There is an increasing interest in understanding nursing phenomena directly related to clinical practice. Accompanying this interest is the need for clarifying the conceptual base of the clinical nursing specialty areas ( Hoeffer, 1983; McLaughlin, 1982; Stevens, 1984). This is particularly relevant for undergraduate and graduate nursing programs that have clinical specialty foci within their curricula. Clinical specialization, although sometimes a bane in efforts to establish a holistic perspective of human beings, presents an opportunity for nursing students to learn about the critical link between theory and practice. This learning can be facilitated by incorporating a conceptual framework developed for the clinical specialty into the educational process. The broad yet meaningful nature of the conceptual framework renders it applicable to a variety of educational needs that exist in clinical nursing specialty curricula, such as organizing theoretical content, interpreting and integrating clinical experiences, and student participation in clinically-oriented research.
The purpose of this article is to explicate a model for developing conceptual frameworks for teaching in the clinical specialty areas. The primary functions of the model are to aid educators in clarifying a conceptual base for clinical specialty teaching and to illuminate for students the conceptual processes underlying their clinical nursing practice. Application of the model in education can also promote student understanding of the significance of a conceptual base for practice in developing nursing science.
A major characteristic of the model is that it employs concepts selected from extant nursing conceptual models. At first glance it may seem paradoxical that the nursing conceptual models, which tend to be abstract and broad in scope, offer a means for constructing a conceptual base for education in a clinical practice area of nursing. However, it is suggested that concepts may be borrowed from nursing models and organized to formulate a specific clinical perspective for education and practice. This linking of concepts from various nursing models to "form a new whole" is a process similar to one described by Meléis (1985) in her discussion of "multiple theory usage" in development of nursing theories. The forming of a new whole here refers to the process of constructing a conceptual framework for a clinical specialty.
Nursing conceptual models, when carefully selected, may provide a set of complementary rather than conflicting concepts (McFarlane, 1980; Meléis, 1985) from which a framework for a clinical practice area can be developed. Compatible concepts from various nursing models can be linked together to construct a conceptual framework. This approach, depicted in terms of a "Process Model," is based upon Kaplan's (1964) principle of "autonomy of the conceptual base." The principle espouses that any concepts may be used in scientific endeavors as long as they can be anchored to relevant observables. Observables, in this case, refer to the phenomena of the particular clinical nursing specialty.
The Process Model
The structure of the Process Model is based upon the metaparadigm of nursing, that is, the four domains of environment, person, health, and nursing practice* The model is patterned after a spiral form (Figure 1). The spiral depicts the fluidity and interaction of knowledge that exists among the four conceptual domains. Three domains of environment, person, and nursing practice are all depicted as revolving around health, the central axis.
FIGURE 1: Process Model structure
"Human health" is regarded as the central concept in the Model; theorizing about environment, human beings, or practice is relevant to the discipline of nursing insofar as these three concepts are linked in some way to human health. Reasoning for this is similar to that reflected in Kim's (1983) typology of three conceptual domains in nursing: client, environment, and nursing action. The concepts of person and health are collapsed into the category, client. Moreover, the centrality of human health in nursing is supported by her statement that "of all concepts relevant for inclusion within the nursing framework, the concepts of humans and health are the most essential holistic ones for theoretical thinking" (p. 45).
The turns of the spiral represent planes that are distinguishable but nevertheless continuous with each other and connected to the "health" axis. This implies that development of knowledge for nursing practice ultimately involves interactions among all four domains of the metaparadigm: environment, person, health, nursing practice. Each domain, then, is linked to the other domains via the spiraling planes.
The Model also indicates the systematic process to research and theory development, a "research continuum" (Downs, 1979). The "nursing practice" plane marks the "highest" or most advanced level of theory development for a professional discipline (Donaldson & Crowley, 1978). Theory for nursing practice is built upon knowledge gained in other domains. Knowledge in each domain contributes in establishing a core of nursing theories for the clinical practice area. Theory development that occurs exclusively on other planes of the spiral is: 1. descriptive, explanatory, or predictive but not prescriptive, and 2. addresses less than four of the conceptual domains (Fawcett, 1978). For example, on the "person" plane of the spiral, theories may describe the relationship between certain human variables and human health experiences with little, if any, attention to environmental or nursing practice factors. Ideally, the nursing prescriptions of practice level theories would account for the holistic nature of human health.
The dynamics of the Process Model consist of two phases. Phase I entails identifying and linking together compatible concepts across the four domains of the model to result in a conceptual framework that is meaningful to education in a particular clinical specialty. Phase II addresses the importance of attaining empirical support for the conceptual ideas and refinement of the conceptual framework.
Phase I: Conceptual. Development of the conceptual framework occurs primarily during Phase I. The first phase is conceptual in nature and depicts those nursing theorists who contribute to a broad understanding in one or more of the four domains for a specified area of clinical practice. During this phase, nursing theorists are selected and embedded in the framework. (Figure 2 is an example of this.) These nursing models are then used to guide the selection of concepts. One or more concepts from each model may be incorporated into the developing framework. The nursing conceptual models and their concepts are interchangeable and may vary to fit the needs across the clinical specialties.
Concepts that are identified may be borrowed from the nursing models, borrowed from non-nursing theories that are congruent with the nursing models, or originated by the educator or student as guided by the nursing models. These theories and models function as "conceptual nets" which filter perceptions of reality (Popper, 1959) and influence the selection of concepts for the framework. The models, theories, and concepts selected reflect underlying assumptions about the environment, person, health, and nursing practice.
In delineating the conceptual elements for the framework, it is important to attend to criteria for evaluation of conceptual models (Fawcett, 1980) and analysis of client, environment, and nursing action concepts (Kim, 1983). Although the conceptual framework is only a general guide for clinical teaching and practice, there is still a need to address such criteria as clarity, appropriateness for nursing, social relevance and logical congruence. For example, concepts of stress reaction, body systems, regression, energy conservation, and equilibrium refìect perspectives about person and environment that are not logically consistent with concepts of interaction, human rhythms, development, transformation, and homeodynamics and, thus, would not be included within the same conceptual framework. Careful selection of concepts facilitates identification of meaningful linkages among concepts. Linkages are likely to exist, for example, between human rhythms and homeodynamics, and between development and transformation.
FIGURE 2: Process Model - Conceptual Phase
FIGURE 3: Process Model - Empirical Phase.
It is intended, then, that Phase I culminates in an organization of concepts that provides a perspective for teaching in a clinical specialty. In this framework, each of the four nursing domains are represented by concepts selected according to criteria, including relevance to the clinical area. Adherence to criteria for developing a conceptual framework facilitates identification of meaningful linkages among concepts within and across the four domains. Although the resulting framework would lack the sophistication of empirically based support, it would outline conceptual underpinnings to guide the focus of education and empirical endeavors in a clinical practice specialty.
Phase II: Empirical. This second phase of the model is included as a means of informing students about the role of research in refining a knowledge base for practice; research as well as theory are linked to practice. Phase II presents the process by which theoretical ideas generated by the conceptual framework acquire empirical support. Once the concepts are selected and linkages between concepts are identified, attention is directed toward operationalizing the concepts in terms of clinical specialty referents. Empirical study further elucidates the meaning of concepts and their relationships for nursing practice (Ellis, 1982).
The empirical phase is depicted by an inverted structure (Figure 3) of the first phase of the Model. The upward spiraling continues, but toward a different purpose; during this phase theoretical statements are formulated which can be empirically tested for their relevance and accuracy in describing, explaining, predicting, or prescribing phenomena within the clinical specialty. This testing requires empirical "anchors" (Kaplan, 1964) in the environment, person, health, and practice dimensions of the clinical area. These anchors help to ensure the social relevancy of the framework.
Empirical validation of conceptual ideas and statements in the framework, then, transfers the theoretical into the practice areas. Revision or refinement of the framework, given the empirical findings, may result. The desired outcome of this phase is the generation of empirically-based theories for clinical practice.
A full view of the model would depict a pattern of continuous spiraling in developing the knowledge base, shifting from the conceptual to empirical to conceptual and so on. The distinction between the conceptual and empirical phases is functional in portraying for students the integral link between theory and practice and in outlining an approach to developing and refining a knowledge base for practice. Theory development, however, may involve what seem to be simultaneous interactions among conceptual, empirical, and practical activities of nursing.
Application of the Process Model to Education
Undergraduate. The Process Model can be applied to the education of both undergraduate and graduate level students. At the undergraduate level, key concepts for theory and practice can be organized according to Phase I of the Model and presented within the conceptual framework of the clinical specialty. Teaching at this level would focus primarily on the substantive issues generated by the concepts plugged into the Model as they relate to the students' clinical rotation.
FIGURE 4: Example of Developing a Conceptual Framework for a Clinical Specialty.
For example, faculty in an undergraduate psychiatricmental health nursing course might formulate a framework for teaching their clinical specialty based upon compatible concepts from the nursing models of Nightingale, Rogers, Newman, Orem, and King (Figure 4). Content, related to the "environment" domain on therapeutic milieu, community resources, and family would be presented to students based upon Nightingale's (1859/1969) emphasis on the role of environment in nuturing human health and Rogers' (1980) concept of person-environment interaction. Life-span developmental patterns of the "person" domain would be studied from Rogers' (1980) perspective on the nature and direction of human development as represented in her Principles of Homeodynamics. Definitions of "mental health" and implications forjudging mental health needs would be guided by Newman's (1979) concept of health as a life process that includes positive and negative experiences including "disease," and by Rogers' (1970) interpretation of health as a value-laden concept. (These concepts of health may be regarded as essential in a framework for psychiatric-mental health nursing wherein clients commonly face stigma and other value judgments.)
Lastly, learning experiences directly related to the "nursing practice" domain in the psychiatric-mental health specialty would incorporate concepts borrowed from Orem and King. Categories for assessment would derive from Orem's (1980) concept of self-care and those mental health skills identified as requisites of self-care in nursing clients. King's (1981) concepts of interaction and transaction would be applied in teaching the process of intervention with individuals and groups of clients.
This brief example of borrowing concepts from nursing models to develop a framework for teaching in a clinical specialty can be expanded to include relationships between concepts that have implications for clinical practice. Examples of potential relationships within and across the four domains include the relationship between environmental nuturance and degree of interaction, between developmental patterns and self-care ability, and between interaction and interactive-transactive outcomes in intervention. Delineation of relationships that can be examined empirically would enhance the potential usefulness of the framework for clinical practice.
In developing the conceptual framework for undergraduate teaching, educators would be challenged to use their creativity and expertise to identify compatible and relevant concepts for their particular clinical specialty. Students as well may be encouraged to contribute their ideas about the utility of the framework in their practice throughout their clinical experience. Student input can not only assist faculty in refining their conceptual framework but help students gain appreciation of the link between the theoretical and practical dimensions of nursing.
Graduate. The Process Model also can be applied in constructing a framework to guide learning in the clinical specialty at the graduate level. Substantive knowledge would be presented in a manner similar to that at the undergraduate level, that is, based upon the framework and organized within the four-dimension structure of environment, person, health, and nursing practice. Moreover, the Model could be used to develop one framework to be applied in teaching the same clinical specialty across undergraduate and graduate nursing programs. This could promote consistency in the curriculum without precluding individual program needs such as increased breadth and depth of knowledge at the graduate level.
At the graduate level, the Model can also serve as a springboard for discussing and debating the conceptual focus of practice and research activities. Concepts and theories from students' non-nursing studies may be inserted into the Model and examined for their congruence with and relevance to the conceptual framework of the clinical specialty. Students may find that some concepts enhance and clarify the framework while others obfuscate the framework's clinical nursing perspective. Students can also be aided in integrating increasingly sophisticated and complex clinical encounters, using as their anchor the perspective of their conceptual framework.
The Model can function as a guide for students in formulating a research focus which includes one or more of the four domains. The conceptual framework supports inductive approaches to research in which, for example, nursing concept(s) are selected as a general focus for grounded theory research. Alternatively, research questions and hypotheses may be derived directly from theoretical ideas embedded in the framework. Regardless of the student's research approach, the educational objective would be to instill in the student a sense that one has contributed to developing an empirical knowledge base for the clinical specialty.
Summary and Future Directions
The Process Model is one strategy for stimulating and organizing theoretical knowledge for education in the nursing practice specialties. With its process orientation and interchangeable concepts, the Model can be used as a method for teaching students about both the process and content of theory in each clinical specialty. Using this method to teach the conceptual base for practice across clinical specialties may enable students to discern the similarities as well as critical differences among nursing practice areas; students would be able to identify those concepts and definitions that are consistent across conceptual frameworks and those that are unique to one clinical specialty. Moreover, this method may assist students in differentiating their clinical practice from other health-care disciplines.
The Process Model is designed to accommodate any nursing or non-nursing theoretical concepts deemed relevant for educating students in a clinical specialty. Physiological theories, for example, may yield useful "person" concepts for adult medical-surgical or maternal-child nursing. Concepts from sociological as well as nursing models may function well in the "environment" domain of a community health nursing conceptual framework. Extant nursing models alone offer a rich variety of concepts that can be borrowed to construct a conceptual framework.
It is expected that, over time, the conceptual framework can be modified or refined as the changing perspectives and research findings within the clinical field indicate. The metaparadigm-structure of the Model, i.e., a structure in which the environment, person, and nursing practice domains revolve around the health domain, is flexible in its capacity to absorb differing and new ideas from all clinical nursing specialties. Yet it offers stability by helping students maintain a nursing perspective while conceptualizing their clinical specialty.
It is conceivable and perhaps desirable that nursing will embrace a unified conceptual framework to guide development of theories for all nursing practice specialties. However, predominating educational needs and health care system constraints necessitate conceptual frameworks that promote understanding of nursing phenomena unique to specific practice arenas. The conceptual and empirical phases of the Process Model are both important in defining areas of clinical specialization, worthy of focus at baccalaureate and master's levels of nursing education. The ultimate utility of this Model is to be found in its ability to generate conceptual bases for education and facilitate communication of knowledge across all dimensions within the discipline of nursing.
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