Nursing Theories BT Basavanthappa
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Introduction to TheoryChapter 1

The term “theory” is used in many ways. For example, Nursing teachers and students use the term “theory” to refer to the content covered in classroom, as opposed to the actual practice of performing nursing activities. Sometimes the term “theory” is used to refer to someone's hunches or ideas as in “My theory is that if I postpone cleaning my room, long enough, my mother will clean it for me”, or “My theory is not to tell lie or not to bluff any body”, etc. Whatever the usages the term, “theory” almost always connoted an abstraction or generalization.
 
DEFINITIONS OF THEORY
Scientists generally use the term “theory” in a precise way, i.e. theory has always been defined in a number of ways as given below.
  • “A theory is a statement that purports to account for or characterize some phenomenon” and that “it pulls out the salient parts of a phenomenon so that one can separate the critical and necessary factors for relationships, from the accidental and unessential factors or relationships” (Barnum 1990).
  • “Theory is a systematic abstraction of reality that serves some purpose (Chinn and Kramer 1991). They describe each part of the definition, i.e. systematic implies a specific organizational pattern, abstraction means that theory is a representation of reality and purposes include description, explanation, and prediction of phenomena and control of some reality.”
  • “Theory enables to explain a maximum number of observable relationships, by setting limits on “What question to ask and what methods to use to pursue answers to the questions” (Meleis 1985).
  • “A theory is a set of interrelated constructs (concepts adapted for a scientific purpose), definitions, and prepositions that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting the phenomena” (Kerlinger 1986). This definition takes a basic view of science, that development of a general explanation about natural phenomena via theories.
  • Theory is a set of interrelated concepts, definitions and propositions that present 2a systematic way of viewing facts/events by specifying relations among variables, with the purpose of explaining and predicting the fact or event (Kerlinger 1973).
    The key ideas of this definition are, interrelation of concepts, propositions specifying relations among the variables and stated purposes of explaining or predicting facts or events. This definition states that a theory suggests a direction in how to view facts and events. For example, Nightingale proposed a beneficial relationship between fresh air and health.
  • Theory is a “Creative and rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenomena (Chinn and Kramer 1991).
    This definition adds additional element, i.e. focus on the tentative nature of theory. It says that theories cannot be equated with scientific laws. Laws are the basis of natural science. Nursing is a human science. The rigour and objectivity of the laboratory are both inappropriate and impossible to duplicate.
  • A theory can be defined as an organizing statement about abstract concepts that gives them meaning in relation to the real world. Theories describe, explain or predict relationships among abstract concepts. Abstract concepts are mental images of reality; they may be highly abstract and non-observable, such as intelligence, or relatively concrete and directly measurable, such as caring behaviour. Theories are linked to the real world through definitions that specify how concepts will be known, experienced, observed and measured. Theories guide decision making by providing the supporting conceptualisation for the study such as “significance of the problem, background, and problem definition or statement of the problem (Phillips, 1986).
    Thus, theory is an abstract generalization that presents a systematic explanation about the relationships among phenomena. Theories embody principles for explaining, predicting and controlling phenomena. So theory construction and testing are intimately related to the advancement of scientific knowledge, and it may even be claimed that theory is the ultimate goal of science. Theoretical and conceptual systems represent the highest and most advanced efforts of humans to understand the complexities of the world in which they live.
    The ideal of theory carries varying conceptualisations within and outside the discipline of nursing. Belief about the nature of theory arise in part from the various fields of inquiry from which nursing knowledge is developed. Some nursing theorists come from traditions in which the ideal theory is logically linked sets of confirmed hypothesis. Others view theory as loosely connected hypothetic conjectures. Still others think of theory as philosophically based sets of belief and values about human nature and action. As a result, the nursing literature contains for theory, but this diversity serves to stimulate further understanding and development of theory. The following definitions in the nursing literature emphasize important dimensions of theory.
  • “Theory is a logically interconnected set of confirmed hypotheses” (McKay 1969). 3This definition implies a specific form of expression based on rules of logic. It also requires that hypotheses are tested and confirmed by using methods of research to qualify as a theory.
  • “Theory is a conceptual system of framework invented to some purpose” (Dickoff and James, 1963). In this definition, the purpose for which a theory is created is emphasized. The term invented implies a creative purpose.
  • “Theory is an imaginative grouping of knowledge, ideas, and experience that are represented symbolically and seek to illuminate a given phenomenon” (Watson, 1985). Here creativity again emphasized, but the purpose for which theory is created shifts away from a specific purpose to the aim of enhancing understanding of a given phenomenon.
  • “Theory is a conceptual and pragmatic principle forming a general frame of reference for a field of inquiry” (Ellis, 1968). This definition implies that theory provides a philosophic view that guides inquiry in a discipline and also that theory serves a pragmatic or practical purpose for the discipline.
    From the above definition, all theory comprises a creative and rigourous structuring of ideas. The ideas are structured as concepts that are represented by word symbols. For theory to project a systematic view of phenomena, the concepts contained within the theory must be conveyed within the relationship statement and defined within the context of the theory. The theorists created a language and structure that impart the theory for some reason. The purpose may take many forms. Theory is tentative and thus is grounded in assumptions, value choices and the creative and imaginative judgement of the theorist. Therefore, “theory is a creative, rigorous structuring of ideas that projects a tentative, purposeful and systemic view of phenomena. Theories are general explanations which scholars use to explain, predict, control and understand commonly occurring events. Theory is defined as a “set of propositions used to describe, explain, predict and control of events” in which
  • Set: a group of circumstances, situations, and so on, joined and treated as a whole. For example, negative number is treated as set in mathematics.
  • Propositions, statements about how two or more concepts are related, e.g. heart rate increase as anxiety increases.
  • Concept. Abstract classification of data, e.g. ‘temperature’ increases.
  • Describe: to tell about in detail.
  • Explain: to offer reason for
  • Predict: to foretell
  • Control: to exercise a regulating influence over.
  • Phenomenon: an occurrence or incident; event.
 
PURPOSES OF THEORY
The overall purpose of theory is to make scientific finding meaningful and generalizable. Theories allow scientists to knit together observations and facts into an orderly system. They are efficient, mechanises for drawing together and summarizing accumulated facts from separate and isolated investigations. The linkage of findings into a coherent structure makes the body of accumulated knowledge more 4accessible, and thus more useful both to practitioners who seek to implement findings and to researchers who seek to extend the knowledge base, in addition to summarizing, theories serve to explain scientific findings. Theory guides the scientists understanding of not only the ‘what’ of natural phenomena but also the ‘why’ of that occurrence. The power of theories to explain, lies in their specification of which variables are related to one another and what the nature of that relationship is. Finally theories help stimulate research and the extension of knowledge by providing both direction and impetus. On the basis of theory scientists draw inferences (formulate hypothesis) about what will occur in specific situations. These hypotheses are then subject to empirical testing in research studies. Theories thus serve as a spring board for scientific advances.
Theories provide a method of classifying and organizing data in a logical and meaningful manner. It is important to remember that theory is an explanation that has not yet been disapproved. For example, Einstein's theory of relativity, which states that matter and energy are equivalent and form the basis for nuclear energy and that space and time are relative rather than absolute concepts (It is good working definition of theory).
According to the above definitions, there are four functions of theory—i.e. description, explanation, prediction and control—represents a different phase of theory development. The perfect theory would do all four things well. However, no perfect theories exist in any discipline. Because science is evolving and because humans are fallible, that is liable to make mistakes. Theories are always changing at any given point of time. In a given area of study, theories in all stages of development can be found. This is certainly true in Nursing.
As a science, Nursing is in its infancy. Professional nurses are aware of this and conscious of the need for both nursing theory development and theory-based practice. As nursing comes of age, not only as a practice discipline but also as a scholarly discipline, there will be increasing interest in delineating the theory base for nursing. Some believe that theory development is the most crucial task facing nursing (Chinn and Jacobs 1978).
There are three reasons for this interest in theory as given below:
  1. Firstly, one criterion for profession is a distinct body of knowledge upon which practice is based. There has been interest in identifying a body of nursing knowledge that is essential to professional nursing practice. Theory development contributes to knowledge building and is seen as a means of establishing nursing as a profession.
  2. Secondly, commitment to practice based on sound, reliable knowledge is intrinsically valuable to nursing. That is to say, knowledge is desirable by its very nature. The growth and enrichment of theory in and of itself is an important goal for nursing, as a scholarly discipline to pursue.
  3. And thirdly, theory is useful. Nursing practice settings are complex and the amount of data available to nurses is virtually endless. Nurses must analyse a tremendous amount of information about each patient and decide what to do. If a theory helps practising nurses categorize 5and understand what is going on in nursing practice, if it helps them predict patient's responses to nursing care, and if it is helpful in clinical decision making it is useful as a guide to practice.
 
THE NATURE OF THEORY
Concepts are the basic ingredients of a theory. Examples of nursing concepts are health, interaction, and adaptation. Theories also consist of a set of statements or propositions, each of which indicates a relationship. Relationships are denoted by such phrases as “is associated with,” “varies directly with,” or “is contingent upon.” In theories the propositions must form a logical interrelated deductive system.
This means that the theory must provide a mechanism for logically arriving at new statements from the original propositions.
A simple illustration is classical learning theory, also referred to as the theory of reinforcement. According to this theory, behaviour that is reinforced (i.e. that is rewarded) will tend to be repeated and therefore, learned. This theory consists of broad concepts (reinforcement and learning) and a proposition stating the relationship between those concepts. Furthermore, the proposition readily lends itself to deductive hypothesis generation. For example, if the theory of reinforcement is valid, then we could deduce that hyperactive children who are praised or rewarded when they are engaged in quiet play will exhibit less acting-out behaviours than similar children who are not praised. Or we could deduce that elderly nursing home residents who are praised or given a reward for self-grooming activities will be more likely than others to care for their appearance and personal hygiene. Both of these predictions, as well as many others based on the theory of reinforcement, could then be tested in a research investigation.
Two additional nature of theories should be emphasized. The first concerns their origin. Theories are not discovered by scientists; they are created and invented by them. The building of a theory depends not only on the observable facts in out environment but also on the scientist's ingenuity in pulling those facts together and making sense of them. Thus, theory construction is a creative and intellectual enterprise that can be engaged in by anyone with sufficient imagination. But imagination alone is not an adequate qualification; theories must be congruent with the realities of the world around us and with existing knowledge.
The second concerns to the tentative nature of theories. It cannot be stressed too strongly that a theory can never be proven or confirmed. A theory represents a scientist's best efforts to describe and explain phenomena; today's successful theory may be relegated to tomorrow's intellectual garbage dump. This may happen if new evidence or observations disprove or discredit a theory that previously had some support. It is also possible that a new theoretical system can integrate new observations with the observations that the old theory made and result in a more parsimonious explanation of some phenomena. Furthermore, the theories that are not congruent with a culture's values and philosophical orientation may be discredited. This link between theory and values may surprise those who think that science is completely objective. It should be remembered, however, that theories are 6deliberately invented by human; they can, thus, never be freed totally from the human perspective, which is amenable to change over time. For example, numerous theories, such as psychoanalytic theory, that had widespread support for decades have come to be challenged by changes in society's views about the roles of women. In sum, no theory, no matter what its subject matter, can ever be considered final and verified. There always remains the possibility that a theory will be modified or discarded.
 
CHARACTERISTICS OF A THEORY
Torres (1990) presented the following characteristics of a theory.
  1. Theories can interrelated concepts in such a way as to create a different way of looking at a particular phenomenon.
    Theories are constructed from concepts, which are mental images representing reality. Theory must identify more than one concept and then the relationship between these concepts must be clear. These concepts need to be explicitly defined so that one can picture the events and experiences that the theory is designed to describe, explain or predict. For example, needs-oriented theorist must identify the concepts of “Self-care deficit and nursing.” The concept of self-care deficit may be described as a client who experiences an inability to perform health promotion activities. Nursing may be defined in terms of actions that can be taken to assist the client to perform health promotions activities. Theories guide practice by directing the nurse to look for needs or deficits that the client may be experiencing.
  2. Theories must be logical in nature.
    Logic is an orderly reasoning. Interrelationship of concepts must be sequential and consistently used within the theory. There should not be any contradictions between the definitions, of concepts, their relationships within the theory and the goals of the theory. These relationships and goals should flow directly from the theoretical assumptions. For example, if “man-universe” is defined to be continuous interaction, this concept must be consistent with all parts of the theory, from the assumptions to the practice methodology.
  3. Theories should be relatively simple yet generalizable.
    A theory may be defined as “tight” or “parsimonious,” if it is stated in most simple terms possible but at the same time describes, explains, or predicts wide range of possible experiences in nursing practice. A theory of communication can be explained simply and generalized to all person-to-person interaction would be considered parsimonious.
  4. Theories can be the bases for hypotheses that can be tested or for theory to be expanded.
    • Quantitative research tests hypotheses in clinical practice and uses statistical analysis to arrive at findings. These findings represent the testing of the precision of the theory in describing, explaining or predicting reality.
    • Qualitative research expands theory by using different research methodology that focuses on the lived experiences of persons. These findings represent determining. Identifying and exploring themes in the reality lived by the persons who participate in the studies.
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  5. Theories contribute to and assist in increasing the general body of knowledge within the discipline through the research implemented to validate them.
    Theories that can be tested, whether by quantitative or qualitative research methods, contribute to the general body of knowledge of discipline of nursing. Validation of the theories enhances the ability of the nurse to describe, predict or control of nursing practice.
  6. Theories can be used by practitioners to guide and improve their practice.
    One of the most significant characteristics of a theory is its usefulness to the practitioner. Theories guide practice by describing, explaining, or predicting events in clinical practice.
  7. Theories must be consistent with other validated theories, laws, and principles but will leave open unanswered questions that need to be investigated.
Logic of theories and their assumptions must be based on underlying laws, previously validated knowledge, and humanitarian values that are generally accepted as good and right, however, tentative nature of theory continues to raise questions that challenge aspects or knowledge that have not yet been challenged.
 
Analysis and Evaluation of Theory
There is a variety of methods for analysing and evaluating nursing theories. Analysis gather, refers to examining the content of the theory, whereas evaluation refers to a critique or judgement about the theory.
Chinn and Kramer (1991) suggested that one should consider the following four criteria for analysis and evaluation of theory.
  • Clarity (semantic and structural)
  • Simplicity
  • Generality
  • Empirical applicability and
  • Consequences (derivable)
    1. Clarity: Semantic and structural clarity and consistency are important. To assess these, one should identify the major concepts and subconcepts and identify definitions for them. Words should be invented only if necessary and they should be carefully defined. Sometimes, words have multiple and competing meanings within and across discipline. Therefore words should be borrowed cautiously and defined carefully. Diagrams and examples may provide more clarity and should be consistent. The logical development should be clear and assumption should be consistent with theory's goals.
    2. Simplicity: In nursing, practitioners needs simple theory to guide practice. That a theory should be maximally comprehensive and concrete, and it should do so with the fewest concepts and the simplest relations of concepts and simply counting the number of concepts is not sufficient, but most useful theory provides the greatest sense of understanding.
    3. Generality: To determine generality of theory, the scope of concepts and goals within the theory are examined. The more limited the concepts and goals the less general the theory.
    4. Empirical precision/applicability: Empirical precision is linked to the testability and ultimate use of a theory and refers to the extent that the defined concepts are 8grounded in observable reality. In theory there should be match between theoretical claims and the empirical evidence. Theories should be clearly recognized as tentative and hypothetical. If the theory cannot generate hypothesis, it is not useful to anyone and does not add to the body of knowledge. So, testability of the theory can be sacrificed in favour of scope, complexity and clinical usefulness. If research, theory, and practice are meaningfully related, then theory in nursing should lend itself to research testing, and research testing should guide nursing practice.
    5. Derivable consequences: Nursing theory ought to guide research and practice, new ideas, and differentiate the focus of nursing from other professions. Theories should reveal what knowledge nurses must and should spend time pursuing. It is essential for nursing theory to develop and guide practice. The nursing profession should make use of existing theory to predict certain outcomes and control events in such a way that desired outcomes are achieved.
    Fawcett (1989) differentiates between analysis and evaluation. She developed this framework of analysis and evaluation of conceptual models but it can readily be applied to theories.
  • For analysis, she proposes a consideration of the historical evolution of the theory the approach to model development, content and source of concern.
  • For evaluation, she proposes evaluation of explicitness of the assumption, degree of competitiveness of content, logical congruences, ability of the model to test and generate hypothesis, how much the model contributes to nursing knowledge development and social conditions.
    Barnum (1990) proposes evaluative criteria for internal criticism (internal construction) and external criticism (the theory and its relationship to people, nursing and health).
  • The criteria for internal criticism are clarity, consistency, adequacy, logical development and levels of theory development.
  • The criteria for external criticism are reality convergence, utility.
    Meleis (1991) suggests a model that defines evaluation as encompassing description, analysis, critique, and testing.
 
THEORY OF STRUCTURE AND DEVELOPMENT
A theory is a set of concepts, definitions, and propositions that project a systematic view of phenomena by designing specific interrelationships among concepts for purposes of describing, exploring, explaining and predicting. The purpose of scientific theory is to describe, explore and predict a part of the empirical world. The same purpose can be ascribed to nursing theory.
To identify nursing theory in its various stages of development, it is necessary to understand the components parts of theory and the steps through which theory is developed.
  • A concept is a complex mental formulation of object, property of event that is derived from individual perceptual experience. It is an idea, a mental image, or generalization formed and developed in the mind. Concepts may be abstract or concrete. Abstract concepts are completely independent of time or place, for example, 9temperature. A concrete concept is specific to time and place, for example body temperature.
  • Definitions are the statements of the meaning of the word, phrase of term. Theoretical definitions convey the general meaning of the concept in a manner that fits the theory and operational definitions specify “the activities of operations” necessary to measure a construct or a variable. Constructs are complex concepts.
  • Propositions are theorems or statements derived from axioms. Axioms are a basic set of statements each independent of the others (they say different things) from which all statements of the theory may be logically derived. The proposition often used interchangeably with hypothesis to mean any idea or hunch that is prescribed in the form of a scientific statement, thus describe a relation between two or more concepts.
  • A phenomenon is any occurrence or fact that is directly perceptible by senses. It is in reality on what exists in the real world.
Theory development is a process that primarily involves induction, deduction and retroduction.
  • Induction is a form of reasoning that moves from the specific to the general. In inductive logic, a series of particulars is combined into a larger who or set of things. In inductive research, particular events are observed and analysed as a basis for formulating general theoretical statements, often called grounded theory.’ This is a research is theory approach.
  • Deduction is a form of logical reasoning that progresses from general to specific. This process involves a sequence of theoretical statements derived from few general statements or axioms. Two or more relational statements are used to draw a conclusion. Abstract theoretical relationships are used to draw a conclusion. Abstract theoretical relationships are used to derive specific empirical hypothesis. This is a theory to research approach.
  • Retroduction combines induction and deduction.
  • Research is application of systematic methods to obtain reliable and valid knowledge and to test impirical reality. Research may generate theory with an inductive approach or test it a deductive approach.
 
STEPS OF THEORY DEVELOPMENT
According to Dickoff, James and Weidenbach (1968) theory building is practice and is refined through research, and then is returned to practice. After elaboration on their work as well as on the work of Jacox (1974) the steps of theory development can be seen as follows:
 
Criticism or Fault Finding
Criticism is the result of concern. One does not bother to criticize something about which one is indifferent. A criticism serves to articulate a belief that something is amiss and brings to awareness one or more salient features of the situation. Frequently the process is aborted at this initial step, and movement to a more constructive reaction is never achieved.
 
Statement of the Problem
A desire to improve the situation results in a delineation of the problem with a refinement 10of the criticism to the point of being articulate about the defect in the situation. Delineation of the problem involves following steps.
 
Concept Identification
A concept is a term that has been given an operational meaning. Key ideas, thoughts, and words in a problem become concepts that require further exploration and delineation to create a precise meaning. Concepts are individual, idiosyncratic impression with distinguishing attributes that can be related within a framework. Thus attributes of concepts can be divided into categories such as values, number, form, dominance, size and colour. Jacox described concepts on the abstract representation of reality that indicate the subject matter of theory. Constructs are more complex entities constructed of concepts that are directly or indirectly observable.
Concepts are traditionally defined as a class of stimuli having common characteristics but in reality they are impressions individual and idiosyncratic, that cause factors to be related in a framework—a framework into which the person expresses experience, interpretations and emotional component, so that the very stimuli are distorted, e.g. anaemia patient.
Concept can be conjunctive, disjunctive, or relative in nature. In conjunctive concepts, several similar values are jointly present, e.g. Anaemias have pale and other signs and symptoms similar as hen face, fatigue, cold, weakness, etc.
Disjunctive are those in which one or more attributes do not match, e.g. anaemic patient also have other than similar signs and symptoms. Relational concepts clearly define the relationship between two attributes such as distance and direction, e.g. cause and effect. In nursing one might sum these up as conjunctive or comparative concepts, disjunctive or contrasting concepts, need relational or cause and effect concepts.
 
Proposition or Principle Formulation
A statement of generalization called as proposition or principle relates two or more concepts or facts, there by serving to reduce the complexity of the problem. The statement of relationship between two or more concepts becomes a rule for generalizations and is called a principle. For example, if the patient haemorrhages and the blood volume decreases, the heart rate will increase. The relationship between the concepts of haemorrhage, blood volume and heart rate is combined into one if, then principle is formulated.
 
Theory Construction
The product of linking, propositions or principles deductively in theory, a conceptual framework designed to show interrelation-ships. Theory construction, then, is the systematic hierarchical arrangement of propositions. Rules of generalisation provide one type of guide for prediction of outcome and thus serve as guide to action. Theory is existing on four levels, i.e.
  • Factor-isolating
  • Factor-relating
  • Situation-relating
  • Situation-producing (Prescriptive theory)
Each of these levels of theory presupposes lower-level supporting theories. Prescriptive theory has the essential ingredients of justifiable goal, a prescription of activity to achieve that goal, and a number of component parts which are defined as follows:11
  1. Agency: the performer of the action.
  2. Patience: the recipient of the action.
  3. Framework: the context of the situation.
  4. Terminus: the end point of the activity.
  5. Procedure: the protocol for the activity.
  6. Dynamics: the type and amount of energy utilized.
By the systematic organization of proposition about these attributes, prescriptive theory may be constructed utilizing the process of induction and deduction. To clarify the role of theory in nursing practice further. Jacox (1974) stated that theory in one field may be utilized as a model in another field if the elements of the theory behave in the same way in both fields. Kaplan (1964) identified an empirical theoretical continuum to theory that any given theory can be located at some point on the continuum where it will have some reference of reality. Theory may be clarified with the use of models.
 
Validation of Theory
Once developed, theory can serve as a guide for:
  • Collection of facts.
  • Search for new knowledge.
  • Explanation of the nature of the phenomena being studied.
  • Further action.
The professional nurse can put theory to the same use. She/he can and should develop and use theory to collect facts, seek new knowledge, explain phenomena and direct nursing action. With such use of theory, the nurse functions at a professional level as opposed to becoming the heir to routines born of habit; however, theory can be taken one more step. By testing theory in practice, theory can be validated and then be considered to be doctrine or essential truth. Validation of theory is the endpoint of theory and the beginning of scientific fact that can be utilized in nursing practice.
To sum up the steps in development of theory are as follows:
  1. Articulation of criticism.
  2. Statement of the problem through.
    • Identification of the concepts involved.
    • Formation of propositions or principles from two or more concepts.
  3. Construction of theory by relating concepts and propositions in hierarchical order.
  4. Testing theory in practice to validate it and produce a fact which can be incorporated into nursing practice as evidence of scientific basic or nursing action.
 
Testing Theory
Researchers test theory by formulating hypothesis deductively from the theory and testing the hypothesis in research construction of theory, on he other and, begins after observation. The researcher uses inductive reasoning to order the observation into categories and concepts, and attempts to relate one concept to the other in a statement—the empirical generalization. From the empirical generalization the researches deduces hypotheses for further testing. As the evidence for relationships between concept grows, the researcher may use creative abilities to purpose a general explanation for the interrelationships among the concepts and propositions. Thus a theory formulated that summarizes the interrelation-ships and predicts the relationships that will be found in the future observations. Theory construction involves observation, forming categories, conceptualisation, and both inductive and deductive reasoning.12
Jacox (1981) summarizes the efforts to develop a theory:
  1. Specifying, defining, and classifying the concepts used to describe the phenomena of the field.
  2. Developing statements or propositions that propose how two or more concepts are related.
  3. Specifying how all of the propositions are related to each other in a systematic way.
In the first step, the emphasis on concepts, in the second step, the emphasis on the propositions and in the third step, the propositions are related to one another.
Dickoff and James (1968) suggest that theory is a mental invention for some purposes to describe, explain, predict, or prescribe. Theories may be constructed (As stated earlier) in their view at four different levels.
  1. Situation-producing theory prescribes the activities necessary to reach defined goals.
  2. Situation-relating theory explains the interrelationships among concepts or propositions. Once such explanations have been formulated, predictive statements or hypothesis may be deduced. The hypothesis may produce causation or correlation.
  3. Factor-relating theory. It relates the named concepts to one another. This is also the same level as the construction of empirical generalization-statement that proposes the relationship between two concepts.
  4. Naming theory (factor-isolating theory) is the lowest level of theory construction but also the most basic. This kind of naming and describing theory is basic because the higher level depends on its development for their own emergence. Naming theory puts observation into named categories and includes both the name of the phenomenon and its description. Nursing diagnosis are an example of naming theory.
Each level of theory construction presupposes that the lower level have been developed. Not all the theorists would induce description and naming on a theory unless a relationship between the names is shown. However, such as Diers have found the approach useful for proposing on research in nursing practice.
 
THEORY AND NURSING RESEARCH
Nurses traditionally have based their practice on intuition, experience or the “way I was taught.” These methods lead to role and stereotypical practice. Practice based on theories however allows for hypothesis about practice, which make it possible to derive a rationale for nursing actions. Testable theories provide a knowledge for the science of nursing. As the science of nursing develops, nurses will be able to (i) more accurately understand and explains past events and (ii) provide a basis for predicting and controlling future events. In addition, practice-based on science will suggest the image of nursing as a professional discipline.
When evaluating published nursing research, reader will see terms such as theoretical framework and conceptual framework used in some, but not all, of these studies. Several basic definitions should help to understand terms related to the use of theory in research studies as follow:
  • A concept is an idea or a complex mental formulation of a specific phenomenon. For example, if you think of the word “table”, what comes to your mind? Is it a piece of wooden furniture that is round and has 13four legs? Or is it square like a card table? Or is your table a food chart? Or is it a table of contents for a book you are using in your nursing courses? Most likely, each person who is asked to think about the concept of “table” will have a different idea or mental formulation of what this abstract phenomenon called “table” looks like. Concepts range from being relatively concrete and more directly observable and measurable (such as height and weight) to being relatively abstract (such as wellness and self-esteem).
  • A construct is a highly abstract and complex concept—such as intelligence—that is deliberately invented (constructed) by researchers for scientific purposes. A construct cannot be directly measured but must be indirectly measured by nothing the presence of indicators of concept. For example, the more concrete concept of weight (in pounds) can be directly determined by reading the numbers on a scale. The more abstract and complex construct of intelligence cannot be as directly measured but must be interred from such indicators of intelligence as verbal skills and mathematical reasoning on a standardized intelligence test.
  • A model is a symbolic representation of reality used to demonstrate the interrelationships among a set of concepts or phenomena that cannot be directly observed but that do represent reality. Examples of models include verbal models, which are worded statements; schematic models, which may be diagrams, drawings, graphs, or pictures; and quantitative models, which are mathematical symbols. Models may function to provide a sense of understanding as to how “theoretic relationships develop and are useful to illustrate various forms of theoretic relationships.” Models may be presented as part of a theory or can be constructed to show links between related theories. In nursing, a model is most often characterized as a conceptual models, a term that is used interchangeably with the term conceptual framework.”
Conceptual models of nursing include Dorothy Orem's Self-Care Model, Sister Callista Roy's Adaptation Model, Betty Neuman's Systems Model, Martha Roger's Model: Science of Unitary Persons, and Imogene King's System Framework (Fitzpartick and Whall, 1996). Each of these nursing theorists “developed conceptual models that helped direct theory development.” Concepts are the major components or building blocks of theories. A theory is a set of logically interrelated statements that is “a creative and rigorous structuring of ideas that project a tentative, purposeful, and systematic view of phenomena.” Note that a theory consists of ideas—theory is not reality—and that these ideas are created and structured by the theorist. It is important to note the tentative nature of theory and that theory cannot be proved: theory is “grounded in assumptions, value choices, and the creative imaginative judgement of the theorist.“
The basic function of theory is to describe, explain, and predict phenomena. A specific type of theory—prescriptive theory—is intended to control or change phenomena by identifying a goal and specifying the specific procedures to attain the goal. A theory contains propositions. A propositions a statement of a relationship between two or more concept in the theory. The proposition 14is stated in such a way that a testable hypotheses can be derived from the abstract statements of the theory. A hypothesis is a statement of the predicted relationship between two or more variables in a research study.
Thus, concepts are the components of theory. A theory consists of propositions, which are the testable part of a theory from which research hypotheses can be derived.
Theory helps to provide knowledge to improve nursing practice by describing, explaining, predicting, and controlling the specific phenomena related to nursing. Nurses power is increased through theoretical knowledge because systematically developed methods are more likely to be successful. In addition, nurses will know why they are doing what they are doing if challenged. Theory provides professional autonomy by guiding the practice, education, and research functions of the profession.
 
Classification of Theory
Theory can be classified according to the range and specificity of the phenomena dealt with in the theory. The subject matter for a theory can range from being very broad and all-inclusive to being very narrow and limited.
  • Broad-range theories (also called grand theories) are “systematic constructions of the nature of nursing, the mission of nursing, and the goals of nursing care.” Broad-range theories in nursing deal with the scope, philosophy, and general characteristics of nursing. For example, a conceptualisation of nursing's goal for high-level wellness for all individuals in society would be classified as nursing as broad-range theory. Although not all conceptual models can be classified as nursing theories, the following are examples of conceptual models that are classified as grand theories in nursing: Dorothea E. Orem's Self-Care Deficit Theory of Nursing; Martha E. Roger's Unitary Human Beings; Imogene King's Systems Framework and Theory of Goal Attainment; and Betty Neuman's Systems Model.
  • Middle-range theories (also termed midrange theories) have a narrower focus than broad-range theories. “Middle-range theories are more precise than grand theories and focus on developing theoretical statements to answer question about nursing.” Both middle-range and broad-range theories deal with a wide range of phenomena. However, unlike broad-range theories, middle-range theories do not deal with the entire range of phenomena of concern within a discipline. “When a theory is at the grand-theory level, many applications of that theory can be made in practice at the middle-range level by specifying such factors as the age of the patient, the situation, the health condition, the location, or the action of the nurse.”
    Chinn and Kramer (1995) describe an example of middle-range theory: “A theory of pain alleviation represents a midrange theory for nursing; it is broader than a theory of neural conduction of pain stimuli but narrower than the goal of achieving high-level wellness.” A theory of pain alleviation would be classified as a middle-range theory in that the phenomenon of pain is only one of the many phenomenon of concern within the discipline of nursing. Other phenomena include quality of life, incontinence, and uncertainty in illness. Examples of middle-range 15nursing theories include Nola Pender's Health Promotion Model; Madeline Leininger's Culture Care: Diversity and Universality Theory; and Ida Jean Orlando's Nursing Process Theory.
  • Narrow-range theories (also called microtheories) deal with a limited range of discrete phenomena of concern to a discipline. They are the most specific and least complex of the types of theories, and their theoretical formulations are not extended to link with the total range of phenomena of concern within a discipline. A discrete theory of neural conduction of pain stimuli (as cited above) is an example of narrow-range theory.
  • The conceptual models of a discipline are broad conceptual structures or frameworks that provide a total perspective of the phenomena that are specific to that discipline. There is considerable agreement that nursing's metaparadigm (a specific type of paradigm) consists of the phenomena that are specific to the discipline of nursing. These central domain concepts are person, environment, health, and nursing. Nursing models can then be described as broad conceptual structures that provide a perspective of the total phenomena of nursing (details of conceptual model see page 20 towards).
What this means in terms of nursing practice is that the way nurses think about people and about nursing has a direct impact on how people are approached, what questions are asked, how information is learned and processed, and what nursing activities are included in nursing care.
The propositions or relationship statements of theories are consistent with the model or the framework from which they are derived. Theories, also consisting of sets of concepts, are less broad than models and propose more specific outcomes: “When the nurse approaches people from the perspective of a certain nursing model and asks questions, processes information, and carries out activities in a certain way according to that model, a specific outcome is proposed based on the application of the theory of that model.”
The research proposal for example, “Compliance With Universal Precautions in Pediatric Settings,” provides an example of a theory that has been derived from a model. The research study was developed within King's systems framework or model and its resultant theory of goal attainment. King developed her theory of goal attainment from her own systems framework. Two other theories that have been derived from King's systems framework are Frey's theory of social support and health and Sieloff's theory of departmental power.
In summarizing relationship of nursing theory to nursing models, the following definitions are offered. “The conceptual models of a discipline provide different perspectives or frames of reference for the phenomena identified by the metaparadigm of that discipline.” The different perspectives identified by the nursing paradigm are person, environment, health and nursing. Nursing theory can be defined as:
An articulated and communicated conceptualisation of invented or discovered reality pertaining to nursing for the purpose of describing, explaining, predicting, or prescribing nursing care. Nursing theory is developed to answer central domain questions.
Although we have chosen to cite these particular definitions of nursing models and nursing theory, it must be noted that 16distinctions between to two are a debated issue and one on which not all authors agree.
 
PURPOSE OF THEORY IN A NURSING RESEARCH
Theory gives purpose and direction to a research study throughout the entire research process. Theory guides the research from the initial statement of the research problem through the analysis of the study data and provides a framework within which to analyze and interpret the results of the study. Analysing the study results within the framework of the theory not only guides the research in organizing and giving meaning to the phenomena, but may also increase the applicability and generalizability of the study findings.
The following hypothetical and very simplified–example should help clarify the function of theory in a research study. The purpose of this hypothetical study is to describe the characteristics of 100 hypertensive male adults who do or do not adhere to their medication regimen. If the study is not designed within a theory, the report of the results, although interesting, has limited applicability and generalizability to other than the 100 hypertensive male adults receiving medications who participated in the study.
If, however, the research were formulated within the framework of a theory, such as Orem's theory of self-care, the applicability and genralizability of the findings could then be broadened. Consider the following example of the same study formulated within Orem's self-care theory. In describing her theory of self-care Orem (1995) offered this definition of self-care.
The practice of activities that maturing and mature persons initiate and perform, within time frames, on their own behalf in the interest of maintaining life, healthful functioning, continuing personal development, and well-being.
In hypothetical study, formulated within Orem's self-care theory, the researcher was specifically looking for the relationship between adherence to medication regimens and self-care agency among the participants of the study. Self-care agency is defined by Orem's as “the complex acquired ability of mature and maturing persons to know and meet their continuing requirements for deliberate, purposive action to regulate their own human functioning and development.” In analysing the study results within the framework provided by self-care theory, the research could now observe that study participants with enough self-care agency to adhere to their medication regimen could be viewed as having positive outcomes of good self-care: the ability to meet their own requirements for care that promotes health and well-being.
Thus, the knowledge gained from the study could now move from merely describing the 100 subjects of the study, as in the first design, to the broader area of describing hypertensive adult male's health and health care. Guided by the explanatory function of the theory, the research could now understand why the phenomena are occurring; the predictive feature could permit the ability to forecast what is most likely to occur in adult male hypertensive patients in the future. Providing we could assume that there is a prescriptive feature of self-care theory, caregivers could now be directed to 17assess systematically the self-care agency of medicated hypertensive adult males. They could then prescribe the enhancement of individual self-care agency, thereby potentially increasing adherence to the regimen and the attainment of positive outcomes of good self-care.
 
Research Frameworks
All research studies have a framework of background knowledge that provides the foundation for the study. This framework serves to organize the study by placing it in the context of existing related knowledge, as well as providing a context within which to interpret the results of the study. If a study is based on a conceptual model, the framework for the study is most often referred to as a conceptual framework; if a study is based on a specific theory or theories, the framework is most often referred to as a theoretical framework. The terms conceptual framework and theoretical framework are often used interchangeably.
Although all research studies have framework—that is, have conceptual underpinnings—not all researchers explicitly identify and describe their research framework, especially, when the research is not based on a specific theory or conceptual model. In a study based on a single concept or more than one concept, each major concept should be identified, defined, and discussed by the researcher.
Not all research studies linked to the theory development process. Chinn and Kramer (1995) describe two types of research, isolated research and theory-linked research, that “reflect certain basic standards that have been established in order to obtain results that are considered reliable and valid or accurately representative of empiric reality.”
Isolated research is research that is not linked to the theory development process. Out hypothetical study of hypertensive adult male's adherence to their medication regimen, when designed without a theoretical or conceptual framework, is an example of isolated research. The study focused on a specific problem and offered little potential for applying the results beyond the findings of the study. However, isolated research does have certain merits, according to Chinn and Kramer (1995): “The results of isolated research can provide new insights that prompt the researcher, or someone reading the report of the research, to speculate about larger implications of the research for the discipline, which in turn can lead to developing theory that has broader meaning for the discipline.”
Theory-linked research, on the other hand, “is designed with reference or linkage to theory.” Theory-linked research is designed to develop theory or to test theory, and “it is this quality that sets the stage for the study to contribute to the larger knowledge of the discipline.” Theory-linked research is linked to the theory development process in one of two ways: the research is either theory-generating (designed to develop theory) or theory-testing (designed to test how accurately the theory depicts phenomena and their relationships).
Theory-generating research is most often associated with the qualitative research approach. In a theory-generating qualitative study, the theory is “built up” from the data. The researcher does not begin with a theory or theories to test or verify; instead, “consistent with the inductive model of 18thinking, a theory may emerge during the data collection and analysis phase of the research or be used relatively late in the research process as a basis for comparison, with other theories.”
Theory-testing research is most often associated with the quantitative research approach, in which deductive reasoning is used to test the theory. “In quantitative studies one uses theory deductively and places it toward the beginning of the plan for a study. In quantitative research the objective is to test or verify theory, rather that to develop it.” The researcher tests a theory or theories by testing a hypothesis or research questions derived from the theory. Our hypothetical example using Orem's self-care theory was theory-testing research. The theory-guided the research, and the researcher could test how accurately the theory depicted the phenomena and their relationships.
Theory and research are reciprocal in their relationship, that is, theory guides research and research tests (validates) the theory. “If you begin with a theory, research derived from the theory is used to clarify and extend the theory. If you begin with research, theory that is formed from the findings can be subsequently used to direct research.”
Chinn and Kramer (1995) provide the following observation regarding the role of both theory-linked and isolated research in the development of nursing knowledge: “From a research point of view, both can be of excellent quality. Both types of research can ultimately contribute to knowledge, although isolated research is much more limited in the contribution it can make to a discipline.”
 
Selection of Theory in Research
Nurse researchers who use theories to guide their studies select theories that are unique to nursing as well as those borrowed from other disciplines. Selecting the most appropriate theory (or theories) depends on several considerations. Researchers must select a theory that has concepts and propositions that fit with the proposed study and one in which there are no contradictions between the theory and the variables selected for study. The theory should be one that provides a “best fit” with the proposed study and that can be useful in describing the relationship(s) between study variables.
It has already mentioned some of the nursing theories (conceptual frameworks) used by researchers. Examples of those from other disciplines include Selye's Stress Theory. Festinger's Cognitive Dissonance theory, Lazarus and Folkman's Coping Theory, Kohlberg's Moral Reasoning Theory, and Bandura's Social Learning Theory.
 
Statement of the Purpose of the Study
After formulating the research problem and deciding on the research approach and the role of theory in the study, researchers then state the purpose of the study. For both quantitative and qualitative research, the purpose of the study is a single sentence or a short paragraph that summarizes the essence of the study.
The statement of the research study's purpose can be written in three ways (i) as a declarative statement, (ii) as a question, or (iii) as a hypothesis. The form depends on the way the research question is asked and 19the extent of the researcher's knowledge about the problem. The statement of the purpose should include information about what the researcher intends to do to collect data (such as observe, describe, or measure some variable), information about the setting of the study (where the researcher plans the collect the data), and information about who the study subjects/participants will be.
 
The Purpose as a Declarative Statement
In previously formulated research question designed to describe the relationship between the type of teaching and success in breast-feeding by primiparas, the purpose of the study written as a declarative statement could read: “The purpose of this study is to describe the effect of structured individualized versus structured group instruction on successful breast feeding by primiparas in their home setting.” Note that the statement includes information about what the researcher intends to (to describe), the setting of the study (home setting), and the subjects of the study (primiparas).
 
The Purpose as a Question
Using the same research question, the purpose of the study written as a question could read: “The purpose of this study is to answer the question: Is there a significant relationship between a specific method of teaching about breast-feeding and successful breast-feeding by primiparas in their home setting?” Specific methods of teaching might include structured individual teaching, structured group teaching, and unstructured (incidental) teaching. The primiparas in the study could be interviewed regarding their perceptions of their own success with breast-feeding and their satisfaction with the method of teaching to prepare them for breast-feeding.
 
The Purpose as a Hypothesis
Using the same research question, the purpose of the study, written as a hypothesis, could read: “The purpose of the study is to test the following hypothesis: Primiparas who receive individualized instruction about breast-feeding will have a significantly more successful breast-feeding experience in their home setting than primiparas who receive group instruction about breast-feeding.”
 
CONCEPTUAL MODEL
The basic unit in the language of theoretical thinking is the concept:
  • Concept is something conceived in the mind—a thought or notion.
  • Concepts are words that represent reality and enhance our ability to communicate about it.
  • Concept may be empirical or abstract, depending on their ability to observe in the real world.
    • Empirical concepts can be observed or experienced through the senses, e.g. stethoscope. In this there is an object.
    • Abstract concepts are those that cannot be observed through senses, e.g. hope, infinity. In these there is no object.
    In nursing theories, which are developed by nurse scientists, usually four major concepts are emphasized which includes person, health environment, and nursing. These concepts formulate the metaparadigm of nursing which identifies the core content of a discipline. These concepts are presented as an abstraction here:
    20
  • Person may represent one individual, a family, a community, or all mankind. The person is the recipient of nursing care.
  • Health represents a state of well-being mutually decided on by the client and the nurse.
  • Environment may represent the immediate surroundings, the community or the universe and all it contains.
  • Nursing is the science and art of the discipline.
Thus, concepts are the elements used to generate theories.
Concept is an image or symbolic representation of an abstract idea. It is an abstraction based on observation of certain behaviours or characteristics (e.g., stress, pain). It is formed by generalizing from particular characteristics. To illustrate, health is a concept formed by generalizing from particular behaviours. For example, being mobile, being free from infections and communicating appropriately. Other concepts include pain, intelligence, weight, grieving, self-concept, and achievement.
Concept is a complex mental formulation of experience. By experience we mean perceptions of the world—objects, other people, visual images, colour, movement, sounds, behaviour, interactions, the totality of what is perceived. Concepts are major components of theory and convey the abstract ideas within the theory.
Concept facilitates the delineation of ideas so that systematic inquiry can proceed. Some concepts are directly observable such as pen or rain and others are indirectly observable such as anxiety in intelligence. It is better to know the concepts because they are the basis for refining ideas and developing theory. So it is important to select those concepts that clearly reflect the subject matter being pursued.
Concepts, no matter what their level of abstraction, must be, defined as unambiguously as possible, so that they can be easily communicated to others. Even the word ‘can’ is open to various interpretations. For example, a container, being able to or a commode.
A conceptual definition conveys the general meaning of the concept, as does a dictionary definition. It reflects the theory used in the study of that concept. The following are the example of conceptual definitions.
  • Recovery: “The process of healing that takes place after an injury.”
  • Adaptation: “The degree to which an individual adjusts, psychologically, socially and physiologically to long-term illness.”
  • Postoperative pain: “Discomfort, an individual experiences after surgical procedure.”
  • Coping effort: Amount of physical and\or emotional energy an event or situation required to adjust to or handle the situation.
Operationalization is the process of translating concepts into observable, measurable phenomena. Operational definition refers to the measurements used to observe or measure a variable, delineates to procedures or operations required to measure the concept. In other words, operationalization adds another dimension to the conceptual definition by delineating the procedures or operational terms. For example, pulse and counting the number of beats or pulsations for a minute. Other concepts are more difficult 21to define operationally, such as coping, leaving it up to the investigator to locate and select an instrument that best measures the concepts as defined. The following are examples of operational definitions.
  • Dyspnea: “The sensation of difficult breathing” is measured by the Visual Analogue Dyspnea Scale (VADS).
  • Hopelessness: “The perceptual experience of anticipation of undesirable situation or (consequences that are largely beyond one's control) was measured by hopelessness scale” (Abraham, Neundorfer & Currie, 1992).
  • Body attitude: “Individuals’ general attitude about the outward form and appearance of their bodies, as measured by the Body attitude scale” (Drake, Verhutst, Fawcett and Barger, 1988).
  • Social support: A characteristics of the social elements that buffers the effect of stress on the health of the individual as measured by the Social Support Questionnaire (Northeuse, 1998).
The terms “theory,” “theoretical frame-work,” “conceptual scheme,” “conceptual model,” and “model” are sometimes used synonymously in the research literature. We have been careful in the preceding discussion to restrict our terminology to theory and theoretical framework and to use these terms to refer to a well-formulated deductive system of abstract formal statements. Distinguish of theories from conceptual frameworks and models as follows:
Conceptual Frameworks or Schemes (we will use the two terms interchangeably) represent a less formal and less well-developed mechanism for organising phenomena than theories. As the name implies, conceptual frameworks deal with abstractions (concepts) that are assembled by virtue of their relevance to a common theme. Both conceptual schemes and theories use concepts as building blocks. What is absent from conceptual schemes is the deductive system of propositions that assert relationships among the concepts.
Most of the conceptual work that has been done in connection with nursing practice is more correctly designated as conceptual frameworks or schemes than as theories. This label in no way diminishes the importance and vale of these endeavours. Indeed many existing conceptual frameworks will undoubtedly serve as the preliminary steps in the construction of more formal theories. In the meantime, conceptual frameworks can serve to guide research that will further support theory development. Conceptual frameworks, like theories can serve as a springboard for the generation of hypotheses to be tested. This chapter describes a few of the major conceptual frameworks in nursing and illustrates how they have been used in nursing research.
Models, like conceptual frameworks, are constructed representations of some aspect of our environment; they use abstractions (concepts) as the building blocks. However, models attempt to represent reality with a minimal use of words. Language is, and probably always will be, a problem of scientists. A word or phrase that designates a concept can convey different meanings to different people. A visual or symbolic representation of a theory or conceptual framework often helps express abstract ideas in a more readily understandable or precise form than the original conceptualisation.
Schematic models are quite common and undoubtedly are familiar to all readers. A schematic model or diagram represents the 22phenomenon of interest figuratively. Concepts and the linkages between them are represented diagrammatically through the use of boxes, arrows, or other symbols. An example of a schematic model is presented in (Fig. 1.1). This model is described by its designer as “a human interaction diagram showing nurse and client interactions” (King, 1981, p. 145).
Schematic models of this type can be quite useful in the research process in clarifying concepts and their associations, in enabling researchers to place a specific problem into an appropriate context, and in revealing areas of inquiry.
In summary, it may not always prove possible to identify a formal theory that is relevant to a nursing research problem, but conceptual schemes and models of the type discussed here can also be used to clarify concepts and to provide a context for findings that might otherwise be isolated and meaningless. Conceptual schemes in nursing are very much in need of testing if theories for nursing are to be formulated.
zoom view
Figure 1.1: An example of schematic model
 
Conceptual Models in Nursing
In the past few decades, nurses have formulated a number of conceptual models of nursing and for nursing practice. These models constitute formal explanations of what the nursing discipline is according to the model developer's point of view. As Fawcett (1984) has noted, there are four central concepts of the nursing discipline; person, environment, health and nursing. However, the various models define these concepts differently, link them in diverse ways, and give different emphasis to the relationships among them. Nurse researches increasingly are turning towards these conceptual models for their inspiration and theoretical foundations in formulating research questions and hypotheses. This section briefly reviews some of the major conceptual models in nursing and gives examples of research that claimed its intellectual roots in these models.
 
Johnson's Behavioural Systems Model
Johnson's model focuses on a behavioural system (the patient), its subsystems, and its environment. According to this model, each individual behavioural system is a collection of seven interrelated subsystems (attachment, dependency, ingestion, elimination, sexuality, aggression, and achievement), the response patterns of which form an organized and integrated whole. Each subsystem carries out specialized tasks for the integrated system, and each is structured by four motivational elements: goal, set, choice, and action/behaviour. The model is concerned primarily with behavioural functioning that results in the equilibrium of the integrated system. In 23Johnson's model, the function of nursing is to help restore the balance of each subsystem in the event of disequilibrium and to help prevent future system disturbance. Several researchers have designated Johnson's Behavioural Systems Model as their conceptual basis. For example, Derdiarian and Forsythe (1983) described the development of an instrument (the Derdiarian Behavioural System Model Instrument) to measure the perceived behavioural changes of cancer patients. Holaday (1981) focused on Johnson's concept of “behavioural set” in her study of the crying bouts of chronically-ill infants and their mothers responses.
 
King's Open System Model
King's conceptual model (1981) includes three types of dynamic, interacting systems; personal systems (represented by individuals); interpersonal systems (represented by such dyadic interactions such as hospitals and families). The social system provides a context in which nurses work. Within King's model, the domain of nursing includes promoting, maintaining, and restoring health. Nursing is viewed as “a process of action, reaction and interaction whereby nurse and client share information about their perceptions of the nursing situation” (King, 1981). King herself (1981) conducted a descriptive observational study of nurse-client encounters that yielded a classification of elements in nurse-client interactions. The study provided preliminary support for the proposition that goal attainment was facilitated by accurate nurse-client perceptions, satisfactory communication, and mutual goal setting.
 
Levine's Conservation Model
Levine's (1973) model focuses on individuals as holisting beings, and the major area of concern for nurses is maintenance of the persons wholeness. The model identifies adaptation as the process by which the integrity or wholeness of individuals is maintained. Levine's model identifies several principles of conservation the aim to facilitate patient's adaptation processes. Through these principles, the model emphasizes the nurse's responsibility to maintain the client's integrity in the threat of assault through illness or environmental influence. Newport (1984) based a study on Levine's model, she investigated two alternative methods of conserving newborn thermal energy and social integrity.
 
Neuman's Health Care Systems Model
Neuman's (1982) model focuses on the person as a complete system, the sub parts of which are interrelated physiological, psychological, sociocultural, and developmental factors. In this model, the person maintains balance and harmony between internal and external environments by adjusting to stress and by defending against tension-producing stimuli. Wellness is equated with equilibrium. The primary goal of nursing is to assist in the attainment and maintenance of client system stability. Nursing interventions include activities to strengthen flexible lines of defense, to strengthen resistance to stressors, and to maintain adaptation, Craddock and Stanhope (1980) applied Neuman's scheme in a study of clients’ and health care provider's perceptions of stressors. Ziemer (1983) operationalized many of Neuman's concepts 24in a study of the effects preoperative information on the postoperative outcomes of clients who have had abdominal surgery.
 
Orem's Model of Self-care
Orem's (1985) model focuses on each individual's ability to perform Self-care, defined as “the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being.” One's ability to care for oneself is referred to as Self-care Agency, and the ability to care for others is referred to as Dependent-care Agency. In Orem's model, the goal of nursing is to help people meet their own therapeutic self-care demands. Orem identified three types of nursing systems: (i) wholly compensatory, wherein the nurse compensates for the patient's total inability to perform self-care activities; (ii) partially compensatory wherein the nurse compensates for the patient's partial inability to perform these activities; and (iii) supporting-educative, wherein the nurse assists the patient in making decisions and acquiring skills and knowledge. Orem's Self-care Model has generated considerable interest among nurse researchers. For example, Chang and Colleagues (1984) examined components of nurse practitioner care in the context of Orem's model to determine what aspects of the care contributed most to the elderly patient's intentions to adhere to the care plan. Moore (1987) explored alternative strategies for promoting autonomy and self-care agency in fifth-grade students. Dodd (1984) studied the self-care behaviours of cancer patients in chemotherapy.
 
Roger's Model of the Unitary Person
Roger's Model (1970) focuses on the individual as a unified whole in constant interaction with the environment. The unitary person is viewed as an energy field that is more than, as well as different from the sum of the biological, social and psychological parts. In Roger's model, nursing is concerned with the unitary person as a synergistic phenomenon. Nursing science is devoted to the study of the nature and direction of unitary human development. Nursing practice helps individuals achieve maximum well-being within their potential. Examples of studies that have been based on Roger's model include Floyd's (1983) study of sleep-wake patterns with samples of rotating shift workers and hospitalised psychiatric patients and Fitzpatrick's (1980) study relating to patient's temporal experiences.
 
Roy's Adaptation Model
In Roy's Adaptation Model (1980), humans are biopsychosocial adaptive systems who cope with environmental change through the process of adaptation. Within the human system there are four subsystems: physiological needs, self-concept, role function, and interdependence. These subsystems constitute adaptive modes that provide mechanisms for coping with environmental stimuli and change. The goal of nursing according to this model, is to promote patients adaptation during health and illness. Nursing also regulates stimuli affecting adaptation. Nursing interventions generally take the form of increasing, decreasing, modifying, removing, or 25maintaining internal and external stimuli that affect adaptation. Norris, Campbell and Brenkert (1982) used Roy's concepts of focal, contextual, and residual stimuli in their study of the effect of nursing procedures on transcutaneous oxygen tension in premature infants. Shannahan and Cottrell (1985) invoked Roy's concept of manipulation of contextual stimuli in their assessment of the effects of delivering in a birth chair versus a traditional delivery table.
 
Types of Theory to be Tested
Theories may describe a particular phenomenon, explain relationships between or among phenomena, or predict how one phenomenon affects another. Different types of theories are tested by different approaches. For example, descriptive theories “describe or classify specific dimensions or characteristics of individuals, groups, situations, or events by summarizing the commonalities found in discrete observations” (Fawcett, 1989). To test descriptive theories, researchers conduct descriptive research studies. Hutchison and Bahr (1991) used a grounded theory approach to describe the types and meanings of caring behaviours in elderly nursing home residents. They observed residents and interviewed them to understand their views of caring. The commonalities that the investigators found led them to develop models of the types of cawing behaviours and their meaning as expressed by the residents.
Explanatory theories are those are that “specify relations among the dimensions or characteristics of individuals, groups, situations or events” (Fawcett, 1989), and are tested by using correlational research. Grey et al, (1991) conducted a correlational study to determine the influence of age, coping behaviour, and self-care on social, psychological, and physiological adaptation in adolescents and preadolescents with diabetes. Through their review of literature, they found that several factors influence adaptation to chronic illness during adolescence; however, the relative impact of these factors had not been determined.
Nursing theory is an articulated and communicated conceptualisation of invented or discovered reality (Central Phenomena and Relationships) in or pertaining to Nursing for the purpose of describing, explaining, predicting or prescribing nursing care” (Melis, 1991).
This definition adds the importance of communicating nursing theory and the purpose of prescription of nursing care.
Complete nursing theory is one that has context, content and process. (Barnum 1994). Here,
  • Context is the environment in which the nursing acts place.
  • Content is the subject of the theory.
  • Process is the method by which the nurse acts in using the theory.
The nurse acts on, with or through the content elements of the theory.
 
Level of Theory
The level of the theory refers to the scope or range of phenomena to which the theory applies. The levels of abstraction of the concepts in the theory is closely tied to its scope.26
Theory may be characteristic on micro, macro, molecular, midrange, molar, atom-istic, and holistic (Chinn & Kramer 1991).
Micro, molecular and atomistic suggest relatively narrow range phenomenon where on macro, holistic and molar implies that theory covers a broader scope. Graded theory is the term used to mean that covers broad areas of concern within discipline. Meta theory is the term used to label theory about the theoretical process and theory development.
According to Dickoff, James and Wedenbach (1968) theory develops on four levels.
Level 1:
Factor-isolating is descriptive in nature. It involves naming or classifying facts or events.
Level 2:
Factor-relating, require correlating or associating factors in such a way that they meaningfully depict a larger situation.
Level 3:
Situation-relating, explains and predicts how situations are related.
Level 4:
Situation-producing requires sufficient knowledge about how and why situations are related, so that when the theory issued as a guide valued situations can be produced.
Among these levels level 4 is most powerful because it controls or does more than describe, explain or predict.
 
Categories of Theories
1. Needs/Problem-oriented
:
Nightingale, Abdellah, Henderson, Orem, Hull, Watson.
2. Interaction-oriented
:
Peplau, Orlando, Weidenback, King Patterson, Erickson.
3. System-oriented-oriented
:
Johnson, Roy, Neuman, Levine, Leininger.
4. Energyfield
:
Rogers, Parse, Newman.
 
NURSING THEORY AND KNOWLEDGE
Nursing is a unique health care discipline in which a service, based on knowledge and skill, is provided to others. Nursing therefore, has two parts—a body of knowledge through Nursing Practice. The body of knowledge, called a knowledge base, provides a rationale for nursing actions.
It is the general conception of any field of enquiry that ultimately determines the kind of knowledge that field aims to develop as well as the manner in which that knowledge is to be organized, tested and applied. Such an understanding, involves critical attention to the question of what it means to know and what kinds of knowledge are held to be most value in the discipline of nursing.
 
Concepts of Knowing and Knowledge
The term ‘Knowing’ refers to ways of perceiving and understanding the self and the world. Knowing is an ontologic, dynamic, changing process (ontology is pertaining to ways of being in the world, perspectives on the existence and experience of being).
Knowledge refers to knowing that is in a form that can be shared or communicated with others. Knowledge is an awareness or perception of reality acquired through learning or investigation. Additionally, knowledge represents what is collectively taken to be a reasonably accurate accounting of the world as it is known by the members 27of the discipline. Knowledge then, is a representation of knowing that is collectively judged by standards and criteria shared within the nursing community. The ways in which knowledge and knowing are developed are epistemologic concerns that reveal how we come to know and how we acquire shared knowledge in the discipline. (Epistemology – pertaining to the ‘stem’ or basis of knowledge: perspectives on how knowing becomes knowledge and/or how knowledge is created.
Thus, knowing is the individual human processes of perceiving and understanding self and the world in ways that can be brought to some level of conscious awareness. Not all that is comprehended in the process of knowing can be shared or communicated, and expressed in words or in actions become knowledge of discipline.
Knowledge, is the awareness or perception of reality acquired through insight, learning or investigation expressed in a form that can be shared. Knowledge is a reasonably accurate accounting of the world as known and shared by members of a discipline. It is a representation of knowing that is collectively judged by shared standards and criteria.
As nurses practice, they know more than they can communicate symbolically or justify as knowledge. Much of what is known is expressed through actions, movements, and/or sounds. These are the everyday actions or non-discursive expressions of knowing that always reflect the whole of knowing. Each of the patterns of knowing has nondiscursive forms of expression that give nursing its distinctive character as a healing practice and that can be recognized as arising from a particular pattern of knowing. At the time what is expressed in a nurse's action always conveys a simultaneous wholeness. Action also conveys a fuller expression of what is known than formal, discursive expression of knowledge.
It has been believed that much of what nurses know has potential to become formally expressed. Although language and other symbols will only partially reflect the whole of knowing, it is important to begin the challenge and formal expression of knowledge in order to communicate what is known within the discipline as a whole. This makes possible focus, shape, question and influence what is collectively accepted as sound, useful and valued. It is the formal expression that have potential to become the knowledge of the discipline. Sharing knowledge is important because it creates a disciplinary community, beyond the isolation of individual experience. once this happens, social purposes form, and knowledge development and shared purposes form a cyclic interrelationship that moves us toward prospective, value grounded or praxis.
Knowing and knowledge are reflections of four patterns: empirics, aesthetics, ethical and personal. Together they form an essential whole. Praxis—thoughtful reflections and action that occur in synchrony—comes from the whole of knowing and knowledge in nursing practice.
 
Pattern of Knowing in Nursing
Carper (1978) examined early nursing literature and named four fundamental and enduring patterns of knowing that nurses have valued and used in practice. one of the patterns is the familiar and respected patterns of empirics, the science of nursing. In addition, the identified ethics, the component of moral knowledge in nursing; aesthetics, 28the art of nursing; and personal knowing in nursing.
The fundamental patterns of knowing remain valuable in that they conceptualise a broad scope of knowing that accounts for a holistic practice. we retain our focus on these fundamental patterns in this text because until very recently the development of empiric knowledge has been the prevailing approach to knowledge development, and the other fundamental patterns have not been formally developed within the discipline. In part, neglect of the personal, ethical, and aesthetic patterns of knowing reflect, an overvaluing of empirics as the knowledge of the discipline. In addition methods for developing knowledge within the other patterns, particularly personal and aesthetic knowledge, are only beginning to be systematically described and developed.
In the following sections we describe each of the fundamental patterns and provide an overview of the methods we propose for developing each of the patterns.
 
Empirics: The Science of Nursing
Empirics is based on the assumption that what is known is accessible through the senses; seeing, touching, hearing, and so forth. Empirics can be traced to Nightingale's precepts concerning the importance of accurate observation and record keeping. The science of nursing emerged during the late 1950s. Empirics as a pattern of knowing draws on an additional idea of science in which reality is viewed as something that can be known by observation and verified by other observers.
Empiric knowing is expressed in practice through the nurse's scientific competence—embodied knowing that makes possible competent acting rounded in scientific theory. There is a cognitive component of empiric competence that involves problem-solving and logical reasoning, but much remains in the background of conscious awareness. It is also accessible to conscious reasoning when attention turns to the reasoning process itself.
Empiric knowledge is formally expressed in the form of empiric theories, statements, of fact, or descriptions of empiric events or objects. The development of empiric knowledge has traditionally been accomplished by the methods of science. Usually this has involved testing hypothesis derived from a theory that offers a tentative explanation of empiric phenomena. Although many conceptualisations of empiric knowledge in nursing are linked to this traditional view of science, ideas about what is legitimate for developing the science of nursing have broadened to include activities that are not strictly within the realm of hypothesis testing, such as phenomenologic or ethnographic descriptions or inductive means of generating theory.
 
Ethics: The Moral Component of Knowledge in Nursing
Ethics in nursing is focused on matters of obligation or what ought to be done. The moral component of knowing in nursing goes beyond knowledge of the norms or ethical codes of nursing, other related disciplines, and society, it involves making moment-to-moment judgements about what ought to be done, what is good and right, and what is responsible. Ethical knowing guides and directs how nurses conduct their practice, what they select as important, where loyalties are placed, and what priorities demand advocacy.
Ethical knowing also involves confronting and resolving conflicting values, norms, 29interests, or principles. There may be no satisfactory answer to an ethical dilemma or moral distress—only alternatives, some of which are more or less satisfactory. Ethical knowing in nursing requires both an experiential knowledge, from which ethical reasoning arises, and knowledge of the formal principles, ethical codes, and theories of the discipline and society. Like empiric knowing, ethical knowing is expressed in nursing actions —what we call moral-ethical comportment. Nursing actions based on ethical principles can be discerned and examined.
The discipline's ethical principles, codes, and theories are set forth in the philosophic ideals on which ethical decisions rest. Ethical knowledge does not describe or prescribe what a decision or action should be, rather, it provides insight about which choices are possible and why and it provides direction towards choices that are sound, good, responsible, or just.
Ethical theories are like empiric theories in that they describe some dimensions of reality and express relationships between phenomena. However, empiric theory relies on observable reality that can be confirmed by others. Ethical theory cannot be tested in this sense because the relationships of the theory rest on underlying philosophic reasoning that leads to conclusions concerning what is right, good, responsible, or just. The reasoning can include description of experience to substantiate an argument, but the conclusions are value statements that cannot be perceived or confirmed empirically.
 
Personal Knowing in Nursing
Personal knowing in nursing concerns the inner experience of becoming a whole, aware genuine self. Personal knowing encompasses knowing one's own self and self of others. It has been stated that “One does not know about the self, one strives simply to know the self.” It is through knowing one's own self that one is able to know the other. Full awareness of the self, the moment, and the context of interaction makes possible meaningful, shared human experience. Without this component of knowledge, the idea of therapeutic use of self in nursing would not be possible.
Personal knowing is most fully communicated as an authentic, aware genuine self. What is perceived by others is the existence of a person, an embodied self. As personal knowing emerges more fully throughout life, the unique or genuine self can be more fully-expressed and becomes accessible as a means by which deliberate action and interaction take form. It is possible to describe certain things about the self in personal stories and autobiographies. These descriptions provide sources for deep reflection and a shared understanding of how personal knowledge can be developed and used in a deliberative way. Descriptions about the self are limited in what they never fully reflect personal knowing, and they are retrospective in that they can describe only the self that was. However, publicly expressed descriptions can be a tool for developing self-awareness and self-intimacy and for communicating to others valuable possibilities for developing personal knowing.
In a sense, all knowing is personal, each individual can know only through their personal senses and sensibilities. Empiric theories can be learned, but their meaning for the individual comes from personal reflection and experience with the phenomena of the theory. Aesthetic sensibilities, ethical 30precepts, and moral beliefs are likewise highly personal in nature. We recognise this broad meaning of personal knowing, but our focus is the aspect of personal knowing that develops into the process of knowing the self and of developing self-knowing through healing encounters with others.
 
Aesthetics: The Art of Nursing
Aesthetic knowing in nursing involves deep appreciation of the meaning of a situation, calling forth inner creative resources that transform experience into what is not yet real but possible. Aesthetics knowledge make it possible to move beyond the surface – beyond the limits and circumstances of a particular moment—to sense the meaning of the moment and connect with depths of human experience that are common but unique in each experience (sickness, suffering, recovery, birth, death). Aesthetic knowing in nursing is made visible through the actions, bearing, conduct attitude, narrative and interactions of the nurse in relation to others. It is also expressed in art forms such as poetry, drawing, stories, and music that reflect and communicate symbolic meanings embedded in nursing practice.
Aesthetic knowledge is what makes possible knowing what to do with and how to be in the moment instantly, without conscious deliberation. It arises from a direct perception of what is significant in the moment that is, grasping meaning in the encounter. Perception of meaning in an encounter creates artful nursing action, and the nurse's perception of meaning is reflected in the action taken. The meaning is often a shared meaning that is perceived without conscious exchange of words and may not be consciously or cognitively formed. Sometimes, meaning is brought to the situation from the nurse's own creative sensibilities, opening possibilities that would not otherwise enter into the encounter. The actions—movements and verbal expressions—of the nurse serve to transform and shape the experience into what would not otherwise exist, creating new possibilities in the encounter. The nurse's actions take on an element of artistry, creating unique meaningful deeply moving interactions with others that touch common chords of human experience. We refer to the aspect of nursing practice as the transformative art-act.
Aesthetic knowing is expressed in the moment of experience-action, in the transformative art-act. Aesthetic knowledge is formally expressed in aesthetic criticism and in works of art that symbolize experience. Aesthetic criticism is the discursive expression of aesthetic knowledge that conveys the artful aspects of the art, the technical skill required to perform the art-act, knowledge that informs the development of the art-act, the historical and cultural significance of specific aspects of nursing as an art, and the potential for the future development of the art.
 
Empirics
  • Fundamental pattern of knowing in nursing focussed on the use of sensory experience for creation of mediated knowledge expressions, expressed as knowledge by theories and models and integrated in practice as scientific competence.
  • Theory is an expression of knowledge within the empirics pattern. Creative and 31rigorous structuring of ideas that project a tentative, purposeful and systematic view of phenomena.
  • Models is a symbolic representative of empiric experience in words, pictorial or graphic diagram, mathematical notations or physical material (model of heart). A form of knowledge within the empirics pattern.
  • Explaining—process that focuses on how concepts and variable interrelate. Interacts with the process of structuring to create empiric knowledge.
  • Structuring—process that involves forming empiric concepts into formal expressions such as theories, models, or framework interact with the process of explaining to create empiric knowledge.
  • Replication—process that draws on methods of science to determine the extent to which an observation remains consistent from one situation or time to another. Interacts with the process of validation to challenge and authenticate empiric knowledge.
  • Validation—process that draws on methods of science to substantiate the accuracy of conceptual meaning in terms of empiric evidence. Interacts with replication to challenge and authenticate empiric knowledge.
  • Scientific competence—expression of empiric knowledge and knowing in nursing practice, integrated with ethics, aesthetics and personal knowing and knowledge.
 
Ethics
  • Fundamental pattern of knowing in nursing, focussing on matters of moral and ethical significance expressed as knowledge by principles and codes and integrated in practice as moral-ethical comportment.
  • Dialogue refer to process of exchanging various points of view concerning what is right, good or responsible. Interacts with the process of justification to challenge and authenticate ethical knowledge.
  • Justification is the process of developing explicit descriptions of the values of which an ethical ideal rests and the line of reasoning toward which an ethical conclusion flows. Interacts with dialogue to challenge and authenticate ethical knowledge.
  • Moral-ethical component is the expression of ethical knowledge and knowing in nursing practice, integrated with personal, aesthetic, and empiric knowledge and knowing.
  • Valuing is the process of examining motives, actions, outcomes and other dimensions of experience to embrace and reflect chosen values as basis for understanding moral ethical behaviour. Increases with the process of clarifying to create ethical knowledge.
  • Clarifying is the process involving a deliberate focus on understanding those actions that are right and good. Interacts with the process of valuing to create ethical knowledge.
  • Principles is a form of knowledge expression within the ethical pattern. They are general statements that reflect general and fundamental principles of values or truths that are followed in providing nursing care such as ‘do no harm.’
  • Codes are short hand expressions of prescribed professional behaviour that are 32generally accepted as right and good. Codes primarily describe behaviours that represent the nursing accountability to the client as expressed in rights, duties and obligation.
 
Personal
  • Personal pattern of knowing in nursing focussed on the inner experience of becoming a whole, aware of self. Expressed as knowledge through autobiographic stories and the genuine self and integrated in practice with other patterns as therapeutic use of self.
  • Response is a process of interacting with one's own self and others to provide insight concerning the meanings conveyed in experience. Interacts with the process of reflections to challenge and authenticate personal knowledge.
  • Reflection is the process that requires integrating a wide range of perceptions in order to realize what is known within the self. Interacts with the process of response to challenge and authenticate personal knowledge.
  • Therapeutic use of self is the expression of personal knowledge and knowing in nursing practice, integrated with ethics, empiric and aesthetic knowledge and knowing.
 
Aesthetics
  • Fundamental pattern of knowing in nursing related to the perception of deep meanings, calling forth inner creative resources that transform experience into what is not yet real, but possible. Expressed as knowledge through works of art and criticism and integrated in practice as transformative-art-acts.
  • Appreciation is the process of focussing and reflecting on aesthetic knowledge as it is understood and valued by members of the discipline. Interacts with the process of inspiration to challenge and authenticate aesthetic knowledge.
  • Inspiration is the process of responding to aesthetic knowledge to imagine new possibilities and directions. Interacts with appreciation to challenge and authenticate aesthetic knowledge.
  • Envisioning is the process of imagining forms, ways of being, actions and outcomes into a possible future. Interacts with the process of rehearsing to create aesthetic knowledge.
  • Rehearsing is the process of creating and recreating narrative body movements, gestures and actions in relation to an anticipated situation. Interacts with the process of envisioning to create aesthetic knowledge.
Criticism is a form of knowledge within the aesthetics pattern that is a discursive representation of meaning for expressions of aesthetic knowledge. Criticism is formed from aesthetic methods that are designed to deepen shared meanings for aesthetic knowledge (Fig. 1.2).
Above Figure 1.1 showing the practice or action expression of knowing that is associated with the pattern. The inner sphere is shown as a whole, without quadrant boundaries, representing our view that in nursing practice knowing is experienced as a whole and cannot be experienced as discrete patterns. Along the vertical axis, represented by vertical broken arrows, are the processes for developing the formal knowledge expressions. Along the horizontal axis, represented by horizontal broken arrows, are the collective processes used within the discipline for validating or authenticating what is known.33
zoom view
Figure 1.2: Fundamental pattern of knowing
The outer area, where the critical questions appear, and the inner sphere, showing the action expressions of knowing, represent the ontologic dimensions of knowing. The processes shown along the vertical and horizontal arrows represent the epistemologic dimensions of processes for developing and authenticating knowledge.
Another way of conceptualising these processes is shown in Table 1.1. The dimensions of the critical questions, the creative processes for developing knowledge, the formal expression of knowledge, the processes for authenticating knowledge, and the nondiscursive expressions of knowing in practice are shown for each pattern. Each of the dimensions are unique to each pattern of knowing; you cannot create empiric theory, for example, by using the creative processes of ethics, personal, or aesthetic knowing. However, in the realm of nondiscursive expression of knowing in practice, knowing is experienced as a whole, even though you can discern those aspects of practice that are possible because of each fundamental pattern of knowing.34
Table 1.1   Dimensions associated with each of the fundamental patterns of knowing
Dimensions
Empirics
Ethics
Personal
Aesthetics
Critical questions
What is this?
How does it work?
Is this right?
Is this responsible?
Do I know what I do?
Do I do what I know?
What does this mean?
How is it significant?
Creative processes
Explaining, structuring
Valuing, clarifying
Opening, centering
Envisioning, rehearsing
Formal expression of knowledge
Facts, models, theories, description
Principles, codes, ethical theories
Autobiographical stories, the genuine self
Aesthetic criticism, works of art
Authentication process
Replication, validation
Dialogue, justification
Response, reflection
Appreciation, inspiration
Nondiscursive expression of knowing in practice
Scientific competence
Moral-ethical component
Therapeutic use of self
Transformative art/acts
Critical questions represent the kind of understanding that emerges within the individual patterns. Empirics, the science of nursing, poses the critical questions “what is this?” and “How does it work?” Personal knowing poses the critical questions “Do I know what I do?” and “Do I do responsible?” Aesthetics the critical questions “Is this right?” and “Is this responsible?” Aesthetics poses the critical questions “what does this mean?” and “How is this significant?”
The creative inquiry processes lead toward formal expression of knowledge. Empiric knowledge development uses the reasoning processes of explaining and structuring empirical phenomena. Personal knowledge is developed by opening and centering the self. Development of ethical knowledge uses processes of clarifying and valuing issues of rights and responsibilities in practice. Aesthetic knowledge is developed by envisioning possibilities and rehearsing art-acts that can be called upon to transform experience.
From these processes, formal discursive forms of expression are created that can be presented to members of the discipline. In Figure 1.1, these are shown in the large arrows leading to the center sphere. Empiric inquiry leads to the development of theories, models, and other formal expressions, such as statements of fact and conceptual frameworks. Personal inquiry leads to the creation of autobiographic stories and the lived expression of the nurse's being in nursing care situations. This lived experience of being who we are is what we call the genuine self. Ethical inquiry leads to ethical principles and codes and to other expressions such as theories and precepts that guide ethical conduct in practice. Aesthetic inquiry leads to aesthetic criticism that reveals deep meaning embedded in nursing art-acts and works of art that symbolize nursing experience.
The formal expressions of each pattern, once they are available to the members of the discipline, make possible certain kinds of formal inquiry processes that depend on the community or on the collective efforts of several members of the discipline. These are the processes for authenticating knowledge, 35represented in Figure 1.1 along the horizontal axis. In the empiric pattern, statements representing empiric reality are translated into inquiry statements that can be replicated in similar but different situations, and the adequacy of the statement can be validated in these similar but different situations. Autobiographic stories and the expression of the genuine self lead to reflection and response from others in the discipline with the intent of discerning the value and adequacy of personal insights. Ethical principles and codes lead to collective dialogue and justification of the soundness of the principles in addressing nursing's ethical and moral dilemmas. Aesthetic criticism and works of art lead to formation of collective appreciation of aesthetic meanings in practice and becomes a source of inspiration for development of the art of nursing.
The innermost sphere in Figure 1.1 represents the nondiscursive forms of expression of knowing that are enacted in the practice of nursing. The nondiscursive expressions represent nursing praxis-the synchrony of thoughtful reflection and action that constitutes nursing as a human caring practice. Praxis assures, through reflections, the continual asking of critical questions associated with each fundamental pattern of knowing, as well as ongoing knowledge development.
All of these processes are interactive and nonlinear, and there is no one starting point. Nurses in practice and nurses who primarily engage in the formal inquiry processes all contribute to the activities that are involved in creating nursing knowledge. Each nurse engages in activities that make possible scientific competence, moral-ethical comportment, therapeutic use of self, and transformative art-acts.
To illustrate how these processes interact, suppose you have an empiric problem concerning what nursing approaches to relieving pain are effective in practice, and why, You might begin by planning a research program to systematically study two different approaches to pain relief. You would identify the theoretical explanations associated with each approach and plan research studies that test selected hypothetical relationships. Whereas the empiric questions are the starting point and remain the focus of your method, your approaches and methods are influenced by aesthetic meanings of experiences of relieving pain and suffering, personal meanings concerning the experience of pain, and ethical values that influence how and when pain relief is given and received.
Personal knowing is frequently the avenue through which awareness of possibilities that are not yet fully understood first emerges. For example, suppose a nurse comes to realize and appreciate the perspective of a family who is receiving care in the clinic. Something has not seemed to fit, has not felt right, and a growing appreciation of the family's perspective gradually brings a new perspective. The nurse shares her awareness with the family, and the relationship shifts to bring the family's perspective to the center. Personal knowing is the starting point to bring a situation to awareness, but as you explore your awareness, your knowledge of empiric theories also is used as a tool, within a frame of ethical and aesthetic sensibilities.
Suppose you want to address an ethical question concerning what is right. You might begin with the focused creative activities of making explicit the personal and group values 36(valuing) that should guide your actions, clarifying the positions you find in ethical theories and principles that inform the issue, and setting forth how the application of these principles would function with the people with whom you work. These processes would lead reasoning. When you begin to share your ideas with your colleagues, the questioning and discussion that result will bring to awareness the personal insights of others engaged in the dialogue, empiric evidence about similar situations, and the range of aesthetic meanings that are possible in this and similar situations.
Aesthetics as a starting point, like personal knowing, often begins with a nurse's own awareness, but the expression often taken an art form that shows what the nurse envisions about the situation. The art can be in the form of the nurse's action in a situation. Suppose a nurse feels a connection to a person's experience of chronic pain. In a moment of caring for the person, the nurse acts from a deeply developed knowing of the meaning of chronic pain in a way that connects with the person's own experience, bringing together empiric, personal, and ethical knowing and creating a possibility that was not previously present.
 
Patterns Gone Wild
When knowledge within any one pattern is not critically examined and integrated with the whole of knowing, distortion instead of understanding is produced. Failure to develop knowledge integrated within all of the patterns of knowing leads to uncritical acceptance, narrow interpretation, and partial utilization of knowledge. We call this “the patterns gone wild.” When this occurs, the patterns are used in isolation from one another, and the potential for syntheses of the whole is lost.
Empirics removed from the context of the whole of knowing produces control and manipulation. Ironically, these have been explicit traditional goals of the empiric sciences. When the validity of empiric knowledge is not questioned, one danger is its potential use in contexts where it does not belong. When you recognize how all the patterns contribute to the validity of empirics, you begin to see the unquestioned goals of control and manipulation as a distortion or misuse of empiric knowledge.
Ethics removed from the context of the whole of knowing produces rigid doctrine and insensitivity to the rights of others. This happens when someone simply sets forth personal ideas concerning what is right or good and advocates a position on reasoning derived from personal perspectives. The person may present a justification for a perspective to others but not take seriously the processes of dialogue that the justification invites. In the absence of this integrating process, the person's position remains isolated, with little or no opportunity for empiric, personal, or aesthetic insights to give meaning and social relevance to the ideas.
Personal knowing removed from the context of the whole of knowing produces isolation and self-distortion. When this happens, the self remains isolated, and knowledge of self comes only from what is known internally. Self-distortions can take a wide range of forms, from aggrandizement and overestimation of self to destruction and underestimation of self.
Aesthetics removed from the context of the whole of knowing produces indulgence in self-serving expressions and lack of 37appreciation for the fullness of meaning in a context. Human actions emerge from and are represented by the tastes and desires of the individual alone, without taking into account the deep cultural meanings inherent in the art-act. Art-acts become self-serving, shallow, arrogant, and empty. Self-serving preferences grow out of a failure to comprehend the deeper cultural, historical, and political significance of the art-act itself. Inauthentic meanings are assigned to another's experience, or a self-serving posture is assumed with respect to another person.
To illustrate “patterns gone wild,” imagine an elderly woman admitted to a nursing home. She has lived a life rich in experience and activities and loves to verbally explore her past, making sense of what it means and how it relates to her present life. Having always been physically active, she takes a nightly stroll before going to bed. In the nursing home, she climbs over the bed rails after the lights are out and, with her walker, walks the halls, unsteady but determined, smiling and peering into other rooms. Hearing other residents talking or moaning, she sometimes goes into their rooms and tells them stories or talks with them to ease their troubled nights.
Consider what you might see if any one of the patterns of knowing were isolated from the context of the whole of knowing. Empirics isolated from the other patterns of knowing might require giving a drug that would be effective in bringing sleep to the woman soon after the lights go out, thereby controlling the situation and manipulating her into compliance, regardless of any other concerns. Ethics taken alone might impose the nurse's view of what is right or good for the woman and lead to a rule that would confine the woman to her bed after the lights are out and create a rigid, rule-oriented atmosphere that is insensitive to what the woman and others see as right or good. Personal knowing in isolation would impose the nurse's perspective, with the nurse isolated in the view that the old woman is a nuisance who is interfering with the time needed to complete the charting for the night. Aesthetics alone would impose the nurse's own tastes, preferences, and meanings on the situation. The nurse might restrain the woman in her bed and use a tape recorder to play the nurse's favourite new age music without considering whether the woman can hear the music or whether she finds the music soothing or appealing.
When ethics, aesthetics, personal knowing, and empirics come together as a whole, the purposes of developing knowledge and the actions based on that knowledge become more responsible and humane and create liberating choices. A whole understanding of the woman in the nursing home would take into account the woman's own safety and the needs of other residents; her personal life history and that which gives her pleasure; the ethical dimensions of personal empowerment, moral development, and caring for others; the aesthetic meaning of her actions in the cultural context of aging; and the personal perspective of the nurses who care for her. Many choices remain open in addressing this situation, but all of these considerations together would lead to nursing approaches that would differ from any of the approaches taken from one knowing perspective alone.
 
Reasons for Developing Nursing's Patterns of Knowing
As is shown in Figure 1.1 and our discussion of it, the fundamental reason for developing a body of knowledge in nursing is for the 38purpose of creating expert nursing practice. Nursing's unique perspective and the particular contributions nurses bring to care come from the whole of knowing, a wholeness that has survived despite a cultural and contextual dominance of empiric knowing. In a sense the discipline of nursing can be viewed as the empiric pattern of knowing gone wild in that the majority of formal knowledge development efforts have focused on empiric knowledge development methods. Moreover, knowledge has been equated with empiric forms to the exclusion of any other forms of expression.
The idea that knowledge development is separate from the realities of practice can be seen as deriving from the dominance of empirics. Empiric theory is inadequate to represent the complexity of the practice world, and the methods of science traditionally have considered the uncontrolled and unpredictable contingencies in the practice realm unacceptable for the purposes of developing empiric knowledge. The practice implications of empiric theory are often not direct or immediately obvious, and empiric theory often uses a different language from that used in practice.
A shift to a balance in knowledge development to reflect each of the patterns of knowing in nursing holds potential to bring the realm of knowledge development and the realm of practice together. Methods for developing aesthetic, personal, and ethical knowing compel immersion within the realm of practice. Giving attention to these aspects of knowledge development shifts how empirics itself is viewed; empirics becomes part of a larger whole, and its value takes on different meaning other than empirics, many of the traditions and assumptions that underlie empiric methods are challenged, opening the way for creating empiric methods that better accommodate the contingencies of practice.
Formally expressed nursing knowledge provides professional and disciplinary identity, which in turn conveys to others what nursing contributes to the health care process. Professional identity that evolves from distinct disciplinary knowledge provides a basis from which nurses can create certain aspects of their practice. Nursing practice has traditionally been controlled by others, and what nurses do is often invisible. The knowledge that forms nursing practice provides a language for talking about the nature of nursing practice and for demonstrating its effectiveness. Once nursing practice is described, it is made visible. Moving to a conceptualisation of knowledge that more fully embraces the whole of practice will serve to impart value to what has been intangible. Also, when nursing's effectiveness can be shown, it can be deliberately shaped or controlled by those who practice it.
On an individual level, nursing knowledge can provide self-identity and esteem as a nurse because you will have a firmer base when your ideas are questioned. As you become familiar with the language and processes of knowledge development, you can begin to think about how assumptions, definitions, and relationships within each of the patterns of knowing can be challenged. The study and understanding of knowledge development will provide a basis on which to take risks, to act deliberately, and to improve practice.
Imagine yourself as a nurse who is using massage to ease chronic pain for a hospitalised person. A physician notices that you are using 39this method of care. Because this is an unfamiliar approach to the physician, she asks you about it. You explain your reasoning, which is based on nursing knowledge. You can provide research evidence of the effectiveness of massage and information about the positive results that this particular person is experiencing. You can explain the ethical dimensions of providing relief from suffering, the aesthetic components of meaning in the situation, and what you have learned about the therapeutic use of self in giving a massage. Your explanation leads to an informed discussion about various approaches to caring for people with pain and why your approach seems to be effective for this person. As other practitioners learn of your knowledge in this area, they seek your consultation in caring for people with pain. Your knowledge of empiric pain theory and what is effective in caring for people with pain, as well as your ethical, aesthetic, and personal knowledge, provides a valuable resource for developing and improving practice.
Nursing's formally expressed body of knowledge also provides the discipline with a coherence of purpose. Coherence of professional purpose is closely linked to professional identity. Coherence of purpose contributes to a collective identity when nurses agree on the general practice domain. The processes of developing nursing's body of knowledge serve as a means for resolving significant disagreements among practitioners about what is to be accomplished. Varying points of view concerning the general purpose of nursing are reflected in the following questions:
  • Should nurses address prevention of illness?
  • Should nurses treat human responses to illness?
  • Should educational programs be structured around nursing process?
  • Nursing diagnosis? Patterns of knowing? Critical thinking?
  • Should nurses view health and illness as opposites?
  • Can ill or diseased people also be healthy?
As nurses develop individual and collective responses to these questions, our directions for developing knowledge will be clearer, and in turn our knowledge development efforts will contribute to clarifying responses to questions such as these. Nursing knowledge facilities coherence by examining such questions as a basis for deliberate choices. When nurses examine and agree about professional purposes and develop knowledge related to those purposes, the public and other practitioners will recognize nursing's expertise in relation to that arena. The fact that nurses are responsible for certain situations will be directly and indirectly communicated to society, and professional identity and coherence of purpose will continue to evolve. By shifting to a balance in the development of all the fundamental knowledge patterns, a sense of purpose can develop that is grounded in the whole of knowing that shapes and directs nursing practice.