UNIT II

EVOLUTION OF NURSING

I. Introduction_____________________________________________________________

Nursing is a unique profession on its own. It has its unique wealth of knowledge to
rely on. Much of the nursing arts knowledge has persisted because of individuals
who continuously seek to advance nursing. This motivation for scientific inquiry also
persisted because it has seen many improvements in man's quality of life. It has
satisfied human needs for creativity, a sense of order, and the desire to understand
and appreciate the unknown. The development of the nursing sciences required
formalizing given phenomena of interest and events about the science of nursing.
Therefore, the development of nursing theories is the formalization of efforts to
describe, explain, predict, or control the states of affairs in the nursing profession.

Although it was only in the early 10th century that people began to understand
nursing as a profession and its unique role in health care, the past half the century
has seen an exponential rise of nursing knowledge with the advent of technology
and advances in technology communication. New theories and model has
consequently developed to understand better the complex relationship between the
nursing profession, the nurses, the patient, and his environment. (joy Bautista,2008).
II. Objectives____________________________________________________________

After completing this unit, I will be able to:

1. Discus the history of nursing

2. Know the importance of history and philosophy of science
3. Know Why discipline is important.
III. Lecture Proper__________________________________________________________

A.Introduction to Nursing Theory

 1. History of Nursing Theory

The first nursing theories appeared  in the late 1800s when a strong emphasis
was placed on nursing education. In 1860, Florence Nightingale defined nursing in her
“Environmental Theory” as “the act of utilizing the patient's environment to assist him in his
recovery.

 In 1860, Florence Nightingale defined nursing in her “Environmental Theory” as “the act

of utilizing the patient’s environment to assist him in his recovery.”
 In the 1950s, there is a consensus among nursing scholars that nursing needed to
validate itself by producing its own scientifically tested body of knowledge.
 In 1952, Hildegard Peplau introduced her Theory of Interpersonal Relations that
emphasizes the nurse-client relationship as the foundation of nursing practice.
 In 1955, Virginia Henderson conceptualized the nurse’s role as assisting sick or healthy
individuals to gain independence in meeting 14 fundamental needs. Thus her Nursing
Need Theory was developed.
 In 1960, Faye Abdellah published her work “Typology of 21 Nursing Problems,” which
shifted the focus of nursing from a disease-centered approach to a patient-centered
approach.
 In 1962, Ida Jean Orlando emphasized the reciprocal relationship between patient and
nurse and viewed nursing’s professional function as finding out and meeting the
patient’s immediate need for help.
 In 1968, Dorothy Johnson pioneered the Behavioral System Model and upheld the
fostering of efficient and effective behavioral functioning in the patient to prevent
illness.
 In 1970, Martha Rogers viewed nursing as both a science and an art as it provides a way
to view the unitary human being, who is integral with the universe.
 In 1971, Dorothea Orem stated in her theory that nursing care is required if the client
cannot fulfill biological, psychological, developmental, or social needs.
 In 1971, Imogene King‘s Theory of Goal attainment stated that the nurse is considered
part of the patient’s environment, and the nurse-patient relationship is for meeting
goals towards good health.
 In 1972, Betty Neuman, in her theory, states that many needs exist, and each may
disrupt client balance or stability. Stress reduction is the goal of the system model of
nursing practice.
 In 1979, Sr. Callista Roy viewed the individual as interrelated systems that balance these
various stimuli.
 In 1979, Jean Watson developed the philosophy of caring and highlighted humanistic
nursing as they intertwine with scientific knowledge and nursing practice.
2. Significance for the :

 Discipline. On the other hand, a discipline is more related to a branch of education, a

department of learning, or a knowledge domain (Donaldson and Crowley, 1978).

 Profession. A profession is a specialized field of practice founded upon the

theoretical structure of a given discipline's science knowledge and the
accompanying practice abilities(Donaldson and Crowley,1978).
Theoretical works in nursing represent the most comprehensive ideas and
systematic presentations of nursing knowledge. Thus, nursing theories are
deemed significant to the future of both the profession and the discipline of
nursing.
Nursing Theory and the Nursing Profession

Nursing theory is important to advance the practice of professional nursing

to classify a profession. It should meet some criteria. Bixler (1959) publish

in the American Journal of Nursing the results of several sociological studies of

professional development that identified nursing as one of the subjects for criteria-

setting. These criteria include:

 1. Utilizes in its practice a well-defined and well-organized body of specialized
knowledge that is on the intellectual level of higher learning.
2. Constantly enlarges the body of knowledge it uses and improves its education
and service techniques by using scientific methods.
3. Entrusts the education of its practitioners to institutions of higher education
4. Applies each body of knowledge in practical services vital to human and social
welfare
5. Functions autonomously in the formulation of professional policy and in the
control of professional activity, thereby
6. Attracts individual or intellectual and personal qualities who exalt service
above personal gain and who recognize their chosen occupation as a life-work
7. Strive to compensate its practitioners by providing freedom of action, the
opportunity for continuous professional growth, and economic security.
B. History and Philosophy of Science

Historical views of the nature of science

In the science of nursing, basic questions must be considered: What are science,
knowledge, and truth? What methods produce scientific knowledge? These are
philosophical questions. The term epistemology is concerned with the theory of
knowledge in philosophical inquiry. The philosophical perspective selected to answer
these questions will influence how scientists perform scientific activities, interpret
outcomes, and even regard science and knowledge (Brown, 1977). Although philosophy
has been documented as an activity for 3000 years, formal science is a relatively new
human pursuit (Brown, 1977; Foucault, 1973). Scientific activity has only recently
become the object of investigation.

Two competing philosophical foundations of science, rationalism and

empiricism, have evolved in modern science with several variations. Gale (1979) labeled
these alternative epistemologies as centrally concerned with the power of reason and
the power of sensory experience. Gale noted the similarity in the divergent views of
 science in the time of the classical Greeks. For example, Aristotle believed that advances
in biological science would develop through systematic observation of objects and
events in the natural world, whereas Pythagoras believed that knowledge of the natural
world would develop from mathematical reasoning (Brown, 1977; Gale, 1979).

Nursing science has been characterized by two branching philosophies of

knowledge as the discipline developed. Various terms are utilized to describe these two
stances: empiricist and interpretive, mechanistic and holistic,
quantitative and qualitative, and deductive and inductive forms of science.
Understanding the nature of these philosophical stances facilitates appreciation for
what each form contributes to nursing knowledge.

1. Rationalism
Rationalism is the use of the rational senses in ensuring the
truthfulness of a phenomenon. It is an enhanced way of looking at things from
the point of view of the empiricist. Rationalists will argue that what is real is
the essence of the phenomenon being described, not just on whether the five
general senses can test it. Rationalists will often look at a theory before figuring
out the many ramifications or practical applications. It is a form of deductive
reasoning where you understand the whole first before appreciating the lesser
parts. According to the rationalist, the logical structure of a theory and the
logical reasoning involved in its development should be addressed before you
can appreciate the lesser parts. According to rationalists, the logical structure
of a theory and the logical reasoning involved in its development should be
addressed before any theoretical assumptions can be made. These assertions
will then be subjected to experimentation to support or confirm the theory.
Rationalist epistemology (scope of knowledge) emphasizes the importance of a
priori reasoning as the appropriate method for advancing knowledge. A priori reasoning
utilizes deductive logic by reasoning from the cause to an effect or from a generalization to
a particular instance. An example in nursing is to reason that a lack of social support (cause)
will result in hospital readmission (effect). This causal reasoning is a theory until disproven.
The traditional approach explains hospitalization systematically (theory) of a given
phenomenon (Gale, 1979). This conceptual system is analyzed by addressing the logical
structure of the theory and the logical reasoning involved in its development. Theoretical
assertions derived by deductive reasoning are then subjected to experimental testing to
corroborate the theory. Reynolds (1971) labeled this approach the theory-then-research
strategy. If the research findings fail to correspond with the theoretical assertions,
additional research is conducted, or modifications are made in theory, and further tests are
devised; otherwise, the theory is discarded in favor of an alternative explanation (Gale,
1979; Zetterberg, 1966). Popper (1962) argued that science would evolve more rapidly
through conjectures and refutations by devising research to refute new ideas. For example,
his point is simple; you can never prove that all individuals without social support have
frequent rehospitalizations since one individual presents with no rehospitalization. A single
person with no social support that does not have readmission disproves the theory
that all individuals with a lack of social support have hospital readmissions. From Popper’s
perspective, “research consists of generating general hypotheses and then attempting to
refute them” (Lipton, 2005, p. 1263). So the hypothesis that a lack of social support results
in hospital readmission is the phenomenon of interest to be refuted.

The rationalist view is most clearly evident in the work of Einstein, the theoretical
physicist who made extensive use of mathematical equations in developing his theories.
Einstein's theories offered an imaginative framework that directed research in numerous
areas (Calder, 1979). As Reynolds (1971) noted if someone believes that science is a process
of inventing descriptions of phenomena, the appropriate strategy for theory construction is
the theory-then-research strategy. In Reynolds’ view, “as the continuous interplay between
theory construction (invention) and testing with empirical research progresses, the theory
becomes more precise and complete as a description of nature and, therefore, more useful
for the goals of science” (Reynolds, 1971, p. 145).

2. Empiricism
Empiricism looks at reality using the five general senses of sight, touch,
hearing, taste, and smell. An object is real only as seen, felt, heard, tasted, or
 smelled. If its truth cannot be established using any five senses, then that
object is not real. In establishing knowledge, empiricists will most likely conduct
experiments directly measurable by any of the five senses. It uses observable
facts to generalize scientific truths. Thus, it is inductive in terms of theories;
empiricists will gather as much information and observable facts as possible
before finally saying that a particular theory exists to explain the many
phenomena observed.
The empiricist view is based on the central idea that scientific knowledge can be
derived only from sensory experience (i.e., seeing, feeling, hearing facts). Francis Bacon
(Gale, 1979) received credit for popularizing the basis for the empiricist approach to inquiry.
Bacon believed that scientific truth was discovered through generalizing observed facts in
the natural world. This approach, called the inductive method, is based on the idea that the
collection of facts precedes attempts to formulate generalizations, or as Reynolds (1971)
called it, the research-then-theory strategy. One of the best examples to demonstrate this
form of logic in nursing is formulating differential diagnoses. Formulating a differential
diagnosis requires collecting the facts and then devising a list of possible theories to explain
the facts.

The strict empiricist view is reflected in the work of the behaviorist Skinner. In a
1950 paper, Skinner asserted that advances in psychology could be expected if scientists
would focus on collecting empirical data. He cautioned against drawing premature
inferences and proposed a moratorium on theory building until further facts were
collected. Skinner’s (1950) approach to theory construction was inductive. His view of
science and the popularity of behaviorism has been credited with influencing psychology’s
shift in emphasis from building theories to gathering facts between the 1950s and 1970s
(Snelbecker, 1974). The difficulty with the inductive mode of inquiry is that the world
presents infinite possible observations. Therefore, scientists must bring their experiences to
decide what to observe and exclude (Steiner, 1977).

In summary, deductive inquiry uses the theory-then-research approach, and inductive

inquiry
 uses the research-then-theory approach. Both approaches are utilized in the field of
nursing.

3. Early twentieth-century views of science and theory

During the first half of this century, philosophers focused on analyzing theory
structure, whereas scientists focused on empirical research (Brown, 1977). There was
minimal interest in the history of science, the nature of scientific discovery, or the similarities
between the philosophical view of science and the scientific methods (Brown,
1977). Positivism, a term first used by Comte, emerged as the dominant view of modern
science (Gale, 1979). Modern logical positivists believed that empirical research and logical
analysis (deductive and inductive) were two approaches that would produce scientific
knowledge (Brown, 1977).

The logical empiricists offered a more lenient view of logical positivism and argued that
theoretical propositions (proposition affirms or denies something) must be tested through
observation and experimentation (Brown, 1977). This perspective is rooted in the idea that
empirical facts exist independently of theories and offer the only basis for objectivity in
science (Brown, 1977). In this view, objective truth exists independently of the researcher,
and the task of science is to discover it, which is an inductive method (Gale, 1979). This view
of science is often presented in research method courses as: “The scientist first sets up an
experiment; observes what occurs …. reaches a preliminary hypothesis to describe the
occurrence; runs further experiments to test the hypothesis [and] finally corrects or modifies
the hypothesis in light of the results” (Gale, 1979, p. 13).

The increasing use of computers, which permit the analysis of large data sets, may have
contributed to accepting the positivist approach to modern science (Snelbecker, 1974).
However, in the 1950s, the literature began to reflect an increasing challenge to the positivist
view, thereby ushering in a new view of science in the late twentieth century (Brown, 1977).

4. Emergent views of science and theory in the late twentieth century

In the latter years of the twentieth century, several authors presented analyses
challenging the positivist position, thus offering the basis for a new perspective of science
 (Brown, 1977; Foucault, 1973; Hanson, 1958; Kuhn, 1962; Toulmin, 1961). Foucault (1973)
analyzed human sciences' epistemology (knowledge) from the seventeenth to the
nineteenth century. His major thesis stated that empirical knowledge was arranged in
different patterns at a given time and in a given culture and that humans were emerging as
objects of study. In The Phenomenology of the Social World, Schutz (1967) argued that
scientists seeking to understand the social world could not cognitively know an external
world independent of their own life experiences. Phenomenology, set forth by Edmund
Husserl (1859 to 1938), proposed that the objectivism of science could not provide an
adequate apprehension of the world (Husserl 1931, 1970). A phenomenological approach
reduces observations or text to the meanings of phenomena independent of their particular
context. This approach focuses on the lived meaning of experiences.

In 1977, Brown argued an intellectual revolution in philosophy that emphasized the history
of science was replacing formal logic as the major analytical tool in the philosophy of science.
One of the major perspectives in the new philosophy emphasized science as a process of
continuing research rather than a product-focused on findings. The emphasis shifted to
understanding scientific discovery and process in this emergent epistemology as theories
change over time.

Empiricists view phenomena objectively, collect data, and analyze them to inductively
proposed a theory (Brown, 1977). This position is based upon objective truth existing in the
world, waiting to be discovered. Brown (1977) set forth a new epistemology challenging the
empiricist view proposing that theories play a significant role in determining what the
scientist observes and interpreting. The following story illustrates Brown’s premise that
observations are concept laden; that is, values and ideas influence an observation in the
mind of the observer:

“An elderly patient has been in trauma and appears to be crying. The nurse on admission
observes that the patient has marks on her body and believes that she has been abused;
the orthopedist has viewed an x-ray and believes that the crying patient is in pain due to
a fractured femur that will not require surgery only a closed reduction; the chaplain
 observes the patient crying and believes the patient needs spiritual support. Each
observation is concept laden.”

The knowledge embodied in nursing is the collection of different

observations of reality accumulated through the years. These observations are

collected, organized, and systematically arranged to explain, describe, or define a

phenomenon of interest. These phenomena are then clustered to become the body
of

knowledge. Since knowledge is composed of ideas based on a person’s

mind of what is real and what is not, it is important to realize how knowledge is

studied or analyzed for its truth.

C. Structure of Nursing Knowledge

1. Structure Level
Martha Raile Alligood

This chapter presents the structure for specialized nursing knowledge used to
organize the units of this text. As presented in Chapter 1, the requirement for a body of
specialized knowledge to recognize nursing as a profession was a driving force in the
twentieth century. Because of the importance of nurses to the nation’s health, early in
the twentieth century, nursing studies were legislated and conducted by sociologists
who recommended that nursing be developed as a profession. The criteria for a
profession guided this process (Bixler & Bixler, 1959; Kalish & Kalish, 2003). The criterion
that called for specialized nursing knowledge and knowledge structure was a particularly
important driving force in recognizing nursing as a profession (Bixler & Bixler, 1959).
The criterion reads:
Utilizes in its practice a well-defined and well-organized body of specialized knowledge
[that] is on the intellectual level of higher learning (p. 1143).
The types of knowledge, levels, and examples of each are included in Table 4-1. The
theoretical works presented in Chapters 6 to 36 are nursing frameworks organized into
four types. Box 4-1 list the theorists included in each type. The placement of works
within the four types reflects a level of abstraction or the preference of the theorist.

Structure Level Example

Metaparadigm Person, environment, health, and nursing
Philosophy Nightingale
Conceptual Model Neuman System Model
Theory Neuman’s theory of optimal client stability
Middle-range theory Maintaining optimal client stability with structured
activity (body recall) in a community setting for
healthy aging

2.Meta-paradigm A meta-paradigm is a set of theories or ideas that provide

structure for how a discipline should function. For a nursing discipline, these
theories consist of four basic concepts that address the patient as a whole, the
patient’s health and well-being, environment, and nursing responsibilities. While
several nursing theories exist, these four basic nursing meta paradigms point to a
holistic care view. A person’s well-being and medical health are connected to four
interactive components.

a. The person, the person component of the meta-paradigm, focuses on the

receiver of care. However, the person connection also includes family
members and other groups important to the patient. The care structure
considers the Person’s spiritual and social needs as well as health care needs.
The resulting health outcome is attributed to how the Person interacts with
these physical and social connections. The premise is that the Person is
 empowered to manage his health and well-being with dignity and self-
preservation with positive personal connections.
b. Health, the four meta paradigms, refers to the extent of wellness and health
care access that a patient has. This health component is characterized as one
with multiple dimensions in a constant state of motion. Health and wellness
cover a person’s lifespan and genetic makeup and how the physical,
emotional, intellectual, social, and spiritual well-being is integrated into health
care for maximum health benefits. The theory is that these factors influence
the patient’s state of well-being.
c. Environment, The environment aspect of the nursing meta paradigms focuses
on the surroundings that affect the patient. The environment consists of
internal and external influences and contends that how a person continuously
interacts with her surroundings has a bearing on health and wellness.
Interactions with family, friends and other people are part of the
environment, including physical and social factors such as economic
conditions, geographic locations, culture, social connections, and technology.
This meta-paradigm component theorizes that a person can modify her
environmental factors to improve her health status.
d. Nursing The nursing component of the meta-paradigm involves delivering
optimal health outcomes for the patient through a mutual relationship in a
safe and caring environment. The nursing component applies knowledge,
skills, technology, collaborations, professional judgment, and communication
to carry out duties and responsibilities to achieve the best possible patient
health outcome scenario. This nursing component values a high degree of
service and integrates with other meta paradigm components for patient well-
being.
3.Philosophy

Philosophy (from Greek, Latin, philosophy, “love of wisdom”) is the rational,

abstract, and methodical consideration of reality as a whole or fundamental
 dimension of human existence and experience. Philosophical inquiry is a central
element in the intellectual history of many civilizations.

The subject of philosophy is treated in several articles. For discussion of major

systems of Eastern philosophy, see Buddhism; Chinese
philosophy; Confucianism; Daoism; Hinduism; Indian
philosophy; Jainism; Japanese philosophy; Shintō; Sikhism.

4.Conceptual Models

 A set of interrelated concepts that symbolically represents and coveys a mental

image of a phenomenon. Conceptual nursing models identify concepts and
describe their relationship to the phenomena of central concern to the discipline:
Person, environment, health, and nursing (Power and Knapp,1995).
 A set of concepts and propositions integrates them into a meaningful
configuration (Marriner-Tomey and Alligod,1998).
 Composed of concepts or constructs that describe ideas about individuals, groups,
situations, and events of particular interest or discipline(e.g., Nursing).
 A conceptual model is a representation of a system. It consists of concepts used to
help people know, understand, or simulate a subject the model represents. It is
also a  set of concepts. In contrast, physical models are physical objects, for
example, toy models.
 The conceptual model may refer to models which are formed after
a conceptualization or generalization process.[1][2] Conceptual models are often
abstractions of things in the real world, whether physical or
social. Semantic studies are relevant to various stages of concept formation.
Semantics is basically about concepts, the meaning that thinking being gives to
various elements of their experience.
5.Theory
 In layman’s terms, if something is said to be “just a theory,” it usually means
a mere guess or is unproved. It might even lack credibility. Theory means “a vision” or
“a scene.” It comes from the Greek word “theory.” But in scientific terms, a theory
implies that something has been proven and generally accepted as true. A theory
explains a set of related observations or events based upon proven hypotheses and
verified multiple times by a separate group of researchers. It is generally an attempt to
make sense of what we observe and experience. A scientist cannot create a theory; he
can only create a hypothesis.

6.Middle-range theory

Middle-range theories are the second level of nursing theories.

These

Theories are moderately abstract, comprehensive, organized within a limited scope,

and have a limited number of variables, which are testable in a direct manner. Middle-
range theories have a stronger relationship with research and practice. The relationship
between research and practice, according to Merton(1968). Indicated middle-range
theories are particularly important for practice disciplines.

Middle-range theories focus on concepts of interest to nurses and

include pain, empathy, grief, self-esteem, hope, comfort, dignity, and quality of life.
Examples of nursing middle-range theories are Roger’s theory of Accelerating Change,
Roy’s Theory of the Person as an Adaptive System, and King’s Theory of Goal
Attainment.