24 years ago while completing the first baccalaureate nursing degree program offered in Tanzania, East Africa at Muhimbili University of Health and Allied Sciences (MUHAS); I sat in a nursing theory class trying to grasp concepts and principles that shape nursing as a professional discipline (i.e. the grand and middle range nursing theories and models). Surprisingly, most of the concepts I learned mirror concepts I have since encountered in my academic career as a graduate student and nurse scholar. For instance, self-care concepts in chronic disease management mirror concepts in Orem’s self-care theory; concepts in interprofessional models mirror concepts in nursing interpersonal and interactional theories (e.g. Imogene King’s theory and Peplau’s theory); Systems thinking concepts mirror concepts in Roy’s conceptual model and Betty Neumann’s conceptual model; concepts in psychotherapeutic approaches mirror concepts in the nursing humanistic theories (e.g. relational and caring concepts) and concepts in the acculturation theories (e.g. Gordon’s theory, John Berry’s theory) mirror those in Leininger’s cultural care theory. These are just a few examples on how rich nursing theoretical underpinnings play a key role guiding health care actions and outcomes in addition to the medical disease-centered perspective. In this case, I think we need to strategically revisit the existing models, refine and adapt them to our changing health care environments as well as develop new approaches and educational models that have an impact on health outcomes of interest.
This critical reflective query originates from a quote I read in the 2010 Institute of Medicine Future of Nursing: Focus on Nursing Education Research Brief stating that, “New approaches and educational models must be developed to respond to burgeoning information in the field. For example, fundamental concepts that can be applied across all settings and in different situations need to be taught, rather than requiring rote memorization” (p2). This statement made me think further: Have we adequately synthesized the existing key concepts and principles? Is it time to re-visit the nursing metaparadigm concepts? What new concepts do we need to develop and how can we develop them? Which concepts and principles of the disciplines should we teach in undergraduate vs graduate nursing programs to avoid rote memorization? Are we at risk of re-inventing wheels of nursing knowledge? Have we been instrumental in advancing implementation science to promote “empirical and practical generalizability” of nursing theories and models?
A memorable photo of the burn patient I cared for in the surgical ward.
Let me flashback on my personal educational and career journey to make the case: I was trained to understand and embrace the art and science of nursing within the realities of closing my own personal knowledge gap on nursing theory (didactic), research and practice. My first taste of nursing knowledge application and development started when I was assigned to take care of a burn patient for my clinical case study assignment during my medical-surgical clinical rotation. As a BSN prepared student, the ‘why” of what we do as nurses was emphasized. In this case, the nursing action of “turning and repositioning patients every two hours to prevent pressure sores” opened new insights on my nursing knowledge application beyond just doing a task. I was intrigued by the Braden scale for predicting pressure sores risk developed by Drs. Barbara Braden and Nancy Bergstrom from a conceptual schema that attributed key determinants of pressure ulcers from current evidence–intensity and duration, tissues tolerance of the skin, and supporting structure or pressure (Braden & Bergstrom, 1987). I continued my inquiry by completing my fourth year BSN capstone project on the topic of pressure sores in the medical and surgical population. Moreover, as part of my training, I was introduced to a course on principles of teaching and learning in our curriculum. Nursing students were expected to learn how to write up a philosophy in teaching, practice and research. Learning about philosophy helped me appreciate the importance of nursing values, beliefs, the different ways of knowing and different approaches to nursing education and practice that continue to shape our discipline to this day. I can truly attest to Bruce, Reitz and Lim’s (2014) statement that: “Philosophy is not only understood as relevant but vital to our discipline and professional practice (p. 70).
Completing my Carnegie African Diaspora Fellowship (CADFP) at MUHAS in 2017. Top: Group photo with nursing students and faculty at the MUHAS scientific conference
Later, as part of my graduate studies, I was exposed to concept analysis methods and how to evaluate and apply theories/models to a problem of interest. My graduate education provided me with a great foundation in nursing knowledge grounded within the health promotion and preventive care paradigms at the individual, family, population, community and systems levels of practice (i.e., MS Community/Public Health Clinical Nurse Specialist, MS and PhD in Family Science (focus on Family Life Education and Consultation). Armed with this knowledge, I was successful in completing a concept analysis paper in my nursing theory class (Eustace & Ilagan, 2010), evaluated the family socio-ecological theory for my family theory class, and applied Berry’s acculturation theory in my doctoral dissertation to study acculturative stress (Eustace, 2007, 2010). Additionally, I learned how to appreciate the difference between conceptualization and operationalization of variables (concepts) across studies and disciplines.
Group photo with nursing students enrolled in the community/public health course. Invited guest lecture to teach concepts and principles of health promotion theories and models.
Overall, this knowledge has been instrumental in my nursing career as a nurse educator and scholar. I continue to learn and try to understand key concepts of interest to further my research agenda in the field of family nursing and how it impacts chronic disease prevention and risk reduction outcomes: “HIV/AIDS family interventions” (Eustace, 2013), “family health nursing intervention” (Eustace, Gray & Curry, 2015), “male involvement” (Eustace, 2018) and “family nursing” (Eustace, in press). I am currently in the process of conceptualizing a “Family Health Strength-Based Socio-Ecological Model of Breast Cancer in Sub-Saharan Africa” (Eustace, Nyamhanga & Lee, 2018) to guide my international collaborative research agenda. This model is grounded in the theoretical foundations for nursing of families: the Bioecological systems theory (Bronfenbrenner & Lerner, 2004) and Strength based-nursing (SBN) approach (Gottlieb & Gottlieb, 2017).
An inspirational reunion with my undergraduate dean and mentor –a pioneer of the BSN program in Tanzania, Professor Pauline P. Mella, (middle) with her sponsor Dr Eileen Stuart-Shor at the 2016 American Academy of Nursing Conference
Along the way, I must give credit to my professors early on in my nursing career as well as faculty mentors and external reviewers who have inspired me in the utilization of nursing theories and the process of theorizing nursing knowledge. I wish all nursing students today are exposed to these kind of learning and critical reflective discovery opportunities in their undergraduate or graduate studies. Similarly, I wish junior and mid-level career nurses interested in nursing theories and the process of theorizing nursing knowledge have access to qualified educators and mentors.
Therefore, the following question remains to be answered: As a community of nurse scholars and practitioners, how are we strategic in building our capacity to meet the demands of developing a generation of nurses who will advance nursing knowledge as part of the future of nursing? We need a well-trained and competent nurse educator and mentor workforce that is capable of offering the next generation of nurses (i.e., LPNs, RNs, DNPs, PhDs) and nursing paraprofessionals (e.g., nursing assistants, community health workers, and traditional attendants) the opportunity to learn and translate nursing knowledge that will impact health outcomes of interest. For example, a nursing workforce with expertise in theory who will teach nursing theory and serve on dissertation and doctoral project committees, nursing research grant applications and nursing practice committees. If that were to happen, we will need proactive and revolutionary nurse scholars and leaders to lead the way in the areas of nursing education, nursing research, evidence based-practice, and policy-making as part of the future of nursing.
Food for thought: Why don’t we have clear standards to measure how nursing theoretical concepts and principles are integrated into nursing program curricula as part of our accreditation systems, as part of magnets status applications, and as part of nursing research agenda? Will taking this “backward step (to revisit our standards) as a way forward” be asking for too much from our leaders? Should we do this? How should we do this? If we should not do this, why not? I welcome readers of nursology.net to reflect and share their thoughts on these epistemological issues and practical challenges in the comments section of this blog.
Braden, B., & Bergstrom, N. (1987). A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing, 12(1), 8-16.
Bronfenbrenner, U. & Lerner, R. M. (EdS.) (2004). Making human beings human: Biological perspective on human development. Thousand Oaks, CA: Sage Publications.
Bruce, A., Rietze, L., & Lim, A. (2014). Understanding Philosophy in a Nurse’s World: What, Where and Why? Nursing and Health, 2(3), 65-71. doi: 10.13189/nh.2014.020302
Eustace, R.W (in press). Family Nursing. Macmillan Encyclopedia of Families, Marriages, and Intimate Relationships,
Eustace, R.W. (2018) Male Involvement: An Evolving Global Cross-Cultural Concept inFamily-Centered Health Care. NCFR Report, Family Focus: Families and Cultural Intersections, p 4.
Eustace, R. W. (2010). Factors Influencing Acculturative Stress among International Students: From the International Students’ Perspectives. Germany: VDM Verlag Dr. Muller Aktiengesellschaft & Co. KG.
Eustace, R. W. (2007). Factors influencing acculturative stress among international students in the United States (Doctoral dissertation, Kansas State University).
Eustace, R. W. (2013). A discussion of HIV/AIDS family interventions: implications for family‐focused nursing practice. Journal of Advanced Nursing, 69(7), 1660-1672.
Eustace, R.W. (1994). The prevalence of pressure sores in the Medical surgical patients at Muhimbili Medical Center (Undergraduate Research Report). Muhimbili University of Health and Allied Sciences.
Eustace, R.W, Gray, B. & Curry. D. (2015). The meaning of family nursing intervention: what do acute care nurses think? Research and theory for nursing practice, 29(2), 125.
Eustace, R. W., & Ilagan, P. R. (2010). HIV disclosure among HIV positive individuals: a concept analysis. Journal of Advanced Nursing, 66(9), 2094-2103.
Eustace, R. W., Nyamhanga, T. Lee, E. (2018). A Discussion of Social Determinants of Breast Cancer among Women in Tanzania: Advantages, Gaps and Future Directions in Family Scholarship. The 2018 Annual NCFR Conference, San Diego, California, November 7-10, 2018
Gottlieb, L. N., & Gottlieb, B. (2017). Strengths-Based Nursing: A Process for Implementing a Philosophy into Practice. Journal of family nursing, 23(3), 319-340.
Institute of Medicine (US). Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. (2010). The future of nursing: Focus on nursing education. Washington, DC: National Academies Press. http://www.nationalacademies.org/hmd/ ~/media/ Files/Report %20Files/2010/The-Future-of-Nursing/Nursing%20Education %202010%20Brief.pdf