Chapter 5
Patterns of Knowing
and Nursing Science
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Evolution of Scientific Thought
• Early humans differentiated world into two parts: me
(internal), not me (external)
– Used trial, error to discover that patterns of action
led to predictable outcomes
• Nursing functioned primarily from protocols, procedures
• Disease, aches, pains assumed to be caused by gods,
evil spirits
– Early medicine associated with religion or magical
beliefs
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The Search for Certainty
• The 1500s
• Mechanistic world view
– Math
– Determinism
– Counting
– Quantity
– Philosophy of logical
positivism
– Continuity
• Time, space were
absolute
• Humans seen as having
separate psyche, soma
(Cartesian dualism)
– Impersonality
• Principles led Galileo,
Newton to develop
scientific method, based
on logic
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The Relative World of Process
• Scientists realized that physical world consisted of
matter, forces that interact with matter:
– Gravity, magnetism, electricity
• All systems considered interrelated and interdependent,
on continuum of relativity and probability, thus
uncertainty
• Awareness of limitations, biases of individual perception
has increased, implying that truth and meaning are not
absolute but relative
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Philosophy of Knowledge
• Plato
– Knowledge considered to be belief justified through
reason
• Philosophy considers questions such as whether there is
such a thing as truth, how one can be certain that
something is true
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Question
• The prior use of scientific thought prompted nursing to
function using which method to guide care?
A. Good and evil causes for aches and pains
B. Trial and error to discover cause for illness
C. Protocols and procedures to care for clients
D. Logic- and reasoning-guided practice
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Answer
• C. Protocols and procedures to care for clients
• Rationale: Nursing operated on a series of protocols and
procedures that guided client care. Trial and error, evil
spirits, and logic were all past methods of scientific
inquiry or thought. These methods did not guide nursing
practice.
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Processes of Knowing
• Rationalism
• Empiricism
• Intuition
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Approaches to Knowing
• Logical empiricism
– Body of facts, principles
– Cause-and-effect (linear) relationships
– It is necessary to control values, biases to achieve
“objective” knowledge
– Theoretical reduction is important scientific goal
– Whole is sum of parts
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Approaches to Knowing (cont’d)
• Logical empiricism synonymous with logical positivism
– To predict, explain, control world events, situations,
occurrences
– Nursing knowledge based on “hard sciences” has
roots in logical empiricism
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Approaches to Knowing (cont’d)
• Historicism based on these assumptions:
– “Truth” is dynamic, constantly changing
– Whole is more than sum of parts
– Individual or phenomenon must be studied as whole
in natural setting
– Multiple research traditions desirable to explain
different dimensions of same phenomenon
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Approaches to Knowing (cont’d)
• Historicism based on these assumptions:
– Knowledge is related to context
– In professional nursing, historicism provides valueladen approach to nursing knowledge
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Approaches to Knowing (cont’d)
• Postmodernism perspectives on knowledge development
are based on
– Focuses on understanding multiple meanings, ways
of knowing reality, rather than single, transcendent
meaning of reality
– Multiple truths are accepted, knowledge is considered
uncertain, provisional
– Statements reflect concern for context rather than
universality
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Approaches to Knowing (cont’d)
• Postmodernism
– Emphasis of knowledge development shifts “from
concern over the truth of one’s findings to concern
over the practical significance of the findings”
– Problems are not “solved,” but “deconstructed”
– Shift toward lived experience, toward “creativity,
flexibility, uniqueness, local value”
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Patterns of Nursing Knowledge
• Ways of perceiving, understanding self, world
• Gender differences have been identified in ways men and
women may develop frameworks for organization of
knowledge
– Linked to distribution of power, privilege in society
• Four fundamental patterns (ways) of knowing in nursing:
empiricism, aesthetics, personal knowledge, ethics
(Carper)
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Empirical Knowledge
• “Encompasses publically verifiable, factual descriptions,
explanations, and predictions based on subjective or
objective group data”
• Obtained through senses, can be verified, is credible, is
used to impart understanding
– Explaining
– Structuring
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Aesthetic Knowledge
• Aesthetic knowing in nursing:
– “That aspect of knowing that connects with deep
meanings of a situation and calls forth inner creative
resources that transform experience.”
• Rehearsing
• Envisioning
• Integrating aesthetic knowledge into nursing process is
important
– Result: richness, appreciation of practice of nursing
as art as well as science
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Personal Knowledge
• “Person’s individualized and subjective ways of learning,
storing, retrieving information about the world”
• “Pattern of personal knowing refers to the quality and
authenticity of the interpersonal process between each
nurse and each [client]”
– Experiential knowing
– Interpersonal knowing
– Intuitive knowing
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Ethical Knowledge
• Obligation, “what ought to be done”
• Theoretical/ethical knowledge
– Intellectual conception of what is good, right
– Organized into concepts, propositions formulated into
judgments, rules, principles, theories
– Moral action
– Personal moral
– Situational knowledge
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Ethical Knowledge (cont’d)
• Biomedical ethics
– Derived from models of patient good, rights-based
notions of autonomy, or social contract of medical
practice
• Nursing ethics
– Should be based on ethic of caring
– Must consider nature of nurse–client relationship
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Ethical Knowledge (cont’d)
• Three different perspectives reflecting different point of
view (paradigm) of how to develop nursing knowledge:
– Particulate–deterministic perspective
– Interactive–integrative perspective
– Unitary–transformative perspective
• Different ways of knowing are not judged against one
another
• Comprehensive nursing knowledge must be based on
integration of all ways of knowing
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The Development of Nursing Science
• Defining nursing science poses challenge
• Attaining clear definition of nursing science would provide
foundation for profession’s unique body of knowledge
• Failure to articulate nursing’s exact contributions to
health care delivery may place profession at risk
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Concepts
• Highly abstract, general “word[s] or phrase[s] that
summarize the essential characteristics or properties of a
phenomenon”
• Four concepts accepted as central to discipline of
nursing:
– Human beings
– The environment
– Health
– Nursing
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Concepts (cont’d)
• Five conceptualizations of caring have been identified:
– Human trait
– Moral imperative
– Affect
– Interpersonal interaction
– Therapeutic intervention
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Concepts (cont’d)
• Nursing: highly complex, has various specialty areas of
practice, attaining single definition for nursing concepts is
extremely difficult
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Theories
• Communicate links or relationships among concepts in
organized, coherent, systematic way and vary in levels of
abstraction, scope
• Help nurses understand how, why phenomena of nursing
are associated with one another
• Effectiveness in practice directly related to ability to
understand, describe, explain, anticipate human
responses concerning health
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Theoretical Frameworks
• Theoretical or conceptual framework:
– “A logical grouping of related concepts or theories”
– Provides guidance, direction for nursing research
endeavors
– Tend to address phenomena more global in nature
• Developing theoretical frameworks for nursing ensures
practice that considers complex nature of professional
practice
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Models for Nursing
• Nursing scientists proposed individual, distinctive models
about interrelationships of concepts that form nature,
processes of nursing
– Based on empirical observation, intuitive insights, or
deductive reasoning “that creatively combine[s]
ideas from several fields of inquiry”
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Models for Nursing (cont’d)
• Nursing conceptual models identify interventions that
nurses use in practice while explaining four central
concepts of nursing:
– Human beings
– The environment
– Health
– Nursing
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Summary and Significance to Practice
• Nurses
– Use variety of methods of knowing when providing
professional nursing services
– Rely on personal, ethical knowing to make effective
clinical judgments, decisions
• Nursing scholars
– Have general agreement on central concepts of
discipline of nursing
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Summary and Significance to Practice
(cont’d)
• Central concepts
– Help describe phenomenon of professional nursing
practice
– Guide nurses
• Clinical practice
• Research endeavors
• Educational programs
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 4
Theoretical Foundations of
Nursing Practice
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
The Domain of Nursing

Domain



Is the perspective of a profession
Provides the subject, central concepts, values and
beliefs, phenomena of interest, and central
problems of a discipline
Domain of nursing provides both practical
and theoretical aspects of the discipline.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Paradigm

Paradigm


Links science, philosophy, and theories accepted
and applied by a discipline
Nursing paradigm

Links person, health, environment/situation, and
nursing
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Terminology






Person
Health
Environment/situation
Nursing
Nursing process: Method of applying the
theory or knowledge
Integration of theory and nursing process is
the basis for professional nursing.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
35
Theory



A theory contains a set of concepts,
definitions, and assumptions or propositions
that explain a phenomenon.
Theories guide the design of nursing
interventions.
Nursing theory


Is a conceptualization of some aspect of nursing
Describes, explains, predicts, and/or prescribes
nursing care
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Components of a Theory
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37
Types of Theory

Grand


Middle-range


More limited in scope and less abstract
Descriptive


Broad in scope, complex, require specification
Describe phenomena, speculate on why
phenomena occur, and describe the
consequences of phenomena.
Prescriptive

Address nursing interventions for a phenomenon,
and predict the consequence of a specific nursing
intervention.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Theory-Based Nursing Practice

Theories




Generate nursing knowledge for use in practice
Can direct how to use nursing process
Are adaptable to different patients and all care
settings
The goal of nursing knowledge is to explain
the practice of nursing as different and
distinct from the practice of medicine,
psychology, and other health care disciplines.
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39
Interdisciplinary Theories

Explain systematic views of phenomena
specific to the discipline of inquiry:
 Basic
human needs
 Developmental
 Psychosocial
 Systems
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
40
Quick Quiz!
1.
Nursing theories provide nurses with
perspectives from which to
A. Analyze patient data.
B. Predict phenomena.
C. Formulate legislation.
D. Link science to nursing.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
41
Models and Theories for
Professional Nursing

Metaparadigm
 Greek prefix “meta”
• More comprehensive or transcending
 Greek word “paradigm”
• Overall concept accepted by most people in
intellectual community

Although nursing models, theories vary
according to philosophical world views, all
flow from metaparadigm of nursing
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Models and Theories for
Professional Nursing

Four key concepts serve as metaparadigm:
 Human
beings (recipients of nursing care)
 Environment
 Health
(physical, social)
(process or state)
 Nursing
(goals, roles, functions)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Models

Florence Nightingale


Model


Primary source of nursing theory, nursing science
derived principally from social, biologic, medical
science theories before 1950
Provides way to visualize reality to simplify
thinking
Conceptual model

Gives structure to, shows how various concepts
are interrelated
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Nursing Models in Research and
Practice

Research
 Three kinds of research related to models
of nursing are being conducted:
• Testing relationships predicted by mode
• Using model as framework for
descriptive analysis
• Attempting to modify nursing care
through use of model
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Nursing Models in Research and
Practice (cont’d)

Practice
 Nursing
models, theories provide
• Guidance to nurses engaged in practice
for holistic assessments
• Rationale for various nursing
interventions
• Delineation of professional nursing roles
in health care delivery
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
46
Categories of Nursing Models
and Theories

Growth, stability models of change

Two world views
• Recognizes change as continuous, desired
opportunity for growth to attain maximum
human potential
• Persistence, which maintains that human
beings strive for stability, endurance results
from synthesis of growth, stability

Stability model of change
• Natural order of things revolves around consistency
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Stress/Adaptation Theory as a
Framework

Provides way to understand how balance is
maintained, possible effects of disturbed
equilibrium

Used to explain, predict, control biologic
(physiologic and psychological) responses of
human beings, serves as traditional medical
therapy

Callista Roy’s Adaptation Model
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The Growth Model of Change

Focuses on helping human beings grow to
realize, attain full human potential

Uses caring theory or complexity theory as
underlying framework


Dorothea Orem’s Self-Care Deficit Theory
Jean Watson’s Human Science and Human Care
Theory
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Categories of Nursing Models
and Theories (cont’d)

Systems Theory
 Concerned
with elements, interactions
among all factors (variables) in situation
 Understanding
interaction among various
parts of system, rather than describing
function of parts themselves
• Imogene King’s Systems Interaction Model
(Theory of Goal Attainment)
• Betty Neuman’s Health Care Systems Model
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Systems Theories
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51
Complexity Theory as a Framework


Emphasizes change
over time, long-term
unpredictability,
openness to
environment with
mutual simultaneous
interactions
Seeks to understand
patterns of phenomena
as wholes within their
contexts




Martha Rogers’
Science of Unitary
Human Beings
Rosemarie Parse’s
Human Becoming
Theory
Margaret Newman’s
Theory of Health as
Expanding
Consciousness
Susan Leddy’s Human
Energy Model
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
52
Question

Which nursing theory framework can be used
to assist clients in adapting to stressors in
their environment?
A.
Caring theory
B.
Complexity theory
C.
Stability Model of Change
D.
Callista Roy’s Adaptation Model
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Answer

D. Callista Roy’s Adaptation Model

Rationale: Roy’s Adaptation Model specifies
that the purpose of nursing is promoting a
human being’s adaptation, the process and
outcome by which thinking and feeling human
beings use conscious awareness and choice
to create human and environmental
integration. It integrates adaptation with
stimulus and coping.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
54
Case Study


Susan is a new nurse who tutors a nursing
student, Bill, who has difficulty mastering
good study habits and prioritizing school
assignments. Susan is helping Bill learn the
theoretical foundations of nursing practice.
After Susan and Bill review interdisciplinary
theories such as Maslow’s hierarchy of needs
and the developmental theories, they move
on to the topic of nursing theories.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Selected Nursing Theories (cont’d)

Nightingale (mid-1800s)



Peplau (1952)



Environment as the focus of nursing care
Descriptive theory
Focus on interpersonal relations between nurse,
patient, and patient’s family
Development of nurse-patient relationship
Henderson (1955, 1966)


14 basic needs of the whole person
Framing nursing care are the needs of the
individual.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Selected Nursing Theories (cont’d)

Orem (2001)



Leininger (2010)



Focuses on patient’s self-care needs
Goal is for patient to manage his or her health
problems.
Theory of cultural care diversity and universality
Considers social structure factors
Neuman (2010)
Based on stress and the patient’s reaction to the
stressor
 Role of nursing is to stabilize the patient or
situation.

Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
57
Selected Nursing Theories (cont’d)

Roy (1989)



Watson (1996)



Views the patient as an adaptive system
When patient cannot adapt to stressors, nursing is
needed.
Defines the outcome of nursing activity with regard
to the humanistic aspects of life
Purpose is to understand the interrelationships
among health, illness, and human behavior.
Benner and Wrubel (1989)

Caring is central.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
58
Case Study (cont’d)

Bill reads about the concept of people’s
responses and adaptation to change. The
theory that views the patient as an adaptive
system is ______________.
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The Link Between Theory
and Knowledge Development



Nursing knowledge is theoretical and
practical.
The goals of theoretical knowledge are to
stimulate thinking and create a broad
understanding of the “science” and practices
of the nursing discipline.
Experiential knowledge, or the “art” of
nursing, is based on nurses’ experiences in
providing care to patients.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
60
Quick Quiz!
2. Nursing process is central to nursing
practice. Nursing practice
A. Is a theory.
B. Is derived from a theory.
C. Is not adaptable to all patients.
D. Generates knowledge for use in practice.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)



Susan quizzes Bill about the core concept of
Benner and Wrubel’s theory. Benner and
Wrubel’s theory is based on the premise that
persons, events, projects, and things matter
to people.
True
False
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The Link Between Theory
and Knowledge Development




Theories provide direction for nursing
research.
Nursing theory and nursing research build the
knowledge base for nursing, which is then
applied to practice.
Theory-generating or theory-testing research
refines the knowledge base of nursing.
Nurses incorporate research-based
interventions into theory-based practice.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
63