3Evidence for nursing practice comes from research and oth.docx

3
Evidence for nursing practice comes from research and other
sources. Evidence-based prac-
tice requires an understanding of how research findings and
other evidence inform and
guide practice. In this chapter, you will learn the importance of
conducting nursing
research and the connection between research and evidence-
based nursing practice. We
start by providing definitions for research and nursing research.
We continue with a dis-
cussion of the reason research is conducted and add definitions
for evidence and evidence-
based practice. We also provide an overview of different
sources of knowledge that are used
as evidence, a definition of theory, and a discussion of the
evidence provided by five dif-
ferent types of theories.
Chapter 1
Research and Evidence-Based
Nursing Practice
KEYWORDS
Aesthetic Nursing Theories
Applied Research
A Priori

Authority
Basic Research
Clinical Research
Concepts
Data
Descriptive Nursing Theories
Empirical Nursing Theories
Ethical Nursing Theories
Evidence
Evidence-Based Nursing Practice
Explanatory Nursing Theories
Knowledge
Metaparadigm
Metaparadigm of Nursing
Nursing Research
Predictive Nursing Theories
Propositions
Research

Sociopolitical Theories
Tenacity
Theories of Personal Knowing
Theory
Utilization of Research
WHAT IS RESEARCH?
Research can be defined in various ways. Some definitions of
research found in the Oxford
English Dictionary (OED) (2005) are:
• the act of searching (closely or carefully) for or after a
specified thing or person
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EBSCO : eBook Collection (EBSCOhost) - printed on 9/18/2018
2:40 AM via WALDEN UNIV
AN: 247372 ; Fawcett, Jacqueline, Garity, Joan.; Evaluating
Research for Evidence-based Nursing
Practice
Account: s6527200.main.ehost
• a search or investigation directed to the discovery of some fact
by careful consideration
or study of a subject; a course of critical or scientific inquiry
• an investigation; an inquiry into things
The dictionary definitions draw our attention to research as a
thorough search, an investi-
gation, or a critical inquiry. The goal of the search,
investigation, or inquiry is the discovery
of something.
Definitions of research found in textbooks, such as the
definitions listed below, underscore
the thorough and critical nature of research and draw attention
to the discovery or develop-

ment of knowledge as the specific goal. The definitions indicate
that research is:
• “A diligent, systemic inquiry or study that validates and
refines existing knowledge and
develops new knowledge” (Burns & Grove, 2007, p. 3)
• “Systematic inquiry that uses disciplined methods to answer
questions or solve problems”
(Polit & Beck, 2006, p. 4)
• “A rigorous process of inquiry designed to provide answers to
questions about things of
concern in an academic discipline or profession” (Anders, Daly,
Thompson, Elliott, &
Chang, 2005, p. 155)
• A formal, systematic, and rigorous process used to generate
and test theories
(Fawcett, 1999)
Although Polit and Beck (2006) refer to research as a way to
solve problems, it is important
to point out that research is not the same as problem-solving.
Research focuses on developing
knowledge to enhance understanding, whereas problem-solving
focuses on using existing
knowledge to resolve practical problems (Fain, 2004). More
precisely, knowledge developed by
means of research does not provide answers to problems but
rather helps us to think differently
about the problems we encounter in practice.
Knowledge,Theory, and Research
Fawcett (1999) mentions theories in her definition of research,

whereas Burns and Grove (2007)
mention knowledge, as did Hunt (1981), who also pointed out
that “research increases the body
of knowledge” (p. 190).
Knowledge is a very broad term that encompasses all that is
known about something
(OED, 2005). The spectrum of knowledge ranges from very
broad statements to very precise
statements.
A theory is regarded as knowledge that is at the relatively
precise end of the knowledge
spectrum. Theories are made up of one or more ideas and
statements about those ideas.
When discussing theories, ideas are referred to as concepts, and
statements are referred to as
propositions. Examples of theory concepts are functional status
and physical energy. One
type of proposition is a statement that defines a concept. An
example is:
Functional status is defined as the performance of usual
activities of daily living.
Another type of proposition is a statement about the association
between two concepts. An
example is:
Physical energy is related to functional status.
4 Part 1 ■ Introduction to Research
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Our definition of theory given below identifies the number of
concepts (one or more) and
the type of concepts (concrete and specific), as well as the type

of propositions (descriptions
of concepts and associations between concepts) that make up a
theory.
• A theory is made up of one or more relatively concrete and
specific concepts, the
propositions that narrowly describe those concepts, and the
propositions that state
relatively concrete and specific associations between two or
more of the concepts.
Research is the process used to gather and convert words and
numbers—which are
referred to as data—into theories. The definition of research we
prefer combines the idea
that research is a rigorous and systematic type of inquiry with
the idea that research
is directed toward the development of knowledge through the
generation and testing of
theories.
• Research is a formal, systematic, and rigorous process of
inquiry used to generate and
test theories.
Unfortunately, in some cases, the theory that is generated or
tested through the use of data
is not always obvious, and the research appears to be what
Chinn and Kramer (2004) called
“theory-isolated” (p. 123). They explained that the contribution
of research that is not expli-
citly directed toward theory development is very limited.
WHAT IS NURSING RESEARCH?
Nursing research “provides the scientific basis for the practice

of the profession” (American
Association of Colleges of Nursing, 2005, p. 1). Definitions of
nursing research tend to be
circular, requiring an understanding of the meaning of research
and the meaning of nursing.
For example, Nieswiadomy (2008) defined nursing research as
“the systematic, objective
process of analyzing phenomena of importance to nursing” (p.
54). Burns and Grove (2007)
pointed out that the definition of nursing research requires an
understanding of what knowl-
edge is relevant for nursing, and specifically what knowledge is
needed to improve nursing
practice.
The meaning of nursing and the identification of categories of
knowledge that are rele-
vant for nursing practice are summarized in what is called the
metaparadigm of nursing.
A metaparadigm is a global statement that identifies the subject
matter of each discipline or
field of study (Fawcett, 2005b). The metaparadigm of nursing
identifies human beings, the
environment, health, and nursing as the subject matter of
interest to nurses. The distinctive
focus of the discipline of nursing is on nursing actions and
processes directed toward human
beings that take into account the environment in which human
beings reside and in which
nursing practice occurs.
We have already defined research. Based on that definition and
the metaparadigm of nurs-
ing, we offer this definition of nursing research:
• Nursing research is a formal, systematic, and rigorous process

of inquiry used to
generate and test theories about the health-related experiences
of human beings
within their environments and about the actions and processes
that nurses use in
practice.
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Practice
WHY CONDUCT RESEARCH?
We believe that one of the most compelling reasons to conduct
research is to develop theories.
Sometimes research is conducted to generate theories, while at
other times research is conducted
to test theories.
Basic,Applied, and Clinical Research
Research designed to generate or test theories is considered
basic research. Tests of the limits
of the applicability of theories in different situations with
diverse populations are considered
applied research (Donaldson & Crowley, 1978). Tests of
theories about the effectiveness of
interventions are considered clinical research (Donaldson &
Crowley).
Research and Theory Development
The product of research is always theory. In Box 1–1, we
deliberately use equal signs (�) to
signify the equivalence of the terms. Thus, we believe that
research does not lead to theory
development but rather that research is the process of theory
development. Similarly, theory

does not lead to evidence but instead is the evidence. And
practice does not lead to research,
but rather practice and research are the same process.
Appreciating the equivalence of practice
and research highlights the practicing nurse’s ability to be a
“knowledge producer” as well as a
“knowledge consumer or user” (Reed, 2006, p. 36).
BOX
1-1
Research,Theory, Evidence, and Practice
• Research � Theory development
• Theory � Evidence
• Practice � Research
Theories as Evidence
Theories can be thought of as evidence (see Box 1–1), which is
something that serves as
proof (OED, 2005). When theories are used as evidence, the
“proof ” should be considered
tentative or uncertain, because no theory is absolutely true and
actually may be false
(Popper, 1965). In other words, a theory can never be proved to
be true, so it should never
be considered final or absolute. It is always possible that
additional tests of the theory will
yield findings that would contradict it or that other theories will
provide a better fit with
the data (Hoyle, Harris, & Judd, 2002). In nursing, evidence in

the form of theory is used
to guide practice.
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WHAT IS EVIDENCE-BASED NURSING
PRACTICE?
In recent years, a great deal of attention has been paid to the
need to base practice on evidence.
The term evidence-based nursing practice refers to the use of
evidence to guide nurs-
ing practice. Some discussions of evidence-based nursing
practice reflect an atheoretical,
Practice and Research
When theories are thought of as evidence, it becomes clear that
the evidence needed for practice
actually is theory (Walker & Avant, 2005). It may not be
surprising, therefore, to learn that prac-
tice and research are essentially the same process (see Box 1–
1). This means that the nursing prac-
tice process and the nursing research process involve the same
critical thinking skills and actions.
When professional practice is as rigorous and systematic as we
expect research to be, the nursing
practice process “mirrors” the nursing research process
(Cipriano, 2007, p. 27). In each process,
a problem is identified and then a plan is developed,
implemented, and evaluated.
As can be seen in Table 1–1, the results of assessment of a
person’s health-related experiences
can be considered the statement of the research problem—that
is, the purpose of the research.
Sometimes, the results of the assessment are summarized with a
label or diagnosis that specifies

a health-related experience and influencing factors. The label or
diagnosis used in practice
becomes a more elaborate statement of the problem in research.
Planning in nursing practice,
or developing a plan of care for a person, a family, or a
community, is the same as identifica-
tion of the methods for research. Implementation in practice
comprises the nursing interven-
tions; in research, implementation refers to the actual conduct
of research, including recruiting
research participants and collecting and analyzing data.
Evaluation in practice can be consid-
ered the same as the interpretation of research results. Written
or computerized documentation
of each step of the nursing process in practice is equivalent to
the research report.
Table 1–1 The Parallel Between the Nursing
Practice Process and the Nursing
Research Process
NURSING PRACTICE PROCESS NURSING RESEARCH
PROCESS
Assessment
Planning
Implementation
Evaluation
Documentation

Statement of the problem
Research methods
Conduct of the research
Interpretation of results
Research report
Adapted from Fawcett, J. (2005). Contemporary nursing
knowledge: Analysis and evaluation of nursing models
and theories (2nd ed., p. 595). Philadelphia: F.A. Davis, with
permission.
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biomedically dominated, empirical perspective in which the
randomized clinical trial—a very
rigorous type of experimental research—is the only legitimate
source of evidence. Along with
Fawcett and colleagues (2001) and Ingersoll (2000), we believe
that such a narrow viewpoint
detracts from thinking about theories as the evidence for
practice. A broader viewpoint, but
one that does not explicitly include theory, was given by
Pearson, Wiechula, Court, and
Lockwood (2007), who are associated with the Joanna Briggs
Institute, an Australian organi-
zation devoted to advancement of evidence-based nursing care.
They stated, “The Joanna
Briggs Institute (JBI) model of evidence-based healthcare
conceptualizes evidence-based prac-
tice as clinical decision-making that considers the best available
evidence, the context in which
the care is delivered, client preference, and the professional
judgment of the health professional”
(p. 85). Similarly, Porter-O’Grady (2006) defined evidence-

based practice as “simply the inte-
gration of the best possible research . . . evidence with clinical
expertise and with patient
needs” (p. 1).
The definitions of evidence-based practice given here highlight
theory as central. These
definitions assert that evidence-based practice is:
• “Conscientious, explicit, and judicious use of theory-derived,
research-based information
in making decisions about care delivery to individuals or groups
of patients and in con-
sideration of individual needs and preferences” (Ingersoll, 2000,
p. 152)
• “Conscious and intentful use of research- and theory-based
information to make deci-
sions about patient care delivery” (Macnee, 2004, p. 5)
• “Explicit and judicious decision making about health care
delivery for individuals or
groups of patients based on the consensus of the most relevant
and supported evidence
derived from theory-derived research and data-based
information to respond to con-
sumers’ preferences and societal expectations” (Driever, 2002,
p. 593)
Our definition of evidence-based nursing practice draws from
those definitions, as well as
from our emphasis on research as theory development, theory as
evidence, and practice as
research (see Box 1–1).
• Evidence-based nursing practice is the deliberate and critical

use of theories about
human beings’ health-related experiences to guide actions
associated with each step of
the nursing process.
At times, evidence-based practice is equated with research
utilization (Hasseler, 2006),
which has been the focus of a great deal of literature and many
projects during the past
30 years. At other times, evidence-based practice is regarded as
different from or broader than
research utilization. Stetler (2001b) viewed evidence-based
practice and research utilization
as different but acknowledged that the connection between them
“is somewhat murky in the
literature” (p. 272). She pointed out that research utilization
“provides the requisite prepara-
tory steps for research-related actions that, when implemented
and sustained, result in
[evidence-based practice]” (p. 272). Polit and Beck (2006)
regard evidence-based practice as
broader than research utilization, claiming that evidence-based
practice involves basing nurs-
ing care decisions on the best available evidence, whereas
research utilization involves the
translation of the results of research into the real world of
practice. Brown (1999) referred to
“research-based practice,” which can be thought of as a bridge
between research utilization and
evidence-based practice. She defined research-based practice as
“healthcare practitioners’ use
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of research findings and collective research evidence to shape
general approaches to care, spe-

cific courses of action, and recommendations made to individual
patients” (p. 4). In this book,
we focus on evidence-based practice.
WHAT ARE THE SOURCES OF KNOWLEDGE
USED AS EVIDENCE FOR PRACTICE?
We believe that theory is the very best source of knowledge
used as evidence for nursing
practice. We acknowledge, however, that other sources of
knowledge exist and sometimes
are evidence for practice. For example, knowledge that serves
as evidence for practice may
come from medical record data, quality improvement and
infection control reports, health-
care professionals’ clinical expertise and judgment, and patient
preferences based on values
and culture (Driever, 2002; Macnee & McCabe, 2008; Pearson
et al., 2007).
Other sources of knowledge are various methods of knowing.
The philosopher Charles
Sanders Peirce (1839–1914) identified four methods of
knowing—tenacity, authority, a priori,
and science—as sources of knowledge that sometimes are used
as evidence for practice (Cohen
& Nagel, 1934; Kerlinger & Lee, 2000). We have substituted
“theory” for “science” because
“[t]he basic aim of science is theory” (Kerlinger & Lee, p. 11).
Understanding the meaning
and the limitations of each method of knowing can help increase
our commitment to develop
the theories that are needed to guide nursing practice (Table 1–
2).
Tenacity

One method of knowing is tenacity, which has also been called
tradition (Dzurec, 1998;
Polit & Beck, 2006). Tenacity refers to persistent,
unsubstantiated, personal opinions about
things in the world. Tenacious opinions are those that people
believe to be true because they
know that they are true on the basis of their always having
known that they are true
(Kerlinger & Lee, 2000). In practice, tenacity guides us to do
certain things in a certain way
just because we have always done them that way. Tenacity is
evident in the many habits, rit-
uals, and customs we find in practice. For example, it is
customary to bathe a patient from
head to toe.
A major limitation of tenacity is that any opinion that
contradicts the tenaciously held
opinion is ignored as unworthy of attention or regarded as
disloyal. Another limitation is that
there is no way for a person to decide which one of various
conflicting opinions might be best.
Still another limitation is that reliance on tenacity as evidence
“sometimes [leads] to unantic-
ipated outcomes” that may be harmful (Thompson, McCaughan,
Cullum, Sheldon, &
Reynor, 2005, p. 438).
Authority
Another method of knowing is authority. This method, which is
similar to faith, involves
appeal to a highly respected source—the authority—for
evidence. The authority might be a

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book, a journal article, a governmental agency, or a person who
is considered an expert. The
words written in the book, article, or agency report or uttered by
the person are accepted as
the truth because the book, article, report, or person is highly
respected. Authority is evident
in the laws, rules, and procedures of daily life and practice.
Authority, in the form of the
opinions of people regarded by their peers as experts, also is
evident in organizational or
national standards for practice that are not based on theory
(Panfil & Wurster, as cited in
Hasseler, 2006).
Use of authority as evidence may be justified because
authorities may be correct
or because people do not have the time or adequate knowledge
and skills to find the evi-
dence themselves. Reliance on authoritative sources may,
however, ignore the potential
fallibility of written or spoken words. For example, errors may
be found in a textbook; a
teacher may present evidence that has been discredited by new
research results; or a nurse
manager may hold atheoretical opinions. And because some
authorities sometimes rely
on other persons who also are thought to be authorities or on
their own tenacious opinions,
their words cannot always be regarded as accurate evidence. A
teacher, for example, may not
notice an error on a particular page in a textbook before
referring students to that page.

Table 1–2 Description and Limitations of Four
Methods of Knowing Used as Evidence
DESCRIPTION LIMITATIONS
Tenacity
“We’ve always done it that way; it’s the
custom.”
“It’s the traditional way to do it here.”
Authority
“The textbook tells us to do it that way.”
“My teacher told me to do it this way.”
A Priori
“It seems reasonable.”
Theory
“The theory guides me to do it.”
Ignores contradictory evidence and
opinions.
There is no way to decide between con-
flicting opinions.
There are unanticipated negative outcomes.
Authoritative sources are not infallible.

There is no way to decide which authori-
tative source is correct.
One person’s idea of reasonable is not
the same as another’s.
There is no way to decide whether rea-
sonableness depends on the current way
of thinking or previous education.
Must be developed through rigorous
inquiry.
Theories can be false.
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A Priori
Still another method of knowing is a priori—that is, “the use of
reason alone, without exper-
imental evidence” (Payton, 1994, p. 11). This method, which is
also referred to as intuition or
common sense, involves reliance on the obviously true or self-
evident nature of the evidence.
The evidence may agree with reason, although it may not agree
with experience. The a priori
method often involves trial and error or “isolated and
unsystematic clinical experiences” (Stetler,
2001a, p. 186) that are never formalized as procedures, although
a procedure that seems to be
effective may be passed from one practitioner to others. For
example, one nurse may tell other
nurses that all patients experience good outcomes when they
walk a short distance on the first
postoperative day.

A limitation of the a priori method is that what one person
regards as reasonable may not
be the same as what another person regards as reasonable.
Another limitation is that the self-
evident nature of something may reflect a way of thinking that
is popular at a particular time
or that was learned at an earlier time.
Theory
The best method of knowing used for evidence is theory. Others
have identified science or
research, which is the method of science, as the best way to
acquire evidence in the form of
theory because it is much more reliable and self-corrective than
the tenacity, authority, and
a priori methods (Cohen & Nagel, 1934; Kerlinger & Lee,
2000). We agree with Polit and
Beck (2006) that research “is the most sophisticated method of
acquiring evidence that
humans have developed” (p. 13). Research can be regarded as
sophisticated because it requires
the researcher to consider alternatives. Researchers, as Cohen
and Nagel pointed out, are
“never too certain about [their] results” (p. 195). Consequently,
as the product of research,
theory is not regarded as the truth but rather as the best
currently available evidence. A theory
that represents the best available evidence may, for example,
indicate that words of encourage-
ment from nurses and family members hasten patients’ recovery
from surgery.
A limitation of theory as evidence is that it must be developed
through careful and system-
atic research, which typically takes a long time. Thus, a theory

may not yet be available to
guide a particular practice action. Another limitation is that a
theory may be false (Popper,
1965). The geocentric theory, which asserts that the planet
Earth is the center of our solar sys-
tem, is an example of a theory about the physical world that
currently is regarded as false.
WHAT TYPES OF THEORIES ARE USED
AS EVIDENCE FOR NURSING PRACTICE?
Many nursing actions are very complex and “are based to a very
large degree on interaction,
communication, and human care, [which] cannot be measured at
all, nor can they be stan-
dardized or shown to be effective” (Hasseler, 2006, p. 227).
Nursing actions may also be based
on “clinical expertise, patient choices, and critical evaluation of
the literature” (Cumulative
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Index of Nursing and Allied Health Literature, 2005).
Consequently, our thinking about the-
ory as evidence for evidence-based nursing practice has to
account for all of the complex
human care actions performed by nurses.
Five types of theories can be used as evidence for evidence-
based nursing practice—
empirical, aesthetic, ethical, personal knowing, and
sociopolitical (Carper, 1978; Chinn &
Kramer, 2004; White, 1995). Each type of theory is developed
by means of a different type
of inquiry, and each is a different type of evidence.

Empirical Theories
Empirical nursing theories are publicly verifiable factual
descriptions, explanations, or pre-
dictions based on subjective or objective data about groups of
people. The data used for empir-
ical theories are summarized as group averages. Empirical
theories make up the science of
nursing (Table 1–3).
Chinn and Kramer (2004, p. 10) identified two critical questions
that are answered by
empirical theories:
• “What is this?”
• “How does it work?”
We add two other questions that are answered by empirical
theories:
• How do I know what my own best practices are?
• How do I know how to get desired outcomes?
Three types of empirical theories are used as evidence for
nursing practice—descriptive the-
ories, explanatory theories, and predictive theories. Each type
of empirical theory is developed
by means of a particular type of empirical research (see Table
1–3).
Descriptive Nursing Theories
Descriptive nursing theories are detailed descriptions of
people’s health-related experiences;
they are developed by means of descriptive research.
Descriptive theories are the evidence

needed to develop tools that nurses can use to assess people’s
health-related experiences. A the-
ory about the concept of empathy, called the Theory of Personal
System Empathy, is an exam-
ple of a descriptive nursing theory (Alligood & May, 2000).
This theory is a description of what
nurses do when they feel empathy for a patient. Specifically, the
theory “proposes that empathy
organizes perceptions; facilitates awareness of self and others;
increases sensitivity; promotes
shared respect, mutual goals, and social awareness; cultivates
understanding of individuals with-
in a historical and social context; and affects learning” (p. 243).
This theory is the evidence
needed for development of a nursing practice tool to assess
nurses’ empathy for patients.
Explanatory Nursing Theories
Explanatory nursing theories are explanations of the relation
between people’s health-
related experiences and environmental factors that influence
those experiences; they are
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developed by means of correlational research. Explanatory
theories are the evidence nurses
need to link assessments of health-related experiences with
assessments of environmental
factors and to understand which environmental factors influence
which aspects of health-
related experiences. The Theory of Chronic Pain is an example
of an explanatory nursing
theory (Tsai, Tak, Moore, & Palencia, 2003). The theory
indicates that pain, disability, and

social support are related to daily stress and that daily stress is
related to depression in older
individuals with arthritis. This theory is the evidence needed to
link assessments of pain, dis-
ability, and social support with assessment of daily stress and
assessment of daily stress with
assessment of depression in older people who have arthritis.
Predictive Nursing Theories
Predictive nursing theories are predictions about the effects of
some nursing intervention on
people’s health-related experiences; they are developed by
means of experimental research.
Table 1–3 Types of Nursing Theories and Modes
of Inquiry with Examples: Empirical
Theories
TYPE OF MODE OF
THEORY DESCRIPTION INQUIRY EXAMPLES
Empirical
theories
The science of
nursing
Descriptive
theories
Explanatory
theories

Predictive
theories
Publicly verifiable
factual descrip-
tions, explanations,
or predictions
based on subjec-
tive or objective
group data
Descriptions of
people and
situations
Explanations of
environmental
factors that influ-
ence people and
situations
Predictions about
the effects of
some actions or
processes on
people and
situations
Empirical research
Descriptive
research
Correlational
research

Experimental
research
Scientific data
Descriptions of
people’s health
experiences
Explanations of
factors that influ-
ence health
experiences
Outcomes of
nursing interven-
tions
Adapted from Fawcett, J.,Watson, J., Neuman, B., Hinton-
Walker, P., & Fitzpatrick, J. J. (2001). On theories
and evidence. Journal of Nursing Scholarship, 33, 115–119,
with permission.
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Predictive theories are the evidence needed to link nursing
interventions to outcomes experi-
enced by people with diverse health conditions. The Theory of
Dependent Care is an exam-
ple of a predictive nursing theory (Arndt & Horodynski, 2004).
This theory predicts that
group and individual education for parents about child
development, feeding, food, nutrition,
and parent mealtime practices will result in toddlers’ self-
regulation of feeding and mealtime
interactions. The theory is the evidence needed for the
development of group and individual
educational programs for parents that are targeted to toddlers’

feeding behaviors and interac-
tions during meals.
Knowledge progresses from descriptive theories developed by
means of descriptive research
to explanatory theories developed by means of correlational
research to predictive theories
developed by means of experimental research. Although
researchers sometimes are tempted to
omit the crucial steps of descriptive and explanatory theory
development in their haste to test
predictive theories of the effects of interventions, we agree with
Lobo (2005) that “[w]e must
value and support the descriptive research that helps us
understand individuals, families, and
groups of people with specific needs. . . . We must encourage
the logical development of nurs-
ing knowledge, starting with descriptive, foundational research
that must be completed before
specific interventions can be developed and tested” by means of
experimental research (p. 6).
Aesthetic Nursing Theories
Aesthetic nursing theories focus on individuals, rather than
groups. They emphasize the
nurse’s perception of what is significant in an individual’s
behavior. This type of theory high-
lights the nurse’s ability to know what is happening to a
particular patient in a subjective,
intuitive way, without relying on objective information, such as
vital signs. Aesthetic theories
also address the “artful” performance of manual and technical
skills. They make up the art of
nursing (Table 1–4).

that are answered by aes-
thetic theories:
• What does this mean?”
• “How is this significant?”
We add one other question:
• How do I know what each individual needs?
Aesthetic theories are developed by means of envisioning the
possibilities about nursing
practice with each individual and rehearsing the art and acts of
nursing, with emphasis on
developing an appreciation of aesthetic meanings in practice
and inspiration for the develop-
ment of the art of nursing. This type of theory is expressed in
philosophical essays about nurs-
ing as an art, in aesthetic criticism of the performance of the art
of nursing through manual
and technical skills, and in works of art, such as paintings,
drawings, sculpture, poetry, fiction
and nonfiction, music, acting, and dance. An example of an
aesthetic nursing theory is the
Theory of Nursing Art (Chinn, 2001). This theory “offers a
conceptual definition of the art
of nursing—explanations as to how nursing art evolves as a
distinct aspect of nursing practice
and explanations of artistic validity in nursing” (p. 287). Chinn
emphasized that the theory is
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not empirical and therefore “is not intended to be subjected to
empirical testing but rather to

be considered from a logical, philosophic, and aesthetic
perspective” (p. 287). Another exam-
ple of an aesthetic nursing theory is Masson’s (2001) poem
about her experiences with a sister
who had breast cancer.
Ethical Theories
Ethical nursing theories, which are descriptions of obligations,
values, and desired outcomes,
also are used for practice. This type of theory is made up of
concepts and propositions about
nurses’ personal beliefs and values and the collective values of
the professional discipline of
nursing. Ethical theories make up the ethics of nursing (Table
1–5).
that are answered by
ethical theories:
• “Is this right?”
• “Is this responsible?”
We add two other questions:
• How do I know what I should do?
• How do I know what the right things to do are?
Ethical theories are developed by means of ethical inquiries that
focus on identification
and analysis of the beliefs and values held by individuals and
groups, dialogue about and

of Inquiry with Examples:Aesthetic
Theories
TYPE OF MODE OF
Aesthetic theories
The art and act of
nursing
Expressions of the
nurse’s perception
of what is signifi-
cant in the individ-
ual patient’s
behavior
Performance of
nursing actions in
an artful manner
Envisioning the
possibilities of
practice with an
individual
Rehearsing nursing
art and acts and
observing or per-
forming nursing
art
Philosophical
essays

Works of art
Aesthetic criticism
with permission.
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clarification of beliefs and values, and establishment of
justification for beliefs and values.
Sometimes, ethical inquiry and empirical research overlap. As
Chinn and Kramer (2004)
pointed out, descriptive ethics is an empirical endeavor, in that
people are asked about their
beliefs and values.
Codes of ethics, standards of practice, and philosophical essays
about how nurses should
behave can be considered ethical theories. An example is the
American Nurses’ Association
(ANA) (2001) Code of Ethics. The Code of Ethics is a statement
of professional goals and
values that guide nurses’ conduct (ANA’s Code of Ethics
Project Task Force, 2000).
Theories of Personal Knowing
Nursing theories of personal knowing are another type of theory
used as evidence for prac-
tice. This type of theory is concerned with the nurse’s knowing,
encountering, and actualizing
the authentic self. This means that personal knowing theories
focus on how each nurse knows
how to be authentic in relationships with patients—that is, how

he or she knows how to
express concern and caring for another human being. Personal
knowing is not “knowing one’s
self,” but rather knowing how to be authentic with others, what
can be thought of as know-
ing one’s own personal style of being with another person.
Personal knowing is what we mean
when we talk about therapeutic nurse/patient relationships and
when we discuss the quality
and authenticity of the interpersonal process between each nurse
and each patient. Personal
knowing theories are the interpersonal relationships of nursing
(Table 1–6).
that are answered by per-
sonal knowing theories:
• “Do I know what I do?”
• “Do I do what I know?”
of Inquiry with Examples: Ethical
Theories
TYPE OF MODE OF
Ethical theories
The ethics of
nursing
Descriptions of

moral obligations,
moral and non-
moral values, and
desired ends
Identification, analy-
sis, and clarifica-
tion of beliefs and
values
Dialogue about and
justification of
beliefs and values
Standards of
practice
Codes of ethics
Philosophies of
nursing
with permission.
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We add two other questions:
• How do I know how to be with people who come to me for
nursing?
• How do I know how to be therapeutic?
Personal knowing theories are developed as nurses open and
center themselves in their
work with patients, as they think about how they are or can be

authentic, and as they listen
to responses from others and reflect on those responses. This
type of theory requires the nurse
to draw on “personal qualities . . . [such as] self-awareness,
sensitivity, warmth, and a positive
non-blaming attitude” to develop effective and authentic
relationships with patients (Hewitt
& Coffey, 2005, p. 563). Theories of personal knowing are
found in nurses’ autobiographical
stories about the genuine, authentic self, as well as in essays
about personal knowing. Diers’
(2005) description of her work as a nurse is an example of a
nursing theory of personal know-
ing presented as a short autobiographical story. Meisenhelder’s
(2006) discussion of personal
knowledge of spirituality is an example of a personal knowing
nursing theory presented as an
essay. The theory proposes that nurses’ personal self-knowledge
of spirituality is required to
address patients’ spiritual needs.
Sociopolitical Theories
Sociopolitical nursing theories help nurses to understand the
context of nursing practice and
facilitate acceptance of multiple perspectives of a situation.
This type of theory provides the
context or cultural location for nurse/patient interactions and
the broader context in which
nursing and health care take place. They focus on exposing and
exploring alternate
constructions of reality (Table 1–7).
The question we think is relevant for sociopolitical knowing is:
• How do I know what is “real” in practice situations?

of Inquiry with Examples:Theories
of Personal Knowing
TYPE OF MODE OF
Theories of per-
sonal knowledge
The interpersonal
relationships of
nursing
Expressions of the
quality and authen-
ticity of the inter-
personal process
between each
nurse and each
patient
Opening, centering,
thinking, listening,
and reflecting
Essays
Nurses’ autobio-
graphical stories

with permission.
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Sociopolitical theories are generated and tested by means of
critiques of situations and of
alternate constructions of reality, as well as by hearing and
attending to the voices of all who
are concerned with a particular situation, the stakeholders.
Henderson (2005) pointed out
that a combination of methods, including description of “the
‘stage’ upon which practice
occurs, . . . shared implicit meanings within an interaction, . . .
and . . . beliefs and values
ascribed to symbolic acts and objects inherent in the hospital”
or other health-care organiza-
tion, can be used to describe the context of health care (p. 555).
This type of theory is found
in documents and statements that indicate that the many voices
involved in nursing practice
are heard and acknowledged. For example, a sociopolitical
theory is evident in Browne’s
(2001) discussion of the influence of liberal political ideology
on nursing science. Browne
proposed that the development of empirical nursing theories is
strongly influenced by the
beliefs and values of liberal political philosophy, including
individualism, egalitarianism,
individual freedom and tolerance, neutrality, and a free-market
economy. Her theory is a cri-
tique of nursing’s “implicit political allegiances” and the
implications of those allegiances on
nursing knowledge development that “help us to understand
whether our science disrupts or
inadvertently helps to maintain social inequities” (Browne, p.
129). Daiski’s (2004) response
to Browne brings other viewpoints and voices to our attention.

She cited Carper’s (1978) and
White’s (1995) contributions to our understanding of
nonempirical nursing theories, as well
as Silva and Rothbart’s (1984) discussion of historicism as a
strong influence on nursing the-
ory development. Historicism, Daiski explained, is “concerned
with whole persons and their
experiences . . . [and acknowledges] multiple realities” (p. 117).
Browne (2004) later
acknowledged that “a diversity of paradigms, theories and
perspectives are required to inform
knowledge development in nursing” (p. 123). She also pointed
out, “Studies of health and
illness are not neutral scholarly activities; they are loaded with
social, political and economic
consequences for individuals and society” (p. 123).
of Inquiry with Examples: Sociopolitical
Theories
TYPE OF MODE OF
Sociopolitical
theories
The politics and
policies of nursing
Descriptions and
expressions of the
context or cultural
location for nurse/

patient interac-
tions and the
broader context in
which nursing and
health care take
place
Critique of
situations
Critique of alter-
nate constructions
of reality
Hearing and attend-
ing to all relevant
views
Written or oral
criticism
Written or oral
criticism
Written or oral
documentation of
voices heard and
acknowledged
with permission.
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HOW ARE NURSING THEORIES USED
IN NURSING PRACTICE?

Nursing’s distinctive body of knowledge includes empirical,
aesthetic, ethical, personal knowing,
and sociopolitical theories. Each type of theory is an essential
component of the integrated
knowledge base for evidence-based nursing practice, so no one
type of theory should be used in
isolation from the others. As Carper (1978) pointed out,
“Nursing [practice] depends on the
scientific knowledge of human behavior in health and in illness,
the aesthetic perception of sig-
nificant human experiences, a personal understanding of the
unique individuality of the self and
the capacity to make choices within concrete situations
involving particular moral judgments”
(p. 22). White (1995) added that sociopolitical theories are
“essential to an understanding of all
the [other types of theories]” (p. 83). Furthermore, Hallberg
(2003) mentioned the need for the-
ories about clinical expertise and patient choices, as well as
empirical theories, for evidence-based
nursing practice. Aesthetic theories and theories of personal
knowing address clinical expertise,
and ethical and sociopolitical theories address patient choices.
No one type of theory should be regarded as superior or inferior
to another. Rather, each
type of theory is useful for understanding particular aspects of
nursing practice. When nurses
integrate specific empirical, aesthetic, ethical, personal
knowing, and sociopolitical theories,
they combine them to form a new, interactive, and unified base
of knowledge for practice
(Westra & Rodgers, 1991). Nurses then use the unified
knowledge to help people attain their
health-related goals. An example of the integration of multiple

types of theories is Schwartz’s
(2001) commentary about the presence of family members when
a patient is receiving inva-
sive procedures or is being resuscitated. Pointing out that nurses
frequently know when a
patient’s family members should be present and when they
should not be present, Schwartz
stated, “Nursing will always entail the balance of art [aesthetic
theory] and science [empirical
theory]” (p. 11), as well as ethical, personal knowing, and
sociopolitical theories.
Another example is Andrews and Waterman’s (2005)
description of the knowledge nurses
use to report patients’ physiological deterioration to physicians.
They developed an Early
Warning Score (EWS), which “packages” the nurse’s objective
(empirical) and subjective
(aesthetic, ethical, personal, and sociopolitical) knowledge
about a patient’s deteriorating
physiological condition. The EWS “gives nurses a precise,
concise, and unambiguous means
of communicating deterioration” (p. 473) to physicians.
Conclusion
In this chapter, you have learned how research, theory,
evidence, and evidence-based practice
are defined. You also have learned why research is conducted
and the links between research
and theory and theory and evidence, as well as the link between
the nursing practice process
and the nursing research process. And you have learned about
various sources of knowledge
used as evidence for practice, various types of theories, and the
type of evidence that each

source of evidence and each type of theory provides.
The remainder of this book focuses on how empirical research
provides the evidence needed
for evidence-based nursing practice. Although we recognize and
value the contributions of all
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five types of theories—empirical, aesthetic, ethical, personal
knowing, and sociopolitical—as
evidence, we will focus on empirical theories and empirical
research throughout the rest of
the book.
Three questions about information contained in published
research reports provide the
organizing framework for the remaining chapters in this book
(Box 1–2).
You will be able to answer the question, “Where is the
information?” when you learn how
to identify where in research reports you can find each
component of conceptual-theoretical-
empirical (C-T-E) structures for research. We introduce C-T-E
structures in Chapter 2 and
discuss where to find the information about each of the
components in research reports in
Chapter 3. We then discuss each component in detail in
Chapters 5 through 15.
You will be able to answer the question, “What is the
information?” when you learn how
to identify what the information is. In Chapter 3, we explain not
only where to find the infor-
mation but also what information is contained in each section of

a research report. We discuss
that information in much more detail in subsequent chapters.
Finally, you will be able to answer the question, “How good is
the information?” when you
learn how to determine whether the information meets certain
criteria. We identify those cri-
teria in Chapter 4 and discuss them in more detail in Chapters 5
through 15.
References
Full citations for all references cited in this chapter are
provided in the Reference section at the
end of the book.
Learning Activities
Activities to supplement what you have learned in this chapter,
along with practice examina-
tion questions, are provided on the CD that comes with this
book.
BOX
1-2
Three Questions About Information
• Where is the information?
• What is the information?
• How good is the information?

1489_Ch01_001-020.qxd 7/8/08 2:21 PM Page 20
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