The Development of Nursing Theories

CHAPTER © JonesThe & Bartlett Development Learning, LLC of © Jones & Bartlett Learning, LLC NOT NursingFOR SALE OR Theories DISTRIBUTION NOT FOR SALE OR DISTRIBUTION3

ost nurse theorists did not set out to create a nursing theory. Most © Jones & Bartlettbegan constructing Learning, a theoryLLC as a way to improve the© Jonescare delivered & Bartlett Learning, LLC NOT MFOR SALEto clients, OR DISTRIBUTION whether through direct clinical practiceNOT or through FOR SALE the OR DISTRIBUTION education of nurses. The theorists were risk takers with lifelong commitments to the nursing profession. They viewed nursing as a career rather than as an alternative to marriage, which was the view of many nurses during the 1940s, 1950s, and 1960s. These theorists had broad, well-rounded educational back- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC grounds and a variety of interests. They were inquisitive, bold, and unafraid NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to question or challenge the status quo. The demands of their professional lives were great, and their home lives suffered, causing one nursing leader to remark that the early great leaders needed a “wife” to assist them or manage the personal dimension of their lives (R. Schlotfeldt, personal communica- tion with Lisa© Jones Eichelberger, & Bartlett 1982). Learning,Most of the earlyLLC theorists made profes-© Jones & Bartlett Learning, LLC sional choicesNOT that FOR affected SALE their OR personal DISTRIBUTION lives, and most never married orNOT FOR SALE OR DISTRIBUTION had children. Interestingly, two major universities were responsible for edu- cating most of the early nurse theorists: Peplau, Henderson, Hall, Abdellah, Orlando, Wiedenbach, King, and Rogers all graduated from either Columbia © JonesUniversity’s & Bartlett Teachers Learning, College in LLC New York or Yale University© inJones New Haven, & Bartlett Learning, LLC NOT Connecticut.FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 11

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE9781284098075_CH03.indd OR DISTRIBUTION 11 NOT FOR SALE OR DISTRIBUTION 10/8/15 3:00 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

12 Chapter 3 The Development of Nursing Theories

© JonesWhy & Bartlett Theories Learning, Were LLC Developed © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Theory development was an integral part of modern nursing, as evidenced by Nightingale’s Notes on Nursing: What It Is and What It Is Not, published in 1859. This small book was the first of its kind to theoretically describe the nature of nurs- © Jones & Bartletting. Learning, Research was LLC also an integral part of modern© Jones nursing, & Bartlett as evidenced Learning, by LLC NOT FOR SALE ORNightingale’s DISTRIBUTION extensive research projects andNOT publications FOR SALE related OR to examin-DISTRIBUTION ing the economics and efficacy of army hospitals. Unfortunately, Nightingale’s examples of theory development and research were not carried forth. It would be nearly 100 years before nursing theory and research were again consid- © Jones & Bartlett Learning, LLCered essential for nurses. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION It was not until the 1950s that nurse scholars started to develop nursing theories. This occurred during a time when professional thought in nursing was moving toward conceptualizing nursing as a profession based on science rather than as a trade-based apprenticeship. Also at this time, nursing © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC education was in transition, with the education and training of nurses NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION moving into college-level educational institutions and out of hospital-based training schools (Kalisch & Kalisch, 1995).

In the 1960s, the first doctoral programs in nursing were established (Chinn © Jones & Bartlett& Learning,Kramer, 1999). LLC Prior to the 1960s most nurses© Jones who wished & Bartlett to pursue Learning, a doc- LLC NOT FOR SALE ORtorate DISTRIBUTION did so in related fields such as sociology,NOT education,FOR SALE psychology, OR DISTRIBUTION and anthropology and then adapted theories from those fields for use in nursing. This approach was initially helpful; however, it became apparent that nursing was unique and contained many aspects not addressed in theories © Jones & Bartlett Learning, LLCfrom other disciplines. Other© Jones disciplines & Bartlett from which Learning, nursing theories LLC were NOT FOR SALE OR DISTRIBUTIONadapted were not immersedNOT in the FOR actual, SALE real-life particularsOR DISTRIBUTION of embodiment; that is, professionally managing the specifics of humans in various states of well- ness. For instance, nurses often assess a client’s mental, social, and spiritual well-being while at the same time giving a bed bath, evaluating skin integrity, © Jonesassessing & Bartlett the stage Learning, of healing of LLC a surgical wound, and observing© Jones for patency & Bartlett Learning, LLC NOT ofFOR a urinary SALE bladder OR DISTRIBUTIONcatheter. Psychologists, sociologists, andNOT anthropologists FOR SALE OR DISTRIBUTION would generally not be expected to provide intimate physical assessment and care while evaluating the psychological and social concerns of an individual or group of individuals. Because of this difference, theories from other re- © Jones & Bartlettlated Learning, disciplines LLC were (and are) applicable ©to Jonesnursing only& Bartlett in a limited Learning, sense. LLC NOT FOR SALE ORNursing DISTRIBUTION leaders began to understand that NOTif nursing FOR was SALE to develop OR DISTRIBUTION its own

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How Theorists Created Theories 13

body of knowledge,© Jones the & Bartlettcreation of Learning, nursing theory LLC was essential, and doctoral© Jones & Bartlett Learning, LLC level nursing NOT education FOR and SALE research OR wereDISTRIBUTION critical (Wilde, 1999). NOT FOR SALE OR DISTRIBUTION

Why the Theorists Created Theories © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT WhenFOR theSALE biographies OR DISTRIBUTION and works of the individual theoristsNOT are examined, FOR SALE it OR DISTRIBUTION becomes apparent that the impetus for developing a theory, model, or framework was two primary reasons: to further nursing as a scholarly profession and to organize and improve the delivery of nursing care. Almost without exception, the nurse theorists created their theories, at least in part, as a result of their © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC direct experiences in practice and their desire to improve practice, whether NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION clinical or classroom based. Imogene King (General Systems Framework) and Martha Rogers (Science of Unitary Human Beings) stated specifically that they developed a conceptual framework/theory because of their concern over the lack of nursing knowledge. These two theorists believed that this knowledge was essential© Jones to the development & Bartlett Learning,of nursing as LLCa science. Other reasons for© Jones & Bartlett Learning, LLC theory developmentNOT FOR given SALE by early OR theorists DISTRIBUTION were that theories could be toolsNOT FOR SALE OR DISTRIBUTION to provide structure for the improvement of clinical practice, teaching nursing students effectively, or organizing a nursing curriculum.

The development of nursing theory started with Nightingale and her astute and mindful observations of actual nursing practice environments. The idea © Jones & Bartlettthat Learning, nursing theory LLC comes from practice is consistent© Jones with & BartlettDickoff and Learning, James’s LLC NOT FOR SALE ORclassic DISTRIBUTION theory development article (1968) thatNOT says FOR theory SALE about OR a practiceDISTRIBUTION discipline must come from actual practice experience. Discovery of knowledge, concepts, and relationships among and between concepts about the discipline occurs when practitioners are immersed in practice. It is through reflective thinking© Jones that & practitioners Bartlett Learning, are able to gainLLC insight into the patterns© Jones & Bartlett Learning, LLC that may existNOT in theFOR practice SALE arena OR (Johns, DISTRIBUTION 1994). NOT FOR SALE OR DISTRIBUTION

Creating a theory is like constructing a complex puzzle (Van Sell & Kalofissudis, 2003). The nurse theorists relate very similar stories as to © Joneshow they& Bartlett approached Learning, theory development.LLC They reflected© uponJones personal & Bartlett Learning, LLC NOT andFOR professional SALE OR experiences DISTRIBUTION to make sense of worldviewsNOT and FOR then SALE put OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE9781284098075_CH03.indd OR DISTRIBUTION 13 NOT FOR SALE OR DISTRIBUTION 10/8/15 3:00 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

14 Chapter 3 The Development of Nursing Theories

© Jonestogether & Bartlett the pieces Learning, of the puzzle LLC with the goal of coherent© Jones description & Bartlett Learning, LLC NOT andFOR explanation. SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

The nurse theorists used reflection to gain understanding and to glean new knowledge from practice experience. Reflection is an intentional undertaking that requires time and commitment. The purpose of reflection is to allow prac- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC titioners to examine clinical anecdotes and resolve contradictions between NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION what the nurse desires to achieve and what is experienced in actual practice, with the goal to achieve more effective outcomes (Johns, 1994). Reflection was described by many of the nurse theorists as one way to generate nursing theory. However, frustration, confusion, the need for organization of content, © Jones & Bartlett Learning, LLCand the need for a way to communicate© Jones & outcomes Bartlett to Learning, others also provedLLC help- NOT FOR SALE OR DISTRIBUTIONful in stimulating theory developmentNOT FOR (Fitne, SALE Inc., OR 1987–1989). DISTRIBUTION

Theorists wanted to improve the nursing profession and also improve daily clinical nursing care. Reflective practice allowed them to learn and draw con- © Jonesclusions & Bartlett through lived Learning, experiences. LLC Nurse theorists sought ways© Jones to represent & Bartlett Learning, LLC NOT theFOR realities SALE and OR relationships DISTRIBUTION found within nursing practice.NOT Theories FOR wereSALE OR DISTRIBUTION developed to enhance practice either directly, by stimulating practice-based thinking through reflection, or indirectly, through further development of theory (Ingram, 1991). Said another way, the theorists observed a phenom- © Jones & Bartlettenon Learning, in practice, LLC reflected on it over time,© compared Jones &it toBartlett what was Learning, known, LLC NOT FOR SALE ORand DISTRIBUTION determined goodness of fit and usefulness.NOT ThenFOR the SALE phenomenon OR DISTRIBUTION was named, classified, and categorized, and relationships/interrelationships were described (Peden, 1998).

© Jones & Bartlett Learning, LLCAn example of practice-based© Jones theory & Bartlettdevelopment Learning, can be foundLLC in the NOT FOR SALE OR DISTRIBUTIONwork of Peplau and her useNOT of participant FOR SALE observation OR DISTRIBUTION with depressed women (Peplau, 1989). Peplau’s work was the earliest published work (1952) after Nightingale. Peplau used several methods of observation, such as interviews, spectator observation, and random observation. She recorded her observa- © Jonestions of& theBartlett nurses Learning,and patients, LLC classified and categorized the© data,Jones assigned & Bartlett Learning, LLC NOT meaningFOR SALE at different OR DISTRIBUTION levels of abstraction within the phenomenon,NOT FOR and inter- SALE OR DISTRIBUTION preted the observations in the context of the phenomenon. Patterns emerged throughout this process, and Peplau was able to develop interventions from the patterns that helped the patient gain interpersonal competencies during © Jones & Bartlettillness Learning, (Peden, LLC 1998). It was through this process© Jones that Peplau& Bartlett developed Learning, her LLC NOT FOR SALE ORmodel DISTRIBUTION Interpersonal Relations in Nursing. NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE9781284098075_CH03.indd OR DISTRIBUTION 14 NOT FOR SALE OR DISTRIBUTION 10/8/15 3:00 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Testing of Theory 15

Testing© ofJones Theory & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Theory, practice, and research are interrelated and interdependent. Theory, once conceptualized, must be tested. While theories were being developed in the 1950s and 1960s, doctoral programs in nursing were being established and © Jonesmaster’s & Bartlettprograms wereLearning, becoming LLC entrenched. Research programs© Jones were estab-& Bartlett Learning, LLC NOT lished,FOR SALEand nurses OR began DISTRIBUTION to conduct nursing research. ColumbiaNOT University’sFOR SALE OR DISTRIBUTION Teachers College primarily used a biomedical model for its research focus in the 1950s and concentrated on the roles of nurses. In the 1960s, Yale School of Nursing’s research focus was on nursing as a process (George, 2002). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC During the subsequent decades, the number and quality of nursing re- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION search efforts grew significantly, and the emergence of nursing as a science began. However, there was debate over the methodology being used to study nursing concepts. Since the 1920s, the academic community has primarily used the scientific method of discovery, also known as Logical Positivism, which is based on the© Jones assumption & Bartlett that objective Learning, truth couldLLC be discovered through© Jones & Bartlett Learning, LLC rigorous observationNOT FOR and SALE experimentation. OR DISTRIBUTION According to Logical Positivism, aNOT FOR SALE OR DISTRIBUTION statement or theory is meaningful and adds to knowledge through objective verification: measuring, observing, and quantifying for the purpose of gener- alizing (Ayers, 1990). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORDuring SALE the late OR twentieth DISTRIBUTION century, much debate occurred betweenNOT FOR the social, SALE OR DISTRIBUTION philosophical, educational, spiritual, and scientific disciplines, and many academic scholars started to view science, theory building, and the generation of knowledge as more of a process rather than as a way to create a “solution” © Jones & Bartlettor Learning,“discover the LLC truth.” The idea of flexibility© withJones regard & toBartlett the generation Learning, of LLC NOT FOR SALE ORknowledge DISTRIBUTION and theory development startedNOT gaining FOR acceptance, SALE andOR theDISTRIBUTION process of theory development in more recent times has begun to encompass phenomena that cannot be concretely measured and quantified using methods based on the tenets of Logical Positivism (Allmark, 2003). Given the fact that nursing deals© Joneswith human & Bartlett beings and Learning, controlled experimentationLLC is very often© Jones & Bartlett Learning, LLC impossible,NOT many FOR nurse SALE researchers OR useDISTRIBUTION qualitative research methods. TheseNOT FOR SALE OR DISTRIBUTION qualitative methods, along with alternative approaches, often referred to as “postmodern” methods (Crotty, 1998), are sometimes not fully embraced in the scientific community. Some nurses find these postmodern approaches liberat- © Jonesing; others & Bartlett (who still Learning, accept Logical LLC Positivism and scientific method© Jones as the & “gold Bartlett Learning, LLC NOT standard”FOR SALE for knowledge OR DISTRIBUTION development) are skeptical of theseNOT new approaches. FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE9781284098075_CH03.indd OR DISTRIBUTION 15 NOT FOR SALE OR DISTRIBUTION 10/8/15 3:00 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

16 Chapter 3 The Development of Nursing Theories

© JonesIt is& normal Bartlett for individualsLearning, to LLC develop opinions that favor© oneJones method & Bartlett of Learning, LLC NOT theoryFOR SALEdevelopment OR DISTRIBUTION and inquiry over another. The kind orNOT type ofFOR research SALE OR DISTRIBUTION one chooses should depend on the questions to be answered rather than on the method of inquiry deemed “acceptable” in most academic circles. Some important questions associated with nursing phenomena that cannot be answered using a controlled, experimental approach lend themselves well to © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC exploration through postmodern methods. An example of such a question NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION might be “What is the experience of parenting a chronically ill child?” Other important nursing questions can be answered only through strict scientific methods of inquiry. An example of this type of question might be “Do axillary temperature measurements in newborns accurately reflect core body tem- © Jones & Bartlett Learning, LLCperature?” Approaches spanning© Jones Logical & BartlettPositivism Learning, to postmodern LLC methods NOT FOR SALE OR DISTRIBUTIONare essential because of theNOT need FOR for variedSALE tools OR toDISTRIBUTION use in describing the manifold aspects of nursing practice. All methods contribute to the development of nursing knowledge.

Nursing theories facilitate the process of describing, explaining, and predict- ing relevant phenomena, and they support a wide range of research-related © Jones & Bartlettendeavors. Learning, The LLC best way to truly understand© Jones the usefulness& Bartlett of Learning, nursing LLC NOT FOR SALE OR theories DISTRIBUTION is to explore the work of nurses whoNOT have FOR utilized SALE them OR in research DISTRIBUTION studies and other knowledge development activities. The classic, well- established nursing theories presented in this book have formed the theo- retical scaffolding upon which many scholarly endeavors have been built and © Jones & Bartlett Learning, LLCcarried out. At the end of each© Jones theorist & chapter,Bartlett under Learning, the heading LLC “Theory NOT FOR SALE OR DISTRIBUTIONin Action,” examples of publishedNOT FOR knowledge SALE developmentOR DISTRIBUTION related to that specific theory are presented.

© JonesReferences & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Allmark, P. (2003). Popper and nursing theory. Nursing Philosophy, 4(1), 13–16. Ayers, A. (1990). Language, truth, and logic (2nd ed.). London, England: Penguin. Chinn, P. L., & Kramer, M. K. (1999). Theory and nursing: Integrated knowledge development. St. Louis, MO: Mosby. © Jones & BartlettCrotty, Learning, M. (1998). LLC Foundations of social research: Meaning© Jones and perspective & Bartlett in the research Learning, process. LLC NOT FOR SALE OR DISTRIBUTIONLondon, England: Sage. NOT FOR SALE OR DISTRIBUTION

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References 17

Dickoff, J., &© James, Jones P. (1968). & Bartlett A theory ofLearning, theories: A position LLC paper. Nursing Research, © Jones & Bartlett Learning, LLC 17, 197–203. Fitne, Inc. (Producer).NOT FOR (1987–1989). SALE ORNurse DISTRIBUTIONtheorists: Portraits of excellence [DVD]. Available NOT FOR SALE OR DISTRIBUTION from http://www.fitne.net/nurse_theorists1.jsp George, J. B. (2002). Nursing theories: The base for professional nursing practice. Upper Saddle River, NJ: Prentice Hall. © JonesIngram, & R. Bartlett (1991). Why Learning, does nursing needLLC theory? Journal of Advanced Nursing© Jones, 16, 350–353. & Bartlett Learning, LLC Johns, C. C. (1994). Guided reflection. In A. Palmer, S. Burns, & C. Bulman (Eds.). NOT FORReflective SALE practice OR inDISTRIBUTION nursing: Growth of the professional practitioner (pp.NOT 110–130). FOR SALE OR DISTRIBUTION Oxford, England: Blackwell Scientific. Kalisch, P. A., & Kalisch, B. J. (1995). The advance of American nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. © Jones & BartlettNightingale, Learning, F. (1859). LLC Notes on nursing: What it is, and© whatJones it is not &. Philadelphia, Bartlett Learning, PA: LLC Edward Stern and Company. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Peden, A. R. (1998). The evolution of an intervention—the use of Peplau’s process of practice-based theory development. Journal of Psychiatric and Mental Health Nursing, 5, 173–178. Peplau, H. E. (1952). Interpersonal Relations in Nursing. New York, NY: Putnam. Peplau, H. E.© (1989). Jones Theory: & Bartlett The professional Learning, dimension. LLC In A. O. O’Toole & S. Welt © Jones & Bartlett Learning, LLC (Eds.), Interpersonal theory in nursing practice: Selected works of Hildegard E. Peplau (pp. 21–30).NOT NewFOR York, SALE NY: Springer. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Van Sell, S. L., & Kalofissudis, I. A. (2003). Formulating nursing theory. Retrieved from http://www.nursing.gr/theory/theory.html Wilde, M. H. (1999). Why embodiment now? Advances in Nursing Science, 22(2), 25–38. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC© Jones & Bartlett Learning, LLC.© NOTJones FOR SALE& Bartlett OR DISTRIBUTION. Learning, LLC NOT FOR SALE9781284098075_CH03.indd OR DISTRIBUTION 17 NOT FOR SALE OR DISTRIBUTION 10/8/15 3:00 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION