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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

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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

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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
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D E D I C AT I O N

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

7

C O N T R I B U T O R S

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

8

R E V I E W E R S

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

9

College of Nursing
The Ohio State University
Columbus, Ohio

10

P R E FA C E

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
administration/management.

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
strategies.

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

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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
research.

■ 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
discussion.

■ 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

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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

13

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

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
relevant.

14

C O N T E N T S

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
Epistemology

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

Summary
Key Points

Learning Activities

2. Overview of Theory in Nursing
Melanie McEwen

Overview of Theory
The Importance of Theory in Nursing
Terminology of Theory

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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
Metatheory
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
Summary
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

Rodgers
Schwartz-Barcott and Kim

Theoretical Phase

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Fieldwork Phase
Analytical Phase

Meleis
Concept Exploration
Concept Clarification
Concept Analysis

Morse
Concept Delineation
Concept Comparison
Concept Clarification

Penrod and Hupcey
Comparison of Models for Concept Development

Summary
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

Purpose
Concepts and Conceptual Definitions
Theoretical Statements

Existence Statements
Relational Statements

Structure and Linkages
Assumptions
Models

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

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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

Summary
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:
Whall
Theory Evaluation: Dudley-Brown

Comparisons of Methods
Synthesized Method of Theory Evaluation
Summary
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
Usefulness
Testability
Parsimony

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Value in Extending Nursing Science
The Purpose of Critiquing Theories
Summary
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
Usefulness
Testability
Parsimony
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

Assumptions
Concepts

Usefulness
Testability
Parsimony
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

Assumptions
Usefulness
Testability
Parsimony
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

Concepts
Relationships

Usefulness
Testability
Parsimony
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

Assumptions
Concepts
Relationships

Usefulness

19

Testability
Parsimony
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

Concepts
Relationships

Usefulness
Testability
Parsimony
Value in Extending Nursing Science

Summary
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

Assumptions
Concepts
Relationships

Usefulness
Testability
Parsimony
Value in Extending Nursing Science

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

Background of the Theorists
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships

Concepts
Relationships

Usefulness
Testability
Parsimony
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

Assumptions
Concepts
Relationships

Usefulness
Testability
Parsimony
Value in Extending Nursing Science

20

Sister Callista Roy: The Roy Adaptation Model
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships

Concepts
Relationships

Usefulness
Testability
Parsimony
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

Assumptions
Concepts
Relationships

Usefulness
Testability
Parsimony
Value in Extending Nursing Science

Summary
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

Concepts
Relationships

Usefulness
Testability
Parsimony
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

Concepts
Relationships

Usefulness
Testability
Parsimony
Value in Extending Nursing Science

Rosemarie Parse: The Humanbecoming Paradigm
Background of the Theorist
Philosophical Underpinnings of the Theory
Major Assumptions, Concepts, and Relationships

Concepts
Relationships

21

Usefulness
Testability
Parsimony
Value in Extending Nursing Science

Summary
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
Summary
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

22

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

Summary
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

Summary
Key Points

Learning Activities

Unit III: Shared Theories Used by Nurses

13. Theories From the Sociologic Sciences

23

Joan C. Engebretson
Systems Theories

General Systems Theory
Overview
Application to Nursing

Social Ecological Models
Overview
Application to Nursing

Social Networks
Overview
Application to Nursing

Social Construction and Interaction Theories
Symbolic Interactionism

Overview
Application to Nursing

Cultural Diversity
Overview
Application to Nursing

Role Theory
Overview
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
Summary
Key Points

Learning Activities

14. Theories From the Behavioral Sciences
Melanie McEwen and Sattaria Smith Dilks

Psychodynamic Theories
Psychoanalytic Theory: Freud

Overview
Application to Nursing

Developmental (or Ego Developmental) Theory: Erikson
Overview
Application to Nursing

Interpersonal Theory: Sullivan
Overview
Application to Nursing

Behavioral and Cognitive-Behavioral Theories
Operant Conditioning: Skinner
Cognitive Theory: Beck
Rational Emotive Theory: Ellis

24

Application of Behavioral and Cognitive-Behavioral Theories to Nursing
Humanistic Theories

Human Needs Theory: Maslow
Overview
Application to Nursing

Person-Centered Theory: Rogers
Overview
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

Summary
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

Overview
Application to Nursing

The Epidemiologic Triangle
The Web of Causation

Overview
Application to Nursing

Natural History of Disease
Overview
Application to Nursing

Theories and Principles Related to Physiology and Physical Functioning
Homeostasis

Overview
Application to Nursing

Stress and Adaptation: General Adaptation Syndrome
Overview
Application to Nursing

Theories of Immunity and Immune Function
Overview
Application to Nursing

Genetic Principles and Theories
Overview
Application to Nursing

Cancer Theories
Overview
Application to Nursing

Pain Management
Gate Control Theory

25

Application to Nursing
Summary
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

Background
Application in Nursing

Modern Ethical Theories
Deontology
Utilitarianism
Deontology and Utilitarianism—A Summary
Application to Nursing

Bioethical Principles
Historical Perspective on the Bioethical Principles
Autonomy

Overview
Application to Nursing

Beneficence
Overview
Application to Nursing

Nonmaleficence
Overview
Application to Nursing

Justice
Overview
Application to Nursing

Other Bioethical Principles
Ethical Decision Making

Overview
Application to Nursing

Summary
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

26

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
Power
Empowerment
Change

Planned Change Theory
Resilience

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
Summary
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

Overview
Application to Nursing

Cognitive Learning Theories
Cognitive-Field (Gestalt) Theories

Overview
Application to Nursing

Cognitive Development or Interaction Theories
Piaget
Gagne
Bandura

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Humanistic Learning Theory
Rogers

Information-Processing Models
Cognitive Load Theory
Application to Nursing

Adult Learning
Overview
Application to Nursing

Summary of Learning Theories
Learning Styles
Principles of Learning
Application of Learning Theories in Nursing
Summary
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
System

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

Summary
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

Overview
Nursing Studies

Explanatory Theory and Correlational Research

28

Overview
Nursing Studies

Predictive Theory and Experimental Research
Overview
Nursing Studies

How Theory Is Used in Research
Theory-Generating Research

Overview
Nursing Studies

Theory-Testing Research
Overview
Nursing Studies

Theory as the Conceptual Framework or Context of a Study
Overview
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

Summary
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
Departmentalization

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

Summary
Key Points

Learning Activities

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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

Summary
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

Summary
Key Points

Learning Activities

Glossary
Author Index
Subject Index

30

UNIT I

Introduction to Theory

31

1

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.

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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

33

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,
1978).

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
follows:

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

34

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).

35

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,
1995).

36

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
knowledge.

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.

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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,
sociology).

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,
2009).

Postmodernism has loosened the notions of what counts as knowledge development that have persisted

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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
Sciences

Postmodernism,
Poststructuralism, and
Postcolonialism

Empiricism/positivism/logical
positivism

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
ahistorical

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;

microstructures
Quantitative research Qualitative research methods Methodologic pluralism methods

Sources: Meleis (2012); Moody (1990).

Nursing Philosophy, Nursing Science, and Philosophy of Science in
Nursing
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

39

recognize.

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
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

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replication.
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,
1992).

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

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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
tested.

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
Knowing

Relationship
to Nursing

Source or
Creation

Source of
Validation

Method of
Expression

Purpose or
Outcome

Empirics Science of nursing Direct or indirect
observation and
measurement

Replication Facts, models,
scientific principles,
laws statements,
theories,
descriptions

Description,
explanation,
prediction

Esthetics Art of nursing Creation of value
and meaning,
synthesis of abstract
and concrete

Appreciation;
experience;
inspiration;
perception of
balance, rhythm,
proportion, and
unity

Appreciation;
empathy; esthetic
criticism; engaging,
intuiting, and
envisioning

Move beyond what
can be explained,
quantitatively
formulated,
understanding,
balance

Personal knowledge Therapeutic use of
self

Engagement,
opening, centering,
actualizing self

Response,
reflection,
experience

Empathy, active
participation

Promote wholeness
and integrity in
personal encounters

Ethics Moral component of
nursing

Values clarification,
rational and
deliberate reasoning,
obligation,
advocating

Dialogue,
justification,
universal
generalizability

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
empirical.

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

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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
research.

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
forms.

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

43

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
alternative.

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,

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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.

Summary
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–

45

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
knowledge.

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
support.

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

46

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
convictions.

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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2

Overview of Theory in Nursing
Melanie McEwen

Matt Ng has been an emergency room nurse for almost 6 years and recently decided to enroll in a master’s
degree program to become an acute care nurse practitioner. As he read over the degree requirements, Matt
was somewhat bewildered. One of the first courses 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”

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(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

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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
philosophically.

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

Concept Concepts are the elements or components of a phenomenon necessary
to understand the phenomenon. They are abstract and derived from
impressions the human mind receives about phenomena through
sensing the environment.

Conceptual model/conceptual
framework

A conceptual model is a set of interrelated concepts that symbolically
represents and conveys a mental image of a phenomenon. Conceptual
models of nursing identify concepts and describe their relationships to
the phenomena of central concern to the discipline.

Construct Constructs are the most complex type of concept. They comprise more
than one concept and are typically built or constructed by the theorist
or philosopher to fit a purpose. The terms concept and construct are
often used interchangeably, but some authors use concept as the more

51

general term—all constructs are concepts, but not all concepts are
constructs.

Empirical indicator Empirical indicators are very specific and concrete identifiers of
concepts. They are actual instructions, experimental conditions, and
procedures used to observe or measure the concept(s) of a theory.

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

Hypotheses Hypotheses are tentative suggestions that a specific relationship exists
between two concepts or propositions. As the hypothesis is repeatedly
confirmed, it progresses to an empirical generalization and ultimately
to a law.

Knowledge Knowledge refers to the awareness or perception of reality acquired
through insight, learning, or investigation. In a discipline, knowledge is
what is collectively seen to be a reasonably accurate understanding of
the world as seen by members of the discipline.

Laws A law is a proposition about the relationship between concepts in a
theory that has been repeatedly validated. Laws are highly
generalizable. Laws are found primarily in disciplines that deal with
observable and measurable phenomena, such as chemistry and physics.
Conversely, social and human sciences have few laws.

Metaparadigm A metaparadigm represents the worldview of a discipline—the global
perspective that subsumes more specific views and approaches to the
central concepts with which the discipline is concerned. The
metaparadigm is the ideology within which the theories, knowledge,
and processes for knowing find meaning and coherence. Nursing’s
metaparadigm is generally thought to consist of the concepts of person,
environment, health, and nursing.

Middle range theory Middle range theory refers to a part of a discipline’s concerns related
to particular topics. The scope is narrower than that of broad-range or
grand theories.

Model Models are graphic or symbolic representations of phenomena that
objectify and present certain perspectives or points of view about
nature or function or both. Models may be theoretical (something not
directly observable—expressed in language or mathematics symbols)
or empirical (replicas of observable reality—e.g., model of an eye).

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

Paradigm A paradigm is an organizing framework that contains concepts,
theories, assumptions, beliefs, values, and principles that form the way
a discipline interprets the subject matter with which it is concerned. It
describes work to be done and frames an orientation within which the
work will be accomplished. A discipline may have a number of
paradigms. The term paradigm is associated with Kuhn’s Structure of
Scientific Revolutions.

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

Philosophy A philosophy is a statement of beliefs and values about human beings

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and their world.
Practice or situation-specific
theory

A practice or situation-specific theory deals with a limited range of
discrete phenomena that are specifically defined and are not expanded
to include their link with the broad concerns of a discipline.

Praxis Praxis is the application of a theory to cases encountered in experience.
Relationship statements Relationship statements indicate specific relationships between two or

more concepts. They may be classified as propositions, hypotheses,
laws, axioms, or theorems.

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

Theory Theory refers to a set of logically interrelated concepts, statements,
propositions, and definitions, which have been derived from
philosophical beliefs of scientific data and from which questions or
hypotheses can be deduced, tested, and verified. A theory purports to
account for or characterize some phenomenon.

Worldview Worldview is the philosophical frame of reference used by a social or
cultural group to describe that group’s outlook on and beliefs about
reality.

Sources: Alligood (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.”

53

Table 2-2 Stages in the Development of Nursing Theory
Stage Source of Knowledge Impact on Theory and Research

Silent knowledge Blind obedience to medical
authority

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

Received knowledge Learning through listening to
others

Theories were borrowed from
other disciplines. As nurses
acquired non-nursing doctoral
degrees, they relied on the
authority of educators,
sociologists, psychologists,
physiologists, and anthropologists
to provide answers to nursing
problems.

Research was primarily
educational research or sociologic
research.

Subjective knowledge Authority was internalized to
foster a new sense of self.

A negative attitude toward
borrowed theories and science
emerged.

Nurse scholars focused on
defining nursing and on
developing theories about and for
nursing.

Nursing research focused on the
nurse rather than on clients and
clinical situations.

Procedural knowledge Includes both separate and
connected knowledge

Proliferation of approaches to
theory development. Application
of theory in practice was
frequently underemphasized.
Emphasis was placed on the
procedures used to acquire
knowledge, with focused attention
to the appropriateness of
methodology, the criteria for
evolution, and statistical
procedures for data analysis.

Constructed knowledge Combination of different types of
knowledge (intuition, reason, and
self-knowledge)

Recognition that nursing theory
should be based on prior
empirical studies, theoretical
literature, client reports of clinical
experiences and feelings, and the
nurse scholar’s intuition or related
knowledge about the phenomenon
of concern

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

Nursing theory will increasingly
incorporate information from
published literature with enhanced

54

emphasis on clinical application
as situation-specific/practice
theories and middle range
theories.

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)

55

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,
2015).

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

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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,
2004).

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.

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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)

1960–
1966

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
Curricula

1972

Key articles publish in Nursing Research (Hardy—Theories: Components, Development, and
Evaluation; Jacox—Theory Construction in Nursing; and Johnson—Development of Theory)

1974

Nurse educator conferences on nursing theory 1975,
1978

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

1980s

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
concepts

1990s

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

2000s

Introduction of the doctor of nursing practice (DNP) 2004
Growing emphasis on development of situation-specific and middle range theories in nursing 2010+

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Attention to theory utilization and development of theories to guide nursing research, practice,
education, and administration

2010+

Focus on clinical application of evidence-based practice, practice-based evidence, and
translational research

2010+

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

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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

Behavior
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

Universality”
2001 Culture Care Diversity and Universality
2006 2nd edition
2015 3rd edition (Edited by M. R. McFarland and H. B. Wehbe-

Alamah)
Joan Riehl Sisca 1980 The Riehl Interaction Model

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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

Research
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
Wrubel

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
Schoenhofer

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.

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Figure 2-1 Comparison of the scope of nursing theories.

Metatheory
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
theories.

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

62

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

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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-
management.

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.

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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

65

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
Metaparadigm
Concept

Author/Source of
Definition Definition

Person/human
being/client

D. Johnson A behavioral system with patterned, repetitive, and
purposeful ways of behaving that link person to the
environment

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

66

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
(1985).

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-

67

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

68

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.

Summary
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
nursing.

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

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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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3

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

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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
years.

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

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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
measured.

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

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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

Concept
Theoretical
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–
11.

Health
literacy

“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.
94)

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),
94–100.

Health-
promoting
lifestyle

“ . . . activities that
encourage or
improve overall
general health” (p.
328)

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-

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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
skills.

Ornia, G., & Lopez, M. L.
(2015). Emotional intelligence
and health risk behaviors in
nursing students. The Journal of
Nursing Education, 54(8), 464–
467.

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
Literature

Naturalistic
concepts

Present in nursing
practice

May be defined and developed
for use in research and theory
development Often have medical
implications as well as nursing
use

Body weight, pain,
thermoregulation, depression,
hematologic complications,
circadian dysregulation

Research-
based
concepts

Developed through
qualitative research
processes (e.g.,
grounded theory or
existential
phenomenology)

Often relate to a nursing
specialty

Hope, grief, cultural competence,
chronic pain

Existing
concepts

Borrowed from other
disciplines

Developed for nursing practice
but are useful in research and
theory

Job satisfaction, quality of life,
abuse, adaptation, stress

Sources: Cowles and Rogers (1993); Parse (1999); Verhulst and Schwartz-Barcott (1993); Wang (2000).

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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

operationalized
Determining the fit between the definition of the concept and its clinical application (Morse et al.,

1996)

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
Denial

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Forgiveness
Functional status
Healing
Hoarding
Inner strength
Postdeployment reassimilation
Second victim
Successful aging
Thermoregulation
Waiting
Wholeness
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.

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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
analysis.

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
available.

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.

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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
disturbance

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.

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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.

Nurse–patient
interaction

Evans, E. C. (2016). Exploring the nuances of nurse-patient interaction through
concept analysis: Impact on patient satisfaction. Nursing Science Quarterly, 29(1),
62–70.

Proactive behavior in
midwifery

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
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

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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.
91).

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-
management

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
culture-centered
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.

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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
illness

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
data.

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

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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.

Compassion
competence

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–
767.

Meleis
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

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excluded.
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

Delineating
antecedents

Defining the contextual conditions under which the concept is perceived and
expected to occur

Delineating
consequences

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).

Morse
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.

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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

86

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
Constructed
Cases

Other
Factors/Steps

Walker and
Avant

Concept
analysis

Clarify
meaning of
terms

8 Model,
borderline,
related,
contrary

Identify empirical
referents and
defining
attributes;
delineate
antecedents and
consequences

Rodgers Evolutionary
concept
analysis

Refine and
clarify
concepts for
use in research
and practice

5 Model only
(identified—
not
constructed)

Identify
appropriate realm
(setting and
sample); analyze
data about
characteristics,
conduct
interdisciplinary
or temporal
comparisons;
identify
hypotheses and
implications for
further study

Schwartz-
Barcott and
Kim

Hybrid model
of concept
development

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
literature,
participant
observation,
collect and

87

to measure a
concept

analyze data, write
findings

Meleis Concept
development

Define
concepts
theoretically
and
operationally,
clarify
ambiguities,
relate concepts
to empirical
referents

7 Same or like
models;
contrary
models

Define concept,
use an analogy to
describe a similar
concept,
synthesize
findings;
differentiate
similarities and
differences
between like
concepts;
delineate
antecedents and
consequences

Morse Concept
comparison

Clarifies the
meaning of
competing
concepts

3 phases Not specified Use extensive
literature review
to examine and
describe
preconditions
(status of use of
the concepts in
teaching or
practice), process,
and outcomes of
use of the concept

Penrod and
Hupcey

Principle-
based concept
analysis

Concept
analysis

4 phases based
on principles

Not specified Sampling within
bodies of large
multidisciplinary
literature yields a
theoretically based
scientific
definition

Summary
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.

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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.

discrete).
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.

CONCEPT ANALYSIS EXEMPLAR
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
2015.

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.

Antecedents:

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

89

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
confidence.

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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4

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.

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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
theories.

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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

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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
development.

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
relatives.

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

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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
chronicity).

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.

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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

adaptation
Theory of planned behavior

Theories from biomedical sciences Pain
Self-regulation theory
Immune function
Symptomology
Germ theory

Theories from administration and management
sciences

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.

Purpose
The purpose of a theory explains why the theory was formulated and specifies the context and situations in

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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.

Empirical
generalizations

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
situations.

Laws Well-grounded, with strong empirical support and evidence of empirical
regulatory. Laws contain concepts that can be measured or identified in concrete
settings.

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

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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,
2015).

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
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

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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
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

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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,
2012).

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

Theory–practice–
theory

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
theory

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
situations.

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
findings.

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

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theoretical statements.
Theory–research–
theory

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
formed.

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

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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

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Step Description

Concept development Specifying, defining, and clarifying the concepts used to describe a phenomenon of
interest

Statement
development

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
relationships

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;

104

designing relationship statements; and delineating the organization, structure, or relationship among the
components.

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
development.

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

105

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.

Summary
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.

THEORY DEVELOPMENT EXEMPLAR
Garmon , S. C. ( 2012 ). Theory of perceived access to breast health care in African American women . ANS. Advances in

106

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
stage

Health behaviors and
practices

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
care

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

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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).

Assumptions
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.

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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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5

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
inconsistencies.

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

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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

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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
theories

Margaret Hardy 1974, 1978 Theory evaluation
Mary Duffey and Ann
Muhlenkamp

1974 Theory analysis and theory
evaluation

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-
Madeya

1980, 1993, 1995, 2000, 2005,
2013

Theory (conceptual framework)
analysis and theory (conceptual
framework) evaluation

Peggy Chinn and Maeona Kramer
(Jacobs)

1983, 1987, 1991, 1995, 1999,
2004, 2008, 2011, 2015

Theory description and critical
reflection

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.

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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
Testability
Generality
Contribution to understanding
Predictability
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
Muhlenkamp

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?

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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
Clarity
Consistency
Adequacy
Logical development
Level of theory development

External Criticism
Reality convergence (how the theory relates to the real world)
Utility
Significance
Discrimination (differentiation between nursing and other health professions)
Scope
Complexity

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.

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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

complex?
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.

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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
examine:

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

definitions?
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

phenomena?
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

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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
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
Basic
Considerations

Internal Analysis and
Evaluation

External Analysis
and Evaluation

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Practice theory Can the concepts be
operationalized? Are
operationalized
concepts congruent
with empirical data?
Do statements lead to
directives for nursing
care? Are statements
sufficient to practice
and not
contradictory?

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
groups?

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
intervention
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
statements?

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
theory?

Nursing models What are the
definitions of person,
nursing, health, and
environment? What
are additional
understandings of the
metaparadigm
concepts? What are
the interrelationships
among the
metaparadigm
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
interventions
systems?

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

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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

Walker
and
Avant Fawcett

Chinn
and
Kramer Meleis Whall

Dudley-
Brown

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
(definitions)

X X X X X X

Logical adequacy X X X X

Validity/accuracy/empirical
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

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Assumptions X X X

Purpose X X

Consequences X

Nursing therapeutics
interventions

X X X

Method of development X

Circle of contagion X X X

Social/cultural significance X X X X

Correspondence to
standards/professional values

X X

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
criteria.

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)?

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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

administrators?
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?

Summary
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.

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THEORY EVALUATION EXEMPLAR:
THEORY OF CHRONIC SORROW

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
Kluwer.

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

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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
disparity.

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.

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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

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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,
2016).

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
different?

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.

R E F E R E N C E S
Alligood, M. R. (2014a). Introduction to nursing theory: Its history, significance, and analysis. In M. R. Alligood (Ed.), Nursing theorists and

their work (8th ed., pp. 2–13). St. Louis, MO: Mosby.
Alligood, M. R. (2014b). Nursing theorists and their work (8th ed.). St. Louis, MO: Mosby.
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

Education.
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–

83.

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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:

Davis.
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-

Hall.
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.

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UNIT II

Nursing Theories

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6

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).

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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
Essentials

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

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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
function

Interaction, illness as
experience

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
experience/meaning

Adaptive,
developmental being

Man-living-health,
continuously becoming,
continuous
person/environment
relationship

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Patient Needs deficit Helpless being, human
experience/meaning

Lacks adaptation,
systems deficiency

Unique human being,
transformation,
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
mechanism

Connect, be present, extract
meaning

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).

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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.

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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–

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environment
interactions

Interactions
Needs, interaction,

outcomes, caring
Newman Paradigm Philosophical schools Particulate–deterministic

Interactive–integrative
Unitary–transformative

Parse Paradigm Difference between
worldviews

Totality
Simultaneity–

humanbecoming

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.

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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
Usefulness
Testability
Parsimony
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

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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).

Usefulness
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).

Testability
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
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

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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

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the scholarly impulse in each of us, guides the research process, provides structure for safe and effective
practice, and extends the science of nursing.

Summary
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
classmates.

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7

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

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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
discipline.

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

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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

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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.

Usefulness
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).

Testability
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.

Parsimony
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

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(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
nurses.

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
world.

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–
21).

Assumptions
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

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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.

Concepts
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).

Usefulness
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.

Testability
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.

Parsimony

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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.

Assumptions
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).

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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

needs
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

patients.
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

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service to individuals and families and to society, which helps people cope with their health needs) (Abdellah
et al., 1960).

Usefulness
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.

Testability
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.

Parsimony
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 &

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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.

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Figure 7-1 Self-Care Deficit Nursing Theory.
(Source: Orem, D. [2001]. Nursing: Concepts of practice [6th ed.]. St. Louis, MO: Mosby.)

Concepts

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
physician.

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
community.

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.

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requisites
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
demand

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).

Relationships
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,
2001).

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.

Usefulness
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

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nurses across the globe (Biggs, 2008).

Testability
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.
doi:10.1097/NXN.0b013e318266ca22

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

Parsimony
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.

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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,
2014).

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
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).

Concepts
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).

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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
Functional
requirements

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
Stability Balance or steady state in maintaining balance of behavior within an acceptable

range
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).

Relationships
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

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3. To be stimulated to enhance growth and prevent stagnation

Usefulness
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.

Testability
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.

Parsimony
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).

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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

Concepts
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
defense

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.

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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
defense

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
determination.

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
interaction.

Prevention as
intervention

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.)

Relationships
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 &

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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
7-6).

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
stressors.

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.

Usefulness
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).

Testability

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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-
2013-101704

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.

Parsimony
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).

Summary
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
clients.

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.

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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
research.

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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8

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
illnesses.

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

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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
(SSOC)

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).

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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.

Assumptions
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.

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5. The human spirit is at the center of the person’s being, transcending time and affecting all aspects of
life.

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).

Concepts
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.

Relationships

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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.

Usefulness
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.

Testability
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).

Parsimony
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

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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,
2007).

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
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)

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“nursing is an integrated and integrative helping of persons to better care for themselves” (H. C. Erickson et
al., 1983, p. 50).

Concepts
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
development

Lifetime growth and development are continuous processes. When needs are met,
growth and development promote health.

Affiliated-
individuation

The dependence on support systems while maintaining the independence of the
individual.

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.

Role-modeling

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).

Relationships
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

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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).

Usefulness
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).

Testability
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
Theory

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
https://repositories.lib.utexas.edu/handle/2152/21865

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.
doi:10.1177/0898010115611788

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.

Parsimony
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
affiliation.

MRM theory is used in education, practice, and research. Research has been completed with people of all

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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.

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(Source: King, I. M. [1981]. A theory for nursing: Systems, concepts, process [p. 61]. Reprinted with permission of Sage Publications.)

Assumptions
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,
1995b).

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.

Concepts
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
individual.

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
exchanges.

Interaction A process of perception and communication between person and environment and
between person and person represented by verbal and nonverbal behaviors that are
goal-directed.

Transaction A process of interactions in which human beings communicate with the
environment to achieve goals that are valued; transactions are goal-directed human
behaviors.

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

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information between human and environment for regulation and control of
stressors.

Source: King (1981).

Relationships
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).

Usefulness
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 Theory of Goal Attainment to explore and expand upon the concept of functional status,
concluding that evaluation of functional status is vital and should be incorporated within mutual decision-
making processes from the client family’s perspective. M. L. Joseph, Laughon, and Bogue (2011) examined
the “sustainable adoption of whole-person care” (p. 989) in a Florida hospital guided by King’s Theory of
Goal Attainment. Finally, Gemmill and colleagues (2011) assessed nurses’ knowledge about and attitudes
toward ostomy care using King’s Theory of Goal Attainment to guide the research. Their findings explained
that it is difficult for staff nurses to maintain their clinical abilities when there are few opportunities.
Maintaining currency may require creative teaching interventions, such as simulations.

Testability
Parts of the Theory of Goal Attainment have been tested, and a number of research studies reported in the
literature used the model as a conceptual framework. For example, recent research includes a study by L.
Joseph (2013) who used King’s Theory of Goal Attainment to evaluate the effectiveness of a teaching
program to improve accuracy on pediatric growth measurements. In other works, Chacko, Kharde, and
Swamy (2013) used King’s theory as the framework to assess the efficacy of use of infrared lamps on
reducing pain and inflammation due to episiotomy, and Isac, Venkatesaperumal, and D’Sousa (2013) used
King’s theory to develop and evaluate the efficacy of a nurse-led information desk on assisting patients to
manage their sickle cell disease.

Parsimony
The conceptual system and theory were presented together in several versions of King’s writings and remain
largely as written in 1981. The theory is not parsimonious, having numerous concepts, multiple assumptions,

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many statements, and many relationships on a number of levels. This complexity, however, mirrors the
complexity of human transactions for goal attainment. The model is general and universal and can be the
umbrella for many midrange and practice theories.

Value in Extending Nursing Science
In addition to application in practice and research described previously, King’s work has been the basis for
development of several middle range nursing theories. For example, the Theory of Goal Attainment was used
by Rooda (1992) to develop a model for multicultural nursing practice. King’s Systems Framework was
reportedly used by Alligood and May (2000) to develop a theory of personal system empathy and by
Doornbos (2000) to derive a middle range theory of family health.

King’s conceptual system and theory have been used internationally in Australia, Brazil, Canada,
Pakistan, and Sweden, as well as in numerous university nursing programs in the United States, and have
provided a foundation for many research studies. Her work has extended nursing science by its usefulness in
education, practice, and research across international boundaries (King, 2001; Sieloff & Messmer, 2014).

Sister Callista Roy: The Roy Adaptation Model
The Roy Adaptation Model (RAM) focuses on the interrelatedness of four adaptive systems. Like many of the
models/theories in this unit, it is a deductive theory based on nursing practice. The RAM guides the nurse who
is interested in physiologic adaptation as well as the nurse who is interested in psychosocial adaptation.

Background of the Theorist
Sister Callista Roy is a member of the Sisters of Saint Joseph of Carondelet. She received a bachelor of
science in nursing from Mount Saint Mary’s College in Los Angeles, California, a master’s of science in
nursing from UCLA, and a master’s degree and doctorate in sociology from UCLA (Phillips & Harris, 2014).
Roy first proposed the RAM while studying for her master’s degree at UCLA, where Dorothy Johnson
challenged students to develop conceptual models of nursing (Phillips & Harris, 2014; Roy, 2009). Her work
is known internationally; she has presented at conferences in at least 36 countries and throughout the United
States. She has received numerous honors and awards for her scholarly and professional work. She was an
inaugural inductee into Sigma Theta Tau International’s Nurse Researcher hall of fame. In 2007, she was
awarded the American Academy of Nursing’s Living Legend award. She is currently professor and nurse
theorist at Boston College’s Connell School of Nursing (Connell School of Nursing, 2016).

Philosophical Underpinnings of the Theory
Johnson’s nursing model was the impetus for the development of the RAM. Roy also incorporated concepts
from Helson’s Adaptation Theory, von Bertalanffy’s System Model, Rapoport’s System Definition, the stress
and adaptation theories of Dohrenrend and Selye, and the Coping Model of Lazarus (Phillips & Harris, 2014).

Major Assumptions, Concepts, and Relationships
Assumptions
In the RAM, assumptions are specified as philosophical, scientific, and cultural (Roy, 2009). Philosophical
assumptions include:

Persons have mutual relationships with the world and God.
Human meaning is rooted in the omega point convergence of the universe.
God is intimately revealed in the diversity of creation.
Persons use human creative abilities of awareness, enlightenment, and faith.
Persons are accountable for sustaining and transforming the universe (Roy, 2009, p. 31).

Scientific assumptions of the RAM for the 21st century include:

Systems of matter and energy progress to higher levels of complex self-organization.
Consciousness and meaning constitute person and environment integration.

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Self and environmental awareness is rooted in thinking and feeling.
Human decisions account for integration of creative processes.
Thinking and feeling mediate human action.
System relationships include acceptance, protection, and fostering interdependence.
Persons and the earth have common patterns and integral relationships.
Person and environment transformations are created in human consciousness.
Integration of human and environment results in adaptation (Roy, 2009, p. 1).

Cultural assumptions include:

Cultural experiences influence how RAM is expressed.
A concept central to the culture may influence the RAM to some extent.
Cultural expressions of the RAM may lead to changes in practice activities such as nursing assessment.
As RAM evolves within a culture, implications for nursing may differ from experience in the original

culture (Roy, 2009, p. 31).

All elements of the model are part of the care of clients and groups. The nurse undertakes a bilevel
assessment to accurately define the problem and come to decisions on the plan of care. The process in
formulating the nursing plan is intricate and is prescriptive in its objectives.

Concepts
The RAM contains many defined concepts, including the metaparadigm concepts. Table 8-5 lists some of
these.

Table 8-5 Major Concepts of the Roy Adaptation Model
Concept Definition

Environment Conditions, circumstances, and influences that affect the development and behavior
of humans as adaptive systems.

Health A state and process of being and becoming integrated and whole.
Person “The human adaptive system” and defined as “a whole with parts that function as a

unity for some purpose. Human systems include people groups organizations,
communities, and society as a whole” (p. 31).

Goal of nursing The “promotion of adaptation in each of the four modes” (p. 31).
Adaptation The “process and outcome whereby thinking and feeling persons as individuals or

in groups use conscious awareness and choice to create human and environmental
integration” (p. 30).

Focal stimuli Those stimuli that are the proximate causes of the situation.
Contextual stimuli All other stimuli in the internal or external environment, which may or may not

affect the situation.
Residual stimuli Those immeasurable and unknowable stimuli that also exist and may affect the

situation.
Cognator subsystem “A major coping process involving four cognitive-emotive channels: perceptual

and information processing, learning, judgment, and emotion” (p. 31).
Regulator subsystem “A basic type of adaptive process that responds automatically through neural,

chemical, and endocrine coping channels” (p. 46).
Stabilizer control
processes

The structures and processes aimed at system maintenance and involving values
and daily activities whereby participants accomplish the primary purpose of the
group and contribute to the common purposes of the society.

Innovator control
processes

The internal subsystem that involves structures and processes for growth.

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Source: Roy and Andrews (1999).

Relationships
Roy’s model is composed of four adaptive modes that constitute the specific categories that serve as
framework for assessment (Figure 8-3). Through the four modes, “Responses to and interaction with the
client’s environment are carried out and adaptation can be observed” (Roy, 2009, pp. 69–72).

Figure 8-3
(From Roy, S. C., & Andrews, H. A. The Roy Adaptation Model, 2nd ed., © 1998. Reprinted by permission of Pearson Education, Inc., New
York, New York.)

They are the:

1. Physiologic–physical mode: Physical and chemical processes involved in the function and activities of
living organisms; the underlying need is physiologic integrity: the degree of wholeness achieved
through adaptation to changes in needs. In groups, this is the manner in which human systems
manifest adaptation to basic operating resources.

2. Self-concept–group identity mode: Focuses on psychological and spiritual integrity and a sense of
unity, meaning, and purposefulness in the universe.

3. Role function mode: Refers to the roles that individuals occupy in society fulfilling the need for social
integrity; it is knowing who one is, in relation to others.

4. Interdependence mode: The close relationships of people and their purpose, structure, and
development, individually and in groups, and the adaptation potential of these relationships.

Two subsystems require assessment in the RAM: the regulator and the cognator. These are coping
subsystems that allow the client to adapt and make changes when stressed. The regulator is the physiologic
coping subsystem, and the cognator is the cognitive–emotive coping subsystem (Roy, 2009). In her writing,
Roy (2011a) explained how the four modes work in communities and globally. She stated that “this
theoretical work . . . portends well . . . for nurse scholars to meet the challenges . . . for the nursing role in the
global community” (Roy, 2011a, p. 350).

Usefulness
The RAM has been used extensively to guide practice and to organize nursing education. International

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conferences on the RAM have been conducted across the United States and abroad (Roy, 2009). The RAM
was adopted as a component of the curricular framework of such widely diverse colleges and departments of
nursing as Mount Saint Mary’s College Department of Nursing; the University of Texas at Austin School of
Nursing; Boston College School of Nursing; and the nurse practitioner program at the University of Miami in
Florida. The RAM has also been implemented internationally at the University of Ottawa School of Nursing
and in university schools of nursing in Japan and France (Phillips & Harris, 2014).

Several middle range nursing theories derived from the RAM were recently compiled into a book edited
by Roy (2014a). These included a middle range theory of coping (Roy, 2014b), a middle range theory of
adapting to loss (Dobratz, 2014), and a middle range theory of adapting to chronic health conditions (Buckner
& Hayden, 2014). Other examples from the literature are the middle range theory of adaptive spirituality
(Dobratz, 2016) and a middle range theory of psychological adaptation (Lévesque, Ricard, Ducharme,
Duquette, & Bonin, 1998).

Testability
The RAM is testable. Indeed, an international nursing society specifically focused on researching adaptation
nursing, Roy Adaptation Association (RAA), is based in Boston College School of Nursing (Connell School
of Nursing, 2016). The goal of the RAA is “to advance nursing practice by developing basic and clinical
nursing knowledge based on the Roy Adaptation Model” (RAA, 2016), and the association meets regularly to
present research efforts to that end. Box 8-3 lists a few recent examples of nursing research using aspects of
the RAM.

Box 8-3 Examples of Studies Using the Roy Adaptation Model
Aber, C., Weiss, M., & Fawcett, J. (2013). Contemporary women’s adaptation to motherhood: The first 3 to

6 weeks postpartum. Nursing Science Quarterly, 26(4), 344–351.
Akyil, R. Ç., & Ergüney, S. (2013). Roy’s adaptation model-guided education for adaptation to chronic

obstructive pulmonary disease. Journal of Advanced Nursing, 69(5), 1063–1075.
Bockwoldt, D., Staffileno, B. A., Coke, L., & Quinn, L. (2016). Perceptions of insulin treatment among

African Americans with uncontrolled type 2 diabetes. Journal of Transcultural Nursing, 27(2), 172–180.
Buckner, B. S., & Buckner, E. B. (2015). Post-revolution Egypt: The Roy adaptation model in community.

Nursing Science Quarterly, 28(4), 300–307.
Kaur, H., & Mahal, R. (2013). Development of nursing assessment tool: An application of Roy’s adaptation

theory. International Journal of Nursing Education, 5(1), 60–64.
Perrett, S. E., & Biley, F. C. (2013). A Roy model study of adapting to being HIV positive. Nursing Science

Quarterly, 26(4), 337–343.
Pullen, L., Modrcin, M. A., McGuire, S. L., Lane, K., Kearnely, M., & Engle, S. (2015). Anger in adolescent

communities: How angry are they? Pediatric Nursing, 41(3), 135–140.
Seah, X. Y., & Tham, X. C. (2015). Management of bulimia nervosa: A case study with the Roy adaptation

model. Nursing Science Quarterly, 28(2), 136–141.

Parsimony
The RAM is not parsimonious because of its many elements, systems, structures, and concepts. However,
Clarke, Barone, Hanna, and Senesac (2011) state that the RAM is “accessible, elegant and practical” (p. 338)
in its presentation. It is complete and comprehensive, and it attempts to explain the reality of the clients so that
nursing interventions can be specifically targeted. The nursing assessment is conducted on two levels and is
extensive and complex. It requires assessment of the stimuli to which the client is responding and of the
coping subsystems. It targets the client in the four adaptive modes, and an assessment must be made to
determine how effectively the subsystems (i.e., cognator and regulator) are working.

Value in Extending Nursing Science
The RAM has been a valuable asset in extending nursing science. Phillips and Harris (2014) summarized the

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impact of the RAM on nursing practice, education, and administration, stating that it has contributed
significantly to the science and practice of nursing. Indeed, the RAM has generated hundreds of research
studies and has contributed to nursing education for more than 35 years (Roy, 2011b). Frederickson (2011)
states that chapters of the RAM society are present in such disparate areas such as several countries of South
America as well as Japan, thus extending the reach of Roy’s principles globally. Indeed, the RAM is used in
almost every country in Europe, Asia, South America, and others as well (Clarke et al., 2011). Roy (2011a)
states that “ . . . the criteria for good . . . is to promote adaptation of individuals and groups; to transform a
society to one that promotes dignity, and to sustain and transform the universe” (p. 346).

Jean Watson: Human Caring Science, A Theory of Nursing
Jean Watson’s (2012) Human Caring Science: A Theory of Nursing is the title of Jean Watson’s latest work. It
was renamed “to convey a deeper human to human involvement and connection” (p. xi). This theory is one of
the newest of nursing’s grand theories, having first been completely codified in 1979, revised in 1985
(Watson, 1988), and broadened and advanced several times. Watson (1985) initially called her work a
descriptive theory of caring and stated that it was the only theory of nursing to incorporate the spiritual
dimension of nursing at the time it was first conceptualized. The theory is both deductive and inductive in its
origins and is written at an abstract level of discourse.

It is somewhat difficult to categorize Watson’s work with the works of other nursing theorists. It has many
characteristics of a human interaction model, although it also incorporates many ideals of the unitary process
theories, which are discussed in Chapter 9. Watson has always described the human as a holistic, interactive
being and is now explicit in describing the human as an energy field and in explaining health and illness as
manifestations of the human pattern (Watson, 2012), two tenets of the unitary process theories. Parse (2014)
points out, however, that although theorists profess belief in unitary human beings, other definitions and
relationships still separate theories from the interactive process paradigms and the unitary process nursing
paradigms. Based on overall considerations, the philosophy and science of caring reflects the interactive
process nursing theories.

Background of the Theorist
Jean Watson was born in West Virginia in 1939 and attended Lewis-Gale School of Nursing in Roanoke,
Virginia. She earned a bachelor’s degree in nursing, master’s of science degrees in psychiatric–mental health
nursing and sociology and a doctorate in educational psychology and counseling, all from the University of
Colorado (Jesse & Alligood, 2014). Watson is an internationally published author, having written many
books, book chapters, and articles about the science of human caring (Watson, 1994, 1996, 1999, 2005, 2008,
2012).

Watson was formerly dean of the School of Nursing at the University of Colorado, and she founded and
directed the Center for Human Caring at the Health Sciences Center in Denver. She has received numerous
awards and honors and is a distinguished professor of nursing and dean emerita at the University of Colorado
Denver College of Nursing and Anschutz Medical Center, where she held an endowed chair in Caring Science
for 16 years (Jesse & Alligood, 2014). She is a fellow of the American Academy of Nursing and past
president of the National League for Nursing, and some of her honors include Fetzer Institute Norman
Cousins Award; an International Kellogg Fellowship in Australia; a Fulbright research award in Sweden; and
10 honorary doctoral degrees, including those from Sweden, United Kingdom, Spain, British Columbia and
Quebec in Canada, and Japan (Watson Caring Science Institute [WCSI] 2016a). Dr. Watson has been formally
designated a “living legend in Nursing” by the American Academy of Nursing (WCSI, 2016a).

Philosophical Underpinnings of the Theory
Watson (1988) noted that she drew parts of her theory from nursing writers, including Nightingale and
Rogers. She also used concepts from the works of psychologists Giorgi, Johnson, and Koch as well as
concepts from philosophy. She reported being widely read in these disciplines and synthesized a number of
diverse concepts from them into nursing as a science of human caring. Watson (2012) further conveys the
ideal that changing the title and the use of the words “human caring” and “caring” are meant to convey the

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ideal of the depth of involvement between humans that is the experience of nurses (p. xi).

Major Assumptions, Concepts, and Relationships
The value system that permeates Watson’s Human Caring Science includes a “deep respect for the wonders
and mysteries of life” (Watson, 1988, p. 34) and recognition that spiritual and ethical dimensions are major
elements of the human care process. Furthermore, she explained that in order to care for humans, there must
be a deep responsibility to care for the planet itself (Watson, 2012). A number of assumptions are both stated
and implicit in her theory. Additionally, several concepts were defined, refined, and adapted for it. From this,
10 carative factors were developed (Box 8-4).

Box 8-4 Watson’s 10 Carative Processes
1. Practicing loving-kindness and equanimity within context of caring consciousness
2. Being authentically present and enabling, and sustaining the deep belief system and subjective life

world of self and one-being cared for
3. Cultivating one’s own spiritual practices and transpersonal self, going beyond ego-self
4. Developing and sustaining a helping–trusting, authentic, caring relationship
5. Being present to and supportive of the expression of positive and negative feelings
6. Creatively using self and all ways of knowing as part of the caring process; engaging in artistry of

caring-healing practices
7. Engaging in genuine teaching–learning experience that attends to wholeness and meaning, attempting to

stay within other’s frame of reference
8. Creating healing environment at all levels, whereby wholeness, beauty, comfort, dignity, and peace are

potentiated
9. Assisting with basic needs, with an intentional caring consciousness, administering “human care

essentials” which potentiate alignment of mind-body-spirit, wholeness in all aspects of care
10. Opening and attending to mysterious dimensions of one’s life-death; soul care for self and the one-

being-cared for; “allowing and being open to miracles”

Source: Watson Caring Science Institute (2016b).

Assumptions
Watson (2012) describes the tenets of human caring science. She proposed that caring and love are universal
and mysterious “cosmic forces” that comprise the primal and universal psychic energy. She believes that
health professionals make social, moral, and scientific contributions to humankind and that nurses’ caring
ideal can affect human development. Furthermore, she explained that it is critical in today’s society to sustain
human caring ideals and a caring ideology in practice, as there has been a proliferation of radical treatment
and “cure techniques,” often without regard to costs or human considerations. She concluded that human
caring goes “beyond objectivism, verification, rigid operations, and definitions, and concern itself more with
meaning, relationships, intersubjective and intrasubjective context and patterns”(Watson, 2012, p. 2).

Explicit assumptions that were derived for Watson’s (2005) work include:

An ontologic assumption of oneness, wholeness, unity, relatedness, and connectedness.
An epistemologic assumption that there are multiple ways of knowing.
Diversity of knowing assumes all, and various forms of evidence can be included.
A caring science model makes these diverse perspectives explicitly and directly.
Moral-metaphysical integration with science evokes spirit; this orientation is not only possible but also

necessary for our science, humanity, society-civilization, and world-planet.
A caring science emergence, founded on new assumptions, makes explicit an expanding unitary,

energetic worldview with a relational human caring ethic and ontology as its starting point.

Concepts

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Watson (2012) defined three of the four metaparadigm concepts (human, health, and nursing). She coined
several other concepts and terms that are integral to understanding the science of human caring (Table 8-6).
Her 10 caritas processes are caring needs specific to human experiences that should be addressed by nurses
with their clients in the caring role (Watson, 2012; WCSI, 2016b). The carative processes are listed in Box 8-
4.

Table 8-6 Major Concepts of the Science of Human Caring
Concept Definition

Human “A unique, valued and precious person . . . to be cared for, respected, nurtured,
understood, and assisted” (p. 19).

Health “. . . subjective experience . . . unity and harmony with body-mind-spirit. Health is
associated with the degree of congruence between the self as perceived and the self
as experienced” (p. 60).

Nursing “A human caring science of persons and human health–illness experiences that are
mediated by professional, personal, scientific, esthetic, and ethical human care
connections and relationships” (p. 66).

Actual caring
moment occasion

“Involves actions and choice both by the nurse and the individual. The moment of
coming together in a caring moment occasion presents the two persons with the
opportunity to decide how to be in the relationship—what to do with the moment”
(p. 71).

Transpersonal caring
moment

“Includes the nurse’s consciousness, intentionality and unique energetic health
presence . . . in which he or she transmits and reflects the person’s condition back
to that person . . . in a way that allows for the release and flow of his or her
intersubjective feelings and thoughts and pent-up energy. . . it opens up shared
access to spirit-filled source of infinity” (p. 70).

Phenomenal field “The totality of human experience (one’s being in the world) . . . is the individual’s
frame of reference that can only be known to that person” (p. 67).

Life “Human life . . . is defined as spiritually, mentally, emotionally and physically
being-in-the-world as a unitary being which is continuous in time and space” (p.
59).

Harmony-
disharmony

“Where there is disharmony among the mind, body and soul or between a person
and his or her nature and relationship with the larger world/universe, there is a
disjunctive between the self as perceived and one’s actual experience . . . If there is
harmony and unity of mind-body-spirit, then a sense of congruence exists . . .
between the self as perceived and the self as experienced by the person” (p. 69).

Time “The present is more subjectively real and the past is both objectively and
subjectively real. The past is prior to, or in a different mode of being, than the
present, but it is not clearly distinguishable. Past, present, and future instants merge
and fuse” (p. 73).

Source: Watson (2012).

Relationships
Watson has refined and updated the relationships of the theory, bringing them closer to her current way of
understanding human caring and spirituality. Her continued study has involved lengthy examination of her
beliefs about caring, spirituality, and human and energy fields (Watson, 2005, 2008). The following are some
of the relationships of the theory:

A transpersonal caring field resides within a unitary field of consciousness and energy that transcends
time, space, and physicality.

A transpersonal caring relationship connotes a spirit-to-spirit unitary connection within a caring

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moment, honoring the embodied spirit of both practitioner and patient within a unitary field of
consciousness.

A transpersonal caring relationship transcends the ego level of both practitioner and patient, creating a
caring field with new possibilities for how to be in the moment.

The practitioner’s authentic intentionality and consciousness of caring has a higher frequency of energy
than noncaring consciousness, opening up connections to the universal field of consciousness and
greater access to one’s inner healer.

Transpersonal caring is communicated via the practitioner’s energetic patterns of consciousness,
intentionality, and authentic presence in a caring relationship.

Caring-healing modalities are often noninvasive, nonintrusive, natural-human, energetic environmental
field modalities.

Transpersonal caring promotes self-knowledge, self-control, and self-healing patterns and possibilities.
Advanced transpersonal caring modalities draw on multiple ways of knowing and being; they

encompass ethical and relational caring, along with those intentional consciousness modalities that are
energetic in nature (e.g., form, color, light, sound, touch, vision, scent) that honor wholeness, healing,
comfort, balance, harmony, and well-being (Watson, 2005, p. 6).

Usefulness
Watson’s works and the Science of Human Caring are used by nurses in diverse settings. For example,
Brockopp and colleagues (2011) detail an evidence-based, practice-based practice model grounded in
Watson’s theory of caring. The 10 carative factors are explicated throughout the hospital to provide a
framework for nursing activities in this magnate hospital. The outcomes include 34 research projects, 9
published articles, and 9 funded research studies. Furthermore, the nurses “maintain high levels of work
satisfaction, strong retention rates and a large percentage of associate-degree nurses return to school for
baccalaureate degrees” (Brockopp et al., 2011, p. 511).

In other examples, Hills and colleagues (2011) developed a text to promote caring science curriculum in
nursing, which they called an emancipatory pedagogy for nursing. It is based on Watson’s science of caring
and explores an alternative method of student evaluation. Lukose (2011) developed a practice model for
Watson’s theory of caring that “can be used by nurse educators to teach staff nurses and students” (p. 27).
Sitzman and Watson (2014) developed methods of implementing Watson’s human caring theory, which
includes complete instructions in implementing caritas and mindful practices that Sitzman has used for
decades in her practice. Sitzman (2015) also determined that all 10 caritas factors were at work with students
and validated the possibility and responsibility for educators “to fully address the needs, and facilitate student
growth learning and apprehension of caring in the online educational environment” (p. 26). Finally, Link to
Practice 8-1 illustrates how Watson’s work can be used to help alleviate stress among nurses.

Link to Practice 8-1
Jean Willowby, the nurse from the opening case study, and her preceptor, Allison Manheim, were having
coffee one morning in their hospital’s cafeteria. During their conversation, Allison told Jean that there
appeared to be an increasing number of nurses in the pediatric intensive care unit (PICU) who were taking
unscheduled personal days. She explained that the absences seemed to follow the death of a baby or young
child and questioned whether the nurses might be experiencing increased levels of stress related to the
death of one of their patients. Following the discussion, Jean decided to study the relationship between
nurse absenteeism and loss of a patient and to devise a solution for the capstone nursing project required
for her program.

Jean’s project involved application of Watson’s Caritas Processes to work with the PICU nurses to
reduce stress. She devised several interventions focused on “caring for one’s self” and “caring for each
other.” She and Allison held both scheduled and impromptu counseling sessions to “develop and sustain
helping-trusting and caring relationships.” Jean also worked to develop interventions to “create a healing
environment” and “align mind-body and spirit” of the nurses. According to the scores on a stress

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instrument the nurses were asked to complete, Jean found that holding touch therapy sessions—during
which the nurses could openly share their personal stories—seemed to be the most useful in stress
reduction. Another effective intervention was back and foot massage, combined to listening to soft music,
after a shift.

Following implementation of the various caring process interventions, the nurses were able to better
tolerate the stressors of the PICU. Furthermore, hospital administrators noted a decrease in unscheduled
personal days. These findings were striking enough that Jean was hired after her graduation to continue to
develop stress-reduction and caring interventions for all staff.

Testability
Testing of Watson’s theory and dissemination of findings are progressing. The science allows both
quantitative and qualitative research methods. Indeed, Watson’s science of caring has been researched by an
extremely large number of nurses. A number of recent research articles are listed in Box 8-5.

Box 8-5 Examples of Research Using Watson’s Model
Arslan-Özkan, I., Okumus˛, H., & Buldukog˘lu, K. (2014). A randomized controlled trial of the effects of

nursing care based on Watson’s theory of human caring on distress, self-efficacy and adjustment in
infertile women. Journal of Advanced Nursing, 70(8), 1801–1812. doi:10.1111/jan.12338.

Berry, D. M., Kaylor, M. B., Church, J., Campbell, K., McMillin, T., & Wamsley, R. (2013). Caritas and job
environment: A replication of Persky et al. Contemporary Nurse, 43(2), 237–243.

Cooley, S. S., & DeGagne, J. C. (2016). Transformative experience: Developing competence in novice
nursing faculty. The Journal of Nursing Education, 55(2), 96–100. doi:10.3928/01484834-20160114-07

Derby-Davis, M. J. (2014). Predictors of nursing faculty’s job satisfaction and intent to stay in academe.
Journal of Professional Nursing, 30(1), 19–25. doi:10.1016/j.profnurs.2013.04.001

Lamke, D., Catlin, A., & Mason-Chadd, M. (2014). “Not just a theory”: The relationship between Jin Shin
Jyutsu® self-care training for nurses and stress, physical health, emotional health, and caring efficacy.
Journal of Holistic Nursing, 32(4), 278–289. doi:10.1177/0898010114531906

Ozan, Y. D., Okumus˛, H., & Lash, A. A. (2015). Implementation of Watson’s theory of human caring: A
case study. International Journal of Caring Sciences, 8(1), 25–35.

Ozkan, I. A., Okumus˛, H., Buldukoglu, K., & Watson, J. (2013). A case study based on Watson’s theory of
human caring: Being an infertile woman in Turkey. Nursing Science Quarterly, 26(4), 352–359.
doi:10:1177/0894318413500346

Reed, F. M., Fitzgerald, L., & Rae, M. (2016). Mixing methodology, nursing theory and research design for
a practice model of district nursing advocacy. Nurse Researcher, 23(3), 37–41. doi:10.7748/nr.23.3.37.s8

Rew, L. (2014). Intentional, present and grateful: Holistic nursing research with homeless youths.
Beginnings, 34(2), 16–20.

Torregosa, M. B., Ynalvez, M. A., & Morin, K. H. (2016). Perceptions matter: Faculty caring, campus racial
climate and academic performance. Journal of Advanced Nursing, 72(4), 864–877.
doi:10.1111/jan.12877

Wicklund Gustin, L., & Wagner, L. (2013). The butterfly effect of caring—clinical nursing teachers’
understanding of self-compassion as a source to compassionate care. Scandinavian Journal of Caring
Sciences, 27(1), 175–183. doi:10.1111/j.1471-6712.2012.01033.x

Parsimony
Watson’s theory is comparatively parsimonious. Although a number of new concepts and terms are defined,
there are only 10 carative processes or areas to be addressed by nurses. In addition, there are six “working
assumptions” (Watson, 2005, p. 28) and three considerations as to how to frame caring science.

Value in Extending Nursing Science
Watson (2012) explicitly describes the connection between nursing and caring. Her work has been used in

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education and in practice internationally and in numerous research studies. Collectively, findings present
impressive indicators of the value of Watson’s theory of caring to the discipline of nursing.

Summary
The models presented in this chapter all focus on human interactive processes as the basis for nursing care,
research, and education. Some of the theories described (e.g., King and Levine) are among the oldest of the
grand nursing theories, whereas others (e.g., Watson and Artinian) are among the most recently developed.
There is a wide variety of complexity among the models, but each has demonstrated applicability to the
discipline, and all are currently used in schools of nursing, hospital clinical and community settings, and
nursing research.

Like Jean, the nurse in the case study, nurses in all settings will be able to relate to the perspective
described by these theorists. Indeed, the premise that humans are adaptive, holistic beings, in constant
interaction with their environment, is easily applied in nursing practice. Some philosophical bases, concepts,
assumptions, and relationships (e.g., systems focus, adaptation, goal of nursing, and interaction) are relatively
consistently held within the works of this group of theorists, whereas others (e.g., SSOC [Artinian], cognator
and regulator subsystems [Roy], and carative processes [Watson]) are unique to just one theory. Evidence-
based practice (EBP) fits well with these theories and models because they ascribe to outcomes-based
quantitative and to reality-based qualitative research principles.

Nurses studying this group of theories will become aware of how they present and prescribe nursing
practice. Many will undoubtedly consider adopting one as a basis for their own professional practice.

Key Points
The theories in this chapter depend on the ideal that nurses, other health care professionals, and patients are

constantly interacting. The environment defined by most of these theorists is also foremost in individuals’
interactions.

The theorists who have developed these theories and models generally include and provide definitions of the
four metaparadigm concepts of person, health, environment, and nursing. Several also include spirituality
among their concepts.

Most interactive process theories are practice-based and correspond closely to the work of nurses in clinical
practice.

Several interactive process theories are well suited to and are chosen to guide EBP and research to gather
that evidence.

Several of the theories and models in this group have been used or are being used to guide and structure
educational programs in university nursing schools worldwide.

Learning Activities
1. Compare and contrast two of the models or theories presented in this chapter, considering

their usefulness in practice, research, education, and/or administration. Share findings with
classmates.

2. Select one of the models from this chapter and obtain the original work(s) of the theorist.
From the work(s), outline a plan for a research study either using the work as the conceptual
framework or testing components of the work.

3. What concepts, assumptions, or relationships can be studied?
4. To what population(s) can the work be applied?
5. What concepts can be used as study variables?
6. Jean, the nurse from the opening case study, determined that Watson’s theory best fit her

current and future practice as a pediatric nurse practitioner. Review the models presented in
this chapter and determine which could best be used to guide your practice. Share you
observations with classmates.

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9

Grand Nursing Theories Based on Unitary Process
Evelyn M. Wills

Kristin Kowalski is a hospice nurse who wishes to expand the scope of her therapeutic practice. She desires to
delve more deeply into holistic health care, having recently completed courses of study in herbal medicine,
touch therapy, and holistic nursing. Kristin is aware that to practice independently, she needs professional
credentials that will be widely accepted; therefore, she applied to the graduate program of a nationally ranked
nursing school at a large state university.

Because Kristin believes strongly in holistic nursing practice, for her master’s degree, she decided to focus
her study of nursing theories on those that look at the whole person and have a broad, nontraditional view of
health. She is particularly interested in Rosemarie Parse’s Humanbecoming Paradigm because this viewpoint
stresses the individual’s way of being and becoming healthy and the nurse as an intersubjective presence.

Kristin is attracted to Parse’s idea of true presence and wishes to further explore this concept as well as the
rest of the perspective. She hopes to eventually apply it to her practice and use it as the research framework
for her thesis. For her thesis, Kristin wants to examine the experiences of nurses who practice therapeutic
touch. She desires to learn their perceptions of how therapeutic touch interventions help their clients. She also
wants to learn more about Parse’s research method and hopes to use it for her study.

The term simultaneity paradigm was first coined by nursing theorist Rosemarie Parse (1987) to describe a
group of theories that adhered to a unitary process perception of human beings. This group of theorists
believed that humans are unitary beings: energy systems embedded in the universal energy system. Within
this group of theories, human beings are seen as unitary, “Whole, open and free to choose ways of becoming”
(Parse, 1998, p. 6), and health is described as continuous human environmental interchanges (Newman,
1994).

The unitary process nursing model and the work of two of her students are described in this chapter:
Science of Unitary Human Beings (Rogers, 1994), Health as Expanding Consciousness (Newman, 1999), and
Humanbecoming Paradigm (Parse, 2014). The three are grouped together because they are significantly
different in their concepts, assumptions, and propositions when compared to the theories described in
Chapters 7 and 8. They are universal in scope and relatively abstract.

The unitary process theories of nursing reflect the newer views of science in their complexity and view the
human as energy field, as intentional, as dynamic, limitless, and unpredictable. These are views of humans
and their energy fields that place these three theories within the new scientific realm of complexity science
(Davidson, Ray, & Turkel, 2011). Rolfe (2015), however, brings us the realization that nursing as a human
science relies on engagement with persons and that may include art, science, philosophy, music, and other
human endeavors, persons being whole beings. The three theorists, nay, philosophers, Rogers, Newman, and
Parse, attest to the necessity for engagement between persons and families experiencing unwanted changes in
health and the person who would help them, the nurse.

Martha Rogers: The Science of Unitary and Irreducible Human Beings
Martha Rogers first described her Theory of Unitary Man in 1961, and almost from the first, there has been

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widespread controversy and debate among nursing theorists and scholars regarding her work (Phillips, 2010,
2016). Prior to Rogers, it was rare that anyone in nursing viewed human beings as anything other than the
receivers of care by nurses and physicians. Furthermore, the health care system was organized by
specialization, in which nurses and other health providers focused on discrete areas or functions (e.g., a
dressing change, medication administration, or health teaching) rather than on the whole person. As a result, it
took many professionals working in isolation, none of whom knew the whole person, to care for patients.
Rogers’s (1970) insistence that the person was a “unitary energy system” in “continuous mutual interaction
with the universal energy system” (p. 90) dramatically influenced nursing by encouraging nurses to consider
each person as a whole (a unity) when planning and delivering care. Phillips (2013) states that Rogers’s
“vision was concerned with unitary wholes, a vision she used in creating the science of unitary human beings
(SUBH) . . . ” (p. 241). A new and dramatically different ideal in health care.

Background of the Theorist
Martha Rogers was born on May 12, 1914 (the anniversary of Florence Nightingale’s birth) (Dossey, 2010),
in Dallas, Texas. She earned a diploma in nursing from Knoxville General Hospital in 1936 and a bachelor’s
degree from George Peabody College in Nashville, Tennessee, in 1937. She later received a master’s degree
in public health nursing from Teachers College, Columbia University in New York, and a master’s degree in
public health and a doctor of science from The Johns Hopkins University in Baltimore, Maryland (Gunther,
2014).

Rogers became the head of the Division of Nursing of New York University (NYU) in 1954, where she
focused on teaching and formulating and elaborating her theory (Hektor, 1989). She was teacher and mentor
to an impressive list of nursing scholars and theorists, including Newman and Parse, whose works are
described later in the chapter. Rogers continued her work and writing until her death in March 1994.

Philosophical Underpinnings of the Theory
The Science of Unitary and Irreducible Human Beings started as an abstract theory that was synthesized from
theories of numerous sciences; therefore, it was deductively derived. She drew from Einstein’s Theory of
Relativity as well as Heisenberg’s Uncertainty Principle to demonstrate the unpredictability of this universe
(Caratao-Mojica, 2015). Of particular importance was von Bertalanffy’s theory on general systems, which
contributed the concepts of entropy and negentropy and posited that open systems are characterized by
constant interaction with the environment. The work of Rapoport provided a background on open systems,
and the work of Herrick contributed to the premise of evolution of human nature (Rogers, 1994).

Rogers’s synthesis of the works of these scientists formed the basis of her proposition that human systems
are open systems embedded in larger, open environmental systems. She also brought in other concepts,
including the idea that time is unidirectional, that living systems have pattern and organization, and that man
is a sentient, thinking being capable of awareness, feeling, and choosing. From all these theories, and from her
personal study of nature, Rogers (1970) developed her original Theory of Unitary Man. She continuously
refined and elaborated her theory, which she retitled Science of Unitary Humans (Rogers, 1986) and, finally,
shortly before her death, the Science of Unitary and Irreducible Human Beings (Rogers, 1994).

Major Assumptions, Concepts, and Relationships
Assumptions
Rogers (1970) presented several assumptions about man. These are as follows:

Man is a unified whole possessing integrity and manifesting characteristics that are more than and
different from the sum of his parts (p. 47).

Man and environment are continuously exchanging matter and energy with one another (p. 54).
The life process evolves irreversibly and unidirectionally along the space–time continuum (p. 59).
Pattern and organization identify man and reflect his innovative wholeness (p. 65).
Man is characterized by the capacity for abstraction and imagery, language and thought, sensation, and

emotion (p. 73).

Rogers (1990) later revised the term man to human being to coincide with the request for gender-neutral

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language in the social sciences and nursing science.

Concepts
In Rogers’s work, the unitary human being and the environment are the focus of nursing practice. Other
central components are energy fields, openness, pandimensionality, and pattern; these she identified as the
“building blocks” (Rogers, 1970, p. 226) of her system. Rogers also derived three other components for the
model, which served as a basis of her work. These were based on principles of homeodynamics and were
termed resonancy, helicy, and integrality (Rogers, 1990) (Box 9-1). Definitions of the nursing metaparadigm
concepts and other important concepts in Rogers’s work are listed in Table 9-1.

Box 9-1 Principles of Homeodynamics Applied in Rogers’s Theory
1. Resonancy is continuous change from lower to higher frequency wave patterns in human and

environmental fields.
2. Helicy is continuous innovative, unpredictable, increasing diversity of human and environmental field

patterns.
3. Integrality is continuous mutual human and environmental field processes.

Source: Rogers (1990, p. 8).

Table 9-1 Central Concepts of Rogers’s Science of Unitary Human Beings
Concept Definition

Human–unitary human beings “Irreducible, indivisible, multidimensional energy fields identified by
pattern and manifesting characteristics that are specific to the whole
and which cannot be predicted from the knowledge of the parts” (p. 7).

Health “Unitary human health signifies an irreducible human field
manifestation. It cannot be measured by the parameters of biology or
physics or of the social sciences” (p. 10).

Nursing “The study of unitary, irreducible, indivisible human and
environmental fields: people and their world” (p. 6). Nursing is a
learned profession that is both a science and an art.

Environmental field “An irreducible, indivisible, pandimensional energy field identified by
pattern and integral with the human field” (p. 7).

Energy field “The fundamental unit of the living and the non-living. Field is a
unifying concept. Energy signifies the dynamic nature of the field; a
field is in continuous motion and is infinite” (p. 7).

Openness Refers to qualities exhibited by open systems; human beings and their
environment are open systems.

Pandimensional “A nonlinear domain without spatial or temporal attributes” (p. 28).
Pattern “The distinguishing characteristic of an energy field perceived as a

single wave” (p. 7).

Source: Rogers (1990).

Relationships
The Science of Unitary and Irreducible Human Beings is fundamentally abstract; therefore, specifically
defined relationships differ from those in more linear theories. The major components of Rogers’s model
revolve around the building blocks (energy fields, openness, pattern, and pandimensionality) and the
principles of homeodynamics (resonancy, helicy, and integrality). These explain the nature of, and direction
of, the interactions between unitary human beings and the environment.

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Among the relationships that Rogers posited are that all things are integral in that their energy fields are in
continuous mutual process and that pattern is the manifestation of the integrality of each entity and of the
environmental energy field (Rogers, 1986). Other major relationships within Rogers’s (1990) work are
contained in the following statements:

Humans and environment are interrelated in that neither “has an energy field,” both are integral energy
fields (pp. 6–7).

Manifestations of pattern emerge out of the human/environmental field mutual process and are
continuously innovative (p. 8).

The group field is irreducible and indivisible to itself and integral with its own environmental field (p. 8).

Nursing is concerned with maintaining and promoting health, preventing illness, and caring for those who are
sick or disabled. The purpose of nursing for Rogers (1986) is to help human beings achieve well-being within
the potential of each individual, family, or group. Because human energy fields are complex, individualizing
nursing services supports simultaneous human and environmental exchange, encouraging health (Rogers,
1990).

Usefulness
Rogers’s theory is a synthesis of phenomena that are important to nursing. It is an abstract, unified, and highly
derived framework and does not define particular hypotheses or theories. Rather, it provides a worldview
from which nurses may derive theories and hypotheses and propose relationships specific to different
situations. In essence, the theory allows many options for studying humans as individuals and groups and for
studying various situations in health as manifestations of pattern and innovation. Rogers’s model stresses the
unitary experience and provides an abstract philosophical framework that can guide nursing practice.

Rogers’s theory has been evident in nursing education, scholarship, and practice for more than four
decades. In education, among other programs, it has guided the nursing curriculum at NYU, where Rogers
was head of the Division of Nursing in the 1970s. This resulted in the education of numerous nurses who use
her theory in practice internationally (Hektor, 1989). In the area of nursing scholarship, several noted nursing
theorists (e.g., Fitzpatrick, 1989; Newman, 1994; Parse, 1998) derived theories from Rogers’s work. A
number of middle range nursing theories are based on Rogers’s work as reported by Fawcett (2015). Among
these middle range theories are Health Empowerment Theory (Shearer, 2009), Theory of the Art of Nursing
(Alligood, 2002), Theory of Self-Transcendence (Reed, 2014), Theory of Diversity of Human Field Pattern
(Hastings-Tolsma, 2006), and Theory of Intentionality (Zahourek, 2005).

In other scholarly works, Barrett (1986, 1989) derived a theory, Power as Knowing Participation in
Change, for nursing practice from Rogers’s theory. She used several of Rogers’s concepts (e.g., energy fields,
openness, pattern, and four-dimensionality [now pandimensionality]) and the principles of resonancy, helicy,
and integrality to form her theory. The Theory of Power as Knowing Participation in Change consists of
awareness, choices, freedom to act intentionally, and involvement in creating changes and was tested in
research using Barrett’s Power as Knowing Participation in Change (PKPIC) tool. Barrett’s (1989) theory
consequently has been used in research on patterning of pain and power with guided imagery by Fuller, Davis,
Servonsky, and Butcher (2012), who examined field patterns in adult substance users in rehab, and Kirton and
Morris (2012), who used Barrett’s theory to examine adherence to antiretroviral therapy in adults who are
infected with HIV. Farren (2010) found in a secondary analysis of data collected using Barrett’s PKPIC tool
with breast cancer survivors that the dimensions of power (awareness, choices, freedom to act with intention,
and involvement in creating change) were responsible for all the variance. Moreover, the breast cancer
survivors showed differing intensities of these dimensions.

In clinical settings, Rogerian practitioners employ the visible manifestations of Rogers’s science. Madrid,
Barrett, and Winstead-Fry (2010), for example, studied the feasibility of using therapeutic touch with patients
who were undergoing cerebral angiography. The design was a randomized, single blind clinical pilot study
with outcome assessments of blood pressure, pulse, and respirations. The findings of this study were
inconclusive, but the researchers followed up with exploration of the reasons and studied the implications.
Reed (2008) wrote about nursing time as a dimension of practice, research, and theory. In a nursing
educational setting, Malinski and Todaro-Franceschi (2011) studied comeditation to reduce anxiety and

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facilitate relaxation. Their data from the qualitative study suggested that the participants reported feeling
calmer, more relaxed, and balanced and centered after 1 month of practice. Their findings suggest that
comeditation may help transform education in nursing programs, most of which have reputations as being
stressful to students.

Testability
Because of the model’s abstractness, Rogers’s (1990) work is not directly testable, but it is testable in
principle (Bramlett, 2010). Numerous research studies using Rogers’s model have been completed and
reported in the nursing literature. A plethora of these studies can be found in Visions: The Journal of Rogerian
Nursing Science. Madrid and Winstead-Fry (2001) also found in a focused review of literature that from 1990
through 2000, 28 research studies on therapeutic touch were published in peer-reviewed journals, and 18 of
them were based on the Science of Unitary Human Beings, typically using Rogers’s model as explanation for
the underlying processes of therapeutic touch and its relation to energy fields and energy transfer. Examples
of some recent nursing studies using Rogers’s theory are listed in Box 9-2.

Box 9-2 Examples of Research Studies Using Rogers’s Theory

Caratoa-Mojica, R. (2015). Being one with the universe: Finding a silver lining in dying. Nursing Science
Quarterly, 28(3), 229–233. doi:10.1177/0894318415585621

Chang, S. J., Kwak, E. Y., Hahm, B., Seo, S. H., Lee, D. W., & Jang, S. J. (2016). Effects of a meditation
program on nurses’ power and quality of life. Nursing Science Quarterly, 29(3), 227–234.
doi:10.1177/0894318416647778

Grumme, V. S., Barry, C. D., Gordon, S. C., & Ray, M. A. (2016). On virtual presence. ANS. Advances in
Nursing Science, 39(1), 48–59. doi:10.1097/ANS.0000000000000103

Heelan-Fancher, L. (2016a). Improving maternal outcomes: The dynamic role of power in patient advocacy
[Abstract]. Nursing Research, 65(2), E99

Heelan-Fancher, L. M. (2016b). Patient advocacy in an obstetric setting. Nursing Science Quarterly, 29(4).
316–327. doi:10.1177/0894318416660531

Onieva-Zafra, M. D., García, L. H., & Del Valle, M. G. (2015). Effectiveness of guided imagery relaxation
on levels of pain and depression in patients diagnosed with fibromyalgia. Holistic Nursing Practice,
29(1), 13–21. doi:10.1097/HNP.0000000000000062

Reis, P. J., & Alligood, M. R. (2014). Prenatal yoga in late pregnancy and optimism, power, and well-being.
Nursing Science Quarterly, 27(1), 30–36. doi:10.1177/0894318413509706

Smith, M. C., Zahourek, R., Hines, M. E. Engebretson, J., & Wardell, D. W. (2013). Holistic nurses’ stories
of personal healing. Journal of Holistic Nursing, 31(3), 173–187.

Willis, D. G., DeSanto-Madeya, S., & Fawcett, J. (2015). Moving beyond dwelling in suffering: A situation-
specific theory of men’s healing from childhood maltreatment. Nursing Science Quarterly, 28(1), 57–63.
doi:10.1177/0894318414558606

Parsimony
This theory is relatively parsimonious. The model has five key definitions. These, combined with the three
principles of homeodynamics and the six assumptions about human beings, are the major elements of the
work. Despite its simplicity, however, it is difficult for many nurses to comprehend because the concepts are
extremely abstract. Nurses who wish their research and practice to be guided by Rogers’s model will benefit
from studying with a Rogerian scholar who uses the model regularly.

Value in Extending Nursing Science
Rogers’s contributions to nursing have been noted in the nursing literature, and she has had a significant
influence on scientific inquiry in professional nursing practice. The major value of Rogers’s work has been
extending nursing science by challenging traditional ways of thinking about the world and nursing. She
moved beyond a focus on such concepts and principles as adaptation, biopsychosocial beings,

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causal/probabilistic views, and the human-as-sum-of-parts thinking that had been common in nursing science
(Parse, 2010; Phillips, 2010, 2013; Rogers, 1990). The contribution to nursing science of the Science of
Unitary and Irreducible Human Beings is that it carries nursing into areas that are impossible to study using
linear, three-dimensional, and reductionistic methods, now understood as complexity science (Rickles, Hawe,
& Schiell, 2007).

Margaret Newman: Health as Expanding Consciousness
Margaret Newman reported that she became interested in theory when asked to speak at a nursing conference
in 1978 (George, 2010). She published a theory of health a year later (Newman, 1979) and Health as
Expanding Consciousness in 1986. She revised this work in 1994 and 1999. Newman has published
extensively on her theory and theoretical issues in books, book chapters, and articles (Newman, 1990a, 1990b,
1994, 1995, 1999, 2005, 2008a, 2008b).

Newman’s Health as Expanding Consciousness is one of the most recent nursing theories; her work builds
on the work of Rogers and others. Because of its similarity to Rogers’s theory, particularly with regard to its
conceptualizations of person, nursing, and the environment, it is included here among the unitary process
theories. In 2008, Newman published a new, related work, which she entitled Transforming Presence: The
Difference That Nursing Makes (Newman, 2008b); in this work, Newman makes the point that the three
paradigms are not necessarily contradictory, but “the unitary perspective can include the more particulate
view”(p. 15). Just as the theory of relativity may include special cases of more mechanistic theories (p. 15).

Background of the Theorist
As a young woman, Margaret Newman was involved in caring for her mother, who suffered from
amyotrophic lateral sclerosis. She explained that it was during this period that she came to know her mother in
ways that would have been impossible otherwise (Newman, 1986). This experience led Newman to study
nursing, and she enrolled at the University of Tennessee, where she completed her bachelor’s degree in 1962.
She earned her master’s degree from the University of California, San Francisco, in 1964 and a doctorate from
NYU in 1971 (Brown & Alligood, 2014).

Newman has served on the faculty at the University of Tennessee (which named her an outstanding
alumna), NYU, Pennsylvania State University, and the University of Minnesota. She is currently professor
emeritus at the University of Minnesota, Minneapolis. Her work has been recognized internationally, and she
has received numerous awards and honors both in the United States and abroad (Jones, 2007).

Philosophical Underpinnings of the Theory
While at NYU, Newman attended seminars taught by Martha Rogers, and she stated that Rogers’s Science of
Unitary Human Beings was the basis of her theory of Health as Expanding Consciousness. She also noted
that, among others, Itzhak Bentov’s explanation of the concept of expanding consciousness, Arthur Young’s
work on pattern recognition, and David Bohm’s theory of implicate order brought perspective to her thoughts
and ideas (Newman, 2008b).

Major Assumptions, Concepts, and Relationships
Assumptions
As a student of Rogers, Newman believed that “the human is unitary, that is, cannot be divided into parts, and
is inseparable from the larger unitary field” (Newman, 1994, p. xviii). She saw humans as open energy
systems in continual contact with a universe of open systems (i.e., the environment). Additionally, humans are
continuously active in evolving their own pattern of the whole (i.e., health) and are intuitive as well as
cognitive and affective beings. She further posited that “persons as individuals, and human beings as a
species, are identified by their patterns of consciousness” and that “the person does not possess consciousness
—the person is consciousness” (Newman, 1999, p. 33).

In describing health, Newman (1994) explained that health encompasses illness or pathology and that
pathologic conditions can be considered manifestations of the pattern of the individual. In addition, the pattern
of the individual that eventually manifests itself as pathology is primary and exists prior to structural or

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functional changes; removal of the pathology in itself will not change the pattern of the individual. Finally,
she noted an assumption that changes occur simultaneously and not in linear fashion (Newman, 1994).

Concepts
Newman built on Rogers’s definitions for human and environment, but she redefined nursing and health.
Health is an essential component of the theory of Health as Expanding Consciousness and is seen as a process
of developing awareness of self and the environment together with increasing the ability to perceive
alternatives and respond in a variety of ways. Nursing is described as “caring in the human health experience”
(Newman, 1994, p. 139). Other central concepts in Newman’s theory are pattern, pattern recognition,
movement, and time and space. Definitions for these and other concepts specific to the theory are presented in
Table 9-2.

Table 9-2 Central Concepts of Newman’s Health as Expanding Consciousness
Concept Definition

Nursing The act of assisting people to use the power within them to evolve
toward higher levels of consciousness. Nursing is directed toward
recognizing the patterns of the person in interaction with the
environment and accepting the interaction as a process of evolving
consciousness. Nursing facilitates the process of pattern recognition by
a rhythmic connecting of the nurse with the client for the purpose of
illuminating the pattern and discovering the rules of a higher level of
organization.

Health The expanding of consciousness; an evolving pattern of the whole of
life. A unitary process; a fluctuating pattern of rhythmic phenomena
that includes illness within the pattern of energy. Sickness can “be the
shock that reorganizes the relationships of the person’s pattern in a
more harmonious way” (Newman, 1999, p. 11).

Person A dynamic pattern of energy and an open system in interaction with
the environment. Persons can be defined by their patterns of
consciousness.

Consciousness The information of the system; consciousness refers to the capacity of
the system to interact with the environment and includes thinking,
feeling, and processing the information embedded in physiologic
systems.

Expanding consciousness The evolving pattern of the whole. Expanding consciousness is the
increasing complexity of the living system and is characterized by
illumination and pattern recognition resulting in transformation and
discovery. Expanding consciousness is health.

Integration via movement The natural condition of living creatures. Consciousness is expressed
in movement, which is the way that the organism interacts with the
environment and exerts control over it. Movement patterns reflect and
communicate the person’s inner pattern and organization. Changes in
the person’s health patterns may be reflected in changes in their
movement rhythms.

Pattern Relatedness, which is characterized by movement, diversity, and
rhythm. Pattern is a scheme, design, or framework and is seen in
person–environment interactions. Pattern is recognized on the basis of
variation and may not be seen all at once. It is manifest in the way one
moves, speaks, talks, and relates with others.

Pattern recognition The insight or recognition of a principle, realization of a truth, or

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reconciliation of a duality. Pattern recognition illuminates the
possibilities for action and is the key to the process of evolving to a
higher level of consciousness.

Time and space Temporal patterns that are specific to individuals and define their ways
of being within their world. Patterns of health may be detected in
temporal patterns.

Source: Newman (1999).

Relationships
A fundamental proposition in Newman’s model is the idea that health and illness are synthesized as “health.”
Indeed, the fusion of one state of being (disease) with its opposite (nondisease) results in what can be regarded
as health (Newman, 2008b).

To Newman, health is pattern. Pattern is information that depicts the whole, and pattern recognition is
essential. Pattern recognition involves moving from looking at parts to looking at patterns. Expanding
consciousness occurs as a process of pattern recognition (insight) following a synthesis of contradictory
events or disturbances in the flow of daily living. Pattern recognition comes from within the observer, and
patterns unfold over time and cannot be predicted with certainty. Understanding the meaning of relationships
through pattern recognition is important in providing care because patterns are the essence of a unitary view
of health.

Newman also wrote of the interrelatedness of time, space, and movement. She explained that time and
space have a complementary relationship, and movement is the means by which space and time become
reality. Movement is seen as a reflection of consciousness, time is a function of movement, and time is a
measure of consciousness (Newman, 2008a). Humans are in a constant state of motion and are constantly
changing; movement through time and space gives modern people our unique perception of reality. Constant
change is visible currently as technology; for example, smartphones and tablet computers can access e-books
and e-libraries, giving people immediate access to high volumes of information. New technology, such as
handheld laboratory testing and physical examination technology, is currently being used in clinics and
physician and nurse practitioner offices. Such technology gives health professionals and other individuals
immediate, conscious, and unrestricted access to information.

Access to information places people in constant contact with the whole world; indeed, instant
communications, such as social media, have made it possible for people to respond immediately to a question,
concern, or idea. Having information available at their fingertips lessens the need to try to remember
telephone numbers and other facts that can be found easily online (Stein & Sanburn, 2013). In these cases,
currently expanding consciousness may be more important to them than memory.

Time, space, and movement have all changed in the past few years; indeed, “the person is the center of
consciousness with information flow . . . [throughout] the universe” (Newman, 2008b, p. 36). Humans can
only expect more and faster change as consciousness expands and our world of knowledge progresses.

Usefulness
Newman (1994) believed that theory must be derived from practice and theory must inform practice. To
illustrate this relationship, she proposed a model for practice that she derived from her theory.

Her work has been used by nurses in a number of settings, providing care for different types of clients and
for a variety of interventions. For example, Arcari and Flanagan (2015) described the development of a post-
master’s certificate program in Mind-Body-Spirit nursing certification which was heavily influenced by
Newman’s Theory of Health as Expanding Consciousness. In another recent example, Sethares and Gramling
(2014) described how Newman’s theory was used by under graduate nursing students to enhance clinical
learning experiences by focusing on student–client partnerships. Stec (2016) also used Newman’s theory to
describe patterns of relating, knowing, and clinical decision making in a group of senior-level nursing
students.

Testability

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Newman’s theory has been the basis for research projects that have tested parts of the theory (i.e., time and
movement) or used it as a framework. Most of the nursing studies using Newman’s theory, found in recent
literature, were qualitative in nature. In one example, MacNeil (2012) used Newman’s theory as the
framework in a qualitative study of individuals living with hepatitis C. In another example, Brown, Chen,
Mitchell, and Province (2007) used a grounded theory approach to study help-seeking by older husbands who
were caring for wives with dementia, and Musker (2008) published her work on life transitions in menopausal
women. These studies indicate that the ideal of Health as Expanding Consciousness is useful for generating
caring interventions in numerous populations.

Box 9-3 lists recent research studies that were conducted using Newman’s model.

Box 9-3
Examples of Research Studies Using Newman’s Health as Expanding
Consciousness

Ananian, L. (2016). Relationship based care: Exploring the manifestations of health as expanding
consciousness within a patient and family centered medical intensive care unit. Nursing Research, 65(2),
E92–E93.

Bateman, G. C., & Merryfeather, L. (2014). Newman’s theory of health as expanding consciousness: A
personal evolution. Nursing Science Quarterly, 27(1), 57–61.

Condon, B. B. (2014). The living experience of feeling overwhelmed: A Parse research study. Nursing
Science Quarterly, 27(3), 216–225.

Haney, T., & Tufts, A. (2012). A pilot study using electronic communication in home healthcare:
Implications on parental well-being and satisfaction caring for medically fragile children. Home
Healthcare Nurse, 30(4), 216–224.

Hayes, M. (2015). Life pattern of incarcerated women: The complex and interwoven lives of trauma, mental
illness, and substance abuse. Journal of Forensic Nursing, 11(4), 214–222.

Rosa, K. C. (2016). Integrative review on the use of Newman praxis relationship in chronic illness. Nursing
Science Quarterly, 29(3), 211–218.

Stec, M. W. (2016). Health as expanding consciousness: Clinical reasoning in baccalaureate nursing
students. Nursing Science Quarterly, 29(1), 54–61.

Parsimony
Newman’s model consists of two major concepts: health and consciousness, and thus, it seems parsimonious.
Despite this seeming simplicity, however, the theory is one of great complexity (George, 2010). Those who
do not comprehend the simultaneity paradigm may wander in its enfolded relationships. The real complexity
relates to the nature of the relationships between and among the concepts and to its abstractness.

Value in Extending Nursing Science
The focus of Newman’s work is on the person, client, individual, and family. It places the client and nurse as
integrated actors in understanding the client’s health as consciousness. It also requires the understanding that
health and disease are the same and not separate in the life of the individual (Newman, 2008b).

As illustrated by the examples from the literature presented, Newman’s model has been successfully used
in nursing practice and research. Newman’s view can be applied in any setting, and research and practice
application are underway to further verify its importance to the discipline (Jones, 2007).

Rosemarie Parse: The Humanbecoming Paradigm
Rosemarie Parse is a noted nursing scholar and prolific author. She first published her theory of nursing, Man-
Living-Health, in 1981 and has continually revised the work. In 1992, Parse changed the name to the Theory
of Humanbecoming. She combined human and becoming into a single word because that is how she sees this
phenomenon (Parse, 2014). She is the author of many books and numerous articles. Her works have been
translated into Danish, Finnish, French, German, Japanese, Korean, and other languages. She holds that
humanbecoming has become a new paradigm, and the adherents to the scholarship of humanbecoming agree

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(Bournes, 2013; Parse, 2008, 2010, 2013, 2014; Smith, 2010).

Background of the Theorist
Parse was educated at Duquesne University in Pittsburgh, Pennsylvania, and earned her master’s and doctoral
degrees from the University of Pittsburgh. Some years later, she became dean of the College of Nursing at
Duquesne, and she is currently Distinguished Professor emeritus at Loyola University in Chicago, Illinois.
She is the founder and editor of Nursing Science Quarterly and president of Discovery International, which
sponsors international nursing theory conferences. She is also the founder of the Institute of Humanbecoming,
where she teaches the ontologic, epistemologic, and methodologic aspects of the Humanbecoming Paradigm.
The Humanbecoming Paradigm is honored and acknowledged in colleges of nursing worldwide. She has
currently realized that although a student of Martha Rogers, her work has developed into a wholly new
paradigm, and she has titled this the Humanbecoming Paradigm (Parse, 2014).

Philosophical Underpinnings of the Theory
Parse synthesized the Humanbecoming Paradigm from principles and concepts from Rogers’s work. She also
incorporated concepts and principles from existential phenomenologic thought as expressed by Heidegger,
Sartre, and Merleau-Ponty (Parse, 2014). The theory comes from her experience in nursing and from a
synthesis of theoretical principles of human sciences.

Major Assumptions, Concepts, and Relationships
Assumptions
As with many of the major concepts, the major assumptions of Parse’s theory originated with Rogers’s
Science of Unitary Human Beings and from existential phenomenology. Parse’s thinking has brought her to a
new ontology. Kuhn (1996) warned the scientific community that when the facts no longer support the current
paradigm, the paradigm must change. For the humanbecoming perspective, a new paradigm has ascended.
The language comes from the humanbecoming school of thought but has developed beyond that to a newer
realm. Assumptions about Humanbecoming Paradigm are shown in Box 9-4.

Box 9-4 The Philosophical Assumptions of the Humanbecoming Paradigm

Humanuniverse is indivisible, unpredictable, and ever-changing.
Humanuniverse is cocreating reality as a seamless symphony of becoming.
Humanuniverse is an illimitable mystery with contextually construed pattern preferences.
Ethos of humanbecoming is dignity.
Ethos of humanbecoming is august presence, a noble bearing of immanent distinctness.
Ethos of humanbecoming is embedded with the abiding truths of presence, existence, trust, and worth.
Living quality is the becoming visible-invisible becoming of the emerging now.
Living quality is the ever-changing whatness of becoming.
Living quality is the personal expression of uniqueness.

Source: Parse (2014, pp. 29–30).

Parse synthesized the nine assumptions of humanbecoming in four broad statements:

Humanbecoming is structuring meaning, freely choosing the situation.
Humanbecoming is configuring rhythmic humanuniverse patterns.
Humanbecoming is cotranscending illimitably with emerging possibilities.
Humanbecoming is humanuniverse cocreating a seamless symphony (Parse, 2013, p. 113).

Concepts
Parse builds on previous concepts and provides concepts and paradoxes that are found in this paradigm:

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Imaging: explicit–tacit; reflective–prereflective
Valuing: confirming–not confirming
Languaging: speaking–being silent; moving–being still

Revealing–concealing: disclosing–not disclosing
Enabling–limiting: potentiating–restricting
Connecting–separating: attending–distracting

Powering: pushing–resisting; affirming–not affirming; being–nonbeing
Originating: certainty–uncertainty; conforming–not conforming
Transforming: familiar–not familiar (Parse, 2013, p. 113)

Relationships
From the major concepts, outlined three principles in the theory. These are updated and meaningful as
enduring principles.

1. Structuring meaning is the imaging and valuing of languaging.
2. Configuring rhythmic patterns of relating the revealing–concealing and enabling–limiting of

connecting–separating.
3. Cotranscending with the possible is powering and originating of transforming (Parse, 2010, p. 258).

Nurses guide individuals and families in choosing possibilities in changing the health process; this is
accomplished by intersubjective participation with the clients. Practice focuses on illuminating meaning, and
the nurse acts as a guide to choose possibilities in the changing health experiences (Parse, 2013).

Practitioners using Parse’s method do not focus on changing an individual’s behavior to fit a defined
nursing process and do not attempt to label them with possibly erroneous nursing diagnoses. Rather, they
practice from the understanding that the human–universe process involves the nurse’s true presence with the
person and the family. The nurse “dwells with the rhythms of the person and family” (Parse, 1995, p. 83) as
they move through the experience. Nurses taking the time “to be fully present with the patient provides patient
and nurse [who are] grounded in the humanbecoming theory [sic]” with meaningful and enlightening
experiences (Smith, 2010, p. 216).

Usefulness
Parse’s theory has been a guide for nurses all over the world. For example, in practice, McLeod-Sordjan
(2013) used Parse’s theory to illustrate the concept of “death acceptance.” In this work, she described how to
promote communication with low-English proficiency patients near the end of life. In other examples, Doucet
(2015) described how the humanbecoming model could be applied to caring for a family who had a member
with severe dementia, and Hart (2015) used a case study approach to demonstrate how the humanbecoming
theory may be used to evaluate long-term care. Finally, Wilson (2016) applied Parse’s humanbecoming theory
in developing a comprehensive plan of care for a family experiencing the loss of a pregnancy or an infant.

In educational settings, Ursel (2015) used Parse’s humanbecoming theory to describe a tool to enhance
communication between patients and nursing students, seeking to use the theory to better focus on
communicating relevant, timely, and accurate patient information. Several service learning opportunities
directed by Parse’s theory of humanbecoming were provided to a cohort of nursing students (Condon,
Grimsley, Knaack, Pitz, & Stehr, 2015). In this work, theory and practice were creatively and effectively
connected to the benefit of both students and various community groups. Finally, Drummond and Oaks (2016)
describe how concepts and processes from Parse’s theory have been interwoven within the curricula of both
undergraduate and graduate programs in one nursing school.

Testability
The humanbecoming perspective is testable in principle, and many concepts that arise from it are being
studied as the researchers develop perspectives on the human science of nursing. Research within Parse’s
method describes the lives, lived experiences, and ways of being of humans differently from research in the
more reductionistic models. To study humanbecoming, Parse developed a research method similar to those of
existential phenomenologists and derived specific steps that are rigorous and reproducible. The method

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involves dwelling with the information from the participant’s perspective (dialogical engagement) and
deriving themes from that data (extraction–synthesis) and then synthesizing the meanings into a relevant
whole through heuristic interpretation (Parse, 1987). The inductive research method Parse and others have
created is a research strategy that values the lived experiences of humans as they go about their daily lives,
cocreating their health in human universe concert. Welch (2004) explored his experience using the method
developed by Parse. His comments (Table 9-3) are important to students who wish to develop themselves as
researchers within the method.

Table 9-3 Lessons From a Doctoral Dissertation

Lessons
Writings as He Worked
Through the Process Welch’s Actions

Finding a focus for the study Considered depression incurable
and had other preconceived ideas.

Reviewed literature, thought
through process. Came to view
depression as a time for people to
work through difficult times (p.
202).

Locating a philosophical
approach to inquiry

Considered several different
approaches to phenomenologic
inquiry.

Realized the superficiality of his
understanding but was unaware of
the significance of the differences
in the approaches.

Deciding on a phenomenologic
position

Found himself at an impasse,
different terms, philosophical
stances. Read the works of Parse.

Developed a lexicon of terms to
understand the world of
phenomenology (p. 203).

Walked in the desert of theoretical
confusion and increasing
disillusionment with lack of
progress in 2 years.

Found humanbecoming method,
but his advisors were not familiar
with process and terminology of
Parse’s method.

Discussion with Parse was a
“watershed” in realizing that he
needed to review the focus on the
study and also his philosophical
disposition toward adopting the
humanbecoming perspective.

Attended Humanbecoming
Institute in Pittsburgh. Dialogued
with Parse and other scholars.
Parse agreed to assist with
dissertation as a second advisor.

Selecting participants for the
study

Wanted to include only the best
and most appropriate potential
participants to tell their stories of
taking life day by day.

Realized that his inclination to
take only the best candidates
would compromise the integrity
of the study. Therefore, he
decided he had to adhere to the
established criteria and remain
cognizant of his personal bias.

Engaging the participants As each participant talked of
taking life day by day, I sensed
myself moving with the rhythms
of their stories (p. 205).

Being with the participants in true
presence as they shared their
stories was a profound experience
(p. 205).

Inadvertently straying from the
humanbecoming path

Embracing the art of living
humanbecoming was an affirming
enterprise; however, learning the
art of humanbecoming was
difficult (p. 205).

Dr. Parse provided important
feedback about the conduct of the
first tape and it was subsequently
excluded. Came to the
understanding of the importance
of maintaining rigor (p. 205).

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Allowing the voice of the text to
be heard

My initial attempts to move the
essences of the participants’
stories to the language of the
researcher and engage in the
process of heuristic interpretation
could be described only as
throwing seed on barren ground
(p. 206).

“I realized that the process of
abstraction is concept driven; in
other words, language is a vehicle
for expressing what has already
been formulated in the mind’s
eye. The extraction–synthesis and
heuristic interpretation processes
of Parse’s method were perceived
as pathways to new levels of
knowing in explicating the
participants’ lived experiences”
(p. 206).

Gleaning insights from the
journey

Being comfortable with the
uncomfortable: A willingness to
learn from the experienced
scholars and a preparedness to
move with the rhythms of the
humanbecoming school of
thought.

Mapping the journey: The
telling of the researchers’
experience is an opportunity for
other researchers contemplating
such endeavors (p. 206).

Rethinking authentic rigor:
Authentic rigor involves more
than adhering strictly to an
established set of protocols; it also
requires the researcher to be the
embodiment of humanbecoming.
Living the spirit of
humanbecoming has to engage in
a seamless movement of
researcher with participant,
researcher with text, and
researcher with reader in the
process of cocreating new
horizons of understanding of the
phenomenon under study (p. 206).

“I feel comfortable about testing
the boundaries of conventional
scientific inquiry. I no longer feel
the need to engage in academic
debate concerning the primacy of
particular research paradigms
within the community of scholars.
Of importance to me is keeping
alive the creative process or
inquiry even though at times
doing so means being lost in the
labyrinthine paths of creative
discovery” (p. 207).

Source: Welch (2004). Reprinted by permission of Sage Publications.

Parse’s method for research, a descriptive phenomenologic method of inquiry, entitled “the Human
Becoming Hermeneutic Method” (Barrett, 2002, p. 53), has been selected by nurse scholars in Australia,
Canada, Denmark, Finland, Greece, Italy, Japan, South Korea, Sweden, the United Kingdom, and the United
States. Baumann (2016) used this method to study how older adults experience suffering, and Doucet (2013)
used the method to discover the lived experience of “feeling at home” in community-dwelling adults. A small
sample of the numerous current studies of other aspects of human experience within Parse’s Humanbecoming
Paradigm are listed in Box 9-5.

Box 9-5
Examples of Current Research Using Parse’s Humanbecoming
Perspective

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Bauman, S. L. (2016). The living experience of suffering: A Parse method study with older adults. Nursing
Science Quarterly, 29(4), 308–315. doi:10.1177/0894318416660530

Florczak, K. L. (2016). Power relations: Their embodiment in research. Nursing Science Quarterly, 29(3),
192–196. doi:10.1177/0894318416647167

Hawkins, K. (2015). Feeling disrespected: An exploration of the extant literature. Nursing Science Quarterly,
28(1), 8–12. doi:10.1177/0894318414558612

Ma, L. (2014). A humanbecoming qualitative descriptive study on quality of life with older adults. Nursing
Science Quarterly, 27(2), 132–141. doi:10.1177/0894318414522656

Parse, R. R. (2016). Parsciencing: A basic science mode of inquiry. Nursing Science Quarterly, 29(4), 271–
274. doi:10.1177/0894318416661103

PetersonLund, R. R. (2013). Living on the edge: A review of the literature. Nursing Science Quarterly,
26(4), 303–310. doi:10.1177/0894318413500311

Parsimony
Parse’s model is parsimonious and artistic, having nine assumptions, which have been synthesized to four
working assumptions; four postulates; three principles; and numerous concepts and paradoxes organized
together in artful, logical, balanced ways to explain humanbecoming. With careful study, the paradigm lends
itself to scholarly research and debate. The paradigm may seem complicated because much of the terminology
is unfamiliar to most nurses. Indeed, this is a new and working way of seeing nursing in the real world (Smith,
2010). Students who want to use this model to guide their research and practice might consider contacting
Parse and or one of her students for assistance to fully understand this new paradigm.

Value in Extending Nursing Science
The principal value of the Humanbecoming Paradigm is the worldview that sees humans as intentional beings,
freely choosing to live within paradoxical ways of being. It is a unique way to view health and gives insight
into how individuals create their own destiny.

Practice and research in the Humanbecoming Paradigm are quite different from those espoused in the
other nursing perspectives. By living true presence with their clients, nurses guide and cocreate ways of being
that enable choosing health. The amount of literature depicting use of Parse’s work is multiplying rapidly, and
support for the Humanbecoming Paradigm is growing.

Summary
The models presented in this chapter are considerably different from those described in the previous chapters.
Additionally, significant similarities and differences are evident among these three models. Table 9-4
summarizes some of these by comparing definitions of the metaparadigm concepts. As Table 9-4 shows, the
conceptualization of human beings is similar because Rogers heavily influenced both Newman and Parse. On
the other hand, Parse was more specific when describing the environment, and Newman was much more
explicit in her discussions of health. Perhaps, the greatest difference, however, relates to how they view nurses
and nursing. Those wishing to use these theories should study these concepts closely and seek to apply them
in their practice and research. When employing the research methods, which are unique, close work with the
researchers or their former students will assist the novice researcher to develop the depth of effort that is
required (Welch, 2004).

Table 9-4 Comparison of Concepts Common to the Unitary Process Nursing Theories
Author and Model Human Health Environment Nursing

Rogers: Unitary Human
Beings (Rogers, 1990)

A sentient, unitary being;
a multidimensional
irreducible energy field
known by pattern
manifestation, and who

Signifies an irreducible
human field
manifestation.

“An irreducible,
indivisible,
multidimensional energy
field identified by pattern
. . . integral with the

A learned profession, a
science and an art, whose
uniqueness lies in
concern for human
beings.

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cannot be known by the
sum of parts.

human field” (p. 7).

Newman: Health as
Expanding
Consciousness
(Newman, 1999)

Accepts the definition of
human as stated by
Rogers.

Health is a unitary
process, a fluctuating
pattern of rhythmic
phenomena. Health
includes illness within
the pattern of energy.

Universal energy system
as in Rogers’s Science of
Unitary Human Beings.

Assist persons to use
innate power to evolve
toward a higher level of
consciousness. Nurses
facilitate pattern
recognition in this
process.

Parse: Humanbecoming
Paradigm (Parse, 2010)

Intentional beings
involved with their
world, having a
fundamental nature of
knowing, being present,
and open to their world.
The unitary human is one
who “coparticipates in
the universe in creating
becoming and who is
whole, open, free to
choose ways of
becoming” (p. 260).

A way of being in the
world; it is not a
continuum of healthy to
ill, nor is it a dichotomy
of health or illness, rather
it is the living of day-to-
day ways of being.

The world, the universe,
and those who occupy
spaces along with others
who freely choose to be
in the situation.

Guides humans toward
ways of being, finding
meaning in situations,
and choosing ways of
cocreating their own
health. Nurses live true
presence in the day to
day of the person’s life.

Nurses, such as Kristin from the opening case study, who prefer to view the person as a unitary being and
who have a comprehensive view of health often find the theories from the simultaneity paradigm fascinating
and helpful. These works have been extremely enlightening and helpful for the discipline of nursing, and all
three have many adherents worldwide. A large and growing body of research explores patterns of lived
experiences and health perspectives based on them, and the expanding topics of study currently enhance
nursing science and will continue to do so into the future.

Key Points
The simultaneity paradigm is an entirely different and nursing-centered way of studying nursing and

humans.
Martha Rogers and two of her students, Margaret Newman and Rosemarie Parse, have been active in

providing education, collaborative communities, and the groundwork for students and nursing scientists
who are currently working within the paradigm.

Newman’s Health as Expanding Consciousness is conversant with the current lives of the millennial age.
Young people live an age of motion, information, and continuous communication. Expanding
consciousness is the hallmark of this generation.

Parse continues to develop the Humanbecoming Paradigm and frame its research processes. This paradigm
offers new ways to understand the human–environment process and new lenses through which nursing care
is provided. This paradigm generates considerable nursing-focused research and scholarship.

Learning Activities
1. Select one of the theories described and apply it in developing comprehensive patterns of

nursing care for young teenagers who are becoming first-time mothers. How would a nurse
practicing in this paradigm care for new mothers and the issues they encounter as they prepare
for the birth of their babies. Share findings with classmates.

2. Select two simultaneity paradigm theories and apply them in developing comprehensive
patterns of nursing care for the family of an elderly client with Alzheimer disease. Compare
the two models for depth of understanding the client and family responses.

3. These three theorists suggest that health—rather than being a dichotomy (health-illness)—is
as a way of being, a pattern of consciousness, or a manifestation of the human field. Can you
envision health in this way? How would such a belief affect your practice?

4. Two of the theorists, (Newman and Parse) provide art and musical referents in their theories.
Can you describe how using art and music might add to the ability of nurses to effectively

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interact with patients?
5. Kristin, the nurse from the opening case study, determined that Parse’s Humanbecoming

Paradigm best fits her practice of hospice nursing. Reflect on a case or situation from your
personal practice or experience. Can you apply one of the theories described in this chapter to
the situation? How does the perspective from the theory change how you view the situation?
Are nursing interventions the same? Do you anticipate that the care would be more holistic?
Why or why not?

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10

Introduction to Middle Range Nursing Theories
Melanie McEwen

Annette Cohen is a second-year graduate nursing student interested in starting her major research/scholarship
project. For this project, she would like to develop some of her experiences in hospice nursing into a
preliminary middle range theory of spiritual health. Annette has studied spiritual needs and spiritual care for
many years but believes that the construct of spiritual health is not well understood. She views spiritual health
as the result of the interaction of multiple intrinsic values and external variables within a client’s experiences,
and she believes that it is a significant contributing factor to overall health and well-being.

After reviewing theoretical writings dealing with spiritual nursing care, Annette found a starting point for
her work in Jean Watson’s Theory of Human Caring (Watson, 2012) because of its emphasis on spirituality
and faith. From Watson’s (2012) work, she was particularly interested in applying the concepts of “actual
caring occasion” and “transpersonal” care. To develop the theory, Annette obtained a copy of Watson’s most
recent work and performed a comprehensive review of the literature covering theory development and the
Theory of Human Caring. She then did an analysis of the concept of spiritual health. Combining the concept
analysis and the literature review of Watson’s work led to the development of assumptions and formal
definitions of related concepts and empirical indicators. After conversing with her instructor, she concluded
that her next steps were to construct relational statements and then draw a model depicting the relationships
among the concepts that comprise spiritual health.

As discussed in Chapter 2, middle range nursing theories lie between the most abstract theories (grand nursing
theories, models, or conceptual frameworks) and more circumscribed, concrete theories (practice theories,
situation-specific theories, or microtheories). Compared to grand theories, middle range theories are more
specific, have fewer concepts, and encompass a more limited aspect of the real world. Concepts are relatively
concrete and can be operationally defined. Propositions are also relatively concrete and may be empirically
tested.

The discipline of nursing recognizes middle range theory as one of the contemporary trends in knowledge
development, and there is broad acceptance of the need to develop middle range theories to support nursing
practice and nursing research (Alligood, 2014; Fitzpatrick, 2014; Kim, 2010; Peterson, 2017). According to
Suppe (1996), this call to develop middle range theory is consistent with the third stage of legitimizing the
discipline of nursing. The first stage focuses on differentiation of the perspective of the emerging discipline,
which is characterized by separation from antecedent disciplines (i.e., medicine) and the establishment of
university-based education, which in nursing occurred during the 1950s and 1960s. The second stage is
marked by the quest to secure institutional legitimacy and academic autonomy. This stage characterized
nursing during the 1970s and through the 1980s, when pursuit of nursing’s unique perspective on and
clarification of the phenomena of interest to the discipline were stressed. The third stage began in the 1990s
and is distinguished by increased attention to substantive knowledge development, which includes
development and testing of middle range theories. This stage is expanding and evolving further to include
evidence-based practice and situation-specific theories (see Chapter 12).

Middle range theories are increasingly being used in nursing research studies. Many researchers prefer to
work with middle range theories rather than grand theories or conceptual frameworks because they provide a

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better basis for generating testable hypotheses and addressing particular client populations. A review of
nursing research journals and dissertation abstracts indicates that nursing research is currently being used in
the development and testing of a number of middle range theories, and middle range theories are frequently
being used as frameworks for investigation. Furthermore, middle range theories are presently being refined on
the basis of research results.

Despite the recent promotion of middle range theories, there is a lack of clarity regarding what constitutes
middle range theory in nursing. According to Cody (1999), “It appears that almost any theoretical entity that
is more concrete than the broadest of grand theories is considered middle range by someone” (p. 10). Several
nursing theory textbooks (e.g., Alligood, 2014; Chinn & Kramer, 2015; Fawcett & DeSanto-Madeya, 2013;
M. C. Smith & Parker, 2015) disagree to some extent on which theories should be labeled as middle range.
Indeed, some authors list a few of the readily accepted grand theories (e.g., Parse, Newman, Peplau, and
Orlando) as middle range. Others consider somewhat more circumscribed theories (e.g., Leininger, Pender,
Benner and Erickson, Tomlin, and Swain) to be middle range, although the theory’s authors may not agree. In
essence, there has been a paucity of discussion on the subject, and therefore, there is little consensus. This
issue is discussed in more detail later in the chapter.

Purposes of Middle Range Theory
Middle range theories were first suggested in the discipline of sociology in the 1960s and were introduced to
nursing in 1974. Scholars came to believe that middle range theories were useful for emerging disciplines
because they are more readily operationalized and addressed through research than are grand theories. More
than 15 years elapsed, however, before there was a concerted call for middle range theory development in
nursing (Blegen & Tripp-Reimer, 1997; Meleis, 2012).

Development of middle range theories is supported by the frequent critique of the abstract nature of grand
theories and the difficulty of their application to practice and research. The function of middle range theories
is to describe, explain, or predict phenomena, and, unlike grand theory, they must be explicit and testable.
Thus, they are easier to apply in practice situations and to use as frameworks for research studies. In addition,
middle range theories have the potential to guide nursing interventions and change conditions of a situation to
enhance nursing care. Finally, a major role of middle range theory is to define or refine the substantive
component of nursing science and practice (Higgins & Moore, 2000). Indeed, Lenz (1996) noted that
practicing nurses are actually using middle range theories but are not consciously aware that they are doing so.

Each middle range theory addresses relatively concrete and specific phenomena by stating what the
phenomena are, why they occur, and how they occur. In addition, middle range theories can provide structure
for the interpretation of behavior, situations, and events. They support understanding of the connections
between diagnosis and outcomes and between interventions and outcomes (Fawcett & DeSanto-Madeya,
2013).

Enhancing the focus on middle range theories in nursing is supported by several factors. These include the
observations that middle range theories:

Are more useful in research than grand theories because of their low level of abstraction and ease of
operationalization

Tend to support prediction better than grand theories due to circumscribed range and specificity of the
concepts

Are more likely to be adopted in practice because their relative simplicity eases the process of
developing interventions for identified health problems (Cody, 1999; Peterson, 2017)

Like theory in general, middle range theory has three functions in nursing knowledge development. First,
middle range theories are used as theoretical frameworks for research studies. Second, middle range theories
are open to use in practice and should be tested by research. Finally, middle range theories can be the
scientific end product that expresses nursing knowledge (Suppe, 1996).

Characteristics of Middle Range Theory
Several characteristics identify nursing theories as middle range. First, the principal ideas of middle range

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theories are relatively simple, straightforward, and general. Second, middle range theories consider a limited
number of variables or concepts; they have a particular substantive focus and consider a limited aspect of
reality. In addition, they are receptive to empirical testing and can be consolidated into more wide-ranging
theories. Third, middle range theories focus primarily on client problems and likely outcomes as well as the
effects of nursing interventions on client outcomes. Finally, middle range theories are specific to nursing and
may specify an area of practice, age range of the client, nursing actions or interventions, and proposed
outcomes (Meleis, 2012; Peterson, 2017).

The more frequently used middle range theories tend to be those that are clearly stated, easy to understand,
internally consistent, and coherent. They deal with current nursing perspectives and address socially relevant
topics that solve meaningful and persistent problems. In summary, middle range theories for nursing combine
postulated relationships between specific, well-defined concepts with the ability to measure or objectively
code concepts. Thus, middle range theories contain concepts and statements from which hypotheses may be
logically derived and empirically tested, and they can be easily adopted to guide nursing practice. Table 10-1
compares characteristics of grand theory, middle range theory, and practice/situation-specific theory, and
characteristics of middle range theory are shown in Box 10-1.

Table 10-1 Characteristics of Grand, Middle Range, and Practice/Situation-Specific Theories

Characteristic Grand Theories
Middle Range
Theories

Practice/Situation-
Specific Theories

Complexity/abstractness,
scope

Comprehensive, global
viewpoint (all aspects
of human experience)

Less comprehensive
than grand theories,
middle view of reality

Focused on a narrow
view of reality, simple
and straightforward

Generalizability/specificity Nonspecific, general
application to the
discipline irrespective
of setting or specialty
area

Some generalizability
across settings and
specialties, but more
specific than grand
theories

Linked to special
populations or an
identified field of
practice

Characteristics of concepts Concepts abstract and
not operationally
defined

Limited number of
concepts that are fairly
concrete and may be
operationally defined

Single, concrete concept
that is operationalized

Characteristics of
propositions

Propositions not always
explicit

Propositions clearly
stated

Propositions defined

Testability Not generally testable May generate testable
hypotheses

Goals or outcomes
defined and testable

Source of development Developed through
thoughtful appraisal and
careful consideration
over many years

Evolve from grand
theories, clinical
practice, literature
review, and practice
guidelines

Derived from practice or
deduced from middle
range or grand theory

Box 10-1 Characteristics of Middle Range Nursing Theory
Not comprehensive but not narrowly focused
Some generalizations across settings and specialties
Limited number of concepts
Propositions that are clearly stated
May generate testable hypotheses

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Concepts and Relationships for Middle Range Theory
Middle range theories consist of two or more concepts and a specified relationship between the concepts.
Middle range theories address phenomena (concepts) that are toward the middle of a continuum of scope with
the metaparadigm concepts (nursing, person, health, environment) at one end and specific concrete actions or
events (medication administration, preoperative teaching, electrolyte management, fall prevention) at the
other. The concepts should be discrete, observable, and sufficiently abstract to be applied across multiple
settings and used with clients with differing problems (Blegen & Tripp-Reimer, 1997). Examples from the
nursing literature include theories describing health promotion, comfort, coping, resilience, uncertainty, pain,
grief, fatigue, self-care, adaptation, self-transcendence, and transitions (Meleis, 2012; Peterson, 2017; M. J.
Smith & Liehr, 2014).

Middle range theories link discrete and observable phenomena or concepts in relationships statements. In
middle range theory, relationships are explicitly stated, and, preferably, they are unidirectional. Relationships
can be of several types. The most common are causal relationships that state that a change in the value of one
variable or concept is associated with a change in the value of another variable or concept (Peterson, 2017).

Categorizing Middle Range Theory
The question as to which nursing theories are middle range is not clear-cut. Middle range theory is more
specific than grand theory but abstract enough to support both generalization and operationalization across a
range of populations; this sets it apart from practice or situation-specific theory.

In a well-researched effort to describe the place of middle range theory in nursing, Liehr and Smith (1999)
analyzed 22 middle range theories published during the previous decade. These theories were categorized as
“high-middle,” “middle,” and “low-middle” based on their level of abstraction or degree of specificity. In the
review, high-middle theories included concepts such as caring, growth and development, self-transcendence,
resilience, and psychological adaptation. Middle theories included concepts such as uncertainty in illness,
unpleasant symptoms, chronic sorrow, peaceful end of life, cultural brokering, and nurse-expressed empathy.
Low-middle theories, those that are closer to practice or situation-specific theories, included hazardous
secrets, women’s anger, nurse midwifery care, acute pain management, helplessness, and intervention for
postsurgical pain.

As mentioned, there is some debate on which theories should be considered middle range. Indeed, some
theories not termed middle range more appropriately fit the criteria of middle range theory than a grand
theory, and some theories that are labeled middle range better fit the criteria of situation-specific or practice
theory. Chapter 11 presents a number of middle range nursing theories described in the literature, organized as
high, middle, and low theories. It should be noted that the designations are arguably arbitrary and that one
theory that is listed here as “high-middle” may be considered by others to be a grand theory. Likewise,
another theory listed here as “middle” might be considered by others to be “high-middle” and so forth.
Situation-specific theories and their relationship to evidence-based practice are discussed in more detail in
Chapter 12.

Development of Middle Range Theory
Several methods for development of middle range theories have been identified in the nursing literature.
Middle range theories emerge from combining research and practice and building on the work of others.
Sources used to generate middle range theory include literature reviews, qualitative research, field studies,
conceptual models, taxonomies of nursing diagnoses and interventions, clinical practice guidelines, theories
from other disciplines, and statistical analysis of empirical data (Fawcett & DeSanto-Madeya, 2013; Peterson,
2017). Five approaches for middle range theory generation were identified by Liehr and Smith (1999) (Box
10-2). The following sections present examples describing the source and development process of middle
range theories from each of the five approaches listed in Box 10-2.

Box 10-2 Approaches for Middle Range Theory Generation
1. Induction through research and practice

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2. Deduction from research and practice or application of grand theories
3. Combination of existing nursing and non-nursing middle range theories
4. Derivation from theories of other disciplines that relate to nursing
5. Derivation from practice guidelines and standards rooted in research

Middle Range Theories Derived From Research and/or Practice
The most common sources for development of middle range nursing theories and models are nursing research
and nursing practice. Grounded theory research and other qualitative methods in particular are frequently
noted as sources for middle range theory development. Examples of middle range theories derived from
qualitative research include the Theory of Family Vigilance (Carr, 2014) (see Nursing Exemplar 1), the
Theory of Spiritual Care in Nursing Practice (Burkhart & Hogan, 2017), a theory describing sustaining health
in faith community nursing practice (Dyess & Chase, 2012), a theory describing “death imminence
awareness” of family member of patients in critical care (Baumhover, 2015), and a theory of career
persistence in acute care nurses (Hodges, Troyan, & Keeley, 2010).

NURSING EXEMPLAR 1: MIDDLE RANGE
THEORY DERIVED FROM
RESEARCH/PRACTICE
The process used to develop a middle range Theory of Family Vigilance was described by
Carr (2014). Her purpose was to provide an explanation of “the meanings, patterns and
day-to-day experience of family members staying with hospitalized relatives” (p. 251).

Theory Development Process: The Theory of Family Vigilance was derived from three
ethnographic studies carried out among family members of patients in various units of a
large, acute care hospital. The first study among family members of patients in a
neurology unit, yielded five “categories of meaning”—commitment to care, resilience,
emotional upheaval, dynamic nexus, and transition. Carr (2014) noted that each of these
categories of meaning were supported by the findings of the subsequent studies.

Carr (2014) then described how she employed the strategies of concept synthesis and
statement synthesis to define and then illustrate the relationships between and among the
different defining characteristics of the categories that comprise family vigilance. Finally,
through the process of theory synthesis, she constructed the information into a formalized
theory.

Variations of the idea of development of middle range theory from research are fairly common. Theorists
report combining qualitative research with literature review, concept analysis, concept synthesis, theory
synthesis, and other techniques in the process of developing middle range theory. For example, Murrock and
Higgins (2009) explained that they used statement and theory synthesis, along with literature review, to
develop “the theory of music, mood and movement to improve health outcomes.” In other works, Davidson
(2010) developed “facilitated sensemaking” to support families of intensive care unit (ICU) patients following
systematic literature review and synthesis, and Eakes, Burke, and Hainsworth developed the middle range
Theory of Chronic Sorrow from an extensive review of the literature and data gathered through 10 qualitative
research studies (Eakes, 2017).

Identification of middle range theories and models derived primarily from practice is more difficult. One
example is the Theory of Unpleasant Symptoms (Lenz, Pugh, Milligan, & Gift, 2017), which was reportedly
developed by integrating or melding existing practice and research information about a variety of symptoms.
A second example is the Client Experience Model (Holland, Gray, & Pierce, 2011), which was reportedly
developed through clinical observations in acute care settings using a practice-to-theory method.

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Some models that describe areas of specialty nursing practice report being developed from combination of
practice and another source, typically research or standards. One example of this technique is Benoit and
Mion’s (2012) model for pressure ulcer etiology in critically ill patients, which was constructed from
combining a literature review and practice standards. The Omaha System, which is a model for community
and home health nursing practice, is a second example. Martin (2005) explained that the conceptual
framework for the Omaha System was a combination of practice, research, and literature review.

Middle Range Theory Derived From a Grand Theory
As explained previously, many nursing theorists and scholars agree that grand theories are difficult to apply in
research and practice and suggest development of middle range theories derived from them. During the last
two decades, several theories developed from grand theories have been published in the nursing literature.
One example is a middle range theory of health promotion for preterm infants (Mefford, 2004), which was
derived from application of Levine’s Conservation Model (see Nursing Exemplar 2). Two examples used
Orem’s theory. In one, Riegel, Jaarsma, and Strömberg (2012) developed the Theory of Self-Care of Chronic
Illness, patterning their notion of self-care from Orem’s theory. Similarly, Pickett, Peters, and Jarosz (2014)
developed a middle range Theory of Weight Management based on Orem’s theory.

NURSING EXEMPLAR 2: MIDDLE RANGE
THEORY DERIVED FROM A GRAND THEORY
Mefford (2004) used Levine’s Conservation Model of Nursing to develop a Theory of
Health Promotion for Preterm Infants. In this case, Levine’s theory was used as a
framework for nursing practice for the neonatal intensive care unit (NICU) to ensure that
needs of both the infant and family are addressed.

Theory Development Process: To develop the Theory of Health Promotion for Preterm
Infants, the theorist first described elements of Levine’s Conservation Model internal and
external environments, wholeness, and conservation principles (conservation of energy,
structural integrity, personal integrity, and social integrity) and applied these concepts in
the NICU. She determined a “goal of restoring a state of wholeness, or health” (p. 260)
(Figure 10-1).

Figure 10-1
Conceptual diagram of Levine’s conservation model of
nursing.

(From Mefford, L. C. [2004]. A theory of health promotion for preterm infants based on Levine’s conservation model
of nursing. Nursing Science Quarterly, 17[3], 261. Used with permission of Sage Publications, Inc.)

Following initial development of the theory, its validity was tested in a retrospective
study of 235 preterm infants. This study was designed to examine the influence of
“consistency nursing care” on the health outcomes of the infants at discharge. Structural
equation modeling demonstrated “strong support for the utility of this theory of health
promotion . . . as a guide for nursing practice in the NICU” (p. 266). It was noted that the

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derived middle range theory validated Levine’s work.

In other examples, Hastings-Tolsma (2006) developed the Theory of Diversity of Human Field Pattern
from Martha Rogers’s Science of Unitary Human Beings. Cazzell (2008) employed the Neuman Systems
Model as a basis for the middle range theory of adolescent vulnerability to risk behaviors, and in another
work, Polk (1997) cited the work of both Margaret Newman and Martha Rogers as sources contributing to her
middle range theory of resilience.

Several middle range theories were found which were developed from the Roy Adaptation Model (RAM).
In one example, Dobratz (2011) derived the Theory of Psychological Adaptation in death and dying from a
series of studies linked to the RAM, and in a similar example, she synthesized the middle range Theory of
Adaptive Spirituality based on 21 published studies in which the RAM examined aspects of spirituality
(Dobratz, 2016). In other examples, Hamilton and Bowers (2007) developed the Theory of Genetic
Vulnerability from Roy’s work, and Troutman-Jordan (2015) applied the results of a concept analysis within
the RAM to develop the Theory of Successful Aging. Finally, Roy (2014) described synthesis of a middle
range Theory of Coping using concepts and processes from the RAM.

Middle Range Theory Combining Existing Nursing and Non-Nursing Theories
Combining concepts or elements of multiple theories is common in middle range theory development. In
many cases found in recent nursing literature, the authors of a middle range theory reported that they had
derived their theory from both nursing and non-nursing theories. For example, Sousa and Zauszniewski
(2005) used Orem’s Self-Care Theory and Bandura’s Self-Efficacy Theory to develop a theory of diabetes
self-care management. Similarly, Ulbrich (1999) developed the Theory of Exercise as Self-Care through
“triangulation of Orem’s self-care deficit theory of nursing, the transtheoretical model of exercise behavior,
and characteristics of a population at risk for cardiovascular disease” (p. 65). In another example, Reed (2014)
used the philosophic views of Rogers’s Science of Unitary Human Beings to relate the nursing perspective to
self-transcendence. For this theory, Rogers’s work was used as a framework, and it was reportedly combined
with concepts and processes from developmental psychologists, including Piaget and Fagan. Finally, Dunn
(2004) combined several non-nursing theories with the RAM to develop her middle range Theory of Adaption
to Chronic Pain (see Nursing Exemplar 3).

NURSING EXEMPLAR 3: MIDDLE RANGE
THEORY COMBINING EXISTING NURSING
AND NON-NURSING THEORIES
Dunn (2004) provided an excellent example of combining existing nursing and non-
nursing theories in development of a middle range Theory of Adaptation to Chronic Pain.
Her intention was to describe coping and pain control in older adults with the purpose of
maintaining their quality of life and functional ability.

Theory Development Process: Dunn wrote that the first step in developing her theory
was to review and synthesize the theoretical knowledge related to pain in older adults,
coping with pain, religious coping, and spirituality. She reported identification of three
theoretical models that addressed concepts related to pain control and coping in older
adults. These were Melzack and Wall’s (1992) Gate Control Theory of Pain, Lazarus and
Folkman’s (1984) Stress and Coping Theory, and Wallace, Benson, and Wilson’s (1971)
Relaxation Response. To ensure that the final model was applicable to nursing, she
selected the RAM to guide the theory development process.

The second step reported by Dunn was to define assumptions for the theory; these
were reportedly based on the assumptions from the four models from which the theory
was drawn. Using the process of theoretical substraction, she then took concepts,

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relational statements, and propositions from the existing theories and arranged them into a
diagram to represent the theoretical and operational systems. Finally, the concepts from
the Adaptation to Chronic Pain Model were linked to empirical indicators to provide a
logical and consistent connection.

Middle Range Theory Derived From Non-Nursing Disciplines
A significant number of middle range nursing theories are developed from one or more non-nursing theories.
Indeed, non-nursing theories, including those from the behavioral sciences, sociology, physiology, and
anthropology, appear to be the most common source for theory development, and many examples are evident.
Kolcaba’s Theory of Comfort, for example, was reportedly derived from a review of literature from medicine,
psychiatry, ergonomics, and psychology as well as from nursing literature and history (Dowd, 2014). Role
Theory was foundational for both Meleis’s Transitions Theory (Meleis, 2015) and Mercer’s Theory of
Maternal Role Attainment (Meighan, 2014). In other examples, Benner explained that the Dreyfus Model of
Skill Acquisition, developed by a mathematician and a philosopher, was the primary source for her work
(Brykczynski, 2014) and Mishel’s Uncertainty in Illness Theory incorporated elements of Chaos Theory
(Mishel, 2014).

In a work of theory synthesis, Pickering and Phillips (2014) described how their model for elder
mistreatment was derived from several sources including Caregiver Burden Theory, theories describing “non-
normal caregivers,” Transgenerational Transmission of Violence Theory, ecological theory, the Family
Caregiving Dynamics Model, and the Phenomenon of Caregiver Dependency. Lastly, Covell (2008) explained
how she derived the middle-range Theory of Nursing Intellectual Capital from a number of organizational
behavior theories (see Nursing Exemplar 4).

NURSING EXEMPLAR 4: MIDDLE RANGE
THEORY DERIVED FROM A NON-NURSING
DISCIPLINE
Covell (2008) proposed the middle range Theory of Nursing Intellectual Capital to explain
the influence of nurses’ knowledge, skills, and experience on patient and organizational
outcomes.

Theory Development Process: Covell (2008) described using strategies of concept and
theory derivation followed by research synthesis to develop and support the theory’s
propositions. Specifically, she noted how “Intellectual Capital Theory” (ICT) consisted of
concepts from economics, accounting, and organizational learning theory. Key concepts
or elements from ICT applied to her work were human capital, structural capital, relational
capital, social capital, and business performance outcomes.

In applying ICT to nursing, Covell (2008) explained that she followed the steps in
Walker and Avant’s process of theory derivation to identify and define the theory’s major
concepts: nursing human capital and nursing structural capital. She also identified two
factors within the work environment that influences nursing human capital—specifically
nurse staffing and employer support for continuing professional developing. Following
this, she proposed relationships among the concepts and illustrated how they influence
both patient and organizational outcomes (Figure 10.2).

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Figure 10-2 Middle range nursing intellectual capital theory.
(From Covell, C. L. [2008]. The middle-range theory of nursing intellectual capital. Journal of Advanced Nursing,
63[1], 94–103. Reprinted with permission of John Wiley and Sons.)

Several middle range nursing theories have been derived from theories or models of behavioral change.
Frequently cited are the Health Belief Model (Becker & Maiman, 1975; Rosenstock, 1990), the Theory of
Reasoned Action (Ajzen & Fishbein, 1980), and the Social Learning/Social Cognitive Theory (Bandura, 1977,
1986), along with others. Table 10-2 lists some of these middle range theories and gives sources from which
the theorist claims derivation of portions of their work.

Table 10-2 Middle Range Nursing Theories Derived From Behavioral Theories
Theory Non-Nursing Theory Source(s)

Commitment to Health Theory (Kelly, 2008) Transtheoretical Model of Behavior Change
Recovery Alliance Theory of Mental Health Nursing
(Shanley & Jubb-Shanley, 2007)

Humanistic Philosophy

Health Promotion Model (Pender, Murdaugh, &
Parsons, 2015)

Social Learning Theory and Expectancy-Value
Theory

Theory of Care-Seeking Behavior (Lauver, 1992) Health Belief Model and the Theory of Reasoned
Action

Medication Adherence Model (Johnson, 2002) Health Belief Model, Social Learning Theory, the
Theory of Reasoned Action, and the Self-Regulation
Model

Self-Efficacy in Nursing Theory (Lenz &
Shortridge-Baggett, 2002)

Social Learning Theory

Theory of Prenatal Care Access (Phillippi & Roman,
2013)

Lewin’s Theory of Human Behavior

Cues to Participation in Prostate Screening (Nivens,
Herman, Pweinrich, & Weinrich, 2001)

Health Belief Model, Social Learning Theory

Model for Cross-Cultural Research (Poss, 2001) Health Belief Model, Theory of Reasoned Action

Middle Range Theory Derived From Practice Guidelines or Standard of Care
Practice guidelines or standards of care appear to be the least common source for middle range theory
development, as only a few examples could be found. In one example, the Public Health Nursing Practice
Model (K. Smith & Bazini-Barakat, 2003) was developed by “melding of nationally recognized components”
(p. 44) of public health nursing (PHN) practice. The identified components were the Standards of PHN
practice, the 10 Essential Public Health Services, Healthy People 2010’s 10 Leading Health Indicators, and
Minnesota’s Public Health Interventions Model. In other examples, Good (1998) used clinical guidelines for
management of postoperative pain to develop a middle range Theory of Acute Pain Management, and Huth
and Moore (1998) used practice standards to develop a Theory of Acute Pain Management in infants and
children. Finally, Ruland and Moore (1998) used standards of care to develop the Theory of the Peaceful End

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of Life from standards of care for terminally ill patients (see Nursing Exemplar 5).

NURSING EXEMPLAR 5: MIDDLE RANGE
THEORY DERIVED FROM PRACTICE
GUIDELINES OR STANDARD OF CARE
Ruland and Moore (1998) developed the Theory of the Peaceful End of Life from
standards of care for terminally ill patients. In this work, the theorists observed that
relational statements of the standards needed to be more specifically defined to make them
applicable for empirical testing. Because the standards were too specific, they were too
detailed to illustrate the major themes succinctly.

Theory Development Process: The first step of the theory development process was to
define the theory’s assumptions based on the standards of care. The second step was to
perform a “statement synthesis,” whereby five outcome criteria were developed that
contributed to a peaceful end of life (not being in pain, experiencing comfort,
experiencing dignity and respect, being at peace, and experiencing closeness to significant
others or another caring person). For the third step, conceptual definitions for each of the
outcome indicators were determined, and the fourth step involved defining relational
statements between the outcome indicators and the nursing interventions. In this step, all
process criteria from the standard were examined and combined into “prescriptors” to
facilitate the desired outcome. The process of theory synthesis was then used to combine
the relational statements into an integrated structure or theory. The final step was to draw
a diagram of the relationships as a model (Figure 10-3).

Figure 10-3
Theory of peaceful end of life: Relationships between the
concepts of the theory.

(Reprinted from Ruland, C. M., & Moore, S. M. [1998]. Theory construction based on standards of care: A proposed
theory of the peaceful end of life. Nursing Outlook, 46[4], 174. Used with permission from Elsevier.)

Final Thoughts on Middle Range Theory Development
Middle range theories should be “user-friendly” in language and style. They need to be described with
practice implications in journals that practicing nurses are likely to read, and the theorists need to identify
implications and specific interventions suggested by the theory (Lenz, 1996). Liehr and Smith’s (1999)

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specific recommendations to enhance development and use of middle range theory include:

Clearly articulate the theory name.
Succinctly describe approaches used for generating the theory.
Clarify the conceptual linkages of the theory in a diagrammed model.
Elucidate the research–practice links of the theory.
Explain the association between the theory and the discipline of nursing.

Analysis and Evaluation of Middle Range Theory
The move to enhance middle range theory development and use in nursing practice and research necessitates
corresponding analysis and critique. Like grand theories and conceptual frameworks, middle range theories
should be subject to evaluation. In addition, research guided by middle range theory should be congruent with
the philosophical underpinnings of the theory and should be critiqued with regard to more than just the
statistical significance of the findings.

Whall (2016) specifically addressed analysis and evaluation of middle range theory. Her criteria modified
the guidelines she used for analysis and evaluation of grand nursing theories. The modifications removed
explicit review of the metaparadigm concepts, which are assumed to be more implicit than explicit in middle
range theory, and added questions regarding the congruence and fit of the middle range theory with the
existing nursing perspective and domains. Furthermore, Whall explained that middle range theories should
provide specific empirical referents for defined concepts. The ability to operationalize and measure aspects of
the theory is extremely important in middle range theory, and operational definitions should be evaluated.
Finally, she suggested analysis of middle range theories to assess their congruence with grand theories.

Smith (2014) also proposed a format for evaluation of middle range theories. She suggested evaluation
based on three categories: substantive foundations, structural integrity, and functional adequacy. When
evaluating substantive foundations, one would determine whether the theory was within the focus of nursing;
whether assumptions are specified and congruent with the focus; whether the theory provides substantive
description, explanation, or interpretation of a phenomenon that would be considered middle range; and
whether the theory is rooted in practice or research experience. Evaluation of structural integrity would
determine whether concepts are clearly defined and at the middle range of abstraction, whether the number of
concepts is appropriate, and whether the concepts and relationship are logically represented with a model.
Evaluation of functional adequacy examines whether the theory can be applied in practice or with various
client groups, if empirical indicators have been identified for theoretical concepts, and if there are published
examples of use of the theory in practice or research.

Chapter 5 includes a more detailed discussion of analysis and evaluation of middle range theories. In
addition, the synthesized method for theory evaluation (see Box 5-3, p. 107) can be used as a guide for
analysis and evaluation of middle range theory.

Summary
This chapter has described the current emphasis of nursing theory development, which focuses on efforts to
construct, test, refine, and evaluate middle range theories. To help advance the discipline, nurses should be
encouraged to write and publish papers that describe middle range theories and report research studies in
which a middle range theory has been used. This process of middle range theory generation and refinement
will further develop the discipline’s substantive knowledge base.

Annette Cohen, the graduate student in the opening case study who was working toward development of a
theory of spiritual health, related it to the practice of hospice nursing. Like Annette, nurses in all settings
should strive to learn about existing or emerging middle range theories or seek to develop and describe
theories that will explain phenomena they observe in practice.

Nursing has the knowledge, skills, manpower, and resources to move beyond delineation of conceptual
models and domain concepts to emphasize development and application of middle range theory. Middle range
theory holds much promise for the evolution of the discipline’s science and practice. But, as Liehr and Smith
(1999) pointed out, the challenge is to develop middle range theories that are empirically sound, coherent,

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meaningful, useful, and illuminating.

Key Points
Middle range nursing theories were first introduced into nursing in the mid-1970s; their number and use

have grown dramatically in the last decade.
Middle range theories are more specific, have fewer concepts, and encompass a more limited aspect of the

real world compared with grand nursing theories; they are also more readily testable in research.
Middle range theories may be developed through research, practice, or literature synthesis; they may be

derived from grand nursing theories or non-nursing theories; or they may be derived from practice
guidelines and standards.

Before being used in a research study or applied in practice, middle range nursing theories should be
analyzed or evaluated.

Learning Activities
1. Search current nursing journals for examples of the development, analysis, or use of middle

range theories in the discipline of nursing. Can any trends be identified?
2. Select one of the middle range theories derived from a grand nursing theory and one derived

from a non-nursing theory. Analyze both for ease of application to research and practice.
3. Annette, the nurse from the opening case study, determined that she wanted to develop a

middle range theory of spiritual health. Consider a concept of interest or one relevant to your
practice. How could you develop the concept into a preliminary middle range theory
following one of the processes presented in this chapter?

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11

Overview of Selected Middle Range Nursing Theories
Melanie McEwen

Elaine Chavez is employed as a nurse at a public health clinic in an urban area. She is also in her second
semester of a graduate nursing program preparing to become a mental health nurse practitioner. In her
practice, Elaine has worked with a number of women who have been abused by their partners, and she has
observed a pattern of comorbidities in these women, including depression, alcoholism, substance abuse, and
suicide attempts. Over the last few months, Elaine has reviewed the nursing literature and identified several
intervention strategies that have been effective in working with women who have been victims of domestic
violence. Using this information, she would like to implement a program to promote early identification of
abuse and multiple-level interventions. This is a project that will work well with one of her master’s portfolio
assignments.

From her literature review, Elaine identified several theories related to her study. She was particularly
interested in examining the set of circumstances that would cause the women to seek help. For this, she
performed a more detailed literature review and identified Kolcaba’s (2003, 2017) Theory of Comfort, which
helped her conceptualize many of the issues faced by abused women. Indeed, the theory described individual
characteristics that contributed to health-seeking behavior. These were stimulus situations, which can cause
negative tension. By providing comfort measures, the nurse can help decrease negative tensions and promote
positive tension. Elaine wanted to continue to identify comfort measures that would encourage the women to
seek care for their problems.

For the next phase of her project, Elaine collected all of the information she could find on Kolcaba’s
theory. This included studies that had used the model as a conceptual framework and studies that had tested
the model. From that information and the articles she had gathered previously about issues related to domestic
violence, she was able to draft a set of interventions that she hoped to implement at the clinic following
approval by her supervisor.

Previous chapters have described the growing emphasis on the development and testing of middle range
theories in nursing. As a result, during the past two decades, a significant number of these theories have been
presented in the nursing literature. The purpose of this chapter is to introduce some of the commonly used
middle range nursing theories as well as some of the recently published ones to familiarize readers with these
works and direct them to resources for more information. An attempt was made to include works from a
variety of areas and from many scholars but by no means is the list presented here exhaustive. Nor does
inclusion or exclusion relate to the quality or significance of the theory or its usefulness in research or
practice.

To assist with organization of the chapter, the theories are divided into sections based on whether they
appear to be “high,” “middle,” or “low” middle range theories. As explained in Chapter 10, the
high/middle/low distinction relates to the level of abstraction as posed by Liehr and Smith (1999), with the
“high” middle range theories being the most abstract and nearest to the grand theories. The “low” middle
range theories, on the other hand, are the least abstract, and they are similar to practice or situation-specific
theories. It is noted that these designations are arguably arbitrary and that one theory that is listed here as
“high middle” may be considered by others to be a grand theory. Likewise, another theory listed here as

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“middle middle” might be considered by others to be a high middle range theory, and so forth.
Elements of theory description and theory analysis as explained in Chapter 5 serve as the basis for the

more detailed discussions of selected theories. Each will include a brief overview, an outline of the purpose
and major concepts of the theory, and context for use and nursing implications. Finally, evidence of empirical
testing and application in practice are described (Box 11-1).

Box 11-1 American Association of Colleges of Nursing Essentials
Middle range theory is vital for the ongoing development of the nursing profession. Indeed, according to the
doctorate of nursing practice “essentials,” “Nursing science frames the development of middle range theories
and concepts to guide nursing practice” (American Association of Colleges of Nursing, 2006, p. 9).

High Middle Range Theories
The high middle range theories presented here are some of the most well-known and widely used theories in
nursing. Included are the works of Benner, Leininger, Pender, and Meleis. These theories may be considered
grand theories or conceptual frameworks by other nursing scholars and possibly by the author of the theory.
These theories, however, do not totally fit with the criteria for grand theories as outlined in this text and
therefore are not covered in the chapters dealing with that content. In addition, the Synergy Model, a nursing
model that is widely used in research and practice, particularly in critical care, will be discussed. Table 11-1
lists other high middle range theories or conceptual models, their purposes, and major concepts.

Table 11-1 High Middle Range Nursing Theories
Theory/Model Purpose Major Concepts

Tidal model
(psychiatric and
mental health
nursing)
(Barker, 2001a,
2001b)

Describes psychiatric nursing
practice focusing on three care
processes; emphasizes the fluid
nature of human experience
characterized by change and
unpredictability

Personhood (dimensions—world, self, others), discrete
holistic (exploratory) assessment; focused (risk)
assessment, empowerment, narrative as the medium of
self

Spiritual Care
in Nursing
Practice Theory
(Burkhart &
Hogan, 2008)

Describes the process in which
positive nurse–patient spiritual
encounters can lead to positive
spiritually growth-filled
memories that will increase
nurses’ spiritual well-being

Patient cue, decision to engage/not engage, spiritual
intervention, immediate emotional response (positive
or negative), search for meaning, formation of a
spiritual memory, spiritual well-being

Parish nursing
(Bergquist &
King, 1994)

Describes the integration of
physical, emotional, and
spiritual components in
provision of holistic health care
in a faith community

Client (spiritual, physical, emotional components),
parish nurse (spiritual maturity, pastoral team member,
autonomy, caring, effective communication), health
(physical, emotional, and spiritual wellness and
wholeness), environment (faith community)

Parish nursing
(L. W. Miller,
1997)

Integrates the concepts of
evangelical Christianity with
application of parish nursing
interventions

Person/parishioner, health, nurse/parish nurse,
community/parish, the triune God

Neal Theory of
Home Health
Nursing (Neal,
1999a, 1999b)

Describes the practice of home
health nurses as they use
process of adaptation to attain
autonomy

Autonomy, three stages (dependence, moderate
dependence, and autonomy), logistics, client’s home,
client’s resources, client’s needs, and learning capacity

Occupational Shows how the occupational Work setting influences (corporate culture/mission,

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health nursing
(Rogers, 1994)

health nurse works to improve,
protect, maintain, and restore
the health of the
worker/workforce and depicts
how practice is affected by both
external and internal work
setting influences

resources, work hazards, workforce characteristics),
external factors (economics, population/health trends,
legislation/politics, technology), occupational health
nursing practice (health promotion, workplace hazard
detection, case management/primary care, counseling,
management, research, legal/ethical monitoring,
community orientation)

Omaha System
(Martin, 2005)

Comprehensive classification
system that promotes
documentation of client care,
generally in community and
home health nursing practice

Depicts the nursing process as circular rather than
linear; steps are collect and assess data, state problems,
identify admission problem rating, plan and intervene,
identify interim/dismissal problem rating, and evaluate
problem outcomes.

Schuler Nurse
Practitioner
Practice Model
(Shuler &
Davis, 1993)

Integrates essential nursing and
medical orientations to provide
a framework for holistic
practice for nurse practitioners
(NP)

Patient and NP inputs (noted as episodic and
comprehensive with and without health problem); data
gathering/role modeling; patient and NP throughputs
include identification of problems and diagnosing,
contracting, and planning and implementing of the
plan of care. Outputs involve comprehensive
evaluation of patient and NP outcomes.

Public health
nursing practice
(K. Smith &
Bazini-Barakat,
2003)

Guides public health nurses to
improve the health of
communities and target
populations

Interdisciplinary public health team, standards of
public health nursing practice, essential public health
services, health indicators, population-based practice
(systems, community, individual, and family focus),
healthy people in health communities

Rural nursing
(Weinert &
Long, 1991)

Guides rural nursing practice,
research, and education by
understanding and addressing
the unique health care needs
and preferences of rural persons

Health (health as ability to work), environment
(distance and isolation), person (self-reliance and
independence), nursing (lack of anonymity,
outsider/insider, and old-timer/newcomer)

Benner’s Model of Skill Acquisition in Nursing
Patricia Benner’s theoretical model was first published in 1984. The model, which applies the Dreyfus model
of skill acquisition to nursing, outlines five stages of skill acquisition: novice, advanced beginner, competent,
proficient, and expert. Although Benner’s work is much more encompassing in regard to nursing domains and
specific functions and interventions, it is the five stages of skill acquisition that has received the most attention
with regard to application in administration, education, practice, and research.

Purpose and Major Concepts
Benner’s model delineates the importance of retaining and rewarding nurse clinicians for their clinical
expertise in practice settings because it describes the evolution of “excellent caring practices.” She notes that
research demonstrates that practice grows “through experiential learning and through transmitting that
learning in practical settings” (Benner, 2001, p. vi). Expertise develops when the clinician tests and refines
propositions, hypotheses, and principle-based expectations in actual practice situations. Finally, the model
seeks to describe clinical expertise including six areas of practical knowledge (graded qualitative distinctions;
common meanings; assumptions, expectations, and sets; paradigm cases and personal knowledge; maxims;
and unplanned practices) (Benner, Tanner, & Chesla, 2009).

The central concepts of Benner’s model are those of competence, skill acquisition, experience, clinical
knowledge, and practical knowledge. She also identifies the following seven domains of nursing practice:

Helping role
Teaching or coaching function

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Diagnostic client-monitoring function
Effective management of rapidly changing situations
Administering and monitoring therapeutic interventions and regimens
Monitoring and ensuring quality of health care practices
Organizational and work-role competencies (Benner, 2001)

Context for Use and Nursing Implications
The Benner model has been used extensively as rationale for career development and continuing education in
nursing. Areas specifically cited for utilization include nursing management, career enhancement, clinical
specialization, staff development programs, staffing, evaluation, clinical internships, and precepting students
and novice nurses (Benner, 2001; Benner et al., 2009).

Evidence of Empirical Testing and Application in Practice
Over the previous decade, dozens of articles have been written based on Benner’s model, and a number of
these were research-based studies. For example, Wilson, Harwood, and Oudshoorn (2015) examined the
“perpetual novice phenomenon,” and Cates and colleagues (2015) employed a Delphi method to develop a
simulation-based competency assessment instrument for neonatal nurse practitioners, both based on Benner’s
model. In other research, Meretoja and Koponen (2012) used Benner’s model to compare nurses’ optimal and
actual competencies in clinical settings, and Abraham (2011) reported on a study to evaluate a program based
on Benner’s model, which was designed to develop leadership skills and professionalism. Lastly, Homard
(2013) reported on a correlational study which used Benner’s novice-to-expert theory to compare exit
examination scores and National Council Licensure Examination for Registered Nurses (NCLEX-RN) pass
rates among students in a prelicensure nursing program following implementation of a program using
standardized testing. Non–research-based articles included a report by Woody and Davis (2013) which
described how to use Benner’s model to develop and implement an educational module designed to improve
nurse competence in peripheral intravenous therapy.

A fairly common theme was noted as several writers discussed Benner’s applicability in development of
procedures and protocols for orientation of new graduates or nurses into new specialty areas. For example,
using Benner’s model, Koharchik, Caputi, Robb, and Culleiton (2015) presented a process which can be used
by clinical faculty and preceptors to develop clinical reasoning in nursing students; Coyle (2011) discussed an
internship program in home health for new graduates; and Dumchin (2010) described a method for using
online learning experiences to develop perioperative nurses. Finally, Benner’s work was used in several
articles (e.g., Bitanga & Austria, 2013; Haag-Heitman, 2012; Owens & Cleaves, 2012) to discuss the
development or updating of career enhancement or clinical ladder programs.

Leininger’s Cultural Care Diversity and Universality Theory
Madeleine Leininger was instrumental in demonstrating to nurses the importance of considering the impact of
culture on health and healing (Leininger, 2002). Prior to her death in 2012, Leininger was a prolific nursing
researcher and scholar, and she is credited with starting the specialty of transcultural nursing. In addition, she
was a leading proponent of the idea that nursing is synonymous with caring.

Leininger reported that she conceptualized transcultural nursing as a distinct area of nursing practice in the
late 1950s during her doctoral work in anthropology; she continued to study and develop a transcultural
nursing conceptual framework throughout the 1960s. In the mid-1970s, she presented a “transcultural health
model” that was expanded in 1978 and 1980. The Leininger Sunrise Model was first described as such in
1984 and depicts the transcultural dimensions of culturologic interviews, assessments, and therapies
(McFarland, 2014; McFarland & Wehbe-Alamah, 2015).

Purpose and Major Concepts
The purpose of Leininger’s theory is to generate knowledge related to the nursing care of people who value
their cultural heritage and lifeways. Major concepts of the model are culture, culture care, and culture care
differences (diversities) and similarities (universals) pertaining to transcultural human care. Other major
concepts are care and caring, emic view (language expressions, perceptions, beliefs, and practice of

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individuals or groups of a particular culture in regard to certain phenomena), etic view (universal language
expression beliefs and practices in regard to certain phenomena that pertain to several cultures or groups), lay
system of health care, professional system of health care, and culturally congruent nursing care (Leininger,
2007; McFarland, 2014).

Context for Use and Nursing Implications
The goal for application of Leininger’s theory is to provide culturally congruent nursing care to persons of
diverse cultures. A central tenet of the theory is that it is important for the nurse to understand the individual’s
view of illness. Also, the focus is on recognizing and understanding cultural similarities and differences and
using this information to positively influence nursing care and health (McFarland & Wehbe-Alamah, 2015).
The theory has been widely used for research, and findings are appropriate for nurses in any setting who work
with individuals, families, and groups from a cultural background different from the nurse’s.

Evidence of Empirical Testing and Application in Practice
Leininger (2007) explained that her theory was derived and refined through a number of years of study. Over
the past two decades, research on various groups was conducted, and she listed cultural values and culture
care meanings and action modes for 23 cultural groups in her book. Many graduate students and nursing
scholars have used Leininger’s theory as a basis for research, and as a result, hundreds of examples of articles
can be located in the literature. Many of these used Leininger’s work as a conceptual framework to study
cultural implications of a variety of health problems. For example, J. M. Long and colleagues (2012)
examined health beliefs among four different Latino subgroups specifically related to type 2 diabetes; Gillum
and colleagues (2011) researched cardiovascular disease in the Amish; Mixer, Fornehed, Varney, and Lindley
(2014) examined end-of-life care for people in rural Appalachia; and López-Entrambasaguas, Granero-
Molina, and Fernandez-Sola (2013) studied the incidence of HIV/AIDS among a group of sex workers in
Bolivia.

Leininger’s model has also been used by many authors to identify variables or characteristics of cultural
groups or subcultures that might influence health. For example, Farren (2015) performed a comprehensive
literature review of research that examined cultural differences in cancer survivors’ perceptions and
experiences to promote patient-centered, culturally congruent care for adult cancer patients, and Lee (2012)
used Leininger-inspired “ethnonursing research methods” to discover care meanings and expression among
Appalachian mothers living with their children in a homeless shelter. Other examples of research studies using
Leininger’s model are listed in Box 11-2.

Box 11-2
Research Studies Using Leininger’s Theory of Cultural Care Diversity
and Universality

Bhat, A. M., Wehbe-Alamah, H., McFarland, M., Filter, M., & Keiser, M. (2015). Advancing cultural
assessments in palliative care using web-based education. Journal of Hospice and Palliative Nursing,
17(4), 348–354.

Doornbos, M. M., Zandee, G. L., & DeGroot, J. (2014). Attending to communication and patterns of
interaction: Culturally sensitive mental health care for groups of urban, ethnically diverse, impoverished
and underserved women. Journal of the American Psychiatric Nurses Association, 29(4), 239–249.

McCullagh, M. C., Sanon, M. A., & Foley, J. G. (2015). Cultural health practices of migrant seasonal
farmworkers. Journal of Cultural Diversity, 22(2), 64–67.

Millender, E. (2012). Acculturation stress among Maya in the United States. Journal of Cultural Diversity,
19(2), 58–64.

Missal, B. (2013). Gulf Arab women’s transition to motherhood. Journal of Cultural Diversity, 20(4), 170–
176.

Morris, E. J. (2012). Respect, protection, faith, and love: Major care constructs identified within the
subculture of selected urban African American adolescent gang members. Journal of Transcultural
Nursing, 23(3), 262–269.

Street, D. J., & Lewallen, L. P. (2013). The influence of culture on breast-feeding decisions by African
American and white women. The Journal of Perinatal & Neonatal Nursing, 27(1), 43–51.

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Tasçi-Duran, E., & Sevil, U. (2013). A comparison of the prenatal health behaviors of women from four
cultural groups in Turkey: An ethnonursing study. Nursing Science Quarterly, 26(3), 257–266.

Turk, M. T., Fapohunda, A., & Zoucha, R. (2015). Using photovoice to explore Nigerian immigrants’ eating
and physical activity in the United States. Journal of Nursing Scholarship, 47(1), 16–24.

A number of nonresearch articles describing aspects of transcultural nursing and focusing on Leininger’s
works have also been published in recent years. These include a review of a workshop to enhance cultural
awareness for nurse practitioners (Elminowski, 2015); a report on how to provide culturally competent,
patient-centered nursing care (Darnell & Hickson, 2015); and an article describing the impact of international
service learning on nursing student’s cultural competence (T. Long, 2016).

Pender’s Health Promotion Model
Nola Pender began studying health-promoting behavior in the mid-1970s and first published the Health
Promotion Model (HPM) in 1982. She reported that the model was constructed from expectancy-value theory
and social cognitive theory using a nursing perspective. The model was modified slightly in the late 1980s and
again in 1996 (Pender, Murdaugh, & Parsons, 2015).

Purpose and Major Concepts
The HPM was proposed as a framework for integrating nursing and behavioral science perspectives on factors
that influence health behaviors. The model is to be used as a guide to explore the biopsychosocial processes
that motivate individuals to engage in behaviors directed toward health enhancement (Pender et al., 2015).
The model has been used extensively as a framework for research aimed at predicting health-promoting
lifestyles as well as specific behaviors.

Major concepts of the HPM are individual characteristics and experiences (prior related behavior and
personal factors), behavior-specific cognitions and affect (perceived benefits of action, perceived barriers to
action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences), and
behavioral outcomes (commitment to a plan of action, immediate competing demands and preferences, and
health-promoting behavior). Figure 11-1 shows the HPM.

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Figure 11-1 Health Promotion Model.
(Adapted from Pender, N. J., Murdaugh, C. L., & Parsons, M. A. Health Promotion in Nursing Practice, 7th ed., © 2015. Reprinted by
permission of Pearson Education, Inc., New York, New York.)

Context for Use and Nursing Implications
Health promotion interventions are essential for improving the health of populations everywhere. It is noted
that people of all ages can benefit from health promotion care, which should be delivered at sites where
people spend much of their time (e.g., schools and workplaces). Nurses can develop and execute health-
promoting interventions for individuals, groups, and families in schools, nursing centers, occupational health
settings, and the community at large. Per the HPM, nurses should work toward empowerment for self-care
and enhancing the client’s capacity for self-care through education and personal development.

Evidence of Empirical Testing and Application in Practice
Pender and colleagues (2015) wrote that the model has been used by a very significant number of nursing
scholars and researchers and has been useful in explaining and predicting specific health behaviors. Indeed, in
the last decade, more than 250 English language articles that reported using or applying Pender’s HPM have
been published.

Most research studies used Pender’s work as one component of a conceptual framework for study. For
example, Park, Choi-Kwon, and Han (2015) used the HPM to study health behaviors of Korean nursing
students related to obesity and osteoporosis, and Jackson and colleagues (2016) used the model to explain the
relationship between several factors including physical functioning, personal factors, and behavioral
influences on physical activity between prehypertensive and hypertensive African American women. Also
focusing on physical activity, Hatzfeld, Nelson, Waters, and Jennings (2016) used the HPM to examine
factors influencing health behaviors among active duty air force personnel.

Other studies use health promotion as an outcome or to predict behaviors. Burns, Murrock, and Graor
(2012), for example, used the model to identify the relationship between body mass and injury severity among
adolescents, concluding that overweight/obese adolescents may be at increased risk for serious injury.

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Additional examples of recent research studies using Pender’s HPM are listed in Box 11-3.

Box 11-3 Research Studies Using Pender’s Health Promotion Model
Anderson, K. J., & Pullen, C. H. (2013). Physical activity with spiritual strategies intervention: A cluster

randomized trial with older African American women. Research in Gerontological Nursing, 6(1), 11–21.
Bhandari, P., & Kim, M. Y. (2016). Predictors of the health-promoting behaviors of Nepalese migrant

workers. The Journal of Nursing Research, 24(3), 232–239.
Bryer, J., Cherkis, F., & Raman, J. (2013). Health-promotion behaviors of undergraduate nursing students: A

survey analysis. Nursing Education Perspectives, 34(6), 410–415.
Kim, H. J., Choi-Kwon, S., Kim, H., Park, Y. H., & Koh, C. K. (2015). Health-promoting lifestyle behaviors

and psychological status among Arabs and Koreans in the United Arab Emirates. Research in Nursing &
Health, 38(1), 133–141.

Lubinska-Welch, I., Pearson, T., Comer, L., & Metcalfe, S. E. (2016). Nurses as instruments of healing: Self-
care practices of nursing in a rural hospital setting. Journal of Holistic Nursing, 34(3), 223–228.

McClune, A. J., & Conway, A. (2016). Farm safety: A tale of translational research and collaboration.
Pediatric Nursing, 42(1), 31–35.

Valek, R. M., Greenwald, B. J., & Lewis, C. C. (2015). Psychological factors associated with weight loss
maintenance: Theory-driven practice for nurse practitioners. Nursing Science Quarterly, 28(2), 129–135.

Transitions Theory
Meleis (2010) wrote that the Transitions Theory evolved over the course of about four decades. She explained
that it began in practice with her observations of the experiences that humans face as they deal with changes
relating to health, well-being, and their ability to care for themselves. Meleis’s work moved through multiple
steps, including concept analysis and several comprehensive literature reviews. The result was a conclusion
that “transitions” is a central concept in nursing (Schumacher & Meleis, 1994). More focused attention
through observation and research has contributed to formal development, testing, and application of the theory
(Meleis, 2010).

Purpose and Major Concepts
Transitions Theory attempts to describe and attend to the interactions between nurses and patients, suggesting
that nurses are concerned with the experiences of people as they undergo transitions whenever health and
well-being are the desired outcome. The goal of “nursing therapeutics,” then, is to conceptualize and address
the potential problems that individuals encounter during transitional experiences and develop preventative and
therapeutic interventions to support the patient during these occasions (George & Hickman, 2011; Im, 2014;
Meleis, 2010).

Meleis (2010) defined transitions as “a passage from one fairly stable state to another fairly stable state,
and it is a process triggered by a change” (p. 11). Furthermore, transitions are characterized by different
stages, milestones, and turning points. These changes, or transitions, can be assisted or managed by nurses as
they care for patients.

Numerous years of research and analysis into transitions led Meleis and her colleagues to the
identification “of four major categories of transitions that nurses tend to be involved in” (Meleis, 2010, p. 3).
These transitions and representative examples are:

Developmental transitions—birth, adolescence, menopause, aging, death
Situational transitions—changes in educational and professional roles, changes in family situations

(e.g., divorce, widowhood), or changes in living arrangements (e.g., move to a nursing home,
homelessness)

Health–illness transitions—recovery process, hospital discharge, diagnosis of chronic illness
Organizational transition—changing environmental conditions that affect the lives of clients; may be

social, political, or economic (Im, 2014)

Other key concepts include “patterns” and “properties” of the transitions. Patterns denote whether the

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transitions are single, multiple, sequential, simultaneous, related, or unrelated. Properties of the transition
experience are often interrelated in a complex way and refer to awareness, engagement, change/difference,
time span, and critical points and events (Im, 2014).

In Transitions Theory, the nurse must consider the “facilitators” and “inhibitors” of the transition
conditions. These include personal meanings, cultural beliefs and attitudes, socioeconomic status, preparation,
and knowledge. Community conditions and societal conditions may also facilitate or inhibit transitions (Im,
2014).

“Nursing therapeutics” are those activities and actions that nurses may take during times of transitions
(Schumacher & Meleis, 1994). These include assessment of readiness (assessment of each of the transition’s
conditions), preparation for transition (typically involves education to enhance optimal conditions to prepare
for transition), and role supplementation (use of education and practice to facilitate the transitional process)
(George & Hickman, 2011). The outcomes of transitions, and potential for nursing therapeutics, include the
“patterns of response” of the patient. These are designated as process indicators (feeling connected,
interacting, locating and being situated, developing confidence, and coping) and outcome indicators (mastery
and “fluid integrative identities”) (Im, 2014). Figure 11-2 shows the interaction of the major constructs of the
theory.

Figure 11-2 Transitions Theory.
(From Meleis, A. I., Sawyer, L. M., Im, E.-O., Messias, D. K. H., & Schumacher, K. [2000]. Experiencing transitions: An emerging middle
range theory. ANS. Advances in Nursing Science, 23[10], 12–28. Used with permission.)

Context for Use and Nursing Implications
According to Meleis (2010), most nursing care occurs during a transition that the patient is experiencing, and
the goal of nursing care is to promote or encourage health outcomes during these occasions. Indeed, Meleis
and Trangenstein (1994) defined nursing as the art and science of facilitation of the transitions of health and
well-being and noted that nurses are concerned “with the processes and experiences of human beings
undergoing transitions where health and perceived well-being is the outcome” (p. 257).

Transitions Theory is widely applicable and provides a comprehensive guide that considers cultural and
social diversity. It was developed from multiple research studies among very diverse groups of people, during
many types of transitions. Additionally, it has been shown repeatedly to be able to direct nursing practice,
research, and education.

Evidence of Empirical Testing and Application in Practice
Transitions Theory has been based in both research and generated research (George & Hickman, 2011;
Meleis, 2010). Meleis (2010) compiled and published a history of the development of the theory along with
multiple examples of research and application in practice. Additional examples are becoming increasingly

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evident in the literature. Some of these focus on research examining patient transitions encountered by nurses
in various specialty areas. For example, Joly (2016) addressed supportive care for young people with
medically complex needs as they transition into adulthood; Rew, Tyler, Fredland, and Hannah (2012)
examined adolescents’ concerns as they transition through high school; Ekim and Ocakci (2016) looked at the
transitions involved in discharge planning for children with asthma; and Häggström, Asplund, and Kristiansen
(2012) researched patients’ transition from the intensive care unit (ICU).

Several research studies using Transitions Theory focused on the experience of caregivers. One (Beaudet
& Ducharme, 2013) such study identified transitions encountered by patients with Parkinson disease and their
caregivers. The intent was to develop more focused interventions to assist the caregivers. In another example,
Dossa, Bokhour, and Hoenig (2012) performed a grounded theory study that examined the transitions from
hospital to home for patients with mobility impairments and their family caregivers; they concluded that
health care providers need to improve systems to address patient concerns after discharge, focusing on
improving communication and coordination to facilitate recovery and prevent complications.

Finally, Geary and Schumacher (2012) presented an interesting look at the integration of Transitions
Theory with concepts from complexity science. They argued that the complexity of many of the transition
situations encountered by nurses today is better described when the theories are integrated, concluding that the
integration encourages recognition that transitions affect many, including the patients, their caregivers, health
care providers, and the health care system. Integration of the theories should enhance dialogue and promote
better understanding of the situations through changing outcomes for the better.

The Synergy Model
The Synergy Model for Patient Care was developed in the mid-1990s by a panel of nurses of the American
Association of Critical-Care Nurses (AACN) Certification Corporation as a framework for certified practice.
The initial model was revised somewhat, and the revised version was then used as the basis for the AACN’s
certification examination (Curley, 2007; Hardin, 2017).

Purpose and Major Concepts
The purpose of the Synergy Model is to articulate nurses’ contributions, activities, and outcomes with regard
to caring for critically ill patients. The model identifies eight patient needs or characteristics and eight
competencies of nurses in critical care situations (AACN, 2016; Pate, 2017). Of the many unique
characteristics nurses assess, the eight most consistently observed are listed in Box 11-4. The nursing
competencies denote how knowledge, skills, and experience are integrated within nursing care.

Box 11-4 The Synergy Model: Patient Characteristics and Nurse Competencies

Patient Characteristics
Resiliency
Vulnerability
Stability
Complexity
Resource availability
Participation in care
Participation in decision making
Predictability

Nurse Competencies
Clinical judgment
Clinical inquiry
Facilitation of learning
Collaboration
Systems thinking
Advocacy and moral agency

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Caring practices
Response to diversity

Source: AACN (2016).

The Synergy Model also describes three levels of outcomes—those relating to the patient, the nurse, and
the system. Patient outcomes include functional and behavioral change, trust, satisfaction, comfort, and
quality of life. Nurse outcomes include physiologic changes, presence or absence of complications, and extent
to which care objectives were attained. System outcomes include recidivism, costs, and resource utilization
(Curley, 1998, 2007). For more information, see AACN (2017).

Context for Use and Nursing Implications
As mentioned, the Synergy Model was originally developed to structure the AACN’s certification
examination by identifying nursing competencies that are essential for those providing care to the critically ill.
In 2002, assumptions of the model were expanded to establish it as a conceptual framework for designing
practice and developing competencies required to care for critically ill patients. Use of the Synergy Model in
practice is designed to optimize patient outcomes. When patient characteristics and nurse competencies match
and synergize, outcomes for the patient are optimal (Curley, 2007; Hardin, 2017). In addition, the model can
be used for developing nursing curricula and for conducting research (Curley, 2007; Hardin, 2017).

Evidence of Empirical Testing and Application in Practice
Although the Synergy Model is relatively new, a significant number of articles have been published
describing its use in practice. Identified were two articles that tested application of the model in critical care
situations. For example, Swickard, Swickard, Reimer, Lindell, and Winkelman (2014) described the process
of development of a tool to determine the appropriate level of care needed for interfacility patient transport,
using the Synergy Model as a guide. In another work, Stacy (2011) used the Synergy Model as a framework
when reporting on “progressive care units,” which are increasingly being used to bridge the gap between ICUs
and medical-surgical units. A few works (Hardin, 2012; Hart, Hardin, Townsend, Ramsey, & Mahrle-Henson,
2013; Tejero, 2012) described research studies using the Synergy Model as a framework. Box 11-5 shows
several examples of articles describing the model’s use in leadership/administration, practice, and education.

Box 11-5 The Synergy Model in Practice and Education
Goran, S. F. (2011). A new view: Tele-intensive care unit competencies. Critical Care Nurse, 31(5), 17–29.
Gralton, K. S., & Brett, S. A. (2012). Integrating the synergy model for patient care at Children’s Hospital of

Wisconsin. Journal of Pediatric Nursing, 27(1), 74–81.
Hardin, S. R. (2012). Engaging families to participate in care of older critical care patients. Critical Care

Nurse, 32(3), 35–40.
Hardin, S. R. (2015). Vulnerability of older patients in critical care. Critical Care Nurse, 35(3), 55–61.
Helman, S., Lisanti, A. J., Adams, A., Field, C., & Davis, K. F. (2016). Just-in-time training for high-risk

low-volume therapies: An approach to ensure patient safety. Journal of Nursing Care Quality, 31(1), 33–
39.

Jeffery, A. D., Christen, M., & Moore, L. (2015). Beyond a piece of paper: Learning to hire with synergy.
Nursing Management, 46(1), 52–54.

Kohr, L. M., Hickey, P. A., & Curley, M. A. Q. (2012). Building a nursing productivity measure based on
the synergy model: First steps. American Journal of Critical Care, 21(6), 420–430.

Schleifer, S. J., Carroll, K., & Moseley, M. J. (2014). Developing criterion-based competencies for tele-
intensive care unit. Dimensions of Critical Care Nursing, 33(3), 116–120.

Middle Middle Range Theories
A number of nursing theories may be categorized as “middle middle range.” Four theories that have been

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cited in a considerable number of nursing studies are discussed in the following sections. They are Mishel’s
(1984) Uncertainty in Illness Theory, Kolcaba’s (1994) Theory of Comfort, Lenz and colleagues’ Theory of
Unpleasant Symptoms (Lenz, Pugh, Milligan, Gift, & Suppe, 1997; Lenz, Suppe, Gift, Pugh, & Milligan,
1995), and Reed’s (1991b) Self-Transcendence Theory. Table 11-2 lists other middle middle range theories
that have been used in nursing practice and research.

Table 11-2 Middle Middle Range Nursing Theories
Theory/Model Purpose Major Concepts

Self-help (Braden, 1990) Describes a process of factors that
decrease self and life quality and
factors that increase learning a self-
help response and thus a greater
quality of life

Disease characteristics, background
inducements, monitoring (level of
information about illness), severity of
illness, dependency, uncertainty,
enabling skill, self-help, life quality

Chronic Illness Trajectory
Framework (Corbin &
Strauss, 1991, 1992)

Describes a view of chronic illness
with eight phases, from pretrajectory
to dying, with each possessing the
possibilities of reversals, plateaus,
and upward or downward movement;
allows for conceptualization of the
course of illness to comprehensively
direct care and conduct research

Trajectory, trajectory phases
(pretrajectory, trajectory onset, crisis,
acute, stable, unstable, downward,
and dying), trajectory projection,
trajectory scheme (shape illness
course, control symptoms, and handle
disability)

Motivation in health
behavior (health behavior,
self-determinism) (Cox,
1985)

Describes intrinsic motivation in
health behavior

Individual’s self-determined health
judgments, self-determined health
behavior, perceived competency in
health matters, internal–external cue
responsiveness

Theory of Care-Seeking
Behavior (Lauver, 1992)

Explains the probability of engaging
in health behavior as a function of
psychosocial variables and facilitating
conditions regarding the behavior

Clinical and sociodemographic
variables, affect (feelings associated
with care-seeking behavior), utility
(expectations and values about
outcomes), normative influences,
habits, care-seeking behavior

Self-efficacy (Lenz &
Shortridge-Baggett, 2002)

Applies Bandura’s work in nursing to
assist people to be as independent as
possible in managing their health

Person (perception, self-referent),
behavior (initiation, effort,
persistence), efficacy–expectation
(magnitude, strength, generality),
information sources (performance,
vicarious experiences, verbal
persuasion, physiologic information),
and outcome expectations

Model for social support
(Norbeck, 1981)

Outlines the elements and
relationships that must be studied to
incorporate social support into
nursing practice; emphasis placed on
developing the environment

Properties of the person (age,
demographic characteristics, needs),
properties of the situation (role
demands, resources, stressors), need
for social support, available social
support

Theory of Resilience
(Polk, 1997)

Proposes interrelatedness of
dispositional, relational, situational,
and philosophical patterns to describe
concept of resilience to guide

Dispositional pattern (pattern of
physical and ego-related psychosocial
attributes that contribute to
manifestation of resilience), relational

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generation of nursing interventions to
assess and strengthen resilience

pattern (roles and relationships that
influence resilience), situational
pattern (characteristic approach to
situations or stressors), philosophical
pattern (personal beliefs)

Theory of Caring
(Swanson, 1991)

Proposes a definition of caring and
the five essential categories or
processes that characterize caring

Knowing, being with, doing for,
enabling, and maintaining belief

Theory of Successful
Aging (Troutman-Jordan,
2015)

Describes the process in which
individuals use various coping
mechanism to progress toward
desirable adaption to physiologic and
functional changes over their lifetime

Successful aging (meaning, purpose
in life), functional performance
mechanisms (health promotion
activities, physical health, physical
activities), geotranscendence
(decreased death anxiety, purpose in
life), intrapsychic factors (creativity,
personal control), spirituality
(spiritual perspectives, religiosity)

Theory of Self-Care of
Chronic Illness (Riegel,
Jaarsma, & Strömberg,
2012)

Describes the process of maintaining
health with health-promoting
practices within the context of the
management required of a chronic
illness

Self-care maintenance, self-care
monitoring, and self-care
management, influencing factors
(experience, skill, motivation, culture,
confidence, habits, function,
cognition, support, access to care)

Mishel’s Uncertainty in Illness Theory
Merle Mishel began studying the concept of uncertainty in illness in the early 1980s when she desired to
explain the stress that results from hospitalization (Mishel, 1981, 1984). In the late 1980s, she formally
developed the theory, which she then revised in the early 1990s (Mishel, 2014). The Mishel Uncertainty in
Illness Scale was created to better examine the concept, and since that time, her model and instruments have
been used in numerous nursing studies (Bailey & Stewart, 2014; Mishel, 2014).

Purpose and Major Concepts
According to Mishel (1999, 2014), the Uncertainty in Illness Theory explains how clients cognitively process
illness-related stimuli and construct meaning in these events. Uncertainty is seen as “the inability to structure
meaning of illness-related events inclusive of inability to assign definite value and/or to accurately predict
outcomes” (Mishel, 2014, p. 56).

The early iteration of the model (Mishel, 1988) described the concepts of “stimuli frame” (symptom
pattern, event familiarity, event congruency), “cognitive capacities,” and “structure providers” (credible
authority, social support, education) that may lead to uncertainty. Other concepts include appraisal, inference,
illusion, and opportunity as well as coping mechanisms; these may lead to adaptation. In 1990, the process of
theory derivation was used to update and revise the theory to address issues related to chronic uncertainty.
Interestingly, chaos theory was used in this process (Mishel, 1990). Figure 11-3 shows the Uncertainty in
Illness Theory.

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Figure 11-3 Model of perceived uncertainty in illness.
(From Mishel, M. H. [1990]. Reconceptualization of the uncertainty in illness theory. Image—The Journal of Nursing Scholarship, 22[4], 256–
262. Used with permission of Wiley.)

Context for Use and Nursing Implications
The Uncertainty in Illness Theory explains how individuals cognitively process illness-related stimuli and
how they structure meaning for those events. In the theory, adaptation is the desirable end-state achieved after
coping with the uncertainty. Nurses may develop nursing interventions that attempt to influence the person’s
cognitive process to address the uncertainty. This, in turn, should produce positive coping and adaptation
(Mishel, 1999, 2014).

Evidence of Empirical Testing and Application in Practice
During the process of theory development and refinement, Mishel developed and tested several research
instruments. These are the Adult Uncertainty in Illness Scale and the Adult Uncertainty in Illness Scale—
Community Form, the Parents’ Perception of Uncertainty in Illness Scale, the Parents’ Perception of
Uncertainty in Illness Scale—Family Member (Mishel, 2014), and the Uncertainty Scale for Kids (Stewart,
Lynn, & Mishel, 2010).

The Uncertainty in Illness Theory is becoming increasingly recognized in nursing literature as a resource
for research and practice. A significant number of research studies were identified using Mishel’s theory or
instruments or both in addressing health issues among a wide variety of groups and covering many different
health problems. For example, in a longitudinal study, Bailey, Kazer, Polascik, and Robertson (2014) used
Mishel’s theory as part of the conceptual framework that examined uncertainty experienced by men who must
have their prostate-specific antigen levels monitored following prostate cancer surgery. Other research
employing Mishel’s instruments included works by Kurita, Garon, Stanton, and Meyerowitz (2013), who
studied uncertainty among patients with lung cancer and their psychological adjustment, and Cypress’s (2016)
examination of the uncertainty experienced by patients in the ICU. Interestingly, many studies using Mishel’s
theory were directed at patients and their families or caregivers. For example, White, Barrientos, and Dunn
(2014) examined uncertainty experienced by stroke survivors and family caregivers; Unson, Flynn, Glendon,
Haymes, and Sancho (2015) studied the stress and uncertainty of the caregivers of persons with dementia; and
Germino and colleagues (2013) looked at uncertainty of breast cancer survivors and their families.

Mishel’s work has achieved worldwide recognition, and her instruments have been translated into several
languages including Italian (Giammanco, Gitto, Barberis, & Santoro, 2015), Persian (Saijadi, Rassouli,
Abbaszadeh, Alavi Majd, & Zendehdel, 2014), and French (C. A. Miller, 2015). Finally, Christensen (2015)
described development of the Health Change Trajectory Model—a new middle range theory—integrating
concepts and relationships from Mishel’s Uncertainty in Illness Theory and the Corbin and Strauss Chronic
Illness Trajectory Framework (Corbin, 1998).

Kolcaba’s Theory of Comfort
Katherine Kolcaba (2017) wrote that the first step in developing the Theory of Comfort was a concept

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analysis conducted in 1988 while she was a graduate student. Following a number of steps over several years,
the Theory of Comfort was initially published in 1994 and later modified (Kolcaba, 1994, 2001).

Purpose and Major Concepts
Kolcaba (1994) defined comfort within nursing practice as “the satisfaction (actively, passively, or co-
operatively) of the basic human needs for relief, ease, or transcendence arising from health care situations that
are stressful” (p. 1178). She explained that a client’s needs arise from a stimulus situation that can cause
negative tension. Increasing comfort measures can result in having negative tensions reduced and positive
tensions engaged. Comfort is viewed as an outcome of care that can promote or facilitate health-seeking
behaviors. It is posited that increasing comfort can enhance health-seeking behaviors. One proposition notes
that “if enhanced comfort is achieved, patients, family members and/or nurses are strengthened to engage in
HSBs [health-seeking behaviors], which further enhance comfort” (Kolcaba, 2017, p. 200).

Major concepts described in the Theory of Comfort include comfort, comfort care, comfort measures,
comfort needs, health-seeking behaviors, institutional integrity, and intervening variables. There are also eight
defined propositions that link the defined concepts (Box 11-6) (Kolcaba, 2001, 2017). Figure 11-4 presents
the Theory of Comfort.

Box 11-6 Propositions of Comfort Theory

1. Nurses and members of the health care team identify comfort needs of patients and family members.
2. Nurses design and coordinate interventions to address comfort needs.
3. Intervening variables are considered when designing interventions.
4. When interventions are delivered in a caring manner and are effective, the outcome of enhanced

comfort is attained.
5. Patients, nurses, and other health care team members agree on desirable and realistic health-seeking

behaviors.
6. If enhanced comfort is achieved, patients, family members, and/or nurses are more likely to engage in

health-seeking behaviors; these further enhance comfort.
7. When patients and family members are given comfort care and engage in health-seeking behaviors, they

are more satisfied with health care and have better health-related outcomes.
8. When patients, families, and nurses are satisfied with health care in an institution, public

acknowledgment about that institution’s contributions to health care will help the institution remain
viable and flourish. Evidence-based practice or policy improvements may be guided by these
propositions and the theoretical framework.

Sources: Kolcaba (2001, 2017).

Figure 11-4 The conceptual framework for the Theory of Comfort.
(© Kolcaba [2007]. Used with permission. http://thecomfortline.com.)

Context for Use and Nursing Implications
Comfort Theory observes that patients experience needs for comfort in stressful health care situations. Some

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of these needs are identified by the nurse, who then implements interventions to meet the needs (Kolcaba,
1995). Kolcaba (2017) stated that “Comfort Theory can be adapted to any health care setting or age group . . .
” (p. 200). Understanding of comfort can promote nursing care that is holistic and inclusive of physical,
psychospiritual, social, and environmental interventions. It is noted that any actually unhappy, unhealthy, or
unwell patients can be made more comfortable (Kolcaba, 1994). Finally, outcomes of comfort can be
measurable, holistic, positive, and nurse sensitive.

Evidence of Empirical Testing and Application in Practice
The General Comfort Questionnaire (GCQ) is a 48-item Likert-type scale that was developed to measure
concepts and propositions described in the theory. The GCQ has been modified to be used for different
populations in a number of studies, and a shortened GCQ (28 items) is also in use (Kolcaba, 2017).

Kolcaba (2017) described development of other tools to assist in research and practice application for the
Theory of Comfort. These include the Verbal Rating Scale Questionnaire, the Radiation Therapy Comfort
Questionnaire, the Hospice Comfort Questionnaire, the Urinary Incontinence and Frequency Comfort
Questionnaire, and the Healing Touch Comfort Questionnaire. In addition, the Comfort Behaviors Checklist
was developed to measure comfort in patient who can’t use traditional questionnaires or other instruments.

A number of research studies have been conducted by Kolcaba and her colleagues using the instruments
listed earlier. For example, Andersen, Jylli, and Ambuel (2014) used Kolcaba’s Comfort Behaviors Checklist
to evaluate the comfort care provided by a group of health providers and Seyedfatemi, Rafii, Rezaei, and
Kolcaba (2014) used her instruments to study comfort and hope among preoperative patients. Whitehead,
Anderson, Redican, and Stratton (2010) reported using Kolcaba’s instruments to study the effects of an end-
of-life nursing education program on nurses’ death anxiety, knowledge of the dying process, and related
concerns. Also examining nursing care at the end of life, Murray (2010) used Kolcaba’s instruments to assess
spiritual beliefs and practices of nurses caring for patients at the end of life, along with similarities and
differences in spiritual beliefs and practices comparing hospice nurses and nurses working on oncology and
other special care units.

In practice-specific examples, Marchuk (2016) described how Comfort Theory can be applied in end-of-
life care in the neonatal intensive care unit (NICU), and Krinsky, Murillo, and Johnson (2014) explained how
comfort measures can be used to improve nursing care for cardiac patients. Finally, Boudiab and Kolcaba
(2015) presented a comprehensive look at the application of Comfort Theory in directing holistic, quality care
for veterans and their families.

Lenz and Colleagues’ Theory of Unpleasant Symptoms
The Theory of Unpleasant Symptoms was developed by a group of nurses interested in a variety of nursing
issues, including symptom management, theory development, and nursing science (Lenz, Pugh, Milligan, &
Gift, 2017). The theory was initially published in the nursing literature in the mid-1990s (Lenz et al., 1995)
and then updated a few years later (Lenz et al., 1997). The theory was based on the premise that there are
commonalities in experiencing different symptoms among different groups and in different situations. The
theory was developed to integrate existing knowledge about a variety of symptoms to better prepare nurses in
symptom management.

Purpose and Major Concepts
The purpose of the Theory of Unpleasant Symptoms is “to improve understanding of the symptom experience
in various contexts and to provide information useful for designing effective means to prevent, ameliorate, or
manage unpleasant symptoms and their negative effects” (Lenz & Pugh, 2014, p. 166). Lenz and colleagues
(1997) reported that the theory has three major components: (1) the symptoms that the individual is
experiencing, (2) the influencing factors that produce or affect the symptom experience, and (3) the
consequences of the symptom experience.

Within the theory, symptoms are described in terms of duration, intensity, distress, and quality.
Influencing factors can be physiologic factors, psychological factors, and/or situational factors. Performance
is described in terms of functional status, cognitive functioning, or physical performance (Lenz et al., 2017).
Figure 11-5 depicts the Theory of Unpleasant Symptoms.

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Figure 11-5 Updated version of the middle range Theory of Unpleasant Symptoms.
(From Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. [1997]. The middle range theory of unpleasant symptoms: An update.
ANS. Advances in Nursing Science, 19[3], 14–27. Used with permission.)

Context for Use and Nursing Implications
The Theory of Unpleasant Symptoms helps nurses recognize the need to assess multiple aspects of symptoms,
including characteristics of the symptom(s) itself; the underlying disease or other cause; as well as the
frequency, intensity, duration, quality, and distress felt by the patient due to the symptom(s) (Lenz et al.,
2017). The developers of the Theory of Unpleasant Symptoms note that it is clinically applicable to multiple
client situations because it should stimulate nurses to consider factors that might influence more than one
symptom and the ways in which symptoms interact with each other (Lenz et al., 1997). The theory’s
developers noted that it has been used in an emergency department (ED) to develop a symptom assessment
scale for cardiac patients and has been useful in predicting the need for hospitalization among patients with
chronic obstructive pulmonary disease (COPD).

Evidence of Empirical Testing and Application in Practice
A growing number of research studies using the Theory of Unpleasant Symptoms as a conceptual or
organizing framework have been conducted. One study by Kim, Oh, Lee, Kim, and Kim (2015) used the
theory in their investigation of predictors of symptoms and symptom experience among cancer patients
undergoing chemotherapy. Also studying cancer patients, Hsu and Tu (2014) used the Theory of Unpleasant
Symptoms to evaluate the effects of cancer treatments on functional status, depressive symptoms, fatigue, and
quality of life. Other works applied the Theory of Unpleasant Symptoms in caring for patients undergoing
bariatric surgery (Tyler & Pugh, 2009), patients with coronary heart disease (Eckhardt, Devon, Piano, Ryan,
& Zerwic, 2014), and patients with inflammatory bowel disease (Farrell & Savage, 2010).

Reed’s Self-Transcendence Theory
Pamela Reed first wrote about the concept of self-transcendence in 1983 and formally outlined her theory in
1991 (Reed, 1991b). She reported that she used “deductive reformulation” of theories of life span
development in constructing the theory. These she integrated with Rogers’s conceptual system, clinical
experience, and empirical work (Reed, 1991b). Self-transcendence is developed by introspective activities and
concerns about the welfare of others and by integrating perceptions of one’s past and future to enhance the
present (Reed, 1991a).

Purpose and Major Concepts
Self-transcendence is considered to be a “characteristic of developmental maturity whereby there is an
expansion of self-boundaries and orientation toward broadened life perspectives and purposes” (Reed, 1991b,

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p. 64). Self-transcendence moves the individual beyond the immediate or constricted view of self and the
world (Reed, 1996). Within self-transcendence, there is “an expansion of personal boundaries outwardly
(toward others and the environment), inwardly (toward greater awareness of beliefs, values, and dreams), and
temporally (toward integration of past and future in the present)” (Reed, 1996, p. 3). Other central concepts of
the theory include well-being (a sense of wholeness and health) and vulnerability (awareness of personal
mortality) (Coward, 2014; Reed, 2014).

Context for Use and Nursing Implications
Reed (1991b) reported that a theory of self-transcendence may be used by nurses to attend to spiritual and
psychosocial expressions of self-transcendence in clients who are confronted with end-of-life issues. To
promote self-transcendence, nurses may use interventions such as meditation, self-reflection, visualization,
religious expression, counseling, and journaling to expand the individual’s boundaries.

Evidence of Empirical Testing and Application in Practice
A number of nursing research studies have used the theory of self-transcendence. In an early work, Reed
(1991a) found support for the theory in an examination of the mental health of older adults. In the study, she
identified a relationship between self-transcendence and mental health and an inverse relationship between
self-transcendence and depression. More recently, studies have been undertaken to examine self-
transcendence and its effect on well-being or other variables. These studies are conducted among those with
health issues such as spinal muscular atrophy (Ho, Tseng, Hsin, Chou, & Lin, 2016), Alzheimer disease
(Walsh et al., 2011), hypertension (Thomas & Dunn, 2014), and at the end of life (Shockey-Stephenson &
Berry, 2015).

Several projects have looked at self-transcendence among nurses and/or nursing students. For example,
Hunnibell and colleagues (2008) studied differences in self-transcendence between hospice and oncology
nurses, analyzing how it influenced burnout in those groups. In similar works, Palmer, Quinn Griffin, Reed,
and Fitzpatrick (2010) studied self-transcendence and engagement in acute care registered nurses (RNs), and
Haugan (2014) examined whether student nurses’ self-transcendence could positively influence their attitudes
toward caring for older adults. Finally, several works were identified that sought to enhance self-
transcendence or to associate it with successful ageing. These included a study by McCarthy, Ling, and Carini
(2013) and a second study by McCarthy, Ling, Bowland, Hall, and Connelly (2015).

Low Middle Range Theories
The number of low middle range theories appears to be growing as nursing researchers and nursing scholars
describe phenomena directly related to practice. Three theories are examined in the following sections. They
are Eakes, Burke, and Hainsworth’s (1998) Theory of Chronic Sorrow; Beck’s (1993) Postpartum Depression
Theory; and Mercer’s (1981) Conceptualization of Maternal Role Attainment/Becoming a Mother. Table 11-3
lists other low middle range theories.

Table 11-3 Low Middle Range Nursing Theories
Theory/Model Purpose Major Concepts

Theory of Adaptation to
Chronic Pain (Dunn,
2004)

Describes the process and
outcome of adaptation to
chronic pain through use of
religious and nonreligious
coping to create human and
environmental integration that
promotes survival, growth, and
integrity

Stimuli (background contextual variables,
total pain intensity), compensatory life
process (religious and nonreligious coping),
adaptive modes (functional ability,
psychological, and spiritual well-being)

Acute pain management
(Good, 1998; Good &

Proposes prescriptions for
nursing activities to reduce pain

Potent pain medication, pharmacologic
adjuvant, nonpharmacologic adjuvant,

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Moore, 1996) after surgery or trauma to
ensure that clients have less
intense pain with minimal side
effects of medications

assessment of pain and side effects, goal
setting, and balance between analgesia and
side effects

Theory of Suffering
(Morse, 2001)

Describes phases of suffering
and relationship between states
of enduring suffering and
caregiver response

Enduring (emotional suppression) and
emotional suffering, outcomes (recognition,
acknowledgments, acceptance)

Theory of the Peaceful
End of Life (Ruland &
Moore, 1998)

Directs care necessary for
terminally ill clients; enhances
nursing care by combining the
dimensions that are important to
dying in a unifying whole

Not being in pain, experience of comfort,
experience of dignity and respect, being at
peace, closeness to significant others and
people who care

Caregiving Effectiveness
Model (C. E. Smith et al.,
2002)

Explains and predicts outcomes
of technology-based home
caregiving provided by family
members

Caregiving context (caregiving
characteristics, caregiving/care-receiving
interactions, patient education), adaptive
context (family economic stability,
caregiver health status, family adaptation,
reactions to caregiving), caregiving
effectiveness outcomes (patient quality of
life, caregiver quality of life, patient
condition, technologic side effects)

Theory of Caregiver
Stress (Tsai, 2003)

Predicts caregiver stress and its
outcomes from demographic
characteristics, burden in care
giving, stressful life events,
social support, and social roles

Caregiver adaptation, input (objective
burden, stressful life events, social support,
social roles, demographic information),
control process (perceived caregiver stress
and depression), output (physical function,
self-esteem, role enjoyment, marital
satisfaction)

Theoretical model for the
development of skin
ulcers of nonsystemic
origin and dependence-
related lesions (García-
Fernández, Agreda,
Verdú, & Pancorbo-
Hidalgo, 2013)

Explains the production
mechanism of seven
dependence-related lesions
considered to lead to pressure
ulcers

Moisture lesions (incontinence exposure),
friction lesions (friction/grazing), pressure
ulcers (pressure [decreased capacity for
repositioning, decreased sensory
perception], shear)

Theory of Family
Vigilance (Carr, 2014)

Describes the meanings,
patterns, and day-to-day
experience of family members
staying with hospitalized
relatives

Commitment to care (advocacy, love,
responsibility, solicitude, involvement),
resilience (caring for self, perseverance,
hope), emotional upheaval (anxiety,
uncertainty, life and death decisions),
dynamic nexus (relationships with
family/friends, relationship with health care
providers), transition (lifestyle, daily
rhythm, comfort, space)

Eakes, Burke, and Hainsworth’s Theory of Chronic Sorrow
The concept of chronic sorrow was introduced in the early 1960s to describe grief observed in the parents of
children with mental deficiencies. Subsequent research indicated similar patterns of chronic sorrow in parents

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of mentally or physically disabled children. The Nursing Consortium for Research on Chronic Sorrow
expanded the concept to include individuals who experience a variety of loss situations and to their family
caregivers (Eakes, 2017; Eakes et al., 1998).

The middle range Theory of Chronic Sorrow was formalized in 1998. The theory was inductively derived
and validated through a series of studies and a critical review of the existing research. Chronic sorrow is
defined as the “periodic recurrence of permanent, pervasive sadness or other grief related feelings associated
with a significant loss” (Eakes et al., 1998, p. 179), which was described as a normal response to ongoing
disparity associated with loss.

Purpose and Major Concepts
The Theory of Chronic Sorrow was developed to help analyze individual responses of people experiencing
ongoing disparity due to chronic illness, caregiving responsibilities, loss of the “perfect” child, or
bereavement. Chronic sorrow was characterized as pervasive, permanent, periodic, and potentially progressive
in nature. The person has a perception of sadness or sorrow over time in a situation with no predictable end.
The sadness or sorrow is cyclic or recurrent and brings to mind a person’s losses, disappointments, or fears
(Eakes, 2017).

The primary antecedent to chronic sorrow is involvement in an experience of significant loss. The loss is
often ongoing with no predictable end. Disparity is a second antecedent and is created by loss experiences
when the individual’s current reality differs from the idealized. Trigger events (e.g., milestones,
circumstances, situations, and conditions that create negative disparity resulting from the loss experience)
focus or exacerbate the experience of disparity. The “lack of closure associated with ongoing disparity sets the
stage for chronic sorrow, with the loss experienced in bits and pieces over time” (Eakes, 2017, p. 95).

Context for Use and Nursing Implications
Chronic sorrow is commonly experienced by individuals across the life span who have encountered
significant loss or experience ongoing loss. The theory’s developers suggest that nurses need to view chronic
sorrow as a normal response to loss and provide support by fostering positive coping strategies and
encouraging activities that increase comfort.

Interventions that demonstrate an empathic presence and a caring professional are helpful. These include
taking time to listen, offering support and reassurance, recognizing and focusing on feelings, and appreciating
the uniqueness of each individual. Other interventions include providing information in a manner that can be
understood and offering practical tips for dealing with the challenges of caregiving.

Evidence of Empirical Testing and Application in Practice
Eakes and colleagues (1998) reported that a number of research studies were used to develop and support the
theory. Several recent research studies were identified using the Theory of Chronic Sorrow as a conceptual
framework. These include Vitale and Falco’s (2014) examination of parental chronic sorrow experienced with
the premature birth of their infants; Nikfarid, Rassouli, Borimnejad, and Alavimajd’s (2015) study of chronic
sorrow in mothers of children with cancer; and Bowes, Lowes, Warner, and Gregory’s (2009) study of
chronic sorrow in parents of children with type 1 diabetes.

Other works focused on how to care for those experiencing chronic sorrow. Among them, Glenn (2015)
described the use of online health communication technology to help mothers of children with rare diseases
manage chronic sorrow. Also, Joseph (2012) described the importance of ED nurses recognizing chronic
sorrow among family member of patients seen in the ED.

Beck’s Postpartum Depression Theory
Building on a background of research on postpartum depression (Beck, Reynolds, & Rutowski, 1992), Cheryl
Beck (1993) developed a theory regarding postpartum depression. A grounded theory approach was used to
formulate the theory, which she described as a four-stage process of “teetering on the edge” into postpartum
depression.

Purpose and Major Concepts

237

The purpose of the theory was to provide insight into the experience of postpartum depression. The concepts
or stages in Beck’s (1993) theory were defined as encountering terror (horrifying anxiety attacks, obsessive
thinking, and enveloping fogginess), dying of self (alarming “unrealness,” isolation of self, and contemplation
of self-destruction), struggling to survive (battling the system, praying for relief, and seeking solace), and
regaining control (making transitions, mounting lost time, and attaining a guarded recovery). A meta-
synthesis of postpartum depression by Beck (2002a) produced a list of predictors or risk factors, including
prenatal depression, child care stress, life stress, social support, prenatal anxiety, marital satisfaction, history
of depression, infant temperament, maternity blues, self-esteem, socioeconomic status, marital status, and
whether the pregnancy was planned. Distillation of predictors and risk factors of postpartum depression added
these stressors/potential consequences: sleeping and eating disturbances, anxiety and insecurity, emotional
lability, mental confusion, loss of self, guilt and shame, and suicidal thoughts (Maeve, 2014).

Context for Use and Nursing Implications
The model proposed nursing interventions to alert nurses to the incidence and impact of postpartum
depression. Beck stressed the importance of identifying new mothers who might be suffering from postpartum
depression and suggested interventions such as referral to postpartum depression support groups (Beck et al.,
1992).

Evidence of Empirical Testing and Application in Practice
Beck’s theory has been used in a significant number of nursing studies and in practice situations (Marsh,
2013). To further examine the concept of postpartum depression, Beck (1995, 1998) performed a meta-
analysis to document its effects. Based on the information from a meta-analysis, Beck and Gable (2000)
developed the Postpartum Depression Screening Scale (PDSS) to improve detection of the disorder. The tool
was revised in 2002 (Beck, 2002b), translated into Spanish (Beck & Gable, 2003), and revised further in 2006
(Beck, Records, & Rice, 2006). These tools have been validated (Beck et al., 2006; Clemmens, Driscoll, &
Beck, 2004) and used by nurses in a growing list of research studies in many countries and in additional
languages (Maeve, 2014).

In one example, Le, Perry, and Sheng (2009) used the PDSS to examine the feasibility of using the
Internet to screen for postpartum depressive symptoms, concluding that it is viable and feasible tool to screen
for postpartum depression. In another work, Logsdon, Tomasulo, Eckert, Beck, and Dennis (2012) presented
guidelines for hospital-based postpartum depression screening using the PDSS. A team lead by Thomason
(Thomason et al., 2014) used the PDSS to examine parenting stress and depressive symptoms, and Lucero,
Beckstrand, Callister, and Sanchez Birkhead (2012) used the Spanish version of the PDSS to examine the
prevalence of postpartum depression among Hispanic immigrants in the United States.

Mercer’s Conceptualization of Maternal Role Attainment/Becoming a Mother
Ramona Mercer first described a theoretical framework for the maternal role in the early 1980s; she expanded
on the process in a subsequent publication in 1985. She reported that the theory was based on role theory,
knowledge of the infant’s traits, and a review of the literature to identify variables that influence or are
influenced by maternal roles. She defined maternal role attainment as a process “in which the mother achieves
competence in the role and integrates the mothering behaviors into her established role set so that she is
comfortable with her identity as a mother” (Mercer, 1985, p. 198).

Following a review and synthesis of research related to the concept of “maternal role attainment,” Mercer
(2004) proposed changing the name of her theory to “Becoming a Mother.” This change was later expanded
on (Mercer, 2006), and a number of related nursing interventions were identified supporting the change
(Mercer & Walker, 2006).

Purpose and Major Concepts
Mercer attempted to identify the “form and strength of the relationships between key maternal and infant
variables and maternal role attainment” as well as “other factors that appear to influence maternal role
attainment” (Mercer, 1981, p. 73). She proposed that the variables of age, perception of the birth experience,
early maternal–infant separation, social stress, support system, self-concept and personality traits, maternal

238

illness, childrearing attitudes, infant temperament, infant illness, culture, and socioeconomic level affect the
maternal role.

In the more recent iteration of her theory, Mercer (2004) explains that the process of establishing maternal
identity in becoming a mother is (1) commitment, attachment, and preparation (during pregnancy); (2)
acquaintance, learning, and physical restoration (in the first 2 to 6 weeks following birth); (3) moving toward
a new normal (2 weeks to 4 months); and (4) achievement of the maternal identity (around 4 months). She
noted that these stages may overlap and may be highly variable due to maternal and infant variables as well as
the social/environmental context. Additional key concepts and ideas identified in Mercer’s works include
infant temperament, infant health status, infant characteristics, and infant cues as well as family, family
functioning, father or intimate partner, mother–father relationship, and social support (Meighan, 2014).

Context for Use and Nursing Implications
Nurses in postpartum situations should recognize that competency in the maternal role toward “becoming a
mother” increases with age and experience. Also, the demands on first-time mothers challenge the nurse to be
active in anticipatory socialization and guidance to prepare for the realities of the maternal role. Interventions
suggested in Mercer’s works include promoting parenting groups to highlight maternal needs during the first
months (Noseff, 2014).

Evidence of Empirical Testing and Application in Practice
In early works, Mercer (1985) reported that mothering over the first year presents similar challenges for all
groups, and a study by Fowles (1994) used Mercer’s theory as part of her conceptual framework to examine
the relationship between maternal attachment, postpartum depression, and maternal role attainment. More
recently, a comprehensive study of maternal role attainment with medically fragile infants was undertaken to
examine the quality of parenting (Holditch-Davis, Miles, Burchinal, & Goldman, 2011) and characteristics
that influenced maternal role attachment longitudinally (Miles, Holditch-Davis, Burchinal, & Brunssen,
2011). In other works, Kinsey, Baptiste-Roberts, Zhu, and Kjerulff (2014) studied the effect of miscarriage
history on maternal–infant bonding, and Sriyasak, Akerlind, and Akhavan (2013) examined childrearing
among Thai teenage mothers using Mercer’s theory as a framework. Lastly, Fouquier (2013) performed a
comprehensive literature review to evaluate the applicability of Mercer’s theory to African American women.
She determined that the homogeneity of the samples for most of the research on Mercer’s theory is not
necessarily generalizable to African American women and concluded that more research is needed to identify
attributes that influence maternal role attainment to that population.

Summary
This chapter presented a wide variety of middle range nursing theories. Because of space limitations, the
descriptions are very brief and are intended to merely introduce the theories. The readers are directed to
original and supporting sources for more information.

Elaine Chavez, the graduate student from the opening case study, saw how one of the numerous middle
range nursing theories that have been published in recent years could be used to develop interventions in her
practice. All nurses should likewise continue to review current nursing literature for new theories and ideas
that are being presented to remain current and knowledgeable about nursing practice. To illustrate, Link to
Practice 11-1 provides some thoughts on how nurses can apply middle range theories in their daily practice.

Link to Practice 11-1
Applying Multiple Middle Range Theories in Practice
How might nurses apply multiple middle range theories in their practice? Consider these situations:

1. A nurse is providing care for a woman with ovarian cancer (Theory of Unpleasant Symptoms) who
recently immigrated to the United States from Somalia (Leininger’s Culture Care Diversity and

239

Universality Theory) in an ICU (Synergy Model).
2. A nurse manager is charged with developing an orientation packet (Benner’s Model of Skill

Acquisition) for nurses new to a hospice practice (Kolcaba’s Theory of Comfort) focusing on their
awareness of beliefs, values, and well-being (Reed’s Self-Transcendence Theory).

3. A family nurse practitioner is working with a new mother (Mercer’s Theory of Becoming a Mother)
who has just given birth to a child with a severe genetic disorder (Theory of Chronic Sorrow).

4. A public health nurse is charged with teaching a group of American Indian women (Leininger’s
Culture Care Diversity and Universality Theory) how to develop a healthy lifestyle (Pender’s Health
Promotion Model).

It must be mentioned again that the high, middle, and low range theories described here are by no means
an exhaustive display of the growing number that have been presented in the nursing literature. Indeed, it was
remarkable to observe the growth in middle range theory development over the last decade, and it is
anticipated that this emphasis will continue well into the future.

Key Points
A growing number of widely used middle range theories have been proposed, applied, and tested and have

been presented in the nursing literature.
Among the “high” middle range nursing theories (theories that are relatively abstract and apply to a very

broad aspect of nursing) frequently used by nurses for research and practice are the works of Benner,
Pender, Leininger, and Meleis and the Synergy Model.

“Middle” middle range nursing theories (theories that apply in a many aspects and situations) frequently
used by nurses for research and practice include the Uncertainty in Illness Theory, the Theory of Comfort,
the Theory of Unpleasant Symptoms, and Reed’s Self-Transcendence Theory.

“Low” middle range nursing theories (theories that are fairly concrete and apply to a narrow range of
patients and situations) frequently used by nurses in research and practice include the Theory of Chronic
Sorrow, Beck’s Postpartum Depression Theory, and Mercer’s Theory of Maternal Role Attainment.

Many other middle range theories have been described in the nursing literature, and new ones are being
developed by researchers and scholars to improve nursing care and patient outcomes.

Learning Activities
1. Select one of the middle range theories discussed in this chapter. Obtain a copy of the original

work(s) and perform an analysis/evaluation using the criteria presented in Chapter 5.
2. Select one of the high middle range theories covered in this chapter and obtain a copy of the

original work. Review three or four of the research studies cited for that theory that either
study relationships of the theory or use it as a conceptual framework. While reviewing these
works, consider the following questions: Do the studies appear to use the theory
appropriately? Are the works consistent in their use of the theory? Do the studies contribute to
the knowledge base of the theory? How? Write a paper describing your findings.

3. Search current nursing journals for examples of the development, analysis, or use of middle
range theories in the discipline of nursing. Debate trends with classmates or develop your
analysis into a paper.

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12

Evidence-Based Practice and Nursing Theory
Evelyn M. Wills and Melanie McEwen

Helen Soderstrom was stricken with changes in her vision, disturbances of gait, and occasional periods of
severe fatigue during her senior year of nursing school. She experienced intermittent periods of normality as
well as illness, and the periods when she had no symptoms lasted many months. During a time when her
symptoms were unusually active, she sought medical help, and her physician determined that her symptoms
were related to stress. Despite the periods of weakness and fatigue, she was able to complete the nursing
program and graduated with honors.

During Helen’s first year of practice, she experienced two periods of symptom exacerbation, but each was
short-lived. With full insurance, she was able to see a neurologist who concluded that she was experiencing
the beginning stages of a neuromuscular disease. Because there was no “cure,” the neurologist worked with
Helen to find interventions that helped her manage the symptoms when they became problematic.

After a few years in practice, Helen enrolled in a graduate program to work toward a career as a nurse
educator. During her first year of graduate studies, she seldom experienced neurologic symptoms, but during
her practice teaching course, they returned.

The recurrence of symptoms, along with a new understanding of evidence-based practice (EBP) from her
graduate courses, led Helen to make her personal health experience the topic of her final, capstone paper. To
learn more, she sought resources that would help her gain better control of the neuromuscular symptoms as
well as assist her in her studies. To that end, she contacted her university hospital’s neuroscience department
and applied to join a clinical team to learn about the efficacy of treatments and evidence-based interventions
currently being used for patients with neuromuscular diseases. As she gained more experience with EBP, she
considered what system she would use to develop guidelines on symptom management and selected the Iowa
Model of Evidence-Based Practice because of its basis in research applied to clinical problems.

Florence Nightingale, nursing’s first investigator, devised a statistical means of deciphering her data from
Scutari during the Crimean war (Cohen, 1984; McDonald, 2014). Despite her accomplishments as an
epidemiologist and researcher, however, Nightingale failed to recognize this vital role for nurses as she
described nursing as an “art” and medicine as a “science” (Nightingale, 1860/1957/1969). Focused on the
“art” of nursing and the apprentice-style nature of early nursing education, Nightingale developed a
systematic method for showing the results of nursing care in her own practice (see Chapter 2). In contrast, the
idea of “science-based medicine” has been recognized since “mid-nineteenth century France and even earlier”
(Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71). Furthermore, the ideal of science-based
medicine was influenced by the great influenza epidemic of 1918 to 1919 when physicians learned that
understanding factors leading to that health crisis were necessary to prevent similar occurrences (Barry, 2005).

In the 1960s, several physicians led by Dr. Archie Cochrane endeavored to begin teaching and practicing
medicine based on data produced by scientific and epidemiologic research (Sur & Dahm, 2011). Cochrane
questioned the efficacy of non–research-based practices in medicine (Sackett et al., 1996; Shah & Chung,
2009) and emphasized the critical review of research, focusing on randomized control trials (RCTs) to support
medical practice. His influence led to development of the Cochrane Collaboration (now simply “Cochrane”)
in 1993, an endeavor supported by a group of 70 international physicians (Shah & Chung, 2009). That effort,

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originally termed “evidence-based medicine,” and now “evidence-based practice,” has grown exponentially.
Today, the Cochrane initiative, and its attendant partners, is an organization charged with developing,
maintaining, and updating systematic reviews of health care interventions (Cochrane, 2017). The intent of
Cochrane is to help transform how health decisions are made by gathering and summarizing the best available
evidence from health-related research to help patients and health providers make informed treatment choices.

Following efforts by Cochrane to collect and summarize research information, the requirement for
scientific review of research and practice has become widespread in health disciplines. The Joanna Briggs
Institute, for example, was named for an Australian nurse. Implemented in the 1990s, it now has worldwide
influence in EBP (Joanna Briggs Institute, 2016; Polit & Beck, 2017). More recently, Sigma Theta Tau
International, which has supported nursing research for decades, now sponsors a journal focused on
publishing evidence-based nursing research (Polit & Beck, 2017). Although the notion of EBP was somewhat
delayed in being recognized and implemented in nursing, over the past two decades, EBP has now essentially
become the standard for research-based, informed decision making for nursing care.

In contrast to “research,” which refers to the systematic, rigorous, critical investigation to answer
question(s), EBP is an approach to problem solving that conscientiously collects, evaluates, and integrates the
most current, or “best,” evidence based on meta-analyses of the latest research for patient care (LoBiondo-
Wood & Haber, 2018). Nurses have expanded the original EBP requirements (which largely espouse
experimental research) by including qualitatively derived findings from phenomenologic, ethnographic, and
grounded theory research and case studies (Polit & Beck, 2017). “Metasynthesis” is the term applied to the
process of systematic review of qualitative studies on a topic and is a way to systematize such evidence for
use in nursing situations (Butler, Hall, & Copnell, 2016; Melnyk & Fineout-Overholt, 2015).

Thus, EBP is a process that involves identifying a clinical problem, searching the literature, synthesizing
the findings to critically evaluate the research evidence, and then determining appropriate interventions.
Nursing scholars note that EBP relies on integrating research, theory, and practice and is equivalent to theory-
based practice as the objective of both is the highest level of safety and efficacy for patients (Fawcett &
Garity, 2009). Finally, EBP is an “essential” component of advanced nursing education and vital for both
master’s- and doctorate-prepared nurses (Box 12-1).

Box 12-1
American Association of Colleges of Nursing Essentials and Evidence-
Based Nursing Practice

Evidence-based practice (EBP) is one of the critical elements identified in the “Essentials of Master’s
Education” (American Association of Colleges of Nursing [AACN], 2011), and EBP is mentioned more than
50 times in the document. One statement helps summarize the relationship between EBP, theory, and
professional nursing practice: “Master’s-prepared nurses, when appropriate, lead the healthcare team in the
implementation of evidence-based practice. . . . Integrate theory, evidence, clinical judgement, research and
interprofessional perspectives using translational processes to improve practice and associated health
outcomes for patient aggregates” (p. 16).

Similarly, according to the AACN (2006), doctor of nursing practice (DNP) programs are designed to
prepare experts in specialized advanced nursing practice. It has been determined that DNP programs should “
. . . focus heavily on practice that is innovative and evidence-based, reflecting the application of credible
research findings” (p. 3). Indeed, Essential III explains the importance of “Analytical Models for Evidence-
Based Practice” and includes a number of related competencies and objectives for DNP programs.

Overview of Evidence-Based Practice
The concept of EBP is widely accepted as a requisite in health care. EBP is based on the premise that health
professionals should not center practice on tradition and belief but on sound information grounded in research
findings and scientific development (Melnyk & Fineout-Overholt, 2015; Schmidt & Brown, 2015). Until the
early part of the 21st century, the concept of EBP was more common in Canadian and British nursing
literature than in U.S. nursing literature. Over the last decade, however, the term has become ubiquitous. This
is attributed in part to the guideline initiatives of the Agency for Healthcare Research and Quality, the Institute

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of Medicine, and the U.S. Preventative Services Task Force, among others (Hudson, Duke, Haas, & Varnell,
2008; Melnyk & Fineout-Overholt, 2015).

Many nursing scholars (DiCenso, Guyatt, & Ciliska, 2005; Hall, 2014; Ingersoll, 2000; LoBiondo-Wood
& Haber, 2018; Melnyk & Fineout-Overholt, 2015; Pugh, 2012; Rycroft-Malone, 2004) have pointed out that
EBP and research are not synonymous. They are both scholarly processes but focus on different phases of
knowledge development—application versus discovery. In general, EBP refers to the integration of individual
clinical expertise with the best available external clinical evidence from systematic research. It is largely
based on research studies, particularly studies using clinical trials, meta-analysis, and studies of client
outcomes, and it is more likely to be applied in practice settings that value the use of new knowledge and in
settings that provide resources to access that knowledge. However, nursing studies that employ qualitative
methods or mixed method research are considered valuable to the discipline, as mentioned above (Hall, 2014).

Definition and Characteristics of Evidence-Based Practice
In medicine, EBP has been defined as the conscientious, explicit, and judicious use of the current best
evidence in making decisions about the care of individual patients (Sackett, Straus, Richardson, Rosenberg, &
Haynes, 2000). It is an approach to health care practice in which the clinician is aware of the evidence that
relates to clinical practice and the strength of that evidence (Jennings & Loan, 2001; Tod, Palfreyman, &
Burke, 2004).

To distinguish nursing from medicine in discussing EBP, a number of definitions have been presented in
the literature. Sigma Theta Tau International (2005) defined “evidence-based nursing” as “an integration of
the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and
communities who are served” (para. 4). Similarly, DiCenso and colleagues (2005) defined EBP as “the
integration of best research evidence with clinical expertise and patient values to facilitate clinical decision
making” (p. 4). Both of these definitions use similar terms (e.g., best evidence, expertise, patient values).

In nursing, EBP generally includes careful review of research findings according to guidelines that nurse
scholars have used to measure the merit of a study or group of studies. Evidence-based nursing de-emphasizes
ritual, isolated, and unsystematic clinical experiences; ungrounded opinions; and tradition as a basis for
practice and stresses the use of research findings. Other measures or factors, including nursing expertise,
health resources, patient/family preferences, quality improvement efforts, and the consensus of recognized
experts, are also incorporated as appropriate (Melnyk & Fineout-Overholt, 2015; Schmidt & Brown, 2015).

In summary, EBP has several critical features. First, it is a problem-based approach and considers the
context of the practitioner’s current experience. In addition, EBP brings together the best available evidence
and current practice by combining research results with tacit knowledge and theory. Third, it incorporates
values, beliefs, and desires of the patients and their families. Finally, EBP facilitates the application of
research findings by incorporating first- and secondhand knowledge into practice. Link to Practice 12-1
presents information on databases that nurses and others can access to find specific information on current
guidelines and other collections of “evidence” that can be used to improve health care.

Link to Practice 12-1
Key Resources for Evidence-Based Practice
Several important databases have been set up over the last 20 years to promote integration of “evidence” in
health care. Information on three of the most influential are presented here.

Cochrane Collaboration—http://www.cochrane.org/
The Cochrane Collaboration is an international network that helps health care practitioners, policy makers,
patients, and their advocates make informed decisions about health care. The Cochrane Library prepares,
updates, and promotes the accessibility of the Cochrane Database of Systematic Reviews.

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Joanna Briggs Institute—http://www.joannabriggs.edu.au/
The Joanna Briggs Institute is an international research and development organization from the School of
Translational Science at the University of Adelaide, South Australia. The Institute and its collaborating
entities promote and support the synthesis, transfer, and utilization of evidence through identifying
feasible, appropriate, meaningful, and effective health care practices to assist in the improvement of health
care outcomes.

Agency for Healthcare Research and Quality (U.S. Preventative Services Task
Force/National Guideline Clearinghouse)—http://www.guideline.gov/
The National Guideline Clearinghouse (NGC) is a database of evidence-based clinical practice guidelines.
It is intended to be used by health professionals, practitioners, patients, and others to obtain objective,
detailed information on clinical practice guidelines and to further their dissemination, implementation, and
use.

Concerns Related to Evidence-Based Practice in Nursing
Despite growing acceptance of application of EBP in nursing, some criticisms and concerns have been voiced
in the nursing literature. For example, there is the concern that EBP is more focused on the science of nursing
than on the art of nursing. Some authors have expressed concern that strict concentration on empirically based
knowledge will lead to the failure to capture the uniqueness of nursing and the importance of holistic care in
contemporary practice (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Hudson et al., 2008; Upton,
1999).

Another concern is that strict reliance on EBP will place nurses in the role of medical extender or medical
technician, where nursing will be reduced to a technical practice. This concern was voiced as equating EBP
with “cookbook care” and a disregard for individualized patient care (Finkelman & Kenner, 2016; Melnyk &
Fineout-Overholt, 2015). Indeed, although evidence may provide direction for development of procedures,
techniques, and protocols for nursing, it has been established that these are not the only knowledge that
informs the nursing practice and that consideration of individual needs and values is essential (Hudson et al.,
2008; Mitchell, 2013).

Third, because research involving humans is complex, findings may be open to interpretation and
therefore should not be the sole basis for practice. Research must be considered within the context of the
practice prescribed by theory, and it must integrate the values and beliefs of nursing philosophy (Chinn &
Kramer, 2015; McKenna & Slevin, 2008; Walker & Avant, 2011).

A fourth concern relates to promoting a link with evidence-based medicine and its emphasis on positivist
thinking and the dominance of randomized clinical trials as the major evidence. This concern is related to the
absence of consideration of evidence gathered through qualitative research and theory development (Fawcett
et al., 2001; Jennings & Loan, 2001; Stevens, 2002).

A fifth concern relates to the potential for linking health care reimbursement exclusively to interventions
that can be substantiated by a documented body of evidence (Ingersoll, 2000). This leads to a number of
ethical questions and issues that should be considered. For example, restricting “off-label” use of medications
that may be helpful for certain patients or certain diagnoses, attempts to alter financial reimbursement to
reduce emergency and specialty care, and adjusting payment to providers for over (or under) use of
prescription pain medications.

Finally, it is argued that not all practice in the health professions can or should be based on science. In
many cases, researchers have yet to accumulate a sufficient body of knowledge. In other cases, a different
frame of reference provides a different rationale for action (McKenna & Slevin, 2008). In these instances,
strict reliance on EBP may result in numerous voids when developing a plan of care.

Concerns such as these have been addressed by DiCenso and colleagues (2005), who assert that a
fundamental principle of EBP is that research evidence alone is not sufficient to plan care. Other ethical and
pragmatic factors, such as benefits and risks, associated costs, and patient’s wishes, should be considered.
Furthermore, they note that “best research evidence” can be quantitative or qualitative and does not

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necessarily rely on RCTs. These notions are also supported by Rycroft-Malone (2004), who maintains that
well-conceived and well-conducted qualitative and quantitative research evidence, clinical experience, and
patient experiences, combined with local or organizational influences, are necessary to facilitate EBP.

Evidence-Based Practice and Practice-Based Evidence
A new concept—“practice-based evidence” (PBE)—was introduced into the discussion of EBP a few years
ago (Horn & Gassaway, 2007). The notion of PBE addresses many of the concerns noted previously and is
grounded in the recognition that frequently interventions have limited formal research support, particularly in
the number or quality of RCTs.

The premise of PBE is that large databases—not just clinical research—should be reviewed or “mined” to
gather data to demonstrate quality and effectiveness. This type of review can provide comprehensive
information about patient characteristics, care processes, and outcomes while controlling for patient
differences (Walker & Avant, 2011). PBE acknowledges the importance of the environment in determining
practice recommendations and recognizes that knowledge can be generated from practice as well as from
research (Chinn & Kramer, 2015).

The intent behind PBE is to determine what works best for which patients, under what circumstances, and
at what costs by providing a more comprehensive picture than RCTs, which typically examine one
intervention with limited populations and under strictly controlled circumstances (Huston, 2017). Additional
sources beyond formal research studies that are appropriate as PBE include benchmarking data, clinical
expertise, cost-effective analyses, infection control data, medical record data, national standards of care,
quality improvement data, and patient and family preferences (Huston, 2017).

Horn and Gassaway (2007) concluded that use of the PBE analyses can uncover better practices more
rapidly leading to improved patient outcomes. Figure 12-1 illustrates one interpretation of the
interrelationships among EBP, PBE, research, and theory in nursing.

Figure 12-1
Relationships among practice, theory, research, and the practice-based
evidence/evidence-based practice cycle.

(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.)

Promotion of Evidence-Based Practice in Nursing
Implementation of EBP in nursing is still evolving, as often, nursing interventions are based on experience,

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tradition, intuition, common sense, and untested theories. Although emphasis on EBP has grown rapidly,
especially over the last decade, the actual incorporation of nursing research findings in practice has lagged.
Melnyk and Fineout-Overholt (2015) have outlined barriers to implementation of research and EBP in nursing
(Box 12-2).

Box 12-2 Barriers to Evidence-Based Practice in Nursing

Lack of evidence-based practice (EBP) knowledge and skills
Misperceptions or negative attitudes about research and evidence-based care
Lack of belief that EBP will result in more positive outcomes than traditional care
Voluminous amounts of information in professional journals
Lack of time and resources to search for and critically appraise evidence
Overwhelming patient loads
Organizational constraints, such as lack of administrative support or incentives
Demands from patients for a certain type of treatment
Peer pressure to continue with practices that are steeped in tradition
Resistance to change
Lack of consequences for not implementing EBP
Peer and leader/manager resistance
Lack of autonomy over practice and incentives
Inadequate EBP content and behavioral skills in educational programs
Continued teaching of rigorous research methods in bachelor of science in nursing (BSN) and master’s of

science in nursing (MSN) programs instead of teaching evidence-based approach to care

Source: Melnyk and Fineout-Overholt (2015).

There is significant support for increasing emphasis on EBP in nursing, and many organizations, such as
the Institute of Medicine, Sigma Theta Tau International, and the Magnet Recognition Program of the
American Nurses Credentialing Center, among others, have designed initiatives to advance EBP (Finkelman
& Kenner, 2016; Huston, 2017; Melnyk & Fineout-Overholt, 2015). Indeed, practitioners, researchers, and
scholars should welcome it because a systematic process of EBP may assist nurses in reducing the gap
between theory and practice.

Theory and Evidence-Based Practice
The growing interest and appreciation of EBP in nursing, along with its considerable interconnectedness with
research, has served in some ways to de-emphasize theory. As nurses become more aware of and attuned to
EBP, however, they are renewing their appreciation of the linkages among research, theory, and practice. It
has been observed that nursing focus on EBP has the potential to promote and draw new attention to this
connection (Chinn & Kramer, 2015).

Walker and Avant (2011) pointed out that practice is the central and core phenomenon and focus of
nursing; arguably, it is the reason for nursing’s existence. Thus, it is critical to remember that theory guides
practice, and it also generates models of testing in research through both PBE and EBP. Furthermore, research
and clinical data provide evidence for EBP or PBE and can generate practice guidelines and/or theories (e.g.,
situation-specific theories). This process is interactive and iterative (Walker & Avant, 2011). For nursing,
therefore, practice must not only be evidence-based but also be theory-based, for when research validates a
theory, it provides the evidence required for EBP. Finally, as more research is conduced about a specific
theory, more evidence is provided to support practice (Chinn & Kramer, 2015; George, 2011).

Fawcett and colleagues (2001) wrote of a preference for the term “theory-guided, evidence-based
practice,” noting that theory is the reason for, and the value of, evidence. The “evidence,” they stated, must
extend beyond an emphasis on empirical research and RCTs to include evidence generated from theories.
Indeed, the evidence itself refers to evidence about theories. Furthermore, they contend that theory determines

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what counts as evidence; thus, theory and evidence are inextricably linked.

Theoretical Models of Evidence-Based Practice
Numerous models of EBP have been developed by nurses to encourage translation of nursing research into
practice. In many instances, the goal or intent is to create or establish EBP protocols, procedures, or
guidelines. In some instances, universities and hospital groups have developed models to assist students or
health care professionals in implementing EBP in their setting. In other instances, nurse researchers and
scholars have interpreted the transfer of research evidence to nursing education and practice through processes
that progressed from theory-based nursing, quality improvement, research utilization, and lately, evidence-
based nursing practice. This section reviews five EBP models that are among the most frequently cited in the
nursing literature. These have been widely studied and applied, many in multiple settings and for a variety of
patient issues, situations, or nursing care processes. These models include:

Academic Center for Evidence-Based Practice Star Model (ACE Star Model) (Stevens, 2005, 2012)
Advancing Research and Clinical Practice Through Close Collaboration (ARCC Model) (Melnyk &

Fineout-Overholt, 2015)
Iowa Model (Titler et al., 2001)
Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model (Dearholt, 2012; Newhouse,

Dearholt, Poe, Pugh, & White, 2007)
Stetler Model of Evidence-Based Practice (Stetler, 2001)

These models can provide guidance for practicing nurses and advanced practice nurses to promote or
enhance EBP and to develop practice guidelines, protocols, or interventions as appropriate. Each model will
be described briefly and reviewed for its utility in nursing practice and education.

Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation
The ACE Star Model was developed by faculty at the University of Texas Health Science Center at San
Antonio (UTHSCSA) (Stevens, 2012). The Star Model is depicted by five points of knowledge
transformation. The five forms of knowledge transformation occur in “relative sequence” when research
evidence progresses through several cycles and is combined with other knowledge and then applied in
practice.

Each point of the star represents a step in a process. The stepwise depiction allows for easy comprehension
and is therefore useful even for novice nurses. In order, the points are:

1. Discovery research
2. Evidence summary
3. Translation to guidelines
4. Practice integration
5. Process, outcome evaluation (Stevens, 2012) (Figure 12-2)

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Figure 12-2
Diagram of the Academic Center for Evidence-Based Practice Star Model
for evidence-based practice.

(Used with permission from Stevens, K. R. [2012]. Star model of EBP: Knowledge transformation. San Antonio, TX: Academic Center for
Evidence-Based Practice, University of Texas Health Science Center. Retrieved from http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp.)

This sequence allows the nurse to move research-based knowledge from one point to the next in sequence
to provide a translation of evidence on which to base practice (Stevens, 2005, 2012). Knowledge
transformation consists of eight premises that underlie and explain the position of the researchers who created
the model. These are presented in Box 12-3. The rigor of the process the nurse or committee uses is part of the
value of the knowledge transformation that occurs when using this model.

Box 12-3
Academic Center for Evidence-Based Practice Star Model: Knowledge
Transformation—Underlying Premises

1. Knowledge transformation (KT) is necessary prior to using research results in clinical decision making.
2. KT derives from multiple sources, including research, experience, authority, trial and error, and

theoretical principles.
3. Systematic processes control bias; the research process is the most stable source of knowledge.
4. Evidence can be classified into a hierarchy of strength of evidence depending on the rigor of the science

that produced the evidence.
5. Knowledge exists in a variety of forms. As research is converted through a system of steps, other

knowledge is created.
6. The form in which knowledge exists can be referenced to its use.
7. The form of knowledge determines its usability.
8. Knowledge is transformed through steps, such as summarization, translation, application, integration,

and evaluation.

Abstracted from Stevens, K. R. (2012). Star model of EBP: Knowledge transformation. San Antonio, TX: Academic Center for Evidence-
Based Practice, University of Texas Health Science Center. Retrieved from http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp

The model is used at UTHSCSA hospitals, and their nursing program maintains a very detailed and
informative online educational site (http://www.acestar.uthscsa.edu/). The website provides an extensive
online tutorial on the ACE Star Model complete with detailed information, resources, instructive videos, and
slides. A quiz and a certificate of attendance are available for those completing instruction in the model (see
Link to Practice 12-2). The ACE Star Model is useful in teaching nurses and nursing students the process of
research evidence utilization in practice (Schaffer, Sandau, & Diedrick, 2013). One concern or criticism of the
ACE Star Model has been noted by White (2016), who pointed out that it does not use evidence other than

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research per se.

Link to Practice 12-2
Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation
Access the website, take the tutorial, and complete the quiz to obtain a certificate of completion of the
program at http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp. This website may be useful for
teaching the elements of evidence-based practice to nursing students.

Advancing Research and Clinical Practice Through Close Collaboration Model
Melnyk and Fineout-Overholt (2002) developed the ARCC Model through their work with many health care
institutions seeking to advance and sustain EBP. This development was a process that involved many
iterations and empirical testing of key relationships. The framework of the ARCC Model is taken from control
theory and cognitive behavioral theories, which help guide nurses’ behaviors as they gain acumen in EBP
(Melnyk & Fineout-Overholt, 2015). Numerous studies and examples of how the ARCC Model has been
implemented in clinical practice are available in the literature (Melnyk, 2002; Melnyk, 2017; Melnyk,
Feinstein, & Fairbanks, 2002; Melnyk & Fineout-Overholt, 2011; Melnyk, Fineout-Overholt, Giggleman, &
Choy, 2016; Melnyk, Rycroft-Malone, & Bucknall, 2004).

The AARC Model relates best to clinical practice, and much of the research supporting its development
and implementation was conducted in acute care, pediatric settings. The central constructs are assessment of
organizational culture and readiness for EBP, identification of strengths and major barriers to EBP, and
development and use of EBP mentors. These constructs are done sequentially and followed by EBP
implementation. Outcomes that should be evaluated include health care provider satisfaction, cohesion, intent
to leave, turnover, improved patient outcomes, and hospital costs (Melnyk & Fineout-Overholt, 2015).

In employing the ARCC Model, the authors developed several scales to measure the ability to implement
EBP. These are the Organizational Culture and Readiness Scale for System-Wide Integration of Evidence-
Based Practice (OCRSIEP) and the EBP Beliefs (EBPB) scale (Melnyk & Fineout-Overholt, 2015).
Organizational readiness is first assessed, and when feasible, mentors are identified and developed. The
clinical nurses are then mentored through use of the ARCC system. Melnyk and Fineout-Overholt (2015) state
that measuring the key constructs along with workshops and academic offerings assist organizations to adopt
and sustain EBP. Finally, Melnyk and Fineout-Overholt (2015) developed a flow chart to assist in use of the
model. Box 12-4 gives examples of research that has been conducted employing the ARCC Model of EBP.

Box 12-4
Research Based on the Advancing Research and Clinical Practice
Through Close Collaboration Model of Evidence-Based Practice

Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson, C., Greiner, J., et al. (2015). Sacred cow
gone to pasture: A systematic evaluation and integration of evidence-based practice. Worldviews on
Evidence-Based Nursing, 12(1), 3–11.

Kim, S. C., Stichler, J., Ecoff, L., Brown, C., Gallo, A.-M., & Davidson, J. (2016). Predictors of evidence-
based practice implementation, job satisfaction, and group cohesion among regional fellowship program
participants. Worldviews on Evidence-Based Nursing, 13(5), 340–348.

Thorsteinsson, H. S. (2013). Icelandic nurses’ beliefs, skills, and resources associated with evidence-based
practice and related factors: A national survey. Worldviews on Evidence-Based Nursing, 10(2), 116–126.

Underhill, M., Roper, K., Siefert, M. L., Boucher, J., & Berry, D. (2015). Evidence-based practice beliefs
and implementation before and after an initiative to promote evidence-based nursing in an ambulatory
oncology setting. Worldviews on Evidence-Based Nursing, 12(2), 70–78.

The Iowa Model of Evidence-Based Practice to Promote Quality Care

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The Iowa Model of EBP was developed in 1994 to promote quality care through research utilization. It is
intended to provide guidance for nurses and others in making decisions about practice that affects patient
outcomes. The Iowa Model incorporates starting points, which are nursing problems that are termed
“triggers.” It continues through multiple decision points and feedback loops to provide for evaluation of any
changes (Titler et al., 2001).

The model has been refined over time to produce the current iteration (Titler, 2004, 2014). The diagram of
the model shows the starting points, decision points, and feedback loops. When implemented, it will assist in
providing quality care to clients of clinics, home health agencies, and hospitals (Titler et al., 2001) (Figure 12-
3). The Iowa Model is very detailed and specific and has been applied to address a number of clinical topics.
It is also one of the best researched EBP models. Box 12-5 shows some of the recent research studies that
have used the Iowa model.

Figure 12-3 Diagram of the Iowa model of evidence-based practice.
(Reprinted with permission from University of Iowa Hospitals and Clinics. © 1998. For permission to use or reproduce the model, please
contact University of Iowa Hospitals and Clinics at 319-384-9098.)

Box 12-5
Research Based on the Iowa Model of Evidence-Based Practice to
Promote Quality Care

Bankhead, S., Chong, K., & Kamai, S. (2014). Preventing extubation failures in a pediatric intensive care

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unit. The Nursing Clinics of North America, 49(2), 321–328.
Brown, C. G. (2014).The Iowa model of evidence-based practice to provide quality care: An illustrated

example in oncology nursing. Clinical Journal of Oncology Nursing, 18(2), 157–159.
Estus, K. (2014). Cancer survivorship using IM & EBP to promote quality of care. Clinical Nurse Specialist,

28(3), 173–174.
Turenne, J. P., Héon, M., Aita, M., Faessler, J., & Doddridge, C. (2016). Educational intervention for an

evidence-based nursing practice of skin to skin contact at birth. The Journal of Perinatal Education,
25(2), 116–128. doi:10.1891/1058-1243.25.2.116

White, S., & Spruce, L. (2015). Perioperative nursing leaders implement clinical practice guidelines using
the Iowa model of evidence-based practice. AORN Journal, 102(1), 51–56.
doi:10.1016/j.aorn.2015.04.001

The Johns Hopkins Nursing Evidence-Based Practice Model
The JHNEBP Model was developed to accelerate the transfer of research to practice and to promote nurse
autonomy, leadership, and engagement with interdisciplinary colleagues (Dearholt & Dang, 2012). The
JHNEBP Model was designed as a problem-solving approach to clinical decision making. It combines
elements of the nursing process, the American Nurses Association’s Standards of Practice, critical thinking,
and research utilization processes (Dearholt, 2012; Newhouse et al., 2007). The model has numerous levels of
activity, but it is based on practical teaching processes to promote use by novice nurses as well as more
experienced nurses.

The JHNEBP process is based on three core elements: a practice question, evidence, and translation (PET)
(Dearholt, 2012; Newhouse et al., 2007). As presented in Box 12-6, 18 steps are included in the model. As
shown, each of the PET phases is based on several steps that clarify how the processes are to proceed.

Box 12-6 Steps of the Johns Hopkins Nursing Evidence-Based Practice Model
Practice Question
1. Recruit interprofessional team.
2. Develop and refine the evidence-based practice (EBP) question. (Apply PICO elements.)
3. Define the scope of the EBP question and identify stakeholders.
4. Determine responsibility for project leadership.
5. Schedule team meetings.

Evidence
6. Conduct internal and external search for evidence.
7. Appraise the level and quality of each piece of evidence.
8. Summarize the individual evidence.
9. Synthesize overall strength and quality of evidence.
10. Develop recommendations for change based on evidence synthesis.

Translation
11. Determine fit, feasibility, and appropriateness of recommendation for translation pathway.
12. Create action plan.
13. Secure support and resources to implement action plan.
14. Implement action plan.
15. Evaluate outcomes.
16. Report outcomes to stakeholders.
17. Identify next steps.
18. Disseminate findings.

Source: Dearholt (2012, pp. 33–53).

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This method begins with an EBP question, following the PICOT format. The first step is to generate an
answerable practice question which includes the Patient, population, and the problem. It goes on to define an
Intervention, makes a Comparison with other treatments if possible, and finally defines the desired Outcome
and the Time table (PICOT) (Dearholt, 2012; Elias, Polancich, Jones, & Colvin, 2015). Other steps in the
“practice question” phase include defining the scope of the question and identifying stakeholders, assigning
responsibility for project leadership, recruiting a team, and scheduling a meeting.

In the evidence phase, the team conducts internal and external searches for evidence; this includes
comprehensive literature searches. Appraisal of the level and quality of the evidence follows, and the evidence
is summarized. This phase concludes with a synthesis of the overall strength and quality of the evidence
leading to recommendations for change (Dearholt, 2012).

In the third phase, translation, the team decides whether or not and how to implement the changes. This
involves determining the fit, feasibility, and appropriateness of the recommendations, before creating an
action plan. Support and resources are secured, and the action plan is implemented and evaluated. The
outcomes are reported to stakeholders and “next steps” are identified, and the findings are disseminated to
appropriate individuals or groups (Dearholt, 2012). The JHNEBP Model is clearly explained and simple to
apply. Related writings include the guidelines and definitions of the background, elements of the process, and
the steps of the model (Dearholt & Dang, 2012; Newhouse et al., 2007). Lately, Elias et al. (2015) have added
a “D” to the PICOT method to denote “digital data” components. This takes into account the factor of the
current digital records and systems changes in the patient care industry.

Stetler Model of Evidence-Based Practice
The Stetler Model was initiated in the 1970s as a quality improvement (QI) effort employing the research
utilization (RU) ideals then in widespread use (Melnyk & Fineout-Overholt, 2015). Over time and through
several iterations, Stetler updated the approach and clarified the series of phases of the model such that it is
readily implemented by practicing nurses and useful at the bedside (Stetler, Ritchie, Rycroft-Malone, Schultz,
& Charns, 2007). Stetler and colleagues (1998) and Stetler and Caramanica (2007) argued that all research
studies are not ready for use at the bedside. Furthermore, they explained that alternative sources of evidence
are necessary to fill the gaps in nursing research evidence.

The current Stetler Model of EBP is similar to the nursing process; therefore, it is easily assimilated by
practicing bedside nurses. The phases of the approach include preparation, validation, comparative
evaluation/decision making, translation/application, and evaluation. It provides practitioners with stepwise
directions for integrating research into practice. See Table 12-1 for description of the phases. The Stetler
Model incorporates five steps to generate a process that takes into account the many other facets of nursing
and the clinical situation prior to using research findings in the nurse’s clinical practice. When implemented,
the results should be systematically evaluated to track goal-oriented outcomes and proffer both formative and
summative evaluation strategies. The major outcomes of RU or EBP should be improved patient results as
well as enhanced professional practice (Stetler & Caramanica, 2007).

Table 12-1 Phases of the Stetler Model
Phase Content Actions

I Preparation (purpose, control,
and sources of research
evidence)

Define potential issues
Seek sources of research evidence
Perceive problems
Focus on high-priority issues
Decide on need for a team
Consider other influential factors
Define desired outcomes
Seek systematic reviews
Determine need for explicit research evidence
Select research sources with conceptual fit

II Validation (credibility of Credibility of findings

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findings and potential
for/detailed qualifiers of
application)

Critique and synthesize resources
Critique systematic reviews
Reassess fit of individual sources
Rate the level and quality of evidence
Differentiate statistical and clinical significance
Eliminate noncredible sources
End the process if there is no evidence or clearly

insufficient credible research evidence

III Comparative
evaluation/decision making
(synthesis and
decisions/recommendations
for criteria of applicability)

Synthesize the cumulative findings
Evaluate the degree and nature of other criteria
Make a decision whether/what to use
If decide to “not use,” STOP use of the model
If decide to use, determine recommendations for a

specific practice

IV Translation/application
(operational definition of
use/actions for change)

Types
Methods
Levels
Direct instrumental use
Cognitive use
Symbolic use
Caution: Assess whether translation/product or use

goes beyond actual findings/evidence
Formal dissemination and change strategies should be

planned per relevant research
Consider need for appropriate reasoned variation

V Evaluation (alternative types
of evaluation)

Evaluation can be formal or informal, individual or
institutional

Consider cost-benefit of evaluation efforts
Use RU as a process to enhance credibility of

evaluation data
For both dynamic and pilot evaluations include two

types of evaluative information

From Stetler, C. B. (2001). Updating the Stetler model of research utilization to facilitate evidence-based practice. Nursing Outlook, 49(6),
272–279. From Figure 3B. Stetler Model Part II: Additional, per phase details.

Theoretical Models: A Summary
The five EBP models described above are compared in Table 12-2 using the following criteria:

Groups of health care professionals affected (groups affected)
Environmental factors in which the model is useful (environment)
Analysis of the model (analysis)
Implementation: barriers/facilitators (implementation)
Evaluation of effectiveness identified by the model (evaluation)

Table 12-2 Comparison of Selected Models of Evidence-Based Practice
Models of Evidence-Based Practice

Comparison
Element ACE Star Model ARCC Model Iowa Model

Johns Hopkins
Model Stetler Model

Groups of health
care professionals

Instructors,
students, practicing

Advanced practice
nurses, practicing

Instructors,
students, practicing

Practicing nurses Practicing nurses or
groups of nurses

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(users) nurses nurses nurses

Environmental
factors in which the
model is useful
(environment)

Learning
environments,
hospitals

Patient care
organizations

Nursing schools
and patient care
agencies

Learning
environments,
hospitals

Clinical situations

Analysis of the
model (analysis)

Five major points
similar to the
nursing process

Five constructs
with similarity to
nursing process

Six steps of the
model:
Identify knowledge
or problem-focused
triggers (catalysts
to critical thinking).
Priority:
organizational
Form a team
responsible for
development,
implementation,
and evaluation of
EBP

PET (see Figure 3-
3, p. 42) steps are
the basis for the
model.
Team approach to
answer Practice
questions, critique
Evidence, and
Translate it into
usable form

Five phases:
(I) Preparation
(II) Validation
(III) Comparative
evaluation/decision
making
(IV)
Translation/application
(V) Evaluation

Implementation:
barriers/facilitators
(implementation)

Implementation
into practice is the
fifth stage and
involves bringing
evidence to clinical
decision making.

Implementation is
based on the
mentor’s
determination of
organizational
readiness.

Determine
sufficiency of
evidence.
If yes: Pilot
recommended
change.

Team determines
feasibility and
creates an action
plan to implement
the change.

Translation and
application is the fourth
step.

Evaluation of the
effectiveness of the
model (evaluation)

Evaluation is the
final stage and
focuses on
verification of the
success EBP
(Stevens, 2005).

Evaluation is the
fifth of the
constructs and has
three levels that
provide feedback
(Melnyk &
Fineout-Overholt,
2002).

Evaluate pilot
success and
disseminate results;
implement into
practice (Titler et
al., 2001).

Evaluate outcomes.
Report outcomes to
stakeholders.
Identify next steps
(Dearholt, 2012, p.
51)

Evaluation is the last
step (Stetler, 2001).

As shown, there are a number of similarities among the models. Schafffer and colleagues (2013) recently
compiled a review of models for organizational change based on EBP. Similar to what has been presented
here, their overview examined the key features of six models with the view to change practice in
organizations. Most of the models incorporate the steps of the research process in some way, and all the
models are focused on bringing the best in safe and effective nursing care to their major focus: the patient, or
recipient of nursing care. Nurses who are actively engaged in promoting EBP are encouraged to review these
as well as other published models and to select the one that best fits their needs and desired outcomes.

Helen, the nurse from the opening case study, conducted a systematic review of neuromuscular illnesses
and management protocols using the Iowa Model of EBP. During this process and while working with the
clinical team, she came to better understand her illness and the treatments that would most likely forestall
deterioration of her condition. The complexity and high level of information she accumulated through her
review of the research guided by theories of EBP brought Helen to a level of practice where she could not
only help herself but also her patients and clients. Following graduation, she based her clinical practice on the
expertise she had gained through her extensive study of the research and practice in neuromuscular diseases.

Summary
There is little doubt that EBP has become one of the key tenets of quality nursing care. As described,
however, it is critical to remember that EBP must go beyond research per se and emphasis on RCT but must
also be theory based. Many authors have written about the problems and barriers to EBP, and others have
written on how to strengthen the process and make it relevant to practicing nurses.

Over the last decade, a number of models have been constructed to assist nurses to learn how to proceed in
the development of evidence-based guidelines and promotion of EBP, as illustrated by the work of Helen in
the case study. The five models described here, along with a number of others that have been mentioned in the
nursing literature, give nurses information about the steps and processes necessary to elicit the evidence that is
needed to provide safe interventions that are effective in nursing practice. Nurses who seek to use tested and

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published evidence in their clinical areas are advised to seek out a working model of EBP and follow it
through to effect reasonable, safe, and effective changes for the benefit of their patients or clients.

Key Points
Research, theory, and practice are integrated in nursing; EBP is a key element and outcome of that linkage.
EBP is an approach to problem solving that uses the current best evidence in the care of patients.
In nursing, EBP has been defined as “the conscientious, explicit, and judicious use of theory-derived,

research-based information in making decisions about care delivery . . . in consideration of individual
needs and preferences.”

Nursing as a profession has been relatively slow to incorporate EBP; this has changed in recent years.
Some nurses are concerned that too much attention to EBP will draw attention away from the art of nursing

care—that nursing will become lost in the science.
Models of EBP have developed from early studies of research utilization and quality improvement. Many of

these models have been developed with the impetus of hospitals or educational institutions’ support.
The major impetus for integration and implementation of research evidence—guided by EBP—should be

reasonable, effective, and safe care for patients.

Learning Activities
1. Similar to the process used by Helen, the nurse in the opening case study, select one model of

EBP presented. Using your current clinical setting and a practice problem you have noticed,
determine what you would do to institute EBP into your current practice to address the
problem.

2. Compare and contrast two EBP models and write a blog on which would most likely work in
your agency or clinical unit. Explain why one model would work better than the other with
your colleagues or your organizational culture.

3. Prepare a proposal for practice change in your agency or clinical unit using one of the models
given in this chapter. Use as many of the steps of the model as possible and project the
outcomes for the remaining steps.

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