Joumal c^ Advanced Nursing, 1992,17, 224-228

Conceptual models and nursing practice: the reciprocal relationship* Jacqueline Fawcett PhD FAAN Professor, School of Nurstng, University of Permsylvama, Philadelphia, Pennsylvania, USA

Accepted for publication 1 July 1991

FAWCETT J (1992) ]ourmJ of Advanced Nursmg 17, 224-228 Conceptual models and nursing practice: the reciprocal relationship There is a reaprocal relationship between conceptual models of nursing and nursmg practice Conceptual models influence dmical nursmg practice by speafymg standards for and purposes of practice, identifymg relevant dmical problems, settmgs for practice, legitimate reapients of nursmg care, and the content for the nursmg process, suggestmg methods for debvery of nursmg services, and by providmg frameworks for dmical mformation systems, pahent dassificahons systems and quality assurance programmes Nursmg practice, m tum, provides data that can be used to determme the credibility of the conceptual models Sources of data from dimcal practice for credibility detennmation mdude evaluations of nursmg mterventions, the reapient's f>erspechve of nursmg care and quality assurance reviews

THE MISSION OF NURSING Nursing is a disapline with a soaal mission to serve people As such, the aim of nursing knowledge is to guide and direct the clinical services nurses offer to people across the health continuum Despite continued claims to the contrary, nursing knowledge, m the form of conceptual models, does not lack practical value Furthermore, prachce IS not devoid of implications for refinement of conceptual models This paper presents a discussion of the relahonship between conceptual models of nursing and nursmg prachce The central thesis of the discussion is that conceptual models inform and transform nursmg practice by informmg and transforming the ways in which prachce is expenenced and understood, and that nursing prachce informs and transforms conceptual models by informing and transforming the content of the conceptual model (Speedy 1989) There is, then, a reaprocal relahonship between conceptual models and nursmg prachce (see Figure 1) 'Adapted from a paper presented at the Thrd BunmtJ Nursit^ Theory Confereme 'Nursmg Theory ChdUnge for Practice The Cathohc University of Amenca Wiehrngtm DC 30 March 1990 Dr] Fauxett 72OMideUe Tumptie Storrs Cmmecttatt 06268 USA

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Conceptual model

- • Nursing practice

Figure 1 The reciprocal relationship between conceptual models and nursing practice

CONCEPTUAL MODELS AND NURSING PRACTICE The influence of conceptual models on nursmg practice is considered first A conceptual model is defined as as set of abstract and general concepts and the propositions that state something about the concepts Given the abshact and general nature of the concepts, the proposihons, which descnbe or link the concepts, also are abstract and general Environmental shmuli and adaptahon are examples of conceptual model concepts These concepts are linked by the proposition statmg that changes m envirorunental stimub are assoaated with changes m adaptation At least sevea different formulations that fit thedefiruhon of a conceptual model are used m contemporary nursmg prachc£ (Fawcett 1989) These are Dorothy Johnson's

Conceptual models and nursing practice

Table 1 Ways in which the conceptual model influences nursing practice Conceptual models

- • Nursing practice structuring nursmg services

Standards for nursing practice Purposes to be fulfilled by nursing practice Clinical problems to be considered Settings m which nursing practice should occur Legitimate recipients of nursing care Nursing process format and content System of nursing care dehvery Qinical information system Patient classiftcation system Quality assurance programme

Behavioral System Model, Imogene King's Interacting Systems Framework, Myra Levine's Conservation Model, Betty Neuman's Systems Model, Dorothea Orem's SelfCare Framework, Martha Rogers' Saence of Unitary Human Beings, and Callista Roy's Adaptation Model Each of these conceptual models represents its author's view of nursing's intellectual and soaal domain (Johnson 1989) The content of each conceptual model, then, reflects its author's philosophy of nursing and her way of thinking about the health of people as they interact with their environments The content of each model also reflects its author's idea of nursing's mission in soaety and specifies her prescnptions for practice Each conceptual model, therefore, represents a particular fi-ame of reference for nursmg practice

Standards The speafic ways in which a conceptual model influences nursmg practice are hsted m Table 1 Each conceptual model identifies certain standards for nursmg practice, certain purposes to be fulfilled by nursmg practice, and certam clmical problems to be considered Each model also identifies certam settmgs m which nursmg practice should occur and the charactenstics of what the model's author considers legitimate reapients of nursing care Furthennore, each model identifies a distinctive nursmg process to be employed and technologies to be used, mdudmg paramet«^ for patient assessment, labels for pati«it problems, a strategy for plannmg, a typology of intervenhons, and cntena for evaluation of mtervention outconws. Thus, the grawnc nursmg process of assessment, labelling, plannu^ mtervenhon and evaluation is given a distmctive context and format by each coiKeptual model

Conceptual models also direct the delivery of nursing services Walsh (1989) maintained that because nursmg models lead to mdividualized patient care, pnmary nursmg 'is the only way that a model can be properiy used, with one nurse responsible for plarming a patient's care throughout his or her stay' Shea and her colleagues concurred They noted that conceptually based practice (CBP) is facilitated by 'either pnmary nursmg or total patient care [and that] mtroduang CBP seems to be easier if one of these two types of nursing is in place' (Shea et al 1989) Furthermore, conceptual models of nursmg serve as the basis for clinical information systems, mcludmg the admission data base, nursing orders, care plan, progress notes and discharge summary (Chnstmyereffl/ 1988) This means that the conceptual model is systematically reflected in all nursing documentation tools This also means that each model requires its own documentation strategies (Herbert 1988) King (1989), for example, used her Interacting Systems Framework as the basis for a comprehensive documentation system called the Goal Onented Nursmg Record System The components of the system are a data base, nursing diagnoses, a goal list, nursing orders, flow sheets, progress notes and a discharge summitry In contrast, Orem's Self-Care Framework has been used as the basis for a computenzed nursing information documentation system (Bbss-Holtz et al 1990, McLaughlm et al 1990) The computer software currently is being tested m several clmical agencies in the United States and Canada that use Orem's conceptual model as the basis for nursmg practice Each of these mformation systems can be used to document practice only if practice is based on the underlying conceptual model Thus, the Goal Onented Nursing Record System can be used only when practice is based on King's Interacting Systems Framework, and the Sayers computer software can be used only if nursing practice is based on Orem's Self-Care Framework

Patient classification Conceptucil models guide the development of patient classification systems For example. Auger & Dee formulated a classification system denved from Johnson's Behavioral System Model They first stated cntical behaviours for each behavioural subsystem Then they categonzed the overall level of behaviour for each patient as adaptive, in the process of being leamed and/or minimally maladaptive, or maladaptive Finally, they linked specific nursing mterventions to spea&c behaviours Ai^er & Dee's classification system provides an objective means for evaluating the quality of nursing care on the 225

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Table 2 Sources of data ham clinical nursmg practice used for deternunaticKi of conceptual model credibility

Nursing practice credibility determination

Conceptual mode!

I

Evaluation of individual encounters between nurse and care reapient The recipient's perspective of nursing care QuaLty assurance review

basis of common behavioural problems or nursmg treatments rather than usmg medical diagnoses as the basis for evaluation of patient outcomes (Auger & Dee 1983, Dee & Auger 1983) In fact, datafi-ompatient records, whidi are based on the classification system, reveal changes m the behaviours, and hence the classification, of pahents on the basis of speafic nursmg mterventions (Randell 1989) Obviously, this classification system wouid make no sense if nursmg practice were based on a conceptual model other than Johnson's Quahty assurance programmes are also based on the conceptual model used to giude nursmg practice Ference (1989) maintained that when practice and administrati(Hi of a service are orgaruzed using a [particular coiKeptual model], the mdex, or measure of their functional intensity must match Therefore, a speafic set of quality measures need to be used to judge intensity of function and adherence to standards in accord with [the conceptual model]

Ference gave examples of quality assurance measures based on Rogers' Saence of Unitary Human Bemgs, mcludmg standards and outccone cntena for safety with regard to mobilization as well as for sleep/wake cycles It IS important to underscore the fact that the conceptual model guides nursing practice This means that nursmg knowledge, as formalized m a particular conceptual model, IS the startmg pomt m the reaprocal relationship with nursmg practice If practice were the startmg pomt, thai the boundaries of nursmg knowledge would be so severely restncted that, as Donaldson & Crowley (1978) pomted out, 'professional nursmg [wjouid be limited to the realm of disaster relief rather than servmg as a force m the promotion of world healtfi' Furthermore, if practice were the starting point, much time could be wasted ard mudi vital infbnnaHon wcKild not be reccn-ded because the wror^ questions imght be asked (Walsh 1989). 226

NURSING PRACTICE AND CONCEPTUAL MODELS

This IS not to say that nursmg practice has no influence on a conceptual model or that the conceptual model must be regarded as an ideology that cannot be changed Rather, modifications m any conceptual model should be based on systematic use of the model and documentation of outcomes Indeed, the reaprocal relationship between a conceptual model and nursing practice progresses from the abstract content of the conceptual model to the real worid of clinical practice back to the conceptual model (Figure 1) Silva (1986) identified the cntical need to examme outcomes of use of a conceptual model to detemune its credibility Although she focused on the use of conceptual modeb m nursing research, her idea can be extended to clinical nursing practice Thus, every encounter between a nurse and a reapient of nursmg care serves as a source of data for credibility determination Nursmg practice, therefore, IS not only a dimcal service to people, but also is a means of knowledge development The ways m which nursmg practice contnbutes to the determination of the credibility of a conceptual model are listed in Table 2 One source of data from clinical practice that can be used for credibility determination is the evaluation of nursmg mterventions that is earned out m mdividual encounters between nurses and nursmg care reapients Every report or case study of the use of a conceptual model should mdude conclusions regardmg the credibdity of the model This method of credibdity determination begins with development of protocols for areas of nursmg practice encompassed by the contmt of the conceptual model Next, individualized systems of care are fonnukted by each nurse for particular pahents Nursmg care then is earned out m accordance with the nursmg process (^ the elected cofKeptual model and outcomes are measured The results of tfie evaluahcm step of die nursu^ process represent datatfiatmay \x used to detemune the credibility of the cofK^^ud model

Conceptual models and nursmg practice

The conceptual model is considered credible if patient outcomes are congruent with expectahons raised by the model If, however, patient outcomes are not congruent with expectations, the credibility of the conceptual model must be questioned When the credibility of a conceptual model IS examined in this way, the reflechve, thoughtful nursmg practice that is the hallmark of clirucal scholarship is dearly evident The beginning of an example of this method of credibility IS reflected m Gemsh's (1989) evaluation of the use of Roy's Adaptahon Model for assessment of a 25-year-old woman with Hodgkm's disease Gemsh stated that she selected the Roy model because she wanted to view pahents from a broad perspective She concluded that although she found 'the assessment stage time-consuming, it yielded a wealth of valuable mformahon, giving [her] a deep understandmg of the patient, which later helped to identify problems, set goals and plan care' Gemsh's thoughtful evaluahon of the use of a conceptual model for assessment is only the first step m credibility determinahon for mdividual encounters between nurses and care recipients More comprehensive case studies that draw conclusions regardmg credibility for all components of the nursing process are definitely needed

Recipient's perspective Another source of data from clinical practice that can be used for credibility determmation is the reapient's perspechve of nursing care (Table 2) This method of credibility determinahon requires the care reapient's answers to the following queshons (Aggleton & Chalmers 1985) 1

2 3 4

Did the nursing model provide guidelmes for assessment that enabled the care reapient's problems to be dearly identified? Did the plarmmg of care and settmg of goals match the reapient's expectations for care? Did the model suggest a range of nursing intervenhons that were feasible for the care recipient? Did the nursmg mterventions reflect a standard of care acceptable to the care recipient?

Affirmahve answers to these questions would, of course, add to the aedibibty of the concepHial model Negative answers may indicate lack of credibility but also may mdicate that the reapient of care was not fully informed of the services that are assoaated with the model As Dorothy Johnson (1974) pointed out, 'soaety rmght come to expect a different form of prachce, given the opporturuty to expenence it' Unfortunately, as jor^s (1989) pomted out, 'very little woric has been cjimed out to examme the

[reapients'] view of the nursmg care they are receivmg, and whether they have, m fact, nohced an improvement m the quality of care because of the adoption of nursing models' Qearly, then, this method of credibility determination requires increased attention Still another source of data from clinical prachce that can be used for credibility determination is the quality assurance review When judgements regardmg the quality of nursing care are tied to the conceptual model that guided the nursing care, the data from the quality assurance review can be used to examme the credibility of the conceptual model upon which prachce is based Once agam, the conceptual model IS considered credible if patient outcomes are congruent with expectahons raised by the model If, however, patient outcomes are not congruent with expectahons, the credibility of the conceptual model must be queshoned This method moves credibility determinahon to a macroscopic view that encompasses the entire clinical agency, whereas the previous methods are microscopic views focusmg on the individual encounter between nurse and care reapient

CONCLUSION Objections to the extant conceptual models of nursing voiced by clinicicins are at least m part based on the accurate percephon that some users of the models regard them as ideologies that must not be questioned or cntiazed Systemahc and objective scrutiny of the outcomes of conceptual model-based nursmg practice is cruaal, along with modificahons in the model or even elimination of the model if the data warrant this Note that 'nursing models were devised to move nursing away from ntualistic and task onented care to thoughtful practice [They were] created to shape nursing into what it ought to be' Oones 1989) The use of conceptual models, tests of their credibdity m the reiil world of dmical practice, and subsequent refinement or elimmahon of the model, are mandatory if nursmg is to survive as a distinct professionai discipline and if nurses are to continue to have the nght to tcike Ccire of people References Aggleton P & Chalmers H (1985) Cntical examination Nursing Times 81(14), 38-39 Auger JR &DeeV (1983) A patient classification system based on the behavioral system model of nursing Part 1 Joumal of Nursmg Admimstratton 13(4), 38-43 Bhss-Holtz J, McLaughlm K. & Taylor S G (1990) Validating nursmg theory for use withm a computenzed nursmg information system Advances in Nursing Saence 13(2), 46-52 227

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Chnstmyer C S , Catanzarrti PM, Langford AJM & Reitz ]A Jones S (1989) Is umty posable? Nursing Stmdard 3(1), (1988) Bndging the gap theory to prachce — Part I, dmical 22-23 apf^icaticms Nursing h4ana^ment 19(8), 42—50 King IM (1989) King's systems framework for nursing admmIDee V & Auger J R. (1983) A patient classification syston based lstration In Dimensions of Nursing Administration (Henry B, on the behavioral system model of nursing Part 2 Joumal of Amdt C, Di Vin

Conceptual models and nursing practice: the reciprocal relationship.

There is a reciprocal relationship between conceptual models of nursing and nursing practice. Conceptual models influence clinical nursing practice by...
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