Theoretical frameworks for research

After reading this chapter, you should be able to do the following:

• Identify the purpose of conceptual and theoretical frameworks for nursing research.

• Describe how a conceptual framework guides research.

• Differentiate between conceptual and operational definitions.

• Describe the relationship between theory, research, and practice.

• Describe the points of critical appraisal used to evaluate the appropriateness, cohesiveness, and consistency of a framework guiding research.

• Explain the ways in which theory is used in nursing research.

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

The author would like to acknowledge the contribution of Patricia Liehr, who contributed this chapter in a previous edition.

To introduce the discussion of the use of theoretical frameworks for nursing research, consider the example of Emily, a novice oncology nurse. From this case study, reflect on how nurses can understand the theoretical underpinnings of both nursing research and evidence-based nursing practice, and re-affirm how nurses should integrate research into practice.

Emily graduated with her BSN a little more than a year ago and recently changed positions to work on a pediatric oncology unit in a large hospital. She quickly learned that working with very ill, and often dying children is tremendously rewarding, even though it is frequently heartbreaking.

One of Emily’s first patients was Benny, a 14-year-old boy admitted with a recurrence of leukemia. When she first cared for Benny, he was extremely ill. Benny’s oncologist implemented the protocols for cases such as his, but the team was careful to explain to Benny and his family that his prognosis was guarded. In the early days of his hospitalization, Emily cried with his mother when they received his daily lab values and there was no apparent improvement. She observed that Benny was growing increasingly fatigued and had little appetite. Despite his worsening condition, however, Benny and his parents were unfailingly positive, making plans for a vacation to the mountains and the upcoming school year.

At the end of her shift one night before several days off, Emily hugged Benny’s parents as she feared that Benny would die before her next scheduled work day. Several days later, when she listened to the report at the start of her shift, Emily was amazed to learn that Benny had been heartily eating a normal diet. He was fully ambulatory and had been cruising the halls with his baseball coach and playing video games with two of his cousins. When she entered Benny’s room for her initial assessment, she saw the much-improved teenager dressed in shorts and a T-shirt, sitting up in bed using his iPad. A half-finished chocolate milkshake was on the table in easy reaching distance. He joked with Emily about Angry Birds as she performed her assessment. Benny steadily improved over the ensuing days and eventually went home with his leukemia again in remission.

As Emily became more comfortable in the role of oncology nurse, she continued to notice patterns among the children and adolescents on her floor. Many got better, even though their conditions were often critical. In contrast, some of the children who had better prognoses failed to improve as much, or as quickly, as anticipated. She realized that the kids who did better than expected seemed to have common attributes or characteristics, including positive attitudes, supportive family and friends, and strong determination to “beat” their cancer. Over lunch one day, Emily talked with her mentor, Marie, about her observations, commenting that on a number of occasions she had seen patients rebound when she thought that death was imminent.

Marie smiled. “Fortunately this is a pattern that we see quite frequently. Many of our kids are amazingly resilient.” Marie told Emily about the work of several nursing researchers who studied the phenomenon of resilience and gave her a list of articles reporting on their findings. Emily followed up with Marie’s prompting and learned about “psychosocial resilience in adolescents” (Tusaie et al., 2007) and “adolescent resilience” (Ahern, 2006; Ahern et al., 2008). These works led her to a “middle range theory of resilience” (Polk, 1997). From her readings, she gained insight into resilience, learning to recognize it in her patients. She also identified ways she might encourage and even promote resilience in children and teenagers. Eventually, she decided to enroll in a graduate nursing program to learn how to research different phenomena of concern to her patients and discover ways to apply the findings to improve nursing care and patient outcomes.

Practice-theory-research links

Several important aspects of how theory is used in nursing research are embedded in Emily’s story. First, it is important to notice the links among practice, theory, and research. Each is intricately connected with the others to create the knowledge base for the discipline of nursing (Figure 4-1). In her practice, Emily recognized a pattern of characteristics in some patients that appeared to enhance their recovery. Her mentor directed her to research that other nurses had published on the phenomenon of “resilience.” Emily was then able to apply the information on resilience and related research findings as she planned and implemented care. Her goal was to enhance each child’s resilience as much as possible and thereby improve their outcomes.

FIGURE 4-1 Discipline knowledge: theory-practice-research connection.

Another key message from the case study is the importance of reflecting on an observed phenomenon and discussing it with colleagues. This promotes questioning and collaboration, as nurses seek ways to improve practice. Finally, Emily was encouraged to go to the literature to search out what had been published related to the phenomenon she had observed. Reviewing the research led her to a middle range theory on resilience and challenged her to consider how she might ultimately conduct her own research into the phenomenon.

Overview of theory

Theory is a set of interrelated concepts that provides a systematic view of a phenomenon. A theory allows relationships to be proposed and predictions made, which in turn can suggest potential actions. Beginning with a theory gives a researcher a logical way of collecting data to describe, explain, and predict nursing practice, making it critical in research.

In nursing, science is the result of the interchange between research and theory. The purpose of research is to build knowledge through the generation or testing of theory that can then be applied in practice. To build knowledge, research should develop within a theoretical structure or blueprint that facilitates analysis and interpretation of findings. The use of theory provides structure and organization to nursing knowledge. It is important that nurses understand that nursing practice is based on the theories that are generated and validated through research (McEwen & Wills, 2011).

In an integrated, reciprocal manner, theory guides research and practice; practice enables testing of theory and generates research questions; and research contributes to theory-building and establishing practice guidelines (see Figure 4-1). Therefore, what is learned through practice, theory, and research interweaves to create the knowledge fabric of nursing. From this perspective, like Emily in the case study, each nurse should be involved in the process of contributing to the knowledge or evidence-based practice of nursing.

Several key terms are often used when discussing theory. It is necessary to understand these terms when considering how to apply theory in practice and research. They include concept, conceptual definition, conceptual/theoretical framework, construct, model, operational definition, and theory. Each term is defined and summarized in Box 4-1. Concepts and constructs are the major components of theories, and convey the essential ideas or elements of a theory. When a nurse researcher decides to study a concept/construct, the researcher must precisely and explicitly describe and explain the concept, devise a mechanism to identify and confirm the presence of the concept of interest, and determine a method to measure or quantify it. To illustrate, Table 4-1 shows the key concepts and conceptual and operational definitions provided by Alhusen and colleagues (2012) in their study on maternal fetal attachment and neonatal outcomes (see Appendix B).

BOX 4-1 DEFINITIONS

Concept

Image or symbolic representation of an abstract idea; the key identified element of a phenomenon that is necessary to understand it. Concept can be concrete or abstract. A concrete concept can be easily identified, quantified, and measured; whereas an abstract concept is more difficult to quantify or measure. For example, weight, blood pressure, and body temperature are concrete concepts. Hope, uncertainty, and spiritual pain are more abstract concepts. In the case study, resilience is a relatively abstract concept.

Conceptual definition

Much like a dictionary definition, conveying the general meaning of the concept. However, the conceptual definition goes beyond the general language meaning found in the dictionary by defining or explaining the concept as it is rooted in the theoretical literature.

Conceptual framework/theoretical framework

A set of interrelated concepts that represents an image of a phenomenon. These two terms are often used interchangeably. The conceptual/theoretical framework refers to a structure that provides guidance for research or practice. The framework identifies the key concepts and describes their relationships to each other and to the phenomena (variables) of concern to nursing. It serves as the foundation on which a study can be developed or as a map to aid in the design of the study.

Construct

Complex concept; constructs usually comprise more than one concept and are built or “constructed” to fit a purpose. Health promotion, maternal-infant bonding, health-seeking behaviors, and health-related quality of life are examples of constructs.

Model

A graphic or symbolic representation of a phenomenon. A graphic model is empirical and can be readily represented. A model of an eye or a heart is an example. A symbolic or theoretical model depicts a phenomenon that is not directly observable and is expressed in language or symbols. Written music or Einstein’s theory of relativity are examples of symbolic models. Theories used by nurses or developed by nurses frequently include symbolic models. Models are very helpful in allowing the reader to visualize the key concepts/constructs and their identified interrelationships.

Operational definition

Specifies how the concept will be measured. That is, the operational definition defines what instruments will be used to assess the presence of the concept and will be used to describe the amount or degree to which the concept exists.

Theory

TABLE 4-1

CONCEPTS AND VARIABLES: CONCEPTUAL AND OPERATIONAL DEFINITIONS

CONCEPT	CONCEPTUAL DEFINITION	VARIABLE	OPERATIONAL DEFINITION
Maternal-fetal attachment (Alhusen et al., 2012)	“The extent to which women engage in behaviors that represent an affiliation and interaction with their unborn child”	MFA	Total score on Maternal-Fetal Attachment Scale (a 24-item, Likert-type questionnaire)
Health practices (Alhusen et al., 2012)	Health practices that mother engages in during pregnancy	Health practices	Total score on the Health Practices in Pregnancy Questionnaire II (a 34-item, Likert-type questionnaire)
Neonatal outcomes	Compilation of birth weight and gestational age	Neonatal outcomes	Scores based on gestational age and scored against reference values of birth weight at 22-44 completed weeks of gestation

HELPFUL HINT

In research and practice, concepts often create descriptions or images that emerge from a conceptual definition. For instance, pain is a concept with different meanings based on what type or aspect of pain being referred to. As such, there are a number of methods and instruments to measure pain. So a nurse researching postoperative pain would conceptually define pain based on the patient’s perceived discomfort associated with surgery, and then select a pain scale/instrument that allows the researcher to operationally define pain as the patient’s score on that scale.

Types of theories used by nurses

As stated previously, a theory is a set of interrelated concepts that provides a systematic view of a phenomenon. Theory provides a foundation and structure that may be used for the purpose of explaining or predicting another phenomenon. In this way, a theory is like a blueprint or a guide for modeling a structure. A blueprint depicts the elements of a structure and the relationships among the elements; similarly, a theory depicts the concepts that compose it and suggests how the concepts are related.

Nurses use a multitude of different theories as the foundation or structure for research and practice. Many have been developed by nurses and are explicitly related to nursing practice; others, however, come from other disciplines. Knowledge that draws upon both nursing and non-nursing theories is extremely important in order to provide excellent, evidence-based care.

Theories from related disciplines used in nursing practice and research

Like engineering, architecture, social work, and teaching, nursing is a practice discipline. That means that nurses use concepts, constructs, models, and theories from many disciplines in addition to nursing-specific theories. This is, to a large extent, the rationale for the “liberal arts” education that is required before entering a baccalaureate nursing (BSN) program. Exposure to knowledge and theories of basic and natural sciences (e.g., mathematics, chemistry, biology) and social sciences (e.g., psychology, sociology, political science) provides a fundamental understanding of those disciplines and allows for application of key principles, concepts, and theories from each, as appropriate.

Likewise, BSN-prepared nurses use principles of administration and management and learning theories in their patient-centered, holistic practices. Table 4-2 lists a few of the many theories and concepts from other disciplines that are commonly used by nurses in practice and research that become part of the foundational framework for nursing.

TABLE 4-2

THEORIES USED IN NURSING PRACTICE AND RESEARCH

DISCIPLINE	EXAMPLES OF THEORIES/CONCEPTS USED BY NURSES
Biomedical sciences	Germ theory (principles of infection), pain theories, immune function, genetics/genomics, pharmacotherapeutics
Sociologic sciences	Systems theory (e.g., VonBertalanffy), family theory (e.g., Bowen), role theory (e.g., Merton), critical social theory (e.g., Habermas), cultural diversity (e.g., Leininger)
Behavioral sciences	Developmental theories (e.g., Erikson), human needs theories (e.g., Maslow), personality theories (e.g., Freud), stress theories (e.g., Lazarus & Folkman), health belief model (e.g., Rosenstock)
Learning theories	Behavioral learning theories (e.g., Pavlov, Skinner), cognitive development/interaction theories (e.g., Piaget), adult learning theories (e.g., Knowles)
Leadership/management	Change theory (e.g., Lewin), conflict management (e.g., Rapaport), quality framework (e.g., Donabedian)