Nursing theory: A discussion on an ambiguous concept

Abstract

For the past few decades, nursing has struggled dramatically to reach scientific status. Theories were "borrowed" from the social sciences, or were developed specifically for nursing. However there is a lot of ambiguity about the whole effort as issues of definition, interpretation and implementation are still being addressed. This paper aims to elucidate the ambiguous world of Nursing Theories and its relevance to contemporary Nursing. Nursing theory is defined and discussed, and reasons why nursing needs theories are explained. An overview of the frameworks and methods used in the analysis and evaluation of Nursing Theories is presented. Considerations with regards to the advantages and disadvantages of the use of the Theories in Nursing are discussed. Suggestions are made about contradictory concepts, their interpretation and incorporation into practice. Simple examples of nursing theories are provided.

Headnote

BACKGROUND: For the past few decades, nursing has struggled dramatically to reach scientific status. Theories were "borrowed" from the social sciences, or were developed specifically for nursing. However there is a lot of ambiguity about the whole effort as issues of definition, interpretation and implementation are still being addressed.

AIM: This paper aims to elucidate the ambiguous world of Nursing Theories and its relevance to contemporary Nursing.

DISCUSSION: Nursing theory is defined and discussed, and reasons why nursing needs theories are explained. An overview of the frameworks and methods used in the analysis and evaluation of Nursing Theories is presented. Considerations with regards to the advantages and disadvantages of the use of the Theories in Nursing are discussed.

CONCLUSIONS: Suggestions are made about contradictory concepts, their interpretation and incorporation into practice. Simple examples of nursing theories are provided.

KEY-WORDS: Theory, nursing practice

INTRODUCTION

Nurses, in order to practice competent nursing, have to combine knowledge already generated from many other disciplines, as well as to create solid and rigorous facts from the nursing profession. Nursing has numerous overlaps with neighbouring subject groups and a heterogeneous set of professional concerns (Becher 1989, Moss & Schell 2004).

As clinical nurses we need to be concerned not only with the practical side of nursing but with nursing theory development as well, because theories enable us to distinguish facts from fallacies (Roberts 1985, Facione & Facione 1996). Theories are necessary in any attempt to structure converging facts from a number of different fields. This is especially true for the nursing profession.

There are yet more reasons why nursing should have appropriate theories. These are as follows: nurses' power is increased through theoretical knowledge because systematically developed methods are more likely to be successful. Secondly, nurses know why they are doing what they are doing, if challenged. And finally, theory provides autonomy by building the practice, education and research functions of the profession (Mariner-Tomey 1990).

Draper (1991) states that "nursing theory is a tool". This simile, although quite crude, captures the notion of goal orientation that a nursing theory is said to require. Drapper focuses on two goals that a nursing theory has or should have in view. First, a nursing theory serves as a framework to provisionally understand some part of the nursing world by identifying relevant phenomena that need examining, and second, it identifies a special task of nursing, i.e. to postulate an ideal world of nursing.

According to Dickoff et al (1968), "theory is born in practice, is refined in research and must and can return to practice". This statement captures the essence of theory and the essence of nursing itself. As nursing is a practice oriented discipline it needs guidance by appropriate theories, and if theory is to guide practice, this must be explored through further research. Thus, nursing as a discipline needs theories which are developed through nursing research, tested and modified in practice, and finally refined again in order to guide current nursing practice and establish a paradigm status for the profession and the discipline as a whole.

It has been argued that a great deal of the literature dealing with nursing theories and models is confusing, largely because the terminology used is inconsistent and the language convoluted (McFarlane 1986). As a result, nurses who are not familiar with this "internal language" may experience confusion, anxiety, or even fear when they try to comprehend nursing theories, and perhaps quit the whole effort as fruitless activity and hair splitting (Tadd & Chadwick 1992, Richman & Mercer 2004). This is especially true for non-native speakers of English struggling to grasp unfamiliar terms like element, construct, conceptual framework and paradigm, which are key concepts of the common language in theory development. Yet, there is still a lot of ambiguity in how these terms are used and in what context they are delivered, rather than the content of the terms themselves, as different theorists tend to use them inconsistently.

In nursing academic language, theory has been defined in many ways but one of the clearest definitions is that of Barnum (1990) "a theory is a statement that purports to account for or characterize some phenomenon". A more complex definition is given by Chinn & Jacobs (1987) who propose that theory is "a set of concepts, definitions and propositions that project a systematic view of phenomena by designating specific interrelationships among concepts for the purpose of describing, explaining, predicting or controlling phenomena". Yet, in every day nursing language, in countries such as Greece, many nurses comprehend theory as a statement representing a law waiting to happen. For example, nurses take certain steps under the theory of pressure sore prevention in order to keep patients free of bed sores. To complicate the issue, nurses carry and, all too often, apply their own personal theories to practice, derived from experience, the literature, peer knowledge or cross-fertilization of ideas.

Furthermore, paradigm has been defined as "pattern", a supposedly close translation of the Greek word «παρåδειγµα». Yet, as Greeks, we would probably define paradigm as "ideal example". In contemporary nursing theory language it could be defined as "state of the art", a noun describing an ideal state of theory perfected. In this sense, it represents "global ideas about the individuals, groups, situations and events of interest to a discipline" (Fawcett 1992).

Furthermore, a serious implication of the widely felt frustration with nursing theories is that it might prevent nurses from understanding, evaluating and, therefore, possibly incorporating a theoretical model in everyday practice (Cormark & Reynolds 1992).

There are a lot of simple questions that one could address in order to analyze and evaluate a nursing theory, such as: Is it theory? Is it nursing theory? How useful is it? Many of the nursing theories that were formulated during the 1970's have been studied and practiced by nurses and have been subsequently revised or modified. However, there is considerable lack of agreement on the kinds of theories that the nursing profession needs and this is a challenge to the scientific status of the discipline.

Nevertheless, it is generally agreed that a nursing theory should be developed by using the following four necessary elements:

i. Concepts: These that are derived from individual perception or event that is derived from personal experience (Chinn & Jacobs 1987). Yet, each theory of nursing should address four central concepts (otherwise known as paradigm concepts) namely the person, the environment, the degree of health/illness, and the nursing profession itself (Nyatanga 1990).

ii. Definitions of concepts: These are described as theoretical definitions which convey a general meaning in a manner that fits the theory (Chinn & Jacobs 1987).

iii. Constructs and propositions: Constructs describe relationships between two or more concepts, and are generated from special clinical knowledge. The theoretical constructs, that are special building blocks of a given theory, are observable. In this case, the term proposition is used interchangeably with the term hypothesis (Marriner-Tomey & Alligood 2006).

iv. Links between the constructs: These actually formulate a theory which in turn explains and predicts phenomena.

Analysis of nursing theories

Analysis is an objective breakdown of content into component elements (Fawcett 1989). This procedure aims to clarify the contents of the theory and explore its organization. Therefore, a theory should be broken into parts which are examined individually, in relation to each other, and consequently the theoretical structure as a whole should be examined for such things as validity and approximation to the "real world". The whole effort could provide a means of examining the theory structure in order to determine its (theoretical) strengths and weaknesses and consequently use it in practice (Ume- Nwagbo et al. 2006). Later, further development of the theory under scope could be initiated, provided that its strengths and weaknesses are made explicit.

According to Walker & Avant (1988), there are six steps to follow in a theory analysis pathway. These are to:

* determine the origins of the theory,

* examine the meaning of the theory,

* analyze the logical adequacy of the theory,

* determine the usefulness of the theory,

* define the degree of generalizability and the parsimony of the theory, and

* determine the testability of the theory.

They also emphasize the need for identifying the methodology that was used to construct the theory, because the methods for developing a theory base in nursing have not been delineated in any complete manner. They also argue that methodologies currently available in other disciplines, such as sociology, have not been translated into a nursing context.

Fawcett (1989) introduced a framework for analysis of conceptual models of nursing, incorporating a series of questions with regards to the development of the model, its content and its areas of concern.

Stevens (1979) introduced a three level system of theory examination. The second level of this method is an analysis which initially attempts to identify the building blocks of the theory and the principles essential to stating or explaining the theory. The next step is the identification of methodology used for the theory's construction and, finally, it is also appropriate to incorporate the notion of dynamics or the source of energy.

Therefore, through theory analysis, the power of a theory can be exposed, its limitations or "blinders" identified, and its power can then be used to expand our knowledge and understanding of the phenomena that characterize the nursing situation (Melnyk 1989).

Theory evaluation

The generation of a nursing theory, initially involves construction without apparent knowledge of the theory's usefulness. Once the theory is formulated, it can be analyzed and evaluated. Theory analysis aims to determine the theory's strengths and weaknesses in terms of its structure, while theory evaluation serves to highlight the strengths and weaknesses of the theory by examining the outcomes of theory testing in the real world and by comparing the theory with other criteria, such as logical consistency.

Therefore, justifying a theory's value just by analyzing it and making explicit its strengths and weaknesses would not be enough in itself. Marx (1963) supported this view by stating that: "we need to recognize most explicitly that both discovery and confirmation are necessary to produce effective scientific work. The most ingenious theories are of limited value until empirical tests are produced; the best confirmed proposition is of little value unless it deals with meaningful variables" (p. 13).

However, Hardy (1986) highlights that "the lack of criticism or comment, in a field (nursing) which is claiming to have arrived in the scientific world, but which is not yet established, may be damming evidence to the true state of nursing as a profession".

Many authors have provided frameworks or sets of criteria for evaluating a nursing theory. Ellis (1968) in an early attempt to determine the characteristics of significant theories for nursing, delineated the criteria for evaluating a theory, the most important of which, was the theory's usefulness. "Usefulness" refers to clinical practice in terms of developing or guiding practice. Stevens (1979) provided a very detailed framework for evaluating a theory, distinguishing between internal and external criticism. Internal criticism is identified as being approached through four criteria which examine the internal construction of the theory. These are: clarity, logical elaboration, consistency, and significant level of the theory's evolution. External criticism relates to the external aspects of the theory with regards to the real world of person, environment, health and nursing. External criticism is made up of six criteria, which are: adequacy, usefulness, significance, distinction, scope and simplicity.

However, the construction of a theory is distinct from its evaluation, suggesting that initially we should examine, or even better, scrutinize a nursing theory without having immediate knowledge of its usefulness or applicability or implications to nursing practice.

Fawcett (1989), in her review of substantive theories which have been important conceptual landmarks in nursing thought, incorporated a series of questions in order to evaluate a theory. These questions, simple in nature, aimed at comparing the theory's content to criteria focusing on explication of assumptions, comprehensiveness of content, logical congruence, theory generating and testing capabilities, social considerations and contributions to nursing knowledge.

Considerations of analysis and evaluation

Constructing a theory is far distinct from testing that theory and therefore, analysis and evaluation are two procedures that require specific timing and order. In other words, a practitioner with a given interest in a nursing theory X, could proceed in analysis to gain insights into the theory's construction and its theoretical strengths and weaknesses. If the outcomes are positive, the next step would be to test the theory's assumptions in practice and measure outcomes where appropriate. Finally, he/she should implement the theory in practice.

In this context, Walker & Avant (1988), in writing about strategies for theory construction in nursing, argued that "criticizing the methods of origins from which a theory has been developed because these do not conform to those used in theory evaluation is dangerous... while a well-developed theory should be expected to pass review by rigorous standards for theory evaluation, these same standards may not be appropriate for generating theory" (p. 14).

Analysis is associated with deep understanding. It is a process of uncovering structures and how concepts are related without judging them, without involving our own beliefs and biases, without imposing our own view of the world into the theory under analysis, as much as possible. Ideally, it is a neutral procedure. Evaluation on the contrary, is related to decision. It is a powerful tool that will enable one to decide if and how useful a theory is for practice, education and research. The final step is to actually act, by implementing the "promising and useful" theory into practice and its associated fields (McKenna 1997).

When it comes to analysis or evaluation of a theory, one should always keep in mind the old saw: "A theory that predicts everything, predicts nothing!" Regardless of how well developed and structured a theory might be, none could describe, explain and predict nursing phenomena in an all-embracing way. After all, a truly scientific stance is invariably a skeptical one (Judd et al 1991).

Practitioners have been heavily criticized for adopting theories without analysis, testing and evaluating them adequately. Therefore, time should not be wasted in search of the perfect theory, but rather nurses should focus on looking for a theory that can explain, describe and predict nursing phenomena, in the most appropriate manner at that time.

A commonality in all efforts to evaluate and test a model is the aspect of the model's simplicity and comprehensibility. A way of lessening the gap between theory and practice, leading theorists and average practitioners, academics and lay professionals, would be for theorists to ensure that their models are accessible and fully comprehended by the "average" nurse clinician, who in turn must recognize the enormous value these academics play in lifting the standards and status of the nursing profession. Otherwise, a theory model will have extremely limited value and applicability for all (Cormack & Reynolds 1992).

Why nursing needs theories?

Every Paradise has its own serpent and poisoned apple, thus, using a nursing model in practice is not free of disadvantages. According to Hardy (1986), although nursing theories help us see the whole situation and everything that works in it, there are nevertheless four factors which nurses should consider before using a theory.

As one of the main purposes of this paper is to explore the ambiguous world of nursing theories (models). Hardy's reasoning will now be cited (in italics) and discussions will be given below. According to Hardy (1986), the disadvantages of theory usage include the following:

1. "Any particular model presents the subjective view or views of those constructing it. Necessarily, then, their conceptions are biased because of their particular learning and experiences".

It can be argued that any particular model, or preferably, every theory, in any discipline, includes some of its creator's subjectivity. But, on the other hand, who could produce a purely "objective" model that would not have its own creator's views built within it to some degree? It is like searching for a model that was not constructed by humans, but made for use by humans. Therefore, such a model would not actually be of this world! To the nursing world, this is equivalent to a model being devised by people well outside the profession and being introduced straight on to everyday nursing practice.

In this context Heisenberg said that, "there is no observer outside the experiment", meaning that even purely scientific experimental designs are subject to the researcher's influence. This also applies to the construction of a theory as one could argue that, a theoretical framework without its own constructor's views within its structure is not possible. Nurses who use a model should not focus on exploring the extent to which a particular model has been influenced by its creators own ideas, beliefs, biases, and culture. More importantly, it can be argued that users must be convinced that the particular model is of actual usefulness in practice. In other words, focus on the content and not the creator.

2. "Models promote the view that everyone's world view is the same, that all persons may be assessed in the same way".

By their very nature, nursing models, just like any other conceptual framework in any other discipline, are highly abstract and "given the abstract and general nature of the concepts, the propositions which describe or link concepts are also abstract and general" (Fawcett 1989). Models represent, reflect or, in simple words, stand for the world, by analogy. Their abstract aim is to reproduce the structure of the original inasmuch that there is a point-by-point correspondence between the model's pattern of relationships and the original (Robinson 1992).

Therefore, models do not imply that everyone's world view is, or ought to be, the same. They merely help nurses to conceptualize the accumulative world views in a single highly abstracted way. If, according to Hardy's argument, a model was to provide all existing different world views, then the model would be a world-size one!

Accordingly, models do not promote the view that all persons may be assessed in the same way. On the contrary, models put a great deal of emphasis on the concept of patient-centered approaches and individualized care. For the sake of argument, some representative comparisons, from Rosenbaum's (1986) critical comparison of two nursing models, Orem's and Leininger's will be cited.

Leininger: "Care is a universal human phenomenon, but caring patterns vary among cultures. Care-specific and care-universal dimensions must be identified and studied to advance nursing knowledge of care".

Orem: "What is unique to nursing is the provision of self care. Central to this concept is the notion of action taken by the practitioner on behalf of the individual".

3. "Models adopted rigidly, restrict questioning and change. This type of behavior is directly opposed to critical analysis"

Earlier in this paper has been shown that analysis and evaluation is crucial before implementing a particular model into practice. Therefore, it is not a fault of the model if it is adopted "rigidly", but rather it is its user's mistake if he/she takes it on board without appropriate questioning.

4. "Models promote the use of specialized concepts and jargon which necessitate lengthy orientation, a procedure which is not available to health consumers, thus a distance is created between care and consumer, and between professions".

On a personal level, we would agree with Hardy here, with regards to the use of specialized concepts and jargon in nursing models. This is a reason why, not only consumers but carers too, find it difficult to familiarize themselves with them. There are several reasons for this, mainly the fact that nursing as a scientific discipline is relatively "very young", around half a century old! Although the profession dates back to millennia, the terminology has grown with relatively recent academic advances so it is "foreign" and even suspicious to the majority of hard working overstretched nurses all around the world.

To develop the nursing profession as a science, alongside its art-element, one needed a new thinking, a new internal language, and independence from authoritarian mainstream medicine. This evolution of the nursing theoretical basis was extremely short in comparison to other disciplines. The whole process of nursing theorizing needed to be descriptive, not only for an ideal nursing situation, but with more real life built within, so that the gap between the ideal and the actual practice will be understood and practitioners will be more likely to face theories in a constructive manner.

Yet, theorizing in itself carries a risk; it could lead to distancing the new nursing academia from those providing practical care and this might fracture the powerful care identity bestowed upon the socially valuable discipline of nursing. In our view, one excellent example of constructive theorizing comes from the nurse scholar McCance (1999) who conducted an in depth search in order to do a concept analysis of care. Her definition was refined to four essential attributes of caring:

- Serious attention

- Concern

- Providing for

- Regard, respect, or liking

This simple summary could be mediated and reflected on by all nurses and applied indisputably, improving health outcomes of patients and status of nursing profession it self. Nursing theory needs to be listened to, applied and constructively challenged to change with the times.

CONCLUSIONS

The main purpose of this paper has been to explore the "ambiguous" concept of nursing theory, and to make explicit that although the scientific essence and theoretical development of nursing may still remain unclear, nursing theories are not ambiguous concepts. The vagueness rather lies in the way that these theories are expressed, perceived, interpreted and incorporated into practice.

The most ethical nursing theories should introduce holistic, optimistic and promising approaches. However, users of the theories should not be too overwhelmed by the model's potential power.

Analysis and evaluation on the other hand, have been identified as crucial procedures because they help to understand a theory's potential and actual adequacy or usefulness. But, even if some theories are proved to be weak in terms of structure or applicability, they may still be of value because they may stimulate discussion and debate on best nursing practices. In addition, nursing theories generated by nurse scholars give weight to the notion that there is something called Nursing which has an independent identity, quite distinct from other health care profession. After all, a nursing theory is built by nurses for nurses, so that they can improve on their care for people.

References

REFERENCES

1. Barnum B (1990). Nursing Theory: Analysis, Application, Evaluation (3rd ed), Philadelphia, Little Brown

2. Becher T (1989). Academic Tribes and Territories: intellectual inquiry across the disciplines. Society for Research into Higher Education, Open University Press

3. Clinn PL, Jacobs MK (1987). Theory and Nursing; A Systematic Approach, St Louis: CV Mosby

4. Cormack DF, Reynolds W (1992). Criteria for evaluating the clinical and practical utility of models used by nurses. Journal of Advanced Nursing, 17:1472-1478

5. Dickoff J, James P, Wiendenbach E (1968). Theory in a practice discipline. Nursing Research, 17:415-435

6. Draper P (1991). The ideal and the real: some thoughts on theoretical developments in British Nursing. Nurse Education Today, 11:292-294

7. Ellis R (1968). Characteristics of significant theories. Nursing Research, 17:117-222

8. Facione NC, Facione PA (1996). Externalizing the critical thinking in clinical judgment. Nursing Outlook, 44:129-136

9. Field PA (1987). The impact of nursing theory on the clinical decision making progress. Journal of Advanced Nursing, 12:563- 571

10. Fawcett J (1989). Analysis and Evaluation of Conceptual Models of Nursing. Philadelphia Davis Co

11. Fawcett J (1992). Conceptual models and nursing practice: the reciprocal relationship. Journal of Advanced Nursing, 17:224-228

12. Hardy LK (1986). Identifying the place of theoretical frameworks in an evolving discipline. Journal of Advaced Nursing, 11:103-107

13. Judd CM, Smith ER, Kidder LH (1991). Research Methods in Social Relations (6th ed.), Holt, Rinehart and Winston, Inc., Orlando, Florida

14. Marriner-Tomey A, Alligood R (2006). Nursing Theorists and Their Work. Mosby, London

15. Marx MH (1963). The general nature of theory construction in (Marx MH (ed). Theories in Contemporary Psychology. Macmillan, New York

16. McCance T, McKenna H, Boore J (1999). Caring: theoretical perspectives of relevance to nursing. Journal of Advanced Nursing, 30:1388-1395

17. Melnyk K. The process of theory analysis: an examination of the nursing theory of Dorothea E. Orem. Nursing Research 1989, 32:170-174

18. McFarlane J (1986). Look to the future. In: Kershaw B, Salvage J (eds) Models for nursing. J Willey & Sons, New York, 111-116

19. McKenna H (1997). Nursing Theories and Models. Routledge, London

20. Moss MP, Schell MC (2004). A Scientific Framework and Methodological Tool for Nursing Research. Advances in Nursing Science. Advances in Research Methods (Part I), 27:150-159

21. Nyatanga L. Nursing paradigm: the state of art. Senior Nurse 1990, 10:18-19

22. Richman J, Mercer D (2004). "Modern language" or "spin"? Nursing, 'newspeak' and organizational culture: new health scriptures. Journal of Nursing Management, 12:290-298

23. Roberts K (1985). Theory of nursing as curriculum content. Journal of Advanced Nursing, 10:209-215

24. Robinson JA (1992). Problem with paradigms in a caring profession. Journal of Advanced Nursing , 17:632-637

25. Rosenbaum JN (1986). Comparison of two theorists on care: Orem and Leininger. Journal of Advanced Nursing , 11:409-416

26. Stevens B (1979). Nursing theory: Analysis, Application, Evaluation. Little Brown, Boston

27. Tadd W, Chadwick RF (1992) . Ethics and Nursing Practice: a case approach, Macmillan, London

28. Ume-Nwagbo PN, DeWan SA, Lowry LW (2006). Using the Neuman systems model for best practices. Nursing Science Quarterly, 19:31-35

29. Walker L, Avant K (1988). Strategies for Theory Construction in Nursing (2nd ed), Appleton & Lange