Nursing Theories and Models

Hugh McKenna

• Editore: Routledge
• Anno: 2006
• ISBN:
  9781134766536
• Edizione: 1
• Argomento: Medicine
• Categoria: Health Care Delivery

Encourages nurses to develop theories from their practice as opposed to using "off-the-peg" theories Provides a critique of nursing theory, making it ideal for nursing students who are now encouraged to adopt a critical approach to their learning

Chapter 1

The trouble with terminology

Throughout our lives we are always learning new words and terms. For instance, ‘compact disc’, ‘CD-ROM’, ‘greenhouse effect’ and the ‘Le Shuttle’ are not terms which were familiar to our recent ancestors. Similarly, learning the rules of a new sport, starting a new job or taking up a hobby will bring with it a new set of terms. If we have sufficient interest we will spend some time learning the meaning of these new words.

The development of knowledge in nursing also brings with it new terms. These include ‘theory’, ‘paradigm’ and ‘construct’, to name just three. The same nurses who eagerly learn those new words associated with hobbies and sports often take an antiintellectual stance when it comes to new words in nursing. This opening chapter proposes to introduce you to a range of terms which many readers may not have come across. My advice is that you look to the meaning behind the words and you will be richer for it.

While trawling the literature I have come across hundreds of definitions for the theoretical terms I will be addressing. I have noted that many definitions contradict each other and there is much disagreement among the experts. Therefore, it is highly probable that for each of the following definitions there is a contrary definition. I have attempted to get around this problem by selecting those definitions which have the most support in the literature.

I have categorised the terms into three groups. These are:

• Global terms
• Working terms
• Middle terms

Global terms

• Metaparadigm
• Domain
• Philosophy

Global terms are those expressions which represent a very broad view of issues that are relevant to nursing. A global view is like the view of a country from a satellite. The image is so allencompassing that it is difficult to begin to describe the detail. None the less, this perspective is useful in that it provides you with a truly philosophic vantage-point.

Perhaps the best-known global term is ‘metaparadigm’. This term is associated with the writings of Thomas Kuhn (1970), a philosopher, and Jacqueline Fawcett (1995), a nurse. According to Fawcett, a metaparadigm is:

the most global perspective of a discipline acting as an encapsulating unit or framework within which the more restricted structures develop. It identifies certain phenomena which are of interest to a discipline and explains how that discipline deals with those phenomena in an unique manner.

(Fawcett, 1992: 64)

Most authors subscribe to a four-component metaparadigm. These four components are: ‘nursing’, ‘health’, ‘person’, and ‘environment’ (Yura and Torres, 1975; Fawcett, 1995). These are also referred to as the ‘essential elements’ of any theory (Pearson and Vaughan, 1986).

Fawcett (1995) points out that every discipline has a metaparadigm; its purpose is to single out certain phenomena with which the discipline will deal. Most professions have a single metaparadigm from which numerous theories emerge – contemporary nursing appears to have reached this level of theoretical development.

During the 1970s and 1980s authors wrote extensively about the importance of the metaparadigm for nursing science. The argument was put forward that unless a conceptualisation included assumptions about nursing, health, person, and environment, it could not be considered to be a theory (Fitzpatrick and Whall 1996).

However, the complete four-element metaparadigm has its dissenters. For example, Stevens (1979) excludes ‘environment’, while Kim (1983) excludes ‘health’. Others believe that ‘nursing’ should be omitted as a concept, maintaining that its inclusion is a redundancy of terms and that ‘caring’ should be included instead (Leininger, cited in Huch, 1995). However, to exclude nursing and include caring would mean that the resultant ‘health, person, caring and environment’ could well be perceived as a metaparadigm for medicine! The inclusion of nursing, however, may be seen as excluding midwifery and health visiting from the debate.

Since Fitzpatrick and Whall (1996) argue that the metaparadigm represents the foundation stones for nursing theories, one would expect each theorist to outline her (all the major nurse theorists are female) beliefs and assumptions regarding the person, to present an identification of the person’s environment, to define her view of nursing and to discuss her views on health. Close examination of nursing theories shows that this is the case. Each theorist does conceptualise the four elements of the metaparadigm, but they tend to view them from different perspectives.

Therefore, how nursing, health, person and environment are described and defined varies greatly from theorist to theorist. So, while each one considers the metaparadigm, they may emphasise different aspects and see them in different relations to one another. Such a rich diversity of assumptions concerning the same factors will only serve to enrich our profession. Nightingale (1859), for instance, believed that nursing put the patient in the best condition for nature to act upon him. She placed great emphasis on the environment and the detrimental effect that poor environments had on people’s health. Although she too dealt with each of the metaparadigm components, she focused specifically on the patient and the environment. Of the modern theorists, Martha Rogers (1980) was perhaps the most influential in continuing this emphasis on the importance of the environment.

To illustrate how some theorists have taken cognisance of the metaparadigm I have extracted the components from the works of Roper, Logan and Tierney (1990), Henderson (1966), Orem (1980) and Roy (1971).

Person/man

Definitions:

• Biological human beings with inseparable mind and body who share certain fundamental human needs (Henderson, 1966).
• An unfragmented whole who carries out or is assisted in carrying out those activities that contribute to the process of living (Roper, Logan and Tierney, 1990).
• A functional integrated whole with a motivation to achieve self-care (Orem, 1980).
• A bio-psycho-social being who presents as an integrated whole (Roy, 1971).

Nursing

Definitions:

• A profession whose focus is to help the client to prevent, solve, alleviate or cope with problems associated with the activities he or she carries out in order to live (Roper, Logan and Tierney, 1990).
• A profession that assists the person sick or well in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he or she would perform unaided, given the necessary strength, will or knowledge (Henderson, 1966).
• A human service related to the clients’ need and ability to undertake self-care and to help them sustain health, recover from disease and injury or cope with their effects (Orem, 1980).
• A socially valued service whose goal is to promote a positive adaptation to the stimuli and stresses encountered by the client (Roy, 1971).

Health

• The ability to function independently regarding fourteen activities of daily living (Henderson, 1966).
• The optimum level of independence in each activity of living which enables the individual to function at his/her maximum potential (Roper, Logan and Tierney, 1990).
• A state of wholeness or integrity of the individual, his parts and his modes of functioning (Orem, 1980).
• The adaptation of the person to stimuli on a continuous line between wellness and illness (Roy, 1971).

Environment

Definitions:

• That which may act in a positive or negative way upon the client (Henderson, 1966).
• Circumstances that may impinge upon the individual as he or she travels along the life-span and cause movement towards maximum dependence or maximum independence (Roper, Logan and Tierney, 1990).
• A sub-component of man, and with man forms an integrated system related to self-care (Orem, 1980).
• Both internal and external. From the environment people are subject to stresses (Roy, 1971).

Afaf Meleis, a highly influential author on theorising in nursing, uses the term ‘domain’ when referring to nursing’s field of interest. Although it does not have the exact same components as the metaparadigm, it has a similar meaning. She defines domain as ‘the perspective and territory of a discipline’ (Meleis, 1991: 12). She goes further than Fawcett and identifies seven concepts as central to the domain of nursing. These are: ‘nursing client’, ‘transitions’, ‘interaction’, ‘nursing process’, ‘environment’, ‘nursing therapeutics’ and ‘health’.

To illustrate the relationship between these concepts Meleis (1991) believes that the nurse interacts (interaction) in a health/ illness situation with a human being (nursing client) who is an integral part of his or her socio-cultural context (environment) and who is in some sort of transition or is anticipating a transition (transition); the nurse–patient interactions are organised around some purpose (nursing process), and the nurse uses some actions (nursing therapeutics) to enhance or facilitate health (health).

In her 1995 book, Fawcett ably addresses the criticisms levelled at her perception of the metaparadigm. She also appears to be coming closer to the ideas of Meleis in that she specifies that ‘nursing’ within her four-component metaparadigm does include nursing therapeutics, and ‘person’ does include groups and communities. In essence, therefore, both metaparadigm and domain are terms which may be used to identify those broad parameters of nursing.

Another global term often referred to in the literature is ‘philosophy’. According to Silva (1986a) a philosophy is concerned with the nature of being, the nature of reality and the limits of knowledge. A philosophy is also perceived as ‘a statement of beliefs and values about the world, a perspective on human beings and their world, and an approach to the development of knowledge’ (Fawcett, 1992: 68). According to Salsberry (1994), a philosophy identifies what is believed to be the basic or central issues of a discipline. This latter definition illustrates that philosophy can have a similar meaning to metaparadigm or domain.

In this text Fawcett’s definition of philosophy will be adopted. Therefore, while you may agree that the client is an essential part of the metaparadigm of nursing, two practitioners may have varying values and beliefs (philosophy) as to how they perceive the client: one may believe and value the client to be an independent self-caring individual while the other may believe and value the client to be a dependent person relying on the nurse to meet or help him or her meet basic needs.

Working terms

• Phenomenon
• Concept
• Construct
• Proposition

Phenomenon

A phenomenon (plural: phenomena) is a thing, event or activity that we perceive through our senses. I include in this the sixth sense of intuition or ‘gut reaction’. You could say that phenomena represent the subject-matter of a discipline. It has been stated: ‘when experience and sensory and intuitive data become coherent as a whole, and prior to any attachment of meaning, we have a phenomenon’ (Meleis, 1991: 201). For instance, prior to surgery you may perceive a patient being restless in bed, you note that she is biting her nails, she is sighing, your hand on her brow tells you she is perspiring and clammy. As another example, you may note that elderly male patients on certain medications wander out of their bedroom between 3a.m. and 5a.m. and, when asked, do not know who they are or where they are. Other nurses you ask have also noted this behaviour. Prior to putting a name to either of these occurrences, you are noting a phenomenon. A phenomenon remains a phenomenon as long as no cognitive or inferential interpretation is attached to it.

Figure 1.1 Representation of relationship between theoretical ‘working terms’

Nurses must attend to those phenomena that are of central importance to nursing. We must guard against teaching and researching issues and basing our practice around phenomena which are of more interest to another discipline than they are to nursing. On occasions this happens, and authors like Meleis (1991) have urged nursing to get back to the substantive issues which hold relevance for nursing.

Concept

Meleis defines a concept as ‘a label used to describe a phenomenon or a group of phenomena’ (1991: 12). Therefore, when we put a name to a phenomenon we are identifying concepts. In the first example above you may label the phenomenon ‘anxiety’, while the second may be labelled ‘early morning drug-related confusion’.

As a mental image, a concept is a view of reality tinted with the observer’s perception, experience and philosophical bent. You should remember that the same phenomenon may be given a different conceptual label by two different nurses. Therefore, a concept is a tool and not a real entity – it merely facilitates observation of a real phenomenon. It refers to the properties of a phenomenon; the concept is not the phenomenon itself, rather it is a name one gives to a phenomenon. Concepts give meaning for filing purposes, enabling us to categorise, interpret and structure the phenomenon. Concepts are also the building blocks of theory, they convey the ideas within the theory. To Fawcett and Downs (1992) the concepts of a theory are its special vocabulary.

Construct

If the phenomena are very abstract and the resultant concept is not directly observable or measurable it is often referred to as a ‘construct’ (e.g., self-esteem). A construct is sometimes confused with the term ‘concept’. But, according to Chinn and Kramer (1995), ‘a construct is a type of highly complex concept whose reality base can only be inferred’ (1995: 212). Therefore, if you could imagine a continuum of concepts from concrete (thermometer) to abstract (caring, compassion), constructs would be placed at the abstract end. You must remember that all constructs are concepts, but not all concepts are constructs.

Duldt and Griffin (1985) illustrate the continuum of abstraction of concepts in the following way. They identified a ‘cow’ as a very concrete conceptualisation and proceed through the following more abstract levels of conceptualisation: ‘cow’ – ‘Bessie’ – ‘livestock’ – ‘farm asset’ – ‘asset’ – ‘wealth’. Two things are happening as the concepts become more abstract; more of the characteristics of the concept ‘cow’ are being omitted and the ability to directly observe and measure the concept is becoming more difficult.

Constructs may be made measurable by identifying ‘variables’. Powers and Knapp (1995: 166) define variable as ‘an operationalisation of a construct’. For example, if ‘civil status’ is perceived as a construct, it could be made measurable by breaking it into the variables ‘single’ and ‘widowed’, ‘divorced’, ‘married’, etc.

Proposition

Different concepts, constructs and variables can be linked by statements of relationships. Such linking statements are called ‘propositions’. Therefore, propositions are ‘tentative statements about reality and its nature. They describe relationships between events, situations or actions’ (Meleis, 1991: 205). The different types of proposition which go to make up theory will be discussed in greater depth in Chapter 3.

In the literature there are different types of prepositional statement. These include:

• Assumption
• Supposition
• Premise
• Axiom
• Postulate
• Conclusion
• Hypothesis
• Theorem

An assumption is ‘a notion that is widely accepted to be true’ (George, 1985: 339). Assumptions are important parts of theories. In essence, they are taken-for-granted statements which may not have been proved or undergone empirical testing. ‘Man is a bio-psycho-social being’ is an assumption.

A supposition is another prepositional term which means the same as assumption. According to Chinn and Kramer (1995), suppositions are taken to be true for the sake of argument. We tend to accept the supposition that the environment is forever changing.

A premise is a relationship statement ‘used in deductive logic as a basis for forming a conclusion’ (Chinn and Kramer, 1995: 217).

This term will be explained further in Chapter 2, when deductive reasoning is discussed.

Axioms and postulates are similar to premises and form the major components within deductive logic. According to Marriner-Tomey (1994a: 4), an axiom is ‘a statement from which other statements of a theory may be logically derived’.

A conclusion is also a prepositional statement and is the end result of deductive reasoning. An example of deductive reasoning would be:

See Table

A hypothesis is also a proposition and has been defined by Chinn and Kramer (1995: 214) as ‘a tentative statement which suggests some sort of relationship between two or more variables in a theory and can be tested through using r...