Nursing is involved in identifying its own unique knowledge base—that is, the body of knowledge essential to nursing practice, or a so-called nursing science. To identify this knowledge base, nurses must develop and recognize concepts and theories that are specific to nursing.
Theory has been defined as a supposition or system of ideas that is proposed to explain a given phenomenon. For now, think of theory as a major, very well articulated idea about something important. The four most influential theories from the 20th century were Marx’s theory of alienation, Freud’s theory of the unconscious, Darwin’s theory of evolution, and Einstein’s theory of relativity. Most undergraduate students are introduced to the major theories in their disciplines.
Psychology majors study Freud and Jung’s theories of the unconscious, Sullivan and Piaget’s theories of development, and Skinner’s theory of behaviorism. Psychology majors are also introduced to critiques of those theories. Sociology majors study Marx’s theory of alienation and Weber’s theories of modern work, as well as the critiques of their theories. Both sociology and psychology majors spend the majority of their time studying theories and approaches to research.
A. Purposes of Nursing Theory
Direct links exist among theory, education, research, and clinical practice.
a) In Education
Because nursing theory was used primarily to establish the profession’s place in the university, it is not surprising that nursing theory became more firmly established in academia than in clinical practice. In the 1970s and 1980s, many nursing programs identified the major concepts in one or two nursing models, organized these concepts into a conceptual framework, and attempted to organize the entire curriculum around that framework.
The unique language in these models was typically introduced into program objectives, course objectives, course descriptions, and clinical performance criteria. The purpose was to elucidate the central meanings of the profession and to gain status vis-à-vis other professions. Occasionally, the language of nursing syllabi became so torturous that neither the faculty nor the students had a clear understanding of what was meant. Many nursing programs have abandoned theory-driven conceptual frameworks.
A. In Research
Nurse scholars have repeatedly insisted that nursing research identifies the philosophical assumptions or theoretical frameworks from which it proceeds. That is because all thinking, writing, and speaking is based on previous assumptions about people and the world. New theoretical perspectives provide an essential service by identifying gaps in the way we approach specific fields of study such as symptom management or quality of life. Different theoretical perspectives can also help generate new ideas, research questions, and interpretations.
Grand theories only occasionally direct nursing research. Nursing research is more often informed by midlevel theories that focus on the exploration of concepts such as pain, self-esteem, learning, and hardiness. Qualitative research in nursing and the social sciences can also be grounded in theories from philosophy or the social sciences.
The term critical theory is used in academia to describe theories that help elucidate how social structures affect a wide variety of human experiences from art to social practices. In nursing, critical theory helps explain how these structures such as race, gender, sexual orientation, and economic class affect patient experiences and health outcomes.
a) In Clinical Practice
Where nursing theory has been employed in a clinical setting, its primary contribution has been the facilitation of reflection, questioning, and thinking about what nurses do. Because nurses and nursing practice are often subordinated to powerful institutional forces and traditions, the introduction of any framework that encourages nurses to reflect on, think about, and question what they do provides an invaluable service.
An increasing body of theoretical scholarship in nursing has been outside the framework of the formal theories presented in the next pages. Benner (2000) argues that formalistic theories are too often superimposed on the life-worlds of patients, overshadowing core values of the profession and our patient’s humanity.
Philosophy is used to explore both clinical and theoretical issues in the journal Nursing Philosophy. Family theorists and critical theorists have encouraged the profession to move the focus from individuals to families and social structures. Debates about the role of theory in nursing practice provide evidence that is nursing is maturing, both as an academic discipline and as a clinical profession.
B. Nursing Theories
The nursing theories discussed in this paper vary considerably (a) in their level of abstraction; (b) in their conceptualization of the client, health/illness, environment, and nursing; and (c) in their ability to describe, explain, or predict. Some theories are broad in scope; others are limited. The works presented in this paper may be categorized as philosophies, conceptual frameworks or grand theories, or midlevel theories (Tomey, 2001).
A philosophy is often an early effort to define nursing phenomena and serves as the basis for later theoretical formulations. Examples if philosophies are those of Nightingale, Henderson, and Watson. Conceptual models/grand theories include those of Orem, Rogers, Roy, and King, whereas midlevel theorists are Peplau, Leininger, Parse, and Neuman.
a) Nightingale’s Environmental Theory
Florence Nightingale, often considered the first nurse theorist, defined nursing more than 100 years ago as “the act of utilizing the environment of the patient to assist him in his recovery (Nightingale, 1999). She linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3) efficient drainage, (4) cleanliness and (5) light, especially direct sunlight. Deficiencies
These environmental factors attain significance when one considers that sanitation conditions in the hospitals of the mid-1800s were extremely poor and that women working in the hospitals were often unreliable, uneducated, and incompetent to care for the ill. In addition to those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending of the client’s diet in terms of assessing intake, timeliness of the food, and its effect on the person (Nightingale, 1999).
Nightingale set the stage for further work in the development of nursing theories. Her general concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care today.
b) Roger’s Science of Unitary Human Beings
Martha Rogers first presented her theory of unitary human beings in 1970. It contains complex conceptualizations related to multiple scientific disciplines (e.g., Einstein’s theory of relativity, Burr and Northrop’s electrodynamic theory of life; von Bertalanffy’s general systems theory; and many other disciplines, such as anthropology, psychology, sociology, astronomy, religion, philosophy, history, biology, and literature.
Rogers views the person as an irreducible whole, the whole being greater than the sum of its parts. Whole is differentiated from holistic, the latter often being used to mean only the sum of all parts. She states that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. The “human field image” perspective surpasses that of the physical body. Both human and environmental fields are characterized by pattern, a universe of open systems, and four dimensionalities (Rogers, 2000).
Nurses applying Roger’s theory in practice (a) focus on the person’s wholeness, (b) seek to promote symphonic interaction between the two energy fields (human and environment) to strengthen the coherence and integrity of the person, (c) coordinate the human field with the rhythmicities of the environmental field, and (d) direct and redirect patterns of interaction between the two energy fields to promote maximum health potential.
Nurses’ use of non-contact therapeutic touch is based on the concept of human energy fields. The qualities of the field vary from person to person and are affected by pain and illness. Although the field is infinite, realistically it is most clearly “felt” within several feet of the body. Nurses trained in non-contact therapeutic touch claim they can assess and feel the energy field and manipulate it to enhance the healing process of people who are ill or injured (Rogers, 2000).
c) Orem’s General Theory of Nursing
Dorothea Orem’s theory, first published in 1971, includes the related concepts: self-care, self-care deficit, and nursing systems. Self-care theory is based in four concepts: self-care, self-care agency, self-care requisites, and therapeutic self-care demand. Self-care refers to those activities an individual performs independently throughout life to promote and maintain personal well-being.
Self-care agency is the individual’s ability to perform self-care activities. It consists of two agents: A self-care agent (an individual who performs self-care independently) and a dependent care agent (a person other than the individual who provides the care) (Orem, 2001). Most adults care for themselves, whereas infants and people weakened by illness or disability require assistance with self-care activities.
Self-care requisites, also called self-care needs, are measures or actions taken to provide self-care. Self-care deficit results when self-care agency is not adequate to meet the known self-care demand. Orem’s self-care deficit theory explains not only when nursing is needed but also how people can be assisted through five methods of helping; acting or doing for, guiding, teaching, supporting, and providing an environment that promotes the individual’s abilities to meet current and future demands.
d) King’s Goal Attainment Theory
Imogene King’s theory of goal attainment was derived from her conceptual framework. King’s framework shows the relationship of operational systems (individuals), interpersonal systems (groups such as nurse-patient), and social systems (such as educational system, health care system). She selected 15 concepts from the nursing literature (self, role, perception, communication, interaction, transaction, growth and development, stress, time, personal space, organization, status power, authority, and decision making) as essential knowledge for use by nurses.
Ten of the concepts in the framework were selected (self, role, perception, communication, interaction, transaction, growth and development, stress, time, and personal space) as essential knowledge for use by nurses in concrete nursing situations.
Within this theory, a transaction process model was designed (King, 2001). This process describes the nature of and standard for nurse—patient interactions that leads to goal attainment— that nurses purposefully interact and mutually set, explore, and agree to means to achieve goals. Goal attainment represents outcomes. When this information is recorded in the patient record, nurses have data that represent evidence-based nursing practice.
King’s theory offers insight into nurses’ interactions with individuals and groups within the environment. It highlights the importance of a client’s participation in decisions that influence care and focuses on both the process of nurse-client interaction and the outcomes of care (King, 2001).
In the natural sciences, the main function of theory is to guide research. In the practice disciples, the main function of theory (and research) is to provide new possibilities for understanding the discipline’s focus (music, art, management, and nursing).
To Nightingale, the knowledge required to provide good nursing was neither unique nor specialized. Rather, Nightingale viewed nursing as central human activity grounded in observation, reason, and commonsense health practices.
Theories articulate significant relationship between concepts in order to point something larger, such as gravity, the unconscious, or the experiences of pain.
Benner, P. (2000). The roles of embodiment, emotion and lifeworld for rationality and agency in nursing practice. Nursing Philosophy, 1(1), 5-19.
Nightingale, F. (1999). Notes on nursing: What it is, and what it is not. New York: Dover. (Original work published in 1860).
Orem, D. (2001). Nursing: Concepts of practice (8th Ed.). St. Louis, M.O. Mosby.
Rogers, M.E. (2000). An introduction to the theoretical basis if nursing. Philadelphia: F.A. Davis.
Tomey, A.M. (2001). Nursing theorist and their work (7th Ed.). St. Louis MO: Mosby.
King, I. M. (2001). A theory fir nursing: Systems, concepts, process. Albany, NY: Delmar.