Theories and Frameworks for Professional Nursing Practice

At the completion of this chapter, the reader will be able to:

• Distinguish among a concept, a theory, a conceptual framework, and a model.

• Identify and define the four central concepts of nursing theories.

• Compare the main precepts of selected theories of nursing.

• Examine criteria for evaluating the utility of a specific nursing theory for its relevance to practice, education, or research.

• Identify selected theories from related disciplines that have application to nursing.

PROFILE IN PRACTICE

Jacqueline Fawcett PhD, RN, FAAN College of Nursing, University of Massachusetts—Boston, Boston, Massachusetts

I earned my baccalaureate degree in nursing from Boston University in 1964 and worked as an operating room staff nurse during that summer. My first exposure to a nursing discipline–specific theory occurred during my nursing coursework at Boston University. I learned Orlando’s theory of the deliberative nursing process and have continued to find this simple yet elegant nursing theory of great utility in assisting patients, colleagues, and students to express their immediate needs for help.

I began teaching in a small hospital-based diploma nursing program in Connecticut in January 1965. I have continued to teach nursing since that time, first at the University of Connecticut for 6 years, with interruptions for my master’s degree in parent-child nursing and my doctorate in nursing, then at the University of Pennsylvania for 21 years, and now at the University of Massachusetts in Boston.

During my master’s program at New York University, I was introduced to theory-guided nursing practice. The clinical courses in parent-child nursing emphasized the application of theory to the nursing of childbearing women and their families, well children, and children with acute and chronic illnesses. At that time, knowledge about nursing discipline–specific conceptual models and theories was limited. The New York University nursing faculty, my classmates, and I worked hard to adapt crisis theory to nursing situations and to explore the applicability of developmental theories and family theories to nursing situations. I immediately recognized the benefit of using theories to guide nursing practice—I had finally found a way to organize my thinking and my practice. Indeed, I finally knew what to say and do and the reasons for what I was saying and doing when I interacted with a patient!

When I returned to the University of Connecticut after earning my master’s degree in 1970, my faculty colleagues and I began to design and implement a new curriculum based on crisis theory. We extended the original theory to encompass physiological as well as psychological events (White, 1983; Infante, 1982).

I returned to New York University 2 years later and entered the brave new world of Martha Rogers’ conceptual system, now called the science of unitary human beings, which was my first exposure to a comprehensive nursing discipline–specific conceptual model. Given my strong interest in theory-guided nursing practice, I was very attracted to Rogers’ work. I rapidly immersed myself in the coursework that led to my dissertation research, which was based on my extension of Rogers’ conceptual system to the family (Fawcett, 1975, 1977). My coursework sensitized me to the need to use nursing discipline–specific conceptual models and theories to guide not only nursing practice but also nursing research. Furthermore, the coursework sensitized me to the reciprocal relationship between research and conceptual models and between practice and conceptual models. I realized that conceptual models inform research and practice and that research findings and the results observed in practice in turn inform revisions in the conceptual model.

I returned to the University of Connecticut in 1975 and completed all requirements for the doctoral degree in 1976. I began to teach nursing research courses and had the opportunity to develop courses in contemporary nursing knowledge and the relationship of theory and research. The latter two courses became the focus of my scholarly work and the underlying reason for my passion about nursing.

I was recruited by the University of Pennsylvania in 1978 and had the honor of teaching the subject matter of my scholarly work in a new nursing doctoral program. Throughout all the years at University of Pennsylvania and now at the University of Massachusetts in Boston, my teaching has informed my scholarly work and my scholarly work has informed my teaching. My books about analysis of nursing models and theories (Fawcett, 1989, 1993, 2000, 2005) and the relationship of theory and research (Fawcett, 1999) are the direct result of my students’ requests for more information and more examples about the use of nursing discipline–specific conceptual models and theories.

Since 1979, I have used Roy’s adaptation model to guide my empirical research, which has focused on women’s responses to cesarean birth and on functional status in normal life transitions and serious illness. I have found Roy’s model to be a very useful guide for my research and for the nursing practice that stems from the findings of the research.

Much of my current work focuses on helping nurses understand the connection between research and practice (Fawcett, 2000). I am firmly convinced that all nurse clinicians are also nurse researchers because the nursing practice process (assessment, labeling, goal setting, implementation, evaluation) is similar to the nursing research process (collection of baseline data, statement of the problem and hypotheses, experimental and control treatments, data analysis). I also am firmly convinced that the parallels between the nursing practice process and the nursing research process are most readily understood when both nursing practice and nursing research are guided by a nursing discipline–specific conceptual model or theory. The challenge is to assist nurses in practice to recognize that clinical information is research data and to report the effects of nursing practice in ways that will help other nurses and other health professionals and policymakers understand how nursing practice benefits the health of humankind.

Theory is the poetry of science. The poet’s words are familiar, each standing alone, but brought together they sing, they astonish, they teach. (Levine, 1995, p. 14)

Introduction

Nursing is both a science and an art. The empirical science of nursing includes both the natural sciences (e.g., biology, chemistry) and the human sciences (e.g., sociology, psychology). The art of nursing is the ability to form trusting relationships, perform procedures skillfully, prescribe appropriate treatments, and morally conduct nursing practice (Johnson, 1994). Nursing is a knowledge-based discipline significantly different from medicine. Medicine focuses on the identification and treatment of disease, whereas nursing focuses on the wholeness of human beings (Fawcett, 1993). Nursing claims the health of human beings in interaction with the environment as its domain. Knowledge is commonly defined as a general awareness or possession of information, facts, ideas, truths, or principles and an understanding of the same gained through experience or study (Encarta World English Dictionary, 2009). Nursing knowledge is the organization of the discipline-specific concepts, theories, and ideas published in the literature (both print and electronic media) and demonstrated in professional practice. Nursing’s desire to be regarded as a profession (e.g., law, medicine) was the impetus for building a substantial body of discipline-specific knowledge. Many of the existing theories emerged from the response to the simple question, “What is nursing?”

Theories and conceptual frameworks consist of the theorist’s words brought together to form a meaningful whole. Theories and frameworks provide direction and guidance for structuring professional nursing practice, education, and research. They act as a “tool for reasoning, critical thinking, and decision-making” (Alligood, 2005, p. 272). In practice, theories and frameworks help nurses describe, explain, and predict everyday experiences. They also assist in organizing assessment data, making diagnoses, choosing interventions, and evaluating nursing care. In education, a conceptual framework provides the general focus for curriculum design. In research, the framework offers a systematic approach to identifying questions for study, selecting appropriate variables, and interpreting findings. The research findings may trigger revision and refinement of the theory. Figure 5-1 illustrates the relationships among theory, practice, education, and research.

FIGURE 5-1 Relationships among theories and frameworks and nursing education, research, and practice.

Many nurse theorists have made substantial contributions to the development of a body of nursing knowledge. Offering an assortment of perspectives, the theories vary in their level of abstraction and their conceptualization of the client, health and illness, the environment, and nursing. From a historical perspective, nursing theories reflect the influence of the larger society and illustrate increased sophistication in the development of nursing ideas. Table 5-1 presents a chronology of events related to the development of nursing theories. While this chapter provides a comprehensive overview of nursing theory, other chapters in this text will make reference to specific nursing theories as they relate to individual chapter topics.

TABLE 5-1

History of Nursing Theory Development

Event	Year	Nurse Theorists
	1860	Florence Nightingale Described nursing and environment
	1952	Hildegard E. Peplau Nursing as an interpersonal process: patients with felt needs
Scientific era: nurses questioned purpose of nursing	1960	Faye Abdellah (also 1965, 1973) Patient-centered approaches
	1961	Ida Jean Orlando Nurse-patient relationship; deliberative nursing approach
Process of theory development discussed among professional nurses	1964	Ernestine Weidenbach (also 1970, 1977) Nursing: philosophy, purpose, practice, and art
	1966	Lydia E. Hall Core (patient), care (body), cure (disease)
	1966	Virginia Henderson (also 1971, 1978) Nursing assists patients with 14 essential functions toward independence
Symposium: theory development in nursing	1967	Myra Estrin Levine (also 1973) Four conservation principles of nursing
Symposium: nature of science and nursing Dickoff, James, and Weidenbach published “Theory in a Practice Discipline” in Nursing Research	1968
Symposium: nature of science in nursing First nursing theory conference	1969
Second nursing theory conference	1970	Martha E. Rogers (also 1980) Science of unitary man: energy fields, openness, pattern, and organization
Consensus on nursing concepts: nurse/nursing, health, client/patient/individual, society/environment	1971	Dorothea E. Orem (also 1980, 1985) Nursing facilitates patients’ self-care
Discussion on what theory is: the elements, criteria, types, and levels and the relationship to research	1971	Imogene King (also 1975, 1981) Theory of goal attainment through nurse-client transactions
National League for Nursing required conceptual frameworks in nursing education	1973
Borrowed theories from other disciplines Expanded theories from other disciplines	1974	Sister Callista Roy (also 1976, 1980, 1984, 1989, 1999) Roy’s adaptation model: nurse adjusts patient’s stimuli (focal, contextual, or residual)
		Betty Neuman Health care systems model: a total person approach
Recognized problems in practice and developed theories to test and use in practice	1976	Josephine Paterson and L. Zderad Humanistic nursing
Second nurse educator conference on nursing theory	1978	Madeleine Leininger (also 1980, 1981) Transcultural nursing Caring nursing
Articles on theory development in ANS, Nursing Research, and Image	1978 1979	Jean Watson (also 1985) Philosophy and science of caring; humanistic nursing
Books written for nurses on how to critique and develop theory and describing application of nursing theories Graduate schools of nursing develop courses on how to analyze and apply nursing theories	1980	Dorothy E. Johnson Behavioral system model for nursing
Research studies in nursing identified nursing theories as framework for study	1981	Rosemarie Rizzo Parse (also 1987) Man-living-health: a theory of nursing
Numerous books published on analysis, application, evaluation, development, and expansion of nursing theories	1982–present

Modified from Christensen, P. J., & Kenney, J. W. (1995). Nursing process: Application of conceptual models. (4th ed.). St. Louis: Mosby.

Terminology Associated with Nursing Theory

The most fundamental building block of a theory is a concept, which is defined as “a word or phrase that summarizes ideas, observations, and experiences” (Fawcett, 2005, p. 4). For a theory to exist, concepts must be related to one another. Theoretical statements, also called propositions, describe a concept or the relationship between two or more concepts (Fawcett, 2005). One theoretical statement, or several theoretical statements taken together, can constitute a theory. A theory, then, is a statement or a group of statements that describe, explain, or predict relationships among concepts.

A nursing theory is composed of a set of concepts and propositions that claims to account for or characterize the central phenomena of interest to the discipline of nursing: person, environment, health/illness, and nursing. Persons are the recipients of nursing care and include individuals, families, and communities. Environment refers to the surroundings of the client, internal factors affecting the client, and the setting where nursing care is delivered. Health and illness describe the client’s state of well-being. Nursing refers to the actions taken when providing care to a patient. These concepts, taken together, make up what is known as the metaparadigm of nursing (Fawcett, 1997). Most nursing theories define or describe these central concepts, either explicitly or implicitly. Because a concept is an abstract representation of the real world, concepts embedded in a theory represent the theorist’s perspective of reality and may differ from that of the reader without invalidating the theory.

Theories represent abstract ideas rather than concrete facts (Alligood, 2005) and may be broad or limited in scope, thus varying in their ability to describe, explain, or predict. Theories may be categorized by their level of abstraction as grand theories, midrange theories, or practice theories. Grand theories (also known as conceptual models or frameworks) are representations of the broad nature, purpose, and goals of the discipline. Concepts and their relationships are very abstract, not operationally defined, and not empirically testable. Midrange theories, which may be derived from grand theories, are less abstract with relatively concrete concepts that address specific phenomena across nursing settings and specialties. Relationships between and among concepts can be defined explicitly and measured. Because they are narrower in scope, midrange theories appear more applicable to practice and remain abstract enough to allow a wide range of empirical research. Practice theories (sometimes called situation-specific theories) are limited further to a patient population or type of nursing practice (Im & Meleis, 1999; Meleis, 2005). Most practice theories are either descriptive (portraying an experience) or prescriptive (advocating specific nursing actions) in nature.

Descriptions of the theoretical perspectives presented in this chapter include a brief overview; the theory’s basic assumptions about the individual and the environment; definitions of health and illness; a description of nursing, including the goal of nursing; and definitions of concepts and subconcepts specific to each theory. Some theories are more amenable to this scheme than others because of their degree of specificity or stage of development. When the needed information is not explicitly detailed by the theorist, inferences are made on the basis of what seems to be implicitly stated. Direct quotes from the theorists are used whenever possible to ensure that such interpretations are valid and reliable. The reader is encouraged to consult the primary source to gain a full appreciation of the depth, scope, and extent of the relationships put forth.