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AND THEIR WORK Nursing Theorists

Martha Raile Alligood, PhD, RN, ANEF Professor Emeritus College of Nursing

East Carolina University Greenville, North Carolina



3251 Riverport Lane St. Louis, Missouri 63043


Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Copyright © 2010, 2006, 2002, 1998, 1994, 1989, 1986 by Mosby, Inc., an affiliate of Elsevier Inc.

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Library of Congress Cataloging-in-Publication Data

Nursing theorists and their work / [edited by] Martha Raile Alligood. — Eighth edition. p. ; cm. Includes biographical references and index. ISBN 978-0-323-09194-7 9pbk. ; alk. Paper) I. Alligood, Martha Raile, editor of compilation. [DNLM: 1. Nursing Theory. 2. Models, Nursing. 3. Nurses—Biography. Philosophy, Nursing. WY 86] RT84.5 610.7301—dc23


Printed in the United States of America

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Dedicated to the memory of my mother: Winifred Havener Raile, RN

1914-2012 Class of 1936,

Good Samaritan School of Nursing, Zanesville, Ohio



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Herdis Alvsvåg, RN, Cand Polit Associate Professor Department of Education and Health Promotion University of Bergen Bergen, Norway; Associate Professor II Bergen Deaconess University College Bergen, Norway

Donald E. Bailey, Jr., PhD, RN Associate Professor School of Nursing Duke University Durham, North Carolina

Barbara Banfield, RN, PhD Farmington Hills, Michigan

Violeta A. Berbiglia, EdD, MSN, RN Associate Professor, Retired The University of Texas Health Science Center

at San Antonio School of Nursing San Antonio, Texas

Debra A. Bournes, RN, PhD Director of Nursing New Knowledge and Innovation University Health Network Toronto, Canada

Nancy Brookes, PhD, RN, BC, MSc (A), CPMHN (C) Nurse Scholar and Adjunct Professor Royal Ottawa Health Care Group Royal Ottawa Mental Health Centre University of Ottawa Faculty of Health Sciences Ottawa, Ontario, Canada

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

Karen A. Brykczynski, PhD, RN, FNP-BC, FAANP, FAAN Professor School of Nursing at Galveston The University of Texas Medical Branch Galveston, Texas

Sherrilyn Coffman, PhD, RN Professor and Assistant Dean School of Nursing Nevada State College Henderson, Nevada

Doris Dickerson Coward, RN, PhD Associate Professor, Retired School of Nursing The University of Texas at Austin Austin, Texas

Thérèse Dowd, PhD, RN, HTCP Associate Professor Emeritus College of Nursing The University of Akron Akron, Ohio

Nellie S. Droes, DNSc, RN Associate Professor, Emerita College of Nursing East Carolina University Greenville, North Carolina




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

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

Dana M. Hansen, RN, MSN, PhD Assistant Professor College of Nursing Kent State University Kent, Ohio

Sonya R. Hardin, PhD, RN, CCRN, NP-C Professor College of Nursing East Carolina University Greenville, North Carolina

Robin Harris, PhD, ANP-BC, ACNS-BC Nurse Practitioner Wellmont CVA Heart Institute Kingsport, Tennessee

Patricia A. Higgins, PhD, RN Assistant Professor Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio

Bonnie Holaday, DNS, RN, FAAN Professor and Director, Graduate Studies School of Nursing and Institute on Family and

Neighborhood Life Clemson University Clemson, South Carolina

Eun-Ok Im, PhD, MPH, RN, CNS, FAAN Professor and Marjorie O. Rendell Endowed

Professor School of Nursing The University of Pennsylvania Philadelphia, Pennsylvania

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

Lisa Kitko, PhD, RN, CCRN Assistant Professor School of Nursing The Pennsylvania State University University Park, Pennsylvania

Theresa Gunter Lawson, PhD, APRN, FNP-BC Assistant Professor Department of Nursing Lander University Greenwood, South Carolina

Unni Å. Lindström, PhD, RN Professor Department of Caring Science Faculty of Social and Caring Sciences Åbo Academy University Vasa, Finland

M. Katherine Maeve, PhD, RN Nurse Researcher Charlie Norwood VAMC Augusta, Georgia

Marilyn R. McFarland, PhD, RN, FNP, BC, CTN Associate Professor of Nursing and Family Nurse

Practitioner Urban Health and Wellness Center University of Michigan Flint, Michigan

Gwen McGhan, PhD(c), RN Jonas/Hartford Doctoral Scholar School of Nursing The Pennsylvania State University University Park, Pennsylvania

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



Contributors ix

Patricia R. Messmer, PhD, RN-BC, FAAN Director Patient Care Services Research Children’s Mercy Hospital and Clinics Kansas City, Missouri

Gail J. Mitchell, PhD, RN, MScN, BScN Professor School of Nursing Chair/Director York-UHN Nursing Academy York University Toronto, Ontario, Canada

Lisbet Lindholm Nyström, PhD, RN Associate Professor Department of Caring Science Faculty of Social and Caring Sciences Åbo Academy University Vasa, Finland

Janice Penrod, PhD, RN, FGSA, FAAN Director, Center for Nursing Research Associate Professor School of Nursing The Pennsylvania State University University Park, Pennsylvania

Susan A. Pfettscher, DNSc, RN Retired Bakersfield, California

Kenneth D. Phillips, PhD, RN Professor and Associate Dean for Research and

Evaluation College of Nursing The University of Tennessee Knoxville, Tennessee

Marie E. Pokorny, PhD, RN Director of the PhD Program College of Nursing East Carolina University Greenville, North Carolina

Marguerite J. Purnell, PhD, RN, AHN-BC Assistant Professor Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Teresa J. Sakraida, PhD, RN Assistant Professor College of Nursing University of Colorado, Denver Aurora, Colorado

Karen Moore Schaefer, PhD, RN Associate Chair and Associate Professor, Retired Department of Nursing College of Health Professions Temple University Philadelphia, Pennsylvania

Ann M. Schreier, PhD, RN Associate Professor College of Nursing East Carolina University Greenville, North Carolina

Carrie J. Scotto, PhD, RN Associate Professor College of Nursing University of Akron Akron, Ohio

Christina L. Sieloff, PhD, RN, NE, BC Associate Professor College of Nursing Montana State University Billings, Montana

Janet L. Stewart, PhD, RN Assistant Professor Department of Health Promotion and Development School of Nursing University of Pittsburgh Pittsburgh, Pennsylvania




Danuta M. Wojnar, PhD, RN, MEd, IBCLC Assistant Professor College of Nursing Seattle University Seattle, Washington

Joan E. Zetterlund, PhD, RN Professor Emerita of Nursing School of Nursing North Park University Chicago, Illinois




Jean Logan, RN, PhD Professor Grand View University Des Moines, Iowa

Karen Pennington, PhD, RN Associate Professor Regis University Denver, Colorado


Nancy Stahl, RN, MSN, CNE Associate Professor BSN Coordinator University of North Georgia Dahlonega, Georgia




About the Editor

Martha Raile Alligood is professor emeritus at East Carolina University College of Nursing in Greenville, North Carolina, where she was Director of the Nursing PhD program. A graduate of Good Samaritan School of Nursing, she also holds a bachelor of sacred literature (BSL) from Johnson University, a BSN from University of Virginia, an MS from The Ohio State University, and a PhD from New York University.

Her career in nursing education began in Zimbabwe (formerly Rhodesia) in Africa and has included graduate appointments at the University of Florida, University of South Carolina, and University of Tennessee. Among her professional memberships are Epsilon and Beta Nu Chapters of Sigma Theta Tau International (STTI), Southern Nursing Research Society (SNRS), North Carolina Nurses Association/American Nurses Association (NCNA/ANA), and Society of Rogerian Scholars (SRS).

A recipient of numerous awards and honors, she is a Fellow of the National League for Nursing (NLN) Acad- emy of Nursing Education, received the SNRS Leadership in Research Award, and was honored with the East Carolina University Chancellors’s Women of Distinction Award. A member of the Board of Trustees at Johnson University, Dr. Alligood chairs the Academic Affairs Committee.

She served as contributing editor for the Theoretical Concerns column in Nursing Science Quarterly, Vol. 24, 2011, and is author/editor of Nursing Theory: Utilization & Application, fifth edition, as well as this eighth edition of Nursing Theorists and Their Work.




This book is a tribute to nursing theorists and a classic in theoretical nursing literature. It presents many major thinkers in nursing, reviews their important knowledge-building ideas, lists their publications, and points the reader to those using the works and writing about them in their own theoretical publications. Unit I introduces the text with a brief history of nursing knowledge development and its significance to the

discipline and practice of the profession in Chapter 1. Other chapters in Unit I discuss the history, philosophy of science and the framework for analysis used throughout the text, logical reasoning and theory development processes, and the structure of knowledge and types of knowledge within that structure. Ten works from earlier editions of Nursing Theorists and Their Work are introduced and discussed briefly as nursing theorists of historical significance in Chapter 5. They are Peplau; Henderson; Abdellah; Wiedenbach; Hall; Travelbee; Barnard; Adam; Roper, Logan, Tierney, and Orlando.

In Unit II, the philosophies of Nightingale, Watson, Ray, Benner, Martinsen, and Eriksson are presented. Unit III includes nursing models by Levine, Rogers, Orem, King, Neuman, Roy, and Johnson. The work of Boykin and Schoenhofer begins Unit IV on nursing theory, followed by the works of Meleis; Pender; Leininger; Newman; Parse; Erickson, Tomlin, and Swain; and the Husteds. Unit V presents middle range theoretical works of Mercer; Mishel; Reed; Wiener and Dodd; Eakes, Burke, and Hainsworth; Barker; Kolcaba; Beck; Swanson; Ruland and Moore. Unit VI addresses the state of the art and science of nursing theory from three perspectives: the philosophy of nursing science, the expansion of theory development, and the global nature and expanding use of nursing theoretical works.

The works of nurse theorists from around the world are featured in this text, including works by international theorists that have been translated into English. Nursing Theorists and Their Work has also been translated into numerous languages for nursing faculty and students in other parts of the world as well as nurses in practice.

Nurses and students at all stages of their education are interested in learning about nursing theory and the use of nurse theorist works from around the world. Those who are just beginning their nursing education, such as associate degree and baccalaureate students, will be interested in the concepts, definitions, and theoreti- cal assertions. Graduate students, at the masters and doctoral levels, will be more interested in the logical form, acceptance by the nursing community, the theoretical sources for theory development, and the use of empirical data. The references and extensive bibliographies are particularly useful to graduate students for locating primary and secondary sources that augment the websites specific to the theorist. The following comprehensive websites are excellent resources with information about theory resources and links to the individual theorists featured in this book:

• Nursing Theory link page, Clayton College and State University, Department of Nursing: http: //www. healthsci.clayton.edu/eichelberger/nursing.htm

• Nursing Theory page, Hahn School of Nursing and Health Science, University of San Diego: http: //www. sandiego.edu/academics/nursing/theory/

• A comprehensive collection of nursing theory media, The Nurse Theorists: Portraits of Excellence, Vol. I and Vol. II and Nurse Theorists: Excellence in Action: http: //www.fitne.net/

The works of the theorists presented in this text have stimulated phenomenal growth in nursing literature and enriched the professional lives of nurses around the world by guiding nursing research, education, administra- tion, and practice. The professional growth continues to multiply as we analyze and synthesize these works,





generate new ideas, and develop new theory and applications for education in the discipline and quality care in practice by nurses.

The work of each theorist is presented with a framework using the following headings to facilitate uniformity and comparison among the theorists and their works:

• Credentials and background • Theoretical sources for theory development • Use of empirical data • Major concepts and definitions • Major assumptions • Theoretical assertions • Logical form • Acceptance by the nursing community • Further development • Critique of the work • Summary • Case study based on the work • Critical thinking activities • Points for further study • References and bibliographies

Acknowledgments I am very thankful to the theorists who critiqued the original and many subsequent chapters about themselves to keep the content current and accurate. The work of Paterson and Zderad was omitted at their request.

I am very grateful to those who have contributed or worked behind the scenes with previous editions to develop this text over the years. In the third edition, Martha Raile Alligood joined Ann Marriner Tomey, to reorder the chapters, serve as a contributing author, and edit for consistency with the new organization of the text. Subsequently Dr. Tomey recommended Dr. Alligood to Mosby-Elsevier to design and coedit a practice focused text, Nursing Theory: Utilization and Application and based on Alligood’s expertise in nursing theory, invited her to become coeditor and contributing author to future editions of this text, Nursing Theorists and Their Work. I want to recognize and thank Ann Marriner Tomey for her vision to develop the first six editions of this book. Her mentorship, wisdom, and collegial friendship have been special to me in my professional career. Most of all, she is to be commended for her dedication to this text that continues to make an important and valuable contribution to the discipline and the profession of nursing. I wish Ann well in her retirement.

Finally, I would like to thank the publishers at Mosby-Elsevier for their guidance and assistance through the years to bring this text to this eighth edition. The external reviews requested by Mosby-Elsevier editors have contributed to the successful development of each new edition. The chapter authors who over the years have contributed their expert knowledge of the theorists and their work continue to make a most valuable contribution.

Martha Raile Alligood




UNIT I Evolution of Nursing Theories 1 Introduction to Nursing Theory: Its History, Significance, and Analysis, 2 Martha Raile Alligood

2 History and Philosophy of Science, 14 Sonya R. Hardin

3 Theory Development Process, 23 Sonya R. Hardin

4 The Structure of Specialized Nursing Knowledge, 38 Martha Raile Alligood

5 Nursing Theorists of Historical Significance, 42 Marie E. Pokorny

Hildegard E. Peplau Virginia Henderson Faye Glenn Abdellah Ernestine Wiedenbach Lydia Hall Joyce Travelbee Kathryn E. Barnard Evelyn Adam Nancy Roper, Winifred W. Logan, and Alison J. Tierney Ida Jean (Orlando) Pelletier

UNIT II Nursing Philosophies 6 Florence Nightingale: Modern Nursing, 60 Susan A. Pfettscher

7 Jean Watson: Watson’s Philosophy and Theory of Transpersonal Caring, 79 D. Elizabeth Jesse and Martha R. Alligood

8 Marilyn Anne Ray: Theory of Bureaucratic Caring, 98 Sherrilyn Coffman

9 Patricia Benner: Caring, Clinical Wisdom, and Ethics in Nursing Practice, 120 Karen A. Brykczynski

10 Kari Martinsen: Philosophy of Caring, 147 Herdis Alvsvåg

11 Katie Eriksson: Theory of Caritative Caring, 171 Unni Å. Lindström, Lisbet Lindholm Nyström, and Joan E. Zetterlund





UNIT III Nursing Conceptual Models 12 Myra Estrin Levine: The Conservation Model, 204 Karen Moore Schaefer

13 Martha E. Rogers: Unitary Human Beings, 220 Mary E. Gunther

14 Dorothea E. Orem: Self-Care Deficit Theory of Nursing, 240 Violeta A. Berbiglia and Barbara Banfield

15 Imogene M. King: Conceptual System and Middle-Range Theory of Goal Attainment, 258 Christina L. Sieloff and Patricia R. Messmer

16 Betty Neuman: Systems Model, 281 Theresa G. Lawson

17 Sister Callista Roy: Adaptation Model, 303 Kenneth D. Phillips and Robin Harris

18 Dorothy E. Johnson: Behavioral System Model, 332 Bonnie Holaday

UNIT IV Nursing Theories 19 Anne Boykin and Savina O. Schoenhofer: The Theory of Nursing as Caring: A Model for

Transforming Practice, 358 Marguerite J. Purnell

20 Afaf Ibrahim Meleis: Transitions Theory, 378 Eun-Ok Im

21 Nola J. Pender: Health Promotion Model, 396 Teresa J. Sakraida

22 Madeleine M. Leininger: Culture Care Theory of Diversity and Universality, 417 Marilyn R. McFarland

23 Margaret A. Newman: Health as Expanding Consciousness, 442 Janet Witucki Brown and Martha Raile Alligood

24 Rosemarie Rizzo Parse: Humanbecoming, 464 Debra A. Bournes and Gail J. Mitchell

25 Helen C. Erickson, Evelyn M. Tomlin, Mary Ann P. Swain: Modeling and Role-Modeling, 496

Margaret E. Erickson

26 Gladys L. Husted and James H. Husted: Symphonological Bioethical Theory, 520 Carrie Scotto

UNIT V Middle Range Nursing Theories 27 Ramona T. Mercer: Maternal Role Attainment—Becoming a Mother, 538 Molly Meighan

28 Merle H. Mishel: Uncertainty in Illness Theory, 555 Donald E. Bailey, Jr. and Janet L. Stewart



Contents xvii

29 Pamela G. Reed: Self-Transcendence Theory, 574 Doris D. Coward

30 Carolyn L. Wiener and Marylin J. Dodd: Theory of Illness Trajectory, 593 Janice Penrod, Lisa Kitko, and Gwen McGhan

31 Georgene Gaskill Eakes, Mary Lermann Burke, and Margaret A. Hainsworth: Theory of Chronic Sorrow, 609

Ann M. Schreier and Nellie S. Droes

32 Phil Barker: The Tidal Model of Mental Health Recovery, 626 Nancy Brookes

33 Katharine Kolcaba: Theory of Comfort, 657 Thérèse Dowd

34 Cheryl Tatano Beck: Postpartum Depression Theory, 672 M. Katherine Maeve

35 Kristen M. Swanson: Theory of Caring, 688 Danuta M. Wojnar

36 Cornelia M. Ruland and Shirley M. Moore: Peaceful End-of-Life Theory, 701 Patricia A. Higgins and Dana M. Hansen

UNIT VI The Future of Nursing Theory 37 State of the Art and Science of Nursing Theory, 712 Martha Raile Alligood

Index, 721



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n Searching for specialized nursing knowledge led nurse scholars to theories that guide research, education, administration, and professional practice.

n Nursing followed a path from concepts to conceptual frameworks to models to theories, and finally to middle range theory, in this theory utilization era.

n Nursing history demonstrates the significance of theory for nursing as a division of education (the discipline) and a specialized field of practice (the profession).

n Knowledge of the theory development process is basic to a personal understanding of the theoretical works of the discipline.

n Analysis facilitates learning through systematic review and critical reflection of the theoretical works of the discipline.

n Theory analysis begins the process of identifying a decision making framework for nursing research or nursing practice.

Evolution of Nursing Theories





“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).

Introduction to Nursing Theory: Its History, Significance, and Analysis

Martha Raile Alligood

C H A P T E R 1

Bixler, 1959; Chinn & Kramer, 2011; George, 2011; Im & Chang, 2012; Judd, Sitzman & Davis, 2010; Meleis, 2007; Shaw, 1993).

This text is designed to introduce the reader to nursing theorists and their work. Nursing theory became a major theme in the last century, and it con- tinues today to stimulate phenomenal professional growth and expansion of nursing literature and edu- cation. Selected nursing theorists are presented in this text to expose students at all levels of nursing to a broad range of nurse theorists and various types of theoretical works. Nurses of early eras delivered excellent care to patients; however, much of what was known about nursing was passed on through forms of education that were focused on skills and functional tasks. Whereas many nursing practices seemed effective, they were not tested nor used uni- formly in practice or education. Therefore, a major goal put forth by nursing leaders in the twentieth century was the development of nursing knowledge on which to base nursing practice, improve quality of care, and gain recognition of nursing as a profession. The history of nursing clearly documents sustained efforts toward the goal of developing a specialized body of nursing knowledge to guide nursing practice (Alligood, 2010a; Alligood & Tomey, 1997; Bixler &

Previous authors: Martha Raile Alligood, Elizabeth Chong Choi, Juanita Fogel Keck, and Ann Marriner Tomey.

This chapter introduces nursing theory from three different perspectives: history, significance, and anal- ysis. Each perspective contributes understanding of the contributions of the nursing theorists and their work. A brief history of nursing development from vocational to professional describes the search for nursing substance that led to this exciting time in nursing history as linkages were strengthened be- tween nursing as an academic discipline and as pro- fessional practice. The history of this development provides context and a perspective to understand the continuing significance of nursing theory for the dis- cipline and profession of nursing. The history and significance of nursing theory leads logically into analysis, the third section of the chapter and final perspective. Analysis of nursing theoretical works and its role in knowledge development is presented as an essential process of critical reflection. Criteria for analysis of the works of theorists are presented, along with a brief discussion of how each criterion



CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 3

and individual hospital procedure manuals (Alligood, 2010a; Kalisch & Kalisch, 2003). Although some nurs- ing leaders aspired for nursing to be recognized as a profession and become an academic discipline, nursing practice continued to reflect its vocational heritage more than a professional vision. The transition from vocation to profession included successive eras of his- tory as nurses began to develop a body of specialized knowledge on which to base nursing practice. Nurs- ing had begun with a strong emphasis on practice, and nurses worked throughout the century toward the development of nursing as a profession. Progress toward the goal of developing a specialized basis for nursing practice has been viewed from the perspec- tive of historical eras recognizing the thrust toward professional development within each era (Alligood, 2010a; Alligood & Tomey, 1997).

The curriculum era addressed the question of what content nurses should study to learn how to be a nurse. During this era, the emphasis was on what courses nursing students should take, with the goal of arriving at a standardized curriculum (Alligood, 2010a). By the mid-1930s, a standardized curriculum had been published and adopted by many diploma programs. However, the idea of moving nursing edu- cation from hospital-based diploma programs into colleges and universities also emerged during this era (Judd, Sitzman & Davis, 2010). In spite of this early idea for nursing education, it was the middle of the century before many states acted upon this goal, and during the second half of the twentieth century, diploma programs began closing and significant numbers of nursing education programs opened in colleges and universities (Judd, Sitzman, & Davis, 2010; Kalisch & Kalisch, 2003). The curriculum era emphasized course selection and content for nursing programs and gave way to the research era, which focused on the research process and the long-range goal of acquiring substantive knowledge to guide nursing practice.

As nurses increasingly sought degrees in higher education, the research emphasis era began to emerge. This era began during the mid-century as more nurse leaders embraced higher education and arrived at a common understanding of the scientific age—that research was the path to new nursing knowledge. Nurses began to participate in research, and research courses were included in the nursing curricula of early

contributes to a deeper understanding of the work (Chinn & Kramer, 2011).

History of Nursing Theory The history of professional nursing began with Flor- ence Nightingale. Nightingale envisioned nurses as a body of educated women at a time when women were neither educated nor employed in public service. Following her wartime service of organizing and car- ing for the wounded in Scutari during the Crimean War, Nightingale’s vision and establishment of a School of Nursing at St. Thomas’ Hospital in London marked the birth of modern nursing. Nightingale’s pioneering activities in nursing practice and education and her subsequent writings became a guide for establishing nursing schools and hospitals in the United States at the beginning of the twentieth century (Kalisch & Kalisch, 2003; Nightingale, 1859/1969).

Nightingale’s (1859/1969) vision of nursing has been practiced for more than a century, and theory development in nursing has evolved rapidly over the past 6 decades, leading to the recognition of nursing as an academic discipline with a specialized body of knowledge (Alligood, 2010a, 2010b; Alligood & Tomey, 2010; Bixler & Bixler, 1959; Chinn & Kramer, 2011; Fawcett, 2005; Im & Chang, 2012; Walker & Avant, 2011). It was during the mid-1800s that Night- ingale recognized the unique focus of nursing and declared nursing knowledge as distinct from medical knowledge. She described a nurse’s proper function as putting the patient in the best condition for nature (God) to act upon him or her. She set forth the follow- ing: that care of the sick is based on knowledge of persons and their surroundings—a different knowl- edge base than that used by physicians in their prac- tice (Nightingale, 1859/1969). Despite this early edict from Nightingale in the 1850s, it was 100 years later, during the 1950s, before the nursing profession began to engage in serious discussion of the need to develop nursing knowledge apart from medical knowledge to guide nursing practice. This beginning led to aware- ness of the need to develop nursing theory (Alligood, 2010a; Alligood, 2004; Chinn & Kramer, 2011; Meleis, 2007; Walker & Avant, 2011). Until the emergence of nursing as a science in the 1950s, nursing practice was based on principles and traditions that were handed down through an apprenticeship model of education



UNIT I Evolution of Nursing Theories4

developing graduate nursing programs (Alligood, 2010a). In the mid-1970s, an evaluation of the first 25 years of the journal Nursing Research revealed that nursing studies lacked conceptual connections and theoretical frameworks, accentuating the need for conceptual and theoretical frameworks for develop- ment of specialized nursing knowledge (Batey, 1977). Awareness of the need for concept and theory devel- opment coincided with two other significant mile- stones in the evolution of nursing theory. The first milestone is the standardization of curricula for nurs- ing master’s education by the National League for Nursing accreditation criteria for baccalaureate and higher-degree programs, and the second is the deci- sion that doctoral education for nurses should be in nursing (Alligood, 2010a).

The research era and the graduate education era developed in tandem. Master’s degree programs in nursing emerged across the country to meet the pub- lic need for nurses for specialized clinical nursing practice. Many of these graduate programs included a course that introduced the student to the research process. Also during this era, nursing master’s pro- grams began to include courses in concept develop- ment and nursing models, introducing students to early nursing theorists and knowledge development processes (Alligood, 2010a). Development of nursing knowledge was a major force during this period. The baccalaureate degree began to gain wider acceptance as the first educational level for professional nursing, and nursing attained nationwide recognition and acceptance as an academic discipline in higher edu- cation. Nurse researchers worked to develop and clarify a specialized body of nursing knowledge, with the goals of improving the quality of patient care, providing a professional style of practice, and achiev- ing recognition as a profession. There were debates and discussions in the 1960s regarding the proper direction and appropriate discipline for nursing knowledge development. In the 1970s, nursing con- tinued to make the transition from vocation to pro- fession as nurse leaders debated whether nursing should be other-discipline based or nursing based. History records the outcome, that nursing practice is to be based on nursing science (Alligood, 2010a; Fawcett, 1978; Nicoll, 1986). It is as Meleis (2007) noted, “theory is not a luxury in the discipline of nursing . . . but an integral part of the nursing lexicon

in education, administration, and practice” (p. 4). An important precursor to the theory era was the gen- eral acceptance of nursing as a profession and an academic discipline in its own right.

The theory era was a natural outgrowth of the re- search and graduate education eras (Alligood, 2010a; Im & Chang, 2012). The explosive proliferation of nursing doctoral programs from the 1970s and nursing theory literature substantiated that nursing doctorates should be in nursing (Nicoll, 1986, 1992, 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, 2009; 2012). As understanding of research and knowledge development increased, it became obvi- ous that research without conceptual and theoretical frameworks produced isolated information. Rather, there was an understanding that research and theory together were required to produce nursing science (Batey, 1977; Fawcett, 1978; Hardy, 1978). Doctoral education in nursing began to flourish with the introduction of new programs and a strong emphasis on theory development and testing. The theory era accelerated as works began to be recognized as theory, having been developed as frameworks for curricula and advanced practice guides. In fact, it was at the Nurse Educator Conference in New York City in 1978 that theorists were recognized as nurs- ing theorists and their works as nursing conceptual models and theories (Fawcett, 1984; Fitzpatrick & Whall, 1983).

The 1980s was a period of major developments in nursing theory that has been characterized as a tran- sition from the pre-paradigm to the paradigm period (Fawcett, 1984; Hardy, 1978; Kuhn, 1970). The pre- vailing nursing paradigms (models) provided per- spectives for nursing practice, administration, educa- tion, research, and further theory development. In the 1980s, Fawcett’s seminal proposal of four global nursing concepts as a nursing metaparadigm served as an organizing structure for existing nursing frame- works and introduced a way of organizing individual theoretical works in a meaningful structure (Fawcett, 1978, 1984, 1993; Fitzpatrick & Whall, 1983). Clas- sifying the nursing models as paradigms within a metaparadigm of the person, environment, health, and nursing concepts systematically united the nurs- ing theoretical works for the discipline. This system clarified and improved comprehension of knowledge development by positioning the theorists’ works in a



CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 5

larger context, thus facilitating the growth of nursing science (Fawcett, 2005). The body of nursing science and research, education, administration, and prac- tice continues to expand through nursing scholar- ship. In the last decades of the century, emphasis shifted from learning about the theorists to utiliza- tion of the theoretical works to generate research questions, guide practice, and organize curricula. Evidence of this growth of theoretical works has pro- liferated in podium presentations at national and international conferences, newsletters, journals, and books written by nurse scientists who are members of societies as communities of scholars for nursing models and theories. Members contribute to the gen- eral nursing literature and communicate their re- search and practice with a certain paradigm model or framework at conferences of the societies where they present their scholarship and move the science of the selected paradigm forward (Alligood, 2004; Alligood 2014, in press; Fawcett & Garity, 2009; Im & Chang, 2012; Parker, 2006).

These observations of nursing theory develop- ment bring Kuhn’s (1970) description of normal science to life. His philosophy of science clarifies our understanding of the evolution of nursing theory through paradigm science. It is important histori- cally to understand that what we view collectively today as nursing models and theories is the work of individuals in various areas of the country who pub- lished their ideas and conceptualizations of nursing. These works later were viewed collectively within a systematic structure of knowledge according to analysis and evaluation (Fawcett, 1984, 1993, 2005). Theory development emerged as a process and prod- uct of professional scholarship and growth among nurse leaders, administrators, educators, and practi- tioners who sought higher education. These leaders recognized limitations of theory from other disci- plines to describe, explain, or predict nursing out- comes, and they labored to establish a scientific basis for nursing management, curricula, practice, and research. The development and use of theory con- veyed meaning for nursing processes, resulting in what is recognized today as the nursing theory era (Alligood, 2010a; Alligood 2010b; Nicoll, 1986, 1992, 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, 2012; Wood, 2010). It was as Fitzpatrick and Whall (1983) had said, “. . . nursing is on the brink of an

exciting new era” (p. 2). This awareness ushered in the theory utilization era.

The accomplishments of normal science accompa- nied the theory utilization era as emphasis shifted to theory application in nursing practice, education, administration, and research (Alligood, 2010c; Wood, 2010). In this era, middle-range theory and valuing of a nursing framework for thought and action of nursing practice was realized. This shift to the appli- cation of nursing theory was extremely important for theory-based nursing, evidence-based practice, and future theory development (Alligood, 2011a; Alligood, 2014, in press; Alligood & Tomey, 2010; Alligood & Tomey, 1997, 2002, 2006; Chinn & Kramer, 2011; Fawcett, 2005; Fawcett & Garity, 2009).

The theory utilization era has restored a balance between research and practice for knowledge devel- opment in the discipline of nursing. The reader is referred to the fifth edition of Nursing Theory: Utili- zation & Application (Alligood, 2014, in press) for case applications and evidence of outcomes from utilization of nursing theoretical works in practice. Table 1-1 presents a summary of the eras of nursing’s search for specialized nursing knowledge. Each era addressed nursing knowledge in a unique way that contributed to the history. Within each era, the per- vading question “What is the nature of the knowl- edge that is needed for the practice of nursing?” was addressed at a level of understanding that prevailed at the time (Alligood, 2010a).

This brief history provides some background and context for your study of nursing theorists and their work. The theory utilization era continues today, emphasizing the development and use of nursing theory and producing evidence for professional practice. New theory and new methodologies from qualitative research approaches continue to expand ways of knowing among nurse scientists. The utili- zation of nursing models, theories, and middle- range theories for the thought and action of nursing practice contributes important evidence for quality care in all areas of practice in the twenty-first century (Alligood, 2010b; Fawcett, 2005; Fawcett & Garity, 2009; Peterson, 2008; Smith & Leihr, 2008; Wood, 2010). Preparation for practice in the pro- fession of nursing today requires knowledge of and use of the theoretical works of the discipline (Alligood, 2010c).



UNIT I Evolution of Nursing Theories6

Significance of Nursing Theory At the beginning of the twentieth century, nursing was not recognized as an academic discipline or a profession. The accomplishments of the past century led to the recognition of nursing in both areas. The terms discipline and profession are interrelated, and some may even use them interchangeably; however they are not the same. It is important to note their differences and specific meaning, as noted in Box 1-1:

The achievements of the profession over the past century were highly relevant to nursing science devel- opment, but they did not come easily. History shows that many nurses pioneered the various causes and challenged the status quo with creative ideas for both the health of people and the development of nursing. Their achievements ushered in this exciting time when nursing became recognized as both an aca- demic discipline and a profession (Fitzpatrick, 1983; Kalisch & Kalisch, 2003; Meleis, 2007; Shaw, 1993). This section addresses the significance of theoretical works for the discipline and the profession of nursing. Nursing theoretical works represent the most com- prehensive presentation of systematic nursing knowl- edge; therefore, nursing theoretical works are vital to the future of both the discipline and the profession of nursing.

Significance for the Discipline Nurses entered baccalaureate and higher-degree programs in universities during the last half of the twentieth century, and the goal of developing knowl- edge as a basis for nursing practice began to be real- ized. University baccalaureate programs proliferated, master’s programs in nursing were developed, and

TA B L E 1-1 Historical Eras of Nursing’s Search for Specialized Knowledge

Historical Eras Major Question Emphasis Outcomes Emerging Goal

Curriculum Era:

1900 to 1940s

What curriculum content should student nurses study to be nurses?

Courses included in nursing programs

Standardized curricula for diploma programs

Develop specialized knowledge and higher education

Research Era: 1950 to 1970s

What is the focus for nursing research?

Role of nurses and what to research

Problem studies and studies of nurses

Isolated studies do not yield unified knowledge

Graduate Edu- cation Era:

1950 to 1970s

What knowledge is needed for the practice of nursing?

Carving out an advanced role and basis for nursing practice

Nurses have an impor- tant role in health care

Focus graduate educa- tion on knowledge development

Theory Era: 1980 to 1990s

How do these frame- works guide research and practice?

There are many ways to think about nursing

Nursing theoretical works shift the focus to the patient

Theories guide nursing research and practice

Theory Utilization Era: Twenty-first


What new theories are needed to produce evidence of quality care?

Nursing theory guides research, practice, education, and administration

Middle-range theory may be from quanti- tative or qualitative approaches

Nursing frameworks produce knowledge (evidence) for quality care

Alligood, M. R. (2014, in press). Nursing theory: Utilization & application. Maryland Heights, (MO): Mosby-Elsevier.

n A discipline is specific to academia and refers to a branch of education, a department of learning, or a domain of knowledge.

n A profession refers to a specialized field of prac- tice, founded upon the theoretical structure of the science or knowledge of that discipline and accompanying practice abilities.

B OX 1-1 The Meaning of a Discipline and a Profession

Data from Donaldson, S. K., & Crowley, D. M. (1978). The discipline of nursing. Nursing Outlook, 26(2), 1113–1120.; Orem, D. (2001). Nursing: Concepts of practice (6th ed.). St. Louis: Mosby.; Styles, M. M. (1982). On nursing: Toward a new endowment. St. Louis: Mosby.



CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 7

a standardized curriculum was realized through accreditation. Nursing had passed through eras of gradual development, and nursing leaders offered their perspectives on the development of nursing sci- ence. They addressed significant disciplinary ques- tions about whether nursing was an applied science or a basic science (Donaldson & Crowley, 1978; Johnson, 1959; Rogers, 1970). History provides evidence of the consensus that was reached, and nursing doctoral programs began to open to generate nursing knowledge.

The 1970s was a significant period of development. In 1977, after Nursing Research had been published for 25 years, studies were reviewed comprehensively, and strengths and weaknesses were reported in the journal that year. Batey (1977) called attention to the impor- tance of nursing conceptualization in the research process and the role of a conceptual framework in the design of research for the production of science. This emphasis led the theory development era and moved nursing forward to new nursing knowledge for nursing practice. Soon the nursing theoretical works began to be recognized to address Batey’s call (Johnson, 1968, 1974; King, 1971; Levine, 1969; Neuman, 1974; Orem, 1971; Rogers, 1970; Roy, 1970).

In 1978, Fawcett presented her double helix meta- phor, now a classic publication, on the interdependent relationship of theory and research. Also at this time, nursing scholars such as Henderson, Nightingale, Orlando, Peplau, and Wiedenbach were recognized for the theoretical nature of their earlier writings. These early works were developed by educators as frameworks to structure curriculum content in nurs- ing programs. Similarly, Orlando’s (1961, 1972) theory was derived from the report of an early nationally funded research project designed to study nursing practice.

I attended the Nurse Educator Nursing Theory Conference in New York City in 1978, where the ma- jor theorists were brought together on the same stage for the first time. Most of them began their presenta- tions by stating that they were not theorists. Although complete understanding of the significance of these works for nursing was limited at the time, many in the audience seemed to be aware of the significance of the event. After the first few introductions, the audi- ence laughed at the theorists’ denial of being theorists and listened carefully as each theorist described the

theoretical work they had developed for curricula, research, or practice.

Also noteworthy, Donaldson and Crowley (1978) presented the keynote address at the Western Com- mission of Higher Education in Nursing Conference in 1977, just as their nursing doctoral program was about to open. They reopened the discussion of the nature of nursing science and the nature of knowl- edge needed for the discipline and the profession. The published version of their keynote address has be- come classic for students to learn about nursing and recognize the difference between the discipline and the profession. These speakers called for both basic and applied research, asserting that knowledge was vital to nursing as both a discipline and a profession. They argued that the discipline and the profession are inextricably linked, but failure to separate them from each other anchors nursing in a vocational rather than a professional view.

Soon nursing conceptual frameworks began to be used to organize curricula in nursing programs and were recognized as models that address the values and concepts of nursing. The creative conceptualiza- tion of a nursing metaparadigm (person, environ- ment, health, and nursing) and a structure of knowl- edge clarified the related nature of the collective works of major nursing theorists as conceptual frame- works and paradigms of nursing (Fawcett, 1984). This approach organized nursing works into a system of theoretical knowledge, developed by theorists at different times and in different parts of the country. Each nursing conceptual model was classified on the basis of a set of analysis and evaluation criteria (Fawcett, 1984; 1993). Recognition of the separate nursing works collectively with a metaparadigm um- brella enhanced the recognition and understanding of nursing theoretical works as a body of nursing knowledge. In short, the significance of theory for the discipline of nursing is that the discipline is dependent upon theory for its continued existence, that is, we can be a vocation, or we can be a discipline with a professional style of theory-based practice. The theoretical works have taken nursing to higher levels of education and practice as nurses have moved from the functional focus, or what nurses do, to a knowledge focus, or what nurses know and how they use what they know for thinking and decision mak- ing while concentrating on the patient.



UNIT I Evolution of Nursing Theories8

Frameworks and theories are structures about human beings and their health; these structures pro- vide nurses with a perspective of the patient for profes- sional practice. Professionals provide public service in a practice focused on those whom they serve. The nursing process is useful in practice, but the primary focus is the patient, or human being. Knowledge of persons, health, and environment forms the basis for recognition of nursing as a discipline, and this knowl- edge is taught to those who enter the profession. Every discipline or field of knowledge includes theoretical knowledge. Therefore, nursing as an academic disci- pline depends on the existence of nursing knowledge (Butts & Rich, 2011). For those entering the profes- sion, this knowledge is basic for their practice in the profession. Kuhn (1970), noted philosopher of science, stated, “The study of paradigms . . . is what mainly prepares the student for membership in the particular scientific community with which he [or she] will later practice” (p. 11). This is significant for all nurses, but it is particularly important to those who are entering the profession because “in the absence of a paradigm . . . all of the facts that could possibly pertain to the devel- opment of a given science are likely to seem equally relevant” (Kuhn, 1970, p. 15). Finally, with regard to the priority of paradigms, Kuhn states, “By studying them and by practicing with them, the members of their cor- responding community learn their trade” (Kuhn, 1970, p. 43). Master’s students apply and test theoreti- cal knowledge in their nursing practice. Doctoral students studying to become nurse scientists develop nursing theory, test theory, and contribute nursing sci- ence in theory-based and theory-generating research studies.

Significance for the Profession Not only is theory essential for the existence of nursing as an academic discipline, it is vital to the practice of professional nursing. Recognition as a profession was a less urgent issue as the twentieth century ended because nurses had made consistent progress toward professional status through the century. Higher-degree nursing is recognized as a profession today having used the criteria for a profession to guide development. Nursing development was the subject of numerous studies by sociologists. Bixler and Bixler (1959) pub- lished a set of criteria for a profession tailored to nurs- ing in the American Journal of Nursing (Box 1-2).

These criteria have historical value for enhancing our understanding of the developmental path that nurses followed. For example, a knowledge base that is well defined, organized, and specific to the discipline was formalized during the last half of the twentieth century, but this knowledge is not static. Rather, it continues to grow in relation to the profession’s goals for the human and social welfare of the society that nurses serve. So although the body of knowledge is important, the theories and research are vital to the discipline and the profession, so that new knowledge continues to be generated. The application of nursing knowledge in practice is a criterion that is currently at the forefront, with emphasis on accountability for nursing practice, theory-based evidence for nursing practice, and the growing recognition of middle-range theory for professional nursing practice (Alligood, 2014, in press).

1. Utilizes in its practice a well-defined and well- organized body of specialized knowledge [that] is on the intellectual level of the higher learning

2. Constantly enlarges the body of knowledge it uses and improves its techniques of education and service through use of the scientific method

3. Entrusts the education of its practitioners to institutions of higher education

4. Applies its body of knowledge in practical services vital to human and social welfare

5. Functions autonomously in the formulation of professional policy and thereby in the control of professional activity

6. Attracts individuals with intellectual and personal qualities of exalting service above personal gain who recognize their chosen occupation as a life work

7. Strives to compensate its practitioners by providing freedom of action, opportunity for continuous professional growth, and economic security

B OX 1-2 Criteria for Development of the Professional Status of Nursing

Data from Bixler, G. K., & Bixler, R. W. (1959). The professional status of nursing. American Journal of Nursing, 59(8), 1142–1146.



CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 9

In the last decades of the twentieth century, in anticipation of the new millennium, ideas targeted toward moving nursing forward were published. Styles (1982) described a distinction between the col- lective nursing profession and the individual profes- sional nurse and called for internal developments based on ideals and beliefs of nursing for continued professional development. Similarly, Fitzpatrick (1983) presented a historical chronicle of twentieth century achievements that led to the professional status of nursing. Both Styles (1982) and Fitzpatrick (1983) referenced a detailed history specific to the develop- ment of nursing as a profession. Now that nursing is recognized as a profession, emphasis in this text is placed on the relationship between nursing theoreti- cal works and the status of nursing as a profession. Similarities and differences have been noted in sets of criteria used to evaluate the status of professions; however, they all call for a body of knowledge that is foundational to the practice of the given profession (Styles, 1982).

As individual nurses grow in their professional status, the use of substantive knowledge for theory- based evidence for nursing is a quality that is charac- teristic of their practice (Butts & Rich, 2011). This commitment to theory-based evidence for practice is beneficial to patients in that it guides systematic, knowledgeable care. It serves the profession as nurses are recognized for the contributions they make to the health care of society. As noted previously in relation to the discipline of nursing, the development of knowl- edge is an important activity for nurse scholars to pursue. It is important that nurses have continued recognition and respect for their scholarly discipline and for their contribution to the health of society. Finally and most important, the continued recognition of nursing theory as a tool for the reasoning, critical thinking, and decision making required for quality nursing practice is important because of the following:

Nursing practice settings are complex, and the amount of data (information) confronting nurses is virtually endless. Nurses must analyze a vast amount of information about each patient and decide what to do. A theoretical approach helps practicing nurses not to be overwhelmed by the mass of information and to progress through the nursing process in an orderly manner. Theory

enables them to organize and understand what happens in practice, to analyze patient situations critically for clinical decision making; to plan care and propose appropriate nursing interven- tions; and to predict patient outcomes from the care and evaluate its effectiveness.

(Alligood, 2004, p. 247)

Professional practice requires a systematic approach that is focused on the patient, and the theoretical works provide just such perspectives of the patient. The theo- retical works presented in this text illustrate those various perspectives. Philosophies of nursing, concep- tual models of nursing, nursing theories, and middle- range theories provide the nurse with a view of the patient and a guide for data processing, evaluation of evidence, and decisions regarding action to take in practice (Alligood 2014, in press; Butts & Rich, 2011; Chinn & Kramer, 2011; Fawcett & Garity, 2009). With this background of the history and significance of nursing theory for the discipline and the profession, we turn to analysis of theory, a systematic process of critical reflection for understanding nursing theoreti- cal works (Chinn & Kramer, 2011).

Analysis of Theory Analysis, critique, and evaluation are methods used to study nursing theoretical works critically. Analysis of theory is carried out to acquire knowledge of theo- retical adequacy. It is an important process and the first step in applying nursing theoretical works to education, research, administration, or practice. The analysis criteria used for each theoretical work in this text are included in Box 1-3 with the questions that guide the critical reflection of analysis.

n Clarity: How clear is this theory? n Simplicity: How simple is this theory? n Generality: How general is this theory? n Accessibility: How accessible is this theory? n Importance: How important is this theory?

B OX 1-3 Analysis Questions to Determine Theoretical Adequacy

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



UNIT I Evolution of Nursing Theories10

The analysis process is useful for learning about the works and is essential for nurse scientists who intend to test, expand, or extend the works. When nurse scientists consider their research interests in the context of one of the theoretical works, areas for further development are discovered through the pro- cesses of critique, analysis, and critical reflection. Therefore, analysis is an important process for learn- ing, for developing research projects, and for expand- ing the science associated with the theoretical works of nursing in the future. Understanding a theoretical framework is vital to applying it in your practice.

Clarity Clarity and structure are reviewed in terms of seman- tic clarity and consistency and structural clarity and consistency. Clarity speaks to the meaning of terms used, and definitional consistency and structure speaks to the consistent structural form of terms in the the- ory. Analysis begins as the major concepts and sub- concepts and their definitions are identified. Words have multiple meanings within and across disciplines; therefore, a word should be defined carefully and specifically according to the framework (philosophy, conceptual model, or theory) within which it is de- veloped. Clarity and consistency are facilitated with diagrams and examples. The logical development and type of structure used should be clear, and assumptions should be stated clearly and be consistent with the goal of the theory (Chinn & Kramer, 2011; Reynolds, 1971; Walker & Avant, 2011). Reynolds (1971) speaks to intersubjectivity and says, “There must be shared agreement of the definitions of concepts and relation- ships between concepts within a theory” (p. 13). Hardy (1973) refers to meaning and logical adequacy and says, “Concepts and relationships between concepts must be clearly identified and valid” (p. 106). Ellis (1968) used “the criterion of terminology” to evaluate theory and warns about “the danger of lost meaning when terms are borrowed from other disciplines and used in a different context” (p. 221). Walker and Avant (2011) assess “logical adequacy” according to “the logical structure of the concepts and statements” pro- posed in the theory (p. 195).

Simplicity Simplicity is highly valued in nursing theory devel- opment. Chinn and Kramer (2011) called for simple

forms of theory, such as middle range, to guide prac- tice. A theory should be sufficiently comprehensive, presented at a level of abstraction to provide guid- ance, and have as few concepts as possible with simplistic relations to aid clarity. Reynolds (1971) contends, “The most useful theory provides the greatest sense of understanding” (p. 135). Walker and Avant (2011) describe theory parsimony as “brief but com- plete” (p. 195).

Generality The generality of a theory speaks to the scope of application and the purpose within the theory (Chinn & Kramer, 2011). Ellis (1968) stated, “The broader the scope . . . the greater the significance of the the- ory” (p. 219). The generality of a theoretical work varies by how abstract or concrete it is (Fawcett, 2005). Understanding the levels of abstraction by doctoral students and nurse scientists facilitated the use of abstract frameworks for the development of middle-range theories. Rogers’ (1986) Theory of Accelerating Change is an example of an abstract theory from which numerous middle-range theories have been generated.

Accessibility Accessibility is linked to the empirical indicators for testability and ultimate use of a theory to describe aspects of practice (Chinn & Kramer, 2011). Acces- sible” addresses the extent to which empiric indica- tors for the concepts can be identified and to what extent the purposes of the theory can be attained” (Chinn & Kramer, 2011, p. 203). Reynolds (1971) evaluates empirical relevance by examining “the cor- respondence between a particular theory and the objective empirical data” (p. 18). He suggests that scientists should be able to evaluate and verify results by themselves. Walker and Avant (2011) evaluate testability based on the theory’s capacity to “generate hypotheses and be subjected to empirical research” (p. 195).

Importance A parallel can be drawn between outcome and impor- tance. Because research, theory, and practice are closely related, nursing theory lends itself to research testing, and research testing leads to knowledge for practice. Nursing theory guides research and practice,



CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 11

generates new ideas, and differentiates the focus of nursing from that of other professions (Chinn & Kramer, 2011). Ellis (1968) indicates that to be con- sidered useful, “it is essential for theory to develop and guide practice . . . theories should reveal what knowledge nurses must, and should, spend time pur- suing” (p. 220).

The five criteria for the analysis of theory—clarity, simplicity, generality, accessibility, and importance— guide the critical reflection of each theoretical work in Chapters 6 to 36. These broad criteria facilitate the analysis of theoretical works, whether they are applied to works at the level of philosophies, concep- tual models, theories, or middle-range theories.

Summary This chapter presents an introduction to nursing theory with a discussion of its history, significance, and analysis. A nurse increases professional power when using theoretical research as systematic evi- dence for critical thinking and decision making. When nurses use theory and theory-based evidence to structure their practice, it improves the quality of care. They sort patient data quickly, decide on appro- priate nursing action, deliver care, and evaluate out- comes. They also are able to discuss the nature of their practice with other health professionals. Con- sidering nursing practice in a theory context helps students to develop analytical skills and critical thinking ability and to clarify their values and as- sumptions. Theory guides practice, education, and research (Alligood 2014, in press; Chinn & Kramer, 2011; Fawcett, 2005; Meleis, 2007).

Globally, nurses are recognizing the rich heritage of the works of nursing theorists, that is, the philoso- phies, conceptual models, theories, and middle- range theories of nursing. The publication of this text in multiple (at least 10) languages reflects the global use of theory. The contributions of global theorists present nursing as a discipline and provide knowledge structure for further development. The use of theory-based research supports evidence- based practice. There is worldwide recognition of the rich diversity of nursing values the models rep- resent. Today we see added clarification of the theo- retical works in the nursing literature as more and more nurses learn and use theory-based practice. Most important, the philosophies, models, theories, and middle-range theories are used broadly in all areas—nursing education, administration, research, and practice.

There is recognition of normal science in the theoretical works (Wood, 2010). The scholarship of the past 3 decades has expanded the volume of nursing literature around the philosophies, mod- els, theories, and middle-range theories. Similarly, the philosophy of science has expanded and fos- tered nursing knowledge development with new qualitative approaches. As more nurses have ac- quired higher education, understanding of the im- portance of nursing theory has expanded. The use of theory by nurses has increased knowledge devel- opment and improved the quality of nursing prac- tice (Alligood, 2010a; Alligood, 2011b; Chinn & Kramer, 2011; Fawcett & Garity, 2009; George, 2011; Im & Chang, 2012; Reed & Shearer, 2012; Wood, 2010).

POINTS FOR FURTHER STUDY n Judd, D., Sitzman, K., & Davis, G. M. (2010). A his-

tory of American nursing. Boston: Jones & Bartlett. n The Nursing Theory Page at Hahn School of

Nursing, University of San Diego: Retrieved from: http://www.sandiego.edu/ACADEMICS/nursing/ theory.

n Donaldson, S. K., & Crowley, D. M. (1978). The disci- pline of nursing. Nursing Outlook, 26(2), 1113–1120.

n Fawcett, J. (1984). The metaparadigm of nursing: current status and future refinements. Image: The Journal of Nursing Scholarship, 16, 84–87.

n Kalisch, P. A., & Kalisch, B. J. (2003). American nursing: A history (4th ed.). Philadelphia: Lippincott Williams & Wilkins.



UNIT I Evolution of Nursing Theories12

Alligood, M. R. (2011a). The power of theoretical knowl- edge. Nursing Science Quarterly, 24(4), 304–305.

Alligood, M. R. (2011b). Theory-based practice in a major medical centre. The Journal of Nursing Management, 19, 981–988.

Alligood, M. R. (2014, in press). Nursing theory: Utilization & application, (5th ed.). Maryland Heights, (MO): Mosby-Elsevier.

Alligood, M. R. (2010a). The nature of knowledge needed for nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 3-15). St. Louis: Mosby.

Alligood, M. R. (2010b). Models and theories: critical thinking structures. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 43–65). St. Louis: Mosby.

Alligood, M. R. (2010c). Areas for further development of theory-based nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization & application (4th ed., pp. 487–497). St. Louis: Mosby.

Alligood, M. R. (2004). Nursing theory: the basis for professional nursing practice. In K. K. Chitty (Ed.), Professional nursing: Concepts and challenges (4th ed., pp. 271–298). Philadelphia: Saunders.

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Alligood, M. R., & Tomey, A. M. (Eds.). (2002). Nursing theory: Utilization & application (2nd ed.). St. Louis: Mosby.

Alligood, M. R., & Tomey, A. M. (Eds.). (2006). Nursing theory: Utilization & application (3rd ed.). St. Louis: Mosby.

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Batey, M. V. (1977). Conceptualization: knowledge and logic guiding empirical research. Nursing Research, 26(5), 324–329.

Bixler, G. K., & Bixler, R. W. (1959). The professional status of nursing. American Journal of Nursing, 59(8), 1142–1146.

Butts, J. B., & Rich, K. L. (2011). Philosophies and theories for advanced nursing practice. Sudbury, (MA): Jones & Bartlett.

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Fawcett, J. (1978). The relationship between theory and research: a double helix. Advances in Nursing Science, 1(1), 49–62.

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Johnson, D. (1968). One conceptual model for nursing. Unpublished paper presented at Vanderbilt University, Nashville,(TN).

Johnson, D. (1974). Development of the theory: a requisite for nursing as a primary health profession. Nursing Research, 23, 372–377.

Judd, D., Sitzman, K., & Davis, G. M. (2010). A history of American nursing. Boston: Jones & Bartlett.

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CHAPTER 1 Introduction to Nursing Theory: Its History, Significance, and Analysis 13

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“Why should nurses be interested in the history and philosophy of science? The history and philosophy of science is important as a foundation for exploring whether scientific results are actually

truth. As nurses our practice should be based upon truth and we need the ability to interpret the results of science. Nursing science provides us with knowledge to describe, explain and predict outcomes. The legitimacy of any profession is built on its ability to generate and apply theory.”

(McCrae, 2011, p. 222)

History and Philosophy of Science Sonya R. Hardin

C H A P T E R 2

Modern science was established over 400 years ago as an intellectual activity to formalize given phenomena of interest in an attempt to describe, explain, predict, or control states of affairs in nature. Scientific activity has persisted because it has improved quality of life and has satisfied human needs for creative work, a sense of order, and the desire to under- stand the unknown (Bronowski, 1979; Gale, 1979; Piaget, 1970). The development of nursing science has evolved since the 1960s as a pursuit to be understood as a scientific discipline. Being a scientific discipline means identifying nursing’s unique contribution to the care of patients, families, and communities. It means that nurses can conduct clinical and basic nursing research to establish the scientific base for the care of individuals across the life span. For example, research revealed gaps between the pain management needs of patients and the information communicated by patients and clinicians during office visits. Although many older adults have painful but not readily visible conditions (e.g., symptomatic osteoarthritis), little re- search has examined how the style or format of a health care practitioner’s questions influence the quality and amount of diagnostic information obtained from older

adults. A recent study tested the theory that a certain type of question would elicit the most response. The theory was confirmed when findings supported that the open-ended questions prompted patients to provide a larger amount of diagnostically useful pain informa- tion than did the closed-ended questions (McDonald, Shea, Rose, & Fedo, 2009). While this study is one example of nursing science, advance practice nurses should be familiar with the long history of the science of nursing.

Previous author: Sue Marquis Bishop.

Historical Views of the Nature of Science

To formalize the science of nursing, basic questions must be considered, such as: What is science, knowl- edge, and truth? What methods produce scientific knowledge? These are philosophical questions. The term epistemology is concerned with the theory of knowledge in philosophical inquiry. The particular philosophical perspective selected to answer these questions will influence how scientists perform sci- entific activities, how they interpret outcomes, and even what they regard as science and knowledge



CHAPTER 2 History and Philosophy of Science 15

additional research is conducted or modifications are made in the theory and further tests are devised; otherwise, the theory is discarded in favor of an alternative explanation (Gale, 1979; Zetterberg, 1966). Popper (1962) argued that science would evolve more rapidly through the process of conjectures and refuta- tions by devising research in an attempt to refute new ideas. For example, his point is simple; you can never prove that all individuals without social support have frequent rehospitalizations since there might be one individual that presents with no rehospitalization. A single person with no social support that does not have a readmission disproves the theory that all individuals with a lack of social support have hospital readmis- sions. From Popper’s perspective, “research consists of generating general hypotheses and then attempting to refute them” (Lipton, 2005, p. 1263). So the hypoth- esis that a lack of social support results in hospital readmission is the phenomena of interest to be refuted.

The rationalist view is most clearly evident in the work of Einstein, the theoretical physicist, who made extensive use of mathematical equations in developing his theories. The theories Einstein constructed offered an imaginative framework, which has directed research in numerous areas (Calder, 1979). As Reynolds (1971) noted, if someone believes that science is a process of inventing descriptions of phenomena, the appropriate strategy for theory construction is the theory-then- research strategy. In Reynolds’ view, “as the continuous interplay between theory construction (invention) and testing with empirical research progresses, the theory becomes more precise and complete as a description of nature and, therefore, more useful for the goals of science” (Reynolds, 1971, p. 145).

Empiricism The empiricist view is based on the central idea that scientific knowledge can be derived only from sensory experience (i.e., seeing, feeling, hearing facts). Francis Bacon (Gale, 1979) received credit for popularizing the basis for the empiricist approach to inquiry. Bacon believed that scientific truth was discovered through generalizing observed facts in the natural world. This approach, called the inductive method, is based on the idea that the collection of facts precedes attempts to formulate generalizations, or as Reynolds (1971) called it, the research-then-theory strategy. One of the best examples to demonstrate this form of logic in nursing

(Brown, 1977). Although philosophy has been docu- mented as an activity for 3000 years, formal science is a relatively new human pursuit (Brown, 1977; Foucault, 1973). Scientific activity has only recently become the object of investigation.

Two competing philosophical foundations of sci- ence, rationalism and empiricism, have evolved in the era of modern science with several variations. Gale (1979) labeled these alternative epistemologies as centrally concerned with the power of reason and the power of sensory experience. Gale noted similarity in the divergent views of science in the time of the classical Greeks. For example, Aristotle believed that advances in biological science would develop through systematic observation of objects and events in the natural world, whereas Pythagoras believed that knowl- edge of the natural world would develop from mathe- matical reasoning (Brown, 1977; Gale, 1979).

Nursing science has been characterized by two branching philosophies of knowledge as the discipline developed. Various terms are utilized to describe these two stances: empiricist and interpretive, mechanistic and holistic, quantitative and qualitative, and deductive and inductive forms of science. Understanding the nature of these philosophical stances facilitates appre- ciation for what each form contributes to nursing knowledge.

Rationalism Rationalist epistemology (scope of knowledge) empha- sizes the importance of a priori reasoning as the appropriate method for advancing knowledge. A priori reasoning utilizes deductive logic by reasoning from the cause to an effect or from a generalization to a particular instance. An example in nursing is to reason that a lack of soc

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