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Types of Theories In Nursing Leonore Ann Dumlao I.

PHILOSOPHY OF NURSING Philosophy According to Meleis (2007), philosophy is a distinct discipline in its own right, and all disciplines can claim their own philosophical bases that form guidelines for their goals. It is concerned with the values and beliefs of a discipline and with the values and beliefs held by members of the discipline. It focuses on providing the framework and worldview for asking both ontological and epistemological questions. Philosophy helps in defining or questioning priorities and goals. Philosophy of Nursing Philosophies present the general meaning of nursing and nursing phenomena through reasoning and logical presentation of ideas (Alligood, 2010). Each philosophy provides a unique view of nursing practice. Philosophies address questions such as the following: y What is nursing? y What is the nature of human caring? y What is the nature of nursing practice? y What is the social purpose of nursing practice? Nightingales Philosophy of Nursing According to Alligood (2010), Nightingale provides an answer to the question What is nursing? in her work Notes on Nursing: What It Is and What It Is Not. In that work, Nightingale 1) distinguishes nurses from the household servant of her day, 2) contrasts the differences between nursing and medicine, and 3) specifies the concern of nursing to be involved with health as well as illness. Also within this work includes directives for her unique perspective that is focused on the relationship of patients and their surroundings. Watsons Philosophy of Nursing As proposed in Nursing: The Philosophy and Science of Caring, Watson provides a unique approach to nursing. Her work states that nursing is a human science that addresses the nature of human caring. Watson also introduces theoretical propositions for the human-tohuman relationships of nursing and specifies 10 carative factors to guide application of her work in nursing practice. Transpersonal caring is the proposed approach to achieve connectedness in which the nurse and the patient change together. Benners Philosophy of Nursing Benners philosophy of nursing emphasizes the nature of nursing practice, specifically on 1) how knowledge of practice is acquired, and 2) how it develops overtime. According to Alligood (2010), her interpretative research led to a description of the progress of nurses from novice to expert.

II. THEORY Definition A theory is an organized system of accepted knowledge that is composed of concepts, propositions, definitions, and assumptions intended to explain a set of fact, event, or phenomena. (Octaviano, 2008) According to Kozier (2008), theory is a supposition or system of ideas that is proposed to explain a given phenomenon. Theories may be derived from a philosophy, a nursing model, a more abstract theory, or another model or framework (Alligood, 2010). Characteristics: y can correlate concepts to generate a different way of looking at a certain fact or phenomenon y logical in nature y simple but generally broad in nature y source of hypotheses that can be tested y contribute in enriching the general body of knowledge y used by practitioners to direct and enhance their practice y consistent with other validated theories, laws and principles

III. NURSING THEORY

Definition Meleis (2007) defined nursing theory as a conceptualization of some aspect of nursing reality communicated for the purpose of 1) describing phenomena, 2) explaining relationships between phenomena, 3) predicting consequences, or 4) prescribing nursing care. They serve as a reservoir in which findings are stored that are related to nursing concepts, as well as for answers related to significant nursing phenomena. In short, nursing theory is defined by Octaviano (2008) as a group of interrelated concepts that are developed from various studies of disciplines and related experiences. They reflect particular views of person, health, environment, nursing and other concepts that contribute to the development of a body of knowledge specific to nursing concerns. According to Barnum (1994), a complete nursing theory is one that has context, content, and process. Context refers to the environment to which nursing act takes place, content refers to the subject of the theory, and process refers to the method by which nurse acts in using nursing theory. IV. TYPES OR CATEGORIES OF NURSING THEORIES A. According to Function 1) Descriptive (Factor- Isolating)

Considered as the primary level of theory development, descriptive theories identify and describe major concepts of phenomena. Their main purpose is to present a phenomenon, and not explain the relationship of concepts of the phenomenon. Example: A descriptive research about the Filipino nursing practices like the use of herbal medicines and other alternative forms of treatment. 2) Explanatory (Factor- Relating) These are the type that present relationships among concepts and propositions, including cause and effect relationships. They aim to provide information on how or why concepts are related. Example: A research study about the factors affecting newborns in failing to thrive. 3) Predictive (Situation-Relating) This type of theory is achieved when the relationships of concepts under a certain condition are able to describe future outcomes consistently. This is generated and tested using experimental research. Example: A Theoretical model based on the observation of the effects of unsanitary environmental condition on the recovery of the post-operative patients. 4) Prescriptive (Situation- Producing) This deals with nursing actions, and test the validity and certainty of a specific nursing intervention. This type of theory is commonly used in testing new nursing interventions. Example: Laurentes (1996) theory validates and explains the different nursing management in the emergency room in relieving anxiety among its clients. B. According to Scope (Tomey & Alligood, 2002) 1) Philosophies Theorists had developed philosophies that were derived through analysis, reasoning and logical arguments, and that the theorists provided the meaning of nursing phenomena. Writings of the following are considered philosophies by Tomey and Alligood: y Florence Nightingale- Environmental Theory y Ernestine Wiedenbach- The Helping Art of Clinical Nursing y Virginia Henderson- 14 Basic Needs y Faye Glenn Abdellah- 21 Nursing Problems y Lydia Hall- Three Interlocking Circles Theory y Jean Watson- The Philosophy and Science of Caring y Patricia Benner- Stages of Nursing Expertise 2) Conceptual Models or Grand Theories These are less universal than the philosophies, but are comprehensive in that they provide structure for all the views that interest nurses- human, environment, and health, and propositional direction for the profession in a scientific field. Tomey and Alligood consider the following as grand theories: y Dorothea Orem- Self-Care Theory y Myra Levine- Conventional Model

y y y y y

Martha Rogers- Science of Unitary Human Beings Dorothy Johnson- Behavioral System Model Sr. Callista Roy- Adaptation Model Betty Neuman- Health Care System Model Imogene King- Goal Attainment Model

3) Middle Range Theories These theories are more limited in scope. They relate more clearly to nursing situations that can be placed within the model from which each theory was derived. Examples of theorists are the following: y Hildegard Peplau- Psychodynamic Theory y Ida Jean Orlando- Nursing Process Theory y Joyce Travelbee- Human-to-Human Relationship Model y Katherine Kolkaba- Comfort Theory y Madeleine Leininger- Transcultural Nursing y Rosemarie Rizzo Parse- Human Becoming Theory y Margaret Newman- Health as Expanding Consciousness C. According to Nursing Domains (Meleis, 2004) 1) Nursing Clients The major influence on each of the theorists was the client and the clients need for nursing. y Dorothy Johnson- Behavioral System Model y Sr. Callista Roy- Adaptation Model y Betty Neuman- System Model in Nursing Practice 2) Client- Environment Interactions The major points in this domain were that human beings and environments are unitary, irreducible, and pandimensional energy fields that are identifiable by patterns. Humans and their environment cannot be discussed, considered, or understood in isolation from the other; they are interrelated in an irreducible way. y Martha Rogers- The Science of Unitary and Irreducible Human Beings 3) Interactions The theories that were included in this category are those that consider Nursing as a process of interaction, including those often classified by others as grand or as practice and middle range theories. y Imogene King- Goal Attainment Theory y Ida Jean Orlando- Nursing Process Theory y Joyce Travelbee- Human-to-Human Relationship Model y Ernestine Wiedenbach- The Helping Art of Clinical Nursing 4) Nursing Therapeutics

This category is defined by the type of activities and interventions nurses design to assist actual or prospective clients or people who are vulnerable. The stance of the theorist and the substance of the theory dictate the design and type of interventions. y Myra Levine- theory was concerned with the conservation of clients energy y Dorothea Orem- theory focused on returning clients to self-care D. According to Paradigms 1) Parses Categorization a) Totality Paradigm This includes all theoretical perspectives in which humans are biopsychosocial-spiritual beings, adapting to their environment, in whatever way the theory defines environment. y Dorothea Orem- Self-Care Theory y Sr. Callista Roy- Adaptation Model y Dorothy Johnson- Behavioral System Model b) Simultaneity Paradigm This includes the theoretical perspectives in which humans are identified as unitary beings, which are energy systems in simultaneous, continuous, mutual process with, and embedded in, the universal energy system. y Rosemarie Rizzo Parse- Human Becoming Theory y Martha Rogers- The Science of Unitary and Irreducible Human Beings y Margaret Newman- Health as Expanding Consciousness 2) Newmans Categorization a) Particulate-Deterministic This paradigm is characterized by the positivist view of the theory of science and stresses research methods that demanded control in the search of knowledge. Entities (e.g. humans) are viewed as reducible, and change is viewed as linear and causal. These paradigms are conceptualized as evolving; the more complex paradigms encompass but extend the knowledge in a previous paradigm. From the perspective of the theories within the particulatedeterministic paradigm, human health and caring are understood through their component parts or activities; there is an underlying order and predictable antecedents and consequences, and knowledge development progresses to uncover these causal relationships. Reduction and causal inferences are characteristics of this paradigm. (Smith & Liehr, 2008) y Florence Nightingale y Dorothea Orem y Ida Jean Orlando y Hildegard Peplau b) Interactive-Integrative Objectivity and control are still important but reality is seen as multidimensional and contextual, and both objectivity and subjectivity are viewed as desirable. This paradigm acknowledges contextual, subjective, and multidimensional relationships among the phenomena central to the discipline. The interrelationships among parts and the probabilistic nature of change are assumptions that guide the way phenomena are conceptualized and studied. (Smith & Liehr, 2008) y Patterson

Sr. Callista Roy Margaret Jean Watson c) Unitary-Transformative Humans are viewed as unitary beings, which are self-evolving and self-regulating. The person environment unity is a patterned, self-organizing eld within larger patterned selforganizing elds. Change is characterized by uctuating rhythms of organization, disorganization, toward more complex organization. Subjective experience is primary and reects the whole pattern. (Smith & Liehr, 2008) y Margaret Newman y Martha Rogers y Rosemarie Rizzo Parse y y 3) Fawcetts Categorization This model was synthesized from the analysis of views of mechanism versus organism, persistence versus change, and the Parse and Newman and colleagues nursing paradigm structure. (Smith & Liehr, 2008) a) Reaction Humans are classified as biopychosocial-spiritual beings who react to the environment in a causal way. The interaction changes predictably and controllably as humans survive and adapt. Reactions are causal and stability is valued; change is a mechanism for survival. b) Reciprocal Interaction Humans are viewed as holistic, active, and interactive with their environments, with the environments returning interactions. She noted that these theorists viewed reality as multidimensional, dependent on context (the surrounding conditions), and relative. This means that change is probabilistic and a result of multiple antecedent factors. These theories support the study of both objective and subjective phenomena, and both qualitative and quantitative research. c) Simultaneous Action Humans and their environment are constantly interacting, changing, and evolving. Human beings are characterized by pattern and are in a mutual rhythmic open process with the environment. Change is continuous, unpredictable, and toward greater complexity and organization. E. According to Scope or Level of Abstraction Scope refers to the qualified level of precision of a certain theory and the accuracy of its concepts and propositions (Octaviano, 2008). Level of abstraction refers to the level of complexity by which a system is viewed. The higher the level, the less detail; the lower the level, the more detail. According to Octaviano (2008), there are three categories that relate to the scope of a theory: Grand Theories, Middle-range Theories, and Micro-range Theories. 1) Grand Theories According to Potter & Perry (2009), grand theories are broad in scope, complex, and therefore require further specification through research. They are simply known to speak about a broad range of important relationships among concepts of a discipline (Octaviano, 2008). Grand theories are composed of relatively abstract concepts, typically lack operational definitions, and are not amenable to testing. They are developed through thoughtful and insightful appraisal of

existing ideas as opposed to empirical research. Early theorizations in nursing are considered grand theories, when Nursing was addressing its nature, mission, and goals. Grand theories are further categorized based on human needs, interactive process, and unitary process. a) Based on Human Needs Majority of early works were strongly influenced by the needs theories of social scientists (Maslow). These theories followed the philosophical school of thought of the time by considering the person to be biopsychosocial being and focusing on meeting the individuals needs. y Florence Nightingale- Nursing: What It Is and What It Is Not (1860) Nightingales basis tenet was healing and secondary to it are the tenets of leadership and global action which are necessary to support healing at its deepest level (Dossey, 2005). Nightingales philosophy was inductively derived, it is abstract yet descriptive in nature, and it is classified as a grand theory or philosophy by most nursing writers. (Dossey, 2000; Selanders, 1993, 2005a; Tomey & Alligood, 2002) y Virginia Henderson- The Principles and Practice of Nursing Henderson was educated during the empiricist era in medicine and nursing, which focused on patient needs. The theory presents the patient as a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer. The major assumption of the theory is that nurses care for patients until patients can care for themselves once again. y Faye G. Abdellah- Patient-Centered Approaches to Nursing Abdellahs patient-centered approach is considered a human needs theory. The theory was created to assist with nursing education and is most applicable to education and practice. Abdellah had six assumptions. These relate to change and anticipated changes that affect nursing; the need to appreciate the interconnectedness of social enterprises and social problems; the impact of problems such as poverty, racism, pollution, education, and so forth on health and health care delivery; changing nursing education; continuing education for professional nurses; and development of nursing leader from underserved groups (Abdellah, Beland, Martin, & Matheney, 1973). She was one of the early writers who referred to nursing diagnosis during a time when nurses are taught that diagnosis was not a nurses prerogative. Nursing diagnoses were a determination of the nature and extent of nursing problems presented by individuals receiving nursing care. y Dorothea E. Orem- The Self-Care Deficit Nursing Theory According to Orem, Nursing is seen as an art through which the practitioner of nursing gives specialized assistance to persons with disabilities which makes more than ordinary assistance necessary to meet needs for self-care. y Dorothy Johnson- The Behavioral System Model Nightingales philosophical leanings prompted Johnson to consider the person experiencing a disease more important than the disease itself. The concept of human was defined as a behavioural system that strives to make continual adjustments to achieve, maintain or regain balance to the steady state that is adaptation. y Betty Neuman- The Neuman Systems Model Neumans model uses a systems approach that is focused on the human needs of protection or relief from stress. Neuman believed that the causes of stress can be identified and remedied through nursing interventions. She emphasized the need for humans for dynamic

balance that the nurse can provide through identification of problems, mutually agreeing on goals, and using the concept of prevention as intervention. Neumans model is one of only a few considered prescriptive in nature. The model is universal, abstract, and applicable for individuals form many cultures. b) Based on Interactive Process Theorists believe that humans are holistic beings who interact with and adapt to situations in which they find themselves. These theorists ascribe to systems theory and agree that there is constant interaction between humans and their environments. y Myra Levine- The Conservation Model She state that nursing is a human interaction. Her model deals with the interactions of nurse and client. It considers multiple factorial interactions, which may produce predictable effects using probability as the reality. y Barbara Artinian- The Intersystem Model In the Intersystem Model, there is a differentiation between the human as a system (the intrasystem) and the interactive systems of individuals or groups, known as the intersystem. Nursing is specified as nursing action, which is identified by the mutual communication, negotiation, organization, and priorities of both the client and nurse intrasystems. This is accomplished through intersystem interaction; feedback loops are necessary to produce a mutually determined plan of care. y Helen Erickson, Evelyn Tomin, & Mary Ann Swain- Modeling and RoleModeling, a Paradigm and Theory for Nursing Philosophically, Erickson, Tomlin, and Swain believe that Nursing is a process between the nurse and client and requires an interpersonal and interactive nurse-client relationship. For this reason, their work is considered to be human interaction theory. y Imogene King- Theory of Goal Attainment and Transactional Process The Theory of Goal Attainment lists several assumptions relating to individuals, nurseclient interactions, and nursing. Regarding nurse-client interactions, King believes that perceptions, as well as the goals, needs, and values, of the nurse and client influence the interaction process. If the nurse and client make transactions, goals will be attained. If transactions are made in nurse-client interactions, growth and development will be enhanced. y Roper, Logan, and Tierney- Model of Nursing Based on Activities of Living The model was developed from the nursing education experiences of the authors as they analyzed data from numerous hospitals and other clinical practicum locations to identify a core of nursing knowledge across specialties. The data they gathered from clinical areas were analyzed and they determined that there was a core of common, everyday living activities. Thus, the model was inductively formulated. Health refers to how the individual carries out the activities of living in interaction with the five factors (biological, psychological, sociocultural, environmental, and politicoeconomic) along the continuum from dependence to independence, and across the lifespan of the person. y Sister Calista Roy- The Roy Adaptation Model Like many of the models/ theories, it is a deductive theory based on nursing practice. The Roy Adaptation Model is focused on the interrelatedness of four adaptive systems/ modes that constitute the specific categories that serve as framework for assessment. Through the four modes, responses to and interaction with the clients environment are carried out and adaptation can be observed.

Jean Watson- Caring Science as Sacred Science Watson called her earlier work a descriptive theory of caring and stated that it was the only theory of nursing to incorporate the spiritual dimension of nursing at the time it was first conceptualized. The theory was both deductive and inductive in its origins and was written at an abstract level of discourse. One of the basic assumptions of this theory states that caring can be effectively demonstrated and practiced only interpersonally (Octaviano, 2008). y c) Based on Unitary Process This group of theorists believed that humans are unitary beings: energy systems embedded in the universal energy system. Within this group of theories, human beings are seen as unitary, whole, open and free to choose ways of becoming. Health is described as continuous humanenvironmental interchanges. y Martha Rogers- The Science of Unitary and Irreducible Human Beings This theory started as an abstract theory that was synthesized from theories of numerous sciences. According to Rogers, human systems are open systems, embedded in larger, open environmental systems. Man is a unified whole possessing integrity and manifesting characteristics that are more than and different from the sum of its parts. Man and environment are continuously exchanging matter and energy with one another. y Margaret Newman- Health as Expanding Consciousness Built on the works of Rogers and others, this theory is one of the most recent nursing theories. As a student of Rogers, Newman believed that the human is unitary, that is, cannot be divided into parts, and is inseparable for the larger unitary field. She saw humans as open energy systems in continual contact with a universe of open systems. A fundamental proposition in Newmans model is the idea that health and illness are synthesized as health. The fusion of one state of being (disease) with its opposite (nondisease) results in what can be regarded as health. Health and disease are the same and not separate in the life of the individual. y Rosemarie Parse- The Theory of Human Becoming The theory comes from her experience in nursing and from a synthesis of theoretical principles of human sciences. According to Parse, nursing is grounded in view that the human is a unitary being who is free to choose in situations. Nursing is guiding humans toward ways of being, finding meaning in situations, choosing ways of cocreating their own health, and living true presence in the day-to-dayness of the persons life. 2) Middle- Range Theories Middle-range theories have a more limited scope, and are considered as the least abstract level of knowledge because they include details specific to nursing practice. They offer a more direct application to research and practice. They emerge at the intersection of research and practice, when theory guides practice, practice generates research questions, and research creates/ informs understanding of theory and practice. Descriptions, explanations, and predictions are made with the purpose of answering questions about different nursing phenomena. They specify such things as the health condition, the patient population, the location of practice and the different interventions of the nurse (Octaviano, 2008). Based on Source and Development Process: a) Derived from Research &/or Practice The approach is induction through research and practice.

y Chronic Illness Trajectory Framework (Corbin & Strauss, 1991,1992)- developed from a series of studies related to management of chronic illness, combined with numerous accounts of practice experiences by nurses. y Model for Cultural Competence (Purnell, 2000)- developed from practice and working with staff and students in culturally diverse clinical settings. b) Derived from a Grand Theory The approach is deduction from research and practice or application of grand theories. Many nursing theorists and scholars agree that grand theories are difficult to apply in research and practice. They suggest the development of middle range theories derived from grand theories. y Theory of Self-Care (Rew, 2003)- developed from experiences of homeless youth based on Orems work y Theory of Prevention as Intervention (August-Brady, 2000)- employed Neuman Systems Model as basis c) Combining Existing Nursing and Non-Nursing Theories The approach is a combination of existing nursing and non-nursing middle range theories. Combining concepts or elements of multiple theories is very common in middle range theory development. y Theory of Exercise as Self-Care (Ulbrich, 1999)- developed through triangulation of Orems self-care deficit theory of nursing, the, and characteristics of a population at risk for cardiovascular disease. d) Derived from Non-Nursing Disciplines The approach is the derivation from theories of other disciplines that relate to nursing. A very significant number of middle rang nursing theories are developed from one or more nonnursing theories, including those from the behavioral sciences, sociology, physiology and anthropology. y Theory of Comfort (Kolcaba, 1994)- reportedly derived from a review of literature from medicine, psychiatry, ergonomics, and psychology, as well as from nursing literature and history. y Uncertainty in Illness Theory (Mishel, 2003)- incorporated elements of chaos theory e) Derived from Practice Guidelines or Standard of Care The approach is the derivation from practice guidelines and standards rooted in research. Practice guidelines or standards appear to be the least common source for middle range theory development, as only a few examples could be found. y Public Health Nursing Practice Model (Smith & Bazini-Barakat, 2003)- developed by melding of nationally recognized components of public health nursing practice. The identified components were the Standards of PHN practice, the 10 Essential Services of Public Health,Healthy People 2010s 10 Leading Health Indicators, and Minnesotas Public Health Interventions Model. y Theory of the Peaceful End of Life (Ruland and Moore, 1998)- used standards of care for terminally-ill patients Based on their Level of Abstraction: Liehr and Smith (1999) analyzed 22 middle range theories published during the previous decade. They are categorized as follows: a) High Middle Range Theories

These include concepts such as caring, growth and development, self-transcendence, resilience, and psychological adaptation. y Benners Model of Skill Acquisition in Nursing o The model outlines five stages of skill acquisition: novice, advanced beginner, competent, proficient, and expert. Benners work delineates the importance of retaining and rewarding nurse clinicians for their clinical expertise in practice settings, because it describes the evolution of excellent caring practices. y Leiningers Cultural Care Diversity and Universality Theory o Madeline Leninger has been instrumental in demonstrating to nurses the importance of considering the impact of culture on health and healing. She is credited with starting the specialty of transcultural nursing. The purpose of the theory is to generate knowledge related to the nursing care of people who value their cultural heritage and lifeways. y Barkers Tidal Model o This describes psychiatric nursing practice, and emphasizes the fluid nature of human experience characterized by change and unpredictability. It is a philosophical approach to the discovery of mental health, focused on helping people recover their personal story of distress, as a first step towards reclaiming control over their lives. b) Middle Middle Range Theories These include concepts such as uncertainty in illness, unpleasant symptoms, chronic sorrow, peaceful end of life, cultural brokering, and nurse-expressed empathy. y Mishels Uncertainty of Illness Theory o The theory explains how clients cognitively process illness-related stimuli and construct meaning in these events. In the theory, adaptation is the desirable end-state achieved after coping with the uncertainty. Nurses may develop nursing interventions that attempt to influence the persons cognitive process to address the uncertainty. y Kolcabas Theory of Comfort o Kolcaba defined comfort within nursing practice as the satisfaction of the basic human needs for relief, ease, or transcendence arising from health care situations that are stressful. Increasing comfort can result in having negative tensions reduced and positive tensions engaged. Comfort is viewed as an outcome of care that can promote or facilitate health-seeking behaviors. y Theory of Unpleasant Symptoms o This was developed by a group of nurses interested in a variety of nursing issues including symptom management, theory development and nursing science. The theory was developed to integrate existing knowledge about a variety of symptoms to better prepare nurses in symptom management. c) Low Middle Range Theories These include hazardous secrets, womens anger, nurse midwifery care, acute pain management, helplessness, and intervention for postsurgical pain. The number of low middle range theories appears to be growing rapidly as nursing researchers and nursing scholars describe phenomena directly related to practice. y Eakes, Burke, and Hainsworths Theory of Chronic Sorrow o The concept of chronic sorrow describes the grief observed in the parents of children with mental deficiencies. The theory was inductively derived and validated through a series of studies and a critical review of existing research. y Becks Postpartum Depression Theory

o The theory provides insight into the experience of postpartum depression. The concepts or stages were defined as 1) encountering terror (anxiety attacks), 2) dying of self (isolation), 3) struggling to survive (seeking solace, praying for relief), and 4) regaining control (recovery). y Urine Control Theory o The purpose of this model is to provide a framework for practicing nurses as well as nurse researchers in addressing urine control problems. The theory was developed following a research study of 119 incontinent, memory-impaired elders and their caregivers. The researchers identified significant correlations between incontinence and impaired mobility. 3) Micro- Range or Situation-Specific Theories According to Octaviano (2008), micro-range theories are known to be the most concrete and narrow in scope. They focus on specific nursing phenomena, and are limited to specific populations or a particular field of practice. y Menopausal transition of Korean immigrant women y Learned response to chronic illness of patients with rheumatoid arthritis y Womens responses when dealing with their multiple roles