For this Assignment, you compare two theoretical frameworks used in nursing research and explain how each theoretical framework informs nursing research.

 What is theory, and how does it shape research? Most research is based on a theoretical framework. Theoretical frameworks, also known as “conceptual frameworks” or “models,” are used in nursing research to provide a structure for organizing and understanding the research problem and to guide the research design and analysis. Theoretical frameworks are shaped over time as empirical data and observations regarding a phenomenon accumulate. For this Assignment, you compare two theoretical frameworks used in nursing research and explain how each theoretical framework informs nursing research. Review the Learning Resources for this Module. Reflect on the theoretical frameworks presented and focus on two theoretical frameworks for this Assignment. Consider how these frameworks might be used in nursing research. The Assignment Select two theoretical frameworks from this Module’s readings. Summarize their key assumptions. Be specific. Describe how the theoretical frameworks you selected are used in nursing research. Be specific and include examples. Compare the two frameworks and explain the similarities and differences between them. Be sure to cite sources in APA format as needed. To introduce the discussion of the use of theoretical frameworks for research, consider the example of Emily, a novice oncology nurse. From this case study, reflect on how nurses can understand the theoretical underpinnings of both research and evidence-based practice, and reaffirm how nurses should integrate research into practice. Emily graduated with her bachelor of science in nursing (BSN) a little more than 1year ago, and she recently changed positions to work on a pediatric oncology unit in a large hospital. She quickly learned that working with very ill and often dying children is tremendously rewarding, even though it is frequently heartbreaking. One of Emily’s first patients was Benny, a 14-year-old boy admitted with a recurrence of leukemia. When she first cared for Benny, he was extremely ill. Benny’s oncologist implemented the clinical practice guidelines for cases such as his, but the team was careful to explain to Benny and his family that his prognosis was guarded. In the early days of his hospitalization, Emily cried with his mother when they received his daily laboratory values and there was no apparent improvement. She observed that Benny was growing increasingly Page 82–fatigued and had little appetite. Despite his worsening condition, however, Benny and his parents were unfailingly positive, making plans for a vacation to the mountains and the upcoming school year. At the end of her shift one night before several days off, Emily hugged Benny’s parents, as she feared that Benny would die before her next scheduled workday. Several days later, when she listened to the report at the start of her shift, Emily was amazed to learn that Benny had been heartily eating a normal diet. He was ambulatory and had been cruising the halls with his baseball coach and playing video games with two of his cousins. When she entered Benny’s room for her initial assessment, she saw the much-improved teenager dressed in shorts and a T-shirt, sitting up in bed using his iPad. A half-finished chocolate milkshake was on the table within easy reaching distance. He joked with Emily about Minecraft as she performed her assessment. Benny steadily improved over the ensuing days and eventually went home with his leukemia again in remission. As Emily became more comfortable in the role of oncology nurse, she continued to notice patterns among the children and adolescents on her unit. Many got better, even though their conditions were often critical. In contrast, some of the children who had better prognoses failed to improve as much or as quickly as anticipated. She realized that the kids who did better than expected seemed to have common attributes or characteristics, including positive attitudes, supportive family and friends, and strong determination to “beat” their cancer. Over lunch 1day, Emily talked with her mentor, Marie, about her observations, commenting that on a number of occasions she had seen patients rebound when she thought that death was imminent. Marie smiled. “Fortunately this is a pattern that we see quite frequently. Many of our kids are amazingly resilient.” Marie told Emily about the work of several nurse researchers who studied the phenomenon of resilience and gave her a list of articles reporting on their findings. Emily followed up with Marie’s prompting and learned about “adolescent resilience” (Ahern, 2006; Ahern et al., 2008) and “resilience in middle adolescents” (Scoloveno, 2015). These works led her to a “middle-range theory of resilience” (Polk, 1997). Focusing her literature review even more, Emily was able to discover several recent research studies (Hughes et al., 2024; O’Daffer et al., 2023; Raybin et al., 2022; Schwartz et al., 2022) that examined aspects of resilience among adolescents with cancer, further piquing her interest in the subject. From her readings, Emily gained insight into resilience, learning to recognize it in her patients. She also identified ways she might encourage and even promote resilience in children and teenagers. Eventually, she decided to enroll in a graduate nursing program to learn how to investigate different phenomena of concern to her patients and discover ways to apply the evidence-based findings to improve nursing care and patient outcomes. Practice-Theory-Research Links • Learning Objective: Describe how practice, theory, and research are interrelated in nursing, including key concepts and definitions. Several important aspects of how theory is used in nursing research are embedded in Emily’s story. First, it is important to notice the links among practice, theory, and research. Each is inextricably connected with the others to create a knowledge base that can be applied to nursing practice to promote high-quality and cost-effective patient care (Fig. 5.1). In her practice, Emily recognized a pattern of characteristics in some patients that appeared to enhance their recovery. Her mentor directed her to research other nurses had published on the phenomenon of “resilience.” Emily was then able to apply the information on resilience Page 83–and related research findings as she planned and implemented care. Her goal was to support and enhance each child’s resilience as much as possible and thereby improve their outcomes. FIG. 5.1 Discipline knowledge: theory-practice-research connection Follow for extended description Another key message from the case study is the importance of reflecting on an observed phenomenon and discussing it with colleagues. This promotes questioning and collaboration as nurses seek ways to improve practice. Finally, Emily was encouraged to do a literature search to see out what had been published related to the phenomenon she had observed. Reviewing the research literature led her to a middle-range theory of resilience as well as current research that examined its importance in caring for adolescents with cancer. This then challenged her to consider how she might ultimately conduct her own research. Overview of Theory • Learning Objectives: Explain the different types of theories that inform nursing research and practice. Theory is a set of interrelated concepts that provides a systematic view of a phenomenon. A theory allows relationships to be proposed and predictions made, which in turn can suggest potential actions. Beginning with a theory gives the researcher a logical way of collecting data to describe, explain, and support nursing practice. In nursing, science is the result of the interchange between research and theory. The purpose of research is to build knowledge through theory generation and testing the concepts within the theory that can be applied in practice. To build knowledge, research should develop within a theoretical structure or blueprint that facilitates analysis and interpretation of findings. The use of theory provides structure and organization to nursing knowledge. It is important that nurses understand that nursing practice is based on the theories that are generated and validated through research (McEwen & Wills, 2023). In an integrated, reciprocal manner, theory guides research and practice; practice generates research questions that are tested in studies or quality improvement projects; research contributes to theory building and establishing practice guidelines (see Fig. 5.1). What is learned through practice, theory, and research interweaves to create the knowledge fabric of nursing. From this perspective, like Emily in the case study, each nurse should be involved in the process of contributing to the knowledge or evidence-based practice.Page 84 Box 5.1 Definitions Concept Image or symbolic representation of an abstract idea. A concept can be concrete or abstract. A concrete concept can be easily identified, quantified, and measured, whereas an abstract concept is more difficult to quantify or measure. For example, weight, blood pressure, and body temperature are concrete concepts. Hope, uncertainty, resilience, and spiritual pain are abstract concepts. Conceptual Definition Much like a dictionary definition, a conceptual definition conveys the general meaning of the concept. However, the conceptual definition goes beyond the general language meaning found in the dictionary by defining or explaining the concept as it is rooted in theoretical literature. Conceptual/Theoretical Framework A set of interrelated concepts that represents an image of a phenomenon. These two terms are often used interchangeably. The conceptual/theoretical framework refers to a structure that provides guidance for research or practice. The framework identifies the key concepts and describes their relationships to each other and to the phenomena (variables) of concern to nursing. It serves as the foundation on which a study can be developed or as a map to aid in the design of the study. Construct A construct complex concept; constructs usually comprise more than one concept and are built or “constructed” to fit a purpose. Health promotion, maternal-infant bonding, health-seeking behaviors, and health-related quality of life are examples of constructs. Model A graphic or symbolic representation of a phenomenon. A graphic model is empirical and can be readily represented. A model of an eye or a heart is an example. A symbolic or theoretical model depicts a phenomenon that is not directly observable and is expressed in language or symbols. Written music or Einstein’s theory of relativity are examples of symbolic models. Theories used by nurses or developed by nurses frequently include symbolic models. Models are very helpful in allowing the reader to visualize key concepts/constructs and their identified interrelationships. Operational Definition Specifies how the concept will be measured. That is, the operational definition defines what instruments will be used to assess the presence of the concept and will be used to describe the amount or degree to which the concept exists. Theory Set of interrelated concepts that provides a systematic view of a phenomenon. Several key terms are often used when discussing theory. It is necessary to understand these terms when considering how to apply theory in practice and research. They include concept, conceptual definition, conceptual/theoretical framework, construct, model, operational definition, and theory. Each term is defined and summarized in Box 5.1. Concepts and constructs are the major components of theories and convey the essential ideas or elements of a theory. When a nurse researcher decides to study a concept/construct, the researcher must precisely and explicitly describe and explain the concept, devise a mechanism to identify and confirm the presence of the concept of interest, and determine a method to measure or quantify it. To illustrate, Table 5.1 shows the key concepts and conceptual and operational definitions provided by Flanders et al. (2020) in their study of a program to promote resilience among nurses in a pediatric intensive care unit. Theory Types • Learning Objective: Describe the types of theories used in research. As stated previously, a theory is a set of interrelated concepts that provide a systematic view of a phenomenon. Theory provides a foundation and structure that may be used for the purpose of explaining or predicting another phenomenon. In this way, a theory is like a blueprint or a guide for building a structure like a house. A blueprint depicts the elements of a structure and the relationships among the elements; similarly, a theory depicts the concepts that compose it and suggests how the concepts are related.Page 85 Table 5.1 Concepts and Variables: Conceptual and Operational Definitions Concept Conceptual Definition Variable Operational Definition Compassion fatigue (Flanders et al., 2020) Compassion fatigue is seen as the “cost of caring.” It is composed of “burnout” and “secondary traumatic stress.” Compassion Fatigue Burnout+secondary traumatic stress subscales of the Professional Quality of Life Instrument (ProQOL) Secondary traumatic stress (Flanders et al., 2020) “The stress one experiences from caring for a person who has suffered from a traumatic event” occurs when health care providers are repeatedly exposed to patients suffering from trauma or devastating illnesses. STS Subscale of the Professional Quality of Life Instrument (ProQOL) Burnout (Flanders et al., 2020) Exhaustion, anger, frustration, and depression. Burnout Subscale of the Professional Quality of Life Instrument (ProQOL) Compassion satisfaction (Flanders et al., 2020) Pleasure derived from doing your job well. Compassion satisfaction Subscale of the Professional Quality of Life Instrument (ProQOL) Resilience (Flanders et al., 2020) A recurrent human need to weather periods of stress and change successfully throughout life. Turnover and employee engagement (outcome of resiliency program) RN turnover and employee engagement portions of the Press Ganey instrument Nurses use a multitude of theories as the foundation for research and practice. Many have been developed by nurses and are explicitly related to practice; others, however, come from other disciplines like psychology, sociology, and anthropology. Theories From Related Disciplines Like engineering, architecture, social work, and teaching, nursing is a practice discipline. This means that nurses use concepts, constructs, models, and theories from many disciplines in addition to nursing-specific theories. This is, to a large extent, the rationale for the “liberal arts” education that is required before entering a nursing program. Exposure to knowledge and theories of basic and natural sciences (e.g., mathematics, chemistry, biology) and social sciences (e.g., psychology, sociology, political science) provides a fundamental understanding of these disciplines and allows for application of key principles, concepts, and theories from each, as appropriate. Likewise, nurses use principles of administration and management and learning theories in patient-centered, holistic practices. Table 5.2 lists a few of the many theories and concepts from other disciplines that are commonly used in practice and research and are part of the foundational framework for nursing. Nursing Theories Used in Practice and Research In addition to the theories from other disciplines, the nursing literature presents a number of theories that were developed by nurses. Typically, nursing theories reflect concepts, relationships, and processes that contribute to the development of a body of knowledge applied to interventions. Understanding these interactions and relationships among the concepts and phenomena is essential to evidence-based care.Page 86 Table 5.2 Theories Used in Nursing Practice and Research Discipline Examples of Theories/Concepts Used by Nurses Biomedical sciences Germ theory (principles of infection), pain theories, immune function, genetics/genomics, pharmacotherapeutics Sociological sciences Systems theory (e.g., von Bertalanffy), family theory (e.g., Bowen), role theory (e.g., Merton), critical social theory (e.g., Habermas), cultural diversity (e.g., Leininger) Behavioral sciences Developmental theories (e.g., Erikson), human needs theories (e.g., Maslow), personality theories (e.g., Freud), stress theories (e.g., Lazarus & Folkman), health belief model (e.g., Rosenstock) Learning theories Behavioral learning theories (e.g., Pavlov, Skinner), cognitive development/interaction theories (e.g., Piaget), adult learning theories (e.g., Knowles) Leadership/management Change theory (e.g., Lewin), conflict management (e.g., Rapaport), quality framework (e.g., Donabedian) Helpful Hint In research and practice, concepts often create descriptions or images that emerge from a conceptual definition. For instance, pain is a concept with different meanings based on the type or aspect of pain being referred to. As such, there are a number of methods and instruments to measure pain. A nurse researching postoperative pain would conceptually define pain based on the patient’s perceived discomfort associated with surgery and then select a pain scale/instrument that allows the researcher to operationally define pain as the patient’s score on that scale. Nursing theories are often described based on their scope or degree of abstraction. Typically, these are reported as grand, middle-range, or situation-specific (also called microrange) nursing theories. Each is described in this section. Grand Nursing Theories Grand nursing theories are sometimes referred to as conceptual models and include the theories/models that were developed to describe the discipline of nursing as a whole. This composes the works of nurse theorists such as Florence Nightingale, Virginia Henderson, Martha Rogers, Dorothea Orem, and Betty Neuman. Grand nursing theories/models are all-inclusive conceptual structures that tend to include views on persons, health, and environment to create a perspective about nursing. This most abstract level of theory has established a knowledge base for the discipline. These works are used as the conceptual basis for practice and research, and they are tested in research studies. One grand theory is not better than another with respect to research. Rather, these varying perspectives allow the researcher to select a framework for research that best depicts the concepts and relationships of interest, and then decide where and how they can be measured as study variables. What is most important about the use of grand nursing theoretical frameworks is the logical connection of the theory to the research question and the study design. Nursing literature contains excellent examples of research studies that examine concepts and constructs from grand nursing theories. See Box 5.2 for an example. Middle-Range Nursing Theories Nurses recognized that grand theories were difficult to apply in research, and considerable attention moved to the development and research of “middle-range” nursing theories. In contrast to Page 87grand theories, middle-range nursing theories contain a limited number of concepts and are focused on a limited aspect of reality. As a result, they are more easily tested through research and more readily used as frameworks for research studies (McEwen & Wills, 2023). Box 5.2 Grand Theory Example Isik et al. (2021) used Orem’s self-care deficit nursing theory to evaluate a nurse-led intervention to improve asthma self-management among school-aged children. The researchers used a randomized controlled, two-group, repeated measures design, in which the sample consisted of 73 students, with 37 students in the treatment group and 36 students in the control group. The intervention consisted of an education program of six 30-minute lessons led by the school nurse. The lessons were based on Orem’s theory, and designed to promote self-care activities in the children to manage their asthma symptoms. The outcomes measured included use of peak flow meters, completion of daily activities, and school absences. The researchers found that the intervention group had significant improvements in reported symptoms, use of the peak flow meter and ability to complete daily activities. Additionally, school absences were lower than the control group, but the difference was not significant. It was concluded that applying Orem’s theory as a framework to promote self-care could be influential in improving self-management of asthma symptoms in school aged children. Box 5.3 Middle-Range Theory Exemplar HPM, Health Promotion Model. Hepburn et al. (2021) conducted a study of health promotion behaviors among urban black women. This study was based on Pender’s health promotion model (HPM) (Pender et al., 2015). Several variables for the study were operationalized and measured using the Health Promotion Lifestyle Profile II, a survey instrument that was developed to be used in studies that focus on HPM concepts, and the researchers concluded that health promoting behaviors among the participants were associated with spirituality, self-efficacy, and a history of domestic violence. A growing number of middle-range nursing theories have been developed, tested through research, and/or used as frameworks for research. Examples are Pender’s Health Promotion Model (Murdaugh et al., 2019), the Theory of Uncertainty in Illness (Clayton et al., 2024; Mishel, 1988, 1990), the Theory of Unpleasant Symptoms (Lenz et al., 1997, 2020), and the Theory of Holistic Comfort (Kolcaba, 1994; Kolcaba & Crawford, 2020). Examples of development, use, and testing of middle-range theories and models are becoming increasingly common in the nursing literature (Box 5.3). The comprehensive health-seeking and coping paradigm is one example. Indeed, Nyamathi’s model served as the conceptual framework of a recent study that examined interventions to improve hepatitis C treatment among individuals experiencing homelessness (Nyamathi et al., 2023). In this study, the findings were interpreted according to the model. The researchers identified several methods to improve taking HCV medications and reduce drug use. They noted that access to healthcare services was vital to help promote health-seeking and coping behaviors among high-risk populations. Situation-Specific Nursing Theories: Microrange, Practice, or Prescriptive Theories Situation-specific nursing theories are sometimes referred to as microrange, practice, or prescriptive theories. Situation-specific theories are more specific than middle-range theories and are composed of a limited number of concepts. They are narrow in scope, explain a small aspect of phenomena and processes of interest to nurses, and are usually limited to a Page 88specific population or field of practice (Chinn & Kramer, 2022; Im, 2021; Peterson, 2020). Im (2021) observed that as nursing research began to require theoretical bases that are easily operationalized into research, situation-specific theories provided closer links to research and practice. Often what is noted by an author as a middle-range theory would more appropriately be termed situation-specific. Most commonly, however, a theory is developed from a research study, and no designation (e.g., middle-range, situation-specific) is attached to it. Examples of self-designated, situation-specific theories include a theory that describes the social-ecological resilience of indigenous adolescents in the United States and Canada (Hodgson et al., 2023), and a situation-specific theory of heart failure self-care (Riegel & Dickson, 2008; Riegel et al., 2022). Increasingly, nurses are using qualitative studies to develop and support theories and models that can and should be expressly identified as situation-specific. Indeed, they have become progressively more common over the last decade as more nurses seek graduate study and are involved in research, and increasing attention is given to the importance of evidence-based practice (Im, 2020; McEwen & Wills, 2023). Im and Chang (2012) conducted a comprehensive research review that examined how theory has been described in nursing literature for the previous decade. They reported a dramatic increase in the number of grounded theory research studies, along with increases in studies using both middle-range and situation-specific theories. In contrast, the number and percentage directly dealing with grand nursing theories have become fewer. More recently, Im (2020) conducted a review of self-described situation-specific theories, highlighting the processes that were used in their development. Table 5.3 provides examples of grand, middle-range, and situation-specific nursing theories used in nursing research. How Theory is Used in Research • Learning Objective: Explain various ways theory guides nursing research. Nursing research is concerned with the study of individuals in interaction with their environments. The intent is to discover interventions that promote optimal functioning and Page 89self-care across the life span; the goal is to foster maximum wellness (McEwen & Wills, 2023). In research, theories are used in one of three ways: Table 5.3 Levels of Nursing Theory: Examples of Grand, Middle-Range, and Situation-Specific Nursing Theories Grand Nursing Theories Middle-Range Nursing Theories Situation-Specific (or Micro) Nursing Theories Florence Nightingale: Notes on Nursing (1860) Dorothy Johnson: The Behavioral Systems Model for Nursing (1990) Martha Rogers: Nursing: A Science of Unitary Human Beings (1970, 1990) Betty Neuman: The Neuman Systems Model (2011) Dorothea Orem: The Self Care Deficit Nursing Theory (2011) Callista Roy: The Roy Adaptation Model (2009) Pender’s Health Promotion Model (Murdaugh et al., 2019) Transitions Theory (Meleis, 2010) Uncertainty in Illness Theory (Mishel, 1988, 1990; Clayton et al., 2024) Theory of Unpleasant Symptoms (Lenz et al., 2020) Theory of Holistic Comfort/Theory of Comfort (Kolcaba, 1994, 2020) Theory of Resilience (Polk, 1997) Theory of Flight Nursing Expertise (Reimer & Moore, 2010) Rivera’s Gender Affirming Nursing Care Model (Rivera et al., 2022) Theory of the Peaceful End of Life (Ruland & Moore, 1998) Theory of Chronic Sorrow (Eakes, 2020; Eakes et al., 1998) Nutritional Deficits in Children With Cancer (Teixeira et al., 2020) Systemic Assessment of Depressive Symptoms Among Registered Nurses (Ross et al., 2020) Anticipatory Grief (Shore et al., 2016) Caregiver Contributions to Heart Failure Self-care (Vellone et al., 2019) Health Management in Heart Failure (Hirano et al., 2023) • Theory is generated as the outcome of a research study (qualitative designs). • Theory is used as a research framework, as the context for a study (qualitative or quantitative designs). • Research is undertaken to test a theory (quantitative designs). Theory-Generating Nursing Research When research is undertaken to create or generate theory, the idea is to examine a phenomenon within a particular context and identify and describe its major elements or events. Theory-generating research is focused on “What” and “How,” but does not usually attempt to explain “Why.” Theory-generating research is inductive; that is, it uses a process in which generalizations are developed from specific observations. Research methods used by nurses for theory generation include concept analysis, case studies, phenomenology, grounded theory, ethnography, and historical inquiry. Chapters 6–8 describe these research methods. As you review qualitative methods and study examples in the literature, be attuned to the stated purpose(s) or outcomes of the research, and note whether a situation-specific (practice or micro) theory or model or a middle-range theory is presented as a finding or outcome. Theory as Framework for Nursing Research In nursing research, theory is most commonly used as the conceptual framework, theoretical framework, or conceptual model. Frequently, correlational studies attempt to discover and specify relationships among characteristics of individuals, groups, situations, or events. Correlational research often focuses on one or more concepts, frameworks, or theories to collect data to measure dimensions or characteristics of variables and explain why and the extent to which one variable is related to another. Data are typically gathered by observation or self-report instruments (see Chapter 11 for nonexperimental designs). Helpful Hint When researchers use conceptual frameworks to guide studies, you can expect to find a system of ideas synthesized for the purpose of organizing, thinking, and providing study direction. Whether the researcher is using a conceptual or theoretical framework, conceptual and then operational definitions will emerge from the framework. Often in correlational (nonexperimental/quantitative) research, a theory will be used as the study’s conceptual/theoretical framework. In these cases, a theory is used as the context for the study and basis for interpretation of the findings. The theory helps guide the study and enhances the value of its findings by setting the findings within the context of the theory, previous works, and describing use of the theory in practice or research. When using a theory as a conceptual framework to guide research, the researcher will do the following: • Identify an existing theory (or theories), and designate and explain the study’s theoretical framework. • Develop research questions/hypotheses consistent with the framework. • Provide conceptual definitions taken from the theory/framework. • Use data collection instrument(s) (and operational definitions) appropriate to the framework. Page 90 • Interpret/explain findings based on the framework. • Determine support for the theory/framework based on the study findings. • Discuss implications for nursing and recommendations for future research to address the concepts and relationships designated by the framework. Theory-Testing Research Finally, nurses may use research to test the concepts of a theory. Theory testing is deductive—that is, hypotheses are derived from theory and tested employing experimental methods. In experimental research such as a randomized controlled trial, the intent is to move beyond explanation to prediction of relationships among characteristics or phenomena within different groups or in various situations. Experimental research requires manipulation of one or more variables to determine how the manipulation affects or changes the dimension or characteristics of other phenomena. In these cases, theoretical statements are posed as research questions or hypotheses. Experimental research requires quantifiable data, and statistical analyses are used to measure differences (see Chapter 9). In theory-testing research, the researcher (1) chooses a theory and selects a propositional statement to be examined; (2) develops hypotheses that have measurable variables; (3) conducts the study; (4) interprets the findings considering the predictive ability of the theory; and (5) determines whether there are implications for further use of the theory in practice and/or whether further research could be beneficial. Evidence-Based Practice Tip In practice, you can use observation and analysis to consider the nuances of situations that matter to patient health. This process often generates questions that are cogent for improving patient care. In turn, following the observations and questions into the literature can lead to published research that can be applied in practice. Highlight When an interprofessional quality improvement team launches a project to develop evidence-based behavior change self-management strategies for a targeted patient population, it may be helpful to think about the Transtheoretical Model of Change and Health Self-Efficacy as an appropriate theoretical framework to guide the project. Application to Research and Evidence-Based Practice • Learning Objective: Explain various impacts of theory on nursing research and evidence-based practice. To build knowledge that promotes evidence-based practice, research should develop within a theoretical structure that facilitates analysis and interpretation of findings. When a study is placed within a theoretical context, the theory or theoretical framework guides the research, informs the research questions or hypotheses, and aids in design, analysis, and interpretation. In this regard, a theory, conceptual model, or conceptual framework provides parameters for the research and enables the researcher to weave the facts together. As you read research, you should know how to recognize the theoretical foundation of a study. Whether evaluating a qualitative or quantitative study, it is essential to understand where and how the research can be integrated within nursing science and applied in evidence-based practice. As a result, it is important to identify whether the intent is to (1) generate a theory, (2) use a theory as the framework that guides the study, or (3) test a theory. This section provides examples that illustrate different types of theories used in Page 91nursing research (e.g., nonnursing theories, middle-range nursing theories) and examples from the literature highlighting the different ways nurses can use theory in research (e.g., theory-generating study, theory testing, theory as a conceptual framework). Application of Theory in Qualitative Research As discussed, in many instances, a theory, framework, or model is the outcome of nursing research. This is often the case in research employing qualitative methods such as grounded theory. From the study’s findings, the researcher builds either an implicit or an explicit structure explaining or describing the findings of the research. Example:  Cardin et al. (2023, Appendix E) reported findings from a study examining the complex issues faced by the health professionals involved with feeding infants in the neonatal intensive care unit (NICU). Using a qualitative approach to data collection, the team interviewed 13 participants recruited from a variety of professional disciplines (e.g., nurses, speech language pathologists, dieticians, lactation consultants). The researchers identified three major themes and subthemes related to feeding participation: “doing” (subthemes – “interpreting the feeding experience,” “managing time,” and “doing our job”); “doing with others” (subthemes – “collaborating with infants” and “collaborating with other neonatal health care professionals”); and “doing for others” (subthemes – “guiding” and “speaking up”). The researchers then described the interconnections between and among the major themes and subthemes to help promote understanding of the perspectives of the healthcare professionals as they worked to promote infant feeding success. For example, in the “doing with others” it was explained that “a team approach is essential for incorporating developmental and therapeutic goals and intervention strategies” (p. 898). Finally, the researchers concluded that the health professionals noted that feeding success relied on being familiar with the infant and family and working collaboratively to develop consistency in caring for each infant. Generally, when the researcher is using qualitative methods and inductive reasoning, you will find the framework or theory at the end of the manuscript in the discussion section (see Chapters 6–8). You should be aware that the framework may be implicitly suggested rather than explicitly diagrammed as in the work described here (Cardin et al., 2023). Box 5.4 presents another example of a qualitative study resulting in a model (Box 5.4). The nursing literature is rich with similar examples in which inductive qualitative research methods were used to develop theory. Example:  Welch and Carter (2020) used grounded theory methods to conduct interviews with 10 critical care nurses to examine the nurses’ perceptions of expertise, expert performance, and transition from novice to expert in clinical practice. They identified three themes describing the performance of the expert critical care nurse. These are experience, knowledge, and self-actualization. The team Page 92concluded that research is needed to understand the processes that result in transformation to expert critical cares nurses and should focus on the interaction among the three themes. In another example, a team led by Markey et al. (2019) used grounded theory methods to develop a theory to explain nurses’ behaviors when caring for culturally and linguistically diverse patients. The researchers interviewed 30 nursing students and registered nurses and conducted 10 focus groups to better understand the challenges experienced in caring for patients from diverse backgrounds and gather information. From the interviews, the researchers discussed the observation of “resigned indifference” that resulted in gaps in care. “Masking,” “distancing,” and “fitting in” were “disengagement strategies” the nurses used to deal with uncertainties of caring for patients from different cultural backgrounds. From their research, it was concluded that nurse managers should work to support and empower ways to address gaps in care by communicating a clearer message of the responsibility to acknowledge and respect cultural differences so as to provide quality, patient-centered care. Box 5.4 Research Campbell, Harris, and Stoddart (2022) used grounded theory research methods to develop an understanding of the experiences of hematology cancer patients during their last year of life. In this study, the team conducted interviews with 21 cancer patients to learn about their experiences during the process of dying. The result was a model that explained four phases of “facing death”: transitional phase, chronic phase, dying phase, and liminal phase, while setting them within the context of “time” and “uncertainty.” The researchers noted that healthcare service providers need to be responsive to the ambiguity of living and dying and to provide holistic care incorporating discussions of the process of dying. Examples of Theory as Research Framework When a researcher uses quantitative research methods, the framework is typically identified and explained at the beginning of the paper, before the discussion of study methods. Example:  In their study examining racial disparities and barriers in mammography utilization among Medicare beneficiaries in Texas, Liu et al. (2024) (see Appendix C) indicated that their work was based on “Andersen’s Behavioral Model of Health Services Utilization” (Andersen, 1995). The behavioral model of health services utilization explains that use of health care is influenced by factors such as sociodemographic characteristics, “enabling factors” such as healthcare access, and the perceived need of care. In the study, the researchers hypothesized that factors such as low socioeconomic status, social injustice, and cultural factors that contribute to disparities in breast cancer would be reflected in mammography utilization among rural minority women. After a detailed review of Medicare data from 2years, the researchers identified significant racial disparities among the rural women with respect to adherence to mammography screening guidelines; Hispanic and non-Hispanic Black women were most affected. The findings were interpreted based on Anderson’s Behavioral Model of Health Services Utilization, and it was concluded that having an established primary care provider increased the likelihood regular use of mammography. Additionally, as anticipated, low socioeconomic status and poor health status significantly negatively influenced compliance. In another example, one of the works read by Emily from the case study dealt with resilience in adolescents (Tusaie et al., 2007). The researchers in this work used Lazarus and Folkman’s (1984) theory of stress and coping as part of the theoretical framework, researching factors such as optimism, family support, age, and life events. Examples of Theory-Testing Research Although many nursing studies that are experimental and quasiexperimental (see Chapter 10) are frequently conducted to test interventions, examples of research expressly conducted to test a theory are relatively rare in nursing literature. One such work was an experimental study by Sharma and Kalia (2021) examining the effectiveness of interventions based on Kolcaba’s Comfort Theory provided for school-aged children undergoing surgery. The study compared the effectiveness of “integrative comfort care interventions” such as identification of comfort needs of the patient and family; design of interventions to meet the Page 93needs identified; and consideration of “intervening variables” in order to enhance comfort. The study tested whether the group that received Comfort-specific interventions experienced improved levels of comfort when compared to control groups who received standard care. The researchers determined that among other findings, subjects who received integrative comfort care interventions experienced a more “comfortable state” when compared to the control group for several aspects of care studied. It was concluded that applying the Comfort Theory in a pediatric setting was supported and that pediatric patients and their families could benefit from application of Comfort Theory interventions. Critical Appraisal Criteria Critiquing Theoretical Framework 1. Is the framework for research clearly identified? 2. Is the framework consistent with a nursing perspective? 3. Is the framework appropriate to guide research on the subject of interest? 4. Are the concepts and variables clearly and appropriately defined? 5. Was sufficient literature presented to support study of the selected concepts? 6. Is there a logical, consistent link between the framework, the concepts being studied, and the methods of measurement? 7. Are the study findings examined in relationship to the framework? Critiquing the Use of Theory in Nursing Research It is beneficial to seek out, identify, and follow the theoretical framework or source of the background of a study. The framework for research provides guidance for the researcher as study questions are fine-tuned, methods for measuring variables are selected, and analyses are planned. Once data are collected and analyzed, the framework is used as a basis for comparison. Ideally, the research should explain: Did the findings coincide with the framework? Did the findings support or refute findings of other researchers who used the framework? If there were discrepancies, is there a way to explain them using the framework? The reader of research needs to know how to critically appraise a framework for research (see the Critical Appraisal Criteria box). The first question posed is whether a framework is presented. Sometimes a theory may be guiding the research, but a diagrammed model is not included in the manuscript. You must then look for the theoretical framework in the narrative description of the study concepts. When the framework is identified, it is important to consider its relevance for nursing. The framework does not have to be one created by a nurse, but the importance of its content for nursing should be clear. The question of how the framework depicts a structure congruent with nursing should be addressed. For instance, although the Lazarus Transaction Model of Stress and Coping was not developed by a nurse, it is clearly related to nursing practice when working with people facing stress. Sometimes frameworks from different disciplines, such as physics or art, may be relevant. It is the responsibility of the author to clearly articulate the meaning of the framework for the study and to link the framework to nursing. Once the meaning and applicability of the theory (if the objective of the research was theory development) or the theoretical framework to nursing are articulated, you will be able to determine whether the framework is appropriate to guide the research. As you critically appraise a study, you would identify a mismatch, for example, in which the researcher Page 94presents a study of students’ responses to the stress of being in the clinical setting for the first time within a framework of stress related to recovery from chronic illness. You should look closely at the framework to determine whether it is “on target” and the “best fit” for the research question and proposed study design. Next, the reader should focus on the concepts being studied. Does the researcher clearly describe and explain concepts that are being studied and how they are defined and translated into measurable variables? Is there literature to support the choice of concepts? Concepts should clearly reflect the area of study. Example:  Using the concept of “anger,” when “incivility” or “hostility” is more appropriate to the research focus creates difficulties in defining variables and determining methods of measurement. These issues are related to the logical consistency among the framework, the concepts being studied, and the methods of measurement. Throughout the entire critiquing process, from worldview to operational definitions, the reader is evaluating the fit. Finally, the reader will expect to find a discussion of the findings as they relate to the theory or framework. This final point enables evaluation of the framework for use in further research. It may suggest necessary changes to enhance the relevance of the framework for continuing study, and thus serves to let others know where to go from there. Evaluating frameworks for research requires skills that must be acquired through repeated critique and discussion with others who have critiqued the same work. As with other abilities and skills, you must practice and use the skills to develop them further. With continuing education and a broader knowledge of potential frameworks, you will build a repertoire of knowledge to assess the foundation of a research study and the framework for research and/or to evaluate findings where theory was generated as the outcome of the study. Key Points • The interaction among theory, practice, and research is central to knowledge development in the discipline of nursing. • The use of a framework for research is important as a guide to systematically identify concepts and to link appropriate study variables with each concept. • Conceptual and operational definitions are critical to the evolution of a study. • In developing or selecting a framework for research, knowledge may be acquired from other disciplines or directly from nursing. In either case, this knowledge is used to answer specific nursing questions. • Theory is distinguished by its scope. Grand theories are broadest in scope, and situation-specific theories are the narrowest in scope and at the lowest level of abstraction; middle-range theories are in the middle. • In critiquing a framework for research, it is important to examine the logical, consistent link among the framework, the concepts for study, and the methods of measurement. Clinical Judgment Challenges • Search recent issues of a prominent nursing journal (e.g., Nursing Research, Research in Nursing & Health) for notations of conceptual frameworks of published studies. How many explicitly discussed the theoretical framework? How many did not mention any theoretical framework? What kinds of theories were mentioned (e.g., grand nursing Page 95theories, middle-range nursing theories, nonnursing theories)? How many studies were theory generating? How many were theory testing? • Identify a nonnursing theory that you would like to know more about. How could you find information on its applicability to nursing research and nursing practice? How could you identify if and how it has been used in nursing research? • Select a nursing theory, concept, or phenomenon (e.g., resilience from the case study) that you are interested in and would like to know more about, and consider: How could you find studies that have used that theory in research and practice? How could you locate published instruments and tools that reportedly measure concepts and constructs of the theory? • You have just joined an interprofessional primary care quality improvement team focused on developing evidence-based self-management strategies to decrease hospital admissions for the practice’s heart failure patients. Which theoretical framework could be used to guide your project?

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