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Describe the internal and external criticism used to assess middle-range theories.

Describe the internal and external criticism used to assess middle-range theories.

Describe the internal and external criticism used to assess middle-range theories.
QUESTION
It is critical to determine whether a theory can be adapted for use in research. Describe the internal and external criticism used to assess middle-range theories.

ANSWER
Nursing theories have traditionally taken the form of rules, beliefs, and customs (Chinn and Kramer, 2004), with no questioning of routine practice. As a result, the experienced nurse was evaluated based on a combination of a caring attitude and some technical skills gained through hospital-based practice (Lasiuk and Ferguson, 2005). Furthermore, the nursing discipline relied on a few theories borrowed from other disciplines [ibid]. Nonetheless, a significant revolution in the discipline occurred in 1965, when the American Nurses Association formally declared theory development as the profession’s goal (Meleis, 1997). A few years after this declaration, grand theories and conceptual models were published, which served as the theoretical foundations of nursing programs.

The purpose of this essay is to apply a nursing theory to a phenomenon that has piqued my interest in my clinical practice. It will begin with a case study from my practice and will be followed by a critical reflection on Carper’s epistemological patterns in nursing. The essay will then proceed with a brief review of the literature on the main concepts identified in the reflection. Kolcaba’s Comfort Theory will then be described, analyzed, and applied to my practice area (surgical setting). Finally, the essay will conclude with my thoughts on this nursing theory.

CARPER’S KNOWING PATTERNS FOR CRITICAL REFLECTION
According to Carper (1978, 1992), knowledge can be acquired in four ways: aesthetically, personally, empirically, and ethically.

According to Carper (1978), aesthetics is the perception gained from observing an event at a specific time. At its most developed, aesthetics is the ability to understand a situation and act without much thought (Slevin, 2003). I approached Baba Musah because I could tell there was something more to it than postoperative pain. This is what Polanyi (1966) refers to as tacit knowledge, or what Benner (1984) refers to as intuitive expert practitioner; it is the knowing that cannot be explained. I then introduced myself and assured him that everything was private. I went on to ask him about his problems. As he began to speak, he began to cry, but I supported and comforted him. Following that, he relaxed and resumed his narration. I inquired about his issues because he appeared distressed and helpless. I had no idea that this could make someone cry. Regardless, it compelled me to sit by his bedside and investigate his condition further.

The incident taught me that people react differently in different situations. I felt guilty at first because I thought my efforts had exacerbated his problem. Furthermore, I was unsure how I would communicate with Baba in order to provide him with the support and comfort he required. For Baba Musah, I hoped he felt I was of assistance and that he could put his trust in me. The nurses I worked with were clearly pleased with the outcome of the intervention, as evidenced by their facial and verbal expressions. It’s difficult for me to say how Baba felt in the situation, but he later expressed his gratitude to me. I could tell he was upset at first, but after the conversation, he appeared relaxed and comfortable in bed.

Personal knowledge is the awareness of oneself and others during a conversation (Carper, 1978, 1992). I was surprised and uneasy at first when dealing with his tears. This is because men in Ghanaian culture do not typically cry in public. As a result, I was perplexed and had no idea what was going on. This viewpoint is shared by Zborowski (1952), who proposed that people hold certain pain beliefs based on their socialization culture. Regardless, I expressed empathy and care for Baba because of my own personal experiences with pain during a trauma. This is also consistent with the findings of a survey that found that care-providers’ previous pain experiences influence their attitudes toward others in pain (Brunier, Carson, and Harrison 1995; O’ Brien, S., Dalton, J., Konsler, G., and Carlson, 1996). Experienced oncology nurses’ knowledge and attitude toward the management of cancer-related pain. 515-521 in Oncology Nursing Forum 23. O’Brien, Dalton, Konsler, and others, 1996). Baba was embarrassed to be crying in public after the incident, but I assured him that he would be fine.

The factual and impersonal knowledge gained from principles, laws, theories, and science is referred to as empirical knowledge. Carpenter (1978, 1992) Baba Musah was evaluated and managed in accordance with hospital protocol for postoperative patients. As a result, his vital signs were monitored on a regular basis until stabilisation was achieved. Pain medication (intravenous pethidine) was administered as needed based on the pain score. I reflected on the importance of communication as a therapeutic tool in the absence of significant improvement in his condition. This influenced me to approach him and find out what was causing his pain. We talked about how to deal with his current concerns after we explored them. Baba was taught about the disease’s progression, treatment, and outcomes. Following the interaction, subsequent assessments revealed that the pain had improved and the vital signs had remained stable.

Ethical knowledge entails making rational and moral judgments about what is right and wrong (Carper, 1978, 1992). Baba Musah was treated with dignity and respect by using his title, attending to his needs, and giving him the privacy he requested. Regardless, some of the ethical issues that arise concern nurses’ right or wrongfulness in turning away from a patient in pain in order to attend to other patients who also require care. Another ethical quandary raised by this case study is the provision of adequate information prior to an emergent operation to reduce the fear of unknown outcomes. However, after assessing the patient, this conundrum can be successfully resolved.

CONCEPTS
Pain management, communication, and comfort are some of the key concepts that emerge from this reflection. Morris (1991) defines pain management as the reduction of an individual’s pain to an acceptable level. Communication is a two-way process of conveying information using both verbal and nonverbal means (Arnold and Boggs, 1995; Balzer-Riley, 1996). According to Slater (1985), comfort is a pleasant state of physiological, psychological, and physical harmony between a person and their surroundings.

The therapeutic nurse-patient relationship is essential for effective pain management (Briggs, 1995). This implies that effective pain management requires effective communication. Patients become more comfortable as their pain is effectively managed. From the concepts listed above, I will select comfort as the main concept because it is a broader construct that includes pain management. Furthermore, through communication, nurses become aware of the patient’s comfort.

For many years, various authors have defined comfort from various points of view. Some regard it as an essential factor for patients (Nightingale, 1859), while others regard it as the primary concern of nursing (Harmer, 1926). Although the term “comfort” is implied in these descriptions, it is clear that it is the primary focus of nursing. Thus, Harmer (1926) emphasizes the importance of providing care in a comfortable environment.

Comfort is regarded as an important nursing action and responsibility (Morse, 1983). (Van Blarcom, 1953). As a result, nurses are evaluated based on their ability to make their patients feel at ease (Goodnow, 1935). As a result, the American Nurses Association (1987) emphasized the importance of maintaining a patient’s dignity and comfort until death. Without a doubt, nurses are the most effective people in providing comfort to patients (Funk and Tornquist, 1989). However, comfort is a subjective state that is best determined by the patient (Richards, 1980; Paterson and Zderad, 1988). Furthermore, the goal of comfort aids individuals in achieving a state of well-being (Gropper, 1992).

Comfort can be used as a noun, verb, adjective, or gerund in relation to a process or an outcome. However, in nursing practice, the term is defined as a state of satisfaction following stressful health care conditions (Kolcaba, 1994). The controversies surrounding this contested concept have revealed that the concept of “comfort is multi-dimensional, meaning different things to different people” (Hamilton, 1985: 32). Personally, I define comfort as the fulfillment of needs, expectations, or desires that, when received, motivates an individual to feel good.

THE COMFORT THEORY IS DESCRIBED.
Theoretical Background
Katharine Kolcaba began developing her theory during her master’s program in nursing (MSN) and finished it over a ten-year period while pursuing her doctorate degree. She received her PhD from Case Western University in 1997 and published a book on Comfort Theory in 2003. Induction, concept analysis, deduction, and retroduction were used to develop the theory of comfort (Kolcaba, 2003).

Kolcaba incorporated comfort into her dementia care framework during the inductive stage. She spent two years analyzing comfort and came up with three types of comfort (relief, ease and renewal). This was later modified to produce the current taxonomic structure of comfort, which defines comfort as the state of meeting needs for relief, ease, and transcendence in physical, psychospiritual, environmental, and sociocultural contexts (Kolcaba 1991).

Comfort was linked to other nursing concepts during the deductive stage to produce a theory. Murray’s (1938) work provided a framework for incorporating Kolcaba’s nursing concepts, whereas the three types of comfort were derived from other nursing theorists’ work. Orlando (1961) identified relief, Henderson (1966) identified ease, and Paterson and Zderad identified transcendence (1976). Schlotfeldt’s concept of health seeking behaviors (HSBs) was also adopted (1975). Kolcaba incorporated the concept of institutional integrity into her middle range theory of comfort during the retroductive stage (Kolcaba, 2003). Comfort theory describes individualised patient care and predicts the benefits of continuous comfort measures, comfort, and participation in health seeking behaviors (Kolcaba, 2003).

Ideas and Propositions
The theory of comfort describes major concepts such as comfort needs, comfort measures, intervening variables, comfort, health seeking behaviors, and institutional integrity. Comfort requirements arise as a result of stressful health-care situations that cannot be met by a patient’s support system. Nursing measures are designed to meet these needs while taking into account patient factors such as past experience, age, attitude, emotional state, support system, and finances (Kolcaba 1994).

Comfort is a multifaceted experience that can be provided in physical, psychospiritual, environmental, and sociocultural contexts (Kolcaba, 1994; Kolcaba and Fox,1999). Kolcaba (2001) defines three types of comfort as follows: relief as meeting a specific health care need, ease as a state of steadiness or happiness, and transcendence as rising above life’s challenges.

The table below depicts the comfort needs I identified using Kolcaba’s (1991) taxonomic structure and my case study.

Staff and significant others must provide assistance. Information is required.

Health seeking behaviors refer to the outcomes that occur when comfort is achieved; these outcomes can be internal, external, or lead to a peaceful death (Schlotfeldt, 1975). Kolcaba (2001) defines institutional integrity as the entirety of an organization’s elements and expresses a recursive relationship between comfort and institutional integrity.

Important Assumptions
According to Kolcaba (2001), the metaparadigm concepts are as follows: Nursing is the systematic assessment of comfort needs prior to and following comfort interventions. A patient is a person, family, or community who requires comfort. The environment is defined as a patient’s external background that can be controlled to increase comfort. A patient’s health is his or her best performance.

According to Kolcaba (1994), the theory’s basic assumptions are as follows: comfort is a desired outcome; humans actively strive to meet their comfort needs; and patients are strengthened when their comfort needs are met.

ANALYSIS OF THE COMFORT THEORY
According to Barnum (1990), when analyzing a theory, the internal and external aspects should be considered; internal criticism pertains to the inner structure, while external criticism describes its peripheral relationship.

Internal Critique
Clarity: refers to how a theory is presented and how the reader understands it (Barnum, 1990). Aside from the difficult-to-read article on concept analysis (Dowd, 2006), the theory is well presented in the literature and is simple to grasp (Wilson, 2009). Kolcaba clearly presents the evolution of the theory for additional acknowledgement and comprehension (Wilson, 2009).

A consistent theory maintains consistency in its definitions, principles, and interpretations (Barnum, 1990). It is clear that the definitions of concepts, derivations, propositions, and assumptions are uniform throughout the literature (Wilson, 2009).

Adequacy: The theory’s concepts, propositions, and assumptions are nursing-specific and can be easily implemented in a variety of settings (Dowd, 2006; Wilson, 2009). The theory not only describes what nurses do, but it also takes into account outcomes that are important to patients, their health, and the integrity of institutions (Kolcaba, 1994; 2001; 2003). According to Wilson (2009), each type and context of comfort has been thoroughly explained and is relevant to the provision of care for any patient.

Logical development is determined by the coherence of arguments that leads to the conclusions of a theory (Barnum, 1990). Kolcaba thoroughly discusses the theory’s evolution in the literature (Wilson, 2009). Her findings are supported by detailed arguments (Wilson, 2009) and research conducted with appropriate tools such as visual analog scales, the Comfort Behaviour Checklist, and various questionnaires adapted from the General Comfort Questionnaire to suit the target population (Kolcaba, 2001).

Comfort theory conforms to the standards of a middle range due to its limited number of concepts and propositions, low degree of abstraction, and application in practice (Wilson, 2009). Some studies tested and supported the theory (Kolcaba and Fox, 1999; Dowd, Kolcaba, and Steiner, 2000), while others found little significance (Kolcaba, Schirm and Steiner, 2006).

External Criticism
The relationship between variables in a theory determines its complexity (Barnum, 1990). The theory’s six concepts are well related in a conceptual framework (Wilson, 2009), which facilitates its application in practice and research. The theory is straightforward, precise, and thoroughly explained (Dowd, 2006). As a result, nurses and nursing students can easily learn and apply it in practice (Panno, Kolcaba and Holder, 2000)

Discrimination: refers to a theory’s uniqueness in relation to a practice discipline (Barnum, 1990). The four contexts of comfort experience represent the holistic nature of nursing (Wilson, 2009). The theory is prevalent in the field of nursing, but it can be applied in a variety of settings (Dowd, 2006; Wilson, 2009). Regardless of the variations in its meaning, comfort has been defined as a desirable state and outcome (Kolcaba, 1994).

Describe the internal and external criticism used to assess middle-range theories.

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