Concepts_&_Theories_of_Nursing

‘Theory forces a view, at the expense of knowledge, and at the expense of creativity in practice’ (Kozial-McLain & Maeve 1993). This essay is going to present arguments both for and against the above quote by analysis of the available literature. The theory-practice gap is a well known phenomenon in nursing and its existence had been acknowledged for many years. The disparity between theory and practice has exercised the minds of reformers and policy makers since the time of Florence Nightingale (Baly 1986). Theory and practice are powerful vehicles for socialization and transmission of cultural norms. Underlying the theory-practice debate is the assumption that theory is and can be separated from practice, theory and practice do not, however exist in splendid isolation (Rafferty et al 1996).The two are inseparable, their development has historically been regarded as the domain primarily of nurse educators rather than the concern of practitioners (Lathlean 1994).As the profession of nursing becomes increasingly complex, nurses assume greater responsibilities in the areas of clinical practice, theory development, and the advance of nursing science through research (Krouse & Holloran, 1992). A changing face of the broader society drives change in nursing (Loveridge, 1991). Nagle and Mitchell (1994) believe that the art of nursing is the way theoretical knowledge is lived in relationships with others. Whereas Koziol- McLain and Maeve (1993) suggest that nursing theories are not already linked to philosophical underpinnings and that theories are myopic and inadequate representations of reality. Koziol-McLain and Maeve (1993) suggest that practicing nurses should be wary of nursing theory. While recognizing a role for theory in nursing, they stated that nursing theory is useful only when ‘used to describe and when it entices us to want to know more’ but that theory in nursing is not useful when such theory is prescriptive in nature. According to Nagle and Mitchell (1994) this position denies the fact that all knowledge is already theoretical. If nurses think and rely on knowledge when they are with persons in practice, whether in the ‘highlands or in the swamps,’ then they must be relying on theoretical knowledge since there is no other kind. According to Miller (1985) during the development of nursing in the United Kingdom, nursing theory and nursing practice tended to be separate, with one group of nurses involved in caring for patients and another group of nurses involved in teaching nursing. The term nursing theory was once used to differentiate classroom teaching from ward practice. Nursing theory is an organized and systematic articulation of a set of statements related to questions in the discipline of nursing. A nursing theory is a set of concepts, definitions, relationships, and assumptions or propositions derived from nursing models or from other disciplines and project a purposive, systematic view of phenomena by designing specific inter-relationships among concepts for the purposes of describing, explaining, predicting, and or prescribing (Nursing Theories 2010). Botha (1989) suggests that theories provide ways of thinking about and looking at the world around us. Draper (1990) asserts that the generation of theory has several functions, to define nursing broadly, to aid curriculum design, to enhance professional nursing practice and to form the basis for a language through which nurses can communicate.  From the time of Florence Nightingale, the concept of person has played a major role in nursing theory and its development. While nursing theory has evolved since the nineteenth century, Nightingale's concept of person has remained as a central feature of much of this theory. The concept of person, however, has not remained central in all nursing theory, nor does the concept play a prominent role in all nursing research. By contrast, however, the concept of person continues as the central emphasis in nursing practice (Flynn and Heffron 1988). Dickoff and James (1968) cited by Tolley (1995) propose that there are four levels of theory classified according to their scope and depth. Firstly meta theory, which focuses on broad issues particularly related to theory in nursing. Recent examples include Botha (1989) and Shaw (1993). Secondly grand theories, which give some broad perspective to the goals and structure of nursing practice. Grand theories include conceptual models such as Orem (1971). Thirdly, another approach for translating knowledge into practice is through the use of middle range theories, examples include Reed (1991) middle range theory of self-transcendence and Barretts (1988) theory of power (Smith & Liehr 2008). Middle range theories focus on specific phenomena or concepts central to nursing practice in a variety of care settings and they provide a practical way for nurses to link philosophical perspectives of the discipline with real word applications of theory to practice. Finally there are practice theories, theses are theories which come from clinical practice, their purpose is to explain a specific nursing practice (Melius 1991). Dickoff and James (1968) cited by Tolley (1995) define practice theory as a situation producing theory and that it is there to guide action to the production of reality. Logical positivism and behaviourism influenced the development of nursing theory (Flynn and Heffron 1988). The nursing theory of Hildegard Peplau incorporated aspects of both behaviourism and logical positivism. Peplau's theory was the theory of psychodynamic nursing which is an interpersonal theory of nursing that is highly compatible with both the practice of nursing and nursing research (Bower el al 1994). The holistic approach to nursing that is incorporated in many contemporary nursing theories is significant for the relationship between the practice of nursing and theory development in nursing in relation to clinical practice (Lauder 1994). Clinical decision-making refers to the cognitive processes involved in the formulation of a patient diagnosis by a decision-maker, and to the selection by the decision-maker of appropriate interventions to correct the patient's problems. The primary sources of error in clinical decision-making are misperception of outcomes, and misperception of the values patients place on outcomes. The incorporation of holism into the theory of nursing could lead to improvements in clinical decision-making in that the nurse acting within the parameters of this theory of nursing would be more knowledgeable of and sympathetic to the values patients place on outcomes. Goal attainment, a holistic perspective, patient autonomy, interaction between nurse and patient, and adaptation are common both, to much contemporary nursing theory and to the practice of nursing (Bevis and Watson 1989). According to Allmark (1995) the perceived problem of the theory-practice gap is built upon the assumption that theory can and must be directly applied to nursing practice, otherwise it is irrelevant. Whilst the spirit in which this claim is made is healthy, the assumption is false; the type of knowledge associated with practice could not be taught through theory nor well represented in theoretical terms. McCaugherty (1991) explains the theory practice gap using the symbol-object dichotomy as an analogy. He states that a symbol such as a picture or an image is not the same as the actual object, thus, what is taught in the classroom is not the same as that which is experienced in the clinical environment. Russell (1967) cited by (McCaugherty 1991) identifies the former as ‘knowledge by description’ and the latter, ‘knowledge by acquaintance’. McCaugherty (1991) argues that theory can only ever offer generalisations and can never capture the richness of that which individuals encounter in practice, but theory gives students an idea of what can be expected. Benner (1984) argues that the art of nursing cannot be found in text books and that this intuitive knowledge is characteristic of expert nursing practice gained through experience informed by theoretical knowledge but not enslaved by it. According to Cook (1991) the theory-practice gap in nursing exists partly due to the influence of ‘the hidden curriculum’, that is, the learning that takes that is unplanned and unintended in any given learning setting. He argues that attempts to close the theory / practice gap are doomed to failure since they are based on an inadequate understanding of why the gap exists in the first place. Sandelands (1991) gives pointers to the distinctive nature of practice and theory, understanding and explanation, he states that practice often develops without theory; he gives the example of children learning language, he also states that knowing theory is rarely a guarantor for good practice, e.g. playing the piano or nursing. So not only are theory and practice logically distinct but they are characterized by different types of knowledge. Miller (1985) states that although it is clear that nursing practice must alter in order to accommodate both changes in society and changes in our ideas about nursing, one cannot also expect practitioners to adopt idealized theories of nursing which are impossible to apply to practice. Nor can one educate students to enter a practical world by teaching theories of nursing which bear little relationship to the reality of nursing practice, and which are perceived as irrelevant by many nursing practitioners. The relationship between thinking and doing is probably one of the most important debates within the nursing profession. It was thought that the problem of how to link both was solved in the idea if the reflective practitioner. Aristotle’s notions of practical wisdom and the practical syllogism provide a theoretical and conceptual framework that facilitates the explication of that vital bridge between theory and practice (Lauder 1994). The concept of the reflective practitioner has been an important and central feature in nursing education for some years now, with nurses constantly being reminded that reflecting on the acts they perform is the essence of professional practice (Cervero 1988). According to Conway (1994) artistry and reflection appear to be ideal vehicles for bridging the theory-practice gap in nursing. If practitioners are coached to develop reflective practice abilities, which enable them to reframe problems in the practice setting and to devise and test hypotheses related to practice within the practice setting, then both the theory and practice of nursing are fused into one. Reflection is ideal for uniting the art and science of nursing, reflection-in-action, as demonstrated in the professional artistry of expert practitioners is a process in which the art of the practitioner fuses with a form of action research to produce a science of practice (Conway 1994). Action research is an intentional, systematic method of enquiry used by a group of practitioner-researchers who reflect and act on the real life problems encountered in their own practice (Munhall 2007). If this process is reflected on as in reflection-on-action, it is possible for the knowledge that is found in practical nursing knowledge to be identified and developed into theories, which in turn can guide and inform practice. Benner (1984) identifies that the failure of nurses to chart their practice and clinical observations has deprived theory of the uniqueness and richness of the knowledge embedded inn expert clinical practice. Well-charted practices and observations are essential for theory development. Reflection links the artistry of nursing with the science of hypotheses testing, so that essentially both the art and the science of nursing are united through the reflective process. Bridging the gap between theory research and practice is essential to bringing innovations from nursing research into practical application by practicing nurses; much of this gap exists by default related to a lack of awareness by nurses of the theory that guides their practice (Jensen and Onyskiw 2003). The primary failure within the theory-practice gap is not simply recognition; it is the lack of incorporation of research within current nursing practice. A second and equally important component is Evidence-Based Practice, an approach to providing care that integrates nursing experience and intuition with valid and current clinical research (Ritter 2001). Balas and Boren (2000) found that it can take an average of seventeen years to translate research findings into clinical practice. DePalma (2000) defines Evidence-Based Practice as ‘a total process beginning with knowing what clinical questions to ask, how to find the best practice, and how to critically appraise the evidence for validity and applicability to the particular care situation. The best evidence then must be applied by a clinician with expertise in considering the patient’s unique values and needs. The final aspect of the process is evaluation of the effectiveness of care and the continual improvement of the process’. According to Billings and Kowalski (2006) ultimately, the value of integrating Evidence-Based Practice into current nursing practice is the bridging of the gap between theory and practice by providing nurses with recognition of the value of theory in practice. The theory-practice gap, which certainly exists within nursing practice, threatens to fragment nursing practice. However, by means of Evidence-Based Practice this fragmentation can be, and often is, eliminated. The result is not only a bridge between theory and practice, but also nurses who think more clearly and, ultimately improved patient care. Constructing the bridge over this gap by means of Evidence-Based Practice may not be easy, but its benefits simply cannot be denied (Billings and Kowalski 2006). However, according to Upton (1999) the present principles of Evidence-Based Practice threaten to continue to exacerbate the theory-practice gap by the recognition that some of the principles and beliefs underpinning the concept are in direct contrast to contemporary nursing opinion and subsequently limit the practitioners’ creativity and autonomy. If nursing is to engage in research for the common good, nursing philosophies, models and theories must be used as guides to practice (McCurry et al 2010). Where nursing theory has been utilised in a clinical setting, its main contribution has been the facilitation of reflection, questioning and thinking about what nurses do (kozier et al 2008) and according to Whelton (2008) nursing theory bridges philosophical reflection and nursing practice. The integration of theory into practice serves as a guide to achieve nursing’s disciplinary goals of promoting health and preventing illness across the globe (McCurry et al 2010). By using models and theories congruent with our philosophical perspectives, nursing knowledge is advanced and practicing nurses become empowered through their ability to use knowledge to transform perspectives, organise critical thinking and articulate rationales for decision making, actions and goals (Kenney 2002) cited by (McCurry et al 2010). Nursing will continue to be in conflict between its life as an academic discipline (Visintainer 1986). If academics and practitioners cannot reduce this divide and communicate their ideas then the future of nursing is at risk. Nursing theory and practice are viewed as two separate nursing activities, with theorists seen as those who write and teach about the ideal, separate from those who implement care in reality (Lindsay 1990). Even more depressing is the view that theory is anything that is taught in the classroom and practice is what is done on the wards (McCaugherty 1991). Some authors argue that the shift of nurse education into Higher Education Institutions and the adoption of androgogic principles, where the students are facilitated to be self directed, critical, reflective thinkers, had led to nurse training having a ‘process’ rather than a ‘product’ focus, and has paradoxically further enhanced the gap (Hewison and Wildman 1996). They also point out that the higher status of academia over practice skills has also added to the chasm, they argue that the conflicting nature of underpinning philosophies of the two environments, that is, the humanistic, holistic values of nurse education and the increasing management values where targets and finance are priority within the clinical environment, will inevitably result in a mismatch between theory and practice. Nursing as a profession has a social mandate to contribute to the good of society through knowledge- based practice. Knowledge is built upon theories, and theories, together with their philosophical bases and disciplinary goals are the guiding frameworks for practice. (McCurry et al 2010).As a discipline nursing needs multiple theories that embrace diverging paradigmatic perspectives. If nursing is limited to being an applied science as proposed in the Koziol-McLain and Maeve article, then borrowed knowledge will continue to be used for guiding practice and nurses can relinquish opportunities to conceptualise their own theories about human health experience (Nagle & Mitchell 1994). It is suggested that a ‘gap’ between theory and practice is not only inevitable and healthy but necessary for change to occur in nurse education. The pervasive nature of the theory / practice divide suggests that it is likely to remain a permanent feature in the nursing education calendar. Rather than decrying the theory / practice gap or lamenting its existence, we need to consider the factors by which it is perpetuated. Political as well as practical problems attend the translation of theory into practice, understanding the ways in which nurses can influence the policy process and the possibilities for transformation are important preconditions for change (Rafferty et al 1996). Rafferty et al (1996) ask ‘Should theory support and or transform practice'’ and reply by suggesting that the relationship should be reciprocal, so that practice informs theory as much as theory tests practice. Rafferty et al (1996) conclude that the theory-practice gap can never be sealed entirely, that theory and practice are by their nature always in dynamic tension, and that this tension is essential for change in clinical practice to occur. Nagel and Mitchell (1994) contend that the position of Koziol- McLain and Maeve (1993) places nursing in the realm of applied science, whereas according to them nursing is a basic science. This difference in perspective underscores a major problem that characterises the relationships between nursing practice and theory. That problem is that practicing nurses, nurse theorists, and nurse researchers often have difficulty in agreeing on a definition of just what nursing is. Within the context of this problem of defining nursing, it is not surprising that conflict frequently characterizes the relationships between practicing nurses, nurse theorists, and nurse researchers. Theory / practice issues have a long standing history in nurse education and are a chronic source of controversy to which there is no easy or perfect solution (Rafferty el al 1996).     References Allmark, P. (1995) ‘A classical view of the theory-practice gap in nursing’, Journal of Advanced Nursing, 22, p. 18-23. Balas, E.A. and Boren, S.A. (2000). Managing clinical knowledge for healthcare improvements, Stuttgart, Germany: Schattauer. Baly, M. (1986) Florence Nightingale and the Nursing Legacy, London: Croom Helm. Benner, P. (1984) From Novice to Expert, California: Addison-Wesley. Bevis, E.O. and Watson, J. (1989). Toward a caring curriculum: A new pedagogy for nursing, New York: National League for Nursing Billings, D.M. and Kowalski, K. 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