1.4 History and Evolution of Nursing Theories

Historical Nursing Theories

The earliest nursing theories emerged in the nineteenth century with the work of pioneers such as Florence Nightingale. Nightingale’s environmental theory (discussed in Nightingale’s Environmental Theory) laid the groundwork for considering the impact of the environment on health. During this period, nursing was primarily seen as a task-oriented and apprenticeship-based profession. In the mid-twentieth century, nursing theories began to take a more systematic and conceptual form. Theories such as Virginia Henderson’s nursing need theory (discussed in Henderson’s Nursing Need Theory) and Hildegard Peplau’s interpersonal relations theory (discussed in Peplau’s Theory of Interpersonal Relations) emphasized the importance of understanding patient needs and interpersonal relationships in nursing practice.

In the late twentieth century, there was a proliferation of nursing theories addressing various aspects of nursing, health, and care. Betty Neuman’s systems model, Dorothea Orem’s self-care deficit nursing theory (discussed in Orem’s Self-Care Deficit Nursing Theory), and Madeleine Leininger’s culture care theory (discussed in Leininger’s Culture Care Theory) are examples of theories developed during this period, reflecting a diversity of perspectives within the field. With the increasing emphasis on EBP, nursing theories have become more integrated with research over time. Theories such as Roy’s adaptation model (discussed in Roy’s Adaptation Model) and the model of nursing as caring by Anne Boykin and Savina Schoenhofer highlight the importance of research in refining and validating theoretical concepts (Alligood, n.d.; Gaines, 2023; Wayne, 2023).

Many contemporary nursing theories in the twenty-first century have emphasized holistic and person-centered care. Theories like Jean Watson’s theory of human caring (discussed in Watson’s Theory of Human Caring) and Patricia Benner’s “novice to expert” model of nursing (discussed in Patricia Benner) underscore the significance of understanding the whole person and the nurse’s role in promoting well-being. In response to increasing globalization and cultural diversity, nursing theories have expanded to incorporate cultural competence and global health considerations. Leininger’s Culture Care Theory and the Transcultural Nursing Model exemplify this shift in focus. The current landscape of nursing theory has also seen an increasing emphasis on interdisciplinary collaboration. Theories, such as the general systems theory (discussed in General Systems Theory), underscore the interconnected nature of systems, which can include not only biological and organizational systems but also interdisciplinary collaborations within the healthcare field.

Throughout their history, nursing theories have adapted to changes in healthcare delivery, technological advancements, and a deeper understanding of human experiences. Theories continue to evolve as nurses and theorists engage with new evidence, technologies, and societal challenges, ensuring the ongoing relevance and advancement of nursing knowledge and practice.

Concepts

A concept is an idea that serves as a foundational element of a theory, contributing to its overall structure and coherence. Concepts are like building blocks that capture essential aspects of nursing practice and collectively provide a theoretical framework that guides the profession. Concepts may be abstract, representing general notions rather than specific instances, or concrete, representing specific and tangible ideas or objects that can be directly observed or experienced. Regardless of whether a concept is abstract or concrete, it is accompanied by a precise definition to ensure clarity and consistency in interpretation (Wayne, 2023).

The interrelatedness of concepts within a nursing theory illustrates the dynamic relationships that exist among them, contributing to the theory’s coherence and ability to explain how the concepts influence each other. Concepts must be operationalized to make them observable, relevant, and transferable to research and clinical practice (Wayne, 2023). Examples of concepts that are fundamental to nursing are holism (individuals should be viewed and treated as whole beings), caring (nurses should give patients compassionate and empathetic attention), adaptation (people adjust to changes in the internal and external environments to maintain optimal health), and self-care (activities that individuals perform to maintain their own health and well-being).

Phenomena

A phenomenon is a specific aspect of interest or an observable occurrence that is the focus of theoretical exploration and study. Phenomena in nursing theories refer to whatever theorists seek to understand, describe, explain, or predict within the context of nursing practice. They are often complex and multifaceted, encompassing various dimensions of human health and nursing care (Wayne, 2023).

Examples of phenomena include the experience of pain, coping mechanisms for chronic illness, nurse-patient interactions, health promotion strategies, and cultural competence in nursing. Theories in nursing are developed to explore, describe, explain, or predict these phenomena, providing a structured framework for understanding the complexities of health care. Phenomena are not only the subjects of theoretical exploration but also the catalysts for advancing EBP, guiding nursing research, and enhancing the quality of patient care. As nurses engage with and seek to address phenomena, theoretical frameworks offer valuable perspectives and insights, contributing to the ongoing evolution and refinement of nursing knowledge.

Definitions

A definition is a clear and precise explanation of the meaning attributed to a specific concept or term within the theoretical framework. Definitions serve to establish a shared understanding among theorists, researchers, educators, and practitioners who engage with the theory. The clarity of definitions is essential for consistency in communication and application of the theory across diverse contexts (Wayne, 2023).

Definitions within nursing theories aim to articulate the intended meaning of key concepts, ensuring that these concepts are interpreted and used in a standardized manner. Clear definitions contribute to the conceptual clarity and coherence of a nursing theory, fostering a common language within the nursing discipline. They provide a foundation for theoretical development, research design, and practical application of the theory in clinical settings. As nursing theories evolve, definitions may be refined or expanded to accommodate new insights and understandings within the dynamic field of health care (Wayne, 2023).

Assumptions

An assumption is a foundational belief or proposition that is accepted without direct empirical evidence. For instance, assumptions may revolve around the inherent worth of individuals, the impact of the environment on health, or the nurse’s role in promoting well-being. While assumptions are not subjected to direct testing, they lay the groundwork for the theoretical framework, providing a lens through which the theorist explores, explains, and contributes to the evolving body of nursing knowledge. As nursing theories advance, assumptions may be reevaluated in light of new evidence and insights, ensuring the ongoing relevance and applicability of the theoretical perspectives within the dynamic field of health care (Wayne, 2023).

Perspective on Person

The person domain, often referred to as the patient or client domain, is the central focus of nursing philosophy. This domain emphasizes the individual as a holistic being with physical, psychological, social, cultural, and spiritual dimensions. It acknowledges each individual’s inherent dignity, autonomy, and interconnectedness with the environment (Gaines, 2023; Wayne, 2023).

Nursing philosophy underscores the importance of approaching patients with a person-centered perspective, considering not only their physical health but also their values, preferences, and experiences. Person-centered care recognizes the uniqueness of each individual and aims to provide care that is tailored to their specific needs, values, and preferences. The domain of the person reflects a commitment to providing individualized and culturally competent care that respects the uniqueness of each individual.

Perspective on Environment

The environment domain encompasses the surroundings, context, and external factors that influence a person’s well-being. This domain recognizes that health is not solely determined by individual factors but is also shaped by the broader physical, social, cultural, economic, and global environment (Table 1.2) (Gaines, 2023; Wayne, 2023). Nurses consider the impact of these environmental factors on the health and well-being of the person and adapt care accordingly.

Perspective on Health

The health domain goes beyond the absence of illness. In nursing philosophy, health is a dynamic and holistic concept that encompasses the overall well-being of the person, including physical, mental, social, and spiritual dimensions. The understanding of health in nursing philosophy is broad, recognizing that individuals exist on a continuum of wellness and that health is influenced by various factors. The focus is on promoting optimal health, which includes preventing illness but also supporting individuals in achieving their highest level of functioning and quality of life (Gaines, 2023; Wayne, 2023).

Health emphasizes preventive measures and wellness promotion, placing a strong emphasis on patient education and empowerment. Cultural sensitivity is paramount, as nursing philosophy recognizes that diverse cultural perspectives influence perceptions of health and that nursing must ensure care aligns with the individual’s cultural beliefs and practices related to health and well-being. By placing the person at the center of care, nurses collaborate with patients to set goals and develop care plans that align with the individual’s personal definitions of health and well-being. By supporting individuals in building resilience and coping mechanisms to maintain or restore their health, nurses may positively influence the individual’s ability to adapt and cope with life’s challenges.

Perspective on Nursing

The nursing domain is a fundamental and central concept that defines the unique role, purpose, and responsibilities of the nursing profession. This domain encompasses the art and science of nursing, outlining the scope of practice and guiding principles that underpin the delivery of care. It captures the essence of the profession, guiding nurses in their dedication to providing high-quality, ethical, and person-centered care that positively impacts the health and well-being of those served (Gaines, 2023; Wayne, 2023).

At its core, nursing is envisioned as a holistic and person-centered discipline, extending beyond the treatment of illness to encompass the promotion of health, the prevention of disease, and the enhancement of overall well-being for individuals and communities. Nurses operate with a commitment to delivering care that is both comprehensive and individualized, recognizing the intricate interplay of physical, emotional, social, cultural, and spiritual dimensions in each person. Advocacy and empowerment are integral elements, with nurses championing the rights and voices of their patients, fostering autonomy, and facilitating shared decision-making. The philosophy underscores the importance of health promotion, compassionate interactions, and continuous pursuit of knowledge through evidence-based practices. Ethical considerations form a foundation for nursing practice, emphasizing integrity, confidentiality, and delivery of care that aligns with moral principles.

Relation to Clinical Judgment

You have seen the term clinical judgment several times in this chapter, but what exactly does it mean? Essentially, clinical judgment utilizes nursing knowledge, critical thinking, and clinical reasoning, drawing from evidence, theories, and interdisciplinary insights to make informed and patient-centered decisions. It involves the practical application of the domains of nursing philosophy: person, environment, health, and nursing. Together, these domains comprise a conceptual framework that informs clinical judgment, guiding nurses to make sound decisions and provide effective care. They provide a holistic perspective, emphasizing individualized care, consideration of environmental influences, promotion of health, and adherence to the principles of nursing.

More concretely, clinical judgment involves the nurse’s ability to assess and understand the unique characteristics, needs, and responses of each individual receiving care. By recognizing the holistic aspects of the person, including their physical, emotional, social, and cultural dimensions, nurses can make informed and person-centered decisions, tailoring interventions to the individual’s specific context. Clinical judgment also requires nurses to consider environmental factors—including the patient’s physical, social, and cultural contexts—when assessing and planning care. Understanding the impact of the environment on an individual’s health and well-being helps nurses adapt interventions, identify potential challenges, and create a setting conducive to optimal patient outcomes. The domain of health guides nurses in setting goals, preventing complications, and promoting well-being. Continually assessing the patient’s health status enables the nurse to determine the most appropriate intervention at a given time. Finally, the domain of nursing directly informs clinical judgment by defining the scope of nursing practice. Nurses draw on their knowledge, skills, and ethical principles to make decisions aligned with the philosophy of nursing.