Integrated Approach
An integrated approach to theory development describes an evolutionary process that is particularly useful in addressing complex clinical situations. It requires gathering of data from the clinical setting, identification of exemplars, discovery of solutions, and recognition of supportive information from other sources (Meleis, 2007).
Integrated theory development is rooted in clinical practice. Practice drives the basic questions and provides opportunities for clinical involvement in research that is designed to answer the questions. In this process for theory development, hunches and conceptual ideas are communicated with other clinicians or participants to allow for critique and further development. Among other strategies, the integrated ap- proach uses skills and tools from clinical practice, various research methods, clinical diaries, descriptive journals, and collegial dialogues in developing a framework or con- ceptualization (Meleis, 2007).
situation (Chinn & Kramer, 2008). Methods of concept development are described in detail in Chapter 3.
Statement Development: Formulation and Validation of Relational Statements
Relational statements are the skeletons of theory; they are the means by which the theory comes together. The process of formulation and validation of relational state- ments involves developing the relational statements and determining empirical refer- ents that can validate them.
After a statement has been delineated initially, it should be scrutinized or analyzed.
Statement analysis is a process described by Walker and Avant (2005) to thoroughly examine relational statements. Statement analysis classifies statements and examines the relationships between the concepts and helps direct theoretical construction.
There are seven steps in the process of statement analysis (Box 4-2). Following the process of statement analysis, the statements are refined and may be operationalized.
Theory Construction: Systematic Organization of the Linkages
The third stage in theory development involves structuring and contextualizing the components of the theory. This includes formulating systematic linkages between and among concepts, which results in a formal, coherent theoretical structure. The format used depends on what is known or assumed to be true about the phenomena in ques- tion (Chinn & Kramer, 2008). Aspects of theory construction include identifying and defining the concepts, identifying assumptions, clarifying the context within which the theory is placed, designing relationship statements, and delineating the organiza- tion, structure, or relationship among the components.
Theory synthesis is a theory construction strategy developed by Walker and Avant (2005). In theory synthesis, concepts and statements are organized into a network or whole. The purposes of theory synthesis are to represent a phenomenon through an in- terrelated set of concepts and statements, to describe the factors that precede or influ- ence a particular phenomenon or event, to predict effects that occur after some event, or to put discrete scientific information into a more theoretically organized form.
Theory synthesis can be used to produce a compact, informative graphic repre- sentation of research findings on a topic of interest, and synthesized theories may be expressed in several ways such as graphic or model form. The three steps in theory synthesis are summarized in Box 4-3.
Validating and Confirming Theoretical Relationships in Research
Chinn and Kramer (2008) include the process of validating and confirming theoretical relationships as a component of theory development. Validating theoretical relation- ships involves empirically refining concepts and theoretical relationships, identifying
1. Select the statement to be analyzed.
2. Simplify the statement.
3. Classify the statement.
4. Examine concepts within the statement for definition and validity.
5. Specify relationship between concepts.
6. Examine the logic.
7. Determine stability.
Source: Walker and Avant (2005).
BOX 4-2
Steps in Statement Analysis
empirical indicators, and testing relationships through empirical methods. In this step, the focus is on correlating the theory with demonstrable experiences and designing research to validate the relationships. Additionally, alternative explanations are consid- ered, based on the empirical evidence.
Validation and Application of Theory in Practice
An important final step in theory development identified by Chinn and Kramer (2008) is applying the theory in practice. In this step, research methods are used to assess how the theory can be applied in practice. The theoretical relationships are examined in the practice setting and results are recorded to determine how well the theory achieves the desired outcomes. The research design should provide evidence of the effect of the interventions on the well-being of recipients of care. Questions to be considered in this step include: Are the theory’s goals congruent with practice goals?
Is the intended context of the theory congruent with the practice situation? Are ex- planations of the theory sufficient for use in the nursing situation? Is there research evidence supporting use of the theory?
Summary
Jill Watson, the nurse/graduate student introduced in the case study at the beginning of this chapter, was unable to identify a theory or conceptual model that completely met the needs for her study on health motivation. Because of this, she determined that it would be appropriate and feasible to use theory development techniques to revise an existing theory to use in her research project.
Theory development is an important but complex and time-consuming process.
This chapter has presented a number of issues related to the process of theory devel- opment. These issues included the purpose of developing theory and the components of a theory. Discussion focused on concepts, theoretical statements, assumptions, and model development and explained the relationships among theory, research, and practice. Finally, the process of theory development was presented.
To further illustrate the process of theory development, a summary report of a the- ory recently published in the nursing literature is presented. In the following exemplar, each of the components of the theory is clearly identified. In addition, Chapter 5 ex- pands on the process of theory development by examining the processes of theory analysis and evaluation.
1. Select a topic of interest and specify focal concepts (may be one concept/variable or a framework of several concepts).
2. Conduct a review of the literature to identify related factors and note their relationships.
Identify and record relationships indicating whether they are bidirectional, unidirectional, positive, neutral or negative, weak or ambiguous, or strong in support evidence.
3. Organize concepts and relational statements into an integrated representation of the phenomena of interest. Diagrams may be used to express the relationships among the concepts.
Source: Walker and Avant (2005).
BOX 4-3
Steps in Theory Synthesis
T
HEORY DEVELOPMENT EXEMPLARSmith, C. E., Pace, K., Kochinda, C., Kleinbeck, S. V. M., Koehler, J., & Popkess-Vawter, S. (2002). Caregiving effectiveness model evolution to a midrange theory of home care: A process for critique and replication. Advances in Nursing Science, 25 (1), 50–64.
Smith and colleagues developed the “Caregiving Effectiveness Model” to be applied to home care situa- tions in which the patient requires “technologically based treatment.” Provided here is a summary of the components of this theory outlined by the criteria described in this chapter.
Scope of theory: Middle range
Purpose: “To explain and predict outcomes of technology-based home caregiving provided by family members” (p. 50). Outcomes of the model are “to help nurses develop relevant nursing interventions to support positive patient and caregiver outcomes” (p. 51).
Concepts and definitions are listed in the following table.
Concept Definition Empirical Indicator
Caregiving effectiveness The provision of technical, physical, and emotional care by family members that results in outcomes of optimal patient condition, yet maintains the well-being of caregivers
Caregiving Context Concepts Measures !Adaptive Context Concepts Measures "
Caregiving Effectiveness Outcomes
Caregiving Context Concepts Caregiving characteristics Personal characteristics
potentially affecting caregiving
Age, gender, education level
Caregiving/care-receiving
interactions Quality of relationships between caregivers and patients (mutuality) and motivation to provide home care
Mutuality Scale Motivation to Help
Home care management
strategies Educational preparation;
health professional teaching and resource management
Preparedness Scale Efficient use of resources (DEA coefficient)
Adaptive Context Concepts Family economic stability Income adequacy; degree of
health care services use Health care services use/cost Caregiver health status Mental health status
(presence or absence of depression); physical health status
Quality of Life Index Depression Score (CES-D Scale)
Family adaptation Family coping and problem-
solving skills Family Coping Scale Reactions to caregiving Caregiving esteem Caregiver Reactions Scale
Theoretical Statement and Linkages
1. Caregiving Effectiveness Outcomes are the result of the variables in the Caregiving Context being mediated by Adaptive Context Variables.
2. Caregiving characteristics mediated by the caregiver mental health status (depression) affect Care- giving Effectiveness Outcomes.
3. Home care management strategies (preparedness) mediated by reactions to caregiving influence patient condition.
4. Caregiving Effectiveness Outcome of Efficient Use of Resources is influenced by caregiving and adap- tive context variables.
Model: Smith et al.’s schematic diagram combines the statements to illustrate linkages and gives the theory structure as follows.
Caregiving Context Concepts/Measures
Caregiving/Care-Receiving Interactions
• Mutuality
• Motivation to Help
Home Care Management Strategies • Education Preparedness
Caregiver Health Status
Mental Health Status Depression Physical Health Status
Family Adaptation Family Coping Problem-solving
Skills
Reactions to Caregiving Caregiving Esteem
Family Economic Stability • Income Adequacy • Health Care Services
Use Efficient Use of
Resources
Patient (Health Status) Condition
Technological Side Effects
Quality of Life (Patient and Caregiver) Adaptive Context
Concepts/Measures
+ = Caregiving Effectiveness Outcomes
Concepts/Measures
Health Professional Teaching Resource Management Caregiving Characteristics
Concepts in the respecified Caregiving Effectiveness Model. Rectangles enclose concepts in the model; el- lipses enclose recommended interventions derived from the model and found efficacious in clinical trial;
and efficient use of resources is added as an outcome.
Assumptions
1. Caregiving with complex technological home care is stressful and disruptive to usual family activities.
2. Families prefer home technological care as opposed to institutional care.
3. Model concepts are clinically relevant for nursing practice with patients and their caregivers.
4. Models about caregiving of terminally ill and frail or cognitively impaired older persons are not directly applicable to technology-dependent patients.
LEARNING ACTIVITIES
1. Find an example of a nursing theory in a current book or periodical. Review the theory and classify it based on scope or level of abstraction (grand theory, middle range theory, practice theory), the purpose of the theory (describe, explain, pre- dict, control), and the source or discipline in which the theory was developed.
2. Find an example of a middle range nursing theory (see Chapter 10 or 11 for ideas). Following the above exemplar, identify the components of the theory (i.e., scope of the theory, purpose, concepts and definitions, etc.).
3. Find an example of a middle range theory that does not contain a model. With classmates, try to create a model that depicts the relationships between and among the concepts. Discuss the challenges posed by this exercise.
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As nurses began to participate in the processes of theory development in the 1960s, they realized that there was a corresponding need to identify criteria or develop mech- anisms to determine if those theories served their intended purpose. As a result, the first method to describe, analyze, and critique theory was published in 1968. Over the following decades, a number of methods or techniques for theory evaluation were
J
erry Thompson is nearing completion of his master’s degree in nursing. He is currently a case manager for a home health agency and his goal is to become an agency director after he completes his degree. For his research application project, Jerry wants to compare the effectiveness of health teaching in the hospital setting with the effectiveness of health teaching in the home setting. He has identified several areas to examine. These include the quality and type of health information provided, professional competencies of the nurses providing the information, the client’s support system, and environmental resources.Outcome variables he will measure focus on utilization of health care (e.g., length of time on home health service, hospital readmissions, development of complications).
As his research project began to take shape, Jerry realized he needed a conceptual framework for the project. His advisor suggested Pender’s Health Promotion Model. To determine if the model would be appropriate for his study, Jerry obtained the latest edition of Pender’s book (Pender, Murdaugh, & Parsons, 2006), which described the model in depth. He then read commentaries in nursing theory books that analyzed her work and completed a literature search to find examples of research studies using the Health Promotion Model as a conceptual framework. After he had compiled these data, Jerry summarized his findings by using Whall’s (2005) criteria for analysis and evaluation of middle range theories.
This exercise helped Jerry gain insight into the major concepts of the model and let him examine its important assumptions and linkages. From the evaluation, he determined that the model would be appropriate for use as the conceptual framework for his research study.
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C H A P T E R
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5 Theory Analysis
and Evaluation
proposed. A general understanding of these methods will help the advanced practice nurse select an evaluation method for theory, which is appropriate to the stage of the- ory development and for the application of the theory (research, practice, administra- tion, or education). This will, in turn, help ensure that the theory is valid and is being used correctly. It will also provide information for developing and testing new theo- ries by identifying gaps and inconsistencies.
Definition and Purpose of Theory Evaluation
Theory evaluation has been defined as the process of systematically examining a the- ory. Criteria for this process are variable, but they generally include examination of the theory’s origins, meaning, logical adequacy, usefulness, generalizability, and testabil- ity. Theory evaluation does not generate new information outside the confines of the theory, but it often leads to new insights about the theory being examined.
Theory evaluation identifies a theory’s degree of usefulness to guide practice, re- search, education, and administration. Such evaluation gives insight into relationships among concepts and their linkages to each other and allows the reviewer to determine the strengths and weaknesses of a theory. It also assists in identifying the need for ad- ditional theory development or refinement. Finally, theory evaluation provides a sys- tematic, objective way of examining a theory that may lead to new insights and new formulations that will add to the body of practice or research (Walker & Avant, 2005). The ultimate goal of theory evaluation is to determine the potential contribu- tion of the theory to scientific knowledge.
In nursing practice, theory evaluation may provide a clinician with additional knowledge about the soundness of the theory. It also helps identify which theoretical relationships are supported by research, provides guidelines for the choice of appro- priate interventions, and gives some indication of their efficacy. In research, theory evaluation helps clarify the form and structure of a theory being tested or will allow the researcher to determine the relevance of the content of a theory for use as a con- ceptual framework, as described in the case study. Evaluation will also identify incon- sistencies and gaps in the theory used in practice or research (Walker & Avant, 2005).
Various methods have been outlined to assist with this process. The methods are de- scribed by several overlapping terms or terms that are used in different ways by different authors. For example, theory analysis, theory description, theory evaluation, and theory critique all describe the process of critically reviewing a theory to assess its relevance and applicability to nursing practice, research, education, and administration. In this chap- ter, theory evaluation is used as a global term to discuss the process of reviewing theory.
Theory evaluation has been described as a single-phase process (theory analysis) by Alligood (2006) as well as Hardy (1974) (theory evaluation); a two-phase process (theory analysis and theory critique!evaluation) by Fawcett (2005) and Duffey and Muhlenkamp (1974); or a three-phase process (theory description, theory analysis, and theory critique!evaluation) by scholars including Meleis (2007) and Moody (1990). It should be noted that the methods are similar whether they describe one, two, or three phases. A three-phase process is outlined briefly in the following section.
Later sections provide more detailed discussions of each phase.