The Nature of Knowledge Needed for Nursing Practice
Martha Raile Alligood
The systematic accumulation of knowledge is essential to progress in any profession… however, theory and practice must be constantly interactive. Theory without practice is empty and practice without theory is blind.
This chapter highlights developments in nursing history that advanced nursing toward the goal of substantive knowledge for practice and recognition of nursing as an academic discipline and a profession. The historical achievements by nursing leaders are reviewed in successive eras toward the challenge of developing a body of substantive knowledge to guide nursing practice. The significance of these achievements may be better understood when considered in relation to the challenges the nurses faced in the eras of the twentieth century. Factors are emphasized within each era of this brief history that contributed to progress toward substantive knowledge and recognition of nursing as a discipline and a profession. In this twenty-first century, many nurses understand the vital role of conceptual and theoretical knowledge structures for quality nursing practice and nursing research. We have theoretical structures that provide nurses with a patient focus and frameworks to identify and interpret patient data for evidence-based practice. Whereas nursing had been understood as an art and a science, the theory era strengthened understanding of the vital nature of coordinated thought and action in practice now referred to by many as nursing praxis. Praxis is descriptive of knowledge-guided action and action-guided theory (Chinn & Kramer, 2011; Kagan, 2009; Kilpatrick, 2008). This understanding of the theory, research, and practice relationships is different from earlier nursing eras, when they wereconsidered separately. Today their interrelationships are better understood, that is, the vital nature of theory-research and theory-research-practice relationships. Given the challenges nursing faces today, disciplinary thought and action in the utilization of theoretical works is vital for professional nursing practice.
Early in the twentieth century nurses recognized the need to establish nursing as a profession and began the transition from vocation to profession (Alligood, 1997, 2010; Judd, Sitzman, & Davis, 2010; Kalisch & Kalisch, 2004; Meleis, 2007; Rogers, 1961). Guided by the words of Florence Nightingale and the goal of professionalism, American nurses began entering academia, first in individual courses and finally in collegiate nursing programs. This movement toward professionalism provides a context to understand the eras as nursing’s march toward achievement of a body of nursing knowledge.
Despite different emphases in each era, one criterion became a constant force—the one specifying that nursing practice be guided by a body of specialized knowledge (Bixler & Bixler, 1959): the criterion for specialized nursing knowledge and transition from vocation to profession. Today that criterion calling for recognition of a specialized body of knowledge for nursing practice is more relevant than ever as the discipline of nursing embraces challenging changes in society and health care.
Reviewing some of the efforts that were made to address the criterion helps us understand the struggles of these eras and demonstrates how events led us back to practice as nursing’s central concern. Nursing’s answer to the question of the nature of knowledge needed for the practice of nursing is viewed as a driving force that has shaped our profession. Their drive for nursing knowledge led nurses and student nurses in directions that, although unclear and not fully understood at times, contributed to recognition of nursing as a learned profession.
Eras of Nursing Knowledge
As the beginning of the twentieth century drew near, nurses began to express the need for communication with other nurses to improve their practice. Signs of a national consciousness for nursing may be seen in the first national gathering of nurses at the World’s Fair in Chicago in 1893 and in the publication of the first edition of the American Journal of Nursing (AJN), the first national organ of communication for nurses, in October 1900 (Kalisch & Kalisch, 2004). These initial efforts by nurses began the transition toward a profession. At this early time the focus was clearly on practice and on teaching the practice of nursing to students. There was recognition of the need for specialized knowledge to guide the practice of nursing from the beginning. AJN was one early symbol of nursing’s movement toward professional status, and another was their need to communicate with other nurses about their practice and about teaching nursing. With the boom of the industrial age, hospital training schools flourished as America grew, and the curriculum era of the 1900s to the 1940s followed (Judd, et al., 2010; Kalisch & Kalisch, 2004).
Curriculum Era: The 1900s to the 1940s
In the curriculum era, evidence of efforts to understand what knowledge was needed for the practice of nursing led to an emphasis on curricular content andprogression toward standardizing curricula. The focus of this era was evident in state activities such as the 1933 curriculum survey of New York training schools (Kalisch & Kalisch, 2004). This emphasis on what nurses needed to know to practice nursing led to an expansion of curricula beyond physiological and pathophysiological knowledge to include social sciences, pharmacology, and formal classes on nursing procedures (Judd, et al., 2010). It is interesting to note that courses to teach content were called fundamentals, a term that means “basic essentials,” and that the term is still used in nursing education today. This early appreciation of essential content specific to nursing action and beyond knowledge of the illness of the patient is an observation that is pertinent to the progress of this era. The differences between the medical view of the patient and those of the nurse were obvious in these developments, as had been emphasized by Nightingale (1946).
It is also interesting to note that nursing procedures were taught in class and practiced in large wardlike rooms called “nursing arts” laboratories. Reference to the art of nursing was common in this era. In later decades, with the research and science emphasis in nursing curricula, these rooms came to be referred to as “skills or simulation labs.” The change in terminology may be related to nursing’s movement into colleges and universities and the transition from vocational nurse training to professional nursing education with emphasis on science. The discipline of nursing is indebted to those scholars who maintained a focus on the art of nursing as science gained popularity (Judd, et al., 2010; Kalisch & Kalisch, 2004).
Nursing curricula taught mostly in diploma programs in this era became standardized and some nurses began to seek higher education courses related to nursing in colleges and universities. The idea of developing nursing programs in colleges and universities soon followed. The transition of nursing into schools of higher learning brought with it a significant change in the search for a substantive body of knowledge. Those nurses introduced to research process began to recognize and write about its value as an essential process for the progression toward a body of substantive knowledge (Kalisch & Kalisch, 2004), leading to the research era.
Research Era: The 1950s and the 1970s
In the 1950s, research emerged as a beginning force. Nurses were encouraged to learn how to conduct research, developing the role for nurses for that specialized body of knowledge. The task of embracing this new content was so great that rather than being a means to an end it often became an end in itself. Learning to conduct research led to an emphasis on statistics and research methods introduced as new curriculum areas in baccalaureate programs. The general level of understanding was such that some thought just by conducting research, the body of knowledge would be formed as a basis for practice.
This era saw the development of scholarship and the dissemination of early research findings. Nursing Research, the first nursing research journal, was established for this purpose in 1952. In addition, two programs funded by the federal government were instituted in 1955 to prepare nurses as researchers and teachers of research—the U.S. Public Health Service predoctoral research fellowships and the Nurse Scientist Training Program (Schlotfeldt, 1992).
This development began a major shift that affected all levels of nursing. Nurses had to consider what that change in nursing education meant with regard to their level of nursing preparation, and the question of the nature of the knowledge needed for nursing practice persisted.
Selection of nursing education programs for potential students was difficult at this time. Although the transition of nursing education into schools of higher learning was a key development for the nursing profession, the effects of that transition are still felt today in debates about multiple levels of nursing education and the failure to establish differentiated practice.
The research and graduate education eras overlap, as other reviewers have noted (Judd, et al., 2010; Meleis, 2007; Styles, 1982). The developments in research influenced nursing education, emphasizing graduate education with nursing research courses. Emphasis on faculty nursing scholarship during the research and graduate education eras undoubtedly contributed to their interrelationship, as well as the close ties of knowledge and research. Master’s programs were being introduced in universities across the country and nursing knowledge or concept development courses were being taught and emphasized in most programs, along with introductory courses in the research process by the late 1950s and early 1970s.
Graduate Education Era: The 1950s and the 1970s
During the graduate education era, curricula for master’s-level preparation were becoming standardized through accreditation that most schools were seeking by the National League for Nursing (NLN). Nurse educators came together at national meetings where accreditation criteria were approved. By the end of the 1970s, most accredited master’s programs included courses in nursing research, clinical specialty practice, leadership, and concept development or nursing theory in a core curriculum organized with a nursing philosophy and conceptual or organizing framework. A major task of this era was carving out a role in health care for the master’s-prepared nurses who were graduating.
Only three nursing doctoral programs existed at the beginning of this era, and the federally funded programs established in the 1950s as a result of the post–World War II shortage of nurses were still in place. Nurses were being prepared for research and teaching roles in nursing with doctorates in education and a range of related science disciplines. The American Nurses Association (ANA) set forth the need for nursing theory development in 1965; however, there were various perceptions among nursing leaders as to what that meant because most had advanced degrees from various disciplines and perspectives of knowledge and theory.
During this era a series of national conferences united nurses to exchange ideas and evaluate knowledge obtained from non-nursing doctoral programs that could address nursing’s knowledge-building needs. The papers and discussions from these conferences were published in Nursing Research in 1968 and 1969 and were republished by Nicoll (1986) in her first edition under the unit heading Three Landmark Symposia (p. 91). Those conferences centered on nursing science and theory development and facilitated discussion of the application of knowledge from the various disciplines in nursing. The Nurse Scientist Training Program is noteworthy in this history because that program addressed the question of the nature of thebody of nursing knowledge—that is, will nursing be based on applied knowledge from other disciplines or nursing science? Dealing with this question was a major turning point in nursing history regarding graduate nursing education because it led to the realization that the nature of knowledge needed for nursing practice was nursing knowledge. Doctoral education in nursing began to flourish, and by the late 1970s, 21 nursing doctoral programs existed and several more universities indicated intent to develop programs. A driving force in this era was the need for nursing knowledge and an awareness that the knowledge should be developed by nurses prepared in the discipline of nursing. It is not surprising that recognition of the difference between nursing knowledge and borrowed knowledge surfaced in the nursing literature at this time (Johnson, 1968). This differentiation emerged from recognition that theory from other disciplines was specific to that discipline and not specific to nursing (Johnson, 1968; Rogers, 1970). Rogers (1970) reasoned that nurses needed to clarify the phenomenon of concern for the discipline and use frameworks that addressed nursing’s phenomenon of concern to frame their research and develop nursing knowledge. Rogers (1970) specified people and their environment as nursing’s concern.
It was during this era that early versions of nursing frameworks began to be published. The works by Johnson (1974, 1980), King (1971), Levine (1967), Neuman (1972), Orem (1971), Rogers (1970), and Roy (1970) are evidence of the general recognition that nursing theoretical approaches were needed. Research continued to develop during this era of graduate education; however, nurse scholars soon noted that much of the research being published lacked form and direction. In fact, Nursing Research celebrated its twenty-fifth anniversary in 1977 (volume 26, number 3) with published reviews of progress in its first 25 years. These reviews presented recommendations for development in five practice areas of nursing: medical-surgical, community, maternal-child, psychiatric, and gerontological. Lack of conceptual or theoretical direction or conceptual connections in the research was identified as a weakness of the studies. It was also noted that the research focused on nurses or student nurses rather than patients. The headings of the reviews were noted to reflect medical practice specialties as evidence of the struggle throughout nursing history to move beyond a medical view to the nursing view.
Batey (1977) conducted a comprehensive review of those first 25 years of published nursing research, and identified conceptualization as the greatest limitation of the projects. She emphasized the importance of the conceptual phase of research to provide a content basis as well as connection with other studies in order to develop nursing science. It should be noted that reference to concepts and conceptualization was common in that era and a forerunner to the theory era. The general understanding that a group of related concepts is a theory or that theory derives from a conceptual framework came later.
Indications of the theory emphasis in nursing education at the national level were with the Nurse Educator conferences in Chicago (1977) and New York (1978). The theme for the Chicago conference was Nursing Education; however, Sister Callista Roy’s workshop illustrating the use of her adaptation conceptual framework as a guide for nursing education was so popular that the theme for the New York conference a year later was Nursing Theory. This conference brought nurse theoristsonto the same stage for the first time in history. It was the New York conference that underscored a growing awareness that the nature of knowledge needed for nursing practice was theoretical knowledge. This was an exciting time in nursing as scholarly works of nurse scholars from across the country began to be recognized as theoretical frameworks for research and practice. In this era, nursing publications began to proliferate and time has shown three publications of this era to be particularly important to this history: Carper’s (1978) patterns of knowing, Fawcett’s (1978) description of the helical relationship between theory and research, and the first edition of Advances in Nursing Science (1978) where Carper and Fawcett’s seminal articles were published.
Carper (1978) presented a summary of her dissertation research describing four types of nursing knowledge and their contexts. Her work is significant in this history for recognition that nursing knowledge went beyond empirical to include ethical, personal, and esthetic knowledge. Clarifying types of nursing knowledge at the time nursing began to embrace qualitative approaches opened nurses to a broader view of research. Fawcett (1978) presented a description of the vital relationship between theory and research in the development of science with her classic double-helix metaphor, ushering in the 1980s and 1990s theory era.
Theory Era: The 1980s and 1990s
The theory era began with a strong emphasis on knowledge development. Although in the previous two decades proponents of nursing theory and nursing theorists had begun to publish their works, it is noteworthy that they denied being theorists when they were introduced as such at the 1978 Nurse Educator Conference in New York with the Nursing Theory theme. There was understanding among those attending the conference that the presenters were theorists, and by the second day, the audience responded to their denials with laughter. This seems strange today, but this was the first time most of the theorists even met each other. Their works had grown out of content organization in nursing education courses, nursing practice administration in large agencies, and structures for the thought and action of practice. It was clear that their works were nursing theoretical structures even before they recognized them as such. The theory era, coupled with the research and graduate education eras, led to understanding of the scientific process beyond production of a scientific product (Kuhn, 1970).
First editions of several nursing theory texts in this era included contemporary nursing theorists, some with chapters written by students in master’s programs (Marriner Tomey, 1986; Meleis, 1985; Riehl & Roy, 1980). Proliferation of nursing literature; new nursing journals; regional, national, and international nursing conferences; and new nursing doctoral programs were evidence of exponential growth in this era. Schlotfeldt (1992) concluded that this period stimulated growth in nursing scholarship in ways never before experienced in nursing history.
Fawcett (1984, 1989) contributed significantly to our understanding of the nature of nursing knowledge. She proposed a metaparadigm of nursing knowledge for nursing, specifying discipline boundaries of person, environment, health, and nursing. Her application of this metaparadigm in criteria for analysis and evaluation of nursing theoretical works in early publications clarified types of nursingconceptual and theoretical works and a structure of knowledge at different levels of abstraction. Fawcett’s use of the structure demonstrated how nursing theory linked to conceptual models which then led to an understanding of conceptual-theoretical-empirical linkages for nursing knowledge development and the development of nursing science (Fawcett, 2005). Fawcett (1984, 1989) led the way by presenting a collective view of nursing’s theoretical works using criteria to clarify their conception as a metaparadigm (person, environment, health, and nursing) in a uniform structure of knowledge.
Theory Utilization Era: The Twenty-First Century
Nursing is now in the era of theory utilization—nurses using philosophies, models, and theories for theory-based nursing practice. Soon after we entered the twenty-first century sufficient evidence of theory-based practice existed to declare a theory utilization era (Alligood, 2010). This important era in the history of nursing continued to thrive and be recognized as vital to nursing’s future (Algase, 2007; Alligood, 1994; Colley, 2003; Pearson, 2007). Bond and colleagues (2011) recently researched “who uses nursing theory?” (p. 404), and reported…“increasing numbers, both in quantity and in the use of nursing theory” (p. 407).
Continued theory development is essential for our progress as a profession, and as a discipline this is especially important. Theory development with analysis and critique of syntax and the structure of theory is how knowledge development is learned in nursing doctoral programs, especially PhD, which are vital to the discipline. Theory courses in practice-focused master’s and doctor of nursing practice (DNP) programs focus on the application of theory in nursing practice. Experiences of nursing practice with holistic nursing frameworks led to in-depth understanding of the theories and their utility for practice. The genesis of this text in the early 1990s grew out of the doctoral education focus on development and testing of theory. This led to revision of master’s-level courses to focus on applications and utilization for advanced nursing practice and all other courses throughout the curriculum. Theory is not just to know but is to use.
Therefore, in this fifth edition we continue to celebrate the shift to a theory emphasis in this theory utilization era. With the current emphasis on evidence-based practice, inquiry-based practice, best practices, and the consistent quality outcomes, the purpose of this text takes on added value. Quality care is a prominent theme in Institute of Medicine reports, health care regulatory policies, the call for nursing education reform, and nurse researchers themselves (Benner, et al., 2010; Bigbee & Issel, 2012; Burhans & Alligood, 2010; Ellerbe & Regen, 2012; Sherwood & Barnsteiner, 2012). The connection between this emphasis and nursing theory is especially important. As Nola Pender (personal communication, April 2008) shared, “Middle-range theories that have been tested in research provide evidence for evidence-based practice, thus facilitating translation of research into practice.” Whether the emphasis is evidence, best practices, translation to practice, or quality care, all are facilitated by theory (Bigbee & Issel, 2012; Bond, et al., 2011; Fawcett & Garity, 2009). It has been reported that the absence of structure (framework) to specify outcomes creates the risk of a deficit in quality patient care and hampers the growth of nursing science (Conn, et al., 2008; Fawcett & Garity, 2009; Pearson, et al., 2007). Theory utilization is in concert with national goals for quality health care. This text presents philosophies, nursing models, and theories of nursing to guide logical reasoning, thoughtful action, and efficient information processing. Table 1-1 summarizes nursing’s search for specialized knowledge.
TABLE 1-1
Summary of Historical Eras of Nursing’s Search for Specialized Knowledge
| Historical Eras | Major Question | Emphasis | Outcomes | Emerging Goal |
| Curriculum era: 1900 to the 1940s | What curriculum content should student nurses study? | Courses taught in nursing programs | Standardized curricula for diploma programs | Specialized knowledge and higher education |
| Research era: 1950 to the 1970s | What is focus for nursing research? | Role for nurses and what to research | Problem studies and studies of nurses | Theory-based studies for unified knowledge |
| Graduate education era: 1950 to the 1970s | What knowledge is needed for nursing practice? | Carving out an advanced role and basis for nursing practice | Nurses have an important role in quality health care | Focus graduate education on knowledge development |
| Theory era: 1980 to the 1990s | How do these frameworks guide research and practice? | There are many ways to think about nursing | Nursing theoretical works clearly focus on the patient | These theories guide nursing research and practice |
| Theory utilization era: 21st century | What new theories are needed as evidence for quality care? | Nursing theory guides research, practice, education, and administration | Middle-range theories are from quantitative or qualitative approaches | Nursing frameworks are the knowledge (evidence) for quality care |
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