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·-• •• Fourth Edition

Nursing Theories and Nursing Practice

Nursing Theories & Nursing Practice Fourth Edition

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Nursing Theories & Nursing Practice Fourth Edition

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

Marilyn E. Parker, PhD, RN, FAAN

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Library of Congress Cataloging-in-Publication Data

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

p. ; cm. Preceded by Nursing theories and nursing practice / [edited by] Marilyn E. Parker, Marlaine C. Smith.

3rd ed. c2010. Includes bibliographical references and index. ISBN 978-0-8036-3312-4 (alk. paper) I. Smith, Marlaine C. (Marlaine Cappelli), editor. II. Parker, Marilyn E., editor. III. Title. [DNLM: 1. Nursing Theory—Biography. 2. Nurses—Biography. WY 86] RT84.5 610.7301—dc23

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Preface to the Fourth Edition

v

This book offers the perspective that nursing is a professional discipline with a body of knowl- edge that guides its practice. Nursing theories are an important part of this body of knowl- edge, and regardless of complexity or abstrac- tion, they reflect phenomena central to the discipline, and should be used by nurses to frame their thinking, action, and being in the world. As guides, nursing theories are practical in nature and facilitate communication with those we serve as well as with colleagues, stu- dents, and others practicing in health-related services. We hope this book illuminates for the readers the interrelationship between nursing theories and nursing practice, and that this un- derstanding will transform practice to improve the health and quality of life of people who are recipients of nursing care.

This very special book is intended to honor the work of nursing theorists and nurses who use these theories in their day-to-day practice. Our foremost nursing theorists have written for this book, or their theories have been de- scribed by nurses who have comprehensive knowledge of the theorists’ ideas and who have a deep respect for the theorists as people, nurses, and scholars. To the extent possible, contributing authors have been selected by theorists to write about their work. Three middle-range theories have been added to this edition of the book, bringing the total number of middle-range theories to twelve. Obviously, it was not possible to include all existing middle-range theories in this volume; how- ever, the expansion of this section illustrates the recent growth in middle-range theory de- velopment in nursing. Two chapters from the third edition, including Levine’s conservation

theory and Paterson & Zderad’s humanistic nursing have been moved to supplementary on- line resources at http://davisplus.fadavis.com.

This book is intended to help nursing stu- dents in undergraduate, masters, and doctoral nursing programs explore and appreciate nurs- ing theories and their use in nursing practice and scholarship. In addition, and in response to calls from practicing nurses, this book is in- tended for use by those who desire to enrich their practice by the study of nursing theories and related illustrations of nursing practice. The contributing authors describe theory de- velopment processes and perspectives on the theories, giving us a variety of views for the twenty-first century and beyond. Each chapter of the book includes descriptions of a theory, its applications in both research and practice, and an example that reflects how the theory can guide practice. We anticipate that this overview of the theory and its applications will lead to deeper exploration of the theory, lead- ing students to consult published works by the theorists and those working closely with the theory in practice or research.

There are six sections in the book. The first provides an overview of nursing theory and a focus for thinking about evaluating and choos- ing a nursing theory for use in practice. For this edition, the evolution of nursing theory was added to Chapter 1. Section II introduces the work of early nursing scholars whose ideas provided a foundation for more formal theory development. The nursing conceptual models and grand theories are clustered into three parts in Sections III, IV, and V. Section III contains those theories classified within the interactive-integrative paradigm, and those in

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the unitary-transformative paradigm are in- cluded in Section IV. Grand theories that are focused on the phenomena of care or caring appear in Section V. The final section contains a selection of middle-range theories.

An outline at the beginning of each chapter provides a map for the contents. Major points are highlighted in each chapter. Since this book focuses on the relationship of nursing theory to nursing practice, we invited the authors to share a practice exemplar. You will notice that some practice exemplars were writ- ten by someone other than the chapter author. In this edition the authors also provided content about research based on the theory. Because of page limitations you can find additional chapter content online at http:// davisplus.fadavis.com. While every attempt was made to follow a standard format for each of the chapters throughout the book, some of the chapters vary from this format; for exam- ple, some authors chose not to include practice exemplars.

The book’s website features materials that will enrich the teaching and learning of these nursing theories. Materials that will be helpful for teaching and learning about nursing theo- ries are included as online resources. For exam- ple, there are case studies, learning activities, and PowerPoint presentations included on both the instructor and student websites. Other online resources include additional content, more extensive bibliographies and longer biog- raphies of the theorists. Dr. Shirley Gordon and a group of doctoral students from Florida Atlantic University developed these ancillary materials for the third edition. For this edition, the ancillary materials for students and faculty were updated by Diane Gullett, a PhD candi- date at Florida Atlantic University. She devel- oped all materials for the new chapters as well as updating ancillary materials for chapters that appeared in the third edition. We are so grate- ful to Diane and Shirley for their creativity and leadership and to the other doctoral students for their thoughtful contributions to this project .

We hope that this book provides a useful overview of the latest theoretical advances of many of nursing’s finest scholars. We are grateful for their contributions to this book. As

editors we’ve found that continuing to learn about and share what we love nurtures our growth as scholars, reignites our passion and commitment, and offers both fun and frustra- tion along the way. We continue to be grateful for the enthusiasm for this book shared by many nursing theorists and contributing authors and by scholars in practice and research who bring theories to life. For us, it has been a joy to renew friendships with col- leagues who have contributed to past editions and to find new friends and colleagues whose theories enriched this edition.

Nursing Theories and Nursing Practice, now in the fourth edition, has roots in a series of nursing theory conferences held in South Florida, beginning in 1989 and ending when efforts to cope with the aftermath of Hurricane Andrew interrupted the energy and resources needed for planning and offering the Fifth South Florida Nursing Theory Conference. Many of the theorists in this book addressed audiences of mostly practicing nurses at these conferences. Two books stimulated by those conferences and published by the National League for Nursing are Nursing Theories in Practice (1990) and Patterns of Nursing Theories in Practice (1993).

For me (Marilyn), even deeper roots of this book are found early in my nursing career, when I seriously considered leaving nursing for the study of pharmacy. In my fatigue and frus- tration, mixed with youthful hope and desire for more education, I could not answer the question “What is nursing?” and could not dis- tinguish the work of nursing from other tasks I did every day. Why should I continue this work? Why should I seek degrees in a field that I could not define? After reflecting on these questions and using them to examine my nursing, I could find no one who would con- sider the questions with me. I remember being asked, “Why would you ask that question? You are a nurse; you must surely know what nurs- ing is.” Such responses, along with a drive for serious consideration of my questions, led me to the library. I clearly remember reading se - veral descriptions of nursing that, I thought, could just as well have been about social work or physical therapy. I then found nursing

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defined and explained in a book about educa- tion of nurses written by Dorothea Orem. During the weeks that followed, as I did my work of nursing in the hospital, I explored Orem’s ideas about why people need nursing, nursing’s purposes, and what nurses do. I found a fit between her ideas, as I understood them, with my practice, and I learned that I could go even further to explain and design nursing according to these ways of thinking about nursing. I discovered that nursing shared some knowledge and practices with other serv- ices, such as pharmacy and medicine, and I began to distinguish nursing from these related fields of practice. I decided to stay in nursing and made plans to study and work with Dorothea Orem. In addition to learning about nursing theory and its meaning in all we do, I learned from Dorothea that nursing is a unique discipline of knowledge and professional prac- tice. In many ways, my earliest questions about nursing have guided my subsequent study and work. Most of what I have done in nursing has been a continuation of my initial experience of the interrelations of all aspects of nursing scholarship, including the scholarship that is nursing practice. Over the years, I have been privileged to work with many nursing scholars, some of whom are featured in this book. My love for nursing and my respect for our discipline and practice have deepened, and knowing now that these values are so often shared is a singular joy.

Marlaine’s interest in nursing theory had similar origins to Marilyn’s. As a nurse pursu- ing an interdisciplinary master’s degree in pub- lic health, I (Marlaine) recognized that while all the other public health disciplines had some unique perspective to share, public health nursing seemed to lack a clear identity. In search of the identity of nursing I pursued a second master’s in nursing. At that time nurs- ing theory was beginning to garner attention, and I learned about it from my teachers and mentors Sr. Rosemary Donley, Rosemarie Parse, and Mary Jane Smith. This discovery was the answer I was seeking, and it both expanded and focused my thinking about nursing. The question of “What is nursing?” was answered for me by these theories and I couldn’t get

enough! It led to my decision to pursue my PhD in Nursing at New York University where I studied with Martha Rogers. During this same time I taught at Duquesne University with Rosemarie Parse and learned more about Man-Living-Health, which is now humanbe- coming. I conducted several studies based on Rogers’ conceptual system and Parse’s theory. At theory conferences I was fortunate to dialogue with Virginia Henderson, Hildegard Peplau, Imogene King, and Madeleine Leininger. In 1988 I accepted a faculty posi- tion at the University of Colorado when Jean Watson was Dean. The School of Nursing was guided by a caring philosophy and framework and I embraced caring as a central focus of the discipline of nursing. As a unitary scholar, I studied Newman’s theory of health as expand- ing consciousness and was intrigued by it, so for my sabbatical I decided to study it further as well as learn more about the unitary appre- ciative inquiry process that Richard Cowling was developing.

We both have been fortunate to hold faculty appointments in universities where nursing the- ory has been valued, and we are fortunate today to hold positions at the Christine E. Lynn Col- lege of Nursing at Florida Atlantic University, where faculty and students ground their teach- ing scholarship and practice on caring theories, including nursing as caring, developed by Dean Anne Boykin and a previous faculty member at the College, Savina Schoenhofer. Many faculty colleagues and students continue to help us study nursing and have contributed to this book in ways we would never have adequate words to acknowledge. We are grateful to our knowl- edgeable colleagues who reviewed and offered helpful suggestions for chapters of this book, and we sincerely thank those who contributed to the book as chapter authors. It is also our good fortune that many nursing theorists and other nursing scholars live in or visit our lovely state of Florida. Since the first edition of this book was published, we have lost many nursing theorists. Their work continues through those refining, modifying, testing, and expanding the theories. The discipline of nursing is expanding as research and practice advances existing theories and as new theories emerge. This is especially

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important at a time when nursing theory can provide what is missing and needed most in health care today.

All four editions of this book have been nur- tured by Joanne DaCunha, an expert nurse and editor for F. A. Davis Company, who has shep- herded this project and others because of her love of nursing. Near the end of this project Joanne retired, and Susan Rhyner, our new ed- itor, led us to the finish line. We are both grate- ful for their wisdom, kindness, patience and understanding of nursing. We give special thanks to Echo Gerhart, who served as our con- tact and coordinator for this project. Marilyn thanks her husband, Terry Worden, for his abiding love and for always being willing to help,

and her niece, Cherie Parker, who represents many nurses who love nursing practice and scholarship and thus inspire the work of this book. Marlaine acknowledges her husband Brian and her children, Kirsten, Alicia, and Brady, and their spouses, Jonathan Vankin and Tori Rutherford, for their love and understand- ing. She honors her parents, Deno and Rose Cappelli, for instilling in her the love of learning, the value of hard work, and the importance of caring for others, and dedicates this book to her granddaughter Iyla and the new little one who is scheduled to arrive as this book is released.

Marilyn E. Parker, Marlaine C. Smith, Olathe, Kansas Boca Raton, Florida

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Nursing Theorists

ix

Elizabeth Ann Manhart Barrett, PhD, RN, FAAN Professor Emerita Hunter College City University of New York New York, New York Charlotte D. Barry, PhD, RN, NCSN, FAAN Professor of Nursing Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida Anne Boykin, PhD, RN* Dean and Professor Emerita Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN,

HWNC-BC Co-Director, International Nurse Coach

Association Core Faculty, Integrative Nurse Coach

Certificate Program Miami, Florida Joanne R. Duffy, PhD, RN, FAAN Endowed Professor of Research and

Evidence-based Practice and Director of the PhD Program

West Virginia University Morgantown, West Virginia Helen L. Erickson* Professor Emerita University of Texas at Austin Austin, Texas Lydia Hall†

Virginia Henderson†

Dorothy Johnson†

Imogene King†

Katharine Kolcaba, PhD, RN Associate Professor Emeritus Adjunct The University of Akron Akron, Ohio Madeleine M. Leininger†

Patricia Liehr, PhD, RN Professor Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida Rozzano C. Locsin, PhD, RN Professor Emeritus Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida Afaf I. Meleis, PhD, DrPS(hon), FAAN Professor of Nursing and Sociology University of Pennsylvania Philadelphia, Pennsylvania Betty Neuman, PhD, RN, PLC, FAAN Beverly, Ohio Margaret Newman, RN, PhD, FAAN Professor Emerita University of Minnesota College of Nursing Saint Paul, Minnesota Dorothea E. Orem†

Ida Jean Orlando (Pelletier)†

Marilyn E. Parker, PhD, RN, FAAN Professor Emerita Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

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Rosemarie Rizzo Parse, PhD, FAAN Distinguished Professor Emeritus Marcella Niehoff School of Nursing Loyola University Chicago Chicago, Illinois Hildegard Peplau†

Marilyn Anne Ray, PhD, RN, CTN Professor Emerita Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida Pamela G. Reed, PhD, RN, FAAN Professor University of Arizona Tucson, Arizona Martha E. Rogers†

Sister Callista Roy, PhD, RN, FAAN Professor and Nurse Theorist William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts Savina O. Schoenhofer, PhD, RN Professor of Nursing University of Mississippi Oxford, Mississippi Marlaine C. Smith, PhD, RN, AHN-BC, FAAN Dean and Helen K. Persson Eminent Scholar Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Mary Jane Smith, PhD, RN Professor West Virginia University Morgantown, West Virginia Mary Ann Swain, PhD Professor and Director, Doctoral Program Decker School of Nursing Binghamton University Binghamton, New York Kristen M. Swanson, PhD, RN, FAAN Dean Seattle University Seattle, Washington Evelyn Tomlin*

Joyce Travelbee†

Meredith Troutman-Jordan, PhD, RN Associate Professor University of North Carolina Chapel Hill, North Carolina Jean Watson, PhD, RN, AHN-BC, FAAN Distinguished Professor Emeritus University of Colorado at Denver—Anschutz

Campus Aurora, Colorado Ernestine Wiedenbach†

x Nursing Theorists

*Retired †Deceased

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Contributors

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Patricia Deal Aylward, MSN, RN, CNS Assistant Professor Santa Fe Community College Gainesville, Florida

Howard Karl Butcher, PhD, RN, PMHCNS-BC Associate Professor University of Iowa Iowa City, Iowa

Lynne M. Hektor Dunphy, PhD, APRN-BC Associate Dean for Practice and Community

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

Laureen M. Fleck, PhD, FNP-BC, FAANP Associate Faculty Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Maureen A. Frey, PhD, RN*

Shirley C. Gordon, PhD, RN Professor and Assistant Dean Graduate Practice

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

*Retired.

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xii Contributors

Diane Lee Gullett, RN, MSN, MPH Doctoral Candidate Christine E. Lynn College of NursingFlorida

Atlantic University Boca Raton, Florida

Donna L. Hartweg, PhD, RN Professor Emerita and Former Director Illinois Wesleyan University Bloomington, Illinois

Bonnie Holaday, PhD, RN, FAAN Professor Clemson University Clemson, South Carolina

Beth M. King, PhD, RN, PMHCNS-BC Assistant Professor and RN-BSN Coordinator Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Lois White Lowry, DNSc, RN* Professor Emerita East Tennessee State University Johnson City, Tennessee

Violet M. Malinski, PhD, MA, RN Associate Professor College of New Rochelle New Rochelle, New York

Mary B. Killeen, PhD, RN, NEA-BC Consultant Evidence Based Practice Nurse Consultants,

LLC Howell, Michigan

Ann R. Peden, RN, CNS, DSN Professor and Chair Capital University Columbus, Ohio

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Contributors xiii

Margaret Dexheimer Pharris, PhD, RN, CNE, FAAN Associate Dean for Nursing St. Catherine University St. Paul, Minnesota

Maude Rittman, PhD, RN Associate Chief of Nursing Service for Research Gainesville Veteran’s Administration

Medical Center Gainesville, Florida

Christina L. Sieloff, PhD, RN Associate Professor Montana State University Billings, Montana

Jacqueline Staal, MSN, ARNP, FNP-BC PhD Candidate Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Marian C. Turkel, PhD, RN, NEA-BC, FAAN Director of Professional Nursing Practice Holy Cross Medical Center Fort Lauderdale, Florida

Pamela Senesac, PhD, SM, RN Assistant Professor University of Massachusetts Shrewsbury, Massachusetts

Hiba Wehbe-Alamah, PhD, RN, FNP-BC, CTN-A Associate Professor University of Michigan-Flint Flint, Michigan

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xiv Contributors

Terri Kaye Woodward, MSN, RN, CNS, AHN-BC, HTCP Founder Cocreative Wellness Denver, Colorado

Kelly White, RN, PhD, FNP-BC Assistant Professor South University West Palm Beach, Florida

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Reviewers

xv

Ferrona Beason, PhD, ARNP Assistant Professor in Nursing Barry University – Division of Nursing Miami Shores, Florida Abimbola Farinde, PharmD, MS Clinical Pharmacist Specialist Clear Lake Regional Medical Center Webster, Texas Lori S. Lauver, PhD, RN, CPN, CNE Associate Professor Jefferson School of Nursing Thomas Jefferson University Philadelphia, Pennsylvania Elisheva Lightstone, BScN, MSc Professor Department of Nursing Seneca College King City, Ontario, Canada

Carol L. Moore, PhD, APRN, CNS Assistant Professor of Nursing, Coordinator,

Graduate Nursing Studies Fort Hays State University Hays, Kansas Kathleen Spadaro, PhD, PMHCNS, RN MSN Program Co-coordinator & Assistant

Professor of Nursing Chatham University Pittsburgh, Pennsylvania

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Contents

xvii

Section I An Introduction to Nursing Theory, 1

Chapter 1 Nursing Theory and the Discipline of Nursing, 3 Marlaine C. Smith and Marilyn E. Parker

Chapter 2 A Guide for the Study of Nursing Theories for Practice, 19 Marilyn E. Parker and Marlaine C. Smith

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

Marilyn E. Parker and Marlaine C. Smith

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

Chapter 4 Florence Nightingale’s Legacy of Caring and Its Applications, 37 Lynne M. Hektor Dunphy

Chapter 5 Early Conceptualizations About Nursing, 55 Shirley C. Gordon

Chapter 6 Nurse-Patient Relationship Theories, 67 Ann R. Peden, Jacqueline Staal, Maude Rittman, and Diane Lee Gullett

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

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

Bonnie Holaday

Chapter 8 Dorothea Orem’s Self-Care Deficit Nursing Theory, 105 Donna L. Hartweg

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Chapter 9 Imogene King’s Theory of Goal Attainment, 133 Christina L. Sieloff and Maureen A. Frey

Chapter 10 Sister Callista Roy’s Adaptation Model, 153 Pamela Sensac and Sister Callista Roy

Chapter 11 Betty Neuman’s Systems Model, 165 Lois White Lowry and Patricia Deal Aylward

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

Helen L. Erickson

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

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

Chapter 14 Martha E. Rogers Science of Unitary Human Beings, 237 Howard Karl Butcher and Violet M. Malinski

Chapter 15 Rosemarie Rizzo Parse’s Humanbecoming Paradigm, 263 Rosemarie Rizzo Parse

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

Margaret Dexheimer Pharris

Section V Grand Theories about Care or Caring, 301

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

Hiba Wehbe-Alamah

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

Chapter 19 Theory of Nursing as Caring, 341 Anne Boykin and Savina O. Schoenhofer

Section VI Middle-Range Theories, 357

Chapter 20 Transitions Theory, 361 Afaf I. Meleis

xviii Contents

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Chapter 21 Katharine Kolcaba’s Comfort Theory, 381 Katharine Kolcaba

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

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

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

Chapter 25 The Community Nursing Practice Model, 435 Marilyn E. Parker, Charlotte D. Barry. and Beth M. King

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

Rozzano C. Locsin

Chapter 27 Marilyn Anne Ray’s Theory of Bureaucratic Caring, 461 Marilyn Anne Ray and Marian C. Turkel

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

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

Elizabeth Ann Manhart Barrett

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

Chapter 31 Kristen Swanson’s Theory of Caring, 521 Kristen M. Swanson

Index, 533

Contents xix

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Section I An Introduction to Nursing Theory

1

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2

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

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

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

Section

I An Introduction to Nursing Theory

2

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Chapter 1Nursing Theory and the Discipline of Nursing

MARLAINE C. SMITH AND MARILYN E. PARKER

The Discipline of Nursing Definitions of Nursing Theory

The Purpose of Theory in a Professional Discipline

The Evolution of Nursing Science The Structure of Knowledge in the

Discipline of Nursing Nursing Theory and the Future

Summary References

Marilyn E. ParkerMarlaine C. Smith

3

What is nursing? At first glance, the question may appear to be one with an obvious an- swer, but when it is posed to nurses, many define nursing by providing a litany of func- tions and activities. Some answer with the elements of the nursing process: assessing, planning, implementing, and evaluating. Oth- ers might answer that nurses coordinate a patient’s care.

Defining nursing in terms of the nursing process or by functions or activities nurses per- form is problematic. The phases of the nursing process are the same steps we might use to solve any problem we encounter, from a bro- ken computer to a failing vegetable garden. We assess the situation to determine what is going on and then identify the problem; we plan what to do about it, implement our plan, and then evaluate whether it works. The nurs- ing process does nothing to define nursing.

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

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and family members might change dressings, monitor vital signs, and administer medications, so defining nursing based solely on functions or activities performed is not useful.

To answer the question “What is nursing?” we must formulate nursing’s unique identity as a field of study or discipline. Florence Nightingale is credited as the founder of mod- ern nursing, the one who articulated its dis- tinctive focus. In her book Notes on Nursing: What It Is and What It Is Not (Nightingale, 1859/1992), she differentiated nursing from medicine, stating that the two were distinct practices. She defined nursing as putting the person in the best condition for nature to act, insisting that the focus of nursing was on health and the natural healing process, not on disease and reparation. For her, creating an environment that provided the conditions for natural healing to occur was the focus of nurs- ing. Her beginning conceptualizations were the seeds for the theoretical development of nursing as a professional discipline.

In this chapter, we situate the understand- ing of nursing theory within the context of the discipline of nursing. We define the dis- cipline of nursing, describe the purpose of theory for the discipline of nursing, review the evolution of nursing science, identify the structure of the discipline of nursing, and speculate on the future place of nursing the- ory in the discipline.

The Discipline of Nursing Every discipline has a unique focus that directs the inquiry within it and distinguishes it from other fields of study (Smith, 2008, p. 1). Nurs- ing knowledge guides its professional practice; therefore, it is classified as a professional disci- pline. Donaldson and Crowley (1978) stated that a discipline “offers a unique perspective, a distinct way of viewing . . . phenomena, which ultimately defines the limits and nature of its inquiry” (p. 113). Any discipline includes net- works of philosophies, theories, concepts, ap- proaches to inquiry, research findings, and practices that both reflect and illuminate its dis- tinct perspective. The discipline of nursing is formed by a community of scholars, including

nurses in all nursing venues, who share a commitment to values, knowledge, and processes to guide the thought and work of the discipline.

The classic work of King and Brownell (1976) is consistent with the thinking of nurs- ing scholars (Donaldson & Crowley, 1978; Meleis, 1977) about the discipline of nursing. These authors have elaborated attributes that characterize all disciplines. As you will see in the discussion that follows, the attributes of King and Brownell provide a framework that contextualizes nursing theory within the dis- cipline of nursing.

Expression of Human Imagination Members of any discipline imagine and create structures that offer descriptions and explana- tions of the phenomena that are of concern to that discipline. These structures are the theories of that discipline. Nursing theory is dependent on the imagination of nurses in practice, ad- ministration, research, and teaching, as they create and apply theories to improve nursing practice and ultimately the lives of those they serve. To remain dynamic and useful, the dis- cipline requires openness to new ideas and in- novative approaches that grow out of members’ reflections and insights.

Domain A professional discipline must be clearly defined by a statement of its domain—the boundaries or focus of that discipline. The do- main of nursing includes the phenomena of in- terest, problems to be addressed, main content and methods used, and roles required of the discipline’s members (Kim, 1997; Meleis, 2012). The processes and practices claimed by members of the disciplinary community grow out of these domain statements. Nightingale provided some direction for the domain of the discipline of nursing. Although the discipli- nary focus has been debated, there is some degree of consensus. Donaldson and Crowley (1978, p. 113) identified the following as the domain of the discipline of nursing: 1. Concern with principles and laws that

govern the life processes, well-being, and

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optimal functioning of human beings, sick or well

2. Concern with the patterning of human behavior in interactions with the environ- ment in critical life situations

3. Concern with the processes through which positive changes in health status are affected Fawcett (1984) described the metapara-

digm as a way to distinguish nursing from other disciplines. The metaparadigm is very general and 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 be- liefs held about nursing. By virtue of being nurses, all nurses have some awareness of nursing’s metaparadigm. However, because the term may not be familiar, it offers no di- rect guidance for research and practice (Kim, 1997; Walker & Avant, 1995). The metapara- digm consists of four concepts: persons, envi- ronment, health, and nursing. According to Fawcett, nursing is the study of the interrela- tionship among these four concepts.

Modifications and alternative concepts for this framework have been explored throughout the discipline (Fawcett, 2000). For example, some nursing scholars have suggested that “caring” replace “nursing” in the metaparadigm (Stevenson & Tripp-Reimer, 1989). Kim (1987, 1997) set forth four domains: client, client–nurse encounters, practice, and environ- ment. In recent years, increasing attention has been directed to the nature of nursing’s rela- tionship with the environment (Kleffel, 1996; Schuster & Brown, 1994).

Others have defined nursing as the study of “the health or wholeness of human beings as they interact with their environment” (Donaldson & Crowley, 1978, p. 113), the life process of unitary human beings (Rogers, 1970), care or caring (Leininger, 1978; Watson, 1985), and human–universe–health interrela- tionships (Parse, 1998). A widely accepted focus statement for the discipline was published by Newman, Sime, and Corcoran-Perry (1991): “Nursing is the study of caring in the human health experience” (p. 3). A consensus

statement of philosophical unity in the disci- pline was published by Roy and Jones (2007). Statements include the following: • The human being is characterized by

wholeness, complexity, and consciousness. • The essence of nursing involves the nurse’s

true presence in the process of human- to-human engagement.

• Nursing theory expresses the values and be- liefs of the discipline, creating a structure to organize knowledge and illuminate nursing practice.

• The essence of nursing practice is the nurse– patient relationship.

In 2008, Newman, Smith, Dexheimer- Pharris, and Jones revisited the disciplinary focus asserting that relationship was central to the discipline, and the convergence of seven concepts—health, consciousness, car- ing, mutual process, presence, patterning, and meaning—specified relationship in the pro- fessional discipline of nursing. Willis, Grace, and Roy (2008) posited that the central uni- fying focus for the discipline is facilitating humanization, meaning, choice, quality of life, and healing in living and dying (p. E28). Finally, Litchfield and Jondorsdottir (2008) defined the discipline as the study of human- ness in the health circumstance. Smith (1994) defined the domain of the discipline of nurs- ing as “the study of human health and healing through caring” (p. 50). For Smith (2008), “nursing knowledge focuses on the wholeness of human life and experience and the processes that support relationship, integra- tion, and transformation” (p. 3). Nursing conceptual models, grand theories, middle- range theories, and practice theories explicate the phenomena within the domain of nurs- ing. In addition, the focus of the nursing dis- cipline is a clear statement of social mandate and service used to direct the study and prac- tice of nursing (Newman et al., 1991).

Syntactical and Conceptual Structures Syntactical and conceptual structures are essential to any discipline and are inherent in nursing theories. The conceptual structure

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delineates the proper concerns of nursing, guides what is to be studied, and clarifies ac- cepted ways of knowing and using content of the discipline. This structuṙe is grounded in the focus of the discipline. The conceptual struc- ture relates concepts within nursing theories. The syntactical structures help nurses and other professionals to 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 effect on nursing practice. In addition, these structures guide nursing’s use of knowledge in research and practice approaches developed by related disciplines. It is only by being thor- oughly grounded in the discipline’s concepts, substance, and modes of inquiry that the bound- aries of the discipline can be understood and possibilities for creativity across disciplinary 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 spe- cific to nursing. The complex concepts used in nursing scholarship and practice require lan- guage that can be specific and understood. The language of nursing theory facilitates commu- nication among members of the discipline. Expert knowledge of the discipline is often required for full understanding of the meaning of these theoretical terms.

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 elec- tronic media that have developed over cen- turies to communicate the nature of nursing knowledge and practice. Conferences and fo- rums on every aspect of nursing held through- out the world are part of this network. Nursing organizations and societies also provide critical communication links. Nursing theories are part of this heritage of literature, and those working with these theories present their work

at conferences, societies, and other communi- cation networks of the nursing discipline.

Tradition The tradition and history of the discipline is ev- ident in the study of nursing over time. There is recognition that theories most useful today often have threads of connection with ideas originating in the past. For example, many the- orists 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 and transformed as the content of the discipline and are evident in many nursing theories (Gray & Pratt, 1991).

Values and Beliefs Nursing has distinctive views of persons and strong commitments to compassionate and knowledgeable care of persons through nurs- ing. Fundamental nursing values and beliefs include a holistic view of person, the dignity and uniqueness of persons, and the call to care. There are both shared and differing values and beliefs within the discipline. The metapara- digm reflects the shared beliefs, and the para- digms reflect the differences.

Systems of Education A distinguishing mark of any discipline is the education of future and current members of the community. Nursing is recognized as a professional discipline within institutions of higher education because it has an identifiable body of knowledge that is studied, advanced, and used to underpin its practice. Students of any professional discipline study its theories and learn its methods of inquiry and practice. Nursing theories, by setting directions for the substance and methods of inquiry for the dis- cipline, should provide the basis for nursing education and the framework for organizing nursing curricula.

Definitions of Nursing Theory A theory is a notion or an idea that explains experience, interprets observation, describes

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relationships, and projects outcomes. Parsons (1949), often quoted by nursing theorists, wrote that theories help us know what we know and decide what we need to know. The- ories are mental patterns or frameworks cre- ated to help understand and create 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.

Theories are organizing structures of our re- flections, observations, projections, and infer- ences. Many describe theories as lenses because they color and shape what is seen. The same phenomena will be seen differently depending on the theoretical perspective assumed. 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 reflec- tions of understanding, guide our actions, help us set forth desired outcomes, and give evi- dence 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 on nursing theory brought definitions of theory from other disciplines to direct future work within nursing. Dickoff and James (1968, p. 198) defined theory as a “con- ceptual system or framework invented for some purpose.” Ellis (1968, p. 217) defined theory as “a coherent set of hypothetical, con- ceptual, and pragmatic principles forming a general frame of reference for a field of in- quiry.” 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 offered a more open definition of theory as a “construct that accounts for or or- ganizes some phenomenon” and simply stated that a nursing theory describes or explains nursing.

Definitions of theory emphasize its various aspects. Those developed in recent years are more open and conform to a broader concep- tion of science. The following definitions of the- ory are consistent with general ideas of theory

in nursing practice, education, administration, or research: • Theory is a set of concepts, definitions, and

propositions that project a systematic view of phenomena by designating specific inter- relationships among concepts for purposes of describing, explaining, predicting, and/or controlling phenomena (Chinn & Jacobs, 1987, p. 71).

• Theory is a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena (Chinn & Kramer, 2004, p. 268).

• 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, predict- ing, or prescribing nursing care (Meleis, 1997, p. 12).

• Nursing theory is an inductively and/or de- ductively derived collage of coherent, cre- ative, and focused nursing phenomena that frame, give meaning to, and help explain specific and selective aspects of nursing re- search and practice (Silva, 1997, p. 55).

• A theory is an imaginative grouping of knowledge, ideas, and experience that are rep - resented symbolically and seek to illuminate a given phenomenon.” (Watson, 1985, p. 1).

The Purpose of Theory in a Professional Discipline All professional disciplines have a body of knowledge consisting of theories, research, and methods of inquiry and practice. They organize knowledge, guide inquiry to advance science, guide practice and enhance the care of patients. Nursing theories addre ss the phenomena of in- terest to nursing, human beings, health, and caring in the context of the nurse–person rela- tionship1. On the basis of strongly held values and beliefs about nursing, and within con- texts of various worldviews, theories are pat- terns that guide the thinking about, being, and doing of nursing.

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1Person refers to individual, family, group, or community.

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Theories provide structures for making sense of the complexities of reality for both practice and research. Research based in nurs- ing theory is needed to explain and predict nursing outcomes essential to the delivery of nursing care that is both humane and cost- effective (Gioiella, 1996). Some conceptual structure either implicitly or explicitly directs all avenues of nursing, including nursing edu- cation and administration. Nursing theories provide concepts and designs that define the place of nursing in health care. Through theories, nurses are offered perspectives for relating with professionals from other disci- plines, who join with nurses to provide human services. Nursing has great expecta- tions of its theories. At the same time, the- ories must provide structure and substance to ground the practice and scholarship of nursing and must also be flexible and dynamic to keep pace with the growth and changes in the discipline and practice of 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 develop- ment and understanding of nursing practice. Because nursing theory exists to improve prac- tice, the test of nursing theory is a test of its usefulness in professional practice (Colley, 2003; Fitzpatrick, 1997). The work of nursing theory is moving from academia into the realm of nursing practice. Chapters in the re- maining sections of this book highlight the use of nursing theories in nursing practice.

Nursing practice is both the source and the goal of nursing theory. From the viewpoint of practice, Gray and Forsstrom (1991) suggested that theory provides nurses with different ways of looking at and assessing phenomena, ratio- nales for their practice, and criteria for evalu- ating outcomes. Many of the theories in this book have been used to guide nursing practice, stimulate creative thinking, facilitate commu- nication, and clarify purposes and processes in practice. The practicing nurse has an ethical re- sponsibility to use the discipline’s theoretical knowledge base, just as it is the nurse scholar’s ethical responsibility to develop the knowledge base specific to nursing practice (Cody, 1997,

2003). Engagement in practice generates the ideas that lead to the development of nursing theories.

At the empirical level of theory, abstract concepts are operationalized, or made concrete, for practice and research (Fawcett, 2000; Smith & Liehr, 2013). Empirical indicators provide specific examples of how the theory is experi- enced in reality; they are important for bringing theoretical knowledge to the practice level. These indicators include procedures, tools, and instruments to determine the effects of nursing practice and are essential to research and man- agement of outcomes of practice (Jennings & Staggers, 1998). The resulting data form the basis for improving the quality of nursing care and influencing health-care policy. Empirical indicators, grounded carefully in nursing con- cepts, provide clear demonstration of the utility of nursing theory in practice, research, admin- istration, and other nursing endeavors (Allison & McLaughlin-Renpenning, 1999; Hart & Foster, 1998).

Meeting the challenges of systems of care delivery and interprofessional work demands practice from a theoretical perspective. Nurs- ing’s disciplinary focus is important within the interprofessional health-care environment (Allison & McLaughlin-Renpenning, 1999); otherwise, its unique contribution to the in- terprofessional team is unclear. Nursing ac- tions reflect nursing concepts from a nursing perspective. Careful, reflective, and critical thinking are the hallmarks of expert nursing, and nursing theories should undergird these processes. Appreciation and use of nursing theory offer opportunities for successful col- laboration with colleagues from other disci- plines and provide definition for nursing’s overall contribution to health care. Nurses must know what they are doing, why they are doing it, and what the range of outcomes of nursing may be, as well as indicators for doc- umenting nursing’s effects. These theoretical frameworks serve as powerful guides for ar- ticulating, reporting, and recording nursing thought and action.

One of the assertions referred to most often in the nursing-theory literature is that theory is born of nursing practice and, after examination

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and refinement through research, must be re- turned to practice (Dickoff, James, & Wieden- bach, 1968). 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 rec- ommendations of nursing research are evalu- ated 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.

The Evolution of Nursing Science Disciplines can be classified as belonging to the sciences or humanities. In any science, there is a search for an understanding about specified phenomena through creating some organizing frameworks (theories) about the nature of those phenomena. These organizing frameworks (theories) are evaluated for their empirical accuracy through research. So sci- ence is composed of theories developed and tested through research (Smith, 1994).

The evolution of nursing as a science has occurred within the past 70 years; however, before nursing became a discipline or field of study, it was a healing art. Throughout the world, nursing emerged as a healing min- istry to those who were ill or in need of sup- port. Knowledge about caring for the sick, injured, and those birthing, dying, or expe- riencing normal developmental transitions was handed down, frequently in oral tradi- tions, and comprised folk remedies and prac- tices that were found to be effective through a process of trial and error. In most societies, the responsibility for nursing fell to women, members of religious orders, or those with spiritual authority in the community. With the ascendency of science, those who were engaged in the vocations of healing lost their authority over healing to medicine. Tradi- tional approaches to healing were marginal- ized, as the germ theory and the development of pharmaceuticals and surgical procedures were legitimized because of their grounding in science.

Although there were healers from other countries who can be acknowledged for their importance to the history of nursing, Florence Nightingale holds the title of the “mother of modern nursing” and the person responsible for setting Western nursing on a path toward scientific advancement. She not only defined nursing as “putting the person in the best con- dition for nature to act,” she also established a phenomenological focus of nursing as caring for and about the human–environment rela- tionship to health. While nursing soldiers dur- ing the Crimean War, Nightingale began to study the distribution of disease by gathering data, so she was arguably the first nurse-scientist in that she established a rudimentary theory and tested that theory through her practice and research.

Nightingale schools were established in the West at the turn of the 20th century, but Nightingale’s influence on the nursing profes- sion waned as student nurses in hospital-based training schools were taught nursing primarily by physicians. Nursing became strongly influ- enced by the “medical model” and for some time lost its identity as a distinct profession.

Slowly, nursing education moved into in- stitutions of higher learning where students were taught by nurses with higher degrees. By 1936, 66 colleges and universities had bac- calaureate programs (Peplau, 1987). Graduate programs began in the 1940s and grew signifi- cantly from the 50s through the 1970s.

The publication of the journal Nursing Re- search in 1952 was a milestone, signifying the birth of nursing as a fledgling science (Peplau, 1987). But well into the 1940s, “many text- books for nurses, often written by physicians, clergy or psychologists, reminded nurses that theory was too much for them, that nurses did not need to think but rather merely to follow rules, be obedient, be compassionate, do their ‘duty’ and carry out medical orders” (Peplau, 1987, p. 18). We’ve come a long way in a mere 70 years.

The development of nursing curricula stim- ulated discussion about the nature of nursing as distinct from medicine. In the 1950s, early nursing scholars such as Hildegard Peplau, Virginia Henderson, Dorothy Johnson, and

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Lydia Hall established the distinct character- istics of nursing as a profession and field of study. Faye Abdellah, Ida Jean Orlando, Joyce Travelbee, Ernestine Wiedenbach, Myra Levine, and Imogene King followed during the 1960s, elaborating their conceptualizations of nursing. During the early 1960s, the federally- funded Nurse Scientist Program was initiated to educate nurses in pursuit of doctoral degrees in the basic sciences. Through this program nurses received doctorates in education, soci- ology, physiology, and psychology. These grad- uates brought the scientific traditions of these disciplines into nursing as they assumed faculty positions in schools of nursing.

By the 1970s, nursing theory development became a priority for the profession and the discipline of nursing was becoming estab- lished. Martha Rogers, Callista Roy, Dorothea Orem, Betty Newman, and Josephine Pater- son and Loraine Zderad published their theo- ries and graduate students began studying and advancing these theories through research. During this time, the National League for Nursing required a theory-based curriculum as a standard for accreditation, so schools of nurs- ing were expected to select, develop, and im- plement a conceptual framework for their curricula. This propelled the advancement of theoretical thinking in nursing. (Meleis, 1992). A national conference on nursing theory and the Nursing Theory Think Tanks were formed to engage nursing leaders in dialogue about the place of theory in the evolution of nursing sci- ence. The linkages between theory, research, and philosophy were debated in the literature, and Advances in Nursing Science, the premiere journal for publishing theoretical articles, was launched.

In the 1980s additional grand theories such as Parse’s man-living-health (later changed to human becoming); Newman’s health as expanding consciousness; Leininger’s tran- scultural nursing; Erickson, Tomlinson, and Swain’s modeling and role modeling; and Watson’s transpersonal caring were dissemi- nated. Nursing theory conferences were con- vened, frequently attracting large numbers of participants. Those scholars working with the

published theories in research and practice formalized networks into organizations and held conferences. For example the Society for Rogerian Scholars held the first Rogerian Conference; the Transcultural Nursing Society was formed, and the International Association for Human Caring was formed. Some of these organizations developed journals publishing the work of scholars advancing these concep- tual models and grand theories. Metatheorists such as Jacqueline Fawcett, Peggy Chinn, and Joyce Fitzpatrick and Ann Whall published books on nursing theory, making nursing theories more accessible to students. Theory courses were established in graduate programs in nursing. The Fuld Foundation supported a series of videotaped interviews of many theo- rists, and the National League for Nursing dis- seminated videos promoting theory within nursing. Nursing Science Quarterly, a journal focused exclusively on advancing extant nurs- ing theories, published its first issue in 1988.

During the 1990s, the expansion of con- ceptual models and grand theories in nursing continued to deepen, and forces within nurs- ing both promoted and inhibited this expan- sion. The theorists and their students began conducting research and developing practice models that made the theories more visible. Regulatory bodies in Canada required that every hospital be guided by some nursing the- ory. This accelerated the development of nurs- ing theory–guided practice within Canada and the United States. The accrediting bodies of nursing programs pulled back on their require- ment of a specified conceptual framework guiding nursing curricula. Because of this, there were fewer programs guided by specific conceptualizations of nursing, and possibly fewer students had a strong grounding in the theoretical foundations of nursing. Fewer grand theories emerged; only Boykin and Schoenhofer’s nursing as caring grand theory was published during this time. Middle-range theories emerged to provide more descriptive, explanatory, and predictive models around circumscribed phenomena of interest to nurs- ing. For example, Meleis’s transition theory, Mishel’s uncertainty theory, Barrett’s power

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theory, and Pender’s health promotion model were generating interest.

From 2000 to the present, there has been accelerated development of middle-range the- ories with less interest in conceptual models and grand theories. There seems to be a de- valuing of nursing theory; many graduate pro- grams have eliminated their required nursing theory courses, and baccalaureate programs may not include the development of concep- tualizations of nursing into their curricula. This has the potential for creating generations of nurses who have no comprehension of the im- portance of theory for understanding the focus of the discipline and the diverse, rich legacy of nursing knowledge from these theoretical perspectives.

On the other hand, health-care organiza- tions have been more active in promoting at- tention to theoretical applications in nursing practice. For example, those hospitals on the magnet journey are required to select a guiding nursing framework for practice. Watson’s the- ory of caring is guiding nursing practice in a group of acute care hospitals. These hospitals have formed a consortium so that best prac- tices can be shared across settings.

Although nursing research is advancing and making a difference in people’s lives, the re- search may not be linked explicitly to theory, and probably not linked to nursing theory. This compromises the advancement of nursing sci- ence. All other disciplines teach their founda- tional theories to their students, and their scientists test or develop their theories through research.

There is a trend toward valuing theories from other disciplines over nursing theories. For example, motivational interviewing is a practice theory out of psychology that nurse re- searchers and practitioners are gravitating to in large numbers. Arguably, there are several sim- ilar nursing theoretical approaches to engaging others in health promotion behaviors that pre- ceded motivational interviewing, yet these have not been explored. Interprofessional prac- tice and interdisciplinary research are essential for the future of health care, but we do not do justice to this concept by abandoning the rich,

distinguishing features of nursing science over others.

If nursing is to advance as a science in its own right, future generations of nurses must re- spect and advance the theoretical legacy of our discipline. Scientific growth happens through cumulative knowledge development with cur- rent research building on previous findings. To survive and thrive, nursing theories must be used in nursing practice and research.

The Structure of Knowledge in the Discipline of Nursing Theories are part of the knowledge structure of any discipline. The domain of inquiry (also called the metaparadigm or focus of the disci- pline) is the foundation of the structure. The knowledge of the discipline is related to its general domain or focus. For example, knowl- edge of biology relates to the study of living things; psychology is the study of the mind; sociology is the study of social structures and behaviors. Nursing’s domain was discussed earlier and relates to the disciplinary focus statement or metaparadigm. Other levels of the knowledge structure include paradigms, conceptual models or grand theories, middle- range theories, practice theories, and research and practice traditions. These levels of nursing knowledge are interrelated; each level of devel- opment is influenced by work at other levels. Theoretical work in nursing must be dynamic; that is, it must be continually in process and useful for the purposes and work of the disci- pline. It must be open to adapting and extend- ing to guide nursing endeavors and to reflect development within nursing. Although there is diversity of opinion among nurses about the terms used to describe the levels of theory, the following discussion of theoretical develop- ment in nursing is offered as a context for further understanding nursing theory.

Paradigm Paradigm is the next level of the disciplinary structure of nursing. The notion of paradigm can be useful as a basis for understanding nursing

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knowledge. A 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. Paradigms are particular perspectives on the metaparadigm or disciplinary domain. 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. Because paradigms are broad, shared perspec- tives held by members of the discipline, they are often called “worldviews.” Kuhn set forth the view that science does not always evolve as a smooth, regular, continuing path of knowl- edge development over time, but that period- ically there are times of revolution when traditional thought is challenged by new ideas, and “paradigm shifts” occur.

Kuhn’s ideas provide a way for us to think about the development of science. Before any discipline engages in the development of theory and research to advance its knowledge, it is in a preparadigmatic period of development. Typically, this is followed by a period of time when a single paradigm emerges to guide knowledge development. Research activities initiated around this paradigm advance its the- ories. This is a time during which knowledge advances at a regular pace. At times, a new par- adigm can emerge to challenge the worldview of the existing paradigm. It can be revolution- ary, overthrowing the previous paradigm, or multiple paradigms can coexist in a discipline, providing different worldviews that guide the scientific development of the discipline.

Kuhn’s work has meaning for nursing and other scientific disciplines because of his recog- nition that science is the work of a community of scholars in the context of society. Paradigms and worldviews of nursing are subtle and pow- erful, reflecting different values and beliefs about the nature of human beings, human–en- vironment relationships, health, and caring. 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 biomedical science, developments in the nursing discipline are directed by at least two paradigms, or worldviews, outside the medical model. These are now described.

Several nursing scholars have named the ex- isting paradigms in the discipline of nursing (Fawcett, 1995; Newman et al., 1991; Parse, 1987). Parse (1987) described two paradigms: the totality and the simultaneity. The totality paradigm reflects a worldview that humans are integrated beings with biological, psychological, sociocultural, and spiritual dimensions. Humans adapt to their environments, and health and ill- ness are states on a continuum. In the simultane- ity paradigm, humans are unitary, irreducible, and in continuous mutual process with the environment (Rogers, 1970, 1992). Health is subjectively defined and reflects a process of becoming or evolving. In contrast to Parse, Newman and her colleagues (1991) identi- fied three paradigms in nursing: particulate– deterministic, integrative–interactive, and unitary– transformative. From the perspective of the particulate–deterministic paradigm, humans are known through parts; health is the absence of disease; and predictability and control are essential for health management. In the integrative–interactive paradigm, humans are viewed as systems with interrelated dimensions interacting with the environment, and change is probabilistic. The worldview of the unitary– transformative paradigm describes humans as patterned, self-organizing fields within larger patterned, self-organizing fields. Change is characterized by fluctuating rhythms of organization–disorganization toward more complex organization. Health is a reflection of this continuous change. Fawcett (1995, 2000) provided yet another model of nursing para- digms: reaction, reciprocal interaction, and si- multaneous action. In the reaction paradigm, humans are the sum of their parts, reaction is causal, and stability is valued. In the reciprocal interaction worldview, the parts are seen within the context of a larger whole, there is a reciprocal nature to the relationship with the environment, and change is based on multiple factors. Finally, the simultaneous-action worldview includes a belief that humans are known by pattern and are

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in an open ever-changing process with the environment. Change is unpredictable and evolving toward greater complexity (Smith, 2008, pp. 4–5).

It may help you to think of theories being clustered within these nursing paradigms. Many theories share the worldview established by a particular paradigm. At present, multiple paradigms coexist within nursing.

Grand Theories and Conceptual Models Grand theories and conceptual models are at the next level in the structure of the discipline. They are less abstract than the focus of the dis- cipline and paradigms but more abstract than middle-range theories. Conceptual models and grand theories focus on the phenomena of con- cern to the discipline such as persons as adaptive systems, self-care deficits, unitary human be- ings, human becoming, or health as expanding consciousness. The grand theories, or concep- tual models, are composed of concepts and re- lational statements. Relational statements on which the theories are built are called assump- tions and often reflect the foundational philoso- phies of the conceptual model or grand theory. These philosophies are statements of enduring values and beliefs; they may be practical guides for the conduct of nurses applying the theory and can be used to determine the compatibility of the model or theory with personal, profes- sional, organizational, and societal beliefs and values. Fawcett (2000) differentiated conceptual models and grand theories. For her, conceptual models, also called conceptual frameworks or conceptual systems, are sets of general concepts and propositions that provide perspectives on the major concepts of the metaparadigm: per- son, environment, health, and nursing. Fawcett (1993, 2000) pointed out that direction for re- search must be described as part of the concep- tual model to guide development and testing of nursing theories. We do not differentiate be- tween conceptual models and grand theories and use the terms interchangeably.

Middle-Range Theories Middle-range theories comprise the next level in the structure of the discipline. Robert Merton

(1968) described this level of theory in the field of sociology, stating that they are theories broad enough to be useful in complex situa- tions 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 narrower in scope than grand theories and offer an effective bridge between grand theo- ries and the description and explanation of specific nursing phenomena. They present con- cepts and propositions at a lower level of ab- straction and hold great promise for increasing theory-based research and nursing practice strategies (Smith & Liehr, 2008). Several middle-range theories are included in this book. Middle-range theories may have their foundations in a particular paradigmatic per- spective or may be derived from a grand theory or conceptual model. The literature presents a growing number of middle-range theories. This level of theory is expanding most rapidly in the discipline and represents some of the most exciting work published in nursing today. Some of these new theories are synthesized from knowledge from related disciplines and transformed through a nursing lens (Eakes, Burke, & Hainsworth, 1998; Lenz, Suppe, Gift, Pugh, & Milligan, 1995; Polk, 1997). The literature also offers middle-range nursing theories that are directly related to grand the- ories of nursing (Ducharme, Ricard, Duquette, Levesque, & Lachance, 1998; Dunn, 2004; Olson & Hanchett, 1997). Reports of nursing theory developed at this level include implica- tions for instrument development, theory test- ing through research, and nursing practice strategies.

Practice-Level Theories Practice-level theories have the most limited scope and level of abstraction and are developed for use within a specific range of nursing situa- tions. Theories developed at this level have a more direct effect on nursing practice than do more abstract theories. Nursing practice theories provide frameworks for nursing interventions/ activities and suggest outcomes and/or the effect of nursing practice. Nursing actions may be described or developed as nursing practice

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theories. Ideally, nursing practice theories are interrelated with concepts from middle-range theories or developed under the framework of grand theories. A theory developed at this level has been called a prescriptive theory (Crowley, 1968; Dickoff, James, & Wiedenbach, 1968), a situation-specific theory (Meleis, 1997), and a micro-theory (Chinn & Kramer, 2011). 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. Dialogue with expert nurses in practice can be fruitful for discovery and de- velopment of practice theory. Research find- ings on various nursing problems offer data to develop nursing practice theories. 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). The LIGHT model (Andersen & Smereck, 1989) and the atten- dant nurse caring model (Watson & Foster, 2003) are examples of the development of practice level theories.

Associated Research and Practice Traditions Research traditions are the associated meth- ods, procedures, and empirical indicators that guide inquiry related to the theory. For exam- ple, the theories of health as expanding con- sciousness, human becoming, and cultural care diversity and universality have specific associ- ated research methods. Other theories have specific tools that have been developed to measure constructs related to the theories. The practice tradition of the theory consists of the activities, protocols, processes, tools, and prac- tice wisdom emerging from the theory. Several conceptual models and grand theories have specific associated practice methods.

Nursing Theory and the Future Nursing theory is essential to the continuing evolution of the discipline of nursing. Several trends are evident in the development and use of nursing theory. First, there seems to be more agreement on the focus of the discipline of nursing that provides a meaningful direction for our study and inquiry. This disciplinary di- alogue has extended beyond the confines of Fawcett’s metaparadigm and explicates the im- portance of caring and relationship as central to the discipline of nursing (Newman et al., 2008; Roy & Jones, 2007; Willis et al., 2008). The development of new grand theories and conceptual models has decreased. Dossey’s (2008) theory of integral nursing, included in this book, is the only new theory at this level that has been developed in nearly 20 years. In- stead, the growth in theory development is at the middle-range and practice levels. There has been a significant increase in middle-range theories, and many practice scholars are work- ing on developing and implementing practice models based on grand theories or conceptual models.

Several changes in the teaching and learning of nursing theory are troubling. Many bac- calaureate programs include little nursing the- ory in their curricula. Similarly, some graduate programs are eliminating or decreasing their emphasis on nursing theory. This alarming trend deserves our attention. If nursing is to continue to thrive and to make a difference in the lives of people, our practitioners and researchers need to practice and expand knowl- edge within the structure of the discipline. As health care becomes more interprofessional, the focus of nursing becomes even more im- portant. If nurses do not learn and practice based on the knowledge of their discipline, they may be co-opted into the practice of another discipline. Even worse, another discipline could emerge that will assume practices associated with the discipline of nursing. For example, health coaching is emerging as an area of prac- tice focused on providing people with help as they make health-related changes in their lives. However, this is the practice of nursing, as articulated by many nursing theories.

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On a positive note, nursing theories are being embraced by health-care organizations to structure nursing practice. For example, organizations embarking on the journey to- ward magnet status (www.nursecredentialing .org/magnet) are required to identify a theo- retical perspective that guides nursing practice, and many are choosing existing nursing mod- els. This work has great potential to refine and extend nursing theories.

The use of nursing theory in research is in- consistent at best. Often, outcomes research is not contextualized within any theoretical perspective; however, reviewers of proposals for most funding agencies request theoretical frameworks, and scoring criteria give points for having one. This encourages theoretical think- ing and organizing findings within a broader perspective. Nurses often use theories from other disciplines instead of their own and this expands the knowledge of another discipline.

We are hopeful about the growth, continu- ing development, and expanded use of nursing theory. We hope that there will be continued growth in the development of all levels of nurs- ing theory. The students of all professional dis- ciplines study the theories of their disciplines in their courses of study. We must continue to include the study of nursing theories within our baccalaureate, master’s, and doctoral programs. Baccalaureate students need to understand the foundations for the discipline, our historical de- velopment, and the place of nursing theory in its history and future. They should learn about conceptual models and grand theories. Didactic and practice courses should reflect theoretical values and concepts so that students learn to practice nursing from a theoretical perspective. Middle-range theories should be included in the study of particular phenomena such as self- transcendence, sorrow, and uncertainty. As they prepare to become practice leaders of the disci- pline, doctor of nursing practice students should learn to develop and test nursing theory-guided models. PhD students will learn to develop and extend nursing theories in their research. New and expanded nursing specialties, such as nurs- ing informatics, call for development and use of nursing theory (Effken, 2003). New, more

open and inclusive ways to theorize about nurs- ing will be developed. These new ways will ac- knowledge the history and traditions of nursing but will move nursing forward into new realms of thinking and being. Reed (1995) noted the “ground shifting” with the reforming of philosophies of nursing science and called for a more open philosophy, grounded in nursing’s values, which connects science, philosophy, and practice. Gray and Pratt (1991, p. 454) pro- jected that nursing scholars will continue to de- velop theories at all levels of abstraction and that theories will be increasingly interdepend- ent with other disciplines such as politics, eco- nomics, and ethics. These authors expect a continuing emphasis on unifying theory and practice that will contribute to the validation of the nursing discipline. Theorists will work in groups to develop knowledge in an area of con- cern to nursing, and these phenomena of inter- est, rather than the name of the author, will define the theory (Meleis, 1992). Newman (2003) called for a future in which we transcend competition and boundaries that have been constructed between nursing theories and in- stead appreciate the links among theories, thus moving toward a fuller, more inclusive, and richer understanding of nursing knowledge.

Nursing’s philosophies and theories must increasingly reflect nursing’s values for under- standing, respect, and commitment to health beliefs and practices of cultures throughout the world. It is important to question to what extent theories developed and used in one major culture are appropriate for use in other cultures. To what extent must nursing theory be relevant in multicultural contexts? Despite efforts of many international scholarly soci- eties, how relevant are American nursing the- ories for the global community? Can nursing theories inform us about how to stand with and learn from peoples of the world? Can we learn from nursing theory how to come to know those we nurse, how to be with them, to truly listen and hear? Can these questions be recognized as appropriate for scholarly work and practice for graduate students in nursing? Will these issues offer direction for studies of doctoral students? If so, nursing theory

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will prepare nurses for humane leadership in national and global health policy. Perspec- tives of various times and worlds in relation to present nursing concerns were described by Schoenhofer (1994). Abdellah (McAuliffe, 1998) proposed an international electronic

“think tank” for nurses around the globe to di- alogue about nursing theory. Such opportuni- ties could lead nurses to truly listen, learn, and adapt theoretical perspectives to accommodate cultural variations.