THEORETICAL AND CONCEPTUAL MODELS
During the past 50 years, the nursing profession has given considerable attention to theoretical and conceptual models. This attention has served to differentiate nursing from other disciplines (Marrs & Lowry 2009; Russell & Fawcett, 2005). However, nursing theories are not new in nursing. Nightingale (1859/1992) elaborated on the relationship of the environment to health and well-being. Numerous theoretical and conceptual models exist.
What relevance do nursing theories have to practice? Can't nurses merely practice nursing? Meleis (2011) noted that a theory articulates and communicates a mental image of a certain order that exists in the world. This image includes components, and these components inform a model or perspective that guides each nurse's practice. This model may be identical to one of the publicized nursing theories, or it may be based on a theoretical perspective from another discipline. In some instances, eclectic models are used in which nurses combine elements from established nursing theories or theories from other disciplines. New nursing theories continue to be developed. Of particular importance is the delineation of nursing theories that incorporate various cultural perspectives, because the Western philosophical perspective to date has not pervaded many of the existing theories.
There has been much discussion about whether one grand nursing theory is needed. Would the existence of a grand or meta-theory be advantageous to the progression of the profession and discipline? Riehl-Sisca (1989) stated that nursing has benefited from having a multiplicity of theories. The wide range of perspectives elaborated in these theories has helped nurses to more clearly define the nature of the discipline and profession, to evaluate various approaches that can be employed in practice, and to respect diversity as a positive element. Alligood and Marriner-Tomey (2005) identified seven theorists who have developed primary grand theories or conceptual frameworks for nursing: Johnson (1980), King (1971), Levine (1967), Neuman (1974), Orem (1980), Rogers (1970), and Roy (1984). Many other nurses have developed midrange theories or conceptual frameworks that have served as a basis for research and practice.
More recently, nurses have turned their attention to midrange theories. Midrange theories, which focus on a limited number of variables, are more amenable to empirical testing than are grand theories by definition. Examples of midrange theories include empathy (Olson & Hanchett, 1997), uncertainty in illness (Mishel, 1990), resilience (Polk, 1997), mastery (Younger, 1991), self-transcendence (Reed, 1991), caring (Swanson, 1991), and illness trajectory (Wiener & Dodd, 1993).
Duffy (2009) developed the quality-caring model, providing the APRN with a framework that emphasizes the less visible value of nursing—that is, caring. This is often the less obvious value, but one that guides practice, provides a foundation for quality care, improved outcomes, and patient satisfaction, and supports research. In her model, the evidence-based care environment in health care today is merged with the caring qualities and attributes of nursing. Caring values, attitudes, knowledge, and behaviors will guide and drive the process of the care plan and interventions, and will establish the foundation for strong relationships. The APRN patient-nurse relationship is primary and includes all interactions and interventions for which the APRNs are accountable and will implement autonomously. To be a successful APRN leader, collaborative relationships are necessary and include "those activities and responsibilities that nurses share with the members of the interprofessional healthcare team" (Duffy, 2009, p. 82).
Many nurses give little thought to the tenets that guide their practice; however, these philosophical underpinnings have a profound impact on the nature and scope of their practice. When APRNs have a theory-guided practice, they improve the care being provided by offering structure, efficiency in regard to continuity of care, and higher quality of care and improved health outcomes. The discipline of nursing, including professionalism, accountability, and APRN autonomy as a care provider, is supported with a nursing theory-guided practice. Often, an APRN practices and applies clinical decision making within a nursing framework but is not consciously aware of doing so. Nurses have an ethical and moral responsibility to practice nursing with a consciously defined approach to care. The theoretical or conceptual model used by a nurse provides the basis for making the complex decisions that are crucial in the delivery of high-quality nursing care. In this regard, Smith (1995) stated the following:
The core of advanced practice nursing lies within nursing's disciplinary perspective on human-environment and caring interrelationships that facilitate health and healing. This core is delineated specifically in the philosophic and theoretic foundations of nursing, (p. 3)
Thus, nursing theory is an important component of APRN education. Nursing is a practice discipline, and theories achieve importance in relation to their impact on nursing care. Recently, attempts have been made to relate nursing theories to practice and to begin testing these theories. However, only minimal testing of these theories in practice settings has occurred. The number of theoretical nursing studies, particularly studies examining the efficacy of nursing interventions, is an indication of the apparent separation of theories and practice that has characterized much of nursing practice. As DNP programs continue to mature and develop, it is anticipated that the application gap between theories and practice will narrow.
The theoretical or conceptual framework that an APRN selects and uses has a major impact on the assessments that are made and the nature of the interventions that are chosen to achieve individual outcomes. Gordon (2007) and Johnson (1989) have noted the profound impact a nurse's theoretical perspective can have on a nursing practice. Gordon (1987) stated the following:
One's conceptual perspective on clients and on nursing's goals strongly determines what kinds of things one assesses. Everyone has a perspective, whether in conscious awareness or not. Problems can arise if the perspective "in the head" is inconsistent with the actions taken during assessment. Information collection has to be logically related to one's view of nursing, (p. 69)
A conceptual model provides the practitioner with a general perspective or a mind-set of what is important to observe, which in turn provides the basis for making nursing diagnoses and selecting nursing interventions.
INCORPORATING NURSING INTO ADVANCED PRACTICE NURSING
Guaranteeing that APRNs view the provision of health care from a nursing perspective has implications for graduate curricula. The American Association of Colleges of Nursing (AACN, 2006) includes nursing theory as a component of its document Essentials of Doctoral Education for Advanced Practice Nursing. Students also need assistance in utilizing this theoretical content in their practice. Faculty and preceptors who model this approach for advanced practice nursing students are critical for helping them integrate theory into practice and to build bridges over the theory to practice gap that currently exists.
APRNs provide health care to many individuals and populations in diverse care environments and settings. APRNs have the opportunity to make major contributions to advance the nursing profession. By focusing on the nursing elements of health care, APRNs have the opportunity to demonstrate to the public and to policy makers the unique and significant contributions that nursing has on health outcomes. In using nursing frameworks rather than the medical model as the focus of practice, APRNs provide the public with a distinct and adjunctive model of care rather than a substitutive model (i.e., replacing physicians). APRNs may carry out activities that have traditionally been a part of medicine, but the manner, approach, style, and performance of these activities by APRNs need to be translated into the realm of nursing.
The author acknowledges the contributions of Michaelene Jansen to this chapter in the previous edition.