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 theavailable literature. The theory-practice gap is a well known phenomenon in nursing and its existencehad been acknowledged for many years. The disparity between theory and practice has exercised theminds of reformers and policy makers since the time of Florence Nightingale (Baly 1986). Theory andpractice are powerful vehicles for socialization and transmission of cultural norms. Underlying thetheory-practice debate is the assumption that theory is and can be separated from practice, theory andpractice do not, however exist in splendid isolation (Rafferty et al 1996).The two are inseparable, theirdevelopment has historically been regarded as the domain primarily of nurse educators rather than theconcern 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 theadvance of nursing science through research (Krouse & Holloran, 1992). A changing face of thebroader society drives change in nursing (Loveridge, 1991). Nagle and Mitchell (1994) believe that theart 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 philosophicalunderpinnings and that theories are myopic and inadequate representations of reality. Koziol-McLainand Maeve (1993) suggest that practicing nurses should be wary of nursing theory. While recognizinga role for theory in nursing, they stated that nursing theory is useful only when ???used to describe andwhen it entices us to want to know more??™ but that theory in nursing is not useful when such theory isprescriptive in nature. According to Nagle and Mitchell (1994) this position denies the fact that allknowledge is already theoretical. If nurses think and rely on knowledge when they are with persons inpractice, whether in the ???highlands or in the swamps,??™ then they must be relying on theoreticalknowledge since there is no other kind. According to Miller (1985) during the development of nursingin the United Kingdom, nursing theory and nursing practice tended to be separate, with one group ofnurses involved in caring for patients and another group of nurses involved in teaching nursing. Theterm 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 inthe discipline of nursing. A nursing theory is a set of concepts, definitions, relationships, andassumptions or propositions derived from nursing models or from other disciplines and project apurposive, systematic view of phenomena by designing specific inter-relationships among concepts forthe 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, toaid curriculum design, to enhance professional nursing practice and to form the basis for a languagethrough which nurses can communicate. ? From the time of Florence Nightingale, the concept of personhas played a major role in nursing theory and its development. While nursing theory has evolved sincethe nineteenth century, Nightingales concept of person has remained as a central feature of much ofthis theory. The concept of person, however, has not remained central in all nursing theory, nor doesthe concept play a prominent role in all nursing research. By contrast, however, the concept of personcontinues 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 classifiedaccording to their scope and depth. Firstly meta theory, which focuses on broad issues particularlyrelated 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 nursingpractice. Grand theories include conceptual models such as Orem (1971).Thirdly, another approach for translating knowledge into practice is through the use of middle rangetheories, 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 orconcepts central to nursing practice in a variety of care settings and they provide a practical way fornurses to link philosophical perspectives of the discipline with real word applications of theory topractice. Finally there are practice theories, theses are theories which come from clinical practice, theirpurpose is to explain a specific nursing practice (Melius 1991). Dickoff and James (1968) cited byTolley (1995) define practice theory as a situation producing theory and that it is there to guide actionto the production of reality. Logical positivism and behaviourism influenced the development ofnursing theory (Flynn and Heffron 1988). The nursing theory of Hildegard Peplau incorporated aspectsof both behaviourism and logical positivism. Peplaus theory was the theory of psychodynamic nursingwhich is an interpersonal theory of nursing that is highly compatible with both the practice of nursingand nursing research (Bower el al 1994).The holistic approach to nursing that is incorporated in many contemporary nursing theories issignificant for the relationship between the practice of nursing and theory development in nursing inrelation to clinical practice (Lauder 1994). Clinical decision-making refers to the cognitive processesinvolved in the formulation of a patient diagnosis by a decision-maker, and to the selection by thedecision-maker of appropriate interventions to correct the patients problems. The primary sources oferror in clinical decision-making are misperception of outcomes, and misperception of the valuespatients place on outcomes. The incorporation of holism into the theory of nursing could lead toimprovements in clinical decision-making in that the nurse acting within the parameters of this theoryof 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, andadaptation 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 theassumption 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 knowledgeassociated 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 ananalogy. 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 clinicalenvironment. Russell (1967) cited by (McCaugherty 1991) identifies the former as ???knowledge bydescription??™ and the latter, ???knowledge by acquaintance??™.McCaugherty (1991) argues that theory can only ever offer generalisations and can never capture therichness of that which individuals encounter in practice, but theory gives students an idea of what canbe expected. Benner (1984) argues that the art of nursing cannot be found in text books and that thisintuitive knowledge is characteristic of expert nursing practice gained through experience informed bytheoretical knowledge but not enslaved by it. According to Cook (1991) the theory-practice gap innursing exists partly due to the influence of ???the hidden curriculum??™, that is, the learning that takes thatis 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 gapexists in the first place. Sandelands (1991) gives pointers to the distinctive nature of practice andtheory, understanding and explanation, he states that practice often develops without theory; he givesthe example of children learning language, he also states that knowing theory is rarely a guarantor forgood practice, e.g. playing the piano or nursing. So not only are theory and practice logically distinctbut they are characterized by different types of knowledge.Miller (1985) states that although it is clear that nursing practice must alter in order to accommodateboth changes in society and changes in our ideas about nursing, one cannot also expect practitioners toadopt idealized theories of nursing which are impossible to apply to practice. Nor can one educatestudents to enter a practical world by teaching theories of nursing which bear little relationship to thereality 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 thenursing profession. It was thought that the problem of how to link both was solved in the idea if thereflective practitioner. Aristotle??™s notions of practical wisdom and the practical syllogism provide atheoretical and conceptual framework that facilitates the explication of that vital bridge between theoryand practice (Lauder 1994). The concept of the reflective practitioner has been an important andcentral feature in nursing education for some years now, with nurses constantly being reminded thatreflecting on the acts they perform is the essence of professional practice (Cervero 1988). According toConway (1994) artistry and reflection appear to be ideal vehicles for bridging the theory-practice gapin nursing. If practitioners are coached to develop reflective practice abilities, which enable them toreframe problems in the practice setting and to devise and test hypotheses related to practice within thepractice setting, then both the theory and practice of nursing are fused into one. Reflection is ideal foruniting the art and science of nursing, reflection-in-action, as demonstrated in the professional artistryof expert practitioners is a process in which the art of the practitioner fuses with a form of actionresearch to produce a science of practice (Conway 1994). Action research is an intentional, systematicmethod of enquiry used by a group of practitioner-researchers who reflect and act on the real lifeproblems encountered in their own practice (Munhall 2007). If this process is reflected on as inreflection-on-action, it is possible for the knowledge that is found in practical nursing knowledge to beidentified 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 theoryof the uniqueness and richness of the knowledge embedded inn expert clinical practice. Well-chartedpractices and observations are essential for theory development. Reflection links the artistry of nursingwith the science of hypotheses testing, so that essentially both the art and the science of nursing areunited through the reflective process.Bridging the gap between theory research and practice is essential to bringing innovations fromnursing research into practical application by practicing nurses; much of this gap exists by defaultrelated to a lack of awareness by nurses of the theory that guides their practice (Jensen and Onyskiw2003). The primary failure within the theory-practice gap is not simply recognition; it is the lack ofincorporation of research within current nursing practice. A second and equally important componentis Evidence-Based Practice, an approach to providing care that integrates nursing experience andintuition with valid and current clinical research (Ritter 2001). Balas and Boren (2000) found that itcan 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 whatclinical questions to ask, how to find the best practice, and how to critically appraise the evidence forvalidity and applicability to the particular care situation. The best evidence then must be applied by aclinician with expertise in considering the patient??™s unique values and needs. The final aspect of theprocess 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-BasedPractice into current nursing practice is the bridging of the gap between theory and practice byproviding nurses with recognition of the value of theory in practice.The theory-practice gap, which certainly exists within nursing practice, threatens to fragment nursingpractice. 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 moreclearly and, ultimately improved patient care. Constructing the bridge over this gap by means ofEvidence-Based Practice may not be easy, but its benefits simply cannot be denied (Billings andKowalski 2006). However, according to Upton (1999) the present principles of Evidence-BasedPractice threaten to continue to exacerbate the theory-practice gap by the recognition that some of theprinciples and beliefs underpinning the concept are in direct contrast to contemporary nursing opinionand subsequently limit the practitioners??™ creativity and autonomy.If nursing is to engage in research for the common good, nursing philosophies, models and theoriesmust be used as guides to practice (McCurry et al 2010). Where nursing theory has been utilised in aclinical setting, its main contribution has been the facilitation of reflection, questioning and thinkingabout what nurses do (kozier et al 2008) and according to Whelton (2008) nursing theory bridgesphilosophical reflection and nursing practice. The integration of theory into practice serves as a guideto 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 useknowledge to transform perspectives, organise critical thinking and articulate rationales for decisionmaking, 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). Ifacademics and practitioners cannot reduce this divide and communicate their ideas then the future ofnursing is at risk. Nursing theory and practice are viewed as two separate nursing activities, withtheorists seen as those who write and teach about the ideal, separate from those who implement care inreality (Lindsay 1990). Even more depressing is the view that theory is anything that is taught in theclassroom 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 theadoption 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 hasparadoxically further enhanced the gap (Hewison and Wildman 1996). They also point out that thehigher status of academia over practice skills has also added to the chasm, they argue that theconflicting 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 arepriority within the clinical environment, will inevitably result in a mismatch between theory andpractice.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 basesand disciplinary goals are the guiding frameworks for practice. (McCurry et al 2010).As a disciplinenursing needs multiple theories that embrace diverging paradigmatic perspectives. If nursing is limitedto being an applied science as proposed in the Koziol-McLain and Maeve article, then borrowedknowledge will continue to be used for guiding practice and nurses can relinquish opportunities toconceptualise 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 necessaryfor change to occur in nurse education. The pervasive nature of the theory / practice divide suggeststhat it is likely to remain a permanent feature in the nursing education calendar. Rather than decryingthe theory / practice gap or lamenting its existence, we need to consider the factors by which it isperpetuated. 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 fortransformation are important preconditions for change (Rafferty et al 1996).Rafferty et al (1996) ask ???Should theory support and or transform practice??™ and reply by suggestingthat the relationship should be reciprocal, so that practice informs theory as much as theory testspractice. Rafferty et al (1996) conclude that the theory-practice gap can never be sealed entirely, thattheory and practice are by their nature always in dynamic tension, and that this tension is essential forchange 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 themnursing is a basic science. This difference in perspective underscores a major problem thatcharacterises the relationships between nursing practice and theory. That problem is that practicingnurses, nurse theorists, and nurse researchers often have difficulty in agreeing on a definition of justwhat nursing is. Within the context of this problem of defining nursing, it is not surprising that conflictfrequently characterizes the relationships between practicing nurses, nurse theorists, and nurseresearchers. Theory / practice issues have a long standing history in nurse education and are a chronicsource of controversy to which there is no easy or perfect solution (Rafferty el al 1996).? ? ? ReferencesAllmark, 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. 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