Martha Raile Alligood
“The art of nursing is the creative use of the science of nursing for human betterment.”
(Rogers, 1990, p. 5)
As presented in Chapter 1, development of the body of specialized knowledge required for nursing to be recognized as a profession was a driving force in the 20th century. Because of the importance of nurses to the nation’s health, studies of nursing were legislated early in the century and conducted by sociologists who recommended that nursing be developed as a profession. The criteria for a profession provided guidance in this process (Bixler & Bixler, 1959; Kalisch & Kalisch, 2003). The criterion that called for specialized nursing knowledge and knowledge structure was a particularly important driving force in the recognition of nursing as a profession (Bixler & Bixler, 1959). The criterion reads: “Utilizes in its practice a well-defined and well-organized body of specialized knowledge [that] is on the intellectual level of the higher learning” (p. 1143).
This chapter presents the structure and analysis of specialized nursing knowledge to explain the organization of the text. Specifically, the structure of knowledge that was used to organize the units of the text and the definitions of the analysis criteria used for the review process of the theoretical works in each chapter.
The theoretical works presented in Chapters 6–36 are nursing frameworks that have been organized into types. Box 5.1 lists the theorists who have been selected for each type. The identification of selected works within each of the types is arbitrary at best. Effort has been made to reflect the level of abstraction for each type or preference of the theorist. Types of knowledge, levels, and examples of each within the structure are illustrated in Table 5.1 and discussed in the following text.
TABLE 5.1
| Structure Level | Examples |
| Metaparadigm | Human beings, environment, health, and nursing |
| Philosophy | Nightingale’s philosophy |
| Conceptual models | Neuman’s systems model |
| Grand theory | Neuman’s optimal client stability |
| Theory | Flexible line of defense moderate optimal client stability |
| Middle-range theory | Maintaining optimal client stability with structured activity (body recall) in a community setting for healthy aging |
Modified from Alligood, M. R. (2014). Nursing theory: Utilization & application (5th ed.). St Louis: Mosby; Fawcett, J., & DeSanto Madeya, S. (2013). Contemporary nursing knowledge: Conceptual models of nursing and nursing theories (3rd ed.). Philadelphia: F. A. Davis.
The first type is the metaparadigm level that includes the broad conceptual boundaries of nursing knowledge, human beings, health, nursing, and environment (Fawcett, 1984, 2000; Fawcett & DeSanto-Madeya, 2013).
The next type is nursing philosophy. Philosophy is an abstract type that sets forth the meaning of nursing phenomena through analysis, reasoning, and logical presentation. Early works that predate the nursing theory era, such as Nightingale (1969/1859), contributed to knowledge development by providing direction or a basis for subsequent developments. Later works reflect contemporary science methods and approaches (Alligood, 2014b; Chinn & Kramer, 2015; Meleis, 2012). Selected works for the classification of nursing philosophies are presented in Unit II, Chapters 6–11.
The next type, nursing conceptual models, comprises nursing works by theorists referred to by some as pioneers in nursing (Chinn & Kramer, 2015; Meleis, 2012). Conceptual models are a set of concepts that address phenomena central to nursing in propositions that explain relationships among them (Fawcett & DeSanto-Madeya, 2013). The nursing models are comprehensive, and each addresses the metaparadigm concepts of person, environment, health, and nursing (Fawcett, 1984, 2000; Fawcett & DeSanto-Madeya, 2013). The nursing conceptual models have explicit theories derived from them by theorists or other nurse scholars and implicit theories within them yet to be developed (Alligood, 2014a; Wood, 2014). Works classified as nursing models are discussed in Unit III, Chapters 12–18. Theorists who developed nursing conceptual models often proposed a grand theory from their model.
The grand theory level derives from the conceptual model and proposes an abstract testable theory. These theories have the capacity to threaten the solvency of the conceptual model from which they are derived, because they test the major premise of the conceptual model. Examples of this level of grand theory are Roy’s theory of the person as an adaptive system, King’s theory of goal attainment, and Neuman’s theory of optimal client stability (Alligood, 2014b). Interestingly, each of these grand theories has been and continues to be supported.
The nursing theory type comprises works derived from nursing philosophies, conceptual models, grand theories, abstract nursing theories, or works in other disciplines (Alligood, 2014b; Wood, 2014). A work classified as a nursing theory is developed from some conceptual framework or grand theory and is generally not as specific as a middle-range theory. Although some use the terms model and theory interchangeably, theories propose a testable action (Alligood 2014a, 2014b; Wood, 2014). An example of a grand theory derived from a nursing model is in Roy’s work (see Chapter 17) in which she derives the person as an adaptive system from her adaptation model. The abstract level of the grand theory in this example facilitates derivation of theories and middle-range theories specific to nursing practice from it (Alligood 2014a, 2014b). Theories may be specific to a particular aspect or setting of nursing practice. Another example is Meleis’s transition theory (see Chapter 20), which is specific to changes in a person’s life process in health and illness. Nursing theories are presented in Unit IV, Chapters 19–26.
The last type, middle-range theory, has the most specific focus and is concrete in its level of abstraction (Alligood 2014a, 2014b; Chinn & Kramer, 2015; Fawcett & DeSanto-Madeya, 2013). Middle-range theories propose precise testable nursing practice questions. They address the specifics of nursing situations within the perspective of the model, grand theory, or theory from which they originate (Alligood, 2014a, 2014b; Fawcett & DeSanto-Madeya, 2013; Wood, 2014). The specifics in middle-range theories are such things as the age group of the patient; the family situation; the patient’s health condition; the location of the patient; and, most important, the action of the nurse (Alligood, 2014b; Wood, 2014). There are many examples of middle-range theories in the nursing literature that have been developed inductively as well as deductively. Selected middle-range theories are presented in Unit V, Chapters 27–36.
The second aspect of this introduction to Chapters 6–36 and Units II–V is analysis of theory, an essential systematic process of critical reflection that is a vital aspect of review of theoretical works (Chinn & Kramer, 2015). Criteria for analysis of the works of theorists are presented, along with a brief discussion of how each criterion contributes to a deeper understanding of the work (Chinn & Kramer, 2015).
Analysis, critique, and evaluation are methods used to study nursing theoretical works critically. Analysis of theory is carried out to acquire knowledge of theoretical adequacy. It is an important process and the first step in applying nursing theoretical works to education, research, administration, or practice. The analysis criteria used for each theoretical work in this text are included in Box 5.2 with the questions that guide the critical reflection of analysis.
The analysis process is useful for learning about the works and is essential for nurse scientists who intend to test, expand, or extend the works. When nurse scientists consider their research interests in the context of one of the theoretical works, areas for further development are discovered through the processes of critique, analysis, and critical reflection. Therefore analysis is an important process for learning, for developing research projects, and for expanding the science associated with the theoretical works of nursing in the future. Understanding a theoretical framework is vital to applying it in practice.
Clarity and structure are reviewed in terms of semantic clarity and consistency and structural clarity and consistency. Clarity speaks to the meaning of terms used, and definitional consistency and structure speak to the consistent structural form of terms in the theory. Analysis begins as the major concepts and subconcepts and their definitions are identified. Words have multiple meanings within and across disciplines; therefore a word should be defined specifically according to the framework (philosophy, conceptual model, theory, or middle-range theory) within which it is used. Clarity and consistency are facilitated with diagrams and examples. The logical development and type of structure used should be clear, and assumptions should be stated clearly and be consistent with the goal of the theory (Chinn & Kramer, 2015).
Simplicity is highly valued in nursing theory development. Chinn and Kramer (2015) discuss degrees of simplicity and call for simple forms of theory, such as middle range, to guide practice. Complex practice situations may call for more complex theory. A theory should be sufficiently comprehensive, presented at a level of abstraction to provide guidance, and have as few concepts as possible with as simplistic relations as possible to aid clarity.
The generality of a theory speaks to the scope of application and the purpose within the theory (Chinn & Kramer, 2015). The generality of a theoretical work varies by how abstract or concrete it is (Fawcett & DeSanto-Madeya, 2013). Understanding the levels of abstraction by doctoral students and nurse scientists has facilitated the use of abstract frameworks and the development of middle-range theories. Rogers’ (1986) theory of accelerating change is an example of an abstract theory from which numerous middle-range theories have been generated.
“Accessible addresses the extent to which empiric indicators for the concepts can be identified and to what extent the purposes of the theory can be attained” (Chinn & Kramer, 2015, p. 205).
Accessibility is vital to developing nursing research to test a theory. Accessibility facilitates testing, because the empirical indicators provide linkage to practice for testability and ultimate use of a theory to describe and test aspects of practice (Chinn & Kramer, 2015).
A parallel can be drawn between outcome and importance. Chinn and Kramer (2015) say the central question is, “Does this theory create understanding that is important to nursing?” (p. 207). Because research, theory, and practice are closely related, nursing theory lends itself to research testing, and research testing leads itself to knowledge for practice. Nursing theory guides research and practice, generates new ideas, and differentiates the focus of nursing from other service professions (Chinn & Kramer, 2015).
The five criteria for the analysis of theory—clarity, simplicity, generality, accessibility, and importance—guide the critical reflection of each theoretical work discussed in Chapters 6–36. These broad criteria facilitate the analysis of theoretical works, whether they are applied to works at the level of philosophies, conceptual models, grand theories, theories, or middle-range theories. Box 5.3 describes the content provided in each chapter of Units II–V.
Finally, the content headings in the theorist chapters (6–36) are the same in each chapter to facilitate uniformity for review and comparison of the theorists and their works. A list of the chapter content headings is presented in Box 5.4.