Philosophies, Models, and Theories
Critical Thinking Structures
Martha Raile Alligood
It is not simply knowing a lot of things; it is a way of knowing things.
(Levine, 1988)
“Theory development in nursing science is critical for evolution of the discipline” (Clarke & Lowry, 2012, p. 333), and growth of the profession is dependent on nurses knowing and using nursing theoretical works in their practice of nursing. Studies continue to generate evidence of the connections among knowledgeable use of nursing theoretical works, education, and quality nursing practice (Bigbee & Issel, 2012; Erickson, 2007; Fawcett & Garity, 2009; Hatlevik, 2012; Im & Chang, 2012; McCrae, 2011; Sieloff & Bularzik, 2011). This evidence is vital for the practicing nurse.
This chapter sets the stage for the chapters that follow and introduces new understandings as Carper’s (1978) patterns of knowing are proposed as types of nursing theory and evidence for nursing practice (Fawcett, 2012a). These works represent the empirical pattern or the science of nursing understood as a type of theory and the form of evidence necessary for quality nursing practice (Carper, 1978; Fawcett, 2012a). Descriptions of the levels of abstraction of these nursing works from seven nursing models, three philosophies of nursing, and six theories of nursing illustrate their linkages with the practice level in middle-range theory. The theoretical frameworks guide professional practice; organizing the thought processes for decision making and reasoning for quality nursing practice. The content of nurses’ decisions may be unique nursing knowledge, but the modes of making practice decisions are generic processes of logic and critical thinking (Scriven & Paul, 2004). Nursing theoretical works (philosophies, models, theories) are knowledge structures that link logically with inherent critical thinking processes.
A key part of this chapter presents points to be considered when selecting a nursing theoretical work to guide your practice. You may discover thatcertain of the works resonate with you more than others. A good fit between the nurse and the theoretical work selected is important and is usually related to mutual values inherent in a theoretical work and the nurse. Chapter 4 presents an insightful discussion of the moral obligations and values inherent in theoretical works. Once a theory is selected it is recommended that you expand your understanding of that theory by reading published materials written by the theorist.
I want to introduce you to the use of the clinical case of Debbie in this text. Debbie has been featured in each application chapter since the first edition of this text in 1997. The case of Debbie was written by Dr. Ken Phillips, author of the Roy chapter. The idea for this feature sprang from a classroom teaching/learning exercise I had used with graduate students. Each student was asked to select a nursing framework and develop a plan of care for the same case (Mrs. Corbett). Their presentations illustrated the similarities and differences in the focus and plan of care when thought and action were guided by a particular nursing framework. This exercise led to important insights and understandings of the frameworks by the students. Therefore, that feature was included in the plans for the first edition of this text. The authors of the chapters in the Application section (Chapters 5 through 20) have developed a plan of care for Debbie, and each author also introduces a case of his or her choice and plan of care for that person. As you read the application chapters, watch for the unique focus of each philosophy, model, and theory noticeable in the care of Debbie. This text focuses on the use of theoretical works in practice. The reader is referred to Nursing Theorists and Their Work (Alligood & Tomey, 2010) for analytical critiques of the philosophies, models, and theories.
The Relationship of Philosophies, Models, and Theories
The philosophies, models, and theories of a discipline are theoretical structures that address the central concepts of that discipline. The science of nursing is recognized as a fundamental pattern of knowing for nurses (Carper, 1978). Fawcett (2005) proposes a nursing metaparadigm based on Kuhn’s (1970) philosophy of science and paradigm development. The metaparadigm specifies disciplinary boundaries of human beings, environment, health, and nursing as a context to understand the interrelationships among those elements of contemporary nursing science (Fawcett, 2005).
Theoretical knowledge may be differentiated by the way it is named or labeled. A model tends to be named for the person who authors it, for example, the Neuman Systems Model. Grand theories tend to be named for the outcome they propose, for example, the Theory of Optimal Client System Stability, and theories tend to be named for the characteristics their content demarcates as an explanatory shell of the outcomes they propose. An example is Gigliotti’s (2003) theory of women’s multiple role stress, which she validated as middle range with the age groups of women and forms of stress (Gigliotti, 2011, 2012).
Table 3-1 presents types of nursing knowledge at each level of abstraction and an example of nursing knowledge for each type.
• Philosophies present the general meaning of nursing and nursing phenomena through reasoning and logical presentation of ideas (Alligood, 2005). Although Nightingale (1946) did not present her philosophy on the relationship of patients and their surroundings as a theory, her philosophy contains implicit theory that guides nursing practice.
• Conceptual models (also called paradigms or frameworks) such as the Neuman Systems Model (Neuman & Fawcett, 2011) are the next less abstract set of concepts in the structure.
• Finally, as mentioned earlier, middle-range theory is the least abstract set of concepts and the most specific to nursing practice (e.g., promoting Optimal Client System Stability through a stress reduction intervention in the work environment). The understanding of theory terminology is developed over time with knowledge of works at the different levels of abstraction (Fawcett, 2005; Reynolds, 1971).
TABLE 3-1
A Structure of Nursing Knowledge Types and an Example of Each Type
| Knowledge Type | Examples of Types of Nursing Knowledge |
| Metaparadigm | Human beings, environment, health, nursing |
| Philosophy | Nightingale’s philosophy |
| Conceptual models | Neuman Systems Model |
| Grand theory | Optimal Client System Stability |
| Theory | Flexible line of defense moderates Optimal Client System Stability |
| Middle-range theory | Flexible line of defense moderates stress levels for Optimal Client System Stability in women who are enacting multiple roles (Gigliotti, 2011) |
Knowledge types based on Fawcett, J. (2005). Contemporary nursing knowledge: Conceptual models and theories (2nd ed.). Philadelphia: F. A. Davis.
Philosophies are theoretical works that address one or more of the metaparadigm concepts (person, environment, health, and nursing) in a broad philosophical way. Philosophies address questions such as:
Therefore, philosophies are broad statements of values and beliefs that propose general ideas about what nursing is, what nursing’s concerns are, and how the profession addresses its moral obligation to society. Each philosophy is a unique view of nursing.
Nursing models are frameworks or paradigms of the science of nursing that address the person, environment, health, and nursing metaparadigm. What this means in terms of nursing practice is that the way you think about people and about nursing has a direct effect on your approach with people, what questions you ask, how you process the information that is learned, and what nursing activities are included in your care. Therefore, a model provides a perspective of the person for whom you are caring, specifies the focus for the delivery of care, and structures the reasoning, critical thinking, and decision making in your practice.
Nursing theories derive from models and are guiding structures for reasoning and decision making about the person, the person’s health situation, and the care indicated. Theories are composed of sets of concepts, but they are less broad and propose specific outcomes. Theories may have been derived from a philosophy, a nursing model, a more abstract nursing theory, or a model or framework from another discipline. Theories are based on propositions or relationship statements that are consistent with theoretical works from which they are derived, but a theory coming from a nursing model such as Theory of Accelerating Change (based on Rogers’ Science of Unitary Human Beings) or Theory of the Person as an Adaptive System (based on Roy’s Adaptation Model) is more focused and guides your approach and perspective. When you approach people from the perspective of a certain nursing theory and ask questions, process information, and carry out specific activities, an outcome is anticipated based on the theory. This is true whether the theory is guiding the design and delivery of nursing care or the design and conduct of a research project. Just as theory strengthens nursing practice, theory-based research produces evidence for practice (Fawcett, 2012a,b). Theories have been specified as important forms of evidence. Evidence-based nursing practice is encouraged but is dependent on ways to recognize quality evidence. And the quality of evidence-based practice is dependent on recognition of quality research (Fawcett & Garity, 2009).
Middle-range theory is the least abstract in the structure of knowledge and as the term range suggests middle-range theories are at various levels of abstraction. These theories are at the practice level, and include details of nursing practice. Grand Theories such as Rogers’ Theory of Accelerating Change, Roy’s Theory of the Person as an Adaptive System, and Neuman’s Theory of Optimal Client System Stability are examples of grand theories because they are broad and their level of abstraction is close to the model from which they are derived. When a theory is atthe grand theory level, many middle-range applications of that theory can be developed for practice by specifying factors such as:
• The situation or health condition
• The client population or age group
• The location or area of nursing practice (e.g., home, hospital, community)
The process of specifying the details in the theory makes it less abstract and less broad; therefore, it applies to specific types of patients, in specific situations, and proposes specific outcomes about the care for the patient. Research reports of studies that test middle-range theories and specify the details yield findings that are evidence for evidence-based practice.
In this theory utilization era the communities of scholars surrounding nursing theoretical works (philosophies, models, and theories) continue to grow and expand globally (Bond, Eshah, Bani-Khaled, et al., 2011; Im & Chang, 2012). Growth in the development and use of middle-range theory in research and practice has exploded in the global nursing literature. Expansion is obvious by publications in scholarly nursing books and journals. A few recent examples are Bultemeier (2012) in Malawi and the long history of Neuman’s Systems Model in Holland (Merks, Verberk, Kuiper, et al., 2012). Nursing theory societies have global members who contribute ideas for middle-range theory development, testing, and use in theory-based practice (Biggs, 2008; Bond, et al., 2011; Daiski, 2000; Dobratz, 2008; Dunn, 2005; Fawcett & Garity, 2009; Frey, Sieloff, & Norris, 2002; Gigliotti, 2012; Im & Chang, 2012; Sieloff & Frey, 2007).
Discussion of these types of nursing theoretical works follows, and the application chapters in Part II (Chapters 5 through 20) of this text illustrate nursing practice with each type.
Philosophies
Philosophies provide us with broad general views of nursing that clarify nursing values to answer broad disciplinary questions. Three nursing philosophies are included in this chapter that present different philosophical views of nursing. Examples of these differing views are noted in the works of Nightingale (1946), Watson (1979), and Benner (1984).
Nightingale’s Philosophy of Nursing
Nightingale (1946) provides an answer to the question “What is nursing?” in her often-cited work Notes on Nursing: What It Is and What It Is Not. In that work Nightingale distinguishes nurses from the household servant of her day, contrasts the differences between nursing and medicine, and specifies the concern of nursing to be involved with health as well as illness. She includes directives for her unique perspective that is focused on the relationship between patients and their surroundings (often referred to as environment). She addresses the categories of pure air, pure water, efficient drainage, cleanliness, and light and provides directives on diet, noise, rest, and the nurse’s responsibility for protection and management of the care of the patient. Nightingale’s work is very relevant to current nursing practice, as reflected by the nursing literature. For example, Erlen (2007) cites Nightingale in regard topatient safety and error reduction in care of orthopedic patients. Bolton and Goodenough (2003) recognized Nightingale’s work for the nursing contribution to quality improvement, and Jarrin (2012) describes situated caring in nursing and the environment. In Chapter 5, Kim Bolton describes her nursing practice using Nightingale as a guide, illustrates with case applications, and adds an updated bibliography.
Watson’s Philosophy of Nursing
Watson (1979, 2011) continues to provide a unique approach to nursing as first proposed in Nursing: The Philosophy and Science of Caring. Her work states that nursing is a human science that addresses the nature of human caring. She suggests a return to the earlier values of nursing, which emphasized the caring aspects (Watson, 1988). In this philosophical work she also introduces theoretical propositions for the human-to-human relationships of nursing and specifies 10 carative factors to guide application of her work in nursing practice. Transpersonal caring is the proposed approach to achieve connectedness in which the nurse and the patient change together. Emphasis is on harmony for unity in body, mind, and soul, and illness represents disharmony as the nurse and the patient participate together in their relationship. Watson’s work has been used to direct care in various areas of practice and nursing administration to address nurse effectiveness in caring (Persky, Nelson, Watson, et al., 2008). Watson (2011) has updated her caring science, its measurement (Nelson & Watson, 2011), and its curriculum approach (Hills & Watson, 2011). In Chapter 6, the authors discuss Watson’s work in nursing practice and illustrate with case applications.
Benner’s Philosophy of Nursing
Benner (1984) provides yet another philosophical view of nursing with emphasis on the nature of nursing practice, specifically how knowledge of practice is acquired and how it develops over time. In this way her work might be viewed as personal knowing using Carper’s (1978) patterns. Her interpretive research led to a description of the progression of nurses from novice to expert and an awareness of the importance of caring in nursing. Benner’s work has been used to guide the examination of nursing practice innovations and changes. Benner and colleagues (2010) assessed nursing education for quality improvement recommendations. Her work guides patient care (Levy, 2004) and the development of nursing knowledge (Altmann, 2007). In Chapter 7, Benner scholar Karen Brykczynski, reviews Benner’s work, illustrates its utilization and application with case presentations, and discusses use of the interpretive approach in her nursing practice.
Nursing Models
Nursing conceptual models (or frameworks) provide comprehensive perspectives for nursing practice. Models are broad conceptual structures that provide holistic views and specific foci of nursing. They are organizing frameworks for a particular perspective of nursing practice, such as adaptation, person-environmental process, interaction, or self-care. This section reviews seven works that have been specified as nursing models by analysis and evaluation (Fawcett, 2005; Fawcett & Garity, 2009).
Johnson’s Behavioral System Model
In nursing practice with the Behavioral System Model, the nurse views the person as a system of behaviors (Johnson, 1980). The actions and responses of the person comprise a system of interacting subsystems. Therefore, assessment of the subsystems leads to an understanding of the behavior of the patient. Seven subsystems and three theories of the Johnson Behavioral System Model are presented in Box 3-1.
The Theory of the Person as a Behavioral System is a grand theory implied in the model. Two middle-range theories have been derived from the model: the Theory of Sustenal Imperatives, developed by Holaday, Turner-Henson, and Swan (1997) and based on the work of Holaday (1974) and Grubbs (1974) and the Theory of a Restorative Subsystem (Grubbs, 1974), that proposes an additional subsystem to the seven-subsystem model developed by Johnson (see Box 3-1). Johnson’s model was recently applied to adolescent dating relationships for developmental understanding (Draucker, Martsolf, & Stephenson, 2012). In Chapter 8, Johnson scholar Bonnie Holaday illustrates the utilization and application of the model and theory in nursing practice (see Box 3-1).
King’s Conceptual System
Nurses practicing with King’s Conceptual System think in terms of three interacting systems: a personal system, an interpersonal system, and a social system (King, 1971, 1981, 1997). Nursing practice with this system is interactive because the nurse views the patient as a personal system with interpersonal and social systems. King identifies a group of concepts for each of the systems, that, when considered together, specify the processes of that system. The concepts of the three systems and theories derived from that model are presented in Box 3-2.
King (1981) developed the Theory of Goal Attainment from her own Conceptual System. Her theory that perceptual congruence and transactions in thenurse-patient interaction lead to goal attainment has been applied in many different areas of nursing practice (Alligood, 2010; Sieloff & Frey, 2007). Frey and Sieloff (2002) observed middle-range theory development as a major extension of King’s work. So they updated their first book (Frey & Sieloff, 1995) in a second book, Middle Range Theory Development Using King’s Conceptual System (Sieloff & Frey, 2007). King’s many contributions to nursing have been noted (Clarke, Killeen, Messmer, et al., 2009). Sieloff and Bularzik (2011) updated the Sieloff-King Instrument for Organizational Assessment of Group Power. The King International Nursing Group (KING) maintains a website and holds annual conferences. In Chapter 9, Mary Gunter, a King scholar, presents King’s work and practice applications (see Box 3-2).
Levine’s Conservation Model
Nursing practice with the conservation model and principles focuses on conserving the patient’s energy for health and healing (Levine, 1967, 1991). Four principles that constitute conservation for the whole person and three theories are noted (Box 3-3).
The Theory of Conservation is a grand theory that is implicit from the model and principles. Levine proposed two middle-range theories: the Theory of Redundancy that described the fail-safe systems of the human body and the Theory of Therapeutic Intention. Of these two theories, the Theory of Therapeutic Intention has been used by Schaefer (1991) in nursing practice and found highly relevant based on the connection to intervention. Mefford proposed (2004) and tested the middle-range Theory of Health Promotion for Preterm Infants based on Levine’s Conservation Model (Mefford & Alligood, 2011a,b). In Chapter 10, Karen Moore Schaefer illustrates use of Levine’s model and application of the conservation principles in nursing practice (see Box 3-3).
Neuman’s Systems Model
When practicing nursing with The Neuman Systems Model (Neuman, 1982, 1989, 1995, 2002, 2011), the nurse views the client as a system of five variables interacting with the environment while focusing on stressors as they relate to client health. The five variables are physiological, psychological, sociocultural, developmental, and spiritual. These variables interact systematically with the lines of resistance, the normal line of defense, and the flexible line of defense as the client system responds wholistically with intrapersonal, interpersonal, and extrapersonal stressors as the two theories—the Theory of Optimal Client System Stability and the Theory of Prevention as Intervention—propose (Neuman & Fawcett, 2011). The Theory of Optimal Client System Stability is adaptable with changes in clients or other details of the client situation. The Theory of Prevention as Intervention is inherent in the systematic model because interventions are focused on increasing awareness ofstress and stress reduction for a prevention outcome. Both theories are useful in practice, linking nursing action with outcomes. These broad theories have many applications with age, health status, and stressors specified. Casalenuovo (2002) tested a middle-range theory of well-being in persons with diabetes. Other Neuman scholars continue to use the model in various areas of practice (Bigbee & Issel, 2012; Cazzell, 2008; Gigliotti, 2003; Lowry, Beckman, Gehrling, et al., 2007). In Chapter 11, Kathleen Flaherty demonstrates utilization and application of the Neuman Systems Model in nursing practice (see Box 3-4).
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