EVOLUTION OF NURSING

THEORIES
 THIS SESSION WILL
HIGHLIGHT ON
A. Introduction to nursing theories
B. Historical evolution of Nursing theory
C. Stages of theory development in nursing
D. Trends in theory development
E. Terminologies
F. Overview of nursing theory
G. Definition and meaning of nursing theory
H. Importance of nursing theories
I. Characteristics of nursing theories
J. Classification of nursing theories under various forms
1.Level of theories
2.Philosophical underpinnings
3.Functions of nursing theories
4. Process development of nursing
theories
K. Common concepts in Nursing theories
L. Process of theory development
M. Criteria for analyzing theory
N. Application of theory in Nursing practice
 (A). INTRODUCTION: WHY
THEORY?
• Theory enables understanding of what, how and why we
do the practice of nursing
• It facilitates questions about the relevance & application
of nursing practice & research
• It stimulates thinking, identifying what is mindless and
what needs to be changed
• It facilitates the development of nursing knowledge and
evidence based practice
• Nursing theory has been a prevalent theme in the
nursing literature for the past 30years and has
stimulated phenomenal growth in the nursing
profession.

• It is interesting to note that 90% of all Nursing theories

have been generated in the last 20 years.
 (B). EVOLUTION OF NURSING
THEORY
• The history of professional nursing began with Florence
Nightingale who envisioned nurses as a body of
educated women.
• In last century, nursing began with a strong emphasis on
practice.
 HISTORICAL ERAS IN
NURSING
1. Curriculum era
2. Research era
3. Graduate nursing era
4. Theory era
 CURRICULUM ERA

Addressed the question of what

prospective nurses must study and
learn to become a nurse. i.e.
Courses nurses need to take, the
need to move from hospital based
nursing program to college level
education and university level
education.
 RESEARCH ERA
As more and more nurses sought degrees in higher
education, research era emerged. Nurses began to
participate in research and research course began to
be included in nursing curricula.
 GRADUATE NURSING
EDUCATION ERA
• Masters program in nursing emerged to
meet the need for nurse with specialized
education in nursing .
• The masters education had an
embedded course in nursing research
• nearing the end of this era a course in
nursing theory or nursing conceptual
models that introduced students to the
early nursing theorists and development of
nursing theories was introduced.
 THEORY ERA
• Was the natural outgrowth of research era.
• With an increased understanding of research and
knowledge development
• It became obvious that research without theory
produced isolated information,
however research and theory produced nursing
science.
©. STAGES OF THEORY DEVELOPMENT IN NURSING:
Stage Source of Impact on theory and research
knowledge
1. Silent Blind obedience · little attempt to develop theory.
knowledge stage to medical · Research was limited to collection
authority of epidemiological data

2. Received Learning · Theories were borrowed from other

knowledge stage through listening disciplines. As nurses acquired non-nursing
to others doctoral degrees, they relied on the authority
of the educators, sociologists, psychologists
to provide answers to nursing problems.

3.Subjective Authority was · A negative attitude toward

knowledge stage internalized and borrowed theories and science emerged.
a new sense of Nurse scholars focused on defining nursing
self emerged and on developing theories about and for
nursing. Nursing research focused on the
nurse rather than on clients and clinical
4. Procedural Includes both Proliferation of approaches to theory
knowledge separate and development.
stage connected • Application of theory in practice was
knowledge frequently underemphasized.
• Emphasis was placed on the
procedures used to acquire knowledge,
with over attention to the appropriateness
of methodology, the criteria for
evolution, and statistical procedure for
data analysis.

5. Constructed Integration of · Nursing theory should be based on

Knowledge different types prior empirical studies, theoretical
of literature, client reports of clinical
knowledge(int experience and feeling, nurse scholar’s
uition, reason intuition or related knowledge
and self-
knowledge)
 (D). Trends in theory development
• Conceptual models and philosophies of
practice
• The nature of nursing
• The purposes for which nursing exist.
• Nursing process as a framework for viewing
nursing practice.
• Deliberate, reflective, critical, and self-correcting.
• Encouraged nurses to cultivate basic inquiry skills.
• Development of philosophies with emphasis
on knowledge associated with:
• Esthetic
• Ethical
• Personal
• Application of theories borrowed from
other disciplines.
• Means to resolve problems.
• Use with caution.
• Nursing theories in the 1960s and 1970s--
functional view of nursing.
• What nursing is; describes how nursing
functions; variables influencing health and
illness.
• Development of midrange practice-linked
theory.
• Needed to provide specific guidance for
nursing practice.
• Tend to cluster around a concept of interest.
 (E). Terminologies

S.No Terminology Definition

1. Metaparadigm It is the most abstract level of knowledge. It

specifies the main concepts that encompass the
subject matter and the scope of a discipline.
Nursing metaparadigm consists of the central
concepts “Person, Environment, Health and
Nursing.
2 Philosophy It is the next knowledge level; it specifies the
definitions of the metaparadigm concepts in each
of the conceptual models of nursing.

3 Conceptual models to the phenomena with which the are frameworks

or paradigms that provide “a broad frame of
reference for systematic approaches discipline is
concerned”. It differs according to the concepts
of the models.
4 Theory It is a group of related concepts that propose
actions that guide practice.

5 Nursing Theory Is a group of related concepts that derive from the

nursing models.

6 Middle range They are least abstract level of theoretical

theories knowledge because they include details specific to
nursing practice. They include information
indicating the situation or health condition , the
patient population or age group, the location or
area of practice and the action of the nurse or the
intervention.
7 Grand theories Grand Theories are defined as the broadest in
scope, less abstract than conceptual models but
composed of general concepts still relatively
abstract, and the relationships cannot be tested
empirically.
8 Understanding acquired through learning or
Knowledge
investigation of what is known about a
discipline’s subject matter. It may be facts or
theoretically based knowledge that is more
tentative.
9 They are subject matter of a discipline
Phenomena
10 Is an idea or complex mental image of a
Concept
phenomenon(object property or event). They
are the major components of a theory.
11 Are independent of time or place and they are
Abstract
concepts indirectly observable. Hope is an example of
abstract concepts.
12 Are specific to time and place and are
Concrete
concepts observable. A person features like, eye color,
height, weight are examples of concrete
concepts.
13 It can be Verbal: Verbal model are worded
Model
statements.
2.Schema: means symbols or physical
visualization. Schematic models can be
diagrams, graphs or pictures that facilitate
understanding.
14 Is another term for conceptual framework or
Paradigm
conceptual model

15 They are theoretical statements that specify the

Propositions
proposed relationships of the concepts of theory.

16 Is a form of reasoning that is loosely described as

Induction
moving from specific to general.

17 Deduction Logical reasoning from general to specific.,

 (F). OVERVIEW OF THEORY:

• The uniqueness of theories and perspectives used by

a discipline distinguishes it from other disciplines.
• The theories used by members of a profession clarify
basic assumptions and values shared by its members
and define the nature, outcome and purpose of
practice.
• Kerlinger ---views theories as a set of
interrelated concepts that give a
systematic view of a phenomenon ( an
observable fact or event ) that is
explanatory and predictive in nature.
• Theories are composed of concepts,
definitions, models , propositions and are
based on assumptions. They are derived
through two principal methods:
1) Deductive reasoning
2) Inductive reasoning.
Nursing theorists use both of these methods.
•
DEDUCTIVE REASONING
It is a form of reasoning from the general to the specific.
In deductive logic were two or more premises as relational
statements are used to draw a conclusion.
• In deductive process, an abstract theoretical
relationship is used to derive specific questions or
hypothesis.
• Theory that is developed from the applications of
deductive logical System is only as sound as premises upon
which the argument is based.
•
INDUCTIVE REASONING
It is a form of logical reasoning in which a
generalization is induced from a number of specific
observed instances.
• The inductive form is based on the assumption that
members of any given class share common
characteristics. Therefore what is true for any
randomly selected members of the class is accepted
as true for all members of the class.
 Comparison:

Inductive Deductive

Empirical Observations Laws

Facts Theories

Concepts Concepts

Theories Facts

Laws Empirical observations

 (G). DEFINITION AND
MEANING OF NURSING
THEORY
• Nursing theories are an organized and
systematic expression of a set of statements
related to questions in the discipline of nursing.

• Powers and Knapp (1995), defined theory as

“a set of statements that tentatively describe,
explain, or predict relationships among
concepts that have been systematically
selected and organized as an abstract
representation of some phenomenon.
• Bodie and Chitty (1993) defined theory as “an
internally consistent group of relational statements
(concepts, definitions and propositions) that present a
systematic view about a phenomenon and which is
useful for description, explanation, prediction and
control”
• Socialization into a discipline is guided by
theories use of language
identification of concepts
definition of relationships
structured ideas
and facilitation of disciplined inquiry,
practice and communication, as well as
predicting outcomes of practice.
Nursing professionals apply theory to
describe, explain, predict or prescribe
nursing practice.
 (H). IMPORTANCE OF NURSING
1. Nursing theory aims to describe, THEORIES
predict
and explain the phenomenon of nursing
(Chinn and Jacobs1978).

2. It provides the foundations of nursing

practice, help to generate further
knowledge and indicate in which
direction nursing should develop in the
future (Brown 1964).

3. Theory is important because it helps us to

decide what we know and what we need
to know (Parsons1949).
4. It helps to distinguish what should form
the basis of practice by explicitly
describing nursing.
5. The benefits of having a defined body of
theory in nursing include
 better patient care,
 enhanced professional status for nurses
 improved communication between nurses,
 and guidance for research and education (Nolan
1996).
 In addition, because the main exponent of nursing –
caring – cannot be measured, it is vital to have the
theory to analyze and explain what nurses do.
6. As medicine tries to make a move
towards adopting a more multidisciplinary
approach to health care, nursing
continues to strive to establish a unique
body of knowledge.
 (I). THE CHARACTERISTICS OF THEORIES
Theories
1) interrelate concepts in such a way as to create a
different way of looking at a particular phenomenon.
2) are logical in nature.
3) are generalizable.
4) are the bases for hypotheses that can be tested.
5) increase the general body of knowledge within the
discipline through the research implemented to validate
them.
6) are used by the practitioners to guide and improve their
practice.
7) are consistent with other validated theories, laws, and
principles but will leave open unanswered questions that
need to be investigated
 (J). CLASSIFICATION OF NURSING THEORIES
1. Level of theories:
Metatheory
grand theory
middle range theory
practice theory.
2. Philosophical underpinnings
Interaction theories
Needs theories
Outcome theories
Humanistic theories
3. Functions:
Descriptive
Explanatory
Predictive
Prescriptive
4. Process development of nursing theories
General systems theory
Adaptation theory
Developmental theory
 LEVELS OF THEORIES

Theory Levels of Abstraction

Meta theory Most abstract

Grand Theory

Middle range theories

Practice theories Least Abstract

 1. LEVELS OF THEORIES
• Meta theory:
The fourth level of theory or Meta theory is the highest
level of theory, and is defined by the prefix META,
meaning “changed in position”, “beyond”, “on a higher
level”, or “transcending,” and refers to the body of
knowledge or about a field of study
A nursing metatheory presents the most global perspective of
the nursing discipline by identifying and evaluating critical
phenomena in unique ways.

Even though nursing metatheory is very abstract and may not

be easily tested, nursing metatheory provides the meanings,
sentences, and structures interconnecting situations and
events observed by nurses on a global scale.
Meta theory is criticized as being limited, without
boundaries, abstract and very difficult for practical
application.
However, a true meta theory in nursing will emerge as a
superstructure with multiple practical applications and
extensive opportunities for researchers to discover grand
theories, mid-range theories, interconnected paradigms,
and models, as well as explore how nursing reconstructs
and is reconstructed
 GRAND THEORIES
• The third level of nursing theory is Grand
Theory
• Emphasizes a global viewpoint with a board
perspective of nursing practice, and a distinct
nursing perspective of nursing phenomenon.
• Fawcett (1995) defined Grand Theories as the
broadest in scope, less abstract than
conceptual models but composed of general
concepts still relatively abstract, and the
relationships cannot be tested empirically.
 Categorization of Grand nursing theories
Human needs model Interactive process models Unitary models and
and theories and thoeires theories

Abdellah Arthian and Conger- Mragaret Newman-health

Intersystem model as an expanding
consciousness

Henderson Erickson,tomlin and swain- Parse

Modeling and Role
modeling(MRM), a paradigm
and theory for nursing

Johnson King Rogers

Nightingale Levine

Neuman Roy

Orem Watson
 MIDDLE RANGE THEORIES
• Middle Range Theories, the second level of nursing theories,
are moderately abstract, inclusive, organized within a limited
scope; have a limited number of variables, which are
testable in a direct manner.

• The mid-range theories have a stronger relationship with

research and practice.
• Mid-range theories provide nurses with the “best of
both worlds”---easy applicability in practice and
abstract enough to be scientifically interesting.
• Mid-range theories focus on concepts of interest to
nurses, and include: pain, empathy, grief, self-esteem,
hope, comfort, dignity, and quality of life.
 They are categorized as
1. High Middle range theories: Benner’s
skill acquisition in nursing model, Leninger
and Pender
2. Middle- Middle Range theories:
Mishels’s uncertainity of illness theory,
Schumacher and Meleis work on
transitions and Reed;s self-Transcedence
theory
3. Low middle range theories: Eakes,
Burke and Hainsworth theory of chronic
sorrow. Becks postpartum depression
theory and Mercers conceptualization of
maternal role attainment.
 PRACTICE
THEORIES/MICROTHEORY
• The first level of nursing theory, describe prescriptions or
modalities for practice.

• Four steps are involved to determine practice theories,

which include:
1. Factor isolating: to identify and describe a
phenomenon
2. Factor relating: to identify and describe possible
explanations or causes of the phenomenon
3.Situation relating: to predict occurrence of a
phenomenon when the cause is present. Example:
the post open-heart surgery patient will experience
cardiac arrhythmias if the blood potassium level goes
below 3.5 meq.
4.Situation producing control: to prevent occurrence
of the phenomenon by controlling or eliminating
possible causes. Examples include: pregnant women
receive RHO-gram to prevent possible hemolysis in
their infants; and the frequent turning and positioning
of bed-ridden patients to prevent pressure ulcers.
 2. CATEGORIES BASED ON
PHILOSOPHICAL
UNDERPINNINGS:
• "Needs "theories.
• "Interaction" theories.
• "Outcome "theories.
• "Humanistic theories"
 NEEDS THEORIES
• These theories are based around helping individuals to
fulfill their physical and mental needs..
• Needs theories have been criticized for relying too
much on the medical model of health and placing the
patient in an overtly dependent position.
 INTERACTION THEORIES
• As described by Peplau (1988), these theories revolve
around the relationships nurses form with patients.
• Such theories have been criticized for largely ignoring
the medical model of health and not attending to
basic physical needs.
 OUTCOME THEORIES
• These portray the nurse as the changing force, who
enables individuals to adapt to or cope with ill health
(Roy 1980).
• Outcome theories have been criticized as too abstract
and difficult to implement in practice (Aggleton and
Chalmers 1988).
 HUMANISTIC THEORIES
• Humanistic theories developed in response
to the psychoanalytic thought that a
person’s destiny was determined early in
life.
• Humanistic theories emphasize a person’s
capacity for self actualization .
• Humanists believes that the person
contains within himself the potential for
healthy and creative growth.
 3. CATEGORIES BASED ON
FUNCTIONS:

• Descriptive
• Explanatory
• Predictive
• Prescriptive
 DESCRIPTIVE THEORIES
• Descriptive theories describe, observe, and name
concepts, properties, and dimensions, but they do not
indicate how changes in one concept affect other
concepts.
 EXPLANATORY THEORIES
• Relate concepts to one another and
describe and specify some of the
association or interrelations between and
among the concepts.
• Further, explanatory theories attempt to tell
how or why the concepts are related and
may deal with causality, correlations, and
rules that regulate interactions (Barnum,.
1998; Dickoff et al., 1968).
 PREDICTIVE THEORIES
• describe precise relationships between
concepts and are the third level of theory
development.
• Predictive theories presuppose the prior
existence of the more elementary types of
theory.
• They result after concepts are defined and
relational statements are generated and are
able to describe future outcomes consistently.
• Predictive theories include statements of
causal or consequential relatedness (Dickoff et
al., 1968).
 PRESCRIPTIVE THEORIES
• are perceived to be the highest level of theory
development (Dickoff et al., 1968)
• Prescriptive theories prescribe activities necessary to
reach defined goals.
• In nursing, prescriptive theories address nursing
therapeutics and predict the consequence of
interventions (Meleis, 2005).
 4. CATEGORIES
BASED ON PROCESSES IN THE
DEVELOPMENT OF NURSING THEORIES
General System Theory:
• It describes how to break whole things into parts and
then to learn how the parts work together in " systems".
These concepts may be applied to different kinds of
systems, e.g.Betty Newman’s systems theory.
Developmental Theory
• It outlines the process of growth and development of
humans as orderly and predictable , beginning with
conception and ending with death.
• The progress and behaviors of an individual within
each stage are unique.
• The growth and development of an individual are
influenced by heredity , temperament , emotional,
and physical environment , life experiences and
health status.
Adaptation Theory
• It defines adaptation as the adjustment of
living matter to other living things and to
environmental conditions. Adaptation is a
continuously occurring process that
effects change and involves interaction
and response . Human adaptation occurs
on three levels:
• --- the internal ( self )
• --- the social (others)
• --- and the physical ( biochemical
reactions )
 (K). COMMON CONCEPTS IN
NURSING THEORIES

• A METAPARADIGM is the most global

conceptual or philosophical framework of
a discipline or profession
• It defines and describes relationships
among major ideas and values
It guides the organization of theories and
models for a profession
• The nursing metaparadigm comprises four
concepts: person, environment, health,
and nursing
 THE NURSING METAPARADIGM
COMPRISES FOUR CONCEPTS: PERSON,
ENVIRONMENT, HEALTH, AND NURSING
1.Person refers to the recipient of nursing
care, including physical, spiritual,
psychological, and sociocultural
components, and can include an
individual, family, or community
2.Environment refers to all the internal and
external conditions, circumstances, and
influences affecting the person
3.Health refers to the degree of wellness or
illness experienced by the son
4. Nursing refers to the actions,
characteristics, and attributes of the
individual providing the nursing care
 (L). PROCESS OF THEORY
DEVELOPMENT
a. Concept development: Creation of a conceptual
meaning, that includes, specifying, defining, and
clarifying the concepts used to describe the
phenomenon of interest.
• Concept :
• Building block of theories
• Classify the phenomenon of interest
• A symbolic statement describing a phenomenon
• May be classified as abstract or concrete
• Discrete ( non-variable ) or continuous
 TYPES OF CONCEPTS
• Concepts can be characterized
• Enumerative
• Associative
• Relational
• Statistical
• Summative
Concepts Characteristics Examples

Enumerative Always present and Age ,Height

concepts Universal Weight

Associative •Exist only in a Income, Disease

concepts particular condition condition,
• May have Zero Anxiety
value too
Relational concepts Can be derived Longevity
only through
interaction with an
associative concept
Statistical Relate the property of •Average blood
concepts one thing in terms of • Acquired immune
its distribution in the deficiency Syndrome
population rate

Summative •Represent an entire Nursing :Health:

concepts complex entity of a Environment
phenomenon
•Not measurable
 SOURCES OF CONCEPTS
• Naturalistic Concepts:(These are measurable). Body
Weight, Depression, Pain.
• Research Based Concepts
• Quantitative
• Phenomenological
• Existing concepts
-Human needs on Maslow’s
Hierarchy of needs
 PURPOSE OF CONCEPTS
DEVELOPMENT
• Identify gaps in knowledge
• Determine the need to refine or clarify
• Evaluating the adequacy of competing
concepts in relation to other
phenomenon
• Examines the similarity – between the
definition concept
• and how it is being operational
• determines the coherence between the
theory of concept and its application
 PROCESS OF CONCEPT
DEVELOPMENT
Concept Analysis (Walker and Avant (1995)
• Select
• Determine the aims and purpose
• Identify the uses
• Determine the defining attributes
• Construct a a case model
• Define a boundary
• Identify Antecedents and consequences
• Define the empirical referent of concept
Concept Synthesis
• Quantitative Method
• Qualitative Method
• Literary Method
Concept Derivation
• Familiar with the existing literature
• Search fields of interest for having a new
perception on the topic
• Select a parent topic
• Redefine in terms of topic of interest
b. Statement development: Formulation
and validation of rationale statements.
Steps in statement analysis include (Walker
and Avant)
1. Select the statement to be analyzed
2. simplify the statement
3. classify the statement
4. Examine concepts within statement for
definition and validity
5. Specify relationship between concepts
6. examine he logic
7. determine stability
c.Theory construction: Systematic organization of
linkages for a formal theoretical structure
d.Testing of theoretical relationships
e.Theory application: research methods are used to
assess how the theory can be applied to practice
which is measured how the desired outcomes are
achieved
 (M). CRITERIA FOR
ANALYZING A THEORY

• Clarity: “How clear is this theory”

• Simplicity: “How simple is this theory”
• Generality: “How general is this theory”
• Empirical precision: “How accessible is this
theory”
• Derivable consequences: “How important
is this theory”
• Clarity:
Consistency and structural clarity are
important. To assess these, the major
concepts, sub concepts, and their
definitions are identified. The logical
development should be clear and
assumptions should be consistent with the
theory’s goals.

• Simplicity: It is very valued in theory

development. Nurses require simple
theory like middle range theory to guide
nursing practice. Theory should be
sufficiently comprehensive and at a level
of abstraction to provide guidance.
• Generality: To determine generality the scope of
concepts and goals within the theory are examined.
The more limited the concepts and goals, the less
general the theory.

• Empirical precision: Empirical precision is linked to the

testability and ultimate use of a theory and it refers to
the “extent that the defined concepts are grounded
in observable reality.
• Derivable consequences: If research, theory and
practice are to be meaningfully related then nursing
theory should lend itself to research testing and testing
should lead to knowledge that guides practice.
 (N). APPLICATION OF THEORY IN
NURSING PRACTICE NURSING
RESEARCH
1. Strong relationship between theory and
practice.
2. Theory based nursing practice: helps in informed
decision making
3. Closing the Theory practice gap:
4. Application in Nursing research:
-Theory generating research and
-Theory testing research.
 HOW THEORY GUIDES
NURSING RESEARCH
• Identify meaningful and relevant area of study
• Propose Plausible approached to help problems to
examine
• Develop or reformulate Middle range theory linked
to research
• Define the concept and propose relationships among
concepts
• Interpret research findings
• Develop Clinical practice protocols
• Generate Nursing Diagnosis based on research
findings
THANK YOU
It is Professional Nurses ethical
“

responsibility to utilize the knowledge

base of her or his discipline”