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The purpose of this assignment is to draft and submit a comprehensive and complete rough draft of your Nursing Theory Comparison paper in APA format. Your rough draft should include all of the research paper elements of a final draft, which are listed below. This will give you an opportunity for feedback from your instructor before you submit your final draft during week 7.
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Based on the reading assignment ( McEwen & Wills, Theoretical Basis for Nursing, Unit II: Nursing Theories, chapters 6–9), select a grand nursing theory.
· After studying and analyzing the approved theory, write about this theory, including an overview of the theory and specific examples of how it could be applied in your own clinical setting.
Based on the reading assignment ( McEwen & Wills, Theoretical Basis for Nursing, Unit II: Nursing Theories, chapters 10 and 11), select a middle-range theory.
· After studying and analyzing the approved theory, write about this theory, including an overview of the theory and specific examples of how it could be applied in your own clinical setting.
The following should be included:
1. An introduction, including an overview of both selected nursing theories
2. Background of the theories
3. Philosophical underpinnings of the theories
4. Major assumptions, concepts, and relationships
5. Clinical applications/usefulness/value to extending nursing science testability
6. Comparison of the use of both theories in nursing practice
7. Specific examples of how both theories could be applied in your specific clinical setting
10. References: Use the course text and a minimum of three additional sources, listed in APA format
The paper should be 8–10 pages long and based on instructor-approved theories. It should be typed in Times New Roman with 12-point font, and double-spaced with 1″ margins. APA format must be used, including a properly formatted cover page, in-text citations, and a reference list. The proper use of headings in APA format is also required.
CHAPTER 6: Overview of Grand Nursing Theories
Evelyn M. Wills
Janet Turner works as a nurse on a postsurgical, cardiovascular floor. Because she desires a broader view of nursing knowledge and wants to become a clinical specialist or family nurse practitioner, she recently began an online RN to BSN degree program that would prepare her to enter a master’s degree program in nursing. The requirements for a course entitled “Scholarly Foundations of Nursing Practice” led Janet to become familiar with some of the many nursing theories. From her readings, she learned about a number of ways to classify theories: grand theory, conceptual model, middle range theory, practice theory, borrowed theory, interactive–integrative model, totality paradigm, and simultaneous action paradigm. She came to the conclusion that there is no cohesion among authors of nursing theory and even wondered what relation theory had to what she was doing in her critical care nursing practice.
Janet’s theory course was delivered through online distance learning methods. To express her frustration and to try to understand the material, she consulted with her theory professor via the Web-based live chat room that was part of the course. The entire class eventually logged on to the chat and a long discussion resulted in which students shared their frustration with these new and abstract ideas. The instructor, a teacher who had come from an RN to BSN program herself, shared with them that frustration and confusion were the normal feelings one had when learning these abstractions. She presented them with several interesting ways to conceptualize grand nursing theories. The chat broke up with the agreement that each student would review the assigned readings again and return to next week’s live chat ready to discuss their findings.
Theories evolved from several schools of philosophical thought and differing scientific traditions. To better understand the theories, Janet looked for ways to group or categorize them based on similarities of perspective. As she studied theories based on similar perspectives, she was able to read and analyze the theories more effectively, and to select three that she intended to examine further.
In Chapter 2 , the reader was introduced to grand nursing theories and given a brief historical overview of their development. Fawcett and DeSanto-Madeya (2013) distinguish between conceptual models and grand theories, and this chapter discusses that differentiation in an effort to assist nursing students to understand the material. According to Fawcett and DeSanto-Madeya (2013), conceptual models are broad formulations of philosophy that are based on an attempt to include the whole of nursing reality as the scholar understands it. The concepts and propositions are abstract and not likely to be testable in fact. Grand nursing theories, by contrast, may be derived from conceptual models and are the most complex and widest in scope of the levels of theory; they attempt to explain broad issues within the discipline. Grand theories are composed of relatively abstract concepts and propositions that are less abstract than those of conceptual models (p. 15) and may not be directly amenable to testing (Butts, 2011; Fawcett & DeSanto-Madeya, 2013; Higgins & Moore, 2000). They were developed through thoughtful and insightful appraisal of existing ideas as opposed to empirical research and may provide the basis for scholars to produce innovative middle range or practice theories (Figure 6-1 ).
FIGURE 6-1: Relationship of conceptual model, theory, and hypotheses.
The grand nursing theories guide research and assist scholars to integrate the results of numerous diverse investigations so that the findings may be applied to education, practice, further research, and administration. Eun-Ok and Chang (2012), in their review of literature, found support for the idea that grand theories have an important place in nursing, for example, in research and clinical practice. They also found that theorists are further refining concepts and theories. They stated that theories are “essential for our discipline at multiple levels” (p. 162). Eun-Ok and Chang (2012) also noted that the grand theories provide a background of philosophical reasoning that allows nurse scientists to develop organizing principles for research or practice, sometimes referred to as middle range theory (middle range theories will be discussed in Chapters 10 and 11 .) One of the most important benefits of invoking theories in education, administration, research, and practice has been the systematization of those domains of nursing activity.
Practitioners are more likely to succeed in analyzing research results using meta-analysis for evidence-based practice (EBP) when the research fits into a particular theoretical framework. Cody (2003) stated that “nursing theory guided practice can be shown to enhance health and quality of life when it is implemented with strong, well-qualified guidance” (p. 167). Mark, Hughes, and Jones (2004) echoed his beliefs and posited that theory-guided research results not only in greater patient safety but also in more predictable outcomes. These beliefs among nursing scientists provide clear direction that theory-guided research is necessary for evaluating nursing interventions in practice.
Over the last five decades of theory development, review of the health care literature demonstrates that changes in health care, society, and the environment, as well as changes in population demographics (e.g., aging, urbanization, and increase in minorities), led to a need to renew or update existing theories and to develop different theories. In fact, some theoretical writers would exclude the grand theory–middle range theory–microtheory relationship in favor of value-based and socially attuned constructions of nursing knowledge that fit contemporary understanding of human interactions (Risjord, 2010).
Health care delivery is a constantly changing process, and to be relevant to health care, theories require constant renewal and reevaluation. Indeed, many established nursing theorists continue to write, reevaluate, and improve their theories in light of these changes. Inspiration for many of the newer theories is linked not only to the changes in the health sciences but also to changes in society worldwide (Boykin & Schoenhofer, 2001). Such theorists as Roper, Logan, and Tierney (2000) (United Kingdom), Ray (Canada), and Martinson (Norway) have achieved worldwide recognition. This chapter introduces conceptual frameworks and grand nursing theories. Chapters 7 through 9 provide additional information about some of the more commonly known and widely recognized nursing frameworks and theories. To better assist the reader in understanding the conceptual frameworks and grand nursing theories, this chapter presents methods for categorizing or classifying them and describes the criteria that will be used to examine them in the subsequent chapters.
Categorization of Conceptual Frameworks and Grand Theories
The sheer number and scope of the conceptual frameworks and grand theories are daunting. Students and novice nursing scholars are understandably intimidated when asked to study them, as illustrated in the opening case study. To help understand the formulations, a number of methods categorizing them have been described in the nursing literature. Several are presented in the following sections. Categorizatio
CHAPTER 7: Grand Nursing Theories Based on Human Needs
Evelyn M. Wills
Donald Crawford is an intensive care unit (ICU) clinical nurse specialist (CNS) who has just completed his graduate degree. Donald strongly believes that evidence guiding nursing practice should be experiential and measurable, and during his master’s program, he derived a system for evaluation of the needs of the seriously ill individuals for whom he cared. He also devised a way to diagram the disease pathophysiology for many of his patients based on the Neuman Systems Model (Neuman & Fawcett, 2009).
During his graduate studies, Donald began to apply concepts and principles from Neuman’s model in his practice with encouraging results. He observed that the model helped predict what would happen next with some patients and helped him define patient’s needs, predict outcomes, and prescribe nursing interventions more accurately. In particular, he appreciated how Neuman focused on identification and reduction of stressors through nursing interventions and liked the construct of prevention as intervention. Using his position as CNS, he is developing a proposal to implement his methods throughout the ICU to help other nurses apply Neuman’s model in managing patient care.
The earliest theorists in nursing drew from the dominant worldviews of their time, which were largely related to the medical discoveries from the scientific era of the 1850s through 1940s (Artinian, 1991). During those years, nurses in the United States were seen as handmaidens to doctors, and their practice was guided by disease theories of medical science. Even today, much of nursing science remains based in the positivist era with its focus on disease causality and a desire to produce measurable outcome data. Evidence-based medicine is the current means of enacting the positivist focus on research outcomes for effective clinical therapeutics (Cody, 2013).
In an effort to define the uniqueness of nursing and to distinguish it from medicine, nursing scholars from the 1950s through the 1970s developed a number of nursing theories. In addition to medicine, the majority of these early works were strongly influenced by the needs theories of social scientists (e.g., Maslow). In needs-based theories, clients are typically considered biopsychosocial beings who are the sum of their parts, who are experiencing disease or trauma, and who need nursing care. Further, clients are thought of as mechanistic beings, and if the correct information can be gathered, the cause or source of their problems can be discerned and measured. At that point, interventions can be prescribed that will be effective in meeting their needs (Dickoff, James, & Wiedenbach, 1968). Evidence-based nursing fits with these theories completely and comfortably.
The grand theories and models of nursing described in this chapter focus on meeting clients’ needs for nursing care. These theories and models, like all personal statements of scholars, have continued to grow and develop over the years; therefore, several sources were consulted for each model. The latest writings of and about the theories were consulted and are presented. As much as possible, the description of the model is either quoted or paraphrased from the original texts. Some needs theorists may have maintained their theories over the years with little change; others have updated and adapted theirs to later ideas and methods. Nevertheless, new research has often extended the original work. Students are advised to consult the literature for the newest research using the needs theory of interest.
It should be noted that a concerted attempt was made in this book to ensure that the presentation of the works of all theorists is balanced. Some theories (e.g., Orem and Neuman) are more complex than others, and the body of information is greater for some than for others. As a result, the sections dealing with some theorists are a little longer than others. This does not imply that shorter works are inferior or less important to the discipline.
Finally, all theory analysts, whether novice or expert, will comprehend theories and models from their own perspectives. If the reader is interested in using a model, the most recent edition of the work of the theorist should be obtained and used as the primary source for any projects. All further works using the theory or model should come from researchers using the theory in their work. Current research writings are one of the best ways to understand the development of the needs theories.
Florence Nightingale: Nursing: What It Is and What It Is Not
Nightingale’s model of nursing was developed before the general acceptance of modern disease theories (i.e., the germ theory) and other theories of medical science. Nightingale knew the germ theory (Beck, 2005), and prior to its wide publication she had deduced that cleanliness, fresh air, sanitation, comfort, and socialization were necessary to healing. She used her experiences in the Scutari Army Hospital in Turkey and in other hospitals in which she worked to document her ideas on nursing (Beck, 2005; Dossey, 2000; Selanders, 1993; Small, 1998).
Nightingale was from a wealthy family, yet she chose to work in the field of nursing, although it was considered a “lowly” occupation. She believed nursing was her call from God, and she determined that the sick deserved civilized care, regardless of their station in life (Nightingale, 1860/1957/1969).
Through her extensive body of work, she changed nursing and health care dramatically. Nightingale’s record of letters is voluminous, and several books have been written analyzing them (Attewell, 2012; Dossey, Selanders, Beck, & Attewell, 2005). She wrote many books and reports to federal and worldwide agencies. Books she wrote that are especially important to nurses and nursing include Notes on Nursing: What It Is and What It Is Not (original publication in 1860; reprinted in 1957 and 1969), Notes on Hospitals (published in 1863), and Sick-Nursing and Health-Nursing, originally published in Hampton’s Nursing of the Sick, 1893) (Reed & Zurakowski, 1996) and reprinted in toto in Dossey et al. (2005a), to name but a small portion of her great body of works. Much of her work is now available, where once it was kept out of circulation; perhaps because of the sheer volume and perhaps because she originally asked that her papers all be destroyed at her death. She later recanted that request (Bostridge, 2011; Cromwell, 2013).
Background of the Theorist
Nightingale was born on May 12, 1820, in Florence, Italy; her birthday is still honored in many places. She was privately educated in the classical tradition of her time by her father, and from an early age, she was inclined to care for the sick and injured (Bostridge, 2011; Dossey, 2000, 2005a; Selanders, 1993). Although her mother wished her to lead a life of social grace, Nightingale preferred productivity, choosing to school herself in the care of the sick. She attended nursing programs in Kaiserswerth, Germany, in 1850 and 1851 (Bostridge, 2011; Dossey et al., 2010; Small, 1998), where she completed what was at that time the only formal nursing education available. She worked as the nursing superintendent at the Institution for Care of Sick Gentlewomen in Distressed Circumstances, where she instituted many changes to improve patient care (Cromwell, 2013; Dossey, 2000; Selanders, 1993; Small, 1998).
During the Crimean War, she was urged by Sidney Herbert, Secretary of War for Great Britain, to assist in providing care for wounded soldiers. The dire conditions of British servicemen had resulted in a public outcry that prompted the government to institute changes in the system of medical care (Small, 1998). At Herbert’s request, Nightingale and a group of 38 skilled nurses were transported to Turkey to provide nursing care to the soldiers in the hospital at Scutari Army Barracks. There, despite daunting opposition by army physicians, Nightingale instituted a system of care that reportedly cut casualties from 48% to 2% within approximately 2 years (Bostridge, 2011; Dossey, 2000, 2005a; Selanders, 1993; Zurakowski, 2005).
Early in her work at the army hospital, Nightingale noted that the majority of soldiers’ deaths was caused by transport to the hospital and conditions in the hospital itself. Nightingale found that open sewers and lack of cleanliness, pure water, fresh air, and wholesome food were more often the causes of soldiers’ deaths than their wounds; she implemented changes to address these problems (Small, 1998). Although her recommendations were known to be those that would benefit the soldiers, physicians in charge of the hospitals in the Crimea blocked her efforts. Despite this, by her third trip to the Crimea, Nightingale had been appointed the supervisor of all the nurses (Bostridge, 2011; Dossey, 2000).
At Scutari, she became known as the “lady with the lamp” from her nightly excursions through the wards to review the care of the soldiers (Audain, 1998; Bostridge, 2011). To prove the value of the work she and the nurses were doing, Nightingale instituted a system of record keeping and adapted a statistical reporting method known as the polar area diagram (Audain, 2007; O’Connor & Robertson, 2003), or Cock’s Comb model, to analyze the data she so rigorously collected (Small, 1998). Thus, Nightingale was the first nurse to collect and analyze evidence that her methods were working.
On her return to England from Turkey, Nightingale worked to reform the Army Medical School, instituted a program of record keeping for government health statistics and assisted with the public health system in India. The effort for which she is most remembered, however, is the Nightingale School for Nurses at St. Thomas’
n Based on Scope
One of the most logical ways to categorize grand nursing theories is by scope. For example, Alligood and Tomey (2010) organized theories according to the scope of
CHAPTER 8: Grand Nursing Theories Based on Interactive Process
Evelyn M. Wills
Jean Willowby is a student in an RN to master of science in nursing program. She is working to become a pediatric nurse practitioner. For one of her practicum assignments, she must incorporate a nursing theory into her clinical work, using the theory as a guide. During an earlier course on theory, Jean read several nursing theories that focused on interactions between the client and the nurse and between the client and the health care system. She remembered that in the interaction models and theories, human beings are viewed as interacting wholes and client problems are seen as multifactorial.
The theories that stress human interactions best fit Jean’s personal philosophy of nursing because they take into account the multitude of factors she believes to be part of clinical nursing practice. Like the perspective taken by interaction model theorists, Jean understands that, at times, the results of interventions are unpredictable and that many elements in the client’s background and environment have an effect on the outcomes of interventions. She also acknowledges that there are many interactions between clients and their environments, both internal and external, some of which cannot be measured.
To better prepare for the assignment, Jean studied several of the human interaction models and theories, focusing most of her attention on the works of Roy and King. But after discussing her thoughts with her professor, she was referred to the Artinian Intersystem Model (AIM), a relatively new model by Barbara Artinian. After reviewing some of the precepts of the model, she thought that it appeared to best fit her pediatrics practice and determined that she would learn more about it.
As discussed in Chapter 6 , interactive process nursing theories occupy a place between the needs-based theories of the 1950s and 1960s, most of which were philosophically grounded in the positivist school of thought, and the unitary process models, which are grounded in humanist philosophy, which expresses the belief that humans are unitary beings and energy fields in constant interaction with the universal energy field. The interactive theories are grounded in the postpositive schools of philosophy.
The theorists presented in this chapter 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. In general, human interaction theorists believe that health is a value and that a continuum of health ranges from high-level wellness to illness. They acknowledge, however, that people with chronic illnesses may have healthy lives and live well despite their illnesses.
Nursing models that can be described as interactive process theories include Levine’s Conservation Model; Artinian’s Intersystem Model; Erickson, Tomlin, and Swain’s Modeling and Role-Modeling; King’s Systems Framework and Theory of Goal Attainment; Roy’s Adaptation Model; and Watson’s Philosophy and Science of Caring. Each is discussed in this chapter. The models treated in this chapter are not arranged historically; some date back to the 1960s, whereas some are relatively new. Levine’s model is placed early in the chapter because it is one of the classic models.
An attempt was made to ensure that a balanced approach was used in presenting the works of these theorists. However, some of the theories are quite complex (e.g., those of Erickson, Tomlin, and Swain; King; and Roy), whereas others are quite parsimonious (e.g., those of Levine and Watson). Additionally, some of the models have been revised repeatedly (e.g., Artinian, King, Roy, and Watson). As a result, the sections dealing with some models are longer or more involved than others, but this does not imply that the works of any of the theorists discussed are more or less important to the discipline than others.
Myra Estrin Levine: The Conservation Model
The ideal of conservation pervades the background of some nurses’ ideas (Mefford, 2004). Myra Levine (1973) stated that “nursing is a human interaction” (p. 237). 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.
Background of the Theorist
Myra Levine earned a diploma in nursing from Cook County School of Nursing in Chicago, Illinois, in 1944; a bachelor’s degree in science at the University of Chicago in 1949; and a master of science in nursing from Wayne State University in Detroit, Michigan, in 1962. She held numerous clinical and education positions during her long career (Schaefer, 2010). She published An Introduction to Clinical Nursing in 1969; this work was revised in 1973 and again in 1989 (Levine, 1989). Levine enjoyed a long and productive career, which included a distinguished publication record. She died in 1996, at age 75, leaving a legacy to nursing of education, administration, and scholarship (Schaefer, 2002).
Philosophical Underpinnings of the Theory
Levine (1973) based the Conservation Model on Nightingale’s idea that “the nurse created an environment in which healing could occur” (p. 239). She drew from the works of Tillich on the unity principle of life, Bernard on internal environment, Cannon on the theory of homeostasis, and Waddington on the concept of homeorrhesis. The works of other scientists were also used. Four conservation principles form the basis of the model; these were synthesized from her scientific study and practice (Levine, 1990).
Major Assumptions, Concepts, and Relationships
The following four conservation principles are the major principles around which the model is constructed:
· The principle of the conservation of energy
· The principle of the conservation of structural integrity
· The principle of the conservation of personal integrity
· The principle of the conservation of social integrity (Levine, 1990, p. 331)
According to Levine’s model, nursing interventions are based on conservation of the client’s integrity in each of the conservation domains. The nurse is seen as a part of the environment and shares the repertoire of skill, knowledge, and compassion, assisting each client to confront environmental challenges in resolving the problems encountered in the client’s own unique way. The effectiveness of the interventions is measured by the maintenance of client integrity (Levine, 1973, 1990).
Assumptions About Individuals
· Each individual “is an active participant in interactions with the environment constantly seeking information from it” (Levine, 1969, p. 6).
· The individual “is a sentient being and the ability to interact with the environment seems ineluctably tied to his sensory organs” (Levine, 1973, p. 450).
· “Change is the essence of life and it is unceasing as long as life goes on. Change is characteristic of life” (Levine, 1973, p. 10).
Assumptions About Nursing
· “Ultimately the decisions for nursing intervention must be based on the unique behavior of the individual patient” (Levine, 1973, p. 6).
· “Patient-centered nursing care means individualized nursing care. It is predicated on the reality of common experience: every man is a unique individual, and as such he requires a unique constellation of skills, techniques and ideas designed specifically for him” (Levine, 1973, p. 23).
Many concepts are discussed in the model. Major concepts are listed in Table 8-1 .
Table 8-1: Major Concepts of the Conservation Model
Includes both the internal and external environment.
The unique individual in unity and integrity, feeling, believing, thinking, and whole.
Patterns of adaptive change of the whole being.
The human interaction relying on communication, rooted in the organic dependency of the individual human being in his [sic] relationships with other human beings.
The process of change and integration of the organism in which the individual retains integrity or wholeness. It is possible to have degrees of adaptation.
The part of the person’s environment that includes ideas, symbolic exchange, belief, tradition, and judgment.
Includes joining together and is the product of adaptation including nursing intervention and patient participation to maintain a safe balance.
Nursing interventions based on the conservation of the patient’s energy.
The singular, yet integrated response of the individual to forces in the environment.
Stable state normal alterations in physiologic parameters in response to environmental changes; an energy-sparing state, a state of conservation.
Modes of communication
The many ways in which information, needs, and feelings are transmitted among the patient, family, nurses, and other health care workers.
A person’s sense of identity and self-definition. Nursing intervention is based on the conservation of the individual’s personal integrity.
Life’s meaning gained through interactions with others. Nurses intervene to maintain relationships.
Healing is a process of restoring structural integrity through nursing interventions that promote healing and maintain structural integrity.
Interventions that influence adaptation in a favorable way, enhancing the adaptive responses available to the person.
Source: Adapted from Levine (1973).
Relationships are not specifically stated but can be extracted from the descriptions given by Levine (1973). The relationships serve as the basis for nursing interventions and include:
· 1. Conservation of energy is based on nursing interventions to conserve energy through a deliberate decision as to the balance between activity and the person’s available energy. 2. Conservation of structural integrity is the basis for nursing interventions to limit the amount of tissue involvement.
CHAPTER 9: Grand Nursing Theories Based on Unitary Process
Evelyn M. Wills
Kristin Kowalski is a hospice nurse who wishes to expand the scope of her therapeutic practice. She desires to delve more deeply into holistic health care, having recently completed courses of study in herbal medicine, touch therapy, and holistic nursing. Kristin is aware that to practice independently, she needs professional credentials that will be widely accepted; therefore, she applied to the graduate program of a nationally ranked nursing school at a large state university.
Because Kristin believes strongly in holistic nursing practice, for her master’s degree she decided to focus her study of nursing theories on those that look at the whole person and have a broad, nontraditional view of health. She is particularly interested in Rosemarie Parse’s Humanbecoming Paradigm because this viewpoint stresses the individual’s way of being and becoming healthy and the nurse as an intersubjective presence.
Kristin is attracted to Parse’s idea of true presence and wishes to further explore this concept as well as the rest of the perspective. She hopes to eventually apply it to her practice and use it as the research framework for her thesis. For her thesis, Kristin wants to examine the experiences of nurses who practice therapeutic touch. She desires to learn their perceptions of how therapeutic touch interventions help their clients. She also wants to learn more about Parse’s research method and hopes to use it for her study.
The term simultaneity paradigm was first coined by nursing theorist Rosemarie Parse (1987) to describe a group of theories that adhered to a unitary process perception of human beings. This group of theorists believed that humans are unitary beings: energy systems embedded in the universal energy system. Within this group of theories, human bein