Abstract
Theory is a key component in nursing scholarship. A fundamental aim of nursing scholarship is to generate understanding of processes and human experiences of health. The combined practices of nursing science and the profession can be uniquely beneficial to theory development. However, traditional views of science in nursing may dampen the synergy between these two practices for developing nursing theories. In this article, I present particular ideas about nursing theory today, including some traditions that we may need to transcend, drawing from current thinking in philosophy of science and nursing science.
Theory is a key component in nursing scholarship. A fundamental aim of nursing scholarship is to generate scientific theories about processes and human experiences of health. Nursing is both a discipline of epistemic practices and a profession of caring practices, and the combined practices of nursing science and the profession can be uniquely beneficial to knowledge production. However, traditional views of science in nursing may dampen the synergy between these two practices for theory development. Contemporary philosophy of science offers a more open and inclusive view than what is sometimes evident in nursing literature—for example, that science necessarily focuses on facts and leaves behind humanist values central to practice. This is traditional thinking. In this article, I offer particular ideas about nursing theory today as motivated by current thinking in philosophy of science and nursing science. The following sections were organized according to the 1978 National League of Nursing book Theory Development: What, Why, How?
WHAT Is Nursing Theory?
Nursing theory is scientific. In science, theory is an empirically validated description of an explanatory process or mechanism, which consists of concepts and their interrelationships, that produces or influences a phenomenon of interest. Phenomena are “stable and general features of the world” similar to empirical generalizations formed from specific observations and empirical data (Borsboom et al., 2021, p. 758). A process or mechanism is a system of components that interact to produce regularities or patterns underlying the phenomenon (Borsboom et al., 2021; Thagard, 2009).
Nursing phenomena have been described by metaparadigmatic themes elaborated in nursing conceptual models, paradigms, and philosophies of nursing. The broad phrases human-environment-health processes and human health experiences are often used to summarize focuses of nursing. These phrases represent a range of phenomena—from the cellular to the system and beyond—for developing nursing theory. Moreover, scientists in disciplines other than nursing study human-environment-health processes and health experiences.
An approach to distinguishing nursing theory and research within the community of sciences is to delimit these broad focuses by adding qualifying content (see italicized text) to the two components of scientific theory, phenomenon and explanation:
The phenomena of interest are human health experiences of well-being or wellbecoming.
Potential explanations of phenomena are based on human-environment-health processes that interact with (are associated with, affected by, or facilitated by) trustworthy, caring actions and interactions.
In addition, these caring actions and interactions typically but not necessarily involve professional nurses and may involve others, such as family caregivers, friends, and self-caregiver, who are equipped with nursing knowledge needed to foster well-being in health experiences. These actions and interactions are the context that defines the domain of reality that nursing scientists seek to explain.
To summarize what a nursing theory is, I inserted substantive content of nursing theory into a simple template of structural components of scientific theory (in bold):
● In other words, the underlying process or mechanism in a nursing theory that explains a nursing phenomenon of interest, a health experience of well-being or wellbecoming, is a human-environment-health process facilitated by trustworthy and caring interactions. Well-being and wellbecoming may be realized across various health experiences, including robust physical health, chronic illness, or ending of life.
A scientific theory is not a set of statements derived deductively from natural law or from a stable set of principles as according to the positivist philosophy of science of time past. Theories derive from empirical inquiry and inferential, often abductive, critical reasoning to explain processes or mechanisms of phenomena. Nurses have never been positivist in their philosophical views about nursing phenomena. Notably, even when vestiges of positivism were prevalent in the sciences during the 20th century, Whall (1989) demonstrated that practicing nurses were not influenced by this philosophy of science. Theoretical works by nurses today illustrate that nurses do not theorize by positivist perspectives.
Some philosophers suggest that the term “theory” be replaced with “model” to better align nursing theoretical structures with those described in philosophy of science, as well as to avoid reference to positivist notions of theory as derived from universal, unchanging principles (Bender, 2018; Risjord, 2014). In general, models are concrete or conceptual representations of a system or process underlying a phenomenon. Some nurses may find that “model” is useful to describe their theoretical work (see Reed, 2019, for a specific discussion of models and theories in nursing science). We can consider models as conceptual structures that are either based on or independent of explanatory theories. Models serve in various ways to facilitate knowledge production in preliminary, exploratory, or interpretive roles for theory development (see Borsboom et al., 2021; Frigg & Hartmann, 2024). Currently, the term “theory” with related terms of theoretical framework, model, or theoretical model is often used in nursing to refer to scientific theory, particularly from sociology’s midrange theory approach.
However, this flexibility in theory terminology requires at least that we clarify the distinctions between scientific theory and nursing’s classic nursing conceptual models (and conceptual frameworks, paradigms, grand theories), which lack the scrutiny of empirical testing and direct applicability to practice. A half-century ago, Engstrom (1984) identified as one of the prevailing obstacles in nursing theory the failure to bring empirical findings to theories—to validate, refine, reformulate, or refute their propositions. Still too often today nursing theory is taken to refer traditionally to the nursing conceptual models or similarly broad conceptualizations when, for example, discussing content for a nursing theory course or criticizing a gap between theory and practice. Of course, there is a gap when the so-called nursing theory is not designed for empirical research and practice. In efforts to avoid confusion and make our scientific theories “explicit” (Pickler, 2018), it is important to reserve use of the term “nursing theory” for those conceptualizations with active connections to research.
Nursing conceptual models articulate a variety of guiding or inspiring narratives—but not required narratives as in a “top-down” hierarchical approach to theory development (Bluhm, 2014)—on human-environment-health processes and nursing practice. Nursing conceptual models hold significance for their historical and contemporary roles in articulating focuses of the discipline and remain irreplaceable in the infrastructure of nursing knowledge, even as understandings of nursing theory develop and change.
WHY Theory?
It is “impossible to put empirical results to use without recruiting some theoretical resources” (Boyd & Bogen, 2021). Scientists collect empirical data about their phenomena of concern and then “make sense of it in the form of theories” (Rovelli, 2018, p. 486). In particular, the concept of mechanisms (or processes) is a central theoretical resource in scientific theory.
Philosophers and scientists promote the concept of mechanisms to improve knowledge development for healthcare practice and policy (Konsman, 2024; Pérez-González, 2024). Konsman elaborated on an expanded view of mechanisms to examine interrelations among bio-psycho-social variables to better explain depression and unexplained pain. Furthermore, he suggested placing “mechanism” at the top of the evidence hierarchy along with randomized controlled trials to validate medical knowledge. Similarly, philosopher of science Nancy Cartwright and her colleague critiqued the limitations of the statistical, atheoretical approach to knowledge in evidence-based medicine (Cowen & Cartwright, 2020). To boost the internal validity of evidence for practice, they argued for supplementing data analysis with theoretical knowledge of underlying mechanisms of interventions.
Nurse scientists and philosophers promote knowledge of mechanisms to gain deeper understanding of phenomena such as mindfulness, resilience, and nurse compassion; see overviews of research from Risjord (2014) and Saban and Janusek (2021). Ramsay (2021) reported research on work to theorize better about concussion in children, describing his reconceptualization of the philosophical concept of objectivity to gain fuller understanding of this complex problem. His reconceptualization moved beyond a solely biomedical view to incorporate a systems perspective of a range of mechanisms—molecular, cellular, cognitive network, social, and nursing practice knowledge of pediatric patients’ symptom experiences. Notably, experiential as well as underlying mechanistic processes were included in his inquiry to understand healing from concussive injuries.
Access to an adequate fund of explanatory theories minimizes the need for nurses to resort to intuition, philosophy, beliefs, or other nonscientific sources as the primary explanation for nursing phenomena that they observe each day. Concepts in scientific theory are in principle observable, so they and their interrelationships can be described, measured, tested, validated (or not), and taught to inform people about a phenomenon of interest. Scientific theories are best when they provide not just descriptive knowledge from observations but also theoretical knowledge that explains causes or influences of phenomena in a particular domain of the world.
WHY Nursing Theory?
Why is nursing theory—not just theory—important for nursing science? Because nursing is not just a science, it is a special science. In a classic philosophical paper, Fodor (1974) argued against the positivist thesis in philosophy of science that “all true theories in the special sciences [the many sciences other than physics] should reduce to physical theories in the long run” (p. 97). Fodor conceived of the existence of specialized and autonomous disciplines, distinct from physics, that contribute to scientific advancement. He identified these disciplines as the “special sciences.” Furthermore, he proposed that special sciences exist not just because of the unique methods or perspectives of disciplines but “because of the way the world is put together” (p. 113). Fodor’s statement aligns with perspectival realism, as a philosophical view of reality (see Massimi, 2022; Reed, 2019).
Nursing is a special science that has evolved to study human health phenomena from the perspective of nursing proper—health-related trustworthy and caring actions and interactions that facilitate well-being or wellbecoming. No other discipline is expected to produce theoretical knowledge that explains nursing phenomena. This is an unspoken responsibility inherent in nursing’s social mandate since disciplinary knowledge is essential for professional practice.
HOW? A Unique Approach to Developing Nursing Theory
In the domain of high-energy physics, dark matter, which makes up to 85% of our universe and is “tremendously important” in understanding the nature and evolution of the universe, is elusive since it “interacts very weakly or almost not at all with the ordinary matter that we and our measuring instruments are made of” (U.S. Department of Energy, n.d.). Scientists know that dark matter exists by its gravitational force. They are challenged with work on new theoretical models that will inform efforts to interact with dark matter as their phenomenon of interest. We must interact with reality to understand reality.
In the domain of nursing, we too are challenged to advance understanding about phenomena of interest. In seeking to understand health processes and experiences, nursing theorists and scientists have access to a special form of interaction that can enhance the validity of their inquiry: connections to contexts of nursing practice. Philosopher Potochnik (2016) presented an account of scientific explanation aligned with linking nursing theory and practice. She argued for a communicative approach to developing explanatory theory, asserting that “good explanations” have both “the proper relationship to the world” in depicting underlying processes of phenomena and the “proper relationship to their audience” in fostering understanding (p. 723). Potochnik’s philosophical view of explanation emphasized interaction between explanation and the audience as “explanation-seekers,” an interaction ignored by traditional philosophers of science concerned instead with theory connections by logical deductions from stable principles or natural laws. However, “the relationship between an explanation and its audience is absolutely central to the nature of scientific explanation” (p. 730).
For nursing science, I propose that this “audience” of explanation-seekers extends beyond the researcher or theorist to include the interests of practicing nurses, patients, families, or communities—those affected by and who can contribute to the understanding, interventions, and policies informed by the theory. Such individuals, according to Longino (2008, 2022), are relevant knowers in knowledge production. Explanation-seekers influence what features of the phenomenon are salient, even including potential correlates and contextual factors that may influence the phenomenon (Potochnik, 2016). In other words, this communication between explanation and explanation-seekers focuses not only on identifying the relevant problems (phenomena) for inquiry but on proposing theoretical explanations of the phenomena. In doing this, the audience participates in the abductive reasoning process of theory development.
For nursing, the scope of abductive reasoning in this communicative approach to theory is broader than that for traditional science; that is, the proposed explanation of a phenomenon is inferred from various sources of knowing, including empirical research, existing theories, disciplinary perspectives, and insights of the nursing practice community. Scientific endeavors to explain phenomena are best served by a deliberative, participatory approach to knowledge that brings a diverse set of values and viewpoints to the process (Longino, 2008). Furthermore, since “phenomena have many different causal influences and there are many different patterns in how these influences play out,” engagement with a community of knowers assists in producing contextually relevant theoretical explanations (Evans & Potochnik, 2023, p 13). In other words, this communicative approach facilitates development of scientific theories that maintain the distinct perspectives and interests of its community of knowers (Potochnik, 2016).
Transcending Traditions in Theory
Philosophers remind us that scientific disciplines benefit from philosophical reflection on their practices of science, some of which may insulate a discipline from opportunities for scientific progress (Bender, 2018; Risjord, 2014; Rovelli, 2018; Thagard, 2009; Thorne, 2022). Nursing scholarship moves forward by appreciating and building on the discipline’s legacy of theory and scientific practices while nevertheless transcending some traditions.
The philosophical reflections on theory in this article outline opportunities for scientific progress:
In reference to What theory is—Scientific progress means encouraging development of more explanatory theories than descriptive theories more common in nursing. Describing phenomena gives an account of things and associations already there, whereas explaining phenomena brings in something new, previously unknown but created out of reasoning and inquiry.
In reference to Why nursing theory—Scientific progress means embracing nursing’s status as a special science with its unique perspectives on human health processes and experiences for theorizing explanations. It means transforming traditional conceptual tools—for example, caring, human-environment process, spirituality, wellbecoming—into explanatory tools (empirically-based theories) that effectively explicate nursing phenomena for human betterment.
In reference to the How of nursing theory—Scientific progress means activating latent connections between theory and practice to generate theoretical explanations. It means engaging nursing practices (those trustworthy, caring actions and interactions) upstream, not downstream, from theory development. The creative generation of ideas, artistic or scientific, is energized by interactions between the idea and its audience. Tucson muralist Joe Pagac produces brilliant, building-sized public murals that resonate truth with the community. But first, he engages with the community by volunteering, working, and exploring the space where he will produce his mural (Blaser, 2024). Similarly, progress and productivity in nursing theory and science may require more active engagement in those spaces where nursing actions and interaction occur.
We must interact with our domain of reality to understand reality. This is so for physicists’ understanding of dark matter, for Pagac’s understanding what makes a mural meaningful to his community, and for nursing’s understanding of underlying person-environment processes that foster human well-being and wellbecoming. Progress in nursing theory depends on valuing and valorizing the interaction between the epistemic and caring practices of nursing.
