NSG 416 Nursing Models Fundamentals of Nursing Models

5 Nursing theories or nursing models Fundamentals of Nursing Models, Theories and Practice, Second Edition. Hugh P. McKenna, Majda Pajnkihar and Fiona A. Murphy. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wileyfundamentalseries.com/nursingmodels Outline of content In the previous chapter we described how new nursing roles and nursing theories have evolved and the importance of midrange and practice theories for guiding practice within these new roles. In this chapter we will further explain construction of the theory, talk about the often controversial relationship between theories and models, and show how models can lead to the development of theory. In the following section, we will build on what was described and discussed in previous chapters. We will finish by outlining in detail the advantages and disadvantages of nursing theories. Learning outcomes At the end of this chapter you should be able to: 1. Explain reasons for the development of nursing theory 2. NSG 416 Nursing Models Fundamentals of Nursing Models

Define nursing ‘theory’ and ‘model’ 3. Explain the basic parts of the theory 4. Differentiate between nursing theory and nursing model 5. Discuss theory classification 6. Explain the main paradigms used in theoretical nursing 7. Describe the elements of the metaparadigm 8. Outline the main criticisms and benefits of nursing theories Introduction In Chapters 1 and 3 we explained that there are numerous definitions of nursing theories. You will have seen that the terms grand theory and model are used interchangeably. You saw that one of the most important features of a grand theory/model seems to be its abstract nature (Fawcett 2005a; Meleis 2012); mid-range theories are, by contrast, more narrow in scope and more defined and refined. Theories are always in the process of development and the differences between the terms theory and model are at best tentative, semantic and unclear. NSG 416 Nursing Models Fundamentals of Nursing Models

We have stated on numerous occasions that nurses employ theories in their everyday work, using different types of theories to help describe, explain, predict and, as Dickoff and James (1968) pointed out, prescribe nursing care. It is also important to bear in mind that different authors have different views on the level of abstraction of their own and others’ theories. One way of classifying nursing theories is according to their level of abstraction (McKenna 1997; Meleis 2012); another is by reference to the range of the theory (Marriner Tomey 1998). But first let us explain reasons for nursing theory development. Reasons for historical nursing theory evolution In Chapter 1 it was noted that all the early 20th-century nursing theories emanated from the USA, with theories starting to emerge from the UK some 20 years later (see Reflective Exercise 5.1). NSG 416 Nursing Models Fundamentals of Nursing Models

The exception was that of Florence Nightingale. You saw in Chapter 3 how in the late 1950s other American nursing theories were developed, essentially to distinguish nursing from other health professions and to define nurses as professionals and their essential obligations to patient care. In the 1950s, nurse education programmes were increasingly being delivered, not in schools of nursing on isolated hospital sites but in universities. It comes as no surprise, then, that the various curricula had to show that nursing had its own knowledge base and scientific approaches for studying nursing. Otherwise all the lectures would be based on a variant of the biomedical model and of social and psychological theories. You will recall that the basic structure of the biomedical model was discussed in Chapter 4. NSG 416 Nursing Models Fundamentals of Nursing Models

Therefore, the reasons why theorising took place in 1950s America were: • the desire to develop a scientific basis for nursing practice; • the quest for professional recognition; • the advent of university education for nurses; • the increase in the number of master’s and doctoral-prepared nurses; • women’s contribution to the Second World War effort, leading to an increase in the debate around the female role in work and education; • the wish to make clear the boundaries of nursing and nurses’ work. In Chapter 4 you were introduced to the names of theorists who developed their theories in America in the 1960s and 1970s. Interestingly, many were reluctant to claim theoretical status for their work. It would seem that such reluctance was no longer common in the 1980s and 1990s. For example, in 1970 Orem published her first book Nursing: Concepts of Practice, with subsequent editions in 1980, 1985, 1991 and 1995. She worked alone and with colleagues on the continued conceptual development of the self-care deficit nursing theory. The fifth edition is organised into two parts: nursing as a unique field of knowledge, and nursing as practical science. In the 1980s some theorists also tried to revise their earlier work in line with some of the criticisms of meta-theorists (Pajnkihar 2003). NSG 416 Nursing Models Fundamentals of Nursing Models

Orem developed her theory with the help of theory analysis and evaluation and according to the changes and needs in practice. Reflective Exercise 5.1: Reasons for the evolution of theories In Chapter 4 you saw a long list of theories that were developed in the US and a shorter list of those developed in the UK. Form a small group with your fellow students and consider whether the reasons for their emergence were the same in each country and why the times and places were important. Also consider the reasons why there was a slowing down in the development of nursing theories in the US in the 1980s and in the UK in the 1990s. So-called ‘caring theories’ first appeared in the 1980s. NSG 416 Nursing Models Fundamentals of Nursing Models

Perhaps the most famous was that of Jean Watson. In 1998, Tracey et al. wrote that Watson’s framework was still being taught in numerous baccalaureate nursing curricula in the USA and that these concepts were also widely used in nursing programmes in many countries, including the UK. Morris (1996) noted that Watson’s human care theory was used as the basis for doctoral nursing programmes in the USA and Canada. The incorporation of this theory model into nursing curricula added a new dimension to nursing as a whole (Pajnkihar 2003). NSG 416 Nursing Models Fundamentals of Nursing Models

As the recognition of the importance of caring in nursing has grown, researchers in middle and eastern Europe have explored the value of nursing theories. In Poland, for instance, Zarzycka et al. (2013) noted the importance of caring theories. There is also great interest in caring theories in some southern European countries and Russia, where research projects on the value of Watson’s theory for education and practice have been undertaken but not yet published. In the 1980s it was generally accepted among most theorists that a qualitative research methodology with a historicist paradigm (see Chapter 2) was the basic methodology for nursing. Therefore, many nursing theorists started to revise their work, thus increasing the number of mid-range theories (Pajnkihar 2003). As a result, in the 1990s, numerous research studies were carried out in a drive to test nursing theories (Hickman 1995) and many mid-range theories emerged from this work (Pajnkihar 2003). The stimuli for the development of theories in the UK in the 1980s, just as nurse theorising was slowing down in the USA, are interesting. These may have followed from the perception that American theories were not suitable for practice in the UK. NSG 416 Nursing Models Fundamentals of Nursing Models

As with the US, the introduction in the UK of university education for nurses in the late 1970s forced many lecturers and students to look at how knowledge unique to their discipline might be developed and taught. A similar trend can be seen in other European countries and in Australia, where nursing programmes were being delivered in universities. In addition, as had happened previously with their American counterparts, UK nurses began to examine the biomedical model and found it an inappropriate framework to guide nursing care. The biomedical model was also questioned in some other European countries but later than in the USA and the UK. Model In Chapter 4 you saw that the term model, in the eyes of most meta-theorists (apart from Jacqueline Fawcett), is synonymous with grand theory. However, the term model continues to be referred to in the literature and in practice. You will hear practising nurses talking about Orem’s model or Roper, Logan and Tierney’s model. They would seldom refer to these c onceptualisations as theories. Therefore, in this short section we will discuss what is meant by models. NSG 416 Nursing Models Fundamentals of Nursing Models

You can decide for yourself if you think that model or theory is the best way to describe the work of the various theorists. The term ‘nursing model’ has been defined as (Chinn & Kramer 2004: 264) a symbolic representation of empirical experience in words, pictorial or graphic diagrams, mathematical notations, or physical material [and] a form of knowledge within the empirical pattern. Some of the simplest definitions of a model describe it as a representation of reality (McFarlane 1986) or a simplified way of organising a complex phenomenon (Stockwell 1985). Other authors have elaborated on both these descriptions. Fawcett (2006) stated that a model comprises a set of concepts and the assumptions that integrate them into a meaningful configuration. Thus models are tools that enable users to understand more complex phenomena in a simple way.

Models are highly abstract and represent a world view that helps nurses to understand easily the many such world views that are encountered every day (Theofanidis & Fountouki 2008). McKenna (1994) suggested that a model is a mental or diagrammatic representation of care that is systematically constructed and assists practitioners in organising their thinking about what they do. In addition, transferring their thinking into practice benefits the patient and the profession. Models can therefore be seen as conceptual tools or devices that can be used by an individual to understand complex situations and put them in perspective. Models take various forms. Some are presented in a one-dimensional format as verbal statements or philosophical beliefs about phenomena. One-dimensional models tend to be at a high level of abstraction. They cannot be taken apart or explicitly observed, but they can be thought about and mentally manipulated. Two-dimensional models include diagrams, drawings, graphs or pictures, such as those that show how parts fit together into a whole. Think of a diagram of a plant in a gardening book – this is a perfect illustration of a two-dimensional model. Most models tend to begin as a one-dimensional conceptualisation and later develop into a two-dimensional format. Three-dimensional models are what Craig (1980) referred to as physical models. These are scale models or structural replicas of things. In this form they may be intimately examined and manipulated. Examples of three-dimensional models are an architect’s model of a building or a model of a car. NSG 416 Nursing Models Fundamentals of Nursing Models

All three classes of model provide enormous amounts of information to those who use them. They tend to give a structured view of the particular circumstances under consideration. In this way users are able to understand the represented concepts and the relationship of those concepts (propositions) to each other. One-, two- and three-dimensional models try to represent reality, from a high level of abstraction to the concrete, giving a structured view of how the parts fit together as a whole (see Reflective Exercise 5.2). Reflective Exercise 5.2: The three model dimensions Think of an object and conceptualise it, using all three dimensions described. For instance, you could take the example of a bodily organ. If you were to describe what it is and what it does, this would be a one-dimensional model.

Now, if you were to draw a rough diagram of the organ, this would be a two-dimensional model. This model is likely to provide you with more information than the one-dimensional version. If you were next to obtain a plastic teaching replica of the organ in your school of nursing, one that can be taken apart and its internal structures manipulated, this would be a three-dimensional model, providing even more information about the structure of the organ than the previous two models. You could do the same exercise with kitchen appliances, methods of transport and so on. Now carry out the exercise and write a short note about the different dimensions and whether they provided you with increasing knowledge about the object. We can define models as describing nursing phenomena and assumptions in very abstract and logical ways. They can then be presented and organised into whole pictures using nursing language, words, mental pictures, diagrams, drawings or logical structures to help understand what was observed in practice. In this way, models help in organising and understanding situations in practice and in thinking about their reality. Models are very abstract tools in research for developing a theory. NSG 416 Nursing Models Fundamentals of Nursing Models

They are used in all disciplines and also in everyday life, e.g. toys and instructions on how to put together a new bookshelf. The oldest model in nursing is the biomedical model, which you saw in Chapter 4 and which still influences nursing education and practice. Theory In Chapter 1 we explained that there are numerous definitions of nursing theories. The theories describe, explain or predict how nursing may concisely but holistically and individually support and help patients, families or society at large, and support practice, education and research (see Reflective Exercise 5.3). Reflective Exercise 5.3: Defining theory Refer back to Chapter 1 to review the different definitions of nursing theory that were identified. It is not necessary to reiterate the various descriptions of theory here, but the following section will show there that is still some confusion as to whether the work of a theorist is a model or a grand theory or a paradigm. Readers should select the view they feel comfortable with and be aware that not everyone will agree with them. McKenna (1997) suggested that nurses selected the term model rather than theory because of their lack of confidence as a profession. At the time, they had only just entered the hallowed surroundings of the university, so how could they suddenly come up with all these theories. To call them models and steps towards theory building was more acceptable (see Reflective Exercise 5.4). NSG 416 Nursing Models Fundamentals of Nursing Models

Reflective Exercise 5.4: Model or theory – you decide In Chapter 1 you were introduced to theory and its working elements of concepts, propositions and assumptions. In this chapter, the term model has been described. Think of those theorists whose work you are most familar with and decide whether you think ‘model’ or ‘theory’ is the best descriptor. Discuss your thinking with a fellow student or colleague – remember, they may not ageee with you but that does not mean you are wrong. Theory or model? Peplau published her theory of Interpersonal Relations in Nursing in 1952. You will learn more about her work in the next chapter. With no obvious explanation, she called it a ‘partial theory for the practice of nursing’. A second edition of the book appeared in 1988 with little change. The aim of the theory, as Peplau (1952: xiii) said, was ‘helping nurses to understand the relationship of nurse personalities to these functions’. Later, the meta-theorist Marriner Tomey (1998) classified Peplau’s work as a mid-range theory, whereas Belcher and Fish (1995) described it as a theory! In contrast, Reed (1996) classifies it as a practice theory (Pajnkihar 2003). More recently and shortly before her death, Peplau (1995a) did explicitly refer to her work as a theory. Analyses of Orem’s theory are replete with controversy. Meleis (1997: 398) asserted that it is a descriptive theory. According to Feathers (1989), Orem had developed a complete descriptive theory, adding some elements of explanatory theory. More recently, Marriner Tomey (1998) and Pajnkihar (2003) both saw Orem’s work as a grand theory. Watson (1988: 1) argued that her caring theory is ‘not hard scientific theory’ but is still a theory – a descriptive theory. Some explanation from her as to why she thought this would have been helpful but it was not forthcoming. Tracey et al. NSG 416 Nursing Models Fundamentals of Nursing Models

(1998) confusingly stated that it could be called a conceptual model, a framework and a theory. Morris (1996) maintained that Watson’s work is a conceptual model and Marriner Tomey (1998) classified it as a philosophy! Some authors accept that models are the most appropriate precursors of theory (Chinn & Kramer 2004; Fawcett 2005a). This position centres on their belief in the rigid criteria necessary for theory recognition, and the inability of many models to meet them. In essence, their position is that models are believed to lead to the identification of concepts and assumptions and that, when tested by research, they will ultimately lead to the formation of theory. The theory-model debate may best be understood by looking at the views of the chief protagonists. Jacqueline Fawcett was a firm believer in differentiating models from theories. In the opposite corner is Afaf Meleis, who has a determined view that all these conceptualisations are theories. Both are respected meta-theorists; let’s examine their arguments. According to Jacqueline Fawcett (2005a), models are more abstract than their theoretical counterparts. They present a generalised broad and abstract view of phenomena. To underpin her strong views Fawcett wrote several editions of two distinct books, one on nursing theories and the other on conceptual modes. She maintained that theories are more specific and precise, containing more clearly defined concepts with a narrower focus. So, as we have seen in earlier chapters, the difference is one of abstraction, explication and application. Let’s refer to this argument as ‘position A’ (Figure 5.1). Figure 5.1 The theory-model controversy: position A. NSG 416 Nursing Models Fundamentals of Nursing Models

This differentiation would appear to clear up the confusion, but Meleis (2007) argued that it matters little what we call these ‘things’. She believed that much time has been wasted debating the differences between models, theories and paradigms. Rather, she maintains that time would be better spent evaluating the effects of these conceptualisations on patient care. Meleis based her argument on her desire to concentrate on content and not on labels. She asserted that theory exists at different stages of development, from the most primitive to the most sophisticated form, and therefore even the simplest conceptualisation is a theory. Her stance would be that models are theories, but at a more abstract level than the theories developed through research. The most primitive may be referred to as grand (or broad) theories, while the most sophisticated are referred to as mid-range or practice theories. We will refer to this view as ‘position B’ (Figure 5.2). NSG 416 Nursing Models Fundamentals of Nursing Models

Figure 5.2 The theory-model controversy: position B. However, for the purpose of this book you will have detected that the term we will use throughout will be theory (position B). The basis for this decision lies with Meleis’s call for professionals to concentrate on substance (content) rather than structure (terminology). When theories or models are mentioned in the remainder of this book, we will be referring to grand theories, unless otherwise specified (see Key Concepts 5.1 and Reflective Exercise 5.5). It is important that both theories and models present phenomena in systematic ways, that both help to organise the work of nurses in practice as well as in education, and both develop the body of nursing knowledge and science. Key Concepts 5.1 Theory and model Theory exists at different stages of development and a conceptual model is a stage of development on the way to becoming a theory. Reflective Exercise 5.5: Position A or position B? Both positions can be support …