The Structure of Contemporary Nursing Knowledge · The Structure of Contemporary Nursing Knowledge This chapter lays the groundwork for the remain-der of the book. Here, a structural

The Structure of Contemporary NursingKnowledge

This chapter lays the groundwork for the remain-der of the book. Here, a structural hierarchy of con-temporary nursing knowledge is identified anddescribed. Each component of the structure-metaparadigm, philosophies, conceptual models,theories, and empirical indicators-is defined and itsfunctions are delineated. Then the distinctions be-tween the components are discussed, with spe-cial emphass placed on the differences betweenconceptual models and theories and the need toview and use those two knowledge components ind i f f e r e n t w a y s .

OVERVIEW AND KEY TERMS

The structural hierarchy differentiates the variouscomponents of contemporary nursing knowledge ac-cording to their level of abstraction. The compo-nents of the structural hierarchy are listed here.Each component is defined and described in detailin this chapter.

STRUCTURAL HIERARCHY OF CONTEMPORARYNURSING KNOWLEDGE

CONCEPTPROPOSITION

Nonrelational PropositionRelational Proposition

METAPARADIGMRequirements for a Metaparadigm

METAPARADIGM OF NURSINGPHILOSOPHYPHILOSOPHIES OF NURSING

Reaction World ViewReciprocal Interaction World ViewSimultaneous Action World ViewCategories of Nursing Knowledge

CONCEPTUAL MODELCONCEPTUAL MODELS OF NURSING

THEORYGrand TheoryMiddle-Range Theory

NURSING THEORIESEMPIRICAL INDICATORS

STRUCTURAL HIERARCHY OFCONTEMPORARY NURSING KNOWLEDGE

An analysis of the terminology used to describecontemporary nursing knowledge led to the identifi-cation of five components: metaparadigm, rhi!oso-phies, conceptual models, theories, and empirical itidicators (Fawcett, 1993a; King & Fawcett, 1997). TheSTRUCTURAL HIERARCHY OF CONTEMPORARYNURSING KNOWLEDGE is a heuristic device thatplaces those five components into a hierarchy basedon level of abstraction. The hierarchy is depicted inFigure l-l.

The components of the structural hierarchy aremade up of concepts and propositions. A CONCEPTis a word or phrase that summarizes the essentialcharacteristics or properties of a phenomenon. APROPOSITION is a statement about a concept or astatement of the relation between two or more con-cepts. A Nonrelational Proposition is a descriptionor definition of a concept. A nonrelational propo-sition that states the meaning of a concept is calleda constitutive definition. A nonrelational proposi-tion that states how a concept is observed or mea-sured is called an operational definition. A Rela-tional Proposition asserts the relation, or linkage,between two or more concepts.

Metaparadigm

The first component of the STRUCTURAL HIER-ARCHY OF CONTEMPORARY NURSING KNOWL-

3

COMPC NENTS

Metapn adigm

LEVEL OF ABSTRACTION

Most Abstract

- Philosophies,.. n

Conceptual Models,,. n

Theories,,,,,

D G E is the METAPARADIGM (Figure l-l). A

a?taparadigm is defined a s

he global concepts that identi fy the phenom-

ena of central interest to a discipline, theglobal propositions that describe the concepts,and the global propositions that state the re-lat ions between the concepts.

The metaparadigm is the most abstract componentf the structural hierarchy of contemporary nurs-,g knowledge, and acts as “an encapsulating unit,r framework, within which the more re-

tricted structures develop” (Eckberg & Hill,979, p. 927). The concepts and propositions of aletaparadigm are admittedly extremely global androvide no definitive direction for such activitiess research and clinical practice. That is to be ex-acted because the metaparadigm “is the broadestJnsensus within a discipline. It provides the gen-ral parameters of the field and gives scientists aroad orientation from which to work” (Hardy, 1978,. 38).Functions of a Metaparadigm

The functions of a metaparadigm arc? to summarizeme intellectual and social missions of a disciplinertd place a boundary on the subject matter of thatiscipline (Kim, 1989). Those functions are re-

ectcd in certain Requirements for a Metaparadigm.

4

The four requirements, which pertain to the meta-paradigm of any discipline, are listed in Table l-l.

-TABLE 111 Requirements for a Metaparadigm

1. The metaparadigm must idenfify a domain that is dis-

tinctive from the domains of other disciplines. That

requirement is fulfilled only when the concepts and

propositions represent a unique perspective for inquiry

and practice.

2. The metaparadigm must encompass all phenomena

of interest to the discipline in a parsimonious mar,-

ner. That requirement is fulfilled only if the concepts

and propositions are global and if there are no redun-

dancies in concepts or propositions.

3. The metaparadigm must be perspective-neutra/. That

requirement is fulfilled only if the concepts and propo-

sitions do not represent a specific perspective, that is, a

specific paradigm or conceptual model, or a combina-

tion of perspectives.

4. The metaparadigm must be international in scope and

substance. That requirement, which is a corollary of

the third requirement, is fulfilled only if the concepts

and propositions do not reflect particular national, cul-

tural, or ethnic beliefs and values.

(From Fawcett, 1992, 1996.)

Part 1 Structure and Use of Nursing Knowledge

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Chapter

Metaparadigm of Nursing

The METAPARADIGM OF NURSING is made up offour concepts, four nonrelat ional proposit ions,

and four relat ional proposit ions. The concepts and

proposit ions of the metaparadigm of nursing are

described in Table 1-2.

The nonrelat ional proposit ions of the metapara-

Qm of nursing are consti tut ive definit ions of the

metaparadigm concepts. The relat ional proposit ions

of the metaparadigm of nursing, which were drawn

f r om work by Dona ldson and Crowley (1978 ) and

G o r t n e r (19801, assert the l inkages between meta-

paradigm concepts. Relat ional proposit ion 1 l inks

the concepts person and health. Relat ional proposi-

t ion 2 l inks the concepts person and environment.

Relational proposition 3 links the concepts health

and nursing. Relational proposition 4 links the con-

cepts person, environment, and health.

The version of the metaparadigm of nursing pre-

sented here represents an extension and elaboration

of the original metaparadigm of nursing published

many years ago (Fawcett , 198413). One difference

is the addition of a constitutive definition for each

rnetaparadigm concept. Another difference between

the earlier and current versions is the formaliza-

tm of themes into proposit ions. St i l l another differ-

PIICE! is the addit ion of the fourth proposit ion. Con-

tlnued ref inement in the consti tut ive definit ions of

the metaparadigm concepts has resulted in the cur-

rent reference to the person as a part icipant in

nursing, rather than a recipient of nursing. That

change was made to better reflect the contemporary

emphasis on the person as an active participant in

the nursing process, rather than a passive recipi-

ent of pronouncements by and ministrat ions from

nurses. Continued ref inement also has resulted in an

expansion of the constitutive Cefinition for them e t a p a r a d i g m c o n c e p t environ1 lent. That change

was made to better reflect the rr,ultitude of environ-

mental conditions that are relevant in nursing(Kleffel, 1991).

The current version of the metaparadigm meets thefour requirements for a metaparadigm listed in Tablel - l . In part icular, the four metaparadigm concepts-

person, environment, health, nursing-generally areregarded as the central or domain concepts of nurs-

ing (Flaskerud & Halloran, 1980; Jennings, 1987;Wagner, 1986). They are a modification of four con-

cppts induced from the conceptual frameworks

1, I. .^ .

‘[ TAB,,LE, i - 2 The Met&&ad& of Nursing:2.,’ Concepts, Nonreiationai Propositions,

:’ and Relational Propositions

Concepts

Person

Environment

Health

Nursing

Nonrelational Propositions

1. The metaparadigm concept person refers to the indi-

viduals, families, communities, and other groups who

are participants in nursing.

2. The metaparadigm concept environment refers to the

person’s significant others and physical surroundings,

as well as to the setting in which nursing occurs,

which ranges from the person’s home to clinical agen-

cies to society as a whole. The metaparadigm concept

environment also refers to all the local, regional, na-

tional, and worldwide cultural, social, political, and

economic conditions that are associated with the per-

son’s health.

3. The metaparadigm concept health refers to the person’s

state of well-being at the time that nursing occurs,

which can range from high-level wellness to terminal

illness.

4. The metaparadigm concept nursing refers to the defini-

tion of nursing, the actions taken by nurses on behalf of

or in conjunction with the person, and the goals or

outcomes of nursing actions. Nursing actions typically

are viewed as a systematic process of assessment,

labeling, planning, intervention, and evaluation.

Relational Propositions

1. The discipline of nursing is concerned with the prin-

ciples and laws that govern the life-process, well-

being, and optimal functioning of human beings, sick

or well.

2. The discipline of nursing is concerned with the pattern-

ing of human behavior in interaction with the environ-

ment in normal life events and critical life situations.

3. The discipline of nursing is concerned with the nursing

actions or processes by which positive changes in

health status are effected.

4. The discipline of nursing is concerned with the

wholeness or health of human beings, tecogniri~w thatthey are in continuous interaction with their environ-

ments.

Chapter 1 The Structure of Contemporary Nursing Knowledge 5

of baccalaureate programs accredlt>d by thevational League for Nursing. The orIginal conceptswere man, society, health, and nursirlg (Yura &Torres, 1975). The term man was changed to person:a avoid gender-specific language, and the termsociety was changed to environment to more fullyencompass phenomena of relevance to the per-$on (Fawcett, 19781. Additional support for the cen-trality of the four metaparadigm concepts comesfrom the successful use of those concepts as aschema fnr analysis of the content of conceptualmodels of nursing and nursing theories (Fawcett,1993a, 1995; Fitzpatrick & Whall, 1996; George, 1995;Marriner Tomey & Alligood, 1998).

etaparadigm of dental hygiene. More specifically,

health/oral health, and dental hygiene ac-

The relational propositions of the metaparadigm5 xe Table l-2) provide a unique perspective of the:(#I cepts that helps distinguish nursing from other-lisl.iplines. Relational propositions 1, 2, and 3 repre-;rJnt recurrent themes identified in the writings of:Icrence Nightingale and many other nursing schol-mrs and clinicians of the nineteenth and twentieth!enturies. Donaldson and Crowley (1978) com-nented that “these themes suggest boundaries ofn area for systematic [ilnquiry and theory develop-nent with potential for making the nature of theliscipline of nursing more explicit than it is at pres-knt” (p. 113). Relational proposition 4, accordingo Donaldson and Crowley (19781, “evolveldl fromhe practical aim of optimizing of human envi-onments for health” (p. 119).

:T&en together, the four concepts, the four nonrela-onai propositions, and the four relational propo-kions identify the unique focus of the discipline ofursing and encompass all relevant phenomena in aBrsimonious manner. Furthermore the conceptsnd propositions are perspective-neutral because<ey do not reflect a specific paradigm or conceptual~adel. Moreover, the metaparadigm concepts andWtjositions do not reflect the beliefs and valuesf nurses from any one country or culture and,i&forp, are international in scope and substance.

/

6

Proposals for Alternative MetaparadigmConcepts and Propositions

The version of the nursing metaparadigm pre-sented her; should not be regarded as prematureclosure on explication of phenomena of interest tothe discipline of nursing. Indeed, it is anticipatedthat modifications in the metaparadigm conceptsand propositions will continue to be offered as thediscipline of nursing evolves. Modifications must,however, fulfill the four requirements for a meta-paradigm (see Table l-l). The alternative versions ofthe metapa’radigm of nursing are presented in Ta-ble l-3, along with discussion about and critique ofeach proposal. None of those proposals meets allfour requirements for a metaparadigm.

Philosophies

The second component of the STRUCTURAL HIER-ARCHY OF CONTEMPORARY NURSING KNOWL-EDGE is the PHILOSOPHY (see Fig. I-l). A philoso-phy may be defined as

a statement encompassing ontological claimsabout the phenomena of central interest to adiscipline, epistemic claims about howthose phenomena come to be known, and ethi-cal claims about what the members of a disci-pline value.

Function of a Philosophy

The function of a philosophy is to communicatewhat the members of a discipline believe to be truein relation to the phenomena of interest to thatdiscipline, what they believe about the developmentof knowledge about those phenomena, and whatthey value with regard to their actions and practices(Kim, 1989; Salsberry, 1994; Seaver & Cartwright,1977). In other words, the function of each philoso-phy is to inform the members of disciplines andthe general public about the beliefs and values of aparticular discipline.

Philosophies of Nursing

PHILOSOPHIES OF NURSING encompass ontologi-cal and epistemic claims about the phenomena ofinterest to the discipline of nursing and ethicalclaims about nursing actions, nursing practices, andthe character of individuals who choose to practicenursing (Salsberry, 1994). The ontological claimsin philosophies of nursing state what is believedabout the nature of the person, the environment,

(Text continued on p. 70)


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i TABLE 1-3 Propos& for Alternafive'Vekioni _‘ "of the Meteparadigm of Nursing: PDiscussion end Critique ,’

The Newman Proposal

Replace the concept person with the concept client.

N~wrnan (1983) proposed that the term client replace the

term petson in the metaparadigm.

i Critique

: The term client reflects a particular view of the person and,

! therefore, is not a perspective-neutral concept. Therefore,

the suggested modification does not fulfill the third re-

‘; quirement for a metaparadigm (see Table l-l).

’ The Conway Proposal

‘,’ Eliminate the concept nursing from the metaparadigm.

1: ’ Discussion

i

Conway (1985, 1989) claimed that the term nursing repre-

.sents the discipline or the profession and is not an appro-

1priate me&paradigm concept because it creates a tautol-

ogy. Meleis (1997). apparently in agreement with Conway,

commented, “It would be an instance of tautological

conceptualizing to define nursing by all the concepts and

then include nursing as one of the concepts” (p. 106).

Crifiqrie

Kolcaha and Kolcaba (1991) rejected the charge of a tautol-

ogy. They noted that inasmuch as the metaparadigm con-

cept nursing stands for nursing activities or actions, a

tautology is not created. Furthermore, other scholars

view nursing as a distinct phenomenon of interest to the

discipline. Kim (1987) identified nursing as a component of

IWO domains of nursing knowledge. She regarded nurs-

. ing as the central feature of the practice domain and as an

:’ essential component of the client-nurse domain. In addi-

‘ion, Barnum (1998) identified nursing acts as a common-

place, that is, a topic addressed by most nursing theo-

WS. Finally, King (1984) found that nursing was a central

concept in the philosophies of nursing education of several

lursing education programs. That finding suggests that

‘_ !he concept nursing is a discipline-wide phenomenon and,

Mefore, must be included in the metaparadigm.

Conway (1985) did not offer a substitute metaparadigm

concept to represent the actions ar activities of nurses,

‘. Consequently, her proposal to eliminate nursing from the

1’ lnelaparadigm does not encompass all phenomena of

.i’ it,ter?st to the discipline of nursing. Moreover, Conway

offered no justification for the uniqueness of a discipline

dealing with the person, environment, and health. Her pro-

posal, therefore, does not fulfill the first and second re-

quirements for a metaparadigm (see Table l-l).

The Kim Proposal

Exclude the concept health from the metaparadigm.

Discussion

Kim (1987, 1997) identified four domains of nursing knowl-

edge. The client domain is concerned with the client’s de-

velopment, problems, and health care experiences. The

client-nurse domain focuses on encounters between client

and nurse and the interactions between the two in the

process of providing nursing care. The practice domain

emphasizes the cognitive, behavioral, and social aspects

of nurses’ professional actions. The environment domain

takes in the time, space, and quality variations of the

client’s environment. Hinshaw (1987) pointed out that

Kim’s work does not include the concept health, and asked,

“Is health a strand that permeates each of the do-

mains rather than a major separate domain?” (p. 112).

Kim (personal communication, October 31, 1986) indi-

cated that the client domain could encompass health.

Critique

Kim’s failure to explicitly identify health as a distinct

domain or a component of one or more other domains cre-

ates a void in an otherwise informative explication of the

discipline of nursing. Thus, her proposal does not fulfill the

second requirement for a metaparadigm (see Table l-l).

The Meleis Proposal

The central concepts of nursing are nursing client, transi-

tions, interaction, nursing process, environment, nursing

therapeutics, and health.

Discussion

Meleis (1997) maintained that “the nurse interacts (inter-

action) with a human being in a health/illness situation

(nursing client) who is in an integral part of his sociocul-

turat context (environment) and who is in some sort of

transition or is anticipating a transition (transition): the

nurse/patient interactions are organized around some pur-

pose (nursing process, problem solving, holistic assess-

ment, or caring actions) and the nurse uses some actions

(nursing therapeutics) to enhance, bring about, or facilitate

health (health)” (p. 106). Meleis and Trangenstein (1994)

and Schumacher and Meleis (1994) highlighted the impor-

tance and centrality of the concept transitions. In particu-

lar, Meleis and Trangenstein (1994) maintained that “the

Structure of Canter qporary Nursing Knowledge

,)’) 1!lrABLE l-3 Proposals ‘for Alternati~a%&kqL‘I:!. of the Metaparadigm of Nursing: I:;j; Discussion and Critique (Continued) I

‘ransition experience of clients, families, communities,

nurses, and organizations, with health and well-being as a

goal and an outcome, meets the criteria . . of an or-

ganizing concept that allows for a variety of viewpoints

and theoties within the discipline of nursing, . [is] not

culture hound, and should help in identifying the focus

of thr discipline” (p. 255).

Crftirlrir

Thp inclI!sinn of nursing process, nursing therapeutics, and

intrractions in Meleis’s proposal represents a redundancy

that can be avoided by use of the single concept, nurs-

ing Moreover, the inclusion of transitions reflects a par-

ticular perspective of human life. Indeed, Meleis and

Trangpnstein (1994) referred to their discussion of transi-

tions as a “conceptual framework” (p. 258). Thus, Meleis’s

proposal for the central concepts of nursing, although

meritorious, does not meet the second and third require-

ments for a metaparadigm (see Tab’- l-l).

The King Proposal

The domain of nursing is represented by the concepts

man, health, role, and social systems.

DiSCUSSiO/,

King’s (1984) review of the philosophies of a representative

sample of National League for Nursing accredited nursing

education programs in the United States revealed nine

concepts: man, health, environment, social systems, role,

perceptions, interpersonal relations, nursing, and God.

King found that all nine concepts were not evident in the

philosophies of all the schools included in the sample. She

recommended that the most frequently cited concepts

cror~lti represent the domain of nursing. Those concepts

a,re: man, health, role, and social systems.

Ckitiqoe

King’s proposal falls short of meeting all requirements for

a metaparadigm. First, the inclusion of role and social

systems reflects a sociological orientation to nursing. Sec-

&d, the elimination of environment and nursing results

in a narrow view of the domain. Moreover, the elimination

of environment and nursing leaves a list of concepts more

.‘osely aligned with the discipline of social work (Ben-

‘i .n, 1987) than with nursing. Thus, her proposal does not

i’leet the first, second, and third requirements for a

~letaparatligrn (see Table l-l).

8

The Newman, Sime, and Corcoran-Perry Proposal

Nursing is the study of caring in the human health expe-

r i e n c e . .

Discussion

Newman, Sime, and Corcoran-Perry (1991) claimed that the

focus of the discipline of nursing is summarized in the fol-

lowing statement: “Nursing is the study of caring in the

human health experience” (p. 3). In a later publication,

they asserted that “the theme of caring is sufficiently dom-

inant, when combined with the theme of the human health

experience, to be considered as the focus of the disci-

pline” (Newman, Sime, & Corcoran-Perry, 1992, p. vii).

Critique

Despite Newman and colleagues’ (1992) claims to the con-

trary, their proposition represents just one frame of refer-

ence for nursing and for health. In fact, Newman and her

colleagues (1991) ended their initial treatise by maintaining

that caring in the human health experience can be most

fully elaborated only through a unitary-transformative per-

spective. Moreover, although Newman et al. (1991) of-

fered their proposition as a single statement that integrates

“concepts commonly identified with nursing at the meta-

paradigm level” (p. 31, and although they identified the

metaparadigm concepts as person, environment, health,

and nursing, their proposition does not include environ-

ment. In an attempt to clarify their position, Newman,

Sime, and Corcoran-Perry (1992) later stated, “we view the

concept of environment as inherent in and inseparable

from the integrated focus of caring in the human health ex-

perience” (p. vii). Despite that clarification, their proposal

does not meet the second and third requirements for a

metaparadigm because it is neither sufficiently comprehen-

sive nor perspective-neutral (see Table l-l).

The Malloch, Martinez, Nelson, Predeger, Speakman,

Steinbinder, and Tracy Proposal

Nursing is the study and practice of caring within contexts

of the human health experience.

Discussion

Malloch, Martinez, Nelson, Predeger, Speakman. Stein-

binder, and Tracy (1992) suggested a revision of the New-

man, Sime, and Corcoran-Perry (1991) statement. Their

focus statement is as follows: “Nursing is the study and

practice of caring within contexts of the human health ex-

perience” (p. vi). Malloch and her colleagues (1992)

maintained that their statement extends the focus of the

discipline to nursing practice and incorporates the environ-


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ment by the use of the term contexts. They noted that en-

,vironment “includes, but is not limited to, culture, com-

munity. and ecology” (p. vi). Moreover, they claimed that

a :the use of the term caring brings unity to the metapara-

’ digm concepts of person, environment, health, and nurs-

inn. Apparently, they do not regard caring as a particu-

Jar perspective of nursing.

Although the Malloch et al. proposal is sufficiently compre-

iiensive, it does not meet the third requirement for a

metaparadigm because it is not perspective-neutral (see

jTable l-1).

‘The Parse Proposal

The core focus of nursing is the human-universe-health

’ process.

; ~Discussion

Parse (1997) asserted that “the core focus of nursing, the

metaparadigm, is the human-universe-health process”

(p. 74). She went on to explain that the “hyphens between

the words create a unitary construct incarnating the notion

that the study of nursing is the science of the human-

universe-health process. Consequently, all nursing knowl-

edge is in some way concerned with this phenomenon”

‘p 74).

Parse’s proposal has merit in that her use of the term uni-

VPTSI? extends the environment far beyond the immediate

surrntlndings of the person and setting in which nursing

occurs. However, her proposal does not explicitly name

nrlrsing as a concept of the metaparadigm. That omission

is problematic in that many disciplines could be inter-

ested in hllmans, the universe, and health. Furthermore,

the meaning Parse ascribed to the hyphens used reflects a

‘particular perspective of the named phenomenon. That

is, humans. the universe, and health must be viewed as

’ unitary. Consequently, her proposal does not meet the first

and third requirements for a metapartligm (see Table 1-l).

The Leininger/Watson Proposal

Eliminate the four metaparadigm concepts (see Table l-2)

snd substitute the concepts human care, health, and en-

vironmental cultural context.

Eliminate the four metaparadigm concepts and the four

relational propositions (see Table l-2) and substitute the

concepts human care, environmental cantexts, and

well being (health) and a proposition asserting the central-

ity of caring to the discipline of nursing.

Discussion

Leininger (1995) asserted that “with transcultural nurse

knowledge and consumer demands, many nurses are rec-

ognizing that human care, health, and environmental

cultural context must become the central focus, essence,

and dominant domains of nursing knowledge to re-

place the;Eastern’ four concept metaparadigm” (p. 97). In

setting the stage for her proposal, Leininger (1995) charged

that “a small group of ‘Eastern’ USA nurse researchers .

declared in nursing publications that nursing’s major foci

or ‘metaparadigm’ for the discipline . would be health,

nursing, person, and environment. It was quite clear to me

that these nurses blatantly failed to recognize [that] hu-

man care, caring, and cultural factors were important phe-

nomena of nursing. It appeared to me and other care

scholars that this small elite group were lobbying against

the rapidly growing interest in care and transcultural nurs-

ing” (p. 96). In another publication, Leininger (1990)

claimed that “human care/caring [is] the central phenome-

non and essence of nursing” (p. 19). and Watson (1990)

maintained that “human caring needs to be explicitly incor-

porated into nursing’s metaparadigm” (p. 21). Even more

to the point, Leininger (1991a) maintained that: “care is the

essence of nursing and the central, dominant, and unify-

ing focus of nursing” (p. 35). On the basis of that position,

Leininger (1988) rejected the metaparadigm concepts of

person and nursing. She commented, “[II reject the idea

that nursing and person explain nursing, for one cannot

explain nor predict the same phenomenon one is studying.

Nursing is the phenomenon to be explained. Moreover,

person, per se, is not sufficient to explain nursing as it fails

to account for groups, families, social institutions, and

cultures” (p. 154). Leininger (1991c) went on to assert that

“the concepts of person and nursing are quite inappro-

priate. Person is far too limited and nursing cannot be logi-

cally used to explain and predict nursing. The latter is a

redundancy and a contradiction to explain the same phe-

nomenon being studied by the same concept” (p. 152).

In another publication, Leininger (1991a) continued to re-

ject the metaparadigm concept of person, and she ap-

parently rejected environment and health as well. She

stated, “From an anthropological and nursing perspective,

the use of the term person has serious problems when

used transculturally, as many non-Western cultures do not

focus on or believe in the concept person, and often there

is no linguistic term for person in a culture, family and

institutions being more prominent. While environment is

very important to nursing, I would contend it is cer-

tainly not unique to nursing, and there are very few nurses

who have advanced formal study and are prepared to

(Continued)

Chapter 1 The Structure of Contemporary Nursing Knowledge 9

&ABLE 1-3 Proposals for Altekat~$‘kit$ionst. of the Metaparadigm of lb-sing:’

r4. n;i Lliscussion a n d Ctit~qutr (Contimmdl _ _ 1

study a large number of different types of environments or

ecological niches worldwide. [The metaparadigml con-

cepts had serious problems except for that of health.

Again, as a concept health is not distinct to nursing al-

tholrgh nursing plays a major role in health attainment and

maintenance-many disciplines have studied health” (pp.

3 9 40).

Critique

In her tliscttssions, Leininger failed to acknowledge that an

entlier discussion of the metaparadigm concept person

intlicntpd that that concept can refer to any entity that is

a participant in nursing actions, including individuals, fami-

lips, anri nther types of groups, communities, and soci-

eties (Fnwcett, 1984a). Furthermore, Leininger (1991a, 1995)

d~tl not acknowledge that the point of the inclusion of the

ro~~-cpt environment in the metaparadigm is to provide

a context for the person, to indicate that participants in

nlrrsing actions are surrounded by and interact with other

people and the social structure (Fawcett, 1984a). Indeed,

she neither acknowledged her own statement that “care

shorild he central to [the] nursing metaparadigm and sup-

ported by the concepts of health and environmental con-

texts” (Leininger, 1988, p. 154). nor ler statement that

“in the very near future, one can pre:iict that the current

concepts of person, environment, ho tlth, and nursing will

no longer be upheld. Instead, human care, environmen-

tal contexts, and well-being (or health) will become of ma-

jor interest to most nurse researchers and new theorists”

(Leininger, 1991b, p. 406). Moreover, Leininger did not

acknowledge that the inclusion of the concept nursing in

the metaparadigm was not to create a tautology, but rather

to serve as a single-word symbol of all nursing actions

and activities taken on behalf of or in conjunction with the

person, family, community, or other entity (Fawcett, 1984a).

In addition, both Leininger and Watson failed to acknowl-

edge that although the term caring is included in sev-

eral conceptualizations of the discipline of nursing (Morse,

Solberg, Neander, Bottorff. & Johnson, 19901, it is not a

dominant theme in every conceptualization and, therefore,

does not represent a discipline-wide viewpoint (Wilson,

1994). Indeed, caring reflects a particular view of nursing

and a particular kind of nursing (Eriksson, 19891. Further-

rnnrn, RR Swanson (1991) pointed out, althnwgh there maybe “characteristic behavior patterns that are universal

expressions of nurse caring . caring is not uniquely a

nursing phenomenon” (p. 165). Caring behaviors, more-

10

over, may not be generalizable across national and cultural

boundaries (Mandelbaum, 1991). And, as Rogers (1992)

asserted, “as such, caring does not identify nurses any

more than it identifies workers from another field. Every-

one needs to care” (p. 33). Rogers (1994b) went on to say,

“I don’t think nurses care any more than anybody else,

or that it’s a characteristic any more peculiar to nursing

than to any other field. [But caring1 does differ among dif-

ferent groups. It is the body of knowledge about the

phenomenon of concern that determines the nature of the

caring that one is going to demonstrate” (p. 34). Elabo-

rating, Rogers (1994a) added, “Caring is doing, it is prac-

tice. Caring is a way of using knowledge” (p. 7). Viewed

from a different vantage point, Roper (1994) commented,

“I consider that ‘care’ is implicit in ‘nursing’ and there-

fore ‘nursing care’ is a tautology” (p. 460). In addition,

Leininger’s (1995) charge regarding lobbying against her

ideas by a small, elite group of “Eastern” nurses has no

basis-none of the discussions of the metaparadigm con-

cepts as person, environment, health, and nursing have in-

cluded negative comments about caring or transcultural

nursing: the only point has been that caring is not unique

to nursing. Leininger’s discussions about the metapara-

digm, then, tend to be contradictory, and she fails to ac-

knowledge that her ideas could be readily incorporated

into the widely cited metaparadigm concepts person, envi-

ronment, health, and nursing. More specifically, person

already refers to collectives as well as to individuals, envi-

ronment already is viewed as context, health already refers

to a broad spectrum of states that includes well-being, and

nursing can be viewed as directed toward human care.

Clearly, then, the Leininger/Watson proposal does not meet

the first, third, and fourth requirements for a metapara-

digm (see Table l-1).

(Text cbntinued from p. 6)

health, and nursing. The epistemic claims in philospphies of nursing provide “some information on howone may come to learn about the world [and] abouthow the basic phenomena can be known” (Sals-berry, 1994, p. 13). Epistemic claims in nursing ex-tend the ontological claims by directing how knowl-edge about the person, the environment, health,and nursing is developed.

Ontological and epistemic claims in philosophiesof nursing reflect one or more of three contrastingworld views: the Reaction World View, the Recipro-


tz1

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raction World View, and the SimultaneousWorld View. Those three world views

ed from an analysis of four existing sets ofviews: mechanism and organicism (Ackoff,

’ Reese & Overton. 1970); change and persis-(Hall, 1981, 1983; Thomae, 1979; Wells &

tyker, 1988); totality and simultaneity (Parse,and particulate-deterministic, interactive-

ative, and unitary-transformative (Newman,The different world views lead to different

eptualizations of the metaparadigm concepts,rent statements about the nature of the rela-between those metaparadigm concepts (Alt-

a@ & Rogoff, 1987), and different ways to generatedtest knowledge about the concepts and theirnnections. The features of each world view areTmarized in Table l-4.

’ TABLE 1-4 Features of the Reaction World View.the Reciprocal InteractionWorld View, and fhe.‘

1 Simultaneous Action World view

Reaction World View

Contains elements of the mechanistic, persistence, totality,

and particulate-deterministic world views.

Humans are bio-psycho-social-spiritual beings. The meta-

phor is the compartmentalized human being, who is

viewed as the sum of discrete biological, psychological,

sociological, and spiritual parts.

Human beings react to external environmental stimuli in

a linear, causal manner. The person is regarded as inher-

ently at rest, responding in a reactive manner to exter-

nal environmental stimuli. Behavior is considered a linear

chain of causes and effects, or stimuli and reactions.

*tological claims in philosophies of nursing also!I: ?t one or more broad Categories of Knowledgerrnd in adjunctive disciplines and in nursing..+gories of knowledge from adjunctive disciplinese developmental, systems, and interaction

hnson, 1974; Reilly, 1975; Riehl & Roy, 1980).egories of knowledge mentioned in the nursing

erature are needs and outcomes (Meleis, 1997);

ient focused, person-environment focused, andrsing therapeutics focused (Meleis, 1997); energyIds (Hickman, 1995; Marriner-Tomey, 1989); and

tervention, substitut ion, conservation, sustenance/

Ipport, a n d e n h a n c e m e n t ( B a r n u m , 1 9 9 8 ) .

Change occurs only for survival and as a consequence of

predictable and controllable antecedent conditions. Change

occurs only when the person must modify behaviors to

survive. Consequently, stability is valued. Threats to stabil-

ity are, however, predictable and controllable if enough is

known about the stimuli that would force a change.

Only objective phenomena that can be isolated, ob-

served, defined, and measured are stt/died. Knowledge is

developed only about objective, quantifiable phenom-

ena that can be isolated and observed, defined in a con-

crete manner, and measured by objective instruments.

Reciprocal Interaction World View

various categories of knowledge are “different

es of approaches to understanding the per-who is a patient, [so that they1 not only call forring forms of pract ice toward dif ferent objec-

, but also point to different kinds of phenom-

suggest different kinds of questions, and leadtually to dissimilar bodies of knc, vledge” (John-1974, p. 376). Each category, then, emphasizesrent phenomena and leads to dif feront ques-

s about the nurse-patient situation. Conse-

h category fosters development of a dif-of knowledge about the person, the

ent, health, and nursing. The characteris-

h category of knowledge are summar ized

A synthesis of elements from the organismic, simulta-

neity, totality, change, persistence, and interactive-

integrative world views.

Human beings are holistic; parts are viewed only in the

context of the whole. The metaphor is the holistic, interact-

ing human being, who is viewed as an integrated, orga-

nized entity not reducible to discrete parts. Although parts

are acknowledged, they have meaning only within the

context of the whole person.

Human beings are active, and interactions between hu-

man beings and their environments are reciprocaL The

person is regarded as inherently and spontaneously active.

The person and the environment interact in a reciprocal

manner.

cal claims in phi losophies of nursing ad-

values “that guide the nurse’s relation-patients/clients, . . . the character of the

ntering and remaining in the f ield of

(Text continued on p. 151

Change is a function of multiple antecedent factors, is

probabilistic, and may be continuous or may be only for

survival. Changes in behavior occur throughout life as the

result of multiple factors within the individual and within

the environmerit. At times, changes are continuous. At

other times, persistence or stability reigns and change

(Continued1

1 T h e S t r u c t u r e o f C o n t e m p o r a r y N u r s i n g K n o w l e d g e

Simultaneous Action World view ‘.(Continued) b’

II 1occurs only to foster survival. The probability of change at

any given time can only be estimated.

Realrfy is multidimensional, context-dependent, and rela-

tive. Both objective and subjective phenomena are stud-

ied through quantitative and qualitative methods of

inquiry: emphasis is placed on empirical observations,

methodological controls, and inferential data analytic tech-

niques. Knowledge development focuses on both objec-

tive phenomena and subjective experiences and is accom-

plished hy means of both quantitative and qualitative

methodologies. Multiple dimensions of experience are

taken into account, the context of the person-environment

interaction is considered, and the product of knowledge

development efforts is regarded as relative to historical

time and place. Emphasis always is placed on empirical

observations within methodologically controlled situations,

and quantitative data typically are analyzed objectively by

means of descriptive and inferential statistics.

S mtrltaneous Action World View

ombillas elements of the organismic, simultaneity,

ilange, and unitary-transformative world views.

Unitary human beings are identified by pattern. The met-

@OI is the unitary human being, who is regarded as a

.iolistic, self-organized field. The human being is more than

snd different from the sum of parts and is recognized

.hrocrglr oatterns of behavior.

HU,JJ~?IJ hcings are in mutual rhythmical interchange with

‘heir environments. The person-environment interchange

s a n~titr~al. rhythmical process.

Nurr~ar~ heirqs change continuously, unpredictably,

?nd in the direction of more complex self-organization.

Changes in patterns of behavior occur continuously, uni-

:lirectinnally, and unpredictably as the human being

?vnlves. Although the patterns are sometimes organized

and sometimes disorganized, change ultimately is in the

Jirectinn of increasing organization of behavioral patterns.

The phenomena of interest are personal knowledge and

Tattern recognition. Knowledge develo, ment empha-

;tzes personal becoming through recognition of patterns.

The phenomena of interest are, thereforc , the person’s

ryer experiences, feelings, values, thoughts, and

,hoices.

from Fawcratt, 1993b.)

12

.TABtE i-5 Characteristics of ’ ’ ”Categories of Knowledge

Developmental Category of Knowledge

Origin is the discipline of psychology.

Emphasizes identification of actual and potential develop-

mental problems and delineation of intervention strate-

gies that foster maximum growth and development of peo-

ple and their environments.

Growth, Development, and Maturation

Emphasis is placed on processes of growth, development,

and maturation.

Change

Change is the major focus, with the assumption made

“that there are noticeable differences between the states of

a system at different times, that the succession of these

states implies the system is heading somewhere, and that

there are orderly processes that explain how the system

gets from its present state to wherever it is going” (Chin,

1980, p. 30).

Direction of Change

Changes are directional-the individuals, groups, situa-

tions, and events of interest are headed in some direction.

The direction of change is: “(a) some goal or end state

(developed, mature), (b) the process of becoming (develop-

ing, maturing), or (c) the degree of achievement toward

some goal or end state (increased development, increase

in maturity)” (Chin, 1980, p. 31).

Identifiable State

Different states of the person are seen over time. Those

states frequently are termed stages, levels, phases, or peri.

ods of development; they may be quantitatively or quali-

tatively differentiated from one another. Shifts in state may

be either small, nondiscernible steps that eventually are

recognized as change, or sudden, cataclysmic changes

(Chin, 1980).

Form of Progression

Developmental change is possible through four different

forms of progression: (I) unidirectional development

may be postulated, such that “once a stage is worked

through, the client system shows continued progression

and normally never turns back;” (2) developmental change

rnay take the form of a spiral, so that although return to

a previous problem may occur, the problem is dealt with at

a higher level; (3) development may be seen as “phases

(Continued!


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grol

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(b) i

facts

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Peop

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System

“A set

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1968, 1

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“maintc

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fl closet

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continue

entropy

more ciii

Conversl

move to!

Chapter 1

whirh occlur and recur. where no chronological priority

is assigned to each state; there are cycles;” or (4) devel-

opment may take the form of “a branching out into differ-

entiated forms and processes, each part increasing in its

specialization and at the same time acquiring its own

8utonorny and significance” (Chin, 1980, pp. 31-32).

Forces are “causal factors producing de\.elopment and

growth” (Chin. 1980, p. 32), and may be diewed as (a) a

nattlral component of the person undergoing change,

(b) a coping response to new situations and environmental

factors that leads to growth and development, or (c) in-

ternal tensions within the person that at some time reach a

peak and cause a disruption that leads to further growth

and development.

ioten,ia/ity

People have the inherent potential for change; potentiality

may be overt or latent, triggered by internal states or

certain environmental conditions.

Systems Category of Knowledge

Origins are the disciplines of biology and physics.

Emphasizes identification of actual and potential prob-

lems in the function of systems and delineation of inter-

vention strategies that maximize efficient and effective sys-

tem operation; change is of secondary importance.

Systen,

“A set of objects together with relationships between the

lbjects and between their attributes” (Hall & Fagen,

,168, p. 83).

Megration of Parfs

Phenomena are treated “as if there existed organization,

interaction, interdependency, and integration of parts and

elements” (Chin, 1980, p. 24).

Lfw7 and Closed Systems

Systems are viewed as open or closed. An open system

Plalntains itself in a continuous inflow and outflow, a

building up and breaking down of components,” [whereas

4 closed system is] “considered to be isolated from [its]

environment” (van Bertalanffy, 1968, p. 39). Open systems

continuously import energy in a process called negative

entropy or negentropy, so that the system may become

More differentiated, more complex, and more ordered.

Conversely, closed systems exhibit entropy, such that they

%JVP toward increasing disorder. All living organisms are

Chapter 1 The Structure of Contempt rary Nursing Knol

open systems (van Bertalanffy, 1968). Although closed sys-

terns therefore do not,exist in nature, it sometimes is

convenient to view a system as if it had no interaction with

its environment (Chin, 1980). The artificiality of that view,

however, must be taken into account.

Environment

“The set of all objects a change in whose attributes affects

the system and also those objects whose attributes are

changed by the behavior of the system” (Hall & Fagen,

1968, p. 83).

. Boundary

The line of demarcation between a system and its environ-

ment, “the line forming a closed circle around selected

variables, where there is less interchange of energy

across the line of the circle than within the delimiting cir-

cle” (Chin, 1980, p. 24). The placement of the boundary

must take a’ll relevant system parts into account. Bound-

aries may be thought of as more or less permeable. The

greater the boundary permeability, the greater the inter-

change of energy between the system and its environment.

Tension, Stress, Strain, Conflict

The forces that alter system structure. The differences in

system parts, as well as the need to adjust to outside

disturbances, lead to different amounts of tension within

the system (Chin, 1980). Internal tensions arising from the

system’s structural arrangements are called the stresses

and strains of the system (Chin, 1980). Conflict occurs

when tensions accumulate and become opposed along the

lines of two or more components of the system. Change

then occurs to resolve the conflict.

Equilibrium and Steady State

Systems are assumed to tend to move toward a balance

between internal and external forces. “When the balance

is thought of as a fixed point or level, it is called ‘equi-

librium.’ ‘Steady state,’ on the other hand, is the term

used to describe the balanced relationship of parts that

is not dependent upon any fixed equilibrium point or

level” (Chin, 1980, p. 25). Steady state, which also is re-

ferred to as a dynamic equilibrium, is characteristic of liv-

ing open systems and is maintained by a continuous

flow of energy within the system and between the system

and its environment (van Bertalanffy, 1968).

Feedback

The flow of energy between a system and its environment.

Systems “are affected by and in turn affect the environ-

(Continued)

!dge

’ TABLE 1-5 Characteristics of . * ICefeguries of Knowledge (Continued)

ment. While affecting the environment, a process we call

o11i~)t11, systems gather information about how they are

doinct Stlch information is then fed back into the system

as ilrl>ut to gllide and steer its operations” (Chin, 1980,

p. 77). Tll~ feedback process works so that as open sys-

tems illferact with their environments, any change in the

systc’tn is associated with a change in the environment,

a11(1 vice versa.

Interaction Category of Knowledge

Origin is symbolic interactionism from the discipline of

sociology. Symbolic interactionism views human beings

“as creatures who define and classify situations, including

themselves. and who choose ways of acting toward and

within them” (Benoliel, 1977, p, 1 l?‘. and “postulates

that the importance of social life lies (7 providing the

[persnn] with language, self-concept, tale-taking ability,

and other skills” (Heiss, 1976, p. 467).

Emphnsi7es identification of actual and potential prob-

lenls in interpersonal relationships and delineation of inter-

vention strategies that promote optimal socialization.

Social Acts and Relationships

Emphasis is on social acts and relationships between

people.

The person’s perceptions of other people, the environment,

situations, and events-that is, the awareness and experi-

enc‘e of phenomena-depend on meanings attached to

those phenomena. The meanings, or definitions of the situ-

ation, determine how the person behaves in a given situa-

tion. People actively set goals on the basis of their per-

ceptions of the relevant factors in a given situation, which

are derived from social interactions with others.

:$ommunication is through language, “a system of signifi-

cant symbols” (Heiss, 1981, p. 5). Communication, there-

fore, involves the transfer of arbitrary meanings of

.hings from one person to another. People are thought to

actively evaluate communication from others, rather

than passively accept their ideas.

No/f?

“PrpscripGnns for hehavior which are associated with par-

ticrllnr R(:I~I nther c o m b i n a t i o n s t h e w a y s w e t h i n k

pc<~[~lr, r.! J particular kind ought to act toward various cat-

14

egories of others” (Heiss, 1981, p. 65). Each person has

many different roles, each one providing a behavioral rep-

ertoire. People adopt the behaviors associated with a

given role, when, through communication, they determine

that a given role is called for in a particular situation,

Self-Concept

“The individual’s thoughts and feelings about him[her]self’

(Heiss, 1981, p. 83). An important aspect of self-concept

is self-evaluation, which refers to “our view of how good

we are at what we think we are” (Heiss, 1981, p. 83).

Other Categories of Knowledge

Needs

Focuses on nurses’ functions and consideration of the

patient in terms of a hierarchy of needs. When patients

cannot fulfill their own needs, nursing is required. The

function of the nurse is to provide the necessary action to

help patients meet their needs. The human being is re-

duced to a set of needs, and nursing is reduced to a set

of functions. Nurses are portrayed as the final decision

makers for nursing practice (Meleis, 1997).

Outcomes

Emphasis is placed on the outcomes of nursing practice

and comprehensive descriptions of the recipient of that

practice (Meleis, 1997).

Client-Focused

Refers to a comprehensive focus on the client as viewed

from a nursing perspective (Meleis, 1997).

Person-Environment Focused

Emphasis is placed on the relationship between clients and

their environments (Meleis, 1997).

Nursing Therapeutics

Emphasis is placed on what nurses should do and under

(

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strong

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nursirqwhat circumstances they should act (Meleis, 1997).

Energy Fields

8 practice

I nursing

: philosolIncorporates the concept of energy (Marriner-Tomey, 19891 i phasize:

and focuses on persons as energy fields in constant inter-

action with their environment or the universe (Hickman,

1995).

intervention1 Ihe respf

I “simply I

Emphasizes the nurse’s professional actions and decisions/ eration 0

and regards the patient as an object of nursing rather / practice,than a participant in nursing. Agency, or action, rests with ! omy, va]l

Part 1 Structure and Use of Nursing Knowledgd Chapter 1

the nurse, who makes the practice decisions and manipu-

lates selected patient or environmental variables to bring

about change (Barnum, 1998).

Conservation

Fmphasires preservation of beneficial aspects of the pa-

! MS situation that are threatened by illness or actual or

1” tential problems. Agency rests with the nurse, but he or

yhe acts IO conserve the existing capabilities of the pa-

rent (Barnum, 1998).

f&uses on provision of substitutes for patient capabilities

that cannot be enacted or have been lost. Agency rests

with the patient, in that the patient exercises his or her

will and physical control to the greatest possible extent.

krsing acts as a substitute for the patient’s will or intent

when fhe patient is incapacitated (Barnum, 1998).

Focuses on helping the patient endure insults to health and

supporting the patient while building psychological and

physiological coping mechanisms. Required nursing is

detarmined by the extent to which the patient can or can-

not cope without assistance in a particular situation

,Batnum, 1998).

lnhancemenf

‘Wing is regarded as a way to improve the quality of the

:atient’s existence following a health insult. Nursing en-

&es the patient to emerge from a health insult somehow

ilronger, better, or improved because he or she experi-

%ed or overcame the health insult (Barnum, 1998).

!t *

i! j\; :

!&It continued from p. 11)

rsing Iandl the values that regulate nursingrpctice” (Salsberry, 1994, p. 18). Ethical claims in

are summarized in the dominant collectiveUosophy of humanism (Gortner, 1990), which em-

sizes “humanistic (moral) values of caring andepromotion of individual welfare and rights” (Fry,$1, p. 5). Ethical claims in nursing also articulate&es about “the treatment of others,” including:&respect that should be accorded human beings

ply for what they are,” values about consid-n of human dignity when engaging in nursingce. values about caring, values about auton-

,q, values about the rights of people to health

The propqsitions of a conceptual model also are soabstract and general that they are not amenable todirect empirical observation or test. Nonrelationalpropositions found in conceptual models are generaldescriptions or constitutive definitions of the con-ceptual model concepts. Because conceptual modelconcepts are so abstract, their constitutive defini-tions typically are broad. Adaptation level, for exam-ple, is defined as “a changing point influenced bythe demands of the situation and the internal re-sources [of the human adaptive system, including]capabilities, hopes, dreams, aspirations, motivations,and all that makes humans constantly move towardmastery” (Roy 81 Andrews, 1999, p. 33). Moreover,because the concepts are so abstract, nonrelational

$@er 1 The Structure of Contemporary Nursing Knowledge 15

care, and values about beneficence (Salsberry, 1994,pp. 13-14).

Conceptial Models

The third component of the STRUCTURAL HIERAR-CHY OF CONTEMPORARY NURSING KNOWL-EDGE is the CONCEPTUAL MODEL (see Fig. l-l). A

conceptual model is defined as

a set of relatively abstract and general con-cepts that address the phenomena of centralinterest to a discipline, the propositions thatbroadly describe those concepts, and thepropositions that state relatively abstract andgeneral relations between two or more ofthe concepts.

The term conceptual model is synonymous withthe terms conceptual framework, conceptual system,paradigm, and disciplinary matrix. Conceptualmodels have existed since people began to thinkabout themselves and their surroundings. They nowexist in all areas of life and in all disciplines. In-deed, everything that a person sees, hears, reads,and experiences is filtered through the cognitivelens of some conceptual frame of reference(Kalideen, 1993; Lachman, 1993).

The concepts of a conceptual model are so ab-stract and general that they are not directly ob-served in the real world, nor are they limited to anyparticular individual, group, situation, or event.Human adaptive system is an example of a concep-tual model concept (Roy & Andrews, 1999). It can re-fer to several types of human systems, includingindividuals, families, groups, communities, and en-tire societies.

propositions that are operational definitions, that is,propositions that state how the concepts are em-pirically observed or measured, are not found inconceptual models, nor should they be expected.

,The relational propositions of a conceptualmodel state the relations between conceptual modelconcepts in a relatively abstract and general man-ner. They are exemplified by the followingstatement: “Adaptation level affects the human‘adaptive1 system’s ability to respond positively in a2 ituation” (Roy & Andrews, 1999, p. 36).

Conceptual models evolve from the empiricalobservations and intuitive insights of scholars orfrom deductions that creatively combine ideas fromseveral fields of inquiry. A conceptual model is in-ductively developed when generalizations aboutspecific observations are formulated and is deduc-tively developed when specific situations are seenas examples of other more general events. Forexample, much of the content of the Self-CareFramework was induced from Orem’s observationsof “the constant elements and relationships of nurs-ing practice situations” (Orem & Taylor, 1986, p. 38).In contrast, Levine (1969) indicated that she de-duced the Conservation Model from “ideas from allareas of knowledge that contribute to the devel-opment of the nursing process” (p. viii).

Functions of a Conceptual Model

A conceptual model provides a ct stinctive frame ofreference-“a horizon of expectatio:ls” (Popper,1965, p. 47)--and “a coherent, internally unified wayof thinking about.. . events and processes” (Frank,1968, p. 45) for its adherents that tells them howto ohserve and interpret the phenomena of interestto the discipline. Each conceptual model, then,presents a unique focus that has a profound influ-ence on individuals’ perceptions. The unique fo-cus of each conceptual model is an approximationor simplification of reality that includes only thoseconcepts that the model author considers rele-vant and as aids to understanding (Lippitt, 1973;Reilly, 1975). Thus certain aspects of the phenomenaof in?erest to a discipline are regarded as particu-larly relevant, and other aspects are ignored. For ex-ample, Neuman’s (1995) Systems Model focuses onpreventing a deleterious reaction to stressors,wh.+rcas Orem’s (1995) Self-Care Framework empha-sizes enhancing the person’s self-care capabilitiesand actions. Note that Neuman’s conceptual model

’ 16

does not deal with self-care, and Orem’s does notfocus on reactions to stressors.

Each conceptual model also provides a structureand a rationale for the scholarly and practical activi-ties of its adherents, who comprise a subculture orcommunity of scholars within a discipline (Eck-berg & Hill, 1979). More specifically, each conceptualmodel gives direction to the search for relevantquestions about the phenomena of central interestto a discipline and suggests solutions to practicalproblems. Each one also provides general criteriafor knowing when a problem has been solved.Those features of a conceptual model are illustratedin the following example. The Roy Adaptation Modelfocuses on adaptation of the person to environ-mental stimuli and proposes that management ofthe most relevant stimuli leads to adaptation (Roy &Andrews, 1999). Here, a relevant question mightbe, What are the most relevant stimuli in a given sit-uation? Anyone interested in solutions to adapta-tion problems would focus on the various ways ofmanaging stimuli, and one would be led to look formanifestations of adaptation when seeking to de-termine if the problem has been solved.

Conceptual Mode/s of Nursing

Conceptual models are not new to nursing; theyhave existed since Nightingale (1859/1946) first ad-vanced her ideas about nursing. Most early concep-tualizations of nursing, however, were not pre-sented in the formal manner of models. It remainedfor the Nursing Development Conference Group(1973, 19791, Johnson (19741, Riehl and Roy (1974,1980), and Reilly (1975) to explicitly label variousperspectives of nursing as conceptual models.

Peterson (1977) and Hall (1979) linked the prolifer&tion of formal conceptual models of nursing with in-terest in conceptualizing nursing as a distinct disci-pline and the concomitant introduction of ideasabout nursing theory. Meleis (1997) reached thesame conclusion in her historiography of nursingknowledge development. Readers who are espe-cially interested in the progression of nursing knowledge are referred to Meleis’s (1997) excellent work,because a comprehensive historic review is be-yond the scope of this book.

The works of several nursa scholars currently are

recognized as conceptual models. Among the bestknown are Johnson’s Behavioral System Model,

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Part 1 Structure and Use of Nursing Knowledge ChaPter 1 :

ag’s General Systems Framework, Ll?vine’s Con-rvation Model, Neuman’s Systems Model, Orem’s:lf-Care Framework, Rogers’ Science of Unitaryrman Beings, and Roy’s Adaptation Model (John-R, 1980, 1990; King, 1971, 1981, 1990; Levine,69, 1991; Neuman, 1995; Neuman & Young, 1972;‘em, 1971, 1995; Rogers, 1970, 1990; Roy, 1976;ry & Andrews, 1999). Those conceptual models ofI$ng are discussed in Chapters 4 through 10 ofis ‘book.;:he development of conceptual models of nursingd labeling them as such was an important ad-acr for the discipline. Reilly’s (1975) commentsIi1 underscore this point:

.we all have a private image (concept) of nurs-@g practice. In turn, this private image influ-;”$r)ces our interpretation of data, our decisions,‘atd our actions. But can a discipline continue‘)baevelop when its members hold so many

4@ering private images? The proponents ofkkt(uceptual models of practice are seeking tosake us aware of these private images, so thatx ‘e can begin to identify commonalities in ournsrrcebtions of the nature of practice andmove toward the evolution of a well-orderedc,oncept. (p. 567)I,.$nson (1987) also pointed out that nurses al-~ys use some frame of reference for their activitiesd explained the drawbacks of implicit frameworks:

It is important to note that some kind of im-plicit framework is used by every practicingnurse, for we cannot observe, see, or describe,nor can we prescribe anything for which wedo not already have some kind of mental im-age or concept. Unfortunately, the mentalimages used by nurses in their practice, im-&es developed through education and experi-enca and continuously governed by the mul-&de of factors in the practice setting, havererrded to be disconnected, diffused, incom-pteze and frequently heavily weighted by con-c#Xs drawn from the conceptual sc;lema&ad by medicine to achieve its own social+sion. (p. 195)

tfsimilar vein, Bradshaw (1995) stated:

,$th the modern academic nursing approacht&Y the old-fashioned practical trainingrtursing approach presume some kind of Icon-“ytual model1 about the needs of patients and: r

clients and how nurses can best provide forthese needs. The difference may be that formodern nursing such Ia conceptual model] isself-consciously explicit, while for nursestrained in the traditional manner [the concep-tual model] was implicit; it was the hidden mu-tually accepted but taken for granted under-standing that underpinned the fabric of care.(p. 82)

Elaborating, Kalideen (1993) stated:

Whatever you may think, we all use models toguide our actions, be it the way we conductour personal lives or the way we nurse. Theseare based on the beliefs and values of fam-ily, friends, peers, and those we respect orthose who have influenced us greatly. One ofthe problems of each of us using an individualmodel of practice is that it is difficult for oth-ers to understand how we think, and whywe do what we do. Since none of us care forpatients in isolation, it is important that othersfour peers, ward colleagues, medical staff)can understand us. (p. 4)

Conceptual models of nursing, then, are the ex-plicit and formal presentations of some nurses’ im-plicit, private images of nursing. Explicit concep-tual models of nursing “provide [explicit] philosoph-ical and pragmatic orientations to the service nursesprovide patients-a service which only nurses canprovide-a service which provides a dimension tototal care different from that provided by any otherhealth professional” (Johnson, 1987, p. 195). Explicitconceptual models of nursing provide explicit ori-entations not only for nurses but also for otherhealth professionals and the general public. Theyidentify the purpose and scope of nursing and pro-vide frameworks for objective records of the ef-fects of nursing. Johnson (1987) explained that ex-plicit conceptual models “specify for nurses and so-ciety the mission and boundaries of the profes-sion. They clarify the realm of nursing responsibilityand accountability, and they allow the practitionerand/or the profession to document services and out-comes” (pp. 196-197). Moreover, use of an explicitconceptual model helps achieve consistency in nurs-ing practice by facilitating communication amongnurses, reduces conflict among nurses who mighthave different implicit goals for practice, andprovides a systematic approach to nursing research,education, administration, and practice.

b 1 The Structure of Contemporary Nursing KnowledgeIf ‘

:: : T h e o r i e s

,

iThe fourth component of the STRUCTURAL HIER-

ARCHY OF CONTEMPORARY NIJ’ISING KNOWL-EDGE is the THEORY (see Fig. I-1). A theory is de-fined as

one or more relatively concrete and specificconcepts that are derived from a conceptualmodel, the propositions that narrowly describethose concepts, and the propositions that staterelatively concrete and specific relations be-tween two or more of the concepts.

:.fi I j Grand Theory and Middle-Range Theory

:: I.Theories vary in their level of abstraction andi *scope. The more abstract and broader type of theory’ is referred to as a Grand Theory. The more con-

crete and narrower type of theory is referred to as aMiddle-Range Theory.

Grand theories are broad in scope. They are madeup of concepts and propositions that are less ab-stract and general than the concepts and proposi-tions of a conceptual model but are not as concreteand specific as the concepts and propositions of amiddle-range theory. Consciousness is an exam-ple of a grand theory concept (Newman, 1994). Anexample of a grand theory nonrelational propositionis as follows: Consciousness is the informationalcapacity of the human system and encompasses in-terconnected cognitive (thinking) and affective(feeling) awareness, physiochemical maintenance in-cluding the nervous and endocrine systems, growthprocesses, the immune system, and the geneticcode (Newman, 1994). An example of a grand the-ory relational proposition, which links the con-cepts consciousness and pattern, is as follows: “Theevolving pattern of person-environment can beviewed as a process of expanding consciousness”(Newman, 1994, p. 33).

r:. Middle-range theories are narrower in scope than

,’grand theories. They are made up of a limited num-ber of concepts and propositions that are writtenat a relatively concrete and specific level. Nurse’s ac-tivity is an example of a middle-range theory con-

[ -cept (Orlando, 1961). An example of a middle-rangetheory nonrelational proposition is as follows:.Nurse’s activity is “only what [thz nurse1 says ordoes with or for the benefit of the patient,” such asinstructions, suggestions, direction s, explana-

,tions, information, requests, and questions directed

~18

toward the patient; making decisions for the patient;handling the patient’s body; administering medica-tions or treatments; and changing the patient’simmediate environment (Orlando, 1961, p. 60). Anexample of a middle-range theory relational proposi-tion, which links the concepts nurse’s reaction andnurse’s activity, is as follows: “What a nurse says ordoes is necessarily an outcome of her reaction tosomething in the situation” (Orlando, 1961, p. 61).

Each middle-range theory addresses a more or lessrelatively concrete and specific phenomenon bydescribing what the phenomenon is, explaining whyit occurs, or predicting how it occurs. Middle-rangedescriptive theories are the most basic type ofmiddle-range theory. They describe or classify aphenomenon and, therefore, may encompass justone concept. When a middle-range descriptive the-ory describes a phenomenon, it simply names thecommonalities found in discrete observations of in-dividuals, groups, situations, or events. When amiddle-range descriptive theory classifies a phenom.enon, it categorizes the described commonalitiesinto mutually exclusive, overlapping, hierarchical, orsequential dimensions. A middle-range classifica-tion theory may be referred to as a typology or ataxonomy.

Middle-range explanatory theories specify relationsbetween two or more concepts. They explain whyand the extent to which one concept is related to aa.other concept. Middle-range predictive theoriesmove beyond explanation to the prediction of pre-cise relations between concepts or the effects of oneor more concepts on one or more other concepts.This type of middle-range theory addresses howchanges in a phenomenon occur.

The definition of a theory used in this book indi-cates that a conceptual model always is the precur-sor to a grand theory or a middle-range theory.Indeed, the belief that theory development proceedsoutside the context of a conceptual frame of refer-ence is “absurd” (Popper, 1965, p. 46). As Slifeand Williams (1995) explained, “All theories haveimplied understandings about the world that arecrucial to their formulation and use. . . . [In otherwords,] all theories have assumptions and implica-tions embedded in them [and1 stem from culturaland historic contexts that lend them meaning andinfluence how they are understood and imple-mented” (pp. 2, 9).

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Part 1 Structure and Use of Nursing Knowledge Chapter 1

Moreover, inasmuch as each grand theory andeach middle-range theory deals only with a limitedaspect of reality, many theories are needed to dealwith all of the phenomena encompassed by aconceptual model. Each conceptual model, then, is*ore fully specified by several grand or middle-qnge theories, as indicated in Figure l-l by thelubscript notation, 1 . . . n.

‘Grand theories are derived directly from concep-tual models (Fig. I-2). For example, Rogers (1986)Perived three grand theories from her concep-tual model, the Science of Unitary Human Beings:Ihe Theory of Accelerating Evolution, the Theory of@hythmical Correlates of Change, and the Theoryef Paranormal Phenomena.

!?he grand theories derived from conceptual mod-es can serve as the starting points for middle-rangetheory development (see Fig. I-2). Alligood (19911,for example, derived a middle-range theory ofbeativity, actualization, and empathy from Rogers’(1986) grand Theory of Accelerating Evolution.

Alternatively, middle-range theories can be deriveddirectly from the conceptual model (see Fig. l-2).for example, King (1981) derived the middle-rangeTheory of Goal Attainment from her conceptualmodel, the General Systems Framework.

CONCEPTUAL MODEL

///_’

Functions of a Theory

One function of a theory is to narrow and morefully specjfy the phenomena contained in a concep-tual model. Another function is to provide a rela-tively concrete and specific structure for the inter-pretation of initially puzzling behaviors, situations,and events.

Nursing Theories

A few nurses have presented their ideas aboutnursing in the form of explicit grand theories. Lein-inger (1991a) has presented her Theory of CultureCare Diversity and Universality, Newman (1986,1994) has presented her Theory of Health as Ex-panding Consciousness, and Parse (1981, 1998) haspresented her Theory of Human Becoming. Thesegrand theories are discussed in Chapters 12 through14 of this book.

A few other nurses have presented their ideasabout nursing in the form of explicit middle-rangetheories. Orlando (1961) presented her Theory of theDeliberative Nursing Process, Peplau (1952, 1992)presented her Theory of Interpersonal Relations, andWatson (1985, 1997) presented her Theory of Hu-man Caring. Peplau’s work is a middle-range de-scriptive classification theory, Watson’s work is amiddle-range explanatory theory, and Orlando’s

MIDDLE-RANGE THEORIES,,,,, MIDDLE-RANGE THEORIES,,,,,

Flgzrre I - 2 Ikritwltotr ofgrarrd tbeorks arul middle-range lbeorics fionr atuJ?ll’cJ/mrcll ?lrodd.

thpter 1 The Structure of Contempt rary Nursing Knowledge 19

work is a middle-range predictive theory. These the-ories are discussed in Chapters 15 through 17 ofthis book.

It is likely that many other middle-range nursingtheories exist, but they are not always recognizableas strch. The paucity of recognizable middle-rangentlrsing theories is due to nurse researchers’ failure

to he explicit about the theoretical components oftheir stltdies and to label their work as theories andto nurse clinicians’ failure to be explicit about thetheoretical elements in their discussions of nursingpractice. Therefore, the ideas presented by nurses

, in books, monographs, and journal articles shouldbe closely examined for evidence of the con-: ,cepts and propositions that make up middle-rangetheories. Identification of the cbTponents of a‘theory is accomplished by the tee hnique of theory,formalization, also called theoretir.al substruc-

tion. Discussion of that technique is beyond the: scope of this book. Readers who are interested intheory formalization are referred to Hinshaw’s (1979)pioneering work and Fawcett’s (1999) more recent

‘work.

Unique, Borrowed, and Shared NursingTheories

Some theories used by nurses are unique to nurs-ing, and others are borrowed from adjunctive disci-plines. The theories developed by Leininger,Newman, Orlando, Parse, Peplau, and Watson areIlnique nursing theories. Many other theoriesused by nurses have been borrowed from other dis-ciplines. Theories of stress, coping, locus of con-trol, reasoned action, and self-efficacy are just a few

’ ;examples of borrowed theories. Unfortunately, those; Theories sometimes are used with no consideration’ igiven to their empirical adequacy in nursing situ-41ations. There is, however, increasing awareness of

?he need to test borrowed theories to determine: if they are empirically adequate in nursing situa-tions. The theory testing work by Lowery and asso-ciates (1987) is an especially informative exampleof what can happen when a theory, borrowed in thiscase from the discipline of psychology, is tested inthe real world of acute and chronic illness. Theinvestigators determined that a basic proposition ofattribution theory, stating that people search forcauses to make sense of their lives, was not fullys[lpported in their research with patients with arthri-tis, diabetes, hypertension, or myocardial infarction.

Further research should determine whether a modi-fication of attribution theory is empirically ade-quate in nursing situations or if an entirely newtheory ie required. The available results, however,mean that attribution theory cannot be considered ashared theory, that is, a theory that is borrowedfrom another discipline and found to be empiricallyadequate in nursing situations (Barnum, 1990).

In contrast, the theory of self-efficacy is a bor-rowed theory that appears to be developing into ashared theory. This theory was developed initially inthe discipline of social psychology and has re-ceived empirical support in some nursing situations(e.g., Burns et al., 1998; Froman & Owen, 1990;Hickey, Owen, & Froman, 1992).

Empirical Indicators

The fifth and final component of the STRUCTURALHIERARCHY OF CONTEMPORARY NURSINGKNOWLEDGE is the EMPIRICAL INDICATOR (see Fig.l-l). An empirical indicator is defined as

a very concrete and specific real world proxyfor a middle-range theory concept; an ac-tual instrument, experimental condition, orclinical procedure that is used to observe ormeasure a middle-range theory concept.

Function of an Empirical Indicator

The function of empirical indicators is to providethe means by which middle-range theories are gen-erated or tested. Empirical indicators that are in-struments yield data that can be sorted into qualita-tive categories or calculated as quantitative scores.For example, responses to an interview schedulemade up of open-ended questions can be analyzedto yield categories or themes, and responses toquestionnaires made up of fixed-choice items can bosubjected to mathematical calculations that yield anumber or score.

Empirical indicators that are experimental condi-tions or clinical procedures tell the researcher or cli.nician exactly what to do. They are, in effect, pro-tocols or scripts that direct actions in a precisemanner.

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Nursing Empirical Indicators

Nurses have developed a plethora of empirical in. losop~dicators in the form of research instruments and tinct fcclinical tools. Those that measure concepts associ- certain

20 Part 1 Structure and Use of Nursing Knowledge Chapter

ated with the conceptual models of nursing andnursing theories discussed in this book are listed

’ and described in tables in Chapters 4 through 10and 12 through 17.

1i Distinctions Between the Components of the

r Structural Hierarchy of Contemporary Nursing’ K n o w l e d g e

, The distinctions between the various components.! of the structural hierarchy of contemporary nursingI’:.

knowledge require some discussion. The discus-ii sion that follows should be kept in mind when read-

ing the remainder of this book.

: The Metaparadigm, Philosophies, Conceptual: Models, Theories, and Empirical Indicators

’ Empirical indicators are directly connected to theo-, ries by means of the operational definition foreach middle-range theory concept. As can be seenin Figure l-l, there is no direct connection between

empirical indicators and concep,qlal models, phi-I losophies, or the metaparadigm. Consequently,’

I

those components of the structur II hierarchy of con-temporary nursing knowledge cannot be subjected

1 to empirical testing. Rather, the credibility of aconceptual model is determined indirectly through

of middle-range theories that arederived from or linked with the model. Furthermore,philosophies cannot be empirically tested either di-rectly or indirectly because they are statements ofbeliefs and values. Philosophies should, however, bedefendable on the basis of logic or through dia-logue. More specifically, philosophies can andshould be “reconsidered, rejected, or modifiedthrough a process of considered reflection spurred

discussion with one’s peers”p. 18). Similarly, the metaparadigm

ically tested, but should be de-basis of dialogue and debate aboutof interest to the discipline as a

11’ whple.P-

1

The Metaparadigm, Philosophies, Conceptuali. Models, and Theories

.;i When viewed from the perspective of the structural

‘: hierarchy of contemporary nursing knowledge (see:; Fig’. l-l), it is clear that the metaparadigm, phi-; losophies, conceptual models, and theories are dis-i tinct formulations. Yet Kikuchi (1997) argued that

.;’ certain aspects of the structural hierarchy of contem-

porary nursing knowledge are “problematic in thatthey contain seeds of confusion regarding thenature of conceptions about nursing-seeds sown, itwould seem, by virtue of the failure to see that theconceptions are philosophical, rather than scien-tific in nature and the eclectic amalgamation ofideas” (p. 102). She went on to argue that, with theexception of empirical indicators, all other com-ponents of the structural hierarchy are betterthought of as philosophies of nursing, “having theform of a philosophic nursing theory” (p. 107).

Moreover, Salsberry (1994) implied that what arecalled conceptual models in this book actually arephilosophies. She noted, “Much of what hasbeen referred to a conceptual model is, in fact, aphilosophy-that is, a set of beliefs about what thebasic entities of nursing are, how these entitiesare known, and what values should guide the disci-pline. The model development arises when thesephilosophical claims are arranged into a particularstructure” (p. 18).

Support for the structural hierarchy as presented inthis book is especially evident in the content ofChapters 4 through 10, where clear distinctions aremade between philosophical claims and the con-cepts and propositions that make up conceptualmodels of nursing and reflect underlying philosophi-cal claims. Further support is evident in the contentof Chapters 12 through 17, where clear distinc-tions are made between philosophical claims andthe concepts and propositions that make up grandtheorie.5 or middle-range theories and reflect under-lying philosophical claims. More specifically, eachof those chapters explicitly identifies statements thatare beliefs and values, that is, philosophical claims,and then identifies the concepts and propositionsof the conceptual model, grand theory, or middle-range theory that clearly reflect-but do not du-plicate-those philosophical claims.

The Mefaparadigm, Philosophies, andConceptual Models

Philosophies do not follow directly in line from themetaparadigm of the discipline, nor do they directlyprecede conceptual models (see Fig. 1-I). Rather,the metaparadigm of a discipline identifies the phe-nomena about which ontological, epistemic, andethical claims are made. The unique focus and con-tent of each conceptual model then reflect certain

-i Cbapter 1 The Structure of Contemporary Nursing Knowledge

phi)osophical claims. The philosophies therefore areundation for other formulations, includingptual models, grand theories, and middle-theories. Salsberry (1994) explained, “A phi-y consists of the basic assumptions andthat are built upon in theorizing” (p. 18).

t example, a metaparadigm might identify peo-as a central concept. A philosophy then might

the claim that all people are equal. That philo-cal claim then would be reflected in a con-al model that depicts the nurse and the patient

equal partners in the process of nursing.

The Metaparadigm and Conceptual Models

ost disciplines have a single metaparadigm butultiple conceptual models, as indicated by the sub-ript notation 1 . . . n in Figure l-l. For example,is book identifies seven different conceptual mod-

address the concepts of the metaparadigming, and Darby and Walsh (1994) identifiedfferent conceptual models that address the

pts of the metaparadigm of dental hygiene.oreover, Waters (1994) identified five different gen-al conceptual models, and Nye and Berardo (1981)entified 16 different conceptual models of themily that address the concepts of the discipline of

ltiple conceptual models allow the members ofscipline to think about the phenomena of centralrest in different ways. They spe.lk to the view

at “there is no one reality of [a dis:iplinel. There islear and universal [conceptual model1 of what

uld underpin practice precisely because there isch thing as universal knowledge” (Brad-

nceptual models address the phenomena identi-by a metaparadigm and, therefore, incorpo-

te the most global concepts and propositions in arestrictive yet still abstract manner. Eachptual model, then, provides a different viewmetaparadigm concepts. As Kuhn (1970) ex-

&-red, although adherents of different concep-al models are looking at the same phenomena, “inme areas they see different things, and they seeem in different relations to one another” (p.

J. The acceptance of multiple conceptual modelsn outgrowth of the recognition of the advan-s of diverse perspectives for a discipline (Moore,

0; Nagle & Mitchell, 1991).

As in other disciplines, the conceptual models ofnursing represent various paradigms that addressthe phenomena identified by the metaparadigmof the discipline of nursing. Thus it is not surprisingthat each defines the four metaparadigm conceptsdifferently and links those concepts in diverse ways(see Chapters 4 through 10).

Examination of conceptual models of nursing re-veals that person usually is identified as an inte-grated bio-psycho-social being, but is defined in di-verse ways, such as an adaptive system (Roy &Andrews, 1999), a behavioral system (Johnson,1990), a self-care agent (Orem, 1995), or an energyfield (Rogers, 1990). Environment frequently is iden-tified as internal structures and external influ-ences, including family members, the community,and society, as well as the person’s physical sur-roundings. The environment is seen as a source ofstressors in some models (Neuman, 1995), but asource of resources in others (Rogers, 1990). Healthis presented in various ways, such as a continuumof client system wellness or stability (Neuman,1995), a dichotomy of behavioral stability or instabil.ity (Johnson, 1990). or a value identified by eachcultural group (Rogers, 1990).

The conceptual models also present descriptions ofthe concept of nursing, usually by defining nurs-ing and then specifying goals of nursing actions anda nursing process. The goals of nursing action fre-quently are derived directly from the definition ofhealth given by the model. For example, a nursinggoal might be to assist people to attain, maintain, orregain client system stability (Neuman, 1995). Thenursing process, or practice methodology, describedin each conceptual model emphasizes assessingand labeling the person’s health status, setting goalsfor nursing action, implementing nursing actions,and evaluating the person’s health status after nurs.ing intervention. The steps or components of theprocess, however, frequently differ from one con-

betweenhere andmodels a(1970), Jcnursing; FpsycholofsociologyWalsh (19

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Conceptual Models and Theories

A central thesis of this book is that a conceptualmodel is not a theory, nor is a theory a conceptualmodel. This thesis requires further discussion be-cause considerable confusion about those two cornportents of the structure1 hiererchy of contempo-rary nursing knowledge still exists in the minds ofsome students and scholars. The distinctions

ceptual model to another. distinctive krof nursing, tlmodel. Giverpose of such(1971), Levinl1972t, Oremtheir works a

If the purpoaspect of a c(

,

22 Part 1 Structure and Use of Nursing Knowledp Chapter 1 The

between conceptual models and theories describedhere and the-meaning ascribed to conceptualmodels are in keeping with earlier works by Rogers(1970), Johnson (1974), and Reilly (1975) innursing; Reese and Over-ton (1970) in developmentalpsychology; and Nye and Berardo (1966) insociology; and more recent work by Darby andWalsh (1994) in dental hygiene.

,Although some writers consider distinctions be-tween conceptual models and theories a semanticpoint (e.g., Flaskerud 81 Halloran, 1980; Meleis,1997). the issue should not be dismissed so easily.Indeed, King (1997) called for “a consensus on adefinition of the term ‘theory’ to clearly differentiateit from ‘conceptual system’ ” (p. 16), which is theterm she prefers over conceptual model, conceptualframework, or paradigm.,;The distinction between a conceptual model and atheory should be made because of the differences inthe way that each is used-if one is to know whatto do next, one must know whether the startingpoint is a conceptual model or a theory. As can beseen in Figure l-l, conceptual models and theo-ries differ in their level of abstraction. A conceptualmodel is made up of several abstract and generalconcepts and propositions. A grand theory or amiddle-range theory, in contrast, deals with one ormore relatively concrete and specific concepts andpropositions.

Distinguishing between conceptual models, grandtheories, and middle-range theories on the basis oflevel of abstraction raises the question of how ab-stract is abstract enough for a work to be considereda conceptual model. Although the decision in a fewcases may be somewhat arbitrary, the following ruleserves as one guideline for distinguishing betweenconceptual models and theories. The rule re-quires determination of the purpose of the work.

tf the purpose of the work is to articulate a body ofdistinctive knowledge for the whole of the disciplineof nursing, the work most likely is a conceptualmodel. Given that that was the explicitly stated pur-pose of such authors as Johnson ( 1980), King(1971), Levine (1969), Neuman (Neuman & Young,4972), Orem (1971), Rogers (1970), and Roy (1976),their works are classified as conceptual models.

If the purpose of the work is to further develop oneaspect of a conceptual model, the work most likely

is a grand theory. For example, both Newman (1986)and Parse (1981) explained that they elected to fur-ther develop the concept of health from the perspec-tive of Rogers’ (1970) conceptual model. As can bediscerned from these examples, nurse scholars whoconsider conceptual models and grand theories tobe synonymous (e.g., Barnum, 1998; Kim, 1983;Marriner-Tomey & Alligood, 1998) mislead theirreaders..

If the purpose of the work is to describe, explain,or predict concrete and specific phenomena, thework most likely is a middle-range theory. For ex-ample, Peplau’s (1952) Theory of InterpersonalRelations is a classification of the stages of thenurse-patient relationship. Peplau did not, nor didshe intend to, address the entire domain of nursing.Consequently, her theory is classified as a middle-range theory.

In summary, if a given work is an abstract and gen-eral frame of reference addressing all four con-cepts of the metaparadigm of nursing, it is a con-ceptual model. If the work is more concrete, specific,and restricted to a more limited range of phenom-ena than that identified by the conceptual model,it is a grand theory or middle-range theory.

Another rule for distinguishing between conceptualmodels and theories requires determination ofhow many levels of knowledge are needed beforethe work may be applied in particular nursing situa-tions. If, for example, the work identifies physio-logical needs as an assessment parameter, but doesnot explain the differences between normal andpathological functions of body systems in concreteterms, it most likely is a conceptual model. As such,the work is not directly applicable in clinical prac-tice. A theory of normal and pathological functionsmust be linked with the conceptual model so thatjudgments about the physiological functions of bodysystems may be made. Conversely, if the work in-cludes a detailed description of particular peo-ple’s behavior, or an explanation of how particularfactors influence particular behaviors, it mostlikely is a middle-range theory. In that case, the workmay be directly applied in clinical practice.

The rule also is exemplified by the number ofsteps required before empirical testing can occur(Reilly, 1975). A conceptual model cannot be testeddirectly, because its concepts and propositions are

f&~&r 1 The Structure of Contemporary Nursing Knowledge 23

not empirically measurable. More concrete and spe-cific concepts and propositions have to be derivedfrom the conceptual model; that is, a middle-range theory must be formulated. Those more con-crete concepts then must be operationally definedand empirically testable hypotheses must be derivedfrom the propositions of the theory. Four steps areriquired before a conceptual modt.1 can be tested,albeit indirectly. First, the conceptual model must beformulated; second, a middle-range theory must bederived from the conceptual model; third, empiri-cal indicators must be identified; and fourth, empiri-cally testable hypotheses must be specified. Incontrast, only three steps are required for empiricaltesting of a middle-range theory. First, the theory,must be stated; second, empirical indicators must beidentified; and third, empirically testable hypothe-ses must be specified.

: jailure to distinguish between a conceptual modelaGd a theory leads to considerable misunder-stdnding and inappropriate expectations about thework. When a conceptual model is labeled agrand theory or, especially, a middle-range theory,expectations regarding empirical testing and clinicalapplicability immediately arise. When such expec-tations cannot be met, the work is frequently re-garded as inadequate. Similarly, when a grand the-ory or’ a middle-range theory is labeled a conceptualmodel, expectations regarding comprehensivenessarise. When those expectations cannot be met,

‘that work also may be regarded as inadequate.

A NOTE ON LANGUAGE

The meaning given to conceptual models in this‘tlaok should not be confused with the meaning of‘jrtibdel found in the philosophy of science literaturei&d some nursing literature. The latter refers to rep-resentations of testable theories. Rudner (1966), for

~‘example, defined a model for a middle-range theory:;& “an alternative interpretation of the same calcu-

&s of which the theory itself is an interpretation”‘Q5. 24). That kind of a model is made up of ideas ordiagrams that are more familiar to the novice thanare the concepts and propositions of the theory.T,hus the model is a heuristic device that facilitatesunderstanding of the theory. Rudner illustrated.this by the analogy of the flow of water throughpjpes as a model for a middle-range theory of elec-

tric current wires. So-called models that actually,are diagrams of theories are found with increasing

24

frequency in reports of nursing research. For exam-ple, Hamner (1996) labeled her diagrams of the re-lations between the concepts of a middle-range the-ory of facmrs associated with patient length of stayin an intensive care unit as a model.

The concepts and propositions of each conceptualmodel and each theory often are stated in a distinc-tive vocabulary. One conceptual model, for exam-ple, uses the terms stimuli and adaptation level (Roy& Andrews, 1999), and another uses the termsresonancy, helicy, and integrality (Rogers, 1990). Fur.thermore, the meaning of each term usually is con-nected to the unique focus of the conceptualmodel or theory. Thus the same or similar termsmay have different meanings in different conceptualmodels and theories. For example, adaptation isdefined in one conceptual model as “the processand outcome whereby thinking and feeling persons,as individtials or in groups, use conscious aware-ness and choice to create human and environmentalintegration” (Roy & Andrews, 1999, p. 30), and inanother conceptual model as “the process by whichindividuals ‘fit’ the environments in which they live”(Levine, 1996, p. 38).

The vocabulary of each conceptual model and eachtheory should not be considered jargon. Rather,the terminology used by the author of each conceptual model and each theory is the result of consid-erable thought about how to best convey the mean-ing of that particular perspective to others (Biley,1990). Furthermore, as Akinsanya (1989) pointed out,“Every science has its own peculiar terms, con-cepts and principles which are essential for the de-velopment of its knowledge base. In nursing, as inother sciences, an understanding of these is aprerequisite to a critical examination of their contri-bution to the development of knowledge and itsapplication to practice” (p. ii). Watson (1997) added,“The attention to language is especially critical toan evolving discipline, in that during this postmod-ern era, one’s survival depends upon havinglanguage; writers in this area remind us ‘if you donot have your own language you don’t exist’ ”(p. 50).

CONCLUSION

This chapter presented the definition and functionof each component of the structural hierarchy ofcontemporary nursing knowledge. It is important to


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point out that metaparadigms, philosophies, concep-tual models, and theories are not real or tangibleentities. Rather, they are tentative formulations that

represent scholars’ best efforts to understandphenomena (Payton, 1994; Polit 81 Hungler, 1995).Their tentative nature means that the knowledge

contained in metaparadigms, philosophies, concep-tual models, and theories carries with it a degreeof uncertainty. Thus metaparadigms, philosophies,conceptual models, and theories are not un-

i changeable ideologies but rather ideas that are sub-: ject to continual revision or even rejection in re-: sponse to ongoing dialogue, debate, and systematicj inquiry.:I‘I,i!.

This chapter also presented a discussion of the dis-j1

tinctions between the various components of thestructural hierarchy of contempopary nursing knowl-

!i

edge, with emphasis on the distinctions betweeni conceptual models and theories. The distinctions be-; tween conceptual models and theories mandate/ separate analysis and evaluation schemata. Chapteri 3 presents a framework expressly designed for the

analysis and evaluation of conceptual models ofnursing. The framework expressly designed for theanalysis and evaluation of nursing theories is pre-sented in Chapter 11.

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Cody, W.K. (19951. About all those paradigms: Many in the universe, two innursing. Nursing Science (luarterly, 8. 144-147.

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Hall, B.A. (1983). Toward an understanding of stability in nursing phenomena.Advances in Nursing Science, 5f3). 15-20.

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Johnson, M.B. (19901. The holistic paradigm in nursing: The diffusion of an in-novation. Research in Nursing and Health, 13, 129-139.

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31

Koben 1. & Fnlan. M. 119901. Coming of age in nursing. Rethinking the philos-oplm?s behind holism and nursing process. Nursing and Health Care, 11,308 312

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Mullnr Srrilrh. PA. (1992). When paradrgms shift Journal of Pdst AnesthesiaNw~wq. 1, 778 280.

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Nagle. ! M & hl~tchnll. G.J. (19911. Theoretic diversih/: Evolving paradigmatic:ss!~rls 111 research and practice. Advances in Nursing Science, 14(l),17 2%

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i\eece. H W, PI Overton. W.F. (1970). Models of development and theories ofdevelnmm?rlt In L R Goulet & P.B. Bakes (Eds ). Life span developmentalpsvchologv: Research and theory (pp. 115-145). New York: AcademicPfPSS

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See also Chapters 12 through 17.

Structural Hierarchy of ContemporaryNursing Knowledge: Theories

Structural Hierarchy of ContemporaryNursing Knowledge: EmpiricalIndicators

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See also Chapters 4 through 10 and 12 through 17.

L,ib@ar 1 The Structure of Contemporary Nursing Knowledge 33

The Structure of Contemporary Nursing Knowledge · The Structure of Contemporary Nursing Knowledge This chapter lays the groundwork for the remain-der of the book. Here, a structural

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