EVALUATION OF THE INTERNAL ELEMENTS OF MIDDLE-RANGE THEORY FOR NURSING IN CARDIOVASCULAR REHABILITATIONABSTRACT
Objective: To describe the process of evaluating the internal elements of the Middle-Range Theory for Nursing in Cardiovascular Rehabilitation.
Method: Methodological study with theoretical evaluation conducted through the Delphi consensus method, with the application of systematic criteria for evaluating substantive foundations, structural integrity, and functional adequacy. The experts' judgment was quantified by the Content Validity Coefficient, with descriptive interpretation of the results.
Results: The eleven analysts of the theory (5 experts, 4 proficient, and 2 competent ones), most of them PhDs from the Northeast and Southeast regions of Brazil, judged indicating that the value of the general Content Validity Coefficient of the theory was considered good (CVCt=0.82); the substantive foundations were excellent (average CVC=0.95); the structural integrity was good (average CVC=0.86); and the functional adequacy was deficient (average CVC=0.66).
Conclusion: The evaluation of the Middle-Range Theory for Nursing in Cardiovascular Rehabilitation points to internal validity based on its substantive foundations and structural integrity, which support anchoring in the nursing course, clarity and logic in the organization of concepts. Functional adequacy, considered deficient, is consistent with the current state of translation of theory into practice and research, being a criterion that emphasizes the quality and rigor of the analysis carried out by the judges.
DESCRIPTORS:
Nursing; Validation study; Nursing theory; Cardiovascular rehabilitation; Cardiovascular diseases
RESUMO
Objetivo: Descrever o processo de avaliação dos elementos internos da Teoria de Médio Alcance para Enfermagem em Reabilitação Cardiovascular.
Método: Estudo metodológico com avaliação teórica conduzido por método Delphi de consenso, com aplicação de critérios sistemáticos de avaliação de fundamentos substantivos, integridade estrutural e adequação funcional. O julgamento dos especialistas foi quantificado pelo Coeficiente de Validade de Conteúdo, com interpretação descritiva dos resultados.
Resultados: Os onze analistas da teoria (5 peritos, 4 proficientes e 2 competentes), a maioria doutores das Regiões Nordeste e Sudeste do Brasil, produziram juízo que indicou o valor do Coeficiente de Validade de Conteúdo geral da teoria considerado bom (CVCt=0,82); sendo ainda excelente os fundamentos substantivos (CVC médio=0,95), boa a integridade estrutural (CVC médio=0,86) e deficiente a adequação funcional (CVC médio=0,66).
Conclusão: A avaliação da Teoria de Médio Alcance para Enfermagem em Reabilitação Cardiovascular aponta para validade interna pelos fundamentos substantivos e integridade estrutural, o que suporta a ancoragem na disciplina da enfermagem, clareza e lógica na organização dos conceitos. A adequação funcional, considerada deficiente, é compatível com o atual estado de translação da teoria na prática e pesquisa, sendo critério que reforça a qualidade e o rigor da análise realizada pelos juízes.
DESCRITORES:
Enfermagem; Estudo de validação; Teoria de enfermagem; Reabilitação cardiovascular; Doenças cardiovasculares
RESUMEN
Objetivo: Describir el proceso de evaluación de los elementos internos de la Teoría de Rango Medio para Enfermería de Rehabilitación Cardiovascular.
Método: Estudio metodológico con evaluación teórica realizado mediante el método de consenso Delphi, con aplicación de criterios sistemáticos de evaluación de fundamentos sustantivos, integridad estructural y adecuación funcional. El juicio de los expertos fue cuantificado mediante el Coeficiente de Validez de Contenido, con interpretación descriptiva de los resultados.
Resultados: Los once analistas de la teoría (5 especialistas, 4 competentes y 2 proficientes), mayoría doctores de las regiones Nordeste y Sudeste de Brasil, produjeron un juzgamiento que indicó que el valor del Coeficiente de Validez de Contenido general de la teoría fue considerado bueno (CVCt=0,82); los fundamentos sustantivos fueron excelentes (CVC promedio=0,95), la integridad estructural fue buena (CVC promedio=0,86) y la adecuación funcional fue deficiente (CVC promedio=0,66).
Conclusión: La evaluación de la Teoría de Rango Medio para Enfermería de Rehabilitación Cardiovascular apunta a la validez interna por sus fundamentos sustantivos e integridad estructural, lo que apoya el anclaje en la disciplina enfermería, la claridad y la lógica en la organización de los conceptos. La adecuación funcional, considerada deficiente, es compatible con el estado actual de la traslación de la teoría a la práctica y a la investigación, siendo un criterio que refuerza la calidad y el rigor del análisis realizado por los jueces.
DESCRIPTORES:
Enfermería; Estudio de validación; Teoría de enfermería; Rehabilitación cardiovascular; Enfermedades cardiovasculares
INTRODUCTION
Cardiovascular Rehabilitation (CVR) is considered an adaptation process that must be implemented after a cardiovascular event, that is, following a pathophysiological condition that affects the cardiac system and promotes physical, social, psychological and spiritual changes, which may occur in the health-disease process environment1.
As CVR is a process that requires multidisciplinary action; thus, the nursing professional contributes to these patients’ rehabilitation, intervening so that clinical care can reduce the losses resulting from the cardiovascular event, in what regards the social, physical, psychological and spiritual context of the person, the family and other systems related to them. Therefore, clinical nursing care, directed at patients who require CVR, must be based on knowledge of the clinical situation presented, as well as on the basic nursing knowledge that supports professional action.
Regarding basic knowledge itself, theories have been a critical part since the initial stage of nursing as a scientific course. Nursing theorization incorporated the definition of the nature and characteristics of the person receiving nursing care, the professional goals or objectives, as well as the nurses’ intervention and role2.
In the hierarchical perspective of theories, it is commonly used in nursing science. Grand theories are the most abstract and broad, and mid-range theories are more concrete and capable of guiding nursing interventions3. The Middle-Range Theory for Nursing in Cardiovascular Rehabilitation (MRT Nur-CVR)1 was created based on evidence from the literature that provided empirical elements for mid-level theorization. It aims to support the nursing care process aimed at people after a cardiovascular event, with a view to physical, social, and psychological rehabilitation, enabling them to maintain daily activities.
Supposedly, the theoretical, descriptive, and explanatory structure of the MRT Nur-CVR and the level of theorization are facilitating elements, so that rehabilitative care goals are achieved1. However, it is essential to carry out a theoretical and clinical evaluation of this MRT, so that the adequacy of the theoretical properties can, in fact, be verified, from a metatheoretical perspective.
Judgments about good theory involve consideration of internal and external validity; the internal validity, commonly called “theory evaluation” in nursing, is related to intrinsic elements4. This theoretical evaluation can employ systematic, deliberative, criterion-based or subjective, experiential, and rapid criteria to decide which theory would be most appropriate for structuring teaching, research, and administration5. Thus, the internal validation of theory becomes a challenge for theorists and metatheorists in establishing good practices to carry it out, and, with that, obtain epistemological justification5.
Based on the perspective by the philosopher Abraham Kaplan, the evaluation of a theory refers to decisions about whether a given theory deserves to be published, taught and, above all, applied in research contexts or other conditions of use. Thus, for the author, the norms for this process can refer to norms of correspondence (semantics), coherence (syntactics), and functional (pragmatics)6.
Although there are different models for evaluating nursing theories, not all of them apply to middle-range theories. Of those available, the following stand out: Smith and Liehr7, for presenting a philosophical view consistent with that presented by Kaplan and being indicated with the characteristics of application in the evaluation of middle-range theories, organizing itself precisely in three categories: substantive foundations, structural integrity, and functional adequacy.
In this sense, the evaluation of a Middle-Range Theory (MRT) involves preparation, judgment, and justification to identify the strengths and limitations of the theory, and suggests specific recommendations for clarification, extension, or revision.
From this perspective, the question arises: how does the MRT Nur-CVR meet the substantive foundations of structural integrity and functional adequacy, as assessed by judges? Thus, the objective of this study was to describe the process of evaluating the internal elements of the Middle-Range Theory for Nursing in Cardiovascular Rehabilitation, according to Smith and Liehr’s criteria.
METHOD
This is a methodological study with theoretical evaluation, considering internal elements. The Middle-Range Theory for Nursing in Cardiovascular Rehabilitation (MRT Nur-CVR) is evaluated, according to Smith and Liehr’s criteria7: substantive foundations, structural integrity, and functional adequacy.
The evaluation of the MRT Nur-CVR was carried out by evaluators (judges), who were selected through the guideline proposed by Borel4, in which the Delphi method is applied to the evaluation of nursing theories, which takes place through three phases: the preparatory, the intermediate, and theory evaluation.4
In the preparatory phase, it was decided to evaluate the MRT Nur-CVR, considering the future purposes of application in research and clinical practice. Also, the evaluation strategy was established using the theoretical framework by Smith and Lierh7. The choice was made based on the philosophical vision congruent with the theoretical characteristics of the MRT Nur-CVR strategy. In addition, the evaluation strategy has comprehensive analysis categories that possibly reduce errors linked to the specificity of particular theories.
In the intermediate phase, nine procedures linked to the use of the Delphi method were applied, which are more detailed herein.
The first procedure concerns the selection of the type of Delphi to be used. In this study, the Delphi consensus was applied, which seeks to reach consensus on a given topic, aiming at reducing variability in estimates and minimizing biases among evaluating judges8.
The second procedure deals with the definition of the theoretical evaluation coordinator, which refers to a person from the theory development team, who can also accumulate the condition of primary evaluator, which occurred in this research. The other, secondary, evaluators were incorporated later to provide an opinion, acting as judges of the task carried out by the primary evaluator.
In the third procedure, candidates for evaluators/judges were located and selected, using searches and interactions in virtual environments. The search for electronic CVs on the Lattes platform of potential evaluators was modulated by location filters and delimitation of the evaluator: Brazilian, educational background in nursing theories, experience in the area of the theory to be evaluated, experience in the development of nursing theories, dissemination of knowledge on the topic of metatheories or nursing theories, and with recognized expertise in the topic of metatheories or nursing theories4. From May to August 2021, the search allowed the selection of 11 judges.
The selection of 11 judges followed the guidelines proposed by Borel⁷, considering the sum of individual points and the diversity of expertise levels. Although the minimum required was seven evaluators, a larger number was chosen to ensure adequate scoring, maintain the mixed composition, and prevent common losses in the Delphi method, strengthening results reliability.
In the fourth procedure, the candidates selected in the previous stage were invited, the first contact with the experts being by email, containing the invitation letter and the Free and Informed Consent Form (FICF).
The fifth procedure involved reapplication of the criteria for categorizing evaluators/judges by level of expertise, and adjustments to the composition of the teams, considering refusals to invitations to participate, as required4. It is important to note that, based on collective wisdom, teams of evaluators (judges) must have diverse levels of expertise, namely: beginner, advanced beginner, competent, proficient, and expert. To assess the judges' expertise, five domains were assessed: educational background in nursing theories; professional experience in the area of the theory; metatheoretical experience and knowledge; dissemination of knowledge produced on the topic of metatheories or nursing theories; and recognition of expertise on the topic of metatheories or nursing theories4.
The candidate for evaluator/judge had his/her level of expertise ranked according to the score obtained by the sum of the items in the five domains. The maximum score for each domain was 4 points and the minimum was 2. The evaluator who did not meet any of the criteria for a domain received a score of zero. The total score would range from 0 to 20, with 4 points being the minimum value arbitrated to consider the candidate suitable to be part of the theoretical evaluation team4.
In the sixth procedure, the number of rounds and interruption criteria were planned. The main criterion was to interrupt the Delphi rounds upon reaching consensus among participants. Given that consensus was reached in the first round, partly attributed to the lower level of abstraction and complexity of the theory, Delphi was interrupted in the aforementioned round.
In the seventh procedure, explicit criteria for discarding items in each round, such as the Smith and Lierh principles7, were followed. The evaluators were clear that the decision to exclude an item from the theory was driven by the selected strategy and not just by freely expressed personal opinions.
The eighth procedure includes defining the scope of consensus and the stability of responses. In this study, consensus was verified using the Content Validity Coefficient (CVC), using a Likert-type scale, with at least 80% equality of opinions.
As a ninth procedure, after accepting the invitation previously made, as well as signing the FICF, specific guidelines were provided regarding the theoretical evaluation strategy, so that the third phase of the guideline, theory evaluation, could begin as soon as possible. For this, some other documents were important for evaluating the theory: a) scientific article on the theory, object of analysis; and a Standard Operating Procedure (SOP) type document about the filling of the instrument.
The data collection instrument has two parts: Part I, related to the identification characteristics of the secondary evaluator; and Part II, containing the evaluation criteria by Smith and Liehr7: substantive foundations, structural integrity, and functional adequacy. It should be noted that this entire procedure was carried out via email.
In substantive foundations, there are questions about the meaning or semantic elements of the theory, with four main criteria related to substantive meaning: (1) whether the theory is within the focus of the nursing course; (2) whether the premises are specified and are congruent with the focus of the nursing course; (3) whether the theory provides substantive description, explanation, or interpretation of a named phenomenon at the intermediate level of discourse; and (4) whether the origins are rooted in research practice and experience7.
In structural integrity, there is the evaluation of four criteria related to the concept: (1) the concepts are clearly defined, (2) the concepts of the theory are at the intermediate level of abstraction, (3) there are no more concepts than necessary to explain the phenomenon, and (4) the concepts and relationships between them are represented logically by a model7.
Finally, in functional adequacy, the link between research and practice is assessed using five criteria: the theory can be applied to a variety of practice settings and client groups, empirical indicators have been identified for concepts in the theory, there are published examples of the use of the theory in practice, there are published examples of research related to the theory, and the theory has evolved through academic investigation7.
Data were obtained by applying an instrument completed using a Likert-type scale. The scale used was composed of five attributable points: I totally agree (value 5), I partially agree (value 4), I neither agree nor disagree (value 3), I partially disagree (value 2), I totally disagree (value 1). The total score was the sum of the points for each item. The consensus of the evaluated MRT was verified using the CVC. CVC values were calculated using the formula suggested by Hernandez-Nieto9 (Figure 1). The calculation considered the average of the experts' scores, divided by the maximum score on the scale, adjusted for a bias factor, calculated as 1 divided by the number of experts raised to the number of experts itself. The Content Validity Coefficient per item (CVCi), the average Content Validity Coefficient, and the total Content Validity Coefficient (CVCt) were analyzed.
There were 95% Confidence Intervals (CI) and binomial test. The binomial test was applied, and the items that presented p>0.05 were considered relevant, indicating that there was agreement among the experts of at least 80%. This means that, for these items, there was no statistically significant difference in the evaluation, suggesting agreement among the judges. Conversely, items with p<0.05 showed agreement of less than 80%, indicating divergence in the assessments. Quantitative analysis of the Likert scale items was performed, along with the interpretation of the qualitative justifications for the results obtained from the evaluation.
The research was developed in accordance with Resolution 466/2012 of the National Health Council10 and approved by the Research Ethics Committee of the Universidade Estadual do Ceará, with a favorable opinion. Data collection only began after the judges approved and signed the Informed Consent Form.
RESULTS
The analysis of the internal evaluation of the MRT Nur-CVR took place according to each item evaluated, and the following categories are presented:
Identification characteristics of the evaluator of the Middle-Range Theory for Nursing in Cardiovascular Rehabilitation
When using the Delphi technique, the contributions of evaluators/judges are loaded with particular knowledge, experiences and points of view in the evaluation of the theory. To this end, Table 1 presents the identification characteristics of the group of evaluators who judged the MRT Nur-CVR.
According to Table 1, the profile of young evaluators with graduate degrees is evident, with a predominance of females (72.73%). When sizing, according to national regions, it is evident that, in the Northeast Region, there were five evaluators (45.45%); in the Southeast, four (36.36%); and in the South, two (18.18%). Regarding the time of training, six to 10 years prevailed and, regarding the level of education, PhDs were more prevalent (72.73%).
Categorization of Middle-Range Theory evaluators and their respective classification, according to the total score obtained in the application of the expertise criteria
Regarding the domains for categorizing the evaluators/judges of the theory, related to the criterion of educational training in nursing theories, seven of the eleven evaluators obtained the best score (4); only one evaluator obtained a score of 3; and three evaluators obtained a score of 2. With reference to professional experience in the area of theory to be evaluated, that is, MRT Nur-CVR, nine of the eleven evaluators achieved the best score (4); only one evaluator achieved a score of 3; and one evaluator with a score of 2.
Concerning the criterion of experience and metatheoretical knowledge, five of the eleven evaluators obtained a score of 4; four evaluators obtained a score of 3 and two evaluators obtained a score of 0. Referring to the dissemination of knowledge produced on the topic of metatheories or nursing theories, six of the eleven evaluators achieved the best score, that is, 4; only one evaluator obtained a score of 3; and two evaluators obtained a score of 2.
When referring to the recognition of expertise in the topic of metatheories or nursing theories, eight of the eleven evaluators achieved the best score, with four and three evaluators obtaining a score of 3.
Based on the criteria analyzed for categorizing the MRT Nur-CVR judges, they are classified according to the total score obtained in the application of the expertise criteria. Based on this assumption, the team consisted of five expert evaluators, four proficient evaluators, and two competent evaluators. Therefore, there is a group made up of evaluators with better expertise, since these are the best scores obtained, according to the framework used.
Evaluation criteria, according to Smith and Liehr: substantive foundations, structural integrity, and functional adequacy
Table 2 presents the item's Content Validity Coefficient and the CVC averages for assessment categories and total CVC, based on the judges' responses.
Presentation of the item's Content Validity Coefficient (CVCi), average Content Validity Coefficient of the category and total CVC of the theory assessment, based on the responses of the eleven judges. Fortaleza, Ceará, Brazil, 2021.
Items 10 to 12 obtained the lowest CVCi values, not reaching the minimum acceptable validity condition. The categories of substantive foundations and structural adequacy were those that achieved the highest average CVC.
In general terms, the theory evaluation reached a total CVC of 0.82, considered good, which points to general validity, even if the interpretation of the functional adequacy of 0.66 in this category indicates a validity problem in this evaluated aspect.
DISCUSSION
The MRT Nur-CVR presents evidence of internal validity, based on the evaluation of substantive foundations, structural integrity, and functional adequacy, demonstrating a theory with a high degree of agreement among evaluators. This result indicates the tendency of validity of the intrinsic aspects of the theory, representing the perspective that it can be used by nurses, as a guide for strategies that aim to improve the nursing care implemented for patients in the CVR process.
Regarding the sociodemographic profile of the evaluators/judges, there is congruence with the profiles presented in the literature: a high number of relatively young people with graduate degrees. Women were identified as the vast majority, representing 67% of the sample. This datum strongly confirms one of the trends in national graduate studies. Furthermore, it is important to emphasize that women are generally the majority in Brazilian higher education. Statistics show that they occupy, on average, around 55% of places on undergraduate courses11,12.
A bibliometric study indicated that of the 39 theories produced, 64.1% of them were produced in the Northeast Region, 20.5% in the Southeast, and 15.4% in the South of the country13. This evidence converges to the distribution of regions, where graduate programs producing middle and micro-range theories and those on the specific situation of nursing in the country until October 202314 are allocated. These equivalent proportions rule out the inaccurate assumption of validation bias due to geographic concentration or overestimation or underestimation of the population proportion of likely judges.
Substantive foundations concern the semantic correspondence between theories and facts6,7. The high values for CVC have relevant implications. The first one refers to the focus on the nursing course that was considered fully validated in items 1 and 2 by the judges. When dealing with a multidisciplinary action event, such as CVR, it is especially useful for nurses to have a structure that delimits descriptions of phenomena and produces explanations, in this case, theoretical ones, aligned with the course and profession of nursing, potentially allowing advancement in research and clinical practice, by incorporating the singularity of nursing work1. The validation of these elements also ensures that, in the MRT evaluated, the origins and ontological foundations are clearly established, which facilitates the understanding of the context of construction and use of the theory7.
Second, the high scores for items 3 and 4 point to a trait that is fundamental to middle-range theories of a course that relates to a profession: the ability to provide descriptions and explanations that have theory-practice correspondence.
In nursing, middle-range theories are heralded as frameworks that connect grand theories with the empirical level of professional practice15. However, these generic statements of a metatheoretical nature need to be verified in each theory, based on validation in this correspondence standard. Correspondence refers primarily to the recognition by judges of the middle level of the phenomenon of cardiovascular recovery, that is, both ensuring generalizable abstraction and maintaining anchoring with clinical, social and cultural indicators related to life situations and care demands.
Additionally, correspondence can align with the modes of theory production. Middle-range nursing theories are built from evidence derived from research and the practice of developers. When judges believe that there are roots in these contexts that provide evidence for theorization, then another criterion of adequacy and substantive virtue of the theory is deemed to have been met.
Structural integrity is derived from coherence standards6,7. The most widely applied norm of coherence is that of simplicity, a norm internal to the theory being evaluated6. In the present study, this rule was directly evaluated by item 7, which obtained acceptable validation and refers to the property of parsimony, that is, the presentation of a number of concepts that is essential and in no way excessive. Certainly, this judgment depends on the conceptions that an evaluator may have about the scope, characteristics, and limits of the theory; therefore, it is not an objective criterion that can have an established metric.
Thus, the internal validation of a theory is not an official and unanimous decision in the field; otherwise, it is a judgment that allows different scientists to accept or reject a theory, totally or partially, depending on the purposes or contexts of application6. Therefore, this item having the lowest magnitude of validity in structural integrity is not a surprising outcome.
Still in structural integrity, other aspects were evaluated with higher validity coefficients, being, respectively: conceptual definitions, the representation of concepts in a model, and the level of abstraction of concepts. In a way, the findings were consistent with the complexity of dealing with less objective and measurable aspects.
It is plausible to argue that it is less challenging to judge the coherence of concept definitions and the coherence of schematizations in a conceptual model than to decide whether all concepts are, in fact, organized appropriately at appropriate levels of abstraction. The very notion of “abstraction” is difficult to define, and can include many relationships, such as: the association with the degree of detail or precision, with the ability to link to sensory or motor bases, and with the nature of how conceptual knowledge can be.16
For a recent theory, therefore, with little time to mature and be updated, an effective indicator is that it has achieved the high scores conferred by the evaluation of more than ten judges.
However, it is precisely in the recent proposition of the theory that, consequently, the items that received the lowest evidence of validity and are arranged in functional adequacy are observed. The MRT Nur-CVR was originally published in a master's thesis report in 2018,17 and later in article format in 20211. Data collection for this research with the judges was four years prior to the first theoretical publication, which reinforces the recent nature of theoretical dissemination.
Notably, items 11 and 12 basically deal with the publication of examples of theory in practice and research, which depends, to a large extent, on the dissemination of the theory. Therefore, a low score tells us much more about how reliable the judges' assessment can be, rather than judging a deficiency in the theory being evaluated. It is not surprising that the MRT Nur-CVR has not yet achieved capillarity and robustness in clinical use and scientific research.
A study evaluating the Interactive Theory of Breastfeeding in 2024, of middle-range, produced in Brazil and originally published in a dissertation report, in 2015, and in an article, in 2017,18 found that almost a decade after the first publication, there were still few records of the theory's applicability18. Therefore, low scores on functional adequacy, resulting from the use of recent theories, should be interpreted with caution to avoid imprecise conclusions about inadequacy.
Furthermore, the MRT Nur-CVR proponents categorically state that before application, the theory should undergo a theoretical test, which may be the reason for its lack of use when evaluated by judges1.
Finally, the deficient judgment regarding the identification of empirical indicators in the theory (item 10) may refer to the very formation of the theory that privileged the more conceptual and model structures. In fact, the theory, in its most theoretical-empirical connection, ends with theoretical propositions1.
In summary, the theoretical evaluation carried out indicates that the MRT Nur-CVR points to full validity in terms of substantive foundations and structural integrity. Regarding functional adequacy, as it is a young theory, it needs to be applied in practice and research, so that the evaluation can occur in a fully appropriate manner in the three categories. This application, after validation by intrinsic criteria, represents the external validation of the theory, particularly conducted in empirical testing.
As a limitation of the study, the difficulty of participation acceptance by evaluators from other regions of Brazil stands out, which limited the regional representation of the final sample.
CONCLUSION
MRT Nur-CVR, after an internal evaluation process, presents evidence of validity regarding substantive foundations, structural integrity and partial functional adequacy, considering that the agreement between the judges reached the values considered adequate. The findings of bias for functional adequacy are more related to the recent availability of the theory than to actual limitations of use.
The validity results tend to support that the uses of the theory are carried out in what represents the empirical test, that is, the verification of the external validity of the descriptive and explanatory attributes of the MRT Nur-CVR. Based on evidence from empirical testing in research and records of application in clinical practice, the authors of the theory or other contributors can proceed with future updates that may be necessary for the initially proposed theory. Thus, it can be inferred that the study contributes to the consolidation of nursing as a science with its own theoretical basis.
REFERENCES
-
1. Farias MS, Silva LF, Brandão MAG, Guedes MVC, Pontes KMA, Lopes ROP. Medium reach theory for nursing in cardiovascular rehabilitation. Rev Bras Enferm [Internet]. 2021 [cited 2024 Dec 20];74(3):e20190718. Available from: https://doi.org/10.1590/0034-7167-2019-0718
» https://doi.org/10.1590/0034-7167-2019-0718 -
2. Im EO, Chang SJ. Current Trends in Nursing Theories. J Nurs Scholarsh [Internet]. 2012 [cited 2024 Dec 20];44(2):156-64. Available from: https://doi.org/10.1111/j.1547-5069.2012.01440.x
» https://doi.org/10.1111/j.1547-5069.2012.01440.x -
3. Hoeck B, Delmar C. Theoretical development in the context of nursing - The hidden epistemology of nursing theory. Nurs Philos [Internet]. 2018 [cited 2024 Dec 20];19(1):e12196. Available from: https://doi.org/10.1111/nup.12196
» https://doi.org/10.1111/nup.12196 -
4. Borel MCG, Lopes ROP, Thofehrn MB, Nóbrega MML, Arreguy-Sena C, Brandão MAG. Guideline for incorporating the Delphi method in the evaluation of nursing theories. Rev Latino-Am Enferm [Internet]. 2021 [cited 2024 Dec 20];29:e3387. Available from: https://doi.org/10.1590/1518-8345.4157.3387
» https://doi.org/10.1590/1518-8345.4157.3387 - 5. Meleis AI. Theoretical nursing - development and progress. 3rd ed. Philadelphia, PA(US): J. B. Lippincott Company; 1997.
- 6. Kaplan A. The Conduct of Inquiry: Methodology for Behavioural Science. 2nd ed. London, UK(EN): Routledge; 1998.
- 7. Smith MJ, Liehr PR. Middle range theory for nursing. 3rd ed. New York, NY(US): Springer; 2014.
-
8. Niederberger M, Spranger J. Delphi technique in health sciences: A map. Front Public Health [Internet]. 2020 [cited 2024 Dec 20];8:457. Available from: https://doi.org/10.3389/ fpubh.2020.00457
» https://doi.org/10.3389/ fpubh.2020.00457 - 9. Hernandez- Nieto R. Contributions to statistical analysis. Bogotá, (CO): Los Andes University Press; 2002.
-
10. Brasil. Conselho Nacional de Saúde. Resolução nº 466, de 12 de janeiro de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos [Internet]. 2013 [cited 2020 Dec 20]. Available from: https://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf
» https://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf -
11. Costa EG, Nebel L. O quanto vale a dor? Estudo sobre a saúde mental de estudantes de pós-graduação no Brasil. Polis (Santiago) [Internet]. 2018 [cited 2024 Dec 20];17(50):207-27. Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-65682018000200207&lng=es&nrm=iso
» http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-65682018000200207&lng=es&nrm=iso -
12. Brasil. Instituto Nacional de Estudos e Pesquisas Educacionais. Censo da Educação Superior [Internet]. 2015 [cited 2020 Dec 20]. Available from: https://conselho.saude.gov.br/resolucoes/201210
» https://conselho.saude.gov.br/resolucoes/201210 -
13. Cardoso RB, Brandão MAG, Cavalcante JCSS, Lopes ROP, Zaccaro KRL, Primo CC. Brazilian nursing specific situation, middle and micro-range theories: A bibliometric study. Rev Bras Enferm [Internet]. 2024 [cited 2024 Dec 19];77(4):e20230520. Available from: https://doi.org/10.1590/0034-7167-2023-0520
» https://doi.org/10.1590/0034-7167-2023-0520 -
14. Leandro TA, Nunes MM, Teixeira IX, Lopes MVO, Araújo TL, Lima FET, et al. Development of middle-range theories in Nursing. Rev Bras Enferm [Internet]. 2020 [cited 2024 Dec 19];73(1):e20170893. Available from: https://doi.org/10.1590/0034-7167-2017-0893
» https://doi.org/10.1590/0034-7167-2017-0893 -
15. Yee E. Abstraction and concepts: When, how, where, what and why? Lang Cogn Neurosci [Internet]. 2019 [cited 2025 Apr 28];34(10):1257-65. Available from: https://doi.org/10.1080/23273798.2019.1660797
» https://doi.org/10.1080/23273798.2019.1660797 - 16. Farias MS. Reabilitação cardiovascular: proposta de uma teoria de enfermagem de médio alcance [dissertation]. Fortaleza, CE(BR): Universidade Estadual do Ceará; 2018.
-
17. Primo CC, Brandão MAG. Interactive theory of breastfeeding: Creation and application of a middle-range theory. Rev Bras Enferm [Internet]. 2017 [cited 2025 Apr 28];70(6):1191-8. Available from: https://doi.org/10.1590/0034-7167-2016-0523
» https://doi.org/10.1590/0034-7167-2016-0523 - 18. Gomes SC, Rodrigues IP, Lopes MVO, Silva VM, Guedes NG, Pinheiro PNC. Interactive breastfeeding theory: Fawcettʼs pragmatic adequacy assessment. Rev Esc Enferm USP [Internet]. 2024 [cited 2025 Apr 28];58:e20240144. Available from: https://doi.org/10.1590/1980-220X-REEUSP-2024-0144en
NOTES
-
ORIGIN OF THE ARTICLE
Excerpt from the dissertation - Middle-Range Theory for Nursing in Cardiovascular Rehabilitation: theoretical-empirical evaluation, presented to the Postgraduate Program in Clinical Nursing and Health Care at the Universidade Estadual do Ceará, 2021.
-
APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Research Ethics Committee of the Universidade Estadual do Ceará, with favorable opinion No. 4,585,472, CAAE: 42010920.1.0000.5534
-
TRANSLATED BY
Denise Costa Rodrigues
-
DATA AVAILABILITY
Available at the repositor of the Universidade Estadual do Ceará: https://www.uece.br/ppcclis/pesquisa/teses/teses-2021/
Available at the repositor of the Universidade Estadual do Ceará: https://www.uece.br/ppcclis/pesquisa/teses/teses-2021/
Source: Hernandez-Nieto (2002)