Theories are composed of concepts, definitions, models, propositions & are based on assumptions. They are derived through two principal methods; deductive reasoning and inductive reasoning. Nursing theorists use both of these methods.  Theory is “a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena”. A theory makes it possible to “organize the relationship among the concepts to describe, explain, predict, and control practice”

Definition

• Concepts are basically vehicles of thought that involve images. Concepts are words that describe objects, properties, or events & are basic components of theory.

• Types: Empirical concepts

Inferential concepts

Abstract concepts

• Models are representations of the interaction among and between the concepts showing patterns.
• Propositions are statements that explain the relationship between the concepts.
• Process it is a series of actions, changes or functions intended to bring about a desired result. During a process one takes systemic & continuous steps to meet a goal & uses both assessments & feedback to direct actions to the goal.
• A particular theory or conceptual frame work directs how these actions are carried out. The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks & theories define the person (patient), the environment, health & nursing.
• The terms ‘model’ and ‘theory’ are often wrongly used interchangeably, which further confounds matters.
• In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981).
• They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment.
• Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981).
• Their main limitation is that they are only as accurate or useful as the underlying theory.

Importance of nursing theories

• Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978).
•  It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964).
• Theory is important because it helps us to decide what we know and what we need to know (Parsons1949).
• It helps to distinguish what should form the basis of practice by explicitly describing nursing.
• The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education (Nolan 1996). In addition, because
• The main exponent of nursing – caring – cannot be measured, it is vital to have the theory to analyze and explain what nurses do.
• As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge.
• This can be seen as an attempt by the nursing profession to maintain its professional boundaries.

The characteristics of theories

Theories are

1. interrelating concepts in such a way as to create a different way of looking at a    particular phenomenon.
2. logical in nature.
3. generalizable.
4. bases for hypotheses that can be tested.
5. increasing the general body of knowledge within the discipline through the research implemented to validate them.
6. used by the practitioners to guide and improve their practice.
7. consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.

Basic processes in the development of nursing theories

Nursing theories are often based on & influenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts.

General System Theory

It describes how to break whole things into parts & then to learn how the parts work together in “systems”. These concepts may be applied to different kinds of systems, e.g. Molecules in chemistry, cultures in sociology, and organs in Anatomy & Health in Nursing.

Adaptation Theory

• It defines adaptation as the adjustment of living matter to other living things & to environmental conditions. 

• Adaptation is a continuously occurring process that effects change & involves interaction & response.

·        Human adaptation occurs on three levels :

1.      The internal (self)

2.      The social (others) &

3.      the physical (biochemical reactions)

Developmental Theory

• It outlines the process of growth & development of humans as orderly & predictable, beginning with conception & ending with death.

• The progress & behaviors of an individual within each stage are unique.

• The growth & development of an individual are influenced by heredity, temperament, emotional, & physical environment, life experiences & health status.

Common concepts in nursing theories

Four concepts common in nursing theory that influence & determine nursing practice are:

1. The person (patient).

2. The environment

3. Health

4. Nursing (goals, roles, functions)

Each of these concepts is usually defined & described by a nursing theorist, often uniquely; although these concepts are common to all nursing theories. Of the four concepts, the most important is that of the person. The focus of nursing, regardless of definition or theory, is the person.

Historical perspectives and key concepts

• Nightingale (1860): To facilitate “the body’s reparative processes” by manipulating client’s environment
• Peplau 1952: Nursing is; therapeutic interpersonal process.
• Henderson 1955: The needs often called Henderson’s 14 basic needs
• Abdellah 1960: The nursing theory developed by Faye Abdellah et al (1960) emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family.
• Orlando 1962: To Ida Orlando (1960), the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being.
• Johnson’s Theory 1968: Dorothy Johnson’s theory of nursing 1968 focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery.
• Rogers 1970: to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through “humanistic science of nursing”
• Orem1971: This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs.
• King 1971: To use communication to help client reestablish positive adaptation to environment.
• Neuman 1972: Stress reduction is goal of system model of nursing practice.
• Roy 1979: This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes.
• Watson’s Theory 1979: Watson’s philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life.

Classification of nursing theories

Depending On  Function (Polit et al 2001)
Descriptive	To identify the properties and workings of a discipline
Explanatory	To examine how properties relate and thus affect the discipline
Predictive	To calculate relationships between properties and how they occur
Prescriptive	To identify under which conditions relationships occur

Depending on the Generalisability of their principles

Metatheory: the theory of theory. Identifies specific phenomena through abstract concepts. Grand theory: provides a conceptual framework under which the key concepts and Principles of the discipline can be identified. Middle range theory: is more precise and only analyses a particular situation with a limited number of variables. Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved.

Based on the philosophical underpinnings of the theories

■ “Needs “theories. ■ “Interaction” theories. ■ “Outcome “theories. ■ Humanistic theories.

“Needs” theories

• These theories are based around helping individuals to fulfill their physical and mental needs. The basis of these theories is well-illustrated in Roper, Logan and Tierney’s Model of Nursing (1980).
• Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position.

“Interaction” theories

• As described by Peplau (1988), these theories revolve around the relationships nurses form with patients.
• Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs.

“Outcome” theories

• These portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health (Roy 1980). 
• Outcome theories have been criticized as too abstract and difficult to implement in practice (Aggleton and Chalmers 1988).

“Humanistic” Theories

• Humanistic theories developed in response to the psychoanalytic thought that a person’s destiny was determined early in life.
•  Humanistic theories emphasize a person’s capacity for self-actualization.
• Humanists believe that the person contains within himself the potential for healthy & creative growth.
• Carl Rogers developed a person –centered model of psychotherapy that emphasizes the uniqueness of the individual.
• The major contribution that Rogers added to nursing practice is the understandings that each client is a unique individual, so, person-centered approach now practice in nursing.

Models of nursing

• Until fairly recently, nursing science was derived principally from social, biologic, and medical science theories.
• However, from the 1950s to the present, an increasing number of nursing theorists have developed models of nursing that provide bases for the development of nursing theories and nursing knowledge.
• A model, as an abstraction of reality, provides a way to visualize reality to simplify thinking.
• A conceptual model shows how various concepts are interrelated and applies theories to predict or evaluate consequences of alternative actions.
• According to Fawcett (2000),
• A conceptual model “gives direction to the search for relevant questions about the phenomena of central interest to a discipline and suggests solutions to practical problems”
• Four concepts are generally considered central to the discipline of nursing: the person who receives nursing care (the patient or client); the environment (society); nursing (goals, roles, functions); and health. These four concepts form a metaparadigm of nursing.
• The term metaparadigm comes from the Greek prefix  “meta,” which means more comprehensive or transcending, and the word Greek word “paradigm,” which means a philosophical or theoretical framework of a discipline upon which all theories, laws, and generalizations are formulated (Merriam-Webster’s Collegiate  Dictionary, 1994).

Growth and Stability Models of Change

• There are two major differences in philosophical beliefs, or world views, about the nature of change.
• “The world view of change uses the growth metaphor, and the persistence view focuses
  on stability” (Fawcett, 1989,).
• Within the change world view, change and growth are continual and desirable, “progress is valued, and realization of one’s potential is emphasized” (Fawcett).
• Persistence is endurance in time
• Persistence world view emphasizes equilibrium and balance.

Categories of Conceptual Models

• Ten conceptual models of nursing have been classified according to two criteria:
  • the world view of change reflected by the model (growth or stability); and
  • the major theoretical conceptual classification with which the model seems most consistent (systems, stress/adaptation, caring, or growth/development).

Systems Theory as a Framework

• Systems theory is concerned with changes caused by interactions among all the factors (variables)
• General systems theory is emphasized
• A system is defined as “a whole with interrelated parts, in which the parts have a function and the system as a totality has a function” (Auger, 1976,
• A general systems approach allows for consideration of the subsystems levels of the human being, as a total human being, and as a social creature who networks himself with others in hierarchically arranged human systems of increasing complexity. Thus the human being, from the level of the individual to the level of society, can be conceptualized as the client and becomes the target system for nursing intervention (Sills & Hall, 1977).

An example of systems interaction

• Input (Diet teaching)
• Throughput (Assimilation of information)
• Output (Food intake)
• Feedback (Weight record, Hb estimation etc.)
• Two nursing models based on systems theory:
  • Imogene King’s systems interaction model, and
  • Betty Neuman’s health care systems model.

Major Concepts as Defined in King’s Model
Person (human being)	A personal system that interacts with interpersonal and social systems
Environment	A context “within which human beings grow, develop, and perform daily activities”
Health	dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living”
Nursing	A process of human interaction

Imogene King’s Systems Interaction Model

• In interaction model, the purpose of nursing is to help people attain, maintain, or restore health. King’s model conceptualizes three levels of dynamic interacting systems.

1.      Individuals are called “personal systems.”

2.      Groups (two or more persons) form “interpersonal systems.”

3.      Society is composed of “social systems.”

• As the person interacts with the environment, he or she must continuously adjust to stressors in the internal and external environment (King, 1981).
• Health assumes achievement of maximum potential for daily living and an ability to function in social roles. It is the “dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” (King, 1981,).
• “Illness is a deviation from normal, that is, an imbalance in a person’s biological structure or in his psychological makeup, or a conflict in a person’s social relationships” (King, 1989).
• “The goal of nursing is to help individuals and groups attain, maintain, and restore health”
• Stress: “a dynamic state whereby a human being interacts with the environment to maintain balance for growth, development, and performance”

Betty Neuman’s Health Care Systems Model

• Betty Neuman specifies that the purpose of nursing is to facilitate optimal client system stability.
• Normal line of defense: an adaptational level of health considered normal for an individual
• Lines of resistance: protection factors activated when stressors have penetrated the normal line of defense
• Neuman’s model, organized around stress reduction, is concerned primarily with how stress and the reactions to stress affect the development and maintenance of health.
• The person is a composite of physiologic, psychological, sociocultural, developmental, and spiritual variables considered simultaneously.
•  “Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences” (Neuman, 2002).
• A person is constantly affected by stressors from the internal, external, or created environment.
• Stressors are tension-producing stimuli that have the potential to disturb a person’s equilibrium or normal line of defense.
•  This normal line of defense is the person’s “usual steady state.”
• It is the way in which an individual usually deals with stressors.
• Stressors may be of three types:

1.      Intrapersonal: forces arising from within the person

2.      Interpersonal: forces arising between persons

3.      Extrapersonal: forces arising from outside the person

• Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person’s resistance to any given stressor or stressors.
• If the flexible line of defense is no longer able to protect the person against a stressor, the stressor breaks through, disturbs the person’s equilibrium, and triggers a reaction. The reaction may lead toward restoration of balance or toward death.
• Neuman intends for the nurse to “assist clients to retain, attain, or maintain optimal system stability” (Neuman, 1996).
• Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense.
•  Neuman defines illness as “a state of insufficiency with disrupting needs unsatisfied” (Neuman, 2002).
• Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person’s lines of resistance.

Stress/Adaptation Theory as a Framework

• In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect.
• The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand both how the balance is maintained and the possible effects of disturbed equilibrium.
• This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological) phenomenon.

A unique body of knowledge

• The drive for a unique body of knowledge is based on the assumption that ‘borrowed’ knowledge is less worthy.
• However, nurse education is based on theory borrowed from other disciplines, such as sociology and psychology.
• It has been argued that applying knowledge from different disciplines only serves to dilute nursing practice.
• Nevertheless, as the occupation is focused on humans, perhaps it is inevitable that nursing uses knowledge from other social sciences.
• It has been argued that no knowledge is exclusive, and because of nursing’s diverse nature it is impossible for it to have a unique body of knowledge and one unified body of theory (Castledine 1994, Levine 1995).

Criticisms of nursing theories

To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice.

Use of language

• Scott (1994) states that the crucial ingredients of nursing theory should be accessibility and clarity. However, one of the main criticisms of nursing theory is its use of overtly complex language (Kenny 1993). It is important that the language used in the development of nursing theory be used consistently.

Not part of everyday practice

•  Despite theory and practice being viewed as inseparable concepts, a theory-practice gap still exists in nursing (Upton 1999).  Yet despite the availability of a vast amount of literature on the subject, nursing theory still means very little to most practicing nurses. Perhaps this is because the majority of nursing theory is developed by and for nursing academics (Lathlean 1994). It has been recognised that traditionally nurses are used to ‘speaking with their hands’ (Levine 1995). Therefore, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory. This makes it difficult for the majority of nurses to understand and apply theory to practice (Miller 1985).

Summarization

• Definition
• Importance of Nursing Theories
• The characteristics of theories:
• Basic Processes in the Development Of Nursing Theories:
• Nursing theories are often based on & influenced
• ANA definition of Nursing Practice
• Common concepts in Nursing Theories:
• Historical Perspectives & Key Concepts
• Clasification of Nursing Theories
• Models  Of  Nursing
• Growth and Stability Models of Change
• Betty Neuman’s Health Care Systems Model
• Stress/Adaptation Theory as a Framework
• A unique body of knowledge
• Criticisms of nursing theories

Conclusion

Littlejohn (2002) comments that, irrespective of nursing theories nurses will continue to exhibit a caring response to the ‘sick and troubled’.  If this is true, perhaps nurses are ‘nursing’ without the knowledge of theories and theory is irrelevant. However, theory and practice are related, and if nursing is to continue to develop, the concept of theory must be addressed. If nursing theory does not drive the development of nursing, it will continue to develop in the footsteps of other disciplines such as medicine

Reference

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