tfn module 1

UNIVERSITY OF LA SALETTE, INC.

Dubinan East, Santiago City, Philippines, 3311

COLLEGE OF NURSING, PUBLIC HEALTH AND MIDWIFERY

UNIVERSITY OF LA SALETTE, INC.

Dubinan East, Santiago City, Philippines, 3311

COLLEGE OF NURSING, PUBLIC HEALTH AND MIDWIFERY

MODULE1
EVOLUTION OF NURSING

INTRODUCTION

Nursing theory has become a major theme over the past 50 years, stimulating phenomenal growth and vast
expansion of nursing education and literature. Selected nursing theorists are presented to expose students to a broad
range of nurse theorists and different types of theoretical works. Many nurses of early eras delivered excellent care to
patients. However, much of what was known about nursing was passed on through vocational education that was
focused on skillful completion of functional tasks. Whereas many of these practices seemed effective, they were not
tested nor used uniformly. Developing nursing knowledge on which to base nursing practice was a major goal put
forth by leaders of the nursing profession in the twentieth century, as nurses sought to improve practice and to gain
recognition of nursing as a profession. The history of nursing clearly documents sustained efforts put forth toward the
goal of developing a substantive body of nursing knowledge to guide nursing practice (Alligood, 2006a; Bixler
& Bixler, 1959; Chinn & Kramer, 2008; George, 2002; Johnson & Webber, 2004; McEwen & Wills, 2006; Meleis,
2007; Parker, 2006). In this module, the reader is introduced to nursing theory under three major headings: history,
significance, and analysis.

LEARNING OUTCOMES:

1. Integrate relevant concepts and metaparadigm of theories on person, health, environment and nursing in
nursing practice.

2. Apply appropriate nursing concepts and actions holistically and comprehensively.
3. Appreciate the value of evidence-based nursing practice in the application of nursing and related models/

theories

HISTORY OF NURSING THEORY

The nursing profession has impressively evolved over time, and along this transition came nursing theories.
The beginning of nursing theory development can be traced to Florence Nightingale. However, it was not until the
second half of the twentieth century that nursing as an academic discipline and a profession, a body of knowledge to
guide nursing practices essential. Furthermore, it was realized that theory development is significant to develop a body
of substantive knowledge to guide nursing practice to establish nursing as a profession and an academic discipline.

In this twenty-first century, it is fully understood that nursing theories play vital role in guiding critical
thinking in nursing practice. It is nursing theories that provide the nurse with patient focus and a framework to sort
patient data in practice. Theory guides both thinking and nursing action. It is recognized that theory informs practice
and also that practice informs theory.

The systematic accumulation of knowledge is essential to progress in any profession, however, theory
without practice is empty and practice without theory is blind" (Cross, 1981.p.110)

Overall, nursing theory is the backbone of clinical care. To apply nursing theory in practice, the nurse must
have adequate knowledge of the theoretical works of the nursing profession. However, it is noteworthy that
development of a body of substantive knowledge to guide nursing practice, to establish nursing as a profession and as
an academic discipline has been achieved through the challenges and struggles met and overcome by the various
nursing theorists.

As aforementioned, the history of theory development and theoretical thinking in nursing began with the
writings of Florence Nightingale and continues to the present.

The following are the highlights of significant events in this history:

UNIVERSITY OF LA SALETTE, INC.

Dubinan East, Santiago City, Philippines, 3311

COLLEGE OF NURSING, PUBLIC HEALTH AND MIDWIFERY

1. Florence Nightingale Nightingale's (1859/1992), "Notes on Nursing" presents the first nursing theory that
focuses on the manipulation of the environment for the benefit of the patient. Although Nightingale did not present
her works a "nursing theory", it has directed nursing practice for over 140 years ---- a timeless legacy for the nursing
profession.

2. The Columbia School --- The 1950s

 In the 1950s the need to prepare nurses at the graduate level for administrative and faculty positions
was recognized.

 Theorists of the Columbia School focused primarily on what nurses do, that is, their functional roles.
They considered patient problems and needs to be the practice focus.

 Johnson suggested that nursing knowledge is based on a theory of nursing diagnosis that is different
from medical diagnosis. (Meleis, 1997)

3. The Yale School- The 1960’s

 Focus of theoretical thinking in nursing moved rom a problem/need and functional role focus to the
relationship between the nurse and the patient.

 Theorists of the Yale School view nursing as a process rather than an end in itself.
 It is important to note that it was during 1960’s that federal funds were made available for doctoral

study for nurse educators.
4. The 1970’s

 It was in this decade that many nursing theories were first presented. Most of these theories have
been revised since their original presentation. (Rogers, King, Orem, Levine, Neuman, Roy,
Paterson, Zderad, Newman, Watson)

5. The 1980’s

 In the 1980’s, many nursing theories were revised based on the research findings that expanded
them. In addition, the works of Johnson, Parse, Leininger and Erickson Tomlin and Swain were
added to the body of theoretical thoughts in nursing.

6. The 1990’s

 In the 1990s, research studies that tested and expanded nursing theory were numerous.
 "Nursing Science Quarterly" (edited by Rosemarie Rizzo Parse and published by Chestnut House

1988 - 1998, Sage, 1999 - ) is devoted exclusively to the presentation of nursing theory - based
research findings and theoretical topics.
 Rogers published "Nursing: Science of Unitary, Irreducible Human Beings: Update 1990", which
is the latest refinement of her theory,
 In 1992, Parse changed the language of her theory from Man-Living-Health to the Theory of
Human Becoming. She explained that the reason for the change is that contemporary dictionary
definition of "man" tend to be gender-based as opposed to meaning mankind.
 In 1993, Boykin and Schoenhofer published their theory of Nursing as Caring." They presented
this theory as grand theory with caring as a moral imperative for nursing.

ERAS OF NURSING KNOWLEDGE

1. Curriculum Era (1900-1940s)
 In the curriculum era, efforts to understand the nature of the knowledge needed for the practice of nursing
are evident from an emphasis on curricular content and the movement toward the goal of standardized
curricula.

2. Research Era (1950-1960s)
 As nurses were introduced to research, they saw the need for nursing research and that led to the research
era.
 This era emphasized scholarship and the need to disseminate research findings in scholarly publications.

3. Graduate Education Era (1960-1970s)
 Curricula for master’s level preparation included courses in nursing research, clinical specialty practice and
leadership.
 Many also began to include a core course in nursing theory or nursing models in a core curriculum
organized with a nursing philosophy and conceptual or organizing framework.

UNIVERSITY OF LA SALETTE, INC.

Dubinan East, Santiago City, Philippines, 3311

COLLEGE OF NURSING, PUBLIC HEALTH AND MIDWIFERY

4. Theory Era (1980-1990s)
 The theory era began with a strong emphasis on development
 The theory era, coupled with the research era, led to understanding of the scientific process for the
production of a scientific product (Whall, 1996).

5. Theory Utilization
 Nursing has moved into a new era of utilization of philosophies, models or theories in practice and referred
to as theory- based nursing practice.
 Shift from theory development to theory application and utilization recognizes the importance of a
framework for critical thinking and decision making in professional nursing practice.

6. The Future
 In 1992, Meleis predicted that six characteristics of the discipline of nursing would direct theory
development in the twenty-first century. These predictions, which follow, are still valid today
1. The human science underlying the discipline that is predicated on understanding the meanings of daily
lived experiences as they are perceived by the members or the participants of the science" (p. 112).
2. There is increased emphasis on the practice-orientation, or actual rather than "ought-to- be" practice
3. Nursing's mission is to develop theories to empower nurses, the discipline, and clients.
4. "Acceptance of the act that women may have different strategies and approaches to knowledge
development than men" (p. 113).
5. Nursing's attempt to "understand consumers' experiences for the purpose of empowering them to receive
optimum care and to maintain optimum health" (p. 114).
6. "The effort to broaden nursing's perspective includes efforts to understand the practice of nursing in third
world countries” (p. 114).

Meleis (1992) forecasts that nursing theories will become theories for health, developed by nurses,
physicians, occupational therapists, and others. She also forecasts that "the domain of nursing that focuses
on environment-person interactions, energy levels, human responses, and caring will have long been accepted
as central and complementary perspective in providing health care to clients” (p. 115). She states that
neglected aspects of care, such as advocacy, comfort, rest, access, sleep, trust, grief, symptoms distress,
harmony, and self-care will receive attention and will lead to collaborative programs of research and theory
building. Contemporary nursing literature supports the validity of these predictions.

SIGNIFICANCE OF NURSING THEORY FOR DISCIPLINE & PROFESSION

SIGNIFICANCE OF NURSING THEORY FOR THE DISCIPLINE
 Discipline is dependent on theory for its continued existence
 The theoretical works have taken nursing to higher levels of education and practice as nurses moved from
functional focus with emphasis on what nurses do, to a patient focus, emphasizing what nurses know for
thought, decision making and action.
 Knowledge of persons, health and environment forms the basis for recognition of nursing as a discipline
and this knowledge is taught to those who enter the profession.

SIGNIFICANCE OF NURSING THEORY FOR THE PROFESSION
 Nursing is recognized as a profession today because its development was guided by the criteria for a
profession.
 The application of nursing knowledge in practice is the criterion for a profession that is currently at the fore
front, with emphasis on quality, accountability, theory-based or informed evidence and recognition of
middle- range theory for professional nursing practice. (Alligood, 2014).

UNIVERSITY OF LA SALETTE, INC.

Dubinan East, Santiago City, Philippines, 3311

COLLEGE OF NURSING, PUBLIC HEALTH AND MIDWIFERY

HISTORY AND PHILOSOPHY OF NURSING SCIENCE

Historical views of the nature of science

 To formalize the science of nursing, basic questions must be considered, such as: What is science,
knowledge, and truth? What methods produce scientific knowledge? These are philosophical questions.
The term epistemology is concerned with the theory of knowledge in philosophical inquiry.

 The particular philosophical perspective selected to answer these questions will influence how scientists
perform scientific activities, how they interpret outcomes, and even what they regard as science and
knowledge (Brown, 1977). Although philosophy has been documented as an activity for 3000 years,
formal science is a relatively new human pursuit (Brown, 1977; Foucault, 1973). Scientific activity has
only recently become the object of investigation.

 Two competing philosophical foundations of science, rationalism and empiricism, have evolved in the
era of modern science with several variations. Gale (1979) labeled these alternative epistemologies as
centrally concerned with the power of reason and the power of sensory experience. Gale noted similarity
in the divergent views of science in the time of the classical Greeks. For example, Aristotle believed that
advances in biological science would develop through systematic observation of objects and events in
the natural world, whereas Pythagoras believed that knowledge of the natural world would develop from
mathematical reasoning (Brown, 1977; Gale, 1979).

 Nursing science has been characterized by two branching philosophies of knowledge as the discipline
developed. Various terms are utilized to describe these two stances:
o Empiricist, mechanistic quantitative and deductive and
o Interpretive holistic, qualitative and inductive forms of science.

 Understanding the nature of these philosophical stances facilitates appreciation for what each form
contributes to nursing knowledge.

1. Rationalism
 Rationalist epistemology (scope of knowledge) emphasizes the importance of a priori reasoning as the
appropriate method for advancing knowledge. A priori reasoning utilizes deductive logic by reasoning
from the cause to an effect or from a generalization to a particular instance.
 An example in nursing is to reason that a lack of social support (cause) will result in hospital readmission
(effect). This causal reasoning is a theory until disproven. The traditional approach proceeds by
explaining hospitalization with a systematic explanation (theory) of a given phenomenon (Gale, 1979).
This conceptual system is analyzed by addressing the logical structure of the theory and the logical
reasoning involved in its development. Theoretical assertions derived by deductive reasoning are then
subjected to experimental testing to corroborate the theory.
 Reynolds (1971) labeled this approach the theory-then-research strategy. If the research findings fail to
correspond with the theoretical assertions, additional research is conducted or modifications are made in
the theory and further tests are devised; otherwise, the theory is discarded in favor of an alternative
explanation (Gale, 1979; Zetterberg, 1966).
 As Reynolds (1971) noted, if someone believes that science is a process of inventing descriptions of
phenomena, the appropriate strategy for theory construction is the theory-then-research strategy. In
Reynolds’ view, “as the continuous interplay between theory construction (invention) and testing with
empirical research progresses, the theory becomes more precise and complete as a description of nature
and, therefore, more useful for the goals of science”

2. Empiricism
 The empiricist view is based on the central idea that scientific knowledge can be derived only from
sensory experience (i.e., seeing, feeling, hearing facts).
 Francis Bacon (Gale, 1979) received credit for popularizing the basis for the empiricist approach to
inquiry. Bacon believed that scientific truth was discovered through generalizing observed facts in the
natural world.

UNIVERSITY OF LA SALETTE, INC.

Dubinan East, Santiago City, Philippines, 3311

COLLEGE OF NURSING, PUBLIC HEALTH AND MIDWIFERY

 This approach, called the inductive method, is based on the idea that the collection of facts precedes
attempts to formulate generalizations, or as Reynolds (1971) called it, the research-then-theory
strategy. One of the best examples to demonstrate this form of logic in nursing has to do with formulating
differential diagnoses. Formulating a differential diagnosis requires collecting the facts and then devising
a list of possible theories to explain the facts.

 The difficulty with the inductive mode of inquiry is that the world presents an infinite number of possible
observations, and, therefore, the scientist must bring ideas to his or her experiences to decide what to
observe and what to exclude (Steiner, 1977).

 In summary, deductive inquiry uses the theory-then-research approach, and inductive inquiry uses the
research-then-theory approach. Both approaches are utilized in the field of nursing.

3. Early twentieth century views of science and theory
 During the first half of this century, philosophers focused on the analysis of theory structure,
whereas scientists focused on empirical research (Brown, 1977). There was minimal interest in the
history of science, the nature of scientific discovery, or the similarities between the philosophical view
of science and the scientific methods (Brown, 1977).
 Positivism, a term first used by Comte, emerged as the dominant view of modern science (Gale, 1979).
Modern logical positivists believed that empirical research and logical analysis (deductive and inductive)
were two approaches that would produce scientific knowledge (Brown, 1977).
 The logical empiricists offered a more lenient view of logical positivism and argued that theoretical
propositions (proposition affirms or denies something) must be tested through observation and
experimentation (Brown, 1977). This perspective is rooted in the idea that empirical facts exist
independently of theories and offer the only basis for objectivity in science (Brown, 1977).

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