Advances in Nurstng ScienceVol. 28, No. 2, pp. t37-151© 2005 Uppineott WUUams & Wilkins, tnc.

Development ofSituation-specific TheoriesAn Integrative Approach

Eun-Ok Im, PhD, MPH, RN, CNS

One type of "ready-to-wear" theories that can bring about better nursing care outcomes re-gardless of their philosophical bases is situation-specific theories proposed hy Im and Mt-lcisin 1999. In this paper, sonic propositions tor an Lntejtnitive approach to the deveiopment ofsituation-specific iheorics are made. First, situation-specific theories are described as practicetheories while they arc compared with middie-range theories. Then the integrative approachis detailed, wliich includes («) checking assumptions for theory development; {h) exploritigthnnigh multiple sources; (t) theorizing; and (cf) reporting, sharing, and validating. Finally, thepaper concltides with suggestions for furtlier development of the integrative approach. Keywortls: iutearatii'e cipprruich, nursing theoiy, sittialion-specific theory, lbeor)> development

ACROSS disciplines, scholars can nowsympathize with the epistemic plural-

ism that is the practical philosophy of mostworking scientists in general.' Until recently,scholars believed iti the unity of scientificknowledge, and they accepted its fragmen-tation only as a pragmatic necessit>'. How-ever, these days, scholars are quite happy togo along with philosophical plurality acrossmany disciplines.^

Nursing history also shows the samechanges toward epistemic pluralism in the-oretical and philosopliical thinking. In the1950s, under the tremendous influences oflogical positivism, grand theories were de-veloped and used to answer questions onthe nature, mission, and goals of nursing,

From the School of Nursing, University of Texas atAustin, Austin, Tex.

The author acknowledges tbe expertise, feedback, andsupport of Drs Afaf I. Meleis and Lorraine Walkerin the dvivlopment of ideas and preparation of thisinanu.icript.

Convsponding author: Eu7i-Ok Im. PhD, MPH, RN, CNS..School of Nursing. University of Texas at Austin, 1700Red Riivr. Austin, TX 78701 (e-mail: eim@mail.nur.utexa.t.edu).

and nursing scholars and theorists believedin the unity of nursing knowledge. In the1960s-1980s, metatheoreticai questions onthe types and contents of theories wereasked and argtied, yet their philosophical ba-sis was still empiricism. '"^ From the mid-dle of the 1980s onward, tremendous effortsin concept development were made withthe introduction of qualitative philosophi-cal thinking."'" From the beginning of the1990s, numerous middle-range theories weredeveloped and published,'^"'^ and philosoph-ical pluntlism in theoretical nursing becamemore prominent.'-"" Tlirough these histori-cal changes, now, nursing scholars even en-vision and sympathize with epistemic plu-ralism, and seek ready-to-wear theories innursing practice that may bring about bet-ter nursing care outcomes regardless of theirphilosophical bases. "'

Nursing has struggled to develop "ready-to-wear" theories. "Ready to wear" refers to easyapplicability to research and practice. Onet>'pe of "ready-to-wear" theories is sittiation-specific theories, proposed by Im and Meleisin 1999-'** Situation-specific theories are de-fined as theories that focus on specific nurs-ing phenomena, that reflect clinical practice,and that are limited to specific populations or

137

138 ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2005

to particular fields of practice.'^ ' Situation-specific theories belong to a different levelthan grand theories and middle-range theo-ries, which can incorporate diversities andcomplexities in nursing phenomenon, con-sider sociopolitical, cultural, and historicalcontexts of nursing encounters, and be eas-ily applicable to nursing practice.'" In this pa-per, middle-range theories mean theories thathave more limited scope and less abstractionthan grand theories, address specific phenom-ena or concepts, reflect practice, and aim tobe easily testable'**; grand theories are sys-tematic constructions of the nature of nurs-ing, the mission of nursing, and the goalsof nursing care.'^ Situation-specific theoriesare also intended not to be universal theo-ries that can be applicable to any time, anysocially constraining strtictures, or any polit-ically limiting situations. Ratber, they are in-tended to be more clinically specific, reflecta particular context, and include blueprintsfor action."'-' Philosophically, this new typeof theory has roots in postempiricism, criticalsocial theory, feminism, and hermeneutics,'^al! of which agree with current epistemic plu-ralism in nursing,

When situation-specific theories were proposed, an integrative approach was also pro-posed as a strategy for developing them.The integrative approach was originally pro-posed by Meleis'" and has been extendedthrough later work by Im and Meleis.'^The integrative approach has some essentialcomponents, such as the clinical groundingthat drives the basic or clinical questions aswell as the questions themselves. Also es-sential are opportunities for clinical involve-ment and for conceptually thinking aboutthe health/illness responses, the situations,and the environment.' However, the propo-sitions of the integrative approach tended tobe too abstract for novice theorists to uti-lize in actual theory development. Further de-velopment/refinement of the integrative ap-proach is essential for the future developmentand practical use of situation-specific theo-ries, which may ultimately result in a strongerlink between theory and practice and sub-

sequently produce better nursing care out-comes than other types of theories. In thispaper, some propositions for the integrativeapproach to the development of situation-specific tbeories are made. First, situation-specific theories are described as practice the-ories while they are compared with othertypes of theories. Then the integrative ap-proach is detailed. Finally, the paper con-cludes with suggestions for further develop-ment of the integrative approach.

SITUATION SPECIFIC THEORIES,PRACTICE THEORIES, ANDMIDDLE-RANGE THEORIES

Figure 1 shows the relationships amongpractice theories, situation-specific theories,middle-range theories, and grand theoriesreported in the literature. In recent liter-ature, situation-specific theories are some-times labeled as micro-theories or prac-tice theories (a term that is interchangeablewith micro-theories^, or even as middle-rangetheories." '^'" In a sense, situation-specifictheories can be categorized as practice the-ories because sittiation-specific theories cer-tainly aim at functioning as practice theories.Jacox'' proposed that practice theories beconsidered those theories that outline the ac-tions that nurses must take to meet a nursinggoal (producing some desired change or ef-fect in the patient's condition). In these terms,situation-specific theories can be consideredpractice theories because one of the goalsof situation-specific theories is to provide ablueprint for nursing practice.'*^ Peterson'"even categorized situation-specific theoriesand practice theories in the same category,noting that the literature included a confusingvariety of terms to refer to the level of theorythat is considered less abstract, more specific,and narrower iti scope than middle-range the-ories.

Although practice theories have been wel-come in nursing because ntirsing is inherentlya practice-oriented discipline, they have oftenbeen criticized as well. The major criticism

DeiHilopment of Situation-specific Tbeories 139

Practice theories ormicro theories

Figure 1. Relationships among practice theories, middle-range theories, grand theories, and situation-specifictheories.

is that they are procedural and not based ona well-developed body of nursing science.'**For this reason, some theorists have workedto blend middle-range theories with prac-tice theories, and their hybrid efforts havebeen highly evaluated because they ele-vate the resulting practice above simpledictates or imperatives." Since situatioti-specific theories, in nature, are practice the-ories, those blending efforts are unnecessaryfor situation-specific theories. In addition,situation-specific theories can provide a ba-sis for the development of the knowledgebase for nursing practices through researchand practice efforts in specific nursing situa-tions because they are more than just guide-lines or standardized procedures for nursingpractice.'^'

Situation-specific theories, however, aredifferent from middle-range theories becausethe former can be applicable only to sp>e-cific nursing pbenomenon or particular nurs-ing clients while the latter can be applicableacross nursing practice fields.'^ '" For exam-ple, the middle-range theory of transition pro-posed by Meleis and her colleagues'^ w as de-veloped based on several studies of ethnicallydiverse samples undergoing a wide range oftransitions, including menopausal, maternal,

and caregiving transition; subsequently, theyaimed to cover all types of transitions in nurs-ing situations. However, the situation-specifictheory ofthe menopausal transition of Koreanimmigrant women by Im and Meleis^" aimedat only the specific population of menopausallow-income Korean immigrant women in theUnited States.

Sititation-specific theories are also differ-ent from middle-range theories in terms oftheir testability. Middle-range theories containa limited number of variables and testable rela-tionships. -' In other words, middle-range the-ories are based on logical positivistic atid/orpostpositivistic ideas that assume the testabil-ity of a theory.'" Grand theories are criticizedas too abstract to be tested empirically. Thebasic assumption here is that the testabilityof theories is based on a logical positivisticidea.

Situation-specific theories do not alwaysassume their testability.'*' Some situation-specific theories will certainly aim at the oper-ationalization of central concepts for hypothe-ses testing in real settings. However, othersituation-specific theories are not stipposedto be testable because they are developedon philosophical foundations (eg, herme-neutics. phenomenology, critical theory,

140 ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2O()5

pt)stmodernism) in which positivistic ap-paratuses such as hypotheses do not havea place.'*' Rather, the situation-specifictheories aim at helping researchers under-stand central concepts through qualitativefieldwork and/or participant observation. Ifa situation-specific theory was developedbased on postempiricism. it can aim at opera-tionalization, measurements, and hypothesistesting. On the contrary, if a situation-specifictheory originated with a phenomenologicalperspective, the theory may not he usedto operationalize, measure, and/or test ahypothesis. Rather, the theory may aimat explaining and understanding the livedexperience of human heings in the middle ofthe phenomenon.

In the discipline of nursing, many strate-gies for concept development and theory de-velopment have heen proposed. Tlie conceptdevelopment strategies proposed and used innursing include the Wilsonian method,^''^^the Walker and Avant approach,'*' " Rogers'evolutionary concept analysis method/^ theHybrid method,'^ and the simultaneous analy-sis method."** Many strategies for developinga theory have been also proposed, and used as^ .11 M),ii.n,2.V24 Rojgersand Knafl ^ assertedthat these currently existing concept and the-ory development strategies for grand theo-ries and middle-range theories do not ade-quately consider that the theory developmentprocess, specifically the concept develo[5-ment process, is evolutionary', and that thereis no step-by-step recipe for developing atheory.

The view of Rodgers and Knafl assumesthat concepts are formed by the identificationof characteristics common to a class of ob-jects or phenomena and the abstraction andclustering of these characteristics, which isinfluenced heavily by socialization and pub-lic interaction.^^"^ This view assumes that,because these contextual factors vary, therewill he variations in concepts over time oracross situations. Currently, most nursing the-orists and scholars agree that the theory de-velopment process is a continuous, dynamic,and evolutionary' process influenced by con-

texts surrounding the theory developmentprocess.""^^ This is somewhat problematicin pnictical applications to nursing practiceand research, however. It is easy to under-stand in an abstract way, but in reality, theassumption that theory development is evo-lutionary, not algorithmic and linear, posesa potential contradiction because a theorymight evolve away from the specific time,place, and population for which it was orig-inally conceived. Since situation-specific the-ories are limited to a specific population anda particular nursing phenomenon/situation,which, in turn, limits the contexts (eg, time,place, situation) for theory applications, thetheor>' development process becomes morefeasible and easily applicable to nursing prac-tice and research even in light of the evo-lutionary nature of theory development.""C^ionsequently. with the specificity and easyapplicability of situation-specific theories,nurses may produce better nursing care out-comes than with other types of theories thatdo not limit the time, nursing situations, ornursing clients.

THE INTEGRATIVE APPROACH

In the integrative approach, the conceptu-alization and theorizing processes can happenall at once, or they might take years and neverquite evolve into a useful integrated view ofreality.'" Yet, to provide a convenient guide-line, in this section, the process of the integra-tive approach to the development of situation-specific theories is proposed step by step.This process may not happen subsequentlyor in a continuous way. Rather, some stepsof the process would he skipped, while oth-ers could happen repetitively. The steps sug-gested in this paper are actually what nursingresearchers and practitioners have frequentlyused in their research projects and practicewithout recognition. Based on an in-depth re-view of the literature published witliin thepast 5 years, the steps used in the devel-opment of situation-specific theories in theliterature are summarized and proposed as

Development of Situation-specific Theories 141

Checking assumptions for theory development

• Multiple truths• Evolutionary nature of theo• Sociopolitical contextuality• Nursing perspectives

ry development

Exploring the phenomenon through multiple sources

• Currently existing nursing i• Literature review• Experiences and findings fr• Collaborative efforts

i

nd non-nursing theories

om research, education, and practice

k

r

Theorizing

• Initiation• Process• Integration

t

1

Reporting, sha

k

r

ring, and validating

Figure 2. An integrative approach to situation-specific theories.

follows. The process of the integrative ap-proach is also summarized in Figure 2.

Checking assumptions for theorydevelopment

A theorist who wants to develop asituation-specific theory needs to check heror his assumptions for theory developmentfirst. The assumptions for the developmentof situation-specific theories include (a) mul-tiple truths: ib) evolutionary nature of theorydevelopment; (c) sociopolitical contextuality:and id) nursing perspectives. These assump-tions are the basis for the whole theorydevelopment process of situation-specifictheories. If a theorist does not agree withtiiese assumptiotis, she or he may need toreconsider if she or he really wants to develop

a situation-specific theory. For example, if heror his assumption for theory developmentis hased on the universality of health/illnessexperience, she or he might not aim at thedevelopment of a situation-specific theorybecause a situation-specific theory assumesmultiple truths, which negates the univer-sality of health/iliness experience. Rather,she or he needs to aim at developing a grandtheory or a middle-range theory.

Multiple truths

Under the influences of positivism and sci-entism, nursing phenomena have been con-sidered to be universal phenomena whichcan occur to any racial, cultural, and gendergroups in the same way. ^ • ' Thtis, most nutT»-ing theories have also assumed that nursing

142 AiWANCES IN NURSING SCIENCE/APRIL-JUNE 2005

phenomena arc universal and homogeneous,and traditional approaches to knowledge de-velopment depend on the assumptions ofuniversality, homogeneity, and normality. ^Yet nursing phenomenon are becoming morecomplex and are complicated by multiplefactors, including the increasing diversity ofnursing clients.- '' A consensus has developedamong nurse scholars recently in which theo-retical deveiopmem must take into considera-tion the diversity and complexity of nursingphenomena. '*" ' Without doing so, the the-oretical foundation of the nursing disciplinecannot achieve the connections for whichnursing has been striving.

As posited in the paper by Im and Meleis,'*'the development of situation-specific theo-ries assumes philosophical, theoretical, andmethodological plurality, which is more con-gruent with the nature and goals of nurs-ing and which can incorporate the diversityand complexity of nursing phenomenon. Thephilosophical bases of the substance and syn-tax of nursing knowledge have been debatedby many nursing scholars.• * ''~" Meieis'^ di-vided the philosophical positions of nursingscholars into three: (a) the purist position;(&) the radical sepanitionist position; and(c) the nonpurist position. The bona fidepurist position claims that a philosophicalviewpoint should guide aiid direct theorydevelopment, research strategy, and clini-cal practice.'" The radical separationist po-sition asserts that a discipline s theory andresearch are distinct entities and do not nec-essarily have to be congruent pbilosophicallyand methodologically.'" The nonpurist posi-tion takes a philosophical, theoretical, andmethodological pluralistic position.'"' Tlieproject to develop situation-specific theoriesassumes this nonpurist philosophical positionas well as the existence of multiple truths, notone universal scientific truth.

Evolutionary nature of theorydei'eiopment

Another assumption for the developmentof situation-specific theories is that the the-

ory development process is cyclic and evolu-tionary. As discussed above, a concept whichis currently regarded as a norm or a stan-dard may not be a norm or a standard inthe future.^^ In other words, the integrityor stability of that norm through time can-not be predicted or ensured. Concepts areformed by the identification of characteris-tics common to a class of objects or phe-nomena and the abstraction and clustering ofthese characteristics.'^'' Therefore, as charac-teristics of nursing phenomena change, con-cepts also change. A concept which is notconsidered as important now can evolve intoan important concept in future nursing. c:on-sequently. a situation-specific theory which isdeveloped for a particular population in a spe-cific situation will not be appropriate for thesame population in a different time or a differ-ent sociopolitical context. Thus, the situation-specific theory for the same population in thesame situation also needs to be changed withchanges in time and sociopolitical contexts.

Sociopolitical contextuality

A third assumption for the development ofsituation-specific theories is the sociopoliti-cal contextuality of nursing phenomena. Thecurrent theory development process involvedin the development of grand theories andmiddle-range theories rarely considers the so-ciopolitical, cultural, and/or historic contextsinlierent to each ciient-nurse encounter.^^Rather than accounting for the contextual-ity of nursing phenomenon, they usually tryto reduce the phenomenon into several cen-tral concepts; operationalize and measure theconcepts; explore/test the concepts and con-structs tiirougli quantitative and qualitativedata collections; and refine the theories."'*'Consequently, they frequently aim at theoriesthat can be applicable to all nursing fieldsand explain central concepts across the fields.Since situation-specific theories are limited toa specific population and/or a particular areaof interest, the theories can easily incorpo-rate the contextuality of the phenomenon.""Indeed, the development of situation-specific

Development of Situation-specific Theories 143

theories assumes that nursing phenomena orclient-nurse encounters happen in sociopo-litical contexts, that sociopolitical contextsneed to be incorporated in the theory devel-opment process, and that the theories can-not be always applicable to any historicalmoment, any .social stnictiire, or any politicalsituation.

Nursing perspectives

An essential assumption for the develop-ment of situation-specific theories is thatthey are based on nursing perspectives. Nurs-ing perspectives give a unique view on aphenomenon. When we view a same phe-nomenon with two different perspectives,the phenomenon described by each of thetwo different perspectives may be differentfrom each other. For example, when we viewAsian American cancer patients' lack of painreporting using a biological perspective, wemay focus on the physiological characteris-tics of Asian Americans without consideringtheir whole beings in the contexts of theirdaily lives. Consequently, we may assume thatAsian Americans' lack of pain reporting is asimple biological difference from otber eth-nic groups, which may lead us to look forbasic biological difference between the etb-nic groups. When we view the same phe-nomenon (lack of pain reporting) from a nurs-ing perspective, we may view the patients'bio-psycho-socio-cultural beings within thecontexts of their daily lives. Rather than focus-ing on inter-ethnic biological differences, wemay focus on how their psycho-socio-culmralcontexts circumscribe their pain experienceand how we could provide adequate painmanagement while considering their uniquepain experience.

In the development of situation-specific theories, a nursing perspectiveis mandatory."' The theories developedwithout a nursing perspective might distortthe descriptions of nursing phenomenon andmislead nursing research and/or practice. Yetmore than one nursing perspective exists.'^A nursing perspective may he based onbiomedical models; it may also be based on

feminist perspectives emphasizing sociopo-litical environments and reflecting oppressedgroups' interests (mostly women's). In eithercase, it should also reflect nurses' concerns,views, values, and attitudes.

Exploring through multiple sources

After checking assumptions for her orhis theory development, a theorist needs toexplore her or his phenomenon of inter-est through multiple sources. Tlie multiplesources may include: (a) currently existingnursing and non-nursing theories related tothe phenomenon of interest; ib) literature re-views, (c) fmdings and experiences from re-search, education, and practice, and {d) col-laborative efforts. Theorists usually use morethan one of these sources for theory devel-opment at the same time. Each source is dis-cussed in detail as follows.

Currently existing nursing andnonnursing theories

Nursing and non-nursing conceptual mod-els, grand theories, and middle-range theo-ries can serve as the foundation for the devel-opment of situation-specific theories. Fromthe early days of nursing theory develop-ment, theory derivation has been prevalentin nursing," Usually, theory derivation innursing has been done by using analogy toobtain explanations or predictions ahout aphenomenon in nursing from the explana-tions or predictions in another field includingmedicine, psychology, sociology, and publichealth.'' Recently, theories from nursing havebeen combined with those from other dis-ciplines to create middle-range theories.""^In the development of situation-specific the-ories, both nursing and/or non-nursing tbeo-ries may provide tbe basis for analogy for ex-planations, understandings, or predictions ofa particular situation of a specific populationof interest as well.

An example is the above mentionedtheory of menopausal transition of Koreanimmigrant women,"" which was devel-oped based on a middle-range theory of

144 ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2005

transition.^^ In tbe development of thesituation-specific theory, major researchquestions were set based on the middle-rangetbeory of transition. Then, each concept wasexplored tlirough both quantitative and qual-itative findings from a study on menopausaltransition of Korean immigrant women. Basedon the findltigs related to the concepts, thetheoty of transition was modified, and furtherdeveloped as a situatioti-specific tbeory formetiopaitsal tratisition of Korean immigrantwomen. Compared with the middle-rangetbeory of transition, tbe situation-specifictbeory of menopausal transition of Koreanimmigrant women has increased specificityof tbe conceptualization and is easily applica-ble to the situation through the modificationsbased on actual study findings.

Literature reviews

Ati extensive review of literature can pro-vide a systematic analysis of currently exist-ing knowledge about a nursing phenomenonand frequently provide an excellent sourcefor theory development.'"" In tbis paper,the literature review means a review of pre-vious research findings, tbeoretical work, andstatistical governmental reports. Indeed, tbeliterature review has been an essential basistor concept development and theory develop-ment. Walker and Avant'' included literaturesynthesis as a method of concept synthesisand suggested that theory synthesis incorpo-rate published research literature, direct sta-tistical information, and qualitative researchas the second step of three phases of tbeorydevelopment.

Many examples of theory developmentthrough literature review can be easily foundin tbe nursing literature. An example wouldbe tbe tnmsition tbeory by Schumacher andMeleis- - who conducted an extensive litera-ture review on all types of transitions in nurs-ing and proposed a theoretical framework oftransitions. Based on the atialysis of tbe liter-ature, they proposed a set of major conceptsrelated to transitions, wbich include types oftransitions, properties of transitions, transi-

tion conditions, and nursing therapeutics. Al-tbough this example of the transition theoryaims to be a middle-range tbeory, the reviewof tbe literature as a source of theory develojvment can be easily iticorporated into tbe inte-grative approach, hi addition, a literature re-view frequently provides a starting point fortheory development by giving us a picture ofthe state of the science in the area and ini-tiating our theoretical thinking on the majorand/or central concept(s) in tbe nursing pbe-nomenon in question.'' Hulme- ^ provided anexcellent example of an integrative literaturereview on currently existing grand, middle-range, and situation-specific theories relatedto health problems of adttlts who experiencedcbildhood sexual abuse.

Findings and experiences fromresearcb, education, and practice

Findings and experiences from researchprojects, educational programs, and/or clin-ical practice in hospital and/or communitysettings can provide a source tor theoreti-cal development. Most nursing theories tendto be initiated by tbe tbeorists' experiencesfrom their long clinical, academic, or researchexperience in nursing.'^ Tbeorists can eas-ily raise theoretical questions from tbeir ownexperience. Kirkevold^^ posited tbat integra-tive nursing researcb experience has great po-tential for clarifying tbe theoretical perspec-tive and substance of the nursitig di.scipline,as well as making research-based knowledgemore accessible to clinical nurses. Lyons ** ar-gued tbat nursing can generate a knowledgebase tbrough reflecting on nurses' own expe-rience. Reed^ mentioned that her tbeory ofself-transcendence was developed using clin-ical experience and empirical investigations.

Collaborative efforts

International and interdisciplinary collab-orative efforts may provide sources for thedevelopment of situation-specific tbeories aswell. To be specific to a situation and/or apopulation, such a theory sometimes needs toiticorporate a more detailed and exact source

Dei'etopment of Situation-specific Theories 145

for theory development. Collaborative effortsallow comparisons of ideas, scholarly dia-logues, and an integration of different and/ordisperse opinions and findings.^" Experts indifferent areas of nursing who are working ontbe same nursing phenomenon will give dif-ferent and new views/visions on nursing phe-nomena which cannot be easily obtained byindependent work by one person. For exam-ple, when a collaborative team is working to-gether on midlife women's menopausal expe-rience, a nurse whose expertise is physiologycan provide a different view on menopausalexperience from a nurse anthropologist ora nurse feminist. Iti terms of tbeoretical de-velopment, the theory will be a nursing tbe-ory. but it will be based on diverse views onmetiopause.

(x)llaborations between academics andclinicians can also provide a source for the-ory development, wbich will provide a stronglink between theory and practice. Gassneret al. ^ proposed a model devised by tbeproject team, including fVnir academics andsix clinicians, and concluded that the modelwas effective in facilitating tbe collaborativerelationships necessary for successful devel-opment and implementation of reality-basedlearning for nursing students. Collaborationwitb research participants can also providean excellent source of theory development.*"Taking the lead in identifying areas of practicefor action research is a natural extension ofnurses' role as advocates for nursing clients,and it may provide a new view of the researchparticipants."'

International collaborative efforts also canprovide an excellent source for tbeory devel-opment, especially for situation-specific tbe-ories, because such theories tieed to pro-vide blueprints for nursing practice with aspecific population that can be usually cat-egorized along ethnic/cultural lines. Walkerand Avant" even envision tbat internationalefforts of nursing tbeory development willstrengthen nursing knowledge and theorydevelopment by incorporating different per-spectives/views from different cultural back-grounds. International collaboration can give

a new view on everything from tbe philoso-phy of life, accepted behaviors, and butnanrelations to tbe way in whicb people Uve. '"*^Recent advances in computer and commu-nication technologies may facilitate interna-tional collaboration tlirougli electronic net-works more easily than in the past, and wewill see more and more international collabo-rative woriis in theoretical nursing."*^

TheorizingInitiation

Wbile exploring the pbenomenon of inter-est through multiple sources, a theorist mayinitiate ber or his theory development witha simple literature review on a specific nurs-ing pbenomenon of ber or his interests, fromher or his own research, atid/or from ber orbis practice experiences even before the re-view of tbe literature. Tbeory developmentcan start from a motber theory and resultin a modified form of the theory, wbich ismore specific to tbe population of her orbis interest or to the nursing situation. The-ory development can be initiated by a singleperson or a group of colleagues who bavebeen involved in the same area of interests.Recently, some tbeories bave been even de-veloped tbrough international or interdisci-plinary collaboration."'*'"''" Tbeory develop-ment in the integrative approacb may be initi-ated from one source or multiple sources at atime or at separate time points.

Process

Developing a situation-specific theory cantake place through a theorizing process inseveral different ways. Although few nursingtheorists claim to have developed situation-specific tbeories, many theories in nursingmeet the definition of situation-specific the-ories. Tbe following examples sbow tbatthe process involved in the developmentof situation-specific tbeories can be diverse.These examples were searched using tbePUBMED database. For the PUBMED search,key words including nursing, theory, and the-ory developtnent were used, and only the

146 ADVANCES IN NURSINC; SCIENCE/APRIL-JUNE 2005

A qualitative exploratory study using focus group discussions;Research findings

Conceptualization of empowennent and theorizing

Validation through interviews with clients

3. The process involved in the development ofthe theoretical work hy FiiJk-Rafacl.

articles publisbed in Englisb during the past5 years were searcbed in order to capturethe current trends in nursing theory develop-ment. From the 215 articles retrieved throughthe search, tutorials, editorials, and literaturereview articles were excluded. Then, all tbearticles were reviewed in order to identify' theprocess used in theory development. Amongthem, otily the articles presenting situation-specific theories were selected for this paper.

One of tbe examples is tbe theoretical workby Falk-Rafael ' (see Fig 3). Her theoreticalwork sbows a unique type of process for the-ory development. She initiated her theoreticalwork tbrough a qualitative exploratory study.Sbe began the study by using a nominal grouptecbnique in a series of focus groups witbpublic health nurses to identify their con-ceptualization of empowerment, the strate-gies tbey identified as empowering, and theoutcomes of empowering strategies tbey ob-served in their practice. Based on tbe quali-

tative study, she then initiated the theorizingprocess and developed a model that concep-tualized empowerment as a process of evolv-ing consciousness in which increasing aware-ness, knowledge, and skills interacted withthe clients' active participation to move to-ward actualizing potential. Finally, tbe devel-oped model was shared and validated tbroughinterviews with clients whom nurses identi-fied as having been empowered tbrough theirpractice.

Recent nursing literature notes a typeof tbeory development tbat integrates the-ory, research and practice. For example,LaCoursiere's theory of online social support(see Fig 4) was developed with an integratedframework tbat iticorporates knowledge frommultiple sources including (a) a conceptualliterature review of existing frameworks andresearch findings related to social support,online comtnunications, and the effect of theInternet or the Web; (&) reports and statistics

Literature review Reports and statistics

Theorizing

Experience with communities

Figure 4. The process involved in the development of the theoretical work by LaCoursiere.

Development of Situation-specific Tbeories 147

Literature review Two models related to heaithbehaviors

Research studies amongMexican migrant tarm

workers

Figure S< The process involved in the development of the theoretical woric by Poss.

from agencies and organizations focusing ontbe online bealth care experience; and (c) theauthor's experiences w itb online social sup-port communities over a number of years.Tbis type of tbeorizing can be easily found innursing.

Anotber example of this type of theoriz-ing is Poss's model for cross-cultural researcbamong Mexican migrant workers in tubercu-losis screening tests (see Fig 5). **' In tbe tbeo-retical work, tbe model was developed basedon a literature review, two models tbat are of-ten used to study bealtb bebaviors (the HealtbBelief Model and the Theory of Reasoned Ac-tion), and previous researcb studies amongMexican migrant farm workers participatingin a tuberculosis screening program.

The tbeory development process ofsituation-specific tbeories can also be foundin the development of tbe integrative model

for environmental health research by Dixonand Dixon (see Fig 6)."*'' Tlie tbeorists devel-oped the tbeory based on their experiencesin botb academic and activist communitiesrelative to environmental health and a reviewof the research literature. Tben, a workinghypothesis that may be useful in guidinginvestigations or suggesting needed policieswas extracted and used in tbeir researcbon tbe engagement in environmental healtbissues at the individual and community levels.

Integration

Wbile initiating and proceeding theorizingprocess based on explorations of nursing pbe-nomenon through multiple sources, a theo-rist can integrate her or his analysis, discovery,formulation, and evaluation through concep-tual schemes, reflexivity, and documentation.

Experience in academics

. " • •

I . . .

j

r

Experience in activistcommunities

Literature review

1 r

Theorizing and e.xtracting a working hypothesis

f

Research on the engagement in environmental health issues at theindividual and community levels

•

. The process involved in the development of the theoretical work by Dixon and Dixon.

148 ADVANCES IN NtjRSiNG SCJENCE/APRIL-JUNE 2005

Tbe integration process tbat a tbeorist canadopt includes several different components.From existing nursing and non-nursing the-ories, a theorist may start with broad estab-lished facts, principles, laws, or theories thatare known and generally accepted as trueand u.se them to address narrower yet relatedphenomena, concepts/variables, and propo-sitions. A tbeorist may start from her or hisexperience in researcb, education, practice,research findings, or literature review withsmaller, narrower concepts/variables and for-mulates new propositiotis that may ultimatelylead to tbe development of new facts, prin-ciples, laws, and theories. A theorist mayalso formulate potential propositiotis basedon personal and nursing knowledge, skills,values, meanings, and experience and not onempirically-based evidence or facts. Altbtjugbdistinctively different, these ways of integra-tion may combine. Furthermore, these inte-gration processes can happen for a long pe-riod of time, and a tbeorist might go tbrougbseveral waves of integration through her orhis researcb projects and practice in clinicalsettings.

In these integration efforts, conceptualschemes witb beginning hunches can beinstrumental."' Conceptual schemes can beinitiated, developed, and refined throughouttbe theory deveiopment process. The mostimportant part of the conceptual schemes isinternal and external dialogues. " "' Throughconceptital thinking, memo-writing, andjournal-writing, a theorist can initiate andmaintain her or his internal dialogues so tbather or his theorizing process can be furtherorganized, refined, and integrated.'^ In addi-tion, a theorist may initiate and maintain anexternal dialogue tbrougb discussions withcolleagues, research members, students, andresearch participants and tbrougb participa-tion in seminars, conferetices, and/or paneldiscussions. In both ways, the theorist candevelop and refine ber or his conceptualschemes that are related to the nursingphenomenon of her or his interests and canintegrate various theorizing processes.

Reflectivity is also instrumental in tbe pro-cess of integration. Situation-specific tbeo-

ries consider social, cultuml, and historicalcontexts, but tbeir scope and the questionsare limited to specific situations and/or spe-cific populations.'''-^" Therefore, in the de-velopment of situation-specific theories, con-siderations of social, cultural, and historicalcontexts should be incorporated from tbe be-ginning stage ofthe thcor>' development pro-cess, which requires reflectivity' of tbe theo-rists. Sufficient reflectivity to uncover whatmay be deep-seated but poorly recognizedviews on the specific situations and/or thespecific populations central to the tbeory de-velopment and a full account of the theorists'views, thinking, and conduct cati belp thetheorist's integration of her or his theorizingprocesses. '

Tbe theorists also need to be reflectiveabout tbeir own values aiid meanings re-lated to specific situations and/or specificpopulations. Values arc enduring beliefs, at-tributes, or ideals that establisb moral and eth-ical boundaries of wbat is right and wrongin thought, judgment, character, attitude, andbebavior."*** Tbus, values form a foundationfor correct thinking and decision makingthroughout the theorist's life; values developover time and reflect individual, family, so-cial, cultural, and religious influences as wellas personal choice.'** Tbits, during tbe inte-gration process, a theorist needs to be re-flective on their own meanings attached tothe specific situations and/or the specificpopulations.

Documentation of all stages involved intbe theory deveiopment process can be in-stmmentai in integration efforts. As situation-specific tbeories empbasize contextuality andreflectivity in tbe process of tbeory develop-ment, tbe theoretical and analytic decisiontrails created by the tbeorists during thedevelopment process need to be ascertainedas well.'^ Theorists may continually ques-tion their conceptualization and tiieorizing,critiquing each step of the developmentprocess and the impact of the theorieswithin their social and political environment.Tbis process needs to be well documentedthrough tbeoretical diaries and/or memos,so tbat the documentation supports tbe

Development of Situation-specific Tbeories 149

integration of the tbeory developmentprocess. ' Systematically documenting the ra-tionale, outcome, and evaluation of all actionsrelated to theory development is an impor-tant component of the deveiopment of thesituation-specific theories.' This documen-tation will result in well-grounded, cogent,justifiable, relevant, and meaningful theorydeveiopment processes and outcomes.

Reporting, sharing, and validating

Wiien tbe documenting of theorizing andintegration takes the form of a manuscript,a model, or a researcb report, these need tobe reported and shared with nursing com-munities. Nurse theorists bave emphasizedreporting and sharing of their work.^'^ Tliecriteria for theory evaluation that have beenproposed and used in nursing usually includesocial utility and/or contagiousness as an im-portant criterion.'^ ''" Tbrough reporting andsbaring, theory development may be con-stnictively critiqued by peers, and theoreticalproducts can be further developed.

Tbe validation of theories by nursingclients can also enbance the efforts to de-veiop a tbeory. Tlie reievance of an approachneeds to be reflected from tbe very beginningof the process. Here, relevance means thata nursing tbeory can serve nursing clients'own issues and interests in improving tbeirlives.*- To ensure relevance, situatioti-specifictheories may be checked with nursing clientsin the specific situation and/or witb the par-ticular population througli a member valida-tion process, and tbeorists always need to bereflective about nursing clients' own views,needs, and interests throughout the theorydevelopment process. Wlien nursing clientsperceive a theory to be representative of theirreal experience, the theorized modei is moreeasily applicable to the nursing pbenomenon

that the cUents are experiencing, which sub-sequently improves understanding and nurs-ing care outcomes.

CONCLUSIONS

In this article, an integrative approacb tothe development of situation-specific theoriesis proposed. This proposition is an extensionof a suggested outline of the integrative ap-proach previously drawn by Im and Meieis.'^Tlie proposed integrative approacb describestbe development process of situation-specifictbeories that aim to produce ready-to wear-theories and tbat ultimately aim to link betternursing care outcomes through their speci-ficity and diversity'. None of tbe steps/stagesin tbe proposed approacb is entirely newto nurses, whetber they are clinicians, the-orists, or researchers.'^ Nurses may be in-volved in the tbeory development process inmany ways, and we can see tbe growing ac-ceptance of theory development as a signif-icant aspect of knowledge development in

Theory development cannot grow inisolation.'" Tbe integrative approacb pro-posed in tbis paper needs more discussion,constnictive criticism, and feedback fromresearchers, practitioners, and tbeoristsalike. The integrative approach should notbe limited only to tbe proposed process.As knowledge and technology in nursingadvance, we may see different types andprocesses of theory development in nursingin the near future." As we keep in mindthat tbeory development process is dynamic,cyclic, and changing over time, we need tocontinue to welcome the changes and remainopen to tbe potential growth of theoreticalnursing for better nursing care outcomes.

REFERENCES

1. ZimanJ, Midgk-y M. Plunilisni in science: a statement.hiterdisdp Sci Rvv. 2(H) I; >(>: 113.

2. Ziman .1. tmcrging out ot nutiirt' into liistnr)': thfplurality of the sciences. Phii Trans R Soc Lond.2O()3;.V>1:16I7-1633.

3. Chinn I'L. RfspoiLSf: revision and passion. Sch InqNursPracl. 19K7;l:2i-24.

4. Ellis R. t:haracteristics of stgni/icani theories. NursRes. l968;l7:217-222.

5. Hardy ME. The nature of theories. In: Hardy ME, ed.

150 ADVANCES IN NURSING SctENCE/APRiL-JUNE 2005

Theoretical Foundatiorts for Nursing. New York:MSS Information Corp; 1974.

6. Jacox A. Theory construction in nursing: anoverview. A'wrs/?«. t974;23:4-13.

7. Haa.se JE, Britt T. Coward DD, Leidy NK, PennPE. Simultaneous concept analysis of spiritualperspective, hope, acceptance, and self tran-scendence. Image f Nurs Sch. 1992;24:14I-147.

8. Haasc JE, Uidy NK, Coward DD, Britt T. Penn PE.Simultaneous concept analysis: a strategy for devel-oping multiple interrelated concepts. In: RodyersB, Knafl K, eds. Concept Denelopment in Nurs-ing. Philadelphia: WB Saunders Co; 1993:175-192.

9. Schwartz-Barcott D, Kim HS. An expansion and elab(>ration of thf hybrid mtxlel of concept development.In: Rodgers BI., Knafl KA, eds. Concept Developmentin Nursing: Foundations, Techniques, and Applica-tions. Philadelphia, PA: WB Saunders Co; 2000:129-160.

10. Walker LO, Avant KC. Strategies for Theory Con-struction in Nursing. 3rd ed.. Norwalk, CT: Apple-ton & Lange; 1995

11. Walker LO. Avant KC. Strategies for Theory Con-struction in Nursing. 4th ed.. Norwalk, Cf; Apple-ton & Lange; 2()O5,

12. Chinn PL. Why middle-range theory? Adv Nurs Scl.t997;19O):viii.

13. Peterson SJ, Bredow TS. Middle Range TJjeorles:Application to Nursing Research. Philadelphia, PA:Lippinccott Williams & Wilkins; 2004.

t4. Smith MJ. Liehr PR. Middle Range Theory for Nurs-ing. New York: Springer Publishing Co; 2(K)3.

15. Gortner SR. The history and philosophy of nursingscience and rescarLh. In: Reed PCi. Shearer NC, NicoltLH, eds. Perspectii-es on Nursing Theory. Philadel-phia: JB Lippincott; 2(K)3:IO5-112.

16. Im EO, Meleis AL Situation-specific theories; phiUhsophical roots, pniperties, and approach. Adv NursSci. 1999:22(2): n - 2 4 .

17. Meleis AI. Tbeoretical Nursing: Development andProgress. 3rd ed. Philadelphia: Lippincotl; 1997.

18. Peterson SJ. Introduction to the nature of nursingknowledge. In: Peterson SJ. Bredow TS, eds. MiddleRange Theories: Application to Nursing Research.Philadelphia. PA: Lippinccott Williams & Wilkins;2004:3-41.

19. Meleis AI. Sawyer LM, Im EO. Messias DK.Schumacher K. Experiencing transitions: an emerg-ing middle-range theory. Adr Nurs Scl. 2OOO;23(l):12-28.

20. Im EO, Meleis AI. A situation-specific theory ofKorean immigrant women s menopausal transition.Image. l'>y9;31:.333-3.^8.

21. Whittcmore R, Roy SC. Adapting to diabetes melli-tus: a theory synthesis. Nurs Scl Q. 2002; 15(4);311 -317. . -" -V •

22. Hupcey JE, Morse JM, Lenz ER, Tason MC. Wilsonianmethods of concept anal> sis: a critique. Scb Inq NursPract. 1996;1O;253-2T7.

23. Rodgers BL, Knafl KA. Concept Development InNursing: Foundatiotis, Techniques, and Applica-tions. Philadelphia, PA: WB Saunders Co; 2000.

24. Chinn PL, Kramer MK. Theory and Nursing: In-tegrated Knowledge Deivlopment. St Louise: CVMosby; 1999.

25. Rodgers BL. Philosophical foundations of conceptdevelopment. In: Rodgers BL. Knall KA, eds. ConceptDevelopment iti Nursing: Foundations, Techniques,and Applications. Philadelphia, PA: WB SaundersCo; 2(KH):7-37.

26. Kim HS. Putting theory into practice: problems andprospects.//irfr/VMrs. 1993;18(I): 1632-1639.

27. Moccia PA. A critique of compromise: Beyond themethods debate. .4rfr A'urs Sci. 1988:10:1-9.

28. Thompson JL. Practical discourse on tiursing; goingbeyond empiricism and historicism. Adv Nurs Sd.1985;7;59-71.

29. Hall JM, Stevens PE. Rigor in feminist research. AdvNursSd. 1991;13:l6-29.

30. Meleis AL A passion for making a difference: Revi-sions for empowerment. Sch Inq Nurs Pract. 1998;12:87-94.

31. Baker C. Cultural relativism and cultural diversir>: im-plications tor nursing prairtice. y'tirs .Sci. 1997:20:3-11.

32. Hall JM, Stevens PE, Meleis Al. Marginalization: aguiding concept or valuing diversity in nursingknowledge development./tt/r Nurs Sci. 1994:16(4):23-41.

33. Schumacher KL. Meleis AI. Transitions: a central con-cept in nursing. Image. 1994:26:119-127.

34. Hulme PA, Theoretical perspectives on the healthpn>blems of adults who experienced childhood sex-ual abuse. Issues Mental Health Nurs. 2OO4;25:339-361.

35. Kiiicevold M. Integrative nursing research—an im-portant strategy to further the development ofnursing science and nursing practice./ Adi- Nurs.1997;25(5);977-984.

36. Lyons J. Reflective education for professional prac-tice: discovering knowledge from experience. Nurseliduc Today. 1999;19(l):29-34.

37. Reed W^. Toward a nursing lheor>' of self-transcendence: deductive retbrmutation using de-velopmental theories. Adv Nurs Sci. 1991;13(4):64-77.

38. Norbeck JS, Tilden VE International nursing researchin social support: theoretical and methodological is-sues, f Adi' Nurs. 1988; 13(2); 173-178.

39. Gassner LA. Wotton K. ClareJ. Hofmeyer A, BuckmanJ. Evaluation of a model of collaboration: academicand clinician partncrsiiip in the development and im-plementatit>n of undergraduate teaching. Collegian.1999;6(3): 14-21.

Development of Situation-specific Tbeories 151

40. Neill SJ. Developing diildren's nursing through ac-tion research, f Child Health Care. 1998;2:11-15.

41. Gennaro S. International nursing: the past 25 yearsand beyond. MCN Am f Matem Child Nurs.2000; 25(6): 296-299.

42. Beunza I, Boulton N, f-erguson <'. Serrano R. Diversityand commonality in international nursing. Int NursRet'. 1994;4l(2):47-52.

43. Sparks SM. Electninic networking for nurses. Image.1993;25(3>:245-248.

44. Falk-Rafael AR. Empowerment as a process of evolv-ing con.sciou.sncss: a mode! of empowered caring.Adr Nurs .-id. 2001;24(l):l-l6.

45. LaCioursiere .SP A theorj' of online social support.Adv Nurs Sci. 2001:24( l>;60-77.

46. Poss JE. Developing a new model for cross-cultural re-

search: s>'nthesizing the health belief mixlel and thetheory of reasoned action. Adv Nurs Sci. 2(H>I ;23(4):1-15.

47. Dixon JK, Dixon JP An integrative model forenvironmental health research. Adv Nurs .St/.2(X)2;24{3);43-57.

48. Johnson BM, Webber PB. An Introduction to Tbe-ory and Reas<ming in Nursing Philadelphia. PA:Uppincott Williams & Wilkins: 2004.

49. Benner I* Tanner CA. Chesia C;A. Expertise in Nurs-ing Practice: Caring, Clinical Judgment, and Ethics.New York: Springer I'ublishing (AI; 1996.

50. Faweett J. Framework for analyses and evaluation ofconceptual modeK of nursing. In: Reed PG. CrawfordNB. Nicoll LH. eds. I'erspectives on Nursing Tlfeory.4th ed. Philadelphia: Uppincon Williams & Wilkins;2004;87-94.