Gerontological Nursing: The Interrelationship between Theory, Practice, and Research
This paper discusses the interrelationship between nursing theory, research, and practice in the specialty area of gerontological nursing. Knowledge needs within gerontological nursing, as well as suggestions for further middle range theories and research, are explored.
Theory, research, science, and practice are the four core elements of the discipline of nursing. They form a continuous "circle of knowledge" (Moccia, 1987). Theory leads to research, research leads to science, science leads to practice, and practice then cycles back to theory. New theory emanating from practice will generate new studies that will, in turn, produce new knowledge for practice. It is an interactive and reciprocal relationship, with the ultimate aim of improving nursing practice (McKenna, 1997). This cyclical process is especially important in nursing care of vulnerable populations, such as the elderly.
Nursing knowledge is the sum total of the theoretical structure, research, and practice wisdom of the discipline. The theoretical structure may be compared to a ladder consisting of hierarchical rungs that address nursing's central tenets: the metaparadigm, philosophies, conceptual models, and theories. The metaparadigm level, the top rung of the theoretical structure, is the most abstract and encompasses the broad central concepts of person, environment, health, and nursing (Alligood, 2006a; Alligood, 2006b).
The philosophical level next examines the nature and meaning of nursing phenomena and entities in the metaparadigm. Nursing philosophy is a statement of universal assumptions, general principles, values, belief systems, logical arguments, and unique perspectives (Alligood, 2006a; Alligood, 2006b; Blais, Hayes, Kozier, & Erb, 2006; Fawcett, 2006; McEwen & Wills, 2007; Smith & Liehr, 2008). Philosophies comprise early nursing works that led to nursing theory such as the writings of Nightingale, Watson, and Benner (Alligood, 2006b; Blais et al., 2006).
Conceptual models, also termed frameworks or paradigms, are the next lower level of abstraction on the theoretical ladder. These address the central concepts of the nursing metaparadigm and tend to be named for the originator of the model. Models provide unique perspectives on human beings, specify approaches to take in health care delivery, and structure reasoning, decision making, and critical thinking in practice. Examples of nursing conceptual models include Johnson's Behavioral System Model, King's Conceptual System, Levine's Conservation Model, Neuman's Systems Model, Orem's Conceptual Model, Rogers' Science of Unitary Human Beings, and Roy's Adaptation Model (Alligood, 2006b).
Nursing theories, the next less abstract level, are derived from conceptual models. Theories consist of more specific sets of related concepts to explain, describe, predict, and control phenomena (Alligood, 2006b; McEwen & Wills, 2007). Theories are often named for characteristics of content or proposed outcomes (Alligood, 2006b) and can be classified as grand theories, middle-range theories, or situation-specific theories (Meleis, 2007). Grand theories are nearly as abstract as the conceptual models and are broad systematic frameworks concerning the nature, mission, and goals of nursing. They can provide particularly useful insights for research and practice (Alligood, 2006b). Examples of grand theories are King's theory of goal attainment and Roger's theory of energy fields (Meleis, 2007).
Middle-range theories, less abstract still, are narrower in scope, concrete, address specific concepts or phenomena, and reflect a wide variety of practice situations (Alligood, 2006a; Meleis, 2007). They are refined through repeated studies, each providing a more precise focus (Blais et al. 2006). Middle range theories are particularly suited to empirical testing because the specific concepts can be operationalized without much difficulty. Examples of middle-range theories are incontinence, quality of life, social support, comfort, and unpleasant symptoms (Meleis, 2007).
Situation-specific theories focus on finite phenomena that are limited to a particular context, practice field, or client population. These types of theories operate within specific social or historical contexts and incorporate, but do not transcend, time or sociopolitical structures. Examples of situation-specific theories are the lived experiences of Asian-American women caring for elderly relatives and menopausal experiences of Korean immigrants (Meleis, 2007).
As a practice discipline, nursing has traditionally measured the relevance of theory by the extent to which it can inform practice. Nursing research forms the bridge from theory to practice, by testing the theory in the practice setting using deduction. Research may also generate new theory through induction (DePoy & Gitlin, 1998). Theory directs nursing research towards building a systematic structure of nursing knowledge (Blais et al., 2006). Research, through the function of enquiry, is a tool of science. Knowledge is furnished through research, whereas an understanding may be gained through theory. Knowledge generated without understanding is incomplete and deficient. Research without theory is similar to bricklayers throwing bricks haphazardly into a pile without a blueprint, and somehow hoping a house will appear. Without theory, knowledge becomes an incoherent mass of statistics, data, and understanding that is of no practical worth (McKenna, 1997).
With the rapidly expanding geriatric population, bedside nurses need to be well-informed concerning the most current evidence-based, theory-guided practice, especially concerning common geriatric syndromes, such as falls, urinary incontinence, and eating difficulties (Mezey & Zwicker, 2006). Theories of aging help guide gerontological nursing practice. Theories originate from numerous scholarly disciplines (biology, economics, psychology, sociology, etc.). Each theory concerns distinct facets of aging or characteristics of elderly people, but no theory covers everything. No single theory prevails in gerontology (Moberg, 2001).
Theories of aging are biological, psychosocial, or sociological in focus. (Tabloski, 2006; Eliopoulos, 2010). Biological aging theories include programmed theories such as programmed longevity, endocrine theory, and immunological theory, or error theories such as the wear and tear theory, the cross-link theory, the free-radical theory, and the somatic DNA damage theory. Psychosocial aging theories include Jung's Theory of Individualism and Erickson's Developmental Theory. Sociological aging theories include the disengagement theory, the activity theory, and the continuity theory (Tabloski, 2006).
Nursing models and theories that are useful in gerontological nursing practice include King's Conceptual System, Orem's Conceptual Model, Orem's Self-Care Deficit Nursing Theory, Pender's Health Promotion Model, and Roy's Adaptation Model. Optimal functional level, attainment of realistic and measurable goals regarding self-care, lifestyle changes to improve health, quality of life, and successful adaptation to situational and maturational stressors are critically important concepts concerning nursing care for the geriatric patient (Alligood, 2006b; Berbiglia, 2006; Sakraida, 2006; Tabloski, 2006). Living with chronic illnesses and maintaining independence are major challenges to the elderly population (Tabloski, 2006).
Middle range theories are developed at the intersection of research and practice to provide guidance for practice and spawn further scholarly research. Middle range theories that are applicable in caring for the geriatric client include the Uncertainty in Illness Theory (Bailey & Stewart, 2006), the Theory of Health-Related Quality of Life (Bredow & Peterson, 2004), and Olson's Theory of the Empathetic Process (Olson & Kunyk, 2004). Other pertinent middle range theories include Chronic Sorrow, Caregiver Stress, and the Theory of Unpleasant Symptoms (Kohlenberg, Kennedy-Malone, Crane, & Letvak, 2007).
The systematic approach for clinical decision-making utilizing existing research is termed evidence-based practice. Best practice depends on the synthesis of evidence from research, adherence to professional standard obligations, and the expertise of the nurse (Eliopoulos, 2010). The tripartite interacting structure of theory, research and best practice standards should guide professional gerontological nursing practice. The American Nurses Association (ANA) Standards of Gerontological Nursing Practice stipulate that, "The gerontological nurse interprets, applies, and evaluates research findings to inform and improve gerontological nursing practice" (Standard VII. Research) and "The gerontological nurse considers the factors related to safety, effectiveness, and cost in planning and delivering patient care" (Standard VIII. Resource Utilization) (Eliopoulos, 2010, p. 73). The John A. Hartford Institute for Geriatric Nursing has initiated the "Assessments and Best Practices in Care of Older Adults" project to bridge the gap between theory and practice in the care of the elderly (NursingCenter.com, 2009).
An example of a nursing research study that utilizes nursing theory and is applicable for gerontological nursing practice is "The Role of Communication in Nursing Care: A Review of the Literature." In this literature search, the authors explore the role of communication in various nursing theoretical models, such as Peplau's Theory of Interpersonal Relations, Orlando's Interaction Theory, King's Interacting Systems Framework, Orem's Self-Care Theory, and Neuman's System Theory. They also overview numerous research studies concerning nurse-elder communication. The authors identify the need for reliable and valid instruments to observe nurse-patient communication interactions in practice (Caris-Verhallen, Kerkstra, & Bensing, 1997).
Another study, "Practice Development: Providing Benefits for Both Managers and Older Patients with Delirium and Dementia," outlines theories and strategies for improving the care of older individuals with delirium and dementia in hospital settings. These types of patients often experience poor quality care and endure prolonged lengths of stay. The need for incorporation of evidence-based knowledge into the practice environment is underscored in this article. Too often, practice is carried out without being guided by research or theory, to the detriment of the patient (Bezzant, 2008).
Yet another study, "Toward a Theory of Helpfulness for The Elderly Bereaved: An Invitation to a New Life," describes the process of generating a new middle-range theory, the Invitation to a New Life. The authors discuss the need to conceptualize grief as a psychosocial transition instead of a crisis. Five themes to help the newly bereaved elder widow or widower in the grief process are identified. The authors conclude that further studies are needed to explore differences and similarities of helpfulness in other cultural settings and with other types of losses. The theory also needs to be tested in the practice environment (Rigdon, Clayton, & Dimond, 1987).
There is a clearly identified need for gerontological nursing research that is linked to theory. More middle range theories are needed to explicate best practices for geriatric syndromes. More studies are needed in the areas of delirium, dementia, geriatric depression, hearing impairment, incontinence, prevention of falls and pressure ulcers, promoting positive student nurse clinical experiences with older adults, advocacy for nursing home residents, quality care indicators in nursing homes, increasing job satisfaction in long-term care, and translating resident into daily practice.
This paper has discussed the need to translate theory and research into gerontological nursing practice. Suggestions have been made for further middle range theories and research studies. Elders will benefit from safer and higher standards of care delivery.
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