State of the art and science of nursing theory
Martha Raile Alligood
“Nursing theoretical knowledge has demonstrated powerful contributions to education, research, administration and professional practice for guiding nursing thought and action. That knowledge has shifted the primary focus of the nurse from nursing functions to the person. Theoretical views of the person raise new questions, create new approaches and instruments for nursing research, and expand nursing scholarship throughout the world.”
Alligood, M. R. (2011). Nursing Science Quarterly, 24(4), p. 304.
It becomes obvious from studying texts such as this one that understanding and use of nursing theoretical works is active and growing globally, pointing the way to new knowledge through research, education, administration, and practice applications. Reviews of the seventh edition of this text by consumers identified by the publisher as well as published reviews in scholarly nursing journals recognize its contribution to professional nursing. Suggestions that are given receive careful consideration for each new edition (Dickson & Wright, 2012; Smith, 2012; Paley, 2006). Smith (2012) points out, “The text is significant in that it provides nursing students with an accurate and scholarly reference to identify significant philosophies, models and theories that are pertinent to their own nursing practice” (p. 201). Similarly, Dickson and Wright (2012) conclude, the text “simply and elegantly describes the great progress that nursing as a discipline and profession has accomplished guided by the vision of leading nursing theorists. The scope and depth … may address the concerns and critics who argue nursing theory is outdated or irrelevant to current practice and research” (p. 204). In this eighth edition, effort was given to updating the chapters while maintaining clarity and integrity of each work and keeping the size of the text workable. Unit I content was updated and restructured, and a new Chapter 4 was added on knowledge structure and the role of analysis in theory development.
Units II to VI were updated, and the uniform outline of each chapter was maintained. The philosophies, nursing models, and theories in Units II to IV address each metaparadigm concept (person, environment, health, and nursing). Since middle-range nursing theories (Unit V) are limited in scope and specific to practice, care was given to clarifying this and specifying the metaparadigm concepts addressed. Rodgers (2005) notes that “middle-range theories currently have the most emphasis in nursing” (p. 191). Similarly, Im & Chang (2012) conclude that “…. middle range [theory] will play an essential role in nursing research ….” (p. 162).
As in previous editions, the chapters in this eighth edition are written by those who use the various theoretical works in their professional practice and research. Nurses around the world are increasingly recognizing the vital nature of theoretical works and applying them to their practice, research, education, and administration (Alligood & Marriner Tomey, 1997, 2002, 2006; Alligood & Tomey, 2010; Butts & Rich, 2011; George, 2011; Marriner, 1986; Marriner Tomey, 1989; Marriner Tomey, 1994; Marriner Tomey & Alligood, 1998; 2002; 2006).
As indicated in Chapter 1, this eighth edition continues to clarify the relevance of nursing theoretical works, facilitate their recognition as systematic demonstrations of nursing substance, and inspire their use as frameworks for nursing scholarship in practice, research, education, and administration. Simply put, the framing of an issue guides to the desired outcome. There are many different ways to survey the art and science of nursing theory. This chapter explores the growth of nursing theory from three perspectives.
First, as noted in Chapter 2, the philosophy of science continues to open new ways of developing and using theoretical works (Butts & Rich, 2011; Carper, 1978; Chinn & Kramer, 2011; Fawcett & Garity, 2009; Kuhn, 1962, 1970). The significance of normal science (Chapter 3) to the discipline is considered (Kuhn, 1962, 1970). Second, nursing theory is viewed in the context of new growth that encourages framing knowledge in present day understanding. The phenomenal expansion of middle-range theory development and use in all areas of nursing is discussed (Butts & Rich, 2011). Third and finally, the global development and use of nursing theoretical works by nurse scholars around the world highlights growth and reminds the reader of the vital nature of theory for the profession, discipline, and science (Johnson & Webber, 2004).
Nature of normal science
Many nursing models and theories included in this text exhibit characteristics of Kuhn’s (1970) criteria for normal science (Wood, 2010). Increasingly over the past 30 years, the conceptual models of nursing and nursing theories as presented by Alligood (2010a, 2014), Alligood and Marriner Tomey (1997, 2002, 2006), Alligood & Marriner Tomey (2010), Fawcett (1984a, 1989, 1993, 1995, 2005), Fitzpatrick and Whall (1984, 1989, 1996), George (1985, 1986, 1989, 1995, 2002, 2011), Marriner Tomey (1986, 1989, 1994), Marriner Tomey and Alligood (1998, 2002, 2006), McEwen and Wills (2002, 2006), Meleis (1985, 1991, 1997, 2005, 2007, 2012), and Parker (2001, 2006) have led to theory-based education, administration, research, and practice. Communities of scholars associated with a model or theory continue to grow globally as formally organized societies that share knowledge and address questions from their research and practice on websites and in newsletters and journals. Nursing models and theories address the central concepts of the discipline: person, environment, health, and nursing, (Fawcett, 1984b).
Nurses generate theory-based scholarship for research and practice. Work by the communities of scholars in the nursing models has led to the development of research instruments or clinical measurement tools unique to that paradigm (Fawcett, 2005, 2009).
Kuhn (1970) stated, “Paradigms gain their status by being more successful than their competitors in solving a few problems that the group of practitioners have come to recognize as acute” (p. 23). Kuhn (1970) defines normal science as “research firmly based upon one or more past scientific achievements, achievements that some particular scientific community acknowledges for a time as supplying the foundation for its further practice” (p. 10). The characteristics of paradigms that evidence their nature and lead to normal science include the following:
• A community of scholars who base their research and practice on the paradigm
• The formation of specialized journals
• The foundation of specialists’ societies
Rodgers (2005) describes normal science as…. “the highly cumulative process of puzzle solving in which the paradigm guides scientific activity and the paradigm is, in turn, articulated and expanded” (p. 100). Rodgers (2005) cites Kuhn’s premise that research in normal science “is directed to the articulation of those phenomena and theories that the paradigm supplies” (p.100).
The conceptual models of nursing in this text exhibit these characteristics. Each model is unique with ranges of development in these characteristics. Rogers’ Science of Unitary Human Beings (Chapter 13) is an excellent example having generated hundreds of research studies, 13 research instruments, and 12 nursing process clinical tools for practice (Fawcett, 2005; Fawcett & Alligood, 2001). The Society of Rogerian Scholars, founded in 1988, publishes a refereed journal, Visions: The Journal of Rogerian Nursing Science, with issues available on the Society of Rogerian Scholars website to foster development of the science among the community of scholars. Rogerian science is the basis of award winning texts and curricula for undergraduate and graduate nursing programs (Fawcett, 2005). In 2008, the Society of Rogerian Scholars celebrated 25 years of Rogerian conferences, the 20th anniversary of the society and 15 years of Visions: The Journal of Rogerian Nursing Science. Similarly, the International Orem Society for Orem’s Self-Care Deficit Theory (Chapter 14). King International Nursing Group for King’s Conceptual System (Chapter 15), the Neuman Trustee Group for Neuman’s Systems Model (Chapter 16), and the Boston-based Adaptation Research in Nursing Society for Roy’s Adaptation Model (Chapter 17) are well developed and productive communities of scholars.
Nursing theories that have developed normal science include: Boykin & Schoenhofer’s Theory of Nursing as Caring (Chapter 19). Meleis’s Transitions Theory (Chapter 20), Pender’s Health Promotion Model (Chapter 21), Leininger’s Theory of Culture Care (Chapter 22), Margaret Newman’s Theory of Health as Expanding Consciousness (Chapter 23), Parse’s Theory of Human Becoming (Chapter 24), and Erickson, Tomlin, and Swain’s Theory of Modeling and Role-Modeling (Chapter 25). Many of these have founded consortia or societies for development of research, presentations, publications, and practice applications.
Expansion of theory development
Theoretical works provide ways to think about nursing. Johnson and Webber (2001, 2004) addressed the future of nursing in questions about the importance of theory development for recognition of nursing as a profession, as a discipline, and as a science. They identify three significant areas affected by nursing knowledge and dependent on its continued development. Theory affects recognition of nursing as 1) a profession, 2) a discipline, and 3) a science. Substantive knowledge is the heart of nursing for recognition but most importantly for quality care of patients whom we serve. Moving nurses beyond functional practice to a style of practice with a professional delivery model requires transposing from emphasis on what the nurse does to emphasis on the patient. This requires practice based on a systematic presentation and focus on persons. As knowledge is transferred to those coming into the profession, a style of practice is also related. As nurses shift to a professional style of nursing, most agree that, “nursing knowledge arises from inquiry and guides practice” (Parse, 2008, p. 101). The growth of middle-range theory accentuates the practice-theory connection opening new insights and vistas for theory development. The literature demonstrates numerous ways for scholars to classify nursing theoretical works. Classifications vary based on the framework used for the classification. Of importance is that nurses: know the individual works, recognize them as evidence on which to base practice, teach them to students, and select one for a professional style of practice and improved quality of care.
Nurses eagerly embraced qualitative research approaches to explore questions that quantitative research methods could not answer, and this expanded theory development led to new qualitative middle-range theories (Alligood & May, 2000; Peterson & Bredow, 2009; Sieloff & Frey, 2007; Smith & Liehr, 2008; Thorne, Kirkham, & O’Flynn-Magee, 2004). New theories expand the volume of middle-range or practice theory applications. Examples include new theories in Orem (Biggs, 2008; Reigel, Jaarsma, & Stromberg, 2012), in Neuman (Bigbee & Issel, 2012; Casalenuovo, 2002; Gigliotti, 2003; Shamsudin, 2002), in Roy (DeSanto-Madeya, 2007; Dobratz, 2011; Dunn, 2005; Hamilton & Bowers, 2007; Roy, 2011), in Rogers (Kim, Kim, Park, et al., 2008; Malinski, 2012; Willis & Grace, 2011), in Newman (Brown, 2011; MacNeil, 2012; Pharris & Endo, 2007), in King (Alligood, 2010e; Sieloff & Frey, 2007), and in Parse (Smith, 2012; Wang, 2008). This exciting development closes the gap between research and practice (Alligood, 2010c) coming from quantitative and qualitative methods.
Considering nursing knowledge in a generic structure as presented in Figure 37–1 is a view of knowledge based on the nature of the content within nursing science rather than focusing on the research method. Middle-range theories vary in range and level of abstraction as the name of the classification indicates. Actually, this is true for theoretical works in other classifications (philosophies, models, and theories) as they also have similarities and differences in their levels of abstraction (Fawcett, 2005). Middle-range theories are recognizable as they include details that are specific to practice, such as the situation or health condition involved, client population or age group, location or area of nursing practice, and action of the nurse or the nursing intervention (Alligood, 2010a, p. 482).
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