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D I S C U S S I O N P A P E R

Whither Nursing Models? The value of nursing theory in the context

of evidence-based practice and multidisciplinary health care

Niall McCrae

Accepted for publication 23 July 2011

Correspondence to N. McCrae:

e-mail: n.mccrae@kcl.ac.uk

Niall McCrae PhD RMN

Lecturer

Mental Health Nursing

Florence Nightingale School of Nursing &

Midwifery, King’s College London, UK

M C C R A E N . ( 2 0 1 2 )M C C R A E N . ( 2 0 1 2 ) Whither Nursing Models? The value of nursing theory in the

context of evidence-based practice and multidisciplinary health care. Journal of

Advanced Nursing 68(1), 222–229. doi: 10.1111/j.1365-2648.2011.05821.x

Abstract
Aim. This paper presents a discussion of the role of nursing models and theory in

the modern clinical environment.

Background. Models of nursing have had limited success in bridging the gap

between theory and practice.

Data sources. Literature on nursing models and theory since the 1950s, from health

and social care databases.

Discussion. Arguments against nursing theory are challenged. In the current context

of multidisciplinary services and the doctrine of evidence-based practice, a unique

theoretical standpoint comprising the art and science of nursing is more relevant

than ever.

Implications for nursing. A theoretical framework should reflect the eclectic,

pragmatic practice of nursing.

Conclusion. Nurse educators and practitioners should embrace theory-based

practice as well as evidence-based practice.

Keywords: evidence-based practice, nursing models, nursing theory, philosophy

Introduction

The legitimacy of any profession is built on its ability to

generate and apply theory. While enjoying a cherished status

in society, nursing has struggled to assert itself as a

profession. Despite efforts to improve its academic

credentials, the discipline lacks esoteric expertise, and while

an eclectic pragmatism may serve patients well, failure to

articulate a distinct theoretical framework exposes nursing to

external control (Macdonald 1995). Aggleton and Chalmers

(2000, p. 9) assert: ‘Until nurses themselves value the unique

contribution that they make to health care and the special

body of knowledge that informs their practice, the subordi-

nate role to that undertaken by doctors will continue’. Over

several decades, scholars have attempted to encompass the

trinity of physical, psychological and social aspects of care in

theories and models of nursing, which were intended to guide

practice and provide a platform for training curricula and

research, thus supporting the development of professional

knowledge.

Misunderstood and misused, the models of nursing that

pervaded preregistration training in the 1970s and 1980s

failed to bridge the gap between theory and practice. While

evidence of successful application has continued to flow in

the United States of America (Meleis 2007), where nursing

science is supported by substantial funding by federal

government and private foundations, nursing models faded

from professional discourse in the United Kingdom.

� 2011 The Author
222 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

However, it could be argued that the baby was thrown out

with the bathwater, and there is now a growing movement to

rejuvenate nursing theory (Pridmore et al. 2010). The Mag-

net Recognition Program (American Nurses Credentialing

Center 2008) is an international accreditation of excellence in

nursing, and a key requirement for organizations is to

describe and implement a professional practice model. The

author, who is involved in introducing such a model in a large

mental health service provider, argues that theoretical devel-

opment is crucial to the progress of nursing as a caring

profession.

Background

Nursing models were identified in the 1950s, as a thinking

profession began to emerge from its traditional handmaiden

status, with a primary objective to advance from a narrow

focus on illness to a broader concern with human needs. The

first recognized theory of nursing was by Hildegard Peplau,

who was highly influential in reconceptualizing the role from

‘doing things to people’ to a therapeutic relationship.

Illustrating the barriers faced by nurses at the time, Peplau’s

Interpersonal Relations in Nursing was completed in 1948

but not published until 1952 due to lack of medical

co-authorship or endorsement (Johnson & Webber 2005).

Influenced by the psychodynamic psychiatrist Harry Stack

Sullivan and the human motivation theory of Abraham

Maslow, Peplau emphasized the nurse (rather than physical

treatments and service organization) as the agent of change.

Although her expertise was in psychiatric nursing, Peplau

described an interactional process relevant to all nurses:

• Orientation – person feels a need and seeks professional
help; nurse helps patient understand problem.

• Identification – patient relates to someone who they believe
can help.

• Exploitation – patient attempts to make most of helping
situation; nurse formulates goals for patient.

• Resolution – patient discards previous goals and accepts
new goals, while relinquishing dependence on nurse.

An important step for theorists was to provide a definition

of nursing. In the textbook The Principles and Practice of

Nursing (Harmer & Henderson 1955), Virginia Henderson

presented nursing as a response to human functional needs.

Equating health with independence, she described 14 funda-

mental needs: breathing, eating and drinking, eliminating,

mobilizing, sleeping and resting, dressing, maintaining body

temperature, cleaning and grooming, avoiding injury, com-

municating and expressing emotions, worshipping, working,

playing and learning. Although Henderson and Peplau

intended their theories to apply across the spectrum of care

settings, the contrast between the mindsets of general and

mental nursing are evident here.

As the theoretical enterprise gained momentum, models

diversified, each based on assumptions about human nature

and nurture, and extending to the wider socio-environmental

context. Systems thinking was prominent in the Adaptation

Model of Sister Callista Roy (1980), who described a natural

human tendency towards biological, psychological and social

equilibrium, with maladaptive responses the target of nursing

intervention. Drawing on her scientific education, polymath

Rogers (1970) devised a novel theory of the human being as a

unitary energy field in dynamic interaction with the environ-

ment. Rejecting a Cartesian division of somatic and mental

functioning, Rogers propounded holism in its true meaning.

Health and illness were reinterpreted as manifestations of the

rhythmic fluctuations of life, and the role of the nurse was to

decipher each patient’s patterns, and to promote synergy with

his or her surroundings. Riehl’s Interaction Model (1980),

based on the symbolic interaction theory of Chicago sociol-

ogists, emphasized unique meaning in each situation, with the

nurse helping the patient to acquire or adapt roles in response

to health changes. Citations in the nursing literature

(Alligood 2002) indicated that the most widely used model

is that of Orem (1991), which facilitates progress from self-

care deficit to independent living skills.

The authorship of nursing theory has reflected the relatively

advanced intellectual culture of nursing in the USA. In the fifth

edition of Nursing Theorists and Their Work, a compendium

of nursing models (Marriner-Tomey & Alligood 2002), all but

one model was from North America (later editions have wider

international representation including the work of Katie

Erikkson; Alligood & Marriner-Tomey 2010). The exception

was by British nurses Nancy Roper, Winifred Logan and Alison

Tierney (1980), who orientated nursing to 12 activities of

living: maintaining a safe environment, communicating,

breathing, eating and drinking, eliminating, personal cleansing

and dressing, controlling body temperature, mobilizing, work-

ing and playing, expressing sexuality, sleeping and dying.

Similarities with Henderson are clear, but Roper et al. explic-

itly applied the nursing process, with its logical sequence of

assessment, planning, implementation and evaluation.

From this brief resumé, theorists have attempted in various

ways to present a comprehensive, rational and systematic

approach to nursing. With a plethora of models and theories,

various classifications have been offered; Aggleton and

Chalmers (2000), for example, categorize models as devel-

opmental, systemic or interactional. Unwittingly, such epis-

temological discussion has muddied the waters, as illustrated

by McKenna and Slevin (2008, p. 109): ‘Callista Roy’s work

was seen as a conceptual framework by Williams, a grand

JAN: DISCUSSION PAPER The value of nursing theory

� 2011 The Author
Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd 223

theory by Kim, an ideology by Beckstrand and as neither a

model nor a theory by Webb’. Meleis (2007, p. 40) argued

that ‘differences are tentative at best, and hair-splitting,

unclear and confusing at worst’. Semantic resolution is not

attempted here, but the definition of a nursing model by Riehl

and Roy (1980, p. 6) may be helpful:

A systematically constructed, scientifically based and log-

ically related set of concepts, which identify the essential

components of nursing practice together with the theoretical

basis of these concepts and values required for their use by

the practitioner.

A hierarchical clarification is provided by Fawcett (2005),

ranging from metaparadigms (the most abstract) to empirical

indicators (the most concrete). Between these poles, nursing

theorists have provided plenty of conceptual models, but not so

much at the level of theory, which comprises testable propo-

sition on which may be generated evidence of utility and benefit.

Theorists anticipated that models of nursing would enable

practitioners to become more autonomous and accountable

in their clinical decisions and organization of care, while

boosting the development of nursing as a discipline. So what

has gone wrong? Instead of elevating nursing to the sunny

uplands of theoretically grounded practice, models have been

perceived as unrealistic dogma from the ivory towers, and as

diversions from intuitive care; consequently, manuals gather

dust on library shelves. Constructing, teaching and applying a

theory of nursing is undoubtedly a great challenge, but that is

no justification for abandoning the endeavour. Practical

application has been hindered by a range of constraints, but

all of these may be overcome.

Data sources

This paper was informed by literature on nursing models and

theories from the 1950s to date, with material gathered from

ISI Web of Knowledge and other health and social care

databases. Use of literature was not driven by search strategy

but as a qualitative selection of the major contributions to

theory and relevant debate.

Discussion

Arguments against nursing models

Various arguments presented against nursing models are

scrutinized here.

Nursing eludes definition

Hesook Suzie Kim argues (2000, p. 2) that ‘a rigorous and

exact delineation of nursing as a role and as a scientific dis-

cipline is necessary specifically when it is used as the con-

ceptual basis for the development of nursing’s theoretical

knowledge’. Yet despite protracted debate, a consensual

statement on the meaning of nursing remains elusive. With-

out a satisfactory definition, how can a theory of nursing be

produced? To accommodate the diversity of practice, the

concept of holistic care is often presented as a defining

statement. Models devised by writers of general hospital

background have been perceived as incompatible with spe-

cialties such as mental health (Gournay 1995), and clearly for

the patient in acute nephritic pain immediate physical inter-

vention is a priority over attending to existential needs, but to

compartmentalize bodily and psychological care would be

regressive to a holistic ethos. However, as explained by

Clarke (1999), the philosophical idea of holism tends to be

misunderstood by nurses as an eclectic approach, when it

really means integration of soma and psyche. The medical

model and positivism are often the straw men of nursing

literature, but medicine too considers the patient in context,

as in the biopsychosocial model espoused by psychiatry.

Holistic care should be central to nursing theory, but is

insufficient as a raison d’être. Theoretical development is a

step forward from vague ideals of the nursing mission to

more clearly demarcated scope, purpose and method, but this

is an iterative process whereby theory informs practice and

vice versa. Similarly, we should not expect a static definition

of nursing.

Lack of prescription for practice

As a vehicle for nursing theory, a model should comprise

clear concepts, processes and goals. Difficulty in utilization of

nursing models was possibly exacerbated by terminology

such as Newman’s ‘expanding consciousness’ (1994) and the

‘dynamic energy fields’ of Rogers (1970), which deviate from

contemporary nursing discourse. However cogent a theory, it

is soon redundant if it does not make sense to the practi-

tioner. Yet theorists spent years refining their models to make

the unavoidable theoretical complexity readily comprehensi-

ble for everyday application. The problem was not only an

intellectually lukewarm attitude that theory belongs to aca-

deme, but also a tendency for task orientation in practice,

leading to the original spirit of a nursing model being lost. In

a previous paper, the author (1992) described his training

experience with the Roper-Logan-Tierney Model, which was

presented in readily accessible terms. The nursing school and

general hospital had pursued integration of teaching and

practice by instilling this model throughout clinical settings,

but in reality the system deteriorated into a ritualistic docu-

mentary procedure mostly performed by students as a

learning exercise. The apparent strength of the model as a

N. McCrae

� 2011 The Author
224 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd

straightforward implementation of the nursing process made

it prone to compartmentalized, concrete thinking. Roper-

Logan-Tierney was set in stone, with its immutable 12

activities of daily living etched in tablets afoot patients’ beds.

By contrast with some theoretically orientated centres of

excellence in the USA, there is little evidence that models have

changed practice in the British context. Comparing two

wards using different nursing models, Griffiths (1998) found

no difference in how nursing care was provided. This finding

would not surprise many nurses, but it must be acknowledged

that a model can only be as good as the theoretical inclination

of the discipline. In a qualitative study of postregistration

training in nursing models (Wimpenny 2002), nurses

expressed dissatisfaction with the burden imposed by models,

one participant commenting: ‘When I see models, I see

documentation’. This is a fault in application rather than in

design. Applying theory demands thought as well as action:

nursing needs ‘knowledgeable doers’ to integrate theory and

practice (McCaugherty 1992). Without being naively opti-

mistic, it may be anticipated that the capacity of nurses to

comprehend and use theory will be enhanced as a graduate

profession and advanced practice develops.

Incompatibility with evidence-based practice

With a plethora of conceptual frameworks for nursing,

Barnum (1998) appealed for systematic evaluation, and the

need for rigorous validation is pronounced by the current

mantra of evidence-based practice. Much nursing theory may

be criticized as untested philosophical musings that would

fail the Popperian test of falsifiability. However, we must be

wary of the notion that practices with the best evidence are

the best practices. For example, patients often feel distressed

on being admitted to the strange environment of the hospital.

To engage in the anxious patient’s world, the nurse is guided

not by positivist research findings but by an intuitive

humanistic ethos tuned by professional training and experi-

ence. The most valued activities of nurses are those relating to

compassion and empathy (Attree 2001), but these are the

elements least supported by hard scientific data. Indeed,

the prioritization of evidence has troubled some scholars,

particularly in mental health, where bold empiricism is least

appropriate to understanding patients’ problems. Holmes

et al. (2006) argue that ‘the evidence-based movement in the

health sciences is outrageously exclusionary and dangerously

normative’.

Nonetheless, nurses should not stand on the sidelines

muttering a postmodern critique of objective science, as this

would perpetuate their perceived deficits in research literacy

and the power imbalances in health care. All healthcare

practitioners apply a mixture of personal and professional

knowledge, not all of which is supported by causal analysis.

To illustrate, in a medical outpatient session, scientifically

validated concepts are applied in diagnosis and treatment

decisions, but patient and physician contribute to an inter-

personal rapport; accordingly, there is a phenomenological

whole greater than the sum of technical parts. A more

persuasive argument for nursing is that its core activities are

devalued by an episteme that gives primacy to physical

science methodology, and to privileged professions. Regard-

ing scientific evidence as the sole basis of knowledge is

intellectually sterile, and of dubious validity. The real value

of nursing can only be represented by a broad theoretical

framework that includes both tested procedures and the

humane caring role, and which is operationalized not

primarily for research, but for utility. As Kim (2000)

emphasizes, there is a distinction between theory in nursing,

and little theory of nursing. Unsupported by overarching

theory, nursing is more susceptible to bureaucratically

imposed outcomes, critical pathways and quality standards

(Chambers 1998), amidst a targets regime in public services

that serves administrative rather than clinical objectives,

while creating perverse incentives (Seddon 2008).

Limits to professional demarcation and autonomy

An impediment to the utilization of models is the context of

de facto medical leadership and managerial control. As

Clarke (1999, p. 16) observes: ‘Unlike their medical coun-

terparts, nurses are seemingly unwilling to rely on profes-

sional rationales for their actions, opting instead for

occupational/managerial justifications’. Yet most nursing

occurs as a one-to-one interaction, and there is no reason why

this therapeutic relationship should not be underpinned by

theory. In the past, nursing was almost entirely hospital

based, with clear demarcation between medical and nursing

tasks. In the multidisciplinary, community-orientated health

care of today, nursing must be able to define its role, rather

than leaving other disciplines, managers and policy makers to

do this by proxy. A firmer theoretical foundation would

protect nursing from managerialism and cost-saving

replacement by workers without professional training.

Multidisciplinary teamwork is generally found stimulating

and rewarding by nurses, although blurring of roles may lead

to professional insecurity. According to Lewy (2008), the

interprofessional approach is a positive development that

‘should not be misinterpreted and used as a management tool

for undermining professions because this effectively destroys

the essence of what the agenda has been developed to

achieve’. Nursing-specific theory and research may be

frowned upon in a multidisciplinary ethos, but there is a

problem with a generic concept of evidence: a standardized

JAN: DISCUSSION PAPER The value of nursing theory

� 2011 The Author
Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd 225

procedure such as cognitive behaviour therapy is well

supported by research, but does it matter whether this is

provided by a clinical psychologist or a nurse? It would not

be unreasonable to surmise that each of these disciplines

would bring something different to the therapeutic table, and

this requires clarification at a theoretical level. The multidis-

ciplinary context therefore is an argument for nursing theory.

Irrelevance to modern health care

Gournay (2001) rejected nursing models as anachronisms in

the evidence-based schema of modern multidisciplinary ser-

vices, while Clarke (2006, p. 72) claims that theoretical

frameworks did little more than ‘cosmetically enhance the

credibility of nursing’.

Perhaps we have passed a necessary stage in the evolution

of nursing from subservient vocation to professional account-

ability. McKenna and Slevin (2008) argue that models

written three or four decades ago are now outmoded, but

this is contestable. Theory of nursing should be regarded as a

continual developmental process, but it should also be

emphasized that while practice and wider society have

transformed, human needs are basically the same.

The relationship between theory and evidence in nursing

can be analogized to the timeless debate between science and

ethics. The former entails what we can do; the latter what we

should do. While morality in modern society does not

necessarily have the permanence given by monotheist reli-

gions, there are human values that transcend time and

technology. The issue of assisted dying is an example of

conflict between the enduring concept of the sanctity of life

and the possibilities of a medically ameliorated passage for

the terminally ill patient. Such controversy raises unavoidable

questions about the role of nursing. A balance must be found

between instrumental flexibility to the changing expectations

of individuals and society, and a durable ethical stance;

ideally, these will evolve in tandem, but there will be

contentious issues where nurses are expected to act against

their professional inclinations. A code of conduct protects

nurses to some extent, but a coherent theory of nursing would

provide a rationale for practice in difficult circumstances.

Implications for nursing

From basic tasks to skilled therapeutic interventions, nursing

is a pragmatic discipline, whose role and responsibilities are

determined by a range of factors including the code of

conduct, local and national policies and procedures, research

evidence, professional and social norms, and cultural trends.

It is also heuristic, the nurse’s problem-solving approach

coloured by personal values and experience. Edwards and

Liaschenko (2003) describe a commonly expressed a theo-

retical stance whereby nursing is considered as practical

rather than propositional knowledge; hence there cannot be a

theory of nursing. Erroneously, nurses may separate the

intellectual domain of theory from the clinical setting in the

belief that different types of knowledge are used in practice.

Carper (1978) identified four equally valid elements of

nursing episteme:

• Empirics (verifiable, objective knowledge)
• Aesthetics (tacit, intuitive)
• Ethics (moral)
• Personal knowing (unique perspective based on character

and life experience)

At the nurse–patient interface, personal ‘knowing’ is often

more useful than impersonal knowledge. However, as scien-

tific thinking is inculcated in trainees and practitioners, nurses

are appreciating the advantages (if not supremacy) of the

generalizable over the anecdotal. Kim (2000, p. 2) argues that

‘the essential features of nursing knowledge required for

practice must embrace the science of control and therapy as

well as the science of understanding and care’. Note the term

‘science’ for what others might consider the ‘art’ of nursing.

This is the crux of the modelling issue: if therapeutic use of self

is not conducive to scientific testing, nursing can never achieve

objectivity. The challenge is to build theory in a way that

maximizes evidence while minimizing reductionism. Research

has repeatedly shown correlation between good nursing and

positive patient outcomes, but without establishing a concep-

tual and empirical link. Recent theoretical offerings have

emphasized the caring relationship as fundamental to nursing,

such as Relationship-Based Care (Koloroutis 2004) and

Joanne Duffy’s Quality-Caring Model (2003). The latter

model, however, claims that relationships are tangible phe-

nomena and thus measurable, but this is a dubious proposi-

tion: nursing cannot be objectified by conjecture.

Johnson (1996) asserts that nursing should be pursued as a

practical rather than basic or applied science. In other words,

it is a means to an end, helping patients to adapt positively to

illness, to resume independence and to achieve personal

growth. Perhaps pragmatism provides a reasonable and

realistic philosophical basis for building the theory of

nursing. According to Benner and Wrubel (1989), p.5), ‘a

theory is needed that describes, interprets, and explains not

an imagined ideal of nursing, but actual expert nursing as it is

practised day to day’. However, while practice theory, as

defined by Ada Jacox (1974), tells the nurse what actions are

necessary to achieve a particular goal, a prescriptive

approach cannot embody the whole of nursing practice,

and as experience with nursing models has shown, it may

exacerbate impersonal, ritualized care.

N. McCrae

� 2011 The Author
226 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd

In a report on the future of nursing commissioned by the

Chief Nursing Officer in England, Maben and Griffiths

(2008) present a trinity of nurse roles, each entailing a

relationship to others:

• Practitioner
• Partner
• Leader

This shows the relative breadth of nursing to other

professions, but can this be encompassed in an overarching

theory of nursing? Theoretical development may help

practitioners to articulate their purpose in an increasingly

complex healthcare environment, with roles and responsi-

bilities in constant flux. It is also important for the

advancement of the discipline, as its function extends into

care episode management, prescribing and specialist skills

previously performed by physicians. Credibility and confi-

dence in nursing depends on a change of perception of the

role in society, which continues to harbour an angelic

image of the nurse as a caring accessory to heroic

medicine.

Generation of nursing theory should proceed as a creative,

collaborative enterprise, taking account of the diverse settings

in which nursing operates. Where possible theory should be

of global relevance, covering generic and specialist fields, thus

maintaining the unity of nursing. This project need not start

afresh, but build on the work of earlier theorists. As urged by

Fawcett (2005), scholars should pursue epistemological

progression from conceptual model (which are foundational

but not testable), to empirical ‘middle-range’ theories with

operationalized variables and relationships (as espoused by

sociologist Robert K Merton). However, we must also

embrace the unquantifiable elements of nursing. Eriksson

(2002) highlights the ethical essence of caring science, and the

need for a ‘different key’ in constructing a humanistic

knowledge for practice. Acknowledging the measurable and

abstract properties of nursing, integration should be pursued

in three key dualisms:

• Art/science
• Mind/matter
• Teaching/practice

According to Fawcett (1992), ‘nursing knowledge, as

formalized in a conceptual model, is the starting point in

the reciprocal relationship with nursing practice’. Knowledge

therefore has primacy when the nurse first enters the ward. A

coherent theoretical framework would combine the tremen-

dous diversity of theoretical, experiential and intuitive

knowledge into a single schema, guiding nurses in the

procedures, interpersonal engagement and values of profes-

sional practice.

Conclusion

In recent years, broad theories and conceptual models have

been overshadowed by empirical evidence in the episteme of

nursing. Attempts to infuse a theoretical outlook in the

humanistic enterprise of nursing have had limited success, but

the structural and philosophical challenges are not insur-

mountable. Without being prescriptive, this paper argues for

the promotion of theory in preregistration curricula, and for

its rightful place in the cycle of nursing knowledge, thus

helping practitioners to assert, apply and evaluate their

unique role in health care. Curre

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