Situation-specific Theory Research Articles

Abstract 11819: Self-Care Adherence and Related Factors in Koreans With Heart Failure

Introduction: Self-care is pivotal in managing heart failure (HF). However, patients’ adherence to self-care and associated factors are not fully understood in Koreans with HF. The aim of this secondary analysis was to assess the level of adherence to self-care and to identify associated factors in patients with HF. Methods: We analyzed baseline data from 122 HF patients (mean age 66.22 [SD 13.58] years; 50.8% female) enrolled in a randomized controlled trial. To determine adherence to self-care behaviors, the proportion of patients answering “completely agree” or “agree” to each item in the European self-care behavior scale (EHFScBS) was calculated. Based on the situation-specific theory of HF self-care, we investigated the effects of person-related factors (i.e., age, sex, socioeconomic status, health literacy, and self-efficacy), problem factors (i.e., multimorbidity, physical functioning, and depression), environmental factor (i.e., social support), and knowledge on adequate self-care (EHFScBS score ≥ 70) using logistic regression analyses. Results: The mean EHFScBS score was 58.29 (SD 19.23), and 34 patients (27.9%) reported adequate self-care. The adherence rate was lowest for fluid restriction (25.4%) and low salt diet (36.1%). Self-care confidence, depressive symptoms, and social support were significantly associated with adequate self-care in univariate analyses (Table 1). After adjusting for other factors, higher levels of self-care confidence (adjusted odds ratio 1.03, p =.004) and lower levels of depressive symptoms (adjusted odds ratio 0.89, p =.03) were significant factors for adequate self-care. Conclusions: Efforts are needed to help patients with HF to engage in self-care practice. Self-care interventions should focus on promoting self-care confidence and reducing depressive symptoms in patients with HF. Routine assessment of self-care confidence and depressive symptoms may help clinicians to identify high-risk patients.

Fostering Scholarly Development in Nursing Science: The Promise of Dimensional Analysis.

Scholarly development in nursing science is a challenging process of academic evolution. In doctoral programs, students move from mastering technical research skills toward developing scholarly identities. This article explores the utility of dimensional analysis as a method of inquiry for nursing PhD students seeking to deepen their scholarly development when completing course assignments and reaching doctoral program milestones. Using a brief case study, dimensional analysis was described as an interactionist method used to develop grounded theory and illustrate application of the method throughout a 3-year nursing PhD program. Nursing PhD students have the opportunity to drive the depth of their own scholarly development through engaging with theory, method, and independent inquiry. Dimensional analysis holds promise for scholars to simultaneously develop methodological skill, derive situation-specific theory, ground a program of research, and anchor that program of research with theory and method. [J Nurs Educ. 2023;62(2):112-115.].

The Situation-Specific Theory of Heart Failure Self-Care Updated: Analysis and Evaluation for Use in Coronary Disease

The Situation-Specific Theory of Self-Care in Heart Failure Updated proposes and explains how situational (person, problem, and environment) and process factors influence self-care actions. The updating of the Theory provides us with a framework to propose process factors as mediators in the influence of self-care. At present, an analysis and evaluation of the Theory for its use in coronary diseases has not been carried out. Objective: to analyze and evaluate the Theory of the Specific Situation of Self-Care in Heart Failure Updated, for its use in research on other coronary disease. Method: The theoretical analysis was carried out according to the analysis strategy proposed by Walker and Avant, which consist of: identifying the origins of the theory, examining the meaning of the theory, logical consistency, utility, transferability, and parsimony. Original indexed studies using the Updated Theory were analyzed. Conclusion: The Theory presents concepts that are simple in their definitions and easy to be explored and measured. The theoretical structure allows hypothesizing that process factors can be tested as mediators or moderators between situational factors and self-care actions. The focus of the theory facilitates its use in creating mid-range and situation-specific theories in other chronic diseases. The theory provides a framework to explore new phenomena related to the decision-making process in self-care and the perception of symptoms in patients with coronary heart disease (such as, acute myocardial infarction, coronary syndrome and others), through the use of qualitative, quantitative correlational and mixed research.

A Socioecological Model of Heart Failure Self-Care.

Heart failure is a chronic, progressively worsening condition afflicting more than 64 million individuals worldwide. Heart failure outcomes are influenced by self-care, a naturalistic patient-centered decision-making process. The situation-specific theory of heart failure self-care addresses how this decision-making process determines actions and outcomes. However, little is known about the impact of socioecological determinants of health on heart failure self-care. A theoretical synthesis could advance the situation-specific theory of heart failure self-care through the inclusion of socioecological determinants of health. Thus, socioecological determinants of health related to heart failure self-care can be better explored, understood, and overcome through research and health promotion.

Predictors of Self-care Among Chinese Patients With Chronic Heart Failure: A Situation-Specific Theory-Guided Structural Equation Model Analysis.

Self-care is important for improving the health outcomes of individuals with chronic heart failure (CHF). However, predictors of self-care behaviors remain unclear in Chinese society. The aims of this study were to explore predictors of self-care in Chinese patients with CHF and clarify the complex relationships between predictors and self-care behaviors guided by the Situation-Specific Theory of Heart Failure Self-Care. A cross-sectional study was conducted among individuals hospitalized with CHF in China. Person, problem, and environmental factors pertaining to self-care were collected by a questionnaire survey. Self-care was assessed by the Self-Care of Heart Failure Index version 6. Direct and indirect relationships between factors and self-care behaviors and the mediating role of self-care confidence were analyzed by the structural equation model. In total, 204 participants were involved in this study. The Situation-Specific Theory of Heart Failure Self-Care model demonstrated a good fit (root mean square error of approximation, 0.046; goodness of fit index, 0.966; normed fit index, 0.914; comparative fit index, 0.971). Inadequate self-care capabilities were common among Chinese patients with CHF. Person-related factors (female gender, higher monthly income and educational level), problem-related factors (severe New York Heart Association function class and better instrumental activities of daily living), and environmental factors (better social support and living in more developed areas) were significant predictors of better self-care behaviors ( P < .05). These associations were partly or fully mediated by self-care confidence. The Situation-Specific Theory of Heart Failure Self-Care can be used to guide research and practice in patients with CHF. Interventions and policies on promoting self-care in Chinese population living with CHF are encouraged, particularly for underserved populations.

The Situation-Specific Theory of Heart Failure Self-care: An Update on the Problem, Person, and Environmental Factors Influencing Heart Failure Self-care.

Many studies of heart failure (HF) self-care have been conducted since the last update of the situation-specific theory of HF self-care.ObjectiveThe aim of this study was to describe the manner in which characteristics of the problem, person, and environment interact to influence decisions about self-care made by adults with chronic HF.MethodsThis study is a theoretical update. Literature on the influence of the problem, person, and environment on HF self-care is summarized.ResultsConsistent with naturalistic decision making, the interaction of the problem, person, and environment creates a situation in which a self-care decision is needed. Problem factors influencing decisions about HF self-care include specific conditions such as cognitive impairment, diabetes mellitus, sleep disorders, depression, and symptoms. Comorbid conditions make HF self-care difficult for a variety of reasons. Person factors influencing HF self-care include age, knowledge, skill, health literacy, attitudes, perceived control, values, social norms, cultural beliefs, habits, motivation, activation, self-efficacy, and coping. Environmental factors include weather, crime, violence, access to the Internet, the built environment, social support, and public policy.ConclusionsA robust body of knowledge has accumulated on the person-related factors influencing HF self-care. More research on the contribution of problem-related factors to HF self-care is needed because very few people have only HF and no other chronic conditions. The research on environment-related factors is particularly sparse. Seven new propositions are included in this update. We strongly encourage investigators to consider the interactions of problem, person, and environmental factors affecting self-care decisions in future studies.

Healthy life of Korean patients with chronic kidney failure undergoing hemodialysis: A situation-specific nursing theory

PurposeThis study explored to develop a situation-specific theory explaining the healthy life of Korean patients with chronic kidney failure undergoing hemodialysis. BackgroundChronic kidney failure (CKF) patients have to reorganize their lives around their hemodialysis sessions for their survival. Nursing interventions based on specific theories may promote their health-related behaviors and outcomes. However, few theoretical frameworks or theories are available to guide hemodialysis patients on how to construct their lives under various constraints, while considering their experiences and sociocultural contexts. MethodsAn integrated approach was used to develop the situation-specific theory based on the network episode model (NEM), a review of related literature, and four of the authors' studies on hemodialysis patients' lives. ResultsThe major concepts in the proposed theory include sociocultural context, social networks, individual-level factors, illness experiences, health-related behaviors, and health outcomes. Each major concept includes several relevant subconcepts. ConclusionsWe used this theory to identify factors involved in shaping the illness experiences, health-related behaviors, and outcomes of Korean CKF patients undergoing hemodialysis. By exploring the links between these factors, we explained the healthy life that considers the uniqueness of Korean patients' sociocultural context, social network, and individual-level factors. Nurse and other healthcare professionals could integrate the proposed situation-specific theory into the development of nursing interventions based on this theory to promote health-related behaviors and outcomes of Korean CKF patients undergoing hemodialysis.

Empirical Indicators: Conceptual and Theoretical Origins

This paper discusses the connections between nursing conceptual model concepts, middle-range theory, and situation-specific theory concepts, as well as between the theory concepts and how they are measured, that is, empirical indicators. Three types of empirical indicators are described—instruments, assessment tools, and interventions—and an example of each type is given. The paper’s central thesis is that a conceptual model concept is —or should be— the starting point for selecting or constructing an empirical indicator.

The Development of a Situation-Specific Nurse-Led Culturally Tailored Self-Management Theory for Chinese Patients With Heart Failure.

Self-management is essential for treating heart failure (HF). Culture influences the ability to cope, negotiate, and adopt self-management behaviors. However, current HF self-management interventions for Chinese patients do not take culture into consideration. The aim of this article is to describe the development of a situation-specific nurse-led culturally tailored self-management theory for Chinese patients with HF. An integrative approach was used as theory development strategy for the situation-specific theory. Based on theoretical and empirical evidence, and theorists' experiences from research and practice, a nurse-led culturally tailored self-management theory for Chinese patients with HF was developed. Researchers addressing health phenomena often have difficulty defining, conceptualizing, and operationalizing culture. The situation-specific theory developed in this study has the potential to increase specificity (i.e., logical adequacy and usefulness) of existing theories while informing the application to nursing practice. Further critique and testing of the situation-specific theory is warranted.

Self-care perception and behaviour in patients with heart failure: A qualitative and quantitative study.

Background and objectiveSelf‐care strategies in heart failure (HF) are effective for disease management, yet adherence in many patients is inadequate. Reasons are presumably multifactorial but remain insufficiently investigated; thus, we aimed to analyse self‐care adherence and associated factors in outpatients with HF.Methods and resultsTo measure self‐care levels and explore barriers and facilitators to self‐care adherence in patients with HF, quantitative study using the European Self‐Care Behaviour Scale (EHFScBS‐9) (n = 80; NYHA II–III, mean age 72 ± 10 years, 58% male) and qualitative study using semi‐structured interviews (n = 32; NYHA II–III, mean age 73 ± 11, 63% male) were conducted. We detected lowest adherence to regular exercise (39%) and contacts with healthcare provider in case of worsening symptoms (47%), whereas adherence was highest for regular medication taking (94%). Using the EHFScBS‐9 standardized cut‐off score ≤ 70, 51% of patients reported inadequate self‐care. Binary logistic regression analysis showed significant influence of education (OR = 0.314, 95% CI: 0.103–0.959) and perceived control (OR = 1.236, 95% CI: 1.043–1.465) on self‐care adequacy. According to the situation‐specific theory of HF self‐care, most commonly reported factors affecting the process of self‐care were knowledge about HF self‐care behaviours (84%), experience with healthcare professionals (84%), beliefs about their expertise (69%) and habits related to medication taking (72%). Among values, working responsibilities (53%) and maintenance of traditions (31%) appeared as the most prevalent socially based values affecting motivation for self‐care. Situational characteristics related to the person (self‐confidence, 53%; adaptive coping strategies, 88%), problem (burdensome breathing difficulties, 56%; co‐morbidities, 81%) and environment (practical support from family/caregivers, 59%; financial difficulties, 50%) were also commonly reported.ConclusionsVarious factors, including health‐related beliefs, habits and socially based values, need to be taken into account when planning self‐care interventions in patients with HF. A patient tailored approach should be based on adequate patient evaluation, taking into consideration the particular personal and social context.

Nurses' Experiences of the COVID-19 Crisis

This study aimed to develop a situation-specific theory to explain nurses' experiences of the COVID-19 crisis. The participants were 16 hospital nurses who experienced the COVID-19 crisis. Data were collected through in-depth individual interviews from September 2, 2020 to January 20, 2021. Transcribed interview contents were analyzed using Corbin and Strauss's grounded theory method. A total of 38 concepts and 13 categories were identified through an open coding process. The core category found was becoming a pioneering nurse who turns crises into opportunities. The causal conditions were the chaos of being exposed defenselessly to an unexpected pandemic, fear caused by a nursing care field reminiscent of a battlefield, and moral distress from failing to protect patients' human dignity. The contextual conditions were feeling like the scapegoat of the hospital organization, increasing uncertainty due to the unpredictable state of COVID-19, and relative deprivation due to inappropriate treatment. The central phenomenon was suffering alone while experiencing the dedication of the COVID-19 hero image. The action/interactional strategy were efforts to find a breakthrough and getting the nurse's mind right, and the intervening conditions were gratitude for those who care for broken hearts and getting used to myself with repetitive work. The Consequences were becoming an independent nurse and frustration with the unchanging reality. This study provides the foundation for the nurse's situation-specific theory of the COVID-19 crisis by defining the crisis perceived by nurses who cared for COVID-19 patients and suggesting types of coping with the crisis.

Exploring Inner Strength in People Aging With Serious Illness and Cognitive Impairment

Inner strength is a psychological resource that supports people as they move through challenging life events. Understanding how people living with serious illness conceptualize inner strength is key in informing person-centered healthcare. This concept analysis used dimensional analysis methods to explore the nature of inner strength in people aging with serious illness to define a situation specific theory. 1212 abstracts and articles from the published literature were reviewed. 30 articles were included and analyzed as data sources. The resulting explanatory matrix conceptualized inner strength in people as an inward and outward process of “meeting me” – an authentic version of oneself – in the context of shifting health. Of note, while other serious illnesses were represented, no literature focused on dementia. Understanding inner strength in people with dementia is the next step for further inquiry. A pilot study exploring feasibility and informing further research is planned.

The Influence of Preparedness, Mutuality, and Self-efficacy on Home Care Workers' Contribution to Self-care in Heart Failure: A Structural Equation Modeling Analysis.

Home care workers (HCWs) are increasingly caring for patients with heart failure (HF). Previous studies have shown that they contribute to HF patients' care, but how their preparedness and their relationship with patients (mutuality) influence caregiving is unknown, as well as the role of HCWs' self-efficacy. Guided by the Situation-Specific Theory of Caregiver Contribution to HF Self-Care, we investigated the influence of HCWs' preparedness and mutuality on HCWs' contribution to HF self-care and the mediating effect of HCWs' self-efficacy in the process. We conducted a cross-sectional survey of HCWs who cared for patients with HF. The survey included the Caregiver Preparedness Scale, Mutuality Scale, Caregiver Contribution to Self-Care of HF Index, and Caregiver Self-Efficacy in Contributing to Self-Care Scale. We performed structural equation modeling and a mediation analysis. A total of 317 HCWs employed by 22 unique home care agencies across New York, NY, completed the survey. They had a median age of 50 years, 94% were women, and 44% were non-Hispanic Black. Results demonstrated that mutuality had a direct influence on HCW contribution to self-care and preparedness influenced their contribution to self-care, but only through the mediation of self-efficacy. Home care workers' preparedness, mutuality, and self-efficacy have important roles in influencing their contribution to HF self-care. As a workforce increasingly involved in the care of patients with HF, knowing the mechanisms underpinning HCWs' contribution to self-care may illuminate future interventions aimed at improving their contributions and HF patient outcomes.

Properties of Situation-Specific Theories and Neo-pragmatism.

The purpose of this article is to discuss whether the properties of existing situation-specific theories are congruent with the philosophical stance of neo-pragmatism. A literature review was conducted using PubMed, CINAHL, and PsycInfo with keywords of "situation-specific theory" and "nursing." Fifteen situation-specific theories were included in the analysis. The properties of existing situation-specific theories included "high specificity and low level of abstraction," "context understanding," "direct linkages to research and practice," and "reflecting diversities and complexities with limited generalizability." Finally, the findings are discussed in terms of their linkages to the major tenets of neo-pragmatism.

Nutritional Deficits In Children With Cancer: A Situation-Specific Theory.

To construct a situation-specific theory (SST) to represent nutritional deficits for assessing children with cancer. Literature review. The SST included the definition of key concepts, a pictorial scheme, propositions, causal relationships, and evidence for nursing practice. It was possible to characterize the elements as antecedent and consequent clinical factors to allow for an understanding of the existing relationships between them and their temporality. These elements differed considerably from those included in NANDA International. This study provides additional information so that nurses in clinical practice can infer the presence of nutritional deficits in children with cancer early, given the risk already inherent in the diagnosis of cancer and treatment.

Abstract 223: The Role of Confidence in Home Care Workers' Contribution to Heart Failure Patients' Self-care: Testing a Structural Equation Model

Background: Home healthcare workers (HCWs) frequently care for adults with heart failure (HF). Prior studies have found that HCWs promote HF patients’ self-care, but are poorly prepared to do so and lack confidence. Also, how mutuality (the positive quality of the relationship) between HCWs and HF patients contributes to care is unknown. We investigated these issues quantitatively, guided by the Situation-specific Theory of Caregiver Contribution to HF self-care. We hypothesized that HCW preparedness and mutuality influenced HCW contribution to HF self-care maintenance (behaviors to maintain HF stability) and management (response to HF symptoms), with confidence mediating the relationship. Methods: We conducted a cross-sectional survey of English-speaking HCWs employed by 23 home care agencies who cared for a HF patient in the last year in New York, NY. HCWs completed a sociodemographic questionnaire, the Caregiver Preparedness Scale (CPS), the Mutuality Scale (MS), and the Caregiver Contribution to Self-Care of HF Index (CC-SCHFI), which assesses caregiver contribution to self-care maintenance, management, and caregiver confidence. We tested our hypotheses with structural equation modeling (SEM). Mediation analysis was done to test indirect effects. Results: The 317 HCWs had a median age of 50, 94% were women, 44% were Non-Hispanic Black, 79% had ≥ high school education, 71% were foreign-born, and all spoke English. The HCW had a median of 8.5 years of caregiving experience. Overall, HCWs felt prepared for HF caregiving (CPS mean 3.86 [SD: 0.93]) and had moderately positive relationships with patients (MS mean 3.87 [SD: 0.76]). 63% contributed adequately to self-care maintenance, 22% to self-care management, and 44% felt confident with HF caregiving. The tested model fit the data well (CFI=.98; RMSEA=.04) and showed the following significant relationships: mutuality and preparedness covaried (r=.47); preparedness influenced HCW confidence (b=.79); mutuality influenced HCW contribution to self-care maintenance (b=.25); HCWs confidence influenced their contributions to self-care maintenance (b=.22) and management (b=.52). HCWs’ contribution to self-care maintenance influenced their contribution to self-care management (b=.47). Analysis of the indirect effects showed that HCW confidence fully mediated the relationship between preparedness and contributions to self-care maintenance (effect=.17) and management (effect=.41). Conclusions: While HCWs’ preparedness heavily influenced their contribution to HF self-care, HCWs’ confidence, mediated this relationship. Thus, confidence, a modifiable factor, plays a key role in HCWs’ contribution to HF self-care. As this workforce increasingly cares for HF patients, the mechanisms underpinning the relationships among HCWs’ preparedness, mutuality, confidence, and self-care warrant further study.

Validity and Reliability of the Caregiver Contribution to Self-Care of Heart Failure Index Version 2.

Lay caregivers are important in contributing to self-care of patients with heart failure (HF). The Caregiver Contributions to Self-Care of Heart Failure Index (CC-SCHFI) measures these contributions, but after developing the Situation-Specific Theory of Caregiver Contributions to Heart Failure Self-Care, the CC-SCHFI needed updating to reflect the theory. The aim of this study was to test the psychometric characteristics of the CC-SCHFI 2 that measures caregiver contributions (CC) to HF self-care with 3 scales: CC to self-care maintenance, CC to symptom perception, and CC to self-care management. This is a cross-sectional study. We tested the CC-SCHFI 2 with confirmatory factor analysis, internal consistency, item-total correlations, and test-retest reliability. With the CC-SCHFI 2, we also administered the Self-Care of Heart Failure Index v.7.2 to patients and the Caregiver Contribution to Heart Failure Self-Care Scale to caregivers to assess concurrent validity. A sample of 277 caregivers was enrolled (mean [SD] age, 52.7 [14.9] years; 70.4% female). In confirmatory factor analysis, each CC-SCHFI 2 scale had supportive fit indices: comparative fit index ranged between 0.94 and 0.95, and root mean square error of approximation ranged between 0.05 and 0.07. Internal consistency of the 3 scales was evident with a Cronbach α between .81 and .83 and a global reliability index between 0.79 and 0.86. Item-total correlations were all greater than 0.30. In concurrent validity testing, there were significant correlations between the CC-SCHFI 2 and the Self-Care of Heart Failure Index v.7.2 and the Caregiver Contribution to Heart Failure Self-Care Scale. Test-retest reliability showed intraclass correlation coefficients between 0.72 and 0.91. Testing of the CC-SCHFI 2 supported validity and reliability, indicating that the instrument can be used in clinical practice and research to evaluate CC to the self-care of patients with HF.

The Disease Management Experience of Patients with Asthma: Grounded Theory Approach

The aim of this study was to develop a situation-specific theory to explain the disease management experience of patients with asthma. Twenty participants with asthma were selected using the theoretical sampling method. The data were acquired through in-depth interviews conducted from June to October 2018 and analyzed using the grounded theory approach of Strauss and Corbin. In total, 69 concepts, 30 subcategories, and 13 categories were generated to explain the disease management experience of patients with asthma. The core category of the disease management experience of patients with asthma was 'management of the disease to prevent aggravation of symptoms over the lifetime'. The disease management process of asthma patients included three steps: the 'cognition phase', the 'adjustment phase', and the 'maintenance phase'. However, some patients remained in the 'stagnation phase' of disease management, which represents the result of the continual pursuit of risky health behavior. There were three types of disease management experiences among patients with asthma: 'self-managing', 'partially self-managing', and 'avoidant'. This study shows that patients with asthma must lead their disease management process to prevent exacerbation of their symptoms. It is imperative to develop nursing strategies and establish policies for effective disease management of patients with asthma based on their individual disease management processes and types.

Situation-specific theory of surgical site infection-related stimuli in patients undergoing heart transplantation

Background and objective: Heart transplant is a life-saving treatment and currently is the definitive gold-standard in the treatment of refractory heart failure. Surgical site infection is a serious complication of heart transplantation. A nursing theory predicting consequences related to the management of risk factors for surgical site infection in patients undergoing heart transplantation can be useful to nursing practice. The objective of this study was to develop a situation-specific theory of surgical site infection-related stimuli in patients undergoing heart transplantation.Methods: It was adopted an integrative strategy to develop the theory. Multiple sources of knowledge were accessed. The Roy Adaptation Model was adopted as the foundation for the development of this situation-specific theory in a nursing perspective. A literature review on risk factors for surgical site infection in patients undergoing heart transplantation was conducted. By configuring those sources with practice expertise in a collaborative effort, risk factors for surgical site infection in patients undergoing heart transplantation were classified as contextual or residual stimuli, focal stimulus was defined, and seven theory propositions were developed.Results: Heart transplant surgery was considered as focal stimulus. The contextual stimuli were classified as preoperative, intraoperative, and postoperative contextual stimuli. The residual stimuli were classified as preoperative and intraoperative residual stimuli. No postoperative residual stimulus was identified. Ten theory propositions were created.Conclusions: The emerging theory can help nurses to prevent surgical site infections in patients undergoing heart transplantation. Further developments must be made in order to consider nurse-patient interactions during the prevention of surgical site infections.

Systemic assessment of depressive symptoms among registered nurses: A new situation-specific theory

A mentally-healthy nursing workforce is vital to providing quality healthcare. While there has been research conducted internationally on depressive symptoms in nurses, most studies have lacked a theoretical framework. The purpose of this article is to describe the development of a situation-specific theory, the Systemic Assessment of Depressive Symptoms among Registered Nurses (SAD-RN). The SAD-RN was developed through theory synthesis using the Roy's Adaptation Model (RAM) as a framework. Sixty-four research articles were selected to abstract relevant concepts based on a priori RAM concepts. Using depressive symptoms as the anchor concept, related emergent concepts of SAD-RN include context, stressors, protective factors, negative health outcomes, and low patient care quality. SAD-RN is an evidence-based comprehensive model that offers researchers a guiding theory to be used in their future research on depressive symptoms among RNs.