14

Anthropo log is t in the F ie ld by Jongrnans. 0.0. and P.C.W. G u t k i n d (eds.) N e w York : Humani t ies Press. 1967.

l 0 i o r add i t iona l diSCuSSion of par t i c ipant observat ion see ChJpter I1 of Oleson. V i rg in ia L. and E l v i W. Whitsker. T h e Si lent Dialogue. San Francisco: Jossey Bass Inc.. 1968 and eyer ly . El i -aberh Lee. "The Nurse RCsebrcher as Part ic ipant Observer in a Nurs ing Setting." Nurs ing Research X V I I I . May-June. 1969. p. 230-236.

l lDickolf . James, Patricia James a n d Ernest ine Weiden- back, "Theory in a Practice Discipline." Par t I1 "Practice Or ien ted Research." Nurs ing Research X V I I I . Novernber-December. 1968. p. 552.

BI BLlOG RAPHY Beauchamp. George A. Cur r i cu lum Theory Wi lmette. I l l inois: T h e Kagg Press. 1968. Byerlv. El izabeth Lee. "The Nurse Researcher as a Pdrt ic ipant OSserver in a Nurs ing Setting." Nurs ing Research X V l l i May-June 1969. 230-236.

a its

Dicko f f . Jones and others. "Theory in a Practice Disci- pline:' Part. 11. "Practice Or ien ted Rerearch." Nursing Research X V l l November-December, 1968. 5JS-554. Glaser. Barney G. an3 Anrelrn L. Strauss. T h e Dis- covery of Grounded Theory : Strategies f o r Qual i tat ive Research. Chicago: A ld ine Publishing Co.. 1967.

Awareness of Dying . Chicago: A ld ine Pu>lishing Com2any. is55

Jongmans. 9. G. and P. C. W. G u t k i n d (eds.) Anthro pologists in the Field. N e w York : HurnJni t ies Press. 1967. Kerlinger. F red N. Foundat ions of Behavioral Re- search. N e w York : Hall . Rinehart and Winston. Inc.. 1965. Oleson. V i rg in ia L. a n d E lv i W. Whitaker. T h e S i len t Dialogue. San Franc ism: Jossey Bass. Inc.. 1968. Osborne. Oliver H. "Anthropo logy and Nursing: Some C o m m o n Tradi?:ons anc! Interests." Nursing Research X V I I I May-June 1969. 251-255.

iheorelical model: uutentlal for adautalierr to nursin j

Frances Cleary As I began preparing for this presen-

tation and the task of adapting a socio- logical model to nursing, I became more 3nd more convinced that nursing should carefully consider some very important issues relative to theory building in nurs- ing. What do we really mean by a theory (or theories) of nursing? Is a theory (or theories) of nursing what nursing needs? Is the desire for theory per se, in fact inappropriate for nursing? That is, nursing is not an academic discipline such as sociology, psychology, physiology and the like. These academic disciplines study a particilar aspect of a phenomenon, develop a h d y of knowledge relative to it and endeavor\ to give explanation and prediction t!ircugh theory formulation and testing.

I s this our' aim - to explain professio- al nursing by Oevcloping a logical system of thought? Unlike the xademic disci- plines, nursing as a proLsssion renders service to those requiring i t s specialized areas of ccntribution. We do not study the patient nor the phenomenon of illness as a matter of academic concern. Rather, our basic question is, "How can we best service the health needs of individuals in

the community?" What then, are the im- plications as well as potentials for de- velopment of theory in nursing?

I am not suggesting that we attempt to answer these questions now. What I am suggesting i s that we as nurses need to face some of the dilemmas of theory building for nursing. First, we need to ask - What i s the nature of nursing and what is the direction it is taking? Speaking to this point Marjorie Moore, in her article "Nursing: A Scientific Discipline?" makes the following statement: "nursing needs to be a well-structured discipline in order to assure a firm foundation for theory."' In other words this means we need a defined body of knowledge that i s nursing so that we can identify concepts, build conceptual systems, theoretical frame- works, and the like which evolve from the uniqueness of nursing rather than to borrow from sociology, psychology and other related disciplines. The magnitude of this problem is confounded by the fact that the breadth and scope of the nursing perspective i s often arnbigious, that i; to say exhibiting no well-defined or agreed upon parameters of patient care.

A second critical question the nurse-

scholar must consider is: Why nursing theory? Theory for what? I s i t to develop a theory (or theories) of nursing practice or for nursing practice - a crucial distinc- tion. A theory of nursiag is scientific, whereas a theory for nursing i s normative. I f theory is scientific in nature, then the aim is toward the explanatory power which the theory gives in terms of ex- p I a in i ng the re1 a tionships between selected variables which can be empiri- cally verified. This type of theory likely wou!d be asking questions about the pur- poses, functions. and operations of nurs- ing, while taking into account the pertin- ent variables operatiog within nursing in order to explain the phenomenon of nurs- ing. In contrast, normative theory implies the expression of value judgments, either implicitly or explicitly, as to what nursing practice should be. The questions for normative theory would be centered around the issue of how patient care should be approached and rendered.

A separate but related question revolves around identifying a starting point for theory building .- do we s t a r t with em- pirical data relating to fiurse-patient behavior and nursing situations, or do we begin with the hypothesized relationships as suggested by some conceptual model? For each of these starting points we need to be aware of associated problems, ad- vantages, disadvantages, and the appropri- ate methodology.

Ir; summary, the essential point is that the kind of theory needs to be made explicit, as well as any underlying assump- tions about the nature of nursing, the nature of marl and his relationship to society so that there i s a logical progres- sion of ideas and an internal consistancy betweeq them. The decisions made as to the type of theory to be developed whet her deductive, inductive; basic, applied; descriptive, scientif ic, normative - are the prerogatives of those interested in developing theory; however. i t should relate to the kind of data or infofmation desired as weil as to the purpose of :he theory.

We are not alone! Al l the suciai science disciplines are faced with similar problems of theory building. For instance. in Sociology, Robert Merton suggests that theory begin in progressive steps starting with 1) an orientation which leads to 2)

identification of the type of variables to be included; 3) specification and clarifi- cation of key concepts; 4) development of classification systems; and finally 5) to formulate empirical generalizations.

It i s interesting to note that sociologists a*.rclid the word "theory." Instead they Jre more cautious by gsing such terms as theoretical frameworks, models, con- ceptualizations and the like. *Very few are willing to lay claim that they have de- veloped a "theory." In i t s place the phrase "toward a theory" i s often used thereby leaving the author less vulnerable to criti- cism from his colleagues.

Nursing, on the contrary, i s not so 5hy! Perhaps we should take heed and learn what Theory i s a l l about from other disci- plines to avoid making the assumption that we have theory in wrsing. In reality we merely have borrowed somebody else's concepts without really defining them for nursing, and then have tried to put them together to show some kind of relation- ship. Theories which have substantive meaning for others, may not be directly appiicable to nursing, per se. Many of the theoreiical notions from other disciplines, however, can bs highly suggestive for nursing thewy if we take the time to "reconceptualire" the original so that i t becomes fruitful tor nursing.

In order f w theory to evolve which i s really meaningful for nursing I submit we must know what it is we are talking about, and not use the semdnfics and rhetoric of the "ultra-erudite.'' Do we want rhetoric or do we want reaiism? I f we could develop concepts unique to nursing w adapt those flom other disci- plines but with definitions that have sub- stantive meaning for nursing, this i~ me would be a giant step. Hildegarde Peplau has contributed greatly to this kind of endeavor. Not only has she identified pertinent concepts but also has attempted to define them operationally. Dr. Peplau separates concepts into explanatory and directional categories: 1) explanatory con- cepts are those which help explain patient behavior or nurse-patient interaction, such as the concept of anxiety, and 2) di- rectional concepts or those which give direction to patient care such as the con- cept of prevention. The explanatory con- cepts parallel scientific theory in that they have explanatoiy power, and the direc-

15

tional concepts parallel normative theory in that they give direction to nursing care.

This i s a oood beginning - a necessary beginning i f iursing theories are ?o have cogency and huristic value, and i f nursing i s to move beyond the rote and the pre- scriptive. I f our effort in theory building could begin by deJeloping this kind of conceptual basis for nursing care, so that concepts either generic to nursing or adapted to nursing could emerge, then the sequential steps of theory building would logically follow.

The nexi effort might be to formulate coi,ceptual models by logically linking together concepts which have been clearly defined and which have specified refer- ents. The nursing literature abounds with "conceptual models." My quarrel with the use of these models directly refers to what I have been saying - within a conceptual model the 3, 4 or 5 concepts are often borrowed from other disciplines without really being defined in terms of nursing content. Their relationship to one another is indicated by arrows, and the total model i s presented as a triangle, circle or squares, etc. I t seems to me the notion "model" has been handled with a sug- gestion of concreteness while the concepts employed seem vague in their meaning. The "goodness of fit" between the model and nursing care seems at best - awkward - and not really useful toward explaining nursing nor to give direction to nursing care. A sociologist friend of mine calls the phenomenon of building models -- "word-magic." He is saying we haven't gone any further than to propose the model - we don't put it to the empirical test for validation, yet it is accepted as if i t has been substantiated.

From the literature and from reports such as from the Southern Regional Edu- cational Conference3 the notion of theoretical framework appears to reflect a better understanding. The following is a compilation of definitions by nurses inter- ested in this kind of conceptualization. A theoretical framework i s a conceptual scheme by which one can selectively look a t some kind of phenomenon such as nursing content, or look for some kind of phenomenon i.e., certain kinds of re- lationships. The term scheme implies structure that should be logical, consis- tent, and c!ear. A theoretical framework i s

16

made up of a set of logically related con- cepts each selected for their usefulness in describing or abstracting phenomena ac- cording to the particular point of view or school of thought. A theoretical frame- work also should make explicit i t s assumptions about the nature of man and his relationships to society.

To me the advantage of theoretical frameworks in nursing is their usefulness for sys tema tizing substantive knowledge and empirical data in some meaningfdl way; furthermore, they give consistency of perspective and a logical approach to nurs- ing practice as well as a rationale for the kind of nursing care rendered. Whether we have actually produced any theoretical frameworks which meet the above defi- nition and criteria, and which are heuristi- cally valuable to nursing i s the question that remains. I think we can develop theoretical frameworks relevant to nursing provided we understand why we are using the particular framework; what it implies and how to define the concepts in terms of nursing.

I have raised some issues relative to theory building in nursing - not to be arbitrary, but hopefully to be provacative. Toward theoretical formulations is a necessary direction for nurse-scholars. However, my point has been that in our eagerness for theory and maybe under pressure to become more "academic" we have given only cursory consideration to the problematics of theory building. In summary. we need to take time to ask and to answer fundamental questions relative to theory building and to take the neces- sary preliminary steps leading to sound theoretical formulations and conceptual models.

As a way ot illustrating some of the points of theory building I have been dis- cussing, ! would like first to present to you the theoretical model of Lefton and Rosengren, and secondly to explore i t s potential for adaptation to nursing

Lefton and Rosengren4 began by really looking a t the phenomenon of service- oriented organizations in order to find a new entree to the analysis of such organi- zations. The client emerged as the unique or additional variable. With the client as the starting point, the question was raised: in what way could the organi- zation's relationship with the client help

f was looking a t the student and to ferret out what i s ur;ique about this kind of client and this kind of institution which would give us direction for applying these two dimensions of client concern. Briefly, we viewed the student’s biographical space in terms of the institution‘s concern for the student’s 1) academic life and 2) social life. We viewed longitudinality of concern in terms of responsible interest (or the school’s formal concern), and i t s general concern for the stodent (or formal interest). Thus the definitions of the two concepts took into account the unique- ness of education and i t s client, the student. We found that the two indepen- dent variables, faculty perception and ideological goals, as reflected along the two dimensions of client concern could explain the variation of selected structural elements of the two schools which we were comparing - a baccalaureate school of nursing and a liberal arts college for women. The Lefton-Rosengren model i s an example of one kind of theory develop- ment - beginning with a theoretical notion, hypothesizing relationships with given variables and put to the empirical test Its heuristic value is to explain the unique phenomena of service organizations.

What are the implications of this model for nursing?

1. Can nursing use this model? and 2. Of what use is it to nursing?

Two efforts were made to adapt this model to nursing 1) at the organizational level, 2) at the social-psychological level.

Since it i s a client-centered model for analysis of organizations, one can easily define the notion of client to mean patient. Directing analysis toward general hospitals, this model could explore the relationship between the various kinds of services, nursing and/or the hierarchy of nurse positions, and the laterality and longitudinality of patient concern. A question arises however, does thid kind of analysis merely describe nursing per- ception and if this is so, i s it enough? Can this model be utilized to ascertain the influence of perception of the patient on hospital structure? Logically it can be applied, but is i t worth the effort? The practicalities of hospital dynamics suggest otherwise. Nursing perception pf the patient in itself does not, in my opinion, explain enough of the variance in hospital

17

explain in a more meaningful way the operations of client-serving organizations. The concept of client concern was central to their theoretical model - a single con- cept unique to service organizations. The concept of client concern was made less abstract by viewing it along two dimen- sions: Laterality, the organization’s con- cern for or interest in the client’s present b i og ra p h ica I space ; and I o ng i t u d i na I it y , concern or interest in the client’s l i fe span. From this conceptualization the questions raised were:

l..With reference tc? the lateral dimen- sion of client concern, how much of the client i s relevant to the organi- zation?

2. As for the longitudinal dimension, the question i s how long is the insti- tution interested or concerned in the client?

Lefton and Fbsengren next proposed or hypothesized specific kinds of possible relationships between the general or main purpose of the organization, the nature of the organization’s concern for the client (such as + lateral, - lateral, + longitudi- nality, - longitudinality), so that conse- quent structural elements could be expected. For instance, these two dimen- sions logically yield four different types of organizations. An organization which has limited lateral and limited longitudinal interest in the client i s the acute emer- gency hospital. A medical school is likely to have a limited lateral interest in i t s students but an extended longitudinal interest. A short-term psychiatric hospital would have an extensive interest in the client’s biographical space (laterality) and limited interest in his biographical time ( I ong i tu d i n a I i ty ) . A I onq- t e r m psych i a t r i c hospital would be interested in both the client’s life space and l i fe lime. therefore would have both extended lateral and extended longitudinal postures toward the client.

The next challenge was to try to oper- ationalize these two concepts and see if they could be rendered empirically and to test the heuristic value of this conceptual model by applying it to analysis of an on-going service organization. My col- league (Gladys Kuoska) and I attempted to do the above by applying the Lefton- Rosengren model to educational insti- tutions. The starting point for this task

structure. There are other critical variables related to the patient which have to be taken into account such as the nature and duration of illness, age. t i i s status as a private or staff patient. I n addition, there are other major variables relating to hospital control which i s the province of ielat ivel y few aam inist ra t ive people. T t i us, the variability of patient population and nursing personnel in a general hospital setting and the nature of hospital adminis- tratiotl diminishes the usefulness of the model. By way of contrast, the relatively homogenous clientele plus the collegeal nature of a faculty body allowed for the emergence of faculty perception of the student as a salient variable in explaining the structural elements of institutions of higher learning.

Continuing the search for a more fruit- ful adaptation of laterality and longitudi- nality of client concern, I switched gears. Rather than look a t the model from an organizational point of view, I sought to explore i t s potential within a socio- psychological frame of reference by examining the laterality of pErception of both patier4 and nurse. Could this model give any insight into nurse-patient re- lationships and the consequent patient response? The following presentation then, i s the attempt to adapt the clknt- centered model of Lefton and Rosengren to explore the relationship between con- gruency of role perception between nurse and patient, and the consequent patterns of patient response.

On the one hand, the laterality of nurse pzrception of the patient is composed of the nurse's view of her role coupled with her view of the patient. The nurse's per- ception of her role may range from a narrow to a broad interpretation of nursing functions and responsibilities. The nurse's view of the patient also may vary from a narrow to a broad concern for the patient. That i s to say, within the narrow perception the person is seen solely as a patient, whereas in the broad perspective the patient i s primarily considered as a person.

On the other hand, the laterality of the patient's view of the nurse role varies from a narrow to a broad set of expecta- tions as to nurse responsibility. His view of his role as patient also can be narrow or broad. With a narrow view he would be

18

concerned with his specific illness event; whereas with a broader view of himself as patient he has expectations of being treated first and foremost as a person.

The concept role i s defined here as the more or less known, and the more or iess organized expectations and/or responsi- bilities of self and the other under a given set of conditions. It involves the nurse, the patient, the condition of illness and social setting. Role congruency is defined as the extent of agreement between nurse and patient with regard to the responsibilities and/or expectations of one's own role and that of the other under a given set of conditions. The con- cept role congruency then emerges as the central concept by which to look a t later- ality of role perception for both nurse and patient.

The concept of role congruency is highly relevant to nursing because the nu rse-patient relationship contains a mixture of professior?al and non-profes- sional persons. For instance, the nurse i s prepared formally for her role and develops concurrently a professional per- spective of the patient. This is a voluntary role for the nurse and one that is super- ordinate to the patient role. A different situation exists however, for the patient. He i s neither formally nor psychologically prepared for the patient role; he may have some notion of the nurse according to heresay or past experience, but his notion is not formally developed. Moreover, the patient role usually i s non-voluntary a t least when the illness dimension iz in- cluded. Complementing the superordinate position of the nurse, the patient plays the subordinate role. All these factors singly or collectively may result in role incongruency. Other aspects of the nurse- patient relatioriship which could give rise to role incongruency, beside that of the professional vs. the layman statuses, i s in the area of patient diagnoses and prog- nosis - the expert knowledge which the nurse has, in contrast to the limited knowledge on the part of the patient. As a consequence the patient, who is the "victim" of illness and the recipient of nursing care i s in a relatively vulnerable position. As you know, these are only a few examples illustrating potentials for disparities within the nurse-patient re- lationship. It i s the nurse's responsibility

as the professional person to be aware of any existing incongruence between her perspective and that of the patient's. The nurse needs to take into account whether the patient wants to be considered within a narrow perspective or from a broad view. For instance, a patient with an appendectomy who has a narrow per- spective of his role as well as that of the nurse's role would probably expect the nurse's responsibility or concern to focus on his spxific illness. He i s saying, "Just take care of my appendectomy, not the rest of me. I can do that." The nurse with a broad perspective who assumes a l l patients want to be considered as a total person may be violating the rights of this particular kind of patient. His reaction to this kind of nurse may be one of resent- ment based on his feeling that she in in- vading his privacy. Because of the incon- gruence of perspective in this nurse- patient relationship, I propose that the patient's response to her therapeutic ef- forts will be resistive and negative. Both the nurse and the patient become dis- satisfied.

Another type of nurse-patient relation- ship is one in which the patient with a broad view of both his role and that of the nurse is saying, "Look a t me, treat me, not my illness." When he broadly interprets the nurse's responsibility, but the nurse has a narrow view of the patient and her role, the relationship i s again one of incongruency. The patieiit wants more than an efficient, technically skillful nurse; i.e., he does not want depersonalized care. His response to the specifically oriented nurse, I would hypothesize,would take the form of insistence. Insistence to be known as a person. This insistence on the part of the patient might be interpreted by the nurse as making demands of her.

Although I have elaborated upon role- incongruency because of i t s dysfunctional effects upon nurse-patient relationships, I am not ignoring the potential for agree- ment between nurse and patient per- ceptions. Briefly stated, congruency of broad role perceptions between nurse and patient i s apt to be reflected in personal- ized type of care which the patient desires; he is satisfied, and he is more likely to cooperate with the nurse. When congruency occurs with shared narrow role perceptions, the patient is likely to be

satisfied also because his sense of privacy has been preserved. This type of patient response to the nurse intervention can be anticipated as one of compliance, in that he is letting the nurse take care of him in a limited or segmented way as compared to more comprehensive kind of care.

As the result of examining the various combinations of narrow and broad views of role in the nurse-patient relationship four logical outcomes of the congruency- incongruency of nurse-patient perspective and hypothesized resultant patient response patterns are illustrated by the following d' !a g ram:

Laterality of Interpretation and Role Perspective Response Patterns Nurse Patient I + Personalization

Hypothesized Patient

Cooperativeness Invasion of privacy Resistance

Compliance

Insistence

role and role of the other.

role and role of the other.

- +

- - Preservation of privacy

- + Depersonalization

+Laterality = broad perspective of own

-Laterality = narrow perspective of own

Another way of looking a t this: Congruency of Nurse-Patient

Role Perspective Patient

Narrow Perspective Broad Perspective (- laterality) I+ laterality)

Congruence Non-congruence - +

Non-congruence Congruence In the interest of time, a similar treatment could not be given to the concept of longitudinality of perspectives but it should be understood that the same approach could be used.

By way of summary, the attempt has been to show the process involved in applying a sociological model to nursing in a manner that i s meaningful without merely superimposing the original model onto nursing. The starting point was the question - of what use to nursing is the Lefton-Rosengren model which was de-

veloped for analysis of service-orien ted organizations. The concept, "Laterality o i Client Concern," was hete interpreted from two view points - that of the nurse and of the patient in terms of their per- ception of their own roles and of the other.

T hr; concept of role congruency emerged as central to the model, i t i s founded on the proposition that role con- gruency between nurse and patient, leads to positive patient response to nursing care whereas, role incongruency leads to negative response. In other words, role agreement is based on either a shared narrow perception or a shared broad per- ception of the roles involved in the nurse- patient relationship. Disagreement arises from differences in the perspectives of the nurse and the patient. Logical outcomes between the relationship G 'ongruency- incongruency and pattern5 of patient response were proposed.

This exercise in the analytic process has been purely theoretical in the everyday sense of the term and was not meant to be normative nor prescriptive. I t goes beyond the theoretical and the academic. I have tried to show how an existing model for analysis of organizational behavior could be fruitfully adapted to test a very signifi-

cant and viable concept which has been accepted on faith as a guiding principle in nursing practice - that is, the treatment of the whole person. That all patients want l o be treated as a whole person has been a "given" in nursing. The concept of role congruency defined with nursing con- tent sheds a new light on nurse-patient relationships that it has implications for nursing practice and cursing education. Rather than take for granted the notion that a l l patients want to be treated com- prehensively, the logical outcome of th3 model suggests this basic assumptions needs to be examined not only for the patient's own sense of well-being but for positive outcomes in nurse-patient re- lationships. This model can be tested empirically to see i f in fact these sug- gested patterns of patient responses are confirmed. I f so, the heuristic value of the model would be enhanced by its predicta- bility of patient response. REFERENCES lMarjorie A. Moore, R.N., Ph.D., "Nursing: A Scien-

tific Discipline!" Nursing Forum, Vol. VI I , No. 4,

2Robert Merton. "Notes on Problem Findings in Soci- ology," Sociology Today, (New York: Harper and Row, 1959). pp. ix - xxxiv.

3Loretta T. Zderad; Helen Belcher. Developing Behavior- al Concepts in Nursing, Southern Regional Education Board, Atlanta, Georgia: 1968.

4Mark Lefton and William Rosengren. "Organizations and Clients: Lateral and Longitudinal Dimensions, " American Sociological Review, xxxi (December. 1966).

pp. 340-348.

pp. 802-10.

nursing science the theere t ica l core of nursing knowledge Gean Mathwig

When I learned that the theme of the two-day work conference of Sigma Theta Tau in October was to be "Theory Building in Nursing", I was elated, for I believe that the development of the theoretical core of nursing to be a neces- sary and essential requisite of highest priority for nursing to fulfil l the criteria of the profession and the fulfillment of the profession's responsibilities to the consumer public. When I was asked if I wou!d present a paper at this conference, I was reticent. for the magnitude of de-

veloping the theoretics! core of nursing knowledge in accord with ibe criteria of higher and professional educatiLn, and the standards for developing and verifying theories i s indeed very great. Hc:vever, I also believe that we in nursing can no longer rest securely in our old alibi that nursing i s in the process of becoming a profession, therefore, the academic and practitioner expertise demanded of other professions i s not germane to us. Both the range and complexity of contemporary health care indicate thst the consumer