Conceptual Basis for Nursing Practice Keynote

One of the things that I personally have a bit of a challenge with is terminology. What exactly does this or that mean and what does that have to do with me and my practice? I’ll be providing you with a number of definitions from various sources; some that you are familiar with and some that you may not be. However, feel free to explore on your own as well and share in the class discussion area. I’ll share with you some thoughts on these topics and some examples and then in the class discussion area we will all share some of our ideas of how this applies to our advanced nursing practice.

During the preceding units, you have learned of the importance of the advanced practice nurse to practice from a philosophical, theoretical, and conceptual basis. A foundation…a framework, so to speak. What is meant by that and why is it important? As said in Zaccagnini and White (2011), “Whether we appreciate it or not, every nurse operates from a philosophical and theoretical base” (p. 3). As advanced practice nurses, you will become more aware of this basis and it will help guide your practice. How you choose to do that and what theoretical framework you choose is completely up to you. Theories guide our practice….when you see a patient(s), you are formulating a plan to care for them, no matter your role. This plan that you are developing is based on prior knowledge, experience, cognition (etc.) and in that, a recognition of patterns. Nursing theory gives our practice structure and the ability to predict outcomes.

When you see a patient with diabetes come to your clinic complaining of certain symptoms and exhibiting certain behaviors, you go to your pre-understanding of diabetes and the patient’s response to the illness. You may begin to think of the patterns that you have seen with diabetic patients and you can predict what outcomes may result from their symptomatology. Based on the patient’s complaints, you may begin to run through the possible diagnoses and the predictable outcomes of each. This structured approach to patient care and ability to predict outcomes has a theoretical basis. A framework for your thinking exists, whether implicit or explicitly described. Although at first glance abstract thought may seem to have little to do with the day to day work in the world of nursing, it is actually required in order to see patterns and predict outcomes (Zaccagnini and White, 2011).

When you think about the theoretical basis of care from this standpoint, it is very clear that we have to have some kind of framework from which to practice. Yes, it may be a part of us that some of us are unaware of, but do not mistake…it is a part of our practice.

Let’s go to one of the most important points….How can we use this philosophical, theoretical basis to improve patient outcomes? First, we have to become self-aware. Self-awareness is one of the key tenets of emotional intelligence. You will be doing a great deal of reflection in the graduate curriculum…your journey towards full self-awareness has begun. Which philosophical framework speaks to you? Do you relate to any in particular? What tenets of the philosophy correlate to your personal beliefs and values? Is there a particular grand nursing theory that you can relate to from your practice? What mid-range theory is readily identifiable from your day to day work? Are there theories from other scientific disciplines that you think may be helpful to your practice? (These are not questions that you have to answer right this minute, they will all be discussed in future units). At the end of this class, you will be speaking to your framework of praxis….that framework that you intend to use to base your practice on as an Advanced Practice Nurse. You will have the opportunity this semester to review philosophies, theories, and concepts and see which you think are the most useful for your practice.

The American Association of Colleges of Nursing (AACN) noted in the DNP Essentials that graduates should be able to “develop and evaluate new practice approaches based on nursing theories and theories from other disciplines” (AACN, 2006, p.9). The MSN Essentials speak to graduates about using advanced nursing science, including a variety of theories (nursing and other), to provide advanced nursing care. At the end of the curriculum, many of you will be planning and implementing a practice project that has a theoretical framework. We hope in this class that you take advantage of the opportunity to familiarize yourself with theories that are useful in your practice and helpful for your phenomenon of interest.

So, let’s start from the ground up to help us see how this framework comes together to form our basis of practice.

Let’s begin by discussing what a phenomenon is and how it relates to you. First, let me say, that there are many different definitions and perspectives and they can be quite confusing. So, I like to go to what I consider a wise source who really explains difficult content well and that is Afaf Meleis (pronounced Ma-Lease).

Dr. Meleis is one our foremost nurse scholars and has such a grasp of difficult theoretical content. (You can see a video about her through the mediasite presentations on nurse theorists in the theoretical basis unit…her life is quite extraordinary). Meleis (1997) describes a phenomenon (singular) as “An aspect of reality that can be consciously sensed or experienced” (p. 11). Phenomena (plural) can be described from evidence that is sense based and can be seen, heard, smelled, or felt, or is derived from evidence that is grouped together through connections.

For example, let’s say that you notice that in the PICU, more children seem to die during the 3 to 11 pm shift than any other. In this example, just observing the deaths does not make the phenomenon; it is the grouping together and making a connection between the deaths and the shift that makes it a phenomenon (Meleis, 1997). Another example: You are flying home from Europe and you feel tired, groggy, and have trouble adjusting to the new time zone and remembering. These are all related to the phenomenon of flying or specifically flying across time zones. What is a phenomenon in your practice that you are noticing?

For example, is it that you are seeing immigrant patients come in repeatedly to the hospital for conditions that would have been avoided if they had followed discharge instructions from previous admissions? This is the phenomenon that you are observing… repeated admissions for non-English speaking immigrants in your community. Does this make sense to you? Give it some thought…for some of us it may take a lot of thought (I’m one of those people).

Now…how does that relate to concepts? According to our friend Meleis (1997), a concept “is a term used to describe a phenomenon or a group of phenomena” (p.12). A concept “provides us with a concise summary of thoughts related to a phenomenon”…a labeling of sorts. If we didn’t have that label, we would have to go into detail to describe the phenomenon. So, from our example above related to flying, we can give that the label “jetlag.” Our concept is jetlag….when you hear that term, you automatically think of what that means…that groggy icky feeling you get when flying across time zones. From our other example of a phenomenon related to the repeated admissions of immigrants, we might say that the concept is health literacy. What if we’re not sure what the concept is that is the label for a phenomenon of interest? Search the literature and read about the concepts, particularly focusing on concept analysis to figure out if the label (concept) is correct. Sometimes, the appropriate labeling of the phenomenon will be very clear and other times it is more abstract.

In your readings from Chapter 7 in your Chinn & Kramer (2011) text, you can see that a concept lies along a continuum from the empiric (more directly experienced) to the abstract (more mentally constructed). For example, (chapter 7) the most concrete empirical concepts are those that can be directly experienced such as height and weight (at one end of the continuum), and progress and get more and more abstract, to self-esteem and wellness. Do you see the difference? Of course, the more empiric and concrete, the easier it is to understand and measure. The more abstract the concept, the more difficult to understand and measure. The most abstract concepts, such as self-esteem and wellness in our example, are often called “constructs.” I know….another term to keep straight… but this term, construct, is used quite frequently to represent abstract concepts.

How does this relate to theory? Concepts are the building blocks of theory.

So, when you are thinking about your phenomenon of interest and come up with the appropriate concept, there may be a theory out there that also might fit. We will be thinking about theories in the units to come.

In our class discussion, I want you to share your phenomenon of interest and the corresponding concept. If it’s confusing for you, review your readings and think about our examples here. Also, feel free to ask for feedback from peers in the discussion area. I will be entering the discussion periodically, but I want you all to share your wisdom with each other. The discussion is not a one way discussion between me and all of you, but an area for dialogue between students with periodic faculty comment.

The Concept Analysis Assignment:

How do we make sure we understand what a concept means and how it applies to our phenomenon of interest? We do a concept analysis. We are including some examples of concept analysis articles below that may be helpful for you to review as you prepare for your paper.

Examples of Concept Analysis Articles:

Hansen-Kyle, L. (2005). A concept analysis of healthy aging. Nursing Forum, 40(2), 45-57.

Purdy, I. B. (2004). Vulnerable: A concept analysis. Nursing Forum, 39(4), 25-33.

Shattell, M. (2004). Risk: A concept analysis. Nursing Forum, 39(2), 11-17.

Simonelli, M.C. (2005). Relapse: A concept analysis. Nursing Forum, 40(1), 3-10.

The process of analyzing a concept helps you understand and define the concept to determine its fit for your phenomenon of interest. It really gives you insight into your phenomenon and helps you see how the concept works. It also helps clarify those concepts that are commonly used in nursing but mean different things to different people. Here at the USA College of Nursing, the faculty have decided to use a variation of the Walker and Avant method of concept analysis. These authors adapted Wilson’s 1963 concept analysis methodology. Walker and Avant’s concept analysis methodology is fairly straight forward, but does require some thought. Probably the most difficult step is actually selecting a concept to begin with. You will be posting your phenomenon of interest and corresponding concept in the class discussion for this unit. As I discuss this methodology in the upcoming paragraphs, keep in mind that my reference is the Walker and Avant text: Walker, L. O., & Avant, K. C. (2005). Strategies for theory construction in nursing (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. (As an aside: Why is it important for you to know my source of information? First, you need to know that we’re not pulling information out of thin air…there really is an accepted methodology that is universally used. Second, you may want to purchase this text for use should you decide to publish your paper. “Publish my paper”, you say??? Yes, absolutely! The concept analysis papers you see in the literature were primarily published by graduate nursing students. If you desire to publish your paper, feel free to talk with one of your faculty members to help you. Very often we are happy to publish with students for second authorship. It is an expectation of working with someone else on a manuscript that you include them with an offer for authorship. If you primarily wrote the paper, then you should definitely be first author, even as a student. It’s your work unless your professor has to do almost a complete rewrite then you need to discuss with them about order of authorship. (Most professors I know are happy to be second author.)

Select a Concept

We have already talked about selection of the concept…that is derived from your phenomenon of interest. Feel free to toss out ideas to your colleagues in the class discussion. The faculty member will let you know if your concept has been approved. Typically, your concept will be fine unless it has an odd twist or absolutely no applicability to your phenomenon and then we’ll question what you’re thinking. Don’t feel defensive…remember our class discussions are to mimic dialogue in a classroom as if we’re all around a conference table tossing out ideas and brainstorming. In the same breath, I want to remind everyone to be respectful, courteous, and professional at all times in the course (even when you are aggravated and want to say how you feel). (Another aside: If you receive a grade or an email that angers you, wait at least 24 hours before hitting reply and sending an email).

Significance to your practice and to nursing:

We want to hear from you why you think the concept is important. What is it about this concept that is significant to your practice and to nursing? Referring to our previous example about the health literacy concept for the phenomenon of frequent readmissions for non-English speaking immigrants…why is that important to your practice? Ex…because you are spending time and resources providing care to individuals that could be avoided….those individuals are suffering through additional hospitalizations and all of the related consequences. Why is it important to nursing? Think about the big picture of how the lack of access to information in their language causes many immigrants difficulties adhering to medical regimens….impact on the healthcare system for our nation. Is this making sense to you?

Identify uses and define the concept:

This section is so very important! What you want to do is look at many, many different sources for uses and definitions of your concept…dictionaries, literature, thesauruses, colleagues. Do not stick only to the nursing or medical literature. Present the historical development of the concept and its origins in language. Gather all the definitions you can find, even those that you think are unrelated. For example, if your concept is coping, then even look at uses from the architecture literature…there are copings on buildings…coping saws, a coping garment..etc. Even though you may not think it is related to nursing, looking at a concept from as many different perspectives as possible helps you gain a thorough understanding of your concept and gives it a richness in meaning. You will be required in the rubric (guidelines) of the paper to obtain definitions from at least 5 sources and 3 different disciplines. This is a minimum expectation. Look at literature from other disciplines such as engineering, business, art, etc… Some concepts will have many more definitions/uses and remember that you want to be as thorough as possible (within the limits of the page limit of 7 pages of text, which is strictly enforced)
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Define the attributes (include antecedents & consequences):

As you are looking at the uses and definitions of the concept, make a list of the characteristics you are seeing over and over. You want to try to show the cluster of attributes that are the most frequently associated with the concept and gives the analyst the broadest insight into the concept. Also include the antecedents and consequences. Antecedents are those events or incidents that must occur prior to the occurrence of the concept. Thus an antecedent (nor a consequence) cannot be a defining attribute. Consequences are those events or incidents that occur as a result of the occurrence of the concept…the outcomes of the concept. In the coping example, an antecedent was an intensely stressful stimulus …the consequence was the regaining of balance. These may be difficult to understand…be sure to refer to the concept analysis examples for further review.

Cases: Write these as actual scenarios.

Model Case:

The model case, also often called the exemplar case, is an example of what the concept looks like. You need to apply the concept to a clinical situation sort of like a case study. You can make this up, use an example from your clinical practice, or an example from the literature (It is not appropriate to use the cases developed by an author of a published concept analysis). Bold the defining attributes as your example includes them in the scenario.

Borderline Case:

The borderline case is an example that contains some of the defining attributes but not all of them. The case is inconsistent in some way from the concept under consideration. In Chinn & Kramer, they speak of an analysis of fatigue. For the borderline case, the case could include military fatigue clothing. Another example is the concept of mothering. A borderline case might be about a computer motherboard.

Related Case:

A related case is an instance of concepts that are related to the concept being analyzed but that do not contain all of the defining attributes. For example, the concept quality of life may include a related case that is an example of satisfaction with life, well-being or health status.

Contrary Case:

This case is probably one of the easiest to understand. It is what the case absolutely is not. For example, with the concept of coping, a contrary case would be the host who burns the roast, has a group of people to their house, serves them no food and sends them home. There is no coping to the stressful event.

You will include an introduction & conclusion in the paper as well. Remember that the introduction is really not a long paragraph. Open an introduction with an attention grabber, add a few more overview sentences and close the opening paragraph with the thesis statement. For example, “This paper will include an analysis….”

The conclusion paragraph does not contain any new information or new references; it is a restatement of the main points of the paper.

I hope you have found this discussion of the conceptual basis of practice helpful as you begin your journey towards developing a theoretical framework for your practice.

Please go to Assignments for more details about the Concept Analysis Paper.

Unit IV Theoretical Basis for Practice
Readings

Readings:

Cody: Philosophical and Theoretical Perspectives: Chapters 13, 26, 31

Chism: Chapter 4

Chinn & Kramer: Integrated Theory and Knowledge Development in Nursing Chapters 2, 8, 9,10

APA Manual

Review the nursing theorist videotapes on mediasite

http://numedia.usouthal.edu/mediasite/viewer/ (Helpful hint: You may have to right click on the link and open in a new window in order to see the presentations)

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User ID: NU607Student
Password: 1qa2ws

Once the link opens, if the videotapes are not seen, look at the left corner of the window and click nursing theorists. Good viewing!!

Recommended Reading:

Zaccagnini & White – Chapter 1