MODULE 1

EVOLUTION OF NURSING

INTRODUCTION

Nursing theory has become a major theme over the past 50 years, stimulating phenomenal growth
and vast expansion of nursing education and literature. Selected nursing theorists are presented to expose
students to a broad range of nurse theorists and different types of theoretical works. Many nurses of early
eras delivered excellent care to patients. However, much of what was known about nursing was passed on
through vocational education that was focused on skillful completion of functional tasks. Whereas many of
these practices seemed effective, they were not tested nor used uniformly. Developing nursing knowledge
on which to base nursing practice was a major goal put forth by leaders of the nursing profession in the
twentieth century, as nurses sought to improve practice and to gain recognition of nursing as a profession.
The history of nursing clearly documents sustained efforts put forth toward the goal of developing a
substantive body of nursing knowledge to guide nursing practice (Alligood, 2006a; Bixler & Bixler, 1959;
Chinn & Kramer, 2008; George, 2002; Johnson & Webber, 2004; McEwen & Wills, 2006; Meleis, 2007;
Parker, 2006). In this module, the reader is introduced to nursing theory under three major headings:
history, significance, and analysis.

HISTORY OF NURSING THEORY

The nursing profession has impressively evolved over time, and along this transition came nursing
theories. The beginning of nursing theory development can be traced to Florence Nightingale. However, it
was not until the second half of the twentieth century that nursing as an academic discipline and a
profession, a body of knowledge to guide nursing practices essential. Furthermore, it was realized that
theory development is significant to develop a body of substantive knowledge to guide nursing practice to
establish nursing as a profession and an academic discipline. In this twenty-first century, it is fully
understood that nursing theories play vital role in guiding critical thinking in nursing practice. It is nursing
theories that provide the nurse with patient focus and a framework to sort patient data in practice. Theory
guides both thinking and nursing action. It is recognized that theory informs practice and also that practice
informs theory. The systematic accumulation of knowledge is essential to progress in any profession,
however, theory without practice is empty and practice without theory is blind" (Cross, 1981.p.110) Overall,
nursing theory is the backbone of clinical care. To apply nursing theory in practice, the nurse must have
adequate knowledge of the theoretical works of the nursing profession. However, it is noteworthy that
development of a body of substantive knowledge to guide nursing practice, to establish nursing as a
profession and as an academic discipline has been achieved through the challenges and struggles met and
overcome by the various nursing theorists. As aforementioned, the history of theory development and
theoretical thinking in nursing began with the writings of Florence Nightingale and continues to the present.

The following are the highlights of significant events in this history:

1. Florence Nightingale Nightingale's (1859/1992), "Notes on Nursing" presents the first nursing
theory that focuses on the manipulation of the environment for the benefit of the patient.
Although Nightingale did not present her works a "nursing theory", it has directed nursing
practice for over 140 years ---- a timeless legacy for the nursing profession.
2. The Columbia School --- The 1950s
 In the 1950s the need to prepare nurses at the graduate level for administrative
and faculty positions was recognized.
 Theorists of the Columbia School focused primarily on what nurses do, that is, their
functional roles.
 They considered patient problems and needs to be the practice focus.
 Johnson suggested that nursing knowledge is based on a theory of nursing diagnosis
that is different from medical diagnosis. (Meleis, 1997)

3. The Yale School- The 1960’s

• Focus of theoretical thinking in nursing moved rom a problem/need and functional role
focus to the relationship between the nurse and the patient.
• Theorists of the Yale School view nursing as a process rather than an end in itself.
• It is important to note that it was during 1960’s that federal funds were made available for
doctoral study for nurse educators.

4. The 1970’s
• It was in this decade that many nursing theories were first presented. Most of these theories
have been revised since their original presentation. (Rogers, King, Orem, Levine, Neuman, Roy,
Paterson, Zderad, Newman, Watson).

5. The 1980’s
• In the 1980’s, many nursing theories were revised based on the research findings that
expanded them. In addition, the works of Johnson, Parse, Leininger and Erickson Tomlin and
Swain were added to the body of theoretical thoughts in nursing.

6. The 1990’s
• In the 1990s, research studies that tested and expanded nursing theory were numerous.
• "Nursing Science Quarterly" (edited by Rosemarie Rizzo Parse and published by Chestnut
House 1988 - 1998, Sage, 1999 - ) is devoted exclusively to the presentation of nursing theory -
based research findings and theoretical topics.
• Rogers published "Nursing: Science of Unitary, Irreducible Human Beings: Update 1990",
which is the latest refinement of her theory,
• In 1992, Parse changed the language of her theory from Man-Living-Health to the Theory of
Human Becoming. She explained that the reason for the change is that contemporary
dictionary definition of "man" tend to be gender-based as opposed to meaning mankind.
• In 1993, Boykin and Schoenhofer published their theory of Nursing as Caring." They
presented this theory as grand theory with caring as a moral imperative for nursing.
ERAS OF NURSING KNOWLEDGE
1. Curriculum Era (1900-1940s)
• In the curriculum era, efforts to understand the nature of the knowledge needed for the
practice of nursing are evident from an emphasis on curricular content and the movement
toward the goal of standardized curricula.

2. Research Era (1950-1960s)

• As nurses were introduced to research, they saw the need for nursing research and that
led to the research era.
• This era emphasized scholarship and the need to disseminate research findings in
scholarly publications.

3. Graduate Education Era (1960-1970s)

• Curricula for master’s level preparation included courses in nursing research, clinical
specialty practice and leadership.
• Many also began to include a core course in nursing theory or nursing models in a core
curriculum organized with a nursing philosophy and conceptual or organizing framework.

4. Theory Era (1980-1990s)

• The theory era began with a strong emphasis on development
• The theory era, coupled with the research era, led to understanding of the scientific
process for the production of a scientific product (Whall, 1996).

5. Theory Utilization
• Nursing has moved into a new era of utilization of philosophies, models or theories in
practice and referred to as theory- based nursing practice.
• Shift from theory development to theory application and utilization recognizes the
importance of a framework for critical thinking and decision making in professional
nursing practice.

6. The Future
• In 1992, Meleis predicted that six characteristics of the discipline of nursing would direct
theory development in the twenty-first century. These predictions, which follow, are still
valid today:
1. The human science underlying the discipline that is predicated on
understanding the meanings of daily lived experiences as they are perceived by the
members or the participants of the science" (p. 112).
2. There is increased emphasis on the practice-orientation, or actual rather than
"ought-to- be" practice
3. Nursing's mission is to develop theories to empower nurses, the discipline,
and clients.
4. "Acceptance of the act that women may have different strategies and
approaches to knowledge development than men" (p. 113).
 5. Nursing's attempt to "understand consumers' experiences for the purpose of
empowering them to receive optimum care and to maintain optimum health" (p.
114).
6. "The effort to broaden nursing's perspective includes efforts to understand the
practice of nursing in third world countries” (p. 114).

Meleis (1992) forecasts that nursing theories will become theories for health,
developed by nurses, physicians, occupational therapists, and others. She also forecasts that "the domain of
nursing that focuses on environment-person interactions, energy levels, human responses, and caring will
have long been accepted as central and complementary perspective in providing health care to clients” (p.
115). She states that neglected aspects of care, such as advocacy, comfort, rest, access, sleep, trust, grief,
symptoms distress, harmony, and self-care will receive attention and will lead to collaborative programs of
research and theory building. Contemporary nursing literature supports the validity of these predictions.

SIGNIFICANCE OF NURSING THEORY FOR THE DISCIPLINE

• Discipline is dependent on theory for its continued existence

• The theoretical works have taken nursing to higher levels of education and practice as nurses moved
from functional focus with emphasis on what nurses do, to a patient focus, emphasizing what nurses
know for thought, decision making and action.
• Knowledge of persons, health and environment forms the basis for recognition of nursing as a
discipline and this knowledge is taught to those who enter the profession.

SIGNIFICANCE OF NURSING THEORY FOR THE PROFESSION

• Nursing is recognized as a profession today because its development was guided by the criteria for a
profession.

• The application of nursing knowledge in practice is the criterion for a profession that is currently at
the fore front, with emphasis on quality, accountability, theory-based or informed evidence and
recognition of middle- range theory for professional nursing practice. (Alligood, 2014).

HISTORY AND PHILOSOPHY OF NURSING SCIENCE

Historical views of the nature of science

• To formalize the science of nursing, basic questions must be considered, such as: What is science,
knowledge, and truth? What methods produce scientific knowledge? These are philosophical
questions. The term epistemology is concerned with the theory of knowledge in philosophical
inquiry.
• The particular philosophical perspective selected to answer these questions will influence how
scientists perform scientific activities, how they interpret outcomes, and even what they regard as
science and knowledge (Brown, 1977). Although philosophy has been documented as an activity for
 3000 years, formal science is a relatively new human pursuit (Brown, 1977; Foucault, 1973).
Scientific activity has only recently become the object of investigation.

• Two competing philosophical foundations of science, rationalism and empiricism, have evolved in
the era of modern science with several variations. Gale (1979) labeled these alternative
epistemologies as centrally concerned with the power of reason and the power of sensory
experience. Gale noted similarity in the divergent views of science in the time of the classical
Greeks. For example, Aristotle believed that advances in biological science would develop through
systematic observation of objects and events in the natural world, whereas Pythagoras believed that
knowledge of the natural world would develop from mathematical reasoning (Brown, 1977; Gale,
1979).

• Nursing science has been characterized by two branching philosophies of knowledge as the
discipline developed. Various terms are utilized to describe these two stances:
- Empiricist, mechanistic quantitative and deductive and
- Interpretive holistic, qualitative and inductive forms of science.

• Understanding the nature of these philosophical stances facilitates appreciation for what each
form contributes to nursing knowledge.

1. Rationalism

• Rationalist epistemology (scope of knowledge) emphasizes the importance of a priori reasoning as the
appropriate method for advancing knowledge. A priori reasoning utilizes deductive logic by reasoning from
the cause to an effect or from a generalization to a particular instance.

• An example in nursing is to reason that a lack of social support (cause) will result in hospital readmission
(effect). This causal reasoning is a theory until disproven. The traditional approach proceeds by explaining
hospitalization with a systematic explanation (theory) of a given phenomenon (Gale, 1979). This conceptual
system is analyzed by addressing the logical structure of the theory and the logical reasoning involved in its
development. Theoretical assertions derived by deductive reasoning are then subjected to experimental
testing to corroborate the theory.

• Reynolds (1971) labeled this approach the theory-then-research strategy. If the research findings fail to
correspond with the theoretical assertions, additional research is conducted or modifications are made in
the theory and further tests are devised; otherwise, the theory is discarded in favor of an alternative
explanation (Gale, 1979; Zetterberg, 1966).

• As Reynolds (1971) noted, if someone believes that science is a process of inventing descriptions of
phenomena, the appropriate strategy for theory construction is the theory-then-research strategy. In
Reynolds’ view, “as the continuous interplay between theory construction (invention) and testing with
empirical research progresses, the theory becomes more precise and complete as a description of nature
and, therefore, more useful for the goals of science”
2. Empiricism
• The empiricist view is based on the central idea that scientific knowledge can be derived only
from sensory experience (i.e., seeing, feeling, hearing facts).
• Francis Bacon (Gale, 1979) received credit for popularizing the basis for the empiricist
approach to inquiry. Bacon believed that scientific truth was discovered through generalizing
observed facts in the natural world.
• This approach, called the inductive method, is based on the idea that the collection of facts
precedes attempts to formulate generalizations, or as Reynolds (1971) called it, the research-
then-theory strategy. One of the best examples to demonstrate this form of logic in nursing
hasto do with formulating differential diagnoses. Formulating a differential diagnosis requires
collecting the facts and then devising a list of possible theories to explain the facts.
• The difficulty with the inductive mode of inquiry is that the world presents an infinite number
of possible observations, and, therefore, the scientist must bring ideas to his or her experiences
to decide what to observe and what to exclude (Steiner, 1977).
• In summary, deductive inquiry uses the theory-then-research approach, and inductive inquiry
uses the research-then-theory approach. Both approaches are utilized in the field of nursing.

3. Early twentieth century views of science and theory

• During the first half of this century, philosophers focused on the analysis of theory structure,
whereas scientists focused on empirical research (Brown, 1977). There was minimal interest in
the history of science, the nature of scientific discovery, or the similarities between the
philosophical view of science and the scientific methods (Brown, 1977).
• Positivism, a term first used by Comte, emerged as the dominant view of modern science
(Gale, 1979). Modern logical positivists believed that empirical research and logical analysis
(deductive and inductive) were two approaches that would produce scientific knowledge
(Brown, 1977).
• The logical empiricists offered a more lenient view of logical positivism and argued that
theoretical propositions (proposition affirms or denies something) must be tested through
observation and experimentation (Brown, 1977). This perspective is rooted in the idea that
empirical facts exist independently of theories and offer the only basis for objectivity in science
(Brown, 1977).