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Selecting a theoretical framework to guide research on the COVID-19 pandemic impacts on nursing care delivery and the critical care work system (using Reed's Intermodern approach to theory critique)
Understanding the impact of COVID-19 on nursing care delivery in critical care work systems is urgently needed. Theoretical frameworks guide understanding of phenomena in research. In this paper, we critique four theoretical frameworks (Donabedian's Quality Model, the Quality Health Outcomes Model, the Systems Research Organizing Model, and the Systems Engineering (SEIPS) 2.0 Model) using Reed's (2018) Intermodern philosophical perspective of nursing science. Reed's (2018) Intermodern approach to theory critique was selected for its pragmatic perspective and focus on personal and professional health and wellbeing. The SEIPS 2.0 Model was ultimately selected to guide the study of the impact of the COVID-19 Pandemic on nursing care delivery in the critical care work systems.
Nursing care delivery impacts both patient and nurse outcomes ( Cheung et al., 2008 ). Some researchers have explored the early impact of the COVID-19 Pandemic on nursing care delivery broadly in acute care settings ( Schroeder et al., 2020 ), yet few have concentrated on critical care settings (ICUs). ICUs are work systems designed to provide care to critically ill patients ( Marshall et al., 2017 ). COVID-19 illness has caused unparalleled patient admissions to ICUs ( Huang et al., 2020 ).
Theoretical frameworks are essential to understand phenomena of interest in healthcare systems (Brewer et al., 2008). Theory-based research into systems shifts attention from a superficial focus on problem-elimination and outcomes to a broader and deeper analysis of structures and processes that affect delivery of care ( Verran, 1997 ). This paper presents the process of analyzing and evaluating four theoretical framework for selection to study the impact of the COVID-19 Pandemic on nursing care delivery in the critical care work system. The four frameworks evaluated are Donabedian's (1988) Quality Model, Mitchell et al.' (1998) Quality Health Outcomes Model, Brewer and colleagues' (2008) Systems Research Organizing Model, and Holden et al.’ (2013) Systems Engineering Initiative for Patient Safety 2.0 Model. The critique was completed using Reed's (2018) Intermodern perspective of nursing science and theory development.
1. Frameworks and models for understanding work systems
The four theoretical frameworks, also called models, were selected for their potential to describe systems, processes, and outcomes in healthcare. Each model was analyzed and evaluated for relevance to describe the critical care work system, processes of nursing care delivery, and subsequent outcomes. Other important concepts included in the analysis/evaluation were patients' family members, healthcare professionals' well-being, and the explicit inclusion of the external environment. These concepts were added because patients' family members play a crucial role in the social support of patients, healthcare professionals' well-being has the potential to impact patient outcomes ( Cheung et al., 2008 ), and because of the nature of how drastically the COVID-19 Pandemic altered care delivery ( Schroeder et al., 2020 ), respectively. Reed's (2019) Intermodern perspective of nursing science was used to critique and select a theoretical framework to describe the impact of COVID-19 on nursing care delivery in critical care work systems for the following reasons: its congruence with the nursing metaparadigm, situation and broad use in a human factors/systems research, consideration of the external environment, and explicit inclusion of the professionals' health and wellness as an outcome.
2. Reed's Intermodern approach to theory critique
The Intermodern ( Reed, 2018 ) approach to theory critique was selected for its emphasis on the role of practice in knowledge development, and its useful perspective for theory critique among researchers who consider themselves pragmatists who value scientific theories for their success in practical application. The Intermodern approach focuses on professional well-being, which is an important issue of concern during the COVID-19 Pandemic for its potential to impact patient outcomes ( National Academy of Medicine, n.d. ).
Like other theory critique approaches, an Intermodern approach includes analysis and evaluation. Analysis includes a look at the 1) theory components, 2) underlying assumptions, and 3) relationships among concepts. Evaluation includes assessment of multiple components of the theory for a specific research or theory purpose. These components include the following: 1) meaning and significance for ethical and effective practice, 2) underlying worldview as congruent with nursing practice needs, 3) contribution to practice knowledge that stimulates new ideas or challenges the status quo, and 4) applications in supporting professional and personal practices that promote health and well-being ( Reed, 2018 ).
3. Theoretical frameworks
The theoretical frameworks described below were selected for their potential to describe the critical care work system, processes of nursing care delivery, and subsequent outcomes. The first model described in this paper is Donabedian's (1988) Quality Model, which is broadly considered the first model describing the healthcare system structures, processes, and patient outcomes. The subsequent models are predicated on the structures, processes, and outcomes as described in Donabedian's (1988) Quality Model. Mitchell et al. (1998) Quality Health Outcomes Model, Brewer and colleagues' (2008) Systems Research Organizing Model, and Holden et al. (2013) Systems Engineering Initiative for Patient Safety 2.0 Model are critiqued below using Reed's (2018) Intermodern approach in order of chronology.
3.1. Donabedian's quality model
Donabedian's Quality Model (1988) is a theoretical framework for evaluating the quality of healthcare. The model depicts the relationship between the structures and processes that contribute to the outcomes of care. The structures construct in the model represents the attributes of the setting where care occurs; for example, organizational structures refer to settings such as teaching, urban, or rural hospitals and the processes of each involved in giving and receiving care. These settings in turn impact the processes that occur in giving and receiving care. The outcomes construct denotes the impact of care processes on the health status of patients ( Donabedian, 1988 ). The Quality Model has mechanistic philosophic roots as evidenced by the simple, unidirectional, and linear relationships ( Pepper, 1942 ) proposed among the structures, processes, and outcomes.
The constructs within the model are sufficiently broad, allowing for consistency with the metaparadigm of nursing, and inclusion of the patient's family/caregivers, the environment beyond where care occurs, and the impact on clinicians. However, the model lacks an explicit focus on professional practices that promote health and well-being for professionals.
Donabedian's Quality Model (1988) has been used in many research studies and supported by many research studies in healthcare research ( Berwick & Fox, 2016 ), particularly in reference to promoting understanding phenomena in healthcare research of quality patient outcomes ( Ayanian & Markel, 2016 ). The Quality Model has stimulated new thinking and generated development of models based loosely on this model.
3.2. Quality health outcomes model
The Quality Health Outcomes Model (QHOM) (1998) is a theoretical framework of the relationships between multiple factors that affect care quality. Proposed in 1998, the QHOM was built on Donabedian's Quality Model (1988) by the American Academy of Nursing Expert panel on Quality to guide quality of care evaluation and research ( Mitchell et al., 1998 ). When the QHOM was first published, it challenged the status quo through its consideration of the reciprocal relationships between system and client characteristics to produce outcomes, and its inclusion of policy implications ( Mitchell et al., 1998 ). The QHOM has been used widely in nursing quality research and improvement efforts ( Aiken et al., 2018 ), although the model is nearly a quarter century old.
The model is comprised of four main concepts including: system characteristics (structure and process elements), interventions (clinical processes), client characteristics (to whom interventions are directed), and outcomes (impact of clinical processes on patients) ( Mitchell et al., 1998 ). The QHOM reflects an organismic philosophical view ( Pepper, 1942 ) in that health outcomes are depicted within an organization of dynamic, interrelated factors, and the whole system is not necessarily predictable by the sum of its parts.
The model has several weaknesses. The interventions construct is not directly related to outcomes, but rather indirectly related through system and client characteristics ( Pepper, 1942 ). The constructs of the QHOM are quite broad for applications in databases used for quality improvement and intervention research ( Mitchell et al., 1998 ). While the theoretical ideas are consistent with the metaparadigm of nursing, there is an internal inconsistency in the model's theoretical separation of the system characteristics processes from clinical intervention processes; in reality, the system has considerable influence over clinical processes. Further, similar to the Quality Model (1988), the QHOM lacks consideration of environment beyond the immediate context of care. The model does not address professional practices in promoting health and wellbeing, however it has been cited over 500 times.
3.3. Systems research organizing model
The Systems Research Organizing Model (SROM) is a theoretical framework that explains the relationships among variables of interest in healthcare (e.g. person, environment, healthcare professionals, and health) (Brewer et al., 2008). The model contains four main constructs including the client that drives the model, the environment which is not the focus of change but can influence other constructs, an action focus which is the process measures, and the outcomes or performance measures. All of the constructs are interrelated and comprise the system as a whole (Brewer et al., 2008). The SROM has contextualistic philosophic roots as evidenced by the client depicted as interconnected with their environment and inseparable from the system ( Pepper, 1942 ). Brewer along with faculty and doctoral students at The University of Arizona developed the SROM to evaluate nursing systems research by examining the systems' influences on outcomes of care and healthcare design (Brewer et al., 2008).
The SROM constructs are clear and broad yet sufficiently diverse. The theoretical ideas are consistent with the metaparadigm of nursing and with a systems-focus as evidenced by depiction of the constructs comprising the whole system ( Von Bertalanffy, 1969 ). The SROM has been used to explain and predict patient mental health outcomes ( Saewert, 2003 ) and healthcare facilities design (Brewer et al., 2008). Though it has not been used in research in the last ten years, knowledge from the SROM contributed to a systems view in nursing research by which individuals are inseparable from their environment (Brewer et al., 2008). Unlike Donabedian's (1988) Quality Model and Mitchell et al. (1998) QHOM, the SROM challenged the status quo in its flexibility and its view of interaction among all model constructs. This enables a focus on professional practices that promote health and wellbeing.
3.4. Systems engineering initiative for patient safety 2.0 model
The Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 Model is a theoretical framework for studying and improving health and healthcare ( Holden et al., 2013 ). The model is comprised of three main constructs including work systems, processes, and outcomes . The work system is further delineated into person(s) including the healthcare professionals and patients/their families, hospital organization, tasks, internal environment (e.g. sounds, temperature) and external environment (e.g. state policy, economics).
Processes are delineated into professional work, collaborative professional-patient work, and patient work. Outcomes are delineated into patient, professional, and organizational outcomes ( Holden et al., 2013 ). The SEIPS 2.0 Model has contextualistic philosophic roots ( Pepper, 1942 ) as evidenced by the patient depicted as inseparable from the internal environment of care and impacted by the external environment ( Holden et al., 2013 ). The original SEIPS model was developed by Carayon et al. (2006) and was based on Donabedian's Quality Model (1988) and Balance Theory, which emphasizes the relationships between the components of the system and importance of considering the entire system as other system elements may act as barriers or facilitators. While a SEIPS 3.0 Model does exist, its focus is on patient safety during the transition out of the acute care setting; and therefore, was not included in this theory critique ( Carayon et al., 2020 ).
The SEIPS 2.0 Model (2013) is comprised of three main constructs with sub-concepts that further define how the constructs are sufficiently broad yet diverse. There is ample contemporary research evidence supporting the use of the SEIPS 2.0 Model in practice ( Center for Quality and Productivity Improvement, n.d. ). The SEIPS 2.0 Model was recently used by Lumley et al. (2020) to conceptualize what nursing care delivery may look like in critical care settings during the COVID-19 Pandemic. The model has applications for evidence-based practice, quality evaluation, testing interventions, and supporting professional and personal practices promoting personal and professional health and wellbeing as evidenced by inclusion of professional outcomes in the model ( Holden et al., 2013 ). Finally, the SEIPS 2.0 Model challenged the status quo by proposing that negative elements or barriers to work processes can be overcome by focusing on the positive elements of the system ( Carayon, 2009 ).
3.5. Summary of a comparison of theoretical frameworks
The four theoretical frameworks presented above were compared overall for selecting the one most appropriate for the research on the impact of the COVID-19 Pandemic on the critical care work system from a nursing perspective. First, while Donabedian's (1988) Quality Model has been widely used in healthcare systems research to understand quality outcomes, several key details including the patients' family members, the external environment, and the consideration of the healthcare professional were not explicitly included in the model. Second, Mitchell and colleagues' (1998) QHOM also does not include consideration of the external environment. Neither model explicitly addresses promotion of professionals' health and wellness. Third, while the SROM is nested in the nursing metaparadigm, is consistent with a systems view (Brewer et al., 2008), and includes consideration of the external environment and promotion of professionals' health and wellness; however, it has not been recently used in research. Fourth, the SEIPS 2.0 Model ( Holden et al., 2013 ) is consistent with the nursing metaparadigm, is situated in a human factors/systems view, includes consideration of the external environment, explicitly includes the professional health and wellness as an outcome, and has been used widely in recent nursing research and implemented in critical care work systems ( Center for Quality and Productivity Improvement, n.d. ). Therefore, the SEIPS 2.0 Model was selected to guide a research study describing the impact of the COVID-19 Pandemic on the critical care work system from a nursing perspective.
3.6. The SEIPS 2.0 model and the impact of COVID-19 on the critical care work system
Because the SEIPS 2.0 Model can be used to describe work systems design with a focus on patient safety ( Holden et al., 2013 ), it is ideal for comprehensively describing nursing care delivery which aims to deliver safe nursing care to patients. More specifically, the SEIPS 2.0 Model will be used as a framework to guide development of semi-structured interviews with critical care nurse participants to elicit their descriptions of describing the impact of the COVID-19 Pandemic on nursing care delivery in the critical care work system.
The SEIPS model in Fig. 1 depicts the components of the critical care work system during COVID-19 and the process of nursing care delivery. The model's major components of the work system, work process, and outcomes outline the major interview areas designed for data collection in the research as described briefly below.
SEIPS 2.0 model as adapted for this study.
3.6.1. Work system
3.6.1.1. person(s).
Consistent with SEIPS 2.0 ( Holden et al., 2013 ), both the nurse and patient (and their family) will be simultaneously represented at the center of the model. Nurses will be asked to describe characteristics of their patients including their needs, preferences and goals ( Holden et al., 2013 ). The nurses will be described through demographic characteristics including age, gender, highest level of nursing education, and years of experience.
3.6.1.2. Nursing tasks
The focus of the nursing tasks will be those completed by the nurse for the patient. These tasks vary in difficulty, complexity, and ambiguity as described by Holden et al. (2013) . Nurses will be asked about the tasks completed for critically ill patients in the critical care work system. Other factors, such as who was responsible for completing the task and who was responsible for delegation of tasks, will be used to provide a comprehensive description of nursing care delivery models.
3.6.1.3. Tools & technology
Tools and technologies include information technologies, devices, and resources used to facilitate patient care ( Holden et al., 2013 ). Nurses will be asked about the tools and technology used in caring for patients in the ICU during COVID-19. As Holden et al. (2013) describe, tools and technology factors in the SEIPS 2.0 Model include usability, accessibility, familiarity, portability, and functionality.
3.6.1.4. Organization
According to Holden et al. (2013) , organizations are structures that organize time, space, resources, and activities that may be put in place by people but are external to people. Nurses will be asked about factors related to organizations. Organizational factors include work assignments, such as number of patients and complexity and how work was assigned to be completed for the patient, work schedules, availability of resources such as personal protective equipment and ventilators, and management and incentive systems, and training and policies and procedures specific to caring patients in the ICU during the COVID-19 Pandemic ( Holden et al., 2013 ).
3.6.1.5. Internal environment
Internal environments include layout, noise, temperature, and lighting in the work setting ( Holden et al., 2013 ). Nurse participants will be asked about what the internal environment of an ICU looked, sounded, and physically felt like during the COVID-19 Pandemic.
3.6.1.6. External environment
Because COVID-19 is ravaging our nation and globe, it will be important to include a macroergonomic (work system design) approach. External factors which may impact the work system include societal, economic, and policy factors ( Holden et al., 2013 ). Nurse participants will be asked about how greater society, economics, and policy impacted their ICU and their experiences with care delivery.
3.6.2. Nursing care delivery as a process
Nursing care delivery is an example of professional work process completed by a nurse ( Holden et al., 2013 ). The different components of the critical care work system will be explored for how each impacted nursing care delivery including physical, cognitive, and social/behavioral work processes. Physical work processes describe the actual process of delivering nursing care to the patient, while cognitive work processes describe the critical thinking processes and the social/behavioral work processes describe the interaction between the patient/family member and the professional and the team member interaction ( Holden et al., 2013 ).
3.6.3. Outcomes
Outcomes in the SEIPS 2.0 Model include patient, professional, and organizational outcomes ( Holden et al., 2013 ). Patient outcomes include satisfaction and quality of care, while professional outcomes include the health versus illness, job satisfaction, and burnout of the healthcare team members, and organizational outcomes include staffing difficulties, financial performance, and cultural changes ( Holden et al., 2013 ). Nurses will be asked about nurse outcomes relating to care delivery during the COVID-19 Pandemic.
4. Conclusion
Theory critique including in-depth analysis and evaluation is time-consuming, yet critically important. There must be a match between the purpose of the research, the researcher's views, and the theoretical framework. One must not only consider the theories to critique, but also the approach to theory critique. Reed's (2018) Intermodern approach to critique was used for its pragmatic perspective of theory critique, which includes evaluation of a theory in terms of its practice implications and its emphasis on personal and professional health and well-being. Use of Reed's (2018) Intermodern approach facilitated selection of the SEIPS 2.0 Model was selected in part because it will provide a comprehensive framework for describing the critical care work system, processes of nursing care delivery, and subsequent outcomes with an emphasizes on professional wellbeing ( Carayon et al., 2006 ). This model offers a systems perspective to guide research on describing impact of the COVID-19 Pandemic on the critical care work systems, processes, and outcomes while emphasizing professional well-being.
This work was supported by the Sigma Beta Mu Dissertation Grant.
CRediT authorship contribution statement
Claire Bethel: Conceptualization, Writing – Original Draft, Funding Acquisition, Investigation/Analysis, Project Administration, Supervision.
Pamela Reed: Methodology, Writing – Original Draft, Writing – Review & Editing, Investigation/Analysis.
Barbara Brewer: Writing – Original Draft, Writing – Review & Editing.
Jessica Rainbow: Writing – Review & Editing.
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Understanding Nursing Theories
What are Nursing Theories?
Nursing theories help guide and define nursing care and provide a foundation for clinical decision-making . Although some nursing theories have been around for hundreds of years in public health, many are still being used in today’s hospitals and healthcare settings.
If you’re thinking about going to school to become a nurse, it’s safe to assume that nursing theory will be a critical part of your curriculum. However, you can get a head start and learn more about nursing theories in this article.
The Metaparadigm of Nursing
A metaparadigm is a set of ideas that provide structure for how a health care discipline should function. In nursing, this refers to the four main concepts that are tied to nursing theory.
The person component of the metaparadigm focuses on the receiver of care, as well as the people in their life, and takes into consideration the patient’s social, spiritual, and healthcare needs. The theory is that a person can be more empowered to manage their health when they have positive personal connections.
The health concept realizes the multiple factors that go into a patient’s well-being—including physical, emotional, intellectual, spiritual, and social components—and how they can be integrated to achieve maximum health outcomes.
Environment
This concept focuses on the surroundings that affect the patient and how those surroundings can influence their health and wellness. It theorizes that a person can alter their environment to improve their health.
This aspect of the metaparadigm recognizes the relationship between a nurse and patient. It focuses on the nurse’s role in providing a safe and caring environment and values the high degree of service necessary to provide the best patient health outcomes.
There are a host of different nursing models and theories, based on nursing research, that drive nursing practice and the nursing profession at large all around the country and the world. These theories each incorporate the concepts of the metaparadigm of nursing, with specific nursing practice being shaped by the ideas of the nursing theorists that created the various models as nursing education and implementation strategies.
What are Types of Nursing Theories?
All nursing theories are organized into three levels: grand, middle-range, and practice-level. Here’s a look at each:
Grand Nursing Theories
Like the name implies, any theory based on broad, abstract, or more complex concepts will fall under this category. Grand nursing theories typically provide a high-level framework for nursing ideas rather than diving into the details.
Middle-Range Nursing Theories
Middle-range theories get into more specific areas of nursing as opposed to grand theories. They can come from day-to-day nursing practice, research, or from theories of similar disciplines.
Practice-Level Nursing Theories
Theories categorized in this level are the most focused. They deal with very situation-specific concepts that are narrow in scope and home in on a specific patient population.
What are Some Examples of Nursing Theories?
There are many nursing theories out there, but here are some of the most common:
Environmental Theory
Known as the first nursing theorist and the founder of modern nursing, Florence Nightingale created the Environmental Theory in 1860, and its principles are still used today. She served as a nurse during the Crimean War, where she observed a connection between patients who died and their environmental conditions. As a result, the Environment Theory was born. In it, Florence Nightingale identifies five environmental factors—fresh air, pure water, efficient drainage, cleanliness, and sunlight—as essential factors in human health.
Casey’s Model of Nursing
Developed by Anne Casey in 1988, Casey’s Model of Nursing is considered one of the earliest nursing theories developed specifically for child health nursing. This theory focuses on the nurse working in partnership with the child and their family. The philosophy is that the best people to care for a child are their family with the assistance of health professionals.
Patient-Centered Approach to Nursing
Faye Abdellah’s patient-centered approach was created in the 1940s to help with nursing education and is intended to guide care in hospitals. Her theory outlines 10 steps to identify a patient’s problem and expands into additional skills to develop a treatment. The 10 steps include:
- Learn to know the patient.
- Sort out relevant and significant data.
- Make generalizations about available data in relation to similar nursing problems presented by other patients.
- Identify the therapeutic plan.
- Test generalizations with the patient and make additional generalizations.
- Validate the patient’s conclusions about their nursing problems.
- Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues affecting their behavior.
- Explore the patient and their family’s reactions to the therapeutic plan and involve them in the plan.
- Identify how the nurses feel about the patient’s nursing problems.
- Discuss and develop a comprehensive nursing care plan.
Theory of Comfort
Katharine Kolcaba’s Theory of Comfort was developed in the 1990s. According to the model, comfort is an immediate desirable outcome of nursing care. Kolcaba described comfort in three forms: relief, ease, and transcendence. If a patient’s comfort needs are met, they’re provided a sense of relief. As a patient’s comfort needs change, the nurse’s interventions change too.
Tidal Model
Developed by nurse and psychotherapist Phil Barker in the 1990s, this model is widely used in mental health nursing and psychiatry. It focuses on the fundamental care process and draws on values about relating to people to help others in moments of distress. The Tidal Model draws from Ten Commitments, which are to value the voice, respect the language, develop genuine curiosity, become the apprentice, use the available toolkit, craft the step beyond, give the gift of time, reveal personal wisdom, know that change is constant, and be transparent.
Self Care Deficit Theory
Developed by Dorothea Orem, self care deficit theory is a health care theory developed between 1959 and 2001. This nursing model holds that people want to take care of themselves, and that those in the nursing profession can enhance patient care by allowing the patient to do as much of their own self care as they are capable of. The Orem self care nursing model is intended to help patients recover by moving them through the recovery process in a maturational way. Meaning that as the patient becomes more capable, the patient is allowed to do more of their own care.
Cultural Care Theory
The Cultural Care Theory created by Madeleine Leininger, focuses on the idea that patient care should be culturally congruent. In other words, care should be in harmony with the patients' cultural or religious beliefs, practices, and values.
Why Are Nursing Theories Important?
Theories provide a foundation for all professions, and health care theories provide the same foundation for nursing students and professionals. As the field of nursing continues to grow, theories are key in structuring patient care—however, that’s just the start. Here are more reasons why nursing theories are important:
- Provide nurses with rationale in making healthcare decisions
- Guide evidence-based research, which then leads to best practices and policies
- Help nurses evaluate patient care
- Give nurses a better understanding of their purpose and role in a healthcare setting
- Ensure nursing best practices are being used
- Provide an identity to nurses that differentiates nursing practice from the medical practice
- Help patients and other healthcare professional recognize the contribution nurses make
This article only scratches the surface on this topic. There’s so much more to explore. A nursing degree program is a great way to gain a deeper understanding of nursing theories and expand your knowledge in the field—whether you’re an aspiring student nurse , just starting nursing school , or looking to elevate your current nursing position .
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Theoretical and Conceptual Frameworks
Identify major characteristics of theories, conceptual models, and frameworks Identify several conceptual models or theories frequently used by nurse researchers Describe how theory and research are linked in quantitative and qualitative studies Critique the appropriateness of a theoretical framework—or its absence—in a study Define new terms in the chapter Key Terms Conceptual framework Conceptual map Conceptual model Descriptive theory Framework Middle-range theory Model Schematic model Theoretical framework Theory High-quality studies typically achieve a high level of conceptual integration . This happens when the research questions fit the chosen methods, when the questions are consistent with existing evidence, and when there is a plausible conceptual rationale for expected outcomes—including a rationale for any hypotheses or interventions. For example, suppose a research team hypothesized that a nurse-led smoking cessation intervention would reduce smoking among patients with cardiovascular disease. Why would they make this prediction—what is the “theory” about how the intervention might change people’s behavior? Do the researchers predict that the intervention will change patients’ knowledge? their attitudes? their motivation? The researchers’ view of how the intervention would “work” should drive the design of the intervention and the study. Studies are not developed in a vacuum—there must be an underlying conceptualization of people’s behaviors and characteristics. In some studies, the underlying conceptualization is fuzzy or unstated, but in good research, a defensible conceptualization is made explicit. This chapter discusses theoretical and conceptual contexts for nursing research problems. THEORIES, MODELS, AND FRAMEWORKS Many terms are used in connection with conceptual contexts for research, such as theories, models, frameworks, schemes, and maps. These terms are interrelated but are used differently by different writers. We offer guidance in distinguishing these terms as we define them. Theories In nursing education, the term theory is used to refer to content covered in classrooms, as opposed to actual nursing practice. In both lay and scientific language, theory connotes an abstraction . Theory is often defined as an abstract generalization that explains how phenomena are interrelated. As classically defined, theories consist of two or more concepts and a set of propositions that form a logically interrelated system, providing a mechanism for deducing hypotheses. To illustrate, consider reinforcement theory , which posits that behavior that is reinforced (i.e., rewarded) tends to be repeated and learned. The proposition lends itself to hypothesis generation. For example, we could deduce from the theory that hyperactive children who are rewarded when they engage in quiet play will exhibit fewer acting-out behaviors than unrewarded children. This prediction, as well as others based on reinforcement theory, could be tested in a study. The term theory is also used less restrictively to refer to a broad characterization of a phenomenon. A descriptive theory accounts for and thoroughly describes a phenomenon. Descriptive theories are inductive, observation-based abstractions that describe or classify characteristics of individuals, groups, or situations by summarizing their commonalities. Such theories are important in qualitative studies. Theories can help to make research findings interpretable. Theories may guide researchers’ understanding not only of the “what” of natural phenomena but also of the “why” of their occurrence. Theories can also help to stimulate research by providing direction and impetus. Theories vary in their level of generality. Grand theories (or macrotheories ) claim to explain large segments of human experience. In nursing, there are grand theories that offer explanations of the whole of nursing and that characterize the nature and mission of nursing practice, as distinct from other disciplines. An example of a nursing theory that has been described as a grand theory is Parse’s Humanbecoming Paradigm ( Parse, 2014 ). Theories of relevance to researchers are often less abstract than grand theories. Middle-range theories attempt to explain such phenomena as stress, comfort, and health promotion. Middle-range theories, compared to grand theories, are more specific and more amenable to empirical testing. Models A conceptual model deals with abstractions (concepts) that are assembled because of their relevance to a common theme. Conceptual models provide a conceptual perspective on interrelated phenomena, but they are more loosely structured than theories and do not link concepts in a logical deductive system. A conceptual model broadly presents an understanding of a phenomenon and reflects the assumptions of the model’s designer. Conceptual models can serve as springboards for generating hypotheses. Some writers use the term model to designate a method of representing phenomena with a minimal use of words, which can convey different meanings to different people. Two types of models used in research contexts are schematic models and statistical models. Statistical models , not discussed here, are equations that mathematically express relationships among a set of variables and that are tested statistically. Schematic models (or conceptual maps ) visually represent relationships among phenomena and are used in both quantitative and qualitative research. Concepts and linkages between them are depicted graphically through boxes, arrows, or other symbols. As an example of a schematic model, Figure 8.1 shows Pender’s Health Promotion Model , which is a model for explaining and predicting the health-promotion component of lifestyle ( Pender et al., 2015 ). Schematic models are appealing as visual summaries of complex ideas. Frameworks A framework is the conceptual underpinning of a study. Not every study is based on a theory or model, but every study has a framework. In a study based on a theory, the framework is called the theoretical framework ; in a study that has its roots in a conceptual model, the framework may be called the conceptual framework . However, the terms conceptual framework , conceptual model , and theoretical framework are often used interchangeably. A study’s framework is often implicit (i.e., not formally acknowledged or described). Worldviews shape how concepts are defined, but researchers often fail to clarify the conceptual foundations of their concepts. Researchers who clarify conceptual definitions of key variables provide important information about the study’s framework. Quantitative researchers are less likely to identify their frameworks than qualitative researchers. In qualitative research within a research tradition, the framework is part of that tradition. For example, ethnographers generally begin within a theory of culture. Grounded theory researchers incorporate sociological principles into their framework and approach. The questions that qualitative researchers ask often inherently reflect certain theoretical formulations. In recent years, concept analysis has become an important enterprise among students and nurse scholars. Several methods have been proposed for undertaking a concept analysis and clarifying conceptual definitions (e.g., Walker & Avant, 2011 ). Efforts to analyze concepts of relevance to nursing should facilitate greater conceptual clarity among nurse researchers. Example of developing a conceptual definition Ramezani and colleagues (2014) used Walker and Avant’s (2011) eight-step concept analysis methods to conceptually define spiritual care in nursing . They searched and analyzed national and international databases and found 151 relevant articles and 7 books. They proposed the following definition: “The attributes of spiritual care are healing presence, therapeutic use of self, intuitive sense, exploration of the spiritual perspective, patient centredness, meaning-centred therapeutic intervention and creation of a spiritually nurturing environment” (p. 211). The Nature of Theories and Conceptual Models Theories, conceptual frameworks, and models are not discovered ; they are created. Theory building depends not only on observable evidence but also on a theorist’s ingenuity in pulling evidence together and making sense of it. Because theories are not just “out there” waiting to be discovered, it follows that theories are tentative. A theory cannot be proved—a theory represents a theorist’s best efforts to describe and explain phenomena. Through research, theories evolve and are sometimes discarded. This may happen if new evidence undermines a previously accepted theory. Or, a new theory might integrate new observations with an existing theory to yield a more parsimonious explanation of a phenomenon. Theory and research have a reciprocal relationship. Theories are built inductively from observations, and research is an excellent source for those observations. The theory, in turn, must be tested by subjecting deductions from it (hypotheses) to systematic inquiry. Thus, research plays a dual and continuing role in theory building and testing. CONCEPTUAL MODELS AND THEORIES USED IN NURSING RESEARCH Nurse researchers have used both nursing and nonnursing frameworks as conceptual contexts for their studies. This section briefly discusses several frameworks that have been found useful by nurse researchers. Conceptual Models of Nursing Several nurses have formulated conceptual models representing explanations of what the nursing discipline is and what the nursing process entails. As Fawcett and DeSanto-Madeya (2013) have noted, four concepts are central to models of nursing: human beings , environment , health , and nursing . The various conceptual models define these concepts differently, link them in diverse ways, and emphasize different relationships among them. Moreover, the models emphasize different processes as being central to nursing. The conceptual models were not developed primarily as a base for nursing research. Indeed, most models have had more impact on nursing education and clinical practice than on research. Nevertheless, nurse researchers have turned to these conceptual frameworks for inspiration in formulating research questions and hypotheses. TIP The Supplement to Chapter 8 on website includes a table of several prominent conceptual models in nursing. The table describes the model’s key features and identifies a study that claimed the model as its framework. Let us consider one conceptual model of nursing that has received research attention, Roy’s Adaptation Model . In this model, humans are viewed as biopsychosocial adaptive systems who cope with environmental change through the process of adaptation ( Roy & Andrews, 2009 ). Within the human system, there are four subsystems: physiologic/physical, self-concept/group identity, role function, and interdependence. These subsystems constitute adaptive modes that provide mechanisms for coping with environmental stimuli and change. Health is viewed as both a state and a process of being, and becoming integrated and whole, that reflects the mutuality of persons and environment. The goal of nursing, according to this model, is to promote client adaptation. Nursing interventions usually take the form of increasing, decreasing, modifying, removing, or maintaining internal and external stimuli that affect adaptation. Roy’s Adaptation Model has been the basis for several middle-range theories and dozens of studies. Research example using Roy’s Adaptation Model Alvarado-García and Salazar Maya (2015) used Roy’s Adaptation Model as a basis for their in-depth study of how elderly adults adapt to chronic benign pain. Middle-Range Theories Developed by Nurses In addition to conceptual models that describe and characterize the nursing process, nurses have developed middle-range theories and models that focus on more specific phenomena of interest to nurses. Examples of middle-range theories that have been used in research include Beck’s(2012) Theory of Postpartum Depression; Kolcaba’s (2003) Comfort Theory, Pender and colleagues’ (2015) Health Promotion Model, and Mishel’s (1990) Uncertainty in Illness Theory. The latter two are briefly described here. Nola Pender’s (2011) Health Promotion Model (HPM) focuses on explaining health-promoting behaviors, using a wellness orientation. According to the model (see Fig. 8.1 ), health promotion entails activities directed toward developing resources that maintain or enhance a person’s well-being. The model embodies a number of propositions that can be used in developing and testing interventions and understanding health behaviors. For example, one HPM proposition is that people engage in behaviors from which they anticipate deriving valued benefits, and another is that perceived competence (or self-efficacy ) relating to a given behavior increases the likelihood of performing the behavior. Example using the Health Promotion Model Cole and Gaspar (2015) used the HPM as their framework for an evidence-based project designed to examine the disease management behaviors of patients with epilepsy and to guide the implementation of a self-management protocol for these patients. Mishel’s Uncertainty in Illness Theory ( Mishel, 1990 ) focuses on the concept of uncertainty—the inability of a person to determine the meaning of illness-related events. According to this theory, people develop subjective appraisals to assist them in interpreting the experience of illness and treatment. Uncertainty occurs when people are unable to recognize and categorize stimuli. Uncertainty results in the inability to obtain a clear conception of the situation, but a situation appraised as uncertain will mobilize individuals to use their resources to adapt to the situation. Mishel’s conceptualization of uncertainty and her Uncertainty in Illness Scale have been used in many nursing studies. Example using Uncertainty in Illness Theory Cypress (2016) used Mishel’s Uncertainty in Illness Theory as a foundation for exploring uncertainty among chronically ill patients in the intensive care unit. Other Models Used by Nurse Researchers Many concepts in which nurse researchers are interested are not unique to nursing, and so their studies are sometimes linked to frameworks that are not models from nursing. Several alternative models have gained prominence in the development of nursing interventions to promote health-enhancing behaviors and life choices. Four nonnursing theories have frequently been used in nursing studies: Bandura’s (2001) Social Cognitive Theory, Prochaska et al.’s (2002) Transtheoretical (Stages of Change) Model, the Health Belief Model ( Becker, 1974 ), and the Theory of Planned Behavior ( Ajzen, 2005 ). Social Cognitive Theory ( Bandura, 2001 ), which is sometimes called self-efficacy theory , offers an explanation of human behavior using the concepts of self-efficacy, outcome expectations, and incentives. Self-efficacy concerns people’s belief in their own capacity to carry out particular behaviors (e.g., smoking cessation). Self-efficacy expectations determine the behaviors a person chooses to perform, their degree of perseverance, and the quality of the performance. For example, C. Lee and colleagues (2016) examined whether social cognitive theory–based factors, including self-efficacy, were determinants of physical activity maintenance in breast cancer survivors 6 months after a physical activity intervention. TIP Self-efficacy is a key construct in several models discussed in this chapter. Self-efficacy has repeatedly been found to affect people’s behaviors and to be amenable to change, and so self-efficacy enhancement is often a goal in interventions designed to change people’s health-related behavior.
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Nursing and Allied Health: Find Evidence (info sources)
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To better understand (and write about) your research topic, you should brainstorm the main concept(s) involved , and find encyclopedia entries on that concept . This will not only give you an historical context (how has the thing, theory, or technology evolved over time?, what people, laws/policies are involved?), but will also help you find the words and phrases that are essential for searching the scholarly literature. Once you have a handle on your concept(s), search the journal, book and other literature, using the "Information Sources" section below.
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The theoretical framework you select for your DNP scholarly project sets the backbone, tone, and process for your project, but you cannot usually simply search the literature for 'nursing frameworks' to select one. The framework you select should be based on how well it will work for your project - does it aid in assessing what you want it to? is it easy to implement? does it work within your timeframe? To find one, return to any course readings that discussed potential frameworks. Also look at studies that are similar to your own for the researcher's process. Searching for frameworks be field and type of research. Below are a few links to spark your thinking, but by no means an exhaustive list of options.
- How to I select a theoretical framework? This USC guide outlines the purpose of a theoretical framework for your research, and how to go about selecting one.
- Commonly used frameworks for quality improvement in health care This article from Pediatric Investigation, outlines some common Conceptual Frameworks for Quality Improvement
- Examples of theoretical frameworks This guide from SUNY Buffalo lists some commonly used frameworks.
- Frameworks organized by type of research University of Washington's Implementation Science Resource hub
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Resources - Specific
- Nursing Theory - Health Promotion Model
- Pender, Nola J., (2011). Health Promotion Model Manual , University of Michigan
- Grandell, Kate, (2015) Nola Pender's Health Promotion Model, 2:12 min animation
- Kern, Angela, (2016) Nola Pender: Health Promotion Model , 16:24 min
- Bandura A. (1977) Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. ; vol. 84 :191–215. doi: 10.1037/0033-295X.84.2.191
- Pajares, Frank. (2002) Emory University, Overview of Social Cognitive Theory ad of Self-efficacy
- Yildirim, Caglar (2011) Self Efficacy: Its Role and Sources 5:42 min, animation
- Burditt, Raina (2015) Self Efficacy , PowToon, 7:06 min, animation
- Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, 1(1), 5–41. doi:10.1177/00187267470010010 3, LML Per H1.H8
- Lewin, K. (1951). Field theory in social science: Selected theoretical papers. New York, NY : Har per. LML H61. L48 1951
- Carroll, Meredith, (2016), Plan-Do-Study-Act (PDSA) Cycle , 6.21 min,
- Christoff, Patricia (2018). Running PDSA cycles . Current Problems in Pediatric and Adolescent Health Care. vol 48, pp 198-201.
- Taylor, Michael J., (2013), Systematic review of the application of the plan-to-study-act method to improve quality in healthcare . BMJ Quality & Safety. DOI: 10.1136/bmjqs-2013-001862
- Reed, Julie E., (2015), The problem with Plan-Do-Study-Act cycles . BMJ Quality & Safety. doi: 10.1136/bmjqs-2015-005076
- Braun, Virginia., & Clarke, Victoria. (2006). Using thematic analysis in psychology, Qualitative Research in Psychology, vol. 3(2), pp 77-101.
- Braun, Virginia, & Clarke, Victoria (2013) Successful qualitative research: a practical guide for beginners. London: Sage Publications
- Donabedian, Avedis (1966). Evaluating the Quality of Medical Care. Health Services Research I. A Series of Papers Commissioned by the Health Services Research Study Section of the United States Public Health Service. Discussed at a Conference Held in Chicago, October 15-16, 1965, The Milbank Memorial Fund Quarterly, Vol. 44, No. 3, July, pp. 166-206. https://www.jstor.org/stable/3348969
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Theoretical frameworks are essential to understand phenomena of interest in healthcare systems (Brewer et al., 2008). Theory-based research into
Environmental Theory · Casey's Model of Nursing · Patient-Centered Approach to Nursing · Theory of Comfort · Tidal Model · Self Care Deficit Theory.
Examples of middle-range theories that have been used in research include Beck's(2012) Theory of Postpartum Depression; Kolcaba's (2003) Comfort
This is often done using a theoretical framework (sometimes called a conceptual framework). Such a framework helps to situate your topic, the
The theoretical framework you select for your DNP scholarly project sets the ... Searching for frameworks be field and type of research.
Unfortunately, some research articles claim that the study was designed using a particular theoretical framework, but the connection between the theory and the
Developed the first theory of nursing. · Focused on changing and manipulating the environment in order to put the patient in the best possible conditions for
Typically, nursing theory provides an autonomy that reinforces nursing education, practice as well as nursing research. Peplau's theory is one of the major
Resources - Specific · Article. Braun, Virginia., & Clarke, Victoria. (2006). Using thematic analysis in psychology, Qualitative Research in Psychology, vol. 3(2)
Four major concepts are frequently interrelated and fundamental to nursing theory: person, environment, health, and nursing. These four are