The philosophy of nursing has to begin with a prayer in memory of the famous Florence Nightingale whose rich heritage and writings made the profession an indispensable one in society (Kim and Kollak, 2006). Theories and philosophies are creative products of various nursing researchers. The theories which have been classified into philosophies, grand theories ad middle range theories facilitate the nursing practice; they have become experts in their field based on the theories. It is debatable whether the theories are mature enough or are rigorously developed; however, they have undoubtedly contributed to the guiding of nursing practice.
Numerous theories are present, unique with assumptions, philosophies, values, perspectives and scope (Kim and Kollak, 2006). The diversity of nursing is addressed in the many theories. Faults have been found with the concept of precision, constituents and logic in structure. However, the perspectives are correctly assumed. Categorization of the theories is varied by different researchers (Kim and Kollak, 2006). Meleis found theories as having “systems, holistic, adaptation and behavioral orientations” (1996 cited in Kim and Kollak, 2006).
The grand theories of nursing include Roy’s adaptation model, Orem’s self-care model, Neuman’s systems framework, Parse’s human-becoming theory and Watson’s theory of human care. Initially, the grand theories were significant but recently the middle-range theories are gaining significance. The examples of middle-range theories are Engerbretson and Littletons’ theory of cultural negotiation (2001), Kelly’s commitment to health theory (2001), Leininger’s culture care theory and Kolkaba’s comfort theory (1992).
The transtheoretical model of behavior change of Prochaska and DiClemete was first developed when work was being done to motivate the cessation of smoking. Five stages of change are proposed in the theory (Prochaska and DiClemente, 1983). The stages are pre-contemplation, contemplation, preparation, action and maintenance.
Pre-contemplation is the stage where the patient has not even thought about changing (Prochaska and DiClemente, 1983). This is the stage he is first approached in. The next two stages find him thinking about it and then planning for change. Action begins when he has started the change of behavior. Maintenance begins when his behavior becomes permanent and the new behavior becomes a habit and gets incorporated into his daily routine (Prochaska and DiClemente, 1983). The decisional balance scale refers to the decision-making process by the patient where he weighs the pros and cons. When the pros are more, the change is evident. In the event of more cons, change does not take place or if it takes place, it gets quickly reverted. This is the strong and weak principle. The patient does not attain health. Self-efficacy and the processes of change are catalysts for behavior change (Prochaska and DiClemente, 1983).
Kelly thought out the commitment to health theory after indicating a few negative points about the Transtheoretical Model (TTM). It could be applied to only one unhealthy behavior (Kelly, 2008). Biological, environmental and social issues are not addressed in the TTM. A difference is not observed about the people who do not make the change possible. Change is the aim of all health behavior interventions. Kelly chose the commitment-to-health theory, a middle-range theory which is taken from Prochaska and DiClemente’s Transtheoretical Model of Behavior change (1983). The promotion of health is the main theme. Health interventions include healthy eating, physical activity and abstinence from smoking (CDC, 1996). The possibility of behavior change between the action and the maintenance of change is predicted with this theory (Kelly, 2008)… Here “commitment is defined as a freely chosen internal resolve to perform health behaviors, even when encumbered or inconvenienced by difficulties” and “health as the optimal level of well-being” (Kelly, 2008). The more the commitment, the greater is the possibility for adoption of behavior change.
Leininger’s theory of culture care diversity
This theory involved the subjects of culture and care. Leininger discovered during her days of study as a nursing student that she was unable to provide the right extent of care to people of different cultural cities (Nelson, 2006). She decided to acquire knowledge about the cultural factors that were a missing link in her capacity as carer. She studied further and learned to provide culturally sensitive care. Caring is the essence of nursing. Universal culture care involves many culture care constructs.
Leininger (1991) adopted many steps to inculcate in herself the theme of cultural care diversity: respect and concern for the patient, anticipating difficulties, facilitating or assisting, active listening, being physically present, understanding their different cultural values and beliefs, establishing a connectedness, providing protection for women and children, touching and comfort measures (Nelson, 2006). Leininger also developed a short culturological assessment in 5 steps where she took care to recognize values and beliefs, recorded observations, identified recurring patterns, synthesized and develop a culturally feasible plan.
Being sensitive to a patient’s cultural background and doing research to further understand the differences in behaviors and remembering to apply the principles of ethics helps a nurse to practice cultural care diversity. This theory has had an immense impact on the nursing practice (Nelson, 2006). The process of acculturating people and their groups focuses on two issues that trouble them. They would prefer to maintain ethnic distinctiveness and also decide whether to retain their distinct cultural values or merge with the external world (Berry, 2003). Their interest in cultivating inter-ethnic contact is another issue which they would like to decide upon. Berry indicates four group-level acculturation strategies and four larger societal acculturation methods. Integration, assimilation, separation, and marginalization from the group-level activities. Societal acculturation involves multi-culturalism, melting pot, segregation and exclusion (Racher and Annis, 2007).
Katherine Kolcaba propounded the comfort theory. It is indicated to be a complex construct and aims to bring comfort to the distressed patient. She describes comfort as “a multidimensional personal experience with differing degrees of intensity (Kolcaba, 1992). The construct goes much beyond the provision of mere “hope, contentment, certainty or function” (Kolcaba, 1992). Holism is the answer to comfort issues. The patient’s holistic evaluation of physical, psychological, spiritual and social behaviors enables the nurse to decide on what changes are needed to bring comfort to him.
Interventions that produce a mind-body interaction satisfying many needs at one go are now opted for. Instruments that measure holistic status must be designed. Comfort is a desirable outcome for patients (Kolcaba, 1992). Holistic assessment is not merely to collect facts; it must convey information as to what efforts would provide comfort. The efficiency of the nurse would depend on how comfortable, physically and mentally, she can make the patient. The anticipation itself of the patient for a comfortable period in hospital provides comfort (Kolcaba, 1992).
Comfort is the standard of care selected by many Heath Departments. Quality care has been defined as that care that can provide maximum physical and mental comfort to the patient. The American Nurses Association has emphasized the maintenance of life “in dignity and comfort until death” (Kolcaba, 1992). Comfort is a standard for oncology patients too. Comfort is not what everyone considers as comfort; it is that desired comfort that would satisfy the patient who is anticipating it. The definition in wellness circles goes like this: “the state in which the body is relieved of unpleasant sensory or environmental stimuli” (Kolcaba, 1992). In the comfortable state, the patient is able to plan his destiny.
Comfort in psychiatry means something a little different: “personalization, freedom of choice, space and warmth” are the factors considered (Kolcaba, 1992). If patients were to be asked for the themes in comfort, the answer would probably be the following: “disease process, self-esteem, positioning, approach and attitudes of staff and hospital life” (Kolcaba, 1992). Hospital life becomes comfortable when staff is friendly and reliable. Accessibility to care is another major comfort.
Nursing theories based on theology have been advocated by Anne Bradshaw and Kate Erikkson (Lundmark, 2007). The themes would involve “ideals of altruism, service, caring, and nurturing” (Lundmark, 2007). Exploitation of nurses could be a problem in this theory. Nurses have the acumen to focus on other people and their experiences. Bradshaw spoke about the covenant notion. Five principles were elaborated by her: seeing God within the patients, an extremely high value for life, freedom, and love, relationality, hope and peace (Lundmark, 2007)
Research and enhancing knowledge
Nurses are expected to provide high-quality cost-effective care with favorable outcomes. Selecting the best evidence-based research material is essential for a nurse to enhance her efficiency and experience (Meeker, 2008). The value of research, its implications, and its contribution to the nursing discipline must be thoroughly understood. Nursing students are being introduced to newer techniques that project the value of research (Meeker, 2008). Newer theories and philosophies of nursing are being introduced by eminent nurse researchers.
Berry, J.W. (2003). Conceptual approaches to acculturation. In K.M. Chun, P.B. Organista,& G.Marin (Eds.). Acculturation: Advances in theory, measurement, and applied research (p. 17-37). Washington: American Psychological Association.
Kelly, C.W., (2008). Commitment to health theory, Research and Theory for Nursing practice: An international journal, Vol. 22, No. 2, Springer Publishing.
Kim, H.S. & Kollak, I. (2006). The nursing theories: Conceptual and philosophical Foundations Springer Publishing: New York.
Kolcaba, K.Y. (1992). Holistic comfort: Operationalizing the construct as a nurse-sensitive outcome. Advances in Nursing Science, Vol. 15, No. 1, p. 1-10. Aspen Publishers.
Lundmark, M. (2007). Vocation in theology-based nursing theories. Nursing Ethics, Vol. 14, No. 6, Sage Publications.
Meeker, M.A. et al (2008). Teaching undergraduate nursing research from an evidence-based practice perspective. Journal of Nursing Education, Vol. 47, No. 8.
Nelson, J. (2006). Madeleine Leininger’s Culture Care theory: The theory of Culture care diversity and universality. International Journal for Human Caring, Vol. 10, No. 4, International Association for Human Caring.
Prochaska, J.O. & DiClemente, C.C. (1983). Stages and processes of self-change of smoking: Towards an integrative model of change. Journal of Consulting and Clinical Psychology Vol. 51, No. 3. p. 390-395.
Racher, F.E. & Annis, R.C. (2007). Respecting Culture and honoring diversity in community practice. Research and Theory for Nursing practice: An international journal, Vol. 21, No. 4, p. 255-270, Springer Publishing.