Evolution Of Nursing Theories 2s3346

EVOLUTION OF NURSING THEORIES

BY Prof.(Mrs).S.Kanchana Principal Omayal Achi college of Nursing

This session will highlight on A. Introduction to nursing theories B. Historical evolution of Nursing theory C. Stages of theory development in nursing D. Trends in theory development E. Terminologies F. Overview of nursing theory G. Definition and meaning of nursing theory

H. Importance of nursing theories I. Characteristics of nursing theories J. Classification of nursing theories under various forms 1.Level of theories 2.Philosophical underpinnings 3.Functions of nursing theories 4. Process development of nursing theories

K. Common concepts in Nursing theories L. Process of theory development M. Criteria for analyzing theory N. Application of theory in Nursing practice

(A). Introduction: Why Theory? • Theory enables understanding of what, how and why we do the practice of nursing • It facilitates questions about the relevance & application of nursing practice & research • It stimulates thinking, identifying what is mindless and what needs to be changed • It facilitates the development of nursing knowledge and evidence based practice

• Nursing theory has been a prevalent theme in the nursing literature for the past 30years and has stimulated phenomenal growth in the nursing profession.

• It is interesting to note that 90% of all Nursing theories have been generated in the last 20 years.

(B). EVOLUTION OF NURSING THEORY • The history of professional nursing began with Florence Nightingale who envisioned nurses as a body of educated women. • In last century, nursing began with a strong emphasis on practice.

Historical eras in nursing 1. 2. 3. 4.

Curriculum era Research era Graduate nursing era Theory era

Curriculum era Addressed the question of what prospective nurses must study and learn to become a nurse. i.e. Courses nurses need to take, the need to move from hospital based nursing program to college level education and university level education.

Research era As more and more nurses sought degrees in higher education, research era emerged. Nurses began to participate in research and research course began to be included in nursing curricula.

Graduate nursing education era • Masters program in nursing emerged to meet the need for nurse with specialized education in nursing . • The masters education had an embedded course in nursing research • nearing the end of this era a course in nursing theory or nursing conceptual models that introduced students to the early nursing theorists and development of nursing theories was introduced.

Theory era • • •

Was the natural outgrowth of research era. With an increased understanding of research and knowledge development It became obvious that research without theory produced isolated information, however research and theory produced nursing science.

©. STAGES OF THEORY DEVELOPMENT IN NURSING: Stage

Source of knowledge

1. Silent

Blind obedience to medical authority

knowledge stage

2. Received knowledge stage

Learning through listening to others

3.Subjective

Authority was internalized and a new sense of self emerged

knowledge stage

Impact on theory and research

·

· of

little attempt to develop theory. Research was limited to collection epidemiological data

Theories were borrowed from other disciplines. As nurses acquired non-nursing doctoral degrees, they relied on the authority of the educators, sociologists, psychologists to provide answers to nursing problems. ·

· A negative attitude toward borrowed theories and science emerged. Nurse scholars focused on defining nursing and on developing theories about and for nursing. Nursing research focused on the nurse rather than on clients and clinical

4. Procedural

knowledge stage

5. Constructed

Knowledge

Includes both separate and connected knowledge

Integration of different types of knowledge(int uition, reason and selfknowledge)

Proliferation of approaches to theory development. • Application of theory in practice was frequently underemphasized. • Emphasis was placed on the procedures used to acquire knowledge, with over attention to the appropriateness of methodology, the criteria for evolution, and statistical procedure for data analysis.

Nursing theory should be based on prior empirical studies, theoretical literature, client reports of clinical experience and feeling, nurse scholar’s intuition or related knowledge ·

(D). Trends in theory development • Conceptual models and philosophies of practice – The nature of nursing – The purposes for which nursing exist.

•

Nursing process as a framework for viewing nursing practice. – Deliberate, reflective, critical, and self-correcting. – Encouraged nurses to cultivate basic inquiry skills.

•

Development of philosophies with emphasis on knowledge associated with: – Esthetic – Ethical – Personal

• Application of theories borrowed from other disciplines. – Means to resolve problems. – Use with caution.

• Nursing theories in the 1960s and 1970s-functional view of nursing. – What nursing is; describes how nursing functions; variables influencing health and illness.

• Development of midrange practice-linked theory. – Needed to provide specific guidance for nursing practice. – Tend to cluster around a concept of interest.

(E). Terminologies S.No

Terminology

Definition

1.

Metaparadigm

2

Philosophy

It is the most abstract level of knowledge. It specifies the main concepts that encom the subject matter and the scope of a discipline. Nursing metaparadigm consists of the central concepts “Person, Environment, Health and Nursing. It is the next knowledge level; it specifies the definitions of the metaparadigm concepts in each of the conceptual models of nursing.

3

Conceptual models

to the phenomena with which the are frameworks or paradigms that provide “a broad frame of reference for systematic approaches discipline is concerned”. It differs according to the concepts of the models.

4

Theory

It is a group of related concepts that propose actions that guide practice.

5

Nursing Theory

Is a group of related concepts that derive from the nursing models.

6

Middle range theories

They are least abstract level of theoretical knowledge because they include details specific to nursing practice. They include information indicating the situation or health condition , the patient population or age group, the location or area of practice and the action of the nurse or the intervention.

7

Grand theories

Grand Theories are defined as the broadest in scope, less abstract than conceptual models but composed of general concepts still relatively abstract, and the relationships cannot be tested empirically.

8

Knowledge

Understanding acquired through learning or investigation of what is known about a discipline’s subject matter. It may be facts or theoretically based knowledge that is more tentative.

9

Phenomena

They are subject matter of a discipline

10

Concept

Is an idea or complex mental image of a phenomenon(object property or event). They are the major components of a theory.

11

Abstract concepts

Are independent of time or place and they are indirectly observable. Hope is an example of abstract concepts.

12

Concrete concepts

Are specific to time and place and are observable. A person features like, eye color, height, weight are examples of concrete concepts.

13

Model

It can be Verbal: Verbal model are worded statements. 2.Schema: means symbols or physical visualization. Schematic models can be diagrams, graphs or pictures that facilitate understanding.

14

Paradigm

Is another term for conceptual framework or conceptual model

15

Propositions

They are theoretical statements that specify the proposed relationships of the concepts of theory.

16

Induction

Is a form of reasoning that is loosely described as moving from specific to general.

17

Deduction

Logical reasoning from general to specific.,

(F). Overview of Theory: •

The uniqueness of theories and perspectives used by a discipline distinguishes it from other disciplines. • The theories used by of a profession clarify basic assumptions and values shared by its and define the nature, outcome and purpose of practice.

•

Kerlinger ---views theories as a set of interrelated concepts that give a systematic view of a phenomenon ( an observable fact or event ) that is explanatory and predictive in nature. • Theories are composed of concepts, definitions, models , propositions and are based on assumptions. They are derived through two principal methods: 1) Deductive reasoning 2) Inductive reasoning. Nursing theorists use both of these methods.

•

Deductive reasoning

It is a form of reasoning from the general to the specific. In deductive logic were two or more premises as relational statements are used to draw a conclusion. • In deductive process, an abstract theoretical relationship is used to derive specific questions or hypothesis. • Theory that is developed from the applications of deductive logical System is only as sound as premises upon which the argument is based.

Inductive reasoning •

It is a form of logical reasoning in which a generalization is induced from a number of specific observed instances. • The inductive form is based on the assumption that of any given class share common characteristics. Therefore what is true for any randomly selected of the class is accepted as true for all of the class.

Comparison: Inductive

Deductive

Empirical Observations

Laws

Facts

Theories

Concepts

Concepts

Theories

Facts

Laws

Empirical observations

(G). Definition and meaning of Nursing Theory • Nursing theories are an organized and systematic expression of a set of statements related to questions in the discipline of nursing. • Powers and Knapp (1995), defined theory as “a set of statements that tentatively describe, explain, or predict relationships among concepts that have been systematically selected and organized as an abstract representation of some phenomenon.

•

Bodie and Chitty (1993) defined theory as “an internally consistent group of relational statements (concepts, definitions and propositions) that present a systematic view about a phenomenon and which is useful for description, explanation, prediction and control”

• Socialization into a discipline is guided by  theories use of language  identification of concepts  definition of relationships  structured ideas  and facilitation of disciplined inquiry, practice and communication, as well as predicting outcomes of practice. Nursing professionals apply theory to describe, explain, predict or prescribe nursing practice.

(H). Importance of Nursing Theories 1. Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs1978). 2. It provides the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964). 3. Theory is important because it helps us to decide what we know and what we need to know (Parsons1949).

4. It helps to distinguish what should form the basis

of practice by explicitly describing nursing. 5. 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.

6. 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.

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

(J). CLASSIFICATION OF NURSING THEORIES 1. Level of theories:  Metatheory  grand theory  middle range theory  practice theory. 2. Philosophical underpinnings  Interaction theories  Needs theories  Outcome theories  Humanistic theories

3. Functions: Descriptive Explanatory Predictive Prescriptive 4. Process development of nursing theories General systems theory Adaptation theory Developmental theory

LEVELS OF THEORIES Theory

Levels of Abstraction

Meta theory

Most abstract

Grand Theory Middle range theories

Practice theories

Least Abstract

1. Levels of theories • Meta theory: The fourth level of theory or Meta theory is the highest level of theory, and is defined by the prefix META, meaning “changed in position”, “beyond”, “on a higher level”, or “transcending,” and refers to the body of knowledge or about a field of study

A nursing metatheory presents the most global perspective of the nursing discipline by identifying and evaluating critical phenomena in unique ways. Even though nursing metatheory is very abstract and may not be easily tested, nursing metatheory provides the meanings, sentences, and structures interconnecting situations and events observed by nurses on a global scale.

Meta theory is criticized as being limited, without boundaries, abstract and very difficult for practical application. However, a true meta theory in nursing will emerge as a superstructure with multiple practical applications and extensive opportunities for researchers to discover grand theories, mid-range theories, interconnected paradigms, and models, as well as explore how nursing reconstructs and is reconstructed

Grand theories • The third level of nursing theory is Grand Theory • Emphasizes a global viewpoint with a board perspective of nursing practice, and a distinct nursing perspective of nursing phenomenon. • Fawcett (1995) defined Grand Theories as the broadest in scope, less abstract than conceptual models but composed of general concepts still relatively abstract, and the relationships cannot be tested empirically.

Categorization of Grand nursing theories Human needs model and theories

Interactive process models and thoeires

Unitary models and theories

Abdellah

Arthian and CongerIntersystem model

Mragaret Newman-health as an expanding consciousness

Henderson

Erickson,tomlin and swainModeling and Role modeling(MRM), a paradigm and theory for nursing

Parse

Johnson

King

Rogers

Nightingale

Levine

Neuman

Roy

Orem

Watson

Middle range theories • Middle Range Theories, the second level of nursing theories, are moderately abstract, inclusive, organized within a limited scope; have a limited number of variables, which are testable in a direct manner. • The mid-range theories have a stronger relationship with research and practice.

• Mid-range theories provide nurses with the “best of both worlds”---easy applicability in practice and abstract enough to be scientifically interesting. • Mid-range theories focus on concepts of interest to nurses, and include: pain, empathy, grief, self-esteem, hope, comfort, dignity, and quality of life.

 They are categorized as 1. High Middle range theories: Benner’s skill acquisition in nursing model, Leninger and Pender 2. Middle- Middle Range theories: Mishels’s uncertainity of illness theory, Schumacher and Meleis work on transitions and Reed;s selfTranscedence theory 3. Low middle range theories: Eakes, Burke and Hainsworth theory of chronic sorrow. Becks postpartum depression theory and Mercers conceptualization of maternal role attainment.

Practice theories/Microtheory • The first level of nursing theory, describe prescriptions or modalities for practice. • Four steps are involved to determine practice theories, which include:

1. Factor isolating: to identify and describe a phenomenon 2. Factor relating: to identify and describe possible explanations or causes of the phenomenon 3.Situation relating: to predict occurrence of a phenomenon when the cause is present. Example: the post open-heart surgery patient will experience cardiac arrhythmias if the blood potassium level goes below 3.5 meq.

4.Situation producing control: to prevent occurrence of the phenomenon by controlling or eliminating possible causes. Examples include: pregnant women receive RHO-gram to prevent possible hemolysis in their infants; and the frequent turning and positioning of bed-ridden patients to prevent pressure ulcers.

2. Categories based on philosophical underpinnings: • • • •

"Needs "theories. "Interaction" theories. "Outcome "theories. "Humanistic theories"

Needs theories • These theories are based around helping individuals to fulfill their physical and mental needs.. • Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position.

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 believes that the person contains within himself the potential for healthy and creative growth.

3. Categories based on functions: • • • •

Descriptive Explanatory Predictive Prescriptive

Descriptive theories •

Descriptive theories describe, observe, and name concepts, properties, and dimensions, but they do not indicate how changes in one concept affect other concepts.

Explanatory theories • Relate concepts to one another and describe and specify some of the association or interrelations between and among the concepts. • Further, explanatory theories attempt to tell how or why the concepts are related and may deal with causality, correlations, and rules that regulate interactions (Barnum,. 1998; Dickoff et al., 1968).

Predictive theories • describe precise relationships between concepts and are the third level of theory development. • Predictive theories presuppose the prior existence of the more elementary types of theory. • They result after concepts are defined and relational statements are generated and are able to describe future outcomes consistently. • Predictive theories include statements of causal or consequential relatedness (Dickoff et al., 1968).

Prescriptive theories • are perceived to be the highest level of theory development (Dickoff et al., 1968) • Prescriptive theories prescribe activities necessary to reach defined goals. • In nursing, prescriptive theories address nursing therapeutics and predict the consequence of interventions (Meleis, 2005).

4. Categories Based on Processes in the Development Of Nursing Theories

General System Theory: • It describes how to break whole things into parts and then to learn how the parts work together in " systems". These concepts may be applied to different kinds of systems, e.g.Betty Newman’s systems theory.

Developmental Theory • It outlines the process of growth and development of humans as orderly and predictable , beginning with conception and ending with death. • The progress and behaviors of an individual within each stage are unique. • The growth and development of an individual are influenced by heredity , temperament , emotional, and physical environment , life experiences and health status.

 Adaptation Theory • It defines adaptation as the adjustment of living matter to other living things and to environmental conditions. Adaptation is a continuously occurring process that effects change and involves interaction and response . Human adaptation occurs on three levels: • --- the internal ( self ) • --- the social (others) • --- and the physical ( biochemical reactions )

(K). Common concepts in nursing theories • A METAPARADIGM is the most global conceptual or philosophical framework of a discipline or profession • It defines and describes relationships among major ideas and values It guides the organization of theories and models for a profession • The nursing metaparadigm comprises four concepts: person, environment, health, and nursing

The nursing metaparadigm comprises four concepts: person, environment, health, and nursing 1. Person refers to the recipient of nursing care, including physical, spiritual, psychological, and sociocultural components, and can include an individual, family, or community 2. Environment refers to all the internal and external conditions, circumstances, and influences affecting the person 3. Health refers to the degree of wellness or illness experienced by the son 4. Nursing refers to the actions, characteristics, and attributes of the individual providing the nursing care

(L). PROCESS OF THEORY DEVELOPMENT a. Concept development: Creation of a conceptual meaning, that includes, specifying, defining, and clarifying the concepts used to describe the phenomenon of interest.

• Concept : – Building block of theories – Classify the phenomenon of interest – A symbolic statement describing a phenomenon – May be classified as abstract or concrete – Discrete ( non-variable ) or continuous

Types of concepts • Concepts can be characterized – – – – –

Enumerative Associative Relational Statistical Summative

Concepts

Characteristics Examples

Enumerative concepts

Always present and Age ,Height Universal Weight

•Exist only in a particular condition • May have Zero value too Relational concepts Can be derived only through interaction with an associative concept Associative concepts

Income, Disease condition, Anxiety Longevity

Statistical concepts

Relate the property of one thing in of its distribution in the population

•Average blood • Acquired immune deficiency Syndrome rate

Summative concepts

•Represent an entire complex entity of a phenomenon •Not measurable

Nursing :Health: Environment

Sources of concepts • Naturalistic Concepts:(These are measurable). Body Weight, Depression, Pain. • Research Based Concepts – Quantitative – Phenomenological

• Existing concepts -Human needs on Maslow’s Hierarchy of needs

Purpose of concepts development • Identify gaps in knowledge • Determine the need to refine or clarify • Evaluating the adequacy of competing concepts in relation to other phenomenon • Examines the similarity – between the definition concept – and how it is being operational

• determines the coherence between the theory of concept and its application

Process of concept development Concept Analysis (Walker and Avant (1995) – – – – – – – –

Select Determine the aims and purpose Identify the uses Determine the defining attributes Construct a a case model Define a boundary Identify Antecedents and consequences Define the empirical referent of concept

Concept Synthesis – Quantitative Method – Qualitative Method – Literary Method Concept Derivation – Familiar with the existing literature – Search fields of interest for having a new perception on the topic – Select a parent topic – Redefine in of topic of interest

b. Statement development: Formulation and validation of rationale statements. Steps in statement analysis include (Walker and Avant) 1. Select the statement to be analyzed 2. simplify the statement 3. classify the statement 4. Examine concepts within statement for definition and validity 5. Specify relationship between concepts 6. examine he logic 7. determine stability

c.Theory construction: Systematic organization of linkages for a formal theoretical structure d.Testing of theoretical relationships e.Theory application: research methods are used to assess how the theory can be applied to practice which is measured how the desired outcomes are achieved

(M). CRITERIA FOR ANALYZING A THEORY • • • •

Clarity: “How clear is this theory” Simplicity: “How simple is this theory” Generality: “How general is this theory” Empirical precision: “How accessible is this theory” • Derivable consequences: “How important is this theory”

• Clarity: Consistency and structural clarity are important. To assess these, the major concepts, sub concepts, and their definitions are identified. The logical development should be clear and assumptions should be consistent with the theory’s goals.

• Simplicity: It is very valued in theory development. Nurses require simple theory like middle range theory to guide nursing practice. Theory should be sufficiently comprehensive and at a level of abstraction to provide guidance.

• Generality: To determine generality the scope of concepts and goals within the theory are examined. The more limited the concepts and goals, the less general the theory.

• Empirical precision: Empirical precision is linked to the testability and ultimate use of a theory and it refers to the “extent that the defined concepts are grounded in observable reality.

• Derivable consequences: If research, theory and practice are to be meaningfully related then nursing theory should lend itself to research testing and testing should lead to knowledge that guides practice.

(N). APPLICATION OF THEORY IN NURSING PRACTICE NURSING RESEARCH 1. Strong relationship between theory and practice. 2. Theory based nursing practice: helps in informed decision making 3. Closing the Theory practice gap: 4. Application in Nursing research: -Theory generating research and -Theory testing research.

How Theory guides nursing research • Identify meaningful and relevant area of study • Propose Plausible approached to help problems to examine • Develop or reformulate Middle range theory linked to research • Define the concept and propose relationships among concepts • Interpret research findings • Develop Clinical practice protocols • Generate Nursing Diagnosis based on research findings

THANK YOU It is Professional Nurses ethical responsibility to utilize the knowledge base of her or his discipline” “