Nursing and Health Interventions. Souraya Sidani

are considered as potential moderators, indicating the need for tailoring of the intervention (Fleury & Sidani, 2018).

      3.2.2 Consequences of the Problem

      Consequences of the health problem represent complications that may arise if the problem is not effectively addressed. Complications are changes in condition resulting from the problem and interfering with clients' general functioning, health and well‐being. Examples of consequences associated with insomnia include: physical and mental fatigue that limit physical and psychosocial functioning, which in turn, contributes to accidents. The experience of consequences may be the reason for which clients seek healthcare. As such, interventions are designed to address the health problem with the ultimate goal of preventing or minimizing the severity of its consequences.

      3.2.3 Illustrative Example

Once developed, the theory or logic model of the health problem is presented textually to detail the conceptual and operational definitions of the problem; identify and describe its determinants and consequences; and explain the proposed direct and indirect (mediated and/or moderated) relationships among them. The theory is also summarized in a table and its main propositions illustrated in a figure. Table 3.1 and Figure 3.1 illustrate the theory of insomnia.

3.3 APPROACHES FOR GENERATING THEORY OF THE HEALTH PROBLEM

Different approaches can be utilized, independently or in combination, to gain an understanding of the health problem and generate a theory of the problem. The approaches include theoretical, empirical, and experiential. They reflect different logic and methods of reasoning: deductive (top‐down), inductive (bottom‐up), retroductive (backtracking process of logical inference going beyond an existing theory and empirical observations), and abductive (alternative explanation process). The approaches can be used independently. With the emphasis on evidence‐based practice, the empirical approach was considered the most robust. With the recent emphasis on client engagement in the design of health services and in research, and the widening recognition of the role of context in health and healthcare, the experiential approach has been increasingly advocated. Since each approach has its strengths and limitations, the use of a combination of approaches is recommended (e.g. Aráujo‐Soares et al., 2018; Bartholomew et al., 2016; Bleijenberg et al., 2018) to develop a comprehensive understanding of the health problem as experienced by the target client population in the respective context. The approaches and methods for applying them are discussed next.

TABLE 3.1 Summary of the theory of insomnia.

Conceptual definition	Nature	Insomnia is conceptualized as a learned behavior Insomnia refers to self‐reported disturbed sleep in the presence of adequate opportunity and circumstances for sleep Insomnia is actually experienced by clients across the life span
Operational definition	Defining indicators	Types: Insomnia is manifested in any or a combination of difficulty initiating or maintain sleep Levels: Sleep difficulties reported at ≥30 minutes per night, reported on ≥3 nights per week
	Severity	Insomnia Severity Index total score: ≤7 = no clinically significant insomnia 8–14 = subthreshold insomnia 15–21 = clinical insomnia of moderate severity 22–28 = clinically severe insomnia
	Duration	Acute insomnia: indicators experienced at the specified level, periodically for <3 months Chronic insomnia: indicators experienced at the specified level for ≥3 months
Contributing factors	Determinants	Precipitating factors: onset of illness, stress, life or work‐related events that disrupt sleep
		Perpetuating factors: cognitions (unrealistic beliefs about sleep, insomnia and its consequences); general behaviors (physical inactivity, smoking); sleep habits or behaviors (irregular sleep schedules, engaging in activities in bed); and engagement in behaviors (extended time in bed) that fuel or maintain insomnia
	Moderators	Predisposing factors: innate characteristics (age, sex, familial or genetic tendency) that increase vulnerability to poor sleep
	Environment	Features (light, noise, temperature) in the sleep environment that interfere with good sleep
Consequences		Physical and mental daytime fatigue; reduced engagement in physical and psychosocial functions; home, work, or traffic accidents; development of physical (e.g. hypertension) and psychological (e.g. depression) health conditions

FIGURE 3.1 Representation of theory of insomnia.

      3.3.1 Theoretical Approach

      3.3.1.1 Overview

      The theoretical approach relies on relevant theories to develop an understanding of the health problem requiring intervention. Middle range theories are most useful because they describe the health problem and explain its associations with determinants, within a particular context (Moore & Evans, 2017).

       Elements of Theory

      Theories consist of a group of statements, based on careful reasoning and/or evidence that present a systematic and logical view of the health problem. The statements are logically organized to identify, define, and describe the problem and its determinants, and to explain the direct and indirect relationships among the determinants and the problem. The explanations clarify conceptually why and how the relationships come about, that is, what goes on that connects each determinant to the problem. For example, the following pathway explains the association between age and insomnia: As individuals age, they spend more time in light, than deep, stages of sleep; they are prone to arousability resulting in frequent awakenings during the night, manifested in difficulty maintaining sleep.

       Types of Relationships

      A direct relationship reflects an immediate linkage between a determinant and the problem, where the problem flows straightforwardly from or is a function of the determinant. For example, there is a direct association between caffeine and nicotine intake close to bedtime and insomnia; caffeine and nicotine are stimulants that interfere with sleep.

An indirect relationship can take either of two forms: mediated or moderated. The relationship between a determinant and the health problem is considered mediated when another factor intervenes between the two, whereby the determinant influences the mediator (also called intervening factor), which in turn affects the health problem (MacKinnon & Fairchild, 2009). For example, cognitions are erroneous beliefs, resulting from worry or rumination about sleep‐related issues such as inability to get eight hours of sleep and