Nursing Theorists
AND THEIR WORK
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Nursing Theorists
AND THEIR WORK
Martha Raile Alligood, PhD, RN, ANEF
Professor Emeritus
College of Nursing
East Carolina University
Greenville, North Carolina
3251 Riverport Lane
St. Louis, Missouri 63043
NURSING THEORISTS AND THEIR WORK, EIGHTH EDITION ISBN: 978-0-323-09194-7
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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Library of Congress Cataloging-in-Publication Data
Nursing theorists and their work / [edited by] Martha Raile Alligood. — Eighth edition.
p. ; cm.
Includes biographical references and index.
ISBN 978-0-323-09194-7 9pbk. ; alk. Paper)
I. Alligood, Martha Raile, editor of compilation.
[DNLM: 1. Nursing Theory. 2. Models, Nursing. 3. Nurses—Biography. Philosophy, Nursing. WY 86]
RT84.5
610.7301—dc23
2013023220
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Dedicated to the memory of my mother:
Winifred Havener Raile, RN
1914-2012
Class of 1936,
Good Samaritan School of Nursing,
Zanesville, Ohio
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Contributors
Herdis Alvsvåg, RN, Cand Polit Janet Witucki Brown, PhD, RN, CNE
Associate Professor Associate Professor
Department of Education and Health Promotion College of Nursing
University of Bergen University of Tennessee
Bergen, Norway; Knoxville, Tennessee
Associate Professor II
Bergen Deaconess University College Karen A. Brykczynski, PhD, RN, FNP-BC,
Bergen, Norway FAANP, FAAN
Professor
Donald E. Bailey, Jr., PhD, RN School of Nursing at Galveston
Associate Professor The University of Texas Medical Branch
School of Nursing Galveston, Texas
Duke University
Durham, North Carolina Sherrilyn Coffman, PhD, RN
Professor and Assistant Dean
Barbara Banfield, RN, PhD School of Nursing
Farmington Hills, Michigan Nevada State College
Henderson, Nevada
Violeta A. Berbiglia, EdD, MSN, RN
Associate Professor, Retired Doris Dickerson Coward, RN, PhD
The University of Texas Health Science Center Associate Professor, Retired
at San Antonio School of Nursing School of Nursing
San Antonio, Texas The University of Texas at Austin
Austin, Texas
Debra A. Bournes, RN, PhD
Director of Nursing Thérèse Dowd, PhD, RN, HTCP
New Knowledge and Innovation Associate Professor Emeritus
University Health Network College of Nursing
Toronto, Canada The University of Akron
Akron, Ohio
Nancy Brookes, PhD, RN, BC, MSc (A),
CPMHN (C) Nellie S. Droes, DNSc, RN
Nurse Scholar and Adjunct Professor Associate Professor, Emerita
Royal Ottawa Health Care Group College of Nursing
Royal Ottawa Mental Health Centre East Carolina University
University of Ottawa Faculty of Health Sciences Greenville, North Carolina
Ottawa, Ontario, Canada
vii
viii Contributors
Margaret E. Erickson, PhD, RN, CNS, AHN-BC D. Elizabeth Jesse, PhD, RN, CNM
Executive Director Associate Professor
American Holistic Nurses’ Certification Corporation College of Nursing
Cedar Park, Texas East Carolina University
Greenville, North Carolina
Mary E. Gunther, RN, MSN, PhD
Associate Professor Lisa Kitko, PhD, RN, CCRN
College of Nursing Assistant Professor
University of Tennessee School of Nursing
Knoxville, Tennessee The Pennsylvania State University
University Park, Pennsylvania
Dana M. Hansen, RN, MSN, PhD
Assistant Professor Theresa Gunter Lawson, PhD, APRN, FNP-BC
College of Nursing Assistant Professor
Kent State University Department of Nursing
Kent, Ohio Lander University
Greenwood, South Carolina
Sonya R. Hardin, PhD, RN, CCRN, NP-C
Professor Unni Å. Lindström, PhD, RN
College of Nursing Professor
East Carolina University Department of Caring Science
Greenville, North Carolina Faculty of Social and Caring Sciences
Åbo Academy University
Robin Harris, PhD, ANP-BC, ACNS-BC Vasa, Finland
Nurse Practitioner
Wellmont CVA Heart Institute M. Katherine Maeve, PhD, RN
Kingsport, Tennessee Nurse Researcher
Charlie Norwood VAMC
Patricia A. Higgins, PhD, RN Augusta, Georgia
Assistant Professor
Frances Payne Bolton School of Nursing Marilyn R. McFarland, PhD, RN, FNP, BC, CTN
Case Western Reserve University Associate Professor of Nursing and Family Nurse
Cleveland, Ohio Practitioner
Urban Health and Wellness Center
Bonnie Holaday, DNS, RN, FAAN University of Michigan
Professor and Director, Graduate Studies Flint, Michigan
School of Nursing and Institute on Family and
Neighborhood Life Gwen McGhan, PhD(c), RN
Clemson University Jonas/Hartford Doctoral Scholar
Clemson, South Carolina School of Nursing
The Pennsylvania State University
Eun-Ok Im, PhD, MPH, RN, CNS, FAAN University Park, Pennsylvania
Professor and Marjorie O. Rendell Endowed
Professor Molly Meighan, RNC, PhD
School of Nursing Professor Emerita
The University of Pennsylvania Division of Nursing
Philadelphia, Pennsylvania Carson-Newman College
Jefferson City, Tennessee
Contributors ix
Patricia R. Messmer, PhD, RN-BC, FAAN Marguerite J. Purnell, PhD, RN, AHN-BC
Director Assistant Professor
Patient Care Services Research Christine E. Lynn College of Nursing
Children’s Mercy Hospital and Clinics Florida Atlantic University
Kansas City, Missouri Boca Raton, Florida
Gail J. Mitchell, PhD, RN, MScN, BScN Teresa J. Sakraida, PhD, RN
Professor Assistant Professor
School of Nursing College of Nursing
Chair/Director University of Colorado, Denver
York-UHN Nursing Academy Aurora, Colorado
York University
Toronto, Ontario, Canada Karen Moore Schaefer, PhD, RN
Associate Chair and Associate Professor, Retired
Lisbet Lindholm Nyström, PhD, RN Department of Nursing
Associate Professor College of Health Professions
Department of Caring Science Temple University
Faculty of Social and Caring Sciences Philadelphia, Pennsylvania
Åbo Academy University
Vasa, Finland Ann M. Schreier, PhD, RN
Associate Professor
Janice Penrod, PhD, RN, FGSA, FAAN College of Nursing
Director, Center for Nursing Research East Carolina University
Associate Professor Greenville, North Carolina
School of Nursing
The Pennsylvania State University Carrie J. Scotto, PhD, RN
University Park, Pennsylvania Associate Professor
College of Nursing
Susan A. Pfettscher, DNSc, RN University of Akron
Retired Akron, Ohio
Bakersfield, California
Christina L. Sieloff, PhD, RN, NE, BC
Kenneth D. Phillips, PhD, RN Associate Professor
Professor and Associate Dean for Research and College of Nursing
Evaluation Montana State University
College of Nursing Billings, Montana
The University of Tennessee
Knoxville, Tennessee Janet L. Stewart, PhD, RN
Assistant Professor
Marie E. Pokorny, PhD, RN Department of Health Promotion and Development
Director of the PhD Program School of Nursing
College of Nursing University of Pittsburgh
East Carolina University Pittsburgh, Pennsylvania
Greenville, North Carolina
x Contributors
Danuta M. Wojnar, PhD, RN, MEd, IBCLC Joan E. Zetterlund, PhD, RN
Assistant Professor Professor Emerita of Nursing
College of Nursing School of Nursing
Seattle University North Park University
Seattle, Washington Chicago, Illinois
Reviewers
Jean Logan, RN, PhD Nancy Stahl, RN, MSN, CNE
Professor Associate Professor
Grand View University BSN Coordinator
Des Moines, Iowa University of North Georgia
Dahlonega, Georgia
Karen Pennington, PhD, RN
Associate Professor
Regis University
Denver, Colorado
xi
About the Editor
Martha Raile Alligood is professor emeritus at East Carolina University College of Nursing in Greenville,
North Carolina, where she was Director of the Nursing PhD program. A graduate of Good Samaritan School of
Nursing, she also holds a bachelor of sacred literature (BSL) from Johnson University, a BSN from University of
Virginia, an MS from The Ohio State University, and a PhD from New York University.
Her career in nursing education began in Zimbabwe (formerly Rhodesia) in Africa and has included graduate
appointments at the University of Florida, University of South Carolina, and University of Tennessee. Among
her professional memberships are Epsilon and Beta Nu Chapters of Sigma Theta Tau International (STTI),
Southern Nursing Research Society (SNRS), North Carolina Nurses Association/American Nurses Association
(NCNA/ANA), and Society of Rogerian Scholars (SRS).
A recipient of numerous awards and honors, she is a Fellow of the National League for Nursing (NLN) Acad-
emy of Nursing Education, received the SNRS Leadership in Research Award, and was honored with the East
Carolina University Chancellors’s Women of Distinction Award. A member of the Board of Trustees at Johnson
University, Dr. Alligood chairs the Academic Affairs Committee.
She served as contributing editor for the Theoretical Concerns column in Nursing Science Quarterly, Vol. 24,
2011, and is author/editor of Nursing Theory: Utilization & Application, fifth edition, as well as this eighth edition
of Nursing Theorists and Their Work.
xii
Preface
his book is a tribute to nursing theorists and a classic in theoretical nursing literature. It presents many
major thinkers in nursing, reviews their important knowledge-building ideas, lists their publications, and
Tpoints the reader to those using the works and writing about them in their own theoretical publications.
Unit I introduces the text with a brief history of nursing knowledge development and its significance to the
discipline and practice of the profession in Chapter 1. Other chapters in Unit I discuss the history, philosophy
of science and the framework for analysis used throughout the text, logical reasoning and theory development
processes, and the structure of knowledge and types of knowledge within that structure. Ten works from earlier
editions of Nursing Theorists and Their Work are introduced and discussed briefly as nursing theorists of
historical significance in Chapter 5. They are Peplau; Henderson; Abdellah; Wiedenbach; Hall; Travelbee;
Barnard; Adam; Roper, Logan, Tierney, and Orlando.
In Unit II, the philosophies of Nightingale, Watson, Ray, Benner, Martinsen, and Eriksson are presented.
Unit III includes nursing models by Levine, Rogers, Orem, King, Neuman, Roy, and Johnson. The work of
Boykin and Schoenhofer begins Unit IV on nursing theory, followed by the works of Meleis; Pender; Leininger;
Newman; Parse; Erickson, Tomlin, and Swain; and the Husteds. Unit V presents middle range theoretical works
of Mercer; Mishel; Reed; Wiener and Dodd; Eakes, Burke, and Hainsworth; Barker; Kolcaba; Beck; Swanson;
Ruland and Moore. Unit VI addresses the state of the art and science of nursing theory from three perspectives:
the philosophy of nursing science, the expansion of theory development, and the global nature and expanding
use of nursing theoretical works.
The works of nurse theorists from around the world are featured in this text, including works by international
theorists that have been translated into English. Nursing Theorists and Their Work has also been translated into
numerous languages for nursing faculty and students in other parts of the world as well as nurses in practice.
Nurses and students at all stages of their education are interested in learning about nursing theory and
the use of nurse theorist works from around the world. Those who are just beginning their nursing education,
such as associate degree and baccalaureate students, will be interested in the concepts, definitions, and theoreti-
cal assertions. Graduate students, at the masters and doctoral levels, will be more interested in the logical form,
acceptance by the nursing community, the theoretical sources for theory development, and the use of empirical
data. The references and extensive bibliographies are particularly useful to graduate students for locating
primary and secondary sources that augment the websites specific to the theorist. The following comprehensive
websites are excellent resources with information about theory resources and links to the individual theorists
featured in this book:
• Nursing Theory link page, Clayton College and State University, Department of Nursing: http: //www.
healthsci.clayton.edu/eichelberger/nursing.htm
• Nursing Theory page, Hahn School of Nursing and Health Science, University of San Diego: http: //www.
sandiego.edu/academics/nursing/theory/
• A comprehensive collection of nursing theory media, The Nurse Theorists: Portraits of Excellence, Vol. I and
Vol. II and Nurse Theorists: Excellence in Action: http: //www.fitne.net/
The works of the theorists presented in this text have stimulated phenomenal growth in nursing literature and
enriched the professional lives of nurses around the world by guiding nursing research, education, administra-
tion, and practice. The professional growth continues to multiply as we analyze and synthesize these works,
xiii
xiv Preface
generate new ideas, and develop new theory and applications for education in the discipline and quality care in
practice by nurses.
The work of each theorist is presented with a framework using the following headings to facilitate uniformity
and comparison among the theorists and their works:
• Credentials and background
• Theoretical sources for theory development
• Use of empirical data
• Major concepts and definitions
• Major assumptions
• Theoretical assertions
• Logical form
• Acceptance by the nursing community
• Further development
• Critique of the work
• Summary
• Case study based on the work
• Critical thinking activities
• Points for further study
• References and bibliographies
Acknowledgments
I am very thankful to the theorists who critiqued the original and many subsequent chapters about themselves
to keep the content current and accurate. The work of Paterson and Zderad was omitted at their request.
I am very grateful to those who have contributed or worked behind the scenes with previous editions to
develop this text over the years. In the third edition, Martha Raile Alligood joined Ann Marriner Tomey, to
reorder the chapters, serve as a contributing author, and edit for consistency with the new organization of the
text. Subsequently Dr. Tomey recommended Dr. Alligood to Mosby-Elsevier to design and coedit a practice
focused text, Nursing Theory: Utilization and Application and based on Alligood’s expertise in nursing theory,
invited her to become coeditor and contributing author to future editions of this text, Nursing Theorists and Their
Work. I want to recognize and thank Ann Marriner Tomey for her vision to develop the first six editions of this
book. Her mentorship, wisdom, and collegial friendship have been special to me in my professional career. Most
of all, she is to be commended for her dedication to this text that continues to make an important and valuable
contribution to the discipline and the profession of nursing. I wish Ann well in her retirement.
Finally, I would like to thank the publishers at Mosby-Elsevier for their guidance and assistance through
the years to bring this text to this eighth edition. The external reviews requested by Mosby-Elsevier editors
have contributed to the successful development of each new edition. The chapter authors who over the years
have contributed their expert knowledge of the theorists and their work continue to make a most valuable
contribution.
Martha Raile Alligood
Contents
UNIT I Evolution of Nursing Theories
1 Introduction to Nursing Theory: Its History, Significance, and Analysis, 2
Martha Raile Alligood
2 History and Philosophy of Science, 14
Sonya R. Hardin
3 Theory Development Process, 23
Sonya R. Hardin
4 The Structure of Specialized Nursing Knowledge, 38
Martha Raile Alligood
5 Nursing Theorists of Historical Significance, 42
Marie E. Pokorny
Hildegard E. Peplau
Virginia Henderson
Faye Glenn Abdellah
Ernestine Wiedenbach
Lydia Hall
Joyce Travelbee
Kathryn E. Barnard
Evelyn Adam
Nancy Roper, Winifred W. Logan, and Alison J. Tierney
Ida Jean (Orlando) Pelletier
UNIT II Nursing Philosophies
6 Florence Nightingale: Modern Nursing, 60
Susan A. Pfettscher
7 Jean Watson: Watson’s Philosophy and Theory of Transpersonal Caring, 79
D. Elizabeth Jesse and Martha R. Alligood
8 Marilyn Anne Ray: Theory of Bureaucratic Caring, 98
Sherrilyn Coffman
9 Patricia Benner: Caring, Clinical Wisdom, and Ethics in Nursing Practice, 120
Karen A. Brykczynski
10 Kari Martinsen: Philosophy of Caring, 147
Herdis Alvsvåg
11 Katie Eriksson: Theory of Caritative Caring, 171
Unni Å. Lindström, Lisbet Lindholm Nyström, and Joan E. Zetterlund
xv
xvi Contents
UNIT III Nursing Conceptual Models
12 Myra Estrin Levine: The Conservation Model, 204
Karen Moore Schaefer
13 Martha E. Rogers: Unitary Human Beings, 220
Mary E. Gunther
14 Dorothea E. Orem: Self-Care Deficit Theory of Nursing, 240
Violeta A. Berbiglia and Barbara Banfield
15 Imogene M. King: Conceptual System and Middle-Range Theory of Goal Attainment, 258
Christina L. Sieloff and Patricia R. Messmer
16 Betty Neuman: Systems Model, 281
Theresa G. Lawson
17 Sister Callista Roy: Adaptation Model, 303
Kenneth D. Phillips and Robin Harris
18 Dorothy E. Johnson: Behavioral System Model, 332
Bonnie Holaday
UNIT IV Nursing Theories
19 Anne Boykin and Savina O. Schoenhofer: The Theory of Nursing as Caring: A Model for
Transforming Practice, 358
Marguerite J. Purnell
20 Afaf Ibrahim Meleis: Transitions Theory, 378
Eun-Ok Im
21 Nola J. Pender: Health Promotion Model, 396
Teresa J. Sakraida
22 Madeleine M. Leininger: Culture Care Theory of Diversity and Universality, 417
Marilyn R. McFarland
23 Margaret A. Newman: Health as Expanding Consciousness, 442
Janet Witucki Brown and Martha Raile Alligood
24 Rosemarie Rizzo Parse: Humanbecoming, 464
Debra A. Bournes and Gail J. Mitchell
25 Helen C. Erickson, Evelyn M. Tomlin, Mary Ann P. Swain:
Modeling and Role-Modeling, 496
Margaret E. Erickson
26 Gladys L. Husted and James H. Husted: Symphonological Bioethical Theory, 520
Carrie Scotto
UNIT V Middle Range Nursing Theories
27 Ramona T. Mercer: Maternal Role Attainment—Becoming a Mother, 538
Molly Meighan
28 Merle H. Mishel: Uncertainty in Illness Theory, 555
Donald E. Bailey, Jr. and Janet L. Stewart
Contents xvii
29 Pamela G. Reed: Self-Transcendence Theory, 574
Doris D. Coward
30 Carolyn L. Wiener and Marylin J. Dodd: Theory of Illness Trajectory, 593
Janice Penrod, Lisa Kitko, and Gwen McGhan
31 Georgene Gaskill Eakes, Mary Lermann Burke, and Margaret A. Hainsworth:
Theory of Chronic Sorrow, 609
Ann M. Schreier and Nellie S. Droes
32 Phil Barker: The Tidal Model of Mental Health Recovery, 626
Nancy Brookes
33 Katharine Kolcaba: Theory of Comfort, 657
Thérèse Dowd
34 Cheryl Tatano Beck: Postpartum Depression Theory, 672
M. Katherine Maeve
35 Kristen M. Swanson: Theory of Caring, 688
Danuta M. Wojnar
36 Cornelia M. Ruland and Shirley M. Moore: Peaceful End-of-Life Theory, 701
Patricia A. Higgins and Dana M. Hansen
UNIT VI The Future of Nursing Theory
37 State of the Art and Science of Nursing Theory, 712
Martha Raile Alligood
Index, 721
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I
UNIT
Evolution of Nursing Theories
n Searching for specialized nursing knowledge led nurse scholars to theories
that guide research, education, administration, and professional practice.
n Nursing followed a path from concepts to conceptual frameworks to models
to theories, and finally to middle range theory, in this theory utilization era.
n Nursing history demonstrates the significance of theory for nursing as a
division of education (the discipline) and a specialized field of practice
(the profession).
n Knowledge of the theory development process is basic to a personal
understanding of the theoretical works of the discipline.
n Analysis facilitates learning through systematic review and critical reflection
of the theoretical works of the discipline.
n Theory analysis begins the process of identifying a decision making
framework for nursing research or nursing practice.
1
CHAP TER
Introduction to Nursing Theory:
Its History, Significance, and Analysis
Martha Raile Alligood
“The systematic accumulation of knowledge is essential to progress in any
profession . . . however theory and practice must be constantly interactive.
Theory without practice is empty and practice without theory is blind.”
(Cross, 1981, p. 110).
his text is designed to introduce the reader to Bixler, 1959; Chinn & Kramer, 2011; George, 2011;
Tnursing theorists and their work. Nursing theory Im & Chang, 2012; Judd, Sitzman & Davis, 2010;
became a major theme in the last century, and it con- Meleis, 2007; Shaw, 1993).
tinues today to stimulate phenomenal professional This chapter introduces nursing theory from three
growth and expansion of nursing literature and edu- different perspectives: history, significance, and anal-
cation. Selected nursing theorists are presented in ysis. Each perspective contributes understanding of
this text to expose students at all levels of nursing the contributions of the nursing theorists and their
to a broad range of nurse theorists and various types work. A brief history of nursing development from
of theoretical works. Nurses of early eras delivered vocational to professional describes the search for
excellent care to patients; however, much of what nursing substance that led to this exciting time in
was known about nursing was passed on through nursing history as linkages were strengthened be-
forms of education that were focused on skills and tween nursing as an academic discipline and as pro-
functional tasks. Whereas many nursing practices fessional practice. The history of this development
seemed effective, they were not tested nor used uni- provides context and a perspective to understand the
formly in practice or education. Therefore, a major continuing significance of nursing theory for the dis-
goal put forth by nursing leaders in the twentieth cipline and profession of nursing. The history and
century was the development of nursing knowledge significance of nursing theory leads logically into
on which to base nursing practice, improve quality of analysis, the third section of the chapter and final
care, and gain recognition of nursing as a profession. perspective. Analysis of nursing theoretical works
The history of nursing clearly documents sustained and its role in knowledge development is presented
efforts toward the goal of developing a specialized as an essential process of critical reflection. Criteria
body of nursing knowledge to guide nursing practice for analysis of the works of theorists are presented,
(Alligood, 2010a; Alligood & Tomey, 1997; Bixler & along with a brief discussion of how each criterion
Previous authors: Martha Raile Alligood, Elizabeth Chong Choi, Juanita Fogel Keck, and Ann Marriner Tomey.
2
CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 3
contributes to a deeper understanding of the work and individual hospital procedure manuals (Alligood,
(Chinn & Kramer, 2011). 2010a; Kalisch & Kalisch, 2003). Although some nurs-
ing leaders aspired for nursing to be recognized as a
profession and become an academic discipline, nursing
History of Nursing Theory practice continued to reflect its vocational heritage
The history of professional nursing began with Flor- more than a professional vision. The transition from
ence Nightingale. Nightingale envisioned nurses as vocation to profession included successive eras of his-
a body of educated women at a time when women tory as nurses began to develop a body of specialized
were neither educated nor employed in public service. knowledge on which to base nursing practice. Nurs-
Following her wartime service of organizing and car- ing had begun with a strong emphasis on practice,
ing for the wounded in Scutari during the Crimean and nurses worked throughout the century toward
War, Nightingale’s vision and establishment of a School the development of nursing as a profession. Progress
of Nursing at St. Thomas’ Hospital in London marked toward the goal of developing a specialized basis for
the birth of modern nursing. Nightingale’s pioneering nursing practice has been viewed from the perspec-
activities in nursing practice and education and her tive of historical eras recognizing the thrust toward
subsequent writings became a guide for establishing professional development within each era (Alligood,
nursing schools and hospitals in the United States at 2010a; Alligood & Tomey, 1997).
the beginning of the twentieth century (Kalisch & The curriculum era addressed the question of
Kalisch, 2003; Nightingale, 1859/1969). what content nurses should study to learn how to be
Nightingale’s (1859/1969) vision of nursing has a nurse. During this era, the emphasis was on what
been practiced for more than a century, and theory courses nursing students should take, with the goal
development in nursing has evolved rapidly over the of arriving at a standardized curriculum (Alligood,
past 6 decades, leading to the recognition of nursing 2010a). By the mid-1930s, a standardized curriculum
as an academic discipline with a specialized body had been published and adopted by many diploma
of knowledge (Alligood, 2010a, 2010b; Alligood & programs. However, the idea of moving nursing edu-
Tomey, 2010; Bixler & Bixler, 1959; Chinn & Kramer, cation from hospital-based diploma programs into
2011; Fawcett, 2005; Im & Chang, 2012; Walker & colleges and universities also emerged during this
Avant, 2011). It was during the mid-1800s that Night- era (Judd, Sitzman & Davis, 2010). In spite of this
ingale recognized the unique focus of nursing and early idea for nursing education, it was the middle of
declared nursing knowledge as distinct from medical the century before many states acted upon this goal,
knowledge. She described a nurse’s proper function and during the second half of the twentieth century,
as putting the patient in the best condition for nature diploma programs began closing and significant
(God) to act upon him or her. She set forth the follow- numbers of nursing education programs opened in
ing: that care of the sick is based on knowledge of colleges and universities (Judd, Sitzman, & Davis,
persons and their surroundings—a different knowl- 2010; Kalisch & Kalisch, 2003). The curriculum era
edge base than that used by physicians in their prac- emphasized course selection and content for nursing
tice (Nightingale, 1859/1969). Despite this early edict programs and gave way to the research era, which
from Nightingale in the 1850s, it was 100 years later, focused on the research process and the long-range
during the 1950s, before the nursing profession began goal of acquiring substantive knowledge to guide
to engage in serious discussion of the need to develop nursing practice.
nursing knowledge apart from medical knowledge to As nurses increasingly sought degrees in higher
guide nursing practice. This beginning led to aware- education, the research emphasis era began to emerge.
ness of the need to develop nursing theory (Alligood, This era began during the mid-century as more nurse
2010a; Alligood, 2004; Chinn & Kramer, 2011; Meleis, leaders embraced higher education and arrived at a
2007; Walker & Avant, 2011). Until the emergence of common understanding of the scientific age—that
nursing as a science in the 1950s, nursing practice was research was the path to new nursing knowledge.
based on principles and traditions that were handed Nurses began to participate in research, and research
down through an apprenticeship model of education courses were included in the nursing curricula of early
4 UNIT I Evolution of Nursing Theories
developing graduate nursing programs (Alligood, in education, administration, and practice” (p. 4). An
2010a). In the mid-1970s, an evaluation of the first important precursor to the theory era was the gen-
25 years of the journal Nursing Research revealed that eral acceptance of nursing as a profession and an
nursing studies lacked conceptual connections and academic discipline in its own right.
theoretical frameworks, accentuating the need for The theory era was a natural outgrowth of the re-
conceptual and theoretical frameworks for develop- search and graduate education eras (Alligood, 2010a;
ment of specialized nursing knowledge (Batey, 1977). Im & Chang, 2012). The explosive proliferation of
Awareness of the need for concept and theory devel- nursing doctoral programs from the 1970s and
opment coincided with two other significant mile- nursing theory literature substantiated that nursing
stones in the evolution of nursing theory. The first doctorates should be in nursing (Nicoll, 1986, 1992,
milestone is the standardization of curricula for nurs- 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer,
ing master’s education by the National League for 2009; 2012). As understanding of research and
Nursing accreditation criteria for baccalaureate and knowledge development increased, it became obvi-
higher-degree programs, and the second is the deci- ous that research without conceptual and theoretical
sion that doctoral education for nurses should be in frameworks produced isolated information. Rather,
nursing (Alligood, 2010a). there was an understanding that research and theory
The research era and the graduate education era together were required to produce nursing science
developed in tandem. Master’s degree programs in (Batey, 1977; Fawcett, 1978; Hardy, 1978). Doctoral
nursing emerged across the country to meet the pub- education in nursing began to flourish with the
lic need for nurses for specialized clinical nursing introduction of new programs and a strong emphasis
practice. Many of these graduate programs included on theory development and testing. The theory
a course that introduced the student to the research era accelerated as works began to be recognized as
process. Also during this era, nursing master’s pro- theory, having been developed as frameworks for
grams began to include courses in concept develop- curricula and advanced practice guides. In fact, it
ment and nursing models, introducing students to was at the Nurse Educator Conference in New York
early nursing theorists and knowledge development City in 1978 that theorists were recognized as nurs-
processes (Alligood, 2010a). Development of nursing ing theorists and their works as nursing conceptual
knowledge was a major force during this period. The models and theories (Fawcett, 1984; Fitzpatrick &
baccalaureate degree began to gain wider acceptance Whall, 1983).
as the first educational level for professional nursing, The 1980s was a period of major developments in
and nursing attained nationwide recognition and nursing theory that has been characterized as a tran-
acceptance as an academic discipline in higher edu- sition from the pre-paradigm to the paradigm period
cation. Nurse researchers worked to develop and (Fawcett, 1984; Hardy, 1978; Kuhn, 1970). The pre-
clarify a specialized body of nursing knowledge, with vailing nursing paradigms (models) provided per-
the goals of improving the quality of patient care, spectives for nursing practice, administration, educa-
providing a professional style of practice, and achiev- tion, research, and further theory development. In
ing recognition as a profession. There were debates the 1980s, Fawcett’s seminal proposal of four global
and discussions in the 1960s regarding the proper nursing concepts as a nursing metaparadigm served
direction and appropriate discipline for nursing as an organizing structure for existing nursing frame-
knowledge development. In the 1970s, nursing con- works and introduced a way of organizing individual
tinued to make the transition from vocation to pro- theoretical works in a meaningful structure (Fawcett,
fession as nurse leaders debated whether nursing 1978, 1984, 1993; Fitzpatrick & Whall, 1983). Clas-
should be other-discipline based or nursing based. sifying the nursing models as paradigms within a
History records the outcome, that nursing practice metaparadigm of the person, environment, health,
is to be based on nursing science (Alligood, 2010a; and nursing concepts systematically united the nurs-
Fawcett, 1978; Nicoll, 1986). It is as Meleis (2007) ing theoretical works for the discipline. This system
noted, “theory is not a luxury in the discipline of clarified and improved comprehension of knowledge
nursing . . . but an integral part of the nursing lexicon development by positioning the theorists’ works in a
CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 5
larger context, thus facilitating the growth of nursing exciting new era” (p. 2). This awareness ushered in
science (Fawcett, 2005). The body of nursing science the theory utilization era.
and research, education, administration, and prac- The accomplishments of normal science accompa-
tice continues to expand through nursing scholar- nied the theory utilization era as emphasis shifted
ship. In the last decades of the century, emphasis to theory application in nursing practice, education,
shifted from learning about the theorists to utiliza- administration, and research (Alligood, 2010c; Wood,
tion of the theoretical works to generate research 2010). In this era, middle-range theory and valuing
questions, guide practice, and organize curricula. of a nursing framework for thought and action of
Evidence of this growth of theoretical works has pro- nursing practice was realized. This shift to the appli-
liferated in podium presentations at national and cation of nursing theory was extremely important for
international conferences, newsletters, journals, and theory-based nursing, evidence-based practice, and
books written by nurse scientists who are members future theory development (Alligood, 2011a; Alligood,
of societies as communities of scholars for nursing 2014, in press; Alligood & Tomey, 2010; Alligood &
models and theories. Members contribute to the gen- Tomey, 1997, 2002, 2006; Chinn & Kramer, 2011;
eral nursing literature and communicate their re- Fawcett, 2005; Fawcett & Garity, 2009).
search and practice with a certain paradigm model or The theory utilization era has restored a balance
framework at conferences of the societies where they between research and practice for knowledge devel-
present their scholarship and move the science of the opment in the discipline of nursing. The reader is
selected paradigm forward (Alligood, 2004; Alligood referred to the fifth edition of Nursing Theory: Utili-
2014, in press; Fawcett & Garity, 2009; Im & Chang, zation & Application (Alligood, 2014, in press) for
2012; Parker, 2006). case applications and evidence of outcomes from
These observations of nursing theory develop- utilization of nursing theoretical works in practice.
ment bring Kuhn’s (1970) description of normal Table 1-1 presents a summary of the eras of nursing’s
science to life. His philosophy of science clarifies our search for specialized nursing knowledge. Each era
understanding of the evolution of nursing theory addressed nursing knowledge in a unique way that
through paradigm science. It is important histori- contributed to the history. Within each era, the per-
cally to understand that what we view collectively vading question “What is the nature of the knowl-
today as nursing models and theories is the work of edge that is needed for the practice of nursing?” was
individuals in various areas of the country who pub- addressed at a level of understanding that prevailed
lished their ideas and conceptualizations of nursing. at the time (Alligood, 2010a).
These works later were viewed collectively within This brief history provides some background and
a systematic structure of knowledge according to context for your study of nursing theorists and their
analysis and evaluation (Fawcett, 1984, 1993, 2005). work. The theory utilization era continues today,
Theory development emerged as a process and prod- emphasizing the development and use of nursing
uct of professional scholarship and growth among theory and producing evidence for professional
nurse leaders, administrators, educators, and practi- practice. New theory and new methodologies from
tioners who sought higher education. These leaders qualitative research approaches continue to expand
recognized limitations of theory from other disci- ways of knowing among nurse scientists. The utili-
plines to describe, explain, or predict nursing out- zation of nursing models, theories, and middle-
comes, and they labored to establish a scientific basis range theories for the thought and action of nursing
for nursing management, curricula, practice, and practice contributes important evidence for quality
research. The development and use of theory con- care in all areas of practice in the twenty-first
veyed meaning for nursing processes, resulting in century (Alligood, 2010b; Fawcett, 2005; Fawcett &
what is recognized today as the nursing theory era Garity, 2009; Peterson, 2008; Smith & Leihr, 2008;
(Alligood, 2010a; Alligood 2010b; Nicoll, 1986, 1992, Wood, 2010). Preparation for practice in the pro-
1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, fession of nursing today requires knowledge of
2012; Wood, 2010). It was as Fitzpatrick and Whall and use of the theoretical works of the discipline
(1983) had said, “. . . nursing is on the brink of an (Alligood, 2010c).
6 UNIT I Evolution of Nursing Theories
TABLE 1-1 Historical Eras of Nursing’s Search for Specialized Knowledge
Historical Eras Major Question Emphasis Outcomes Emerging Goal
Curriculum What curriculum content Courses included in Standardized curricula Develop specialized
Era: should student nurses nursing programs for diploma programs knowledge and higher
1900 to 1940s study to be nurses? education
Research Era: What is the focus for Role of nurses and what Problem studies and Isolated studies do not
1950 to 1970s nursing research? to research studies of nurses yield unified knowledge
Graduate Edu- What knowledge is Carving out an advanced Nurses have an impor- Focus graduate educa-
cation Era: needed for the role and basis for tant role in health tion on knowledge
1950 to 1970s practice of nursing? nursing practice care development
Theory Era: How do these frame- There are many ways to Nursing theoretical Theories guide nursing
1980 to 1990s works guide research think about nursing works shift the focus research and practice
and practice? to the patient
Theory What new theories Nursing theory guides Middle-range theory Nursing frameworks
Utilization Era: are needed to produce research, practice, may be from quanti- produce knowledge
Twenty-first evidence of quality education, and tative or qualitative (evidence) for quality
Century care? administration approaches care
Alligood, M. R. (2014, in press). Nursing theory: Utilization & application. Maryland Heights, (MO): Mosby-Elsevier.
Significance of Nursing Theory The achievements of the profession over the past
At the beginning of the twentieth century, nursing century were highly relevant to nursing science devel-
was not recognized as an academic discipline or a opment, but they did not come easily. History shows
profession. The accomplishments of the past century that many nurses pioneered the various causes and
led to the recognition of nursing in both areas. The challenged the status quo with creative ideas for both
terms discipline and profession are interrelated, and the health of people and the development of nursing.
some may even use them interchangeably; however Their achievements ushered in this exciting time
they are not the same. It is important to note their when nursing became recognized as both an aca-
differences and specific meaning, as noted in Box 1-1: demic discipline and a profession (Fitzpatrick, 1983;
Kalisch & Kalisch, 2003; Meleis, 2007; Shaw, 1993).
This section addresses the significance of theoretical
works for the discipline and the profession of nursing.
BOX 1-1 The Meaning of a Discipline Nursing theoretical works represent the most com-
and a Profession prehensive presentation of systematic nursing knowl-
n A discipline is specific to academia and refers edge; therefore, nursing theoretical works are vital to
to a branch of education, a department of the future of both the discipline and the profession
learning, or a domain of knowledge. of nursing.
n A profession refers to a specialized field of prac-
tice, founded upon the theoretical structure of Significance for the Discipline
the science or knowledge of that discipline and Nurses entered baccalaureate and higher-degree
accompanying practice abilities. programs in universities during the last half of the
twentieth century, and the goal of developing knowl-
Data from Donaldson, S. K., & Crowley, D. M. (1978). The discipline of edge as a basis for nursing practice began to be real-
nursing. Nursing Outlook, 26(2), 1113–1120.; Orem, D. (2001). Nursing:
Concepts of practice (6th ed.). St. Louis: Mosby.; Styles, M. M. (1982). ized. University baccalaureate programs proliferated,
On nursing: Toward a new endowment. St. Louis: Mosby. master’s programs in nursing were developed, and
CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 7
a standardized curriculum was realized through theoretical work they had developed for curricula,
accreditation. Nursing had passed through eras of research, or practice.
gradual development, and nursing leaders offered Also noteworthy, Donaldson and Crowley (1978)
their perspectives on the development of nursing sci- presented the keynote address at the Western Com-
ence. They addressed significant disciplinary ques- mission of Higher Education in Nursing Conference
tions about whether nursing was an applied science in 1977, just as their nursing doctoral program was
or a basic science (Donaldson & Crowley, 1978; about to open. They reopened the discussion of the
Johnson, 1959; Rogers, 1970). History provides nature of nursing science and the nature of knowl-
evidence of the consensus that was reached, and edge needed for the discipline and the profession. The
nursing doctoral programs began to open to generate published version of their keynote address has be-
nursing knowledge. come classic for students to learn about nursing and
The 1970s was a significant period of development. recognize the difference between the discipline and
In 1977, after Nursing Research had been published for the profession. These speakers called for both basic
25 years, studies were reviewed comprehensively, and and applied research, asserting that knowledge was
strengths and weaknesses were reported in the journal vital to nursing as both a discipline and a profession.
that year. Batey (1977) called attention to the impor- They argued that the discipline and the profession are
tance of nursing conceptualization in the research inextricably linked, but failure to separate them from
process and the role of a conceptual framework in the each other anchors nursing in a vocational rather
design of research for the production of science. This than a professional view.
emphasis led the theory development era and moved Soon nursing conceptual frameworks began to be
nursing forward to new nursing knowledge for nursing used to organize curricula in nursing programs and
practice. Soon the nursing theoretical works began to were recognized as models that address the values
be recognized to address Batey’s call (Johnson, 1968, and concepts of nursing. The creative conceptualiza-
1974; King, 1971; Levine, 1969; Neuman, 1974; Orem, tion of a nursing metaparadigm (person, environ-
1971; Rogers, 1970; Roy, 1970). ment, health, and nursing) and a structure of knowl-
In 1978, Fawcett presented her double helix meta- edge clarified the related nature of the collective
phor, now a classic publication, on the interdependent works of major nursing theorists as conceptual frame-
relationship of theory and research. Also at this time, works and paradigms of nursing (Fawcett, 1984).
nursing scholars such as Henderson, Nightingale, This approach organized nursing works into a system
Orlando, Peplau, and Wiedenbach were recognized of theoretical knowledge, developed by theorists at
for the theoretical nature of their earlier writings. different times and in different parts of the country.
These early works were developed by educators as Each nursing conceptual model was classified on
frameworks to structure curriculum content in nurs- the basis of a set of analysis and evaluation criteria
ing programs. Similarly, Orlando’s (1961, 1972) theory (Fawcett, 1984; 1993). Recognition of the separate
was derived from the report of an early nationally nursing works collectively with a metaparadigm um-
funded research project designed to study nursing brella enhanced the recognition and understanding
practice. of nursing theoretical works as a body of nursing
I attended the Nurse Educator Nursing Theory knowledge. In short, the significance of theory for
Conference in New York City in 1978, where the ma- the discipline of nursing is that the discipline is
jor theorists were brought together on the same stage dependent upon theory for its continued existence,
for the first time. Most of them began their presenta- that is, we can be a vocation, or we can be a discipline
tions by stating that they were not theorists. Although with a professional style of theory-based practice.
complete understanding of the significance of these The theoretical works have taken nursing to higher
works for nursing was limited at the time, many in the levels of education and practice as nurses have moved
audience seemed to be aware of the significance of from the functional focus, or what nurses do, to a
the event. After the first few introductions, the audi- knowledge focus, or what nurses know and how they
ence laughed at the theorists’ denial of being theorists use what they know for thinking and decision mak-
and listened carefully as each theorist described the ing while concentrating on the patient.
8 UNIT I Evolution of Nursing Theories
Frameworks and theories are structures about BOX 1-2 Criteria for Development of the
human beings and their health; these structures pro- Professional Status of Nursing
vide nurses with a perspective of the patient for profes-
sional practice. Professionals provide public service 1. Utilizes in its practice a well-defined and well-
in a practice focused on those whom they serve. The organized body of specialized knowledge
nursing process is useful in practice, but the primary [that] is on the intellectual level of the higher
focus is the patient, or human being. Knowledge of learning
persons, health, and environment forms the basis for 2. Constantly enlarges the body of knowledge it
recognition of nursing as a discipline, and this knowl- uses and improves its techniques of education
edge is taught to those who enter the profession. Every and service through use of the scientific
discipline or field of knowledge includes theoretical method
knowledge. Therefore, nursing as an academic disci- 3. Entrusts the education of its practitioners to
pline depends on the existence of nursing knowledge institutions of higher education
(Butts & Rich, 2011). For those entering the profes- 4. Applies its body of knowledge in practical
sion, this knowledge is basic for their practice in the services vital to human and social welfare
profession. Kuhn (1970), noted philosopher of science, 5. Functions autonomously in the formulation of
stated, “The study of paradigms . . . is what mainly professional policy and thereby in the control
prepares the student for membership in the particular of professional activity
scientific community with which he [or she] will later 6. Attracts individuals with intellectual and
practice” (p. 11). This is significant for all nurses, but it personal qualities of exalting service above
is particularly important to those who are entering the personal gain who recognize their chosen
profession because “in the absence of a paradigm . . . occupation as a life work
all of the facts that could possibly pertain to the devel- 7. Strives to compensate its practitioners by
opment of a given science are likely to seem equally providing freedom of action, opportunity for
relevant” (Kuhn, 1970, p. 15). Finally, with regard to the continuous professional growth, and economic
priority of paradigms, Kuhn states, “By studying them security
and by practicing with them, the members of their cor- Data from Bixler, G. K., & Bixler, R. W. (1959). The professional status of
responding community learn their trade” (Kuhn, nursing. American Journal of Nursing, 59(8), 1142–1146.
1970, p. 43). Master’s students apply and test theoreti-
cal knowledge in their nursing practice. Doctoral
students studying to become nurse scientists develop These criteria have historical value for enhancing
nursing theory, test theory, and contribute nursing sci- our understanding of the developmental path that
ence in theory-based and theory-generating research nurses followed. For example, a knowledge base that is
studies. well defined, organized, and specific to the discipline
was formalized during the last half of the twentieth
Significance for the Profession century, but this knowledge is not static. Rather, it
Not only is theory essential for the existence of nursing continues to grow in relation to the profession’s goals
as an academic discipline, it is vital to the practice of for the human and social welfare of the society that
professional nursing. Recognition as a profession was nurses serve. So although the body of knowledge is
a less urgent issue as the twentieth century ended important, the theories and research are vital to the
because nurses had made consistent progress toward discipline and the profession, so that new knowledge
professional status through the century. Higher-degree continues to be generated. The application of nursing
nursing is recognized as a profession today having used knowledge in practice is a criterion that is currently at
the criteria for a profession to guide development. the forefront, with emphasis on accountability for
Nursing development was the subject of numerous nursing practice, theory-based evidence for nursing
studies by sociologists. Bixler and Bixler (1959) pub- practice, and the growing recognition of middle-range
lished a set of criteria for a profession tailored to nurs- theory for professional nursing practice (Alligood,
ing in the American Journal of Nursing (Box 1-2). 2014, in press).
CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 9
In the last decades of the twentieth century, in enables them to organize and understand what
anticipation of the new millennium, ideas targeted happens in practice, to analyze patient situations
toward moving nursing forward were published. critically for clinical decision making; to plan
Styles (1982) described a distinction between the col- care and propose appropriate nursing interven-
lective nursing profession and the individual profes- tions; and to predict patient outcomes from the
sional nurse and called for internal developments care and evaluate its effectiveness.
based on ideals and beliefs of nursing for continued (Alligood, 2004, p. 247)
professional development. Similarly, Fitzpatrick (1983)
presented a historical chronicle of twentieth century Professional practice requires a systematic approach
achievements that led to the professional status of that is focused on the patient, and the theoretical works
nursing. Both Styles (1982) and Fitzpatrick (1983) provide just such perspectives of the patient. The theo-
referenced a detailed history specific to the develop- retical works presented in this text illustrate those
ment of nursing as a profession. Now that nursing is various perspectives. Philosophies of nursing, concep-
recognized as a profession, emphasis in this text is tual models of nursing, nursing theories, and middle-
placed on the relationship between nursing theoreti- range theories provide the nurse with a view of the
cal works and the status of nursing as a profession. patient and a guide for data processing, evaluation of
Similarities and differences have been noted in sets evidence, and decisions regarding action to take in
of criteria used to evaluate the status of professions; practice (Alligood 2014, in press; Butts & Rich, 2011;
however, they all call for a body of knowledge that is Chinn & Kramer, 2011; Fawcett & Garity, 2009). With
foundational to the practice of the given profession this background of the history and significance of
(Styles, 1982). nursing theory for the discipline and the profession,
As individual nurses grow in their professional we turn to analysis of theory, a systematic process of
status, the use of substantive knowledge for theory- critical reflection for understanding nursing theoreti-
based evidence for nursing is a quality that is charac- cal works (Chinn & Kramer, 2011).
teristic of their practice (Butts & Rich, 2011). This
commitment to theory-based evidence for practice is
beneficial to patients in that it guides systematic, Analysis of Theory
knowledgeable care. It serves the profession as nurses Analysis, critique, and evaluation are methods used
are recognized for the contributions they make to the to study nursing theoretical works critically. Analysis
health care of society. As noted previously in relation of theory is carried out to acquire knowledge of theo-
to the discipline of nursing, the development of knowl- retical adequacy. It is an important process and the
edge is an important activity for nurse scholars to first step in applying nursing theoretical works to
pursue. It is important that nurses have continued education, research, administration, or practice. The
recognition and respect for their scholarly discipline analysis criteria used for each theoretical work in this
and for their contribution to the health of society. text are included in Box 1-3 with the questions that
Finally and most important, the continued recognition guide the critical reflection of analysis.
of nursing theory as a tool for the reasoning, critical
thinking, and decision making required for quality
nursing practice is important because of the following: BOX 1-3 Analysis Questions to
Determine Theoretical Adequacy
Nursing practice settings are complex, and the
amount of data (information) confronting nurses n Clarity: How clear is this theory?
is virtually endless. Nurses must analyze a vast n Simplicity: How simple is this theory?
amount of information about each patient and n Generality: How general is this theory?
decide what to do. A theoretical approach helps n Accessibility: How accessible is this theory?
practicing nurses not to be overwhelmed by the n Importance: How important is this theory?
mass of information and to progress through the Data from Chinn, P. L., & Kramer, M. K. (2011). Integrated knowledge
nursing process in an orderly manner. Theory development in nursing (8th ed.). St. Louis: Elsevier-Mosby.
10 UNIT I Evolution of Nursing Theories
The analysis process is useful for learning about forms of theory, such as middle range, to guide prac-
the works and is essential for nurse scientists who tice. A theory should be sufficiently comprehensive,
intend to test, expand, or extend the works. When presented at a level of abstraction to provide guid-
nurse scientists consider their research interests in ance, and have as few concepts as possible with
the context of one of the theoretical works, areas for simplistic relations to aid clarity. Reynolds (1971)
further development are discovered through the pro- contends, “The most useful theory provides the greatest
cesses of critique, analysis, and critical reflection. sense of understanding” (p. 135). Walker and Avant
Therefore, analysis is an important process for learn- (2011) describe theory parsimony as “brief but com-
ing, for developing research projects, and for expand- plete” (p. 195).
ing the science associated with the theoretical works
of nursing in the future. Understanding a theoretical Generality
framework is vital to applying it in your practice. The generality of a theory speaks to the scope of
application and the purpose within the theory (Chinn
Clarity & Kramer, 2011). Ellis (1968) stated, “The broader
Clarity and structure are reviewed in terms of seman- the scope . . . the greater the significance of the the-
tic clarity and consistency and structural clarity and ory” (p. 219). The generality of a theoretical work
consistency. Clarity speaks to the meaning of terms varies by how abstract or concrete it is (Fawcett,
used, and definitional consistency and structure speaks 2005). Understanding the levels of abstraction by
to the consistent structural form of terms in the the- doctoral students and nurse scientists facilitated the
ory. Analysis begins as the major concepts and sub- use of abstract frameworks for the development
concepts and their definitions are identified. Words of middle-range theories. Rogers’ (1986) Theory of
have multiple meanings within and across disciplines; Accelerating Change is an example of an abstract
therefore, a word should be defined carefully and theory from which numerous middle-range theories
specifically according to the framework (philosophy, have been generated.
conceptual model, or theory) within which it is de-
veloped. Clarity and consistency are facilitated with Accessibility
diagrams and examples. The logical development and Accessibility is linked to the empirical indicators for
type of structure used should be clear, and assumptions testability and ultimate use of a theory to describe
should be stated clearly and be consistent with the goal aspects of practice (Chinn & Kramer, 2011). Acces-
of the theory (Chinn & Kramer, 2011; Reynolds, sible” addresses the extent to which empiric indica-
1971; Walker & Avant, 2011). Reynolds (1971) speaks tors for the concepts can be identified and to what
to intersubjectivity and says, “There must be shared extent the purposes of the theory can be attained”
agreement of the definitions of concepts and relation- (Chinn & Kramer, 2011, p. 203). Reynolds (1971)
ships between concepts within a theory” (p. 13). Hardy evaluates empirical relevance by examining “the cor-
(1973) refers to meaning and logical adequacy and respondence between a particular theory and the
says, “Concepts and relationships between concepts objective empirical data” (p. 18). He suggests that
must be clearly identified and valid” (p. 106). Ellis scientists should be able to evaluate and verify results
(1968) used “the criterion of terminology” to evaluate by themselves. Walker and Avant (2011) evaluate
theory and warns about “the danger of lost meaning testability based on the theory’s capacity to “generate
when terms are borrowed from other disciplines and hypotheses and be subjected to empirical research”
used in a different context” (p. 221). Walker and Avant (p. 195).
(2011) assess “logical adequacy” according to “the
logical structure of the concepts and statements” pro- Importance
posed in the theory (p. 195). A parallel can be drawn between outcome and impor-
tance. Because research, theory, and practice are
Simplicity closely related, nursing theory lends itself to research
Simplicity is highly valued in nursing theory devel- testing, and research testing leads to knowledge for
opment. Chinn and Kramer (2011) called for simple practice. Nursing theory guides research and practice,
CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 11
generates new ideas, and differentiates the focus Globally, nurses are recognizing the rich heritage
of nursing from that of other professions (Chinn & of the works of nursing theorists, that is, the philoso-
Kramer, 2011). Ellis (1968) indicates that to be con- phies, conceptual models, theories, and middle-
sidered useful, “it is essential for theory to develop range theories of nursing. The publication of this
and guide practice . . . theories should reveal what text in multiple (at least 10) languages reflects the
knowledge nurses must, and should, spend time pur- global use of theory. The contributions of global
suing” (p. 220). theorists present nursing as a discipline and provide
The five criteria for the analysis of theory—clarity, knowledge structure for further development. The
simplicity, generality, accessibility, and importance— use of theory-based research supports evidence-
guide the critical reflection of each theoretical work based practice. There is worldwide recognition of
in Chapters 6 to 36. These broad criteria facilitate the rich diversity of nursing values the models rep-
the analysis of theoretical works, whether they are resent. Today we see added clarification of the theo-
applied to works at the level of philosophies, concep- retical works in the nursing literature as more and
tual models, theories, or middle-range theories. more nurses learn and use theory-based practice.
Most important, the philosophies, models, theories,
and middle-range theories are used broadly in all
Summary areas—nursing education, administration, research,
This chapter presents an introduction to nursing and practice.
theory with a discussion of its history, significance, There is recognition of normal science in the
and analysis. A nurse increases professional power theoretical works (Wood, 2010). The scholarship
when using theoretical research as systematic evi- of the past 3 decades has expanded the volume
dence for critical thinking and decision making. of nursing literature around the philosophies, mod-
When nurses use theory and theory-based evidence els, theories, and middle-range theories. Similarly,
to structure their practice, it improves the quality of the philosophy of science has expanded and fos-
care. They sort patient data quickly, decide on appro- tered nursing knowledge development with new
priate nursing action, deliver care, and evaluate out- qualitative approaches. As more nurses have ac-
comes. They also are able to discuss the nature of quired higher education, understanding of the im-
their practice with other health professionals. Con- portance of nursing theory has expanded. The use
sidering nursing practice in a theory context helps of theory by nurses has increased knowledge devel-
students to develop analytical skills and critical opment and improved the quality of nursing prac-
thinking ability and to clarify their values and as- tice (Alligood, 2010a; Alligood, 2011b; Chinn &
sumptions. Theory guides practice, education, and Kramer, 2011; Fawcett & Garity, 2009; George,
research (Alligood 2014, in press; Chinn & Kramer, 2011; Im & Chang, 2012; Reed & Shearer, 2012;
2011; Fawcett, 2005; Meleis, 2007). Wood, 2010).
POINTS FOR FURTHER STUDY
n Donaldson, S. K., & Crowley, D. M. (1978). The disci- n Judd, D., Sitzman, K., & Davis, G. M. (2010). A his-
pline of nursing. Nursing Outlook, 26(2), 1113–1120. tory of American nursing. Boston: Jones & Bartlett.
n Fawcett, J. (1984). The metaparadigm of nursing: n The Nursing Theory Page at Hahn School of
current status and future refinements. Image: The Nursing, University of San Diego: Retrieved from:
Journal of Nursing Scholarship, 16, 84–87. http://www.sandiego.edu/ACADEMICS/nursing/
n Kalisch, P. A., & Kalisch, B. J. (2003). American theory.
nursing: A history (4th ed.). Philadelphia: Lippincott
Williams & Wilkins.
12 UNIT I Evolution of Nursing Theories
REFERENCES
Alligood, M. R. (2011a). The power of theoretical knowl- Ellis, R. (1968). Characteristics of significant theories.
edge. Nursing Science Quarterly, 24(4), 304–305. Nursing Research, 27(5), 217–222.
Alligood, M. R. (2011b). Theory-based practice in a major Fawcett, J. (1978). The relationship between theory and
medical centre. The Journal of Nursing Management, 19, research: a double helix. Advances in Nursing Science,
981–988. 1(1), 49–62.
Alligood, M. R. (2014, in press). Nursing theory: Utilization Fawcett, J. (1984). The metaparadigm of nursing: current
& application, (5th ed.). Maryland Heights, (MO): status and future refinements. Image: The Journal of
Mosby-Elsevier. Nursing Scholarship, 16, 84–87.
Alligood, M. R. (2010a). The nature of knowledge needed Fawcett, J. (1993). Analysis and evaluation of nursing
for nursing practice. In M. R. Alligood (Ed.), Nursing theories. Philadelphia: F. A. Davis.
theory: Utilization & application (4th ed., pp. 3-15). Fawcett, J. (2005). Contemporary nursing knowledge:
St. Louis: Mosby. Conceptual models of nursing and nursing theories
Alligood, M. R. (2010b). Models and theories: critical (2nd ed.). Philadelphia: F. A. Davis.
thinking structures. In M. R. Alligood (Ed.), Nursing Fawcett, J., & Garity, J. (2009). Evaluating research for
theory: Utilization & application (4th ed., pp. 43–65). evidence-based nursing practice. Philadelphia: F.A.Davis.
St. Louis: Mosby. Fitzpatrick, M. L. (1983). Prologue to professionalism.
Alligood, M. R. (2010c). Areas for further development of Bowie, (MD): Robert J. Brady.
theory-based nursing practice. In M. R. Alligood (Ed.), Fitzpatrick, J., & Whall, A. (1983). Conceptual models of
Nursing theory: Utilization & application (4th ed., nursing. Bowie, (MD): Robert J. Brady.
pp. 487–497). St. Louis: Mosby. George, J. (2011). Nursing theories (6th ed.). Upper Saddle
Alligood, M. R. (2004). Nursing theory: the basis for River, (NJ): Pearson.
professional nursing practice. In K. K. Chitty (Ed.), Hardy, M. E. (1973). Theories: components, development,
Professional nursing: Concepts and challenges (4th ed., evaluation. Nursing Research, 23(2), 100–107.
pp. 271–298). Philadelphia: Saunders. Im, E. O., & Chang, S. J. (2012). Current trends in nursing
Alligood, M. R., & Tomey, A. M. (Eds.). (1997). Nursing theories. Journal of Nursing Scholarship, 44(2), 156–164.
theory: Utilization & application. St. Louis: Mosby. Johnson, D. (1959). The nature of a science of nursing.
Alligood, M. R., & Tomey, A. M. (Eds.). (2002). Nursing Nursing Outlook, 7, 291–294.
theory: Utilization & application (2nd ed.). St. Louis: Johnson, D. (1968). One conceptual model for nursing.
Mosby. Unpublished paper presented at Vanderbilt University,
Alligood, M. R., & Tomey, A. M. (Eds.). (2006). Nursing Nashville,(TN).
theory: Utilization & application (3rd ed.). St. Louis: Johnson, D. (1974). Development of the theory: a requisite
Mosby. for nursing as a primary health profession. Nursing
Alligood, M. R. & Tomey, A. M. (Eds.). (2010). Nursing Research, 23, 372–377.
theorists and their work (7th ed.). Maryland Heights, Judd, D., Sitzman, K., & Davis, G. M. (2010). A history of
(MO): Mosby-Elsevier. American nursing. Boston: Jones & Bartlett.
Batey, M. V. (1977). Conceptualization: knowledge and Kalisch, P. A., & Kalisch, B. J. (2003). American nursing:
logic guiding empirical research. Nursing Research, A history (4th ed.). Philadelphia: Lippincott.
26(5), 324–329. King, I. (1971). Toward a theory of nursing. New York: Wiley.
Bixler, G. K., & Bixler, R. W. (1959). The professional status of Kuhn, T. S. (1970). The structure of scientific revolutions.
nursing. American Journal of Nursing, 59(8), 1142–1146. Chicago: University of Chicago Press.
Butts, J. B., & Rich, K. L. (2011). Philosophies and theories Levine, M. (1969). Introduction to clinical nursing. Phila-
for advanced nursing practice. Sudbury, (MA): Jones & delphia: F. A. Davis.
Bartlett. Meleis, A. (2007). Theoretical nursing: Development and
Chinn, P. L., & Kramer, M. K. (2011). Integrated knowledge progress (4th ed.). Philadelphia: Lippincott.
development in nursing (8th ed.). St. Louis: Elsevier- Neuman, B. (1974). The Betty Neuman health systems model:
Mosby. a total person approach to patient problems. In J. P. Riehl
Cross, K. P. (1981). Adults as learners. Washington DC: & C. Roy (Eds.), Conceptual models for nursing practice
Jossey-Bass. (pp. 94–114). New York: Appleton-Century-Crofts.
Donaldson, S. K., & Crowley, D. M. (1978). The discipline Nicoll, L. (1986). Perspectives on nursing theory. Boston:
of nursing. Nursing Outlook, 26(2), 1113–1120. Little, Brown.
CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 13
Nicoll, L. (1992). Perspectives on nursing theory (2nd ed.). Reed, P., Shearer, N., & Nicoll, L. (2003). Perspectives
Philadelphia: Lippincott, Williams & Wilkins. on nursing theory (4th ed.). Philadelphia: Lippincott,
Nicoll, L. (1997). Perspectives on nursing theory(3rd ed.). Williams & Wilkins.
Philadelphia: Lippincott, Williams & Wilkins. Reynolds, P. D. (1971). A primer for theory construction.
Nightingale, F. (1969). Notes on nursing: What it is and Indianapolis: Bobbs-Merrill.
what it is not. New York: Dover. (Originally published Rogers, M. E. (1970). An introduction to the theoretical
1859.) basis of nursing. Philadelphia: F. A. Davis.
Orem, D. (1971). Nursing: Concepts of practice. St. Louis: Rogers, M. E. (1986). Science of unitary human beings.
Mosby. In V. Malinski (Ed.), Explorations on Martha Rogers’
Orem, D. (2001). Nursing: Concepts of practice (6th ed.). science of unitary human beings. Norwalk, (CT):
St. Louis: Mosby. Appleton-Century-Crofts.
Orlando, I. (1961). The dynamic nurse-patient relationship. Roy, C. (1970). Adaptation: a conceptual framework for
New York: Putnam. nursing. Nursing Outlook, 18, 42–45.
Orlando, I. (1972). The discipline and teaching of nursing Shaw, M.C. (1993). The discipline of nursing: historical
process. New York: Putnam. roots, current perspectives, future directions. Journal of
Parker, M. (2006). Nursing theory and nursing practice Advanced Nursing, 18, 1651–1656.
(2nd ed.). Philadelphia: F. A. Davis. Smith, M., & Leihr, P. (2008). Middle range theory for
Peterson, S. (2008). Middle-range theories: Applications to nursing (2nd ed.). New York: Springer.
nursing research (2nd ed.). Philadelphia: Lippincott, Styles, M. M. (1982). On nursing: Toward a new endowment.
Williams & Wilkins. St. Louis: Mosby.
Reed, P., & Shearer, N. (2009). Perspectives on nursing Walker, L. O., & Avant, K. C. (2011). Strategies for theory
theory (5th ed.). New York: Lippincott Williams & construction in nursing (5th ed.). Boston: Prentice Hall.
Wilkins. Wood, A. F. (2010). Nursing models: normal science for
Reed, P., & Shearer, N. (2012). Perspectives on nursing nursing practice. In M. R. Alligood (Ed.) Nursing
theory (6th ed.). New York: Lippincott Williams & theory: Utilization & application, 4th ed. (pp. 17–46).
Wilkins. Maryland Heights, (MO): Mosby-Elsevier.
2
CHAP TER
History and Philosophy of Science
Sonya R. Hardin
“Why should nurses be interested in the history and philosophy of science? The history and philosophy
of science is important as a foundation for exploring whether scientific results are actually
truth. As nurses our practice should be based upon truth and we need the ability to interpret the
results of science. Nursing science provides us with knowledge to describe, explain and predict
outcomes. The legitimacy of any profession is built on its ability to generate and apply theory.”
(McCrae, 2011, p. 222)
odern science was established over 400 years adults. A recent study tested the theory that a certain
Mago as an intellectual activity to formalize given type of question would elicit the most response. The
phenomena of interest in an attempt to describe, theory was confirmed when findings supported that
explain, predict, or control states of affairs in nature. the open-ended questions prompted patients to provide
Scientific activity has persisted because it has improved a larger amount of diagnostically useful pain informa-
quality of life and has satisfied human needs for tion than did the closed-ended questions (McDonald,
creative work, a sense of order, and the desire to under- Shea, Rose, & Fedo, 2009). While this study is one
stand the unknown (Bronowski, 1979; Gale, 1979; example of nursing science, advance practice nurses
Piaget, 1970). The development of nursing science has should be familiar with the long history of the science
evolved since the 1960s as a pursuit to be understood of nursing.
as a scientific discipline. Being a scientific discipline
means identifying nursing’s unique contribution to the Historical Views of the Nature
care of patients, families, and communities. It means
that nurses can conduct clinical and basic nursing of Science
research to establish the scientific base for the care of To formalize the science of nursing, basic questions
individuals across the life span. For example, research must be considered, such as: What is science, knowl-
revealed gaps between the pain management needs edge, and truth? What methods produce scientific
of patients and the information communicated by knowledge? These are philosophical questions. The
patients and clinicians during office visits. Although term epistemology is concerned with the theory of
many older adults have painful but not readily visible knowledge in philosophical inquiry. The particular
conditions (e.g., symptomatic osteoarthritis), little re- philosophical perspective selected to answer these
search has examined how the style or format of a health questions will influence how scientists perform sci-
care practitioner’s questions influence the quality and entific activities, how they interpret outcomes, and
amount of diagnostic information obtained from older even what they regard as science and knowledge
Previous author: Sue Marquis Bishop.
14
CHAPTER 2 History and Philosophy of Science 15
(Brown, 1977). Although philosophy has been docu- additional research is conducted or modifications
mented as an activity for 3000 years, formal science are made in the theory and further tests are devised;
is a relatively new human pursuit (Brown, 1977; otherwise, the theory is discarded in favor of an
Foucault, 1973). Scientific activity has only recently alternative explanation (Gale, 1979; Zetterberg, 1966).
become the object of investigation. Popper (1962) argued that science would evolve more
Two competing philosophical foundations of sci- rapidly through the process of conjectures and refuta-
ence, rationalism and empiricism, have evolved in tions by devising research in an attempt to refute new
the era of modern science with several variations. ideas. For example, his point is simple; you can never
Gale (1979) labeled these alternative epistemologies prove that all individuals without social support have
as centrally concerned with the power of reason and frequent rehospitalizations since there might be one
the power of sensory experience. Gale noted similarity individual that presents with no rehospitalization. A
in the divergent views of science in the time of the single person with no social support that does not have
classical Greeks. For example, Aristotle believed that a readmission disproves the theory that all individuals
advances in biological science would develop through with a lack of social support have hospital readmis-
systematic observation of objects and events in the sions. From Popper’s perspective, “research consists
natural world, whereas Pythagoras believed that knowl- of generating general hypotheses and then attempting
edge of the natural world would develop from mathe- to refute them” (Lipton, 2005, p. 1263). So the hypoth-
matical reasoning (Brown, 1977; Gale, 1979). esis that a lack of social support results in hospital
Nursing science has been characterized by two readmission is the phenomena of interest to be refuted.
branching philosophies of knowledge as the discipline The rationalist view is most clearly evident in the
developed. Various terms are utilized to describe these work of Einstein, the theoretical physicist, who made
two stances: empiricist and interpretive, mechanistic extensive use of mathematical equations in developing
and holistic, quantitative and qualitative, and deductive his theories. The theories Einstein constructed offered
and inductive forms of science. Understanding the an imaginative framework, which has directed research
nature of these philosophical stances facilitates appre- in numerous areas (Calder, 1979). As Reynolds (1971)
ciation for what each form contributes to nursing noted, if someone believes that science is a process of
knowledge. inventing descriptions of phenomena, the appropriate
strategy for theory construction is the theory-then-
Rationalism research strategy. In Reynolds’ view, “as the continuous
Rationalist epistemology (scope of knowledge) empha- interplay between theory construction (invention) and
sizes the importance of a priori reasoning as the testing with empirical research progresses, the theory
appropriate method for advancing knowledge. A priori becomes more precise and complete as a description
reasoning utilizes deductive logic by reasoning from of nature and, therefore, more useful for the goals of
the cause to an effect or from a generalization to a science” (Reynolds, 1971, p. 145).
particular instance. An example in nursing is to reason
that a lack of social support (cause) will result in hos- Empiricism
pital readmission (effect). This causal reasoning is a The empiricist view is based on the central idea that
theory until disproven. The traditional approach pro- scientific knowledge can be derived only from sensory
ceeds by explaining hospitalization with a systematic experience (i.e., seeing, feeling, hearing facts). Francis
explanation (theory) of a given phenomenon (Gale, Bacon (Gale, 1979) received credit for popularizing
1979). This conceptual system is analyzed by address- the basis for the empiricist approach to inquiry. Bacon
ing the logical structure of the theory and the logical believed that scientific truth was discovered through
reasoning involved in its development. Theoretical generalizing observed facts in the natural world. This
assertions derived by deductive reasoning are then approach, called the inductive method, is based on the
subjected to experimental testing to corroborate the idea that the collection of facts precedes attempts to
theory. Reynolds (1971) labeled this approach the formulate generalizations, or as Reynolds (1971) called
theory-then-research strategy. If the research findings it, the research-then-theory strategy. One of the best
fail to correspond with the theoretical assertions, examples to demonstrate this form of logic in nursing
16 UNIT I Evolution of Nursing Theories
has to do with formulating differential diagnoses. For- that empirical facts exist independently of theories and
mulating a differential diagnosis requires collecting offer the only basis for objectivity in science (Brown,
the facts and then devising a list of possible theories to 1977). In this view, objective truth exists independently
explain the facts. of the researcher, and the task of science is to discover
The strict empiricist view is reflected in the work it, which is an inductive method (Gale, 1979). This
of the behaviorist Skinner. In a 1950 paper, Skinner view of science is often presented in research method
asserted that advances in the science of psychology courses as: “The scientist first sets up an experiment;
could be expected if scientists would focus on the observes what occurs . . . reaches a preliminary hy-
collection of empirical data. He cautioned against pothesis to describe the occurrence; runs further ex-
drawing premature inferences and proposed a mora- periments to test the hypothesis [and] finally corrects
torium on theory building until further facts were or modifies the hypothesis in light of the results” (Gale,
collected. Skinner’s (1950) approach to theory con- 1979, p. 13).
struction was clearly inductive. His view of science The increasing use of computers, which permit the
and the popularity of behaviorism have been credited analysis of large data sets, may have contributed to the
with influencing psychology’s shift in emphasis from acceptance of the positivist approach to modern sci-
the building of theories to the gathering of facts ence (Snelbecker, 1974). However, in the 1950s, the
between the 1950s and 1970s (Snelbecker, 1974). The literature began to reflect an increasing challenge to
difficulty with the inductive mode of inquiry is that the positivist view, thereby ushering in a new view of
the world presents an infinite number of possible science in the late twentieth century (Brown, 1977).
observations, and, therefore, the scientist must bring
ideas to his or her experiences to decide what to Emergent Views of Science and Theory
observe and what to exclude (Steiner, 1977).
In summary, deductive inquiry uses the theory- in the Late Twentieth Century
then-research approach, and inductive inquiry uses In the latter years of the twentieth century, several
the research-then-theory approach. Both approaches authors presented analyses challenging the positivist
are utilized in the field of nursing. position, thus offering the basis for a new perspective
of science (Brown, 1977; Foucault, 1973; Hanson,
1958; Kuhn, 1962; Toulmin, 1961). Foucault (1973)
Early Twentieth Century Views published his analysis of the epistemology (knowledge)
of Science and Theory of human sciences from the seventeenth to the nine-
During the first half of this century, philosophers teenth century. His major thesis stated that empirical
focused on the analysis of theory structure, whereas knowledge was arranged in different patterns at a
scientists focused on empirical research (Brown, given time and in a given culture and that humans
1977). There was minimal interest in the history of where emerging as objects of study. In The Phenome-
science, the nature of scientific discovery, or the simi- nology of the Social World, Schutz (1967) argued that
larities between the philosophical view of science and scientists seeking to understand the social world could
the scientific methods (Brown, 1977). Positivism, a not cognitively know an external world that is indepen-
term first used by Comte, emerged as the dominant dent of their own life experiences. Phenomenology, set
view of modern science (Gale, 1979). Modern logical forth by Edmund Husserl (1859 to 1938) proposed that
positivists believed that empirical research and logical the objectivism of science could not provide an ade-
analysis (deductive and inductive) were two ap- quate apprehension of the world (Husserl 1931, 1970).
proaches that would produce scientific knowledge A phenomenological approach reduces observations or
(Brown, 1977). text to the meanings of phenomena independent of
The logical empiricists offered a more lenient view their particular context. This approach focuses on the
of logical positivism and argued that theoretical propo- lived meaning of experiences.
sitions (proposition affirms or denies something) must In 1977, Brown argued an intellectual revolution
be tested through observation and experimentation in philosophy that emphasized the history of science
(Brown, 1977). This perspective is rooted in the idea was replacing formal logic as the major analytical tool
CHAPTER 2 History and Philosophy of Science 17
in the philosophy of science. One of the major per- are not the single determining factor of the scientist’s
spectives in the new philosophy emphasized science perception. He identified the following three differ-
as a process of continuing research rather than a ent views of the relationship between theories and
product focused on findings. In this emergent episte- observation:
mology, emphasis shifted to understanding scientific 1. Scientists are merely passive observers of occur-
discovery and process as theories change over time. rences in the empirical world. Observable data are
Empiricists view phenomena objectively, collect objective truth waiting to be discovered.
data, and analyze it to inductively proposed theory 2. Theories structure what the scientist perceives in
(Brown, 1977). This position is based upon objective the empirical world.
truth existing in the world, waiting to be discovered. 3. Presupposed theories and observable data interact
Brown (1977) set forth a new epistemology challenging in the process of scientific investigation (Brown,
the empiricist view proposing that theories play a 1977, p. 298).
significant role in determining what the scientist Brown’s argument for an interactionist’s perspective
observes and how it is interpreted. The following story coincides with the scientific consensus in the study of
illustrates Brown’s premise that observations are con- pattern recognition in how humans process informa-
cept laden; that is, an observation is influenced by tion. The following distinct mini-theories have directed
values and ideas in the mind of the observer: research efforts in this area: (1) the data-driven, or
bottom-up, theory and (2) the conceptually driven,
“An elderly patient has been in a trauma and or top-down, theory (Norman, 1976). In the former,
appears to be crying. The nurse on admission cognitive expectations (what is known or ways of orga-
observes that the patient has marks on her body nizing meaning) are used to select input and process
and believes that she has been abused; the ortho- incoming information from the environment. The
pedist has viewed an x-ray and believes that the second theory asserts that incoming data are perceived
crying patient is in pain due to a fractured femur as unlabeled input and analyzed as raw data with in-
that will not require surgery only a closed reduc- creasing levels of complexity until all the data are clas-
tion; the chaplain observes the patient crying and sified. Current research evidence suggests that human
believes the patient needs spiritual support. Each pattern recognition progresses through an interaction
observation is concept laden.”
of both data-driven and conceptually driven processes,
Brown (1977) presented the example of a chemist and it uses sources of information in both currently
and a child walking together past a steel mill. The organized, cognitive categories and in stimuli from the
chemist perceived the odor of sulfur dioxide and the sensory environment. The interactionist’s perspective
child smelled rotten eggs. Both observers in the exam- also is clearly reflected in Piaget’s theory of human
ples responded to the same observation but with dis- cognitive functioning:
tinctly different interpretations. Concepts and theories
set up boundaries and specify pertinent phenomena “Piagetian man actively selects and interprets
for reasoning about specific observed patterns. These environmental information in the construction of
examples represent different ideas that emerge for his own knowledge, rather than passively copying
each person. the information just as it is presented to his senses.
If scientists perceive patterns in the empirical While paying attention to and taking account of
world based on their presupposed theories, how can the structure of the environment during knowledge
new patterns ever be perceived or new discoveries seeking, Piagetian man reconstrues and reinter-
become formulated? Gale (1979) answered by pro- prets that environment [according to] his own
posing that the scientist is able to perceive forceful mental framework . . . The mind neither copies
intrusions from the environment that challenge his the world . . . nor does it ignore the world [by]
or her a priori mental set, thereby raising questions creating a private mental conception of it out of
regarding the current theoretical perspective. Brown whole cloth. The mind meets the environment in
(1977) maintained that a presupposed theoretical an extremely active, self-directed way.”
framework influences perception, however theories (Flavell, 1977, p. 6)
18 UNIT I Evolution of Nursing Theories
If the thesis is accepted that objective truth does to a normal science, then to a crisis, then to a revolu-
not exist and science is an interactive process between tion, and then to a new normal science. Once normal
invented theories and empirical observations, how are science develops, the process begins again when a
scientists to determine truth and scientific knowledge? crisis erupts and leads to revolution, and a new normal
In the new epistemology, science is viewed as an science emerges once again (Kuhn, 1970; Nyatanga,
ongoing process. Much importance is given to the idea 2005). This is what Kuhn refers to as paradigm shift in
of consensus among scientists. As Brown (1977) con- the scientific development within a discipline. For
cluded, it is a myth that science can establish final example, recent research supports that early mobiliza-
truths. Tentative consensus based on reasoned judg- tion of critically ill patients shows better patient out-
ments about the available evidence is what can be comes (Schweickert & Kress, 2011). Theory-based
expected. In this view, scientific knowledge is what nursing practice has demonstrated the capacity to
the consensus of scientists in any given historical era restructure professional care, improving outcomes
regard as scientific knowledge. At any point in time, and satisfaction (Alligood, 2011).
the current consensus among scientists determines the
truth of a given theoretical statement by concluding Interdependence of Theory
whether or not it presents a plausible description of
reality (Brown, 1977). This consensus is possible and Research
through the collaboration of many scientists as they Traditionally, theory building and research have been
make their work available for public review and debate presented to students in separate courses. Often, this
and as they build upon previous scientific discoveries separation has caused problems for students in under-
(Randall, 1964). standing the nature of theories and in comprehending
In any given era and in any given discipline, science the relevance of research efforts (Winston, 1974). The
is structured by an accepted set of presuppositions that acceptance of the positivist view of science may have
define the phenomena for study and define the appro- influenced the sharp distinction between theory and
priate methods for data collection and interpretation research methods (Gale, 1979). Although theory and
(Brown, 1977; Foucault, 1973; Kuhn, 1962). These pre- research can be viewed as distinct operations, they
suppositions set the boundaries for the scientific enter- are regarded more appropriately as interdependent
prise in a particular field. In Brown’s view of the trans- components of the scientific process (Dubin, 1978). In
actions between theory and empirical observation: constructing a theory, the theorist must be knowledge-
able about available empirical findings and be able
“Theory determines what observations are worth to take these into account because theory is, in part,
making and how they are to be understood, concerned with organizing and formalizing available
and observation provides challenges to accepted knowledge of a given phenomenon. The theory is sub-
theoretical structures. The continuing attempt to ject to revision if hypotheses fail to correspond with
produce a coherently organized body of theory empirical findings, or the theory may be abandoned
and observation is the driving force of research, in favor of an alternative explanation that accounts
and the prolonged failure of specific research for the new information (Brown, 1977; Dubin, 1978;
projects leads to scientific revolutions.” Kuhn, 1962).
(Brown 1977, p. 167)
In contemporary theories of science, the scientific
The presentation and acceptance of a revolution- enterprise has been described as a series of phases
ary theory may alter the existing presuppositions and with an emphasis on the discovery and verification (or
theories, thereby creating a different set of boundaries acceptance) phases (Gale, 1979; Giere, 1979). These
and procedures. The result is a new set of problems or phases are concerned primarily with the presentation
a new way to interpret observations; that is, a new and testing of new ideas. New ways of thinking about
picture of the world (Kuhn, 1962). In this view of phenomena or new data are introduced to the scien-
science, the emphasis must be placed on ongoing tific community during the discovery phase. During
research rather than established findings. According this time, the focus is on presenting a persuasive argu-
to Kuhn, science progresses from a pre-science, then ment to show that the new conceptions represent an
CHAPTER 2 History and Philosophy of Science 19
improvement over previous conceptions (Gale, 1979). research, the scientific community does not necessarily
Verification is characterized by the scientific commu- reject it. Rather than agreeing that a problem exists with
nity’s efforts to critically analyze and test the new the theory itself, the community may make judgments
conceptions in an attempt to refute them. The new about the validity or the reliability of the measures used
views are then subjected to testing and analyses in testing the theory or about the appropriateness of the
(Gale, 1979). However, Brown (1977) argued that research design. These possibilities are considered in
discovery and verification could not be viewed as critically evaluating all attempts to test a given theory.
distinct phases, because the scientific community does Scientific consensus is necessary in three key areas
not usually accept a new conception until it has been for any given theory as follows: (1) agreement on the
subjected to significant testing. Only then can it be boundaries of the theory; that is, the phenomenon it
accepted as a new discovery. addresses and the phenomena it excludes (criterion of
In any scientific discipline, it is not appropriate to coherence), (2) agreement on the logic used in con-
judge a theory on the basis of authority, faith, or intu- structing the theory to further understanding from
ition; it should be judged on the basis of scientific a similar perspective (criterion of coherence), and
consensus (Randall, 1964). For example, if a specific (3) agreement that the theory fits the data collected
nursing theory is deemed acceptable, this judgment and analyzed through research (criterion of corre-
should not be made because a respected nursing leader spondence) (Brown, 1977; Dubin, 1978; Steiner, 1977,
advocates the theory. Personal feelings, such as “I like 1978). Essentially, consensus in these three areas
this theory” or “I don’t like this theory,” do not provide constitutes an agreement among scientists to “look at
a valid basis for judgment. The theory should be judged the same ‘things,’ to do so in the same way, and to have
acceptable on the basis of logical and conceptual or a level of confidence certified by an empirical test”
empirical grounds. The scientific community makes (Dubin, 1978, p. 13). Therefore, the theory must be
these judgments (Gale, 1979). capable of being operationalized to test it against
The advancement of science is thus a collaborative reality.
endeavor in which many researchers evaluate and Scientific inquiry in normal science involves test-
build on the work of others. Theories, procedures, ing a given theory, developing new applications of
and findings from empirical studies must be made a theory, or extending a given theory. Occasionally, a
available for critical review by scientists for evidence new theory with different assumptions is developed
to be cumulative. The same procedures can be used to that could replace previous theories. Kuhn (1962)
support or refute a given analysis or finding. A theory described this as revolutionary science and described
is accepted when scientists agree that it provides a the theory with different presuppositions as a revo-
description of reality that captures the phenomenon lutionary theory. A change in the accepted presup-
based on current research findings (Brown, 1977). positions creates a set of boundaries and procedures
The acceptance of a scientific hypothesis depends on that suggest a new set of problems or a new way to
the appraisal of the coherence of theory, which in- interpret observations (Kuhn, 1962). One previously
volves questions of logic, and the correspondence of accepted theory is abandoned for another theory if
the theory, which involves efforts to relate the theory it fails to correspond with empirical findings or if it
to observable phenomena through research (Steiner, does not present clear directions for further research.
1978). Gale (1979) labeled these criteria as epistemo- The scientific community judges the selected alterna-
logical and metaphysical concerns. tive theory to account for available data and to sug-
The consensus regarding the correspondence of gest further lines of inquiry (Brown, 1977). Hence, a
the theory is, therefore, not based on a single study. new worldview is formed.
Repeated testing is crucial. The study must be repli- In the social and behavioral sciences, there is some
cated under the same conditions, and the theoretical challenge to the assumptions underlying the accepted
assertions must be explored under different condi- methods of experimental design, measurement, and
tions or with different measures. Consensus is, there- statistical analysis that emphasizes the search for uni-
fore, based on accumulated evidence (Giere, 1979). versal laws and the use of procedures for the random
When the theory does not appear to be supported by assignment of subjects across contexts. Mishler (1979)
20 UNIT I Evolution of Nursing Theories
argued that, in studying behavior, scientists should interaction that emphasize situation, context, and
develop methods and procedures that are dependent the multiple cognitive constructions individuals cre-
on context for meaning rather than eliminate context ate from everyday events (Ford-Gilboe, et al., 1995).
by searching for laws that hold across contexts. This A critical paradigm for knowledge development
critique of the methods and assumptions of research is in nursing also has been described as an emergent,
emerging from phenomenological and ethnomethod- postmodern paradigm that provides the framework
ological theorists who view the scientific process from for inquiring about the interaction between social,
a very different paradigm (Bowers, 1992; Hudson, political, economic, gender, and cultural factors
1972; Mishler, 1979; Pallikkathayil & Morgan, 1991). and the experiences of health and illness (Ford-
Phenomenology is a science that describes how we Gilboe, et al., 1995). A broad conception of post-
experience the objects of the external world and pro- modernism includes the particular philosophies that
vides an explanation of how we construct objects of challenge the “objectification of knowledge,” such
experience. In phenomenology, the investigator posits as phenomenology, hermeneutics, feminism, critical
that all objects exist because people perceive and theory, and poststructuralism (Omery, Kasper, &
construct them as such. Ethnomethodology focuses Page, 1995).
on the world of “social facts” as accomplished or The philosophy of nursing has been developing
co-created through people’s interpretive work. When over a 150-year period. The philosophy of caring,
examining phenomena from this perspective, social naturalism, and holism are themes that can be found
reality and social facts are constructed, produced, and in the literature. Numerous authors have written
organized through the mundane actions and circum- about caring. Caring is the wholeness of the patient’s
stances of everyday life. situation, which implies that nursing care requires
There is neither a single science nor a single scien- interpretation, understanding, and hermeneutic ex-
tific method. There are several sciences, each with perience. The philosophy of caring involves knowl-
unique phenomena and structure and methods for edge, skills, patient trust, and the ability to manage
inquiry (Springagesh & Springagesh, 1986). How- all elements simultaneously in the context of care
ever, the commonality among sciences concerns the (Austgard, 2008).
scientists’ efforts to separate truth from speculation Wholism is another philosophy in understanding
to advance knowledge (Snelbecker, 1974). In ques- the patient (Hennessey, 2011). Wholistic nursing
tions regarding the structure of knowledge in a given views the biophysical, psychological, and sociological
science, the consensus of scientists in the discipline subsystems as related but separate, thus the whole is
decides what is to be regarded as scientific knowl- equal to the sum of the parts. Holistic nursing recog-
edge and the methods of inquiry (Brown, 1977; nizes that multiple subsystems are in continuous
Gale, 1979). interaction and that mind-body relationships do exist
Consensus has emerged in the field of nursing (Kinney & Erickson, 1990).
that the knowledge base for nursing practice is in- Naturalism has a metaphysical component that
complete, and the development of a scientific base implicates that the natural world exists; there is no
for nursing practice is a high priority for the disci- non-natural or supranatural realm. The natural world
pline. The postpositivist and interpretive paradigms is open, because it depends upon what method the
have achieved a degree of acceptance in nursing as enquiry requires. Naturalism insists that knowledge
paradigms to guide knowledge development (Ford- and beliefs are gained by one’s senses guided by
Gilboe, Campbell, & Berman, 1995). Postpositivism reason, and by the various methods of science
focuses on discovering patterns that may describe, (Hussey, 2011). While these philosophies are pro-
explain, and predict phenomena. It rejects the older, posed in the literature, nursing science is in the early
traditional positivist views of an ultimate objective stages of scientific development.
knowledge that is observable only through the senses As the discipline of nursing moves forward, there
(Ford-Gilboe, et al., 1995; Weiss, 1995). The interpre- is abundant evidence that a greater number of nurse
tive paradigm tends to promote understanding by scholars are actively engaged in the advancement
addressing the meanings of the participants’ social of knowledge for the discipline of nursing through
CHAPTER 2 History and Philosophy of Science 21
research and scholarly dialogue. This can be seen with enterprise (Brown, 1977). For example, the popularity
the emergence of middle-range theories that utilize of certain ideologies may influence how phenomena
inductive, deductive, and synthesis theories from are viewed and what problems are selected for
nursing and other disciplines (Peterson & Bredow, study (Hudson, 1972). In addition, the availability
2008; Sieloff & Frey, 2007; Smith & Liehr, 2008). This of funds for research in a specified area may in-
new century of nursing scholarship by nurse scientists crease research activity in that area. However, sci-
and scholars explores nursing phenomena of interest ence does not depend on the personal characteris-
and provides evidence for quality advanced practice. tics or persuasions of any given scientist or group of
scientists, but it is powerfully self-correcting within
the community of scientists (Randall, 1964). Science
Science as a Social Enterprise progresses by the diversity of dialogue within the
The process of scientific inquiry may be viewed as discipline of nursing. The use of a single paradigm,
a social enterprise (Mishler, 1979). In Gale’s words, multiple paradigms, or the creation of a merged
“Human beings do science” (Gale, 1979, p. 290). paradigm from many paradigms is debated in rela-
Therefore, it might be anticipated that social, eco- tionship to the advancement in the epistemology of
nomic, or political factors may influence the scientific nursing.
POINTS FOR FURTHER STUDY
n 100 Basic Philosophical Terms:http://www.str.org/ n Phenomenology: http://plato.stanford.edu/
site/News2?page5NewsArticle&id55493 entries/phenomenology/
n Edmund Husserl: http://plato.stanford.edu/ n Naturalism: http://plato.stanford.edu/entries/
entries/husserl/ naturalism/
n Kant’s Philosophy of Science: http://plato.stanford.
edu/entries/kant-science/
REFERENCES
Alligood, M.R. (2011). Theory-based practice in a major Foucault, M. (1973). The order of things: An archaeology
medical center. Journal of Nursing Management, 19, of the human sciences. New York: Vintage Books.
981–988. Gale, G. (1979). Theory of science: An introduction to the
Austgard, K. I. (2008). What characterises nursing care? history, logic and philosophy of science. New York:
A hermenutical philosophical inquiry. Scand J Caring, McGraw-Hill.
22, 314–319. Giere, R. N. (1979). Understanding scientific reasoning.
Bowers, L. (1992). Ethnomethodology I: an approach to New York: Holt, Rhinehart, & Winston.
nursing research. International Journal of Nursing Hanson, N. R. (1958). Patterns of discovery. Cambridge,
Studies, 29(1), 59–67. (MA): Cambridge University Press.
Bronowski, J. (1979). The visionary eye: Essays in the Hennessey, S. (2011). Wholism: another perspective.
arts, literature and science. Cambridge, (MA): California Journal of Oriental Medicine, 22(2),
MIT Press. 7–11.
Brown, H. (1977). Perception, theory and commitment: Hudson, L. (1972). The cult of the fact. New York: Harper
The new philosophy of science. Chicago: University of & Row.
Chicago Press. Husserl, E. (1931). Ideas: General introduction to pure
Calder, N. (1979). Einstein’s universe. New York: Viking. phenomenology. (W. R. Boyce Gibson, Trans.).
Dubin, R. (1978). Theory building. New York: Free Press. New York: Humanities Press.
Flavell, J. H. (1977). Cognitive development. Englewood Husserl, E. (1970). The crisis of European sciences and tran-
Cliffs, (NJ): Prentice-Hall. scendental phenomenology.(D. Carr, Trans.). Evanston,
Ford-Gilboe, M., Campbell, J., & Berman, H. (1995). (IL): Northwestern University Press.
Stories and numbers: coexistence without compromise. Hussey, T. (2011). Naturalistic nursing. Nursing Philosophy,
Advances in Nursing Science, 18(1), 14–26. 12, 45–52.
22 UNIT I Evolution of Nursing Theories
Kinney, C. K., & Erickson, H. C. (1990). Modeling the Randall, J. H. (1964). Philosophy: An introduction.
client’s world: a way to holistic care. Issues in Mental New York: Barnes & Noble.
Health Nursing, 11(2), 93–108. Reynolds, P. (1971). A primer in theory construction.
Kuhn, T. S. (1962). The structure of scientific revolutions. Indianapolis, (IN): Bobbs-Merrill.
Chicago: University of Chicago Press. Schutz A. (1967). The phenomenology of the social world.
Kuhn, T. S. (1970). The structure of scientific revolutions Evanston, (IL): Northwestern University Press.
(2nd ed.). Chicago: University of Chicago Press. Schweickert, W. D., & Kress J. P. (2011). Implementing
Lipton, P. (2005). The Medawar lecture 2004: the truth early mobilization interventions in mechanically
about science. Philosophical Transactions of The Royal ventilated patients in the ICU. Chest, 140, 1612–1617.
Society, 360, 1259–1269. Sieloff, C. L. & Frey, M. A. (Eds.). (2007). Middle range
McCrae, N. (2011). Whither nursing models? The value theory development using King’s conceptual system.
of nursing theory in the context of evidence-based New York: Springer.
practice and multidisciplinary health care. Journal Skinner, B. F. (1950). Are theories of learning necessary?
of Advanced Nursing, 68(1), 222–229. Psychological Review, 57, 193–216.
McDonald, D.D., Shea, M., Rose, L., & Fedo, J. (2009). Smith, M. J., & Liehr, P. R. (2008). Middle range theory
The effect of pain question phrasing on older adult pain for nursing. (2nd ed.). New York: Springer.
information. J Pain Symptom Manage, 37, 1050–1060. Snelbecker, G. (1974). Learning theory, instructional theory,
Mishler, E. G. (1979). Meaning in context: is there any and psychoeducational design. New York: McGraw-Hill.
other kind? Harvard Educational Review, 49, 1–19. Springagesh, K., & Springagesh, S. (1986). Philosophy
Norman, D. A. (1976). Memory and attention: An and scientific approach. Contemporary Philosophy,
introduction to human information processing. 11(6), 18–20.
New York: Wiley. Steiner, E. (1977). Criteria for theory of art education.
Nyatanga, L. (2005). Nursing and the philosophy of Unpublished monograph presented at Seminar for
science. Nurse Education Today, 25(8), 670–674. Research in Art Education. Philadelphia.
Omery, A., Kasper, C. E., & Page, G. G. (1995). In search of Steiner, E. (1978). Logical and conceptual analytic techniques
nursing science. Thousand Oaks, (CA): Sage. for educational researchers. Washington, (DC): University
Pallikkathayil, L., & Morgan, S. (1991). Phenomenology as Press.
a method for conducting clinical research. Applied Toulmin, S. (1961). Foresight and understanding. New York:
Nursing Research, 4(4), 195–200. Harper & Row.
Peterson, S. J., & Bredow, T. S. (2008). Middle range theories: Weiss, S. J. (1995). Contemporary empiricism. In A. Omery,
Application to nursing research (2nd ed.). Philadelphia: C. E. Kasper, & G. G. Page (Eds.), In search of nursing
Lippincott, Williams & Wilkins. science. Thousand Oaks, (CA): Sage.
Piaget, J. (1970). The place of the sciences of man in the Winston, C. (1974). Theory and measurement in sociology.
system of sciences. New York: Harper & Row. New York: Wiley.
Popper, K. (1962). Conjectures and refutations. New York: Zetterberg, H. L. (1966). On theory and verification in
Basic Books. sociology. Totowa, (NJ): Bedminster Press.
3
CHAP TER
Theory Development Process
Sonya R. Hardin
“Nursing’s potential for meaningful human service rests
on the union of theory and practice for its fulfillment.”
(Rogers, 1970, p. viii)
heory development in nursing is an essential Deductive reasoning is narrow and goes from general
Tcomponent in nursing scholarship to advance the to specific. In the clinical area, nurses often have ex-
knowledge of the discipline. The legitimacy of any perience with a general rule and apply it to a patient.
profession is built on its ability to generate and apply Inductive reasoning is much broader and explor-
theory (McCrae, 2011, p. 222). Nursing theories that atory in nature as one goes from specific to general.
clearly set forth understanding of nursing phenomena Abductive reasoning begins with an incomplete set of
(i.e., self care, therapeutic communication, chronic observations and proceeds to the likeliest possible
sorrow) guide scholarly development of the science of explanation for the set. A medical diagnosis is an
nursing through research. Once a nursing theory is application of abductive reasoning: given this set
proposed addressing a phenomenon of interest, sev- of symptoms, what is the diagnosis that would best
eral considerations follow, such as its completeness explain most of them? One aspect they have in com-
and logic, internal consistency, correspondence with mon is to approach theory development in a precise,
empirical findings, and whether it has been operation- systematic manner, making the stages of development
ally defined for testing. Analyses of these lead logically explicit. The nurse who systematically devises a the-
to the further development of the theory. Scientific evi- ory of nursing and publishes it for the nursing com-
dence accumulates through repeated rigorous research munity to review and debate engages in a process
that supports or refutes theoretical assertions and that is essential to advancing theory development. As
guides modifications or extensions of the theory. Nurs- scholarly work is published in the literature, nurse
ing theory development is not a mysterious activity, but theoreticians and researchers review and critique the
a scholarly endeavor pursued systematically. Rigorous adequacy of the logical processes used in the develop-
development of nursing theories, then, is a high priority ment of the theory with fresh eyes in relation to prac-
for the future of the discipline and the practice of the tice and available research findings.
profession of nursing.
It is important to understand the concept of sys-
tematic development since approaches to construction Theory Components
of theory differ. A theory may emerge through deduc- Development of theory requires understanding of
tive, inductive, or retroductive (abductive) reasoning. selected scholarly terms, definitions, and assumptions
Previous author: Sue Marquis Bishop.
23
24 UNIT I Evolution of Nursing Theories
so that scholarly review and analysis may occur. At- directly experienced and relate to a particular time or
tention is given to terms and defined meanings to place (Chinn & Kramer, 2011; Hage, 1972; Reynolds,
understand the theory development process that was 1971) (Table 3-2).
used. Therefore, the clarity of terms, their scientific The stretcher, stroke, wheelchair, and hospital bed
utility, and their value to the discipline are important are examples of concrete concepts of the abstract
considerations in the process. concept, transport and the other examples illustrate
Hage (1972) identified six theory components the concrete to abstract difference. In a given theo-
and specified the contributions they make to theory retical system, the definition, characteristics, and
(Table 3-1). Three categories of theory components functioning of a nurse competency clarify more spe-
are presented as a basis for understanding the cific instances, such as medication administration
function of each element in the theory-building nurse competency.
process. Concepts may be classified as discrete or continu-
ous concepts. This system of labels differentiates types
Concepts and Definitions of concept that specify categories of phenomena. A
Concepts, the building blocks of theories, classify the discrete concept identifies categories or classes of
phenomena of interest (Kaplan, 1964). It is crucial that phenomena, such as patient, nurse, health, or envi-
concepts are considered within the theoretical system ronment. A student can become a nurse or choose
in which they are embedded and from which they another profession, but he or she cannot become a
derive their meaning, since concepts may have differ- partial nurse. Phenomena identified as belonging to,
ent meanings in various theoretical systems. Scientific or not belonging to, a given class or category may be
progress is based on critical review and testing of a called nonvariable concepts. Sorting phenomena into
researcher’s work by the scientific community. nonvariable discrete categories carries the assump-
Concepts may be abstract or concrete. Abstract tion that the associated reality is captured by the
concepts are mentally constructed independent of a classification (Hage, 1972). The amount or degree of
specific time or place, whereas concrete concepts are the variable is not an issue.
TABLE 3-1 Theory Components and Their Contributions to the Theory
Theory Components Contributions to the Theory
Concepts and Definitions
Concepts Describe and classify phenomena
Theoretical definitions of concept Establish meaning
Operational definitions of concept Provide measurement
Relational Statements
Theoretical statements Relate concepts to one another; permit analysis
Operational statements Relate concepts to measurements
Linkages and Ordering
Linkages of theoretical statements Provide rationale of why theoretical statements are linked;
add plausibility
Linkages of operational statements Provide rationale for how measurement variables are linked;
permit testability
Organization of concepts and definitions into primitive and Eliminates overlap (tautology)
derived terms
Organization of statements and linkages into premises and Eliminates inconsistency
derived hypotheses and equations
Modified from Hage, J. (1972). Techniques and problems of theory construction in sociology. New York: John Wiley & Sons.
CHAPTER 3 Theory Development Process 25
TABLE 3-2 Concepts: Abstract versus degrees of marital conflict in their relationships from
Concrete low to high.
Abstract Concepts Concrete Concepts
Degree of Marital Conflict
Transport Stretcher, wheelchair, 0 120
hospital bed
Cardiovascular disease Stroke, myocardial infarction Low High
Telemetry Electrocardiogram, Holter monitor
Other continuous concepts that may be used to
Loss of relationship Divorce, widowhood classify couples might include amount of communi-
Nurse competency Cultural, nasogastric tube cation, number of shared activities, or number of
placement, medication children. Examples of continuous concepts used to
administration
classify patients are degree of temperature, level of
Data from Chinn & Kramer, 2011; Hage, 1972; Reynolds, 1971 anxiety, or age. Another example is how nurses con-
ceptualize pain as a continuous concept when they
ask patients to rate their pain on a scale from 0 to 10
Theories may be used as a series of nonvariable to better understand their pain threshold or pain
discrete concepts (and subconcepts) to build typolo- experience.
gies. Typologies are systematic arrangements of con-
cepts within a given category. For example, a typology Degree of Pain
on marital status could be partitioned into marital 0 10
statuses in which a population is classified as married,
divorced, widowed, or single. These discrete catego- Low High
ries could be partitioned further to permit the classi-
fication of an additional variable in this typology. A Continuous concepts are not expressed in either/
typology of marital status and gender is shown in or terms but in degrees on a continuum. The use of
Table 3-3. The participants are either one gender or variable concepts on a continuum tends to focus on
the other since there are no degrees of how much they one dimension but does so without assuming that a
are in this discrete category. Taking the illustration single dimension captures all of the reality of the
further, the typology could be partitioned adding the phenomenon. Additional dimensions may be de-
discrete concept of children. Participants would be vised to measure further aspects of the phenome-
classified for gender, marital status, and as having or non. Instruments may measure a concept and have
not having children. subscales that measure discrete concepts related to
A continuous concept, on the other hand, permits the overall concept. Variable concepts such as ratio
classification of dimensions or gradations of a phe- of professional to nonprofessional staff, communica-
nomenon, indicating degree of marital conflict. Mari- tion flow, or ratio of registered nurses to patients,
tal couples may be classified with a range representing is used to characterize health care organizations.
Although nonvariable concepts are useful in classi-
fying phenomena in theory development, Hage
TABLE 3-3 Typology of Marital Status (1972) notes several major breakthroughs in disci-
and Gender plines as the focus shifts from nonvariable to vari-
Marital Status able concepts, because variable concepts permit the
scoring of the phenomenon’s full range of variation.
Participants Single Married Divorced Widowed The development of concepts, then, permits descrip-
Male 15 75 23 6 tion and classification of phenomena (Hage, 1972). The
Female 25 72 41 13 labeled concept specifies boundaries for selecting phe-
nomena to observe and for reasoning about the phenom-
Total 40 147 64 19
ena of interest. New concepts may focus attention on new
26 UNIT I Evolution of Nursing Theories
phenomena or facilitate thinking about phenomena in a relate the concepts to observable phenomena specify-
different way (Hage, 1972). Scholarly analysis of the con- ing empirical indicators. Table 3-5 provides examples
cepts in nursing theories is a critical beginning step in the of concepts with their theoretical and operational
process of theoretical inquiry. The concept process con- definitions. These linkages are vital to the logic of the
tinues to flourish with many examples in the nursing lit- theory, its observation, and its measurement.
erature. See Table 3-4 for references to analyses carried The concept-building process emerges from prac-
out using different approaches. tice, incorporating the literature and research findings
Concept analysis is an important beginning step in from multiple disciplines. Concepts are built into a
the process of theory development to develop a con- conceptual framework and are further refined. A
ceptual definition. It is crucial that concepts are clearly 10-phase process for concept building is described in
defined to reduce ambiguity in the given concept or the literature (Smith & Liehr, 2008; Smith & Liehr,
set of concepts. To eliminate perceived differences in 2012). The process of concept building is guided by
meaning, explicit definitions are necessary. As the patient stories. The 10 phases are as follows: (1) write a
theory develops, theoretical and operational defini- meaningful practice story; (2) name the central phe-
tions provide the theorist’s meaning of the concept nomenon in the practice story; (3) identify a theoretical
and the basis for the empirical indicators. For exam- lens for viewing the phenomenon; (4) link the phenom-
ple, McMahon and Fleury (2012) published a concept enon to existing literature; (5) gather a story from some-
analysis on wellness in older adults. Wellness in older one who has lived the phenomenon; (6) reconstruct the
adults was theoretically defined as wellness is a pur- shared story (from Phase 5) and create a mini-saga that
poseful process of individual growth, integration of captures its message; (7) identify the core qualities of
experience, and meaningful connection with others, the phenomenon; (8) use the core qualities to create a
reflecting personally valued goals and strengths, and definition; (9) create a model of the phenomenon; and
resulting in being well and living values. The concept (10) write a mini-synthesis that integrates the phe-
of wellness in older adults was operationalized as an nomenon with a population to suggest a research direc-
ever changing process of becoming, integrating, and tion. The process, which provides the scaffolding for
relating. beginning scholars to move from the familiarity of
Theories are tested in reality; therefore, the con- practice to the unfamiliarity of phenomena for research,
cepts must be linked to operational definitions that will be shared with brief examples that demonstrate
TABLE 3-4 Examples of Published Concept Analyses with Different Approaches
Concept Approach Author
Spirituality Chinn & Kramer Buck (2006)
Readiness to change Chinn & Kramer Dalton & Gottlieb (2003)
Acculturation Morse Baker (2011)
Ethical sensitivity Morse Weaver, Morse, & Mitcham (2008)
Disability and aging Rodgers Greco & Vincent (2011)
Moral distress in neuroscience nursing Rodgers Russell (2012)
Symptom perception Schwartz-Barcott & Kim Posey (2006)
Being sensitive Schwartz-Barcott & Kim Sayers, K., & de Vries, K. (2008)
Work engagement in nursing Walker & Avant Bargagliotti (2012)
Migration Walker & Avant Freeman, Baumann, Blythe, Fisher, & Akhtar-Danesh (2012)
Infant distress Wilson method Hatfield & Polomano (2012)
Social justice Wilson method Buettner-Schmidt & Lobo (2012)
CHAPTER 3 Theory Development Process 27
TABLE 3-5 Examples of Theoretical and Operational Definitions
Concept Theoretical Definition Operational Definition
Body temperature Homeothermic range of one’s internal environment Degree of temperature measured by oral
maintained by the thermoregulatory system of thermometer taken for 1 minute under the
the human body tongue
Quality of Life Perceptions of the effects of heart failure and its The physical, emotional, social, and mental
treatment on daily life* dimensions of daily life when diagnosed with
heart failure as measured with the Minnesota
Living with Heart Failure Questionnaire †
Spirituality A pandimensional awareness of the mutual Score on the Spiritual Inventory Belief Scale
human/environmental field process (integrality) (SIBS), an instrument that measures a person’s
as a manifestation of higher-frequency spirituality as the search for meaning and
patterning (resonancy) associated with purpose §
innovative, increasingly creative and diverse
(helicy) experiences ‡
The SIBS has four subscales:
1) Internal/fluid
2) Humility/personal application
3) External/meditative
4) External/ritual ¶
* Hussey & Hardin, 2003.
† Rector & Cohen, 1992.
‡ Malinski, 1994.
§ Hatch, Burg, Naberhaus, & Hellmich, 1998.
¶ Hardin, Hussey, & Steele, 2003.
potential and lessons learned in nearly a decade of use in the development of a theory. These statements can
(Smith & Liehr, 2012, p. 65). be reformulated later as the theory evolves or as new
information becomes available. An example of an
Relational Statements antecedent and a consequent variable is explained
Statements in a theory may state definitions or rela- looking at the concept of well in older adults, where
tions among concepts. Whereas definitions provide the antecedents were identified as connecting with
descriptions of the concept, relational statements pro- others, imagining opportunities, recognizing strengths,
pose relationships between and among two or more and seeking meaning. The consequences identified
concepts. Concepts are the building blocks of theory, were living values and being well. These antecedents
and theoretical statements are the chains that link the and consequences were developed from the literature
blocks to build theory. Concepts must be connected (McMahon & Fleury, 2012).
with one another in a series of theoretical statements Theoretical assertions are either a necessary or suf-
to devise a nursing theory. ficient condition, or both. These labels characterize
In the connections between variables, one vari- conditions that help explain the nature of the relation-
able may be proposed to influence a second. In this ship between two variables in theoretical statements.
case, the first variable may be viewed as the anteced- For example, a relational statement expressed as a
ent or determinate (independent) variable and the sufficient condition could be: If nurses react with
second as the consequent or resultant (dependent) approval of patients’ self-care behaviors (NA), patients
variable (Giere, 1997). Zetterberg (1966) concluded increase their efforts in self-care activities (PSC). This
that the development of two-variate theoretical is a type of compound statement linking antecedent and
statements could be an important intermediate step consequent variables. The statement does not assert
28 UNIT I Evolution of Nursing Theories
the truth of the antecedent. Rather, the assertion is case, (1) the consequent never occurs in the absence
made that if the antecedent is true, then the conse- of the antecedent and (2) the consequent always
quent is true (Giere, 1979). In addition, no assertion occurs when the antecedent occurs (Giere, 1979). It
appears in the statement explaining why the anteced- should be noted that not all conditional statements
ent is related to the consequent. In symbolic notation are causal. For example, “If this month is November,
form, the statements may be expressed as: then the next month is December,” does not assert
that November causes December to occur; rather, the
NA PSC sequence of months suggests that December follows
(Antecedent/determinant Consequent/ November (Dubin, 1978; Giere, 1979).
resultant) Giere (1997) further differentiates deterministic
models from probabilistic models in his discussion of
A sufficient condition asserts that one variable causal statements. Theoretical statements from a de-
results in the occurrence of another variable. It does terministic model assert that the presence or absence
not claim it is the only variable that can result in of one variable determines the presence or absence of
the occurrence of the other variable. This statement a second variable. The probabilistic model is another
asserts that nurse approval of a patient’s self-care approach that views humans as complex social and
behaviors is sufficient for the occurrence of the patient’s environmental phenomena best conceptualized from
self-care activities. However, patient assumption of a probability framework. Probabilistic statements
self-care activities resulting from other factors, such generally are based on statistical data and assert
as the patient’s health status and personality variables, relationships between variables that do not occur in
is not ruled out. There may be other antecedent con- every instance, but are likely to occur based on some
ditions sufficient for the patient’s assumption of self- estimate of probability. As an example, it has been
care activities. asserted that a lack of exercise may lead to obesity, a
A statement in the form of a necessary condition growing national health problem. It is clear that a lack
asserts that one variable is required for the occur- of exercise (LE) does not always lead to obesity, be-
rence of another variable. For example: If patients are cause not all couch potatoes become medically obese
motivated to get well (WM 5 wellness motivation) (MO). However, the probability of developing medi-
then they adhere to their prescribed treatment regi- cal obesity (P MO) may be increased for persons who
men (AR). routinely avoid exercise at least to some degree of
probability. In symbolic notation:
WM AR
IF LE P MO
This means that adherence to a treatment regimen
(AR) never occurs unless wellness motivation (WM) Relational statements that assert connections
occurs. It is not asserted that the patients’ adherence between variables provide for analysis and establish
to the treatment regimen stems from their wellness a basis for explanation and prediction (Hage, 1972).
motivation. However, it is asserted that if the wellness
motivation is absent, patients will not assume strict Linkages and Ordering
adherence to their treatment regimens. The wellness Specification of linkages is a vital part of the develop-
motivation is a necessary, but not a sufficient, condi- ment of theory (Hage, 1972). Although the theoretical
tion for the occurrence of this consequent. statements assert connections between concepts, the
The term if is generally used to introduce a suffi- rationale for the stated connections must be developed
cient condition, whereas only if and if . . . then are and clearly presented. Development of theoretical link-
used to introduce necessary conditions (Giere, 1979). ages provides an explanation of why the variables
Usually conditional statements are not both necessary are connected in a certain manner; that is, the theo-
and sufficient. However, it is possible for a statement retical reason for particular relationships (Hage,
to express both conditions. In such instances, the 1972). Operational linkages contribute testability to
term if and only if is used to imply that conditions are the theory by specifying how measurement variables
both necessary and sufficient for one another. In this are connected (Hage, 1972). Operational definitions
CHAPTER 3 Theory Development Process 29
specify the measurability of the concepts, and opera- concepts that are necessary to understand the phe-
tional linkages provide the testability of the assertions. nomenon of interest (Foster, 1997).
It is the operational linkages that contribute a perspec- Reynolds (1971) concluded that the set-of-laws
tive for understanding the nature of the relationship approach provides for classification of phenomena or
between concepts, to know whether the relationship prediction of relationships between selected variables,
between the concepts is negative or positive, linear, or however it does not further understanding or advance
curvilinear (Hage, 1972). A theory may be considered science since it is based on what is already known.
fairly complete if it presents the concepts, definitions, Finally, Reynolds (1971) notes that each statement
relational statements, and linkages. Complete develop- or law is considered to be independent, since the
ment of a theory, however, requires organizing the various statements have not been interrelated into a
concepts, definitions, relational statements, and link- system of description and explanation or evolved
ages into premises and hypotheses (Hage, 1972). A from an organized conceptual model or framework.
premise is a proposition upon which an argument is Table 3-6 describes the principles of theory develop-
based or from which a conclusion is drawn. A hypoth- ment: laws, hypotheses, and theory. Therefore, each
esis is a proposed explanation made on the basis of statement must be tested since the statements are not
limited evidence as a starting point for further investi- interrelated, and one statement does not provide
gation. As the theory evolves, concepts and theoretical support for another statement. This set of laws may
statements are developed establishing a logical organi- be useful to begin theory development; however,
zation of the theory components. The conceptual ar- research efforts must be more extensive.
rangement of statements and linkages into premises The organizationof a theory is an interrelated, logi-
reveals any areas of inconsistency (Hage, 1972). Prem- cal system. Specifically, a theory consists of explicit
ises (or axioms) are the more general assertions from definitions, a set of concepts, a set of existence state-
which the hypotheses are derived. It is generally agreed ments, and a set of relationship statements arranged
that conceptual ordering of theoretical statements and in hierarchical order (Reynolds, 1971). The concepts
their linkages is indicated when the theory contains a may include abstract, intermediate concepts, and
logical list of theoretical statements. concrete concepts. The set-of-existence statements
Reynolds (1971) describes three forms for organiz- describe situations in which the theory is applicable.
ing theory: laws, theory, and causal process (prediction). Statements that delineate the boundaries describe
Each is a different conceptual approach to organization the scope of the theory (Dubin, 1978; Hage, 1972;
with different limitations. Establishing a set of laws or-
ganizes findings from available research in an area of
particular interest from the literature for evaluation.
Findings are evaluated and sorted into the categories of TABLE 3-6 Theory Development
laws and hypotheses based on the degree of research Principles
evidence supporting each assertion (Reynolds, 1971).
Limitations to the set-of-laws approach to theory Principle Definition Proof
building have been noted. Scientific A statement of fact Simple, true,
First, the nature of research requires focusing on laws meant to describe universal, and
the relationships between a limited set of variables, an action or a set of absolute
therefore attempts to develop a set-of-laws theory actions.
from statements of findings may result in a lengthy Hypothesis An educated guess based Has not been
number of statements asserting relationships between upon observation proved
but limited to two or more variables. The lengthy set Theory One or more hypotheses Accepted at true
of generalizations may be difficult to organize and that explains a set of and proved
interrelate. Second, for research to be conducted, con- related observations
cepts must be operationally defined so they can or events and has
be measurable. Therefore, the reported empirical been verified multiple
findings may eliminate the abstract or theoretical times
30 UNIT I Evolution of Nursing Theories
Reynolds, 1971). Relational statements consist of incorporating Newton’s law of gravitation is a classic
axioms and propositions. Abstract, theoretical state- example. Axiomatic theories (theories with equations)
ments, or axioms, are at the top of the hierarchy are less common in the social and behavioral sci-
of relational statements. The other propositions are ences, but they are quite evident in the fields of phys-
developed through logical deduction from the axioms ics and mathematics.
or from research findings in the literature (Table 3-7). Developing theories in axiomatic form has several
This results in a highly interrelated, explanatory advantages (Reynolds, 1971; Salmon, 1973). First,
system. because theory is a set of interrelated statements in
Theorists avoid the problem of contradictory axi- which some statements derive from others, only con-
oms by using a conceptual system with a few broad cepts to be measured need to be operationally de-
axioms from which a set of propositions are derived. fined (Reynolds, 1971). This allows the theorist to
The seven nursing conceptual models (Unit III, incorporate highly abstract less measurable concepts
Chapters 12 to 18) in this text are examples of to provide explanation. The theoretical system also
frameworks with broad axioms from which theory may be more efficient for explanation than a lengthy
may be developed. As science progresses and new number of theoretical statements in the form of laws.
empirical data are known, the general axioms may In addition, empirical support for one theoretical
be modified or extended. Examples of this type of statement may be based on findings of support from
extension are some of the nursing theories and earlier research, thereby permitting less extensive
middle-range theories that were developed using a research than the requirement to test each statement
nursing conceptual model as their broad axioms. in the laws form. In certain instances, the theory may
However, these additions must be consistent with be organized in a causal process form to increase
the logical system of the model and not include con- understanding and substantiate findings.
tradictions in the theory, or the theory will be re- The distinguishing feature of the causal process
jected (Schlotfeldt, 1992). New theories may also form of theory development is the theoretical state-
subsume portions of previous theories as special ments that specify causal mechanisms between inde-
cases (Brown, 1977). Einstein’s theory of relativity pendent and dependent variables. Hence, the states
TABLE 3-7 Theory Development in the Scientific Method
Steps Example
Observation: Start with an observation that evokes a Autotransfusion is time-consuming for nurses caring for total knee
question. replacement patients.
Logical hypothesis: Using abductive, inductive, or deductive Autotransfusion patients have a higher hemoglobin level at discharge
logic, state a possible answer (hypothesis). than allogenic blood recipients.
Testing: Perform an experiment or test. Autotransfusion use results in an increased hemoglobin level at
discharge.
Dissemination: Publish your findings for the discipline. Poulin-Tabor, D., & Hyrkas, K. (2008). Evaluation of postoperative
blood salvage and re-transfusion in a total knee arthoplasty
patient population: A retrospective study. MEDSURG Nursing,
17(5), 317-321.
Replication: Other scientists will read your published Faber, F. C., & Hardin, S. R. (2010). Outcomes of knee replacement
work and try to duplicate it (verification). patients using autotransfusion. Orthopedic Nursing, 29(5), 333-337.
Findings: No significant difference in hemoglobin
Theory: If experiments from other researchers support No theory
your hypothesis, it will become a theory.
CHAPTER 3 Theory Development Process 31
are to some degree attempting to predict. This form highly developed form of theory development that
of theory organization consists of a set of concepts, a builds successively on previous research findings in
set of definitions, a set of existence statements, and a the researchers’ area of research with extensive theory
set of theoretical statements specifying a causal pro- building and testing over time. Figure 3-1 displays a
cess (Reynolds, 1971). Concepts include abstract and causal model for testing a theory of active coping. The
concrete ideas. Existence statements function as they broken lines show direction of expected linkage. The
do in axiomatic theories to describe the scope condi- dotted lines indicate potential new relationships.
tions of the theory; that is, the assumed situations The arrows indicate the direction of cause that is pre-
where the theory applies (Dubin, 1978; Hage, 1972; dicted in the hypotheses of the study. The numbers
Reynolds, 1971). Causal statements specify the hy- along the lines identify previous studies that lend sup-
pothesized effects of one variable upon one or more port for the relationships being proposed.
other variables for testing. In complex causal pro-
cesses, feedback loops and paths of influence through Contemporary Issues in Nursing
several variables are hypothesized in a set of interre- Theory Development
lated causal statements (Mullins, 1971; Nowak, 1975).
Reynolds (1971) concludes that the causal process Theoretical Boundaries and Levels
form of theory provides for testing an explanation to Advance Nursing Science
of the process of how events happen. He identified Since Fawcett’s (1984) seminal proposal of the four
several advantages of the causal process form of orga- metaparadigm concepts: person, environment, health,
nization. First, like axiomatic theory, it provides for and nursing, general agreement has emerged among
highly abstract, theoretical concepts. Second, like nursing scholars such that the proposed framework
axiomatic theory, this form permits more efficient is now used without reference to the author for the
research testing with its interrelated theoretical state- development of nursing science. In general, a metapar-
ments. Finally, the causal process statements provide adigm should specify the broad boundaries of the
a sense of understanding in the phenomenon of inter- phenomenon of concern in a discipline, for example,
est that is not possible with other forms. This is a to set nursing apart from other disciplines, such as
Passive/
avoidance
1,2,3,4 (+) coping
1,2,3 (+) 1,3 (+)
1,2,3 (+)
1,2,3,4 (+) 1,2,3 (+)
Conflicts Perceived Psychological
stress distress
1,2,3 (+)
Available/ 1,2,4 (+) Active
enacted coping
social support
FIGURE 3-1 Causal model of active coping. (From Ducharme, F., Ricard, N., Duquette, A., & Lachance, I.
(1998). Empirical testing of a longitudinal model derived from the Roy Adaptation Model. Nursing Science
Quarterly, 11(4), 149–159.)
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