Theoretical Basis of Practice

Nursing’s Meta-paradigm
The term “paradigm” is defined as the development of knowledge within a specific field or discipline. In 1984, Dr. Jacqueline Fawcett evaluated existing nursing theories and identified four concepts common to the individual paradigms within each theory:Patient-Environment-Health-Nursing.  Placing the nursing theories within one context enhanced the potential for the development of nursing knowledge.  Dr. Fawcett’s work is commonly referred to as the “Meta-paradigm” of nursing (Fawcett, 1984).  Nursing knowledge and knowledge development focuses on the “whole” and is directed at defining and understanding the inter-relationships among the four core concepts identified above (Smith & Liehr, 2014).
Grand Nursing Theory
Among the core beliefs of nursing is the idea that nursing should be founded on the best empirical evidence, incorporate the beliefs of patients and families, and be guided by disciplinary theory (Pipe, 2013).  Beginning in the 1950’s multiple theories of nursing were developed; some scholars believe the first nursing theory was postulated by Florence Nightingale when she published her “Notes on Nursing” in 1860.  As we discussed in an earlier Unit, concepts are the building blocks of theory.  A theory defines the relationship between two or more concepts; conceptual models of nursing are typically called “Grand nursing theories”.  Grand theories are quite abstract and usually do not provide specific instruction for nursing actions (Kenney, 2013).
While there are a number of grand nursing theories, a few will be briefly discussed here.  Martha Rogers (1970) described what she called the ”Science of Unitary Human Beings”; the central tenet of this discussion is that human beings must be viewed in totality and are more than just a sum of their parts.  Roger’s placed emphasis on the concepts of Nursing and Person in her writings; this work has influenced the development of additional theoretical perspectives including the work of Rosemarie Parse, Joyce Fitzpatrick, Pamela Reed, and others (Griffin & Landers, 2014). Sr. Calista Roy first published the Adaptation Model in 1970 based largely on her work in pediatrics. The core concept within this theory is “adaptation” and this concept is seen as the desired outcome for health, coping, etc. Roy incorporates all four of the Meta-paradigm concepts into her theoretical framework.  Dorothea Orem developed her theory of Self Care Deficits in the early 1970s.  The central focus of Orem’s theory is to seek to understand why persons seek nursing care, it also provides guidance on when nursing is required and even the type of nursing care that is needed. Orem’s theory encompasses all four of Fawcett’s meta -paradigm concepts.  Jean Watson published her theory of Caring in 1979.  Watson views the concept of caring to be both the basis of each nursing action and the very essence of nursing itself.  The Theory of Caring addresses all four meta-paradigm concepts with emphasis on the uniqueness of each individual person. (Griffin & Landers, 2014).

Middle Range Nursing Theories
In contrast to Grand Nursing Theories, middle range theories have a more focused content and are therefore easier to apply to clinical practice.  Each middle range theory seeks to address a particular patient experience and typically focuses on only one of the nursing meta-paradigm concepts.  Examples of such middle range theories include Kolcaba’s Theory of Comfort, Pender’s Health Promotion Model, Lenz’s Theory of Unpleasant Symptoms, etc. Many times, middle range theories have evolved from a grand theory of nursing or have resulted from nursing research (Chism, 2013; Hamric, Hanson, Tracy, & O’Grady, 2014; Smith & Liehr, 2014).
It is very important that the middle range theory you select work well with the Grand Nursing theory you have chosen.  You want these two theories to work together to give you a fuller understanding of the patient situation, environment, or problem you are encountering.

Complexity Science
Complexity science is not a single theory but rather an emerging interdisciplinary paradigm.  Complexity science incorporates elements of multiple fields of study including chaos theory and non-linear mathematics.  While this sounds complicated (and it is!), the basic tenet of Complexity Science is that “the whole is more than the sum of its parts” which is also the basic tenet of nursing.  Complexity science is being applied to multiple areas of study including Organizational and Systems Analysis, Healthcare facilities, even medical research (Butts & Rich, 2015).
The identification of Complex Adaptive systems is an off shoot of complexity science. Examples of complex adaptive systems consist of such things as a school of fish, a flock of birds, and the human body.  In 2001, the Institute of Medicine (IOM) referred to health care facilities in this context (IOM, 2001).  All complex adaptive systems are composed of individual parts or “agents” who are connected to one another is some way, but who act independently and unpredictably at times.  Using a healthcare facility for an example of a complex adaptive system, the facility itself may be thought of as the “whole”, the “agents” would include the various departments such as Nursing, Environmental services, Social Work, the Business office, etc. Breaking this down even further, within the Nursing department, each individual nursing unit would be an “agent”, and so on down to the level of the individual nurse, unit secretary, or nursing assistant.  A  hallmark of complex adaptive systems is that oftentimes, small changes can have large effects throughout the system; actions taken by one “agent” often have profound effects on others within the system (Butts & Rich, 2015).

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