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Formulating Nursing Theory

Sharon L Van Sell

Ioannis A Kalofissudis
The difficulty lies, not in the new ideas, but in escaping the old ones, which ramify, for
those brought up as most of us have been, into every corner of our

John Maynard Keynes, 1936

Forming a theory is like the completion of a puzzle. Each puzzle piece contains meaning of a structural
concept. The puzzle pieces are individually colored, however, the interlocking of all the pieces provide a
total picture, just as the parts of a nursing theory interconnect to form the whole theory. In the nursing
theory puzzle, meanings are absolute when referring to measurable items and quantities; and meanings are
abstract when referring to situations and object qualities. Meanings have a direct relationship with the
utterance and the linguistic pathways of each civilization. Also, meanings change from one language to
another as a word can expand with a similar word or words can interconnect with each other. In this
manner, the definition of the meaning can be included under a generalization representing the features of an
object, and as a team of relatives or homogenous objects in which all can be rendered in one key word or
one paraphrase. The analysis of meaning can be qualitative or quantitative. Nursing theory connects
meanings in order to make a whole theory, and to form sentences describing the relationship of meanings,
such as a with b, with x, with y, and with z, for a clear logical synthesis of a nursing theory. Sentences
describing relationships expressed by nursing theories result from observation, whereas nursing theory
structures are not known, because structures constitute all of the meanings and originate from the intellect.
As exemplified by putting a puzzle together, four pieces of the puzzle provided a small colored object (or
interconnected meanings), but a series of interconnected pieces (or sentences) are required for a systematic
view of the entire puzzle picture (or entire nursing theory). As puzzles have a varying number of pieces
constituting small, large, and even enormous puzzles, nursing theories have a varying number of
components constituting models, grand theory, or metatheory. The puzzle of a comprehensive metatheory
of nursing was realized by the Complexity Integration Nursing Theory evolving the meanings, sentences,
and structures interconnecting situations and events observed by nurses on a global scale, and incorporating
multiple grand theories such as the Human Being, the Individual Essence of the Nurse, and the Social

Theories result from each disciplines search and exploration for truth. The term theory evolved from the
Greek word theoria signifying a “vision”; however, theories need to do more than foster intellectual visions
of how nursing should practice.

Nursing theories are an organized and systematic expression of a set of statements related to questions in
the discipline of nursing. Powers and Knapp (1995), defined theory as “a set of statements that tentatively
describe, explain, or predict relationships among concepts that have been systematically selected and
organized as an abstract representation of some phenomenon (p.170-171). Moreover, Bodie and Chitty
(1993) defined theory as “an internally consistent group of relational statements (concepts, definitions and
propositions) that present a systematic view about a phenomenon and which is useful for description,
explanation, prediction and control”.

The concept of theory was expanded with Chinn and Kramer (1995) defining theory as: “A creative and
rigorous structuring of ideas that project a tentative, purposeful, and systematic view of phenomenon”
(page 72). The systematic view of a phenomenon provided by a theory encourages validation of existing
knowledge as well as discovery of new knowledge. Socialization into a discipline is guided by theories use
of language, identification of concepts, definition of relationships, structured ideas, and facilitation of
disciplined inquiry, practice and communication, as well as predicting outcomes of practice. Nursing
professionals apply theory to describe, explain, predict or prescribe nursing practice.

The nursing profession recognized four levels of theory, including: metatheory, grand theory, middle range
theory, and practice theory. Theories are classified by their levels of abstraction along a continuum from
the metatheory as the most abstract to practice theories as the least abstract.

The fourth level of theory or Metatheory is the highest level of theory, and is defined by the prefix META,
meaning “changed in position”, “beyond”, “on a higher level”, or “transcending,” and refers to the body of
knowledge about a body of knowledge or about a field of study such as metaMATHEMATICS
(Krippendorff K, 1986). A nursing metatheory presents the most global perspective of the nursing
discipline by identifying and evaluating critical phenomena in unique ways. Even though nursing
metatheory is very abstract and may not be easily tested, nursing metatheory provides the meanings,
sentences, and structures interconnecting situations and events observed by nurses on a global scale. In
addition, metatheory may contain grand theories, middle range theories, or practice theories. A nursing
metatheory is a nursing theory about nursing theory, as represented with the Complexity Integration
Nursing Theory.

Metatheory may be criticized as being limited, without boundaries, abstract and very difficult for practical
application. However, a true metatheory in nursing will emerge as a superstructure with multiple practical
applications and extensive opportunities for researchers to discover grand theories, mid-range theories,
interconnected paradigms, and models, as well as explore how nursing reconstructs and is reconstructed.

The third level of nursing theory, Grand Theory, emphasizes a global viewpoint with a board perspective of
nursing practice, and a distinct nursing perspective of nursing phenomenon. Fawcett (1995) defined Grand
Theories as the broadest in scope, less abstract than conceptual models but composed of general concepts
still relatively abstract, and the relationships cannot be tested empirically. Examples of nursing grand
theories are Martha Rogers “Science of Unitary Human Being”; Margaret Newman’s Health as Expanding
Consciousness”; Rosemarie Rizzo Parse’s “Theory of Human Becoming”; and the Human Being Theory in
the Complexity Integration Nursing Theory. In addition, grand theories may provide the foundation for a
mid-range theory. For example, the mid-range theory of “self-care deficit” evolved from Orem’s (1971)
grand theory of “self care”.

Middle Range Theories, the second level of nursing theories, are moderately abstract, inclusive, organized
within a limited scope; have a limited number of variables, which are testable in a direct manner. The mid-
range theories have a stronger relationship with research and practice. The relationship between research
and practice, according to Merton (1968), indicated mid-range theories are particularly important for
practice disciplines. Additionally, Walker and Avant (1995) maintain that mid-range theories balance this
specificity with the conceptual economy normally seen in grand theories. As a result, mid-range theories
provide nurses with the “best of both worlds”---easy applicability in practice and abstract enough to be
scientifically interesting. Chinn and Kramer (1995, p 216) reported that mid-range theory deals with a
relatively broad scope of phenomena but does not cover the full range of phenomena that are of concern
within a discipline. They provided the example that the theory of pain alleviation represents a mid-range
theory for nursing; it is broader than a theory of neural conduction of pain stimuli but narrower than the
goal of achieving high level wellness. Thus, the phenomenon of pain is a mid-range concept of concern for
nursing, because pain is one of many phenomena that comprise the global concept of the discipline. Mid-
range theories focus on concepts of interest to nurses, and include: pain, empathy, grief, self-esteem, hope,
comfort, dignity, and quality of life. Examples of nursing middle range theories are: Rogers’ Theory of
Accelerating Change, Roy’s Theory of the Person as an Adaptive System, and King’s Theory of Goal

Practice theories, the first level of nursing theory, describe prescriptions or modalities for practice. Four
steps are involved to determine practice theories, which include:

-Factor isolating: to identify and describe a phenomenon;

-Factor relating: to identify and describe possible explanations or causes of the phenomenon;
-Situation relating: to predict occurrence of a phenomenon when the cause is present. For example, the post
open-heart surgery patient will experience cardiac arrhythmias if the blood potassium level goes below 3.5
meq.; and
-Situation producing control: to prevent occurrence of the phenomenon by controlling or eliminating
possible causes. Examples include: pregnant women receive RHO-gram to prevent possible hemolysis in
their infants; and the frequent turning and positioning of bed-ridden patients to prevent pressure ulcers.

The Evolving Essence of the Science of Nursing: A Complexity Integration Nursing Theory is a Nursing
Metatheory comprised by numerous Grand Nursing Theories, which are:
-The Theory of Nursing Knowledge and Nursing Practice
-The Nursing Theory of Human Being
-The Nursing Theory of Social Entirety
-The Self Observation Methodology

In the Complexity Integration Nursing theory, nursing is both science and art and as Albert Einstein (1927)
wrote: “If what is seen and experienced is portrayed in the language of logic, we are engaged in science. If
it is communicated through forms whose connections are accessible to the conscious mind, but are
recognized intuitively as meaningful, then we are engaged in art”. Moreover, “All philosophy is like a
tree”, wrote Descartes. “The roots are metaphysics, the trunk is physics, and the branches are all the other
sciences” (cited in: Capra F., 1982, p.55). Thus, Nursing Science is more than a branch of the tree of
philosophy, because nursing is nature’s law. So, Nursing as a Science is within the whole philosophy tree,
and as Nightingale suggested: ‘Nursing is an art, and if it is to be made an art, it requires as exclusive
devotion and as hard a preparation, as any painter’s or sculptor’s work, for what is having to do with the
living body - the temple of God’s spirit? It is one of the fine Arts; I had almost said the finest of the fine
Arts’ (cited in Donahue 1996:501). Nursing as both Science and Art incorporates all the useful criteria
giving to nurses the logic, the analysis, the evaluation, the experience, the reflection, the intuition, and the

The Complexity Integration Nursing Theory embodies the past and present theoretical background of the
Science of Nursing and goes further and beyond, as we truly believe that: “Very few really seek knowledge
in this world. Mortal or immortal, few really ask. On the contrary, they try to wring from the unknown the
answers they have already shaped in their own minds - justification, explanations, forms of consolation
without which they can’t go on. To really ask is to open the door to the whirlwind. The answer may
annihilate the question and the questioner” (Rice A, 1985).

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