HISTORY OF NURSING THEORY

The history of professional nursing began with Florence Nightingale. It was Nightingale who envisioned nurses as a body of educated women at a time when women were neither educated nor employed in public service. Following her service of organizing and caring for the wounded in Scutari, during the Crimean War, her vision and establishment of a School of Nursing at St. Thomas’ Hospital in London marked the birth of modern nursing. Nightingale’s pioneering activities in nursing practice and subsequent writings describing nursing education became a guide for establishing nursing schools in the United States at the beginning of the twentieth century (Kalisch & Kalisch, 2003; Nightingale, 1859/1969). Nursing began with a strong emphasis on practice, but throughout the century, nurses worked toward the development of nursing as a profession through successive periods recognized as historical eras (Alligood, 2006a).

The curriculum era addressed the question of what prospective nurses should study to learn how to be a nurse. In this era, the emphasis was on what courses nursing students should take, with the goal of arriving at a standardized curriculum (Alligood, 2006a). By the mid-1930s, a standardized curriculum had been published. However, it was also in this era that the idea of moving nursing education from hospital-based diploma programs into colleges and universities emerged. Even so, it was the middle of the century before this goal began to be acted upon in many states (Kalisch & Kalisch, 2003).

As nurses increasingly sought degrees in higher education, a research emphasis era, as it is deemed, began to emerge. This era came about as more and more nurses embraced higher education and arrived at a common understanding of the scientific age, that is, that research is the path to new nursing knowledge. Nurses began to participate in research, and research courses began to be included in the nursing curricula of many developing graduate programs (Alligood, 2006a).

The research era and the graduate education era developed in tandem. Master’s degree programs in nursing emerged to meet the public need for nurses with specialized clinical nursing education. Many of these programs included a nursing research course. It was also in this era that most nursing master’s programs began to include courses in concept development or nursing models that introduced students to early nursing theorists and the knowledge development process (Alligood, 2006a).

The theory era was a natural outgrowth of the research and graduate education eras. As our understanding of research and knowledge development increased, it soon became obvious that research without theory produced isolated information, and that it was research and theory together that produced nursing science (Batey, 1977; Fawcett, 1978; Hardy, 1978). In the early years of the theory era, doctoral education in nursing flourished with an emphasis on theory development.

In the theory utilization era, emphasis was placed on middle range theory for theory-based nursing practice, as well as on theory development (Alligood & Tomey, 1997, 2002, 2006; Batey, 1977; Chinn & Kramer, 2008; Fawcett, 2005; Tomey & Alligood, 2006).

Each era addressed nursing knowledge in a unique way that contributed to and is observable in the history of nursing. Within each era, the pervading question “What is the nature of the knowledge that is needed for the practice of nursing?” seems to have been addressed at the level of understanding that prevailed at that time (Alligood, 2006a).

Nightingale’s (1859/1969) vision of nursing has been practiced for more than a century, and theory development in nursing has evolved rapidly over the past 5 decades, leading to the recognition of nursing as an academic discipline with a substantive body of knowledge (Alligood, 2006a, 2006b; Alligood & Tomey, 2006; Chinn & Kramer, 2008; Fawcett, 2005; Tomey & Alligood, 2006; Walker & Avant, 2005). In the mid-1800s, Nightingale wrote that nursing knowledge is distinct from medical knowledge. She described a nurse’s proper function as putting the patient in the best condition for nature (God) to act upon him or her. She proposed that care of the sick is based on knowledge of persons and their surroundings—a different knowledge base than that used by physicians in their practice. Despite this early edict from Nightingale in the 1850s, it was 100 years later, during the 1950s, that the nursing profession began to engage in serious discussion about the need to develop, articulate, and test nursing theory (Alligood, 2006d; Alligood, 2004; Chinn & Kramer, 2008; Meleis, 2007; Walker & Avant, 2005). Until the emergence of nursing as a science in the 1950s, nursing practice was based on principles and traditions that had been passed on through an apprenticeship model of education and hospital-kept procedure manuals (Alligood, 2002a; Kalisch & Kalisch, 2003).

Although some nursing leaders aspired for nursing to be recognized as a profession and become an academic discipline, nursing practice continued to reflect its vocational heritage more than a professional vision. The transition from vocation to profession included successive eras of history as nurses searched for a body of substantive knowledge on which to base nursing practice. The curriculum era emphasized course selection and content for nursing programs and gave way to the research era, which focused on learning the research process and meeting the long-range goal of acquiring substantive knowledge to guide nursing practice.

In the mid-1970s, an evaluation of the first 25 years of the journal Nursing Research revealed that nursing studies lacked conceptual connections and theoretical frameworks (Batey, 1977). An awareness of the need for concept and theory development coincided with two other significant milestones in the evolution of nursing theory. One was the standardization of curricula for nursing master’s education provided by the National League for Nursing accreditation criteria for baccalaureate and higher degree programs, and the second was the decision that doctoral education for nurses should be in nursing (Alligood, 2006a). The nursing theory era, coupled with an awareness of nursing as a profession and as an academic discipline in its own right, emerged from debates and discussions in the 1960s regarding the proper direction and appropriate discipline for nursing knowledge development. The explosive proliferation of nursing doctoral programs and nursing theory literature substantiated that nursing doctorates should be in nursing (Nicoll, 1986, 1992, 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, 2008). In the 1970s, nursing continued to make the transition from vocation to profession as more and more nurses asked, “Will nursing be other-discipline based or be nursing based?” The history records the answer, “Nursing practice needs to be based on nursing science” (Alligood, 2006a; Fawcett, 1978; Nicoll, 1986). It is as Meleis (2007) noted, “theory is not a luxury in the discipline of nursing … but an integral part of the nursing lexicon in education, administration, and practice” (p. 4).

The 1980s was a period of major developments in nursing theory characterized as a transition from the pre-paradigm to the paradigm period (Fawcett, 1984; Hardy, 1978). The prevailing nursing paradigms (models) provided perspectives for nursing practice, administration, education, research and further theory development. In the 1980s, Fawcett’s seminal proposal of four global nursing concepts presented a nursing metaparadigm that served as an organizing structure for existing nursing frameworks, and introduced a way of grouping what previously had been viewed as individual theoretical works (Fawcett, 1978, 1984, 1993). Classifying the nursing models as paradigms within a metaparadigm of the concepts person, environment, health, and nursing systematically united the nursing theoretical works for the discipline. This system clarified and improved comprehension of a knowledge development process by embedding the theorists’ works in a larger context, thus facilitating understanding of the growth of nursing science from a paradigm perspective (Alligood & Tomey, 2006; Fawcett, 2005). The body of nursing science and research, education, administration, and practice continues to expand through nursing scholarship. Podium presentations at national and international conferences, newsletters, journals, and books written by communities of scholars associated with the various nursing models and theories describe a theoretical basis for practice and research presenting their scholarship on a selected model or theory from a paradigm perspective (Alligood, 2004; Alligood & Tomey, 2006; Fawcett, 2005; Parker, 2006).

These observations of nursing theory development bring Kuhn’s (1970) description of normal science to life. His philosophy of science clarifies our understanding of the evolution of nursing theory through paradigm science. It is important historically that it was individual efforts that led to the first theory as nurse leaders in various areas of the country published their works, which later came to be viewed collectively within a systematic structure of knowledge (Fawcett, 1984, 2000, 2005). Theory development emerged as a product of professional scholarship and growth among nurse leaders, administrators, educators, and practitioners who sought higher education. These leaders recognized limitations of theory from other disciplines to describe, explain, or predict nursing outcomes, and they labored to establish a scientific basis for nursing management, curricula, practice, and research. The use of theory to convey an organizing structure and meaning for these processes led to the convergence of ideas that resulted in what is recognized today as the nursing theory era (Alligood, 2006b; Alligood & Tomey, 2006; Nicoll, 1986, 1992, 1997; Reed, Shearer & Nicoll, 2003; Reed & Shearer, 2008).

The accomplishments of normal science opened the theory utilization era as emphasis shifted to theory application in nursing practice, education, administration, and research (Alligood, 2006c; Wood & Alligood, 2006). The theory utilization era restored balance between research and practice for knowledge development in the discipline of nursing. The reader is referred to the fourth edition Nursing Theory: Utilization & Application (Alligood, 2010, in press) for case applications and discussion of utilization of nursing theoretical works in practice.

This brief history provides a context for your study of the nursing theorists and their work. The theory era continues with emphasis on development and use of nursing theory to produce evidence for professional practice. Particular utility of middle range theories to guide the thought and action of nursing practice is noted (Alligood, 2006c; Alligood & Tomey, 2006; Fawcett, 2005; Peterson, 2008; Smith & Leihr, 2008). Therefore, preparation for practice in the profession of nursing requires knowledge of the theoretical works of the discipline.

The theoretical works presented in this text are frameworks that have been organized into four types. Box 1-1 lists the theorists included in each type. The four types, although somewhat arbitrary, reflect a certain level of abstraction or the preference of the theorist.

The first type is nursing philosophy. Philosophy sets forth the meaning of nursing phenomena through analysis, reasoning, and logical presentation. Early works that pre-date the nursing theory era contributed to knowledge development by providing direction or a basis for subsequent developments. Later works reflect contemporary human science and its methods (Alligood, 2006b; Chinn & Kramer, 2008; Meleis, 2007). Selected works classified as nursing philosophies are presented in Unit II, Chapters 6 through 11.

A second type, nursing conceptual models, comprises nursing works by the theorists who also are referred to as pioneers in nursing (Chinn & Kramer, 2008; Fawcett, 2005; Meleis, 2007). Fawcett (2005) explains, “A conceptual model provides a distinct frame of reference for its adherents … that tells them how to observe and interpret the phenomena of interest to the discipline” (p. 16). The nursing models are comprehensive and define the metaparadigm concepts—person, environment, health, and nursing—according to their framework (Fawcett, 2005; Tomey & Alligood, 2006). Many nursing conceptual models include theories that the theorists have explicitly derived from them, and some models have implicit theories within them. Theories differ from models in that they propose a direction or action that is testable (Alligood & Tomey, 2006). An example of theory derived from a nursing model is seen in Roy’s work, wherein a theory of the person as an adaptive system is derived from her Adaptation Model. The highly abstract level of the theory (sometimes referred to as grand theory) in this example facilitates the derivation from it of many middle range theories that are specific to nursing practice (Alligood, 2006d). Works classified as nursing models are discussed in Unit III, Chapters 12 through 18.

The third type, nursing theory, is derived from nursing philosophies, conceptual models, or more abstract nursing theories, or from works of other disciplines (Tomey & Alligood, 2006). A work that is classified as a nursing theory is developed from some conceptual framework and is more specific than the framework. Theories may be specific to a particular aspect or setting of nursing practice. For example, Meleis’s transition theory (Chapter 20) is specific to aspects of the patient’s life process in health and illness. Nursing theories are presented in Unit IV, Chapters 19 through 26.

The fourth type, middle range theory, has an even more specific focus and is more concrete than nursing theory in its level of abstraction (Alligood 2006b, 2006d; Chinn & Kramer, 2008; Fawcett, 2005). Therefore, middle range theories are more precise, with a focus on answering specific nursing practice questions. They specify such factors as the age group of the patient, the family situation, the health condition, the location of the patient, and, most important the action of the nurse (Alligood, 2006c). Middle range theories address the specifics of nursing situations within the perspective of the model or theory from which they are derived (Alligood, 2006b, 2006c, 2006d; Fawcett, 2005). Middle range theories in the nursing literature have been developed inductively as well as deductively. Selected middle range theories are presented in Unit V, Chapters 27 through 36. Table 1-1 presents an example of theoretical knowledge at each level of abstraction within a knowledge structure.

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