THEORIES OF NURSING PRACTICE
DEFINITIONS OF NURSING THEORY
A theory, as a general term, is a notion or an idea that explains experience, interprets observation, describes relationships, and projects outcomes. Theories are mental patterns or constructs created to help understand and find meaning from our experience, organize and articulate our knowing, and ask questions leading to new insights. As such, theories are not discovered in nature but are human inventions. They are descriptions of our reflections, of what we observe, or of what we project and infer. For these reasons, theory and related terms have been defined and described in a number of ways according to individual experience and what is useful at the time. Theories, as reflections of understanding, guide our actions, help us set forth desired outcomes, and give evidence of what has been achieved. A theory, by traditional definition, is an organized, coherent set of concepts and their relationships to each other that offers descriptions, explanations, and predictions about phenomena.
Early writers about nursing theory brought definitions of theory from other disciplines to direct future work within nursing. A theory is a “conceptual system or framework invented for some purpose” (Dickoff & James, 1968, p. 198). Ellis (1968, p. 117) defined theory as “a coherent set of hypothetical, conceptual, and pragmatic principles forming a general frame of reference for a field of inquiry.” McKay (1969, p. 394) asserted that theories are the capstone of scientific work, and that the term refers to “logically interconnected sets of confirmed hypotheses. Barnum (1998, p. 1) later offers a more open definition of theory as a “construct that accounts for or organizes some phenomenon,” and states simply that a nursing theory describes or explains nursing.
Definitions of theory emphasize various aspects of theory and demonstrate that even the conceptions of nursing theory are various and changing. Definitions of theory developed in recent years are more open and less structured than definitions created before the last decade. Not every nursing theory will fit every definition of what is a nursing theory. For purposes of nursing practice, a definition of nursing theory that has a focus on the meaning or possible impact of the theory on practice is desirable. The following definitions of theory are consistent with general ideas of theory in nursing as well as in other disciplines. They are inclusive enough to be used for purposes of nursing practice, education, and administration, as well as nursing research, but can also provide a focus on one main nursing endeavor.
Theory is a set of concepts, definitions, and propositions that projects a systematic view of phenomena by designating specific interrelationships among concepts for purposes of describing, explaining, predicting, and/or controlling phenomena. (Chinn & Jacobs, 1987, p. 70)
Theory is a creative and rigorous structuring of ideas that projects a tentative purposeful and systematic view of phenomena. (Chinn & Kramer, 1995, p. 71)
Nursing theory is a conceptualization of some aspect of reality (invented or discovered) that pertains to nursing. The conceptualization is articulated for the purpose of describing, explaining, predicting or prescribing nursing care. (Meleis, 1997, p. 12)
Nursing theory is an inductively and/or deductively derived collage of coherent, creative, and focused nursing phenomena that frame, give meaning to, and help explain specific and selective aspects of nursing research and practice. (Silva, 1997, p. 55)
NURSING THEORY IN THE CONTEXT OF NURSING KNOWLEDGE
The notion of paradigm can be useful as a basis for understanding nursing knowledge. Paradigm is a global, general framework made up of assumptions about aspects of the discipline held by members to be essential in development of the discipline. The concept of paradigm comes from the work of Kuhn (1970, 1977), who used the term to describe models that guide scientific activity and knowledge development in disciplines.
Kuhn set forth the view that science does not evolve as a smooth, regular, continuing path of knowledge development over time, but that there are periodic times of revolution when traditional thought is challenged by new ideas, and “paradigm shifts” occur. In addition, Kuhn’s work has meaning for nursing and other practice disciplines because of his recognition that science is the work of a community of scholars in the context of society. Because paradigms are broad, shared perspectives held by members of the discipline, they are often called “worldviews.” Paradigms and worldviews of nursing are subtle and powerful, permeating all aspects of the discipline and practice of nursing. Kuhn’s (1970, 1977) description of scientific development is particularly relevant to nursing today as new perspectives are being articulated, some traditional views are being strengthened, and some views are taking their places as part of our history. As we continue to move away from the historical conception of nursing as a part of medical science, developments in the nursing discipline are directed by several new worldviews. Among these are fresh and innovative perspectives on person, nursing, and knowledge development. Changes in the nursing paradigm are being brought about by nursing scholars addressing disciplinary concerns based on values and beliefs about nursing as a human science, caring in nursing, and holistic nursing.
The literature offers additional ways to describe and understand nursing theory. Fawcett (1993) asserts that nursing theory is one component of a hierarchical structure of nursing knowledge development that includes metaparadigm, philosophy, conceptual models, nursing theory, and empirical indicators. These conceptual levels of knowledge development in nursing are interdependent; each level of development is influenced by work at other levels. Walker and Avant (1995) describe the importance of relating theories that have been developed at these various levels of abstraction.
Theoretical work in nursing must be dynamic; that is, it must be continually in process and useful for the purposes and work of the discipline. It must be open to adapt and extend in order both to guide nursing endeavors and to reflect development within nursing. Although there is diversity of opinion among nurses about terms used to describe theoretical development, the following discussion of types of theoretical development in nursing is offered as a context for further understanding nursing theory.
Metaparadigm for Nursing
The metaparadigm for nursing is a framework for the discipline that sets forth the phenomena of interest and the propositions, principles, and methods of the discipline. The metaparadigm is very general and is intended to reflect agreement among members of the discipline about the field of nursing. This is the most abstract level of nursing knowledge and closely mirrors beliefs held about nursing. The metapara- digm offers a context for developing conceptual models and theories. Dialogue on the metaparadigm of nursing today is dynamic because of the range of considerations about what comprises the essence and form of nursing.
All nurses have some awareness of nursing’s metaparadigm by virtue of being nurses. However, because the term may not be familiar, it offers no direct guidance for research and practice (Walker & Avant, 1995; Kim, 1997). Historically, the metaparadigm of nursing described concepts of person, environment, health, and nursing. Modifications and alternative concepts for this framework are being explored throughout the discipline (Fawcett, 1993). An example of alternative concepts is the work of Kim (1987, 1997), which sets forth four domains focusing on client, client-nurse encounters, practice, and environment. In recent years, increasing attention has been directed to the nature of nursing’s relationship with the environment (Schuster & Brown, 1994; Kleffel, 1996). Newman, Sime, and Corcoran-Perry (1991, p. 3) propose that a single focus statement, “nursing is the study of caring in the human health experience,” guide the overall direction of the discipline. Reed (1995) challenges nurses to continue the dialogue about perspectives on knowledge development in the discipline.
Developments in the metaparadigm of nursing are accompanied by changes in statements of values and beliefs written as nursing philosophies. A philosophy comprises statements of enduring values and beliefs held by members of the discipline. These statements address the major concepts of the discipline, setting forth beliefs about what nursing is, how to think about and do nursing, the relationships of nursing, and the environment of nursing. Philosophical statements are practical guides for examining issues and clarifying priorities of the discipline. Nurses use philosophical statements to examine fit among personal, professional, organizational, and societal beliefs and values.
Conceptual Models of Nursing
Conceptual models are sets of general concepts and propositions that provide perspectives on the major concepts of the metaparadigm, such as person, health and well-being, and the environment. Conceptual models also reflect sets of values and beliefs, as in philosophical statements as well as preferences for practice and research approaches. Fawcett (1993, 1999) points out that direction for research must be described as part of the conceptual model in order to guide development and testing of nursing theories. Conceptual models are less abstract than the metaparadigm and more abstract than theories, offering guidance to nursing endeavors but no distinct direction. Conceptual models may also be called “conceptual frameworks” or “systems.”
In general, nursing theory describes and explains the phenomena of interest to nursing in a systematic way in order to provide understanding for use in nursing practice and research. Theories are less abstract than conceptual models or systems, although they vary in scope and levels of abstraction. Grand theories of nursing are those general constructions about the nature and goals of nursing. Middle-range nursing theories point to practice and are useful in a defined set of nursing situations. Theories developed at the mid- dle range include specific concepts and are less abstract than grand theories. At the next level, nursing practice theories address issues and questions in a particular practice setting in which nursing provides care for a specific population. In addition to considering the scope and levels of abstraction of nursing theories, they are also sometimes described by the content or focus of the theory, such as health promotion, and caring and holistic nursing theories.
TYPES OF NURSING THEORY
Nursing theories have been organized into categories and types. George (1995) sets forth categories of theories according to the orientation of the theorist: nursing problems, interactions, general systems, and energy fields. Another view is that nursing theory forms a continuum of grand theories at one end and theories focused on practice at the other (Chinn & Kramer, 1995; Walker & Avant, 1995; Fitzpatrick, 1997). Meleis (1997) describes types of nursing theory based on their levels of abstraction and goal orientation. Barnum (1998) divides theories into those that describe and those that explain nursing phenomena. Types of nursing theories generally include grand theory, middle-range theory, and practice theory. These will be described below.
Grand Nursing Theory
Grand theories have the broadest scope and present general concepts and propositions. Theories at this level may both reflect and provide insights useful for practice but are not designed for empirical testing. This limits the use of grand theories for directing, explaining, and predicting nursing in particular situations. Theories at this level are intended to be pertinent to all instances of nursing.
Development of grand theories resulted from the deliberate effort of committed scholars who have engaged in thoughtful reflection on nursing practice and knowledge and the many contexts of nursing over time. Nursing theorists who have worked at this level have had insights guided by nursing and related metaparadigms and sometimes have experienced leaps of knowing grounded in these insights. Although there is debate about which nursing theories are grand in scope, the following are usually considered to be at this level: Leininger’s Theory of Culture Care Diversity and Universality, Newman’s Theory of Health as Expanding Consciousness, Rogers’ Science of Unitary Human Beings, Orem’s Self-Care Deficit Nursing Theory, and Parse’s Theory of Human Becoming. These theories are presented in the third section of this book.
Middle-range Nursing Theory
Middle-range theory was proposed by Robert Merton (1968) in the field of sociology to provide theories that are both broad enough to be useful in complex situations and appropriate for empirical testing. Nursing scholars proposed using this level of theory because of the difficulty in testing grand theory (Jacox, 1974). Middle-range theories are more narrow in scope than grand theories and offer an effective bridge between grand theories and nursing practice. They present concepts and propositions at a lower level of abstraction and hold great promise for increasing theory-based research and nursing practice strategies.
The literature presents a growing number of reports of nurses’ experiences of developing and using middle-range theory. The nursing practice issues to which these nurses are responding are complex and represent a wide range of practice arenas (Chinn, 1994). The methods used for developing middlerange theories are many and represent some of the most exciting work being published in nursing today. Many of these new theories are built on content of related disciplines and brought into nursing practice and research (Lenz, Suppe, Gift, Pugh, & Milligan, 1995; Polk, 1997; Eakes, Burke, & Hainsworth, 1998). The literature also offers middle-range nursing theories that are directly related to grand theories of nursing (Olson & Hanchett, 1997; Ducharme, Ricard, Duquette, Levesque, & Lachance, 1998). Reports of nursing theory developed at this level include implications for instrument development, theory testing through research, and nursing practice strategies. Illustrations of the process and product of nursing theory developed at the middle range are presented in Section IV of this book.
Nursing Practice Theory
Nursing practice theory has the most limited scope and level of abstraction and is developed for use within a specific range of nursing situations. Theories developed at this level have a more direct impact on nursing practice than do theories that are more abstract. Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice. At the same time, nursing questions, actions, and procedures may be described or developed as nursing practice theories. Ideally, nursing practice theories are interrelated with concepts from middle-range theories, or may be deduced from theories at the middle range. Practice theories should also reflect concepts and propositions of more abstract levels of nursing theory. Theory developed at this level is also termed prescriptive theory (Dickoff, James, & Wiedenbach, 1968; Crowley, 1968), situation-specific theory (Meleis, 1997), and micro theory (Chinn & Kramer, 1995).
The day-to-day experience of nurses is a major source of nursing practice theory. The depth and complexity of nursing practice may be fully appreciated as nursing phenomena and relations among aspects of particular nursing situations are described and explained. Benner (1984) demonstrated that dialogue with expert nurses in practice is fruitful for discovery and development of practice theory. Research findings on various nursing problems offer data to develop nursing practice theories as nursing engages in research-based development of theory and practice. Nursing practice theory has been articulated using multiple ways of knowing through reflective practice (Johns & Freshwater, 1998). The process includes quiet reflection on practice, remembering and noting features of nursing situations, attending to one’s own feelings, reevaluating the experience, and integrating new knowing with other experience (Gray & Forsstrom, 1991).
NURSING’S NEED FOR NURSING THEORY
Nursing theories address the phenomena of interest to nursing, including the focus of nursing; the person, group, or population nursed; the nurse; the relationship of nurse and nursed; and the hoped-for goal or purposes of nursing. Based on strongly held values and beliefs about nursing, and within contexts of various worldviews, theories are patterns that guide the thinking about, being, and doing of nursing. They provide structure for developing, evaluating, and using nursing scholarship and for extending and refining nursing knowledge through research. Nursing theories either implicitly or explicitly direct all avenues of nursing, including nursing education and administration. Nursing theories provide concepts and designs that define the place of nursing in health and illness care. Through theories, nurses are offered perspectives for relating with professionals from other disciplines who join with nurses to provide human services. Nursing has great expectations of its theories. Theories must, at the same time, provide structure and substance to ground the practice and scholarship of nursing and also be flexible and dynamic to keep pace with the growth and changes in the discipline and practice of nursing.
Nursing Is a Discipline
Nursing has taken its place as a discipline of knowledge that includes networks of facts, concepts, and approaches to inquiry. The discipline of nursing is also a community of scholars, including nurses in all venues where nursing occurs, which shares commitment to values, concepts, and processes to guide the thought and work of the discipline. Consistent with thinking of nursing scholars about the discipline of nursing (Donaldson & Crowley, 1978; Meleis, 1997) is the classic work of King and Brownell (1976). These authors have set forth attributes of all disciplines. These have particular relevance for nursing and illustrate the need for nursing theory. The attributes of King and Brownell are used as a framework to address the need of the discipline for nursing theory. Each of the attributes is described below from the perspective of the discipline of nursing.
Expression of Human Imagination
Nursing theory requires curiosity and wonder, as well as critical thinking on the part of the theorists and students of theory. Nursing theory is dependent on the imagination and questioning of nurses in practice and on their creativity to bring ideas of nursing theory into practice. In order to remain dynamic and useful, our discipline requires openness to new ideas and innovative approaches that grow out of members’ reflections and insights. There must be support for creative exploration and expression in new theoretical ways.
A discipline of knowledge and professional practice must be clearly defined by statements of the domain— the theoretical and practical boundaries of that discipline and practice. The domain of nursing includes the phenomena of interest, problems to be addressed, main content and methods used, and roles required of members of the discipline (Kim, 1997; Meleis, 1997). The processes and practices claimed by members of the discipline community grow out of these domain statements. Nursing theories containing descriptions of nursing’s domain may incorporate a statement of focus of the discipline. The focus may be set in statements about human, social, and ecological concerns addressed by nursing. The focus of the discipline of nursing is a clear statement of social mandate and service used to direct the study and practice of nursing (Newman, Sime, & Corcoran-Perry, 1991).
Nightingale (1859/1992) may have led the call for domain and focus by distinguishing nursing from medicine and other services. Later, Donaldson and Crowley (1978) stated that a discipline has a special way of viewing phenomena and a distinct perspective that defines the work of the discipline. The call for clarity of focus continues in the current environment of nursing practice (Parse, 1997). Nursing theories set forth focus statements or definitions of the discipline and practice of nursing and direct thought and action to fulfill the unique purposes of nursing. This enhances autonomy, and accountability and responsibility are defined and supported. The domain of nursing is also called the “metaparadigm of nursing,” as described in the previous section of this chapter.
Syntactical and Conceptual Structures
These structures essential to the discipline are inherent in each of the nursing theories. The conceptual structure delineates the proper concerns of nursing, guides what is to be studied, and clarifies accepted ways of knowing and using content of the discipline. This structure is grounded in the metaparadigm and philosophies of nursing. The conceptual structure relates concepts within nursing theories, and it is from this structure that we learn what is and is not nursing. The syntactical structures help nurses and other professionals understand the talents, skills, and abilities that must be developed within the community. This structure directs descriptions of data needed from research as well as evidence required to demonstrate the impact of nursing practice.
In addition, these structures guide nursing’s use of knowledge, research, and practice approaches developed by related disciplines. It is only by being thoroughly grounded in the concepts, substance, and modes of inquiry of the discipline that the boundaries of the discipline, however tentative, can be understood and possibilities for creativity across interdisciplinary borders can be created and explored.
Specialized Language and Symbols
As nursing theory has evolved, so has the need for concepts, language, and forms of data that reflect new ways of thinking and knowing in nursing. The complex concepts used in nursing scholarship and practice require language that can be used and understood. The language of nursing theory facilitates communication among members of the discipline. Expert knowledge of the discipline is often required for full understanding of the meaning of special terms. At the same time, it is often realized that nursing chooses to use commonly understood language in order to communicate more fully with those served.
Heritage of Literature and Networks of Communication
This attribute calls attention to the array of books, periodicals, artifacts, and aesthetic expressions, as well as audio, visual, and electronic media that have developed over centuries to communicate the nature and development of nursing. Conferences and other forums on every aspect of nursing and for nurses of all interests occur frequently throughout the world. Nursing organizations and societies also provide critical communication links. Nursing theories form the bases for many of the major contributions to the literature, conferences, societies, and other communication networks of the discipline of nursing.
The tradition and history of the discipline of nursing is evident in study of nursing theories that have been developed over time. There is recognition that theories most useful today often have threads of connection with theoretical developments of past years. For example, many theorists have acknowledged the influence of Florence Nightingale and have acclaimed her leadership in influencing nursing theories of today. In addition, nursing has a rich heritage of practice. Nursing’s practical experience and knowledge have been shared, transformed into content of the discipline, and are evident in the work of many nursing theorists (Gray & Pratt, 1991).
Values and Beliefs
Nursing has distinctive views of persons and strong commitments to compassionate and knowledgeable care of persons through nursing. Nurses often express their love and passion for nursing. Nurses in small groups and in larger nursing organizations express values, hopes, and dreams for the future of their discipline and offer recognition of and appreciation for achievements in the field. The statements of values and beliefs are expressed in the philosophies of nursing that are essential underpinnings of theoretical developments in the discipline.
Systems of Education
Nursing holds the stature and place of a discipline of knowledge and professional practice within institutions of higher education because of the grounding of articulated nursing theories that have set forth the unique contribution of nursing to human affairs. A distinguishing mark of any discipline is the education of future and current members of the community. Nursing theories, by setting directions for the substance and methods of inquiry for the discipline, provide the basis for nursing education and often the framework to organize nursing curricula.
Nursing Is a Professional Practice
Closely aligned with attributes of nursing as a discipline described above is consideration of nursing as a professional practice. Professional practice includes clinical scholarship and processes of nursing persons, groups, and populations who need the special human service that is nursing. The major reason for structuring and advancing nursing knowledge is for the sake of nursing practice. The primary purpose of nursing theories is to further the development and understanding of nursing practice. Theory-based research is needed in order to explain and predict nursing outcomes essential to the delivery of nursing care that is both humane and cost-effective (Gioiella, 1996). Because nursing theory exists to improve practice, the test of nursing theory is a test of its usefulness in professional practice (Fitzpatrick, 1997). The work of nursing theory is moving from academia into the realm of nursing practice. Chapters in the remaining sections of this book highlight use of nursing theories in nursing practice.
Nursing practice is both the source of and goal for nursing theory. From the viewpoint of practice, Gray and Forsstrom (1991) suggest that through use of theory, nurses find different ways of looking at and assessing phenomena, have rationale for their practice and criteria for evaluating outcomes. Recent studies reported in the literature affirm the importance of use of nursing theory to guide practice (Baker, 1997; Olson & Hanchett, 1997; Barrett, 1998; O’Neill & Kenny, 1998; Whitener, Cox, & Maglich, 1998). Further, these studies illustrate that nursing theory can stimulate creative thinking, facilitate communication, and clarify purposes and relationships of practice. The practicing nurse has an ethical responsibility to use the theoretical knowledge base of the discipline, just as it is the nurse scholars’ ethical responsibility to develop the knowledge base specific to nursing practice (Cody, 1997).
Integral to both the professional practice of nursing and nursing theory is the use of empirical indicators. These are developed to meet demands of clinical decision making in the context of rapidly changing needs for nursing and the knowledge required for nursing practice. These indicators include procedures, tools, and instruments to determine the impact of nursing practice and are essential to research and management of outcomes of practice (Jennings & Staggers, 1998). Resulting data form the basis for improving quality of nursing care and influencing health-care policy. Empirical indicators, grounded carefully in nursing concepts, provide clear demonstration of the utility of nursing theory in practice, research, administration, and other nursing endeavors (Hart & Foster, 1998; Allison & McLaughlin-Renpenning, 1999). Fawcett (1993) has placed empirical indicators in the hierarchy of nursing knowledge and relates them to nursing theory when they are an outgrowth of particular aspects of nursing theories.
Meeting the challenges of systems of care delivery and interdisciplinary work demands practice from a theoretical perspective. Nursing’s disciplinary focus is essential within an interdisciplinary environment (Allison & McLaughlin-Renpenning, 1999). Nursing actions reflect nursing concepts and thought. Careful, reflective, and critical thinking is the hallmark of expert nursing and nursing theories should undergird these processes. Appreciation and use of nursing theory offer opportunity for successful collaboration with related disciplines and practices, and provide definition for nursing’s overall contribution to health care. Nurses must know what they are doing, why they are doing what they are doing, what may be the range of outcomes of nursing, and indicators for measuring nursing’s impact. These nursing theoretical frameworks serve in powerful ways as guides for articulating, reporting, and recording nursing thought and action.
One of the assertions referred to most often in the nursing theory literature is that theory is given birth in nursing practice and, following examination and refinement through research, must be returned to practice (Dickoff, James, & Wiedenbach, 1968).Within nursing as a practice discipline, nursing theory is stimulated by questions and curiosities arising from nursing practice. Development of nursing knowledge is a result of theory-based nursing inquiry. The circle continues as data, conclusions, and recommendations of nursing research are evaluated and developed for use in practice. Nursing theory must be seen as practical and useful to practice and the insights of practice must in turn continue to enrich nursing theory.
NURSING THEORY AND THE FUTURE
Many of the chapters of this book contain insights and projections about nursing theory in the coming century. It is somewhat frightening to write about nursing theory in the twenty-first century and it takes courage and perhaps more than a bit of humor to do so. All of us have ways to look back to the year 1900; even if we were not present or cannot remember the context of our lives then, we have heard and read about those times. All can realize the vast changes that have taken place during the twentieth century. Nurses and nursing have participated in these changes. Nursing theorists and scholars who are contributing authors for this book have not only reflected and projected about the future, they have also been willing to share with us their thoughts on the future of nursing theory as we enter the new millennium.
One challenge of nursing theory is the perspective that theory is always in the process of developing and that, at the same time, it is useful for the purposes and work of the discipline. This may be seen as ambiguous or as full of possibilities. Continuing students of the discipline are required to study and know the basis for their contributions to nursing and to those we serve, while at the same time be open to new ways of thinking, knowing, and being in nursing. Exploring structures of nursing knowledge and understanding the nature of nursing as a discipline of knowledge and professional practice provides a frame of reference to clarify nursing theory. The wise study and use of nursing theory can be a helpful companion in the new millennium.