REFERENCE: Fundamentals of Nursing 10TH EDITION, 2021

(Hall, Amy M. Perry, Anne Griffin Potter etc.)

THEORETICAL FOUNDATIONS OF NURSING

THEORY

A nursing theory describes, explains, predicts, or prescribes nursing care (Meleis, 2018). Theories
help you understand your patients' conditions. Also, they assist you arrange data. Using Orem's
theory, you may examine and interpret data to determine patients' self-care needs,
deficiencies, and capacities. Orem's theory then guides your nursing interventions.

Nursing is an art and a science. The art of nursing derives from a nurse's experience and the
caring relationship she creates with a patient (Chinn and Kramer, 2018). A nursing philosophy
guides practice focus, means, and goals. Nursing theories improve patient communication
and responsibility (Meleis, 2018).

COMPONENTS OF THEORY

Assumptions and beliefs that explain a phenomenon are called theories. In this way, the
phenomenon is explained. These components help nurses direct and provide caring nursing
practices. Researchers test theories to get a better perspective and knowledge of a
phenomenon.

PHENOMENON

Nursing theories study nursing and nursing care. A phenomenon is a phrase, description, or
label used to define an event, circumstance, process, or series of events or situations.
Temporary or permanent phenomena Nursing phenomena include caring, self-care, and
patient stress responses.

CONCEPTS

A theory is made up of concepts that describe or label phenomena. (Smith and Liehr, 2018) A
notion is a thought or idea of reality expressed in words or phrases. Emotions and actual
objects are examples of concepts (Chinn and Kramer, 2018). Nightingale highlighted real
concepts such as physical circumstances and health care surroundings, while Meleis
described abstract notions like as coping and adapting (Meleis, 2018). Concepts convey
meaning in theories.

DEFINITIONS

Theorists employ definitions to convey a theory's general meaning. Definitions might be

theoretical or practical. Theoretical or conceptual definitions merely define a term from the
theorist's perspective (Meleis, 2018; McEwen and Wills, 2019). Operational definitions define
concepts (Chinn and Kramer, 2018). So, a nurse might define pain as physical discomfort or a
patient reporting a pain level of three or higher on a scale of zero to ten.

ASSUMPTIONS

Assumptions are implicit statements that describe a theory's concepts, definitions, purpose,
relationships, and structure. Values and beliefs are assumed to be true (Masters, 2015; Meleis,
2018). In Watson's transpersonal caring theory, intentional purpose to care promotes healing
and completeness (Alligood, 2018).
THE DOMAIN OF NURSING

A domain is a profession or discipline's perspective (Meleis, 2018). It provides a discipline's

subject, key concepts, values, and difficulties. Nursing encompasses both a practical and
theoretical element of the field. It includes nursing history, theory, education, and research.
The domain of nursing allows nurses to recognize and treat patients' health care needs in all
health care settings.

A paradigm is a set of beliefs that describes a discipline's realm. It connects the discipline's
concepts, theories, beliefs, values, and assumptions (McEwen and Wills, 2019). It's typically
used interchangeably with paradigm. A conceptual framework helps arrange major ideas
and visualize relationships between phenomena. Frameworks represent the author's
perspective on a discipline's subject matter. For example, the big theorists all address
comparable issues, but each defines and describes them differently based on their individual
thoughts and experiences (Schmidt and Brown, 2015).

The nursing metaparadigm helps nurses comprehend what nursing is, does, and why nurses
do it (Peterson and Bredow, 2017). Personnel, health, environment/situation, and nursing are
the four concepts in the nursing metaparadigm. Individuals, groups, families, and communities
get nursing care. The person is the focus of your nursing care. Individualized patient-centered
treatment is critical due to the complexity of each person's needs. Each patient, clinical
context, and health care profession defines health differently. It is a state of being defined by
personal ideals, personality, and lifestyle. It is dynamic and ever-changing. Nursing challenges
you to provide the finest care possible based on a patient's health and care needs at the time
of birth.

The environment/situation includes all conditions impacting patients and their healthcare
settings. A patient's environment is constantly changing. Positive and negative consequences
of this interplay on health and health care needs. Home, school, workplace, and
neighborhood factors all influence these demands. For example, an adolescent girl with type
1 diabetes must adjust her treatment plan to accommodate school activities, a part-time job,
and social events like prom.

All ages, families, groups, and communities are cared for in nursing. Nursing involves health
promotion, illness prevention, and care of the sick, disabled, and dying (International Council
of Nurses, 2018). Nursing has a broad scope. For example, a nurse does not diagnose heart
failure in a patient. Nurses diagnose fatigue, activity intolerance, and difficulty coping as a
result of the disease. The nurse then develops a patient-centered plan of care for each of the
patient's health issues. Use critical thinking skills to incorporate knowledge, experience,
attitudes, and standards into each patient's care plan.

EVOLUTION OF NURSING THEORY

Theoretical creation: Florence Nightingale was the first nursing theorist, believing that nursing
could improve a patient's environment to aid recovery and prevent complications. In the
Victorian era, when Nightingale lived, nurses were taught to keep an eye on patients and
report changes to the doctor (Chinn and Kramer, 2018).

Through the twentieth century, nursing became a profession, prompting American nurses to
standardize nursing education in diploma programs and urge more nurses to pursue
academic degrees. 1893 saw the first national assembly of nurses, and 1900 saw the inaugural
issue of the American Journal of Nursing (AJN) (Alligood, 2014). The “curriculum era” of nursing
was 1900–1940. During this time period, nursing education grew to incorporate social sciences,
pharmacology, and “nursing arts” courses that emphasized nursing actions, skills, and
procedures (Alligood, 2014).

During the 1950s, 1960s, and 1970s, nurses became increasingly interested in research and
disseminating their findings. Early investigations were psychological, anthropological, or
pedagogical in nature. Their opinions, ties with other professions, and roles in society were
explored. Initially, nursing research avoided clinical issues based on the medical research
model in order to distinguish itself from medicine. During this time period, early nursing theories
 were formed, giving structure to nursing research. A few of the famous theorists of this time
period were Johnson and King (Alligood, 2014).

The nursing metaparadigm was postulated by Fawcett throughout the 1980s and 1990s theory
era. Several nursing publications were published, nursing conferences were developed, and
more nursing doctoral programs were offered (Alligood, 2018).

The 21st century is the age of theory application. Today's nurses try to give EBP based on
theory, research, and experience. EBP focuses on quality, safe, complete care. The early big
theories paved the way for the more recent middle-range ideas, which offered “evidence”
for EBP and aided in its implementation. Theory utilization aligns with current national quality
health care goals (Alligood, 2018).

Nursing theories have evolved to reflect societal and global trends. Nightingale's theory was
shaped by the wartime context. Rogers' introduction of “energy fields” was developed during
the 1980s when the space shuttle program offered an attraction of space (Meleis, 2018).

Theorists drew on their own nursing education and practice experiences as well as information
from philosophy, sociology, psychology, and anthropology. Many nursing theorists alter their
theories to keep up with changing health care. This evolution demonstrates that theories are
alive and responsive to the changing world in which we live (McEwen and Wills, 2019).

GOALS OF THEORETICAL NURSING MODELS

1. Determine the nursing domain and objectives.

2. To advance nursing administration, practice, education, and research through the
dissemination of knowledge.
3. Conduct research to further the nursing profession's knowledge base.
4. Recognize the research methods and instruments that are used to validate nursing
treatments.
5. Create nursing education curriculum plans.
6. Establish criteria for evaluating nursing care, education, and research quality.
7. Assist with the creation of a system for the delivery of nursing care.
8. Provide nursing actions with a logical structure and reason.

TYPES OF THEORY

GRAND THEORIES

− Grand theories are abstract, broad-scoped, and complex, requiring research to be

applied to nursing practice.
− A general theory doesn't guide specific nursing actions. Instead, it provides a framework
for global nursing ideals.
− Grand theories aim to answer the question "What is nursing?" rather than focusing on a
single style of nursing. Their writings reflected their own experiences and the times in which
they lived, which explains the wide range of theories.
− Grand theories address person, nursing, health, and environment.

In Imogene King's philosophy of goal achievement, nursing is focused on the human-

environment interaction with the end objective of health (Meleis, 2018).

MIDDLE-RANGE THEORIES

− Middle-range theories are less abstract and more constrained. Aspects of practice
(administrative, clinical, or instructional) are addressed.
− While grand theories include a broad variety of topics, middle-range theories focus on
specific topics including uncertainty, incontinence, social support, quality of life, and care
(Peterson and Bredow, 2017; Smith and Liehr, 2018).
 − This includes meeting patients' physical, psychospiritual, environmental, and social
requirements (Schmidt and Brown 2015).

Kolcaba's idea was founded on the works of a grand theorist, in this case Nightingale. Middle-
range theories can be derived from research, nursing practice, or other fields' theories
(McEwen and Wills, 2019)

PRACTICE THEORIES

− Practice theories, also known as situation-specific theories, bring theory to the bedside.
These theories guide the nursing care of a certain patient population at a particular period
(Meleis, 2018).
− A pain-management plan for heart surgery patients is an example of a practice theory.
− In contrast to grand and middle range theories, practice theories are more concrete
(Meleis, 2018).

DESCRIPTIVE THEORIES

The initial phase of theory development is descriptive. They describe phenomena and their
causes (Meleis, 2018). For example, growth and development theories describe an
individual's maturing processes. Descriptive theories don't try to change anything but help
explain patient judgments.

PRESCRIPTIVE THEORIES

Prescriptive theories address a phenomenon, drive practice improvement, and predict

outcomes. Nurses employ prescriptive theories to predict nursing outcomes (McEwen and
Wills, 2019). Clinical practice is guided by prescriptive theories. The objective of nursing,
according to Wiedenbach's prescriptive theory, is to stimulate the patient, enable efforts
to overcome obstacles, and generate nursing action depending on the immediate
situation (Meleis, 2018).

THEORY-BASED NURSING PRACTICE

Basic and nursing sciences, experience, aesthetics, nurses' attitudes, and norms of
practice all contribute to nursing knowledge. As nursing develops as a practice-oriented
profession, new knowledge is required to prescribe targeted interventions that improve
patient outcomes.

In clinical settings, the nursing process is utilized to assess patient needs. The nursing process
is not a theory. It is a method for delivering nursing care, not a body of knowledge.
However, nurses employ theory to guide their nursing procedure.

SHARED THEORY

A shared theory, sometimes referred to as a borrowed or interdisciplinary theory, is one that

explains a phenomenon unique to the discipline that generated it (McEwen and Wills, 2019).

− A child's cognitive growth is explained by Piaget's theory of cognitive development. A

pediatric nurse can use this theory to construct therapeutic play interventions for sick
toddlers or school-aged children.

− Adult learning theory (Knowles) helps a nurse plan and give appropriate discharge
instruction for a surgical patient.
Many nursing theories use systems theory. Nursing is a system. The nursing process, like all systems,
has a purpose. To arrange and offer patient-centered care. The nursing process comprises four
parts: input, output, feedback, and content.

1. Input for the nursing process is the data or information that comes from a patient’s
assessment.
2. Output is the product of a system, it is whether the patient's health status improves,
deteriorates, or remains steady as a result of nursing care.
3. Feedback is used to educate a system about how it works. For instance, outcomes in
nursing represent the patient's response to nursing interventions. The outcomes serve as
part of the feedback mechanism used to fine-tune the care plan. Additionally, the nursing
process include feedback from family members and contact with other health care
specialists.
4. The content consists of the product and data gathered from the system. For example,
patients with restricted bed mobility have basic skin care requirements and interventions
(e.g., hygiene and scheduled posture changes) that have been shown to significantly
reduce the risk of pressure injuries.

OVERVIEW OF SELECT SHARED THEORIES

CATEGORY FOCUS APPLICATION TO NURSING

HUMAN NEEDS Human behavior is Fundamental physiological and safety needs
motivated by need. are typically a patient's top priority, even more
Maslow's hierarchy of so when the patient is reliant on others to supply
fundamental human these needs. When a patient does not have an
needs is comprised of urgent physical or safety requirement, the nurse
five tiers of prioritizes the patient's psychological,
importance (e.g., sociocultural, developmental, or spiritual
physiological, safety needs. Most patients who join the health care
and security, love and system do so with unmet needs. After surgery, a
belonging, self- patient who is in pain (basic need) is not ready
esteem, and self- for discharge teaching (higher-level need) until
actualization) the discomfort is alleviated. The need hierarchy
is a method for planning for personalized
patient care (McEwen and Wills, 2019).
STRESS/ADAPTATION Humans adapt to Patients react to stress in similar physiological
threats, real or and psychological ways. Stress-resistance can
perceived, in order to lead to weariness and health problems. Nurses
sustain function and must understand the body's and mind's
existence. response to stress in order to assist patients
cope and adapt to illness and disease.
DEVELOPMENTAL Humans share a Human growth and development follow a
common growth and predictable pattern from conception to death.
development pattern. Several tested theories describe and predict
behavior and development across the life span
(McEwen and Wills, 2019).
BIOMEDICAL Theory elucidates the A nurse's knowledge of science is essential to
origins of sickness; providing holistic patient care that promotes
principles of health and prevents sickness (McEwen and
physiology. Wills, 2019)
PSYCHOSOCIAL Human responses in Nursing is a broad field that aims to help people
the physiological, holistically. It has models for understanding
psychological, social, cultural diversity and providing care that meets
developmental, and patient requirements. Thus, it discusses family
spiritual domains are theory and how to address the requirements of
explained and/or the patient or caregiver's family. It also shows
predicted by theory. how to help patients cope with loss, death, and
mourning.
EDUCATIONAL Theory explains how to Nurses educate patients, families, community
teach and learn by groups, and other health care professionals.
 looking at behavioral, This component of the professional nurse's duty
cognitive, and adult requires knowledge of several teaching-
learning principles. learning philosophies (Butts and Rich, 2015).
LEADERSHIP/ Theory helps with Nurses frequently hold leadership roles in health
MANAGEMENT organization, change, care and are required to successfully manage
power/empowerment, individuals and groups to improve quality care
motivation, conflict and outcomes (McEwen and Wills, 2019).
management, and
making decisions.

OVERVIEW OF SELECT GRAND AND MIDDLE-RANGE NURSING THEORIES

GRAND THEORIES
THEORIST FOCUS APPLICATION
HENDERSON Principles and Nurses assist patients with 14 activities (breathing,
practice of nursing eating/drinking, elimination,
movement/positioning, sleep/rest, clothing, body
temperature, hygiene, safety,
communication/socialization/play, religious
practice, and learning) until they can meet these
needs on their own or until they die peacefully
(Butts and Rich, 2015; McEwen and Wills, 2019).
JOHNSON Behavioral System Nurses value patients more than their sickness; a
patient is considered as a collection of subsystems
that combine to produce an entire behavioral
system focused on meeting basic impulses such as
achievement, affiliation, aggression/protection,
dependence, elimination, ingestion, sex, and
restoration. Nursing's objective is to assist patients
in achieving/maintaining balance, function, and
stability in each of the subsystems (Butts and Rich,
2015).
NEUMAN System Nurses see a patient as an open system that is
constantly exchanging energy with both internal
and external settings. Nurses help patients cope
with intrapersonal, interpersonal, and extra
personal pressures that might cause sickness. The
focus of nursing is on wellness and disease
prevention (McEwen and Wilks, 2019).
ADELLAH Patient centered Nurses should address 21 "nursing challenges" to
care meet patients' physical, psychological, and social
needs. To deliver patient-centered care, nurses
build information from previous experiences to
develop a broad plan of care. An effective nurse
incorporates the patient's family in the treatment
plan (McEwen and Wills, 2019).
KING Goal attainment Nurses help patients become active participants
in their treatment by working with them to develop
goals for achieving, recovering, or sustaining
health (Johnson and Webber, 2014; McEwen and
Wills, 2019).
ROY Adaptation To cope or adapt to physiological, self-
conceptual, role-function and interdependent
changes (Masters, 2015).
WATSON Caring Professional nursing care is founded on ten
curative components. More than only curing
diseases, nursing seeks to understand the
interrelationships between health, illness, and
human behavior. A transpersonal interaction
between a nurse and patient promotes self-
healing (Johnson and Webber, 2014).
 ROGERS/PARSE/ Unitary beings / Nursing care focuses on helping patients use their
NEWMAN human becoming own potential to detect and adapt personal
/ expanding rhythms/patterns (e.g., eating, breathing,
consciousness sleeping) to promote and sustain health. The
nurse's role is to be truly present with the patient
and accept his or her view of reality while guiding
the patient in making health-related choices in
accordance with his or her belief system (Johnson
and Webber, 2014; McEwen and Wills, 2019).

MIDDLE RANGE THEORIES

THEORIST FOCUS APPLICATION
BENNER Skill acquisition Nurses learn skills in five stages: novice, advanced
beginner, competent, proficient, and expert (Butts
and Rich, 2015).
KOLCABA Comfort Nurses help patients pursue health by relieving
physical, emotional, social, environmental, and
spiritual discomfort (McEwen and Wills, 2019).
PENDER Health Patients' motivation to adopt healthy habits is
promotion influenced by their personal qualities, experiences,
and beliefs. (McEwen and Wills, 2019).
AMERICAN Synergy Matching nurse skills to patient demands improves
ASSOCIATION OF patient outcomes in critical care (McEwen and Wills,
CRITICAL CARE 2019).
NURSES
MELESIS, SAWYER, IM, Transitions Patients are more vulnerable during illness and
MESSIAS, AND recovery. Nurses can help patients make good
SCHUMACHER transitions by customizing nursing interventions. For
example, moving from home to a nursing home
owing to health issues (Alligood, 2018).

NIGHTINGALE’S ENVIRONMENTAL THEORY

Florence Nightingale is credited for creating the first nursing theory. Nurses,
according to Nightingale's grand theory, should manipulate a patient's
environment to allow nature to heal the patient (McEwen and Wills, 2019).
During the Crimean War, she enhanced cleanliness and sanitary
conditions by observing and collecting data. According to Nightingale,
“vital observation [assessment] is not for the sake of piling up miscellaneous
information or curious facts, but to save life and increase health and
comfort” (Nightingale, 1860).

PEPLAU’S INTERPERSONAL THEORY

Hildegard Peplau is the mother of psychiatric nursing; her middle-range

theory focuses on developing the nurse-patient interaction (McEwen and
Wills, 2019). (McEwen and Wills, 2019) According to Peplau, nurses assist
patients minimize anxiety by redirecting it. They build polite, empathic,
nonjudgmental therapy interactions with patients (Hagerty et al., 2017).
The nurse-patient connection comprises four phases: preorientation (data
gathering), orientation (defining issue), and working phase (therapeutic
activity) (termination of relationship).

The nurse acts as a resource, counselor, and surrogate in the patient-nurse

interaction. When a patient seeks treatment, the nurse first discusses the
nature of the issues, then outlines the resources available. As the nurse-
patient relationship grows, the two define the issues and possible remedies.
After the patient's initial demands are addressed, other ones may arise. To
gather a nursing history, educate patients, or counsel patients and their
families, this middle-range theory is useful.

OREM’S SELF-CARE DEFICIT NURSING THEORY

This theory was developed by Dorothea Orem (Alligood, 2014). This grand
idea requires a nurse to regularly assess a patient's ability to self-care and
intervene as needed to address physical, psychological, socio-economic
and developmental needs. Self-care practices, according to Orem,
improve health outcomes (Kur and Schmidt, 2016; Rusten et al., 2014).
Patients who cannot meet their biological, psychological, developmental,
or social needs require nursing care. In addition, nurses regularly review
patients' ability to meet their own needs, set goals to support them,
intervene to help them execute self-care, and assess their ability to do so.
During an acute illness, a patient may require a nurse to bathe or feed
them, but as their condition improves, the nurse encourages them to do it
independently.

LEININGER’S CULTURE CARE THEORY

Madeleine Leininger predicted that nursing and health care will become
more worldwide in the 1950s. Her middle-range theory of cultural care
variation and universality combines anthropology and nursing (Alligood,
2014). Cultures' manifestations, processes, and patterns of human care
vary. Politics, society, and traditions are key elements affecting care and
determining patient health and sickness patterns. Consider the range of
patients and their nursing needs. The purpose of nursing care is to offer a
patient with culturally specific nursing care (Alligood, 2014). Nurses safely
incorporate patients' cultural customs, attitudes, and beliefs into a care
plan. It highlights the relevance of culture and its influence on patient
care, including health attitudes, family and community roles, and dietary
behaviors (Alligood, 2014).

LINK BETWEEN THEORY AND KNOWLEDGE DEVELOPMENT IN NURSING

Nursing has its own corpus of theoretical and experiential knowledge. You learn theory through
“reading, observing, or discussing” ideas (Alligood, 2014, p. 123). Theoretical knowledge
encourages thinking and broadens nursing scientific and practice knowledge. Experiential or
clinical knowledge is formed by nurses' clinical experience. Both sorts of expertise are required for
safe nursing care.

Nursing theories provide direction for nursing practice (McEwen and Wills, 2019). When you
practice theory-based nursing, you apply the principles of a theory to the delivery of nursing
interventions. Grand theories assist in shaping and defining your practice, while middle-range
theories improve nursing knowledge through nursing research. Practice theories assist you in
providing particular care for individuals and groups from varied populations and situations.

RELATIONSHIP BETWEEN NURSING THEORY AND NURSING RESEARCH

The relationship between nursing theory and nursing research contributes to the development of
nursing's scientific knowledge base, which is then used in practice. As more research is completed,
nurses will gain a better understanding of the appropriate application of a theory to improve
patient care. The links between the components of a theory frequently assist in defining research
questions and determining the study's overall design.
THEORY GENERATING RESEARCH:

− It is designed to develop and describe relationships between and among phenomena

without imposing preconceived notations.
− It is inductive and includes field observations and phenomenology.
− During the theory generating process the researcher moves by logical thought from fact
to theory by means of a proposition stated as an empirical generalization.

THEORY TESTING RESEARCH:

− In theory testing research theoretical statements are translated into questions and
hypothesis. It requires a deductive reasoning process.
− The interpretation determines whether the study supports are contradicts the propositional
statement.
− If a conceptual model is used as a theoretical framework for research, it is not theory
testing.
− Theory testing requires detailed examination of theoretical relationships.

KEY ELEMENTS

1. The components of a theory provide a foundation for knowledge for nurses to direct and
deliver nursing care.
2. Theories are dynamic and responsive to the changing environment in which we live.
3. The types of nursing theories include grand theories, middle-range theories, practice
theories, descriptive and prescriptive theories.
4. The integration of theory into practice leads to coordinated care delivery.
5. Nurses need a strong scientific knowledge base from nursing and other disciplines, such as
the biomedical, sociological, and behavioral sciences.
6. Grand and middle-range nursing theories can help you understand the practice of
nursing.
7. The relationship between theory and research builds the scientific knowledge base of
nursing, which is then applied to practice.