To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at http://evolve. elsevier.com/Black/professional.

“Theory” is a word that is used often in daily language, such as “I have a theory about that” or “In theory, this should work.” The word “theory” in this context means that the person has some idea about a phenomenon and the way this phenomenon works in the world. When people say, “I have a theory . . .” about a certain phenomenon or situation, they are demonstrating something about their own distinct orientation or way of seeing the world. “Theory” comes from the Latin and Greek word for “a viewing” or “contemplating.”

Chapter opening photo from Photos.com.

Nursing as a profession has a distinct theoretical orientation to practice. This means that the practice of nursing is based on a specific body of knowledge that is built on theory. This body of knowledge shapes and is shaped by how nurses see the world. The word theory has many definitions, but generally it refers to a group of related concepts, definitions, and statements that describe a certain view of nursing phenomena (observable occurrences) from which to describe, explain, or predict outcomes (Chinn and Kramer, 1998). Theories represent abstract ideas rather than concrete facts. New theories are always being generated, although some theories are useful for many years. When new knowledge becomes available, theories that are no longer useful are modified or discarded. You will be reading about Sister Callista Roy’s adaptation model, one that has “stood the test of time” since the 1970s; its use expanded from its origins as a curriculum framework for bachelor of science in nursing (BSN) education to its current use as an organizing framework for nurses (Alligood, 2011).

So why is theory important? First, nursing as a profession is strengthened when nursing knowledge is built on sound theory. As seen in Chapter 3, one criterion for a profession is a distinct body of knowledge as the basis for practice. Nursing began its transition from a vocation to a profession and academic discipline in the 1950s (Bond, Eshah, Bani-Kaled et al, 2011). Nursing has knowledge that is distinct from, although related to, other disciplines such as medicine, social work, sociology, and physiology, among others. The development of nursing knowledge is the work of nurse researchers and scholars. The evolution of the profession of nursing depends on continued recognition of nursing as a scholarly academic discipline that contributes to society. In today’s research environment, where theory is developed and tested, interdisciplinary collaboration is now considered to be a critical approach to the development of knowledge. Use of nursing theory in other disciplines is not yet common, however (March and McCormack, 2009). Even in our own discipline, unfortunately, nursing theory is underused in supporting research. A recent study demonstrated that nursing theory was used infrequently in research published in nursing journals between 2002 and 2006: only 460 of 2184 (21%) research articles published in seven top nursing research journals used nursing theory (Bond et al, 2011).

Second, theory is a useful tool for reasoning, critical thinking, and decision making (Tomey and Alligood, 2010). The ultimate goal of nursing theory is to support excellence in practice. Pilson (2009) argued that subspecialties of nursing, not simply basic nursing, should be theory based, which will assist novices to become experts, therefore improving patient care. Nursing practice settings are complex, and a vast amount of information about each patient is available to nurses. Nurses must analyze this information to make sound clinical judgments and to generate effective interventions. From organization of patient data to the development and evaluation of interventions, theory provides a guide for nurses in developing effective care. Box 13-1 shows how theory guides nursing practice.

Several words are used to describe abstract thoughts and their linkages. From the most to least abstract, these include metaparadigm, philosophy, conceptual model or framework, and theory. Metaparadigm refers to the most abstract aspect of the structure of nursing knowledge (March and McCormack, 2009). The metaparadigm of nursing consists of the major concepts of the discipline—person, environment, health, and nursing—that were discussed in Chapter 12. More recently, caring has been added as a major concept of the discipline as a central to nursing knowledge development and practice. Simply stated, these five concepts comprise the metaparadigm of nursing; that is, these are the concepts (abstract notions or ideas) of most importance to nursing practice and research. Nursing philosophies, models, and theories contain most or all of these concepts.

A philosophy is a set of beliefs about the nature of how the world works. A nursing philosophy begins to put together some or all concepts of the metaparadigm. For instance, Florence Nightingale, whose work will be considered in more detail later in this chapter, wrote Notes on Nursing: What It Is and What It Is Not, in which her basic philosophy of nursing is described in detail. A conceptual model or framework is a more specific organization of nursing phenomena than philosophies. As the words “model” or “framework” imply, models provide an organizational structure that makes clearer connections between concepts.

Theories are more concrete descriptions of concepts that are embedded in propositions. Propositions are statements that describe linkages between concepts and are more prescriptive; that is, they propose an outcome that is testable in practice and research. For example, Peplau’s book Interpersonal Relations in Nursing (1952) contains a theory that describes very specific elements of effective interaction between the nurse and patient. Using concepts from nursing’s metaparadigm, Peplau created a theory delineating elements of excellent and effective practice in psychiatric nursing. She linked abstract concepts such as health and nursing to create a concrete, useful theory for practice. Peplau’s theory will be described later in this chapter.

The primary source—the original writings of the theorist—is the best source for in-depth understanding of theoretical works. Explanatory texts written by other scholars can be helpful in interpreting primary sources. Explanatory texts introduce students to the theoretical basis of the discipline of nursing from a nursing science perspective that is much broader than any one of the primary sources. That is, these explanatory texts trace the historical development of the philosophy, model, or theory and specify criteria (standards) by which to analyze, critique, and evaluate them. Texts such as these were first published in the early 1980s with a completely different purpose than the theorists’ original writings. They are designed to contribute to the general understanding of nursing theory and theoretical developments in nursing in a unique but complementary way. Undergraduate and graduate students, faculty, and practicing nurses have found that these explanatory texts on nursing theory make a significant contribution to their knowledge and understanding of nursing science in its own right.

In this chapter, four types of nursing theoretical works will be presented: philosophies, conceptual models, theories, and middle-range theories. Selected works from each of these four types provide a broad overview of theory within the discipline of nursing. This introduction is designed to help you develop a beginning understanding of nursing theory on which to build as you pursue your nursing education and career in the profession of nursing.

Philosophies of nursing

Chapter 12 introduced nursing philosophy and discussed its function in nursing practice and educational institutions. A philosophy provides a broad, general view of nursing that clarifies values and answers broad disciplinary questions such as the following: “What is nursing?” “What is the profession of nursing?” “What do nurses do?” “What is the nature of human caring?” “What is the nature of nursing practice and the development of practice expertise?” Three philosophies representing different positions in the development of nursing theory are presented here. Table 13-1 contains questions that represent the different views of the same patient situation among nurses who subscribe to the philosophies of Florence Nightingale, Virginia Henderson, and Jean Watson, whose work is presented here.

TABLE 13-1

THREE PHILOSOPHIES OF NURSING: THREE DIFFERENT RESPONSES TO THE SAME PATIENT SITUATION

Florence Nightingale	What needs to be adjusted in this environment to protect the patient?
Virginia Henderson	What can I help this patient do that he would do for himself if he could?
Jean Watson	How can I create an environment of trust, understanding, and openness so that the patient and I can work together in meeting his or her needs?

Nightingale’s philosophy

Florence Nightingale was born in 1820, in Florence, Italy. She was the daughter of a wealthy English landowner and his wife, Fanny, whose goal in life was to find a suitable husband for her daughters. Florence was very close to her father, and he undertook the responsibility for her education, teaching her a classical curriculum of Greek, Latin, French, German, Italian, history, philosophy, and mathematics. At 25 years of age, after deciding to remain unmarried, Florence announced her decision to go to Kaiserswerth, Germany, to study nursing, over the strong objections of her parents. At that time, nursing was considered the pursuit of working-class women. Her persistence in the face of her parents’ opposition proved to be a sustained characteristic over the course of her life. This trait enabled her to accomplish work that most women of the time would not have had the education or willingness to achieve.

Nightingale’s work represents the beginning of professional nursing as we know it today. In Notes on Nursing: What It Is and What It Is Not (1969; originally published in 1859), Nightingale wrote her philosophy of health, illness, and the nurse’s role in caring for patients. Importantly, she made a distinction between the work of nursing and the work of physicians by identifying health rather than illness as the major concern of nursing. Her writing about nursing reflected the sociohistorical context in which she lived, making a distinction between the work of nursing and the work of household servants, who were common in her day and often cared for the sick.

Nightingale’s unique perspective on nursing practice focused on the relationship of patients to their surroundings. She set forth principles that were foundational to nursing and remain relevant to nursing practice today. For example, her description of the importance of observing the patient and accurately recording information and her principles of cleanliness still shape hospital-based nursing practice today. Nightingale focused the profession on what has become known as the metaparadigm of nursing: person (patient), health (as opposed to illness), environment (how the environment affects health and recovery from illness), and nursing (as opposed to medicine).

Using nightingale’s philosophy in practice

Nightingale believed that the health of patients was related to their environment. She recognized the importance of clean air and water and of adequate ventilation and sunlight and encouraged the arrangement of patients’ beds so that they were in direct sunlight. In her writing, she described both the necessity of a balanced diet and the nurse’s responsibility to observe and record what was eaten. Cleanliness of the patient, the bed linens, and the room itself were essential. Nightingale recognized the problem of noise in hospital rooms and halls, which foreshadowed the attention given to excess noise in inpatient settings in recent years. Rest is important in the restoration of health; Nightingale believed that sudden disruption of sleep was a serious problem. The relationship of health to the environment seems obvious today, but for nursing in the second half of the nineteenth century, Nightingale’s work was radically different.

Nightingale recognized nursing’s role in protecting patients. Nurses were newly responsible for shielding patients from possible harm by well-meaning visitors who may provide false hope, discuss upsetting news, or tire the patient with social conversation. Nightingale even suggested that the nurse’s responsibility for patients did not end when the nurse was off duty. This view underpins the system of primary nursing found in some settings today. Interestingly, Nightingale suggested that patients might benefit from visits by small pets, an idea that has been newly revisited in long-term care settings.

The nurse whose practice is guided by Nightingale’s philosophy is sensitive to the effect of the environment on the patient’s health or recovery from illness. This philosophy provided the foundational work for theory development that proposed changing patients’ environments to effect positive changes in their health. Nightingale promoted the view that nurses’ primary responsibility was to protect patients by careful management of their surroundings.

Henderson’s philosophy

Virginia Henderson was born in 1897 in Kansas City, Missouri, and was named for the state her mother longed for and to which the family returned 4 years later. Although she received an excellent education from a family friend who was a schoolmaster and from her father who was a former teacher, Henderson did not receive a traditional education that awarded a diploma. This delayed her entry into nursing school. During World War II, she studied under Annie Goodrich at Teachers College, Columbia University, where, after numerous interruptions, she received her bachelor’s and master’s degrees. By the time she died in 1996, Virginia Henderson was internationally known and regarded by many as “the Florence Nightingale of the twentieth century.”

One hundred years after Nightingale, Virginia Henderson’s work first was published, emerging at a time when efforts to clarify nursing as a profession emphasized the need to define nursing. Henderson’s philosophical approach to nursing is contained in her comprehensive definition: 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 a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge” (Henderson, 1966, p. 15). Although Henderson, pictured in Figure 13-1, was recognized for many contributions to nursing throughout her long career, her early work remains particularly noteworthy and relevant, defining nursing and specifying the role of the nurse in relation to the patient. Henderson’s relationship with one of her former students, who recognizes the ongoing contributions of Henderson’s work to nursing, is described in Box 13-2.

BOX 13-2   REMEMBERING VIRGINIA HENDERSON

Although I had known Virginia Henderson from the time I was a graduate student at Yale, geography later brought us more closely together. Knowing her family lived in Virginia (mine was in Connecticut), whenever I traveled by car from North Carolina to Connecticut I called and asked if she wanted a ride back home with me, because I could drop her off in Virginia en route to North Carolina. Six times we made the 8-hour ride together. Our conversations were wide-ranging because we were both world travelers. We talked much about politics; most about nurses—”see a nurse before you go to a doctor” as a solution to health care cost, quality, and access problems; some about patients—”give them their records” as a most important patient education tool; and some about our large extended families. I was introduced to two of Virginia Henderson’s sisters when they were all in their 90s. Four brothers and a sister had predeceased them, but Frances [Fanny] had maintained the old family homestead so all who could come were welcomed to stay. Come they did for over two generations of reunions, weddings, funerals, and holidays, especially Christmas.

What was most amazing to me about our time together was that Virginia Henderson never said anything to me about our profession that she had not written down somewhere for all nurses to read. Yale’s School of Nursing asked me to address the topic of her writing in their Bellos Lecture the year they celebrated her 90th birthday. I read her textbook, Principles and Practice of Nursing, sixth edition, and discovered any number of conversations I had experienced with her over the years. In preparing the Virginia Henderson Reader: Excellence in Nursing, I discovered even more. Her writings are conversational, that is, completely without the jargon of the medical and nursing professions. Her description of nursing is best used by nurses to tell patients what can be expected—to paraphrase: I am here to help you do what you would do for yourself if you had the strength, will, or knowledge, and to do so for you to become free of my help as rapidly as possible. It is quite reassuring for a patient to know what the nurse is going to do.

Virginia Henderson’s writings are timeless. The information in The Nature of Nursing and Basic Principles of Nursing Care is as relevant today as the day the books were written. The Nature of Nursing is the most important document written about nurses and nursing in the twentieth century, because it provided evidence of effective and efficient nursing. If you read her work, you can have a conversation with her, too.

Edward J. Halloran, RN, MPH, PhD,

Fellow, American Academy of Nursing

Courtesy Edward J. Halloran.

Henderson’s philosophy linked her definition of nursing that emphasized the functions of the nurse with a list of basic patient needs that are the focus of nursing care. She proposed an answer to questions similar to those addressed by Nightingale a century earlier: “What is the nursing profession?” and “What do nurses do?” Henderson described the nurse’s role as that of a substitute for the patient, a helper to the patient, or a partner with the patient.

Henderson identified 14 basic needs (Box 13-3) as a general focus for patient care. She proposed that these needs shaped the fundamental elements of nursing care. The function of nurses was to assist patients if they were unable to perform any of these 14 functions themselves. Although these needs can be categorized as physical, psychological, emotional, sociological, spiritual, or developmental, thoughtful analysis reveals a holistic view of human development and health.

BOX 13-3   HENDERSON’S 14 BASIC NEEDS OF THE PATIENT

1. Breathe normally.

2. Eat and drink adequately.

3. Eliminate body wastes.

4. Move and maintain desirable position.

5. Sleep and rest.

6. Select suitable clothes—dress and undress.

7. Maintain body temperature within normal range by adjusting clothing and modifying the environment.

8. Keep the body clean and well groomed and protect the integument (skin).

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.

Data from Henderson V: The Nature of Nursing: A Definition and Its Implications for Practice, Research, and Education, New York, 1966, Macmillan.

The first nine needs emphasize the importance of care of the physical body: breathing, eating and drinking, elimination, movement and positioning, sleep and rest, suitable clothing, maintenance of suitable environment for the body temperature, cleanliness, and avoidance of danger or harm. Next she included psychosocial needs such as communication and spirituality, including worship and faith. She concluded with three developmental needs: the need for work and the sense of accomplishment; the need for play and recreation; and the need to learn, discover, and satisfy curiosity. Henderson believed that all 14 basic needs are amenable to nursing care. They continue to be used today in philosophical statements of schools and departments of nursing.

Using henderson’s philosophy in practice

Nurses whose practice is consistent with Henderson’s philosophy adopt an orientation to care from the perspective of the 14 basic needs. Henderson’s clarity about the role and function of the nurse is a strength of her work. This philosophy is easily applied to a variety of patient care settings, from brief outpatient encounters in which a limited number of needs are addressed to a complex setting such as intensive care where patients are extremely vulnerable. Henderson used her definition of nursing and the basic needs approach in her well-known case study of a young patient who had undergone a leg amputation. Using this case, Henderson (1966) demonstrated how the nurse’s role changes on a day-to-day, week-to-week, and month-to-month basis in relation to the patient’s changing needs and the contributions of other members of the health care delivery team.

Watson’s philosophy

Jean Watson is a more recent contributor to the evolving philosophy of nursing. Born in West Virginia, she earned her BSN degree from the University of Colorado in 1964, her master of science (MS) from the University of Colorado in 1966, and her doctor of philosophy (PhD) from the University of Colorado in 1973. Six years later, she published her first book, The Philosophy and Science of Caring. In this initial work, she called for a return to the earlier values of nursing and emphasized the caring aspects of nursing. Watson’s work is recognized as human science. Caring as a theme is reflected in her other professional accomplishments, such as the Center for Human Caring at the University of Colorado in Denver, where nurses can incorporate knowledge of human caring as the basis of nursing practice and scholarship. Watson proposed 10 factors (Box 13-4), which she initially labeled as “carative” factors, a term she contrasted with “curative” to differentiate nursing from medicine. More recently, the term “caritas processes” has replaced carative factors as Watson’s work has continued to be refined. Recently, these processes taken together were found to be a measure of the concept of caring (DiNapoli, Turkel, Nelson, Watson, 2010).

BOX 13-4   WATSON’S 10 CARITAS PROCESSES

1. Practice loving kindness

2. Decision making

3. Instill faith and hope

4. Teaching and learning

5. Spiritual beliefs and practices

6. Holistic care

7. Helping and trusting relationship

8. Healing environment

9. Promote expression of feelings

10. Miracles

Adapted from DiNapoli PP, Turkel M, Nelson J, & Watson J: Measuring the caritas processes: Caring factor survey, Intern J Human Caring 14(3):16–21, 2010.

Watson’s work (1979, 1988, 1999) addressed the philosophical question of the nature of nursing as viewed as a human-to-human relationship. She focused on the relationship of the nurse and the patient, drawing on philosophical sources for a new approach that emphasized how the nurse and patient change together through transpersonal caring. She proposed that nursing be concerned with spiritual matters and the inner knowledge of nurse and patient as they participate together in the transpersonal caring process. She equated health with harmony, resulting from unity of body, mind, and soul, for which the patient is primarily responsible. Illness or disease was equated with lack of harmony within the mind, body, and soul experienced in internal or external environments (Watson, 1979). Nursing is based on human values and interest in the welfare of others and is concerned with health promotion, health restoration, and illness prevention.

Using watson’s philosophy in practice

Watson’s caritas processes guide nurses who use transpersonal caring in practice. Caritas processes specify the meaning of the relationship of nurse and patient as human beings. Nurses are encouraged to share their genuine selves with patients. Patients’ spiritual strength is recognized, supported, and encouraged for its contribution to health. In the process of transpersonal relationships, nurses develop and encourage openness to understanding of self and others. This leads to the development of trusting, accepting relationships in which feelings are shared freely and confidence is inspired. Even a core element of practice such as patient teaching can be carried out in an interpersonal manner true to the philosophy and nature of the caring relationship.

The nurse guided by Watson’s work has responsibility for creating and maintaining an environment supporting human caring while recognizing and providing for patients’ primary human requirements. In the end, this human-to-human caring approach leads the nurse to respect the overall meaning of life from the perspective of the patient. Watson’s (1988) work formalized the theory of human caring from this philosophy. Key aspects of nursing’s metaparadigm evident in Watson’s work are environment (one that supports human caring), person (both the patient and the nurse), health (in terms of health promotion and illness prevention), and nursing (what nurses contribute to the encounter with the patient). Importantly, Watson’s work on caring has contributed another aspect to the metaparadigm of nursing, because caring itself is now considered by many scholars to be a central concept of the discipline of nursing.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Critical thinking, the nursing process, and clinical judgment
2. The education of nurses: On the leading edge of transformation
3. Illness, culture, and caring: Impact on patients, families, and nurses
4. Health care in the United States

Stay updated, free articles. Join our Telegram channel

Join