Nursing Theories: A Practical View Elakkuvana Bhaskara Raj D
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Introduction to Nursing Theories1

 
INTRODUCTION
Nursing theories and models are very important to development of a specialized body of knowledge. In recent decades nursing theories started to independently, previous days, the nursing profession relied on theories from other disciplines such as medicine, psychology and sociology as a basis for practice.
Theory is the term given to the body of knowledge that is used to support nursing practice. In their professional education nurses will study a range of interconnected subjects which can be applied to the practice setting. This knowledge may be derived from experiential learning, from formal sources such as nursing research or from nonnursing sources. To speak of nursing theory is often difficult. Nursing is many things to many people. Most universally agreed upon is that Nursing is a science involving people, environment and process fueled by a vision of transcendence in the context of health care. It is interesting to note that 90% of all Nursing theories have been generated in the last 20 years. Many schools encourage students to formulate personal philosophies or midrange theories of Nursing as part of their curriculum. Some might argue that this multiplicity of theory is detrimental to the practice and undermines common vision. Others would say that the nature of the young science is sufficiently far reaching to require such tactics in order to elicit true consensus.
Nursing models are conceptual models, constructed of theories and concepts. They are used to help nurses assess, plan, and implement patient care by providing a framework within which to work. They also help nurses achieve uniformity and seamless care.2
 
UNIVERSAL FEATURES OF NURSING MODELS
Unlike most sciences, Nursing theories seem primarily concerned with what “Nursing” is or should do, rather than a phenomenon of “Nursing”. All nursing models involve some method of assessing a patient's individual needs and implementing appropriate patient care. An essential portion of each nursing model is measurable goals in order that the process can be evaluated in order to provide better, is used to determine a patient's treatment by nurses, doctors and other health care professionals and auxiliary workers. These documents are considered to be living documents—they are changed and evaluated on a daily basis as the patients condition and abilities change. Theories of Nursing fall into theories. “Neuman's model focuses on the person a complete system, the subparts of which are interrelated physiological, psychological, transcultural, spiritual, and developmental factors.” - Polit and Henderson p. 103.
 
History of Nursing Models
The original role of the nurse was primarily to care for the patient as prescribed by a physician. This evolved into the biomedical model of nursing care which still strongly influences nursing practice today. The biomedical model focuses heavily upon pathophysiology and altered homeostasis but fails to identify individual differences and whilst it works well for traditional medical and physical care, it focuses solely on the treatment of disease, making little account of psychological, social, cultural, and economic differences between individuals. The Biomedical Model essentially views all patients with the same disease as the same problem regardless of their religion, culture, or ethnicity. This is in contrast to the social model of health care that places emphasis on changes that can be made in society and in people's own lifestyles to make the population healthier.
The first theorist to clearly articulate a role of nurses distinct from the medical profession was Florence Nightingale. Her theories were developed during the Crimean War and published in Notes on Nursing: What it is, and What it is Not in 1859. Nightingale's model is based on the idea that the nurse manipulates the environment to promote the patient's well-being.
3Nurses quickly realized that treating patients based upon their disease rather than making a holistic assessment was not a satisfactory way of attending patient care. Presently, some of today contributing theorist include Roy (Kansas), Newman (Harvard), Waga (Rutgers), and Johnson (Yale).
 
Theory
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. Nursing Theory: Barnum(1998) —— “attempts to describe or explain the phenomenon (process, occurrence and event) called nursing”.
Theory—a set of related statements that describes or explains phenomena in a systematic way.
 
THEORIES FOR PROFESSIONAL NURSING
  • 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
  • Theory is a set of concepts, definitions and propositions that projects a systematic view of phenomena by designating specific interrelationships among concepts for purposes of describing, explaining, predicting and / or controlling phenomena (Chinn and Jacobs, 1987).
  • Theory is a creative and rigorous structuring of ideas that projects a tentative purposeful and systematic view of phenomena (Chinn and Kramer, 1995).
  • Nursing theory is a conceptualization of some aspect of reality (invented or discovered) that pertains to nursing. The 4conceptualization is articulated for the purpose of describing, explaining, predicting or prescribing nursing care (Meleis,1997).
  • Concepts—are basically vehicles of thought that involve images. Concepts are words that describe objects, properties, or events and are basic components of theory. It is an idea of an object, property or event and can be empirical or concrete, inferential or abstract that is derived from individual perceptual experience.
    Types:
    Empirical concepts
    Inferential concepts
    Abstract concepts.
  • Models—are representations of the interaction among and between the concepts showing patterns.
  • Concept—a mental idea of a phenomenon.
  • Construct—a phenomena that cannot be observed and must be inferred.
  • Conceptual models—made up of concepts and propositions.
  • Conceptual models—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”.
Conceptual models are set of general concepts and propositions that provide perspectives on the major concepts of the metaparadigm, such as person, health and well-being and environment.
Conceptual models are made up of abstract and general ideas (concepts) and propositions that specify their relationship.
  • Propositions are statements that explain the relationship between the concepts.
  • Process is a series of actions, changes or functions intended to bring about a desired result. During a process one takes systemic and continuous steps to meet a goal and uses both assessments and feedback to direct actions to the goal.5
  • A particular theory or conceptual framework directs how these actions are carried out. The delivery of nursing care within the nursing process is directed by the way specific conceptual frameworks and theories define the person (patient), the environment, health and 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.
  • Metaparadigm is the most global conceptual or philosophical framework of a discipline or profession. Metaparadigm to helps define and explain relationship between ideas and values. Metaparadigm to guide the organization of theories and models.
 
METAPARADIGM COMPONENTS
There are four components:
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).
  1. Person: It means those are recipient of nursing care including physical needs, spiritual needs, psychological 6needs and sociocultural needs. Person may be an individual, family or community.
  2. Environment: It can divided to the internal and external environment. Internal deals with individual inner condition like body temperature, blood pressure, etc. and external environment deals with external condition like climate.
  3. Health: It refers to the degree of wellness or illness experience by the person.
  4. Nursing: It refers caring the ill person / client. Nursing helps to achieve their health for environment.
 
CATEGORIES OF CONCEPTUAL MODELS
Ten conceptual models of nursing have been classified according to two criteria:
  1. The world view of change reflected by the model (growth or stability).
  2. The major theoretical conceptual classification with which the model seems most consistent (systems, stress/adaptation, caring, or growth/development).
 
IMPORTANCE OF NURSING THEORIES
  • Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs,1978).
  • 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 (Parsons,1949).
  • 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.7
  • 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.
 
CHARACTERISTICS OF THEORIES
  • They interrelate concepts in such a way as to create a different way of looking at a particular phenomenon.
  • They are logical in nature.
  • They are generalizable.
  • They are the bases for hypotheses that can be tested.
  • They increase the general body of knowledge within the discipline through the research implemented to validate them.
  • They are used by the practitioners to guide and improve their practice.
  • They are 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 and influenced by broadly applicable processes and theories. Following theories are basic to many nursing concepts.
 
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. molecules in chemistry, cultures in sociology, organs in anatomy and health in nursing.
 
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 8interaction and response. Human adaptation occurs on three levels:
  • the internal (self)
  • the social (others) and
  • the physical (biochemical reactions)
 
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.
 
COMMON CONCEPTS IN NURSING THEORIES
Four concepts common in nursing theory that influence and determine nursing practice are:
  • The person (patient)
  • The environment
  • Health
  • Nursing (goals, roles, functions).
Each of these concepts is usually defined and 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, 9intellectual, 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 (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 (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 the Generalisability of their Principles
 
Meta Theory
The theory of theory. Identifies specific phenomena through abstract concepts.
 
Grand Theory
Grand theories have the broadest scope and complex. It also called broad range theories “systematic constructions of the nature of nursing, the mission of nursing and the goals of nursing care”. Grand theories contain summative concepts that 10incorporate smaller range theories. Provides a conceptual framework under which the key concepts and principles of the discipline can be identified.
Examples: Orem's self-care Deficit Theory of Nursing, Martha E Roger's Unitary Human Beings, Imogene King's System Framework and Theory of Goal Attainment and Betty Neuman's Systems Model.
 
Middle Range Theory
It is more precise and only analyses a particular situation with a limited number of variables. Middle range theories are more narrow in scope than grand theories. It is effective bridge between grand theories and nursing practice. It is more precise than grand theories and focus on theoretical statement to answer about nursing. Many of these new theories are built on content of related disciplines and brought into nursing practice.
 
Practice Theory
Explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved. It has the most limited scope and level of abstraction. It is developed for use within a specific range of nursing situations. Theories developed at this level have a more direct impact on nursing practice. Nursing practice theory provides frameworks for nursing interventions and predicts outcomes and the impact of nursing practice. This level theories also known as prescriptive theory, situation-specific theory and microtheory.
“A set of theoretical statement, usually hypotheses that deal with narrowly defined phenomena”.
 
Other Theories
Theories can also be categorized as:
  • Needs theories.
  • Interaction theories.
  • Outcome theories.
  • Humanistic theories.
  • System theories.
These categories indicate the basic philosophical underpinnings of the theories.11
 
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 believes that the person contains within himself the potential for healthy and 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 understanding that each client is a unique individual, so person-centered approach now practice in Nursing.12
 
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 and 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 are:
  1. Imogene King's systems interaction model
  2. Betty Neuman's health care systems model.
 
Imogene King's Systems Interaction Model
  • 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 13continuous 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.”
14It is the way in which an individual usually deals with stressors.
Stressors may be of three types:
Intrapersonal: Forces arising from within the person.
Interpersonal: Forces arising between persons.
Extrapersonal: Forces arising from outside the person.
Resistance to stressors is provided by a flexible line of defense, a dynamic protective buffer made up of all variables affecting a person at any given moment the person's resistance to any given stressor or stressors.
If the flexible line of defense is no longer able to protect the person against a stressor, the stressor breaks through, disturbs the person's equilibrium, and triggers a reaction. The reaction may lead toward restoration of balance or toward death.
Neuman intends for the nurse to “assist clients to retain, attain, or maintain optimal system stability” (Neuman, 1996).
Thus, health (wellness) seems to be related to dynamic equilibrium of the normal line of defense, where stressors are successfully overcome or avoided by the flexible line of defense.
Neuman defines illness as “a state of insufficiency with disrupting needs unsatisfied” (Neuman, 2002).
Illness appears to be a separate state when a stressor breaks through the normal line of defense and causes a reaction with the person's lines of resistance.
 
Stress/Adaptation Theory as a Framework
In contrast to systems theory, stress and adaptation theories view change caused by person–environment interaction in terms of cause and effect.
The person must adjust to environmental changes to avoid disturbing a balanced existence. Adaptation theory provides a way to understand both how the balance is maintained and the possible effects of disturbed equilibrium.
This theory has been widely applied to explain, predict, and control biologic (physiologic and psychological).15
 
CRITICISMS OF NURSING THEORIES
  1. 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.
  2. 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).
  3. It is important that the language used in the development of nursing theory be used consistently.
  4. Not part of everyday practice Despite theory and practice being viewed as inseparable concepts, a theory-practice gap still exists in nursing (Upton 1999).
  5. 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).
  6. It has been recognized that traditionally nurses are used to ‘speaking with their hands’ (Levine 1995).
  7. Therefore, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory.
  8. This makes it difficult for the majority of nurses to understand and apply theory to practice (Miller 1985).
 
SUMMARY
Basically all theories can apply to nursing process in different types of patient's condition. But certain theories can make perfect nursing care and prognosis.
 
Examples of nursing models
The models used vary greatly between institutions and countries. However, different branches of nursing have different “preferred” nursing models. These are summarized below.
 
Family nursing
  • Family centered care.16
 
Psychiatric nursing
  • Roy's model of nursing
  • Tidal model.
 
Children's nursing
  • Casey's model of nursing.
 
Perinatal nursing
  • Ramona T Mercer maternal role attainment.
 
Adult nursing
  • Nightingale's model of nursing / Roper, Logan and Tierney/ Orem's model of nursing.
 
Community and rehabilitation nursing
  • Orem's model of nursing.
 
Critical care nursing
  • Synergy model of nursing.
 
Holistic nursing
  • Rogers: Science of Unitary Human Beings
  • McGill Model of Nursing
  • Parse: Human Becoming
  • Erickson, Tomlin and Swain: Modeling and Role-Modeling
  • Newman: Health as Expanding Consciousness