Nursing theories in palliative care investigation: a review

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Introduction
Palliative care is considered an essential component of any
healthcare system. In spite of that, the access to this type of care is
still inadequate in many countries. It is estimated that palliative care
needs will continue to grow, as the rapidly aging of the population
leads to increasingly complex health conditions.1 Palliative care is an
approach that promotes and improves the quality of life of patients
and their families facing problems associated with life-threatening
illness, through the prevention and relief of suffering by means of
early identication and accurate assessment and treatment of pain
and other physical, psychosocial and spiritual problems.2 This is
an interdisciplinary approach that involves patient, family and
community into action.3 In fact, the practical and philosophical notion
of an interdisciplinary team is crucial to provide quality palliative
care.4
Although the composition of palliative care teams varies depending
on patient needs and available resources, the presence of a nurse
is constant and constitutes the rst link between team, patient and
family, putting into practice the established healthcare plan in every
context of care.5 Thus, nurses play a central role in palliative care,
acting in the best interest of patients and their families and providing
care on a continuous basis.6 The relationship established between
patient and nurse is fundamental and provides an unique contribution
to palliative care.7–11 The link between palliative care and nursing is
so narrow that many times it is said that palliative care is the epitome
of good nursing practice.12 Therefore, there is a risk that the role of
nursing in palliative care would be confused with a vague description
of its interdisciplinarity, losing the sense and importance of nursing
intervention.13 Some authors claim that too much emphasis in
interdisciplinary research can dilute nursing knowledge and outshine
the nursing role on planning and providing care.14
Lynch and collaborators claim that the multidimensional
concept of quality of life requires a shared contribution of different
disciplines and that identifying the singular contribution of each one
is also essential to enrich the interdisciplinary focus of palliative care,
assuring high quality care.15 Consequently, there is a growing need
to afrm nursing in palliative care in theory, practice and research.
The link between theory and research is characterized by a mutual
and dynamic interaction in which research ndings supports theory
and theory provides questions and hypothesis to research.16 Fawcett
says that the functions of a theory are to clearly specify conceptual
models phenomena and to provide a specic structure to understand
behaviors, situations and events.17 The current study aims to identify
and analyze the nursing theories used in palliative care research.
Methods
This review was undertaken to identify palliative care research that
used a nursing theory. These standard bibliographic databases were
researched: PubMed, CINAHL, B-On, Cuiden, Scopus, Cochrane
Library and Embase. A combination of the following search terms
were used with the Boolean phrase ‘and/or’ in order to maximize
the type and range of material captured by the search: (“palliative
nursing” or “palliative care” or “terminal care” or “end-of-life care”)
and (“nursing theory” or “nursing model”). Publications that were
based on opinion or commentary, editorials and conference abstracts
were excluded. Publications were selected based on the following
inclusion criteria: 1) Research relevant to palliative care; 2) Research
that used at least one nursing theory; 3) Research published between
January 1994 and December 2014. Duplicates were removed and then
the titles and abstracts of publications returned in the database results
were manually reviewed by two independent researchers in order to
conrm the inclusion criteria. Then the researchers analyzed the full
text articles and developed a list gathering data on year of publication,
country where the research took place, methodology, nursing theory
used and its application.
Results
A ow diagram about the selection of articles is detailed in
Figure 1. Overall, 360 articles were identied. Ninety two articles
Hos Pal Med Int Jnl. 2018;2(4):231‒234. 231
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Nursing theories in palliative care investigation: a
review
Volume 2 Issue 4 - 2018
Alexandra Pereira,1,2 Amélia Ferreira,1,2
José Martins,3 Céu Barbieri-Figueiredo M4
1Community Care Unit of Lousada, Portugal
2Nursing Sciences Doctoral Program, Abel Salazar Institute of
Biomedical Sciences, Portugal
3Nursing School of Coimbra, Portugal
4Nursing School of Porto, Portugal
Correspondence: Alexandra Pereira, Community Care Unit
of Lousada, Largo da Beneditina, 7, 4150-132, Porto, Portugal, Tel
+351 91 700 76 18, Email alemnap@gmail.com
Received: June 30, 2018 | Published: August 03, 2018
Abstract
Background: Palliative care needs are increasing worldwide. Although palliative care
is an interdisciplinary approach, nurses play a central role in the team context. As it is
necessary to clarify the unique contribution of nursing to palliative care, the current
study aims to identify and analyze the nursing theories used in Palliative Care research.
The methodology was a literature review of investigation articles published between
1994 and 2014 in the databases Pubmed, CINAHL, B-on, Cuiden, Scopus, Cochrane
Library and Embase. Fifteen articles from 6 countries that used 10 different theories
were found. The grand theory was the most used type of theory and the Humanistic
Nursing Theory was the most used theory. We conclude that there is no consensus
surrounding the utilization of one unique theory in Palliative Nursing. It is considered
that the use of different theories in different contexts and different populations can
contribute to a sustained reflection. There needs to be more studies developed in this
context with a theoretical background.
Keywords: nursing theory, palliative care, hospice and palliative care nursing
Hospice & Palliative Medicine International Journal
Review Article Open Access

Nursing theories in palliative care investigation: a review 232
Copyright:
©2018 Pereira et al.
Citation: Pereira A, Ferreira A, Martins J, et al. Nursing theories in palliative care investigation: a review. Hos Pal Med Int Jnl. 2018;2(4):231‒234.
DOI: 10.15406/hpmij.2018.02.00097
were removed as they were duplicates. The titles and abstracts of the
remaining 268 studies were reviewed. This resulted in 183 of studies
being excluded as they did not meet the inclusion criteria. Eighty
ve articles were retrieved for full text examination. The nal review
included 15 articles studies that were published over the period under
examination.
Figure 1 Selection and review process.
A summary of reviewed articles is presented in Table 118–32
Only 4 articles had one single author and 11 articles were written
by research teams composed by 2 to 6 elements. There was an upward
trend in the number of studies published from 2005 to 2014 (80,0%).
The oldest article was published in 1995 and the most recent was
published in 2014. There was an absence of articles in 1994, 1996,
1998 to 2000, 2002 to 2004 and 2011. Apart from that, one article was
published every year, except for 2007 (3 articles) and 2005 (2 articles)
(Figure 2). The authors of the articles were from 6 different countries.
USA was the most represented country (6 articles), followed by Brazil
(3 articles). We also found 2 articles from Sweden, 2 from the United
Kingdom, 1 from Thailand and 1 from France (Table 2). In terms of
research design, 13 articles (86,7%) were qualitative in nature when
compared to 2 articles (13,3%) that were qualitative. The majority
of articles studied one type of population, only 2 articles studied two
different populations. Patients were the most studied population (9
articles), followed by nurses (6 articles) and family caregivers (2
articles). One article analyzed health records.
Figure 2 Review results distributed by publication year(n).
Regarding the nursing theory, a great variety was used. The 15
articles were distributed by 10 different theories. The most used
theory was the humanistic nursing theory (4 articles), followed by
man living health theory (3 articles). The other theories were used
once, one in each article (Table 3). In terms of type of theory, 10
articles used a grand theory, 4 articles used a middle-range theory
and 1 article used a conceptual model. There was an upward trend
in the application of the theory as a provider of framework for data
analysis and interpretation (11 articles) and in 9 articles the theory
provided the philosophical underpinnings of the study.
Table 1 Summary of reviewed articles
Author &
nationality Methodology Theory Application of theory
Laferrièr,18 France Qualitative Study Self-care Theory Provides the philosophical underpinnings of the study
Morrissey,19 UK Qualitative Study Theory of Awareness
Contexts Provides framework for data analysis and interpretation
Bonura et al,20 USA Qualitative Study Culture Care Theory Provides the philosophical underpinnings of the study
De Paula & Crossetti,21
Brazil Qualitative Study Humanistic Nursing
Theory Provides the philosophical underpinnings of the study
Pilkington,22 USA Qualitative Study Man Living Health
Theory Provides framework for data analysis and interpretation
Hopkinson et al,23 UK Qualitative Study Humanistic Nursing
Theory Provides framework for data analysis and interpretation
Bunkers,24 USA Qualitative Study Man Living Health
Theory Provides framework for data analysis and interpretation
Larsson & Wijk,25
Sweden Qualitative Study Man Living Health
Theory Provides framework for data analysis and interpretation
Rice & Betcher,26 USA Quantitative Study Theory of
Transpersonal Care Provides framework for data analysis and interpretation
Isaksson & Ahlstrom,27
Sweden Qualitative Study Theory of Chronic
Sorrow
Provides the philosophical underpinnings of the study and a framework for
data analysis and interpretation
Duncan et al,28 USA Quantitative Study Theory of Unpleasant
Symptoms Provides the philosophical underpinnings of the study
Kongsuwan & Locsin,29
Thailand Qualitative Study Theory of nursing as
caring
Provides the philosophical underpinnings of the study and a framework for
data analysis and interpretation
Schulman-Green et
al,30 USA Qualitative Study Theory of transition Provides the philosophical underpinnings of the study and a framework for
data analysis and interpretation
França et al,31 Brazil Qualitative Study Humanistic Nursing
Theory
Provides the philosophical underpinnings of the study and a framework for
data analysis and interpretation
França et al,32 Brazil Qualitative Study Humanistic Nursing
Theory
Provides the philosophical underpinnings of the study and a framework for
data analysis and interpretation

Nursing theories in palliative care investigation: a review 233
Copyright:
©2018 Pereira et al.
Citation: Pereira A, Ferreira A, Martins J, et al. Nursing theories in palliative care investigation: a review. Hos Pal Med Int Jnl. 2018;2(4):231‒234.
DOI: 10.15406/hpmij.2018.02.00097
Table 2 Review results distributed by author’s country (n; %)
Country n %
Brazil 3 20,0
France 1 6,7
Sweden 2 13,3
Thailand 1 6,7
UK 2 13,3
USA 6 40,0
Total 15 100,0
Table 3 Review results distributed by nursing theories (n)
Type of theory n Theory (Author) n
Grand theory 10
Culture care theory (M. Leininger) 1
Humanistic care theory (J. Paterson & L.
Zderad) 4
Man living health theory (R. Parse) 3
Self-care theory (D. Orem) 1
Theory of transpersonal care (J. Watson) 1
Middle-range
theory 4
Theory of awareness contexts (B. Glaser
& A. Strauss) 1
Theory of chronic sorrow (G. Eakes, M.
Burke & M. Hainsworth) 1
Theory of transition (A. Meleis) 1
Theory of unpleasant symptoms (E. Lenz,
L. Pugh, R. Miligan, A. Gift & F. Suppe) 1
Conceptual
model 1Theory of nursing as caring (A. Boykin &
S. Schoenhofer) 1
Total 15 Total 15
Discussion
The utilization of nursing theories in palliative care research is
uncommon. In fact, although many journals require the identication
of a conceptual or theoretic framework on submitted articles, this
does not seem to be traditional.33 Even so, we admit that some
authors may use a nursing theory in their studies and not include
this information on the published articles. Regarding the obtained
results, we consider that the utilization of a unique nursing theory in
palliative care research is not consensual. In spite of that, there is a
predominance of grand theories and a trend regarding the utilization
of the humanistic nursing theory. This is understandable because this
theory share common concepts with the principles of palliative care as
relationship, communication, lived experience and suffering. There is
also an upward trend of publications after 2005, even though the rst
article was published in 1995. Curiously, it was in the mid-nineties
that some authors began to demonstrate their concern regarding
the loss of focus on the development of specic nursing science
knowledge as healthcare began to be increasingly provided using an
interdisciplinary approach. These authors argued that it was necessary
to develop specic nursing research to consolidate the evidence of
its importance as an autonomous science and its relevance in an
interdisciplinary approach.34-35
The distribution of articles by 6 different countries is coherent
with the level of development of palliative care provision, presented
in 2014 by the World Palliative Care Alliance and the World Health
Organization. USA, Sweden, the United Kingdom and France are
countries with advanced integration of palliative care in their health
care system. Brazil and Thailand are countries with isolated provision
of palliative care in their health care system. In spite of that, these
two countries have a strong tradition in nursing research. It can be
considered that palliative care research using a nursing theory as
reference occurs in countries with a more advanced practice in this
context.1 In terms of methodology, there is a clear predominance of
the qualitative approach. This is comprehensive regarding the nature
of the studied themes. This kind of approach is frequently considered
to be a more holistic and humanized method. Quantitative research
emphasizes the quality of entities, processes and their signicance
instead of quantities, intensities and frequencies.36 The fact that
four different populations were studied explains the complexity on
developing palliative nursing and palliative care research. These
populations go through different living experiences and may have
different needs that must be studied to improve the quality of care
provided.
Conclusion
The focus of this literature review was on the theoretic base that
nurses use in palliative care research. Fifteen articles that specied
the utilization of a nursing theory in their investigation were found.
Ten different theories emerged and were used in a different manner.
The most used type of theory was the grand theory and the most used
theory was the humanistic nursing theory. There’s a lack of consensus
about the utilization of a nursing theory as a framework in palliative
care research. Therefore, we consider that the application of different
theories in different contexts and populations might contribute to a
needed thought and discussion about palliative nursing practice. As a
relatively recent area of knowledge, it is necessary to develop more
and better research in palliative nursing using a theoretic framework.
We also suggest an analysis on the existing palliative care models
and their importance to develop and consolidate nursing as a specic
discipline in this interdisciplinary context of care.
Funding details
No funding.
Acknowledgements
None.
Conict of interests
The author declares no conict of interest.
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Citation: Pereira A, Ferreira A, Martins J, et al. Nursing theories in palliative care investigation: a review. Hos Pal Med Int Jnl. 2018;2(4):231‒234.
DOI: 10.15406/hpmij.2018.02.00097
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