theory builrlinfl in nursing a reWw o f litsraluse M. Isabel Harris

I n troduct ion When asked to deal with this topic, I

agreed for several reasons, 1) I have long been interested in theory and models, 2) it’s good for me - since such an assign- ment creates a stimulus to do what I ought to do anyway, and 3) I fe l t i t would help me to better organize this infor- mation for a course in research which I teach. Last year I did a somewhat similar paper for a regional Sigma Theta Tau meeting and felt that the attempt to organize the material for presentation was somewhat akin to having a tiger by the tail. I should like to indicate that this year’s assignment was more like having Smaug - Tolkien’s Dragon by the tail. Bigger and more frightening +!-an a tiger and quite resistant to efforts Lo ‘line up’ neatly into a paper. Indeed, at times i t whiffled and snorted.

I hope that this is a reasonably ade- quate coverage of the topic. I think i t would not be possible to digest all rele- vant literatu,e even if one could locate a l l of it. Present indexing in nursing, while improving makes such a survey of uncer- tain thoroughness, since whether or not one locates ‘all’ articles depends upon what Bronowski refers to as the logical insufficiency of language. I might add that authors are not a t all helpful in titling their publications. For the moment I have great empathy for students who become frustrated with ‘Iibrarocracy’ and 1 long for the day when one can press a button and summon up information from the computer a t will. Only one nagging worry remains. What if one forget, the key word to retrieve needed information and the

pearls are forever lost in the recesses of the data processing equipment? What i s theory?

According to Webster. Theory is a more or less plausible or scientifically accept- able general principle offered to explain phenomena. There are many more com- plex definitions but this one seems ade- quate for our purposes today. In similar vein, Abdellah (1966) indicates that theory can provide ways of looking at data and grouping facts into a rationale. Theory means a conceptual structure built for a purpose. For nursing, that purpose i s practice (Ellis, 1969). Some theories are most effectively communicated when they can be portrayed as a diagram or model, a symbolic or physical visuali- zation of a theory. Howland’s (1963) “Hospital System Model” and Brunwik’s “Lens Model of Behavior” used by Kelly (1964) are examples of models useful to the study of nursing.

A t a Conference on the Nature of Science and Nursing reported in the November-December 1968 issue of Nursing Research, Research in Nursing and Nursing Research were differentiated by Jeannette Folta as 1) studies of nurses and 2) studies of how we can best take care of patients and what kinds of nursing will net us certain kinds of goals in patient care. Similarly, there are ”Theories about Nursing” and ”Nursing Theory.” The latter is the concern of this paper.

In complexity, nursing theories and models vary from relatively simple state- ments about relationships to very com- plex formulations that involve many

variables. The nature of nursing suggests that many of those useful to nursing prac- titioners need to account for considerable complexity. When Did Nursing Theory Develop?

Having resolved what to be concerned with, i t seemed that the word ‘buildirig’ implied that there was a beginning some- where. I t has been postulated that practice and theory are interdependent; that effective practitioners base their per- formance on theory - not stated ex- plicitly and often not recognized. In Florence Nightingale’s Notes on Nursing one can identify the implicit theory. as for example:

“all disease, at some period, i s more less a reparative process - an effort of nature to remedy a process of poisoning or of decay which has taken place weeks, months, some- times years beforehand”

or, - “Knowledge of Nursing - how to put the constitution in such a state that i t will have no disease, or that i t can recover from disease.”

Interestingly. also, some of her exhor- tations relative to air currents sound almost like the ideas involved today in laminar air flow - a most current ide- ology.

Similarly one can sense the theory implicit in the writings of such individuals as Bertha Harmer, (1922) and Annie Goodrich (1932). Except to comment on existence, it seemed that search for any extensive body of implicit theory was beyond the scope of this investigation.

While explicit theory i s not intrinsically more valuable than implicit theory, the latter is in need of validation i f i t i s to serve the purpose of improving nursing practice. Ellis (1969) cites T.L.C. as an example of a concept that exists, -that i s associated with nursing. “ I t has not yet been made explicit, nor yet fully thought through.”

The emergence of explicit nursing theory i s relatively recent. Simmons and Henderson (1964) list the nurse authors and titles of 152 doctoral studies com- pleted between 1928 and 1959. Only two of these titles, and these in 1955 and 1959, suggested a theoretical basis for

nursing research. Abdellah (1966) in re- counting the accomplishments of a decade of intensive work in nursing research, 1955-1965, cited theory development in nursing as one area of growth. Thus i t would seem that explicit nursing theory associated with research efforts has been largely a phenomenon of the past 15 years. Indeed the median year of publi- cation for bibliography of this survey was 1966.

Where “I t is in the colleges and universities

that nursing will find the synthesis and resynthesis of fac ts that will enable srudents to know and understand the rich soil of which nursing is an integral part,” states Martha Rogers (1961). With few exceptions, major efforts to formulate nursing theory to test relevant hypotheses and to confirm or re’rise is taking place on campuses. AlthouGh by no means limited to Yale, University of California a t Los Angeles, University of California at San Francisco, New York University, Ohio State University, and Western Reserve University, one identifies these insti- tutions as those whose faculty and students have made early contributions to nu rsi n g theory deve I o pme n t .

A somewliat different point of view is expressed by Ellis (1969) who says that the theorists in nursing are not in the ivory towers but rather nurses who work directly with patients. Hopefully, this dichotomy will not persist. Who

Who are the nursing theorists? One can only identify those who have made their formulations explicit in newsprint and have subjected them to professional scrutiny. i t i s hardly safe to cite names, particularly when the comprehensiveness of this survey i s not established. However, from the bibliography, it is easy to identify a t least 20 individuals with whom theoretical formulation can be identified. Development of nursing theory, however, i s not limited to nurses. Help tias come from many persons, some of whom have participated directly; others have de- veloped basic science theory or models which can be tested for their applicability to nursing. The majority, if not all of this latter group, are social scientists.

7

The 'Why' of Nursing Theory A cursory glance at almost any research

related publication in nursing gives clues as to the need that i s felt for substantive nursing theory. "Theory in reseasrch can provide ways of looking a t data and gt.oupirig facts into a rationale," according to Abdellah (1966). Theory is cited by Meyer and Heidgerken (1962) as one means of transmission of knowledge.

In nursing, JS in r>ther applied science fields, the accumulation of a Substantive body of knowledge on whiLh to base practice is dependent upon the assem- bling, ordering and relating of facts into theory. Thus derivation and testing of hypotheses to support, modify or extend the theory can be facilitated.

Stein (1969) proposes that expanded and more complex nursing roles are a con- sequence of theoretical expansion in physical and behavioral sciences. As a result of the changes in nursing pJtterns - there is need for greater theoretical orien- tations, initiative and originality in the service of community organization di- rected toward physical and mental health promntion. How is Nursing Theory Built

Reaaing in this area suggests that there are essentially two methods of formu- lating nursing theory - either inductively from empirical data or deductively from other theoretical formulatioris. Wald and Leonard (1964) make a case for the inductive method or empirical approach to building knowledge directly from systematic study of nursing experience. Conant (1967) also described this me thodology of arriving a t nursing practice theory.

Brown's (1968) use of Socialization Theory applied to older persons, and Kellys (1964) use of the "Lens Model of Behavior" in the study of clinical infer- ence are examples of the deductive approach.

A method described by Glaser and Strauss (1967) seems to be a variant on the empit ical approach. Titled "Grounded Theory" it i s a strategy in which emphasis is placed on theory as process, an ever developing entity generated through field work.

Conant (1967) describes a two way street, indicating that although nursing may borrow from the basic sciences, the

tests of the applicability of such theory can make a contribution to general knowledge of human behavior. Increasing- ly sound testing of hypotheses related to basic science theories by competent nurse researchers is extending these same theories, and providing useful knowledge to other disciplines.

In summary, I will try to depict some problems encountered in the building of nursing theory, the progress that seems to have been made, and the potential for f u r the r devel opm en t . Problems

Henderson (1966) indicated that ef- forts to improve the preparation of nurses, and to recruit and retain practi- t ioners are major energy consumers leaving little think time. I am reminded of a comment by Bertrand Russell -that there is a major difference between American experimental rats and European experimental rats; the American rats are forever running through mazes while the European rats s i t and think. Perhaps we could take a lesson from the European rats. Another problem stated by Hender- son is !;'tat frequently nurses have received their advanced preparation in teaching or administration are involved in these areas in eniployment and hence tend toward development of theory in those areas rather than theory of nursing practice. I f as Ellis (1969) proposed the theorists are the practitioners of nursing, it is quite possible that many do not have sufficient financial support, preparation and encour- agement to move forward with theory building.

Another problem implied in the writings of many is that in viewing man holistically, theory will need to take into account his psyche and his soma as well as the impact of the social and cultural milieu in which he moves. In the present explosion of knowledge, i t is doubtful that any individual can have sufficient background in all these areas to formulate a comprehensive theory, and there are pitfalls in omitting areas of knowledge. Progress

It is most encouraging to look a t this aspect of theory building. The increasing incidence of explicit nursing theory in all types of publications, and the iricreasina concern for this area in prograrns of the various nursing organizations i!, hearten-

ing. The holistic view of man as expressed by Levine (1969) and Sarosi (1968) while adding problems, also evidences progress toward a uniquely useful body of theory.

Another area of progress i s the creative extension of theories and models by various individuals. Howland's systems model for one has been utilized in the study of pain, in postoperative cardiac nursing research by Chow (1969) and in studying nurse-patient-physician triad (McDowell, 1962). The Venn Diagram has been proposed by Thigpen and others (1967) for a variety of areas of study.

Likewise a concept like adaptation is being utilized by a variety of individuals in what would seem to be complementary ways; Peplau (1966), Levine (1969), and Pitel (1963). As disparate efforts shed light on one concept there would seem to be progress in our understanding of that concept and its usefulness in direction of nursing practice.

The Concerted effort at Yale University to develop the deliberative nursing process first made explicit by Orlando (1961) has been profitable with hoth students and faculty building various aspects of this theory.

Potential The way ahead does not look easy, but

surely exciting and challenging - with many new and unknown worlds to conqiler.

Conani (1967) speaks to the necessity of closing the practice-theory gap and points out the complexities of a practice theory for back care: "It must encompass maintenance of skin and underlying tissues, nutritional and fluid balance, and physical manipulation of the body." She further points out that nursing i s the only group with interest to develop such an area of theory.

The proposal of Dickoff and James (1968) of practice theory at the fourth level, si tuation-producing theory, is chal- lenging holds promise of meeting some of nursing's rather sqecial needs.

Nurse scientist programs and the in- creasing numbers of yc;ung people going on for graduate preparation in the sciences and in nursing i s perhaps our greatest hope for building theory and extending the body of knowledge avail- able to the practitioner o f nursing.

REFERENCES Abdel la l i , Faye G. Fron t ie rs in Nurs ing Research. Nurs ing Fo rum, 5:1:31, 1966. Abdcl la l i . Faye G. and Eugene Levine. Bet te r Pat ient Care Th rough Nursing Research, Macmi l lac Co., N e w York . 1965. B rown . M y r t l e I., Social Theory in Geriatr ic Nurs ing Re- SCJrCh, Nurs ing Research, 17:3:213, May-June. 1968. B rown , M y r t l e I., Research in the Deve lopment of Nurs lng Theory , Nurs ing Research. 13:2: 109, Spring, 1964.

B rown , M y r t l e I., Social i rat ior i - A Social T h e o r y of Adapta t ion . Nurs ing Science, 1:4:280. October- November, 1963. Chow, Rita. Postoperat ive Cardiac Nursing Research: A M e t h o d fo r I den t i f y i ng anU Categorizing Nurs ing Ac t i on , Nurs ing Research. 18:1:4, January-February. 1969. Cleland. Virginia S.. T h e Use o f Ex is t ing Theories, Nurs ing Research, 16:2:118. Spring, 1967. Conaiit. L u c y H., A Search f o r Resolut ion 01 Exis t ing Problems in Nursing, Nurs ing Research, 16:2:114. Spring, 1967. Conant, Lucy , Closing the Pract ice-Theory Gap, Nurs ing Ou t look , 15:37-39. November, 1967. D i c k o f f , James and Patricia James, Researching Re- search's Role in Theory Development, Nurs ing Re- search. 17:3:204, May-June, 1968. Dumas, Rhetaugh. e t al, Val ida t ing a Theory of Nurs ing Practice, Amer i can Journa l o f Nursing, 63:52-59. August 1963. Ell is. Rosemary, Characteristics cf Signi f icant Theories, Nurs ing Research, 17:3:217, May-June 1368. Ellis, Rosemary. T h e Pract i t ioner as Theor ist , Arner ican Journa l of Nursing, 69:7:1434. Ju l y 1969. Fel ta, Jeannette R. and E d i t h S. Deck, A Sociological F ramework f o r Pat ient Care, John Wiley and Sons, N e w York , 1966. F o x , Dav id J.. Fundamenta ls of Research in Nursing. N e w Y o r k : App le ton-Century -Cro f ts . 1966.

Glaser. Barney G. a n d Anse lm L. Strauss. T h e Discovery of Grounded Theory : Strategies f o r Qua l i ta t i ve Re- search, Chicago, I l l inois: A ld ine Publ ishing Co.. 1967. Goodr ich , Ann ie , T h e Social anti E th ica l Significi?nce Of Nursing, N e w York : MacMi l lan Co.. 1932. Gunter. Laur ie, Notes o n a Thcore t ica l F ramework fo r Nursing Research, Nursing Research. 11:4:219. Fal l 196 2. Harmer, Bertha. Pr inciples and Practice o f Nursing, N e w York : MacMi l lan Co.. 1922. Heidgerken, Lore t ta . Nursing Research - It's Ro le in Research Act iv i t ies. Nurs ing Research, 11:140-143. Summer 1962.

: lenderion. Virginia. T h e Nature of Nursing, NCW York : MacMi l lan Co.. 1966.

Howland. Daniel. A Hosp i ta l System Moael, Nurs ing Research, 12:4:232. Fal l 1963. Johnson, D o r o t h y E., Theory in Nursing: Bo r rowed and Unique. Nc rs ing Research, 17:3:206. May-June, 19G8. Ke l l y , Ka ther ine J. and Kenneth R. Hammond , A n Approach t o the S tudy o f Cl in ical Inference in Nursing, Nurs ing Research. 13:4:314. Fa l l 1964. K ing . lmoyene M.. A Conceptual Frame of Reference for Nursing. Nurs ing Research. 17: 1 :27. January- February 1968. Levine, M y r a E.. T h e Pursui t of Wholeness, Amer i can Journa l of Nursing, 69:1:93, January 1969. Le./ine. M y r a E.. Adap ta t i on and Assessment: A Rat ion- ale for Nurs i i i y Intervention. Amer ican Journa l o f Nursing. 66: 11 :2450. November 1966. McOowel l . Wanda E.. "Nurse-Patient-Physician Be- I iJv ior : Nurs ing Care and the Rcgulat ion o f Pat ient Cond i t ion . " Paper presented at the Amer ican Nurses' Association. 1 9 6 2 Cl in ical Sessions, De t ro i t . Michigan. Meier. Lois, l r i l e rac f i on o f Speci f ic Sopor i f ics and Selected Senescents. Nursing Science, 1 :4:295. October. November 1963.

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Meyer , B u r t o n ai id L o r e t t a E. Hcidqerken. I n t r o d u c t i o n t o Research in Nursing. J. B. L ipv i r~Co t l . Phl ladelphia, 1962. Norr is, Cathcr inc M., Tuwdrd a Sciciice of Nursing, Nurs ing F o r u m , 3:3:10. 19G4. Night ingale. Floret icc. Notes o n Nursing, D. A o p l c t o n & Co.. N e w York. I S G O . Ortando. Ida. The Dynan i i c Nurse-Pat ient Relat ionship. N c w V o r k : G. P. Put i iam Sun j . 1961. Pcp~au . H i ldcyard E.. Interpersonal Rclatiol?: Jnd the Prccr5s o f AJJp ta t i on .

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lo sualitative data as a Dolsnlial sobre8 of theori in nursln! Margaret Jacobson

First of all, I'd like to change the title of this paper from that listed on the pro- gram "Grounded Theory and its Potential for Adaptation to Nursing" to that of "Qualitative D a t a as a Potential Source of Theory in Nursing," for t h e reason that the original title may imply that I plan to take grounded social theory and adapt i t as a nursing theory. As nurses, concerned with identifying or buildifis theory in nursing, I propose that we concern our- selves with a more systematic use of our rich sources of qualitative data. I am not primarily concerned with theory develop- ment for intellectual exercise, for pro- fessionalization or for enhancing nursing in the academe. I am concerned with theory in nursing because I believe that theory has pragmatic value which will ultimately contribute to the improvement of health care.'

This does not precluae the use of theory that applies to humans in their processes of growth, development, be- havior, socialization, interaction, and so on. The fact that nursing deals with

people in their l i fe cycles from precon- ception to postmortem presumes an inter- disciplinary orientation. ti we are to generate and develop usable practical theories in nursing they might well be derived, tested, developed and discarded in nursing practice. Some of such theories may stand the tests of time, use, and inquiry.

Glaser and Strauss. sociologists a t the University of California a t San Francisco have presented their methodology for "discovering" theory from data in the book ent i t led, The Discovery of Grounded Theory: Strategies for Qualita- tive R e s e a r c h . 2 Grounded theory i s theory "discovered" from data "systema- tically obtained and analyzed from social research."3 It is theory generated and inductively developed from data, and it is illustrated by characteristic examples of the data in contrast to logically deduced theory where examples are selected for their confirming value. The writers, them- selves, have stated that they perceive their work as a beginning and purposely have not posed clear-cut procedures and definitions.