·-•
••
Fourth Edition
Nursing Theories
and Nursing Practice
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Nursing Theories & Nursing Practice
Fourth Edition
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Nursing Theories & Nursing Practice
Fourth Edition
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN
Marilyn E. Parker, PhD, RN, FAAN
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Library of Congress Cataloging-in-Publication Data
Nursing theories and nursing practice.
Nursing theories & nursing practice / [edited by] Marlaine C. Smith, Marilyn E. Parker. — Fourth edition.
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Preceded by Nursing theories and nursing practice / [edited by] Marilyn E. Parker, Marlaine C. Smith.
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Preface to the Fourth Edition
This book offers the perspective that nursing is
a professional discipline with a body of knowledge that guides its practice. Nursing theories
are an important part of this body of knowledge, and regardless of complexity or abstraction, they reflect phenomena central to the
discipline, and should be used by nurses to
frame their thinking, action, and being in the
world. As guides, nursing theories are practical
in nature and facilitate communication with
those we serve as well as with colleagues, students, and others practicing in health-related
services. We hope this book illuminates for the
readers the interrelationship between nursing
theories and nursing practice, and that this understanding will transform practice to improve
the health and quality of life of people who are
recipients of nursing care.
This very special book is intended to honor
the work of nursing theorists and nurses who
use these theories in their day-to-day practice.
Our foremost nursing theorists have written
for this book, or their theories have been described by nurses who have comprehensive
knowledge of the theorists’ ideas and who have
a deep respect for the theorists as people,
nurses, and scholars. To the extent possible,
contributing authors have been selected by
theorists to write about their work. Three
middle-range theories have been added to this
edition of the book, bringing the total number
of middle-range theories to twelve. Obviously,
it was not possible to include all existing
middle-range theories in this volume; however, the expansion of this section illustrates
the recent growth in middle-range theory development in nursing. Two chapters from the
third edition, including Levine’s conservation
theory and Paterson & Zderad’s humanistic
nursing have been moved to supplementary online resources at http://davisplus.fadavis.com.
This book is intended to help nursing students in undergraduate, masters, and doctoral
nursing programs explore and appreciate nursing theories and their use in nursing practice
and scholarship. In addition, and in response
to calls from practicing nurses, this book is intended for use by those who desire to enrich
their practice by the study of nursing theories
and related illustrations of nursing practice.
The contributing authors describe theory development processes and perspectives on the
theories, giving us a variety of views for the
twenty-first century and beyond. Each chapter
of the book includes descriptions of a theory,
its applications in both research and practice,
and an example that reflects how the theory
can guide practice. We anticipate that this
overview of the theory and its applications will
lead to deeper exploration of the theory, leading students to consult published works by the
theorists and those working closely with the
theory in practice or research.
There are six sections in the book. The first
provides an overview of nursing theory and a
focus for thinking about evaluating and choosing a nursing theory for use in practice. For
this edition, the evolution of nursing theory
was added to Chapter 1. Section II introduces
the work of early nursing scholars whose ideas
provided a foundation for more formal theory
development. The nursing conceptual models
and grand theories are clustered into three
parts in Sections III, IV, and V. Section III
contains those theories classified within the
interactive-integrative paradigm, and those in
v
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Preface to the Fourth Edition
the unitary-transformative paradigm are included in Section IV. Grand theories that are
focused on the phenomena of care or caring
appear in Section V. The final section contains
a selection of middle-range theories.
An outline at the beginning of each chapter
provides a map for the contents. Major points
are highlighted in each chapter. Since this
book focuses on the relationship of nursing
theory to nursing practice, we invited the
authors to share a practice exemplar. You will
notice that some practice exemplars were written by someone other than the chapter author.
In this edition the authors also provided
content about research based on the theory.
Because of page limitations you can find
additional chapter content online at http://
davisplus.fadavis.com. While every attempt
was made to follow a standard format for each
of the chapters throughout the book, some of
the chapters vary from this format; for example, some authors chose not to include practice
exemplars.
The book’s website features materials that
will enrich the teaching and learning of these
nursing theories. Materials that will be helpful
for teaching and learning about nursing theories are included as online resources. For example, there are case studies, learning activities,
and PowerPoint presentations included on
both the instructor and student websites. Other
online resources include additional content,
more extensive bibliographies and longer biographies of the theorists. Dr. Shirley Gordon
and a group of doctoral students from Florida
Atlantic University developed these ancillary
materials for the third edition. For this edition,
the ancillary materials for students and faculty
were updated by Diane Gullett, a PhD candidate at Florida Atlantic University. She developed all materials for the new chapters as well
as updating ancillary materials for chapters that
appeared in the third edition. We are so grateful to Diane and Shirley for their creativity and
leadership and to the other doctoral students for
their thoughtful contributions to this project .
We hope that this book provides a useful
overview of the latest theoretical advances of
many of nursing’s finest scholars. We are
grateful for their contributions to this book. As
editors we’ve found that continuing to learn
about and share what we love nurtures our
growth as scholars, reignites our passion and
commitment, and offers both fun and frustration along the way. We continue to be grateful
for the enthusiasm for this book shared by
many nursing theorists and contributing
authors and by scholars in practice and
research who bring theories to life. For us, it
has been a joy to renew friendships with colleagues who have contributed to past editions
and to find new friends and colleagues whose
theories enriched this edition.
Nursing Theories and Nursing Practice, now
in the fourth edition, has roots in a series of
nursing theory conferences held in South
Florida, beginning in 1989 and ending when
efforts to cope with the aftermath of Hurricane
Andrew interrupted the energy and resources
needed for planning and offering the Fifth
South Florida Nursing Theory Conference.
Many of the theorists in this book addressed
audiences of mostly practicing nurses at these
conferences. Two books stimulated by those
conferences and published by the National
League for Nursing are Nursing Theories in
Practice (1990) and Patterns of Nursing Theories
in Practice (1993).
For me (Marilyn), even deeper roots of this
book are found early in my nursing career,
when I seriously considered leaving nursing for
the study of pharmacy. In my fatigue and frustration, mixed with youthful hope and desire
for more education, I could not answer the
question “What is nursing?” and could not distinguish the work of nursing from other tasks
I did every day. Why should I continue this
work? Why should I seek degrees in a field
that I could not define? After reflecting on
these questions and using them to examine my
nursing, I could find no one who would consider the questions with me. I remember being
asked, “Why would you ask that question? You
are a nurse; you must surely know what nursing is.” Such responses, along with a drive for
serious consideration of my questions, led me
to the library. I clearly remember reading several descriptions of nursing that, I thought,
could just as well have been about social work
or physical therapy. I then found nursing
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Preface to the Fourth Edition
defined and explained in a book about education of nurses written by Dorothea Orem.
During the weeks that followed, as I did my
work of nursing in the hospital, I explored
Orem’s ideas about why people need nursing,
nursing’s purposes, and what nurses do. I
found a fit between her ideas, as I understood
them, with my practice, and I learned that I
could go even further to explain and design
nursing according to these ways of thinking
about nursing. I discovered that nursing shared
some knowledge and practices with other services, such as pharmacy and medicine, and I
began to distinguish nursing from these related
fields of practice. I decided to stay in nursing
and made plans to study and work with
Dorothea Orem. In addition to learning about
nursing theory and its meaning in all we do, I
learned from Dorothea that nursing is a unique
discipline of knowledge and professional practice. In many ways, my earliest questions about
nursing have guided my subsequent study and
work. Most of what I have done in nursing has
been a continuation of my initial experience of
the interrelations of all aspects of nursing
scholarship, including the scholarship that is
nursing practice. Over the years, I have been
privileged to work with many nursing scholars,
some of whom are featured in this book.
My love for nursing and my respect for our
discipline and practice have deepened, and
knowing now that these values are so often
shared is a singular joy.
Marlaine’s interest in nursing theory had
similar origins to Marilyn’s. As a nurse pursuing an interdisciplinary master’s degree in public health, I (Marlaine) recognized that while
all the other public health disciplines had some
unique perspective to share, public health
nursing seemed to lack a clear identity. In
search of the identity of nursing I pursued a
second master’s in nursing. At that time nursing theory was beginning to garner attention,
and I learned about it from my teachers and
mentors Sr. Rosemary Donley, Rosemarie
Parse, and Mary Jane Smith. This discovery was
the answer I was seeking, and it both expanded
and focused my thinking about nursing. The
question of “What is nursing?” was answered
for me by these theories and I couldn’t get
vii
enough! It led to my decision to pursue my
PhD in Nursing at New York University
where I studied with Martha Rogers. During
this same time I taught at Duquesne University
with Rosemarie Parse and learned more about
Man-Living-Health, which is now humanbecoming. I conducted several studies based on
Rogers’ conceptual system and Parse’s theory.
At theory conferences I was fortunate to
dialogue with Virginia Henderson, Hildegard
Peplau, Imogene King, and Madeleine
Leininger. In 1988 I accepted a faculty position at the University of Colorado when Jean
Watson was Dean. The School of Nursing was
guided by a caring philosophy and framework
and I embraced caring as a central focus of the
discipline of nursing. As a unitary scholar, I
studied Newman’s theory of health as expanding consciousness and was intrigued by it, so
for my sabbatical I decided to study it further
as well as learn more about the unitary appreciative inquiry process that Richard Cowling
was developing.
We both have been fortunate to hold faculty
appointments in universities where nursing theory has been valued, and we are fortunate today
to hold positions at the Christine E. Lynn College of Nursing at Florida Atlantic University,
where faculty and students ground their teaching scholarship and practice on caring theories,
including nursing as caring, developed by Dean
Anne Boykin and a previous faculty member at
the College, Savina Schoenhofer. Many faculty
colleagues and students continue to help us
study nursing and have contributed to this book
in ways we would never have adequate words to
acknowledge. We are grateful to our knowledgeable colleagues who reviewed and offered
helpful suggestions for chapters of this book,
and we sincerely thank those who contributed
to the book as chapter authors. It is also our
good fortune that many nursing theorists and
other nursing scholars live in or visit our lovely
state of Florida. Since the first edition of this
book was published, we have lost many nursing
theorists. Their work continues through those
refining, modifying, testing, and expanding the
theories. The discipline of nursing is expanding
as research and practice advances existing theories
and as new theories emerge. This is especially
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Preface to the Fourth Edition
important at a time when nursing theory can
provide what is missing and needed most in
health care today.
All four editions of this book have been nurtured by Joanne DaCunha, an expert nurse and
editor for F. A. Davis Company, who has shepherded this project and others because of her
love of nursing. Near the end of this project
Joanne retired, and Susan Rhyner, our new editor, led us to the finish line. We are both grateful for their wisdom, kindness, patience and
understanding of nursing. We give special
thanks to Echo Gerhart, who served as our contact and coordinator for this project. Marilyn
thanks her husband, Terry Worden, for his
abiding love and for always being willing to help,
and her niece, Cherie Parker, who represents
many nurses who love nursing practice and
scholarship and thus inspire the work of this
book. Marlaine acknowledges her husband
Brian and her children, Kirsten, Alicia, and
Brady, and their spouses, Jonathan Vankin and
Tori Rutherford, for their love and understanding. She honors her parents, Deno and Rose
Cappelli, for instilling in her the love of learning,
the value of hard work, and the importance of
caring for others, and dedicates this book to her
granddaughter Iyla and the new little one who
is scheduled to arrive as this book is released.
Marilyn E. Parker,
Olathe, Kansas
Marlaine C. Smith,
Boca Raton, Florida
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Nursing Theorists
Elizabeth Ann Manhart Barrett, PhD, RN, FAAN
Professor Emerita
Hunter College
City University of New York
New York, New York
Charlotte D. Barry, PhD, RN, NCSN, FAAN
Professor of Nursing
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Anne Boykin, PhD, RN*
Dean and Professor Emerita
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Barbara Montgomery Dossey, PhD, RN, AHN-BC, FAAN,
HWNC-BC
Co-Director, International Nurse Coach
Association
Core Faculty, Integrative Nurse Coach
Certificate Program
Miami, Florida
Joanne R. Duffy, PhD, RN, FAAN
Endowed Professor of Research and
Evidence-based Practice and Director
of the PhD Program
West Virginia University
Morgantown, West Virginia
Helen L. Erickson*
Professor Emerita
University of Texas at Austin
Austin, Texas
Lydia Hall†
Virginia Henderson†
Imogene King†
Katharine Kolcaba, PhD, RN
Associate Professor Emeritus Adjunct
The University of Akron
Akron, Ohio
Madeleine M. Leininger†
Patricia Liehr, PhD, RN
Professor
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Rozzano C. Locsin, PhD, RN
Professor Emeritus
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Afaf I. Meleis, PhD, DrPS(hon), FAAN
Professor of Nursing and Sociology
University of Pennsylvania
Philadelphia, Pennsylvania
Betty Neuman, PhD, RN, PLC, FAAN
Beverly, Ohio
Margaret Newman, RN, PhD, FAAN
Professor Emerita
University of Minnesota College of Nursing
Saint Paul, Minnesota
Dorothea E. Orem†
Ida Jean Orlando (Pelletier)†
Marilyn E. Parker, PhD, RN, FAAN
Professor Emerita
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Dorothy Johnson†
ix
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x
Nursing Theorists
Rosemarie Rizzo Parse, PhD, FAAN
Distinguished Professor Emeritus
Marcella Niehoff School of Nursing
Loyola University Chicago
Chicago, Illinois
Hildegard Peplau†
Marilyn Anne Ray, PhD, RN, CTN
Professor Emerita
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Pamela G. Reed, PhD, RN, FAAN
Professor
University of Arizona
Tucson, Arizona
Martha E. Rogers†
Sister Callista Roy, PhD, RN, FAAN
Professor and Nurse Theorist
William F. Connell School of Nursing
Boston College
Chestnut Hill, Massachusetts
Savina O. Schoenhofer, PhD, RN
Professor of Nursing
University of Mississippi
Oxford, Mississippi
Marlaine C. Smith, PhD, RN, AHN-BC, FAAN
Dean and Helen K. Persson Eminent Scholar
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
*Retired
†Deceased
Mary Jane Smith, PhD, RN
Professor
West Virginia University
Morgantown, West Virginia
Mary Ann Swain, PhD
Professor and Director, Doctoral Program
Decker School of Nursing
Binghamton University
Binghamton, New York
Kristen M. Swanson, PhD, RN, FAAN
Dean
Seattle University
Seattle, Washington
Evelyn Tomlin*
Joyce Travelbee†
Meredith Troutman-Jordan, PhD, RN
Associate Professor
University of North Carolina
Chapel Hill, North Carolina
Jean Watson, PhD, RN, AHN-BC, FAAN
Distinguished Professor Emeritus
University of Colorado at Denver—Anschutz
Campus
Aurora, Colorado
Ernestine Wiedenbach†
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Contributors
Patricia Deal Aylward, MSN, RN, CNS
Assistant Professor
Santa Fe Community College
Gainesville, Florida
Howard Karl Butcher, PhD, RN, PMHCNS-BC
Associate Professor
University of Iowa
Iowa City, Iowa
Lynne M. Hektor Dunphy, PhD, APRN-BC
Associate Dean for Practice and Community
Engagement
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Laureen M. Fleck, PhD, FNP-BC, FAANP
Associate Faculty
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Maureen A. Frey, PhD, RN*
Shirley C. Gordon, PhD, RN
Professor and Assistant Dean Graduate Practice
Programs
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
*Retired.
xi
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xii
Contributors
Diane Lee Gullett, RN, MSN, MPH
Doctoral Candidate
Christine E. Lynn College of NursingFlorida
Atlantic University
Boca Raton, Florida
Beth M. King, PhD, RN, PMHCNS-BC
Assistant Professor and RN-BSN Coordinator
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Donna L. Hartweg, PhD, RN
Professor Emerita and Former Director
Illinois Wesleyan University
Bloomington, Illinois
Lois White Lowry, DNSc, RN*
Professor Emerita
East Tennessee State University
Johnson City, Tennessee
Bonnie Holaday, PhD, RN, FAAN
Professor
Clemson University
Clemson, South Carolina
Violet M. Malinski, PhD, MA, RN
Associate Professor
College of New Rochelle
New Rochelle, New York
Mary B. Killeen, PhD, RN, NEA-BC
Consultant
Evidence Based Practice Nurse Consultants,
LLC
Howell, Michigan
Ann R. Peden, RN, CNS, DSN
Professor and Chair
Capital University
Columbus, Ohio
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Contributors
Margaret Dexheimer Pharris, PhD, RN, CNE, FAAN
Associate Dean for Nursing
St. Catherine University
St. Paul, Minnesota
Jacqueline Staal, MSN, ARNP, FNP-BC
PhD Candidate
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
Maude Rittman, PhD, RN
Associate Chief of Nursing Service for Research
Gainesville Veteran’s Administration
Medical Center
Gainesville, Florida
Marian C. Turkel, PhD, RN, NEA-BC, FAAN
Director of Professional Nursing Practice
Holy Cross Medical Center
Fort Lauderdale, Florida
Pamela Senesac, PhD, SM, RN
Assistant Professor
University of Massachusetts
Shrewsbury, Massachusetts
Hiba Wehbe-Alamah, PhD, RN, FNP-BC, CTN-A
Associate Professor
University of Michigan-Flint
Flint, Michigan
Christina L. Sieloff, PhD, RN
Associate Professor
Montana State University
Billings, Montana
xiii
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xiv
Contributors
Kelly White, RN, PhD, FNP-BC
Assistant Professor
South University
West Palm Beach, Florida
Terri Kaye Woodward, MSN, RN, CNS, AHN-BC, HTCP
Founder
Cocreative Wellness
Denver, Colorado
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Reviewers
Ferrona Beason, PhD, ARNP
Assistant Professor in Nursing
Barry University – Division of Nursing
Miami Shores, Florida
Abimbola Farinde, PharmD, MS
Clinical Pharmacist Specialist
Clear Lake Regional Medical Center
Webster, Texas
Lori S. Lauver, PhD, RN, CPN, CNE
Associate Professor
Jefferson School of Nursing
Thomas Jefferson University
Philadelphia, Pennsylvania
Carol L. Moore, PhD, APRN, CNS
Assistant Professor of Nursing, Coordinator,
Graduate Nursing Studies
Fort Hays State University
Hays, Kansas
Kathleen Spadaro, PhD, PMHCNS, RN
MSN Program Co-coordinator & Assistant
Professor of Nursing
Chatham University
Pittsburgh, Pennsylvania
Elisheva Lightstone, BScN, MSc
Professor
Department of Nursing
Seneca College
King City, Ontario, Canada
xv
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Contents
Section I An Introduction to Nursing Theory, 1
Chapter 1 Nursing Theory and the Discipline of Nursing, 3
Marlaine C. Smith and Marilyn E. Parker
Chapter 2 A Guide for the Study of Nursing Theories for Practice, 19
Marilyn E. Parker and Marlaine C. Smith
Chapter 3 Choosing, Evaluating, and Implementing Nursing Theories
for Practice, 23
Marilyn E. Parker and Marlaine C. Smith
Section II Conceptual Influences on the Evolution of Nursing
Theory, 35
Chapter 4 Florence Nightingale’s Legacy of Caring and Its Applications, 37
Lynne M. Hektor Dunphy
Chapter 5 Early Conceptualizations About Nursing, 55
Shirley C. Gordon
Chapter 6 Nurse-Patient Relationship Theories, 67
Ann R. Peden, Jacqueline Staal, Maude Rittman, and Diane Lee Gullett
Section III Conceptual Models/Grand Theories in the IntegrativeInteractive Paradigm, 87
Chapter 7 Dorothy Johnson’s Behavioral System Model and Its
Applications, 89
Bonnie Holaday
Chapter 8 Dorothea Orem’s Self-Care Deficit Nursing Theory, 105
Donna L. Hartweg
xvii
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xviii
Contents
Chapter 9 Imogene King’s Theory of Goal Attainment, 133
Christina L. Sieloff and Maureen A. Frey
Chapter 10 Sister Callista Roy’s Adaptation Model, 153
Pamela Sensac and Sister Callista Roy
Chapter 11 Betty Neuman’s Systems Model, 165
Lois White Lowry and Patricia Deal Aylward
Chapter 12 Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s
Theory of Modeling and Role Modeling, 185
Helen L. Erickson
Chapter 13 Barbara Dossey’s Theory of Integral Nursing, 207
Barbara Montgomery Dossey
Section IV Conceptual Models and Grand Theories in the
Unitary–Transformative Paradigm, 235
Chapter 14 Martha E. Rogers Science of Unitary Human Beings, 237
Howard Karl Butcher and Violet M. Malinski
Chapter 15 Rosemarie Rizzo Parse’s Humanbecoming Paradigm, 263
Rosemarie Rizzo Parse
Chapter 16 Margaret Newman’s Theory of Health as Expanding
Consciousness, 279
Margaret Dexheimer Pharris
Section V Grand Theories about Care or Caring, 301
Chapter 17 Madeleine Leininger’s Theory of Culture Care Diversity
and Universality, 303
Hiba Wehbe-Alamah
Chapter 18 Jean Watson’s Theory of Human Caring, 321
Jean Watson
Chapter 19 Theory of Nursing as Caring, 341
Anne Boykin and Savina O. Schoenhofer
Section VI Middle-Range Theories, 357
Chapter 20 Transitions Theory, 361
Afaf I. Meleis
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Contents
Chapter 21 Katharine Kolcaba’s Comfort Theory, 381
Katharine Kolcaba
Chapter 22 Joanne Duffy’s Quality-Caring Model©, 393
Joanne R. Duffy
Chapter 23 Pamela Reed’s Theory of Self-Transcendence, 411
Pamela G. Reed
Chapter 24 Patricia Liehr and Mary Jane Smith’s Story Theory, 421
Patricia Liehr and Mary Jane Smith
Chapter 25 The Community Nursing Practice Model, 435
Marilyn E. Parker, Charlotte D. Barry. and Beth M. King
Chapter 26 Rozzano Locsin’s Technological Competency as Caring
in Nursing, 449
Rozzano C. Locsin
Chapter 27 Marilyn Anne Ray’s Theory of Bureaucratic Caring, 461
Marilyn Anne Ray and Marian C. Turkel
Chapter 28 Troutman-Jordan’s Theory of Successful Aging, 483
Meredith Troutman-Jordan
Chapter 29 Barrett’s Theory of Power as Knowing Participation
in Change, 495
Elizabeth Ann Manhart Barrett
Chapter 30 Marlaine Smith’s Theory of Unitary Caring, 509
Marlaine C. Smith
Chapter 31 Kristen Swanson’s Theory of Caring, 521
Kristen M. Swanson
Index, 533
xix
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3312_Ch01_001-018 26/12/14 9:35 AM Page 1
Section
I
An Introduction to Nursing Theory
1
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Section
I
An Introduction to Nursing Theory
In this first section of the book, you will be introduced to the purpose of nursing
theory and shown how to study, analyze, and evaluate it for use in nursing
practice. If you are new to the idea of theory in nursing, the chapters in this section
will orient you to what theory is, how it fits into the evolution and context of nursing
as a professional discipline, and how to approach its study and evaluation. If
you have studied nursing theory in the past, these chapters will provide you with
additional knowledge and insight as you continue your study.
Nursing is a professional discipline focused on the study of human health and
healing through caring. Nursing practice is based on the knowledge of nursing,
which consists of its philosophies, theories, concepts, principles, research findings,
and practice wisdom. Nursing theories are patterns that guide the thinking about
nursing. All nurses are guided by some implicit or explicit theory or pattern of
thinking as they care for their patients. Too often, this pattern of thinking is implicit
and is colored by the lens of diseases, diagnoses, and treatments. This does not
reflect practice from the disciplinary perspective of nursing. The major reason for
the development and study of nursing theory is to improve nursing practice and,
therefore, the health and quality of life of those we serve.
The first chapter in this section focuses on nursing theory within the context of
nursing as an evolving professional discipline. We examine the relationship of
nursing theory to the characteristics of a discipline. You’ll learn new words that
describe parts of the knowledge structure of the discipline of nursing, and we’ll
speculate about the future of nursing theory as nursing, health care, and our global
society change. Chapter 2 is a guide to help you study the theories in this book.
Use this guide as you read and think about how nursing theory fits in your practice. Nurses embrace theories that fit with their values and ways of thinking. They
choose theories to guide their practice and to create a practice that is meaningful
to them. Chapter 3 focuses on the selection, evaluation, and implementation of
theory for practice. Students often get the assignment of evaluating or critiquing
a nursing theory. Evaluation is coming to some judgment about value or worth
based on criteria. Various sets of criteria exist for you to use in theory evaluation.
We introduce some that you can explore further. Finally, we offer reflections on
the process of implementing theory-guided practice models.
2
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Nursing Theory and the
Discipline of Nursing
Chapter
1
M ARLAINE C. S MITH AND
M ARILYN E. P ARKER
The Discipline of Nursing
Definitions of Nursing Theory
The Purpose of Theory in a Professional
Discipline
The Evolution of Nursing Science
The Structure of Knowledge in the
Discipline of Nursing
Nursing Theory and the Future
Summary
References
Marlaine C. Smith
Marilyn E. Parker
What is nursing? At first glance, the question
may appear to be one with an obvious answer, but when it is posed to nurses, many
define nursing by providing a litany of functions and activities. Some answer with the
elements of the nursing process: assessing,
planning, implementing, and evaluating. Others might answer that nurses coordinate a
patient’s care.
Defining nursing in terms of the nursing
process or by functions or activities nurses perform is problematic. The phases of the nursing
process are the same steps we might use to
solve any problem we encounter, from a broken computer to a failing vegetable garden.
We assess the situation to determine what is
going on and then identify the problem; we
plan what to do about it, implement our plan,
and then evaluate whether it works. The nursing process does nothing to define nursing.
Defining ourselves by tasks presents other
problems. What nurses do—that is, the functions associated with practice—differs based
on the setting. For example, a nurse might
start IVs, administer medications, and perform treatments in an acute care setting. In a
community-based clinic, a nurse might teach
a young mother the principles of infant feeding
or place phone calls to arrange community
resources for a child with special needs. Multiple professionals and nonprofessionals may
perform the same tasks as nurses, and persons
with the ability and authority to perform certain tasks change based on time and setting.
For example, both physicians and nurses may
listen to breath sounds and recognize the presence of rales. Both nurses and social workers
might do discharge planning. Both nurses
3
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SECTION I • An Introduction to Nursing Theory
and family members might change dressings,
monitor vital signs, and administer medications,
so defining nursing based solely on functions or
activities performed is not useful.
To answer the question “What is nursing?”
we must formulate nursing’s unique identity
as a field of study or discipline. Florence
Nightingale is credited as the founder of modern nursing, the one who articulated its distinctive focus. In her book Notes on Nursing:
What It Is and What It Is Not (Nightingale,
1859/1992), she differentiated nursing from
medicine, stating that the two were distinct
practices. She defined nursing as putting the
person in the best condition for nature to act,
insisting that the focus of nursing was on
health and the natural healing process, not on
disease and reparation. For her, creating an
environment that provided the conditions for
natural healing to occur was the focus of nursing. Her beginning conceptualizations were
the seeds for the theoretical development of
nursing as a professional discipline.
In this chapter, we situate the understanding of nursing theory within the context of
the discipline of nursing. We define the discipline of nursing, describe the purpose of
theory for the discipline of nursing, review
the evolution of nursing science, identify the
structure of the discipline of nursing, and
speculate on the future place of nursing theory in the discipline.
The Discipline of Nursing
Every discipline has a unique focus that directs
the inquiry within it and distinguishes it from
other fields of study (Smith, 2008, p. 1). Nursing knowledge guides its professional practice;
therefore, it is classified as a professional discipline. Donaldson and Crowley (1978) stated
that a discipline “offers a unique perspective, a
distinct way of viewing . . . phenomena, which
ultimately defines the limits and nature of its
inquiry” (p. 113). Any discipline includes networks of philosophies, theories, concepts, approaches to inquiry, research findings, and
practices that both reflect and illuminate its distinct perspective. The discipline of nursing is
formed by a community of scholars, including
nurses in all nursing venues, who share a
commitment to values, knowledge, and
processes to guide the thought and work of
the discipline.
The classic work of King and Brownell
(1976) is consistent with the thinking of nursing scholars (Donaldson & Crowley, 1978;
Meleis, 1977) about the discipline of nursing.
These authors have elaborated attributes that
characterize all disciplines. As you will see in
the discussion that follows, the attributes of
King and Brownell provide a framework that
contextualizes nursing theory within the discipline of nursing.
Expression of Human Imagination
Members of any discipline imagine and create
structures that offer descriptions and explanations of the phenomena that are of concern to
that discipline. These structures are the theories
of that discipline. Nursing theory is dependent
on the imagination of nurses in practice, administration, research, and teaching, as they
create and apply theories to improve nursing
practice and ultimately the lives of those they
serve. To remain dynamic and useful, the discipline requires openness to new ideas and innovative approaches that grow out of members’
reflections and insights.
Domain
A professional discipline must be clearly
defined by a statement of its domain—the
boundaries or focus of that discipline. The domain of nursing includes the phenomena of interest, problems to be addressed, main content
and methods used, and roles required of the
discipline’s members (Kim, 1997; Meleis,
2012). The processes and practices claimed by
members of the disciplinary community grow
out of these domain statements. Nightingale
provided some direction for the domain of the
discipline of nursing. Although the disciplinary focus has been debated, there is some
degree of consensus. Donaldson and Crowley
(1978, p. 113) identified the following as the
domain of the discipline of nursing:
1. Concern with principles and laws that
govern the life processes, well-being, and
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing
optimal functioning of human beings, sick
or well
2. Concern with the patterning of human
behavior in interactions with the environment in critical life situations
3. Concern with the processes through
which positive changes in health status
are affected
Fawcett (1984) described the metaparadigm as a way to distinguish nursing from
other disciplines. The metaparadigm is very
general and intended to reflect agreement
among members of the discipline about the
field of nursing. This is the most abstract level
of nursing knowledge and closely mirrors beliefs held about nursing. By virtue of being
nurses, all nurses have some awareness of
nursing’s metaparadigm. However, because
the term may not be familiar, it offers no direct guidance for research and practice (Kim,
1997; Walker & Avant, 1995). The metaparadigm consists of four concepts: persons, environment, health, and nursing. According to
Fawcett, nursing is the study of the interrelationship among these four concepts.
Modifications and alternative concepts for
this framework have been explored throughout
the discipline (Fawcett, 2000). For example,
some nursing scholars have suggested that
“caring” replace “nursing” in the metaparadigm
(Stevenson & Tripp-Reimer, 1989). Kim
(1987, 1997) set forth four domains: client,
client–nurse encounters, practice, and environment. In recent years, increasing attention has
been directed to the nature of nursing’s relationship with the environment (Kleffel, 1996;
Schuster & Brown, 1994).
Others have defined nursing as the study
of “the health or wholeness of human beings
as they interact with their environment”
(Donaldson & Crowley, 1978, p. 113), the life
process of unitary human beings (Rogers,
1970), care or caring (Leininger, 1978; Watson,
1985), and human–universe–health interrelationships (Parse, 1998). A widely accepted focus
statement for the discipline was published
by Newman, Sime, and Corcoran-Perry
(1991): “Nursing is the study of caring in the
human health experience” (p. 3). A consensus
5
statement of philosophical unity in the discipline was published by Roy and Jones (2007).
Statements include the following:
• The human being is characterized by
wholeness, complexity, and consciousness.
• The essence of nursing involves the nurse’s
true presence in the process of humanto-human engagement.
• Nursing theory expresses the values and beliefs of the discipline, creating a structure to
organize knowledge and illuminate nursing
practice.
• The essence of nursing practice is the nurse–
patient relationship.
In 2008, Newman, Smith, DexheimerPharris, and Jones revisited the disciplinary
focus asserting that relationship was central
to the discipline, and the convergence of
seven concepts—health, consciousness, caring, mutual process, presence, patterning, and
meaning—specified relationship in the professional discipline of nursing. Willis, Grace,
and Roy (2008) posited that the central unifying focus for the discipline is facilitating
humanization, meaning, choice, quality of
life, and healing in living and dying (p. E28).
Finally, Litchfield and Jondorsdottir (2008)
defined the discipline as the study of humanness in the health circumstance. Smith (1994)
defined the domain of the discipline of nursing as “the study of human health and healing
through caring” (p. 50). For Smith (2008),
“nursing knowledge focuses on the wholeness
of human life and experience and the
processes that support relationship, integration, and transformation” (p. 3). Nursing
conceptual models, grand theories, middlerange theories, and practice theories explicate
the phenomena within the domain of nursing. In addition, the focus of the nursing discipline is a clear statement of social mandate
and service used to direct the study and practice of nursing (Newman et al., 1991).
Syntactical and Conceptual Structures
Syntactical and conceptual structures are
essential to any discipline and are inherent
in nursing theories. The conceptual structure
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SECTION I • An Introduction to Nursing Theory
delineates the proper concerns of nursing,
guides what is to be studied, and clarifies accepted ways of knowing and using content of
the discipline. This structuṙe is grounded in the
focus of the discipline. The conceptual structure relates concepts within nursing theories.
The syntactical structures help nurses and
other professionals to understand the talents,
skills, and abilities that must be developed
within the community. This structure directs
descriptions of data needed from research, as
well as evidence required to demonstrate the
effect on nursing practice. In addition, these
structures guide nursing’s use of knowledge in
research and practice approaches developed by
related disciplines. It is only by being thoroughly grounded in the discipline’s concepts,
substance, and modes of inquiry that the boundaries of the discipline can be understood and
possibilities for creativity across disciplinary
borders can be created and explored.
Specialized Language and Symbols
As nursing theory has evolved, so has the need
for concepts, language, and forms of data that
reflect new ways of thinking and knowing specific to nursing. The complex concepts used in
nursing scholarship and practice require language that can be specific and understood. The
language of nursing theory facilitates communication among members of the discipline.
Expert knowledge of the discipline is often
required for full understanding of the meaning
of these theoretical terms.
Heritage of Literature and
Networks of Communication
This attribute calls attention to the array
of books, periodicals, artifacts, and aesthetic
expressions, as well as audio, visual, and electronic media that have developed over centuries to communicate the nature of nursing
knowledge and practice. Conferences and forums on every aspect of nursing held throughout the world are part of this network. Nursing
organizations and societies also provide critical
communication links. Nursing theories are
part of this heritage of literature, and those
working with these theories present their work
at conferences, societies, and other communication networks of the nursing discipline.
Tradition
The tradition and history of the discipline is evident in the study of nursing over time. There
is recognition that theories most useful today
often have threads of connection with ideas
originating in the past. For example, many theorists have acknowledged the influence of
Florence Nightingale and have acclaimed her
leadership in influencing nursing theories of
today. In addition, nursing has a rich heritage
of practice. Nursing’s practical experience and
knowledge have been shared and transformed
as the content of the discipline and are evident
in many nursing theories (Gray & Pratt, 1991).
Values and Beliefs
Nursing has distinctive views of persons and
strong commitments to compassionate and
knowledgeable care of persons through nursing. Fundamental nursing values and beliefs
include a holistic view of person, the dignity
and uniqueness of persons, and the call to care.
There are both shared and differing values and
beliefs within the discipline. The metaparadigm reflects the shared beliefs, and the paradigms reflect the differences.
Systems of Education
A distinguishing mark of any discipline is the
education of future and current members of
the community. Nursing is recognized as a
professional discipline within institutions of
higher education because it has an identifiable
body of knowledge that is studied, advanced,
and used to underpin its practice. Students of
any professional discipline study its theories
and learn its methods of inquiry and practice.
Nursing theories, by setting directions for the
substance and methods of inquiry for the discipline, should provide the basis for nursing
education and the framework for organizing
nursing curricula.
Definitions of Nursing Theory
A theory is a notion or an idea that explains
experience, interprets observation, describes
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing
relationships, and projects outcomes. Parsons
(1949), often quoted by nursing theorists,
wrote that theories help us know what we
know and decide what we need to know. Theories are mental patterns or frameworks created to help understand and create meaning
from our experience, organize and articulate
our knowing, and ask questions leading to new
insights. As such, theories are not discovered
in nature but are human inventions.
Theories are organizing structures of our reflections, observations, projections, and inferences. Many describe theories as lenses because
they color and shape what is seen. The same
phenomena will be seen differently depending
on the theoretical perspective assumed. For
these reasons, “theory” and related terms have
been defined and described in a number of
ways according to individual experience and
what is useful at the time. Theories, as reflections of understanding, guide our actions, help
us set forth desired outcomes, and give evidence of what has been achieved. A theory, by
traditional definition, is an organized, coherent
set of concepts and their relationships to each
other that offers descriptions, explanations,
and predictions about phenomena.
Early writers on nursing theory brought
definitions of theory from other disciplines to
direct future work within nursing. Dickoff and
James (1968, p. 198) defined theory as a “conceptual system or framework invented for
some purpose.” Ellis (1968, p. 217) defined
theory as “a coherent set of hypothetical, conceptual, and pragmatic principles forming a
general frame of reference for a field of inquiry.” McKay (1969, p. 394) asserted that
theories are the capstone of scientific work and
that the term refers to “logically interconnected
sets of confirmed hypotheses.” Barnum (1998,
p. 1) later offered a more open definition of
theory as a “construct that accounts for or organizes some phenomenon” and simply stated
that a nursing theory describes or explains
nursing.
Definitions of theory emphasize its various
aspects. Those developed in recent years are
more open and conform to a broader conception of science. The following definitions of theory are consistent with general ideas of theory
7
in nursing practice, education, administration,
or research:
• Theory is a set of concepts, definitions, and
propositions that project a systematic view
of phenomena by designating specific interrelationships among concepts for purposes
of describing, explaining, predicting, and/or
controlling phenomena (Chinn & Jacobs,
1987, p. 71).
• Theory is a creative and rigorous structuring
of ideas that projects a tentative, purposeful,
and systematic view of phenomena (Chinn
& Kramer, 2004, p. 268).
• Nursing theory is a conceptualization
of some aspect of reality (invented or
discovered) that pertains to nursing. The
conceptualization is articulated for the
purpose of describing, explaining, predicting, or prescribing nursing care (Meleis,
1997, p. 12).
• Nursing theory is an inductively and/or deductively derived collage of coherent, creative, and focused nursing phenomena that
frame, give meaning to, and help explain
specific and selective aspects of nursing research and practice (Silva, 1997, p. 55).
• A theory is an imaginative grouping of
knowledge, ideas, and experience that are represented symbolically and seek to illuminate
a given phenomenon.” (Watson, 1985, p. 1).
The Purpose of Theory in
a Professional Discipline
All professional disciplines have a body of
knowledge consisting of theories, research, and
methods of inquiry and practice. They organize
knowledge, guide inquiry to advance science,
guide practice and enhance the care of patients.
Nursing theories address the phenomena of interest to nursing, human beings, health, and
caring in the context of the nurse–person relationship1. On the basis of strongly held values
and beliefs about nursing, and within contexts of various worldviews, theories are patterns that guide the thinking about, being,
and doing of nursing.
1Person refers to individual, family, group, or community.
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SECTION I • An Introduction to Nursing Theory
Theories provide structures for making
sense of the complexities of reality for both
practice and research. Research based in nursing theory is needed to explain and predict
nursing outcomes essential to the delivery of
nursing care that is both humane and costeffective (Gioiella, 1996). Some conceptual
structure either implicitly or explicitly directs
all avenues of nursing, including nursing education and administration. Nursing theories
provide concepts and designs that define the
place of nursing in health care. Through
theories, nurses are offered perspectives for
relating with professionals from other disciplines, who join with nurses to provide
human services. Nursing has great expectations of its theories. At the same time, theories must provide structure and substance
to ground the practice and scholarship of
nursing and must also be flexible and dynamic
to keep pace with the growth and changes in
the discipline and practice of nursing.
The major reason for structuring and
advancing nursing knowledge is for the sake
of nursing practice. The primary purpose
of nursing theories is to further the development and understanding of nursing practice.
Because nursing theory exists to improve practice, the test of nursing theory is a test of its
usefulness in professional practice (Colley,
2003; Fitzpatrick, 1997). The work of nursing
theory is moving from academia into the
realm of nursing practice. Chapters in the remaining sections of this book highlight the
use of nursing theories in nursing practice.
Nursing practice is both the source and the
goal of nursing theory. From the viewpoint of
practice, Gray and Forsstrom (1991) suggested
that theory provides nurses with different ways
of looking at and assessing phenomena, rationales for their practice, and criteria for evaluating outcomes. Many of the theories in this
book have been used to guide nursing practice,
stimulate creative thinking, facilitate communication, and clarify purposes and processes in
practice. The practicing nurse has an ethical responsibility to use the discipline’s theoretical
knowledge base, just as it is the nurse scholar’s
ethical responsibility to develop the knowledge
base specific to nursing practice (Cody, 1997,
2003). Engagement in practice generates the
ideas that lead to the development of nursing
theories.
At the empirical level of theory, abstract
concepts are operationalized, or made concrete,
for practice and research (Fawcett, 2000; Smith
& Liehr, 2013). Empirical indicators provide
specific examples of how the theory is experienced in reality; they are important for bringing
theoretical knowledge to the practice level.
These indicators include procedures, tools, and
instruments to determine the effects of nursing
practice and are essential to research and management of outcomes of practice (Jennings &
Staggers, 1998). The resulting data form the
basis for improving the quality of nursing care
and influencing health-care policy. Empirical
indicators, grounded carefully in nursing concepts, provide clear demonstration of the utility
of nursing theory in practice, research, administration, and other nursing endeavors (Allison
& McLaughlin-Renpenning, 1999; Hart &
Foster, 1998).
Meeting the challenges of systems of care
delivery and interprofessional work demands
practice from a theoretical perspective. Nursing’s disciplinary focus is important within
the interprofessional health-care environment
(Allison & McLaughlin-Renpenning, 1999);
otherwise, its unique contribution to the interprofessional team is unclear. Nursing actions reflect nursing concepts from a nursing
perspective. Careful, reflective, and critical
thinking are the hallmarks of expert nursing,
and nursing theories should undergird these
processes. Appreciation and use of nursing
theory offer opportunities for successful collaboration with colleagues from other disciplines and provide definition for nursing’s
overall contribution to health care. Nurses
must know what they are doing, why they are
doing it, and what the range of outcomes of
nursing may be, as well as indicators for documenting nursing’s effects. These theoretical
frameworks serve as powerful guides for articulating, reporting, and recording nursing
thought and action.
One of the assertions referred to most often
in the nursing-theory literature is that theory is
born of nursing practice and, after examination
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing
and refinement through research, must be returned to practice (Dickoff, James, & Wiedenbach, 1968). Nursing theory is stimulated by
questions and curiosities arising from nursing
practice. Development of nursing knowledge
is a result of theory-based nursing inquiry. The
circle continues as data, conclusions, and recommendations of nursing research are evaluated and developed for use in practice. Nursing
theory must be seen as practical and useful to
practice, and the insights of practice must in
turn continue to enrich nursing theory.
The Evolution of
Nursing Science
Disciplines can be classified as belonging to
the sciences or humanities. In any science,
there is a search for an understanding about
specified phenomena through creating some
organizing frameworks (theories) about the
nature of those phenomena. These organizing
frameworks (theories) are evaluated for their
empirical accuracy through research. So science is composed of theories developed and
tested through research (Smith, 1994).
The evolution of nursing as a science has
occurred within the past 70 years; however,
before nursing became a discipline or field
of study, it was a healing art. Throughout
the world, nursing emerged as a healing ministry to those who were ill or in need of support. Knowledge about caring for the sick,
injured, and those birthing, dying, or experiencing normal developmental transitions
was handed down, frequently in oral traditions, and comprised folk remedies and practices that were found to be effective through
a process of trial and error. In most societies,
the responsibility for nursing fell to women,
members of religious orders, or those with
spiritual authority in the community. With
the ascendency of science, those who were
engaged in the vocations of healing lost their
authority over healing to medicine. Traditional approaches to healing were marginalized, as the germ theory and the development
of pharmaceuticals and surgical procedures
were legitimized because of their grounding
in science.
9
Although there were healers from other
countries who can be acknowledged for their
importance to the history of nursing, Florence
Nightingale holds the title of the “mother of
modern nursing” and the person responsible
for setting Western nursing on a path toward
scientific advancement. She not only defined
nursing as “putting the person in the best condition for nature to act,” she also established a
phenomenological focus of nursing as caring
for and about the human–environment relationship to health. While nursing soldiers during the Crimean War, Nightingale began to
study the distribution of disease by gathering
data, so she was arguably the first nurse-scientist
in that she established a rudimentary theory
and tested that theory through her practice and
research.
Nightingale schools were established in the
West at the turn of the 20th century, but
Nightingale’s influence on the nursing profession waned as student nurses in hospital-based
training schools were taught nursing primarily
by physicians. Nursing became strongly influenced by the “medical model” and for some
time lost its identity as a distinct profession.
Slowly, nursing education moved into institutions of higher learning where students
were taught by nurses with higher degrees. By
1936, 66 colleges and universities had baccalaureate programs (Peplau, 1987). Graduate
programs began in the 1940s and grew significantly from the 50s through the 1970s.
The publication of the journal Nursing Research in 1952 was a milestone, signifying the
birth of nursing as a fledgling science (Peplau,
1987). But well into the 1940s, “many textbooks for nurses, often written by physicians,
clergy or psychologists, reminded nurses that
theory was too much for them, that nurses did
not need to think but rather merely to follow
rules, be obedient, be compassionate, do their
‘duty’ and carry out medical orders” (Peplau,
1987, p. 18). We’ve come a long way in a mere
70 years.
The development of nursing curricula stimulated discussion about the nature of nursing
as distinct from medicine. In the 1950s, early
nursing scholars such as Hildegard Peplau,
Virginia Henderson, Dorothy Johnson, and
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SECTION I • An Introduction to Nursing Theory
Lydia Hall established the distinct characteristics of nursing as a profession and field
of study. Faye Abdellah, Ida Jean Orlando,
Joyce Travelbee, Ernestine Wiedenbach, Myra
Levine, and Imogene King followed during
the 1960s, elaborating their conceptualizations
of nursing. During the early 1960s, the federallyfunded Nurse Scientist Program was initiated
to educate nurses in pursuit of doctoral degrees
in the basic sciences. Through this program
nurses received doctorates in education, sociology, physiology, and psychology. These graduates brought the scientific traditions of these
disciplines into nursing as they assumed faculty
positions in schools of nursing.
By the 1970s, nursing theory development
became a priority for the profession and the
discipline of nursing was becoming established. Martha Rogers, Callista Roy, Dorothea
Orem, Betty Newman, and Josephine Paterson and Loraine Zderad published their theories and graduate students began studying and
advancing these theories through research.
During this time, the National League for
Nursing required a theory-based curriculum as
a standard for accreditation, so schools of nursing were expected to select, develop, and implement a conceptual framework for their
curricula. This propelled the advancement of
theoretical thinking in nursing. (Meleis, 1992).
A national conference on nursing theory and
the Nursing Theory Think Tanks were formed
to engage nursing leaders in dialogue about the
place of theory in the evolution of nursing science. The linkages between theory, research,
and philosophy were debated in the literature,
and Advances in Nursing Science, the premiere
journal for publishing theoretical articles, was
launched.
In the 1980s additional grand theories such
as Parse’s man-living-health (later changed
to human becoming); Newman’s health as
expanding consciousness; Leininger’s transcultural nursing; Erickson, Tomlinson, and
Swain’s modeling and role modeling; and
Watson’s transpersonal caring were disseminated. Nursing theory conferences were convened, frequently attracting large numbers of
participants. Those scholars working with the
published theories in research and practice
formalized networks into organizations and
held conferences. For example the Society for
Rogerian Scholars held the first Rogerian
Conference; the Transcultural Nursing Society
was formed, and the International Association
for Human Caring was formed. Some of these
organizations developed journals publishing
the work of scholars advancing these conceptual models and grand theories. Metatheorists
such as Jacqueline Fawcett, Peggy Chinn, and
Joyce Fitzpatrick and Ann Whall published
books on nursing theory, making nursing
theories more accessible to students. Theory
courses were established in graduate programs
in nursing. The Fuld Foundation supported a
series of videotaped interviews of many theorists, and the National League for Nursing disseminated videos promoting theory within
nursing. Nursing Science Quarterly, a journal
focused exclusively on advancing extant nursing theories, published its first issue in 1988.
During the 1990s, the expansion of conceptual models and grand theories in nursing
continued to deepen, and forces within nursing both promoted and inhibited this expansion. The theorists and their students began
conducting research and developing practice
models that made the theories more visible.
Regulatory bodies in Canada required that
every hospital be guided by some nursing theory. This accelerated the development of nursing theory–guided practice within Canada and
the United States. The accrediting bodies of
nursing programs pulled back on their requirement of a specified conceptual framework
guiding nursing curricula. Because of this,
there were fewer programs guided by specific
conceptualizations of nursing, and possibly
fewer students had a strong grounding in the
theoretical foundations of nursing. Fewer
grand theories emerged; only Boykin and
Schoenhofer’s nursing as caring grand theory
was published during this time. Middle-range
theories emerged to provide more descriptive,
explanatory, and predictive models around
circumscribed phenomena of interest to nursing. For example, Meleis’s transition theory,
Mishel’s uncertainty theory, Barrett’s power
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing
theory, and Pender’s health promotion model
were generating interest.
From 2000 to the present, there has been
accelerated development of middle-range theories with less interest in conceptual models
and grand theories. There seems to be a devaluing of nursing theory; many graduate programs have eliminated their required nursing
theory courses, and baccalaureate programs
may not include the development of conceptualizations of nursing into their curricula. This
has the potential for creating generations of
nurses who have no comprehension of the importance of theory for understanding the focus
of the discipline and the diverse, rich legacy
of nursing knowledge from these theoretical
perspectives.
On the other hand, health-care organizations have been more active in promoting attention to theoretical applications in nursing
practice. For example, those hospitals on the
magnet journey are required to select a guiding
nursing framework for practice. Watson’s theory of caring is guiding nursing practice in a
group of acute care hospitals. These hospitals
have formed a consortium so that best practices can be shared across settings.
Although nursing research is advancing and
making a difference in people’s lives, the research may not be linked explicitly to theory,
and probably not linked to nursing theory. This
compromises the advancement of nursing science. All other disciplines teach their foundational theories to their students, and their
scientists test or develop their theories through
research.
There is a trend toward valuing theories
from other disciplines over nursing theories.
For example, motivational interviewing is a
practice theory out of psychology that nurse researchers and practitioners are gravitating to in
large numbers. Arguably, there are several similar nursing theoretical approaches to engaging
others in health promotion behaviors that preceded motivational interviewing, yet these
have not been explored. Interprofessional practice and interdisciplinary research are essential
for the future of health care, but we do not do
justice to this concept by abandoning the rich,
11
distinguishing features of nursing science over
others.
If nursing is to advance as a science in its
own right, future generations of nurses must respect and advance the theoretical legacy of our
discipline. Scientific growth happens through
cumulative knowledge development with current research building on previous findings. To
survive and thrive, nursing theories must be
used in nursing practice and research.
The Structure of Knowledge
in the Discipline of Nursing
Theories are part of the knowledge structure
of any discipline. The domain of inquiry (also
called the metaparadigm or focus of the discipline) is the foundation of the structure. The
knowledge of the discipline is related to its
general domain or focus. For example, knowledge of biology relates to the study of living
things; psychology is the study of the mind;
sociology is the study of social structures and
behaviors. Nursing’s domain was discussed
earlier and relates to the disciplinary focus
statement or metaparadigm. Other levels of
the knowledge structure include paradigms,
conceptual models or grand theories, middlerange theories, practice theories, and research
and practice traditions. These levels of nursing
knowledge are interrelated; each level of development is influenced by work at other levels.
Theoretical work in nursing must be dynamic;
that is, it must be continually in process and
useful for the purposes and work of the discipline. It must be open to adapting and extending to guide nursing endeavors and to reflect
development within nursing. Although there
is diversity of opinion among nurses about the
terms used to describe the levels of theory, the
following discussion of theoretical development in nursing is offered as a context for
further understanding nursing theory.
Paradigm
Paradigm is the next level of the disciplinary
structure of nursing. The notion of paradigm can
be useful as a basis for understanding nursing
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SECTION I • An Introduction to Nursing Theory
knowledge. A paradigm is a global, general
framework made up of assumptions about
aspects of the discipline held by members to
be essential in development of the discipline.
Paradigms are particular perspectives on the
metaparadigm or disciplinary domain. The
concept of paradigm comes from the work of
Kuhn (1970, 1977), who used the term to
describe models that guide scientific activity
and knowledge development in disciplines.
Because paradigms are broad, shared perspectives held by members of the discipline, they
are often called “worldviews.” Kuhn set forth
the view that science does not always evolve as
a smooth, regular, continuing path of knowledge development over time, but that periodically there are times of revolution when
traditional thought is challenged by new ideas,
and “paradigm shifts” occur.
Kuhn’s ideas provide a way for us to think
about the development of science. Before any
discipline engages in the development of theory
and research to advance its knowledge, it is
in a preparadigmatic period of development.
Typically, this is followed by a period of time
when a single paradigm emerges to guide
knowledge development. Research activities
initiated around this paradigm advance its theories. This is a time during which knowledge
advances at a regular pace. At times, a new paradigm can emerge to challenge the worldview
of the existing paradigm. It can be revolutionary, overthrowing the previous paradigm, or
multiple paradigms can coexist in a discipline,
providing different worldviews that guide the
scientific development of the discipline.
Kuhn’s work has meaning for nursing and
other scientific disciplines because of his recognition that science is the work of a community
of scholars in the context of society. Paradigms
and worldviews of nursing are subtle and powerful, reflecting different values and beliefs
about the nature of human beings, human–environment relationships, health, and caring.
Kuhn’s (1970, 1977) description of scientific
development is particularly relevant to nursing
today as new perspectives are being articulated,
some traditional views are being strengthened,
and some views are taking their places as part
of our history. As we continue to move away
from the historical conception of nursing as
a part of biomedical science, developments
in the nursing discipline are directed by at
least two paradigms, or worldviews, outside
the medical model. These are now described.
Several nursing scholars have named the existing paradigms in the discipline of nursing
(Fawcett, 1995; Newman et al., 1991; Parse,
1987). Parse (1987) described two paradigms:
the totality and the simultaneity. The totality
paradigm reflects a worldview that humans are
integrated beings with biological, psychological,
sociocultural, and spiritual dimensions. Humans
adapt to their environments, and health and illness are states on a continuum. In the simultaneity paradigm, humans are unitary, irreducible,
and in continuous mutual process with the
environment (Rogers, 1970, 1992). Health is
subjectively defined and reflects a process of
becoming or evolving. In contrast to Parse,
Newman and her colleagues (1991) identified three paradigms in nursing: particulate–
deterministic, integrative–interactive, and unitary–
transformative. From the perspective of the
particulate–deterministic paradigm, humans are
known through parts; health is the absence
of disease; and predictability and control
are essential for health management. In the
integrative–interactive paradigm, humans are
viewed as systems with interrelated dimensions
interacting with the environment, and change
is probabilistic. The worldview of the unitary–
transformative paradigm describes humans as
patterned, self-organizing fields within larger
patterned, self-organizing fields. Change
is characterized by fluctuating rhythms of
organization–disorganization toward more
complex organization. Health is a reflection of
this continuous change. Fawcett (1995, 2000)
provided yet another model of nursing paradigms: reaction, reciprocal interaction, and simultaneous action. In the reaction paradigm,
humans are the sum of their parts, reaction is
causal, and stability is valued. In the reciprocal
interaction worldview, the parts are seen within
the context of a larger whole, there is a reciprocal
nature to the relationship with the environment,
and change is based on multiple factors. Finally,
the simultaneous-action worldview includes a
belief that humans are known by pattern and are
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing
in an open ever-changing process with the
environment. Change is unpredictable and
evolving toward greater complexity (Smith,
2008, pp. 4–5).
It may help you to think of theories being
clustered within these nursing paradigms.
Many theories share the worldview established
by a particular paradigm. At present, multiple
paradigms coexist within nursing.
Grand Theories and
Conceptual Models
Grand theories and conceptual models are at
the next level in the structure of the discipline.
They are less abstract than the focus of the discipline and paradigms but more abstract than
middle-range theories. Conceptual models and
grand theories focus on the phenomena of concern to the discipline such as persons as adaptive
systems, self-care deficits, unitary human beings, human becoming, or health as expanding
consciousness. The grand theories, or conceptual models, are composed of concepts and relational statements. Relational statements on
which the theories are built are called assumptions and often reflect the foundational philosophies of the conceptual model or grand theory.
These philosophies are statements of enduring
values and beliefs; they may be practical guides
for the conduct of nurses applying the theory
and can be used to determine the compatibility
of the model or theory with personal, professional, organizational, and societal beliefs and
values. Fawcett (2000) differentiated conceptual
models and grand theories. For her, conceptual
models, also called conceptual frameworks or
conceptual systems, are sets of general concepts
and propositions that provide perspectives on
the major concepts of the metaparadigm: person, environment, health, and nursing. Fawcett
(1993, 2000) pointed out that direction for research must be described as part of the conceptual model to guide development and testing of
nursing theories. We do not differentiate between conceptual models and grand theories
and use the terms interchangeably.
Middle-Range Theories
Middle-range theories comprise the next level
in the structure of the discipline. Robert Merton
13
(1968) described this level of theory in the field
of sociology, stating that they are theories
broad enough to be useful in complex situations and appropriate for empirical testing.
Nursing scholars proposed using this level of
theory because of the difficulty in testing grand
theory (Jacox, 1974). Middle-range theories
are narrower in scope than grand theories and
offer an effective bridge between grand theories and the description and explanation of
specific nursing phenomena. They present concepts and propositions at a lower level of abstraction and hold great promise for increasing
theory-based research and nursing practice
strategies (Smith & Liehr, 2008). Several
middle-range theories are included in this
book. Middle-range theories may have their
foundations in a particular paradigmatic perspective or may be derived from a grand theory
or conceptual model. The literature presents a
growing number of middle-range theories.
This level of theory is expanding most rapidly
in the discipline and represents some of the
most exciting work published in nursing today.
Some of these new theories are synthesized
from knowledge from related disciplines and
transformed through a nursing lens (Eakes,
Burke, & Hainsworth, 1998; Lenz, Suppe,
Gift, Pugh, & Milligan, 1995; Polk, 1997).
The literature also offers middle-range nursing
theories that are directly related to grand theories of nursing (Ducharme, Ricard, Duquette,
Levesque, & Lachance, 1998; Dunn, 2004;
Olson & Hanchett, 1997). Reports of nursing
theory developed at this level include implications for instrument development, theory testing through research, and nursing practice
strategies.
Practice-Level Theories
Practice-level theories have the most limited
scope and level of abstraction and are developed
for use within a specific range of nursing situations. Theories developed at this level have a
more direct effect on nursing practice than do
more abstract theories. Nursing practice theories
provide frameworks for nursing interventions/
activities and suggest outcomes and/or the effect
of nursing practice. Nursing actions may be
described or developed as nursing practice
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SECTION I • An Introduction to Nursing Theory
theories. Ideally, nursing practice theories are
interrelated with concepts from middle-range
theories or developed under the framework of
grand theories. A theory developed at this level
has been called a prescriptive theory (Crowley,
1968; Dickoff, James, & Wiedenbach, 1968), a
situation-specific theory (Meleis, 1997), and a
micro-theory (Chinn & Kramer, 2011). The
day-to-day experience of nurses is a major
source of nursing practice theory.
The depth and complexity of nursing
practice may be fully appreciated as nursing
phenomena and relations among aspects of
particular nursing situations are described and
explained. Dialogue with expert nurses in
practice can be fruitful for discovery and development of practice theory. Research findings on various nursing problems offer data
to develop nursing practice theories. Nursing
practice theory has been articulated using
multiple ways of knowing through reflective
practice (Johns & Freshwater, 1998). The
process includes quiet reflection on practice,
remembering and noting features of nursing
situations, attending to one’s own feelings,
reevaluating the experience, and integrating
new knowing with other experience (Gray
& Forsstrom, 1991). The LIGHT model
(Andersen & Smereck, 1989) and the attendant nurse caring model (Watson & Foster,
2003) are examples of the development of
practice level theories.
Associated Research and
Practice Traditions
Research traditions are the associated methods, procedures, and empirical indicators that
guide inquiry related to the theory. For example, the theories of health as expanding consciousness, human becoming, and cultural care
diversity and universality have specific associated research methods. Other theories have
specific tools that have been developed to
measure constructs related to the theories. The
practice tradition of the theory consists of the
activities, protocols, processes, tools, and practice wisdom emerging from the theory. Several
conceptual models and grand theories have
specific associated practice methods.
Nursing Theory and the Future
Nursing theory is essential to the continuing
evolution of the discipline of nursing. Several
trends are evident in the development and use
of nursing theory. First, there seems to be
more agreement on the focus of the discipline
of nursing that provides a meaningful direction
for our study and inquiry. This disciplinary dialogue has extended beyond the confines of
Fawcett’s metaparadigm and explicates the importance of caring and relationship as central
to the discipline of nursing (Newman et al.,
2008; Roy & Jones, 2007; Willis et al., 2008).
The development of new grand theories and
conceptual models has decreased. Dossey’s
(2008) theory of integral nursing, included in
this book, is the only new theory at this level
that has been developed in nearly 20 years. Instead, the growth in theory development is at
the middle-range and practice levels. There has
been a significant increase in middle-range
theories, and many practice scholars are working on developing and implementing practice
models based on grand theories or conceptual
models.
Several changes in the teaching and learning
of nursing theory are troubling. Many baccalaureate programs include little nursing theory in their curricula. Similarly, some graduate
programs are eliminating or decreasing their
emphasis on nursing theory. This alarming
trend deserves our attention. If nursing is to
continue to thrive and to make a difference
in the lives of people, our practitioners and
researchers need to practice and expand knowledge within the structure of the discipline.
As health care becomes more interprofessional,
the focus of nursing becomes even more important. If nurses do not learn and practice
based on the knowledge of their discipline, they
may be co-opted into the practice of another
discipline. Even worse, another discipline could
emerge that will assume practices associated
with the discipline of nursing. For example,
health coaching is emerging as an area of practice focused on providing people with help
as they make health-related changes in their
lives. However, this is the practice of nursing,
as articulated by many nursing theories.
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CHAPTER 1 • Nursing Theory and the Discipline of Nursing
On a positive note, nursing theories are
being embraced by health-care organizations
to structure nursing practice. For example,
organizations embarking on the journey toward magnet status (www.nursecredentialing
.org/magnet) are required to identify a theoretical perspective that guides nursing practice,
and many are choosing existing nursing models. This work has great potential to refine and
extend nursing theories.
The use of nursing theory in research is inconsistent at best. Often, outcomes research
is not contextualized within any theoretical
perspective; however, reviewers of proposals
for most funding agencies request theoretical
frameworks, and scoring criteria give points for
having one. This encourages theoretical thinking and organizing findings within a broader
perspective. Nurses often use theories from
other disciplines instead of their own and this
expands the knowledge of another discipline.
We are hopeful about the growth, continuing development, and expanded use of nursing
theory. We hope that there will be continued
growth in the development of all levels of nursing theory. The students of all professional disciplines study the theories of their disciplines
in their courses of study. We must continue to
include the study of nursing theories within our
baccalaureate, master’s, and doctoral programs.
Baccalaureate students need to understand the
foundations for the discipline, our historical development, and the place of nursing theory in
its history and future. They should learn about
conceptual models and grand theories. Didactic
and practice courses should reflect theoretical
values and concepts so that students learn to
practice nursing from a theoretical perspective.
Middle-range theories should be included in
the study of particular phenomena such as selftranscendence, sorrow, and uncertainty. As they
prepare to become practice leaders of the discipline, doctor of nursing practice students should
learn to develop and test nursing theory-guided
models. PhD students will learn to develop and
extend nursing theories in their research. New
and expanded nursing specialties, such as nursing informatics, call for development and use
of nursing theory (Effken, 2003). New, more
15
open and inclusive ways to theorize about nursing will be developed. These new ways will acknowledge the history and traditions of nursing
but will move nursing forward into new realms
of thinking and being. Reed (1995) noted
the “ground shifting” with the reforming of
philosophies of nursing science and called for
a more open philosophy, grounded in nursing’s
values, which connects science, philosophy, and
practice. Gray and Pratt (1991, p. 454) projected that nursing scholars will continue to develop theories at all levels of abstraction and
that theories will be increasingly interdependent with other disciplines such as politics, economics, and ethics. These authors expect a
continuing emphasis on unifying theory and
practice that will contribute to the validation of
the nursing discipline. Theorists will work in
groups to develop knowledge in an area of concern to nursing, and these phenomena of interest, rather than the name of the author, will
define the theory (Meleis, 1992). Newman
(2003) called for a future in which we transcend
competition and boundaries that have been
constructed between nursing theories and instead appreciate the links among theories, thus
moving toward a fuller, more inclusive, and
richer understanding of nursing knowledge.
Nursing’s philosophies and theories must
increasingly reflect nursing’s values for understanding, respect, and commitment to health
beliefs and practices of cultures throughout
the world. It is important to question to what
extent theories developed and used in one
major culture are appropriate for use in other
cultures. To what extent must nursing theory
be relevant in multicultural contexts? Despite
efforts of many international scholarly societies, how relevant are American nursing theories for the global community? Can nursing
theories inform us about how to stand with
and learn from peoples of the world? Can we
learn from nursing theory how to come to
know those we nurse, how to be with them, to
truly listen and hear? Can these questions be
recognized as appropriate for scholarly work
and practice for graduate students in nursing?
Will these issues offer direction for studies
of doctoral students? If so, nursing theory
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SECTION I • An Introduction to Nursing Theory
will prepare nurses for humane leadership in
national and global health policy. Perspectives of various times and worlds in relation to
present nursing concerns were described by
Schoenhofer (1994). Abdellah (McAuliffe,
1998) proposed an international electronic
“think tank” for nurses around the globe to dialogue about nursing theory. Such opportunities could lead nurses to truly listen, learn, and
adapt theoretical perspectives to accommodate
cultural variations.
■ Summary
This chapter focused on the place of nursing
theory within the discipline of nursing. The relationship and importance of nursing theory
to the characteristics of a professional discipline were reviewed. A variety of definitions of
theory were offered, and the evolution and
structure of knowledge in the discipline was
outlined. Finally, we reviewed trends and speculated about the future of nursing theory development and application. One challenge of
nursing theory is that theory is always in the
process of developing and that, at the same
time, it is useful for the purposes and work of
the discipline. This paradox may be seen as
ambiguous or as full of possibilities. Continuing students of the discipline are required to
study and know the basis for their contributions to nursing and to those we serve; at the
same time, they must be open to new ways
of thinking, knowing, and being in nursing.
Exploring structures of nursing knowledge and
understanding the nature of nursing as a professional discipline provide a frame of reference to clarify nursing theory.
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A Guide for the Study of
Nursing Theories for Practice
Chapter
2
M ARILYN E. P ARKER AND
M ARLAINE C. S MITH
Study of Theory for Nursing Practice
A Guide for Study of Nursing Theory for
Use in Practice
Summary
References
Marilyn E. Parker
Marlaine C. Smith
Nursing is a professional discipline, a field of
study focused on human health and healing
through caring (Smith, 1994). The knowledge
of the discipline includes nursing science, art,
philosophy, and ethics. Nursing science includes the conceptual models, theories, and research specific to the discipline. As in other
sciences such as biology, psychology, or sociology, the study of nursing science requires a
disciplined approach. This chapter offers a
guide to this disciplined approach in the form
of a set of questions that facilitate reflection,
exploration, and a deeper study of the selected
nursing theories.
As you read the chapters in this book, use
the questions in the guide to facilitate your
study. These chapters offer you an introduction
to a variety of nursing theories, which we hope
will ignite interest in deeper exploration of
some of the theories through reading the
books written by the theorists and other published articles related to the use of the theories
in practice and research. This book’s online resources can provide additional materials as you
continue your exploration.1 The questions in
this guide can lead you toward this deeper
study of the selected nursing theories.
Rapid and dramatic changes are affecting
nurses everywhere. Health-care delivery
systems are in crisis and in need of real
change. Hospitals continue to be the largest
employers of nurses, and some hospitals
are recognizing the need to develop nursing
theory–guided practice models. A criterion for
hospitals seeking magnet hospital designation
1For additional information please go to bonus chapter
content available at FA Davis http://davisplus.fadavis.com
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SECTION I • An Introduction to Nursing Theory
by the American Nurses Credentialing Center (www.nursecredentialing.org/magnet) includes the selection of a theoretical model for
practice. The list of questions in this chapter
can be useful to nurses as they select theories
to guide practice.
Increasingly, nurses are practicing in diverse
settings and often develop organized nursing
practices through which accessible health care
to communities can be provided. Community
members may be active participants in selecting, designing, and evaluating the nursing
they receive. In these situations, it is important
for nurses and the communities they serve to
identify the approach to nursing that is most
consistent with the community’s values. The
questions in this chapter can be helpful in the
mutual exploration of theoretical approaches
to practice.
In the current health-care environment, interprofessional practice is the desired standard.
This does not mean that practicing from a
nursing-theoretical base is any less important.
Interprofessional practice means that each discipline brings its own lens or perspective to the
patient care situation. Nursing’s lens is essential for a complete picture of the person’s
health and for the goals of caring and healing.
The nursing theory selected will provide this
lens, and the questions in this chapter can assist nurses in selecting the theory or theories
that will guide their unique contribution to the
interprofessional team.
Theories and practices from a variety of disciplines inform the practice of nursing. The
scope of nursing practice is continually being
expanded to include additional know...
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