In wound care practice, the problem of itch occurring with chronic wounds has been recognised, but is often ignored in practice. Wound-related itch has been found to affect 28% of people with chronic wounds (Paul, 2013) and can reduce quality of life, interfere with sleep and cause depression and anxiety (Upton et al, 2013). Additionally, the scratching and rubbing resulting from the itching cause further trauma to the wound and surrounding skin (Upton et al, 2013).
Itch can be highly distressing to a person with a wound so should be a priority in wound management (Parnell, 2018). As the discipline of nursing is held to be responsible for ‘conserving life, alleviating suffering, and promoting health’, the problem is appropriate for nursing inquiry (Carper, 1978: 20).
This article describes how a middle-range theory, the ‘theory of wound itch’, was formed and how it was derived from Levine's conservation model.
The phenomenon of interest is ‘integrity’ as per Levine's conservation model. The concept of interest is ‘wound itch’. Wound itch is found clinically, but not described in the literature.
Middle-range theories have been formulated to address distressing symptoms; however, no middle-range theory has been developed for the study of wound itch. According to Walker and Avant (2005: 16): ‘Middle-range theories direct prescription of practice theories aimed at concrete goal attainment.’
Through formulation of a middle-range theory of wound itch, a theoretical basis for the study of wound itch will be established.
Phenomenon of interest
Integrity is the phenomenon of interest for the study of wound itch. The Oxford English Dictionary (Oxford University Press (OUP), 2020) defines integrity as ‘the condition of having no part or element taken away or wanting; undivided or unbroken state; material wholeness, completeness, entirety’ with Latin etymology from integritas, which means wholeness and entirety, as with integer, which means whole.
Levine (1991: 3) speaks of integrity as the ‘unique oneness of the whole person’ and says that the promotion of integrity is the goal of nursing (Levine, 1973). Levine (1996: 40) also states: ‘Conserving the integrity of the individual is the hallmark of nursing intervention.’
Conceptual framework
Philosophical background
Ontology
Ontology is ‘the science or study of being’ (OUP, 2020). According to Fawcett (2005), ontological claims in nursing address what is believed about the nature of human beings, the environment, health and nursing. Levine's conservation model has ontological and epistemic claims that are consistent with the world view of reciprocal interaction—a post-positivist perspective. In this perspective, reality is not just what can be observed but is ‘multidimensional, context-dependent and relative’ (Fawcett, 2005: 13). It addresses both subjective sensory information and objective physical reality (Jacox et al, 1999).
Epistemology
Epistemology is ‘the theory of knowledge and understanding’ (OUP, 2020). Levine's conservation model is consistent with the systems category of knowledge, which has its origins in biology and physics. The human being is an open system, interacting with the environment ‘with fluidity and change’ (Levine, 1969a: 94).
Philosophical assumptions
The theory of wound itch is based on the following assumptions:
Concepts and propositions of the conceptual framework
Fawcett (2005) explains that it is reasonable to expect the conceptual framework to provide adequate descriptions of the four components of nursing's metaparadigm: human beings; health; environment; and nursing.
Levine's model is based on the premise that human beings are organismic, having a combination of related and even redundant systems that function as a single, integrated whole (Levine, 1969a). According to Levine, the expression of ‘wholeness’ can ‘only be used if it can be converted to manageable parts’ (Levine, 1989b: 326). ‘Health’ means whole (Levine, 1971).
Illness occurs when positive feedback within the system runs without the usual controls that restore balance (Levine, 1973). Levine contends that a person cannot be studied separately from the environment, which is the ‘predicament of time and place’ (Levine, 1989b:326). Environment is both internal and external (Levine, 1973). The internal environment is characterised by ‘homeostasis’—being in equilibrium or a stable state (Levine, 1969b: 7); and ‘homeorhesis’—a stabilised flow (Levine, 1973: 7).
The external environment is at once perceptual (sensed), operational (not sensed, yet present and potentially threatening) and conceptual (interpreted based on beliefs and values)(Levine, 1969a).
Five concepts from Levine's conservation model were used for middle-range theory development: environment; organismic response; adaptation; conservation; and integrity. Nonrelational propositions about each of these concepts are discussed below, followed by their relational propositions.
Nonrelational propositions
Environment
Existence proposition
The environment is both internal and external (Levine, 1969a).
Definition propositions
The internal environment has two dimensions: homeostasis; and homeorhesis. Homeostasis is the ‘remarkable equilibrium that is maintained in the internal environment in the face of constant change’ (Levine, 1969b: 7). Homeorhesis is defined as a stabilised flow in a person that permits the body to sustain its wellbeing within the vast changes that encroach upon it from the environment (Levine, 1973: 7).
The external environment has three dimensions: the perceptual environment; the operational environment; and the conceptual environment. The perceptual environment is the part of the environment to which an individual responds with sense organs (Levine, 1969a). The operational environment is the portion of the environment that is not perceived directly by an individual, and includes radiation, microorganisms and pollutants; it is of vital concern to a person because of its potential danger (Levine, 1969a). The conceptual environment is defined as the ‘exchange of language, the ability to think and experience emotion … value systems, religious beliefs, ethnic and cultural traditions, and the individual psychological patterns that come from life experiences’ (Levine, 1973: 12). According to Levine (1969b: 10): ‘The nurse participates actively in every patient's environment.’
Organismic response
Existence proposition
Levine (1969a: 95) states: ‘There are at least four levels of organismic response, each physiologically predetermined.’
Definition propositions
Organismic responses encompass four dimensions: the fight or flight response; the inflammatory-immune response; the stress response; and perceptual awareness.
The fight or flight response is the most primitive level of organismic response and is an adrenocortical-sympathetic reaction that is an instantaneous response to a real or imagined threat (Levine, 1969a; 1991). The inflammatory-immune response is the second level of organismic response and is a ‘systematized concentration of available energy directed at the exclusion and removal an intruding irritant or pathogen’ (Levine, 1969a: 95). The stress response, the third level of organismic response, is the ‘long-term organismic reaction to the exigencies of life and the sum total of the individual's life experiences’ (Levine, 1969a: 95).
The perceptual awareness response is the fourth level of organismic response and is defined as ‘all the experiences of life … mediated through tissues of the living individual’ (Levine, 1969a: 95). It covers five systems: the basic orienting system; the visual system; the auditory system; the haptic system; and the taste-smell system. The basic orienting system provides general orientation in the environment. The visual system enables an individual to see. The auditory system enables a person to hear. The haptic system is relevant to wound itch as it responds to touch with information ‘received by the skin surfaces and body orifices as well as the joints and muscles and their associated tendons. It enables the individual to explore his environment and establishes contact with the material nature of his environment’ (Levine, 1969a: 97). The taste-smell system provides information about chemical stimuli and facilitates safe nourishment.
Conservation
Existence proposition
Levine (1990: 192) states: ‘Conservation is a universal concept.’
Definitional propositions
Conservation is defined as ‘the guardian activity that defends and protects the [wholeness, which is] the universal target of selfhood’ (Levine, 1991: 4). ‘Conservation describes the way complex systems can continue to function, even when severely challenged. This work is accomplished in the most economic way possible’ (Levine, 1990: 192).
Conservation encompasses four principles: conservation of energy; conservation of structural integrity; conservation of personal integrity; and conservation of social integrity (Levine, 1969b).
The principle of conservation of energy refers to balancing energy output and energy input to avoid excessive fatigue, ie it concerns the interplay between rest, nutrition and exercise. The principle of conservation of structural integrity refers to maintaining and restoring the structure of the body by preventing physical breakdown and through healing. The principle of conservation of personal integrity refers to the maintenance or restoration of the person's sense of identity, self-worth and acknowledgement of uniqueness. The principle of conservation of social integrity refers to the acknowledgement of the patient as a social being.
The nursing process is one of conservation, which is ‘keeping together’ (Levine, 1967: 46). According to Levine (1991: 331), conservation ‘should be the major guideline of all nursing intervention wherever it takes place’.
Adaptation
Adaptation is not an all-or-none process but a matter of degree (Levine, 1973).
Definitional proposition
Adaptation is ‘the process of change whereby an individual retains his integrity within the realities of his environments’ (Levine, 1969b: 9–10).
Levine also states (1969b: 9): ‘Change is characteristic of life, and adaptation is the method of change. The organism retains its integrity in both the internal and external environment through its adaptive capability.’
Integrity
Definitional proposition
Integrity is the ‘unique oneness of the whole person’ (Levine, 1991: 3). Conservation of energy, structural integrity, personal integrity and social integrity to promote the unique oneness of the person are the basis of nursing interventions.
Relational propositions of the conceptual framework
The first relational proposition concerns the association of environment with organismic response: ‘A person responds to changes that encroach upon it from the environment with an organismic response’ (Levine, 1973: 7). The second relational statement links organismic response to adaptation: ‘The capacity of the organismic response to respond adequately to the environment is ‘determined by adaptation that is available to the organism’ (Levine, 1969a: 95).
Two relational propositions describe a reciprocal relationship between adaptation and conservation: ‘Integration is defended by adaptations that create the condition of conservation’ (Levine, 1989b: 330). Adaptation occurs when conservation measures effect changes whereby the individual retains integrity within the environment. A fifth relational proposition links conservation with integrity: conservation defends the wholeness of living systems by ensuring their ability to respond to change appropriately and retain their unique identity (Levine, 1990: 192).
The relationships are not explicit but can be inferred from Levine's work. There has been much thought over whether adaptation is a precursor to or consequence of conservation.
Methods of theory, proposition and concept development
Theory derivation
Theory derivation was the process chosen for the middle-range theory development because it ‘provides a way at arriving at explanation and prediction about a phenomenon where there may be little or no information, literature, or formal studies available’ (Walker and Avant, 2005: 156).
The process of theory derivation involves: becoming thoroughly familiar with the topic of interest; reading widely in other fields to find useful analogies; selecting a parent theory to use for derivation; identifying the content and/or relationships from the parent theory that will be used; and modifying or redefining concepts, statements and/or structure pertinent to the topic of interest (Walker and Avant, 2005).
Substruction is a process of taking apart a theory to study its consistency and logic. A substruction diagram enabled a deductive process of theory development (Figure 1).
As noted above, while itch is common, the concept of wound itch is not described in current literature. A fit of the theory was found in Levine's conservation model.
Statement derivation
Statement derivation was used to determine theoretical propositions. This is a ‘strategy for developing a set of statements about a phenomenon by using analogy’ and its purpose ‘is to formulate one or more statements about a phenomenon that is currently not well understood’ (Walker and Avant, 2005: 109; 111).
The process is similar to theory derivation and involves: becoming thoroughly familiar with existing literature on the topic of interest; searching other fields for new approaches to the topic; selecting the source or parent field and identifying structural and content features to be used; developing new statements similar to those found in the parent field; and redefining new concepts or structural relationships (Walker and Avant, 2005).
Concept synthesis and derivation
A combination of concept synthesis and derivation was used in the development of the theory of wound itch. Qualitative synthesis is a process of using sensory data such as that gained from listening or observing to obtain information (Walker and Avant, 2005). Qualitative synthesis was used to develop the concept of ‘wound itch’.
Concept derivation involves: becoming thoroughly familiar with existing literature related to the topic; examining other fields for new ways of looking at the topic; choosing a parent concept from another field; and redefining the concept or set of concepts in terms of the topic of interest.
Concept derivation was used for development of the following concepts: disruption of skin integrity; regulation; protection; and continuity. The concept of wound itch was derived from Levine's concept of organismic response.
Theory of wound itch
Concepts and propositions of the theory
Wound itch
Wound itch is the concept of interest in this middle-range theory. It can be determined only by the relationship of its components.
Existence proposition
Wound itch exists.
Definitional propositions
A wound is defined as ‘a hurt caused by the laceration or separation of the tissues of the body’ (OUP, 2020). Baharestani (2008: 3) defines a wound as ‘a disruption of the integrity and function or tissue in the body’. Itch is defined as ‘an uneasy sensation of irritation in the skin, which is relieved by scratching or rubbing’ (OUP, 2020). Wound itch, therefore, is the irritating sensation or disturbing feeling related to a disruption of the skin.
Relational proposition
An organismic response at the conceptual level is represented by wound itch at the theoretical level. Wound itch has fight or flight, inflammatory-immune (physiological), stress (psychological) and perceptual awareness (sensation) dimensions.
Disruption of skin integrity
Existence proposition
Disruption of skin integrity exists.
Definitional proposition
Disruption is ‘violent dissolution of continuity’ (OUP, 2020). Skin is defined as ‘integument’ (OUP, 2020). Integrity is ‘material wholeness, completeness, entirety’ (OUP, 2020). Disruption of skin integrity therefore is the dissolution of completeness of the integument.
Representational proposition
Disruption of the environment at the conceptual level is represented by disruption of skin integrity at the theoretical level.
Protection
Existence proposition
There is a phenomenon known as protection.
Definitional proposition
Protection is ‘shelter, defence or preservation from harm, danger, damage etc; guardianship, care’ (OUP, 2020). For the theory, protection is measures taken by the individual who has disruption of skin integrity or by the nurse to influence regulation.
Representational proposition
Conservation at the conceptual level is represented by protection at the theoretical level.
Regulation
Existence proposition
There is a phenomenon known as regulation.
Definitional proposition
Regulation is the ‘process whereby a living organism, embryo, etc, adapts its structure in order to accommodate disturbances or damage that it undergoes, so that it develops as an integrated whole’ (OUP, 2020).
Representational proposition
Adaptation at the conceptual level is represented by regulation at the theoretical level. Adaptation can be positive (effective) or negative (ineffective), as regulation can be positive (eg tissue growth) or negative (eg eschar development).
Continuity
Existence proposition
There is a phenomenon known as continuity.
Definitional proposition
Continuity is defined as a ‘state or quality of being uninterrupted in extent or substance, of having no interstices or breaks’ (OUP, 2020).
Representational proposition
Integrity at the conceptual level is represented by continuity at the theoretical level.
Relational propositions of the theory
Figure 1 shows the relationships between the concepts of the theory. There is a reciprocal relationship between disruption in skin integrity and wound itch. In the itch-scratch cycle, itch elicits a scratch response (Yosipovitch and Hundley, 2004). The scratching causes inflammation and further stimulation of nerve fibres, which result in the sensation of itch. The sensation of itch then prompts further scratching or rubbing.
Regulation is associated with wound itch as the systems of the person with wound itch adjust in response to the itch. A reciprocal relationship exists between regulation and protection as protective measures are taken by the person and, as indicated, by the nurse, to respond with most economical means when regulation is ineffective.
Protection is associated with continuity as disruption in skin integrity resolves when protective measures are taken to prevent further disruption. Figure 2 shows a model of the theory.
Assumptions of the theory
Assumptions of the theory of wound itch are those of Levine's conservation model as described above with several additional assumptions:
Final thoughts on theory formulation
The process of middle-range theory formulation has resulted in a careful analysis of Levine's conservation model. With the overarching conceptual framework from nursing, the deductive processes allowed for theory generation clearly within the discipline of nursing. As noted by Walker and Avant (2005), middle-range theories become reference points for further refining grand theories to which they are connected.
Theory development was done freely within the context of discovery. The context of discovery is theory generation and should be kept separate from the context of justification that is theory evaluation (Walker and Avant, 2005). Prematurely imposing the standards and methods used in theory evaluation on theory generation can result in rejection of otherwise promising theories and stifling of the creative process.
The theory of wound itch contains newly derived concepts and propositions. Further substruction will result in the empirical level of the middle-range theory to ready the theory for clinical testing. As previously noted, wound itch is not well understood and has not been thoroughly explored. The formulation of a middle-range theory of wound itch will provide a basis for the study of wound-related itch by nurses to build the science and practice of nursing.