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Nursing theory: its

importance to practice

Colley S (2003) Nursing theory: its importance to practice. Nursing Standard. 17, 46, 33-37. Date of acceptance: May 9 2003.

Abstract

Background Nursing theory should provide the principles that underpin practice and help to generate further nursing knowledge. However, a lack of agreement in the professional literature on nursing theory confuses nurses and has caused many to dismiss nursing theory as irrelevant to practice. This article aims to identify why nursing theory is important in practice. Conclusion By giving nurses a sense of identity, nursing theory can help patients, managers and other healthcare professionals to recognise the unique contribution that nurses make to the healthcare service (Draper 1990). Providing a definition of nursing theory also helps nurses to understand their purpose and role in the healthcare setting.

THERE ARE constant arguments surrounding nursing theory and what constitutes nursing knowledge, yet no definitive conclusions have been reached. Lack of agreement in the professional literature serves to confuse nurses and has caused many to dismiss nursing theory as long-winded and irrelevant to everyday practice.

Ideally, nursing theory should provide the principles that underpin practice. In terms of traditional science, a theory can be described as a set of established statements or rules that are able to be tested (Hardy 1978). Historically, nursing theory has been based around and developed alongside medical knowledge and theory. However, in the 1950s there was a consensus among nursing scholars that the discipline needed to validate itself through the production of its own scientifically tested body of knowledge (Newman 1972).

Herein lay ? and still lies ? the main discrepancy in nursing theory. Many nurses argue that nursing existed well before the inception of the concept of nursing theory and continues to exist despite many nurses knowing little about nursing theory. If nursing theory existed in the same terms as traditional science, then it would be impossible for nurses to practise without an understanding of nursing theory. Because of the diverse nature of nursing and its lack of palpable end-product, it is difficult to test or verify the input nurses make to the healthcare profession. For this reason, nursing theory cannot be thought of within the scope of traditional science. Nursing theory aims to describe, predict and explain the phenomenon of nursing (Chinn and Jacobs 1978). It should provide the foundations of nursing practice, help to generate further knowledge and indicate in which direction nursing should develop in the future (Brown 1964).

Despite the contradictions noted in viewing nursing as a traditional science, nursing theory remains subject to traditional frameworks. Kuhn (1970) identified that any subject undergoing the early stages of scientific development, or the `pre-paradigm' stage, would be subject to a number of schools of thought relating to a single phenomenon. Nursing remains in the pre-paradigm stage as it is still subject to many theories and has yet to reach the paradigm stage when one theory is deemed absolute (Kuhn 1970). Consequently, nurses must be able to appreciate different types of theory to critique them and to contribute to the continued development of nursing.

Classification of nursing theories

Broadly speaking, nursing theories can be divided into different categories according to function

Sarah Colley RGN, BN(Hons), is Staff Nurse, Medical Directorate, University Hospital Wales, Cardiff. Email: sarahj27@lycos.co.uk

Online archive For related articles and author guidelines visit our online archive at: nursing-standard.co.uk and search using the key words below.

Key words Education: theory and

philosophy Models and theories Nursing: models

These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.

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Table 1. Classification of nursing theories depending on function

Theory

Function

Descriptive

To identify the properties and workings of a discipline

Explanatory

To examine how properties relate and thus affect the discipline

Predictive

To calculate relationships between properties and how they occur

Prescriptive

To identify under which conditions relationships occur

(Polit et al 2001)

Box 1. Classification of nursing theories depending on the generalisability of their principles

Nursing models

Added to the confusion over the grouping of different types of theory is the use of nursing models. The terms `model' and `theory' are often wrongly used interchangeably, which further confounds matters. In nursing, models are often designed by theory authors to depict the beliefs in their theory (Lancaster and Lancaster 1981). They provide an overview of the thinking behind the theory and may demonstrate how theory can be introduced into practice, for example, through specific methods of assessment. Models are useful as they allow the concepts in nursing theory to be successfully applied to nursing practice (Lancaster and Lancaster 1981). Their main limitation is that they are only as accurate or useful as the underlying theory.

Metatheory: the theory of theory. Identifies specific phenomena through abstract concepts.

Grand theory: provides a conceptual framework under which the key concepts and principles of the discipline can be identified.

Middle range theory: is more precise and only analyses a particular situation with a limited number of variables.

Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved.

(Polit et al 2001)

(Table 1). Theories can also be classified according to the extent their principles can be generalised (Box 1). They can also be categorised as: Needs theories. Interaction theories. Outcome theories. Humanistic theories. These categories indicate the basic philosophical underpinnings of the theories. Needs theories These theories are based around helping individuals to fulfil their physical and mental needs. The basis of these theories is well-illustrated in Roper, Logan and Tierney's Model of Nursing (1980). Needs theories have been criticised for relying too much on the medical model of health and placing the patient in an overtly dependent position. Interaction theories As described by Peplau (1988), these theories revolve around the relationships nurses form with patients. Such theories have been criticised for largely ignoring the medical model of health and not attending to basic physical needs. Outcome theories These portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health (Roy 1980). Outcome theories have been criticised as too abstract and difficult to implement in practice (Aggleton and Chalmers 1988).

The importance of nursing theory

Theory is important because it helps us to decide what we know and what we need to know (Parsons 1949). It helps to distinguish what should form the basis of practice by explicitly describing nursing. The benefits of having a defined body of theory in nursing include better patient care, enhanced professional status for nurses, improved communication between nurses, and guidance for research and education (Nolan 1996). In addition, because the main exponent of nursing ? caring ? cannot be measured, it is vital to have the theory to analyse and explain what nurses do.

Nolan et al (1998) note the disparity between current trends in the healthcare service. As medicine tries to make a move towards adopting a more multidisciplinary approach to health care, nursing continues to strive to establish a unique body of knowledge. This can be seen as an attempt by the nursing profession to maintain its professional boundaries. The issue is blurred further because the boundaries between nursing and medicine are never static. For example, as nurses increasingly extend their scope of practice by performing tasks previously carried out by doctors, many of their own traditional roles are being passed on to healthcare assistants.

However, because these boundaries are constantly changing, perhaps it is more important than ever that nurses are able to define their position and their role. By providing nurses with a sense of identity, nursing theory can help patients, managers and other healthcare professionals to recognise the unique contribution nurses make to the healthcare service (Draper 1990). A formal definition of nursing theory also provides nurses with an understanding of their purpose and role in health care.

An art or a science?

Coupled with the confusion surrounding nursing theory is the question of whether nursing is an art

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or a science. The alignment of nursing to either the field of art or science has been debated since the inception of modern nursing (LeVasseur 1999). Once nursing was being taught in institutions of higher education, it had to align itself with one of the main schools of knowledge (Rose and Parker 1994). These two schools ? art and science ? were traditionally, and to some extent are still, seen as mutually exclusive. This meant that alignment with either school had a major effect on the underpinning philosophy of the discipline, the types of research that could be carried out, the extent of funding and so on. As nursing shares common ground with both schools, it is stuck between them.

Traditionally, nursing has followed the medical or scientific approach to health care. Scientific knowledge is viewed as objective and, therefore, is more highly valued academically than the subjects whose concepts cannot be measured. The assumptions of science are also viewed as universal and able to explain phenomena irrespective of circumstance (Tinkle and Beaton 1983). Nursing acknowledged that to be taken seriously as a profession in its own right, it needed to discover its own scientifically tested body of knowledge. The search to try to quantify all aspects of nursing scientifically has been described as `physics envy' (Gould 1981). It has been impossible to explain a science based around the humanities using the same concepts as traditional or natural science. This is because, unlike the concepts described in natural science, humans cannot be described in context-free terms (Dunlop 1986).

The consensus is that nursing is both an art and a science (Carper 1978, LeVasseur 1999, Nightingale 1860). Carper (1978) encompasses both schools of knowledge through the identification of four ways of knowing in nursing: empirical, ethical, personal and aesthetical. According to Silva et al (1995), Carper's greatest contribution was to encourage nurses to move away from empirical knowledge and address their discipline in terms of artistry. This provided nursing with an opportunity to move away from the medically dominated view of health care and allowed nurses to describe their unique contribution to patient care.

It is more difficult to identify the art than the science of nursing in practice. Some of the ways of knowing are difficult to validate as nurses often follow these ways without being aware of them, for example, intuition and the therapeutic use of self. This might not be such a problem if nursing in particular and health care as a whole stopped trying to validate their existence through scientific outcomes. Health care today emphasises the importance of evidence-based practice in nursing, which in turn places more pressure on nurses to substantiate their practice. Instead of using research techniques based on existing nursing theory, as outlined by Carper (1978), nurses continue to rely on medically based

randomised controlled trials to validate their practice (Fawcett et al 2001).

However, there is a backlash against the traditional view of science as absolute. Science has been criticised for presenting a narrow picture of humans (Clifton 1991). In addition, in terms of `new physics', the entire universe is presented as interconnected energy fields, giving credit to the work of existing nursing theorists, such as Rogers (1970), who already presented such a notion (Clifton 1991). Expanding scientific views, such as naturalism, have allowed a more flexible approach to science (Lincoln and Guba 1985). Therefore, as these new scientific theories develop it is hoped that the issue of whether nursing is a science or an art will become irrelevant; it will just be.

A unique body of knowledge

The drive for a unique body of knowledge is based on the assumption that `borrowed' knowledge is less worthy. However, nurse education is based on theory borrowed from other disciplines, such as sociology and psychology. It has been argued that applying knowledge from different disciplines only serves to dilute nursing practice.

Nevertheless, as the occupation is focused on humans, perhaps it is inevitable that nursing uses knowledge from other social sciences. It has been argued that no knowledge is exclusive, and because of nursing's diverse nature it is impossible for it to have a unique body of knowledge and one unified body of theory (Castledine 1994, Levine 1995). In addition, the application of existing concepts to nursing forms `new knowledge' (Walker 1971). It is the way in which existing information is combined and used that makes it unique (Gunter 1962).

Criticisms of nursing theory

To understand why nursing theory is generally neglected on the wards it is necessary to take a closer look at the main criticisms of nursing theory and the role that nurses play in contributing to its lack of prevalence in practice. Use of language Scott (1994) states that the crucial ingredients of nursing theory should be accessibility and clarity. However, one of the main criticisms of nursing theory is its use of overtly complex language (Kenny 1993). Traditionally, nurses have been accustomed to using simple language; they have always understood medical terminology, but have chosen to communicate with patients and other healthcare professionals using lay terminology (Levine 1995). The introduction of nursing theory brought about the creation of a new language (Levine 1995). It is important that the language used in the development of nursing theory be used consistently, but as each nursing theory is based on a different author's perspective, the terminology remains unclear

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REFERENCES Aggleton P, Chalmers H (1988) Nursing

Models and the Nursing Process. London, Macmillan. Brown M (1964) Research in the development of nursing theory: the importance of a theoretical framework in nursing research. Nursing Research. 13, 2, 109-112. Burroughs V, Burroughs B (1993) Therapeutic touch: why do we believe? Skeptical Inquirer. 17, 2, 169-174. Carper B (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science. 1, 1, 13-23. Castledine G (1994) Nursing can never have a unified theory. British Journal of Nursing. 3, 4, 180-181. Chinn P, Jacobs M (1978) A model for theory development in nursing. Advances in Nursing Science. 1, 1, 1-11. Clark J (2001) Defining moment. Nursing Standard. 16, 12, 16-17. Clifton B (1991) Nursing and the new physics. Nurse Education Today. 11, 5, 347-353. Derrida J (1967) Writing and Difference. Paris, Seuil. Draper P (1990) The development of theory in British nursing: current position and future prospects. Journal of Advanced Nursing. 15, 1, 12-15. Dunlop M (1986) Is a science of caring possible? Journal of Advanced Nursing. 11, 6, 661-670. Fawcett J et al (2001) On nursing theories and evidence. IMAGE: Journal of Nursing Scholarship. 33, 2, 115-119. Fitzpatrick J et al (1993) The relationship between nursing and higher education. Journal of Advanced Nursing. 18, 9, 1488-1497. Gould S (1981) The Mismeasure of Man. New York NY, WW Norton. Gunter L (1962) Notes on a theoretical framework for nursing research. Nursing Research. 11, 4, 219-222. Hardy M (1978) Perspectives on nursing theory. Advances in Nursing Science. 1, 1, 27-48. Kenny T (1993) Nursing models fail in practice. British Journal of Nursing. 2, 2, 133-135. Kuhn T (1970) The Structure of Scientific Revolutions. Second edition. Chicago Ill, University of Chicago Press. Lancaster W, Lancaster J (1981) Models and model building in nursing. Advances in Nursing Science. 3, 3, 31-42. Lathlean J (1994) Historical and empirical approaches. In Lathlean J, Vaughan B (Eds) Unifying Nursing Practice and Theory. Oxford, Butterworth-Heinemann. Lenz E et al (1995) Collaborative development of middle-range theories: toward a theory of unpleasant symptoms. Advances in Nursing Science. 17, 3, 1-13. LeVasseur J (1999) Towards an understanding of art in nursing. Advances in Nursing Science. 21, 4, 48-63. Levine M (1995) The rhetoric of nursing theory. IMAGE: Journal of Nursing Scholarship. 27, 1, 11-14. Lincoln Y, Guba E (1985) Naturalistic Inquiry. Beverly Hills CA, Sage. Littlejohn C (2002) Are nursing models to blame for low morale? Nursing Standard. 16, 17, 39-41.

(Upton 1999). This can only serve to hinder the expansion of theory. The large number of subgroups, coupled with the lack of absolute answers, can make nursing theory appear daunting. The theory should be able to provide insight into the uniqueness of nursing, but if nurses cannot understand it, patients and other healthcare professionals will find it even less meaningful.

The use of complicated language and concepts seems to be an integral part of nursing theory. Levine (1995) stated that if nursing theory was deemed understandable, it was then not classed as good theory. Part of the confusion arises from the tendency of nursing theorists to give recognised phenomena new theoretical meanings (Lundh 1988). When faced with nursing theory, nurses spend the majority of time trying to understand new concepts and often fail to see its relevance to practice. If the links between theory and practice were made clearer, theory might not seem so mystifying. Draper (1990) stated that effective nursing theory would provide nurses with the language to discuss nursing. However, nurses are unlikely to share common definitions and language due to the vast number of theories available and the general lack of understanding. The terminology in nursing theory is also used inconsistently and interchangeably, which exacerbates poor communication between nurses and other members of the multidisciplinary team.

The primary reason for the development of nursing theory is ultimately to show nursing as a profession in its own right (Draper 1990). It is acknowledged that the only way to promote nursing as a distinct discipline is for the profession to develop its own theories (Brown 1964). However, nursing theory is often criticised for over-complicating practice. In essence, the theories have tried to explain everything, but have explained nothing (Nolan et al 1998).

The use of jargon ? `the language of the insecure' (Scott 1994) ? in nursing theory further confuses nurses. Scott (1994) argues that, as nursing is still largely undefined, it has to manipulate the language it uses to define its role. Such pseudointellectualism has alienated the majority of nurses and caused them to dismiss nursing theory as irrelevant (Miller 1985). Nursing theory has failed nurses, as they remain unable to describe themselves in nursing terms. They continue to identify themselves in accordance with the medical model of division of labour, for example, `geriatric nurses' (Draper 1990).

Philosopher Jacques Derrida (1967) first recognised the concept of text portraying more than the actual words. He argued that passages could be subject to multiple interpretations. It could be argued that by using complex terms and concepts, nursing is trying to present itself as a more complicated subject, and that choosing complicated explanations of nursing supports the notion that it is a complex, skilled occupation.

Not part of everyday practice

Despite theory and practice being viewed as inseparable concepts, a theory-practice gap still exists in nursing (Upton 1999). A constant stream of articles in the nursing journals argue the advantages and disadvantages of various nursing theories. Yet despite the availability of a vast amount of literature on the subject, nursing theory still means very little to most practising nurses. Perhaps this is because the majority of nursing theory is developed by and for nursing academics (Lathlean 1994). The majority of nursing theories have been collated in isolation and often the author's intention was to provide a guide for the development of education, not practice (Meleis 1991). Therefore, some theories were not meant to be applied literally to practice and would not work in that context. This has caused some nurses to dismiss all nursing theories as unworkable.

Nevertheless, it can also be argued that the lack of input from ward-based staff has only succeeded in making nursing theory more difficult to apply to practice. It has been recognised that traditionally nurses are used to `speaking with their hands' (Levine 1995). Therefore, many nurses have not had the training or experience to deal with the abstract concepts presented by nursing theory. This makes it difficult for the majority of nurses to understand and apply theory to practice (Miller 1985). Whereas nursing students are expected to use theory and argue its relevance, current theory is far removed from day-to-day nursing and is given low priority by ward-based nurses (Levine 1995).

Kenny (1993) suggests that the implementation of nursing theories in the ward setting would be more accepted if the nurses themselves discovered and introduced the theories. However, the increasing use of pre-printed care plans may mean that nurses are less likely to seek alternative theories. The use of pre-printed care plans is partly responsible for the dwindling popularity of theories. Preprinted care plans may encourage uniform, good practice, but if they are imposed on nurses the plans may also discourage staff from exploring other theories.

Conversely, the style and substance of nursing theory cannot be completely to blame for its poor uptake in practice. All nursing students are exposed to nursing theory during their training and the uptake of advanced qualifications means that an increasing number of qualified staff should have an understanding of nursing theory.

The lack of application of nursing theory to practice could be due to a failure on the part of nurses to apply what they have learnt during their training. Gunter (1962) states that nursing is practical, not theoretical, in nature, but there is also a large gap between what nurses know and what nurses do (Scott 1994).

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The nursing profession appears to be contradicting itself. Most nurses want to gain increased recognition from other healthcare professionals and in the form of financial gain; however, nurses choose to dismiss the `arty-farty theoretical stuff' (Clark 2001), which could ultimately prove their unique contribution to the health service. Such an antiintellectualist stance in nursing makes it difficult to encourage nurses to embrace what is seen as the academic side of the profession.

It is important to strike a balance between the pseudo-intellectualism, which alienates many nurses, and the reluctance to gain any theoretical knowledge. However, nurses need to be persuaded that theory is an essential part of their profession (Levine 1995). Woodward (1997) identified that a failure in nursing theory to support nurses' professional principles resulted in disillusionment, but there are many nursing theories catering for different professional principles. Perhaps it is the passivity of the profession, not the difficulty of the theory, that is the problem.

The future of nursing theory

It is clear from the literature that existing nursing theories have failed to dramatically affect nursing practice. One of the main criticisms of nursing theory is that it is too generalised. The very nature of humans means it is impossible to apply generalised assumptions to all individuals. This has led to increasing support for the development of so-called midrange theories (Meleis 1987).

These theories could provide the theoretical basis for specific situations, such as pain control, but would not provide an outline for every nursing intervention (Nolan et al 1998). Lenz et al (1995) argue that these types of theories would be universally accepted, as they are easier to understand and are based on clinical experiences.

It is also clear that for future nurses to be able to appreciate and use nursing theory, changes must be made to nursing research and nurse education. Although growing numbers of nurses are becoming involved in research, their research methods remain based on techniques used by other disciplines, such as medicine. The majority of nursing research takes a theoretical stance, which is not suited to nursing practice (Rolfe 1996). Therefore, nursing researchers are failing to answer the questions posed by practising nurses (Upton 1999). This impedes the development of research-based nursing knowledge. The government and the health service should encourage the use of alternative research techniques and nurses should push for the development of these techniques.

The idea of an all-graduate nursing profession has been debated widely (Fitzpatrick et al 1993). Many nurses believe that this would benefit the profession as a whole, as nurses would develop the skills

required to perform research and understand nursing theory. Conversely, moving nursing further into the academic arena may widen the theory-practice gap even further. Perhaps an update on nursing theory should become a statutory part of continuing professional development, not just advanced qualifications.

Nurse education will fulfil its responsibility when nurses have developed their critical and analytical skills to such an extent that they no longer accept nursing theory as it is taught (Burroughs and Burroughs 1993). True professionalism in nursing will only occur when all nurses take an interest in theory development and contribute to its introduction to practice.

Conclusion

Littlejohn (2002) comments that irrespective of nursing theories, nurses will continue to exhibit a caring response to the `sick and troubled'. If this is true, perhaps nurses are `nursing' without the knowledge of theories and theory is irrelevant. However, theory and practice are related, and if nursing is to continue to develop, the concept of theory must be addressed. If nursing theory does not drive the development of nursing, it will continue to develop in the footsteps of other disciplines such as medicine.

Because of the diverse nature of nurses and patients, it seems unlikely that nursing will ever reach the paradigm stage. Therefore, perhaps it is time that academic and practice-based nurses accept that one theory will never be able to explain the entire phenomenon of nursing. If this was accepted, nurses could work together to form theories and models that would not only satisfy academics but also nurses in clinical practice. It is also necessary to promote the view that practical and academic skills should be valued equally.

Nurses involved in academia are often criticised for being ?litist (Lenz et al 1995), and nurses working in clinical practice may undermine those who choose to develop their skills in the academic field. It is essential that nursing finds some middle ground between the two areas.

The key to developing nursing theory is to stimulate an interest in this area. For example, nursing journals and nurse educators should make the promotion of nursing theory a priority. Ultimately, it is the responsibility of each nurse to pursue an understanding of nursing theory, which provides nurses with foundations for professional practice.

Nurses should actively support the development of nursing theory because it offers them a sense of identity, and can help patients, managers and other healthcare professionals to recognise the unique contribution nurses make to the healthcare service (Draper 1990). The definition of nursing theory also provides nurses with an understanding of their purpose and role in the healthcare setting

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