Five stages in the development of nursing theory and philosophy

CHAPTER 2: 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researchers use theories and frameworks from other disciplines, whereas others believe the notion of nursing theory is outdated and ask why they should bother with theory.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

Term

Definition and Characteristics

Assumptions

Assumptions 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 theory

A borrowed theory is a theory developed in another discipline that is not adapted to the worldview and practice of nursing.

Concept

Concepts 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 framework

A 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.

Construct

Constructs 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 indicator

Empirical 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.

Epistemology

Epistemology refers to theories of knowledge or how people come to have knowledge; in nursing, it is the study of the origins of nursing knowledge.

Hypotheses

Hypotheses 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.

Knowledge

Knowledge 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.

Laws

A 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.

Metaparadigm

A 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 theory

Middle 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.

Model

Models 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).

Ontology

Ontology is concerned with the study of existence and the nature of reality.

Paradigm

A 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.

Phenomena

Phenomena are the designation of an aspect of reality; the phenomena of interest become the subject matter particular to the primary concerns of a discipline.

Philosophy

A philosophy is a statement of beliefs and values about human beings and their world.

Practice or situation-specific theory

A 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.

Praxis

Praxis is the application of a theory to cases encountered in experience.

Relationship statements

Relationship statements indicate specific relationships between two or more concepts. They may be classified as propositions, hypotheses, laws, axioms, or theorems.

Taxonomy

A taxonomy is a classification scheme for defining or gathering together various phenomena. Taxonomies range in complexity from simple dichotomies to complicated hierarchical structures.

Theory

Theory 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.

Worldview

Worldview 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

Stage

Source of Knowledge

Impact on Theory and Research

Silent knowledge

Blind obedience to medical authority

Little attempt to develop theory. Research was limited to collection of epidemiologic data.

Received knowledge

Learning through listening to others

Theories 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 knowledge

Authority 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 knowledge

Includes both separate and connected knowledge

Proliferation 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 knowledge

Combination 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 knowledge

Assimilation and application of “evidence” from nursing and other health care disciplines

Nursing 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).

RIt 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).