Nursing theories and nursing practice 4th edition

McEwen, M., & Wills, E. (2014). Theoretical basis for nursing (4th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.

· Chapter 2: Overview of Theory in Nursing "Nursing's Metaparadigm" ePages 40 - 45

· Chapter 6: Overview of Grand Nursing Theories

· Chapter 10: Introduction to Middle Range Nursing Theories

There are global areas of knowledge in professional nursing that provide an organizing structure to theory and knowledge development. Nursing is organized by a metaparadigm, which consists of four concepts that define the discipline. The concepts within a metaparadigm help to form a central focus of the nursing discipline. Another way of thinking about this is that a dominant metaparadigm helps form the world view of a discipline (Parker & Smith, 2015). Research, theory, and practice are oriented around this dominant way of thinking about the discipline's world.

Reflection

Think about it

Look at the theories in your text, think about the many concepts in those theories, and reflect on the values, beliefs, and principles that were part of your nursing education and are part of your nursing practice. All of these make up the dominant metaparadigm of nursing (Parker & Smith, 2015).

Within any profession, there must be a consensus about the concepts of the metaparadigm. For a nursing theory to comprehensively reflect the profession of nursing, each of the key concepts must be addressed, explained, and applied to practice. In doing so, research ideas may be generated, resulting in knowledge development. Once the metaparadigm concepts are agreed upon, theory and knowledge development have organization or a central theme.

Several nursing theorists developed different variations of terms and concepts for the metaparadigm. For professional nursing, consensus in the literature identifies person, environment, health, and nursing as being the concepts within our metaparadigm (Parker & Smith, 2015). This is the most commonly accepted metaparadigm and was initially developed by Fawcett in 1978 and revised in later years.

Metaparadigm Click each term and review the definition

Nursing Person Health Environment

Background

Jaqueline Fawcett, RN, PhD, ScD (hon), FAAN, ANEF was the original theorist who identified the nursing metaparadigm. What follows is an interview with Dr. Fawcett conducted on July 2011 by a professor of nursing as part of a learning activity for an online nursing course.

The Interview

Rebecca Lee (RL): Would you please share with the students your own educational pathway to nursing?

Jacqueline Fawcett (JF): I earned a baccalaureate degree in nursing in 1964, a master's degree in parent-child nursing with a minor in nursing education in 1970, and a PhD in nursing in 1976.

RL: What originally inspired you to develop the metaparadigm concepts?

JF: I was asked to present a paper, "The What of Theory Development," at a conference sponsored by the National League for Nursing in 1977 (Fawcett, 1978). Viewed through the lens of Kuhn's (1970) work on the structure of scientific revolutions, Dubin's (1969) idea of the central concepts of a discipline became nursing's central concepts, which evolved into the concepts of the metaparadigm of nursing (Fawcett, 2005).

RL: How did these concepts influence the discipline of nursing, both at the time of creation and in the years since?

JF: The metaparadigm concepts, indeed the very idea of a metaparadigm of nursing, influences nurses' understanding of what nursing is, and especially their understanding that nursing is an intellectual discipline and not only skills used in the care of people who are sick. I believe that a considerable amount of nurse burnout could be reduced if nurses took the time to step back from their concrete clinical practice activities and examine their practice from an abstract theoretical perspective. One theoretical perspective is the concepts of the metaparadigm of nursing. I think that in doing so, nurses will begin to realize that nursing is an intellectual enterprise that encompasses clinical practice activities that are guided by theoretical rationale. Thinking in this way requires nurses to embrace change, which can be scary! But all of us must be willing to take the risks that are inherent in change to grow.

RL: How have your original metaparadigm concepts evolved over the years?

JF: The central concepts I included in my 1978 paper (Fawcett, 1978) were man, society, health, and nursing. Later, I changed man to person in the interests of gender-neutral language, and I changed society to environment in the interests of a broad perspective of the surroundings of nurses and nursing participants. The most recent change, from person to human beings, was in response to the critique that person is not recognized in some cultures. I described these changes in detail in my book, Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (Fawcett, 2005). In that book, I also present other versions of the metaparadigm concepts offered by several nurse scholars There has been some discussion as to whether "nursing" is a tautological concept within the metaparadigm of nursing. However, I have maintained that the inclusion of nursing as a distinct metaparadigm concept is necessary to capture the notion of the definition, goals, and processes of nursing.

RL: Would you please discuss the relevance of the metaparadigm concepts to the profession of nursing in 2011, and beyond?

JF: The concepts of the metaparadigm of nursing, whether my version or another version, are as relevant today as at any other time in nursing's history, because they are a way to identify what are the boundaries and scope of the knowledge of nursing. Specifically, the metaparadigm concepts identify the global areas of knowledge needed for nursing at the bedside and in administration, education, and research. Individuals who might dismiss the idea of a metaparadigm of nursing as dated should consider their position carefully. For if people do not accept that there is a body of knowledge that constitutes nursing that is distinctive and different from other disciplines, then they do not have the right to say that they are practicing a profession or that they are members of a professional discipline. Instead, they are functioning as trades people.

RL: Could you share with us your own vision for the future of professional nursing?

JF: I regret that I am not optimistic. Too often, we behave as if we are members of a trade rather than of a professional discipline by ignoring the metaparadigm of nursing and by denying the utility of nursing's discipline-specific knowledge. Instead, we willingly assume tasks and functions given to us by physicians who would rather not bother with certain tasks and functions. See, for example, Sandelowski's (1999) seminal paper about the history of intravenous nursing.

RL: In closing, do you have any advice for my students as they embark on their educational journey?

JF: Keep going! Don't be afraid to envision possibilities in your own future. That takes courage! You will no doubt reach a point at which you want more education, so it is best to pursue that education while you are used to being a student. Above all, have the faith of your convictions and don't be afraid of being alone.

(Lee, & Fawcett, 2013, p. 96-97).

The focus of this week's content can be summarized by the following question: "Should the nature of nursing knowledge be abstract or concrete?" To answer this question, the following questions need to be considered first:

· How can something abstract be useful at the bedside?

· How can something concrete consider all of the diversity of possible nursing care situations with individuals, families, and communities?

Theory

Consider the following questions: "Should the nature of nursing knowledge be abstract or concrete?"

To answer this question, the following questions need to be considered first:

· How can something abstract be useful in nursing practice?

· How can something concrete consider all of the diversity of possible nursing care situations with individuals, families, and communities?

· How can something concrete consider different roles and practice settings of nurses?

Definition of a Theory

A theory is a frame of reference on how individuals view reality. A formal definition notes that theory is a group of interrelated concepts, assumptions, and propositions that explains or guides action. For the nursing profession, a nursing theory provides a view of or a window into the reality of nursing. It guides the thinking about and the doing of nursing. A comprehensive theory includes an explanation of both the noun and verb aspects of the profession, as well as a consideration of the concepts of the nursing metaparadigm: person, health, environment, and nursing (Melnyk & Fineout-Overholt, 2011; McEwen & Wills, 2014). Theories go beyond interventions to consider, in both speculative and practical manners; the focus of the person using the theory; and the desired nursing outcome. Practitioners, researchers, and educators of nursing have a common discussion point of what is and what is not nursing (Parker & Smith, 2015).

Level of Abstraction

Grand Theories

How can something abstract be useful in nursing practice?

Let’s first consider the level of abstraction and how it applies to the scope of a theory. Take a moment a look into the following picture.

https://lms.courselearn.net/lms/CourseExport/files/663217a4-28fb-4ba6-a471-75983f537998/images--W4_Topic1.jpg

Image Description (Links to an external site.)

How many objects do you see?

The first time you read a grand nursing theory with its high level of abstraction, the words may seem fuzzy and unclear. But as you peer into the words more closely, the theory along with its concepts becomes discernible and comprehensible, similar to the picture (Parker & Smith, 2015).

A grand theory uses a high level of abstraction so that its scope or picture of the nursing profession is very broad and generalized. Only by being abstract, ideal, visionary, and even transcendental is a grand nursing theory able to address all of the variables that a professional nurse may encounter while providing care to individuals, families, groups, and communities (Parker & Smith, 2015).

By definition, a grand theory must consider all of the concepts of a profession. Remember, for the profession of nursing, the metaparadigm concepts are person, health, environment, and nursing itself (Parker & Smith, 2015). So the question becomes: How can something abstract be useful in nursing practice? Without careful thought, the initial answer may be: "It can't be used, because it is abstract."

Actually, grand nursing theories are too broad to orchestrate direct patient-care activities, but they are useful in nursing practice because more specific theories (i.e., middle-range, practice) can be derived from the grand theories.

Examples of Grand Theories

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Betty Neuman: The Neuman Systems Model

Since the 1960s, Betty Neuman has been recognized as a pioneer in nursing, particularly in the specialty area of mental health. She developed her model while lecturing in community mental health at UCLA. The model uses a systems approach that is focused on human needs and protection against stress. Neuman believed that stress can be modified and remedied through nursing interventions (McEwen & Wills, 2010). She emphasized the need for humans to maintain a dynamic balance that nurses can provide to patients by assisting them to identify problems and agreed-upon mutual goals. The environment component of Neuman's model is both the internal and external forces surrounding the client and can be influenced or changed at any time. Neuman identified five variables of her theory: physiological, sociocultural, psychological, developmental, and spiritual (McEwen & Wills, 2014).

Virginia Henderson: The Principles and Practice of Nursing

In 1937, Virginia Henderson and other scholars developed a nursing curriculum for the National League of Nursing in which the education was focused on patient-centered care and nursing problems. Thus, her theory was derived from her practice and education. The major assumption of Henderson’s framework is that nurses care for patients until patients can care for themselves. For patients, the desire is to return to a state of wellness and health. The major concepts of the theory relate to the nursing metaparadigm (i.e., patient, nursing, health, and environment). Henderson believes that the unique function of the nurse was to assist the patient during illness and assist in performing those activities that restore the patient to health. She defined the patient as someone who needs nursing care but not limited to illness (McEwen & Wills, 2014).

Faye Abdellah: Patient Centered Approaches to Nursing

Faye Abdellah was one of the first major nursing theorists. Her nursing theory was developed inductively form her practice and considered a human-needs framework. Abdellah and her colleagues developed a list of 21 nursing problems and 10 steps in identifying patient problems. They also identified 10 nursing skills to be used in developing treatment typology. Furthermore, her team distinguished between nursing diagnosis and nursing functions. Diagnoses were a determination of the nature and extent of the patient problems. Other concepts central to her work were: healthcare team, professionalization of nursing, patient, and nursing (McEwen & Wills, 2014).

Dorothea Orem: The Self-Care Deficit Nursing Theory

Dorothea Orem is well recognized for her conceptual framework of self-deficit nursing theory. Between 1971 and 1995, several revisions have been made to the model, but the premise underlying her theory is the individual and the idea of nursing as a system. The paradigms supporting her theory include: nursing meets the needs of patients for self-care; humans are defined as men, women, and children; the environment has a physical and chemical component; and health is defined as beings structurally and functionally whole (McEwen & Wills, 2014). Orem felt that humans engage in continuous interaction between themselves and the environment to remain well and live. Human agency is exercised and discovered by developing, engaging, and transmitting with others in a way that provides meaning to oneself. Self-care requisites are common to all humans, as is growth and development and deficits. Nurses play a major role in assisting patients with healthcare deficits. Orem’s theory has been adopted by many nursing school curriculums (McEwen & Wills, 2014).

Betty Neuman: The Neuman Systems Model

Since the 1960s, Betty Neuman has been recognized as a pioneer in nursing, particularly in the specialty area of mental health. She developed her model while lecturing in community mental health at UCLA. The model uses a systems approach that is focused on human needs and protection against stress. Neuman believed that stress can be modified and remedied through nursing interventions (McEwen & Wills, 2010). She emphasized the need for humans to maintain a dynamic balance that nurses can provide to patients by assisting them to identify problems and agreed-upon mutual goals. The environment component of Neuman's model is both the internal and external forces surrounding the client and can be influenced or changed at any time. Neuman identified five variables of her theory: physiological, sociocultural, psychological, developmental, and spiritual (McEwen & Wills, 2014).

Virginia Henderson: The Principles and Practice of Nursing

In 1937, Virginia Henderson and other scholars developed a nursing curriculum for the National League of Nursing in which the education was focused on patient-centered care and nursing problems. Thus, her theory was derived from her practice and education. The major assumption of Henderson’s framework is that nurses care for patients until patients can care for themselves. For patients, the desire is to return to a state of wellness and health. The major concepts of the theory relate to the nursing metaparadigm (i.e., patient, nursing, health, and environment). Henderson believes that the unique function of the nurse was to assist the patient during illness and assist in performing those activities that restore the patient to health. She defined the patient as someone who needs nursing care but not limited to illness (McEwen & Wills, 2014).

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Using Different Levels of Theories

Middle-Range Theories

How can something concrete consider all of the diversity of possible nursing care situations with individuals, families, and communities?

The initial answer is that as a theory becomes more concrete or narrow in scope, something is left out. For example, a middle-range theory regarding chronic illness leaves out acute illnesses, as well as preventive healthcare. A middle-range theory regarding home healthcare would leave out providing healthcare to individuals in other settings such as an extended-care facility. A practice theory concerning abused children from chemically addicted parents would not consider abused children from other situations, such as economically stressed families (Melnyk & Fineout-Overholt, 2011).

Middle-range theories were first suggested in the discipline of sociology in the 1960s and introduced into nursing in 1974. Middle-range theories were useful in other disciplines because they were more readily operationalized and addressed through research than grand theories (McEwen & Wills, 2014). Development of middle-range theories was supported by the critique that grand theories were difficult to understand and apply to the practice setting. Thus, the function of the middle-range theory is to describe, explain, or predict phenomena and be explicit and testable. Middle-range theories are more readily applied to research studies. In addition, middle-range theories are able to guide nursing interventions and change conditions to enhance nursing care. Furthermore, each middle-range theory addresses concrete or specific phenomena by stating what the phenomena are, why they occur, and how they occur. These theories support the connection between diagnosis and outcomes of care (McEwen & Wills, 2014).

A major disadvantage to a middle-range and/or practice theory is that something is left out, but one advantage is that the information gained is far more focused and can be verified with research. This would contribute to evidence-based practice for nursing. To see the comprehensive picture of the nursing profession, a grand theory is needed. But to work with specific actions or develop researchable topics, a middle-range or practice theory is needed (McEwen & Wills, 2014).

Examples of Middle Range Theories

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The Synergy Model

The synergy model for patient care was developed in the 1990s by a panel of nurses of the American Association of Critical-Care Nurses. The purpose of the theory is to acknowledge nurses’ activities, contributions, and outcomes with regard to caring for critically ill patients. The model identifies eight patient needs and eight competencies of nurses in critical-care situations. The nursing competencies depict how knowledge, skills, and experience are integrated within nursing care. The model describes three levels of outcomes—those relating to the patient, the nurse, and the system (McEwen & Wills, 2014).

Benner’s Model of Skill Acquisition in Nursing

Benner’s model depicts five stages of skill acquisition: novice, advanced beginner, competent, proficient, and expert. The model emphasizes the importance of rewarding nurses for their clinical expertise and leadership in clinical practice settings because it describes the process of excellence and a caring practice. Expertise develops when the nurse tests and refines clinical expertise and practical knowledge. The central essentials of Benner’s model are those of skill acquisition, experience, competence, clinical knowledge, and practical knowledge (McEwen & Wills, 2014).

Leininger's Cultural Care Diversity Theory

The purpose of Leininger’s theory is to enhance knowledge related to the uniqueness of nursing care of each patient as well as to value the cultural heritage of human care. Major components of the model are culture, culture care, and culture-care similarities and differences pertaining to transcultural human care. Other major components are care and caring, emic view (language expressions), etic view (beliefs and practices), professional system of healthcare, and culturally congruent nursing care (McEwen & Wills, 2014).

Pender’s Health Promotion Model

Pender’s health promotion model was developed as the theory for integrating behavioral and nursing-science perspectives on factors that influence health behaviors. The model is used to explore and guide the psychosocial processes that motivate individuals to engage in behaviors directed toward wellness and health enhancement. The model has been used extensively in nursing research as a framework for predicting health-promoting lifestyles. Major components of the model include individual characteristics and experiences, self-efficacy, situational influences, and behavioral outcomes (McEwen & Wills, 2014).

The Synergy Model

The synergy model for patient care was developed in the 1990s by a panel of nurses of the American Association of Critical-Care Nurses. The purpose of the theory is to acknowledge nurses’ activities, contributions, and outcomes with regard to caring for critically ill patients. The model identifies eight patient needs and eight competencies of nurses in critical-care situations. The nursing competencies depict how knowledge, skills, and experience are integrated within nursing care. The model describes three levels of outcomes—those relating to the patient, the nurse, and the system (McEwen & Wills, 2014).

Benner’s Model of Skill Acquisition in Nursing

Benner’s model depicts five stages of skill acquisition: novice, advanced beginner, competent, proficient, and expert. The model emphasizes the importance of rewarding nurses for their clinical expertise and leadership in clinical practice settings because it describes the process of excellence and a caring practice. Expertise develops when the nurse tests and refines clinical expertise and practical knowledge. The central essentials of Benner’s model are those of skill acquisition, experience, competence, clinical knowledge, and practical knowledge (McEwen & Wills, 2014).

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Reflection

Think about it

Think about your future professional nursing practice. Explore a theory identified below related to your specialty track and considers ways in which the selected theory could be used to guide your practice.

Click here for link to theories related to your specialty track

NR 501 Specialty Areas Nursing Theories.docx (Links to an external site.)Links to an external site.

Summary

A metaparadigm defines a professional discipline and provides a framework for theory and knowledge development. The most common nursing metaparadigm includes the concepts of person, environment, health, and nursing. These concepts are evident in nursing theories. A formal definition notes that theory is a group of interrelated concepts, assumptions, and propositions that explains or guides action. Grand theories are abstract, general, and broad incorporating all concepts of the metaparadigm. Mid-range and practice theories are narrower in focus, may include one or all of the metaparadigm concepts, and lend to practical application in practice settings. For the nursing profession, a nursing theory provides a view or a window into the reality of nursing.

References

Lee, R.C., & Fawcett, J. (2013). The influence of the metaparadigm of nursing on professional identity development among RN-BSN students. Nursing Science Quarterly, 26(1), 96-98. doi:10.1177/0894318412466734

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

McEwen, M., & Wills, E. (2014). Theoretical basis for nursing (4th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

Parker, M. E., & Smith, M. C. (2015). Nursing theories and nursing practice (4th ed.). Philadelphia, PA: F. A. Davis.

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Family Nurse Practitioner

1. McCormack and McCance’s Person-Centred Care Nursing (PCN) Framework

1. American Association of Critical Care Nurses (AACN) Synergy Model for Patient Care

1. Fawcett and Ellenbecker’s Conceptual Model of Nursing and Population Health (CMNPH)