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Fifth Edition

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Copyright © 2014, 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2002 Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at, or via our website at (products and services).

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Library of Congress Cataloging-in-Publication Data

Names: McEwen, Melanie, author. | Wills, Evelyn M., author. Title: Theoretical basis for nursing / Melanie McEwen, Evelyn M. Wills. Description: Fifth edition. | Philadelphia : Wolters Kluwer, [2018] |

Includes bibliographical references and index. Identifiers: LCCN 2017049174 | ISBN 9781496351203 Subjects: | MESH: Nursing Theory Classification: LCC RT84.5 | NLM WY 86 | DDC 610.73—dc23 LC record available at

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author(s), editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.

The author(s), editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have U.S. Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.






To Kaitlin and Grant—You have helped me broaden my thoughts and consider all kinds of possibilities; I hope I’ve done the same for you.

Also for Helen and Keith—Our children chose well. Besides, you have given us Madelyn, Logan, Brenna, Liam, Lucy, Andrew, Michael, and Jacob; they are gifts beyond words.

Melanie McEwen

To Tom, Paul, and Vicki, who light up my life, and to Marian, who left us for a better place. You were always my best listener. To Teddy, Gwen, Merlyn, and Madelyn, who have been so patient and loving during this process.

My deepest gratitude to Leslie, who has supported me through this writing process.

Evelyn M. Wills





Sattaria Smith Dilks, DNP, APRN-BC, FNP, PMHNP/CNS Professor and Co-Coordinator Graduate Program College of Nursing McNeese State University Lake Charles, Louisiana Chapter 14: Theories From the Behavioral Sciences

Joan C. Engebretson, DrPH, AHN-BC, RN, FAAN Judy Fred Professor in Nursing University of Texas Health Science Center at Houston School of Nursing, Department of Family Nursing Houston, Texas Chapter 13: Theories From the Sociologic Sciences

Melinda Granger Oberleitner, DNS, RN Associate Dean, College of Nursing & Allied Health Professions Professor, Department of Nursing SLEMCO/BORSF Endowed Professor of Nursing University of Louisiana at Lafayette Lafayette, Louisiana Chapter 17: Theories, Models, and Frameworks From Leadership and Management Chapter 21: Application of Theory in Nursing Administration and Management

Cathy L. Rozmus, PhD, RN PARTNERS Endowed Professorship in Nursing Vice Dean Department of Family Health The University of Texas Health Science Center at Houston School of Nursing Houston, Texas Chapter 16: Ethical Theories and Principles

Jeffrey P. Spike, PhD Professor of Family and Community Medicine The University of Texas Health Science Center at Houston School of Medicine Professor, Department of Management, Policy, and Community Health University of Texas Health Science Center School of Public Health Houston, Texas Chapter 16: Ethical Theories and Principles






Cynthia Dakin, PhD, RN Director of Graduate Studies Associate Professor Department of Nursing Elms College Chicopee, Massachusetts

Janet DuPont, RNC-OB, MSN, MEd, PhD Master of Science in Nursing Instructor/Developer Nursing Program Norwich University Northfield, Vermont

Ruth Neese, PhD, RN, CEN Assistant Professor Department of Nursing Indian River State College Fort Pierce, Florida

Brandon N. Respress, PhD, RN, MPH, MSN Assistant Professor College of Nursing and Health Innovation University of Texas at Arlington Arlington, Texas

Jacqueline Saleeby, PhD, RN, CS Associate Professor Department of Nursing Maryville University St. Louis, Missouri

Stephen J. Stapleton, PhD, MS, RN, CEN, FAEN Associate Professor Mennonite College of Nursing Illinois State University Normal, Illinois

Kathleen Williamson, MSN, PhD, RN Associate Professor and Chair Wilson School of Nursing Midwestern State University Wichita Falls, Texas

Cindy Zellefrow, DNP, MSEd, RN, LSN, APHN-BC Assistant Professor of Clinical Practice Assistant Director, Center for Transdisciplinary and Evidence-based Practice




College of Nursing The Ohio State University Columbus, Ohio





Rare is the student who enrolls in a nursing program and is excited about the requirement of taking a course on theory. Indeed, many fail to see theory’s relevance to the real world of nursing practice and often have difficulty applying the information in later courses and in their research. This book is the result of the frustration felt by a group of nursing instructors who met a number of years ago to adopt a textbook for a theory course. Indeed, because of student complaints and faculty dissatisfaction, we were changing textbooks yet again. A fairly lengthy discussion arose in which we concluded that the available books did not meet the needs of our students or course faculty. We were determined to write a book that was a general overview of theory per se, stressing how it is—and should be—used by nurses to improve practice, research, education, and management/leadership.

As in past editions, an ongoing review of trends in nursing theory and nursing science has shown an increasing emphasis on middle range theory, evidence-based practice (EBP), and situation-specific theories. To remain current and timely, in this fifth edition, we have added a new chapter entitled “Ethical Theories and Principles,” presenting information on these topics and describing how they relate to theory in nursing. We have also included new middle range and situation-specific nursing theories as well as new “shared” theories from non-nursing disciplines. One notable addition is a significant section discussing Complexity Science and Complex Adaptive Systems in Chapter 13 (Theories From the Sociologic Sciences) helping to explain their importance to nursing. Updates and application examples have been added throughout the discussions on the various theories.

Organization of the Text Theoretical Basis for Nursing is designed to be a basic nursing theory textbook that includes the essential information students need to understand and apply theory in practice, research, education, and administration/management.

The book is divided into four units. Unit I, Introduction to Theory, provides the background needed to understand what theory is and how it is used in nursing. It outlines tools and techniques used to develop, analyze, and evaluate theory so that it can be used in nursing practice, research, administration and management, and education. In this unit, we have provided a balanced view of “hot” topics (e.g., philosophical world views and utilization of shared or borrowed theory). Also, rather than espousing one strategy for activities such as concept development and theory evaluation, we have included a variety of strategies.

Unit II, Nursing Theories, focuses largely on the grand nursing theories and begins with a chapter describing their historical development. This unit divides the grand nursing theories into three groups based on their focus (human needs, interactive process, and unitary process). The works of many of the grand theorists are briefly summarized in Chapters 7, 8, and 9. Because this volume is intended to serve as a broad foundation, these analyses provide the reader with enough information to understand the basis of the work and to whet the reader’s appetite to select one or more for further study rather than delving into significant detail.

Chapters 10 and 11 cover the significant topic of middle range nursing theory. Chapter 10 presents a detailed overview of the origins and growth of middle range theory in nursing and gives numerous examples of how middle range theories have been developed by nurses. Chapter 11 provides an overview of some of the growing number of middle range nursing theories. The theories presented include some of the most commonly used middle range nursing theories (e.g., Pender’s Health Promotion Model and Leininger’s Culture Care Diversity and Universality Theory) as well as some that are less well known but have a growing body of research support (e.g., Meleis’s Transitions Theory, the Theory of Unpleasant Symptoms, and the




Uncertainty in Illness Theory). The intent is to provide a broad range of middle range theories to familiarize the reader with examples and to encourage them to search for others appropriate to their practice or research. Ultimately, it is hoped that readers will be challenged to develop new theories that can be used by nurses.

Chapter 12, which discusses EBP, explains and defines the idea/process of EBP and describes how it relates to nursing theory and application of theory in nursing practice and research. The chapter concludes with a short presentation and review of five different EBP models that have been widely used by nurses and are well supported in the literature.

Unit III, Shared Theories Used by Nurses, is rather unique in nursing literature. Our book acknowledges that “shared” or “borrowed” theories are essential to nursing and negates the idea that the use of shared theory in practice or research is detrimental. In this unit, we have identified some of the most significant theories that have been developed outside of the discipline of nursing but are continually used in nursing. We have organized these theories based on broad disciplines: theories from the sociologic sciences, behavioral sciences, biomedical sciences, and philosophy as well as from administration, management, and learning. Each of these chapters was written by a nurse with both educational and practical experience in his or her respective area. These theories are presented with sufficient information to allow the reader to understand the theories and to recognize those that might be appropriate for his or her own work. These chapters also provide original references and give examples of how the concepts, theories, and models described have been used by other nurses.

Chapter 16, new to the fifth edition, describes ethical theories and principles that apply to nursing practice. This addition was suggested by nursing faculty who recognized the importance of maintaining an ethical perspective within the very complex health care system. This information is vital to professional nursing practice and absolutely essential for nurses in advanced practice, management, or educational roles.

Finally, Unit IV, Application of Theory in Nursing, explains how theories are applied in nursing. Separate chapters cover nursing practice, nursing research, nursing administration and management, and nursing education. These chapters include many specific examples for the application of theory and are intended to be a practical guide for theory use. The heightened development of practice theories and EBP guidelines are critical to theory application in nursing today, so these areas have been expanded. The unit concludes with a chapter that discusses some of the future issues in theory within the discipline.

Key Features In addition to numerous tables and boxes that highlight and summarize important information, Theoretical Basis for Nursing contains case studies, learning activities, exemplars, and illustrations that help students visualize various concepts. New to this edition is a special boxed feature in most chapters that highlights how a topic is outlined in the American Association of Colleges of Nursing (AACN’s) The Essentials of Master’s Education in Nursing or The Essentials of Doctoral Education for Advanced Nursing Practice. Other key features include:

■ Link to Practice: All chapters include at least one “Link to Practice” box, which presents useful information or clinically related examples related to the subject being discussed. The intent is to give additional tools or resources that can be used by nurses to apply the content in their own practice or research.

■ Case Studies: At the end of Chapter 1 and the beginning of Chapters 2 to 23, case studies help the reader understand how the content in the chapter relates to the everyday experience of the nurse, whether in practice, research, or other aspects of nursing.

■ Learning Activities: At the end of each chapter, learning activities pose critical thinking questions, propose individual and group projects related to topics covered in the chapter, and stimulate classroom discussion.

■ Exemplars: In five chapters, an exemplar discusses a scholarly study from the perspectives of concept analysis (Chapter 3); theory development (Chapter 4); theory analysis and evaluation (Chapter 5); middle range theory development (Chapter 10); and theory generation via research, theory testing via research, and use of a theory as the conceptual framework for a research study (Chapter 20).

■ Illustrations: Diagrams and models are included throughout the book to help the reader better




understand the many different theories presented.

New to This Edition ■ New Chapter 16, Ethical Theories and Principles ■ Detailed section on Complexity Science and Complex Adaptive Systems in Chapter 13. ■ More detailed explanation of EBP, situation-specific theories, and their relationship to theory in nursing ■ Numerous recent examples of application of theories in nursing practice, nursing research,

leadership/administration, and education ■ Enhanced instructional support, focusing on activities and information directed toward online learning

Student Resources Available on ■ Literature Assessment Activity provides an interactive tool featuring journal articles along with

critical thinking questions that will encourage students to engage with the literature. Students can print or e-mail their responses to their instructor.

■ Case Studies with applicable questions guide students in understanding how the various theories link to nursing practice.

■ Learning Objectives for each chapter help focus the student on outcomes. ■ Internet Resources provide live web links to pertinent sites so that students can further their study and

understanding of the various theories. ■ Journal Articles for each chapter offer opportunities to gain more knowledge and understanding of the

chapter content.

Instructor Resources Available on ■ Instructor’s Guide includes application-level discussion questions and classroom/online activities that

Melanie McEwen uses in her own teaching! ■ Strategies for Effective Teaching of Nursing Theory provide ideas for instructors to help make the

nursing theory class come alive. ■ Test Generator Questions provide multiple-choice questions that can be used for testing general

content knowledge. ■ PowerPoints with audience response (Iclicker) questions, based on the ones used by Melanie

McEwen in her own classroom, help highlight important points to enhance the classroom experience. ■ Case Studies with questions, answers, and related activities offer opportunities for instructors to make

the student case studies an exciting, fun, and rewarding classroom/online experience. ■ Image Bank provides images from the text that instructors can use to enhance their own presentations.

In summary, the focus of this learning package is on the application of theory rather than on the study, analysis, and critique of grand theorists or a presentation of a specific aspect of theory (e.g., construction or evaluation). It is hoped that practicing nurses, nurse researchers, and nursing scholars, as well as graduate students and theory instructors, will use this book and its accompanying resources to gain a better understanding and appreciation of theory.

Melanie McEwen, PhD, RN, CNE, ANEF Evelyn M. Wills, PhD, RN





Our heartfelt thanks to Senior Development Editor, Michael Kerns, and Editorial Coordinator, Tim Rinehart, for their assistance, patience, and persistence in helping us complete this project. They made a difficult task seem easy! We also want to thank Senior Acquisitions Editor, Christina Burns, and Helen Kogut, for their support and assistance in getting this project started and help with previous editions. Finally, a huge word of thanks to our contributors who have diligently worked to present the notion of theory in a manner that will engage nursing students and to look for new examples and applications to help make theory fresh and relevant.






Unit I: Introduction to Theory

1. Philosophy, Science, and Nursing Melanie McEwen

Case Study Nursing as a Profession Nursing as an Academic Discipline Introduction to Science and Philosophy

Overview of Science Overview of Philosophy

Science and Philosophical Schools of Thought Received View (Empiricism, Positivism, Logical Positivism)

Contemporary Empiricism/Postpositivism Nursing and Empiricism

Perceived View (Human Science, Phenomenology, Constructivism, Historicism) Nursing and Phenomenology/Constructivism/Historicism

Postmodernism (Poststructuralism, Postcolonialism) Nursing and Postmodernism

Nursing Philosophy, Nursing Science, and Philosophy of Science in Nursing Nursing Philosophy Nursing Science Philosophy of Science in Nursing

Knowledge Development and Nursing Science Epistemology

Ways of Knowing Nursing Epistemology Other Views of Patterns of Knowledge in Nursing Summary of Ways of Knowing in Nursing

Research Methodology and Nursing Science Nursing as a Practice Science Nursing as a Human Science Quantitative Versus Qualitative Methodology Debate

Quantitative Methods Qualitative Methods Methodologic Pluralism

Summary Key Points

Learning Activities

2. Overview of Theory in Nursing Melanie McEwen

Overview of Theory The Importance of Theory in Nursing Terminology of Theory




Historical Overview: Theory Development in Nursing Florence Nightingale Stages of Theory Development in Nursing

Silent Knowledge Stage Received Knowledge Stage Subjective Knowledge Stage Procedural Knowledge Stage Constructed Knowledge Stage Integrated Knowledge Stage

Summary of Stages of Nursing Theory Development Classification of Theories in Nursing

Scope of Theory Metatheory Grand Theories Middle Range Theories Practice Theories

Type or Purpose of Theory Descriptive (Factor-Isolating) Theories Explanatory (Factor-Relating) Theories Predictive (Situation-Relating) Theories Prescriptive (Situation-Producing) Theories

Issues in Theory Development in Nursing Borrowed Versus Unique Theory in Nursing Nursing’s Metaparadigm

Relationships Among the Metaparadigm Concepts Other Viewpoints on Nursing’s Metaparadigm

Caring as a Central Construct in the Discipline of Nursing Summary Key Points

Learning Activities

3. Concept Development: Clarifying Meaning of Terms Evelyn M. Wills and Melanie McEwen

The Concept of “Concept” Types of Concepts

Abstract Versus Concrete Concepts Variable (Continuous) Versus Nonvariable (Discrete) Concepts Theoretically Versus Operationally Defined Concepts

Sources of Concepts Concept Analysis/Concept Development

Purposes of Concept Development Context for Concept Development Concept Development and Conceptual Frameworks Concept Development and Research

Strategies for Concept Analysis and Concept Development Walker and Avant

Concept Analysis Concept Synthesis Concept Derivation Examples of Concept Analysis Using Walker and Avant’s Techniques

Rodgers Schwartz-Barcott and Kim

Theoretical Phase




Fieldwork Phase Analytical Phase

Meleis Concept Exploration Concept Clarification Concept Analysis

Morse Concept Delineation Concept Comparison Concept Clarification

Penrod and Hupcey Comparison of Models for Concept Development

Summary Key Points

Learning Activities

4. Theory Development: Structuring Conceptual Relationships in Nursing Melanie McEwen

Overview of Theory Development Categorizations of Theory

Categorization Based on Scope or Level of Abstraction Philosophy, Worldview, or Metatheory Grand Theories Middle Range Theories Practice Theories Relationship Among Levels of Theory in Nursing

Categorization Based on Purpose Descriptive Theories Explanatory Theories Predictive Theories Prescriptive Theories

Categorization Based on Source or Discipline Components of a Theory

Purpose Concepts and Conceptual Definitions Theoretical Statements

Existence Statements Relational Statements

Structure and Linkages Assumptions Models

Theory Development Relationship Among Theory, Research, and Practice

Relationship Between Theory and Research Relationship Between Theory and Practice Relationship Between Research and Practice

Approaches to Theory Development Theory to Practice to Theory Practice to Theory Research to Theory Theory to Research to Theory Integrated Approach

Process of Theory Development




Concept Development: Creation of Conceptual Meaning Statement Development: Formulation and Validation of Relational Statements Theory Construction: Systematic Organization of the Linkages Validating and Confirming Theoretical Relationships in Research Validation and Application of Theory in Practice

Summary Key Points

Learning Activities

5. Theory Analysis and Evaluation Melanie McEwen

Definition and Purpose of Theory Evaluation Theory Description Theory Analysis Theory Evaluation

Historical Overview of Theory Analysis and Evaluation Characteristics of Significant Theories: Ellis Theory Evaluation: Hardy Theory Analysis and Theory Evaluation: Duffey and Muhlenkamp Theory Evaluation: Barnum Theory Analysis: Walker and Avant Theory Analysis and Evaluation: Fawcett Theory Description and Critique: Chinn and Kramer Theory Description, Analysis, and Critique: Meleis Analysis and Evaluation of Practice Theory, Middle Range Theory, and Nursing Models: Whall Theory Evaluation: Dudley-Brown

Comparisons of Methods Synthesized Method of Theory Evaluation Summary Key Points

Learning Activities

Unit II: Nursing Theories

6. Overview of Grand Nursing Theories Evelyn M. Wills

Categorization of Conceptual Frameworks and Grand Theories Categorization Based on Scope Categorization Based on Nursing Domains Categorization Based on Paradigms

Parse’s Categorization Newman’s Categorization Fawcett’s Categorization

Specific Categories of Models and Theories for This Unit Analysis Criteria for Grand Nursing Theories

Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships Usefulness Testability Parsimony




Value in Extending Nursing Science The Purpose of Critiquing Theories Summary Key Points

Learning Activities

7. Grand Nursing Theories Based on Human Needs Evelyn M. Wills

Florence Nightingale: Nursing: What It Is and What It Is Not Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships Usefulness Testability Parsimony Value in Extending Nursing Science

Virginia Henderson: The Principles and Practice of Nursing Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Assumptions Concepts

Usefulness Testability Parsimony Value in Extending Nursing Science

Faye G. Abdellah: Patient-Centered Approaches to Nursing Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Assumptions Usefulness Testability Parsimony Value in Extending Nursing Science

Dorothea Orem: The Self-Care Deficit Nursing Theory Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Dorothy Johnson: The Behavioral System Model Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Assumptions Concepts Relationships





Testability Parsimony Value in Extending Nursing Science

Betty Neuman: The Neuman Systems Model Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Summary Key Points

Learning Activities

8. Grand Nursing Theories Based on Interactive Process Evelyn M. Wills

Barbara Artinian: The Intersystem Model Background of the Theorist Philosophic Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Assumptions Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain: Modeling and Role- Modeling

Background of the Theorists Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Imogene King: King’s Conceptual System and Theory of Goal Attainment and Transactional Process

Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Assumptions Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science




Sister Callista Roy: The Roy Adaptation Model Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Jean Watson: Human Caring Science, A Theory of Nursing Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Assumptions Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Summary Key Points

Learning Activities

9. Grand Nursing Theories Based on Unitary Process Evelyn M. Wills

Martha Rogers: The Science of Unitary and Irreducible Human Beings Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Margaret Newman: Health as Expanding Consciousness Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Concepts Relationships

Usefulness Testability Parsimony Value in Extending Nursing Science

Rosemarie Parse: The Humanbecoming Paradigm Background of the Theorist Philosophical Underpinnings of the Theory Major Assumptions, Concepts, and Relationships

Concepts Relationships




Usefulness Testability Parsimony Value in Extending Nursing Science

Summary Key Points

Learning Activities

10. Introduction to Middle Range Nursing Theories Melanie McEwen

Purposes of Middle Range Theory Characteristics of Middle Range Theory Concepts and Relationships for Middle Range Theory Categorizing Middle Range Theory Development of Middle Range Theory

Middle Range Theories Derived From Research and/or Practice Middle Range Theory Derived From a Grand Theory Middle Range Theory Combining Existing Nursing and Non-Nursing Theories Middle Range Theory Derived From Non-Nursing Disciplines Middle Range Theory Derived From Practice Guidelines or Standard of Care Final Thoughts on Middle Range Theory Development

Analysis and Evaluation of Middle Range Theory Summary Key Points

Learning Activities

11. Overview of Selected Middle Range Nursing Theories Melanie McEwen

High Middle Range Theories Benner’s Model of Skill Acquisition in Nursing

Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Leininger’s Cultural Care Diversity and Universality Theory Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Pender’s Health Promotion Model Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Transitions Theory Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

The Synergy Model Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Middle Middle Range Theories Mishel’s Uncertainty in Illness Theory

Purpose and Major Concepts Context for Use and Nursing Implications




Evidence of Empirical Testing and Application in Practice Kolcaba’s Theory of Comfort

Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Lenz and Colleagues’ Theory of Unpleasant Symptoms Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Reed’s Self-Transcendence Theory Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Low Middle Range Theories Eakes, Burke, and Hainsworth’s Theory of Chronic Sorrow

Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Beck’s Postpartum Depression Theory Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Mercer’s Conceptualization of Maternal Role Attainment/Becoming a Mother Purpose and Major Concepts Context for Use and Nursing Implications Evidence of Empirical Testing and Application in Practice

Summary Key Points

Learning Activities

12. Evidence-Based Practice and Nursing Theory Evelyn M. Wills and Melanie McEwen

Overview of Evidence-Based Practice Definition and Characteristics of Evidence-Based Practice Concerns Related to Evidence-Based Practice in Nursing Evidence-Based Practice and Practice-Based Evidence Promotion of Evidence-Based Practice in Nursing Theory and Evidence-Based Practice Theoretical Models of Evidence-Based Practice

Academic Center for Evidence-Based Practice Star Model of Knowledge Transformation Advancing Research and Clinical Practice Through Close Collaboration Model The Iowa Model of Evidence-Based Practice to Promote Quality Care The Johns Hopkins Nursing Evidence-Based Practice Model Stetler Model of Evidence-Based Practice Theoretical Models: A Summary

Summary Key Points

Learning Activities

Unit III: Shared Theories Used by Nurses

13. Theories From the Sociologic Sciences




Joan C. Engebretson Systems Theories

General Systems Theory Overview Application to Nursing

Social Ecological Models Overview Application to Nursing

Social Networks Overview Application to Nursing

Social Construction and Interaction Theories Symbolic Interactionism

Overview Application to Nursing

Cultural Diversity Overview Application to Nursing

Role Theory Overview Application to Nursing

Exchange Theories, Conflict and Critical Theories Exchange Theories

Historical Overview Modern Social Exchange Theories Application to Nursing

Conflict and Critical Theories Critical Social Theory Feminist Theory

Complexity Science, Chaos Theory and Complex Adaptive Systems Chaos Theory Complex Adaptive Systems

Application to Nursing Summary Key Points

Learning Activities

14. Theories From the Behavioral Sciences Melanie McEwen and Sattaria Smith Dilks

Psychodynamic Theories Psychoanalytic Theory: Freud

Overview Application to Nursing

Developmental (or Ego Developmental) Theory: Erikson Overview Application to Nursing

Interpersonal Theory: Sullivan Overview Application to Nursing

Behavioral and Cognitive-Behavioral Theories Operant Conditioning: Skinner Cognitive Theory: Beck Rational Emotive Theory: Ellis




Application of Behavioral and Cognitive-Behavioral Theories to Nursing Humanistic Theories

Human Needs Theory: Maslow Overview Application to Nursing

Person-Centered Theory: Rogers Overview Application to Nursing

Stress Theories General Adaptation Syndrome: Selye Stress, Coping, and Adaptation Theory: Lazarus Application of Stress Theories to Nursing

Social Psychology Health Belief Model Theory of Reasoned Action (Theory of Planned Behavior) Transtheoretical Model and Stages of Change Application of Social Psychology Theories to Nursing

Summary Key Points

Learning Activities

15. Theories From the Biomedical Sciences Melanie McEwen

Theories and Models of Disease Causation Evolution of Theories of Disease Causation Germ Theory and Principles of Infection

Overview Application to Nursing

The Epidemiologic Triangle The Web of Causation

Overview Application to Nursing

Natural History of Disease Overview Application to Nursing

Theories and Principles Related to Physiology and Physical Functioning Homeostasis

Overview Application to Nursing

Stress and Adaptation: General Adaptation Syndrome Overview Application to Nursing

Theories of Immunity and Immune Function Overview Application to Nursing

Genetic Principles and Theories Overview Application to Nursing

Cancer Theories Overview Application to Nursing

Pain Management Gate Control Theory




Application to Nursing Summary Key Points

Learning Activities

16. Ethical Theories and Principles Cathy L. Rozmus and Jeffrey P. Spike

Ethics and Philosophy: An Overview Theory in the Humanities and Philosophy Ethics Versus Morality

Philosophical Theories of Ethics Virtue Ethics

Background Application in Nursing

Modern Ethical Theories Deontology Utilitarianism Deontology and Utilitarianism—A Summary Application to Nursing

Bioethical Principles Historical Perspective on the Bioethical Principles Autonomy

Overview Application to Nursing

Beneficence Overview Application to Nursing

Nonmaleficence Overview Application to Nursing

Justice Overview Application to Nursing

Other Bioethical Principles Ethical Decision Making

Overview Application to Nursing

Summary Key Points

Learning Activities

17. Theories, Models, and Frameworks From Leadership and Management Melinda Granger Oberleitner

Overview of Concepts of Leadership and Management Early Leadership Theories

Trait Theories of Leadership Emotional Intelligence Behavioral Theories of Leadership

Leader–Member Exchange Theory Motivational Theories of Leadership

Theory X and Theory Y Motivation–Hygiene Theory (Herzberg’s Two-Factor Theory)

Contingency Theories of Leadership: Leadership and Management by Situation




The Fiedler Contingency Theory of Leadership Path–Goal Theory Situational Leadership Theory

Contemporary Leadership Theories Transactional and Transformational Leadership Authentic Leadership Charismatic Leadership Servant Leadership Followership Theory

Organizational/Management Theories Scientific Management Theory of Bureaucracy/Organizational Theory Classic Management Theory

Motivational Theories Achievement–Motivation Theory Expectancy Theory Equity Theory

Concepts of Power, Empowerment, and Change Power Empowerment Change

Planned Change Theory Resilience

Problem-Solving and Decision-Making Processes The Rational Decision-Making Model Group Decision Making Organizational Quantitative Decision-Making Techniques

Conflict Management Quality Improvement

The Case for Quality Improvement in Health Care Quality Improvement Frameworks Quality Improvement Processes and Tools

Evidence-Based Practice Summary Key Points

Learning Activities

18. Learning Theories Evelyn M. Wills and Melanie McEwen

What Is Learning? What Is Teaching? Categorization of Learning Theories Behavioral Learning Theories

Overview Application to Nursing

Cognitive Learning Theories Cognitive-Field (Gestalt) Theories

Overview Application to Nursing

Cognitive Development or Interaction Theories Piaget Gagne Bandura




Humanistic Learning Theory Rogers

Information-Processing Models Cognitive Load Theory Application to Nursing

Adult Learning Overview Application to Nursing

Summary of Learning Theories Learning Styles Principles of Learning Application of Learning Theories in Nursing Summary Key Points

Learning Activities

Unit IV: Application of Theory in Nursing

19. Application of Theory in Nursing Practice Melanie McEwen

Relationship Between Theory and Practice Theory-Based Nursing Practice The Theory–Practice Gap

Closing the Theory–Practice Gap Situation-Specific/Practice Theories in Nursing

Definition and Characteristics of Situation-Specific/Practice Theories Examples of Practice and Situation-Specific Theories From Nursing Literature Situation-Specific Theory and Evidence-Based Practice

Application of Theory in Nursing Practice Theory in Nursing Taxonomy: Examples From the Nursing Intervention Classification System

Urinary Catheterization: Intermittent Patient Contracting

Examples of Theory From Nursing Literature Application of “Borrowed” and “Implied” Theories in Nursing Practice Application of Grand and Middle Range Theories in Nursing Practice

Summary Key Points

Learning Activities

20. Application of Theory in Nursing Research Melanie McEwen

Historical Overview of Research and Theory in Nursing Relationship Between Research and Theory

Nursing Research Purpose of Theory in Research The Research Framework

Types of Theory and Corresponding Research Descriptive Theory and Descriptive Research

Overview Nursing Studies

Explanatory Theory and Correlational Research




Overview Nursing Studies

Predictive Theory and Experimental Research Overview Nursing Studies

How Theory Is Used in Research Theory-Generating Research

Overview Nursing Studies

Theory-Testing Research Overview Nursing Studies

Theory as the Conceptual Framework or Context of a Study Overview Nursing Studies

Nursing and Non-Nursing Theories in Nursing Research Rationale for Using Nursing Theories in Nursing Research Concerns Over Reliance on Nursing Models to Direct Nursing Research

Other Issues in Nursing Theory and Nursing Research The Research Report Nursing’s Research Agenda

Summary Key Points

Learning Activities

21. Application of Theory in Nursing Administration and Management Melinda Granger Oberleitner

Organizational Design Work Specialization Chain of Command Span of Control Authority and Responsibility Centralization Versus Decentralization Departmentalization

Shared Governance Transformational Leadership in Nursing and in Health Care Patient Care Delivery Models

Total Patient Care (Functional Nursing) Team Nursing Primary Nursing Patient-Focused Care/Patient-Centered Care Use of Patient Care Delivery Models Today American Nurses Credentialing Center Magnet Recognition Program

Case Management Disease/Chronic Illness Management

Disease Management Models Population Health Accountable Care Organizations and Medical Home Models of Care

Quality Management Evidence-Based Practice

Summary Key Points

Learning Activities




22. Application of Theory in Nursing Education Melanie McEwen and Evelyn M. Wills

Theoretical Issues in Nursing Curricula Curriculum Design in Nursing Education Nursing Curricula and Regulating Bodies Conceptual/Organizational Frameworks for Nursing Curricula

Purposes of the Conceptual Framework Designing a Curriculum Conceptual Framework Components of the Curricular Conceptual Framework Patterns of Curricular Conceptual Frameworks

Current Issues in Curriculum Development Theoretical Issues in Nursing Instruction

Theory-Based Teaching Strategies Dialectic Learning Problem-Based Learning Strategies Operational Teaching Strategies Logistic Teaching Strategies

Use of Technology in Nursing Education Issues in Technology-Based Teaching

Summary Key Points

Learning Activities

23. Future Issues in Nursing Theory Melanie McEwen

Future Issues in Nursing Science Future Issues in Nursing Theory

Implications for Theory Development Theoretical Perspectives on Future Issues in Nursing Practice, Research, Administration and Management, and Education

Future Issues and Nursing Practice Theoretical Implications for Nursing Practice

Future Issues and Nursing Research Theoretical Implications for Nursing Research

Future Issues and Nursing Leadership and Administration Theoretical Implications for Nursing Administration and Management

Future Issues and Nursing Education Theoretical Implications for Nursing Education

Summary Key Points

Learning Activities

Glossary Author Index Subject Index





Introduction to Theory





Philosophy, Science, and Nursing Melanie McEwen

Largely due to the work of nursing scientists, nursing theorists, and nursing scholars over the past five decades, nursing has been recognized as both an emerging profession and an academic discipline. Crucial to the attainment of this distinction have been numerous discussions regarding the phenomena of concern to nurses and countless efforts to enhance involvement in theory utilization, theory generation, and theory testing to direct research and improve practice.

A review of the nursing literature from the late 1970s until the present shows sporadic discussion of whether nursing is a profession, a science, or an academic discipline. These discussions are sometimes pleading, frequently esoteric, and occasionally confusing. Questions that have been raised include: What defines a profession? What constitutes an academic discipline? What is nursing science? Why is it important for nursing to be seen as a profession or an academic discipline?

Nursing as a Profession In the past, there has been considerable discussion about whether nursing is a profession or an occupation. This is important for nurses to consider for several reasons. An occupation is a job or a career, whereas a profession is a learned vocation or occupation that has a status of superiority and precedence within a division of work. In general terms, occupations require widely varying levels of training or education, varying levels of skill, and widely variable defined knowledge bases. In short, all professions are occupations, but not all occupations are professions (Finkelman & Kenner, 2016).

Professions are valued by society because the services professionals provide are beneficial for members of the society. Characteristics of a profession include (1) defined and specialized knowledge base, (2) control and authority over training and education, (3) credentialing system or registration to ensure competence, (4) altruistic service to society, (5) a code of ethics, (6) formal training within institutions of higher education, (7) lengthy socialization to the profession, and (8) autonomy (control of professional activities) (Ellis & Hartley, 2012; Finkelman & Kenner, 2016; Rutty, 1998). Professions must have a group of scholars, investigators, or researchers who work to continually advance the knowledge of the profession with the goal of improving practice. Finally, professionals are responsible and accountable to the public for their work (Hood, 2014). Traditionally, professions have included the clergy, law, and medicine.

Until near the end of the 20th century, nursing was viewed as an occupation rather than a profession. Nursing has had difficulty being deemed a profession because many of the services provided by nurses have been perceived as an extension of those offered by wives and mothers. Additionally, historically, nursing has been seen as subservient to medicine, and nurses have delayed in identifying and organizing professional knowledge. Furthermore, education for nurses is not yet standardized, and the three-tier entry-level system (diploma, associate degree, and bachelor’s degree) into practice that persists has hindered professionalization because a college education is not yet a requirement. Finally, autonomy in practice is incomplete because nursing is still dependent on medicine to direct much of its practice.

On the other hand, many of the characteristics of a profession can be observed in nursing. Indeed, nursing has a social mandate to provide health care for clients at different points in the health–illness continuum.




There is a growing knowledge base, authority over education, altruistic service, a code of ethics, and registration requirements for practice. Although the debate is not closed, it can be successfully argued that nursing is an aspiring, evolving profession (Finkelman & Kenner, 2016; Hood, 2014; Judd & Sitzman, 2014). See Link to Practice 1-1 for more information on the future of nursing as a profession.

Link to Practice 1-1 The Future of Nursing The Institute of Medicine (IOM, 2011) issued a series of sweeping recommendations directed to the nursing profession. The IOM explained their “vision” is to make quality, patient-centered care accessible for all Americans. Recommendations included a three-pronged approach to meeting the goal.

The first “message” was directed toward transformation of practice and precipitated the notion that nurses should be able to practice to the full extent of their education. Indeed, the IOM advocated for removal of regulatory, policy, and financial barriers to practice to ensure that “current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health” (p. 30).

A second key message related to the transformation of nursing education. In this regard, the IOM promotes “seamless academic progression” (p. 30), which includes a goal to increase the number and percentage of nurses who enter the workforce with a baccalaureate degree or who progress to the degree early in their career. Specifically, they recommend that 80% of registered nurses (RNs) be bachelor of science in nursing (BSN) prepared by 2020. Last, the IOM advocated that nurses be full partners with physicians and other health professionals in the attempt to redesign health care in the United States.

These “messages” are critical to the future of nursing as a profession. Indeed, standardization of entry level into practice at the BSN level, coupled with promotion of advanced education and independent practice, and inclusion as “leaders” in the health care transformation process, will help solidify nursing as a true profession.

An update (IOM, 2016) indicated that there has been “significant progress” (p. 50) toward reducing APRN scope of practices issues from a national perspective, as more states now allow nurse practitioners (NPs) full practice authority. Furthermore, although there has been some progress with expansion of the percentage of RNs with a BSN (from 49% to 51%), there is still much to do to meet the goal of 80%. Finally, the IOM concluded that data are lacking on efforts to develop the skills and competencies nurses need for leadership. The report reinforced the goal for nurses to seek “leadership positions in order to contribute their unique perspective and expertise on such issues as health care delivery, quality, and safety” (p. 149).

Nursing as an Academic Discipline Disciplines are distinctions between bodies of knowledge found in academic settings. A discipline is “a branch of knowledge ordered through the theories and methods evolving from more than one worldview of the phenomenon of concern” (Parse, 1997, p. 74). It has also been termed a field of inquiry characterized by a unique perspective and a distinct way of viewing phenomena (Fawcett, 2012; Rodgers, 2015).

Viewed another way, a discipline is a branch of educational instruction or a department of learning or knowledge. Institutions of higher education are organized around disciplines into colleges, schools, and departments (e.g., business administration, chemistry, history, and engineering).

Disciplines are organized by structure and tradition. The structure of the discipline provides organization and determines the amount, relationship, and ratio of each type of knowledge that comprises the discipline. The tradition of the discipline provides the content, which includes ethical, personal, esthetic, and scientific knowledge (Northrup et al., 2004; Risjord, 2010). Characteristics of disciplines include (1) a distinct perspective and syntax, (2) determination of what phenomena are of interest, (3) determination of the context in which the phenomena are viewed, (4) determination of what questions to ask, (5) determination of what




methods of study are used, and (6) determination of what evidence is proof (Donaldson & Crowley, 1978). Knowledge development within a discipline proceeds from several philosophical and scientific

perspectives or worldviews (Litchfield & Jónsdóttir, 2008; Newman, Sime, & Corcoran-Perry, 1991; Risjord, 2010; Rodgers, 2015). In some cases, these worldviews may serve to divide or segregate members of a discipline. For example, in psychology, practitioners might consider themselves behaviorists, Freudians, or any one of a number of other divisions.

Several ways of classifying academic disciplines have been proposed. For instance, they may be divided into the basic sciences (physics, biology, chemistry, sociology, anthropology) and the humanities (philosophy, ethics, history, fine arts). In this classification scheme, it is arguable that nursing has characteristics of both.

Distinctions may also be made between academic disciplines (e.g., physics, physiology, sociology, mathematics, history, philosophy) and professional disciplines (e.g., medicine, law, nursing, social work). In this classification scheme, the academic disciplines aim to “know,” and their theories are descriptive in nature. Research in academic disciplines is both basic and applied. Conversely, the professional disciplines are practical in nature, and their research tends to be more prescriptive and descriptive (Donaldson & Crowley, 1978).

Nursing’s knowledge base draws from many disciplines. In the past, nursing depended heavily on physiology, sociology, psychology, and medicine to provide academic standing and to inform practice (Box 1- 1). In recent decades, however, nursing has been seeking what is unique to nursing and developing those aspects into an academic discipline (Parse, 2015). Areas that identify nursing as a distinct discipline are as follows:

An identifiable philosophy At least one conceptual framework (perspective) for delineation of what can be defined as nursing Acceptable methodologic approaches for the pursuit and development of knowledge (Oldnall, 1995)

Box 1-1 Theory and the American Association of Colleges of Nursing Essentials “The scientific foundation of nursing practice has expanded and includes a focus on both the natural and social sciences. These sciences that provide a foundation for nursing practice include human biology, genomics, the psychosocial sciences as well as the science of complex organizational structures” (American Association of Colleges of Nursing, 2006, p. 9).

To begin the quest to validate nursing as both a profession and an academic discipline, this chapter provides an overview of the concepts of science and philosophy. It examines the schools of philosophical thought that have influenced nursing and explores the epistemology of nursing to explain why recognizing the multiple “ways of knowing” is critical in the quest for development and application of theory in nursing. Finally, this chapter presents issues related to how philosophical worldviews affect knowledge development through research. This chapter concludes with a case study that depicts how “the ways of knowing” in nursing are used on a day-to-day, even moment-by-moment, basis by all practicing nurses.

Introduction to Science and Philosophy Science is concerned with causality (cause and effect). The scientific approach to understanding reality is characterized by observation, verifiability, and experience; hypothesis testing and experimentation are considered scientific methods. In contrast, philosophy is concerned with the purpose of human life, the nature of being and reality, and the theory and limits of knowledge. Intuition, introspection, and reasoning are examples of philosophical methodologies. Science and philosophy share the common goal of increasing knowledge (Fawcett, 2012; Polifroni, 2015; Silva, 1977). The science of any discipline is tied to its philosophy, which provides the basis for understanding and developing theories for science (Gustafsson, 2002; Morse, 2017; Silva & Rothbart, 1984).

Overview of Science Science is both a process and a product. Parse (1997) defines science as the “theoretical explanation of the




subject of inquiry and the methodological process of sustaining knowledge in a discipline” (p. 74). Science has also been described as a way of explaining observed phenomena as well as a system of gathering, verifying, and systematizing information about reality (Streubert & Carpenter, 2011). As a process, science is characterized by systematic inquiry that relies heavily on empirical observations of the natural world. As a product, it has been defined as empirical knowledge that is grounded and tested in experience and is the result of investigative efforts. Furthermore, science is conceived as being the consensual, informed opinion about the natural world, including human behavior and social action (Gortner & Schultz, 1988).

Science has come to represent knowledge, and it is generated by activities that combine advancement of knowledge (research) and explanation for knowledge (theory) (Powers & Knapp, 2011). Citing Van Laer, Silva (1977) lists six characteristics of science (Box 1-2).

Box 1-2 Characteristics of Science 1. Science must show a certain coherence. 2. Science is concerned with definite fields of knowledge. 3. Science is preferably expressed in universal statements. 4. The statements of science must be true or probably true. 5. The statements of science must be logically ordered. 6. Science must explain its investigations and arguments.

Source: Silva (1977).

Science has been classified in several ways. These include pure or basic science, natural science, human or social science, and applied or practice science. The classifications are not mutually exclusive and are open to interpretation based on philosophical orientation. Table 1-1 lists examples of a number of sciences by this manner of classification.

Table 1-1 Classifications of Science Classification Examples

Natural sciences Chemistry, physics, biology, physiology, geology, meteorology Basic or pure sciences Mathematics, logic, chemistry, physics, English (language) Human or social sciences Psychology, anthropology, sociology, economics, political science,

history, religion Practice or applied sciences Architecture, engineering, medicine, pharmacology, law

Some sciences defy classification. For example, computer science is arguably applied or perhaps pure. Law is certainly a practice science, but it is also a social science. Psychology might be a basic science, a human science, or an applied science, depending on what aspect of psychology one is referring to.

There are significant differences between the human and natural sciences. Human sciences refer to the fields of psychology, anthropology, and sociology and may even extend to economics and political science. These disciplines deal with various aspects of humans and human interactions. Natural sciences, on the other hand, are concentrated on elements found in nature that do not relate to the totality of the individual. There are inherent differences between the human and natural sciences that make the research techniques of the natural sciences (e.g., laboratory experimentation) improper or potentially problematic for human sciences (Gortner & Schultz, 1988).

It has been posited that although nursing draws on the basic and pure sciences (e.g., physiology and chemistry) and has many characteristics of social sciences, it is without question an applied or practice science. However, it is important to note that it is also synthesized, in that it draws on the knowledge of other established disciplines—including other practice disciplines (Dahnke & Dreher, 2016; Holzemer, 2007; Risjord, 2010).




Overview of Philosophy Within any discipline, both scholars and students should be aware of the philosophical orientations that are the basis for developing theory and advancing knowledge (Dahnke & Dreher, 2016; DiBartolo, 1998; Northrup et al., 2004; Risjord, 2010). Rather than a focus on solving problems or answering questions related to that discipline (which are tasks of the discipline’s science), the philosophy of a discipline studies the concepts that structure the thought processes of that discipline with the intent of recognizing and revealing foundations and presuppositions (Blackburn, 2016).

Philosophy has been defined as “a study of problems that are ultimate, abstract, and general. These problems are concerned with the nature of existence, knowledge, morality, reason, and human purpose” (Teichman & Evans, 1999, p. 1). Philosophy tries to discover knowledge and truth and attempts to identify what is valuable and important.

Modern philosophy is usually traced to Rene Descartes, Francis Bacon, Baruch Spinoza, and Immanuel Kant (ca. 1600–1800). Descartes (1596–1650) and Spinoza (1632–1677) were early rationalists. Rationalists believe that reason is superior to experience as a source of knowledge. Rationalists attempt to determine the nature of the world and reality by deduction and stress the importance of mathematical procedures.

Bacon (1561–1626) was an early empiricist. Like rationalists, he supported experimentation and scientific methods for solving problems.

The work of Kant (1724–1804) set the foundation for many later developments in philosophy. Kant believed that knowledge is relative and that the mind plays an active role in knowing. Other philosophers have also influenced nursing and the advance of nursing science. Several are discussed later in the chapter.

Although there is some variation, traditionally, the branches of philosophy include metaphysics (ontology and cosmology), epistemology, logic, esthetics, and ethics or axiology. Political philosophy and philosophy of science are added by some authors (Rutty, 1998; Teichman & Evans, 1999). Table 1-2 summarizes the major branches of philosophy.

Table 1-2 Branches of Philosophy Branch Pursuit

Metaphysics Study of the fundamental nature of reality and existence—general theory of reality

Ontology Study of theory of being (what is or what exists) Cosmology Study of the physical universe Epistemology Study of knowledge (ways of knowing, nature of truth, and

relationship between knowledge and belief) Logic Study of principles and methods of reasoning (inference and argument) Ethics (axiology) Study of nature of values; right and wrong (moral philosophy) Esthetics Study of appreciation of the arts or things beautiful Philosophy of science Study of science and scientific practice Political philosophy Study of citizen and state

Sources: Blackburn (2016); Teichman and Evans (1999).

Science and Philosophical Schools of Thought The concept of science as understood in the 21st century is relatively new. In the period of modern science, three philosophies of science (paradigms or worldviews) dominate: rationalism, empiricism, and human science/phenomenology. Rationalism and empiricism are often termed received view and human science/phenomenology and related worldviews (i.e., historicism) are considered perceived view (Hickman, 2011; Meleis, 2012). These two worldviews dominated theoretical discussion in nursing through the 1990s. More recently, attention has focused on another dominant worldview: “postmodernism” (Meleis, 2012; Reed, 1995).




Received View (Empiricism, Positivism, Logical Positivism) Empiricism has its roots in the writings of Francis Bacon, John Locke, and David Hume, who valued observation, perception by senses, and experience as sources of knowledge (Gortner & Schultz, 1988; Powers & Knapp, 2011). Empiricism is founded on the belief that what is experienced is what exists, and its knowledge base requires that these experiences be verified through scientific methodology (Dahnke & Dreher, 2016; Gustafsson, 2002). This knowledge is then passed on to others in the discipline and subsequently built on. The term received view or received knowledge denotes that individuals learn by being told or receiving knowledge.

Empiricism holds that truth corresponds to observable, reduction, verification, control, and bias-free science. It emphasizes mathematic formulas to explain phenomena and prefers simple dichotomies and classification of concepts. Additionally, everything can be reduced to a scientific formula with little room for interpretation (DiBartolo, 1998; Gortner & Schultz, 1988; Risjord, 2010).

Empiricism focuses on understanding the parts of the whole in an attempt to understand the whole. It strives to explain nature through testing of hypotheses and development of theories. Theories are made to describe, explain, and predict phenomena in nature and to provide understanding of relationships between phenomena. Concepts must be operationalized in the form of propositional statements, thereby making measurement possible. Instrumentation, reliability, and validity are stressed in empirical research methodologies. Once measurement is determined, it is possible to test theories through experimentation or observation, which results in verification or falsification (Cull-Wilby & Pepin, 1987; Suppe & Jacox, 1985).

Positivism is often equated with empiricism. Like empiricism, positivism supports mechanistic, reductionist principles, where the complex can be best understood in terms of its basic components. Logical positivism was the dominant empirical philosophy of science between the 1880s and 1950s. Logical positivists recognized only the logical and empirical bases of science and stressed that there is no room for metaphysics, understanding, or meaning within the realm of science (Polifroni, 2015; Risjord, 2010). Logical positivism maintained that science is value free, independent of the scientist, and obtained using objective methods. The goal of science is to explain, predict, and control. Theories are either true or false, subject to empirical observation, and capable of being reduced to existing scientific theories (Rutty, 1998).

Contemporary Empiricism/Postpositivism Positivism came under criticism in the 1960s when positivistic logic was deemed faulty (Rutty, 1998). An overreliance on strictly controlled experimentation in artificial settings produced results that indicated that much significant knowledge or information was missed. In recent years, scholars have determined that the positivist view of science is outdated and misleading in that it contributes to overfragmentation in knowledge and theory development (DiBartolo, 1998). It has been observed that positivistic analysis of theories is fundamentally defective due to insistence on analyzing the logically ideal, which results in findings that have little to do with reality. It was maintained that the context of discovery was artificial and that theories and explanations can be understood only within their discovery contexts (Suppe & Jacox, 1985). Also, scientific inquiry is inherently value laden, as even choosing what to investigate and/or what techniques to employ will reflect the values of the researcher.

The current generation of postpositivists accepts the subjective nature of inquiry but still supports rigor and objective study through quantitative research methods. Indeed, it has been observed that modern empiricists or postpositivists are concerned with explanation and prediction of complex phenomena, recognizing contextual variables (Powers & Knapp, 2011; Reed, 2008).

Nursing and Empiricism As an emerging discipline, nursing has followed established disciplines (e.g., physiology) and the medical model in stressing logical positivism. Early nurse scientists embraced the importance of objectivity, control, fact, and measurement of smaller and smaller parts. Based on this influence, acceptable methods for knowledge generation in nursing have stressed traditional, orthodox, and preferably experimental methods.

Although positivism continues to heavily influence nursing science, that viewpoint has been challenged in recent years (Risjord, 2010). Consequently, postpositivism has become one of the most accepted contemporary worldviews in nursing.




Perceived View (Human Science, Phenomenology, Constructivism, Historicism) In the late 1960s and early 1970s, several philosophers, including Kuhn, Feyerbend, and Toulmin, challenged the positivist view by arguing that the influence of history on science should be emphasized (Dahnke & Dreher, 2016). The perceived view of science, which may also be referred to as the interpretive view, includes phenomenology, constructivism, and historicism. The interpretive view recognizes that the perceptions of both the subject being studied and the researcher tend to de-emphasize reliance on strict control and experimentation in laboratory settings (Monti & Tingen, 1999).

The perceived view of science centers on descriptions that are derived from collectively lived experiences, interrelatedness, human interpretation, and learned reality, as opposed to artificially invented (i.e., laboratory- based) reality (Rutty, 1998). It is argued that the pursuit of knowledge and truth is naturally historical, contextual, and value laden. Thus, there is no single truth. Rather, knowledge is deemed true if it withstands practical tests of utility and reason (DiBartolo, 1998).

Phenomenology is the study of phenomena and emphasizes the appearance of things as opposed to the things themselves. In phenomenology, understanding is the goal of science, with the objective of recognizing the connection between one’s experience, values, and perspective. It maintains that each individual’s experience is unique, and there are many interpretations of reality. Inquiry begins with individuals and their experiences with phenomena. Perceptions, feelings, values, and the meanings that have come to be attached to things and events are the focus.

For social scientists, the constructivist approaches of the perceived view focus on understanding the actions of, and meaning to, individuals. What exists depends on what individuals perceive to exist. Knowledge is subjective and created by individuals. Thus, research methodology entails the investigation of the individual’s world. There is an emphasis on subjectivity, multiple truths, trends and patterns, discovery, description, and understanding.

Feminism and critical social theory may also be considered to be perceived view. These philosophical schools of thought recognize the influence of gender, culture, society, and shared history as being essential components of science (Riegel et al., 1992). Critical social theorists contend that reality is dynamic and shaped by social, political, cultural, economic, ethnic, and gender values (Streubert & Carpenter, 2011). Critical social theory and feminist theories will be described in more detail in Chapter 13.

Nursing and Phenomenology/Constructivism/Historicism Because they examine phenomena within context, phenomenology, as well as other perceived views of philosophy, are conducive to discovery and knowledge development inherent to nursing. Phenomenology is open, variable, and relativistic and based on human experience and personal interpretations. As such, it is an important, guiding paradigm for nursing practice theory and education (DiBartolo, 1998).

In nursing science, the dichotomy of philosophic thought between the received, empirical view of science and the perceived, interpretative view of science has persisted. This may have resulted, in part, because nursing draws heavily both from natural sciences (physiology, biology) and social sciences (psychology, sociology).

Postmodernism (Poststructuralism, Postcolonialism) Postmodernism began in Europe in the 1960s as a social movement centered on a philosophy that rejects the notion of a single “truth.” Although it recognizes the value of science and scientific methods, postmodernism allows for multiple meanings of reality and multiple ways of knowing and interpreting reality (Hood, 2014; Reed, 1995). In postmodernism, knowledge is viewed as uncertain, contextual, and relative. Knowledge development moves from emphasis on identifying a truth or fact in research to discovering practical significance and relevance of research findings (Reed, 1995).

Similar or related constructs and worldviews found in the nursing literature include “deconstruction,” “postcolonialism,” and, at times, feminist philosophies. In nursing, the postcolonial worldview can be connected to both feminism and critical theory, particularly when considering nursing’s historical reliance on medicine (Holmes, Roy, & Perron, 2008; McGibbon, Mulaudzi, Didham, Barton, & Sochan, 2014; Racine, 2009).

Postmodernism has loosened the notions of what counts as knowledge development that have persisted




among supporters of qualitative and quantitative research methods. Rather than focusing on a single research methodology, postmodernism promotes use of multiple methods for development of scientific understanding and incorporation of different ways to improve understanding of human nature (Hood, 2014; Meleis, 2012; Rodgers, 2015). Increasingly, in postmodernism, there is a consensus that synthesis of both research methods can be used at different times to serve different purposes (Hood, 2014; Meleis, 2012; Risjord, Dunbar, & Moloney, 2002).

Criticisms of postmodernism have been made and frequently relate to the perceived reluctance to address error in research. Taken to the extreme as Paley (2005) pointed out, when there is absence of strict control over methodology and interpretation of research, “Nobody can ever be wrong about anything” (p. 107). Chinn and Kramer (2015) echoed the concerns by acknowledging that knowledge development should never be “sloppy.” Indeed, although application of various methods in research is legitimate and may be advantageous, research must still be carried out carefully and rigorously.

Nursing and Postmodernism Postmodernism has been described as a dominant scientific theoretical paradigm in nursing in the late 20th century (Meleis, 2012). As the discipline matures, there has been recognition of the pluralistic nature of nursing and an enhanced understanding that the goal of research is to provide an integrative basis for nursing care (Walker & Avant, 2011).

In terms of scientific methodology, the attention is increasingly on combining multiple methods within a single research project (Chinn & Kramer, 2015). Postmodernism has helped dislodged the authority of a single research paradigm in nursing science by emphasizing the blending or integration of qualitative and quantitative research into a holistic, dynamic model to improve nursing practice. Table 1-3 compares the dominant philosophical views of science in nursing.

Table 1-3 Comparison of the Received, Perceived, and Postmodern Views of Science

Received View of Science— Hard Sciences

Perceived View of Science—Soft Sciences

Postmodernism, Poststructuralism, and Postcolonialism

Empiricism/positivism/logical positivism

Historicism/phenomenology Macroanalysis

Reality/truth/facts considered acontextual (objective)

Reality/truth/facts considered in context (subjective)

Contextual meaning; narration

Deductive Inductive Contextual, political, and structural analysis

Reality/truth/facts considered ahistorical

Reality/truth/facts considered with regard to history

Reality/truth/facts considered with regard to history

Prediction and control Description and understanding Metanarrative analysis One truth Multiple truths Different views Validation and replication Trends and patterns Uncovering opposing views Reductionism Constructivism/holism Macrorelationship;

microstructures Quantitative research Qualitative research methods Methodologic pluralism methods

Sources: Meleis (2012); Moody (1990).

Nursing Philosophy, Nursing Science, and Philosophy of Science in Nursing The terms nursing philosophy, nursing science, and philosophy of science in nursing are sometimes used interchangeably. The differences, however, in the general meaning of these concepts are important to





Nursing Philosophy Nursing philosophy has been described as “a statement of foundational and universal assumptions, beliefs and principles about the nature of knowledge and thought (epistemology) and about the nature of the entities represented in the metaparadigm (i.e., nursing practice and human health processes [ontology])” (Reed, 1995, p. 76). Nursing philosophy, then, refers to the belief system or worldview of the profession and provides perspectives for practice, scholarship, and research.

No single dominant philosophy has prevailed in the discipline of nursing. Many nursing scholars and nursing theorists have written extensively in an attempt to identify the overriding belief system, but to date, none has been universally successful. Most would agree then that nursing is increasingly recognized as a “multiparadigm discipline” (Powers & Knapp, 2011, p. 129), in which using multiple perspectives or worldviews in a “unified” way is valuable and even necessary for knowledge development (Giuliano, Tyer- Viola, & Lopez, 2005).

Nursing Science Parse (2016) defined nursing science as “the substantive, discipline-specific knowledge that focuses on the human-universe-health process articulated in the nursing frameworks and theories” (p. 101). To develop and apply the discipline-specific knowledge, nursing science recognizes the relationships of human responses in health and illness and addresses biologic, behavioral, social, and cultural domains. The goal of nursing science is to represent the nature of nursing—to understand it, to explain it, and to use it for the benefit of humankind. It is nursing science that gives direction to the future generation of substantive nursing knowledge, and it is nursing science that provides the knowledge for all aspects of nursing (Holzemer, 2007; Parse, 2016).

Philosophy of Science in Nursing Philosophy of science in nursing helps to establish the meaning of science through an understanding and examination of nursing concepts, theories, laws, and aims as they relate to nursing practice. It seeks to understand truth; to describe nursing; to examine prediction and causality; to critically relate theories, models, and scientific systems; and to explore determinism and free will (Nyatanga, 2005; Polifroni, 2015).

Knowledge Development and Nursing Science Development of nursing knowledge reflects the interface between nursing science and research. The ultimate purpose of knowledge development is to improve nursing practice. Approaches to knowledge development have three facets: ontology, epistemology, and methodology. Ontology refers to the study of being: what is or what exists. Epistemology refers to the study of knowledge or ways of knowing. Methodology is the means of acquiring knowledge (Powers & Knapp, 2011). The following sections discuss nursing epistemology and issues related to methods of acquiring knowledge.

Epistemology Epistemology is the study of the theory of knowledge. Epistemologic questions include: What do we know? What is the extent of our knowledge? How do we decide whether we know? and What are the criteria of knowledge? (Schultz & Meleis, 1988).

According to Streubert and Carpenter (2011), it is important to understand the way in which nursing knowledge develops to provide a context in which to judge the appropriateness of nursing knowledge and methods that nurses use to develop that knowledge. This in turn will refocus methods for gaining knowledge as well as establishing the legitimacy or quality of the knowledge gained.

Ways of Knowing In epistemology, there are several basic types of knowledge. These include the following:

Empirics—the scientific form of knowing. Empirical knowledge comes from observation, testing, and




replication. Personal knowledge—a priori knowledge. Personal knowledge pertains to knowledge gained from

thought alone. Intuitive knowledge—includes feelings and hunches. Intuitive knowledge is not guessing but relies on

nonconscious pattern recognition and experience. Somatic knowledge—knowledge of the body in relation to physical movement. Somatic knowledge

includes experiential use of muscles and balance to perform a physical task. Metaphysical (spiritual) knowledge—seeking the presence of a higher power. Aspects of spiritual

knowing include magic, miracles, psychokinesis, extrasensory perception, and near-death experiences. Esthetics—knowledge related to beauty, harmony, and expression. Esthetic knowledge incorporates art,

creativity, and values. Moral or ethical knowledge—knowledge of what is right and wrong. Values and social and cultural

norms of behavior are components of ethical knowledge.

Nursing Epistemology Nursing epistemology has been defined as “the study of the origins of nursing knowledge, its structure and methods, the patterns of knowing of its members, and the criteria for validating its knowledge claims” (Schultz & Meleis, 1988, p. 217). Like most disciplines, nursing has both scientific knowledge and knowledge that can be termed conventional wisdom (knowledge that has not been empirically tested).

Traditionally, only what stands the test of repeated measures constitutes truth or knowledge. Classical scientific processes (i.e., experimentation), however, are not suitable for creating and describing all types of knowledge. Social sciences, behavioral sciences, and the arts rely on other methods to establish knowledge. Because it has characteristics of social and behavioral sciences, as well as biologic sciences, nursing must rely on multiple ways of knowing.

In a classic work, Carper (1978) identified four fundamental patterns for nursing knowledge: (1) empirics —the science of nursing, (2) esthetics—the art of nursing, (3) personal knowledge in nursing, and (4) ethics— moral knowledge in nursing.

Empirical knowledge is objective, abstract, generally quantifiable, exemplary, discursively formulated, and verifiable. When verified through repeated testing over time, it is formulated into scientific generalizations, laws, theories, and principles that explain and predict (Carper, 1978, 1992). It draws on traditional ideas that can be verified through observation and proved by hypothesis testing.

Empirical knowledge tends to be the most emphasized way of knowing in nursing because there is a need to know how knowledge can be organized into laws and theories for the purpose of describing, explaining, and predicting phenomena of concern to nurses. Most theory development and research efforts are engaged in seeking and generating explanations that are systematic and controllable by factual evidence (Carper, 1978, 1992).

Esthetic knowledge is expressive, subjective, unique, and experiential rather than formal or descriptive. Esthetics includes sensing the meaning of a moment. It is evident through actions, conduct, attitudes, and interactions of the nurse in response to another. It is not expressed in language (Carper, 1978).

Esthetic knowledge relies on perception. It is creative and incorporates empathy and understanding. It is interpretive, contextual, intuitive, and subjective and requires synthesis rather than analysis. Furthermore, esthetics goes beyond what is explained by principles and creates values and meaning to account for variables that cannot be quantitatively formulated (Carper, 1978, 1992).

Personal knowledge refers to the way in which nurses view themselves and the client. Personal knowledge is subjective and promotes wholeness and integrity in personal encounters. Engagement, rather than detachment, is a component of personal knowledge.

Personal knowledge incorporates experience, knowing, encountering, and actualizing the self within the practice. Personal maturity and freedom are components of personal knowledge, which may include spiritual and metaphysical forms of knowing. Because personal knowledge is difficult to express linguistically, it is largely expressed in personality (Carper, 1978, 1992).

Ethics refers to the moral code for nursing and is based on obligation to service and respect for human life. Ethical knowledge occurs as moral dilemmas arise in situations of ambiguity and uncertainty and when




consequences are difficult to predict. Ethical knowledge requires rational and deliberate examination and evaluation of what is good, valuable, and desirable as goals, motives, or characteristics (Carper, 1978, 1992). Ethics must address conflicting norms, interests, and principles and provide insight into areas that cannot be tested.

Fawcett, Watson, Neuman, Walkers, and Fitzpatrick (2001) stress that integration of all patterns of knowing is essential for professional nursing practice and that no one pattern should be used in isolation from others. Indeed, they are interrelated and interdependent because there are multiple points of contact between and among them (Carper, 1992). Thus, nurses should view nursing practice from a broadened perspective that places value on ways of knowing beyond the empirical (Silva, Sorrell, & Sorrell, 1995). Table 1-4 summarizes selected characteristics of Carper’s patterns of knowing in nursing.

Table 1-4 Characteristics of Carper’s Patterns of Knowing in Nursing Pattern of Knowing

Relationship to Nursing

Source or Creation

Source of Validation

Method of Expression

Purpose or Outcome

Empirics Science of nursing Direct or indirect observation and measurement

Replication Facts, models, scientific principles, laws statements, theories, descriptions

Description, explanation, prediction

Esthetics Art of nursing Creation of value and meaning, synthesis of abstract and concrete

Appreciation; experience; inspiration; perception of balance, rhythm, proportion, and unity

Appreciation; empathy; esthetic criticism; engaging, intuiting, and envisioning

Move beyond what can be explained, quantitatively formulated, understanding, balance

Personal knowledge Therapeutic use of self

Engagement, opening, centering, actualizing self

Response, reflection, experience

Empathy, active participation

Promote wholeness and integrity in personal encounters

Ethics Moral component of nursing

Values clarification, rational and deliberate reasoning, obligation, advocating

Dialogue, justification, universal generalizability

Principles, codes, ethical theories

Evaluation of what is good, valuable, and desirable

Sources: Carper (1978, 1992); Chinn and Kramer (2015).

Other Views of Patterns of Knowledge in Nursing Although Carper’s work is considered classic, it is not without critics. Schultz and Meleis (1988) observed that Carper’s work did not incorporate practical knowledge into the ways of knowing in nursing. Because of this and other concerns, they described three patterns of knowledge in nursing: clinical, conceptual, and empirical.

Clinical knowledge refers to the individual nurse’s personal knowledge. It results from using multiple ways of knowing while solving problems during client care provision. Clinical knowledge is manifested in the acts of practicing nurses and results from combining personal knowledge and empirical knowledge. It may also involve intuitive and subjective knowing. Clinical knowledge is communicated retrospectively through publication in journals (Schultz & Meleis, 1988).

Conceptual knowledge is abstracted and generalized beyond personal experience. It explicates patterns revealed in multiple client experiences, which occur in multiple situations, and articulates them as models or theories. In conceptual knowledge, concepts are drafted and relational statements are formulated. Propositional statements are supported by empirical or anecdotal evidence or defended by logical reasoning.

Conceptual knowledge uses knowledge from nursing and other disciplines. It incorporates curiosity, imagination, persistence, and commitment in the accumulation of facts and reliable generalizations that pertain to the discipline of nursing. Conceptual knowledge is communicated in propositional statements (Schultz & Meleis, 1988).

Empirical knowledge results from experimental, historical, or phenomenologic research and is used to justify actions and procedures in practice. The credibility of empirical knowledge rests on the degree to which




the researcher has followed procedures accepted by the community of researchers and on the logical, unbiased derivation of conclusions from the evidence. Empirical knowledge is evaluated through systematic review and critique of published research and conference presentations (Schultz & Meleis, 1988).

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