Ultimately, the value of any nursing theory, not just of grand theory, is its ability to extend the discipline and science of nursing. Understanding the nature of human be- ings and their interaction with the environment, and the impact of this interaction on their health, will help direct holistic and comprehensive nursing interventions that im- prove health and well-being. Improvement in nursing care is ultimately the reason for formulating theory. Further, the value of the theory in adding to and elaborating nursing science is an important function of grand theory. Questions to be answered
The Purpose of Critiquing Theories
Critiquing theory is a necessary part of the process when a scholar is selecting a the- ory for some disciplinary work. Determining whether a grand theory holds promise or value for the effort at hand, and whether middle range theories, which are useful in research, practice, education, or administration, can be generated from it is a product of critique.
It is likely that a graduate nursing student may find it difficult to critique the work of nursing’s grand theorists. Yet determining the usefulness of the theory to a project is important. The user of the theory must comprehend the paradigm of the theory, believe in the concepts and assumptions from which it is built, and be able to internal- ize the basic philosophy of the theorist. It is hardly beneficial to attempt to use a theory that one cannot accept or understand, or one that seems inappropriate. The choice of a theoretical framework or model must fit with the student’s or scholar’s personal ideals, and this requires the student or scholar to critique the theory for its value in extending the selected professional work.
One problem that arises among both novice and experienced scholars is combining theories from competing paradigms. Often the work generated from these efforts is confusing and obfuscating; it does not generate clear results that extend the think- ing within either paradigm. Therefore the conscientious student or scholar selects theories that relate to the same paradigm in science, philosophy, and nursing when combining theories to guide research or practice. Wide reading in the discipline of nursing and the scientific literature of the disciplines from which the theorist has gen- erated ideas will assist in preventing such errors. Theory review and extraction from the grand theories can result in work that satisfies the scholar, guides the research process, provides structure for safe and effective practice, and extends the science of nursing.
Summary
Grand theories are global in their application to the discipline of nursing and have been instrumental in helping to develop nursing science. Because of their diversity, their complexity, and their differing worldviews, learning about grand nursing theo- ries can be confusing and frustrating, as illustrated by the experiences of Janet Turner, the student nurse from the opening case study. To help make the study of grand the- ories more logical and rewarding, this chapter presented several methods for catego- rizing the grand theories on the basis of scope, basic philosophies, and needs of the discipline. It has also presented the criteria that will be used to describe grand nursing theories in subsequent chapters.
Chapters 7, 8, and 9 discuss many of the grand nursing theories that have been placed into the three defined paradigms of nursing. These analyses are meant to be descriptive to allow the student to choose from different paradigms and the theories contained within them to further their work. The student or scholar must recognize when analyzing any theory include: Does the theory generate new knowledge? Can the theory suggest or support new avenues of knowledge generation beyond those that already exist? Does the theory suggest a disciplinary future that is growing and changing? Can the theory assist nurses to respond to the rapid change and growth of health care?
that health care is constantly changing and that some theories may no longer seem applicable, whereas other theories are timeless in their abstraction. Before selecting a theory to guide practice, research, or other endeavors, it is the student’s responsibil- ity to obtain and read the theory in its latest iteration by the theorist, read analyses by other scholars in the discipline, and become thoroughly familiar with the theory.
LEARNING ACTIVITIES
1. With classmates, discuss the three categorization schemes for grand nursing theories described in the chapter. Debate similarities and differences in the cate- gorization schemes. Which system appears to be the easiest to understand? Does categorizing or classifying grand theories in this manner assist in studying and understanding them? Why or why not?
2. A group of nurses are interested in testing a nursing intervention and creating evidence that will stand up to the rigors of the EBP model. You and your class- mates are this group of nurses. Develop theory-based research that will yield such evidence. Consider how a research program will have to be structured in such a way that the model guides the finding of strong evidence for your testing of the interventions.
REFERENCES
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Cody, W. K. (2003). Nursing theory as a guide to practice.
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Einstein, A. (1961). Relativity. New York: Crown.
Ellis, R. (1968). Characteristics of significant theories.
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Fawcett, J. (1993). Analysis and evaluation of nursing theories. Philadelphia: Davis.
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Higgins, P. A., & Moore, S. M. (2000). Levels of theoreti- cal thinking in nursing. Nursing Outlook, 48(4), 179–183.
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Tomey, A. M., & Alligood, M. R. (2006). Nursing theo- rists and their work(6th ed.). St. Louis: Mosby.
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C H A P T E R
7
E v e l y n W i l l s
D
onald Crawford is an intensive care clinical nurse specialist. During his graduate studies, Donald read about various nursing theories from books edited by theory analysts and felt an affinity for the works of a nursing theorist whose writings fit well with his specialty. But, to improve his practice, he felt he needed to learn more.Donald strongly believed that evidence to guide his practice should be experiential and measurable, and during his master’s program, he derived a system for evaluation of the needs of the seriously ill individuals for whom he cared. He also devised a way to diagram the disease pathophysiology for many of his clients. Donald observed that the diagram helped predict what would happen next with some clients, and it helped him formulate nursing interventions to achieve his therapeutic goals. His methods were not without error, however, and Donald sought to identify a nursing theory that would help him define clients’ needs, predict outcomes, and prescribe nursing interventions more accurately.
For this project, Donald read several theoretical works more thoroughly and found three theorists whose works fit his conceptualization of nursing and the client’s need for care. He was particularly intrigued by Betty Neuman’s Systems Model and its focus on identification and reduction of stressors through nursing interventions. He liked the construct of prevention as intervention and appreciated how the model helped prescribe nursing care. Donald bought a copy of the book describing Neuman’s model (Neuman & Fawcett, 2002) and began to apply concepts and principles from her theory in his practice with encouraging results.
Grand Nursing Theories Based on Human Needs
The earliest theorists in nursing drew from the dominant worldviews of their time and largely related to the medical discoveries from the scientific era of the 1850s through 1940s (Artinian, 1991). During these years, nurses in the United States were seen as handmaidens to the medical profession, and their practice was guided by disease theories of medical science. Even today, much of nursing science remains based in the positivist era with its focus on disease causality and a desire to produce measurable outcome data.
In an effort to define the uniqueness of nursing and to distinguish it from medicine, nursing scholars from the 1950s through the 1970s developed a number of nursing theories. In addition to medicine, the majority of these early works were strongly influenced by the needs theories of social scientists (e.g., Maslow). In needs- based theories, clients are typically considered to be biopsychosocial beings who are the sum of their parts and who need nursing care. Further, clients are mechanistic be- ings, and if the correct information can be gathered, the cause or source of their prob- lems can be discerned and measured. At that point, interventions can be prescribed that will be effective in meeting their needs (Dickoff, James, & Wiedenbach, 1968).
Evidence-based nursing fits with these theories completely and comfortably.
The grand theories and models of nursing described in this chapter focus on meet- ing clients’ needs for nursing care. These theories and models, like all personal state- ments of scholars, have continued to grow and develop over the years; therefore, several sources were consulted for each model. The latest writings of and about the theories were consulted and are presented. As much as possible, the description of the model is either quoted or paraphrased from the original texts. Some needs theorists may have maintained their theories over the years with little change; nevertheless, new research has often taken place that extends the original work. Students are advised to consult the literature for the newest research using the needs theory of interest.
It should be noted that a concerted attempt was made to ensure that the presen- tation of the works of all theorists is balanced. Some theories (e.g., Orem, Neuman) are more complex than others; however, the body of information is greater for some.
As a result, the sections dealing with some theorists are a little longer than others. This does not imply that shorter works are inferior or less important to the discipline.
Finally, all theory analysts, whether novice or expert, will comprehend theories and models from their own perspectives. If the reader is interested in using a model, the most recent edition of the work of the theorist should be obtained and used as the primary source for any projects. All further works using the theory or model should come from researchers using the theory in their work. Current research writings are one of the best ways to understand the development of the needs theories.
Florence Nightingale: Nursing: What It Is and What It Is Not
Nightingale’s model of nursing was developed before the general acceptance of mod- ern disease theories (i.e., the germ theory) and other theories of medical science.
Nightingale knew the germ theory (Beck, 2005), and prior to its wide publication she had deduced that cleanliness, fresh air, sanitation, comfort, and socialization were necessary to healing. She used her experiences in the Scutari Army Hospital in Turkey and in other hospitals in which she worked to document her ideas on nursing (Beck, 2005; Dossey, 2000; Selanders, 1993; Small, 1998).
Nightingale was from a wealthy family, yet she chose to work in the field of nurs- ing, although it was considered a “lowly” occupation. She believed nursing was her call from God, and she determined that the sick deserved civilized care, regardless of their station in life (Nightingale, 1860/1957/1969).
Through her extensive body of work she changed nursing and health care dramat- ically. Nightingale’s record of letters is voluminous, and several books have been writ- ten analyzing them, Dossey, Selanders, Beck, and Attewell (2005a) include many of them in their current publication. She wrote many books and reports to federal and worldwide agencies. Books she wrote that are especially important to nurses and nurs- ing include Notes on Nursing: What It Is and What It Is Not(original publication in
1860; reprinted in 1957 and 1969), Notes on Hospitals(published in 1863), and Sick- Nursing and, Health-Nursing(originally published in Hampton’s Nursing of the Sick, 1893) (Reed & Zurakowski, 1996) and reprinted in totoin Dossey, Selanders, Beck, and Attewell (2005a) to name but a small proportion of her great body of works.
BACKGROUND OF THE THEORIST
Nightingale was born on May 12, 1820, in Florence, Italy; her birthday is still hon- ored in many places. She was privately educated in the classical tradition of her time by her father, and from an early age, she was inclined to care for the sick and injured (Dossey, 2000, 2005a; Selanders, 1993). Although her mother wished her to lead a life of social grace, Nightingale preferred productivity, choosing to school herself in the care of the sick. She attended nursing programs in Kaiserswerth, Germany, in 1850 and 1851, where she completed what was at that time the only formal nurs- ing education available. She worked as the nursing superintendent at the Institution for Care of Sick Gentlewomen in Distressed Circumstances, where she instituted many changes to improve patient care (Dossey, 2000; Selanders, 1993; Small, 1998).
During the Crimean War, she was urged by Sidney Herbert, Secretary of War for Great Britain, to assist in providing care for wounded soldiers. The dire conditions of British servicemen had resulted in a public outcry that prompted the government to institute changes in the system of medical care (Small, 1998). At Herbert’s request, Nightingale and a group of 38 skilled nurses were transported to Turkey to provide nursing care to the soldiers in the hospital at Scutari Army Barracks. There, despite daunting opposition by army physicians, Nightingale instituted a system of care that reportedly cut casualties from 48% to 2% within approximately 2 years (Dossey, 2000, 2005a; Selanders, 1993; Zurakowski, 2005).
Early in her work at the army hospital, Nightingale noted that the majority of sol- diers’ deaths was caused by transport to the hospital and conditions in the hospital it- self. Nightingale found that open sewers and lack of cleanliness, pure water, fresh air, and wholesome food were more often the causes of soldiers’ deaths; she implemented changes to address these problems (Small, 1998). Although her recommendations were known to be those that would benefit the soldiers, physicians in charge of the hospitals in the Crimea blocked her efforts. Despite this, by her third trip to the Crimea, Nightingale had been appointed the supervisor of all the nurses (Dossey, 2000).
At Scutari, she became known as the “lady with the lamp” from her nightly ex- cursions through the wards to review the care of the soldiers (Audain, 1998). To prove the value of the work she and the nurses were doing, Nightingale instituted a system of record keeping and adapted a statistical reporting method known as the polar area diagram (Audain, 2007; O’Connor & Robertson, 2003) or Cock’s Comb model, to analyze the data she so rigorously collected (Small, 1998). Thus, Nightin- gale was the first nurse to collect and analyze evidence that her methods were working.
On her return to England from Turkey, she worked to reform the Army Medical School, instituted a program of record keeping for government health statistics and assisted with the public health system in India. The effort for which she is most re- membered, however, is the Nightingale School for Nurses at St. Thomas’ Hospital.
This school was supported by the Nightingale Fund, which had been instituted by grateful British citizens in honor of her work in the Crimea (O’Connor & Robertson, 2003; Selanders, 1993).
PHILOSOPHICAL UNDERPINNINGS OF THE THEORY
Nightingale’s work is considered a broad philosophy. Zurakowski (2005) indicates it is a “perspective” (p. 21). By contrast, Selanders (2005a) states that her work is a founda- tional philosophy (p. 66). Dossey (2005a) demonstrates that the three tenets of Nightingale’s philosophy are “healing, leadership, and global action” (p. 1). Dossey states that “her basic tenet was healing and secondary to it are the tenets of leadership and global action which are necessary to support healing at its deepest level” (p. 1).
Nightingale’s work has influenced the nursing profession and nursing education for more than 150 years. To Nightingale, nursing was the domain of women, but was an independent practice in its own right. Nurses were, however, to practice in accord with physicians, whose prescriptions nurses were faithfully to carry out (Nightingale, 1893/1954). Nightingale did not believe that nurses were meant to be subservient to physicians. Rather, she believed that nursing was an independent profession or a calling in its own right (Selanders, 1993). Nightingale’s educational model is based on antici- pating and meeting the needs of patients, and is oriented toward the works a nurse should carry out in meeting those needs. Nightingale’s philosophy was inductively de- rived, abstract yet descriptive in nature, and is classified as a grand theory or philosophy by most nursing writers (Dossey, 2000; Selanders, 1993, 2005a; Tomey & Alligood, 2002, 2006).
MAJOR ASSUMPTIONS, CONCEPTS, AND RELATIONSHIPS
Nightingale was an educated gentlewoman of the Victorian era. The language she used to write her books—Notes on Nursing: What It Is and What It Is Not(1860/
1957/1969) and Sick-Nursing and Health-Nursing (1893/1954)—was cultured, flowing, logical in format, and elegant in style. She wrote numerous letters many of which are still available. These were topical, direct and yet abstract, and addressed a plethora of topics, such as personal care of patients and sanitation in army hospitals and communities to name only a few (Dossey, 2005b; Selanders, 2005b).
Nightingale (1860/1957/1969) believed that five points were essential in achiev- ing a healthful house: “pure air, pure water, efficient drainage, cleanliness, and light”
(p. 24). She thought buildings should be constructed to admit light to every occupant and to allow the flow of fresh air. Further, she wrote that proper household manage- ment makes a difference in healing the ill and that nursing care pertained to the house in which the patient lived, and to those who came into contact with the patient, as well as to the care of the patient.
Although the metaparadigm concepts had not been so labeled until over 130 years later, Nightingale (1893/1954) addressed them—human, environment, health, and nursing—specifically in her writings. She believed that a healthy environment was es- sential for healing. For example, noise was harmful and impeded the need of the per- son for rest, and noises to avoid included caregivers talking within the hearing of the individual, the rustle of the wide skirts (common at the time), fidgeting, asking un- necessary questions, and a heavy tread while walking. Nutritious food, proper beds and bedding, and personal cleanliness were variables Nightingale deemed essential, and she was convinced that social contact was important to healing. Although the germ theory had been proposed, Nightingale’s writings do not specifically refer to it.
Her ideals of care, however, indicate that she recognized and agreed that cleanliness prevents morbidity (Nightingale, 1999).
Nightingale believed that nurses must make accurate observations of their patients and report the state of the patient to the physician in an orderly manner (Nightingale,