Evaluating Two Middle Range Theories Nursing Essay.

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Evaluating Two Middle Range Theories Nursing Essay.

The purpose of this paper is to evaluate two middle range theories abilities to test the concept of comfort for the practice question “Do neonatal nurses who care for dying infants who attend an end of life care educational training program compared to neonatal nurses who do not attend the program experience a difference in comfort levels (Comfort Level for Caring for Dying Infants (CLCDI)) when caring for a dying infant? ” A summary of two middle range theories the Comfort Theory (Kolcaba, 1994) and the Theory of Self-Efficacy (Resnick, xxxx) will be summarized and then critiqued using Smith and Liehr’s (xxxx) Framework for Evaluating Middle Range Theory. The discussion will conclude with a summary of strengths and weakness’ of the theories and a research hypothesis to reflect that reflects the most appropriate theories conceptual definitions and propositions.Evaluating Two Middle Range Theories Nursing Essay.

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Introduction

Background

Despite nurses as frontline caregivers for dying patients and their families many nurses have identified that they struggle with the responding adequately to the emotional devastation to parents and siblings when caring for a neonate with an unresolved terminal condition (Frommet, 1991). With the advances in neonatal care and life sustaining treatments, sick and very preterm infants do not often die in utero, at birth, or shortly after birth, but instead they often live much longer in a healthcare paradigm of comfort care and dignified death. This relatively new emersion of the end of life model integrates a more holistic approach which considers a more comprehensive view of the patient’s needs (emotional, spiritual, and medical) (Mallory, 2002; Mallory, 2003; WHO, 2002). With this paradigm shift, health care professionals are obligated to assess the adequacy of their own knowledge, attitudes, and beliefs about death and dying. Multiple studies regarding nurses preparation for dealing with death and dying have consistently found that nurses that nurses do not feel educationally prepared to care for dying patients and insist that healthcare professionals should receive additional education on end of life care to bridge the deficit gap (Frommet, 1991; Robinson, 2004; White, Coyne, Patel, 2001; Beckstrand, Callister, Kirchhoff, 2006). These findings have led to a further observation that nurses caring for these complex patients regularly experience moral distress from competing principles of their personal, collegial, organizational, and religious/spiritual ethics (Frommet, 1991).Evaluating Two Middle Range Theories Nursing Essay.

Practice Problem

To help ease this moral distress an evidence based end-of -life educational training program for NICU nurses has been successfully implemented in several neonatal intensive care units (NICU’s) to increase the nurses comfort level of caring for neonates and their families at the end of life (Bagbi, Rogers, Gomez, & McMahon, 2008). To determine if an evidence based end of life educational program impacts nurses comfort levels in caring for dying infants and their families a question was developed using the population (P) intervention (I) compared to (C) outcome (O) format (Newhouse, Dearhold, 1997). The following discussion will focus on this PICO question “Do neonatal nurses who care for dying infants who attend an end of life care educational training program compared to neonatal nurses who do not attend the program experience a difference in comfort levels (Comfort Level for Caring for Dying Infants (CLCDI)) when caring for a dying infant? ” During the intervention a monthly 1 hour, neonatal end of life education program will be conducted over a 6 month period of time based on research about what nurses would like to know about caring for a dying infant (Robinson, 2004).Evaluating Two Middle Range Theories Nursing Essay.

For the purpose of this problem, comfort is defined as the ability of the NICU nurse(s) to show adequate knowledge and skills in providing neonatal end of life care for dying babies and their families. For this problem comfort will be measured as a score on the ordinal scale of Comfort Level Caring for Dying Infants (CLCDI). The instrument consisting of 15 items, measured on a 5 point Likert type scale equates scores of 1=never; 2=rarely; 3=sometimes; 4=often, 5=always measures the level of comfort a NICU nurse has caring for dying infants as opposed to their perception toward pediatric or neonatal end of life care (Bagbi, Rogers, Gomez, and McMahon, 2008). In evaluating the score, the higher the reported score the greater level of comfort NICU nurses have in caring for dying babies.

Testing the Concept of Comfort

A portion of Kolbaca’s (1991) Theory of Comfort and Resnick’s (2008) Theory of Self-Efficacy, two middle range theories, will be used to test the concept of comfort for providing an organizing structure. Based on previous studies about nurse’s comfort when caring for patients’, propositions five and six of Kolbaca’s Theory of Comfort seem to be a promising fit for this problem (Kolbaca, 1991, Kolbaca, XXX). These propositions collectively propose that patients, nurses, and other members of the healthcare team agree upon desirable and realistic health seeking behaviors (HSB’s) and if enhanced comfort is achieved, patients, family members, and/or nurses are strengthened to engage in HSB’s, comfort is further enhanced (Kolbaca, 1991).Evaluating Two Middle Range Theories Nursing Essay. However, comfort as defined conceptually in this case as “knowledge and skill” can alternatively be equated with a sense of competence or self-efficacy of the NICU nurse to care for a dying infant and their family. There are many examples in the nursing literature linking self-efficacy to knowledge and skill (xxxx, xxxxx).) Self-efficacy, knowledge, and skills are also central to Bandura’s theory, which is the basis for Resnick’s (xxxx) Self-Efficacy theory. Self-efficacy as described in Resnick’s (xxxx) Theory of Self-Efficacy for this context is described as the judgment about the nurses’ ability to organize and execute a course of action required to attain designated types of performances. The theory states that perceived self-efficacy, defined as the individual’s judgment of his or her capabilities to organize and execute courses of action, is a determinant of performance (Resnick, xxxx). Self-efficacy beliefs provide the foundation for human motivation, well-being, and personal accomplishment (Resnick, xxxx). According to Resnick (XXXX) theory individuals with higher levels of self-efficacy for a specific behavior (caring for a dying infant) are more likely to attempt that behavior. There are many examples in the literature using the Theory of Self-Efficacy to support nursing education interventions (xxxxx, xxxxx). For these reasons, Resnick’s Theory of Self-Efficacy (xxx) will be used to test the concept of nurses comfort or knowledge and skill (self-efficacy) in caring for dying infants and their families. The purpose of the following discussion is to summarize, describe, analyze, and evaluate these theories using the Framework for the Evaluation of Middle Range Theories (Smith, 2008) and conclude with a synthesis and research hypothesis to reflect conceptual definitions and propositions of the theory with the best fit.Evaluating Two Middle Range Theories Nursing Essay.

Theory Summaries: Comfort and Self-Efficacy

Kolcaba’s Comfort Theory

The Comfort Theory is a humanistic, holistic, patient need based nursing derived middle range theory (Kolbaca, xxxx). The concept of comfort has had a historic and consistent presence in nursing. In the early 1900’s , comfort was considered to be a goal for both nursing and medicine, as it was believed that comfort led to recovery (McIlveen & Morse, 1995). Over time comfort has become an increasingly minor focus, at times reserved only for those patients for whom no further medical treatment options are available (McIlveen & Morse, 1995).Evaluating Two Middle Range Theories Nursing Essay.

The term comfort is used as a noun (comforter), adjective (comforting), verb (to comfort), or adverb (comfort the patient) (xxx). It is also used as a negative (absence of discomfort), neutral (ease), or positive (hope inspiring). Webster (1990) defines comfort as relief from distress; to soothe in sorrow or distress; a person or thing that comforts; a state of ease and quiet enjoyment free from worry; anything that makes life easy; and the lessening of misery or grief by calming or inspiring with hope. The origin of comfort is confortrare which means “to strengthen greatly”(Kolcaba, 1992). Based on the diversity of these terms comfort is a complex term. Kolcaba’s (1991) concept analysis of comfort helped to clarify the role of comfort as a holistic concept for nursing. This review confirmed that comfort is a positive concept and is associated with activities that nurture and strengthen patients (David, 2002). Over a period of years and revisions Kolcaba (1994) developed the comfort theory which continues to evolve and change with changes as recent as 2007 (Figure 2).Evaluating Two Middle Range Theories Nursing Essay.

Kolcaba (1994, 2001, 2003) has defined comfort as “the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psychospiritual, sociocultural, and environmental)”. The terms relief, ease, and transcendence are types of comfort that occur physically and mentally (Figure 2). The terms are defined based on definitions from medicine, theology, ergonomics, psychology, and nursing (Kolcaba & Kolcaba, 1991). Relief is the state of having a discomfort mitigated or alleviated. Ease is the absence of specific discomforts. Transcendence is the ability to “rise above” discomforts when they cannot be eradicated or avoided (e.g., the child feels confident about ambulation although (s)he knows it will exacerbate pain). Transcendence, as a type of comfort, accounts for its strengthening property and reminds nurses to “never give up” helping their children and family members feel comforted. Interventions for increasing transcendence can be targeted to improving the environment, increasing social support, or providing reassurance.Evaluating Two Middle Range Theories Nursing Essay.

The three types of comfort occur in four contexts of experience: physical, psychospiritual, sociocultural, and environmental. These contexts were derived from an extensive review of the nursing literature on holism (Kolcaba, 1992). When the three types of comfort are juxtaposed with the four contexts of experience, a 12-cell grid is created, which is called a taxonomic structure (TS) (Figure 1) . Taken together, these cells represent all relevant aspects (defining attributes) of comfort for nursing and demonstrate the holistic nature of comfort as an important goal of care. All comfort needs can be placed somewhere on the taxonomic structure, and the cells are not mutually exclusive. A sample pediatric case study using the TS as a guide for a holistic comfort assessment is demonstrated below (see Figure 1).Evaluating Two Middle Range Theories Nursing Essay.

The concepts for the middle range for Comfort Theory include comfort needs, comfort interventions, intervening variables, enhanced comfort, health-seeking behaviors, and institutional integrity (Kolcaba, 1994). All of these concepts are relative to patients, families, and nurses (Kolcaba, 2003; Kolcaba, Tilton, & Drouin, 2006). There are eight propositions which link the above concepts together. All or parts of the Comfort Theory can be tested for research (Peterson & Bredow, 2010).

In the comfort theory, Kolcaba asserts that when healthcare needs of a patient are appropriately assessed and proper nursing interventions carried out to address those needs, taking into account variables intervening in the situation, the outcome is enhanced patient comfort over time (Kolcaba, 2007). Once comfort is enhanced, the patient is likely to increase health-seeking behaviors. These behaviors may be internal to the patient (eg, wound healing or improved oxygenation), external to the patient (eg, active participation in rehabilitation exercises), or a peaceful death. Furthermore, Kolcaba asserted that when a patient experiences health-seeking behaviors, the integrity of the institution is subsequently increased because the increase in health-seeking behaviors will result in improved outcomes. Increased institutional integrity lends itself to the development and implementation of best practices and best policies secondary to the positive outcomes experienced by patients (Kolcaba, 2007).Evaluating Two Middle Range Theories Nursing Essay.

To translate the concepts to practice the effectiveness of a holistic intervention can be targeted to the taxonomic structure for enhancing comfort in a specific patient, family, or nurse population over time. Holistic comfort is defined as the immediate experience of being strengthened through having the needs for relief, ease, and transcendence met in four contexts of experience (physical, psychospiritual, social, and environmental).The comfort theory has been operationalized in many research settings with a variety of patient and target populations ranging from end of life care to the comfort of nurses (xxxx).

Resnick Theory of Self-Efficacy

Self efficacy is described as a way to organize an individual’s judgment of his or her capability to execute a course of action. The Theory of Self-efficacy states that self-efficacy expectations and outcome expectations are not only influenced by behavior, but also verbal encouragement, reflective thinking, physiological sensations and role or self-modeling (Bandura, 1995).. Through self evaluation an individual judges their capability to perform and established self expectations which is visually depicted in the conceptual model (Appendix 2) (Resnick, 2008).Evaluating Two Middle Range Theories Nursing Essay.

Resnick’s Theory of Self Efficacy is based on Bandura’s social cognitive theory and conceptualizes person-behavior-environment as triadic reciprocity the foundation for reciprocal determinism (Bandura, 1977, 1986).

Most of the research into self-efficacy beliefs among older adults has been quantitative and has consistently supported the influence of those beliefs on behavior. However, it has not been established how efficacy beliefs actually influence motivation in older adults, or what sources of efficacy-enhancing information help strengthen those beliefs.Evaluating Two Middle Range Theories Nursing Essay.

Kolcaba’s Comfort Theory: Description, Analysis, and Evaluation

Theory Description

Historical context. The Comfort Theory is a humanistic, holistic, patient need based nursing derived middle range theory (Kolbaca, xxxx). The concept of comfort has had a historic and consistent presence in nursing. In the early 1900’s , comfort was considered to be a goal for both nursing and medicine, as it was believed that comfort led to recovery (McIlveen & Morse, 1995). Over time comfort has become an increasingly minor focus, at times reserved only for those patients for whom no further medical treatment options are available (McIlveen & Morse, 1995).

Structural Components.

Assumptions. Kolcaba’s Theory of Comfort (1994) makes four basic assumptions about reality. She assumes that humans beings have holistic responses to complex stimuli; comfort is a desirable holistic state that is germane to the discipline of nursing; human beings actively strive to meet, or to have met, their basic comfort needs, and that comfort is more than the absence of pain, anxiety, and other physical discomforts (Kolcaba , 2009).

Concepts. Kolcaba defines six concepts of comfort which are relative to patients, families, and nurses (Table 1) . The term family, as defined by Kolcaba (2003) encompasses significant others as determined by the patient (Kolcaba, 2003; Kolcaba, Tilton &Drouin, 2006). The first concept is of comfort needs which is the relief/ease/transcendence in physical, psychospiritual, sociocultural and environmental contexts of human experience. Comfort interventions in the model are defined as interventions of the health care team specifically targeting comfort of the patient, family and nurses. Intervening variables are positive or negative factors over which the health care team has little control, including physical limitations of the hospital or patient’s home, cultural influences, socioeconomic factors, prognosis, concurrent medical or psychological conditions. Health-seeking behaviors are those behaviors of patient, family or nurses (conscious or unconscious) which promote well-being; may be internal, external or towards promoting a peaceful death. The final concept, institutional integrity, added in most recently, are values, financial stability and wholeness of health care facilities at the local state or national levels.Evaluating Two Middle Range Theories Nursing Essay.

Propositions. To help test the concept of nurses’ comfort caring for dying infants, propositions five and six of Kolcaba’s comfort theory are examined. These propositions state that patients, nurses, and other members of the healthcare team agree upon desirable and realistic health seeking behaviors (HSB’s) (five) and if enhanced comfort is achieved, patients, family members, and/or nurses are strengthened to engage in HSB’s, which further enhances comfort (six). These propositions provide rationale for why nurses and other health care professionals should focus on the patient, family, or in this case the nurses comfort beyond altruistic reasons. Because health seeking behaviors include internal and external behaviors almost any health-related outcome important in a healthcare setting can be classified as a health seeking behavior (Peterson & Bredow, 2010). The desirable and realistic health seeking behavior (HSB) for this study is nurses’ comfort (knowledge and skills) to relieve moral distress in caring for a dying infant and their family. Several studies support that moral and other types of distress are frequently observed in nurses who care for dying infants (Frommet, 1991) and most importantly indicate that nurses are seeking education regarding patient end of life issues (XXXXX). It is believed that reducing this distress and frustration can be affected through an effective end of life educational programs and is likely to improve the knowledge and skills nurses need to help increase their comfort level in caring for dying infants (xxxxx).Evaluating Two Middle Range Theories Nursing Essay.

Functional Components. Visualizing the concepts in the conceptual model, the

Theory Analysis and Evaluation

To analyze and evaluate Kolcaba’s Comfort Theory (1994) the substantive foundation, structural integrity, and functional adequacy of the theory using Smith and Liehr’s (2008) Framework for the Evaluation of Middle Range Theories is discussed below (Appendix 1).

Substantive foundations. Assessing the substantive foundation of a middle range theory is based on four criteria (Smith, 2003). The first criterion evaluates whether the theory is within the focus of the discipline of nursing. Kolcaba’s comfort theory successfully addresses four concepts comprising the metaparadigm of nursing, defining the concepts as they correspond to the theory (Dowd, 2002; Kolbaca, 2007) as well as presents a diagram of how the Comfort Theory relates theoretically to other nursing concepts (Figure 2) (Kolcaba, 1994) . Nursing is described as the process of assessing the patient’s comfort needs, developing and implementing appropriate nursing interventions, and evaluating patient comfort following nursing interventions. Person is described as the recipient of nursing care; the patient may be an individual, family, institution, or community. Environment is considered to be the external surroundings of the patient and can be manipulated to increase patient comfort. Finally, health is viewed as the optimum functioning of the patient as they define it. The ability of the framework to suggest interventions that help guide nursing interventions to increase comfort supports the discipline of nursing, and in doing so meeting the first criteria.Evaluating Two Middle Range Theories Nursing Essay.

The second criterion evaluates whether the assumptions are specified and congruent with the focus. The four assumptions in the Comfort Theory are explicitly stated and so meet the second criteria. Comfort theory (xxxx) assumes that humans beings have holistic responses to complex stimuli; comfort is a desirable holistic state that is germane to the discipline of nursing; human beings actively strive to meet, or to have met, their basic comfort needs, and that comfort is more than the absence of pain, anxiety, and other physical discomforts (Kolcaba , 2009).

Because the Comfort Theory (XXXX) substantially describes the concept of comfort at the middle range level of discourse, the third criterion of the substantive foundation is met. Kolcaba’s (1991) concept analysis of comfort helped to clarify the role of comfort as a holistic concept for nursing. This review confirmed that comfort is a positive concept and is associated with activities that nurture and strengthen patients (David, 2002). The Comfort Theory provides an excellent description, explanation, and interpretation of the comfort concept in multiple domains and practice settings. Comfort theory is at the middle range level in that is defined in a measurable way and can be operationalized in both research and practice settings.Evaluating Two Middle Range Theories Nursing Essay.

The final criterion for this category evaluates if the origins are rooted in practice and research experience. The Comfort Theory has been used in numerous practice and research settings to provide a framework where patients have comfort needs and enhancing their comfort is valued. It has also been used to enhance working environments, especially for nurses, and most recently as a framework for working toward national institutional recognitions. More specifically parts are all of the theory have been used to test the effectiveness of holistic interventions for increasing comfort (xxxxxxx), to demonstrate the correlation between comfort and subsequent HSB’s (xxxxx) and to relate HSB’s to desirable institutional outcomes. It has also been used as a framework for helping families make difficult decisions about end of life (xxxxx). International and national healthcare institutions have also used Comfort Theory to enhance the work environment for nurses (xxxx). In these cases, nurses comfort is of interest and is theoretically related to the integrity of the institution. Summarize specific studies and tools used here.

Structural integrity. There are four criterion for evaluating structural integrity. The first criterion is that the concepts are well defined. The concepts (defined above) of comfort needs, comfort interventions, intervening variables, enhanced comfort, health-seeking behaviors, and institutional integrity are clearly defined and easy to understand. There are numerous examples of applying the concepts in the literature for further clarification (xxxxx).

The second criterion of structural integrity is that concepts within the theory are at the middle range level of abstraction. The concepts of the Comfort Theory-comfort needs, comfort interventions, intervening variables, enhanced comfort, health seeking behaviors, and institutional integrity are near the same level on the ladder of abstraction at the middle range level. They are more concrete because they can and have been operationalized and measured (xxxxx).Evaluating Two Middle Range Theories Nursing Essay.

The third criterion of structural integrity is that there are no more concepts than needed to explain the phenomena. Overall, the concepts adequately explain the phenomena of comfort. The theory is synthesized and organized in a simple manner. Lastly, the fourth criterion evaluates whether the concepts and relationships among the concepts are logically presented with a model. In the Comfort Theory (1994) model the ideas are integrated to create an understanding of the whole phenomenon of comfort in a model. The Comfort Theory (1994) model is a great example of presenting the concepts and statements in a linear logical order so the appreciation of the theory can be recognized (Smith, 2003).

Functional adequacy. Because the criterion for functional adequacy overlap somewhat the five criterion will be discussed collectively. The five criterion include: theory can be applied to a variety of practice environments and clients; empirical indicators have been identified; published examples exist of research and theory in practice; and that the theory has evolved through scholarly inquiry. The Comfort Theory easily meets all of these criterions. For example, the Comfort Theory has been used widely in a variety of research in practice settings and patient and family populations. Even though the Comfort Theory has been used most widely with patients and families at the end of life and surrounding holistic palliative care nursing interventions, there has been a broad application of the theory in other populations as well including mothers in labor (xxxx), Alzheimer patients (xxxx), pediatric intensive care unit patients and families (xxxx), patients on bedrest (xxxx), those undergoing radiation therapy (xxxx) and for infants comfort and pain (xxxx). Most recently research of using the theory in practice has expanded to support institutional nursing recognition and comfort in the nursing working environment. In each of the populations mentioned above a psychometric comfort instrument has been developed as empirical indicators of concepts in the theory. However, the empirical indicators extend beyond empiricism and some include perceptions, self reports, observable behaviors and biological indicators (Ford-Gibloe, Campbell, & Berman, 1995; Reed, 1995). The Comfort Theory (1994) has also been revised with the latest revision in 2007. The empirical adequacy of the Comfort Theory is evidence of the maturity of this theory (Smith, 2003).

Summary

The Comfort Theory (1994) is a well defined and well tested theory. Its strength lies in the versatility, adaptability, and testability of the concepts. The comfort theory clearly defines the concepts in the theory and the relationship between them. Because the comfort theory meets most of the substantitive foundations, structural integrity, and functional adequacy criteria the Comfort Theory (1994) is a strong middle range theory. An area that could increase the generalizability especially for nursing institutions is a change in the term in the model of “nursing interventions” to “comfort interventions” (xxxxx).

Resnick’s Self-Efficacy Theory: Description, Analysis, and Evaluation

Theory Description

Historical context. Resnick’s Theory of Self Efficacy is based on Bandura’s social cognitive theory and conceptualizes person-behavior-environment as triadic reciprocity the foundation for reciprocal determinism (Bandura, 1977, 1986).Evaluating Two Middle Range Theories Nursing Essay.

The cognitive appraisal of these factors results in a perception of a level of confidence in the individual’s ability to perform a certain behavior. The positive performance of this behavior reinforces self-efficacy expectations (Bandura, 1995).

Structural Components. Although it is not explicitly stated, the core of this theory assumes that people can consciously change and develop or control their behavior. This is important to the proposition that self-efficacy also can be changed or enhanced through reflective thought, general knowledge, skills to perform a specific behavior, and self influence. This perspective is rooted in the model of triadic reciprocality (foundation for reciprocal determinism) in which personal determinants (self-efficacy), environmental conditions (treatment conditions) and action (practice) are mutually interactive influences. Therefore, improving performance depends on changing some of these influences (Bandura, 1977). In order to determine self-efficacy an individual must have the opportunity for self evaluation to evaluate how likely it is he or she can achieve a given level of performance.

Concepts. The two major components of self efficacy include self-efficacy expectations and outcome expectations (Table 2). Self-efficacy expectations are judgments about the personal ability to accomplish a given task. Outcome expectations are judgments about what will happen if a given task is accomplished. These two components are differentiated because individuals can believe a certain behavior will result in a specific outcome, however, they may not believe they are capable of performing the behavior required for the outcome to occur (Bandura 1977, 1986). For example, a NICU nurse may believe attending an end of life education series will increase his/her knowledge and skill and ease moral distress, but may not believe that they could provide sensitive care for some ethical, religious, or moral reason. It is generally anticipated, but not always realistic that self-efficacy will have a positive impact on behavior. There are times when self-efficacy will have no or a negative impact on performance (Vancouver, Thomspon, & Williams, 2001). Bandura (1977, 1986, 1997) suggests that outcome expectations are based largely on the individual’s self-efficacy expectations, which generally depend on their judgment about how well they can perform the behavior; can be disassociated with self-efficacy expectations; and are partially separable from self-efficacy judgments when extrinsic outcomes are fixed. Because the outcomes an individual expects are the results of the judgments about what he or she can accomplish, they are unlikely to contribute to predictions of behavior (Bandura, 1977).

Judgments about one’s self-efficacy is based on four informational sources including enactive attainment, vicarious experience, verbal persuasion and physiological state. The first source, enactive attainment, or the actual performance of a behavior has been described as the most influential source of self-efficacy information (Bandura, 1986,; Bandura & Adams, 1977). There has been repeated empirical evidence that actually performing an activity strengthens self-efficacy beliefs due to informational sources (Bandura, 1995). The second source, vicarious experience or visualizing other similar people perform a behavior, also influence self-efficacy (Bandura, Adams, Hardy, & Howells, 1980). Conditions that impact vicarious experience include amount of exposure or experience to the behavior (least experience causes greater impact) and amount of instruction given (influence of others is greater with unclear guidelines) (Resnick & Galik, 2006). Another source verbal persuasion or exhortation involves telling an individual he or she has the capabilities to master the given behavior. Verbal encouragement from a trusted, credible source in counseling or education form has been used alone to strengthen efficacy expectations (Castro, King, & Brassington, 2001; Hitunen et al. 2005; Moore et al., 2006; Resnick, Simpson, et al., 2006). The final information source physiological feedback or state during a behavior can be important in relation to coping with stressors, health functioning, and physical accomplishments. Interventions can be used to alter the interpretation of physiological feedback and help individuals cope with physical sensations, enhancing self efficacy and resulting in improved performance (Bandura & Adams, 1977).Evaluating Two Middle Range Theories Nursing Essay.

Propositions. To help test the concept of nurses’ comfort caring for dying infants, propositions of self-efficacy theory are discussed below. Because the theoretical derivation of the self-efficacy theory is from the social cognitive theory it must be considered in the context of reciprocal determinism. The four sources of experiences mentioned above can potentially influence self-efficacy and outcome expectations interact with characteristics of the individual and environment. Since self-efficacy and outcome expectations are influenced by performance of behavior, it is likely that there is a recipricol relationship between performance and efficacy expectations (Bandura, 1977).

Operationalizing self efficacy constructs is based on Bandura’s (1977) early work. Traditionally in developing self-efficacy measures items are derived from quantitative and qualitiative research which explore factors that influenced adherence to a specific behavior, for example exercise (Resnick & Jenkins, 2000). Developing outcome expectation measures has been less well defined, although the process for establishing appropriate items is the same for self-efficacy expectations (Resnick, Zimmerman, Orwing, Furstenberg, & Magaziner, 2001).

Functional Components.

Theory Analysis and Evaluation

To analyze and evaluate Resnick’s Theory of Self-Efficacy (xxxx) the substantive foundation, structural integrity, and functional adequacy of the theory using Smith and Liehr’s (2008) Framework for the Evaluation of Middle Range Theories is discussed below (Appendix 1).

Substantive foundations. Assessing the substantive foundation of a middle range theory is based on four criteria (Smith, 2003). The first criterion evaluates whether the theory is within the focus of the discipline of nursing which includes the interaction between the nurse, the patient, health, and environment. The paradigmatic perspective of this theory is based on reciprocal determinism (xxxx). The self-efficacy theoretical framework is situated within the discipline of nursing because the framework can and has been used to generate testable hypothesis about the interaction between the core nursing concepts, specifically predicting outcomes of nursing interventions which often involve targeting intrinsic patient behaviors and manipulating the environment to improve patient’s health (xxxx, xxxx, xxxx). This increases the utility of the framework for research and practice.Evaluating Two Middle Range Theories Nursing Essay.

The second criterion evaluates whether the assumptions are specified and congruent with the focus. Self-efficacy theory (XXXX) assumes that assumes that people can consciously change and develop or control their behavior. This is important to the proposition that self-efficacy also can be changed or enhanced through reflective thought, general knowledge, skills to perform a specific behavior, and self influence. Although the assumption is identifiable, it is not explicitly stated, which would make it a stronger middle range theory. However, the ideas of the parent theory, Bandura’s (1977) social cognitive theory are clearly identified, cited, and accessed contributing greater depth in understanding this theory. The basic assumption of the theory that individuals have control over their behavior is congruent with other behavior change theories and supports the logical development of the self-efficacy framework (Bandura, 1977; Simpson, 2009).

Because the theory substantially describes the concept of self-efficacy at the middle range level of discourse, the third criterion of the substantive foundation is met. The scope of the theory narrowly focuses on the elements that influence behavior (information sources, person, environment, self-efficacy expectations, and outcome expectations) which captures the complexities of the phenomenon. Even though the concept of behavior is multidimensional the sources of efficacy expectations and outcome expectations are comprehensive and account for factors that may influence behavior. The self-efficacy theoretical model has been adapted and used in nursing research for many nursing interventions. The description and application of the concept of self-efficacy to nursing leads to a new understanding of the phenomenon. The framework is predictive and can be used to explain an individual’s response to an intervention in both research and clinical settings. For these reasons self-efficacy is a middle range theory that is widely applicable and practical for behavior focused nursing research and practice (Simpson, 2009).Evaluating Two Middle Range Theories Nursing Essay.

The final criterion for this category evaluates if the origins are rooted in practice and research experience. Bandura’s (1977) early research about self-efficacy was done in a controlled environment with individuals with snake phobias.. And although a tightly controlled situation is not feasible in the practice setting, self-efficacy can be used in nursing research focusing on the clinical aspects of care such as education and nursing competency (Resnick, 2008). The majority of the work with self-efficacy has been geared toward interventions that change behavior mostly in the areas of chronic illness and health promotion (xxxx, xxxx). Much of the literature using self-efficacy is correlational, although there are an increasing number of intervention studies testing self-efficacy based interventions (xxxxxpg192smith). Most of the studies have been done within the United States, however, there is an increasing amount of international literature using the self-efficacy theoretical framework (Smith & Liehr, 2008). The Self-Efficacy theoretical framework meets this criterion due to its documented ability to relate to both practice and research.

Structural integrity. There are four criterion for evaluating structural integrity. The first criterion is that the concepts are well defined. Self-efficacy is a clearly defined theoretical framework with main concepts that include the above defined concepts of efficacy expectations and outcome expectations as the source of self-efficacy. Semantic clarity is supported by the well defined constructs and their relationship to each other. In the model self-efficacy precedes human behavior. The propositions clearly articulate the relationships among the central ideas or concepts within the theory and in so doing meet this criterion.Evaluating Two Middle Range Theories Nursing Essay.

The second criterion of structural integrity is that concepts within the theory are at the middle range level of abstraction. The concepts of the Self-Efficacy theory-efficacy expectations, outcome expectations, and information resources are near the same level on the ladder of abstraction at the middle range level. They are more concrete and circumscribed because they can and have been operationalized and measured (xxxxx).

The third criterion of structural integrity is that there are no more concepts than needed to explain the phenomena. Overall, the concepts adequately explain the phenomena of self-efficacy. The theory is synthesized and organized parsimoniously. Lastly, the fourth criterion evaluates whether the concepts and relationships among the concepts are logically presented with a model. In the self-efficacy theoretical framework the ideas are integrated to create an understanding of the whole phenomenon of self-efficacy in a model. The self efficacy theoretical framework demonstrates the concepts and statements in a linear logical order so the appreciation of the theory can be recognized (Smith, 2003). Semantic consistency is demonstrated by the consistent use of definitions in the theory and in the literature. Structural clarity is demonstrated by how apparent the connections and reasoning within the theory is. For example, in the model self-efficacy precedes human behavior. Structural consistency is demonstrated by the consistent relationships between the concepts.Evaluating Two Middle Range Theories Nursing Essay.

Synthesis

It appears that both Kolcaba’s Comfort Theory (propositions five and six) and Resnick’s Self-Efficacy theory could be used to test the concept of comfort in NICU nurses caring for dying infant and their families although in very different ways. Using propositions five and six of Kolcaba’s comfort theory, nurses “comfort” or knowledge and skills when caring for a dying infant and their family are targeted to increase nurse’s health seeking behavior, which in this case is relief of moral distress. In the context of Kolcaba’s comfort theory comfort for this practice problem as “knowledge and skill” strengthen the nurses state of being through having the human needs for relief, ease, and transcendence (types of comfort that occurs physically and mentally) in two of the four context of experience (pscyhospiritual and sociocultural). Comfort for this problem does not fit into physical (bodily sensation and homeostatic mechanism) and environmental (light, noise, color, temperature, etc.) contexts. Because comfort as knowledge and skill is not the typical use for this framework, the application to this problem needs to be used with caution. A discussion and critique of applying the concept of comfort as nurses’ knowledge and skill follows.

Propositions five and six state that patients, nurses, and other members of the healthcare team agree upon desirable and realistic health seeking behaviors (HSB’s) (five) and if enhanced comfort is achieved, patients, family members, and/or nurses are strengthened to engage in HSB’s, which further enhances comfort (six). Because health seeking behaviors include internal and external behaviors almost any health-related outcome important in a healthcare setting can be classified as a health seeking behavior (Peterson & Bredow, 2010). The desirable and realistic health seeking behavior (HSB) for this study is nurses’ comfort (knowledge and skills) to relieve moral distress in caring for a dying infant and their family.Kolcaba (1994, 2001, 2003) has defined comfort as “the immediate state of being strengthened through having the human needs for relief, ease, and transcendence addressed in four contexts of experience (physical, psychospiritual, sociocultural, and environmental)”. The terms relief, ease, and transcendence are types of comfort that occur physically and mentally (Figure 2). In the context of this problem, nurses ‘comfort’ has the potential to be strengthened by having the nurses’ needs for relief, ease, and transcendence met through an educational intervention in the pscyhospiritiaul and sociocultural context, however it is not clear if these needs could be met in the physical or environmental context. Using the theoretical model as a guide the health care needs of the nurse (relief of moral distress) plus comforting interventions (educational program) plus intervening variables (sociocultural, beliefs, etc.) lead to enhanced comfort or in this case increased knowledge and skill which then in turn leads to a health seeking behavior (relief of moral distress) and increase comfort in caring for a dying infant and their family. According to propositions five and six in this theory, if enhanced comfort is achieved, patients, family members, and/or nurses are strengthened to engage in HSB’s, which further enhances comfort (six).Evaluating Two Middle Range Theories Nursing Essay. Linking this to the model, increased comfort will increase evidence based practice and institutional integrity, which would theoretically be the case if more nurses have “comfort” in caring for dying infants and their families then this could contribute to increased institutional integrity. Even though the concept of comfort for this problem fits into the theoretical model of Kolcaba’s comfort theory, the conceptual definition of comfort in this problem as “knowledge and skills” and the conceptual definition of this model as

However, using Resnick’s theory of self efficacy to influence nurses comfort or knowledge and skill in caring for dying infants the concept is used in a different context. In Resnick’s self efficacy theory, comfort as defined in this case as knowledge and skill is interpreted in terms of the nurses competence or self-efficacy in caring for dying infants and their families. Comfort in the context of Resnick’s theory is the assumption that people can exercise influence over what they do.

For several reasons it appears that propositions five and six of Kolcaba’s Theory of Comfort (1994) appears to be the best theory to operationalize the concept of comfort level of NICU nurses when caring for a dying infant and their family. Kolcaba’s Theory of Comfort is grounded in nursing and has a substantial foundation, structural integrity, and functional adequacy as well as repetitive use in translating research into practice (XXXX). This strong foundation is supported by the broad application of the theory. It can provide a framework for research in any setting where patients, families, or nurses have comfort needs and enhancing their comfort is valued. It can also be used to enhance working environments, especially for nurses (Peterson and Bredow).

In order to use the middle range theory in practice three steps are required: (a) understanding the technical definition of comfort and its origins, (b) understanding the relationships (propositions) between the general concepts entailed in the theory, and (c) relating the general concepts to specific pediatric problems/settings in order to enlighten practice and generate research questions (Kolcaba, 2003).

Middle range theories have a limited number of concepts and propositions, a low level of abstraction and are easy to apply to practice, but in order to apply to practice it is important to understand the technical definition and origin of the concept, the relationship or propositions between the general concepts in the theory and to relate the general concepts to specific problems such as comfort of the nurse to generate a research question or hypothesis.Evaluating Two Middle Range Theories Nursing Essay.