Theories provide a way of understanding the world and serve to describe, explain, predict, or control phenomena. A widely accepted definition of theory is that it is an organized set of concepts that explains a phenomenon or set of phenomena (American Psychological Association, 2009). Theories can be categorized based on their level of abstraction as grand theories, middle range theories, and micro-level theories (Smith & Liehr, 2008). There are many theoretical understandings that psychiatric-mental health advanced practice registered nurses (
The literature is replete with theories that inform therapeutic interventions in psychiatric-mental health disciplinary practices, including psychodynamic, biological, social psychological, behavioral, cognitive, humanistic, and change theories. These theories have influenced nursing knowledge development and professional practice in psychiatric-mental health nursing.
The most well-known psychodynamic theory is that of psychoanalysis proposed by Sigmund Freud. Many of the assumptions of this theoretical perspective serve as the foundation for psychodynamic theories. Freud’s students, Carl Jung and Alfred Adler, developed their psychodynamic theories based on their work with Freud. Others who developed psychodynamic theories included Karen Horney and Erich Fromm. The basic psychodynamic understanding is that there are conscious and unconscious mental processes that influence thoughts and behavior. The goal in therapy is to develop understanding of the unconscious mental processes and use this understanding to address mental health issues. Many of the concepts in psychodynamic theories are used in psychiatric-mental health nursing practice. These are the concepts of defense mechanisms, transference, and countertransference.
Several cognitive theories have influenced the development of psychiatric-mental health nursing; many of these are used to guide professional practice and research. Examples include the theories of Bandura (1963, 1977), who is well known for his work on self-efficacy, a theory that also permeates the work of other social scientists; and Beck (1997), best known within nursing for his theoretical and empirical work on depression and the development of measures of depression and hopelessness. Cognitive theories as a group are focused on understanding that human behavior is guided primarily by thought processes. Thus, cognitive therapy is focused on helping individuals understand and change their thought processes in order to change their behavior. Cognitive therapy is often combined with a behavioral approach. One of the therapies commonly used by
Behavioral theories stem from the early work of Pavlov (1927), who studied the stimulus-response cycle and explained human behavior from this perspective. In particular, Pavlov focused on classical conditioning, in which he demonstrated a direct connection between thought processes and physiological responses. Other early behavioral theorists are Thorndike (1916), who developed a learning theory focused primarily on a problem-solving approach, and Skinner (1935), who described the stimulus-response model of learning. Both of these behavioral theories have influenced the science and professional practice of nursing. The problem-solving approach is foundational to the nursing process as well as to much of the
There are a number of theories in the literature that are based on the psychosocial perspective. Theoretical perspectives that have influenced the development of the psychiatric-mental health field across disciplines and professions can be categorized in a variety of ways, depending on the understandings of the core concepts and the guiding principles of the theories.
Most of these theories can be understood to have psychosocial dimensions, including theories that can be classified as development, interpersonal, and humanistic. Some of the most influential theoretical perspectives on the development of
Developmental theories are focused on stages of human development over time, often sequentially. The theory of Erik Erikson (1963, 1968) is most widely used in nursing and adds the cultural dimension to an understanding of the psychosocial aspects of development. Erikson delineated stages of development that were age-based, each characterized by conflicts. He framed these as trust versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, identity versus role diffusion, intimacy versus isolation, generativity versus stagnation, and ego integrity versus despair. Much of the work of crisis theory is framed from Erikson’s theoretical perspectives along with their psychodynamic roots. According to Erikson, successful resolution of a crisis within the stages of development leads one to develop more resources for future crisis resolution.
The interpersonal theory and work of Harry Stack Sullivan (1953) has influenced nursing theory and professional practice, as has the work of Peplau (1952), among others. Sullivan’s theory is based on the understanding of personality as energy, which can be manifest as tensions or transformations. Sullivan also referred to behavior as dynamic. Sullivan was particularly interested in interpersonal relationships as a basis for understanding all of human behavior. He attributed health and illness to the ways in which one interacted with others. Sullivan also attributed one’s image of self, that is, self-esteem, to one’s relationships with others, particularly in the formative years. He described seven stages of development, which suggests that his theory has much in common with other developmental theories that see self-esteem as core to understanding human behavior. The stages of development were described as infancy, childhood, juvenile era, preadolescence, early adolescence, late adolescence, and adulthood. Furthermore, Sullivan pioneered the notion of the participant observer in therapy, a concept and technique that permeates much of the
Humanistic theories and therapies are rooted in an understanding of human potential for goodness and a focus on the positive. Two humanistic theories that are predominant in
Carl Rogers’s (1980) theory and therapy also have resonated with
Selye’s (1956) theory and research on the physiological responses to stress, and the description of the adaptation responses of the individual, including at the cellular level as well as at the system level, have received much attention in the nursing literature. Selye described the fight-or-flight mechanism within the general adaptation syndrome. He noted three stages within adaptation: the alarm reaction, resistance, and exhaustion. The adaptation model developed for nursing by Roy (1980) and the Stuart Stress Adaptation Model (Stuart, 2008) specific to psychiatric nursing are examples of nursing theories that have a strong biological emphasis, as they are built on the core concept of stress found in Selye’s work. However, both of these nursing models have also incorporated other dimensions, reflecting the holistic meta-theoretical perspective of nursing.
General systems theory, sometimes referred to as
Martha Rogers (1970) was one of the first nurse theorists who presented a model of holism within nursing; she viewed persons as open systems, in continuous interaction with, and continuously exchanging energy with, the environment. For Rogers, the whole is greater than the sum of the parts; thus, this conceptualization is particularly suited to an integrative approach to psychiatric-mental health nursing practice. According to Rogers, persons move through the life process in a pattern that is constantly evolving. Rogers delineated three principles that postulate the direction of unitary human development: resonancy, helicy, and integrality. There is considerable research based on Rogers’s model, and a number of new theoretical perspectives were derived from the Rogerian conceptualization. Furthermore, several authors have described the applications to professional practice (Hemphill & Quillin, 2005).
Betty Neuman’s systems model is also consistent with an integrative approach within psychiatric-mental health nursing. Within the Neuman systems model, persons are viewed as clients and a wellness perspective is emphasized (Neuman, 1989). Neuman proposed that the client or client system is a dynamic composite of the interrelationships among physiological, psychological, sociocultural, developmental, spiritual, and basic structure variables. Thus, this is a holistic view of persons, but differs from Rogers’s (1970) view that the whole cannot be understood by considering the parts. There is considerable research and professional practice derived from the Neuman systems model, and several nursing education programs use this model to guide their curricula (Walker, 2005).
There are several change theories that have been applied to explain health and illness behaviors in general, and mental health in particular. Two of the most prominent change theories are the theory of reasoned action and planned behavior (Azjen, 1991) and the Stages of Change Model (Prochaska & Velicer, 1997).
This theory has guided considerable research in nursing, particularly as related to attitude and behavior change. Azjen’s (1991) theoretical premise is that the intention to change determines behavior change. In order for an individual to change behavior, there must be a positive attitude toward the behavior. Furthermore, the influence of the individual’s social environment is important, that is, the normative factors in one’s environment. Thus, the beliefs of one’s peers are particularly important in shaping one’s own beliefs and attitudes. According to this theory, it is also important that the individual perceive that he or she has control over the desired behavior, and the resources and skills to perform the behavior. This theoretical understanding is similar to the concept of self-efficacy that is central to the social learning theory developed by Bandura (1963). Bandura’s theory has been used extensively to guide nursing research.
The Transtheoretical Model of Behavior Change is sometimes referred to as the Stages of Change Model or simply by the acronym
Precontemplation—At this stage, the individual is not aware that his or her actions are problematic and thus is not likely to take action.
Contemplation—The individual has the beginning awareness that the behavior is causing a problem, and starts to consider the pros and cons of the problematic behavior.
Preparation—The individual intends to take action in the immediate future, and may take small steps toward change in this stage.
Action—The individual takes explicit action to change the problematic behavior, and positive changes occur as a result.
Maintenance—The individual actively works to prevent relapse; this stage lasts as long as the problematic behavior no longer occurs.
Termination—The individual has no temptation to return to the problematic behavior and is confident that he or she will not return to the problematic behavior (Prochaska & Velicer, 1997).
Not all of the six stages are included in all of the versions of
There are several processes of change embedded in the
Several components of the
The
Hildegard Peplau is considered the founder of psychiatric nursing. She developed her theory of interpersonal relationships in the early 1950s, and published her classic book, Interpersonal Relations in Nursing, in 1952. According to Peplau, the person is a developing self-system composed of biochemical, physiological, and interpersonal characteristics and needs (Peplau, 1992). Anxiety was an important concept within Peplau’s understanding of persons. She proposed that anxiety is produced when the individual is threatened in some way, and the nursing role is to assist persons to understand that anxiety and learn new behaviors to use the anxiety to effect a positive outcome (Peplau, 1963). The nurse develops a therapeutic interpersonal relationship with patients in order to help them learn and change. Peplau’s work has been traced to the influence of Harry Stack Sullivan and other theorists who emphasized the interpersonal process as the core concept. In addition to her theoretical contributions, Peplau also developed the first graduate-level psychiatric nursing program, and prepared the early specialists in psychiatric-mental health nursing. Peplau described six roles for the nurse: stranger, resource person, teacher, leader, surrogate, and counselor. She also delineated the sequence of the interpersonal nursing process as including four phases of development: orientation, identification, exploitation, and resolution. For Peplau, communication, both verbal and nonverbal, was a cornerstone of therapeutic work. Overall, Peplau’s influence on the field of psychiatric-mental health nursing specifically, and of nursing more generally, is legendary.
Gail Stuart has proposed the Stuart Stress Adaptation Model to guide psychiatric-mental health nursing practice (Stuart, 2008). In this model, she integrates knowledge from the biological, psychological, sociocultural, environmental, and legal-ethical theoretical perspectives. Underlying this model are five basic assumptions: (a) nature is ordered in a social hierarchy that goes from the simplest unit to the most complex; (b) nursing care is provided within a biological, psychological, sociocultural, environmental, and legal-ethical context; (c) health/illness and adaptation/maladaptation are two distinct continuums, and health/illness has its roots in the medical model, whereas adaptation/maladaptation comes from a nursing worldview; (d) primary, secondary, and tertiary levels of prevention are included by describing four distinct levels of treatment: crisis, acute, maintenance, and health promotion; and (e) the model is based on the nursing process and the standards of care and professional performance for psychiatric nurses (Stuart, 2008, pp. 44–45).
Theory and research are the two core components of science. Theory may be used to guide research through a deductive process, or research may be used to generate theory through an inductive process. Many examples of the relationship between theory and research can be found in the psychiatric-mental health nursing advanced practice literature. These studies have been related to the theories in other disciplines from which some of the nursing theories have been derived, and also specifically to the nursing theories, including those particular to psychiatric-mental health nursing such as the theory of Peplau.
Beeber (1996, 1998), for example, has described the treatment of depression through the use of the therapeutic nurse–patient relationship model described by Peplau. Peden (1993) also used Peplau’s model to guide her research on women with depression. And Forchuk and colleagues have conducted a number of studies of the therapeutic process according to the stages outlined by Peplau (Forchuk, 1992, 1994; Forchuk et al., 1998). Fawcett and Giangrande (2001) detailed the substantial research undertaken based on the Neuman systems model. Malinski (1986) has described the research related to Martha Rogers: Science of Unitary Human Beings.
Another area of research that demonstrates the integration of theory and professional practice, and builds on the integrative perspective in psychiatric-mental health nursing, is that of resilience. There are several nurse researchers exploring this concept. The early theoretical work of Polk (1997) to develop a middle range theory of resilience in nursing, the historical review of the concept presented by Tusaie and Dyer (2004), and the further theoretical and methodological work of Zauszniewski and Bekhet (2010) set the stage for future scientific work for a perspective that builds holistic understandings and provides a foundation for integrated interventions. Recently, there has been a renewed interest in extending the theoretical understandings of resilience within nursing, for both providers and recipients of care. Building on the work of Earvolino-Ramirez (2007), Garcia-Dia and O’Flaherty (2016) presented a concept analysis of resilience in nursing, particularly as related to the nurse provider.
Other recent theoretical developments that have relevance to advanced practice psychiatric-mental health nursing include the explication of middle range theories of meaning (Stark, 2014) and self-transcendence (Reed, 2014). These theorists have updated their prior work and provided additional implications for nursing research and practice. Further explications regarding nursing theoretical understandings are evidenced in the work of Jones (2014) on interpersonal nursing theory, Heffernan (2014) on caring theory, DiNapoli and colleagues (2014) on self-transcendence theory, and Weathers (2014) on the theory of meaning. Each of these theories is focused on specific applications to nursing research and practice, and each can be used to further develop theoretical understandings underlying advanced practice psychiatric-mental health nursing.
Additional conceptual development work applicable to advanced practice psychiatric-mental health nursing has also been completed. Murphy and O’Donovan (2016) have explored the concept of hope in mental health recovery, Weathers (2016) has delineated the relevance of the concept of meaning in life, and Matthes (2016) has further described the concept of mindfulness, particularly from the provider perspective.
Research is one form of evidence that can be used to guide clinical practice. The discovery processes that guide research and evidence-based practice are similar, and thus, at times, there is a lack of clarity about which process is being applied. Both processes, for example, require a sourcing of the literature, as well as a synthesis of what is known about a phenomenon and what needs to be discovered. While research is based on the review of the scientific literature, evidence-based practice takes into account other sources of knowledge, including expert clinical knowledge.
The steps in the research process include identification and explication of the problem for study, identification of the purpose of the study, review of the scientific literature (including theoretical and research literature), delineation of the research method to be used to address the problem, implementation of the research methodology, presentation and discussion of findings, and interpretations based on the previous literature.
The four basic steps in the evidence-based practice process are: (a) converting the information needed into an answerable question; (b) finding the best evidence; (c) appraising the search results for validity and usefulness; and (d) applying the findings to clinical practice. The basic goals of evidence-based practice are to reduce variations in care that is provided, increase the cost-effectiveness of care, lead to efficient and effective decision making, and improve interventions and patient outcomes.
The
P =
Who is the patient population?
I =
What is the potential intervention or area of interest?
C =
Is there a comparison intervention or control group?
O =
What is the desired outcome?
These questions guide professionals in designing evidence-based practice projects that are directly relevant to the persons being cared for at that point in time. Furthermore, several levels of evidence are accessed in using any evidence-based practice model and the clinician must evaluate the evidence before application to practice. Cochrane Reviews (which are primarily focused on research that includes randomized clinical trials) are considered the highest level of evidence. Other systematic reviews are the next level of evidence, followed by other research evidence, such as that from single-site studies in which the methodology might be questioned. Evidence garnered from expert clinical practice should also weigh into the evidence-based practice applications.
Although it is important to emphasize the empirical research according to the methods described, it is also important to consider other sources of evidence, particularly within a professional discipline, such as nursing. Fawcett, Watson, Neuman, Walker, and Fitzpatrick (2001) argue for using a model that includes all of the evidence gathered from the ways of knowing delineated by Carper (1978), in her seminal work on ways of knowing in nursing. Carper described the personal, ethical, and aesthetic ways of knowing in addition to the empirical way of knowing. Too often in evidence-based practice, these other ways of knowing are not fully addressed or are dismissed in preference for empirical knowing. Within an integrative practice model, multiple ways of knowing and interacting are encouraged. Thus, the psychiatric-mental health nurse practicing from a holistic perspective would have an inclusive approach in evaluating the evidence.
While there are a number of theoretical perspectives that have influenced the development of nursing theory and professional practice, the emphasis on nursing science, including theory development and research, holds the most promise for the further development of
A wide range of opportunities exist for psychiatric nurses, especially in advanced practice and particularly in demonstrating the positive results of the integrative approach to mental health care that is so essential to individuals, families, groups, and communities. The expectation is that both the science and the professional practice will expand, and that the leaders and practitioners in psychiatric-mental health nursing will chart the course for holistic interventions for generations to come.
