Seminar

on
Domains of nursing

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Introduction:
“Theory development in nursing science is critical for evolution of the
discipline” (Clarke & Lowry, 2012, p. 333), and growth of the profession is
dependent on nurses knowing and using nursing theoretical works in their
practice of nursing. Studies continue to generate evidence of the connections
among knowledgeable use of nursing theoretical works, education, and quality
nursing practice (Bigbee & Issel, 2012; Erickson, 2007; Fawcett & Garity,
2009; Hatlevik, 2012; Im & Chang, 2012; McCrae, 2011; Sieloff & Bularzik,
2011). This evidence is vital for the practicing nurse. This chapter sets the stage
for the chapters that follow and introduces new understandings as Carper’s
(1978) patterns of knowing are proposed as types of nursing theory and
evidence for nursing practice (Fawcett, 2012a). These works represent the
empirical pattern or the science of nursing understood as a type of theory and
the form of evidence necessary for quality nursing practice (Carper, 1978;
Fawcett, 2012a).
Descriptions of the levels of abstraction of these nursing works from seven
nursing models, three philosophies of nursing, and six theories of nursing
illustrate their linkages with the practice level in middle-range theory. The
theoretical frameworks guide professional practice; organizing the thought
processes for decision making and reasoning for quality nursing practice. The
content of nurses’ decisions may be unique nursing knowledge, but the modes
of making practice decisions are generic processes of logic and critical thinking
(Scriven & Paul, 2004).
Nursing theoretical works (philosophies, models, theories) are knowledge
structures that link logically with inherent critical thinking processes. A key part
of this chapter presents points to be considered when selecting a nursing
theoretical work to guide your practice. You may discover that certain of the
works resonate with you more than others. A good fit between the nurse and the
theoretical work selected is important and is usually related to mutual values
inherent in a theoretical work and the nurse. Chapter 4 presents an insightful
discussion of the moral obligations and values inherent in theoretical works.
Once a theory is selected it is recommended that you expand your
understanding of that theory by reading published materials written by the
theorist.
The Relationship of Philosophies, Models, and Theories
The philosophies, models, and theories of a discipline are theoretical structures
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that address the central concepts of that discipline. The science of nursing is

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recognized as a fundamental pattern of knowing for nurses (Carper, 1978).
Fawcett
(2005) proposes a nursing metaparadigm based on Kuhn’s (1970) philosophy of
science and paradigm development. The metaparadigm specifies disciplinary
boundaries of human beings, environment, health, and nursing as a context to
understand the interrelationships among those elements of contemporary
nursing science (Fawcett, 2005). Theoretical knowledge may be differentiated
by the way it is named or labelled.
A model tends to be named for the person who authors it, for example, the
Neuman Systems Model. Grand theories tend to be named for the outcome they
propose, for example, the Theory of Optimal Client System Stability, and
theories tend to be named for the characteristics their content demarcates as an
explanatory shell of the outcomes, they propose. An example is Gigliotti’s
(2003) theory of women’s multiple role stress, which she validated as middle
range with the age groups of women and forms of stress (Gigliotti, 2011,2012).
A Structure of Nursing Knowledge Types and an Example of Each Type

Knowledge Type Examples of Types of Nursing Knowledge

Metaparadigm Human beings, environment, health, nursing

Philosophy Nightingale’s philosophy

Conceptual models Neuman Systems Model

Grand theory Optimal Client System Stability

Theory Flexible line of defense moderates Optimal Client System

Stability

Middle-range theory Flexible line of defense moderates stress levels for Optimal
Client System
Stability in women who are enacting multiple roles
(Gigliotti, 2011)

The above table presents types of nursing knowledge at each level of

abstraction and an example of nursing knowledge for each type.

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• The metaparadigm is the most abstract set of central concepts for the
discipline of nursing (i.e., human being, environment, health, nursing), and
these concepts are defined within each of the conceptual models and according
to the philosophy of that model.
• Philosophies present the general meaning of nursing and nursing phenomena
through reasoning and logical presentation of ideas (Alligood, 2005). Although
Nightingale (1946) did not present her philosophy on the relationship of patients
and their surroundings as a theory, her philosophy contains implicit theory that
guides nursing practice.
• Conceptual models (also called paradigms or frameworks) such as the Neuman
Systems Model (Neuman & Fawcett, 2011) are the next less abstract set of
concepts in the structure.
• Grand theory (e.g., Neuman’s Theory of Optimal Client System Stability) is
next as the level of abstraction descends. Theory can be considered grand when
it is nearly as abstract as the model itself and when the usefulness of the model
depends on the soundness of that theory. Grand theory is especially useful in
research and practice because it is more general, and theories specifying the
details of practice can be derived from it.
• Theory is the next less abstract level; it is more specific than grand theory but
not as specific as middle-range theory (e.g., Optimal Client System Stability in
specific settings).
• Finally, as mentioned earlier, middle-range theory is the least abstract set of
concepts and the most specific to nursing practice (e.g., promoting Optimal
Client System Stability through a stress reduction intervention in the work
environment). The understanding of theory terminology is developed over time
with knowledge of works at the different levels of abstraction (Fawcett, 2005;
Reynolds, 1971).
Philosophies are theoretical works that address one or more of the
metaparadigm concepts (person, environment, health, and nursing) in a broad
philosophical way. Philosophies address questions such as:
• What is nursing?
• What is the nature of human caring?
• What is the nature of nursing practice?
• What is the social purpose of nursing? (Alligood, 2005).

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Therefore, philosophies are broad statements of values and beliefs that propose
general ideas about what nursing is, what nursing’s concerns are, and how the
profession addresses its moral obligation to society. Each philosophy is a
unique view of nursing.
Nursing models are frameworks or paradigms of the science of nursing that
address the person, environment, health, and nursing metaparadigm. What this
means in terms of nursing practice is that the way you think about people and
about nursing has a direct effect on your approach with people what questions
you ask, how you process the information that is learned, and what nursing
activities are included in your care. Therefore, a model provides a perspective of
the person for whom you are caring, specifies the focus for the delivery of care,
and structures the reasoning, critical thinking, and decision making in your
practice. Nursing theories derive from models and are guiding structures for
reasoning and decision making about the person, the person’s health situation,
and the care indicated. Theories are composed of sets of concepts, but they are
less broad and propose specific outcomes. Theories may have been derived
from a philosophy, a nursing model, a more abstract nursing theory, or a model
or framework from another discipline. Theories are based on propositions or
relationship statements that are consistent with theoretical works from which
they are derived, but a theory coming from a nursing model such as Theory of
Accelerating Change (based on Rogers’ Science of Unitary Human Beings) or
Theory of the Person as an Adaptive System (based on Roy’s Adaptation
Model) is more focused and guides your approach and perspective. When you
approach people from the perspective of a certain nursing theory and ask
questions, process information, and carry out specific activities, an outcome is
anticipated based on the theory. This is true whether the theory is guiding the
design and delivery of nursing care or the design and conduct of a research
project. Just as theory strengthens nursing practice, theory based research
produces evidence for practice (Fawcett, 2012a,b). Theories have been specified
as important forms of evidence. Evidence-based nursing practice is encouraged
but is dependent on ways to recognize quality evidence. And the quality of
evidence-based practice is dependent on recognition of quality research
(Fawcett & Garity, 2009).
Middle-range theory is the least abstract in the structure of knowledge and as
the term range suggests middle-range theories are at various levels of
abstraction. These theories are at the practice level, and include details of
nursing practice. Grand Theories such as Rogers’ Theory of Accelerating
Change, Roy’s Theory of the Person as an Adaptive System, and Neuman’s
Theory of Optimal Client System Stability are examples of grand theories

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because they are broad and their level of abstraction is close to the model from
which they are derived. When a

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theory is at the grand theory level, many middle-range applications of that
theory can be developed for practice by specifying factors such as:
• The situation or health condition
• The client population or age group
• The location or area of nursing practice (e.g., home, hospital, community)
• The action of the nurse or nursing intervention
The process of specifying the details in the theory makes it less abstract and less
broad; therefore, it applies to specific types of patients, in specific situations,
and proposes specific outcomes about the care for the patient. Research reports
of studies that test middle-range theories and specify the details yield findings
that are evidence for evidence-based practice.
In this theory utilization era the communities of scholars surrounding nursing
theoretical works (philosophies, models, and theories) continue to grow and
expand globally (Bond, Eshah, Bani-Khaled, et al., 2011; Im & Chang, 2012).
Growth in the development and use of middle-range theory in research and
practice has exploded in the global nursing literature. Expansion is obvious by
publications in scholarly nursing books and journals. A few recent examples are
Bultemeier (2012) in Malawi and the long history of Neuman’s Systems Model
in Holland (Merks, Verberk, Kuiper, et al., 2012). Nursing theory societies have
global members who contribute ideas for middle- range theory development,
testing, and use in theory-based practice.
Definition of Nursing, Nursing Beliefs, and Domains
Nursing is a profession in the health care sector that contains both art and
science of delivering care to a patient with respect, kindness, and compassion.
According to Potter, Perry, Stockert, and Hall (2013), nursing includes limitless
paths of career developments, such as “clinical practice, education, research,
management, administration, and even entrepreneurship” (p.1). Generally, a
nurse works with patients and their families in order to help them with their
treatment, to provide them a sufficient knowledge about illness, and to fulfil
their medical desires, such as a relief from pain. Underlining beliefs are very
important in order to become a successful nurse because this type of profession
is strongly interrelated with civilized moral values and principles. Thus, nursing
must be based on best practices, such as orientation on customer, respect and
compassion, honesty, responsiveness, human dignity, equality, prevention of
suffering.
There are several existed domains in nursing. Most important are knowledge,

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competence and skills, ethics, and the environment. According to Reimanis

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(2015), there are seven major domains in nursing, such as direct clinic practice,
guidance and coaching, consultation, evidence-based practice/research,
leadership, collaboration, and ethical decision-making. Kim (2010) adds that
there are four theoretical domains in nursing, such as Client, Client-Nurse,
Practice, and Environment. The author underlines that all four of these domains
are interrelated. For instance, the Domain of Client that includes pain
experience, stress, and overweight can be impacted by the Domain of
Environment that consists of noise, and family’s eating habits. Alternatively, the
Domain of Practice that includes nursing assessment and personalization of care
can have a profound impact on the Client-Nurse Domain that consists of Client-
nurse distancing and empathy (Kim, 2010). Additionally, nursing is always not
merely about physical care, but also is a process of providing of experience.
Domains
A professional discipline must be clearly defined by a statement of its domain—
the boundaries or focus of that discipline. The domain of nursing includes the
phenomena of interest, problems to be addressed, main content and methods
used, and roles required of the discipline’s members (Kim, 1997; Meleis, 1997).
The processes and practices claimed by members of the disciplinary community
grow out of these domain statements. Nightingale provided some direction for
the domain of the discipline of nursing. While the disciplinary focus has been
debated, there is some degree of consensus. Donaldson and Crowley (1978)
identified the following as the domain of the discipline of nursing:
1. Concern with principles and laws that govern the life processes, well-being,
and optimum functioning of human beings, sick or well
2. Concern with the patterning of human behaviour in interactions with the
environment in critical life situations
3. Concern with the processes by which positive changes in health status are
affected Fawcett (1984) described the metaparadigm as a way to distinguish
nursing from other disciplines.
The metaparadigm is very general and is intended to reflect agreement among
members of the discipline about the field of nursing. This is the most abstract
level of nursing knowledge and closely mirrors beliefs held about nursing. By
virtue of being nurses, all nurses have some awareness of nursing’s
metaparadigm. However, because the term may not be familiar, it offers no
direct guidance for research and practice (Kim, 1997; Walker & Avant, 1995).
The metaparadigm consists of four concepts: persons, environment, health, and
nursing.

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According to Fawcett, nursing is the study of the interrelationship among these
four concepts. Modifications and alternative concepts for this framework have
been explored throughout the discipline (Fawcett, 2000). For example, nursing
scholars have suggested that “caring” replace “nursing” in the metaparadigm
(Stevenson & Tripp-Reimer, 1989). Kim (1987, 1997) set forth four domains:
client, client–nurse encounters, practice, and environment. In recent years,
increasing attention has been directed to the nature of nursing’s relationship
with the environment (Kleffel, 1996; Schuster & Brown, 1994). Others have
defined nursing as the study of: “the health or wholeness of human beings as
they interact with their environment” (Donaldson & Crowley, 1978, p. 113); the
life process of unitary human beings (Rogers, 1970); care or caring (Leininger,
1978; Watson, 1985); and human–universe– health interrelationships (Parse,
1998). A widely accepted focus statement for the discipline was published by
Newman, Sime, and Corcoran-Perry (1991) as “Nursing is the study of caring in
the human health experience” (p. 3). A consensus statement of philosophical
unity in the discipline was published by Roy and Jones (2007). Statements
include:
• The human being is characterized by wholeness, complexity, and consciousness.
• The essence of nursing involves the nurse’s true presence in the process of
human-to human engagement.
• Nursing theory expresses the values and beliefs of the discipline, creating a
structure to organize knowledge and illuminate nursing
practice.
• The essence of nursing practice is the nurse–patient relationship.
Syntactical and Conceptual Structures
Syntactical and conceptual structures are essential to any discipline and are
inherent in nursing theories. The conceptual structure delineates the proper
concerns of nursing, guides what is to be studied, and clarifies accepted ways of
knowing and using content of the discipline. This structure is grounded in the
focus of the discipline. The conceptual structure relates concepts within nursing
theories.
The syntactical structures help nurses and other professionals to understand the
talents, skills, and abilities that must be developed within the community. This
structure directs descriptions of data needed from research, as well as evidence
required to demonstrate the impact on nursing practice. In addition, these
structures guide nursing’s use of knowledge in research and practice approaches
developed by related disciplines. It is only by being thoroughly grounded in the
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discipline’s concepts, substance, and modes of inquiry that the boundaries of the
discipline can be understood and possibilities for creativity across disciplinary
borders can be created and explored.
Specialized Language and Symbols
As nursing theory has evolved, so has the need for concepts, language, and
forms of data that reflect new ways of thinking and knowing specific to nursing.
The complex concepts used in nursing scholarship and practice require language
that can be specific and understood. The language of nursing theory facilitates
communication among members of the discipline. Expert knowledge of the
discipline is often required for full understanding of the meaning of these
theoretical terms.
Heritage of Literature and Networks of Communication
This attribute calls attention to the array of books, periodicals, artifacts, and
aesthetic expressions, as well as audio, visual, and electronic media that have
developed over centuries to communicate the nature of nursing knowledge and
practice. Conferences and forums on every aspect of nursing held throughout
the world are part of this network. Nursing organizations and societies also
provide critical communication links. Nursing theories are part of this heritage
of literature, and those working with these theories present their work at
conferences, societies, and other communication networks of the nursing
discipline.
Tradition
The tradition and history of the discipline is evident in the study of nursing over
time. There is recognition that theories most useful today often have threads of
connection with ideas originating in the past. For example, many theorists have
acknowledged the influence of Florence Nightingale, and have acclaimed her
leadership in influencing nursing theories of today. In addition, nursing has a
rich heritage of practice. Nursing’s practical experience and knowledge have
been shared and transformed as the content of the discipline and are evident in
many nursing theories (Gray & Pratt, 1991).
Values and Beliefs
Nursing has distinctive views of persons and strong commitments to
compassionate and knowledgeable care of persons through nursing.
Fundamental nursing values and beliefs include a holistic view of person, the
dignity uniqueness of persons and the call to care.

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There are both shared and differing values and beliefs within the discipline. The
metaparadigm reflects the shared beliefs while the paradigms reflect the
differences.
Systems of Education
A distinguishing mark of any discipline is the education of future and current
members of the community. Nursing is recognized as a professional discipline
within institutions of higher education because it has an identifiable body of
knowledge that is studied, advanced, and used to underpin its practice. Students
of any professional discipline study its theories and learn its methods of inquiry
and practice.
Metaparadigms in different professions
Each profession has its own metaparadigm, which encapsulates the central
elements of that discipline. For architecture, they could be structure, design,
aestheticism and materials. For the legal profession a metaparadigm might
include, law, crime and justice. Think about the professions of teaching and
religion. For each one, identify what you believed the metaparadigm elements
would be. You may want to compare these with what other students or
colleagues thought.
Metaparadigm of nursing

Before discussing the Metaparadigm concepts that are important to nursing, it is

important to define the term “concept”. A concept is a term or label that
describes a phenomenon or group of phenomena (Meleis, 2007). The label may
be a word or phrase that summarizes ideas, observations, and experiences so as
to provide a mental image for the purpose of facilitating communication and
understanding about the phenomenon (Fawcett, 2005). The phenomenon
described by a concept may be either empirical or abstract. An empirical
concept is one that can be either observed or experienced through the senses. An
abstract concept is one that is not observable, such as hope or caring (Hickman,
2002).

A metaparadigm is the most global perspective of a discipline. A

metaparadigm is defined by Fawcett (2005, p. 4) “as the global concepts that
identify the phenomenon of central interest to a discipline, the global
propositions that describe the concepts, and the global propositions that state the
relations between or among the concepts, and the global propositions that state
the relations between or among the concepts.” Each discipline singles out
phenomena of interest that it will deal with in a unique manner. The concepts
and propositions that identify and interrelate these phenomena are even more
abstract in the metaparadigm than those found in the conceptual models, yet
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identification of

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these metaparadigm concepts allows members of the discipline to identify and
communicate the boundaries of the subject matter specific to the discipline
(Kim, 200). Most disciplines have a single metaparadigm but multiple
conceptual models. Multiple conceptual models allow the members of the
discipline to view the phenomena of interest in different ways (Fawcett, 2005).

While several proposals have sought to define what should be included as

the metaparadigm concepts for the discipline of nursing, most scholars accept
the central concepts of the discipline of nursing as person (human being),
environment, health, and nursing.

 Human being or person: individuals, families, communities, and

other groups who are participants in nursing.
 Environment: human beings’ significant others and physical
surroundings as well as local, regional, national, and worldwide
cultural, social, political, and economic conditions that are
associated with human beings’ health
 Health: human processes of living and dying
 Nursing: the definition of nursing, the actions taken by nurses on
behalf of or in conjunction with human beings, and the goals or
outcomes of nursing actions; the process of which encompasses
activities that are referred to as assessment, diagnosis (labelling),
planning, intervention, and evaluation (Fawcett, 2005, p. 6)

Because concepts are so abstract at the metaparadigm level, many

conceptual models have developed from the metaparadigm of nursing.
Subsequently, multiple theories have been developed from each
conceptual model in an effort to describe, explain, and predict the
phenomena within the model. These conceptual models and theories of
nursing represent various paradigms derived from the metaparadigm of
the discipline of nursing. Therefore, although each of the conceptual
models and nursing theories may link and define the four metaparadigm
concepts somewhat differently, the four-metaparadigm concept are
generally present and defined either implicitly or explicitly in each of the
models and theories.

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 How different theorists viewed the metaparadigm:
In the following we extract the metaparadigm concepts from the works of
Henderson (1966), Orem (1991, 1995), Watson (1988) and Peplau (1952).
Person
● Henderson (1966, 1991) believed that body and mind are inseparable, and
viewed the patient as a person who needs help with basic life activities and with
achieving health and independence, or to die peacefully.
● Orem (1991: 181) described a person or human being as ‘a unity that can be
viewed as functioning biologically, symbolically, and socially’.
● Watson (1988: 45) viewed the person as ‘a being in the world’ who is the
locus of human existence. A person exists as a living and growing gestalt and
possesses the three dimensions of being – mind, body and soul – which exist in
harmony in good health, where the essence of the person is the soul, which is
‘spirit, or a higher sense of self’.
● Peplau (1952: 82) defined humans as organisms that live in an unstable
equilibrium (i.e. physiological, psychological and social fluidity). She asserted
that all individuals have physical, psychological and social needs, and that in an
unstable environment, they constantly meet new situations and new problems.
Nursing
● Henderson (1966) described nursing as a profession that helps people, sick or
well, in the performance of the 14 basic life activities that contribute to health or
its recovery (or to a peaceful death) that they would perform unaided if they had
the necessary strength, will or knowledge.
Orem (1995) described nursing as a specialised human service to society. She
characterised nursing as action and assistance with the goal of helping people to
meet their own demands for self-care on a therapeutic and continuous basis.
● Watson (1988: 73) asserted that caring is essential to nursing and is ‘a moral
ideal that includes concepts such as a phenomenal field, an actual caring
occasion, and transpersonal caring’, which are central to her theory. She saw
nursing as both a science and an art. Watson (1988: 54) defined nursing as ‘a
human science of persons and human health illness experiences that are
mediated by professional, personal, scientific, aesthetic, and ethical human care
transactions. Watson (1988: 17) further explained that in this view of nursing as
a human science, nursing can combine and integrate science with beauty, art,
ethics and aesthetics of the human-to-human care process.

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 ● Peplau (1952) defined nursing as a significant, therapeutic, interpersonal
process. It functions cooperatively with other processes that make health
possible for people and communities. ‘Nursing is an educative instrument, a
maturing force, that aims to promote forward movement of personality in the
direction of creative, constructive, productive, personal, and community living’.

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Health
● Henderson (1966, 1991) did not specifically define her own concept of
health, but she sees it as the ability of people to function independently by
reference to the 14 basic life activities. Therefore, health relates to
independence.
● Orem (1995: 96) suggested that the ‘term health has considerable general
utility in describing the state of wholeness or integrity of human beings’. Orem
(1995: 101) explained that well-being is used in the sense of an individual’s
‘perceived condition of existence’. The nursing domain concerning health
involves the promotion and maintenance of health and protection against
specific diseases and injuries.
● Watson (1988: 48) referred to health as ‘unity and harmony within the mind,
body, and soul’. To her, health is associated with ‘the degree of congruence
between the self as perceived and the self as experienced’. A person becomes ill
when there is conscious or unconscious disharmony between these. ‘Illness is
not necessarily disease.’
● Peplau (1952: 12) maintained that health ‘is a word symbol that implies
forward movement of personality and other ongoing human processes in the
direction of creative, constructive, productive, personal, and community living’.
She saw health as a process whereby an individual has a quality of life that
enables the contribution to personal and community living.
Environment
● Henderson (1966, 1991) did not explicitly define the environment, but
through her explanation of what a patient is, it is evident that she was concerned
with the influences affecting the life and health of patients, especially the family
and cultural influences.
● For Orem (1991: 38), the person and the environment are in constant
interaction and the nurse must consider the human environment, analysing and
understanding the various ‘physical, chemical, biological, and social features.
● Watson (1988: 75) did not explicitly define environment, but the
environment is specifically used in her 10 curative factors, in particular, the
promotion of a ‘supportive, protective, and/ Chapter 5 Nursing theories or
nursing models 114 or corrective mental, physical, societal, and spiritual
environment’. Nurses must recognise the influence of internal and external
environments on the health and illness of individuals and also the need to
support and protect individuals.

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 ● Peplau (1952: 14) defined the environment as forces existing ‘outside the
organism and in the context of the culture’. Students often have problems

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differentiating between concepts of metaparadigms and basic concepts of theory
and their interactions. Basic concepts of the theory are always synchronised and
well connected with concepts of metaparadigms. For example, the central
concepts of Watson’s theory are human care, transpersonal care relationships,
the self, the phenomenal field, events, actual caring occasions and curative
factors.
Summary: The health metaparadigm is concerned with the holistic wellness of
the client’s body, soul, and mind. It is incorporated into the theory by stipulating
the guidelines for achieving health in its totality through prevention. Nursing is
about the individual nurse; in theory, they are urged to demonstrate
competencies and empathy in dealing with their patients. Thus, by incorporating
the paradigms, the nursing theory provides a perfect framework that
professionals can follow to achieve optimum care for their clients.
Conclusion:
The philosophical dimension provides many opportunities to gain an in-depth
understanding of essential notions. Particularly, it offers four domains through
which nursing can be realized – person, health, environment, and nursing. These
are interrelated concepts that seem to form the essence of nursing itself.

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