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
ongoing process that requires periodic analysis and
synthesis of an entire body of work. This article
examines 4 related levels of theoretical thinking that
are currently used in developing knowledge for
nursing practice, education, and science: meta-theory,
grand theory, middle-range theory, and micro-range
theory. Each level of theory is discussed according to
typology, scope, and generalizability, level of
abstraction, and role. Suggestions are made for clar-
ification of terminology, and examples are provided
for each level of theoretical thinking. Evidence associ-
ated with the 4 levels of theoretical thinking is
discussed, and applications for use of the levels of
theoretical thinking to meet future challenges in
nursing’s knowledge development are offered.
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
earliest period, scholars focused their attention on building
grand theory and debating the structure and methods for devel-
oping nursing theory. More recently, there has been a call for the
development of middle-range theory. Thus theory in nursing
has been conceptualized as existing on several levels although
there are wide differences in the definitions and terminology
associated with the levels of theoretical thinking and the classifi-
cation of theoretical products. This lack of clarity impedes
our use of theoretical thinking to extend and communicate our
nursing knowledge. Therefore, the purpose of this article is to
present an examination of levels of theoretical thinking in
nursing and provide examples of how several existing nursing
theories can be classified within the theoretical levels.
Applications of levels of theoretical thinking to meet challenges
in knowledge development in nursing are suggested.
A theory in its simplest view is the creation of relationships
among two or more concepts to form a specific view of a
Patricia A. Higgins is an assistant professor of nursing at the Frances
Payne Bolton School of Nursing, Case Western Reserve University,
Cleveland, Ohio.
Shirley M. Moore is an associate professor of nursing at the Frances
Payne Bolton School of Nursing, Case Western Reserve University,
Cleveland, Ohio.
Nurs Outlook 2000;48:179-83.
Copyright © 2000 by Mosby, Inc.
0029-6554/2000/$12.00 + 0 35/1/105248
doi:10.1067/mno.2000.105248
NURSING OUTLOOK JULY/AUGUST 2000
phenomenon. As constructions of our mind, theories provide
explanations about our experiences of phenomena in the
world.1 The understanding provided by theories is of two
types: explanatory (describing concepts and understanding
interactions among concepts) or predictive (anticipating a
particular set of outcomes).2 Theories consist of the following
components: (1) concepts that are identified and defined, (2)
assumptions that clarify the basic underlying truths from
which and within which theoretical reasoning proceeds, (3)
context within which the theory is placed, and (4) identified
relationships between and among the concepts.3
Theoretical thinking in nursing
uses concepts and their relation-
ships to organize and critique
existing knowledge and guide new
discoveries to advance practice.
The terms theory, theoretical (or conceptual) model, theoret-
ical framework, and theoretical system are often used to distin-
guish different types of theory. This practice has created confusion
among scholars and practitioners, and we believe a more useful
approach to understanding theory is to consider all of the afore-
mentioned terms as parallel synonyms. Each can be used inter-
changeably, but each term also requires further specification
through an adjective modifier, such as “grand” or “middle range,”
that describes its fit with other theoretical work. Thus the notion
of different levels of theoretical thinking can be a more useful way
to develop, disseminate, and use knowledge in nursing. We use
the word “level” to imply a relative degree of relationship rather
than a ranking or a distinct advantage. Each level of theoretical
thinking has defining characteristics and purposes that are specific
to that level. The scope or breadth of the concepts and goals of a
theoretical system determine its use for research and practice.
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
and use is not limited to particular venues, time frames, or
formats, and although all nurses may not use theoretical thinking
at all times, its actual use is more frequent than some nurses may
acknowledge. For instance, theoretical thinking regarding a
family’s psychologic well being can be briefly and automatically
accessed as part of the gestalt of clinical practice or formally devel-
oped into a more permanent, written framework. Both types of
theoretical thinking are crucial for practice, and either may be
critiqued, modified, and tested.
Higgins and Moore 179
Levels of Theoretical Thinking in Nursing
Figure 1. Levels of theoretical thinking.
Linkages between the theoretical world and the empirical
world to which it applies are made through the formulation
and testing of hypotheses. Both scientists and practitioners
use this process to make the empirical world and the theoret-
ical world as congruent as possible. It is important to distin-
guish an empirical system from a theoretical system. An
empirical system is what we apprehend, through senses, in the
environment. A theoretical system is what we construct in our
mind’s eye to model the empirical system.1 Nurse scientists
and practitioners focus on understanding the variables of a
particular practice situation. To better understand a specific
event, they formulate working definitions and associations
among variables (hypotheses) and either develop a new theo-
retical system or link them to existing organizing frameworks.
The theoretical system then serves as guidance about how to
proceed, and as long as the abstraction of a theory can be
represented with empiric indicators, hypotheses can be gener-
ated and empirically tested.2
LEVELS OF THEORETICAL THINKING
Theory in the human sciences has been used to delineate and
legitimate the emerging disciplines and substantiate knowl-
edge development.4 There are 4 levels of theoretical thinking
in nursing: meta-theory, grand theory, middle-range theory,
and micro-range theory.5 Each level of theory will be
discussed according to level of abstraction and scope, general-
180
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
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
nursing, and (4) examination and interpretation of fundamental
philosophic perspectives and their connection to nursing
science. The long list of exemplary scholarship that represents
these 4 categories of philosophic inquiry in nursing is well repre-
sented in anthologies such as the one by Nicoll,6 but one
example also illustrates the value of the discipline’s meta-theo-
retical thinking. In 1978 when Carper7 published her influen-
tial article on the fundamental patterns of knowing in nursing,
she initiated a spirited dialogue that continues to this day—in
print, classrooms, and practice arenas throughout the world.
Grand Theory
Nursing grand theories are the global paradigms of nursing
science.8 They are formal, highly abstract theoretical systems
that frame our disciplinary knowledge within the principles of
nursing, and their concepts and propositions transcend specific
events and patient populations. The substantial body of analytic
and philosophic reasoning that has emerged from grand theory
provides evidence of scholarship that distinguishes nursing from
other closely related disciplines and legitimizes its existence
among academic disciplines.9 Thus grand theory’s most signifi-
cant contribution to nursing is the establishment and substanti-
ation of the discipline’s identity and boundaries.
Given their abstract nature, grand theories provide
universal explanations and an understanding of nursing, but
not the particulars that are necessary for empirical testing. As
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Levels of Theoretical Thinking in Nursing
a result, they have little predictive capability. Some grand
theories also use language that is difficult for the beginning
student and unfamiliar to many potential users. Nevertheless,
they have significantly influenced knowledge development
within the discipline and there are numerous examples of
their use in guiding nursing research, practice, and education.
Grand theories also contribute to the historical perspective of
nursing, reflecting the time and context in which the authors
developed their theories, as well as their philosophic under-
pinnings and their educational and practice perspectives. In
charting the growth of the discipline, Nightingale10 can be
considered the first grand theorist and Notes on Nursing, the
original paradigm of contemporary nursing.
There is debate about what constitutes a grand theory and
thus, which nursing scholars’ work should be classified as grand
theory. For example, is Jean Watson’s11 Philosophy and Science of
Caring more accurately categorized as a “philosophy” or “grand
theory” of nursing? Further, should Madeleine Leininger’s12
conceptual model, Culture Care: Diversity and Universality
Theory, be classified as a grand or middle-range theory? Our
view is that this type of debate reflects the growth of nursing’s
disciplinary knowledge. Although we may never have a
consensus of answers for such questions, it also indicates that we
have sufficiently established our external boundaries, and we can
now redirect our energy to further distinguish the internal
substance and structure of our knowledge through the construc-
tion of middle-range theories.
Middle-range Theory
In terms of historical development, middle-range theory is the
relative newcomer to nursing science. Similar to grand theory,
middle-range theory explains the empirical world of nursing,
but it is more specific and less formal. For example, the philo-
sophic underpinnings and assumptions of the middle-range
theorist may be more implicit than explicit. As indicated by its
name, any explanation of middle-range theory requires
discussing “what it is” and “what comes before and after in its
range.” Suppe3 was one of the first to clarify and define
middle-range theory for nursing science. By using Merton’s
examination of sociologic theory,13 Suppe3 provided 3 criteria
for delimiting middle-range theory from grand theory and the
next lower level, micro-range theory. These 3 criteria, scope,
level of abstraction, and testability are widely accepted.14,15
In terms of scope and level of abstraction, Lenz et al15 stated
that “middle-range theories (are those) that are sufficiently
specific to guide research and practice, yet sufficiently general
to cross multiple clinical populations and to encompass similar
phenomena.” In the quote from Lenz et al,15 the guidance for
research and practice is much more direct than is that offered
by grand theory; therefore, middle-range theory can be tested
in the empirical world. The concepts or phenomena of interest
can be coded objectively (by using either qualitative or quanti-
tative methods) and it has the potential to postulate measurable
relationships between the phenomena; thus it has a “time-rela-
tivistic distinction.”4 The generalizability of middle-range
theory is further defined by boundaries that limit measurement
of the person-environment interaction. Although testable
NURSING OUTLOOK JULY/AUGUST 2000
Higgins and Moore
across several different patient populations and environments,
a particular middle-range theory does not address all patients
in all environments. For example, Good and Moore’s14 theory
on pain management applies only to adults who experience
acute surgical pain and is appropriately tested only during the
immediate postoperative period. Because of the aforemen-
tioned characteristics, middle-range theory is not as limited as
grand theory in its typology and can be classified as either
explanatory or predictive. A major role of middle-range theory
is to define or refine the substantive content of nursing science
and practice, and it should be an important focus of both
nurse scholars and practitioners as we continue to build
knowledge for the discipline.
Micro-range Theory
Micro-range theory is the least formal and most tentative of
the theoretical levels discussed in this article. It also is the most
restrictive in terms of time and scope or application. However,
its particularistic approach is invaluable for scientists and prac-
titioners as they work to describe, organize, and test their
ideas. We propose 2 levels of micro-range theory. At the higher
level, micro-range theory is closely related to middle-range
theory but is comprised of 1 or 2 major concepts, and its appli-
cation frequently is limited to a particular event; for example,
theories related to decubitus or catheter care.16
At the lower level, micro-range theory is defined as a set of
working hypotheses or propositions.17 Scientists and practi-
tioners use these working propositions to tentatively categorize,
explain, or test health-related person-environment interactions.
As such, they are not coded and entered into a formal theoret-
ical system, but two examples serve to illustrate their invaluable
contribution to science and practice. In the first example, scien-
tists interested in developing and testing larger theoretical
frameworks isolate and organize proposed conceptual relation-
ships into propositions. The scientific literature is then used to
investigate the relationships of the propositions and, if there is
evidence for the truth of the relationships, to determine
conceptual-empirical correspondence. In the second example,
the clinician also uses propositions to identify, describe, and
organize the working conceptual relationships in practice. The
investigation, although identical in process to the scientist’s,
differs in terms of its scope and its generalizability; that is, the
practitioner investigates more particular and immediate rela-
tionships in a smaller group of persons; or frequently, a single
person. For instance, a nurse working on a general medical unit
is assigned to admit an elderly patient with the medical diag-
nosis of chronic obstructive pulmonary disease. Before meeting
the patient, and in attempt to organize knowledge, the nurse
hypothesizes several possible conceptual relationships; for
example, the patient’s age and medical diagnosis limit the
patient’s functional status. The nurse then tests the working
hypothesis through assessment and works to directly change
the concepts’ relationships through manipulation of the
person-environment interaction.
Any discussion of micro-range theory must consider the
term “practice theory.” We jump into the debate on what
constitutes practice theory with the realization that numerous
181
Levels of Theoretical Thinking in Nursing
definitions exist and many authors consider micro-theory, as
the most concrete and applicable of all theoretical levels, to be
an equivalent term for practice theory.5,16 We believe this cate-
gorization limits the understanding of theoretical thinking in
nursing and a broader definition of practice theory is more
useful. Based on Ellis,18,19 who stated that all nursing knowl-
edge ultimately is developed for practice, we maintain that all
nursing theory, regardless of level, is practice theory.
Regardless of the method used to
create the theory or whether the
theory is explanatory or predictive,
the amount of evidence accrued to
support it promotes confidence in its
use by practitioners and scientists.
EVIDENCE AND LEVELS OF THEORETICAL
THINKING
Regardless of the method used to create the theory or whether
the theory is explanatory or predictive, the amount of evidence
accrued to support it promotes confidence in its use by practi-
tioners and scientists. In addition to the previously cited exam-
ples, varying degrees of evidence exist among the different
types and levels of theoretical thinking.
On the meta-theoretical level, the accrual of bodies of
research findings (evidence) demonstrates our ability to
produce and critique our knowledge. Our progress is measured
by the usefulness of the knowledge that is accrued, the
explanatory and predictive theories that are created and tested,
and the articulation of philosophic perspectives that are
connected to nursing science and practice.
At the grand theory level, evidence is represented by prac-
titioners’ and scientists’ use of the philosophic approaches
presented in the theories. As we have sought to build an aca-
demic discipline, grand theories have assisted in legitimizing
the emerging discipline by providing broad guidelines about
the focus of the discipline. There are varying degrees of
evidence about the usefulness of existing nursing grand theo-
ries. Their frequent use by schools of nursing, care institu-
tions, and practitioners, and their use in guiding research
initiatives are examples of their value.
Middle-range theories often have evidence that is acquired
by using many repetitions under controlled conditions (scien-
tific method). An example is Johnson’s20,21 self-regulation
theory that addresses the use of preparatory information to
assist persons in coping with threatening illness situations.
Middle-range theoretical frameworks provide some evidence to
support the relationships posed. However, to date no nursing
theories have sufficient evidence to be considered “laws,” which
is not unexpected, given that nursing is a newly established
discipline and our phenomena of interest are highly complex.
In micro-range theory, relationships exist among a limited
number of concepts that characterize a specific situation. The
working hypothesis (of either the practitioner or the scientist)
182
Higgins and Moore
has the least amount of evidence behind it. The evidence
behind this kind of theoretical thinking is not usually accrued
by planned repetitions under controlled situations, but instead
it is built from a limited number of repetitions and observa-
tions. For example, the best way to approach first-time ambu-
lation for surgical patients may be hypothesized by a nurse as
the result of providing postoperative care to a series of patients.
The theoretical-empirical congruence of this hypothesis is
then tested in subsequent surgical patients.
USE OF LEVELS OF THEORETICAL THINKING TO
ENHANCE KNOWLEDGE DEVELOPMENT IN
NURSING
Several challenges prevail in the development of nursing knowl-
edge. Conceptualizing theory at different levels of theory may
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
theory, we often use traditional methods of theory construction
and substruction. The appropriate use of inductive and deduc-
tive approaches to develop nursing knowledge may be
improved by the consideration of the relationships among
levels of theories. Conceptualizing levels of theories also
provides a beginning tool to assess whether the philosophic
roots of our grand theories are reflected in our middle-range
and micro-range theories. Such analyses can potentially
enhance the consistency and logic in our decision making
about care issues and the theoretical design of future research.
As a discipline, we also are looking for ways to integrate
related theories that have arisen from the multiple ways of
building knowledge. For instance, how does the theory about
stages of behavior change, developed from grounded theory
methods, relate to theories of self-efficacy for health behaviors
that were developed by using hypothesis-testing methods?
Similarly, we are searching for ways to integrate related theo-
ries from different disciplines. For example, how do middle-
range theories of health promotion in psychology relate to
those in sociology and nursing? The analysis and integration of
related theories may be facilitated by comparison of related
theories at the same theoretical level across disciplines and
arising from multiple methodologic approaches.
Recognition and discussion about
the levels of theoretical thinking
can serve as a vehicle for increased
communication between practi-
tioners and scientists about the
knowledge each is developing.
Another challenge in the discipline’s knowledge develop-
ment is understanding the mechanisms needed to enhance
articulation of the knowledge produced by practitioners and
researchers. Regardless of whether the methods used to
develop theory are inductive or deductive, and originate from
a philosophic, practice, or research perspective, multiple levels
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Levels of Theoretical Thinking in Nursing
of theoretical thinking exist. Although practitioners and
researchers may use divergent methods, each uses theoretical
thinking for the generation of knowledge. Recognition and
discussion about the levels of theoretical thinking can serve as
a vehicle for increased communication between practitioners
and scientists about the knowledge each is developing.
CONCLUSION
Knowledge development in any discipline is a dynamic process
that pursues probable truths about reality. It begins with
creative approaches from multiple perspectives and continues
by testing the knowledge according to appropriate truth
criteria. In nursing, our “reality” is clinical practice, and we
construct theories about probable truths related to the experi-
ence of health in the person-environment interaction.
Development of a knowledge base is an iterative and ongoing
process that requires periodic analysis and synthesis of an
entire body of work. In an attempt to further the under-
standing of the current status of nursing theory, we provided
an examination of the different levels of theory currently being
used to develop nursing knowledge. This meta-theoretical
discussion of theory is not meant to create artificial domains;
rather, it is an attempt to understand the current status of
nursing theory through clarification of the terminology and a
discussion of the related categories of theoretical thinking.
Perhaps more important, the final purpose of this article is to
recognize the strength of our disciplinary knowledge base and
generate public discussion about the future of theory develop-
ment and testing. ■
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