Theoretical Foundations of Nursing Practice

Components of a Theory

A theory contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon. The theory explains how these elements are uniquely related in the phenomenon (Fig. 4-1). For example, Kristin Swanson developed her theory about the phenomenon of caring by conducting extensive interviews with patients and their professional caregivers (Swanson, 1991). Swanson’s theory of caring defines five components of caring: knowing, being with, doing for, enabling, and maintaining belief (see Chapter 7). These components provide a foundation of knowledge for nurses to direct and deliver caring nursing practices. Researchers test theories, and as a result they get a clearer perspective of all parts of a phenomenon. Swanson’s theory of caring is one that provides a basis for identifying and testing nurse caring behaviors to determine if caring improves patient health outcomes (Watson, 2010).

Types of Theory

The general purpose of a theory is important because it specifies the context and situation in which the theory applies (Chinn and Kramer, 2011). For example, theories about pain focus on pain: its cause, effects, and alleviation measures. Theories have different purposes and are sometimes classified by levels of abstraction (grand theories versus middle-range theories) or the goals of the theory (descriptive or prescriptive). For example, a descriptive theory describes a phenomenon such as grief or caring. A predictive theory identifies conditions or factors that predict a phenomenon. A prescriptive theory details nursing interventions for a specific phenomenon and the expected outcome of the care. Box 4-1 summarizes goals of theoretical nursing models.

Grand theories are systematic and broad in scope, complex, and therefore require further specification through research. A grand theory does not provide guidance for specific nursing interventions; but it provides the structural framework for broad, abstract ideas about nursing. For example, Neuman’s systems model is a grand theory that provides a comprehensive foundation for scientific nursing practice, education, and research (Walker and Avant, 2009).

Middle-range theories are more limited in scope and less abstract. They address a specific phenomenon and reflect practice (administration, clinical, or teaching). A middle-range theory tends to focus on a specific field of nursing, such as uncertainty, incontinence, social support, quality of life, and caring, rather than reflect on a wide variety of nursing care situations (Meleis, 2011). For example, Mishel’s theory of uncertainty in illness (1990; 1997) focuses on patients’ experiences with cancer while living with continual uncertainty. The theory provides a basis to help nurses understand how patients cope with uncertainty and the illness response.

Descriptive theories are the first level of theory development. They describe phenomena, speculate on why they occur, and describe their consequences. These theories explain, relate, and in some situations predict nursing phenomena (Meleis, 2011). For example, theories of growth and development describe the maturation processes of an individual at various ages (see Chapter 11). Descriptive theories do not direct specific nursing activities but help to explain patient assessments.

Prescriptive theories address nursing interventions for a phenomenon, describe the conditions under which the prescription (i.e., nursing interventions) occurs, and predict the consequences (Meleis, 2011). Prescriptive theories are action oriented and test the validity and predictability of a nursing intervention. These theories guide nursing research to develop and test specific nursing interventions (George, 2011). For example, Mishel’s theory of uncertainty predicts that increasing the coping skills of patients with gynecological cancer assists their ability to deal with the uncertainty of the cancer diagnosis and treatment (Mishel, 1997). Thus the theory provides a framework to design interventions that support and strengthen patients’ coping resources.

Theory-Based Nursing Practice

Nursing is a practice-oriented discipline. Nursing knowledge is derived from basic and nursing sciences, experience, aesthetics, nurses’ attitudes, and standards of practice. As nursing continues to grow as a profession, knowledge is needed to prescribe specific interventions to improve patient outcomes. Nursing theories and related concepts continue to evolve. Florence Nightingale spoke with firm conviction about the “nature of nursing as a profession that requires knowledge distinct from medical knowledge” (Nightingale, 1860; Selanders, 2010). The overall goal of nursing knowledge is to explain the practice of nursing as different and distinct from the practice of medicine, psychology, and other health care disciplines. Theory generates nursing knowledge for use in practice, thus supporting evidence-based practice. The integration of theory into practice is the basis for professional nursing (McEwen and Wills, 2011).

The nursing process is used in clinical settings to determine individual patient needs (see Unit 3). Although the nursing process is central to nursing, it is not a theory. It provides a systematic process for the delivery of nursing care, not the knowledge component of the discipline. However, a theory can direct how a nurse uses the nursing process. For example, the theory of caring influences what to assess, how to determine patient needs, how to plan care, how to select individualized nursing interventions, and how to evaluate patient outcomes.

Systems Theory

A system is composed of separate components. The components are interrelated and share a common purpose to form a whole. There are two types of systems, open and closed. An open system such as a human organism or a process such as the nursing process interacts with the environment, exchanging information between the system and the environment. Factors that change the environment also affect an open system. Neuman’s systems theory (2011) defines a total-person model of wholism and an open-systems approach. A closed system such as a chemical reaction within a test tube does not interact with the environment.

Like all systems, the nursing process has a specific purpose or goal (see Unit 3). The goal of the nursing process is to organize and deliver patient-centered care. As a system the nursing process has the following components: input, output, feedback, and content (Fig. 4-2). Input for the nursing process is the data or information that comes from a patient’s assessment (e.g., how the patient interacts with the environment and the patient’s physiological function). Output is the end product of a system; and in the case of the nursing process it is whether the patient’s health status improves, declines, or remains stable as a result of nursing care.

Feedback serves to inform a system about how it functions. For example, in the nursing process the outcomes reflect the patient’s responses to nursing interventions. The outcomes are part of the feedback system to refine the plan of care. Other forms of feedback in the nursing process include responses from family members and consultation from other health care professionals.

The content is the product and information obtained from the system. Again, using the nursing process as an example, the content is the information about the nursing interventions for patients with specific health care problems. For example, patients with impaired bed mobility have common skin care needs and interventions (e.g., hygiene and scheduled positioning changes) that are very successful in reducing the risk for pressure ulcers.

Basic Human Needs

Maslow’s hierarchy of needs is an interdisciplinary theory that is useful for designating priorities of nursing care (see Fig. 6-3, p. 69.) The hierarchy of basic human needs includes five levels of priority. The most basic, or first level, includes physiological needs such as air, water, and food. The second level includes safety and security needs, which involve physical and psychological security. The third level contains love and belonging needs, including friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The final level is the need for self-actualization, the state of fully achieving potential and having the ability to solve problems and cope realistically with situations of life. When using this hierarchy, basic physiological and safety needs are usually the first priority, especially when a patient is severely dependent physically. However, you will encounter situations in which a patient has no emergent physical or safety needs. Instead, you will give high priority to the psychological, sociocultural, developmental, or spiritual needs of the patient.

Patients entering the health care system generally have unmet needs. For example, a person brought to an emergency department experiencing acute pneumonia has an unmet need for oxygen, the most basic physiological need. An older woman in a high-crime area is concerned about physical safety. A widowed homemaker whose children have moved away feels that she does not belong or is not loved. The hierarchy of needs is a way to plan for individualized patient care.

Developmental Theories

Human growth and development are orderly predictive processes that begin with conception and continue through death. A variety of well-tested theoretical models describe and predict behavior and development at various phases of the life continuum. Chapter 11 details these developmental theories, and Chapters 12 through 14 demonstrate changes in growth and development in various age-groups.

Psychosocial Theories

Nursing is a diverse discipline that strives to meet the physiological, psychological, sociocultural, developmental, and spiritual needs of patients. Theoretical models to explain and/or predict patient responses exist in each of these domains. For example, Chapter 9 discusses models for understanding cultural diversity and implementing care to meet the diverse needs of the patient. Chapter 10 describes family theory and how to meet the needs of the family when the family is the patient or when the family is the caregiver. Chapter 36 discusses several models of grieving and demonstrates how to assist patients through loss, death, and grief.

Nightingale’s Theory

Florence Nightingale’s work was an initial model for nursing. Meleis (2011) notes that Nightingale’s concept of the environment was the focus of nursing care and her suggestion that nurses need not know all about the disease process differentiated nursing from medicine. The focus of nursing is caring through the environment and helping the patient deal with the symptoms and changes in function related to an illness (Selanders, 2010).

Nightingale did not view nursing as limited to the administration of medications and treatments but oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition (Nightingale, 1860). Through observation and data collection, she linked the patient’s health status with environmental factors and initiated improved hygiene and sanitary conditions during the Crimean War.

Nightingale’s “descriptive theory” provides nurses with a way to think about patients and their environment. Her letters and writings direct the nurse to act on behalf of the patient. Her visionary principles included the areas of practice, research, and education. Most important, her concepts and principles shaped and defined nursing practice (Alligood and Tomey, 2010). Nightingale taught and used the nursing process, noting that “vital observation [assessment] … is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort (Nightingale, 1860).”

Peplau’s Theory

Hildegard Peplau’s theory (1952) focuses on interpersonal relations between the nurse, the patient, and the patient’s family and developing the nurse-patient relationship. The patient is an individual with a need, and nursing is an interpersonal and therapeutic process. This nurse-patient relationship is influenced by both the nurse’s and the patient’s perceptions and preconceived ideas (George, 2011).

In developing a nurse-patient relationship, the nurse can serve as a resource person, counselor, and surrogate. For example, when the patient seeks help, the nurse and patient first discuss the nature of any problems, and the nurse explains the services available. As the nurse-patient relationship develops, the nurse and patient mutually define the problems and potential solutions. The patient gains from this relationship by using available services to meet needs, and the nurse helps the patient reduce anxiety related to the health care problems.

Peplau’s theory is unique: the collaborative nurse-patient relationship creates a “maturing force” through which interpersonal effectiveness meets the patient’s needs. This theory is useful in establishing effective nurse-patient communication when obtaining a nursing history, providing patient education, or counseling patients and their families (see Chapter 24). When the patient’s original needs are resolved, new needs sometimes emerge. According to Peplau, the following phases characterize the nurse-patient interpersonal relationship: orientation, working phase, and termination (George, 2011).

Henderson’s Theory

Virginia Henderson defines nursing as “assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge” (Harmer and Henderson, 1955; Henderson, 1966). Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the patient: physiological, psychological, sociocultural, spiritual, and developmental. The interpersonal relationship between the nurse and the patient creates a caring environment to identify the patient’s needs, plan the goals of care, and provide patient-centered nursing care (George, 2011). Framing nursing care around the needs of the individual allows you to use Henderson’s theory for a variety of patients across the life span and in multiple settings along the health care continuum.

Orem’s Theory

Dorothea Orem’s self-care deficit theory (2001) focuses on the patient’s self-care needs. Orem defines self-care as a learned, goal-oriented activity directed toward the self in the interest of maintaining life, health, development, and well-being. The goal of Orem’s theory is to help the patient perform self-care and manage his or her health problems. Nursing care is necessary when the patient is unable to fulfill biological, psychological, developmental, or social needs. This theory works well in all steps of the nursing process (George, 2011). The nurse assesses and determines why a patient is unable to meet these needs, identifies goals to assist the patient, intervenes to help the patient perform self-care, and evaluates how much self-care the patient is able to perform. According to Orem’s theory, the goal of nursing is to increase the patient’s ability to independently meet these needs (George, 2011; Orem, 2001).

Leininger’s Theory

Leininger used her background in anthropology to form her theory of cultural care diversity and universality (Alligood, 2010). Human caring varies among cultures in its expressions, processes, and patterns. Social structure factors such as the patient’s religion, politics, culture, and traditions are significant forces affecting care and influencing the patient’s health and illness patterns. While reading the chapter on culture, think about the diversity of the patients and their nursing care needs (see Chapter 9). The major concept of Leininger’s theory is cultural diversity, and the goal of nursing care is to provide the patient with culturally specific nursing care (Alligood, 2010; Leininger, 1991). To provide care to patients of unique cultures, the nurse safely integrates the patient’s cultural traditions, values, and beliefs into the plan of care. Leininger’s theory recognizes the importance of culture and its influence on everything that involves the patient and the providers of nursing care (George, 2011). For example, some cultures believe that the leader in the community needs to be present during health care decisions. As a result, the health care team may need to reschedule when rounds occur to include the community leader. In addition, symptom expression also differs among cultures. A person with an Irish background might be stoic and not complain about pain, whereas a person from a Middle Eastern culture might be very vocal about pain. In both cases the nurse needs to skillfully incorporate the patient’s cultural practices in assessing the patient’s level of pain (e.g., is the pain getting worse or remaining the same?).

Betty Neuman’s Theory

The Neuman systems model is based on stress and the client’s reaction to the stressor (George, 2011). In this model the client is the individual, group, family, or community. The system is composed of five concepts that interact with one another: physiological, psychological, sociocultural, developmental, and spiritual (Neuman, 2011). These concepts interact with both internal and external environmental factors and all levels of prevention (primary, secondary, and tertiary) to achieve optimal wellness (Neuman and Reed, 2007). Neuman considers any internal and external factors as stressors (Alligood, 2010) that affect the patient’s stability and any or all of the five system concepts. The role of nursing is to stabilize the patient or situation. When you apply the Neuman systems model, you assess the stressor and the patient’s response to the stressor, identify nursing diagnoses, plan patient-centered care, implement interventions, evaluate the patient’s response, and determine if the stressor is resolved.

Roy’s Theory

The Roy adaptation model (Roy, 1989; Roy et al., 2009) views the patient as an adaptive system. According to Roy’s model, the goal of nursing is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness (Alligood and Tomey, 2010). The need for nursing care occurs when the patient cannot adapt to internal and external environmental demands. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

The nurse determines which demands are causing problems for a patient and assesses how well the patient is adapting to them. Nurses direct care at helping the patient adapt to the changes (George, 2011; Alligood, 2010). For example, a patient recovering from a worsening of heart failure needs nursing interventions to assist in adapting to the resultant activity in tolerance (Box 4-2).

Watson’s Theory

Jean Watson’s theory of transpersonal caring (2005, 2008) defines the outcome of nursing activity in regard to the humanistic aspects of life (Alligood and Tomey, 2010). The purpose of nursing action is to understand the interrelationship among health, illness, and human behavior. Thus nursing is concerned with promoting and restoring health and preventing illness.

Watson designed the model around the caring process, assisting patients in attaining or maintaining health or dying peacefully (Watson, 2005). This caring process requires the nurse to be knowledgeable about human behavior and human responses to actual or potential health problems (see Chapter 7). The nurse also needs to know individual patient needs, how to respond to others, and strengths and limitations of the patient and family and those of the nurse. In addition, the nurse comforts and offers compassion and empathy to patients and their families. Caring represents all factors the nurse uses to deliver care to the patient (Watson, 1996).

Benner and Wrubel’s Theory

The primacy of caring is a model proposed by Patricia Benner and Judith Wrubel (1989). Caring is central to nursing and creates possibilities for coping, enables possibilities for connecting with and concern for others, and allows for giving and receiving help (Chinn and Kramer, 2011). Caring means that persons, events, projects, and things matter to people. It presents a connection and represents a wide range of involvement (e.g., caring about one’s family, one’s friendships, and one’s patients). Benner and Wrubel see the personal concern as an inherent feature of nursing practice. In caring for one’s patients, nurses help patients recover by noticing interventions that are successful and that guide future caregiving.

• • •

Application of nursing theory in practice depends on nurses having knowledge of the theories and an understanding of how they relate to one another. Theories are the organizing frameworks for the science of nursing and the substantive approaches for nursing care. They provide critical thinking structures to guide clinical reasoning and problem solving.

Relationship Between Nursing Theory and Nursing Research

The relationship between nursing theory and nursing research builds the scientific knowledge base of nursing, which is then applied to practice. As more research is conducted, the discipline learns to what extent a given theory is useful in providing information to improve patient care. The relationships of components in a theory often help drive the research questions. For example, the components within Orem’s self-care deficit theory have led nurse researchers to test interventions for improving self-care. In one study, older hospitalized adults were able to learn their medication schedules and improve their activities of daily living before discharge, were discharged earlier, and had fewer complications (Glasson et al., 2006).

Sometimes research is used to identify new theories. Theory-generating research tries to discover and describe relationships of phenomena without imposing preconceived notions (e.g., hypotheses) of what the phenomena under study mean (George, 2011). In theory-generating research the investigator makes observations to view a phenomenon in a new way. For example, a researcher wants to understand end-of-life decision making. In this example, the researcher interviews surrogate decision makers. From these interviews he or she makes objective observations about the surrogate’s decision-making process, resulting in an initial theory of surrogate decision making (Loomis, 2009).

Theory-testing research determines how accurately a theory describes a nursing phenomenon. Testing helps to develop the evidence for describing or predicting patient outcomes. The researcher has some preconceived idea as to how patients describe or respond to a phenomenon and generates research questions or hypotheses to test the assumptions of the theory. No one study tests all components of a theory; researchers test the theory through a variety of research activities. Referring to the previous example of surrogate decision making, the researcher tests elements of the theory. For example, interviews of decision makers indicated that there was a need for more knowledge about end-of-life care expectations (Loomis, 2009). The researcher then designs and tests an educational program that incorporates end-of-life expectation with one that does not to determine which is most effective for groups of surrogate caregivers. Theory-generating or theory-testing research refines the knowledge base of nursing. As a result, nurses incorporate research-based interventions into theory-based practice. As research activities continue, not only does the knowledge and science of nursing increase, but patients are the recipients of the best evidence-based nursing practice (see Chapter 5).

As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a science, nursing draws on scientifically tested knowledge applied in the practice setting (Kikuchi, Simmons, and Romyn, 1996). But it is the “expert nurse” who transports the art and science of nursing into the scientific realm of creative caring.

• A nursing theory is a conceptualization of some aspect of nursing communicated for the purpose of describing, explaining, predicting, and/or prescribing nursing care.

• Grand theories are the complex structural framework for broad, abstract ideas.

• Middle-range theories are more limited in scope and less abstract. These theories address specific phenomena or concepts and reflect practice.

• The paradigm of nursing identifies four links of interest to the profession: the person, health, environment/situation, and nursing. Nurse theorists agree that these four components are essential to the development of theory.

• Theory is the generation of nursing knowledge used for practice. Nursing process is the method for applying the theory or knowledge. The integration of theory and nursing process is the basis for professional nursing.

• Theories from nursing and other disciplines help explain how the roles and actions of nurses fit together in nursing.

• Theory-generating research tries to discover and describe relationships without imposing preconceived notions (e.g., hypotheses) of what the phenomenon under study means.

• Theory-testing research determines how accurately a theory describes nursing phenomena.

Clinical Application Questions

Review Questions

Alligood, MR. Nursing theory utilization & application, ed 4. St Louis: Mosby; 2010.

Alligood, MR, Tomey, AM. Nursing theorists and their work, ed 7. St Louis: Mosby; 2010.

American Nurses Association. Nursing’s social policy statement: the essence of the profession. Silver Spring, Md: American Nurses Publishing; 2010.

Benner, P, Wrubel, J. The primacy of caring: stress and coping in health and illness. Menlo Park, Calif: Addison-Wesley; 1989.

Benner, P, et al. Educating nurses: a call for radical transformation. Stanford, Calif: Carnegie Foundation for the Advancement of Teaching; 2010.

Chinn, PL, Kramer, MK. Integrated knowledge development in nursing, ed 8. St Louis: Mosby; 2011.

DeSanto-Madeya, S, Fawcett, J. Toward understanding and measuring adaptation level in the context of the Roy adaptation model. Nurs Sci Q. 2009;22(4):355.

Fawcett, J. Contemporary nursing knowledge: analysis and evaluation of conceptual models of nursing, ed 2. Philadelphia: FA Davis; 2005.

George, J. Nursing theories: a base for professional nursing practice, ed 6. Saddle River, NJ: Pearson; 2011.

Harmer, D, Henderson, V. Textbook of the principles and practice of nursing, ed 5. Riverside, NJ: Macmillan; 1955.

Henderson, V. The nature of nursing. New York: Macmillan; 1966.

Kikuchi, JF, Simmons, H, Romyn, D. Truth in nursing inquiry. Thousand Oaks, Calif: Sage Publications; 1996.

King, IM. Toward a theory for nursing. New York: John Wiley & Sons; 1971.

Leininger, M. Transcultural nursing: concepts, theories, and practice. John Wiley & Sons; 1978.

Leininger, MM. Culture care diversity and universality: a theory of nursing, Pub No 15-2402. New York: National League for Nursing Press; 1991.

McEwen, M, Wills, EM. Theoretical basis for nursing, ed 3. Philadelphia: Lippincott Williams & Wilkins; 2011.

Meleis, AI. Theoretical nursing: development and progress, ed 5. Philadelphia: Lippincott Williams & Wilkins; 2011.

Neuman, B, The Betty Neuman health-care systems model: A total person aproach to patient problems. (1974). JP Riehl, C Roy, eds. Conceptual models for nursing practice, ed 2, Norwalk, CT: Appleton-Century-Crofts, 1974.

Neuman, BM. The Neuman systems model, ed 5. Norwalk, Conn: Pearson, Prentice Hall.; 2011.

Neuman, BM, Reed, KS. A Neuman systems model perspective on nursing in 2050. Nurs Sci Q. 2007;20:111.

Nightingale, F. Notes on nursing: what it is and what it is not. London: Harrison & Sons; 1860.

Orem, DE. Nursing: concepts of practice. New York: McGraw-Hill; 1971.

Orem, DE. Nursing: concepts of practice, ed 6. New York: McGraw-Hill; 2001.

Peplau, HE. Interpersonal relations in nursing. New York: GP Putnam’s Sons; 1952.

Porter, S. Fundamentals patterns of knowing in nursing: the challenge of evidenced-based practice. Adv Nurs Sci. 2010;33(1):3.

Roy, C. Adaptation: A conceptual framework for nursing. Nurs Outlook. 1970;18:42.

Roy, C. Relating nursing theory to nursing education: A new era. Nurse Educator. 1979;4:16.

Roy, C. The Roy adaptation model. In Riehl JP, Roy C, eds.: Conceptual models for nursing practice, ed 3, New York: Appleton-Century-Crofts, 1989.

Roy, R, et al. The Roy adaptation model and research. Nurs Sci Q. 2009;21:209.

Selanders, LC. The power of environmental adaptation: Florence Nightingale’s original theory for nursing practice. J Holistic Nurs. 2010;28(1):81.

Walker, LO, Avant, KC. Strategies for theory construction in nursing, ed 5. Upper Saddle River, NJ: Prentice Hall; 2009.

Watson, J. Nursing: the philosophy and science of caring. Boston: Little, Brown; 1979.

Watson, J. Watson’s theory of transpersonal care, In Walker PH, Neuman B: Blueprint for use of nursing models: education, research, practice, and administration, Pub NO 14-2696. New York: National League of Nursing Press; 1996.

Watson, J. Caring science as sacred science. Philadelphia: FA Davis; 2005.

Watson, J. The philosophy and science of caring. Boulder: University Press of Colorado; 2008.

Watson, J. Caring science and the next decade of holistic healing: transforming self and system from the inside out. Am Holistic Nurses Assoc. 2010;30(2):14.

Bakan, G, Akyol, AD. Theory-guided interventions for adaptation to heart failure. J Adv Nurs. 2008;61(6):596.

Glasson, J, et al. Evaluation of a model of nursing care for older patients using participatory action research in an acute medical ward. J Clin Nurs. 2006;15(5):588.

Loomis, B. End-of-life issues: difficult decisions and dealing with grief. Nurs Clin North Am. 2009;44:223.

Mishel, MH. Reconceptualization of the uncertainty in illness theory. Image J Nurs Sch. 1990;22(4):256.

Mishel, MH. Uncertainty in acute care. Annu Rev Nurs Res. 1997;15:57.

Sumner, J. A critical lens on the instrumentation of caring in nursing research. Adv Nurs Sci. 2010;33(1):E17.

Swanson, KM. Empirical development of a middle-range theory of caring. Nurs Res. 1991;40(3):161.

Veo, P. Concept mapping for applying theory to nursing practice. J Nurses Staff Dev. 2010;26(1):22.