Nursing theory is defined as a conceptualization of some aspect of nursing reality com- municated for the purpose of describing phenomena, explaining relationships between phe- nomena, predicting consequences, or prescribing nursing care.Nursing theories are reservoirs in which are stored those findings that are related to nursing concepts, such as comfort, healing, recovering, mobility, rest, caring, enabling, fatigue, and family care. They are also reservoirs for answers related to significant nursing phenomena, such as levels of cognition after a stroke, process of recovery, refusing a rehabilitation regimen for myocardial infarction patients, and revolving admissions.
The definition of nursing theory has been most problematic, as demonstrated by many exchanges in the nursing literature. Many concepts have been used interchangeably with the term theory, such as conceptual framework, conceptual model, paradigm, metaparadigm, theorem, and perspective. The multiple use of concepts to describe the same set of relationships has resulted in more confusion and perhaps in less use of nursing theory.
Several types of theory definitions (Table 3-1) are identified by Chinn and Jacobs (1987), Chinn and Kramer (2004), and Fawcett (2005):
1. The first type of definition focuses on the structure of theory, as exemplified by McKay (1969), who defined theory as “logically interrelated sets of confirmed hypotheses”
(p. 394). This definition incorporates research as a significant step in theory development
TABLE 3-1 TYPES OF THEORY DEFINITIONS
Chinn and Jacobs (1987) identify four types:
1. Definitions focusing on structure 2. Definitions focusing on practice goals 3. Definitions focusing on tentativeness 4. Definitions focusing on research
From these, Chinn and Kramer (2004) present a fifth type:
5. Definitions focusing on creativity in developing and connecting concepts and the use of theory in practice as well as research
Fawcett (2005) provides a sixth type:
6. Definitions focusing on progression from conceptual framework to theory
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and discounts conceptualizations that are based only on mental processes. Therefore, using this definition would not allow the consideration of any of the current nursing theo- ries as theories.
2. The second type of definition focuses on the goals on which the theory is based. Different theorists, such as Dickoff and James (1968), define nursing theory as “a conceptual sys- tem or framework invented for some purpose” (p. 198). Not only do they focus on out- comes and consequences because of their premise that prescriptive theory should be the ultimate goal for all theory activities in nursing, but they also do not distinguish between conceptual framework and theory. Indeed, theory is defined in terms of a conceptual framework. This definition also brings to our attention the potential for inventing nursing reality (Chinn and Jacobs, 1987); mental images are therefore not restricted to the discov- ery of reality but to the construction of reality.
3. The third type of definition alludes to the tentative nature of theory, as exemplified by Barnum (1998). Barnum defines theory as “a construct that accounts for or organizes some phenomena” (p. 1). Barnum emphasizes that the source of nursing theory is not
“what is” but “what ought to be,” and that existing conceptualizations are indeed nursing theories because, she asserts, quibbling over labels of theory, concept, framework, and so forth are “mere splitting of hairs” (p. 1). Barnum’s definition is significant in a number of ways: It acknowledges that theories are always in the process of development (Chinn and Jacobs, 1987), that existing conceptualizations are theories, and that invention is as much an arena for theory development in nursing as is discovery.
4. The fourth type of definition focuses on research and is exemplified by Ellis (1968). Ellis defines theory as “a coherent set of hypothetical, conceptual, and pragmatic principles forming a general frame of reference for a field of inquiry” (p. 217). Ellis’ definition reminds us that theory is developed for the purpose of guiding research. This definition assumes that practice guides theory development, theory guides research, and research guides theory.
5. A fifth definition emerged from the previous four and was articulated by Chinn and Kramer (2004). They define theory as “a creative and rigorous structuring of ideas that projects a tentative, purposeful, and a systematic view of phenomena” (p. 58).
According to this definition, imagination and a coherent vision are important, but a rigorous process of ordering of these imaginative ideas is essential. Tentativeness in put- ting these ideas together is essential.
Also according to this definition, when concepts are defined and interrelated in some coherent whole for some purpose, we have a theory. The definition leaves the door wide open for using theory in practice and research, and it does not restrict the- ory to research-verified propositions. This definition exemplifies the multiple usages of theory.
6. A sixth definition of theory is exemplified by Fawcett (2005), who differentiates between conceptual models and theories, indicating that few nurses present their ideas as theories. For example, Newman (1994) and Parse (1996) did present their ideas in the form of a theory, whereas others such as Orlando (1987), Peplau (1992), and Watson (1989) are a few, according to Fawcett, who spoke about their ideas as theories, whether grand or middle-range. She defines theory as “one or more relatively concrete and specific concepts that are derived from a conceptual model, the propositions that narrowly describe these concepts, and the propositions that state relatively concrete and specific relations between two or more of the concepts” (Fawcett, 2005, p. 18). This def- inition and differentiation adds another dimension to how theories are viewed in nursing.
The definition of nursing theory adopted in this text was based on the work and definitions of previous theorists. I have considered the common themes that evolved from these definitions and incorporated them into the definition offered here. Theorists and utilizers of theory used labels
CHAPTER 3 Theory: Metaphors, Symbols, Definitions 31 interchangeably to describe their conceptualizations, and sometimes different labels were used to describe the same structures. The criteria for the selection of the different labels (model, para- digm, science, theory, and framework) are not always entirely clear. For example, the utilizers of theory have used models and theories interchangeably; and, although some usage differentiated between models and theories, such differentiation was not completely clear. For some, models are considered structures of concepts that precede the development of theory. They are also used as structures of concepts evolving from theories. (Refer to Chapter 20, wherein a cursory review of the section titles will document this multiple usage.)
A deliberate decision was made to avoid fine-line debates about how to label existing con- ceptualizations about nursing. These differences are tentative at best, and hair-splitting, unclear, and confusing at worst. Some theorists who differentiate between theory, metaparadigm, con- ceptual framework, and model have provided analyses that tend to overlap the properties of each of these concepts. If, indeed, conceptual models are more abstract, less specific, and con- tain fewer defined concepts and testable propositions, then their linkages with research and practice should not be expected. Because the utility of these models in practice and research has in fact been evaluated, and the linkages between theory and practice, research, education, and administration have been addressed by the utilizers, the properties of the existing conceptual- izations do not lend themselves to the label “conceptual models.” (See Chapter 7 for further dis- cussion.) Therefore, the differences between the different labels (theory, metaparadigm, conceptual frameworks, and so forth) are differences in emphasis rather than substance and may not be worth continued debate or the creation of new esoteric entities to describe the mental images of nurse theorists. There is limited support that the use of one label over another has helped in the differentiation of the type of knowledge developed, and it may have managed to create more ambiguity for the novice and the experienced alike. Perhaps we need to debate more substance and less form!
When comparing nursing theories with theories in other fields, such as role theory in sociol- ogy or psychoanalytical theory in psychology, we often find that some of our nursing theories may be as specific or as nonspecific as those theories, or as abstract or as concrete. That being said, why did we continue to unwittingly downgrade nursing theory by relegating it to a conceptual framework status when other conceptualizations have been called theory? The early reluctance of nurses to designate their work or the work of others as theories changed in the mid-1990s (Lenz, Suppe, Gift, Pugh, and Milligan, 1995).
Theories are always in the process of development. Therefore, a theory in process should not be considered a conceptual framework just because it is in progress or in process. It is simply in an expected stage in the process of development, and, in a human science, it will always be in process and in progress.
Some theorists and theory utilizers may prefer the use of one particular label over another;
however, they may find that they use the same conceptualization differently and for different pur- poses. Theories could be used as conceptual frameworks when concepts from different theories are linked together to form a new whole. They could be used as theoretical frameworks when con- cepts from one theory are given new meanings or when they are linked with another theory to form a new structure that will be tested. They could be labeled a conceptual model when a theory is used as a prototype and is modeled in form or structure.
Nurse theorists (such as Rogers, Johnson, and Henderson) developed coherent, systematic, and organized visions of what nursing is and what the nursing mission ought to be. To consider these conceptualizations as models and frameworks for nursing as a whole is to convey the idea that nursing is conceptualized in one way and according to one model. Therefore, other conceptu- alizations may be excluded prematurely by the one-particular-model advocate. Proponents may ask: How can we see the world through different pairs of glasses simultaneously?
The position taken in this book is that existing nursing conceptualizations are theories that could be used to describe and explain different aspects of nursing care. They are not competing models; they are complementary theories that may provide a conceptualization of different
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aspects, components, or concepts of the domain. They reflect and represent different realities.
They also address different aspects of nursing. Nursing theory is then defined as a conceptual- ization of some aspect of reality (invented or discovered) that pertains to nursing. The con- ceptualization is articulated for the purpose of describing, explaining, predicting, or prescribing nursing care.Therefore, not only is nursing theory an articulation of phenomena and their relationships, but it is an articulation that has to be communicated to colleagues in ways that make it possible to test, evaluate, interpret, and use these articulations.
Nursing theories evolve from extant nursing reality, as seen through the mind of a theorist who is influenced by certain historical and philosophical processes or events. These theories also may evolve from a perception of ideal nursing practice, tinted by one’s history (personal, profes- sional, and disciplinary) and philosophy. Furthermore, they may reflect a coherent representation of nurses’ daily work. Theory is a tool for the development of research propositions (see the left side of Fig. 3-1). Theory is also a goal, a reservoir in which findings (both quantitative and quali- tative) become more coherent and meaningful. The cyclical nature of theory, practice, philosophy, history, research, and science is depicted in Figure 3-1. Taken together, and in relationship to each other, theories constitute the knowledge base for the discipline of nursing.
Examples of the phenomena and relationships depicted in nursing theories are:
• A nursing client is conceptualized as a self-care agent.
• A nursing client is a biopsychosocial and cultural being.
• A nursing client is a system with a number of behavioral subsystems.
Knowledge Base: Truth, Evidence, Perception, and Belief
FIGURE 3-1 ◆ Knowledge base for nursing theory (H, health; C, client; T, transitions; E, environment; , interactions and process).
CHAPTER 3 Theory: Metaphors, Symbols, Definitions 33
• A nursing client is conceptualized as a conglomerate of needs.
• A nursing client is a system of such modes as interdependence, self-concept, roles, and psyche, among others.
• Person–environment interactions are the focus of nursing care.
• Health and illness behavior is a product of person–environment interactions.
• Communication is a tool for diagnosis and intervention in nursing.
• An efficient, functional, productive interaction has several components: sensing, perceiv- ing, and conceiving.
• A goal of interaction is to develop rapport, which in turn enhances patient care.
• The focus of intervention is the client’s environment.
• Environment is a composite of energy fields.
• Nursing care deals with manipulation of environment.
• Nursing provides self-care needs only until the client or a significant other is capable of providing self-care.
• A nurse is conceptualized as performing a number of functions designed to meet the patient’s needs.
• Nurses deliver care that focuses on patients’ outcomes; these outcomes reflect medical and/or nursing perspectives.
• Nurse–patient interactions are a framework for assessment or intervention.