EVOLUTION OF NURSING

THEORIES

BY
Prof.(Mrs).S.Kanchana
Principal
Omayal Achi college of Nursing

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.
2.
3.
4.

Curriculum era
Research era
Graduate nursing era
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
knowledge

1. Silent

Blind obedience
to medical
authority

knowledge stage

2. Received
knowledge stage

Learning
through listening
to others

3.Subjective

Authority was
internalized and
a new sense of
self emerged

knowledge stage

Impact on theory and research

of

little attempt to develop theory.

Research was limited to collection
epidemiological data

Theories were borrowed from other

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

A negative attitude toward

borrowed theories and science emerged.
Nurse scholars focused on defining nursing
and on developing theories about and for
nursing. Nursing research focused on the
nurse rather than on clients and clinical

4. Procedural

knowledge
stage

5. Constructed

Knowledge

Includes both
separate and
connected
knowledge

Integration of
different types
of
knowledge(int
uition, reason
and selfknowledge)

Proliferation of approaches to theory

development.
Application of theory in practice was
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.

Nursing theory should be based on

prior empirical studies, theoretical
literature, client reports of clinical
experience and feeling, nurse scholars
intuition or related 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

Philosophy

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.
It is the next knowledge level; it specifies the
definitions of the metaparadigm concepts in each
of the conceptual models of nursing.

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.

Theory

It is a group of related concepts that propose

actions that guide practice.

Nursing Theory

Is a group of related concepts that derive from the

nursing models.

Middle range
theories

They are least abstract level of theoretical

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.

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.

Knowledge

Understanding acquired through learning or

investigation of what is known about a
disciplines subject matter. It may be facts or
theoretically based knowledge that is more
tentative.

Phenomena

They are subject matter of a discipline

10

Concept

Is an idea or complex mental image of a

phenomenon(object property or event). They
are the major components of a theory.

11

Abstract
concepts

Are independent of time or place and they are

indirectly observable. Hope is an example of
abstract concepts.

12

Concrete
concepts

Are specific to time and place and are

observable. A person features like, eye color,
height, weight are examples of concrete
concepts.

13

Model

It can be Verbal: Verbal model are worded

statements.
2.Schema: means symbols or physical
visualization. Schematic models can be
diagrams, graphs or pictures that facilitate
understanding.

14

Paradigm

Is another term for conceptual framework or

conceptual model

15

Propositions

They are theoretical statements that specify the

proposed relationships of the concepts of theory.

16

Induction

Is a form of reasoning that is loosely described as

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 Theories

1. Nursing theory aims to describe, 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
and theories

Interactive process models

and thoeires

Unitary models and

theories

Abdellah

Arthian and CongerIntersystem model

Mragaret Newman-health
as an expanding
consciousness

Henderson

Erickson,tomlin and swainModeling and Role

modeling(MRM), a paradigm
and theory for nursing

Parse

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: Benners skill
acquisition in nursing model, Leninger and Pender
2. Middle- Middle Range theories: Mishelss
uncertainity of illness theory, Schumacher and
Meleis work on transitions and Reed;s selfTranscedence 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 persons destiny was
determined early in life.
Humanistic theories emphasize a persons
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 Newmans 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
concepts

Always present and Age ,Height

Universal
Weight

Exist only in a
particular condition
May have Zero
value too
Relational concepts Can be derived
only through
interaction with an
associative concept
Associative
concepts

Income, Disease
condition,
Anxiety
Longevity

Statistical
concepts

Relate the property of

one thing in terms of
its distribution in the
population

Average blood
Acquired immune
deficiency Syndrome
rate

Summative
concepts

Represent an entire
complex entity of a
phenomenon
Not measurable

Nursing :Health:
Environment

Sources of concepts
Naturalistic Concepts:(These are
measurable). Body Weight, Depression,
Pain.
Research Based Concepts
Quantitative
Phenomenological

Existing concepts
-Human needs on Maslows 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 theorys 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