FAILURE to define clearly the domain of nursing has contributed to a problem we face that some have called the “profession at the crossroads.” The authors, including myself, who took this position, noted that 21st-century advances in science and technology have left nurse scholars struggling to balance philosophical and conceptual/theoretical knowledge developments and their associated critiques with empirical inquiry,1 particularly in the omics of the life sciences.2 We see evidence of this conflict in debates over curricula for the PhD and resulting confusion of focus among new scholars, in disputes about hiring and promoting faculty, in priorities for research funding, and in disparate approaches to direct practice changes. If the profession is at a crossroads, as some believe, then it is time to clarify the domain of nursing, choose a direction for the pathway that is domain specific, describe what this pathway looks like, and create strategies for knowledge development on that pathway. Leaders in nursing have long recognized that the discipline's scholars should continue to “identify, verify, structure, and continually update the extant content or subject matter of the discipline.”3 (p16) This obligation remains a priority for creating nursing's future.4 , 5 The 21st century calls for describing clearly the domain of nursing and deriving knowledge development for that domain that envisions nursing's future and identifies the strategies needed to create this future. In an earlier article, I proposed a definition of nursing science and a structure for nursing knowledge for the domain.5 This definition is a beginning for having domain-driven content and a central role for nursing theory.
I define nursing science as “the knowledge derived from the goals and values of the discipline focused on persons and environment as described in theories and studied with multiple methods of inquiry and integrated with relevant practice-shaped basic sciences.”5 (pp90-91) I see nursing science defined in this way as the outline of the domain of nursing. The science developed within this domain is what nurses contribute to promoting health of people. The purpose of this article is to explore the implications of taking the pathway of science of nursing that is domain-derived and practice-shaped from basic sciences. What does renovation of the place of theory in domain-driven knowledge look like? How do nurses update strategies for developing theory at all levels? What are the research agenda and strategies for this knowledge? How do nurses integrate domain-derived knowledge with basic science practice-shaped knowledge? What are the relevant criteria and processes for comparative evaluation of theories as reenvisioned?
Statements of Significance
What is known or assumed to be true about this topic:
In a time of rapidly developing sciences, it seems that nursing may be at risk of losing its own focus on nursing knowledge development for practice.
What this article adds:
This article defines the domain of nursing, and a central unifying goal then shows both what domain-driven knowledge is and how it can meet the goals of nursing practice. I outline a central role for nursing theory together with practice alliances.
NURSING THEORY IN DOMAIN-DERIVED KNOWLEDGE
A domain is defined as a sphere of knowledge, influence, or activity.6 In the 1968 Symposium on Nursing Theory we celebrated, Ellis7 noted that the domain of nursing practice should delimit the domain appropriate to theory development for nursing. Furthermore, inquiry that can improve nursing practice requires both methodological development and theory development. The noteworthy article by Donaldson and Crowley8 outlined knowledge in broad form for nursing as an academic and practice discipline that focused on ways of knowing and substantive content. Nurses have long made efforts to identify the body of knowledge for practice or the domain of nursing. Rodgers9 summarized this history and concluded that nursing needs to move beyond the past to expand the knowledge base and realize the potential for nursing by a reconsideration of the core of nursing. Indications are strong that we need to revisit and redefine the place of nursing theory in developing nursing knowledge contemporarily. Given the growth of the discipline, nursing needs a renovation of how the profession looks at knowledge. To facilitate the project of renovation, an exploration of the place and role of theory in knowledge development is required. Scholars can strengthen the relationship of theory and practice. Furthermore, it is time to examine the developments in nursing theory since the 1980s and past and present contributions. From this perspective, we can update strategies for developing theory for practice in the future at 3 levels: grand theory, middle-range theory (MRT), and practice-level theory. Examining nursing theories, based on person and environment integration and using multiple methods of inquiry, will lead the way to drive and carry out the research agenda for the profession. This direction setting is a significant part of recognizing the implications of choosing the pathway of focusing on the domain of nursing and the domain driving nursing knowledge development.
Theory and knowledge development
Theory is central to knowledge development in all disciplines. In early work, Zetterberg10 cited the 1045 propositions listed as research findings related to human behavior and noted that they are not theory. The author pointed out that facts alone do not lead to major advances in any science. The function of theory is to interrelate concepts and data so that they can be interpreted and unified. Dubin described the atmosphere he encountered at the University of Chicago, as a student in social sciences, being permeated by “constant clashes between self-conscious empiricists and rather defensive theorists.”11 (pvii) As a faculty member, he later developed a seminar in theory building to put together theory and empirical research for use by working social scientists. Scientific work of explaining and understanding goes on when scholars create and test theories. Literature in philosophy of science, in other disciplines, and in nursing has shown that in a theory, scholars identify concepts and interrelate concepts in propositions that they turn into hypothesis to be tested.12–15
Rodgers9 indicated that the theory development movement, beginning in the late 1960s, promoted a systematic expansion of knowledge appropriate for nursing. This progress continued through the end of the 20th century and into the 21st century with new features and questions. In summary, the 20th-century developments included maturing of the discipline; clarifying the theoretical focus of nursing as holistic persons with processes and patterns for environmental integration to attain well-being; and a plurality of grand theories that provided for articulating and testing of theories in practice and research. Two surveys since 2000 show continued theoretical work at several levels. Im and Chang16 looked at nursing theory literature from 2001 to 2011 to identify trends. Grand theories publications numbered 257 and documented how authors used the theories to refine concepts, test associations, create instruments, and guide practice. In this survey, the most commonly used of the grand theories were those of Neuman, Orem, Rodgers, and Roy. The authors reported 84 articles about MRTs, in which the authors linked MRTs to research, developed them from grand theory, used MRTs to create instruments, and used MRTs in practice. Of the 13 publications identified that related to situation-specific theory (SST), they documented links to research and that the authors created SST from grounded theory findings or concept analysis.
I did a similar review that covered the theoretical literature from 2011 to 2016 (C. R., unpublished data, 2018). Within a 5-year period, there were 443 publications focused on grand theories. The authors described the various uses of grand theories in research and/or practice or how they extended the theories in some way, including measurement for research and for deriving MRTs. In this report, the most commonly used grand theories were of Neuman, Orem, Roy, and Watson. I identified 144 articles on MRTs with a broad range of uses for knowledge development and practice. The articles variously explained MRT in research projects; derivation from other MRTs or from combining grand theory and MRT; their source from basic science theory; how they had been tested in education initiatives; their expansion to other disciplines; and how authors recommended using paradigms to derive MRT. In the recent 5-year review, I also found 27 SST articles. These showed links to research; how authors derived SST from grand theory and MRT; extensions to permit measurement; and descriptions of their evolution from grounded theory findings or concept analysis. From these 2 reports, one can note that theoretical work is extensive in the 21st century and is involved in many strategies for knowledge development.
One of the trends that Im and Chang16 noted was “integration in practice” as grand theories, and sometimes theories from other disciplines, were applied to specific areas of practice. The authors noted that this trend could be interpreted as a long overdue effort to have prescriptive theories that can guide nursing practice. Still, the impact of the theories on the multidisciplinary health care scene is not clear. Particularly, the theories have not answered clearly the questions of what kind of knowledge is needed for nursing in a rapidly changing world of science and how it will be created. Still this work seems not to be compelling enough for other disciplines to recognize the unique contribution nursing theories make to health care.
Types of theories and updated strategies for development
In the proposed domain-led view of nursing knowledge, nursing theory at 3 levels—grand, middle-range, and practice—holds the central position. In the first edition of Advances in Nursing Science, Chinn and Jacobs17 claimed that theory development was the most crucial task facing nursing because of its predictive potential. Theory development was the major means by which nursing could accomplish its identified goals. Theorists have variously stated the goals of nursing. In the proposed perspective on knowledge, I recommend that nursing use the central unifying focus of the discipline derived by Willis et al.18 I call humanization the central goal to simplify the conceptual and structural rendering of the goals, with the understanding that this includes meaning, choice, quality of life, and healing in living and dying. The role of nursing theories is to explain these common goals of nursing and the activities or processes to accomplish them. We have seen broad development of nursing theories. It is now time to direct the potential of theory building toward creating knowledge to achieve the goals of nursing practice. In the previous article, I placed the goals within an updated structure.5 For this article, I focus in greater depth on knowledge development, the what, and the how.
Theories in nursing have a plurality of foci. Focusing on nursing knowledge development (Figure 1), theories are placed at the center and their aim is to explain and fulfill the common goals of the discipline. There is agreement that in general nursing goals mean the outcome to be accomplished by using nursing knowledge-based activities in contributing to health. The goals are the unique function for which the profession exists and therefore is accountable to society to achieve. Early on, Johnson19 , 20 described the importance of articulating clear goals to develop knowledge for nursing. Some authors more recently link both professionalism and ensuring viability of nursing to knowledge with a unique goal.15 , 21
The central unifying focus article,18 of which I was one of the authors, evolved from our conversations and concerns that all nurses should be able to articulate clearly a central focus for their work. We believed that synthesizing from the historical and extant literature this focus and clearly articulating it would provide an anchor for all levels of nurses, nursing scholars, and particularly nursing practice. It would at this time in nursing history clarify who we are as a profession. From this position, it would be clear what nursing could offer individuals and society. Our analysis provides perspective for the discipline—facilitating humanization, meaning, choice, quality of life, and healing in living and dying. Willis et al offer that a central unifying focus can unite us within the discipline, “serve as a basis for our continuing scholarly evolution, and foster interdisciplinary work in which nursing is clearly and substantively visible.”18 (pE31)
The goal of facilitating humanization is manifested in nursing practice “when the nurse works with all human beings grounded in an ontology of human beings as relational, experiential, valuable, respect-worthy, mean-oriented, flawed, imperfect, vulnerable, fragile, complex, and capable of health and healing even if not capable of being cured.”18 (pE34) Humans reach meaning by understanding life experiences and their significance as they process those experiences, often with another person. Choice is the human capacity for making personally derived decisions that are congruent with one's values, beliefs, and meanings and depend on the person's developmental and reasoning skills. Quality of life is the value and significance that individuals ascribe to their lives within their changing situations. By the goal of healing in living and dying, Johnson means “the multidimensional unitary human-natural world process of restoring bodily experiences of wholeness, meaning and integrity of one's existence in a human body in the world and changing until death.”19 (pE35) Healing may occur in the absence of resolution of a physiological disruption or may not occur when a disruption is resolved. These goals provide a unique focus for nursing knowledge in language that is understandable in practice and for other health care disciplines and that the public we serve will value. This perspective has received wide acceptance and is quoted by others.12 , 22
According to Wills et al,18 these goals represent an interpretation and convergence of ideas in major nursing conceptual and theoretical works. Nursing theory at 3 levels—grand, middle-range, and practice—will lead domain-derived knowledge to achieve the goals of the discipline. Domain-derived knowledge is the development of knowledge by nurses for nursing within the central focusing goals of the discipline and based on nursing theory. It is the knowledge that is unique to nursing practice. Grand-level theories are those that provide a broad perspective to understand the key concepts and principles within nursing. Descriptions of the history of nursing theory generally start with Peplau's work on interpersonal relations in nursing in 1952 and emphasize theories by Orlando, Wiedenbach, Henderson, Levine, and Ujhely in the 1960s. The 1970s and 1980s were rich with nursing theories by Rodgers, King, Orem, Travelbee, Neuman, Roy, Newman, Johnson, Parse, Erickson et al, Leininger, Watson, Roper et al and Newman, with Boykin and Schoenhofer added in the 1990s. The contributions of theories are described elsewhere (see Fitzpatrick and Smith, in this issue).5
What I suggested in the 21st-century structure proposal for creating nursing knowledge based on common goals is that as each theory continues to develop, the scholars, often a next generation from original grand theorists, will make explicit the relationship of the theory's given perspective to the common goals of the discipline. That is, the theorists and those working in their organizations can link grand theories to the goal of facilitating humanization and all that that means. All the grand theorists address the person and environment connections related to health, and adding the specificity of the common focus is both possible and of great advantage to nursing knowledge. Each grand theory can describe specific ways that nurses can facilitate humanization, meaning, choice, quality of life, and healing in living and dying. Promoting self-care or adaptation or finding ways to expand consciousness and human becoming provides multiple beliefs, principles, and strategies to achieve the common goals of nursing. Unity at the broad level brings the discipline together and makes our purpose clear to others. The plurality of approaches at the grand theory level provides rich insights into how to view clinical situations. Some grand theories have stood the test of time and as noted earlier have wide publications. Furthermore, some theorists are still working on the development of their work, particularly Parse, Watson, and Roy. Second-generation individuals and theory organizations carry out the work of grand theory development, for example, the International Association of Human Caring, International Caritas Consortium, International Consortium of Parse Scholars, Neuman Systems Model Trustee Group, Inc, Orem International Society, Roy Adaptation Association, Society of Rogerian Scholars, Transcultural Nursing Society, and Watson Caring Science Institute. This work is important as the groups form schools of thought that generate scholarship as frameworks for research and guides for theory-based nursing practice.22 The grand theories in use that meet the criteria for theory evaluation on the individual level can add to nursing knowledge by claiming the common goals of the discipline. Each theorist can describe, for nursing and other disciplines, how a given perspective fulfills the broad central unifying goal of the discipline, humanization, and all that it entails.
When Wills et al proposed the central unifying focus of the discipline and emphasized facilitating humanization, they stressed that for nurses to articulate the substance of the discipline it was important for “nursing students, at all levels, to be exposed to, study and incorporate the central unifying focus in their practice.”18 (pE37) This argument is extended to suggest that the revised structure of knowledge calls for each nursing textbook/teaching tool to begin with the common goals of the discipline and with a review from each grand theorist, or a successor, that describes how these goals are fulfilled from that theoretical perspective. In this way, nurses will be prepared to learn, create in practice, and extend in research domain-derived person and environment knowledge for practice.
The developments in grand theories and the promise of placing them at the center of nursing knowledge development relate to advances in MRTs for nursing. Historically, MRTs were introduced into nursing in about 1980 based on the work by Mills and Merton in sociology.23 , 24 MRTs are those that can bridge a gap between research and practice. They come between the more abstract grand theories and those theories that are specific to a particular phenomenon. Theory development at the middle range has gained recognition as the latest step in substantive knowledge development. Scholars in nursing have increasingly accepted the work on developing and testing of MRTs as the level of theory development needed to guide nursing research and practice. MRTs by definition do not capture the whole picture of nursing's perspective on the nature of nursing work; rather, they comprise “a set of related ideas that are focused on a limited dimension of the reality of nursing.”25 (pxiii) MRTs are not narrowly focused on explaining a specific discrete phenomenon as in SSTs. MRTs characteristics include that they have a limited number of concepts, and their propositions are clearly stated; they may generate testable hypotheses; they can be generalized across settings and specialties; they can apply more directly to practice and can be empirically tested; and they are more easily comprehended by readers of practice journals. Meleis22 called an MRT a significant milestone beginning about 1991 to 1995 that marked considerable progress in knowledge development. In particular, MRTs focus on specific nursing phenomena that reflect and emerge from nursing practice and focus on the clinical process. The number of MRTs has increased significantly in the 21st century. There are books devoted to MRT,25 and the more encompassing books on nursing theory now include MRTs.26 Some of the best know MRTs are Meleis' theory of transitions, Mischel's uncertainty theory, and Mercer's theory of becoming a mother.
Scholars use many strategies to develop MRTs including deduction from grand theories. An example is Levine's conservation model used to develop a theory of health promotion for preterm infants. Another common approach scholars use is MRTs developed from inductive research. For example, grounded theory was the approach for Corbin and Strauss' trajectory theory of chronic illness management. Other scholars use concept analysis to construct MRTs such as the Bu and Jezewski theory of patient advocacy. Induction from practice is also a common strategy as in Meleis' observations of immigrants that led to identifying the major concepts of the theory of transitions. Some MRTs are combinations of existing theories from nursing and other fields as in Dunn's theory of adaptation to chronic pain that uses the Roy adaptation model with the gate control theory of pain, stress, and coping theory and the relaxation response. Pender derived the health promotion model, considered a MRT, from expectancy and value theory described by several authors and Bandura's social learning theory.
Some criticisms of MRT focus on the lack of definitional clarity that leads to a lack of precision about what constitutes an MRT. Other authors have been concerned that increasing numbers can lead to fragmentation of nursing's knowledge base into unrelated and distinct theories. Some authors note that nursing has continued reliance on outdated psychosocial theories and less on nursing.22 Roy's review of the literature from 2011 to 2016 showed some use of MRTs in research, practice, and education. How extensive this use is remains unclear, and we have not answered the question of the impact of MRTs in practice and in multidisciplinary dialogue.
In showing the implications of the proposed perspective for developing nursing knowledge, I view MRTs as a part of domain-derived knowledge and suggest ways this work can proceed under the common goals of nursing. The key for how this can occur came from a rereading of Merton.27 He began his treatise on MRTs by considering their relationship to the broader, classic theories in sociology. Three of Merton's characteristics of MRTs offer some insights to think about relating middle-range and grand theories in nursing today. First, Merton noted that these theories (MRTs) “do not remain separate but are consolidated into wider networks of theory.”27 (p68) Furthermore, because of how they are developed, many theories of the middle range are consonant with a variety of systems of sociological thought. Finally, theories of the middle range, Merton pointed out, “are typically in direct line of continuity with the work of classical formulations. Durkheim and Weber's work furnish ideas to be followed up, exemplify tactics of theorizing, provide models for the exercise of taste and selection of problems, and instruct us in raising theoretical questions.”27 (p66)
Nursing knowledge today is at a more developed stage than sociological knowledge when Merton summarized the attributes of MRTs and nursing knowledge, as a practice discipline is different in many ways from sociology. Still, for nursing today, the promise of the impact for nursing knowledge may be realized by deriving strategies to link MRTs into wider networks. The first question in creating such networks would be “what are the criteria for linking?” One might think of clinical areas of practice. However, areas of practice use wide ranges of knowledge in dealing with holistic persons, families, and communities. Rather, under the perspective of nursing proposed the logical choice for linking MRTs is how given theories reach the goals of the discipline. The work of grand theories in describing how they are used to accomplish the goals of nursing can be helpful. In some cases, it might be appropriate to identify the grand theory most useful in understanding the MRT. This suggestion may seem strange. Still, we are trying to move forward with nursing knowledge that is not fragmented, is recognizable, and has an impact. It may be worthwhile to follow this line of thinking in developing strategies for nursing knowledge development. Grand theorists, and their successors, can identify MRTs that fit their conceptualizations or theorists of the middle range can identify to which grand theories their work can contribute. We might anticipate that some MRTs would not relate to any given grand theory. These theories, considering the goals of nursing, might have other conceptual links. Making such links explicit can contribute creative insights into nursing knowledge now and for the future.
One example of relating middle-range and grand theories stems from a theory-based research review project by Roy and associates, with myself as the leader of the executive board of the Roy's association.28 The team reviewed 200 studies of Roy's model-based research published from 1995 to 2010. Of these studies, 172 met established criteria for sound research and criteria for adequate links to the nursing model. The studies published in refereed journal numbered 106 and dissertations were 72. The articles were published in 47 English-language journals, and the dissertations were completed at 32 different universities in the United States. The team developed a 6-step process for creating 5 new MRTs. (1) Studies that were alike conceptually were clustered together and each cluster included studies using a number of different qualitative and quantitative research methods. (2) The studies were used as observations and concepts identified under the Roy's model concepts of stimuli, coping processes, and outcomes. (3) The team members responsible for a given cluster synthesized the concepts as discrete and observable but at a level of abstraction that could be generalized across clinical situations. For example, in the MRT of adapting to loss, the team member identified the focal stimuli as loss, a profound emotional experience. (4) For each cluster of studies, team members then derived theoretical statements or propositions relating to the concepts. (5) The team used the stated propositions to draw a pictorial schema of the interrelated concepts. (6) The final step was that the findings from the research provided evidence to support the new MRT. The MRTs developed were general coping, adapting to life events, adapting to loss, adapting to chronic health conditions, and adaptation in family health.
Using grand theories has been recognized as one approach to developing MRT. Furthermore, we saw that in a 10-year review, one theme in theory development identified by Im and Chang16 was grand theories used to create MRTs. There can be considerable advantages to filling out the perspective of knowledge by consciously extending the connection between middle-range and grand theories. The wide recognition of the appropriateness of MRT for research and practice can make this an appealing approach to those who are committed to a particular grand theory approach. These scholars now can extend their efforts to be at the forefront of developing knowledge for the discipline that is oriented toward the common goals on the broad level, facilitating humanization, meaning, choice, quality of life, and healing in living and dying.
A third level of nursing theory has been variously called practice theory, SST, and microtheory, all with differing histories but treated similarly in nursing knowledge discussions.13 Dickoff and colleagues began to write about specific approaches to practice theory in the 1960s.29 The most widely recognized article on the approach was that published from the symposium on nursing theory by Nursing Research. 29 The authors were philosophers working with the nursing faculty at Yale University. They called the approach practice-oriented theory with 4 phases leading to a theory base for nursing practice. The phases were factor isolating (descriptive identifying of concepts), factor relating (situation depicting), situation relating (predictive statements), and situation producing (prescriptive statements). Although the authors described the process in detail, Walker and Avant14 noted that the activity component, that is, predictive statements, was vague as a guide to constructing the practice theory. In conjunction with colleagues, Dickoff and James,30 in the tradition of Yale University focusing on nursing practice, promoted practice theory simultaneously with the early days of the grand theory movement. The term “practice theory” at that time referred to seeing the causal nature of theoretical statements that had a specific desired goal and then stated the prescriptions for action to attain the goal.
Walker and Avant gave several reasons for the slow development of this type of theory including the astute observation that a theory for nursing practice “requires a well-developed body of nursing science on effective nursing interventions.”14 (p18) There have been efforts toward developing knowledge of nursing interventions, particularly the projects out of the University of Iowa related to taxonomies of interventions and outcomes related to nursing diagnoses.31 , 32 While these projects are making contributions to nursing practice, they are generally seen as providing possibilities for knowledge development but not for theories seen as practice theories. Some research teams have focused on particular practice phenomena, created theories, and applied these theories to research with many populations, for example, the University of California at San Francisco School of Nursing developed a symptom management model.33 The model includes the experience of symptoms, symptom management strategies, and symptom outcomes. The members of the team have used the model to address fatigue in the care of persons with HIV/AIDS and management of symptoms among African Americans with diabetes. Other sources of knowledge-based interventions are the databases for evidence-based practice. The place of this work in nursing knowledge is being debated.34
Im and Meleis35 published an article on SSTs. The authors defined these as theories that focus on specific nursing phenomena that reflect clinical practice, are limited to specific populations or to particular fields of practice, and provide a particular context, historical or social. Eventually, these theories could be specific enough to provide blueprints for action. SSTs could emerge from synthesizing and integrating research findings and clinical experience about a specific situation or population. Meleis noted that with SSTs, there is “the intent of giving a framework or blueprint to understand the particular situation of a group of clients.”22 (p78) SSTs are limited in both scope and focus. One example is the Bennett et al36 SST of cognitive deficits among patients with heart failure. Fifteen years after the first article, Im37 conducted an integrated literature review on SSTs published since the first article and identified 19 SSTs and extracted 4 themes from the synthesis. One theme was that the authors either claimed or they did not claim an SST. Multiple theoretical bases were used along with unique theorizing methods. Although the theorists provided clear directions for nursing interventions, these were rarely evaluated.
The third term used for the final level of nursing theory is “microtheory.” This term is used in books on nursing theory but is not discussed as a preferred term related to practice. In the general nursing literature, there appear to be 2 movements in nursing that stimulated a specific use of the term. First in the postmodern turn in nursing epistemology.9 Rodgers related literature indicated the need to focus on microtheory, presumable meaning the relationship of concepts in the immediate situation. For example, Lupton38 refers to microtheory when discussing power in the nurse and medical encounter. Another movement that encouraged scholars to use the term was the “evaluation of quality of nursing care.” Sidani et al39 noted that the focus in the theory-driven approach to evaluation is on identifying patient, professional, and setting characteristics that affect the processes of care at micro and meso levels, which, in turn, contribute to outcome achievement. From this brief review, it appears that this is not a term that is used broadly to indicate theory at the practice level. Rather, it is a description of how to focus on concepts in practice for given purposes.
Given the history and ongoing use of the 3 terms, the term “practice theory” is selected for the third level of theory placed in the middle of the perspective on knowledge development proposed. It already has a meaning to nurses and other health care providers. In addition, it has a history that provides more potential than has been realized to date. The question now is how practice theory can be developed to contribute to the renovated place of theory in domain-derived nursing knowledge that accomplishes the goals of nursing as facilitating humanization, meaning, choice, quality of life, and healing in living and dying. Early in the theory development era, Ellis40 highlighted the role of the practitioner as theorist. Roy5 pointed out that the profession experienced the loss of many years of practitioners not playing an integral part in theory development. I have mentioned, Walker and Avant's14 observation that in the 1960s, Dickoff and James' practice-oriented theory with 4 phases did not immediately lead to developing theories of this type, partly because of the lack of a well-developed nursing science on effective nursing interventions. With the nursing knowledge developed in the intervening years, significant progress has been made in efforts related to interventions such as those described earlier. Furthermore, nurses in practice identify the needs for new knowledge to work effectively within the complexities of the current practice arena. Nurses in practice today are natural partners for theorists in developing practice theory.
In describing the characteristics of practice theory, McEwen and Wills41 noted that practice theories may be derived from middle-range or grand theories, from clinical practice, and/or from research. Their function is similar to other levels of theory, that is, to describe, explain, predict, or prescribe specific nursing practices. These authors also noted that the nursing literature reflects only a few examples of practice theories. To be central to knowledge development in nursing, as with middle-range and grand theories, what is needed are the links that place practice theory in direct line with contributing to the broad goals of nursing. Consistency and logic require these links to be conceptual and theoretical. I have already introduced the notion that nursing textbooks/teaching tools will begin with describing the common goals of nursing. Furthermore, these introductions would describe how each nursing grand theory provides perspectives for achieving these goals. The creating of practice theory could receive a major forward impetus by being related to established middle-range and/or grand theories. More nurses are attaining PhD degrees and desiring to maintain positions in practice. This situation can provide a basis for institution-centered theory-based practice. The Magnet Recognition Program has led the way in nurses creating professional practice structures. Both Watson and Roy report working with hospitals related to implementing their theoretical work as the basis of building a nursing philosophy, and studies are in progress to evaluate this effectiveness of the process (Turkel, unpublished report 2018). A schematic (Figure 2) of the central portion of the process of domain-derived nursing knowledge development, the linking of levels of nursing theory, is presented in what I call the domain-derived nursing knowledge tree.
I am not advocating mandating that institutions focus on given grand theories but simply suggesting the advantages to the process of developing practice theory when nurses are committed to common assumptions about nursing and to common goals. Placing theory experts with practicing nurses will enhance the natural growth of solving clinical problems with theory-based knowledge. The literature has long included the observation that practicing nurses use implicit theory rather than explicit theory.41 , 42 Similarly, the gaps between research and practice, between theory and practice, and between evidence-based practice and practice are frequent themes. Trying a new approach to linking theorists and practitioners has promise of closing these gaps and making explicit the knowledge used in practice. Bender and Feldman43 propose a specific kind of practice theory that links the environment domain of nursing theory with real-world environments where nurses practice. The result could be nurse-led delivery models such as those featured in the EdgeRunner program.44
With theory placed at the center of nursing knowledge development, I have suggested some updated conceptual/theoretical strategies for developing theory in the future at 3 levels, grand theory, MRT, and practice-level theory. From the discussion of these theories, based on person and environment integration, the use of multiple methods of inquiry is recognized. Nurse scholars often use quantitative empirical approaches to test middle-range and practice theories. The nursing theories provide clear delineation of the concepts and their interrelationships. From statements of relations between the concepts, known as propositions, researchable questions are derived. Methods and measurement to answer the questions follow a clear theoretical framework. Outcomes of empirical studies are feedback to clarify the middle-range and practice theories and offer insights to refine grand theories. Philosophical inquiry clarifies the values of nursing theory at all levels. In addition, it provides the epistemological understandings as to when and how to use approaches other than empirical. For example, based on philosophical inquiry, a scholar using Parse's theory of human becoming would understand the use of qualitative research in expanding knowledge on the middle-range or practice level. Other grand theorists such as Watson and Roy use assumptions and theoretical formulations that rely on both qualitative and quantitative research to further their work.
I have placed theory at the center of the development of knowledge and renovated its role in describing, explaining, and predicting by expanding the strategies to create and link theory at all levels. This renovation puts nursing theory in a position to drive and carry out the nursing research agenda. The question of what domain-derived knowledge is needed to attain the goals of nursing is answered by the theory development described. The needs for knowledge of persons in their environments are embedded in each nursing grand theory and will continue to change as the demands on persons and the health care environments change. As noted, one can envision a tree of knowledge, with grand theories linked to MRTs linked to budding practice theories. We may also see a ring of bushes around the tree that represent related consolidations of networks of MRTs and practice theories that may yet grow into grand theories of their own. With clear goals for the discipline, we can recognize where knowledge is lacking and a new theory with related knowledge development is needed. Nurse scholars, beginning and advanced, can identify where their knowledge development work fits on the tree and what related work is needed. Or, a scholar may plant a new bush.
At the same time that we update the role of theory in creating nursing knowledge, we will also need to update the evaluation of nursing theory. The development of domain-derived knowledge stemming from theories raises the obligation to evaluate the effectiveness of theories for meeting practice goals. Theories to be epistemologically rigorous will accurately represent the phenomenon, be philosophically sound and able to direct practice.45 Quality for a theory requires that we can say a given theory accounts for and explains certain facts in practice better than rival theories. Effective changes in practice can be created from the robust basis of rigorously developed theories. Theory evaluation criteria have been proposed by a number of scholars from the 1960s through the 1990s.15 These criteria are used to evaluate one theory at a time and do not provide for comparisons. The approach has been useful to help nurses become familiar with nursing theories. Paley,46 a non-nurse philosopher, noted that the vagueness of many nursing theories leads to questions about what observations can be explained by what theory. In the literature, I did not find designs for comparing various nursing theories and, possibly, they do not exist. Recognizing this need, for a number of years, 1982 to 1988, I designed and attempted to conduct a study that permitted the comparison of 3 major theoretical approaches in 3 defined clinical situations, called the MINC project (Models in Nursing Care). This venture failed because I could not find a clear implementation strategy for one of the theoretical perspectives among the experts I consulted at that point in time.
Methodological issues in testing nursing theories are abundant. Nursing theories not only assume holism of persons and belief in expressed patterns but also consider that these may be almost infinite in their variety. Constantly, we call into question the adequacy of outcome measures. In general, nursing does not do enough refinement and replication of studies. Many phenomena in nursing require longitudinal studies. The proposed nursing knowledge development schema includes time as a concept under the domain-derived person and environment knowledge development. In many nursing conceptualizations, time is needed, for example, for building relationships and for processes of humanization, finding meaning, and healing. Comparative evaluation of the effectiveness of different models in given clinical situations will not be easy. Still, it is an important strategy in nursing knowledge development. The definitions by theorists of how their assumptions contribute to nursing goals will help clarify the variables of interest. The teams of theorist experts and practice nurses will help make possible the time needed for comparison and longitudinal studies. The outcomes of such studies are important to the continued development of knowledge for nursing.
PRACTICE-SHAPED KNOWLEDGE FROM THE BASIC SCIENCES
In filling out the proposed perspective of knowledge development (see Figure 1), the all-important step of integrating the theory-based domain-derived knowledge with the basic science practice-shaped knowledge follows. With rapidly developing sciences, nurse scholars are challenged to raise significant questions from the discipline perspective so that new science knowledge is created that can be practice-shaped for use in nursing. In a recent article, I proposed “that deriving an updated structure for nursing knowledge can move the discipline forward by making nursing theory the global positioning system (GPS) for knowledge development.”5 (p89) What does integrating new knowledge in life sciences—including genomics and omics, behavioral, social, biomedical, and management sciences—into nursing knowledge look like? What kind of strategies can be used to create this integration?
Nursing has long integrated other sciences into nursing knowledge. The challenge now is that with information technology developments, these sciences are developing rapidly in both depth and breadth. Henly47 noted that these developments can be a part of nursing science as another way of looking at individual differences. It is neither simply adding knowledge nor setting aside our nursing perspective. The author suggested the omics create circumstances needed to incorporate biology with psychosocial and behavioral aspects of nursing science and thereby create an in-depth, multiscale, dynamic understanding of people related to health and illness. Nurses can identify the practice-shaped knowledge they want to integrate by asking questions such as: How close is this knowledge to being ready for human use? Is the basic science knowledge compatible with nursing's central unifying goals? Do nurses have the capabilities to shape this knowledge with the realities of practice so that it can be integrated?
Some nurse scientists may contribute to knowledge development of the basic sciences. At the professional crossroads where we stand, it is important to not detour from our primary professional commitment to develop domain-derived knowledge for use in practice. As noted earlier,5 nursing's domain-derived knowledge can be helpful to scientists/practitioners from other disciplines who contribute to dealing with human health issues. Nursing can inform basic science knowledge for application to people. The essential point is that for nurses to achieve the goals of the discipline and maintain our social mandate as the profession of nursing, we must focus on domain-derived knowledge.
Nurses must use the majority of our scholarly resources to develop the domain-derived knowledge. We will likely develop new nursing knowledge development roles that are part of upscaling from individual practice to changes in practice at the organizational level. Nurses can describe practice-shaped basic science for nursing as theories from sciences other than nursing that have been examined and honed to meet the goals of nursing in practice. We need nurses who can evaluate developing sciences, beginning with the questions listed earlier. The steps of practice-shaped knowledge will require nurses with knowledge and commitment to the practice arena. This role will also require creative ways of communicating between basic scientists and practicing nurses. In 2012, Brennan and Bakken48 wrote about how nursing needs big data and big data need nursing. The authors provided a graphic depiction of the role of nursing theory in data-driven research. For example, theory determines how such data are structured and visualized. Science knowledge developments can be classified by level of readiness for practice. Resources for nurses to learn about developments can be provided. Special information technology bulletin boards may be useful. Programs of trial implementation can be instituted. Given the significance of the path we are taking, these trials may receive funding at the same level as the basic science funding for nurses. Nursing's roles in transforming basic science knowledge for use in practice will make nursing more visible. Nurses will help enhance adoption of best practices in the community and collaborate to change health care to bring nursing science to every setting where needed. The domain-derived knowledge provides the voice nurses need at the interdisciplinary table to lead research that envisions a goal of humanization (see the last row of Figure 1).
Nursing may be at a crossroads, with the balance for knowledge development among philosophical, conceptual/theoretical, and empirical inquiry seemingly tilting toward prioritizing the empirical approaches. This imbalance is related particularly to what are called the emerging areas of basic sciences. The issue is that this movement may obscure our primary obligation to develop nursing knowledge that is domain driven. Given this concern, in this article, I have clarified the domain of nursing and described the central role of nursing theory in creating domain-derived nursing knowledge to attain the common goals of nursing. These goals are based on a central unifying focus for the discipline that includes facilitating humanization, meaning, choice, quality of life, and healing in living and dying.18 The knowledge development perspective and derived strategies include integration with practice-shaped basic sciences. I have suggested strategies to implement this knowledge development with outcomes for patients/families, organizations, and multidisciplinary research.
1. Grace PJ, Willis DG, Roy C, Jones DA. Profession at the crossroads: a dialogue concerning the preparation of nursing scholars and leaders. Nurs Outlook. 2015;64(1):61–70. doi:10.1016/j.outlook.2015.10.002.
2. Henly SJ, McCarthy DO, Wyman JF, et al Emerging areas of science: recommendations for nursing science education from the Council for the Advancement of Nursing Science Idea Festival. Nurs Outlook. 2015;63(4):398–407. doi:10.1016/j.outlook.2015.04.007.
3. Schlotfeldt R. Structuring nursing knowledge
: priority for creating nursing's future. Nurs Sci Q. 1988;1(1):35–38.
4. Kim HS. Critical narrative epistemology. In: Roy C, Jones DA, eds. Nursing Knowledge
Development and Clinical Practice. New York, NY: Springer; 2007:201–213.
5. Roy C. Key issues in nursing theory
: developments, challenges, and future directions. Nurs Res. 2018;67(2):81–92.
7. Ellis R. Characteristics of significant theories. Nurs Res. 1968;17(3):217–222.
8. Donaldson SK, Crowley DM. The discipline of nursing [reprinted in: Reed PG, Shearer NC, Nicoll LH. Perspectives on Nursing Theory
. 4th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2004:293–304]. Nurs Outlook. 1978;26:113–120.
9. Rodgers BL. Developing Nursing Knowledge
: Philosophical Traditions and Influences. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
10. Zetterberg H. On Theory
and Verification in Sociology. Totoux, NJ: Bedminister Press; 1954.
11. Dubin R. Theory
Building. New York, NY: The Free Press, A Division of Macmillan Publishing Co Inc; 1969.
12. Reynolds P. A Primer in Theory
Construction. Indianapolis, IN: Bobbs-Merrill; 1971.
13. Moody L. Advancing Nursing Science Through Research. Newbury Park, CA: Sage; 1990.
14. Walker LO, Avant KC. Strategies for Theory
Construction in Nursing. Upper Saddle, NJ: Pearson-Prentice-Hall; 2011.
15. McEwen M, Wills EM. Theoretical Basis for Nursing. 4th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2014.
16. Im EO, Chang SJ. Current trends in nursing theories. J Nurs Scholarsh. 2012;44(2):156–164.
17. Chinn PL, Jacobs MK. A model for theory
development in nursing. ANS Adv Nurs Sci. 1978;1(1):1–11.
18. Willis DG, Grace PJ, Roy C. A central unifying focus for the discipline: facilitating humanization, meaning choice, quality of life, and healing in living and dying. ANS Adv Nurs Sci. 2008;31(1):E28–E30. doi:10.1097/01.ANS.0000311534.04059.d9.
19. Johnson DE. Theory
in nursing: borrowed and unique. Nurs Res. 1968;17:206–209.
20. Johnson DE. Development of theory
: a requisite for nursing as a primary health profession. Nurs Res. 1974;23:372–377.
21. Cody W, Mitchell G. Nursing knowledge
and human science revisited. Practical and political considerations. Nurs Sci Q. 2002;15(1):4–13.
22. Meleis AI. Theoretical Nursing: Development and Progress. 5th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2012.
23. Lenz E. Mid-range theory
: impact on knowledge development and use in practice. In: Roy C, Jones DA, eds. Nursing Knowledge
Development and Clinical Practice. New York, NY: Springer; 2007:61–77.
24. Hardy ME. Evaluating nursing theory
. In: Theory
Development: What, Why? How? New York, NY: National League for Nursing; 1978:75–86.
25. Smith MJ, Liehr P. Middle Range Theory
for Nursing. 3rd ed. New York, NY: Springer; 2014.
26. Alligood MR, Marriner Tomey A. Nursing Theorists and Their Work. 8th ed. St Louis, MO: Elsevier Mosby; 2014.
27. Merton RK. Social Theory
and Social Structure. New York, NY: The Free Press; 1968.
28. Roy C. Generating Middle Range Theory
: From Evidence to Practice. New York, NY: Springer; 2014.
29. Dickoff J, James P. A theory
of theories: a position paper. Nurs Res. 1968;17(3):197–203.
30. Dickoff J, James P, Wiedenbach E. Theory
in a practice discipline, part I: practice oriented theory
. Nurs Res. 1968;17(5):415–435.
31. Bulechek GM, Butcher HK, McCloskey Dochterman JM, Wagner CM. Nursing Intervention Classification. 6th ed. St Louis, MO: Elsevier; 2012.
32. Herdman T, Kamitsuru S; NANDA International, Inc. Nursing Diagnoses Definitions and Classification: 2015-2017. 10th ed. Ames, IA: Wiley-Blackwell; 2014.
33. Dodd M, Janson S, Facione N, et al Advancing the science of symptom management. J Adv Nurs. 2001;33(5):668–676.
34. Porter S. Fundamental patterns of knowing in nursing: the challenge of evidence-based practice. ANS Adv Nurs Sci. 2010;33(1):3–14.
35. Im EO, Meleis AI. Situation-specific theories: philosophical roots, properties, and approach. ANS Adv Nurs Sci. 1999;22(2):11–24.
36. Bennett SJ, Sauve MJ, Shaw RM. A conceptual model or cognitive deficits in chronic heart failure. J Nurs Scholarsh. 2005;37(3):222–228.
37. Im EO. The status quo of situation-specific theories. Res Theory
Nurs Pract. 2014;28(4):278–298.
38. Lupton D. Perspectives on power, communication and the medical encounter: implications for nursing theory
and practice. Nurs Inq. 1995;2(3):157–163.
39. Sidani S, Doran DM, Mitchell PH. A theory
–driven approach to evaluating quality of nursing care. J Nurs Scholarsh. 2004;36(1):60–65.
40. Ellis R. The practitioner as theorist. Am J Nurs. 1969;69(7):1434–1438.
41. McEwen M, Wills EM. Theoretical Basis for Nursing. 3rd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2011.
42. Barnum BS. Nursing Theory
: Analysis, Applications, Evaluation. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1998.
43. Bender M, Feldman MS. A practice theory
approach to understanding the interdependency of nursing practice and the environment implications for nurse-led care delivery models. ANS Adv Nurs Sci. 2015;38(2):96–109.
44. Mason DJ, Jones DA, Roy C, Sullivan CG, Wood LJ. Commonalities of nurse-designed models of health care. Nurs Outlook. 2015;63(5):540–553. doi:10.1016/j.outlook.2015.04.009.
45. Grace PJ. Philosophies, models, and theories: moral obligations. In: Alligood MR, ed. Nursing Theory
: Utilization and Application. 5th ed. St Louis, MO: Elsevier/Mosby; 2014:68–82.
46. Paley J. Theorists and Their Work, 6th ed [book review]. Nurs Philos. 2006;7:275–280. doi:10.1111/j.1466-769X.2006.00276.x.
47. Henly SJ. Editorial. Nurs Res. 2018;67(2):89–90.
48. Brennan PF, Bakkan S. Nursing needs big data and big data needs nursing. J Nurs Scholarsh. 2015;47(5):477–484.