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Nursing theory is the framework that guides nursing actions and it gives us a philosophy of what we believe (Watson, 1999). The theory consists of ideas that attempt to explain a relationship between different views, concepts, or ideas about something. The theoretical knowledge of nursing is not a new concept. It has a rich heritage emanating from the work of many nursing scholars of the past three decades. More than 140 years ago, Florence Nightingale, the first nursing theorist developed her environmental theory and documented what she believed to be the factors affecting health and wellness (Lynch, 2005, p. 4).

Nursing theories helps provide supportive, researched data that in turn helps to improve nursing practice through describing, predicting, and controlling of an occurrence (Watson, 1999). They interrelate nursing concepts in a way they create different ways of dealing with a particular phenomenon. Nursing theories use present or previous knowledge of nursing and the theories are used to describe, develop, and disseminate nursing knowledge (Watson, 1999). Descriptive theory recognizes components and properties of a discipline. The theory identifies the meaning and observes and describes the elements found in that discipline. They have become the cornerstone for understanding and guiding nursing practice in the current decade.

Nursing theorists affirm that this nursing theory offers guides practice, thus provides direction for conducting the research and it answers queries arising from practice. For theory to be useful, it must provide direction for and organization of knowledge deemed to be important to a discipline (Marriner-Tomey & Alligood, 2006). Thus, it is essential for any theory to give guidance for any research and practice. In a practice-based discipline such as nursing, reality is clinical practice and reality is consulted through research. In other words, theory provides knowledge about the world of clinical practice through research.

Theory, research, and practice are three key elements in any discipline practicing science. Nursing as a practice discipline calls for a close relationship between research, theory and practice, to achieve the underlying objective of practice- including promoting, enhancing, and facilitating the health care requirements of the individuals and the community. 

The relationship between nursing theory, research and practice has been defined to be mutually interdependent and interrelated (Marriner-Tomey & Alligood, 2006).  The explanation of this interdependent and interrelation is that a theory is born in practice, is developed through research and can and must go again to practice if research is to be but an exhausting energy from the nursing business and theory more than idle conjecture. Research therefore is the key to the development of a practice and forms the link between theory and the practice.

Theory, practice, and research, according to Lutjens and Horan (1992), can be pointed out as a cyclical process that defines how science of nursing Practice acts as the catalyst for the cycle, it involves asking of questions and derivation of hypotheses. Problems conceptualization is guided by the theory and thus researchable questions are generated; studies are designed by researchers that will refine or develop those and then the theories are tested by the practitioners. Research, then, is the vehicle that drives theory development. This is the method used to collect the needed data for the theory. This is a fact regardless whether the research was for the purpose of generating a theory or for testing one. When the research is conducted to generate a theory, the phenomenon of interest suggests the information to look for. On the other hand, if it were conducted for the purpose of testing a theory, it dictates the information to be gathered (Watson, 1999). For instance, if a theory suggests that emotional support that is provided by spouses is the best predictor of clients' adherence to nursing care plans, then the statistics to be gathered should include the extent of emotional support offered by spouses and the level to which clients stick to care plans.

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The relationship between theory and research is therefore reciprocal and mutually beneficial. Concepts and relationships validated empirically through research becomes the foundation for theory development. The theory, in turn must be tested by subjecting deductions from it to further systematic inquiry.  Thus research plays a continuing and a dual role in theory building and testing. Theory guides and generates ideas for research, whereas research assesses the worth of the theory and provides a foundation for new ideas. Practice should lead to theory, theory should lead to research, and research should lead back to practice. In other words, new theory generated from practice will lead to new knowledge for practice, and new knowledge presents new facts that encourage us to develop theories to explain these facts. Knowledge is of little use without understanding. Knowledge is acquired through research studies while understanding is gained by theory. This is a reciprocal relationship whereby knowledge can be increased for a time without understanding; however, understanding is not possible without new knowledge being developed.

Grand theories and middle range theories

Theory is defined as a system of ideas proposed to explain something (Peterson & Bredow, 2008). Theory helps to offer knowledge that will improve practice by describing, predicting, explaining, and controlling occurrence. It guides practice, education, and research and provides professional autonomy as knowledge is systematically developed, producing practices that are more likely to be successful. Different theories represent different worldviews, which are different ways of conceiving of knowledge. Theories are not discovered but they are created by individuals who think and see the world in different ways (Smith & Liehr, 2008, P. 7).

Theories differ in their scope and have been categorized as grand theories, middle age theories, and philosophies (Smith & Liehr, 2008). A grand theory is broad and complex and tends to be very general; grand theories are abstract but may provide insights useful for practice. They are conceptual and have concepts, definitions, and prepositions. They are created through the observations and insights of theorists. Middle range theory has a narrower focus and is derived from earlier works, such as philosophies and grand theories, or from works in other disciplines. Middle age theories may be refined through a series of studies, each providing an increased focus.

Grand theories attempt to create a view of the whole of nursing by addressing the nature, mission, and goals of nursing care in a general fashion (Peterson & Bredow, 2008, P. 29). The unstructured nature of grand or general theories allows a wide range of knowledge available to practitioners and scholars within the nursing-specific frame of reference. The benefits of grand theories include; acting as a guide for practice as an alternative to practicing solely by institution or tradition; a framework for education by suggesting a framework and structure for curricula; an aid to professionalization of nursing by providing a basis for practice. Grand theories also serve as a basis for development of the more specific theories of the middle and practice range, which can undergo empirical testing (Smith & Liehr, 2008, P. 7).

Compared to grand theories, middle range theories are less abstract (Peterson & Bredow, 2008, P. 29). They can be described as lying-in-between. Middle range theories compared to grand theories, have a narrow scope; they are concerned with less abstract, more specific phenomenon; they are composed of fewer concepts and propositions; they are more appropriate for empirical testing; and they are more applicable directly to practice for explanation and implementation.

There may also be an explicit relationship between some grand theories and middle range theories. Other middle range theories may not have such direct links to grand theories.

Leininger's Theory of Culture Care Diversity and Universality

The Leininger theory is set forth as a foundation basis for the primary care relative practice, educational preparation, and results-aimed research activities of highly developed nursing practices. This theory of Culture Care Diversity and Universality commenced from clinical experiences that recognized that culture, a holistic concept, was the link that was missing in the knowledge and practice of nursing. Through an ingenious process of concept explication, re-synthesis, and reformulation, the theory of cultural care was presented as a guide for the nursing knowledge development. According to theorist, cultural care provides the most important and the most extensive means of studying, explaining, and predicting the knowledge of nursing and concomitant nursing care practice. The theory's ultimate goal is to offer cultural harmonious nursing care practices. The author argues that one can explain and foresee health or well-being if he or she fully discovers the meanings, processes, and patterns of care.

The Culture Care Theory is founded on the basis that there are differences or diversities and universalities-similarities or commonalities in trans-cultural care awareness. Also, that the practices have anticipated discovery to set up a body that is growing and that which is appropriate to trans-cultural knowledge of nursing to act as a guide to nursing practices. Culture is defined as the learned symbolic or history of human and structural organization and those activities that humans do that makes them to be human; culture 'refers to patterned ways of life, principles, norms, values, symbols, and individuals, groups or societies practices that they have gained knowledge from, shared and regularly passed on inter-generationally over time'. Leininger described care as ideas or experience that are assistive, encouraging, and enabling toward others people with obvious or expected needs to improve or ameliorate a human life way care or their condition has cultural and figurative meanings, for example, care as protection, respect or presence' and that caring involves 'measures, attitudes, and practices to aid others toward healing and health.


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Leininger, explains an individual's health and caring behavior through underlining the meaning and importance of culture. She also states that caring is the core of nursing and unique to nursing. Leininger (1997) criticizes the four nursing meta-paradigm theory of person, nursing, health, and environment (Fawcett, 1989). First, he considers nursing a profession and a discipline, and thus the term 'nursing' cannot explain the nursing phenomenon. Instead, care has the greatest ontological and epistemic explanatory power to explain nursing. From Leininger (1995a) point of view is that 'caring' as the verb complements 'care' as a noun and refers it to a feeling of empathy, concern, and interest for people. Second, the term 'person' is culture-bound and very limited to explain nursing, as the concept of 'person' is not in existence in every culture. Leininger (1997) argues that nurses at times use the term 'person' when referring to families, groups, societies and collectivities, though each of the concepts has a different meaning from the term 'person'. Third, the 'health' concept is not distinct to nursing as used by many disciplines (Leininger, 1997). Fourth, Leininger uses the concept 'environmental context' instead of 'environment', which consists of events with meanings and interpretations given in particular physical, sociopolitical, ecological, or cultural settings.

Definition of Nursing according to Leininger

According to Leininger, nursing is a humanistic art and science learned and that which focuses upon personalized care functions, and behaviours, processes directed toward maintaining and promoting healthy behaviours and recovery from poor health that have social, psycho-cultural as well as physical implication or consequence for those being assisted either by a qualified nurse or one with similar professional qualifications and competency.

Margret Newman's Theory

Margret Newman extensive writing focuses on health as an expanding consciousness, a pattern of the whole, and the unitary transformative paradigm (Alligood & Ann, 2006). Margret Newman's nursing theory focuses on health as an expanding consciousness and on the relationships among the concepts of consciousness, movement, space, and time, as they interact as a pattern of the whole. Consequently, less emphasis is placed on the other commonly accepted concepts of nursing theories: person, environment, and nursing.  The theory of health as expanding consciousness was stirred by alarm for those individuals whose health as the absence of disease or disability is impossible (Alligood & Ann, 2006, P. 516). Often nurses relate to such people: people facing debilitation, uncertainty, loss, and ultimate death related with chronic illness. The theory has developed and to include the health of all people regardless of whether the disease is present or absent. The theory affirms that every individual in all situation, regardless of how hopeless and disordered it might appear, is an essential part of the expanding consciousness universal process- a process which persons become more of oneself, of discovering greater meaning in life, and of attaining new dimensions of connectedness with other persons and the world.

Nurses working within this perspective experience the pleasure of taking part in the expanding process of others and in the process their own lives are improved and transformed (Newman, 2000). Recognition of pattern is vital to both research and practice, which reflects a hermeneutic, dialectic praxis approach. The significance of time, space, and movement was part of the original elucidation and has resurfaced in the developing patterning of unfolding consciousness.

Newman's definition of Health

Newman's definition of health is the most developed of all her concepts. She defines as a pattern of evolving, expanding consciousness regardless of the form or direction it takes. She also defines manifest health as the health one manifests at any given time as the explication of the underlying pattern of person-environment interaction (Newman, 2000).

 Definition of person and environment

Newman describes person and environment within the context of the life process. Newman emphasizes open systems, pattern, wholeness, and space time reality as well as organization, rythmicity, and undirectionality (Newman, 2000). Person and environment are defined within the context of the life process as coextensive energy fields that evolve simultaneously, moving toward increasing complexity and diversity manifested by rhythmic patterns along the dimensions of space and time. Person is defined as consciousness, and individual is identified by his or her pattern.

Definition of nursing

 Newman's theory of health defined nursing practice as a process of mutual nurse-client interaction for the purpose of pattern identification and augmentation, and the essence of nursing practice as the expansion of consciousness (Newman, 2000). Newman focuses on the process of nursing assessment rather than on nursing intervention, stressing on the importance assessment nondirective and that involves the client as a co-participant in the process of pattern identification.

Rosemarie Rizzo Parse

Rosemarie Rizzo Parse, in the 1970s commenced her work on the Human Becoming theory and in 1981 the theory was first published. The theory was developed as a human science nursing theory. The hypothesis emphasizing the theory were synthesized from works done by the European philosophers, Merleau-Ponty, Sartre, and Heidegger, together with works of Martha Rogers, a pioneer American nurse theorist (Dossey & Keegan, 2009). The theory was founded on Dr. Parse's life knowledge in nursing & its poor fit with the existing paradigms.  The human becoming theory main focus is on the human-universe-health process and is founded on the basis that the humans pursue and create their own process of being with the world. The distinctiveness of this theory is the perspective it has on paradoxes of human becoming. The theory puts more emphasis on the relationship that exists between human and the environment with paradoxical rhythmical patterns. Through combing concepts from Martha Rogers and from existential-phenomenological thought, Rosemarie Rizzo Parse developed the Theory of Human Becoming basing her nine assumptions on three main themes of meaning, transcendence, and rhythmicity (Alligood & Ann, 2006, p. 438).

Each of the three themes leads to a principle: meaning relates to imagining, languaging , and valuing; transcendence relates to originating, transforming, and powering; rhythmicity relates to connecting-separating, enabling-limiting, and revealing-concealing. The principles and themes of -human becoming are infused by four postulates: mystery, freedom, paradox, and illimitability (Parse, 2007). MYSTERY "cannot be explained, that thing which cannot be entirely known" (p. 309). It is the unimaginable, indescribable, unknowable nature of the unpredictable, indivisible, ever-changing human universe (Parse, 2007, 2008). FREEDOM is "contextually interpreted as liberation" (p. 309). Humans are free to choose ways they want to be in their situations. PARADOX is "an obscure rhythm which is expressed in a pattern preference." Paradoxes are not "predicaments to be overcome or opposites to be acquiescent but, are rather the lived rhythms" (p. 309). ILLIMITABILITY is "the indivisible boundless knowing that extends to infinity, the all-at-once prospecting and recollection with the moment."

Rosemarie Rizzo Parse's definition of humans

The theory of Health as Human Becoming by Rosemarie Rizzo Parse forms a foundation for holistic nursing and it terms humans as synergistic beings and nursing as a method of supporting life's quality as perceived by the individual.

Rosemarie Rizzo Parse's definition of health

Parse suggests that health is a flowing process of human becoming. It is a synthesis of values and the way a person is, in interconnection with the world. Parse further defines health as 'a personal commitment lived through abiding with the struggles and joys of every day in a way that incarnates one's quality of life.

 Rosemarie Rizzo Parse's definition of person

Parse suggested that there are two world views in nursing; a summative paradigm in which the person is viewed as a combination of component parts-with the believe that the whole or the essence of the person is greater than the sum of the parts-and the simultaneity paradigm in which a person can be viewed as a unity; a person is a holistic energy field and cannot be broken down into parts. For parse, the only appropriate definition of the person is in terms of the unitary whole. According to his theory, it is impossible to view a person as having component parts e.g. psychological, social, biological and spiritual components-and that any discussion of a part is improper (Dossey & Keegan, 2009 119).

Rosemarie Rizzo Parse's definition of Nursing

According to Parse, nursing is a human science. The nursing responsibility to society relative to nursing practice is guiding in choosing of responsibilities in the changing health practice. The nursing practice is directed toward illuminating and mobilizing family interrelationship in light of the meaning assigned to health and possibilities as language in the correlated pattern of relation. The goal of nursing is to focus on man's qualitative participation with health experiences.

Applying Leininger's Theory of Culture Care Diversity and Universality

The Leininger's Theory of Culture Care Diversity and Universality is the most congruent with my beliefs. Leininger (1999) defined transcultural Nursing as An area of formal study and practice that focuses on comparison of diverse cultures, health, care, and illness patterns of each group, putting into consideration the diversities and similarities in their cultural practices, values, and beliefs with a goal of providing culturally congruent, competent, and sensitive health care to people of diverse cultures. He also pointed out the importance of transcultural nursing in the education of nursing students. Leininger (1999) emphasized the significance of a cultural approach in healthcare care; and recommended the integration of Transcultural Nursing concepts into Nursing Programs in providing culturally congruent, competent, and sensitive healthcare to people of diverse cultures (Ryan et al. 2000).

Nurses today are facing a world in which they are required to apply transculturally based nursing concepts and practices so as to care for patients from diverse cultures (Leininger, 1996). A care with cultural content prevents both the patient and the nurse from experiencing a cultural shock and it also enhances the healthcare service quality (Pinikahana et al., 2003).

Previous related studies on transcultural nursing show that the awareness of cultural distinctiveness has a positive influence on the nursing practice (Tanriverdi et al, 2009). Nevertheless, healthcare practitioners are well aware of the significance and value of transcultural nursing. In fact, the healthcare practitioners may have to attend to people whose worth judgments are totally different from theirs. People who migrate from their country of origin to another country bring with them beliefs and cultures about sickness, health and medical care that may be strange to local health care providers (Tanriverdi et al, 2009). Cultural diversities influence these patients' preferences about health care in ways that local nurses may consider unsuitable or even risky. Persons from a particular cultural tradition that differ from the prevailing culture may view the local medical practices as strange. In both cases, health care providers will be faced with the challenge of building a culture acceptable to the patients and obligatory to health care providers (Tanriverdi et al, 2009).

As a result of cultural disparity, the inclination of ethical care calls for different components (Tanriverdi et al, 2009). Nurses should be aware of, or be skillful so as to understand such disparity in beliefs about illness. Tanriverdi (2009) propose that the level of skills required for taking care of vulnerable populations should be incorporated in undergraduate nursing education.

To assist in recovery from an illness, health care providers need to be aware of and use patients' understanding of their illness while helping them to comply with the treatment at the same time (Dogan et al 2009). According to one American hospital nurse, one great problem that nurses encounters when attending foreign patients is caused by their lack of knowledge as regard culturally determined thoughts of illness and health, and inadequate adjustment of these patients to the American culture and hospitals (Dogan, et al 2009). The major one source of these problems was is the inadequate appreciation of other cultural and ethnic groups for, which has led to attitudes characterized by stereotyping, intolerance, utterances and behaviors highlighted by cultural prejudice and the transfer of guilt to alien patients (Dogan, et al 2009).

Living in a foreign nation with a dissimilar cultural orientation and lifestyle is a multifactor challenge for many immigrants (Ryan et al. 2000). For the people from dissimilar cultures to freely express their cultural value is a fundamental human right and this should be esteemed (Ryan et al., 2000). It is therefore inevitable that nurses are trained so as to have the adequate knowledge and the ability to apply it to provide transcultural nursing (Tanriverdi et al, 2009). It is also necessary to set some courses into the curricula of the nursing programs such as introduction to transcultural communication, sociology, multicultural psychology, anthropology, and other such courses with transcultural content (Ryan et al., 2000).

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