You are on page 1of 5

Levels of Theoretical Thinking in Nursing

Patricia A. Higgins, RN, PhD


Shirley M. Moore, RN, PhD

Development of a knowledge base is an iterative and phenomenon. As constructions of our mind, theories provide
ongoing process that requires periodic analysis and explanations about our experiences of phenomena in the
synthesis of an entire body of work. This article world.1 The understanding provided by theories is of two
examines 4 related levels of theoretical thinking that types: explanatory (describing concepts and understanding
are currently used in developing knowledge for interactions among concepts) or predictive (anticipating a
nursing practice, education, and science: meta-theory,
particular set of outcomes).2 Theories consist of the following
grand theory, middle-range theory, and micro-range
theory. Each level of theory is discussed according to
components: (1) concepts that are identified and defined, (2)
typology, scope, and generalizability, level of assumptions that clarify the basic underlying truths from
abstraction, and role. Suggestions are made for clar- which and within which theoretical reasoning proceeds, (3)
ification of terminology, and examples are provided context within which the theory is placed, and (4) identified
for each level of theoretical thinking. Evidence associ- relationships between and among the concepts.3
ated with the 4 levels of theoretical thinking is
discussed, and applications for use of the levels of
Theoretical thinking in nursing
theoretical thinking to meet future challenges in
nursing’s knowledge development are offered. uses concepts and their relation-
ships to organize and critique

I n an effort to build a knowledge base for the clinical, educa-


tional, and scientific endeavors of the discipline, nursing
theory has undergone several phases of development. In the
existing knowledge and guide new
discoveries to advance practice.

earliest period, scholars focused their attention on building The terms theory, theoretical (or conceptual) model, theoret-
grand theory and debating the structure and methods for devel- ical framework, and theoretical system are often used to distin-
oping nursing theory. More recently, there has been a call for the guish different types of theory. This practice has created confusion
development of middle-range theory. Thus theory in nursing among scholars and practitioners, and we believe a more useful
has been conceptualized as existing on several levels although approach to understanding theory is to consider all of the afore-
there are wide differences in the definitions and terminology mentioned terms as parallel synonyms. Each can be used inter-
associated with the levels of theoretical thinking and the classifi- changeably, but each term also requires further specification
cation of theoretical products. This lack of clarity impedes through an adjective modifier, such as “grand” or “middle range,”
our use of theoretical thinking to extend and communicate our that describes its fit with other theoretical work. Thus the notion
nursing knowledge. Therefore, the purpose of this article is to of different levels of theoretical thinking can be a more useful way
present an examination of levels of theoretical thinking in to develop, disseminate, and use knowledge in nursing. We use
nursing and provide examples of how several existing nursing the word “level” to imply a relative degree of relationship rather
theories can be classified within the theoretical levels. than a ranking or a distinct advantage. Each level of theoretical
Applications of levels of theoretical thinking to meet challenges thinking has defining characteristics and purposes that are specific
in knowledge development in nursing are suggested. to that level. The scope or breadth of the concepts and goals of a
A theory in its simplest view is the creation of relationships theoretical system determine its use for research and practice.
among two or more concepts to form a specific view of a Therefore, theoretical thinking in nursing uses concepts and their
relationships to organize and critique existing knowledge and
guide new discoveries to advance practice. Its development
Patricia A. Higgins is an assistant professor of nursing at the Frances and use is not limited to particular venues, time frames, or
Payne Bolton School of Nursing, Case Western Reserve University, formats, and although all nurses may not use theoretical thinking
Cleveland, Ohio. at all times, its actual use is more frequent than some nurses may
Shirley M. Moore is an associate professor of nursing at the Frances
acknowledge. For instance, theoretical thinking regarding a
Payne Bolton School of Nursing, Case Western Reserve University,
Cleveland, Ohio. family’s psychologic well being can be briefly and automatically
accessed as part of the gestalt of clinical practice or formally devel-
Nurs Outlook 2000;48:179-83.
Copyright © 2000 by Mosby, Inc. oped into a more permanent, written framework. Both types of
0029-6554/2000/$12.00 + 0 35/1/105248 theoretical thinking are crucial for practice, and either may be
doi:10.1067/mno.2000.105248 critiqued, modified, and tested.

NURSING OUTLOOK JULY/AUGUST 2000 Higgins and Moore 179


Levels of Theoretical Thinking in Nursing Higgins and Moore

izability, typology, and role. Figure 1 describes the relation-


ships among the 4 levels and provides examples of theoretical
thinking for each level.

Meta-theory
Meta-theory, the most abstract and universal of the 4 levels of
theoretical thinking, addresses issues related to the conduct of
inquiry. Therefore, it is the theory of inquiry. Meta-theory or
philosophic inquiry uses logic and analytic reasoning to
examine the direction, methods, and standards of inquiry and
thus it differs from the other levels of theory as its product is
primarily knowledge-about-knowledge (second-order knowl-
edge), rather than specific theoretical frameworks that explain
the empirical world (first-order knowledge). Meta-theoretical
inquiry related to scientific issues is known as philosophy of
science, and it focuses on a critical examination of science, its
processes, and products. Used by both scientists and practi-
tioners, meta-theoretical inquiry also addresses questions that
science cannot answer. For example, in the study of death and
dying, scientific inquiry seeks to answer questions about the
physiologic changes leading to death. However, philosophic
inquiry is needed to address the question, “Is death best under-
stood as a process or a product?” Therefore, an understanding
of meta-theoretical thinking is central to both the research and
practice of nursing.
As the most well established of the 4 levels, the significance
and role of meta-theoretical knowledge in nursing is revealed
through a partial list of issues addressed through this mode of
Figure 1. Levels of theoretical thinking. inquiry: (1) clarification of the relationship between nursing
science and practice, (2) definition, development, and testing of
nursing theory, (3) establishment of the academic discipline of
Linkages between the theoretical world and the empirical nursing, and (4) examination and interpretation of fundamental
world to which it applies are made through the formulation philosophic perspectives and their connection to nursing
and testing of hypotheses. Both scientists and practitioners science. The long list of exemplary scholarship that represents
use this process to make the empirical world and the theoret- these 4 categories of philosophic inquiry in nursing is well repre-
ical world as congruent as possible. It is important to distin- sented in anthologies such as the one by Nicoll,6 but one
guish an empirical system from a theoretical system. An example also illustrates the value of the discipline’s meta-theo-
empirical system is what we apprehend, through senses, in the retical thinking. In 1978 when Carper7 published her influen-
environment. A theoretical system is what we construct in our tial article on the fundamental patterns of knowing in nursing,
mind’s eye to model the empirical system.1 Nurse scientists she initiated a spirited dialogue that continues to this day—in
and practitioners focus on understanding the variables of a print, classrooms, and practice arenas throughout the world.
particular practice situation. To better understand a specific
event, they formulate working definitions and associations Grand Theory
among variables (hypotheses) and either develop a new theo- Nursing grand theories are the global paradigms of nursing
retical system or link them to existing organizing frameworks. science.8 They are formal, highly abstract theoretical systems
The theoretical system then serves as guidance about how to that frame our disciplinary knowledge within the principles of
proceed, and as long as the abstraction of a theory can be nursing, and their concepts and propositions transcend specific
represented with empiric indicators, hypotheses can be gener- events and patient populations. The substantial body of analytic
ated and empirically tested.2 and philosophic reasoning that has emerged from grand theory
provides evidence of scholarship that distinguishes nursing from
LEVELS OF THEORETICAL THINKING other closely related disciplines and legitimizes its existence
Theory in the human sciences has been used to delineate and among academic disciplines.9 Thus grand theory’s most signifi-
legitimate the emerging disciplines and substantiate knowl- cant contribution to nursing is the establishment and substanti-
edge development.4 There are 4 levels of theoretical thinking ation of the discipline’s identity and boundaries.
in nursing: meta-theory, grand theory, middle-range theory, Given their abstract nature, grand theories provide
and micro-range theory.5 Each level of theory will be universal explanations and an understanding of nursing, but
discussed according to level of abstraction and scope, general- not the particulars that are necessary for empirical testing. As

180 VOLUME 48 • NUMBER 4 NURSING OUTLOOK


Levels of Theoretical Thinking in Nursing Higgins and Moore

a result, they have little predictive capability. Some grand across several different patient populations and environments,
theories also use language that is difficult for the beginning a particular middle-range theory does not address all patients
student and unfamiliar to many potential users. Nevertheless, in all environments. For example, Good and Moore’s14 theory
they have significantly influenced knowledge development on pain management applies only to adults who experience
within the discipline and there are numerous examples of acute surgical pain and is appropriately tested only during the
their use in guiding nursing research, practice, and education. immediate postoperative period. Because of the aforemen-
Grand theories also contribute to the historical perspective of tioned characteristics, middle-range theory is not as limited as
nursing, reflecting the time and context in which the authors grand theory in its typology and can be classified as either
developed their theories, as well as their philosophic under- explanatory or predictive. A major role of middle-range theory
pinnings and their educational and practice perspectives. In is to define or refine the substantive content of nursing science
charting the growth of the discipline, Nightingale10 can be and practice, and it should be an important focus of both
considered the first grand theorist and Notes on Nursing, the nurse scholars and practitioners as we continue to build
original paradigm of contemporary nursing. knowledge for the discipline.
There is debate about what constitutes a grand theory and
thus, which nursing scholars’ work should be classified as grand Micro-range Theory
theory. For example, is Jean Watson’s11 Philosophy and Science of Micro-range theory is the least formal and most tentative of
Caring more accurately categorized as a “philosophy” or “grand the theoretical levels discussed in this article. It also is the most
theory” of nursing? Further, should Madeleine Leininger’s12 restrictive in terms of time and scope or application. However,
conceptual model, Culture Care: Diversity and Universality its particularistic approach is invaluable for scientists and prac-
Theory, be classified as a grand or middle-range theory? Our titioners as they work to describe, organize, and test their
view is that this type of debate reflects the growth of nursing’s ideas. We propose 2 levels of micro-range theory. At the higher
disciplinary knowledge. Although we may never have a level, micro-range theory is closely related to middle-range
consensus of answers for such questions, it also indicates that we theory but is comprised of 1 or 2 major concepts, and its appli-
have sufficiently established our external boundaries, and we can cation frequently is limited to a particular event; for example,
now redirect our energy to further distinguish the internal theories related to decubitus or catheter care.16
substance and structure of our knowledge through the construc- At the lower level, micro-range theory is defined as a set of
tion of middle-range theories. working hypotheses or propositions.17 Scientists and practi-
tioners use these working propositions to tentatively categorize,
Middle-range Theory explain, or test health-related person-environment interactions.
In terms of historical development, middle-range theory is the As such, they are not coded and entered into a formal theoret-
relative newcomer to nursing science. Similar to grand theory, ical system, but two examples serve to illustrate their invaluable
middle-range theory explains the empirical world of nursing, contribution to science and practice. In the first example, scien-
but it is more specific and less formal. For example, the philo- tists interested in developing and testing larger theoretical
sophic underpinnings and assumptions of the middle-range frameworks isolate and organize proposed conceptual relation-
theorist may be more implicit than explicit. As indicated by its ships into propositions. The scientific literature is then used to
name, any explanation of middle-range theory requires investigate the relationships of the propositions and, if there is
discussing “what it is” and “what comes before and after in its evidence for the truth of the relationships, to determine
range.” Suppe3 was one of the first to clarify and define conceptual-empirical correspondence. In the second example,
middle-range theory for nursing science. By using Merton’s the clinician also uses propositions to identify, describe, and
examination of sociologic theory,13 Suppe3 provided 3 criteria organize the working conceptual relationships in practice. The
for delimiting middle-range theory from grand theory and the investigation, although identical in process to the scientist’s,
next lower level, micro-range theory. These 3 criteria, scope, differs in terms of its scope and its generalizability; that is, the
level of abstraction, and testability are widely accepted.14,15 practitioner investigates more particular and immediate rela-
In terms of scope and level of abstraction, Lenz et al15 stated tionships in a smaller group of persons; or frequently, a single
that “middle-range theories (are those) that are sufficiently person. For instance, a nurse working on a general medical unit
specific to guide research and practice, yet sufficiently general is assigned to admit an elderly patient with the medical diag-
to cross multiple clinical populations and to encompass similar nosis of chronic obstructive pulmonary disease. Before meeting
phenomena.” In the quote from Lenz et al,15 the guidance for the patient, and in attempt to organize knowledge, the nurse
research and practice is much more direct than is that offered hypothesizes several possible conceptual relationships; for
by grand theory; therefore, middle-range theory can be tested example, the patient’s age and medical diagnosis limit the
in the empirical world. The concepts or phenomena of interest patient’s functional status. The nurse then tests the working
can be coded objectively (by using either qualitative or quanti- hypothesis through assessment and works to directly change
tative methods) and it has the potential to postulate measurable the concepts’ relationships through manipulation of the
relationships between the phenomena; thus it has a “time-rela- person-environment interaction.
tivistic distinction.”4 The generalizability of middle-range Any discussion of micro-range theory must consider the
theory is further defined by boundaries that limit measurement term “practice theory.” We jump into the debate on what
of the person-environment interaction. Although testable constitutes practice theory with the realization that numerous

NURSING OUTLOOK JULY/AUGUST 2000 181


Levels of Theoretical Thinking in Nursing Higgins and Moore

definitions exist and many authors consider micro-theory, as has the least amount of evidence behind it. The evidence
the most concrete and applicable of all theoretical levels, to be behind this kind of theoretical thinking is not usually accrued
an equivalent term for practice theory.5,16 We believe this cate- by planned repetitions under controlled situations, but instead
gorization limits the understanding of theoretical thinking in it is built from a limited number of repetitions and observa-
nursing and a broader definition of practice theory is more tions. For example, the best way to approach first-time ambu-
useful. Based on Ellis,18,19 who stated that all nursing knowl- lation for surgical patients may be hypothesized by a nurse as
edge ultimately is developed for practice, we maintain that all the result of providing postoperative care to a series of patients.
nursing theory, regardless of level, is practice theory. The theoretical-empirical congruence of this hypothesis is
then tested in subsequent surgical patients.
Regardless of the method used to USE OF LEVELS OF THEORETICAL THINKING TO
create the theory or whether the ENHANCE KNOWLEDGE DEVELOPMENT IN
theory is explanatory or predictive, NURSING
the amount of evidence accrued to Several challenges prevail in the development of nursing knowl-
support it promotes confidence in its edge. Conceptualizing theory at different levels of theory may
use by practitioners and scientists. assist us to address some of these challenges. For example, one
challenge is to determine how different levels of theory relate to
each other. How can one level of theory be used to develop
related theories at another level? As we analyze and generate
EVIDENCE AND LEVELS OF THEORETICAL theory, we often use traditional methods of theory construction
THINKING and substruction. The appropriate use of inductive and deduc-
Regardless of the method used to create the theory or whether tive approaches to develop nursing knowledge may be
the theory is explanatory or predictive, the amount of evidence improved by the consideration of the relationships among
accrued to support it promotes confidence in its use by practi- levels of theories. Conceptualizing levels of theories also
tioners and scientists. In addition to the previously cited exam- provides a beginning tool to assess whether the philosophic
ples, varying degrees of evidence exist among the different roots of our grand theories are reflected in our middle-range
types and levels of theoretical thinking. and micro-range theories. Such analyses can potentially
On the meta-theoretical level, the accrual of bodies of enhance the consistency and logic in our decision making
research findings (evidence) demonstrates our ability to about care issues and the theoretical design of future research.
produce and critique our knowledge. Our progress is measured As a discipline, we also are looking for ways to integrate
by the usefulness of the knowledge that is accrued, the related theories that have arisen from the multiple ways of
explanatory and predictive theories that are created and tested, building knowledge. For instance, how does the theory about
and the articulation of philosophic perspectives that are stages of behavior change, developed from grounded theory
connected to nursing science and practice. methods, relate to theories of self-efficacy for health behaviors
At the grand theory level, evidence is represented by prac- that were developed by using hypothesis-testing methods?
titioners’ and scientists’ use of the philosophic approaches Similarly, we are searching for ways to integrate related theo-
presented in the theories. As we have sought to build an aca- ries from different disciplines. For example, how do middle-
demic discipline, grand theories have assisted in legitimizing range theories of health promotion in psychology relate to
the emerging discipline by providing broad guidelines about those in sociology and nursing? The analysis and integration of
the focus of the discipline. There are varying degrees of related theories may be facilitated by comparison of related
evidence about the usefulness of existing nursing grand theo- theories at the same theoretical level across disciplines and
ries. Their frequent use by schools of nursing, care institu- arising from multiple methodologic approaches.
tions, and practitioners, and their use in guiding research
initiatives are examples of their value. Recognition and discussion about
Middle-range theories often have evidence that is acquired the levels of theoretical thinking
by using many repetitions under controlled conditions (scien- can serve as a vehicle for increased
tific method). An example is Johnson’s20,21 self-regulation
communication between practi-
theory that addresses the use of preparatory information to
assist persons in coping with threatening illness situations. tioners and scientists about the
Middle-range theoretical frameworks provide some evidence to knowledge each is developing.
support the relationships posed. However, to date no nursing
theories have sufficient evidence to be considered “laws,” which Another challenge in the discipline’s knowledge develop-
is not unexpected, given that nursing is a newly established ment is understanding the mechanisms needed to enhance
discipline and our phenomena of interest are highly complex. articulation of the knowledge produced by practitioners and
In micro-range theory, relationships exist among a limited researchers. Regardless of whether the methods used to
number of concepts that characterize a specific situation. The develop theory are inductive or deductive, and originate from
working hypothesis (of either the practitioner or the scientist) a philosophic, practice, or research perspective, multiple levels

182 VOLUME 48 • NUMBER 4 NURSING OUTLOOK


Levels of Theoretical Thinking in Nursing Higgins and Moore

of theoretical thinking exist. Although practitioners and nursing. In: Fitzpatrick JJ, Whall AL. Conceptual modes of
researchers may use divergent methods, each uses theoretical nursing. 3rd ed. Stamford (CT): Appleton & Lange; 1996. p. 1-12.
9. Fawcett J. Analysis and evaluation of conceptual models of nursing.
thinking for the generation of knowledge. Recognition and 3rd ed. Philadelphia (PA): FA Davis Co; 1995.
discussion about the levels of theoretical thinking can serve as 10. Nightingale F. Notes on nursing. New York: Churchill Livingstone;
a vehicle for increased communication between practitioners 1859.
and scientists about the knowledge each is developing. 11. Watson J. Nursing: the philosophy and science of caring. Boston:
Little Brown & Co Inc; 1979.
12. Leininger M. Transcultural nursing: concepts, theories, and prac-
CONCLUSION tices. New York: Wiley; 1978.
Knowledge development in any discipline is a dynamic process 13. Merton RK. On sociological theories of the middle range. In:
that pursues probable truths about reality. It begins with Merton RK. Social theory and social structure. New York: Free
creative approaches from multiple perspectives and continues Press; 1968. p. 39-72.
by testing the knowledge according to appropriate truth 14. Good M, Moore SM. Clinical Practice guidelines as a new source
of middle-range theory: focus on acute pain. Nurs Outlook
criteria. In nursing, our “reality” is clinical practice, and we 1996;44:74-9.
construct theories about probable truths related to the experi- 15. Lenz ER, Suppe F, Gift AG, Pugh LC, Milligan RA. Collaborative
ence of health in the person-environment interaction. development of middle-range nursing theories: toward a theory of
Development of a knowledge base is an iterative and ongoing unpleasant symptoms. Adv Nurs Sci 1995;17(3):1-13.
process that requires periodic analysis and synthesis of an 16. Whall AL. The structure of nursing knowledge: analysis and evalu-
ation of practice, middle-range, and grand theory. In: Fitzpatrick JJ,
entire body of work. In an attempt to further the under- Whall AL. Conceptual modes of nursing. 3rd ed. Stamford (CT):
standing of the current status of nursing theory, we provided Appleton & Lange; 1996. p. 13-25.
an examination of the different levels of theory currently being 17. Kim HS. The nature of theoretical thinking in nursing. East
used to develop nursing knowledge. This meta-theoretical Norwalk (CT): Appleton-Century-Crofts; 1983.
discussion of theory is not meant to create artificial domains; 18. Ellis R. The practitioner as theorist. Am J Nurs 1969;69:428-35.
19. Ellis R. Values and vicissitudes of the scientist nurse. Nurs Res
rather, it is an attempt to understand the current status of 1970;19:440-5.
nursing theory through clarification of the terminology and a 20. Johnson JE, Fieler VK, Jones LS, Wlasowicz GS, Mitchell ML. Self-
discussion of the related categories of theoretical thinking. regulation theory: applying theory to your practice. Pittsburgh
Perhaps more important, the final purpose of this article is to (PA): Oncology Nursing Press; 1997.
recognize the strength of our disciplinary knowledge base and 21. Leventhal H, Johnson JE. Laboratory and field experimentation:
development of a theory of self-regulation. In: Wooldridge PJ,
generate public discussion about the future of theory develop- Schmitt MH, Skipper JK, Leonard RC, editors. Behavioral science
ment and testing. ■ and nursing theory. St Louis: Mosby; 1983. p. 189-262.
22. Rogers ME. An introduction to the theoretical basis of nursing.
REFERENCES Philadelphia (PA): F. A. Davis Company; 1970.
23. Neuman B. The Neuman systems model: application to nursing
1. Stevens BJ. Nursing theory, analysis, application, evaluation. 2nd education and practice. New York: Appleton-Century-Crofts; 1982.
ed. Boston: Little Brown & Co Inc; 1984. 24. Orem DE. Nursing: concepts of practice. New York: McGraw Hill;
2. Dubin R. Theory building. 2nd ed. New York: Free Press; 1978. 1971.
3. Chinn PL, Kramer MK. Theory and nursing. 5th ed. St Louis: 25. Levine ME. The four conservation principles of nursing. Nurs
Mosby; 1999. Forum 1967;6:45-59.
4. Suppe F. Middle range theories: what they are and why nursing 26. Swanson KM. Empirical development of a middle range theory of
science needs them. Proceedings of the ANA/Council of Nurse caring. Nurs Res 1991;40(3):161-6.
Researchers Symposium; 1993 Nov 15. 27. Pender NJ. Health Promotion in nursing practice. New York:
5. Walker LO, Avant KC. Strategies for theory construction in Appleton-Century-Crofts; 1982.
nursing. 3rd ed. Norwalk (CT): Appleton & Lange; 1995. 28. Meek SS. Effects of slow stroke back massage on relaxation in
6. Nicoll LH. Perspectives on nursing theory. 3rd ed. Philadelphia hospice clients. IMAGE J Nurs Sch 1993;25:17-20.
(PA): Lippincott-Raven; 1997. 29. Kikuchi JF, Simmons H, editors. Philosophic inquiry in nursing.
7. Carper BA. Fundamental patterns of knowing in nursing. Adv Newbury Park (CA): Sage Publications; 1992.
Nurs Sci 1978;1:13-23. 30. Fawcett J, Downs FS. The relationship of theory and research. 2nd
8. Whall AL. Current debates and issues critical to the discipline of ed. Philadelphia (PA): FA Davis Co; 1992.

NURSING OUTLOOK JULY/AUGUST 2000 183