The Structure of Contemporary Nursing
Knowledge
This chapter lays the groundwork for the remain-
der of the book. Here, a structural hierarchy of con-
temporary nursing knowledge is identified and
described. Each component of the structure-
metaparadigm, philosophies, conceptual models,
theories, and empirical indicators-is defined and its
functions are delineated. Then the distinctions be-
tween the components are discussed, with spe-
cial emphass placed on the differences between
conceptual models and theories and the need to
view and use those two knowledge components in
different ways.
OVERVIEW AND KEY TERMS
The structural hierarchy differentiates the various
components of contemporary nursing knowledge ac-
cording to their level of abstraction. The compo-
nents of the structural hierarchy are listed here.
Each component is defined and described in detail
in this chapter.
STRUCTURAL HIERARCHY OF CONTEMPORARY
NURSING KNOWLEDGE
CONCEPT
PROPOSITION
Nonrelational Proposition
Relational Proposition
METAPARADIGM
Requirements for a Metaparadigm
METAPARADIGM OF NURSING
PHILOSOPHY
PHILOSOPHIES OF NURSING
Reaction World View
Reciprocal Interaction World View
Simultaneous Action World View
Categories of Nursing Knowledge
CONCEPTUAL MODEL
CONCEPTUAL MODELS OF NURSING
THEORY
Grand Theory
Middle-Range Theory
NURSING THEORIES
EMPIRICAL INDICATORS
STRUCTURAL HIERARCHY OF
CONTEMPORARY NURSING KNOWLEDGE
An analysis of the terminology used to describe
contemporary nursing knowledge led to the identifi-
cation of five components: metaparadigm, rhi!oso-
phies, conceptual models, theories, and empirical iti
dicators (Fawcett, 1993a; King & Fawcett, 1997). The
STRUCTURAL HIERARCHY OF CONTEMPORARY
NURSING KNOWLEDGE is a heuristic device that
places those five components into a hierarchy based
on level of abstraction. The hierarchy is depicted in
Figure l-l.
The components of the structural hierarchy are
made up of concepts and propositions. A CONCEPT
is a word or phrase that summarizes the essential
characteristics or properties of a phenomenon. A
PROPOSITION is a statement about a concept or a
statement of the relation between two or more con-
cepts. A Nonrelational Proposition is a description
or definition of a concept. A nonrelational propo-
sition that states the meaning of a concept is called
a constitutive definition. A nonrelational proposi-
tion that states how a concept is observed or mea-
sured is called an operational definition. A Rela-
tional Proposition asserts the relation, or linkage,
between two or more concepts.
Metaparadigm
The first component of the STRUCTURAL HIER-
ARCHY OF CONTEMPORARY NURSING KNOWL-
3
 COMPC NENTS LEVEL OF ABSTRACTION

Metapn adigm Most Abstract

fc
ai
- Philosophies,.. n

11
Conceptual Models,,. n

di
m
of
frc
Theories,,,,, Gc
pa
the
tio
Re
ant
w
TI
set-
of I
ma
D G E is the METAPARADIGM (Figure l-l). A The four requirements, which pertain to the meta-
is tl
a?taparadigm is defined a s paradigm of any discipline, are listed in Table l-l.
me1
he global concepts that identify the phenom- the
enaof central interest to a discipline, the tion
-TABLE 111 Requirements for a Metaparadigm
global propositions that describe the concepts, en0
and the global propositions that state the re- 1. The metaparadigm must idenfify a domain that is dis- tinu
lations between the concepts. tinctive from the domains of other disciplines. That the
requirement is fulfilled only when the concepts and rent
The metaparadigm is the most abstract component
propositions represent a unique perspective for inquiry nurs
f the structural hierarchy of contemporary nurs-
and practice. char
,g knowledge, and acts as “an encapsulating unit,
r f r a m e w o r k , w i t h i n w h i c h t h e m o r e re- 2. The metaparadigm must encompass all phenomena em
tricted structures develop” (Eckberg & Hill, of interest to the discipline in a parsimonious mar,- the I
979, p. 927). The concepts and propositions of a ner. That requirement is fulfilled only if the concepts ent c
letaparadigm are admittedly extremely global and and propositions are global and if there are no redun- nursl
rovide no definitive direction for such activities dancies in concepts or propositions. expa
s research and clinical practice. That is to be ex- 3. The metaparadigm must be perspective-neutra/. That meta
acted because the metaparadigm “is the broadest requirement is fulfilled only if the concepts and propo- was I
Jnsensus within a discipline. It provides the gen- sitions do not represent a specific perspective, that is, a ment
ral parameters of the field and gives scientists a specific paradigm or conceptual model, or a combina- (Kleff
road orientation from which to work” (Hardy, 1978, tion of perspectives. The
. 38). 4. The metaparadigm must be international in scope and four r
Functions of a Metaparadigm substance. That requirement, which is a corollary of l-l. II
The functions of a metaparadigm arc? to summarize the third requirement, is fulfilled only if the concepts perso
me intellectual and social missions of a discipline and propositions do not reflect particular national, cul- regarc
rtd place a boundary on the subject matter of that tural, or ethnic beliefs and values. ing (F
iscipline ( K i m , 1 9 8 9 ) . T h o s e f u n c t i o n s a r e re- Wagn
ectcd in certain Requirements for a Metaparadigm. (From Fawcett, 1992, 1996.) cepts

4 Part 1 Structure and Use of Nursing Knowledge Chapter

 Metaparadigm of Nursing
The METAPARADIGM OF NURSING is made up of
four concepts, four nonrelational propositions,
and four relational propositions. The concepts and
propositions of the metaparadigm of nursing are
described in Table 1-2.
The n o n r e l a t i o n a l p r o p o s i t i o n s o f t h e metapara-
Qm o f n u r s i n g a r e c o n s t i t u t i v e d e f i n i t i o n s o f t h e
metaparadigm concepts. The relational propositions
of the metaparadigm of nursing, which were drawn
from work by Donaldson and Crowley (1978) and
G o r t n e r (19801, a s s e r t t h e l i n k a g e s b e t w e e n meta-
paradigm concepts. Relational proposition 1 links
the concepts person and health. Relational proposi-
tion 2 links the concepts person and environment.
Relational proposition 3 links the concepts health
and nursing. Relational proposition 4 links the con-
cepts person, environment, and health.
The version of the metaparadigm of nursing pre-
sented here represents an extension and elaboration
of the original metaparadigm of nursing published
m a n y y e a r s a g o ( F a w c e t t , 198413). One difference
is the addition of a constitutive definition for each
rnetaparadigm concept. Another difference between
the earlier and current versions is the formaliza-
tm o f t h e m e s i n t o p r o p o s i t i o n s . S t i l l a n o t h e r differ-
PIICE! i s t h e a d d i t i o n o f t h e f o u r t h p r o p o s i t i o n . Con-
tlnued r e f i n e m e n t i n t h e c o n s t i t u t i v e d e f i n i t i o n s o f
the m e t a p a r a d i g m c o n c e p t s h a s r e s u l t e d i n t h e c u r -
rent r e f e r e n c e t o t h e p e r s o n a s a p a r t i c i p a n t i n
nursing, rather than a recipient of nursing. That
c h a n g e was made to better reflect the contemporary
emphasis on the person as an active participant in
the nursing process, rather than a passive recipi-
ent of pronouncements by and ministrations from
nurses. Continued refinement also has resulted in an
expansion of the constitutive Cefinition for the
m e t a p a r a d i g m c o n c e p t environ1 l e n t . T h a t c h a n g e
was made to better reflect the rr,ultitude o f e n v i r o n -
mental conditions that are relevant in nursing
(Kleffel, 1991).
The current version of the metaparadigm meets the
four requirements for a metaparadigm listed in Table
l - l . I n p a r t i c u l a r , t h e f o u r m e t a p a r a d i g m concepts-
person, environment, health, nursing-generally are
regarded as the central or domain concepts of nurs-
ing (Flaskerud & Halloran, 1980; Jennings, 1987;
Wagner, 1986). They are a modification of four con-
cppts i n d u c e d f r o m t h e c o n c e p t u a l f r a m e w o r k s
Chapter 1 The Structure of Contemporary Nursing Knowledge
1, I. .^ .
‘[ TAB,,LE, i - 2 The Met&&ad& of Nursing:
,’ 2. Concepts, Nonreiationai Propositions,
:’ and Relational Propositions
Concepts
Person
Environment
Health
Nursing
Nonrelational Propositions
1. The metaparadigm concept person refers to the indi-
viduals, families, communities, and other groups who
are participants in nursing.
2. The metaparadigm concept environment refers to the
person’s significant others and physical surroundings,
as well as to the setting in which nursing occurs,
which ranges from the person’s home to clinical agen-
cies to society as a whole. The metaparadigm concept
environment also refers to all the local, regional, na-
tional, and worldwide cultural, social, political, and
economic conditions that are associated with the per-
son’s health.
3. The metaparadigm concept health refers to the person’s
state of well-being at the time that nursing occurs,
which can range from high-level wellness to terminal
illness.
4. The metaparadigm concept nursing refers to the defini-
tion of nursing, the actions taken by nurses on behalf of
or in conjunction with the person, and the goals or
outcomes of nursing actions. Nursing actions typically
are viewed as a systematic process of assessment,
labeling, planning, intervention, and evaluation.
Relational Propositions
1. The discipline of nursing is concerned with the prin-
ciples and laws that govern the life-process, well-
being, and optimal functioning of human beings, sick
or well.
2. The discipline of nursing is concerned with the pattern-
ing of human behavior in interaction with the environ-
ment in normal life events and critical life situations.
3. The discipline of nursing is concerned with the nursing
actions or processes by which positive changes in
health status are effected.
4. The discipline of nursing is concerned with the
wholeness or health of human beings, tecogniri~w that
they are in continuous interaction with their environ-
ments.
5
of baccalaureate programs accredlt>d by the
vational League for Nursing. The orIginal concepts
were man, society, health, and nursirlg (Yura &
Torres, 1975). The term man was changed to person
:a avoid gender-specific language, and the term
society was changed to environment to more fully
encompass phenomena of relevance to the per-
$on (Fawcett, 19781. Additional support for the cen-
trality of the four metaparadigm concepts comes
from the successful use of those concepts as a
schema fnr analysis of the content of conceptual
models of nursing and nursing theories (Fawcett,
1993a, 1995; Fitzpatrick & Whall, 1996; George, 1995;
Marriner Tomey & Alligood, 1998).
Proposals for Alternative Metaparadigm
Concepts and Propositions
The version of the nursing metaparadigm pre-
sented her; should not be regarded as premature Th
closure on explication of phenomena of interest to
the discipline of nursing. Indeed, it is anticipated Re
that modifications in the metaparadigm concepts Db
and propositions will continue to be offered as the
discipline of nursing evolves. Modifications must, Ne
however, fulfill the four requirements for a meta- ten
paradigm (see Table l-l). The alternative versions of
Cri,
the metapa’radigm of nursing are presented in Ta-
ble l-3, along with discussion about and critique of Tk
each proposal. None of those proposals meets all the1

four requirements for a metaparadigm. the

quii
Philosophies The
etaparadigm of dental hygiene. More specifically,
The second component of the STRUCTURAL HIER- Elirr
ARCHY OF CONTEMPORARY NURSING KNOWL-
Disc
EDGE is the PHILOSOPHY (see Fig. I-l). A philoso-
health/oral health, and dental hygiene ac-
phy may be defined as Con\
a statement encompassing ontological claims sent.
The relational propositions of the metaparadigm about the phenomena of central interest to a priat
5 xe Table l-2) provide a unique perspective of the discipline, epistemic claims about how WV.
:(#I cepts that helps distinguish nursing from other those phenomena come to be known, and ethi- comi
-lisl.iplines. Relational propositions 1, 2, and 3 repre- cal claims about what the members of a disci- COIlC

;rJnt recurrent themes identified in the writings of pline value. then

:Icrence Nightingale and many other nursing schol-
Function of a Philosophy Critir,
mrs and clinicians of the nineteenth and twentieth
!enturies. Donaldson and Crowley (1978) com- The function of a philosophy is to communicate Kolcz
nented that “these themes suggest boundaries of what the members of a discipline believe to be true v-w.~
n area for systematic [ilnquiry and theory develop- in relation to the phenomena of interest to that cept i
nent with potential for making the nature of the discipline, what they believe about the development taut01

liscipline of nursing more explicit than it is at pres- of knowledge about those phenomena, and what view

knt” (p. 113). Relational proposition 4, according they value with regard to their actions and practices discip
o Donaldson and Crowley (19781, “evolveldl from (Kim, 1989; Salsberry, 1994; Seaver & Cartwright, two d
he practical aim of optimizing of human envi- 1977). In other words, the function of each philoso- ing a9
onments for health” (p. 119). phy is to inform the members of disciplines and essen
the general public about the beliefs and values of a tion, E
:T&en together, the four concepts, the four nonrela- particular discipline. place,
onai propositions, and the four relational propo- ries. F
kions identify the unique focus of the discipline of
Philosophies of Nursing
cancel
ursing and encompass all relevant phenomena in a PHILOSOPHIES OF NURSING encompass ontologi- nursin
Brsimonious manner. Furthermore the concepts cal and epistemic claims about the phenomena of the COI
nd propositions are perspective-neutral because interest to the discipline of nursing and ethical therefc
<ey do not reflect a specific paradigm or conceptual claims about nursing actions, nursing practices, and Con\n
~adel. Moreover, the metaparadigm concepts and the character of individuals who choose to practice concep
Wtjositions do not reflect the beliefs and values nursing (Salsberry, 1994). The ontological claims Consec
f nurses from any one country or culture and, in philosophies of nursing state what is believed metap:
i&forp, are international in scope and substance. about the nature of the person, the environment, interesl
(Text continued on p. 70)
/

6 Part 1 Structure and Use of Nursing Knowledge Chapter


i TABLE 1-3 Propos& for Alternafive'Vekioni _‘ "
of the Meteparadigm of Nursing: P
Discussion end Critique ,’
The Newman Proposal
Replace the concept person with the concept client.
N~wrnan (1983) proposed that the term client replace the
term petson in the metaparadigm.
i Critique
: The term client reflects a particular view of the person and,
! therefore, is not a perspective-neutral concept. Therefore,
the suggested modification does not fulfill the third re-
‘; quirement for a metaparadigm (see Table l-l).
’ The Conway Proposal
‘,’ Eliminate the concept nursing from the metaparadigm.
1: ’ Discussion
Conway (1985, 1989) claimed that the term nursing repre-
.sents the discipline or the profession and is not an appro-
i priate me&paradigm concept because it creates a tautol-
1 ogy. Meleis (1997). apparently in agreement with Conway,
commented, “It would be an instance of tautological
conceptualizing to define nursing by all the concepts and
then include nursing as one of the concepts” (p. 106).
Crifiqrie
Kolcaha and Kolcaba (1991) rejected the charge of a tautol-
ogy. They noted that inasmuch as the metaparadigm con-
cept nursing stands for nursing activities or actions, a
tautology is not created. Furthermore, other scholars
view nursing as a distinct phenomenon of interest to the
discipline. Kim (1987) identified nursing as a component of
IWO domains of nursing knowledge. She regarded nurs-
. ing as the central feature of the practice domain and as an
:’ essential component of the client-nurse domain. In addi-
‘ion, Barnum (1998) identified nursing acts as a common-
place, that is, a topic addressed by most nursing theo-
WS. Finally, King (1984) found that nursing was a central
concept in the philosophies of nursing education of several
lursing education programs. That finding suggests that
‘_ !he concept nursing is a discipline-wide phenomenon and,
Mefore, must be included in the metaparadigm.
Conway (1985) did not offer a substitute metaparadigm
concept to represent the actions ar activities of nurses,
‘. Consequently, her proposal to eliminate nursing from the
1’ lnelaparadigm does not encompass all phenomena of
.i’ it,ter?st to the discipline of nursing. Moreover, Conway
Structure of Canter qporary Nursing Knowledge
offered no justification for the uniqueness of a discipline
dealing with the person, environment, and health. Her pro-
posal, therefore, does not fulfill the first and second re-
quirements for a metaparadigm (see Table l-l).
The Kim Proposal
Exclude the concept health from the metaparadigm.
Discussion
Kim (1987, 1997) identified four domains of nursing knowl-
edge. The client domain is concerned with the client’s de-
velopment, problems, and health care experiences. The
client-nurse domain focuses on encounters between client
and nurse and the interactions between the two in the
process of providing nursing care. The practice domain
emphasizes the cognitive, behavioral, and social aspects
of nurses’ professional actions. The environment domain
takes in the time, space, and quality variations of the
client’s environment. Hinshaw (1987) pointed out that
Kim’s work does not include the concept health, and asked,
“Is health a strand that permeates each of the do-
mains rather than a major separate domain?” (p. 112).
Kim (personal communication, October 31, 1986) indi-
cated that the client domain could encompass health.
Critique
Kim’s failure to explicitly identify health as a distinct
domain or a component of one or more other domains cre-
ates a void in an otherwise informative explication of the
discipline of nursing. Thus, her proposal does not fulfill the
second requirement for a metaparadigm (see Table l-l).
The Meleis Proposal
The central concepts of nursing are nursing client, transi-
tions, interaction, nursing process, environment, nursing
therapeutics, and health.
Discussion
Meleis (1997) maintained that “the nurse interacts (inter-
action) with a human being in a health/illness situation
(nursing client) who is in an integral part of his sociocul-
turat context (environment) and who is in some sort of
transition or is anticipating a transition (transition): the
nurse/patient interactions are organized around some pur-
pose (nursing process, problem solving, holistic assess-
ment, or caring actions) and the nurse uses some actions
(nursing therapeutics) to enhance, bring about, or facilitate
health (health)” (p. 106). Meleis and Trangenstein (1994)
and Schumacher and Meleis (1994) highlighted the impor-
tance and centrality of the concept transitions. In particu-
lar, Meleis and Trangenstein (1994) maintained that “the
 ,)’
)!lr
1 ABLE l-3 Proposals ‘for Alternati~a%&k
qL‘ of the Metaparadigm of Nursing: I
I:!.
:;j; Discussion and Critique (Continued) I
‘ransition experience of clients, families, communities,
nurses, and organizations, with health and well-being as a
goal and an outcome, meets the criteria . . of an or-
ganizing concept that allows for a variety of viewpoints
and theoties within the discipline of nursing, . [is] not
culture hound, and should help in identifying the focus
of thr discipline” (p. 255).
Crftirlrir
Thp inclI!sinn of nursing process, nursing therapeutics, and
intrractions in Meleis’s proposal represents a redundancy
that can be avoided by use of the single concept, nurs-
ing Moreover, the inclusion of transitions reflects a par-
ticular perspective of human life. Indeed, Meleis and
Trangpnstein (1994) referred to their discussion of transi-
tions as a “conceptual framework” (p. 258). Thus, Meleis’s
proposal for the central concepts of nursing, although
meritorious, does not meet the second and third require-
ments for a metaparadigm (see Tab’- l-l).
The King Proposal
The domain of nursing is represented by the concepts
The Newman, Sime, and Corcoran-Perry Proposal
Nursing is the study of caring in the human health expe-
rience. .
Discussion
Newman, Sime, and Corcoran-Perry (1991) claimed that the
focus of the discipline of nursing is summarized in the fol-
t
lowing statement: “Nursing is the study of caring in the
human health experience” (p. 3). In a later publication,
they asserted that “the theme of caring is sufficiently dom-
inant, when combined with the theme of the human health
experience, to be considered as the focus of the disci-
pline” (Newman, Sime, & Corcoran-Perry, 1992, p. vii).
7
Critique
T,
Despite Newman and colleagues’ (1992) claims to the con- P’
trary, their proposition represents just one frame of refer-
D,
ence for nursing and for health. In fact, Newman and her
colleagues (1991) ended their initial treatise by maintaining Pa
that caring in the human health experience can be most ml
fully elaborated only through a unitary-transformative per- (P.
spective. Moreover, although Newman et al. (1991) of- the
fered their proposition as a single statement that integrates the
rln
“concepts commonly identified with nursing at the meta-
paradigm level” (p. 31, and although they identified the ed(

man, health, role, and social systems. metaparadigm concepts as person, environment, health, (P.
and nursing, their proposition does not include environ- Cril
DiSCUSSiO/,
ment. In an attempt to clarify their position, Newman,
Sime, and Corcoran-Perry (1992) later stated, “we view the Par:
King’s (1984) review of the philosophies of a representative
concept of environment as inherent in and inseparable ver:
sample of National League for Nursing accredited nursing
from the integrated focus of caring in the human health ex- stlrr
education programs in the United States revealed nine
perience” (p. vii). Despite that clarification, their proposal OCCI
concepts: man, health, environment, social systems, role,
does not meet the second and third requirements for a nurz
perceptions, interpersonal relations, nursing, and God.
metaparadigm because it is neither sufficiently comprehen- is pf
King found that all nine concepts were not evident in the
sive nor perspective-neutral (see Table l-l). este,
philosophies of all the schools included in the sample. She
the I
recommended that the most frequently cited concepts
The Malloch, Martinez, Nelson, Predeger, Speakman, parti
cror~lti represent the domain of nursing. Those concepts
Steinbinder, and Tracy Proposal is, hr
a,re: man, health, role, and social systems.
unita
Nursing is the study and practice of caring within contexts
Ckitiqoe and t
of the human health experience.
King’s proposal falls short of meeting all requirements for The 1
Discussion
a metaparadigm. First, the inclusion of role and social
Elimil
systems reflects a sociological orientation to nursing. Sec- Malloch, Martinez, Nelson, Predeger, Speakman. Stein-
and s
&d, the elimination of environment and nursing results binder, and Tracy (1992) suggested a revision of the New-
vironr
in a narrow view of the domain. Moreover, the elimination man, Sime, and Corcoran-Perry (1991) statement. Their
Elim
of environment and nursing leaves a list of concepts more focus statement is as follows: “Nursing is the study and
relatic
.‘osely aligned with the discipline of social work (Ben- practice of caring within contexts of the human health ex-
cancel
‘i .n, 1987) than with nursing. Thus, her proposal does not perience” (p. vi). Malloch and her colleagues (1992)
well-b1
i’leet the first, second, and third requirements for a maintained that their statement extends the focus of the
ity of (
~letaparatligrn (see Table l-l). discipline to nursing practice and incorporates the environ-

8 Part 1 Structure and Use of Nursing Knowledge Chapter

 ment by the use of the term contexts. They noted that en-
,vironment “includes, but is not limited to, culture, com-
munity. and ecology” (p. vi). Moreover, they claimed that
a :the use of the term caring brings unity to the metapara-
’ digm concepts of person, environment, health, and nurs-
inn. Apparently, they do not regard caring as a particu-
Jar perspective of nursing.
Although the Malloch et al. proposal is sufficiently compre-
iiensive, it does not meet the third requirement for a
metaparadigm because it is not perspective-neutral (see
jTable l-1).
‘The Parse Proposal
The core focus of nursing is the human-universe-health
’ process.
; ~Discussion
Parse (1997) asserted that “the core focus of nursing, the
metaparadigm, is the human-universe-health process”
(p. 74). She went on to explain that the “hyphens between
the words create a unitary construct incarnating the notion
that the study of nursing is the science of the human-
universe-health process. Consequently, all nursing knowl-
edge is in some way concerned with this phenomenon”
‘p 74).
Parse’s proposal has merit in that her use of the term uni-
VPTSI? extends the environment far beyond the immediate
surrntlndings of the person and setting in which nursing
occurs. However, her proposal does not explicitly name
nrlrsing as a concept of the metaparadigm. That omission
is problematic in that many disciplines could be inter-
ested in hllmans, the universe, and health. Furthermore,
the meaning Parse ascribed to the hyphens used reflects a
‘particular perspective of the named phenomenon. That
is, humans. the universe, and health must be viewed as
’ unitary. Consequently, her proposal does not meet the first
and third requirements for a metapartligm (see Table 1-l).
The Leininger/Watson Proposal
Eliminate the four metaparadigm concepts (see Table l-2)
snd substitute the concepts human care, health, and en-
vironmental cultural context.
Eliminate the four metaparadigm concepts and the four
relational propositions (see Table l-2) and substitute the
concepts human care, environmental cantexts, and
well being (health) and a proposition asserting the central-
ity of caring to the discipline of nursing.
Chapter 1 The Structure of Contemporary Nursing Knowledge
Discussion
Leininger (1995) asserted that “with transcultural nurse
knowledge and consumer demands, many nurses are rec-
ognizing that human care, health, and environmental
cultural context must become the central focus, essence,
and dominant domains of nursing knowledge to re-
place the;Eastern’ four concept metaparadigm” (p. 97). In
setting the stage for her proposal, Leininger (1995) charged
that “a small group of ‘Eastern’ USA nurse researchers .
declared in nursing publications that nursing’s major foci
or ‘metaparadigm’ for the discipline . would be health,
nursing, person, and environment. It was quite clear to me
that these nurses blatantly failed to recognize [that] hu-
man care, caring, and cultural factors were important phe-
nomena of nursing. It appeared to me and other care
scholars that this small elite group were lobbying against
the rapidly growing interest in care and transcultural nurs-
ing” (p. 96). In another publication, Leininger (1990)
claimed that “human care/caring [is] the central phenome-
non and essence of nursing” (p. 19). and Watson (1990)
maintained that “human caring needs to be explicitly incor-
porated into nursing’s metaparadigm” (p. 21). Even more
to the point, Leininger (1991a) maintained that: “care is the
essence of nursing and the central, dominant, and unify-
ing focus of nursing” (p. 35). On the basis of that position,
Leininger (1988) rejected the metaparadigm concepts of
person and nursing. She commented, “[II reject the idea
that nursing and person explain nursing, for one cannot
explain nor predict the same phenomenon one is studying.
Nursing is the phenomenon to be explained. Moreover,
person, per se, is not sufficient to explain nursing as it fails
to account for groups, families, social institutions, and
cultures” (p. 154). Leininger (1991c) went on to assert that
“the concepts of person and nursing are quite inappro-
priate. Person is far too limited and nursing cannot be logi-
cally used to explain and predict nursing. The latter is a
redundancy and a contradiction to explain the same phe-
nomenon being studied by the same concept” (p. 152).
In another publication, Leininger (1991a) continued to re-
ject the metaparadigm concept of person, and she ap-
parently rejected environment and health as well. She
stated, “From an anthropological and nursing perspective,
the use of the term person has serious problems when
used transculturally, as many non-Western cultures do not
focus on or believe in the concept person, and often there
is no linguistic term for person in a culture, family and
institutions being more prominent. While environment is
very important to nursing, I would contend it is cer-
tainly not unique to nursing, and there are very few nurses
who have advanced formal study and are prepared to
(Continued)
9
 over, may not be generalizable across national and cultural
&ABLE 1-3 Proposals for Altekat~$‘kit$ions ’
t. of the Metaparadigm of lb-sing: boundaries (Mandelbaum, 1991). And, as Rogers (1992)
;i Lliscussion a n d Ctit~qutr (Contimmdl _ _ 1 asserted, “as such, caring does not identify nurses any
r4. n
more than it identifies workers from another field. Every-
study a large number of different types of environments or
one needs to care” (p. 33). Rogers (1994b) went on to say,
ecological niches worldwide. [The metaparadigml con-
“I don’t think nurses care any more than anybody else, t
cepts had serious problems except for that of health.
Again, as a concept health is not distinct to nursing al-
or that it’s a characteristic any more peculiar to nursing z
than to any other field. [But caring1 does differ among dif- 1
tholrgh nursing plays a major role in health attainment and
ferent groups. It is the body of knowledge about the i
maintenance-many disciplines have studied health” (pp.
phenomenon of concern that determines the nature of the 1
3 9 40).
caring that one is going to demonstrate” (p. 34). Elabo- C
rating, Rogers (1994a) added, “Caring is doing, it is prac- C
Critique
tice. Caring is a way of using knowledge” (p. 7). Viewed ti
In her tliscttssions, Leininger failed to acknowledge that an from a different vantage point, Roper (1994) commented, n
entlier discussion of the metaparadigm concept person “I consider that ‘care’ is implicit in ‘nursing’ and there- a
intlicntpd that that concept can refer to any entity that is fore ‘nursing care’ is a tautology” (p. 460). In addition, C
a participant in nursing actions, including individuals, fami- Leininger’s (1995) charge regarding lobbying against her S
lips, anri nther types of groups, communities, and soci- ideas by a small, elite group of “Eastern” nurses has no
eties (Fnwcett, 1984a). Furthermore, Leininger (1991a, 1995) basis-none of the discussions of the metaparadigm con-
rl
d~tl not acknowledge that the point of the inclusion of the cepts as person, environment, health, and nursing have in-
cluded negative comments about caring or transcultural
fc
ro~~-cpt environment in the metaparadigm is to provide
nursing: the only point has been that caring is not unique
C
a context for the person, to indicate that participants in
a
nlrrsing actions are surrounded by and interact with other to nursing. Leininger’s discussions about the metapara-
people and the social structure (Fawcett, 1984a). Indeed, digm, then, tend to be contradictory, and she fails to ac-
L
knowledge that her ideas could be readily incorporated
C
she neither acknowledged her own statement that “care
into the widely cited metaparadigm concepts person, envi-
Ii,
shorild he central to [the] nursing metaparadigm and sup-
ronment, health, and nursing. More specifically, person
cl
ported by the concepts of health and environmental con-
already refers to collectives as well as to individuals, envi-
n
texts” (Leininger, 1988, p. 154). nor ler statement that
fit
“in the very near future, one can pre:iict that the current ronment already is viewed as context, health already refers
in
concepts of person, environment, ho tlth, and nursing will to a broad spectrum of states that includes well-being, and
SI
no longer be upheld. Instead, human care, environmen- nursing can be viewed as directed toward human care.
tal contexts, and well-being (or health) will become of ma- Clearly, then, the Leininger/Watson proposal does not meet
jor interest to most nurse researchers and new theorists” the first, third, and fourth requirements for a metapara- cl
(Leininger, 1991b, p. 406). Moreover, Leininger did not digm (see Table l-1). SC
acknowledge that the inclusion of the concept nursing in di
the metaparadigm was not to create a tautology, but rather tit
to serve as a single-word symbol of all nursing actions er
and activities taken on behalf of or in conjunction with the e\
person, family, community, or other entity (Fawcett, 1984a). SC
(Text cbntinued from p. 6)
In addition, both Leininger and Watson failed to acknowl- di
health, and nursing. The epistemic claims in philosp
edge that although the term caring is included in sev- tic
phies of nursing provide “some information on how
eral conceptualizations of the discipline of nursing (Morse, q1
one may come to learn about the world [and] about
Solberg, Neander, Bottorff. & Johnson, 19901, it is not a fe
how the basic phenomena can be known” (Sals-
dominant theme in every conceptualization and, therefore, er
berry, 1994, p. 13). Epistemic claims in nursing ex-
does not represent a discipline-wide viewpoint (Wilson, tic
tend the ontological claims by directing how knowl-
1994). Indeed, caring reflects a particular view of nursing in
edge about the person, the environment, health,
and a particular kind of nursing (Eriksson, 19891. Further-
and nursing is developed. 1
rnnrn, RR Swanson (1991) pointed out, althnwgh there may
dr
be “characteristic behavior patterns that are universal Ontological and epistemic claims in philosophies
sh
expressions of nurse caring . caring is not uniquely a of nursing reflect one or more of three contrasting
world views: the Reaction World View, the Recipro- pe
nursing phenomenon” (p. 165). Caring behaviors, more-

10 Part 1 Structure and Use of Nursing Knowledge CL

 raction World View, and the Simultaneous
World View. Those three world views
ed from an analysis of four existing sets of
views: mechanism and organicism (Ackoff,
’ Reese & Overton. 1970); change and persis-
(Hall, 1981, 1983; Thomae, 1979; Wells &
tyker, 1988); totality and simultaneity (Parse,
and particulate-deterministic, interactive-
ative, and unitary-transformative (Newman,
The different world views lead to different
eptualizations of the metaparadigm concepts,
rent statements about the nature of the rela-
between those metaparadigm concepts (Alt-
a@ & Rogoff, 1987), and different ways to generate
dtest knowledge about the concepts and their
nnections. The features of each world view are
Tmarized in Table l-4.
*tological claims in philosophies of nursing also
!I: ?t one or more broad Categories of Knowledge
rrnd in adjunctive disciplines and in nursing.
.+gories of knowledge from adjunctive disciplines
e developmental, systems, and interaction
hnson, 1974; Reilly, 1975; Riehl & Roy, 1980).
egories of knowledge mentioned in the nursing
erature a r e n e e d s a n d o u t c o m e s ( M e l e i s , 1 9 9 7 ) ;
ientfocused, person-environment focused, and
rsing therapeutics focused (Meleis, 1997); energy
Ids (Hickman, 1995; Marriner-Tomey, 1989); and
tervention, s u b s t i t u t i o n , conservation, sustenance/
Ipport, a n d e n h a n c e m e n t ( B a r n u m , 1 9 9 8 ) .
various categories of knowledge are “different
es of approaches to understanding the per-
who is a patient, [so that they1 not only call for
ring f o r m s o f p r a c t i c e t o w a r d d i f f e r e n t objec-
, but also point to different kinds of phenom-
suggest different kinds of questions, and lead
tually to dissimilar bodies of knc, vledge” (John-
1974, p. 376). Each category, then, emphasizes
r e n t p h e n o m e n a a n d l e a d s t o d i f f e r o n t ques-
s about the nurse-patient situation. Conse-
h categoryfosters development of a dif-
of knowledge about the person, the
ent, h e a l t h , a n d n u r s i n g . T h e characteris-
h category of knowledge are summarized
c a l c l a i m s i n p h i l o s o p h i e s o f n u r s i n g ad-
values “that guide the nurse’s relation-
patients/clients, . . . the character of the
ntering a n d r e m a i n i n g i n t h e f i e l d o f
(Text continued on p. 151
1 The Structure of Contemporary Nursing Knowledge
’ TABLE 1-4 Features of the Reaction World View.
the Reciprocal Interaction
World View, and fhe
.‘
1 Simultaneous Action World view
Reaction World View
Contains elements of the mechanistic, persistence, totality,
and particulate-deterministic world views.
Humans are bio-psycho-social-spiritual beings. The meta-
phor is the compartmentalized human being, who is
viewed as the sum of discrete biological, psychological,
sociological, and spiritual parts.
Human beings react to external environmental stimuli in
a linear, causal manner. The person is regarded as inher-
ently at rest, responding in a reactive manner to exter-
nal environmental stimuli. Behavior is considered a linear
chain of causes and effects, or stimuli and reactions.
Change occurs only for survival and as a consequence of
predictable and controllable antecedent conditions. Change
occurs only when the person must modify behaviors to
survive. Consequently, stability is valued. Threats to stabil-
ity are, however, predictable and controllable if enough is
known about the stimuli that would force a change.
Only objective phenomena that can be isolated, ob-
served, defined, and measured are stt/died. Knowledge is
developed only about objective, quantifiable phenom-
ena that can be isolated and observed, defined in a con-
crete manner, and measured by objective instruments.
Reciprocal Interaction World View
A synthesis of elements from the organismic, simulta-
neity, totality, change, persistence, and interactive-
integrative world views.
Human beings are holistic; parts are viewed only in the
context of the whole. The metaphor is the holistic, interact-
ing human being, who is viewed as an integrated, orga-
nized entity not reducible to discrete parts. Although parts
are acknowledged, they have meaning only within the
context of the whole person.
Human beings are active, and interactions between hu-
man beings and their environments are reciprocaL The
person is regarded as inherently and spontaneously active.
The person and the environment interact in a reciprocal
manner.
Change is a function of multiple antecedent factors, is
probabilistic, and may be continuous or may be only for
survival. Changes in behavior occur throughout life as the
result of multiple factors within the individual and within
the environmerit. At times, changes are continuous. At
other times, persistence or stability reigns and change
(Continued1
 wt
.TABtE i-5 Characteristics of ’ ’ ”
is i
Categories of Knowledge
oP
Simultaneous Action World view ‘. Developmental Category of Knowledge ent
(Continued) b’
II 1 Origin is the discipline of psychology. sPc
occurs only to foster survival. The probability of change at Emphasizes identification of actual and potential develop- aut

any given time can only be estimated. mental problems and delineation of intervention strate- For
Realrfy is multidimensional, context-dependent, and rela- gies that foster maximum growth and development of peo-
tive. Both objective and subjective phenomena are stud- ple and their environments. For1

ied through quantitative and qualitative methods of grol

Growth, Development, and Maturation natt
inquiry: emphasis is placed on empirical observations,
methodological controls, and inferential data analytic tech- Emphasis is placed on processes of growth, development, (b) i

niques. Knowledge development focuses on both objec- and maturation. facts

tive phenomena and subjective experiences and is accom- tern.

Change peab
plished hy means of both quantitative and qualitative
methodologies. Multiple dimensions of experience are Change is the major focus, with the assumption made and

taken into account, the context of the person-environment “that there are noticeable differences between the states of
interaction is considered, and the product of knowledge a system at different times, that the succession of these
development efforts is regarded as relative to historical states implies the system is heading somewhere, and that Peop

time and place. Emphasis always is placed on empirical there are orderly processes that explain how the system may

observations within methodologically controlled situations, gets from its present state to wherever it is going” (Chin, certa

and quantitative data typically are analyzed objectively by 1980, p. 30).

Systc
means of descriptive and inferential statistics.
Direction of Change
Origin
S mtrltaneous Action World View
Changes are directional-the individuals, groups, situa- Emr
ombillas elements of the organismic, simultaneity, tions, and events of interest are headed in some direction. lems

ilange, and unitary-transformative world views. The direction of change is: “(a) some goal or end state ventic

Unitary human beings are identified by pattern. The met- (developed, mature), (b) the process of becoming (develop- tern 0
@OI is the unitary human being, who is regarded as a ing, maturing), or (c) the degree of achievement toward
System
.iolistic, self-organized field. The human being is more than some goal or end state (increased development, increase
snd different from the sum of parts and is recognized in maturity)” (Chin, 1980, p. 31). “A set
.hrocrglr oatterns of behavior. object:
Identifiable State
HU,JJ~?IJ hcings are in mutual rhythmical interchange with 1968, 1
‘heir environments. The person-environment interchange Different states of the person are seen over time. Those
lrltngrc
s a n~titr~al. rhythmical process. states frequently are termed stages, levels, phases, or peri.
Nurr~ar~ heirqs change continuously, unpredictably, ods of development; they may be quantitatively or quali- Ptienor
?nd in the direction of more complex self-organization. tatively differentiated from one another. Shifts in state may interac
Changes in patterns of behavior occur continuously, uni- be either small, nondiscernible steps that eventually are clemen
:lirectinnally, and unpredictably as the human being recognized as change, or sudden, cataclysmic changes
Open a
?vnlves. Although the patterns are sometimes organized (Chin, 1980).
and sometimes disorganized, change ultimately is in the System
Form of Progression
Jirectinn of increasing organization of behavioral patterns. “maintc
The phenomena of interest are personal knowledge and Developmental change is possible through four different building
Tattern recognition. Knowledge develo, ment empha- forms of progression: (I) unidirectional development fl closet
;tzes personal becoming through recognition of patterns. may be postulated, such that “once a stage is worked environ1
The phenomena of interest are, thereforc , the person’s through, the client system shows continued progression continue
ryer experiences, feelings, values, thoughts, and and normally never turns back;” (2) developmental change entropy
,hoices. rnay take the form of a spiral, so that although return to more ciii
a previous problem may occur, the problem is dealt with at Conversl
from Fawcratt, 1993b.) a higher level; (3) development may be seen as “phases move to!
(Continued!

12 Part 1 Structure and Use of Nursing Knowledge Chapter 1

whirh occlur and recur. where no chronological priority
is assigned to each state; there are cycles;” or (4) devel-
opment may take the form of “a branching out into differ-
entiated forms and processes, each part increasing in its
specialization and at the same time acquiring its own
8utonorny and significance” (Chin, 1980, pp. 31-32).
Forces are “causal factors producing de\.elopment and
growth” (Chin. 1980, p. 32), and may be diewed as (a) a
nattlral component of the person undergoing change,
(b) a coping response to new situations and environmental
factors that leads to growth and development, or (c) in-
ternal tensions within the person that at some time reach a
peak and cause a disruption that leads to further growth
and development.
ioten,ia/ity
People have the inherent potential for change; potentiality
may be overt or latent, triggered by internal states or
certain environmental conditions.
Systems Category of Knowledge
Origins are the disciplines of biology and physics.
Emphasizes identification of actual and potential prob-
lems in the function of systems and delineation of inter-
vention strategies that maximize efficient and effective sys-
tem operation; change is of secondary importance.
Systen,
“A set of objects together with relationships between the
lbjects and between their attributes” (Hall & Fagen,
,168, p. 83).
Megration of Parfs
Phenomena are treated “as if there existed organization,
interaction, interdependency, and integration of parts and
elements” (Chin, 1980, p. 24).
Lfw7 and Closed Systems
Systems are viewed as open or closed. An open system
Plalntains itself in a continuous inflow and outflow, a
building up and breaking down of components,” [whereas
4 closed system is] “considered to be isolated from [its]
environment” (van Bertalanffy, 1968, p. 39). Open systems
continuously import energy in a process called negative
entropy or negentropy, so that the system may become
More differentiated, more complex, and more ordered.
Conversely, closed systems exhibit entropy, such that they
%JVP toward increasing disorder. All living organisms are
Chapter 1 The Structure of Contempt rary Nursing Knol
open systems (van Bertalanffy, 1968). Although closed sys-
terns therefore do not,exist in nature, it sometimes is
convenient to view a system as if it had no interaction with
its environment (Chin, 1980). The artificiality of that view,
however, must be taken into account.
Environment
“The set of all objects a change in whose attributes affects
the system and also those objects whose attributes are
changed by the behavior of the system” (Hall & Fagen,
1968, p. 83).
. Boundary
The line of demarcation between a system and its environ-
ment, “the line forming a closed circle around selected
variables, where there is less interchange of energy
across the line of the circle than within the delimiting cir-
cle” (Chin, 1980, p. 24). The placement of the boundary
must take a’ll relevant system parts into account. Bound-
aries may be thought of as more or less permeable. The
greater the boundary permeability, the greater the inter-
change of energy between the system and its environment.
Tension, Stress, Strain, Conflict
The forces that alter system structure. The differences in
system parts, as well as the need to adjust to outside
disturbances, lead to different amounts of tension within
the system (Chin, 1980). Internal tensions arising from the
system’s structural arrangements are called the stresses
and strains of the system (Chin, 1980). Conflict occurs
when tensions accumulate and become opposed along the
lines of two or more components of the system. Change
then occurs to resolve the conflict.
Equilibrium and Steady State
Systems are assumed to tend to move toward a balance
between internal and external forces. “When the balance
is thought of as a fixed point or level, it is called ‘equi-
librium.’ ‘Steady state,’ on the other hand, is the term
used to describe the balanced relationship of parts that
is not dependent upon any fixed equilibrium point or
level” (Chin, 1980, p. 25). Steady state, which also is re-
ferred to as a dynamic equilibrium, is characteristic of liv-
ing open systems and is maintained by a continuous
flow of energy within the system and between the system
and its environment (van Bertalanffy, 1968).
Feedback
The flow of energy between a system and its environment.
Systems “are affected by and in turn affect the environ-
(Continued)
!dge
 egories of others” (Heiss, 1981, p. 65). Each person has
’ TABLE 1-5 Characteristics of . * I
many different roles, each one providing a behavioral rep-
Cefeguries of Knowledge (Continued)
ertoire. People adopt the behaviors associated with a
ment. While affecting the environment, a process we call given role, when, through communication, they determine
o11i~)t11, systems gather information about how they are (
that a given role is called for in a particular situation,
doinct Stlch information is then fed back into the system
E
as ilrl>ut to gllide and steer its operations” (Chin, 1980, Self-Concept
ti
p. 77). Tll~ feedback process works so that as open sys- “The individual’s thoughts and feelings about him[her]self’ P
tems illferact with their environments, any change in the (Heiss, 1981, p. 83). An important aspect of self-concept sl
systc’tn is associated with a change in the environment, is self-evaluation, which refers to “our view of how good tic
a11(1 vice versa. we are at what we think we are” (Heiss, 1981, p. 83).
St
Interaction Category of Knowledge Other Categories of Knowledge
Fo
Origin is symbolic interactionism from the discipline of
Needs thi
sociology. Symbolic interactionism views human beings wit
“as creatures who define and classify situations, including Focuses on nurses’ functions and consideration of the
wil
themselves. and who choose ways of acting toward and patient in terms of a hierarchy of needs. When patients
NUI
within them” (Benoliel, 1977, p, 1 l?‘. and “postulates cannot fulfill their own needs, nursing is required. The
whc
that the importance of social life lies (7 providing the function of the nurse is to provide the necessary action to
help patients meet their needs. The human being is re- SUS
[persnn] with language, self-concept, tale-taking ability,
and other skills” (Heiss, 1976, p. 467). duced to a set of needs, and nursing is reduced to a set
Fact
Emphnsi7es identification of actual and potential prob- of functions. Nurses are portrayed as the final decision
suPF
lenls in interpersonal relationships and delineation of inter- makers for nursing practice (Meleis, 1997).
phys
vention strategies that promote optimal socialization. detet
Outcomes
not c
Social Acts and Relationships
Emphasis is placed on the outcomes of nursing practice
(Barn
Emphasis is on social acts and relationships between and comprehensive descriptions of the recipient of that
practice (Meleis, 1997). Enhar
people.

Client-Focused Nursil
patien
The person’s perceptions of other people, the environment, Refers to a comprehensive focus on the client as viewed ables I
situations, and events-that is, the awareness and experi- from a nursing perspective (Meleis, 1997). strong
enc‘e of phenomena-depend on meanings attached to enced
Person-Environment Focused
those phenomena. The meanings, or definitions of the situ-
ation, determine how the person behaves in a given situa- Emphasis is placed on the relationship between clients and
tion. People actively set goals on the basis of their per- their environments (Meleis, 1997).
ceptions of the relevant factors in a given situation, which
Nursing Therapeutics
are derived from social interactions with others. (Text CO
Emphasis is placed on what nurses should do and under nursirq
what circumstances they should act (Meleis, 1997). 8 practice
:$ommunication is through language, “a system of signifi- I nursing
Energy Fields
cant symbols” (Heiss, 1981, p. 5). Communication, there- : philosol
fore, involves the transfer of arbitrary meanings of Incorporates the concept of energy (Marriner-Tomey, 19891 i phasize:
.hings from one person to another. People are thought to and focuses on persons as energy fields in constant inter-
actively evaluate communication from others, rather action with their environment or the universe (Hickman,
than passively accept their ideas. 1995).
1 Ihe respf
No/f? intervention
I “simply I
“PrpscripGnns for hehavior which are associated with par- Emphasizes the nurse’s professional actions and decisions/ eration 0
ticrllnr R(:I~I nther c o m b i n a t i o n s t h e w a y s w e t h i n k and regards the patient as an object of nursing rather / practice,
pc<~[~lr, r.! J particular kind ought to act toward various cat- than a participant in nursing. Agency, or action, rests with ! omy, va]l

14 Part 1 Structure and Use of Nursing Knowledgd Chapter 1

the nurse, who makes the practice decisions and manipu-
lates selected patient or environmental variables to bring
about change (Barnum, 1998).
Conservation
Fmphasires preservation of beneficial aspects of the pa-
! MS situation that are threatened by illness or actual or
1” tential problems. Agency rests with the nurse, but he or
yhe acts IO conserve the existing capabilities of the pa-
rent (Barnum, 1998).
f&uses on provision of substitutes for patient capabilities
that cannot be enacted or have been lost. Agency rests
with the patient, in that the patient exercises his or her
will and physical control to the greatest possible extent.
krsing acts as a substitute for the patient’s will or intent
when fhe patient is incapacitated (Barnum, 1998).
Focuses on helping the patient endure insults to health and
supporting the patient while building psychological and
physiological coping mechanisms. Required nursing is
detarmined by the extent to which the patient can or can-
not cope without assistance in a particular situation
,Batnum, 1998).
lnhancemenf
‘Wing is regarded as a way to improve the quality of the
:atient’s existence following a health insult. Nursing en-
&es the patient to emerge from a health insult somehow
ilronger, better, or improved because he or she experi-
%ed or overcame the health insult (Barnum, 1998).
! tire societies.
t *
i! j
\; :
!&It continued from p. 11)
rsing Iandl the values that regulate nursing
rpctice” (Salsberry, 1994, p. 18). Ethical claims in
are summarized in the dominant collective
Uosophy of humanism (Gortner, 1990), which em-
sizes “humanistic (moral) values of caring and
epromotion of individual welfare and rights” (Fry,
$1, p. 5). Ethical claims in nursing also articulate
&es about “the treatment of others,” including
:&respect that should be accorded human beings
ply for what they are,” values about consid-
n of human dignity when engaging in nursing
ce. values about caring, values about auton-
,q, values about the rights of people to health
$@er 1 The Structure of Contemporary Nursing Knowledge
care, and values about beneficence (Salsberry, 1994,
pp. 13-14).
Conceptial Models
The third component of the STRUCTURAL HIERAR-
CHY OF CONTEMPORARY NURSING KNOWL-
EDGE is the CONCEPTUAL MODEL (see Fig. l-l). A
conceptual model is defined as
a set of relatively abstract and general con-
cepts that address the phenomena of central
interest to a discipline, the propositions that
broadly describe those concepts, and the
propositions that state relatively abstract and
general relations between two or more of
the concepts.
The term conceptual model is synonymous with
the terms conceptual framework, conceptual system,
paradigm, and disciplinary matrix. Conceptual
models have existed since people began to think
about themselves and their surroundings. They now
exist in all areas of life and in all disciplines. In-
deed, everything that a person sees, hears, reads,
and experiences is filtered through the cognitive
lens of some conceptual frame of reference
(Kalideen, 1993; Lachman, 1993).
The concepts of a conceptual model are so ab-
stract and general that they are not directly ob-
served in the real world, nor are they limited to any
particular individual, group, situation, or event.
Human adaptive system is an example of a concep-
tual model concept (Roy & Andrews, 1999). It can re-
fer to several types of human systems, including
individuals, families, groups, communities, and en-
The propqsitions of a conceptual model also are so
abstract and general that they are not amenable to
direct empirical observation or test. Nonrelational
propositions found in conceptual models are general
descriptions or constitutive definitions of the con-
ceptual model concepts. Because conceptual model
concepts are so abstract, their constitutive defini-
tions typically are broad. Adaptation level, for exam-
ple, is defined as “a changing point influenced by
the demands of the situation and the internal re-
sources [of the human adaptive system, including]
capabilities, hopes, dreams, aspirations, motivations,
and all that makes humans constantly move toward
mastery” (Roy 81 Andrews, 1999, p. 33). Moreover,
because the concepts are so abstract, nonrelational
15
propositions that are operational definitions, that is, does not deal with self-care, and Orem’s does not K
St
propositions that state how the concepts are em- focus on reactions to stressors.
pirically observed or measured, are not found in Sl
Each conceptual model also provides a structure HI
conceptual models, nor should they be expected.
and a rationale for the scholarly and practical activi- SC
,The relational propositions of a conceptual ties of its adherents, who comprise a subculture or 19
model state the relations between conceptual model community of scholars within a discipline (Eck- 01
concepts in a relatively abstract and general man- berg & Hill, 1979). More specifically, each conceptual Ra
ner. They are exemplified by the following model gives direction to the search for relevant nu
statement: “Adaptation level affects the human questions about the phenomena of central interest thi
‘adaptive1 system’s ability to respond positively in a to a discipline and suggests solutions to practical
2 ituation” (Roy & Andrews, 1999, p. 36). problems. Each one also provides general criteria TI
for knowing when a problem has been solved. ant
Conceptual models evolve from the empirical van
Those features of a conceptual model are illustrated
observations and intuitive insights of scholars or hell
in the following example. The Roy Adaptation Model
from deductions that creatively combine ideas from
focuses on adaptation of the person to environ- CI
several fields of inquiry. A conceptual model is in-
mental stimuli and proposes that management of it
ductively developed when generalizations about
the most relevant stimuli leads to adaptation (Roy & e
specific observations are formulated and is deduc-
Andrews, 1999). Here, a relevant question might a
tively developed when specific situations are seen
be, What are the most relevant stimuli in a given sit- tc
as examples of other more general events. For
uation? Anyone interested in solutions to adapta- di
example, much of the content of the Self-Care
tion problems would focus on the various ways of cc
Framework was induced from Orem’s observations
managing stimuli, and one would be led to look for m
of “the constant elements and relationships of nurs-
manifestations of adaptation when seeking to de- W!
ing practice situations” (Orem & Taylor, 1986, p. 38).
termine if the problem has been solved. pe
In contrast, Levine (1969) indicated that she de-
mc
duced the Conservation Model from “ideas from all Conceptual Mode/s of Nursing
COI
areas of knowledge that contribute to the devel- Conceptual models are not new to nursing; they
opment of the nursing process” (p. viii). Johi
have existed since Nightingale (1859/1946) first ad-
ways
Functions of a Conceptual Model vanced her ideas about nursing. Most early concep- and e:
tualizations of nursing, however, were not pre-
A conceptual model provides a ct stinctive frame of It is
sented in the formal manner of models. It remained
reference-“a horizon of expectatio:ls” (Popper, plic
for the Nursing Development Conference Group
1965, p. 47)--and “a coherent, internally unified way nun
(1973, 19791, Johnson (19741, Riehl and Roy (1974,
of thinking about.. . events and processes” (Frank, nor
1980), and Reilly (1975) to explicitly label various
1968, p. 45) for its adherents that tells them how do I
perspectives of nursing as conceptual models.
to ohserve and interpret the phenomena of interest age
to the discipline. Each conceptual model, then, Peterson (1977) and Hall (1979) linked the prolifer& imat
presents a unique focus that has a profound influ- tion of formal conceptual models of nursing with in- ages
ence on individuals’ perceptions. The unique fo- terest in conceptualizing nursing as a distinct disci- ence
cus of each conceptual model is an approximation pline and the concomitant introduction of ideas titud,
or simplification of reality that includes only those about nursing theory. Meleis (1997) reached the tends
concepts that the model author considers rele- same conclusion in her historiography of nursing plete
vant and as aids to understanding (Lippitt, 1973; knowledge development. Readers who are espe- cepts
Reilly, 1975). Thus certain aspects of the phenomena cially interested in the progression of nursing knowl used
of in?erest to a discipline are regarded as particu- edge are referred to Meleis’s (1997) excellent work, missi,
larly relevant, and other aspects are ignored. For ex- because a comprehensive historic review is be-
In a sin
ample, Neuman’s (1995) Systems Model focuses on yond the scope of this book.
Both t
preventing a deleterious reaction to stressors,
The works of several nursa scholars currently are and tb
wh.+rcas Orem’s (1995) Self-Care Framework empha-
recognized as conceptual models. Among the best nursin
sizes enhancing the person’s self-care capabilities
known are Johnson’s Behavioral System Model, ceptua
and actions. Note that Neuman’s conceptual model

’ 16 Part 1 Structure and Use of Nursing Knowledge ChaPter 1 :

ag’s General Systems Framework, Ll?vine’s Con-
rvation Model, Neuman’s Systems Model, Orem’s
:lf-Care Framework, Rogers’ Science of Unitary
rman Beings, and Roy’s Adaptation Model (John-
R, 1980, 1990; King, 1971, 1981, 1990; Levine,
69, 1991; Neuman, 1995; Neuman & Young, 1972;
‘em, 1971, 1995; Rogers, 1970, 1990; Roy, 1976;
ry & Andrews, 1999). Those conceptual models of
I$ng are discussed in Chapters 4 through 10 of
is ‘book.
;:
he development of conceptual models of nursing
d labeling them as such was an important ad-
acr for the discipline. Reilly’s (1975) comments
Ii1 underscore this point:
.we all have a private image (concept) of nurs-
@g practice. In turn, this private image influ-
;”
$r)ces our interpretation of data, our decisions,
‘atd our actions. But can a discipline continue
‘)baevelop when its members hold so many
4 @ering private images? The proponents of
kkt(uceptual models of practice are seeking to
sake us aware of these private images, so that
x ‘e can begin to identify commonalities in our
nsrrcebtions of the nature of practice and
move toward the evolution of a well-ordered
c,oncept. (p. 567)
I,.
$nson (1987) also pointed out that nurses al-
~ys use some frame of reference for their activities
d explained the drawbacks of implicit frameworks:
It is important to note that some kind of im-
plicit framework is used by every practicing
nurse, for we cannot observe, see, or describe,
nor can we prescribe anything for which we
do not already have some kind of mental im-
age or concept. Unfortunately, the mental
images used by nurses in their practice, im-
&es developed through education and experi-
enca and continuously governed by the mul-
&de of factors in the practice setting, have
rerrded to be disconnected, diffused, incom-
pteze and frequently heavily weighted by con-
c#Xs drawn from the conceptual sc;lema
&ad by medicine to achieve its own social
+sion. (p. 195)
tfsimilar vein, Bradshaw (1995) stated:
,$th the modern academic nursing approach
t&Y the old-fashioned practical training
rtursing approach presume some kind of Icon-
“ytual model1 about the needs of patients and
: r
b 1 The Structure of Contemporary Nursing Knowledge
If ‘
clients and how nurses can best provide for
these needs. The difference may be that for
modern nursing such Ia conceptual model] is
self-consciously explicit, while for nurses
trained in the traditional manner [the concep-
tual model] was implicit; it was the hidden mu-
tually accepted but taken for granted under-
standing that underpinned the fabric of care.
(p. 82)
Elaborating, Kalideen (1993) stated:
Whatever you may think, we all use models to
guide our actions, be it the way we conduct
our personal lives or the way we nurse. These
are based on the beliefs and values of fam-
ily, friends, peers, and those we respect or
those who have influenced us greatly. One of
the problems of each of us using an individual
model of practice is that it is difficult for oth-
ers to understand how we think, and why
we do what we do. Since none of us care for
patients in isolation, it is important that others
four peers, ward colleagues, medical staff)
can understand us. (p. 4)
Conceptual models of nursing, then, are the ex-
plicit and formal presentations of some nurses’ im-
plicit, private images of nursing. Explicit concep-
tual models of nursing “provide [explicit] philosoph-
ical and pragmatic orientations to the service nurses
provide patients-a service which only nurses can
provide-a service which provides a dimension to
total care different from that provided by any other
health professional” (Johnson, 1987, p. 195). Explicit
conceptual models of nursing provide explicit ori-
entations not only for nurses but also for other
health professionals and the general public. They
identify the purpose and scope of nursing and pro-
vide frameworks for objective records of the ef-
fects of nursing. Johnson (1987) explained that ex-
plicit conceptual models “specify for nurses and so-
ciety the mission and boundaries of the profes-
sion. They clarify the realm of nursing responsibility
and accountability, and they allow the practitioner
and/or the profession to document services and out-
comes” (pp. 196-197). Moreover, use of an explicit
conceptual model helps achieve consistency in nurs-
ing practice by facilitating communication among
nurses, reduces conflict among nurses who might
have different implicit goals for practice, and
provides a systematic approach to nursing research,
education, administration, and practice.
:: : T h e o r i e s
, The fourth component of the STRUCTURAL HIER-
i ARCHY OF CONTEMPORARY NIJ’ISING KNOWL-
EDGE is the THEORY (see Fig. I-1). A theory is de-
fined as
one or more relatively concrete and specific
concepts that are derived from a conceptual
model, the propositions that narrowly describe
those concepts, and the propositions that state
relatively concrete and specific relations be-
tween two or more of the concepts.
:.
fi I j Grand Theory and Middle-Range Theory
I.Theories vary in their level of abstraction and
::
i *scope. The more abstract and broader type of theory
’ is referred to as a Grand Theory. The more con-
crete and narrower type of theory is referred to as a
Middle-Range Theory.
Grand theories are broad in scope. They are made
up of concepts and propositions that are less ab-
stract and general than the concepts and proposi-
tions of a conceptual model but are not as concrete
and specific as the concepts and propositions of a
middle-range theory. Consciousness is an exam-
ple of a grand theory concept (Newman, 1994). An
example of a grand theory nonrelational proposition
is as follows: Consciousness is the informational
capacity of the human system and encompasses in-
terconnected cognitive (thinking) and affective
(feeling) awareness, physiochemical maintenance in-
cluding the nervous and endocrine systems, growth
processes, the immune system, and the genetic
code (Newman, 1994). An example of a grand the-
ory relational proposition, which links the con-
cepts consciousness and pattern, is as follows: “The
evolving pattern of person-environment can be
viewed as a process of expanding consciousness”
(Newman, 1994, p. 33).
r:. Middle-range theories are narrower in scope than
grand theories. They are made up of a limited num-
,’ ber of concepts and propositions that are written
at a relatively concrete and specific level. Nurse’s ac-
tivity is an example of a middle-range theory con-
[ -cept (Orlando, 1961). An example of a middle-range
theory nonrelational proposition is as follows:
.Nurse’s activity is “only what [thz nurse1 says or
does with or for the benefit of the patient,” such as
instructions, suggestions, direction s, explana-
,tions, information, requests, and questions directed
18
~
toward the patient; making decisions for the patient;
handling the patient’s body; administering medica- ei
tions or treatments; and changing the patient’s 8s
immediate environment (Orlando, 1961, p. 60). An W
example of a middle-range theory relational proposi- cc
tion, which links the concepts nurse’s reaction and m
nurse’s activity, is as follows: “What a nurse says or ra
does is necessarily an outcome of her reaction to su
something in the situation” (Orlando, 1961, p. 61).
c
Each middle-range theory addresses a more or less tut
relatively concrete and specific phenomenon by de1
describing what the phenomenon is, explaining why tua
it occurs, or predicting how it occurs. Middle-range the
descriptive theories are the most basic type of Rh!
middle-range theory. They describe or classify a of I
phenomenon and, therefore, may encompass just
one concept. When a middle-range descriptive the- Tt
els
ory describes a phenomenon, it simply names the
commonalities found in discrete observations of in- thee
dividuals, groups, situations, or events. When a for I
middle-range descriptive theory classifies a phenom. crea
enon, it categorizes the described commonalities (198
into mutually exclusive, overlapping, hierarchical, or Alt
sequential dimensions. A middle-range classifica- direr
tion theory may be referred to as a typology or a For 4
taxonomy. Thee
mod,
Middle-range explanatory theories specify relations
between two or more concepts. They explain why
and the extent to which one concept is related to aa.
other concept. Middle-range predictive theories
move beyond explanation to the prediction of pre-
cise relations between concepts or the effects of one
or more concepts on one or more other concepts.
This type of middle-range theory addresses how
changes in a phenomenon occur.
The definition of a theory used in this book indi-
cates that a conceptual model always is the precur-
sor to a grand theory or a middle-range theory.
Indeed, the belief that theory development proceeds
outside the context of a conceptual frame of refer-
ence is “absurd” (Popper, 1965, p. 46). As Slife
and Williams (1995) explained, “All theories have
implied understandings about the world that are
crucial to their formulation and use. . . . [In other
words,] all theories have assumptions and implica-
tions embedded in them [and1 stem from cultural
and historic contexts that lend them meaning and
influence how they are understood and imple-
mented” (pp. 2, 9).
Part 1 Structure and Use of Nursing Knowledge Chapter 1
 Moreover, inasmuch as each grand theory and
each middle-range theory deals only with a limited
aspect of reality, many theories are needed to deal
with all of the phenomena encompassed by a
conceptual model. Each conceptual model, then, is
*ore fully specified by several grand or middle-
qnge theories, as indicated in Figure l-l by the
lubscript notation, 1 . . . n.
‘Grand theories are derived directly from concep-
tual models (Fig. I-2). For example, Rogers (1986)
Perived three grand theories from her concep-
tual model, the Science of Unitary Human Beings:
Ihe Theory of Accelerating Evolution, the Theory of
@hythmical Correlates of Change, and the Theory
ef Paranormal Phenomena.
!?he grand theories derived from conceptual mod-
es can serve as the starting points for middle-range
theory development (see Fig. I-2). Alligood (19911,
for example, derived a middle-range theory of
beativity, actualization, and empathy from Rogers’
(1986) grand Theory of Accelerating Evolution.
Alternatively, middle-range theories can be derived
directly from the conceptual model (see Fig. l-2).
for example, King (1981) derived the middle-range
Theory of Goal Attainment from her conceptual
model, the General Systems Framework.
CONCEPTUAL MODEL
//
/_’
MIDDLE-RANGE THEORIES,,,,,
Flgzrre I - 2 Ikritwltotr ofgrarrd tbeorks arul middle-range lbeorics fionr a
tuJ?ll’cJ/mrcll ?lrodd.
thpter 1 The Structure of Contempt rary Nursing Knowledge
Functions of a Theory
One function of a theory is to narrow and more
fully specjfy the phenomena contained in a concep-
tual model. Another function is to provide a rela-
tively concrete and specific structure for the inter-
pretation of initially puzzling behaviors, situations,
and events.
Nursing Theories
A few nurses have presented their ideas about
nursing in the form of explicit grand theories. Lein-
inger (1991a) has presented her Theory of Culture
Care Diversity and Universality, Newman (1986,
1994) has presented her Theory of Health as Ex-
panding Consciousness, and Parse (1981, 1998) has
presented her Theory of Human Becoming. These
grand theories are discussed in Chapters 12 through
14 of this book.
A few other nurses have presented their ideas
about nursing in the form of explicit middle-range
theories. Orlando (1961) presented her Theory of the
Deliberative Nursing Process, Peplau (1952, 1992)
presented her Theory of Interpersonal Relations, and
Watson (1985, 1997) presented her Theory of Hu-
man Caring. Peplau’s work is a middle-range de-
scriptive classification theory, Watson’s work is a
middle-range explanatory theory, and Orlando’s
MIDDLE-RANGE THEORIES,,,,,
19
 work is a middle-range predictive theory. These the- Further research should determine whether a modi- at
ories are discussed in Chapters 15 through 17 of fication of attribution theory is empirically ade- nt
this book. quate in nursing situations or if an entirely new ar
theory ie required. The available results, however, ar
It is likely that many other middle-range nursing
mean that attribution theory cannot be considered a
theories exist, but they are not always recognizable
shared theory, that is, a theory that is borrowed
as strch. The paucity of recognizable middle-range
from another discipline and found to be empirically
ntlrsing theories is due to nurse researchers’ failure
adequate in nursing situations (Barnum, 1990).
to he explicit about the theoretical components of
their stltdies and to label their work as theories and In contrast, the theory of self-efficacy is a bor- T
to nurse clinicians’ failure to be explicit about the rowed theory that appears to be developing into a of
theoretical elements in their discussions of nursing shared theory. This theory was developed initially in knc
practice. Therefore, the ideas presented by nurses the discipline of social psychology and has re- sio
, in books, monographs, and journal articles should ceived empirical support in some nursing situations ing
be closely examined for evidence of the con- (e.g., Burns et al., 1998; Froman & Owen, 1990;
: ,cepts and propositions that make up middle-range Hickey, Owen, & Froman, 1992). 7i
theories. Identification of the cbTponents of a N,
‘theory is accomplished by the tee hnique of theory Empirical Indicators Er
,formalization, also called theoretir.al substruc- ries
The fifth and final component of the STRUCTURAL
tion. Discussion of that technique is beyond the eat
HIERARCHY OF CONTEMPORARY NURSING
: scope of this book. Readers who are interested in in F
KNOWLEDGE is the EMPIRICAL INDICATOR (see Fig.
theory formalization are referred to Hinshaw’s (1979) em
l-l). An empirical indicator is defined as
pioneering work and Fawcett’s (1999) more recent lost
‘work. a very concrete and specific real world proxy
thos
for a middle-range theory concept; an ac-
Unique, Borrowed, and Shared Nursing tern,
tual instrument, experimental condition, or
Theories to 81
clinical procedure that is used to observe or
cone
Some theories used by nurses are unique to nurs- measure a middle-range theory concept.
em
ing, and others are borrowed from adjunctive disci- Function of an Empirical Indicator derh
plines. The theories developed by Leininger, philc
Newman, Orlando, Parse, Peplau, and Watson are The function of empirical indicators is to provide
rectlt
Ilnique nursing theories. Many other theories the means by which middle-range theories are gen-
belie
used by nurses have been borrowed from other dis- erated or tested. Empirical indicators that are in-
struments yield data that can be sorted into qualita- defer
ciplines. Theories of stress, coping, locus of con- loguc
trol, reasoned action, and self-efficacy are just a few tive categories or calculated as quantitative scores.
shou
’ ;examples of borrowed theories. Unfortunately, those For example, responses to an interview schedule
throu
; Theories sometimes are used with no consideration made up of open-ended questions can be analyzed
to yield categories or themes, and responses to on b\
’ igiven to their empirical adequacy in nursing situ- (Salsl
41 questionnaires made up of fixed-choice items can bo
ations. There is, however, increasing awareness of cannc
?he need to test borrowed theories to determine subjected to mathematical calculations that yield a
fenda
: if they are empirically adequate in nursing situa- number or score.
the pl
tions. The theory testing work by Lowery and asso- Empirical indicators that are experimental condi- whole
ciates (1987) is an especially informative example tions or clinical procedures tell the researcher or cli.
of what can happen when a theory, borrowed in this nician exactly what to do. They are, in effect, pro-
The
case from the discipline of psychology, is tested in tocols or scripts that direct actions in a precise Moo
the real world of acute and chronic illness. The manner. Whe
investigators determined that a basic proposition of hieran
attribution theory, stating that people search for
Nursing Empirical Indicators
Fig. l-
causes to make sense of their lives, was not fully Nurses have developed a plethora of empirical in. losop~
s[lpported in their research with patients with arthri- dicators in the form of research instruments and tinct fc
tis, diabetes, hypertension, or myocardial infarction. clinical tools. Those that measure concepts associ- certain

20 Part 1 Structure and Use of Nursing Knowledge Chapter

 ated with the conceptual models of nursing and
nursing theories discussed in this book are listed
’ and described in tables in Chapters 4 through 10
and 12 through 17.
i
Distinctions Between the Components of the
1
r Structural Hierarchy of Contemporary Nursing
’ Knowledge
, The distinctions between the various components
.! of the structural hierarchy of contemporary nursing
I’ knowledge require some discussion. The discus-
:.
ii sion that follows should be kept in mind when read-
ing the remainder of this book.
: The Metaparadigm, Philosophies, Conceptual
: Models, Theories, and Empirical Indicators
’ Empirical indicators are directly connected to theo-
, ries by means of the operational definition for
each middle-range theory concept. As can be seen
in Figure l-l, there is no direct connection between
empirical indicators and concep,qlal models, phi-
I losophies, or the metaparadigm. Consequently,
’ those components of the structur II hierarchy of con-
I temporary nursing knowledge cannot be subjected
1 to empirical testing. Rather, the credibility of a
conceptual model is determined indirectly through
of middle-range theories that are
derived from or linked with the model. Furthermore,
philosophies cannot be empirically tested either di-
rectly or indirectly because they are statements of
beliefs and values. Philosophies should, however, be
defendable on the basis of logic or through dia-
logue. More specifically, philosophies can and
should be “reconsidered, rejected, or modified
through a process of considered reflection spurred
discussion with one’s peers”
p. 18). Similarly, the metaparadigm
ically tested, but should be de-
basis of dialogue and debate about
of interest to the discipline as a
11’ whple.
P-
The Metaparadigm, Philosophies, Conceptual
1i. Models, and Theories
.; When viewed from the perspective of the structural
i precede conceptual models (see Fig. 1-I). Rather,
‘: hierarchy of contemporary nursing knowledge (see
:; Fig’. l-l), it is clear that the metaparadigm, phi-
; losophies, conceptual models, and theories are dis-
i tinct formulations. Yet Kikuchi (1997) argued that
.;’ certain aspects of the structural hierarchy of contem-
-i Cbapter 1 The Structure of Contemporary Nursing Knowledge
porary nursing knowledge are “problematic in that
they contain seeds of confusion regarding the
nature of conceptions about nursing-seeds sown, it
would seem, by virtue of the failure to see that the
conceptions are philosophical, rather than scien-
tific in nature and the eclectic amalgamation of
ideas” (p. 102). She went on to argue that, with the
exception of empirical indicators, all other com-
ponents of the structural hierarchy are better
thought of as philosophies of nursing, “having the
form of a philosophic nursing theory” (p. 107).
Moreover, Salsberry (1994) implied that what are
called conceptual models in this book actually are
philosophies. She noted, “Much of what has
been referred to a conceptual model is, in fact, a
philosophy-that is, a set of beliefs about what the
basic entities of nursing are, how these entities
are known, and what values should guide the disci-
pline. The model development arises when these
philosophical claims are arranged into a particular
structure” (p. 18).
Support for the structural hierarchy as presented in
this book is especially evident in the content of
Chapters 4 through 10, where clear distinctions are
made between philosophical claims and the con-
cepts and propositions that make up conceptual
models of nursing and reflect underlying philosophi-
cal claims. Further support is evident in the content
of Chapters 12 through 17, where clear distinc-
tions are made between philosophical claims and
the concepts and propositions that make up grand
theorie.5 or middle-range theories and reflect under-
lying philosophical claims. More specifically, each
of those chapters explicitly identifies statements that
are beliefs and values, that is, philosophical claims,
and then identifies the concepts and propositions
of the conceptual model, grand theory, or middle-
range theory that clearly reflect-but do not du-
plicate-those philosophical claims.
The Mefaparadigm, Philosophies, and
Conceptual Models
Philosophies do not follow directly in line from the
metaparadigm of the discipline, nor do they directly
the metaparadigm of a discipline identifies the phe-
nomena about which ontological, epistemic, and
ethical claims are made. The unique focus and con-
tent of each conceptual model then reflect certain
phi)osophical claims. The philosophies therefore are As in other disciplines, the conceptual models of between
undation for other formulations, including nursing represent various paradigms that address here and
ptual models, grand theories, and middle- the phenomena identified by the metaparadigm models a
theories. Salsberry (1994) explained, “A phi- of the discipline of nursing. Thus it is not surprising (1970), Jc
y consists of the basic assumptions and that each defines the four metaparadigm concepts nursing; F
that are built upon in theorizing” (p. 18). differently and links those concepts in diverse ways psycholof
(see Chapters 4 through 10). sociology
t example, a metaparadigm might identify peo-
Walsh (19
as a central concept. A philosophy then might Examination of conceptual models of nursing re-
the claim that all people are equal. That philo- veals that person usually is identified as an inte- Althougf
cal claim then would be reflected in a con- grated bio-psycho-social being, but is defined in di- tween car
al model that depicts the nurse and the patient verse ways, such as an adaptive system (Roy & point (e.g.
equal partners in the process of nursing. Andrews, 1999), a behavioral system (Johnson, 1997), the
1990), a self-care agent (Orem, 1995), or an energy Indeed, Ki
The Metaparadigm and Conceptual Models
field (Rogers, 1990). Environment frequently is iden- definition
ost disciplines have a single metaparadigm but tified as internal structures and external influ- it from ‘co
ultiple conceptual models, as indicated by the sub- ences, including family members, the community, term she F
ript notation 1 . . . n in Figure l-l. For example, and society, as well as the person’s physical sur- framework
is book identifies seven different conceptual mod- roundings. The environment is seen as a source of
The distir
address the concepts of the metaparadigm stressors in some models (Neuman, 1995), but a
theory sho
ing, and Darby and Walsh (1994) identified source of resources in others (Rogers, 1990). Health
the way th,
fferent conceptual models that address the is presented in various ways, such as a continuum
to do next,
pts of the metaparadigm of dental hygiene. of client system wellness or stability (Neuman,
point is a c
oreover, Waters (1994) identified five different gen- 1995), a dichotomy of behavioral stability or instabil.
seen in Fig
al conceptual models, and Nye and Berardo (1981) ity (Johnson, 1990). or a value identified by each
ries differ il
entified 16 different conceptual models of the cultural group (Rogers, 1990).
model is m
mily that address the concepts of the discipline of
The conceptual models also present descriptions of concepts ar
the concept of nursing, usually by defining nurs- middle-ran<
ltiple conceptual models allow the members of ing and then specifying goals of nursing actions and more relath
scipline to think about the phenomena of central a nursing process. The goals of nursing action fre- proposition
rest in different ways. They spe.lk to the view quently are derived directly from the definition of
Distinguisl
at “there is no one reality of [a dis:iplinel. There is health given by the model. For example, a nursing
theories, an
lear and universal [conceptual model1 of what goal might be to assist people to attain, maintain, or
level of abr,;
uld underpin practice precisely because there is regain client system stability (Neuman, 1995). The
stract is ahs
ch thing as universal knowledge” (Brad- nursing process, or practice methodology, described
a conceptua
in each conceptual model emphasizes assessing
cases may t
and labeling the person’s health status, setting goals
nceptual models address the phenomena identi- serves as or
for nursing action, implementing nursing actions,
by a metaparadigm and, therefore, incorpo- conceptual r
and evaluating the person’s health status after nurs.
te the most global concepts and propositions in a quires deter1
ing intervention. The steps or components of the
restrictive yet still abstract manner. Each
process, however, frequently differ from one con- If the purpc
ptual model, then, provides a different view
ceptual model to another. distinctive kr
metaparadigm concepts. As Kuhn (1970) ex-
of nursing, tl
&-red, although adherents of different concep- Conceptual Models and Theories
model. Giver
al models are looking at the same phenomena, “in
A central thesis of this book is that a conceptual pose of such
me areas they see different things, and they see
model is not a theory, nor is a theory a conceptual (1971), Levinl
em in different relations to one another” (p.
model. This thesis requires further discussion be- 1972t, Orem
J. The acceptance of multiple conceptual models
cause considerable confusion about those two corn their works a
n outgrowth of the recognition of the advan-
portents of the structure1 hiererchy of contempo-
s of diverse perspectives for a discipline (Moore, If the purpo ,
rary nursing knowledge still exists in the minds of
0; Nagle & Mitchell, 1991). aspect of a c(
some students and scholars. The distinctions

22 Part 1 Structure and Use of Nursing Knowledp Chapter 1 The

between conceptual models and theories described
here and the-meaning ascribed to conceptual
models are in keeping with earlier works by Rogers
(1970), Johnson (1974), and Reilly (1975) in
nursing; Reese and Over-ton (1970) in developmental
psychology; and Nye and Berardo (1966) in
sociology; and more recent work by Darby and
Walsh (1994) in dental hygiene.
,Although some writers consider distinctions be-
tween conceptual models and theories a semantic
point (e.g., Flaskerud 81 Halloran, 1980; Meleis,
1997). the issue should not be dismissed so easily.
Indeed, King (1997) called for “a consensus on a
definition of the term ‘theory’ to clearly differentiate
it from ‘conceptual system’ ” (p. 16), which is the
term she prefers over conceptual model, conceptual
framework, or paradigm.
, range theory.
;The distinction between a conceptual model and a
theory should be made because of the differences in
the way that each is used-if one is to know what
to do next, one must know whether the starting
point is a conceptual model or a theory. As can be
seen in Figure l-l, conceptual models and theo-
ries differ in their level of abstraction. A conceptual
model is made up of several abstract and general
concepts and propositions. A grand theory or a
middle-range theory, in contrast, deals with one or
more relatively concrete and specific concepts and
propositions.
Distinguishing between conceptual models, grand
theories, and middle-range theories on the basis of
level of abstraction raises the question of how ab-
stract is abstract enough for a work to be considered
a conceptual model. Although the decision in a few
cases may be somewhat arbitrary, the following rule
serves as one guideline for distinguishing between
conceptual models and theories. The rule re-
quires determination of the purpose of the work.
tf the purpose of the work is to articulate a body of
distinctive knowledge for the whole of the discipline
of nursing, the work most likely is a conceptual
model. Given that that was the explicitly stated pur-
pose of such authors as Johnson ( 1980), King
(1971), Levine (1969), Neuman (Neuman & Young,
4972), Orem (1971), Rogers (1970), and Roy (1976),
their works are classified as conceptual models.
If the purpose of the work is to further develop one
aspect of a conceptual model, the work most likely
f&~&r 1 The Structure of Contemporary Nursing Knowledge
is a grand theory. For example, both Newman (1986)
and Parse (1981) explained that they elected to fur-
ther develop the concept of health from the perspec-
tive of Rogers’ (1970) conceptual model. As can be
discerned from these examples, nurse scholars who
consider conceptual models and grand theories to
be synonymous (e.g., Barnum, 1998; Kim, 1983;
Marriner-Tomey & Alligood, 1998) mislead their
readers..
If the purpose of the work is to describe, explain,
or predict concrete and specific phenomena, the
work most likely is a middle-range theory. For ex-
ample, Peplau’s (1952) Theory of Interpersonal
Relations is a classification of the stages of the
nurse-patient relationship. Peplau did not, nor did
she intend to, address the entire domain of nursing.
Consequently, her theory is classified as a middle-
In summary, if a given work is an abstract and gen-
eral frame of reference addressing all four con-
cepts of the metaparadigm of nursing, it is a con-
ceptual model. If the work is more concrete, specific,
and restricted to a more limited range of phenom-
ena than that identified by the conceptual model,
it is a grand theory or middle-range theory.
Another rule for distinguishing between conceptual
models and theories requires determination of
how many levels of knowledge are needed before
the work may be applied in particular nursing situa-
tions. If, for example, the work identifies physio-
logical needs as an assessment parameter, but does
not explain the differences between normal and
pathological functions of body systems in concrete
terms, it most likely is a conceptual model. As such,
the work is not directly applicable in clinical prac-
tice. A theory of normal and pathological functions
must be linked with the conceptual model so that
judgments about the physiological functions of body
systems may be made. Conversely, if the work in-
cludes a detailed description of particular peo-
ple’s behavior, or an explanation of how particular
factors influence particular behaviors, it most
likely is a middle-range theory. In that case, the work
may be directly applied in clinical practice.
The rule also is exemplified by the number of
steps required before empirical testing can occur
(Reilly, 1975). A conceptual model cannot be tested
directly, because its concepts and propositions are
23
 not empirically measurable. More concrete and spe- frequency in reports of nursing research. For exam- point
cific concepts and propositions have to be derived ple, Hamner (1996) labeled her diagrams of the re- tual I
from the conceptual model; that is, a middle- lations between the concepts of a middle-range the- entiti
range theory must be formulated. Those more con- ory of facmrs associated with patient length of stay repn
crete concepts then must be operationally defined in an intensive care unit as a model. phen
and empirically testable hypotheses must be derived Their
The concepts and propositions of each conceptual
from the propositions of the theory. Four steps are model and each theory often are stated in a distinc- contt
riquired before a conceptual modt.1 can be tested, tual I
tive vocabulary. One conceptual model, for exam-
albeit indirectly. First, the conceptual model must be of un
ple, uses the terms stimuli and adaptation level (Roy
formulated; second, a middle-range theory must be concc
& Andrews, 1999), and another uses the terms
derived from the conceptual model; third, empiri- chanj
resonancy, helicy, and integrality (Rogers, 1990). Fur.
cal indicators must be identified; and fourth, empiri- ject tc
thermore, the meaning of each term usually is con-
cally testable hypotheses must be specified. In span:
nected to the unique focus of the conceptual
contrast, only three steps are required for empirical inquil
model or theory. Thus the same or similar terms
testing of a middle-range theory. First, the theory may have different meanings in different conceptual This
,must be stated; second, empirical indicators must be models and theories. For example, adaptation is tinctic
identified; and third, empirically testable hypothe- defined in one conceptual model as “the process struct
ses must be specified. and outcome whereby thinking and feeling persons, edge,
: jailure to distinguish between a conceptual model as individtials or in groups, use conscious aware- conce
aGd a theory leads to considerable misunder- ness and choice to create human and environmental tween
stdnding and inappropriate expectations about the integration” (Roy & Andrews, 1999, p. 30), and in separl
work. When a conceptual model is labeled a another conceptual model as “the process by which 3 pres
grand theory or, especially, a middle-range theory, individuals ‘fit’ the environments in which they live” analya
expectations regarding empirical testing and clinical (Levine, 1996, p. 38). nursin
applicability immediately arise. When such expec- analys
The vocabulary of each conceptual model and each
tations cannot be met, the work is frequently re- sentec
theory should not be considered jargon. Rather,
garded as inadequate. Similarly, when a grand the- the terminology used by the author of each concep
ory or’ a middle-range theory is labeled a conceptual
model, expectations regarding comprehensiveness
tual model and each theory is the result of consid- Refer1
erable thought about how to best convey the mean- Ackoff. R.
arise. When those expectations cannot be met, ing of that particular perspective to others (Biley, probIt
‘that work also may be regarded as inadequate. 1990). Furthermore, as Akinsanya (1989) pointed out, Akmsanyt

A NOTE ON LANGUAGE “Every science has its own peculiar terms, con- Allynod, I
tianst
cepts and principles which are essential for the de- years
The meaning given to conceptual models in this velopment of its knowledge base. In nursing, as in Al1man. I.,
‘tlaok should not be confused with the meaning of other sciences, an understanding of these is a “tga”
‘jrtibdel found in the philosophy of science literature IEds.),
prerequisite to a critical examination of their contri-
i&d some nursing literature. The latter refers to rep- Barnum. t
bution to the development of knowledge and its ed 1. 1
resentations of testable theories. Rudner (1966), for application to practice” (p. ii). Watson (1997) added, Rarmm1. E
~‘example, defined a model for a middle-range theory “The attention to language is especially critical to ed.1. F
:;& “an alternative interpretation of the same calcu- an evolving discipline, in that during this postmod- Renoliel. J
&s of which the theory itself is an interpretation” ern era, one’s survival depends upon having
OUtlOO

‘Q5. 24). That kind of a model is made up of ideas or Rm-Sira, ;

language; writers in this area remind us ‘if you do rlolls t
diagrams that are more familiar to the novice than not have your own language you don’t exist’ ” hley. F (I!
are the concepts and propositions of the theory. (p. 50). Rrndshaw,
T,hus the model is a heuristic device that facilitates 0r “UT,
understanding of the theory. Rudner illustrated CONCLUSION flmns. K J.
.this by the analogy of the flow of water through of de
This chapter presented the definition and function Clinica
pjpes as a model for a middle-range theory of elec- of each component of the structural hierarchy of Ctrm, R 11:
tric current wires. So-called models that actually contemporary nursing knowledge. It is important to prflctiti
,are diagrams of theories are found with increasing mq pro

24 Part 1 Structure and Use of Nursing Knowledge Chapter ’

 point out that metaparadigms, philosophies, concep-
tual models, and theories are not real or tangible
entities. Rather, they are tentative formulations that
represent scholars’ best efforts to understand
phenomena (Payton, 1994; Polit 81 Hungler, 1995).
Their tentative nature means that the knowledge
contained in metaparadigms, philosophies, concep-
tual models, and theories carries with it a degree
of uncertainty. Thus metaparadigms, philosophies,
conceptual models, and theories are not un-
i changeable ideologies but rather ideas that are sub-
: ject to continual revision or even rejection in re-
: sponse to ongoing dialogue, debate, and systematic
j inquiry.
:I
‘I
,i This chapter also presented a discussion of the dis-
!j. tinctions between the various components of the
1 structural hierarchy of contempopary nursing knowl-
! edge, with emphasis on the distinctions between
i 3/92. pp. 13-21). Tampere. Finland: Tampere University Department of
i conceptual models and theories. The distinctions be-
; tween conceptual models and theories mandate
/ separate analysis and evaluation schemata. Chapter
i 3 presents a framework expressly designed for the
analysis and evaluation of conceptual models of
nursing. The framework expressly designed for the
analysis and evaluation of nursing theories is pre-
sented in Chapter 11.
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See also Chapters 4 through 10 and 12 through 17.
33