What were the most important concepts you learned in week 7? Why are these concepts important?
How will they prepare you for your future role as an NP? In what ways do you feel prepared for your new role? In what ways do you feel unprepared?
Chapter 25: Theory Testing and Theory Evaluation*
The focus of this chapter is the science and art of theory development and evaluation. The chapter begins with a definition of theory and a description of the process of theory development and continues with a discussion of the critical thinking that is required for the evaluation of theories. The emphasis in this chapter is theory development and evaluation activities that are required for advanced practice nursing. The content of this chapter is especially relevant to two of the American Association of Colleges of Nursing’s Essentials of DoctoralColleges of Nursing’s Essentials of Doctoral Education for Advanced Nursing Practice: Essential I, Scientific Underpinnings for Practice, and Essential III, Clinical Scholarship and Analytical Methods for Evidence-Based Practice.
THE SCIENCE AND ART OF THEORY DEVELOPMENT
The term theory is used to refer to diverse works, ranging from very abstract and general conceptual models to less abstract and general grand theories, to relatively concrete and specific middle-range theories, to very concrete and specific narrow-range situation-specific theories. Despite the lack of consensus about the meaning of theory, King and Fawcett (1997) found considerable agreement about the existence of levels of abstraction for theoretical work. In this chapter, the term refers to middle-range theories and situation-specific theories. The term conceptual model refers to the very abstract and general work from which theories are derived.
Theories A theory is made up of concepts and propositions about a phenomenon. A concept is a word or phrase that captures the essence of something, such as adjustment or distress. It may have one or more dimensions. An example of a single-dimensional concept is resiliency. An example of aa multidimensional concept is perceived stigma, the six dimensions of which are fear of contagion, healthcare neglect, negative self-perception, social isolation, verbal abuse, and workplace stigma (Mwangi, 2013).
A proposition is a statement about one or more concepts. A proposition about one concept is a definition or a description of the concept; resiliency, for example, is defined as “The capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the ability to bounce back quickly after an insult” (American Association of Critical Care Nurses, 2014, p. 1). A proposition about two or more concepts states an association between the concepts, including the relation between the concepts or the effect of one concept on one or more other concepts. An example of a statement of the relation between two concepts is, “Socio-demographic characteristics are related to perceived stigma” (Mwangi, 2013). An example of a statement about the effect of a concept on other concepts, which typically involves the effect of some intervention on some outcomes, is, “Information about walking exercise has a positive effect on symptoms, fatigue, emotional distress, and physical function” (Mock et al., 2007)Nursing theories usually focus on experiences of health conditions and health-related events. Examples of health conditions
include such medical diagnoses as congestive heart failure cancer, and diabetes. Examples of health-related events include pregnancy, childbirth, the postpartum period, and aging. The health condition or health event of interest provides a context for a theory. For example, the concepts of exercise intervention, fatigue, and emotional distress and the propositions about those concepts could make up a theory about the effects of an exercise intervention on fatigue and emotional distress experienced by men with colon cancer. Alternatively, the concepts of fatigue and emotional distress might make up a theory about the relation between fatigue and emotional distress during the postpartum period.
Types of Theories Three types of theories are descriptive, explanatory, and predictive. Descriptive theories simply describe some phenomenon. They typically comprise one concept and one proposition that is a definition or description of the concept. An example of a descriptive theory is the theory of fatigue. In this ccase, the theory concept is fatigue. The theory proposition asserts that fatigue is a multidimensional concept defined as behavioral, sensory, and affective experiences (Piper et al., 1998).
Explanatory theories specify how concepts are related to each other and, therefore, provide explanations for phenomena. They consist of two or more concepts, the propositions that are definitions or descriptions of each concept, and the propositions that specify the relation(s) between the concepts. An example is the theory of chronic pain (Tsai, Tak, Moore, & Palencia, 2003). The theory concepts are chronic pain, physical disability, social support, age, gender, perceived daily stress, and depression. The propositions that are definitions of each concept are as follows:
Chronic pain is defined as the frequency and severity of pain (Tsai et al., 2003).Physical disability is defined as the frequency and extent of mobility, walking, bending, and hand and finger function (Tsai et al., 2003). Social support is defined as “perceived levels of social support . . . [including] (a) provision of attachment/intimacy, (b) social integration, (c) opportunity for nurturant behavior, (d) reassurance of worth, and (e) availability of informational, emotional, and material help” (Tsai et al., 2003, p. 162). Age is defined as age in years (Tsai et al., 2003). Gender is defined as male or female (Tsai et al., 2003). Perceived daily stress is defined as “the degree to which older persons experience daily stress from irritating, frustrating, or repeated occurrences in their lives” (Tsai et al., 2003, p. 162). Depression is defined as the frequency of depressed mood symptoms within the past week (Tsai et al., 2003). The following theory proposition specifies the relations between the concepts: Chronic pain, physical disability, social support, age, and gender are related to perceived daily stress, which is related to depression.
Predictive theories specify how a concept affects one or more other concepts. They are made up of two or more concepts, the propositions that are definitions or descriptions of each concept, and the propositions that specify the effect(s) of one concept on one or more other concepts. An example is the theory of the effects of simulated conflict management training (Pines et al., 2014). The theory concepts aresimulated conflict management training
exercises, stress resiliency, psychological empowerment, and conflict management style. The propositions that are definitions of each concept are as follows:
Simulated conflict management training exercises are defined as “didactic and simulated training using a variety of scenarios for learning resiliency skills, enhancing perceptions of empowerment and increasing knowledge of personal styles of conflict management” (Pines et al., 2014, p. 87). Stressr resiliency is defined as “the ability of an individual to adjust to adversity, maintain equilibrium, retain some control over the environment, and move in a positive direction” (Pines et al., 2014, p. 86). Psychological empowerment is defined as “the individual’s perceived sense of meaning and purpose, competence, self-determination, and impact on the work role” (Pines et al., 2014, p. 86). Conflict management style is defined as “[depending] on the situation and the parties involved and [involving] a choice of methods to manage a situation. . . . [The five] conflictmanagement styles [are] accommodating, avoiding, collaborating, competing, and compromising. Accommodating is unassertive and cooperative and allows the other person to dominate. Avoiding is both uncooperative and unassertive and is characterized by the individual’s avoidance of taking any action. Collaborating is assertive and cooperative and represents an attempt to find a solution to the conflict. Competing is assertive and uncooperative. Finally, compromising is intermediate in both assertiveness and cooperativeness and partially satisfies the needs of each party. With competing, [an individual] assertively pursues personal concerns at the expense of the concerns of another. In compromising, the object is to find a mutually agreeable solution that partially satisfies both parties. Resiliency and empowerment reflect application of the appropriate strategy/style in response to the situation” (Thomas & Kilmann, as cited in Pines et al., 2014, p. 86). The following theory proposition specifies effects: Simulated conflict management training exercises have a positive effect on stress resiliency, psychological empowerment, and conflictmanagement style (Pines et al., 2014).
Empirical Indicators and Other Empirical Methods Most theory concepts and propositions cannot be directly observed or measured. Instead, each concept must be connected to an empirical indicator, which serves as a real-world proxy—or substitute—for a concept. Empirical indicators that are particularly useful for advanced practice nurses are assessment tools and intervention protocols. Assessment tools include various types of questionnaires, such as checklists and rating scales, which contain one or more items. For example, postpartum mood disorder is assessed by the 21-item Neuman Postpartum Mood Questionnaire (Fashinpaur, 2002), or as a one-item rating scale that asks the woman to indicate, on a scale of 0 to 10, the extent to which she feels depressed. One-item assessment tools are particularly useful in advanced practice nursing because they do not impose a burden on patients, which may occur when a tool with many items is used. One-item assessment tools also are useful because they do not impose an undue burden on the advanced practice nurse, which may occur with use of a multi-item tool that requires calculation of a score.
Theories are developed through a melding of science and art in the form of creative conversion of ideas stemming from provocative facts (Levine, 1966; 1991) observed in practice and in the literature. These facts are noticed because they fit with the observer’s frame of reference about nursing, which also is called a conceptual model of nursing. Among the best-known conceptual models are Levine’s Conservation Model, Neuman’s Systems Model, Orem’s Self-Care Framework, and Roy’s Adaptation Model. Overviews of these and other conceptual models of nursing are found in Appendix N-1 of Taber’s Cyclopedic Medical Dictionary (Fawcett, 2013). A comprehensive analysis and evaluation of each of these and other conceptual models of nursing is given in Fawcett and DeSanto-Madeya’s (2013) book Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories.
Each conceptual model of nursing is made up of concepts and propositions that are more abstract and general than those of a theory. Examples of concepts from Roy’s adaptation model include stimuli andgeneral than those of a theory. Examples of concepts from Roy’s adaptation model include stimuli and adaptation. For example, the following proposition defines a conceptual model concept: Adaptation is defined as “the process and outcome whereby thinking and feeling people, as individuals and in groups, use conscious awareness and choice to create human and environment integration” (Roy, 2009, p. 26). An example of a proposition that links the concepts of stimuli and adaptation is as follows: Stimuli are related to the physiological, self-concept, role function, and interdependence modes of adaptation (Fawcett, 2003).
Conceptual–Theoretical–Empirical Structures for Theory Development Theory development involves specification of a conceptual–theoretical–empirical (C-T-E) structure made up of three components:
A conceptual model A theory Empirical indicators and other empirical methodsTheory development is the product of research, which is a systematic process of inquiry (Fawcett & Garity, 2009). Thus, every study is explicitly or implicitly designed to develop a theory by means of generation of new theory or testing of an existing theory. Theory-generating research is descriptive research, the findings of which are new descriptive theories. Theory testing research can be descriptive, correlational, or experimental research. The findings of descriptive theory-testing research determine the empirical adequacy of an existing descriptive theory. The findings of correlational theory-testing research determine the empirical adequacy of an existing explanatory theory. The findings of experimental theory-testing research determine the empirical adequacy of an existing predictive theory. Although the conduct of research typically is thought of as a rigorous scientific process, it is also a creative endeavor involving an appreciation of the beauty of logical reasoning and the “aha” moments that come when developing elegant C-T-E structures, designing studies, and interpreting data.