BOOK 1 The case for nursing theory
Fundamentals of Nursing Models, Theories and Practice, Second Edition. Hugh P. McKenna, Majda
Pajnkihar and Fiona A. Murphy. © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons,
Ltd. Companion website: www.wileyfundamentalseries.com/nursingmodels
Outline of content
This chapter covers the following: the case for theory; the argument that all intentional and rational
actions, including nursing actions, by definition must have an underlying theory; an initial definition of
theory; how theory and practice become integrated in nursing praxis.
At the end of this chapter you should be able to:
1. Understand what nursing theory is
2. Define theory
3. Understand the construction/development of a theory
4. Discuss the relationship between nursing theory and science
5. Evaluate the relationship between nursing theory and practice
6. Know the limitations of the nursing theory
7. Understand the importance of nursing theory for contemporary nursing
Before nursing students and registered nurses recognise the content and function of theory, they often
ask themselves question such as the following. What are nursing theories? Why study them? What has
this got to do with nursing? How can something that is divorced from action, that is by definition
abstract and conjectural, be of value to something like nursing, which is one of the most practical of
This book will help to answer these questions. Theories exist everywhere in society. There are numerous
theories of the family, of the internal combustion engine, of how cancer cells multiply, of changes in the
weather. There are even lots of theories as to who killed President John F. Kennedy or Marilyn Monroe.
The world is full of theories, some tested as accurate, some untested and some speculative. It is no
surprise, then, that there are theories of nursing. But what do theories do? In essence, they are simply
used to describe, explain or predict phenomena (see Reflective Exercise 1.1). This will be explored in
Reflective Exercise 1.1: Theory
Write down or discuss with other people two different theories for one of the following:
• the break-up of the Beatles
• the assassination of John F. Kennedy
• global warming
• newborn babies smiling when spoken to
Consider if there is the basis of truth in any of these theories.
Now, none of the theories that you outlined for any of the topics in Reflective Exercise 1.1 may be true.
In fact, they may be erroneous or downright preposterous. The point is that we all use theories to
explain what goes on in our lives or in the world. But if you wanted to, you could probably test or find
out whether your theories are true. Later on in this chapter we will outline what theories are made of
and how they are formed.
In many ways, theories are like maps. Maps are used to give us directions or to help us find our way in a
complicated landscape or terrain. Maps often make simple what is a very complex picture. At their best,
nursing theories also give us directions as to how to best care for patients. But why have we got so many
nursing theories (over 50 at last count)? If you take any large city, there are many maps. For instance, in
London, there are street maps, underground maps, electricity supply maps, Ordinance Survey maps and
so on. Consider the London Underground map or the Moscow or Paris Metro maps - they are simple and
easy to follow but they do not look anything like the complex reality of the underground networks they
represent. In other words, they make a complex system understandable.
Similarly, nursing is highly complex and we need different theories to help us understand what is going
on. A theory that can be used in emergency care may not be much use in mental health care, and a
theory that can be used to help nurses in a busy surgical ward may be of little use in community care.
Nursing theories can provide frameworks for practice and in many clinical settings they have been used
in the assessment of patients’ needs. For instance, in the UK one of the most popular nursing theories
was designed by three nurses who worked at Edinburgh University - Nancy Roper, Winifred Logan and
Alison Tierney. They based their theory on the work of an American nurse called Virginia Henderson. Her
theory outlined how nurses should be focused on encouraging patients to be independent in certain
activities of daily living (ADLs) such as sleeping, eating, mobilising etc. Roper et al. took this a step
further by identifying 12 ADLs. They stressed that it was the nurses’ role to prevent people having
problems with these ADLs. If this could not be achieved then nurses should help the patients to be
independent in the ADLs. If this was not possible then nurses should give the patient and/or the
patient’s family the knowledge and skills to cope with their dependence on the ADLs. Many clinical
nurses used the ADL theory to assess patients. They simply see how independent the patient is for each
ADL and then focus their care on those for which the patient is dependent.
Therefore, theory can help us to carry out an individual patient’s care and can contribute to better
observation and recognition of specific patient needs, be they biological, social or psychological. Nursing
theories are often derived from practice. In other words, nursing theorists have constructed their
theories based on what they have experienced when working with patients and their families.
Understanding the basic elements of a theory and its role, as well as taking a critical view of it, can help
to develop a body of knowledge that nurses need for everyday work.
In this book we want to highlight the need for and use of nursing theory and its function. We will try to
convince you of the importance of nursing theories to the nursing profession, to nursing education and
especially to practice. This first chapter will introduce you to new words and ideas and it will take some
concentration to understand the terminology. You may decide to read it in small doses, rather than all of
it in one sitting. However, once you have mastered this first chapter, the rest of the book will be
relatively easy to understand and, believe it or not, enjoyable. Several aspects of nursing theory are
discussed in later chapters, and when reading those, dipping back into this first chapter will be helpful.
Have a look at Reflective Exercise 1.2.
Reflective Exercise 1.2: Terminology
When you get involved in a new subject, you often have to learn new words to understand the topic. If
you are a nursing student, you have had to learn many new anatomical or psychological words and
phrases. Also, think of all the new words you would have to learn to take on any of the following
See how many more you can think of. People accept learning new terms as part of understanding
something in which they have an interest. The same is true in nursing theory.
The necessity and meaning of theory
Some people argue that in the real world of practice most nurses are not concerned with theories and
that they are of interest only to nursing academics. However, our position is that there is no such thing
as nursing without theory, because there is no such thing as atheoretical nursing. Nursing is theory in
action and every nursing act finds its basis in some theory. For instance, if a nurse is talking to a patient,
she may be using communication theory. At its simplest, a communication theory would include a
speaker, a listener, a message and understanding between the speaker and the listener. Similarly, if she
is putting a dressing on a patient, she may be using a theory of asepsis from the field of microbiology.
Nurses may not always have a named theory in mind or they may even reject the notion that they are
using a theory at all. Yet nurses do what they do for a reason and where there is a reason or purpose in
mind, there is, more often than not, a theory.
When providing care to a patient, we are doing something in a purposeful manner. While doing it, we
are seeking to understand, to uncover meaning, to determine how we should act on the basis of our
understanding. This process describes theorising or theory construction. In this sense, theory is not
some rarefied academic pursuit, but something that every nurse employs many times a day.
From the moment we start to think about something intentionally, we are constructing a theory. When
we speak of construction, we are referring to how something is built or how the parts are put together
to form a whole structure. Frequently we are referring to a building that has been constructed, such as a
house or a bridge. When we bring thoughts together to form some understanding, we are also
constructing. In this instance we are producing a mental building that has about it a sense of wholeness,
which can be explained and shared with others through language.
This draws attention to another significant aspect of this process: when we think, we do so in language.
A set of symbols that label the mental images are constructed, made up of our thoughts and the
connections we make between them. In daily life too, people use different words and symbols to
express meaning. In the same way, all theorists constructing their own theory use their own language
and symbols to express and describe the theory. For example, an American nurse theorist, Jean Watson
(1979), developed a theory that differentiates nursing from medicine, and advocates a moral stance on
caring and nursing as a service driven by specific value systems regarding human caring. According to
this theory, the purpose of nursing is to preserve the dignity of clients.
Similarly, another American theorist, Dorothy Orem (1991) began to see that most people are selfcaring, e.g. they feed themselves, they get themselves out of bed and they wash themselves. This is a
normal way of living for most of the population. Orem saw that self-caring is very important for the
preservation of dignity and independence. How would you feel if someone started feeding you or
helping you to walk when you could do these things very well yourself? Her theory focused on
encouraging patients and helping them towards as much self-caring as possible (Pajnkihar 2003).
Therefore, theory involves thinking (describing) and seeking meanings and connections (explaining), and
often leads to actions (predicting). Such knowledge included in different nursing theories can help not
only to describe and explain what is significant about patient care, but also to assist with the prediction
of what would work with different patients’ problems (Pajnkihar 2003). As we outlined earlier, there are
many nursing theories to help us describe, explain or predict caring practices. However, we need to be
selective in the use of theories and this will be dealt with in a later chapter. We can, of course, adopt,
adapt or develop our own theories, but many of the existing ones have been researched and found to
be useful guides for practice and so might be more useful than simply constructing our own. But as with
the map analogy discussed earlier, we need to consider them as guides that inform our actions (Meleis
1997, 2007). It has been said that there is nothing as practical as a good theory, so theories only have
value if they can be applied in practice.
The issue of what theory actually is will be returned to frequently in this and subsequent chapters. There
are almost as many definitions of theory as there are nursing theories. Various definitions are offered
here with the intention of showing differences in describing and defining what a nursing theory is.
To best understand the various definitions of theory, it would be useful to describe the bits that make
up a theory – the working parts of a theory. We have already alluded to some of these. For instance,
theories describe, explain or predict phenomena. The singular of phenomena is phenomenon. But what,
you may ask, are phenomena? Put simply, phenomena are things we witness through our senses. So a
patient falling is a phenomenon, a dog barking is a phenomenon and a wet floor is a phenomenon.
Kennedy’s assassination was a phenomenon and wound healing is a phenomenon (see Reflective
Reflective Exercise 1.3: Phenomena
Consider your average day in class or at work. Identify five phenomena that you have seen, heard,
smelled, touched or tasted.
As you have read, theories seek to explain, describe or predict these phenomena.
When we put a name to a phenomenon, it becomes a concept. To take the examples discussed earlier of
a patient falling, a dog barking, a wet floor and an assassination are all concepts. They tend to
encapsulate what the phenomenon is. If we can define the concepts, they help clarify our view of the
phenomena. So, concepts are the building blocks of a theory (see Reflective Exercise 1.4).
Reflective Exercise 1.4: Concepts
See if you can put a label or name to the five phenomena you identified in Reflective Exercise 1.3. If you
can provide a name such that any other person hearing it would know what the phenomenon is then so
much the better. Try to define each of the concepts in one sentence.
When two or more concepts are linked, this is called a proposition. The obvious proposition from one of
the concepts introduced earlier would be the link between a wet floor and a patient falling. So a
proposition would be that the patient fell because of the wet floor. This would be termed a causal
proposition. There are different types of propositions and, as you will see in the following, they can be
seen as the cement or mortar that binds the concepts (bricks) together to form the structure (a theory)
(see Reflective Exercise 1.5).
Reflective Exercise 1.5: Proposition
Consider the names (concepts) you gave to your five phenomena in Reflective Exercise 1.4. Think of
other possible concepts they could be linked to. For example, let’s say one of your phenomena was
seeing a car crash on your way to work or to class. The name you put on this to make it a concept was
‘road traffic accident’. Anyone seeing this concept would know what the phenomenon was. What other
concepts in the situation could be linked to this concept? Let’s say that the traffic lights were not
working at that junction or the road was wet and slippery. These are also phenomena and can be
expressed as concepts. When you form linkages or relationships between different phenomena, you are
Another term that you will find when you study nursing theory is assumption. An assumption is
something that you accept as true even though it has not been tested. For instance, I think readers can
assume that people are composed of biological, psychological and social dimensions. If you take the
example of the car crash, you may assume that the driver did not want to crash (see Key Concepts 1.1).
Key Concepts 1.1
Phenomenon: something that you experience through your senses
Concept: a name given to a phenomenon
Proposition: a statement that links concepts together different types of relationships
Assumption: something that you take for granted even though it has not been proved or tested
From these exercises you will hopefully be able to understand some of the definitions that exist to
explain nursing theory. For example, Dickoff and James (1968: 105) defined nursing theory as a
‘conceptual system or framework’ whereas Chinn and Jacobs (1979: 2) saw theory as ‘an internally
consistent body of relational statements about phenomena which is useful for prediction and control’.
Chinn & Jacobs later developed the definition further. The more recent definition is more complex
(Chinn & Jacobs 1987), but you should understand its meaning: ‘a set of concepts, definitions and
propositions that project a systematic view of phenomena by designating specific interrelationships
among concepts for the purpose of describing, explaining, predicting or controlling the phenomenon’.
The definition highlights the content, context and function of the theory, pointing to the construction of
a theory (concepts, definitions and propositions) and the interrelationships between theory elements
and functions of a theory (describing, explaining and predicting).
It is important to note here that this description is close to the original meaning of the term ‘theory’. It is
derived from the Ancient Greek term theoria, meaning a spectacle, i.e. something that is witnessed - in
other words, a phenomenon!
Another definition, this time by Im and Meleis (1999: 11), drew attention to a theory as something that
is purposefully structured: ‘an organised, coherent and systematic articulation of a set of statements
related to significant questions in a discipline that are communicated in a meaningful whole to describe
or explain a phenomenon or a set of phenomena’. This clearly states that the theory is a body of
knowledge of nursing, and provides answers to questions that are of interest to nursing.
However, more recently, Chinn and Kramer (2008: 219) defined theory as ‘a creative and rigorous
structuring of ideas that project a tentative, purposeful, and systematic view of phenomena’. Earlier in
this chapter, we wrote that theories may reflect fact or, indeed, be totally untrue. When a theory is
tested many times and stands up to that test, in theoretical language it is beginning to take on the shape
of a law. Theofanidis and Fountouki (2008: 16) stated that a theory can be defined as ‘a statement
representing a law waiting to happen’. For example, let us say a theory of skin integrity led nurses to
turn bed-bound patients once every two hours to prevent pressure ulcers. If this was consistently tested
through research and found to be true then the theory could be taking on law-like properties.
According to these various definitions, a nursing theory is constructed out of specific nursing
phenomena represented as concepts, definitions, assumptions and propositions that help describe,
explain or predict how nursing may support and help patients, families or society (see Key Concepts 1.2
and Reflective Exercise 1.6).
Key Concepts 1.2
A priori knowledge: knowledge that arises before experience or, more accurately, without the need for
A posteriori knowledge: sometimes called propositional knowledge, this is where knowledge emerges
from experience, and we make deductions arising from this. In this instance, it is termed a posteriori to
denote that it is derived from empirical experience, which, in all instances, precedes it and is its source
Reflective Exercise 1.6: Defining theory
Using your learning and library resources, look up the definitions for phenomena, concepts,
propositions, description, explanation and prediction. See if you can find six different definitions of a
theory. They do not have to be from the nursing literature. You should find that most of the definitions
are composed of the words in the list.
To summarise, the definitions point out that:
• Theory consists of an organised and coherent set of concepts (two or more), definitions and
propositions (two or more) that encapsulate specific phenomena in a purposeful and systematic way.
• The proposition(s) must claim a relationship or relationships between the concepts contained in the
• It is a purposeful process and demands creative and rigorous structuring and tentative description of
• The purpose of a theory is to describe, explain and/or predict.
• Theories use specific language, ideas or sometimes symbols to give answers to practice-based
• Theories are made up of mental building blocks and they can be explained and shared with others
Some of the definitions proposed here are rather complex. ...
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