Posting 1 Reply Required What concerns should be underst.docx

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What concerns should be understood about data communications
being sent over wireless networks?
1. Wireless Network transmission is more presented to assault
by unapproved clients, so specific consideration must be paid to
security.
2. You may encounter obstruction in the event that others in a
similar building additionally utilize remote innovation, or where
different wellsprings of electromagnetic (radio) impedance
exist. This could prompt poor correspondence or, in outrageous
cases, finish loss of remote correspondence.
3. In a few structures getting steady scope can be troublesome,
prompting 'dark spots' the place no flag is accessible. For
instance, in structures manufactured utilizing steel fortifying
materials, you may think that its hard to get the radio
frequencies utilized.
4. Wireless Networks can be slower and less proficient than
'wired' systems. In bigger remote systems, the 'spine' arrange is
typically wired or fiber instead of remote.
Discuss the pros and cons of one method of transmission, such
as Wireless Application Protocol
Pros:
1. Transporting information in the versatile systems of today,
for instance GSM, has been contrasted with 'Conveying an ice
block in a plastic sack in the leave warmth of 40C'. The states
of the versatile system are cruel. Consequently, given these
unforgiving conditions, it is basic to choose a suitable
application condition and outline the application for the
versatile client and the difficulties gave by the portable system.
2. The portable system is unique, the transmission capacity is
thin, and delays are more prominent than in the PC/Wired

system which bolsters 2 Mbits for each second. The portable
system in correlation gives assets of 9.6kbps to a client. The
difficulties for building up an application for the versatile
condition are for the most part these conspicuous contrasts
between the Mobile system and the Wired condition.
3. A portable handheld gadget e.g. Cell Phone or Smart
telephone is diverse to a PC/Laptop. The screen estimate is
little, the quantity of keys a client approaches is constrained to
16 keys or less. The gadget additionally is restricting is memory
stockpiling, preparing force and battery control.
4. The WAP protocol is outlined with the system, gadget and UI
confinements as a primary concern. This implies WAP is
enhanced for portable systems with limit data transfer
capacities, cell phones with little screens and constrained keys
for client passage, little memory stockpiling, and restricted
preparing and battery control. This settles on WAP a perfect
decision for building up an application for the portable system.
Yet, any perfect practically speaking has advantages and
disadvantages. In this manner, this paper will additionally
portray these points of interest and give an understanding into
the constraints or inconveniences.
Cons:
1. Low speeds, security, and little UI;
2. Not extremely recognizable to the clients;
3. Plan of action is costly;
4. Structures are difficult to outline;
5. Outsider is incorporated
Posting 2 Reply required
WAP is a rundown of conventions and determinations with the
purpose of permitting Internet substance to be served to remote
customers. These details are controlled by the WAP Forum and
can be uninhibitedly downloaded in PDF design. WAP is the
outline of the TCP/IP Protocol stack in that there are 6

reflection levels that perform one of a kind undertakings. The
largest amount is the Wireless Application Environment Layer.
This layer gives the application interface to the convention
suite. One of these interfaces is the Wireless Markup Language
(WML). WML is like HTML however it is enhanced for hand-
held portable terminals. The vast majority of the substance that
is served to the remote gadget is in WML. The explanation
behind not utilizing HTML is that the size and determination of
the show on a phone are endlessly not the same as that of a
screen. Space is at a top-notch, so WAP powers content
suppliers to re-compose their applications to produce more
straightforward code that the gadget will have the capacity to
sufficiently show. The following layer is the Wireless Session
Protocol (WSP). This layer gives the capacity to oversee
sessions and furthermore gives HTTP 1.1 usefulness. The third
layer is the Wireless Transaction Protocol (WTP). This layer
gives exchanges abilities like standard TCP. The fourth is the
Wireless Transport Layer Security (WTLS). WTLS is the
concentration of this report as it gives the security components
to WAP, so it will be assessed in more noteworthy detail later.
The fifth layer is the Wireless Datagram Protocol (WDP). This
layer gives a typical transport interface to the wide range of
system sorts that the remote gadget can work on. The last layer
is known as the Bearers layer. This layer is the real strategy that
the remote specialist co-op runs their framework on. Upheld
Bearers incorporate CDMA and GSM. More bearers are
included as new system sorts are made or altered. By utilizing
this layering approach, WAP can give similar administrations
paying little respect to the fundamental physical system that the
supplier employments.
There are some security issues with WAP. The most critical
danger related to WAP is the utilization of the WAP entryway.
There are however adding some security shortcomings in the
WTLS convention and some conceivable dangers by utilizing
cell phones.
3.1 WAP gateway

WAP does not offer end-to-end security. WAP gadgets speak
with web servers through a middle of the road WAP portal.
WTLS is just utilized between the gadget and the portal, while
SSL/TLS can be utilized between the door and the web server
on the Internet. This implies the WAP door contains, at any rate
for some timeframe, decoded information. The entryway
merchants need to find a way to guarantee that the unscrambling
and re-encryption happen in memory, that keys and decoded
information are never spared to circle, and that all memory
utilized as a component of the encryption and an unscrambling
process is cleared before given back to the working framework.
3.2 WTLS takes into account feeble encryption calculations
The encryption convention used to encode information amid a
WTLS session is consulted in the handshake stage. There is the
likelihood to pick the 40-bit DES encryption strategy. In this
technique, a 5-byte key is utilized which contains 5 equality
bits. This implies there are just 35 viable key bits in the DES
key. It is anything but difficult to discover this DES key by a
beast drive assault. A 40-bit DES encryption is an extremely
powerless encryption calculation.
3.3 Predictable IVs
The WTLS convention ought to have the capacity to work over
an untrustworthy transport layer, so datagrams might be lost,
copied or reordered. On the off chance that CBC-encryption
mode is utilized, this implies it is fundamental for the IV
(Initial Value) to be contained in the parcel itself or that the IV
for that piece can be gotten from information that is as of now
accessible to the beneficiary. WTLS dependably utilizes a
straight IV calculation. At the point when a piece figure is
utilized as a part of CBC mode, the IV for scrambling every
bundle is registered as takes after IVs = IV0 ⊕ (s|s|s|s) In this
equation, s is a 16-bit grouping number of the parcel and IV0 is
the first IV, inferred amid key age. At the point when CBC
mode is utilized as a part of a blend with a terminal application
where each keypress is sent as an individual parcel, (for
example, telnet), this can give issues when low-entropy

mysteries, (for example, passwords) are entered in the
application.
3.4 Potential for infections
Cell phones are getting increasingly progressed and have a
modern working framework. Besides, WAP contains a scripting
dialect (WMLScript). This makes it simpler for infections to
influence a cell phone. What makes it considerably more
perilous is that it isn't conceivable to run modern hostile to
infection programming on a cell phone.
3.5 Physical security
The weakest connection in the framework will be simply the
cell phone. It effortlessly gets lost or stolen and it is probably
going to be utilized increasingly for the capacity of delicate
information. The PIN code offers some security, yet it just
comprises of 4 digits and most clients pick frail PINS. On the
off chance that one makes a hazard investigation of WAP, at
that point, the physical security of the cell phone
unquestionably must be considered as well!
Posting 3 Reply required :
Net Neutrality and its effects on IT: The primary concept of net
neutrality is that broadband service providers should interpret
all data in internet equal, it was essentially intended at ensuring
internet is a free place of information. nowadays most of us get
our internet through one of the BSP's like Comcast, AT&T,
Verizon etc. generally what we expect is when someone sends
data over the internet one of the BSP's should transfer the
information from one peer of the network to another peer. but
what they generally do is they analyze and manipulate it by
monitoring every piece of information and program computers
that route information to interfere with data by slowing down
speed on sites they don't like and increasing speed on sites
which they like for extra money which is a lot of manipulation
with user’s interests. So, when net neutrality is applied it means
applying well-formed common rules to the internet to restrict
internet independence and openness. These common carrier

rules have both pros and cons because when a common carrier
rule prevents all users from information access by stopping,
reducing speed or tamper data over wire otherwise it's genuine
or blocks spam content over the internet. What I think is net
neutrality will affect newcomers into the market because those
with good market cap and funds available they can always use
their money and power to advertise more of their products and
increasing speed into their websites and blocking others will
effect transparency, in that case, new companies will thrive a
lot to come into market and compete with established companies
there is high possibility very good upcoming products and
services will be missed out by coming generations. not just the
products freedom of speech will be ruled out completely
nowadays people are choosing internet to express their opinion
and share information by applying common rules companies and
government can always prevent such information from
spreading and control people’s opinions. on the other hand, by
setting common rules you can avoid spammers on the internet
who spread viruses and many other malicious activities can be
prevented.
Posting 4 Reply Required:
Net neutrality is a big issue for today’s web users and it is
under attack. Net neutrality is the idea that the web is available
to everybody, implying that web access suppliers can't piece
content or deliberately back offload times for specific sites. The
standard, which was at first affirmed by the FCC in 2010,
basically expresses that web get to is a human right that ought
to be accessible for all.
Net neutrality brings that idea into the 21st century and
applies it to data. Simply expressed; all information crossing
the Internet ought to be respected similarly by the Internet

Service Providers and government controllers without respect to
its maker, client, content, stage, application, type or mode of
communication. This implies all clients ought to have measured
up to get to and particularly be charged similar expenses for an
association, and have that association be free and unhindered,
paying little mind to how you utilize the net. At the point when
Comcast was accused of using packet shaping to intentionally
limit the flow of traffic for users of Bit Torrent conventions. Bit
Torrent, on the off chance that you don't know, is an extremely
mainstream individual to individual file sharing administration
that permits the exchange of all types of computerized content
including bandwidth consuming music and video. The
consequences of the grumbling are blended, Comcast was
considered responsible however conceded no wrong, and have
prompted a time of civil argument that is yet continuous.
Another problem and this one from the viewpoint of the
consumer is that ISPs could charge more for better/different
services if there were no net neutrality. A state of a dispute is
that the Internet foundation we have today isn't adequate to deal
with the measure of movement potential inborn in worldwide
society. The ISPs say they require checks on the unhindered
internet so they can control the framework there is and shield it
from over-burden, and have the privilege to give premium
support of an excellent cost. The customer side says the
appropriate response is to construct more foundations with a
specific end goal to ensure free and simple access for all who
need it.The U.S. Federal Communications Commission has
revoked the net neutrality rules it passed only more than two
years prior. This move has sent many individuals over the edge,
as far as its potential effect on buyers, independent companies,
and little sites. In addition, there is a great deal of theory that
the costs for web conveyed media administrations, for example,
Netflix and Amazon Prime Video could essentially increment
FCC Chairman Ajit Pai, has since quite a while ago condemned
net neutrality rules as unnecessary, expensive directions on web

access suppliers. In reality, Republicans have contended that the
principles debilitate interest in broadband systems. This
depends on the affirmation that as far as possible the sorts of
plans of action ISPs can send.Although many tech organizations
upheld the now-gone unhindered internet rules, there are a
couple of that didn't. Innovation suppliers, for example, Oracle
and Cisco Systems promoted the 2017 FCC plan to repeal net
neutrality.
Title
ABC/123 Version X
1
Timeline of Scientific Knowledge in Nursing Writing Guide
NRP/513 Version 2
1
Timeline of Scientific Knowledge in Nursing Writing Guide
<Title: Same as on cover page>
<Begin introduction here. For this assignment, it will a short
introduction of the timeline, defining the subject of the timeline
as well as its scope.>
Prior to l950
<Florence Nightingale is considered to be the first nursing
theorist and researcher for modern nursing. Any historical
events such as changes in nursing education and reports from
committees, such as the Goldmark and Brown reports, growth of
professional organizations, and journals, can be included in this

section. You will find that there is more happening in these
years for research than for theory.>
Decade of the l950s
Decade of the l960s
Decade of the l970s
Decade of the l980s
1990 and Beyond
Conclusion
Note:You do not have to use these headings. You can collapse
some of the decades if you want or come up with headings that
represent topics instead of time. However, this is a timeline so
the expectation is that you will present information in
chronological order.
One way to organize this paper is to write one paragraph under
each decade that describes what is happening in theory
development and a second paragraph that describes what is
happening in research. Logical order helps you to write and the
reader to interpret your writing. If you choose to present
information on theory and research separately within each
decade, always keep to the same order. If theory is presented
first for the first section, then present theory first in all others.
If you integrate both together, do this for all. In APA, this is
referred to as parallel construction. It enhances organization and
readability.
Two other APA criteria are clarity and precision. Be precise in

your choice of words; use the same word when you mean the
same thing. Avoid ambiguity. Your writing should be clear, not
ambiguous. Do not use a thesaurus. This is a useful tool for
English literature, not for writing in the social sciences. Learn
the terminology for theory and research and use it freely. It is
not plagiarism to use specialized terminology.
References
<References to works cited will go here.>
Note that the heading for the reference list is NOT bold. If there
is only one reference, then write Reference. For this
assignment, you should have two references: your two
textbooks. A page break is inserted after the word Conclusion.
This ensures that references will remain on their own page, i.e.,
reference page. When constructing a paper, use the insert
command in toolbar for Word, then click on page break. Then as
you add information to the paper, the reference page will always
start at the top of the next page following any text.
Copyright © XXXX by University of Phoenix. All rights
reserved.
Copyright © 2017 by University of Phoenix. All rights reserved.
CHAPTER 2: Overview of Theory in Nursing
Melanie McEwen
Matt Ng has been an emergency room nurse for almost 6 years
and recently decided to enroll in a master’s degree program to
become an acute care nurse practitioner. As he read over the
degree requirements, Matt was somewhat bewildered. One of
the first courses required by his program was entitled
Application of Theory in Nursing. He was interested in the
courses in advanced pharmacology, advanced physical
assessment, and pathophysiology and was excited about the

advanced practice clinical courses, but a course that focused on
nursing theory did not appear congruent with his goals.
Looking over the syllabus for the theory application course did
little to reassure Matt, but he was determined to make the best
of the situation and went to the first class with an open mind.
The first few class periods were increasingly interesting as the
students and instructor discussed the historical evolution of the
discipline of nursing and the stages of nursing theory
development. As the course progressed, the topics became more
relevant to Matt. He learned ways to analyze and evaluate
theories, examined a number of different types of theories used
by nurses, and completed several assignments, including a
concept analysis, an analysis of a middle range nursing theory,
and a synthesis paper that examined the use of non-nursing
theories in nursing research.
By the end of the semester, Matt was able to recognize the
importance of the study of theory. He understood how
theoretical principles and concepts affected his current practice
and how they would be essential to consider as he continued his
studies to become an advanced practice nurse.
When asked about theory, many nurses and nursing students,
and often even nursing faculty will respond with a furrowed
brow, a pained expression, and a resounding “ugh.” When
questioned about their negative response, most will admit that
the idea of studying theory is confusing, that they see no
practical value, and that theory is, in essence, too theoretical.
Likewise, some nursing scholars believe that nursing theory is
practically nonexistent, whereas others recognize that many
practitioners have not heard of nursing theory. Some nurses
lament that nurse researchers use theories and frameworks from
other disciplines, whereas others believe the notion of nursing
theory is outdated and ask why they should bother with theory.
Questions and debates about “theory” in nursing abound in the
nursing literature.
Myra Levine, one of the pioneer nursing theorists, wrote that
“the introduction of the idea of theory in nursing was sadly

inept” (Levine, 1995, p. 11). She stated,
In traditional nursing fashion, early efforts were directed at
creating a procedure—a recipe book for prospective theorists—
which then could be used to decide what was and was not a
theory. And there was always the thread of expectation that the
great, grand, global theory would appear and end all
speculation. Most of the early theorists really believed they
were achieving that.
Levine went on to explain that every new theory posited new
central concepts, definitions, relational statements, and goals
for nursing, and then attracted a chorus of critics. This resulted
in nurses finding themselves confused about the substance and
intention of the theories. Indeed, “in early days, theory was
expected to be obscure. If it was clearly understandable, it
wasn’t considered a very good theory” (Levine, 1995, p. 11).
The drive to develop nursing theory has been marked by nursing
theory conferences, the proliferation of theoretical and
conceptual frameworks for nursing, and the formal teaching of
theory development in graduate nursing education. It has
resulted in the development of many systems, techniques or
processes for theory analysis and evaluation, a fascination with
the philosophy of science, and confusion about theory
development strategies and division of choice of research
methodologies.
There is debate over the types of theories that should be used by
nurses. Should they be only nursing theories or can nurses use
theories “borrowed” from other disciplines? There is debate
over terminology such as conceptual framework, conceptual
model, and theory. There have been heated discussions
concerning the appropriate level of theory for nurses to develop,
as well as how, why, where, and when to test, measure, analyze,
and evaluate these theories/models/conceptual frameworks. The
question has been repeatedly asked: Should nurses adopt a
single theory, or do multiple theories serve them best? It is no
wonder, then, that nursing students display consternation,
bewilderment, and even anxiety when presented with the

prospect of studying theory. One premise, however, can be
agreed upon: To be useful, a theory must be meaningful and
relevant, but above all, it must be understandable. This chapter
discusses many of the issues described previously. It presents
the rationale for studying and using theory in nursing practice,
research, management/administration, and education; gives
definitions of key terms; provides an overview of the history of
development of theory utilization in nursing; describes the
scope of theory and levels of theory; and, finally, introduces the
widely accepted nursing metaparadigm.
Overview of Theory
Most scholars agree that it is the unique theories and
perspectives used by a discipline that distinguish it from other
disciplines. The theories used by members of a profession
clarify basic assumptions and values shared by its members and
define the nature, outcome, and purpose of practice (Alligood,
2010; Butts, Rich, & Fawcett, 2012; Rutty, 1998).
Definitions of the term theory abound in the nursing literature.
At a basic level, theory has been described as a systematic
explanation of an event in which constructs and concepts are
identified and relationships are proposed and predictions made
(Streubert & Carpenter, 2011). Theory has also been defined as
a “creative and rigorous structuring of ideas that project a
tentative, purposeful and systematic view of phenomena”
(Chinn & Kramer, 2011, p. 257). Finally, theory has been called
a set of interpretative assumptions, principles, or propositions
that help explain or guide action (Young, Taylor, &
Renpenning, 2001).
In their classic work, Dickoff and James (1968) state that theory
is invented, rather than found in or discovered from reality.
Furthermore, theories vary according to the number of elements,
the characteristics and complexity of the elements, and the kind
of relationships between or among the elements.
The Importance of Theory in Nursing
Before the advent of development of nursing theories, nursing
was largely subsumed under medicine. Nursing practice was

generally prescribed by others and highlighted by traditional,
ritualistic tasks with little regard to rationale. The initial work
of nursing theorists was aimed at clarifying the complex
intellectual and interactional domains that distinguish expert
nursing practice from the mere doing of tasks (Omrey, Kasper,
& Page, 1995). It was believed that conceptual models and
theories could create mechanisms by which nurses would
communicate their professional convictions, provide a
moral/ethical structure to guide actions, and foster a means of
systematic thinking about nursing and its practice (Chinn &
Kramer, 2011; Peterson, 2013; Sitzman & Eichelberger, 2011;
Ziegler, 2005). The idea that a single, unified model of
nursing—a worldview of the discipline—might emerge was
encouraged by some (Levine, 1995; Tierney, 1998).
It is widely believed that use of theory offers structure and
organization to nursing knowledge and provides a systematic
means of collecting data to describe, explain, and predict
nursing practice. Use of theory also promotes rational and
systematic practice by challenging and validating intuition.
Theories make nursing practice more overtly purposeful by
stating not only the focus of practice but also specific goals and
outcomes. Theories define and clarify nursing and the purpose
of nursing practice to distinguish it from other caring
professions by setting professional boundaries. Finally, use of a
theory in nursing leads to coordinated and less fragmented care
(Alligood, 2010; Chinn & Kramer, 2011; Ziegler, 2005).
Ways in which theories and conceptual models developed by
nurses have influenced nursing practice are described by
Fawcett (1992), who stated that in nursing they:
· Identify certain standards for nursing practice
· Identify settings in which nursing practice should occur and
the characteristics of what the model’s author considers
recipients of nursing care
· Identify distinctive nursing processes and technologies to be
used, including parameters for client assessment, labels for
client problems, a strategy for planning, a typology of

intervention, and criteria for evaluation of intervention
outcomes
· Direct the delivery of nursing services
· Serve as the basis for clinical information systems, including
the admission database, nursing orders, care plan, progress
notes, and discharge summary
· Guide the development of client classification systems
· Direct quality assurance programs
Terminology of Theory
Young and colleagues (2001) wrote that in nursing, conceptual
models or frameworks detail a network of concepts and describe
their relationships, thereby explaining broad nursing
phenomena. Theories, they noted, are the narrative that
accompanies the conceptual model. These theories typically
provide a detailed description of all of the components of the
model and outline relationships in the form of propositions.
Critical components of the theory or narrative include
definitions of the central concepts or constructs; propositions or
relational statements, the assumptions on which the framework
is based; and the purpose, indications for use, or application.
Many conceptual frameworks and theories will also include a
schematic drawing or model depicting the overall structure of or
interactivity of the components (Chinn & Kramer, 2011).
Some terms may be new to students of theory and others need
clarification. Table 2-1 lists definitions for a number of terms
that are frequently encountered in writings on theory. Many of
these terms will be described in more detail later in the chapter
and in subsequent chapters.
Table 2-1: Definitions and Characteristics of Theory Terms and
Concepts
Term
Definition and Characteristics
Assumptions
Assumptions are beliefs about phenomena one must accept as
true to accept a theory about the phenomena as true.
Assumptions may be based on accepted knowledge or personal

beliefs and values. Although assumptions may not be
susceptible to testing, they can be argued philosophically.
Borrowed or shared theory
A borrowed theory is a theory developed in another discipline
that is not adapted to the worldview and practice of nursing.
Concept
Concepts are the elements or components of a phenomenon
necessary to understand the phenomenon. They are abstract and
derived from impressions the human mind receives about
phenomena through sensing the environment.
Conceptual model/conceptual framework
A conceptual model is a set of interrelated concepts that
symbolically represents and conveys a mental image of a
phenomenon. Conceptual models of nursing identify concepts
and describe their relationships to the phenomena of central
concern to the discipline.
Construct
Constructs are the most complex type of concept. They
comprise more than one concept and are typically built or
constructed by the theorist or philosopher to fit a purpose. The
terms concept and construct are often used interchangeably, but
some authors use concept as the more general term—all
constructs are concepts, but not all concepts are constructs.
Empirical indicator
Empirical indicators are very specific and concrete identifiers
of concepts. They are actual instructions, experimental
conditions, and procedures used to observe or measure the
concept(s) of a theory.
Epistemology
Epistemology refers to theories of knowledge or how people
come to have knowledge; in nursing, it is the study of the
origins of nursing knowledge.
Hypotheses
Hypotheses are tentative suggestions that a specific relationship
exists between two concepts or propositions. As the hypothesis
is repeatedly confirmed, it progresses to an empirical

generalization and ultimately to a law.
Knowledge
Knowledge refers to the awareness or perception of reality
acquired through insight, learning, or investigation. In a
discipline, knowledge is what is collectively seen to be a
reasonably accurate understanding of the world as seen by
members of the discipline.
Laws
A law is a proposition about the relationship between concepts
in a theory that has been repeatedly validated. Laws are highly
generalizable. Laws are found primarily in disciplines that deal
with observable and measurable phenomena, such as chemistry
and physics. Conversely, social and human sciences have few
laws.
Metaparadigm
A metaparadigm represents the worldview of a discipline—the
global perspective that subsumes more specific views and
approaches to the central concepts with which the discipline is
concerned. The metaparadigm is the ideology within which the
theories, knowledge, and processes for knowing find meaning
and coherence. Nursing’s metaparadigm is generally thought to
consist of the concepts of person, environment, health, and
nursing.
Middle range theory
Middle range theory refers to a part of a discipline’s concerns
related to particular topics. The scope is narrower than that of
broad-range or grand theories.
Model
Models are graphic or symbolic representations of phenomena
that objectify and present certain perspectives or points of view
about nature or function or both. Models may be theoretical
(something not directly observable—expressed in language or
mathematics symbols) or empirical (replicas of observable
reality—model of an eye, for example).
Ontology
Ontology is concerned with the study of existence and the

nature of reality.
Paradigm
A paradigm is an organizing framework that contains concepts,
theories, assumptions, beliefs, values, and principles that form
the way a discipline interprets the subject matter with which it
is concerned. It describes work to be done and frames an
orientation within which the work will be accomplished. A
discipline may have a number of paradigms. The
term paradigm is associated with Kuhn’s Structure of Scientific
Revolutions.
Phenomena
Phenomena are the designation of an aspect of reality; the
phenomena of interest become the subject matter particular to
the primary concerns of a discipline.
Philosophy
A philosophy is a statement of beliefs and values about human
beings and their world.
Practice or situation-specific theory
A practice or situation-specific theory deals with a limited
range of discrete phenomena that are specifically defined and
are not expanded to include their link with the broad concerns
of a discipline.
Praxis
Praxis is the application of a theory to cases encountered in
experience.
Relationship statements
Relationship statements indicate specific relationships between
two or more concepts. They may be classified as propositions,
hypotheses, laws, axioms, or theorems.
Taxonomy
A taxonomy is a classification scheme for defining or gathering
together various phenomena. Taxonomies range in complexity
from simple dichotomies to complicated hierarchical structures.
Theory
Theory refers to a set of logically interrelated concepts,
statements, propositions, and definitions, which have been

derived from philosophical beliefs of scientific data and from
which questions or hypotheses can be deduced, tested, and
verified. A theory purports to account for or characterize some
phenomenon.
Worldview
Worldview is the philosophical frame of reference used by a
social or cultural group to describe that group’s outlook on and
beliefs about reality.
Sources: Alligood & Tomey (2010); Blackburn (2008); Chinn &
Kramer (2011); Powers & Knapp (2011).
Historical Overview: Theory Development in Nursing
Most nursing scholars credit Florence Nightingale with being
the first modern nursing theorist. Nightingale was the first to
delineate what she considered nursing’s goal and practice
domain, and she postulated that “to nurse” meant having charge
of the personal health of someone. She believed the role of the
nurse was seen as placing the client “in the best condition for
nature to act upon him” (Hilton, 1997, p. 1211).
Florence Nightingale
Nightingale received her formal training in nursing in
Kaiserswerth, Germany, in 1851. Following her renowned
service for the British army during the Crimean War, she
returned to London and established a school for nurses.
According to Nightingale, formal training for nurses was
necessary to “teach not only what is to be done, but how to do
it.” She was the first to advocate the teaching of symptoms and
what they indicate. Further, she taught the importance of
rationale for actions and stressed the significance of “trained
powers of observation and reflection” (Kalisch & Kalisch, 2004,
p. 36).
In Notes on Nursing, published in 1859, Nightingale proposed
basic premises for nursing practice. In her view, nurses were to
make astute observations of the sick and their environment,
record observations, and develop knowledge about factors that
promoted healing. Her framework for nursing emphasized the
utility of empirical knowledge, and she believed that knowledge

developed and used by nurses should be distinct from medical
knowledge. She insisted that trained nurses control and staff
nursing schools and manage nursing practice in homes and
hospitals (Chinn & Kramer, 2011; Kalisch & Kalisch, 2004).
Stages of Theory Development in Nursing
Subsequent to Nightingale, almost a century passed before other
nursing scholars attempted the development of philosophical
and theoretical works to describe and define nursing and to
guide nursing practice. Kidd and Morrison (1988) described five
stages in the development of nursing theory and philosophy: (1)
silent knowledge, (2) received knowledge, (3) subjective
knowledge, (4) procedural knowledge, and (5) constructed
knowledge. Table 2-2 gives an overview of characteristics of
each of these stages in the development of nursing theory, and
each stage is described in the following sections. To
contemporize Kidd and Morrison’s work, attention will be given
to the current decade and a new stage—that of “integrated
knowledge.”
Table 2-2: Stages in the Development of Nursing Theory
Stage
Source of Knowledge
Impact on Theory and Research
Silent knowledge
Blind obedience to medical authority
Little attempt to develop theory. Research was limited to
collection of epidemiologic data.
Received knowledge
Learning through listening to others
Theories were borrowed from other disciplines. As nurses
acquired non-nursing doctoral degrees, they relied on the
authority of educators, sociologists, psychologists,
physiologists, and anthropologists to provide answers to nursing
problems.
Research was primarily educational research or sociologic

research.
Subjective knowledge
Authority was internalized to foster a new sense of self.
A negative attitude toward borrowed theories and science
emerged.
Nurse scholars focused on defining nursing and on developing
theories about and for nursing.
Nursing research focused on the nurse rather than on clients and
clinical situations.
Procedural knowledge
Includes both separate and connected knowledge
Proliferation of approaches to theory development. Application
of theory in practice was frequently underemphasized. Emphasis
was placed on the procedures used to acquire knowledge, with
focused attention to the appropriateness of methodology, the
criteria for evolution, and statistical procedures for data
analysis.
Constructed knowledge
Combination of different types of knowledge (intuition, reason,
and self-knowledge)
Recognition that nursing theory should be based on prior
empirical studies, theoretical literature, client reports of clinical
experiences and feelings, and the nurse scholar’s intuition or
related knowledge about the phenomenon of concern.
Integrated knowledge
Assimilation and application of “evidence” from nursing and
other health care disciplines
Nursing theory will increasingly incorporate information from
published literature with enhanced emphasis on clinical
application as situation-specific/practice theories and middle
range theories.
Source: Kidd & Morrison (1988).

Silent Knowledge Stage
Recognizing the impact of the poorly trained nurses on the
health of soldiers during the Civil War, in 1868, the American
Medical Association advocated the formal training of nurses and
suggested that schools of nursing be attached to hospitals with
instruction being provided by medical staff and resident
physicians. The first training school for nurses in the United
States was opened in 1872 at the New England Hospital. Three
more schools, located in New York, New Haven, and Boston,
opened shortly thereafter (Kalisch & Kalisch, 2004). Most
schools were under the control of hospitals and superintended
by hospital administrators and physicians. Education and
practice were based on rules, principles, and traditions that were
passed along through an apprenticeship form of education.
There followed rapid growth in the number of hospital-based
training programs for nurses, and by 1909, there were more than
1,000 such programs (Kalisch & Kalisch, 2004). In these early
schools, a meager amount of theory was taught by physicians,
and practice was taught by experienced nurses. The curricula
contained some anatomy and physiology and occasional lectures
on special diseases. Few nursing books were available, and the
emphasis was on carrying out physicians’ orders. Nursing
education and practice focused on the performance of technical
skills and application of a few basic principles, such as aseptic
technique and principles of mobility. Nurses depended on
physicians’ diagnosis and orders and as a result largely adhered
to the medical model, which views body and mind separately
and focuses on cure and treatment of pathologic problems
(Donahue, 2011). Hospital administrators saw nurses as
inexpensive labor. Nurses were exploited both as students and
as experienced workers. They were taught to be submissive and
obedient, and they learned to fulfill their responsibilities to
physicians without question (Chinn & Kramer, 2011).
Unfortunately, with a few exceptions, this model of nursing
education persisted for more than 80 years. One exception was
Yale University, which started the first autonomous school of

nursing in 1924. At Yale, and in other later collegiate
programs, professional training was strengthened by in-depth
exposure to the underlying theory of disease as well as the
social, psychological, and physical aspects of client welfare.
The growth of collegiate programs lagged, however, due to
opposition from many physicians who argued that university-
educated nurses were overtrained. Hospital schools continued to
insist that nursing education meant acquisition of technical
skills and that knowledge of theory was unnecessary and might
actually handicap the nurse (Andrist, 2006; Donahue, 2011;
Kalisch & Kalisch, 2004).
RIt was not until after World War II that substantive changes
were made in nursing education. During the late 1940s and into
the 1950s, serious nursing shortages were fueled by a decline in
nursing school enrollments. A 1948 report, Nursing for the
Future, by Esther Brown, PhD, compared nursing with teaching.
Brown noted that the current model of nursing education was
central to the problems of the profession and recommended that
efforts be made to provide nursing education in universities as
opposed to the apprenticeship system that existed in most
hospital programs (Donahue, 2011; Kalisch & Kalisch, 2004).
Other factors during this time challenged the tradition of
hospital-based training for nurses. One of these factors was a
dramatic increase in the number of hospitals resulting from the
Hill-Burton Act, which worsened the ongoing and sometimes
critical nursing shortage. In addition, professional organizations
for nurses were restructured and began to grow. It was also
during this time that state licensure testing for registration took
effect, and by 1949, 41 states required testing. The registration
requirement necessitated that education programs review the
content matter they were teaching to determine minimum
criteria and some degree of uniformity. In addition, the
techniques and processes used in instruction were also reviewed
and evaluated (Kalisch & Kalisch, 2004).
Over the next decade, a number of other events occurred that
altered nursing education and nursing practice. In 1950, the

journal Nursing Research was first published. The American
Nurses Association (ANA) began a program to encourage nurses
to pursue graduate education to study nursing functions and
practice. Books on research methods and explicit theories of
nursing began to appear. In 1956, the Health Amendments Act
authorized funds for financial aid to promote graduate education
for full-time study to prepare nurses for administration,
supervision, and teaching. These events resulted in a slow but
steady increase in graduate nursing education programs.
The first doctoral programs in nursing originated within schools
of education at Teachers College of Columbia University (1933)
and New York University (1934). But it would be 20 more years
before the first doctoral program in nursing began at the
University of Pittsburgh (1954) (Kalisch & Kalisch, 2004).
Subjective Knowledge Stage
Until the 1950s, nursing practice was principally derived from
social, biologic, and medical theories. With the exceptions of
Nightingale’s work in the 1850s, nursing theory had its
beginnings with the publication of Hildegard Peplau’s book in
1952. Peplau described the interpersonal process between the
nurse and the client. This started a revolution in nursing, and in
the late 1950s and 1960s, a number of nurse theorists emerged
seeking to provide an independent conceptual framework for
nursing education and practice (Donahue, 2011). The nurse’s
role came under scrutiny during this decade as nurse leaders
debated the nature of nursing practice and theory development.
During the 1960s, the development of nursing theory was
heavily influenced by three philosophers, James Dickoff,
Patricia James, and Ernestine Weidenbach, who, in a series of
articles, described theory development and the nature of theory
for a practice discipline. Other approaches to theory
development combined direct observations of practice, insights
derived from existing theories and other literature sources, and
insights derived from explicit philosophical perspectives about
nursing and the nature of health and human experience. Early
theories were characterized by a functional view of nursing and

health. They attempted to define what nursing is, describe the
social purposes nursing serves, explain how nurses function to
realize these purposes, and identify parameters and variables
that influence illness and health (Chinn & Kramer, 2011).
In the 1960s, a number of nurse leaders (Abdellah, Orlando,
Widenbach, Hall, Henderson, Levine, and Rogers) developed
and published their views of nursing. Their descriptions of
nursing and nursing models evolved from their personal,
professional, and educational experiences, and reflected their
perception of ideal nursing practice.
Procedural Knowledge Stage
By the 1970s, the nursing profession viewed itself as a
scientific discipline evolving toward a theoretically based
practice focusing on the client. In the late 1960s and early
1970s, several nursing theory conferences were held. Also,
significantly, in 1972, the National League for Nursing
implemented a requirement that the curricula for nursing
educational programs be based on conceptual frameworks.
During these years, many nursing theorists published their
beliefs and ideas about nursing and some developed conceptual
models.
During the 1970s, a consensus developed among nursing leaders
regarding common elements of nursing. These were the nature
of nursing (roles/actions/interventions), the individual recipient
of care (client), the context of nurse–client interactions
(environment), and health. Nurses debated whether there should
be one conceptual model for nursing or several models to
describe the relationships among the nurse, client, environment,
and health. Books were written for nurses on how to critique,
develop, and apply nursing theories. Graduate schools
developed courses on analysis and application of theory, and
researchers identified nursing theories as conceptual
frameworks for their studies. Through the late 1970s and early
1980s, theories moved to characterizing nursing’s role from
“what nurses do” to “what nursing is.” This changed nursing
from a context-dependent, reactive position to a context-

independent, proactive arena (Chinn & Kramer, 2011).
Although master’s programs were growing steadily, doctoral
programs grew more slowly, but by 1970, there were 20 such
programs. This growth in graduate nursing education allowed
nurse scholars to debate ideas, viewpoints, and research
methods in the nursing literature. As a result, nurses began to
question the ideas that were taken for granted in nursing and the
traditional basis in which nursing was practiced.
Constructed Knowledge Stage
During the late 1980s, scholars began to concentrate on theories
that provide meaningful foundation for nursing practice. There
was a call to develop substance in theory and to focus on
nursing concepts grounded in practice and linked to research.
The 1990s into the early 21st century saw an increasing
emphasis on philosophy and philosophy of science in nursing.
Attention shifted from grand theories to middle range theories,
as well as application of theory in research and practice.
In the 1990s, the idea of evidence-based practice (EBP) was
introduced into nursing to address the widespread recognition of
the need to move beyond attention given to research per se, in
order to address the gap in research and practice. The
“evidence” is research that has been completed and published
(LoBiondo-Wood & Haber, 2010). Ostensibly, EBP promotes
employment of theory-based, research-derived evidence to
guide nursing practice.
During this period, graduate education in nursing continued to
grow rapidly, particularly among programs that produced
advanced practice nurses (APNs). A seminal event during this
time was the introduction of the doctor of nursing practice
(DNP). The DNP was initially proposed by the American
Association of Colleges of Nursing (AACN) in 2004 to be the
terminal degree for APNs. The impetus for the DNP was based
on recognition of the need for expanded competencies due to the
increasing complexity of clinical practice, enhanced knowledge
to improve nursing practice and outcomes, and promotion of
leadership skills (American Association of Colleges of Nursing

[AACN], 2004).
Integrated Knowledge Stage
More recently, development of nursing knowledge shifted to a
trend that blends and uses a variety of processes to achieve a
given research aim as opposed to adherence to strict, accepted
methodologies (Chinn & Kramer, 2011). In the second decade
of the 21st century, there has been significant attention to the
need to direct nursing knowledge development toward clinical
relevance, to address what Risjord (2010) terms the “relevance
gap.” Indeed, as Risjord states, and virtually all nursing
scholars would agree, “the primary goal … of nursing research
is to produce knowledge that supports practice” (p. 4). But he
continues to note that in reality, a significant portion of
research supports practice imperfectly, infrequently, and often
insignificantly.
In the current stage of knowledge development, considerable
focus in nursing science has been on integration of knowledge
into practice, largely with increased attention on EBP and
translational research (Chinn & Kramer, 2011). Indeed, it is
widely accepted that systematic review of research from a
variety of health disciplines, often in the form of meta-analyses,
should be undertaken to inform practice and policy making in
nursing (Schmidt & Brown, 2012; Melnyk & Fineout-Overholt,
2011). Further, this involves or includes application of evidence
from across all health-related sciences (i.e., translational
research).
Translational research was designated a priority initiative by the
National Institute of Health in 2005 (Powers & Knapp, 2011).
The idea of translational research is to close the gap between
scientific discovery and translation of research into practice; the
intent is to validate evidence in the practice setting (Chinn &
Kramer, 2011). Translational research shifts focus to
interdisciplinary efforts and integration of the perspectives of
different disciplines to “a contemporary movement aimed at
producing a concerted multidisciplinary effort to address
recognized health disparities and care delivery inadequacies”

(Powers & Knapp, 2011, p. 191).
Into the second decade of the 21st century, the number of
doctoral programs in the United States continued to grow
steadily, and by 2013, there were 128 doctoral programs
granting a PhD in nursing (AACN, 2013b). Further, after a
sometimes contentious debate, the DNP gained widespread
acceptance, and by 2013, there were 123 programs granting the
DNP, with more being planned (AACN, 2013a).
In this current stage of theory development in nursing, it is
anticipated that there will be ongoing interest in EBP and
growth of translational research. In this regard, development
and application of middle range and practice theories will
continue to be stressed, with attention increasing on
practical/clinical application and relevance of both research and
theory.
Summary of Stages of Nursing Theory Development
A number of events and individuals have had an impact on the
development and utilization of theory in nursing practice,
research, and education. Table 2-3 provides a summary of
significant events.
Table 2-3: Significant Events in Theory Development in
Nursing
Event
Year
Nightingale publishes Notes on Nursing
1859
American Medical Association advocates formal training for
nurses
1868
Teacher’s College—Columbia University—Doctorate in
Education degree for nursing
1920
Yale University begins the first collegiate school of nursing
1924
Report by Dr. Esther Brown—“Nursing for the Future”
1948

State licensure for registration becomes standard
1949
Nursing Research first published
1950
H. Peplau publishes Interpersonal Relations in Nursing
1952
University of Pittsburgh begins the first PhD program in nursing
1954
Health Amendments Act passes—funds graduate nursing
education
1956
Process of theory development discussed among nursing
scholars (works published by Abdellah, Henderson, Orlando,
Wiedenbach, and others)
1960–1966
First symposium on Theory Development in Nursing (published
in Nursing Research in 1968)
1967
Symposium Theory Development in Nursing
1968
Dickoff, James, and Weidenbach—“Theory in a Practice
Discipline”
First Nursing Theory Conference
1969
Second Nursing Theory Conference
1970
Third Nursing Theory Conference
1971
National League for Nursing adopts Requirement for
Conceptual Framework for Nursing Curricula
1972
Key articles publish in Nursing Research (Hardy—Theories:
Components, Development, and Evaluation; Jacox—Theory
Construction in Nursing; and Johnson—Development of Theory)
1974

Nurse educator conferences on nursing theory
1975, 1978
Advances in Nursing Science first published
1979
Books written for nurses on how to critique theory, develop
theory, and apply nursing theory
1980s
Graduate schools of nursing develop courses on how to analyze
and apply theory in nursing
1980s
Research studies in nursing identify nursing theories as
frameworks for study
1980s
Publication of numerous books on analysis, application,
evaluation, and development of nursing theories
1980s
Philosophy and philosophy of science courses offered in
doctoral programs
1990s
Increasing emphasis on middle range and practice theories for
nursing
1990s
Nursing literature describes the need to establish
interconnections among central nursing concepts
1990s
Introduction of evidence-based practice into nursing
1990s
Philosophy of Nursing first published
1999
Books published describing, analyzing, and discussing
application of middle range theory and evidence-based practice
2000s
Introduction of the Doctor of Nursing Practice (DNP)
2004
Growing emphasis on development of situation-specific and
middle range theories in nursing

2010+
Sources: Bishop & Hardin (2010); Donahue, 2011; Kalisch &
Kalisch (2004); Meleis (2012); Moody (1990).
Beginning in the early 1950s, efforts to represent nursing
theoretically produced broad conceptualizations of nursing
practice. These conceptual models or frameworks proliferated
during the 1960s and 1970s. Although the conceptual models
were not developed using traditional scientific research
processes, they did provide direction for nursing by focusing on
a general ideal of practice that served as a guide for research
and education. Table 2-4 lists the works of many of the nursing
theorists and the titles and
year of key theoretical publications. The works of a number of
the major theorists are discussed in Chapters 7through 9.
Reference lists and bibliographies outlining application of their
work to research, education, and practice are described in those
chapters.
Table 2-4: Chronology of Publications of Selected Nursing
Theorists
Theorist
Year
Title of Theoretical Writings
Florence Nightingale
1859
Notes on Nursing
Hildegard Peplau
1952
Interpersonal Relations in Nursing
Virginia Henderson
1955
Principles and Practice of Nursing, 5th edition
1966
The Nature of Nursing: A Definition and Its Implications for
Practice, Research, and Education

1991
The Nature of Nursing: Reflections After 25 Years
Dorothy Johnson
1959
A Philosophy of Nursing
1980
The Behavioral System Model for Nursing
Faye Abdellah
1960
Patient-Centered Approaches to Nursing
1968
2nd edition
Ida Jean Orlando
1961
The Dynamic Nurse–Patient Relationship
Ernestine Wiedenbach
1964
Clinical Nursing: A Helping Art
Lydia E. Hall
1964
Nursing: What Is It?
Joyce Travelbee
1966
Interpersonal Aspects of Nursing
1971
2nd edition
Myra E. Levine
1967
The Four Conservation Principles of Nursing
1973
Introduction to Clinical Nursing

1989
The Conservation Principles: Twenty Years Later
Martha Rogers
1970
An Introduction to the Theoretical Basis of Nursing
1980
Nursing: A Science of Unitary Man
1983
Science of Unitary Human Being: A Paradigm for Nursing
1989
Nursing: A Science of Unitary Human Beings
Dorothea E. Orem
1971
Nursing: Concepts of Practice
1980
2nd edition
1985
3rd edition
1991
4th edition
1995
5th edition
2001
6th edition
2011
Self-Care Science, Nursing Theory and Evidence-Based
Practice (Taylor & Renpenning)

Imogene M. King
1971
Toward a Theory for Nursing: General Concepts of Human
Behavior
1981
A Theory for Nursing: Systems, Concepts, Process
1989
King’s General Systems Framework and Theory
Betty Neuman
1974
The Betty Neuman Health-Care Systems Model: A Total Person
Approach to Patient Problems
1982
The Neuman Systems Model
1989
2nd edition
1995
3rd edition
2002
4th edition
2011
5th edition
Evelyn Adam
1975
A Conceptual Model for Nursing
1980
To Be a Nurse

1991
2nd edition
Callista Roy
1976
Introduction to Nursing: An Adaptation Model
1980
The Roy Adaptation Model
1984
Introduction to Nursing: An Adaptation Model, 2nd edition
1991
The Roy Adaptation Model
1999
2nd edition
2009
3rd edition
Josephine Paterson and Loretta Zderad
1976
Humanistic Nursing
Jean Watson
1979
Nursing: The Philosophy and Science of Caring
1985
Nursing: Human Science and Human Care
1989
Watson’s Philosophy and Theory of Human Caring in Nursing
1999
Human Science and Human Care

2012
2nd edition
Margaret A. Newman
1979
Theory Development in Nursing
1983
Newman’s Health Theory
1986
Health as Expanding Consciousness
2000
2nd edition
Madeleine Leininger
1980
Caring: A Central Focus of Nursing and Health Care Services
1988
Leininger’s Theory of Nursing: Cultural Care Diversity and
Universality
2001
Culture Care Diversity and Universality
2006
2nd edition
Joan Riehl Sisca
1980
The Riehl Interaction Model
1989
2nd edition
Rosemary Parse
1981
Man-Living-Health: A Theory for Nursing

1985
Man-Living-Health: A Man-Environment Simultaneity Paradigm
1987
Nursing Science: Major Paradigms, Theories, Critiques
1989
Man-Living-Health: A Theory of Nursing
1999
Illuminations: The Human Becoming Theory in Practice and
Research
Joyce Fitzpatrick
1983
A Life Perspective Rhythm Model
1989
2nd edition
Helen Erickson et al.
1983
Modeling and Role Modeling
Nancy Roper, Winifred Logan, and Alison Tierney
1983
A Model for Nursing
1983
The Roper/Logan/Tierney Model for Nursing
1996
The Elements of Nursing: A Model for Nursing Based on a
Model of Living
2000
The Roper/Logan/Tierney Model for Nursing
Patricia Benner and Judith Wrubel

1984
From Novice to Expert: Excellence and Power in Clinical
Nursing Practice
1989
The Primacy of Caring: Stress and Coping in Health and Illness
Anne Boykin and Savina Schoenhofer
1993
Nursing as Caring
2001
2nd edition
Barbara Artinian
1997
The Intersystem Model: Integrating Theory and Practice
2011
2nd edition
Brendan
2010
Person-Centred Nursing: Theory and Practice
McCormack and Tanya McCance
Sources: Chinn & Kramer (2011); Hickman (2011); Hilton
(1997).
Classification of Theories in Nursing
Over the last 40 years, a number of methods for classifying
theory in nursing have been described. These include
classification based on range/scope or abstractness (grand or
macrotheory to practice or situation-specific theory) and type or
purpose of the theory (descriptive, predictive, or prescriptive
theory). Both of these classification schemes are discussed in
the following sections.
Scope of Theory
One method for classification of theories in nursing that has

become common is to differentiate theories based on scope,
which refers to complexity and degree of abstraction. The scope
of a theory includes its level of specificity and the concreteness
of its concepts and propositions. This classification scheme
typically uses the terms metatheory, philosophy,
or worldview to describe the philosophical basis of the
discipline; grand theory or macrotheory to describe the
comprehensive conceptual frameworks; middle
range or midrange theory to describe frameworks that are
relatively more focused than the grand theories; and situation-
specific theory, practice theory, or microtheory to describe
those smallest in scope (Higgins & Moore, 2000; Peterson,
2013). Theories differ in complexity and scope along a
continuum from practice or situation-specific theories to grand
theories. Figure 2-1 compares the scope of nursing theory by
level of abstractness.
FIGURE 2-1: Comparison of the scope of nursing theories.
Metatheory
Metatheory refers to a theory about theory. In nursing,
metatheory focuses on broad issues such as the processes of
generating knowledge and theory development, and it is a forum
for debate within the discipline (Chinn & Kramer, 2011; Powers
& Knapp, 2011). Philosophical and methodologic issues at the
metatheory or worldview level include identifying the purposes
and kinds of theory needed for nursing, developing and
analyzing methods for creating nursing theory, and proposing
criteria for evaluating theory (Hickman, 2011; Walker & Avant,
2011).
Walker and Avant (2011) presented an overview of historical
trends in nursing metatheory. Beginning in the 1960s,
metatheory discussions involved nursing as an academic
discipline and the relationship of nursing to basic sciences.
Later discussions addressed the predominant philosophical
worldviews (received view versus perceived view) and
methodologic issues related to research (see Chapter 1). Recent

metatheoretical issues relate to the philosophy of nursing and
address what levels of theory development are needed for
nursing practice, research, and education (i.e., grand theory
versus middle range and practice theory) and the increasing
focus on the philosophical perspectives of critical theory,
postmodernism, and feminism.
Grand Theories
Grand theories are the most complex and broadest in scope.
They attempt to explain broad areas within a discipline and may
incorporate numerous other theories. The term macrotheory is
used by some authors to describe a theory that is broadly
conceptualized and is usually applied to a general area of a
specific discipline (Higgins & Moore, 2000; Peterson, 2013).
Grand theories are nonspecific and are composed of relatively
abstract concepts that lack operational definitions. Their
propositions are also abstract and are not generally amenable to
testing. Grand theories are developed through thoughtful and
insightful appraisal of existing ideas as opposed to empirical
research (Fawcett & DeSanto-Madeya, 2013). The majority of
the nursing conceptual frameworks (e.g., Orem, Roy, and
Rogers) are considered to be grand theories. Chapters
6 through 9 discuss many of the grand nursing theories.
Middle Range Theories
Middle range theory lies between the grand nursing models and
more circumscribed, concrete ideas (practice or situation-
specific theories). Middle range theories are substantively
specific and encompass a limited number of concepts and a
limited aspect of the real world. They are composed of
relatively concrete concepts that can be operationally defined
and relatively concrete propositions that may be empirically
tested (Higgins & Moore, 2000; Peterson, 2013; Whall, 2005).
A middle range theory may be (1) a description of a particular
phenomenon, (2) an explanation of the relationship between
phenomena, or (3) a prediction of the effects of one
phenomenon or another (Fawcett & DeSanto-Madeya, 2013).
Many investigators favor working with propositions and

theories characterized as middle range rather than with
conceptual frameworks because they provide the basis for
generating testable hypotheses related to particular nursing
phenomena and to particular client populations (Chinn &
Kramer, 2011; Ketefian & Redman, 1997). The number of
middle range theories developed and used by nurses has grown
significantly over the past two decades. Examples include social
support, quality of life, and health promotion. Chapters
10 and 11 describe middle range theory in more detail.
Practice Theories
Practice theories are also called situation-specific
theories, prescriptive theories, or microtheories and are the least
complex. Practice theories are more specific than middle range
theories and produce specific directions for practice (Higgins &
Moore, 2000; Peterson, 2013; Whall, 2005). They contain the
fewest concepts and refer to specific, easily defined phenomena.
They are narrow in scope, explain a small aspect of reality, and
are intended to be prescriptive. They are usually limited to
specific populations or fields of practice and often use
knowledge from other disciplines (McKenna, 1993). Examples
of practice theories developed and used by nurses are theories
of postpartum depression, infant bonding, and oncology pain
management. Chapters 12 and 18 present additional information
on practice theories.
Type or Purpose of Theory
In their seminal work, Dickoff and James (1968) defined
theories as intellectual inventions designed to describe, explain,
predict, or prescribe phenomena. They described four kinds of
theory, each of which builds on the other. These are:
· Factor-isolating theories (descriptive theories)
· Factor-relating theories (explanatory theories)
· Situation-relating theories (predictive theories or promoting
or inhibiting theories)
· Situation-producing theories (prescriptive theories)
Dickoff and James (1968) stated that nursing as a profession
should go beyond the level of descriptive or explanatory

theories and attempt to attain the highest levels—that of
situation-relating/predictive and situation-
producing/prescriptive theories.
Descriptive (Factor-Isolating) Theories
Descriptive theories are those that describe, observe, and name
concepts, properties, and dimensions. Descriptive theory
identifies and describes the major concepts of phenomena but
does not explain how or why the concepts are related. The
purpose of descriptive theory is to provide observation and
meaning regarding the phenomena. It is generated and tested by
descriptive research techniques including concept analysis, case
studies, literature review phenomenology, ethnography, and
grounded theory (Young et al., 2001).
Examples of descriptive theories are readily found in the
nursing literature. Dombrowsky and Gray (2012), for example,
used the process of concept analysis to develop a conceptual
model describing the experiences and contributing factors
of urinary continence and incontinence. In other works, using
grounded theory methodology, Kanacki, Roth, Georges, and
Herring (2012) developed a theoretical model describing the
experience of caring for a dying spouse, and Busby and
Witucki-Brown (2011) constructed a theory describing
situational awareness among emergency response providers.
Lastly, Robles-Silva (2008) used ethnography to construct a
conceptual model explaining the multiple phases that caregivers
experience while working with poor, chronically ill adults in
Mexico.
Explanatory (Factor-Relating) Theories
Factor-relating theories, or explanatory theories, are those that
relate concepts to one another, describe the interrelationships
among concepts or propositions, and specify the associations or
relationships among some concepts. They attempt to
tell how or why the concepts are related and may deal with
cause and effect and correlations or rules that regulate
interactions. They are developed by correlational research and
increasingly through comprehensive literature review and

synthesis. An example of an explanatory theory is the theory of
spirituality-based nursing practice (Nardi & Rooda, 2011). This
theory was developed from a mixed-method research study that
surveyed senior nursing students on several aspects of
awareness and application of spirituality in their practice. In
other works, comprehensive literature review and synthesis
were used by Reimer and Moore (2010) to develop a middle
range theory explaining flight nursing expertise and by Murrock
and Higgins (2009) to develop a middle range theory explaining
the effects of music on improved health outcomes.
Predictive (Situation-Relating) Theories
Situation-relating theories are achieved when the conditions
under which concepts are related are stated and the relational
statements are able to describe future outcomes consistently.
Situation-relating theories move to prediction of precise
relationships between concepts. Experimental research is used
to generate and test them in most cases.
Predictive theories are relatively difficult to find in the nursing
literature. In one example, Cobb (2012) used a quasi-
experimental, model building approach to predict the
relationship between spirituality and health status among adults
living with HIV. In another example, Chang, Wung, and Crogan
(2008) used a quasi-experimental research design to create a
theoretical model supporting an intervention designed to
improve elderly nursing home resident’s ability to provide self-
care. Their research validated the premise that the theory-based
intervention improved performance of activities of daily living
among residents in the study group compared with a control
group.
Another example of a predictive theory in nursing can be found
in the Caregiving Effectiveness Model. The process outlining
development of this theory was described by Smith and
colleagues (2002) and combined numerous steps in theory
construction and empirical testing and validation. In the model,
caregiving effectiveness is dependent on the interface of a
number of factors including the characteristics of the caregiver,

interpersonal interactions between the patient and caregiver,
and the educational preparedness of the caregiver, combined
with adaptive factors, such as economic stability, and the
caregiver’s own health status and family adaptation and coping
mechanisms. The model itself graphically details the interaction
of these factors and depicts how they collectively work to
impact caregiving effectiveness.
Prescriptive (Situation-Producing) Theories
Situation-producing theories are those that prescribe activities
necessary to reach defined goals. Prescriptive theories address
nursing therapeutics and consequences of interventions. They
include propositions that call for change and predict
consequences of nursing interventions. They should describe the
prescription, the consequence(s), the type of client, and the
conditions (Meleis, 2012).
Prescriptive theories are among the most difficult to identify in
the nursing literature. One example is a work by Walling (2006)
that presented a “prescriptive theory explaining medical
acupuncture” for nurse practitioners. The model describes how
acupuncture can be used to reduce stress and enhance well-
being. In another example, Auvil-Novak (1997) described the
development of a middle range theory of chronotherapeutic
intervention for postsurgical pain based on three experimental
studies of pain relief among postsurgical clients. The theory
uses a time-dependent approach to pain assessment and provides
directed nursing interventions to address postoperative pain.
Issues in Theory Development in Nursing
A number of issues related to use of theory in nursing have
received significant attention in the literature. The first is the
issue of borrowed versus unique theory in nursing. A second
issue is nursing’s metaparadigm, and a third is the importance
of the concept of caring in nursing.
Borrowed Versus Unique Theory in Nursing
Since the 1960s, the question of borrowing—or sharing—theory
from other disciplines has been raised in the discussion of
nursing theory. The debate over borrowed/shared theory centers

in the perceived need for theory unique to nursing discussed by
many nursing theorists.
The main premise held by those opposed to borrowed theory is
that only theories that are grounded in nursing should guide the
actions of the discipline. A second premise that supports the
need for unique theory is that any theory that evolves out of the
practice arena of nursing is substantially nursing. Although one
might “borrow” theory and apply it to the realm of nursing
actions, it is transformed into nursing theory because it
addresses phenomena within the arena of nursing practice.
Opponents of using borrowed theory believe that nursing
knowledge should not be tainted by using theory from
physiology, psychology, sociology, and education. Furthermore,
they believe “borrowing” requires returning and that the theory
is not in essence nursing if concepts are borrowed (Levine,
1995; Risjord, 2010).
Proponents of using borrowed theory in nursing believe that
knowledge belongs to the scientific community and to society at
large, and it is not the property of individuals or disciplines
(Powers & Knapp, 2011). Indeed, these individuals feel that
knowledge is not the private domain of one discipline, and the
use of knowledge generated by any discipline is not borrowed
but shared. Further, shared theory does not lessen nursing
scholarship but enhances it (Levine, 1995).
Furthermore, advocates of borrowed or shared theory believe
that, like other applied sciences, nursing depends on the
theories from other disciplines for its theoretical foundations.
For example, general systems theory is used in nursing, biology,
sociology, and engineering. Different theories of stress and
adaptation are valuable to nurses, psychologists, and physicians.
In reality, all nursing theories incorporate concepts and theories
shared with other disciplines to guide theory development,
research, and practice. However, simply adopting concepts or
theories from another discipline does not convert them into
nursing concepts or theories. It is important, therefore, for
theorists, researchers, and practitioners to use concepts from

other disciplines appropriately. Emphasis should be placed on
redefining and synthesizing the concepts and theories according
to a nursing perspective (Fawcett & DeSanto-Madeya, 2013;
Levine, 1995).
Nursing’s Metaparadigm
The most abstract and general component of the structural
hierarchy of nursing knowledge is what Kuhn (1977) called
the metaparadigm. A metaparadigm refers “globally to the
subject matter of greatest interest to member of a discipline”
(Powers & Knapp, 2011, p. 107). The metaparadigm includes
major philosophical orientations or worldviews of a discipline,
the conceptual models and theories that guide research and
other scholarly activities, and the empirical indicators that
operationalize theoretical concepts (Fawcett & Malinski, 1996).
The purpose or function of the metaparadigm is to summarize
the intellectual and social missions of the discipline and place
boundaries on the subject matter of that discipline (Kim, 1989).
Fawcett and DeSanto-Madeya (2013) identified four
requirements for a metaparadigm. These are summarized in Box
2-1.
Box 2-1: Requirements for a Metaparadigm
· 1. A metaparadigm must identify a domain that is distinctive
from the domains of other disciplines … the concepts and
propositions represent a unique perspective for inquiry and
practice.
· 2. A metaparadigm must encompass all phenomena of interest
to the discipline in a parsimonious manner … the concepts and
propositions are global and there are no redundancies.
· 3. A metaparadigm must be perspective-neutral … the
concepts and propositions do not represent a specific
perspective (i.e., a specific paradigm or conceptual model or
combination of perspectives).
· 4. A metaparadigm must be global in scope and substance …
the concepts and propositions do not reflect particular national,
cultural, or ethnic beliefs and values.
Adapted from: Fawcett & DeSanto-Madeya, 2013

According to Fawcett and DeSanto-Madeya (2013), in the 1970s
and early 1980s, a number of nursing scholars identified a
growing consensus that the dominant phenomena within the
science of nursing revolved around the concepts of man
(person), health, environment, and nursing. Fawcett first wrote
on the central concepts of nursing in 1978 and formalized them
as the metaparadigm of nursing in 1984. This articulation of
four metaparadigm concepts (person, health, environment, and
nursing) served as an organizing framework around which
conceptual development proceeded.
Wagner (1986) examined the nursing metaparadigm in depth.
Her sample of 160 doctorally prepared chairpersons, deans, or
directors of programs for bachelor’s of science in nursing
revealed that between 94% and 98% of the respondents agreed
that the concepts that comprise the nursing metaparadigm are
person, health, nursing, and environment. She concluded that
these findings indicated a consensus within the discipline of
nursing that these are the dominant phenomena within the
science. A summary of definitions for each term is presented
here.
Person refers to a being composed of physical, intellectual,
biochemical, and psychosocial needs; a human energy field; a
holistic being in the world; an open system; an integrated
whole; an adaptive system; and a being who is greater than the
sum of his or her parts (Wagner, 1986). Nursing theories are
often most distinguishable from each other by the various ways
in which they conceptualize the person or recipient of nursing
care. Most nursing models organize data about the individual
person as a focus of the nurse’s attention, although some
nursing theorists have expanded to include family or community
as the focus (Thorne et al., 1998). Health is the ability to
function independently; successful adaptation to life’s stressors;
achievement of one’s full life potential; and unity of mind,
body, and soul (Wagner, 1986). Health has been a phenomenon
of central interest to nursing since its inception. Nursing
literature indicates great diversity in the explication of health

and quality of life (Thorne et al., 1998). Indeed, in a recent
work, following a critical appraisal of the works of several
nurse-theorists, Plummer and Molzahn (2012) suggested
replacing the term “health” with “quality of life.” They posited
that quality of life is a more inclusive notion, as health is often
understood in terms of physical status. Alternatively, quality of
life better encompasses a holistic perspective, involving
physical, psychological, and social well-being, as well as the
spiritual and environmental aspects of the human experience.
Environment typically refers to the external elements that affect
the person; internal and external conditions that influence the
organism; significant others with whom the person interacts;
and an open system with boundaries that permit the exchange of
matter, energy, and information with human beings (Wagner,
1986). Many nursing theories have a narrow conceptualization
of the environment as the immediate surroundings or
circumstances of the individual. This view limits understanding
by making the environment rigid, static, and natural. A
multilayered view of the environment encourages understanding
of an individual’s perspective and immediate context and
incorporates the sociopolitical and economic structures and
underlying ideologies that influence reality (Thorne et al.,
1998).
Nursing is a science, an art, and a practice discipline and
involves caring. Goals of nursing include care of the well, care
of the sick, assisting with self-care activities, helping
individuals attain their human potential, and discovering and
using nature’s laws of health. The purposes of nursing care
include placing the client in the best condition for nature to
restore health, promoting the adaptation of the individual,
facilitating the development of an interaction between the nurse
and the client in which jointly set goals are met, and promoting
harmony between the individual and the environment (Wagner,
1986). Furthermore, nursing practice facilitates, supports, and
assists individuals, families, communities, and societies to
enhance, maintain, and recover health and to reduce and

ameliorate the effects of illness (Thorne et al., 1998).
In addition to these definitions, many grand nursing theorists,
and virtually all of the theoretical commentators, incorporate
these four terms into their conceptual or theoretical
frameworks. Table 2-5presents theoretical definitions of the
metaparadigm concepts from selected nursing conceptual
frameworks and other writings.
Table 2-5: Selected Theoretical Definitions of the Concepts of
Nursing’s Metaparadigm
Metaparadigm Concept
Author/Source of Definition
Definition
Person/human being/client
D. Johnson
A behavioral system with patterned, repetitive, and purposeful
ways of behaving that link person to the environment.
B. Neuman
A dynamic composite of the interrelationships between
physiologic, psychological, sociocultural, developmental,
spiritual, and basic structure variables. May be an individual,
group, community, or social system.
D. Orem
Are distinguished from other living things by their capacity (1)
to reflect upon themselves and their environment, (2) to
symbolize what they experience, and (3) to use symbolic
creations (ideas, words) in thinking, in communicating, and in
guiding efforts to do and to make things that are beneficial for
themselves or others.
M. Rogers
An irreducible, indivisible, pan-dimensional energy field
identified by pattern and manifesting characteristics that are
specific to the whole and that cannot be predicted from
knowledge of the parts.

Nursing
M. Leininger
A learned humanistic and scientific profession and discipline
that is focused on human care phenomena and activities to
assist, support, facilitate, or enable individuals or groups to
maintain or regain their well-being (or health) in culturally
meaningful and beneficial ways, or to help people face
handicaps or death.
M. Newman
Caring in the human health experience.
D. Orem
A specific type of human service required whenever the
maintenance of continuous self-care requires the use of special
techniques and the application of scientific knowledge in
providing care or in designing it.
J. Watson
A human science of persons and human health–illness
experiences that are mediated by professional, personal,
scientific, esthetic, and ethical human care transactions.
Health
M. Leininger
A state of well-being that is culturally defined, valued, and
practiced, and that reflects the ability of individuals (or groups)
to perform their daily role activities in culturally expressed,
beneficial, and patterned lifeways.
M. Newman
A pattern of evolving, expanding consciousness regardless of
the form or direction it takes.
C. Roy
A state and process of being and becoming an integrated and
whole person. It is a reflection of adaptation, that is, the

interaction of the person and the environment.
J. Watson
Unity and harmony within the mind, body, and soul. Health is
also associated with the degree of congruence between the self
as perceived and the self as experienced.
Environment
M. Leininger
The totality of an event, situation, or particular experience that
gives meaning to human expressions, interpretations, and social
interactions in particular physical, ecologic, sociopolitical, and
cultural settings.
B. Neuman
All internal and external factors of influences that surround the
client or client system.
M. Rogers
An irreducible, pan-dimensional energy field identified by
pattern and integral with the human field.
C. Roy
All conditions, circumstances, and influences that surround and
affect the development and behavior of human adaptive systems
with particular consideration of person and earth resources.
Sources: Johnson (1980); Leininger (1991); Neuman (1995);
Newman (1990); Orem (2001); Rogers (1990); Roy & Andrews
(1999); Watson (1985).
Relationships Among the Metaparadigm Concepts
The concepts of nursing’s metaparadigm have been linked in
four propositions identified in the writings of Donaldson and
Crowley (1978) and Gortner (1980). These are as follows:
· 1. Person and health: Nursing is concerned with the principles
and laws that govern human processes of living and dying.
· 2. Person and environment: Nursing is concerned with the
patterning of human health experiences within the context of the

environment.
· 3. Health and nursing: Nursing is concerned with the nursing
actions or processes that are beneficial to human beings.
· 4. Person, environment, and health: Nursing is concerned with
the human processes of living and dying, recognizing that
human beings are in a continuous relationship with their
environments (Fawcett & DeSanto-Madeya, 2013, p. 6).
In addressing how the four concepts meet the requirements for a
metaparadigm, Fawcett and DeSanto-Madeya (2013) explain
that the first three propositions represent recurrent themes
identified in the writings of Nightingale and other nursing
scholars. Furthermore, the four concepts and propositions
identify the unique focus of the discipline of nursing and
encompass all relevant phenomena in a parsimonious manner.
Finally, the concepts and propositions are perspective-neutral
because they do not reflect a specific paradigm or conceptual
model and they do not reflect the beliefs and values of any one
country or culture.
Other Viewpoints on Nursing’s Metaparadigm
There is some dissension in the acceptance of
person/health/environment/nursing as nursing’s metaparadigm.
Kim (1987, 1989, 2010) identified four domains (client, client–
nurse, practice, and environment) as an organizing framework
or typology of nursing. In this framework, the most significant
difference appears to be in placing health issues (i.e., health
care experiences and health care environment) within the client
domain and differentiating the nursing practice domain from the
client–nurse domain. The latter focuses specifically on
interactions between the nurse and the client.
Meleis (2012) maintained that nursing encompasses seven
central concepts: interaction, nursing client, transitions, nursing
process, environment, nursing therapeutics, and health.
Addition of the concepts of interaction, transitions, and nursing
process denotes the greatest difference between this framework
and the more commonly described
person/health/environment/nursing framework. (See Link to

Practice 2-1for another thought on expanding the metaparadigm
to include social justice.)
Link to Practice 2-1: Should Social Justice Be Part of Nursing’s
Metaparadigm?
Schim, Benkert, Bell, Walker, and Danford (2006) proposed that
the construct of “ social justice” be added to nursing’s
metaparadigm. They argued that social justice is interconnected
with the four acknowledged metaparadigm concepts of nursing,
person, health, and environment. In their model, social justice
actually acts as the central, organizational foundation that links
the other four concepts, particularly within the context of public
health nursing, and more specifically in urban settings.
Using this macroperspecitve, the goal of nursing is to ensure
adequate distribution of resources to benefit those who are
marginalized. Suggested strategies to enhance attention to
social justice in nursing include shifting to a population health
and health promotion/disease prevention perspective;
diversifying nursing by recruiting and educating
underrepresented minorities into the profession; and engaging in
political action at local, state, national and international levels.
They concluded that as a caring profession, nursing should
expand efforts with a social justice orientation to help ensure
equal access to benefits and protections of society for all.
Caring as a Central Construct in the Discipline of Nursing
A final debate that will be discussed in this chapter centers on
the place of the concept of caring within the discipline and
science of nursing. This debate has been escalating over the last
decade and has been motivated by the perceived urgency of
identifying nursing’s unique contribution to the health care
disciplines and revolves around the defining attributes and roles
within the practice of nursing (Thorne et al., 1998).
The concept of caring has occupied a prominent position in
nursing literature and has been touted as the essence of nursing
by renowned nursing scholars, including Leininger, Watson, and
Erikkson. Indeed, it has been proposed that nursing be defined
as the study of caring in the human health experience (Newman,

Sime, & Corcoran-Perry, 1991).
Although some theorists (i.e., Watson, Leininger, and Boykin)
have gone so far as to identify caring as the essence of nursing,
there is little if any rejection of caring as a central concept for
nursing, although not necessarily the most significant concept.
Thorne and colleagues (1998) cited three major areas of
contention in the debate about caring in nursing. The first is the
diverse views on the nature of caring. These range from caring
as a human trait to caring as a therapeutic intervention and
differ according to whether the act of caring is conceptualized
as being client centered, nurse centered, or both.
A second major issue in the caring debate concerns the use of
caring terminology to conceptualize a specialized role. It has
been asked whether there is a compelling reason to lay claim to
caring as nursing’s unique domain when so many professions
describe their function as involving caring, and the concept of
caring is prominent in the work of many other disciplines (e.g.,
medicine, social work, and psychology) (Thorne et al., 1998).
A third issue centers on the implications for the future
development of the profession that nursing should espouse
caring as its unique mandate. It has been observed that nurses
should ask themselves if it is politically astute to be the primary
interpreters of a construct that is both gendered and devalued
(Meadows, 2007; Thorne et al., 1998).
Thus, it is argued by Fawcett and Malinski (1996) that although
caring is included in several conceptualizations of the discipline
of nursing, it is not a dominant term in every conceptualization
and therefore does not represent a discipline-wide viewpoint.
Furthermore, caring is not uniquely a nursing phenomenon, and
caring behaviors may not be generalizable across national and
cultural boundaries.
Summary
Like Matt Ng, the graduate nursing student described in the
opening case study, nurses who are in a position to learn more
about theory, and to recognize how and when to apply it, must
often be convinced of the relevance of such study to understand

the benefits. The study of theory requires exposure to many new
concepts, principles, thoughts, and ideas, as well as a student
who is willing to see how theory plays an important role in
nursing practice, research, education, and administration.
Although study and use of theoretical concepts in nursing dates
back to Nightingale, little progress in theory development was
made until the 1960s. The past five decades, however, have
produced significant advancement in theory development for
nursing. This chapter has presented an overview of this
evolutionary process. In addition, the basic types of theory and
purposes of theory were described. Subsequent chapters will
explain many of the ideas introduced here to assist professional
nurses to understand the relationship among theory, practice,
and research and to further develop the discipline, the science,
and the profession of nursing.
Key Points
· “Theory” refers to the systematic explanation of events in
which constructs and concepts are identified, relationships are
proposed, and predictions are made.
· Theory offers structure and organization to nursing
knowledge and provides a systematic means of collecting data
to describe, explain, and predict nursing practice.
· Florence Nightingale was the first modern nursing theorist;
she described what she considered nurses’ goals and practice
domain to be.
· There has been an evolution of stages of theory development
in nursing. Nursing is currently in the “integrated knowledge”
stage, which emphasizes EBP and translational research. Theory
development increasingly sources meta-analyses, as well as
nursing research, and is largely directed toward middle range
and situation-specific/practice theories.
· Theories can be classified by scope of level of abstraction
(e.g., metatheory, grand theory, middle range theory, and
situation-specific theory) or by type or purpose of the theory
(e.g., description, explanation, prediction, and prescription).

· Nursing “borrows” or “shares” theories and concepts from
other disciplines to guide theory development, research, and
practice. It is critical that nurses redefine and synthesize these
shared concept and theories according to a nursing perspective.
· The concepts of nursing, person, environment, and health are
widely accepted as the dominant phenomena in nursing; they
have been identified as nursing’s metaparadigm.·
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CHAPTER 1: Philosophy, Science, and Nursing
Melanie McEwen
Largely due to the work of nursing scientists, nursing theorists,
and nursing scholars over the past five decades, nursing has
been recognized as both an emerging profession and an
academic discipline. Crucial to the attainment of this distinction
have been numerous discussions regarding the phenomena of
concern to nurses and countless efforts to enhance involvement
in theory utilization, theory generation, and theory testing to
direct research and improve practice.
A review of the nursing literature from the late 1970s until the
present shows sporadic discussion of whether nursing is a
profession, a science, or an academic discipline. These
discussions are sometimes pleading, frequently esoteric, and
occasionally confusing. Questions that have been raised
include: What defines a profession? What constitutes an
academic discipline? What is nursing science? Why is it
important for nursing to be seen as a profession or an academic
discipline?
Nursing as a Profession
In the past, there has been considerable discussion about
whether nursing is a profession or an occupation. This is
important for nurses to consider for several reasons. An
occupation is a job or a career, whereas a profession is a learned
vocation or occupation that has a status of superiority and
precedence within a division of work. In general terms,

occupations require widely varying levels of training or
education, varying levels of skill, and widely variable defined
knowledge bases. In short, all professions are occupations, but
not all occupations are professions (Finkelman & Kenner,
2013).
Professions are valued by society because the services
professionals provide are beneficial for members of the society.
Characteristics of a profession include (1) defined and
specialized knowledge base, (2) control and authority over
training and education, (3) credentialing system or registration
to ensure competence, (4) altruistic service to society, (5) a
code of ethics, (6) formal training within institutions of higher
education, (7) lengthy socialization to the profession, and (8)
autonomy (control of professional activities) (Ellis & Hartley,
2012; Finkelman & Kenner, 2013; Rutty, 1998).
Professions must have a group of scholars, investigators, or
researchers who work to continually advance the knowledge of
the profession with the goal of improving practice (Schlotfeldt,
1989). Finally, professionals are responsible and accountable to
the public for their work (Hood, 2010). Traditionally,
professions have included the clergy, law, and medicine.
Until near the end of the 20th century, nursing was viewed as an
occupation rather than a profession. Nursing has had difficulty
being deemed a profession because many of the services
provided by nurses have been perceived as an extension of those
offered by wives and mothers. Additionally, historically,
nursing has been seen as subservient to medicine, and nurses
have delayed in identifying and organizing professional
knowledge. Furthermore, education for nurses is not yet
standardized, and the three-tier entry-level system (diploma,
associate degree, and bachelor’s degree) into practice that
persists has hindered professionalization because a college
education is not yet a requirement. Finally, autonomy in
practice is incomplete because nursing is still dependent on
medicine to direct much of its practice.
On the other hand, many of the characteristics of a profession

can be observed in nursing. Indeed, nursing has a social
mandate to provide health care for clients at different points in
the health–illness continuum. There is a growing knowledge
base, authority over education, altruistic service, a code of
ethics, and registration requirements for practice. Although the
debate is ongoing, it can be successfully argued that nursing is
an aspiring, evolving profession (Finkelman & Kenner, 2013;
Hood, 2010; Judd, Sitzman, & Davis, 2010). See Link to
Practice 1-1 for more information on the future of nursing as a
profession.
Link to Practice 1-1: The Future of Nursing
The Institute of Medicine (IOM, 2011) recently issued a series
of sweeping recommendations directed to the nursing
profession. The IOM explained their “vision” is to make
quality, patient-centered care accessible for all Americans.
Recommendations included a three-pronged approach to
meeting the goal.
The first “message” was directed toward transformation of
practice and precipitated the notion that nurses should be able
to practice to the full extent of their education. Indeed, the IOM
advocated for removal of regulatory, policy, and financial
barriers to practice to ensure that “current and future
generations of nurses can deliver safe, quality, patient-centered
care across all settings, especially in such areas as primary care
and community and public health” (p. 30).
A second key message related to the transformation of nursing
education. In this regard, the IOM promotes “seamless academic
progression” (p. 30), which includes a goal to increase the
number and percentage of nurses who enter the workforce with
a baccalaureate degree or who progress to the degree early in
their career. Specifically, they recommend that 80% of RNs be
BSN prepared by 2020. Last, the IOM advocated that nurses be
full partners with physicians and other health professionals in
the attempt to redesign health care in the United States.
These “messages” are critical to the future of nursing as a
profession. Indeed, standardization of entry level into practice

at the BSN level, coupled with promotion of advanced education
and independent practice, and inclusion as “leaders” in the
health care transformation process, will help solidify nursing as
a true profession.
Nursing as an Academic Discipline
Disciplines are distinctions between bodies of knowledge found
in academic settings. A discipline is “a branch of knowledge
ordered through the theories and methods evolving from more
than one worldview of the phenomenon of concern” (Parse,
1997, p. 74). It has also been termed a field of inquiry
characterized by a unique perspective and a distinct way of
viewing phenomena (Butts, Rich, & Fawcett, 2012; Parse,
1999).
Viewed another way, a discipline is a branch of educational
instruction or a department of learning or knowledge.
Institutions of higher education are organized around disciplines
into colleges, schools, and departments (e.g., business
administration, chemistry, history, and engineering).
Disciplines are organized by structure and tradition. The
structure of the discipline provides organization and determines
the amount, relationship, and ratio of each type of knowledge
that comprises the discipline. The tradition of the discipline
provides the content, which includes ethical, personal, esthetic,
and scientific knowledge (Northrup et al., 2004; Risjord, 2010).
Characteristics of disciplines include (1) a distinct perspective
and syntax, (2) determination of what phenomena are of
interest, (3) determination of the context in which the
phenomena are viewed, (4) determination of what questions to
ask, (5) determination of what methods of study are used, and
(6) determination of what evidence is proof (Donaldson &
Crowley, 1978).
Knowledge development within a discipline proceeds from
several philosophical and scientific perspectives or worldviews
(Litchfield & Jonsdottir, 2008; Newman, Sime, & Corcoran-
Perry, 1991; Parse, 1999; Risjord, 2010). In some cases, these
worldviews may serve to divide or segregate members of a

discipline. For example, in psychology, practitioners might
consider themselves behaviorists, Freudians, or any one of a
number of other divisions.
Several ways of classifying academic disciplines have been
proposed. For instance, they may be divided into the basic
sciences (physics, biology, chemistry, sociology, anthropology)
and the humanities (philosophy, ethics, history, fine arts). In
this classification scheme, it is arguable that nursing has
characteristics of both.
Distinctions may also be made between academic disciplines
(e.g., physics, physiology, sociology, mathematics, history,
philosophy) and professional disciplines (e.g., medicine, law,
nursing, social work). In this classification scheme, the
academic disciplines aim to “know,” and their theories are
descriptive in nature. Research in academic disciplines is both
basic and applied. Conversely, the professional disciplines are
practical in nature, and their research tends to be more
prescriptive and descriptive (Donaldson & Crowley, 1978).
Nursing’s knowledge base draws from many disciplines. In the
past, nursing depended heavily on physiology, sociology,
psychology, and medicine to provide academic standing and to
inform practice. In recent decades, however, nursing has been
seeking what is unique to nursing and developing those aspects
into an academic discipline. Areas that identify nursing as a
distinct discipline are as follows:
· An identifiable philosophy
· At least one conceptual framework (perspective) for
delineation of what can be defined as nursing
· Acceptable methodologic approaches for the pursuit and
development of knowledge (Oldnall, 1995)
To begin the quest to validate nursing as both a profession and
an academic discipline, this chapter provides an overview of the
concepts of science and philosophy.
It examines the schools of philosophical thought that have
influenced nursing and explores the epistemology of nursing to
explain why recognizing the multiple “ways of knowing” is

critical in the quest for development and application of theory
in nursing. Finally, this chapter presents issues related to how
philosophical worldviews affect knowledge development
through research. This chapter concludes with a case study that
depicts how “the ways of knowing” in nursing are used on a
day-to-day, even moment-by-moment, basis by all practicing
nurses.
Introduction to Science and Philosophy
Science is concerned with causality (cause and effect). The
scientific approach to understanding reality is characterized by
observation, verifiability, and experience; hypothesis testing
and experimentation are considered scientific methods. In
contrast, philosophy is concerned with the purpose of human
life, the nature of being and reality, and the theory and limits of
knowledge. Intuition, introspection, and reasoning are examples
of philosophical methodologies. Science and philosophy share
the common goal of increasing knowledge (Butts et al., 2012;
Fawcett, 1999; Silva, 1977). The science of any discipline is
tied to its philosophy, which provides the basis for
understanding and developing theories for science (Gustafsson,
2002; Silva & Rothbert, 1984).
Overview of Science
Science is both a process and a product. Parse (1997) defines
science as the “theoretical explanation of the subject of inquiry
and the methodological process of sustaining knowledge in a
discipline” (p. 74). Science has also been described as a way of
explaining observed phenomena as well as a system of
gathering, verifying, and systematizing information about
reality (Streubert & Carpenter, 2011). As a process, science is
characterized by systematic inquiry that relies heavily on
empirical observations of the natural world. As a product, it has
been defined as empirical knowledge that is grounded and tested
in experience and is the result of investigative efforts.
Furthermore, science is conceived as being the consensual,
informed opinion about the natural world, including human
behavior and social action (Gortner & Schultz, 1988).

Science has come to represent knowledge, and it is generated by
activites that combine advancement of knowledge (research)
and explanation for knowledge (theory) (Powers & Knapp,
2011). Citing Van Laer, Silva (1977) lists six characteristics of
science (Box 1-1).
Box 1-1: Characteristics of Science
· 1. Science must show a certain coherence.
· 2. Science is concerned with definite fields of knowledge.
· 3. Science is preferably expressed in universal statements.
· 4. The statements of science must be true or probably true.
· 5. The statements of science must be logically ordered.
· 6. Science must explain its investigations and arguments.
Source: Silva (1977).
Science has been classified in several ways. These include pure
or basic science, natural science, human or social science, and
applied or practice science. The classifications are not mutually
exclusive and are open to interpretation based on philosophical
orientation. Table 1-1 lists examples of a number of sciences by
this manner of classification.
Table 1-1: Classifications of Science
Classification
Examples
Natural sciences
Chemistry, physics, biology, physiology, geology, meteorology
Basic or pure sciences
Mathematics, logic, chemistry, physics, English (language)
Human or social sciences
Psychology, anthropology, sociology, economics, political
science, history, religion
Practice or applied sciences
Architecture, engineering, medicine, pharmacology, law
Some sciences defy classification. For example, computer
science is arguably applied or perhaps pure. Law is certainly a
practice science, but it is also a social science. Psychology
might be a basic science, a human science, or an applied
science, depending on what aspect of psychology one is

referring to.
There are significant differences between the human and natural
sciences. Human sciences refer to the fields of psychology,
anthropology, and sociology and may even extend to economics
and political science. These disciplines deal with various
aspects of humans and human interactions. Natural sciences, on
the other hand, are concentrated on elements found in nature
that do not relate to the totality of the individual. There are
inherent differences between the human and natural sciences
that make the research techniques of the natural sciences (e.g.,
laboratory experimentation) improper or potentially problematic
for human sciences (Gortner & Schultz, 1988).
It has been posited that although nursing draws on the basic and
pure sciences (e.g., physiology and chemistry) and has many
characteristics of social sciences, it is without question an
applied or practice science. However, it is important to note that
it is also synthesized, in that it draws on the knowledge of other
established disciplines—including other practice disciplines
(Dahnke & Dreher, 2011; Holzemer, 2007; Risjord, 2010).
Overview of Philosophy
Within any discipline, both scholars and students should be
aware of the philosophical orientations that are the basis for
developing theory and advancing knowledge (Dahnke & Dreher,
2011; DiBartolo, 1998; Northrup et al., 2004; Risjord, 2010).
Rather than a focus on solving problems or answering questions
related to that discipline (which are tasks of the discipline’s
science), the philosophy of a discipline studies the concepts that
structure the thought processes of that discipline with the intent
of recognizing and revealing foundations and presuppositions
(Blackburn, 2008; Cronin & Rawlings-Anderson, 2004).
Philosophy has been defined as “a study of problems that are
ultimate, abstract, and general. These problems are concerned
with the nature of existence, knowledge, morality, reason, and
human purpose” (Teichman & Evans, 1999, p. 1).
Philosophy tries to discover knowledge and truth and attempts
to identify what is valuable and important.

Modern philosophy is usually traced to Rene Descartes, Francis
Bacon, Baruch Spinoza, and Immanuel Kant (ca. 1600–1800).
Descartes (1596–1650) and Spinoza (1632–1677) were early
rationalists. Rationalists believe that reason is superior to
experience as a source of knowledge. Rationalists attempt to
determine the nature of the world and reality by deduction and
stress the importance of mathematical procedures.
Bacon (1561–1626) was an early empiricist. Like rationalists,
he supported experimentation and scientific methods for solving
problems.
The work of Kant (1724–1804) set the foundation for many later
developments in philosophy. Kant believed that knowledge is
relative and that the mind plays an active role in knowing.
Other philosophers have also influenced nursing and the
advance of nursing science. Several are discussed later in the
chapter.
Although there is some variation, traditionally, the branches of
philosophy include metaphysics (ontology and cosmology),
epistemology, logic, esthetics, and ethics or axiology. Political
philosophy and philosophy of science are added by some
authors (Rutty, 1998; Teichman & Evans, 1999). Table 1-
2 summarizes the major branches of philosophy.
Table 1-2: Branches of Philosophy
Branch
Pursuit
Metaphysics
Study of the fundamental nature of reality and existence—
general theory of reality
Ontology
Study of theory of being (what is or what exists)
Cosmology
Study of the physical universe
Epistemology
Study of knowledge (ways of knowing, nature of truth, and
relationship between knowledge and belief)
Logic

Study of principles and methods of reasoning (inference and
argument)
Ethics (axiology)
Study of nature of values; right and wrong (moral philosophy)
Esthetics
Study of appreciation of the arts or things beautiful
Philosophy of science
Study of science and scientific practice
Political philosophy
Study of citizen and state
Sources: Blackburn (2008); Teichman & Evans (1999).
Science and Philosophical Schools of Thought
The concept of science as understood in the 21st century is
relatively new. In the period of modern science, three
philosophies of science (paradigms or worldviews) dominate:
rationalism, empiricism, and human science/phenomenology.
Rationalism and empiricism are often termed received view and
human science/phenomenology and related worldviews (i.e.,
historicism) are considered perceived view(Hickman, 2011;
Meleis, 2012). These two worldviews dominated theoretical
discussion in nursing through the 1990s. More recently,
attention has focused on another dominant worldview:
“postmodernism” (Meleis, 2012; Reed, 1995).
Received View (Empiricism, Positivism, Logical Positivism)
Empiricism has its roots in the writings of Francis Bacon, John
Locke, and David Hume, who valued observation, perception by
senses, and experience as sources of knowledge (Gortner &
Schultz, 1988; Powers & Knapp, 2011). Empiricism is founded
on the belief that what is experienced is what exists, and its
knowledge base requires that these experiences be verified
through scientific methodology (Dahnke & Dreher, 2011;
Gustafsson, 2002). This knowledge is then passed on to others
in the discipline and subsequently built on. The term received
view or received knowledge denotes that individuals learn by
being told or receiving knowledge.
Empiricism holds that truth corresponds to observable,

reduction, verification, control, and bias-free science. It
emphasizes mathematic formulas to explain phenomena and
prefers simple dichotomies and classification of concepts.
Additionally, everything can be reduced to a scientific formula
with little room for interpretation (DiBartolo, 1998; Gortner &
Schultz, 1988; Risjord, 2010).
Empiricism focuses on understanding the parts of the whole in
an attempt to understand the whole. It strives to explain nature
through testing of hypotheses and development of theories.
Theories are made to describe, explain, and predict phenomena
in nature and to provide understanding of relationships between
phenomena. Concepts must be operationalized in the form of
propositional statements, thereby making measurement possible.
Instrumentation, reliability, and validity are stressed in
empirical research methodologies. Once measurement is
determined, it is possible to test theories through
experimentation or observation, which results in verification or
falsification (Cull-Wilby & Pepin, 1987; Suppe & Jacox, 1985).
Positivism is often equated with empiricism. Like empiricism,
positivism supports mechanistic, reductionist principles, where
the complex can be best understood in terms of its basic
components. Logical positivism was the dominant empirical
philosophy of science between the 1880s and 1950s. Logical
positivists recognized only the logical and empirical bases of
science and stressed that there is no room for metaphysics,
understanding, or meaning within the realm of science
(Polifroni & Welch, 1999; Risjord, 2010). Logical positivism
maintained that science is value free, independent of the
scientist, and obtained using objective methods. The goal of
science is to explain, predict, and control. Theories are either
true or false, subject to empirical observation, and capable of
being reduced to existing scientific theories (Rutty, 1998).
Contemporary Empiricism/Postpositivism
Positivism came under criticism in the 1960s when positivistic
logic was deemed faulty (Rutty, 1998). An overreliance on
strictly controlled experimentation in artificial settings

produced results that indicated that much significant knowledge
or information was missed. In recent years, scholars have
determined that the positivist view of science is outdated and
misleading in that it contributes to overfragmentation in
knowledge and theory development (DiBartolo, 1998). It has
been observed that positivistic analysis of theories is
fundamentally defective due to insistence on analyzing the
logically ideal, which results in findings that have little to do
with reality. It was maintained that the context of discovery was
artificial and that theories and explanations can be understood
only within their discovery contexts (Suppe & Jacox, 1985).
Also, scientific inquiry is inherently value laden, as even
choosing what to investigate and/or what techniques to employ
will reflect the values of the researcher.
The current generation of postpositivists accept the subjective
nature of inquiry but still support rigor and objective study
through quantitative research methods. Indeed, it has been
observed that modern empiricists or postpositivists are
concerned with explanation and prediction of complex
phenomena, recognizing contextual variables (Powers & Knapp,
2011; Reed, 2008).
Nursing and Empiricism
As an emerging discipline, nursing has followed established
disciplines (e.g., physiology) and the medical model in stressing
logical positivism. Early nurse scientists embraced the
importance of objectivity, control, fact, and measurement of
smaller and smaller parts. Based on this influence, acceptable
methods for knowledge generation in nursing have stressed
traditional, orthodox, and preferably experimental methods.
Although positivism continues to heavily influence nursing
science, that viewpoint has been challenged in recent years
(Risjord, 2010). Consequently, postpositivism has become one
of the most accepted contemporary worldviews in nursing.
Perceived View (Human Science, Phenomenology,
Constructivism, Historicism)
In the late 1960s and early 1970s, several philosophers,

including Kuhn, Feyerbend, and Toulmin, challenged the
positivist view by arguing that the influence of history on
science should be emphasized (Dahnke & Dreher, 2011). The
perceived view of science, which may also be referred to as the
interpretive view, includes phenomenology, constructivism, and
historicism. The interpretive view recognizes that the
perceptions of both the subject being studied and the researcher
tend to de-emphasize reliance on strict control and
experimentation in laboratory settings (Monti & Tingen, 1999).
The perceived view of science centers on descriptions that are
derived from collectively lived experiences, interrelatedness,
human interpretation, and learned reality, as opposed to
artificially invented (i.e., laboratory-based) reality (Rutty,
1998). It is argued that the pursuit of knowledge and truth is
naturally historical, contextual, and value laden. Thus, there is
no single truth. Rather, knowledge is deemed true if it
withstands practical tests of utility and reason (DiBartolo,
1998).
Phenomenology is the study of phenomena and emphasizes the
appearance of things as opposed to the things themselves. In
phenomenology, understanding is the goal of science, with the
objective of recognizing the connection between one’s
experience, values, and perspective. It maintains that each
individual’s experience is unique, and there are many
interpretations of reality. Inquiry begins with individuals and
their experiences with phenomena. Perceptions, feelings,
values, and the meanings that have come to be attached to
things and events are the focus.
For social scientists, the constructivist approaches of the
perceived view focus on understanding the actions of, and
meaning to, individuals. What exists depends on what
individuals perceive to exist. Knowledge is subjective and
created by individuals. Thus, research methodology entails the
investigation of the individual’s world (Wainwright, 1997).
There is an emphasis on subjectivity, multiple truths, trends and
patterns, discovery, description, and understanding.

Feminism and critical social theory may also be considered to
be perceived view. These philosophical schools of thought
recognize the influence of gender, culture, society, and shared
history as being essential components of science (Riegel et al.,
1992). Critical social theorists contend that reality is dynamic
and shaped by social, political, cultural, economic, ethnic, and
gender values (Streubert & Carpenter, 2011). Critical social
theory and feminist theories will be described in more detail
in Chapter 13.
Nursing and Phenomenology/Constructivism/Historicism
Because they examine phenomena within context,
phenomenology, as well as other perceived views of philosophy,
are conducive to discovery and knowledge development inherent
to nursing. Phenomenology is open, variable, and relativistic
and based on human experience and personal interpretations. As
such, it is an important, guiding paradigm for nursing practice
theory and education (DiBartolo, 1998).
In nursing science, the dichotomy of philosophic thought
between the received, empirical view of science and the
perceived, interpretative view of science has persisted. This
may have resulted, in part, because nursing draws heavily both
from natural sciences (physiology, biology) and social sciences
(psychology, sociology).
Postmodernism (Poststructuralism, Postcolonialism)
Postmodernism began in Europe in the 1960s as a social
movement centered on a philosophy that rejects the notion of a
single “truth.” Although it recognizes the value of science and
scientific methods, postmodernism allows for multiple meanings
of reality and multiple ways of knowing and interpreting reality
(Hood, 2010; Reed, 1995). In postmodernism, knowledge is
viewed as uncertain, contextual, and relative. Knowledge
development moves from emphasis on identifying a truth or fact
in research to discovering practical significance and relevance
of research findings (Reed, 1995).
Similar or related constructs and worldviews found in the
nursing literature include “deconstruction,” “postcolonialism,”

and at times, feminist philosophies. In nursing, the postcolonial
worldview can be connected to both feminism and critical
theory, particularly when considering nursing’s historical
reliance on medicine (Holmes, Roy, & Perron, 2008; Mackay,
2009; Racine, 2009).
Postmodernism has loosened the notions of what counts as
knowledge development that have persisted among supporters of
qualitative and quantitative research methods. Rather than
focusing on a single research methodology, postmodernism
promotes use of multiple methods for development of scientific
understanding and incorporation of different ways to improve
understanding of human nature (Hood, 2010; Meleis, 2012;
Reed, 1995). Increasingly, in postmodernism, there is a
consensus that synthesis of both research methods can be used
at different times to serve different purposes (Hood, 2010;
Meleis, 2012; Risjord, Dunbar, & Moloney, 2002).
Criticisms of postmodernism have been made and frequently
relate to the perceived reluctance to address error in research.
Taken to the extreme as Paley (2005) pointed out, when there is
absence of strict control over methodology and interpretation of
research, “nobody can ever be wrong about anything” (p. 107).
Chinn and Kramer (2011) echoed the concerns by
acknowledging that knowledge development should never be
“sloppy.” Indeed, although application of various methods in
research is legitimate and may be advantageous, research must
still be carried out carefully and rigorously.
Nursing and Postmodernism
Postmodernism has been described as a dominant scientific
theoretical paradigm in nursing in the late 20th century (Meleis,
2012). As the discipline matures, there has been recognition of
the pluralistic nature of nursing and an enhanced understanding
that the goal of research is to provide an integrative basis for
nursing care (Walker & Avant, 2011).
In terms of scientific methodology, the attention is increasingly
on combining multiple methods within a single research project
(Chinn & Kramer, 2011). Postmodernism has helped dislodged

the authority of a single research paradigm in nursing science
by emphasizing the blending or integration of qualitative and
quantitative research into a holistic, dynamic model to improve
nursing practice. Table 1-3 compares the dominant
philosophical views of science in nursing.
Table 1-3: Comparison of the Received, Perceived, and
Postmodern Views of Science
Received View of Science—Hard Sciences
Perceived View of Science—Soft Sciences
Postmodernism, Poststructuralism, and Postcolonialism
Empiricism/positivism/logical positivism
Historicism/phenomenology
Macroanalysis
Reality/truth/facts considered acontextual (objective)
Reality/truth/facts considered in context (subjective)
Contextual meaning; narration
Deductive
Inductive
Contextual, political, and structural analysis
Reality/truth/facts considered ahistorical
Reality/truth/facts considered with regard to history
Reality/truth/facts considered with regard to history
Prediction and control
Description and understanding
Metanarrative analysis
One truth
Multiple truths
Different views
Validation and replication
Trends and patterns
Uncovering opposing views
Reductionism
Constructivism/holism
Macrorelationship; microstructures
Quantitative research methods
Qualitative research methods

Methodologic pluralism
Sources: Meleis (2012); Moody (1990).
Nursing Philosophy, Nursing Science, and Philosophy of
Science in Nursing
The terms nursing philosophy, nursing science, and philosophy
of science in nursing are sometimes used interchangeably. The
differences, however, in the general meaning of these concepts
are important to recognize.
Nursing Philosophy
Nursing philosophy has been described as “a statement of
foundational and universal assumptions, beliefs and principles
about the nature of knowledge and thought (epistemology) and
about the nature of the entities represented in the metaparadigm
(i.e., nursing practice and human health processes [ontology])”
(Reed, 1995, p. 76). Nursing philosophy, then, refers to the
belief system or worldview of the profession and provides
perspectives for practice, scholarship, and research (Gortner,
1990).
No single dominant philosophy has prevailed in the discipline
of nursing. Many nursing scholars and nursing theorists have
written extensively in an attempt to identify the overriding
belief system, but to date, none has been universally successful.
Most would agree then that nursing is increasingly recognized
as a “multiparadigm discipline” (Powers & Knapp, 2011, p.
129), in which using multiple perspectives or worldviews in a
“unified” way is valuable and even necessary for knowledge
development (Giuliano, Tyer-Viola, & Lopez, 2005).
Nursing Science
Barrett (2002) defined nursing science as “the substantive,
discipline-specific knowledge that focuses on the human-
universe-health process articulated in the nursing frameworks
and theories” (p. 57). To develop and apply the discipline-
specific knowledge, nursing science recognizes the relationships
of human responses in health and illness and addresses biologic,
behavioral, social, and cultural domains. The goal of nursing
science is to represent the nature of nursing—to understand it,

to explain it, and to use it for the benefit of humankind. It is
nursing science that gives direction to the future generation of
substantive nursing knowledge, and it is nursing science that
provides the knowledge for all aspects of nursing (Barrett,
2002; Holzemer, 2007).
Philosophy of Science in Nursing
Philosophy of science in nursing helps to establish the meaning
of science through an understanding and examination of nursing
concepts, theories, laws, and aims as they relate to nursing
practice. It seeks to understand truth; to describe nursing; to
examine prediction and causality; to critically relate theories,
models, and scientific systems; and to explore determinism and
free will (Nyatanga, 2005; Polifroni & Welch, 1999).
Knowledge Development and Nursing Science
Development of nursing knowledge reflects the interface
between nursing science and research. The ultimate purpose of
knowledge development is to improve nursing practice.
Approaches to knowledge development have three facets:
ontology, epistemology, and methodology. Ontology refers to
the study of being: what is or what exists. Epistemology refers
to the study of knowledge or ways of knowing. Methodology is
the means of acquiring knowledge (Powers & Knapp, 2011).
The following sections discuss nursing epistemology and issues
related to methods of acquiring knowledge.
Epistemology
Epistemology is the study of the theory of knowledge.
Epistemologic questions include: What do we know? What is
the extent of our knowledge? How do we decide whether we
know? and What are the criteria of knowledge? (Schultz &
Meleis, 1988).
According to Streubert and Carpenter (2011), it is important to
understand the way in which nursing knowledge develops to
provide a context in which to judge the appropriateness of
nursing knowledge and methods that nurses use to develop that
knowledge. This in turn will refocus methods for gaining
knowledge as well as establishing the legitimacy or quality of

the knowledge gained.
Ways of Knowing
In epistemology, there are several basic types of knowledge.
These include the following:
· Empirics—the scientific form of knowing. Empirical
knowledge comes from observation, testing, and replication.
· Personal knowledge—a priori knowledge. Personal knowledge
pertains to knowledge gained from thought alone.
· Intuitive knowledge—includes feelings and hunches. Intuitive
knowledge is not guessing but relies on nonconscious pattern
recognition and experience.
· Somatic knowledge—knowledge of the body in relation to
physical movement. Somatic knowledge includes experiential
use of muscles and balance to perform a physical task.
· Metaphysical (spiritual) knowledge—seeking the presence of
a higher power. Aspects of spiritual knowing include magic,
miracles, psychokinesis, extrasensory perception, and near-
death experiences.
· Esthetics—knowledge related to beauty, harmony, and
expression. Esthetic knowledge incorporates art, creativity, and
values.
· Moral or ethical knowledge—knowledge of what is right and
wrong. Values and social and cultural norms of behavior are
components of ethical knowledge.
Nursing Epistemology
Nursing epistemology has been defined as “the study of the
origins of nursing knowledge, its structure and methods, the
patterns of knowing of its members, and the criteria for
validating its knowledge claims” (Schultz & Meleis, 1988, p.
21). Like most disciplines, nursing has both scientific
knowledge and knowledge that can be termed conventional
wisdom (knowledge that has not been empirically tested).
Traditionally, only what stands the test of repeated measures
constitutes truth or knowledge. Classical scientific processes
(i.e., experimentation), however, are not suitable for creating
and describing all types of knowledge. Social sciences,

behavioral sciences, and the arts rely on other methods to
establish knowledge. Because it has characteristics of social and
behavioral sciences, as well as biologic sciences, nursing must
rely on multiple ways of knowing.
In a classic work, Carper (1978) identified four fundamental
patterns for nursing knowledge: (1) empirics—the science of
nursing, (2) esthetics—the art of nursing, (3) personal
knowledge in nursing, and (4) ethics—moral knowledge in
nursing.
Empirical knowledge is objective, abstract, generally
quantifiable, exemplary, discursively formulated, and verifiable.
When verified through repeated testing over time, it is
formulated into scientific generalizations, laws, theories, and
principles that explain and predict (Carper, 1978, 1992). It
draws on traditional ideas that can be verified through
observation and proved by hypothesis testing.
Empirical knowledge tends to be the most emphasized way of
knowing in nursing because there is a need to know how
knowledge can be organized into laws and theories for the
purpose of describing, explaining, and predicting phenomena of
concern to nurses. Most theory development and research
efforts are engaged in seeking and generating explanations that
are systematic and controllable by factual evidence (Carper,
1978, 1992).
Esthetic knowledge is expressive, subjective, unique, and
experiential rather than formal or descriptive. Esthetics includes
sensing the meaning of a moment. It is evident through actions,
conduct, attitudes, and interactions of the nurse in response to
another. It is not expressed in language (Carper, 1978).
Esthetic knowledge relies on perception. It is creative and
incorporates empathy and understanding. It is interpretive,
contextual, intuitive, and subjective and requires synthesis
rather than analysis. Furthermore, esthetics goes beyond what is
explained by principles and creates values and meaning to
account for variables that cannot be quantitatively formulated
(Carper, 1978, 1992).

Personal knowledge refers to the way in which nurses view
themselves and the client. Personal knowledge is subjective and
promotes wholeness and integrity in personal encounters.
Engagement, rather than detachment, is a component of personal
knowledge.
Personal knowledge incorporates experience, knowing,
encountering, and actualizing the self within the practice.
Personal maturity and freedom are components of personal
knowledge, which may include spiritual and metaphysical forms
of knowing. Because personal knowledge is difficult to express
linguistically, it is largely expressed in personality (Carper,
1978, 1992).
Ethics refers to the moral code for nursing and is based on
obligation to service and respect for human life. Ethical
knowledge occurs as moral dilemmas arise in situations of
ambiguity and uncertainty and when consequences are difficult
to predict. Ethical knowledge requires rational and deliberate
examination and evaluation of what is good, valuable, and
desirable as goals, motives, or characteristics (Carper, 1978,
1992). Ethics must address conflicting norms, interests, and
principles and provide insight into areas that cannot be tested.
Fawcett, Watson, Neuman, Walkers, and Fitzpatrick (2001)
stress that integration of all patterns of knowing is essential for
professional nursing practice and that no one pattern should be
used in isolation from others. Indeed, they are interrelated and
interdependent because there are multiple points of contact
between and among them (Carper, 1992). Thus, nurses should
view nursing practice from a broadened perspective that places
value on ways of knowing beyond the empirical (Silva, Sorrell,
& Sorrell, 1995). Table 1-4 summarizes selected characteristics
of Carper’s patterns of knowing in nursing.
Table 1-4: Characteristics of Carper’s Patterns of Knowing in
Nursing
Pattern of Knowing
Relationship to Nursing
Source or Creation

Source of Validation
Method of Expression
Purpose or Outcome
Empirics
Science of nursing
Direct or indirect observation and measurement
Replication
Facts, models, scientific principles, laws statements, theories,
descriptions
Description, explanation, prediction
Esthetics
Art of nursing
Creation of value and meaning, synthesis of abstract and
concrete
Appreciation; experience; inspiration; perception of balance,
rhythm, proportion, and unity
Appreciation; empathy; esthetic criticism; engaging, intuiting,
and envisioning
Move beyond what can be explained, quantitatively formulated,
understanding, balance
Personal knowledge
Therapeutic use of self
Engagement, opening, centering, actualizing self
Response, reflection, experience
Empathy, active participation
Therapeutic use of self
Ethics
Moral component of nursing
Values clarification, rational and deliberate reasoning,
obligation, advocating
Dialogue, justification, universal generalizability
Principles, codes, ethical theories
Evaluation of what is good, valuable, and desirable
Sources: Carper (1978); Carper (1992); Chinn & Kramer (2011).
Other Views of Patterns of Knowledge in Nursing

Although Carper’s work is considered classic, it is not without
critics. Schultz and Meleis (1988) observed that Carper’s work
did not incorporate practical knowledge into the ways of
knowing in nursing. Because of this and other concerns, they
described three patterns of knowledge in nursing: clinical,
conceptual, and empirical.
Clinical knowledge refers to the individual nurse’s personal
knowledge. It results from using multiple ways of knowing
while solving problems during client care provision. Clinical
knowledge is manifested in the acts of practicing nurses and
results from combining personal knowledge and empirical
knowledge. It may also involve intuitive and subjective
knowing. Clinical knowledge is communicated retrospectively
through publication in journals (Schultz & Meleis, 1988).
Conceptual knowledge is abstracted and generalized beyond
personal experience. It explicates patterns revealed in multiple
client experiences, which occur in multiple situations, and
articulates them as models or theories. In conceptual
knowledge, concepts are drafted and relational statements are
formulated. Propositional statements are supported by empirical
or anecdotal evidence or defended by logical reasoning.
Conceptual knowledge uses knowledge from nursing and other
disciplines. It incorporates curiosity, imagination, persistence,
and commitment in the accumulation of facts and reliable
generalizations that pertain to the discipline of nursing.
Conceptual knowledge is communicated in propositional
statements (Schultz & Meleis, 1988).
Empirical knowledge results from experimental, historical, or
phenomenologic research and is used to justify actions and
procedures in practice. The credibility of empirical knowledge
rests on the degree to which the researcher has followed
procedures accepted by the community of researchers and on the
logical, unbiased derivation of conclusions from the evidence.
Empirical knowledge is evaluated through systematic review
and critique of published research and conference presentations
(Schultz & Meleis, 1988).

Chinn and Kramer (2011) also expanded on Carper’s patterns of
knowing to include “emancipatory knowing”—what they
designate as the “praxis of nursing.” In their view,
emancipatory knowing refers to human’s ability to critically
examine the current status quo and to determine why it
currently exists. This, in turn, supports identification of
inequities in social and political institutions and clarification of
cultural values and beliefs to improve conditions for all. In this
view, emancipatory knowledge is expressed in actions that are
directed toward changing existing social structures and
establishing practices that are more equitable and favorable to
human health and well-being.
Summary of Ways of Knowing in Nursing
For decades, the importance of the multiple ways of knowing
has been recognized in the discipline of nursing. If nursing is to
achieve a true integration between theory, research, and
practice, theory development and research must integrate
different sources of knowledge. Kidd and Morrison (1988) state
that in nursing, synthesis of theories derived from different
sources of knowledge will
· 1. Encourage the use of different types of knowledge in
practice, education, theory development, and research
· 2. Encourage the use of different methodologies in practice
and research
· 3. Make nursing education more relevant for nurses with
different educational backgrounds
· 4. Accommodate nurses at different levels of clinical
competence
· 5. Ultimately promote high-quality client care and client
satisfaction
Research Methodology and Nursing Science
Being heavily influenced by logical empiricism, as nursing
began developing as a scientific discipline in the mid-1900s,
quantitative methods were used almost exclusively in research.
In the 1960s and 1970s, schools of nursing aligned nursing
inquiry with scientific inquiry in a desire to bring respect to the

academic environment, and nurse researchers and nurse
educators valued quantitative research methods over other
forms.
A debate over methodology began in the 1980s, however, when
some nurse scholars asserted that nursing’s ontology (what
nursing is) was not being adequately and sufficiently explored
using quantitative methods in isolation. Subsequently,
qualitative research methods began to be put into use. The
assumptions were that qualitative methods showed the
phenomena of nursing in ways that were naturalistic and
unstructured and not misrepresented (Holzemer, 2007; Rutty,
1998).
The manner in which nursing science is conceptualized
determines the priorities for nursing research and provides
measures for determining the relevance of various scientific
research questions. Therefore, the way in which nursing science
is conceptualized also has implications for nursing practice. The
philosophical issues regarding methods of research relate back
to the debate over the worldviews of received versus perceived
views of science versus postmodernism and whether nursing is a
practice or applied science, a human science, or some
combination. The notion of evidence-based practice has
emerged over the last few years, largely in response to these
and related concerns. Evidence-based practice as it relates to
the theoretical basis of nursing will be examined in Chapter 13.
Nursing as a Practice Science
In early years, the debate focused on whether nursing was a
basic science or an applied science. The goal of basic science is
the attainment of knowledge. In basic research, the investigator
is interested in understanding the problem and produces
knowledge for knowledge’s sake. It is analytical and the
ultimate function is to analyze a conclusion backward to its
proper principles.
Conversely, an applied science is one that uses the knowledge
of basic sciences for some practical end. Engineering,
architecture, and pharmacology are examples. In applied

research, the investigator works toward solving problems and
producing solutions for the problem. In practice sciences,
research is largely clinical and action oriented (Moody, 1990).
Thus, as an applied or practical science, nursing requires
research that is applied and clinical and that generates and tests
theories related to health of human beings within their
environments as well as the actions and processes used by
nurses in practice.
Nursing as a Human Science
The term human science is traced to philosopher Wilhelm
Dilthey (1833–1911). Dilthey proposed that the human sciences
require concepts, methods, and theories that are fundamentally
different from those of the natural sciences. Human sciences
study human life by valuing the lived experience of persons and
seek to understand life in its matrix of patterns of meaning and
values. Some scholars believe that there is a need to approach
human sciences differently from conventional empiricism and
contend that human experience must be understood in context
(Cody & Mitchell, 2002; Mitchell & Cody, 1992).
In human sciences, scientists hope to create new knowledge to
provide understanding and interpretation of phenomena. In
human sciences, knowledge takes the form of descriptive
theories regarding the structures, processes, relationships, and
traditions that underlie psychological, social, and cultural
aspects of reality. Data are interpreted within context to derive
meaning and understanding. Humanistic scientists value the
subjective component of knowledge. They recognize that
humans are not capable of total objectivity and embrace the idea
of subjectivity (Streubert & Carpenter, 2011). The purpose of
research in human science is to produce descriptions and
interpretations to help understand the nature of human
experience.
Nursing is sometimes referred to as a human science (Cody &
Mitchell, 2002; Mitchell & Cody, 1992). Indeed, the discipline
has examined issues related to behavior and culture, as well as
biology and physiology, and sought to recognize associations

among factors that suggest explanatory variables for human
health and illness. Thus, it fits the pattern of other humanistic
sciences (i.e., anthropology, sociology).
Quantitative Versus Qualitative Methodology Debate
Nursing scholars accept the premise that scientific knowledge is
generated from systematic study. The research methodologies
and criteria used to justify the acceptance of statements or
conclusions as true within the discipline result in conclusions
and statements that are appropriate, valid, and reliable for the
purpose of the discipline.
The two dominant forms of scientific inquiry have been
identified in nursing: (1) empiricism, which objectifies and
attempts to quantify experience and may test propositions or
hypotheses in controlled experimentation; and (2)
phenomenology and other forms of qualitative research (i.e.,
grounded theory, hermeneutics, historical research,
ethnography), which study lived experiences and meanings of
events (Gortner & Schultz, 1988; Monti & Tingen, 1999;
Risjord, 2010). Reviews of the scientific status of nursing
knowledge usually contrast the positivist–deductive–
quantitative approach with the interpretive–inductive–
qualitative alternative.
Although nursing theorists and nursing scientists emphasize the
importance of sociohistorical contexts and person–environment
interactions, they tend to focus on “hard science” and the
research process. It has been argued that there is an
overvaluation of the empirical/quantitative view because it is
seen as “true science” (Tinkle & Beaton, 1983). Indeed, the
experimental method is held in the highest regard. A viewpoint
has persisted into the 21st century in which scholars assume
that descriptive or qualitative research should be performed
only where there is little information available or when the
science is young. Correlational research may follow, and then
experimental methods can be used when the two lower (“less
rigid” or “less scientific”) levels have been explored.
Quantitative Methods

Traditionally, within the “received” or positivistic worldview,
science has been uniquely quantitative. The quantitative
approach has been justified by its success in measuring,
analyzing, replicating, and applying the knowledge gained
(Streubert & Carpenter, 2011). According to Wolfer (1993),
science should incorporate methodologic principles of objective
observation/description, accurate measurement, quantification
of variables, mathematical and statistical analysis, experimental
methods, and verification through replication whenever
possible.
Kidd and Morrison (1988) state that in their haste to prove the
credibility of nursing as a profession, nursing scholars have
emphasized reductionism and empirical validation through
quantitative methodologies, emphasizing hypothesis testing. In
this framework, the scientist develops a hypothesis about a
phenomenon and seeks to prove or disprove it.
Qualitative Methods
The tradition of using qualitative methods to study human
phenomena is grounded in the social sciences. Phenomenology
and other methods of qualitative research arose because aspects
of human values, culture, and relationships were unable to be
described fully using quantitative research methods. It is
generally accepted that qualitative research findings answer
questions centered on social experience and give meaning to
human life. Beginning in the 1970s, nursing scientists were
challenged to explain phenomena that defy quantitative
measurement, and qualitative approaches, which emphasize the
importance of the client’s perspective, began to be used in
nursing research (Kidd & Morrison, 1988).
Repeatedly, scholars state that nursing research should
incorporate means for determining interpretation of the
phenomena of concern from the perspective of the client or care
recipient. Contrary to the assertions of early scientists, many
later nurse scientists believe that qualitative inquiry contains
features of good science including theory and observation,
logic, precision, clarity, and reproducibility (Monti & Tingen,

1999).
Methodologic Pluralism
In many respects, nursing is still undecided about which
methodologic approach (qualitative or quantitative) best
demonstrates the essence and uniqueness of nursing because
both methods have strengths and limitations. Munhall (2007),
Risjord (2010), and Sandelowski (2000), among others, believe
that the two approaches may be considered complementary and
appropriate for nursing as a research-based discipline. Indeed, it
is repeatedly argued that both approaches are equally important
and even essential for nursing science development (Foss &
Ellefsen, 2002; Risjord et al., 2002; Thurmond, 2001; Young,
Taylor, & Renpenning, 2001).
Although basic philosophical viewpoints have guided and
directed research strategies in the past, recently, scholars have
called for theoretical and methodologic pluralism in nursing
philosophy and nursing science as presented in the discussion
on postmodernism. Pluralism of research designs is essential for
reflecting the uniqueness of nursing, and multiple approaches to
theory development and testing should be encouraged. Because
there is no one best method of developing knowledge, it is
important to recognize that valuing one standard as exclusive or
superior restricts the ability to progress.
Summary
Nursing is an evolving profession, an academic discipline, and a
science. As nursing progresses and grows as a profession, some
controversy remains on whether to emphasize a humanistic,
holistic focus or an objective, scientifically derived means of
comprehending reality. What is needed, and is increasingly
more evident as nursing matures as a profession, is an open
philosophy that ties empirical concepts that are capable of being
validated through the senses with theoretical concepts of
meaning and value.
It is important that future nursing leaders and novice nurse
scientists possess an understanding of nursing’s philosophical
foundations. The legacy of philosophical positivism continues

to drive beliefs in the scientific method and research strategies,
but it is time to move forward to face the challenges of the
increasingly complex and volatile health care environment.
Key Points
· Nursing can be considered an aspiring or evolving profession.
· Nursing is a professional discipline that draws much of its
knowledge base from other disciplines, including psychology,
sociology, physiology, and medicine.
· Nursing is an applied or practice science that has been
influenced by several philosophical schools of thought or
worldviews, including the received view (empiricism,
positivism, logical positivism), the perceived view (humanism,
phenomenology, constructivism), and postmodernism.
· Nursing philosophy refers to the worldview(s) of the
profession and provides perspective for practice, scholarship,
and research. Nursing science is the discipline-specific
knowledge that focuses on the human-environment-health
process and is articulated in nursing theories and generated
through nursing research. Philosophy of science in
nursing establishes the meaning of science through examination
of nursing concepts, theories, and laws as they relate to nursing
practice.
· Nursing epistemology (ways of knowing in nursing) has
focused on four predominant or “fundamental” ways of
knowledge: empirical knowledge, esthetic knowledge, personal
knowledge, and ethical knowledge.
· As nursing science has developed, there has been a debate
over what research methods to use (i.e., quantitative methods
vs. qualitative methods). Increasingly, there has been a call for
“methodologic pluralism” to better ensure that research findings
are applicable in nursing practice.
Case Study
The following is adapted from a paper written by a graduate
student describing an encounter in nursing practice that
highlights Carper’s (1978) ways of knowing in nursing.
In her work, Carper (1978) identified four patterns of knowing

in nursing: empirical knowledge (science of nursing), esthetic
knowledge (art of nursing), personal knowledge, and ethical
knowledge. Each is essential and depends on the others to make
the whole of nursing practice, and it is impossible to state
which of the patterns of knowing is most important. If nurses
focus exclusively on empirical knowledge, for example, nursing
care would become more like medical care. But without an
empirical base, the art of nursing is just tradition. Personal
knowledge is gained from experience and requires a scientific
basis, understanding, and empathy. Finally, the moral
component is necessary to determine what is valuable, ethical,
and compulsory. Each of these ways of knowing is illustrated in
the following scenario.
Mrs. Smith was a 24-year-old primigravida who presented to
our unit in early labor. Her husband, and father of her unborn
child, had abandoned her 2 months prior to delivery, and she
lacked close family support.
I cared for Mrs. Smith throughout her labor and assisted during
her delivery. During this process, I taught breathing techniques
to ease pain and improve coping. Position changes were
encouraged periodically, and assistance was provided as
needed. Mrs. Smith’s care included continuous fetal monitoring,
intravenous hydration, analgesic administration, back rubs,
coaching and encouragement, assistance while getting an
epidural, straight catheterization as needed, vital sign
monitoring per policy, oxytocin administration after delivery,
newborn care, and breastfeeding assistance, among many others.
All care was explained in detail prior to rendering.
Empirical knowledge was clearly utilized in Mrs. Smith’s care.
Examples would be those practices based on the Association of
Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
evidence-based standards. These include guidelines for fetal
heart rate monitoring and interpretation, assessment and
management of Mrs. Smith while receiving her epidural
analgesia, the assessment and management of side effects
secondary to her regional analgesia, and even frequency for

monitoring vital signs. Other examples would be assisting Mrs.
Smith to an upright position during her second stage of labor to
facilitate delivery and delaying nondirected pushing once she
was completely dilated.
Esthetic knowledge, or the art of nursing, is displayed in
obstetrical nursing daily. Rather than just responding to
biologic developments or spoken requests, the whole person was
valued and cues were perceived and responded to for the good
of the patient. The care I gave Mrs. Smith was holistic; her
social, spiritual, psychological, and physical needs were all
addressed in a comprehensive and seamless fashion. The
empathy conveyed to the patient took into account her unique
self and situation, and the care provided was reflexively tailored
to her needs. I recognized the profound experience of which I
was a part and adapted my actions and attitude to honor the
patient and value the larger experience.
Many aspects of personal knowledge seem intertwined with
esthetics, though more emphasis seems to be on the meaningful
interaction between the patient and nurse. As above, the patient
was cared for as a unique individual. Though secondary to the
awesome nature of birth, much of the experience revolved
around the powerful interpersonal relationship established. Mrs.
Smith was accepted as herself. Though efforts were made by me
to manage certain aspects of the experience, Mrs. Smith was
allowed control and freedom of expression and reaction. She
and I were both committed to the mutual though brief
relationship. This knowledge stems from my own personality
and ability to accept others, willingness to connect to others,
and desire to collaborate with the patient regarding her care and
ultimate experience.
The ethical knowledge of nursing is continuously utilized in
nursing care to promote the health and well-being of the patient;
and in this circumstance, the unborn child as well. Every
decision made must be weighed against desired goals and
values, and nurses must strive to act as advocates for each
patient. When caring for a patient and an unborn child, there is

a constant attempt to do no harm to either, while balancing the
care of both. A very common example is the administration of
medications for the mother’s comfort that can cause sedation
and respiratory depression in the neonate. This case involved
fewer ethical considerations than many others in obstetrics.
These include instances in which physicians do not respond
when the nurse feels there is imminent danger and the chain of
command must be utilized, or when assistance is required for
the care of abortion patients or in other situations that may be in
conflict with the nurses moral or religious convictions.
A close bond was formed while I cared for Mrs. Smith and her
baby. Soon after admission, she was holding my hand during
contractions and had shared very intimate details of her life,
separation, and fears. Though she had shared her financial
concerns and had a new baby to provide for, a few weeks after
her delivery I received a beautiful gift basket and card. In her
note she shared that I had touched her in a way she had never
expected and she vowed never to forget me; I’ve not forgotten
her either.
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1: Introduction to Nursing Research in an Evidence-Based
Practice Environment
· For additional ancillary materials related to this chapter,
please visit thePoint.
NURSING RESEARCH IN PERSPECTIVE
In all parts of the world, nursing has experienced a profound
culture change. Nurses are increasingly expected to understand

and conduct research and to base their professional practice on
research evidence—that is, to adopt an evidence-based practice
(EBP). EBP involves using the best evidence (as well as clinical
judgment and patient preferences) in making patient care
decisions, and “best evidence” typically comes from research
conducted by nurses and other health care professionals.
What Is Nursing Research?
Research is systematic inquiry that uses disciplined methods to
answer questions or solve problems. The ultimate goal of
research is to develop and expand knowledge.
Nurses are increasingly engaged in disciplined studies that
benefit nursing and its clients. Nursing research is systematic
inquiry designed to generate trustworthy evidence about issues
of importance to the nursing profession, including nursing
practice, education, administration, and informatics. In this
book, we emphasize clinical nursing research, that is, research
to guide nursing practice and to improve the health and quality
of life of nurses’ clients.
Nursing research has experienced remarkable growth in the past
three decades, providing nurses with a growing evidence base
from which to practice. Yet many questions endure and much
remains to be done to incorporate research innovations into
nursing practice.
Examples of Nursing Research Questions:
· How effective is pressurized irrigation, compared to a
swabbing method, in cleansing wounds, in terms of time to
wound healing, pain, patients’ satisfaction with comfort, and
costs? (Mak et al., 2015)
· What are the experiences of women in Zimbabwe who are
living with advanced HIV infection? (Gona & DeMarco, 2015)
The Importance of Research in Nursing
Research findings from rigorous studies provide especially
strong evidence for informing nurses’ decisions and actions.
Nurses are accepting the need to base specific nursing actions
on research evidence indicating that the actions are clinically
appropriate, cost-effective, and result in positive outcomes for

clients.
In the United States, research plays an important role in nursing
in terms of credentialing and status. The American Nurses
Credentialing Center (ANCC)—an arm of the American Nurses
Association and the largest and most prestigious credentialing
organization in the United States—developed a Magnet
Recognition Program to acknowledge health care organizations
that provide high-quality nursing care. As Reigle and her
colleagues (2008) noted, “the road to Magnet Recognition is
paved with EBP” (p. 102) and the 2014 Magnet application
manual incorporated revisions that strengthened evidence-based
requirements (Drenkard, 2013). The good news is that there is
growing confirmation that the focus on research and evidence-
based practice may have important payoffs. For example,
McHugh and co-researchers (2013) found that Magnet hospitals
have lower risk-adjusted mortality and failure to rescue than
non-Magnet hospitals, even when differences among the
hospitals in nursing credentials and patient characteristics are
taken into account.
Changes to nursing practice now occur regularly because of
EBP efforts. Practice changes often are local initiatives that are
not publicized, but broader clinical changes are also occurring
based on accumulating research evidence about beneficial
practice innovations.
Example of Evidence-Based Practice: Numerous clinical
practice changes reflect the impact of research. For example,
“kangaroo care” (the holding of diaper-clad infants skin to skin
by parents) is now practiced in many neonatal intensive care
units (NICUs), but this is a relatively new trend. As recently as
the 1990s, only a minority of NICUs offered kangaroo care
options. Expanded adoption of this practice reflects mounting
evidence that early skin-to-skin contact has benefits without
negative side effects (e.g., Ludington-Hoe, 2011; Moore et al.,
2012). Some of that evidence came from rigorous studies
conducted by nurse researchers in several countries (e.g., Chwo
et al., 2002; Cong et al., 2009; Cong et al., 2011; Hake-Brooks

& Anderson, 2008). Nurses continue to study the potential
benefits of kangaroo care in important clinical trials (e.g.,
Campbell-Yeo et al., 2013).
The Consumer–Producer Continuum in Nursing Research
In our current environment, all nurses are likely to engage in
activities along a continuum of research participation. At one
end of the continuum are consumers of nursing research, who
read research reports or research summaries to keep up-to-date
on findings that might affect their practice. EBP depends on
well-informed nursing research consumers.
At the other end of the continuum are the producers of nursing
research: nurses who design and conduct research. At one time,
most nurse researchers were academics who taught in schools of
nursing, but research is increasingly being conducted by nurses
in health care settings who want to find solutions to recurring
problems in patient care.
Between these end points on the continuum lie a variety of
research activities that are undertaken by nurses. Even if you
never personally undertake a study, you may (1) contribute to
an idea or a plan for a clinical study; (2) gather data for a study;
(3) advise clients about participating in research; (4) solve a
clinical problem by searching for research evidence; or (5)
discuss the implications of a new study in a journal club in your
practice setting, which involves meetings (in groups or online)
to discuss research articles. In all possible research-related
activities, nurses who have some research skills are better able
than those without them to make a contribution to nursing and
to EBP. An understanding of nursing research can improve the
depth and breadth of every nurse’s professional practice.
Nursing Research in Historical Perspective
Table 1.1 summarizes some of the key events in the historical
evolution of nursing research. (An expanded summary of the
history of nursing research appears in the Supplement to this
chapter on ).
TABLE 1.1: Historical Landmarks in Nursing Research
YEAR

EVENT
1859
Nightingale’s Notes on Nursing is published.
1900
American Journal of Nursing begins publication.
1923
Columbia University establishes first doctoral program for
nurses.
Goldmark Report with recommendations for nursing education
is published.
1936
Sigma Theta Tau awards first nursing research grant in the
United States.
1948
Brown publishes report on inadequacies of nursing education.
1952
The journal Nursing Research begins publication.
1955
Inception of the American Nurses Foundation to sponsor
nursing research.
1957
Establishment of nursing research center at Walter Reed Army
Institute of Research.
1963
International Journal of Nursing Studies begins publication.
1965
American Nurses Association (ANA) sponsors nursing research
conferences.
1969
Canadian Journal of Nursing Research begins publication.
1972
ANA establishes a Commission on Research and Council of
Nurse Researchers.
1976
Stetler and Marram publish guidelines on assessing research for

use in practice.
Journal of Advanced Nursing begins publication.
1982
Conduct and Utilization of Research in Nursing (CURN) project
publishes report.
1983
Annual Review of Nursing Research begins publication.
1985
ANA Cabinet on Nursing Research establishes research
priorities.
1986
National Center for Nursing Research (NCNR) is established
within U.S. National Institutes of Health.
1988
Conference on Research Priorities is convened by NCNR.
1989
U.S. Agency for Health Care Policy and Research (AHCPR) is
established.
1993
NCNR becomes a full institute, the National Institute of
Nursing Research (NINR).
The Cochrane Collaboration is established.
Magnet Recognition Program makes first awards.
1995
Joanna Briggs Institute, an international EBP collaborative, is
established in Australia.
1997
Canadian Health Services Research Foundation is established
with federal funding.
1999
AHCPR is renamed Agency for Healthcare Research and
Quality (AHRQ).
2000

NINR’s annual funding exceeds $100 million.
The Canadian Institute of Health Research is launched.
Council for the Advancement of Nursing Science (CANS) is
established.
2006
NINR issues strategic plan for 2006–2010.
2011
NINR celebrates 25th anniversary and issues a new strategic
plan.
2014
NINR budget exceeds $140 million.
Most people would agree that research in nursing began with
Florence Nightingale in the 1850s. Her most well-known
research contribution involved an analysis of factors affecting
soldier mortality and morbidity during the Crimean War. Based
on skillful analyses, she was successful in effecting changes in
nursing care and, more generally, in public health. After
Nightingale’s work, research was absent from the nursing
literature until the early 1900s, but most early studies concerned
nurses’ education rather than clinical issues.
In the 1950s, research by nurses began to accelerate. For
example, a nursing research center was established at the Walter
Reed Army Institute of Research. Also, the American Nurses
Foundation, which is devoted to the promotion of nursing
research, was founded. The surge in the number of studies
conducted in the 1950s created the need for a new
journal; Nursing Research came into being in 1952. As shown
in Table 1.1, dissemination opportunities in professional
journals grew steadily thereafter.
In the 1960s, nursing leaders expressed concern about the
shortage of research on practice issues. Professional nursing
organizations, such as the Western Interstate Council for Higher
Education in Nursing, established research priorities, and
practice-oriented research on various clinical topics began to

emerge in the literature.
During the 1970s, improvements in client care became a more
visible research priority and nurses also began to pay attention
to the clinical utilization of research findings. Guidance on
assessing research for application in practice settings became
available. Several journals that focus on nursing research were
established in the 1970s, including Advances
in Nursing Science, Research in Nursing & Health, and
the Western Journal of Nursing Research. Nursing research also
expanded internationally. For example, the Workgroup of
European Nurse Researchers was established in 1978 to develop
greater communication and opportunities for partnerships
among 25 European National Nurses Associations.
Nursing research continued to expand in the 1980s. In the
United States, the National Center for Nursing Research
(NCNR) at the National Institutes of Health (NIH) was
established in 1986. Several forces outside of nursing also
helped to shape the nursing research landscape. A group from
the McMaster Medical School in Canada designed a clinical
learning strategy that was called evidence-based medicine
(EBM). EBM, which promulgated the view that research
findings were far superior to the opinions of authorities as a
basis for clinical decisions, constituted a profound shift for
medical education and practice, and has had a major effect on
all health care professions.
Nursing research was strengthened and given more visibility
when NCNR was promoted to full institute status within the
NIH. In 1993, the National Institute of Nursing
Research (NINR) was established, helping to put nursing
research more into the mainstream of health research. Funding
opportunities for nursing research expanded in other countries
as well.
Current and Future Directions for Nursing Research
Nursing research continues to develop at a rapid pace and will
undoubtedly flourish in the 21st century. Funding continues to
grow. For example, NINR funding in fiscal year 2014 was more

than $140 million compared to $70 million in 1999—and the
competition for available funding is increasingly vigorous as
more nurses seek support for testing innovative ideas for
practice improvements.
Broadly speaking, the priority for future nursing research will
be the promotion of excellence in nursing science. Toward this
end, nurse researchers and practicing nurses will be sharpening
their research skills and using those skills to address emerging
issues of importance to the profession and its clientele. Among
the trends we foresee for the early 21st century are the
following:
· Continued focus on EBP. Encouragement for nurses to engage
in evidence-based patient care is sure to continue. In turn,
improvements will be needed both in the quality of studies and
in nurses’ skills in locating, understanding, critiquing, and
using relevant study results. Relatedly, there is an emerging
interest in translational research—research on how findings
from studies can best be translated into practice. Translation
potential will require researchers to think more strategically
about long-term feasibility, scalability, and sustainability when
they test solutions to problems.
· Development of a stronger evidence base through
confirmatory strategies. Practicing nurses are unlikely to adopt
an innovation based on weakly designed or isolated studies.
Strong research designs are essential, and confirmation is
usually needed through the replication (i.e., the repeating) of
studies with different clients, in different clinical settings, and
at different times to ensure that the findings are robust.
· Greater emphasis on systematic reviews. Systematic
reviews are a cornerstone of EBP and will take on increased
importance in all health disciplines. Systematic reviews
rigorously integrate research information on a topic so that
conclusions about the state of evidence can be reached. Best
practice clinical guidelines typically rely on such systematic
reviews.
· Innovation. There is currently a major push for creative and

innovative solutions to recurring practice problems.
“Innovation” has become an important buzzword throughout
NIH and in nursing associations. For example, the 2013 annual
conference of the Council for the Advancement of Nursing
Science was “Innovative Approaches to Symptom Science.”
Innovative interventions—and new methods for studying
nursing questions—are sure to be part of the future research
landscape in nursing.
· Expanded local research in health care settings. Small studies
designed to solve local problems will likely increase. This trend
will be reinforced as more hospitals apply for (and
are recertified for) Magnet status in the United States and in
other countries. Mechanisms will need to be developed to
ensure that evidence from these small projects becomes
available to others facing similar problems, such as
communication within and between regional nursing research
alliances.
· Strengthening of interdisciplinary collaboration.
Collaboration of nurses with researchers in related fields is
likely to expand in the 21st century as researchers address
fundamental health care problems. In turn, such collaborative
efforts could lead to nurse researchers playing a more prominent
role in national and international health care policies. One of
four major recommendations in a 2010 report on the future of
nursing by the Institute of Medicine was that nurses should be
full partners with physicians and other health care professionals
in redesigning health care.
· Expanded dissemination of research findings. The Internet
and other electronic communication have a big impact on
disseminating research information, which in turn helps to
promote EBP. Through technologic advances, information about
innovations can be communicated more widely and more
quickly than ever before.
· Increased focus on cultural issues and health disparities. The
issue of health disparities has emerged as a central concern in
nursing and other health disciplines; this in turn has raised

consciousness about the cultural sensitivity of health
interventions and the cultural competence of health care
workers. There is growing awareness that research must be
sensitive to the health beliefs, behaviors, and values of
culturally and linguistically diverse populations.
· Clinical significance and patient input. Research findings
increasingly must meet the test of being clinically significant,
and patients have taken center stage in efforts to define clinical
significance. A major challenge in the years ahead will involve
getting both research evidence and patient preferences into
clinical decisions, and designing research to study the process
and the outcomes.
Broad research priorities for the future have been articulated by
many nursing organizations, including NINR and Sigma Theta
Tau International. Expert panels and research working groups
help NINR to identify gaps in current knowledge that require
research. The primary areas of research funded by NINR in
2014 were health promotion/disease prevention, eliminating
health disparities, caregiving, symptom management, and self-
management. Research priorities that have been expressed by
Sigma Theta Tau International include advancing healthy
communities through health promotion; preventing disease and
recognizing social, economic, and political determinants;
implementation of evidence-based practice; targeting the needs
of vulnerable populations such as the poor and chronically ill;
and developing nurses’ capacity for research. Priorities also
have been developed for several nursing specialties and for
nurses in several countries—for example, Ireland (Brenner et
al., 2014; Drennan et al., 2007), Sweden (Bäck-Pettersson et al.,
2008), Australia (Wynaden et al., 2014), and Korea (Kim et al.,
2002).
SOURCES OF EVIDENCE FOR NURSING PRACTICE
Nurses make clinical decisions based on knowledge from many
sources, including coursework, textbooks, and their own clinical
experience. Because evidence is constantly evolving, learning
about best practice nursing perseveres throughout a nurse’s

career.
Some of what nurses learn is based on systematic research, but
much of it is not. What are the sources of evidence for nursing
practice? Where does knowledge for practice come from? Until
fairly recently, knowledge primarily was handed down from one
generation to the next based on experience, trial and error,
tradition, and expert opinion. Information sources for clinical
practice vary in dependability, giving rise to what is called
an evidence hierarchy, which acknowledges that certain types of
evidence are better than others. A brief discussion of some
alternative sources of evidence shows how research-based
information is different.
Tradition and Authority
Decisions are sometimes based on custom or tradition. Certain
“truths” are accepted as given, and such “knowledge” is so
much a part of a common heritage that few seek verification.
Tradition facilitates communication by providing a common
foundation of accepted truth, but many traditions have never
been evaluated for their validity. There is concern that some
nursing interventions are based on tradition, custom, and “unit
culture” rather than on sound evidence. Indeed, a recent
analysis suggests that some “sacred cows” (ineffective
traditional habits) persist even in a health care center
recognized as a leader in evidence-based practice (Hanrahan et
al., 2015).
Another common source of information is an authority, a person
with specialized expertise. We often make decisions about
problems with which we have little experience; it seems natural
to place our trust in the judgment of people with specialized
training or experience. As a source of evidence, however,
authority has shortcomings. Authorities are not infallible,
particularly if their expertise is based primarily on personal
experience; yet, like tradition, their knowledge often goes
unchallenged.
Example of “Myths” in Nursing Textbooks: A study suggests
that even nursing textbooks may contain “myths.” In their

analysis of 23 widely used undergraduate psychiatric nursing
textbooks, Holman and colleagues (2010) found that all books
contained at least one unsupported assumption (myth) about loss
and grief—that is, assumptions not supported by research
evidence. Moreover, many evidence-based findings about grief
and loss failed to be included in the textbooks.
Clinical Experience, Trial and Error, and Intuition
Clinical experience is a familiar, functional source of
knowledge. The ability to generalize, to recognize regularities,
and to make predictions is an important characteristic of the
human mind. Nevertheless, personal experience is limited as a
knowledge source because each nurse’s experience is too
narrow to be generally useful. A second limitation is that the
same objective event is often experienced and perceived
differently by two nurses.
A related method is trial and error in which alternatives are
tried successively until a solution to a problem is found. We
likely have all used this method in our professional work. For
example, many patients dislike the taste of potassium chloride
solution. Nurses try to disguise the taste of the medication in
various ways until one method meets with the approval of the
patient. Trial and error may offer a practical means of securing
knowledge, but the method tends to be haphazard and solutions
may be idiosyncratic.
Intuition is a knowledge source that cannot be explained based
on reasoning or prior instruction. Although intuition and
hunches undoubtedly play a role in nursing—as they do in the
conduct of research—it is difficult to develop nursing policies
and practices based on intuition.
Logical Reasoning
Solution

s to some problems are developed by logical thought processes.
As a problem-solving method, logical reasoning combines
experience, intellectual faculties, and formal systems of
thought. Inductive reasoning involves developing
generalizations from specific observations. For example, a nurse
may observe the anxious behavior of (specific) hospitalized
children and conclude that (in general) children’s separation
from their parents is stressful. Deductive reasoning involves
developing specific predictions from general principles. For
example, if we assume that separation anxiety occurs in
hospitalized children (in general), then we might predict that
(specific) children in a hospital whose parents do not room-in
will manifest symptoms of stress. Both systems of reasoning are
useful for understanding and organizing phenomena, and both
play a role in research. Logical reasoning in and of itself,
however, is limited because the validity of reasoning depends
on the accuracy of the premises with which one starts.
Assembled Information
In making clinical decisions, health care professionals rely on
information that has been assembled for a variety of purposes.
For example, local, national, and international benchmarking
data provide information on such issues as infection rates or the
rates of using various procedures (e.g., cesarean births) and can
facilitate evaluations of clinical practices. Cost data—
information on the costs associated with certain procedures,

policies, or practices—are sometimes used as a factor in clinical
decision making. Quality improvement and risk data, such as
medication error reports, can be used to assess the need for
practice changes. Such sources are useful, but they do not
provide a good mechanism for determining whether
improvements in patient outcomes result from their use.
Disciplined Research
Research conducted in a disciplined framework is the most
sophisticated method of acquiring knowledge. Nursing research
combines logical reasoning with other features to create
evidence that, although fallible, tends to yield the most reliable
evidence. Carefully synthesized findings from rigorous research
are at the pinnacle of most evidence hierarchies. The current
emphasis on EBP requires nurses to base their clinical practice
to the greatest extent possible on rigorous research-based
findings rather than on tradition, authority, intuition, or
personal experience—although nursing will always remain a
rich blend of art and science.
PARADIGMS AND METHODS FOR NURSING RESEARCH
A paradigm is a worldview, a general perspective on the
complexities of the world. Paradigms for human inquiry are
often characterized in terms of the ways in which they respond
to basic philosophical questions, such as, What is the nature of
reality? (ontologic) and What is the relationship between the
inquirer and those being studied? (epistemologic).

Disciplined inquiry in nursing has been conducted mainly
within two broad paradigms, positivism and constructivism.
This section describes these two paradigms and outlines the
research methods associated with them. In later chapters, we
describe the transformative paradigm that involves critical
theory research (Chapter 21), and a pragmatism paradigm that
involves mixed methods research (Chapter 26).
The Positivist Paradigm
The paradigm that dominated nursing research for decades is
known as positivism (also called logical positivism). Positivism
is rooted in 19th century thought, guided by such philosophers
as Mill, Newton, and Locke. Positivism reflects a broader
cultural phenomenon that, in the humanities, is referred to
as modernism, which emphasizes the rational and the scientific.
As shown in Table 1.2, a fundamental assumption of positivists
is that there is a reality out there that can be studied and known
(an assumption is a basic principle that is believed to be true
without proof or verification). Adherents of positivism assume
that nature is basically ordered and regular and that reality
exists independent of human observation. In other words, the
world is assumed not to be merely a creation of the human
mind. The related assumption of determinism refers to the
positivists’ belief that phenomena are not haphazard but rather
have antecedent causes. If a person has a cerebrovascular
accident, the researcher in a positivist tradition assumes that

there must be one or more reasons that can be potentially
identified. Within the positivist paradigm, much research
activity is directed at understanding the underlying causes of
phenomena.
TABLE 1.2: Major Assumptions of the Positivist and
Constructivist Paradigms
TYPE OF QUESTION
POSITIVIST PARADIGM ASSUMPTION
CONSTRUCTIVIST PARADIGM ASSUMPTION
Ontologic: What is the nature of reality?
Reality exists; there is a real world driven by real natural causes
and subsequent effects
Reality is multiple and subjective, mentally constructed by
individuals; simultaneous shaping, not cause and effect
Epistemologic: How is the inquirer related to those being
researched?
The inquirer is independent from those being researched;
findings are not influenced by the researcher
The inquirer interacts with those being researched; findings are
the creation of the interactive process
Axiologic: What is the role of values in the inquiry?
Values and biases are to be held in check; objectivity is sought
Subjectivity and values are inevitable and desirable
Methodologic: How is evidence best obtained?
Deductive processes → hypothesis testing

Inductive processes → hypothesis generation
Emphasis on discrete, specific concepts
Emphasis on entirety of some phenomenon, holistic
Focus on the objective and quantifiable
Focus on the subjective and nonquantifiable
Corroboration of researchers’ predictions
Emerging insight grounded in participants’ experiences
Outsider knowledge—researcher is external, separate
Insider knowledge—researcher is internal, part of process
Fixed, prespecified design
Flexible, emergent design
Controls over context
Context-bound, contextualized
Large, representative samples
Small, information-rich samples
Measured (quantitative) information
Narrative (unstructured) information

Statistical analysis
Qualitative analysis
Seeks generalizations
Seeks in-depth understanding
Positivists value objectivity and attempt to hold personal beliefs
and biases in check to avoid contaminating the phenomena
under study. The positivists’ scientific approach involves using
orderly, disciplined procedures with tight controls of the
research situation to test hunches about the phenomena being
studied.
Strict positivist thinking has been challenged, and few
researchers adhere to the tenets of pure positivism. In
the postpositivist paradigm, there is still a belief in reality and a
desire to understand it, but postpositivists recognize the
impossibility of total objectivity. They do, however, see
objectivity as a goal and strive to be as neutral as possible.
Postpositivists also appreciate the impediments to knowing
reality with certainty and therefore
seek probabilistic evidence—that is, learning what the true state
of a phenomenon probably is, with a high degree of likelihood.
This modified positivist
position remains a dominant force in nursing research. For the
sake of simplicity, we refer to it as positivism.

The Constructivist Paradigm
The constructivist paradigm (often called the naturalistic
paradigm) began as a countermovement to positivism with
writers such as Weber and Kant. Just as positivism reflects the
cultural phenomenon of modernism that burgeoned after the
industrial revolution, naturalism is an outgrowth of the cultural
transformation called postmodernism. Postmodern thinking
emphasizes the value of deconstruction—taking apart old ideas
and structures—and reconstruction—putting ideas and
structures together in new ways. The constructivist paradigm
represents a major alternative system for conducting disciplined
research in nursing. Table 1.2 compares the major assumptions
of the positivist and constructivist paradigms.
For the naturalistic inquirer, reality is not a fixed entity but
rather is a construction of the individuals participating in the
research; reality exists within a context, and many constructions
are possible. Naturalists thus take the position of relativism: If
there are multiple interpretations of reality that exist in people’s
minds, then there is no process by which the ultimate truth or
falsity of the constructions can be determined.
The constructivist paradigm assumes that knowledge is
maximized when the distance between the inquirer and those
under study is minimized. The voices and interpretations of
study participants are crucial to understanding the phenomenon
of interest, and subjective interactions are the primary way to

access them. Findings from a constructivist inquiry are the
product of the interaction between the inquirer and the
participants.
Paradigms and Methods: Quantitative and Qualitative Research
Research methods are the techniques researchers use to
structure a study and to gather and analyze information relevant
to the research question. The two alternative paradigms
correspond to different methods for developing evidence. A key
methodologic distinction is between quantitative research,
which is most closely allied with positivism, and qualitative
research, which is associated with constructivist inquiry—
although positivists sometimes undertake qualitative studies,
and constructivist researchers sometimes collect quantitative
information. This section provides an overview of the methods
associated with the two paradigms.
The Scientific Method and Quantitative Research
The traditional, positivist scientific method refers to a set of
orderly, disciplined procedures used to acquire information.
Quantitative researchers use deductive reasoning to generate
predictions that are tested in the real world. They typically
move in a systematic fashion from the definition of a problem
and the selection of concepts on which to focus to the solution
of the problem. By systematic, we mean that the investigator
progresses logically through a series of steps, according to a
specified plan of action.

Quantitative researchers use various control
strategies. Control involves imposing conditions on the research
situation so that biases are minimized and precision and validity
are maximized. Control mechanisms are discussed at length in
this book.
Quantitative researchers gather empirical evidence—evidence
that is rooted in objective reality and gathered through the
senses. Empirical evidence, then, consists of observations
gathered through sight, hearing, taste, touch, or smell.
Observations of the presence or absence of skin inflammation,
patients’ anxiety level, or infant birth weight are all examples
of empirical observations. The requirement to use empirical
evidence means that findings are grounded in reality rather than
in researchers’ personal beliefs.
Evidence for a study in the positivist paradigm is gathered
according to an established plan, using structured methods to
collect needed information. Usually (but not always) the
information gathered is quantitative—that is, numeric
information that is obtained from a formal measurement and is
analyzed statistically.
A traditional scientific study strives to go beyond the specifics
of a research situation. For example, quantitative researchers
are typically not as interested in understanding why
a particular person has a stroke as in understanding what factors
influence its occurrence in people generally. The degree to

which research findings can be generalized to individuals other
than those who participated in the study is called the
study’s generalizability.
The scientific method has enjoyed considerable stature as a
method of inquiry and has been used productively by nurse
researchers studying a range of nursing problems. This is not to
say, however, that this approach can solve all nursing problems.
One important limitation—common to both quantitative and
qualitative research—is that research cannot be used to answer
moral or ethical questions. Many persistent, intriguing questions
about human beings fall into this area—questions such as
whether euthanasia should be practiced or abortion should be
legal.
The traditional research approach also must contend with
problems of measurement. To study a phenomenon, quantitative
researchers attempt to measure it by attaching numeric values
that express quantity. For example, if the phenomenon of
interest is patient stress, researchers would want to assess if
patients’ stress is high or low, or higher under certain
conditions or for some people. Physiologic phenomena such as
blood pressure and temperature can be measured with great
accuracy and precision, but the same cannot be said of most
psychological phenomena, such as stress or resilience.
Another issue is that nursing research focuses on humans, who
are inherently complex and diverse. Traditional quantitative

methods typically concentrate on a relatively small portion of
the human experience (e.g., weight gain, depression) in a single
study. Complexities tend to be controlled and, if possible,
eliminated, rather than studied directly, and this narrowness of
focus can sometimes obscure insights. Finally, quantitative
research within the positivist paradigm has been accused of an
inflexibility of vision that does not capture the full breadth of
human experience.
Constructivist Methods and Qualitative Research
Researchers in constructivist traditions emphasize the inherent
complexity of humans, their ability to shape and create their
own experiences, and the idea that truth is a composite of
realities. Consequently, constructivist studies are heavily
focused on understanding the human experience as it is lived,
usually through the careful collection and analysis
of qualitative materials that are narrative and subjective.
Researchers who reject the traditional scientific method believe
that it is overly reductionist—that is, it reduces human
experience to the few concepts under investigation, and those
concepts are defined in advance by the researcher rather than
emerging from the experiences of those under study.
Constructivist researchers tend to emphasize the dynamic,
holistic, and individual aspects of human life and attempt to
capture those aspects in their entirety, within the context of
those who are experiencing them.

Flexible, evolving procedures are used to capitalize on findings
that emerge in the course of the study. Constructivist inquiry
usually takes place in the field (i.e., in naturalistic settings),
often over an extended time period. In constructivist research,
the collection of information and its analysis typically progress
concurrently; as researchers sift through information, insights
are gained, new questions emerge, and further evidence is
sought to amplify or confirm the insights. Through an inductive
process, researchers integrate information to develop a theory or
description that helps illuminate the phenomenon under
observation.
Constructivist studies yield rich, in-depth information that can
elucidate varied dimensions of a complicated phenomenon.
Findings from in-depth qualitative research are typically
grounded in the real-life experiences of people with first-hand
knowledge of a phenomenon. Nevertheless, the approach has
several limitations. Human beings are used directly as the
instrument through which information is gathered, and humans
are extremely intelligent and sensitive—but fallible—tools. The
subjectivity that enriches the analytic insights of skillful
researchers can yield trivial and obvious “findings” among less
competent ones.
Another potential limitation involves the subjectivity of
constructivist inquiry, which sometimes raises concerns about
the idiosyncratic nature of the conclusions. Would two

constructivist researchers studying the same phenomenon in
similar settings arrive at similar conclusions? The situation is
further complicated by the fact that most constructivist studies
involve a small group of participants. Thus, the generalizability
of findings from constructivist inquiries is an issue of potential
concern.
Multiple Paradigms and Nursing Research
Paradigms should be viewed as lenses that help to sharpen our
focus on a phenomenon, not as blinders that limit intellectual
curiosity. The emergence of alternative paradigms for studying
nursing problems is, in our view, a healthy and desirable path
that can maximize the breadth of evidence for practice.
Although researchers’ worldview may be paradigmatic,
knowledge itself is not. Nursing knowledge would be thin if
there were not a rich array of methods available within the two
paradigms—methods that are often complementary in their
strengths and limitations. We believe that intellectual pluralism
is advantageous.
We have emphasized differences between the two paradigms
and associated methods so that distinctions would be easy to
understand—although for many of the issues included in Table
1.2, differences are more on a continuum than they are a
dichotomy. Subsequent chapters of this book elaborate further
on differences in terminology, methods, and research products.
It is equally important, however, to note that the two main

paradigms have many features in common, only some of which
are mentioned here:
· Ultimate goals. The ultimate aim of disciplined research,
regardless of the underlying paradigm, is to gain understanding
about phenomena. Both quantitative and qualitative researchers
seek to capture the truth with regard to an aspect of the world in
which they are interested, and both groups can make
meaningful—and mutually beneficial—contributions to
evidence for nursing practice.
· External evidence. Although the word empiricism has come to
be allied with the classic scientific method, researchers in both
traditions gather and analyze evidence empirically, that is,
through their senses. Neither qualitative nor quantitative
researchers are armchair analysts, depending on their own
beliefs and worldviews to generate knowledge.
· Reliance on human cooperation. Because evidence for nursing
research comes primarily from humans, human cooperation is
essential. To understand people’s characteristics and
experiences, researchers must persuade them to participate in
the investigation and to speak and act candidly.
· Ethical constraints. Research with human beings is guided by
ethical principles that sometimes interfere with research goals.
As we discuss in Chapter 7, ethical dilemmas often confront
researchers, regardless of paradigms or methods.
· Fallibility of disciplined research. Virtually all studies have

some limitations. Every research question can be addressed in
many ways, and inevitably, there are trade-offs. The fallibility
of any single study makes it important to understand and
critique researchers’ methodologic decisions when evaluating
evidence quality.
Thus, despite philosophic and methodologic differences,
researchers using traditional scientific methods or constructivist
methods share overall goals and face many similar challenges.
The selection of an appropriate method depends on researchers’
personal philosophy and also on the research question. If a
researcher asks, “What are the effects of cryotherapy on nausea
and oral mucositis in patients undergoing chemotherapy?” the
researcher needs to examine the effects through the careful
measurement of patient outcomes. On the other hand, if a
researcher asks, “What is the process by which parents learn to
cope with the death of a child?” the researcher would be hard
pressed to quantify such a process. Personal worldviews of
researchers help to shape their questions.
In reading about the alternative paradigms for nursing research,
you likely were more attracted to one of the two paradigms. It is
important, however, to learn about both approaches to
disciplined inquiry and to recognize their respective strengths
and limitations. In this textbook, we describe methods
associated with both qualitative and quantitative research in an
effort to assist you in becoming methodologically bilingual.

This is especially important because large numbers of nurse
researchers are now undertaking mixed methods research that
involves gathering and analyzing both qualitative and
quantitative data (Chapters 26–28).
THE PURPOSES OF NURSING RESEARCH
The general purpose of nursing research is to answer questions
or solve problems of relevance to nursing. Specific purposes
can be classified in various ways. We describe three such
classifications—not because it is important for you to
categorize a study as having one purpose or the other but rather
because this will help us to illustrate the broad range of
questions that have intrigued nurses and to further show
differences between qualitative and quantitative inquiry.
Applied and Basic Research
Sometimes a distinction is made between basic and applied
research. As traditionally defined, basic research is undertaken
to enhance the base of knowledge or to formulate or refine a
theory. For example, a researcher may perform an in-depth
study to better understand normal grieving processes, without
having explicit nursing applications in mind. Some types of
basic research are called bench research, which is usually
performed in a laboratory and focuses on the molecular and
cellular mechanisms that underlie disease.
Example of Basic Nursing Research: Kishi and a
multidisciplinary team of researchers (2015) studied the effect

of hypo-osmotic shock of epidermal cells on skin inflammation
in a rat model, in an effort to understand the physiologic
mechanism underlying aquagenic pruritus (disrupted skin
barrier function) in the elderly.
Applied research seeks solutions to existing problems and tends
to be of greater immediate utility for EBP. Basic research is
appropriate for discovering general principles of human
behavior and biophysiologic processes; applied research is
designed to indicate how these principles can be used to solve
problems in nursing practice. In nursing, the findings from
applied research may pose questions for basic research, and the
results of basic research often suggest clinical applications.
Example of Applied Nursing Research: S. Martin and colleagues
(2014) studied whether positive therapeutic suggestions given
via headphones to children emerging from anesthesia after a
tonsillectomy would help to lower the children’s pain.
Research to Achieve Varying Levels of Explanation
Another way to classify research purposes concerns the extent
to which studies provide explanatory information. Although
specific study goals can range along an explanatory continuum,
a fundamental distinction (relevant especially in quantitative
research) is between studies whose primary intent is
to describe phenomena, and those that are cause-probing—that
is, designed to illuminate the underlying causes of phenomena.
Within a descriptive/explanatory framework, the specific

purposes of nursing research include identification, description,
exploration, prediction/control, and explanation. For each
purpose, various types of question are addressed—some more
amenable to qualitative than to quantitative inquiry and vice
versa.
Identification and Description
Qualitative researchers sometimes study phenomena about
which little is known. In some cases, so little is known that the
phenomenon has yet to be clearly identified or named or has
been inadequately defined. The in-depth, probing nature of
qualitative research is well suited to the task of answering such
questions as, “What is this phenomenon?” and “What is its
name?” (Table 1.3). In quantitative research, by contrast,
researchers begin with a phenomenon that has been previously
studied or defined—sometimes in a qualitative study. Thus, in
quantitative research, identification typically precedes the
inquiry.
TABLE 1.3: Research Purposes and Types of Research
Questions
PURPOSE
TYPES OF QUESTIONS: QUANTITATIVE RESEARCH
TYPES OF QUESTIONS: QUALITATIVE RESEARCH
Identification
What is this phenomenon?

What is its name?
Description
How prevalent is the phenomenon?
How often does the phenomenon occur?
What are the dimensions or characteristics of the phenomenon?
What is important about the phenomenon?
Exploration
What factors are related to the phenomenon?
What are the antecedents of the phenomenon?
What is the full nature of the phenomenon?
What is really going on here?
How is the phenomenon experienced? What is the process by
which the phenomenon evolves?
Explanation
What is the underlying cause of the phenomenon?
Does the theory explain the phenomenon?
How does the phenomenon work?
What does the phenomenon mean?
How did the phenomenon occur?
Prediction
What will happen if we alter a phenomenon or introduce an
intervention?
If phenomenon X occurs, will phenomenon Y follow?
Control

Can the occurrence of the phenomenon be prevented or
controlled?
Qualitative Example of Identification: Wojnar and Katzenmeyer
(2013) studied the experiences of preconception, pregnancy, and
new motherhood for lesbian nonbiologic mothers. They
identified, through in-depth interviews with 24 women, a unique
description of a pervasive feeling they called otherness.
Description is another important research purpose. Examples of
phenomena that nurse researchers have described include
patients’ pain, confusion, and coping. Quantitative description
focuses on the incidence, size, and measurable attributes of
phenomena. Qualitative researchers, by contrast, describe the
dimensions and meanings of phenomena. Table 1.3 shows
descriptive questions posed by quantitative and qualitative
researchers.
Quantitative Example of Description: Palese and colleagues
(2015) conducted a study to describe the average healing time
of stage II pressure ulcers. They found that it took
approximately 23 days to achieve complete reepithelialization.
Qualitative Example of Description: Archibald and colleagues
(2015) undertook an in-depth study to describe the information
needs of parents of children with asthma.
Exploration

Exploratory research begins with a phenomenon of interest, but
rather than simply observing and describing it, exploratory
research investigates the full nature of the phenomenon, the
manner in which it is manifested, and the other factors to which
it is related. For example, a descriptive quantitative study of
patients’ preoperative stress might document the degree of
stress patients feel before surgery and the percentage of patients
who are stressed. An exploratory study might ask: What factors
diminish or increase a patient’s stress? Are nurses’ behaviors
related to a patient’s stress level? Qualitative methods are
especially useful for exploring the full nature of a little-
understood phenomenon. Exploratory qualitative research is
designed to shed light on the various ways in which a
phenomenon is manifested and on underlying processes.
Quantitative Example of Exploration: Lee and colleagues (2014)
explored the association between physical activity in older
adults and their level of depressive symptoms.
Qualitative Example of Exploration: Based on in-depth
interviews with adults living on a reservation in the United
States, D. Martin and Yurkovich (2014) explored American
Indians’ perception of a healthy family.
Explanation
The goals of explanatory research are to understand the
underpinnings of natural phenomena and to explain systematic
relationships among them. Explanatory research is often linked

to theories, which are a method of integrating ideas about
phenomena and their interrelationships. Whereas descriptive
research provides new information and exploratory research
provides promising insights, explanatory research attempts to
offer understanding of the underlying causes or full nature of a
phenomenon. In quantitative research, theories or prior findings
are used deductively to generate hypothesized explanations that
are then tested. In qualitative studies, researchers search for
explanations about how or why a phenomenon exists or what a
phenomenon means as a basis for developing a theory that is
grounded in rich, in-depth evidence.
Quantitative Example of Explanation: Golfenshtein and Drach-
Zahavy (2015) tested a theoretical model (attribution theory) to
understand the role of patients’ attributions in nurses’
regulation of emotions in pediatric hospital wards.
Qualitative Example of Explanation: Smith-Young and
colleagues (2014) conducted an in-depth study to develop a
theoretical understanding of the process of managing work-
related musculoskeletal disorders while remaining at the
workplace. They called this process constant negotiation.
Prediction and Control
Many phenomena defy explanation. Yet it is frequently possible
to make predictions and to control phenomena based on research
findings, even in the absence of complete understanding. For
example, research has shown that the incidence of Down

syndrome in infants increases with the age of the mother. We
can predict that a woman aged 40 years is at higher risk of
bearing a child with Down syndrome than is a woman aged 25
years. We can partially control the outcome by educating
women about the risks and offering amniocentesis to women
older than 35 years of age. The ability to predict and control in
this example does not depend on an explanation of why older
women are at a higher risk of having an abnormal child. In
many quantitative studies, prediction and control are key
objectives. Although explanatory studies are powerful in an
EBP environment, studies whose purpose is prediction and
control are also critical in helping clinicians make decisions.
Quantitative Example of Prediction: Dang (2014) studied
factors that predicted resilience among homeless youth with
histories of maltreatment. Social connectedness and self-esteem
were predictive of better mental health.
Research Purposes Linked to Evidence-Based Practice
The purpose of most nursing studies can be categorized on a
descriptive–explanatory dimension as just described, but some
studies do not fall into such a system. For example, a study to
develop and rigorously test a new method of measuring patient
outcomes cannot easily be classified on this continuum.
In both nursing and medicine, several books have been written
to facilitate evidence-based practice, and these books categorize
studies in terms of the types of information needed by clinicians

(DiCenso et al., 2005; Guyatt et al., 2008; Melnyk & Fineout-
Overholt, 2011). These writers focus on several types of clinical
concerns: treatment, therapy, or intervention; diagnosis and
assessment; prognosis; prevention of harm; etiology; and
meaning. Not all nursing studies have one of these purposes, but
most of them do.
Treatment, Therapy, or Intervention
Nurse researchers undertake studies designed to help nurses
make evidence-based treatment decisions about how
to prevent a health problem or how to manage an existing
problem. Such studies range from evaluations of highly specific
treatments or therapies (e.g., comparing two types of cooling
blankets for febrile patients) to complex multisession
interventions designed to effect major behavioral changes (e.g.,
nurse-led smoking cessation interventions). Such intervention
research plays a critical role in EBP.
Example of a Study Aimed at Treatment/Therapy: Ling and co-
researchers (2014) tested the effectiveness of a school-based
healthy lifestyle intervention designed to prevent childhood
obesity in four rural elementary schools.
Diagnosis and Assessment
A burgeoning number of nursing studies concern the rigorous
development and evaluation of formal instruments to screen,
diagnose, and assess patients and to measure important clinical
outcomes. High-quality instruments with documented accuracy

are essential both for clinical practice and for further research.
Example of a Study Aimed at Diagnosis/Assessment: Pasek and
colleagues (2015) developed a prototype of an electronic
headache pain diary for children and evaluated the clinical
feasibility of the diary for assessing and documenting
concussion headache.
Prognosis
Studies of prognosis examine outcomes associated with a
disease or health problem, estimate the probability they will
occur, and predict the types of people for whom the outcomes
are most likely. Such studies facilitate the development of long-
term care plans for patients. They provide valuable information
for guiding patients to make lifestyle choices or to be vigilant
for key symptoms. Prognostic studies can also play a role in
resource allocation decisions
Example of a Study Aimed at Prognosis: Storey and Von Ah
(2015) studied the prevalence and impact of hyperglycemia on
hospitalized leukemia patients, in terms of such outcomes as
neutropenia, infection, and length of hospital stay.
Prevention of Harm and Etiology (Causation)
Nurses frequently encounter patients who face potentially
harmful exposures as a result of environmental agents or
because of personal behaviors or characteristics. Providing
useful information to patients about such harms and how best to

avoid them depends on the availability of accurate evidence
about health risks. Moreover, it can be difficult to prevent
harms if we do not know what causes them. For example, there
would be no smoking cessation programs if research had not
provided firm evidence that smoking cigarettes causes or
contributes to a wide range of health problems. Thus,
identifying factors that affect or cause illness, mortality, or
morbidity is an important purpose of many nursing studies.
Example of a Study Aimed at Identifying and Preventing
Harms: Hagerty and colleagues (2015) undertook a study to
identify risk factors for catheter-associated urinary tract
infections in critically ill patients with subarachnoid
hemorrhage. The risk factors examined included patients’ blood
sugar levels, patient age, and levels of anemia requiring
transfusion.
Meaning and Processes
Designing effective interventions, motivating people to comply
with treatments and health promotion activities, and providing
sensitive advice to patients are among the many health care
activities that can greatly benefit from understanding the
clients’ perspectives. Research that provides evidence about
what health and illness mean to clients, what barriers they face
to positive health practices, and what processes they experience
in a transition through a health care crisis are important to
evidence-based nursing practice.

Example of a Study Aimed at Studying Meaning: Carlsson and
Persson (2015) studied what it means to live with intestinal
failure caused by Crohn disease and the influence it has on daily
life.
TIP: Several of these EBP-related purposes (except diagnosis
and meaning) fundamentally call for cause-probing research.
For example, research on interventions focuses on whether an
intervention causes improvements in key outcomes. Prognosis
research asks if a disease or health condition causes subsequent
adverse outcomes, and etiology research seeks explanations
about the underlying causes of health problems.
ASSISTANCE FOR USERS OF NURSING RESEARCH
This book is designed primarily to help you develop skills for
conducting research, but in an environment that stresses EBP, it
is extremely important to hone your skills in reading,
evaluating, and using nursing studies. We provide specific
guidance to consumers in most chapters by including guidelines
for critiquing aspects of a study covered in the chapter. The
questions in Box 1.1 are designed to assist you in using the
information in this chapter in an overall preliminary assessment
of a research report.
BOX 1.1: Questions for a Preliminary Overview of a Research
Report
· 1. How relevant is the research problem in this report to the
actual practice of nursing? Does the study focus on a topic that

is a priority area for nursing research?
· 2. Is the research quantitative or qualitative?
· 3. What is the underlying purpose (or purposes) of the study—
identification, description, exploration, explanation, or
prediction and control? Does the purpose correspond to an EBP
focus such as treatment, diagnosis, prognosis, harm/etiology, or
meaning?
· 4. Is this study fundamentally cause-probing?
· 5. What might be some clinical implications of this research?
To what type of people and settings is the research most
relevant? If the findings are accurate, how might I use the
results of this study?
TIP: The Resource Manual that accompanies this book offers
particularly rich opportunities to practice your critiquing skills.
The Toolkit on thePoint with the Resource Manual includes Box
1.1 as a Word document, which will allow you to adapt these
questions, if desired, and to answer them directly into a Word
document without having to retype the questions.
RESEARCH EXAMPLES
· tudy: The effects of a community-based, culturally tailored
diabetes prevention intervention for high-risk adults of Mexican
descent (Vincent et al., 2014)
· Study Purpose: The purpose of the study was to evaluate the
effectiveness of a 5-month nurse-coached diabetes prevention
program (Un Estilo de Vida Saludable or EVS) for overweight

Mexican American adults.
· Study Methods: A total of 58 Spanish-speaking adults of
Mexican descent were recruited to participate in the study.
Some of the participants, at random, were in a group that
received the EVS intervention, while others in a control group
did not receive it. The EVS intervention used content from a
previously tested diabetes prevention program, but the
researchers created a community-based, culturally tailored
intervention for their population. The intervention, which was
offered in community rooms of churches, consisted of an
intensive phase of eight weekly 2-hour sessions, followed by a
maintenance phase of 1-hour sessions for the final 3 months.
Those in the group not receiving the intervention received
educational sessions broadly aimed at health promotion in
general. The researchers compared the two groups with regard
to several important outcomes, such as weight loss, waist
circumference, body mass index, and self-efficacy. Outcome
information was gathered three times—at the outset of the study
(prior to the intervention), 8 weeks later, and then after the
program ended.
· Key Findings: The analysis suggested that those in the
intervention group had several better outcomes, such as greater
weight loss, smaller waist circumference, and lower body mass
index, than those in the control group.
· Conclusions: Vincent and her colleagues (2014) concluded

that implementing the culturally tailored program was feasible,
was well-received among participants (e.g., high rates of
program retention), and was effective in decreasing risk factors
for type 2 diabetes.
Research Example of a Qualitative Study
· Study: Silent, invisible, and unacknowledged: Experiences of
young caregivers of single parents diagnosed with multiple
sclerosis (Bjorgvinsdottir & Halldorsdottir, 2014)
· Study Purpose: The purpose of this study was to study the
personal experience of being a young caregiver of a chronically
ill parent diagnosed with multiple sclerosis (MS).
· Study Methods: Young adults in Iceland whose parents were
diagnosed with MS were recruited through the Icelandic
National Multiple Sclerosis Society, and 11 agreed to be
included in the study. Participants were interviewed in their
own homes or in the home of the lead researcher, whichever
they preferred. In-depth questioning was used to probe the
experiences of the participants. The main interview question
was: “Can you tell me about your personal experience being a
young caregiver of a chronically ill parent with MS?” Several
participants were interviewed twice to ensure rich and deep
descriptions for a total of 21 interviews.
· Key Findings: The young caregivers felt that they were
invisible and unacknowledged as caregivers and received
limited support and assistance from professionals. Their

responsibilities led to severe personal restrictions and they felt
they had lived without a true childhood because they were left
to manage adult-like responsibilities at a young age. Their role
as caregiver was demanding and stressful, and they felt
unsupported and abandoned.
· Conclusions: The researchers concluded that health
professionals should be more vigilant about the needs for
support and guidance for children and adolescents caring for
chronically ill parents.
SUMMARY POINTS
· Nursing research is systematic inquiry to develop knowledge
about issues of importance to nurses. Nurses are adopting
an evidence-based practice (EBP) that incorporates research
findings into their clinical decisions.
· Nurses can participate in a range of research-related activities
that span a continuum from being consumers of research (those
who read and evaluate studies) and producers of research (those
who design and undertake studies).
· Nursing research began with Florence Nightingale but
developed slowly until its rapid acceleration in the 1950s. Since
the 1970s, nursing research has focused on problems relating to
clinical practice.
· The National Institute of Nursing Research (NINR),
established at the U.S. National Institutes of Health in 1993,
affirms the stature of nursing research in the United States.

· Contemporary emphases in nursing research include EBP
projects, replications of research, research integration through
systematic reviews, multisite and interdisciplinary studies,
expanded dissemination efforts, and increased focus on health
disparities.
· Disciplined research is a better evidence source for nursing
practice than other sources, such as tradition, authority,
personal experience, trial and error, intuition, and logical
reasoning.
· Nursing research is conducted mainly within one of two
broad paradigms—worldviews with
underlying assumptions about reality: the positivist paradigm
and the constructivist paradigm.
· In the positivist paradigm, it is assumed that there is an
objective reality and that natural phenomena are regular and
orderly. The related assumption of determinism is the belief that
phenomenas result from prior causes and are not haphazard.
· In the constructivist (naturalistic) paradigm, it is assumed
that reality is not fixed but is rather a construction of human
minds; thus, “truth” is a composite of multiple constructions of
reality.
· The positivist paradigm is associated with quantitative
research—the collection and analysis of numeric information.
Quantitative research is typically conducted within the
traditional scientific method, which is a systematic, controlled

process. Quantitative researchers gather and analyze empirical
evidence (evidence collected through the human senses) and
strive for generalizability of their findings beyond the study
setting.
· Researchers within the constructivist paradigm emphasize
understanding the human experience as it is lived through the
collection and analysis of subjective, narrative materials using
flexible procedures that evolve in the field; this paradigm is
associated with qualitative research.
· Basic research is designed to extend the knowledge base for
the sake of knowledge itself. Applied research focuses on
discovering solutions to immediate problems.
· A fundamental distinction, especially relevant in quantitative
research, is between studies whose primary intent is
to describe phenomena and those that are cause-probing—that
is, designed to illuminate underlying causes of phenomena.
Specific purposes on the description/explanation continuum
include identification, description, exploration,
prediction/control, and explanation.
· Many nursing studies can also be classified in terms of a key
EBP aim: treatment/therapy/intervention; diagnosis and
assessment; prognosis; harm and etiology; and meaning and
process.
STUDY ACTIVITIES
Chapter 1 of the Resource Manual for Nursing Research:

Generating and Assessing Evidence for Nursing Practice, 10th
edition, offers study suggestions for reinforcing concepts
presented in this chapter. In addition, the following questions
can be addressed in classroom or online discussions:
1.
Is your worldview closer to the positivist or the constructivist
paradigm? Explore the aspects of the two paradigms that are
especially consistent with your worldview.
2.
Answer the questions in Box 1.1 about the Vincent et al. (2014)
study described at the end of this chapter. Could this study have
been undertaken as a qualitative study? Why or why not?
3.
Answer the questions in Box 1.1 about the Bjorgvinsdottir and
Halldorsdottir (2014) study described at the end of this chapter.
Could this study have been undertaken as a quantitative study?
Why or why not?
STUDIES CITED IN CHAPTER 1
Archibald, M. M., Caine, V., Ali, S., Hartling, L., & Scott, S.
(2015). What is left unsaid: An interpretive description of the
information needs of parents of children with asthma. Research
in Nursing & Health, 38, 19–28.
Bäck-Pettersson, S., Hermansson, E., Sernert, N., & Bjökelund,
C. (2008). Research priorities in nursing—A Delphi study
among Swedish nurses. Journal of Clinical Nursing, 17, 2221–

2231.
Bjorgvinsdottir, K., & Halldorsdottir, S. (2014). Silent,
invisible and unacknowledged: Experiences of young caregivers
of single parents diagnosed with multiple
sclerosis. Scandinavian Journal of the Caring Sciences, 28, 38–
48.
Brenner, M., Hilliard, C., Regan, G., Coughlan, B., Hayden, S.,
Drennan, J., & Kelleher, D. (2014). Research priorities for
children’s nursing in Ireland. Journal of Pediatric Nursing, 29,
301–308.
*Campbell-Yeo, M., Johnston, C., Benoit, B., Latimer, M.,
Vincer, M., Walker, C., … Caddell, K. (2013). Trial of repeated
analgesia with kangaroo mother care (TRAKC trial). BMC
Pediatrics, 13, 182.
Carlsson, E., & Persson, E. (2015). Living with intestinal
failure by Crohn disease: Not letting the disease conquer
life. Gastroenterology Nursing, 38, 12–20.
Chwo, M. J., Anderson, G. C., Good, M., Dowling, D. A.,
Shiau, S. H., & Chu, D. M. (2002). A randomized controlled
trial of early kangaroo care for preterm infants: Effects on
temperature, weight, behavior, and acuity. Journal of Nursing
Research, 10, 129–142.
*Cong, X., Ludington-Hoe, S., McCain, G., & Fu, P. (2009).
Kangaroo care modifies preterm infant heart rate variability in
response to heel stick pain. Early Human Development, 85,

561–567.
Cong, X., Ludington-Hoe, S., & Walsh, S. (2011). Randomized
crossover trial of kangaroo care to reduce behavioral pain
responses in preterm infants. Biological Research for
Nursing, 13, 204–216.
Dang, M. T. (2014). Social connectedness and self-esteem:
Predictors of resilience in mental health among maltreated
homeless youth. Issues in Mental Health Nursing, 35, 212–219.
DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based
nursing: A guide to clinical practice. St. Louis, MO: Elsevier
Mosby.
Drenkard, K. (2013). Change is good: Introducing the 2014
Magnet Application Manual. Journal of Nursing
Administration, 43, 489–490.
Drennan, J., Meehan, T., Kemple, M., Johnson, M., Treacy, M.,
& Butler, M. (2007). Nursing research priorities for
Ireland. Journal of Nursing Scholarship, 39, 298–305.
Golfenshtein, N., & Drach-Zahavy, A. (2015). An attribution
theory perspective on emotional labour in nurse-patient
encounters: A nested cross-sectional study in paediatric
settings. Journal of Advanced Nursing, 71(5), 1123–1134.
Gona, C., & DeMarco, R. (2015). The context and experience of
becoming HIV infected for Zimbabwean women: Unheard
voices revealed. Journal of the Association of Nurses in AIDS

Care, 26, 57–68.
Guyatt, G., Rennie, D., Meade, M., & Cook, D. (2008). Users’
guide to the medical literature: Essentials of evidence-based
clinical practice (2nd ed.). New York: McGraw Hill.
Hagerty, T., Kertesz, L., Schmidt, J., Agarwal, S., Claassen, J.,
Mayer, S., … Shang, K. (2015). Risk factors for catheter-
associated urinary tract infections in critically ill patients with
subarachnoid hemorrhage. Journal of Neuroscience Nursing, 47,
51–54.
Hake-Brooks, S., & Anderson, G. (2008). Kangaroo care and
breastfeeding of mother-preterm dyads 0–18 months: A
randomized controlled trial. Neonatal Network, 27, 151–159.
Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson,
C., Greiner, J., … Williamson, A. (2015). Sacred cows gone to
pasture: A systematic evaluation and integration of evidence-
based practice. Worldview on Evidence-Based Nursing, 12, 3–
11.
Holman, E., Perisho, J., Edwards, A., & Mlakar, N. (2010). The
myths of coping with loss in undergraduate psychiatric nursing
books. Research in Nursing & Health, 33, 486–499.
*Institute of Medicine. (2010). The future of nursing: Leading
change, advancing health. Washington, DC: The National
Academies Press.
Kim, M. J., Oh, E. G., Kim, C. J., Yoo, J. S., & Ko, I. S. (2002).
Priorities for nursing research in Korea. Journal of Nursing

Scholarship, 34, 307–312.
Kishi, C., Minematsu, T., Huang, L., Mugita, Y., Kitamura, A.,
Nakagami, G., … Sanada, H. (2015). Hypo-osmotic shock-
induced subclinical inflammation of skin in a rat model of
disrupted skin barrier function. Biological Research for
Nursing, 17, 135–141.
Lee, H., Lee, J., Brar, J., Rush, E., & Jolley, C. (2014). Physical
activity and depressive symptoms in older adults. Geriatric
Nursing, 35, 37–41.
Ling, J., King, K., Speck, B., Kim, S., & Wu, D. (2014).
Preliminary assessment of a school-based healthy lifestyle
intervention among rural elementary school children. Journal of
School Health, 84, 247–255.
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science and practice. Neonatal Network, 30, 357–362.
Mak, S., Lee, M., Cheung, J., Choi, K., Chung, T., Wong, T., …
& Lee, D. (2015). Pressurised irrigation versus swabbing
method in cleansing wounds healed by secondary intention: A
randomized controlled trial with cost effectiveness
analysis. International Journal of Nursing Studies, 52, 88–101.
Martin, D., & Yurkovich, E. (2014). “Close knit” defines a
healthy native American Indian family. Journal of Family
Nursing, 20, 51–72.
Martin, S., Smith, A., Newcomb, P., & Miller, J. (2014). Effects
of therapeutic suggestion under anesthesia on outcomes in

children post-tonsillectomy. Journal of Perianesthesia
Nursing, 29, 94–106.
*McHugh, M. D., Kelly, L. A., Smith, H. L., Wu, E. S., Vanak,
J., & Aiken, L. H. (2013). Lower mortality in Magnet
hospitals. Medical Care, 51, 382–388.
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based
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*Moore, E., Anderson, G., Bergman, N., & Dowswell, T.
(2012). Early skin-to-skin contact for mothers and their health
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pressure ulcers? Findings from a secondary analysis. Advances
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negotiating: Managing work-related musculoskeletal disorders

while remaining in the workplace. Qualitative Health
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hyperglycemia on hospitalized leukemia patients. European
Journal of Oncology Nursing, 19, 13–17.
Vincent, D., McEwen, M., Hepworth, J., & Stump, C. (2014).
The effects of a community-based, culturally tailored diabetes
prevention intervention for high-risk adults of Mexican
descent. The Diabetes Educator, 40, 202–213.
Wojnar, D. M., & Katzenmeyer, A. (2013). Experiences of
preconception, pregnancy, and new motherhood for lesbian
nonbiological mothers. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 43, 50–60.
Wynaden, D., Heslop, K., Omari, O., Nelson, D., Osmond, B.,
Taylor, M., & Gee, T. (2014). Identifying mental health nursing
priorities: A Delphi study. Contemporary Nurse, 47, 16–26.
*A link to this open-access journal article is provided in the
Toolkit for this chapter in the accompanyingResource Manual.

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