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Development of Situation-specific Theories An Integrative Approach

Eun-Ok Im, PhD, MPH, RN, CNS

One type of "ready-to-wear" theories that can bring about better nursing care outcomes re- gardless of their philosophical bases is situation-specific theories proposed hy Im and Mt-lcis in 1999. In this paper, sonic propositions tor an Lntejtnitive approach to the deveiopment of situation-specific iheorics are made. First, situation-specific theories are described as practice theories while they arc compared with middie-range theories. Then the integrative approach is detailed, wliich includes («) checking assumptions for theory development; {h) exploritig thnnigh multiple sources; (t) theorizing; and (cf) reporting, sharing, and validating. Finally, the paper concltides with suggestions for furtlier development of the integrative approach. Key wortls: iutearatii'e cipprruich, nursing theoiy, sittialion-specific theory, lbeor)> development

ACROSS disciplines, scholars can nowsympathize with the epistemic plural- ism that is the practical philosophy of most working scientists in general.' Until recently, scholars believed iti the unity of scientific knowledge, and they accepted its fragmen- tation only as a pragmatic necessit>'. How- ever, these days, scholars are quite happy to go along with philosophical plurality across many disciplines.^

Nursing history also shows the same changes toward epistemic pluralism in the- oretical and philosopliical thinking. In the 1950s, under the tremendous influences of logical positivism, grand theories were de- veloped and used to answer questions on the nature, mission, and goals of nursing,

From the School of Nursing, University of Texas at Austin, Austin, Tex.

The author acknowledges tbe expertise, feedback, and support of Drs Afaf I. Meleis and Lorraine Walker in the dvivlopment of ideas and preparation of this inanu.icript.

Convsponding author: Eu7i-Ok Im. PhD, MPH, RN, CNS. .School of Nursing. University of Texas at Austin, 1700 Red Riivr. Austin, TX 78701 (e-mail: [email protected]. utexa.t.edu).

and nursing scholars and theorists believed in the unity of nursing knowledge. In the 1960s-1980s, metatheoreticai questions on the types and contents of theories were asked and argtied, yet their philosophical ba- sis was still empiricism.̂ '"^ From the mid- dle of the 1980s onward, tremendous efforts in concept development were made with the introduction of qualitative philosophi- cal thinking."'" From the beginning of the 1990s, numerous middle-range theories were developed and published,'^"'^ and philosoph- ical pluntlism in theoretical nursing became more prominent.'-"" Tlirough these histori- cal changes, now, nursing scholars even en- vision and sympathize with epistemic plu- ralism, and seek ready-to-wear theories in nursing practice that may bring about bet- ter nursing care outcomes regardless of their philosophical bases. ̂ "'

Nursing has struggled to develop "ready-to- wear" theories. "Ready to wear" refers to easy applicability to research and practice. One t>'pe of "ready-to-wear" theories is sittiation- specific theories, proposed by Im and Meleis in 1999-'** Situation-specific theories are de- fined as theories that focus on specific nurs- ing phenomena, that reflect clinical practice, and that are limited to specific populations or

137

138 ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2005

to particular fields of practice.'^ '̂ Situation- specific theories belong to a different level than grand theories and middle-range theo- ries, which can incorporate diversities and complexities in nursing phenomenon, con- sider sociopolitical, cultural, and historical contexts of nursing encounters, and be eas- ily applicable to nursing practice.'" In this pa- per, middle-range theories mean theories that have more limited scope and less abstraction than grand theories, address specific phenom- ena or concepts, reflect practice, and aim to be easily testable'**; grand theories are sys- tematic constructions of the nature of nurs- ing, the mission of nursing, and the goals of nursing care.'^ Situation-specific theories are also intended not to be universal theo- ries that can be applicable to any time, any socially constraining strtictures, or any polit- ically limiting situations. Ratber, they are in- tended to be more clinically specific, reflect a particular context, and include blueprints for action."'-' Philosophically, this new type of theory has roots in postempiricism, critical social theory, feminism, and hermeneutics,'^ al! of which agree with current epistemic plu- ralism in nursing,

When situation-specific theories were pro posed, an integrative approach was also pro- posed as a strategy for developing them. The integrative approach was originally pro- posed by Meleis'" and has been extended through later work by Im and Meleis.'^ The integrative approach has some essential components, such as the clinical grounding that drives the basic or clinical questions as well as the questions themselves. Also es- sential are opportunities for clinical involve- ment and for conceptually thinking about the health/illness responses, the situations, and the environment.' However, the propo- sitions of the integrative approach tended to be too abstract for novice theorists to uti- lize in actual theory development. Further de- velopment/refinement of the integrative ap- proach is essential for the future development and practical use of situation-specific theo- ries, which may ultimately result in a stronger link between theory and practice and sub-

sequently produce better nursing care out- comes than other types of theories. In this paper, some propositions for the integrative approach to the development of situation- specific tbeories are made. First, situation- specific theories are described as practice the- ories while they are compared with other types of theories. Then the integrative ap- proach is detailed. Finally, the paper con- cludes with suggestions for further develop- ment of the integrative approach.

SITUATION SPECIFIC THEORIES, PRACTICE THEORIES, AND MIDDLE-RANGE THEORIES

Figure 1 shows the relationships among practice theories, situation-specific theories, middle-range theories, and grand theories reported in the literature. In recent liter- ature, situation-specific theories are some- times labeled as micro-theories or prac- tice theories (a term that is interchangeable with micro-theories^, or even as middle-range theories." '^'" In a sense, situation-specific theories can be categorized as practice the- ories because sittiation-specific theories cer- tainly aim at functioning as practice theories. Jacox'' proposed that practice theories be considered those theories that outline the ac- tions that nurses must take to meet a nursing goal (producing some desired change or ef- fect in the patient's condition). In these terms, situation-specific theories can be considered practice theories because one of the goals of situation-specific theories is to provide a blueprint for nursing practice.'*^ Peterson'" even categorized situation-specific theories and practice theories in the same category, noting that the literature included a confusing variety of terms to refer to the level of theory that is considered less abstract, more specific, and narrower iti scope than middle-range the- ories.

Although practice theories have been wel- come in nursing because ntirsing is inherently a practice-oriented discipline, they have often been criticized as well. The major criticism

DeiHilopment of Situation-specific Tbeories 139

Practice theories or micro theories

Figure 1. Relationships among practice theories, middle-range theories, grand theories, and situation-specific theories.

is that they are procedural and not based on a well-developed body of nursing science.'** For this reason, some theorists have worked to blend middle-range theories with prac- tice theories, and their hybrid efforts have been highly evaluated because they ele- vate the resulting practice above simple dictates or imperatives." Since situatioti- specific theories, in nature, are practice the- ories, those blending efforts are unnecessary for situation-specific theories. In addition, situation-specific theories can provide a ba- sis for the development of the knowledge base for nursing practices through research and practice efforts in specific nursing situa- tions because they are more than just guide- lines or standardized procedures for nursing practice.'^'

Situation-specific theories, however, are different from middle-range theories because the former can be applicable only to sp>e- cific nursing pbenomenon or particular nurs- ing clients while the latter can be applicable across nursing practice fields.'^ '" For exam- ple, the middle-range theory of transition pro- posed by Meleis and her colleagues'^ ŵ as de- veloped based on several studies of ethnically diverse samples undergoing a wide range of transitions, including menopausal, maternal,

and caregiving transition; subsequently, they aimed to cover all types of transitions in nurs- ing situations. However, the situation-specific theory ofthe menopausal transition of Korean immigrant women by Im and Meleis^" aimed at only the specific population of menopausal low-income Korean immigrant women in the United States.

Sititation-specific theories are also differ- ent from middle-range theories in terms of their testability. Middle-range theories contain a limited number of variables and testable rela- tionships. -' In other words, middle-range the- ories are based on logical positivistic atid/or postpositivistic ideas that assume the testabil- ity of a theory.'" Grand theories are criticized as too abstract to be tested empirically. The basic assumption here is that the testability of theories is based on a logical positivistic idea.

Situation-specific theories do not always assume their testability.'*' Some situation- specific theories will certainly aim at the oper- ationalization of central concepts for hypothe- ses testing in real settings. However, other situation-specific theories are not stipposed to be testable because they are developed on philosophical foundations (eg, herme- neutics. phenomenology, critical theory,

140 ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2O()5

pt)stmodernism) in which positivistic ap- paratuses such as hypotheses do not have a place.'*' Rather, the situation-specific theories aim at helping researchers under- stand central concepts through qualitative fieldwork and/or participant observation. If a situation-specific theory was developed based on postempiricism. it can aim at opera- tionalization, measurements, and hypothesis testing. On the contrary, if a situation-specific theory originated with a phenomenological perspective, the theory may not he used to operationalize, measure, and/or test a hypothesis. Rather, the theory may aim at explaining and understanding the lived experience of human heings in the middle of the phenomenon.

In the discipline of nursing, many strate- gies for concept development and theory de- velopment have heen proposed. Tlie concept development strategies proposed and used in nursing include the Wilsonian method,^''^^ the Walker and Avant approach,'*' " Rogers' evolutionary concept analysis method/^ the Hybrid method,'^ and the simultaneous analy- sis method."** Many strategies for developing a theory have been also proposed, and used as ^ .̂11 M),ii.n,2.V24 Rojgersand Knafl̂ ^ asserted that these currently existing concept and the- ory development strategies for grand theo- ries and middle-range theories do not ade- quately consider that the theory development process, specifically the concept develo[5- ment process, is evolutionary', and that there is no step-by-step recipe for developing a theory.

The view of Rodgers and Knafl assumes that concepts are formed by the identification of characteristics common to a class of ob- jects or phenomena and the abstraction and clustering of these characteristics, which is influenced heavily by socialization and pub- lic interaction.^^"^ This view assumes that, because these contextual factors vary, there will he variations in concepts over time or across situations. Currently, most nursing the- orists and scholars agree that the theory de- velopment process is a continuous, dynamic, and evolutionary' process influenced by con-

texts surrounding the theory development process.""^^ This is somewhat problematic in pnictical applications to nursing practice and research, however. It is easy to under- stand in an abstract way, but in reality, the assumption that theory development is evo- lutionary, not algorithmic and linear, poses a potential contradiction because a theory might evolve away from the specific time, place, and population for which it was orig- inally conceived. Since situation-specific the- ories are limited to a specific population and a particular nursing phenomenon/situation, which, in turn, limits the contexts (eg, time, place, situation) for theory applications, the theor>' development process becomes more feasible and easily applicable to nursing prac- tice and research even in light of the evo- lutionary nature of theory development."" C^ionsequently. with the specificity and easy applicability of situation-specific theories, nurses may produce better nursing care out- comes than with other types of theories that do not limit the time, nursing situations, or nursing clients.

THE INTEGRATIVE APPROACH

In the integrative approach, the conceptu- alization and theorizing processes can happen all at once, or they might take years and never quite evolve into a useful integrated view of reality.'" Yet, to provide a convenient guide- line, in this section, the process of the integra- tive approach to the development of situation- specific theories is proposed step by step. This process may not happen subsequently or in a continuous way. Rather, some steps of the process would he skipped, while oth- ers could happen repetitively. The steps sug- gested in this paper are actually what nursing researchers and practitioners have frequently used in their research projects and practice without recognition. Based on an in-depth re- view of the literature published witliin the past 5 years, the steps used in the devel- opment of situation-specific theories in the literature are summarized and proposed as

Development of Situation-specific Theories 141

Checking assumptions for theory development

• Multiple truths • Evolutionary nature of theo • Sociopolitical contextuality • Nursing perspectives

ry development

Exploring the phenomenon through multiple sources

• Currently existing nursing i • Literature review • Experiences and findings fr • Collaborative efforts

nd non-nursing theories

om research, education, and practice

Theorizing

• Initiation • Process • Integration

Reporting, sha

ring, and validating

Figure 2. An integrative approach to situation-specific theories.

follows. The process of the integrative ap- proach is also summarized in Figure 2.

Checking assumptions for theory development

A theorist who wants to develop a situation-specific theory needs to check her or his assumptions for theory development first. The assumptions for the development of situation-specific theories include (a) mul- tiple truths: ib) evolutionary nature of theory development; (c) sociopolitical contextuality: and id) nursing perspectives. These assump- tions are the basis for the whole theory development process of situation-specific theories. If a theorist does not agree with tiiese assumptiotis, she or he may need to reconsider if she or he really wants to develop

a situation-specific theory. For example, if her or his assumption for theory development is hased on the universality of health/illness experience, she or he might not aim at the development of a situation-specific theory because a situation-specific theory assumes multiple truths, which negates the univer- sality of health/iliness experience. Rather, she or he needs to aim at developing a grand theory or a middle-range theory.

Multiple truths

Under the influences of positivism and sci- entism, nursing phenomena have been con- sidered to be universal phenomena which can occur to any racial, cultural, and gender groups in the same way.̂ ^ •̂ ' Thtis, most nutT»- ing theories have also assumed that nursing

142 AiWANCES IN NURSING SCIENCE/APRIL-JUNE 2005

phenomena arc universal and homogeneous, and traditional approaches to knowledge de- velopment depend on the assumptions of universality, homogeneity, and normality. ̂ ^ Yet nursing phenomenon are becoming more complex and are complicated by multiple factors, including the increasing diversity of nursing clients.- '̂' A consensus has developed among nurse scholars recently in which theo- retical deveiopmem must take into considera- tion the diversity and complexity of nursing phenomena. ̂ '*"̂ ' Without doing so, the the- oretical foundation of the nursing discipline cannot achieve the connections for which nursing has been striving.

As posited in the paper by Im and Meleis,'*' the development of situation-specific theo- ries assumes philosophical, theoretical, and methodological plurality, which is more con- gruent with the nature and goals of nurs- ing and which can incorporate the diversity and complexity of nursing phenomenon. The philosophical bases of the substance and syn- tax of nursing knowledge have been debated by many nursing scholars.•̂ *̂ ''~" Meieis'^ di- vided the philosophical positions of nursing scholars into three: (a) the purist position; (&) the radical sepanitionist position; and (c) the nonpurist position. The bona fide purist position claims that a philosophical viewpoint should guide aiid direct theory development, research strategy, and clini- cal practice.'" The radical separationist po- sition asserts that a discipline s theory and research are distinct entities and do not nec- essarily have to be congruent pbilosophically and methodologically.'" The nonpurist posi- tion takes a philosophical, theoretical, and methodological pluralistic position.'"' Tlie project to develop situation-specific theories assumes this nonpurist philosophical position as well as the existence of multiple truths, not one universal scientific truth.

Evolutionary nature of theory dei'eiopment

Another assumption for the development of situation-specific theories is that the the-

ory development process is cyclic and evolu- tionary. As discussed above, a concept which is currently regarded as a norm or a stan- dard may not be a norm or a standard in the future.^^ In other words, the integrity or stability of that norm through time can- not be predicted or ensured. Concepts are formed by the identification of characteris- tics common to a class of objects or phe- nomena and the abstraction and clustering of these characteristics.'^'' Therefore, as charac- teristics of nursing phenomena change, con- cepts also change. A concept which is not considered as important now can evolve into an important concept in future nursing. c:on- sequently. a situation-specific theory which is developed for a particular population in a spe- cific situation will not be appropriate for the same population in a different time or a differ- ent sociopolitical context. Thus, the situation- specific theory for the same population in the same situation also needs to be changed with changes in time and sociopolitical contexts.

Sociopolitical contextuality

A third assumption for the development of situation-specific theories is the sociopoliti- cal contextuality of nursing phenomena. The current theory development process involved in the development of grand theories and middle-range theories rarely considers the so- ciopolitical, cultural, and/or historic contexts inlierent to each ciient-nurse encounter.^^ Rather than accounting for the contextual- ity of nursing phenomenon, they usually try to reduce the phenomenon into several cen- tral concepts; operationalize and measure the concepts; explore/test the concepts and con- structs tiirougli quantitative and qualitative data collections; and refine the theories."'*' Consequently, they frequently aim at theories that can be applicable to all nursing fields and explain central concepts across the fields. Since situation-specific theories are limited to a specific population and/or a particular area of interest, the theories can easily incorpo- rate the contextuality of the phenomenon."" Indeed, the development of situation-specific

Development of Situation-specific Theories 143

theories assumes that nursing phenomena or client-nurse encounters happen in sociopo- litical contexts, that sociopolitical contexts need to be incorporated in the theory devel- opment process, and that the theories can- not be always applicable to any historical moment, any .social stnictiire, or any political situation.

Nursing perspectives

An essential assumption for the develop- ment of situation-specific theories is that they are based on nursing perspectives. Nurs- ing perspectives give a unique view on a phenomenon. When we view a same phe- nomenon with two different perspectives, the phenomenon described by each of the two different perspectives may be different from each other. For example, when we view Asian American cancer patients' lack of pain reporting using a biological perspective, we may focus on the physiological characteris- tics of Asian Americans without considering their whole beings in the contexts of their daily lives. Consequently, we may assume that Asian Americans' lack of pain reporting is a simple biological difference from otber eth- nic groups, which may lead us to look for basic biological difference between the etb- nic groups. When we view the same phe- nomenon (lack of pain reporting) from a nurs- ing perspective, we may view the patients' bio-psycho-socio-cultural beings within the contexts of their daily lives. Rather than focus- ing on inter-ethnic biological differences, we may focus on how their psycho-socio-culmral contexts circumscribe their pain experience and how we could provide adequate pain management while considering their unique pain experience.

In the development of situation- specific theories, a nursing perspective is mandatory."' The theories developed without a nursing perspective might distort the descriptions of nursing phenomenon and mislead nursing research and/or practice. Yet more than one nursing perspective exists.'^ A nursing perspective may he based on biomedical models; it may also be based on

feminist perspectives emphasizing sociopo- litical environments and reflecting oppressed groups' interests (mostly women's). In either case, it should also reflect nurses' concerns, views, values, and attitudes.

Exploring through multiple sources

After checking assumptions for her or his theory development, a theorist needs to explore her or his phenomenon of inter- est through multiple sources. Tlie multiple sources may include: (a) currently existing nursing and non-nursing theories related to the phenomenon of interest; ib) literature re- views, (c) fmdings and experiences from re- search, education, and practice, and {d) col- laborative efforts. Theorists usually use more than one of these sources for theory devel- opment at the same time. Each source is dis- cussed in detail as follows.

Currently existing nursing and nonnursing theories

Nursing and non-nursing conceptual mod- els, grand theories, and middle-range theo- ries can serve as the foundation for the devel- opment of situation-specific theories. From the early days of nursing theory develop- ment, theory derivation has been prevalent in nursing," Usually, theory derivation in nursing has been done by using analogy to obtain explanations or predictions ahout a phenomenon in nursing from the explana- tions or predictions in another field including medicine, psychology, sociology, and public health.'' Recently, theories from nursing have been combined with those from other dis- ciplines to create middle-range theories.""^ In the development of situation-specific the- ories, both nursing and/or non-nursing tbeo- ries may provide tbe basis for analogy for ex- planations, understandings, or predictions of a particular situation of a specific population of interest as well.

An example is the above mentioned theory of menopausal transition of Korean immigrant women,"" which was devel- oped based on a middle-range theory of

144 ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2005

transition.^^ In tbe development of the situation-specific theory, major research questions were set based on the middle-range tbeory of transition. Then, each concept was explored tlirough both quantitative and qual- itative findings from a study on menopausal transition of Korean immigrant women. Based on the findltigs related to the concepts, the theoty of transition was modified, and further developed as a situatioti-specific tbeory for metiopaitsal tratisition of Korean immigrant women. Compared with the middle-range tbeory of transition, tbe situation-specific tbeory of menopausal transition of Korean immigrant women has increased specificity of tbe conceptualization and is easily applica- ble to the situation through the modifications based on actual study findings.

Literature reviews

Ati extensive review of literature can pro- vide a systematic analysis of currently exist- ing knowledge about a nursing phenomenon and frequently provide an excellent source for theory development.'"" In tbis paper, the literature review means a review of pre- vious research findings, tbeoretical work, and statistical governmental reports. Indeed, tbe literature review has been an essential basis tor concept development and theory develop- ment. Walker and Avant'' included literature synthesis as a method of concept synthesis and suggested that theory synthesis incorpo- rate published research literature, direct sta- tistical information, and qualitative research as the second step of three phases of tbeory development.

Many examples of theory development through literature review can be easily found in tbe nursing literature. An example would be tbe tnmsition tbeory by Schumacher and Meleis-̂ -̂ who conducted an extensive litera- ture review on all types of transitions in nurs- ing and proposed a theoretical framework of transitions. Based on the atialysis of tbe liter- ature, they proposed a set of major concepts related to transitions, wbich include types of transitions, properties of transitions, transi-

tion conditions, and nursing therapeutics. Al- tbough this example of the transition theory aims to be a middle-range tbeory, the review of tbe literature as a source of theory develojv ment can be easily iticorporated into tbe inte- grative approach, hi addition, a literature re- view frequently provides a starting point for theory development by giving us a picture of the state of the science in the area and ini- tiating our theoretical thinking on the major and/or central concept(s) in tbe nursing pbe- nomenon in question.'' Hulme-̂ ^ provided an excellent example of an integrative literature review on currently existing grand, middle- range, and situation-specific theories related to health problems of adttlts who experienced cbildhood sexual abuse.

Findings and experiences from researcb, education, and practice

Findings and experiences from research projects, educational programs, and/or clin- ical practice in hospital and/or community settings can provide a source tor theoreti- cal development. Most nursing theories tend to be initiated by tbe tbeorists' experiences from their long clinical, academic, or research experience in nursing.'^ Tbeorists can eas- ily raise theoretical questions from tbeir own experience. Kirkevold^^ posited tbat integra- tive nursing researcb experience has great po- tential for clarifying tbe theoretical perspec- tive and substance of the nursitig di.scipline, as well as making research-based knowledge more accessible to clinical nurses. Lyonŝ ** ar- gued tbat nursing can generate a knowledge base tbrough reflecting on nurses' own expe- rience. Reed^̂ mentioned that her tbeory of self-transcendence was developed using clin- ical experience and empirical investigations.

Collaborative efforts

International and interdisciplinary collab- orative efforts may provide sources for the development of situation-specific tbeories as well. To be specific to a situation and/or a population, such a theory sometimes needs to iticorporate a more detailed and exact source

Dei'etopment of Situation-specific Theories 145

for theory development. Collaborative efforts allow comparisons of ideas, scholarly dia- logues, and an integration of different and/or disperse opinions and findings.^" Experts in different areas of nursing who are working on tbe same nursing phenomenon will give dif- ferent and new views/visions on nursing phe- nomena which cannot be easily obtained by independent work by one person. For exam- ple, when a collaborative team is working to- gether on midlife women's menopausal expe- rience, a nurse whose expertise is physiology can provide a different view on menopausal experience from a nurse anthropologist or a nurse feminist. Iti terms of tbeoretical de- velopment, the theory will be a nursing tbe- ory. but it will be based on diverse views on metiopause.

(x)llaborations between academics and clinicians can also provide a source for the- ory development, wbich will provide a strong link between theory and practice. Gassner et al.̂ ^ proposed a model devised by tbe project team, including fVnir academics and six clinicians, and concluded that the model was effective in facilitating tbe collaborative relationships necessary for successful devel- opment and implementation of reality-based learning for nursing students. Collaboration witb research participants can also provide an excellent source of theory development.*" Taking the lead in identifying areas of practice for action research is a natural extension of nurses' role as advocates for nursing clients, and it may provide a new view of the research participants."'

International collaborative efforts also can provide an excellent source for tbeory devel- opment, especially for situation-specific tbe- ories, because such theories tieed to pro- vide blueprints for nursing practice with a specific population that can be usually cat- egorized along ethnic/cultural lines. Walker and Avant" even envision tbat international efforts of nursing tbeory development will strengthen nursing knowledge and theory development by incorporating different per- spectives/views from different cultural back- grounds. International collaboration can give

a new view on everything from tbe philoso- phy of life, accepted behaviors, and butnan relations to tbe way in whicb people Uve.̂ '"*^ Recent advances in computer and commu- nication technologies may facilitate interna- tional collaboration tlirougli electronic net- works more easily than in the past, and we will see more and more international collabo- rative woriis in theoretical nursing."*^

Theorizing Initiation

Wbile exploring the pbenomenon of inter- est through multiple sources, a theorist may initiate ber or his theory development with a simple literature review on a specific nurs- ing pbenomenon of ber or his interests, from her or his own research, atid/or from ber or bis practice experiences even before the re- view of tbe literature. Tbeory development can start from a motber theory and result in a modified form of the theory, wbich is more specific to tbe population of her or bis interest or to the nursing situation. The- ory development can be initiated by a single person or a group of colleagues who bave been involved in the same area of interests. Recently, some tbeories bave been even de- veloped tbrough international or interdisci- plinary collaboration."'*'"''" Tbeory develop- ment in the integrative approacb may be initi- ated from one source or multiple sources at a time or at separate time points.

Process

Developing a situation-specific theory can take place through a theorizing process in several different ways. Although few nursing theorists claim to have developed situation- specific tbeories, many theories in nursing meet the definition of situation-specific the- ories. Tbe following examples sbow tbat the process involved in the development of situation-specific tbeories can be diverse. These examples were searched using tbe PUBMED database. For the PUBMED search, key words including nursing, theory, and the- ory developtnent were used, and only the

146 ADVANCES IN NURSINC; SCIENCE/APRIL-JUNE 2005

A qualitative exploratory study using focus group discussions; Research findings

Conceptualization of empowennent and theorizing

Validation through interviews with clients

3. The process involved in the development ofthe theoretical work hy FiiJk-Rafacl.

articles publisbed in Englisb during the past 5 years were searcbed in order to capture the current trends in nursing theory develop- ment. From the 215 articles retrieved through the search, tutorials, editorials, and literature review articles were excluded. Then, all tbe articles were reviewed in order to identify' the process used in theory development. Among them, otily the articles presenting situation- specific theories were selected for this paper.

One of tbe examples is tbe theoretical work by Falk-Rafael̂ ' (see Fig 3). Her theoretical work sbows a unique type of process for the- ory development. She initiated her theoretical work tbrough a qualitative exploratory study. Sbe began the study by using a nominal group tecbnique in a series of focus groups witb public health nurses to identify their con- ceptualization of empowerment, the strate- gies tbey identified as empowering, and the outcomes of empowering strategies tbey ob- served in their practice. Based on tbe quali-

tative study, she then initiated the theorizing process and developed a model that concep- tualized empowerment as a process of evolv- ing consciousness in which increasing aware- ness, knowledge, and skills interacted with the clients' active participation to move to- ward actualizing potential. Finally, tbe devel- oped model was shared and validated tbrough interviews with clients whom nurses identi- fied as having been empowered tbrough their practice.

Recent nursing literature notes a type of tbeory development tbat integrates the- ory, research and practice. For example, LaCoursiere's theory of online social support (see Fig 4) was developed with an integrated framework tbat iticorporates knowledge from multiple sources including (a) a conceptual literature review of existing frameworks and research findings related to social support, online comtnunications, and the effect of the Internet or the Web; (&) reports and statistics

Literature review Reports and statistics

Theorizing

Experience with communities

Figure 4. The process involved in the development of the theoretical work by LaCoursiere.

Development of Situation-specific Tbeories 147

Literature review Two models related to heaith behaviors

Research studies among Mexican migrant tarm

workers

Figure S< The process involved in the development of the theoretical woric by Poss.

from agencies and organizations focusing on tbe online bealth care experience; and (c) the author's experiences w îtb online social sup- port communities over a number of years. Tbis type of tbeorizing can be easily found in nursing.

Anotber example of this type of theoriz- ing is Poss's model for cross-cultural researcb among Mexican migrant workers in tubercu- losis screening tests (see Fig 5). **' In tbe tbeo- retical work, tbe model was developed based on a literature review, two models tbat are of- ten used to study bealtb bebaviors (the Healtb Belief Model and the Theory of Reasoned Ac- tion), and previous researcb studies among Mexican migrant farm workers participating in a tuberculosis screening program.

The tbeory development process of situation-specific tbeories can also be found in the development of tbe integrative model

for environmental health research by Dixon and Dixon (see Fig 6)."*'' Tlie tbeorists devel- oped the tbeory based on their experiences in botb academic and activist communities relative to environmental health and a review of the research literature. Tben, a working hypothesis that may be useful in guiding investigations or suggesting needed policies was extracted and used in tbeir researcb on tbe engagement in environmental healtb issues at the individual and community levels.

Integration

Wbile initiating and proceeding theorizing process based on explorations of nursing pbe- nomenon through multiple sources, a theo- rist can integrate her or his analysis, discovery, formulation, and evaluation through concep- tual schemes, reflexivity, and documentation.

Experience in academics

. " • •

I . . .

Experience in activist communities

Literature review

1 r

Theorizing and e.xtracting a working hypothesis

Research on the engagement in environmental health issues at the individual and community levels

•

. The process involved in the development of the theoretical work by Dixon and Dixon.

148 ADVANCES IN NtjRSiNG SCJENCE/APRIL-JUNE 2005

Tbe integration process tbat a tbeorist can adopt includes several different components. From existing nursing and non-nursing the- ories, a theorist may start with broad estab- lished facts, principles, laws, or theories that are known and generally accepted as true and u.se them to address narrower yet related phenomena, concepts/variables, and propo- sitions. A tbeorist may start from her or his experience in researcb, education, practice, research findings, or literature review with smaller, narrower concepts/variables and for- mulates new propositiotis that may ultimately lead to tbe development of new facts, prin- ciples, laws, and theories. A theorist may also formulate potential propositiotis based on personal and nursing knowledge, skills, values, meanings, and experience and not on empirically-based evidence or facts. Altbtjugb distinctively different, these ways of integra- tion may combine. Furthermore, these inte- gration processes can happen for a long pe- riod of time, and a tbeorist might go tbrougb several waves of integration through her or his researcb projects and practice in clinical settings.

In these integration efforts, conceptual schemes witb beginning hunches can be instrumental."' Conceptual schemes can be initiated, developed, and refined throughout tbe theory deveiopment process. The most important part of the conceptual schemes is internal and external dialogues. "̂ "'̂ Through conceptital thinking, memo-writing, and journal-writing, a theorist can initiate and maintain her or his internal dialogues so tbat her or his theorizing process can be further organized, refined, and integrated.'^ In addi- tion, a theorist may initiate and maintain an external dialogue tbrougb discussions with colleagues, research members, students, and research participants and tbrougb participa- tion in seminars, conferetices, and/or panel discussions. In both ways, the theorist can develop and refine ber or his conceptual schemes that are related to the nursing phenomenon of her or his interests and can integrate various theorizing processes.

Reflectivity is also instrumental in tbe pro- cess of integration. Situation-specific tbeo-

ries consider social, cultuml, and historical contexts, but tbeir scope and the questions are limited to specific situations and/or spe- cific populations.'''-^" Therefore, in the de- velopment of situation-specific theories, con- siderations of social, cultural, and historical contexts should be incorporated from tbe be- ginning stage ofthe thcor>' development pro- cess, which requires reflectivity' of tbe theo- rists. Sufficient reflectivity to uncover what may be deep-seated but poorly recognized views on the specific situations and/or the specific populations central to the tbeory de- velopment and a full account of the theorists' views, thinking, and conduct cati belp the theorist's integration of her or his theorizing processes. '̂

Tbe theorists also need to be reflective about tbeir own values aiid meanings re- lated to specific situations and/or specific populations. Values arc enduring beliefs, at- tributes, or ideals that establisb moral and eth- ical boundaries of wbat is right and wrong in thought, judgment, character, attitude, and bebavior."*** Tbus, values form a foundation for correct thinking and decision making throughout the theorist's life; values develop over time and reflect individual, family, so- cial, cultural, and religious influences as well as personal choice.'** Tbits, during tbe inte- gration process, a theorist needs to be re- flective on their own meanings attached to the specific situations and/or the specific populations.

Documentation of all stages involved in tbe theory deveiopment process can be in- stmmentai in integration efforts. As situation- specific tbeories empbasize contextuality and reflectivity in tbe process of tbeory develop- ment, tbe theoretical and analytic decision trails created by the tbeorists during the development process need to be ascertained as well.'^ Theorists may continually ques- tion their conceptualization and tiieorizing, critiquing each step of the development process and the impact of the theories within their social and political environment. Tbis process needs to be well documented through tbeoretical diaries and/or memos, so tbat the documentation supports tbe

Development of Situation-specific Tbeories 149

integration of the tbeory development process. '̂ Systematically documenting the ra- tionale, outcome, and evaluation of all actions related to theory development is an impor- tant component of the deveiopment of the situation-specific theories.' This documen- tation will result in well-grounded, cogent, justifiable, relevant, and meaningful theory deveiopment processes and outcomes.

Reporting, sharing, and validating

Wiien tbe documenting of theorizing and integration takes the form of a manuscript, a model, or a researcb report, these need to be reported and shared with nursing com- munities. Nurse theorists bave emphasized reporting and sharing of their work.^'^ Tlie criteria for theory evaluation that have been proposed and used in nursing usually include social utility and/or contagiousness as an im- portant criterion.'^ ''" Tbrough reporting and sbaring, theory development may be con- stnictively critiqued by peers, and theoretical products can be further developed.

Tbe validation of theories by nursing clients can also enbance the efforts to de- veiop a tbeory. Tlie reievance of an approach needs to be reflected from tbe very beginning of the process. Here, relevance means that a nursing tbeory can serve nursing clients' own issues and interests in improving tbeir lives.*- To ensure relevance, situatioti-specific theories may be checked with nursing clients in the specific situation and/or witb the par- ticular population througli a member valida- tion process, and tbeorists always need to be reflective about nursing clients' own views, needs, and interests throughout the theory development process. Wlien nursing clients perceive a theory to be representative of their real experience, the theorized modei is more easily applicable to the nursing pbenomenon

that the cUents are experiencing, which sub- sequently improves understanding and nurs- ing care outcomes.

CONCLUSIONS

In this article, an integrative approacb to the development of situation-specific theories is proposed. This proposition is an extension of a suggested outline of the integrative ap- proach previously drawn by Im and Meieis.'^ Tlie proposed integrative approacb describes tbe development process of situation-specific tbeories that aim to produce ready-to wear- theories and tbat ultimately aim to link better nursing care outcomes through their speci- ficity and diversity'. None of tbe steps/stages in tbe proposed approacb is entirely new to nurses, whetber they are clinicians, the- orists, or researchers.'^ Nurses may be in- volved in the tbeory development process in many ways, and we can see tbe growing ac- ceptance of theory development as a signif- icant aspect of knowledge development in

Theory development cannot grow in isolation.'" Tbe integrative approacb pro- posed in tbis paper needs more discussion, constnictive criticism, and feedback from researchers, practitioners, and tbeorists alike. The integrative approach should not be limited only to tbe proposed process. As knowledge and technology in nursing advance, we may see different types and processes of theory development in nursing in the near future." As we keep in mind that tbeory development process is dynamic, cyclic, and changing over time, we need to continue to welcome the changes and remain open to tbe potential growth of theoretical nursing for better nursing care outcomes.

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