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Integrating transitions theory and grounded theory for nursing research and care

Claudia Feio da Maia Lima^I; José Luis Guedes dos Santos ^II; Aline Lima Pestana Magalhães^III; Célia Pereira Caldas^IV; Alacoque Lorenzini Erdmann^V; Iraci dos Santos^VI

^I PhD in Nursing.Assistant Professor of Nursing Course, Federal University of Recôncavo da Bahia, Brazil.E-mail: claudiafeiolima@yahoo.com.br
^II PhD in Nursing.Assistant Professor, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil. E-mail: joseenfermagem@gmail.com
^III PhD in Nursing.Assistant Professor, Federal University of Santa Catarina, Chapecó, Santa Catarina, Brazil. E-mail: aline.pestana84@gmail.com
^IV PhD in Nursing.Associate Professor of Nursing Course, Federal University of Rio de Janeiro, Brazil. E-mail: celpcaldas@gmail.com
^V PhD in Nursing Philosophy.Full Professor, Federal University of Santa Catarina.Florianópolis, Santa Catarina, Brazil. E-mail: alacoque.erdmann@ufsc.br
^IV PhD in Nursing.Full Professor, Federal University of Rio de Janeiro College of Nursing, Brazil. E-mail: iraci.s@terra.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.19870

ABSTRACT

Objective : the article presents a theoretical framework the allows Transitions Theory and Grounded Theory to be integrated as a frame of reference for nursing research and care. Method: transitions Theory is discussed as a theoretical framework and Grounded Theory, as a qualitative research method. Results: the connections between these references are the assumptions: from the perspective of those who experience them, transitions can be understood and changed; theories focus on lived human experience; theoretical sampling in Grounded Theory includes various participants in order to understand interactions in transitions; and the theoretical and explanatory model produced by Grounded Theory represents and explains transitions experienced in a given context. Conclusion: Transitions Theory can thus be used as a theoretical framework for development of a Grounded Theory.

Keywords : Nursing theory; nursing methodology research; qualitative research; nursing care.

INTRODUCTION

Nursing care has been developed more focused on the individuals' dimension completeness. Thus, the nurse's actions must meet the diagnosed needs, imbued with theoretical and practical knowledge, to provide well-being and recognition as an integral practice¹.

For this purpose, the objective is to produce a body of knowledge, specific to the profession, in order to consider the current social context and the elements that meet the health demands of those involved in the caring process. Constant philosophical and theoretical-methodological reflections, on theoretical propositions and technological innovations in the area of nursing and health, are fundamental for the evolution and the improvement of the theoretical-scientific knowledge of nursing.

It is imperative to continuously elaborate the professional meaning about being, doing and knowledge in nursing, given all the complexity involved in being healthy or not, considering social, cultural, political, ethical, philosophical, humanistic and cultural factors^2,3.

Some improvements have occurred in this scenario, through researches on the understanding of the processes of living, becoming ill, caring and being cared for, among other phenomena, full of meanings and conceptions. These qualitative investigations in nursing allow the approach of the subjective dimensions, related to the human experiences, actions and interactions, overcoming the strictly biomedical view of health and disease approaches ⁴.

The theoretical framework of nursing science is constructed dynamically, arisen from practice and reproduced in researches, especially through the analysis and development of concepts and theories.

With all the potential that the theoretical researches have, directed to science improvement, it is remarkable the importance of suitable models for the analysis and development of concepts little explored in literature ⁵.

Theories are defined as relatively concrete and specific conceptions, derived from a conceptual model and its propositions, which describe tangible and specific relationships between concepts⁶. They can be understood as an abstract generalization, with systematic explanation about the occurrence of the facts and their relations, in order to give meaning the research results.They correspond to the practice of synthesizing a body of knowledge, within a determined scope, establishing the nature among possible variables for a qualified and nursing-oriented care practice⁷.

The theories are classified as large and medium, according to the level of abstraction. The large ones are systematic constructions of the nursing nature, its mission and objectives related to the profession care. They are constructed on experiences, observations, insights and research results.They reflect a broader sense and provide relationships among abstract concepts.They have the highest level of abstraction and are not suitable to empirical tests⁶.

Medium-range theories have a more limited sense, and with less abstraction power; they refer to specific phenomena or concepts, reflecting clinical, administrative or educational practice.Such phenomena tend to cross nursing fields and care situations. They can be submitted to empirical tests, for the specificity of the concepts and are easily operationalized. There is also the specific situation theory, focused on specific nursing phenomena, such as clinical practice, and limited to specific populations or a particular field of practice⁸.

In light of these assumptions, some nursing theories are proposed, as the Theory of Transitions, by Afaf Meleis, which describes, understands, interprets and/or explains specific nursing phenomena resulting from practice.The significant transitions in life, with changes in processes, roles or states, generate behavioral changes and a new definition of each one in the social context⁸.

In Nursing research, the Grounded Theory stands out as a methodological reference, for valuing the subjectivity of integral care. It elucidates som events that occur in a given social context and groups of individuals, by understanding their meanings and knowledge generation, from the elaboration of a theory based on data^9,10.

The adherence between the theoretical foundations of the Grounded Theory and the Theory of Transitions is recognized, as well as the potential of both theories to broaden the vision necessary for the nurses' qualification and performance, in researches and professional practice. Thus, some basic questions have arisen: what are the possibilities of integration between the Grounded Theory and the Theory of Transitions, in Nursing? How are theoretical references interconnected and how do the potentiate the nursing research and care?

This study is justified by the need to socialize differentiated experiences in the knowledge production in nursing and health care. One of the researcher's attributions is to present innovative ways of elaborating and producing researches, especially regarding the methodological path and the production of empirical data¹¹.

It is remarkable that the integration of these references comes from the object of a doctoral thesis, entitled: Giving meaning from the sexuality transitionality of the elderly person's spouse-caregiver in a dementia process to a therapeutic nursing care , through the interaction of the experience meanings and the understanding of the different contexts, pointing to the apprehended phenomenon.

Therefore, the objective was to present a theoretical framework that allows the integration between the Theory of Transition and the Grounded Theory, as a reference for the research and nursing care.

Theory of transition as a theoretical reference for nursing

The Theory of Transitions, developed by Afaf Meleis, had its beginning after questions about the nature of transitions in human experiences, developing as a concept for nursing in 1985.It was important to know how transitions were being used, in the conceptual perspective, in scientific nursing productions, developing the theoretical framework of transitions ⁸.

Transitions are closely linked to life cycle events.Due to the variety of aspects, they are related to nursing care, in what concerns to the prevention and intervention in events, so that nurses have a renewed focus on care, as well as a reaffirmation of the theories already applied and the creation of new ones¹².

The Symbolic Interactionism and the Theory of Florence Nightingale influenced the determination of the Theory of Transitions.In nursing, the transition is an expressive focus to be considered, since the nurse assists individuals to go through various situations and to adapt themselves to the effects of transitions¹³.

For nursing, to understand the changes experienced by individuals and the resources they use, facilitate the development of healthier coping strategies.Thus, the transitions belong to the domain of the nursing subject, when they relate to health and disease, or when their responses are manifested by health-related behaviors¹³.

It is expected that the subjects' stability in relationships and social roles in the experienced event, is the expression of their own redefinition.By expressing the sense of beginning, middle and end, this theory is classified as interactionist, because it focuses human care on the interaction between nurse and individual⁸.

Mastery is defined as the goal of healthy transitions, demonstrated by behaviors, feelings, signs and symbols associated with new functions.The components of the theoretical model for the transition analysis and establishment of nursing therapeutics include types and patterns of transitions, experience properties, facilitating and inhibiting conditions, response patterns (process and outcome indicators) and nursing therapy ¹³.

The transitional care values the individual, considered as the protagonist of the care action.

It is not something definable, palpable, visible or that can be reduced to a simple definition, but arises from the nurse's awareness when perceiving the individual's understanding of the transitional experience¹².

The experience of transitions has implications for professional practice, for it guides the nurse to describe the individual's needs in the transactional process, through a broad vision, with prevention, promotion and therapeutic intervention of care.

The grounded theory as a qualitative research method

The Grounded Theory was created in 1967, by sociologists Barney Glaser and Anselm Strauss, as a method of social research, whose generated theoretical constructs explain the human action in a social context. The social processes that arise from this scenario enable the researcher to explain the phenomenon, through interpretation, using the inductive and deductive approaches.The theory that arises from research is based on data, rather than on a pre-existing theoretical body^4,14.

After 1980, Glauser and Strauss interrupted the work, adopting different paths.Glaser became a defender of the original methodology and Strauss proposed a remodeling of the Grounded Theory, along with Juliet Corbin.From the analysis of the method development, we have Glaser's purist attitude that defends the classical Grounded Theory and the structuralist view of Strauss¹⁵. From 2000, the constructivist side of the method stands out, and Kathy Charmaz is its main author.

In this evolutionary path, the main difference of these methodological approaches is directed to the identification of the research problem and conduction of the investigative process. In the classical approach, the theory is developed by the process of induction and creativity, without deepening in the initial literature review or in the theoretical background.The structuralist and constructivist lines recognize the Grounded Theory as a process of construction and reconstruction of data, towards the theory elaboration^16,17.

To support this process, the use of a theoretical background is recommended as a strategy, in order to achieve the theoretical elevation required for the Grounded Theory development¹⁸.

In the discussion about the use of theoretical background in the Grounded Theory, it is important to highlight that the method had its origins in the Symbolic Interactionism, focusing on the interaction among people who explore the human behaviors and social roles. Because of this initial connection, it is common, in academic studies, to use the Symbolic Interactionism principles, in studies whose method refers to the Grounded Theory; however, is not necessary to legitimize the Grounded Theory as a method of scientific investigation^10,15.

The Grounded Theory value is based on its capacity of creating the theory of collected qualitative data.For the process of analysis, the interpretation is thoroughly systematic.The grounded theories tend to better represent the reality and offer more consciousness and understanding of the researched phenomenon^4,14.

Among the characteristics that guide the development of the Grounded Theory, it is remarkable the data collection, through the concept of theoretical sampling, the use of diagrams for articulation between concepts/subcategories and categories, and elaboration of an illustrative model of results¹⁴.

The theoretical sampling is a guiding concept of the Grounded Theory, in order to define the study's participants.

It maximizes the data acquisition, to aid in the explanation of the categories, in relation to the properties and dimensions, aiming at conceptual and theoretical development. Data collection processes are developed in search of places, individuals or events that may potentiate the discovery of variations between concepts and the condensation of categories, properties and dimensions, according to the information needs that have arisen in the research^10,14.

In the Grounded Theory, the sample is formed throughout the study, following the emerging theory gaps, collecting data from individuals and contexts with characteristics on which the resulting theory is still weak, until it "saturates" the categories.The participants are listed in sample groups, with individuals who have relevant experiences in relation to the research phenomenon¹⁹.

Next to the data collection, the Grounded Theory analytical process begins by coding the data and elaborating concepts, subcategories and categories, with the help of memos and diagrams.

It consists of one of the stages of generating theory process and allows the externalization of ideas, through written records, codes and their relations, taking to the more abstract level the concepts that arise from this process¹⁴.The diagrams present categorized data, facilitating studies about them, since they show the concept relations and demonstrate the theory density and complexity^15,20.

To represent the Grounded Theory results, it is developed a model, which compares, relates and interconnects the elaborated categories in the data analysis.It is a perspective that organizes and explains the emerging connections, which helps the researcher to study the data systematically, relating them in a way to integrate structure and process, establishing relationship between the categories^10,14. There are different references to this model in literature, as a theoretical model, paradigmatic model or codification paradigm, interpretative model and explanatory model^10,14,15,18.

It is observed that the Grounded Theory proposal focuses on human interaction and action.This makes it a relevant methodological reference for the nursing and health areas, whose practices are based on the interactions between individuals, family and work team¹⁵.

Integrating the theory of transition and the grounded theory

To demonstrate the existing connections between the Theory of Transition and the Grounded Theory, with better concepts and reflections visualization, for application in nursing research and care, four assumptions were elaborated:

- The transitions may be understood and changed, according to the particularity of those who experience them.The Grounded Theory understands the phenomenon under study (the transitions), based on the meanings of experiences.Both cooperate in the knowledge production, for the behavioral change, redefinition of the meanings about the event and alteration of the self-perception in the context of the lived reality. There is a dynamism in which the rupture with the known fact occurs, as well as the responses to the occurrence, due to the triggered transitions²¹.

- Both focus on the perception of human experiences, through the connection that the methods have in Symbolic Interactionism. For Strauss, human beings are active agents in their lives and not passive recipients of higher social forces. The process is essential to the human existence - but not the structure -, because individuals create the frameworks, through their engagement in processes. Strauss took, to the Grounded Theory, the social construction of action as the central problem to be dealt with, because subjective social meanings arise from actions.All these ideas reflect the philosophical tradition of pragmatism and the theoretical perspective of Symbolic Interactionism¹⁵. It explores the meanings of human behaviors and the social roles of the individuals in interaction ²². This background is used in theory of transitions, because it plays an important role in the concept of the symbolic world of responses and forms of interactions in transitions²³.

- The concept of theoretical sampling in the Grounded Theory allows the inclusion of different participants in the understanding of the relationships/interactions in the transitions lived. One of the differentials of the Grounded Theory is theoretical sampling, which searches for places, subjects and events that potentiate the varieties of concepts and make the categories dense, in what concerns to the properties and dimensions¹⁴.It allows the understanding of the transitions from various perspectives until reaching the data theoretical saturation.

- The development of the theoretical-explanatory model of the results in the Grounded Theory is a possibility of representing and explaining the transitions lived in certian contexts. The representation by illustrative figure is important for the understanding of the investigated phenomenon, when transitions take place.Moreover, it can be interesting to increase continuous training actions, in order to improve the nursing therapeutical care during the transitions.

It is established that the use of the Theory of Transactions and the Grounded Theory enables the understanding of skills, strategies and interventions developed by the individuals in the transitions. The main components of this theoretical framework of integration are supported by the individuals' transitions, in the search of understanding their relations/interactions established in the experiences lived during their lives.Therefore, the theoretical-explanatory model of the Grounded Theory can show the changes by the perspective of the Theory of Transitions in a lived context.

CONCLUSION

The theoretical framework presented allows the integration between the Theory of Transition and the Grounded Theory, as a reference for the use in research and nursing care, aiming to the study of the relations/interactions lives in the transitional experiences. Therefore, it supports the foundations of the doctoral thesis above mentioned: The understanding of the sexuality transitionality experience of the elderly person's spouse-caregiver in a dementia process allows the elaboration of an interpretive model that points to a therapeutic nursing care specific of that moment of life.

The article expands the perspective, necessary for the nurses' professional training and performance, in the fields of theory, research and care; it contributes to the social skills and abilities relevant to the nurses' care practice in the health services; it encourages the incorporation of new ideas, references and technological innovations in nursing research, indispensable for the development of the Grounded Theory and the Theory of Transition, both capable of potentializing the nurses' professional practice in their different dimensions.

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