is nursing theory important to nursing practice

Woodenpug, BSN · Jul 9, 2009

Okay, I'll bite. Am always interested in expanding my knowledge base. Can you please give me examples or show me how to find relevant information that doesn't rely on antiquated theoretical models? Thanks!

I somewhat question your sincerity. I apologize in advance, because I'm probably mistaken. Three things raise concerns for me. Antiquated and archaic mean two really different things. Being able to find relevant information and whether or not you can link it to a theoretical model has two different meanings. Finally, do you sincerely believe that you must know the nursing theory before you can do a review of the literature?

I should also say that given that you are sincere, we probably should move this to another thread.

jjjoy, LPN · Jul 9, 2009

I appreciate your thoughtful response!

Yes! While we do know much about how pharmaceuticals work within the body, much of pharmacology is based on theories that must be tested through the scientific process. Scientists have learned tremendous things about the body, especially with the discovery of the human genome, but even that started with ideas, theories. And the grand theory behind civil engineering is the theory of gravity.

The theories you mention in regard to pharmaceuticals and civil engineering are not exclusive to the professions of pharmacy or civil engineering. The scientific process is available to all fields and I don't see the *need* for specific "nursing theory" in order to develop a body of knowledge specific to the nursing profession.

We'd use theory as a way to determine our approach. Would we use Pender's theories of health promotion as a guide for our teaching materials? How might we approach this issue if we followed, say, Rogerian theories or the Neumann Systems Model? The Roy Adaptation Model?/

Couldn't one also "borrow" an effective adult learning theory to apply in regards to post-op teaching? Perhaps a nurse can or has developed a specific theory specific to patient teaching and learning. It still wouldn't be unique to nursing. Dieticians, physical therapists, etc might adopt that theory in their teaching efforts.

In regards to Watson's theories of transpersonal caring, I remember sitting in a class one time and nurses were debating whether or not caring was necessary to be a nurse.

Whether or not caring is a requirement of practicing one's profession is a question relevant beyond the nursing profession. Teachers, social workers, and even physicians can debate that.

I value theory as a foundation for nursing practice. I honestly don't believe thinking and doing have to be mutually exclusive in the nursing profession.

I agree with you about thinking and doing not being mutually exclusive. And I do see value in using nursing theory as a foundation for practice. However, as another noted, as ways of thinking become ingrained over time, sometimes the pendulum swings the other way.

I got pounded over the head in nursing school about autonomous nursing actions and nursing rationales (provide comfort, help acheive highest level of self care, etc) based on nursing theory. Meanwhile, we just whizzed by the medical side of things at lightening speed as if THAT was obvious and the cursory overview we got would more than suffice as a foundation that we'd build on once we started practicing. The medical side of nursing care was taught by assigning "pages 150-350 by next class" and requiring a page on pathophys & medical interventions in 8-page care plans or 30-page case studies. The rest of the content focused on autonomous nursing actions (read: anything that doesn't involve a physician getting involved) and/or describing how the listed nursing interventions fit within this or that nursing model of care.

In other words, I felt we got more than enough "critical thinking" & nursing theory and not nearly enough "practical knowledge." We hear many new grads complain that colleagues expect a lot more from them practically than they are able to perform. It seems to have come about that some nursing programs seem to primarily teach nursing as it relates to nursing theory (as opposed to providing a lot of practical training) on the basis that the new grads will learn the practical skills on the job anyway whereas they may never be exposed to nursing theory again.

I think that's a backlash to a history of nursing education focusing solely on practical knowledge. And I hope more of a balance can be found. But that's getting into a whole 'nother can of worms, isn't it?

Interesting discussion!

Multicollinearity, BSN, RN · Jul 9, 2009

I would imagine we aren't the only profession that has theories we grouse about. It's easy to imagine a forum where clinical psychologists occasionally gripe about Freud and "member envy." I think of this when I read anything related to Rogers and "energy fields."

nicurn001 · Jul 9, 2009

You might be interested to know that the ideas you just expressed in the quote above ARE a theory of caring. You are proposing a theory of caring that has been discussed/debated in the literature by caring theorists. The following questions have been discussed for years. How does a person (nurse) acquire the value of caring. Do values have to be taught in early childhood? or can they be acquired as adults? How can teach values to children and/or adults? How can we help people internalize a set of desired values?
Like it or not ... you have just shown that you have a theory of caring.

In my reality as a bedside nurse , I have simply stated the bleeding obvious , re caring ie . you either are or are not a caring person . In the Academic realm you can discuss to your hearts content the theory of caring , but it's practical relevance to bedside nursing as on a par with how many angels can be placed on a pin head .

When I entered nursing in the UK the Nursing Process was the buzz phrase , as time goes by different Buzz words have come and gone , they have kept Academia and Administrators busy come up with new commitees , schemes and ever more paperwork for the bedside nurse , but has it produced an advance in the care provided to patients ?. I know my answer to that question .

I am trying not to dismiss Nursing Theory , it has its place as a component of Nurse Training , but little importance in the day to day struggle of bedside nurses . If academia / administrative nurses would study practical issues such as what safe staffing levels are and how to come up with an acuity tool that reflects patient care , which is not influenced by reimbursement , then maybe I would not have such a jaundiced opinion of of them .

psychonaut · Jul 9, 2009

I would imagine we aren't the only profession that has theories we grouse about. It's easy to imagine a forum where clinical psychologists occasionally gripe about Freud and "member envy." I think of this when I read anything related to Rogers and "energy fields."

Very true, this subject was one I actually became interested when I was pursuing my psych degree. I think looking at the evolution of theory in psychology can inform the debate regarding theory in the nursing world.

This is a fun topic with me, and one I still struggle with. I think you can say I have gone from being a nursing theory atheist when I started my nursing program (as many of us were) to my present "agnostic" state after a couple of grad-level nursing courses and coming up on two years of nursing practice.

When I took my (grad-level) theory course last fall, I told myself I was going to set aside my preconceptions and really make a run at seeking a deeper understanding of the subject. I had already made an uneasy peace with the underlying concepts to nursing diagnosis, and I figured I could give the same thought to this subject.

The result was a similar "uneasy peace." I have definitely come to appreciate the *idea* of nursing theory, and why it is important to our profession. My issue now is with the actual nursing theories themselves. Existing nursing theories, at anything above the "practice theory" level, seem to substitute terminology and diagrams for broad, objective, and generally predictive and applicable concepts.

I am a great admirer of Nightengale's work, and have not yet found any other nursing theorist to match her succinct and relevant ideas about what nursing is.

I don't think I am expressing myself very well, and that is frustrating to me, because this is a subject to which I've given much thought. In fact, I've found myself growing more and more consumed by trying to get a grasp on the nature of our profession. For me, nursing theory (especially educational theory), professional roles, advanced practice nursing, etc. are aspects of this struggle to get a grip on Nursing as a science, a practice, and a profession.

The thread title is fundamental to these concerns, being that we are most definitely a practice profession. Going back to the psychology analogy, all psychologists (clinical and experimental) operate under some form of theoretical grounding. Further, this framework will most times (if not always) be explicitly acknowledged by the practitioner. Now, some may be more eclectic than others, ranging along a continuum from the theoretical purist (radical/Skinnerian behaviorist, Rogerian, Freudian, etc.) to a more varied approach (e.g. a cognitivist who uses behaviorist principals). I wager (though I certainly don't claim to be an expert in this) that you would be hard pressed to find a psychologist who doesn't acknowledge a strong theoretical basis to their practice, even amonsgst the most practical of clinicians.

My readings have led me to believe that this is what a good portion of the academic nurse leadership (aka the "Ivory Tower", not used here perjoratively) wants for practicing nurses, for our day-to-day clinical practice to be strongly and *explicitely* grounded in, and driven by, nursing theory. This is why theory is considered an important part of the educational process, especially at the BSN level.

There is an argument that a prime reason that this is not so (i.e. that nursing practice is not explicitely directed by nursing theory) is due to poor teaching of theory at the RN level. I can see the merit in this viewpoint; as an example, I was very disappointed by the complete lack of interaction offered by the PhD instructor of my theory course, even though the on-line format was perfect for such discussions, and many entreaties were made to the instructor to become involved in our theory discussions.

However, I am also formulating a second explanation for the disconnect between nursing theory and nursing practice: most of nursing theory is just not compelling enough to be an integral part of our day-to-day duties. I'm going to have to go back to my psychology analogy; for example, Behaviorist theories are scientifically established, powerfully predictive and clinically successful for a very wide range of issues that the clinical psychologist may encounter in their daily practice, as are Piaget's developmental theories, gestalt perceptual theories, etc.

We nurses have a few good ones of our own (Orem's SCD, levels of prevention, etc.), and even some that come from borrowed sources but have been "made our own" (Benner's novice-to-expert, some leadership theories, etc). What are needed are a core of high-level theories that are broadly applicable to the majority of nursing practice. For a good example, Nightengale's hygenic theories are just as relevent to me in the NICU as they are to the community health nurse. From this core of broad, *experimentally verified* theories can be generated narrower theories (mid-level, practice-level, etc) for specific circumstances.

I have noticed a tendency to give a pass to the grand theories vis-a-vis experimental confirmation, reserving this requirement for the lower-level theories. This is misguided; the grand theory must be observable, testable, predictive, etc. The allowences made for "non-empiracal" theorizing is what has led us to things like Rogerian "theory" (religion masquerading as philosophy pretending to be science), and the resultant disconnect between the grounded, realistic world of nursing practice and what should be an equally objective nursing science.

Dinith88 · Jul 9, 2009

Very true, this subject was one I actually became interested when I was pursuing my psych degree. I think looking at the evolution of theory in psychology can inform the debate regarding theory in the nursing world.
This is a fun topic with me, and one I still struggle with. I think you can say I have gone from being a nursing theory atheist when I started my nursing program (as many of us were) to my present "agnostic" state after a couple of grad-level nursing courses and coming up on two years of nursing practice.
When I took my (grad-level) theory course last fall, I told myself I was going to set aside my preconceptions and really make a run at seeking a deeper understanding of the subject. I had already made an uneasy peace with the underlying concepts to nursing diagnosis, and I figured I could give the same thought to this subject.
The result was a similar "uneasy peace." I have definitely come to appreciate the *idea* of nursing theory, and why it is important to our profession. My issue now is with the actual nursing theories themselves. Existing nursing theories, at anything above the "practice theory" level, seem to substitute terminology and diagrams for broad, objective, and generally predictive and applicable concepts.
I am a great admirer of Nightengale's work, and have not yet found any other nursing theorist to match her succinct and relevant ideas about what nursing is.
I don't think I am expressing myself very well, and that is frustrating to me, because this is a subject to which I've given much thought. In fact, I've found myself growing more and more consumed by trying to get a grasp on the nature of our profession. For me, nursing theory (especially educational theory), professional roles, advanced practice nursing, etc. are aspects of this struggle to get a grip on Nursing as a science, a practice, and a profession.
The thread title is fundamental to these concerns, being that we are most definitely a practice profession. Going back to the psychology analogy, all psychologists (clinical and experimental) operate under some form of theoretical grounding. Further, this framework will most times (if not always) be explicitly acknowledged by the practitioner. Now, some may be more eclectic than others, ranging along a continuum from the theoretical purist (radical/Skinnerian behaviorist, Rogerian, Freudian, etc.) to a more varied approach (e.g. a cognitivist who uses behaviorist principals). I wager (though I certainly don't claim to be an expert in this) that you would be hard pressed to find a psychologist who doesn't acknowledge a strong theoretical basis to their practice, even amonsgst the most practical of clinicians.
My readings have led me to believe that this is what a good portion of the academic nurse leadership (aka the "Ivory Tower", not used here perjoratively) wants for practicing nurses, for our day-to-day clinical practice to be strongly and *explicitely* grounded in, and driven by, nursing theory. This is why theory is considered an important part of the educational process, especially at the BSN level.
There is an argument that a prime reason that this is not so (i.e. that nursing practice is not explicitely directed by nursing theory) is due to poor teaching of theory at the RN level. I can see the merit in this viewpoint; as an example, I was very disappointed by the complete lack of interaction offered by the PhD instructor of my theory course, even though the on-line format was perfect for such discussions, and many entreaties were made to the instructor to become involved in our theory discussions.
However, I am also formulating a second explanation for the disconnect between nursing theory and nursing practice: most of nursing theory is just not compelling enough to be an integral part of our day-to-day duties. I'm going to have to go back to my psychology analogy; for example, Behaviorist theories are scientifically established, powerfully predictive and clinically successful for a very wide range of issues that the clinical psychologist may encounter in their daily practice, as are Piaget's developmental theories, gestalt perceptual theories, etc.
We nurses have a few good ones of our own (Orem's SCD, levels of prevention, etc.), and even some that come from borrowed sources but have been "made our own" (Benner's novice-to-expert, some leadership theories, etc). What are needed are a core of high-level theories that are broadly applicable to the majority of nursing practice. For a good example, Nightengale's hygenic theories are just as relevent to me in the NICU as they are to the community health nurse. From this core of broad, *experimentally verified* theories can be generated narrower theories (mid-level, practice-level, etc) for specific circumstances.
I have noticed a tendency to give a pass to the grand theories vis-a-vis experimental confirmation, reserving this requirement for the lower-level theories. This is misguided; the grand theory must be observable, testable, predictive, etc. The allowences made for "non-empiracal" theorizing is what has led us to things like Rogerian "theory" (religion masquerading as philosophy pretending to be science), and the resultant disconnect between the grounded, realistic world of nursing practice and what should be an equally objective nursing science.

Man...you're right. You're obviously WAY into nursing theories.

Now...it is my opinion that nursing theory is meant for classrooms and universities and has no bearing on the great mass of nurses actually doing the nursing. In fact, i'd go so far as to call it garbage...again this is my (correct :) )opinion. From my angle (critical-care), there is NEVER a day that i ponder nursing theories...or conciously try to incorporate them into my practice. Period. And i am sure that 99% of nurses who get asked would feel the same way.

I also feel that theory can best be described as sholastic career-student-types trying to EXPLAIN what we do rather than GUIDE what we do or HOW to do what we do...that is their only value.

But...it makes for good class-room fodder and papers and tests and discussions and bunk..And another hoop we have to jump through prior to the scholarly theorist-minded types granting us our degrees.

Now...excuse me whil:specs:e i go lay some energy-field hands on my patient...

psychonaut · Jul 9, 2009

From my angle (critical-care), there is NEVER a day that i ponder nursing theories...or conciously try to incorporate them into my practice.

On a hunch, I went through my theory texts that had biographies of the nursing theorists, looking for what their clinical experience consisted of. I don't have numbers, just an impression that the majority had significant histories in psych/community health type positions, vs acute/critical care of ill patients.

To be fair, most of the theories in the books were developed before the development of critical care as a specialty. However, I still have a hunch that the majority of nursing theorists spent their clinical career more on the behavioral end of the spectrum.

This is another of the big disconnects I have noticed, as so much of nursing theory feels alien to us in critical care settings, where the majority of our time and thought is devoted to managing very immediate medical/nursing needs. Sure, we think long-term as well, but generally in the context of balancing interventions between short term needs and potential long-term sequelae. In this setting, the fact that so much of nursing theory concerns itself with ephemera makes it seem that much more irrelevant to us.

llg, PhD, RN · Jul 9, 2009

I've enjoyed reading your posts, psychonaut. I agree with much/most of what you write. I similarly like the "idea" of nursing theory more than I like the nitty-gritty of most of the major theorists. As I have taught a theory class for a local university while working full time in a hospital, I have spent a lot of time podering some of the same issues and perspectives.

I am one of those people who believe that theory has been horribly taught over the years -- at least most of the time. It is taught by people who received poor teaching and everyone just muddles through the class to fulfill a requirement -- even the teacher. So, I try to do a better job. One of my primary teaching goals if for the students to appreciate the contributions that the theorists have made over the years by promoting discussion of key concepts.

As for the scientific verification and further development of theories ... I think more of that is happening now than happened in the past. Back in the 1960's and 1970's when a lot of grand theories were developed, there were no doctoral level programs in nursing. There were very few people educated in the skills it takes to develop and empirically test theories. Nurses just weren't doing much research (theory-based or not) period.

I think it is very telling that Roy developed her theory as a 27 year old Master's student. Compare that with today's world. I try to inform/remind my students that as we trace the history of nursing thought through theory development in my class. I emphasize that each theory added something of value to our discipline's conversation even though no one ever has and probably never will articulate one perfect theory that fits everything perfectly.

Looking at theory from the perspective of how/why nursing theory has developed along that lines that it has is fascinating and complex -- and opens up new trains of thought beyond the simplistic "I hate theory and all those academics" or "I love theory and everything academic" knee-jerk responses.

jjjoy, LPN · Jul 9, 2009

I also feel that theory can best be described as sholastic career-student-types trying to EXPLAIN what we do rather than GUIDE what we do or HOW to do what we do.

Good point. A psychological theory might influence what type of therapy a psychologist chooses to use in any particular case. How much would one's choice of nursing theory affect the nursing action they choose to take in any given situation? Especially in acute care settings?

However, I still have a hunch that the majority of nursing theorists spent their clinical career more on the behavioral end of the spectrum.... This is another of the big disconnects I have noticed, as so much of nursing theory feels alien to us in critical care settings, where the majority of our time and thought is devoted to managing very immediate medical/nursing needs.

Another good point, I think.

I would argue that this disconnect also occurs outside of critical care. In many other inpatient units, patients are still very acutely ill with immediate physiologic needs taking priority.

And when patient aren't so acutely ill, the nurse-patient ratio goes up higher and higher leaving nurses to "prioritize"... that is sacrifice or hand off to an aide much of the "nursing" as defined in some theories in order to make sure the highest priority tasks get done, which are usually addressing medical/physiological needs.

RNs often also get stuck with "RN-only" responsibilities such as the endless documentation required these days that doesn't allow for much in the way of actually practicing nursing. Other professionals also struggle with this these days, teachers, therapists, etc, so I guess, again, that's a whole 'nother can 'o worms.

psychonaut · Jul 9, 2009

Yes! While we do know much about how pharmaceuticals work within the body, much of pharmacology is based on theories that must be tested through the scientific process. Scientists have learned tremendous things about the body, especially with the discovery of the human genome, but even that started with ideas, theories. And the grand theory behind civil engineering is the theory of gravity.

However, the question posed was not whether or not pharmacists or civil engineers use theory to guide their practice; as you note, they certainly do. Rather, the questioner wanted to know if pharmacists utilize a grand theory of Pharmacists, or if civil engineers have a Theory of Civil Engineering. As a nurse, I use pharmacological and physics principals (derived from theory) every shift that I work.

Nursing theory is rare (unique?) in that it defines, and is defined by, the profession that develops and uses it (nursing). While understandable from a historical viewpoint, I do find the obsession with establishing nursing as a distinct, unique health care profession perplexing at times, especially when theory development is used as the vehicle to do so.

Nursing theory guides nursing research.

Does it? For my grad-level nursing research class, we had an assignment to pick a nursing research journal, review a year's worth of articles, and count how many mentioned nursing theory explicitly. As a class, maybe 20-30 journals were reviewed, with a conservative estimate of ~500 studies looked at. For each journal, it was rare that there were more than 1-2 studies that even mentioned nursing theory, much less used it as a guiding framework. In some of the articles that did mention nursing theory, it almost seemed an afterthought, shoehorning the data into the mold of whatever theorist was chosen (in fact, the phenomenon is discussed frankly in the texts we used for the class).

Without it, nurses are basing their research on "hunches" or conventional wisdom, which simply don't stand the test for scientific rigor. Let's say, jjjoy, you and I decided to do a research project on effective post-op teaching strategies. How would we start? We would determine exactly what it is that we wanted to study. How do we define "effective"? How do we define "post-op teaching"? What is our patient population? How do we come up with our strategy? [sNIP]

Research can be based on hypotheses ("hunches"), the results of which can be used to generate broad, explanatory frameworks (aka theories). We are a practice profession; as such, it is entirely reasonable for practice to generate hypotheses, which are tested via experiment. Having a set theory in place before such research is generated is unnecessary, developing a model via research results will permit the creation of a tested, explanatory/predictive theory.

We'd use theory as a way to determine our approach. Would we use Pender's theories of health promotion as a guide for our teaching materials? How might we approach this issue if we followed, say, Rogerian theories or the Neumann Systems Model? The Roy Adaptation Model? You see, without theory, someone else might pick up the research and decide that, while they are also interested in post-op teaching strategies, they can't use what you learned because you were talking about middle-age men with TURPs and they're interested in helping post-lady partsl hysterectomy women in their forties. But----a nurse researcher doesn't look only at the details. A nurse researcher looks at the underlying theory to see if the study is relevant to his/her clinical or research needs.

This paragraph confuses me. I get what you are saying initially; however I would counter that it is the methodology and setting of the study that determines whether or not the results would be generalizable to a greater population, not the use of a nursing theory.

The thing is, to do actual research, it's necessary to follow certain scientific and academic standards. You need to use statistics to analyze your data. (I hated statistics at the undergrad level and in grad school---but it's a necessary evil in order to understand and conduct nursing research.) Otherwise, how can you tell if what you did actually made a difference? Certainly nurses can publish the things they learn, their approaches in certain situations and how they handled things. But, unless those nurses follow the guidelines of conducting actual research, all their work can be dismissed as anecdotal, working for one patient or one situation, but not necessarily applicable in other persons in other clinical settings.

What does this have to do with nursing theory? If you are looking to generate a General Theory of Post-Op Teaching, you do your post-op study in a multitude of diverse settings. Statistical analysis of the results will tell you how generalizable your method/instrument is.

In regards to Watson's theories of transpersonal caring, I remember sitting in a class one time and nurses were debating whether or not caring was necessary to be a nurse. A debate ensued over the differences between sympathy, empathy and caring. Was it all just semantics, an academic exercise? I don't believe so. I was stunned to discover that many nurses (this was in grad school) did not understand the differences between these concepts and some stated that they felt they could be adequate nurses without caring at all. That goes against my core beliefs and I disagreed with those classmates who said nurses didn't need to care. How does that help me in practice? If I'm working with someone who mistakes empathy for sympathy, it matters in the care our team delivers. If I'm working with someone who believes caring is optional, I might have problems when they don't understand why I felt it necessary to sit at the bedside of a confused, elderly person who was crying at night.

It is situations like this that make the concepts of nursing theory and nursing science so muddy for me. What you wrote above would for me be nursing philosophy. Which is fine, I think philosophical discussions of our profession are great (we're having one right now). Nightengale's writings on what nursing is and should be are philosophy.

How do you test caring in a scientific manner? Easy: define "caring", then define your outcome variable(s) (patient satisfaction, hospital readmission rates, compliance, whatever). Set up an experiment, one group gets "caring", the other does not, analyze your results (I'm not going to go into all of the research methodology stuff, you know that already).

Do we really want to do this research, to make "caring" nursing science? I don't; I have no problem leaving caring as a philosophical construct, and I'm sure most would have no problem conceding it's importance (even primacy) to the profession.

I respect the opinions of those who disagree (but remember, we aren't supposed to be doing anyone's homework here!) but I value theory as a foundation for nursing practice. I honestly don't believe thinking and doing have to be mutually exclusive in the nursing profession.

I share your respect. Regarding homework, I started reading this site ~1 year before I got into nursing school, and things I learned here, and discussions/debates I read, greatly enhanced my educational experience (and gave me a leg up in many circumstances), so I have no problem offering my ideas to help new students.

As for the last, I have to say that nurses can be deep thinkers about our profession AND be skeptical about "nursing theory" at the same time.

classicdame, MSN, EdD · Jul 9, 2009

Theory helps you understand why we do what we do. The nursing process is a result of Orlando's dynamic nurse-patient relationship theory, even though she never used the term "nursing process". What she did was to zero in on why the nurse should involve the patient in patient care and narrowed down our thought processes into an orderly refrain - assess, diagnose, plan, intervene, evaluate. Nurses were already doing that to some degree. Her theory just gave it order so we can have a little checklist in our head when we interact with a patient. Keeps us focused on the REAL problem. But as a new nurse none of this made sense to me at all.

jjjoy, LPN · Jul 9, 2009

Theory helps you understand why we do what we do. The nursing process is a result of Orlando's dynamic nurse-patient relationship theory, even though she never used the term "nursing process". What she did was to zero in on why the nurse should involve the patient in patient care and narrowed down our thought processes into an orderly refrain - assess, diagnose, plan, intervene, evaluate. Nurses were already doing that to some degree. Her theory just gave it order so we can have a little checklist in our head when we interact with a patient. Keeps us focused on the REAL problem. But as a new nurse none of this made sense to me at all.

The "nursing process" is a process that can and is used in many other practices, though it may look a little different in different areas. Educators, for example, must assess their students' needs, target learning goals, create plans, and evaluate outcomes.