HISTORY OF NURSING THEORY

The history of professional nursing began with Florence Nightingale. It was Nightingale who envisioned nurses as a body of
educated women at a time when women were neither educated nor employed in public service. Following her service of organizing
and caring for the wounded in Scutari, during the Crimean War, her vision and establishment of a School of Nursing at St. Thomas’
Hospital in London marked the birth of modern nursing. Nightingale’s pioneering activities in nursing practice and subsequent
writings describing nursing education became a guide for establishing nursing schools in the United States at the beginning of the
twentieth century (Kalisch & Kalisch, 2003; Nightingale, 1859/1969). Nursing began with a strong emphasis on practice, but
throughout the century, nurses worked toward the development of nursing as a profession through successive periods recognized as
historical eras (Alligood, 2006a).

The curriculum era addressed the question of what prospective nurses should study to learn how to be a nurse. In this era, the
emphasis was on what courses nursing students should take, with the goal of arriving at a standardized curriculum (Alligood, 2006a).
By the mid-1930s, a standardized curriculum had been published. However, it was also in this era that the idea of moving nursing
education from hospital-based diploma programs into colleges and universities emerged. Even so, it was the middle of the century
before this goal began to be acted upon in many states (Kalisch & Kalisch, 2003).

As nurses increasingly sought degrees in higher education, a research emphasis era, as it is deemed, began to emerge. This era
came about as more and more nurses embraced higher education and arrived at a common understanding of the scientific age, that
is, that research is the path to new nursing knowledge. Nurses began to participate in research, and research courses began to be
included in the nursing curricula of many developing graduate programs (Alligood, 2006a).

The research era and the graduate education era developed in tandem. Master’s degree programs in nursing emerged to meet the
public need for nurses with specialized clinical nursing education. Many of these programs included a nursing research course. It was
also in this era that most nursing master’s programs began to include courses in concept development or nursing models that
introduced students to early nursing theorists and the knowledge development process (Alligood, 2006a).

The theory era was a natural outgrowth of the research and graduate education eras. As our understanding of research and
knowledge development increased, it soon became obvious that research without theory produced isolated information, and that it
was research and theory together that produced nursing science (Batey, 1977; Fawcett, 1978; Hardy, 1978). In the early years of the
theory era, doctoral education in nursing flourished with an emphasis on theory development.

In the theory utilization era, emphasis was placed on middle range theory for theory-based nursing practice, as well as on theory
development (Alligood & Tomey, 1997, 2002, 2006; Batey, 1977; Chinn & Kramer, 2008; Fawcett, 2005; Tomey & Alligood, 2006).

Each era addressed nursing knowledge in a unique way that contributed to and is observable in the history of nursing. Within
each era, the pervading question “What is the nature of the knowledge that is needed for the practice of nursing?” seems to have been
addressed at the level of understanding that prevailed at that time (Alligood, 2006a).

Nightingale’s (1859/1969) vision of nursing has been practiced for more than a century, and theory development in nursing has
evolved rapidly over the past 5 decades, leading to the recognition of nursing as an academic discipline with a substantive body of
knowledge (Alligood, 2006a, 2006b; Alligood & Tomey, 2006; Chinn & Kramer, 2008; Fawcett, 2005; Tomey & Alligood, 2006; Walker
& Avant, 2005). In the mid-1800s, Nightingale wrote that nursing knowledge is distinct from medical knowledge. She described a
nurse’s proper function as putting the patient in the best condition for nature (God) to act upon him or her. She proposed that care of
the sick is based on knowledge of persons and their surroundings—a different knowledge base than that used by physicians in their
practice. Despite this early edict from Nightingale in the 1850s, it was 100 years later, during the 1950s, that the nursing profession
began to engage in serious discussion about the need to develop, articulate, and test nursing theory (Alligood, 2006d; Alligood,
2004; Chinn & Kramer, 2008; Meleis, 2007; Walker & Avant, 2005). Until the emergence of nursing as a science in the 1950s, nursing
practice was based on principles and traditions that had been passed on through an apprenticeship model of education and hospital-
kept procedure manuals (Alligood, 2002a; Kalisch & Kalisch, 2003).

Although some nursing leaders aspired for nursing to be recognized as a profession and become an academic discipline, nursing
practice continued to reflect its vocational heritage more than a professional vision. The transition from vocation to profession
included successive eras of history as nurses searched for a body of substantive knowledge on which to base nursing practice. The
curriculum era emphasized course selection and content for nursing programs and gave way to the research era, which focused on
learning the research process and meeting the long-range goal of acquiring substantive knowledge to guide nursing practice.

In the mid-1970s, an evaluation of the first 25 years of the journal Nursing Research revealed that nursing studies lacked conceptual
connections and theoretical frameworks (Batey, 1977). An awareness of the need for concept and theory development coincided with
two other significant milestones in the evolution of nursing theory. One was the standardization of curricula for nursing master’s
education provided by the National League for Nursing accreditation criteria for baccalaureate and higher degree programs, and the
second was the decision that doctoral education for nurses should be in nursing (Alligood, 2006a). The nursing theory era, coupled
with an awareness of nursing as a profession and as an academic discipline in its own right, emerged from debates and discussions
in the 1960s regarding the proper direction and appropriate discipline for nursing knowledge development. The explosive
proliferation of nursing doctoral programs and nursing theory literature substantiated that nursing doctorates should be in nursing
(Nicoll, 1986, 1992, 1997; Reed, Shearer, & Nicoll, 2003; Reed & Shearer, 2008). In the 1970s, nursing continued to make the transition
from vocation to profession as more and more nurses asked, “Will nursing be other-discipline based or be nursing based?” The history
records the answer, “Nursing practice needs to be based on nursing science” (Alligood, 2006a; Fawcett, 1978; Nicoll, 1986). It is
as Meleis (2007) noted, “theory is not a luxury in the discipline of nursing … but an integral part of the nursing lexicon in education,
administration, and practice” (p. 4).

The 1980s was a period of major developments in nursing theory characterized as a transition from the pre-paradigm to the
paradigm period (Fawcett, 1984; Hardy, 1978). The prevailing nursing paradigms (models) provided perspectives for nursing
practice, administration, education, research and further theory development. In the 1980s, Fawcett’s seminal proposal of four global
nursing concepts presented a nursing metaparadigm that served as an organizing structure for existing nursing frameworks, and
introduced a way of grouping what previously had been viewed as individual theoretical works (Fawcett, 1978, 1984, 1993).
Classifying the nursing models as paradigms within a metaparadigm of the concepts person, environment, health,
and nursing systematically united the nursing theoretical works for the discipline. This system clarified and improved comprehension
of a knowledge development process by embedding the theorists’ works in a larger context, thus facilitating understanding of the
growth of nursing science from a paradigm perspective (Alligood & Tomey, 2006; Fawcett, 2005). The body of nursing science and
research, education, administration, and practice continues to expand through nursing scholarship. Podium presentations at national
and international conferences, newsletters, journals, and books written by communities of scholars associated with the various
nursing models and theories describe a theoretical basis for practice and research presenting their scholarship on a selected model or
theory from a paradigm perspective (Alligood, 2004; Alligood & Tomey, 2006; Fawcett, 2005; Parker, 2006).

These observations of nursing theory development bring Kuhn’s (1970) description of normal science to life. His philosophy of
science clarifies our understanding of the evolution of nursing theory through paradigm science. It is important historically that it
was individual efforts that led to the first theory as nurse leaders in various areas of the country published their works, which later
came to be viewed collectively within a systematic structure of knowledge (Fawcett, 1984, 2000, 2005). Theory development emerged
as a product of professional scholarship and growth among nurse leaders, administrators, educators, and practitioners who sought
higher education. These leaders recognized limitations of theory from other disciplines to describe, explain, or predict nursing
outcomes, and they labored to establish a scientific basis for nursing management, curricula, practice, and research. The use of theory
to convey an organizing structure and meaning for these processes led to the convergence of ideas that resulted in what is recognized
today as the nursing theory era (Alligood, 2006b; Alligood & Tomey, 2006; Nicoll, 1986, 1992, 1997; Reed, Shearer & Nicoll, 2003; Reed
& Shearer, 2008).

The accomplishments of normal science opened the theory utilization era as emphasis shifted to theory application in nursing
practice, education, administration, and research (Alligood, 2006c; Wood & Alligood, 2006). The theory utilization era restored
balance between research and practice for knowledge development in the discipline of nursing.

This brief history provides a context for your study of the nursing theorists and their work. The theory era continues with emphasis
on development and use of nursing theory to produce evidence for professional practice. Particular utility of middle range theories
to guide the thought and action of nursing practice is noted (Alligood, 2006c; Alligood & Tomey, 2006; Fawcett, 2005; Peterson,
2008; Smith & Leihr, 2008). Therefore, preparation for practice in the profession of nursing requires knowledge of the theoretical works
of the discipline.