Wiedenbach brown the ultimate lighting source

Afaf Ibrahim Meleis, PhD, FAAN Margaret Bond Simon Dean

Professor of Nursing and Sociology University of Pennsylvania

School of Nursing Philadelphia, Pennsylvania

THEORETICAL NURSING Development and Progress

Fifth Edition

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Meleis, Afaf Ibrahim, author. Theoretical nursing : development and progress / Afaf Ibrahim Meleis,

PhD, FAAN, Margaret Bond Simon Dean, Professor of Nursing and Sociology, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania. — Fifth Edition.

p. ; cm. Includes bibliographical references and indexes. Summary: “An additional assumption was that the processes for theory development were new to nursing and

hence, nurses in graduate programs learned strategies for advancing knowledge from other disciplines. This assumption was debunked with the knowledge that nurses were always engaged in knowledge development, driven by their experiences in clinical practice. Because of these assumptions, most of the early writing about theory development was about outlining strategies that should be used, rather than strategies that have already been used in the discipline to develop theories. Theorists themselves did not uncover or adequately discuss ways by which they developed their theories, therefore the tendency was to describe processes that were based on the- ories developed in other disciplines, mainly the physical and social sciences. And an implicit assumption was made that there should be a single strategy for theory development, some claiming to begin the process from practice, and others believing it should be driven by research”—Provided by publisher.

ISBN 978-1-60547-211-9 (hardback : alk. paper) 1. Nursing—Philosophy. I. Title. [DNLM: 1. Nursing Theory. WY 86] RT84.5.M45 2011 610.7301—dc22

2010051628

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In Memory of Soad Hussein Hassan, RN, PhD

A maverick— for exemplifying humanism and commitment,

for encouraging feminism and autonomy, for accepting challenge and diversity,

for tolerating rebellion, for sponsoring inquisitiveness,

and for being my mother.

And For teaching me about the courage

to face a life of challenges and an end of life with Alzheimer’s.

LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page iii

R E V I E W E R S

Patricia M. Burbank, RN, DNSc, MS Professor University of Rhode Island Kingston, Rhode Island

J. Carolyn Graff, PhD, MN Associate Professor University of Tennessee Health Science Center Memphis, Tennessee

Rebecca Otten, RN, EdD, MSN, BA Health Administration

Assistant Professor California State University — Fullerton Fullerton, California And Mount St. Mary’s College Los Angeles, California

Linda A. Streit, RN, DSN Dean and Professor for the Graduate Program Georgia Baptist College of Nursing of Mercer

University Atlanta, Georgia

Cynthia Toman, RN, PhD, MScN, BScN Assistant Professor University of Ottawa School of Nursing Ottawa, Ontario, Canada

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P R E F A C E

v

THROUGHOUT the many editions and revisions of this book, I received a lot of feedback and many responses about the ideas presented. These arrived in writing, in person, in meet- ings, and in e-mails. Many responses, from many corners of the world, reflected a real intellectual engagement in the book. Some were inspired by our theoretical history, others questioned our philosophical past, but most thought the dialogues that evolved from dis- cussing the ideas in the book reaffirmed their identity in nursing and ignited their pride in the profession and the discipline of nursing. These comments, reviews, and suggestions for revisions made me realize that the major role of this book is empowering its readers. It has given the readers a voice to engage, debate, and to challenge sacred cows about how our discipline evolved and ways by which we can evaluate growth in the discipline.

The intent of this book, then, is to demys- tify theory, to chart the different strategies to use in developing and advancing theory, and to provide tools and best practices in evaluating progress in the discipline. It provides both an open invitation to embark on a journey with- out the many preconceived assumptions that may have been a barrier to pursuing knowl- edge development. Among these assumptions were that a select few could engage in devel- oping theory. Perhaps this is because, during 1950–1970, the construction of theory in nurs- ing occupied only a select few members of the discipline. The metatheoreticians and their writings attracted another select group of nurses, and they focused on suggestions about formulating theories, defining types of theories, and identifying sources for theories. Subsequently, conceptualizing nursing phe- nomena commanded the attention of a wider circle of members of the discipline. Many other assumptions shaped our history and influenced our current progress in the disci-

pline. For example, there was the assumption that a conceptual framework was essential for advancing nursing knowledge. This assump- tion changed as we entered the 21st century because the discipline was better defined and was replaced with another assumption: that empirical knowledge and research programs are the only means toward advancing knowl- edge.

An additional assumption was that the processes for theory development were new to nursing and hence, nurses in graduate pro- grams learned strategies for advancing knowl- edge from other disciplines. This assumption was debunked with the knowledge that nurses were always engaged in knowledge develop- ment, driven by their experiences in clinical practice. Because of these assumptions, most of the early writing about theory development was about outlining strategies that should be used, rather than strategies that have already been used in the discipline to develop theories. Theorists themselves did not uncover or ade- quately discuss ways by which they developed their theories, therefore the tendency was to describe processes that were based on theories developed in other disciplines, mainly the physical and social sciences. And an implicit assumption was made that there should be a single strategy for theory development, some claiming to begin the process from practice, and others believing it should be driven by research.

Another implicit assumption was that the- ory development was an elitist activity, to be engaged in only within the halls of academia. Furthermore, it was assumed that what goes on within the halls of academia had no resem- blance to the clinical work that goes on in real life. (Notice the many comments over the years about nursing theory and the lack of cli- nicians’ need for such theory.) Some believed that nursing had always borrowed its theory

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and that nursing was an applied field. To them, nursing practice theory was not needed because theories from science and ethics were enough to guide nursing. Therefore, theory development was an unnecessary process. Some critics did not consider that redevelop- ment, resynthesis, and reintegration of find- ings, ideas, and statistical wisdom were also processes for knowledge development.

Different eras provided different sets of assumptions. In many instances, biomedical sciences dominated more than biopsychologi- cal sciences. And, as educational programs in nursing became more biologically and med- ically based, theories that reflect the human sciences tended to be neglected. Therefore, major journals in nursing tended to capture empirical evidence based on more medically defined outcomes of mortality and morbidity rates as compared to quality of life, levels of functioning, perceived health status, adapta- tion, and energy levels.

The reader of this book will find that it includes many arguments that dispel many of these preconceived assumptions and that:

• Nurses have a fine and useful theoretical heritage that is worthy of analysis. By understanding how and why our heritage evolved as it did, we may be in a better position to consciously and deliberately drive the development of theoretical nursing to meet the mission that we have articulated about our discipline.

• There are sources and resources by which nurses can conceptualize different aspects of the nursing universe for the purpose of facilitating understanding, increasing autonomy in their actions, and enhancing control over their domain. The ultimate objective is to provide quality care utilizing the different tools and strategies for theory development. The reader will find support that clinicians are as valuable in advancing nursing knowledge as theoreticians because they articulate their practical wisdom into exemplars that may help to solve other clin- ical problems.

• The scientific development of the discipline of nursing has followed a unique path,

charted by members of the discipline to suit its unique features and the context of its nursing care complexities. The sociology and the philosophy of nursing science are legitimate and significant areas of investiga- tion to discern the progress and develop- ment of the discipline. As nurses questioned the empiricist’s view of science and embraced other more dynamic and chang- ing conceptions of science, the behavior of scientists and theoreticians, the processes of selection of research and theories, the his- torical environment, and the sociocultural context for the development and utility of the discipline’s theories become legitimate and provide central questions for the domain.

• And finally, our theoretical history, our epistemology, and our domain are the bases for our theoretical future. The novice should be acquainted with them, the advanced should explore and question the relation- ships between the parts and, together with the experienced, they should shape and reshape nursing knowledge.

Demystifying theory and dispelling assump - tions are essential but not sufficient conditions for empowerment. The metaphors that describe the current stage in theory development are epistemic diversity and integrative process, both of which are an acknowledgment and val- uation of nursing history, heritage, and prac- tice. Both of these metaphors reflect and accept the central role of practice in advancing nurs- ing knowledge and nurses’ ways of knowing as vital in uncovering and developing knowl- edge. Empowerment is also about believing in one’s self, abilities, and capacities to advance knowledge and about using these capacities to become an agent for continuous learning and creating. It is about being a criti- cal thinker, an innovative advocate, and an agent for change.

In this book, I present and provide sup- port for our domain as we see it today. The future progress of the discipline depends on the extent to which members of the discipline will embrace epistemic diversity and integra- tive approaches to theory development, and

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the extent to which evidence is translated, utilized, and evaluated. The scholars of the future are those who are as comfortable with theorizing as with researching, practicing, and teaching. They will be able to understand and speak the languages of different disciplines, translate their findings to the different practice fields, and engage in changing policies.

In short, the major goals of this book are to make a contribution to raising the con- sciousness of the reader about the theoretical development and progress of our discipline, to acknowledge our theoretical history, to place the present in the context of our history, and to develop an awareness of the potential inherent in members of the discipline, both men and women. It is about the pride we must have in the contributions our discipline makes to the health and well-being of people.

I offer the ideas in this book as tentative thoughts to provide an even platform to

enforce self-agency in students, faculty, clini- cians, researchers, and theoreticians to drive the development of new coherent frameworks to advance nursing science. By knowing equally, each may be empowered to leverage their competency and use their expertise. A democratization of the processes in developing theory is an empowering process to you, the reader, to believe in your own voice, to respect and value the voices that came before you, but to challenge and build on them.

Every time I work on a new edition, I feel renewed, inspired, and regenerated. It has been a privilege for me to be a nurse, and it is an incredible privilege to write this book honoring the past and envisioning the future. To readers near and far, I thank you for dialoguing with the ideas in this text. I truly value your responses and comments, so keep sending them.

Afaf Ibrahim Meleis, PhD, FAAN

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REVISING and updating this book and bringing this 5th edition to you is a testament to my unwavering passion about its subject matter, the progress we made in advancing knowledge in the discipline, and the incredible support this project received from many people.

I am grateful to Lippincott Williams & Wilkins’ project manager, Helen Kogut, who, knowing my schedule and commitments, planned ahead, monitored progress, provided reminders, respected my work priorities, and recognized that emergencies happen. Her patience and encouragement made it possible to complete and publish this 5th edition.

What made this project most pleasurable in spite of its intensity and time commitment is the partnership that I have developed with Maria Marconi, who oversaw the typing and organiz- ing, seeing it through beginning to end. Watch- ing her enthusiasm and commitment to the quality of the project, her excitement about learning new skills, and her pride in the project at the completion of each phase, added tremen- dously to the pleasure we both derived in com- pleting it. To her, I offer my heartfelt gratitude for her commitment, and my admiration for her professionalism, and for the quality of her work.

I also extend my deep appreciation to members of the Dean’s Office, who allowed me some time flexibility to devote to this project. My responsibilities as the Dean were well man- aged, and the many other projects in our agenda were completed effectively, efficiently, and on time. That I attribute to a highly functioning, effective, productive, and committed team, which includes Caroline Glickman and Lucia

DiNapoli, under the leadership of Ann Marie Franco. I am indebted to them for their expert- ise, caring, and wonderful sense of humor.

I continue to be inspired by how far our discipline has progressed in spite of the many barriers and obstacles its members faced due to gender-, occupational-, and policy-driven inequities. The resilience, the pride, and the commitment of nurses globally are reflected in the many mentees who challenged my thinking while students or junior faculty, and later, as established scholars, extended and expanded my horizon. I am always awed by these mentees from around the world who continue to be in my life. They, along with the many stu- dents and faculty who take the time to read what I write, and whether to extend or argue with it, continue to influence and shape the ideas presented in each new edition. My profes- sional, academic, and personal lives continue to be deepened, renewed, and enriched by each and every one of these interactions.

My partner in life, Dr. Mahmoud Meleis, vacillates between taking pride in all that I do, and wishing that I would slow down to enjoy more together-time at this stage in our lives. In spite of this time-commitment versus time-free paradox, his support never wavers, his advice is always authentic, his voice is always insightful, and his dedication to our family is emulated by our sons, Waleed and Sherief, who are now rais- ing their own families. They all provide a foun- dation of family support that is most inspiring.

I am indebted to all for your support.

A.I.M.

A C K N O W L E D G M E N T S

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C O N T E N T S

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P a r t O N E

Our Theoretical Journey 1

CHAPTER 1 POSITIONING FOR THE JOURNEY 2

Our Theoretical Heritage 3 Assumption, Goals, and Organizations 3 Organization of The Book 4 On a Personal Note 6 Reflective Questions 6

CHAPTER 2 ON BEING AND BECOMING A SCHOLAR 7

Scholarliness in Nursing 9 Nurses as Scholars 15 Revisiting Scholarship in the 21st Century 17 Conclusion 20 Reflective Questions 20

CHAPTER 3 THEORY: METAPHORS, SYMBOLS, DEFINITIONS 23

The Destination: Theory and Theoretical Thinking 23

Definitions 25 Types of Theories 33 Theory Components 35 Uses of Theory 35 Reflective Questions 37

P a r t T W O

Our Theoretical Heritage 39

CHAPTER 4 FROM CAN’T TO KANT: BARRIERS AND FORCES TOWARD THEORETICAL THINKING 40

Barriers to Theory Development 41 Resources to Theory Development 50

Conclusion 55 Reflective Questions 56

CHAPTER 5 ON THE WAY TO THEORETICAL NURSING: STAGES AND MILESTONES 59

Stages in Nursing Progress 59 Milestones in Theory Development 67 Conclusion 80 Reflective Questions 81

P a r t T H R E E

Our Discipline and Its Structure 85

CHAPTER 6 THE DISCIPLINE OF NURSING: PERSPECTIVE AND DOMAIN 87

Nursing Perspective 88 Domain of Nursing Knowledge 94 Definition of Nursing 106 Conclusion 108 Reflective Questions 108

CHAPTER 7 SOURCES, RESOURCES, AND PARADOXES FOR THEORY 113

Spinoza on Knowledge Development 113

Sources for Theory Development 114 Classifications of Nursing Diagnosis,

Nursing Interventions, and Decision Making 120

Resources for Theory Development 122 Identifying Domain Paradoxes 124

Conceptual Models Versus Theory 125 Nursing Theory Versus Borrowed

Theory 128 Conclusion 132 Reflective Questions 133

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CHAPTER 8 OUR SYNTAX: AN EPISTEMOLOGICAL ANALYSIS 136

Knowing from the Received View to Postmodernism View 136

Truth: From Correspondence to Integrative View of Truth 150

Conclusion 155 Reflective Questions 155

P a r t F O U R

Reviewing and Evaluating: Pioneering Theories 159

CHAPTER 9 NURSING THEORIES THROUGH MIRRORS, MICROSCOPES, OR TELESCOPES 160

Images of Nursing, 1950–1970 162 Theories’ Primary Focus 174 Images, Metaphors, and Roles 175 Areas of Agreement Among and

Between Theorists and Schools of Thought 175

Conclusion 177 Reflective Questions 178

CHAPTER 10 A MODEL FOR EVALUATION OF THEORIES: DESCRIPTION, ANALYSIS, CRITIQUE, TESTING, AND SUPPORT 179

Selecting Theories for Utilization 180 Framework for Evaluating Theories 185

Description 185 Analysis 189 Critique of Theory 194 Theory Testing 200 Theory Support 202

Conclusion 203 Reflective Questions 204

CHAPTER 11 ON NEEDS AND SELF-CARE 207

Dorothea Orem 207 Conclusion 224 Reflective Questions 224

CHAPTER 12 ON INTERACTIONS 229

Imogene King—A Theory of Goal Attainment 229

Ida Orlando 241 Josephine Paterson and Loretta Zderad 251 Joyce Travelbee 258 Ernestine Wiedenbach 265 Conclusion 271 Reflective Questions 272

CHAPTER 13 ON OUTCOMES 279

Dorothy Johnson 280 Myra Levine 290 Betty Neuman 300 Martha Rogers 311 Sister Callista Roy 324 Conclusion 338 Reflective Questions 339

P a r t F I V E

Our Theoretical Future 353

CHAPTER 14 CHALLENGES AND OPPORTUNITIES FOR A THEORETICAL FUTURE 354

Opportunities Within Paradoxes 355 Disciplinary or Interdisciplinary

Knowledge 355 Global or Local Theories 356 Marginalized or Privileged Populations 357 Technical Nursing or Expert Nursing

Practice 357 Nursing Informatics or Medical Informatics 358

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Taxonomies or Interpretations 359 Clinical, Conceptual, or Empirical Theorizing 361 Knowing Through Research and Knowing

Through Theory 362 Integration or Isolation of Theoretical

Discourses 365 Middle-Range or Situation-Specific

Theories 367 Conclusion 368 Reflective Questions 368

CHAPTER 15 CONCEPT DEVELOPMENT 371

Concept Exploration 372 Concept Clarification 374 Concept Analysis 376 An Integrated Approach to Concept

Development 380 Conclusion 387 Reflective Questions 388

CHAPTER 16 THEORY DEVELOPMENT 391

Theory Development: Existing Strategies 394 Theory to Practice to Theory Strategy 394 Practice to Theory Strategy 396 Research to Theory Strategy 398 Theory to Research to Theory Strategy 403

Conclusion 404 Reflective Questions 404

CHAPTER 17 MIDDLE-RANGE AND SITUATION- SPECIFIC THEORIES 407

The Integrative Process for Developing Middle-Range and Situation-Specific Theories 407

Tools for Developing Middle-Range or Situation-Specific Theories 409

Middle-Range Theories 410 Situation-Specific Theories 419 Conclusion 423 Reflective Questions 424

CHAPTER 18 MEASURING PROGRESS IN A DISCIPLINE 427

A Theory of Revolution 428 A Theory of Evolution 431 A Theory of Integration 433 Conclusion 436 Reflective Questions 436

P a r t S I X

Our Historical Literature 439

CHAPTER 19 HISTORICAL WRITINGS IN THEORY 440

Section I: Abstracts of Writings in Metatheory, 1960–1984 440

Section II: Abstracts of Writings in Nursing Theory, 1960–1984 469 Dorothy Johnson 469 Myra Levine 478 Dorothea Orem 482 Martha Rogers 489 Sister Callista Roy 494 Joyce Travelbee 501

CHAPTER 20 HISTORICAL AND CURRENT THEORY BIBLIOGRAPHY 502

Theory and Theorizing in Nursing 503 Nursing Theory and Theorists 548 Paradigms That Have Influenced

Nursing 616 Middle-Range Theory 631 Situation-Specific Theory 632 Video and Audio Tapes on Theory 632

AUTHOR INDEX 637

SUBJECT INDEX 663

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Our Theoretical Journey I INVITE you, in this first part of the book, to embark on a journey that will introduce

you to the rich theoretical underpinnings of our discipline. Uncovering the role that

theory plays in our daily experiences as nurses is the first step in the theoretical jour-

ney proposed in this book. In the three chapters in Part One, the theoretical journey,

along with its symbols and scholarly destinations, is described. In Chapter 1, you will find assumptions on which the journey is planned, the organizational plan for

the journey, and some of the supporting material. Chapter 2 includes scholarly goals and the different possible destinations for the journey. The context for the journey is

then set in Chapter 3, where the key definitions of theoretical symbols and terms are provided.

As with any long journey, planning is essential, but it is equally important to

allow flexibility for personal goals to emerge from the experience, side trips that

may distract or enrich you, and serendipitous opportunities that may attract you. It

is the totality of these experiences that will lead to immersion, understanding, and

innovation.

P A R T O N E

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C H A P T E R 1

Positioning for the Journey

Disciplines should be dynamic to respond to emerging and changing needs of societies and to new demands imposed by population movements, health care reforms, and transformation of global order. However dynamic disciplines are, they have a core set of values, assumptions, a perspec- tive, and a mission that maintain their stability and effectiveness. This core is what provides conti- nuity and progress in disciplines.

Quality care for all people continues to be nursing’s top priority. In the 21st century, this goal is even more urgent than it has been because of increasing diversity and better awareness of the changing needs of the public, the conflicting priorities in health care systems, and the emergent costs and reimbursement issues that patients, insurance companies, the health care industry, and health care professionals are confronting. Theory and theoretical thinking may have been pro- moted in the past as answers to the undefined roles of nursing or the diffused nature of the profes- sion of nursing. However, in this new era of unequal access to health care, where disparities in provision of health care services are becoming more recognized, where there are emerging chal- lenges in treating chronic illnesses and infections, and where there is a proliferation of health care professionals and many global dialogues about health care reform, the role of theory has become even more urgent and more compelling. To fully appreciate the role of theory in shaping the future of equitable and accessible quality health care, we must review and analyze our theoretical past and its influence on the present and future of health care.

By uncovering and understanding a discipline’s theoretical journey, members of the discipline learn and build on it. By unfolding the process used in developing the theoretical past, we gain insights that improve our understanding of our current progress, and we are empowered to achieve our discipli- nary goals. When we take a critical and reflective stance on the current theoretical discourse, or lack thereof, as the case may be, we see shadows of past issues and accomplishments, as well as visions of the future of our discipline and profession. Therefore, reconstructing our theoretical heritage is a process that involves reconstructing our present reality. The intent of the historical-to-future journey proposed in this book is to demonstrate the progress of nursing through analyses of the philosophical assumptions, theoretical methods, and theoretical threads that have influenced the development of the discipline. We will perform these analyses in ways that value our experiences as nurses, in ways that support and enhance our progress, and in ways that allow us to proactively develop abstractions, exem- plars, conceptualizations, and theories that reflect and guide our nursing assessments and actions. Syn- thesizing insights from and about the past, considering the current reality of the health care systems, analyzing the societal context, and considering the potential future visions of quality care can enhance creativity in the discipline of nursing, which could further its development and progress.

Despite many crises along the path of quality care, the development of the discipline of nursing has progressed by leaps and bounds during the last 30 years of the 20th century. The new century brought with it many challenges, some new and some merely shadows of the past. Few would dispute the notion that theory in general has been responsible for this development; yet, some continue to question the specific role of theory in the development of the discipline and its effects on the disci- pline’s scientific bases and clinical practice. The thesis of this book is that the evolution of the disci- pline of nursing and its scholarliness is greatly intertwined with its focus on theory. The movement in our discipline to incorporate vigorous philosophical and theoretical discourses is a credit to those who theorized about nursing practice: thinkers who dared to conceptualize in a practice discipline and edu- cators who pioneered theory development, all of whom were instrumental in defining and advancing the discipline of nursing. These thinkers framed the discussions and the discourse about the mission and the boundaries of the discipline of nursing. The discussions in this book go beyond this thesis to

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CHAPTER 1 Positioning for the Journey 3

delineate the very outer boundaries of nursing knowledge, the sources used to advance that knowl- edge, the different approaches to knowing, the theories that guided the development of nursing’s sci- entific base, and the criteria of truth that the discipline may or may not use. Although the dialogues in this book intend to provide the reader with a sense of history, the process itself helps to unfold a futur- istic course. The readers of this text are the agents who will shape the future of the discipline.

Theory is not a luxury in the discipline of nursing. Using theory as a way to develop concep- tual frameworks to be used to guide curriculum development is part of our past. Theory has become an integral part of the nursing lexicon in education, administration, and practice. Mem- bers of the nursing discipline should understand its role in the development of nursing and in the delivery of quality evidence-based nursing care.

OUR THEORETICAL HERITAGE Like all journeys, the journey proposed for you, the reader, could be short or long, detached or involved, superficial or profound, simple or complex, preplanned or spontaneous, or structured or dis- covered. Like all journeys, this one has maps, destinations, lamp posts, detours, setbacks, surprises, disappointments, and insights. Like all journeys, you will get out of it what you put into it. It has been my experience in sharing this journey with many fellow travelers, through teaching, research, and practice, that the insights gained and advancements in knowledge made coincide with the extent to which there is complete openness and flexibility in the discoveries experienced and developed during the journey, to the extent to which there is true involvement in all aspects of the journey, and to the extent that there are opportunities to integrate this journey with personal experiences.

Therefore, you are invited to embark on a long journey that spans the theoretical past, present, and future of our discipline. Journeys are meaningful when they become personal. Therefore, you are also encouraged to reflect on your own theoretical journey and to compare and contrast your experience and responses with that of other members of the discipline, as well as with the journey of the discipline itself. All journeys will take on different meanings—the insights from one journey will enhance the insights from another. For your journey, take some time to question your values about theory, your own assumptions about theoretical thinking, your biases against theory, your goals for reviewing theoretical writings, and your goals for the discipline of nursing. For the disci- pline’s journey, ask questions about the discipline’s focus and ultimate goals, who drives these goals, which discipline’s perspective is driving these goals, why are these the goals set in the 21st century, and are these goals the same for all health care professionals? Questions that include “if then,” and “so what,” could help in promoting critical thinking about the discipline.

ASSUMPTION, GOALS, AND ORGANIZATIONS This book is designed to provide tools and strategies to unfold the thought processes inherent in nursing, analyze the origins of nursing concepts, and contribute to the ongoing dialogue about the role of theoretical thinking in the development of the discipline of nursing. Its intent is to provide the reader with the knowledge base necessary to fully engage in and understand the current situa- tion in health care, and to begin to formulate ideas about how to shape a future for nursing that is more theoretically coherent and effective. This book is about theory, theorizing, and theoretical thinking. Critical thinking is essential for theoretical thinking. Clinicians, theoreticians, and researchers use different forms of theoretical activities in their work. When theory is discussed, the discussion should include how we have been theorizing and using theory in the different com- ponents of the discipline of nursing, perhaps without attaching the label of “theory” to these activ- ities. It is also about how we can continue to advance the discipline of nursing through knowledge development, enhance professional nursing through the processes that nurses use in conceptualiz- ing their actions, and facilitate better care for clients through theory-based policies and theory- driven practices. This book does not provide recipes for achieving these goals; instead, it provides ideas, questions, processes, and some strategies to enable you to pursue your own goals, develop your own action plans, and share your own insights and wisdom with your colleagues.

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4 PART ONE Our Theoretical Journey

The ideas contained in this book are articulated to compete vehemently with any work that deni- grates the theoretical history of nursing—past, present, or future. At the same time, the ideas comple- ment and are intended to collaborate with all other writings of colleagues on theory and metatheory. When I provide critique, I attempt to voice it from a nursing perspective, place the critique within an historical context, and analyze the contributions, allowing for the contextual forces and constraints.

This book is not intended to promote a certain epistemological perspective, a certain theory, or a certain set of ontological propositions over any others. Instead, this book explores, discusses, ana- lyzes, critiques, compares, and contrasts different epistemologies, theories of truth, and nursing theo- ries. It delineates components of theory and criteria for theory critique. It describes different strategies used in the development of nursing theories and the consequences of each strategy. This book is intended to be used by those who want to understand a significant aspect of the nursing discipline that has been dichotomized with practice and shadowed by an emphasis on education of nurses. It attempts to promote understanding, not to dissect the discipline of nursing into separate compart- ments, but rather to emphasize nursing as a discipline that is based on philosophy, theory, practice, and research. Although the focus is on nursing theories, the relationships and interdependence among research, art, philosophy, and practice are highlighted and explicated. The ultimate goals of the differ- ent chapters are to stimulate thinking, inspire robust dialogue, and challenge the status quo.

The development of the ideas for this book is based on several assumptions:

• Understanding theory and its role is enhanced by exploring the origin of ideas and the processes by which ideas develop into theories.

• Pluralism in nursing theories is desirable and inevitable; therefore, an exploration of existing theories is essential for improving the utility of theory and for continuing the development and progress of the discipline.

• A critical assessment of the history of theoretical thought will pave the way for the development of theories that further describe and prescribe nursing practice. This understanding will help delineate issues that could be resolved in the future.

• No evidence can exist without a coherent theoretical framework that drives the questions and answers for practice.

ORGANIZATION OF THE BOOK To improve the potential of achieving the goals of understanding the role of theory in the develop- ment and progress of the discipline, and of understanding the role of members of the discipline in developing and constructing theory, this book is organized into parts and chapters according to potential illuminations throughout the journey. It is divided into six major parts.

Part One describes terms of the theoretical journey, assumptions to guide the journey, the lamp posts that define key elements of the journey, and the destinations of the journey, as well as scholarship and what it means within the context of the 21st century.

The second chapter in Part One focuses on the agents and producers of knowledge—the scholars in the discipline. Different frameworks for scholarship are analyzed, and scholarship is defined within the context of the practice properties of the discipline. Scholarship includes giving careful attention to the development of nursing theories and to ways in which nursing theories are viewed and analyzed.

Part Two presents a historical analysis of the discipline’s progress toward its present theoreti- cal perspective. Stages of development and milestones leading to the next phase are discussed. A pattern of progress unique to the discipline of nursing is explored. Forces and barriers that may have influenced theory development, and therefore indirectly affected the scholarly evolution of the discipline of nursing, are proposed and explored. Chapter 5 presents the evolution of the discipline of nursing and the various stages that have been marked by significant turning points or milestones.

In Part Three, I provide an epistemological discussion of our discipline as it is perceived and articulated by its thought leaders. The dialogue and analysis provided reflect the thinking about our discipline at the end of the first decade of the 21st century. This part contains three chapters

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CHAPTER 1 Positioning for the Journey 5

focused on defining the discipline of nursing, its domain of study, and its perspective of clinical practice as differentiated from other disciplines. Chapter 7 provides an analysis of the sources and resources used to develop theory, and it dispels the myth that only research can be a source of the- ory. Chapter 8 provides a proposed approach to analyzing the structural components of the disci- pline and the different ways by which we claim knowledge. Different theories of progress are explored, and the course of development of nursing knowledge is traced, compared, and con- trasted with other disciplines.

Part Four focuses on the analyses of those theory pioneers who provided the tipping point for initiating a robust theoretical and philosophical dialogue. In Chapter 9, I provide an overall per- spective on the theories by putting them through magnifiers, telescopes, and microscopes. The result is an integrative synthesis providing support for emerging categories. In Chapter 10, I pro- vide a discussion of the different analysis and critique models for evaluating the quality and effec- tiveness of theories. The model provided differentiates between strategies and processes for describing, analyzing, critiquing, and testing theories. The remainder of Part Four is devoted to the use of the model for theory description, analysis, critique, and testing for analyzing the selected nursing theories. The selections, based on the theories’ central questions, are matched with domain concepts. Therefore, the five chapters in Part Four are organized around an integrative analysis of the theories, a proposed model, and focused analyses of needs and self-care, interactions, and out- come theories.

Part Five is devoted to the future, without losing track of our past or the context of our disci- pline. Frameworks and strategies for developing concepts and theories are provided as processes and guideposts for a future of influencing health care policies. In Chapter 14, I outline the chal- lenges and opportunities for advancing our discipline. In Chapters 15, 16, and 17, I discuss processes and tools essential for developing different types of theories. Examples are provided to reflect the major strategies presented. Among these examples are those specific to the development of middle-range and situation-specific theories. And in Chapter 18, I discuss the different theories by which we can continue to measure the progress of and developments in advancing knowledge.

Part Six contains two chapters. Chapter 19 presents an abstracted analysis of selected central writings on metatheory and nursing theory. It is not intended as a comprehensive compilation of abstracts of everything that has been written about metatheory and theory; rather, it is intended as a beginning—but central—collection that you are encouraged to use as a model for your own collection of analytical abstracts. The analyses are intended to provide a starting point for discussion and debate.

The last chapter of the book, Chapter 20, contains an extensive bibliography on metatheory, on paradigms that have been used in nursing, and on nursing theory. Sections 1 through 12 of this chapter contain the metatheory literature and are organized around common themes in nursing and theory, such as philosophy and methods, theory development in nursing, forces and con- straints in theory development, theory and science, theory and research, theory and practice, the- ory and education, and theory analysis and critique. Sections 13 through 37 contain writings about nursing theories by theorists or others who have used the theories for research practice, education, or administration. You can find all the writings related to a theory—to the best of my knowledge— by looking under the theorist’s last name in this section. In addition, there are two new sections on middle-range and situation-specific theories, with many references reflecting both.

Asterisked citations in this chapter indicate citations that have been abstracted and analyzed in the previous chapter under metatheory or theory. Sections 38 through 48 contain writings on several cen- tral paradigms that have influenced the discipline of nursing, including psychoanalytical theory, sym- bolic interaction, developmental systems, adaptation, and role theories. Sections 49 through 53 provide a descriptive list of audiotapes and videotapes that have been created to explain the theorists’ ideas.

This book is designed to be used sequentially or nonsequentially. This free use of each chap- ter and each part necessitates a slight repetition of ideas. The repetitions emphasize and expand on significant themes and present the same or similar ideas with a different analytical posture. This book ideally should be used in four teaching/learning units: the first focusing on Part One and Part Two, the second on Part Three, the third on Part Four, and the fourth on Part Five. Part Six provides the necessary supportive material for each of the parts.

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6 PART ONE Our Theoretical Journey

ON A PERSONAL NOTE Writing and reading books are both existential experiences and ongoing, evolving processes. Nei- ther the reader nor the writer is the same person after reading or writing a book, nor are their ideas and viewpoints the same. A book is never complete because ideas are never complete. Yet, at some point, a project needs to be abandoned so that others can explore its ideas to modify, extend, affirm, refine, or refute their own—all of which, if shared with the author, will allow her to do the same. When I completed the last edition, I had decided to temporarily abandon the project as an individual endeavor. It is now our dynamic project; it belongs to the readers and to me, and engagement in the ideas and constant discourse is the ultimate goal. These assumptions continued to guide the current edition.

I urge you to consider this book complete as well as incomplete, a temporarily abandoned proj- ect that represents my own thinking and analysis. It incorporates my past, present, and future, inter- mingled with the past, present, and future of nursing and of nurse theorists. It is from all of this that my present interpretation of theoretical nursing has evolved, but this continuous, evolving process is presented here with temporal boundaries. Therefore, if I misinterpreted any theorists’ or metatheo- rists’ admonitions, it was unintentional, and my critique should be viewed as an honest epistemolog- ical interpretation bounded by cognitive, historical, and sociocultural meanings of the time.

I firmly believe that without the theorists and metatheorists and their writings, this book would not have been written, and it would not have been necessary. Interpretations and selections of theorists and metatheorists and their ideas were not guided by a desire for omission, but rather by limitations imposed by time and space. The conceptualizations of all theorists and all the analyses of the metatheorists, whether included in this text or not, provide the tapestry that depicts the future of theoretical nursing.

Finally, I have tried to avoid language that suggests stereotypical views of the nurse, patient, and physician, but at times comprehension, clarity, and simplicity took precedence. Because the majority of nurses are women, I have used “she” to encompass both “she” and “he.” I have done the same elsewhere with “he.”

Are these the same as, or different from, those criteria used in selecting or reject- ing nursing theories?

5. In what ways do you demonstrate your critical assessment of progress in theo- retical and scientific nursing? Are these critiques illuminated by a true under- standing of daily experiences of mem- bers of the discipline? Are these critiques guided by a nursing perspec- tive? (Then respond to this question again after reading Chapter 18.)

6. What is your own conception of a nurs- ing perspective, and in what ways does this conception match or not match with your practice environment (or curricular framework)?

REFLECTIVE QUESTIONS The following are some questions to guide a reflective approach to your journey:

1. Comment on this statement that is often heard: “I have practiced (or taught) nurs- ing for many years without the need to use theory, so why do I need theory in a practice discipline?”

2. How did you come to define theory, nursing, human beings, and health? What values and assumptions do these definitions hold, and what courses of action are dictated by those values?

3. What theories guided you in your assess- ment of your patients, in your research projects, and in your teaching methods? Why did you select these theories? How congruent are the ontological beliefs of these theories with your own? With those of the discipline of nursing?

4. What criteria did you use in selecting or rejecting theories to guide your actions?

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C H A P T E R 2

On Being and Becoming a Scholar

Theory and theoretical thinking are intricately intertwined with advancing scholarship in any dis- cipline. Established disciplines provide an intellectual environment that nurtures and promotes scholarly inquiry, and theory and theoretical propositions drive such inquiry. Theory development encompasses those goals and outcomes of inquiry in the discipline that claim scholarship. When I think of scholarship in nursing, I think of a number of renowned individuals who have made an impact on the meaning of scholarship; some of these people are from ancient history, and others are from recent history. Hypatia and Hatshepsut reflect very different types of scholars who con- tinue to fascinate modern thought. Conversely, Ernest Boyer’s name is attached to more contem- porary thoughts regarding scholarship.

Hypatia was a renowned Greek philosopher and scholar of the fifth century (Osen, 1974), and Hatshepsut was the only ruling queen among the pharaohs of Egypt in 2500 BC (Wells, 1969). Both demonstrated commitment, persistence, innovation, leadership, and intelligence. Both were true scholars. Both followed similar paths in their lives—different from the universal and main- stream paths that existed at their respective times. Both met death violently and may have been tortured because they charted different paths for their people, were forceful in expressing their views, and succeeded in making changes.

Hypatia left her mark on the world in the form of innovative devices to study astronomy and to determine the specific gravity of liquids—devices that were praised highly by Socrates. Hatshepsut left her mark in the form of architecturally beautiful temples for her people, peace within her country and between her country and neighboring countries, and new artifacts in her land. Both women demonstrated a unique brand of scholarship; however, scientists had to dig deep to learn about their work and their stories. Was that because they were women? Can they be judged by the same criteria used to evaluate and judge male mathematicians and male pharaohs?

Ernest Boyer (1990), however, inspired most disciplines to engage in robust dialogues about the meaning of scholarship in modern times. His Carnegie Foundation publication, “Scholarship Recon- sidered: Priorities of the Professoriate,” continues to resonate in academic institutions. Boyer dis- cussed the origin of the most prevalent definition of scholarship, as research and discovery corresponding with an emphasis on higher education and on increasing grant support that nurtures the research enterprise. Increasingly, in Boyer’s opinion, scholarship was becoming synonymous with academic work, and professors were expected to compete for grant funding and focus on research, thereby creating a dichotomy between teaching and research. Many groups in U.S. society had begun to question this de-emphasis on teaching in universities, and analyses such as those done by Boyer (1990) and Glassick, Huber, and Maeroff (1997) fueled the call for a redefinition of scholarship.

Boyer proposed that there are four different categories of scholarship. The first and most familiar is the scholarship of discovery that is tied to original research. This type of scholarship calls for activities that enhance a deeper understanding of research processes in a quest to answer a discipline’s pressing questions. The emphasis in this type of scholarship is on research, and research attracts funding from such institutions as the National Institutes of Health (NIH) through the R01 program, among other sources of similar funding. In the U.S. scientific community, the R01 designation is considered the gold standard for research funding, denoting the significance of the research, the credibility of the investigation, and the standing of the investigator in the aca- demic community. However, disciplines, and students within the various disciplines, needed other kinds of scholarship to advance and flourish (Meleis, 2001). Therefore, a second area of scholar- ship, the scholarship of integration, was proposed. This is the quest to find connections between different discoveries, leading to new wisdom and insights about an area of investigation or a

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8 PART ONE Our Theoretical Journey

discipline. Scholarship of integration is achieved when innovative insights are realized that are larger than the smaller disconnected facts produced by research. The exceptional discoveries in sciences in the late 20th century and the complexity and interrelationship between the different disciplines makes the scholarship of integration more timely (Strober, 2006).

The third type of scholarship as defined by Boyer is the scholarship of application. This type of scholarship builds bridges between theory, research, and practice. Scholarship of application encompasses the translation of knowledge to solve problems for individuals, families, or societies. This type of scholarship requires the integration of knowledge of best practices in achieving best outcomes (Shapiro and Coleman, 2000). With the increasing acknowledgment of this interde- pendence between academic institutions and society, there comes an expectation that relevant knowledge must be translated to benefit societies, and, conversely, the knowledge that is devel- oped must emanate from the needs of society.

The fourth type of scholarship is that of teaching (Hutchings and Shulman, 1999; Shulman, 1999; Glassick, 2000). Shulman suggests that good teaching should be differentiated from schol- arly teaching and from scholarship of teaching. He states that for teaching to be scholarship, the work must be communicated and public, should be peer reviewed critically, should be compared to some accepted standards for quality control, must be reproduced, and must be cumulative, building on other scholars’ work.

In what ways are these discourses about scholarship—by Hypatia, a woman philosopher from ancient Greece and Egypt, and Boyer, a contemporary educator—relevant to nursing in gen- eral and to theoretical nursing in particular? This is what we will discuss in the rest of this chapter; let me begin by saying that there is no scholarship without a robust theoretical discourse. Theoret- ical thinking and theory-driven dialogues are essential for any type of scholarship, as will be explained throughout this book. However, developing theory, refining theory, and analyzing theo- ries are more reflective of the scholarship of integration. The discipline of nursing continues to be in dire need of scholars who use the tools of critical thinking (as defined on page 19 in this chapter as well as in Chapters 3 and 14) to develop the theories and theoretical frameworks that guide practice and research. Several questions may be posed at this point.

Is nursing scholarliness different from scholarliness in other disciplines? Do nurse scholars have the same attributes as other scholars? Do some differences exist? What might they be, and how is current scholarship in nursing related to Boyer’s conception of different types of scholar- ship? In this chapter, we discuss these questions. Answers to these questions, however, are dynamic, evolving and changing, reflecting new experiences for nurses and redefined goals for the discipline.

There are some indications that the nature of those disciplines that are oriented to human responses and the nature of those disciplines that focus on clinical matters may differ considerably from other disciplines that focus on physical phenomena or that are purely theoretical in nature (Holmes, 1990; Sarvimki, 1988; Watson, 1990). There are also historical indications that women’s history and their lived experiences may provide them with different voices, different cognitive styles, and different ways of knowing (Belenky, Clinchy, Goldberger, and Tarule, 1986; Gilligan, 1984; Anderson, Reimer–Kirkham, Browne, and Lynam, 2007). The discipline of nurs- ing is defined both by its perspective and domain, and by its historical association with women and the propensities of most societies to assign the work and labor of caring to women. These def- initional characteristics may be reflected in the philosophical perspectives adopted by its mem- bers. They also drive the way in which members of the discipline approach the frameworks they develop or use to define the curricular content and the educational strategies used. These charac- teristics may also define the ethical decision-making frameworks that govern knowledge develop- ment and utilization.

It is also expected that disciplines oriented to human responses may require a different set of criteria to judge their scholarly progress and development. These criteria evolve from the people- oriented nature of the clinical and human sciences, as well as from the struggles that women have endured to achieve equity and to receive acknowledgment for their work and respect for their credibility. Scholarliness in such disciplines may, by necessity, take different routes and reach