Advances in Nursing Science

Vol. 42, No. 1, pp. 28–42

Copyright c 2018 Wolters Kluwer Health, Inc. All rights reserved.

Nursing Knowledge in the

21st Century
Domain-Derived and Basic Science
Practice-Shaped
Callista Roy, PhD, RN, FAAN

Some have described that nursing is at a crossroads that necessitates finding ways to balance
knowledge development that is philosophical and conceptual/theoretical with the empirical
inquiry, particularly of the developing related biologic sciences. This article sets a direction
for nursing knowledge development that is domain-driven. The central role of nursing the-
ory in attaining the common goals of nursing is envisioned. Recommendations include that
grand theories, middle-range theories, and practice theories in tree-like fashion feed into the
common goal of humanization; that all teaching tools in nursing begin with common goals
and describe nursing theories as contributing to these goals; that theory-practice alliances
are central in filling out the envisioned domain-driven knowledge and integrating this with
practice-shaped basic sciences. Key words: common goals, nursing knowledge, theory,
theory evaluation, theory-based practice

F AILURE to define clearly the domain of

nursing has contributed to a problem
we face that some have called the “pro-
new scholars, in disputes about hiring and
promoting faculty, in priorities for research
funding, and in disparate approaches to direct
fession at the crossroads.” The authors, practice changes. If the profession is at a
including myself, who took this position, crossroads, as some believe, then it is time to
noted that 21st-century advances in science clarify the domain of nursing, choose a direc-
and technology have left nurse scholars tion for the pathway that is domain specific,
struggling to balance philosophical and describe what this pathway looks like, and
conceptual/theoretical knowledge develop- create strategies for knowledge development
ments and their associated critiques with on that pathway. Leaders in nursing have
empirical inquiry,1 particularly in the omics long recognized that the discipline’s scholars
of the life sciences.2 We see evidence of should continue to “identify, verify, structure,
this conflict in debates over curricula for the and continually update the extant content or
PhD and resulting confusion of focus among subject matter of the discipline.”3(p16) This
obligation remains a priority for creating
nursing’s future.4,5 The 21st century calls
for describing clearly the domain of nursing
Author Affiliations: Mount Saint Mary’s University,
Los Angeles, California; and Boston College Connell
and deriving knowledge development for
School of Nursing, Boston, Massachusetts. that domain that envisions nursing’s future
The author has disclosed that she has no significant
and identifies the strategies needed to create
relationships with, or financial interest in, any com- this future. In an earlier article, I proposed a
mercial companies pertaining to this article. definition of nursing science and a structure
Correspondence: Callista Roy, PhD, RN, FAAN, Mount for nursing knowledge for the domain.5 This
Saint Mary’s University, 12001 Chalon Rd, Los Angeles, definition is a beginning for having domain-
CA 90049 (Croy1@msmu.edu).
driven content and a central role for nursing
DOI: 10.1097/ANS.0000000000000240 theory.
28

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 Nursing Knowledge in the 21st Century 29

Ellis7 noted that the domain of nursing prac-

Statements of Significance tice should delimit the domain appropriate
What is known or assumed to be true to theory development for nursing. Further-
about this topic: more, inquiry that can improve nursing prac-
In a time of rapidly developing sciences, tice requires both methodological develop-
it seems that nursing may be at risk of los- ment and theory development. The note-
ing its own focus on nursing knowledge worthy article by Donaldson and Crowley8
development for practice. outlined knowledge in broad form for nurs-
What this article adds: ing as an academic and practice discipline
This article defines the domain of nursing, that focused on ways of knowing and substan-
and a central unifying goal then shows tive content. Nurses have long made efforts to
both what domain-driven knowledge is identify the body of knowledge for practice or
and how it can meet the goals of nurs- the domain of nursing. Rodgers9 summarized
ing practice. I outline a central role for this history and concluded that nursing needs
nursing theory together with practice to move beyond the past to expand the knowl-
alliances. edge base and realize the potential for nursing
by a reconsideration of the core of nursing.
Indications are strong that we need to revisit
I define nursing science as “the knowl- and redefine the place of nursing theory in
edge derived from the goals and values of developing nursing knowledge contemporar-
the discipline focused on persons and envi- ily. Given the growth of the discipline, nurs-
ronment as described in theories and stud- ing needs a renovation of how the profession
ied with multiple methods of inquiry and in- looks at knowledge. To facilitate the project
tegrated with relevant practice-shaped basic of renovation, an exploration of the place and
sciences.”5(pp90-91) I see nursing science de- role of theory in knowledge development is
fined in this way as the outline of the domain required. Scholars can strengthen the relation-
of nursing. The science developed within this ship of theory and practice. Furthermore, it is
domain is what nurses contribute to promot- time to examine the developments in nursing
ing health of people. The purpose of this arti- theory since the 1980s and past and present
cle is to explore the implications of taking the contributions. From this perspective, we can
pathway of science of nursing that is domain- update strategies for developing theory for
derived and practice-shaped from basic sci- practice in the future at 3 levels: grand theory,
ences. What does renovation of the place of middle-range theory (MRT), and practice-level
theory in domain-driven knowledge look like? theory. Examining nursing theories, based on
How do nurses update strategies for develop- person and environment integration and us-
ing theory at all levels? What are the research ing multiple methods of inquiry, will lead the
agenda and strategies for this knowledge? way to drive and carry out the research agenda
How do nurses integrate domain-derived for the profession. This direction setting is
knowledge with basic science practice- a significant part of recognizing the implica-
shaped knowledge? What are the relevant cri- tions of choosing the pathway of focusing on
teria and processes for comparative evalua- the domain of nursing and the domain driving
tion of theories as reenvisioned? nursing knowledge development.

NURSING THEORY IN DOMAIN-DERIVED

KNOWLEDGE Theory and knowledge development
Theory is central to knowledge devel-
A domain is defined as a sphere of knowl- opment in all disciplines. In early work,
edge, influence, or activity.6 In the 1968 Sym- Zetterberg10 cited the 1045 propositions
posium on Nursing Theory we celebrated, listed as research findings related to human

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 30 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2019

behavior and noted that they are not theory. in practice. Of the 13 publications identified
The author pointed out that facts alone do that related to situation-specific theory (SST),
not lead to major advances in any science. they documented links to research and that
The function of theory is to interrelate con- the authors created SST from grounded the-
cepts and data so that they can be inter- ory findings or concept analysis.
preted and unified. Dubin described the at- I did a similar review that covered the the-
mosphere he encountered at the University oretical literature from 2011 to 2016 (C. R.,
of Chicago, as a student in social sciences, be- unpublished data, 2018). Within a 5-year pe-
ing permeated by “constant clashes between riod, there were 443 publications focused on
self-conscious empiricists and rather defen- grand theories. The authors described the var-
sive theorists.”11(pvii) As a faculty member, he ious uses of grand theories in research and/or
later developed a seminar in theory building practice or how they extended the theories
to put together theory and empirical research in some way, including measurement for re-
for use by working social scientists. Scientific search and for deriving MRTs. In this report,
work of explaining and understanding goes the most commonly used grand theories were
on when scholars create and test theories. Lit- of Neuman, Orem, Roy, and Watson. I identi-
erature in philosophy of science, in other dis- fied 144 articles on MRTs with a broad range
ciplines, and in nursing has shown that in a of uses for knowledge development and prac-
theory, scholars identify concepts and inter- tice. The articles variously explained MRT in
relate concepts in propositions that they turn research projects; derivation from other MRTs
into hypothesis to be tested.12-15 or from combining grand theory and MRT;
Rodgers9 indicated that the theory develop- their source from basic science theory; how
ment movement, beginning in the late 1960s, they had been tested in education initiatives;
promoted a systematic expansion of knowl- their expansion to other disciplines; and how
edge appropriate for nursing. This progress authors recommended using paradigms to de-
continued through the end of the 20th cen- rive MRT. In the recent 5-year review, I also
tury and into the 21st century with new fea- found 27 SST articles. These showed links
tures and questions. In summary, the 20th- to research; how authors derived SST from
century developments included maturing of grand theory and MRT; extensions to permit
the discipline; clarifying the theoretical focus measurement; and descriptions of their evo-
of nursing as holistic persons with processes lution from grounded theory findings or con-
and patterns for environmental integration to cept analysis. From these 2 reports, one can
attain well-being; and a plurality of grand the- note that theoretical work is extensive in the
ories that provided for articulating and testing 21st century and is involved in many strate-
of theories in practice and research. Two sur- gies for knowledge development.
veys since 2000 show continued theoretical One of the trends that Im and Chang16
work at several levels. Im and Chang16 looked noted was “integration in practice” as grand
at nursing theory literature from 2001 to 2011 theories, and sometimes theories from other
to identify trends. Grand theories publica- disciplines, were applied to specific areas of
tions numbered 257 and documented how au- practice. The authors noted that this trend
thors used the theories to refine concepts, test could be interpreted as a long overdue effort
associations, create instruments, and guide to have prescriptive theories that can guide
practice. In this survey, the most commonly nursing practice. Still, the impact of the theo-
used of the grand theories were those of ries on the multidisciplinary health care scene
Neuman, Orem, Rodgers, and Roy. The au- is not clear. Particularly, the theories have
thors reported 84 articles about MRTs, in not answered clearly the questions of what
which the authors linked MRTs to research, kind of knowledge is needed for nursing in a
developed them from grand theory, used rapidly changing world of science and how it
MRTs to create instruments, and used MRTs will be created. Still this work seems not to

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 Nursing Knowledge in the 21st Century 31

be compelling enough for other disciplines to direct the potential of theory building to-
to recognize the unique contribution nursing ward creating knowledge to achieve the goals
theories make to health care. of nursing practice. In the previous article,
I placed the goals within an updated
Types of theories and updated strategies structure.5 For this article, I focus in greater
for development depth on knowledge development, the what,
In the proposed domain-led view of nursing and the how.
knowledge, nursing theory at 3 levels—grand, Theories in nursing have a plurality of foci.
middle-range, and practice—holds the central Focusing on nursing knowledge development
position. In the first edition of Advances in (Figure 1), theories are placed at the center
Nursing Science, Chinn and Jacobs17 claimed and their aim is to explain and fulfill the com-
that theory development was the most cru- mon goals of the discipline. There is agree-
cial task facing nursing because of its pre- ment that in general nursing goals mean the
dictive potential. Theory development was outcome to be accomplished by using nursing
the major means by which nursing could ac- knowledge-based activities in contributing to
complish its identified goals. Theorists have health. The goals are the unique function for
variously stated the goals of nursing. In the which the profession exists and therefore is
proposed perspective on knowledge, I rec- accountable to society to achieve. Early on,
ommend that nursing use the central unify- Johnson19,20 described the importance of ar-
ing focus of the discipline derived by Willis ticulating clear goals to develop knowledge
et al.18 I call humanization the central goal to for nursing. Some authors more recently link
simplify the conceptual and structural render- both professionalism and ensuring viability of
ing of the goals, with the understanding that nursing to knowledge with a unique goal.15,21
this includes meaning, choice, quality of life, The central unifying focus article,18 of
and healing in living and dying. The role of which I was one of the authors, evolved
nursing theories is to explain these common from our conversations and concerns that all
goals of nursing and the activities or processes nurses should be able to articulate clearly a
to accomplish them. We have seen broad de- central focus for their work. We believed that
velopment of nursing theories. It is now time synthesizing from the historical and extant

Figure 1. Nursing knowledge development: Domain-derived and practice shaped.

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 32 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2019

literature this focus and clearly articulating According to Wills et al,18 these goals
it would provide an anchor for all levels of represent an interpretation and conver-
nurses, nursing scholars, and particularly gence of ideas in major nursing concep-
nursing practice. It would at this time in tual and theoretical works. Nursing the-
nursing history clarify who we are as a ory at 3 levels—grand, middle-range, and
profession. From this position, it would be practice—will lead domain-derived knowl-
clear what nursing could offer individuals and edge to achieve the goals of the discipline.
society. Our analysis provides perspective Domain-derived knowledge is the develop-
for the discipline—facilitating humanization, ment of knowledge by nurses for nursing
meaning, choice, quality of life, and healing within the central focusing goals of the dis-
in living and dying. Willis et al offer that a cipline and based on nursing theory. It is the
central unifying focus can unite us within knowledge that is unique to nursing practice.
the discipline, “serve as a basis for our Grand-level theories are those that provide a
continuing scholarly evolution, and foster broad perspective to understand the key con-
interdisciplinary work in which nursing is cepts and principles within nursing. Descrip-
clearly and substantively visible.”18(pE31) tions of the history of nursing theory generally
The goal of facilitating humanization is start with Peplau’s work on interpersonal re-
manifested in nursing practice “when the lations in nursing in 1952 and emphasize the-
nurse works with all human beings grounded ories by Orlando, Wiedenbach, Henderson,
in an ontology of human beings as relational, Levine, and Ujhely in the 1960s. The 1970s
experiential, valuable, respect-worthy, mean- and 1980s were rich with nursing theories
oriented, flawed, imperfect, vulnerable, frag- by Rodgers, King, Orem, Travelbee, Neuman,
ile, complex, and capable of health and heal- Roy, Newman, Johnson, Parse, Erickson et al,
ing even if not capable of being cured.”18(pE34) Leininger, Watson, Roper et al and Newman,
Humans reach meaning by understanding life with Boykin and Schoenhofer added in the
experiences and their significance as they pro- 1990s. The contributions of theories are de-
cess those experiences, often with another scribed elsewhere (see Fitzpatrick and Smith,
person. Choice is the human capacity for in this issue).5
making personally derived decisions that are What I suggested in the 21st-century struc-
congruent with one’s values, beliefs, and ture proposal for creating nursing knowledge
meanings and depend on the person’s devel- based on common goals is that as each the-
opmental and reasoning skills. Quality of life ory continues to develop, the scholars, often
is the value and significance that individuals a next generation from original grand theo-
ascribe to their lives within their changing rists, will make explicit the relationship of
situations. By the goal of healing in living the theory’s given perspective to the com-
and dying, Johnson means “the multidimen- mon goals of the discipline. That is, the theo-
sional unitary human-natural world process rists and those working in their organizations
of restoring bodily experiences of wholeness, can link grand theories to the goal of facili-
meaning and integrity of one’s existence in a tating humanization and all that that means.
human body in the world and changing until All the grand theorists address the person and
death.”19(pE35) Healing may occur in the ab- environment connections related to health,
sence of resolution of a physiological disrup- and adding the specificity of the common fo-
tion or may not occur when a disruption is cus is both possible and of great advantage
resolved. These goals provide a unique focus to nursing knowledge. Each grand theory can
for nursing knowledge in language that is un- describe specific ways that nurses can facil-
derstandable in practice and for other health itate humanization, meaning, choice, quality
care disciplines and that the public we serve of life, and healing in living and dying. Promot-
will value. This perspective has received wide ing self-care or adaptation or finding ways to
acceptance and is quoted by others.12,22 expand consciousness and human becoming

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 Nursing Knowledge in the 21st Century 33

provides multiple beliefs, principles, and will be prepared to learn, create in prac-
strategies to achieve the common goals of tice, and extend in research domain-derived
nursing. Unity at the broad level brings the person and environment knowledge for
discipline together and makes our purpose practice.
clear to others. The plurality of approaches The developments in grand theories and
at the grand theory level provides rich in- the promise of placing them at the cen-
sights into how to view clinical situations. ter of nursing knowledge development re-
Some grand theories have stood the test of late to advances in MRTs for nursing. Histor-
time and as noted earlier have wide publi- ically, MRTs were introduced into nursing in
cations. Furthermore, some theorists are still about 1980 based on the work by Mills and
working on the development of their work, Merton in sociology.23,24 MRTs are those that
particularly Parse, Watson, and Roy. Second- can bridge a gap between research and prac-
generation individuals and theory organiza- tice. They come between the more abstract
tions carry out the work of grand theory grand theories and those theories that are
development, for example, the International specific to a particular phenomenon. Theory
Association of Human Caring, International development at the middle range has gained
Caritas Consortium, International Consortium recognition as the latest step in substantive
of Parse Scholars, Neuman Systems Model knowledge development. Scholars in nursing
Trustee Group, Inc, Orem International So- have increasingly accepted the work on de-
ciety, Roy Adaptation Association, Society of veloping and testing of MRTs as the level of
Rogerian Scholars, Transcultural Nursing So- theory development needed to guide nurs-
ciety, and Watson Caring Science Institute. ing research and practice. MRTs by definition
This work is important as the groups form do not capture the whole picture of nurs-
schools of thought that generate scholarship ing’s perspective on the nature of nursing
as frameworks for research and guides for work; rather, they comprise “a set of related
theory-based nursing practice.22 The grand ideas that are focused on a limited dimen-
theories in use that meet the criteria for theory sion of the reality of nursing.”25(pxiii) MRTs
evaluation on the individual level can add to are not narrowly focused on explaining a spe-
nursing knowledge by claiming the common cific discrete phenomenon as in SSTs. MRTs
goals of the discipline. Each theorist can de- characteristics include that they have a lim-
scribe, for nursing and other disciplines, how ited number of concepts, and their propo-
a given perspective fulfills the broad central sitions are clearly stated; they may generate
unifying goal of the discipline, humanization, testable hypotheses; they can be generalized
and all that it entails. across settings and specialties; they can apply
When Wills et al proposed the central uni- more directly to practice and can be empir-
fying focus of the discipline and emphasized ically tested; and they are more easily com-
facilitating humanization, they stressed that prehended by readers of practice journals.
for nurses to articulate the substance of the Meleis22 called an MRT a significant mile-
discipline it was important for “nursing stu- stone beginning about 1991 to 1995 that
dents, at all levels, to be exposed to, study and marked considerable progress in knowledge
incorporate the central unifying focus in their development. In particular, MRTs focus on
practice.”18(pE37) This argument is extended specific nursing phenomena that reflect and
to suggest that the revised structure of knowl- emerge from nursing practice and focus on
edge calls for each nursing textbook/teaching the clinical process. The number of MRTs
tool to begin with the common goals of has increased significantly in the 21st century.
the discipline and with a review from each There are books devoted to MRT,25 and the
grand theorist, or a successor, that describes more encompassing books on nursing the-
how these goals are fulfilled from that the- ory now include MRTs.26 Some of the best
oretical perspective. In this way, nurses know MRTs are Meleis’ theory of transitions,

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 34 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2019

Mischel’s uncertainty theory, and Mercer’s came from a rereading of Merton.27 He be-
theory of becoming a mother. gan his treatise on MRTs by considering their
Scholars use many strategies to develop relationship to the broader, classic theories
MRTs including deduction from grand the- in sociology. Three of Merton’s characteris-
ories. An example is Levine’s conservation tics of MRTs offer some insights to think
model used to develop a theory of health about relating middle-range and grand the-
promotion for preterm infants. Another ories in nursing today. First, Merton noted
common approach scholars use is MRTs that these theories (MRTs) “do not remain
developed from inductive research. For separate but are consolidated into wider net-
example, grounded theory was the approach works of theory.”27(p68) Furthermore, because
for Corbin and Strauss’ trajectory theory of of how they are developed, many theories of
chronic illness management. Other scholars the middle range are consonant with a vari-
use concept analysis to construct MRTs such ety of systems of sociological thought. Finally,
as the Bu and Jezewski theory of patient theories of the middle range, Merton pointed
advocacy. Induction from practice is also a out, “are typically in direct line of continu-
common strategy as in Meleis’ observations ity with the work of classical formulations.
of immigrants that led to identifying the Durkheim and Weber’s work furnish ideas to
major concepts of the theory of transitions. be followed up, exemplify tactics of theoriz-
Some MRTs are combinations of existing ing, provide models for the exercise of taste
theories from nursing and other fields as in and selection of problems, and instruct us in
Dunn’s theory of adaptation to chronic pain raising theoretical questions.”27(p66)
that uses the Roy adaptation model with Nursing knowledge today is at a more de-
the gate control theory of pain, stress, and veloped stage than sociological knowledge
coping theory and the relaxation response. when Merton summarized the attributes of
Pender derived the health promotion model, MRTs and nursing knowledge, as a practice
considered a MRT, from expectancy and discipline is different in many ways from soci-
value theory described by several authors ology. Still, for nursing today, the promise of
and Bandura’s social learning theory. the impact for nursing knowledge may be re-
Some criticisms of MRT focus on the lack alized by deriving strategies to link MRTs into
of definitional clarity that leads to a lack of wider networks. The first question in creat-
precision about what constitutes an MRT. ing such networks would be “what are the
Other authors have been concerned that criteria for linking?” One might think of clini-
increasing numbers can lead to fragmentation cal areas of practice. However, areas of prac-
of nursing’s knowledge base into unrelated tice use wide ranges of knowledge in dealing
and distinct theories. Some authors note that with holistic persons, families, and commu-
nursing has continued reliance on outdated nities. Rather, under the perspective of nurs-
psychosocial theories and less on nursing.22 ing proposed the logical choice for linking
Roy’s review of the literature from 2011 to MRTs is how given theories reach the goals
2016 showed some use of MRTs in research, of the discipline. The work of grand theories
practice, and education. How extensive this in describing how they are used to accom-
use is remains unclear, and we have not plish the goals of nursing can be helpful. In
answered the question of the impact of MRTs some cases, it might be appropriate to identify
in practice and in multidisciplinary dialogue. the grand theory most useful in understanding
In showing the implications of the pro- the MRT. This suggestion may seem strange.
posed perspective for developing nursing Still, we are trying to move forward with
knowledge, I view MRTs as a part of domain- nursing knowledge that is not fragmented, is
derived knowledge and suggest ways this recognizable, and has an impact. It may be
work can proceed under the common goals worthwhile to follow this line of thinking in
of nursing. The key for how this can occur developing strategies for nursing knowledge

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 Nursing Knowledge in the 21st Century 35

development. Grand theorists, and their suc- MRTs developed were general coping, adapt-
cessors, can identify MRTs that fit their con- ing to life events, adapting to loss, adapting to
ceptualizations or theorists of the middle chronic health conditions, and adaptation in
range can identify to which grand theories family health.
their work can contribute. We might antici- Using grand theories has been recognized
pate that some MRTs would not relate to any as one approach to developing MRT. Further-
given grand theory. These theories, consid- more, we saw that in a 10-year review, one
ering the goals of nursing, might have other theme in theory development identified by Im
conceptual links. Making such links explicit and Chang16 was grand theories used to create
can contribute creative insights into nursing MRTs. There can be considerable advantages
knowledge now and for the future. to filling out the perspective of knowledge
One example of relating middle-range and by consciously extending the connection be-
grand theories stems from a theory-based re- tween middle-range and grand theories. The
search review project by Roy and associates, wide recognition of the appropriateness of
with myself as the leader of the executive MRT for research and practice can make this
board of the Roy’s association.28 The team an appealing approach to those who are com-
reviewed 200 studies of Roy’s model-based mitted to a particular grand theory approach.
research published from 1995 to 2010. Of These scholars now can extend their efforts
these studies, 172 met established criteria for to be at the forefront of developing knowl-
sound research and criteria for adequate links edge for the discipline that is oriented toward
to the nursing model. The studies published the common goals on the broad level, facili-
in refereed journal numbered 106 and disser- tating humanization, meaning, choice, quality
tations were 72. The articles were published of life, and healing in living and dying.
in 47 English-language journals, and the dis- A third level of nursing theory has
sertations were completed at 32 different uni- been variously called practice theory, SST,
versities in the United States. The team de- and microtheory, all with differing histories
veloped a 6-step process for creating 5 new but treated similarly in nursing knowledge
MRTs. (1) Studies that were alike conceptu- discussions.13 Dickoff and colleagues began
ally were clustered together and each clus- to write about specific approaches to prac-
ter included studies using a number of dif- tice theory in the 1960s.29 The most widely
ferent qualitative and quantitative research recognized article on the approach was that
methods. (2) The studies were used as ob- published from the symposium on nursing
servations and concepts identified under the theory by Nursing Research.29 The authors
Roy’s model concepts of stimuli, coping pro- were philosophers working with the nurs-
cesses, and outcomes. (3) The team members ing faculty at Yale University. They called
responsible for a given cluster synthesized the the approach practice-oriented theory with
concepts as discrete and observable but at a 4 phases leading to a theory base for nurs-
level of abstraction that could be generalized ing practice. The phases were factor isolating
across clinical situations. For example, in the (descriptive identifying of concepts), factor
MRT of adapting to loss, the team member relating (situation depicting), situation relat-
identified the focal stimuli as loss, a profound ing (predictive statements), and situation pro-
emotional experience. (4) For each cluster ducing (prescriptive statements). Although
of studies, team members then derived the- the authors described the process in detail,
oretical statements or propositions relating to Walker and Avant14 noted that the activity
the concepts. (5) The team used the stated component, that is, predictive statements,
propositions to draw a pictorial schema of was vague as a guide to constructing the prac-
the interrelated concepts. (6) The final step tice theory. In conjunction with colleagues,
was that the findings from the research pro- Dickoff and James,30 in the tradition of
vided evidence to support the new MRT. The Yale University focusing on nursing practice,

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 36 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2019

promoted practice theory simultaneously experience about a specific situation or pop-

with the early days of the grand theory move- ulation. Meleis noted that with SSTs, there is
ment. The term “practice theory” at that time “the intent of giving a framework or blueprint
referred to seeing the causal nature of theoret- to understand the particular situation of a
ical statements that had a specific desired goal group of clients.”22(p78) SSTs are limited in
and then stated the prescriptions for action to both scope and focus. One example is the
attain the goal. Bennett et al36 SST of cognitive deficits among
Walker and Avant gave several reasons for patients with heart failure. Fifteen years after
the slow development of this type of the- the first article, Im37 conducted an integrated
ory including the astute observation that a literature review on SSTs published since the
theory for nursing practice “requires a well- first article and identified 19 SSTs and ex-
developed body of nursing science on ef- tracted 4 themes from the synthesis. One
fective nursing interventions.”14(p18) There theme was that the authors either claimed
have been efforts toward developing knowl- or they did not claim an SST. Multiple the-
edge of nursing interventions, particularly the oretical bases were used along with unique
projects out of the University of Iowa related theorizing methods. Although the theorists
to taxonomies of interventions and outcomes provided clear directions for nursing interven-
related to nursing diagnoses.31,32 While these tions, these were rarely evaluated.
projects are making contributions to nurs- The third term used for the final level of
ing practice, they are generally seen as pro- nursing theory is “microtheory.” This term is
viding possibilities for knowledge develop- used in books on nursing theory but is not
ment but not for theories seen as practice discussed as a preferred term related to prac-
theories. Some research teams have focused tice. In the general nursing literature, there ap-
on particular practice phenomena, created pear to be 2 movements in nursing that stim-
theories, and applied these theories to re- ulated a specific use of the term. First in the
search with many populations, for example, postmodern turn in nursing epistemology.9
the University of California at San Francisco Rodgers related literature indicated the need
School of Nursing developed a symptom man- to focus on microtheory, presumable mean-
agement model.33 The model includes the ing the relationship of concepts in the imme-
experience of symptoms, symptom manage- diate situation. For example, Lupton38 refers
ment strategies, and symptom outcomes. The to microtheory when discussing power in the
members of the team have used the model nurse and medical encounter. Another move-
to address fatigue in the care of persons ment that encouraged scholars to use the
with HIV/AIDS and management of symp- term was the “evaluation of quality of nurs-
toms among African Americans with diabetes. ing care.” Sidani et al39 noted that the focus
Other sources of knowledge-based interven- in the theory-driven approach to evaluation is
tions are the databases for evidence-based on identifying patient, professional, and set-
practice. The place of this work in nursing ting characteristics that affect the processes of
knowledge is being debated.34 care at micro and meso levels, which, in turn,
Im and Meleis35 published an article on contribute to outcome achievement. From
SSTs. The authors defined these as theories this brief review, it appears that this is not
that focus on specific nursing phenomena a term that is used broadly to indicate theory
that reflect clinical practice, are limited to spe- at the practice level. Rather, it is a description
cific populations or to particular fields of prac- of how to focus on concepts in practice for
tice, and provide a particular context, histori- given purposes.
cal or social. Eventually, these theories could Given the history and ongoing use of the
be specific enough to provide blueprints for 3 terms, the term “practice theory” is se-
action. SSTs could emerge from synthesizing lected for the third level of theory placed in
and integrating research findings and clinical the middle of the perspective on knowledge

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 Nursing Knowledge in the 21st Century 37

development proposed. It already has a mean- tools will begin with describing the common
ing to nurses and other health care providers. goals of nursing. Furthermore, these introduc-
In addition, it has a history that provides tions would describe how each nursing grand
more potential than has been realized to date. theory provides perspectives for achieving
The question now is how practice theory these goals. The creating of practice theory
can be developed to contribute to the reno- could receive a major forward impetus by be-
vated place of theory in domain-derived nurs- ing related to established middle-range and/or
ing knowledge that accomplishes the goals of grand theories. More nurses are attaining PhD
nursing as facilitating humanization, meaning, degrees and desiring to maintain positions in
choice, quality of life, and healing in living practice. This situation can provide a basis
and dying. Early in the theory development for institution-centered theory-based practice.
era, Ellis40 highlighted the role of the practi- The Magnet Recognition Program has led the
tioner as theorist. Roy5 pointed out that the way in nurses creating professional practice
profession experienced the loss of many years structures. Both Watson and Roy report work-
of practitioners not playing an integral part ing with hospitals related to implementing
in theory development. I have mentioned, their theoretical work as the basis of build-
Walker and Avant’s14 observation that in the ing a nursing philosophy, and studies are in
1960s, Dickoff and James’ practice-oriented progress to evaluate this effectiveness of the
theory with 4 phases did not immediately lead process (Turkel, unpublished report 2018). A
to developing theories of this type, partly be- schematic (Figure 2) of the central portion of
cause of the lack of a well-developed nurs- the process of domain-derived nursing knowl-
ing science on effective nursing interventions. edge development, the linking of levels of
With the nursing knowledge developed in nursing theory, is presented in what I call the
the intervening years, significant progress has domain-derived nursing knowledge tree.
been made in efforts related to interventions I am not advocating mandating that institu-
such as those described earlier. Furthermore, tions focus on given grand theories but sim-
nurses in practice identify the needs for new ply suggesting the advantages to the process
knowledge to work effectively within the of developing practice theory when nurses
complexities of the current practice arena. are committed to common assumptions about
Nurses in practice today are natural partners nursing and to common goals. Placing the-
for theorists in developing practice theory. ory experts with practicing nurses will en-
In describing the characteristics of prac- hance the natural growth of solving clinical
tice theory, McEwen and Wills41 noted that
practice theories may be derived from middle-
range or grand theories, from clinical prac-
tice, and/or from research. Their function is
similar to other levels of theory, that is, to
describe, explain, predict, or prescribe spe-
cific nursing practices. These authors also
noted that the nursing literature reflects only
a few examples of practice theories. To be
central to knowledge development in nurs-
ing, as with middle-range and grand theories,
what is needed are the links that place prac-
tice theory in direct line with contributing
to the broad goals of nursing. Consistency
and logic require these links to be concep-
tual and theoretical. I have already introduced Figure 2. Domain-derived nursing knowledge tree.
the notion that nursing textbooks/teaching MRT indicates middle-range theory.

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 38 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2019

problems with theory-based knowledge. The ical formulations that rely on both qualitative
literature has long included the observation and quantitative research to further their
that practicing nurses use implicit theory work.
rather than explicit theory.41,42 Similarly, the I have placed theory at the center of the
gaps between research and practice, between development of knowledge and renovated its
theory and practice, and between evidence- role in describing, explaining, and predicting
based practice and practice are frequent by expanding the strategies to create and link
themes. Trying a new approach to linking the- theory at all levels. This renovation puts nurs-
orists and practitioners has promise of closing ing theory in a position to drive and carry out
these gaps and making explicit the knowl- the nursing research agenda. The question of
edge used in practice. Bender and Feldman43 what domain-derived knowledge is needed to
propose a specific kind of practice theory attain the goals of nursing is answered by the
that links the environment domain of nursing theory development described. The needs for
theory with real-world environments where knowledge of persons in their environments
nurses practice. The result could be nurse-led are embedded in each nursing grand theory
delivery models such as those featured in the and will continue to change as the demands
EdgeRunner program.44 on persons and the health care environments
With theory placed at the center of nursing change. As noted, one can envision a tree
knowledge development, I have suggested of knowledge, with grand theories linked to
some updated conceptual/theoretical strate- MRTs linked to budding practice theories. We
gies for developing theory in the future at 3 may also see a ring of bushes around the tree
levels, grand theory, MRT, and practice-level that represent related consolidations of net-
theory. From the discussion of these theories, works of MRTs and practice theories that may
based on person and environment integra- yet grow into grand theories of their own.
tion, the use of multiple methods of inquiry With clear goals for the discipline, we can
is recognized. Nurse scholars often use quan- recognize where knowledge is lacking and
titative empirical approaches to test middle- a new theory with related knowledge devel-
range and practice theories. The nursing theo- opment is needed. Nurse scholars, beginning
ries provide clear delineation of the concepts and advanced, can identify where their knowl-
and their interrelationships. From statements edge development work fits on the tree and
of relations between the concepts, known what related work is needed. Or, a scholar
as propositions, researchable questions are may plant a new bush.
derived. Methods and measurement to an-
swer the questions follow a clear theoretical Theory evaluation
framework. Outcomes of empirical studies At the same time that we update the role of
are feedback to clarify the middle-range and theory in creating nursing knowledge, we will
practice theories and offer insights to refine also need to update the evaluation of nursing
grand theories. Philosophical inquiry clarifies theory. The development of domain-derived
the values of nursing theory at all levels. knowledge stemming from theories raises the
In addition, it provides the epistemological obligation to evaluate the effectiveness of the-
understandings as to when and how to use ap- ories for meeting practice goals. Theories to
proaches other than empirical. For example, be epistemologically rigorous will accurately
based on philosophical inquiry, a scholar us- represent the phenomenon, be philosophi-
ing Parse’s theory of human becoming would cally sound and able to direct practice.45 Qual-
understand the use of qualitative research in ity for a theory requires that we can say a
expanding knowledge on the middle-range or given theory accounts for and explains cer-
practice level. Other grand theorists such as tain facts in practice better than rival theories.
Watson and Roy use assumptions and theoret- Effective changes in practice can be created

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 Nursing Knowledge in the 21st Century 39

from the robust basis of rigorously developed teams of theorist experts and practice nurses
theories. Theory evaluation criteria have been will help make possible the time needed for
proposed by a number of scholars from the comparison and longitudinal studies. The
1960s through the 1990s.15 These criteria are outcomes of such studies are important to
used to evaluate one theory at a time and do the continued development of knowledge for
not provide for comparisons. The approach nursing.
has been useful to help nurses become fa-
miliar with nursing theories. Paley,46 a non-
nurse philosopher, noted that the vagueness PRACTICE-SHAPED KNOWLEDGE FROM
of many nursing theories leads to questions THE BASIC SCIENCES
about what observations can be explained by
what theory. In the literature, I did not find de- In filling out the proposed perspective of
signs for comparing various nursing theories knowledge development (see Figure 1), the
and, possibly, they do not exist. Recognizing all-important step of integrating the theory-
this need, for a number of years, 1982 to 1988, based domain-derived knowledge with the
I designed and attempted to conduct a study basic science practice-shaped knowledge fol-
that permitted the comparison of 3 major the- lows. With rapidly developing sciences, nurse
oretical approaches in 3 defined clinical sit- scholars are challenged to raise significant
uations, called the MINC project (Models in questions from the discipline perspective so
Nursing Care). This venture failed because I that new science knowledge is created that
could not find a clear implementation strat- can be practice-shaped for use in nursing.
egy for one of the theoretical perspectives In a recent article, I proposed “that deriving
among the experts I consulted at that point an updated structure for nursing knowledge
in time. can move the discipline forward by making
Methodological issues in testing nursing nursing theory the global positioning system
theories are abundant. Nursing theories not (GPS) for knowledge development.”5(p89)
only assume holism of persons and belief What does integrating new knowledge in life
in expressed patterns but also consider sciences—including genomics and omics, be-
that these may be almost infinite in their havioral, social, biomedical, and management
variety. Constantly, we call into question the sciences—into nursing knowledge look like?
adequacy of outcome measures. In general, What kind of strategies can be used to create
nursing does not do enough refinement and this integration?
replication of studies. Many phenomena in Nursing has long integrated other sciences
nursing require longitudinal studies. The into nursing knowledge. The challenge now
proposed nursing knowledge development is that with information technology develop-
schema includes time as a concept under ments, these sciences are developing rapidly
the domain-derived person and environment in both depth and breadth. Henly47 noted that
knowledge development. In many nursing these developments can be a part of nursing
conceptualizations, time is needed, for science as another way of looking at individ-
example, for building relationships and for ual differences. It is neither simply adding
processes of humanization, finding meaning, knowledge nor setting aside our nursing
and healing. Comparative evaluation of the perspective. The author suggested the omics
effectiveness of different models in given clin- create circumstances needed to incorporate
ical situations will not be easy. Still, it is an im- biology with psychosocial and behavioral
portant strategy in nursing knowledge devel- aspects of nursing science and thereby create
opment. The definitions by theorists of how an in-depth, multiscale, dynamic understand-
their assumptions contribute to nursing goals ing of people related to health and illness.
will help clarify the variables of interest. The Nurses can identify the practice-shaped

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 40 ADVANCES IN NURSING SCIENCE/JANUARY–MARCH 2019

knowledge they want to integrate by asking knowledge developments can be classified

questions such as: How close is this knowl- by level of readiness for practice. Resources
edge to being ready for human use? Is the for nurses to learn about developments can
basic science knowledge compatible with be provided. Special information technology
nursing’s central unifying goals? Do nurses bulletin boards may be useful. Programs of
have the capabilities to shape this knowledge trial implementation can be instituted. Given
with the realities of practice so that it can be the significance of the path we are taking,
integrated? these trials may receive funding at the same
Some nurse scientists may contribute level as the basic science funding for nurses.
to knowledge development of the basic Nursing’s roles in transforming basic science
sciences. At the professional crossroads knowledge for use in practice will make nurs-
where we stand, it is important to not detour ing more visible. Nurses will help enhance
from our primary professional commitment adoption of best practices in the commu-
to develop domain-derived knowledge for nity and collaborate to change health care to
use in practice. As noted earlier,5 nursing’s bring nursing science to every setting where
domain-derived knowledge can be helpful to needed. The domain-derived knowledge pro-
scientists/practitioners from other disciplines vides the voice nurses need at the interdisci-
who contribute to dealing with human health plinary table to lead research that envisions
issues. Nursing can inform basic science a goal of humanization (see the last row of
knowledge for application to people. The Figure 1).
essential point is that for nurses to achieve
the goals of the discipline and maintain CONCLUSION
our social mandate as the profession of
nursing, we must focus on domain-derived Nursing may be at a crossroads, with the
knowledge. balance for knowledge development among
Nurses must use the majority of our schol- philosophical, conceptual/theoretical, and
arly resources to develop the domain-derived empirical inquiry seemingly tilting toward
knowledge. We will likely develop new nurs- prioritizing the empirical approaches. This
ing knowledge development roles that are imbalance is related particularly to what are
part of upscaling from individual practice to called the emerging areas of basic sciences.
changes in practice at the organizational level. The issue is that this movement may obscure
Nurses can describe practice-shaped basic sci- our primary obligation to develop nursing
ence for nursing as theories from sciences knowledge that is domain driven. Given
other than nursing that have been examined this concern, in this article, I have clarified
and honed to meet the goals of nursing in the domain of nursing and described the
practice. We need nurses who can evalu- central role of nursing theory in creating
ate developing sciences, beginning with the domain-derived nursing knowledge to attain
questions listed earlier. The steps of practice- the common goals of nursing. These goals
shaped knowledge will require nurses with are based on a central unifying focus for the
knowledge and commitment to the practice discipline that includes facilitating human-
arena. This role will also require creative ization, meaning, choice, quality of life, and
ways of communicating between basic sci- healing in living and dying.18 The knowl-
entists and practicing nurses. In 2012, Bren- edge development perspective and derived
nan and Bakken48 wrote about how nursing strategies include integration with practice-
needs big data and big data need nursing. The shaped basic sciences. I have suggested
authors provided a graphic depiction of the strategies to implement this knowledge
role of nursing theory in data-driven research. development with outcomes for patients/
For example, theory determines how such families, organizations, and multidisciplinary
data are structured and visualized. Science research.

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 Nursing Knowledge in the 21st Century 41

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