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Leadership the
Hard Way

Why Leadership Can’t Be Taught and
How You Can Learn It Anyway

by Dov Frohman

with Robert Howard

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More Praise for Leadership the Hard Way

“Dov Frohman is a giant of Israeli high tech. His book isn’t only
about leadership, it is about the human spirit and how high it can
soar. Frohman and Howard capture the expansive vision and non-
stop creativity that have made Israel one of the most advanced
centers of high-tech innovation in the world.”

—Yossi Vardi, chairman, International Technologies;
founding investor, Mirabillis Ltd., creator of ICQ

“From an early age, Frohman learned to transform fear of survival
into courageous action. Some lessons for leaders: stick to your
principles, welcome intelligent dissent, take time to daydream but
then make your dreams real. This book will stimulate you to refl ect
on your practice of leading people.”

—Michael Maccoby, author of The Gamesman and The Leaders
We Need, And What Makes Us Follow

“Dov Frohman distills thirty years of experience on the front lines
of the global economy—from Silicon Valley to Israel—in this
beautifully written and compelling narrative. His wisdom is not
just for business leaders, it’s for anyone seeking to lead in today’s
tumultuous environment.”

—AnnaLee Saxenian, dean of the School of Information,
UC Berkeley; author of The New Argonauts: Regional

Advantage in a Global Economy

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ffirs.indd iiffirs.indd ii 2/2/08 10:52:57 AM2/2/08 10:52:57 AM

Leadership the Hard Way

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This collection of books is devoted exclusively to new
and exemplary contributions to management thought
and practice. The books in this series are addressed to
thoughtful leaders, executives, and managers of all
organizations who are struggling with and committed
to responsible change. My hope and goal is to spark
new intellectual capital by sharing ideas positioned at
an angle to conventional thought—in short, to publish
books that disturb the present in the service of a
better future.

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Books in the Warren Bennis Signature Series

Branden Self-Esteem at Work
Mitroff, Denton A Spiritual Audit of Corporate

Schein The Corporate Culture

Survival Guide
Sample The Contrarian’s Guide to

Lawrence, Nohria Driven
Cloke, Goldsmith The End of Management and

the Rise of Organizational

Glen Leading Geeks
Cloke, Goldsmith The Art of Waking People Up
George Authentic Leadership
Kohlrieser Hostage at the Table
Rhode Moral Leadership
George True North
Townsend Up the Organization
Kellerman/Rhode Women and Leadership
Riggio The Art of Followership
Gergen/Vanourek Life Entrepreneurs

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Leadership the
Hard Way

Why Leadership Can’t Be Taught and
How You Can Learn It Anyway

by Dov Frohman

with Robert Howard

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Copyright © 2008 by Dov Frohman and Robert Howard. All rights reserved.

Published by Jossey-Bass
A Wiley Imprint
989 Market Street, San Francisco, CA 94103-1741—www.josseybass.com

No part of this publication may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, recording, scanning,
or otherwise, except as permitted under Section 107 or 108 of the 1976 United States
Copyright Act, without either the prior written permission of the publisher, or authorization
through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc.,
222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the Web
at www.copyright.com. Requests to the publisher for permission should be addressed to the
Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030,
201-748-6011, fax 201-748-6008, or online at www.wiley.com/go/permissions.

Readers should be aware that Internet Web sites offered as citations and/or sources for further
information may have changed or disappeared between the time this was written and when it
is read.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their
best efforts in preparing this book, they make no representations or warranties with respect
to the accuracy or completeness of the contents of this book and specifi cally disclaim any
implied warranties of merchantability or fi tness for a particular purpose. No warranty may
be created or extended by sales representatives or written sales materials. The advice and
strategies contained herein may not be suitable for your situation. You should consult with a
professional where appropriate. Neither the publisher nor author shall be liable for any loss
of profi t or any other commercial damages, including but not limited to special, incidental,
consequential, or other damages.

Jossey-Bass books and products are available through most bookstores. To contact Jossey-Bass
directly call our Customer Care Department within the U.S. at 800-956-7739, outside the
U.S. at 317-572-3986, or fax 317-572-4002.

Jossey-Bass also publishes its books in a variety of electronic formats. Some content that
appears in print may not be available in electronic books.

Library of Congress Cataloging-in-Publication Data

Frohman, Dov, 1939-
Leadership the hard way : why leadership can’t be taught and how you can learn it anyway /
Dov Frohman, Robert Howard. — 1st ed.
p. cm. — (The Warren Bennis series)
Includes bibliographical references and index.
ISBN 978-0-7879-9437-2 (cloth : alk. paper)
1. Leadership. I. Howard, Robert, 1954- II. Title.
HD57.7.F757 2008

Printed in the United States of America
HB Printing 10 9 8 7 6 5 4 3 2 1

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Foreword xi

Introduction: Flying Through a Thunderstorm xiii

1. Insisting on Survival 1

2. Leading Against the Current 17

3. Leveraging Random Opportunities 35

4. Leadership Under Fire 53

5. The Soft Skills of Hard Leadership 69

6. Making Values Real 85

7. Bootstrapping Leadership 99

Epilogue: Knowing When to Let Go 111

Notes 115

Acknowledgments 119

The Authors 123

Index 125

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To the memory of my three sets of parents:

Abraham and Feijga Frohman, Amsterdam
Antonie and Jenneke Van Tilborgh, Sprang Capelle

Lea and Moshe Bentchkowsky, Tel Aviv

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Every now and then, a person of great wisdom and integrity comes
along with a story that everyone needs to hear. Dov Frohman is
such a person. As a maverick in the fi eld of technology from the
earliest days, Dov has been an innovator, a questioner, a radical,
a champion, a sage, a survivor, and above all, a leader. He’s never
backed down from responsibility, and he’s faced some hair-raising
crises with unconventional methods and achieved undeniable
results. Under his guidance, Intel Israel became a key part of the
global company’s success and helped make Israel a real player in
the world’s high-tech market.

Even if this were solely a book of his personal stories, it would
be a very worthwhile read. These stories are highly engaging and
provide an insider’s view into one of the most competitive indus-
tries in the world, not to mention harrowing tales like his child-
hood spent in hiding in Nazi-occupied Holland or his decision
to keep Intel Israel open during the fi rst Gulf War, as Scuds were
raining down around the country. It was a highly risky and contro-
versial move, yet one characteristic of Dov’s commitment to his
company and his country.

Fortunately for us, however, this book is much more than a
memoir. Dov’s unique experiences have given him a perspective
on leadership you won’t fi nd anywhere else, and he’s spent many
years refl ecting on the most critical issues any leader or leader-to-
be might encounter. This book is like having a personal mentor—
someone who tells the truth about leadership, the good and the
bad, the easy calls, and the thorny dilemmas. Dov has stood in

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the trenches, weathered the loneliness along with the accolades,
and really dug deep into the role, and now we the readers get the
benefi t of his insights, which are by no means rote and always
authentic. We rarely see this kind of transparency from our leaders,
so take advantage of it while you can.

Santa Monica
January 2008

xii F O R E W O R D

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Flying Through a Thunderstorm

Few subjects have so preoccupied the business world in recent
years as that of leadership. Witness the explosion of articles,
books, training courses, and programs purporting to teach man-
agers how to lead. Since the early 1990s, for example, the Harvard
Business Review has published some 350 articles on the subject of
leadership — 135 of them since 2000 alone. Recently, one of the
world ’ s leading fi nancial – services companies, Merrill – Lynch, began
publishing an entire magazine devoted to the topic. 1 Initially
targeted at the company ’ s senior – management ranks, the magazine
aims eventually to attract a broad senior – executive audience.
And where business is going, the academy is never far behind.
Leadership has blossomed into a whole new fi eld of study. At some
universities, you can even get a Ph.D. in it! 2

I ’ m sure there is at least some value in all these efforts. But I ’ m
skeptical that they will produce more or better leaders. Indeed,
at the very moment that we are seeing so many efforts to teach
leadership, we are also experiencing widespread and continuous
failures of leadership — and not just in business but in politics,
education, and other institutions of modern society. Corporate
fraud brings down high – fl ying companies such as Enron. CEOs are
driven from offi ce due to unethical, and probably illegal, practices
involving the backdating of stock options. In the United States, at
a time of new and unprecedented global crises, a so – called “ MBA
president ” oversees what many see as one of the most incompetent

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xiv I N T R O D U C T I O N

and corrupt administrations in modern history. And in my native
Israel, polls suggest that leading politicians and military lead-
ers have lost the confidence of the nation over the way they
sleep – walked into the 2006 summer war with Hezbollah. In short,
there is a growing disconnect between our celebration of leader-
ship and what appears to be our systematic inability to practice it.

In my opinion, a major reason for this disconnect is that most
of the conventional wisdom about leadership today is, not wrong
exactly, but surprisingly irrelevant to the true challenges and
dilemmas of leading in today ’ s economy and society. The claim
of so many of the articles, books, and programs on the subject
seems to be that leadership is largely a matter of technique, a set
of skills that can be taught. If you read the right books or take
the right training courses, it should be relatively easy — indeed,
straightforward — to become a leader.

My thirty years on the front lines of the global economy have
taught me that precisely the opposite is the case. I believe that
learning how to lead is more in the nature of cultivating per-
sonal wisdom than it is of acquiring technical skills. No matter
how much training you have or how many books you have read,
nothing can fully prepare you for the challenge. In this respect,
leadership isn ’ t easy; it ’ s diffi cult, necessarily diffi cult. And the
most essential things about it cannot really be taught — although,
in the end, they can be learned.

Thunderstorm Over Greece

I ’ m an active pilot, so allow me to draw an analogy with learn-
ing how to fl y. When I decided in my fi fties to become a pilot,
I took lessons from the retired former head of Israel ’ s Air Force
A cademy. He was in his late sixties at the time; he is still fl ying
today in his eighties! A daredevil fi ghter pilot but a strictly by –
the – book instructor, he taught me the basics, what I like to think
of as “ Flying 101 ” : how to take off, navigate, read the instruments,
make a landing, and so on. He gave me the confi dence that I could
actually do it. But he would never let me make my own mistakes.

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I N T R O D U C T I O N xv

Whenever I did something wrong, he would immediately take
over and tell me what I needed to do to take corrective action. As
a result, I may have learned the basics of fl ying, but my knowledge
was abstract, and I was far from being an experienced pilot.

Later, when I bought a more advanced and technologically
complex airplane, I had a second teacher who trained me on the
avionic systems of my new plane. In contrast to my fi rst teacher, he
took a far more intuitive approach. When we went fl ying together,
he seldom intervened in the process. Rather, he stressed a set of
simple decision rules — and then let me go ahead, make my own
mistakes, and fi gure out how to recover from them. This taught me
how to start integrating the theory of fl ying with the practice of
actually piloting a plane.

Yet neither of these teachers really prepared me for the moment
I experienced a few years later when I was caught unexpectedly in
a sudden thunderstorm over the southern coast of Greece. I was
traveling with my family from our home in Jerusalem to our vaca-
tion home in the Dolomite Mountains of Italy. I had had my pilot ’ s
license for about four years and at the time was fl ying frequently,
at least once or twice a week. So I felt confi dent about making
the long trip. In addition, my son, who was twenty – five at the
time, also had his pilot ’ s license (although he was not qualifi ed to
fl y the particular model of plane that I owned, a single-propeller
Beechcraft Bonanza).

The first leg of the trip from Israel to the Greek island of
Rhodes was uneventful. And when we took off from Rhodes en
route to Corfu, where we were planning to spend the night, the
weather was fi ne. But as we headed toward Athens, we encoun-
tered an unanticipated obstacle. The air traffi c controller at the
Athens airport informed us that there were fl ight restrictions for
small planes over the Athens metropolitan area. So we had to
change our fl ight plan and take a more southwesterly route skirt-
ing the southern coast of Greece ’ s Peloponnesian peninsula.

My plane is equipped with a device known as a stormscope — an
avionics instrument that looks like a radar screen and uses data
from electrical discharge signals generated by lightning in the

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xvi I N T R O D U C T I O N

atmosphere to create a 360 – degree map of areas of severe weather
in the plane ’ s vicinity. We began to notice indications on the
stormscope of a major storm almost directly in our path, about fi fty
miles to the southwest and approaching quickly.

In a matter of minutes, the sky started clouding up. Soon
heavy rain, and then hail, began hitting the windshield. Thunder
pealed and long streaks of lightning shot across the sky. Before we
knew it, we were in the middle of the storm. Enormous updrafts
and downdrafts grabbed the plane, pulling it up and down two
thousand to three thousand feet at a time. The turbulence was gut –
wrenching. Helpless, I watched the altimeter circle furiously, fi rst
in one direction, then the next.

In his classic 1944 book about fl ying, Stick and Rudder, test pilot
Wolfgang Langewiesche makes the observation that “ what makes
flying so difficult is that the flier ’ s instincts — that is, his most
deeply established habits of mind and body — will tempt him to do
exactly the wrong thing. ” 3 The fi rst impulse of an inexperienced
pilot facing a sudden thunderstorm is to turn around and go back.
Sometimes that can actually be the right thing to do — if you have
suffi cient advance warning. But if a storm comes up quickly, turn-
ing back can be dangerous. Turning requires banking, and banking
accelerates the plane with the nose down. If the storm winds are
strong enough, they can force you into a dive, causing the plane to
stall and go into a spin. Without really thinking about it, I realized
immediately that it was far too late for us to turn back. There was
really no choice but to plow ahead.

Another common impulse when flying through a thun-
derstorm is to fi ght the turbulence, to try to correct the violent
updrafts and downdrafts by pushing down (or pulling up) on the
controls. But that is a critical mistake, because it can lead to such
stress on the wings as to cause the breakup of the plane. Rather,
surviving extreme turbulence requires another counterintuitive
trick: instead of fighting the turbulence, a pilot needs to let it
happen. Believe me, it is extremely diffi cult to consciously make
this choice. We were fl ying over high mountains. I had no idea

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I N T R O D U C T I O N xvii

how low the downdrafts would take us. But there was nothing to
do but just let it happen. I struggled simply to keep the wings level
as the violent updrafts and downdrafts took their course.

After about fi fteen minutes (which seemed like a lifetime)
on this aerial roller – coaster ride, my son, who was monitoring the
stormscope, saw a break in the storm to the northeast. We radi-
oed Athens for a change in course, and within about fi ve minutes
things began to calm down. Then, with no warning, we shot out
of the clouds, and almost as quickly as the storm had developed,
it passed. We fl ew on, chastened but relieved, to Corfu. That night
we learned from the news that a small Greek passenger jet, also
caught in the storm, had experienced an especially violent drop of
more than ten thousand feet. Five passengers who had neglected
to fasten their seatbelts were killed.

In the years since, I have often wondered precisely how I got us
through that storm. The answer is: I don ’ t really know. To be sure,
I had taken courses about fl ying in bad weather and had learned
what to do and what not to do. But once I was in the middle of the
storm, those lessons were far from my mind. There were too many
contingencies to handle in too short a period of time to apply those
lessons systematically. Instead, my reactions were immediate —
rapid responses to the developments of the moment, driven by my
realization that our very survival was at stake. We were skirting
the brink of disaster, and all my energy and efforts were focused
simply on getting us through. And, to be honest, there was also an
element of luck involved.

An Environment of Turbulence

My point: leadership in today ’ s economy is a lot like fl ying a plane
through a thunderstorm. More and more organizations fi nd them-
selves in an economic environment of nonstop turbulence. The
social, economic, and technological sources of that turbulence
are broadly familiar, but let me review them briefl y here. First and
foremost is the unrelenting pace of rapid technological change. “ We

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xviii I N T R O D U C T I O N

live in an age in which the pace of technological change is pulsating
ever faster, causing waves that spread outward toward all indus-
tries, ” former Intel CEO Andy Grove wrote more than ten years
ago. “ This increased rate of change will have an impact on you, no
matter what you do for a living. It will bring new competition from
new ways of doing things, from corners that you don ’ t expect. ” 4

With the rapid expansion and evolution of the Internet in
the years since Grove wrote those words, they are more true than
ever before. It ’ s not just that business value increasingly fl ows to
innovation — the ability to take risks and create fundamentally new
ways of doing things. Even the most innovative companies sooner
or later face what Harvard Business School professor Clayton
Christensen has termed the “ innovator ’ s dilemma ” — the supreme
diffi culty for those organizations that have succeeded at one gen-
eration of technology to continue to surf the wave of change and
remain successful over subsequent generations of technology. 5

Technologically driven turbulence is exacerbated by the ongo-
ing globalization of the world economy. In one respect, of course,
globalization is nothing new. Until quite recently, the world econ-
omy was probably more global in the fi rst decade of the twentieth
century than it has been at any time since. But whereas traditional
globalization was dominated by a few centers of economic devel-
opment that ruled over a vast periphery, today ’ s globalization is
different. Increasingly, the periphery is becoming the center. New
players have sprung up in places that used to be on the far edge of
the global economy. As they do, established companies are sud-
denly encountering new competitors that seem to come out of
nowhere and appear almost overnight. Ten years ago, who would
have thought that the world ’ s largest steel company, Arcelor
Mittal, would be owned by an Indian conglomerate? That IBM ’ s
PC business would be bought by a Chinese fi rm, Lenovo? Or that
a tiny country like Israel would have more than seventy compa-
nies listed on the U.S. NASDAQ stock exchange — and attract
twice as much venture capital investment as the entire European

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I N T R O D U C T I O N xix

Since September 11, 2001, business leaders have become
familiar with a third source of turbulence: new levels of geopo-
litical instability associated with global confl ict, environmental
catastrophe, terrorism, and war. The challenges that this insta-
bility poses for political leadership are dramatic (and, in my
opinion, our political leaders — whether in the United States or in
Israel — have not been equal to them). But they pose challenges
to business leadership as well. The distinctive features of today ’ s
turbulent economy include not just rapid change but also grow-
ing uncertainty. Companies across the economy face new kinds
of risks and new kinds of threats — not only to their organizations,
but sometimes to the very lives of their employees.

It is precisely these forces of increased turbulence that have
fueled the growing preoccupation with leadership. In such an
environment, leadership isn ’ t a luxury. It ’ s a matter of survival.
Yet the very forces that make leadership more critical also make
teaching it extremely diffi cult (and, in its essentials, impossible).
What it takes to successfully lead an organization through that
turbulence is neither simple nor straightforward. There are too
many contingencies to take into account, too much uncertainty.
By defi nition, it can ’ t be done “ by the book. ” This is due in part
to the inevitable gap between theory and practice. I believe there
is always something of a disconnect between how we actually do
leadership and how most so – called experts in the fi eld talk about it.
This gap is made even greater by the reality of turbulence. When
circumstances are changing rapidly and outcomes are uncertain,
planning, analysis, and theory can only take you so far.

In his book, Langewiesche describes a similar gap in most
attempts to understand fl ying. He puts it this way: the problem
with the so – called “ Theory of Flight ” is that “ it usually becomes
a theory of building the airplane rather than of fl ying it. It goes
deeply — much too deeply for a pilot ’ s needs — into problems of
aerodynamics; it even gives the pilot a formula by which to calcu-
late his lift! But it neglects those phases of fl ight that interest the
pilot the most. ” 6 One of the purposes of Langewiesche ’ s book is

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xx I N T R O D U C T I O N

to bring the theory of fl ying closer to the actual practice. In these
pages, I want to do something similar for leadership.

Another reason leadership can ’ t be taught is that it is highly
personal. At the moment of truth, when survival is at stake (liter-
ally, in that thunderstorm over the Peloponnese; fi guratively, in
the struggles of global business competition), leadership is a matter
of courage: a willingness to take risks and do the unexpected; to
make judgments with no data or, at best, inadequate data; to face
one ’ s fear of failure. Summoning up such courage is a highly
personal act. Each leader does it differently — and you never know
if you will be able to do it until the moment of truth arrives. For all
the talk about “ managing risk ” (if I had known in advance that we
wouldn ’ t be able to fl y over Athens, maybe I would have checked
the weather on the southwesterly route more carefully, been fore-
warned about the storm, and taken steps to avoid it), every leader
knows in his gut that you can ’ t anticipate everything. Sometimes
risks can ’ t be managed; they simply must be lived.

Put simply, I believe that any genuine leader today has to learn
leadership the hard way — through doing it. That means fl ying
through the thunderstorm; embracing turbulence, not avoiding it;
taking risks; trusting (but also testing) your intuitions; doing the
unexpected. This is not to say that there are no basic principles to
orient you to the challenge (indeed, I will describe some in this
book). But there are no simple recipes. Until you have lived it, you
don ’ t really know how to do it. I call this perspective “ leadership
the hard way. ” It is the subject of this book.

A Self – Taught Leader

Despite the fact that leadership cannot be taught, some individuals
do fi nd a way to learn how to become leaders. In effect, they are
self – taught. And one of the most useful resources for that self –
teaching is the life stories of those who have already made the

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I N T R O D U C T I O N xxi

I never planned to become a leader. I never went to business
school, and I never expected to run a business organization. And
yet, perhaps precisely for that reason, I believe that my experience
makes me especially well suited to describe what it takes to lead in
a turbulent economy. For more than thirty years, I worked as an
inventor, entrepreneur, manager, and global pioneer in one of the
most volatile of global businesses, the semiconductor industry, and
in one of the most dangerous regions of the world, the Middle East.

University of California researcher AnnaLee Saxenian has
recently identifi ed a new category of global business leaders. She
calls them the “ new Argonauts ” : individuals from the traditional
periphery of the global economy who have migrated to developed
economies, learned the disciplines of global business, and then
returned to their home countries to build dynamic, state – of – the –
art, globally competitive businesses. 7

Without knowing it at the time, I was one of the first new
Argonauts. I left Israel in the early 1960s to get a Ph.D. in elec-
trical engineering at the University of California at Berkeley.
I got in on the ground fl oor of what would come to be known as
Silicon Valley, working fi rst at Fairchild Semiconductor ’ s R & D lab
(a famous breeding ground for high – technology startups), then
as one of the early employees at Intel Corporation after Robert
Noyce and Gordon Moore left Fairchild to found the company in
1968. I even made my own contribution to the computer indus-
try with my invention in 1971 of the EPROM (erasable program-
mable read – only memory). The EPROM was the fi rst nonvolatile
but reprogrammable semiconductor memory — an innovation that
Moore termed “ as important in the development of the micro-
computer industry as the microprocessor itself. ” 8

But my dream had always been to bring back a new body of
knowledge to Israel and help found a new fi eld of innovation and
industry there. So in 1974 (after a detour teaching electrical engi-
neering in Ghana), I returned to Israel to set up Intel ’ s fi rst overseas
design and development center in Haifa. Few people know it, but

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xxii I N T R O D U C T I O N

we designed the microprocessor for the original IBM personal
computer. And in 1985 we opened the company ’ s first chip
fabrication plant (or fab) outside the United States, in Jerusalem.
Through the cyclical ups and downs of the semiconductor busi-
ness and through at least two wars, I helped grow Intel Israel into
a key global outpost of the Intel Corporation and an important
player in Israel ’ s high – tech economy. In the process, I helped spark
the development of Israel ’ s high – tech economy, which is cur-
rently the home of some 4,500 technology companies, more than
300 venture capital funds and investment fi rms, and a collection
of startups that is second in size only to Silicon Valley itself.

I retired from Intel in 2001. Today, Intel Israel is the head-
quarters for the company ’ s global R & D for wireless technology (it
developed the company ’ s Centrino mobile computing technology,
which powers millions of laptops worldwide) and is responsible for
designing the company ’ s most advanced microprocessor products.
It ’ s also a major center for chip fabrication: although Intel Israel ’ s
original fab in Jerusalem fi nally closed its doors in March 2008,
Intel has two major semiconductor fabs in the city of Qiryat Gat
in the south of Israel on the edge of the Negev desert. With some
seven thousand employees (projected to reach nearly ten thou-
sand by 2008), Intel Israel is the country ’ s largest private employer.
In 2007, Intel Israel ’ s exports totaled $1.4 billion and represented
roughly 8.5 percent of the total exports of Israel ’ s electronics and
information industry (which themselves equaled about a quarter
of Israel ’ s total industrial exports — the highest percentage for high
tech anywhere in the world).

But my story is not really about technology. As the interna-
tional economy becomes more volatile and uncertain, I believe
that my experience in the semiconductor business and in running
a global business from Israel is relevant to managers across the
economy. True, I can ’ t teach you to be a leader. But I believe
I can show you how to learn to become one: by describing my
personal, hands – on encounter with the turbulence of the global

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I N T R O D U C T I O N xxiii

A Different Kind of Leadership Book

Leadership the Hard Way is a different kind of book about leader-
ship. First, it offers a perspective not from the center but from the
dynamic edge of the new global economy. Second, it is a view of
leadership from within, not from the top, of the global corporation
(I don ’ t believe you necessarily have to be a CEO to be a leader).
Finally, and most important, it avoids simple recipes in favor of
what the anthropologists call thick description : life stories that crys-
tallize the lessons of one leader ’ s lifetime learning how to lead.

For example, I will tell you how my childhood as a Jewish
boy in hiding in Nazi – occupied Holland during World War II, my
experience of the Berkeley counterculture in the 1960s, and the
serendipitous process I went through to invent the EPROM all
helped shape my approach to leadership. And I will use the story
of the creation and development of Intel Israel to describe how
I refi ned my approach and put it into practice. I tell these stories
not to blow my own horn, but rather because no discussion of the
challenges of leadership is complete without somehow communi-
cating the daunting complexity of situations and the bewildering
variety of contexts that real – life leaders face. It is only through
such stories that one can begin to approach the fundamental para-
dox of leadership: the fact that, while it cannot be taught, it can
nevertheless be learned.

The fi rst part of the book explores three general principles
of “leadership the hard way.” In an environment of constant
turbulence, where survival can no longer be taken for granted, the
fundamental responsibility of the leader is to ensure the long – term
survival of the organization. Chapter One explains why insisting
on survival has become so central to the role of the leader — and
how I tried to create a culture at Intel Israel in which the impera-
tive of survival became a powerful catalyst for improvisation and

Survival in a fast – changing environment requires what
I call “ leading against the current, ” or constantly challenging

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xxiv I N T R O D U C T I O N

an organization ’ s conventional wisdom and preconceptions. In
Chapter Two , I describe how I acted against the current to make
Intel Israel into a distinctive counterculture within Intel Corpora-
tion and how, paradoxically, our counterintuitive perspective on
the edge of the corporation allowed us to move to the very center
of Intel ’ s global strategy and operations.

Turbulence is also changing the very nature of opportunity —
making it increasingly less predictable. Leadership the hard way
therefore also requires the leader to be alert to the often random
opportunities that exist in the midst of crisis and to move fast
to exploit them. Chapter Three uses the story of how I created
Intel Israel in the fi rst place to describe the special qualities that
leaders must cultivate in order to leverage random opportunities

Sooner or later, every leader faces a moment of truth, what
Warren Bennis and Robert Thomas call a “ crucible ” experience
that shapes you defi nitively as a leader. 9 Chapter Four tells the
story of what was, without question, the biggest leadership test of
my thirty – year career: my decision to keep Intel Israel open dur-
ing the early days of the First Gulf War in 1991, when Saddam
Hussein ’ s Iraq was raining Scud missiles down on Israel and busi-
nesses across the country were closing at the recommendation of
Israel ’ s civil defense authority. The story may be an excellent case
study of leadership under conditions of extreme turbulence. In the
way that it illustrates the three principles described in the preced-
ing chapters, it is also a compelling conclusion to the fi rst half of
the book.

Leadership the hard way is a demanding way of life. It demands
a lot from the leader as an individual. It also demands a great deal
from people in the organization. The second half of the book
describes the support infrastructure that the leader and the orga-
nization need to put in place to meet these demands. For example,
Chapter Five addresses some rarely discussed “ soft skills of hard
leadership ” — distinctive habits of mind and modes of interaction
with people that need to be in place for leadership the hard way to

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I N T R O D U C T I O N xxv

work. Chapter Six takes a fresh look at the much – discussed subject
of values, arguing that perhaps the most important precondition
for an organization to stay true to its values is the leader ’ s openness
and honesty when he himself falls short of them. Finally, the book
concludes with some general refl ections on the key resources for
you, as an aspiring leader, to bootstrap your own leadership skills —
despite the fact that no one (including me) can really teach you
how to lead.

A beginning pilot at least has the advantage of using a fl ight
simulator to approximate the turbulent conditions that occur
during a thunderstorm. But it ’ s impossible to create a simulator for
leading a complex organization. No book can substitute for the live
ammunition of actually leading through turbulence and crisis.

Yet my hope is that this book will get you thinking and give you
some ideas for how to become a self – taught leader. Think of it as your
own personal stormscope, alerting you to the challenges, dilemmas,
and pitfalls — but also opportunities — ahead. Happy fl ying!

December 2007

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Leadership the Hard Way

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In a turbulent economy, the fi rst task of the leader is insisting on
survival — that is, continuously identifying and addressing poten-
tial threats to the long – term survival of the organization. At fi rst
glance this statement may seem obvious, even trivial. Doesn ’ t it go
without saying that no organization can be successful if it doesn ’ t
fi rst survive? Yet the rapid increase in the pace of change in busi-
ness has made survival more problematic than ever before. The
frequency with which organizations face major challenges to their
survival is growing.

In the days when most established companies had relatively
stable markets and competitors, survival was only rarely an issue.
To be sure, every now and then a company might face a major cri-
sis, but once that crisis was addressed, things went back to normal.
Few companies today have that luxury. Threats to survival aren ’ t
occasional; they are nearly continuous. If an organization waits for
a full – blown crisis to develop, it may fi nd that it is already too late.

The growing frequency of threats to survival is especially
evident in technology – or innovation – based businesses. In such
businesses, success at any one generation of technology is really
only buying an option on the future. It wins you the right to com-
pete at the next level of technology, but offers no guarantees of
continual success. Indeed, quite the opposite: often it is those com-
panies that are most successful at one generation of technology that
have the most diffi culty in adapting to subsequent generations.

I believe it was the increasingly problematic nature of survival
that Andy Grove had in mind when he claimed famously that
“ only the paranoid survive. ” As Grove describes in his book of
that name, sooner or later, every business reaches what he calls

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2 L E A D E R S H I P T H E H A R D W AY

a “ strategic infl ection point ” — that “ time in the life of a business
when its fundamentals are about to change. That change can
mean an opportunity to rise to new heights. But it may just as
likely signal the beginning of the end. ” 1 Grove makes clear that
such strategic infl ection points can be caused by technological
change but they are about more than just technology. They can
be caused by new competitors, but they are about more than just
the competition. “ They are full – scale changes in the way business
is conducted. ” As such they “ can be deadly when unattended to. ”

Despite the proliferation of such threats to survival in business
today, most people in most organizations avoid engaging squarely
with the issue. This is partly a result of the complacency that
comes with success. But even more, there is something in the very
nature of an organization that leads its members to take its ongo-
ing existence for granted. In this respect, an organization is a lot
like an adolescent. It assumes it is going to live forever!

It ’ s easy to understand why most people would prefer not to
think about potential threats to their survival. It ’ s scary, and fear
can be paralyzing. Nobody wants to consider the possibility that
“ I might not survive! ” What ’ s more, threats to survival generate
massive uncertainty. To survive such threats means to take risks.
But risks are by defi nition uncertain. What if we try and fail? What
if things don ’ t work out? No wonder people avoid the issue of sur-
vival, if they can get away with it.

The job of the leader is to make sure they don ’ t get away with
it. A leader must represent to the organization the imperative of
survival, the challenge of survival, and the reality of threats to sur-
vival. By constantly asking “ What will it take to survive? ” leaders
in effect force people to anticipate in advance the potential threats
facing the organization. In this way, they become the catalyst for
continuous adaptation that allows the organization to avoid a gen-
uine crisis of survival.

To do this effectively, you must take a position consciously “ in
opposition ” to the organization and its identity and systematically
resist the taken – for – grantedness that one fi nds in any organization.

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I N S I S T I N G O N S U R V I VA L 3

The leader has to embody the possibility that the organization can
fail and fail disastrously — precisely to make sure that it does not.

A Wartime Childhood

In retrospect, I realize that my preoccupation — some might say
obsession — with survival is, at least in part, a by – product of my
experience as a child during the Second World War. My parents,
Abraham and Feijga Frohman, were Polish Jews who emigrated to
Holland in the early 1930s to escape the rising anti – Semitism in
Poland. I was born in Amsterdam on March 28, 1939, just months
before the start of the war.

After the German invasion of the Low Countries in 1940, we
continued to live in Amsterdam. But in 1942, as the Nazi grip on
Holland ’ s Jewish community steadily tightened, my parents made
the diffi cult decision to give me up to people they knew in the Dutch
underground, who hid me with a family in the Dutch countryside.

Antonie and Jenneke Van Tilborgh were devout Christians,
members of the Gereformeerde Kerk or Calvinist Reformed Church,
the most orthodox branch of Dutch Protestantism. They lived on
a farm on the outskirts of Sprang Capelle, a small village in the
region of Noord Braband, in southern Holland near the Belgian
border. The Van Tilborghs had four children. Their oldest daugh-
ter, Rie, was twenty – one but still living at home. Another daughter,
Jet, was fourteen. And the two boys, Coor and Toon, were ten and
six. The Van Tilborgh family hid me from the Germans for the
duration of the war. Only a few close neighbors knew that I was
staying with them.

I was only three when I arrived at the Van Tilborgh household,
so it is diffi cult to differentiate between what I actually remember
and what I was told later. But one thing I do recall was feeling dif-
ferent. For example, I had dark hair, and the Van Tilborgh children
were all blond. I had to wear a black hat to hide my black hair.

I also remember hiding when the Germans would search
the village. Sometimes I would hide under the bed, sometimes in

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4 L E A D E R S H I P T H E H A R D W AY

the root cellar (I have a warm memory of treating myself to the
apples that were stored there), sometimes with my “ brothers ” and
“ sisters ” out in the surrounding woods. To this day I have a scar on
my wrist that, according to the Van Tilborghs, came from a time
when we were running through the woods and I tried to jump over
a creek and got caught by some barbed wire.

Other memories are more disturbing. One day, looking out
the cellar window, I saw German soldiers execute a fellow soldier.
I don ’ t know why they were doing it; perhaps he was a deserter,
perhaps he himself had helped some Jews who were in hiding.
Whatever the cause, I have the image seared in my mind of seeing
him hit by the bullets and falling to the ground in a heap.

My parents did not survive the war. They were taken in one
of the many roundups of Jews by the Nazis. Much later, I learned
that my father died in Auschwitz. I never learned for sure where
my mother died, although it ’ s likely she was taken to Auschwitz
as well.

I see now that my experience during the war inculcated in me
a stubborn conviction that nothing is truly secure, that survival
must never be taken for granted — but also that the actions of
determined individuals can “ achieve the impossible ” and have a
literally heroic impact on events. If it weren ’ t for my parents ’ abil-
ity to make the excruciatingly diffi cult choice to give me up to the
underground and for the Van Tilborghs ’ willingness to take me in,
I wouldn ’ t be here today.

Who knows what motivates human beings to do something
truly heroic? In the case of the Van Tilborghs, it is clear to me
that a major source of their motivation was their deep religious
faith. Without such bedrock convictions, they wouldn ’ t have been
able to do what they did. I also suspect that their own experience
as members of a minority religious sect in Holland allowed them
to empathize and identify with the plight of Holland ’ s Jews and
develop a compelling urgency to do something about it. Orthodox
Calvinists made up only about 8 percent of the population of the
Netherlands in the 1940s. Yet they were responsible for helping

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I N S I S T I N G O N S U R V I VA L 5

roughly a quarter of the approximately twenty – five thousand
Jews who went into hiding. Thanks to the help of people like the
Van Tilborghs, some sixteen thousand Jews who went into hid-
ing survived the war, including some four thousand children like
myself. 2

In agreeing to hide me, the Van Tilborghs took unimaginable
risks. They endangered not only themselves, but their own chil-
dren as well — to a degree that, seen from the outside, may appear
almost irresponsible. In contemplating their example over the
years, I learned something essential about leadership: survival
requires taking big risks, and sometimes the risks a leader takes,
when viewed from a normal or conventional point of view, can
appear crazy. But it really only looks that way. Often, genuine lead-
ership is the result of the leader ’ s commitment to a transforming
vision and to a set of values that follow from that vision. A key
challenge of leadership is to live with the tension between two
incommensurate sets of values, perspectives, and commitments —
in this particular case, the Van Tilborghs ’ responsibilities to their
children and the responsibilities they took on in protecting me.

I also learned something else from the Van Tilborghs ’ behavior.
If a leader is too focused on personal survival as head of the orga-
nization, he or she may end up, paradoxically, undermining the
organization ’ s long – term capacity to survive. A lot of ineffective
leaders become so focused on their own survival in their leadership
role that they avoid taking necessary risks and, in the long run,
end up damaging the organization ’ s survival capacity. Much like
the Van Tilborghs who saved me during World War II, sometimes
visionary leaders must risk themselves to do the right thing.

After the liberation of southern Holland in 1944, my father ’ s
sister, who had emigrated to Palestine in the 1930s, somehow was
able to locate me. She had a friend who was serving in the Jewish
Brigade — the volunteer fi ghting force of Palestinian Jews raised by
the British that had fought in North Africa and Europe and that,
at the time, was stationed in nearby Belgium. She sent the friend
to meet with the Van Tilborghs and convince them to place me in

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6 L E A D E R S H I P T H E H A R D W AY

a Jewish orphanage, with the intention of eventually emigrating
to Palestine.

The Van Tilborghs were hesitant to let me go and, to be
honest, I didn ’ t want to leave. By that time I barely remembered
my parents. For all intents and purposes, the Van Tilborghs had
become my family. But after all that had happened to European
Jewry during the war, the Jewish community was determined to
recover those children who had survived. Eventually the Van
Tilborghs were persuaded that it was the best thing for me and,
reluctantly, they gave me up. I lived the next few years in orphan-
ages for Jewish children whose parents had died during the war,
fi rst in Antwerp and then in Marseilles, before sailing to the newly
created country of Israel on the Theodore Herzl in 1949.

Eventually I was adopted by relatives in Israel. But I never for-
got the Van Tilborghs, and over the years I have kept in touch
with my Dutch family. Antonie and Jenneke are dead now, as are
two of their four children. But the families continue to keep in
touch. The children of my Dutch brothers and sisters know my
children. We have attended their weddings in Holland, and they
have visited us in Israel, where Antonie and Jenneke ’ s names are
enrolled on the list of the Righteous Among the Nations in the
records of Yad Vashem, Israel ’ s offi cial memorial to those who died
in the Holocaust.

“ The Last Operation to Close in a Crisis ”

It may seem absurd, or perhaps even inappropriate, to compare the
threats I faced as a young Jew in Nazi – occupied Europe to the compet-
itive threats that most companies face today. Yet, in part because of
my childhood experience, I ’ ve always believed that an organization ’ s
survival can never be taken for granted — in bad times certainly, but
also even in good times. For this reason, it is essential for an organiza-
tion to accept complete responsibility for its own survival.

When you ’ re working in a startup, this responsibility is obvi-
ous. Every day you live with the possibility that you might not

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I N S I S T I N G O N S U R V I VA L 7

succeed. But when you are working in a large global corporation,
it ’ s easy to become passive, to assume that the company will be
around forever, even to start thinking that your own fate relies
on decisions made at corporate headquarters far away. When I
founded Intel Israel, I was determined to fi ght this tendency, to
cultivate the atmosphere of a precarious startup, even though we
were part of a successful and fast – growing company. I wanted peo-
ple not only to avoid complacency but also to feel that they — and
they alone — were responsible for their own fate.

For that reason, my vision for Intel Israel always emphasized
survival in a highly volatile industry and region. After all, semi-
conductors is a highly cyclical business, with dizzying booms often
followed by extremely painful busts. And in the 1970s and ’ 80s,
when we were building Intel Israel, Intel was passing through
some of the most important and most dangerous strategic infl ec-
tion points of its history — in particular, the company ’ s exit from
the memory business in the mid – 1980s. If that wasn ’ t turbulence
enough, we were also trying to build an outpost for Intel in the
Middle East, a region wracked by political tension and war and
that, despite moments of hope in the 1990s, still has not found its
way to a defi nitive peace.

So I saw threats to survival everywhere and was determined
to make sure we were tough enough to survive them. As I used to
put it, I wanted Intel Israel to be “ the last Intel operation to close
in a crisis. ” To be honest, many employees, including some of my
direct reports, didn ’ t much like this vision. They thought it was
too negative. “ Is that the best we can do, ” they would ask, “ just
avoid being closed down? ” Eventually we came up with a simple
slogan: “ Survival through success. ” And I used that slogan to drive
our behavior in every area of the business.

Take the example of layoffs. Layoffs at Intel were relatively
rare — but they did happen, especially in the company ’ s early years.
In 1970 the company had had to lay off 10 percent of its (then
still quite small) workforce after the market failure of its very fi rst
product. In 1974 the fi rst big downturn in the industry caused the

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8 L E A D E R S H I P T H E H A R D W AY

company to lay off 30 percent of its workforce, about 350 people.
And in 1986 there were plant closings and layoffs associated with
exiting the memory business.

From the moment I helped establish Intel Israel, I simply
refused to accept the idea that we would lay people off, and I went
out of my way to make sure that whatever layoffs did occur at Intel
as a whole happened to others, not to Intel Israel. Of course, the
only sure way to avoid layoffs was to make sure that our operations
were so competitive that they were “ the last to close in a crisis. ”
But sometimes more extraordinary measures were necessary.

In the 1990s, for example, we had a small software develop-
ment group at the Haifa design center. But in 1994, in a move
aimed to cut costs, the global head of Intel ’ s systems software
unit decided to close it down. To avoid losing what was a cadre of
highly skilled software programmers, I immediately traveled to the
States and met with Intel ’ s then – CEO Andy Grove to see whether
there was any way to fund their positions, at least temporarily,
until other more long – term opportunities opened up.

I argued that these were highly skilled employees and to lay
them off now, although it might be penny – wise, was certainly
pound – foolish. Come the next upturn, we would need these peo-
ple, so we should keep them with Intel. Grove agreed to commit
some $ 700,000 to keep the people at Intel, and we distributed them
among other engineering groups. The decision paid off three years
later when, with the ramp – up to the Internet boom in the late 1990s,
we found ourselves facing yet another shortage of software engineers.
As a result of such efforts, there were fewer than ten employees who
had to be laid off during my entire tenure at Intel Israel.

Containing Fear

Earlier I mentioned that people don ’ t want to think about survival
because it is scary. In fact, there is a complex relationship between
survival and fear. To insist on survival, a leader must know how
to navigate fear. The goal is neither to exaggerate fear nor to
eliminate it, but rather to contain it.

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I N S I S T I N G O N S U R V I VA L 9

It can be difficult for leaders to maintain this delicate bal-
ance. Take an example that is top of mind for so many people
today — the fear of terrorism. In my opinion, many political leaders
in both the United States and Israel aren ’ t containing fear over
terrorism so much as exacerbating it. Indeed, they exploit fear to
further their political agenda. When you think about it, their mes-
sage is completely contradictory: on the one hand, they exaggerate
the “ existential threat ” of terrorism to keep people in a state of
constant anxiety; on the other, they promise perfect security — on
the condition, of course, that the public support their policies.
Both are illusions. In a turbulent world, there is no such thing as
perfect security. But at the same time, extreme fear leads only to
passivity and paralysis, making it all the more diffi cult to address
the genuine challenges that we face. Whether for terrorism or any
of the other threats we face in today ’ s world, it is more true than
ever that “ the only thing we have to fear is fear itself. ”

Yet it is impossible — and unwise — to eliminate fear completely.
I disagree, for example, with the famous advice of quality guru
Edward Deming that leaders must “ banish fear ” from the organi-
zation. This viewpoint strikes me as unrealistic. In situations in
which survival is at stake, a certain degree of fear is inevitable.
Indeed, a healthy fear of failure can be a good — indeed, even an
essential — thing. It helps break through organizational compla-
cency (it certainly kept me focused when confronting that thun-
derstorm over the coast of Greece). With the right amount of fear,
people perform better because nobody wants to fail.

So leaders have to master a delicate balancing act. On the one
hand, they must acknowledge the inevitable fear that survival situ-
ations engender; admit that, in a turbulent world, perfect security
is not achievable; and, indeed, use that realistic fear to keep people
on their toes. But at the same time, they also must contain the fear,
keep it from paralyzing people, encourage risk taking, and mobi-
lize the organization to rise to the occasion when its very survival
is threatened. I call this “ worst – case thinking ” — always trying to
anticipate what can go wrong. A lot of people can mistake this
for simple pessimism, but it has none of the sense of passivity and

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10 L E A D E R S H I P T H E H A R D W AY

futility that often come with pessimism. A determined focus on all
the things that can possibly go wrong can be extremely mobiliz-
ing and galvanizing. (Would that the Bush administration had
embraced this kind of fear in the run – up to the war in Iraq!)

To understand how this worst – case thinking can play a con-
structive role in an organization, let me give you what may seem
like a trivial example. At Intel Israel, as at most companies, when-
ever my managers would propose a new strategic initiative, they
would put together the inevitable slide presentation. And equally
inevitably, almost like clockwork, they would delay any discussion
of potential risks to the project until the very last slide — at which
point, of course, we had already run out of time.

So I developed a simple rule in order to make the reality of
risks to our survival very real to them. “ Don ’ t wait until the last
slide to tell me about the risks, ” I told them. “ Put a ‘ hand grenade ’
icon next to every point where there is even the least question of
potential jeopardy. ”

People hated it. They didn ’ t want to draw attention to where
the land mines were. They assumed that by identifying potential
obstacles they would ruin their chances for getting their project
approved. In fact, the precise opposite turned out to be the case.
The more they surfaced the key risks and uncertainties, and the
more we discussed them in our management team, the more we
increased our comfort level with the proposal and the more likely
it became that it would be approved. The long – term result was
to create an atmosphere in which people were aware of potential
threats to the business but also comfortable with taking the neces-
sary risks to meet those threats and continue to succeed.

Setting “ Impossible ” Goals

It ’ s one thing to get an organization focused on survival when it
faces a serious crisis; it ’ s quite another when things seem to be
going well. In such situations, one of the most effective ways to
insist on survival is to set not just stretch goals, but impossible goals.

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I N S I S T I N G O N S U R V I VA L 11

Especially in good times, when the organization doesn ’ t seem to
face any clear external threats, asking for the impossible creates a
kind of “ virtual ” survival situation. Almost by defi nition, it poses
the likelihood of failure; odds are that the organization will not
succeed. But what often happens is that people become so engaged
in doing what ’ s necessary to meet the impossible goals that they
reach levels of performance they never thought possible — thus
strengthening greatly the organization ’ s long – term prospects.

For example, when we established the Jerusalem fab in the
mid – 1980s, I was determined to do something that had never really
been done inside Intel before: to compete on costs. At that time
Intel was still a relatively young company, and the lion ’ s share of
focus had always been on innovation and product performance —
not cost competitiveness. We already had a labor – cost advantage
in Israel of about 15 to 20 percent compared to Intel ’ s U.S. fabs.
But I didn ’ t want to rely on that wage differential alone. Rather,
I wanted our productivity to be so good that we would be able
to compete on costs with any semiconductor fab anywhere in the
world. To achieve this goal, I set an “ impossible ” target of cut-
ting the average cost per die of the EPROM (our fi rst product)
by roughly fourfold — from $ 2.50, the best performance in Intel at
the time, to sixty – six cents. I christened this program “ Sixty – Six
Cents or Die. ”

To be honest, I had absolutely no idea whether we could
reach this goal. But I wanted to set a dramatic target to get people
focused on cost. We created a pirate fl ag with the campaign slogan
and fl ew it from the fl agpole in front of the fab. We came up with
new metrics to track our progress — for example, complementing
the traditional industry focus on “ die yield ” (the number of usable
integrated circuits per wafer) with a new focus on what we called
“ line yield ” (the number of usable wafers that moved through
the production line during a given period of time). We col-
lected these statistics daily and communicated the results broadly
through the fab workforce. I wanted everybody to feel that if we
didn ’ t meet the goal, we would be sunk.

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12 L E A D E R S H I P T H E H A R D W AY

The campaign had an impact. Employees in the fab started
to focus relentlessly on costs. They would put off purchasing new
equipment until it was absolutely necessary. They reduced parts
inventory signifi cantly and improved productivity through effec-
tive and innovative debugging of new equipment. People worked
so hard and were so creative in fi nding ways to save money and
improve productivity that they did not even realize just how
extraordinary their performance was.

The fact is, we never quite achieved the sixty – six cents tar-
get. But we came close. And as a result, we were able to bring
the costs of the fab down so much that as Intel ’ s microprocessor
production ramped up in the late 1980s, we were able to win the
lion ’ s share of production for the 286 and subsequent generations
of Intel ’ s microprocessor product line. Because we were so focused
on potential failure, we were able to survive through success.

A Catalyst for Innovation

I mentioned earlier that when I fi rst began talking about being
the last Intel operation to close in a crisis, many people at Intel
Israel thought the message was too negative — especially for an
innovation – driven business like semiconductors. They didn ’ t
want to just survive; they wanted to thrive! But in my experience
there is a highly synergistic relationship between survival and inno-
vation. For one thing, the imperative of continuous innovation in
today ’ s global economy is a key factor in creating the turbulence
that makes long – term survival more diffi cult. But perhaps even
more important, threats to survival can become a powerful stimu-
lus for new innovation.

For an example of this synergy between survival and innova-
tion, consider a threat that Intel Israel faced in the early 1990s.
Typically, a semiconductor manufacturing facility has a relatively
limited life, usually somewhere between ten and fifteen years.
Rapid advances in chip design tend to rely on parallel advances
in manufacturing and process technology. As innovation moves

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I N S I S T I N G O N S U R V I VA L 13

forward, a fab designed for one generation of technology can
quickly fi nd itself obsolete.

We faced this situation in 1993, when we began to realize
that the Jerusalem fab was nearing the end of its useful life. The
fab had been designed in the mid – 1980s to manufacture prod-
ucts with channel lengths of one – and – a – half microns (a micron
is one millionth of a meter). Channel length defi nes the distance
between the two terminals (known as the source and the drain ) in
a transistor. It ’ s a key metric of a chip ’ s performance, because the
shorter the channel, the more transistors can be placed on a chip,
and the better the performance in terms of speed and reliability.
One – and – a – half microns was adequate for Intel ’ s 386 microproces-
sor, the product we were running at the time, but the new 486
had a minimum channel length of one micron. If we hoped to
compete for the 486 and subsequent generations of Intel ’ s micro-
processor technology, we would have to retool the plant. Specifi –
cally, we would have to completely replace the fab ’ s laminar – fl ow
air – conditioning system, because the smaller the channel length,
the purer the air would have to be in the fab ’ s cleanroom.

The looming obsolescence of the Jerusalem fab was actually a
quite serious threat to my vision for Intel Israel at the time. In the
early ’ 90s we had started planning to build a second, more techno-
logically advanced fab in Jerusalem, and by 1993 we had reached
agreement with the Israeli government about an incentives pack-
age for the new plant — only to be informed at the last minute
by Intel corporate that they had decided to build the next fab in
Arizona, not Israel. So unless we could fi nd a way to extend the
life of the original Jerusalem facility, we would lose our foothold
in semiconductor manufacturing. What ’ s more, because nobody in
corporate was asking us to modernize the fab, we would have to
fi gure out a way to do it without stopping production — not even
for a single day.

My facilities people said it was impossible. A semiconduc-
tor fab ’ s air – conditioning system is critical for continuously
filtering the air of the cleanroom and making sure impurities

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14 L E A D E R S H I P T H E H A R D W AY

don ’ t get introduced into the chip – making process and ruin the
semiconductors. There was no way we could build a whole new
air – conditioning system while keeping the plant open. It had never
been done anywhere — not at Intel or at any other semiconductor

I tried to explain that this wasn ’ t a satisfactory answer. “ Don ’ t
tell me why it can ’ t be done, ” I said. “ Tell me how we can do it and
what the costs will be. I don ’ t care how crazy the ideas are; just come
up with something. Take a month and see if you can fi gure it out. ”

Three weeks later, the team returned to tell me, “ We think
we ’ ve found something, but you won ’ t buy it. ” The basic idea was
to “ raise the roof ” of the Jerusalem fab ’ s cleanroom by adding a new
structure on top and turning the existing roof into a false ceiling.
Above this false ceiling we would install the new air – conditioning
system in modules, section by section. As each new section of
the system became functional, we would then break through the
false ceiling and connect the new air – conditioning system to
the existing one, in effect creating a hybrid system. By the end
of the process we would have a completely new system, able to
handle Intel ’ s new one – micron technology. Retrofi tting the entire
plant would take time — about a year and a half — but it would have
the advantage of allowing us to introduce the new system piece by
piece without stopping the production line. The team estimated
the cost of the project at about $ 10 million.

It wasn ’ t the money that I was worried about. The fact is, from
Intel ’ s point of view, $ 10 million was a relatively small amount of
money to extend the life of the fab — certainly far less than the
roughly $ 1 billion it would have cost at the time to build a brand
new fab. But could we really pull it off? Despite the risks, I took
the plan to the company ’ s senior executives, who would have
to sign off on the capital expenditure. “ Are you sure you can do it
without affecting current production? ” asked Craig Barrett, who
had recently become Intel ’ s chief operating offi cer. To be honest,
I wasn ’ t completely sure that the plan would work. But I told him
that we had the risks under control.

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I N S I S T I N G O N S U R V I VA L 15

It took three or four months of trial and error to fi gure out the
best way to build the new ceiling, install each module of the new
air – conditioning system, and connect it to the existing system. You
can ’ t imagine the facilities team ’ s pride when they fi nally fi gured it
out and took me to see the fi rst successfully working module. Over
the next eighteen months we proceeded step by step, installing a
new module, linking it to the existing system, then moving on to
the next area of the fab. The project had a galvanizing effect, not
just on the facilities team but on the entire fab workforce. Because
everyone was so worried that production might suffer, they went
out of their way to maintain and even improve on our perfor-
mance. The paradoxical result: our output was even better during
and after the project than before.

This approach to modernizing a cleanroom ’ s air – fi ltering sys-
tem had never been done before — and I suspect it has never been
done since! Yet it is an excellent example of how focusing on
survival and asking the impossible can stimulate risk taking and
innovation. The modernization of the Jerusalem fab was not only
key to our winning a signifi cant part of Intel ’ s global production
for the 486 microprocessor, but it also contributed to our winning
the next round in the global competition for investment in Intel ’ s
expanding production facilities: the creation in 1996 of a second
Intel Israel fab in the town of Qiryat Gat.

In March 2008 the Jerusalem fab fi nally closed down, after
twenty-three years of operation (which in the fast – changing semi-
conductor industry must be some kind of record). Yet despite
the closing of the facility, semiconductor manufacturing at Intel
Israel couldn ’ t be healthier. In 2005, Intel announced that it would
build a second fab at Qiryat Gat. The $ 3.5 billion investment, the
largest ever by a private company in Israel ’ s history, will fund what
will be one of the largest and most technologically advanced semi-
conductor manufacturing facilities in the world. At the new Qiryat
Gat plant, channel length will be forty – fi ve nanometers (a nano-
meter is one thousand – millionth of a meter), allowing transistors
so small that thirty million can fi t on the head of a pin.

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16 L E A D E R S H I P T H E H A R D W AY

Of course, I ’ m now completely retired from Intel and had
nothing to do with the decision. Yet I have to believe that this
investment didn ’ t happen by coincidence. It happened because we
created an organizational culture that, in good times and in bad,
never took its survival for granted. It happened because we created
an organization determined to be the last place to close in a crisis.

c01.indd 16c01.indd 16 2/2/08 10:47:36 AM2/2/08 10:47:36 AM




Survival requires risk taking. Taking risks often involves doing the
unexpected — and sometimes the seemingly impossible — even in
the face of considerable opposition. For that reason, leadership the
hard way means leading against the current — for example, com-
peting on costs at the Jerusalem fab when the rest of Intel was still
focused exclusively on product innovation and performance, or
replacing the fab ’ s air – fi ltering system without shutting down the
production line.

I believe that leading against the current is a general principle
of leadership in an environment of high turbulence. In my experi-
ence, often the best thing to do in the middle of a crisis or when
facing major uncertainty is precisely the opposite of what seems to
be the safest or most commonsensical thing at the time. I don ’ t
mean to suggest that leaders should simply be contrary for con-
trariness ’s sake. But I do believe that acting against the current is
an extremely effective way to turn a crisis situation inside out and
reframe a threat as an opportunity.

Once again, an analogy to fl ying is appropriate. When a plane
loses lift and goes into a free fall, the fi rst inclination is to pull on
the controls to regain altitude. But it ’ s precisely the wrong thing
to do. A plane at the beginning of a free fall has very little veloc-
ity. In that state, trying to lift the nose and pull out of the fall only
slows the plane down even more, leading to a stall. Instead, the
counterintuitive action a pilot needs to learn is to push down on
the controls — in other words, to make the free fall even worse.
It ’ s the only way to acquire suffi cient velocity to regain lift and
come out of the dive.

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18 L E A D E R S H I P T H E H A R D W AY

Leading against the current is the equivalent of making the
free fall worse. By embracing turbulence and not taking the easy
way out, a leader is in a better position to jar the organization out
of its collective rut. In this respect, leading against the current can
be an excellent way to mobilize an organization.

To effectively lead against the current, however, a leader has
to have some distinctive characteristics. First, you must be simul-
taneously an “ insider ” and an “ outsider ” in the organization you
are leading. To do things differently, you fi rst must be able to see
things differently. Only the leader who remains something of an
outsider can see around the corner of the latest crisis to perceive
the potential opportunity hidden in the midst of a threat. And
only from a position on the edge of the organization can the leader
effectively challenge followers ’ conventional wisdom, instincts,
and initial impulses and impressions.

Second, to lead against the current, you must be unafraid to
make decisions or take actions that appear “ crazy. ” Sometimes
they may in fact be crazy, but more often than not they will be in
response to emerging imperatives that you as the leader antici-
pate or sense but that the organization as a whole hasn ’ t really
perceived yet. A leader who is anticipating the next challenge
will likely be marching to a different drummer, making choices
that appear unorthodox and that, in the beginning at least, may
be very diffi cult to justify — at least in the terms or logic commonly
accepted in the organization.

Third, a leader against the current has to know how to manage
the tension between, on the one hand, persevering in the face of
opposition, and on the other, encouraging dissent and respond-
ing to it. Leading against the current means not taking “ no ” for
an answer. You need to know how to push back — and not only
“ down ” inside the organization, but also “ across ” and “ up ” inside
the broader hierarchy of which you are a part. But being persis-
tent in the face of opposition does not mean somehow ignoring or
dismissing what others have to say — indeed, precisely the oppo-
site. When leading against the current, it becomes all the more

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L E A D I N G A G A I N S T T H E C U R R E N T 19

important to consider things from multiple points of view,
especially those of people who disagree with you.

This brings me to a much – discussed — and, in my opinion, rou-
tinely misunderstood — theme of the management literature: the
topic of resistance . So – called experts in change management are
always providing advice on how leaders can “ minimize resistance. ”
I couldn ’ t disagree more. Any against – the – current decision worth
its salt will spark considerable opposition and resistance. And
rather than avoiding it or minimizing it, it ’ s far better to welcome
it, seek it out, and engage with it head – on.

Indeed, I think that often the goal of the leader should be to
maximize resistance — in the sense of encouraging disagreement and
dissent, bringing resistance out into the open so it can be debated
and addressed. Doing so can help you understand the fears, con-
cerns, and perspectives of people in the organization. And in some
cases, resistance and dissent can represent an important corrective
when you go too far.

When an organization is in a crisis, lack of resistance can itself
be a big problem. It can mean either that the change you are trying
to create isn ’ t radical enough — and is therefore unlikely to be truly
effective — or that the opposition has gone underground, where it
will be the most effective in blocking your initiative. If you aren ’ t
even aware that people in the organization disagree with you, then
you are in trouble.

Encouraging and engaging with dissent also requires that you
challenge your own personal inclinations. Nobody likes criticism;
nobody likes to be told “ you ’ re wrong. ” Also, sometimes it can
be diffi cult to differentiate between legitimate critique and mere
excuses. Here ’ s a rough rule of thumb that I ’ ve found useful:
constructive critics are often very blunt; it can be extremely
unpleasant to hear their point of view. Excuse – makers, by con-
trast, often phrase their objections in ways that seem reason-
able, even innocuous — but it ’ s just a sign that they are trying to
sabotage your every move. Excuses are superfi cially reasonable but
profoundly undermining. Genuine dissent is the opposite: it can

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20 L E A D E R S H I P T H E H A R D W AY

seem unreasonable at fi rst, but in fact often provides something
that you should take into account.

But although debate, dissent, and constructive criticism
are essential, it ’ s a mistake to seek “ consensus ” before making a
change — especially major ones affecting the fundamental direc-
tion of the organization. The more radical the change, the less
possible it is to develop a consensus in advance. So let all views be
heard, but in the end, it will be up to you to make the fi nal deci-
sion. A genuine leader must always be prepared to act alone.

Leadership as Counterculture

A typical story one often hears about Israeli high – tech entrepre-
neurs involves a couple of guys who meet as offi cers in the Israeli
Defense Forces (IDF), usually in some elite unit, frequently military
intelligence. They forge close bonds in the army ’ s high – pressure
environment, where one ’ s decisions as a leader can literally mean
life or death. After returning to civilian life, they apply the leader-
ship skills they acquired in the military to the challenging task of
building a new business (often, one that commercializes technol-
ogy fi rst developed by the military).

It ’ s a nice story, but that wasn ’ t my experience. Sure, I served
in the IDF in the late 1950s, but I was in anything but an elite
unit. And when I had the chance to become an offi cer, I turned it
down. After all those years in orphanages, the last thing I wanted
was the regimentation of army life.

No, as strange as it may sound, the experience that probably
taught me more than any other about the importance of leading
against the current was my involvement in the Berkeley counter-
culture of the 1960s. In 1962, during my last year as an under-
graduate at the Technion, Israel ’ s equivalent to MIT, I decided
that I wanted to go to the United States for graduate school. I was
taking a course from an Israeli professor who had recently returned
from the States, where he had become an expert in “ switching

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L E A D I N G A G A I N S T T H E C U R R E N T 21

theory, ” which was a relatively new, cutting – edge fi eld in computer
science at the time. The example of this teacher inspired me to
do something similar — that is, to study in the United States and
bring back a new fi eld of technical expertise to Israel. I applied to
a number of American engineering schools, including Purdue and
MIT, but the University of California was the only one to offer me
a stipend for my living expenses. So in the summer of 1963 I found
myself fl ying from Tel Aviv to New York and then traveling cross –
country by car to Berkeley.

It was a turbulent time. Not long after I arrived at Berkeley, John
F. Kennedy was assassinated. That fi rst year, civil rights became a
burning issue on campus as scores of students were arrested at sit – ins
designed to force Bay Area businesses to hire more black employ-
ees. In 1964, I witnessed the rise of the Free Speech Movement,
which briefl y closed the university down, as well as the fi rst stirrings
of the San Francisco Bay Area coun terculture, which culminated
in the Summer of Love in 1967. And throughout the period there
was growing student activism against the Vietnam War. At my
Ph.D. graduation ceremony in 1969, there was a massive walkout
of students in protest against the war.

As a foreigner, I was fascinated by these events. After my
experiences as a child during World War II and growing up in
the constrained circumstances of Israel in the 1950s, the scene
in Berkeley was like nothing I had ever experienced before.
I was drawn to the atmosphere of freedom, creativity, and self –
expression. The old ’ 60s slogan “ Do your own thing ” had a power-
ful impact on me.

At Berkeley, I led a kind of double life. All day long, I lived
in the world of engineering, going to classes, working in the lab,
studying advanced topics in electronics and computer science. But
then, at fi ve o ’ clock, I would leave my circuits behind and enter
the world of the counterculture — distributing leafl ets, participat-
ing in demonstrations, attending rock concerts, experimenting
with drugs, and spending long hours in the bars of Berkeley and

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22 L E A D E R S H I P T H E H A R D W AY

San Francisco discussing everything from the latest developments
in Vietnam to the meaning of life. Even after I started working in
Silicon Valley, fi rst at Fairchild and then at Intel, I had as many
friends in the counterculture scene as I did at work.

I ’ ll never forget one day, walking in the Haight Ashbury, the
center of the hippie movement in San Francisco. Suddenly a guy
drove up in a Corvette, stopped the car, stepped out, took off his
suit jacket and tie, and put on a fringed jacket and beads. In an
instant, the manager had transformed himself into a hippie for the
evening. Forty years later, it ’ s easy to make fun of that image, to
see this transformation as somehow fake, even self – indulgent. But
that ’ s not how I saw it at the time — or even how I see it today.
Rather, I view it as a symbol of the enormous freedom and fl ex-
ibility in seeing things differently, the valuable insight you can
get when you radically shift your perspective, the power of being
simultaneously an insider and an outsider.

In one respect, the events of the 1960s in Berkeley were
uncannily familiar to me. They reminded me of the power of small
groups of committed people to change history — whether it was
to argue for free speech inside a university, to engage in civil dis-
obedience in support of civil rights, or to protest, and eventually
stop, a war. In this, the Berkeley activists were only the latest in
the line of courageous leaders I had been exposed to — like the Van
Tilborghs and other members of the minority Calvinist church
in Holland who had helped save Jews during the war, or the kib-
butzniks and other Zionist pioneers who had played such a central
role in the founding of Israel. These groups were small minorities
in the worlds they lived in. They acted against great odds, took
big risks, persevered in the face of opposition and setbacks, and
accomplished something signifi cant.

What I learned at Berkeley is that unless you are prepared to
see things differently and go against the current, you are unlikely
to accomplish anything truly important. And to go against the cur-
rent, you have to be something of an outsider, living on the edge,
a member of a small but vibrant counterculture.

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L E A D I N G A G A I N S T T H E C U R R E N T 23

Apart from the Mainstream

The model of the Berkeley counterculture was in the back of my
mind when I fi rst started building Intel Israel in the 1970s and
’ 80s. I knew, of course, that for Intel Israel to be successful, we
needed to make it part of the broader Intel culture. In particular,
this meant introducing key Intel practices and disciplines to the
free – wheeling Israeli business culture. At the same time, however,
for Intel Israel to add value to Intel, we also had to fi nd a way to
take advantage of some unique Israeli strengths. And to do that,
the Intel Israel organizational culture needed to be distinctive and
somewhat apart from the Intel mainstream.

It ’ s probably wise not to put too much stock in broad cultural
generalizations. Still, to understand the strengths and weaknesses
of the Israeli work culture, it pays to compare it to that of the
United States and Japan. In some respects, the U.S. and Israeli
business cultures are similar, but they are also very different. For
example, both societies are what I call “ frontier ” cultures. But
whereas the frontier mentality in the United States focuses on the
“ Gold Rush ” — that is, getting rich quick — the frontier mentality
in Israel emphasizes survival in a hostile and extremely volatile
environment. As a result, the U.S. business culture is much more
individualistic; every single individual is on the lookout for his or
her own opportunity. In contrast, the Israeli business culture is far
more team – oriented. This team orientation can have its downside.
For example, Israelis can sometimes become so team – oriented that
they avoid individual accountability. But on the other hand, in my
experience, they communicate, share information, and collaborate
far more effectively than most American teams.

This team orientation is something that Israelis share with the
Japanese. But unlike most Japanese teams, Israelis combine team-
work with a remarkable fl air for improvisation and innovation. Of
course, this impulse to improvise also has its downside — especially
when it comes to enforcing the kind of process discipline for
which the Japanese are famous. Take the example of one of Intel ’ s
most important manufacturing innovations: the “ Copy Exactly ”

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24 L E A D E R S H I P T H E H A R D W AY

program. Developed by former CEO Craig Barrett, Copy Exactly
is a system of methods and practices for training the employees
in Intel ’ s semiconductor fabs to copy exact procedures as a way
to transfer new technologies from one location to another. The
approach has given Intel a competitive advantage in quickly ramp-
ing up production runs for new processes and technologies.

It was extremely diffi cult to get Copy Exactly to take root in
Israel. In the beginning, people saw it as drag on our ability to
improvise — and therefore a potential threat to our competitive-
ness. But over time I was able to convince them that if we could
somehow combine the Israeli fl air for improvisation with the kind
of disciplined execution represented by the Copy Exactly program,
we would be in an even stronger position. Eventually we decided
that whenever we came up with improvements in a particular
manufacturing process, we would go to the fab that had originated
it to get our “ deviation ” incorporated into the standard proce-
dures. We didn ’ t always succeed, but sometimes we did. When we
were successful, the fact that we had originated the improvement
meant that we had a temporary advantage over other Intel fabs.
And as the new improvements rippled through the entire Intel
manufacturing system, our reputation inside the company grew.

I believe that when Israeli teams harness their natural tal-
ent for innovation without sacrifi cing discipline, they can ’ t be
beat when it comes to solving engineering and manufacturing
problems. Once, during the heyday of Japanese manufacturing, a
Japanese journalist asked me which team I would prefer to lead —
a Japanese team or an Israeli team. I told him that there was no
question in my mind: the Israeli team, because although it is pos-
sible to instill discipline in an Israeli team, it is extremely diffi cult
to instill creativity in a Japanese team.

When it came to Copy Exactly, we were able to fi nd a pro-
ductive point of compromise between the Israeli work culture and
Intel ’ s broader culture. But in some cases compromise wasn ’ t pos-
sible. In those situations I was fully prepared to take tough actions
to establish and maintain our autonomy so that we could leverage

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L E A D I N G A G A I N S T T H E C U R R E N T 25

Intel Israel ’ s unique capabilities — even if it sometimes rubbed my
colleagues in California the wrong way.

One of the early challenges we faced in building Intel Israel, for
example, was to establish the principle inside Intel that we were a
genuine center of operations, not just a “ hiring hall ” where Intel ’ s
U.S. operations could come to fi nd good people. If we were con-
stantly vulnerable to having our best people lured away to positions
in the States, we would never be able to build a strong organiza-
tion in Israel. In the long run that wouldn ’ t be in the best interests
of Intel Corporation.

To give that principle some teeth, I instituted a rule that to
many seemed draconian: whenever people from Intel Israel went
on temporary assignment to the United States (which we encour-
aged, mainly for training purposes), they were forbidden to trans-
fer permanently to a U.S. unit. Rather, they had to come back to
Israel, fulfi ll their commitments to Intel Israel, and then transfer.
If they refused to do so, they had to leave Intel altogether and pay
a penalty of $ 50,000.

Many of Intel ’ s U.S. executives had a hard time accepting this
rule. Indeed, it seemed to go against everything the company stood
for. The Intel culture was a meritocracy, the kind of place where
good people were given a lot of freedom. And like many large cor-
porations, Intel encouraged the free transfer of employees across
organizational units. It was a great way for the employees to get to
know the business, build an internal network, and have exposure
to different kinds of responsibilities and skills.

For all these reasons, my no – transfer rule was a source of con-
siderable tension. “ This is a free country, ” some of my U.S. coun-
terparts would tell me. “ How can you tell somebody what to do? ”
Some saw the rule as almost an act of disloyalty. “ Here ’ s this guy, ”
they would say, “ He came here for two years and now he wants to
stay. That ’ s his free choice. Would you rather that he left the com-
pany than work for us? Where ’ s your loyalty to Intel? ”

From their perspective these were perfectly reasonable ques-
tions. After all, wasn ’ t I denying my people the opportunity to do

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26 L E A D E R S H I P T H E H A R D W AY

precisely what I had done when I was in California — that is, to
“ do your own thing ” ? But I was looking at the situation differently,
from the perspective of what it would take for Intel Israel to grow
and develop over the long term. As I knew better than anyone,
the lure of the States was just too great. If we couldn ’ t enforce the
no – transfer provision, I felt, we would never get Intel Israel off
the ground.

Because I was convinced that the no – transfer rule was essential
to our long – term survival, I was prepared to fi ght to enforce it. In
one case, for example, one of my people was working in an Intel
organization headed by Paul Ottelini, Intel ’ s current CEO. At the
end of his rotation, the individual informed me that he wanted to
stay with the unit and that Ottelini supported him. My insistence
that he return led to a confrontation that eventually went all the
way to the very top of the company. At a meeting with Paul, Andy
Grove (then CEO), and Craig Barrett, I explained my logic. If I
couldn ’ t enforce the no – transfer rule, Intel Israel would be reduced
to a recruiting offi ce, not a real operation. I also explained that
I believed the principle was so important that I was prepared to
resign if I didn ’ t have their support. Eventually they agreed to send
the guy back to Israel.

In another case, I took a position that seemed even more
extreme. Remember my efforts, described in Chapter One , to pre-
vent the layoff of our software development group in Haifa? Well,
at the time, one of the software engineers on the team had just
traveled on a rotation to the United States. When he heard the
news that his home unit in Israel was being disbanded, he asked to
stay permanently with the Intel organization that he was working
with there.

This was a much tougher decision. On the one hand, the Haifa
software systems group didn ’ t really exist anymore, and the future
of the team members was uncertain. Under the circumstances,
it seemed unreasonable to refuse my employee ’ s request. On
the other hand, I had just convinced Intel ’ s CEO to throw me a
fi nancial lifeline. And I knew that if I made one exception to my

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L E A D I N G A G A I N S T T H E C U R R E N T 27

no – transfer rule, it would be like opening the fl oodgates. So I said
no. The software engineer was furious — so much so that he quit in
protest and joined a California software startup.

For a long time I felt that I had made a terrible mistake. Per-
haps this time my impulse to go against the current had gone too
far. Here one of my goals had been to save the highly talented
people in the systems software unit for Intel — yet my actions
had led one of the best people in the group to leave the company

Two years later, one of my direct reports approached me warily.
He had gotten a call from the software engineer who had left in
a huff. He now wanted to return to Intel. What did I think? My
subordinate probably expected me to be angry, unwilling to even
consider the idea that the software engineer might return. In fact,
I was extremely pleased. I could think of no greater achievement
for our organization than that even after all that had happened, he
wanted to come back. Later, he went on to head the Haifa design

Winning the War for Talent

The no – transfer rule was just one of a whole set of against –
the – current decisions that I took to build a strong organization
at Intel Israel. Others involved the kind of people that I tried to
attract to come to the organization in the fi rst place. In this case
I often had to push not against my colleagues in the States but
against my own people.

Success in the semiconductor industry is largely a “ war for
talent. ” 1 In particular, the relative scarcity of top engineer-
ing talent has historically been a major constraint on a company ’ s
growth. The original establishment of Intel Israel in 1974 was a
direct result of Intel ’ s quest to fi nd fresh sources of talent. The
reason we created the Haifa design center in the fi rst place was to
tap in to the rich vein of technical talent in the Israeli engineer-
ing community. (Few people realize it, but Israel has an enormous

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28 L E A D E R S H I P T H E H A R D W AY

reservoir of engineering talent. Today, out of every 10,000
employees in Israel there are some 135 engineers — compared with
only 70 in the United States.)

Yet I was determined to fi nd ways to expand the pool of poten-
tial hires by moving beyond what I saw as the relatively narrow
focus on engineers that was typical in the industry in the United
States and Israel. In the early days of the semiconductor industry
it was a common assumption that to design chips (the fi eld known
as “ design engineering ” ) you had to be an engineer. I disagreed.
I believed that people trained in more science – based disciplines —
physicists, chemists, and the like — would make just as good chip
designers as people with traditional engineering degrees. To test
that intuition, when I fi rst came back to Israel in 1974, instead of
working full time for Intel I took a teaching job in a new School
for Applied Science at the Hebrew University in Jerusalem (later
I would become director of the school), to start building a cadre of
potential future Intel Israel employees.

The expansion of Intel Israel into semiconductor manufactur-
ing posed another recruiting challenge. By the early 1990s Intel
Israel was growing so quickly and the kinds of jobs we needed
to fi ll had broadened so much that even this expanded techni-
cal labor pool wasn ’ t enough. I was constantly receiving messages
from our recruiting organization about the diffi culty of attracting
good people. “ We ’ re going to have to pay more, ” my HR people
kept telling me, “ to get the people that we want. ” But I was wor-
ried that simply offering more money would end up attracting the
kind of people that we didn ’ t really want. I wasn ’ t looking for indi-
viduals motivated primarily by money. I wanted people who could
get excited about our vision and who wanted to make a differ-
ence. So I responded: instead of paying more money, why don ’ t
we start recruiting nontechnical people with backgrounds in the
liberal arts?

This was long before the wave of “ diversity ” had washed over
the business world. But I was convinced that we could get signifi –
cantly more leverage from a more diverse workforce. My interest

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L E A D I N G A G A I N S T T H E C U R R E N T 29

in employee diversity had nothing to do with any altruistic desire
to make opportunities available to a wider range of people. It was
purely self – interested: we needed to do something different to keep
pace with Intel Israel ’ s rapid growth.

The decision had major consequences for how we went about
recruiting. For one thing, it required a wholesale transformation
in our interviewing and hiring processes. But it called for an even
bigger change at the level of organizational psychology. In effect,
I was saying to my managers, all of whom had technical back-
grounds and had been very successful within the Intel Israel orga-
nization, “ Great job, now go out and start hiring people who are
not like you! ”

Many people didn ’ t like it. Although no one put it quite this
way, I suspect they felt that the new recruiting policy somehow
devalued their own training, experience, and contribution. And
some simply disagreed that nontechnical people could ever make
it in what was, after all, a technology – driven business and com-
pany. Another complication was that, because more women were
represented in the ranks of nontechnical graduates than among
technical graduates, broadening our pool to include nontechnical
graduates would inevitably mean hiring a lot more women into
our professional and managerial ranks — not an easy step for our
traditionally male – dominated high – tech culture. There was a lot of
resistance — some of it due to habit, some of it deliberate. It ’ s hard
for a leopard to change its spots — especially when it is a successful

A key moment of truth for me in the campaign to broaden
our labor pool came about two years after I had announced the
change in hiring practices, at a point when Intel Israel was becom-
ing well known for its supposed efforts to reach out to nontechni-
cal candidates. I had been invited by the dean of students at Tel
Aviv University to give a recruiting lecture. After the talk, she
took me aside to say, “ I ’ m very impressed with your philosophy.
But I have to tell you, what you say isn ’ t refl ected in the signals
we are getting from your recruiters. ” She went on to describe how

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30 L E A D E R S H I P T H E H A R D W AY

the dominant recruiting messages coming from Intel were still all
about engineering, computer science, and the like. I realized that
I would need to start intervening systematically in hiring decisions
to push the organization in the direction that I wanted.

In one case, for example, I learned that a woman with fi ve
children had been summarily rejected for a midlevel position in
the HR department in Haifa. When I asked why, I was told “ She
has fi ve kids and lives too far away. It just won ’ t work. ” Not good
enough, I told them, and I simply forced the center to hire her
(today, she is running the HR department).

It took nearly a decade of pushing back against the organiza-
tion to increase signifi cantly nontraditional hires at Intel Israel.
For example, at one point I began insisting that 50 percent of our
new hires must be women. We never quite reached that goal. But
because we had it as a goal, we ended up having many more women
at Intel Israel than one would fi nd at a typical Israeli company — or
even in the semiconductor industry in the United States.

Eventually the pushing paid off. To give just one example:
as of this writing, of the roughly thirty plant managers running
Intel ’ s seventeen semiconductor fabs around the world, only fi ve
are women — and of those fi ve, two are in Israel. One, Maxine
Fassberg, is a former high school chemistry teacher. The other,
Jenny Cohen – Dorfl er, is a former social worker who used to pro-
vide social services to the urban poor. They are responsible for
literally millions of dollars of annual output at some of the most
advanced semiconductor facilities in the world.

Learning from Mistakes

When you lead against the current, inevitably you make mistakes.
The challenge is not so much avoiding these mistakes, which is
impossible, as knowing how to recover from them once they are
made. That ’ s why it is important to listen to dissent. Dissent that
persists or that represents a point of view for which you don ’ t have
a good answer is a signal that a course correction is necessary.

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L E A D I N G A G A I N S T T H E C U R R E N T 31

Take, for example, another against – the – current decision I
made: to institute a comprehensive program of lateral transfers for
senior managers inside the Intel Israel organization. Traditionally,
Intel has always been a pretty functional organization. Especially
in the early days, executives tended to come up either through
the technology and product – development side of the business or
through manufacturing (or, still later, through marketing). By the
early 1990s, however, I became convinced that we needed to pro-
vide our managers with a much broader range of experiences, to
cycle them through multiple functions so that they would acquire
the full range of skills necessary for leading a modern business

I was motivated in part by my own experience. At heart I was
a researcher, and I had grown up on the research side of Intel. But
when we set up the Jerusalem fab, I had had to go back to square
one and learn how to run a highly demanding manufacturing
operation. My capabilities as a leader grew by orders of magnitude
as a result. I felt that a system of lateral transfers would greatly
increase the fl exibility of our management team. I also believed it
would pay organizational dividends as well. Someone who was a
relative outsider, I reasoned, would bring a fresh perspective, not
take things for granted, ask hard questions, and discover new and
better ways of doing things. The ultimate result would be a step –
function improvement in performance.

To kick off the lateral – transfer program and break through the
traditional assumptions of the Intel Israel culture, I decided to
do something dramatic. I announced that the heads of the Haifa
design center and the Jerusalem fab would switch jobs.

The manager who moved from the design center to the fab
was an extremely cautious and careful manager. He spent the fi rst
three months in his new role simply trying to understand how the
fab worked. Only when he had his feet on the ground did he start
making any changes. As a result, his transition went smoothly.
And as I anticipated, there were major benefi ts in operational

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32 L E A D E R S H I P T H E H A R D W AY

The former manufacturing manager who went from Jerusalem
to Haifa, however, was another story. On paper, he was a logical
leader for the design center. He had a strong background in engi-
neering, and one of our strategic goals at the time was to introduce
more process discipline to the innovative but sometimes disor-
ganized practices of the center. However, unlike his counterpart,
he started making big changes right away, which sparked a strong
negative counter – reaction. Soon I began hearing criticism about
his management style — not only from center employees but also
from the executives in California running Intel ’ s global Micropro-
cessor Group, of which the Haifa center was a part. “ You need to
bring in someone who knows how to run a design center, ” they
told me.

At fi rst I ignored the criticisms. I thought they were the typical
response of an inbred culture that didn ’ t want to try new ways of
doing things. I was committed to the principle of lateral transfers.
And I was the last person to back down in the face of criticism or

But eventually the backlash caused me to realize that I had
made a big mistake. I had underestimated the clash between the
manufacturing culture and the design culture. I had also under-
estimated the amount of learning that would be required and
the amount of support that at least some of the people placed in
unfamiliar roles would therefore need. Eventually I came to the
conclusion that the design center ’ s new manager just wasn ’ t going
to make it; his relationship with his peers and employees had
deteriorated to the point that he could never be successful in the
role. Reluctantly, I replaced him with someone who had come up
through the ranks of Intel ’ s design organization.

Another thing I underestimated was the human price of fail-
ure. I had taken an extremely successful manufacturing manager
and put him in a situation where he failed. As a result, there was
no real place left for him in the organization, so he decided to
leave. I felt responsible for the loss of a good manager. The failure
wasn ’ t just his; it was mine.

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L E A D I N G A G A I N S T T H E C U R R E N T 33

The failure, however, didn ’ t cause me to give up on my lateral –
transfer plan. Instead, I started stressing the important cultural
dimension of the change. “ Take time to learn the culture, ” I advised
managers moving into new and unfamiliar roles. I also began to
place more emphasis on the need for senior managers like myself
to provide ongoing support to help people make the transition.

Today, lateral transfers of this type are routine at Intel Israel.
And the diversity of experience that managers pick up over the
course of their careers has put them in a good position to succeed,
not just at Intel Israel but in Intel worldwide. For example, Alex-
ander Kornhauser, the manager who fi fteen years ago successfully
made the transition from the design center to the Jerusalem fab,
went on to manage the construction and startup of Intel Israel ’ s
fi rst fab in Qiryat Gat. He was my successor as general manager of
Intel Israel and, until recently, head of Intel ’ s global fl ash – memory
manufacturing group.

From the Periphery to the Center

Every one of these against – the – current actions was designed to
make Intel Israel a distinctive counterculture, with a strong local
identity and esprit de corps. Paradoxically, this powerful local cul-
ture with its inclination to act against the current is precisely what
has allowed the organization to become an integral part of Intel
worldwide today.

Recent events dramatically demonstrate just how deeply lead-
ing against the current has been institutionalized in the Intel Israel
culture. In the summer of 2006, Intel introduced a new generation
of microprocessor technology, known as Core 2 Duo, that Intel
CEO Paul Ottelini has called “ a revolutionary leap ” compared to
Intel ’ s earlier microprocessors. 2 The technology was created at the
Haifa design center — and the way in which it was developed is a
classic example of against – the – current leadership.

Traditionally, Intel ’ s microprocessors were optimized for speed.
The company had always promoted faster clock speed — the rate

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34 L E A D E R S H I P T H E H A R D W AY

at which a chip executes instructions — as the most important
criterion for microprocessor performance. But increased speed
meant higher power consumption and increased heat. A high –
performing microprocessor could generate as much heat as a small
television set.

The Intel Israel designers in Haifa who were charged with
creating a microprocessor for the laptop market decided to take
a different approach. They realized that unless they could design
a microprocessor that consumed less power and produced less
heat, they would never be able to create ultrathin laptops. The fan
would have to be thicker than the laptop itself. So instead of opti-
mizing processor speed, they optimized low power consumption
(which minimized heat).

At the time, the project was so outside the Intel mainstream
that at one point it was actually cancelled. But Intel Israel design-
ers didn ’ t take no for an answer. And as the laptop market grew
and became more important to the company as a whole, having a
low – power, low – heat microprocessor proved to be a distinct advan-
tage. An early version of Intel Israel’s new microprocessor eventu-
ally became a key component in Intel ’ s Centrino package, which
hit the market in March 2003 and was the catalyst for three years
of 13 – percent annual sales growth at Intel from 2003 to 2005.

Today, Intel Israel is the global headquarters of the compa-
ny ’ s all – important mobile computing platform, which is run by
an Israeli senior vice president, Dadi Perlmutter. What ’ s more,
the core competence that the Haifa design center developed —
microprocessors that combine high performance with relatively
low power consumption — is turning out to be critical for other key
Intel markets, such as servers and home entertainment, as well. So
much so that today Intel ’ s global microprocessor design group is
run out of Haifa.

You might say that by leading against the current, we suc-
ceeded in injecting Intel Israel directly into the Intel mainstream.

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Increased turbulence has a complex impact on the nature of
opportunity. Put simply, the more turbulent the environment, the
more random opportunities become — and the more diffi cult it is to
identify and take advantage of them. Rapid change, sudden disrup-
tions, and high uncertainty all throw up unanticipated threats, but
also unforeseen possibilities. Sometimes the greatest opportunity
lies in the middle of the most threatening crisis, so it can be hard
to distinguish the one from the other. The challenge of the leader
is to seek out such random opportunities and leverage them for the
success and survival of the organization.

When most managers think about pursuing opportunities,
they usually do so in the context of strategic planning. That ’ s
precisely not what I am talking about here. In fact, leveraging
random opportunities is the antithesis of strategic planning. It has
a different logic and requires different skills. Most large established
organizations are not very good at it.

Don ’ t get me wrong; I know that planning is important. Any
complex organization needs to have a plan. But no plan, no matter
how detailed, is really equal to the complexity and richness of pos-
sibility thrown up by turbulence. The more turbulent a company ’ s
situation, the more diffi cult it is to develop a detailed strategic plan
in advance and then execute it. The environment is too uncertain;
conditions change too rapidly and in unanticipated ways. Once
you enter the eye of the thunderstorm, most plans get thrown out
the window (we ’ ll see a detailed example of this phenomenon
in the next chapter). If you become too wedded to your plan, you
run the risk of losing your ability to adapt to new circumstances.

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36 L E A D E R S H I P T H E H A R D W AY

In the end, improvisation is just as important as planning — and
perhaps even more important. I ’ m even tempted to say that while
managers plan, leaders seek out and exploit random opportunities.

Leveraging random opportunities isn ’ t a linear or system-
atic process. It ’ s not analytical — or at least not in the usual way
that term is understood. It is more akin to intuition; though it
has a logic all its own, that logic is rarely self – evident. To identify
random opportunities requires openness, awareness, and an ability
to see connections that at fi rst glance don ’ t appear to be there. It ’ s
as much a state of mind as a way of behaving or acting.

Take, for example, the modernization of the Jerusalem fab
described in Chapter One . In that situation, I faced a problem —
the looming obsolescence of the fab — which produced a convic-
tion that “ something needs to be done. ” I didn ’ t have a plan. The
fact is, I had no idea what exactly we should do. I just knew we
needed to do something. But that imperative to do something
(in order to survive) became the catalyst for improvisation, an
innovative search for a solution. The result: the highly creative
approach of raising the roof of the cleanroom and incrementally
modernizing the laminar – fl ow air – fi ltering system without stopping

As this example suggests, leveraging random opportunity means
two things: fi rst, reframing a problem or crisis as a potential oppor-
tunity, and second, seizing the moment and committing to act with-
out necessarily having a clear plan of what you are going to do.

In my experience, the capacity to identify and exploit random
opportunities is relatively rare in big organizations. That makes
sense when you think about it. Bureaucracy is about standardiza-
tion, establishing routines and then executing them over and over
again. Being good at recognizing random opportunities, in con-
trast, requires improvisation — breaking routines to take advantage
of an unexpected opportunity.

So how do leaders improve their ability to spot random oppor-
tunities and take advantage of them? Four practices are especially
important: having a long – term vision, staying true to your passion,

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 37

seeing the opportunity at the center of every problem, and manag-
ing the delicate balance between “ holding your fi re ” (waiting for a
situation to mature) and “ striking when the iron is hot ” (moving
quickly to take advantage of new developments). In this chapter,
I ’ ll describe some of the experiences that taught me the impor-
tance of random opportunity. And I will fi nally tell the story of
how we created Intel Israel in the fi rst place. It ’ s a great example
of the randomness of opportunity and the long and circuitous
route a leader often has to take in order to realize his vision.

Turning a Problem Into a Product

Sometimes I think that random opportunities are the story of my
life. Take, for example, the decision that was made for me, to leave
the Van Tilborghs and go into a Jewish orphanage, even though
I didn ’ t really want to go. I often wonder: what would have hap-
pened if I had stayed? As a member of a rural family, I probably
wouldn ’ t have gone very far in terms of schooling. Who knows,
maybe I would have become a farmer. At a minimum, I would have
had a very different life — more relaxing perhaps, but certainly less
eventful — than the one I eventually led.

So too with going to graduate school at Berkeley. I had no idea
that this would put me within striking distance of Silicon Valley
precisely at the moment when the semiconductor industry was
about to take off. Would I have achieved as much as I have if I had
chosen to study at, say, Purdue? Who knows?

But the experience that probably more than any other taught
me the power of random opportunity was the one that led to the
most signifi cant technical achievement of my career: my inven-
tion of the EPROM in the early 1970s. That discovery has been
described as a case study in turning “ an intractable technical prob-
lem into a new product. ” 1 I see it as a classic example of taking
advantage of a random opportunity. Understanding why requires
going a bit into the technical details of the early semiconductor
industry — so I ask my nontechnical readers to bear with me.

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38 L E A D E R S H I P T H E H A R D W AY

When I fi rst started at Intel in 1969, there were essentially two
types of semiconductor memories. Random – access memory (RAM)
chips were easy to program, but a chip would lose its charge (and
there fore, the information encoded on the chip) when its power
source was turned off. In industry parlance, RAM chips were volatile .

Read – only memory (ROM) chips, by contrast, were
nonvolatile — that is, the information encoded in the chip was
fi xed and unchangeable. But the process for programming ROM
memories was time – consuming and cumbersome. Typically, the
data had to be “ burned in ” at the factory: physically embedded on
the chip through a process called “ masking ” that generally took
weeks to complete. And once programmed, a ROM chip could not
be easily changed.

Not long after joining Intel, I got pulled into troubleshooting
a serious problem that threatened the release of the company ’ s fi rst
semiconductor memory product, an early RAM chip known as the
1101. The chip worked fi ne at room temperature. But under con-
ditions of high temperature and high humidity (the standard test,
known as “ 85 – 85, ” consisted of running the chip at 85 degrees cen-
tigrade and 85 percent humidity), it became unstable, causing the
information encoded on the chip to be lost. My assignment was to
fi gure out what was causing this major product fl aw and fi x it.

A metal – oxide semiconductor (MOS) is a highly complex
physicochemical device, but for the sake of simplicity we can think
of it as a stack made up of four distinct layers. At the very bottom
is a substrate of semiconducting material, usually silicon. As the
name suggests, semiconductors such as silicon have an electrical
conductivity in between that of a metal and an insulator. Because
it is relatively easy to modify their conductivity, they are a key
component of any semiconducting device.

On top of the semiconducting substrate is deposited a non-
conducting insulator (for example, silicon dioxide), known as the
active insulator . The layer on top of the insulator is known as a gate
(in the 1101, it was made of polysilicon). Finally, another layer
of insulator is put down on top of the gate, and metal lines are

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 39

embedded in the insulator to connect the gate to the source of a
voltage coming from outside the semiconductor.

When a voltage is applied to the gate, it generates an electric
fi eld that penetrates the active insulator and modifi es the conduc-
tivity of the semiconducting layer, making it possible to control
the current fl ow between the source and drain of a transistor. This
creates a basic transistor switch, which is the building block of the
logic gates found in an integrated circuit. It is the voltage applied
to the gates of the circuit that determines whether each switch in
a semiconductor is either on or off.

After a few weeks of testing, I developed a hypothesis of what
was going wrong in the 1101. The heat and humidity were chang-
ing the chemical composition at the interface between the top –
layer insulator and the gate, causing the chip ’ s electric charge to
migrate uncontrollably and thus changing the information in the
chip ’ s memory cells.

To test my hypothesis, I was able to take advantage of another
problem with the 1101 that was totally unrelated to the one that
I was troubleshooting. It turned out that due to problems in the
chip fabrication process, the metal lines connected to the gates on
some of the 1101 chips were breaking when they were laid down
on the chip. This ruined these chips, because the metal lines could
no longer carry a current to the gates and thus to all the memory
cells on the device. But when I applied a voltage to these fl awed
chips under the high – temperature and high – humidity conditions
of the 85 – 85 test, I was able to show that the isolated gates were
in fact conducting charges, even though they were disconnected
from the source of the current — proof positive that the charge was
migrating along the interface of the insulator.

Once I demonstrated that charge migration was the source of
the problem, the solution was relatively straightforward. By modi-
fying the chemical composition of the insulator layer above the
gate, we were able to make the interfaces more inert, thus prevent-
ing them from conducting a charge even when the temperature
and humidity around the device were high.

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40 L E A D E R S H I P T H E H A R D W AY

But for some reason the anomalous image of the isolated gates
that, nevertheless, still conducted charges remained fi xed in my
mind. No one knows when the precise moment of inspiration
comes. But at a certain point I began to realize that if you inten-
tionally designed a series of disconnected gates to “ fl oat ” on top of
an active insulator and then found a way to get a charge onto these
“ fl oating gates, ” the charge would have nowhere to go. The result
would be a whole new kind of semiconductor memory, one that you
could program easily (like a RAM) but that would retain its infor-
mation, even in the absence of continuous power (like a ROM).

This initial concept of the fl oating gate, combined with a tech-
nique for charging the gates that came to be known as “ avalanche
injection ” and a technique for erasing them using ultraviolet light,
eventually led to the development of the EPROM — a nonvola-
tile but easily reprogrammable semiconductor memory. It was the
catalyst for a whole line of innovation and development that even-
tually led to today ’ s ubiquitous fl ash memory technology.

The EPROM had an enormous impact on Intel as a
company — and on the evolution of computing. At fi rst, we had
no idea what to do with this new kind of memory, but it soon
became apparent that the EPROM was the perfect twin to another
new Intel product developed at the time: the programmable
microprocessor. Every application using a microprocessor required
read – only memory to store the program that drove the processor.
With the EPROM, engineers could cut the prototyping cycle for
new computer products from months literally to hours, because
whenever they had to make changes to the master program, they
could immediately reprogram the EPROMs that stored it.

At first we assumed that once customers had finalized a
program for a new microprocessor application, they would then
switch to the much cheaper ROMs in the fi nal product. But to
our surprise — and delight — we discovered that once customers
got used to the instant gratifi cation of the EPROM, they didn ’ t
want to go back. They preferred the fl exibility of the more expen-
sive EPROM even in the fi nal product, because it allowed them

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 41

to make changes up to the last minute and, over time, to easily
incorporate new upgrades to the microprocessor program.

As a result, the EPROM became a cash cow that contributed
tens of millions of dollars to Intel ’ s bottom line. According to one
estimate, Intel ’ s revenues grew sevenfold, from $ 9 million in 1971
to $ 66 million in 1973, largely due to sales of the EPROM. 2 Well
into the 1980s, the EPROM remained one of Intel ’ s most profi table
products. All of this was because of a new kind of semiconductor
memory that I discovered almost by accident.

The experience of inventing the EPROM taught me that
opportunities will emerge when you least expect them — if you
have the imagination to see them.

Staying True to a Vision

Leveraging random opportunities may be the antithesis of
traditional planning. It does, however, require having a long – term
vision. This may seem paradoxical. If opportunity is increasingly
random, wouldn ’ t long – term vision matter less? Isn ’ t the impera-
tive to focus on the moment in order to adapt continually to new

It ’ s not that simple. In a fast – changing environment, you need
to have a vision to be able to recognize those opportunities that
really matter. A long – term vision provides the orienting frame-
work that allows you to identify what is a genuine opportunity and
what is not. Otherwise, a leader risks getting fi xated on short – term
perturbations in the environment and becoming trapped in an
unproductive round of constantly fi refi ghting the problem of the
moment. Only when you have a long – term vision can you appro-
priately adapt to short – term changes and recognize the unantici-
pated opportunities created by a turbulent environment.

Let me give an example of how this relationship between a
long – term vision and random opportunities worked in my own
case. The origins of my vision for Intel Israel go all the way back
to that class on switching theory at the Technion. It was then,

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42 L E A D E R S H I P T H E H A R D W AY

inspired by my teacher ’ s experience, that I got the idea to go to the
United States to bring a new fi eld back to Israel. At the time I had
absolutely no idea either of what I wanted to bring back or how to
do it — but I had the example of my professor and the desire to do
something similar.

Once I found myself in on the ground fl oor of the semiconduc-
tor business, I began to think about perhaps building some kind
of semiconductor research operation in Israel. Even when I was
working at Fairchild, before I had completed my Ph.D., I would
occasionally fl oat the idea with my colleagues and bosses about
“ possibly doing something in Israel. ” But at the time it was just a
pipe dream, not a practical possibility. Once I had invented the
EPROM, I began to have the credibility inside Intel to push my
vision more aggressively. But in those early years I also realized
that the time was not yet ripe. Intel was still an extremely young
company. It just wasn ’ t ready to set up an operation halfway around
the world.

In a turbulent environment leaders need to act quickly. Yet
sometimes if you rush to make things happen, you can end up
undermining your ability to recognize an unanticipated random
opportunity as it emerges. It ’ s important to realize that there are
periods in the evolution of a vision when you just can ’ t force
things. It ’ s better to sit back, bide your time, and wait for the right
opportunity to take shape.

That ’ s why in the spring of 1971, not long after I had presented
the EPROM concept at a major industry conference and we had
built some of the fi rst prototype products, I decided to leave Intel
for a time, to teach electrical engineering at the University of
Kumasi in Ghana in West Africa. I was newly married, and my wife
and I had always wanted to travel. “ Do your own thing ” was still my
mantra. I was looking for adventure, something different, an expe-
rience of personal freedom and self – development. The EPROM
concept was proven, so it seemed like a good time to leave.

People at Intel were astounded by my decision. Precisely at
the moment when I had made my reputation at the company,

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 43

I was leaving. What ’ s more, Intel had just had its fi rst profi table
year and was about to go public. To leave meant walking away from
considerable stock options that would likely result in a great deal of
money. But perhaps most important, although the basic concept
of the EPROM had been demonstrated, the product was still very
much in development. Many technical challenges had still to be
solved in order to reliably manufacture the new chip. How could I
possibly leave at a time like this?

I remember well a lunch I had with Andy Grove in the days
before I left. He knew he couldn ’ t convince me to change my mind.
Nevertheless, he told me a story about two engineers whom he
termed “ Engineer A ” and “ Engineer B. ” Engineer A was the type
of person who had a passion for discovery but who, once the basic
concept had been proven, more or less lost interest in subsequent
developments. Engineer B, by contrast, not only made great dis-
coveries but also did the hard work of seeing the discovery through
production into a great product. It was pretty clear from Andy ’ s
account which engineer he thought I was — and which created
more value for a startup company like Intel.

In retrospect, I realize that Andy was trying to tell me that my
decision to leave at this delicate moment was a failure of leader-
ship. In one respect, he was absolutely right. At the time, I really
was an Engineer A. My attitude was that with the demonstration
of the EPROM concept, the heavy lifting had been done. Creat-
ing a manufacturing process that could reliably produce the chip
was just a detail, something that could be safely left to others. No
doubt I completely underestimated just how complex and diffi cult
a challenge that would be.

But in another respect, my decision wasn ’ t so much a failure of
leadership as a fundamental choice about how and where I wanted
to lead. Any successful person will invariably have access to more
opportunities than he or she can ever take advantage of. Sooner or
later, you have to decide what your ultimate passion is, where you
really want to put your energy. Otherwise, you run the risk of being
consumed by detours that don ’ t really get you where you want to go.

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44 L E A D E R S H I P T H E H A R D W AY

For Andy, the focus of his passion was clear: building Intel
into a great company. At the time he was completely preoccupied
with the challenge of turning great technical ideas into profi table
products. But I had a different perspective. For me, the task of
building Intel certainly was important — but only if, over time, it
could be a vehicle for me to create something in Israel. Although
I had adjusted quite well to U.S. culture, I wanted to get back to
my friends and social networks in Israel. Even more important, I
was convinced that my opportunity to have an impact and make a
contribution was far greater in Israel than in the United States. In
1971 I knew that the company really wasn ’ t ready to take that step.
And I worried that if I devoted myself to the EPROM, I might go
down the path of a U.S. management career and that would take
me too far away from my vision. So I felt the timing was right to
walk away. In a sense, my decision to spend a year in Africa was
a kind of compromise, a way to detach myself from Silicon Valley
and California, even though I wasn ’ t quite ready to go back to

I spent fifteen months in Africa, teaching in Kumasi and
traveling throughout the continent. I suppose one could say
that my time there was a kind of detour. I was biding my time
until conditions were right for returning to Israel. But what-
ever my adventure in Africa represented to me at the time, the
fact is I learned things in Africa that proved incredibly useful in
ultimately realizing my vision — although, once again, there was
absolutely no way to know or predict that in advance.

For example, one of the things that greatly impressed me
about African culture was its rich complexity — in particular, the
way many of the Africans I met seemed to balance comfortably
multiple identities. Kumasi is the capital of the Ashanti people,
one of the key ethnic groups in Ghana, and it wasn ’ t unusual to
meet people who took great pride in their Ashanti heritage with-
out feeling any less Ghanaian. And given the pan – Africanist
ideology of Ghana ’ s founding president Kwame Nkrumah, many
also took pride in their African identity as well.

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 45

This experience had a big impact on my thinking about the
kind of organization I wanted to create when I returned to Israel.
I slowly began to realize that I wanted to build a culture that
refl ected the best features of Intel ’ s corporate culture but also lev-
eraged the unique aspects of the Israeli “ tribe ” ! By the time I left
Africa, I knew that I was ready to go back to Israel, for the fi rst
time in nearly a decade.

Striking When the Iron Is Hot

If leveraging random opportunities sometimes means biding your
time, it also means moving quickly and striking when the iron is
hot. For me, that moment came in early 1973, when my wife and
I returned to California from Africa. My plan was to work at Intel
for six months or so in preparation to fi nally return to Israel. But
as it still wasn ’ t clear whether I could convince Intel to start an
operation there, I made arrangements to teach at a new school for
applied sciences at the Hebrew University in Jerusalem.

Once I returned to Silicon Valley, however, I kept hearing
about a severe engineering shortage in the semiconductor indus-
try. Perhaps the time was right to make my move. Immediately,
I went to Intel ’ s senior management team to suggest that we open
a small design center in Israel. There wasn ’ t a lot of discussion
or analysis of the idea. Grove, who was Intel ’ s COO at the time,
simply organized a small group — including board chairman and
leading venture capitalist Arthur Rock, head of engineering Les
Vadasz, and myself — to travel to Israel to look for potential candi-
dates. Our trip had to be postponed because of the October 1973
Yom Kippur War, and I returned to Israel by myself in January, but
the group eventually came to Israel in April 1974 and hired the
fi rst fi ve employees of the Haifa design center.

It would have been logical for me to head the Haifa operation.
Nevertheless, I elected to continue at Hebrew University and work
with Intel as a consultant. I felt that I could serve my long – term
vision better by building a cadre of trained scientists that would be

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46 L E A D E R S H I P T H E H A R D W AY

future Intel employees. I also thought the new center would have a
better chance of being integrated into the company if its fi rst man-
ager were an American. And to be honest, I had my eyes on an even
bigger prize. I knew the real action in the semiconductor industry
was not in just chip design and product development but in manu-
facturing. I wanted Intel Israel to have a semiconductor fab.

Getting Intel comfortable with the idea of setting up a modest
design center was one thing. Convincing the company to invest
in the establishment of a semiconductor fab was a challenge that
was orders of magnitude more diffi cult. Not only was it a major
financial investment — at the time, a typical fab cost in the
neighborhood of $ 150 million (today the investment is around
$ 3.5 billion). It would also be the fi rst time that Intel built a fab
outside the United States — and at a time when it was becoming
increasingly clear inside the company that manufacturing qual-
ity and reliability were essential to Intel ’ s future. So once again
I waited for the moment when the time was ripe.

A key random opportunity emerged in 1978, when I learned
that Intel founder and then – CEO Gordon Moore was planning
a study trip to Israel. I knew that among the many factors the
company considered when choosing a site for a semiconductor fab,
by far the most important was the quality of the labor force avail-
able. So when Moore came to Israel for his visit, I didn ’ t try to sell
him on the idea that Intel should build a manufacturing facility in
Israel. Indeed, I didn ’ t even bring it up. Instead, I organized a trip
that would impress him with the overall capabilities of the Israeli
scientifi c and technical community.

In those days, whenever an Intel senior executive took a
study trip of this sort, he wrote a detailed report for his col-
leagues. I ’ m not a particularly careful reader of memos. But
I pored over Moore ’ s trip report like it was a commentary from
the Talmud. Moore was not a highly demonstrative person; he
was taciturn, a man of few words. Yet I could tell, reading between
the lines, that he had been impressed with what he had seen.
Within days, I was on a plane to California to start lobbying COO

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 47

Andy Grove for a manufacturing facility. Without making any
commitments, Grove gave me the go – ahead to start preliminary
negotiations with the Israeli government.

A critical part of the equation was convincing the government
to offer a package of investment incentives and tax breaks that
would make Israel competitive with other potential sites in the
United States or Europe. This was standard practice in the semi-
conductor industry, but it was especially important for Israel, given
the relatively high level of geopolitical instability in the region.
Fortunately, the two senior civil servants in Israel ’ s Ministry of
Industry and Ministry of Finance who were my primary counter-
parts in the negotiations well understood the potential leverage for
the economy of a major investment by Intel. But there was consid-
erable public and political opposition to the incentive package.

Like many countries in the developing world, Israel had a
relatively standard formula for attracting foreign investment in
high-technology industries. Israeli law specifi ed that for certain
advanced, high – tech sectors, the government would provide
a grant of up to 38 percent of the total amount invested. But
the overall size of the total investment in this project — $ 150
million — was the largest ever in the country ’ s history, which made
the government subsidy a relatively large number as well: nearly
$ 60 million.

This number provoked a lot of opposition. Two related argu-
ments loomed large. First, the local electronics industry thought it
was unfair that so large a subsidy was going to a foreign company.
Why not support local fi rms instead? What ’ s more, some critics
argued that instead of subsidizing investment by a large global cor-
poration, it would be better to spread the money among some of
the smaller high – tech startups that were just beginning to emerge
in Israel.

My position was that any deal had to be good for Israel and
good for Intel, in that order. The prejudice against Intel as a foreign
company was something we had encountered even when we estab-
lished the Haifa design center (when there was no question of

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48 L E A D E R S H I P T H E H A R D W AY

government subsidy). People had grumbled then about “ a foreign
corporation taking our elite manpower. ” Now they complained
about subsidizing a foreign company that would “ take all its profi ts
out of Israel. ” I felt that such attitudes were a vestige of an old –
fashioned economic nationalism that was completely out of place
in an increasingly global economy. My attitude was, either Israel
is going to be a player in the global economy or it ’ s not. If it is, it
needs to intelligently leverage investment by global companies.
We had the talent to compete on the world stage. Why not take
advantage of it?

As for the startup argument, I felt that it was critical for Israeli
high tech to have at least a few “ anchor tenants ” — that is, a
critical mass of large established global corporations that would
help stabilize and develop the infrastructure of the high – tech
sector. After all, the success rate of new startups is typically in the
neighborhood of 1 to 5 percent. For the government to focus its
investment subsidies exclusively on startups was just too risky and
would result in a much lower return on investment.

Throughout the negotiation process, of course, I worked
hard to fi nd the leverage points of opportunity in the situation to
create the best deal for Intel that I could. For example, early in our
discussions I proposed that we locate the new fab in an industrial
park in Jerusalem. Most people thought it was an odd decision.
The logical choice would have been Haifa, where we already had
our design center, or the Tel Aviv metropolitan area, which was
becoming something of a center for businesses in the electronics
and computing industries. Unlike these cities, Jerusalem had very
little industrial infrastructure at the time.

But I understood that the very absence of an existing infra-
structure would be an advantage. First, it would cause the Israeli
government to award the maximum in tax breaks and other incen-
tives to win the plant — which would make us all the more com-
petitive in the internal competition against other potential sites
in the United States and Europe. Second, the very fact that there

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 49

was little industry in the city meant that we would have more
infl uence in determining prevailing wage rates and more luck in
recruiting employees with minimal experience in Israel ’ s powerful
and, from the perspective of a global high – tech industry, too – rigid
labor unions.

After a series of tough negotiations, I fi nally had a government –
approved incentives package that I thought was competitive. But
I still had to convince Intel to build the plant. Grove declared
that there would be a “ bake – off, ” a competition between the Israeli
proposal and some alternative site. He chose an Intel executive
who was Irish to develop a competing proposal for building a new
fab in Ireland.

The bake – off took place in a large Intel conference room before
the company ’ s senior executives. As I made our presentation, I felt
confi dent. The competing proposal had an assigned champion, not
a real one. As I moved through my presentation, I felt the energy
in the room shift in my direction.

Then, near the end of my presentation, Grove asked suddenly,
“ What about training? ” He meant, how were we going to train our
brand – new workforce to start up and run the new fab? No problem,
I explained. We would send the initial workforce of some 150 to
200 people to the States to work in Intel fabs there. Once trained,
they would return to Israel and train the rest of the staff. Grove hit
the roof. “ Absolutely not! ” he answered. “ Do you have any idea how
much it will cost to bring all those people to the States and train
them? And it will be a major drag on the productivity of the U.S.
fabs. ” With that, the meeting ended. I didn ’ t even get the chance to
fi nish my presentation. After all our effort, the plan seemed dead.

I was completely unprepared for Grove ’ s response. It had never
occurred to me that the training issue would be a deal – breaker. By
this point, however, I knew Grove pretty well. In particular, I knew
that the Andy in public was different from the Andy in private.
I immediately followed him down to his offi ce and caught up with
him just before he was leaving to go skiing for the weekend. “ You

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50 L E A D E R S H I P T H E H A R D W AY

need to give me one more chance, ” I said. We scheduled another
meeting for the following week.

All weekend long, I worked with the training staff to see if
we could fi nd a solution to the high costs of the training program.
After analyzing the data and talking with some of the heads of
other Intel fabs, we came to a new insight. Yes, the impact on
fab productivity of training the Israeli workforce would be nega-
tive in the near term. But over time, as they learned how to run a
fab, their presence would begin to be a major benefi t. By the end
of the six – month training period, they would even be contributing
to the productivity of the U.S. fabs. We created a graph show-
ing how the impact of the trainees would over time contribute to
the U.S. fabs. It was that graph that clinched it when I met with
Grove the following week.

The groundbreaking for the Jerusalem fab took place in July
1981. Jerusalem mayor Teddy Kolleck was there, as were the
two civil servants who had led the negotiations for the Israeli
government, but that was it as far as the politicians were concerned.
To be honest, I think there was still a lot of skepticism that we
could pull this complex project off. Some of that skepticism was
warranted. This was the fi rst time that Intel had ever built a fab
outside the United States. It was the biggest construction project
in the history of Israel up to that time. And we had an entire new
workforce to train. It took roughly three and half years to com-
plete the project. The fab fi nally opened for business in May 1985
and began running — appropriately, but coincidentally — the latest
version of Intel ’ s EPROM chip.

The establishment of the Jerusalem fab also represented a major
step in my own career. Not long after approving the deal, Grove
pulled me aside to say, “ Dov, the design center is one thing, but man-
ufacturing is a much bigger deal. You ’ re going to have to run it. ” So
I stepped down as director of the applied science school at Hebrew
University to rejoin Intel as the Jerusalem fab manager and general
manager for Intel Israel. My evolution into the leader of Intel Israel
was complete. But my education as a leader had just begun.

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L E V E R A G I N G R A N D O M O P P O R T U N I T I E S 51

Going Through the Window

Success always appears inevitable in retrospect. But at any number
of points in this long multiyear process, things could have gone
wrong. Indeed, occasionally they did. For example, a few years
later, in 1993, we negotiated a new package with the Israeli
government to expand the Jerusalem fab — only to see the deal fall
through when, at the last minute, Intel decided to build its next
fab in Arizona, not Israel. (It was that decision that forced us to
modernize the original fab.) But we stayed fl exible, all the while
not taking no for an answer, and we won the next round in 1995
when we got the go – ahead to build a second Israeli fab, this time in
the town of Qiryat Gat, in southern Israel near the Negev Desert.

When we established the Qiryat Gat fab, I had to go through
the same political fight as I had when we were negotiating
for the Jerusalem site. There were the same critiques and the
same opposition — only this time, because the investment (and
therefore the amount of government subsidy) was so much bigger
and the process was so much more public, it was an even tougher
confl ict. But in the end we won. And Qiryat Gat is where Intel is
building its third Israeli fab today.

Andy Grove used to say, “ The thing about Dov, if he can ’ t
come through the front door, he goes through the window. ” It ’ s
true. I don ’ t take no for an answer. I ’ m always trying to fi nd that
opportunity in the middle of whatever the problem or challenge or
crisis of the moment may be — and take advantage of it. Effective
leaders are good at finding random opportunities — and then
exploiting them.

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c03.indd 52c03.indd 52 2/2/08 10:49:23 AM2/2/08 10:49:23 AM




Sooner or later, every leader faces a moment of truth — a crisis or
challenge that tests his or her leadership ability to the utmost. For
me, that moment of truth came in 1991 when I had to guide Intel
Israel through the crisis of the First Gulf War and the Scud missile
attacks of Saddam Hussein ’ s Iraq on Israel. In the days before the
start of the war, I had to make a critical decision with potentially
life – threatening consequences for our employees: whether to keep
our operations open, despite the threat of the missile attacks, or to
close down until the crisis had passed.

Of course, many businesses remain open during wartime.
But in the days before the First Gulf War, Israel confronted what
appeared at the time to be an unprecedented threat. The Israeli
military assumed that Iraqi missiles would be carrying chemical
weapons. The government distributed gas masks and ordered every
household to prepare a special sealed room in case of chemical
attack. Most serious from a business perspective, in anticipation
of the missile attacks the Israeli civil defense authority instructed
all nonessential businesses to close and their employees to remain
at home. The radical uncertainty of the situation — not knowing
how many missiles would fall, where they would fall, what kind of
destruction they would infl ict — threatened to bring our business
to a halt, even before a single missile had been launched.

It would have been easy to follow the civil defense instruction
and close down. Everyone was doing it. Intel ’ s senior executives in
California would have understood. Many of our employees would
probably have appreciated the opportunity to focus on preparing
their families for the attacks. Yet I chose to ignore the government
directive, keep our operations open, and ask our employees to con-
tinue to come to work.

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54 L E A D E R S H I P T H E H A R D W AY

Some people thought I was being irresponsible. What right
did I have to risk people ’ s lives in time of war? Others thought
I was crazy. What if any of our employees were killed? What if
the government took legal action? What if disgruntled employees
went to the press?

Despite these risks, I stuck to my decision because I was con-
vinced that shutting down our operations was a direct threat to the
long – term survival of Intel Israel. And Intel ’ s employees responded.
In the fi rst days of the Scud attacks, when businesses throughout
the nation were closed, roughly 80 percent of Intel ’ s employees
showed up for work, day in and day out, day and night shifts
included. Thanks to their heroic performance, Intel Israel was one
of the few businesses in Israel (and our Jerusalem semiconductor
fab the only manufacturing operation) to remain open throughout
the entire six weeks of the war. Not only did we keep our commit-
ments to global Intel, but we also established the reputation that,
over time, would allow us to grow Intel Israel into an important
center of excellence for the corporation.

The story of our actions during the First Gulf War is a dramatic
example of the challenges to leadership in an environment of
extreme turbulence. Believe me, you don ’ t really know what
turbulence means until you have had to run a business during a
war! The experience taught me a lot of lessons: about the limits of
even the best – laid plans, the impossibility of anticipating risks, the
imperative of radical improvisation, the necessity of trusting your

But even more important, the story also effectively illustrates
the three key principles of leadership the hard way described in
previous chapters. Because I was so focused on our survival and
continuously wary about potential threats to it, I was able to
recognize that whatever else the Scud attacks represented, they
were also a potential threat to the long – term viability of our busi-
ness. Because I was committed to leading against the current, I was
able to make the unconventional decision to stay open — despite
the many risks involved and despite the fact that most businesses

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L E A D E R S H I P U N D E R F I R E 55

in Israel were taking the prudent route and shutting down. And
although it may sound unfeeling, because I was always on the
lookout for random opportunities, I understood intuitively that
the First Gulf War was not only a threat but also an important
opportunity. If we could meet our commitments despite the Scud
attacks, we could establish Intel Israel ’ s reputation in the company
for years to come.

A Different Kind of War

By the early 1990s, Intel Israel had grown from a small outpost of
chip designers to become a major part of Intel ’ s burgeoning global
production system. In 1986, not long after the introduction of the
386 microprocessor, Intel ’ s senior executives had made a critical
strategic decision: instead of licensing the 386 design to another
semiconductor company in order to provide customers with
a second – source supplier (a common practice in the semiconductor
industry at the time), Intel would be the sole supplier of the prod-
uct. This gave the company the potential to maintain a highly
profi table monopoly on supply of the 386 — but it also put intense
pressure on Intel ’ s fabs to keep up with soaring demand.

By the early 1990s, our Jerusalem fab, Intel ’ s fi rst outside the
United States, was a key player in executing this single – source
strategy. We were responsible for about three – quarters of the global
output of the 386 and were gearing up to compete inside Intel for
production of the new, more advanced 486 chip. We were operat-
ing seven days a week and running two twelve – hour shifts in order
to keep up with customer demand. Meanwhile, our design center
in Haifa was hard at work on developing new products that would
be critical to Intel ’ s future, including key components of what
would become the next – generation Pentium microprocessor.

When Iraq invaded Kuwait in August 1990, I knew that
war was likely. So I appointed a task force of senior managers to
develop a contingency plan in case Israel was drawn into the con-
fl ict. At the time, we were assuming it would be a conventional

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56 L E A D E R S H I P T H E H A R D W AY

war, and we were confi dent that we could handle it. We had had
experience with what war would mean for our business from the
call – up of reservists during Israel ’ s incursion into Lebanon in 1982.
We had contingencies for replacing key personnel who were called
up to the military, for operating the plant on a skeleton crew, and
for scaling back the private transportation service we used to bring
our employees to work at the Jerusalem fab (a typical arrangement
at most large Israeli companies).

But almost from the moment we finalized our contingency
plan, signs began to accumulate that this war would be very dif-
ferent. The politics of the U.S. – created anti – Iraq coalition made it
imperative that Israel stay out of the war. Yet for that very reason
it was in Saddam Hussein ’ s interest to provoke Israel to intervene.
By September, U.S. satellites had detected the transport of bal-
listic missiles to western Iraq — a mere seven minutes ’ fl ight time
from Tel Aviv. Israeli defense offi cials were saying that chemical
attacks on the country ’ s major population centers were likely, a
belief that was confi rmed when the government leased two batter-
ies of Patriot anti – aircraft missiles (adapted for use against ballistic
missiles) from the United States. Instead of being behind the lines
of the war zone (something we were used to), we ran the risk of
being the war zone.

In October, tensions mounted when the government issued
every Israeli a personal protection kit, complete with gas mask and
atropine injectors to combat chemical poisoning. Families were
also instructed to create sealed rooms in their houses and apart-
ments with plastic sheeting and masking tape. There was some-
thing about receiving those kits, being instructed to carry your
gas mask with you wherever you went, having to prepare a sealed
room, that brought the uncertainty and potential danger of the
situation home in a palpable way.

By the turn of the year, as the U.S. – set January 15 deadline for
Iraqi withdrawal from Kuwait drew near, my disquiet had grown.
Many airlines suspended fl ights to Israel. The governments of the

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L E A D E R S H I P U N D E R F I R E 57

United States and Great Britain advised their nationals to consider
leaving the country. Then on the fi fteenth itself the Israeli govern-
ment announced that all schools would be closed for the rest of
the week. Slowly it was dawning on me that our contingency plan
might be irrelevant to what was likely to be anything but an ordi-
nary war.

Yet despite all these warning signs, it still came as a complete
surprise when I woke up on Wednesday, January 16, to the news on
the radio that in anticipation of the start of hostilities and likely
missile attacks, the Israeli Civil Defense authority was instruct-
ing businesses to close and everyone but essential emergency
personnel to remain home. It was only then that I fully under-
stood: we were facing a completely different kind of problem
than the one we had anticipated. This wasn ’ t just a matter of a
call – up of reserves. The government was telling us that nobody
should come to work. I immediately called a meeting of the task
force at the Jerusalem fab.

A Question of Survival

In the twenty minutes it took me to drive from my home in the
historic village of Ein Karem on the southwestern outskirts of
Jerusalem to the plant in the Har Hotzvim Industrial District,
I kept revisiting in my mind the logic of what I was about to do. It
seemed almost irresponsible to be worrying about business in the
midst of potential physical danger. Yet if I didn ’ t think about
the possible consequences, who would?

I was convinced that a complete shutdown of our operations
threatened the long – term survival of Intel Israel. Managing a major
unit in a global corporation is a continuous fi ght for resources.
When we fi rst proposed setting up the Jerusalem fab in the early
1980s, we were put in competition with Ireland to see which
country could develop the better proposal. We had won that
round, and by the early ’ 90s we were already starting the process of

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58 L E A D E R S H I P T H E H A R D W AY

negotiating and lobbying inside Intel to convince senior manage-
ment to expand the Jerusalem fab.

I knew Intel ’ s leaders well and had good relations with them.
I had worked with Andy Grove at Fairchild and had been among
the fi rst generation of employees after Gordon Moore and Bob
Noyce founded Intel in 1968. I was confi dent that if we had to
interrupt production due to the war, executives in Santa Clara
would understand. I wasn ’ t worried that there would be a negative
impact in the short term.

But as Intel grew larger, decision making was becoming more
decentralized. The key stumbling block to further investment in
Israel was the lingering impression of geopolitical instability in the
region. Indeed, we had already had a number of struggles inside
the company over the transfer of strategic technologies and criti-
cal products to the Israeli operation. Therefore I was convinced
that if we had to interrupt production, even for a brief period of
time, we would pay a serious price over the long term.

I had had a glimpse of the risks during a phone conversation
with Intel ’ s then executive vice president, Craig Barrett, the pre-
vious September. Barrett was on a stopover in Amsterdam on his
way to Israel for a routine annual operations review. But he called
to tell me that he was considering canceling the trip. “ Grove [then
Intel ’ s CEO] is worried about my coming to Israel, ” he told me.
“ He thinks it ’ s too dangerous. ” Although I convinced him that it
was safe, and he continued his trip as planned, the call provoked a
twinge in my gut. If Intel ’ s senior executives were seeing Israel as
unsafe, what would that mean for our business?

My concern wasn ’ t only for the survival of Intel Israel. It was
also for the survival of Israel ’ s emerging high – tech sector. Intel
Israel was a key anchor of Israel ’ s still small high – tech economy.
If we couldn ’ t operate in an emergency situation, the trust of
multinationals and venture capitalists in the stability of the Israeli
business environment might crumble.

So as I drove to the task-force meeting, I made a quick decision.
We weren ’ t going to take the easy way out. We would ignore the

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L E A D E R S H I P U N D E R F I R E 59

civil defense instruction. We were going to ask our people to come
to work.

Thinking Differently

“ This is a completely different situation, ” I said at the start of the
task-force meeting on Wednesday afternoon, “ so let ’ s think dif-
ferently. ” The fi rst thing we did was to throw out our contingency
plan. The next was to ask how we could keep operations going
despite the civil defense directive.

In Israel, there is an offi cial category of businesses known as
MELACH (an acronym for Meshek Lishe ’ at Cherum ’ or “ economic
infrastructure in a state of emergency ” ). These companies — for
example, utilities, defense contractors, the national telecommuni-
cations network, and the like — are designated as essential for the
ongoing functioning of the economy and are allowed to operate
even during offi cially declared national emergencies. But we didn ’ t
have that legal status. The fact is, we had thought about applying
for it in the past but just never gotten around to it. It had been
pushed aside by more immediate and, at the time, more pressing
concerns. And even if we applied for this essential – industry status
right away, under the current circumstances who knew how long it
would take to receive it? We decided we were going to act like we
already had it until and unless somebody told us otherwise.

For three hours, we discussed the full range of risks that
remaining opened entailed. The main risk, obviously, was the
potential injury of any of our employees on their way to and from
work. People had sealed rooms at home, and we had created them
in all our main facilities, including the Jerusalem fab. But what
about during their daily commute? This was complicated by the
fact that we had a contract with a private transportation com-
pany to bring our employees to work at the Jerusalem fab, so if
we were going to remain open, not only our own employees but
also the transport company ’ s employees would be at risk. I weighed
the physical risk to our employees and contractors heavily, but

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60 L E A D E R S H I P T H E H A R D W AY

in the end concluded that if it was safe enough for employees at
the utility company and the phone company to travel to work,
there was absolutely no reason why we shouldn ’ t risk it as well.

At the Wednesday task-force meeting there were few
objections to the idea of remaining open. To be honest, the whole
prospect of missile attacks seemed so theoretical as to be literally
impossible to imagine, almost unreal. In the end we decided that
we would issue a “ call ” for Intel employees to continue to come to
work — a recommendation, not an order. No one would be pun-
ished if they decided to stay home. I made it extremely clear to my
direct reports that there would be no coercion. No manager was to
pressure employees to come to work who did not want to do so.

This prohibition was especially important to me — and not
just for ethical reasons. The problem with coercion is that it often
leads to backlash, creating the very resistance that it is meant to
overcome. When you order people to do something, their fi rst
reaction is often “ Wait a minute, if they have to force me, there
must be a problem with the whole thing. ” I knew that I couldn ’ t
control every single action of all my managers. But I could make
it clear that there would be no direct pressure. At the same time,
I was confi dent that we had embedded a strong instinct for sur-
vival in our organizational culture and that people would respond.
“ Let the Intel Israel culture do its work, ” I advised. After all, peer
pressure is the most powerful motivator.

We would also make it clear that keeping Intel Israel open for
business was critical to the future success not only of the organiza-
tion but also of Israel ’ s high – tech economy. I believed strongly that
the only way I could expect Israelis to take a risk was if doing so
was critical to the country, not just to the company.

We communicated our decision to the workforce on Wednes-
day. On the following day, with still no sign of missile attacks,
turnout was relatively normal. But that Thursday, January 17, was
also the start of the allied bombardment of Iraq. What only one
day earlier had seemed like a theoretical possibility would very
quickly become reality.

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L E A D E R S H I P U N D E R F I R E 61

The First Attack

At 2:00 in the morning on Friday, January 18, I was awakened
by the sound of an air – raid siren. I joined my wife and teenage
children in the sealed room of our Jerusalem home and listened to
the radio for the news. Eight missiles had landed in Tel Aviv and
Haifa; as far as the authorities could tell, there were no chemical
warheads. I got on the phone to the members of the task force
and told them to meet me at the plant. I grabbed my gas mask and
headed out into the night for the Jerusalem fab.

When I arrived around 3:30, work in the cleanroom had already
resumed. At the sound of the alarm, the employees had evacuated
to the sealed room, except for a few who agreed to stay behind to
operate some etching machines that needed continuous human
presence to keep the fl ow of materials going. After the report that
the missiles had landed, employees were given the opportunity to
call home before returning to the cleanroom. Things were tense,
but relatively normal.

When the task force convened, we reaffi rmed the decision to
call people to work. Managers had to be contacted and instructed
what to say to their staff. Employees had to be called and told that
the plant would indeed be open. The transportation company
needed to devise alternate routes to get around police roadblocks.
In the chaos of a crisis situation, clear communications are
especially important. So we spent the bulk of our time planning
exactly what to say to our workforce and coordinating our commu-
nications with our counterparts in Intel in the United States, who
would be wondering what impact the missile attack was having on
our operations.

Some 75 percent of the employees on the 7:00 AM shift made
it to the plant. Although I hadn ’ t told anyone, I had been expect-
ing maybe 50 percent. The relatively high turnout was a major
endorsement of our decision.

That night, after being at the plant for nearly sixteen hours
straight, I called Intel senior executives in Santa Clara. I stayed at

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62 L E A D E R S H I P T H E H A R D W AY

the plant because I didn ’ t want to call them from my home. I had
no idea what their reaction was going to be, and I wanted them
to see that Intel Israel was operating as normal — or as close to
normal—as possible under the circumstances. I explained that we
had decided to remain open, but we weren ’ t forcing any employees
to come to work who didn ’ t feel comfortable doing so, and that
so far turnout was quite good. They asked a lot of questions; we
discussed the potential risks. But in the end they were 7,500 miles
away. Under the circumstances, they simply had to trust us.

“ Scud Business as Usual ”

The second Scud attack came the following night, early on
Saturday. No one was killed, but some people were injured. And
Intel ’ s employees kept coming to work. When the design center in
Haifa opened on Sunday (the fi rst day of the normal Israeli work-
week), turnout was up to 80 percent.

After the first few days, we entered a period that I took to
calling “ Scud business as usual. ” Attacks continued to happen. On
Tuesday night, for example, after two days with no Scuds, there
was an especially destructive attack outside of Tel Aviv that led to
the deaths of four people, wounded ninety – six, and left hundreds
homeless. But we carried on as if everything were normal, and no
one tried to stop us. By the middle of the week, the civil defense
authority was urging all Israelis to go back to work, so the fact
that we were open for business was no longer so unusual. Still,
because the schools remained closed, absenteeism at most busi-
nesses remained extremely high. The stress was enormous, and
I and my team did all we could to boost employee morale.

As our actions on the night of the fi rst attack suggest, constant
communication was essential. The task force met daily to assess the
rapidly changing situation and plan our communications for
the day. We used every means we could — phone, email, on – site
meetings, face – to – face conversations — to keep our employees
informed of the latest developments. I was traveling continuously

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L E A D E R S H I P U N D E R F I R E 63

among the three Intel sites in Israel — the fab in Jerusalem, the
design center in Haifa, and our small sales – and – marketing opera-
tion in Tel Aviv — to meet with managers and employees in caf-
eterias and on production lines. I felt it was essential that I, as
the organization ’ s leader, be present to employees “ in the fl esh. ”
Over and over again, I tried to make three points: fi rst, to rein-
force employees ’ sense of pride at what they were accomplishing;
second, to remind them that we weren ’ t out of the woods yet — as
far as we knew, the worst might still be yet to come; and third,
to stress that this largely unforeseen crisis was also an enormous
opportunity and we had to take advantage of it. It was time to
show Intel and Israel what we could do.

We also took great care in our communications to global
Intel to keep senior executives informed of the developments on
the ground in Israel. After the fi rst few days of attacks, I sent a
comprehensive email to Intel senior management describing
how we were meeting the “ war challenge ” and delivering on our
commitments to the corporation. Andy Grove sent us an extremely
supportive letter in response, which I had posted on bulletin boards
throughout the organization. His strong public endorsement had
an enormous positive impact on employee morale.

Today, some fi fteen years later, the decision to continue with
business as usual may not seem so radical. At the time, however,
it was pretty controversial. In the white heat of the fi rst few days
of crisis, everybody operated on instinct. People were so busy that
they barely had time to think. But once things settled down into
“ Scud business as usual, ” some doubts and questioning began to

Some saw the decision to remain open as an act of courageous
leadership, but others viewed it as an unnecessary risk, literally
playing with the lives of employees. Some wondered how we
could justify risking people ’ s lives for a company that wasn ’ t even
Israeli. Relatively few people actually refused to come to work, but
some were bitter for quite a while. And one individual, who did
refuse to come to work — and not only during the fi rst week, but

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64 L E A D E R S H I P T H E H A R D W AY

also in subsequent weeks after the civil defense directive had been
withdrawn — eventually had to be let go.

But these complaints never really cohered into full – fl edged
opposition to the decision. For one thing, whatever doubts some
people had, there was the basic fact that the vast majority of
employees had indeed shown up. A successful risk is seldom chal-
lenged in retrospect.

In the years since the war, I have often wondered why so many
answered the call. Partly, I suspect, it was because coming to work
was a welcome alternative to the psychological paralysis brought
about by first the prospect and then the reality of the missile
strikes. One of the advantages of doing the unexpected is that it
can have a galvanizing effect. It shakes people out of their passivity
and helps mobilize them for action. At Intel Israel, our bias to go
against the current made it natural to decide to remain open even
though most businesses in Israel suspended operations. It was the
perfect antidote to terror.

Another part of it, I think, is that the call didn ’ t come in a
vacuum. We had been talking for years about the imperative of
survival and the need to do whatever it takes to be the best. So
though not everyone may have agreed with the decision to keep
operations open, most understood why we were doing it and trusted
that we had the best interests of the people and the organization
at heart.

Another important lesson I learned during this period was
that when it comes to leading in a crisis, good instincts are a lot
more important than good planning. The problem with cha-
otic situations like war is not so much that you can ’ t anticipate
everything — it ’ s that you really can ’ t anticipate anything. All you
can do is trust your instincts, embrace the chaos, and then deal
with the consequences as they emerge.

One issue, for instance, that I completely underestimated was
the impact of my decision on our employees ’ families. To her credit,
my head of human resources had raised the issue early on. The only
woman on the crisis task force, and a mother, she was sensitive

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L E A D E R S H I P U N D E R F I R E 65

to the implications of our decision for our female workforce
(about half of the employees at the Jerusalem fab were women).
I remember her asking, at the task-force meeting when we decided
to remain open, “ Can we really ask mothers to be separated from
their children during the threat of missile attacks? ”

At the time I didn ’ t exactly dismiss her question. But in the
total scheme of things, dealing with the family fallout was not my
highest priority. I felt that such separations were inevitable in a
situation in which the “ front ” was potentially everywhere.

Her concerns, however, turned out to be prescient. A few days
into the attacks, a manager at the Jerusalem fab reported that the
lobby was crawling with young children. Some of our employees,
especially women, were bringing their kids to work. After all, the
schools were still closed and, just as my HR head had predicted,
people didn ’ t want to be separated from their children in case of
an attack.

But here is the great thing about embracing the chaos. Faced
with this unanticipated development, the organization responded,
almost automatically, by temporarily entering the child – care busi-
ness. Local managers in Jerusalem set up a day – care center in a
support building of the fab. It had never occurred to anybody on
the task force (including my HR head) that establishing a tempo-
rary day – care center for employees ’ children might be a good thing
to do. But once faced with the fact that concerned parents were
bringing their children to work, it was an obvious step to take.
Throughout the Scud attacks, on any given day as many as fi fty
children were in the center.

Throughout the war, there were a lot of examples at Intel
Israel of this kind of improvisational everyday heroism. For me,
one story best captures the way the organization rose to the occa-
sion. A team from the Haifa design center was on a conference
call with its U.S. counterparts when the alarm signaling a Scud
attack began to sound. To the amazement of their U.S. colleagues,
they calmly asked for a brief interruption in the meeting so they
could move to the site ’ s sealed room, located in the computer

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66 L E A D E R S H I P T H E H A R D W AY

center, then resumed the call a few minutes later as if nothing had

Delivering — No Matter What

The last Scud attack took place on February 25, not quite six
weeks after the bombardment of Iraq had begun and one day
after the start of the ground war. On Thursday, February 28, the
Israeli state of emergency offi cially ended. All told, some thirty –
nine Scuds in eighteen separate attacks landed on Israeli territory
during the five and a half weeks, none carrying chemical war-
heads. Although only one person was killed directly by an attack,
seventy – four people died of indirect causes — for example, from
heart attacks brought on by the missile strikes or by suffocation
due to improper use of protective gear. More than two hundred
were wounded by blasts, flying glass, and shrapnel. Property
damage to some 4,000 buildings was in the millions of dollars. And
some 1,600 families had to be evacuated. 1

The war had indirect economic costs as well. According to
the Israeli Ministry of Finance, industrial output during the war
was at about 75 percent of its normal level. The costs to the Israeli
economy in lost output totaled approximately $ 3 billion.

At Intel Israel, we were extremely fortunate. None of the Scuds
landed in the Jerusalem area where most of our people worked.
No Intel employee or family member was injured or rendered home-
less by the attacks. And in terms of the economic impact, both the
Jerusalem fab and the Haifa design center were able to meet all of
their manufacturing and product development commitments.

The thing about chaos is that there is no good information.
We had spent a lot of time and energy during the crisis trying to
anticipate the legal ramifi cations of disobeying the government ’ s
instruction to close down. Imagine my surprise when I learned,
weeks after the attacks began, that the civil defense directive to
stay home from work had the status of only a recommendation,
not a legally binding order. At the time, most people, ourselves

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L E A D E R S H I P U N D E R F I R E 67

included, had assumed exactly the opposite. So our decision to
keep operations open was, from a legal point of view, not so risky
after all.

To this day, I ’ m convinced that meeting our commitments to
Intel during the First Gulf War was critical to the future evolu-
tion of Intel Israel — and, indeed, of the entire Israeli high – tech
economy. A few years later, in 1995, Intel invested in its second
semiconductor plant in Israel, at Qiryat Gat. In 1999, the Haifa
design center won the assignment to develop Intel ’ s Centrino
mobile computing technology, which was launched in 2003. And
in subsequent years, whenever we got any push – back about doing
major projects in Israel, it was always helpful to remind our col-
leagues that, as the experience during the war had demonstrated,
“ Intel Israel delivers, no matter what. ”

What ’ s more, the culture of survival that we created during
the First Gulf War has shaped Intel Israel down to the present day.
After the initial version of this chapter appeared in the Harvard
Business Review in December 2006, 2 I received an email from
Shuky Erlich, a former Intel Israel colleague and general manager
of the Haifa design center during the confl ict between Israel and
Hezbollah in the summer of 2006. (By the way, Erlich is that
software engineer who quit Intel in protest over my no – transfer
policy, only to return a few years later.) The war with Hezbollah
was especially costly in terms of loss of life and economic disrup-
tion to the area along the Lebanese border, including Haifa. And
the challenge Erlich faced to keep the business going in the midst
of that disruption was similar to the challenge we faced during
the First Gulf War. “ I found myself looking back more than once
to the 1991 crisis and trying to fi nd answers based on what was
done in those days, ” Erlich wrote me. “ Even just to set the path
for future generations, it was important and dramatic to make the
decisions you made at that time. You were my role model during
the [recent] crisis. ”

On the one hand, I was gratifi ed to hear that the leadership
lessons we learned during the First Gulf War had taken root in the

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68 L E A D E R S H I P T H E H A R D W AY

Intel Israel culture — so much so that they were still operative after
I had retired. On the other, I was sad that due to longstanding fail-
ures of political leadership on both sides of the Israeli – Arab con-
fl ict, my colleagues still had to confront the challenges of doing
business in the middle of a war.

The situation I faced during the First Gulf War was extreme.
I sincerely hope that you will never have to face the equivalent in
your career. That said, the principles of leadership that the story
illustrates are relevant even in more ordinary and less dramatic sit-
uations of turbulence. The job of the leader is to insist on survival,
act against the current, and leverage random opportunities. In the
concluding chapters of this book, I ’ ll discuss some of the supports
you need to put in place in order to do so.

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As the story of the First Gulf War suggests, leadership the hard
way can be a demanding way of life. It asks a lot of the leader,
and it asks a lot of the organization. To meet those demands you
need to develop a support infrastructure that will allow you to rise
to the occasion. In this chapter, I want to focus on a key part of
that infrastructure: what I call the soft skills of hard leadership.

I was trained as an electrical engineer, and for more than thirty
years I worked at a no – nonsense high – tech company founded by
scientists and engineers. Intel ’ s culture values hard data and objec-
tive analysis. It believes in constructive confrontation and “ may
the best idea win. ” This is the hard side of business leadership. It ’ s
absolutely necessary for success in today ’ s environment.

Yet one of the most important things I learned during my career
is that leadership the hard way also requires some extremely soft
skills. These skills are so counterintuitive that they can appear to
be irrational. As a result, they are easy to devalue and dismiss. Most
discussions of leadership ignore them. But in my experience they
are just as important as the more readily accepted hard skills of, say,
strategic management, process discipline, or quantitative analysis.

Some of these soft skills have to do with what I call the inner
life of the leader. The fact is, to lead in the ways that I have been
describing so far — insisting on survival, acting against the current,
leveraging random opportunities — you need to develop a parti-
cular frame of mind, a distinctive way of perceiving and acting.
You must free yourself from habitual ways of looking at things,
cultivate an independent and questioning perspective, and be
ready to embrace alternative and counterintuitive points of view.

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70 L E A D E R S H I P T H E H A R D W AY

Other soft skills concern how leaders interact with their people.
To lead the hard way, you need to develop a close bond with your
people. In particular, you must know how to use your own behav-
ior as a mode of strategic communication to guide the organization
in the direction you want it to go.

Like leadership itself, these soft skills cannot be taught. But
once you are aware of their importance, you can begin to learn
how to develop and use them.

Freeing Up Time

Now that I am retired, I finally have the opportunity to read.
Recently I came upon the following passage by the Roman
philosopher Marcus Aurelius. “ The greatest part of what we say
and do is unnecessary, ” the philosopher writes in his Meditations .
As a result, “ on every occasion a man should ask himself, is this
one of the unnecessary things? ” 1

That ’ s good advice for leaders. Unless you can shed all the
unproductive activities that tend to fi ll up a manager ’ s schedule,
you will never have the mental shelf space to develop a fresh per-
spective on the organization and its challenges. For that reason,
the fi rst soft skill is the ability to free up time.

In my opinion, too much unproductive busyness is the bane
of the modern manager. Most managers spend a great deal of time
thinking about what they plan to do but relatively little time think-
ing about what they plan not to do. As a result, they become so busy,
so consumed by the daily round of meetings and reviews, so caught
up in fighting the fires of the moment that they cannot really
attend to the long – term threats and risks facing the organi zation.
So the fi rst soft skill of leadership the hard way is to cultivate the
perspective of Marcus Aurelius: avoid busyness, free up your time,
stay focused on what really matters.

Let me put it bluntly: every leader should routinely keep a
substantial portion of his or her time — I would say as much as
50 percent — unscheduled. Until you do so, you will never be

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T H E S O F T S K I L L S O F H A R D L E A D E R S H I P 71

able to develop the detachment required to identify long – term
threats to the organization or the fl exibility to move quickly to take
advantage of random opportunities as they emerge. Only when you
have substantial “ slop ” in your schedule — unscheduled time — will
you have the space to be able to refl ect on what you are doing,
learn from experience, and recover from your inevitable mistakes.

Leaders without such free time end up tackling issues only
when there is an immediate or visible problem. When they free
up considerable portions of their time, by contrast, leaders have
the capacity to identify and begin to address problems before they
blossom into a full – blown crisis.

Managers ’ typical response to my argument about free time is,
“ That ’ s all well and good, but here are all the things I have to do. ”
Yet we waste so much time in unproductive activity. It takes enor-
mous effort on the part of the leader to keep time free for the truly
important things.

When I was running Intel Israel, I did a variety of things to
force managers to free up their time. One of the more contro-
versial was to get rid of their administrative assistants. This may
sound paradoxical. After all, isn ’ t the whole point of assistants to
help executives manage their time, to make sure that they do not
get overwhelmed by the press of daily demands?

That ’ s what I used to think myself. But by the mid – 1990s, I was
becoming aware that assistants, the very people whose role was to
facilitate productive interaction, had actually become an obstacle
to it. It wasn ’ t their fault, of course; it was the managers ’ fault.
They saw their assistants as gatekeepers to control the demands
on their time. So they gave over control of their schedule to their
assistants. But the paradoxical result was that my people were so
overscheduled, so busy, that one could barely get any time for
meaningful interaction with them! At a certain point, it suddenly
dawned on me that the best time to reach my people was in the
evening, because they were all booked solid during the day.

At about the same time, laptop computers were just beginning
to become a common tool in business organizations. I had been the

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72 L E A D E R S H I P T H E H A R D W AY

fi rst executive at Intel to distribute them widely throughout the
organization. Every employee at Intel Israel had one. What with
email, calendaring programs, and the like, I began to think that
we could do without assistants completely. I felt that if I forced my
managers to take responsibility for the decisions about how they
used their time, they would make better use of it.

When I made the announcement that I was getting rid of
administrative assistants, my managers were furious. We had many
loud, contentious meetings in which people roundly criticized my
decision. Those meetings were tough; I think the only thing that
made them bearable was that people didn ’ t really believe I was
going to go through with it.

Eventually I came to realize that the only way my managers
would give up their assistants was if I gave up mine. I needed to
model the kind of behavior that I was asking of my people. So
I announced that my assistant of many years was transferring
to another job.

Giving up my assistant was the catalyst for a fascinating change
in my behavior. I became more direct, more focused on what
really mattered. I began interacting with people immediately — in
the moment — rather than scheduling formal times to meet with
them. When people would come up to me in the cafeteria and say,
“ I need an hour of your time, ” I would respond, “ I have fi ve minutes
right now. What ’ s on your mind? ” I estimate that my own availabil-
ity and effi cient use of time increased by at least 50 percent.

Not that being without an assistant didn ’ t cause problems. Of
course it did, but that was precisely the point. Confronting those
problems forced me to innovate. The result was a transformation
in the way I interacted with my people. For example, not long after
I got rid of my assistant, I encountered a problem that I had never
had to deal with before. I was about to leave on one of my frequent
long trips to Intel sites in the United States, and for the fi rst time
I faced the prospect of having to manage my voicemail by myself.
These trips usually lasted anywhere from ten days to two weeks,

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T H E S O F T S K I L L S O F H A R D L E A D E R S H I P 73

and during the period I was gone I would typically receive hundreds
of voicemail messages. My assistant had been an enormous help in
categorizing these voicemails for me and fi guring out which were
really important and needed to be answered right away. How to
avoid being overwhelmed by the sheer quantity of messages?

The solution I fi nally came up with was elegantly simple. I
changed my voicemail message to say that I would be out of the
country for a couple of weeks and to please “ leave only urgent mes-
sages. ” Suddenly my voicemail traffi c plummeted from hundreds of
messages to a handful — and with no discernible degradation in the
performance of the Intel Israel organization!

The moral of this story is how easy it is for the time of the
leader to be consumed by busy work and that once the busy work
is eliminated there is the space for more productive interactions,
more long – term thinking, and real work. Some of my managers
were never convinced that jettisoning their assistants was a good
idea. Yet over time many came to see the value of the change.
Interactions among the management team became more direct.
Much less time was wasted on non – value – adding activities. Slowly,
people began to realize that both their effi ciency and their avail-
ability went way up.

What happened to the assistants? Freeing up my managers ’
time resulted in freeing them up for more productive work as well.
Many of the assistants had considerable education; some even had
advanced degrees. In the vast majority of cases, we were able to
place them in more responsible positions in functional areas such
as logistics or purchasing.

Of course, an even bigger challenge than freeing up time is
fi guring out what to do with it once you have it. Most man agers
are not used to not being busy. In the rest of this chapter, I ’ ll dis-
cuss the kind of activities that managers should be focusing on.
But the starting point for all these activities is freeing up your
time. Remember Marcus Aurelius and always ask: “ Is this one of
the necessary things? ”

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74 L E A D E R S H I P T H E H A R D W AY

The Discipline of Daydreaming

I ’ m not sure why, but daydreaming has always been a big part of my
personality. I suspect it has something to do with the fact that as
a child I spent so much time on my own. Whatever the reason, it
is a powerful personal inclination. Some people fall asleep during
meetings. I daydream. And I have found the habit to be a compel-
ling resource in my role as a leader. That ’ s why I call the second soft
skill of leadership the hard way “ the discipline of daydreaming. ”

Nearly every major decision of my business career was, to some
degree, the result of daydreaming. The fi rst inklings of the vision
to “ bring something back to Israel ” emerged while daydreaming in
my professor ’ s switching – theory class. The concept of the EPROM
occurred to me while musing on the anomaly of the fl oating gate.
The decision to locate our fi rst fab in Jerusalem, not in Haifa or Tel
Aviv, was the product of blue – sky, “ what if? ” thinking very close to
daydreaming. And the origin of our subsequent decision to locate
Intel Israel ’ s second fab in Qiryat Gat was the product of a similar
vague impulse to help “ develop the South ” of Israel. To be sure, in
every one of these cases I had to collect a lot of data, do detailed
analysis, and make a data – based argument to convince superiors,
colleagues, and business partners. But all that came later. In the
beginning, there was the daydream.

By daydreaming, I mean loose, unstructured thinking with
no particular goal in mind. Daydreaming requires letting your
mind go, releasing all constraints — including the constraint of
logic! By defi nition, it ’ s not a linear process. But it can be highly
purposeful — an intensive (although unconscious) targeting and
then distilling of an idea.

In fact, I believe that daydreaming is a distinctive mode of cog-
nition especially well suited to the complex, “ fuzzy ” problems that
characterize a more turbulent business environment. Daydream ing is
a way of knowing, one that is essential for the kind of reframing nec-
essary to perceive and take advantage of random opportunities — as
I did when I redefi ned the fl oating gate problem as the potential

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T H E S O F T S K I L L S O F H A R D L E A D E R S H I P 75

solution for a whole new type of semiconductor memory. It is only
when you release your thinking from the constraints of present – day
reality that you can come up with truly radical solutions to seem-
ingly intractable problems. In this respect, daydreaming is intimately
linked with innovation and improvisation of any kind.

Daydreaming is also an effective means of coping with com-
plexity. When a problem has high degrees of complexity, the
level of detail can be overwhelming. The more one focuses on
the details, the more one risks becoming lost in them. There are
a lot of very smart people in business today who are so detail –
oriented that not only can ’ t they see the forest for the trees, they
can ’ t even see the trees for the leaves! It ’ s impossible to solve a
complex problem only analytically. To see the big picture, some-
times you just have to let your mind go free.

Every child knows how to daydream. But many, perhaps most,
lose the capacity as they grow up. Most institutions of society tend
to devalue daydreaming. The schools punish students who do it.
And in contemporary managerial culture (at least in the West),
daydreaming is too often equated with laziness and seen as an
unproductive waste of time. Given all of society ’ s taboos against
daydreaming, it took me a long time to get comfortable with the
idea that daydreaming is a critical discipline of leadership.

You can ’ t really teach someone to daydream, any more than
you can teach someone to be a leader. Nor can you schedule it or
otherwise plan for it. All you can do is try to be aware of it when
it happens — and, when it does, to appreciate it and cultivate it.
At Intel Israel, for example, one of the reasons that I sought out
people with unusual and, specifi cally, nontechnical backgrounds
was because I felt that diversity would encourage daydreaming.

It ’ s also useful for a leader to make room for experiences
designed to jump – start personal refl ection and learning. These
don ’ t necessarily have to be work – related in any simple or obvious
sense. In today ’ s turbulent economy, you never know what kind of
input is going to trigger a key insight or idea. Take time to prime
the pump for daydreaming.

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76 L E A D E R S H I P T H E H A R D W AY

In my own experience, a variety of activities have been effec-
tive catalysts for daydreaming. Some were traditional, like taking
time to go to lectures and conferences. For example, it was a
lecture by the MIT economist Lester Thurow on global competi-
tiveness that sparked the idea to get rid of administrative assistants
at Intel Israel. To be honest, I don ’ t remember exactly what it was
that Thurow said that gave me the idea. But his general descrip-
tion of the kind of organization that tended to be successful in the
new, more competitive global economy defi nitely got me thinking
of ways to make our organization leaner and more effective.

Another way I stimulated my thinking was to make an effort
to stay in touch with environments and subcultures that were
outside the usual circles I traveled in as a business executive. For
instance, at one point I agreed that Intel Israel would sponsor a
classical music series in the Red Sea town of Eilat. And for a time
I served on the board of an Israeli non – profi t foundation that used
government money to fund documentary fi lm projects through-
out the country. I made these commitments only partly because I
was interested in music and documentary fi lm – making. They were
also a way for me to interact with types of people that I would
never meet on the job — artists, musicians, fi lm – makers, and the
like. These interactions helped stimulate my own creativity and
my capacity to see my own situation in fresh ways.

Finally, I always tried to make time for a few personal avoca-
tions that would take me completely away from my day – to – day life
at Intel and put me into a totally different space. I think that is
partly why I took up fl ying at midlife. I have also been an avid
motorcyclist. And to this day I am an active bicyclist. I fi nd that
alone in the cockpit at ten thousand feet or out on the road cycling
through the Judean hills or in the Italian Dolomites is one of my
best times for letting my mind go free. I often come back with
unexpected new ideas or crazy notions that I want to explore more

So my advice is this: try to be aware when you are daydreaming,
and instead of fi ghting it, nurture it. And try not to discourage or

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T H E S O F T S K I L L S O F H A R D L E A D E R S H I P 77

suppress it in your organization. The next time you ask a question
at a meeting and nobody answers, don ’ t automatically assume that
no one is paying attention. Maybe they ’ re daydreaming. Who
knows, some good may come from it!

Trusting — and Testing — Intuitions

Daydreaming gives birth to intuitions, ideas, or conclusions that
arise with seemingly little effort and with little or no conscious
deliberation. A third soft skill that leaders need to learn is how to
trust their intuitions and use them more actively as the basis for
decisions. When you are fl ying through a thunderstorm, you have
to act quickly, in the moment, and without necessarily analyzing
what you are doing.

A great deal of recent cognitive science research on how the
mind processes information has shown that much of our every-
day thinking, feeling, and acting operates outside our conscious
awareness. 2 Our explicit analytical knowledge is just the tip of the
iceberg. Below the surface there is a vast realm of tacit knowl-
edge that we develop without even being aware of it. Especially in
innovation – based businesses, this tacit knowledge — the kind that
can ’ t be easily codifi ed (nor, therefore, easily copied by competi-
tors) — turns out to be far more important than most organizations
think. 3

Yet in most business organizations, intuitive thinking still has a
bad rap. At Intel, for example, people tended to mistrust intuitive
decision making — what they termed, disparagingly, “ seat – of –
the – pants ” management. The common attitude was “ Show me the
data. ” I would never argue for a manager to ignore data. But leaders
increasingly face situations in which they don ’ t have all the data,
or the data are ambiguous, or the change they are contemplating
is so radical that it ’ s not yet clear what would even qualify as data.
In such situations, it ’ s important to let intuition be your guide. As
Albert Einstein once said, “ Not everything that can be counted
counts, and not everything that counts can be counted. ” 4

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78 L E A D E R S H I P T H E H A R D W AY

Of course, not all intuitions are necessarily good ones. Just as
intuition can easily be a source of new insight, it can also lead us
astray. So in addition to trusting your intuitions, you must also
test them rigorously. Indeed, I would say that systematically test-
ing intuitions is a big part of the process of trusting them. If you
don ’ t value your intuitions enough to bring them into the cold
light of day and confront them with reality, then maybe they are
not so sound after all. To effectively harness intuition, you need
a double loop. You need to test your intuitions and continuously
revise them in the light of what you learn.

Take, for example, the story that I told in Chapter Two about
switching the heads of the Haifa design center and the Jerusalem
fab. I had an intuition about the potential value of developing
more well – rounded, multidisciplinary managers through a program
of lateral transfers. I was right to trust that basic intuition. Yet
I didn ’ t really test it in advance. For example, I made the job
change without consulting any of the Intel managers back in the
States who were responsible for running the company ’ s design and
manufacturing functions worldwide. I was worried that if I started
consulting people, that would be an open invitation for them to
come up with reasons not to make the change.

It took the failure of the manager assigned to run the Haifa
center for me to realize the important elements that I had left
out of my plan — specifically, the need for extensive senior –
management support to help the transferred managers learn the
culture of the new units they were running. To be sure, I learned
from this mistake and changed the transfer program accordingly,
but that knowledge came at a very high cost: the failure (and, ulti-
mately, the loss to the company) of a good manager. In retrospect,
it would have been far better to find ways to test my intuition
before plunging ahead with the transfer program.

One way to make sure you test your intuition is to create and
encourage a culture of dissent. By promoting strong people who
will stand up to you and say no, you can create an environment
in which your intuitions have to run the gauntlet of constructive

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T H E S O F T S K I L L S O F H A R D L E A D E R S H I P 79

criticism. For example, there was one veteran employee at the
Haifa design center who was challenging me all the time. To be
honest, I had extremely ambivalent feelings about this individual.
It ’ s no fun to be constantly challenged and criticized. Yet in the
end I was glad he was there. He kept me on my toes.

Encouraging and welcoming challenges to your intuitions
doesn ’ t necessarily mean always backing down. It ’ s a balanc-
ing act — remaining true to your core intuitions even as you take
into account disagreement and adapt your ideas to criticism and
dissent. Indeed, the stronger you are as a leader, the less likely it is
that you will back down and the harder it will be for your people to
challenge you — which is all the more reason to surround yourself
with strong people who will push their own points of view just as
persistently as you do your own.

By defi nition, intuitive knowledge cannot be taught. Rather, it
is the product of an individual ’ s specifi c experiences. But it is pos-
sible to educate your intuitions — for example, by actively seeking
out feedback, by exposing yourself to new situations and new envi-
ronments that will spark your learning, by systematically exploring
the connections between seemingly unrelated phenomena, or by
carefully considering the trade – offs between alternative courses of
action. 5 But the fi rst step is to trust your intuitions and use them to
inform your actions.

Communicating Through Behavior

So far, the soft skills I have discussed concern the internal mind –
set of the leader. But leadership the hard way isn ’ t just personal; it
is also interpersonal. It requires close bonds with your people. Take
the example of my experience during the First Gulf War. There
was no way the people of Intel Israel would have responded to my
call and kept working if they didn ’ t already trust that I had their
best interests at heart.

How does the leader build that trust? One important way is by
staying true to shared values. Indeed, values are so important that

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80 L E A D E R S H I P T H E H A R D W AY

I will discuss them in a separate chapter. Another way is through
continuous communication — like the high – bandwidth communi-
cation we engaged in during the First Gulf War. But what I want to
focus on here is something different: the way leaders must use their
behavior strategically in their interactions with their people.

Leadership is about action. A leader needs to act in order to
get things done. But action is also a form of communication. There
are many situations in which a leader acts in a certain way to com-
municate his vision and values for the organization. The fi nal soft
skill you as a leader must cultivate is becoming aware of the impact
of your behavior on the organization — and using that behavior,
strategically, to move the organization in the direction in which
you want it to go.

One of the most difficult things for most leaders to under-
stand is just how sensitive the organization is to every move that
the leader makes, every perturbation of style or mood. The eyes
of the organization are always on you. People will watch your every
step and emulate what you do. This is a powerful tool in the sense
that the leader ’ s behavior helps create the organization ’ s culture.
Everything you do will be refl ected in the organization. But unless
you cultivate a double awareness about your behavior, you can end
up doing things that inadvertently contradict what you say and
what you intend.

It took me years to realize just how powerful an impact my
actions could have on employees at Intel Israel. Once, for exam-
ple, I chewed out a subordinate at a team meeting for some error
(I forget what). At the next meeting of the group, the individual
didn ’ t show up. I asked a colleague where the missing manager
was — only to be informed that he had been so upset at my criti-
cism that he had become ill!

Another time, lost in thought, I passed a colleague in the
hallway without saying hello. It was only later that I learned that
my silence had caused him considerable anxiety. Had he done
something wrong? Was he no longer on my good side? My non-
response, which was completely inadvertent, made him genuinely

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T H E S O F T S K I L L S O F H A R D L E A D E R S H I P 81

worried that he had done something to damage his standing in the

Or consider my decision to eliminate administrative assistants.
When I fi rst announced the change, I couldn ’ t understand why
nothing was happening. As strange as it may sound in retrospect,
it took me three months to fi gure out that until I removed my own
assistant, nobody else was going to make the change. They just
didn ’ t take it seriously. It was only by acting that I could make real
the seriousness of my intention.

As I became more aware of the impact of my behavior, I tried
to use it consciously not just to get things done but also expli-
citly to send a message. In 1982, for example, during the construc-
tion of the Jerusalem fab, I arranged for a three – month stay at an
Intel fab in Beaverton, Oregon, to learn the ins and outs of semi-
conductor manufacturing management. Because the stay would be
relatively long, my wife and children were coming with me, and
we had rented an apartment in Beaverton. A few days before we
left, however, I heard news from Intel corporate that complicated
my plans.

The early ’ 80s were a diffi cult period for Intel. The semicon-
ductor industry was mired in recession, and the downturn had
had a strong negative impact on Intel ’ s fi nancial health. In 1981,
for example, sales and profi ts had declined precipitously, for the
fi rst time in the company ’ s history, and Intel ’ s market cap was cut
nearly in half. And in 1982 Intel ’ s key customer, IBM, bought
20 percent of the company on the theory that a major cash infu-
sion was necessary to ensure its survival. As part of the internal
effort to deal with hard times, Intel instituted an across – the – board
10 percent pay cut. The announcement of the new plan was sched-
uled for a few days after my departure.

The timing posed a personal dilemma. I felt it was essential
that I, as Intel Israel ’ s leader, deliver the bad news myself — not
fob the task off on my subordinates. Yet if I delayed my depar-
ture, especially without explaining why, people would know that
something was up. I suppose I could have organized a conference

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82 L E A D E R S H I P T H E H A R D W AY

call and announced the news to the Intel Israel staff from Oregon,
but frankly I didn ’ t even consider it. At this moment of uncer-
tainty and crisis, I strongly believed I needed to be present “ in
the fl esh. ” So, much as I hated to admit it to myself, what I had to
do was clear: I fl ew to Oregon with my family, as scheduled, got
them settled in our apartment there, and then immediately fl ew
back to Israel to personally make the announcement of the pay
cut. After informing my people and dealing with all the fallout,
I got on a plane again and returned to Oregon to take up my
assignment there.

Another way in which I would frequently use my behavior
strategically was to intervene selectively in decisions and processes
down in the organization on issues that I considered of strategic
importance. I ’ m not particularly detail – oriented and am prob-
ably the last person anyone would describe as a micromanager.
Yet at certain key points in my time as the leader of Intel Israel,
I chose to go deeply into aspects of the organization ’ s manage-
ment to communicate the importance of a particular initiative or
plan. One example was the decision, described in Chapter Two ,
to hire a more diverse workforce. There was a period of time in
the mid – 1990s when I was regularly reviewing — and sometimes
reversing — hiring decisions.

Another area in which I felt it was essential to be actively
involved was the negotiations with the Israeli government for
both the Jerusalem and Qiryat Gat fabs. Especially in the latter
case, where I had a full team to support me, I could easily have
left the negotiations to the team until things had reached the
ministerial level. Instead, I handled them personally. It wasn ’ t
that I didn ’ t trust my team. It ’ s just that, given the importance
of the investment to the future of Intel Israel, I felt my presence
as the leader was essential in order to communicate to everyone —
the organization, the Israeli government, municipal authorities,
Intel corporate — just how committed I was to completing the deal

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T H E S O F T S K I L L S O F H A R D L E A D E R S H I P 83

Sometimes a leader ’ s symbolic actions need to be dramatic —
and maybe even a little bit crazy. For instance, I am viscerally
opposed to the idea of using compensation as a means to motivate
people. I get suspicious of anyone who seems to be in it primarily
for the money. I wanted to attract people to Intel Israel who could
really get excited about our values and our mission, not just look
on us as a place to make more money. In fact, I felt so strongly
about this principle that I instituted a policy of never discuss-
ing salary with a potential new hire until we were ready to make
a defi nitive offer to bring the person on board. That was normal
practice in the high – tech industry for most professional jobs,
but it was highly unusual for the hourly jobs in semiconductor
fabrication plants.

One time, we made an offer to someone for a senior leadership
position at Intel Israel. Before accepting, he said that he wanted to
talk directly to me. When we met, the individual explained that in
principle he accepted the offer. But he had a lot of questions about
“ fringe benefi ts. ” For example, what about transportation? Could
he have a company car? His list went on and on. When he fi nished,
I responded simply: “ I appreciate your concerns — so much so that
I ’ m withdrawing the offer. I just don ’ t think you ’ ll fi t in here. ”

Of course, my response wasn ’ t purely symbolic. I really did
believe that the new hire wouldn ’ t fi t in at Intel Israel. Still, I acted
the way I did, at least in part, to deliver a message to the organiza-
tion about the kind of culture we wanted to create and the kind of
people we wanted to hire. I was keenly aware that my behavior was
a powerful form of organizational communication.

A leader has to be careful with this kind of symbolic action. If
you become too conscious about always trying to make an impres-
sion, you can risk becoming inauthentic — even manipulative. If
the organization believes that your actions are “ just an act, ” they
are likely to have the opposite effect of what you intend. But as
long as your actions are consistent with your vision and values,
then they are likely to be perceived as genuine.

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84 L E A D E R S H I P T H E H A R D W AY

Freeing up time; the discipline of daydreaming; trusting, but
also testing, one ’ s intuitions; using one ’ s behavior strategically — all
these soft skills will rarely show up in the typical course on lead-
ership. Yet in my experience they are essential for becoming the
kind of leader who can succeed in turbulent times. Without them,
I wouldn ’ t have been able to lead Intel Israel in the way that I did.

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In a world characterized by turbulence, every organization needs
a solid anchor, some unchanging core that remains the same no
matter how disruptive the environment gets. That anchor is the
organization ’ s values. Markets and competitors, technology and
business models — all may change, some even radically, over time.
But once an organization defi nes its values, those values should
not change. They are an important reference point for orient-
ing the organization to the long term. They provide the stabil-
ity and continuity that allow an organization to adapt to new

With the increasing turbulence of the world economy, more
and more attention has been paid to the critical role of values in
driving competitive success. 1 Yet at the same time that so many
business leaders are talking about values, we are also seeing
massive breakdowns of ethical behavior at many large corpora-
tions. Witness the widespread corporate fraud of a few years ago
that brought down companies such as Enron, or the more recent
scandals involving the backdating of stock options by CEOs and
other senior executives. Apparently, at the precise moment when
companies are fi nding values so essential they are also fi nding it
more diffi cult to live up to them.

It is really not so paradoxical when you think about it. The
same forces that are making values so important are also increas-
ing the pressures to violate them. In an environment in which the
rules are always changing and threats to survival are frequent, it ’ s
natural for people to start thinking that they must “ do anything ”
to survive. There is an enormous temptation to cut corners, take
the easy way out, or look the other way when behavior enters that

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86 L E A D E R S H I P T H E H A R D W AY

murky gray area where value violations tend to happen. In the
middle of a thunderstorm, it becomes far easier to imperceptibly
cross over an ethical line.

The problem is, such shortcuts often bring about precisely the
opposite of what leaders intend, trapping companies in a vicious
circle. An inclination to “ do anything, ” for example, not only
tends to mire an organization in short – term thinking, but sooner
or later it also becomes a convenient excuse for more everyday
vices such as greed, power, and corruption. As a result, the very
actions taken to ensure survival end up making it less likely, not
more. If more executives at Enron had had genuine integrity, the
company might still be around today.

This vicious circle doesn ’ t occur only in the business world.
Consider the U.S. government ’ s so – called war on terror. The Bush
administration used the American public ’ s fears about survival,
stimulated by the attacks on 9/11, to argue that we live in a differ-
ent and more dangerous world, one that requires taking shortcuts
around long standing traditions and practices: shortcuts such as cur-
tailing civil liberties, creating a special extrajudicial legal regime
for detainees, ignoring the Geneva Conventions, even embracing
torture. But these shortcuts have ended up violating some of the
fundamental values of the U.S. Constitution. Not only have they
been ineffective, they have also been used as the cover for rampant
political opportunism, corruption, and abuse. As a result, the much
vaunted war on terror has ended up degrading many of the very
values that it was supposed to protect — and, I fear, caused serious
long – term damage to America ’ s standing in the world.

So although I believe that staying true to an organization ’ s
values is an essential tool for navigating the turbulence of the
current economic environment, I ’ m also realistic enough (and
perhaps pessimistic enough) to realize that value violations are
not rare, but common. Therefore leaders must be relentless — and
sometimes even obsessive — about making the organization ’ s
values real. Not only must they establish the highest ethical stan-
dards; they must also create a culture of transparency that surfaces

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M A K I N G VA L U E S R E A L 87

such violations when they occur, so the organization can recover
from them.

Being Relentless About Values

At Intel Israel we had a values statement that, like the value state-
ments at most organizations, rounded up all the usual suspects. It
was full of high – sounding but generic phrases about “ respect for
people, ” “ results orientation, ” “ quality, ” and the like. I believe that
words matter if for no other reason than that they highlight the
distance between the way things are and the way they are sup-
posed to be. But even the best words can become so corrupted that
they get turned inside out and end up encouraging behavior the
very opposite of what they intend.

Take, for instance, the idea of an “ orientation to results. ” If a
company isn ’ t careful, having an orientation to results can quickly
end up meaning “ the ends justify the means. ” As soon as there
is any problem with producing results, people are immediately
tempted to start sandbagging their plans, falsifying performance
data, and the like. When a leader lets such behavior go on, an
organization will lose its competitiveness over the long term.

So my approach was always to focus on what it would take
to make the words real as refl ected in the behavior of our people.
I took this task so seriously in part because one of the biggest chal-
lenges in creating Intel Israel was implanting Intel ’ s high levels
of integrity in a country where the traditional business culture
involved a lot of cutting of ethical corners. The Israeli business
environment is pretty freewheeling. There is a much greater ten-
dency on the part of companies there than in the United States
to engage in activities that skirt the law. In my experience, for
example, an Israeli company is far more likely to try to get around
the laws governing corporate taxation than a typical American
company. The basic attitude is “ let ’ s try it; the worst thing that can
happen is we get caught — in which case, either we pay the fi ne or
try to fi ght it in court and see what happens. ”

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88 L E A D E R S H I P T H E H A R D W AY

I refused to engage in such practices. My attitude was that Intel
Israel would follow the very highest standards, no matter what the
practices of the local business culture might be. In the early days
I had many clashes inside Intel Israel over this issue. People would
ask, “ Why don ’ t we do things like other companies do? ”

Let me give you what may seem like a relatively minor exam-
ple. It ’ s common practice in Israel for companies to give employees
gifts on major holidays such as New Year ’ s or Passover. Typically,
the process works like this: a company cuts a deal with a big depart-
ment store that, in exchange for major discounts on a range of
products, has a monopoly over the gift selections at the company.
The department store brings the range of qualifying gifts into the
workplace and employees select the ones that they want. Although
the gift is clearly an employee benefi t (and sometimes worth con-
siderable amounts of money), the employee pays no taxes on the
gifts, and the company writes off the cost as a business expense.

We participated in this practice for a while, but it always made
me uncomfortable. Finally, at a certain point I simply said, “ Let ’ s
stop this circus and just give people money instead ” (which, of
course, would have to be declared as income). It was a big shock
for people, both inside and outside the company. “ Intel doesn ’ t
give presents! ”

Other ethical dilemmas were not so minor. My uncompro-
mising approach to the organization ’ s values could affect major
business decisions on which millions of dollars of investment
were riding. When we were defi ning the Qiryat Gat fab incentive
package, for example, the government negotiators asked for some-
thing that from their perspective was perfectly innocuous. A key
raison d ’ ê tre of the deal was to encourage economic development
in Israel, so the government asked us to commit to certain targets
for “ local content ” (that is, coming from Israel – based companies)
in both the construction budget for the plant and the third – party
supplier budget once production commenced.

It wasn ’ t an unreasonable request. After all, in arguing for
government support for the plant, I had made a big deal myself

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M A K I N G VA L U E S R E A L 89

about the benefi ts to the Israeli economy. Yet I had a big problem
with the proposal. At Intel, one of our values is that when we make
a commitment, we keep it. In other words, whatever we commit
to, we do. But it wasn ’ t at all clear that committing to local con-
tent to the extent the government wanted made economic sense.
For example, at that point we didn ’ t yet know whether the Israeli
construction industry could handle a complex construction proj-
ect like that of the Qiryat Gat fab. As for the supplier budget, we
didn ’ t even know what product we would be making. It was simply
too early to determine how much local content we could use. If it
made business sense to use local suppliers, of course we would be
inclined to do it. But at that stage of the game I wasn ’ t going to
commit to hard – and – fast numbers. So I refused.

As an alternative, I proposed language to the effect that Intel
would use its “ best efforts ” to fi nd, develop, and do business with
local suppliers. Moreover, I argued that emphasizing “ best efforts ”
would be more effective than any defi ned targets in stimulating
the organization to work with local suppliers.

The government negotiators weren ’ t buying it. They insisted
on clearly defi ned targets and commitments — so much so that the
impasse threatened to undermine the entire negotiation. But I
remained steadfast in my refusal because I knew that if I brought
such a commitment back to the organization, my people would
know that it wasn ’ t realistic — and this would undermine the orga-
nization ’ s commitment to delivering on its promises.

In the end the government backed down. The negotiators
agreed to the softer language — on the condition that the govern-
ment could closely monitor our performance over time. As I had
initially suspected, we ended up exceeding the proposed targets
that the government had demanded within the fi rst fi ve years of the
fab ’ s existence. But the key point is this: I was fully prepared to walk
away from the deal if the government had insisted on its proposal.

Another issue over which I clashed with the government (and
with my own people) concerned temporary employment incen-
tives. At a number of points during the period that I was running

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90 L E A D E R S H I P T H E H A R D W AY

Intel Israel, the Israeli government set up temporary programs to
give companies fi nancial incentives to hire people. For every new
employee a company took on it would receive a subsidy from the
government. These subsidies could add up to substantial sums
of money.

I refused to accept them. My people couldn ’ t believe it, but
as far as I was concerned, my logic was clear: we didn ’ t hire any-
body unless there was a clear business need for hiring them. And
if it made economic and business sense to hire someone, then
I was willing to pay whatever it took to get them. If Intel Israel
accepted the government ’ s employment subsidies, then soon
enough we would start hiring people we didn ’ t really need — just
to receive the subsidy. But at some point in the future, I knew, the
subsidies would disappear, and we would be left with employees
that would be an economic burden on the organization and that
we would have to let go. That wasn ’ t ethical — either for Intel
Israel or for the individuals involved. It certainly did not display
respect for people.

People thought I was being rigid. But the thing to understand
is that in Israel at the time, the government ’ s policy had led to a
lot of shady dealings — and, in some cases, outright cheating — on
the part of companies to maximize the subsidy they received. We
weren ’ t going to play that game.

It wasn ’ t that I was opposed in principle to the idea of govern-
ment incentives. After all, we had received incentives to locate
our fabs in Jerusalem and Qiryat Gat. I believed strongly (and still
do) that such incentives were both a legitimate means for Israel
to compete effectively with other countries in the competition for
multinational investment and a kind of necessary risk premium
to compensate for the geopolitical instability of the region. But
when a company starts using temporary incentives to lower the
effective wage rate of its operation, that undermines long – term

A funny thing happened with these employment incentives.
In one case, it turns out that even though we refused them, the

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M A K I N G VA L U E S R E A L 91

government paid them to us anyway. So we found ourselves with
over half a million dollars that we didn ’ t quite know what to do
with. “ Should we return the money? ” my fi nance people asked me.

In this case, I decided that I had made my point and wasn ’ t
going to be a fanatic about it. If the government was going to
go out of its way to pay us, despite my refusal to participate in
the subsidy program, we weren ’ t going to return the money. But
I wasn ’ t going to let it fl ow to our top line either. Instead, we used
the money to set up a special fund to provide our employees with
low – interest loans, mainly for housing.

Saying “ No ”

As these examples suggest, in many situations the key to staying
true to your values is not so much doing something as not doing
something — saying “ no ” to behavior that you know in your gut is
inappropriate but for which refusal may also carry some real costs.
Often, however, what appears to be the easy way out is actually the
more costly option.

For example, there was a period in the early days of the
Jerusalem fab when we had a pretty serious problem with employee
pilferage and theft. “ The only way we are going to solve this
problem is to install surveillance cameras, ” my security director
told me. I objected to that approach because it felt antithetical to
the kind of open organization we were trying to create. Instead of
focusing on surveillance, I proposed that we focus on values. We
started talking about the theft problem in every employee forum,
explaining in detail the costs of pilferage both to our competitive-
ness and to our values. Within a matter of months, the losses from
pilferage declined dramatically.

On another occasion, I received a phone call from an offi cial
at Shabak, Israel ’ s internal security service. The agency was setting
up a network of people in the business community to supply
economic intelligence about companies doing business in Israel,
and it wanted Intel to be involved. I unequivocally refused.

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92 L E A D E R S H I P T H E H A R D W AY

It was a risky move. The security establishment in Israel is
highly infl uential, and I ’ m sure many people would believe that
it was our responsibility as loyal Israelis to participate in such a
network. But my attitude was, Intel is in the semiconductor busi-
ness, not the intelligence business. I felt it was inappropriate to be
providing such information to the government. What ’ s more, we
were an open organization. Anything that smelled of covert activ-
ity would be a violation of our values.

When we were negotiating the incentives package for the
Qiryat Gat fab with the Israeli government, there was a tough
impasse on a couple of the terms. In an effort to improve their
leverage, some of the negotiators on the government side leaked
details to the Israeli press. The selective leaks put Intel in a bad
light and we were pummeled by the press. Things got so bad that
I got a message from Intel CEO Craig Barrett saying that he was
considering killing the deal.

Some people on my team thought that the solution was to
fi ght fi re with fi re and start leaking ourselves. But I refused to carry
out our negotiations with the government via the press. I simply
contacted the leader of the government negotiating team and told
him that if the leaks continued, the deal was off. There were no
more leaks after that.

Later, after we had built the Qiryat Gat fab, I got a call from the
offi ce of Israel ’ s Chief Rabbi. Semiconductor fabs are 24/7 opera-
tions. All plants in Intel, no matter where they are located, operate
seven days a week. Therefore we needed a permit from the local
Rabbinic association to allow the plant to operate on Friday, or
Shabbat, the Jewish Sabbath. But we were having a hard time
getting the permit. Without it, the Ministry of Labor could close
us down.

“ The Chief Rabbi would like to meet you, ” the representative
from the Chief Rabbi ’ s offi ce told me. “ He would like to help you
get the permit for Shabbat. He ’ s sure we can work things out. ”
Again, I refused. Either we were going to get the permit or we
weren ’ t going to be able to operate legally. But I wasn ’ t going to get

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M A K I N G VA L U E S R E A L 93

involved in any kind of negotiation with the Chief Rabbi, who, as
far as I was concerned, had no legitimate role to play in the deci-
sions of a global business organization, and I refused to be depen-
dent on him for any favors. What ’ s more, I calculated that after
all the money that the Israeli government had put into the Qiryat
Gat fab, the Rabbinate couldn ’ t very well go to the government to
close us down. Once they saw that we weren ’ t going to budge, the
local Rabbinic association yielded.

In my experience, when you stick to your values, you get
rewarded — whatever the risks involved. Indeed, in the spirit of
leadership the hard way, often the more diffi cult or riskier path
turns out to be the easiest one in the end. Developing strong val-
ues and allowing yourself to be guided by them simplifi es things. In
an uncertain environment, values provide a clear path to follow.

Transparency, Not Purity

In insisting on the importance of staying true to an organization ’ s
values, however, I ’ m not saying that the goal should necessarily be
to eliminate any and all value violations. No large complex organi-
zation is ever going to be pure as the driven snow. Rather, the goal
should be to create a system in which the inevitable value viola-
tions that do occur quickly come to people ’ s attention, are iden-
tifi ed, and then are corrected. The way to stay true to values is to
elevate issues, make people feel comfortable in dealing with them,
bring things into the open rather than covering them up. Put
another way, the goal isn ’ t purity, it ’ s transparency — and recovery.

This lesson was brought home to me in an experience I had not
long after the establishment of the Jerusalem fab. I was traveling
to Israel ’ s Ben – Gurion airport to pick up a senior Intel executive
who had come from the States to tour the site. Because I was late
for his arrival, I left my car parked illegally in the pick – up zone and
hurriedly rushed to meet him inside the terminal. Sure enough,
when we returned to the car, there was a ticket on the windshield.
Later in the day, as we moved from meeting to meeting in the fab,

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94 L E A D E R S H I P T H E H A R D W AY

I quickly stopped by the offi ce of my fi nance director, explained
why I had gotten the ticket, and asked him to take care of it. At
the end of the day, he stopped by my offi ce. “ Dov, we need to talk, ”
he said. “ Your parking ticket is not the company ’ s business. If you
violate the parking regulations, then you have to pay for it. ”

Of course, he was absolutely right. I had been so preoccupied
that I hadn ’ t really taken in what I was doing. When he pointed
it out to me, I was chagrined that I hadn ’ t lived up to my own val-
ues. It is precisely such small, everyday actions — like my assuming
that the company would pay my parking ticket — that establishes a
general tone. It upset me that, in the rush and pressure of the day,
it had been so easy for me to neglect the very values that I talked
about all the time.

Yet at the same time I felt enormously gratifi ed that my fi nance
director had felt confi dent enough to challenge me on it. That
was a sign that the Intel Israel culture was working, that we had
begun to create an environment where people took the values seri-
ously enough to act on them. Creating such an environment is
the biggest achievement you can have. I paid the ticket without

Acknowledging Mistakes

As the parking – ticket example suggests, the importance of values
puts a special burden on an organization ’ s leader. On the one hand,
you have to try to live up to the values in your own behavior. But
even more, you have to be open and honest when you fail — as you
inevitably will. The true test of your integrity as a leader is not in
the moments when you stay true to the organization ’ s values but,
rather, in those when you discover that you have violated them.

It ’ s a key moment of truth. Either you cover up your own
inability to live up to the organization ’ s values or you bring it out
into the open for people to see. In my experience, covering up
only makes things worse, because it ’ s impossible to keep things
secret for any length of time. Sooner or later the cover – up fails,

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M A K I N G VA L U E S R E A L 95

things come out, and the result is often increased hypocrisy about
values in the organization.

Being open about your own value violations can have many
positive effects. For one thing, it tends to humanize you as a leader
and strengthen the bond with your people. It shows that you
struggle just like they do to live up to the organization ’ s values —
and sometimes fall short. It also can lead to a constructive conver-
sation about the inevitable tension of staying true to values in a
high – pressure business organization.

Once Intel Israel reached a certain size, we began to have
formal orientation and training programs for our new employees. I
made sure that one of the orientation sessions was devoted to Intel
Israel values. But instead of having the typical lecture or class,
I insisted that the session be organized as an informal discussion
in which I myself, the organization ’ s leader, would participate.
I would come to the meeting, project the organization ’ s val-
ues statement onto the screen, and then ask the new employees
present (most of whom had already been at the company for six
months or so) to identify any values that they believed, based on
their experience so far, we were not living up to.

It was never an easy conversation to get started. Often
people would hesitate to speak freely. Yet eventually some brave
soul would tell a story about something he or she saw, and that
would get the ball rolling. Then we would discuss — were these
really value violations? If so, how? What were the extenuating
circumstances? How did we think various participants saw the
situation from their perspective? What should you do about it if
you confront a similar situation?

Once I arrived at one of these orientation sessions at the Qiryat
Gat fab about half an hour late. As I was entering the site, I found
myself thinking about an old Israeli saying, “ Menahel lo marcher
hu rak mit ’ akev ” (A manager is never late, only delayed). How
convenient, how self – protective for the manager, I thought. So
when I walked into the room, the fi rst thing I said was, “ This is a
session on Intel Israel values. And by arriving late, I have violated

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96 L E A D E R S H I P T H E H A R D W AY

at least three of the values we espouse. I haven ’ t shown respect
for people. I didn ’ t display a results orientation. And I defi nitely
wasn ’ t committed to quality. ”

Acknowledging my own failure to live up to the organization ’ s
values made the conversation very real. We talked about how
diffi cult it can be to stay true to our values given the daily demands
and pressures of the business, yet how important it was to the long –
term success and survival of Intel Israel. In my opinion, it was one
of the best sessions on values that we had ever had.

Maintaining the Tension Between
Values and Behavior

The battle to establish high ethical standards in an organization
never ends. Again, the goal should not be some impossible purity
but rather a willingness to embrace the necessary tension that
making values real entails. People don ’ t like it when there is a gap
between their behavior and the values they espouse. On the one
hand, they are right: the ultimate goal is to align behavior with
values. But sometimes, in an effort to eliminate that gap, people
rush too quickly to close it. Put simply, they change the values, not
the behavior.

Let me conclude with an example of what I mean. Not long
before I retired, I found myself in a meeting with my senior staff to
revisit the language of the organization ’ s values statement, some-
thing that we did routinely every few years. One of the values on
our list was “ integrity without compromises. ” A number of people
at the meeting thought that defi nitely needed editing. Put simply,
they wanted to remove the phrase “ without compromises. ”

They worried that this strong language promised more than
the organization could deliver. The fact was, we were continu-
ously finding ourselves in somewhat compromising situations,
dealing with boundary issues for which the imperatives of integrity
seemed to confl ict with good business practice. One manager gave
the example of how we handled overtime pay. There was some

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M A K I N G VA L U E S R E A L 97

language in Israeli labor law, albeit somewhat vague, mandating
employers to pay extra for overtime. But at Intel Israel, we fol-
lowed the U.S. practice of distinguishing between exempt (that
is, supervisory) and non – exempt (that is, hourly) employees. For
the non – exempt hourly employees, we of course did pay overtime.
But for the exempt group, who were on salary, we didn ’ t even keep
track of the hours they worked. Their responsibility was to get the
job done, and from the perspective of the company, it didn ’ t matter
if they worked more than eight hours a day — or less.

It wasn ’ t at all clear that our policies violated the law. Cer-
tainly no one, neither employees nor government offi cials, had
ever complained. But the critics argued that it was a bit of a gray
area. Weren ’ t we perhaps compromising our integrity? Better to
avoid the issue by simply eliminating the “ without compromises ”
language. “ Isn ’ t ‘ integrity ’ good enough? ” they asked.

I had a different perspective. The fact that we constantly faced
situations that might compromise our integrity wasn ’ t a reason to
eliminate the “ without compromises ” language. Quite the contrary:
it was a reason to keep it. If we eliminated those two words, we ran
the risk of becoming complacent. We would start taking such situ-
ations for granted instead of continuously question ing them and
asking whether we were in fact doing the right thing. Emphasizing
the ideal of “ integrity without compromises ” created a tension. It
forced us to think about things and to address them pragmatically.
Who knows? Maybe we should reconsider our policy. Or perhaps
we should be working to get the government to revise the law.

I refused to make the change. The values statement remained
as written. I suspect it probably made some of my people nervous.
Could we really live up to the value as written? I wasn ’ t so worried,
because that was exactly the question that I wanted them to keep

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c06.indd 98c06.indd 98 2/2/08 10:51:30 AM2/2/08 10:51:30 AM




At the beginning of this book I argued that the essentials of
leadership are more akin to wisdom than they are to knowledge.
Because leadership is not really a skill, it cannot really be taught.
Rather than hoping to learn in the classroom or from some training
program how to lead, aspiring leaders need to take on the hard work
of bootstrapping leadership — that is, learning how to lead by doing
it. In the body of the book, I have tried to show how this process
played itself out in my own career as I pursued my life project of
creating a new high – tech business in Israel and taking it from the
periphery to the very center of a major global corporation.

It ’ s all well and good to say “ learn by doing. ” But how does
a potential leader learn from doing? In this concluding chapter,
I want to describe four resources that an aspiring leader can use to
learn how to lead. Reading these pages won ’ t necessarily turn you
into a leader any more than any other book on the subject will.
But they just might give you some ideas for where to start your
own bootstrapping once you fi nish this book.

Staying True to Your Passion

No leader can be effective who does not identify 100 percent with
the organization ’ s mission. A leader doesn ’ t have the luxury to be
equivocal. You have to make sure that your personal mission and
the organizational mission are perfectly aligned. After the First
Gulf War, for example, someone at Intel Israel said to me, “ You
were behaving as if your own personal survival was at stake, not
just the survival of Intel Israel. ” It ’ s true, because by that time I had
completely identifi ed with Intel Israel and its future.

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100 L E A D E R S H I P T H E H A R D W AY

Because this identifi cation between leader and organization
is so important, it ’ s critical for you as an aspiring leader to iden-
tify your passion — what really drives you — and to stay true to that
passion through the course of your career. If you do, you will fi nd
that this passion is a powerful resource for guiding you through the
challenges of leadership the hard way.

There are many sources for identifying your passion. One is
your early life experiences. Your fundamental approach to leader-
ship is set long before you ever reach a position of authority. In
my own case, the experiences of my World War II childhood, of
being an observer of and participant in the Berkeley countercul-
ture of the 1960s, and of developing a breakthrough innovation
in the computer industry with my invention of the EPROM all
profoundly shaped the kind of leader I wanted — and was able — to
become. Fortunately, these experiences nurtured an approach
to leadership that turned out to be highly effective in the fast –
moving and highly turbulent economy in which I found myself.
Aspiring leaders need to understand the origins of their individual
leadership styles and how those origins map to the specifi c chal-
lenges of business competition today.

Another key part of staying true to your passion is to defi ne, as
early as possible, a vision or mission to which you want to dedicate
yourself. It doesn ’ t matter how unrealistic or even crazy that vision
might appear at the time. Even the vaguest plan — like my early
desire to “ bring something back ” to Israel — has the value of being
a reference point that orients would – be leaders and helps guide
their choices, actions, and decisions.

Over time, as you gain experience, the vision will become
more concrete. At that point, one of the most important ways to
stay true to your passion will be knowing when to say no. Once you
gain some success, it is extremely easy to get swamped by oppor-
tunities that may seem attractive at the moment but don ’ t really
take you where you want to go. To avoid getting knocked off track,
it ’ s important to always be asking, will this opportunity take me
closer to my goal?

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B O O T S T R A P P I N G L E A D E R S H I P 101

For example, at the time of my conversation with Andy Grove
about Engineer A and Engineer B, I dimly realized that my passion
wasn ’ t really to become an American – style manager at Intel, that
I wanted to do something else: to create something in Israel. Say-
ing no to the role that Andy was holding out for me was a way of
saying yes to my core passion, even though I didn ’ t quite know
then how I would realize it.

Finally, as a leader you must learn how to renew your passion
over time. In the course of an entire career there are bound to
be times when your passion will fl ag. You will lose touch with the
mission that energized you before. Or you may feel that you have
already accomplished what you set out to do. That is the time to
refl ect on the original passion that had brought you to this point
and, if possible, to reframe your mission so that it puts you back in
touch with that passion.

I ’ ll give you an example from my own experience. By the time
I approached retirement, I felt like my dream — to bring something
back from the United States and build a new fi eld of industry and
technology in Israel — was largely fulfi lled. Intel Israel was well
established and thriving. And a dynamic high – tech industry had
grown up around it, making Israel a genuine global center for
high tech.

Yet now I realize that my mission wasn ’ t really over. More
recently I have found myself engaged with the critical question of
what it will take for Israel ’ s high – tech sector to survive and thrive
into the future. And that concern has led to an unanticipated
encounter with Israeli politics and the confl icts of the Middle East.

At the time of the Oslo Accords (1993), there was a lot of hope
that high tech could be a powerful focus for future collaboration
between Israelis and Palestinians and a driver of economic devel-
opment in the entire region. But as of this writing, with the pros-
pect of peace growing increasingly dim, I worry that the worsening
political instability in the region is a serious strategic threat to high
tech ’ s future. The current status quo in Israel, which combines
extraordinary economic dynamism with extreme political stasis,

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102 L E A D E R S H I P T H E H A R D W AY

is neither acceptable nor sustainable. Unless Israel can fi nd its way
to a defi nitive settlement with the Palestinians and the broader
Arab world, Israel ’ s high – tech industry won ’ t be fully secure. Try-
ing to address that challenge is turning out to be a new phase of my
mission and a new focus of my lifelong passion.

The Invisible Mentor

In ancient times those in search of wisdom sought out a guru.
Today we talk about mentors . Mentorship has become a big theme
in the management literature in recent years, and many organiza-
tions have established formal mentorship programs. Having read
this far, you won ’ t be surprised to learn that I ’ m skeptical of their
value. A lot of these mentorship programs, much like formal lead-
ership programs, are pretty formulaic. Sure, they can be useful in
helping new executives enter smoothly into the organizational
culture and develop networks with colleagues and superiors. But
they don ’ t really turn people into leaders.

Other experts emphasize close personal relationships with
senior leaders that last over many years. For example, in his recent
book True North, former Medtronic CEO Bill George argues that
what many aspiring leaders fail to recognize is “ the importance of
the two – way relationship with their mentors. Lasting relationships
must fl ow both ways . The best mentoring interactions spark mutual
learning, exploration of similar values, and shared enjoyment. ” 1
Such two – way relationships are great — if you can fi nd them. But
not every aspiring leader is so fortunate as to forge such a close
personal relationship with a senior leader.

I want to suggest a different approach; call it invisible mentor-
ship . As an aspiring leader, you shouldn ’ t wait to be assigned a
mentor or simply hope for someone in a senior leadership position
to tap you on the shoulder and take you under his or her wing. Be
more active: choose your own invisible mentor, someone whose
behavior you study from afar. It doesn ’ t really matter whether that
individual knows you are doing this or not.

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B O O T S T R A P P I N G L E A D E R S H I P 103

In my career, the most valuable mentors were individuals
who weren ’ t playing the formal role and didn ’ t know I was using
them in that way. I was extremely fortunate, of course, to work at
a company that had some of the best business leaders of the late
twentieth century. Long before anyone was talking about human
capital, Intel founder Robert Noyce understood the centrality
of people to an innovation – based business. And I will always be
grateful to Gordon Moore for his extraordinary technical vision
and for his willingness to take risks and place big bets — whether
on the EPROM as a revolutionary new product or on Israel as a
place where Intel could successfully do business. But the individ-
ual who, more than any other, shaped me as a leader was, as you ’ ve
probably gathered by now, Andy Grove. For many years, Andy
functioned as my invisible mentor, even though neither he nor
I was really aware of it at the time.

I first met Andy in 1965, when I was a graduate student at
Berkeley and he interviewed me for a job in his lab at Fairchild
Semiconductor. In some respects our relationship got off to a rocky
start. Although Andy offered me a job, I chose to work in another
Fairchild lab, not his. And when Andy taught a course for new
employees on solid – state physics at what was to me the ungodly
hour of 7:00 AM, I was the one who complained about his giving us
quizzes before we were even awake (I once overhead him complain-
ing to a colleague about this kid who had barely arrived and was
already giving him trouble). Later, of course, after I had joined Intel,
invented the EPROM, and then decided to give it all up to travel
in Africa, it was Andy who made it clear that he thought the proper
thing for me to do was to stay on and see the prototype through to a
fi nished product.

Andy and I had an odd relationship. We knew each other, of
course, but our relationship was always somewhat distant. In all
my years at Intel, I never reported directly to him. I was always one
or two levels down in the hierarchy and, once I moved to Israel,
thousands of miles away. Despite the widespread belief inside Intel
that we were in constant communication, I would see him, at most,

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104 L E A D E R S H I P T H E H A R D W AY

maybe three or four times a year. In the roughly thirty – fi ve years
that we worked together, we never had a single in – depth personal
conversation. For example, we never discussed our Jewish roots
or our parallel experiences as Jewish children in Nazi – occupied
Europe during World War II. 2

On the other hand, over the years Andy and I developed a
highly productive working relationship. My impression always was
that whenever I asked for a meeting to discuss some new project
or initiative for Intel Israel, Andy already half – knew where I was
going and what I was up to. And although we didn ’ t always agree,
I always found him remarkably open and extremely supportive of
what I was trying to do.

This openness, which was even a kind of generosity, was cap-
tured for me by an incident that happened after I left Africa to spend
six months at Intel in Silicon Valley before finally returning to
Israel. Just before I left Santa Clara for Israel, where I would teach at
Hebrew University, Andy threw a farewell party for me at his house.
At one point I found myself sitting in an extremely comfortable
rocking chair on his front porch. “ What a great chair, ” I told him.

“ Do you want it? ” he asked immediately. My wife was pregnant
at the time, and I answered, “ My wife would love it. ”

“ Take it, ” he said. That chair was one of the few artifacts that
I brought back with me from Silicon Valley to Israel.

Andy ’ s support gave me enormous leverage inside Intel, and
I was happy to exploit it. He was the Intel senior executive respon-
sible for operations, so he was always the key decision maker for
many of the initiatives that I wanted to undertake. Whenever I got
involved in a confrontation with colleagues, they would have to
be careful because they thought that if push came to shove, I might
get Andy involved. I tried not to abuse our relationship, but on a
few critical occasions — the confl icts over Intel Israel ’ s no – transfer
rule, for example, or the bake – off that led to the decision to build
the Jerusalem fab — I didn ’ t hesitate to use it.

My relationship with Andy bothered some people at Intel.
They thought I was short – circuiting established lines of authority.

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B O O T S T R A P P I N G L E A D E R S H I P 105

“ The problem with you, Dov, ” Andy once told me, relatively late
in my career at Intel, “ is that nobody knows whom you report to. ”
He was right. Of course, I did have a formal reporting relationship.
But I never let it stop me or constrain my own sense of my power
or room for maneuver. I treated the Intel hierarchy like a “ fuzzy
network ” in which I had many, many points of interaction. Some
were based on formal reporting relationships, but others were based
on a shared history, personal relationships, and practical alliances
that I had built up over the years.

To be sure, I had the distinct advantage of being a country
manager in an operation that was far away, physically, from
corporate headquarters. Yet a lot of country managers I knew at
Intel seemed to defi ne their role as dependent on corporate. Early
on, I made a conscious decision to take the opposite tack — that is,
to assume that I had the freedom to act, and then to let the chips
fall where they may.

Something about the very distance in my relationship with
Andy seemed to invest small things with large signifi cance. For
example, when I was a young manager at Intel Israel, I sent Andy
a fi ve – page proposal for shifting the Jerusalem fab production line
from memories to microprocessors. He returned it, unread, with a
stamp reading “ Please respect my time. ” His message: the proposal
was way too long. He wanted one page, not fi ve. Grove ’ s request —
“ Please respect my time ” — had an enormous impact on me. Indeed,
it sparked a lifelong refl ection on how leaders use — and abuse —
their time that eventually led to my focus on freeing up time, which
I described in Chapter Five .

I learned a lot of things from Andy over the years: the impor-
tance of integrity and modesty, of finding and following your
own passion, of paying attention to detail (not my strongest suit,
I admit), of not taking no for an answer but instead always asking
“ Why not? ” Indeed, I would say that to the degree I had a model
for leadership the hard way, Andy was it. But again, his example
worked on me only from afar. In all the years we worked together,
we never discussed it.

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106 L E A D E R S H I P T H E H A R D W AY

Recently, I was surprised to learn that Andy had had an
invisible mentor of his own. In his recent biography of Grove,
Harvard Business School professor Richard Tedlow describes
how Charlie Sporck, the legendary semiconductor manufactur-
ing manager and founder of National Semiconductor, was a key
role model for Grove in his transition from scientist to operations
manager. Sporck, Grove told Tedlow, seemed to epitomize
“ the operations guy that I aspired to become. Without my knowing
him particularly well at the time, he became my role model. He
cast a big shadow over my life without ever knowing that he did
so. ” 3 Although the situations are obviously different, I could say
pretty much the same thing about Andy: he cast a big shadow over
my life as a leader without ever really knowing that he did so.

My point: no aspiring leader has to wait to be assigned a men-
tor or has to depend on developing a close personal relationship
with one. Look around you. Choose someone whose leadership
style you relate to and admire. Study that person closely. It will
help you bootstrap your own leadership capacity.

Becoming a “ Refl ective Practitioner ”

A would – be pilot always has the option of using a fl ight simulator.
But there is no effective way to simulate leading an organization.
Instead, aspiring leaders face the difficult challenge of learn-
ing from their own experience at the very moment that they are
experiencing it.

This is different from what usually passes for learning from
experience in the business world. Most management education is
built around the ideas of the success story (think of the typical case
studies produced at places like the Harvard Business School). More
recently, some management thinkers have begun to focus on the
idea of learning from failures as well. 4 But both success stories and
failure stories suffer from two critical limitations. First, they are ex
post facto — that is, they tell the moral of the story after you already
know how the story ends. And second, they are inevitably one

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B O O T S T R A P P I N G L E A D E R S H I P 107

step removed from the would – be leader ’ s own experience. The
kind of learning that is really of value is the learning that happens
in the moment. It ’ s the kind of systematic refl ection on one ’ s own
experience that organizational theorist Donald Sch ö n captured in
his term “ the refl ective practitioner. ” 5

In my experience, there are a variety of ways to develop this
capacity to refl ect systematically on one ’ s own experience in the
moment. One is to realize that although leadership is a public act,
to be effective a leader also has to have an active inner life. In
Chapter Five , I described some of the ways of stimulating habits of
refl ection that worked for me: freeing up time, daydreaming, intui-
tive decision making, and the like.

But another key aspect is to build systematic refl ection into
your everyday activity. I think the organizations that do this best
are found in the military: the “ after action review ” has become
a routine activity after every military engagement. Once, rather
late in my tenure at Intel Israel, I hosted a group of offi cers from
an Israeli air force base in the Negev at our fab in Qiryat Gat.
They were interested in the practices that we had put in place to
ensure quality and continuous improvement in our manufacturing
process. But for me the most interesting moment in the meeting
came when the offi cers described a practice of their own. It was a
system for analyzing what they called “ near accidents ” — that is,
any close calls between maneuvering planes that could easily have
led to disaster but, in the end, did not. Later, I visited the base
and observed the intensive video analysis that pilots did of their
near accidents.

I am intrigued by this concept of the near accident as a poten-
tially useful analogy for leaders – to – be to encourage learning from
experience. Anything a leader does consists of multiple near acci-
dents in which success or failure hangs in the balance. Take for
example my invention of the EPROM. In retrospect it was defi –
nitely a success story. But any number of things could have gone
wrong — and nearly did — along the way. For example, it was a real
challenge getting my colleagues to see the potential value of my

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108 L E A D E R S H I P T H E H A R D W AY

new approach to designing a semiconductor memory. It was like
nothing they had seen before, and they had a hard time getting
their minds around it. What ’ s more, when I fi rst came up with the
concept, I had yet to demonstrate it defi nitively, so it was easy to
dismiss as a crazy idea. What I learned from that experience was
the absolute importance of persistence, of insisting on the impossi-
ble, even in the face of disagreement and resistance. And doing so
gave me the confi dence to follow my dream no matter how “ unre-
alistic ” it might appear and no matter where it might lead.

I learned all this haphazardly, in retrospect, almost by chance.
I think that with a little effort aspiring leaders could engage in
such learning systematically — by regularly exposing their experi-
ences to some version of an after action review.

Learning from Your People

A prominent theme in this book has been the imperative of leaders
to forge close bonds with their people. That close bond is essential
for getting an organization to meet the demands of leadership the
hard way. But it also has another advantage: a close relationship
with your people can give you a tremendous resource for bootstrap-
ping your leadership capabilities.

There are a variety of ways that an aspiring leader can develop
that close bond. In previous chapters, for example, I ’ ve dis cussed the
importance of the leader being present to the organization — in
the way I tried to be present during the First Gulf War or when
we instituted the 10 percent pay cut. It is precisely at difficult
moments, when unpalatable decisions have to be made, that you
need to expose yourself to your people ’ s reactions and input. The
less you insulate yourself from these reactions, the more you learn,
and the better a leader you become.

Another way, frankly, is through self – criticism — not being
afraid to expose one ’ s own mistakes to the organization, as I did
when I discussed the ways that I was violating our values by com-
ing late to the values training session. A would – be leader needs

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B O O T S T R A P P I N G L E A D E R S H I P 109

to get comfortable with the idea that his own actions will be
exposed to the organization. Don ’ t be afraid to reveal yourself, to
talk about your failures and your mistakes. It will humanize you in
the eyes of your people and build a stronger bond. What ’ s more,
it will encourage honest feedback and openness throughout the
organization — organizational characteristics that are essential for
leadership the hard way to work effectively.

A third way — again, much discussed in previous chapters — is
by welcoming dissent. It can be diffi cult, sometimes, to navigate all
the various points of view and to distinguish genuine dissent from
simple excuses. But the more you create an atmosphere in which
all points of view are welcome, the more you will be empowering
your people to contribute to your own capacity to lead.

Finally, leaders form close bonds with their people by using
their own behavior strategically. Aspiring leaders should get in
the habit of thinking of their actions as a form of communication.
Remember, the organization is always watching you. What are the
lessons you want to impart through your behavior?

When you do all these things, you will fi nd that not only does
your own infl uence grow, but you will also have created a two –
way communication with your people that will help you grow and
develop as a leader.

To become a truly effective leader, of course, it isn ’ t enough
just to bootstrap your own leadership capacity. You also have to
bootstrap the next generation of leaders. A lot of companies these
days are setting up formal succession – planning programs. But what
I am talking about is so much more than succession planning. In
effect, leaders are planning for succession every day — in the way
they function as role models, in the way they communicate their
decisions, in the mistakes they make and how they react to them. It
is through everyday behavior that aspiring leaders institution alize
their leadership approach in the organization.

At Intel Israel, many of the decisions I made regarding
people — the no – transfer rule, recruiting a more diverse workforce,
lateral transfers among managers — all had to do with expanding

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110 L E A D E R S H I P T H E H A R D W AY

the pool of potential next – generation leaders and providing them
with the experiences they needed to develop their own leadership
capacities. How they responded to the challenges I set for them
taught me who had the capacity to develop into a genuine leader
and who did not. Over time I was able develop a cadre of leaders
that were empowered to make important decisions without my
direct involvement. Once I had achieved this, succession planning
more or less took care of itself.

In the process, one of the things I learned is that leaders are
found in the strangest places. Often the best candidates turn out
to be people from outside the mainstream — the misfi ts, the critics,
sometimes even the naysayers — who at first glance one would
never expect would have leadership potential. So be prepared
to look for new leaders in unexpected places and to give them
the opportunity they need to bootstrap their own learning. You ’ ll
become a better leader as a result.

Passion, mentors, in – the – moment refl ection, people — these
are some of the key resources that an aspiring leader can use to
bootstrap leadership. What you will learn from using them is not
so much the skills of leadership but the wisdom of leadership: that
ineffable but essential dimension of leadership that cannot really
be taught.

But in the end you will have to fi nd your own way, and, no
doubt, it will be different from my own. You will have to take the
principles outlined in this book and make them come alive in a
way that makes sense for you, given your own history, personality,
and organizational context. When you do, you will have embarked
on the lifelong journey of becoming a self – taught leader — just as
I did more than thirty years ago.

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Knowing When to Let Go

The ultimate act of leadership is knowing when to let go. In
my experience, many leaders, even quite successful ones, stay
on far too long in positions of authority. They don ’ t step down
until they realize that they have begun to fail. But the damage
to the organization is already done, because by the time a leader
recognizes that he or she is failing, chances are it has already been
the case for many years. Better to leave at a point of time that may
seem to be too early. No individual is indispensable. Sometimes,
leaving is the most effective act of leadership there is.
In 2001, I retired from Intel and let go of the reins of leadership
at Intel Israel. I left because I had begun to feel like I was repeating
myself. Often, in meetings with my staff and subordinates, I
found myself thinking “ I ’ ve heard all these questions before. ” And
I distrusted my sense that I also knew all the answers. When you
get to the point that you are fl ying on autopilot most of the time, it
is high time to land.
People were surprised at my decision. I was leaving at the
height of our achievement, much as I did when I fi rst left Intel
after inventing the EPROM to go teach in Africa. Many people
thought it was “ too soon. ” Some even wondered whether Intel
Israel could continue to succeed without me running interference
for the organization with Intel corporate.
I wasn ’ t worried. I felt it was time for the organization to have
new leaders who would bring fresh perspectives on Intel Israel ’ s
challenges and opportunities. I saw my retirement as yet another

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112 L E A D E R S H I P T H E H A R D W AY

way to break through the complacency that can develop in any
successful organization, to force the organization to stay on its
toes and to step up and take responsibility for Intel Israel ’ s future
My attitude was, I had created the Intel Israel culture and
institutionalized a distinctive style of leadership; now it was time
for me to get out of the way. If I stayed to the very last minute, tried
to maintain my control, the new generation of leaders wouldn ’ t be
able to express themselves, to take on more responsibility, and to
become leaders in their own right. And I was confi dent that they
were ready to lead.
Subsequent events proved me right. Intel Israel ’ s actions dur-
ing the 2006 summer war between Israel and Hezbollah (which, for
the Haifa design center, was far more dangerous than anything we
faced in the First Gulf War) demonstrated that the organization is
still insisting on survival. The development of the innovative Core
2 Duo family of low – power microprocessors, introduced in 2006,
showed that Intel Israel continues to lead against the current. And
the 2005 announcement that Intel would invest $3.5 billion to
build a new state – of – the – art semiconductor fab in Qiryat Gat (the
biggest construction project in the history of the state of Israel,
the new fab is taking shape, as I write, next door to the existing
plant) illustrated that Intel Israel is still leveraging random oppor-
tunities to win the global competition for investment.
I made a clean break when I left Intel Israel. Indeed, the fi rst
time I returned to an Intel Israel site was some six years later, when
I was in the midst of writing this book. For years, people would ask
me, “ When are you coming back? ” They still do. But it was clear
to me that there was no need. They are doing far better than I
could have done if I were still around.
Another question I often hear from former colleagues is “ So,
what are you doing these days? ” Usually I respond, “ Trying to fi gure
out what I am going to do when I grow up! ” The real answer is,
spending time at my vacation home in the Dolomite Mountains of
northeastern Italy, a country and culture that I love for its delightful

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K N O W I N G W H E N T O L E T G O 113

randomness and fl air for improvisation that is very much in the spirit
of leadership the hard way; writing this book to capture and share my
thinking about the lessons of my life and my career; and looking for
new creative ways to push my ideas beyond the realm of business
and to address the crisis of leadership in our world.
Back in the 1990s, when we were looking for a site for what
would become the fi rst Qiryat Gat fab, I developed a passion for
Israel ’ s south — a passion that continues to this day. Israel ’ s fi rst
prime minister, David Ben – Gurion, was convinced that the future
of the country would be found there — so much so that when he
retired from politics he went to live at Kibbutz Sde Boker, near
Wadi Hawarim, deep in the Negev Desert. One of my retirement
projects is to create what I call a “ center for alternative thinking ”
on a high plateau above Sde Boker. The purpose of the center is to
expose the next generation of Israelis to unconventional ways of
seeing the world and to promote innovation and creativity. It will
be a place where people from all walks of life can come together to
explore fresh solutions to some of the most intractable problems
facing our society. What will it take to fi nally realize Ben – Gurion ’ s
vision for the development of the south of Israel? How can we
meet the challenges of Israel ’ s failing educational system? And,
perhaps most important, what are the alternatives to the by now
thoroughly exhausted paradigms of “ security ” and “ terrorism ” in
our relations with the Palestinians?
Some people think the idea is crazy. Why would anyone want
to come to the middle of nowhere just to discuss tough, and maybe
even impossible, problems? But I ’ m used to such skepticism.
Thirty – fi ve years ago, who would have imagined that the world ’ s
most advanced microprocessors would be designed and built in the
Middle East?
As I ’ ve said many times, leadership the hard way means not
taking no for an answer.
If you can ’ t go through the door, go through the window.
Sometimes the best way to survive a thunderstorm is to fl y
right through it.

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bepil.indd 114bepil.indd 114 2/2/08 10:45:27 AM2/2/08 10:45:27 AM




1. See 360° : The Merrill Lynch Leadership Magazine , inaugural
issue published Sept. 2006 at http://mag1.olivesoftware

2. See, for example, the description of Gonzaga University ’ s
Ph.D. in Leadership Studies at http://www.gonzaga.edu/

3. Wolfgang Langewiesche, Stick and Rudder: An Explanation of
the Art of Flying (McGraw – Hill, Inc., 1972), p. 3.

4. Andrew S. Grove, Only the Paranoid Survive (Doubleday
Currency, 1996), p. 5.

5. See Clayton M. Christensen, The Innovator ’ s Dilemma: How
New Technologies Cause Great Firms to Fail (Harvard Business
School Press, 1997).

6. Langewiesche, Stick and Rudder , p. 5.
7. See AnnaLee Saxenian, The New Argonauts: Regional Advan-

tage in a Global Economy (Harvard University Press, 2006).
8. As quoted in A Revolution in Progress: A History of Intel to Date

(Intel Corporation, 1984), p. 22.
9. See Warren Bennis and Robert Thomas, Geeks and Geezers:

How Eras, Values, and Defining Moments Shape Leaders
(Harvard Business School Press, 2002).

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116 N O T E S

Chapter One

1. Grove, Only the Paranoid Survive , p. 3.
2. These fi gures come from Bob Moore, Victims and Survivors:

The Nazi Persecution of the Jews in the Netherlands, 1940 – 1945
(Arnold, 1997), pp. 146, 164 – 165.

Chapter Two

1. See Ed Michaels, Helen Handfi eld – Jones, and Beth Axelrod,
The War for Talent (Harvard Business School Press, 2001).

2. See Ian King, “ Intel ’ s Israelis Make Chip to Rescue Company
From Profi t Plunge, ” Bloomberg News , Mar. 27, 2007.

Chapter Three

1. Robert A. Burgelman, Strategy Is Destiny: How Strategy – Making
Shapes a Company ’ s Future (Free Press, 2002), p. 90.

2. Tim Jackson, Inside Intel: Andy Grove and the Rise of the World ’ s
Most Powerful Chip Company (Dutton, 1997), p. 106.

Chapter Four

1. The statistics in this section are from “ The Gulf Crisis in Israel:
A War for the Age of Uncertainty, ” Israel Yearbook and Almanac
1991/92 (IBR Translations/Documentation Limited, 1992).

2. See Dov Frohman, “ Leadership Under Fire, ” Harvard Business
Review , Dec. 2006, pp. 124 – 131.

Chapter Five

1. Marcus Aurelius, Meditations, Book IV (Dover Publications,
1997), p. 23.

2. For recent reviews of this research, see Robin M. Hogarth,
Educating Intuition (University of Chicago Press, 2001); David

bnotes.indd 116bnotes.indd 116 2/2/08 10:46:51 AM2/2/08 10:46:51 AM

N O T E S 117

G. Myers, Intuition: Its Powers and Perils (Yale University Press,
2002); and Malcolm Gladwell, Blink: The Power of Thinking
Without Thinking (Little, Brown and Co., 2005).

3. For the classic description of the role of tacit knowledge in
innovation, see Ikujiro Nonaka and Hirotaka Takeuchi, The
Knowledge – Creating Company: How Japanese Companies Create
the Dynamics of Innovation (Oxford University Press, 1995).

4. As quoted in Myers, Intuition , p. 1.
5. For a comprehensive set of guidelines for educating intuition,

see Hogarth, Educating Intuition , pp. 207 – 212.

Chapter Six

1. For a by now classic statement on this issue, see Robert Howard,
“ Values Make the Company: An Interview with Robert Haas, ”
Harvard Business Review , Sept. – Oct. 1990, p. 134.

Chapter Seven

1. Bill George, with Peter Sims, True North: Discover Your Authen-
tic Leadership (Jossey – Bass, A Warren Bennis Book, 2007),
pp. 120 – 121.

2. For Grove ’ s experiences during the war, see Andrew S. Grove,
Swimming Across: A Memoir (Warner, 2001); and Richard
S. Tedlow, Andy Grove: The Life and Times of an American
(Portfolio Penguin, 2006).

3. Tedlow, Andy Grove , p. 151.
4. See, for example, Sydney Finkelstein, Why Smart Executives

Fail (Penguin Putnam, 2003); and Jeffrey A. Sonnenfeld and
Andrew J. Ward, Firing Back: How Great Leaders Rebound After
Career Disasters (Harvard Business School Press, 2007).

5. See Donald Sch ö n, The Refl ective Practitioner: How Professionals
Think in Action (Basic Books, 1983).

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bepil.indd 114bepil.indd 114 2/2/08 10:45:27 AM2/2/08 10:45:27 AM



This book is the product of a lifetime ’ s work and learning, and
many people have contributed to my perspective on leadership
along the way. I would like to thank, fi rst, all my colleagues at
Fairchild Semiconductor and at Intel Corporation with whom I
shared the challenges of leadership over more than three decades;
in particular, the late Bob Seeds, my fi rst boss in the Digital Elec-
tronics department at Fairchild ’ s R & D laboratories; Les Vadasz,
my fi rst boss at Intel; and Intel ’ s former CEO and current chair-
man, Craig Barrett.

I also want to acknowledge the extraordinary contribution and
achievement of Intel ’ s founders, Gordon Moore and the late Rob-
ert Noyce. Not only did they support me in my endeavors from
the early days of the development of the EPROM, but they also
created an organization and a culture in which I was continually
encouraged to take risks, pursue my dreams, and bring them to
fruition. They were truly inspiring leaders.

As the preceding pages make clear, I owe a special debt of
gratitude to Andy Grove. From that fi rst moment when I turned
down Andy ’ s offer to work in his lab at Fairchild, Andy has been
an important fi gure in my life. It was Andy, more than any other
single individual, who made possible the creation of Intel Israel. I
could not have achieved what I did without his support, advice, and,
sometimes, criticism. He is my model for leadership the hard way.

I would also like to thank all my former colleagues at Intel
Israel and, in particular, the fi rst generation of leaders who helped
build the organization: the late Moshe Balog, Marek Sternheim,
Eli Porat, Rafi Nave, Alex Kornhauser, and Dadi Perlmutter.

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

When I first began to think about writing this book, I
approached the well-known Israeli writer and Yedioth Ahronoth
columnist Meir Shalev. I would like to thank Meir not only for
encouraging me to pursue my project but also for having the good
sense not to tell me just how diffi cult writing a book would be.

My Jerusalem friend Bernard Avishai, author of The Tragedy
of Zionism and contributing editor at the Harvard Business Review,
read an unwieldy early version of my manuscript and helped me
fi gure out what to do with it. I want to thank Bernie especially for
the delicacy and fi nesse with which he persuaded me that I needed
a writing partner and for putting me in touch with one.

This book would not have been possible without the engage-
ment, skills, and experienced counsel of that writer, Robert
Howard. I was always amazed by the way that Bob would
completely change what I had originally written and yet in the
process succeed in capturing exactly what I wanted to say. I want
to thank him for what has been an efficient — and extremely
enjoyable — collaboration. I will remember fondly our working
sessions in the Dolomites, Boston, and Jerusalem. (A special
thanks to Bob and his wife Leslie Schneider for their hospitality
during my visit to Boston in the summer of 2006.)

I also want to thank the various editors who have helped
shepherd the book into publication. Diane Coutu, senior editor
at the Harvard Business Review, championed an early version of
Chapter Four and expertly guided it into the pages of that impor-
tant resource for managers and leaders. Susan Williams saw the
potential of this project and has made a wonderful home for it
at Jossey – Bass. And Rob Brandt has ably managed the editorial
process. I am especially grateful to Warren Bennis, distinguished
professor of business administration and founding chairman of the
Leadership Institute at the University of Southern California ’ s
Marshall School of Business, for choosing this book as a title in
the Warren Bennis Signature series at Jossey – Bass. My thanks to
Warren for this singular honor.

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A C K N O W L E D G M E N T S 121

My heartfelt gratitude and appreciation also go out to my
family — my wife, Eilat, my son, Eran, and my daughter, Lora. For
many years, their sacrifi ces allowed me to pursue with unstinting
focus and engagement my passion to create Intel Israel. They
have graciously put up with my daydreaming and my risk taking
( including in that thunderstorm over the Peloponnese!). And they
have read and commented on early versions of my manuscript.
They have been partners throughout this venture.

Finally, I have chosen to dedicate this book to the memory
of my three sets of parents who, at great sacrifi ce in a dark and
dangerous time, helped launch me on my life ’ s path: my birth par-
ents, Abraham and Feijga Frohman; my temporary war time
parents, Antonie and Jenneke Van Tilborgh; and my adoptive par-
ents in Israel, Lea and Moshe Bentchkowsky.

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The Authors

Dov Frohman

Dov Frohman is a pioneer of the global corporation. A former
executive at Intel Corporation, he was the founder and gen-
eral manager of Intel Israel, the company ’ s operations in Israel.
For nearly thirty years, he created and led a highly successful
organization in one of the most demanding and competitive
industries and in one of the most dangerous regions of the world.

During his time at Intel, Mr. Frohman was a leading innovator
in the semiconductor industry. An Israeli citizen, he was trained in
electrical engineering at the Israel Institute of Technology
( Technion) in Haifa, Israel, and received his Ph.D. in electrical
engineering and computer science from the University of
California at Berkeley. As a new employee at Intel, he invented
the EPROM — the fi rst reprogrammable read – only semiconductor
memory — an innovation that Intel founder Gordon Moore has
termed “ as important in the development of the microcomputer
industry as the microprocessor itself. ” For this singular achieve-
ment, Mr. Frohman received the IEEE Jack Morton Award in 1982
and the prestigious IEEE Edison Medal in 2008.

Mr. Frohman spent most of his career building Intel Israel into
a fl agship of the Intel Corporation and a cornerstone of the Israeli
high – tech economy. He helped found Intel Israel in 1974, became
its general manager in 1981, and ran the organization until his
retirement in 2001. In recognition of his scientifi c and techni-
cal achievements and of his contributions to the development
of Israel ’ s high – technology sector, Mr. Frohman was awarded the
Israel Prize for Engineering and Technology in 1991.

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The Authors

Dov Frohman

Dov Frohman is a pioneer of the global corporation. A former
executive at Intel Corporation, he was the founder and gen-
eral manager of Intel Israel, the company ’ s operations in Israel.
For nearly thirty years, he created and led a highly successful
organization in one of the most demanding and competitive
industries and in one of the most dangerous regions of the world.

During his time at Intel, Mr. Frohman was a leading innovator
in the semiconductor industry. An Israeli citizen, he was trained in
electrical engineering at the Israel Institute of Technology
( Technion) in Haifa, Israel, and received his Ph.D. in electrical
engineering and computer science from the University of
California at Berkeley. As a new employee at Intel, he invented
the EPROM — the fi rst reprogrammable read – only semiconductor
memory — an innovation that Intel founder Gordon Moore has
termed “ as important in the development of the microcomputer
industry as the microprocessor itself. ” For this singular achieve-
ment, Mr. Frohman received the IEEE Jack Morton Award in 1982
and the prestigious IEEE Edison Medal in 2008.

Mr. Frohman spent most of his career building Intel Israel into
a fl agship of the Intel Corporation and a cornerstone of the Israeli
high – tech economy. He helped found Intel Israel in 1974, became
its general manager in 1981, and ran the organization until his
retirement in 2001. In recognition of his scientifi c and techni-
cal achievements and of his contributions to the development
of Israel ’ s high – technology sector, Mr. Frohman was awarded the
Israel Prize for Engineering and Technology in 1991.

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124 T H E A U T H O R S

During his long and illustrious career, Mr. Frohman also served
as visiting professor at the University of Science and Technology in
Kumasi, Ghana, and as professor of applied physics at the Hebrew
University in Jerusalem, Israel, where he directed the School of
Applied Science and Technology.

Today, Mr. Frohman divides his time between his two homes,
one in Jerusalem and one in Selva di Cadore in the Dolomite
region of Italy.

Robert Howard

Robert Howard is a veteran writer on work, technology, and man-
agement. He is the author of Brave New Workplace (The Viking
Press, Elisabeth Sifton Books, 1985) and the editor of The Learn-
ing Imperative: Managing People for Continuous Innovation (Harvard
Business School Press, 1993).

Mr. Howard ’ s writing has appeared in a number of national
publications including the Harvard Business Review , MIT ’ s
Technology Review , the New York Times Book Review , and The New
Republic . He has been the recipient of an Award for Distinguished
Investigative Reporting from Investigative Reporters and Editors
(IRE) and the Jack London Award from the United Steelworkers
Press Association.

Mr. Howard has been a senior editor at Technology Review and
at the Harvard Business Review . He also worked for ten years as
director of idea development at The Boston Consulting Group,
a major international management consulting fi rm.

Mr. Howard is a summa cum laude graduate of Amherst
College and has done graduate work in sociology and history at
the University of Cambridge in England and the Ecole Normale
Sup é rieure in Paris, France. He has been a visiting scholar in the
Program on Science, Technology, and Society at the Massachusetts
Institute of Technology and an affiliate scholar at the Boston
Psychoanalytic Institute.

Mr. Howard lives in Newton, Massachusetts.

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Administrative assistants, 72–73
Anchor tenants, 48


Barrett, Craig, 14, 24, 26, 58, 92
Behavior: communicating through,

79–84; using strategically, 109; and
values, 96–97

Being present in the organization, 108
Ben-Gurion, David, 113


Chaos, embracing, 64–65
Child care, 65
Cohen-Dorfl er, Jenny, 30
Communication, through behavior,

Contingency plans, 55–56
Copy Exactly program, 23–24
Core 2 Duo, 33, 112
Counterculture, 20–22
Crazy action, 18
Criticism, 19–20; self-criticism, 108–109


Daydreaming, 74–77
Deming, Edward, 9
Dissent, 109; encouraging, 18–19;

listening to, 30
Diversity, 28–29


Einstein, Albert, 77
Emigrating to Israel, 6

Employee theft, 91
Employment incentives, 89–91
EPROM, invention of, 37–41
Erlich, Shuky, 67
Excuses, 19


Failure, human price of, 32
Fassberg, Maxine, 30
Fear, containing, 8–10
First Gulf War, 53–68
Freeing up time, 70–73
Frohman, Abraham, 3, 4
Frohman, Feijga, 3, 4
Frontier cultures, 23


George, Bill, 102
Goals, impossible, 10–12
Grove, Andy, 1–2, 8, 26, 43–44, 47,

49–50, 51, 58, 63, 101; as mentor,


Haifa design center, 8, 27, 34, 67.
See also Intel Israel

Hiding from the Nazis, 3–5
Hiring, 27–30
Hussein, Saddam, 56


Identifying with the organization’s
mission, 99–100

Impossible goals, 10–12
Innovation, 12–16; and daydreaming, 75

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Insiders, 18
Instincts, 64–65
Intel Israel, 7–8; Haifa design center,

8, 27, 34, 67; Jerusalem fab, 13–15,
46–50, 51, 55; letting go, 111–113;
no-transfer rule, 25–27; Qiryat Gat
fab, 15, 51, 67, 88–89, 112; staying
open during First Gulf War, 53–68

Intelligence, 91–92
Intuitions, 77–79
Invisible mentors, 102–106
Israel: Chief Rabbi of, 92–93;

engineering talent, 27–28; the
future of high-tech industry in,


Jerusalem fab, 55; establishing, 46–50;
modernizing, 13–15, 51. See also Intel


Kolleck, Teddy, 50
Kornhauser, Alexander, 33


Lateral transfers, 31–33, 78
Layoffs, 7–8
Leaders: characteristics, 18–19;

inner life of, 69
Leadership: bootstrapping, 99–110; as

counterculture, 20–22; under fi re,
53–68; letting go, 111–113

Leading: apart from the mainstream,
23–27; against the current, 17–20

Leaks, 92
Learning from your people,

Letting go, 111–113
Local culture, 33–34


Marcus Aurelius, 70
Mentorship, 102–106
Microprocessors, 33–34
Mistakes: acknowledging, 94–96;

learning from, 30–33
Moore, Gordon, 46, 58, 103


Nkrumah, Kwame, 44
No-transfer rule, 25–27
Noyce, Bob, 58, 103


Opportunity: leveraging random
opportunities, 35–37; not taking no
for an answer, 51; striking when the
iron is hot, 45–50; turning a problem
into a product, 37–41; and vision,

Orientation sessions, 95–96
Orientation to results, 87
Ottelini, Paul, 26, 33
Outsiders, 18


Passion, 36; staying true to, 99–102
Perlmutter, Dadi, 34


Qiryat Gat fab, 15, 51, 67, 88–89, 112.
See also Intel Israel


RAM, 38
Recruiting, 28–29
Refl ective practitioners, 106–108
Resistance, 19
Responsibility for survival, 6–7
Risk-taking, and survival, 5
Rock, Arthur, 45
ROM, 38


Schön, Donald, 107
Scud business as usual, 62–66
Self-criticism, 108–109. See also

Slogan, 7
Soft skills, 69–70
Sporck, Charlie, 106
Strategic infl ection point, 2
Survival: individual vs. organizational, 5;

and innovation, 12–16; responsibility
for, 6–7; and risk-taking, 5; in Second
World War, 3–6; threats to, 1–3

126 I N D E X

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Team orientation, 23; Israeli compared to
Japanese, 24

Tedlow, Richard, 106
Terrorism, fear of, 9
Thurow, Lester, 76
Transparency, 93–94
True North (George), 102
Trust, 79


Values, 5, 79, 85–87; acknowledging
mistakes, 94–96; and behavior, 96–97;

being relentless about, 87–91; saying
“no” to inappropriate behavior, 91–93;
transparency, 93–94

Van Tilborgh, Antonie, 3–6
Van Tilborgh, Jenneke, 3–6
Vision, 5, 36; staying true to, 41–45
Voicemail, 72–73


War for talent, 27–30
War on terror, 86
Worst-case thinking, 9–10

I N D E X 127

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Discussion 4 respond

  You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your responses must be substantive and not just agreeing with someone’s work. You need to add by explaining more, refuting a point or correcting a point.  a minimum of 150 words and one reference with in text citation, one reference for each respond.   

Discussion 1 George


Nursing practice requires specialized knowledge and skills attained through education and training in accredited institutions. The boards of nursing in each state have their requirements for certification and scope of practice. This essay discusses the scope of practice in the state of California and compares it with that of Florida.

Scope of Practice for The Advanced Practice Nurse (APN) in The State of California

The scope of practice for the advanced practice nurse in California is among the strictest laws in the United States. According to Montague (2020), the regulations require nurse practitioners (NPs) to have a written agreement with the supervising physician and make treatment decisions collaboratively with the physician. Notably, one of the Board of Registered Nursing (BRN) requirements is that NPs should practice under a physician’s oversight and comply with the standardized procedures established via teamwork with various healthcare disciplines such as administrators, surgeons, physicians, and nurse practitioners.

The standardized procedures provide NPs with the ability to do tasks that would otherwise fall under the practice of medicine. Additionally, NPs require accreditation from the BRN for prescribing or ordering medications or devices used in the standardized procedures in California (Montague, 2020). Generally, these supervisory agreements render physicians legally responsible for NP’s practice, and they determine the suitable level of supervision.

The state recently introduced some law changes under AB 890, effective from January 2023, which permits independent NPs’ practice after a transitional supervision period (Montague, 2020). Two categories of NPs created by this law function independently. However, if an NP does not want independent practice or does not meet the qualifications under this law for the two categories, they continue to practice their current agreements. The two categories are under sections 2837.103 and 2837.104 with special schooling, preparation, accreditation, governing requirements (Montague, 2020). This law expands the scope of practice of NPs such that they can practice independently without standardized procedures in any setting. The law allows them to open their own practice.

Comparison to Florida state practice laws for APNs

California compares to Florida in terms of supervision laws in that both states require physicians to supervise NPs. In Florida, a physician supervises NPs in at least four settings, excluding their primary practice setting (Toney-Butler & Martin, 2018). The physician does not have to physically avail themselves at the health setting for consultation but must be available via phone. Additionally, the state requires that patients receive notifications about the availability of physicians at a clinic. The stricter rule applies to speciality clinics where physicians can only oversee nurse practitioners in one health setting in addition to their primary practice settings, and they have to be at most 75 miles apart (Toney-Butler & Martin, 2018).

Also, both states require the nurse to meet certain competency standards to become fully certified to perform tasks within their scope of practice as per the state. Bushy (2019) establishes that registered nurses must demonstrate high competence and accountability in all aspects of practice, including suitable recognition, referrals, consultations, and appropriate interventions when complications arise.

In contrast with California, Florida NP prescribing laws do not allow them to prescribe controlled drugs despite a physician’s supervision. To prevent some practices from circumventing this law, the state created laws that bar NPs from using pre-signed physicians’ prescription forms and their DEA numbers on prescriptions (Toney-Butler & Martin, 2018).


Bushy, A. (2019). Laws and Rules Governing Nursing Practice in Florida. Retrieved from https://www.nursece.com/courses/129-laws-and-rules-governing-nursing-practice-in-florida

Montague A. (2020). Expanding scope of practice for nurse practitioners in California: AB 890 compromises to permit independent practice. California legislative beat. Retrieved from https://sourceonhealthcare.org/expanding-scope-of-practice-for-nurse-practitioners-in-california-ab-890-compromises-to-permit-independent-practice/

Discussion 2 Mentor

Scope of Nursing Practice in Texas 

            Scope of nursing practices are the activities performed by nurses in the healthcare setting when delivering patient care. Professional nursing is applying a certain level of skills, judgment and the appropriate performance based on the understanding and the use of the principles of social, physical, and biological science acquired by a nurse after completing a nursing course (Grimes et al., 2018). The legal scope of practice for professional registered nurses in Texas is defined by Nursing Practice Act (NPA) (Grimes et al., 2018). Experienced nurses in Texas have the duty of observing, assessing, evaluating, rehabilitating, caring for, and educating ill patients and those experiencing changes in their normal health processes (Grimes et al., 2018). Nurses are also responsible for upholding health living in the hospital and the prevention of diseases.

            In addition, nurses administer medicines to the patient according to the physician’s prescription. They oversee and educate other nurses; they are also responsible for administering and evaluating nursing practices, policies, and procedures (Grimes et al., 2018). It is the responsibility of practice nurses in Texas to receive, sign, and distribute samples of prescription drugs to patients (Grimes et al., 2018). Therefore, the responsibility of the registered nurse in Texas is to provide safe nursing care to patients.

Scope of Practice in Florida

            In Florida, nurses are responsible for providing specialized and advanced nursing practice. Through professional nursing practice, nurses perform advanced-level nursing acts recommended by the board (Unruh et al., 2018). Nurses might perform certain actions such as medical and nursing diagnosis, nursing treatment, and prescription following an established protocol. Florida has legislation enabling nurses to practice independently in delivering primary care practices (Unruh et al., 2018). The same is applicable in Texas for ARPNs to treat and diagnose illnesses and offer advice to patients concerning their health, control chronic conditions, and engage in continuous education to remain ahead of other developments in the field.

            The scope of nursing practice in the two states is also similar in that they license nurses to operate in the healthcare sector. In Texas, the enhanced nurse licensure compact (eNLC) model allows nurses to physically, electronically, and telephonically practice in the home state and other eNLC states (Unruh et al., 2018). Nurses in Florida are also given licenses to offer patients healthcare services (Unruh et al., 2018). Therefore, the two states are licensure compact states because their nursing licensure compact is a multi-state agreement that enables nurses to practice in different states without applying for a new license.

            Nursing license requirements in Florida differ from those in Texas. For instance, there are various options for primary licensure, which vary according to the professional designation of an individual (Unruh et al., 2018). Florida’s board of nursing handles the initial licensure and renewals for all classes for nursing staff. Even though there are some variations, in all cases, applicants ought to graduate from an accredited institution, complete fingerprinting for a criminal background check, pass a specific examination and pay for the examination and licensing fees (Unruh et al., 2018). On the other hand, Texas issues licenses to graduates of approved nursing education programs seeking licensure by exam.


Grimes, D. E., Thomas, E. J., Padhye, N. S., Ottosen, M. J., & Grimes, R. M. (2018). Do state restrictions on advanced practice registered nurses impact patient outcomes for hypertension and diabetes control?. The Journal for Nurse Practitioners, 14(8), 620-625. https://doi.org/10.1016/j.nurpra.2018.06.005

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pediatric health promotion plan

Please see atachment for instructions

Pediatric Health Promotion Plan

Web Page

Assignment Prompt

A family just migrated from another country to your area and you are seeing them in the clinic for the first time. They do not speak English well. There are two children, ages 2 years 6 months and 6 years. When taking the children’s history, you become aware they have not seen a provider in two years. Utilizing the Health Promotion Guide available in the course and the CDC vaccination schedule, develop a treatment plan to include vaccinations, safety, health promotion, and wellness preservation for these children. Provide a rationale for recommendations from sources such as the CDC. 


Initial Post:

APA format with intext citations

Word count minimum of Length: 1500 words, not including references. References: 2 high-level scholarly references within the last 5 years in APA format.

Plagiarism free.

Turnitin receipt.

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Week 13 dq 2

Answer both of the following questions. Support your summary and recommendations plan with a minimum of two APRN approved scholarly resources.

  1. Differentiate acute renal insufficiency versus acute kidney injury (AKI). Explain the diagnosis, etiology, and treatment for both. Describe the types of AKI including prerenal, intrarenal, and postrenal etiologies. Include diagnostic criteria for each etiology.
  2. Define chronic kidney disease, including stages, diagnosis, treatment, and prevention. Explain the indications for dialysis as well as the differences in the forms of dialysis (Intermittent hemodialysis, CRRT, peritoneal dialysis).

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Cardiovascular/pulmonary powerpoint presentation


Goal: Develop a PowerPoint presentation on CONGESTIVE HEART FAILURE (CHF) (Please explain implications on cardiovascular and respiratory system)

The presentation must provide information about the incidence, prevalence, and pathophysiology of Congestive Heart Failure to the cellular level. The presentation must educate advanced practice nurses on assessment and care/treatment, including genetics/genomics—specific for this disorder. Patient education for management, cultural, and spiritual considerations for care must also be addressed. The presentation must specifically address how the disease/disorder affects 1 of the following age groups: adult, or elderly. (PICK ONE, elderly is the most suitable).

Format Requirements: 

  • Presentation is original work and logically organized.
  • Followed APA 7 edition format including citation of references. References need to be time new roman font size 12.
  • Power point presentation with 10-15 slides were clear and easy to read. Speaker notes expanded upon and clarified content on the slides. Must be info to clarify the slide. DO NOT PUT EXACT SAME WORDS ON BOTH, and include citations at the end of the slide, please).
  • Incorporate a minimum of 6 current (published from 2018 up to now) scholarly journal articles, books or primary legal sources (statutes, court opinions) within your work. APA 7 ED

Content Requirements:

  • Select a cardiovascular or pulmonary disorder= (CHF)
  • Provide information about the incidence, prevalence, and pathophysiology of the disease/disorder to the cellular level.
  • Educate advanced practice nurses on assessment and care/treatment, including genetics/genomics—specific for this disorder.
  • Provide patient education for management, cultural, and spiritual considerations for care must also be addressed.
  • Must specifically address how the disease/disorder affects 1 of the following age groups: adult, or elderly.

APA 7 edition is a must.

NO WEBSITES ALLOWED FOR REFERENCE OR CITATION. References and citation must be only from journal articles or books published from 2018 up to now. Must employ at least 6 references entries which will be cited at the end of the slide, and in the correspondent speaker note. INCLUDE DOI, PAGE NUMBERS. etc. PLAGIARISM NEED TO BE LESS THAN 10%. It will be checked.

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2017) it is the balance that the antidepressant medication solves the mood of the patient


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Hipaa ati virtual scenario

CAN I get this done tonight 


Module Report
Simulation: Skills Modules 3.0

Module: Virtual Scenario: HIPAA

Individual Name: Frank Armoh

Institution: Chamberlain U North Brunswick BSN

Program Type: BSN


Scenario In this virtual simulation, you interacted with other healthcare
professionals at the nursing station of an acute care facility.
The goal was to use clinical judgement to maintain client
privacy and confidentiality through various methods of
communication in accordance with the Health Insurance
Portability and Accountability Act (HIPAA) regulations.
Review your results below to determine how your
performance aligned with the goals of the simulation.

Overall Performance You did not meet the requirements to
complete this virtual skills scenario.
Remediation is recommended before
attempting this virtual skills scenario again.

Score: 53.8%

Essential Activities
Implementing Security Safeguards

You did not demonstrate a thorough understanding of HIPAA
regulations and security safeguards needed to complete this
virtual skills scenario.

Sharing Protected Health Information

You did not demonstrate a thorough understanding in your
responses to protect privacy and maintain client
confidentiality when sharing protected health information.

Time Use And Score

Date Time

Virtual Scenario: HIPAA 7/10/2022 1 hr 9 min

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Pitfall Actions
Implementing Security Safeguards

Major – You selected one or more actions that demonstrated
an increased risk of negative outcome for the client when
implementing security safeguard to protect client privacy and
maintain client confidentiality. Therefore, further study of
implementing security safeguards when using various
methods to communicate with others should be reviewed
prior to completing the scenario again. Spend time reviewing
guidelines for security of electronic health records, promoting
privacy during verbal discussion of client care, use of
whiteboards, communicating with media, leaving voice
messages, using a fax machine to share client information,
and proper disposal of protected health information.

Sharing Protected Health Information

Major – You selected one or more actions that demonstrated
an increased risk of negative outcome for the client when
sharing protected health information. Therefore, further study
of who has the right to share information, whom to share
information with, and what information can be shared. should
be reviewed prior to completing the scenario again. Spend
time reviewing guidelines for sharing client information with
members of the healthcare team, appropriate use of client
photographs, sharing information with the client’s friends and
family, reporting conditions as required by law, and
understanding clients’ rights to access their healthcare

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This work will be a two-page text about concept analysis/development. This will prepare you toward gaining a beginning understanding of knowledge development and nursing theory development. From your personal philosophy (“Always look for opportunities to leave the world a better place”); identify one concept alone that you value very much (Compassion) and that guides you every day in your practice of nursing. Then review Chapter 3 pages 57-59 about steps in concept development and analysis by Walker and Avant. 

Must Answer:

Perhaps you have gone through self introspection every now and then you might ask yourself:

  • Why do I value this? (Always look for opportunities to leave the world a better place)
  • Why do you value compassion?

For this work you will perform an analysis of a concept (compassion). Perhaps you would want to be curious as to how this word came about. In other words, you would want to know it origins. This is what you call the epistemology of a concept. Then go back to values clarification. Ask yourself:

  • Why do I value this concept so much?
  • Explain the reason why it is significant in your life.
  • Further, why did it become important part of my belief system?

Then, ask yourself:

  • Have I been applying my belief system in term of my professional nursing practice? Explain why?

Expand the answers to the “why” to the 4 metaparadigms of nursing: person, health, environment, nursing. At this point you are now connecting your concept with the 4 metaparadigms of nursing. 

It should adhere to 7th edition APA style (includes introduction, body, conclusion).





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Fifth Edition

Copyright © 2019 Wolters Kluwer Health.

Copyright © 2014, 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2002 Lippincott Williams & Wilkins. All
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Library of Congress Cataloging-in-Publication Data

Names: McEwen, Melanie, author. | Wills, Evelyn M., author.
Title: Theoretical basis for nursing / Melanie McEwen, Evelyn M. Wills.
Description: Fifth edition. | Philadelphia : Wolters Kluwer, [2018] |

Includes bibliographical references and index.
Identifiers: LCCN 2017049174 | ISBN 9781496351203
Subjects: | MESH: Nursing Theory
Classification: LCC RT84.5 | NLM WY 86 | DDC 610.73—dc23 LC record available at https://lccn.loc.gov/2017049174

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author(s),
editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and
make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application
of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and
recommended may not be considered absolute and universal recommendations.

The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance
with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government
regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for
each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the
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Some drugs and medical devices presented in this publication have U.S. Food and Drug Administration (FDA) clearance for limited use in
restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use
in his or her clinical practice.




To Kaitlin and Grant—You have helped me broaden my thoughts and consider all kinds of possibilities;
I hope I’ve done the same for you.

Also for Helen and Keith—Our children chose well. Besides, you have given us Madelyn, Logan,
Brenna, Liam, Lucy, Andrew, Michael, and Jacob; they are gifts beyond words.

Melanie McEwen

To Tom, Paul, and Vicki, who light up my life, and to Marian, who left us for a better place. You were
always my best listener. To Teddy, Gwen, Merlyn, and Madelyn, who have been so patient and loving
during this process.

My deepest gratitude to Leslie, who has supported me through this writing process.

Evelyn M. Wills



Sattaria Smith Dilks, DNP, APRN-BC, FNP, PMHNP/CNS
Professor and Co-Coordinator Graduate Program
College of Nursing
McNeese State University
Lake Charles, Louisiana
Chapter 14: Theories From the Behavioral Sciences

Joan C. Engebretson, DrPH, AHN-BC, RN, FAAN
Judy Fred Professor in Nursing
University of Texas Health Science Center at Houston
School of Nursing, Department of Family Nursing
Houston, Texas
Chapter 13: Theories From the Sociologic Sciences

Melinda Granger Oberleitner, DNS, RN
Associate Dean, College of Nursing & Allied Health Professions
Professor, Department of Nursing
SLEMCO/BORSF Endowed Professor of Nursing
University of Louisiana at Lafayette
Lafayette, Louisiana
Chapter 17: Theories, Models, and Frameworks From Leadership and Management
Chapter 21: Application of Theory in Nursing Administration and Management

Cathy L. Rozmus, PhD, RN
PARTNERS Endowed Professorship in Nursing
Vice Dean
Department of Family Health
The University of Texas Health Science Center at Houston
School of Nursing
Houston, Texas
Chapter 16: Ethical Theories and Principles

Jeffrey P. Spike, PhD
Professor of Family and Community Medicine
The University of Texas Health Science Center at Houston
School of Medicine
Professor, Department of Management, Policy, and Community Health
University of Texas Health Science Center School of Public Health
Houston, Texas
Chapter 16: Ethical Theories and Principles



Cynthia Dakin, PhD, RN
Director of Graduate Studies
Associate Professor
Department of Nursing
Elms College
Chicopee, Massachusetts

Janet DuPont, RNC-OB, MSN, MEd, PhD
Master of Science in Nursing Instructor/Developer
Nursing Program
Norwich University
Northfield, Vermont

Ruth Neese, PhD, RN, CEN
Assistant Professor
Department of Nursing
Indian River State College
Fort Pierce, Florida

Brandon N. Respress, PhD, RN, MPH, MSN
Assistant Professor
College of Nursing and Health Innovation
University of Texas at Arlington
Arlington, Texas

Jacqueline Saleeby, PhD, RN, CS
Associate Professor
Department of Nursing
Maryville University
St. Louis, Missouri

Stephen J. Stapleton, PhD, MS, RN, CEN, FAEN
Associate Professor
Mennonite College of Nursing
Illinois State University
Normal, Illinois

Kathleen Williamson, MSN, PhD, RN
Associate Professor and Chair
Wilson School of Nursing
Midwestern State University
Wichita Falls, Texas

Cindy Zellefrow, DNP, MSEd, RN, LSN, APHN-BC
Assistant Professor of Clinical Practice
Assistant Director, Center for Transdisciplinary and Evidence-based Practice


College of Nursing
The Ohio State University
Columbus, Ohio



Rare is the student who enrolls in a nursing program and is excited about the requirement of taking a course
on theory. Indeed, many fail to see theory’s relevance to the real world of nursing practice and often have
difficulty applying the information in later courses and in their research. This book is the result of the
frustration felt by a group of nursing instructors who met a number of years ago to adopt a textbook for a
theory course. Indeed, because of student complaints and faculty dissatisfaction, we were changing textbooks
yet again. A fairly lengthy discussion arose in which we concluded that the available books did not meet the
needs of our students or course faculty. We were determined to write a book that was a general overview of
theory per se, stressing how it is—and should be—used by nurses to improve practice, research, education,
and management/leadership.

As in past editions, an ongoing review of trends in nursing theory and nursing science has shown an
increasing emphasis on middle range theory, evidence-based practice (EBP), and situation-specific theories.
To remain current and timely, in this fifth edition, we have added a new chapter entitled “Ethical Theories and
Principles,” presenting information on these topics and describing how they relate to theory in nursing. We
have also included new middle range and situation-specific nursing theories as well as new “shared” theories
from non-nursing disciplines. One notable addition is a significant section discussing Complexity Science and
Complex Adaptive Systems in Chapter 13 (Theories From the Sociologic Sciences) helping to explain their
importance to nursing. Updates and application examples have been added throughout the discussions on the
various theories.

Organization of the Text
Theoretical Basis for Nursing is designed to be a basic nursing theory textbook that includes the essential
information students need to understand and apply theory in practice, research, education, and

The book is divided into four units. Unit I, Introduction to Theory, provides the background needed to
understand what theory is and how it is used in nursing. It outlines tools and techniques used to develop,
analyze, and evaluate theory so that it can be used in nursing practice, research, administration and
management, and education. In this unit, we have provided a balanced view of “hot” topics (e.g.,
philosophical world views and utilization of shared or borrowed theory). Also, rather than espousing one
strategy for activities such as concept development and theory evaluation, we have included a variety of

Unit II, Nursing Theories, focuses largely on the grand nursing theories and begins with a chapter
describing their historical development. This unit divides the grand nursing theories into three groups based
on their focus (human needs, interactive process, and unitary process). The works of many of the grand
theorists are briefly summarized in Chapters 7, 8, and 9. Because this volume is intended to serve as a broad
foundation, these analyses provide the reader with enough information to understand the basis of the work and
to whet the reader’s appetite to select one or more for further study rather than delving into significant detail.

Chapters 10 and 11 cover the significant topic of middle range nursing theory. Chapter 10 presents a
detailed overview of the origins and growth of middle range theory in nursing and gives numerous examples
of how middle range theories have been developed by nurses. Chapter 11 provides an overview of some of the
growing number of middle range nursing theories. The theories presented include some of the most
commonly used middle range nursing theories (e.g., Pender’s Health Promotion Model and Leininger’s
Culture Care Diversity and Universality Theory) as well as some that are less well known but have a growing
body of research support (e.g., Meleis’s Transitions Theory, the Theory of Unpleasant Symptoms, and the


Uncertainty in Illness Theory). The intent is to provide a broad range of middle range theories to familiarize
the reader with examples and to encourage them to search for others appropriate to their practice or research.
Ultimately, it is hoped that readers will be challenged to develop new theories that can be used by nurses.

Chapter 12, which discusses EBP, explains and defines the idea/process of EBP and describes how it
relates to nursing theory and application of theory in nursing practice and research. The chapter concludes
with a short presentation and review of five different EBP models that have been widely used by nurses and
are well supported in the literature.

Unit III, Shared Theories Used by Nurses, is rather unique in nursing literature. Our book
acknowledges that “shared” or “borrowed” theories are essential to nursing and negates the idea that the use
of shared theory in practice or research is detrimental. In this unit, we have identified some of the most
significant theories that have been developed outside of the discipline of nursing but are continually used in
nursing. We have organized these theories based on broad disciplines: theories from the sociologic sciences,
behavioral sciences, biomedical sciences, and philosophy as well as from administration, management, and
learning. Each of these chapters was written by a nurse with both educational and practical experience in his
or her respective area. These theories are presented with sufficient information to allow the reader to
understand the theories and to recognize those that might be appropriate for his or her own work. These
chapters also provide original references and give examples of how the concepts, theories, and models
described have been used by other nurses.

Chapter 16, new to the fifth edition, describes ethical theories and principles that apply to nursing practice.
This addition was suggested by nursing faculty who recognized the importance of maintaining an ethical
perspective within the very complex health care system. This information is vital to professional nursing
practice and absolutely essential for nurses in advanced practice, management, or educational roles.

Finally, Unit IV, Application of Theory in Nursing, explains how theories are applied in nursing.
Separate chapters cover nursing practice, nursing research, nursing administration and management, and
nursing education. These chapters include many specific examples for the application of theory and are
intended to be a practical guide for theory use. The heightened development of practice theories and EBP
guidelines are critical to theory application in nursing today, so these areas have been expanded. The unit
concludes with a chapter that discusses some of the future issues in theory within the discipline.

Key Features
In addition to numerous tables and boxes that highlight and summarize important information, Theoretical
Basis for Nursing contains case studies, learning activities, exemplars, and illustrations that help students
visualize various concepts. New to this edition is a special boxed feature in most chapters that highlights how
a topic is outlined in the American Association of Colleges of Nursing (AACN’s) The Essentials of Master’s
Education in Nursing or The Essentials of Doctoral Education for Advanced Nursing Practice. Other key
features include:

■ Link to Practice: All chapters include at least one “Link to Practice” box, which presents useful
information or clinically related examples related to the subject being discussed. The intent is to give
additional tools or resources that can be used by nurses to apply the content in their own practice or

■ Case Studies: At the end of Chapter 1 and the beginning of Chapters 2 to 23, case studies help the
reader understand how the content in the chapter relates to the everyday experience of the nurse,
whether in practice, research, or other aspects of nursing.

■ Learning Activities: At the end of each chapter, learning activities pose critical thinking questions,
propose individual and group projects related to topics covered in the chapter, and stimulate classroom

■ Exemplars: In five chapters, an exemplar discusses a scholarly study from the perspectives of concept
analysis (Chapter 3); theory development (Chapter 4); theory analysis and evaluation (Chapter 5);
middle range theory development (Chapter 10); and theory generation via research, theory testing via
research, and use of a theory as the conceptual framework for a research study (Chapter 20).

■ Illustrations: Diagrams and models are included throughout the book to help the reader better


understand the many different theories presented.

New to This Edition
■ New Chapter 16, Ethical Theories and Principles
■ Detailed section on Complexity Science and Complex Adaptive Systems in Chapter 13.
■ More detailed explanation of EBP, situation-specific theories, and their relationship to theory in nursing
■ Numerous recent examples of application of theories in nursing practice, nursing research,

leadership/administration, and education
■ Enhanced instructional support, focusing on activities and information directed toward online learning

Student Resources Available on
■ Literature Assessment Activity provides an interactive tool featuring journal articles along with

critical thinking questions that will encourage students to engage with the literature. Students can print
or e-mail their responses to their instructor.

■ Case Studies with applicable questions guide students in understanding how the various theories link
to nursing practice.

■ Learning Objectives for each chapter help focus the student on outcomes.
■ Internet Resources provide live web links to pertinent sites so that students can further their study and

understanding of the various theories.
■ Journal Articles for each chapter offer opportunities to gain more knowledge and understanding of the

chapter content.

Instructor Resources Available on
■ Instructor’s Guide includes application-level discussion questions and classroom/online activities that

Melanie McEwen uses in her own teaching!
■ Strategies for Effective Teaching of Nursing Theory provide ideas for instructors to help make the

nursing theory class come alive.
■ Test Generator Questions provide multiple-choice questions that can be used for testing general

content knowledge.
■ PowerPoints with audience response (Iclicker) questions, based on the ones used by Melanie

McEwen in her own classroom, help highlight important points to enhance the classroom experience.
■ Case Studies with questions, answers, and related activities offer opportunities for instructors to make

the student case studies an exciting, fun, and rewarding classroom/online experience.
■ Image Bank provides images from the text that instructors can use to enhance their own presentations.

In summary, the focus of this learning package is on the application of theory rather than on the study,
analysis, and critique of grand theorists or a presentation of a specific aspect of theory (e.g., construction or
evaluation). It is hoped that practicing nurses, nurse researchers, and nursing scholars, as well as graduate
students and theory instructors, will use this book and its accompanying resources to gain a better
understanding and appreciation of theory.

Melanie McEwen, PhD, RN, CNE, ANEF
Evelyn M. Wills, PhD, RN



Our heartfelt thanks to Senior Development Editor, Michael Kerns, and Editorial Coordinator, Tim Rinehart,
for their assistance, patience, and persistence in helping us complete this project. They made a difficult task
seem easy! We also want to thank Senior Acquisitions Editor, Christina Burns, and Helen Kogut, for their
support and assistance in getting this project started and help with previous editions. Finally, a huge word of
thanks to our contributors who have diligently worked to present the notion of theory in a manner that will
engage nursing students and to look for new examples and applications to help make theory fresh and



Unit I: Introduction to Theory

1. Philosophy, Science, and Nursing
Melanie McEwen

Case Study
Nursing as a Profession
Nursing as an Academic Discipline
Introduction to Science and Philosophy

Overview of Science
Overview of Philosophy

Science and Philosophical Schools of Thought
Received View (Empiricism, Positivism, Logical Positivism)

Contemporary Empiricism/Postpositivism
Nursing and Empiricism

Perceived View (Human Science, Phenomenology, Constructivism, Historicism)
Nursing and Phenomenology/Constructivism/Historicism

Postmodernism (Poststructuralism, Postcolonialism)
Nursing and Postmodernism

Nursing Philosophy, Nursing Science, and Philosophy of Science in Nursing
Nursing Philosophy
Nursing Science
Philosophy of Science in Nursing

Knowledge Development and Nursing Science

Ways of Knowing
Nursing Epistemology
Other Views of Patterns of Knowledge in Nursing
Summary of Ways of Knowing in Nursing

Research Methodology and Nursing Science
Nursing as a Practice Science
Nursing as a Human Science
Quantitative Versus Qualitative Methodology Debate

Quantitative Methods
Qualitative Methods
Methodologic Pluralism

Key Points

Learning Activities

2. Overview of Theory in Nursing
Melanie McEwen

Overview of Theory
The Importance of Theory in Nursing
Terminology of Theory


Historical Overview: Theory Development in Nursing
Florence Nightingale
Stages of Theory Development in Nursing

Silent Knowledge Stage
Received Knowledge Stage
Subjective Knowledge Stage
Procedural Knowledge Stage
Constructed Knowledge Stage
Integrated Knowledge Stage

Summary of Stages of Nursing Theory Development
Classification of Theories in Nursing

Scope of Theory
Grand Theories
Middle Range Theories
Practice Theories

Type or Purpose of Theory
Descriptive (Factor-Isolating) Theories
Explanatory (Factor-Relating) Theories
Predictive (Situation-Relating) Theories
Prescriptive (Situation-Producing) Theories

Issues in Theory Development in Nursing
Borrowed Versus Unique Theory in Nursing
Nursing’s Metaparadigm

Relationships Among the Metaparadigm Concepts
Other Viewpoints on Nursing’s Metaparadigm

Caring as a Central Construct in the Discipline of Nursing
Key Points

Learning Activities

3. Concept Development: Clarifying Meaning of Terms
Evelyn M. Wills and Melanie McEwen

The Concept of “Concept”
Types of Concepts

Abstract Versus Concrete Concepts
Variable (Continuous) Versus Nonvariable (Discrete) Concepts
Theoretically Versus Operationally Defined Concepts

Sources of Concepts
Concept Analysis/Concept Development

Purposes of Concept Development
Context for Concept Development
Concept Development and Conceptual Frameworks
Concept Development and Research

Strategies for Concept Analysis and Concept Development
Walker and Avant

Concept Analysis
Concept Synthesis
Concept Derivation
Examples of Concept Analysis Using Walker and Avant’s Techniques

Schwartz-Barcott and Kim

Theoretical Phase


Fieldwork Phase
Analytical Phase

Concept Exploration
Concept Clarification
Concept Analysis

Concept Delineation
Concept Comparison
Concept Clarification

Penrod and Hupcey
Comparison of Models for Concept Development

Key Points

Learning Activities

4. Theory Development: Structuring Conceptual Relationships in Nursing
Melanie McEwen

Overview of Theory Development
Categorizations of Theory

Categorization Based on Scope or Level of Abstraction
Philosophy, Worldview, or Metatheory
Grand Theories
Middle Range Theories
Practice Theories
Relationship Among Levels of Theory in Nursing

Categorization Based on Purpose
Descriptive Theories
Explanatory Theories
Predictive Theories
Prescriptive Theories

Categorization Based on Source or Discipline
Components of a Theory

Concepts and Conceptual Definitions
Theoretical Statements

Existence Statements
Relational Statements

Structure and Linkages

Theory Development
Relationship Among Theory, Research, and Practice

Relationship Between Theory and Research
Relationship Between Theory and Practice
Relationship Between Research and Practice

Approaches to Theory Development
Theory to Practice to Theory
Practice to Theory
Research to Theory
Theory to Research to Theory
Integrated Approach

Process of Theory Development


Concept Development: Creation of Conceptual Meaning
Statement Development: Formulation and Validation of Relational Statements
Theory Construction: Systematic Organization of the Linkages
Validating and Confirming Theoretical Relationships in Research
Validation and Application of Theory in Practice

Key Points

Learning Activities

5. Theory Analysis and Evaluation
Melanie McEwen

Definition and Purpose of Theory Evaluation
Theory Description
Theory Analysis
Theory Evaluation

Historical Overview of Theory Analysis and Evaluation
Characteristics of Significant Theories: Ellis
Theory Evaluation: Hardy
Theory Analysis and Theory Evaluation: Duffey and Muhlenkamp
Theory Evaluation: Barnum
Theory Analysis: Walker and Avant
Theory Analysis and Evaluation: Fawcett
Theory Description and Critique: Chinn and Kramer
Theory Description, Analysis, and Critique: Meleis
Analysis and Evaluation of Practice Theory, Middle Range Theory, and Nursing Models:
Theory Evaluation: Dudley-Brown

Comparisons of Methods
Synthesized Method of Theory Evaluation
Key Points

Learning Activities

Unit II: Nursing Theories

6. Overview of Grand Nursing Theories
Evelyn M. Wills

Categorization of Conceptual Frameworks and Grand Theories
Categorization Based on Scope
Categorization Based on Nursing Domains
Categorization Based on Paradigms

Parse’s Categorization
Newman’s Categorization
Fawcett’s Categorization

Specific Categories of Models and Theories for This Unit
Analysis Criteria for Grand Nursing Theories

Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science
The Purpose of Critiquing Theories
Key Points

Learning Activities

7. Grand Nursing Theories Based on Human Needs
Evelyn M. Wills

Florence Nightingale: Nursing: What It Is and What It Is Not
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships
Value in Extending Nursing Science

Virginia Henderson: The Principles and Practice of Nursing
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Faye G. Abdellah: Patient-Centered Approaches to Nursing
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships

Value in Extending Nursing Science

Dorothea Orem: The Self-Care Deficit Nursing Theory
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Dorothy Johnson: The Behavioral System Model
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships




Value in Extending Nursing Science

Betty Neuman: The Neuman Systems Model
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Key Points

Learning Activities

8. Grand Nursing Theories Based on Interactive Process
Evelyn M. Wills

Barbara Artinian: The Intersystem Model
Background of the Theorist
Philosophic Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

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

Background of the Theorists
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Imogene King: King’s Conceptual System and Theory of Goal Attainment and
Transactional Process

Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science


Sister Callista Roy: The Roy Adaptation Model
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Jean Watson: Human Caring Science, A Theory of Nursing
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Key Points

Learning Activities

9. Grand Nursing Theories Based on Unitary Process
Evelyn M. Wills

Martha Rogers: The Science of Unitary and Irreducible Human Beings
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Margaret Newman: Health as Expanding Consciousness
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships


Value in Extending Nursing Science

Rosemarie Parse: The Humanbecoming Paradigm
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships



Value in Extending Nursing Science

Key Points

Learning Activities

10. Introduction to Middle Range Nursing Theories
Melanie McEwen

Purposes of Middle Range Theory
Characteristics of Middle Range Theory
Concepts and Relationships for Middle Range Theory
Categorizing Middle Range Theory
Development of Middle Range Theory

Middle Range Theories Derived From Research and/or Practice
Middle Range Theory Derived From a Grand Theory
Middle Range Theory Combining Existing Nursing and Non-Nursing Theories
Middle Range Theory Derived From Non-Nursing Disciplines
Middle Range Theory Derived From Practice Guidelines or Standard of Care
Final Thoughts on Middle Range Theory Development

Analysis and Evaluation of Middle Range Theory
Key Points

Learning Activities

11. Overview of Selected Middle Range Nursing Theories
Melanie McEwen

High Middle Range Theories
Benner’s Model of Skill Acquisition in Nursing

Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Leininger’s Cultural Care Diversity and Universality Theory
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Pender’s Health Promotion Model
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Transitions Theory
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

The Synergy Model
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Middle Middle Range Theories
Mishel’s Uncertainty in Illness Theory

Purpose and Major Concepts
Context for Use and Nursing Implications


Evidence of Empirical Testing and Application in Practice
Kolcaba’s Theory of Comfort

Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Lenz and Colleagues’ Theory of Unpleasant Symptoms
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Reed’s Self-Transcendence Theory
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Low Middle Range Theories
Eakes, Burke, and Hainsworth’s Theory of Chronic Sorrow

Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Beck’s Postpartum Depression Theory
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Mercer’s Conceptualization of Maternal Role Attainment/Becoming a Mother
Purpose and Major Concepts
Context for Use and Nursing Implications
Evidence of Empirical Testing and Application in Practice

Key Points

Learning Activities

12. Evidence-Based Practice and Nursing Theory
Evelyn M. Wills and Melanie McEwen

Overview of Evidence-Based Practice
Definition and Characteristics of Evidence-Based Practice
Concerns Related to Evidence-Based Practice in Nursing
Evidence-Based Practice and Practice-Based Evidence
Promotion of Evidence-Based Practice in Nursing
Theory and Evidence-Based Practice
Theoretical Models of Evidence-Based Practice

Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation
Advancing Research and Clinical Practice Through Close Collaboration Model
The Iowa Model of Evidence-Based Practice to Promote Quality Care
The Johns Hopkins Nursing Evidence-Based Practice Model
Stetler Model of Evidence-Based Practice
Theoretical Models: A Summary

Key Points

Learning Activities

Unit III: Shared Theories Used by Nurses

13. Theories From the Sociologic Sciences


Joan C. Engebretson
Systems Theories

General Systems Theory
Application to Nursing

Social Ecological Models
Application to Nursing

Social Networks
Application to Nursing

Social Construction and Interaction Theories
Symbolic Interactionism

Application to Nursing

Cultural Diversity
Application to Nursing

Role Theory
Application to Nursing

Exchange Theories, Conflict and Critical Theories
Exchange Theories

Historical Overview
Modern Social Exchange Theories
Application to Nursing

Conflict and Critical Theories
Critical Social Theory
Feminist Theory

Complexity Science, Chaos Theory and Complex Adaptive Systems
Chaos Theory
Complex Adaptive Systems

Application to Nursing
Key Points

Learning Activities

14. Theories From the Behavioral Sciences
Melanie McEwen and Sattaria Smith Dilks

Psychodynamic Theories
Psychoanalytic Theory: Freud

Application to Nursing

Developmental (or Ego Developmental) Theory: Erikson
Application to Nursing

Interpersonal Theory: Sullivan
Application to Nursing

Behavioral and Cognitive-Behavioral Theories
Operant Conditioning: Skinner
Cognitive Theory: Beck
Rational Emotive Theory: Ellis


Application of Behavioral and Cognitive-Behavioral Theories to Nursing
Humanistic Theories

Human Needs Theory: Maslow
Application to Nursing

Person-Centered Theory: Rogers
Application to Nursing

Stress Theories
General Adaptation Syndrome: Selye
Stress, Coping, and Adaptation Theory: Lazarus
Application of Stress Theories to Nursing

Social Psychology
Health Belief Model
Theory of Reasoned Action (Theory of Planned Behavior)
Transtheoretical Model and Stages of Change
Application of Social Psychology Theories to Nursing

Key Points

Learning Activities

15. Theories From the Biomedical Sciences
Melanie McEwen

Theories and Models of Disease Causation
Evolution of Theories of Disease Causation
Germ Theory and Principles of Infection

Application to Nursing

The Epidemiologic Triangle
The Web of Causation

Application to Nursing

Natural History of Disease
Application to Nursing

Theories and Principles Related to Physiology and Physical Functioning

Application to Nursing

Stress and Adaptation: General Adaptation Syndrome
Application to Nursing

Theories of Immunity and Immune Function
Application to Nursing

Genetic Principles and Theories
Application to Nursing

Cancer Theories
Application to Nursing

Pain Management
Gate Control Theory


Application to Nursing
Key Points

Learning Activities

16. Ethical Theories and Principles
Cathy L. Rozmus and Jeffrey P. Spike

Ethics and Philosophy: An Overview
Theory in the Humanities and Philosophy
Ethics Versus Morality

Philosophical Theories of Ethics
Virtue Ethics

Application in Nursing

Modern Ethical Theories
Deontology and Utilitarianism—A Summary
Application to Nursing

Bioethical Principles
Historical Perspective on the Bioethical Principles

Application to Nursing

Application to Nursing

Application to Nursing

Application to Nursing

Other Bioethical Principles
Ethical Decision Making

Application to Nursing

Key Points

Learning Activities

17. Theories, Models, and Frameworks From Leadership and Management
Melinda Granger Oberleitner

Overview of Concepts of Leadership and Management
Early Leadership Theories

Trait Theories of Leadership
Emotional Intelligence
Behavioral Theories of Leadership

Leader–Member Exchange Theory
Motivational Theories of Leadership

Theory X and Theory Y
Motivation–Hygiene Theory (Herzberg’s Two-Factor Theory)

Contingency Theories of Leadership: Leadership and Management by Situation


The Fiedler Contingency Theory of Leadership
Path–Goal Theory
Situational Leadership Theory

Contemporary Leadership Theories
Transactional and Transformational Leadership
Authentic Leadership
Charismatic Leadership
Servant Leadership
Followership Theory

Organizational/Management Theories
Scientific Management
Theory of Bureaucracy/Organizational Theory
Classic Management Theory

Motivational Theories
Achievement–Motivation Theory
Expectancy Theory
Equity Theory

Concepts of Power, Empowerment, and Change

Planned Change Theory

Problem-Solving and Decision-Making Processes
The Rational Decision-Making Model
Group Decision Making
Organizational Quantitative Decision-Making Techniques

Conflict Management
Quality Improvement

The Case for Quality Improvement in Health Care
Quality Improvement Frameworks
Quality Improvement Processes and Tools

Evidence-Based Practice
Key Points

Learning Activities

18. Learning Theories
Evelyn M. Wills and Melanie McEwen

What Is Learning?
What Is Teaching?
Categorization of Learning Theories
Behavioral Learning Theories

Application to Nursing

Cognitive Learning Theories
Cognitive-Field (Gestalt) Theories

Application to Nursing

Cognitive Development or Interaction Theories


Humanistic Learning Theory

Information-Processing Models
Cognitive Load Theory
Application to Nursing

Adult Learning
Application to Nursing

Summary of Learning Theories
Learning Styles
Principles of Learning
Application of Learning Theories in Nursing
Key Points

Learning Activities

Unit IV: Application of Theory in Nursing

19. Application of Theory in Nursing Practice
Melanie McEwen

Relationship Between Theory and Practice
Theory-Based Nursing Practice
The Theory–Practice Gap

Closing the Theory–Practice Gap
Situation-Specific/Practice Theories in Nursing

Definition and Characteristics of Situation-Specific/Practice Theories
Examples of Practice and Situation-Specific Theories From Nursing Literature
Situation-Specific Theory and Evidence-Based Practice

Application of Theory in Nursing Practice
Theory in Nursing Taxonomy: Examples From the Nursing Intervention Classification

Urinary Catheterization: Intermittent
Patient Contracting

Examples of Theory From Nursing Literature
Application of “Borrowed” and “Implied” Theories in Nursing Practice
Application of Grand and Middle Range Theories in Nursing Practice

Key Points

Learning Activities

20. Application of Theory in Nursing Research
Melanie McEwen

Historical Overview of Research and Theory in Nursing
Relationship Between Research and Theory

Nursing Research
Purpose of Theory in Research
The Research Framework

Types of Theory and Corresponding Research
Descriptive Theory and Descriptive Research

Nursing Studies

Explanatory Theory and Correlational Research


Nursing Studies

Predictive Theory and Experimental Research
Nursing Studies

How Theory Is Used in Research
Theory-Generating Research

Nursing Studies

Theory-Testing Research
Nursing Studies

Theory as the Conceptual Framework or Context of a Study
Nursing Studies

Nursing and Non-Nursing Theories in Nursing Research
Rationale for Using Nursing Theories in Nursing Research
Concerns Over Reliance on Nursing Models to Direct Nursing Research

Other Issues in Nursing Theory and Nursing Research
The Research Report
Nursing’s Research Agenda

Key Points

Learning Activities

21. Application of Theory in Nursing Administration and Management
Melinda Granger Oberleitner

Organizational Design
Work Specialization
Chain of Command
Span of Control
Authority and Responsibility
Centralization Versus Decentralization

Shared Governance
Transformational Leadership in Nursing and in Health Care
Patient Care Delivery Models

Total Patient Care (Functional Nursing)
Team Nursing
Primary Nursing
Patient-Focused Care/Patient-Centered Care
Use of Patient Care Delivery Models Today
American Nurses Credentialing Center Magnet Recognition Program

Case Management
Disease/Chronic Illness Management

Disease Management Models
Population Health Accountable Care Organizations and Medical Home Models of Care

Quality Management
Evidence-Based Practice

Key Points

Learning Activities


22. Application of Theory in Nursing Education
Melanie McEwen and Evelyn M. Wills

Theoretical Issues in Nursing Curricula
Curriculum Design in Nursing Education
Nursing Curricula and Regulating Bodies
Conceptual/Organizational Frameworks for Nursing Curricula

Purposes of the Conceptual Framework
Designing a Curriculum Conceptual Framework
Components of the Curricular Conceptual Framework
Patterns of Curricular Conceptual Frameworks

Current Issues in Curriculum Development
Theoretical Issues in Nursing Instruction

Theory-Based Teaching Strategies
Dialectic Learning
Problem-Based Learning Strategies
Operational Teaching Strategies
Logistic Teaching Strategies

Use of Technology in Nursing Education
Issues in Technology-Based Teaching

Key Points

Learning Activities

23. Future Issues in Nursing Theory
Melanie McEwen

Future Issues in Nursing Science
Future Issues in Nursing Theory

Implications for Theory Development
Theoretical Perspectives on Future Issues in Nursing Practice, Research, Administration
and Management, and Education

Future Issues and Nursing Practice
Theoretical Implications for Nursing Practice

Future Issues and Nursing Research
Theoretical Implications for Nursing Research

Future Issues and Nursing Leadership and Administration
Theoretical Implications for Nursing Administration and Management

Future Issues and Nursing Education
Theoretical Implications for Nursing Education

Key Points

Learning Activities

Author Index
Subject Index



Introduction to Theory



Philosophy, Science, and Nursing
Melanie McEwen

Largely due to the work of nursing scientists, nursing theorists, and nursing scholars over the past five
decades, nursing has been recognized as both an emerging profession and an academic discipline. Crucial to
the attainment of this distinction have been numerous discussions regarding the phenomena of concern to
nurses and countless efforts to enhance involvement in theory utilization, theory generation, and theory testing
to direct research and improve practice.

A review of the nursing literature from the late 1970s until the present shows sporadic discussion of
whether nursing is a profession, a science, or an academic discipline. These discussions are sometimes
pleading, frequently esoteric, and occasionally confusing. Questions that have been raised include: What
defines a profession? What constitutes an academic discipline? What is nursing science? Why is it important
for nursing to be seen as a profession or an academic discipline?

Nursing as a Profession
In the past, there has been considerable discussion about whether nursing is a profession or an occupation.
This is important for nurses to consider for several reasons. An occupation is a job or a career, whereas a
profession is a learned vocation or occupation that has a status of superiority and precedence within a division
of work. In general terms, occupations require widely varying levels of training or education, varying levels of
skill, and widely variable defined knowledge bases. In short, all professions are occupations, but not all
occupations are professions (Finkelman & Kenner, 2016).

Professions are valued by society because the services professionals provide are beneficial for members of
the society. Characteristics of a profession include (1) defined and specialized knowledge base, (2) control
and authority over training and education, (3) credentialing system or registration to ensure competence, (4)
altruistic service to society, (5) a code of ethics, (6) formal training within institutions of higher education, (7)
lengthy socialization to the profession, and (8) autonomy (control of professional activities) (Ellis & Hartley,
2012; Finkelman & Kenner, 2016; Rutty, 1998). Professions must have a group of scholars, investigators, or
researchers who work to continually advance the knowledge of the profession with the goal of improving
practice. Finally, professionals are responsible and accountable to the public for their work (Hood, 2014).
Traditionally, professions have included the clergy, law, and medicine.

Until near the end of the 20th century, nursing was viewed as an occupation rather than a profession.
Nursing has had difficulty being deemed a profession because many of the services provided by nurses have
been perceived as an extension of those offered by wives and mothers. Additionally, historically, nursing has
been seen as subservient to medicine, and nurses have delayed in identifying and organizing professional
knowledge. Furthermore, education for nurses is not yet standardized, and the three-tier entry-level system
(diploma, associate degree, and bachelor’s degree) into practice that persists has hindered professionalization
because a college education is not yet a requirement. Finally, autonomy in practice is incomplete because
nursing is still dependent on medicine to direct much of its practice.

On the other hand, many of the characteristics of a profession can be observed in nursing. Indeed, nursing
has a social mandate to provide health care for clients at different points in the health–illness continuum.


There is a growing knowledge base, authority over education, altruistic service, a code of ethics, and
registration requirements for practice. Although the debate is not closed, it can be successfully argued that
nursing is an aspiring, evolving profession (Finkelman & Kenner, 2016; Hood, 2014; Judd & Sitzman, 2014).
See Link to Practice 1-1 for more information on the future of nursing as a profession.

Link to Practice 1-1
The Future of Nursing
The Institute of Medicine (IOM, 2011) issued a series of sweeping recommendations directed to the
nursing profession. The IOM explained their “vision” is to make quality, patient-centered care accessible
for all Americans. Recommendations included a three-pronged approach to meeting the goal.

The first “message” was directed toward transformation of practice and precipitated the notion that
nurses should be able to practice to the full extent of their education. Indeed, the IOM advocated for
removal of regulatory, policy, and financial barriers to practice to ensure that “current and future
generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such
areas as primary care and community and public health” (p. 30).

A second key message related to the transformation of nursing education. In this regard, the IOM
promotes “seamless academic progression” (p. 30), which includes a goal to increase the number and
percentage of nurses who enter the workforce with a baccalaureate degree or who progress to the degree
early in their career. Specifically, they recommend that 80% of registered nurses (RNs) be bachelor of
science in nursing (BSN) prepared by 2020. Last, the IOM advocated that nurses be full partners with
physicians and other health professionals in the attempt to redesign health care in the United States.

These “messages” are critical to the future of nursing as a profession. Indeed, standardization of entry
level into practice at the BSN level, coupled with promotion of advanced education and independent
practice, and inclusion as “leaders” in the health care transformation process, will help solidify nursing as a
true profession.

An update (IOM, 2016) indicated that there has been “significant progress” (p. 50) toward reducing
APRN scope of practices issues from a national perspective, as more states now allow nurse practitioners
(NPs) full practice authority. Furthermore, although there has been some progress with expansion of the
percentage of RNs with a BSN (from 49% to 51%), there is still much to do to meet the goal of 80%.
Finally, the IOM concluded that data are lacking on efforts to develop the skills and competencies nurses
need for leadership. The report reinforced the goal for nurses to seek “leadership positions in order to
contribute their unique perspective and expertise on such issues as health care delivery, quality, and
safety” (p. 149).

Nursing as an Academic Discipline
Disciplines are distinctions between bodies of knowledge found in academic settings. A discipline is “a
branch of knowledge ordered through the theories and methods evolving from more than one worldview of
the phenomenon of concern” (Parse, 1997, p. 74). It has also been termed a field of inquiry characterized by a
unique perspective and a distinct way of viewing phenomena (Fawcett, 2012; Rodgers, 2015).

Viewed another way, a discipline is a branch of educational instruction or a department of learning or
knowledge. Institutions of higher education are organized around disciplines into colleges, schools, and
departments (e.g., business administration, chemistry, history, and engineering).

Disciplines are organized by structure and tradition. The structure of the discipline provides organization
and determines the amount, relationship, and ratio of each type of knowledge that comprises the discipline.
The tradition of the discipline provides the content, which includes ethical, personal, esthetic, and scientific
knowledge (Northrup et al., 2004; Risjord, 2010). Characteristics of disciplines include (1) a distinct
perspective and syntax, (2) determination of what phenomena are of interest, (3) determination of the context
in which the phenomena are viewed, (4) determination of what questions to ask, (5) determination of what


methods of study are used, and (6) determination of what evidence is proof (Donaldson & Crowley, 1978).
Knowledge development within a discipline proceeds from several philosophical and scientific

perspectives or worldviews (Litchfield & Jónsdóttir, 2008; Newman, Sime, & Corcoran-Perry, 1991; Risjord,
2010; Rodgers, 2015). In some cases, these worldviews may serve to divide or segregate members of a
discipline. For example, in psychology, practitioners might consider themselves behaviorists, Freudians, or
any one of a number of other divisions.

Several ways of classifying academic disciplines have been proposed. For instance, they may be divided
into the basic sciences (physics, biology, chemistry, sociology, anthropology) and the humanities (philosophy,
ethics, history, fine arts). In this classification scheme, it is arguable that nursing has characteristics of both.

Distinctions may also be made between academic disciplines (e.g., physics, physiology, sociology,
mathematics, history, philosophy) and professional disciplines (e.g., medicine, law, nursing, social work). In
this classification scheme, the academic disciplines aim to “know,” and their theories are descriptive in nature.
Research in academic disciplines is both basic and applied. Conversely, the professional disciplines are
practical in nature, and their research tends to be more prescriptive and descriptive (Donaldson & Crowley,

Nursing’s knowledge base draws from many disciplines. In the past, nursing depended heavily on
physiology, sociology, psychology, and medicine to provide academic standing and to inform practice (Box 1-
1). In recent decades, however, nursing has been seeking what is unique to nursing and developing those
aspects into an academic discipline (Parse, 2015). Areas that identify nursing as a distinct discipline are as

An identifiable philosophy
At least one conceptual framework (perspective) for delineation of what can be defined as nursing
Acceptable methodologic approaches for the pursuit and development of knowledge (Oldnall, 1995)

Box 1-1 Theory and the American Association of Colleges of Nursing Essentials
“The scientific foundation of nursing practice has expanded and includes a focus on both the natural and
social sciences. These sciences that provide a foundation for nursing practice include human biology,
genomics, the psychosocial sciences as well as the science of complex organizational structures” (American
Association of Colleges of Nursing, 2006, p. 9).

To begin the quest to validate nursing as both a profession and an academic discipline, this chapter
provides an overview of the concepts of science and philosophy. It examines the schools of philosophical
thought that have influenced nursing and explores the epistemology of nursing to explain why recognizing the
multiple “ways of knowing” is critical in the quest for development and application of theory in nursing.
Finally, this chapter presents issues related to how philosophical worldviews affect knowledge development
through research. This chapter concludes with a case study that depicts how “the ways of knowing” in nursing
are used on a day-to-day, even moment-by-moment, basis by all practicing nurses.

Introduction to Science and Philosophy
Science is concerned with causality (cause and effect). The scientific approach to understanding reality is
characterized by observation, verifiability, and experience; hypothesis testing and experimentation are
considered scientific methods. In contrast, philosophy is concerned with the purpose of human life, the nature
of being and reality, and the theory and limits of knowledge. Intuition, introspection, and reasoning are
examples of philosophical methodologies. Science and philosophy share the common goal of increasing
knowledge (Fawcett, 2012; Polifroni, 2015; Silva, 1977). The science of any discipline is tied to its
philosophy, which provides the basis for understanding and developing theories for science (Gustafsson,
2002; Morse, 2017; Silva & Rothbart, 1984).

Overview of Science
Science is both a process and a product. Parse (1997) defines science as the “theoretical explanation of the


subject of inquiry and the methodological process of sustaining knowledge in a discipline” (p. 74). Science
has also been described as a way of explaining observed phenomena as well as a system of gathering,
verifying, and systematizing information about reality (Streubert & Carpenter, 2011). As a process, science is
characterized by systematic inquiry that relies heavily on empirical observations of the natural world. As a
product, it has been defined as empirical knowledge that is grounded and tested in experience and is the result
of investigative efforts. Furthermore, science is conceived as being the consensual, informed opinion about
the natural world, including human behavior and social action (Gortner & Schultz, 1988).

Science has come to represent knowledge, and it is generated by activities that combine advancement of
knowledge (research) and explanation for knowledge (theory) (Powers & Knapp, 2011). Citing Van Laer,
Silva (1977) lists six characteristics of science (Box 1-2).

Box 1-2 Characteristics of Science
1. Science must show a certain coherence.
2. Science is concerned with definite fields of knowledge.
3. Science is preferably expressed in universal statements.
4. The statements of science must be true or probably true.
5. The statements of science must be logically ordered.
6. Science must explain its investigations and arguments.

Source: Silva (1977).

Science has been classified in several ways. These include pure or basic science, natural science, human or
social science, and applied or practice science. The classifications are not mutually exclusive and are open to
interpretation based on philosophical orientation. Table 1-1 lists examples of a number of sciences by this
manner of classification.

Table 1-1 Classifications of Science
Classification Examples

Natural sciences Chemistry, physics, biology, physiology, geology, meteorology
Basic or pure sciences Mathematics, logic, chemistry, physics, English (language)
Human or social sciences Psychology, anthropology, sociology, economics, political science,

history, religion
Practice or applied sciences Architecture, engineering, medicine, pharmacology, law

Some sciences defy classification. For example, computer science is arguably applied or perhaps pure.
Law is certainly a practice science, but it is also a social science. Psychology might be a basic science, a
human science, or an applied science, depending on what aspect of psychology one is referring to.

There are significant differences between the human and natural sciences. Human sciences refer to the
fields of psychology, anthropology, and sociology and may even extend to economics and political science.
These disciplines deal with various aspects of humans and human interactions. Natural sciences, on the other
hand, are concentrated on elements found in nature that do not relate to the totality of the individual. There are
inherent differences between the human and natural sciences that make the research techniques of the natural
sciences (e.g., laboratory experimentation) improper or potentially problematic for human sciences (Gortner
& Schultz, 1988).

It has been posited that although nursing draws on the basic and pure sciences (e.g., physiology and
chemistry) and has many characteristics of social sciences, it is without question an applied or practice
science. However, it is important to note that it is also synthesized, in that it draws on the knowledge of other
established disciplines—including other practice disciplines (Dahnke & Dreher, 2016; Holzemer, 2007;
Risjord, 2010).


Overview of Philosophy
Within any discipline, both scholars and students should be aware of the philosophical orientations that are the
basis for developing theory and advancing knowledge (Dahnke & Dreher, 2016; DiBartolo, 1998; Northrup et
al., 2004; Risjord, 2010). Rather than a focus on solving problems or answering questions related to that
discipline (which are tasks of the discipline’s science), the philosophy of a discipline studies the concepts that
structure the thought processes of that discipline with the intent of recognizing and revealing foundations and
presuppositions (Blackburn, 2016).

Philosophy has been defined as “a study of problems that are ultimate, abstract, and general. These
problems are concerned with the nature of existence, knowledge, morality, reason, and human purpose”
(Teichman & Evans, 1999, p. 1). Philosophy tries to discover knowledge and truth and attempts to identify
what is valuable and important.

Modern philosophy is usually traced to Rene Descartes, Francis Bacon, Baruch Spinoza, and Immanuel
Kant (ca. 1600–1800). Descartes (1596–1650) and Spinoza (1632–1677) were early rationalists. Rationalists
believe that reason is superior to experience as a source of knowledge. Rationalists attempt to determine the
nature of the world and reality by deduction and stress the importance of mathematical procedures.

Bacon (1561–1626) was an early empiricist. Like rationalists, he supported experimentation and scientific
methods for solving problems.

The work of Kant (1724–1804) set the foundation for many later developments in philosophy. Kant
believed that knowledge is relative and that the mind plays an active role in knowing. Other philosophers have
also influenced nursing and the advance of nursing science. Several are discussed later in the chapter.

Although there is some variation, traditionally, the branches of philosophy include metaphysics (ontology
and cosmology), epistemology, logic, esthetics, and ethics or axiology. Political philosophy and philosophy of
science are added by some authors (Rutty, 1998; Teichman & Evans, 1999). Table 1-2 summarizes the major
branches of philosophy.

Table 1-2 Branches of Philosophy
Branch Pursuit

Metaphysics Study of the fundamental nature of reality and existence—general
theory of reality

Ontology Study of theory of being (what is or what exists)
Cosmology Study of the physical universe
Epistemology Study of knowledge (ways of knowing, nature of truth, and

relationship between knowledge and belief)
Logic Study of principles and methods of reasoning (inference and argument)
Ethics (axiology) Study of nature of values; right and wrong (moral philosophy)
Esthetics Study of appreciation of the arts or things beautiful
Philosophy of science Study of science and scientific practice
Political philosophy Study of citizen and state

Sources: Blackburn (2016); Teichman and Evans (1999).

Science and Philosophical Schools of Thought
The concept of science as understood in the 21st century is relatively new. In the period of modern science,
three philosophies of science (paradigms or worldviews) dominate: rationalism, empiricism, and human
science/phenomenology. Rationalism and empiricism are often termed received view and human
science/phenomenology and related worldviews (i.e., historicism) are considered perceived view (Hickman,
2011; Meleis, 2012). These two worldviews dominated theoretical discussion in nursing through the 1990s.
More recently, attention has focused on another dominant worldview: “postmodernism” (Meleis, 2012; Reed,


Received View (Empiricism, Positivism, Logical Positivism)
Empiricism has its roots in the writings of Francis Bacon, John Locke, and David Hume, who valued
observation, perception by senses, and experience as sources of knowledge (Gortner & Schultz, 1988; Powers
& Knapp, 2011). Empiricism is founded on the belief that what is experienced is what exists, and its
knowledge base requires that these experiences be verified through scientific methodology (Dahnke & Dreher,
2016; Gustafsson, 2002). This knowledge is then passed on to others in the discipline and subsequently built
on. The term received view or received knowledge denotes that individuals learn by being told or receiving

Empiricism holds that truth corresponds to observable, reduction, verification, control, and bias-free
science. It emphasizes mathematic formulas to explain phenomena and prefers simple dichotomies and
classification of concepts. Additionally, everything can be reduced to a scientific formula with little room for
interpretation (DiBartolo, 1998; Gortner & Schultz, 1988; Risjord, 2010).

Empiricism focuses on understanding the parts of the whole in an attempt to understand the whole. It
strives to explain nature through testing of hypotheses and development of theories. Theories are made to
describe, explain, and predict phenomena in nature and to provide understanding of relationships between
phenomena. Concepts must be operationalized in the form of propositional statements, thereby making
measurement possible. Instrumentation, reliability, and validity are stressed in empirical research
methodologies. Once measurement is determined, it is possible to test theories through experimentation or
observation, which results in verification or falsification (Cull-Wilby & Pepin, 1987; Suppe & Jacox, 1985).

Positivism is often equated with empiricism. Like empiricism, positivism supports mechanistic,
reductionist principles, where the complex can be best understood in terms of its basic components. Logical
positivism was the dominant empirical philosophy of science between the 1880s and 1950s. Logical positivists
recognized only the logical and empirical bases of science and stressed that there is no room for metaphysics,
understanding, or meaning within the realm of science (Polifroni, 2015; Risjord, 2010). Logical positivism
maintained that science is value free, independent of the scientist, and obtained using objective methods. The
goal of science is to explain, predict, and control. Theories are either true or false, subject to empirical
observation, and capable of being reduced to existing scientific theories (Rutty, 1998).

Contemporary Empiricism/Postpositivism
Positivism came under criticism in the 1960s when positivistic logic was deemed faulty (Rutty, 1998). An
overreliance on strictly controlled experimentation in artificial settings produced results that indicated that
much significant knowledge or information was missed. In recent years, scholars have determined that the
positivist view of science is outdated and misleading in that it contributes to overfragmentation in knowledge
and theory development (DiBartolo, 1998). It has been observed that positivistic analysis of theories is
fundamentally defective due to insistence on analyzing the logically ideal, which results in findings that have
little to do with reality. It was maintained that the context of discovery was artificial and that theories and
explanations can be understood only within their discovery contexts (Suppe & Jacox, 1985). Also, scientific
inquiry is inherently value laden, as even choosing what to investigate and/or what techniques to employ will
reflect the values of the researcher.

The current generation of postpositivists accepts the subjective nature of inquiry but still supports rigor
and objective study through quantitative research methods. Indeed, it has been observed that modern
empiricists or postpositivists are concerned with explanation and prediction of complex phenomena,
recognizing contextual variables (Powers & Knapp, 2011; Reed, 2008).

Nursing and Empiricism
As an emerging discipline, nursing has followed established disciplines (e.g., physiology) and the medical
model in stressing logical positivism. Early nurse scientists embraced the importance of objectivity, control,
fact, and measurement of smaller and smaller parts. Based on this influence, acceptable methods for
knowledge generation in nursing have stressed traditional, orthodox, and preferably experimental methods.

Although positivism continues to heavily influence nursing science, that viewpoint has been challenged in
recent years (Risjord, 2010). Consequently, postpositivism has become one of the most accepted
contemporary worldviews in nursing.


Perceived View (Human Science, Phenomenology, Constructivism, Historicism)
In the late 1960s and early 1970s, several philosophers, including Kuhn, Feyerbend, and Toulmin, challenged
the positivist view by arguing that the influence of history on science should be emphasized (Dahnke &
Dreher, 2016). The perceived view of science, which may also be referred to as the interpretive view, includes
phenomenology, constructivism, and historicism. The interpretive view recognizes that the perceptions of
both the subject being studied and the researcher tend to de-emphasize reliance on strict control and
experimentation in laboratory settings (Monti & Tingen, 1999).

The perceived view of science centers on descriptions that are derived from collectively lived experiences,
interrelatedness, human interpretation, and learned reality, as opposed to artificially invented (i.e., laboratory-
based) reality (Rutty, 1998). It is argued that the pursuit of knowledge and truth is naturally historical,
contextual, and value laden. Thus, there is no single truth. Rather, knowledge is deemed true if it withstands
practical tests of utility and reason (DiBartolo, 1998).

Phenomenology is the study of phenomena and emphasizes the appearance of things as opposed to the
things themselves. In phenomenology, understanding is the goal of science, with the objective of recognizing
the connection between one’s experience, values, and perspective. It maintains that each individual’s
experience is unique, and there are many interpretations of reality. Inquiry begins with individuals and their
experiences with phenomena. Perceptions, feelings, values, and the meanings that have come to be attached to
things and events are the focus.

For social scientists, the constructivist approaches of the perceived view focus on understanding the
actions of, and meaning to, individuals. What exists depends on what individuals perceive to exist.
Knowledge is subjective and created by individuals. Thus, research methodology entails the investigation of
the individual’s world. There is an emphasis on subjectivity, multiple truths, trends and patterns, discovery,
description, and understanding.

Feminism and critical social theory may also be considered to be perceived view. These philosophical
schools of thought recognize the influence of gender, culture, society, and shared history as being essential
components of science (Riegel et al., 1992). Critical social theorists contend that reality is dynamic and
shaped by social, political, cultural, economic, ethnic, and gender values (Streubert & Carpenter, 2011).
Critical social theory and feminist theories will be described in more detail in Chapter 13.

Nursing and Phenomenology/Constructivism/Historicism
Because they examine phenomena within context, phenomenology, as well as other perceived views of
philosophy, are conducive to discovery and knowledge development inherent to nursing. Phenomenology is
open, variable, and relativistic and based on human experience and personal interpretations. As such, it is an
important, guiding paradigm for nursing practice theory and education (DiBartolo, 1998).

In nursing science, the dichotomy of philosophic thought between the received, empirical view of science
and the perceived, interpretative view of science has persisted. This may have resulted, in part, because
nursing draws heavily both from natural sciences (physiology, biology) and social sciences (psychology,

Postmodernism (Poststructuralism, Postcolonialism)
Postmodernism began in Europe in the 1960s as a social movement centered on a philosophy that rejects the
notion of a single “truth.” Although it recognizes the value of science and scientific methods, postmodernism
allows for multiple meanings of reality and multiple ways of knowing and interpreting reality (Hood, 2014;
Reed, 1995). In postmodernism, knowledge is viewed as uncertain, contextual, and relative. Knowledge
development moves from emphasis on identifying a truth or fact in research to discovering practical
significance and relevance of research findings (Reed, 1995).

Similar or related constructs and worldviews found in the nursing literature include “deconstruction,”
“postcolonialism,” and, at times, feminist philosophies. In nursing, the postcolonial worldview can be
connected to both feminism and critical theory, particularly when considering nursing’s historical reliance on
medicine (Holmes, Roy, & Perron, 2008; McGibbon, Mulaudzi, Didham, Barton, & Sochan, 2014; Racine,

Postmodernism has loosened the notions of what counts as knowledge development that have persisted


among supporters of qualitative and quantitative research methods. Rather than focusing on a single research
methodology, postmodernism promotes use of multiple methods for development of scientific understanding
and incorporation of different ways to improve understanding of human nature (Hood, 2014; Meleis, 2012;
Rodgers, 2015). Increasingly, in postmodernism, there is a consensus that synthesis of both research methods
can be used at different times to serve different purposes (Hood, 2014; Meleis, 2012; Risjord, Dunbar, &
Moloney, 2002).

Criticisms of postmodernism have been made and frequently relate to the perceived reluctance to address
error in research. Taken to the extreme as Paley (2005) pointed out, when there is absence of strict control
over methodology and interpretation of research, “Nobody can ever be wrong about anything” (p. 107). Chinn
and Kramer (2015) echoed the concerns by acknowledging that knowledge development should never be
“sloppy.” Indeed, although application of various methods in research is legitimate and may be advantageous,
research must still be carried out carefully and rigorously.

Nursing and Postmodernism
Postmodernism has been described as a dominant scientific theoretical paradigm in nursing in the late 20th
century (Meleis, 2012). As the discipline matures, there has been recognition of the pluralistic nature of
nursing and an enhanced understanding that the goal of research is to provide an integrative basis for nursing
care (Walker & Avant, 2011).

In terms of scientific methodology, the attention is increasingly on combining multiple methods within a
single research project (Chinn & Kramer, 2015). Postmodernism has helped dislodged the authority of a
single research paradigm in nursing science by emphasizing the blending or integration of qualitative and
quantitative research into a holistic, dynamic model to improve nursing practice. Table 1-3 compares the
dominant philosophical views of science in nursing.

Table 1-3 Comparison of the Received, Perceived, and Postmodern Views of Science

Received View of Science—
Hard Sciences

Perceived View of Science—Soft

Poststructuralism, and


Historicism/phenomenology Macroanalysis

Reality/truth/facts considered
acontextual (objective)

Reality/truth/facts considered in
context (subjective)

Contextual meaning; narration

Deductive Inductive Contextual, political, and
structural analysis

Reality/truth/facts considered

Reality/truth/facts considered with
regard to history

Reality/truth/facts considered with
regard to history

Prediction and control Description and understanding Metanarrative analysis
One truth Multiple truths Different views
Validation and replication Trends and patterns Uncovering opposing views
Reductionism Constructivism/holism Macrorelationship;

Quantitative research Qualitative research methods Methodologic pluralism methods

Sources: Meleis (2012); Moody (1990).

Nursing Philosophy, Nursing Science, and Philosophy of Science in
The terms nursing philosophy, nursing science, and philosophy of science in nursing are sometimes used
interchangeably. The differences, however, in the general meaning of these concepts are important to



Nursing Philosophy
Nursing philosophy has been described as “a statement of foundational and universal assumptions, beliefs and
principles about the nature of knowledge and thought (epistemology) and about the nature of the entities
represented in the metaparadigm (i.e., nursing practice and human health processes [ontology])” (Reed, 1995,
p. 76). Nursing philosophy, then, refers to the belief system or worldview of the profession and provides
perspectives for practice, scholarship, and research.

No single dominant philosophy has prevailed in the discipline of nursing. Many nursing scholars and
nursing theorists have written extensively in an attempt to identify the overriding belief system, but to date,
none has been universally successful. Most would agree then that nursing is increasingly recognized as a
“multiparadigm discipline” (Powers & Knapp, 2011, p. 129), in which using multiple perspectives or
worldviews in a “unified” way is valuable and even necessary for knowledge development (Giuliano, Tyer-
Viola, & Lopez, 2005).

Nursing Science
Parse (2016) defined nursing science as “the substantive, discipline-specific knowledge that focuses on the
human-universe-health process articulated in the nursing frameworks and theories” (p. 101). To develop and
apply the discipline-specific knowledge, nursing science recognizes the relationships of human responses in
health and illness and addresses biologic, behavioral, social, and cultural domains. The goal of nursing science
is to represent the nature of nursing—to understand it, to explain it, and to use it for the benefit of humankind.
It is nursing science that gives direction to the future generation of substantive nursing knowledge, and it is
nursing science that provides the knowledge for all aspects of nursing (Holzemer, 2007; Parse, 2016).

Philosophy of Science in Nursing
Philosophy of science in nursing helps to establish the meaning of science through an understanding and
examination of nursing concepts, theories, laws, and aims as they relate to nursing practice. It seeks to
understand truth; to describe nursing; to examine prediction and causality; to critically relate theories, models,
and scientific systems; and to explore determinism and free will (Nyatanga, 2005; Polifroni, 2015).

Knowledge Development and Nursing Science
Development of nursing knowledge reflects the interface between nursing science and research. The ultimate
purpose of knowledge development is to improve nursing practice. Approaches to knowledge development
have three facets: ontology, epistemology, and methodology. Ontology refers to the study of being: what is or
what exists. Epistemology refers to the study of knowledge or ways of knowing. Methodology is the means of
acquiring knowledge (Powers & Knapp, 2011). The following sections discuss nursing epistemology and
issues related to methods of acquiring knowledge.

Epistemology is the study of the theory of knowledge. Epistemologic questions include: What do we know?
What is the extent of our knowledge? How do we decide whether we know? and What are the criteria of
knowledge? (Schultz & Meleis, 1988).

According to Streubert and Carpenter (2011), it is important to understand the way in which nursing
knowledge develops to provide a context in which to judge the appropriateness of nursing knowledge and
methods that nurses use to develop that knowledge. This in turn will refocus methods for gaining knowledge
as well as establishing the legitimacy or quality of the knowledge gained.

Ways of Knowing
In epistemology, there are several basic types of knowledge. These include the following:

Empirics—the scientific form of knowing. Empirical knowledge comes from observation, testing, and


Personal knowledge—a priori knowledge. Personal knowledge pertains to knowledge gained from

thought alone.
Intuitive knowledge—includes feelings and hunches. Intuitive knowledge is not guessing but relies on

nonconscious pattern recognition and experience.
Somatic knowledge—knowledge of the body in relation to physical movement. Somatic knowledge

includes experiential use of muscles and balance to perform a physical task.
Metaphysical (spiritual) knowledge—seeking the presence of a higher power. Aspects of spiritual

knowing include magic, miracles, psychokinesis, extrasensory perception, and near-death experiences.
Esthetics—knowledge related to beauty, harmony, and expression. Esthetic knowledge incorporates art,

creativity, and values.
Moral or ethical knowledge—knowledge of what is right and wrong. Values and social and cultural

norms of behavior are components of ethical knowledge.

Nursing Epistemology
Nursing epistemology has been defined as “the study of the origins of nursing knowledge, its structure and
methods, the patterns of knowing of its members, and the criteria for validating its knowledge claims”
(Schultz & Meleis, 1988, p. 217). Like most disciplines, nursing has both scientific knowledge and knowledge
that can be termed conventional wisdom (knowledge that has not been empirically tested).

Traditionally, only what stands the test of repeated measures constitutes truth or knowledge. Classical
scientific processes (i.e., experimentation), however, are not suitable for creating and describing all types of
knowledge. Social sciences, behavioral sciences, and the arts rely on other methods to establish knowledge.
Because it has characteristics of social and behavioral sciences, as well as biologic sciences, nursing must rely
on multiple ways of knowing.

In a classic work, Carper (1978) identified four fundamental patterns for nursing knowledge: (1) empirics
—the science of nursing, (2) esthetics—the art of nursing, (3) personal knowledge in nursing, and (4) ethics—
moral knowledge in nursing.

Empirical knowledge is objective, abstract, generally quantifiable, exemplary, discursively formulated,
and verifiable. When verified through repeated testing over time, it is formulated into scientific
generalizations, laws, theories, and principles that explain and predict (Carper, 1978, 1992). It draws on
traditional ideas that can be verified through observation and proved by hypothesis testing.

Empirical knowledge tends to be the most emphasized way of knowing in nursing because there is a need
to know how knowledge can be organized into laws and theories for the purpose of describing, explaining,
and predicting phenomena of concern to nurses. Most theory development and research efforts are engaged in
seeking and generating explanations that are systematic and controllable by factual evidence (Carper, 1978,

Esthetic knowledge is expressive, subjective, unique, and experiential rather than formal or descriptive.
Esthetics includes sensing the meaning of a moment. It is evident through actions, conduct, attitudes, and
interactions of the nurse in response to another. It is not expressed in language (Carper, 1978).

Esthetic knowledge relies on perception. It is creative and incorporates empathy and understanding. It is
interpretive, contextual, intuitive, and subjective and requires synthesis rather than analysis. Furthermore,
esthetics goes beyond what is explained by principles and creates values and meaning to account for variables
that cannot be quantitatively formulated (Carper, 1978, 1992).

Personal knowledge refers to the way in which nurses view themselves and the client. Personal knowledge
is subjective and promotes wholeness and integrity in personal encounters. Engagement, rather than
detachment, is a component of personal knowledge.

Personal knowledge incorporates experience, knowing, encountering, and actualizing the self within the
practice. Personal maturity and freedom are components of personal knowledge, which may include spiritual
and metaphysical forms of knowing. Because personal knowledge is difficult to express linguistically, it is
largely expressed in personality (Carper, 1978, 1992).

Ethics refers to the moral code for nursing and is based on obligation to service and respect for human life.
Ethical knowledge occurs as moral dilemmas arise in situations of ambiguity and uncertainty and when


consequences are difficult to predict. Ethical knowledge requires rational and deliberate examination and
evaluation of what is good, valuable, and desirable as goals, motives, or characteristics (Carper, 1978, 1992).
Ethics must address conflicting norms, interests, and principles and provide insight into areas that cannot be

Fawcett, Watson, Neuman, Walkers, and Fitzpatrick (2001) stress that integration of all patterns of
knowing is essential for professional nursing practice and that no one pattern should be used in isolation from
others. Indeed, they are interrelated and interdependent because there are multiple points of contact between
and among them (Carper, 1992). Thus, nurses should view nursing practice from a broadened perspective that
places value on ways of knowing beyond the empirical (Silva, Sorrell, & Sorrell, 1995). Table 1-4
summarizes selected characteristics of Carper’s patterns of knowing in nursing.

Table 1-4 Characteristics of Carper’s Patterns of Knowing in Nursing
Pattern of

to Nursing

Source or

Source of

Method of

Purpose or

Empirics Science of nursing Direct or indirect
observation and

Replication Facts, models,
scientific principles,
laws statements,


Esthetics Art of nursing Creation of value
and meaning,
synthesis of abstract
and concrete

perception of
balance, rhythm,
proportion, and

empathy; esthetic
criticism; engaging,
intuiting, and

Move beyond what
can be explained,

Personal knowledge Therapeutic use of

opening, centering,
actualizing self


Empathy, active

Promote wholeness
and integrity in
personal encounters

Ethics Moral component of

Values clarification,
rational and
deliberate reasoning,


Principles, codes,
ethical theories

Evaluation of what
is good, valuable,
and desirable

Sources: Carper (1978, 1992); Chinn and Kramer (2015).

Other Views of Patterns of Knowledge in Nursing
Although Carper’s work is considered classic, it is not without critics. Schultz and Meleis (1988) observed
that Carper’s work did not incorporate practical knowledge into the ways of knowing in nursing. Because of
this and other concerns, they described three patterns of knowledge in nursing: clinical, conceptual, and

Clinical knowledge refers to the individual nurse’s personal knowledge. It results from using multiple
ways of knowing while solving problems during client care provision. Clinical knowledge is manifested in the
acts of practicing nurses and results from combining personal knowledge and empirical knowledge. It may
also involve intuitive and subjective knowing. Clinical knowledge is communicated retrospectively through
publication in journals (Schultz & Meleis, 1988).

Conceptual knowledge is abstracted and generalized beyond personal experience. It explicates patterns
revealed in multiple client experiences, which occur in multiple situations, and articulates them as models or
theories. In conceptual knowledge, concepts are drafted and relational statements are formulated.
Propositional statements are supported by empirical or anecdotal evidence or defended by logical reasoning.

Conceptual knowledge uses knowledge from nursing and other disciplines. It incorporates curiosity,
imagination, persistence, and commitment in the accumulation of facts and reliable generalizations that
pertain to the discipline of nursing. Conceptual knowledge is communicated in propositional statements
(Schultz & Meleis, 1988).

Empirical knowledge results from experimental, historical, or phenomenologic research and is used to
justify actions and procedures in practice. The credibility of empirical knowledge rests on the degree to which


the researcher has followed procedures accepted by the community of researchers and on the logical, unbiased
derivation of conclusions from the evidence. Empirical knowledge is evaluated through systematic review and
critique of published research and conference presentations (Schultz & Meleis, 1988).

Chinn and Kramer (2015) also expanded on Carper’s patterns of knowing to include “emancipatory
knowing”—what they designate as the “praxis of nursing.” In their view, emancipatory knowing refers to
human’s ability to critically examine the current status quo and to determine why it currently exists. This, in
turn, supports identification of inequities in social and political institutions and clarification of cultural values
and beliefs to improve conditions for all. In this view, emancipatory knowledge is expressed in actions that
are directed toward changing existing social structures and establishing practices that are more equitable and
favorable to human health and well-being.

Summary of Ways of Knowing in Nursing
For decades, the importance of the multiple ways of knowing has been recognized in the discipline of nursing.
If nursing is to achieve a true integration between theory, research, and practice, theory development and
research must integrate different sources of knowledge. Kidd and Morrison (1988) state that in nursing,
synthesis of theories derived from different sources of knowledge will:

1. Encourage the use of different types of knowledge in practice, education, theory development, and

2. Encourage the use of different methodologies in practice and research.
3. Make nursing education more relevant for nurses with different educational backgrounds.
4. Accommodate nurses at different levels of clinical competence.
5. Ultimately promote high-quality client care and client satisfaction.

Research Methodology and Nursing Science
Being heavily influenced by logical empiricism, as nursing began developing as a scientific discipline in the
mid-1900s, quantitative methods were used almost exclusively in research. In the 1960s and 1970s, schools of
nursing aligned nursing inquiry with scientific inquiry in a desire to bring respect to the academic
environment, and nurse researchers and nurse educators valued quantitative research methods over other

A debate over methodology began in the 1980s, however, when some nurse scholars asserted that
nursing’s ontology (what nursing is) was not being adequately and sufficiently explored using quantitative
methods in isolation. Subsequently, qualitative research methods began to be put into use. The assumptions
were that qualitative methods showed the phenomena of nursing in ways that were naturalistic and
unstructured and not misrepresented (Holzemer, 2007; Rutty, 1998).

The manner in which nursing science is conceptualized determines the priorities for nursing research and
provides measures for determining the relevance of various scientific research questions. Therefore, the way
in which nursing science is conceptualized also has implications for nursing practice. The philosophical issues
regarding methods of research relate back to the debate over the worldviews of received versus perceived
views of science versus postmodernism and whether nursing is a practice or applied science, a human science,
or some combination. The notion of evidence-based practice has emerged over the last few years, largely in
response to these and related concerns. Evidence-based practice as it relates to the theoretical basis of nursing
will be examined in Chapter 13.

Nursing as a Practice Science
In early years, the debate focused on whether nursing was a basic science or an applied science. The goal of
basic science is the attainment of knowledge. In basic research, the investigator is interested in understanding
the problem and produces knowledge for knowledge’s sake. It is analytical and the ultimate function is to
analyze a conclusion backward to its proper principles.

Conversely, an applied science is one that uses the knowledge of basic sciences for some practical end.
Engineering, architecture, and pharmacology are examples. In applied research, the investigator works toward
solving problems and producing solutions for the problem. In practice sciences, research is largely clinical and


action oriented (Moody, 1990). Thus, as an applied or practical science, nursing requires research that is
applied and clinical and that generates and tests theories related to health of human beings within their
environments as well as the actions and processes used by nurses in practice.

Nursing as a Human Science
The term human science is traced to philosopher Wilhelm Dilthey (1833–1911). Dilthey proposed that the
human sciences require concepts, methods, and theories that are fundamentally different from those of the
natural sciences. Human sciences study human life by valuing the lived experience of persons and seek to
understand life in its matrix of patterns of meaning and values. Some scholars believe that there is a need to
approach human sciences differently from conventional empiricism and contend that human experience must
be understood in context (Cody & Mitchell, 2002; Polifroni, 2015).

In human sciences, scientists hope to create new knowledge to provide understanding and interpretation of
phenomena. In human sciences, knowledge takes the form of descriptive theories regarding the structures,
processes, relationships, and traditions that underlie psychological, social, and cultural aspects of reality. Data
are interpreted within context to derive meaning and understanding. Humanistic scientists value the subjective
component of knowledge. They recognize that humans are not capable of total objectivity and embrace the
idea of subjectivity (Streubert & Carpenter, 2011). The purpose of research in human science is to produce
descriptions and interpretations to help understand the nature of human experience.

Nursing is sometimes referred to as a human science (Cody & Mitchell, 2002; Polifroni, 2015). Indeed,
the discipline has examined issues related to behavior and culture, as well as biology and physiology, and
sought to recognize associations among factors that suggest explanatory variables for human health and
illness. Thus, it fits the pattern of other humanistic sciences (i.e., anthropology, sociology).

Quantitative Versus Qualitative Methodology Debate
Nursing scholars accept the premise that scientific knowledge is generated from systematic study. The
research methodologies and criteria used to justify the acceptance of statements or conclusions as true within
the discipline result in conclusions and statements that are appropriate, valid, and reliable for the purpose of
the discipline.

The two dominant forms of scientific inquiry have been identified in nursing: (1) empiricism, which
objectifies and attempts to quantify experience and may test propositions or hypotheses in controlled
experimentation, and (2) phenomenology and other forms of qualitative research (i.e., grounded theory,
hermeneutics, historical research, ethnography), which study lived experiences and meanings of events
(Gortner & Schultz, 1988; Morse, 2017; Risjord, 2010). Reviews of the scientific status of nursing knowledge
usually contrast the positivist–deductive–quantitative approach with the interpretive–inductive–qualitative

Although nursing theorists and nursing scientists emphasize the importance of sociohistorical contexts and
person–environment interactions, they tend to focus on “hard science” and the research process. It has been
argued that there is an overvaluation of the empirical/quantitative view because it is seen as “true science”
(Tinkle & Beaton, 1983). Indeed, the experimental method is held in the highest regard. A viewpoint has
persisted into the 21st century in which scholars assume that descriptive or qualitative research should be
performed only where there is little information available or when the science is young. Correlational research
may follow and then experimental methods can be used when the two lower (“less rigid” or “less scientific”)
levels have been explored.

Quantitative Methods
Traditionally, within the “received” or positivistic worldview, science has been uniquely quantitative. The
quantitative approach has been justified by its success in measuring, analyzing, replicating, and applying the
knowledge gained (Streubert & Carpenter, 2011). According to Wolfer (1993), science should incorporate
methodologic principles of objective observation/description, accurate measurement, quantification of
variables, mathematical and statistical analysis, experimental methods, and verification through replication
whenever possible.

Kidd and Morrison (1988) state that in their haste to prove the credibility of nursing as a profession,


nursing scholars have emphasized reductionism and empirical validation through quantitative methodologies,
emphasizing hypothesis testing. In this framework, the scientist develops a hypothesis about a phenomenon
and seeks to prove or disprove it.

Qualitative Methods
The tradition of using qualitative methods to study human phenomena is grounded in the social sciences.
Phenomenology and other methods of qualitative research arose because aspects of human values, culture, and
relationships were unable to be described fully using quantitative research methods. It is generally accepted
that qualitative research findings answer questions centered on social experience and give meaning to human
life. Beginning in the 1970s, nursing scientists were challenged to explain phenomena that defy quantitative
measurement, and qualitative approaches, which emphasize the importance of the client’s perspective, began
to be used in nursing research (Kidd & Morrison, 1988).

Repeatedly, scholars state that nursing research should incorporate means for determining interpretation of
the phenomena of concern from the perspective of the client or care recipient. Contrary to the assertions of
early scientists, many later nurse scientists believe that qualitative inquiry contains features of good science
including theory and observation, logic, precision, clarity, and reproducibility (Monti & Tingen, 1999).

Methodologic Pluralism
In many respects, nursing is still undecided about which methodologic approach (qualitative or quantitative)
best demonstrates the essence and uniqueness of nursing because both methods have strengths and limitations.
Beck and Harrison (2016), Risjord (2010), and Wood and Haber (2018), among others, believe that the two
approaches may be considered complementary and appropriate for nursing as a research-based discipline.
Indeed, it is repeatedly argued that both approaches are equally important and even essential for nursing
science development.

Although basic philosophical viewpoints have guided and directed research strategies in the past, recently,
scholars have called for theoretical and methodologic pluralism in nursing philosophy and nursing science as
presented in the discussion on postmodernism. Pluralism of research designs is essential for reflecting the
uniqueness of nursing, and multiple approaches to theory development and testing should be encouraged.
Because there is no one best method of developing knowledge, it is important to recognize that valuing one
standard as exclusive or superior restricts the ability to progress.

Nursing is an evolving profession, an academic discipline, and a science. As nursing progresses and grows as
a profession, some controversy remains on whether to emphasize a humanistic, holistic focus or an objective,
scientifically derived means of comprehending reality. What is needed, and is increasingly more evident as
nursing matures as a profession, is an open philosophy that ties empirical concepts that are capable of being
validated through the senses with theoretical concepts of meaning and value.

It is important that future nursing leaders and novice nurse scientists possess an understanding of nursing’s
philosophical foundations. The legacy of philosophical positivism continues to drive beliefs in the scientific
method and research strategies, but it is time to move forward to face the challenges of the increasingly
complex and volatile health care environment.

Key Points
Nursing can be considered an aspiring or evolving profession.
Nursing is a professional discipline that draws much of its knowledge base from other disciplines, including

psychology, sociology, physiology, and medicine.
Nursing is an applied or practice science that has been influenced by several philosophical schools of

thought or worldviews, including the received view (empiricism, positivism, logical positivism), the
perceived view (humanism, phenomenology, constructivism), and postmodernism.

Nursing philosophy refers to the worldview(s) of the profession and provides perspective for practice,
scholarship, and research. Nursing science is the discipline-specific knowledge that focuses on the human–


environment–health process and is articulated in nursing theories and generated through nursing research.
Philosophy of science in nursing establishes the meaning of science through examination of nursing
concepts, theories, and laws as they relate to nursing practice.

Nursing epistemology (ways of knowing in nursing) has focused on four predominant or “fundamental”
ways of knowledge: empirical knowledge, esthetic knowledge, personal knowledge, and ethical

As nursing science has developed, there has been a debate over what research methods to use (i.e.,
quantitative methods vs. qualitative methods). Increasingly, there has been a call for “methodologic
pluralism” to better ensure that research findings are applicable in nursing practice.

Case Study
The following is adapted from a paper written by a graduate student describing an encounter in nursing
practice that highlights Carper’s (1978) ways of knowing in nursing.

In her work, Carper (1978) identified four patterns of knowing in nursing: empirical knowledge (science
of nursing), esthetic knowledge (art of nursing), personal knowledge, and ethical knowledge. Each is essential
and depends on the others to make the whole of nursing practice, and it is impossible to state which of the
patterns of knowing is most important. If nurses focus exclusively on empirical knowledge, for example,
nursing care would become more like medical care. But without an empirical base, the art of nursing is just
tradition. Personal knowledge is gained from experience and requires a scientific basis, understanding, and
empathy. Finally, the moral component is necessary to determine what is valuable, ethical, and compulsory.
Each of these ways of knowing is illustrated in the following scenario.

Mrs. Smith was a 24-year-old primigravida who presented to our unit in early labor. Her husband, and
father of her unborn child, had abandoned her 2 months prior to delivery, and she lacked close family

I cared for Mrs. Smith throughout her labor and assisted during her delivery. During this process, I
taught breathing techniques to ease pain and improve coping. Position changes were encouraged
periodically, and assistance was provided as needed. Mrs. Smith’s care included continuous fetal monitoring,
intravenous hydration, analgesic administration, back rubs, coaching and encouragement, assistance while
getting an epidural, straight catheterization as needed, vital sign monitoring per policy, oxytocin
administration after delivery, newborn care, and breastfeeding assistance, among many others. All care was
explained in detail prior to rendering.

Empirical knowledge was clearly utilized in Mrs. Smith’s care. Examples would be those practices based
on the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based
standards. These include guidelines for fetal heart rate monitoring and interpretation, assessment and
management of Mrs. Smith while receiving her epidural analgesia, the assessment and management of side
effects secondary to her regional analgesia, and even frequency for monitoring vital signs. Other examples
would be assisting Mrs. Smith to an upright position during her second stage of labor to facilitate delivery
and delaying nondirected pushing once she was completely dilated.

Esthetic knowledge, or the art of nursing, is displayed in obstetrical nursing daily. Rather than just
responding to biologic developments or spoken requests, the whole person was valued and cues were
perceived and responded to for the good of the patient. The care I gave Mrs. Smith was holistic; her social,
spiritual, psychological, and physical needs were all addressed in a comprehensive and seamless fashion. The
empathy conveyed to the patient took into account her unique self and situation, and the care provided was
reflexively tailored to her needs. I recognized the profound experience of which I was a part and adapted my
actions and attitude to honor the patient and value the larger experience.

Many aspects of personal knowledge seem intertwined with esthetics, though more emphasis seems to be
on the meaningful interaction between the patient and nurse. As above, the patient was cared for as a unique
individual. Though secondary to the awesome nature of birth, much of the experience revolved around the
powerful interpersonal relationship established. Mrs. Smith was accepted as herself. Though efforts were
made by me to manage certain aspects of the experience, Mrs. Smith was allowed control and freedom of
expression and reaction. She and I were both committed to the mutual though brief relationship. This
knowledge stems from my own personality and ability to accept others, willingness to connect to others, and


desire to collaborate with the patient regarding her care and ultimate experience.
The ethical knowledge of nursing is continuously utilized in nursing care to promote the health and well-

being of the patient; and in this circumstance, the unborn child as well. Every decision made must be weighed
against desired goals and values, and nurses must strive to act as advocates for each patient. When caring for
a patient and an unborn child, there is a constant attempt to do no harm to either, while balancing the care of
both. A very common example is the administration of medications for the mother’s comfort that can cause
sedation and respiratory depression in the neonate. This case involved fewer ethical considerations than
many others in obstetrics. These include instances in which physicians do not respond when the nurse feels
there is imminent danger and the chain of command must be utilized, or when assistance is required for the
care of abortion patients or in other situations that may be in conflict with the nurses moral or religious

A close bond was formed while I cared for Mrs. Smith and her baby. Soon after admission, she was
holding my hand during contractions and had shared very intimate details of her life, separation, and fears.
Though she had shared her financial concerns and had a new baby to provide for, a few weeks after her
delivery I received a beautiful gift basket and card. In her note she shared that I had touched her in a way she
had never expected and she vowed never to forget me; I’ve not forgotten her either.

Contributed by Shelli Carter, RN, MSN

Learning Activities
1. Reflect on the previous case study. Think of a situation from personal practice in which

multiple ways of knowing were used. Write down the anecdote and share it with classmates.
2. With classmates, discuss whether nursing is a profession or an occupation. What can current

and future nurses do to enhance nursing’s standing as a profession?
3. Debate with classmates the dominant philosophical schools of thought in nursing (received

view, perceived view, postmodernism). Which worldview best encompasses the profession of
nursing? Why?

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Carper, B. A. (1978). Fundamental patterns of knowing in nursing. ANS. Advances in Nursing Science, 1(1), 13–23.
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Overview of Theory in Nursing
Melanie McEwen

Matt Ng has been an emergency room nurse for almost 6 years and recently decided to enroll in a master’s
degree program to become an acute care nurse practitioner. As he read over the degree requirements, Matt
was somewhat bewildered. One of the first courses in his program was entitled Application of Theory in
Nursing. He was interested in the courses in advanced pharmacology, advanced physical assessment, and
pathophysiology and was excited about the advanced practice clinical courses, but a course that focused on
nursing theory did not appear congruent with his goals.

Looking over the syllabus for the theory application course did little to reassure Matt, but he was
determined to make the best of the situation and went to the first class with an open mind. The first few class
periods were increasingly interesting as the students and instructor discussed the historical evolution of the
discipline of nursing and the stages of nursing theory development. As the course progressed, the topics
became more relevant to Matt. He learned ways to analyze and evaluate theories, examined a number of
different types of theories used by nurses, and completed several assignments, including a concept analysis, an
analysis of a middle range nursing theory, and a synthesis paper that examined the use of non-nursing theories
in nursing research.

By the end of the semester, Matt was able to recognize the importance of the study of theory. He
understood how theoretical principles and concepts affected his current practice and how they would be
essential to consider as he continued his studies to become an advanced practice nurse.

When asked about theory, many nurses and nursing students, and often even nursing faculty, will respond
with a furrowed brow, a pained expression, and a resounding “ugh.” When questioned about their negative
response, most will admit that the idea of studying theory is confusing, that they see no practical value, and
that theory is, in essence, too theoretical.

Likewise, some nursing scholars believe that nursing theory is practically nonexistent, whereas others
recognize that many practitioners have not heard of nursing theory. Some nurses lament that nurse researchers
use theories and frameworks from other disciplines, whereas others believe the notion of nursing theory is
outdated and ask why they should bother with theory. Questions and debates about “theory” in nursing
abound in the nursing literature.

Myra Levine, one of the pioneer nursing theorists, wrote that “the introduction of the idea of theory in
nursing was sadly inept” (Levine, 1995, p. 11). She stated,

In traditional nursing fashion, early efforts were directed at creating a procedure—a recipe book for
prospective theorists—which then could be used to decide what was and was not a theory. And there
was always the thread of expectation that the great, grand, global theory would appear and end all
speculation. Most of the early theorists really believed they were achieving that.

Levine (1995) went on to explain that every new theory posited new central concepts, definitions,
relational statements, and goals for nursing and then attracted a chorus of critics. This resulted in nurses
finding themselves confused about the substance and intention of the theories. Indeed, “In early days, theory
was expected to be obscure. If it was clearly understandable, it wasn’t considered a very good theory”


(Levine, 1995, p. 11).
The drive to develop nursing theory has been marked by nursing theory conferences, the proliferation of

theoretical and conceptual frameworks for nursing, and the formal teaching of theory development in graduate
nursing education. It has resulted in the development of many systems, techniques or processes for theory
analysis and evaluation, a fascination with the philosophy of science, and confusion about theory development
strategies and division of choice of research methodologies.

There is debate over the types of theories that should be used by nurses. Should they be only nursing
theories or can nurses use theories “borrowed” from other disciplines? There is debate over terminology such
as conceptual framework, conceptual model, and theory. There have been heated discussions concerning the
appropriate level of theory for nurses to develop as well as how, why, where, and when to test, measure,
analyze, and evaluate these theories/models/conceptual frameworks. The question has been repeatedly asked:
Should nurses adopt a single theory, or do multiple theories serve them best? It is no wonder, then, that
nursing students display consternation, bewilderment, and even anxiety when presented with the prospect of
studying theory. One premise, however, can be agreed upon: To be useful, a theory must be meaningful and
relevant, but above all, it must be understandable. This chapter discusses many of the issues described
previously. It presents the rationale for studying and using theory in nursing practice, research,
management/administration, and education; gives definitions of key terms; provides an overview of the
history of development of theory utilization in nursing; describes the scope of theory and levels of theory;
and, finally, introduces the widely accepted nursing metaparadigm.

Overview of Theory
Most scholars agree that it is the unique theories and perspectives used by a discipline that distinguish it from
other disciplines. The theories used by members of a profession clarify basic assumptions and values shared
by its members and define the nature, outcome, and purpose of practice (Alligood, 2014a; Fawcett, 2012;
Rutty, 1998).

Definitions of the term theory abound in the nursing literature. At a basic level, theory has been described
as a systematic explanation of an event in which constructs and concepts are identified and relationships are
proposed and predictions made (Streubert & Carpenter, 2011). Theory has also been defined as a “creative
and rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenomena”
(Chinn & Kramer, 2015, p. 255). Finally, theory has been called a set of interpretative assumptions,
principles, or propositions that help explain or guide action (Young, Taylor, & Renpenning, 2001).

In their classic work, Dickoff and James (1968) state that theory is invented rather than found in or
discovered from reality. Furthermore, theories vary according to the number of elements, the characteristics
and complexity of the elements, and the kind of relationships between or among the elements.

The Importance of Theory in Nursing
Before the advent of development of nursing theories, nursing was largely subsumed under medicine. Nursing
practice was generally prescribed by others and highlighted by traditional, ritualistic tasks with little regard to
rationale. The initial work of nursing theorists was aimed at clarifying the complex intellectual and
interactional domains that distinguish expert nursing practice from the mere doing of tasks (Omrey, Kasper, &
Page, 1995). It was believed that conceptual models and theories could create mechanisms by which nurses
would communicate their professional convictions, provide a moral/ethical structure to guide actions, and
foster a means of systematic thinking about nursing and its practice (Chinn & Kramer, 2015; Peterson, 2017;
Sitzman & Eichelberger, 2011; Ziegler, 2005). The idea that a single, unified model of nursing—a worldview
of the discipline—might emerge was encouraged by some (Levine, 1995; Tierney, 1998).

It is widely believed that use of theory offers structure and organization to nursing knowledge and
provides a systematic means of collecting data to describe, explain, and predict nursing practice. Use of theory
also promotes rational and systematic practice by challenging and validating intuition. Theories make nursing
practice more overtly purposeful by stating not only the focus of practice but also specific goals and
outcomes. Theories define and clarify nursing and the purpose of nursing practice to distinguish it from other
caring professions by setting professional boundaries. Finally, use of a theory in nursing leads to coordinated


and less fragmented care (Alligood, 2014a; Chinn & Kramer, 2015; Ziegler, 2005).
Ways in which theories and conceptual models developed by nurses have influenced nursing practice are

described by Fawcett (1992), who stated that in nursing they:

Identify certain standards for nursing practice.
Identify settings in which nursing practice should occur and the characteristics of what the model’s

author considers recipients of nursing care.
Identify distinctive nursing processes and technologies to be used, including parameters for client

assessment, labels for client problems, a strategy for planning, a typology of intervention, and criteria
for evaluation of intervention outcomes.

Direct the delivery of nursing services.
Serve as the basis for clinical information systems, including the admission database, nursing orders,

care plan, progress notes, and discharge summary.
Guide the development of client classification systems.
Direct quality assurance programs.

Terminology of Theory
In nursing, conceptual models or frameworks detail a network of concepts and describe their relationships,
thereby explaining broad nursing phenomena. Theories, according to Young and colleagues (2001), are the
narrative that accompanies the conceptual model. These theories typically provide a detailed description of all
of the components of the model and outline relationships in the form of propositions. Critical components of
the theory or narrative include definitions of the central concepts or constructs; propositions or relational
statements; the assumptions on which the framework is based; and the purpose, indications for use, or
application. Many conceptual frameworks and theories will also include a schematic drawing or model
depicting the overall structure of or interactivity of the components (Chinn & Kramer, 2015).

Some terms may be new to students of theory and others need clarification. Table 2-1 lists definitions for a
number of terms that are frequently encountered in writings on theory. Many of these terms will be described
in more detail later in the chapter and in subsequent chapters.

Table 2-1 Definitions and Characteristics of Theory Terms and Concepts
Term Definition and Characteristics

Assumptions Assumptions are beliefs about phenomena one must accept as true to
accept a theory about the phenomena as true. Assumptions may be
based on accepted knowledge or personal beliefs and values. Although
assumptions may not be susceptible to testing, they can be argued

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

Concept Concepts are the elements or components of a phenomenon necessary
to understand the phenomenon. They are abstract and derived from
impressions the human mind receives about phenomena through
sensing the environment.

Conceptual model/conceptual

A conceptual model is a set of interrelated concepts that symbolically
represents and conveys a mental image of a phenomenon. Conceptual
models of nursing identify concepts and describe their relationships to
the phenomena of central concern to the discipline.

Construct Constructs are the most complex type of concept. They comprise more
than one concept and are typically built or constructed by the theorist
or philosopher to fit a purpose. The terms concept and construct are
often used interchangeably, but some authors use concept as the more


general term—all constructs are concepts, but not all concepts are

Empirical indicator Empirical indicators are very specific and concrete identifiers of
concepts. They are actual instructions, experimental conditions, and
procedures used to observe or measure the concept(s) of a theory.

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

Hypotheses Hypotheses are tentative suggestions that a specific relationship exists
between two concepts or propositions. As the hypothesis is repeatedly
confirmed, it progresses to an empirical generalization and ultimately
to a law.

Knowledge Knowledge refers to the awareness or perception of reality acquired
through insight, learning, or investigation. In a discipline, knowledge is
what is collectively seen to be a reasonably accurate understanding of
the world as seen by members of the discipline.

Laws A law is a proposition about the relationship between concepts in a
theory that has been repeatedly validated. Laws are highly
generalizable. Laws are found primarily in disciplines that deal with
observable and measurable phenomena, such as chemistry and physics.
Conversely, social and human sciences have few laws.

Metaparadigm A metaparadigm represents the worldview of a discipline—the global
perspective that subsumes more specific views and approaches to the
central concepts with which the discipline is concerned. The
metaparadigm is the ideology within which the theories, knowledge,
and processes for knowing find meaning and coherence. Nursing’s
metaparadigm is generally thought to consist of the concepts of person,
environment, health, and nursing.

Middle range theory Middle range theory refers to a part of a discipline’s concerns related
to particular topics. The scope is narrower than that of broad-range or
grand theories.

Model Models are graphic or symbolic representations of phenomena that
objectify and present certain perspectives or points of view about
nature or function or both. Models may be theoretical (something not
directly observable—expressed in language or mathematics symbols)
or empirical (replicas of observable reality—e.g., model of an eye).

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

Paradigm A paradigm is an organizing framework that contains concepts,
theories, assumptions, beliefs, values, and principles that form the way
a discipline interprets the subject matter with which it is concerned. It
describes work to be done and frames an orientation within which the
work will be accomplished. A discipline may have a number of
paradigms. The term paradigm is associated with Kuhn’s Structure of
Scientific Revolutions.

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

Philosophy A philosophy is a statement of beliefs and values about human beings


and their world.
Practice or situation-specific

A practice or situation-specific theory deals with a limited range of
discrete phenomena that are specifically defined and are not expanded
to include their link with the broad concerns of a discipline.

Praxis Praxis is the application of a theory to cases encountered in experience.
Relationship statements Relationship statements indicate specific relationships between two or

more concepts. They may be classified as propositions, hypotheses,
laws, axioms, or theorems.

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

Theory Theory refers to a set of logically interrelated concepts, statements,
propositions, and definitions, which have been derived from
philosophical beliefs of scientific data and from which questions or
hypotheses can be deduced, tested, and verified. A theory purports to
account for or characterize some phenomenon.

Worldview Worldview is the philosophical frame of reference used by a social or
cultural group to describe that group’s outlook on and beliefs about

Sources: Alligood (2014b); Blackburn (2016); Chinn and Kramer (2015); Powers and Knapp (2011).

Historical Overview: Theory Development in Nursing
Most nursing scholars credit Florence Nightingale with being the first modern nursing theorist. Nightingale
was the first to delineate what she considered nursing’s goal and practice domain, and she postulated that “to
nurse” meant having charge of the personal health of someone. She believed the role of the nurse was seen as
placing the client “in the best condition for nature to act upon him” (Hilton, 1997, p. 1211).

Florence Nightingale
Nightingale received her formal training in nursing in Kaiserswerth, Germany, in 1851. Following her
renowned service for the British army during the Crimean War, she returned to London and established a
school for nurses. According to Nightingale, formal training for nurses was necessary to “teach not only what
is to be done, but how to do it.” She was the first to advocate the teaching of symptoms and what they
indicate. Furthermore, she taught the importance of rationale for actions and stressed the significance of
“trained powers of observation and reflection” (Kalisch & Kalisch, 2004, p. 36).

In Notes on Nursing, published in 1859, Nightingale proposed basic premises for nursing practice. In her
view, nurses were to make astute observations of the sick and their environment, record observations, and
develop knowledge about factors that promoted healing. Her framework for nursing emphasized the utility of
empirical knowledge, and she believed that knowledge developed and used by nurses should be distinct from
medical knowledge. She insisted that trained nurses control and staff nursing schools and manage nursing
practice in homes and hospitals (Chinn & Kramer, 2015; Kalisch & Kalisch, 2004).

Stages of Theory Development in Nursing
Subsequent to Nightingale, almost a century passed before other nursing scholars attempted the development
of philosophical and theoretical works to describe and define nursing and to guide nursing practice. Kidd and
Morrison (1988) described five stages in the development of nursing theory and philosophy: (1) silent
knowledge, (2) received knowledge, (3) subjective knowledge, (4) procedural knowledge, and (5) constructed
knowledge. Table 2-2 gives an overview of characteristics of each of these stages in the development of
nursing theory, and each stage is described in the following sections. To contemporize Kidd and Morrison’s
work, attention will be given to the current decade and a new stage—that of “integrated knowledge.”


Table 2-2 Stages in the Development of Nursing Theory
Stage Source of Knowledge Impact on Theory and Research

Silent knowledge Blind obedience to medical

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

Received knowledge Learning through listening to

Theories were borrowed from
other disciplines. As nurses
acquired non-nursing doctoral
degrees, they relied on the
authority of educators,
sociologists, psychologists,
physiologists, and anthropologists
to provide answers to nursing

Research was primarily
educational research or sociologic

Subjective knowledge Authority was internalized to
foster a new sense of self.

A negative attitude toward
borrowed theories and science

Nurse scholars focused on
defining nursing and on
developing theories about and for

Nursing research focused on the
nurse rather than on clients and
clinical situations.

Procedural knowledge Includes both separate and
connected knowledge

Proliferation of approaches to
theory development. Application
of theory in practice was
frequently underemphasized.
Emphasis was placed on the
procedures used to acquire
knowledge, with focused attention
to the appropriateness of
methodology, the criteria for
evolution, and statistical
procedures for data analysis.

Constructed knowledge Combination of different types of
knowledge (intuition, reason, and

Recognition that nursing theory
should be based on prior
empirical studies, theoretical
literature, client reports of clinical
experiences and feelings, and the
nurse scholar’s intuition or related
knowledge about the phenomenon
of concern

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

Nursing theory will increasingly
incorporate information from
published literature with enhanced


emphasis on clinical application
as situation-specific/practice
theories and middle range

Source: Kidd and Morrison (1988).

Silent Knowledge Stage
Recognizing the impact of the poorly trained nurses on the health of soldiers during the Civil War, in 1868,
the American Medical Association advocated the formal training of nurses and suggested that schools of
nursing be attached to hospitals with instruction being provided by medical staff and resident physicians. The
first training school for nurses in the United States was opened in 1872 at the New England Hospital. Three
more schools, located in New York, New Haven, and Boston, opened shortly thereafter (Kalisch & Kalisch,
2004). Most schools were under the control of hospitals and superintended by hospital administrators and
physicians. Education and practice were based on rules, principles, and traditions that were passed along
through an apprenticeship form of education.

There followed rapid growth in the number of hospital-based training programs for nurses, and by 1909,
there were more than 1,000 such programs (Kalisch & Kalisch, 2004). In these early schools, a meager
amount of theory was taught by physicians, and practice was taught by experienced nurses. The curricula
contained some anatomy and physiology and occasional lectures on special diseases. Few nursing books were
available, and the emphasis was on carrying out physicians’ orders. Nursing education and practice focused
on the performance of technical skills and application of a few basic principles, such as aseptic technique and
principles of mobility. Nurses depended on physicians’ diagnosis and orders and as a result largely adhered to
the medical model, which views body and mind separately and focuses on cure and treatment of pathologic
problems (Donahue, 2011). Hospital administrators saw nurses as inexpensive labor. Nurses were exploited
both as students and as experienced workers. They were taught to be submissive and obedient, and they
learned to fulfill their responsibilities to physicians without question (Chinn & Kramer, 2015).

Unfortunately, with a few exceptions, this model of nursing education persisted for more than 80 years.
One exception was Yale University, which started the first autonomous school of nursing in 1924. At Yale,
and in other later collegiate programs, professional training was strengthened by in-depth exposure to the
underlying theory of disease as well as the social, psychological, and physical aspects of client welfare. The
growth of collegiate programs lagged, however, due to opposition from many physicians who argued that
university-educated nurses were overtrained. Hospital schools continued to insist that nursing education meant
acquisition of technical skills and that knowledge of theory was unnecessary and might actually handicap the
nurse (Donahue, 2011; Judd & Sitzman, 2014; Kalisch & Kalisch, 2004).

Received Knowledge Stage
It was not until after World War II that substantive changes were made in nursing education. During the late
1940s and into the 1950s, serious nursing shortages were fueled by a decline in nursing school enrollments. A
1948 report, Nursing for the Future, by Esther Brown, PhD, compared nursing with teaching. Brown noted
that the current model of nursing education was central to the problems of the profession and recommended
that efforts be made to provide nursing education in universities as opposed to the apprenticeship system that
existed in most hospital programs (Donahue, 2011; Kalisch & Kalisch, 2004).

Other factors during this time challenged the tradition of hospital-based training for nurses. One of these
factors was a dramatic increase in the number of hospitals resulting from the Hill-Burton Act, which worsened
the ongoing and sometimes critical nursing shortage. In addition, professional organizations for nurses were
restructured and began to grow. It was also during this time that state licensure testing for registration took
effect, and by 1949, 41 states required testing. The registration requirement necessitated that education
programs review the content matter they were teaching to determine minimum criteria and some degree of
uniformity. In addition, the techniques and processes used in instruction were also reviewed and evaluated
(Kalisch & Kalisch, 2004).

Over the next decade, a number of other events occurred that altered nursing education and nursing
practice. In 1950, the journal Nursing Research was first published. The American Nurses Association (ANA)


began a program to encourage nurses to pursue graduate education to study nursing functions and practice.
Books on research methods and explicit theories of nursing began to appear. In 1956, the Health Amendments
Act authorized funds for financial aid to promote graduate education for full-time study to prepare nurses for
administration, supervision, and teaching. These events resulted in a slow but steady increase in graduate
nursing education programs.

The first doctoral programs in nursing originated within schools of education at Teachers College of
Columbia University (1933) and New York University (1934). But it would be 20 more years before the first
doctoral program in nursing began at the University of Pittsburgh (1954) (Kalisch & Kalisch, 2004).

Subjective Knowledge Stage
Until the 1950s, nursing practice was principally derived from social, biologic, and medical theories. With the
exceptions of Nightingale’s work in the 1850s, nursing theory had its beginnings with the publication of
Hildegard Peplau’s book in 1952. Peplau described the interpersonal process between the nurse and the client.
This started a revolution in nursing, and in the late 1950s and 1960s, a number of nurse theorists emerged
seeking to provide an independent conceptual framework for nursing education and practice (Donahue, 2011).
The nurse’s role came under scrutiny during this decade as nurse leaders debated the nature of nursing
practice and theory development.

During the 1960s, the development of nursing theory was heavily influenced by three philosophers, James
Dickoff, Patricia James, and Ernestine Wiedenbach, who, in a series of articles, described theory development
and the nature of theory for a practice discipline. Other approaches to theory development combined direct
observations of practice, insights derived from existing theories and other literature sources, and insights
derived from explicit philosophical perspectives about nursing and the nature of health and human experience.
Early theories were characterized by a functional view of nursing and health. They attempted to define what
nursing is, describe the social purposes nursing serves, explain how nurses function to realize these purposes,
and identify parameters and variables that influence illness and health (Chinn & Kramer, 2015).

In the 1960s, a number of nurse leaders (Abdellah, Orlando, Wiedenbach, Hall, Henderson, Levine, and
Rogers) developed and published their views of nursing. Their descriptions of nursing and nursing models
evolved from their personal, professional, and educational experiences and reflected their perception of ideal
nursing practice.

Procedural Knowledge Stage
By the 1970s, the nursing profession viewed itself as a scientific discipline evolving toward a theoretically
based practice focusing on the client. In the late 1960s and early 1970s, several nursing theory conferences
were held. Also, significantly, in 1972, the National League for Nursing implemented a requirement that the
curricula for nursing educational programs be based on conceptual frameworks. During these years, many
nursing theorists published their beliefs and ideas about nursing and some developed conceptual models.

During the 1970s, a consensus developed among nursing leaders regarding common elements of nursing.
These were the nature of nursing (roles/actions/interventions), the individual recipient of care (client), the
context of nurse–client interactions (environment), and health. Nurses debated whether there should be one
conceptual model for nursing or several models to describe the relationships among the nurse, client,
environment, and health. Books were written for nurses on how to critique, develop, and apply nursing
theories. Graduate schools developed courses on analysis and application of theory, and researchers identified
nursing theories as conceptual frameworks for their studies. Through the late 1970s and early 1980s, theories
moved to characterizing nursing’s role from “what nurses do” to “what nursing is.” This changed nursing
from a context-dependent, reactive position to a context-independent, proactive arena (Chinn & Kramer,

Although master’s programs were growing steadily, doctoral programs grew more slowly, but by 1970,
there were 20 such programs. This growth in graduate nursing education allowed nurse scholars to debate
ideas, viewpoints, and research methods in the nursing literature. As a result, nurses began to question the
ideas that were taken for granted in nursing and the traditional basis in which nursing was practiced.

Constructed Knowledge Stage


During the late 1980s, scholars began to concentrate on theories that provide meaningful foundation for
nursing practice. There was a call to develop substance in theory and to focus on nursing concepts grounded
in practice and linked to research. The 1990s into the early 21st century saw an increasing emphasis on
philosophy and philosophy of science in nursing. Attention shifted from grand theories to middle range
theories as well as application of theory in research and practice.

In the 1990s, the idea of evidence-based practice (EBP) was introduced into nursing to address the
widespread recognition of the need to move beyond attention given to research per se in order to address the
gap in research and practice. The “evidence” is research that has been completed and published (LoBiondo-
Wood & Haber, 2014). Ostensibly, EBP promotes employment of theory-based, research-derived evidence to
guide nursing practice.

During this period, graduate education in nursing continued to grow rapidly, particularly among programs
that produced advanced practice nurses (APNs). A seminal event during this time was the introduction of the
doctor of nursing practice (DNP). The DNP was initially proposed by the American Association of Colleges
of Nursing (AACN) in 2004 to be the terminal degree for APNs. The impetus for the DNP was based on
recognition of the need for expanded competencies due to the increasing complexity of clinical practice,
enhanced knowledge to improve nursing practice and outcomes, and promotion of leadership skills (AACN,

Integrated Knowledge Stage
More recently, development of nursing knowledge shifted to a trend that blends and uses a variety of
processes to achieve a given research aim as opposed to adherence to strict, accepted methodologies (Chinn &
Kramer, 2015). In the second decade of the 21st century, there has been significant attention to the need to
direct nursing knowledge development toward clinical relevance, to address what Risjord (2010) terms the
“relevance gap.” Indeed, as Risjord states, and virtually all nursing scholars would agree, “The primary goal .
. . of nursing research is to produce knowledge that supports practice” (p. 4). But he continues to note that in
reality, a significant portion of research supports practice imperfectly, infrequently, and often insignificantly.

In the current stage of knowledge development, considerable focus in nursing science has been on
integration of knowledge into practice, largely with increased attention on EBP and translational research
(Chinn & Kramer, 2015). Indeed, it is widely accepted that systematic review of research from a variety of
health disciplines, often in the form of meta-analyses, should be undertaken to inform practice and policy
making in nursing (Melnyk & Fineout-Overholt, 2015; Schmidt & Brown, 2015). Furthermore, this involves
or includes application of evidence from across all health-related sciences (i.e., translational research).

Translational research was designated a priority initiative by the National Institutes of Health in 2005
(Powers & Knapp, 2011). The idea of translational research is to close the gap between scientific discovery
and translation of research into practice; the intent is to validate evidence in the practice setting (Chinn &
Kramer, 2015). Translational research shifts focus to interdisciplinary efforts and integration of the
perspectives of different disciplines to “a contemporary movement aimed at producing a concerted
multidisciplinary effort to address recognized health disparities and care delivery inadequacies” (Powers &
Knapp, 2011, p. 191).

Into the second decade of the 21st century, the number of doctoral programs in the United States
continued to grow steadily, and by 2016, there were 128 doctoral programs granting a doctor of philosophy
(PhD) in nursing (AACN, 2017a). Furthermore, after a sometimes contentious debate, the DNP gained
widespread acceptance, and by 2017, there were 303 programs granting the DNP, with many more being
planned (AACN, 2017b).

In this current stage of theory development in nursing, it is anticipated that there will be ongoing interest
in EBP and growth of translational research. In this regard, development and application of middle range and
practice theories will continue to be stressed, with attention increasing on practical/clinical application and
relevance of both research and theory.

Summary of Stages of Nursing Theory Development
A number of events and individuals have had an impact on the development and utilization of theory in
nursing practice, research, and education. Table 2-3 provides a summary of significant events.


Table 2-3 Significant Events in Theory Development in Nursing
Event Year

Nightingale publishes Notes on Nursing 1859
American Medical Association advocates formal training for nurses 1868
Teacher’s College—Columbia University—Doctorate in Education degree for nursing 1920
Yale University begins the first collegiate school of nursing 1924
Report by Dr. Esther Brown—“Nursing for the Future” 1948
State licensure for registration becomes standard 1949
Nursing Research first published 1950
H. Peplau publishes Interpersonal Relations in Nursing 1952
University of Pittsburgh begins the first doctor of philosophy (PhD) program in nursing 1954
Health Amendments Act passes—funds graduate nursing education 1956
Process of theory development discussed among nursing scholars (works published by
Abdellah, Henderson, Orlando, Wiedenbach, and others)


First symposium on Theory Development in Nursing (published in Nursing Research in 1968) 1967
Symposium Theory Development in Nursing 1968
Dickoff, James, and Wiedenbach—“Theory in a Practice Discipline”
First Nursing Theory Conference 1969
Second Nursing Theory Conference 1970
Third Nursing Theory Conference 1971
National League for Nursing adopts Requirement for Conceptual Framework for Nursing


Key articles publish in Nursing Research (Hardy—Theories: Components, Development, and
Evaluation; Jacox—Theory Construction in Nursing; and Johnson—Development of Theory)


Nurse educator conferences on nursing theory 1975,

Advances in Nursing Science first published 1979
Books written for nurses on how to critique theory, develop theory, and apply nursing theory 1980s
Graduate schools of nursing develop courses on how to analyze and apply theory in nursing 1980s
Research studies in nursing identify nursing theories as frameworks for study 1980s
Publication of numerous books on analysis, application, evaluation, and development of
nursing theories


Philosophy and philosophy of science courses offered in doctoral programs 1990s
Increasing emphasis on middle range and practice theories for nursing 1990s
Nursing literature describes the need to establish interconnections among central nursing


Introduction of evidence-based practice into nursing 1990s
Philosophy of Nursing first published 1999
Books published describing, analyzing, and discussing application of middle range theory and
evidence-based practice


Introduction of the doctor of nursing practice (DNP) 2004
Growing emphasis on development of situation-specific and middle range theories in nursing 2010+


Attention to theory utilization and development of theories to guide nursing research, practice,
education, and administration


Focus on clinical application of evidence-based practice, practice-based evidence, and
translational research


Sources: Alligood (2014a); Chinn and Kramer (2015); Donahue (2011); Kalisch and Kalisch (2004); Meleis (2012); Moody (1990).

Beginning in the early 1950s, efforts to represent nursing theoretically produced broad conceptualizations
of nursing practice. These conceptual models or frameworks proliferated during the 1960s and 1970s.
Although the conceptual models were not developed using traditional scientific research processes, they did
provide direction for nursing by focusing on a general ideal of practice that served as a guide for research and
education. Table 2-4 lists the works of many of the nursing theorists and the titles and year of key theoretical
publications. The works of a number of the major theorists are discussed in Chapters 7 through 9. Reference
lists and bibliographies outlining application of their work to research, education, and practice are described in
those chapters.

Table 2-4 Chronology of Publications of Selected Nursing Theorists
Theorist Year Title of Theoretical Writings

Florence Nightingale 1859 Notes on Nursing
Hildegard Peplau 1952 Interpersonal Relations in Nursing
Virginia Henderson 1955 Principles and Practice of Nursing, 5th edition

1966 The Nature of Nursing: A Definition and Its Implications for
Practice, Research, and Education

1991 The Nature of Nursing: Reflections After 25 Years
Dorothy Johnson 1959 “A Philosophy of Nursing”

1980 “The Behavioral System Model for Nursing”
Faye Abdellah 1960 Patient-Centered Approaches to Nursing

1968 2nd edition
Ida Jean Orlando 1961 The Dynamic Nurse–Patient Relationship
Ernestine Wiedenbach 1964 Clinical Nursing: A Helping Art
Lydia E. Hall 1964 Nursing: What Is It?
Joyce Travelbee 1966 Interpersonal Aspects of Nursing

1971 2nd edition
Myra E. Levine 1967 The Four Conservation Principles of Nursing

1973 Introduction to Clinical Nursing
1996 “The Conservation Principles of Nursing: A Retrospective”

Martha Rogers 1970 An Introduction to the Theoretical Basis of Nursing
1980 “Nursing: A Science of Unitary Man”
1983 Science of Unitary Human Being: A Paradigm for Nursing
1989 “Nursing: A Science of Unitary Human Beings”

Dorothea E. Orem 1971 Nursing: Concepts of Practice
1980 2nd edition
1985 3rd edition
1991 4th edition
1995 5th edition


2001 6th edition
2011 Self-Care Science, Nursing Theory and Evidence-Based Practice

(Taylor and Renpenning)
Imogene M. King 1971 Toward a Theory for Nursing: General Concepts of Human

1981 A Theory for Nursing: Systems, Concepts, Process
1989 “King’s General Systems Framework and Theory”

Betty Neuman 1974 “The Betty Neuman Health-Care Systems Model: A Total
Person Approach to Patient Problems”

1982 The Neuman Systems Model
1989 2nd edition
1995 3rd edition
2002 4th edition
2011 5th edition

Evelyn Adam 1975 A Conceptual Model for Nursing
1980 To Be a Nurse
1991 2nd edition

Callista Roy 1976 Introduction to Nursing: An Adaptation Model
1980 “The Roy Adaptation Model”
1984 Introduction to Nursing: An Adaptation Model, 2nd edition
1991 The Roy Adaptation Model
1999 2nd edition
2009 3rd edition

Josephine Paterson and
Loretta Zderad

1976 Humanistic Nursing

Jean Watson 1979 Nursing: The Philosophy and Science of Caring
1985 Nursing: Human Science and Human Care
1989 Watson’s Philosophy and Theory of Human Caring in Nursing
1999 Human Science and Human Care
2006 Caring Science as Sacred Science
2012 Human Caring Science: A Theory of Nursing, 2nd edition

Margaret A. Newman 1979 Theory Development in Nursing
1983 Newman’s Health Theory
1986 Health as Expanding Consciousness
2000 2nd edition

Madeleine Leininger 1980 Caring: A Central Focus of Nursing and Health Care Services
1988 “Leininger’s Theory of Nursing: Cultural Care Diversity and

2001 Culture Care Diversity and Universality
2006 2nd edition
2015 3rd edition (Edited by M. R. McFarland and H. B. Wehbe-

Joan Riehl Sisca 1980 The Riehl Interaction Model


1989 2nd edition
Rosemary Parse 1981 Man-Living-Health: A Theory for Nursing

1985 Man-Living-Health: A Man-Environment Simultaneity Paradigm
1987 Nursing Science: Major Paradigms, Theories, Critiques
1989 “Man-Living-Health: A Theory of Nursing”
1999 Illuminations: The Human Becoming Theory in Practice and

Joyce Fitzpatrick 1983 A Life Perspective Rhythm Model

1989 2nd edition
Helen Erickson et al. 1983 Modeling and Role Modeling
Nancy Roper, Winifred
Logan, and Alison Tierney

1980 The Elements of Nursing

1985 2nd edition
1996 The Elements of Nursing: A Model for Nursing Based on a

Model of Living
2000 Roper-Logan-Tierney Model of Nursing

Patricia Benner and Judith

1984 From Novice to Expert: Excellence and Power in Clinical
Nursing Practice

1989 The Primacy of Caring: Stress and Coping in Health and Illness
Anne Boykin and Savina

1993 Nursing as Caring

2001 2nd edition
Barbara Artinian 1997 The Intersystem Model: Integrating Theory and Practice

2011 2nd edition
Brendan McCormack and
Tanya McCance

2010 Person-Centred Nursing: Theory and Practice

Sources: Chinn and Kramer (2015); Hickman (2011); Hilton (1997).

Classification of Theories in Nursing
Over the last 40 years, a number of methods for classifying theory in nursing have been described. These
include classification based on range/scope or abstractness (grand or macrotheory to practice or situation-
specific theory) and type or purpose of the theory (descriptive, predictive, or prescriptive theory). Both of
these classification schemes are discussed in the following sections.

Scope of Theory
One method for classification of theories in nursing that has become common is to differentiate theories based
on scope, which refers to complexity and degree of abstraction. The scope of a theory includes its level of
specificity and the concreteness of its concepts and propositions. This classification scheme typically uses the
terms metatheory, philosophy, or worldview to describe the philosophical basis of the discipline; grand theory
or macrotheory to describe the comprehensive conceptual frameworks; middle range or midrange theory to
describe frameworks that are relatively more focused than the grand theories; and situation-specific theory,
practice theory, or microtheory to describe those smallest in scope (Higgins & Moore, 2000; Peterson, 2017;
Whall, 2016). Theories differ in complexity and scope along a continuum from practice or situation-specific
theories to grand theories. Figure 2-1 compares the scope of nursing theory by level of abstractness.


Figure 2-1 Comparison of the scope of nursing theories.

Metatheory refers to a theory about theory. In nursing, metatheory focuses on broad issues such as the
processes of generating knowledge and theory development, and it is a forum for debate within the discipline
(Chinn & Kramer, 2015; Powers & Knapp, 2011). Philosophical and methodologic issues at the metatheory or
worldview level include identifying the purposes and kinds of theory needed for nursing, developing and
analyzing methods for creating nursing theory, and proposing criteria for evaluating theory (Hickman, 2011;
Walker & Avant, 2011).

Walker and Avant (2011) presented an overview of historical trends in nursing metatheory. Beginning in
the 1960s, metatheory discussions involved nursing as an academic discipline and the relationship of nursing
to basic sciences. Later discussions addressed the predominant philosophical worldviews (received view
versus perceived view) and methodologic issues related to research (see Chapter 1). Recent metatheoretical
issues relate to the philosophy of nursing and address what levels of theory development are needed for
nursing practice, research, and education (i.e., grand theory versus middle range and practice theory) and the
increasing focus on the philosophical perspectives of critical theory, postmodernism, and feminism.

Grand Theories
Grand theories are the most complex and broadest in scope. They attempt to explain broad areas within a
discipline and may incorporate numerous other theories. The term macrotheory is used by some authors to
describe a theory that is broadly conceptualized and is usually applied to a general area of a specific discipline
(Higgins & Moore, 2000; Peterson, 2017).

Grand theories are nonspecific and are composed of relatively abstract concepts that lack operational
definitions. Their propositions are also abstract and are not generally amenable to testing. Grand theories are
developed through thoughtful and insightful appraisal of existing ideas as opposed to empirical research
(Fawcett & DeSanto-Madeya, 2013). The majority of the nursing conceptual frameworks (e.g., Orem, Roy,
and Rogers) are considered to be grand theories. Chapters 6 through 9 discuss many of the grand nursing

Middle Range Theories
Middle range theory lies between the grand nursing models and more circumscribed, concrete ideas (practice
or situation-specific theories). Middle range theories are substantively specific and encompass a limited
number of concepts and a limited aspect of the real world. They are composed of relatively concrete concepts
that can be operationally defined and relatively concrete propositions that may be empirically tested (Higgins
& Moore, 2000; Peterson, 2017; Whall, 2016).

A middle range theory may be (1) a description of a particular phenomenon, (2) an explanation of the
relationship between phenomena, or (3) a prediction of the effects of one phenomenon or another (Fawcett &
DeSanto-Madeya, 2013). Many investigators favor working with propositions and theories characterized as
middle range rather than with conceptual frameworks because they provide the basis for generating testable
hypotheses related to particular nursing phenomena and to particular client populations (Chinn & Kramer,
2015; Roy, 2014). The number of middle range theories developed and used by nurses has grown significantly
over the past two decades. Examples include social support, quality of life, and health promotion. Chapters 10
and 11 describe middle range theory in more detail.

Practice Theories
Practice theories are also called situation-specific theories, prescriptive theories, or microtheories and are the


least complex. Practice theories are more specific than middle range theories and produce specific directions
for practice (Higgins & Moore, 2000; Peterson, 2017; Whall, 2016). They contain the fewest concepts and
refer to specific, easily defined phenomena. They are narrow in scope, explain a small aspect of reality, and
are intended to be prescriptive. They are usually limited to specific populations or fields of practice and often
use knowledge from other disciplines. Examples of practice theories developed and used by nurses are
theories of postpartum depression, infant bonding, and oncology pain management. Chapters 12 and 18
present additional information on practice theories.

Type or Purpose of Theory
In their seminal work, Dickoff and James (1968) defined theories as intellectual inventions designed to
describe, explain, predict, or prescribe phenomena. They described four kinds of theory, each of which builds
on the other. These are:

Factor-isolating theories (descriptive theories)
Factor-relating theories (explanatory theories)
Situation-relating theories (predictive theories or promoting or inhibiting theories)
Situation-producing theories (prescriptive theories)

Dickoff and James (1968) stated that nursing as a profession should go beyond the level of descriptive or
explanatory theories and attempt to attain the highest levels—that of situation-relating/predictive and
situation-producing/prescriptive theories.

Descriptive (Factor-Isolating) Theories
Descriptive theories are those that describe, observe, and name concepts, properties, and dimensions.
Descriptive theory identifies and describes the major concepts of phenomena but does not explain how or why
the concepts are related. The purpose of descriptive theory is to provide observation and meaning regarding
the phenomena. It is generated and tested by descriptive research techniques including concept analysis, case
studies, literature review phenomenology, ethnography, and grounded theory (Young et al., 2001).

Examples of descriptive theories are readily found in the nursing literature. Barkimer (2016), for example,
used the process of concept analysis to develop a model of clinical growth for nursing educators. In other
works, using grounded theory methodology, Sacks and Volker (2015) developed a theoretical model
describing hospice nurses’ responses to patient suffering, and El Hussein and Hirst (2016) constructed a
theory describing the clinical reasoning processes nurses use to recognize delirium.

Explanatory (Factor-Relating) Theories
Factor-relating theories, or explanatory theories, are those that relate concepts to one another, describe the
interrelationships among concepts or propositions, and specify the associations or relationships among some
concepts. They attempt to tell how or why the concepts are related and may deal with cause and effect and
correlations or rules that regulate interactions. They are developed by correlational research and increasingly
through comprehensive literature review and synthesis. An example of an explanatory theory is the theory of
health-related outcomes of resilience in middle adolescents (Scoloveno, 2015). This theory was developed
from a correlational research study that surveyed the effects of resilience on hope, well-being, and health-
promoting lifestyle in middle adolescents. In other works, comprehensive literature review and synthesis were
used by Noviana, Miyazaki, and Ishimaru (2016) to develop a conceptual model for meaning in life and by
Lor, Crooks, and Tluczek (2016) to propose a model of person, family, and culture-centered nursing care.

Predictive (Situation-Relating) Theories
Situation-relating theories are achieved when the conditions under which concepts are related are stated and
the relational statements are able to describe future outcomes consistently. Situation-relating theories move to
prediction of precise relationships between concepts. Experimental research is used to generate and test them
in most cases.

Predictive theories are relatively difficult to find in the nursing literature. In one example, Cobb (2012)
used a quasi-experimental, model-building approach to predict the relationship between spirituality and health


status among adults living with HIV. In another example, Fearon-Lynch and Stover (2015) merged two
research-based, extant theories to develop a middle range theory explaining mastery of diabetes self-

Another example of a predictive theory in nursing can be found in the caregiving effectiveness model. The
process outlining development of this theory was described by Smith and colleagues (2002) and combined
numerous steps in theory construction and empirical testing and validation. In the model, caregiving
effectiveness is dependent on the interface of a number of factors including the characteristics of the
caregiver, interpersonal interactions between the patient and caregiver, and the educational preparedness of
the caregiver, combined with adaptive factors, such as economic stability, and the caregiver’s own health
status and family adaptation and coping mechanisms. The model itself graphically details the interaction of
these factors and depicts how they collectively work to impact caregiving effectiveness.

Prescriptive (Situation-Producing) Theories
Situation-producing theories are those that prescribe activities necessary to reach defined goals. Prescriptive
theories address nursing therapeutics and consequences of interventions. They include propositions that call
for change and predict consequences of nursing interventions. They should describe the prescription, the
consequence(s), the type of client, and the conditions (Meleis, 2012).

Prescriptive theories are among the most difficult to identify in the nursing literature. One example is a
work by Walling (2006) that presented a “prescriptive theory explaining medical acupuncture” for nurse
practitioners. The model describes how acupuncture can be used to reduce stress and enhance well-being. In
another example, Auvil-Novak (1997) described the development of a middle range theory of
chronotherapeutic intervention for postsurgical pain based on three experimental studies of pain relief among
postsurgical clients. The theory uses a time-dependent approach to pain assessment and provides directed
nursing interventions to address postoperative pain.

Issues in Theory Development in Nursing
A number of issues related to use of theory in nursing have received significant attention in the literature. The
first is the issue of borrowed versus unique theory in nursing. A second issue is nursing’s metaparadigm, and
a third is the importance of the concept of caring in nursing.

Borrowed Versus Unique Theory in Nursing
Since the 1960s, the question of borrowing—or sharing—theory from other disciplines has been raised in the
discussion of nursing theory. The debate over borrowed/shared theory centers in the perceived need for theory
unique to nursing discussed by many nursing theorists.

The main premise held by those opposed to borrowed theory is that only theories that are grounded in
nursing should guide the actions of the discipline. A second premise that supports the need for unique theory
is that any theory that evolves out of the practice arena of nursing is substantially nursing. Although one might
“borrow” theory and apply it to the realm of nursing actions, it is transformed into nursing theory because it
addresses phenomena within the arena of nursing practice.

Opponents of using borrowed theory believe that nursing knowledge should not be tainted by using theory
from physiology, psychology, sociology, and education. Furthermore, they believe “borrowing” requires
returning and that the theory is not in essence nursing if concepts are borrowed (Levine, 1995; Risjord, 2010).

Proponents of using borrowed theory in nursing believe that knowledge belongs to the scientific
community and to society at large, and it is not the property of individuals or disciplines (Powers & Knapp,
2011). Indeed, these individuals feel that knowledge is not the private domain of one discipline, and the use of
knowledge generated by any discipline is not borrowed but shared. Furthermore, shared theory does not lessen
nursing scholarship but enhances it (Levine, 1995; Rodgers, 2015).

Furthermore, advocates of borrowed or shared theory believe that, like other applied sciences, nursing
depends on the theories from other disciplines for its theoretical foundations. For example, general systems
theory is used in nursing, biology, sociology, and engineering. Different theories of stress and adaptation are
valuable to nurses, psychologists, and physicians.


In reality, all nursing theories incorporate concepts and theories shared with other disciplines to guide
theory development, research, and practice. However, simply adopting concepts or theories from another
discipline does not convert them into nursing concepts or theories. It is important, therefore, for theorists,
researchers, and practitioners to use concepts from other disciplines appropriately. Emphasis should be placed
on redefining and synthesizing the concepts and theories according to a nursing perspective (Fawcett &
DeSanto-Madeya, 2013; Rodgers, 2015).

Nursing’s Metaparadigm
The most abstract and general component of the structural hierarchy of nursing knowledge is what Kuhn
(1974) called the metaparadigm. A metaparadigm refers “globally to the subject matter of greatest interest to
member of a discipline” (Powers & Knapp, 2011, p. 107). The metaparadigm includes major philosophical
orientations or worldviews of a discipline, the conceptual models and theories that guide research and other
scholarly activities, and the empirical indicators that operationalize theoretical concepts (Fawcett, 1996). The
purpose or function of the metaparadigm is to summarize the intellectual and social missions of the discipline
and place boundaries on the subject matter of that discipline (Kim, 1989). Fawcett and DeSanto-Madeya
(2013) identified four requirements for a metaparadigm. These are summarized in Box 2-1.

Box 2-1 Requirements for a Metaparadigm
1. A metaparadigm must identify a domain that is distinctive from the domains of other disciplines . . . the

concepts and propositions represent a unique perspective for inquiry and practice.
2. A metaparadigm must encompass all phenomena of interest to the discipline in a parsimonious manner .

. . the concepts and propositions are global and there are no redundancies.
3. A metaparadigm must be perspective-neutral . . . the concepts and propositions do not represent a

specific perspective (i.e., a specific paradigm or conceptual model or combination of perspectives).
4. A metaparadigm must be global in scope and substance . . . the concepts and propositions do not reflect

particular national, cultural, or ethnic beliefs and values.

Adapted from: Fawcett and DeSanto-Madeya (2013).

According to Fawcett and DeSanto-Madeya (2013), in the 1970s and early 1980s, a number of nursing
scholars identified a growing consensus that the dominant phenomena within the science of nursing revolved
around the concepts of man (person), health, environment, and nursing. Fawcett first wrote on the central
concepts of nursing in 1978 and formalized them as the metaparadigm of nursing in 1984. This articulation of
four metaparadigm concepts (person, health, environment, and nursing) served as an organizing framework
around which conceptual development proceeded.

Wagner (1986) examined the nursing metaparadigm in depth. Her sample of 160 doctorally prepared
chairpersons, deans, or directors of programs for bachelors of science in nursing revealed that between 94%
and 98% of the respondents agreed that the concepts that comprise the nursing metaparadigm are person,
health, nursing, and environment. She concluded that these findings indicated a consensus within the
discipline of nursing that these are the dominant phenomena within the science. A summary of definitions for
each term is presented here.

Person refers to a being composed of physical, intellectual, biochemical, and psychosocial needs; a human
energy field; a holistic being in the world; an open system; an integrated whole; an adaptive system; and a
being who is greater than the sum of his or her parts (Wagner, 1986). Nursing theories are often most
distinguishable from each other by the various ways in which they conceptualize the person or recipient of
nursing care. Most nursing models organize data about the individual person as a focus of the nurse’s
attention, although some nursing theorists have expanded to include family or community as the focus
(Thorne et al., 1998). Health is the ability to function independently; successful adaptation to life’s stressors;
achievement of one’s full life potential; and unity of mind, body, and soul (Wagner, 1986). Health has been a
phenomenon of central interest to nursing since its inception. Nursing literature indicates great diversity in the
explication of health and quality of life (Thorne et al., 1998). Indeed, in a recent work, following a critical


appraisal of the works of several nurse theorists, Plummer and Molzahn (2009) suggested replacing the term
“health” with “quality of life.” They posited that quality of life is a more inclusive notion, as health is often
understood in terms of physical status. Alternatively, quality of life better encompasses a holistic perspective,
involving physical, psychological, and social well-being, as well as the spiritual and environmental aspects of
the human experience.

Environment typically refers to the external elements that affect the person; internal and external
conditions that influence the organism; significant others with whom the person interacts; and an open system
with boundaries that permit the exchange of matter, energy, and information with human beings (Wagner,
1986). Many nursing theories have a narrow conceptualization of the environment as the immediate
surroundings or circumstances of the individual. This view limits understanding by making the environment
rigid, static, and natural. A multilayered view of the environment encourages understanding of an individual’s
perspective and immediate context and incorporates the sociopolitical and economic structures and underlying
ideologies that influence reality (Thorne et al., 1998).

Nursing is a science, an art, and a practice discipline and involves caring. Goals of nursing include care of
the well, care of the sick, assisting with self-care activities, helping individuals attain their human potential,
and discovering and using nature’s laws of health. The purposes of nursing care include placing the client in
the best condition for nature to restore health, promoting the adaptation of the individual, facilitating the
development of an interaction between the nurse and the client in which jointly set goals are met, and
promoting harmony between the individual and the environment (Wagner, 1986). Furthermore, nursing
practice facilitates, supports, and assists individuals, families, communities, and societies to enhance,
maintain, and recover health and to reduce and ameliorate the effects of illness (Thorne et al., 1998).

In addition to these definitions, many grand nursing theorists, and virtually all of the theoretical
commentators, incorporate these four terms into their conceptual or theoretical frameworks. Table 2-5
presents theoretical definitions of the metaparadigm concepts from selected nursing conceptual frameworks
and other writings.

Table 2-5 Selected Theoretical Definitions of the Concepts of Nursing’s Metaparadigm

Author/Source of
Definition Definition


D. Johnson A behavioral system with patterned, repetitive, and
purposeful ways of behaving that link person to the

B. Neuman A dynamic composite of the interrelationships between
physiologic, psychological, sociocultural, developmental,
spiritual, and basic structure variables; may be an
individual, group, community, or social system

D. Orem Are distinguished from other living things by their
capacity (1) to reflect upon themselves and their
environment, (2) to symbolize what they experience, and
(3) to use symbolic creations (ideas, words) in thinking, in
communicating, and in guiding efforts to do and to make
things that are beneficial for themselves or others

M. Rogers An irreducible, indivisible, pan-dimensional energy field
identified by pattern and manifesting characteristics that
are specific to the whole and that cannot be predicted from
knowledge of the parts

Nursing M. Leininger A learned humanistic and scientific profession and
discipline that is focused on human care phenomena and
activities to assist, support, facilitate, or enable individuals
or groups to maintain or regain their well-being (or health)
in culturally meaningful and beneficial ways, or to help


people face handicaps or death
M. Newman Caring in the human health experience
D. Orem A specific type of human service required whenever the

maintenance of continuous self-care requires the use of
special techniques and the application of scientific
knowledge in providing care or in designing it

J. Watson A human science of persons and human health–illness
experiences that are mediated by professional, personal,
scientific, esthetic, and ethical human care transactions

Health M. Leininger A state of well-being that is culturally defined, valued, and
practiced and that reflects the ability of individuals (or
groups) to perform their daily role activities in culturally
expressed, beneficial, and patterned lifeways

M. Newman A pattern of evolving, expanding consciousness regardless
of the form or direction it takes

C. Roy A state and process of being and becoming an integrated
and whole person. It is a reflection of adaptation, that is,
the interaction of the person and the environment.

J. Watson Unity and harmony within the mind, body, and soul.
Health is also associated with the degree of congruence
between the self as perceived and the self as experienced.

Environment M. Leininger The totality of an event, situation, or particular experience
that gives meaning to human expressions, interpretations,
and social interactions in particular physical, ecologic,
sociopolitical, and cultural settings

B. Neuman All internal and external factors of influences that surround
the client or client system

M. Rogers An irreducible, pan-dimensional energy field identified by
pattern and integral with the human field

C. Roy All conditions, circumstances, and influences that surround
and affect the development and behavior of human
adaptive systems with particular consideration of person
and earth resources

Sources: Johnson (1980); Leininger (1991); Neuman (1995); Newman (1990); Orem (2001); Rogers (1990); Roy and Andrews (1999); Watson

Relationships Among the Metaparadigm Concepts
The concepts of nursing’s metaparadigm have been linked in four propositions identified in the writings of
Donaldson and Crowley (1978) and Gortner (1980). These are as follows:

1. Person and health: Nursing is concerned with the principles and laws that govern human processes of
living and dying.

2. Person and environment: Nursing is concerned with the patterning of human health experiences within
the context of the environment.

3. Health and nursing: Nursing is concerned with the nursing actions or processes that are beneficial to
human beings.

4. Person, environment, and health: Nursing is concerned with the human processes of living and dying,
recognizing that human beings are in a continuous relationship with their environments (Fawcett &
DeSanto-Madeya, 2013, p. 6).

In addressing how the four concepts meet the requirements for a metaparadigm, Fawcett and DeSanto-


Madeya (2013) explain that the first three propositions represent recurrent themes identified in the writings of
Nightingale and other nursing scholars. Furthermore, the four concepts and propositions identify the unique
focus of the discipline of nursing and encompass all relevant phenomena in a parsimonious manner. Finally,
the concepts and propositions are perspective-neutral because they do not reflect a specific paradigm or
conceptual model and they do not reflect the beliefs and values of any one country or culture.

Other Viewpoints on Nursing’s Metaparadigm
There is some dissension in the acceptance of person/health/environment/nursing as nursing’s metaparadigm.
Kim (1987, 1989, 2010) identified four domains (client, client–nurse, practice, and environment) as an
organizing framework or typology of nursing. In this framework, the most significant difference appears to be
in placing health issues (i.e., health care experiences and health care environment) within the client domain
and differentiating the nursing practice domain from the client–nurse domain. The latter focuses specifically
on interactions between the nurse and the client.

Meleis (2012) maintained that nursing encompasses seven central concepts: interaction, nursing client,
transitions, nursing process, environment, nursing therapeutics, and health. Addition of the concepts of
interaction, transitions, and nursing process denotes the greatest difference between this framework and the
more commonly described person/health/environment/nursing framework. (See Link to Practice 2-1 for
another thought on expanding the metaparadigm to include social justice.)

Link to Practice 2-1
Should Social Justice Be Part of Nursing’s Metaparadigm?
Schim, Benkert, Bell, Walker, and Danford (2007) proposed that the construct of “social justice” be added
to nursing’s metaparadigm. They argued that social justice is interconnected with the four acknowledged
metaparadigm concepts of nursing, person, health, and environment. In their model, social justice actually
acts as the central, organizational foundation that links the other four concepts, particularly within the
context of public health nursing, and more specifically in urban settings.

Using this macroperspective, the goal of nursing is to ensure adequate distribution of resources to
benefit those who are marginalized. Suggested strategies to enhance attention to social justice in nursing
include shifting to a population health and health promotion/disease prevention perspective; diversifying
nursing by recruiting and educating underrepresented minorities into the profession; and engaging in
political action at local, state, national, and international levels. They concluded that as a caring profession,
nursing should expand efforts with a social justice orientation to help ensure equal access to benefits and
protections of society for all.

Caring as a Central Construct in the Discipline of Nursing
A final debate that will be discussed in this chapter centers on the place of the concept of caring within the
discipline and science of nursing. This debate has been escalating over the last decade and has been motivated
by the perceived urgency of identifying nursing’s unique contribution to the health care disciplines and
revolves around the defining attributes and roles within the practice of nursing (Thorne et al., 1998).

The concept of caring has occupied a prominent position in nursing literature and has been touted as the
essence of nursing by renowned nursing scholars, including Leininger, Watson, and Erickson. Indeed, it has
been proposed that nursing be defined as the study of caring in the human health experience (Newman, Sime,
& Corcoran-Perry, 1991).

Although some theorists (i.e., Watson, Leininger, and Boykin) have gone so far as to identify caring as the
essence of nursing, there is little if any rejection of caring as a central concept for nursing, although not
necessarily the most significant concept. Thorne and colleagues (1998) cited three major areas of contention
in the debate about caring in nursing. The first is the diverse views on the nature of caring. These range from
caring as a human trait to caring as a therapeutic intervention and differ according to whether the act of caring


is conceptualized as being client centered, nurse centered, or both.
A second major issue in the caring debate concerns the use of caring terminology to conceptualize a

specialized role. It has been asked whether there is a compelling reason to lay claim to caring as nursing’s
unique domain when so many professions describe their function as involving caring, and the concept of
caring is prominent in the work of many other disciplines (e.g., medicine, social work, and psychology)
(Thorne et al., 1998).

A third issue centers on the implications for the future development of the profession that nursing should
espouse caring as its unique mandate. It has been observed that nurses should ask themselves if it is politically
astute to be the primary interpreters of a construct that is both gendered and devalued (Meadows, 2007;
Thorne et al., 1998).

Thus, it is argued by Fawcett (1996) that although caring is included in several conceptualizations of the
discipline of nursing, it is not a dominant term in every conceptualization and therefore does not represent a
discipline-wide viewpoint. Furthermore, caring is not uniquely a nursing phenomenon, and caring behaviors
may not be generalizable across national and cultural boundaries.

Like Matt Ng, the graduate nursing student described in the opening case study, nurses who are in a position
to learn more about theory, and to recognize how and when to apply it, must often be convinced of the
relevance of such study to understand the benefits. The study of theory requires exposure to many new
concepts, principles, thoughts, and ideas as well as a student who is willing to see how theory plays an
important role in nursing practice, research, education, and administration.

Although study and use of theoretical concepts in nursing dates back to Nightingale, little progress in
theory development was made until the 1960s. The past five decades, however, have produced significant
advancement in theory development for nursing. This chapter has presented an overview of this evolutionary
process. In addition, the basic types of theory and purposes of theory were described. Subsequent chapters
will explain many of the ideas introduced here to assist professional nurses to understand the relationship
among theory, practice, and research and to further develop the discipline, the science, and the profession of

Key Points
“Theory” refers to the systematic explanation of events in which constructs and concepts are identified,

relationships are proposed, and predictions are made.
Theory offers structure and organization to nursing knowledge and provides a systematic means of collecting

data to describe, explain, and predict nursing practice.
Florence Nightingale was the first modern nursing theorist; she described what she considered nurses’ goals

and practice domain to be.
There has been an evolution of stages of theory development in nursing. Nursing is currently in the

“integrated knowledge” stage, which emphasizes EBP and translational research. Theory development
increasingly sources meta-analyses, as well as nursing research, and is largely directed toward middle
range and situation-specific/practice theories.

Theories can be classified by scope of level of abstraction (e.g., metatheory, grand theory, middle range
theory, and situation-specific theory) or by type or purpose of the theory (e.g., description, explanation,
prediction, and prescription).

Nursing “borrows” or “shares” theories and concepts from other disciplines to guide theory development,
research, and practice. It is critical that nurses redefine and synthesize these shared concept and theories
according to a nursing perspective.

The concepts of nursing, person, environment, and health are widely accepted as the dominant phenomena in
nursing; they have been identified as nursing’s metaparadigm.

Learning Activities


1. Examine early issues of Nursing Research (1950s and 1960s) and determine whether theories
or theoretical frameworks were used as a basis for research. What types of theories were
used? Review current issues to analyze how this has changed.

2. Examine early issues of American Journal of Nursing (1900–1950). Determine if and how
theories were used in nursing practice. What types of theories were used? Review current
issues to analyze how this has changed.

3. Find reports that present middle range or practice theories in the nursing literature. Identify if
these theories are descriptive, explanatory, predictive, or prescriptive in nature.

4. Like Matt, the nurse from the opening case study, many nurses initially struggle with
recognizing the need to study how “theory” can be important in their practice. With
classmates, discuss perceptions, beliefs, and attitudes felt when you learned you were to take a
course on “nursing theory.” How have your thoughts changed? Why?

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Concept Development

Clarifying Meaning of Terms

Evelyn M. Wills and Melanie McEwen

Rebecca Wallis is a certified oncology nurse who is midway through her graduate studies to become an adult
nurse practitioner. Recently, she helped care for Mrs. Janet Benson, a woman in her mid-50s who had
undergone a lumpectomy for breast cancer. Mrs. Benson’s pathology report revealed a slow-growing,
noninvasive carcinoma in situ; there were no involved nodes, and further tests showed no metastasis.

In the hospital, Mrs. Benson progressed well. But after she was discharged and began radiation, she would
frequently weep over things that seemed trivial. Her husband called Rebecca because he was concerned as this
was not Mrs. Benson’s usual behavior. Typically, she was self-contained, stoic, and accepting of life’s
circumstances, seldom demonstrating excessive emotion. Rebecca set up an appointment with the Bensons.
During the consultation, Rebecca asked each to explain how they felt about Mrs. Benson’s cancer. Mr.
Benson replied that the change in his wife’s breast was a small matter to him; he was very grateful that she
was getting well. In response to Rebecca’s questioning, Mrs. Benson focused on her sadness and inquired if
this was normal in women who had undergone a partial mastectomy.

Rebecca explained that the reaction was quite common and that oncology nurses in the region used the
term postmastectomy grief (PMG) reaction to describe it. She told the Bensons how nurses in their facility
had worked out a protocol of nursing therapy for PMG, but it had not been formally tested. In the protocol, the
nurses would request that the oncologist refer the patient to a psychiatric home health nurse for an assessment.
The psychiatric home health nurse would confer with the oncologist and the nurse practitioner and, if needed,
would request a referral to a licensed therapist. Additionally, a group called “Breast Cancer Support” had been
organized in the area by women who had been diagnosed with breast cancer. In this group, problems, such as
sadness, were discussed by women who had experienced them, and support was given to those who were
going through recovery from breast cancer surgery. Rebecca recommended that the Bensons attend a meeting.

Mrs. Benson’s case, and the problem of PMG in general, prompted Rebecca to seek more information
about this reaction of breast cancer patients. Her review of the literature suggested that the phenomena needed
further study to develop the knowledge base for practice. Because of what she had learned in her theoretical
foundations course, she realized that she first needed to define and name the problem. To this end, she chose
to use one of the concept development strategies she had learned to initiate preparation for a formal research
study for her capstone project.

Experienced nurses who are focused on the practical application of evidence-based nursing knowledge
demonstrate an inclination toward generalizing what they have learned from a group of clients to other clients
with similar problems. This is obvious in the professional discussions of clinical nurses, particularly those
educated for advanced practice, who might state, “We see certain phenomenon frequently enough in practice
that we have developed clinical protocols or interventions.”

These observed phenomena are considered by nurses to be reliable, enduring, and stable features of
practical experience, whether or not they have acquired a name and whether or not they have been studied in


research (Kim, 2010). Expert practice and enhanced education lead advanced practice nurses to recognize
commonalities in phenomena that suggest the need for inquiry. This, in turn, may guide development of
clinical hypotheses and testing of interventions. With the current focus on evidence-based practice, clear
delineation of the concepts under study in research requires that the linkages among phenomena, concepts,
and practice be clarified (Penrod & Hupcey, 2005).

For the nurse who desires to discriminately, formally, and concretely examine a phenomenon in depth,
such as described earlier, the most logical place to start is by defining the phenomenon or concept for further
study. This is not an easy task, however, and significant time, research, and effort must be made to adequately
define nursing concepts. To simplify the process, a number of strategies and methods for concept analysis,
concept development, and concept clarification have been proposed and used by nursing scholars for many

The rationale for concept development and several methods commonly used by nurses are discussed in
this chapter. This will allow expert nurse clinicians and advanced practice nurses to develop or clarify
meanings for the phenomena encountered in practice. The outcome can then serve as the basis for further
development of theory for research and practice by master’s- and doctorally prepared nurses (Box 3-1).

Box 3-1 Theory and American Association of Colleges of Nursing Essentials
“The master’s-prepared nurse applies and integrates broad, organizational, patient centered, and culturally
responsive concepts into daily practice” (American Association of Colleges of Nursing, 2011, p. 25).

The Concept of “Concept”
Concepts are terms that refer to phenomena that occur in nature or in thought. Concept has been defined as an
abstract term derived from particular attributes (Kerlinger, 1986) and “a symbolic statement describing a
phenomenon or a class of phenomena” (Kim, 2010, p. 22). Concepts may be abstract (e.g., hope, love, desire)
or relatively concrete (e.g., airplane, body temperature, pain). Concepts are formulated in words that enable
people to communicate their meanings about realities in the world (Cutcliffe & McKenna, 2005; Kim, 2010;
Penrod & Hupcey, 2005) and give meaning to phenomena that can directly or indirectly be seen, heard, tasted,
smelled, or touched (Fawcett, 1999). A concept may be a word (e.g., grief, empathy, power, pain), two words
(e.g., job satisfaction, need fulfillment, role strain), or a phrase (e.g., maternal role attachment, biomarkers of
preterm labor, health-promoting behaviors). Finally, when they are operationalized, concepts become
variables used in hypotheses to be tested in research.

Concepts have been compared to bricks in a wall that lend structure to science (Hardy, 1973). Chinn and
Kramer (2015) believe that concepts are more than terms, and constructing conceptual meaning is a vital
approach to theory building in which mental constructions or ideas are used to represent experiences.
Similarly, Parse (2006) agrees that formal study of concepts enhances knowledge development for nursing
through naming, creating, and confirming the phenomena of interest.

Although it was once thought that concepts could be defined once and for all, that idea has been disputed
(Penrod & Hupcey, 2005; Rodgers & Knafl, 2000). Theorists now understand that conceptual meaning is
created by scholars to assist in imparting the meaning to their readers and, ultimately, to benefit the discipline.
Conceptual fluidity and dependence on the context is common in writings on concept analysis in the nursing
literature (Duncan, Cloutier, & Bailey, 2007; Penrod & Hupcey, 2005). Furthermore, Risjord (2009)
suggested that there are two forms of concept analysis, theoretical and colloquial, each with its own purpose
and evidence, although the two can and often must be used together. Therefore, it is critical that scholars and
researchers define concepts clearly and distinctly so that their readers may thoroughly and accurately
comprehend their work. Because conceptual meanings are dynamic, they should be defined for each specific
use the writer or researcher makes of the term. Indeed, concepts are defined and their meanings are
understood only within the framework of the theory of which they are a part (Hardy, 1973).

Types of Concepts
Concepts explicate the subject matter of the theories of a discipline. For example, concepts from psychology


include personality, intelligence, and cognition; concepts from biology include cell, species, and protoplasm
(Jacox, 1974). Dubin (1978) explained the differences between various types of concepts, characterizing them
as enumerative, associative, relational, statistical, and summative. Table 3-1 shows characteristics and
examples of each of these types of concepts.

Table 3-1 Types of Concepts
Concept Characteristics Examples

Enumerative concepts Are always present and universal Age, height, weight
Associative concepts Exist only in some conditions

within a phenomenon; may have a
zero value

Income, presence of disease, anxiety

Relational concepts Can be understood only through
the combination or interaction of
two or more enumerative or
associative concepts

Elderly (must combine concepts of age and
longevity), mother (must combine man,
woman, and birth)

Statistical concepts Relate the property of one thing
in terms of its distribution in the
population rate

Average blood pressure, HIV/AIDS
prevalence rate

Summative concepts Represent an entire complex
entity of a phenomenon; are
complex and not measurable

Nursing, health, and environment

Source: Dubin (1978).

In nursing, concepts have been borrowed or derived from other disciplines (e.g., adaptation, culture,
homeostasis) as well as developed directly from nursing practice and research (e.g., maternal–infant bonding,
health-promoting behaviors, breastfeeding attrition). In nursing literature, concepts have been categorized in
several ways. For example, they have been described as concrete or abstract, variable or nonvariable (Hardy,
1973), and as operationally or theoretically defined.

Abstract Versus Concrete Concepts
Concepts may be viewed on a continuum from concrete (specific) to abstract (general). At one end of the
continuum are concrete concepts, which have simple, directly observable empirical referents that can be seen,
felt, or heard (e.g., a chair, the color red, jazz music). Concrete concepts are limited by time and space and are
observable in reality.

At the other end of the continuum are abstract concepts (e.g., art, social support, personality, role). These
are not clearly observable directly or indirectly and must be defined in terms of observable concepts (Jacox,
1974). Abstract concepts are independent of time and space. The more abstract a concept is, the more it
transcends time and geography (Meleis, 2012).

Some concepts are formed from direct experiences with reality, whereas others are formed from indirect
experiences. Relatively concrete or “empirical” concepts are formed from direct observations of objects,
properties, or events. Concepts describing objects (e.g., desk or dog) or properties (e.g., cold, hard) are more
empirical because the object or property that represents the idea (the empirical indicator) can be directly
observed. Slightly more abstract properties, such as height, weight, and gender, can also be observed or

As concepts become more abstract, their empirical indicators become less concrete and less directly
measurable, and assessment of abstract concepts increasingly depends on indirect measures. For example,
cardiovascular fitness, social support, and self-esteem are not directly observable properties or objects. To
study these and similar concepts, their empirical referents must be defined and means must be identified or
developed to measure them.

Variable (Continuous) Versus Nonvariable (Discrete) Concepts


Concepts may be categorized as variable or nonvariable (Hardy, 1973). Concepts that describe phenomena
according to some dimensions of the phenomena are termed variables. A discrete (noninterval level) concept
identifies categories or classes of characteristics. Discrete concepts include gender, ethnic background,
religion, and marital status. Discrete variables can be single variable categories that may be answered as “yes”
or “no” (e.g., either one is pregnant or not pregnant; one is a nurse or is not a nurse) or fits into a predefined
category (e.g., religion, marital status, educational attainment).

Continuous (variable) concepts permit classification of dimension or graduation of phenomena on a
continuum (e.g., blood pressure, pain) (Hardin, 2014). Variable concepts include quality of life, health-
promoting behaviors, and cultural identity. An examination of nursing research will lead to numerous
examples of continuous or variable concepts that have been being studied. These include the concepts of hope,
quality of life, resilience, and grief. In each case, the concept was defined operationally and measured by
tools, scales, or some other indicator to show where the respondent’s level of the variable fell relative to
others or relative to a predefined norm.

Theoretically Versus Operationally Defined Concepts
Concepts may be theoretically or operationally defined. A theoretical definition gives meaning to a term in
context of a theory and permits any reader to assess the validity of the definition. The operational definition
tells how the concept is linked to concrete situations and describes a set of procedures that will be performed
to assign a value for the concept. Operational definitions permit the concept to be measured and allow
hypotheses to be tested. Thus, operational definitions form the bridge between the theory and the empirical
world (Hardy, 1973). Examples of theoretically and operationally defined concepts are shown in Table 3-2.

Table 3-2 Examples of Theoretically and Operationally Defined Concepts

Definition Operational Definition Source

Binge eating “Consuming a large
amount of food in a
short period of time
while experiencing
loss of control over
eating” (p. 7)

Binge eating was determined to
be “consuming an amount of
food that is definitely greater
than what most people would eat
within a two hour period” (p. 8).
Responses to four open-ended
questions and demographics

Phillips, K. E., Kelly-Weeder, S.,
& Farrell, K. (2016). Binge
eating behavior in college
students: What is a binge?
Applied Nursing Research, 9, 7–


“The degree in
which individuals
have the capacity to
obtain, process and
understand basic
health information
and services needed
to make appropriate
health decisions” (p.

Health literacy is measured using
the Omaha System’s Problem
Rating Score for Outcomes
Knowledge (p. 96).

Monsen, K. A., Chatterjee, S. B.,
Timm, J. E., Poulsen, J. K., &
McNaughton, D. B. (2015).
Factors explaining variability in
health literacy outcomes of
public health nursing clients.
Public Health Nursing, 32(2),


“ . . . activities that
encourage or
improve overall
general health” (p.

Help promotion behaviors were
measured by the Health-
Promoting Lifestyle Profile II.

Fisher, K., & Kridli, S.A. (2014).
The role of motivation and self-
efficacy on the practice of health
promoting behaviours in the
overweight and obese middle-
aged American women.
International Journal of Nursing
Practice, 20(4), 327–335.

Emotional “The ability to Emotional intelligence was Lana, A., Baizan, E. M., Faya-


intelligence monitor one’s own
and others’ feelings
and emotions to
discriminate among
them and to use this
information to guide
one’s thinking and
action” (p. 464)

measured using the Schutte Self-
Report Inventory, a 33-item
Likert tool which measures
perceptions about emotional

Ornia, G., & Lopez, M. L.
(2015). Emotional intelligence
and health risk behaviors in
nursing students. The Journal of
Nursing Education, 54(8), 464–

Sources of Concepts
When beginning a review of concepts found in nursing practice, research, education, and administration, one
may look to several places or sources for relevant concepts. Indeed, the source of nursing concepts may be
from the natural world, from research, or derived from other disciplines.

Naturalistic concepts are concepts seen in nature or in nursing practice such as body weight,
thermoregulation, hematologic complications, depression, pain, and spirituality. These may be on a continuum
from concrete to abstract, and some may be measurable in fact (e.g., body weight and temperature) and others
(e.g., pain or spirituality) measurable only indirectly and only in principle.

Research-based concepts are the result of conceptual development that is grounded in research processes.
The theorist/researcher studies the realm of interest and identifies themes. Through qualitative,
phenomenologic, or grounded theory approaches, the researcher may uncover meanings of the phenomena of
interest and their theoretical relationships (Parse, 1999; Rodgers, 2000). Examples include Alzheimer’s
caregiver stress (Llanque, Savage, Rosenburg, & Caserta, 2016), food insecurity (Schroeder & Smaldone,
2015), joy and happiness (Cottrell, 2016), and chronic disease self-management (Miller, Lasiter, Ellis, &
Buelow, 2015).

Existing concepts are the final type of concept. The nursing literature is filled with adapted concepts, more
or less well synthesized through derivation from other disciplines. Such concepts include human needs from
Maslow’s (1954) hierarchy of needs and stress from Selye’s (1956) physiologic theory of the stress of life.
Theories of bodily function come from the study of physiology (Guyton & Hall, 1996). Borrowed concepts
from medicine are clearly seen in clinical practice, especially in critical care areas of institutions. Other
existing concepts commonly used in nursing research, administration, and practice are empathy, suffering,
abuse, hope, and burnout. Table 3-3 summarizes the three sources of concepts for nursing.

Table 3-3 Sources of Concepts

Concept Source Characteristics
Examples From Nursing


Present in nursing

May be defined and developed
for use in research and theory
development Often have medical
implications as well as nursing

Body weight, pain,
thermoregulation, depression,
hematologic complications,
circadian dysregulation


Developed through
qualitative research
processes (e.g.,
grounded theory or

Often relate to a nursing

Hope, grief, cultural competence,
chronic pain


Borrowed from other

Developed for nursing practice
but are useful in research and

Job satisfaction, quality of life,
abuse, adaptation, stress

Sources: Cowles and Rogers (1993); Parse (1999); Verhulst and Schwartz-Barcott (1993); Wang (2000).


Concept Analysis/Concept Development
Concept analysis, concept development, concept synthesis (Walker & Avant, 2011), and other terms refer to
the rigorous process of bringing clarity to the definition of the concepts used in science. Concept analysis and
concept development are the terms used most commonly in nursing and are generally applied to the process of
inquiry that examines concepts for their level of development as revealed by their internal structure, use,
representativeness, and relationship to other concepts. Thus, concept analysis/concept development explores
the meaning of concepts to promote understanding.

Purposes of Concept Development
Clarifying, recognizing, and defining concepts that describe phenomena is the purpose of concept
development or concept analysis. These processes serve as the basis for development of conceptual
frameworks, theories, and research studies.

Because a considerable portion of the conceptual basis of nursing theory, research, and practice has been
constructed using concepts adopted from other disciplines, reexamination of these concepts for relevance and
fit is important. The process of applying “borrowed” or “shared” concepts may have altered their meaning,
and it is important to review them for appropriateness of application (Hupcey, Morse, Lenz, & Tasón, 1996).
Also, as knowledge is continually developing, new concepts are being introduced and accepted, and concepts
are continually being investigated and refined. Furthermore, some concepts are poorly defined with
characteristics that have not been described, whereas other concepts that have been defined may present with
inconsistency between the definition and its use in research (Morse, Hupcey, Mitcham, & Lenz, 1996).

In summary, concept analysis can be used to evaluate the level of maturity or development of nursing
concepts by:

Identifying gaps in nursing knowledge
Determining the need to refine or clarify a concept when it appears to have multiple meanings
Evaluating the adequacy of competing concepts in their relation to other phenomena
Examining the congruence between the definition of the concept and the way it has been

Determining the fit between the definition of the concept and its clinical application (Morse et al.,


Link to Practice 3-1 gives examples of a number of different concepts that have been suggested for
development by graduate nursing students. Some of the examples (e.g., “first-time parentitis in the ED” and
“normal birth experience reconciliation”) were derived from clinical practice, and others (e.g., chemo brain
and hoarding) were derived from non-nursing sources. A few (e.g., chemo brain, wholeness, and successful
aging) may have already been presented in the nursing literature and even been a component of nursing
research, but most have not.

Link to Practice 3-1
Student-Generated Examples of Concepts of Interest to Nurses
Like Rebecca, the oncology nurse specialist (ONS) in the opening case study, nurses routinely encounter
ideas, concepts, and phenomena in practice. Here are some concepts suggested by graduate students in the
past that might be amenable to concept analysis or concept development and ultimately to theory
development and research.

Concepts from the literature and other disciplines:
Chemo brain
Chronic fatigue


Functional status
Inner strength
Postdeployment reassimilation
Second victim
Successful aging
Genetic health promotion

Phenomena from observation in clinical settings:
First-time parentitis in the emergency department (ED)
Males are nurturing caregivers
Normal birth experience reconciliation
Palliative care in the neonatal intensive care unit (NICU)
Rally at the end-of-life

Context for Concept Development
In the course of nursing practice, multiple instances of a problem will be seen as shown in the opening case
study. When talking among peers, nurses may clarify a problem so that colleagues can understand the
situation. Eventually, the nurse will develop a term, a word, or a phrase as a name for the problem. This
illustrates the starting point for studying a theoretical phenomenon—concept naming.

In refining the phenomenon so that the phenomenon can be studied, the steps of the concept development
process are instituted. In this process, instances of the phenomenon are collected, the similarities and
differences between the concept being studied and other concepts are reviewed, and those that are material to
the use of the concept are extracted and the concept is defined from its existence in nature. Isolating specific
information from all the surrounding information (the context) is important, but nurses must see the concept
emerging and take note of the context in which the concept occurs.

In the case study at the beginning of the chapter, the nurses recognized the problem of women with breast
cancer and their periodic sadness and noted the context in which the phenomenon occurred. It was important
to focus on those situations that are relevant. Questions that might be asked to assess the context include: Did
the women have unsupportive husbands? Were their lives threatened by nodal involvement and metastasis?
What were the previous experiences of the women with disease or injury? What is the history of cancer in the
women’s families?

Concept Development and Conceptual Frameworks
Once concepts have been identified, named, and developed, the nurse can test them in descriptive studies,
particularly qualitative studies to further develop the concept and make explicit its use in real situations. The
concept can be analyzed for its relation to many facets of the nursing discipline and the meaning made explicit
for the nurse’s use in daily work or scholarly endeavors.

Conceptual frameworks are structures that relate concepts together in a meaningful way. Although
relationships are posited in conceptual frameworks, frequently neither the direction nor the strength of the
relationships is made explicit for use in practice or for testing in a research project. Chapter 4 provides a
detailed discussion of the processes used in the development of theories and conceptual frameworks.

Concept Development and Research
A common language is necessary for communicating the meanings of concepts that comprise theories.


Theory, research, and practice are linked, and most scholars recognize that they cannot be separated.
Researchers relate concepts together into structures that are called models and theories and derive from them
testable relationships called hypotheses (Kerlinger, 1986).

Hickman (2011) points out that nursing research, theory, and practice form a cycle and that entry into this
cycle may be at any point. Research both precedes theory and is guided by theory. Both theory and research
direct practice, and conversely, research and theory are derived from practice situations. Thus, theory, while
guiding research, is simultaneously being tested in the research process. The conceptual elements of the
theory that guide the research or are being tested by the research are named and defined during concept

Difficulties with studying a problem in nursing may be related to the exactness with which the terms in
use are developed and defined. Poorly defined concepts may lead to faulty construction of research
instruments and methods (Morse, 1995). Frequently, a nursing problem does not lend itself precisely to
existing terminology. In this situation, the nurse should engage in the effort of concept development.
Furthermore, if one cannot successfully define the problem so that other professionals can understand it,
concept development is necessary.

Strategies for Concept Analysis and Concept Development
There are multiple methods of constructing meaning for concepts. This can be accomplished through review
of research literature, scholarly critique, and thoughtful definition. When a formal or detailed meaning is
warranted, however, a more structured method for concept development will need to be used.

In the early 1960s, John Wilson (1963), a social scientist, developed a process for defining concepts to
improve communication and comprehension of the meanings of terms in scientific use. Wilson used 11 steps,
or techniques, to guide the concept analysis process. A few recent examples, which used Wilson’s method of
concept development, were discovered in the nursing literature. In one example, Llanque and colleagues
(2016) employed a modification of Wilson’s method to analyze the concept of Alzheimer’s caregiver’s stress.
Similarly, Lynch and Lobo (2012) used Wilson’s method to examine compassion fatigue in family caregivers,
and Chee (2014) used Wilson’s method to describe “deliberate practice” in the context of clinical simulation
in nursing education.

Building on the process presented by Wilson (1963), nurses have published several techniques, methods,
and strategies for concept development. Strategies devised by several nurse scholars will be presented briefly
in the following sections, and examples of published works using these methods will be provided where

Walker and Avant
Walker and Avant first explicated the process of concept analysis for nurses in 1986. Their procedures were
based on Wilson’s method and clarified his methods so that graduate students could apply them to examine
phenomena of interest to nurses. Three different processes were described by Walker and Avant (2011):
concept analysis, concept synthesis, and concept derivation.

Concept Analysis
Concept analysis is an approach espoused by Walker and Avant (2011) to clarify the meanings of terms and
to define terms (concepts) so that writers and readers share a common language. Concept analysis should be
conducted when concepts require clarification or further development to define them for a nurse scholar’s
purposes, whether that is research, theory development, or practice. This method for concept analysis requires
an eight-step approach, as listed in Box 3-2.

Box 3-2 Steps in Concept Analysis
1. Select a concept.
2. Determine the aims or purposes of analysis.
3. Identify all the uses of the concept possible.
4. Determine the defining attributes.


5. Identify model case.
6. Identify borderline, related, contrary, invented, and illegitimate cases.
7. Identify antecedents and consequences.
8. Define empirical referents.

Source: Walker and Avant (2011, p. 160).

Concept Synthesis
Concept synthesis is used when concepts require development based on observation or other forms of
evidence. The individual must develop a way to group or order the information about the phenomenon from
his or her own viewpoint or theoretical requirement. Methods of synthesizing concepts follow:

1. Qualitative synthesis—relies on sensory data and looking for similarities, differences, and patterns
among the data to identify the new concept

2. Quantitative synthesis—requires numerical data to delineate those attributes that belong to the concept
and those that do not

3. Literary synthesis—involves reviewing a wide range of the literature to acquire new insights about the
concept or to find new concepts

4. Mixed methods—use of any of the three methods described together, either sequentially or combined
(Walker & Avant, 2011)

Concept Derivation
Concept derivation from Walker and Avant’s (2011) perspective is often necessary when there are few
concepts currently available to a nurse that explain a problem area. It is applicable when a comparison or
analogy can be made between one field or area that is conceptually defined and another that is not. Concept
derivation can be helpful in generating new ways of thinking about a phenomenon of interest. A four-step
plan for the work of moving likely concepts from disciplines outside nursing into the nursing lexicon has been
developed (Box 3-3).

Box 3-3 Steps in Concept Derivation
1. Become thoroughly familiar with the existing literature related to the topic of interest.
2. Search other fields for new ways of looking at the topic of interest.
3. Select a parent concept or set of concepts from another field to use in the derivation process.
4. Redefine the concept(s) from the parent field in terms of the topic of interest.

Source: Walker and Avant (2011, p. 76).

Examples of Concept Analysis Using Walker and Avant’s Techniques
Walker and Avant’s techniques have been taught for more than three decades in graduate nursing programs,
and their method of concept analysis is the most commonly used in nursing. Table 3-4 lists several examples
from recent nursing literature. In their most recent edition, Walker and Avant (2011) outline the processes for
each of the methods described in depth and provide a number of examples for clarification. The reader is
referred to their work, as well as to the examples listed, for more information.

Table 3-4 Examples of Concept Analyses Using Walker and Avant’s Methods
Concept Reference

Body image

Rhoten, B. A. (2016). Body image disturbance in adults treated for cancer—a
concept analysis. Journal of Advanced Nursing, 72(5), 1001–1011.

Concealed pregnancy Tighe, S. M., & Lalor, J. G. (2015). Concealed pregnancy: A concept analysis.
Journal of Advanced Nursing, 72(1), 50–61.


Ethical competence Kulju, K., Stolt, M., Suhonen, R., & Leino-Kilpi, H. (2016). Ethical competence: A
concept analysis. Nursing Ethics, 23(4), 401–412.

Food insecurity Schroeder, K., & Smaldone, A. (2015). Food insecurity: A concept analysis.
Nursing Forum, 50(4), 274–284.

Meaning in work Lee, S. (2015). A concept analysis of ‘Meaning in work’ and its implications for
nursing. Journal of Advanced Nursing, 71(10), 2258–2267.


Evans, E. C. (2016). Exploring the nuances of nurse-patient interaction through
concept analysis: Impact on patient satisfaction. Nursing Science Quarterly, 29(1),

Proactive behavior in

Mestdagh, E., Van Rompaey, B., Beekman, K., Bogaerts, A., & Timmermans, O.
(2016). A concept analysis of proactive behavior in midwifery. Journal of
Advanced Nursing, 72(6), 1236–1250.

Role transition Barnes, H. (2015). Nurse practitioner role transition: A concept analysis. Nursing
Forum, 50(3), 137–146.

Survivor in the
cancer context

Hebdon, M., Foli, K., & McComb, S. (2015). Survivor in the cancer context: A
concept analysis. Journal of Advanced Nursing, 71(8), 1774–1786.

Rodgers first published her evolutionary method for concept analysis in 1989. According to Rodgers (2000),
concept analysis is necessary because concepts are dynamic, “fuzzy,” and context dependent and possess
some pragmatic utility or purpose. Furthermore, because phenomena, needs, and goals change, concepts must
be continually refined and variations introduced to achieve a clearer and more useful meaning.

Rodgers (2000) examined two viewpoints or schools of thought regarding concept development and
showed that the methods of each differ significantly. She termed these methods “essentialism” and
“evolutionary” viewpoints. In her work, she contrasted the essentialist method of concept development as
exemplified by Wilson (1963) and Walker and Avant (1995) with concept development using the
evolutionary method.

The evolutionary method of concept development is a concurrent task approach. In it, the tasks may be
going on all at the same time rather than a sequence of specific steps that are completed before going to the
next step. The activities involved in the evolutionary method are listed in Box 3-4.

Box 3-4 Steps in Rodgers’s Process of Concept Analysis
1. Identify the concept and associated terms.
2. Select an appropriate realm (a setting or a sample) for data collection.
3. Collect data to identify the attributes of the concept and the contextual basis of the concept (i.e.,

interdisciplinary, sociocultural, and temporal variations).
4. Analyze the data regarding the characteristics of the concept.
5. Identify an exemplar of the concept, if appropriate.
6. Identify hypotheses and implications for further development.

Source: Rodgers (2000, p. 85).

Rodgers (2000) defined many terms and explained the process of concept analysis using the evolutionary
view. The goal of the concept analysis will, to an extent, determine how the researcher identifies the concept
of interest and terms and expressions selected. The incorporation of a new term into a nurse’s way of viewing
a client situation is often a circumstance warranting analysis of a new concept.

The goal of the analysis will also influence selection of the setting and sample for data collection. For
instance, the setting may be a library and the sample might be literature. The sampling might be time-oriented,
say literature from the previous 5 years. In any case, the researcher’s goal is to develop a rigorous design


consistent with the purpose of the analysis. The selection of literature from related disciplines might include
those that typically use the concept. An exhaustive review includes all the indexed literature using the concept
and may be limited by a time frame such as several years.

A randomization process is then used to select the sample across each discipline over time. In collecting
and managing the data, a discovery approach is preferred. The focus of the data analysis is on identifying the
attributes, antecedents, and consequences and related concepts or surrogate terms. The attributes located by
this means constitute a “real definition as opposed to a nominal or dictionary definition” (Rodgers, 2000, p.

Rodgers (2000) defines surrogate terms as ways of expressing the concept other than by the term of
interest. She distinguishes between surrogate terms and related concepts by showing that surrogate terms are
different words that express the concept, whereas “related concepts are part of a network that provide a
background” and “lend significance to the concept of interest” (Rodgers, 2000, p. 92).

Analyzing the data can go on simultaneously with its collection according to Rodgers (2000), or it can be
delayed until all the data are collected. The latter is allowed in concept analysis using the evolutionary process
because data are currently available rather than being constantly created by the subjects as in qualitative
research study. The researcher must beware of considering the data “saturated,” that is, redundant, too early.

Identifying an exemplar from the literature, field observation, or interview is important and will provide a
clear example of the concept. Examples of real cases are preferred over constructed cases (in contrast to
Wilson’s [1963] method). The goal is to illustrate the characteristics of the concept in relevant contexts to
enhance the clarity and effective application of the concept.

Interpreting the results involves gaining insight on the current status of the concept and generating
implications for inquiry based on this status and identified gaps. Interpreting the results may involve
interdisciplinary comparison, temporal comparison, and assessment of the social context within which the
concept analysis was conducted.

Identifying implications for further development and formal inquiry may be the result. The results of the
analysis may direct further inquiry rather than giving the final answer on the meaning of the concept. The
implications of this form of research-based concept analysis may yield questions for further research, or
hypotheses may be extracted from the findings. The major outcome of the evolutionary method of concept
analysis is the generation of further questions for research rather than the static definition of the concept.
Table 3-5 lists a number of references for concept analyses using this method. For more information, the
reader is referred to Rodgers (2000).

Table 3-5 Examples of Concept Analyses Using Rodgers’s Methods
Concept Reference

Chronic disease self-

Miller, W., Lasiter, S., Ellis, R. B., & Buelow, J. M. (2015). Chronic disease self-
management: A hybrid concept analysis. Nursing Outlook, 63(2), 154–161.

Cultural competence Garneau, A. B., & Pepin, J. (2015). Cultural competence: A constructivist
definition. Journal of Transcultural Nursing, 26(1), 9–15.

Joy and happiness Cottrell, L. (2016). Joy and happiness: A simultaneous and evolutionary concept
analysis. Journal of Advanced Nursing, 72(7), 1506–1517.

Nursing workload Swiger, P. A., Vance, D. E., & Patrician, P. A. (2016). Nursing workload in the
acute-care setting: A concept analysis of nursing workload. Nursing Outlook,
64(3), 244–254.

Patient autonomy Lindberg, C., Fagerström, C., Sivberg, B., & Willman, A. (2014). Concept
analysis: Patient autonomy in a caring context. Journal of Professional Nursing,
70(10), 2208–2221.

Person-, family-, and
nursing care

Lor, M., Crooks, N., & Tluczek, A. (2016). A proposed model of person-, family-,
and culture-centered nursing care. Nursing Outlook, 64(4), 352–366.

Resilient aging Hicks, M. M., & Conner, N. E. (2014). Resilient ageing: A concept analysis.


Journal of Advanced Nursing, 70(4), 744–755.
Spiritual care of the
child with cancer at
the end of life

Petersen, C. L. (2014). Spiritual care of the child with cancer at the end of life: A
concept analysis. Journal of Advanced Nursing, 70(6), 1243–1253.

Recovery in mental

McCauley, C. O., McKenna, H. P., Keeney, S., & McLauhlin, D. F. (2015).
Concept analysis of recovery in mental illness in young adulthood. Journal of
Psychiatric and Mental Health Nursing, 22(8), 579–589.

Schwartz-Barcott and Kim
A hybrid model of concept development was initially presented by Schwartz-Barcott and Kim in 1986 and
expanded and revised in 1993 and 2000. This method for concept development involves a three-phase
process, which is summarized in Table 3-6.

Table 3-6 Phases of Schwartz-Barcott and Kim’s Hybrid Model of Concept Development
Phase Activities

Theoretical phase Select a concept.
Review the literature.
Determine meaning and measurement.
Choose a working definition.

Fieldwork phase Set the stage.
Negotiate entry into a setting.
Select cases.
Collect and analyze data.

Final analytical phase Weigh findings.
Write report.

Source: Schwartz-Barcott and Kim (2000).

Theoretical Phase
In the theoretical phase, a borrowed concept, an underdeveloped nursing concept, or a concept from clinical
practice may be selected. The main consideration is that the concept has relevance for nursing. A clinical
encounter may be described in detail to arrive at the concept through analysis. The literature is searched
broadly and systematically across disciplines that may use the concept. A set of questions that provides
inquiry into the essential nature of the concept, the means of clear definition, and ways to enhance its
measurability focuses on questions of measurement and definition. Meaning and measurement are dealt with.
This requires thought for comparing and contrasting the data. A working definition is chosen to be used in the
final phase. The definition should maintain a nursing perspective.

Fieldwork Phase
In the fieldwork phase, the concept is corroborated and refined. The fieldwork phase integrates with the
literature phase and expands into a modified qualitative research approach (e.g., participant observation). The
steps of this phase are setting the stage, negotiating entry, selecting cases, and collecting and analyzing the

Analytical Phase
The final analytical phase includes examination of the details in the light of the literature review. The
researcher reviews the findings with the original purpose in view. Three questions guide the final analysis:

1. How much is the concept applicable and important to nursing?
2. Does the initial selection of the concept seem justified?
3. To what extent do the review of literature, theoretical analysis, and empirical findings support the


presence and frequency of the concept within the population selected for empirical study? (Schwartz-
Barcott & Kim, 2000, p. 147)

The final step of the process is to write up the findings. The work may be reported as either fieldwork or
as a concept analysis. Elements the researcher must consider when writing the findings are length of the study,
the intended audience, timing, pacing of the authorship process, anticipated length of the manuscript, how
much detail of the process to include, and ethics of the interpretation of the analysis (Schwartz-Barcott &
Kim, 2000).

Several results can be realized by this type of analysis:

1. The current meaning of the concept can be supported or refined.
2. A different definition than previously used may stand out.
3. The concept may be completely redefined.
4. A new or refined way of measuring the concept may be the result (Schwartz-Barcott & Kim, 1993).
Examples of published reports using this model are listed in Table 3-7.

Table 3-7 Examples of Concept Analyses Using Schwartz-Barcott and Kim’s Hybrid Method
Concept Reference

Breastfeeding Sherriff, N., Hall, V., & Panton, C. (2014). Engaging and supporting fathers to
promote breast feeding: A concept analysis. Midwifery, 30(6), 667–677.


Lee, Y., & Seomun, G. (2016). Development and validation of an instrument to
measure nurses’ compassion competence. Applied Nursing Research, 30, 76–82.

Grief Zucker, D. M., Dion, K., & McKeever, R. P. (2015). Concept clarification of grief
in mothers of children with an addiction. Journal of Advanced Nursing, 71(4), 751–

Meleis (2012) described three strategies to develop conceptual meaning for use in nursing theory, research,
and practice. These are concept exploration, concept clarification, and concept analysis.

Concept Exploration
Concept exploration is used when concepts are new and ambiguous in a discipline, when concepts are
camouflaged by being embedded in the daily nursing discussion, or when a concept from another discipline is
being redesigned for use in nursing. Concept exploration may awaken nurses to a new concept or revitalize
the meanings of an overused concept to make it explicit for practice, research, and theory building. The steps
Meleis (2012) suggests for this endeavor follow:

1. Identifying the major components and dimensions of the concept
2. Raising appropriate questions about the concept
3. Proposing triggers for continuing the exploration
4. Identifying and defining the advantages to the discipline of continuing the exploration of this concept

(p. 373)

Concept Clarification
Concept clarification is used to “refine concepts that have been used in nursing without a clear, shared, and
conscious agreement on the properties of meanings attributed to them” (Meleis, 2012, p. 374). Concept
clarification is a way to refine existing concepts when they lack clarity for a specific nursing endeavor. The
processes involved in concept clarification allow for reduction of ambiguities while critically reviewing the
properties. The processes are presented in Box 3-5.

Box 3-5 Process of Concept Clarification
1. Clarify the boundaries of the concept, including what attributes should be included and what should be


2. Critically review the properties of the concept.
3. Bring to light new dimensions that had not been considered.
4. Compare, contrast, delineate, and differentiate these properties and provide exemplars of the concept.
5. Identify assumptions and philosophical bases about the events that trigger the phenomena and propose

questions from a nursing perspective.

Source: Meleis (2012, p. 374).

Concept Analysis
Concept analysis, according to Meleis (2012), assumes that the concept has been introduced into nursing
literature but is ready to move to the level of development for research. This process implies that the concept
will be broken down to its essentials and then reconstructed for its contribution to the nursing lexicon. The
goal of the analysis is to bring the concept close to use in research or clinical practice and to ultimately
contribute to instrument development and theory testing.

Meleis (2012) focused on an integrated approach to concept development, which includes defining,
differentiating, delineating antecedents and consequences, modeling, analogizing, and synthesizing. Table 3-8
lists each of these components and presents related activities or tasks to be accomplished for each phase. A
few examples using Meleis’s strategies were located in the literature. For example, Olsen and Harder (2010)
combined Meleis’s strategies with Schwartz-Barcott and Kim’s to describe “network-focused nursing.” Clark
and Robinson (2000) used Meleis’s earlier work to describe the concept of multiculturalism, and Felten and
Hall (2001) used Meleis’s strategies to describe the concept of resilience in elderly women.

Table 3-8 Meleis’s Processes for Concept Development
Process Task or Activity

Defining Creating theoretical and operational definitions that clarify ambiguities, enhance
precision, and relate concepts to empirical referents

Differentiating Sorting in and out similarities and differences between the concept being developed
and other like concepts


Defining the contextual conditions under which the concept is perceived and
expected to occur


Defining events, situations, or conditions that may result from the concept

Modeling Defining and identifying exemplars (i.e., clinical referents or research referents) to
illustrate some aspect of the concept. Models may be same or like models, or
contrary models

Analogizing Describing the concept through another concept or phenomenon that is similar and
has been studied more extensively

Synthesizing Bringing together findings, meanings, and properties that have been discovered and
describing future steps in theorizing

Source:Meleis ( 2012, pp. 384–386).

In response to concerns that some concepts in the nursing lexicon had been derived and not developed
adequately for nursing, or had become overused by those who did not clarify them, Morse (1995) developed a
method of concept development to enhance clarity and distinctiveness of nursing concepts. In this method, she
used the term “advanced techniques of concept analysis” and described the processes of concept delineation,
concept comparison, and concept clarification.


Concept Delineation
Concept delineation is a strategy that requires an extensive literature search and assists in separating two
terms that seem closely linked. The concepts are then compared and contrasted to identify commonalities,
similarities, and differences such that distinctions may be drawn between the terms (Morse, 1995).

Concept Comparison
Concept comparison clarifies competing concepts, again using an extensive literature review and keeping the
literature for each concept separate. Three phases are used in the comparison:

1. Preconditions—the status of the concept in nursing and its use in teaching or clinical practice
2. Process—the type of nursing response to the concept, at what level of consciousness it occurs, and, if

it is identified with the client, at what level
3. Outcomes—whether the concept was used to identify process or product, its accuracy in prediction,

the client’s condition, and the client’s experience with the concept (Morse, 1995, pp. 39–41)

Concept Clarification
For Morse (1995), concept clarification is used with concepts that are “mature” and have a large body of
literature identifying and using them. The concept clarification process requires a “literature review to identify
the underlying values and to identify, describe and compare and contrast the attributes of each” (p. 41).

Published reports using Morse’s methods for concept development can be found in the nursing literature.
For example, Hawkins and Morse (2014) modified the technique to describe the concept of courage as a
foundation for care. Other examples of concepts developed by nurse scholars using Morse’s techniques are:
quality pain management in hospitalized adults (Zoëga, Gunnarsdottir, Wilson, & Gordon, 2016), “crying that
heals” (Griffith, Hall, & Fields, 2011), and rest (Bernhofer, 2016).

Penrod and Hupcey
Penrod and Hupcey (2005) built on Morse’s method and termed their method “principle-based concept
analysis.” Explaining their intent to “determine and evaluate the state of the science surrounding the concept”
(p. 405) and “produce evidence that reveals scholars’ best estimate of ‘probable truth’ in the scientific
literature” (p. 406), they outlined four principles for their method: epistemologic, pragmatic, linguistic, and
logical (Box 3-6).

Box 3-6 Four Principles of Concept Analysis
Epistemologic principle is based on the question “Is the concept clearly defined and well differentiated

from other concepts?” (p. 405).
Pragmatic principle, in which the question to be answered is “Is the concept applicable and useful within

the scientific realm or inquiry? Has it been operationalized?” In this principle, they believe that an
operationalized concept has achieved a level of maturity (p. 405).

Linguistic principle asks, “Is the concept used consistently and appropriately within context?” (p. 406).
Similarly to Morse and to Rodgers, they find that context or lack of context is a factor important in this
type of analysis (p. 406).

Logical principle applies the question “Does the concept hold its boundaries through theoretical integration
with other concepts?” (p. 406). The authors require that the concept not be blurred with respect to other
concepts but that it remains logically clear and distinct.

Source: Penrod and Hupcey (2005, pp. 405–406).

Penrod and Hupcey (2005) explain that in their method of concept analysis, the findings “are summarized
as a theoretical definition that integrates an evaluative summary of each of the criteria posed by the four over-
arching principles.” To do this, the researcher must consider three issues: (1) selection of appropriate
disciplinary literature for review, (2) assurance of the adequacy and appropriateness of the sample derived


from the literature, and (3) employment of “within- and across-discipline analytic techniques.” They have
elucidated that this advanced level of concept development seems to be more relevant to the research
endeavor, as it is a research-based concept analysis.

Despite being developed relatively recently, examples of published works using Penrod and Hupcey’s
(2005) method for concept analysis can be found. For example, Lindauer and Harvath (2014) used a hybrid of
Penrod and Hupcey’s principle-based method to analyze the concept of predeath grief in the context of family
care giving with a dementia victim, and Watson (2015) used the principle-based method of Penrod and
Hupcey to analyze the concept of wrong site surgery. Lastly, Mikkelsen and Frederiksen (2011) analyzed the
concept of “family-centered care” of hospitalized children using Penrod and Hupcey’s method.

Comparison of Models for Concept Development
The nursing literature contains several comparisons and critiques of the various models and methods for
concept development/concept analysis. Indeed, Hupcey and colleagues (1996) and Morse and colleagues
(1996) provided a detailed and well-researched comparison of the techniques presented by Walker and Avant
(1983), Schwartz-Barcott and Kim (1993), and Rodgers (1989). Strengths and weaknesses of each method
were described in their papers. More recently, Duncan and colleagues (2007) and Weaver and Mitcham
(2008) reviewed the history of concept analysis comparing the major methods in common use. Finally,
Risjord (2009) reexamined the philosophical basis and intent of concept analysis and concluded that rather
than preceding theory development, it must be a part of theory development. Table 3-9 compares the various
formats for concept development/concept analysis described earlier.

Table 3-9 Comparison of Selected Methods of Concept Development

Author(s) Method Purpose No. of Steps


Walker and


meaning of

8 Model,

Identify empirical
referents and
antecedents and

Rodgers Evolutionary

Refine and
concepts for
use in research
and practice

5 Model only

appropriate realm
(setting and
sample); analyze
data about
or temporal
hypotheses and
implications for
further study

Barcott and

Hybrid model
of concept

Support or
refine the
meaning of a
concept and/or
develop a new
or refined way

3 phases Model case,
contrary case

Develop working
definitions, search
collect and


to measure a

analyze data, write

Meleis Concept

relate concepts
to empirical

7 Same or like

Define concept,
use an analogy to
describe a similar
similarities and
between like
antecedents and

Morse Concept

Clarifies the
meaning of

3 phases Not specified Use extensive
literature review
to examine and
(status of use of
the concepts in
teaching or
practice), process,
and outcomes of
use of the concept

Penrod and

based concept


4 phases based
on principles

Not specified Sampling within
bodies of large
literature yields a
theoretically based

Rebecca Wallis, the nurse from the opening case study, identified a new phenomenon that was pertinent to her
practice of oncology nursing and decided to develop the concept more fully. By applying techniques of
concept analysis to the PMG reaction, she began the process of formulating information on this concept that
could ultimately be used by other nurses in practice or research.

The process of developing concepts includes reviewing the nurse’s area of interest, examining the
phenomena closely, pondering the terms that are relevant and that fit together with reality, and
operationalizing the concept for practice, research, or educational use. Whether advanced practice nurses or
nursing scholars elect to use the methods proposed by Wilson (1963), Walker and Avant (2011), Morse
(1995), Rodgers (2000), Schwartz-Barcott and Kim (2000), Meleis (2012), Penrod and Hupcey (2005), or a
combination, it is clear that the process of developing, clarifying, comparing and contrasting, and integrating
well-derived and defined concepts is necessary for theory development and to guide research studies. This
will, in turn, ultimately benefit practice. Chapter 4 builds on the process of concept development by
describing the processes used to link concepts to form relationship statements and to construct conceptual
models, frameworks, and theories.


Key Points
A concept is a symbolic statement that describes a phenomenon or a class of phenomena.
There are many different ways to explain or classify concepts (e.g., abstract vs. concrete and variable vs.

Concepts used in nursing practice, research, education, and administration can come from the natural world

(e.g., biology and environment), from research, or from other disciplines.
Concept analysis/concept development refers to the rigorous process of bringing clarity to the definition of

the concepts used in nursing science.
When theoretically and operationally defined, the concepts can be readily applied in nursing practice,

research, education, and administration.
Several methods for concept analysis/concept development have been described in the nursing literature.

The following is an outline delineating the steps of a concept analysis using Rodgers’s
(2000) evolutionary method.

Barkimer, J. (2016). Clinical growth: An evolutionary concept analysis. Advances in
Nursing Science, 39(3), E28–E29.

1. Identify the concept and associated terms.

Concept: Clinical growth

Associated terms: student preparedness, student growth, student development, clinical
learning, student learning, student experiences

2. Select an appropriate realm (setting) for data collection.

The realm for the study was a search of the Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Health Science in ProQuest, Cochrane Library,
MEDLINE, PubMed, Ovid, Web of Science, ERIC, and PsycINFO between 2004 and

3. Identify the attributes of the concept and the contextual basis of the concept.

Attributes of clinical growth:

a. Higher level thinking
b. Socialization
c. Skill development
d. Self-reflection
e. Self-investment
f. Interpersonal communication
g. Linking theory to practice

4. Specify the characteristics of the concept.


a. Having a quality educator
b. Supportive environment
c. Intrinsic characteristics

Consequences: Five themes were presented.

a. Lifelong learning
b. Transition toward autonomy
c. Personal growth
d. Competency


e. Confidence

5. Identify an exemplar of the concept.

An exemplar case study was presented:

It described a senior-level nursing student who was completing his pediatric rotation. Each
of the critical attributes (e.g., quality educator, self-investment, socialization) were
present. The resulting consequences included personal growth, competency, and

6. Identify hypotheses and implications for development.

For further study and application, the author suggested:

Development of a clinical performance evaluation tool based on the identified critical
attributes to facilitate student-entered learning

Learning Activities
1. Collect and review several of the concept analyses mentioned in the chapter. How are they

operationalized? How can they be used for research? In what form(s) of research would you
expect to see the concepts you have chosen used?

2. Review the different methods for concept development presented. How are the methods alike?
How are they different? Which method appears to be the most likely to reveal a concept suited
to the process that the author desires?

3. Consider a phenomenon you have observed in your practice that might be appropriate for
further development. Discuss the phenomenon with colleagues and try to name it and
determine how you might develop it further.

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Theory Development

Structuring Conceptual Relationships in Nursing

Melanie McEwen

Jill Watson is enrolled in a master’s nursing program and is beginning work on her thesis. As an occupational
health nurse at a large telecommunication manufacturing company for the past 7 years, Jill has concentrated
much of her practice on health promotion. She has organized numerous health fairs, led countless health help
sessions, regularly posted health information on intranet bulletin boards, and provided screening programs for
many illnesses. Despite her efforts to improve the health of the workers, many still smoke, are overweight, do
not exercise, and have other deleterious lifestyle habits. Realizing that lack of information about health-related
issues is not a problem, Jill has focused on trying to understand why people choose not to engage in positive
health practices. As a result, she became interested in the concept of motivation.

In one of her early courses in her master’s program, Jill completed an analysis of the concept of health
motivation. During this exercise, she defined the concept; identified antecedents, consequences, and empirical
referents; and developed a number of case studies, including a model case, a related case, and a contrary case.

As her studies progressed, Jill reviewed the literature from nursing, psychology, and sociology on health
beliefs and health motivation and discovered several related theories. The Health Belief Model appeared to
best explain her impressions of the issues at hand, but the model had not been developed for nursing and did
not completely fit her concept of the variables and issues in health motivation. For her thesis, she decided to
modify the Health Belief Model to focus on the concept of health motivation and to develop an instrument to
measure the variables she had generated in her earlier work.

In nursing, theories are systematic explanations of events in which constructs and concepts are identified;
relationships are proposed; and predictions are made to describe, explain, predict, or prescribe practice and
research (Dickoff, James, & Wiedenbach, 1968; Streubert & Carpenter, 2011). Without nursing theory,
nursing activities and interventions are guided by rote, tradition, some outside authority, or hunches, or they
may simply be random.

Theories are not discovered; rather, they are constructed or developed to describe, explain, or understand
phenomena or solve nagging problems (e.g., Why don’t people apply knowledge of positive health
practices?). In the past, nursing leaders saw theory development as a means of clearly establishing nursing as
a profession, and throughout the last 50 years, many nursing scholars developed models and theories to guide
nursing practice, nursing research, nursing administration and management, and nursing education. As
discussed in Chapter 2, these models and theories have been created at different levels (grand, middle range,
practice) and for different purposes (description, explanation, prediction, etc.).

Theory development seeks to help the nurse understand practice in a more complete and insightful way
and provides a method of identifying and expressing key ideas about the essence of practice. Theories help
organize existing knowledge and aid in making new and important discoveries to advance practice (Walker &
Avant, 2011). As illustrated earlier in the case study, development and application of nursing theory are
essential to revise, update, and refine the practice of nursing and to further advance the profession.


Overview of Theory Development
Several terms related to the creation of theory are found in the nursing literature. Theory construction, theory
development, theory building, and theory generation are sometimes used synonymously or interchangeably. In
other cases (Cesario, 1997; Walker & Avant, 2011), authors have differentiated the constructs or subsumed
one term as a component or process within another. In this chapter, the term theory development is used as the
global term to refer to the processes and methods used to create, modify, or refine a theory. Theory
construction is used to describe one of the final steps of theory development in which the components of the
theory are organized and linkages specified.

Theory development is a complex, time-consuming process that covers a number of stages or phases from
inception of concepts to testing of theoretical propositions through research (Powers & Knapp, 2010). In
general, the process of theory development begins with one or more concepts that are derived from within a
discipline’s metatheory or philosophy. These concepts are further refined and related to one another in
propositions or statements that can be submitted to empirical testing (Chinn & Kramer, 2015; Peterson, 2017;
Reynolds, 1971).

Categorizations of Theory
As described in Chapter 2, theories are often categorized using different criteria. Theories may be grouped
based on scope or level of abstraction (grand theory, middle range theory, practice theory), the purpose of the
theory, or the source or discipline in which the theory was developed.

Categorization Based on Scope or Level of Abstraction
An overview of “levels of theory” was presented in Chapter 2. In nursing, theories are often viewed based on
scope or level of abstraction, where the most global or abstract level is the philosophical, or metatheory level,
followed by grand theory, middle range theory, and practice theory. In the early years of nursing theory
(1950–1980), theory development was largely at the metatheory and grand theory levels. Recently, however,
there has been a significant shift with recognition of the need to focus more on middle range and practice
(situation-specific) theories that are more relevant to nursing practice and more amenable to testing through
research. The following sections will review and expand on each level of theory.

Philosophy, Worldview, or Metatheory
Metatheory refers to the philosophical and methodologic questions related to developing a theoretical base for
nursing. It has also been termed “worldview” by some (Hickman, 2011). According to Walker and Avant
(2011), metatheory deals with the processes of generating knowledge and debating broad issues related to the
nature of theory, types of theory needed, and suitable criteria for theory evaluation. Chapter 1 discussed a
number of philosophical issues related to a worldview or metatheory in nursing, including epistemology,
research methods, and related questions.

Grand Theories
In nursing, grand theories are composed of relatively abstract concepts that are not operationally defined and
attempt to explain or describe very comprehensive aspects of human experience and response. Grand theories
consist of conceptual frameworks defining broad perspectives for practice and ways of looking at nursing
phenomena based on these perspectives. They provide global viewpoints for nursing practice, education, and
research, but they are limited because of their generality and abstractness. Indeed, because of their level of
abstraction, these theories are often considered to be difficult to apply to the daily practice of nurses and are
difficult to test (Hickman, 2011; Higgins & Shirley, 2000; Peterson, 2017; Walker & Avant, 2011).

Early grand nursing theories focused on the nurse–client relationship and the role of the nurse. Later grand
theories expanded to more encompassing concepts (holistic perspective, interpersonal relations, social
systems, and health). Recent grand theories have attempted to address phenomenologic aspects of nursing
(caring, transcultural issues) (Moody, 1990). Chapters 6 through 9 provide an examination of grand nursing


Middle Range Theories
The need for practice disciplines to develop middle range theories was first proposed in the field of sociology
in the 1960s. In nursing, development of middle range theory is growing to fill the gaps between grand
nursing theories and nursing practice.

Compared to grand theories, middle range theories contain fewer concepts and are limited in scope.
Within the scope of middle range theories, however, some degree of generalization is possible across specialty
areas and settings. Propositions are clear, and testable hypotheses can be derived. Middle range theories cover
such concepts as pain, symptom management, cultural issues, and health promotion (Higgins & Shirley, 2000;
Peterson, 2017; Walker & Avant, 2011). Chapters 10 and 11 provide a detailed discussion of middle range
theories and their application in nursing.

Practice Theories
Practice theories (microtheories, situation-specific, or prescriptive theories) explain prescriptions or modalities
for practice. The essence of practice theory is a defined or identified goal and descriptions of interventions or
activities to achieve this goal (Walker & Avant, 2011). Practice theories can cover particular elements of a
specialty, such as oncology nursing, obstetric nursing, or operating room nursing, or they may relate to
another aspect of nursing, such as nursing administration or nursing education. Such theories typically
describe specific elements of nursing care, such as cancer pain relief, or a specific experience, such as dying
and end-of-life care.

Practice theories contain few concepts, are narrow in scope, and explain a relatively small aspect of
reality. They are derived from middle range theories, practice experiences, comprehensive literature reviews,
and empirical testing (Peterson, 2017). Furthermore, when the concepts and statements are operationally
defined, they may be tested by appropriate research strategies (Higgins & Shirley, 2000). Chapters 12 and 18
cover practice—or situation-specific—theories in more detail.

Relationship Among Levels of Theory in Nursing
Walker and Avant (2011) state that the four levels of theory may be linked in order to direct and focus the
discipline of nursing. As they describe, metatheory (worldview or philosophy) clarifies the methodologies and
roles for each subsequent level of theory development (grand, middle range, and practice). Each level of
theory provides material for further analysis and clarification at the level of metatheory. Grand nursing
theories guide the phenomena of concern at the middle range level. Middle range theories assist in refinement
of grand theories and direct prescriptions of practice theories. Practice theories are constructed from
scientifically based propositions about reality and test the empirical validity of those propositions as they are
incorporated into client care (Higgins & Shirley, 2000). Figure 4-1 illustrates the relationships among the
levels of theory in nursing.

Figure 4-1 Relationship among levels of theory.
(From Walker , L. O. , & Avant , K. C. Strategies for Theory Construction in Nursing, 5th ed., © 2011. Reprinted by permission of Pearson
Education, Inc., New York, New York.)

Categorization Based on Purpose
As discussed in Chapter 2, Dickoff and James (1968) described four kinds of theory: factor-isolating theories
(descriptive theories), factor-relating theories (explanatory theories), situation-relating theories (predictive
theories), and situation-producing theories (prescriptive theories). Each higher level of theory builds on the


lower levels (Dickoff et al., 1968), and each is reviewed and expanded upon in the following sections.

Descriptive Theories
Descriptive theories describe, observe, and name concepts, properties, and dimensions, but they typically do
not explain the interrelationships among the concepts or propositions, and they do not indicate how changes in
one concept affect other concepts. According to Barnum (1998), descriptive theory is the first and most
important level of theory development because it determines what will be perceived as the essence of the
phenomenon under study. Subsequent theory development expands or refines those elements and specifies
relationships that are determined to be important in the descriptive phase. Thus, it is critical that the most
significant constituents of the phenomenon be recognized and named in this earliest phase of theory

The two types of descriptive theory are naming and classification. Naming theories describe the dimension
or characteristics of a phenomenon. Classification theories describe dimensions or characteristics of a
phenomenon that are structurally interrelated and are sometimes referred to as typologies or taxonomies
(Barnum, 1998; Fawcett, 1999).

Descriptive theories are generated and tested by descriptive or explanatory research. Techniques for
generating and testing descriptive theory include concept analysis, case studies, comprehensive literature
review, surveys, phenomenology, ethnography, grounded theory, and historical inquiry (Fawcett, 1999).
Examples of descriptive theory found in recent nursing literature include the development of a conceptual
model of “almost normal,” which describes the experience of adolescents living with implantable cardioverter
defibrillators (phenomenology) (Zeigler & Tilley, 2011); development of a middle range theory describing the
process of death imminence awareness by family members (grounded theory) (Baumhover, 2015); and a
middle range theory of nursing presence (comprehensive literature review) (McMahon & Christopher, 2011).
In other examples, concept analysis was used as the method to develop a theoretical model of food insecurity
(Schroeder & Smaldone, 2015) and by Lindauer and Harvath (2014) who proposed a situation-specific theory
of predeath grief among caregivers of dementia patients.

Explanatory Theories
Explanatory theory is the second level in theory development. Once phenomena have been identified and
named, they can be viewed in relation to other phenomena. Explanatory theories relate concepts to one
another and describe and specify some of the associations or interrelations between and among the concepts.
Furthermore, explanatory theories attempt to tell how or why the concepts are related and may deal with
causality, correlations, and rules that regulate interactions (Barnum, 1998; Dickoff et al., 1968).

Explanatory theories can be developed only after the parts of the phenomena have been identified and
tested, and they are generated and tested by correlational research. Correlational research requires collection
or measurement of data gathered by observation or self-report instruments that will yield either qualitative or
quantitative data (Fawcett, 1999). Explanatory theories may also be generated by processes involving in-depth
integrative/systematic and rigorous review of extant research literature. Examples of explanatory theories
from recent nursing literature include meta-synthesis of qualitative study data in development of a model
describing the experience of cancer among teenagers and young adults (Taylor, Pearce, Gibson, Fern, &
Whelan, 2013) and a model of nursing care dependence as experienced by adult patients (Piredda et al., 2015).
Similarly, Carr (2014) synthesized findings from three qualitative studies to develop a middle range theory of
family vigilance, which describes the day-to-day experiences of family members staying with hospitalized

Predictive Theories
Predictive theories describe precise relationships between concepts and are the third level of theory
development. Predictive theories presuppose the prior existence of the more elementary types of theory. They
result after concepts are defined and relational statements are generated and are able to describe future
outcomes consistently. Predictive theories include statements of causal or consequential relatedness (Dickoff
et al., 1968).

Predictive theories are generated and tested by experimental research involving manipulation of a


phenomenon to determine how it affects or changes some dimension or characteristic of another phenomenon
(Fawcett, 1999). Different research designs may be used in this process. These include pretest–posttest
designs, quasi-experiments, and true experiments. These research studies produce quantifiable data that are
statistically analyzed. Metasynthesis of research studies or comprehensive reviews of research can also be the
source of predictive theories. Examples of predictive theories include a model describing the health-related
outcomes of resilience in adolescents (Scoloveno, 2015), a theory of family interdependence that predicted the
relationships between spirituality and psychological well-being among elders and their family caregivers
(Kim, Reed, Hayward, Kang, & Koenig, 2011), and a model predicting emotional exhaustion among
hemodialysis nurses (Hayes, Douglas, & Bonner, 2014). In an interesting work, Tourangeau (2005)
synthesized research literature from multiple sources to propose a theoretical model predicting patient
mortality. She identified the following contributing or determining factors to mortality: nurses’ staffing,
burnout, satisfaction, skill mix, experience, and role support as well as such factors as physician expertise,
hospital location, and patient characteristics (e.g., age, gender, comorbidity, socioeconomic status, and

Prescriptive Theories
Prescriptive theories are perceived to be the highest level of theory development (Dickoff et al., 1968).
Prescriptive theories prescribe activities necessary to reach defined goals. In nursing, prescriptive theories
address nursing therapeutics and predict the consequence of interventions (Meleis, 2012). Prescriptive theories
have three basic components: (1) specified goals or outcomes, (2) explicit activities to be taken to meet the
goal, and (3) a survey list that articulates the conceptual basis of the theory (Dickoff et al., 1968).

According to Dickoff and colleagues (1968), the outcome or goal of a prescriptive theory serves as the
norm or standard by which to evaluate activities. The goal must articulate the context of the situation, and this
provides the basis for testing to determine whether the goal has been achieved. The specified actions or
activities are those nursing interventions that should be taken to realize the goal. The goal will not be realized
without the activity, and prescriptions for activities directly affect the goals.

The survey list augments and supplements the prescribed activities. In addition, it serves to prepare for
future prescriptive activities. The survey list asks six questions about the prescribed activity that relate to the
delineated goal (Box 4-1). In current vernacular, as practice guidelines based on research, evidence-based
practice (EBP) consists of many attributes of prescriptive theory. This will be discussed in more detail in
Chapter 12.

Box 4-1 Survey List of Questions for Prescriptive Theories
1. Who performs the activity? (agency)
2. Who or what is the recipient of the activity? (patiency)
3. In what context is the activity performed? (framework)
4. What is the end point of the activity? (terminus)
5. What is the guiding procedure, technique, or protocol of the activity? (procedure)
6. What is the energy source for the activity? (dynamics)

Source: Dickoff et al. (1968).

Examples of prescriptive theory are becoming more common in the literature, enhanced by the expanding
volume of nursing research and increasing calls for EBP. In one work, Ade-Oshifogun (2012) presented a
research-tested and research-supported model to assist and support clinicians to develop interventions to
reduce or minimize truncal obesity in people with chronic obstructive pulmonary disease (COPD). The
descriptions of feeding, pelvic floor exercise, therapeutic touch, and latex precautions are only a few of many
excellent examples of nursing interventions presented by Bulechek, Butcher, Dochterman, and Wagner
(2012). Lastly, Finnegan, Shaver, Zenk, Wilkie, and Ferrans (2010) developed the “symptom cluster
experience profile” framework to anticipate symptom clusters and derive interventions and clinical practice
guidelines among survivors of childhood cancers.


Categorization Based on Source or Discipline
Theories may be classified based on the discipline or source of origin. As briefly discussed in Chapter 1,
many of the theories used in nursing are borrowed, shared, or derived from theories developed in other
disciplines. Because nursing is a human science and a practice discipline, incorporation of shared theories into
practice and modification of them for use and testing are common.

Nurses use theories and concepts from the behavioral sciences, biologic sciences, and sociologic sciences
as well as learning theories and organizational and management theories, among others. In many cases, these
concepts and theories will overlap. For example, adaptation and stress are concepts found in both the
behavioral and biologic sciences, and multiple theories have been developed using these concepts.
Additionally, some theories defy placement in one discipline but relate to many. These include such basic
concepts as systems theory, change theory, and chaos.

This book discusses a number of theories and concepts organized in terms of sociologic sciences,
behavioral sciences, biomedical sciences, administration and management sciences, and learning theories.
Table 4-1 presents examples of theories from each of these areas. Although by no means exhaustive, Chapters
13 through 17 provide information on many of the shared theories commonly used in nursing practice,
research, education, and administration.

Table 4-1 Shared Theory Used in Nursing Practice and Research
Disciplines Examples of Theories Used by Nurses

Theories from sociologic sciences Family systems theory
Feminist theory
Role theory
Critical social theory

Theories from behavioral sciences Attachment theory
Theories of self-determination
Lazarus and Folkman’s theory of stress, coping, and

Theory of planned behavior

Theories from biomedical sciences Pain
Self-regulation theory
Immune function
Germ theory

Theories from administration and management

Donabedian’s quality framework
Theories of organizational behavior
Models of conflict and conflict resolution
Job satisfaction

Learning theories Bandura’s social cognitive learning theory
Developmental learning theory
Prospect theory

Components of a Theory
A theory has several components, including purpose, concepts and definitions, theoretical statements,
structure/linkages and ordering, and assumptions (Chinn & Kramer, 2015; Hardin, 2014; Powers & Knapp,
2010). Creation of conceptual models is also a component of theory development that is promoted to further
explain and define relationships, structure, and linkages.

The purpose of a theory explains why the theory was formulated and specifies the context and situations in


which it should be applied. The purpose might also provide information about the sociopolitical context in
which the theory was developed, circumstances that influenced its creation, the theorist’s past experiences,
settings in which the theory was formulated, and societal trends. The purpose of the theory is usually
explicitly described and should be found within the discussion of the theory (Chinn & Kramer, 2015).

Concepts and Conceptual Definitions
Concepts and concept development are described in detail in Chapter 3. Concepts are linguistic labels that are
assigned to objects or events and are considered to be the building blocks of theories. The theoretical
definition defines the concept in relation to other concepts and permits the description and classification of
phenomena. Operationally defined concepts link the concept to the real world and identify empirical referents
(indicators) of the concept that will permit observation and measurement (Chinn & Kramer, 2015; Hardin,
2014; Walker & Avant, 2011). Theories should include explicit conceptual definitions to describe and clarify
the phenomenon and explain how the concept is expressed in empirical reality.

Theoretical Statements
Once a concept is fully developed and presented, it can be combined with other concepts to create statements
to describe the real world. Theoretical statements, or propositions, are statements about the relationship
between two or more concepts and are used to connect concepts to devise the theory. Statements must be
formulated before explanations or predictions can be made, and development of statements asserting a
connection between two or more concepts introduces the possibility of analysis (Hardin, 2014). The several
types of theoretical statements include propositions, laws, axioms, empirical generalizations, and hypotheses
(Table 4-2).

Table 4-2 Types of Relationship Statements
Type of Statement Characteristics

Axioms Consist of a basic set of statements or propositions that state the general
relationship between concepts. Axioms are relatively abstract; therefore, they are
not directly observed or measured.


Summarize empirical evidence. Empirical generalizations provide some confidence
that the same pattern will be repeated in concrete situations in the future under the
same conditions.

Hypotheses Statements that lack support from empirical research but are selected for study. The
source of hypotheses may be a variation of a law or a derivation from an axiomatic
theory, or they may be generated by a scientist’s intuition (a hunch). All concepts
in a hypothesis must be measurable, with operational definitions in concrete

Laws Well-grounded, with strong empirical support and evidence of empirical
regulatory. Laws contain concepts that can be measured or identified in concrete

Propositions Statements of a constant relationship between two or more concepts or facts.

Sources: Hardy (1973); Jacox (1974); Reynolds (1971).

Theoretical statements can be classified into two groups. The first group consists of statements that claim
the existence of phenomena referred to by concepts (existence statements). The second group describes
relationships between concepts (relational statements) (Reynolds, 1971).

Existence Statements
Existence statements and definitions relate to specific concepts and make existence claims about that concept
(e.g., that chair is brown or that man is a nurse). Each statement has a concept and is identified by a term that
is applied to another object or phenomena. Existence statements serve as adjuncts to relational statements and


clarify meanings in the theory. Existence statements are also termed nonrelational statements and may be
right or wrong depending on the circumstances (Reynolds, 1971).

Relational Statements
Existence statements can only name and classify objects. Knowing the existence of one concept may be used
to convey information about the existence of other concepts. Relational statements assert that a relationship
exists between the properties of two or more concepts. This relationship is basic to development of theory and
is expressed in terms of relational statements that explain, predict, understand, or control.

Like concepts, statements may have different levels of abstraction (theoretical and operational). The more
general statements contain theoretically defined concepts. If the theoretical concepts are replaced with
operational definitions, then the statement is “operationalized.” The two broad groups of relational statements
are those that describe an association between two concepts and those that describe a causal relationship
between two concepts (Reynolds, 1971).

Associational or Correlational Relationships. Associational statements describe concepts that occur or exist
together (Reynolds, 1971; Walker & Avant, 2011). The nature of the association/correlation may be positive
(when one concept occurs or is high, the other concept occurs or is high). For example, as the external
temperature rises during the summer, consumption of ice cream increases. An example in human beings is a
positive correlation between height and weight—as people get taller, in general, their weight will increase.

The association may be neutral when the occurrence of one concept provides no information about the
occurrence of another concept. For example, there is no correlation between gender and scores on a
pharmacology examination. Finally, the association may be negative. In this case, when one concept occurs or
is high, the other concept is low and vice versa. For example, failure to use condoms regularly is associated
with an increase in the occurrence of sexually transmitted infections.

Causal Relationships. In causal relationships, one concept is considered to cause the occurrence of a second
concept. For example, as caloric intake increases, weight increases. In scientific research, the concept or
variable that is the cause is typically referred to as the independent variable and the variable that is affected is
referred to as the dependent variable.

In science, there is often disagreement about whether a relationship is causal or simply highly correlated.
A classic example is the relationship between cigarette smoking and lung cancer. As early as the 1940s, an
association between smoking and lung cancer was recognized, but not until the 1980s was it determined that
smoking actually caused lung cancer. Likewise, genetic predisposition is associated with development of
heart disease; it has not been shown to cause heart disease.

Structure and Linkages
Structuring the theory by logical arrangement and specifying linkages of the theoretical concepts and
statements is critical to the development of theory. The structure of a theory provides overall form to the
theory. Theory structuring includes determination of the order of appearance of relationships, identification of
central relationships, and delineation of direction, strength, and quality of relationships (Chinn & Kramer,

Although theoretical statements assert connections between concepts, the rationale for the stated
connections needs to be developed. Theoretical linkages offer a reasoned explanation of why the variables in
the theory may be connected in some manner, which brings plausibility to the theory. When developed
operationally, linkages contribute to the testability of the theory by specifying how variables are connected.
Thus, conceptual arrangement of statements and linkages can lead to hypotheses (Hardin, 2014).

Assumptions are notations that are taken to be true without proof. They are beliefs about a phenomenon that
one must accept as true to accept a theory, and although they may not be empirically testable, they can be
argued philosophically. The assumptions of a theory are based on what the theorist considers to be adequate
empirical evidence to support propositions, on accepted knowledge, or on personal beliefs or values (Jacox,
1974; Powers & Knapp, 2010). Assumptions may be in the form of factual assertions or they may reflect


value positions. Factual assumptions are those that are known through experience. Value assumptions assert
or imply what is right, or good, or ought to be (Chinn & Kramer, 2015).

In a given theory, assumptions may be implicit or explicit. In many nursing theories, they must be “teased
out.” Furthermore, it is often difficult to separate assumptions that are implicit or integrated into the narrative
of the theory from relationship statements (Powers & Knapp, 2010).

Models are schematic representations of some aspect of reality. Various media are used in construction of
models; they may be three-dimensional objects, diagrams, geometric formulas, or words. Empirical models
are replicas of observable reality (e.g., a plastic model of a uterus or an eye). Theoretical models represent the
real world through language or symbols and directional arrows.

In a classic work, Artinian (1982) described the rationale for creating a theoretical or conceptual model.
She determined that models help illustrate the processes through which outcomes occur by specifying the
relationships among the variables in graphic form where they can be examined for inconsistency,
incompleteness, or errors. By creating a model of the concepts and relationships, it is possible to trace the
effect of certain variables on the outcome variable rather than making assertions that each variable under
study is related to every other variable. Furthermore, the model depicts a process that starts somewhere and
ends at a logical point. Using the model, a person should be able to explain what happened, predict what will
happen, and interpret what is happening. Finally, Artinian stated that once a model has been conceptually
illustrated, the phenomenon represented can be examined in different settings testing the usefulness and
generalizability of the underlying theory. The figure in the exemplar at the end of the chapter shows a model
illustrating the relationships between the variables of the perceived access to breast health care in African
American women theory.

Theory Development
Several factors are vital for nurses to examine the process of theory development. First, an understanding of
the relationship among theory, research, and practice should be recognized. Second, the nurse should be aware
that there are various approaches to theory development based on the source of initiation (i.e., practice, theory,
or research). Finally, the process of theory development should be understood. Each of these factors is
discussed in the following sections.

Relationship Among Theory, Research, and Practice
Many nurses lack a true understanding of the interrelationship among theory, research, and practice and its
importance to the continuing development of nursing as a profession (Pryjmachuk, 1996). As early as the
1970s, nursing scholars commented on the relationships among theory, research, and practice. Indeed, at that
time, nursing leaders urged that nursing research be combined with theory development to provide a rational
basis for practice (Flaskerud, 1984; Moody, 1990).

In applied disciplines such as nursing, practice is based on the theories that are validated through research.
Thus, theory, research, and practice affect each other in a reciprocal, cyclical, and interactive way (Hickman,
2011; Marrs & Lowry, 2006) (Figure 4-2).

Figure 4-2 Research–theory–practice cycle.

Relationship Between Theory and Research
Research validates and modifies theory. In nursing, theories stimulate nurse scientists to explore significant


problems in the field of nursing. In doing so, the potential for the development of nursing knowledge
increases (Meleis, 2012). Theories can be used to formulate a set of generalizations to explain relationships
among variables. When empirically tested, the results of research can be used to verify, modify, disprove, or
support a theoretical proposition.

Relationship Between Theory and Practice
Theory guides practice. One of the primary uses of theory is to contribute insights about nursing practice
situations through provision of goals for assessment, diagnosis, and intervention. Likewise, through practice,
nursing theory is shaped, and guidelines for practice evolve. Theory renders practice more efficient and more
effective, and the ultimate benefit of theory application in nursing is the improvement in client care (Meleis,

Relationship Between Research and Practice
Research is the key to the development of a discipline. Middle range and practice theories may be tested in
practice through clinical research (Hickman, 2011). If individual practitioners are to develop expertise, they
must participate in research. In summary, there is a need to encourage nurses to test and refine theories and
models to develop their own personal models of practice (Marrs & Lowry, 2006; Pryjmachuk, 1996).

Approaches to Theory Development
Several different approaches may be used to initiate the process of theory development. Meleis (2012) cites
four major strategies differentiated by their origin (theory, practice, or research) and by whether sources from
outside of nursing were used to develop the theory. These approaches are theory to practice to theory, practice
to theory, research to theory, and theory to research to theory. She then proposes employment of an integrated
approach to theory development. Table 4-3 summarizes these different approaches.

Table 4-3 Strategies for Theory Development

Origin of Theory
Basis for
Development Type of Theory Methods for Development


An existing non-
nursing theory that
can help describe and
explain a
phenomenon, but the
theory is not
complete or not
completely developed
for nursing

Borrowed or shared

Theorist selects a non-nursing
theory; analyzes the theory;
defines and evaluates each
component; and redefines
assumptions, concepts, and
propositions to reflect nursing.

Practice–theory Existing theories are
not useful in
describing the
phenomenon of
interest; theory is
derived from clinical

Grounded theory Researcher observes phenomenon
of interest, analyzes similarities
and differences, compares and
contrasts responses, and develops
concepts and linkages.

Research–theory Development of
theory is based on
research; theories
evolve from
replicated and
confirmed research

Scientific theory Researcher selects a common
phenomenon, lists and measures
characteristics of the phenomenon
in a variety of situations, analyzes
the data to determine if there are
patterns that need further study,
and formalizes patterns as


theoretical statements.

Theory drives the
research questions;
the result of the
research informs and
modifies the theory.

Theory testing Theorist defines a theory and
determines propositions for
testing; the theory is modified,
refined, or further developed
based on research findings; in
some cases, a new theory will be

Source: Meleis (2012).

Theory to Practice to Theory
The theory to practice to theory approach to theory development begins with a theory (typically non-nursing)
that describes a phenomenon of interest (Meleis, 2012). This approach assumes that the theory can help
describe or explain the phenomenon, but it is not completely congruent with nursing and/or is not directly
defined for nursing practice. Thus, the focus of the theory is different from the focus needed for nursing.

Using the theory to practice to theory strategy, the nurse would select a theory that may be used to explain
or describe a clinical situation (e.g., adaptation, stress, health beliefs). The nurse could modify concepts and
consider relationships between concepts that were not proposed in the original theory. To accomplish this, the
nurse would need to (1) have a basic knowledge of the theory; (2) analyze the theory by reducing it into
components where each component is defined and evaluated; (3) use assumptions, concepts, and propositions
to describe the clinical area; (4) redefine assumptions, concepts, and propositions to reflect nursing; and (5)
reconstruct a theory using exemplars representing the redefined assumptions, concepts, and propositions
(Meleis, 2012). Examples of a theory to practice to theory strategy include Benner’s use of Dreyfus’s Model
of Skill Acquisition to describe novice to expert practice (Benner, 2001) and Roy’s use of Helson’s
Adaptation Theory to describe human responses (Roy & Roberts, 1981). Other examples of theory to practice
to theory in recent nursing literature include a work that applied the theory of mastery and organismic
integration theory in practice to develop a middle range theory for diabetes self-management mastery (Fearon-
Lynch & Stover, 2015) and Davidson’s (2010) middle range theory, facilitated sense-making, which supports
families of ICU patients. The latter was derived from the work of Karl Weick (2001), an expert in
organizational psychology.

Practice to Theory
If no appropriate theory appears to exist to describe or explain a phenomenon, theories may be inductively
developed from clinical practice situations. The practice to theory approach is based on the premise that in a
given situation, existing theories are not useful in describing the phenomenon of interest. It assumes that the
phenomenon is important enough to pursue and that there is a clinical understanding about it that has not been
articulated. Furthermore, insight gained from describing the phenomenon has potential for enhancing the
understanding of other similar situations through development of a set of propositions (Meleis, 2012).

This strategy is a grounded theory approach, which begins with a question evolving from a practice
situation. It relies on observation of new phenomena in a practice situation; development of concepts; and
then labeling, describing, and articulating properties of these concepts. To accomplish this, the researcher
observes the phenomenon, analyzes similarities and differences, and then compares and contrasts responses.
Following this, the researcher may develop concepts and propositional statements and propose linkages
(Meleis, 2012). Examples of the practice to theory strategy of theory development include a model of
“becoming normal,” which describes the emotional process of recovery from stroke (Gallagher, 2011) and a
middle range theory of self-care of chronic illness (Riegel, Jaarsma, & Strömberg, 2012). Similarly, Falk-
Rafael and Betker (2012) developed the “critical caring theory” following detailed interviews of practice
accounts of 25 public health nurses, and Sacks and Volker (2015) created a theory describing hospice nurses’
responses to patient suffering following interviews with 22 hospice nurses.

Research to Theory
The research to theory strategy is the most accepted strategy for theory development in nursing, largely due to


the early emphasis on empiricism described in Chapter 1. For empiricists, theory development is considered a
product of research because theories evolve from replicated and confirmed research findings. The research to
theory strategy assumes that there is truth in real life, that the truth can be captured through the senses, and
that the truth can be verified (Meleis, 2012). Furthermore, the purpose of scientific theories is to describe,
explain, predict, or control a part of the empirical world.

In the research to theory strategy for theory development, the researcher selects a phenomenon that occurs
in the discipline and lists characteristics of the phenomenon. A method to measure the characteristics of the
phenomenon is developed and implemented in a controlled study. The results of the measurement are
analyzed to determine if there are any systematic patterns, and once patterns have been discovered, they are
formalized into theoretical statements (Meleis, 2012). Examples of the research to theory strategy from
nursing include the development of the middle range theory of family vigilance, which was developed
following in-depth review of three ethnographic research studies (Carr, 2014), and “tracking the footsteps” (El
Hussein & Hirst, 2016), which describes the clinical reasoning processes used by registered nurses to
recognize delirium in acute care settings.

Theory to Research to Theory
In the theory to research to theory approach, theory drives the research questions and the results of the
research are used to modify the theory. In this approach, the theorist will begin by defining a theory and
determining propositions for testing. If carried through, the research findings may be used to further modify
and develop the original theory (Meleis, 2012).

In this process, a theory is selected to explain the phenomenon of interest. The theory is a framework for
operational definitions, variables, and statements. Concepts are redefined and operationalized for research.
Findings are synthesized and used to modify, refine, or develop the original theory or, in some cases, to create
a new theory. The goal is to test, refine, and develop theory and to use theory as a framework for research and
theory modification. The researcher/theorist concludes the investigation with a refined, modified, or further
developed explanation of the theory (Meleis, 2012). Examples of the theory to research to theory approach
from recent nursing literature include a middle range theory of weight management developed from Orem’s
theory of self-care (Pickett, Peters, & Jarosz, 2014) and Dobratz’s (2016) middle range theory of adaptive
spirituality (which was derived from Roy’s Adaptation Model). Another example is the theory of diversity of
human field pattern, which was developed from Martha Rogers’s science of unitary human beings using a
quantitative research design (Hastings-Tolsma, 2006).

Integrated Approach
An integrated approach to theory development describes an evolutionary process that is particularly useful in
addressing complex clinical situations. It requires gathering data from the clinical setting, identifying
exemplars, discovering solutions, and recognizing supportive information from other sources (Meleis, 2012).

Integrated theory development is rooted in clinical practice. Practice drives the basic questions and
provides opportunities for clinical involvement in research that is designed to answer the questions. In this
process for theory development, hunches and conceptual ideas are communicated with other clinicians or
participants to allow for critique and further development. Among other strategies, the integrated approach
uses skills and tools from clinical practice, various research methods, clinical diaries, descriptive journals, and
collegial dialogues in developing a framework or conceptualization (Meleis, 2012).

Process of Theory Development
The process of theory development has been described in some detail by several nursing scholars (Jacox,
1974; Walker & Avant, 2011). Despite slight variations related to terminology and sequencing, the sources
are similar in explaining the processes used to develop theory. The three basic steps are concept development,
statement/proposition development, and theory construction. Chinn and Kramer (2015) add two additional
steps that involve validating, confirming, or testing the theory and applying theory in practice. Each of the
steps is described in the following sections, and Table 4-4 summarizes the theory development process.

Table 4-4 Process of Theory Development


Step Description

Concept development Specifying, defining, and clarifying the concepts used to describe a phenomenon of


Formulating and analyzing statements explaining relationships between concepts;
also involves determining empirical referents that can validate them

Theory construction Structuring and contextualizing the components of the theory; includes identifying
assumptions and organizing linkages between and among the concepts and
statements to form a theoretical structure

Testing theoretical

Validating theoretical relationships through empirical testing

Application of theory
in practice

Using research methods to assess how the theory can be applied in practice;
research should provide evidence to evaluate the theory’s usefulness

Concept Development: Creation of Conceptual Meaning
This first step or process of theory development involves creating conceptual meaning. This provides the
foundation for theory development and includes specifying, defining, and clarifying the concepts used to
describe the phenomenon of interest (Jacox, 1974).

Creating conceptual meaning uses mental processes to create mental structures or ideas to be used to
represent experience. This produces a tentative definition of the concept(s) and a set of criteria for
determining if the concept(s) exists in a particular situation (Chinn & Kramer, 2015). Methods of concept
development are described in detail in Chapter 3.

Statement Development: Formulation and Validation of Relational Statements
Relational statements are the skeletons of theory; they are the means by which the theory comes together. The
process of formulation and validation of relational statements involves developing the relational statements
and determining empirical referents that can validate them.

After a statement has been delineated initially, it should be scrutinized or analyzed. Statement analysis is a
process described by Walker and Avant (2011) to thoroughly examine relational statements. Statement
analysis classifies statements and examines the relationships between the concepts and helps direct theoretical
construction. There are seven steps in the process of statement analysis (Box 4-2). Following the process of
statement analysis, the statements are refined and may be operationalized.

Box 4-2 Steps in Statement Analysis
1. Select the statement to be analyzed.
2. Simplify the statement.
3. Classify the statement.
4. Examine concepts within the statement for definition and validity.
5. Specify relationship between concepts.
6. Examine the logic.
7. Determine stability.

Source: Walker and Avant (2011).

Theory Construction: Systematic Organization of the Linkages
The third stage in theory development involves structuring and contextualizing the components of the theory.
This includes formulating systematic linkages between and among concepts, which results in a formal,
coherent theoretical structure. The format used depends on what is known or assumed to be true about the
phenomena in question (Chinn & Kramer, 2015). Aspects of theory construction include identifying and
defining the concepts; identifying assumptions; clarifying the context within which the theory is placed;


designing relationship statements; and delineating the organization, structure, or relationship among the

Theory synthesis is a theory construction strategy developed by Walker and Avant (2011). In theory
synthesis, concepts and statements are organized into a network or whole. The purposes of theory synthesis
are to represent a phenomenon through an interrelated set of concepts and statements, to describe the factors
that precede or influence a particular phenomenon or event, to predict effects that occur after some event, or to
put discrete scientific information into a more theoretically organized form.

Theory synthesis can be used to produce a compact, informative graphic representation of research
findings on a topic of interest, and synthesized theories may be expressed in several ways such as graphic or
model form. The three steps in theory synthesis are summarized in Box 4-3.

Box 4-3 Steps in Theory Synthesis
1. Select a topic of interest and specify focal concepts (may be one concept/variable or a framework of

several concepts).
2. Conduct a review of the literature to identify related factors and note their relationships. Identify and

record relationships indicating whether they are bidirectional, unidirectional, positive, neutral or
negative, weak or ambiguous, or strong in support evidence.

3. Organize concepts and relational statements into an integrated representation of the phenomena of
interest. Diagrams may be used to express the relationships among the concepts.

Source: Walker and Avant (2011).

Validating and Confirming Theoretical Relationships in Research
Chinn and Kramer (2015) include the process of validating and confirming theoretical relationships as a
component of theory development. Validating theoretical relationships involves empirically refining concepts
and theoretical relationships, identifying empirical indicators, and testing relationships through empirical
methods. In this step, the focus is on correlating the theory with demonstrable experiences and designing
research to validate the relationships. Additionally, alternative explanations are considered based on the
empirical evidence.

Validation and Application of Theory in Practice
An important final step in theory development identified by Chinn and Kramer (2015) is applying the theory
in practice. In this step, research methods are used to assess how the theory can be applied in practice. The
theoretical relationships are examined in the practice setting, and results are recorded to determine how well
the theory achieves the desired outcomes. The research design should provide evidence of the effect of the
interventions on the well-being of recipients of care. Questions to be considered in this step include: Are the
theory’s goals congruent with practice goals? Is the intended context of the theory congruent with the practice
situation? Are explanations of the theory sufficient for use in the nursing situation? Is there research evidence
supporting use of the theory? See Link to Practice 4-1 for more information on the process of theory

Link to Practice 4-1
Where Do I Begin?
An experienced emergency department (ED) registered nurse wants to conduct a research study on
“frequent flyers in the ED” (i.e., patients who return multiple times for the same or similar health problem)
and is not sure how to proceed.

Following the guidelines in the chapter, the nurse should begin with developing the concept. For this
step, he or she can search the health literature. Has a concept study of “frequent flyers” been published? If


not, he or she can perform a formal or informal concept analysis, following one of the strategies presented
in Chapter 3. If an analysis of “frequent flyers” has been published, the nurse might use it to set up the next
steps—statement development and theory construction.

In the second and third steps, the nurse should continue to search the literature to learn all he or she can
about the various aspects of “frequent flyers” and related phenomena. What studies have been published
on patients who return to the EDs repeatedly during a short period of time? What characteristics or
diagnoses are typically reported? What other factors are usually found? How do they present? How do ED
personnel care for them? From this review, the nurse can propose linkages between and among the various
concepts/characteristics and draft a conceptual model. This might send him or her back to the literature to
search for other, potentially related terms and phenomena. The literature and published studies can also
lead him or her to instruments or tools that have been developed to measure some of the concepts and
phenomena. Following these steps, the nurse can develop a research study to try to validate and refine the
conceptual linkages. Completion and publication of research will contribute to the evidence that can then
be used to improve nursing practice.

Jill Watson, the nurse/graduate student introduced in the case study at the beginning of this chapter, was
unable to identify a theory or conceptual model that completely met the needs for her study on health
motivation. Because of this, she determined that it would be appropriate and feasible to use theory
development techniques to revise an existing theory to use in her research project.

Theory development is an important but complex and time-consuming process. This chapter has presented
a number of issues related to the process of theory development. These issues included the purpose of
developing theory and the components of a theory. Discussion focused on concepts, theoretical statements,
assumptions, and model development and explained the relationships among theory, research, and practice.
Finally, the process of theory development was presented.

Key Points
In nursing, theories are constructed or developed to describe, explain, or understand phenomena to help

solve clinical problems or improve practice outcomes.
Nursing theory can be categorized based on level (grand theory, middle range theory, or practice theory),

based on purpose (descriptive theories, explanatory theories, predictive theories, or prescriptive theories),
or based on source or background.

Components of theories include purpose, concepts, definitions, theoretical statements, structure/linkages,
assumptions, and often a diagram or model.

There is a reciprocal relationship among theory, research, and practice that is critical for professional nurses
to recognize and understand.

Several approaches to theory development (e.g., theory to practice to theory, theory to research to theory,
practice to theory, and research to theory) are found in the nursing literature.

The process of theory development often follows these steps: concept development, statement development,
theory construction, validation/confirmation of relationships in research, and validation/application of
theory in practice.

To further illustrate the process of theory development, a summary report of a theory published in the nursing
literature is presented. In the following exemplar, each of the components of the theory is clearly identified. In
addition, Chapter 5 expands on the process of theory development by examining the processes of theory
analysis and evaluation.

Garmon , S. C. ( 2012 ). Theory of perceived access to breast health care in African American women . ANS. Advances in


Nursing Science , 35 ( 2 ), E13 – E23 .

Garmon developed the perceived access to breast health care in African American women
theory to help direct future research studies exploring the relationship between access to care
and utilization of preventive services related to breast health care.

Scope of theory: Middle range

Purpose: The perceived access to breast health care in African American women theory was
developed to “propose an alternative view of access to breast health care and to
demonstrate the importance of testing the relationships between culture, definitions of
health, health behaviors, and practices and their influence on the perception of access to
breath health care in AAW [African American women]” (p. E16).

Concepts and definitions are listed in the following table.
Concept Definition

Culture Combination of age, ethnicity, race, gender,
socioeconomic status, religious beliefs, family history,
and geographical origin that shapes and guides the
values, beliefs, practices, thinking, decisions, and actions
of individuals

Health A state of well-being that is culturally defined, valued,
and practiced and that refl ects the ability of individuals
or groups to perform their daily role activities in a
culturally satisfactory way

Health promotion Behavior(s) aimed at increasing the level of well-being
and actualization of health

Health protection Behavior(s) aimed at decreasing the likelihood of
experiencing health problems by active protection or
early detection of health problems in the asymptomatic

Health behaviors and

Culturally guided activities that are performed by an
individual to help maintain his or her definition of health
and well-being. These include health promotion and
disease prevention breast care practices.

Access The perceived necessity, availability, and
appropriateness of breast health care provided by the
health care delivery system, which purposes to assist an
individual in maintaining his or her cultural definition of
health and well-being

Perception of
availably of care

Influenced by economic factors such as location of care;
fit with time schedules; fit with family; and fit with
cultural beliefs, values, and expectations

Perception of
necessity of care

Influenced by incorporation of health promotion and
disease prevention into definitions of health,
symptomatology, and cultural definitions of severity and
personal and family priorities

Perception of
appropriateness of

Influenced by fit of the breast health care with cultural
values, beliefs, and practices; interactions and
relationships with providers of care; and previous
experience associated with breast cancer and breast
health care


Theoretical Statement and Linkages
1. Culture shapes the definition of health.
2. Perceived access to breast health care is postulated to be a product of three subconcepts:

necessity, availability, and appropriateness of care.
3. Health behaviors and practices are a function of the perception of necessity of care, the

availably of care, and the appropriateness of care.
4. When (a) the definition of health includes perspectives of health promotion and disease

prevention; (b) health behaviors and practices include breast health practices; and (c)
access to breast health care is perceived as necessary, available, and appropriate, then
breast cancer diagnosis is likely to occur in its early stages.

5. Delayed diagnosis of breast cancer influences cultural beliefs, values, and practices and
also reshapes individual definitions of health, health practices, and behaviors.

Model: Garmon’s schematic diagram illustrates the main concepts and their
interrelationships. It also depicts how perceptions may lead to either early or delayed
diagnosis of breast cancer.

A theory of perceived access to breast health care in African American women (From
Garmon, S. C. [2012]. Theory of perceived access to breast health care in African American
women. Advances in Nursing Science, 35[2], E13–E23).

1. Definitions of health care are shaped by culture and determine an individual’s

participation in health promotion and disease prevention strategies.
2. Perceived access to necessary care will result in seeking breast health care for health

promotion and disease prevention.


3. Seeking breast health care in a health care delivery system with perceived appropriate and
available care will result in diagnosis of breast cancer in its early stages.

Implications for Nursing
The theory of perceived access provides nurses with an opportunity for testing the
relationships among culture; health definitions; health practices; and perceived necessity,
availability, and appropriateness of breast cancer screening. The theory may aid in the
discovery of the culturally appropriate approaches for promoting breast health care.

Learning Activities
1. Find an example of a nursing theory in a current book or periodical. Review the theory and

classify it based on scope or level of abstraction (grand theory, middle range theory, or
practice theory), the purpose of the theory (describe, explain, predict, or control), and the
source or discipline in which the theory was developed.

2. Find an example of a middle range nursing theory (see Chapter 10 or 11 for ideas). Following
the preceding exemplar, identify the components of the theory (e.g., scope of the theory,
purpose, concepts, and definitions).

3. Find an example of a middle range theory that does not contain a model. With classmates, try
to create a model that depicts the relationships between and among the concepts. Discuss the
challenges posed by this exercise.

4. Jill, the nurse from the opening case study, chose a non-nursing theory to modify to best
explain a phenomenon that she had observed in practice. Review the various theories
described in the unit on “shared theories” and select one that is applicable to one nursing
specialty area. Consider how it might be modified to best reflect advanced nursing practice.

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Theory Analysis and Evaluation
Melanie McEwen

Jerry Thompson is nearing completion of his master’s degree in nursing leadership. He is currently a case
manager for a home health agency, and his goal is to become an agency director after he completes his degree.
For his research application project, Jerry wants to compare the effectiveness of health teaching in the hospital
setting with the effectiveness of health teaching in the home setting. He has identified several areas to
examine. These include the quality and type of health information provided, professional competencies of the
nurses providing the information, the client’s support system, and environmental resources. Outcome
variables he will measure focus on utilization of health care (e.g., length of time on home health service,
hospital readmissions, development of complications).

As his research project began to take shape, Jerry realized he needed a conceptual framework to help him
set it up and organize it. His advisor suggested Pender’s Health Promotion Model. To determine if the model
would be appropriate for his study, Jerry obtained the latest edition of Pender’s book (Pender, Murdaugh, &
Parsons, 2015), which described the model in depth. He then read commentaries in nursing theory books that
analyzed Pender’s work and completed a literature search to find examples of research studies using the
Health Promotion Model as a conceptual framework. After he had compiled the information, Jerry
summarized his findings by using Whall’s (2016) criteria for analysis and evaluation of middle range theories.

This exercise helped Jerry gain insight into the major concepts of the model and let him examine its
important assumptions and linkages. From the evaluation, he determined that the model would be appropriate
for use as the conceptual framework for his research study.

As nurses began to participate in the processes of theory development in the 1960s, they realized that there
was a corresponding need to identify criteria or develop mechanisms to determine if those theories served
their intended purpose. As a result, the first method to describe, analyze, and critique theory was published in
1968. Over the following decades, a number of methods or techniques for theory evaluation were proposed. A
general understanding of these methods will help nurses select an evaluation method for theory, which is
appropriate to the stage of theory development and for the intended application of the theory (research,
practice, administration, or education). This will, in turn, help ensure that the theory is valid and is being used
correctly. It will also provide information for developing and testing new theories by identifying gaps and

Definition and Purpose of Theory Evaluation
Theory evaluation has been defined as the process of systematically examining a theory. Criteria for this
process are variable, but they generally include examination of the theory’s origins, meaning, logical
adequacy, usefulness, generalizability, and testability. Theory evaluation does not generate new information
outside the confines of the theory, but it often leads to new insights about the theory being examined.

In short, theory evaluation identifies a theory’s degree of usefulness to guide practice, research, education,
and administration. Such evaluation gives insight into relationships among concepts and their linkages to each
other and allows the reviewer to determine the strengths and weaknesses of a theory. It also assists in


identifying the need for additional theory development or refinement. Finally, theory evaluation provides a
systematic, objective way of examining a theory that may lead to new insights and new formulations that will
add to the body of knowledge and thereby affects practice or research (Walker & Avant, 2011). The ultimate
goal of theory evaluation is to determine the potential contribution of the theory to scientific knowledge.

In nursing practice, theory evaluation may provide a clinician with additional knowledge about the
soundness of the theory. It also helps identify which theoretical relationships are supported by research,
provides guidelines for the choice of appropriate interventions, and gives some indication of their efficacy. In
research, theory evaluation helps clarify the form and structure of a theory being tested or will allow the
researcher to determine the relevance of the content of a theory for use as a conceptual framework, as
described in the case study. Evaluation will also identify inconsistencies and gaps in the theory when used in
practice or research (Walker & Avant, 2011). See Link to Practice 5-1 for another example.

Link to Practice 5-1
The Synergy Model for Patient Care
The Synergy Model for Care was developed by the American Association of Critical-Care Nurses (AACN)
to be used as the basis for the AACN’s certification examination (Curley, 1998). Although the model was
explicitly designed to be used to direct nursing care for critically ill patients in the acute care settings
(practice), it has also been used in numerous research studies as well as in many different types of settings
and for varying types of patients.

When considering its original intended purpose, what processes or methods might a nurse use to
determine the Synergy Model’s suitability for:

Directing nursing practice in a high school or occupational health setting?
Working with elders in a long-term care facility?
Planning care for a home-based hospice patient?
Guiding a research study in a pediatric hospital?

Various methods have been outlined to assist with this process. The methods are described by several
overlapping terms or terms that are used in different ways by different authors. For example, theory analysis,
theory description, theory evaluation, and theory critique all describe the process of critically reviewing a
theory to assess its relevance and applicability to nursing practice, research, education, and administration. In
this chapter, “theory evaluation” is used as a global term to discuss the process of reviewing theory.

Theory evaluation has been described as a single-phase process (theory analysis) by Alligood (2014a) as
well as Hardy (1974) (theory evaluation), a two-phase process (theory analysis and theory critique/evaluation)
by Fawcett and DeSanto-Madeya (2013) and Duffey and Muhlenkamp (1974), or a three-phase process
(theory description, theory analysis, and theory critique/evaluation) by scholars including Meleis (2012) and
Moody (1990). It should be noted that the methods are similar whether they describe one, two, or three
phases. A three-phase process is outlined briefly in the following section. Later sections provide more detailed
discussions of each phase.

Theory Description
Theory description is the initial step in the evaluation process. In theory description, the works of a theorist
are reviewed with a focus on the historical context of the theory (Hickman, 2011). In addition, related works
by others are examined to gain a clear understanding of the structural and functional components of the
theory. The structural components include assumptions, concepts, and propositions. The functional
components consist of the concepts of the theory and how they are used to describe, explain, predict, or
control (Meleis, 2012; Moody, 1990).

Theory Analysis


Theory analysis is the second phase of the evaluation process. It refers to a systematic process of objectively
examining the content, structure, and function of a theory. Theory analysis is conducted if the theory or
framework has potential for being useful in practice, research, administration, or education. Theory analysis is
a nonjudgmental, detailed examination of a theory, the main aim of which is to understand the theory (Fawcett
& DeSanto-Madeya, 2013; Meleis, 2012).

Theory Evaluation
Theory evaluation, or theory critique, is the final step of the process. Evaluation follows analysis and assesses
the theory’s potential contribution to the discipline’s knowledge base (Fawcett & DeSanto-Madeya, 2013;
Walker & Avant, 2011). In theory evaluation, critical reflection involves ascertaining how well a theory
serves its purpose, with the process of evaluation resulting in a decision or action about use of the theory
(Chinn & Kramer, 2015). This includes consideration of how the theory is used to direct nursing practice and
interventions and whether or not it contributes to favorable outcomes (Hickman, 2011).

Historical Overview of Theory Analysis and Evaluation
Since the late 1960s, a number of nursing scholars have published systems or methods for theory
analysis/evaluation. Table 5-1 provides a list of these works. Basic components of the processes described by
each are presented in the following sections.

Table 5-1 Publications of Methods for Nursing Theory Analysis and Evaluation

Nursing Scholar Dates of Publications
Techniques Described (Most
Recent Publication)

Rosemary Ellis 1968 Characteristics of significant

Margaret Hardy 1974, 1978 Theory evaluation
Mary Duffey and Ann

1974 Theory analysis and theory

Barbara Barnum (Stevens) 1979, 1984, 1990, 1994, 1998 Theory evaluation—internal
criticism, external criticism

Lorraine Walker and Kay Avant 1983, 1988, 1995, 2005, 2011 Theory analysis
Jacqueline Fawcett and DeSanto-

1980, 1993, 1995, 2000, 2005,

Theory (conceptual framework)
analysis and theory (conceptual
framework) evaluation

Peggy Chinn and Maeona Kramer

1983, 1987, 1991, 1995, 1999,
2004, 2008, 2011, 2015

Theory description and critical

Afaf Meleis 1985, 1991, 1997, 2007, 2012 Theory description, theory
analysis, theory critique

Joyce Fitzpatrick and Ann Whall 1989, 1996, 2005, 2016 Analysis and evaluation of
practice theory, middle range
theory, and nursing models

Sharon Dudley-Brown 1997 Theory evaluation

It should be noted that most of the processes/methods for theory analysis and theory evaluation were
implicitly or explicitly developed to review grand nursing theories and conceptual frameworks. Only in recent
years have the processes and methods been applied to middle range theories and, rarely, practice theories.
This observation, however, does not negate the need for analysis and evaluation (whether formal or informal)
of middle range and practice theories. Furthermore, the processes should be applicable to all levels of theory.


Characteristics of Significant Theories: Ellis
Probably the first nursing scholar to document criteria for analyzing theories for use by nurses was Rosemary
Ellis. Although not specifically describing a process or method of theory analysis or evaluation, Ellis (1968)
identified characteristics of significant theories. The characteristics she specified were scope, complexity,
testability, usefulness, implicit values of the theorist, information generation, and meaningful terminology.
Her discussion of these characteristics produced the foundation on which later writers developed their criteria.

Theory Evaluation: Hardy
A few years after Ellis, Margaret Hardy (1974) wrote that theory should be evaluated according to certain
universal standards. In her writings, Hardy provided a more detailed description of criteria for theory
evaluation and presented personal insight on the processes needed. Criteria or standards she suggested for
theory evaluation were as follows:

Meaning and logical adequacy
Operational and empirical adequacy
Contribution to understanding
Pragmatic adequacy

In a later work, Hardy (1978) discussed logical adequacy (diagramming) and stated that because a theory
is a set of interrelated concepts and statements, its structure can be analyzed for internal consistency by
examining the syntax of the theory as well as its content. Diagramming involves identifying all major
theoretical terms (concepts, constructs, operational definitions, and referents). Once identified, each
component can be represented by a symbol, and a model may be drawn illustrating relationships or linkages
between or among the terms. These linkages should specify the direction, the type of relationship (whether
positive or negative), and the form of the relationship.

According to Hardy (1974), empirical adequacy is the single most important criterion for evaluating a
theory applied in practice. Assessing empirical adequacy requires reviewing literature and critically reading
relevant research; it is necessary to determine if hypotheses testing the theory are clearly deduced from the
theory. The entire body of relevant studies should be evaluated in terms of the extent to which it supports the
theory or a part of the theory. Finally, the criteria of usefulness and significance refer to the theory’s use in
controlling, altering, or manipulating major variables and conditions specified by the theory to realize a
desired outcome.

Theory Analysis and Theory Evaluation: Duffey and Muhlenkamp
Writing at approximately the same time as Hardy, Duffey and Muhlenkamp (1974) published a two-phase
approach to critically examining nursing theory. Theory analysis was the first phase, for which they posited
four questions for examination. For theory evaluation, they suggested six additional questions (Box 5-1).

Box 5-1
Questions for Theory Analysis and Theory Evaluation: Duffey and

Theory Analysis
1. What is the origin of the problem(s) with which the theory is concerned?
2. What methods were used in theory development (induction, deduction, synthesis)?
3. What is the character of the subject matter dealt with by the theory?
4. What kind of outcomes of testing propositions is generated by the theory?

Theory Evaluation
1. Does the theory generate testable hypotheses?


2. Does the theory guide practice or can it be used as a body of knowledge?
3. Is the theory complete in terms of subject matter and perspective?
4. Are the biases or values underlying the theory made explicit?
5. Are the relationships among the propositions made explicit?
6. Is the theory parsimonious?

Theory Evaluation: Barnum
Barbara Barnum (Stevens) first published her ideas for theory evaluation in 1979. Subsequent editions were
published in 1984, 1990, 1994, and 1998. Barnum suggested a method of theory evaluation that differentiates
internal and external criticisms. Internal criticism examines how the components of the theory fit with each
other; external criticism examines how a theory relates to the extant world. Box 5-2 lists points to be
examined for both.

Box 5-2 Theory Evaluation Criteria: Barnum

Internal Criticism
Logical development
Level of theory development

External Criticism
Reality convergence (how the theory relates to the real world)
Discrimination (differentiation between nursing and other health professions)

Theory Analysis: Walker and Avant
Lorraine Walker and Kay Avant first presented their detailed methods for theory analysis in 1983. Their work
was subsequently revised in 1988, 1995, 2005, and 2011. Building on a multiphase background of concept
and statement development, which involves concept and statement analysis, synthesis, and derivation, they
expanded the processes to include theory analysis. Table 5-2 gives a brief synopsis of the process of theory
analysis they propose.

Table 5-2 Theory Analysis: Walker and Avant
Step Questions or Tasks

Determine the origins of the theory. Identify the basis of the original development of the
theory. Why was it developed? Was the process of
development inductive or deductive? Is there evidence to
support or refute the theory?

Examine the meaning of the theory. Identify concepts. Examine definitions and their use
(theoretical and operational definitions). Identify
statements. Examine relationships.

Analyze the logical adequacy of the theory. Determine if scientists agree on predictive ability of the
theory. Determine if the content makes sense. Identify any
logical fallacies.


Determine the usefulness of the theory. Is the theory practical and helpful to nursing? Does it
contribute to understanding and predicting outcomes?

Define the degree of generalizability. Is the theory highly generalizable or specific?
Determine if the theory is parsimonious. Can the theory be stated briefly and simply or is it

Determine the testability of the theory. Can the theory be supported with empirical data? Can

testable hypotheses be generated from the theory?

Source: Walker and Avant (2011).

Theory Analysis and Evaluation: Fawcett
Jacqueline Fawcett (Fawcett, 1980, 1993, 1995, 2000, 2005; Fawcett & DeSanto-Madeya, 2013) used a two-
phase process for analysis and evaluation of theories and conceptual frameworks. In her writings, she noted
that analysis is a nonjudgmental, detailed examination of a theory. In Fawcett’s most recent work (Fawcett &
DeSanto-Madeya, 2013), components of the analysis process include the theory’s origins, unique focus, and
content. The theory’s “origins” refers to the historical evolution of the model/theory, the author’s motivation,
philosophical assumptions about nursing, the author’s inclusion of works of nursing and non-nursing scholars,
and the worldview reflected by the model.

The unique focus refers to distinctive views of the metaparadigm concepts, different problems in nurse–
patient situations or interactions, and differences in modes of nursing interventions. She notes that theories
can be categorized as developmental, systems, interaction, needs, client-focused, person–environment
interaction–focused, or nursing therapeutics–focused. The content of the model is examined to analyze the
abstract and general concepts and propositions. Fawcett’s method of theory analysis specifically identifies
whether and how the concepts and propositions of the metaparadigm (nursing, environment, health, and
person) are included in the theory. Representative questions to be addressed relative to the content include:
“How are human beings defined and described? How is environment defined and described? How is health
defined? . . . What is the goal of nursing? . . . and What statements are made about the relations among the
four metaparadigm concepts?” (Fawcett & DeSanto-Madeya, 2013, p. 49).

Theory evaluation requires judgments to be made about a theory’s significance based on how it satisfies
certain criteria (Fawcett & DeSanto-Madeya, 2013). The process of theory evaluation includes review of
previously published critiques, research reports, and reports of practical application of the theory. During the
process of theory evaluation, the criteria to be examined are the explication of the origins of the theory, the
comprehensiveness of the content, its logical congruence, how well it can lead to generation of new theory,
and its legitimacy. The legitimacy is determined by reviewing the theory’s social utility, social congruence,
and social significance. The final step in theory evaluation is to examine the theory’s contribution to the
discipline of nursing.

Theory Description and Critique: Chinn and Kramer
Peggy Chinn and Maeona Kramer (Jacobs) initially wrote on the processes used to analyze theory in 1983.
They used the terms theory description and critical reflection to describe a two-phase process. Theory
description has six elements: purpose, concepts, definitions, relationships, structure, and assumptions. Table
5-3 presents these elements and their defining characteristics.

Table 5-3 Components of Theory Description: Chinn and Kramer
Component Characteristics

Purpose The purpose of the theory should be stated explicitly or at least be identifiable in
the text of the theory.

Concepts The concepts of the theory should be linguistically expressed.
Definitions Meanings of concepts are conveyed in theoretical definitions; these definitions give

character to the theory.


Relationships Concepts are structured into a systematic form that links each concept with others.
Structure The relationships are linked to form a whole when the ideas of the theory

interconnect; structure makes it possible to follow the reasoning of the theory.
Assumptions Assumptions refer to underlying truths that determine the nature of concepts,

definitions, purpose, relationship, and structure; may not be explicitly stated.

Source: Chinn and Kramer (2015).

Critical reflection of a theory involves determining how well a theory serves its purpose. Critical
reflection analyzes clarity and consistency of the theory as well as its complexity, generality, accessibility, and
importance. In assessing clarity and consistency, Chinn and Kramer’s (2015) critical reflection would

Semantic clarity: Are the concepts defined? Do the concepts establish empirical meaning?
Semantic consistency: Are the concepts used consistently? Are the concepts congruent with their

Structural clarity: Are the connections and reasoning within the theory understandable?
Structural consistency: Is the structure of the theory consistent in its form?
Simplicity or complexity: Is the theory simple? Is the theory complex?
Generality: Does the theory cover a wide scope of experiences and phenomena?
Accessibility: How accessible is the theory? How well are concepts grounded in empirically identifiable

Importance: How can the theory contribute to nursing practice, research, and education?

Theory Description, Analysis, and Critique: Meleis
According to Meleis (1985, 2007, 2012), there are three stages involved in theory evaluation: theory
description, theory analysis, and theory critique. During the process of theory description, the reviewer closely
examines the structural and functional components of the theory. The structural components include
assumptions (implicit and explicit), concepts, and propositions. The functional assessment considers the
anticipated consequence of the theory and its purpose. Components that should be examined are the focus of
the theory and how it addresses the client, nursing, health, the nurse–client interactions, environment, nursing
problems, and nursing therapeutics.

Theory analysis involves considering important variables that may have influenced the development of the
theory. These include the theorist, paradigmatic origins of the theory, and internal dimensions of the theory.
During the analysis procedure, Meleis (2012) recommends reviewing external and internal factors that
influenced the theorist as well as the theorist’s experiential background, educational background, and
employment history. Likewise, a reconstruction of the professional and academic networks that surrounded
the theorist while the theory was evolving should be examined.

Second, Meleis (2012) argues that careful consideration of use of theories from other fields or paradigms
is to be encouraged. To identify the paradigm(s) from which the theory may have evolved, or to recognize
other theorists who may have influenced the development of the theory, the reviewer would consider
references, educational and experiential background of the theorist, and the sociocultural context of the theory
as it was developed.

Finally, internal dimensions of the theory should be analyzed. This will provide information about the
rationale on which the theory is built, systems of relationships, content of the theory, goal of the theory, scope
of the theory, context of the theory, abstractness of the theory, and method of development.

Critique of a theory may follow analysis, and Meleis (2012) identified five elements to consider in this
phase: the relationship between structure and function, diagram of the theory, circle of contagiousness,
usefulness, and external components. The relationship between structure and function involves evaluating the
theory’s clarity and consistency, level of simplicity or complexity, and tautology/teleology. In assessing the
tautology of the theory, the reviewer would observe for needless repetition of an idea in different parts of the
theory, which Meleis claims will decrease the clarity of the theory. Teleology occurs when definitions of
concepts, conditions, and events are described by consequences rather than properties and dimensions; this


should be avoided.
Although not all theories contain models graphically or pictorially depicting the structure of the theory,

Meleis (2012) states that theories and models are enhanced by visual representation. The reviewer should
determine if the model does indeed help clarify linkages among the concepts and propositions and, thereby,
enhance clarity of the theory.

The circle of contagiousness refers to whether, and to what extent, the model or theory has been adopted
by other experts in the field. In evaluating usefulness, Meleis (2012) suggests analysis of the theory’s
usefulness in practice, research, education, and administration.

The final component of this method is the review of external components of the theory. These include
implicit and explicit personal values of both the theorist and the critic. It also refers to congruence with other
professional values as well as with social values. Finally, the critic would determine whether the theory has
social significance.

Analysis and Evaluation of Practice Theory, Middle Range Theory, and Nursing Models:
Whall (2016) is the only nurse scholar to explicitly outline three separate criteria for analysis and evaluation
for the three levels of nursing theory. In her most recent edition, she noted that middle range and practice
theories have achieved status equal to that of nursing conceptual models, but it has only been nursing models
that have been systematically examined. Following this observation, she outlined distinct, although similar,
criteria for evaluation of all three levels of nursing theory using a three-phase approach that reviews basic
considerations, internal analysis and evaluation, and external analysis and evaluation.

According to Whall (2016), practice theory (or microtheory) is produced from practice and deduced from
middle range theory as well as from research. Because practice theory is designed for immediate application
to practice, questions regarding the fit with empirical data are important in the evaluation process. Operational
definitions and descriptions of how to apply practice theory are also important. Internal analysis of practice
theory may be accomplished by diagramming the interrelationships of all concepts to detect lapses and
inconsistencies in the theory’s structure. The assumptions of the theory should be considered in light of
historical and current perspectives of nursing. This should include ethical and cultural implications of the
theory. External analysis should compare standards of care with the theory and examine nursing research to
determine if it supports the theory, is neutral, or is in opposition.

Analysis and evaluation of middle range theory modifies the guidelines used for nursing conceptual
models. It examines whether the theory fits with the existing nursing perspective and domains. Propositional
statements should be examined to determine if they are causal or associative in nature, to assess their relative
importance, and to find missing linkages between concepts. It is suggested that diagramming of the
relationships may help identify missing relationships. Concepts should be operationally defined to support
empirical adequacy. External analysis refers to congruence with more global theories and other related middle
range theories. Examination of ethical, cultural, and social policy implications is crucial.

Whall (2016) believes nursing conceptual models should be assessed from a postmodern or neomodern
view. In addition, conceptual models should consider the major paradigm concepts (person, environment,
health, and nursing) as well as additional concepts specific to the model. Analysis should examine whether the
definitions of the concepts and statements are consistently used throughout the model and whether the
interrelationships among the concepts are consistent. Internal analysis considers the assumptions and
philosophical basis of the model and looks at the uniformity of discussion throughout the model. External
consistency examines the model in relation to views external to the model (i.e., whether the model is being
evaluated consistent with other nursing conceptual models and with nursing intervention classification
systems). Table 5-4 lists some of the questions for consideration by Whall in analysis and evaluation of all
three levels of nursing theory.

Table 5-4 Criteria for Analysis and Evaluation of Theory: Whall

Level of Theory

Internal Analysis and

External Analysis
and Evaluation


Practice theory Can the concepts be
operationalized? Are
concepts congruent
with empirical data?
Do statements lead to
directives for nursing
care? Are statements
sufficient to practice
and not

Are there gaps or inconsistencies
within the theory that may lead to
conflicts and difficulties? Are
assumptions congruent with
nursing’s historical perspective?
Are assumptions congruent with
ethical standards and social
policy? Are assumptions in
conflict with given cultural

Is the theory
produced with
existing nursing
standards? Is the
theory consistent with
existing standards of
education within
nursing? Is the theory
related to nursing
diagnoses and nursing
practices? Is the
theory supported by
existing research
internal and external
to nursing?

Middle range theory What are the
definitions and
relative importance of
major concepts?
What is the type and
relative importance of
major theoretical

What are the assumptions of the
theory? What is the relationship
of the theory to philosophy of
science? Are concepts related/not
related via statements? Is there
loss of information? Is there
internal consistency and
congruency of all component
parts of the theory? What is the
empirical adequacy of the theory?
Has the theory been examined in
practice and research, and has it
held up to this scrutiny?

What is the
congruency with
related theory and
research internal and
external to nursing?
What is the
congruence with the
perspective of
nursing, the domains,
and the persistent
questions? What
ethical, cultural, and
social policy issues
are related to the

Nursing models What are the
definitions of person,
nursing, health, and
environment? What
are additional
understandings of the
concepts? What are
the interrelationships
among the
concepts? What are
the descriptions of
other concepts found
in the model?

What are the underlying
assumptions of the model? What
are the definitions of other
components of the model? What
is the relative importance of basic
concepts or other components of
the model? What are the analyses
of internal and external
consistency? What are the
analyses of adequacy?

Is nursing research
based on the model or
related to the model?
Is nursing education
based on the model or
related to the model?
Is nursing practice
based on the model?
What is the
relationship to
existing nursing
diagnoses and

Source: Whall (2016).

Theory Evaluation: Dudley-Brown
One of the most contemporary methods for theory evaluation was presented by Dudley-Brown (1997), who
strongly relied on Kuhn’s (1977) criteria for theory evaluation. In this method, evaluation should consider


accuracy, consistency, fruitfulness, simplicity/complexity, scope, acceptability, and sociocultural utility.
To Dudley-Brown (1997), accuracy is essential because the theory should describe nursing as it exists

today—not the nursing of the future or of the past. The theory should contain a worldview of nursing
consistent with the present reality. Consistency relates to the importance of the nursing theory being internally
consistent. There should be logical order: Terms, concepts, and statements should be used consistently and
defined operationally.

Another criterion Dudley-Brown (1997) identifies for evaluation is fruitfulness. For this criterion, the
theory should be useful in generating information and significant in contributing to the development of
nursing knowledge.

Simplicity/complexity is a fourth criterion for evaluation. Both simple and complex theories are needed. In
general, a theory should be balanced and logical. The theory should describe the phenomenon consistently in
terms of simplicity or complexity.

Scope is a fifth criterion because theories of both broad and limited scope are needed. Scope should be
dependent on the phenomenon and its context. Acceptability refers to the adoption of the theory by others.
Theories should be useful in practice, education, research, or administration.

Sociocultural utility is the final criterion for evaluation. Social congruence encompasses the beliefs,
values, and expectations of different cultures. The theory should be measured against the criterion of social
utility according to the culture for which it was proposed. Theories proposed for Western societies need to be
evaluated for their philosophical and theoretical relevance in other societies and cultures.

Comparisons of Methods
Several authors (Dudley-Brown, 1997; Meleis, 2012; Moody, 1990) have compared many of the theory
analysis and evaluation methods described here. A number of similarities can be found between and among all
the methods. Table 5-5 provides a list of the methods reviewed and criteria specified by each author. It is
important to note that different authors use different terms for similar concepts; thus, some interpretation of
meaning of terms was necessary for the comparison.

Table 5-5 Comparison of Theory Evaluation Criteria

Evaluation Criteria Ellis Hardy Barnum

Avant Fawcett

Kramer Meleis Whall


Complexity/simplicity X X X X X X X

Testability X X X X

Generality/scope X X X X X X X

Usefulness X X X X X X

Contribution to understanding X X X X X

Implicit values X X

Information generation X

Meaningful terminology


Logical adequacy X X X X



Predictability/tested X X X

Origins X X X

Clarity X X X

Consistency X X X X X X

Context X X

Pragmatic adequacy X X

Reality convergence X

Discrimination X

Metaparadigm concepts X X X


Assumptions X X X

Purpose X X

Consequences X

Nursing therapeutics


Method of development X

Circle of contagion X X X

Social/cultural significance X X X X

Correspondence to
standards/professional values


As Table 5-5 shows, the most common criteria identified among the theory evaluation methods were an
examination of complexity/simplicity (seven of nine) and scope/generality (seven of nine). Other common
criteria were inclusion of meaningful terminology, definitions of concepts (six of nine), consistency (six of
nine), contribution to understanding (five of nine), usefulness (six of nine), testability (four of nine), logical
adequacy (four of nine), and validity/accuracy/empirical adequacy (six of nine). Criteria mentioned in only
one or two methods were implicit values of the theorist, information generation, reality convergence,
discrimination between nursing and other health professions, consequences, method of development,
correspondence to existing standards, origins of the theory, context, pragmatic adequacy, and application of or
to nursing therapeutics.

There appears to be an evolution of the processes over the past three decades. Similarities of criteria were
evident based on time of initial writing. Ellis (1968), Duffey and Muhlenkamp (1974), and Hardy (1974) were
the first nurses to describe the processes of theory evaluation, and their criteria are similar. The methods
proposed by Walker and Avant (1983, 1988, 1995, 2005, 2011) are also consistent with those of Hardy and
Ellis. Fawcett’s model (1980, 1993, 2005) is similar to Chinn and Kramer’s (1983, 1987, 1991, 1995)
approach and to Barnum’s (1984, 1990, 1994) internal criticism criteria. Meleis (1985, 1991, 1997) and Whall
(Fitzpatrick & Whall, 1989, 1996) present the most detailed methods. Meleis’s (2012) system has three
components (description, analysis, and critical reflection), and Whall’s (2016) examines three levels of theory.
Barnum (1998) and Whall (2016) are similar in that they describe separate internal and external dimensions.
The later works of Whall (2016), Meleis (2012), and Dudley-Brown (1997) are similar because they include
characteristics of circle of contagion and consideration of social and cultural significance as evaluation

Most methods for analysis and evaluation were developed and used to review grand nursing theories.
Indeed, a literature review resulted in no published report of theory evaluation in nursing beyond those in
nursing theory textbooks. Books that focus on analysis and evaluation of grand nursing theories include those
by Alligood (2014b), Fawcett & DeSanto-Madeya (2013), Fitzpatrick and Whall (2005, 2016), George
(2011), Masters (2015), and M. C. Smith and Parker (2015). Alligood (2014b), M. C. Smith and Parker
(2015), Peterson and Bredow (2017), and M. J. Smith and Liehr (2013) also analyze/evaluate selected middle
range nursing theories in their works.

Synthesized Method of Theory Evaluation
Following the detailed review and comparison of the many methods for theory analysis and evaluation, a
method specifically designed to evaluate middle range and practice theories was developed (Box 5-3). These
criteria were synthesized from the works of noted nursing scholars described earlier and are intended to be
contemporary and responsive to both recent and anticipated changes in use of theory in nursing practice,
research, education, and administration.

Box 5-3 Synthesized Method for Theory Evaluation

Theory Description
What is the purpose of the theory (describe, explain, predict, prescribe)?
What is the scope or level of the theory (grand, middle range, practice/situation specific)?


What are the origins of the theory?
What are the major concepts?
What are the major theoretical propositions?
What are the major assumptions?
Is the context for use described?

Theory Analysis
Are concepts theoretically and operationally defined?
Are statements theoretically and operationally defined?
Are linkages explicit?
Is the theory logically organized?
Is there a model/diagram? Does the model contribute to clarifying the theory?
Are the concepts, statements, and assumptions used consistently?
Are outcomes or consequences stated or predicted?

Theory Evaluation
Is the theory congruent with current nursing standards?
Is the theory congruent with current nursing interventions or therapeutics?
Has the theory been tested empirically? Is it supported by research? Does it appear to be accurate/valid?
Is there evidence that the theory has been used by nursing educators, nursing researchers, or nursing

Is the theory relevant socially?
Is the theory relevant cross-culturally?
Does the theory contribute to the discipline of nursing?
What are implications for nursing related to implementation of the theory?

Nurses in clinical practice, as well as graduate students like Jerry Thompson from the case study, should know
how to analyze or evaluate a theory to determine if it is reliable and valid and to determine when and how to
apply it in practice, research, administration, or education. This chapter has presented and analyzed a number
of different methods for evaluation of theory. Like many issues in the study of use of theory in nursing, the
process of theory evaluation, although important, is often confusing. In addition, with very few exceptions,
the methods or techniques were developed and used almost exclusively to analyze and evaluate grand nursing
theories. It is hoped that with the current emphasis on development and use of both practice and middle range
theories, there will be a concurrent emphasis on the analysis and evaluation of those theories. In this chapter,
the most commonly used methods were described in some detail and compared. Following this comparison, a
synthesized and simplified method for examination of theory was presented.

Key Points
Theory evaluation is the process of systematically examining a theory; the intent of evaluation is to

determine how well the theory guides practice, research, education, or administration.
The process of theory evaluation typically includes examination of the theory’s origins, meaning, logical

adequacy, usefulness, generalizability, and testability. Additional criteria are also considered, depending on
which process or technique is being used.

Several different methods for theory analysis/theory evaluation have been proposed in the nursing literature.
The synthesized method for theory evaluation was derived from other published methods and is intended to

be used to evaluate middle range and practice theories.

To further help the reader understand the theory evaluation process, this chapter presents an exemplar of the
synthesized method for theory evaluation.



Primary References for the Theory of Chronic Sorrow
Burke, M. L., Eakes, G. G., & Hainsworth, M. A. (1999). Milestones of chronic sorrow:

Perspectives of chronically ill and bereaved persons and family caregivers. Journal of
Family Nursing, 5(4), 374–387.

Eakes, G. G. (1993). Chronic sorrow: A response to living with cancer. Oncology Nursing
Forum, 20(9), 1327–1334.

Eakes, G. G. (1995). Chronic sorrow: The lived experience of parents of chronically mentally
ill individuals. Archives of Psychiatric Nursing, 9(2), 77–84.

Eakes, G. G. (2016). Chronic sorrow. In S. J. Peterson & T. S. Bredow (Eds.), Middle range
theories: Application to nursing research (4th ed., pp. 93–105). Philadelphia, PA: Wolters

Eakes, G. G., Burke, M. L., & Hainsworth, M. A. (1998). Middle-range theory of chronic
sorrow. Image—The Journal of Nursing Scholarship, 30(2), 179–184.

Schreier, A. M., & Droes, N. S. (2014). Theory of chronic sorrow. In M. R. Alligood (Ed.),
Nursing theorists and their work (8th ed., pp. 609–625). Maryland Heights, MO: Mosby.

References for Examples of Application of the Theory of Chronic Sorrow in
Practice and Research
Bowes, S., Lowes, L., Warner, J., & Gregory, J. W. (2009). Chronic sorrow in parents of

children with type 1 diabetes. Journal of Advanced Nursing, 65(5), 992–1000.
Glenn, A. D. (2015). Using online health communication to manage chronic sorrow: Mothers

of children with rare diseases speak. Journal of Pediatric Nursing, 30(1), 17–24.
Gordon, J. (2009). An evidence-based approach for supporting parents experiencing chronic

sorrow. Pediatric Nursing, 35(2), 115–159.
Hobdell, E. F., Grant, M. L., Valencia, I., Mare, J., Kothare, S. V., Legido, A., et al. (2007).

Chronic sorrow and coping in families of children with epilepsy. The Journal of
Neuroscience Nursing, 39(2), 76–82.

Isaksson, A. K., & Ahlstrom, G. (2008). Managing chronic sorrow: Experiences of patients
with multiple sclerosis. The Journal of Neuroscience Nursing, 40(3), 180–191.

Joseph, H. A. (2012). Recognizing chronic sorrow in the habitual ED patient. Journal of
Emergency Nursing, 38(6), 539–540.

Kendall, L. C. (2005). The experience of living with ongoing loss: Testing the Kendall
Chronic Sorrow Instrument (Unpublished doctoral dissertation). Virginia Commonwealth
University, Richmond, VA.

Olwit, C., Musisi, S., Leshabari, S., & Sanyu, I. (2015). Chronic sorrow: Lived experiences
of caregivers of patients diagnosed with schizophrenia in Butabika mental Hospital,
Kampala, Uganda. Archives of Psychiatric Nursing, 29(1), 43–48.

Smith, C. S. (2009). Substance abuse, chronic sorrow, and mothering loss: Relapse triggers
among female victims of child abuse. Journal of Pediatric Nursing, 24(5), 401–410.

Vitale, S. A., & Falco, C. (2014). Children born prematurely: Risk of parental chronic
sorrow. Journal of Pediatric Nursing, 29(6), 248–251.

Theory Description
Scope of theory: Middle range

Purpose of theory: Explanatory theory—“to explain the experiences of people across the


lifespan who encounter ongoing disparity because of significant loss” (Eakes, Burke, &
Hainsworth, 1998, p. 179)

Origins of theory: “Chronic sorrow” appeared in the literature in 1962 to describe recurrent
grief experienced by parents of children with disabilities. A number of research projects
were conducted in the 1980s and 1990s describing chronic sorrow among various groups
with loss situations. The resulting theory of chronic sorrow, therefore, was inductively
developed using concept analysis, extensive review of the literature, critical review of
research, and validation in 10 qualitative studies of various loss situations (Eakes, 2016;
Eakes et al., 1998).

Major concepts: Chronic sorrow, loss experience, disparity, trigger events (milestones),
external management methods, internal management methods. All are defined and
explained (Schreier & Droes, 2014).

Major theoretical propositions are as follows:

1. Disparity between a desired relationship and an actual relationship or a disparity between
current reality and desired reality is created by loss experiences.

2. Trigger events bring the negative disparity into focus or exacerbate the experience of

3. For individuals with chronic or life-threatening illnesses, chronic sorrow is most often
triggered when the individual experiences disparity with accepted norms (social,
developmental, or personal).

4. For family caregivers, disparity between the idealized and actual is associated with
developmental milestones.

5. For bereaved individuals, disparity from the ideal is created by the absence of a person
who was central in the life of the bereaved.

Major assumptions: Not stated

Context for use: “Experienced by individuals across the lifespan”; implied that it may be used
in multiple settings and nursing situations

Theory Analysis
Theoretical definitions for major concepts:

Chronic sorrow—the periodic recurrence of permanent, pervasive sadness or other grief-
related feelings associated with ongoing disparity resulting from a loss experience

Loss experience—a significant loss, either actual or symbolic, that may be ongoing, with no
predictable end, or a more circumscribed single-loss event

Disparity—a gap between the current reality and the desired as a result of a loss experience

Trigger events or milestones—a situation, circumstance, or condition that brings the negative
disparity resulting from the loss into focus or exacerbates the disparity

External management methods—interventions provided by professionals to assist individuals
to cope with chronic sorrow

Internal management methods—positive personal coping strategies used to deal with the
periodic episodes of chronic sorrow

Operational definitions for major concepts: No operational definitions are provided in the
original works.

Statements theoretically defined: Theoretical propositions are implicitly stated in the body of
the text.

Statements operationally defined: Theoretical propositions are not operationally defined.


Linkages explicit: Linkages are described in the text and explicated in the model.

Logical organization: Theory is logically organized and described in detail.

Model/diagram: A model is provided and assists in explaining linkages of the concepts.

Consistent use of concepts, statements, and assumptions: Concepts and propositions are used
consistently. Assumptions are not explicitly addressed.

Predicted or stated outcomes or consequences: Anticipated outcomes are stated in the model.

Theory Evaluation
Congruence with nursing standards: The theory appears congruent with nursing standards. A

number of articles were identified in recent nursing literature describing how the construct
of chronic sorrow has been identified among various aggregates (Eakes, 2016).

Congruence with current nursing interventions or therapeutics: Literature-based descriptions
of application of components of the theory in nursing practice include caring for bereaved
persons and family caregivers (Burke, Eakes, & Hainsworth, 1999), a discussion of caring
for children with type 1 diabetes (Bowes, Lowes, Warner, & Gregory, 2009), interventions
for community nurses to help assist families resolving chronic sorrow (Gordon, 2009),
using online health communication to manage chronic sorrow among mothers of children
with rare diseases (Glenn, 2015).

Evidence of empirical testing/research support/validity: The theory was derived from
multiple research studies and a review of the literature.

The Burke/CCRCS Chronic Sorrow Questionnaire is an interview guide comprising 10 open-
ended questions that explore the theory’s concepts.

Research using the questionnaire includes investigation of chronic sorrow among cancer
patients (Eakes, 1993), chronic sorrow in chronically mentally ill individuals (Eakes,
1995), chronic sorrow in women who were victims of child abuse (Smith, 2009), chronic
sorrow in habitual emergency department patients (Joseph, 2012), chronic sorrow and
coping in families of children with epilepsy (Hobdell et al., 2007), chronic sorrow among


parents of children born prematurely (Vitale & Falco, 2014), and chronic sorrow among
patients with multiple sclerosis (Isaksson & Ahlstrom, 2008). Further, a second instrument
designed to measure chronic sorrow (Kendall, 2005) has been developed.

Use by nursing educators, nursing researchers, or nursing administrators: The references
listed previously indicate that the theory has been used in practice and research. Other
studies have cited the work of Eakes and colleagues related to chronic sorrow (Eakes,

Social relevance: Theory is relevant to individuals, families, and groups, irrespective of age
or socioeconomic status.

Transcultural relevance: Theory is potentially relevant across cultures; theorist notes that
“relevance for various cultural groups should be explored” (Eakes et al., 1998, p. 184). For
example Olwit and team (2015) studied chronic sorrow among caregivers of patients with
schizophrenia in a hospital in Uganda.

Contribution to nursing: Authors note that the theory is applicable to different groups, but
more study is needed to test the theory and to identify strategies to reduce disparity created
by loss (prescriptive interventions). Despite the relative newness of the theory, there is a
growing body of nursing literature reporting on use both related to interventions and
research (Eakes, 2016).

Conclusions and implications: The theory is useful and appropriate for nurses practicing in a
variety of settings. Implications for research were described and implications for education
can be inferred. Further development of the theory is warranted to better explicate
relationships and operationalize the concepts and propositions to allow testing.

Learning Activities
1. Obtain the original works of two of the nursing scholars whose theory analysis/evaluation

strategies are discussed. Use the strategies to evaluate a recently published middle range
nursing theory (see Chapter 11 for examples). How are the conclusions similar? How are they

2. For one of the nursing scholars who has published several versions or editions of her work
(e.g., Fawcett, Chinn and Kramer, Meleis), obtain a copy of the oldest version and a copy of
the most recent version and compare the strategies suggested. Have they changed?

3. Search the literature for examples of published accounts of nursing theory evaluation or
theory analysis. Share your findings with classmates.

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their work (8th ed., pp. 2–13). St. Louis, MO: Mosby.
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Barnum, B. S. (1984). Nursing theory: Analysis, application, evaluation (2nd ed.). Boston, MA: Little, Brown.
Barnum, B. S. (1990). Nursing theory: Analysis, application, evaluation (3rd ed.). Glenview, IL: Scott, Foresman/Little, Brown Higher

Barnum, B. S. (1994). Nursing theory: Analysis, application, evaluation (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Barnum, B. S. (1998). Nursing theory: Analysis, application, evaluation (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Chinn, P. L., & Jacobs, M. K. (1983). Theory and nursing: A systematic approach. St. Louis, MO: Mosby.
Chinn, P. L., & Jacobs, M. K. (1987). Theory and nursing: A systemic approach (2nd ed.). St. Louis, MO: Mosby.
Chinn, P. L., & Kramer, M. K. (1991). Theory and nursing: A systematic approach (3rd ed.). St. Louis, MO: Mosby.
Chinn, P. L., & Kramer, M. K. (1995). Theory and nursing: A systematic approach (4th ed.). St. Louis, MO: Mosby.
Chinn, P. L., & Kramer, M. K. (1999). Theory and nursing: Integrated knowledge development (5th ed.). St. Louis, MO: Mosby.
Chinn, P. L., & Kramer, M. K. (2004). Integrated theory and knowledge development in nursing (6th ed.). St. Louis, MO: Mosby.
Chinn, P. L., & Kramer, M. K. (2008). Integrated theory and knowledge development in nursing (7th ed.). St. Louis, MO: Mosby.
Chinn, P. L., & Kramer, M. K. (2011). Integrated theory and knowledge development in nursing (8th ed.). St. Louis, MO: Mosby.
Chinn, P. L., & Kramer, M. K. (2015). Integrated theory and knowledge development in nursing (9th ed.). St. Louis, MO: Elsevier.
Curley, M. A. Q. (1998). Patient-nurse synergy: Optimizing patients’ outcomes. American Journal of Critical Care, 7(1), 64–72.
Dudley-Brown, S. L. (1997). The evaluation of nursing theory: A method for our madness. International Journal of Nursing Studies, 34(1), 76–



Duffey, M., & Muhlenkamp, A. F. (1974). A framework for theory analysis. Nursing Outlook, 22(9), 570–574.
Ellis, R. (1968). Characteristics of significant theories. Nursing Research, 17(3), 217–222.
Fawcett, J. (1980). A framework of analysis and evaluation of conceptual models of nursing. Nurse Educator, 5(6), 10–14.
Fawcett, J. (1993). Analysis and evaluation of nursing theories. Philadelphia, PA: Davis.
Fawcett, J. (1995). Analysis and evaluation of conceptual models of nursing (3rd ed.). Philadelphia, PA: Davis.
Fawcett, J. (2000). Analysis and evaluation of contemporary nursing knowledge: Nursing models and theories. Philadelphia, PA: Davis.
Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (2nd ed.). Philadelphia, PA:

Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd

ed.). Philadelphia, PA: Davis.
Fitzpatrick, J. J., & Whall, A. L. (1989). Conceptual models of nursing: Analysis and application. Stamford, CT: Appleton & Lange.
Fitzpatrick, J. J., & Whall, A. L. (1996). Conceptual models of nursing: Analysis and application (3rd ed.). Stamford, CT: Appleton & Lange.
Fitzpatrick, J. J., & Whall, A. (2005). Conceptual models of nursing: Analysis and application (4th ed.). Upper Saddle River, NJ: Prentice-Hall.
Fitzpatrick, J. J., & Whall, A. (2016). Conceptual models of nursing: Global perspective (5th ed.). Boston, MA: Pearson.
George, J. B. (2011). Nursing theories: The base for professional nursing practice (6th ed.). Upper Saddle River, NJ: Pearson.
Hardy, M. E. (1974). Theories: Components, development, evaluation. Nursing Research, 23, 100–107.
Hardy, M. E. (1978). Perspectives on nursing theory. ANS. Advances in Nursing Science, 1(1), 37–48.
Hickman, J. S. (2011). An introduction to nursing theory. In J. B. George (Ed.), Nursing theories: The base for professional nursing practice

(6th ed., pp. 1–22). Upper Saddle River, NJ: Pearson.
Kuhn, T. S. (1977). Second thoughts on paradigms. In F. Suppe (Ed.), The structure of scientific theories (pp. 459–482). Urbana, IL: University

of Illinois Press.
Masters, K. (2015). Nursing theories: A framework for professional practice (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
Meleis, A. I. (1985). Theoretical nursing: Development and progress. Philadelphia, PA: J.B. Lippincott.
Meleis, A. I. (1991). Theoretical nursing: Development and progress (2nd ed.). Philadelphia, PA: J.B. Lippincott.
Meleis, A. I. (1997). Theoretical nursing: Development and progress (3rd ed.). Philadelphia, PA: J.B. Lippincott.
Meleis, A. I. (2007). Theoretical nursing: Development and progress (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Meleis, A. I. (2012). Theoretical nursing: Development and progress (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Moody, L. E. (1990). Advancing nursing science through research. Newbury Park, CA: Sage.
Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2015). Health promotion in nursing practice (7th ed.). Upper Saddle River, NJ: Prentice-

Peterson, S. J., & Bredow, T. S. (2017). Middle range theories: Application to nursing research and practice (4th ed.). Philadelphia, PA:

Wolters Kluwer.
Smith, M. C., & Parker, M. E. (2015). Nursing theories & nursing practice (4th ed.). Philadelphia, PA: Davis.
Smith, M. J., & Liehr, P. R. (2013). Middle range theory for nursing (3rd ed.). New York, NY: Springer Publishing.
Stevens, B. J. (1979). Nursing theory: Analysis, application, evaluation. Boston, MA: Little, Brown.
Walker, L. O., & Avant, K. (1983). Strategies for theory construction in nursing. Norwalk, CT: Appleton-Century-Crofts.
Walker, L. O., & Avant, K. (1988). Strategies for theory construction in nursing (2nd ed.). Norwalk, CT: Appleton & Lange.
Walker, L. O., & Avant, K. (1995). Strategies for theory construction in nursing (3rd ed.). Norwalk, CT: Appleton & Lange.
Walker, L. O., & Avant, K. (2005). Strategies for theory construction in nursing (4th ed.). Upper Saddle River, NJ: Prentice-Hall.
Walker, L. O., & Avant, K. (2011). Strategies for theory construction in nursing (5th ed.). Upper Saddle River, NJ: Prentice-Hall.
Whall, A. L. (2016). Philosophy of science positions and their importance in cross-national nursing. In J. J. Fitzpatrick & A. L. Whall (Eds.),

Conceptual models of nursing: Global perspectives (5th ed., pp. 8–28). Upper Saddle River, NJ: Prentice-Hall.



Nursing Theories



Overview of Grand Nursing Theories
Evelyn M. Wills

Janet Turner works as a nurse on a postsurgical, cardiovascular floor. Because she desires a broader view of
nursing knowledge and wants to become an acute care nurse practitioner, she recently began a master’s degree
program in nursing. The requirements for a course entitled “Theoretical Foundations of Nursing Practice” led
Janet to become familiar with some of the many nursing theories. From her readings, she learned about a
number of ways to classify theories: grand theory, conceptual model, middle range theory, practice theory,
borrowed theory, interactive–integrative model, totality paradigm, and simultaneous action paradigm. She
came to the conclusion that there is no consistency among nursing theorists and even questioned their
relevance to her practice.

Janet’s theory course was conducted via distance learning technology including online classrooms, chats,
Twitter, Wikis, and other social media formats. To better understand the material, she consulted with her
theory professor and classmates via the Twitter feed and participated in the course’s live chat room. Lively
online discussions resulted in sharing interesting ways of conceptualizing the grand nursing theories.

As Janet continued to study and work with her professor and classmates, she learned that nursing theories
have evolved from several schools of philosophical thought and various scientific traditions. Growing more
confident, she considered ways to group or categorize them based on similarities of perspective; thus, she was
able to read and analyze the theories more effectively. Ultimately, she selected two to examine further for one
of her assignments.

In Chapter 2, the reader was introduced to grand nursing theories and given a brief historical overview of their
development. Fawcett and DeSanto-Madeya (2013) distinguish between conceptual models and grand
theories, explaining that conceptual models are broad formulations of philosophy based on an attempt to
include the whole of nursing reality as the scholar understands it. The concepts and propositions of conceptual
models are abstract and not likely to be testable in fact. Grand nursing theories, by contrast, may be derived
from conceptual models and are the most complex and widest in scope of the levels of theory; they attempt to
explain broad issues within the discipline. Grand theories are composed of relatively abstract concepts and
propositions that are less abstract than those of conceptual models and may not be directly amenable to testing
(Butts, 2015; Fawcett & DeSanto-Madeya, 2013; Higgins & Moore, 2000). They were developed through
thoughtful and insightful appraisal of existing ideas as opposed to empirical research and may provide the
basis for scholars to produce innovative middle range or practice theories (Figure 6-1).


Figure 6-1 Relationship of conceptual model, theory, and hypotheses.

The grand nursing theories guide research and assist scholars to integrate the results of numerous diverse
investigations so that the findings may be applied to education, practice, further research, and administration.
Eun-Ok and Chang (2012), in their review of literature, found support for the idea that grand theories have an
important place in nursing, for example, in research and clinical practice. They also found that theorists are
further refining concepts and theories. They stated that theories are “essential for our discipline at multiple
levels” (p. 162) (Box 6-1). Eun-Ok and Chang also noted that the grand theories provide a background of
philosophical reasoning that allows nurse scientists to develop organizing principles for research or practice,
sometimes referred to as middle range theory (middle range theories will be discussed in Chapters 10 and 11).
One of the most important benefits of invoking theories in education, administration, research, and practice
has been the systematization of those domains of nursing activity. Indeed, according to Bachmann, Danuser,
and Morin (2015), a theoretical base is essential in that it provides a firm connection between new or adapted
knowledge or information and nursing science, thus promoting development of the science.

Box 6-1
Nursing Theories and the American Association of Colleges of Nursing

Essential I of the Essentials of Master’s Education in Nursing (American Association of Colleges of Nursing
[AACN], 2011) specifically notes that “master’s-prepared nurses use a variety of theories and frameworks
including nursing and ethical theories in the analysis of clinical problems, illness prevention and health
promotion strategies” (p. 9). Furthermore, “nursing theories” is listed as one content area to be included in
master of science in nursing (MSN) programs.

Advanced practice nurses are more likely to succeed in analyzing research results for evidence-based
practice (EBP) when the research fits into a particular theoretical framework. Cody (2003) stated that “nursing
theory guided practice can be shown to enhance health and quality of life when it is implemented with strong,
well-qualified guidance” (p. 226). Mark, Hughes, and Jones (2004) echoed their beliefs and posited that
theory-guided research results not only in greater patient safety but also in more predictable outcomes. These
beliefs among nursing scientists provide clear direction that theory-guided research is necessary for evaluating
nursing interventions in practice.

Over the last five decades of theory development, review of the health care literature demonstrates that
changes in health care, society, and the environment as well as changes in population demographics (e.g.,
aging, urbanization, and growth of minority populations) led to a need to renew or update existing theories


and to develop different theories. Furthermore, contemporary theories, such as complexity science, need to be
adapted and adopted within theories to make them more applicable, especially within certain aspects of the
discipline (Engebretson & Hickey, 2015). In fact, some theoretical writers would exclude the grand theory–
middle range theory–microtheory relationship in favor of value-based and socially attuned constructions of
nursing knowledge that fit contemporary understanding of human interactions (Risjord, 2009).

Chapters 7 through 9 provide additional information about some of the more commonly known and
widely recognized nursing frameworks and theories. To better assist the reader in understanding the
conceptual frameworks and grand nursing theories, this chapter presents methods for categorizing or
classifying them and describes the criteria that will be used to examine them in the subsequent chapters.

Categorization of Conceptual Frameworks and Grand Theories
The sheer number and scope of the conceptual frameworks and grand theories are daunting. Students and
novice nursing scholars are understandably intimidated when asked to study them, as illustrated in the
opening case study. To help understand the formulations, a number of methods categorizing them have been
described in the nursing literature. Several are presented in the following sections.

Categorization Based on Scope
One of the most logical ways to categorize grand nursing theories is by scope. For example, Alligood (2014)
organized theories according to the scope of the theory. The categories in her work were philosophies, nursing
conceptual models, nursing theories, theories, and middle range nursing theories. Pokorny (2014) considered
the writings of nursing theorists Peplau; Henderson; Abdellah; Wiedenbach; Hall; Travelbee; Barnard; Adam;
Roper, Logan, and Tierney; and Ida Jean (Orlando) Pelletier (hereafter referred to as Orlando) as of historical
significance. Alligood considered the works of Nightingale, Watson, Ray, Martinson, Benner, and Katie
Eriksson to be philosophies, explaining that those theorists had developed philosophies that were derived
through “analysis, reasoning and logical argument” (p. 59). These philosophies may form a basis for
professional scholarship and help guide understanding of nursing phenomena.

Alligood (2014) categorized the works of Levine, Rogers, Orem, King, Neuman, Roy, and Johnson as
nursing conceptual models. Nursing conceptual models, she explained, “specify a perspective and produce
evidence among phenomena specific to the discipline [of nursing]” (p. 203).

Boykin and Schoenhofer; Meleis; Pender; Leininger; Newman; Parse; Helen Erickson, Tomlin, and
Swain; and Husted and Husted are classified by Alligood (2014) as nursing theories. She observed that these
works are nearly as abstract as conceptual models but apply to nursing practice and form “ways to describe,
explain, or predict relationships among the concepts of nursing phenomena” (p. 357). Furthermore, Alligood
noted that some of these theories evolved from the more global philosophical frameworks or grand theories.

Categorization Based on Nursing Domains
Meleis (2012) did not categorize according to levels of theory (e.g., grand theory, middle range theory, and
practice theory). Rather, she categorized theories based on schools of thought or nursing domains: needs
theorists; interaction theorists; outcomes theorists, as they developed in various eras; and, finally,
caring/becoming theorists in the current era (Table 6-1).

Table 6-1 Meleis’s Method of Categorizing Theories
Theorist’s School

Needs Interaction Outcome Caring/Becoming

Focus Problems, nurse’s

Interaction, illness as

Energy, balance,
stability, homeostasis,
outcomes of care

Human–universe health
process, meaning, mutual
relations, unitary being

Human being Set of needs, problems,
developmental being

Interacting, set of needs,
validated needs, human

developmental being

continuously becoming,


Patient Needs deficit Helpless being, human

Lacks adaptation,
systems deficiency

Unique human being,
transcendence, disharmony
between spirit–body–mind–
soul, sense of incongruence

Orientation Illness/disease Illness/disease Illness/disease Health, humanbecoming:
both client and nurse

Nurse’s role Depends on medical
practice, begin
independent function,
fulfills needs requisites

Helping process, self:
therapeutic agent,
nursing process

External regulatory

Connect, be present, extract

Decision maker Health care provider Health care provider Health care provider Mutual between health care
provider and client

Source: Meleis (2012).

She further defined each school of thought according to the major influences of that genre. The needs
theorists, according to Meleis (2012), are Abdellah, Henderson, and Orem. The interaction theorists are King,
Orlando, Paterson and Zderad, Peplau, Travelbee, and Wiedenbach, and the outcome theorists are Johnson,
Levine, Rogers, and Roy (Meleis, 2012). She lists the caring/becoming theorists as Watson and Parse. Each
school of thought, it was noted, has certain concepts and defining properties.

Meleis (2012) considers areas of agreement among the schools of thought: attention to the client/patient,
who requires a nurse to assist in meeting the changes or transitions and wellness experiences of life, and the
ideal that nurses have means to assist human beings. Furthermore, the schools of thought share the ideal that
nurses’ focus is on human beings and on discovering ways to meet health and illness situations.

Categorization Based on Paradigms
A paradigm is a worldview or an overall way of looking at a discipline and its science. It is seen as a universal
view of life rather than just a model or principle of a theory. Kuhn (1996), a theoretical physicist turned
science historian, awakened the scientific community to revolutions in understanding what he called paradigm
shifts. Paradigm shifts occur when empirical reality no longer fits the existing theories of science. As an
example, he cited Einstein’s theory of general relativity, which came about when the extant theories no longer
fit the evidence that was being generated regarding matter and energy.

Recent scientific revolutions in health disciplines have changed the way scientists view human beings and
their health. For example, immunotherapy and gene therapy are currently being studied extensively. The
human genome has been mapped, and this knowledge has impacted areas of life as varied as ethics, law,
pharmacology, and medicine. The impact of these new ideas and research on health care delivery is, in effect,
a paradigm shift.

Nursing scientists are finding that the theories that have guided practice in the past are no longer sufficient
to explain, predict, or guide current practice. Furthermore, older theories may not be helpful in developing
nursing science because scholars working in nursing’s new paradigm are finding evidence that distinguishes
nursing science from the sciences that nurses have traditionally consulted to explain the discipline, that is,
anthropology, biology, chemistry, physics, psychology, sociology, and medicine (Cody, 2000; Newman,
2008). The following sections outline how three modern nursing scholars (Parse, Newman, and Fawcett) have
categorized nursing theories based on paradigms or worldviews (Figure 6-2).


Figure 6-2 Comparison of categories (paradigms) of theories.

Parse’s Categorization
Parse (1995) categorized the various nursing theories into two basic paradigms. These she termed the totality
paradigm and the simultaneity paradigm, and she later added the humanbecoming paradigm (humanbecoming
is all one word) (Parse, 2013). The totality paradigm includes all theoretical perspectives in which humans are
biopsychosocial-spiritual beings, adapting to their environment, in whatever way the theory defines
environment. The simultaneity paradigm, on the other hand, includes the theoretical perspectives in which
humans are identified as unitary beings, which are energy systems in simultaneous, continuous, mutual
process with, and embedded in, the universal energy system. Using this classification scheme, the works of
Orem, Roy, Johnson, and others would fit within the totality paradigm, and the works of theorists such as
Fawcett, Rogers, and Newman are within the simultaneity paradigm. Recently, Parse noted that Rogers’s and
Newman’s theories differed from her current thinking sufficiently that she named a third paradigm. She calls
the new paradigm the humanbecoming paradigm (Parse, 2013). This new paradigm will be discussed in
Chapter 9.

Newman’s Categorization
Similarly, Newman (1992) classified nursing theories according to existing philosophical schools but found
that nursing paradigms did not neatly fit; therefore, she created three categorizations of theories loosely based
on the extant philosophies (i.e., positivism, postpositivism, and humanism). She named the nursing paradigms
(1) the particulate–deterministic school, (2) the interactive–integrative school, and (3) the unitary–
transformative school. In this classification scheme, the first word in the pair indicates the view of the
substance of the theory, and the second word indicates the way in which change occurs.

To Newman (1992), the particulate–deterministic paradigm is characterized by the positivist view of the
theory of science and stresses research methods that demanded control in the search for knowledge. Entities
(e.g., humans) are viewed as reducible, and change is viewed as linear and causal. Nightingale, Orem,
Orlando, and Peplau are representative of theorists in this realm of theoretical thinking.

The interactive–integrative paradigm (Newman, 1992) has similarities with the postpositivist school of
thought. In this paradigm, objectivity and control are still important, but reality is seen as multidimensional
and contextual, and both objectivity and subjectivity are viewed as desirable. Newman (1992) lists works of
theorists Patterson and Zderad; Roy, Watson, and Erickson; Tomlin; and Swain in this paradigm.

Into the unitary–transformative category, Newman (1992) places her works and those of Rogers and
Parse. Each of these theorists views humans as unitary beings, which are self-evolving and self-regulating.
Humans are embedded in, and constantly and simultaneously interacting with, a universal, self-evolving
energy system. These theorists agree that human beings cannot be known by the sum of their parts; rather,
they are known by their patterns of energy and ways of being apart and distinct from others.


Fawcett’s Categorization
Fawcett and DeSanto-Madeya (2013) simplified Newman’s (1992) categorization of theories when they
created three categories of worldview based on the treatment of change in each theory. The categories Fawcett
and DeSanto-Madeya delineated were (1) reaction, (2) reciprocal interaction, and (3) simultaneous action
(Fawcett & DeSanto-Madeya, 2013). Like Newman, they showed that each category coincided with a
philosophical tradition.

In describing the reaction worldview, Fawcett and DeSanto-Madeya (2013) indicated that these theories
classify humans as biopsychosocial-spiritual beings who react to the environment in a causal way. The
interaction changes predictably and controllably as humans survive and adapt. They argued that in these
theories, phenomena must be objective and observable and may be isolated and measured.

In the reciprocal interaction worldview, humans are viewed as holistic, active, and interactive with their
environments, with the environments returning interactions (Fawcett, 1993; Fawcett & DeSanto-Madeya,
2013). Fawcett (1993) noted that these theorists viewed reality as multidimensional, dependent on context
(i.e., the surrounding conditions), and relative. This means that change is probabilistic (based on chance) and a
result of multiple antecedent factors. The reciprocal interaction theories support the study of both objective
and subjective phenomena, and both qualitative and quantitative research methods are encouraged, although
controlled research methods and inferential statistical techniques are most frequently used to analyze
empirical data (Fawcett & DeSanto-Madeya, 2013).

In the third category of grand theories, the simultaneous action worldview, Fawcett and DeSanto-Madeya
(2013) report that human beings are viewed as unitary, are identified by patterns in mutual rhythmical
interchange with their environments, are changing continuously, and are evolving as self-organized fields. She
states that in the simultaneous action paradigm, change is in a single direction (unidirectional) and is
unpredictable in that beings progress through organization to disorganization on the way to more complex
organization. In this paradigm, knowledge and pattern recognition are the phenomena of interest.

This categorization explained the major differences among the many current and past nursing theories and
conceptual models (Fawcett, 2005; Fawcett & DeSanto-Madeya, 2013). Table 6-2 summarizes the grand
theory categorization scheme. Table 6-3 compares the classification methods of Fawcett and DeSanto-Madeya
(2013), Meleis (2012), Newman (1995), and Parse (1995).

Table 6-2 Fawcett’s Categorization of Nursing Theories
Paradigm Characteristics

Reaction Humans are biopsychosocial-spiritual beings.
Humans react to their environment in a causal way.
Change is predictable as humans survive and adapt.

Reciprocal interaction Humans are holistic beings.
Humans interact reciprocally with their environment.
Reality is multidimensional, contextual, and relative.

Simultaneous action Humans are unitary beings.
Humans and their environment are constantly interacting, changing,

and evolving.
Change is unidirectional and unpredictable.

Table 6-3 Classification of Grand Theories by Current Theory Analysts
Theory Analyst Source Basis for Typology Categories

Fawcett Philosophy Worldviews Reaction
Reciprocal interaction
Simultaneous action

Meleis Patient care philosophy Metaparadigm concepts
Schools of thought

Nursing clients
Human being–



Needs, interaction,

outcomes, caring
Newman Paradigm Philosophical schools Particulate–deterministic


Parse Paradigm Difference between



Sources: Fawcett (2000, 2005); Fawcett and DeSanto-Madeya (2013); Meleis (2012); Newman (1995); Parse (1995, 2013).

Specific Categories of Models and Theories for This Unit
For this book, the conceptual models and grand nursing theories were categorized based on distinctions that
are similar to those described by Fawcett and DeSanto-Madeya (2013) and Newman (1992). Chapters 7
through 9 thus present analyses of models and theories according to the following classifications: (1) the
human needs theories (which relate to Fawcett’s reaction category), (2) the interactive theories, and (3) the
unitary process theories.

The theories discussed in Chapter 7 are based on a classical needs perspective and are among the earliest
theories and models derived for nursing science. They include the works of Nightingale, Henderson, Johnson,
and others. In Chapter 8, each of the perspectives has human interactions as the basis of their content,
regardless of the era in which they were developed. The works of Roy, Watson, King, and others are also
included in Chapter 8. Finally, the unitary process theories are described in Chapter 9. The theorists explained
there are Rogers, Newman, and Parse. Table 6-4 summarizes the theories that are presented in Chapters 7
through 9.

Table 6-4 Categorization of Grand Nursing Theories for Chapters 7–9
Human Needs Models and Theories Interactive Process Unitary Process

Abdellah Artinian Newman
Henderson Eric on, Tomlin, and Swain Parse
Johnson King Rogers
Nightingale Levine
Neuman Roy
Orem Watson

Analysis Criteria for Grand Nursing Theories
Describing how models and theories can be employed in nursing practice, research,
administration/management, and education necessitates a review of selected elements through theory analysis.
Seven criteria were selected for description and analysis of grand theories in this unit. As described in Chapter
5, these seven chosen criteria were among the earliest enumerated by Ellis (1968) and Hardy (1978) and
promoted by Walker and Avant (2011) and Fawcett and DeSanto-Madeya (2013).

Complete analysis of each theory was not performed; instead, the presentation of the models and theories
in Chapters 7 through 9 is largely descriptive rather than analytical or evaluative. Each theory’s ease of
interpretation and application is also briefly critiqued. The criteria used for reviewing the grand theories in
these three chapters are listed in Box 6-2. Each criterion is also discussed briefly in the following sections.


Box 6-2 Review Criteria for Descriptive Analysis of Grand Nursing Theories
Background of the theorist
Philosophical underpinnings of the theory
Major assumptions, concepts, and relationships
Value in extending nursing science

Background of the Theorist
A review of the background of the theorist is likely to reveal the foundations of the theorist’s ideas. The
individual’s educational experiences, in particular, may be relevant to the development of the theory. At one
time, higher education, particularly university education, was open only to the children of financially secure
families and often limited to nonminorities. Only in the years after the 1960s were scholarships for students
with financial hardships and students of ethnic minorities readily available. In addition, nursing graduate
programs were not widely available in most parts of the United States before the creation of federal programs
in the late 1960s. Because of the limited availability of graduate nursing programs, the majority of the early
nursing scholars who developed conceptual models and grand theories received graduate education in
disciplines other than nursing. As a result, the earliest nursing models and theories reflected the paradigms
that were accepted in the scholar’s educative discipline at the time in which they studied or wrote.

The nurse scholar’s experience and specialty also influenced the theoretical perspective. For example,
Orlando and Peplau were psychiatric nurses who were educated in the first half of the 20th century. Their
graduate education in psychology was tempered by the focus of psychology at that time—that of the logical–
positivist era, which emphasized reductionistic principles and was mathematically based. Later scholars (e.g.,
Fawcett, Parse, Fitzpatrick, and Newman) received their doctoral credentials within the discipline of nursing.
The writings of these scholars reflect the scientific thought processes, knowledge base, and current thinking of
the discipline at the time of their writing as well as their personal perspectives and experiences.

The placement of the author of the model or theory in historical and conceptual perspective promotes
understanding of the extant views of science during the time in which the theorist wrote. Only in the most
exceptional of cases are scholars not likely to be influenced by the times in which they formulated their work.
One exception to this was Rogers. Interestingly, the discipline of nursing was deep in the positivist era in the
1960s when she began her work; the hard sciences (i.e., physics and chemistry), however, had entered the
postpositivist era, which posited the idea that change is inherent in a growing discipline. Rogers’s (1970)
theory did not fit easily into the concurrent paradigm of nursing science of that time and was rejected by many
in favor of more intermediate thinking that corresponded to that of the postpositivist thinkers.

Philosophical Underpinnings of the Theory
The background of the scholar most likely contributed heavily to the philosophical basis and paradigmatic
origins of the model or theory. Historically, nursing theories of the 1950s and 1960s corresponded to the
reaction (Fawcett & DeSanto-Madeya, 2013) worldview. In the late 1960s through the early 1980s, the
reciprocal interaction worldviews began to take precedence, and by the 1990s, the unitary process
perspectives began to achieve importance, although the earlier paradigms were still influential (Fawcett &
DeSanto-Madeya, 2013). It is important to note that most of the scholars who adhered to the interaction
worldviews were working and writing in the 1950s, before their ideas achieved general recognition in the
profession. The simultaneous action scholars, beginning with Rogers and followed by Parse and Newman,
developed their ideas in the 1970s and 1980s and continuously grew their theories as each was influenced by
modern thinking and technology.

The fundamental philosophies and the disciplines in which the scholars were educated are reflected in
their works. Those educated in the social sciences, for example, incorporated some of the characteristics,
concepts, and assumptions of those disciplines in their works. Personal philosophies are also reflected in
written views on humans, science, environment, and health. Whether written from the positivist philosophy of


science or the postpositivist or modern worldviews, the philosophical viewpoints that form the basis of the
works are indicated by the chosen concepts. A component of theory analysis is to point out the underlying
philosophy and review the consistency with which the writer demonstrates attention to that background.

Major Assumptions, Concepts, and Relationships
Examination of the major assumptions, concepts, and relationships of the model or theory is vital because
they are the substance of the formulation. These components will direct practice, assist with selection of
concepts to be studied, and generate collateral theories for the discipline of nursing (Walker & Avant, 2011).
Whether the assumptions are spelled out or merely inferred indicates the strength of the theory in elucidating
its content. The concepts, carefully defined and explained, along with their derivation, assist the analyst in
determining the essence of the model or theory. The relationships between and among the concepts, their
strength, and whether they are positive, negative, or neutral indicate the structure of the theory (Walker &
Avant, 2011).

Conceptual models and grand theories are reputed not to be particularly useful in directing nursing practice
because of their scope and level of abstraction and because they were created through the analytical, logical,
and philosophical understandings of a single theorist (Alligood, 2014). The reality is that although many of
the conceptual models and grand theories cannot be tested in a single research project, they have been useful
in guiding nursing scholarship and practice and in providing the structure from which testable theories may be
derived. Grand nursing theories, more often than conceptual models, are likely to provide the basis for
concrete theories, with specifically defined concepts and highly derived relationships that may be more easily
applied in clinical practice, nursing education, research, or nursing administration (Fawcett & DeSanto-
Madeya, 2013).

To be useful, theories should be disprovable (Shuttleworth, 2008); that is, they can be questioned and tested in
the real world through research. Because the major purpose of nursing theory is to guide research, practice,
education, and administration, the theory must be subjected to examination. Theories that are capable of being
tested make the most reliable guides for scholarly work (Walker & Avant, 2011). Many grand theories are not
testable in totality, but they may generate theories that are testable from their conceptual matter, assumptions,
or structure. The grand theories that are likely to generate middle range theories and practice theories, as well
as theoretical models for research, are those most likely to fulfill the requirement of testability and have the
ability to continue to generate new and useful models (Kim, 2006).

Parsimony is a criterion that is important because the more complex the theory, the less easily it is
comprehended. Parsimony does not indicate that a theory is simplistic; in fact, often, the more parsimonious
the theory, the more depth the theory may have. For example, the standard of parsimony in a theory is
Einstein’s theory of relativity (Cody, 2012), which can be reduced to the formula E = mc2. Although the
theory has only three concepts (E = energy, m = mass, and c2 = the speed of light squared) (Einstein, 1961),
the explanation of this theory is extremely complicated indeed.

Considering the complexity of nurses’ primary subjects of interest, human beings in health and illness, it
is unlikely that any of the grand nursing theories could ever approximate the mathematical elegance of
Einstein’s theory of relativity. Parsimonious theoretical constructions, however, provide nurses in research,
administration, practice, and education with broad general categories into which to conceptualize problems
and therefore may assist in the derivation of methods of problem solving. Indeed, the more elegant and
universal a conceptual model or grand theory, the more global it is in contributing to the science of nursing.

Value in Extending Nursing Science
Ultimately, the value of any nursing theory, not just of grand theory, is its ability to extend the discipline and


science of nursing. Understanding the nature of human beings and their interaction with the environment, and
the impact of this interaction on their health, will help direct holistic and comprehensive nursing interventions
that improve health and well-being. Improvement in nursing care is ultimately the reason for formulating
theory. Furthermore, the value of the theory in adding to and elaborating nursing science is an important
function of grand theory (Fawcett & DeSanto-Madeya, 2013). Questions to be answered when analyzing any
theory include: Does the theory generate new knowledge? Can the theory suggest or support new avenues of
knowledge generation beyond those that already exist? Does the theory suggest a disciplinary future that is
growing and changing? Can the theory assist nurses to respond to the rapid change and growth of health care?
(Walker & Avant, 2011).

The Purpose of Critiquing Theories
Critiquing theory is a necessary part of the process when a scholar is selecting a theory for some disciplinary
work. Determining whether a grand theory holds promise or value for the effort at hand and whether middle
range theories, which are useful in research, practice, education, or administration, can be generated from it is
a product of critique.

When a nursing student confronts the overarching ideals of the profession for the first time, it is not at all
unlikely that the feeling is complete and overwhelming confusion and even disorientation. As in the case of
Janet and her quest for advanced education, frustration was a new feeling to her. Her work in the critical care
unit was focused and based on evidence and followed an ordered medical model, whereas the newness of this
conceptually based study of theories left her disgruntled. The understanding displayed by her instructor, who
had felt similar feelings during her education and who ascribed to the pattern that nurses learn together, was
calming and set the stage for Janet to begin to learn the basics of the science of nursing, the theoretical
underpinnings of the profession. See Link to Practice 6-1.

Link to Practice 6-1
Janet, the nurse from the opening case study, decided to incorporate a nursing theory into her practice. She
consulted with her classmates as to whether they had used theories in this way. One colleague stated that in
her baccalaureate program, students were required to use a theory to guide their clinical practicum, and
another had been employed in a hospital that based nursing care around the work of a grand nursing
theorist. Building on their suggestions and what she learned in her course, Janet used key tenets and ideas
from the “human needs” and “interactive process” models in her daily practice, trying out concepts and
interventions from some of the theorists as she worked. She found that no matter which major theorist she
used, she was able to organize her work more effectively.

It is likely that a nursing student may find it difficult to critique the work of nursing’s grand theorists
considering the advanced educational attainment of the theorists. Yet, determining the usefulness of the theory
to a project is important. The user of the theory must comprehend the paradigm of the theory, believe in the
concepts and assumptions from which it is built, and be able to internalize the basic philosophy of the theorist.
It is hardly beneficial to attempt to use a theory that one cannot accept or understand or one that seems
inappropriate in the current time or place. The choice of a theoretical framework or model must fit with the
student’s or scholar’s personal ideals, and this requires the student or scholar to critique the theory for its
value in extending the selected professional work.

One problem that arises among both novice and experienced scholars is combining theories from
competing paradigms. Often, the work generated from these efforts is confusing and obfuscating; it does not
generate clear results that extend the thinking within either paradigm (Todaro-Franceschi, 2010). Therefore,
the conscientious student or scholar selects theories that relate to the same paradigm in science, philosophy,
and nursing when combining theories to guide research or practice. Wide reading in the discipline of nursing
and the scientific literature of the disciplines from which the theorist has generated ideas will assist in
preventing such errors. Theory review and extraction from the grand theories can result in work that satisfies


the scholarly impulse in each of us, guides the research process, provides structure for safe and effective
practice, and extends the science of nursing.

Grand theories are global in their application to the discipline of nursing and have been instrumental in
helping to develop nursing science. Because of their diversity, their complexity, and their differing
worldviews, learning about grand nursing theories can be confusing as illustrated by the experiences of Janet,
the student nurse from the opening case study. To help make the study of grand theories more logical and
rewarding, this chapter presented several methods for categorizing the grand theories on the basis of scope,
basic philosophies, and needs of the discipline. It has also presented the criteria that will be used to describe
grand nursing theories in subsequent chapters.

Chapters 7 through 9 discuss many of the grand nursing theories that have been placed into the three
defined paradigms of nursing. These analyses are meant to be descriptive to allow the student to choose from
different paradigms and the theories contained within them to further their work. The student or scholar must
recognize that health care is constantly changing and that some theories may no longer seem applicable,
whereas other theories are timeless in their abstraction. Before selecting a theory to guide practice, research,
or other endeavors, it is the student’s responsibility to obtain and read the theory in its latest iteration by the
theorist, read analyses by other scholars in the discipline, and become thoroughly familiar with the theory.

Key Points
Nursing scholars and nursing leaders have developed philosophies, conceptual frameworks, and grand

theories to make the very complex study of nursing clear for both students and practitioners.
The purpose of theory is to systematize nursing education and practice so that no important element of

nursing care is forgotten.
Reviewing and critiquing nursing theories is important, as nurse scholars, nurse educators, and nurse

researchers use theories for the purposes of directing and coordinating practice, education, and research.
Using nursing theories to guide their work allows practitioners, educators, and researchers to base their work

on a system that allows critique of the outcomes of their work.
Working within a paradigm, rather than combining disparate paradigms, prevents confusion because nursing

paradigms relate to paradigms in other sciences.

Learning Activities
1. During an online classroom, debate similarities and differences in the several theoretical

categorization schemes put forth by the different theory analysts discussed in this chapter.
Which system appears to be the easiest to understand?

2. Does categorizing or classifying grand theories as the writers have done assist in studying and
understanding them? Why or why not?

3. With classmates, critique theory-based research articles and decide whether they will yield
believable evidence. Do the authors ascribe to the same or similar theoretical worldviews
(paradigms)? Do you think that having differing paradigms will make a difference in your
group’s ability to identify the evidence needed for safe nursing practice?

4. Janet, from the opening case study, practices on a cardiovascular floor and was working
toward a degree to become an acute care nurse practitioner. Consider your practice specialty
area (i.e. critical care, operating room, pediatrics, labor and delivery, primary care). Which
paradigm—human needs, interactive process, or unitary process—best fits that type of
nursing and client needs? Explain your answer and compare your thoughts with those of

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Grand Nursing Theories Based on Human Needs
Evelyn M. Wills

Donald Crawford is an acute care nurse practitioner who works in an intensive care unit (ICU) who is midway
through a doctor of nursing practice (DNP) program. Donald strongly believes that evidence guiding nursing
practice should be experiential and measurable, and during his master’s program, he devised a way to diagram
the disease pathophysiology for many of his patients based on the Neuman Systems Model (Neuman &
Fawcett, 2011).

He observed that the model helped predict what would happen next with some patients and helped him
define patient’s needs, predict outcomes, and prescribe nursing interventions more accurately. In particular, he
appreciated how Neuman focused on identification and reduction of stressors through nursing interventions
and liked the construct of prevention as intervention. As he continues his graduate studies, Donald plans to
expand application of the concepts and principles from Neuman’s model. As one component of his DNP
project, he is developing a proposal to implement his methods throughout the ICU to help other nurses apply
Neuman’s model in improving patient care.

The earliest theorists in nursing drew from the dominant worldviews of their time, which were largely related
to the medical discoveries from the scientific era of the 1850s through 1940s (Artinian, 1991). During those
years, nurses in the United States were seen as handmaidens to doctors, and their practice was guided by
disease theories of medical science. Even today, much of nursing science remains based in the positivist era
with its focus on disease causality and a desire to produce measurable outcome data. Evidence-based medicine
is the current means of enacting the positivist focus on research outcomes for effective clinical therapeutics
(Cody, 2013).

In an effort to define the uniqueness of nursing and to distinguish it from medicine, nursing scholars from
the 1950s through the 1970s developed a number of nursing theories. In addition to medicine, the majority of
these early works were strongly influenced by the needs theories of social scientists (e.g., Maslow). In needs-
based theories, clients are typically considered biopsychosocial beings who are the sum of their parts, who are
experiencing disease or trauma, and who need nursing care. Furthermore, clients are thought of as mechanistic
beings, and if the correct information can be gathered, the cause or source of their problems can be discerned
and measured. At that point, interventions can be prescribed that will be effective in meeting their needs
(Dickoff, James, & Wiedenbach, 1968). Evidence-based nursing fits with these theories completely and
comfortably (Cody, 2013).

The grand theories and models of nursing described in this chapter focus on meeting clients’ needs for
nursing care. These theories and models, like all personal statements of scholars, have continued to grow and
develop over the years; therefore, several sources were consulted for each model. The latest writings of and
about the theories were consulted and are presented. As much as possible, the description of the model is
either quoted or paraphrased from the original texts. Some needs theorists may have maintained their theories
over the years with little change; others updated and adapted theirs to later ideas and methods. Nevertheless,
new research has often extended the original work. Students are advised to consult the literature for the newest
research using the needs theory of interest.

It should be noted that a concerted attempt was made to ensure that the presentation of the works of all


theorists is balanced. Some theories (e.g., Orem and Neuman) are more complex than others, and the body of
information is greater for some than for others. As a result, the sections dealing with some theorists are a little
longer than others. This does not imply that shorter works are in any way inferior or less important to the

Finally, all theory analysts, whether novice or expert, will comprehend theories and models from their
own perspectives. If the reader is interested in using a model, the most recent edition of the work of the
theorist should be obtained and used as the primary source for any project. All further works using the theory
or model should come from researchers using the theory in their work. Current research writings are one of
the best ways to understand the development of the needs theories.

Florence Nightingale: Nursing: What It Is and What It Is Not
Nightingale’s model of nursing was developed before the general acceptance of modern disease theories (i.e.,
the germ theory) and other theories of medical science. Nightingale knew the germ theory (Beck, 2010), and
prior to its wide publication, she had deduced that cleanliness, fresh air, sanitation, comfort, and socialization
were necessary to healing. She used her experiences in the Scutari Army Hospital in Turkey and in other
hospitals in which she worked to document her ideas on nursing (Beck, 2010; Dossey, 2010a; Small, 1998).

Nightingale was from a wealthy family; yet, she chose to work in the field of nursing, although it was
considered a “lowly” occupation. She believed nursing was her call from God, and she determined that the
sick deserved civilized care, regardless of their station in life (Nightingale, 1860/1957/1969).

Through her extensive body of work, she changed nursing and health care dramatically. Nightingale’s
record of letters is voluminous, and several books have been written analyzing them (Attewell, 2012; Dossey,
Selanders, Beck, & Attewell, 2005). She wrote many books and reports to federal and worldwide agencies.
Books she wrote that are especially important to nurses and nursing include Notes on Nursing: What It Is and
What It Is Not (original publication in 1860; reprinted in 1957 and 1969), Notes on Hospitals (published in
1863), and Sick-Nursing and Health-Nursing, originally published in Hampton’s Nursing of the Sick (1893)
and reprinted in toto in Dossey et al. (2005), to name but a small portion of her great body of works. Much of
her work is now available, where once it was kept out of circulation, perhaps because of the sheer volume and
perhaps because she originally asked that her papers all be destroyed at her death. She later recanted that
request (Bostridge, 2008; Cromwell, 2013).

Background of the Theorist
Nightingale was born on May 12, 1820, in Florence, Italy; her birthday is still honored in many places. She
was privately educated in the classical tradition of her time by her father, and from an early age, she was
inclined to care for the sick and injured (Bostridge, 2008; Dossey, 2010b). Although her mother wished her to
lead a life of social grace, Nightingale preferred productivity, choosing to school herself in the care of the
sick. She attended nursing programs in Kaiserswerth, Germany, in 1850 and 1851 (Bostridge, 2008; Dossey,
2010a; Small, 1998), where she completed what was at that time the only formal nursing education available.
She worked as the nursing superintendent at the Institution for Care of Sick Gentlewomen in Distressed
Circumstances, where she instituted many changes to improve patient care (Cromwell, 2013; Small, 1998).

During the Crimean War, she was urged by Sidney Herbert, Secretary of War for Great Britain, to assist in
providing care for wounded soldiers. The dire conditions of British servicemen had resulted in a public outcry
that prompted the government to institute changes in the system of medical care (Small, 1998). At Herbert’s
request, Nightingale and a group of 38 skilled nurses were transported to Turkey to provide nursing care to the
soldiers in the hospital at Scutari Army Barracks. There, despite daunting opposition by army physicians,
Nightingale instituted a system of care that reportedly cut casualties from 48% to 2% within approximately 2
years (Bostridge, 2008; Dossey, 2010b; Zurakowski, 2005).

Early in her work at the army hospital, Nightingale noted that the majority of soldiers’ deaths was caused
by transport to the hospital and conditions in the hospital itself. Nightingale found that open sewers and lack
of cleanliness, pure water, fresh air, and wholesome food were more often the causes of soldiers’ deaths than
their wounds; she implemented changes to address these problems (Small, 1998). Although her
recommendations were known to be those that would benefit the soldiers, physicians in charge of the hospitals


in the Crimea blocked her efforts. Despite this, by her third trip to the Crimea, Nightingale had been appointed
the supervisor of all the nurses (Bostridge, 2008; Dossey, 2010b).

At Scutari, she became known as the “lady with the lamp” from her nightly excursions through the wards
to review the care of the soldiers (Bostridge, 2008). To prove the value of the work she and the nurses were
doing, Nightingale instituted a system of record keeping and adapted a statistical reporting method known as
the polar area diagram or Coxcomb chart to analyze the data she so rigorously collected (Small, 1998). Thus,
Nightingale was the first nurse to collect and analyze evidence that her methods were working.

On her return to England from Turkey, Nightingale worked to reform the Army Medical School, instituted
a program of record keeping for government health statistics, and assisted with the public health system in
India. The effort for which she is most remembered, however, is the Nightingale School for Nurses at St.
Thomas’ Hospital. This school was supported by the Nightingale Fund, which had been instituted by grateful
British citizens in honor of her work in the Crimea (Bostridge, 2008; Cromwell, 2013).

Philosophical Underpinnings of the Theory
Nightingale’s work is considered a broad philosophy. Zurakowski (2005) indicates it is a “perspective” (p.
21). By contrast, Selanders (2005a) states that her work is a foundational philosophy (p. 66). Dossey (2010b)
explains that, in Nightingale’s philosophy, “Her basic tenet was healing and secondary to it are the tenets of
leadership and global action which are necessary to support healing at its deepest level” (p. 1). Nightingale’s
work has influenced the nursing profession and nursing education for nearly 160 years. To Nightingale,
nursing was the domain of women but was an independent practice in its own right. Nurses were, however, to
practice in accord with physicians, whose prescriptions nurses were faithfully to carry out (Nightingale,
1893/1954). Nightingale did not believe that nurses were meant to be subservient to physicians. Rather, she
believed that nursing was an independent profession or a calling in its own right. Nightingale’s educational
model is based on anticipating and meeting the needs of patients and is oriented toward the works a nurse
should carry out in meeting those needs. Nightingale’s philosophy was inductively derived, abstract yet
descriptive in nature, and is classified as a grand theory or philosophy by most nursing writers (Alligood,
2014; Masters, 2015; Selanders, 2005a).

Major Assumptions, Concepts, and Relationships
Nightingale was an educated gentlewoman of the Victorian era. The language she used to write her books
—Notes on Nursing: What It Is and What It Is Not (1860/1957/1969) and Sick-Nursing and Health-Nursing
(1893/1954)—was cultured, flowing, logical in format, and elegant in style. She wrote numerous letters, many
of which are still available. These were topical, direct and yet abstract, and addressed a plethora of topics,
such as personal care of patients and sanitation in army hospitals and communities, to name only a few
(Bostridge, 2008; Cromwell, 2013; Dossey, 2010b; Selanders, 2005b).

Nightingale (1860/1957/1969) believed that five points were essential in achieving a healthful house:
“pure air, pure water, efficient drainage, cleanliness, and light” (p. 24). She thought buildings should be
constructed to admit light to every occupant and to allow the flow of fresh air. Furthermore, she wrote that
proper household management makes a difference in healing the ill and that nursing care pertained to the
house in which the patient lived and to those who came into contact with the patient as well as to the care of
the patient.

Although the metaparadigm concepts had not been so labeled until over 130 years later, Nightingale
(1893/1954) addressed them—human, environment, health, and nursing—specifically in her writings. She
believed that a healthy environment was essential for healing. For example, noise was harmful and impeded
the need of the person for rest, and noises to avoid included caregivers talking within the hearing of the
individual, the rustle of the wide skirts (common at the time), fidgeting, asking unnecessary questions, and a
heavy tread while walking. Nutritious food, proper beds and bedding, and personal cleanliness were variables
Nightingale deemed essential, and she was convinced that social contact was important to healing. Although
the germ theory had been proposed, Nightingale’s writings do not specifically refer to it. Her ideals of care,
however, indicate that she recognized and agreed that cleanliness prevents morbidity (Dossey, 2010b).

Nightingale believed that nurses must make accurate observations of their patients and report the state of
the patient to the physician in an orderly manner. She explained that nurses should think critically about the


care of the patient and do what was appropriate and necessary to assist the patient to heal. Nursing was seen as
a way “to put the constitution in such a state as that it will have no disease, or that it can recover from disease”
(Nightingale, 1893/1954, p. 3), which will “put us in the best possible conditions for nature to restore or to
preserve health—to prevent or to cure disease or injury” (p. 357). She believed that nursing was an art,
whereas medicine was a science, and stated that nurses were to be loyal to the medical plan but not servile.
Throughout her writings, Nightingale enumerated tasks that nurses should complete to care for ill individuals,
and many of the tasks she outlined are still relevant today (Nightingale, 1860/1957/1969).

Health was defined in her treatise, Sickness-Nursing and Health-Nursing (Nightingale, 1893/1954), as “to
be well but to be able to use well every power we have” (p. 357). It is apparent throughout that volume that
health meant more than the mere absence of disease, a view that placed Nightingale ahead of her time.

Nightingale wrote on hospitals, nursing, and community health in the 19th and into the 20th century, and her
works served as the basis of nursing education in Britain and in the United States for over a century. King’s
College Hospital and St. Thomas’ Hospital in London, England, were the initial nursing programs developed
by Nightingale, and she maintained a special interest in St. Thomas’ Hospital during most of her life (Small,
1998). Nursing programs that used the Nightingale method in the United States included Bellevue Hospital in
New York, New Haven Hospital in Connecticut, and Massachusetts Hospital in Boston. Indeed, the influence
of Nightingale’s methods is felt in nursing programs to the present (Pfettscher, 2014).

A resurgence in attention to Nightingale’s philosophy is noteworthy. Jacobs (2001) discussed the attribute
of human dignity as a central phenomenon uniting nursing theory and practice—two areas that were
extensively treated by Nightingale in her own writings. Cromwell (2013) discussed Nightingale’s early
feminism and her willingness to fight local and federal authorities to procure humane treatment for British
soldiers of the time. She showed how Nightingale continued her works for the British army long after
returning from the Bosporus. Many other contemporary writers and researchers have displayed an intense
interest in Nightingale’s work and its applicability to modern nursing. For example, DeGuzman and Kulbok
(2012) used Nightingale’s theory to create a framework for nurses to study the impact of “built environment”
on health, focusing on vulnerable populations. Similarly, Hegge (2013) explained how Nightingale’s focus on
the environment is important for nurses to consider when developing interventions for population health.
Then, Kagan (2014) abstracted elements of Notes on Nursing to apply Nightingale’s concepts to identification
of determinants of health that need interventions to reduce risk of illnesses—specifically cancer. Nursing
educators worldwide continue to use Nightingale’s ideals in teaching nurses. These include Adu-Gyamfi and
Brenya (2016; Ghana); Haddad and Santos (2011; Portugal); Mackey and Bassendowski (2017; Canada);
McDonald (2014; Ireland); and Rahim (2013; Pakistan).

Nightingale’s theory can be the source of testable hypotheses because she treated concrete as well as abstract
concepts. Research that is conversant with her ideas of care includes research on noise (Murphy, Bernardo, &
Dalton, 2013), environment (Jetha, 2015; Zborowsky, 2014), and spirituality (Tanyi & Werner, 2008).
Recently, researchers have written about her statistical work (McDonald, 2010; Rew & Sands, 2010), showing
that it stands up to modern thinking as it did in the 19th century. Indeed, research around the globe is still
progressing using her work.

In her work, Nightingale succinctly stated what she believed was important in caring for ill individuals.
Furthermore, in one small volume, she includes information about nursing care, patient needs, proper
buildings in which the sick are to be treated, and the administration of hospitals.

Value in Extending Nursing Science
Nightingale was a noted nurse of her time. She was a consultant who promoted the collection and analyses of
health statistics. She was deeply involved in nursing education and promoting the science of public health


(Bostridge, 2008; Cromwell, 2013; Small, 1998), hospital administration, community health, and global
health (Dossey, 2010b). Nightingale’s legacy continues to be important to nursing scholars, and her vast
contributions continue to enlighten nursing science. Current Nightingale scholars include Attewell (2012),
Bostridge (2008), Cromwell (2013), Dossey et al. (2005), Jacobs (2001), and many others who have
contributed to the understanding of her multitudinous works. Nightingale’s work was revolutionary for its
impact on nursing and health care. Furthermore, her many works continue to present effective guidelines for

Virginia Henderson: The Principles and Practice of Nursing
Virginia Henderson was a well-known nursing educator and a prolific author. In 1937, Henderson and others
created a basic nursing curriculum for the National League for Nursing in which education was “patient
centered and organized around nursing problems rather than medical diagnoses” (Henderson, 1991, p. 19). In
1939, she revised Harmer’s classic textbook of nursing for its fourth edition and later wrote the fifth edition,
incorporating her personal definition of nursing (Henderson, 1991). Although she was retired, she was a
frequent visitor to nursing schools well into her 90s. O’Malley (1996) states that Henderson was known as the
modern-day mother of nursing. Her work influenced the nursing profession in America and throughout the

Background of the Theorist
Henderson was born in Missouri but spent her formative years in Virginia. She received a diploma in nursing
from the Army School of Nursing at Walter Reed Hospital in 1921 and worked at the Henry Street Visiting
Nurse Service for 2 years after graduation. In 1923, she accepted a position teaching nursing at the Norfolk
Protestant Hospital in Virginia, where she remained for several years. In 1929, Henderson determined that she
needed more education and entered Teachers College at Columbia University, where she earned her
bachelor’s degree in nursing in 1932 and a master’s degree in 1934. Subsequently, she joined Columbia as a
member of the faculty, where she remained until 1948 (Herrmann, 1998). “Ms. Virginia,” as she was known
to her friends, died in 1996 at the age of 98 (Allen, 1996). Because of her importance to modern nursing, the
Sigma Theta Tau International Nursing Library is named in her honor.

Philosophical Underpinnings of the Theory
Henderson was educated during the empiricist era in medicine and nursing, which focused on patient needs,
but she believed that her theoretical ideas grew and matured through her experiences (Henderson, 1991).
Henderson was introduced to physiologic principles during her graduate education, and the understanding of
these principles was the basis for her patient care (Henderson, 1965, 1991). The theory presents the patient as
a sum of parts with biopsychosocial needs, and the patient is neither client nor consumer. Henderson stated
that “Thorndike’s fundamental needs of man” (Henderson, 1991, p. 16) had an influence on her beliefs.

Although her major clinical experiences were in medical-surgical hospitals, she worked as a visiting nurse
in New York City. This experience enlarged Henderson’s view to recognize the importance of increasing the
patient’s independence so that progress after hospitalization would not be delayed (Henderson, 1991).
Henderson was a nurse educator, and the major thrust of her theory relates to the education of nurses.

Major Assumptions, Concepts, and Relationships
Henderson’s concept of nursing was derived from her practice and education; therefore, her work is inductive.
Henderson did not manufacture language to elucidate her theoretical stance; she used correct, scholarly
English in all of her writings. She called her definition of nursing her “concept” (Henderson, 1991, pp. 20–

The major assumption of the theory is that nurses care for patients until patients can care for themselves once
again (Henderson, 1991). She assumes that patients desire to return to health, but this assumption is not
explicitly stated. She also assumes that nurses are willing to serve and that “nurses will devote themselves to


the patient day and night” (p. 23). A final assumption is that nurses should be educated at the university level
in both arts and sciences.

The major concepts of the theory relate to the metaparadigm (i.e., nursing, health, patient, and environment).
Henderson believed that “the unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to a peaceful death) that he would
perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help
him gain independence as rapidly as possible” (Henderson, 1991, p. 21). She defined the patient as someone
who needs nursing care but did not limit nursing to illness care. She did not define environment, but
maintaining a supportive environment is one of the elements of her 14 activities. Health was not explicitly
defined, but it is taken to mean balance in all realms of human life. The concept of nursing involved the nurse
attending to 14 activities that assist the individual toward independence (Box 7-1).

Box 7-1 Henderson’s 14 Activities for Client Assistance
1. Breathe normally.
2. Eat and drink adequately.
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes—dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and modifying environment.
8. Keep the body clean and well groomed and protect the integument.
9. Avoid dangers in the environment and avoid injuring others.

10. Communicate with others in expressing emotions, needs, fears, or opinions.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the

available health facilities.

Source: Henderson (1991, pp. 22–23).

Nursing education has been deeply affected by Henderson’s clear vision of the functions of nurses. The
principles of Henderson’s theory were published in the major nursing textbooks used from the 1930s through
the 1960s, and the principles embodied by the 14 activities are still important in evaluating nursing care in the
21st century. Waller-Wise (2013), for example, found that Henderson’s theory assisted him in attaining
excellence in childbirth education.

Henderson supported nursing research but believed that it should be clinical research (O’Malley, 1996). Much
of the research before her time had been on educational processes and on the profession of nursing itself rather
than on the practice and outcomes of nursing, and she worked to change that.

Each of the 14 activities can be the basis for research. Although the statements are not written in testable
terms, they may be reformulated into researchable questions. Furthermore, the theory can guide research in
any aspect of the individual’s care needs. For example, Englebright, Aldrich, and Taylor (2014) used
Henderson’s model as the framework to help define fundamental nursing care actions for the new electronic
health record in a 170-bed community hospital.



Henderson’s work is parsimonious in its presentation but complex in its scope. The 14 statements cover the
whole of the practice of nursing, and her vision about the nurse’s role in patient care (i.e., that the nurse
perform for the patient those activities the patient usually performs independently until the patient can again
adequately perform them) contributes to that complexity.

Value in Extending Nursing Science
From a historical standpoint, Henderson’s concept of nursing enhanced nursing science; this has been
particularly important in the area of nursing education. Her contributions to nursing literature extended from
the 1930s through the 1990s. Her work has had an international impact on nursing research by strengthening
the focus on nursing practice and confirming the value of tested interventions in assisting individuals to regain
health. Internationally, researchers continue to direct their work with Virginia Henderson’s model as a
framework. For example, Scott, Matthews, and Kirwan (2014) found that internationally, Henderson’s model
was the most often used in evaluating the need for and the practice of nurses. In their reported case study,
Younas and Sommer (2015) found Henderson’s model “close to realism and applicable to Pakistani context”
(p. 443) because of its relevance in developing nursing plans, and Lazenby (2013) argued for the importance
of the patient experience using Henderson’s model in multiple contexts.

Faye G. Abdellah: Patient-Centered Approaches to Nursing
Faye Abdellah was one of the first nursing theorists. In one of her earliest writings (Abdellah, Beland, Martin,
& Matheney, 1960), she referred to the model created by her colleagues and herself as a framework. Her
writings spanned the period from 1954 to 1992 and include books, monographs, book chapters, articles,
reports, forewords to books, and conference proceedings.

Background of the Theorist
Abdellah earned her bachelor’s degree in nursing, master’s degree, and doctorate from Columbia University,
and she completed additional graduate studies in science at Rutgers University. She served as the chief nurse
officer and deputy U.S. Surgeon General, U.S. Public Health Service before retiring in 1993 with the rank of
Rear Admiral. She has been awarded many academic honors from both civilian and military sources
(Abdellah & Levine, 1994). She retired from her position as dean of the Graduate School of Nursing,
Uniformed Services University of the Health Sciences in 2000.

Philosophical Underpinnings of the Theory
Abdellah’s patient-centered approach to nursing was developed inductively from her practice and is
considered a human needs theory (Abdellah et al., 1960). The theory was created to assist with nursing
education and is most applicable to education and practice (Abdellah et al., 1960). Although it was intended to
guide care of those in the hospital, it also has relevance for nursing care in community settings.

Major Assumptions, Concepts, and Relationships
The language of Abdellah’s framework is readable and clear. Consistent with the decade in which she was
writing, she uses the term “she” for nurses and “he” for doctors and patients and refers to the object of nursing
as “patient” rather than client or consumer (Abdellah et al., 1960). Interestingly, she was one of the early
writers who referred to “nursing diagnosis” (Abdellah et al., 1960, p. 9) during a time when nurses were
taught that diagnosis was not a nurse’s prerogative.

There are no openly stated assumptions in Abdellah’s early work (Abdellah et al., 1960), but in a later work,
she added six assumptions. These relate to change and anticipated changes that affect nursing; the need to
appreciate the interconnectedness of social enterprises and social problems; the impact of problems such as
poverty, racism, pollution, education, and so forth on health and health care delivery; changing nursing
education; continuing education for professional nurses; and development of nursing leaders from
underserved groups (Abdellah, Beland, Martin, & Matheney, 1973).


Abdellah and colleagues (1960) developed a list of 21 nursing problems (Box 7-2). They also identified 10
steps to identify the client’s problems and 10 nursing skills to be used in developing a treatment typology.

Box 7-2 Abdellah’s 21 Nursing Problems
1. To maintain good hygiene and physical comfort
2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention

of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions

10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental

19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness

Source: Abdellah et al. (1960).

According to Abdellah and colleagues (1960), nurses should do the following:

1. Learn to know the patient.
2. Sort out relevant and significant data.
3. Make generalizations about available data in relation to similar nursing problems presented by other

4. Identify the therapeutic plan.
5. Test generalizations with the patient and make additional generalizations.
6. Validate the patient’s conclusions about his or her nursing problems.
7. Continue to observe and evaluate the patient over a period of time to identify any attitudes and clues

affecting his or her behavior.
8. Explore the patient’s and family’s reaction to the therapeutic plan and involve them in the plan.
9. Identify how the nurse feels about the patient’s nursing problems.

10. Discuss and develop a comprehensive nursing care plan.

Abdellah and colleagues (1960) distinguished between nursing diagnoses and nursing functions. Nursing
diagnoses were a determination of the nature and extent of nursing problems presented by individuals
receiving nursing care, and nursing functions were nursing activities that contributed to the solution for the
same nursing problem. Other concepts central to her work were (1) health care team (a group of health
professionals trained at various levels, and often at different institutions, working together to provide health
care), (2) professionalization of nursing (requires that nurses identify those nursing problems that depend on
the nurse’s use of his or her capacities to conceptualize events and make judgments about them), (3) patient
(individual who needs nursing care and who is dependent on the health care provider), and (4) nursing (a


service to individuals and families and to society, which helps people cope with their health needs) (Abdellah
et al., 1960).

The patient-centered approach was constructed to be useful to nursing practice, with the impetus for it being
nursing education. Abdellah’s publications on nursing education began with her dissertation; her interest in
education of nurses continues into the present.

Abdellah also published work on nursing, nursing research, and public policy related to nursing in several
international publications. She has been a strong advocate for improving nursing practice through nursing
research and has a publication record on nursing research that dates from 1955 to the present. Box 7-3 lists
only a few of Abdellah’s many publications.

Box 7-3 Examples of Abdellah’s Publications
Abdellah, F. G. (1972). Evolution of nursing as a profession: Perspective on manpower development.

International Nursing Review, 19(3), 219–238.
Abdellah, F. G. (1986). The nature of nursing science. In L. H. Nicholl (Ed.), Perspectives on nursing theory.

Boston, MA: Little, Brown.
Abdellah, F. G. (1987). The federal role in nursing education. Nursing Outlook, 35(5), 224–225.
Abdellah, F. G. (1991). Public policy impacting on nursing care of older adults. In E. M. Baines (Ed.),

Perspectives on gerontological nursing. Newbury Park, CA: Sage.
Abdellah, F. G., Beland, I. L., Martin A., & Matheney, R. V. (1968). Patient-centered approaches to nursing

(2nd ed.). New York, NY: MacMillan.
Abdellah, F. G., & Levine, E. (1994). Preparing nursing research for the 21st century: Evolution,

methodologies, challenges. New York, NY: Springer Publishing.

Abdellah’s work is a conceptual model that is not directly testable because there are few stated directional
relationships. The model is testable in principle, though, because testable hypotheses can be derived from its
conceptual material. One work (Abdellah & Levine, 1957) was identified that described the development of a
tool to measure client and personnel satisfaction with nursing care.

Abdellah and colleagues’ (1960, 1973) model touches on many factors in nursing but focuses primarily on the
perspective of nursing education. It defines 21 nursing problems, 10 steps to identifying client’s problems,
and 10 nursing skills. Because of its focus and complexity, it is not particularly parsimonious.

Value in Extending Nursing Science
Abdellah’s model has contributed to nursing science as an early effort to change nursing education. In the
early years of its application, it helped to bring structure and organization to what was often a disorganized
collection of lectures and experiences. She categorized nursing problems based on the individual’s needs and
developed a typology of nursing treatment and nursing skills. Finally, she posited a list of characteristics that
described what was distinctly nursing, thereby differentiating the profession from other health professions.
Hers was a major contribution to the discipline of nursing, bringing it out of the era of being considered
simply an occupation into Nightingale’s ideal of becoming a profession.

Dorothea Orem: The Self-Care Deficit Nursing Theory
Dorothea Orem was born in Baltimore, Maryland. She received her diploma in nursing from Providence
Hospital School of Nursing in Washington, DC, and her baccalaureate degree in nursing from Catholic
University in 1939. In 1945, she also earned her master’s degree from Catholic University (Berbiglia &


Banfield, 2014).

Background of the Theorist
Orem held a number of positions as private duty nurse, hospital staff nurse, and educator. She was the director
of both the School of Nursing and Nursing Service at Detroit’s Providence Hospital until 1949, moving from
there to Indiana where she served on the Board of Health until 1957. She assumed a role as a faculty member
of Catholic University in 1959, later becoming acting dean (Berbiglia & Banfield, 2014).

Orem’s interest in nursing theory was piqued when she and a group of colleagues were charged with
producing a curriculum for practical nursing for the Department of Health, Education, and Welfare in
Washington, DC. After publishing the first book on her theory in 1971, she continued working on her concept
of nursing and self-care. She had numerous honorary doctorates and other awards as members of the nursing
profession have recognized the value of the self-care deficit theory (Berbiglia & Banfield, 2014). Dr. Orem
died in 2007 after a period of failing health. Nurses will remember her as one of the pioneers of nursing theory
(Bekel, 2007).

Philosophical Underpinnings of the Theory
Orem (2001) denied that any particular theorist provided the basis for the Self-Care Deficit Nursing Theory
(SCDNT). She expressed interest in several theories, although she references only Parsons’s Structure of
Social Action and von Bertalanffy’s System Theory (Orem, 2001). Taylor, Geden, Isaramalai, and
Wongvatunyu (2000), however, stated that the ontology of Orem’s SCDNT is the school of moderate realism,
and its focus is on the person as agent; the SCDNT is a highly developed formalized theoretical system of
nursing. Currently, the theory is referred to as Self-Care Science and Nursing Theory (Taylor & Renpenning,
2011). Taylor and Renpenning (2011) make a case for the scientific basis of the life work that was Orem’s
magnum opus and quote from her works extensively.

Major Assumptions, Concepts, and Relationships
Orem’s theory changed to fit the times most notably in the concept of the individual and of the nursing
system. The original theory, however, remains largely intact.

Orem (2001) delineated three nested theories: theories of self-care, self-care deficit, and nursing systems
(Figure 7-1). The theory of nursing systems is the outer or encompassing theory, which contains the theory of
self-care deficit. The theory of self-care is a component of the theory of self-care deficit.


Figure 7-1 Self-Care Deficit Nursing Theory.
(Source: Orem, D. [2001]. Nursing: Concepts of practice [6th ed.]. St. Louis, MO: Mosby.)


Orem (2001) defined the metaparadigm concepts as follows:

Nursing is seen as an art through which the practitioner of nursing gives specialized assistance to
persons with disabilities which makes more than ordinary assistance necessary to meet needs for self-
care. The nurse also intelligently participates in the medical care the individual receives from the

Humans are defined as “men, women, and children cared for either singly or as social units,” and
are the “material object” (p. 8) of nurses and others who provide direct care.

Environment has physical, chemical, and biological features. It includes the family culture and

Health is “being structurally and functionally whole or sound” (p. 96). Also, health is a state that
encompasses both the health of individuals and of groups, and human health is the ability to reflect on
one’s self, to symbolize experience, and to communicate with others.

Numerous additional concepts were formulated for Orem’s theory; Table 7-1 lists some of the more
significant ones.

Table 7-1 Concepts in Orem’s Self-Care Deficit Theory
Concept Definition

Self-care A human regulatory function that is a deliberate action to supply or ensure the
supply of necessary materials needed for continued life, growth, and development
and maintenance of human integrity.

Self-care requisites Part of self-care; expressions of action to be performed by or for individuals in the
interest of controlling human or environmental factors that affect human
functioning or development. There are three types: universal, developmental, and
health deviation self-care requisites.

Universal self-care Self-care requisites common to all humans.


Developmental self-
care requisites

Self-care requisites necessary for growth and development.

Health deviation self-
care requisites

Self-care requisites associated with health deficits.

Therapeutic self-care

Nurse’s assistance in meeting the client’s or client dependent’s self-care needs is
done therapeutically as a result of the client’s inability to calculate or to meet
therapeutic self-care needs.

Deliberate action Action knowingly taken with some motivation or some outcome sought by the
actor, as self-care or dependent care.

Nursing system The product of a series of relations between the persons: legitimate nurse and
legitimate client. This system is activated when the client’s therapeutic self-care
demand exceeds available self-care agency, leading to the need for nursing.

Product of nursing Nursing has two products:An intellectual product (the design for helping the
client).A system of care of long or short duration for persons requiring nursing

Source: Orem (1995).

An underlying premise of Orem’s theory is the belief that humans engage in continuous communication and
interchange among themselves and their environments to remain alive and to function. In humans, the power
to act deliberately is exercised to identify needs and to make needed judgments. Furthermore, mature human
beings experience privations in the form of action in care of self and others involving making life-sustaining
and function-regulating actions. Human agency is exercised in discovering, developing, and transmitting to
others ways and means to identify needs for, and make inputs into, self and others. Finally, groups of human
beings with structured relationships cluster tasks and allocate responsibilities for providing care to group
members who experience privations for making required deliberate decisions about self and others (Orem,

Needs theories, such as Orem’s are complex in their application. Over the decades that Orem worked on
her theories of nursing, the theory went through several iterations in response to new knowledge and
technology. Her continual work indicated that she was aware of the complex nature of patient’s needs and of
the growing complexity of the health care system. Although this theory is not a complexity theory as such, she
does pay tribute in her later writings to the complexity of care for clients/patients in the health care system at
that time.

In past years, numerous colleges and schools of nursing base their curricula on the SCDNT. Among them are
Illinois Wesleyan University, University of Tennessee at Chattanooga, Anderson College, and University of
Toledo (Berbiglia & Banfield, 2014). Hospitals in several areas of the country have based nursing care on
Orem’s theory, and it has been applied to an ambulatory care setting. Such medical conditions as arthritis or
gastrointestinal and renal diseases, and such areas of practice as community nursing, critical care, cultural
concepts, maternal–child nursing, medical-surgical nursing, pediatric nursing, perioperative nursing, and renal
dialysis, among other specialties have used Orem’s theory to structure care (Berbiglia & Banfield, 2014).
Orem’s SCDNT has received international interest and has been used in many countries including Great
Britain, Germany, Japan, the Netherlands, Norway, Sweden, and New Zealand. Moreover, numerous
publications define methods for using Orem’s SCDNT in practice, research, and education.

Orem was a prolific author and her writings spanned five decades. In addition to her detailed description
of her theory through several iterations (Orem, 1971, 1985b, 1991, 1995, 2001), she authored an analysis of
hospital nursing service (Orem, 1956) and illustrations for self-care for the rehabilitation client (Orem,
1985a). Further evidence of the usefulness of Orem’s work is the International Orem Society, which
celebrates the work of Dr. Orem. Their journal, Self-Care, Dependent-Care & Nursing, indicates the value to


nurses across the globe (Biggs, 2008).

Many nursing research studies have used Orem’s theory as a conceptual framework or as a source of testable
hypotheses. Furthermore, over the years, many research studies have tested elements of the theory. The
researchers have studied people with diminished self-care agency across age and social groups, in numerous
situations, and in many countries. Most research into the SCDNT is descriptive, and the theory has not been
subject to testing in its entirety (Berbiglia & Banfield, 2014; Taylor & Renpenning, 2011). Box 7-4 lists some
of the recent research studies using the SCDNT.

Box 7-4 Orem’s Theory in Nursing Research, Practice, and Education
Green, R. (2013). Application of the self-care deficit nursing theory: The community context. Self-Care,

Dependent-Care & Nursing, 20(1), 5–15.
Guo, S. H.-M., Lin, Y.-H., Chen, R.-R., Kao, S.-F., & Chang, H.-K. (2013). Development and evaluation of

theory-based diabetes support services. Computers, Informatics, Nursing, 31(1), 17–26.

Mohammadpour, A., Rahmati, S. N., Khosravan, S., Alami, A., & Akhond, M. (2015). The effect of a
supportive educational intervention developed based on Orem’s self-care theory on the self-care ability
of patients with myocardial infarction: A randomised controlled trial. Journal of Clinical Nursing,
24(11–12), 1686–1692.

O’Shaughnessy, M. (2014). Application of Dorothea Orem’s theory of self-care to the elderly patient on
peritoneal dialysis. Nephrology Nursing Journal, 41(5), 495–497.

Pickett, S., Peters, R. M., & Jarosz, P. A. (2014). Toward a middle-range theory of weight management.
Nursing Science Quarterly, 27(3), 242–247.

Roldan-Merino, J., Lluch-Canut, T., Menarguez-Alcaina, M., Foix-Sanjuan, A., & Haro Abad, J. M. (2014).
Psychometric evaluation of a new instrument in Spanish to measure self-care requisites in patients with
schizophrenia. Perspectives in Psychiatric Care, 50(2), 93–101. doi:10.1111/ppc.12026

Silén, M., & Johansson, L. (2016). Aims and theoretical frameworks in nursing students’ bachelor’s theses in
Sweden: A descriptive study. Nurse Education Today, 37, 91–96. doi:10.1016/j.ned.2015.11.020

Tadaura, H., Sato, A., Ueda, E., Ishigaki, H., Saita, T., & Kikuchi, T. (2014). Connecting nursing theory with
practice through education based on self-care deficit nursing theory (SCDNT) and utilization of nursing
practice. Self-Care, Dependent-Care & Nursing, 21(1), 27–29.

Wong, C. L., Ip, W. Y., Choi, K. C., & Lam, L. W. (2015). Examining self-care behaviors and their
associated factors among adolescent girls with dysmenorrhea: An application of Orem’s self-care deficit
nursing theory. Journal of Nursing Scholarship, 47(3), 219–227. doi:10.1111/jnu.12134

Orem’s (2001) SCDNT is complex. It consists of three nested theories, many presuppositions, and
propositions in each of the individual theories. Revisions of the theory from the original (1971) have
improved the organization; however, its complexity has increased in response to societal needs throughout the
several editions.

Value in Extending Nursing Science
The SCDNT has been the basis for many college and university nursing curricula (Orem, 2001). It has been
used in practice situations and extensively in research projects, theses, and dissertations (Taylor, 2011). The
practical applicability of the theory is attractive to graduate students because it is perceived as a realistic
reflection of nursing practice.

Dorothy Johnson: The Behavioral System Model
Dorothy Johnson began her work on the Behavioral System Model in the late 1950s and wrote into the 1990s.


The focus of her model is on needs, the human as a behavioral system, and relief of stress as nursing care.
Johnson (1990) reported that her work began as a study of the knowledge that identified nursing while

synthesizing content for nursing curricula at the graduate and undergraduate levels. She wanted the curricula
to be focused on nursing rather than derived from the knowledge bases of other health care disciplines
(Johnson, 1959a, 1959b, 1997). Indeed, she believed that nursing, although relying on the contributions of
other sciences, is a discrete science and a unique discipline.

Johnson’s model was deductively derived through long study of other theories and applying them to
nursing (Johnson, 1997). Her goal was to conceptualize nursing for education of nurses at all levels (Johnson,
1990, 1997), and the model emanated from her practice, study, and teaching experiences.

Although Johnson did not write a book on her theory, she did write several chapters and articles that
explained her theoretical framework. Box 7-5 lists a sampling of these writings.

Box 7-5 Examples of Johnson’s Writings on Nursing Theory
Johnson, D. E. (1959a). A philosophy of nursing. Nursing Outlook, 7(4), 198–200.
Johnson, D. E. (1959b). The nature of a science of nursing. Nursing Outlook, 7(5), 291–294.
Johnson, D. E. (1968). Theory in nursing: Borrowed and unique. Nursing Research, 17(3), 206–209.
Johnson, D. E. (1974). Development of a theory: A requisite for nursing as a primary health profession.

Nursing Research, 23(5), 372–377.
Johnson, D. E. (1980). The behavioral system model for nursing. In J. P. Riehl & C. Roy (Eds.), Conceptual

models for nursing practice (pp. 207–216). New York, NY: Appleton-Century-Crofts.
Johnson, D. E. (1990). The behavioral system model for nursing. In M. E. Parker (Ed.), Nursing theories in

practice (pp. 23–32). New York, NY: National League for Nursing Press.

Background of the Theorist
Dorothy Johnson was reared in Savannah, Georgia, and received a bachelor’s degree in nursing from
Vanderbilt University. She earned a master’s degree in public health from Harvard in 1948 and returned to
Vanderbilt to begin her teaching career. In 1949, she joined the nursing faculty of the University of California,
Los Angeles (UCLA). She retired from UCLA in 1977 and lived in Florida until her death in 1999 (Holaday,

Philosophical Underpinnings of the Theory
Johnson stated that Nightingale’s work inspired her model. Nightingale’s philosophical leanings prompted
Johnson to consider the person experiencing a disease more important than the disease itself (Johnson, 1990).
She reported that she derived portions of her theory from the works of Selye on stress, Grinker’s theory of
human behavior, and Buckley and Chin on systems theories (Johnson, 1980, 1990).

Major Assumptions, Concepts, and Relationships

Assumptions of Johnson’s model are both stated and derived. There are four assumptions about human
behavioral subsystems. First is the belief that drives serve as focal points around which behaviors are
organized to achieve specific goals. Second, it is assumed that behavior is differentiated and organized within
the prevailing dimensions of set and choice. Third, the specialized parts or subsystems of the behavioral
system are structured by dimensions of goal, set, choice, and actions; each has observable behaviors. Finally,
interactive and interdependent subsystems tend to achieve and maintain balance between and among
subsystems through control and regulatory mechanisms (Grubbs, 1980).

Although she adopted concepts from other disciplines, Johnson modified and defined them to apply
specifically to nursing situations. This was an evolving process as shown in her writings (Johnson, 1959a,
1959b, 1968, 1974, 1980, 1990).


The metaparadigm concepts are apparent in Johnson’s writings. Nursing is seen as “an external regulatory
force which acts to preserve the organization and integration of the patient’s behavior at an optimal level
under those conditions in which the behavior constitutes a threat to physical or social health, or in which
illness is found” (Johnson, 1980, p. 214). The concept of human was defined as a behavioral system that
strives to make continual adjustments to achieve, maintain, or regain balance to the steady state that is
adaptation (Johnson, 1980).

Health is seen as the opposite of illness, and Johnson (1980) defines it as “some degree of regularity and
constancy in behavior, the behavioral system reflects adjustments and adaptations that are successful in some
way and to some degree . . . adaptation is functionally efficient and effective” (pp. 208, 209). Environment is
not directly defined, but it is implied to include all elements of the surroundings of the human system and
includes interior stressors. Other concepts defined in Johnson’s model are listed in Table 7-2.

Table 7-2 Concepts in Johnson’s Behavioral System Theory
Concept Definition

Behavioral system Man is a system that indicates the state of the system through behaviors
Boundaries The point that differentiates the interior of the system from the exterior
Function Consequences or purposes of actions

Input that the system must receive to survive and develop

Homeostasis Process of maintaining stability
Instability State in which the system output of energy depletes the energy needed to maintain

Stability Balance or steady state in maintaining balance of behavior within an acceptable

Stressor A stimulus from the internal or external world that results in stress or instability
Structure The parts of the system that make up the whole
System That which functions as a whole by virtue of organized independent interaction of

its parts
Subsystem A minisystem maintained in relationship to the entire system when it or the

environment is not disturbed
Tension The system’s adjustment to demands, change or growth, or to actual disruptions
Variables Factors outside the system that influence the system’s behavior, but which the

system lacks power to change

Source: Grubbs (1980).

Johnson (1980) delineated seven subsystems to which the model applied. These are as follows:

1. Attachment or affiliative subsystem—serves the need for security through social inclusion or intimacy
2. Dependency subsystem—behaviors designed to get attention, recognition, and physical assistance
3. Ingestive subsystem—fulfills the need to supply the biologic requirements for food and fluids
4. Eliminative subsystem—functions to excrete wastes
5. Sexual subsystem—serves the biologic requirements of procreation and reproduction
6. Aggressive subsystem—functions in self and social protection and preservation
7. Achievement system—functions to master and control the self or the environment

Finally, there are three functional requirements of humans in Johnson’s (1980) model. These are:

1. To be protected from noxious influences with which the person cannot cope
2. To be nurtured through the input of supplies from the environment


3. To be stimulated to enhance growth and prevent stagnation

That Johnson’s model is useful for nursing practice and education has been verified in several articles and
chapters. Damus (1980), Dee (1990), and Holaday (1980) described situations in which Johnson’s model has
been used to direct nursing practice. Other authors have used the theory to apply to various aspects of nursing.
For example, Benson (1997) used Johnson’s model as a framework to describe the impact of fear of crime on
an elder person’s health, health-seeking behaviors, and quality of life. Fruehwirth (1989) applied Johnson’s
model to assess and intervene in a group of caregivers for individuals with Alzheimer disease.

Parts of Johnson’s model have been tested or used to direct nursing research. Indeed, more than 20 research
studies have been identified using Johnson’s model. Turner-Henson (1992), for example, used Johnson’s
model as a framework to examine how mothers of chronically ill children perceived the environment (i.e.,
whether it was supportive, safe, and accessible). Poster, Dee, and Randell (1997) used Johnson’s theory as a
conceptual framework in a study of client outcome evaluation; they found that the nursing theory made it
possible to prescribe nursing care and to distinguish it from medical care. Derdiarian and Schobel (1990) used
Johnson’s model to develop an assessment tool for individuals with AIDS.

Aspects of Johnson’s model have been tested in nursing research. In one study, Derdiarian (1990)
examined the relationship between the aggressive/protective subsystem and the other six model subsystems.

Johnson (1980) was able to explicate her entire model in a single short chapter in an edited book. Relatively
few concepts are used in the theory, and they are commonly used terms. Additionally, the relationships are
clear; therefore, the model is considered to be parsimonious.

Value in Extending Nursing Science
Johnson’s model has been used in nursing practice and research to a significant extent. In addition, her work
has been used as a curriculum guide for a number of schools of nursing (Grubbs, 1980; Johnson, 1980, 1990),
and it has been adapted for use in hospital situations (Dee, 1990). Finally, her work inspired the work of at
least two other grand nursing theorists, Betty Neuman and Sister Calista Roy, who were her students.

Betty Neuman: The Neuman Systems Model
Since the 1960s, Betty Neuman has been recognized as a pioneer in the field of nursing, particularly in the
area of community mental health. She developed her model while lecturing in community mental health at
UCLA and first published it in 1972 under the title “A Model for Teaching the Total Person Approach to
Patient Problems” (Neuman & Fawcett, 2011). Since that time, she has been a prolific writer, and her model
has been used extensively in colleges of nursing, beginning with Neumann College’s baccalaureate nursing
program in Aston, Pennsylvania. Numerous other nursing programs have organized their curricula around her
model both in the United States and internationally (Neuman & Fawcett, 2011).

The major elements in this review of the Neuman Systems Model are taken from the fifth edition of her
book (Neuman & Fawcett, 2011), with references to earlier writings to show development of the model over
time. The model was deductively derived and emanated from requests of graduate students who wanted
assistance with a broad interpretation of nursing.

Neuman’s model uses a systems approach that is focused on the human needs of protection or relief from
stress (Neuman & Fawcett, 2011). Neuman believed that the causes of stress can be identified and remedied
through nursing interventions. She emphasized the need of humans for dynamic balance that the nurse can
provide through identification of problems, mutually agreeing on goals, and using the concept of prevention
as intervention. Neuman’s model is one of only a few considered prescriptive in nature. The model is
universal, abstract, and applicable for individuals from many cultures (Neuman & Fawcett, 2011).


Background of the Theorist
Betty Neuman was born in 1924 on a farm near Lowell, Ohio. In 1947, she earned her nursing diploma from
People’s Hospital School of Nursing, Akron, Ohio, and moved to California shortly thereafter. She earned a
bachelor’s degree in nursing from UCLA and also studied psychology and public health. In 1966, she earned a
master’s degree in mental health and public health consultation, also from UCLA, and then earned her
doctorate in clinical psychology in 1985 from Pacific Western University. She worked as a hospital staff
nurse, a head nurse, and an industrial nurse and consultant before becoming a nursing instructor. She has
taught medical-surgical nursing, critical care, and communicable disease nursing at the University of Southern
California Medical Center in Los Angeles and at other colleges in Ohio and West Virginia (Lawson, 2014;
Neuman & Fawcett, 2011).

Philosophical Underpinnings of the Theory
Neuman used concepts and theories from a number of disciplines in the development of her theory. In her
works, she referred to Chardin and Cornu on wholeness in systems, von Bertalanffy and Lazlo on general
systems theory, Selye on stress theory, and Lazarus on stress and coping (Neuman & Fawcett, 2011).

Major Assumptions, Concepts, and Relationships

Neuman (Neuman & Fawcett, 2011) adhered to the metaparadigm concepts and has developed numerous
additional concepts for her model. In her work, she defined human beings as “client system” . . . “a composite
of five interacting variable areas . . . physiological, psychological, sociocultural, developmental, and spiritual”
(Neuman & Fawcett, 2011, p. 16). The ring structure is a “basic structure of protective concentric rings, for
retention attainment or maintenance of system stability and integrity. . . ” (Neuman & Fawcett, 2011, p. 16).
Environment to Neuman is a structure of concentric rings representing the three environments, internal,
external, and created environments, all of which influence the client’s adaptation to stressors. Health is
defined as “a continuum; wellness and illness are at opposite ends. . . . Health for the client is equated with
optimal system stability that is the best possible wellness state at any given time” (p. 23). “Variances from
wellness or varying degrees of system instability are caused by stressor invasion of the normal line of
defense” (p. 24). Finally, in the nursing component, the major concern is to maintain client system stability
through accurately assessing environmental and other stressors and assisting in client adjustments to maintain
optimal wellness. Table 7-3 lists selected additional concepts from Neuman’s model, and Figure 7-2 offers a
visual representation.

Table 7-3 Concepts in Neuman Systems Model
Concept Definition

Basic structure Basic survival factors common to human beings; they are located in the central
core and represent basic client system energy resources.

Boundary lines The flexible line of defense is the outer boundary of the client system.
Degree of reaction The amount of system instability resulting from stressor invasion of the normal line

of defense.
Feedback The process within which matter, energy, and information provides feedback for

corrective action to change, enhance, or stabilize the system.
Flexible line of

A protective, accordion-like mechanism that surrounds and protects the normal line
of defense from invasion by stressors.

Input/output The matter, energy, and information exchanged between client and environment
that is entering or leaving the system at any point in time.

Lines of resistance Protection factors activated when stressors have penetrated the normal line of
defense, causing a reaction symptomatology.


Negentropy A process of energy conservation that increases organization and complexity,
moving the system toward stability or a higher degree of wellness.

Normal line of

An adaptational level of health developed over time and considered normal for a
particular individual client or system; it becomes a standard for wellness–deviance

Open system A system in which there is a continuous flow of input and process, output, and
feedback. It is a system of organized complexity where all elements are in

Prevention as

Intervention modes for nursing action and determinants for entry of both client and
nurse into the health care system.

Reconstitution The return and maintenance of system stability, following treatment of stressor
reaction, which may result in a higher or lower level of wellness.

Stability A state of balance or harmony requiring energy exchanges as the client adequately
copes with stressors to retain, attain, or maintain an optimal level of health, thus
preserving system integrity.

Stressors Environmental factors, intra-, inter-, and extrapersonal in nature, that have potential
for disrupting system stability. A stressor is any phenomenon that might penetrate
both the flexible and normal lines of defense, resulting in either a positive or
negative outcome.

Wellness/illness Wellness is the condition in which all system parts and subparts are in harmony
with the whole system of the client. Illness indicates disharmony among the parts
and subparts of the client system.

Source: Neuman and Fawcett (2011).

Figure 7-2 The Neuman Systems Model.
(From Neuman, B., & Fawcett, J. The Neuman Systems Model, 5th ed., © 2011. Reprinted by permission of Pearson Education, Inc., New York,
New York.)

Neuman defined five interacting variables: physiologic, psychological, sociocultural, developmental, and
spiritual. These five variables function in time to attain, maintain, or retain system stability. The model is
based on the client’s reaction to stress as it maintains boundaries to protect client stability (Neuman &


Fawcett, 2011).
Neuman delineated a three-step nursing process model in which nursing diagnosis (the first step) assumes

that the nurse collects an adequate database from which to analyze variances from wellness to make the
diagnoses (Neuman & Fawcett, 2011). Nursing goals, which are determined by negotiation with the client, are
set in the second step. Appropriate prevention as intervention strategies are decided in that step. The third
step, nursing outcomes, is the step in which confirmation of prescriptive change or reformulation of nursing
goals is evaluated. The nurse links the client, environment, health, and nursing. The findings feed back into
the system as applicable. A table of prevention as intervention strategies clarifies what comprises the nursing
actions to affect this type of intervention. Neuman outlined 10 propositions or assumptions of the model (Box

Box 7-6 Assumptions of Neuman Systems Model—a Summary
1. Each individual client or group as an open system is unique, a composite of factors and characteristics

within a given range of responses contained within a basic structure.
2. The client as a system is in dynamic, constant energy exchange with the environment.
3. Many known, unknown, and universal stressors exist. Each differs in its potential for disturbing a

client’s usual stability level or normal line of defense. The interrelationships of client variables can
affect the degree to which a client is protected by the flexible line of defense against possible reaction to

4. Each client/client system has evolved a normal range of responses to the environment that is referred to
as a normal line of defense. The normal line of defense can be used as a standard from which to
measure health deviation.

5. When the flexible line of defense is no longer capable of protecting the client/client system against an
environmental stressor, the stressor breaks through the normal line of defense.

6. The client, whether in a state of wellness or illness, is a dynamic composite of the interrelationships of
the variables. Wellness is on a continuum of available energy to support the system in an optimal state
of system stability.

7. Implicit within each client system are internal resistance factors known as lines of resistance, which
function to stabilize and realign the client to the usual wellness state.

8. Primary prevention relates to general knowledge that is applied in client assessment and intervention, in
identification, and in reduction or mitigation of possible or actual risk factors associated with
environmental stressors to prevent possible reaction.

9. Secondary prevention relates to symptomatology following a reaction to stressors, appropriate ranking
of intervention priorities, and treatment to reduce their noxious effects.

10. Tertiary prevention relates to the adjustive processes taking place as reconstitution begins and
maintenance factors move the client back in a circular manner toward primary prevention.

Neuman’s model has been used extensively in nursing education and nursing practice. In her latest work, she
provides a number of specific examples of the systems processes (Neuman & Fawcett, 2011). The Neuman
Systems Model is in place in numerous states of the United States and internationally in countries as diverse
as Taiwan and the Netherlands. It reportedly has been initiated to guide nursing practice for the management
of patient care in the areas of medicine and surgery, mental health, women’s health, pediatric nursing,
community as client, and gerontology. Graduate students, in particular, find Neuman’s model realistic to
define their practice.

Because of its utility and popularity as a model, it has been monitored by a group called the Neuman
Systems Model Trustees Group, Inc. This group meets periodically to discuss research and practice related to
the model and to promote exchange of information and ideas. Neuman’s model is in use as a guide in a
plethora of nursing schools at all levels; a partial listing is included in Neuman and Fawcett (2011).



Although the Neuman’s model is not testable in its entirety, it gives rise to directional hypotheses that are
testable in research. As a result, it has been used as a conceptual framework extensively in nursing research,
and aspects of the model have been empirically tested. Intermediate theories using the Neuman Systems
Model have been developed and are being tested. Box 7-7 lists a few of the many nursing research studies that
have used Neuman Systems Model.

Box 7-7 Examples of Nursing Research Studies Using Neuman Systems Model
Adamson, E. (2014). Caring behaviour of nurses in Malaysia is influenced by spiritual and emotional

intelligence, psychological ownership and burnout. Evidence-Based Nursing, 17(4), 121. doi:10.1136/eb-

Adler, M., & Pietsch, T. (2016). Relationship among smoking, chronic pain, mental health and opioid use in
older adults. Catalyst, Neuman Journal of Student Research and Academic Scholarship, 2(1), 97–113.

Bachman, A. O., Danuser, B., & Morin, D. (2015). Developing a theoretical framework using a nursing
perspective to investigate perceived health in the “sandwich generation” group. Nursing Science
Quarterly, 28(4), 308–318.

Bauer, J. S. (2014). The use of stress-reducing techniques in nursing education. Western Journal of Nursing
Research, 36(10), 1386. doi:10.1177/0193945914540097

Phillips, T. M. (2014). Exploration of theoretical models: Postpartum weight retention in African American
adolescents. Nursing Science Quarterly, 27(4), 308–314.

Willis, D., DeSanto-Madeya, S., Ross, R., Sheehan, D. L., & Fawcett, J. (2015). Spiritual healing in the
aftermath of childhood maltreatment: Translating men’s lived experiences utilizing nursing conceptual
models and theory. ANS. Advances in Nursing Science, 38(3), 162–174.

Neuman’s model is complex, and many parts of the model function in multiple ways. The description of the
model’s parts can be confusing; therefore, the model is not considered to be parsimonious. Neuman and
Fawcett (2011), however, have developed intermediate diagrams to clarify the interactions among parts of the
model and to facilitate its use. The definitions are well developed in the latest edition of the model, and the
assumptions (propositions), although multileveled, are well organized.

Value in Extending Nursing Science
The Neuman Systems Model has extended nursing science as a needs and causality-focused framework. It
appeals to nurses who consider the client to be a holistic individual who reacts to stressors because it predicts
the outcomes of interventions to strengthen the lines of defense against stress, which may destabilize the
system. Neuman’s model is useful not only in the acute critical care area because of the focus on attaining,
regaining, and maintaining system stability but also in community health situations because of its focus on
prevention as intervention (Neuman & Fawcett, 2011).

The human needs nursing theories were among the earliest of the nursing theories. In general, these theories
followed the philosophical school of thought of the time by considering the person to be a biopsychosocial
being and focusing on meeting the individual’s needs.

Donald Crawford, the nurse from the opening case study, illustrated how a human needs–based model can
be used to help direct client care through anticipating or predicting client needs and determining desirable
outcomes. Many other nurses in a variety of settings use these models and theories to direct care for their

It should be noted that succeeding generations of nursing theorists based their models and theories on the
works discussed here. Indeed, these theories were building blocks on which the profession of nursing
depended during the last half of the 20th century and into the 21st century.


Key Points
Needs theorists generally come from the positivist school of thought philosophically, and therefore, the

theories fit well with medical theories of care.
The needs theories of nursing work well with the current emphasis on evidence-based practice because of the

bias toward experimental science.
The first nursing theorists mainly focused on the human needs of their patients/clients.
Florence Nightingale is respected as the mother of modern professional nursing. She brought nursing out of

the servant position it held in the 19th century and into the respected professional status it holds currently.
Virginia Henderson is often seen as the mother of American professional nursing. She was a prolific author

and researcher. Her concept of nursing is still used in clinical and community health care.
Faye Abdellah provided nurses with one of the first academic nursing theories. She was a prolific author and

researcher. She categorized nursing problems based on the individual’s needs and developed a typology of
nursing treatment and nursing skills. Finally, she posited a list of characteristics that described what was
distinctly nursing.

Dorothea Orem provided one of the first theories that gave the patient/client the responsibility for self-care.
Her ideas allowed patients to resume more normal lives with respect to their self-care agency.

Dorothy Johnson was a teacher of nursing at all levels. Her theoretical work inspired many other nurses to
become theoretical thinkers.

Betty Neuman gave nurses the systems model with its lines of defense against stress. She believed that the
causes of stress can be identified and remedied through nursing interventions. She developed the concept of
prevention as intervention. Neuman’s model is one of only a few considered prescriptive in nature.

The needs theorists’ works are still in daily use in education, in clinical nursing, and in clinical nursing

Learning Activities
1. Discuss the usefulness of one of the models/theories in this chapter to evidence-based

practice. How would you and colleagues present your evidence?
2. Choose one of the models discussed in this chapter and demonstrate its use in the care of a

selected client. Write a nursing care plan using the model. Define all elements of the nursing
care plan using the language and the assumptions/propositions of the model.

3. Obtain the work of one of the theorists described in this chapter. Outline a research study
testing components of the model.

4. Determine which major concepts or propositions of the model can be tested.
5. Define the elements of the model to be tested in the research project.
6. Develop a hypothesis statement that examines the model’s propositions in a sample from an

acute care or community setting.
7. Donald, the nurse from the opening case study, applied the Neuman Systems Model as a

framework for improving patient care in his DNP project. Considering your nursing specialty
area, illustrate how one of the theories described in this chapter can be used to more
comprehensively provide evidence-based care to your patient population. Discuss your ideas
with your classmates.

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Grand Nursing Theories Based on Interactive Process
Evelyn M. Wills

Jean Willowby is a student in a master’s of science in nursing program, working to become a pediatric nurse
practitioner. For one of her practicum assignments, Jean must incorporate a nursing theory into her clinical
work, using the theory as a guide. During an earlier course on theory, she read several nursing theories that
focused on interactions between the client and the nurse and between the client and the health care system.
She remembered that in the interaction models and theories, human beings are viewed as interacting wholes,
and client problems are seen as multifactorial.

The theories that stress human interactions best fit Jean’s personal philosophy of nursing because they
take into account the complexities of the multitude of factors she believes to be part of clinical nursing
practice. Like the perspective taken by interaction model theorists, Jean understands that at times, the results
of interventions are unpredictable and that many elements in the client’s background and environment have an
effect on the outcomes of interventions. She also acknowledges that there are many interactions between
clients and their environments, both internal and external, many of which cannot be measured.

To better prepare for the assignment, Jean studied several of the human interaction models and theories,
focusing most of her attention on the works of Roy and King. But after discussing her thoughts with her
professor, she was referred to the writings of Jean Watson (Watson, 2012). After reviewing the carative
factors and the caritas processes, she decided that Watson’s Human Caring Science best fit her pediatrics
practice and determined that she would learn more about it.

As discussed in Chapter 6, interactive process nursing theories occupy a place between the needs-based
theories of the 1950s and 1960s, most of which were philosophically grounded in the positivist school of
thought, and the unitary process models, which are grounded in humanist philosophy, which expresses the
belief that humans are unitary beings and energy fields in constant interaction with the universal energy field.
The interactive theories, in contrast, are grounded in the postpositive schools of philosophy.

The theorists presented in this chapter believe that humans are holistic beings who interact with, and adapt
to, situations in which they find themselves. These theorists ascribe to systems theory and agree that there is
constant interaction between humans and their environments. In general, human interaction theorists believe
that health is a value and that a continuum of health ranges from high-level wellness to illness. They
acknowledge, however, that people with chronic illnesses may have healthy lives and live well despite their

Nursing models that can be described as interactive process theories include Artinian’s Intersystem
Model; Erickson, Tomlin, and Swain’s Modeling and Role-Modeling; King’s Systems Framework and
Theory of Goal Attainment; Roy’s Adaptation Model; and Watson’s Human Caring Science. Each is
discussed in this chapter.

An attempt was made to ensure that a balanced approach was used in presenting the works of these
theorists. However, some of the theories are quite complex (e.g., those of Erickson, Tomlin, and Swain; King;
and Roy), whereas others (e.g., Watson) are quite parsimonious. Additionally, some of the models have been
revised repeatedly (e.g., Artinian, King, Roy, and Watson). As a result, the sections dealing with some models
are longer or more involved than others, but this does not imply that the works of any of the theorists


discussed are more or less important to the discipline than others.

Barbara Artinian: The Intersystem Model
The Intersystem Model was first published in 1983 as the Intersystem Patient-Care Model (Artinian, 1983)
and was later expanded to the Intersystem Model (Artinian, 1991). The second edition of Artinian’s work was
published in 2011, expanded on the previous model, and was renamed the Artinian Intersystem Model (AIM).
Its focus is the nursing process using the AIM (Artinian, 2011).

Background of the Theorist
Barbara Artinian received her bachelor’s degree from Wheaton College; master’s degrees from Case Western
Reserve University in Cleveland, Ohio, and the University of California, Los Angeles (UCLA); and her
doctorate from the University of Southern California. Influenced by her education as a sociologist, Artinian
developed a nursing model that used an intersystems approach and focused on the interactions between client
and nurse (Artinian, 2011). She is currently professor emeritus of the School of Nursing at Azusa Pacific
University, having taught graduate and undergraduate students in the areas of community health nursing,
family theory, nursing theory, and qualitative research methods (Artinian, 2016).

Philosophic Underpinnings of the Theory
Several works were used in developing the components of the model. For example, sense of coherence (SOC),
a social science construct proposed by Antonovsky, provided grounding for the concept situational sense of
coherence (SSOC). The SSOC serves as a measure of the integrative potential of clients within the context of
situations (Artinian, 2011) (Table 8-1 and Figure 8-1).

Table 8-1 Relationship Between SOC and SSOC in Artinian’s Model
Term Definition

Sense of coherence (SOC) The progenitor to the SSOC
Situational sense of coherence

The analytic structure for evaluating the effectiveness of interventions
in the plan of care and the current level of health

Comprehensibility The extent to which one perceives the stimuli present in the situational
environment deriving from the internal and external environments as
making cognitive sense, in that information is ordered, consistent,
structured, and clear, versus disordered random or inexplicable

Meaningfulness The extent to which one feels that the problem demands posed by the
situation are worth investing energy in and are challenges for which
meaning or purpose is sought rather than burdens.

Manageability The extent to which one perceives that resources at one’s disposal are
adequate to meet the demands posed by stimuli present in the situation.

Source: Artinian (2011).


Figure 8-1 Artinian Intersystem Model.
(Republished with permission of John Wiley & Sons, from The Artinian intersystem model, Artinian, B. M., 2nd ed., © 2011; permission
conveyed through Copyright Clearance Center, Inc.)

Additionally, the model of intrasystem analysis and intersystem interaction developed by Alfred Kuhn
was refined by Artinian to explain client–nurse interaction processes in health care situations and for use in
developing the nursing plan of care. Finally, the work of Maturana and Varela provided the conceptualization
of the person as a perceiving, self-determining, self-regulating human system and explains the patient/client
concept of the model (Artinian, 1997a).

Major Assumptions, Concepts, and Relationships
In the Intersystem Model, there is a differentiation between the human as a system (the intrasystem) and the
interactive systems of individuals or groups, known as the intersystem (Artinian, 2011). The language of the
Intersystem Model is scholarly English, and nonsexist language is used throughout.

A number of major assumptions of the model (Artinian, 1997a) are listed in Box 8-1.

Box 8-1 Assumptions of Artinian’s Intersystem Model
1. The human being exists within a framework of development and change, which is inherent to life.
2. The human’s life is a unit of interrelated systems that is viewed as past and potential future.
3. Persons interact with the environment on the biologic level, and the senses are the mode of input from

the environment; bodily functions are the mode for output.
4. The person’s present can be seen in terms of his past and future.


5. The human spirit is at the center of the person’s being, transcending time and affecting all aspects of

6. The nurse focuses on all aspects of the total person, systematically noting the interrelations of the
systems and the relationships of the systems to time and environment.

7. The nursing process can take place only in the present.

Source: Artinian (1997a).

The Intersystem Model incorporates nursing’s metaparadigm concepts of person, environment, and health and
specifies the concept nursing action. Definitions for these concepts are presented in Table 8-2. Person is
viewed as a “coherent being who continually strives to make sense of his or her world” (Artinian, 2011, p.
13). The person as an individual has biologic, psychosocial, and spiritual subsystems. Person may also be an
aggregate, meaning a group of people, such as a family, community, or other aggregates. Environment
includes internal and external environments and specifies developmental environment and situational
environment as important to the interaction (Artinian, 2011).

Table 8-2 Concepts of the Intersystem Model
Concept Definition

Person A coherent being who continually strives to make sense of his or her world. The
person is a system, the subsystems of which are biologic, psychosocial, and
spiritual. Subsystem configuration is such that “transactions among the subsystems
result in emergent properties at the systemic level” (p. 13).

Environment The environment has two dimensions: developmental and situational. The
developmental environment is “all the events, factors, and influences that affect the
system . . . as it passes through its developmental stages” (p. 14). This
developmental environment provides the context for other developmental arenas
such as the healing environment. Situational environment occurs when the nurse
and client interact, and this includes all the details of the encounter.

Health Health and disease are considered to be a multidimensional continuum. In the
Intersystem Model, health is defined as having a strong sense of coherence (SOC)
(p. 16).

Nursing Those actions (interventions) that are needed to resolve concerns and move the
client to a higher situational sense of coherence (SSOC). The nurse assesses the
client’s knowledge (comprehensibility of the problem), the available resources
needed to manage the problem (manageability), and the client’s motivation to meet
the challenges posed by the problem (meaningfulness).

Source: Artinian (2011).

Health is viewed on a multidimensional continuum involving health/disease (Artinian, 2011). The focus is
on stability and adaptation, and Artinian developed the concept of SSOC to measure adaptation. Health is
defined as “a strong SOC” indicating that the person is confident and events are worth investing in and
manageable (Artinian, 2011, p. 16).

Nursing is specified as “nursing action,” which is identified by the mutual communication, negotiation,
organization, and priorities of both the client and nurse intrasystems. This is accomplished through
intersystem interaction; feedback loops are necessary to produce a mutually determined plan of care (Artinian,
2011). One major innovation of this model is that client spirituality and values are important in the assessment
of client needs and within the resulting nursing process.



The Intersystem Model consists of two levels: the intrasystem and the intersystem. The intrasystem applies
both to the client and to the nurse and focuses on the individual. The intersystem, by contrast, focuses on the
interactions between the nurse and client (Artinian, 2011).

In the intrasystem model, three basic components comprise each intrasystem: the detector, selector, and
effector. The detector processes information, the selector compares the situation with the attitudes and values
of the individual, and the effector identifies behaviors relevant to the situation (Artinian, 2011).

The first step in an interaction in the intrasystem is to evaluate the detector domain, each person’s
knowledge of the problem. The detector incorporates knowledge about the internal environment (physical
symptoms), social situations, the condition, treatment, and available resources. The selector allows the client
and nurse to examine their attitudes and values in choosing a course of action that fits both patient/client and
nurse. The effector is the behavioral level in which a response is selected from the repertoire of the behaviors
available. This intrasystem level of the model provides the nurse with the capability of progressively
clarifying with the client to bring about a mutual plan of care (Artinian, 2011).

The intersystem is seen when client and nurse interact, which occurs when nursing assistance is required
(Artinian, 2011). Communication and negotiation between nurse and client lead to developing a plan of care.
If the planned intervention is not effective, the determination is made that further assessment is necessary.

SOC and SSOC are the concepts that relate to health. In the intervention phase of the process, “Input is the
nurse–client interaction to change the SSOC if it is judged to be low” (Artinian, 1997a, p. 13). Outcomes are
scored on the SSOC by changes in knowledge, values and beliefs, and behaviors.

The Intersystem Model is relatively new; nonetheless, examples in nursing literature describing its use in
practice and education are available. Indeed, it has been noted that the Glaserian grounded theory method of
research as codified by Artinian (1998) for use specifically in nursing research has been used by her students
for more than 20 years (McCallin, 2012; McCowan & Artinian, 2011).

Examples from the literature include an investigation by Giske and Artinian (2008) which studied adults
aged 80 years and older in a Norwegian hospital who were undergoing gastroenterologic interventions.
Findings indicate that participants were concerned with preparing themselves for life after their diagnosis, a
difficult period for the participants. Bond and colleagues (2008) and a team lead by Cason (Cason et al., 2008)
studied Hispanic students in baccalaureate nursing programs and found multiple barriers and supports. Also,
examining educational issues was a work by Cone, Artinian, and West (2011) which looked at student issues
in both undergraduate and graduate levels.

In clinical research, Critchley and Ball (2007) studied rheumatology patients using Artinian’s descriptive
qualitative method, and van Dover and Pfeiffer (2007) studied spiritual care of Christian clients of parish
nurses. They developed a theory of spirituality for work in parish nursing. Finally, Vuckovich and Artinian
(2005) investigated mental health nurses who administered medications to psychiatric patients and their
methods of avoiding coercion.

The Intersystem Model has not been fully tested. Research studies applying the model primarily involve using
grounded theory methodology to examine the meanings of events and the person’s reactions to those events in
the effort to formulate theories and hypotheses as noted earlier. In addition, the SSOC instrument has been
used in research as a self-report instrument (Artinian, 1997b).

The model developed by Artinian (2011) is parsimonious and is explained in a logical and coherent way using
two simple diagrams. It is not simplistic, however, and has multiple interacting elements. The more current
model has expanded the diagrams to more thoroughly explain the aspects of the model as needed by both
graduate and undergraduate students.

Value in Extending Nursing Science


The Intersystem Model has value in guiding education and in implementing practice. Its innovation is
attention to the spirituality, goals, and values of both the client and nurse. Nurses use it in diverse clinical
settings, such as psychiatric care, acute care, and community nursing. Several chapters, three books by the
author and associates, and numerous journal articles have been generated by this model (Artinian, 1997a,
2011; Artinian, Giske, & Cone, 2009; Giske & Cone, 2012; Giske & Artinian, 2008; Treolar & Artinian,

Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain:
Modeling and Role-Modeling
Modeling and Role-Modeling (MRM) is considered by its authors to be a theory and a paradigm. They
constructed the theory from a multiplicity of resources that explain nurses’ interactions with clients.

Background of the Theorists
Helen Erickson earned a diploma in nursing from Saginaw General Hospital in Saginaw, Michigan. She
earned a bachelor’s degree in nursing, a master’s degree in psychiatric nursing, and a doctorate in educational
psychology from the University of Michigan. Her career spans positions in nursing practice and education,
both in the United States and abroad. She chaired the adult health nursing curriculum in the graduate program
at the University of Texas at Austin and was a special assistant to the dean for graduate studies. She is
professor emeritus of the University of Texas at Austin (M. E. Erickson, 2014).

Evelyn M. Tomlin was educated at Pasadena City College in Southern California and Los Angeles
General Hospital School of Nursing. She received her bachelor’s degree in nursing from the University of
Southern California and her master’s degree from the University of Michigan. She has had varied experiences
in practice and education, including medical-surgical nursing, maternity, and pediatric nursing. Tomlin retired
as a member of the faculty at the University of Michigan (M. E. Erickson, 2014).

Mary Ann P. Swain was educated in psychology at DePauw University in Greencastle, Indiana, and
earned master’s and doctoral degrees from the University of Michigan. She taught research methods in
psychology at DePauw University and at the University of Michigan. She also served as the director of the
doctoral program in nursing at the University of Michigan for a year and assumed the role of chairperson of
nursing research from 1977 to 1982. Later, she was professor of nursing research at the University of
Michigan and, in 1983, was appointed the associate vice president for academic affairs at the same university.
Swain recently retired from her position as a provost for the New York State University system (M. E.
Erickson, 2014).

Philosophical Underpinnings of the Theory
A number of theoretical works served as the foundation for MRM. Indeed, MRM is a synthesis of the
foundational works of Maslow, Milton Erickson, Piaget, Bowlby, Winnicott, Engel, Lindemann, Selye,
Lazarus, and Seligman (M. E. Erickson, 2014).

Philosophically, H. C. Erickson, Tomlin, and Swain (1983) believe “that nursing is a process between the
nurse and client and requires an interpersonal and interactive nurse–client relationship” (p. 43). For this
reason, their work is considered to be human interaction theory.

Major Assumptions, Concepts, and Relationships
Assumptions about adaptation and nursing are proposed in the MRM theory; the authors state that adaptation
“is an innate drive toward holistic health, growth, and development. Self-healing, recovery and renewal, and
adaptation are all instinctual despite the aging process or inherent malformations” (H. C. Erickson et al., 1983,
p. 47).

When describing nursing, it is assumed that (1) “nursing is the nurturance of holistic self-care”; (2)
“nursing is assisting persons holistically to use their adaptive strengths to attain and maintain optimum
biopsychosocial-spiritual functioning”; (3) “nursing is helping with self-care to gain optimum health”; and (4)


“nursing is an integrated and integrative helping of persons to better care for themselves” (H. C. Erickson et
al., 1983, p. 50).

The MRM theory contains a detailed set of concepts, and a glossary is provided in their work that assists in its
comprehension. Table 8-3 provides definitions for some of the major concepts.

Table 8-3 Major Concepts of the Modeling and Role-Modeling Theory
Concept Definition

Holism The idea that “human beings have multiple interacting subsystems including
genetic make up and spiritual drive, body, mind, emotion, and spirit are a total unit
and act together, affecting and controlling one another interactively” (p. 44).

Health “The state of physical, mental, and social well-being, not merely the absence of
disease or infirmity” (p. 46).

Lifetime growth and

Lifetime growth and development are continuous processes. When needs are met,
growth and development promote health.


The dependence on support systems while maintaining the independence of the

Adaptation The individual’s response to external and internal stressors in a health- and growth-
directed manner. The opposite is maladaptation, which is the taxing of the system
when the individual is “unable to engage constructive coping methods or mobilize
appropriate resources to contend with the stressor(s)” (p. 47).

Self-care Knowledge, resources, and action of the client; knowledge considers what has
made the client sick, what will make him or her well, and “the mobilization of
internal resources, and acquisition of additional resources to gain, maintain, or
promote an optimal level of holistic health” (p. 48).

Nursing “The holistic helping of persons with their self-care activities in relation to their
health—an interactive, interpersonal process that nurtures strengths to achieve a
state of perceived holistic health” (p. 49).

Modeling The process by which the nurse seeks to understand the client’s unique model of
the world.


The process by which the nurse understands the client’s unique model within the
context of scientific theories and uses the model to plan interventions that promote
health for the client.

Source: H. C. Erickson et al. (1983).

The active potential assessment model (APAM) directs nursing assessment in the MRM theory. The APAM is
a synthesis of Selye’s general adaptation syndrome and Engel’s response to stressors (H. C. Erickson et al.,
1983). The APAM assists the nurse in predicting a client’s potential to cope and is used to assess three states:
equilibrium, arousal, and impoverishment. Equilibrium has two facets: adaptive and maladaptive. People in
equilibrium have potential for mobilizing resources; those in maladaptive equilibrium have fewer resources.

Both arousal and impoverishment are considered to be states of stress in which mobilizing resources are
expected. Persons in impoverishment have diminished or depleted abilities for mobilizing resources. People
move between the states as their capacities to meet stress change. The APAM is considered dynamic rather
than unidirectional and depends on the person’s abilities to mobilize resources. Nursing interventions
influence the person’s ability to mobilize resources and move from impoverishment to equilibrium within the
APAM (H. C. Erickson et al., 1983).

From the data collected, a client model is developed with a description of the functional relationship


among the factors. Etiologic factors are analyzed, and possible therapeutic interventions are devised
recognizing possible conflicts with treatment plans of other health professionals. Diagnoses and goals are
established to complete the planning process (H. C. Erickson et al., 1983).

The success of the process is predicated on nurse’s coming to know the client. The five aims of nursing
interventions are building trust, promoting the client’s positive orientation, promoting the client’s control,
affirming and promoting the client’s strength, and setting health-directed mutual goals while meeting the
client’s needs (e.g., biophysical, safety and security, love and belonging, esteem, and self-esteem) (H. C.
Erickson et al., 1983; M. E. Erickson, 2014).

The model has been the basis for a series of conferences incorporating MRM into research, practice settings,
and curricula. Adherents of the theory state that it has been used in courses or in the curricula of several
universities. These include East Carolina University, Greenville, North Carolina; Harding University School
of Nursing, Searcy, Arkansas; Metropolitan State University, St. Paul, Minnesota; St. Catherine University
School of Nursing, St. Paul, Minnesota; University of Texas at Austin School of Nursing, Austin, Texas;
Washtenaw Community College School of Nursing, Ann Arbor, Michigan; and Lamar University Department
of Nursing, Beaumont, Texas (M. E. Erickson, 2014).

MRM provides assumptions and relationships that are amenable to testing and have been and continue to be
tested in research. The model has been used by nurses who have studied with Erickson, Tomlin, and Swain,
and many theses and dissertations have incorporated elements of the model. Box 8-2 lists some of the current
works using MRM in research.

Box 8-2
Examples of Research Studies Using Modeling and Role-Modeling

Goldstein, L. A. (2013). Relationships among quality of life, self-care, and affiliated individuation in persons
on chronic warfarin therapy (Doctoral dissertation). University of Texas, Austin, TX. Retrieved from

Gregg, S. R., & Twibell, K. R. (2016). Try-It-On: Experiential learning of holistic stress management in a
graduate nursing curriculum. Journal of Holistic Nursing, 34(3), 300–308.

Koren, M. E., & Papamiditriou, C. (2013). Spirituality of staff nurses: Application of modeling and role
modeling theory. Holistic Nursing Practice, 27(1), 37–44.

Merryfeather, L. (2015). Passionate scholarship or academic safety: An ethical issue. Journal of Holistic
Nursing, 33(1), 60–67.

The MRM theory is not parsimonious. Its complexity, however, reflects human beings, to whom it applies.
MRM incorporates several borrowed theories that are synthesized for use in nursing science. The many
linkages among the concepts and multiple levels need to be addressed, and considerable explanation is needed
to enhance understanding of the tenets of the theory for nursing practice and for client care activities.
However, nurses who use the theory are grateful for the fit it has with their practice.

Value in Extending Nursing Science
In addition to the uses of MRM in nursing education, practice, and research, three middle range nursing
theories have been based on MRM. Acton (1997) developed a model describing affiliated-individuation, Irvin
and Acton (1996) described caregiver stress, and Rogers (1996) discussed the concept of facilitative

MRM theory is used in education, practice, and research. Research has been completed with people of all


ages and with those who are suffering from many different health problems. According to those who espouse
the theory, its major attraction is that it is practical, reflects the domain of nursing, and is a realistic model for
guiding research, practice, and education.

Imogene King: King’s Conceptual System and Theory of Goal
Attainment and Transactional Process
King’s theory evolved from early writings about theory development. In her first book in 1971, she
synthesized scholarship from nursing and related disciplines into a theory for nursing (King, 1971). She wrote
the Theory of Goal Attainment in 1980. The most recent edition (King, 1995a) contains further refinements
and more detailed explanation of the general nursing framework and the theory.

Background of the Theorist
Imogene King graduated from St. John’s Hospital School of Nursing in St. Louis, Missouri, with a diploma in
nursing in 1945. She received a bachelor of science in nursing education from St. Louis University in 1948
and a master’s of science in nursing from the same school in 1957. In 1961, she received the doctor of
education degree from Teacher’s College, Columbia University, in New York (Sieloff & Messmer, 2014).
She held a variety of staff nursing, educational, research, and administrative roles throughout her professional
life. She worked as a research consultant for the Division of Nursing in the Department of Health, Education,
and Welfare for several years before moving to Tampa, Florida, in 1980, assuming the position of professor at
the University of South Florida College of Nursing (Sieloff & Messmer, 2014). She remained active in
professional organizations for many years. When she died in 2008, her work was widely celebrated by her
colleagues (Mensik, 2008; Mitchell, 2008; Smith, Wright, & Fawcet, 2008; Stevens & Messmer, 2008).

Philosophical Underpinnings of the Theory
The von Bertalanffy General Systems Model is acknowledged to be the basis for King’s work. She stated that
the science of wholeness elucidated in that model gave her hope that the complexity of nursing could be
studied “as an organized whole” (King, 1995b, p. 23).

Major Assumptions, Concepts, and Relationships
King’s conceptual system and theory contain many concepts and multiple assumptions and relationships. A
few of the assumptions, concepts, and relationships are presented in the following sections. The scholar
wishing to use King’s model or theory is referred to the original writings as both the model and theory are
complex (Figure 8-2).

Figure 8-2 A model of nurse–patient interactions.


(Source: King, I. M. [1981]. A theory for nursing: Systems, concepts, process [p. 61]. Reprinted with permission of Sage Publications.)

The Theory of Goal Attainment lists several assumptions relating to individuals, nurse–client interactions, and
nursing. When describing individuals, the model shows that individuals (1) are social, sentient, rational,
reacting beings and (2) are controlling, purposeful, action oriented, and time oriented in their behavior (King,

Regarding nurse–client interactions, King (1981) believed that (1) perceptions of the nurse and client
influence the interaction process; (2) goals, needs, and values of the nurse and client influence the interaction
process; (3) individuals have a right to knowledge about themselves; (4) individuals have a right to participate
in decisions that influence their lives, health, and community services; (5) individuals have a right to accept or
reject care; and (6) goals of health professionals and goals of recipients of health care may not be congruent.

With regard to nursing, King (1995b) wrote that (1) nursing is the care of human beings; (2) nursing is
perceiving, thinking, relating, judging, and acting vis-à-vis the behavior of individuals who come to a health
care system; (3) a nursing situation is the immediate environment in which two individuals establish a
relationship to cope with situational events; and (4) the goal of nursing is to help individuals and groups
attain, maintain, and restore health. If this is not possible, nurses help individuals die with dignity.

King’s Theory of Goal Attainment defines the metaparadigm concepts of nursing as well as a number of
additional concepts. Table 8-4 lists some of the major concepts.

Table 8-4 Major Concepts of the Theory of Goal Attainment
Concept Definition

Nursing A process of action, reaction, and interaction whereby nurse and client share
information about their perceptions in the nursing situation. The nurse and client
share specific goals, problems, and concerns and explore means to achieve a goal.

Health A dynamic life experience of a human being, which implies continuous adjustment
to stressors in the internal and external environment through optimum use of one’s
resources to achieve maximum potential for daily living.

Individuals Social beings who are rational and sentient. Humans communicate their thoughts,
actions, customs, and beliefs through language. Persons exhibit common
characteristics such as the ability to perceive, to think, to feel, to choose between
alternative courses of action, to set goals, to select the means to achieve goals, and
to make decisions.

Environment The background for human interactions. It is both external to and internal to the

Perception The process of human transactions with environment. It involves organizing,
interpreting, and transforming information from sensory data and memory.

Communication A process by which information is given from one person to another, either directly
in face-to-face meetings or indirectly. It involves intrapersonal and interpersonal

Interaction A process of perception and communication between person and environment and
between person and person represented by verbal and nonverbal behaviors that are

Transaction A process of interactions in which human beings communicate with the
environment to achieve goals that are valued; transactions are goal-directed human

Stress A dynamic state in which a human interacts with the environment to maintain
balance for growth, development, and performance; it is the exchange of


information between human and environment for regulation and control of

Source: King (1981).

The Theory of Goal Attainment encompasses a great many relationships, many of them complex. King
organized them into useful propositions that enhance the understanding of the relationships of the theory. A
review of some relationships among the theory’s concepts follows:

Nurse and client are purposeful interacting systems.
Nurse and client perceptions, judgments, and actions, if congruent, lead to goal-directed transactions.
If perceptual accuracy is present in nurse–client interactions, transactions will occur.
If nurse and client make transactions, goals will be attained.
If goals are attained, satisfaction will occur.
If goals are attained, effective nursing care will occur.
If transactions are made in nurse–client interactions, growth and development will be enhanced.
If role expectations and role performance as perceived by nurse and client are congruent, transactions

will occur.
If role conflict is experienced by nurse or client or both, stress in nurse–client interactions will occur.
If nurses with special knowledge and skills communicate appropriate information to clients, mutual

goal setting and goal attainment will occur (King, 1981, pp. 61, 149).

King’s Theory of Goal Attainment has enhanced nursing education. For example, it served as a framework for
the baccalaureate program at the Ohio State University School of Nursing, where it determined the content
and processes taught at each level of the program (Daubenmire, 1989). Similarly, in Sweden, King’s model
was used to organize nursing education (Frey, Rooke, Sieloff, Messmer, & Kameoka, 1995). In more recent
years, King’s model has been useful in nursing education programs in Sweden, Portugal, Canada, and Japan
(Sieloff & Messmer, 2014).

King’s conceptual system is an organizing guide for nursing practice. In one example, Caceres (2015)
used King’s T