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is nursing theory important to nursing practice

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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

Specializes in Nursing Professional Development. Has 44 years experience.

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.

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.

Edited by jjjoy

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-vaginal 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

Specializes in Hospital Education Coordinator.

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.

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.

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

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?

That's actually the first 2 discussion assignments in the theory course I teach in a BSN completion program. The students get a single case scenario -- and then have to explain how they would apply 5 different selected theories to that case. We cover 5 theorists with that assignment and students get to see how the patient would be approached differently as each of the 5 different theories is discussed.

How would Nightingale approach this patient?

What aspects of care would be emphasized if you were using Henderson's theory?

How would apply Watson's theory to this patient?

etc.

The students see that their assessment would be a little different and their care would be a little different depending on which theorist they were using as a foundation of their practice. Those 2 assignments (covered over the first month of class) really gets their attention. It's like the light bulb turns on. They see that the choice of theorist doesn't change the facts of the case or that the patient needs lab work, x-rays, etc. regardless of which theory is used. But they see that the choice of theory influences some of the focus of the nurse.

For example, with Nightingale, they are focusing on the environment. With Watson, they are focusing on expressing their caring and the spiritual aspects of care. When applying Abdullah, they are making a nursing problem list and focusing on that problem list. For Benner, they discuss how nurses with different levels of expertise would approach the patient.

Throughout the semester, as we discuss other theorists and have other discussion assignments, they often come back to that first case scenario and talk about how the patient care would be different if they were using whatever theorist they are discussing that week. It's a great academic excericise in that it relates theory to a concrete case scenario of a patient in the Emergency Department -- a place where some people would think that theory would be of little value. It also forcing the students to be flexible in their thinking -- to notice how the patient care would be influenced by the choice of theoretical perspectives.

By mid-semester, most students "get it" and are "on board." They see why theory matters. They also start seeing that many of the concepts and procedures that they learned in their first nursing program are actually based on somebody's theory -- they just didn't know it. They had simply been taught the priniciples without being taught the whole theory. They were using theory but not realizing it. They just thought it was "good practice" or "common sense" etc. As we go through the semester, we note those theoretical ideas that have become deeply embedded within our profession and they see where a lot of those ideas originally came from (or at least, they see the role that the theorists play in articulating those ideas clearly and bringing them into better focus for the world to see and study.)

Edited by llg

Moogie

Specializes in Gerontology, nursing education.

I appreciate your thoughtful response!

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!

Indeed it is! I am certainly learning from you!

I started a MSN program in 2002 that was very research-oriented. I was disappointed with the theory component because it was pretty much glossed over for research. For various reasons I dropped out of that program but have decided to start over at a different school. I will be curious to see if the emphasis on research is as heavy as it was in my previous program.

Personally, I like theory because older theories tell us about the history of ideas in nursing. They tell us what nurses believed at various times and whether or not those theories changed practice or added to our knowledge base.

It may just be me. I may just be a theory nerd. But that's okay---I am passionate about theory.

As someone planning on teaching nursing, though, I find your thoughts about how students perceive theory in a very different way. Perhaps theory should be taught only at the graduate level....

Thanks for the interesting discourse. I am enjoying getting to know your point of view.

Moogie

Specializes in Gerontology, nursing education.

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.

Well, actually, dear Woodenpug, I am too tired to be much of anything right now! I think I'm sincere----I do know I am sincerely sleepy! sleeping-smiley-015.gif

I am interested in what you have to say. I do appreciate the difference between antiquated and archaic. I take it that you have problems with certain archaic theories. Um---do you have any you'd like to discuss?

Yes---I want to see how you find relevant information whether you can or cannot relate it to a theoretical model.

Before I do a lit review----there you've got me. When I do a lit review, I look for articles that are relevant to my topic, not looking for a certain framework. The exception is---if I'm teaching a class on theory and need to provide examples of research articles that follow various frameworks.

I would love to discuss this further with you. We might not ultimately agree but I think we could learn a lot form each other. Want to move it to PM or to visitor messages? LMK! I'll answer when I am not so tired. :yawn:

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

When I do a lit review, I look for articles that are relevant to my topic, not looking for a certain framework.

Yes ... but you are hoping that the material you find is based on a solid foundation of theory. :specs:

Edited by NRSKarenRN

classicdame, MSN, EdD

Specializes in Hospital Education Coordinator.

I agree with jjjoy. The nursing process is simply that, a process. I mentioned this theory because it seems to be the one I turn to most frequently as it is so versatile.

That's actually the first 2 discussion assignments in the theory course I teach in a BSN completion program. The students get a single case scenario -- and then have to explain how they would apply 5 different selected theories to that case. We cover 5 theorists with that assignment and students get to see how the patient would be approached differently as each of the 5 different theories is discussed.

That sounds like a great way to approach teaching theory. Especially using an ED patient as opposed to home health or psych where preventative care, education, therapeutic listening, behavior issues, psychsoc issues tend to be the emphasis as opposed to acute care nursing where medical needs are immediate and intensive and often take priority over other nursing needs. I do believe that small things may vary in one's practice depending on one's underlying theory, even if an unconsciously held theory. But I am curious, in regard to the medical side of nursing (responding to emergent physiologic needs), how much of a difference one's nursing theory makes. Various theories relating to pathophys and treatment modalities definitely lie beneath the standard medical interventions (determining that X, Y & Z symptoms probably means problem A and so do B).

Many nurses work in environments where medical needs, hands on tasks and administrative work make up the largest percentage of their job responsibilities. Making sure a patient is comfortable, feels safe, has a satisfactory environment etc tend to fall to the bottom of the list. They are still there and are definitely important and not be ignored; but when responsible for several different patients at the same time, there are many needs competing for the nurse's attention and the reality is that patients will not get the full spectrum of nursing care as described by many theories. Meanwhile, being able to recognize symptoms, having confidence that one will know what to do in an emergent situation, to have commonly used skills mastered are very important to being successful as an acute care nurse. I'm not saying nursing theory has no place. But in acute care nursing, a lot more than nursing theory needs to be mastered to be successful.

And again, I'm coming from a background where coming out of school, I could pull a case apart in regard to the various nursing needs... be empathetic, promote pt comfort, educate, take measures to prevent skin breakdown, DVTs, constipation, urinary tract infections, etc. And those ARE important aspects of nursing care. However, acute care nurses may find that those aspects of their job only make up a small percentage of their work and that they often delegate that care to CNAs. So all of those things emphasized as being the crux of nursing care end up as just one part of one's job as a nurse. Again, those aspects ARE crucial, but the forces of today's work environment for nurses (eg high ratios, tons of paperwork, high acuity, tons of meds, etc) means that much of what nursing theory emphasizes doesn't address the reality that working nurses are dealing with.

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

jjjoy ....

I totally agree with a lot of what your write. I think nursing has a long way to go before we can say that our theory base is what it should be. We need to keep working on it, providing better education about it so that current and future generations of nurses can take it where it needs to go.

I agree that a person's theoretical perspective will have little or no impact on the technique of starting an IV or giving a medication (as examples ... to use my ED patient in this discussion). However, nurses who have incorporated Nightingale's theory into their practice will be sensitive to the environmental conditions of the room -- cold, light, noise, etc. -- and may help to create an ED environment that helps the patient feel comfortable, cared-for, and a little less frightening. A nurse who has incorporated Jean Watson's caring theory into their practice would be more sensitive to the patient's and families emotional and spiritual needs during this frightening situation and may consciously choose to go a little out her way to provide that something "a little extra" to express her care and concern -- even if it is only to squeeze the patient's hand briefly, give a reassuring smile, etc. .

Even in today's busy (and often understaffed) workplace, the theoretical perspective of the nurse can be seen. Flow sheets and other documentation forms can be designed to emphasize key elements found in selected theories. etc.

I think the closest theoretical match to the types of topics you are talking about in your most recent post is the "Synergy Model" developed by the Association of Critical Care Nurses. It is a theory that basically says that the best outcomes happen when the needs of the patient are in sync with the abilities of the nurse and the resources that are available. The 3 key "players" in this theory are the patient, the nurse, and the system. It's the job of the system to provide the patient with a nurse who has the skills and resources needed to meet the patient needs -- and to provide the nurse with the resources to do the job.

Note that the Synergy Model was developed by intensive care nurses and designed to serve as a foundation for the practice of intensive care nursing. They use it as the foundation for their certification exam, educational programs, etc. If you are not familiar with this theory, you might want to look into it as it addresses those issues of acuity, resources, staffing, etc. in the real world of contemporary hosptials you wrote about in the end of post #66. You might really enjoy knowing that contemporary theorists ARE trying to accommodate today's realities.

That's for the great dialog.

rngolfer53

Has 2 years experience.

I agree with Jolie.

Besides, I would be of no help because I firmly believe nursing theory is important to practice. Thing is, it's hard to see that when you're in school---and you don't always see the value of theory until you've practiced for a while.

I guess a good indicator of one's side in this debate is the quality of the nursing theory instructors in each nurse's school.

We had a couple, one of whom was quite good and well-regarded, while the other was all but universally disrespected.

So, I'm on the fence! :bugeyes:

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

I guess a good indicator of one's side in this debate is the quality of the nursing theory instructors in each nurse's school.

We had a couple, one of whom was quite good and well-regarded, while the other was all but universally disrespected.

So, I'm on the fence! :bugeyes:

I am an adjunct professor who teaches a theory class to BSN completion students while I work full time in a hospital. I am trying to be like the "good one" you describe above. If we could get better theory education throughout the nursing profession, better theories would be developed that would be seen as useful by nurses at the bedside and the average staff nurse would have the skills necessary to apply those theories to provide an even higher level of care.

Woodenpug, BSN

Specializes in MPCU.

I know this is one of the "sacred cows" here on all nurses, so opposing thoughts are poorly tolerated. Still, I don't see nursing theories as important to nursing practice. Nursing theories are useful to nursing practice. Nursing theories are also useful to cleaning the garage or doing yard work. I can describe how a positive outcome is related to a nursing theory. That positive outcome is not dependent on the nursing theory and would have happened anyway.

Would I be able to support my position by saying, "I must be right, because my theory professor was excellent?" If I could prove that my theory professor was excellent and that I got an A, would that make my opinion more correct?

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

Would I be able to support my position by saying, "I must be right, because my theory professor was excellent?" If I could prove that my theory professor was excellent and that I got an A, would that make my opinion more correct?

No, I'm afraid not. The "correct-ness" of a proposition is not established by the quality of the teacher who taught you a class on the topic. Veracity just doesn't work that way ... but that's getting us into a serious discuss of philosophical theories of veracity. Just because you don't choose to use nursing theory directly much doesn't mean that they are not useful to a lot of other people. It also doesn't mean that the people who developed the practice guidelines, policies and procedures, etc. that you use every day didn't use nursing theories to develop those practice guidelines.

If all nurses were well-educated in nursing theory, the quality of the theories would rise and their application by nurses would both increase and improve. Eventually, the use of theory at the bedside would be commonplace and obvious to just about everyone.

You are personally free to go through life as a-theoretically as possible, if that is what you like. But most of the profession is moving in the other direction, towards a more theory-based profession of nursing.

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