INTEGRATIVE APPROACH TO THE DEVELOPMENT OF SITUATION SPECIFIC THEORIES: THEORETICAL REFLECTIONABSTRACT
Objective: reflect on the use of the integrative approach and its contribution as a methodological path for the development of situation specific theories in nursing.
Method: reflexive study, considering the methodological framework of Im and Meleis and the possibilities of its incorporation into Brazilian nursing for the development of situation specific theories.
Results: the following topics are presented: Integrative approach: possibilities to develop situations specific theories; and, Usefulness of the development of situation specific theories from the integrative approach. The reflection is based on the experience of using the methodological framework for the development of situation specific theories, in addition to discussing the potentialities the framework has regarding the construction of theories that guide nursing care in particular contexts.
Conclusion: the integrative approach is underused in the Brazilian context of theory production, despite being a nursing reference. Therefore, it needs to be made visible to strengthen the development of knowledge that represents diverse and specific realities in order to advance in clinical practice.
DESCRIPTORS: Nursing theory; Nursing models; Nursing philosophy; Nursing methodology research; Theoretical models
RESUMEN
Objetivo: reflexionar sobre el uso del enfoque integrador y su contribución como camino metodológico para el desarrollo de teorías de situaciones específicas en enfermería.
Método: estudio reflexivo, considerando el marco metodológico de Im y Meleis y las posibilidades de su incorporación en la enfermería brasileña para el desarrollo de teorías de situaciones específicas.
Resultados: se presentan los siguientes temas: Enfoque integrador: posibilidades de desarrollar teorías de situaciones específicas; y, Utilidad del desarrollo de teorías de situaciones específicas desde el enfoque integrador. La reflexión se basa en la experiencia de utilizar el marco metodológico para el desarrollo de teorías de situaciones específicas, además de discutir las potencialidades que tiene el marco en cuanto a la construcción de teorías que orientan el cuidado de enfermería en contextos particulares.
Conclusión: el enfoque integrador está subutilizado en el contexto brasileño de producción teórica, a pesar de ser un referente en enfermería. Por lo tanto, es necesario visibilizarlo para fortalecer el desarrollo de conocimientos que representen realidades diversas y específicas para avanzar en la práctica clínica.
DESCRITORES: Teoría de enfermería; Modelos de enfermería; Filosofía en enfermería; investigación metodológica en enfermería; Modelos teóricos
RESUMO
Objetivo: refletir sobre a contribuição do uso da abordagem integrativa como caminho metodológico para o desenvolvimento de teorias de situação específica em enfermagem.
Método: estudo do tipo reflexivo, considerando o referencial metodológico de Im e Meleis e as possibilidades de sua incorporação pela enfermagem brasileira para o desenvolvimento de teorias de situação específica.
Resultado: são apresentados os tópicos: Abordagem integrativa: possibilidades para desenvolver teorias de situação específica; e, Utilidade do desenvolvimento de teorias de situação específicas a partir da abordagem integrativa. A reflexão sustenta-se na experiência de utilização do referencial metodológico para o desenvolvimento de teorias de situação específica, bem como discute o potencial do referencial para a construção de teorias que guiem o cuidado de enfermagem em contextos particulares.
Conclusão: a abordagem integrativa é subutilizada no contexto brasileiro de produção de teorias, mesmo sendo um referencial próprio da enfermagem. Por isso, necessita ser visibilizada para fortalecer o desenvolvimento de conhecimento que represente realidades diversas e específicas a fim de avançar na prática clínica.
DESCRITORES: Teoria de enfermagem; Modelos de enfermagem; Filosofia em enfermagem; Pesquisa metodológica em enfermagem; Modelos teóricos
INTRODUCTION
Nursing knowledge has been developed, improved and organized over the years, emphasizing the mastery of a specific, innovative and proprietary field of knowledge that consolidates and legitimizes nursing as a professional field, discipline and science in constant evolution1.
The development of Nursing Theories (NT) is a result of this theoretical advance, which translates into improving the quality of clinical practice, and allows nursing to progressively structure its identity and its importance in the field of scientific and professional development. To the extent that they describe and explain phenomena, as well as predict and prescribe responses to situations that occur in the context of human experiences. NT contributes not only to the understanding of these factors, but also connects the concepts and theoretical structures to the empirical ones, forming new knowledge for the transformation of reality1-2.
Nursing knowledge is based on a hierarchical structure proposed by Jacqueline Fawcett and used in a standardized way to classify theories and conceptual models. Within this hierarchy, different types of knowledge coexist at different levels of abstraction, depending on the complexity and scope of the phenomena3. Situation Specific Theories (SST) are considered less abstract and less complex, but with great susceptibility to testing and real application of elements generated from theorizing processes, as they allow an orderly and systematized articulation of these processes, incorporating specific diversities and complexities, and even more easily transform the knowledge built through theorizations that guide care actions, into operational concepts and constructs2,4.
The need to generate new knowledge from SST is urgent within the discipline of nursing, in view of the difficulty faced by researchers in transforming the concepts of great theories into practical knowledge applicable to care5. In Brazil, there is currently a chain of theory productions, mainly Middle Range Theories (MRT), which have used development strategies guided by inductive, deductive or inductive-deductive reasoning. Among the different methodological approaches for these constructions, the most used in Brazilian productions is the one proposed by Walker and Avant, a methodology based on more rigid processes. In this sense, there are few references that diversify in the use of other approaches, especially when it comes to the development of SST6.
Thus, it urges us to reflect on the use of the theory development strategy outlined by Meleis, which is composed of more fluid processes and, although it presents similar points, it is distinguished from the others by being concerned with apprehending the social context of the phenomenon, determined by political, cultural, racial, social and gender inequalities. In this way, SST can be more easily transposed to the Nursing Process and, mainly, directed to specific populations and scenarios, which will benefit from care which is directed and adequate to their specificities, considering the contexts of health and disease1-2,4.
In view of the above, this is a theoretical-reflexive study, based on the construction of two Brazilian doctoral thesis projects, and aims to reflect on the contribution of the use of the integrative approach as a methodological path for the development of specific nursing situation theories.
INTEGRATIVE APPROACH: POSSIBILITIES TO DEVELOP SITUATION SPECIFIC THEORIES
The development of theories in nursing is possible from deductive and/or inductive research processes, in which, especially in the strategy of the integrative approach, these two forms of reasoning are combined through the combination and association of different sources of data. In this perspective, the researcher can move between different theorizing processes, either from an existing theory, or even from research or insights arising from practice4,7. The integration of all these theoretical development processes gives rise to new theorizations, which can be systematized into knowledge subject to conceptualization, formulation of statements, as well as the proposition of a new theory.
The development of SST by the integrative approach process is fluid and, just as it can follow an order in sequential steps, it may also not be homogeneous or have all the stages contemplated. Thus, each SST will follow a unique path of construction and the consequences will be the level of abstraction of the theory, the scope of the concepts, as well as the approximation and refinement of the operationalization of the propositions.
The integrative approach is developed from four major stages, as seen in Figure 1, which is composed of different principles that guide the development of conceptualizations and theorizations.
The first stage is the researcher's verification of his own assumptions for the development of the theory, that is, it is necessary to analyze, in a broader way, the philosophical contributions, from which derive ontological, epistemological, logical and ethical dimensions, to understand the plurality and the extension of internal and external knowledge to the discipline of nursing. If these assumptions are aligned with the principles of multiple truths, the evolutionary capacity of theoretical development, the socio-political context of phenomena and nursing perspectives, the idea of building a SST can be considered valid4.
The development of a SST presupposes the diversity and philosophical, theoretical and methodological plurality, considered by Meleis as a non-purist position, that is, a view that welcomes the heterogeneity of both scientific and nursing phenomena, understanding that these are increasingly complex and multifactorial, largely due to the multiplicity of clients, users or patients1.
This position is in line with the purpose that care for human beings is based on socially relevant knowledge, and that social and political awareness is used to develop it, in order to provide changes for and with nurses, aimed at qualifying care and care for the person. And this is possible if, above all, it reflects a value system that accepts and respects a nursing perspectives that deals with nurses' concerns, visions, values and attitudes1-2,4.
The second stage consists of exploring the phenomenon through multiple sources, through which the theories will be inferred. Investigating theories in the field of nursing and beyond is a premise of this step, so that, from the deduction of an existing theory, one can similarly obtain explanations or predictions about a phenomenon, situation or specific population, based on explanations or predictions already described in theoretical structures such as, for example, the TMA. Therefore, deductive reasoning is an important source of conceptualization, by allowing the derivation of the theoretical structure of a supporting theory to support the questions regarding the studied phenomenon4. Meleis defends that the development of a SST should improve nursing as a science, therefore, its construction must be grounded in the discipline of nursing, in the scope of practice and in the domain and perspective of the discipline1. Therefore, one should encourage and strengthen existing constructions in nursing to advance one's own knowledge.
Other sources, used inductively, are literature reviews, in which it is possible to broadly understanding the existing knowledge about the phenomenon and find important elements that lead to the development, modification, definition or refinement of concepts, assumptions and propositions arising from the supporting theory. In addition, the results and experiences of research projects, educational programs, extension and/or from practice in hospital and/or community environments can be used as a data source4. There are also collaborative efforts, which may involve internationality and interdisciplinarity, being important elements, as they provide diversity of ideas, increase academic dialogues and, consequently, results for practice, as well as promoting an integration of visions, which strengthens responsiveness to questions about the nature, mission and objectives of nursing1,4.
The third stage of the development of a SST refers to theorizing, being divided into initiation, process and integration. Initiation is the starting point, when the first theories emerge, which can originate from one or several sources of data, such as literature reviews on the phenomenon of interest, the research project, as well as the experience with practice, or even a supporting theory with the derivation of concepts and statements consistent with the specific situation. Depending on what sources are used to initiate theorizations, different processes can be followed, the most used being: theory-practice-theory; practice-theory; research-theory; and theory-research-theory. The integration of data obtained from different sources occurs from the researcher's reflexivity, data analysis, creation of structures that allow the formulation of propositions, which can be facilitated and refined with the sharing of internal and external dialogues to the environment in which the researcher produces research or experiences clinical, extension and/or teaching experiences1,4.
In addition, the documentation of the entire process, including questions/impasses/doubts about conceptualization and theorizing, critiques of each step of the development process and reflection on the possible impact of theories on the social and political environment, which need to be systematically documented, through theoretical diaries and/or memos. This demonstrates transparency in the process, as well as the ability to reflect, further explore issues and recognize specific situations and/or specific populations that are central to the development of the theory1,4.
In the fourth stage of the approach, there is the reporting and sharing of theories in the form of a manuscript, model or research report for the academic nursing community, so that it can be validated by peers through review and criticism. It is also important that the theory is validated by those involved, i.e, the specific population, so that there is an assessment of the relevance and social utility of the theory1.
When analyzing the scientific literature with the objective of identifying SST development methods, it became evident, especially in the international bibliography, that the combination of deductive/inductive reasoning is the theorizing process most used by studies that elaborated SST, being characterized by derivation of conceptual models, grand theories and MRT, as well as exploring diverse sources of information, such as: literature reviews, qualitative and/or quantitative research projects, clinical, research and education experience, and nursing perspectives7-8.
Therefore, the doctoral projects that support the reflections presented here are methodologically guided by the integrative approach and, thus, will follow the steps mentioned above, through various processes of theoretical development, in order to modify, redefine, refine and propose concepts and statements, as shown in Figure 2 and Figure 3.
Pictorial scheme related to the development of the situation specific theory for nursing care for people with elimination intestinal stoma and their families. Curitiba, PR, Brazil, 2022.
Pictorial scheme related to the development of the situation specific theory for nursing care for women who transition to unplanned motherhood after 40 years of age. Curitiba, PR, Brazil, 2022.
It is understood that, when using the integrative approach to elaborate SST, one can detail, explain and clarify specific situations, contexts and/or populations, in an attempt to broaden the perspectives of nursing performance and, then, provide guidelines and support for the most effective and congruent care. Thus, in its methodological framework, it brings together the possibility of combining theoretical and empirical processes, with a view to providing an integrated view of the studied phenomenon, highlighting the relationship between practice, theory and research, as well as its implication for the development of theory.
USEFULNESS OF SITUATION SPECIFIC THEORY DEVELOPMENT FROM THE INTEGRATIVE APPROACH
SST do not transcend time, place or situation, they are constructed from particular contexts, both biological and health, as well as social, political and cultural. However, despite seeming contradictory, the development of these theories is a continuous, dynamic and evolutionary process4, because, although it is linked to a particular conjuncture, it supports and encourages the development of other theories that, when articulated and related, form robust theoretical structures on a given phenomenon, strengthening the body of scientific nursing knowledge. Thus, all this knowledge, which, while being specific, is also broad, while it feeds a larger field that is the unit of the nursing discipline, contributes to its application in practical contexts, as well as to achieving the objective greatest of nursing, which, from Meleis's perspective, is to take care of human beings in the best way, so that the answer to this care is well-being1.
Despite the importance of the great theories in the historical and scientific construction of nursing, and for the consolidation of the current knowledge of the discipline, they are structures given to generalization and abstraction and, therefore, disseminated by peers as difficult or impossible to be applied in practice, making its use increasingly distant from operationalization and application, and more commonly linked to the field of ideas5. Opposing this more generalist position, SST tries to fill this gap by bringing concepts, propositions, constructs, scales/instruments and applicable models closer together, in order to reconnect the theory-research-practice tripod9.
In this context, it would be important for the curricula of undergraduate nursing courses to absorb the new knowledge generated from more practical theories, so that they could be applied in teaching, encouraging and preparing the next generations for clinical reasoning based on theories closer to the reality. In addition, within the scope of postgraduate courses, efforts could be made in order to expand research aimed at exploring MRT and SST already produced by nursing, while preserving knowledge derived from the great existing theories of nursing, which would guarantee the advancement of discipline.
The development of SST is indisputable and indispensable at the current moment of nursing knowledge, in view of the level of disciplinary maturity, that is, theories and concepts have already been developed that are solidified regarding more general issues that involve nursing phenomena. Thus, it is necessary to think about knowledge that is more congruent with the nature of nursing, which encompasses the diversity of nursing patients, the complexities of the health-disease experiences, the responses of human beings to situations of illness and disasters, as well as the dynamic nature of the environment1. Thus, it is considered that it is imperative that SST be constructed, based on plural approaches, with a view to integrating knowledge based on an interpretive, post-modernist, post-structuralist and post-colonialist vision, forming products that are easily transposed to clinical use and practical in the diverse contexts of care2.
Therefore, the integrative approach is a valuable methodological framework that allows to reveal needs and demands collected from different perspectives, making it versatile and dynamic, as well as compatible with social, political and cultural values, just as the SST itself. This makes it flexible to the care and educational reality, allowing the researcher to view its phenomenon both broadly, to understand various aspects pertaining to it, in order to capture particular nuances that compose and characterize it as a situation and/or specific context.
The SST in Brazil is still developing, although there is a growing movement towards the construction of theories that are more applicable to the practical context5. In this sense, a brief search was carried out on the Lattes Platform, in order to find researchers who are developing studies on this theme, and who have a SST as a product. The search mode for “subject” was used with the term “situation specific theory,” in the databases of PhD holders and other researchers. It was possible to locate five researchers and identify that three are PhD students in graduate programs, and, of these, two comprise the authors of this reflection. Another is a doctor producing a SST, and another, her respective supervisor. What can be inferred is that, in fact, SSTs are not being produced, or that they are not being formally called theories, or that they are not being indexed correctly in terms and keywords in the databases. Thus, the issue to reflect on, is that Brazil is still not very aligned with the international tendency to formally develop theories that are less abstract and capable of guiding nursing care, highlighting dimensions that can and need to be explored in the academic scenario in national level.
As for the integrative approach, this is not a methodological path commonly used for the production of nursing theories, even though it is a methodological framework developed by one nurse and improved by another1,4. When searching the Catalogue of Theses and Dissertations of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) with the terms "integrative approach" AND Meleis, "integrated approach" AND Meleis, no production was found.
A search was also conducted in the Portal Regional da Biblioteca Virtual em Saúde, in order to find publications in Latin American journals, based on the following strategy: ("integrative approach" OR "integrated approach") AND Meleis, with no results. This search was restricted to portals and repositories that could return studies in Portuguese, in order to explore Brazilian research that followed this methodological path.
To identify the process of developing new SST, Eun-Ok Im conducted a literature review, restricted to the English language and, in the last 20 years, 15 studies constructed by nurses were found, published in nursing journals that explained the use of the integrative approach in methodology7. It is evident that, even with few studies, this methodological path is used by nurses from other countries, opposing the Brazilian reality.
Although underused, it is understood that this is a possible and plausible path, but supposedly little known by the Brazilian nursing community. Thus, it is interesting that this methodological framework is presented to national researchers, so that it can be used by nurses who intend to develop this type of construction, having a SST as a final product and, consequently, the possibility of creating testable elements, such as scales, terminological sets, protocols, evaluation instruments, proposition of diagnoses, as well as defining and related characteristics.
Using a methodological framework consistent with the values and principles of nursing and the researcher, which instrumentalizes and leads the Nursing Process, is a viable strategy to incorporate experiences and consolidate knowledge, placing Brazil on a par with the context of evolution of international knowledge.
CONCLUSION
The integrative approach is a methodological framework developed, validated and refined by nurses, being a product of scientific knowledge of the discipline. However, it is verified that it is underused by Brazilian researchers to produce theories, revealing a gap that can be explored.
Thus, our intention was to foster reflections about the possibilities of using the integrative approach and instigate the development of SST as guiding structures of reasoning and decision-making in relation to the Nursing Process, aiming for better results in clinical practice and, consequently, in the diffusion of knowledge.
REFERENCES
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2. Im EO, Meleis AI. Situation-specific theories: philosophical roots, properties, and approach. ANS Adv Nurs Sci [Internet]. 1999 [cited 2022 Mar 10];22(2):11-24. Available from: https://doi.org/10.1097/00012272-199912000-00003
» https://doi.org/10.1097/00012272-199912000-00003 - 3. McEwen M, Wills EM. Theoretical bases of nursing. 4th ed. Porto Alegre: Artmed; 2016.
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4. Im EO. Development of situation-specific theories: an integrative approach. ANS Adv Nurs Sci [Internet]. 2005 [cited 2022 Mar 12];28(2):137-51. Available from: https://doi.org/10.1097/00012272-200504000-00006
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5. Brandão MAG, Martins JSA, Peixoto MAP, Lopes ROP, Primo CC. Theoretical and methodological reflections for the construction of middle-range nursing theories. Texto Contexto Enferm [Internet]. 2017 [cited 2022 Apr 15];26(4):e1420017. Available from: https://doi.org/10.1590/0104-07072017001420017
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6. Leandro TA, Nunes MM, Teixeira IX, Lopes MVO, Araújo TL, Lima FET, et al. Development of middle-range theories in Nursing. Rev Bras Enferm [Internet]. 2020 [cited 2022 Apr 15];73(1):e20170893. Available from: https://doi.org/10.1590/0034-7167-2017-0893
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8. Im EO. The status quo of situation-specific theories. Res Theory Nurs Pract [Internet]. 2014 [cited 2022 Apr 15];28(4):278-98. Available from: https://doi.org/10.1891/1541-6577.28.4.278
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9. Im EO. For future development of situation-specific theories. In: Im EO, Meleis AI, editors. Situation specific theories: development, utilization, and evaluation in nursing [Internet]. Springer Cham; 2021 [cited 2022 Apr 15]. p. 339-50. Available from: http://doi.org/10.1007/978-3-030-63223-6
» http://doi.org/10.1007/978-3-030-63223-6
NOTES
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ORIGIN OF THE ARTICLE
Extracted from the thesis projects - Nursing care for women who transition to unplanned motherhood after 40 years: situation specific theory, presented to the Graduate Program in Nursing, Universidade Federal do Paraná, in 2021; and Situation Specific Theory for nursing care for people with stoma and their families from the Theory of Transitions, presented to the Graduate Program in Nursing, Universidade Federal de Santa Maria, in 2022.
Edited by
Publication Dates
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Publication in this collection
07 Apr 2023 -
Date of issue
2023
History
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Received
03 Oct 2022 -
Accepted
22 Nov 2022
Source: Adapted from Im (2005)
NECFAM: Study Center in Care and Family, which is part of the Research Group registered in CNPq Care, Health and Nursing.
NEPECHE: Center for Studies, Research and Extension in Human Nursing Care.