Nursing theory – history and modernity

June 3, 2024
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Nursing theories: history and modernity. General characteristics. Approaches to healthcare and features of nursing models by D. Jonson, F.Abdella, D.Orlando, E.Videnbach, I. King, H. Peplau, L. Hall, D. Orem. Comparative characteristics and features of nursing models by M. Rogers, S. Roy, B. Newman, D.Watson, R. Parsi, M.Leininger, E. Boikin, S. Shoenhofer.

 

This chapter explores the theoretical foundation on which the knowledge base of the nursing profession has been and is being built. Nursing theory provides a perspective from which to define the what of nursing, to describe the who of nursing (who is the client) and when nursing is needed, and to identify the boundaries and goals of nursing’s therapeutic activities. Theory is fundamental to effective nursing practice and research. The professionalization of nursing has been and is being brought about through the development and use of nursing theory.

This chapter first addresses basic ideas about the meaning of nursing theory and its relevance to professional nursing. Issues related to the purpose, use, and diversity of nursing theories are discussed. It then presents a broad overview of selected nursing theories. The major ideas of selected nursing theories are explained and examples of their use iursing situations are provided.

 

COMPONENTS OF THE THEORETICAL FOUNDATION The basic elements that structure a nursing theory are concepts and propositions. In a theory, propositions represent how concepts affect each other.

 

What Is a Concept? A concept is the basic building block of a theory. A concept is a vehicle of thought. According to Chinn and Kramer (1995, p. 78), the term concept refers to a “complex mental formulation of . . . [our] perceptions of the world.” A concept labels or names a phenomenon, an observable fact that can be perceived through the senses and explained. A concept assists us in formulating a mental image about an object or situation. Concepts help us to name things and occurrences in the world around us and assist us in communicating with each other about the world. Independence, self-care, and caring are just a few examples of concepts frequently encountered in health care. Theories are formulated by linking concepts together. A conceptual framework is a structure that links global concepts together and represents the unified whole of a larger reality. The specifics about phenomena within the global whole are better explained by theory.

By its nature, a concept is a socially constructed label that may represent more than a single phenomenon. For example, when you hear the word chair, a mental image that probably comes to mind is an item of furniture used for sitting. The word chair could represent many different kinds of furniture for sitting, such as a desk chair, a high chair, or an easy chair. Further, the word chair could also represent the leader of a committee or the head of a corporation. The meaning of the word chair depends on the context in which it is used.

In health care, the concept of wandering may be represented by words such as aimless and random movement, disorganized thought processes, and conversation that is difficult to follow. To be useful, the multiple meanings that often underlie a concept must be thoroughly understood and clearly defined within the context in which it is used.

It is important to remember that the same concept may be used differently in various theories. For example, one nursing theory may use the concept of environment to mean all that surrounds a human being (the external environment), whereas another theory may use this concept to mean the external environment and all the biological and psychological components of the person (the internal environment).

 

What Is a Proposition? A proposition (another structural element of a theory) is a statement that proposes a relationship between concepts. An example of a nonnursing proposition might be the statement “people seem to be happier in the springtime.” This proposition establishes a relationship between the concept of happiness and the time of the year. A nursing propositional statement linking the concept of helplessness and the concept of loss might be stated as “multiple and rapid losses predispose one to feelings of helplessness.” Propositional statements in a theory represent the theorist’s particular view of which concepts fit together and, in most theories, establish how concepts affect one another.

 

What Is a Theory? A theory is a set of concepts and propositions that provide an orderly way to view phenomena. In the scientific literature, theory may be defined in many different ways, with subtle nuances specific to the particular author’s viewpoint. These various explanations share a commootion of the purpose of the theory, that being description, explanation, and prediction. “The purpose of a theory in scientific disciplines is to guide research to enhance the science by supporting existing knowledge or generating new knowledge” (Parse, 1987 p. 3). A theory not only helps us to organize our thoughts and ideas, but it may also help direct us in what to do and when and how to do it.

The use of the term theory is not restricted to the scientific world, however. It is often used in daily life and conversation. For example, when telling a friend about a mystery novel you are reading, you may have said, “I have a theory about who committed the crime.” Or you may have heard a Little League coach saying to his players, “I have a theory about how to improve our performance.” The way in which this term is used in these statements is a useful way to think about the meaning of theory.

 

USE OF THEORIES FROM OTHER DISCIPLINES In addition to using theories specifically constructed to describe, explain, and predict the phenomena of concern to nursing, the nursing profession has long used theories from other disciplines. A discipline is a field of study. Theories from biological, physical, and behavioral sciences are commonly used in the practice of nursing. For example, nonnursing theories such as Maslow’s Hierarchy of Basic Human Needs, Erikson’s Theory of Human Development, and Selye’s General Adaptation Syndrome have been and continue to be useful iursing practice.

These nonnursing theories are often incorporated into nursing practice together with specific nursing theories. When used in conjunction with a nursing theory, a nonnursing theory is transformed by the unique approach of the nursing perspective. This perspective provides the specific framework or viewpoint within which to use theories and knowledge from other disciplines.

 

IMPORTANCE OF NURSING THEORIES Why do we have nursing theories? In the early part of nursing’s history, knowledge was extremely limited and almost entirely task oriented. The knowledge explosion that occurred in health care in the 1950s produced the need to systematically organize the tremendous volume of new information being generated. From the very beginnings of nursing education, there was a need to categorize knowledge and to analyze client care situations in order to communicate in coherent and meaningful ways.

The literature about the relationship between theory and nursing care yields many interpretations in terms of the role each component plays in the health care environment. According to Barnum (1994, p. 1), “a theory is a construct that accounts for or organizes some phenomenon.” Chinn and Kramer (1995, p. 20) viewed theory as a “systematic abstraction of reality that serves some purpose.” Meleis (1991, p. 13) stated that a theory is “a symbolic depiction of aspects of reality that are discovered or invented for the purpose of describing, explaining, predicting, or prescribing responses, events, situations, conditions, or relationships.” Similarly, Parse (1987, p. 2) defined a theory as a “set of interrelated concepts at the same level of discourse that explains, describes, or makes predictions about the phenomena of the discipline.”

Nursing theories provide a framework for thought in which to examine situations. As new situations are encountered, this framework provides a structure for organization, analysis, and decision making. In addition, nursing theories provide a structure for communicating with other nurses and with other members of the health care team. Nursing theories assist the discipline of nursing in clarifying beliefs, values, and goals, and they help to define the unique contribution of nursing in the care of clients. When the focus of nursing’s contribution is clear, then greater professional autonomy and, ultimately, control of certain aspects of practice are achieved. In the broadest sense, nursing theory is necessary for the continued development and evolution of the discipline of nursing. Because the world of health care changes virtually on a daily basis, nursing needs to continue to expand its knowledge base to proactively respond to changes in societal needs. Knowledge for nursing practice is developed through nursing research that, in turn, is used to either test existing theories or generate new theories. Nursing research is the systematic application of formalized methods for generating valid and dependable information about the phenomena of concern to the discipline of nursing (Chinn & Kramer, 1995). The relationship betweeursing practice, theory, and research is depicted in Figure 2-1.

 

 

  These processes are so closely related that to consider one aspect without considering the other two aspects would be the same as seeing only a part of the whole. Nursing practice is the focal point of the relationship between practice, theory, and research. It provides the raw material for the ideas that are systematically developed and organized in the form of nursing theory. The ideas proposed by nursing theory must be tested and validated through nursing research. In turn, new knowledge that results from nursing research is used to transform and inform nursing practice. Alternatively, nursing practice generates questions that serve as the basis for nursing research. Nursing research, then, influences the development of nursing theory that, in turn, transforms nursing practice. Levine stated that “exploring a variety of nursing theories ought to provide nurses with new insights into patient care, opening nursing options otherwise hidden, and stimulating innovative interventions” (1995, p. 13). Theoretical thinking enhances and strengthens the nurse’s role and helps one to actually think nursing. As nurses learn more about specific nursing theories, it may be discovered that they can relate more to one theory than another or that they can appreciate the ideas contained in several different theories. Nurses may use a specific nursing theory to help guide their practice or may choose a more eclectic approach and adopt ideas from several theories. Both of these approaches are valid. Furthermore, nurses may find some theories more appropriate for certain situations. In that case, one theory can be used with a client in a home health care setting, whereas another theory may be more applicable to a client in an acute care environment. Regardless of the approach chosen, nurses will recognize the value and usefulness of nursing theory as a tool for effective nursing practice. SCOPE OF THEORIES “Although theories address relatively specific and concrete phenomena, they vary in scope. Scope refers to the relative level of substantive specificity of a theory and the concreteness of its concepts and propositions” (Fawcett, 1993, p. 19). Essentially, three different categories relate to the scope of theories: grand theories, middle-range theories, and micro-range theories. This classification is applicable to both nursing and nonnursing theories. Grand Theory A grand theory is composed of concepts representing global and extremely complex phenomena. It is the broadest in scope, represents the most abstract level of development, and addresses the broad phenomena of concern within the discipline. Typically, a grand theory is not intended to provide guidance for the formation of specific nursing interventions, but rather provides an overall framework for structuring broad, abstract ideas (Fawcett, 1993). An example of a grand theory is Orem’s Self-Care Deficit Theory of Nursing. Middle-Range Theory A theory that addresses more concrete and more narrowly defined phenomena than a grand theory is known as a middle-range theory. Descriptions, explanations, and predictions put forth in a middle-range theory are intended to answer questions about nursing phenomena, yet they do not cover the full range of phenomena of concern to the discipline. A middle-range theory provides a perspective from which to view complex situations and a direction for interventions (Fawcett, 1993). An example of a middle-range theory is Peplau’s Theory of Interpersonal Relations. Micro-Range Theory A micro-range theory is the most concrete and narrow in scope. A micro-range theory explains a specific phenomenon of concern to the discipline (Fawcett, 1993), such as the effect of social supports on grieving and would establish nursing care guidelines to address the problem. THE EVOLUTION OF NURSING THEORY The work of early nursing theorists in the 1950s focused on the tasks of nursing practice from a somewhat mechanistic viewpoint. Because of this emphasis, much of the art of nursing—the value of caring, the relationship aspects of nursing, and the esthetics of practice—was diminished. During the decades of the 1960s, 1970s, and 1980s, many nursing theorists struggled with making nursing practice, theory, and research fit into the then prevailing view of science. Table 2-1 provides a chronological summary of the development of nursing’s theory base through the contributions of noted theorists and influential leaders iursing. Reflecting changes in global awareness of health care needs, several contemporary nursing theorists have projected a new perspective for nursing that truly unifies the notion of nursing as both an art and a science. Noted nursing theorists such as Leininger, Watson, Rogers, Parse, and Newman have been urging the discipline of nursing to embrace this new emerging view that is seen as more holistic, humanistic, client focused, and grounded in the notion of caring as the core of nursing. Since the early 1950s, many nursing theories have been systematically developed to help describe, explain, and predict the phenomena of concern to nursing. Each of these established theories provides a unique perspective and each is distinct and separate from other nursing theories in its particular view of nursing phenomena. An overview of several nursing theories is presented later in the chapter. KNOWLEDGE DEVELOPMENT IN NURSING The knowledge in a particular discipline can be arranged in a hierarchical structure that ranges from abstract to concrete. Theories represent the most concrete component of a discipline. Several theories that share a common view of the world can be grouped together to form a paradigm. A paradigm is a particular viewpoint or perspective. Each discipline has a defined metaparadigm, which is the most abstract component of knowledge and which can consist of more than one paradigm (Fawcett, 1989). A metaparadigm is the unifying force in a discipline that names the phenomena of concern to that discipline.

 

 

    The Metaparadigm of Nursing What is it that distinguishes nursing from any other discipline such as biology, sociology, or psychology? Each of these other disciplines—biology, sociology, and psychology—is concerned with specific aspects of the human being. “Each discipline singles out certain phenomena with which it will deal in a unique manner” (Fawcett, 1989, p. 5). The field of biology (the study of living organisms) has defined limits and boundaries that do not extend into psychology. Similarly, psychology (which is concerned with the behavior of individuals) does not extend its concerns into the domain of sociology, which has as its main focus the social behavior of human beings.

The broadly identified concerns of a discipline are defined in its metaparadigm. The metaparadigm concepts provide the boundaries and limitations of a discipline, identify the common viewpoint that all members of a discipline share, and help to focus the activities of the members of that discipline. Disciplines are distinguished from each other by differing metaparadigm concepts. Most metaparadigms consist of several major concepts.

Initial consensus on the metaparadigm concepts iursing was achieved in 1984. According to Fawcett (1984), the major concepts that provide structure to the domain of nursing are person, environment, health, and nursing. These metaparadigm elements name the overall areas of concern for the nursing discipline. Each nursing theory presents a slightly different view of the metaparadigm concepts. Refer to the section entitled “Selected Nursing Theories” for a discussion of how various theorists address and link the metaparadigm concepts.

Consider for a moment the practice of nursing by a school nurse, an emergency room nurse, and a psychiatric nurse. What is the unifying thread among these various nurses? Although each nurse’s practice is obviously different, they all consider their work as part of the profession of nursing because all share the same major concerns. Regardless of the setting or the type of client involved, each nurse is concerned with person, environment, health, and nursing. Nursing’s metaparadigm is shared by all nurses despite differences in their individual practices.

How is nursing’s metaparadigm different from that of other helping professions? The metaparadigm of medicine focuses on pathophysiology and the curing of disease. Nursing’s metaparadigm is broader and focuses on the person, health, and the environment. Consider a physician’s and a nurse’s view of a client who is newly diagnosed with diabetes. The physician is concerned with reducing the client’s abnormal blood glucose values to normal levels, if possible. The physician prescribes medications, an exercise regime, and nutritional counseling in an effort to control blood sugar levels. In dealing with the same client situation, the nurse is concerned with such issues as the client’s ability to cope with a chronic condition, the effect of the diagnosis on the client’s family, and teaching about the need for changes in the client’s daily living patterns. The nurse is concerned with the impact of the diagnosis on all aspects of the client’s life. Although both health care providers are viewing the same client situation, each has a different perspective or focus. Each discipline’s metaparadigm provides a viewpoint that leads to the development of knowledge as seen within that viewpoint.

Despite the fact that person, health, environment, and nursing are the generally accepted metaparadigm elements iursing, there is growing discontent with the limitation of these elements. As dialogue continues and as clarity emerges, the metaparadigm elements will change to reflect contemporary thought and practice.

One example of this evolution in the discipline of nursing is the inclusion of caring as a basic core concept, central to the practice of nursing. Nurse scholars have urged a reconsideration of the identified metaparadigm elements. Watson (1985, p. 35) stated that “care is the essence of nursing and the most central and unifying focus for nursing practice.” According to Watson (1990, p. 21), “human caring needs to be explicitly incorporated into nursing’s metaparadigm.”

 

 

   Paradigms in Nursing The metaparadigm of a discipline identifies common areas of concern. A paradigm is a particular way of viewing the phenomena of concern that have been delineated by the metaparadigm of the discipline. The term paradigm stems from the work of Kuhn (1970), who referred to a paradigm as “worldview” about the phenomena of concern in a discipline.

Two individuals with different paradigmatic views can look at precisely the same phenomenon and each will “see” or view the phenomenon differently. For example, consider the viewpoints of a mother and father who are watching their daughter at T-ball practice. The mother looks at her daughter and “sees” a graceful, yet somewhat shy child who has shown improvement in her ability to make new friends. On the other hand, the father “sees” a strong runner who needs help with batting drills. Each parent is looking at the same phenomenon (their daughter), but each is “seeing” the phenomenon from a completely different perspective. Each parent is operating from a different paradigm.

The prevailing paradigm in a discipline represents the dominant viewpoint of particular concepts. This viewpoint is supported by theories and research that for the time being adequately address the concerns of the discipline. By consensus, the community of scholars in a discipline accepts and agrees on a particular viewpoint or worldview. Wheew theories and research surface that challenge the prevailing paradigm, a new paradigm emerges to compete with the prevailing worldview. The competition between the paradigms results in what Kuhn (1970) refers to as a paradigm revolution. A paradigm revolution is the turmoil and conflict that occur in a discipline when a competing paradigm gains acceptance over the dominant paradigm. If the competing paradigm answers more questions and solves more problems for the discipline than the prevailing paradigm, then a paradigm shift occurs. A paradigm shift refers to the acceptance of the competing paradigm over the prevailing paradigm or a shifting away from one worldview toward another worldview. Again, by consensus the competing paradigm becomes the dominant paradigm and the process begins again (Kuhn, 1970).

The notion of paradigm revolution can be likened to the revolution that might occur in a country where the ruling government is overthrown by a competing group who proposed to have more and better solutions to the country’s problems. In this situation, power shifts from one ruling body to another. In another example, a paradigm shift occurred when people began to view the world as round rather than flat. Once it was agreed on by the community of scholars that the world was round (now the prevailing paradigm), all other views about the world also changed. Paradigms can be mutually exclusive. Members of a discipline cannot subscribe to two competing paradigms at the same time. One cannot believe at the same time that the world is flat and that the world is round.

Several nursing scholars have proposed that the discipline of nursing is in the midst of a paradigm revolution. The implication is that there are at least two paradigms in competition with each other. Although the scholarly literature iursing reflects the views of several authors who present and name different paradigms iursing, the work of Parse is highlighted here. According to Parse (1987), there are currently two paradigms iursing: the Totality Paradigm and the Simultaneity Paradigm (Figure 2-2).

Each of these paradigms is composed of various nursing theories that are similar in their worldview of the metaparadigm concepts. However, each theory, which is grouped within a particular paradigm, has different definitions of concepts and propositions that state how these concepts are related.

In the Totality Paradigm, the person, who is a combination of biological, psychological, social, and spiritual features, is in constant interaction with the environment to accomplish goals and maintain balance. “The goals of nursing in the totality paradigm focus on health promotion, care and cure of the sick, and prevention of illness. Those receiving nursing care are persons designated as ill by societal norms” (Parse, 1987, p. 32). Identification with the Totality Paradigm is understandable because it has been and is the prevailing paradigm iursing. Many of the nursing theories developed to date have a view of the discipline of nursing that fits the Totality Paradigm.

In the competing paradigm, the Simultaneity Paradigm, the person–environment interaction is viewed very differently. In the Simultaneity Paradigm, the person is seen as “more than and different from the sum of the parts, changing mutually and simultaneously with the environment . . . as a freely choosing being cocreating health through mutual interchange with the environment” (Parse, 1987, p. 4). “The goals of nursing in the simultaneity paradigm focus on the quality of life from the person’s perspective. Designation of illness by societal norms is not a significant factor. The authority and prime decision maker in regard to nursing is the persoot the nurse” (Parse, 1987, pp. 136–137).

Clearly, these two paradigms represent very different viewpoints. Each paradigm has several nursing theories that are congruent with the worldview proposed by that paradigm.

Debate, dialogue, discussion, theory development, and research continue within the discipline of nursing. Some nursing scholars argue about the structural elements of the discipline; some debate the value of competing paradigms; and some present alternative metaparadigm elements. Yet, with all the uncertainty that is created by these questions and alternative ideas, the ongoing dialogue is a healthy sign of the development of the nursing profession.

 

SELECTED NURSING THEORIES Although there are many nursing theories, frameworks, and models iursing, this chapter addresses only selected ones. The theories discussed have been selected because they represent the development of nursing’s scientific thought.

 

Florence Nightingale Nightingale did not develop a theory of nursing as theory is defined today, but rather she provided the nursing profession with the philosophical basis from which other theories have emerged and developed. Nightingale’s ideas about nursing have guided both theoretical thought and actual nursing practice throughout the history of moderursing.

Nightingale considered nursing similar to a religious calling to be answered only by women with an all-consuming and passionate response. She considered nursing to be both an art and a science and believed that nurses should be formally educated. Her writings did not focus on the nature of the person but did stress the importance of caring for the ill person rather than caring for the illness. In Nightingale’s view, the person was a passive recipient of care, and nursing’s primary focus was on the manipulation of the person’s environment to maintain or achieve a state of health.

Despite the fact that she did not believe in the germ theory, her experiences in the Crimean War magnified her interest in the principles of sanitation and the relationship between environment and health. A person’s health was the direct result of environmental influences, specifically cleanliness, light, pure air, pure water, and efficient drainage. Through manipulating the environment, nursing “aims to discover the laws of nature that would assist in putting the patient in the best possible condition so that nature can effect a cure” (Nightingale, 1859, p. 6). Nursing’s main focus was health, and health was closely related to nursing. Nursing was concerned with the healthy, as well as the sick (Nightingale, 1859).

Nightingale’s principles regarding environmenthealth– nursing were implemented in America at the turn of the 20th century. With the development of hospital- based schools of nursing, Nightingale’s principles of sanitation were used to clean up the rat-infested, dirty hospitals of the day. With the use of Nightingale’s ideas, hospitals became a place for people to recover rather than a place to die. When, for a variety of reasons, hospitals did not hire their owursing graduates, nurses applied Nightingale’s principles in the community in the development of public health nursing. The Henry Street Settlement founded by Lillian Wald is an excellent example of Nightingale’s theory in practice.

Private duty nursing and public health nursing remained the primary focus of nursing practice until World War II. At this time, there was a tremendous increase in scientific knowledge and technology affecting health care. As the practice of medicine became more scientifically based, more clients were cared for in hospital settings. Nursing practice likewise became centered in the hospital rather than the home. With this development, it became clear that nursing did not have an adequate theory base to organize new knowledge and guide nursing practice. Nursing began to further develop its knowledge base by incorporating the principles of Nightingale into moderursing theory.

 

Early Nursing Theories By its very nature, the development of nursing’s theoretical base has progressed in a methodical and systematic, albeit slow, fashion. Knowledge development is an ongoing process that is often influenced by driving forces outside the discipline of nursing. The early nurse theorists were not attempting to address the metaparadigm concepts because initial consensus on these had not yet been achieved. Rather, these theories were attempting to answer the question, “What is nursing?”

 

Hildegard Peplau Hildegard Peplau, a psychiatric nurse, combined her research and experience in the development of a theory of psychodynamic nursing, published in Interpersonal Relations in Nursing (1952). Drawing from her own knowledge and that from other disciplines, Peplau defined the concepts and stages involved in the development of the nurse-client relationship. From that relationship, she identified the roles of the nurse as stranger, resource person, teacher, leader, surrogate, and counselor. Peplau developed a middle-range theory with a focus on both nursing and the person and did not incorporate all aspects of the metaparadigm into her theory. Although other theories may view the nurseclient relationship differently, the primacy of this relationship iursing has remained.

 

Virginia Henderson Virginia Henderson’s definition of nursing, considered to be a classic, first appeared in 1955. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he has the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15) Together with Bertha Harmer, Henderson attempted to identify those basic humaeeds viewed as the basis of nursing care. These needs include the need to maintain physiologic balance, to adjust to the environment, to communicate and participate in social interaction, and to worship according to one’s faith. Her 14 basic needs were published in the Textbook of the Principles and Practice of Nursing, one of the first nursing textbooks. Henderson viewed the nursing role as helping the client from dependence to independence. As an early nursing theorist, Henderson did not intend to develop a theory of nursing, but rather she attempted to define the unique focus of nursing. Henderson’s emphasis on basic humaeeds as the central focus of nursing practice has led to further theory development regarding the needs of the person and how nursing can assist in meeting those needs.

 

Faye Abdellah Faye Abdellah, acknowledging the influence of Henderson, expanded Henderson’s 14 needs into 21 problems that she believed would serve as a knowledge base for nursing. Throughout her career, she strongly supported the idea that nursing research would be the key factor in helping nursing to emerge as a true profession. The research that was done regarding these commoeeds/problems has served as a foundation for the development of what we now know as nursing diagnoses.

 

Joyce Travelbee Joyce Travelbee, an educator and psychiatric nurse, was influenced by the philosophy of existentialism, a movement that is centered on individual existence in an incomprehensible world and the role that free will plays in it, and searched to find meaning in life’s experiences. She extensively developed the ideas of sympathy, empathy, and rapport in which the nurse could begin to comprehend and relate to the uniqueness of others. Her work focused on the human-to-human relationship and on finding meaning in experiences such as pain, illness, and distress. Travelbee based most of her theory on her own experiences and readings and first published her work in Interpersonal Aspects of Nursing in 1966.

 

Josephine Paterson and Loretta Zderad The work of Josephine Paterson and Loretta Zderad was similar to that of Travelbee in that it emphasized the humanistic and existential basis of nursing practice. According to Paterson and Zderad, theory developed from the practice of nursing. Although the models proposed by Travelbee and Paterson and Zderad had some impact at the time of their initial introduction, they did not gain wide popularity and application iursing. The work of Travelbee and Paterson and Zderad most appropriately fit the Simultaneity Paradigm. Current theorists—such as Watson, Rogers, Parse, Fitzpatrick, and Newman—who have an existential orientation, are rediscovering the merits of Travelbee and Paterson and Zderad. centered in the hospital rather than the home. With this development, it became clear that nursing did not have an adequate theory base to organize new knowledge and guide nursing practice. Nursing began to further develop its knowledge base by incorporating the principles of Nightingale into moderursing theory.

 

Early Nursing Theories By its very nature, the development of nursing’s theoretical base has progressed in a methodical and systematic, albeit slow, fashion. Knowledge development is an ongoing process that is often influenced by driving forces outside the discipline of nursing. The early nurse theorists were not attempting to address the metaparadigm concepts because initial consensus on these had not yet been achieved. Rather, these theories were attempting to answer the question, “What is nursing?”

 

Hildegard Peplau Hildegard Peplau, a psychiatric nurse, combined her research and experience in the development of a theory of psychodynamic nursing, published in Interpersonal Relations in Nursing (1952). Drawing from her own knowledge and that from other disciplines, Peplau defined the concepts and stages involved in the development of the nurse-client relationship. From that relationship, she identified the roles of the nurse as stranger, resource person, teacher, leader, surrogate, and counselor. Peplau developed a middle-range theory with a focus on both nursing and the person and did not incorporate all aspects of the metaparadigm into her theory. Although other theories may view the nurseclient relationship differently, the primacy of this relationship iursing has remained.

 

Virginia Henderson Virginia Henderson’s definition of nursing, considered to be a classic, first appeared in 1955. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he has the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15) Together with Bertha Harmer, Henderson attempted to identify those basic humaeeds viewed as the basis of nursing care. These needs include the need to maintain physiologic balance, to adjust to the environment, to communicate and participate in social interaction, and to worship according to one’s faith.

Her 14 basic needs were published in the Textbook of the Principles and Practice of Nursing, one of the first nursing textbooks. Henderson viewed the nursing role as helping the client from dependence to independence. As an early nursing theorist, Henderson did not intend to develop a theory of nursing, but rather she attempted to define the unique focus of nursing. Henderson’s emphasis on basic humaeeds as the central focus of nursing practice has led to further theory development regarding the needs of the person and how nursing can assist in meeting those needs.

 

Faye Abdellah Faye Abdellah, acknowledging the influence of Henderson, expanded Henderson’s 14 needs into 21 problems that she believed would serve as a knowledge base for nursing. Throughout her career, she strongly supported the idea that nursing research would be the key factor in helping nursing to emerge as a true profession. The research that was done regarding these commoeeds/problems has served as a foundation for the development of what we now know as nursing diagnoses.

 

Joyce Travelbee Joyce Travelbee, an educator and psychiatric nurse, was influenced by the philosophy of existentialism, a movement that is centered on individual existence in an incomprehensible world and the role that free will plays in it, and searched to find meaning in life’s experiences. She extensively developed the ideas of sympathy, empathy, and rapport in which the nurse could begin to comprehend and relate to the uniqueness of others. Her work focused on the human-to-human relationship and on finding meaning in experiences such as pain, illness, and distress. Travelbee based most of her theory on her own experiences and readings and first published her work in Interpersonal Aspects of Nursing in 1966.

 

Josephine Paterson and Loretta Zderad The work of Josephine Paterson and Loretta Zderad was similar to that of Travelbee in that it emphasized the humanistic and existential basis of nursing practice. According to Paterson and Zderad, theory developed from the practice of nursing. Although the models proposed by Travelbee and Paterson and Zderad had some impact at the time of their initial introduction, they did not gain wide popularity and application iursing. The work of Travelbee and Paterson and Zderad most appropriately fit the Simultaneity Paradigm. Current theorists—such as Watson, Rogers, Parse, Fitzpatrick, and Newman—who have an existential orientation, are rediscovering the merits of Travelbee and Paterson and Zderad. child is a unique individual and is a member of a social group, the family. Conservation of social integrity would be accomplished through maintaining interest in and monitoring the family dynamics. Levine is pragmatic, and the conservation principles can be applied to most nursing situations. Her theory is appropriate for use in situations in which the nurse has had a long-term relationship with the client, yet is also useful for short-term relationships. Levine’s theory is congruent with the characteristics of the Totality Paradigm.

 

Dorothea Orem In attempting to plan a nursing curriculum for licensed practical nurses, Dorothea Orem was searching for a pragmatic framework to organize nursing knowledge. She focused on the questions “What is nursing?” and “When do people need nursing care?” and from this she derived that people need nursing when they are unable to care for themselves. In 1971, she presented the Self- Care Deficit Theory of Nursing (S-CDTN) in the book Nursing Concepts of Practice and has continually revised and updated her theory. Orem’s theory incorporates the medical model rather than rejects it, centers on the individual, is problem oriented, and is easily adaptable in varied clinical situations. These attributes create its wide appeal for application iursing practice. Meleis (1991, p. 401) stated that it has “the widest circle of all theories in practice.” As a grand theory, the S-CDTN has three interconnecting theories: Theory of Self- Care, Theory of Self-Care Deficit, and Theory of Nursing Systems. Each one is discussed below.

 

Theory of Self-Care According to this theory, self-care is a learned behavior and a deliberate action in response to a need. Orem identified three categories of self-care requisites: universal self-care requisites, developmental self-care requisites, and health-deviation self-care requisites. Universal self-care requisites are common to all human beings and include both physiological and social interactioeeds. Developmental self-care requisites are the needs that arise as the individual grows and develops. Health-deviation self-care requisites result from the needs produced by disease or illness states. Self-care is performed by mature and maturing individuals. When someone else must perform a self-care need, it is termed dependent care.

 

Theory of Self-Care Deficit This theory purports that nursing care is needed when people are affected by limitations that do not allow them to meet their self-care needs. The relationship between the nurse and the client is established when a self-care deficit is present. Self-care deficits, not medical diagnosis, determine the need for nursing care. According to Orem, the only legitimate need for nursing care is when a self-care deficit exists.

 

Theory of Nursing Systems This is the unifying theory that “subsumes the theory of self-care deficit which subsumes the theory of self-care” (Orem, 1991, p. 66). The Theory of Nursing Systems attempts to answer the question “What do nurses do?” This was the original question that prompted the development of Orem’s theory.

The nurse determines whether or not there is a legitimate need for nursing care. Is a person able to meet self-care needs? Does a deficit exist? If a deficit exists, then the nurse plans care that identifies what is to be done by whom: the nurse, the client, or other (family or significant other). Collectively, the actions of all these people are called the nursing system. Orem identified three types of nursing systems: wholly compensatory, partly compensatory, and supportive-educative.

In the wholly compensatory nursing system, the nurse supports and protects the client, compensates for the client’s inability to care for self, and attempts to provide care for the client. The nurse would use the wholly compensatory nursing system when caring for a newborn or with a client in a postanesthesia care unit who is recovering from surgery. Both of these clients are completely unable to provide self-care.

In the partly compensatory nursing system, both the nurse and client perform care measures. For example, the nurse can assist the postoperative client to ambulate. The nurse may bring in a meal tray for the client who is able to feed self. The nurse compensates for what the client cannot do. The client is able to perform selected self-care activities but also accepts care performed by the nurse for needs the client is unable to meet independently.

In the supportive-educative nursing system, the nurse’s actions are to help clients develop their own self-care abilities through knowledge, support, and encouragement. Clients must learn and perform their own self-care activities. The supportive-educative nursing system is being used when a nurse guides a new mother to breastfeed her baby. Counseling a psychiatric client on more adaptive coping strategies is another example of the use of the supportive-educative nursing system.

Orem focused primarily on the needs of the person and the action of nursing to meet those needs. Lesser emphasis was given to defining health and the environment. The S-CDTN is useful in determining the kind of nursing assistance needed by the client and, therefore, has merit as a theory that guides nursing practice. Orem’s theory is consistent with the characteristics of the Totality Paradigm.

 

Sister Callista Roy Sister Callista Roy combined general systems theory with adaptation theory to produce the Roy Adaptation Model. Roy was greatly influenced by her teacher and mentor, Dorothy E. Johnson, a nursing theorist who developed the Behavioral Systems Model. Roy first published her model in the 1970s and has continued to further refine and develop the theory. As a contemporary theorist, Roy worked with the metaparadigm concepts to define and relate these concepts.

Roy defines a person as “an adaptive system . . . a whole comprised of parts that function as a unity for some purpose” (Andrews & Roy, 1991, p. 4). The person is a biopsychosocial being in constant interaction with a changing internal and external environment. Nursing attempts to alter the environment when the person is not adapting well or has ineffective coping responses.

“The world around and within (the person as an adaptive system) is called the environment” and “includes all conditions, circumstances, and influences that surround and affect the development and behavior of the person” (Andrews & Roy, 1991, p. 18). The environmental stimuli can be classified as either focal, residual, or contextual. Focal stimuli are those that are immediately present in the person’s environment. Focal stimuli are the objects or events that most attract one’s attention. Most stimuli never become focal. Residual stimuli are those attitudes that are developed during previous experiences in one’s life whose effects on the current situation are unclear. Contextual stimuli are “all the other stimuli present in the situation that contribute to the effect of the focal stimulus” (Andrews & Roy, 1991, p. 9). Because stimuli are constantly changing, that which is a focal stimulus one minute can become a residual stimulus the next.

According to the Roy Adaptation Model, the person has coping mechanisms that are broadly categorized in either the regulator or cognator subsystem. Adaptation is accomplished through these coping mechanisms that are innate, “genetically determined . . . and automatic processes” (Andrews & Roy, 1991, p. 13). The regulator subsystem functions through the autonomic nervous system, which “responds automatically through neural, chemical, and endocrine coping processes” (Andrews & Roy, 1991, p. 14). The cognator subsystem enables the person to respond to stimuli through processing stimuli, learning, judgment, and emotion. All input into the system (the person) is channeled through the regulator and cognator subsystems. If the regulator or cognator subsystem fails, there is ineffective adaptation.

Neither the regulator nor the cognator subsystem can be observed directly. Only the responses that each produces are observable. Roy categorized these responses into four adaptive modes: physiologic, self-concept, role function, and interdependence. The physiologic mode allows individuals to respond physiologically to their environment. The self-concept mode “focuses on psychologic and spiritual aspects of the person” (Andrews & Roy, 1991, p. 16). The basic underlying need of the self-concept mode is psychologic integrity. The role function mode focuses on the need to know who one is. The emphasis of the interdependence mode is affectional adequacy or the feeling of security iurturing relationships (Andrews & Roy, 1991).

The purposes of adaptation are survival, growth, reproduction, and mastery. Adaptive responses contribute to these goals, whereas ineffective responses may threaten the person’s survival, growth, reproduction, or mastery (Andrew & Roy, 1991).

The goal of nursing is “the promotion of adaptation in each of the four modes, thereby contributing to the person’s health, quality of life, and dying with dignity” (Andrews & Roy, 1991, p. 20). Nursing care needs to be provided when a person has unusual stressors or when usual coping mechanisms are ineffective. Basically, the nurse attempts to manipulate stimuli in such a way as to allow the client to cope effectively. Roy defines health as “a state and a process of being and becoming an integrated and whole person” and a “lack of integration represents lack of health” (Andrews & Roy, 1991, p. 419).

In Roy’s view, the nurse must first assess how the client behaves in each adaptive mode and then determine what can be altered in that mode to produce more efficient and effective adaptive responses. The nurse then either alters the environment directly or helps the person to alter the environment for better adaptive responses.

In the physiological mode, problems may arise in areas such as exercise, nutrition, elimination, fluid and electrolytes, temperature regulation, and oxygenation. For example, in caring for a client with a fever, the nurse helps the client to adapt by administering medications to lower the temperature, administering cool baths, and providing adequate fluids. Through these interventions, the nurse is attempting to alter both the internal and external environments of the person.

In the self-concept mode, the term self-concept refers to both the physical and the personal self. The physical self is affected or threatened during invasive procedures such as surgery. Anxiety, guilt, and distress are responses within the personal self to physical or emotional stressors. For example, in caring for an obese person who feels guilty about developing diabetes at an early age, a nurse can help reframe the client’s thinking to work through the guilt and anxiety. Through the use of counseling techniques, the nurse can teach the client how to adapt to the present situation and learn how to cope with it in the future.

Within the framework of the role function mode, the nurse would help a woman disabled with arthritis to identify adaptive approaches to maintain the roles of wife and homemaker. Nursing actions might include referral to occupational therapy for needed adaptive devices that could assist the client in maintenance of roles.

In the interdependence mode, problems may include feelings of alienation, disengagement, loneliness, or disenfranchisement that are experienced in various relationships. Examples of clients with problems in interdependence may include a grieving widow or a person with an abusive spouse.

The Roy Adaptation Model has gained wide acceptance iursing practice, research, and education and is part of the dominant worldview of nursing. Roy’s views of the person and the person-environment interaction clearly represent characteristics of the Totality Paradigm.

 

Theories for the New Worldview of Nursing Theories for the new worldview of nursing describe, explain, and predict the phenomena of concern to nursing from a unique, more holistic perspective. In this new worldview, the client has primacy and the clientenvironment interaction is of utmost importance. Theories by Jean Watson, Martha Rogers, and Rosemarie Parse exemplify the new worldview.

 

Jean Watson In the 1980s, Jean Watson developed the Theory of Human Caring, which focuses on the art and science of human caring. According to Watson (1985, p. 33), “caring is the essence of nursing and the most central and unifying focus of nursing practice.” This theory offers a new way of conceptualizing and maximizing human-tohuman transactions that occur daily in nursing practice. Watson’s theory is influenced by Eastern philosophy and is “based on a metaphysical, spiritual-existential, and phenomenological orientation” (Fawcett, 1993, p. 220). These influences link Watson’s theory to the work of early theorists such as Travelbee and Paterson and Zderad.

The Theory of Human Caring evolved from Watson’s beliefs, values, and assumptions about caring. In Watson’s view (1985), care and love comprise the primal universal psychic energy and are the basis for our humanity. Watsooted that, throughout its history, nursing has been involved in caring and has actually evolved out of caring. Furthermore, she stated that caring will determine nursing’s contribution to the humanizing of the world.

Watson’s theory is composed of 10 carative factors, which are classified as nursing actions or caring processes. Watson’s carative factors are:

1. Formation of a humanistic-altruistic system of values

2. Nurturing of faith-hope

3. Cultivation of sensitivity to one’s self and to others

4. Developing a helping-trusting, human caring relationship

5. Promotion and acceptance of the expression of positive and negative feelings

6. Use of creative problem-solving method processes

7. Promotion of transpersonal teaching and learning

8. Provision for a supportive, protective, or corrective mental, physical, sociocultural, and spiritual environment

9. Assistance with gratification of human needs

10. Allowance for existential-phenomenological forces (Watson, 1989)

The first three carative factors serve as the philosophical foundation for the science of caring. The remaining seven provide more specific direction for nursing actions.

Watson stated that “health refers to unity and harmony within the mind, body, and soul. Health is also associated with the degree of congruence between the self as perceived and the self as experienced” (Watson, 1985, p. 48). In Watson’s (1985, p. 49) view, the goal of nursing “is to help persons gain a higher degree of harmony with the mind, body, and soul.” The nurse uses the above carative factors to accomplish the goal of nursing. Watson’s theory clearly fits within the principles of the Simultaneity Paradigm.

Although the concept of caring is being deemphasized in today’s health care environment because of exploding technology and cost-containment strategies, nursing must persevere in delivering care to clients. The challenge of nursing is to create moments of caring through human-to-human interaction in the face of the fast-paced world of health care.

 

Martha Rogers Martha Rogers, a visionary leader and pioneer in the development of nursing’s unique knowledge base, developed the highly abstract theory of the Science of Unitary Human Beings. According to Rogers, “nursing is a learned profession: a science and an art. A science is an organized body of abstract knowledge. The art involved iursing is the creative use of science for human betterment” (Rogers, 1990, p. 198). Rogers’ contribution to the discipline of nursing was revolutionary and provided new directions for the practice of nursing. Rogers first presented her ideas in the book An Introduction to the Theoretical Basis of Nursing (1970). Her ideas regarding the person and the environment as energy fields were not considered to be consistent with the dominant paradigm of the 1970s but are more applicable with the principles of the Simultaneity Paradigm of the late 1980s.

According to Rogers (1990, p. 108), “the uniqueness of nursing is identified in the phenomena of concern. Nursing is the study of unitary, irreducible human beings and their respective environments.” Unitary person is an irreducible pandimensional energy field characterized by pattern and expressing qualities that are unique to the whole and cannot be foreseen from knowledge of the parts (Rogers, 1990). Environment is defined as “an irreducible pandimensional energy field identified by pattern and integral with a given human field” (Rogers, 1990, p. 109).

Within the viewpoint of the Science of Unitary Human Beings, the person is a unified whole and seen as greater than and different from the sum of the parts. The whole person cannot be known by examining any particular aspect or dimension of the person because all aspects together combine to form an entity different from the collection of parts. It is the characterization of the person as a human energy field that unites all aspects of the person into a unified whole. The whole of the person’s energy field interacts with the whole of the environmental energy field, which results in the process of life. There is a constant exchange of matter and energy between the person-environment unit, yet the uniqueness of each person is maintained through rhythmical patterns and relationships. “In a worldview where person and environment are in a constant, dynamic simultaneous process of change the concept of homeostasis is obsolete” (Joseph, 1990, pp. 116–117).

Nursing identifies the patterns and organization of the person-environment unit and aims to repattern the rhythm and organization of these energy fields so that the person’s integrity is heightened. “Maintenance and promotion of health, prevention of disease, nursing diagnosis, intervention, and rehabilitation encompass the scope of nursing’s goals” (Rogers, 1970, p. 86).

 

Rosemarie Parse Rosemarie Parse synthesized Rogers’ Science of Unitary Human Beings with existential-phenomenological philosophy and added emphasis on the meaning and values that influence a person’s behavioral choices. Parse differs from Rogers in that she “does not view Man as an energy field, but rather as an open being who cocreates personal health” (Parse, 1987, p. 159). According to Leddy and Pepper (1993, p. 170), health is a “constantly changing process of becoming that incorporates values. Because it is not a state, health cannot be contrasted with disease.” Parse (1987, p. 169) states that “the practice of nursing . . . is a subject-to-subject interrelationship, a loving, true presence with the other to promote health and quality of life.” Parse provides a practice methodology in which the nurse helps clients to understand their own feelings and situation, find meaning within themselves and the situation, and plan for changes in the lived health patterns. In Parse’s perspective, the nurse does things with people as opposed to for them or to them. Clearly, Parse’s theory is consistent with the principles of the Simultaneity Paradigm.

Similar to the work of Parse, Joyce Fitzpatrick’s Life Perspective Rhythm Model (1989) and Margaret Newman’s Model of Health (1986) are current developing theories within the Simultaneity Paradigm.

 

CONTINUING EVOLUTION OF NURSING THEORY Current theorists are continually expanding and refining the work of theorists before them, and they are developing new ways of looking at the metaparadigm concepts of person, environment, health, and nursing. Our understanding of the nature of nursing is, and always has been, in a state of change. Although change is healthy and leads to growth, it is not always easy. Knowledge is not static, and what one learns today may be challenged by different thoughts tomorrow.

The world of health care changes on a daily basis. Client needs and problems often change on a minuteby– minute basis. Knowledge, information, and technology in both health care and nursing are growing at unprecedented rates. In the face of these advances, nursing strives to preserve the notion of caring in health care. Theories are needed to organize knowledge and to guide nursing practice and nursing research. More nursing research is needed to confirm or refute theories. A strong theoretical foundation on which to base the practice of nursing is essential.

Nurses encounter a variety of clinical situations in which application of nursing theory is needed. In these occurrences, nurses may discover that specific theories will be more appropriate for certain clinical situations than others. Knowledge of specific theories should expand as nurses gain experience iursing practice. In all cases, theories that are selected for application in practice should be congruent with the nurse’s own beliefs and values.

 

K E Y C ONCEPTS

Concepts are abstract vehicles of thought and are the building blocks of theory.

Propositions are relational statements that link concepts together.

Theories help to show how things fit together. The function of theory is to provide a framework for explaining, predicting, and sometimes controlling situations.

Nursing uses theories from other disciplines in conjunction with nursing theory.

The development, use, and testing of nursing theory are necessary for the professionalization of the discipline of nursing.

The relationship betweeursing theory, practice, and research is an interdependent one. As a practiceoriented discipline, nursing theory and research inform and transform nursing practice.

Theories range in scope from grand theories to middle- range theories to micro-range theories.

The metaparadigm names the phenomena of concern to a discipline and distinguishes one discipline from another.

The currently accepted metaparadigm concepts iursing are person, environment, health, and nursing.

The metaparadigm may be composed of more than one paradigm. Parse purports that there are two paradigms iursing: the Totality Paradigm and the Simultaneity Paradigm.

Early nursing theorists were attempting to answer questions related to the “what” and “how” of nursing.

The theories developed by Levine, Orem, and Roy are useful in guiding nursing practice.

A new worldview of nursing is emerging in the work of such theorists as Watson, Rogers, and Parse.

 

C R I T I C A L T H I N K I N G AC T I V I T I E S

1. Explain the relationship between concepts and propositions. How are concepts and propositions related to theory?

2. Define the term theory. What is the purpose of theory?

3. Explain the relationship betweeursing theory, practice, and research.

4. Identify the main features of a metaparadigm. What are the metaparadigm concepts iursing? How is nursing’s metaparadigm different from medicine’s metaparadigm?

5. What is a paradigm? What is the purpose of a paradigm?

6. Name the two paradigms iursing identified by Parse and identify the principal philosophical underpinnings of each.

7. Discuss Nightingale’s influence on moderursing.

8. True or false: The early nursing theorists were attempting to address all of the metaparadigm concepts. Justify your answer.

9. Discuss the features of the following theories: Levine Roy Orem Watson Rogers

10. Discuss how you plan to use nursing theory in your practice.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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