UNIT 1: EVOLUTION OF NURSING THEORIES

I. Topic Chapter 4 Theory Development Process

 Purposes of Nursing Theory
 Interdependence of Theory and Research
 Four Ways of Knowing
Chapter 5 The Structure and Analysis of Specialized Nursing Knowledge
 Scope of Theories and Analysis
 The Significance of Theory to Nursing as a Profession

II. Learning Objectives:

At the end of the lesson, you should be able to:
1. Explain the purposes of nursing theory to research, education, and clinical practice.
2. Discuss the relationship between nursing theory and nursing research in building
nursing knowledge.
3. Differentiate the four ways of knowing and give examples of each.
4. Differentiate the characteristics of grand, middle- range, and micro- range theories.
5. Explain the five criteria for theory analysis.
6. Discuss the significance of theory to nursing as a profession.

III. Pre Assessment

1. Who among the nursing theorists have the most significant involvement in nursing practice at
present and why?
2. Among the four types of knowing, which do you think is the most important that a nurse should
have to provide quality care to patients? Justify your answer.
3. What do you think will happen if theories in nursing were not formulated? Cite an example on
how this will affect our present health care system.

IV. Lesson Opening:

At the heart of every profession lies the core structures that give direction and purpose to
those who practice it, and these are the theories and concepts on which a profession and a
vocation heavily rely upon. Without these, a profession will lack direction, its actions
without sound basis, and its ideas questionable. Thus, its practitioners would be frail,
divided and dangerous. Theories to support practice are indispensable as food, water and
air.

V. Guiding Questions
1. What are the purposes of nursing theory to research, education, and clinical practice?
2. What is the relationship between nursing theory and nursing research in building nursing
knowledge?
3. What are the four ways of knowing and give examples of each?
4. What are the characteristics of grand, middle- range, and micro- range theories?
5. What are the five criteria for theory analysis?
6. What is the significance of theory to nursing as a profession?
 VI. Discussion /Lesson Proper

CHAPTER 4

PURPOSES OF NURSING THEORY

Nursing theories are developed to improve the quality of care rendered by nurses to their clients.
Theory development is inherent in the different nursing fields- education, research and practice.

1. EDUCATION
 Nursing theories were primarily used to develop and guide nursing education in universities and
institutions.
 They were once known to be more strongly established in the field of academics rather than in
clinical practice.
 In the 1970s and 1980s, a number of nursing programs recognized the major concepts of some
nursing models, structured these concepts into conceptual framework, and built the complete
curriculum around the framework.
 With these models, they were able to come up with unique terms such as: program objectives,
course objectives, course description, and clinical performance criteria.
 Theoretical concepts primarily prepare students for practice as members of the professional
community.
 The general purpose of theory development primarily is to ensure adequate and quality nursing
delivery and to clarify and improve the status of the Nursing profession.

NURSE’S NOTE:

A paradigm or model plays a vital role in education because without a framework, all of the
information that the professional nurse encounters seems to be equally related.

2. RESEARCH
 Experts constantly believed that research in nursing was inspired from different theoretical
assumptions or conceptual frameworks in the past.
 Grand theories – are broad in scope and complex in nature.
 Middle- range theories – focus on the discovery of concepts (e.g. pain, self-esteem and learning.
Most frequently used by nursing researchers.
 Critical theory is used in the academe to describe theories e.g. that clarify how social structures
influence a wide variety of human experiences from art to social practices. In nursing, it helps
elaborate on how structures (e.g. race, gender, sexual orientation, economic class) affect
experiences and health outcomes of the patient.
NURSE’S NOTE:

Grand, middle- range and critical theories are used hand- in- hand in academics, research and in
clinical practice. Chances are, all nurses have utilized a form of nursing theory, whether they know it
or not!

3. CLINICAL PRACTICE
 Theories thoroughly guide critical thinking and decision- making in clinical nursing practice.
 Nurses will have a better understanding on the basis and nature of their work and be able to
express it clearly in collaboration with other professionals.
 Nursing theories strengthen professional independence by guiding the deepest and most
important part of their practice.
 Nursing theories are always critical in assisting nurses to facilitate questions, reflections and
critical thinking in every aspect of care.

NURSE’S NOTE:

Studying nursing theories develop analytical skills and critical thinking ability for the purpose of safe
and effective nursing practice.

INTERDEPENDENCE OF THEORY AND RESEARCH

“Practice without theory, like map without route, is blind; theory without practice, like route without
map, is empty.”
NURSE’S NOTE:

The relationship between nursing theory and nursing research helps in building nursing knowledge.

Two Compositions of Nursing Knowledge (Meleis, 1997):

1. Theoretical knowledge – aims to stimulate thinking and broaden understanding of the science
and practice of the Nursing discipline.
2. Practical knowledge – is referred to as the art of nursing.

Research is linked to theory in 2 ways (Chinn and Kramer, 2004)

1. Theory- generating research – is designed to discover and describe relationships and
phenomena without imposing predetermined notions on the nature of the phenomena. In
conducting this type of research, investigators make observations with an open mind in order to
view the phenomenon in a new way.
2. Theory- testing research – is utilized to determine how accurate a theory describes a
phenomenon. The researcher already has some predetermined notions as to how the
phenomenon is and creates a hypothesis to test the assumptions of the theory.

Nursing as an ART relies on knowledge gained from practice and reflection of past experiences.
As a SCIENCE, it is based on scientifically tested knowledge that is applied in the practice setting.

CONTRIBUTIONS OF NURSING THEORISTS

FOUR WAYS OF KNOWING

A good Filipino nurse is shown by her appropriate actions. The proper nursing actions are the result of a
good foundation in knowledge which is an outcome of gathering and processing of information and
experiences. Therefore, knowing oneself in the area of Nursing is important because without it, one
cannot fully know the patient, which hinders provision of total care.

 Empirics- the scientific discipline of Nursing

 Ethics- the moral directions of Nursing
 Personal- method by which nurses approach their patients
 Aesthetics or Esthetics- deal with the empathic aspect of Nursing

1. EMPIRICAL KNOWING
 It is the principal form relating factual and descriptive knowing aimed at the expansion of
abstract and theoretical explanations.
 It is the first primary model of knowing.
 It is information source or base of knowing.
 Clinical and conceptual knowledge are the keys to nursing practice.
 It focuses on evidence- based research for effective and accurate nursing practice.

Any scientific, research- based, theoretical and factual information that the nurse makes use of
is under Empirical Knowing. E.g. knowledge obtained from textbooks, lectures, journals and
online resources.
Examples of Empirical Knowing:
 David, a nursing student answers a question posed by the clinical instructor based on what he
learned from the school.
 Elmer, a nurse researcher, uses scientific method to produce desired study results.
 Nurse Michael, practices nursing interventions based from accepted clinical practices.

Evidenced- Based Practice (EBP)

 It uses a form of evidence in making clinical judgment.
 It involves accurate and thoughtful decision making about health care delivery to clients.
 This is based on the result of the most relevant and support evidence derived from research in
response to client’s preferences and expectations.
 EBP can bridge the gap of nursing practice and research to provide basis for nurses to transform
research into quality care.

6 Characteristics of Quality Health Care:

 Client- centered
 Scientifically- based
 Population outcome based
 Developed through quality improvement and benchmarking
 Individualized to client’s need
 Attuned with system policies and resources

2. ETHICAL KNOWING
 It requires knowledge of different philosophical positions regarding what is good and right in
making moral actions and decisions, particularly in the theoretical and clinical components of
nursing.
 The code of morals or code of ethics that leads the conduct of nurses is the main basis of Ethical
Knowing.
 It is deeply rooted in the concepts of human dignity, service and respect for life.
 Lessening suffering, upholding and preserving health is one of the key elements why nursing is a
core service in society.
 Ethical Knowing involves the judgment of right and wrong in relation to intentions, reasons and
attributes of individuals and situations.

Examples of Ethical Knowing:

 Nurse Carl presents himself as a patient advocate and defends his client’s right to choose care.
 Sir Kevin, a clinical instructor, reprimands a student who cheated on a quiz and explains the
consequences.
 Nurse Renato explains the concepts behind organ donation to a terminally- ill patient.

3. PERSONAL KNOWING
 It encompasses knowledge of the self in relation to others and to self.
 It is the most difficult to master and to teach.
 It is the key to comprehending health in terms of personal well- being.
 It involves therapeutic use of self.
 It stresses that human beings are not in a fixed state but are constantly engaged in a dynamic
state of changes.
  It takes a lot of time to fully know the nature of oneself in relation to the world around.

Examples of Personal Knowing:

 Ruben, a nursing student, strives to promote a meaningful personal relationship with his elderly
patient.
 Roel, a nursing student, undergoes Psychological Counseling and Self- Awareness sessions
before his Psychiatric Nursing rotation.

Personal Knowledge is focused on realizing, meeting and defining the real, true self. One nursing term
defines this as self- awareness.

4. AESTHETIC KNOWING
 It is related to understanding what is of significance to particular patients such as feelings,
attitudes, points of view.
 It is also the manifestation of the creative and expressive styles of the nurse.
 It focuses on empathy- the ability for sharing or vividly understanding another’s feeling. This is
the primary form of aesthetic knowing.
 It also includes the nurse’s ability in changing ways and manner of rendering nursing care based
on the client’s individual needs and perceptions.

Examples of Aesthetic Knowing:

 Nurse Moses places himself in the “patient’s shoes” when communicating, giving judgment and
providing care.
 Nurse Ace shows compassion, mercy and understanding towards patients, co- workers and
supervisors.
 Nurse Miguel uses layman terms in explaining the needs of the patient with Right- sided Heart
Failure.

Aesthetic knowing is used in the process of giving appropriate nursing care through understanding the
uniqueness of every patient, thus emphasizing use of creative and practical styles of care.

CHAPTER 5

SCOPE OF THEORIES AND ANALYSIS

Theories- unique to nursing help the discipline define how it is different from other disciplines. They are
known to have a relative system of ideas that is intended to explain a given phenomena or fact.

Nursing theories- reflect particular views of person, health, environment, nursing and other concepts
that contribute to the development of a body of knowledge specific to nursing concerns.

Scope- refers to the qualified level of precision of a certain theory and the accuracy of its concepts and
propositions.
Scopes of Nursing Theory:
1. Grand Theories
2. Middle- range Theories
3. Micro- range Theories

What are Grand Theories?

Grand Theories are simply known to speak about a broad range of important relationship among
concepts of a discipline. They are made up of concepts representing common ad extremely complex
phenomena. Furthermore, they are viewed to be the broadest in scope, represent the summary of
development, and concentrate on the broad phenomena of concern within the discipline. They arise at a
time when Nursing was addressing its nature, mission and goals.

Characteristics:
Conceptual structures that are nearly as abstract as the nursing models from which they are
derived, but propose outcomes based on use and application of the model in the nursing
practice.
All- inclusive conceptual structures, abstract, including different perspective views of person,
health and environment.
Provide different ways of thinking about nursing and address the metaparadigm concepts that
are central to its meaning.

Examples: Orem’s Self- care Theory of Nursing, Neuman Systems Model Theory, Roy Adaptation Model

What are Middle- range Theories?

They are the least abstract level of theoretical knowledge because they include details specific to
nursing practice. Descriptions, explanations, and predictions are made with the purpose of answering
questions about different nursing phenomena. They specify such things as the health condition, the
patient population (age group), the location of practice, and the different interventions of the nurse.

Characteristics:
Lower in level of abstraction than grand theories, they offer a more direct application to
research and practice
Specific to nursing practice and specify the area of practice, age range of the patient, nursing
action or intervention, and proposed outcome.
Lie between grand and micro; synthesizes practice and research
Emerge at the intersection of research and practice, when theory guides practice, practice
generates research questions, and research informs understanding of theory and practice.

Examples:
Hildegard Peplau’s Psychodynamic Nursing
Joyce Travelbee’s Human-to-Human Relationship Model
Madeleine Leininger’s Transcultural Theory in Nursing
Margaret Newman’s Model of Health
What are Micro- range Theories?

These are situation- specific and limited to particular populations or fields of practice and also a linking
of concrete concepts into a statement that can be observed in practice and research. Micro- range
theories are known to be the most concrete and narrow in scope.

Hypothesis is an example of low abstraction micro- range theory. A student is familiar that a hypothesis
is a greatest guess or prediction about what one expects to discover. It is a tentative statement of
relationship between two or more variables that can be empirically tested.

Characteristics:
Known to be the most concrete and narrow in scope
Situation- specific and limited to particular populations or fields of practice
A linking of concrete concepts into a statement that can be observed in practice and research

ANALYSIS AND EVALUATION OF THEORY

In evaluating a theory, we must consider its degree of usefulness to guide practice, research, education
and administration. Evaluation provides new insight into relationships among concepts and their links to
each other. This allows the researcher to know the theory’s strengths and weakness.

The process of analysis is valuable in learning about the theoretical works and serves as a helpful tool for
nurse researchers who would like to test, expand or extend the works. Furthermore, through the
process of critiquing and analysis areas, which need further development, are discovered. This is the
reason why analysis is a vital process for learning, development of research studies, and expanding the
science associated with upcoming theoretical works of nursing.

Five Criteria in Evaluating a Theoretical Work:

1. Clarity
- Is the theory clearly stated?
- How clear is the theory?
- Is it easily understood?
2. Simplicity
- How simple is the theory?
3. Generality
- How general is the theory?
- How broad is the scope of the theory?
4. Empirical Precision
- Is the theory testable?
- How accessible is the theory?
5. Derivable Consequences
- How important is the theory?
- Does the theory have a significant contribution to nursing knowledge?
THE SIGNIFICANCE OF THEORY TO NURSING AS A PROFESSION

Profession- specialized field of practice; line of work

Theory is significant because it helps us to settle on what we know and what we need to know in the
future. It helps to differentiate what should form the basis of practice by clearly describing what nursing
does and what nursing is all about.

The benefits of having a defined body of knowledge include improved patient care, enhanced
professional status, improved communication between nurse professionals, and guide for research and
education.

As a nurse grows and matures in their professional status, the use of ample knowledge as a basis for
theory- based nursing is a characteristic of their practice.

Theory helps the nurse to:

 Organize, examine and analyze patient’s data
 Make decisions about effective and efficient nursing interventions
 Make a S.M.A.R.T. (Specific, Measurable, Attainable, Realistic, and Time- bounded) plan of care.
 Predict and evaluate outcomes of care