Nursing theory utilization and application

THEORY ASSIGNMENT

Martha Raile Alligood, PhD, RN, ANEF Professor

College of Nursing East Carolina University

Greenville, North Carolina

Nursing Theory UTILIZATION & APPLICATION

3251 Riverport Lane St. Louis, Missouri 63043

Nursing Theory: Utilization and Application, ed 5 ISBN: 978-0-323-09189-3 Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2010, 2006, 2002, 1997 by Mosby, Inc., an affiliate of Elsevier Inc.

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Library of Congress Cataloging-in-Publication Data

Nusing theory (2013) Nursing theory: utilization & application / [edited by] Martha Raile Alligood. –Fifth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-323-09189-3 (pbk.) I. Alligood, Martha Raile, editor of compilation. II. Title. [DNLM: 1. Nursing Theory. 2. Models, Nursing. 3. Philosophy, Nursing. WY 86] RT84.5610.7301–dc23 2013010390

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Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treat- ment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evalu- ating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

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http://www.elsevier.com/permissions
To my grandchildren, Hunter Kent, Charlie Nicholas, John Kent Jr.,

Raymond Charles, and Kendall Lynn Alligood, who are very special to me.

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Martha Raile Alligood, PhD, RN, ANEF Professor College of Nursing East Carolina University Greenville, North Carolina

Kimberly Bolton, PhD, WHNP-BC Chair, Graduate Studies in Nursing Associate Professor Women’s Health Care Nurse Practitioner Carson-Newman College Jefferson City, Tennessee

Debra Bournes, PhD, RN Oakville, Ontario, Canada

Janet Witucki Brown, PhD, RN, CNE Associate Professor College of Nursing University of Tennessee Knoxville, Tennessee

Karen A. Brykczynski, PhD, RN, CS, FNP Associate Professor The University of Texas Medical Branch School of Nursing at Galveston Galveston, Texas

Kaye Bultemeier, PhD, FNP-BC Assistant Professor School of Nursing Georgetown University Washington, DC

Margaret E. Erickson, PhD, RN, CNS, AHN-BC Executive Director American Holistic Nurses’ Certification

Corporation Cedar Park, Texas

Jacqueline Fawcett, PhD, DSc, FAAN Professor, Department of Nursing College of Nursing and Health Sciences University of Massachusetts–Boston Boston, Massachusetts

Kathleen M. Flaherty, PhD, CNS, RN Professor of Nursing Graduate Program Director Malone University School of Nursing and Health Sciences Canton, Ohio

Pamela J. Grace, RN, PhD, FAAN Associate Professor of Nursing and Ethics William F. Connell School of Nursing Boston College Chestnut Hill, Massachusetts

Violeta Berbiglia, EdD, RN Educational Consultant Helotes, Texas

Mary E. Gunther, PhD, RN Associate Professor College of Nursing University of Tennessee–Knoxville Knoxville, Tennessee

Contributors

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vi CONTRIBUTORS

Bonnie Holaday, DNS, RN, FAAN Professor School of Nursing Clemson University Clemson, South Carolina

D. Elizabeth Jesse, PhD, CNM Associate Professor College of Nursing East Carolina University Greenville, North Carolina

Marilyn McFarland, PhD, RN, FNP-BC, CTN-A Professor Department of Nursing School of Health Professions and Studies The University of Michigan–Flint Bay City, Michigan

Barbara A. May, PhD, RN School of Nursing Lamar University Beaumont, Texas

Molly Meighan, RNC, PhD Professor Emerita Division of Nursing Carson-Newman College Jefferson City, Tennessee

Kenneth Phillips, PhD, RN College of Nursing University of Tennessee Knoxville, Tennessee

Karen M. Schaefer, PhD, RN Associate Professor Department of Nursing College of Health Professions Temple University Philadelphia, Pennsylvania

Angela F. Wood, RN, C, NNP-BC, PhD Associate Professor Carson-Newman College Jefferson City, Tennessee

Reviewers

Karen Hessler, PhD, FNP, MSN, RN Assistant Professor College of Natural and Health Sciences University of Northern Colorado Greeley, Colorado

Linda Jensen, RN, PhD, MN Associate Professor Clarkson College Omaha, Nebraska

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The first edition of this book was developed to provide a text that demon-strated the theory-practice relationship and illustrated how theory guides nursing practice. The second edition added 10 new chapters and expanded the professional premises of the first edition. The third edition updated each chap- ter and set forth the following three areas: the explicit value of theoretical knowl- edge for professional nursing practice, the widespread recognition of middle-range theory as practice theory, and the theory utilization era as significant in nursing history. The fourth edition, like each of the previous editions, was designed to demonstrate to faculty and students how nursing philosophies, models, and theo- ries (and particularly middle-range theories) guide the critical thinking and deci- sion making of professional nursing practice and therefore is especially applicable in clinical practice courses. This updated fifth edition continues to demonstrate utility and applicability for professional nursing practice. It is useful in courses that introduce students and new nurses to the theories of the discipline of nurs- ing, as well as in those that address the nature of nursing thought and action, and those that emphasize the processes of patient care. This text illuminates the role of theory in theory-based nursing practice for nursing programs, in-service edu- cation programs for nursing staff development, and especially advanced practice nursing courses in master’s and doctor of nursing practice (DNP) programs.

Nursing Theory: Utilization & Application illustrates the role of theory for pa- tient-focused nursing. It serves as a companion text for Nursing Theorists and Their Work, eighth edition, by Martha Raile Alligood, which provides a more compre- hensive overview of the history and development of nursing’s theoretical works. As a companion text, Nursing Theory: Utilization & Application, fifth edition, leads the reader beyond an introduction to the nurse theorists and their works to an understanding of praxis, as the purpose of theory in professional nursing practice is illustrated with patient-focused care of patients. Therefore, this text exposes the structure and purpose of theory with explanations and case applications from actu- al nursing practice, written by authors with expertise in the use a particular theory in their professional practice. The content of the book is presented in three parts.

Part I, Conceptualization, provides background and context for the major premise of the text, which is the essential nature of theory application for profes- sional nursing practice. Chapter 1 sketches the history of more than a century of nursing profession development that brought us through eras of nursing history to the current theory utilization era. It is proposed that the quest for nursing knowl- edge on which to base nursing practice has been the criterion of a profession and driving force that shaped the nursing profession. Chapter 2 presents the major nursing models and theories with interpretations of “normal science” according to Kuhn’s (1970) criteria. An extensive bibliography leads the reader to research

Preface

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viii PREFACE

literature reporting theory-based nursing practice applications, with tables that il- lustrate its wide use. Chapter 3 presents philosophies, models, theories, and mid- dle-range theories and the relationship among them in a “structure of knowledge” and as critical thinking structures for the thought and action of nursing practice. A guide is presented in Chapter 3 to help students select a model to guide their prac- tice. Chapter 4 is a unique feature of this text that has been highly acclaimed. The chapter is developed by a nurse ethicist who presents the moral obligations inherent in nursing philosophies, models, and theories and theory-based nursing practice.

Part II, Application, is the “heart and soul” of the text. The 16 chapters (Chapters 5 through 20) present philosophies, models, and theories as critical thinking structures, illustrating how they guide the thought and action of nursing practice with application in case presentations. These chapters are written by advanced practice nurses with ex- pertise in clinical knowledge of the philosophy, model, or theory on which they write. Another unique feature of this text is the development of the plan of care for two cases that illustrate actual guidance by the philosophy, model, or theory with the case of “Debbie” and a case from the author’s own practice. (The theory is not applicable in Chapter 17, which presents pregnancy). Each chapter in Part II concludes with Critical Thinking Exercises. Those who use the text report many uses for the exercises, such as posting as weekly discussion threads for online theory course instruction or selecting a certain exercise for class discussion or a clinical conference. The exercises are included to provide additional experiences of application and facilitate student understanding of the unique characteristics of each philosophy, model, or theory.

Part III, Expansion, features two chapters. Chapter 21 presents areas for more theory-based nursing practice applications to be used in research and practice and documented in the nursing literature. Tables are presented that are mirror images of the tables in Chapter 2. Many of the blank areas have been filled in from literature re- porting on expanding use of theory in nursing practice. The tables point out the areas where opportunities still exist to document theory-based nursing practice. Examples of middle-range nursing theories derived from nursing models are presented, with suggestions that illustrate how the details of nursing practice combines to form the shell for middle-range nursing theory development, such as nursing actions, patient/ client population, area of practice, and nursing intervention. Chapter 22 highlights the essential nature of theory-based nursing practice for the discipline and continued professional development. This chapter addresses contemporary nursing practice is- sues of safety and quality in relation to theory use and recognizes the patterns of knowing (empirical, esthetic, ethical, personal, and sociopolitical) as types of theory.

Special Features

• Logical organization that flows: past history to present practice applications and the future

• Relates nursing thought and action to nursing praxis • Presents a chapter on moral obligations inherent in theory-based nursing

practice • Utilization of 16 nursing philosophies, models, theories, and middle-range

theories

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• Application of cases that illustrate theory-based, patient-focused nursing practice

• Comparison of nursing applications in 15 theoretical works with the case of “Debbie”

• Illustrates how knowledge structure levels address critical thinking and deci- sion making

• Critical thinking exercises at the end of application chapters foster experiential learning

• A glossary of terms provides deeper understanding for student development This fifth edition is an exciting and useful text I have developed for teaching

students how to understand and practice theory-based nursing. The current em- phasis on safety and quality makes patient-focused care and utilization of theoreti- cal works of nursing even more important for the professional practice of nursing. The role of nursing theory in praxis, critical thinking and decision making for nurs- ing practice are the hallmark of this text. Nursing faculty who want to take their students beyond learning about the theorists and contemplation of theory to its application will find that this text guides students in using nursing approaches that are clear and direct, giving guidance to achieve that quality practice outcome.

Faculty and students at all levels of nursing have reported that this text was vi- tal to increasing their understanding of theory-based practice. Faculty said that this text improved the quality of their undergraduate teaching by clarifying their com- munication about theory to students. It helped them teach students how theory guides nursing thought and action. A student in a master’s program said, “I have been a nurse for 7 years, and your text has helped me learn what it really means to be a nurse and not just a helper of physicians.” Doctoral students report that the text helped them understand the nature of middle-range theory from a knowledge structure perspective and to develop their dissertation research ideas into a testable middle-range theory. This feedback and published reviews of the text have served as evidence for me to understand the utility of the text for faculty and students of all levels of nursing. I salute them (faculty, students, and practicing nurses) in their efforts to learn nursing and improve patient care, and I offer this fifth edition for their continued growth.

Acknowledgments I would like to thank the staff at Elsevier for their work and support on this new fifth edition. This text would not be possible without the contributions of the ap- plication chapters by the expert authors. I am humbled by their knowledge and offer heartfelt thanks and appreciation to each of them. A special thank-you to Dr. Kenneth D. Phillips, who developed the case of Debbie from his practice for the first edition of the text; its usefulness continues.

Finally, I continue to thank to my colleague and mentor Ann Marriner Tomey, who many years ago saw authorship of a nursing theory textbook focused on appli- cation of theory in practice in me when I didn’t see it myself and challenged me to design this text. After I did so she invited me to be co-author/editor of Nursing Theo- rists and Their Work from the fourth through seventh editions. She has been a dear mentor and colleague and I continue to wish her the very best in her retirement.

Martha Raile Alligood

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PART I Conceptualization 1 The Nature of Knowledge Needed for Nursing Practice, 2 Martha Raile Alligood

2 Nursing Models: Normal Science for Nursing Practice, 13 Angela F. Wood

3 Philosophies, Models, and Theories: Critical Thinking Structures, 40

Martha Raile Alligood

4 Philosophies, Models, and Theories: Moral Obligations, 63 Pamela J. Grace

PART II Application Section One: Nursing Philosophies

5 Nightingale’s Philosophy in Nursing Practice, 84 Kim Bolton

6 Watson’s Philosophy and Science of Caring in Nursing Practice, 96

D. Elizabeth Jesse and Martha Raile Alligood

7 Benner’s Philosophy in Nursing Practice, 118 Karen A. Brykczynski Section Two: Nursing Models

8 Johnson’s Behavioral System Model in Nursing Practice, 138 Bonnie Holaday

9 King’s Conceptual System and Theory of Goal Attainment in Nursing Practice, 160

Mary Gunther

10 Levine’s Conservation Model in Nursing Practice, 181 Karen Moore Schaefer

11 Neuman Systems Model in Nursing Practice, 200 Kathleen M. Flaherty

12 Orem’s Self-Care Deficit Theory in Nursing Practice, 222 Violeta Ann Berbiglia

13 Rogers’ Science of Unitary Human Beings in Nursing Practice, 245

Kaye Bultemeier

Contents

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xii CONTENTS

14 Roy’s Adaptation Model in Nursing Practice, 263 Kenneth D. Phillips and Robin Harris Section Three: Nursing Theories

15 Orlando’s Nursing Process Theory in Nursing Practice, 285 Barbara A. May

16 Modeling and Role-Modeling Theory in Nursing Practice, 303 Margaret E. Erickson

17 Mercer’s Becoming a Mother Theory in Nursing Practice, 332 Molly Meighan

18 Leininger’s Theory of Culture Care Diversity and Universality in Nursing Practice, 350

Marilyn R. McFarland

19 Parse’s Theory of Humanbecoming in Nursing Practice, 368 Debra A. Bournes and Gail J. Mitchell

20 Newman’s Theory of Health as Expanding Consciousness in Nursing Practice, 394

Janet Witucki Brown and Martha Raile Alligood

PART III Expansion 21 Areas for Further Development of Theory-Based Nursing

Practice, 413 Martha Raile Alligood

22 Nursing Philosophies, Models, and Theories: A Focus on the Future, 425

Jacqueline Fawcett

Glossary, 443 Index, 449

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1

Conceptualization

The following conceptualizations provide the context for the premises of this text: • Nursing’s long search for a substantive body of knowledge led to the devel-

opment and discovery of nursing science for quality professional practice in the twenty-first century.

• Applications of conceptual models of nursing and nursing theories pro- duce evidence of “normal science” for the thought and action of profes- sional nursing practice (praxis).

• Theory utilization and application publications are increasing in all areas of nursing practice.

• Nursing’s theoretical works, philosophies, models, and theories specify approaches to practice that generate positive patient outcomes and satis- faction for practicing nurses.

• The empirical, esthetic, ethical, personal and sociopolitical knowledge needed for evidence-based nursing practice is in nursing works: philoso- phies, conceptual models, and theories.

• Nursing’s theoretical works include values that specify the moral and ethi- cal obligations inherent in the work.

• Evidence indicates that this is the “theory utilization era” of nursing his- tory.

P A R T

I

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C H A P T E R

2

1 The Nature of Knowledge Needed for Nursing Practice

Martha Raile Alligood

The systematic accumulation of knowledge is essential to progress in any profession… however, theory and practice must be constantly interactive. Theory without practice is empty and practice without theory is blind.

(Cross, 1981, p. 110)

This chapter highlights developments in nursing history that advanced nursing toward the goal of substantive knowledge for practice and recogni-tion of nursing as an academic discipline and a profession. The historical achievements by nursing leaders are reviewed in successive eras toward the chal- lenge of developing a body of substantive knowledge to guide nursing practice. The significance of these achievements may be better understood when considered in relation to the challenges the nurses faced in the eras of the twentieth century. Factors are emphasized within each era of this brief history that contributed to progress toward substantive knowledge and recognition of nursing as a discipline and a profession. In this twenty-first century, many nurses understand the vital role of conceptual and theoretical knowledge structures for quality nursing prac- tice and nursing research. We have theoretical structures that provide nurses with a patient focus and frameworks to identify and interpret patient data for evidence- based practice. Whereas nursing had been understood as an art and a science, the theory era strengthened understanding of the vital nature of coordinated thought and action in practice now referred to by many as nursing praxis. Praxis is de- scriptive of knowledge-guided action and action-guided theory (Chinn & Kramer, 2011; Kagan, 2009; Kilpatrick, 2008). This understanding of the theory, research, and practice relationships is different from earlier nursing eras, when they were

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3CHAPTER 1 The Nature of Knowledge Needed for Nursing Practice

considered separately. Today their interrelationships are better understood, that is, the vital nature of theory-research and theory-research-practice relationships. Given the challenges nursing faces today, disciplinary thought and action in the utilization of theoretical works is vital for professional nursing practice.

Early in the twentieth century nurses recognized the need to establish nursing as a profession and began the transition from vocation to profession (Alligood, 1997, 2010; Judd, Sitzman, & Davis, 2010; Kalisch & Kalisch, 2004; Meleis, 2007; Rogers, 1961). Guided by the words of Florence Nightingale and the goal of profes- sionalism, American nurses began entering academia, first in individual courses and finally in collegiate nursing programs. This movement toward professionalism provides a context to understand the eras as nursing’s march toward achievement of a body of nursing knowledge.

Despite different emphases in each era, one criterion became a constant force— the one specifying that nursing practice be guided by a body of specialized knowl- edge (Bixler & Bixler, 1959): the criterion for specialized nursing knowledge and transition from vocation to profession. Today that criterion calling for recognition of a specialized body of knowledge for nursing practice is more relevant than ever as the discipline of nursing embraces challenging changes in society and health care.

Reviewing some of the efforts that were made to address the criterion helps us understand the struggles of these eras and demonstrates how events led us back to practice as nursing’s central concern. Nursing’s answer to the question of the nature of knowledge needed for the practice of nursing is viewed as a driving force that has shaped our profession. Their drive for nursing knowledge led nurses and student nurses in directions that, although unclear and not fully understood at times, con- tributed to recognition of nursing as a learned profession.

Eras of Nursing Knowledge

As the beginning of the twentieth century drew near, nurses began to express the need for communication with other nurses to improve their practice. Signs of a na- tional consciousness for nursing may be seen in the first national gathering of nurs- es at the World’s Fair in Chicago in 1893 and in the publication of the first edition of the American Journal of Nursing (AJN), the first national organ of communication for nurses, in October 1900 (Kalisch & Kalisch, 2004). These initial efforts by nurses began the transition toward a profession. At this early time the focus was clearly on practice and on teaching the practice of nursing to students. There was recognition of the need for specialized knowledge to guide the practice of nursing from the beginning. AJN was one early symbol of nursing’s movement toward professional status, and another was their need to communicate with other nurses about their practice and about teaching nursing. With the boom of the industrial age, hospital training schools flourished as America grew, and the curriculum era of the 1900s to the 1940s followed (Judd, et al., 2010; Kalisch & Kalisch, 2004).

Curriculum Era: The 1900s to the 1940s In the curriculum era, evidence of efforts to understand what knowledge was needed for the practice of nursing led to an emphasis on curricular content and

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4 PART 1 Conceptualization

progression toward standardizing curricula. The focus of this era was evident in state activities such as the 1933 curriculum survey of New York training schools (Kalisch & Kalisch, 2004). This emphasis on what nurses needed to know to prac- tice nursing led to an expansion of curricula beyond physiological and pathophysi- ological knowledge to include social sciences, pharmacology, and formal classes on nursing procedures (Judd, et al., 2010). It is interesting to note that courses to teach content were called fundamentals, a term that means “basic essentials,” and that the term is still used in nursing education today. This early appreciation of es- sential content specific to nursing action and beyond knowledge of the illness of the patient is an observation that is pertinent to the progress of this era. The differences between the medical view of the patient and those of the nurse were obvious in these developments, as had been emphasized by Nightingale (1946).

It is also interesting to note that nursing procedures were taught in class and practiced in large wardlike rooms called “nursing arts” laboratories. Reference to the art of nursing was common in this era. In later decades, with the research and science emphasis in nursing curricula, these rooms came to be referred to as “skills or simulation labs.” The change in terminology may be related to nursing’s move- ment into colleges and universities and the transition from vocational nurse train- ing to professional nursing education with emphasis on science. The discipline of nursing is indebted to those scholars who maintained a focus on the art of nursing as science gained popularity (Judd, et al., 2010; Kalisch & Kalisch, 2004).

Nursing curricula taught mostly in diploma programs in this era became standardized and some nurses began to seek higher education courses related to nursing in colleges and universities. The idea of developing nursing programs in colleges and universities soon followed. The transition of nursing into schools of higher learning brought with it a significant change in the search for a substan- tive body of knowledge. Those nurses introduced to research process began to recognize and write about its value as an essential process for the progression toward a body of substantive knowledge (Kalisch & Kalisch, 2004), leading to the research era.

Research Era: The 1950s and the 1970s In the 1950s, research emerged as a beginning force. Nurses were encouraged to learn how to conduct research, developing the role for nurses for that specialized body of knowledge. The task of embracing this new content was so great that rather than being a means to an end it often became an end in itself. Learning to conduct research led to an emphasis on statistics and research methods introduced as new curriculum areas in baccalaureate programs. The general level of understanding was such that some thought just by conducting research, the body of knowledge would be formed as a basis for practice.

This era saw the development of scholarship and the dissemination of early research findings. Nursing Research, the first nursing research journal, was estab- lished for this purpose in 1952. In addition, two programs funded by the federal government were instituted in 1955 to prepare nurses as researchers and teachers of research—the U.S. Public Health Service predoctoral research fellowships and the Nurse Scientist Training Program (Schlotfeldt, 1992).

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5CHAPTER 1 The Nature of Knowledge Needed for Nursing Practice

This development began a major shift that affected all levels of nursing. Nurses had to consider what that change in nursing education meant with regard to their level of nursing preparation, and the question of the nature of the knowledge need- ed for nursing practice persisted.

Selection of nursing education programs for potential students was difficult at this time. Although the transition of nursing education into schools of higher learning was a key development for the nursing profession, the effects of that transi- tion are still felt today in debates about multiple levels of nursing education and the failure to establish differentiated practice.

The research and graduate education eras overlap, as other reviewers have not- ed (Judd, et al., 2010; Meleis, 2007; Styles, 1982). The developments in research in- fluenced nursing education, emphasizing graduate education with nursing research courses. Emphasis on faculty nursing scholarship during the research and graduate education eras undoubtedly contributed to their interrelationship, as well as the close ties of knowledge and research. Master’s programs were being introduced in universities across the country and nursing knowledge or concept development courses were being taught and emphasized in most programs, along with introduc- tory courses in the research process by the late 1950s and early 1970s.

Graduate Education Era: The 1950s and the 1970s During the graduate education era, curricula for master’s-level preparation were becoming standardized through accreditation that most schools were seeking by the National League for Nursing (NLN). Nurse educators came together at national meetings where accreditation criteria were approved. By the end of the 1970s, most accredited master’s programs included courses in nursing research, clinical spe- cialty practice, leadership, and concept development or nursing theory in a core curriculum organized with a nursing philosophy and conceptual or organizing framework. A major task of this era was carving out a role in health care for the master’s-prepared nurses who were graduating.

Only three nursing doctoral programs existed at the beginning of this era, and the federally funded programs established in the 1950s as a result of the post– World War II shortage of nurses were still in place. Nurses were being prepared for research and teaching roles in nursing with doctorates in education and a range of related science disciplines. The American Nurses Association (ANA) set forth the need for nursing theory development in 1965; however, there were various percep- tions among nursing leaders as to what that meant because most had advanced degrees from various disciplines and perspectives of knowledge and theory.

During this era a series of national conferences united nurses to exchange ideas and evaluate knowledge obtained from non-nursing doctoral programs that could address nursing’s knowledge-building needs. The papers and discussions from these conferences were published in Nursing Research in 1968 and 1969 and were republished by Nicoll (1986) in her first edition under the unit heading Three Land- mark Symposia (p. 91). Those conferences centered on nursing science and theory development and facilitated discussion of the application of knowledge from the various disciplines in nursing. The Nurse Scientist Training Program is noteworthy in this history because that program addressed the question of the nature of the

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6 PART 1 Conceptualization

body of nursing knowledge—that is, will nursing be based on applied knowledge from other disciplines or nursing science? Dealing with this question was a ma- jor turning point in nursing history regarding graduate nursing education because it led to the realization that the nature of knowledge needed for nursing practice was nursing knowledge. Doctoral education in nursing began to flourish, and by the late 1970s, 21 nursing doctoral programs existed and several more universities indicated intent to develop programs. A driving force in this era was the need for nursing knowledge and an awareness that the knowledge should be developed by nurses prepared in the discipline of nursing. It is not surprising that recognition of the difference between nursing knowledge and borrowed knowledge surfaced in the nursing literature at this time (Johnson, 1968). This differentiation emerged from recognition that theory from other disciplines was specific to that discipline and not specific to nursing (Johnson, 1968; Rogers, 1970). Rogers (1970) reasoned that nurses needed to clarify the phenomenon of concern for the discipline and use frameworks that addressed nursing’s phenomenon of concern to frame their research and develop nursing knowledge. Rogers (1970) specified people and their environment as nursing’s concern.

It was during this era that early versions of nursing frameworks began to be published. The works by Johnson (1974, 1980), King (1971), Levine (1967), Neuman (1972), Orem (1971), Rogers (1970), and Roy (1970) are evidence of the general rec- ognition that nursing theoretical approaches were needed. Research continued to develop during this era of graduate education; however, nurse scholars soon noted that much of the research being published lacked form and direction. In fact, Nurs- ing Research celebrated its twenty-fifth anniversary in 1977 (volume 26, number 3) with published reviews of progress in its first 25 years. These reviews presented rec- ommendations for development in five practice areas of nursing: medical-surgical, community, maternal-child, psychiatric, and gerontological. Lack of conceptual or theoretical direction or conceptual connections in the research was identified as a weakness of the studies. It was also noted that the research focused on nurses or student nurses rather than patients. The headings of the reviews were noted to reflect medical practice specialties as evidence of the struggle throughout nursing history to move beyond a medical view to the nursing view.

Batey (1977) conducted a comprehensive review of those first 25 years of pub- lished nursing research, and identified conceptualization as the greatest limitation of the projects. She emphasized the importance of the conceptual phase of research to provide a content basis as well as connection with other studies in order to de- velop nursing science. It should be noted that reference to concepts and conceptu- alization was common in that era and a forerunner to the theory era. The general understanding that a group of related concepts is a theory or that theory derives from a conceptual framework came later.

Indications of the theory emphasis in nursing education at the national level were with the Nurse Educator conferences in Chicago (1977) and New York (1978). The theme for the Chicago conference was Nursing Education; however, Sister Cal- lista Roy’s workshop illustrating the use of her adaptation conceptual framework as a guide for nursing education was so popular that the theme for the New York con- ference a year later was Nursing Theory. This conference brought nurse theorists

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7CHAPTER 1 The Nature of Knowledge Needed for Nursing Practice

onto the same stage for the first time in history. It was the New York conference that underscored a growing awareness that the nature of knowledge needed for nursing practice was theoretical knowledge. This was an exciting time in nursing as scholarly works of nurse scholars from across the country began to be recognized as theoretical frameworks for research and practice. In this era, nursing publica- tions began to proliferate and time has shown three publications of this era to be particularly important to this history: Carper’s (1978) patterns of knowing, Faw- cett’s (1978) description of the helical relationship between theory and research, and the first edition of Advances in Nursing Science (1978) where Carper and Faw- cett’s seminal articles were published.

Carper (1978) presented a summary of her dissertation research describing four types of nursing knowledge and their contexts. Her work is significant in this history for recognition that nursing knowledge went beyond empirical to include ethical, personal, and esthetic knowledge. Clarifying types of nursing knowledge at the time nursing began to embrace qualitative approaches opened nurses to a broader view of research. Fawcett (1978) presented a description of the vital rela- tionship between theory and research in the development of science with her clas- sic double-helix metaphor, ushering in the 1980s and 1990s theory era.

Theory Era: The 1980s and 1990s The theory era began with a strong emphasis on knowledge development. Although in the previous two decades proponents of nursing theory and nursing theorists had begun to publish their works, it is noteworthy that they denied being theorists when they were introduced as such at the 1978 Nurse Educator Conference in New York with the Nursing Theory theme. There was understanding among those at- tending the conference that the presenters were theorists, and by the second day, the audience responded to their denials with laughter. This seems strange today, but this was the first time most of the theorists even met each other. Their works had grown out of content organization in nursing education courses, nursing practice administration in large agencies, and structures for the thought and action of prac- tice. It was clear that their works were nursing theoretical structures even before they recognized them as such. The theory era, coupled with the research and gradu- ate education eras, led to understanding of the scientific process beyond produc- tion of a scientific product (Kuhn, 1970).

First editions of several nursing theory texts in this era included contempo- rary nursing theorists, some with chapters written by students in master’s programs (Marriner Tomey, 1986; Meleis, 1985; Riehl & Roy, 1980). Proliferation of nursing literature; new nursing journals; regional, national, and international nursing con- ferences; and new nursing doctoral programs were evidence of exponential growth in this era. Schlotfeldt (1992) concluded that this period stimulated growth in nurs- ing scholarship in ways never before experienced in nursing history.

Fawcett (1984, 1989) contributed significantly to our understanding of the na- ture of nursing knowledge. She proposed a metaparadigm of nursing knowledge for nursing, specifying discipline boundaries of person, environment, health, and nursing. Her application of this metaparadigm in criteria for analysis and evalu- ation of nursing theoretical works in early publications clarified types of nursing

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8 PART 1 Conceptualization

conceptual and theoretical works and a structure of knowledge at different lev- els of abstraction. Fawcett’s use of the structure demonstrated how nursing theory linked to conceptual models which then led to an understanding of conceptual- theoretical-empirical linkages for nursing knowledge development and the devel- opment of nursing science (Fawcett, 2005). Fawcett (1984, 1989) led the way by presenting a collective view of nursing’s theoretical works using criteria to clarify their conception as a metaparadigm (person, environment, health, and nursing) in a uniform structure of knowledge.

Theory Utilization Era: The Twenty-First Century Nursing is now in the era of theory utilization—nurses using philosophies, models, and theories for theory-based nursing practice. Soon after we entered the twenty- first century sufficient evidence of theory-based practice existed to declare a theory utilization era (Alligood, 2010). This important era in the history of nursing contin- ued to thrive and be recognized as vital to nursing’s future (Algase, 2007; Alligood, 1994; Colley, 2003; Pearson, 2007). Bond and colleagues (2011) recently researched “who uses nursing theory?” (p. 404), and reported…“increasing numbers, both in quantity and in the use of nursing theory” (p. 407).

Continued theory development is essential for our progress as a profession, and as a discipline this is especially important. Theory development with analysis and critique of syntax and the structure of theory is how knowledge development is learned in nursing doctoral programs, especially PhD, which are vital to the dis- cipline. Theory courses in practice-focused master’s and doctor of nursing practice (DNP) programs focus on the application of theory in nursing practice. Experi- ences of nursing practice with holistic nursing frameworks led to in-depth under- standing of the theories and their utility for practice. The genesis of this text in the early 1990s grew out of the doctoral education focus on development and testing of theory. This led to revision of master’s-level courses to focus on applications and utilization for advanced nursing practice and all other courses throughout the cur- riculum. Theory is not just to know but is to use.

Therefore, in this fifth edition we continue to celebrate the shift to a theory emphasis in this theory utilization era. With the current emphasis on evidence- based practice, inquiry-based practice, best practices, and the consistent quality outcomes, the purpose of this text takes on added value. Quality care is a promi- nent theme in Institute of Medicine reports, health care regulatory policies, the call for nursing education reform, and nurse researchers themselves (Benner, et al., 2010; Bigbee & Issel, 2012; Burhans & Alligood, 2010; Ellerbe & Regen, 2012; Sher- wood & Barnsteiner, 2012). The connection between this emphasis and nursing theory is especially important. As Nola Pender (personal communication, April 2008) shared, “Middle-range theories that have been tested in research provide evidence for evidence-based practice, thus facilitating translation of research into practice.” Whether the emphasis is evidence, best practices, translation to practice, or quality care, all are facilitated by theory (Bigbee & Issel, 2012; Bond, et al., 2011; Fawcett & Garity, 2009). It has been reported that the absence of structure (frame- work) to specify outcomes creates the risk of a deficit in quality patient care and hampers the growth of nursing science (Conn, et al., 2008; Fawcett & Garity, 2009;

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9CHAPTER 1 The Nature of Knowledge Needed for Nursing Practice

Pearson, et al., 2007). Theory utilization is in concert with national goals for qual- ity health care. This text presents philosophies, nursing models, and theories of nursing to guide logical reasoning, thoughtful action, and efficient information processing. Table 1-1 summarizes nursing’s search for specialized knowledge.

Centrality of Nursing Practice

The centrality of practice to nursing is vital to understand the purpose of theory and this text. Each edition of this text addresses the following question: “What is the nature of the knowledge needed for the practice of nursing?” This question has been a driving force for development from the beginning of professional nursing. Nursing history suggests ways that nurses addressed this question in each era of growth of the twentieth century, and now in this twenty-first century we are in the theory utilization era. The discipline of nursing has reached a long-awaited period in nursing history. More nurses are reimbursed as primary care providers in the United States today than ever before as practice degree programs are developed across the country. Each era of our history was critical to growth of the discipline at that time.

It is vital to progress in the discipline for nurses to use nursing practice ap- proaches in spite of pressure to embrace the biophysical view of medicine for their practice. Continued progress depends on demonstrations of quality outcomes with nursing perspectives. Why would any nurse forsake nursing practice approaches

TABLE 1-1 Summary of Historical Eras of Nursing’s Search for Specialized Knowledge

Historical Eras Major Question Emphasis Outcomes Emerging Goal

Curriculum era: 1900 to the 1940s

What curriculum content should student nurses study?

Courses taught in nursing programs

Standardized curricula for diploma programs

Specialized knowledge and higher education

Research era: 1950 to the 1970s

What is focus for nursing research?

Role for nurses and what to research

Problem studies and studies of nurses

Theory-based studies for unified knowledge

Graduate education era: 1950 to the 1970s

What knowledge is needed for nursing practice?

Carving out an advanced role and basis for nursing practice

Nurses have an important role in quality health care

Focus graduate education on knowledge development

Theory era: 1980 to the 1990s

How do these frameworks guide research and practice?

There are many ways to think about nursing

Nursing theoretical works clearly focus on the patient

These theories guide nursing research and practice

Theory utilization era: 21st century

What new theories are needed as evidence for quality care?

Nursing theory guides research, practice, education, and administration

Middle-range theories are from quantitative or qualitative approaches

Nursing frameworks are the knowledge (evidence) for quality care

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10 PART 1 Conceptualization

for that of another discipline when nurses have been recognized as excellent prima- ry providers with nursing theory-based care? Master’s-prepared nurses and doctors of nursing practice (DNP) have a responsibility and are leading the way with a style of professional nursing practice based in nursing thought and action. As in each era, there are opportunities and risks for the profession that cannot be overlooked (Bigbee & Issel, 2012; Fawcett & Garity, 2009; Mantzoukas & Jasper, 2008; Nelson, Gordon, & McGillian, 2002). For nurses to be recognized for their contribution to health care of individuals, families, and communities, it is essential that they practice professional nursing in a systematic manner with nursing approaches. This requires a consciously defined approach in nursing thought and action. Praxis does not occur automatically. Rather, a professional style of practice develops as knowl- edge is embraced, utilized, and experienced over time (Bigbee & Issel, 2012; Ellerbe & Regen, 2012). Daiski (2000) has suggested “practice based in nursing theories will give nurses the necessary foundation to restructure health care where it counts: improving quality of care at the practice level” (p. 79). Using nursing’s theoretical works in practice not only provides a nursing approach but also guides reasoning and decision making for nurses to practice in a logical, organized manner (Algase, 2007; Arvidsson & Fridlund, 2005; Colley, 2003; Fawcett, 1999, 2005; Gallagher, 2004; Newman, 2002; Pearson, 2007).

Mathwig (1975) noted very early, before the theory era even began, that the first phase of translating theory into practice is the decision to do so. Similarly, use of a model in practice has been described as a habit to be formed (Broncatello, 1980), the practice of a true believer (Oliver, 1991), and the practice of one who has been properly persuaded (Levine, 1995).

Progression of nurses to theory utilization and theory-based practice is best explained by nursing history. Change comes slowly and is influenced by eras of development, but it does come. The words of Rogers are as true today as they were in 1970: “Nursing’s potential for meaningful human service rests on the union of theory and practice for its fulfillment” (Rogers, 1970, p. viii). This text is dedicated to realization of that premise.

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C H A P T E R

13

2 Nursing Models: Normal

Science for Nursing Practice

Angela F. Wood*

In the sciences, the formation of specialized journals, the foundation of specialist societies and claim for a special place in the curriculum have usually been associated

with a group's first reception of a single paradigm. (Kuhn, 1970, p. 19)

Nursing Models and Their Theories in Nursing Practice

The use of nursing models and their theories in nursing practice is presented in this chapter, documenting various areas of application and utilization of the models as re- ported in the nursing literature. As the premise in the third edition (2006) set forth, the shift from theory development to theory utilization restores a proper relationship be- tween theory and practice for a professional discipline such as nursing. The importance of this shift was supported by Levine’s (1995) comment, when she stated in regard to Fawcett’s clarification of models from theories, “It may be that the first prerequisite for effective use of theory in practice… rest[s] on just such a clarification” (p. 12). The lit- erature continues to verify that nursing models and their theories have practical utility for nursing with specific details in areas of practice (Bond, Eshah, Bani-Khaled, et al., 2011; Donohue-Porter, Forbes, & White, 2011; Im & Chang, 2012; McCrae, 2011).

Based on a review of the nursing literature, this chapter begins with examples of practice areas where nursing models and their theories guide nursing. Although all three tables present the use of the nursing models and their theories in nursing prac- tice, these applications are described by their authors in various ways: (1) in terms of the medical conditions; (2) in terms of nursing based on human development, areas of practice, type of care, and type of health; and (3) in terms of nursing interven- tions or the nursing role. (See the Bibliography for references to applications of each model cited in Tables 2-1, 2-2, and 2-3.) This chapter concludes with a review of the

*Previous co-author and contributor: Martha Raile Alligood.

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14 PART I Conceptualization

TABLE 2-1 Areas of Practice with Nursing Models Described in Terms of a Medical Conditions Focus

Practice Area Johnson King Levine Neuman Orem Rogers Roy

Acute care •

Adolescent cancer •

Adult diabetes • •

AIDS management • • • •

Alzheimer’s disease •

Ambulatory care • •

Anxiety • • • •

Breast cancer • •

Burns •

Cancer • • • • •

Cancer pain management •

Cancer-related fatigue •

Cardiac disease • • • • •

Cardiomyopathy •

Chronic inflammatory bowel disease

•

Chronic pain • • •

Chronic sorrow •

Cognitive impairment •

Congestive heart failure •

Critical care • • • • •

Cystitis •

Diabetes • • •

Guillain-Barré syndrome •

Heart • •

Hemodialysis • •

Hypernatremia •

Intensive care • • • •

Kawasaki disease •

Leukemia •

Long-term care • •

Medical illness • • •

Menopause • •

Neurofibromatosis •

Obesity • •

Oncology • • • •

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15CHAPTER 2 Nursing Models: Normal Science for Nursing Practice

TABLE 2-1 Areas of Practice with Nursing Models Described in Terms of a Medical Conditions Focus—cont’d

Practice Area Johnson King Levine Neuman Orem Rogers Roy

Orthopedics • •

Osteoporosis •

Ostomy care • •

Pediatrics • • • • •

Perioperative • • • •

Polio survivors •

Postanesthesia •

Postoperative • • •

Postpartum •

Posttrauma •

Preoperative adults •

Preoperative anxiety • •

Pressure ulcers •

Renal disease • • •

Rheumatoid arthritis •

Schizophrenia •

Stroke • •

Substance abuse • • •

Terminal illness • •

Ventilator patient •

Ventricular tachycardia •

Wound healing •

TABLE 2-2 Areas of Practice with Nursing Models Based on Human Develop- ment, Type of Practice, Type of Care, or Type of Health Focus

Practice Area Johnson King Levine Neuman Orem Rogers Roy

Adolescents • • • •

Battered women • •

Caregiver stress • • •

Case management • •

Cesarean father •

Child health •

Child psychiatric •

Dying process •

Emergency • • • •

Continued

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16 PART I Conceptualization

nursing models using the criteria for normal science set forth by Kuhn (1970) in The Structure of Scientific Revolutions and a discussion of how the discipline of nursing has reached a period of normal science using the nursing models.

The literature review makes it apparent that nurses describe their practice in several ways. Some describe nursing practice in terms of the medical conditions. This view focuses on the patient or area of care, as noted in Table 2-1. Examples of

Practice Area Johnson King Levine Neuman Orem Rogers Roy

Gerontology • • • • •

High-risk infants • •

Holistic care •

Homeless • •

Hospice • •

Managed care • •

Mental health • • • • •

Neonates • •

Nursing administration • • • • •

Nursing adolescents • • •

Nursing adults • • • • •

Nursing children • • • • •

Nursing community • • • • • •

Nursing elderly • • • • • • •

Nursing families • • • • •

Nursing home residents •

Nursing infants • • • • •

Nursing in space •

Nursing service •

Nursing women • •

Occupational health •

Palliative care • •

Pregnancy • • • •

Psychiatric nursing • • •

Public health •

Quality assurance • •

Rehabilitation • • • • • •

Risk education •

Transcultural •

TABLE 2-2 Areas of Practice with Nursing Models Based on Human Development, Type of Practice, Type of Care, or Type of Health Focus—cont’d

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17CHAPTER 2 Nursing Models: Normal Science for Nursing Practice

TABLE 2-3 Areas of Practice with Nursing Models with a Nursing Intervention or Role Focus

Practice Area Johnson King Levine Neuman Orem Rogers Roy

Breastfeeding • •

Community presence

•

Collaboration • •

Counseling •

Esthetic knowing •

Family therapy • •

Group therapy • • •

Health patterning •

Humor • •

Imagery • •

Intentionality •

Knowing participation

•

Laughter •

Leadership/ scholarship

• • •

Life-patterning difficulties

•

Life review •

Movement •

Nutrition • • •

Parenting • • •

Relaxation •

Spiritual intervention • • •

Storytelling •

Therapeutic touch •

this focus are the nursing of cardiovascular patients or of intensive care patients. Several observations have been made about this focus (see Table 2-1). First, it rep- resents the largest body of literature. Second, each model is represented within this focus. This large group of studies is surprising in light of the efforts of the past 40 years to move nursing beyond the medical view to a nursing perspective. However, this focus reflects the practice area, of the largest single group (54%) of practicing nurses, who, according to the Department of Labor Statistics (2010) provide acute care or illness care in hospitals.

Table 2-2 presents model and theory use in publications in which nurses de- scribe their practice in terms of a developmental or life-span focus, a particular

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18 PART I Conceptualization

group in society, a type of care, or a type of health. Examples of this focus are nurs- ing of children, homeless, holistic care, and child health. Table 2-2 reflects the sec- ond largest group of articles. Like Table 2-1, Table 2-2 represents articles based on all seven of the nursing models. Although Table 2-2 is large, it represents a grouping of several perspectives nurses use to describe their practice: nursing groups accord- ing to a developmental category, areas of practice, types of care, and types of health or health promotion.

Table 2-3 presents model and theory use in publications that focus on nursing in- tervention or nursing role. Examples of this focus are life review and counseling. This table is smaller than Tables 2-1 and 2-2 and differs in that not all of the nursing models are represented in Table 2-3. Certain nurses practicing from the perspective of nurs- ing models seem to describe their practice in terms of nursing intervention or nursing role. It is noted that the specificity of the language in Rogerian science has created sev- eral unique categories in this focus. This is not surprising, considering the following: • The development of a science calls for specific language. • A purpose of nursing science is to develop knowledge specific to the

discipline perspective; therefore, one would expect new intervention categories to be created rather than continuing to fit interventions into other previously used categories.

• One would expect categories that are descriptive of the uniqueness of the nurse's perspective.

The nursing categories in Tables 2-1, 2-2, and 2-3 can be considered in the con- text of Kuhn’s (1970) discussion of normal science. Paradigms (or nursing models) not only are frameworks to guide thinking about nursing and research but also the thought and action of practice. As such, their use by members of the profession produces knowledge that is evidence for practice as well as further research and theory development. Normal science verifies the growing maturity of a discipline as it moves beyond a knowledge development focus and focuses on knowledge use. Model-based nursing literature now reflects the characteristics of normal science. Middle-range theories and societies have been developed from nursing philoso- phies and theories in recent years that are beyond the scope of this chapter. The reader is referred to Part III of this text on expansion and Chapter 21 for a brief discussion of those developments.

In his book The Structure of Scientific Revolutions, Kuhn (1970) examines the nature of scientific discovery. He defines normal science as “research firmly based upon one or more past scientific achievements that some particular scientific com- munity acknowledges for a time as supplying the foundation for its further prac- tice” (p. 10). From this definition, Kuhn describes criteria that might be used for evaluation of a given paradigm (nursing model). The following are some of the characteristics of a model as it approaches normal science: • To be accepted by a community of scientists • To provide a basis for practice • To be open-ended—that is, provide a guide for research that would

broaden the scientific knowledge base of the discipline Thus Kuhn’s philosophy of science is useful to examine the science of the disci-

pline of nursing. Three possible interpretations are presented.

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19CHAPTER 2 Nursing Models: Normal Science for Nursing Practice

Examination of the Models

Kuhn (1970) describes a paradigm that results in normal science as “an achieve- ment sufficiently unprecedented to attract an enduring group of adherents away from competing modes of scientific activity” and as “leaving all sorts of problems for the redefined group of practitioners to resolve” (p. 10). In the attempt to develop nursing science, theory from numerous modes of scientific activity including medi- cine, social and physical science, education, and even industrial management had been utilized (Wald & Leonard, 1964). However, it was not until the development of formal conceptual nursing models that nurses had “a systematic approach to nursing research, education, administration, and practice” (Fawcett, 1995, p. 5) that ultimately resulted in normal science for the discipline of nursing. Nursing theory continues to supply the foundation for knowledge development and generate evi- dence for practice (Bond, et al., 2011; Canavan, 2002; Colley, 2003; Im & Chang, 2012; Kikuchi, 2003; McCrae, 2011). Each of the models is reviewed with regard to Kuhn's definition and criteria of normal science.