Overview of Theory in Nursing.

Melanie McEwen

Matt Ng has been an emergency room nurse for almost 6 years and recently decided to enroll in a master’s degree program to become an acute care nurse practitioner. As he read over the degree requirements, Matt was somewhat bewildered. One of the first courses required by his program was entitled Application of Theory in Nursing. He was interested in the courses in advanced pharmacology, advanced physical assessment, and pathophysiology and was excited about the advanced practice clinical courses, but a course that focused on nursing theory did not appear congruent with his goals.

Looking over the syllabus for the theory application course did little to reassure Matt, but he was determined to make the best of the situation and went to the first class with an open mind. The first few class periods were increasingly interesting as the students and instructor discussed the historical evolution of the discipline of nursing and the stages of nursing theory development. As the course progressed, the topics became more relevant to Matt. He learned ways to analyze and evaluate theories, examined a number of different types of theories used by nurses, and completed several assignments, including a concept analysis, an analysis of a middle range nursing theory, and a synthesis paper that examined the use of non-nursing theories in nursing research.

By the end of the semester, Matt was able to recognize the importance of the study of theory. He understood how theoretical principles and concepts affected his current practice and how they would be essential to consider as he continued his studies to become an advanced practice nurse.

When asked about theory, many nurses and nursing students, and often even nursing faculty will respond with a furrowed brow, a pained expression, and a resounding “ugh.” When questioned about their negative response, most will admit that the idea of studying theory is confusing, that they see no practical value, and that theory is, in essence, too theoretical.

Likewise, some nursing scholars believe that nursing theory is practically nonexistent, whereas others recognize that many practitioners have not heard of nursing theory. Some nurses lament that nurse researchers use theories and frameworks from other disciplines, whereas others believe the notion of nursing theory is outdated and ask why they should bother with theory. Questions and debates about “theory” in nursing abound in the nursing literature.

Myra Levine, one of the pioneer nursing theorists, wrote that “the introduction of the idea of theory in nursing was sadly inept” (Levine, 1995, p. 11). She stated,

In traditional nursing fashion, early efforts were directed at creating a procedure—a recipe book for prospective theorists—which then could be used to decide what was and was not a theory. And there was always the thread of expectation that the great, grand, global theory would appear and end all speculation. Most of the early theorists really believed they were achieving that.

Levine went on to explain that every new theory posited new central concepts, definitions, relational statements, and goals for nursing, and then attracted a chorus of critics. This resulted in nurses finding themselves confused about the substance and intention of the theories. Indeed, “in early days, theory was expected to be obscure. If it was clearly understandable, it wasn’t considered a very good theory” (Levine, 1995, p. 11).

The drive to develop nursing theory has been marked by nursing theory conferences, the proliferation of theoretical and conceptual frameworks for nursing, and the formal teaching of theory development in graduate nursing education. It has resulted in the development of many systems, techniques or processes for theory analysis and evaluation, a fascination with the philosophy of science, and confusion about theory development strategies and division of choice of research methodologies.

There is debate over the types of theories that should be used by nurses. Should they be only nursing theories or can nurses use theories “borrowed” from other disciplines? There is debate over terminology such as  conceptual framework  conceptual model , and theory. There have been heated discussions concerning the appropriate level of theory for nurses to develop, as well as how, why, where, and when to test, measure, analyze, and evaluate these theories/models/conceptual frameworks. The question has been repeatedly asked: Should nurses adopt a single theory, or do multiple theories serve them best? It is no wonder, then, that nursing students display consternation, bewilderment, and even anxiety when presented with the prospect of studying theory. One premise, however, can be agreed upon: To be useful, a theory must be meaningful and relevant, but above all, it must be understandable. This chapter discusses many of the issues described previously. It presents the rationale for studying and using theory in nursing practice, research, management/administration, and education; gives definitions of key terms; provides an overview of the history of development of theory utilization in nursing; describes the scope of theory and levels of theory; and, finally, introduces the widely accepted nursing metaparadigm.

Overview of Theory

Most scholars agree that it is the unique theories and perspectives used by a discipline that distinguish it from other disciplines. The theories used by members of a profession clarify basic assumptions and values shared by its members and define the nature, outcome, and purpose of practice (Alligood, 2010; Butts, Rich, & Fawcett, 2012; Rutty, 1998).

Definitions of the term  theory  abound in the nursing literature. At a basic level, theory has been described as a systematic explanation of an event in which constructs and concepts are identified and relationships are proposed and predictions made (Streubert & Carpenter, 2011). Theory has also been defined as a “creative and rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenomena” (Chinn & Kramer, 2011, p. 257). Finally, theory has been called a set of interpretative assumptions, principles, or propositions that help explain or guide action (Young, Taylor, & Renpenning, 2001).

In their classic work, Dickoff and James (1968) state that theory is invented, rather than found in or discovered from reality. Furthermore, theories vary according to the number of elements, the characteristics and complexity of the elements, and the kind of relationships between or among the elements.

The Importance of Theory in Nursing

Before the advent of development of nursing theories, nursing was largely subsumed under medicine. Nursing practice was generally prescribed by others and highlighted by traditional, ritualistic tasks with little regard to rationale. The initial work of nursing theorists was aimed at clarifying the complex intellectual and interactional domains that distinguish expert nursing practice from the mere doing of tasks (Omrey, Kasper, & Page, 1995). It was believed that conceptual models and theories could create mechanisms by which nurses would communicate their professional convictions, provide a moral/ethical structure to guide actions, and foster a means of systematic thinking about nursing and its practice (Chinn & Kramer, 2011; Peterson, 2013; Sitzman & Eichelberger, 2011; Ziegler, 2005). The idea that a single, unified model of nursing—a worldview of the discipline—might emerge was encouraged by some (Levine, 1995; Tierney, 1998).

It is widely believed that use of theory offers structure and organization to nursing knowledge and provides a systematic means of collecting data to describe, explain, and predict nursing practice. Use of theory also promotes rational and systematic practice by challenging and validating intuition. Theories make nursing practice more overtly purposeful by stating not only the focus of practice but also specific goals and outcomes. Theories define and clarify nursing and the purpose of nursing practice to distinguish it from other caring professions by setting professional boundaries. Finally, use of a theory in nursing leads to coordinated and less fragmented care (Alligood, 2010; Chinn & Kramer, 2011; Ziegler, 2005).

Ways in which theories and conceptual models developed by nurses have influenced nursing practice are described by Fawcett (1992), who stated that in nursing they:

·  Identify certain standards for nursing practice

·  Identify settings in which nursing practice should occur and the characteristics of what the model’s author considers recipients of nursing care

·  Identify distinctive nursing processes and technologies to be used, including parameters for client assessment, labels for client problems, a strategy for planning, a typology of intervention, and criteria for evaluation of intervention outcomes

·  Direct the delivery of nursing services

·  Serve as the basis for clinical information systems, including the admission database, nursing orders, care plan, progress notes, and discharge summary

·  Guide the development of client classification systems

·  Direct quality assurance programs

· Terminology of Theory

· Young and colleagues (2001) wrote that in nursing, conceptual models or frameworks detail a network of concepts and describe their relationships, thereby explaining broad nursing phenomena. Theories, they noted, are the narrative that accompanies the conceptual model. These theories typically provide a detailed description of all of the components of the model and outline relationships in the form of propositions. Critical components of the theory or narrative include definitions of the central concepts or constructs; propositions or relational statements, the assumptions on which the framework is based; and the purpose, indications for use, or application. Many conceptual frameworks and theories will also include a schematic drawing or model depicting the overall structure of or interactivity of the components (Chinn & Kramer, 2011).

· Some terms may be new to students of theory and others need clarification.  Table 2-1  lists definitions for a number of terms that are frequently encountered in writings on theory. Many of these terms will be described in more detail later in the chapter and in subsequent chapters.

· Table 2-1: Definitions and Characteristics of Theory Terms and Concepts

TermDefinition and Characteristics
AssumptionsAssumptions are beliefs about phenomena one must accept as true to accept a theory about the phenomena as true. Assumptions may be based on accepted knowledge or personal beliefs and values. Although assumptions may not be susceptible to testing, they can be argued philosophically.
Borrowed or shared theoryA borrowed theory is a theory developed in another discipline that is not adapted to the worldview and practice of nursing.
ConceptConcepts are the elements or components of a phenomenon necessary to understand the phenomenon. They are abstract and derived from impressions the human mind receives about phenomena through sensing the environment.
Conceptual model/conceptual frameworkA conceptual model is a set of interrelated concepts that symbolically represents and conveys a mental image of a phenomenon. Conceptual models of nursing identify concepts and describe their relationships to the phenomena of central concern to the discipline.
ConstructConstructs are the most complex type of concept. They comprise more than one concept and are typically built or constructed by the theorist or philosopher to fit a purpose. The terms  concept  and  construct are often used interchangeably, but some authors use concept as the more general term—all constructs are concepts, but not all concepts are constructs.
Empirical indicatorEmpirical indicators are very specific and concrete identifiers of concepts. They are actual instructions, experimental conditions, and procedures used to observe or measure the concept(s) of a theory.
EpistemologyEpistemology refers to theories of knowledge or how people come to have knowledge; in nursing, it is the study of the origins of nursing knowledge.
HypothesesHypotheses are tentative suggestions that a specific relationship exists between two concepts or propositions. As the hypothesis is repeatedly confirmed, it progresses to an empirical generalization and ultimately to a law.
KnowledgeKnowledge refers to the awareness or perception of reality acquired through insight, learning, or investigation. In a discipline, knowledge is what is collectively seen to be a reasonably accurate understanding of the world as seen by members of the discipline.
LawsA law is a proposition about the relationship between concepts in a theory that has been repeatedly validated. Laws are highly generalizable. Laws are found primarily in disciplines that deal with observable and measurable phenomena, such as chemistry and physics. Conversely, social and human sciences have few laws.
MetaparadigmA metaparadigm represents the worldview of a discipline—the global perspective that subsumes more specific views and approaches to the central concepts with which the discipline is concerned. The metaparadigm is the ideology within which the theories, knowledge, and processes for knowing find meaning and coherence. Nursing’s metaparadigm is generally thought to consist of the concepts of person, environment, health, and nursing.
Middle range theoryMiddle range theory refers to a part of a discipline’s concerns related to particular topics. The scope is narrower than that of broad-range or grand theories.
ModelModels are graphic or symbolic representations of phenomena that objectify and present certain perspectives or points of view about nature or function or both. Models may be theoretical (something not directly observable—expressed in language or mathematics symbols) or empirical (replicas of observable reality—model of an eye, for example).
OntologyOntology is concerned with the study of existence and the nature of reality.
ParadigmA paradigm is an organizing framework that contains concepts, theories, assumptions, beliefs, values, and principles that form the way a discipline interprets the subject matter with which it is concerned. It describes work to be done and frames an orientation within which the work will be accomplished. A discipline may have a number of paradigms. The term  paradigm  is associated with Kuhn’s Structure of Scientific Revolutions.
PhenomenaPhenomena are the designation of an aspect of reality; the phenomena of interest become the subject matter particular to the primary concerns of a discipline.
PhilosophyA philosophy is a statement of beliefs and values about human beings and their world.
Practice or situation-specific theoryA practice or situation-specific theory deals with a limited range of discrete phenomena that are specifically defined and are not expanded to include their link with the broad concerns of a discipline.
PraxisPraxis is the application of a theory to cases encountered in experience.
Relationship statementsRelationship statements indicate specific relationships between two or more concepts. They may be classified as propositions, hypotheses, laws, axioms, or theorems.
TaxonomyA taxonomy is a classification scheme for defining or gathering together various phenomena. Taxonomies range in complexity from simple dichotomies to complicated hierarchical structures.
TheoryTheory refers to a set of logically interrelated concepts, statements, propositions, and definitions, which have been derived from philosophical beliefs of scientific data and from which questions or hypotheses can be deduced, tested, and verified. A theory purports to account for or characterize some phenomenon.
WorldviewWorldview is the philosophical frame of reference used by a social or cultural group to describe that group’s outlook on and beliefs about reality.
Sources: Alligood & Tomey (2010); Blackburn (2008); Chinn & Kramer (2011); Powers & Knapp (2011).

· Historical Overview: Theory Development in Nursing

· Most nursing scholars credit Florence Nightingale with being the first modern nursing theorist. Nightingale was the first to delineate what she considered nursing’s goal and practice domain, and she postulated that “to nurse” meant having charge of the personal health of someone. She believed the role of the nurse was seen as placing the client “in the best condition for nature to act upon him” (Hilton, 1997, p. 1211).

· Florence Nightingale

· Nightingale received her formal training in nursing in Kaiserswerth, Germany, in 1851. Following her renowned service for the British army during the Crimean War, she returned to London and established a school for nurses. According to Nightingale, formal training for nurses was necessary to “teach not only what is to be done, but how to do it.” She was the first to advocate the teaching of symptoms and what they indicate. Further, she taught the importance of rationale for actions and stressed the significance of “trained powers of observation and reflection” (Kalisch & Kalisch, 2004, p. 36).

· In Notes on Nursing, published in 1859, Nightingale proposed basic premises for nursing practice. In her view, nurses were to make astute observations of the sick and their environment, record observations, and develop knowledge about factors that promoted healing. Her framework for nursing emphasized the utility of empirical knowledge, and she believed that knowledge developed and used by nurses should be distinct from medical knowledge. She insisted that trained nurses control and staff nursing schools and manage nursing practice in homes and hospitals (Chinn & Kramer, 2011; Kalisch & Kalisch, 2004).

· Stages of Theory Development in Nursing

· Subsequent to Nightingale, almost a century passed before other nursing scholars attempted the development of philosophical and theoretical works to describe and define nursing and to guide nursing practice. Kidd and Morrison (1988) described five stages in the development of nursing theory and philosophy: (1) silent knowledge, (2) received knowledge, (3) subjective knowledge, (4) procedural knowledge, and (5) constructed knowledge.  Table 2-2  gives an overview of characteristics of each of these stages in the development of nursing theory, and each stage is described in the following sections. To contemporize Kidd and Morrison’s work, attention will be given to the current decade and a new stage—that of “integrated knowledge.”

· Table 2-2: Stages in the Development of Nursing Theory

StageSource of KnowledgeImpact on Theory and Research
Silent knowledgeBlind obedience to medical authorityLittle attempt to develop theory. Research was limited to collection of epidemiologic data.
Received knowledgeLearning through listening to othersTheories were borrowed from other disciplines. As nurses acquired non-nursing doctoral degrees, they relied on the authority of educators, sociologists, psychologists, physiologists, and anthropologists to provide answers to nursing problems.
  Research was primarily educational research or sociologic research.
Subjective knowledgeAuthority was internalized to foster a new sense of self.A negative attitude toward borrowed theories and science emerged.
  Nurse scholars focused on defining nursing and on developing theories about and for nursing.
  Nursing research focused on the nurse rather than on clients and clinical situations.
Procedural knowledgeIncludes both separate and connected knowledgeProliferation of approaches to theory development. Application of theory in practice was frequently underemphasized. Emphasis was placed on the procedures used to acquire knowledge, with focused attention to the appropriateness of methodology, the criteria for evolution, and statistical procedures for data analysis.
Constructed knowledgeCombination of different types of knowledge (intuition, reason, and self-knowledge)Recognition that nursing theory should be based on prior empirical studies, theoretical literature, client reports of clinical experiences and feelings, and the nurse scholar’s intuition or related knowledge about the phenomenon of concern.
Integrated knowledgeAssimilation and application of “evidence” from nursing and other health care disciplinesNursing theory will increasingly incorporate information from published literature with enhanced emphasis on clinical application as situation-specific/practice theories and middle range theories.
Source: Kidd & Morrison (1988).

Silent Knowledge Stage

Recognizing the impact of the poorly trained nurses on the health of soldiers during the Civil War, in 1868, the American Medical Association advocated the formal training of nurses and suggested that schools of nursing be attached to hospitals with instruction being provided by medical staff and resident physicians. The first training school for nurses in the United States was opened in 1872 at the New England Hospital. Three more schools, located in New York, New Haven, and Boston, opened shortly thereafter (Kalisch & Kalisch, 2004). Most schools were under the control of hospitals and superintended by hospital administrators and physicians. Education and practice were based on rules, principles, and traditions that were passed along through an apprenticeship form of education.

There followed rapid growth in the number of hospital-based training programs for nurses, and by 1909, there were more than 1,000 such programs (Kalisch & Kalisch, 2004). In these early schools, a meager amount of theory was taught by physicians, and practice was taught by experienced nurses. The curricula contained some anatomy and physiology and occasional lectures on special diseases. Few nursing books were available, and the emphasis was on carrying out physicians’ orders. Nursing education and practice focused on the performance of technical skills and application of a few basic principles, such as aseptic technique and principles of mobility. Nurses depended on physicians’ diagnosis and orders and as a result largely adhered to the medical model, which views body and mind separately and focuses on cure and treatment of pathologic problems (Donahue, 2011). Hospital administrators saw nurses as inexpensive labor. Nurses were exploited both as students and as experienced workers. They were taught to be submissive and obedient, and they learned to fulfill their responsibilities to physicians without question (Chinn & Kramer, 2011).

Unfortunately, with a few exceptions, this model of nursing education persisted for more than 80 years. One exception was Yale University, which started the first autonomous school of nursing in 1924. At Yale, and in other later collegiate programs, professional training was strengthened by in-depth exposure to the underlying theory of disease as well as the social, psychological, and physical aspects of client welfare. The growth of collegiate programs lagged, however, due to opposition from many physicians who argued that university-educated nurses were overtrained. Hospital schools continued to insist that nursing education meant acquisition of technical skills and that knowledge of theory was unnecessary and might actually handicap the nurse (Andrist, 2006; Donahue, 2011; Kalisch & Kalisch, 2004).

Received Knowledge Stage

It was not until after World War II that substantive changes were made in nursing education. During the late 1940s and into the 1950s, serious nursing shortages were fueled by a decline in nursing school enrollments. A 1948 report, Nursing for the Future, by Esther Brown, PhD, compared nursing with teaching. Brown noted that the current model of nursing education was central to the problems of the profession and recommended that efforts be made to provide nursing education in universities as opposed to the apprenticeship system that existed in most hospital programs (Donahue, 2011; Kalisch & Kalisch, 2004).

Other factors during this time challenged the tradition of hospital-based training for nurses. One of these factors was a dramatic increase in the number of hospitals resulting from the Hill-Burton Act, which worsened the ongoing and sometimes critical nursing shortage. In addition, professional organizations for nurses were restructured and began to grow. It was also during this time that state licensure testing for registration took effect, and by 1949, 41 states required testing. The registration requirement necessitated that education programs review the content matter they were teaching to determine minimum criteria and some degree of uniformity. In addition, the techniques and processes used in instruction were also reviewed and evaluated (Kalisch & Kalisch, 2004).

Over the next decade, a number of other events occurred that altered nursing education and nursing practice. In 1950, the journal Nursing Research  was first published. The American Nurses Association (ANA) began a program to encourage nurses to pursue graduate education to study nursing functions and practice. Books on research methods and explicit theories of nursing began to appear. In 1956, the Health Amendments Act authorized funds for financial aid to promote graduate education for full-time study to prepare nurses for administration, supervision, and teaching. These events resulted in a slow but steady increase in graduate nursing education programs.

The first doctoral programs in nursing originated within schools of education at Teachers College of Columbia University (1933) and New York University (1934). But it would be 20 more years before the first doctoral program in nursing began at the University of Pittsburgh (1954) (Kalisch & Kalisch, 2004).

Subjective Knowledge Stage

Until the 1950s, nursing practice was principally derived from social, biologic, and medical theories. With the exceptions of Nightingale’s work in the 1850s, nursing theory had its beginnings with the publication of Hildegard Peplau’s book in 1952. Peplau described the interpersonal process between the nurse and the client. This started a revolution in nursing, and in the late 1950s and 1960s, a number of nurse theorists emerged seeking to provide an independent conceptual framework for nursing education and practice (Donahue, 2011). The nurse’s role came under scrutiny during this decade as nurse leaders debated the nature of nursing practice and theory development.

During the 1960s, the development of nursing theory was heavily influenced by three philosophers, James Dickoff, Patricia James, and Ernestine Weidenbach, who, in a series of articles, described theory development and the nature of theory for a practice discipline. Other approaches to theory development combined direct observations of practice, insights derived from existing theories and other literature sources, and insights derived from explicit philosophical perspectives about nursing and the nature  of health and human experience. Early theories were characterized by a functional view of nursing and health. They attempted to define what nursing is, describe the social purposes nursing serves, explain how nurses function to realize these purposes, and identify parameters and variables that influence illness and health (Chinn & Kramer, 2011).

In the 1960s, a number of nurse leaders (Abdellah, Orlando, Widenbach, Hall, Henderson, Levine, and Rogers) developed and published their views of nursing. Their descriptions of nursing and nursing models evolved from their personal, professional, and educational experiences, and reflected their perception of ideal nursing practice.

Procedural Knowledge Stage

By the 1970s, the nursing profession viewed itself as a scientific discipline evolving toward a theoretically based practice focusing on the client. In the late 1960s and early 1970s, several nursing theory conferences were held. Also, significantly, in 1972, the National League for Nursing implemented a requirement that the curricula for nursing educational programs be based on conceptual frameworks. During these years, many nursing theorists published their beliefs and ideas about nursing and some developed conceptual models.

During the 1970s, a consensus developed among nursing leaders regarding common elements of nursing. These were the nature of nursing (roles/actions/interventions), the individual recipient of care (client), the context of nurse–client interactions (environment), and health. Nurses debated whether there should be one conceptual model for nursing or several models to describe the relationships among the nurse, client, environment, and health. Books were written for nurses on how to critique, develop, and apply nursing theories. Graduate schools developed courses on analysis and application of theory, and researchers identified nursing theories as conceptual frameworks for their studies. Through the late 1970s and early 1980s, theories moved to characterizing nursing’s role from “what nurses do” to “what nursing is.” This changed nursing from a context-dependent, reactive position to a context-independent, proactive arena (Chinn & Kramer, 2011).

Although master’s programs were growing steadily, doctoral programs grew more slowly, but by 1970, there were 20 such programs. This growth in graduate nursing education allowed nurse scholars to debate ideas, viewpoints, and research methods in the nursing literature. As a result, nurses began to question the ideas that were taken for granted in nursing and the traditional basis in which nursing was practiced.

Constructed Knowledge Stage

During the late 1980s, scholars began to concentrate on theories that provide meaningful foundation for nursing practice. There was a call to develop substance in theory and to focus on nursing concepts grounded in practice and linked to research. The 1990s into the early 21st century saw an increasing emphasis on philosophy and philosophy of science in nursing. Attention shifted from grand theories to middle range theories, as well as application of theory in research and practice.

In the 1990s, the idea of evidence-based practice (EBP) was introduced into nursing to address the widespread recognition of the need to move beyond attention given to research per se, in order to address the gap in research and practice. The “evidence” is research that has been completed and published (LoBiondo-Wood & Haber, 2010). Ostensibly, EBP promotes employment of theory-based, research-derived evidence to guide nursing practice.

During this period, graduate education in nursing continued to grow rapidly, particularly among programs that produced advanced practice nurses (APNs). A seminal event during this time was the introduction of the doctor of nursing practice (DNP). The DNP was initially proposed by the American Association of Colleges of Nursing (AACN) in 2004 to be the terminal degree for APNs. The impetus for the DNP was based on recognition of the need for expanded competencies due to the increasing complexity of clinical practice, enhanced knowledge to improve nursing practice and outcomes, and promotion of leadership skills (American Association of Colleges of Nursing [AACN], 2004).

Integrated Knowledge Stage

More recently, development of nursing knowledge shifted to a trend that blends and uses a variety of processes to achieve a given research aim as opposed to adherence to strict, accepted methodologies (Chinn & Kramer, 2011). In the second decade of the 21st century, there has been significant attention to the need to direct nursing knowledge development toward clinical relevance, to address what Risjord (2010) terms the “relevance gap.” Indeed, as Risjord states, and virtually all nursing scholars would agree, “the primary goal … of nursing research is to produce knowledge that supports practice” (p. 4). But he continues to note that in reality, a significant portion of research supports practice imperfectly, infrequently, and often insignificantly.

In the current stage of knowledge development, considerable focus in nursing science has been on integration of knowledge into practice, largely with increased attention on EBP and translational research (Chinn & Kramer, 2011). Indeed, it is widely accepted that systematic review of research from a variety of health disciplines, often in the form of meta-analyses, should be undertaken to inform practice and policy making in nursing (Schmidt & Brown, 2012; Melnyk & Fineout-Overholt, 2011). Further, this involves or includes application of evidence from across all health-related sciences (i.e., translational research).

Translational research was designated a priority initiative by the National Institute of Health in 2005 (Powers & Knapp, 2011). The idea of translational research is to close the gap between scientific discovery and translation of research into practice; the intent is to validate evidence in the practice setting (Chinn & Kramer, 2011). Translational research shifts focus to interdisciplinary efforts and integration of the perspectives of different disciplines to “a contemporary movement aimed at producing a concerted multidisciplinary effort to address recognized health disparities and care delivery inadequacies” (Powers & Knapp, 2011, p. 191).

Into the second decade of the 21st century, the number of doctoral programs in the United States continued to grow steadily, and by 2013, there were 128 doctoral programs granting a PhD in nursing (AACN, 2013b). Further, after a sometimes contentious debate, the DNP gained widespread acceptance, and by 2013, there were 123 programs granting the DNP, with more being planned (AACN, 2013a).

In this current stage of theory development in nursing, it is anticipated that there will be ongoing interest in EBP and growth of translational research. In this regard, development and application of middle range and practice theories will continue to be stressed, with attention increasing on practical/clinical application and relevance of both research and theory.

Summary of Stages of Nursing Theory Development

A number of events and individuals have had an impact on the development and utilization of theory in nursing practice, research, and education.  Table 2-3  provides a summary of significant events.

Table 2-3: Significant Events in Theory Development in Nursing

Nightingale publishes Notes on Nursing1859
American Medical Association advocates formal training for nurses1868
Teacher’s College—Columbia University—Doctorate in Education degree for nursing1920
Yale University begins the first collegiate school of nursing1924
Report by Dr. Esther Brown—“Nursing for the Future”1948
State licensure for registration becomes standard1949
Nursing Research  first published1950
H. Peplau publishes  Interpersonal  Relations in Nursing1952
University of Pittsburgh begins the first PhD program in nursing1954
Health Amendments Act passes—funds graduate nursing education1956
Process of theory development discussed among nursing scholars (works published by Abdellah, Henderson, Orlando, Wiedenbach, and others)1960–1966
First symposium on Theory Development in Nursing (published in  Nursing Research  in 1968)1967
Symposium Theory Development in Nursing1968
Dickoff, James, and Weidenbach—“Theory in a Practice Discipline” 
First Nursing Theory Conference1969
Second Nursing Theory Conference1970
Third Nursing Theory Conference1971
National League for Nursing adopts Requirement for Conceptual Framework for Nursing Curricula1972
Key articles publish in  Nursing Research  (Hardy—Theories: Components, Development, and Evaluation; Jacox—Theory Construction in Nursing; and Johnson—Development of Theory)1974
Nurse educator conferences on nursing theory1975, 1978
Advances in Nursing Science first published1979
Books written for nurses on how to critique theory, develop theory, and apply nursing theory1980s
Graduate schools of nursing develop courses on how to analyze and apply theory in nursing1980s
Research studies in nursing identify nursing theories as frameworks for study1980s
Publication of numerous books on analysis, application, evaluation, and development of nursing theories1980s
Philosophy and philosophy of science courses offered in doctoral programs1990s
Increasing emphasis on middle range and practice theories for nursing1990s
Nursing literature describes the need to establish interconnections among central nursing concepts1990s
Introduction of evidence-based practice into nursing1990s
Philosophy of Nursing  first published1999
Books published describing, analyzing, and discussing application of middle range theory and evidence-based practice2000s
Introduction of the Doctor of Nursing Practice (DNP)2004
Growing emphasis on development of situation-specific and middle range theories in nursing2010+
Sources: Bishop & Hardin (2010); Donahue, 2011; Kalisch & Kalisch (2004); Meleis (2012); Moody (1990).

Beginning in the early 1950s, efforts to represent nursing theoretically produced broad conceptualizations of nursing practice. These conceptual models or frameworks proliferated during the 1960s and 1970s. Although the conceptual models were not developed using traditional scientific research processes, they did provide direction for nursing by focusing on a general ideal of practice that served as a guide for research and education.  Table 2-4  lists the works of many of the nursing theorists and the titles and 

Table 2-4: Chronology of Publications of Selected Nursing Theorists

TheoristYearTitle of Theoretical Writings
Florence Nightingale1859Notes on Nursing
Hildegard Peplau1952Interpersonal Relations in Nursing
Virginia Henderson1955Principles and Practice of Nursing, 5th edition
 1966The Nature of Nursing: A Definition and Its Implications for Practice, Research, and Education
 1991The Nature of Nursing: Reflections After 25 Years
Dorothy Johnson1959A Philosophy of Nursing
 1980The Behavioral System Model for Nursing
Faye Abdellah1960Patient-Centered Approaches to Nursing
 19682nd edition
Ida Jean Orlando1961The Dynamic Nurse–Patient Relationship
Ernestine Wiedenbach1964Clinical Nursing: A Helping Art
Lydia E. Hall1964Nursing: What Is It?
Joyce Travelbee1966Interpersonal Aspects of Nursing
 19712nd edition
Myra E. Levine1967The Four Conservation Principles of Nursing
 1973Introduction to Clinical Nursing
 1989The Conservation Principles: Twenty Years Later
Martha Rogers1970An Introduction to the Theoretical Basis of Nursing
 1980Nursing: A Science of Unitary Man
 1983Science of Unitary Human Being: A Paradigm for Nursing
 1989Nursing: A Science of Unitary Human Beings
Dorothea E. Orem1971Nursing: Concepts of Practice
 19802nd edition
 19853rd edition
 19914th edition
 19955th edition
 20016th edition
 2011Self-Care Science, Nursing Theory and Evidence-Based Practice (Taylor & Renpenning)
Imogene M. King1971Toward a Theory for Nursing: General Concepts of Human Behavior
 1981A Theory for Nursing: Systems, Concepts, Process
 1989King’s General Systems Framework and Theory
Betty Neuman1974The Betty Neuman Health-Care Systems Model: A Total Person Approach to Patient Problems
 1982The Neuman Systems Model
 19892nd edition
 19953rd edition
 20024th edition
 20115th edition
Evelyn Adam1975A Conceptual Model for Nursing
 1980To Be a Nurse
 19912nd edition
Callista Roy1976Introduction to Nursing: An Adaptation Model
 1980The Roy Adaptation Model
 1984Introduction to Nursing: An Adaptation Model, 2nd edition
 1991The Roy Adaptation Model
 19992nd edition
 20093rd edition
Josephine Paterson and Loretta Zderad1976Humanistic Nursing
Jean Watson1979Nursing: The Philosophy and Science of Caring
 1985Nursing: Human Science and Human Care
 1989Watson’s Philosophy and Theory of Human Caring in Nursing
 1999Human Science and Human Care
 20122nd edition
Margaret A. Newman1979Theory Development in Nursing
1983Newman’s Health Theory
 1986Health as Expanding Consciousness
 20002nd edition
Madeleine Leininger1980Caring: A Central Focus of Nursing and Health Care Services
 1988Leininger’s Theory of Nursing: Cultural Care Diversity and Universality
 2001Culture Care Diversity and Universality
 20062nd edition
Joan Riehl Sisca1980The Riehl Interaction Model
 19892nd edition
Rosemary Parse1981Man-Living-Health: A Theory for Nursing
 1985Man-Living-Health: A Man-Environment Simultaneity Paradigm
 1987Nursing Science: Major Paradigms, Theories, Critiques
 1989Man-Living-Health: A Theory of Nursing
 1999Illuminations: The Human Becoming Theory in Practice and Research
Joyce Fitzpatrick1983A Life Perspective Rhythm Model
 19892nd edition
Helen Erickson et al.1983Modeling and Role Modeling
Nancy Roper, Winifred Logan, and Alison Tierney1983A Model for Nursing
1983The Roper/Logan/Tierney Model for Nursing
 1996The Elements of Nursing: A Model for Nursing Based on a Model of Living
 2000The Roper/Logan/Tierney Model for Nursing
Patricia Benner and Judith Wrubel1984From Novice to Expert: Excellence and Power in Clinical Nursing Practice
1989The Primacy of Caring: Stress and Coping in Health and Illness
Anne Boykin and Savina Schoenhofer1993Nursing as Caring
20012nd edition
Barbara Artinian1997The Intersystem Model: Integrating Theory and Practice
 20112nd edition
Brendan2010Person-Centred Nursing: Theory and Practice
McCormack and Tanya McCance  
Sources: Chinn & Kramer (2011); Hickman (2011); Hilton (1997).

Classification of Theories in Nursing

Over the last 40 years, a number of methods for classifying theory in nursing have been described. These include classification based on range/scope or abstractness (grand or macrotheory to practice or situation-specific theory) and type or purpose of the theory (descriptive, predictive, or prescriptive theory). Both of these classification schemes are discussed in the following sections.

Scope of Theory

One method for classification of theories in nursing that has become common is to differentiate theories based on scope, which refers to complexity and degree of abstraction. The scope of a theory includes its level of specificity and the concreteness of its concepts and propositions. This classification scheme typically uses the terms  metatheory , philosophy, or  worldview  to describe the philosophical basis of the discipline; grand theory or macrotheory to describe the comprehensive conceptual frameworks;  middle range or midrange theory to describe frameworks that are relatively more focused than the grand theories; and situation-specific theory, practice theory, or microtheory to describe those smallest in scope (Higgins & Moore, 2000; Peterson, 2013). Theories differ in complexity and scope along a continuum from practice or situation-specific theories to grand theories.  Figure 2-1  compares the scope of nursing theory by level of abstractness.


Metatheory refers to a theory about theory. In nursing, metatheory focuses on broad issues such as the processes of generating knowledge and theory development, and it is a forum for debate within the discipline (Chinn & Kramer, 2011; Powers & Knapp, 2011). Philosophical and methodologic issues at the metatheory or worldview level include identifying the purposes and kinds of theory needed for nursing, developing and analyzing methods for creating nursing theory, and proposing criteria for evaluating theory (Hickman, 2011; Walker & Avant, 2011).

Walker and Avant (2011) presented an overview of historical trends in nursing metatheory. Beginning in the 1960s, metatheory discussions involved nursing as an academic discipline and the relationship of nursing to basic sciences. Later discussions addressed the predominant philosophical worldviews (received view versus perceived view) and methodologic issues related to research (see Chapter 1 ). Recent metatheoretical issues relate to the philosophy of nursing and address what levels of theory development are needed for nursing practice, research, and education (i.e., grand theory versus middle range and practice theory) and the increasing focus on the philosophical perspectives of critical theory, postmodernism, and feminism.

Grand Theories

Grand theories are the most complex and broadest in scope. They attempt to explain broad areas within a discipline and may incorporate numerous other theories. The term macrotheory is used by some authors to describe a theory that is broadly conceptualized and is usually applied to a general area of a specific discipline (Higgins & Moore, 2000; Peterson, 2013).

Grand theories are nonspecific and are composed of relatively abstract concepts that lack operational definitions. Their propositions are also abstract and are not generally amenable to testing. Grand theories are developed through thoughtful and insightful appraisal of existing ideas as opposed to empirical research (Fawcett & DeSanto-Madeya, 2013). The majority of the nursing conceptual frameworks (e.g., Orem, Roy, and Rogers) are considered to be grand theories.  Chapters 6  through  9  discuss many of the grand nursing theories.

Middle Range Theories

Middle range theory lies between the grand nursing models and more circumscribed, concrete ideas (practice or situation-specific theories). Middle range theories are substantively specific and encompass a limited number of concepts and a limited aspect of the real world. They are composed of relatively concrete concepts that can be operationally defined and relatively concrete propositions that may be empirically tested (Higgins & Moore, 2000; Peterson, 2013; Whall, 2005).

A middle range theory may be (1) a description of a particular phenomenon, (2) an explanation of the relationship between phenomena, or (3) a prediction of the effects of one phenomenon or another (Fawcett & DeSanto-Madeya, 2013). Many investigators favor working with propositions and theories characterized as middle range rather than with conceptual frameworks because they provide the basis for generating testable hypotheses related to particular nursing phenomena and to particular client populations (Chinn & Kramer, 2011; Ketefian & Redman, 1997). The number of middle range theories developed and used by nurses has grown significantly over the past two decades. Examples include social support, quality of life, and health promotion.  Chapters 10  and  11  describe middle range theory in more detail.

Practice Theories

Practice theories are also called  situation-specific theories  prescriptive theories , or microtheories and are the least complex. Practice theories are more specific than middle range theories and produce specific directions for practice (Higgins & Moore, 2000; Peterson, 2013; Whall, 2005). They contain the fewest concepts and refer to specific, easily defined phenomena. They are narrow in scope, explain a small aspect of reality, and are intended to be prescriptive. They are usually limited to specific populations or fields of practice and often use knowledge from other disciplines (McKenna, 1993). Examples of practice theories developed and used by nurses are theories of postpartum depression, infant bonding, and oncology pain management.  Chapters 12  and  18  present additional information on practice theories.

Type or Purpose of Theory

In their seminal work, Dickoff and James (1968) defined theories as intellectual inventions designed to describe, explain, predict, or prescribe phenomena. They described four kinds of theory, each of which builds on the other. These are:

·  Factor-isolating theories (descriptive theories)

·  Factor-relating theories (explanatory theories)

·  Situation-relating theories (predictive theories or promoting or inhibiting theories)

·  Situation-producing theories (prescriptive theories)

Dickoff and James (1968) stated that nursing as a profession should go beyond the level of descriptive or explanatory theories and attempt to attain the highest levels—that of situation-relating/predictive and situation-producing/prescriptive theories.

FIGURE 2-1: Comparison of the scope of nursing theories.


Metatheory refers to a theory about theory. In nursing, metatheory focuses on broad issues such as the processes of generating knowledge and theory development, and it is a forum for debate within the discipline (Chinn & Kramer, 2011; Powers & Knapp, 2011). Philosophical and methodologic issues at the metatheory or worldview level include identifying the purposes and kinds of theory needed for nursing, developing and analyzing methods for creating nursing theory, and proposing criteria for evaluating theory (Hickman, 2011; Walker & Avant, 2011).

Walker and Avant (2011) presented an overview of historical trends in nursing metatheory. Beginning in the 1960s, metatheory discussions involved nursing as an academic discipline and the relationship of nursing to basic sciences. Later discussions addressed the predominant philosophical worldviews (received view versus perceived view) and methodologic issues related to research (see Chapter 1 ). Recent metatheoretical issues relate to the philosophy of nursing and address what levels of theory development are needed for nursing practice, research, and education (i.e., grand theory versus middle range and practice theory) and the increasing focus on the philosophical perspectives of critical theory, postmodernism, and feminism.

Descriptive (Factor-Isolating) Theories

Descriptive theories are those that describe, observe, and name concepts, properties, and dimensions. Descriptive theory identifies and describes the major concepts of phenomena but does not explain how or why the concepts are related. The purpose of descriptive theory is to provide observation and meaning regarding the phenomena. It is generated and tested by descriptive research techniques including concept analysis, case studies, literature review phenomenology, ethnography, and grounded theory (Young et al., 2001).

Examples of descriptive theories are readily found in the nursing literature. Dombrowsky and Gray (2012), for example, used the process of concept analysis to develop a conceptual model describing the experiences and contributing factors of urinary continence and incontinence. In other works, using grounded theory methodology, Kanacki, Roth, Georges, and Herring (2012) developed a theoretical model describing the experience of caring for a dying spouse, and Busby and Witucki-Brown (2011) constructed a theory describing situational awareness among emergency response providers. Lastly, Robles-Silva (2008) used ethnography to construct a conceptual model explaining the multiple phases that caregivers experience while working with poor, chronically ill adults in Mexico.

Explanatory (Factor-Relating) Theories

Factor-relating theories, or explanatory theories, are those that relate concepts to one another, describe the interrelationships among concepts or propositions, and specify the associations or relationships among some concepts. They attempt to tell how or why the concepts are related and may deal with cause and effect and correlations or rules that regulate interactions. They are developed by correlational research and increasingly through comprehensive literature review and synthesis. An example of an explanatory theory is the theory of spirituality-based nursing practice (Nardi & Rooda, 2011). This theory was developed from a mixed-method research study that surveyed senior nursing students on several aspects of awareness and application of spirituality in their practice. In other works, comprehensive literature review and synthesis were used by Reimer and Moore (2010) to develop a middle range theory explaining flight nursing expertise and by Murrock and Higgins (2009) to develop a middle range theory explaining the effects of music on improved health outcomes.

Predictive (Situation-Relating) Theories

Situation-relating theories are achieved when the conditions under which concepts are related are stated and the relational statements are able to describe future outcomes consistently. Situation-relating theories move to prediction of precise relationships between concepts. Experimental research is used to generate and test them in most cases.

Predictive theories are relatively difficult to find in the nursing literature. In one example, Cobb (2012) used a quasi-experimental, model building approach to predict the relationship between spirituality and health status among adults living with HIV. In another example, Chang, Wung, and Crogan (2008) used a quasi-experimental research design to create a theoretical model supporting an intervention designed to improve elderly nursing home resident’s ability to provide self-care. Their research validated the premise that the theory-based intervention improved performance of activities of daily living among residents in the study group compared with a control group.

Another example of a predictive theory in nursing can be found in the Caregiving Effectiveness Model. The process outlining development of this theory was described by Smith and colleagues (2002) and combined numerous steps in theory construction and empirical testing and validation. In the model, caregiving effectiveness is dependent on the interface of a number of factors including the characteristics of the caregiver, interpersonal interactions between the patient and caregiver, and the educational preparedness of the caregiver, combined with adaptive factors, such as economic stability, and the caregiver’s own health status and family adaptation and coping mechanisms. The model itself graphically details the interaction of these factors and depicts how they collectively work to impact caregiving effectiveness.

Prescriptive (Situation-Producing) Theories

Situation-producing theories are those that prescribe activities necessary to reach defined goals. Prescriptive theories address nursing therapeutics and consequences of interventions. They include propositions that call for change and predict consequences of nursing interventions. They should describe the prescription, the consequence(s), the type of client, and the conditions (Meleis, 2012).

Prescriptive theories are among the most difficult to identify in the nursing literature. One example is a work by Walling (2006) that presented a “prescriptive theory explaining medical acupuncture” for nurse practitioners. The model describes how acupuncture can be used to reduce stress and enhance well-being. In another example, Auvil-Novak (1997) described the development of a middle range theory of chronotherapeutic intervention for postsurgical pain based on three experimental studies of pain relief among postsurgical clients. The theory uses a time-dependent approach to pain assessment and provides directed nursing interventions to address postoperative pain.

Issues in Theory Development in Nursing

A number of issues related to use of theory in nursing have received significant attention in the literature. The first is the issue of borrowed versus unique theory in nursing. A second issue is nursing’s metaparadigm, and a third is the importance of the concept of caring in nursing.

Borrowed Versus Unique Theory in Nursing

Since the 1960s, the question of borrowing—or sharing—theory from other disciplines has been raised in the discussion of nursing theory. The debate over borrowed/shared theory centers in the perceived need for theory unique to nursing discussed by many nursing theorists.

The main premise held by those opposed to borrowed theory is that only theories that are grounded in nursing should guide the actions of the discipline. A second premise that supports the need for unique theory is that any theory that evolves out of the practice arena of nursing is substantially nursing. Although one might “borrow” theory and apply it to the realm of nursing actions, it is transformed into nursing theory because it addresses phenomena within the arena of nursing practice.

Opponents of using borrowed theory believe that nursing knowledge should not be tainted by using theory from physiology, psychology, sociology, and education. Furthermore, they believe “borrowing” requires returning and that the theory is not in essence nursing if concepts are borrowed (Levine, 1995; Risjord, 2010).

Proponents of using borrowed theory in nursing believe that knowledge belongs to the scientific community and to society at large, and it is not the property of individuals or disciplines (Powers & Knapp, 2011). Indeed, these individuals feel that knowledge is not the private domain of one discipline, and the use of knowledge generated by any discipline is not borrowed but shared. Further, shared theory does not lessen nursing scholarship but enhances it (Levine, 1995).

Furthermore, advocates of borrowed or shared theory believe that, like other applied sciences, nursing depends on the theories from other disciplines for its theoretical foundations. For example, general systems theory is used in nursing, biology, sociology, and engineering. Different theories of stress and adaptation are valuable to nurses, psychologists, and physicians.

In reality, all nursing theories incorporate concepts and theories shared with other disciplines to guide theory development, research, and practice. However, simply adopting concepts or theories from another discipline does not convert them into nursing concepts or theories. It is important, therefore, for theorists, researchers, and  practitioners to use concepts from other disciplines appropriately. Emphasis should be placed on redefining and synthesizing the concepts and theories according to a nursing perspective (Fawcett & DeSanto-Madeya, 2013; Levine, 1995).

Nursing’s Metaparadigm

The most abstract and general component of the structural hierarchy of nursing knowledge is what Kuhn (1977) called the metaparadigm. A metaparadigm refers “globally to the subject matter of greatest interest to member of a discipline” (Powers & Knapp, 2011, p. 107). The metaparadigm includes major philosophical orientations or worldviews of a discipline, the conceptual models and theories that guide research and other scholarly activities, and the empirical indicators that operationalize theoretical concepts (Fawcett & Malinski, 1996). The purpose or function of the metaparadigm is to summarize the intellectual and social missions of the discipline and place boundaries on the subject matter of that discipline (Kim, 1989). Fawcett and DeSanto-Madeya (2013) identified four requirements for a metaparadigm. These are summarized in  Box 2-1 .

Box 2-1: Requirements for a Metaparadigm

· 1. A metaparadigm must identify a domain that is distinctive from the domains of other disciplines … the concepts and propositions represent a unique perspective for inquiry and practice.

· 2. A metaparadigm must encompass all phenomena of interest to the discipline in a parsimonious manner … the concepts and propositions are global and there are no redundancies.

· 3. A metaparadigm must be perspective-neutral … the concepts and propositions do not represent a specific perspective (i.e., a specific paradigm or conceptual model or combination of perspectives).

· 4. A metaparadigm must be global in scope and substance … the concepts and propositions do not reflect particular national, cultural, or ethnic beliefs and values.

Adapted from: Fawcett & DeSanto-Madeya, 2013

According to Fawcett and DeSanto-Madeya (2013), in the 1970s and early 1980s, a number of nursing scholars identified a growing consensus that the dominant phenomena within the science of nursing revolved around the concepts of man (person), health, environment, and nursing. Fawcett first wrote on the central concepts of nursing in 1978 and formalized them as the metaparadigm of nursing in 1984. This articulation of four metaparadigm concepts (person, health, environment, and nursing) served as an organizing framework around which conceptual development proceeded.

Wagner (1986) examined the nursing metaparadigm in depth. Her sample of 160 doctorally prepared chairpersons, deans, or directors of programs for bachelor’s of science in nursing revealed that between 94% and 98% of the respondents agreed that the concepts that comprise the nursing metaparadigm are person, health, nursing, and environment. She concluded that these findings indicated a consensus within the discipline of nursing that these are the dominant phenomena within the science. A summary of definitions for each term is presented here.

Person  refers to a being composed of physical, intellectual, biochemical, and psychosocial needs; a human energy field; a holistic being in the world; an open system; an integrated whole; an adaptive system; and a being who is greater than the sum of his or her parts (Wagner, 1986). Nursing theories are often most distinguishable from each other by the various ways in which they conceptualize the person or recipient of nursing care. Most nursing models organize data about the individual person as a focus of the nurse’s attention, although some nursing theorists have expanded to include family or community as the focus (Thorne et al., 1998).  Health  is the ability to function independently; successful adaptation to life’s stressors; achievement of one’s full life potential; and unity of mind, body, and soul (Wagner, 1986). Health has been a phenomenon of central interest to nursing since its inception. Nursing literature indicates great diversity in the explication of health and quality of life (Thorne et al., 1998). Indeed, in a recent work, following a critical appraisal of the works of several nurse-theorists, Plummer and Molzahn (2012) suggested replacing the term “health” with “quality of life.” They posited that quality of life is a more inclusive notion, as health is often understood in terms of physical status. Alternatively, quality of life better encompasses a holistic perspective, involving physical, psychological, and social well-being, as well as the spiritual and environmental aspects of the human experience.

Environment  typically refers to the external elements that affect the person; internal and external conditions that influence the organism; significant others with whom the person interacts; and an open system with boundaries that permit the exchange of matter, energy, and information with human beings (Wagner, 1986). Many nursing theories have a narrow conceptualization of the environment as the immediate surroundings or circumstances of the individual. This view limits understanding by making the environment rigid, static, and natural. A multilayered view of the environment encourages understanding of an individual’s perspective and immediate context and incorporates the sociopolitical and economic structures and underlying ideologies that influence reality (Thorne et al., 1998).

Nursing  is a science, an art, and a practice discipline and involves caring. Goals of nursing include care of the well, care of the sick, assisting with self-care activities, helping individuals attain their human potential, and discovering and using nature’s laws of health. The purposes of nursing care include placing the client in the best condition for nature to restore health, promoting the adaptation of the individual, facilitating the development of an interaction between the nurse and the client in which jointly set goals are met, and promoting harmony between the individual and the environment (Wagner, 1986). Furthermore, nursing practice facilitates, supports, and assists individuals, families, communities, and societies to enhance, maintain, and recover health and to reduce and ameliorate the effects of illness (Thorne et al., 1998).

In addition to these definitions, many grand nursing theorists, and virtually all of the theoretical commentators, incorporate these four terms into their conceptual or theoretical frameworks.  Table 2-5 presents theoretical definitions of the metaparadigm concepts from selected nursing conceptual frameworks and other writings.

Table 2-5: Selected Theoretical Definitions of the Concepts of Nursing’s Metaparadigm

Metaparadigm ConceptAuthor/Source of DefinitionDefinition
Person/human being/clientD. JohnsonA behavioral system with patterned, repetitive, and purposeful ways of behaving that link person to the environment.
 B. NeumanA dynamic composite of the interrelationships between physiologic, psychological, sociocultural, developmental, spiritual, and basic structure variables. May be an individual, group, community, or social system.
 D. OremAre distinguished from other living things by their capacity (1) to reflect upon themselves and their environment, (2) to symbolize what they experience, and (3) to use symbolic creations (ideas, words) in thinking, in communicating, and in guiding efforts to do and to make things that are beneficial for themselves or others.
 M. RogersAn irreducible, indivisible, pan-dimensional energy field identified by pattern and manifesting characteristics that are specific to the whole and that cannot be predicted from knowledge of the parts.
NursingM. LeiningerA learned humanistic and scientific profession and discipline that is focused on human care phenomena and activities to assist, support, facilitate, or enable individuals or groups to maintain or regain their well-being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death.
 M. NewmanCaring in the human health experience.
 D. OremA specific type of human service required whenever the maintenance of continuous self-care requires the use of special techniques and the application of scientific knowledge in providing care or in designing it.
 J. WatsonA human science of persons and human health–illness experiences that are mediated by professional, personal, scientific, esthetic, and ethical human care transactions.
HealthM. LeiningerA state of well-being that is culturally defined, valued, and practiced, and that reflects the ability of individuals (or groups) to perform their daily role activities in culturally expressed, beneficial, and patterned lifeways.
 M. NewmanA pattern of evolving, expanding consciousness regardless of the form or direction it takes.
 C. RoyA state and process of being and becoming an integrated and whole person. It is a reflection of adaptation, that is, the interaction of the person and the environment.
 J. WatsonUnity and harmony within the mind, body, and soul. Health is also associated with the degree of congruence between the self as perceived and the self as experienced.
EnvironmentM. LeiningerThe totality of an event, situation, or particular experience that gives meaning to human expressions, interpretations, and social interactions in particular physical, ecologic, sociopolitical, and cultural settings.
 B. NeumanAll internal and external factors of influences that surround the client or client system.
 M. RogersAn irreducible, pan-dimensional energy field identified by pattern and integral with the human field.
 C. RoyAll conditions, circumstances, and influences that surround and affect the development and behavior of human adaptive systems with particular consideration of person and earth resources.
Sources: Johnson (1980); Leininger (1991); Neuman (1995); Newman (1990); Orem (2001); Rogers (1990); Roy & Andrews (1999); Watson (1985).

Relationships Among the Metaparadigm Concepts

The concepts of nursing’s metaparadigm have been linked in four propositions identified in the writings of Donaldson and Crowley (1978) and Gortner (1980). These are as follows:

· 1. Person and health: Nursing is concerned with the principles and laws that govern human processes of living and dying.

· 2. Person and environment: Nursing is concerned with the patterning of human health experiences within the context of the environment.

· 3. Health and nursing: Nursing is concerned with the nursing actions or processes that are beneficial to human beings.

· 4. Person, environment, and health: Nursing is concerned with the human processes of living and dying, recognizing that human beings are in a continuous relationship with their environments (Fawcett & DeSanto-Madeya, 2013, p. 6).

In addressing how the four concepts meet the requirements for a metaparadigm, Fawcett and DeSanto-Madeya (2013) explain that the first three propositions represent recurrent themes identified in the writings of Nightingale and other nursing scholars. Furthermore, the four concepts and propositions identify the unique focus of the discipline of nursing and encompass all relevant phenomena in a parsimonious manner. Finally, the concepts and propositions are perspective-neutral because they do not reflect a specific paradigm or conceptual model and they do not reflect the beliefs and values of any one country or culture.

Other Viewpoints on Nursing’s Metaparadigm

There is some dissension in the acceptance of person/health/environment/nursing as nursing’s metaparadigm. Kim (1987, 1989, 2010) identified four domains (client, client–nurse, practice, and environment) as an organizing framework or typology of nursing. In this framework, the most significant difference appears to be in placing health issues (i.e., health care experiences and health care environment) within the client domain and differentiating the nursing practice domain from the client–nurse domain. The latter focuses specifically on interactions between the nurse and the client.

Meleis (2012) maintained that nursing encompasses seven central concepts: interaction, nursing client, transitions, nursing process, environment, nursing therapeutics, and health. Addition of the concepts of interaction, transitions, and nursing process denotes the greatest difference between this framework and the more commonly described person/health/environment/nursing framework. (See Link to Practice 2-1 for another thought on expanding the metaparadigm to include social justice.)

Link to Practice 2-1: Should Social Justice Be Part of Nursing’s Metaparadigm?

Schim, Benkert, Bell, Walker, and Danford (2006) proposed that the construct of “ social justice” be added to nursing’s metaparadigm. They argued that social justice is interconnected with the four acknowledged metaparadigm concepts of nursing, person, health, and environment. In their model, social justice actually acts as the central, organizational foundation that links the other four concepts, particularly within the context of public health nursing, and more specifically in urban settings.

Using this macroperspecitve, the goal of nursing is to ensure adequate distribution of resources to benefit those who are marginalized. Suggested strategies to enhance attention to social justice in nursing include shifting to a population health and health promotion/disease prevention perspective; diversifying nursing by recruiting and educating underrepresented minorities into the profession; and engaging in political action at local, state, national and international levels. They concluded that as a caring profession, nursing should expand efforts with a social justice orientation to help ensure equal access to benefits and protections of society for all.

Caring as a Central Construct in the Discipline of Nursing

A final debate that will be discussed in this chapter centers on the place of the concept of caring within the discipline and science of nursing. This debate has been escalating over the last decade and has been motivated by the perceived urgency of identifying nursing’s unique contribution to the health care disciplines and revolves around the defining attributes and roles within the practice of nursing (Thorne et al., 1998).

The concept of caring has occupied a prominent position in nursing literature and has been touted as the essence of nursing by renowned nursing scholars, including Leininger, Watson, and Erikkson. Indeed, it has been proposed that nursing be defined as the study of caring in the human health experience (Newman, Sime, & Corcoran-Perry, 1991).

Although some theorists (i.e., Watson, Leininger, and Boykin) have gone so far as to identify caring as the essence of nursing, there is little if any rejection of caring as a central concept for nursing, although not necessarily the most significant concept. Thorne and colleagues (1998) cited three major areas of contention in the debate about caring in nursing. The first is the diverse views on the nature of caring. These range from caring as a human trait to caring as a therapeutic intervention and differ according to whether the act of caring is conceptualized as being client centered, nurse centered, or both.

A second major issue in the caring debate concerns the use of caring terminology to conceptualize a specialized role. It has been asked whether there is a compelling reason to lay claim to caring as nursing’s unique domain when so many professions describe their function as involving caring, and the concept of caring is prominent in the work of many other disciplines (e.g., medicine, social work, and psychology) (Thorne et al., 1998).

A third issue centers on the implications for the future development of the profession that nursing should espouse caring as its unique mandate. It has been observed that nurses should ask themselves if it is politically astute to be the primary interpreters of a construct that is both gendered and devalued (Meadows, 2007; Thorne et al., 1998).

Thus, it is argued by Fawcett and Malinski (1996) that although caring is included in several conceptualizations of the discipline of nursing, it is not a dominant term in every conceptualization and therefore does not represent a discipline-wide viewpoint. Furthermore, caring is not uniquely a nursing phenomenon, and caring behaviors may not be generalizable across national and cultural boundaries.


Like Matt Ng, the graduate nursing student described in the opening case study, nurses who are in a position to learn more about theory, and to recognize how and when to apply it, must often be convinced of the relevance of such study to understand the benefits. The study of theory requires exposure to many new concepts, principles, thoughts, and ideas, as well as a student who is willing to see how theory plays an important role in nursing practice, research, education, and administration.

Although study and use of theoretical concepts in nursing dates back to Nightingale, little progress in theory development was made until the 1960s. The past five decades, however, have produced significant advancement in theory development for nursing. This chapter has presented an overview of this evolutionary process. In addition, the basic types of theory and purposes of theory were described. Subsequent chapters will explain many of the ideas introduced here to assist professional nurses to understand the relationship among theory, practice, and research and to further develop the discipline, the science, and the profession of nursing.

Key Points

·  “Theory” refers to the systematic explanation of events in which constructs and concepts are identified, relationships are proposed, and predictions are made.

·  Theory offers structure and organization to nursing knowledge and provides a systematic means of collecting data to describe, explain, and predict nursing practice.

·  Florence Nightingale was the first modern nursing theorist; she described what she considered nurses’ goals and practice domain to be.

·  There has been an evolution of stages of theory development in nursing. Nursing is currently in the “integrated knowledge” stage, which emphasizes EBP and translational research. Theory development increasingly sources meta-analyses, as well as nursing research, and is largely directed toward middle range and situation-specific/practice theories.

·  Theories can be classified by scope of level of abstraction (e.g., metatheory, grand theory, middle range theory, and situation-specific theory) or by type or purpose of the theory (e.g., description, explanation, prediction, and prescription).

·  Nursing “borrows” or “shares” theories and concepts from other disciplines to guide theory development, research, and practice. It is critical that nurses redefine and synthesize these shared concept and theories according to a nursing perspective.

·  The concepts of nursing, person, environment, and health are widely accepted as the dominant phenomena in nursing; they have been identified as nursing’s metaparadigm.

Learning Activities


Examine early issues of  Nursing Research  (1950s and 1960s) and determine whether theories or theoretical frameworks were used as a basis for research. What types of theories were used? Review current issues to analyze how this has changed.


Examine early issues of American Journal of Nursing (1900–1950). Determine if and how theories were used in nursing practice. What types of theories were used? Review current issues to analyze how this has changed.


Find reports that present middle range or practice theories in the nursing literature. Identify if these theories are descriptive, explanatory, predictive, or prescriptive in nature.


Alligood, M. R. (2010). Introduction to nursing theory: Its history, significance, and analysis. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 3–15). Maryland Heights, MO: Mosby.

Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and their work (7th ed.). Maryland Heights, MO: Mosby.

American Association of Colleges of Nursing. (2004). AACN position statement on the practice doctorate in nursing. Retrieved from http://www.aacn.nche.edu/dnp/position-statement

American Association of Colleges of Nursing (2013a). CCNE-Accredited Doctor of Nursing Practice (DNP) Programs. Retrieved from http://apps.aacn.nche.edu/CCNE/reports/rptAccredited Programs_New.asp?sort=state&sProgramType=3

American Association of Colleges of Nursing. (2013b). PhD nursing programs in the U.S. Retrieved from http://www.aacn.nche.edu/membership/nursing-program-search?search=&name=&state=&category_id=9&x=19&y=8

Andrist, L. C. (2006). The history of the relationship between feminism and nursing. In L. C. Andrist, P. K. Nicholas, & K. A. Wolfe (Eds.), A history of nursing ideas. Boston: Jones & Bartlett Publishers.

Auvil-Novak, S. E. (1997). A middle range theory of chronotherapeutic intervention for postsurgical pain. Nursing Research, 46(2), 66–71.

Bishop, S. M., & Hardin, S. R. (2010). History and philosophy of science. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 16–24). St. Louis: Mosby.

Blackburn, S. (2008). Oxford dictionary of philosophy. New York: Oxford University Press.

Busby, S., & Witucki-Brown, J. (2011). Theory development for situational awareness in multi-casualty incidents. Journal of Emergency Nursing, 37(5), 444–452.

Butts, J. B., Rich, K. L., & Fawcett, J. (2012). The future of nursing: How important is discipline-specific knowledge? A conversation with Jacqueline Fawcett. Nursing Science Quarterly, 25(2), 151–154.

Chang, S. H., Wung, S. F., & Crogan, N. L. (2008). Improving activities of daily living for nursing home elder persons in Taiwan. Nursing Research, 57(3), 191–198.

Chinn, P. L., & Kramer, M. K. (2011). Integrated theory and knowledge development in nursing (8th ed.). St. Louis: Elsevier/Mosby.

Cobb, R. K. (2012). How well does spirituality predict health status in adults living with HIV-disease: A Neuman systems model study. Nursing Science Quarterly, 25(4), 347–355.

Dickoff, J., & James, P. (1968). A theory of theories: A position paper. Nursing Research, 17(3), 197–203.

Dombrowsky, T. A., & Gray, J. (2012). Continence and incontinence: A concept analysis. The Journal of Theory Construction & Testing, 16(2), 31–41.

Donahue, M. P. (2011). Nursing the finest art: An illustrated history (3rd ed.). St. Louis: Mosby.

Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26(2), 113–120.

Fawcett, J. (1992). Contemporary conceptualizations of nursing: Philosophy or science? In J. F. Kikuchi & H. Simmons (Eds.), Philosophic inquiry in nursing (pp. 64–70). Newbury Park, CA: Sage.

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). Philadelphia: F. A. Davis.

Fawcett, J., & Malinski, V. M. (1996). On the requirements for a metaparadigm: An invitation to dialogue. Nursing Science Quarterly, 9(3), 94–97, 100–101.

Gortner, S. R. (1980). Nursing science in transition. Nursing Research, 29(3), 180–183.

Hickman, J. S. (2011). An introduction to nursing theory. In J. George (Ed.), Nursing theories: The base for professional nursing practice (6th ed., pp. 1–22). Upper Saddle River, NJ: Pearson Education.

Higgins, P. A., & Moore, S. M. (2000). Levels of theoretical thinking in nursing. Nursing Outlook, 48(4), 179–183.

Hilton, P. A. (1997). Theoretical perspective of nursing: A review of the literature. Journal of Advanced Nursing, 26(6), 1211–1220.

Johnson, D. E. (1980). The behavioral system model for nursing. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed., pp. 209–216). New York: Appleton-Century-Crofts.

Kalisch, P. A., & Kalisch, B. J. (2004). The advance of American nursing (4th ed.). Philadelphia: Lippincott Williams & Wilkins.

Kanacki, L. S., Roth, P., Georges, J. M., & Herring, P. (2012). Shared presence: Caring for a dying spouse. Journal of Hospice & Palliative Care Nursing, 14(6), 414–425.

Ketefian, S., & Redman, R. W. (1997). Nursing science in the global community. Image: Journal of Nursing Scholarship, 29(1), 11–16.

Kidd, P., & Morrison, E. F. (1988). The progression of knowledge in nursing research: A search for meaning. Image: Journal of Nursing Scholarship, 20(4), 222–224.

Kim, H. S. (1987). Structuring the nursing knowledge system: A typology of four domains. Scholarly Inquiry for Nursing Practice, 1(2), 99–110.

Kim, H. S. (1989). Theoretical thinking in nursing: Problems and prospects. Recent Advances in Nursing, 24, 106–122.

Kim, H. S. (2010). The nature of theoretical thinking in nursing (3rd ed.). New York: Springer.

Kuhn, T. S. (1977). Second thought on paradigms. In F. Suppe (Ed.), The structure of scientific theory (pp. 459–482). Urbana, IL: University of Illinois Press.

Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing.

Levine, M. E. (1995). The rhetoric of nursing theory. Image: Journal of Nursing Scholarship, 27(1), 11–14.

LoBiondo-Wood, G., & Haber, J. (2010). Nursing research: Methods and critical appraisal for evidence based practice (7th ed.). St. Louis: Mosby.

"Looking for a Similar Assignment? Get Expert Help at an Amazing Discount!"