Janice M. Morse

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WHERE WE CAME FROM

                I have a confession—and an apology—to make. Once, in 1982, the director of nursing at a Canadian hospital decided to implement a nursing theory to guide nursing practice uniformly throughout the hospital. It was decided, using the principles of democracy, to let the nurses select the theory. Workshops were held describing the two main contenders, Orem’s and Roy’s theories, and nurses campaigned for their preferences. Signs appeared everywhere, and nurses wore buttons stating their favorite. (I wore both, of course. I still have mine somewhere.) After a certain period of time, elections were held, and nurses voted.

                I cannot remember which theory “won” or, more importantly, if there was any subsequent change in care. But I can remember how scornful I was of the process. “Selecting a theory for care is not a political process,” I said. Did they not understand that, if these theories worked, we would be able to see the difference in nursing care according to the theory selected? Did they not realize that by observing care, we should be able to identify an Orem nurse or a Roy nurse by their style of nursing? And, to my knowledge, because we could not do that, why are we bothering with all this performance? Besides, I muttered, the theory one uses should be in context, according to patient needs, nursing assessment, and patient preferences—it cannot be legislated carte blanche.

                But I did not see it then as an opportunity to conduct research.

                Now, almost, 30 years later, this is happening again, and on a much grander scale. For Magnet^® hospital certification, staff select and implement a theory or framework to guide care within the hospital. Older and wiser, I hold my breath and hold my tongue. And watch.

CHASING NURSING THEORY

In the past century, from about the 1960s, nursing leaders began to realize that in order for it to be a profession in its own right, nursing must be distinct from other disciplines, and they needed to delineate the role of nursing, as a distinct body of nursing knowledge. To attain this, nursing must be cohesively contained within a single nursing paradigm, with its own nursing theory or theories. They recognized that nursing must invest in science and develop a practice based on scientific principles. The result was a determined movement, decades long, to develop the discipline of nursing.¹

Nursing needed leaders with vision, committed nurse theorists to create the theory (or theories), scientists to develop it, and educators to teach it. The key was to develop the theoretical base for nursing, and many components of this plan had to be conducted simultaneously. It was recognized that they needed nurse theorists to create the theory, nurse scientists to test the theory, journals and texts to communicate the theory, nurse educators to teach the theory, and nurses to use the theory for patient care and to develop practice.

In the following 30 years, many theories were created. Consider these theories, which I call traditional nursing theories, as they were envisioned and created by experienced nurses and academics of the past century. Although some theories may have been stimulated by observations from clinical practice, with few exceptions, they were not generally derived from research.

A timeline showing the major nursing theories or models is listed in Figure 2.1. The date preceding the author’s name is the reference date indicating the major work. As these theories were developed over a period of time, the date in square brackets is the date of the first (or last) publication of the theory by the author. References are provided in Appendix 2.1.

THE NEED FOR NURSING THEORY

In the 1970s, the rush to develop nursing theory began in earnest. Some of these theories were very abstract; the theory by Martha Rogers (1970) was the most abstract and the most influential.² But the abstractness of these traditional nursing theories was an anathema: Clinicians complained that they were not relevant to nursing practice; theorists complained that practitioners did not use them. As a result, the separate channels of theorists’ theories and practitioners’ work became dubbed as the “theory–practice gap”—a phenomenon that remains today between traditional nursing theorists and practitioners.

Some theories that developed during 1970 through 1990 were somewhat closer to the patient, directing nursing actions. For instance, Dorothea Orem’s Self-Care Model (1971, 1980, 1985, 1991, 1995; Denyes, Orem, Bekel, & SozWiss, 2001) has endured, and is still used to guide research and practice, even at the institutional level. Sister Callista Roy’s Adaptation Model (1970, 1988, 2009, 2011a, 2011b; Roy & Andrews, 1999; Roy, Whetsell, & Frederickson, 2009) has been applied to research (Roy, 2014). These theories, however, still remain largely too abstract to be operationalized for research and practice, and their use reflects the exception rather than the rule. However, Risjord (2010) notes:

Thus, perhaps the theory–practice gap emerged due to false expectations, too much enthusiasm for the new nursing “theories.” Perhaps there were misunderstandings of their role and false expectations of their performance on the part of nurse educators, educational regulating bodies, and even their developers.³

Nevertheless, as nursing continued determinedly to move toward becoming a discipline and a profession, nursing theorists continued to develop abstract theories or conceptual models.

A Tweeter’s Guide⁴ to Nursing Theory

Publication as a book-length manuscript was initially the major method of dissemination for nursing theory (see Appendix 2.1). Once the theories were developed and published, they were revised and republished as the authors responded to questions of clarification and to criticisms when the theories were implemented in practice or used in research. Alternatively, journal articles were used for the dissemination of nursing theory, and these articles were often updates or minor modifications of the theory. Of necessity, these articles were shorter and lacking essential details about the major theory. In particular, some journals have made significant contributions to nursing theory, especially Advances in Nursing Science, and later, Nursing Science Quarterly (Meleis, 2012).

In the past 20 years, these theory books have been replaced with edited books that devote a chapter to each theorist’s theory, sometimes presented by the theorists themselves, and sometimes by another person familiar their work (e.g., Alligood & Marriner-Torney, 2010; McEwan & Wills, 2014). However, this literature lacks the scientific debate and criticism of nursing theory in these books and nursing journals—something that would normally occur in other disciplines (Paley, 2006)—and this lack ultimately stymied the development and testing of the theories.

Another more recent development in dissemination of these theories is the websites that have appeared, which list skeletal summaries of most of the major theories. For instance, these sites provide only the major concepts, propositions, categories, and so forth in point form for each theory.⁵ Although these summaries are convenient for nurses needing to grasp an overview of each theory, they do not provide a full understanding. We have reached the ultimate reduction of the substance of nursing theory.

The Development of Core Nursing Metaparadigmatic Concepts

Nursing was still concerned about developing a unique domain, which Hardy (1978) described as presenting a general orientation that “holds a commitment and consensus of the scientists of a particular discipline” (p. 39). Attempting to reach consensus on what was nursing, in 1972, the National League for Nursing (NLN) Council of Baccalaureate and Higher Degree Programs in Nursing stated that nursing curricula should be based on a conceptual framework. Yura and Torres surveyed 50 accredited programs from 1972 to 1973 in order to identify “concepts used by the majority” (Yura & Torres, 1975, p. 2). Four central concepts (man, society, health, and nursing) were identified by these researchers (Torres & Yura, 1975) as a curriculum framework to organize and give “clarity and direction to the program’s philosophy, so that it can be clearly developed into courses and learning experiences” (p. 8). These central concepts were intended to link the philosophy, program objectives, “statements of terminal behaviors” (outcome objectives), and “design learning experiences” (p. 7). These four concepts were later championed by Fawcett (1978, 1984, 2000, 2005, Fawcett & DeSanto-Madeya, 2013) as the “metaparadigm of nursing” with the labels modified to person, environment, health, and nursing.

Regarding research, even Fawcett & Hayes (1983) noted that conceptual frameworks are “indirectly tested by research” (p. 200). The problem was that nursing, as a discipline, forgot the tentative nature of the metaparadigmatic concepts. They were treated as “compulsory” through accreditation bodies, adopted by faculty as a criterion of disciplinary relevance, and used for evaluation of curriculum frameworks and models:

Yet, there were other problems: although the metaparadigm concepts consisted of the most abstract concepts that a discipline might use, the four selected were so abstract that they are not unique to nursing (Cody, 1996), with of course, the exception of “nursing.” Risjord (2010) noted that Fawcett’s approach to developing a metaparadigm to unify nursing was an approach akin to mid-century philosophers’ received view.

Were these four propositions helpful to theory development? In 2006 Paley writes:

However, I disagree with Paley’s assertion that “they do nothing.” Because early nursing theories and research were required to address these four metaparadigmatic concepts and propositions explicitly, Paley’s question should be: Did they do harm? Fawcett (1978) argued that these four essential units made theory “readily identified as nursing theories” (p. 26, italics in the original). The metaparadigmatic concepts bounded nursing theory by demanding their presence and thereby dictating the level of the theory produced. For instance, if a nursing study were to explore patient pressure ulcers, and at one level a research project, perhaps linking in-bed movement with pressure ulcers, this may easily accommodate the bounds of the four concepts; but at another level, perhaps a research project exploring pressure ulcer formation at the cellular level, this would not encompass all four concepts, and would be considered as “not nursing research.”

With the wisdom of hindsight, we cannot imagine the ways in which this requirement stunted the growth for nursing. Neither could we imagine how limited the portfolio of National Institute of Nursing Research (NINR) might be, should these metaparadigmatic concepts become criteria for the guiding and funding of nursing research today.

Nevertheless, theories were evaluated according to their definition and description of these metaparadigmatic concepts (Fawcett & DeSanto-Madeya, 2013), regardless of the level, the function of the theory, and the scope actually required by the theory per se.

Fawcett’s notion of theory development is deductive—that “the testability of grand theory is met when the grand theory has led to the generation of one of more middle-range theories” (Fawcett & DeSanto-Madeya, 2013, p. 314). But this is not the way nursing conceptual frameworks and theories were actually used in nursing: They were taught as fact in education and used as criteria for program accreditation, and applied carte blanche at the institutional level in practice. Researchers did not test theories and trial one theory against another, so that they may be modified and improved over time (Morse, 1996; Paley, 2006).

Thus, these four concepts gave direction to nursing science, but even the intended cohesiveness of focusing them for the development of nursing science was lost; authors were free to define these concepts accordingly. Phillips (2006) asks: if “each model and theory has a different philosophical and theoretical foundation, [and] nurses who use them have different realities of nursing, how are these differences related to what constitutes nursing science?” (p. 43). Even the term “nursing” was considered ambiguous and overutilized. One solution to this awkward term was to use nursing as a noun, not a verb, as the central concept, as suggested by Paterson and Zderad (1976) and endorsed by Reed (1996/2013).⁶

Elsewhere, I argued that the compulsory use of the metaparadigmatic concepts forced nursing theory to an inappropriate level of abstraction and to a level that diluted its relevance for clinical practice (Morse, 1996). For a low-level theory, incorporating the metaphysical concepts becomes a task of describing the obvious, which is usually unnecessary, or irrelevant, to the level of theory. Yet without these definitions, the theory did not meet the criteria for evaluation of a nursing theory; it did not pass inspection regardless of the quality and contribution of the remaining content. Some graduate programs even insisted that dissertations, in order to be considered nursing research, must include a nursing framework or theory (Morse, 1996). I trust nursing has now moved beyond this stage.

THE NEED FOR NURSE SCIENTISTS

The nurse scientist program was introduced in the late 1960s, with the goal of developing research and doctoral education in nursing, by the Division of Nursing, Bureau of Health Resources Development, U.S. Department of Health, Education, and Welfare (Bourgeois, 1975). Initially, federal funding was provided for nurses to obtain their doctorates in other disciplines, with the intention they would return to nursing following graduation, and build doctoral programs in nursing and contribute to research in nursing. Most did, but they also brought theories and research methods from those disciplines back into nursing, so that nursing research developed, at least in part, with a borrowed theoretical base.

Yet, the need for nursing research was acute; but it happened relatively slowly. For the large part, with the exceptions of those who obtained their doctorates in anthropology, the first nursing research was quantitative, and often focused on nurse and nursing education.

THE NEED FOR NURSING CONCEPTS

There are several conceptualizations about the relationship of concepts and theories. The earliest descriptions were that concepts enabled full descriptions of phenomena useful to nursing. For instance, Peplau (1952) introduced the term “empathy” into nursing to describe the natural process by which maternal emotions are transmitted to infants. Carl Rogers was invited to keynote at the American Nurses Association (ANA) conventions in 1957 on the essential characteristics of a therapeutic relationship, and this initiated interest in empathy in nursing. Gunter (1962) continued to cite Rogers’s postulates directly, substituting “patient” for “client” to illustrate the applicability of the model for psychiatric nursing, counseling techniques, and later in nursing as a whole. During this period, Hildegard Peplau continued writing on therapeutic communication and theory, not only in the psychiatric nurse–patient interaction (1952, 1962), but also in general nurse–patient relationships (1997), and developing the concepts of anxiety (1963) and loneliness (1955) into nursing. Her work began a revolution into recognizing the need for concept development. The Nursing Concept Development Group (1973) later developed into methods of concept development (e.g., Norris, 1982), and texts appeared such as those by Walker and Avant (1983) and others (see Rodgers & Knafl, 1993, 2000). Books providing analyses of concepts also began to appear (e.g., Norris, 1982; Roberts, 1976).

MID-RANGE AND SITUATION-SPECIFIC THEORIES

In contrast to deductive theory that was constructed by identifying the domain and then the relevant concepts and their definitions, the inductive mode of theory development was first to identify the concepts, which were used as the “building blocks of theory” (Hardy, 1974; Walker & Avant, 2011, p. 59). Although this is considered a poor analogy (Paley, [1996, p. 577], prefers “niches”), it is clear that understanding concepts is critical to the development of disciplinary knowledge and to theory development. Inductive theory construction was conceived as consisting of the relevant concepts of various degrees of abstraction, starting with the context, and with linkages, building up to the domain.

The meaning of concepts depends on how they are used both in the context and in theory; concepts may change over time, and broadly with the context, so that concept analysis is not a time-limited goal for a discipline. Concept analysis must be taken seriously, as a research task.

Introducing the Patient

From the early 1980s with the gradual inroads of qualitative research, pushed by Glaser and Strauss and their students at University of California at San Francisco (UCSF), both a substantive area and the method of grounded theory developed (Glaser & Strauss, 1967), initiating the rise of mid-range (or middle-range⁷) theory (Swartz, 2009). The research group bought the patient forward as a person by writing a series of monographs of mid-range theories of dying (Strauss & Glaser, 1970; Strauss et al., 1984), and the comfort work of nurses (1984). For instance, Jennie Quint (later Benoliel) conducted a study of dying, The Nurse and the Dying Patient, in 1967, which had a profound effect on nursing education and practice. Grounded theories were often directly linked to patient care, to nursing problems, and as applicable to care. Much of the research from the UCSF research group has influenced the course of nursing and illness theory, and that has an influence, which continues today (Swartz, 2009).

The Rise of Mid-Range Theory as a Therapeutic Tool

From the mid-1980s, as qualitative method courses became increasingly adopted into nursing programs and qualitative methods were adapted to clinical research, the relevance for patient care immediately became apparent. In addition to the numerous mid-range theories developed using grounded theory, and other qualitative methods were used to develop nursing mid-range theory. In 1979, Germain published the first monograph-length ethnography conducted in a clinical setting, and phenomenology was used to elicit patient responses to illness (for example, see, Morse, Bottorff, & Hutchinson, 1995).

While these methods continue to be refined and developed, for instance, ethnography now consists of institutional ethnography, or critical ethnography, as well as the various other types (such as community-based participatory research [CBPR] and even autoethnography), our understanding of the experiential aspects of health and illness has also developed. Mid-range theories now comprise a large body of scholarship, and examples appear in this book. However, the last step, application of these models for the use by clinicians and the directing of practice, is still developing.

In 1999, Im and Meleis introduced situation-specific theory, which was connected to context, at a low level of abstract, encompassed diversity, of limited generalizations, but linked theory and practice. It was intended to build a solid nursing base of research that is relevant to practice.

THE NEED FOR NURSE EDUCATORS

Despite the criticisms of traditional nursing theory, these theories, frameworks for organizing nursing practice and nursing approaches to care, were (and still are in some nursing programs) highly influential in nursing education. Therefore, recognizing the importance of the adoption of nursing theory, from the mid-1970s to the mid-1990s, all nurses were taught about these theories in their undergraduate and graduate nursing programs. They were included in many types of courses, from the introduction to nursing, and “nursing theory” courses became established core components of the curriculum (however, it is interesting that these courses were not a part of the research curricula), and were not used by expert practitioners.

All nurses were taught about substance of the major nursing theories. Some programs organized their curriculum around nursing theories, so that nurses were very familiar with traditional nursing theory by the time they graduated. Nurses knew if they attended an Orem program or if their school was based on Roy. They were taught the structure of the theories and their intent to guide practice. It is important to note that many of the nurse theorists were not clinicians, but were academics, largely responsible for nurse educational programs and teaching.

However, when nurses commenced clinical practice, they were disillusioned about the application of the theories to practice. These traditional nursing theories were too abstract (Risjord, 2010); the language of the theories was not the language of patient care (Paley, 2006); and the gap between theory and practice was very wide.

In 1995, Levine made an impassioned plea for the revision of these theories:

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