Nursing Theories & Nursing Practice

••·•- Fourth Edition

Nursing Theories
and Nursing Practice

Nursing Theories & Nursing Practice

Fourth Edition



Nursing Theories & Nursing Practice
Fourth Edition

Marlaine C. Smith, PhD, RN, AHN-BC, FAAN

Marilyn E. Parker, PhD, RN, FAAN

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Nursing theories and nursing practice.

Nursing theories & nursing practice / [edited by] Marlaine C. Smith, Marilyn E. Parker. — Fourth edition.

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I. Smith, Marlaine C. (Marlaine Cappelli), editor. II. Parker, Marilyn E., editor. III. Title.

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Preface to the Fourth Edition

This book offers the perspective that nursing is theory and Paterson & Zderad’s humanistic
a professional discipline with a body of knowl- nursing have been moved to supplementary on-
edge that guides its practice. Nursing theories line resources at http://davisplus.fadavis.com.
are an important part of this body of knowl-
edge, and regardless of complexity or abstrac- This book is intended to help nursing stu-
tion, they reflect phenomena central to the dents in undergraduate, masters, and doctoral
discipline, and should be used by nurses to nursing programs explore and appreciate nurs-
frame their thinking, action, and being in the ing theories and their use in nursing practice
world. As guides, nursing theories are practical and scholarship. In addition, and in response
in nature and facilitate communication with to calls from practicing nurses, this book is in-
those we serve as well as with colleagues, stu- tended for use by those who desire to enrich
dents, and others practicing in health-related their practice by the study of nursing theories
services. We hope this book illuminates for the and related illustrations of nursing practice.
readers the interrelationship between nursing The contributing authors describe theory de-
theories and nursing practice, and that this un- velopment processes and perspectives on the
derstanding will transform practice to improve theories, giving us a variety of views for the
the health and quality of life of people who are twenty-first century and beyond. Each chapter
recipients of nursing care. of the book includes descriptions of a theory,
its applications in both research and practice,
This very special book is intended to honor and an example that reflects how the theory
the work of nursing theorists and nurses who can guide practice. We anticipate that this
use these theories in their day-to-day practice. overview of the theory and its applications will
Our foremost nursing theorists have written lead to deeper exploration of the theory, lead-
for this book, or their theories have been de- ing students to consult published works by the
scribed by nurses who have comprehensive theorists and those working closely with the
knowledge of the theorists’ ideas and who have theory in practice or research.
a deep respect for the theorists as people,
nurses, and scholars. To the extent possible, There are six sections in the book. The first
contributing authors have been selected by provides an overview of nursing theory and a
theorists to write about their work. Three focus for thinking about evaluating and choos-
middle-range theories have been added to this ing a nursing theory for use in practice. For
edition of the book, bringing the total number this edition, the evolution of nursing theory
of middle-range theories to twelve. Obviously, was added to Chapter 1. Section II introduces
it was not possible to include all existing the work of early nursing scholars whose ideas
middle-range theories in this volume; how- provided a foundation for more formal theory
ever, the expansion of this section illustrates development. The nursing conceptual models
the recent growth in middle-range theory de- and grand theories are clustered into three
velopment in nursing. Two chapters from the parts in Sections III, IV, and V. Section III
third edition, including Levine’s conservation contains those theories classified within the
interactive-integrative paradigm, and those in

v

vi Preface to the Fourth Edition editors we’ve found that continuing to learn
about and share what we love nurtures our
the unitary-transformative paradigm are in- growth as scholars, reignites our passion and
cluded in Section IV. Grand theories that are commitment, and offers both fun and frustra-
focused on the phenomena of care or caring tion along the way. We continue to be grateful
appear in Section V. The final section contains for the enthusiasm for this book shared by
a selection of middle-range theories. many nursing theorists and contributing
authors and by scholars in practice and
An outline at the beginning of each chapter research who bring theories to life. For us, it
provides a map for the contents. Major points has been a joy to renew friendships with col-
are highlighted in each chapter. Since this leagues who have contributed to past editions
book focuses on the relationship of nursing and to find new friends and colleagues whose
theory to nursing practice, we invited the theories enriched this edition.
authors to share a practice exemplar. You will
notice that some practice exemplars were writ- Nursing Theories and Nursing Practice, now
ten by someone other than the chapter author. in the fourth edition, has roots in a series of
In this edition the authors also provided nursing theory conferences held in South
content about research based on the theory. Florida, beginning in 1989 and ending when
Because of page limitations you can find efforts to cope with the aftermath of Hurricane
additional chapter content online at http:// Andrew interrupted the energy and resources
davisplus.fadavis.com. While every attempt needed for planning and offering the Fifth
was made to follow a standard format for each South Florida Nursing Theory Conference.
of the chapters throughout the book, some of Many of the theorists in this book addressed
the chapters vary from this format; for exam- audiences of mostly practicing nurses at these
ple, some authors chose not to include practice conferences. Two books stimulated by those
exemplars. conferences and published by the National
League for Nursing are Nursing Theories in
The book’s website features materials that Practice (1990) and Patterns of Nursing Theories
will enrich the teaching and learning of these in Practice (1993).
nursing theories. Materials that will be helpful
for teaching and learning about nursing theo- For me (Marilyn), even deeper roots of this
ries are included as online resources. For exam- book are found early in my nursing career,
ple, there are case studies, learning activities, when I seriously considered leaving nursing for
and PowerPoint presentations included on the study of pharmacy. In my fatigue and frus-
both the instructor and student websites. Other tration, mixed with youthful hope and desire
online resources include additional content, for more education, I could not answer the
more extensive bibliographies and longer biog- question “What is nursing?” and could not dis-
raphies of the theorists. Dr. Shirley Gordon tinguish the work of nursing from other tasks
and a group of doctoral students from Florida I did every day. Why should I continue this
Atlantic University developed these ancillary work? Why should I seek degrees in a field
materials for the third edition. For this edition, that I could not define? After reflecting on
the ancillary materials for students and faculty these questions and using them to examine my
were updated by Diane Gullett, a PhD candi- nursing, I could find no one who would con-
date at Florida Atlantic University. She devel- sider the questions with me. I remember being
oped all materials for the new chapters as well asked, “Why would you ask that question? You
as updating ancillary materials for chapters that are a nurse; you must surely know what nurs-
appeared in the third edition. We are so grate- ing is.” Such responses, along with a drive for
ful to Diane and Shirley for their creativity and serious consideration of my questions, led me
leadership and to the other doctoral students for to the library. I clearly remember reading se-
their thoughtful contributions to this project . veral descriptions of nursing that, I thought,
could just as well have been about social work
We hope that this book provides a useful or physical therapy. I then found nursing
overview of the latest theoretical advances of
many of nursing’s finest scholars. We are
grateful for their contributions to this book. As

defined and explained in a book about educa- Preface to the Fourth Edition vii
tion of nurses written by Dorothea Orem.
During the weeks that followed, as I did my enough! It led to my decision to pursue my
work of nursing in the hospital, I explored PhD in Nursing at New York University
Orem’s ideas about why people need nursing, where I studied with Martha Rogers. During
nursing’s purposes, and what nurses do. I this same time I taught at Duquesne University
found a fit between her ideas, as I understood with Rosemarie Parse and learned more about
them, with my practice, and I learned that I Man-Living-Health, which is now humanbe-
could go even further to explain and design coming. I conducted several studies based on
nursing according to these ways of thinking Rogers’ conceptual system and Parse’s theory.
about nursing. I discovered that nursing shared At theory conferences I was fortunate to
some knowledge and practices with other serv- dialogue with Virginia Henderson, Hildegard
ices, such as pharmacy and medicine, and I Peplau, Imogene King, and Madeleine
began to distinguish nursing from these related Leininger. In 1988 I accepted a faculty posi-
fields of practice. I decided to stay in nursing tion at the University of Colorado when Jean
and made plans to study and work with Watson was Dean. The School of Nursing was
Dorothea Orem. In addition to learning about guided by a caring philosophy and framework
nursing theory and its meaning in all we do, I and I embraced caring as a central focus of the
learned from Dorothea that nursing is a unique discipline of nursing. As a unitary scholar, I
discipline of knowledge and professional prac- studied Newman’s theory of health as expand-
tice. In many ways, my earliest questions about ing consciousness and was intrigued by it, so
nursing have guided my subsequent study and for my sabbatical I decided to study it further
work. Most of what I have done in nursing has as well as learn more about the unitary appre-
been a continuation of my initial experience of ciative inquiry process that Richard Cowling
the interrelations of all aspects of nursing was developing.
scholarship, including the scholarship that is
nursing practice. Over the years, I have been We both have been fortunate to hold faculty
privileged to work with many nursing scholars, appointments in universities where nursing the-
some of whom are featured in this book. ory has been valued, and we are fortunate today
My love for nursing and my respect for our to hold positions at the Christine E. Lynn Col-
discipline and practice have deepened, and lege of Nursing at Florida Atlantic University,
knowing now that these values are so often where faculty and students ground their teach-
shared is a singular joy. ing scholarship and practice on caring theories,
including nursing as caring, developed by Dean
Marlaine’s interest in nursing theory had Anne Boykin and a previous faculty member at
similar origins to Marilyn’s. As a nurse pursu- the College, Savina Schoenhofer. Many faculty
ing an interdisciplinary master’s degree in pub- colleagues and students continue to help us
lic health, I (Marlaine) recognized that while study nursing and have contributed to this book
all the other public health disciplines had some in ways we would never have adequate words to
unique perspective to share, public health acknowledge. We are grateful to our knowl-
nursing seemed to lack a clear identity. In edgeable colleagues who reviewed and offered
search of the identity of nursing I pursued a helpful suggestions for chapters of this book,
second master’s in nursing. At that time nurs- and we sincerely thank those who contributed
ing theory was beginning to garner attention, to the book as chapter authors. It is also our
and I learned about it from my teachers and good fortune that many nursing theorists and
mentors Sr. Rosemary Donley, Rosemarie other nursing scholars live in or visit our lovely
Parse, and Mary Jane Smith. This discovery was state of Florida. Since the first edition of this
the answer I was seeking, and it both expanded book was published, we have lost many nursing
and focused my thinking about nursing. The theorists. Their work continues through those
question of “What is nursing?” was answered refining, modifying, testing, and expanding the
for me by these theories and I couldn’t get theories. The discipline of nursing is expanding
as research and practice advances existing theories
and as new theories emerge. This is especially

viii Preface to the Fourth Edition and her niece, Cherie Parker, who represents
many nurses who love nursing practice and
important at a time when nursing theory can scholarship and thus inspire the work of this
provide what is missing and needed most in book. Marlaine acknowledges her husband
health care today. Brian and her children, Kirsten, Alicia, and
Brady, and their spouses, Jonathan Vankin and
All four editions of this book have been nur- Tori Rutherford, for their love and understand-
tured by Joanne DaCunha, an expert nurse and ing. She honors her parents, Deno and Rose
editor for F. A. Davis Company, who has shep- Cappelli, for instilling in her the love of learning,
herded this project and others because of her the value of hard work, and the importance of
love of nursing. Near the end of this project caring for others, and dedicates this book to her
Joanne retired, and Susan Rhyner, our new ed- granddaughter Iyla and the new little one who
itor, led us to the finish line. We are both grate- is scheduled to arrive as this book is released.
ful for their wisdom, kindness, patience and
understanding of nursing. We give special Marilyn E. Parker, Marlaine C. Smith,
thanks to Echo Gerhart, who served as our con- Olathe, Kansas Boca Raton, Florida
tact and coordinator for this project. Marilyn
thanks her husband, Terry Worden, for his
abiding love and for always being willing to help,

Nursing Theorists

Elizabeth Ann Manhart Barrett, PhD, RN, FAAN Imogene King†
Professor Emerita
Hunter College Katharine Kolcaba, PhD, RN
City University of New York Associate Professor Emeritus Adjunct
New York, New York The University of Akron
Akron, Ohio
Charlotte D. Barry, PhD, RN, NCSN, FAAN
Professor of Nursing Madeleine M. Leininger†
Christine E. Lynn College of Nursing
Florida Atlantic University Patricia Liehr, PhD, RN
Boca Raton, Florida Professor
Christine E. Lynn College of Nursing
Anne Boykin, PhD, RN* Florida Atlantic University
Dean and Professor Emerita Boca Raton, Florida
Christine E. Lynn College of Nursing
Florida Atlantic University Rozzano C. Locsin, PhD, RN
Boca Raton, Florida Professor Emeritus
Christine E. Lynn College of Nursing
Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN, Florida Atlantic University
HWNC-BC Boca Raton, Florida

Co-Director, International Nurse Coach Afaf I. Meleis, PhD, DrPS(hon), FAAN
Association Professor of Nursing and Sociology
University of Pennsylvania
Core Faculty, Integrative Nurse Coach Philadelphia, Pennsylvania
Certificate Program
Betty Neuman, PhD, RN, PLC, FAAN
Miami, Florida Beverly, Ohio

Joanne R. Duffy, PhD, RN, FAAN Margaret Newman, RN, PhD, FAAN
Endowed Professor of Research and Professor Emerita
University of Minnesota College of Nursing
Evidence-based Practice and Director Saint Paul, Minnesota
of the PhD Program
West Virginia University Dorothea E. Orem†
Morgantown, West Virginia
Ida Jean Orlando (Pelletier)†
Helen L. Erickson*
Professor Emerita Marilyn E. Parker, PhD, RN, FAAN
University of Texas at Austin Professor Emerita
Austin, Texas Christine E. Lynn College of Nursing
Florida Atlantic University
Lydia Hall† Boca Raton, Florida

Virginia Henderson† ix

Dorothy Johnson†

x Nursing Theorists Mary Jane Smith, PhD, RN
Professor
Rosemarie Rizzo Parse, PhD, FAAN West Virginia University
Distinguished Professor Emeritus Morgantown, West Virginia
Marcella Niehoff School of Nursing
Loyola University Chicago Mary Ann Swain, PhD
Chicago, Illinois Professor and Director, Doctoral Program
Decker School of Nursing
Hildegard Peplau† Binghamton University
Binghamton, New York
Marilyn Anne Ray, PhD, RN, CTN
Professor Emerita Kristen M. Swanson, PhD, RN, FAAN
Christine E. Lynn College of Nursing Dean
Florida Atlantic University Seattle University
Boca Raton, Florida Seattle, Washington

Pamela G. Reed, PhD, RN, FAAN Evelyn Tomlin*
Professor
University of Arizona Joyce Travelbee†
Tucson, Arizona
Meredith Troutman-Jordan, PhD, RN
Martha E. Rogers† Associate Professor
University of North Carolina
Sister Callista Roy, PhD, RN, FAAN Chapel Hill, North Carolina
Professor and Nurse Theorist
William F. Connell School of Nursing Jean Watson, PhD, RN, AHN-BC, FAAN
Boston College Distinguished Professor Emeritus
Chestnut Hill, Massachusetts University of Colorado at Denver—Anschutz

Savina O. Schoenhofer, PhD, RN Campus
Professor of Nursing Aurora, Colorado
University of Mississippi
Oxford, Mississippi Ernestine Wiedenbach†

Marlaine C. Smith, PhD, RN, AHN-BC, FAAN
Dean and Helen K. Persson Eminent Scholar
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida

*Retired
†Deceased

Contributors

Patricia Deal Aylward, MSN, RN, CNS Laureen M. Fleck, PhD, FNP-BC, FAANP

Assistant Professor Associate Faculty
Santa Fe Community College Christine E. Lynn College of Nursing
Gainesville, Florida Florida Atlantic University
Boca Raton, Florida

Howard Karl Butcher, PhD, RN, PMHCNS-BC Maureen A. Frey, PhD, RN*

Associate Professor
University of Iowa
Iowa City, Iowa

Lynne M. Hektor Dunphy, PhD, APRN-BC Shirley C. Gordon, PhD, RN

Associate Dean for Practice and Community Professor and Assistant Dean Graduate Practice
Engagement Programs

Christine E. Lynn College of Nursing Christine E. Lynn College of Nursing
Florida Atlantic University Florida Atlantic University
Boca Raton, Florida Boca Raton, Florida

*Retired.

xi

xii Contributors

Diane Lee Gullett, RN, MSN, MPH Beth M. King, PhD, RN, PMHCNS-BC

Doctoral Candidate Assistant Professor and RN-BSN Coordinator
Christine E. Lynn College of NursingFlorida Christine E. Lynn College of Nursing
Florida Atlantic University
Atlantic University Boca Raton, Florida
Boca Raton, Florida

Donna L. Hartweg, PhD, RN Lois White Lowry, DNSc, RN*

Professor Emerita and Former Director Professor Emerita
Illinois Wesleyan University East Tennessee State University
Bloomington, Illinois Johnson City, Tennessee

Bonnie Holaday, PhD, RN, FAAN Violet M. Malinski, PhD, MA, RN

Professor Associate Professor
Clemson University College of New Rochelle
Clemson, South Carolina New Rochelle, New York

Mary B. Killeen, PhD, RN, NEA-BC Ann R. Peden, RN, CNS, DSN

Consultant Professor and Chair
Evidence Based Practice Nurse Consultants, Capital University
Columbus, Ohio
LLC
Howell, Michigan

Contributors xiii

Margaret Dexheimer Pharris, PhD, RN, CNE, FAAN Jacqueline Staal, MSN, ARNP, FNP-BC

Associate Dean for Nursing PhD Candidate
St. Catherine University Christine E. Lynn College of Nursing
St. Paul, Minnesota Florida Atlantic University
Boca Raton, Florida

Maude Rittman, PhD, RN Marian C. Turkel, PhD, RN, NEA-BC, FAAN

Associate Chief of Nursing Service for Research Director of Professional Nursing Practice
Gainesville Veteran’s Administration Holy Cross Medical Center
Fort Lauderdale, Florida
Medical Center
Gainesville, Florida

Pamela Senesac, PhD, SM, RN Hiba Wehbe-Alamah, PhD, RN, FNP-BC, CTN-A

Assistant Professor Associate Professor
University of Massachusetts University of Michigan-Flint
Shrewsbury, Massachusetts Flint, Michigan

Christina L. Sieloff, PhD, RN

Associate Professor
Montana State University
Billings, Montana

xiv Contributors Terri Kaye Woodward, MSN, RN, CNS, AHN-BC, HTCP

Kelly White, RN, PhD, FNP-BC Founder
Assistant Professor Cocreative Wellness
South University Denver, Colorado
West Palm Beach, Florida

Reviewers

Ferrona Beason, PhD, ARNP Carol L. Moore, PhD, APRN, CNS
Assistant Professor in Nursing Assistant Professor of Nursing, Coordinator,
Barry University – Division of Nursing
Miami Shores, Florida Graduate Nursing Studies
Fort Hays State University
Abimbola Farinde, PharmD, MS Hays, Kansas
Clinical Pharmacist Specialist
Clear Lake Regional Medical Center Kathleen Spadaro, PhD, PMHCNS, RN
Webster, Texas MSN Program Co-coordinator & Assistant

Lori S. Lauver, PhD, RN, CPN, CNE Professor of Nursing
Associate Professor Chatham University
Jefferson School of Nursing Pittsburgh, Pennsylvania
Thomas Jefferson University
Philadelphia, Pennsylvania

Elisheva Lightstone, BScN, MSc
Professor
Department of Nursing
Seneca College
King City, Ontario, Canada

xv



Contents

Section I An Introduction to Nursing Theory, 1

Chapter 1 Nursing Theory and the Discipline of Nursing, 3

Marlaine C. Smith and Marilyn E. Parker

Chapter 2 A Guide for the Study of Nursing Theories for Practice, 19

Marilyn E. Parker and Marlaine C. Smith

Chapter 3 Choosing, Evaluating, and Implementing Nursing Theories
for Practice, 23

Marilyn E. Parker and Marlaine C. Smith

Section II Conceptual Influences on the Evolution of Nursing
Theory, 35

Chapter 4 Florence Nightingale’s Legacy of Caring and Its Applications, 37

Lynne M. Hektor Dunphy

Chapter 5 Early Conceptualizations About Nursing, 55

Shirley C. Gordon

Chapter 6 Nurse-Patient Relationship Theories, 67

Ann R. Peden, Jacqueline Staal, Maude Rittman, and Diane Lee Gullett

Section III Conceptual Models/Grand Theories in the Integrative-
Interactive Paradigm, 87

Chapter 7 Dorothy Johnson’s Behavioral System Model and Its
Applications, 89

Bonnie Holaday

Chapter 8 Dorothea Orem’s Self-Care Deficit Nursing Theory, 105

Donna L. Hartweg

xvii

xviii Contents

Chapter 9 Imogene King’s Theory of Goal Attainment, 133

Christina L. Sieloff and Maureen A. Frey

Chapter 10 Sister Callista Roy’s Adaptation Model, 153

Pamela Sensac and Sister Callista Roy

Chapter 11 Betty Neuman’s Systems Model, 165

Lois White Lowry and Patricia Deal Aylward

Chapter 12 Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s
Theory of Modeling and Role Modeling, 185

Helen L. Erickson

Chapter 13 Barbara Dossey’s Theory of Integral Nursing, 207

Barbara Montgomery Dossey

Section IV Conceptual Models and Grand Theories in the
Unitary–Transformative Paradigm, 235

Chapter 14 Martha E. Rogers Science of Unitary Human Beings, 237

Howard Karl Butcher and Violet M. Malinski

Chapter 15 Rosemarie Rizzo Parse’s Humanbecoming Paradigm, 263

Rosemarie Rizzo Parse

Chapter 16 Margaret Newman’s Theory of Health as Expanding
Consciousness, 279

Margaret Dexheimer Pharris

Section V Grand Theories about Care or Caring, 301

Chapter 17 Madeleine Leininger’s Theory of Culture Care Diversity
and Universality, 303

Hiba Wehbe-Alamah

Chapter 18 Jean Watson’s Theory of Human Caring, 321

Jean Watson

Chapter 19 Theory of Nursing as Caring, 341

Anne Boykin and Savina O. Schoenhofer

Section VI Middle-Range Theories, 357

Chapter 20 Transitions Theory, 361

Afaf I. Meleis

Contents xix

Chapter 21 Katharine Kolcaba’s Comfort Theory, 381

Katharine Kolcaba

Chapter 22 Joanne Duffy’s Quality-Caring Model©, 393

Joanne R. Duffy

Chapter 23 Pamela Reed’s Theory of Self-Transcendence, 411

Pamela G. Reed

Chapter 24 Patricia Liehr and Mary Jane Smith’s Story Theory, 421

Patricia Liehr and Mary Jane Smith

Chapter 25 The Community Nursing Practice Model, 435

Marilyn E. Parker, Charlotte D. Barry. and Beth M. King

Chapter 26 Rozzano Locsin’s Technological Competency as Caring
in Nursing, 449

Rozzano C. Locsin

Chapter 27 Marilyn Anne Ray’s Theory of Bureaucratic Caring, 461

Marilyn Anne Ray and Marian C. Turkel

Chapter 28 Troutman-Jordan’s Theory of Successful Aging, 483

Meredith Troutman-Jordan

Chapter 29 Barrett’s Theory of Power as Knowing Participation
in Change, 495

Elizabeth Ann Manhart Barrett

Chapter 30 Marlaine Smith’s Theory of Unitary Caring, 509

Marlaine C. Smith

Chapter 31 Kristen Swanson’s Theory of Caring, 521

Kristen M. Swanson

Index, 533



ISection

An Introduction to Nursing Theory

1

Section An Introduction to Nursing Theory

I In this first section of the book, you will be introduced to the purpose of nursing
theory and shown how to study, analyze, and evaluate it for use in nursing
practice. If you are new to the idea of theory in nursing, the chapters in this section
will orient you to what theory is, how it fits into the evolution and context of nursing
as a professional discipline, and how to approach its study and evaluation. If
you have studied nursing theory in the past, these chapters will provide you with
additional knowledge and insight as you continue your study.

Nursing is a professional discipline focused on the study of human health and
healing through caring. Nursing practice is based on the knowledge of nursing,
which consists of its philosophies, theories, concepts, principles, research findings,
and practice wisdom. Nursing theories are patterns that guide the thinking about
nursing. All nurses are guided by some implicit or explicit theory or pattern of
thinking as they care for their patients. Too often, this pattern of thinking is implicit
and is colored by the lens of diseases, diagnoses, and treatments. This does not
reflect practice from the disciplinary perspective of nursing. The major reason for
the development and study of nursing theory is to improve nursing practice and,
therefore, the health and quality of life of those we serve.

The first chapter in this section focuses on nursing theory within the context of
nursing as an evolving professional discipline. We examine the relationship of
nursing theory to the characteristics of a discipline. You’ll learn new words that
describe parts of the knowledge structure of the discipline of nursing, and we’ll
speculate about the future of nursing theory as nursing, health care, and our global
society change. Chapter 2 is a guide to help you study the theories in this book.
Use this guide as you read and think about how nursing theory fits in your prac-
tice. Nurses embrace theories that fit with their values and ways of thinking. They
choose theories to guide their practice and to create a practice that is meaningful
to them. Chapter 3 focuses on the selection, evaluation, and implementation of
theory for practice. Students often get the assignment of evaluating or critiquing
a nursing theory. Evaluation is coming to some judgment about value or worth
based on criteria. Various sets of criteria exist for you to use in theory evaluation.
We introduce some that you can explore further. Finally, we offer reflections on
the process of implementing theory-guided practice models.

2

Nursing Theory and the 1Chapter
Discipline of Nursing

MARLAINE C. SMITH AND
MARILYN E. PARKER

The Discipline of Nursing What is nursing? At first glance, the question
Definitions of Nursing Theory may appear to be one with an obvious an-
The Purpose of Theory in a Professional swer, but when it is posed to nurses, many
define nursing by providing a litany of func-
Discipline tions and activities. Some answer with the
The Evolution of Nursing Science elements of the nursing process: assessing,
The Structure of Knowledge in the planning, implementing, and evaluating. Oth-
ers might answer that nurses coordinate a
Discipline of Nursing patient’s care.
Nursing Theory and the Future
Defining nursing in terms of the nursing
Summary process or by functions or activities nurses per-
References form is problematic. The phases of the nursing
process are the same steps we might use to
Marlaine C. Smith Marilyn E. Parker solve any problem we encounter, from a bro-
ken computer to a failing vegetable garden.
We assess the situation to determine what is
going on and then identify the problem; we
plan what to do about it, implement our plan,
and then evaluate whether it works. The nurs-
ing process does nothing to define nursing.

Defining ourselves by tasks presents other
problems. What nurses do—that is, the func-
tions associated with practice—differs based
on the setting. For example, a nurse might
start IVs, administer medications, and per-
form treatments in an acute care setting. In a
community-based clinic, a nurse might teach
a young mother the principles of infant feeding
or place phone calls to arrange community
resources for a child with special needs. Mul-
tiple professionals and nonprofessionals may
perform the same tasks as nurses, and persons
with the ability and authority to perform cer-
tain tasks change based on time and setting.
For example, both physicians and nurses may
listen to breath sounds and recognize the pres-
ence of rales. Both nurses and social workers
might do discharge planning. Both nurses

3

4 SECTION I • An Introduction to Nursing Theory nurses in all nursing venues, who share a
commitment to values, knowledge, and
and family members might change dressings, processes to guide the thought and work of
monitor vital signs, and administer medications, the discipline.
so defining nursing based solely on functions or
activities performed is not useful. The classic work of King and Brownell
(1976) is consistent with the thinking of nurs-
To answer the question “What is nursing?” ing scholars (Donaldson & Crowley, 1978;
we must formulate nursing’s unique identity Meleis, 1977) about the discipline of nursing.
as a field of study or discipline. Florence These authors have elaborated attributes that
Nightingale is credited as the founder of mod- characterize all disciplines. As you will see in
ern nursing, the one who articulated its dis- the discussion that follows, the attributes of
tinctive focus. In her book Notes on Nursing: King and Brownell provide a framework that
What It Is and What It Is Not (Nightingale, contextualizes nursing theory within the dis-
1859/1992), she differentiated nursing from cipline of nursing.
medicine, stating that the two were distinct
practices. She defined nursing as putting the Expression of Human Imagination
person in the best condition for nature to act,
insisting that the focus of nursing was on Members of any discipline imagine and create
health and the natural healing process, not on structures that offer descriptions and explana-
disease and reparation. For her, creating an tions of the phenomena that are of concern to
environment that provided the conditions for that discipline. These structures are the theories
natural healing to occur was the focus of nurs- of that discipline. Nursing theory is dependent
ing. Her beginning conceptualizations were on the imagination of nurses in practice, ad-
the seeds for the theoretical development of ministration, research, and teaching, as they
nursing as a professional discipline. create and apply theories to improve nursing
practice and ultimately the lives of those they
In this chapter, we situate the understand- serve. To remain dynamic and useful, the dis-
ing of nursing theory within the context of cipline requires openness to new ideas and in-
the discipline of nursing. We define the dis- novative approaches that grow out of members’
cipline of nursing, describe the purpose of reflections and insights.
theory for the discipline of nursing, review
the evolution of nursing science, identify the Domain
structure of the discipline of nursing, and
speculate on the future place of nursing the- A professional discipline must be clearly
ory in the discipline. defined by a statement of its domain—the
boundaries or focus of that discipline. The do-
The Discipline of Nursing main of nursing includes the phenomena of in-
terest, problems to be addressed, main content
Every discipline has a unique focus that directs and methods used, and roles required of the
the inquiry within it and distinguishes it from discipline’s members (Kim, 1997; Meleis,
other fields of study (Smith, 2008, p. 1). Nurs- 2012). The processes and practices claimed by
ing knowledge guides its professional practice; members of the disciplinary community grow
therefore, it is classified as a professional disci- out of these domain statements. Nightingale
pline. Donaldson and Crowley (1978) stated provided some direction for the domain of the
that a discipline “offers a unique perspective, a discipline of nursing. Although the discipli-
distinct way of viewing . . . phenomena, which nary focus has been debated, there is some
ultimately defines the limits and nature of its degree of consensus. Donaldson and Crowley
inquiry” (p. 113). Any discipline includes net- (1978, p. 113) identified the following as the
works of philosophies, theories, concepts, ap- domain of the discipline of nursing:
proaches to inquiry, research findings, and
practices that both reflect and illuminate its dis- 1. Concern with principles and laws that
tinct perspective. The discipline of nursing is govern the life processes, well-being, and
formed by a community of scholars, including

CHAPTER 1 • Nursing Theory and the Discipline of Nursing 5

optimal functioning of human beings, sick statement of philosophical unity in the disci-
or well pline was published by Roy and Jones (2007).
2. Concern with the patterning of human Statements include the following:
behavior in interactions with the environ-
ment in critical life situations • The human being is characterized by
3. Concern with the processes through wholeness, complexity, and consciousness.
which positive changes in health status
are affected • The essence of nursing involves the nurse’s
true presence in the process of human-
Fawcett (1984) described the metapara- to-human engagement.
digm as a way to distinguish nursing from
other disciplines. The metaparadigm is very • Nursing theory expresses the values and be-
general and intended to reflect agreement liefs of the discipline, creating a structure to
among members of the discipline about the organize knowledge and illuminate nursing
field of nursing. This is the most abstract level practice.
of nursing knowledge and closely mirrors be-
liefs held about nursing. By virtue of being • The essence of nursing practice is the nurse–
nurses, all nurses have some awareness of patient relationship.
nursing’s metaparadigm. However, because
the term may not be familiar, it offers no di- In 2008, Newman, Smith, Dexheimer-
rect guidance for research and practice (Kim, Pharris, and Jones revisited the disciplinary
1997; Walker & Avant, 1995). The metapara- focus asserting that relationship was central
digm consists of four concepts: persons, envi- to the discipline, and the convergence of
ronment, health, and nursing. According to seven concepts—health, consciousness, car-
Fawcett, nursing is the study of the interrela- ing, mutual process, presence, patterning, and
tionship among these four concepts. meaning—specified relationship in the pro-
fessional discipline of nursing. Willis, Grace,
Modifications and alternative concepts for and Roy (2008) posited that the central uni-
this framework have been explored throughout fying focus for the discipline is facilitating
the discipline (Fawcett, 2000). For example, humanization, meaning, choice, quality of
some nursing scholars have suggested that life, and healing in living and dying (p. E28).
“caring” replace “nursing” in the metaparadigm Finally, Litchfield and Jondorsdottir (2008)
(Stevenson & Tripp-Reimer, 1989). Kim defined the discipline as the study of human-
(1987, 1997) set forth four domains: client, ness in the health circumstance. Smith (1994)
client–nurse encounters, practice, and environ- defined the domain of the discipline of nurs-
ment. In recent years, increasing attention has ing as “the study of human health and healing
been directed to the nature of nursing’s rela- through caring” (p. 50). For Smith (2008),
tionship with the environment (Kleffel, 1996; “nursing knowledge focuses on the wholeness
Schuster & Brown, 1994). of human life and experience and the
processes that support relationship, integra-
Others have defined nursing as the study tion, and transformation” (p. 3). Nursing
of “the health or wholeness of human beings conceptual models, grand theories, middle-
as they interact with their environment” range theories, and practice theories explicate
(Donaldson & Crowley, 1978, p. 113), the life the phenomena within the domain of nurs-
process of unitary human beings (Rogers, ing. In addition, the focus of the nursing dis-
1970), care or caring (Leininger, 1978; Watson, cipline is a clear statement of social mandate
1985), and human–universe–health interrela- and service used to direct the study and prac-
tionships (Parse, 1998). A widely accepted focus tice of nursing (Newman et al., 1991).
statement for the discipline was published
by Newman, Sime, and Corcoran-Perry Syntactical and Conceptual Structures
(1991): “Nursing is the study of caring in the
human health experience” (p. 3). A consensus Syntactical and conceptual structures are
essential to any discipline and are inherent
in nursing theories. The conceptual structure

6 SECTION I • An Introduction to Nursing Theory at conferences, societies, and other communi-
cation networks of the nursing discipline.
delineates the proper concerns of nursing,
guides what is to be studied, and clarifies ac- Tradition
cepted ways of knowing and using content of
the discipline. This structur˙e is grounded in the The tradition and history of the discipline is ev-
focus of the discipline. The conceptual struc- ident in the study of nursing over time. There
ture relates concepts within nursing theories. is recognition that theories most useful today
The syntactical structures help nurses and often have threads of connection with ideas
other professionals to understand the talents, originating in the past. For example, many the-
skills, and abilities that must be developed orists have acknowledged the influence of
within the community. This structure directs Florence Nightingale and have acclaimed her
descriptions of data needed from research, as leadership in influencing nursing theories of
well as evidence required to demonstrate the today. In addition, nursing has a rich heritage
effect on nursing practice. In addition, these of practice. Nursing’s practical experience and
structures guide nursing’s use of knowledge in knowledge have been shared and transformed
research and practice approaches developed by as the content of the discipline and are evident
related disciplines. It is only by being thor- in many nursing theories (Gray & Pratt, 1991).
oughly grounded in the discipline’s concepts,
substance, and modes of inquiry that the bound- Values and Beliefs
aries of the discipline can be understood and
possibilities for creativity across disciplinary Nursing has distinctive views of persons and
borders can be created and explored. strong commitments to compassionate and
knowledgeable care of persons through nurs-
Specialized Language and Symbols ing. Fundamental nursing values and beliefs
include a holistic view of person, the dignity
As nursing theory has evolved, so has the need and uniqueness of persons, and the call to care.
for concepts, language, and forms of data that There are both shared and differing values and
reflect new ways of thinking and knowing spe- beliefs within the discipline. The metapara-
cific to nursing. The complex concepts used in digm reflects the shared beliefs, and the para-
nursing scholarship and practice require lan- digms reflect the differences.
guage that can be specific and understood. The
language of nursing theory facilitates commu- Systems of Education
nication among members of the discipline.
Expert knowledge of the discipline is often A distinguishing mark of any discipline is the
required for full understanding of the meaning education of future and current members of
of these theoretical terms. the community. Nursing is recognized as a
professional discipline within institutions of
Heritage of Literature and higher education because it has an identifiable
Networks of Communication body of knowledge that is studied, advanced,
and used to underpin its practice. Students of
This attribute calls attention to the array any professional discipline study its theories
of books, periodicals, artifacts, and aesthetic and learn its methods of inquiry and practice.
expressions, as well as audio, visual, and elec- Nursing theories, by setting directions for the
tronic media that have developed over cen- substance and methods of inquiry for the dis-
turies to communicate the nature of nursing cipline, should provide the basis for nursing
knowledge and practice. Conferences and fo- education and the framework for organizing
rums on every aspect of nursing held through- nursing curricula.
out the world are part of this network. Nursing
organizations and societies also provide critical Definitions of Nursing Theory
communication links. Nursing theories are
part of this heritage of literature, and those A theory is a notion or an idea that explains
working with these theories present their work experience, interprets observation, describes

CHAPTER 1 • Nursing Theory and the Discipline of Nursing 7

relationships, and projects outcomes. Parsons in nursing practice, education, administration,
(1949), often quoted by nursing theorists, or research:
wrote that theories help us know what we
know and decide what we need to know. The- • Theory is a set of concepts, definitions, and
ories are mental patterns or frameworks cre- propositions that project a systematic view
ated to help understand and create meaning of phenomena by designating specific inter-
from our experience, organize and articulate relationships among concepts for purposes
our knowing, and ask questions leading to new of describing, explaining, predicting, and/or
insights. As such, theories are not discovered controlling phenomena (Chinn & Jacobs,
in nature but are human inventions. 1987, p. 71).

Theories are organizing structures of our re- • Theory is a creative and rigorous structuring
flections, observations, projections, and infer- of ideas that projects a tentative, purposeful,
ences. Many describe theories as lenses because and systematic view of phenomena (Chinn
they color and shape what is seen. The same & Kramer, 2004, p. 268).
phenomena will be seen differently depending
on the theoretical perspective assumed. For • Nursing theory is a conceptualization
these reasons, “theory” and related terms have of some aspect of reality (invented or
been defined and described in a number of discovered) that pertains to nursing. The
ways according to individual experience and conceptualization is articulated for the
what is useful at the time. Theories, as reflec- purpose of describing, explaining, predict-
tions of understanding, guide our actions, help ing, or prescribing nursing care (Meleis,
us set forth desired outcomes, and give evi- 1997, p. 12).
dence of what has been achieved. A theory, by
traditional definition, is an organized, coherent • Nursing theory is an inductively and/or de-
set of concepts and their relationships to each ductively derived collage of coherent, cre-
other that offers descriptions, explanations, ative, and focused nursing phenomena that
and predictions about phenomena. frame, give meaning to, and help explain
specific and selective aspects of nursing re-
Early writers on nursing theory brought search and practice (Silva, 1997, p. 55).
definitions of theory from other disciplines to
direct future work within nursing. Dickoff and • A theory is an imaginative grouping of
James (1968, p. 198) defined theory as a “con- knowledge, ideas, and experience that are rep-
ceptual system or framework invented for resented symbolically and seek to illuminate
some purpose.” Ellis (1968, p. 217) defined a given phenomenon.” (Watson, 1985, p. 1).
theory as “a coherent set of hypothetical, con-
ceptual, and pragmatic principles forming a The Purpose of Theory in
general frame of reference for a field of in- a Professional Discipline
quiry.” McKay (1969, p. 394) asserted that
theories are the capstone of scientific work and All professional disciplines have a body of
that the term refers to “logically interconnected knowledge consisting of theories, research, and
sets of confirmed hypotheses.” Barnum (1998, methods of inquiry and practice. They organize
p. 1) later offered a more open definition of knowledge, guide inquiry to advance science,
theory as a “construct that accounts for or or- guide practice and enhance the care of patients.
ganizes some phenomenon” and simply stated Nursing theories address the phenomena of in-
that a nursing theory describes or explains terest to nursing, human beings, health, and
nursing. caring in the context of the nurse–person rela-
tionship1. On the basis of strongly held values
Definitions of theory emphasize its various and beliefs about nursing, and within con-
aspects. Those developed in recent years are texts of various worldviews, theories are pat-
more open and conform to a broader concep- terns that guide the thinking about, being,
tion of science. The following definitions of the- and doing of nursing.
ory are consistent with general ideas of theory
1Person refers to individual, family, group, or community.

8 SECTION I • An Introduction to Nursing Theory 2003). Engagement in practice generates the
ideas that lead to the development of nursing
Theories provide structures for making theories.
sense of the complexities of reality for both
practice and research. Research based in nurs- At the empirical level of theory, abstract
ing theory is needed to explain and predict concepts are operationalized, or made concrete,
nursing outcomes essential to the delivery of for practice and research (Fawcett, 2000; Smith
nursing care that is both humane and cost- & Liehr, 2013). Empirical indicators provide
effective (Gioiella, 1996). Some conceptual specific examples of how the theory is experi-
structure either implicitly or explicitly directs enced in reality; they are important for bringing
all avenues of nursing, including nursing edu- theoretical knowledge to the practice level.
cation and administration. Nursing theories These indicators include procedures, tools, and
provide concepts and designs that define the instruments to determine the effects of nursing
place of nursing in health care. Through practice and are essential to research and man-
theories, nurses are offered perspectives for agement of outcomes of practice (Jennings &
relating with professionals from other disci- Staggers, 1998). The resulting data form the
plines, who join with nurses to provide basis for improving the quality of nursing care
human services. Nursing has great expecta- and influencing health-care policy. Empirical
tions of its theories. At the same time, the- indicators, grounded carefully in nursing con-
ories must provide structure and substance cepts, provide clear demonstration of the utility
to ground the practice and scholarship of of nursing theory in practice, research, admin-
nursing and must also be flexible and dynamic istration, and other nursing endeavors (Allison
to keep pace with the growth and changes in & McLaughlin-Renpenning, 1999; Hart &
the discipline and practice of nursing. Foster, 1998).

The major reason for structuring and Meeting the challenges of systems of care
advancing nursing knowledge is for the sake delivery and interprofessional work demands
of nursing practice. The primary purpose practice from a theoretical perspective. Nurs-
of nursing theories is to further the develop- ing’s disciplinary focus is important within
ment and understanding of nursing practice. the interprofessional health-care environment
Because nursing theory exists to improve prac- (Allison & McLaughlin-Renpenning, 1999);
tice, the test of nursing theory is a test of its otherwise, its unique contribution to the in-
usefulness in professional practice (Colley, terprofessional team is unclear. Nursing ac-
2003; Fitzpatrick, 1997). The work of nursing tions reflect nursing concepts from a nursing
theory is moving from academia into the perspective. Careful, reflective, and critical
realm of nursing practice. Chapters in the re- thinking are the hallmarks of expert nursing,
maining sections of this book highlight the and nursing theories should undergird these
use of nursing theories in nursing practice. processes. Appreciation and use of nursing
theory offer opportunities for successful col-
Nursing practice is both the source and the laboration with colleagues from other disci-
goal of nursing theory. From the viewpoint of plines and provide definition for nursing’s
practice, Gray and Forsstrom (1991) suggested overall contribution to health care. Nurses
that theory provides nurses with different ways must know what they are doing, why they are
of looking at and assessing phenomena, ratio- doing it, and what the range of outcomes of
nales for their practice, and criteria for evalu- nursing may be, as well as indicators for doc-
ating outcomes. Many of the theories in this umenting nursing’s effects. These theoretical
book have been used to guide nursing practice, frameworks serve as powerful guides for ar-
stimulate creative thinking, facilitate commu- ticulating, reporting, and recording nursing
nication, and clarify purposes and processes in thought and action.
practice. The practicing nurse has an ethical re-
sponsibility to use the discipline’s theoretical One of the assertions referred to most often
knowledge base, just as it is the nurse scholar’s in the nursing-theory literature is that theory is
ethical responsibility to develop the knowledge born of nursing practice and, after examination
base specific to nursing practice (Cody, 1997,

CHAPTER 1 • Nursing Theory and the Discipline of Nursing 9

and refinement through research, must be re- Although there were healers from other
turned to practice (Dickoff, James, & Wieden- countries who can be acknowledged for their
bach, 1968). Nursing theory is stimulated by importance to the history of nursing, Florence
questions and curiosities arising from nursing Nightingale holds the title of the “mother of
practice. Development of nursing knowledge modern nursing” and the person responsible
is a result of theory-based nursing inquiry. The for setting Western nursing on a path toward
circle continues as data, conclusions, and rec- scientific advancement. She not only defined
ommendations of nursing research are evalu- nursing as “putting the person in the best con-
ated and developed for use in practice. Nursing dition for nature to act,” she also established a
theory must be seen as practical and useful to phenomenological focus of nursing as caring
practice, and the insights of practice must in for and about the human–environment rela-
turn continue to enrich nursing theory. tionship to health. While nursing soldiers dur-
ing the Crimean War, Nightingale began to
The Evolution of study the distribution of disease by gathering
Nursing Science data, so she was arguably the first nurse-scientist
in that she established a rudimentary theory
Disciplines can be classified as belonging to and tested that theory through her practice and
the sciences or humanities. In any science, research.
there is a search for an understanding about
specified phenomena through creating some Nightingale schools were established in the
organizing frameworks (theories) about the West at the turn of the 20th century, but
nature of those phenomena. These organizing Nightingale’s influence on the nursing profes-
frameworks (theories) are evaluated for their sion waned as student nurses in hospital-based
empirical accuracy through research. So sci- training schools were taught nursing primarily
ence is composed of theories developed and by physicians. Nursing became strongly influ-
tested through research (Smith, 1994). enced by the “medical model” and for some
time lost its identity as a distinct profession.
The evolution of nursing as a science has
occurred within the past 70 years; however, Slowly, nursing education moved into in-
before nursing became a discipline or field stitutions of higher learning where students
of study, it was a healing art. Throughout were taught by nurses with higher degrees. By
the world, nursing emerged as a healing min- 1936, 66 colleges and universities had bac-
istry to those who were ill or in need of sup- calaureate programs (Peplau, 1987). Graduate
port. Knowledge about caring for the sick, programs began in the 1940s and grew signifi-
injured, and those birthing, dying, or expe- cantly from the 50s through the 1970s.
riencing normal developmental transitions
was handed down, frequently in oral tradi- The publication of the journal Nursing Re-
tions, and comprised folk remedies and prac- search in 1952 was a milestone, signifying the
tices that were found to be effective through birth of nursing as a fledgling science (Peplau,
a process of trial and error. In most societies, 1987). But well into the 1940s, “many text-
the responsibility for nursing fell to women, books for nurses, often written by physicians,
members of religious orders, or those with clergy or psychologists, reminded nurses that
spiritual authority in the community. With theory was too much for them, that nurses did
the ascendency of science, those who were not need to think but rather merely to follow
engaged in the vocations of healing lost their rules, be obedient, be compassionate, do their
authority over healing to medicine. Tradi- ‘duty’ and carry out medical orders” (Peplau,
tional approaches to healing were marginal- 1987, p. 18). We’ve come a long way in a mere
ized, as the germ theory and the development 70 years.
of pharmaceuticals and surgical procedures
were legitimized because of their grounding The development of nursing curricula stim-
in science. ulated discussion about the nature of nursing
as distinct from medicine. In the 1950s, early
nursing scholars such as Hildegard Peplau,
Virginia Henderson, Dorothy Johnson, and

10 SECTION I • An Introduction to Nursing Theory published theories in research and practice
formalized networks into organizations and
Lydia Hall established the distinct character- held conferences. For example the Society for
istics of nursing as a profession and field Rogerian Scholars held the first Rogerian
of study. Faye Abdellah, Ida Jean Orlando, Conference; the Transcultural Nursing Society
Joyce Travelbee, Ernestine Wiedenbach, Myra was formed, and the International Association
Levine, and Imogene King followed during for Human Caring was formed. Some of these
the 1960s, elaborating their conceptualizations organizations developed journals publishing
of nursing. During the early 1960s, the federally- the work of scholars advancing these concep-
funded Nurse Scientist Program was initiated tual models and grand theories. Metatheorists
to educate nurses in pursuit of doctoral degrees such as Jacqueline Fawcett, Peggy Chinn, and
in the basic sciences. Through this program Joyce Fitzpatrick and Ann Whall published
nurses received doctorates in education, soci- books on nursing theory, making nursing
ology, physiology, and psychology. These grad- theories more accessible to students. Theory
uates brought the scientific traditions of these courses were established in graduate programs
disciplines into nursing as they assumed faculty in nursing. The Fuld Foundation supported a
positions in schools of nursing. series of videotaped interviews of many theo-
rists, and the National League for Nursing dis-
By the 1970s, nursing theory development seminated videos promoting theory within
became a priority for the profession and the nursing. Nursing Science Quarterly, a journal
discipline of nursing was becoming estab- focused exclusively on advancing extant nurs-
lished. Martha Rogers, Callista Roy, Dorothea ing theories, published its first issue in 1988.
Orem, Betty Newman, and Josephine Pater-
son and Loraine Zderad published their theo- During the 1990s, the expansion of con-
ries and graduate students began studying and ceptual models and grand theories in nursing
advancing these theories through research. continued to deepen, and forces within nurs-
During this time, the National League for ing both promoted and inhibited this expan-
Nursing required a theory-based curriculum as sion. The theorists and their students began
a standard for accreditation, so schools of nurs- conducting research and developing practice
ing were expected to select, develop, and im- models that made the theories more visible.
plement a conceptual framework for their Regulatory bodies in Canada required that
curricula. This propelled the advancement of every hospital be guided by some nursing the-
theoretical thinking in nursing. (Meleis, 1992). ory. This accelerated the development of nurs-
A national conference on nursing theory and ing theory–guided practice within Canada and
the Nursing Theory Think Tanks were formed the United States. The accrediting bodies of
to engage nursing leaders in dialogue about the nursing programs pulled back on their require-
place of theory in the evolution of nursing sci- ment of a specified conceptual framework
ence. The linkages between theory, research, guiding nursing curricula. Because of this,
and philosophy were debated in the literature, there were fewer programs guided by specific
and Advances in Nursing Science, the premiere conceptualizations of nursing, and possibly
journal for publishing theoretical articles, was fewer students had a strong grounding in the
launched. theoretical foundations of nursing. Fewer
grand theories emerged; only Boykin and
In the 1980s additional grand theories such Schoenhofer’s nursing as caring grand theory
as Parse’s man-living-health (later changed was published during this time. Middle-range
to human becoming); Newman’s health as theories emerged to provide more descriptive,
expanding consciousness; Leininger’s tran- explanatory, and predictive models around
scultural nursing; Erickson, Tomlinson, and circumscribed phenomena of interest to nurs-
Swain’s modeling and role modeling; and ing. For example, Meleis’s transition theory,
Watson’s transpersonal caring were dissemi- Mishel’s uncertainty theory, Barrett’s power
nated. Nursing theory conferences were con-
vened, frequently attracting large numbers of
participants. Those scholars working with the

CHAPTER 1 • Nursing Theory and the Discipline of Nursing 11

theory, and Pender’s health promotion model distinguishing features of nursing science over
were generating interest. others.

From 2000 to the present, there has been If nursing is to advance as a science in its
accelerated development of middle-range the- own right, future generations of nurses must re-
ories with less interest in conceptual models spect and advance the theoretical legacy of our
and grand theories. There seems to be a de- discipline. Scientific growth happens through
valuing of nursing theory; many graduate pro- cumulative knowledge development with cur-
grams have eliminated their required nursing rent research building on previous findings. To
theory courses, and baccalaureate programs survive and thrive, nursing theories must be
may not include the development of concep- used in nursing practice and research.
tualizations of nursing into their curricula. This
has the potential for creating generations of The Structure of Knowledge
nurses who have no comprehension of the im- in the Discipline of Nursing
portance of theory for understanding the focus
of the discipline and the diverse, rich legacy Theories are part of the knowledge structure
of nursing knowledge from these theoretical of any discipline. The domain of inquiry (also
perspectives. called the metaparadigm or focus of the disci-
pline) is the foundation of the structure. The
On the other hand, health-care organiza- knowledge of the discipline is related to its
tions have been more active in promoting at- general domain or focus. For example, knowl-
tention to theoretical applications in nursing edge of biology relates to the study of living
practice. For example, those hospitals on the things; psychology is the study of the mind;
magnet journey are required to select a guiding sociology is the study of social structures and
nursing framework for practice. Watson’s the- behaviors. Nursing’s domain was discussed
ory of caring is guiding nursing practice in a earlier and relates to the disciplinary focus
group of acute care hospitals. These hospitals statement or metaparadigm. Other levels of
have formed a consortium so that best prac- the knowledge structure include paradigms,
tices can be shared across settings. conceptual models or grand theories, middle-
range theories, practice theories, and research
Although nursing research is advancing and and practice traditions. These levels of nursing
making a difference in people’s lives, the re- knowledge are interrelated; each level of devel-
search may not be linked explicitly to theory, opment is influenced by work at other levels.
and probably not linked to nursing theory. This Theoretical work in nursing must be dynamic;
compromises the advancement of nursing sci- that is, it must be continually in process and
ence. All other disciplines teach their founda- useful for the purposes and work of the disci-
tional theories to their students, and their pline. It must be open to adapting and extend-
scientists test or develop their theories through ing to guide nursing endeavors and to reflect
research. development within nursing. Although there
is diversity of opinion among nurses about the
There is a trend toward valuing theories terms used to describe the levels of theory, the
from other disciplines over nursing theories. following discussion of theoretical develop-
For example, motivational interviewing is a ment in nursing is offered as a context for
practice theory out of psychology that nurse re- further understanding nursing theory.
searchers and practitioners are gravitating to in
large numbers. Arguably, there are several sim- Paradigm
ilar nursing theoretical approaches to engaging
others in health promotion behaviors that pre- Paradigm is the next level of the disciplinary
ceded motivational interviewing, yet these structure of nursing. The notion of paradigm can
have not been explored. Interprofessional prac- be useful as a basis for understanding nursing
tice and interdisciplinary research are essential
for the future of health care, but we do not do
justice to this concept by abandoning the rich,

12 SECTION I • An Introduction to Nursing Theory from the historical conception of nursing as
a part of biomedical science, developments
knowledge. A paradigm is a global, general in the nursing discipline are directed by at
framework made up of assumptions about least two paradigms, or worldviews, outside
aspects of the discipline held by members to the medical model. These are now described.
be essential in development of the discipline.
Paradigms are particular perspectives on the Several nursing scholars have named the ex-
metaparadigm or disciplinary domain. The isting paradigms in the discipline of nursing
concept of paradigm comes from the work of (Fawcett, 1995; Newman et al., 1991; Parse,
Kuhn (1970, 1977), who used the term to 1987). Parse (1987) described two paradigms:
describe models that guide scientific activity the totality and the simultaneity. The totality
and knowledge development in disciplines. paradigm reflects a worldview that humans are
Because paradigms are broad, shared perspec- integrated beings with biological, psychological,
tives held by members of the discipline, they sociocultural, and spiritual dimensions. Humans
are often called “worldviews.” Kuhn set forth adapt to their environments, and health and ill-
the view that science does not always evolve as ness are states on a continuum. In the simultane-
a smooth, regular, continuing path of knowl- ity paradigm, humans are unitary, irreducible,
edge development over time, but that period- and in continuous mutual process with the
ically there are times of revolution when environment (Rogers, 1970, 1992). Health is
traditional thought is challenged by new ideas, subjectively defined and reflects a process of
and “paradigm shifts” occur. becoming or evolving. In contrast to Parse,
Newman and her colleagues (1991) identi-
Kuhn’s ideas provide a way for us to think fied three paradigms in nursing: particulate–
about the development of science. Before any deterministic, integrative–interactive, and unitary–
discipline engages in the development of theory transformative. From the perspective of the
and research to advance its knowledge, it is particulate–deterministic paradigm, humans are
in a preparadigmatic period of development. known through parts; health is the absence
Typically, this is followed by a period of time of disease; and predictability and control
when a single paradigm emerges to guide are essential for health management. In the
knowledge development. Research activities integrative–interactive paradigm, humans are
initiated around this paradigm advance its the- viewed as systems with interrelated dimensions
ories. This is a time during which knowledge interacting with the environment, and change
advances at a regular pace. At times, a new par- is probabilistic. The worldview of the unitary–
adigm can emerge to challenge the worldview transformative paradigm describes humans as
of the existing paradigm. It can be revolution- patterned, self-organizing fields within larger
ary, overthrowing the previous paradigm, or patterned, self-organizing fields. Change
multiple paradigms can coexist in a discipline, is characterized by fluctuating rhythms of
providing different worldviews that guide the organization–disorganization toward more
scientific development of the discipline. complex organization. Health is a reflection of
this continuous change. Fawcett (1995, 2000)
Kuhn’s work has meaning for nursing and provided yet another model of nursing para-
other scientific disciplines because of his recog- digms: reaction, reciprocal interaction, and si-
nition that science is the work of a community multaneous action. In the reaction paradigm,
of scholars in the context of society. Paradigms humans are the sum of their parts, reaction is
and worldviews of nursing are subtle and pow- causal, and stability is valued. In the reciprocal
erful, reflecting different values and beliefs interaction worldview, the parts are seen within
about the nature of human beings, human–en- the context of a larger whole, there is a reciprocal
vironment relationships, health, and caring. nature to the relationship with the environment,
Kuhn’s (1970, 1977) description of scientific and change is based on multiple factors. Finally,
development is particularly relevant to nursing the simultaneous-action worldview includes a
today as new perspectives are being articulated, belief that humans are known by pattern and are
some traditional views are being strengthened,
and some views are taking their places as part
of our history. As we continue to move away

CHAPTER 1 • Nursing Theory and the Discipline of Nursing 13

in an open ever-changing process with the (1968) described this level of theory in the field
environment. Change is unpredictable and of sociology, stating that they are theories
evolving toward greater complexity (Smith, broad enough to be useful in complex situa-
2008, pp. 4–5). tions and appropriate for empirical testing.
Nursing scholars proposed using this level of
It may help you to think of theories being theory because of the difficulty in testing grand
clustered within these nursing paradigms. theory (Jacox, 1974). Middle-range theories
Many theories share the worldview established are narrower in scope than grand theories and
by a particular paradigm. At present, multiple offer an effective bridge between grand theo-
paradigms coexist within nursing. ries and the description and explanation of
specific nursing phenomena. They present con-
Grand Theories and cepts and propositions at a lower level of ab-
Conceptual Models straction and hold great promise for increasing
theory-based research and nursing practice
Grand theories and conceptual models are at strategies (Smith & Liehr, 2008). Several
the next level in the structure of the discipline. middle-range theories are included in this
They are less abstract than the focus of the dis- book. Middle-range theories may have their
cipline and paradigms but more abstract than foundations in a particular paradigmatic per-
middle-range theories. Conceptual models and spective or may be derived from a grand theory
grand theories focus on the phenomena of con- or conceptual model. The literature presents a
cern to the discipline such as persons as adaptive growing number of middle-range theories.
systems, self-care deficits, unitary human be- This level of theory is expanding most rapidly
ings, human becoming, or health as expanding in the discipline and represents some of the
consciousness. The grand theories, or concep- most exciting work published in nursing today.
tual models, are composed of concepts and re- Some of these new theories are synthesized
lational statements. Relational statements on from knowledge from related disciplines and
which the theories are built are called assump- transformed through a nursing lens (Eakes,
tions and often reflect the foundational philoso- Burke, & Hainsworth, 1998; Lenz, Suppe,
phies of the conceptual model or grand theory. Gift, Pugh, & Milligan, 1995; Polk, 1997).
These philosophies are statements of enduring The literature also offers middle-range nursing
values and beliefs; they may be practical guides theories that are directly related to grand the-
for the conduct of nurses applying the theory ories of nursing (Ducharme, Ricard, Duquette,
and can be used to determine the compatibility Levesque, & Lachance, 1998; Dunn, 2004;
of the model or theory with personal, profes- Olson & Hanchett, 1997). Reports of nursing
sional, organizational, and societal beliefs and theory developed at this level include implica-
values. Fawcett (2000) differentiated conceptual tions for instrument development, theory test-
models and grand theories. For her, conceptual ing through research, and nursing practice
models, also called conceptual frameworks or strategies.
conceptual systems, are sets of general concepts
and propositions that provide perspectives on Practice-Level Theories
the major concepts of the metaparadigm: per-
son, environment, health, and nursing. Fawcett Practice-level theories have the most limited
(1993, 2000) pointed out that direction for re- scope and level of abstraction and are developed
search must be described as part of the concep- for use within a specific range of nursing situa-
tual model to guide development and testing of tions. Theories developed at this level have a
nursing theories. We do not differentiate be- more direct effect on nursing practice than do
tween conceptual models and grand theories more abstract theories. Nursing practice theories
and use the terms interchangeably. provide frameworks for nursing interventions/
activities and suggest outcomes and/or the effect
Middle-Range Theories of nursing practice. Nursing actions may be
described or developed as nursing practice
Middle-range theories comprise the next level
in the structure of the discipline. Robert Merton

14 SECTION I • An Introduction to Nursing Theory Nursing Theory and the Future

theories. Ideally, nursing practice theories are Nursing theory is essential to the continuing
interrelated with concepts from middle-range evolution of the discipline of nursing. Several
theories or developed under the framework of trends are evident in the development and use
grand theories. A theory developed at this level of nursing theory. First, there seems to be
has been called a prescriptive theory (Crowley, more agreement on the focus of the discipline
1968; Dickoff, James, & Wiedenbach, 1968), a of nursing that provides a meaningful direction
situation-specific theory (Meleis, 1997), and a for our study and inquiry. This disciplinary di-
micro-theory (Chinn & Kramer, 2011). The alogue has extended beyond the confines of
day-to-day experience of nurses is a major Fawcett’s metaparadigm and explicates the im-
source of nursing practice theory. portance of caring and relationship as central
to the discipline of nursing (Newman et al.,
The depth and complexity of nursing 2008; Roy & Jones, 2007; Willis et al., 2008).
practice may be fully appreciated as nursing The development of new grand theories and
phenomena and relations among aspects of conceptual models has decreased. Dossey’s
particular nursing situations are described and (2008) theory of integral nursing, included in
explained. Dialogue with expert nurses in this book, is the only new theory at this level
practice can be fruitful for discovery and de- that has been developed in nearly 20 years. In-
velopment of practice theory. Research find- stead, the growth in theory development is at
ings on various nursing problems offer data the middle-range and practice levels. There has
to develop nursing practice theories. Nursing been a significant increase in middle-range
practice theory has been articulated using theories, and many practice scholars are work-
multiple ways of knowing through reflective ing on developing and implementing practice
practice (Johns & Freshwater, 1998). The models based on grand theories or conceptual
process includes quiet reflection on practice, models.
remembering and noting features of nursing
situations, attending to one’s own feelings, Several changes in the teaching and learning
reevaluating the experience, and integrating of nursing theory are troubling. Many bac-
new knowing with other experience (Gray calaureate programs include little nursing the-
& Forsstrom, 1991). The LIGHT model ory in their curricula. Similarly, some graduate
(Andersen & Smereck, 1989) and the atten- programs are eliminating or decreasing their
dant nurse caring model (Watson & Foster, emphasis on nursing theory. This alarming
2003) are examples of the development of trend deserves our attention. If nursing is to
practice level theories. continue to thrive and to make a difference
in the lives of people, our practitioners and
Associated Research and researchers need to practice and expand knowl-
Practice Traditions edge within the structure of the discipline.
As health care becomes more interprofessional,
Research traditions are the associated meth- the focus of nursing becomes even more im-
ods, procedures, and empirical indicators that portant. If nurses do not learn and practice
guide inquiry related to the theory. For exam- based on the knowledge of their discipline, they
ple, the theories of health as expanding con- may be co-opted into the practice of another
sciousness, human becoming, and cultural care discipline. Even worse, another discipline could
diversity and universality have specific associ- emerge that will assume practices associated
ated research methods. Other theories have with the discipline of nursing. For example,
specific tools that have been developed to health coaching is emerging as an area of prac-
measure constructs related to the theories. The tice focused on providing people with help
practice tradition of the theory consists of the as they make health-related changes in their
activities, protocols, processes, tools, and prac- lives. However, this is the practice of nursing,
tice wisdom emerging from the theory. Several as articulated by many nursing theories.
conceptual models and grand theories have
specific associated practice methods.

CHAPTER 1 • Nursing Theory and the Discipline of Nursing 15

On a positive note, nursing theories are open and inclusive ways to theorize about nurs-
being embraced by health-care organizations ing will be developed. These new ways will ac-
to structure nursing practice. For example, knowledge the history and traditions of nursing
organizations embarking on the journey to- but will move nursing forward into new realms
ward magnet status (www.nursecredentialing of thinking and being. Reed (1995) noted
.org/magnet) are required to identify a theo- the “ground shifting” with the reforming of
retical perspective that guides nursing practice, philosophies of nursing science and called for
and many are choosing existing nursing mod- a more open philosophy, grounded in nursing’s
els. This work has great potential to refine and values, which connects science, philosophy, and
extend nursing theories. practice. Gray and Pratt (1991, p. 454) pro-
jected that nursing scholars will continue to de-
The use of nursing theory in research is in- velop theories at all levels of abstraction and
consistent at best. Often, outcomes research that theories will be increasingly interdepend-
is not contextualized within any theoretical ent with other disciplines such as politics, eco-
perspective; however, reviewers of proposals nomics, and ethics. These authors expect a
for most funding agencies request theoretical continuing emphasis on unifying theory and
frameworks, and scoring criteria give points for practice that will contribute to the validation of
having one. This encourages theoretical think- the nursing discipline. Theorists will work in
ing and organizing findings within a broader groups to develop knowledge in an area of con-
perspective. Nurses often use theories from cern to nursing, and these phenomena of inter-
other disciplines instead of their own and this est, rather than the name of the author, will
expands the knowledge of another discipline. define the theory (Meleis, 1992). Newman
(2003) called for a future in which we transcend
We are hopeful about the growth, continu- competition and boundaries that have been
ing development, and expanded use of nursing constructed between nursing theories and in-
theory. We hope that there will be continued stead appreciate the links among theories, thus
growth in the development of all levels of nurs- moving toward a fuller, more inclusive, and
ing theory. The students of all professional dis- richer understanding of nursing knowledge.
ciplines study the theories of their disciplines
in their courses of study. We must continue to Nursing’s philosophies and theories must
include the study of nursing theories within our increasingly reflect nursing’s values for under-
baccalaureate, master’s, and doctoral programs. standing, respect, and commitment to health
Baccalaureate students need to understand the beliefs and practices of cultures throughout
foundations for the discipline, our historical de- the world. It is important to question to what
velopment, and the place of nursing theory in extent theories developed and used in one
its history and future. They should learn about major culture are appropriate for use in other
conceptual models and grand theories. Didactic cultures. To what extent must nursing theory
and practice courses should reflect theoretical be relevant in multicultural contexts? Despite
values and concepts so that students learn to efforts of many international scholarly soci-
practice nursing from a theoretical perspective. eties, how relevant are American nursing the-
Middle-range theories should be included in ories for the global community? Can nursing
the study of particular phenomena such as self- theories inform us about how to stand with
transcendence, sorrow, and uncertainty. As they and learn from peoples of the world? Can we
prepare to become practice leaders of the disci- learn from nursing theory how to come to
pline, doctor of nursing practice students should know those we nurse, how to be with them, to
learn to develop and test nursing theory-guided truly listen and hear? Can these questions be
models. PhD students will learn to develop and recognized as appropriate for scholarly work
extend nursing theories in their research. New and practice for graduate students in nursing?
and expanded nursing specialties, such as nurs- Will these issues offer direction for studies
ing informatics, call for development and use of doctoral students? If so, nursing theory
of nursing theory (Effken, 2003). New, more

16 SECTION I • An Introduction to Nursing Theory “think tank” for nurses around the globe to di-
alogue about nursing theory. Such opportuni-
will prepare nurses for humane leadership in ties could lead nurses to truly listen, learn, and
national and global health policy. Perspec- adapt theoretical perspectives to accommodate
tives of various times and worlds in relation to cultural variations.
present nursing concerns were described by
Schoenhofer (1994). Abdellah (McAuliffe,
1998) proposed an international electronic

■ Summary

This chapter focused on the place of nursing time, it is useful for the purposes and work of
theory within the discipline of nursing. The re- the discipline. This paradox may be seen as
lationship and importance of nursing theory ambiguous or as full of possibilities. Continu-
to the characteristics of a professional disci- ing students of the discipline are required to
pline were reviewed. A variety of definitions of study and know the basis for their contribu-
theory were offered, and the evolution and tions to nursing and to those we serve; at the
structure of knowledge in the discipline was same time, they must be open to new ways
outlined. Finally, we reviewed trends and spec- of thinking, knowing, and being in nursing.
ulated about the future of nursing theory de- Exploring structures of nursing knowledge and
velopment and application. One challenge of understanding the nature of nursing as a pro-
nursing theory is that theory is always in the fessional discipline provide a frame of refer-
process of developing and that, at the same ence to clarify nursing theory.

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A Guide for the Study of 2Chapter
Nursing Theories for Practice

MARILYN E. PARKER AND
MARLAINE C. SMITH

Study of Theory for Nursing Practice Nursing is a professional discipline, a field of
A Guide for Study of Nursing Theory for study focused on human health and healing
through caring (Smith, 1994). The knowledge
Use in Practice of the discipline includes nursing science, art,
Summary philosophy, and ethics. Nursing science in-
cludes the conceptual models, theories, and re-
References search specific to the discipline. As in other
sciences such as biology, psychology, or soci-
Marilyn E. Parker Marlaine C. Smith ology, the study of nursing science requires a
disciplined approach. This chapter offers a
guide to this disciplined approach in the form
of a set of questions that facilitate reflection,
exploration, and a deeper study of the selected
nursing theories.

As you read the chapters in this book, use
the questions in the guide to facilitate your
study. These chapters offer you an introduction
to a variety of nursing theories, which we hope
will ignite interest in deeper exploration of
some of the theories through reading the
books written by the theorists and other pub-
lished articles related to the use of the theories
in practice and research. This book’s online re-
sources can provide additional materials as you
continue your exploration.1 The questions in
this guide can lead you toward this deeper
study of the selected nursing theories.

Rapid and dramatic changes are affecting
nurses everywhere. Health-care delivery
systems are in crisis and in need of real
change. Hospitals continue to be the largest
employers of nurses, and some hospitals
are recognizing the need to develop nursing
theory–guided practice models. A criterion for
hospitals seeking magnet hospital designation

1For additional information please go to bonus chapter
content available at FA Davis http://davisplus.fadavis.com

19

20 SECTION I • An Introduction to Nursing Theory Groups of nurses working together as col-
leagues to provide care often realize that they
by the American Nurses Credentialing Cen- share the same values and beliefs about nurs-
ter (www.nursecredentialing.org/magnet) in- ing. The study of nursing theories can clarify
cludes the selection of a theoretical model for the purposes of nursing and facilitate build-
practice. The list of questions in this chapter ing a cohesive practice to meet them. Re-
can be useful to nurses as they select theories gardless of the setting of nursing practice,
to guide practice. nurses may choose to study nursing theories
together to design and articulate theory-
Increasingly, nurses are practicing in diverse guided practice.
settings and often develop organized nursing
practices through which accessible health care The study of nursing theory precedes the
to communities can be provided. Community activities of analysis and evaluation. The eval-
members may be active participants in select- uation of a theory involves preparation, judg-
ing, designing, and evaluating the nursing ment, and justification (Smith, 2013). In the
they receive. In these situations, it is important preparation phase, the student of the theory
for nurses and the communities they serve to spends time coming to know it by reading and
identify the approach to nursing that is most reflecting on it. The best approach involves
consistent with the community’s values. The intellectual empathy, curiosity, honesty, and
questions in this chapter can be helpful in the responsibility (Smith, 2013). Through reading
mutual exploration of theoretical approaches and dwelling with the theory, the student tries
to practice. to understand it from the point of view of the
theorist. Curiosity leads to raising questions in
In the current health-care environment, in- the quest for greater understanding. It involves
terprofessional practice is the desired standard. imagining ways the theory might work in prac-
This does not mean that practicing from a tice, as well as the challenges it might present.
nursing-theoretical base is any less important. Honesty involves knowing oneself and being
Interprofessional practice means that each dis- true to one’s own values and beliefs in the
cipline brings its own lens or perspective to the process of understanding. Some theories may
patient care situation. Nursing’s lens is essen- resonate with deeply held values; others may
tial for a complete picture of the person’s conflict with them. It is important to listen to
health and for the goals of caring and healing. these inner messages of comfort or discomfort,
The nursing theory selected will provide this for they will be important in the selection of
lens, and the questions in this chapter can as- theories for practice.
sist nurses in selecting the theory or theories
that will guide their unique contribution to the Each member of a professional discipline
interprofessional team. has a responsibility to take the time and put in
the effort to understand the theories of that dis-
Theories and practices from a variety of dis- cipline. In nursing, there is an even greater re-
ciplines inform the practice of nursing. The sponsibility to understand and be true to those
scope of nursing practice is continually being that are selected to guide nursing practice.
expanded to include additional knowledge
and skills from related disciplines, such as Responses to questions offered and points
medicine and psychology. Again, this does summarized in the guides may be found in
not diminish the need for practice based on a nursing literature, as well as in audiovisual
nursing theory, and these guiding questions and electronic resources. Primary source ma-
help to differentiate the knowledge and prac- terial, including the work of nurses who are
tice of nursing from those of other disciplines. recognized authorities in specific nursing the-
For example, nurse practitioners may draw on ories and the use of nursing theory, should
their knowledge of pathophysiology, pharma- be used.
cology, and psychology as they provide primary
care. Nursing theories will guide the way of 2“Person” refers to individual, family, groups and com-
viewing the person,2 inform the way of relating munities throughout the chapter.
with the person, and direct the goals of prac-
tice with the person.

CHAPTER 2 • A Guide for the Study of Nursing Theories for Practice 21

Study of Theory for Nursing • What is the place of nursing in interpro-
Practice fessional practice?

Four main questions (described in the next • What is the range of nursing situations
section) have been developed and refined to in which the theory is useful?
facilitate the study of nursing theories for use
in nursing practice (Parker, 1993). They focus How can nursing situations be described?
on concepts within the theories, as well as on
points of interest and general information • What are the attributes of the recipient
about each theory. This guide was developed of nursing care?
for use by practicing nurses and students in un-
dergraduate and graduate nursing education • What are characteristics of the nurse?
programs. Many nurses and students have used • How can interactions between the
these questions and contributed to their con-
tinuing development. As you study each the- nurse and the recipient of nursing be
ory, answer the questions and address the described?
points in the following guide. You will find the • Are there environmental requirements
information you need in the chapters of this for the practice of nursing? If so, what
book; other literature, such as books and jour- are they?
nal articles authored by the theorists and other 2. What is the context of the theory development?
scholars working with the theories; and audio- Who is the nursing theorist as person and as nurse?
visual and electronic resources.
• Why did the theorist develop the
A Guide for Study of Nursing theory?
Theory for Use in Practice
• What is the background of the theorist
1. How is nursing conceptualized in the as a nursing scholar?
theory?
• What central values and beliefs does the
Is the focus of nursing stated? theorist set forth?

• What does the nurse attend to when What are major theoretical influences on this theory?
practicing nursing?
• What previous knowledge influenced
• What guides nursing observations, the development of this theory?
reflections, decisions, and actions?
• What are the relationships between this
• What illustrations or examples show theory and other theories?
how the theory is used to guide
practice? • What nursing-related theories and
philosophies influenced this theory?
What is the purpose of nursing?
What were major external influences on development of the
• What do nurses do when they are theory?
practicing nursing based on the theory?
• What were the social, economic, and
• What are exemplars of nursing assess- political influences that informed the
ments, designs, plans, and evaluations? theory?

• What indicators give evidence of the • What images of nurses and nursing
quality of nursing practice? influenced the development of the
theory?
• Is the richness and complexity of nursing
practice evident? • What was the status of nursing as a dis-
cipline and profession at the time of the
What are the boundaries or limits for nursing? theory’s development?

• How is nursing distinguished from other 3. Who are authoritative sources for information about
health-related professions? development, evaluation, and use of this theory?

• How is nursing related to other disci- Which nursing authorities speak about, write about, and use
plines and services? the theory?

• What are the professional attributes of
these persons?

• What are the attributes of authorities,
and how does one become one?

• Which others can be considered
authorities?

22 SECTION I • An Introduction to Nursing Theory What is the experience of nurses who report consistent use of
the theory?
What major resources are authoritative sources on the theory?
• What books, articles, and audiovisual • What is the range of reports from
and electronic media exist to elucidate practice?
the theory?
• What nursing organizations share and • Has nursing research led to further
support work related to the theory? theoretical formulations?
• What service and academic programs are
authoritative sources for practicing and • Has the theory been used to develop
teaching the theory? new nursing practices?

4. How can the overall significance of the nursing theory • Has the theory influenced the design of
be described? methods of nursing inquiry?

What is the importance of the nursing theory over time? • What has been the influence of the
• What are exemplars of the theory’s use theory on nursing and health policy?
that structure and guide individual
practice? What are projected influences of the theory on nursing’s
• How has the theory been used to guide future?
programs of nursing education?
• How has the theory been used to • How has the theory influenced the com-
guide nursing administration and munity of scholars?
organizations?
• How does published nursing scholarship • In what ways has nursing as a professional
reflect the significance of the theory? practice been strengthened by the theory?

• What future possibilities for nursing
have been opened because of this theory?

• What will be the continuing social value
of the theory?

■ Summary journey from a beginning to a deeper under-
standing of nursing theory. The study of nursing
This chapter contains a guide designed for the theory precedes its analysis and evaluation. Stu-
study of nursing theory for use in practice. As dents should approach the study of nursing the-
members of the professional discipline of nurs- ory with intellectual empathy, curiosity, honesty,
ing, nurses must engage in the serious study of and responsibility. This guide is composed of
the theories of nursing. The implementation of four main questions to foster reflection and fa-
theory-guided practice models is important for cilitate the study of nursing theory for practice.
nursing practice in all settings. The guide pre-
sented in this chapter can lead students on a

References

Parker, M. (1993). Patterns of nursing theories in practice. Smith, M. C. (2013). Evaluation of middle range theo-
New York: National League for Nursing. ries for the discipline of nursing. In M. J. Smith
& P. Liehr (Eds.), Middle range theory for nursing
Smith, M. C. (1994). Arriving at a philosophy of nursing: (3rd ed., pp. 3–14). New York: Springer.
Discovering? Constructing? Evolving? In J. Kikuchi &
H. Simmons (Eds.), Developing a philosophy of nursing
(pp. 43–60). Thousand Oaks, CA: Sage.

Choosing, Evaluating, and 3Chapter
Implementing Nursing
Theories for Practice

MARILYN E. PARKER AND
MARLAINE C. SMITH

Significance of Nursing Theory The primary purpose of nursing theory is
for Practice to improve nursing practice and, therefore,
the health and quality of life of the persons, fam-
Responses to Questions from Practicing ilies, and communities served. Nursing theories
Nurses About Using Nursing Theory provide coherent ways of viewing and approach-
Choosing a Nursing Theory to Study ing the care of persons in their environment.
A Reflective Exercise for Choosing When a theoretical model is used to organize
a Nursing Theory for Practice care in any setting, it strengthens the nursing
Evaluation of Nursing Theory focus of care and provides consistency to the
communication and activities related to nursing
Implementing Theory-Guided Practice care. The development of nursing theories and
Summary theory-guided practice models advances the dis-
cipline and professional practice of nursing.
References
One of the most important issues facing
Marilyn E. Parker Marlaine C. Smith the discipline of nursing is the artificial sepa-
ration of nursing theory and practice. Nursing
can no longer afford to see these dimensions as
disconnected territories, belonging to either
scholars or practitioners. The examination and
use of nursing theories are essential for closing
the gap between nursing theory and nursing
practice. Nurses in practice have a responsibility
to study and value nursing theories, just as
nursing theory scholars must understand and
appreciate the day-to-day practice of nurses.
Nursing theory informs and guides the practice
of nursing, and nursing practice informs and
guides the process of developing theory.

The theories of any professional discipline
are useless if they have no effect on practice.
Just as psychotherapists, educators, and econ-
omists base their approaches and decisions on
particular theories, so should nurses be guided
by selected nursing theories.

When practicing nurses and nurse scholars
work together, both the discipline and practice

23

24 SECTION I • An Introduction to Nursing Theory gain from nursing theory? Then, methods of
analysis and evaluation of nursing theory set
of nursing benefit, and nursing service to our forth in the literature are presented. Finally,
clients is enhanced. There are many examples steps in implementing nursing theory in prac-
throughout this book of how nursing theories tice are described.
have been, or can be, used to guide nursing
practice. Many of the nursing theorists in this Significance of Nursing
book developed or refined their theories based Theory for Practice
on dialogue with nurses who shared descrip-
tions of their practice. This kind of work must Nursing practice is essential for developing,
continue for nursing theories to be relevant testing, and refining nursing theory. The devel-
and meaningful to the discipline. opment of many nursing theories has been en-
hanced by reflection and dialogue about actual
The need to bridge the gap between nurs- nursing situations. The everyday practice of
ing theory and practice is highlighted by con- nursing enriches nursing theories. When nurses
sidering the following brief encounter during think about nursing, they consider the content
a question-and-answer period at a conference. and structure of the discipline of nursing. Even
A nurse in practice, reflecting her experience, if nurses do not conceptualize these elements
asked a nurse theorist, “What is the meaning theoretically, their values and perspectives are
of this theory to my practice? I’m in the real often consistent with particular nursing theo-
world! I want to connect—but how can con- ries. Making these values and perspectives ex-
nections be made between your ideas and my plicit through the use of a nursing theory results
reality?” The nurse theorist responded by de- in a more scholarly, professional practice.
scribing the essential values and assumptions
of her theory. The nurse said, “Yes, I know Creative nursing practice is the direct
what you are talking about. I just didn’t know result of ongoing theory-based thinking,
I knew it, and I need help to use it in my prac- decision-making, and action. Nursing prac-
tice” (Parker, 1993, p. 4). To remain current tice must continue to contribute to thinking
in the discipline, all nurses must join in com- and theorizing in nursing, just as nursing theory
munity to advance nursing knowledge in prac- must be used to advance practice.
tice and must accept their obligations to
engage in the continuing study of nursing the- Nursing practice and nursing theory often
ories. Today, many health-care organizations reflect the same abiding values and beliefs.
that employ nurses adopt a nursing theory as Nurses in practice are guided by their values
a guiding framework for nursing practice. This and beliefs, as well as by knowledge. These val-
decision provides an excellent opportunity for ues, beliefs, and knowledge often are reflected
nurses in practice and in administration to in the literature about nursing’s metaparadigm,
study, implement, and evaluate nursing theo- philosophies, and theories. In addition, nurs-
ries for use in practice. Communicating the ing theorists and nurses in practice think about
outcomes of this process with the community and work with the same phenomena, including
of scholars advancing the theories is a useful the person, the actions and relationships in the
way to initiate dialogue among nurses and to nurse–person (family/community) relation-
form new bridges between the theory and ship, and the context of nursing. It is no won-
practice of nursing. der that nurses often sense a connection and
familiarity with many of the concepts in nurs-
The purpose of this chapter is to describe ing theories. They often say, “I knew this, but
the processes leading to implementation of I didn’t have the words for it.” This is another
nursing theory-guided practice models. These value of nursing theory. It provides a vehicle
processes include choosing possible theories for us to share and communicate the important
for use in practice, analyzing and evaluating concepts within nursing practice.
these theories, and implementing theory-
guided practice models. The chapter begins It is not possible to practice without some
with responses to the questions: Why study theoretical frame of reference. The question is
nursing theory? What do practicing nurses

CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 25

what frame of reference is being used in prac- delivery systems; they can integrate other
tice. As stated in Chapter 1, theories are ways health sciences and technologies as the back-
to organize our thinking about the complexi- ground or context and not the essence of their
ties of any situation. Theories are lenses we se- practice. Nurses who study nursing theory
lect that will color the way that we view reality. realize that although no group actually owns
In the case of nursing, the theories we choose ideas, professional disciplines do claim a unique
to use will frame the way we think about a par- perspective that defines their practice. In the
ticular person and his or her health situation. same way, no group actually owns the tech-
It will inform the ways that we approach the nologies of practice, although disciplines do
person, how we relate, and what we do. Many claim them for their practice. For example, be-
nurses practice according to ideas and direc- fore World War II, nurses rarely took blood
tions from other disciplines, such as medicine, pressure readings and did not give intramus-
psychology, and public health. If your approach cular injections. This was not because nurses
to a person is framed by his or her medical di- lacked the skill, but because they did not claim
agnosis, you are influenced by the medical the use of these techniques within nursing
model that focuses your attention on diagnosis, practice. Such a realization can also lead to un-
treatment, and cure. If you are thinking about derstanding that the things nurses do that are
disease prevention as you work with a commu- often called nursing are not nursing at all. The
nity group, you are influenced by public health skills and technologies used by nurses, such as
theory and approaches. Although we use this taking blood pressure readings, giving injec-
knowledge in practice, nursing theory focuses tions, and auscultating heart sounds, are actu-
us on the distinctive perspective of the disci- ally activities that are part of the context, but
pline, which is more than, and different from, not the essence, of nursing practice. Nursing
these approaches. theories provide an organizing framework that
directs nurses to the essence of their purpose
Historically, nursing practice has been and places the use of knowledge from other
deeply rooted in the medical model, and this disciplines in their proper perspective.
model continues today. The depth and scope
of the practice of nurses who follow notions If nursing theory is to be useful—or
about nursing held by other disciplines are lim- practical—it must be brought into practice. At
ited to practices understood and accepted by the same time, nurses can be guided by nursing
those disciplines. Nurses who learn to practice theory in a full range of nursing situations.
from nursing perspectives are awakened to the Nursing theory can change nursing practice: It
challenges and opportunities of practicing provides direction for new ways of being pres-
nursing more fully and with a greater sense of ent with clients, helps nurses realize ways of
autonomy, respect, and satisfaction for them- expressing caring, and provides approaches to
selves. Hopefully, they also provide different understanding needs for nursing and designing
and more expansive opportunities for health care to address these needs. The chapters of
and healing for those they serve. Nurses who this book affirm the use of nursing theory in
practice from a nursing perspective approach practice and the study and assessment of the-
clients and families in ways unique to nursing. ory to ultimately use in practice.
They ask questions, receive and process infor-
mation about needs for nursing differently, and Responses to Questions from
create nursing responses that are more holistic Practicing Nurses about Using
and client-focused. These nurses learn to re- Nursing Theory
frame their thinking about nursing knowledge
and practice and are then able to bring knowl- Study of nursing theory may either precede or
edge from other disciplines within the context follow selection of a nursing theory for use in
of their practice—not to direct, their practice. nursing practice. Analysis and evaluation of
nursing theory follow the study of a nursing
Nurses who practice from a nursing theo-
retical base see beyond immediate facts and

26 SECTION I • An Introduction to Nursing Theory thinking differently through naming new con-
cepts or ideas. Members of disciplines do share
theory. These activities are demanding and specific language that may be less familiar to
deserve the full commitment of nurses who members outside the discipline. In interprofes-
undertake the work. Because it is understood sional communication, new terms should be
that the study of nursing theory is not a simple, defined and explained to facilitate communica-
short-term endeavor, nurses often question tion as needed. Nursing’s unique perspective
doing such work. The following questions about needs to be represented clearly within the in-
studying and using nursing theory have been terprofessional team. The diversity of each dis-
collected from many conversations with nurses cipline’s perspective is important to provide the
about nursing theory. These queries also identify best care possible for patients. People deserve
specific issues that are important to nurses who and expect high-quality care. Nursing theory
consider the study of nursing theory. has the potential to bring to bear the impor-
tance of relationship and caring in the process
My Nursing Practice of health and healing; the interrelationship of
the environment and health; an understanding
• Does this theory reflect nursing practice as of the wholeness of persons in their life situa-
I know it? Can it be understood in relation tions; and an appreciation of the person’s expe-
to my nursing practice? Will it support what riences, values, and choices in care. These are
I believe to be excellent nursing practice? essential contributions to a multidisciplinary
perspective.
Conceptual models and grand theories can
guide practice in any setting and situation. My Personal Interests, Abilities,
Middle-range theories address circumscribed and Experiences
phenomena in nursing that are directly related
to practice. These levels of theory can enrich • Is the study of nursing theories consistent
perspectives on practice and should foster an with my talents, interests, and goals? Is this
excellent professional level of practice. something I want to do?

• Is the theory specific to my area of nursing? • Will I be stimulated by thinking about and
Can the language of the theory help me ex- trying to use this theory? Will my study of
plain, plan, and evaluate my nursing? Will I nursing be enhanced by use of this theory?
be able to use the terms to communicate
with others? • What will it be like to think about nursing
theory in nursing practice?
• Can this theory be considered in relation to
a wide range of nursing situations? How • Will my work with nursing theory be worth
does it relate to more general views of the effort?
nursing people in other settings?
The study of nursing theory does take an in-
• Will my study and use of this theory support vestment in time and attention. It is a respon-
nursing in my interprofessional setting? sibility of a professional nurse who engages in
a scholarly level of practice. Learning about
• Will those from other disciplines be able nursing theory is a conceptual activity that can
to understand, facilitating cooperation? be challenging and intellectually stimulating.
We need nurses who will invest in these activ-
• Will my work meet the expectations of ities so that knowledgeable theory-guided prac-
those I serve? Will other nurses find my tice is the standard in all health-care settings.
work helpful and challenging?
Resources and Support
Conceptual models and grand theories are
not specific to any nursing specialty. Theories • Will this be useful to me outside the
in any discipline introduce new terminology classroom?
that is not part of general language. For exam-
ple, the id, ego, and superego are familiar terms • What resources will I need to understand
in a particular psychological theory but were fully the terms of the theory?
unknown at the time of the theory’s introduc-
tion. The language of the theory facilitates

CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 27

• Will I be able to find the support I need to will find examples of how a theory has been
study and use the theory in my practice? used in research and in practice. In some cases,
especially with newly formed theories, this ev-
The purpose of nursing theory goes beyond idence may be unavailable. In these situations,
its study within courses. Nursing theory be- you will need to imagine how the theory might
comes alive when the ideas are brought to prac- work in practice. Theories have heuristic, or
tice. The usefulness of theory in practice is one problem-solving, value in that they can lead to
way that we judge its value and worth. It is new ways of thinking about situations. Con-
helpful to read about the theory from primary sider the heuristic value of the theory as you
sources or the most notable scholars and prac- read it. The theory should ignite your passion
titioners who have studied the theory. Nurses about nursing.
interested in particular theories can join online
discussion groups where issues related to the Choosing a Nursing Theory
theory are discussed. Many of the theory groups to Study
have formed professional societies and hold
conferences that support lifelong learning and It is important to give adequate attention to
growing with those applying the theory in prac- the selection of theories. Results of this deci-
tice, administration, research, and education. sion will have lasting influences on your nurs-
ing practice. It is not unusual for nurses who
The Theorist, Evidence, and Opinion begin to work with nursing theory to realize
that their practice is changing and that their
• Who is the author of this theory? What future efforts in the discipline and practice of
background of nursing education and experi- nursing are markedly altered.
ence does the theorist bring to this work? Is
the author an authoritative nursing scholar? There is always some measure of hope mixed
with anxiety as nurses seriously explore nursing
• How is the theorist’s background of nursing theory for the first time. Individual nurses who
education and experience brought to this practice with a group of colleagues often won-
work? der how to select and study nursing theories.
Nurses in practice and nursing students in the-
• What is the evidence that use of the theory ory courses have similar questions. Nurses in
may lead to improved nursing care? Has the new practice settings designed and developed
theory been useful to guide nursing organi- by nurses have the same concerns about getting
zations and administrations? What about started as do nurses in hospital organizations
influencing nursing and health-care policy? who want more from their practice.

• What is the evidence that this nursing the- The following exercise is grounded in the
ory has led to nursing research, including belief that the study and use of nursing theory
questions and methods of inquiry? Did in nursing practice must have roots in the
the theory grow out of research findings practice of the nurses involved. Moreover, the
or out of practice issues and concerns? nursing theory used by particular nurses must
reflect elements of practice that are essential
• Does the theory reflect the latest thinking to those nurses, while at the same time bring-
in nursing? Has the theory kept pace with ing focus and freshness to that practice. This
the times in nursing? Is this a nursing exercise calls on the nurse to think about the
theory for the future? major components of nursing and bring forth
the values and beliefs most important to
Approaching the study of nursing theory nurses. In these ways, the exercise begins to
with openness, curiosity, imagination, and parallel knowledge development reflected in
skepticism is important. Evaluation of any the- the nursing metaparadigm (focus of the disci-
ory should include evidence that practicing pline) and nursing philosophies described in
based on the theory makes a difference in the Chapter 1. Throughout the rest of this book,
lives of people. Theories must have pragmatic
value; that is, they need to generate research
questions and provide models that can be ap-
plied in practice. In the nursing literature, you

28 SECTION I • An Introduction to Nursing Theory • What was the relationship between
the person, family, or community and
the reader is guided to connect nursing theory myself?
and nursing practice in the context of nursing
situations. • What nursing actions emerged in the
context of the relationship?
A Reflective Exercise for
Choosing a Nursing Theory • What other nursing actions might have
for Practice been possible?

Select a comfortable, private, and quiet place • What was the environment of the nursing
to reflect and write. Relax by taking some situation?
deep, slow breaths. Think about the reasons
you went into nursing in the first place. Bring • What about the environment was impor-
your nursing practice into focus. Consider your tant to the person, family or community’s
practice today. Continue to reflect and, while hopes and dreams for health and healing
avoiding distractions, make notes to record and my nursing actions?
your thoughts and feelings. When you have
been thinking for a time and have taken the Nursing can change when we consciously
opportunity to reflect on your practice, pro- connect values and beliefs to nursing situa-
ceed with the following questions. Continue tions. Consider that values and beliefs are the
to reflect and to make notes as you consider basis for our nursing. Briefly describe the con-
each one. nections of your values and beliefs with your
chosen nursing situation.
Enduring Values
Connecting Values and the
• What are the enduring values and beliefs Nursing Situation
that brought me to nursing?
• How are my values and beliefs reflected in
• What beliefs and values keep me in nursing any nursing situation?
today?
• Are my values and beliefs in conflict or
• What are the personal values that I hold frustrated in this situation?
most dear?
• Do my values come to life in the nursing
• How do my personal and nursing values situation?
connect with what is important to society?
Cultivating Awareness
Reflect on an instance of nursing in which and Appreciation
you interacted with a person, family, or com-
munity for nursing purposes. This can be a sit- In reflecting and writing about values and
uation from your current practice or may be nursing situations that are important to us,
from your nursing in years past. Consider the we often come to a fuller awareness and ap-
purpose or hoped-for outcome. preciation of our practice. Make notes about
your insights. You might consider these ini-
Nursing Situations tial notes the beginning of a journal in which
you record your study of nursing theories and
• Who was this person, family, or commu- their use in nursing practice. This is a valu-
nity? How did I come to know him, her, able way to follow your progress and is a
or them as unique? source of nursing questions for future study.
You may want to share this process and ex-
• What were the person’s, family’s, or com- perience with your colleagues. Sharing is a
munity’s hopes and dreams for their own way to explore and clarify views about nursing
health and healing? and to seek and offer support for nursing val-
ues and situations that are critical to your
• Who was I as a person in the nursing practice. If you are doing this exercise in a
situation? group, share your essential values and beliefs
with your colleagues.
• Who was I as a nurse in the situation?

CHAPTER 3 • Choosing, Evaluating, and Implementing Nursing Theories for Practice 29

Multiple Ways of Knowing and nursing theory. Knowing the self is essential in
Reflecting on Nursing Theory selecting a nursing theory to guide practice.
Ultimately, the choice of theoretical perspec-
Multiple ways of knowing are used in theory- tive reflects personal values and beliefs.
guided nursing practice. Carper (1978) studied
the nursing literature and described four essen- Ethical knowing is increasingly important to
tial patterns of knowing in nursing. Using the the study and practice of nursing today. Ac-
Phenix (1964) model of realms of meaning, cording to Carper (1978), ethics in nursing is
Carper described personal, empirical, ethical, the moral component guiding choices within
and aesthetic ways of knowing in nursing. the complexity of health care. Ethical knowing
Chinn and Kramer (2011) use Carper’s pat- informs us of what is right, what is obligatory,
terns of knowing and a fifth pattern, called and what is desirable in any nursing situation.
emancipatory knowing, to develop an inte- Ethical knowing is essential in every action of
grated framework for nursing knowledge de- the nurse in day-to-day practice.
velopment. Additional patterns of knowing in
nursing have been explored and described, and Aesthetic knowing is described by Carper
the initial four patterns have been the focus (1978) as the art of nursing; it is the creative
of much consideration in nursing (Boykin, and imaginative use of nursing knowledge in
Parker, & Schoenhofer, 1994; Leight, 2002; practice (Rogers, 1988). Although nursing is
Munhall, 1993; Parker, 2002; Pierson, 1999; often referred to as art, this aspect of nursing
Ruth-Sahd, 2003; Thompson, 1999; White, may not be as highly valued as the science and
1995). Each of the patterns of knowing and ethics of nursing. Each nurse is an artist, ex-
its relationship to theory-guided practice are pressing and interpreting the guiding theory
articulated in the following paragraphs. uniquely in his or her practice. Reflecting on
the experience of nursing is primary in under-
Empirical knowing is the most familiar of standing aesthetic knowing. Through such re-
the ways of knowing in nursing. Empirical flection, the nurse understands that nursing
knowing is how we come to know the science practice has in fact been created, that each in-
of nursing and other disciplines that are used stance of nursing is unique, and that outcomes
in nursing practice. This includes knowing the of nursing cannot be precisely predicted. Be-
actual theories, concepts, principles, and re- sides the art of nursing, knowing through artis-
search findings from nursing, pathophysiology, tic forms is part of aesthetic knowing. Often
pharmacology, psychology, sociology, epidemi- human experiences and relationships can best
ology, and other fields. Nursing theory is within be appreciated and understood through art
the pattern of empirical knowing. The theoret- forms such as stories, paintings, music, or po-
ical framework for practice integrates the con- etry. Some assert that aesthetic knowing allows
cepts, principles, laws, and facts essential for for understanding the wholeness of experience.
practice. Examples of this most complete knowing are
frequent in nursing situations in which even
Personal knowing is about striving to know momentary connection and genuine presence
the self and to actualize authentic relationships between the nurse and the person, family, or
between the nurse and person. Using this pat- community is realized.
tern of knowing in nursing, the client is not
seen as an object but as a person moving to- Emancipatory knowing as described by
ward fulfillment of potential (Carper, 1978). Chinn and Kramer (2011 ) is realized in praxis,
The nurse is recognized as continuously learn- the integration of knowing, doing and being.
ing and growing as a person and practitioner. Paulo Freire’s (1970) definition of praxis is si-
Reflecting on a person as a client and a person multaneous reflection and action intended to
as a nurse in the nursing situation can enhance transform the world. In this pattern knowing
understanding of nursing practice and the cen- is inseparable from action and is integral to the
trality of relationships in nursing. These in- being of the nurse. The transformative action
sights are useful for choosing and studying alters the power dynamics that maintain dis-
advantage for some and privilege for others,