Journal of Advanced Nursing, 1977, 2, 261-270
Developing a theory of nursing: the relation of theory to practice, education and research Jean K. McFarlane M.A. B.Sc.Soc. S.R.N. S.C.M. H.V. Tutor Cert Professor and Head of Department of Nursing, University of Manchester Acceptedfor publication 11 July
MCFARLANE JEAN K . {igji) Journal of Advanced Nursing 2, 261-270
Developing a theory of nursing: the relationship of nursing theory to practice, education and research The relevant literature is reviewed and it is held that the relationships between nursing theory, practice, education and research are close and reciprocal relationships. Each is related to the other but it is argued that the hub ofthe relationships is nursing practice as nursing is a practice discipline. This paper is based on an address delivered on 10 July 1976 at the annual conference of the Association of Integrated and Degree Courses in Nursing held at the University of Hull, England.
T H E U N C H A R T E R E D SEAS OF N U R S I N G The registered nurse must practise from a theoretical basis adequate to her ftuiction if the care she gives is to be safe and of good quality. At any level of skill in nursing the practitioner needs a basis of theory adequate to support practice at that level. When in 19711 first became involved in an undergraduate nursing programme and, vvith others, started to review ntirsing degree programmes and to consider which sciences were relevant to the practice of nursing, I was overwhelmed with a feeling of frustration and powerlessness as we floundered in the unchartered seas of nursing. In the intervening years, after a great deal of thinking, we are perhaps better prepared for developing a theory of ntirsing, but there is still a great deal which we do not understand. The question is often asked if the practice of the graduate nurse from schools of nursing in centres of higher education is any different from the practice ofthe conventionally trained nurse. Sometimes some of us have been anxious to make no distinction between the undergraduate nursing student and the conventional student nurse in the practical situation. It is now my view that the graduate nurse 261
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is different and that undergraduates are undergoing a different programme. If there is no difference then I think we have no right to use the expensive resources of higher education. If the practice of the graduate nurse is not different in kind then she is an expensive luxury and some of us are wasting our time. It is my conviction that the theoretical basis from which she practises affects the kind of practice of the graduate nurse and that as an undergraduate her programme must always be geared to attaining this rather different repertoire of skills. T H E N A T U R E OF C O N C E P T S , T H E O R Y A N D PRINCIPLES Dickoff and James (1975) in their chapter on Theory Development in Nursing say 'This chapter makes no pretence of being a complete and systematic exposition. Such expositions, we have discovered, overwhelm readers. They become confused and contentious and the aim of the communication—to make others able to go on with fruitful theory development—is unrealized. And so we confine ourselves here simply to assembling a few reminders to a purpose.' It is in that spirit that I think it may be helpful to restate some definitions of the meaning of theory before we move to considering its relation to nursing practice, education and research.
Definitions Theories are not just mental abstractions thought up in the bath and unrelated to reality. They are firmly bedded in experience. It is a propensity ofthe human mind to name, sort and classify, that is to develop taxonomies, and it is thus that the plant and animal kingdoms are classified. The similar features ofthe dandelion and daisy are labelled compositae. Just as one may recognize in the cat common features with the tiger, so is the great 'blooming, buzzing confusion' of nursing classified in terms of common features in many patients regarding oxygen supply, electrolyte balance, immobility, self concept, touch deprivation or helplessness. These are some ofthe 'building bricks' of nursing theory and are some ofthe basic concepts of nursing. Hardy (1973) says 'Concepts are labels, categories or selected properties of objects to be studied; they are the bricks from which theories are constructed. The scientist constructs theories . . . by linking concepts of one class or one attribute to concepts of other classes or attributes. When he has a set of interrelated statements or hypotheses concerning the relationships between concepts, he then has a theory. Concepts are the basic elements of a theory.' Rines & Montag (1976) claim that nursing ' . . . does not exist nor does it change without the use of principles, theories and concepts'. They then define these three classifications: 1 A principle is a 'fundamental, primary, or general law from which others are derived'. They say that nursing uses principles or laws from other sciences. 2 A theory is 'a proposed explanation whose status is still conjectural, in contrast to well established propositions that are regarded as reporting matters of actual
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fact. Thus, theories are partly proved, partly unproved, and are open to question. Theories are always questionable and subject to change. Nursing is only beginning to develop its theories, or at least to state those that are implicit rather than explicit. Theories in nursing . . . need challenge and critical appraisal so that the bases of nursing practice are sound'. 3 A concept is 'a general notion of idea; an idea of something formed by mentally combining all the characteristics or particulars'. Thus concepts are projections of ideas that can serve as guides. 'Concepts. . . serve a purpose even though they are not laws, or truths like principles, not established propositions like theories'.
The concepts of nursing Many authors indicate that nursing has not progressed far beyond the level of identifying concepts. Virginia Henderson (1966) talks about a 'personal concept' of nursing and many other writers indicate by the titles of their work that they are at the level of concept formation (e.g. Rines & Montag (1976) Nursing Concepts and Nursing Care; Orem (1971) Nursing: Concepts of Practice; The Nursing Development Sub-Group (1973) Concept Formalisation in Nursing; Roberts (1976) Behavioural Concepts and the Critically III Patient; Riehl & Roy (1974) Conceptual Models for Nursing Practice).
King (1971) in Toward a Theory for Nursing subtitles her book 'General Concepts of Human Behaviour' and talks about the conceptual frame of reference for nursing and its utilization. Rogers (1970) in her Introduction to the Theoretical Basis of Nursing talks about nursing's conceptual system. It is interesting to note the wide variety of concepts which are identified. This may be a reflection of lack of consensus about the nature of nursing, but it may also indicate the complexity of nursing and the multitude of concepts it enshrines. It is a further indication that knitting these many concepts together is less likely to produce a unitary theory of nursing than a range of theories. Concepts like helping, assisting, caring, the nature of man, wellness, health, protection, oxygenation, homeostasis, homeodynamics, adaptation, body image, hopelessness, territoriality, and many more are concepts identified by individuals and groups of nurses as being inherent in their practice.
Theory of theories It is helpful to consider the Theory of theories postulated by Dickoff & James (1968). They say 'A theory is a set of elements in interrelation. All elements ofa theory are at the conceptual level but theories vary according to the number of elements, the complexity and relationship between elements'. They indicate four levels or phases of theories in a practice discipline: I Factor-isolating theories. These include two activities: a Naming or labelling. b Classifying or categorizing. This would seem to me to be the basic level of conceptualization.
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2 Factor-relating theories. Again there are two activities: a Depicting or describing. b Relating factors. i.e. How a single named factor relates to another single factor (e.g. how fluid intake relates to hydration). 3 Situation-relating theories. These are: a Predictive—if a occurs b will occur. b Promoting or inhibiting—under what circumstances and with what speed and effort things will occur. One ofthe essential ingredients in this level of theory is a causal connecting statement which enables predictions to be made. Hence, their importance in developing realistic alternatives for action in nursing care. Perhaps an example is Norton's (1962) pressure area tool. 4 Situation producing theories. These are prescriptive and enable us to prescribe nursing care. Dickoff & James (1968) describe five necessary aspects ofa prescriptive theory: a The goal to be achieved. b Survey alternatives to achieve the goal. c Choosing among alternatives. d Prescriptions of activities necessary to achieve the goal, e Implementing choice. I suggest that theory at this level has the status of a law or principle.
THE R E L A T I O N OF N U R S I N G T H E O R Y T O P R A C T I C E Ntorsing is a practice discipline and therefore any theory of nursing must be intimately related to this practice. Theory grows out of practice. One observes, names and classifies nursing experience and develops nursing concepts. We must all have been impressed at some time in our professional lives by the wisdom of experienced ward sisters (head nurses). If we could only catch their wisdom and write it down we would have a rich feast of concepts of nursing practice. This is one of the reasons why more emphasis should be placed on recording nursing practice so that we can classify and categorize from their records. This level of theory making is more consciously undertaken by researchers using the grounded theory approach of Glaser & Strauss (1967), although this differs little from the rigorous recording and classifying that scientists have used since the time of Archimedes. In attempting to relate concepts or to demonstrate causal relationships as predictive or prescriptive we are again thrown back on practice. Any theory must be tested. The purpose of a practice theory is to be able to make a prescription for practice where, after all, nursing begins and ends. Hence, I am often a little sceptical of theories of nursing which seem to bear no relationship to any practice I have ever seen. But I also ask myself if it could be that the theory seems unrelated
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to reality because ofthe way in which I have looked at reality? Dickoff & James (1975) say 'These views about first level and fourth level theory lead us to propose that theory begins and ends in practice'.
Introduction and deduction My emphasis so far has been on the inductive method of developing theory from practice, but I suggest that in the process of identifying concepts we become aware that we share concepts, theories and laws with other practitioners and other disciplines. Theories of interaction are no less valid because the interaction occurs between a patient and a nurse; nor is the physiology of stress invalidated because it occurs in a nursing situation. By deductive means one applies concepts, theories and principles from other disciplines. Valuable studies (Hartnett 1968, Rohweder 1975) have been made of the literature in relevant disciplines (behavioural and biological sciences) and the derived concepts applied to nursing. In teaching health visitor students, for instance, we use Erikson's (1965) eight stages of human development, the works of Piaget (see Beard 1969) and Bowlby (1951). We make use of learning theory in teaching patients, relatives and students. It is noteworthy, however, that theorists who apply theories from different disciplines may reach very different conclusions about some ofthe concepts basic to nursing. Schlotfeldt (1975), for instance, reviews the differences in the concepts of pain and death as viewed by behavioural and biological scientists. It is, however, the application which makes these concepts uniquely part of nursing theory and their articulation together in the practice of nursing. This is where a degree in nursing for nurses may have some advantage over a degree in a related subject— there is opportunity to articulate or integrate theories from other disciplines in a unique amalgam.
The nursing process One way of looking at the unique amalgam, which makes nursing theory, is to look at the nursing process. Bevis (1973) suggests that there are in any process three characteristics: purpose; internal organization; and infinite creativity or innovation. If the practice of nursing is regarded as a process Bevis suggests that there are six subprocesses within that process: 1 The stress adaptation process. 2 The decision-making process. 3 The communication process. 4 The learning process. 5 The human development process. 6 The change process. She suggests that these many subprocesses come together to make nursing activity. Hence the 'innovation' as they come together. 'That which is uniquely
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nursing is the "one" (nursing) act or intervention that is novel or different and the result of uniting the many.' We are, however, looking at a highly rational and scientific approach to nursing and a search for a theory which can be the basis of rational description. Murphy (1971) draws attention to the fact that the body of knowledge we have in nursing derives from transmission of superstition, speculation and the accumulation of unrationalized experiences. It is a sobering thought that many of the nursing texts for students are prescriptive about nursing practice without any scientific validity other than the sanctification of ritual. Nursing procedure books do not always allow the student to apply theoretical considerations based on the nature of man and his needs and the process of nursing, which individualizes care. This leads us into the implication of theory for education. Suffice it to say that unless nursing practice grows from an adequate theoretical basis then the care given is likely to be inadequate and of poor quality. Work such as Orem's (1971) in which she has analysed nursing practice and gave some categories of selfcaring activities, methods of assisting, systems which delineate variations in the respective roles of patient and nurse and categories ofnursing acts, provide a basis of theory which has more to do with the practice of nursing than the previous obsession with medical diagnoses.
THE R E L A T I O N OF N U R S I N G T H E O R Y T O E D U C A T I O N Nursing is a practice discipline and the primary objective of education in the profession is education for practice. If as Reilly (1975) claims ' . . . professionals go to the theory base of their discipline to obtain the basis for curriculum and programme development. . . ' it is necessary that nurse educators should be aware of the state of development in theories of nursing. Those theories emanate from practice, are tested in practice situations at the highest level, and are prescriptive of practice. The theoretical basis of nursing can, therefore, only be learned in intimate association with the practice situation. Nursing students from the outset must be encouraged to conceptualize from their own practice and before they are conditioned to unthinking responses. They must be encouraged to use the deductive method and apply the concepts, theories and principles from other discipplines to their own. They must also learn to question our professional wisdom and test the validity of our hypotheses about care. They must be taught the discipline of meticulous observation and description, and the bearing of the theories of perception on what they observe. They must be able to analyse, to classify, and to hypothesize about the outcomes of different nursing activities and their use in achieving nursing goals or objectives. Furthermore, these cognitive skills must be matched by manual dexterity and human relations' skills. This should influence the kinds of educational methods used as this kind of learning will not take place in a classroom in a didactic situation. More than that, the close relationship of theory to practice has many pertinent things to say to educators about their attempts to correlate theory and practice.
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Bendall (1975) and Hunt (1974) have demonstrated the well-known divorce. Dodd (1973) has indicated that the school and the nurse teacher are regarded as irrelevancies to the student who values the ward as the real situation. Our learning strategies are managed in such a way that relatively few students achieve any degree of correlation between theory and practice. We are often teaching a theory which is no part of the theory of nursing because it is patently unrelated to practice and taught in such a way and in such a context that it is seen to be irrelevant to practice. It is as if what God has joined together, we have put asunder. An immense range Some may draw the conclusion that nursing students are being taught 'too much theory', others say that nursing is essentially a practical craft and can best be learned in an apprenticeship situation. Both of these points of view fall short ofthe truth. The truth is rather that there is an immense range of concepts, theories and principles to be learned in an activity as complex as the practice of nursing, but the cognitive skills and content can only be acquired by repeated analysis of nursing situations using, for example, the nursing process. The skills and knowledge required to carry out the nursing process need repeated practice until they become part ofthe nurse's approach and repertoire. The data collection on which the nurse bases an assessment of patient needs can only be made if she is skilled at observation and interviewing, and if she can apply and synthesize knowledge from a wide range of physical, biological, behavioural and medical sciences. This kind of learned behaviour cannot be acquired by rote, only by a careful analysis of real situations and the application of relevant knowledge. Bevis (1973) makes the point that an apprentice system limits learning to an intuitive level. The nature of theory in a practice discipline demands that learning takes place in the practice area but that the theoretical basis of practice is constantly reinforced. So far as learning is concerned Bevis (1973) makes an interesting comparison of the levels of theories outlined by Dickoff & James (1968) and the sequential varieties of learning outlined by Gagne (1965) starting with stimulusresponse connections, then verbal associations, and moving up to concepts, principles and problem-solving. It is also possible to apply Bloom's (1956) taxonomy of educational objectives in the cognitive domain in a similar way.
Cognitive skill in nursing In the acquisition and development of different levels of theory in nursing, the student will require different types of cognitive skill ranging through knowledge, comprehension, application, analysis, synthesis and evaluation. The learning experiences will need to take in these and objectives in the affective domain if there is to be an adequate grasp of theory. Educators tend to go to the theoretical base of their discipline in planning the cognitive content of their curriculum. What does this mean for us as nurse educators? What theoretical content should be taught? There are relatively few
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concepts ofnursing practice which British nurses have identified with any sense of assurance. There are fewer articulated theories which have been hypothesized or tested. The cupboard is pretty bare for curriculum building. We talk about the principles of nursing (an examination is set in this subject at Manchester) and the principles of health visiting. But to what laws ofnursing or health visiting can we point? It is clear that our curricula are built from the conventional wisdom of generations of nurses which is for the most part untested. Conventional wisdom can be a euphemism for ritual, superstition, speculation, unsystematized experience. Only slowly are we beginning to identify concepts, which are born ofnursing rather than medical practice, and to subject them to testing. But the nursing profession is not alone. Only recently it was pointed out to me that the vast body of medical treatment is carried out on a placebo basis. It works, but no-one knows how it works. Sometimes, when defending access to higher education for nurses, I talk about the desirability of placing the practice ofnursing on a scientific basis and I have had medical colleagues say 'I wish someone would do that for medicine'!
THE R E L A T I O N B E T W E E N N U R S I N G T H E O R Y A N D RESEARCH In the discussion ofthe relation ofnursing theory to practice and to education, the importance of research in establishing theory will, hopefully, have been apparent. Whilst theory building may not always be a conscious effort logically undertaken step by step, this can be a fruitful approach and is undertaken by a few. Researchers are increasingly using the inductive method and slowly identifying concepts ofnursing practice (see Stockwell 1972, Towell 1975, Harrisson 1975). The form of literature research which has analysed concepts in other disciplines and their relevance to nursing has already been discussed. The complementary aspect of the relationship of theory to research is in the importance ofthe theoretical basis ofany research undertaken. Thus King (1971) in developing a theory for nursing constructs a model ofthe types of variables in nursing situations. This is a framework linking nurse variables, patient variables, situational variables, nurse behaviour and criteria of effectiveness. Treece & Treece (1973) discuss the relationship between theory and method. They conclude that it is necessary to have theories to guide research, but it is also necessary to do research to produce theories. Schlotfeldt (1975) states that the development of a conceptual or theoretical framework is the fundamental process required before conducting actual research. She states that 'the conceptual framework selected for a research problem influences the nature of the problem studied, the phenomena studied, the techniques and tools employed, the setting in which data are gathered, the methods of analysis and the use made of findings'. Thus the conceptual perspective influences each stage ofthe research process. There is a call to systematize the practice ofnursing and to record and analyse it (i.e. there is a need to document the nursing process). What kinds of data are required for an adequate nursing assessment? What kind of decisions are the
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assessment of nursing problems based on? What relationships exist between nursing actions and their outcomes? It is in research which records and analyses nursing practice that testable relationships and alternative routes to nursing objectives will be detected. This is a form of research to which every nursing practitioner can contribute and only the practitioner can identify the cognitive process by which she arrived at certain actions. It will not be easy to persuade the nursing profession to do so. There is already evidence that nurses regard a systematized approach to caring antithetical to their caring philosophy.
The alpha and omega of nursing It is helpful to quote Dickoff & James (1975) once again. They say: 'We need to ask "What's the use of theory? Why bother to theorize and to research?" Our contention is that nursing practice is the alpha and omega of nursing theorizing and nursing research. The impetus for nursing theorizing and researching must arise from practice, since nursing is a practice.' And 'In so far as the practitioner brings existing practice to conceptual awareness, she is theorizing. The nurse who, immersed in the reality of doing, records conceptually the awareness got in practice, engages in rudimentary theorizing. The nurse as theorist or researcher must exploit; that is, midwife, the nurse as practitioner for that awareness of nursing obtainable only by doing. Undoubtedly it is unrealistic to suppose that one and the same person will simultaneously have as goals—giving service, producing theory and engaging in explicit research. More realistically in practice disciplines, there is a triad of "speculators": the practitioner, the theory builder and the theory tester or researcher.'
References BEARD R. (1969) An Outline ofPiaget's Developmental Psychology. Routledge & Kegan Paul, London. BENDALL E. (1975) So you passed, Nurse. Royal College of Nursing, London. BEVIS E.O. (1973) Curriculum Building in Nursing: A Process. C. V. Mosby, St. Louis. BLOOM B.S. (1956) Taxonomy of Educational Objectives. Cognitive Domain. Longman, Green & Co. Ltd., London. BOWLBY J. (1951) Maternal Care and Maternal Health. World Health Organization, Geneva. DICKOFF J. &JAMES P. (1968) A theory of theories: a position paper. Nursing Research 17,197-203. DICKOFF J. & JAMES P. (1975) In: Nursing Research. Ed. P. J. Verhonick. Little, Brown & Co., Boston. DODD A.P. (1973) Towards an understanding of Nursing. (Unpublished Ph.D. Thesis). University of London. ERIKSON E . H . (1965) Childhood and Society. Penguin, London. GAGNB R.M. (1965) The Conditions of Learning. Holt, Rinehart & Linston, New York. GLASER B . & STRAUSS A. (1967) The Discovery of Grounded Theory. Weidenfeld & Nicholson, London. HARDY M.E. (1973) The Nature of Theories. In: Theoretical foundations for nursing. Ed. M. E. Hardy. M.S.S. Information, New York.
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HARRISSON S. (1975) The Social Consequences of Long Term Medical Treatment of Children. (Unpublished Ph.D. Thesis) University of York.
HARTNETT L . M . (1968) Development of a Theoretical Model for the Identification of Nursing Require ments in a selected aspect of self care. (Unpublished Master's dissertation) Catholic University of America.
HENDERSON V. (1966) The Nature of Nursing. Collier Macmillan, London. HUNT J (1974) The Teaching and Practice of Surgical Dressings in Three Hospitals. Royal College o Nursing, London.
KING L M . (1971) Towards a Theory for Nursing. Wiley, New York. MURPHY J.F. (1971) Theoretical Issues in Professional Nursing. Appleton Century Crofts, New York NORTON D . , MCLAREN R . & EXTON SMITH A.N. (1962) An Investigation of Geriatric Nursing Problems
in Hospital. National Corporation for the Care of Old People, London. NURSING DEVELOPMENT CONFERENCE SUB-GROUP (1973) Concept Formalisation in Nursing. Little,
Brown, Boston. OREM D.E. (1971) Nursing Concepts of Practice. McGraw-Hill, New York. REILLY D.E. (1975) Why a conceptual framework? Nursing Outlook 23, 9, 566-569. RIEHL J.P. & ROY C . (1974) Conceptual Models for Nursing Practice. Appleton Century Crofts, New York.
RINES A. & MONTAG M . (1976) Nursing Concepts and Nursing Care. Wiley, New York & London. ROBERTS S.L. (1976) Behavioural Concepts and the Critically III Patient. Prentice Hall, New Jersey ROGERS M.E. (1970) An Introduction to the Theoretical Basis of Nursing. Davis, Philadelphia. RoHWEDER N. (1975) Scientific Foundations of Nursing. Lippincott, Philadelphia. ScHLOXFELDT R.M. (1975) The Conceptual Framework of Nursing Research. The Need for a Conceptua Framework. In: Nursing Research. Ed. P.J. Verhonick. Little, Brown, Boston. STOCKWELL F. (1972) The Unpopular Patient. Royal College of Nursing, London. TOWELL D . (1975) Understanding Psychiatric Nursing. Royal College of Nursing, London. TREECE F . W . & TREECE J.W. (1973) Elements of Research in Nursing. C. V. Mosby, St. Louis.
Developing a theory of nursing: the relation of theory to practice, education and research Jean K. McFarlane M.A. B.Sc.Soc. S.R.N. S.C.M. H.V. Tutor Cert Professor and Head of Department of Nursing, University of Manchester Acceptedfor publication 11 July
MCFARLANE JEAN K . {igji) Journal of Advanced Nursing 2, 261-270
Developing a theory of nursing: the relationship of nursing theory to practice, education and research The relevant literature is reviewed and it is held that the relationships between nursing theory, practice, education and research are close and reciprocal relationships. Each is related to the other but it is argued that the hub ofthe relationships is nursing practice as nursing is a practice discipline. This paper is based on an address delivered on 10 July 1976 at the annual conference of the Association of Integrated and Degree Courses in Nursing held at the University of Hull, England.
T H E U N C H A R T E R E D SEAS OF N U R S I N G The registered nurse must practise from a theoretical basis adequate to her ftuiction if the care she gives is to be safe and of good quality. At any level of skill in nursing the practitioner needs a basis of theory adequate to support practice at that level. When in 19711 first became involved in an undergraduate nursing programme and, vvith others, started to review ntirsing degree programmes and to consider which sciences were relevant to the practice of nursing, I was overwhelmed with a feeling of frustration and powerlessness as we floundered in the unchartered seas of nursing. In the intervening years, after a great deal of thinking, we are perhaps better prepared for developing a theory of ntirsing, but there is still a great deal which we do not understand. The question is often asked if the practice of the graduate nurse from schools of nursing in centres of higher education is any different from the practice ofthe conventionally trained nurse. Sometimes some of us have been anxious to make no distinction between the undergraduate nursing student and the conventional student nurse in the practical situation. It is now my view that the graduate nurse 261
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is different and that undergraduates are undergoing a different programme. If there is no difference then I think we have no right to use the expensive resources of higher education. If the practice of the graduate nurse is not different in kind then she is an expensive luxury and some of us are wasting our time. It is my conviction that the theoretical basis from which she practises affects the kind of practice of the graduate nurse and that as an undergraduate her programme must always be geared to attaining this rather different repertoire of skills. T H E N A T U R E OF C O N C E P T S , T H E O R Y A N D PRINCIPLES Dickoff and James (1975) in their chapter on Theory Development in Nursing say 'This chapter makes no pretence of being a complete and systematic exposition. Such expositions, we have discovered, overwhelm readers. They become confused and contentious and the aim of the communication—to make others able to go on with fruitful theory development—is unrealized. And so we confine ourselves here simply to assembling a few reminders to a purpose.' It is in that spirit that I think it may be helpful to restate some definitions of the meaning of theory before we move to considering its relation to nursing practice, education and research.
Definitions Theories are not just mental abstractions thought up in the bath and unrelated to reality. They are firmly bedded in experience. It is a propensity ofthe human mind to name, sort and classify, that is to develop taxonomies, and it is thus that the plant and animal kingdoms are classified. The similar features ofthe dandelion and daisy are labelled compositae. Just as one may recognize in the cat common features with the tiger, so is the great 'blooming, buzzing confusion' of nursing classified in terms of common features in many patients regarding oxygen supply, electrolyte balance, immobility, self concept, touch deprivation or helplessness. These are some ofthe 'building bricks' of nursing theory and are some ofthe basic concepts of nursing. Hardy (1973) says 'Concepts are labels, categories or selected properties of objects to be studied; they are the bricks from which theories are constructed. The scientist constructs theories . . . by linking concepts of one class or one attribute to concepts of other classes or attributes. When he has a set of interrelated statements or hypotheses concerning the relationships between concepts, he then has a theory. Concepts are the basic elements of a theory.' Rines & Montag (1976) claim that nursing ' . . . does not exist nor does it change without the use of principles, theories and concepts'. They then define these three classifications: 1 A principle is a 'fundamental, primary, or general law from which others are derived'. They say that nursing uses principles or laws from other sciences. 2 A theory is 'a proposed explanation whose status is still conjectural, in contrast to well established propositions that are regarded as reporting matters of actual
Developing a theory of nursing
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fact. Thus, theories are partly proved, partly unproved, and are open to question. Theories are always questionable and subject to change. Nursing is only beginning to develop its theories, or at least to state those that are implicit rather than explicit. Theories in nursing . . . need challenge and critical appraisal so that the bases of nursing practice are sound'. 3 A concept is 'a general notion of idea; an idea of something formed by mentally combining all the characteristics or particulars'. Thus concepts are projections of ideas that can serve as guides. 'Concepts. . . serve a purpose even though they are not laws, or truths like principles, not established propositions like theories'.
The concepts of nursing Many authors indicate that nursing has not progressed far beyond the level of identifying concepts. Virginia Henderson (1966) talks about a 'personal concept' of nursing and many other writers indicate by the titles of their work that they are at the level of concept formation (e.g. Rines & Montag (1976) Nursing Concepts and Nursing Care; Orem (1971) Nursing: Concepts of Practice; The Nursing Development Sub-Group (1973) Concept Formalisation in Nursing; Roberts (1976) Behavioural Concepts and the Critically III Patient; Riehl & Roy (1974) Conceptual Models for Nursing Practice).
King (1971) in Toward a Theory for Nursing subtitles her book 'General Concepts of Human Behaviour' and talks about the conceptual frame of reference for nursing and its utilization. Rogers (1970) in her Introduction to the Theoretical Basis of Nursing talks about nursing's conceptual system. It is interesting to note the wide variety of concepts which are identified. This may be a reflection of lack of consensus about the nature of nursing, but it may also indicate the complexity of nursing and the multitude of concepts it enshrines. It is a further indication that knitting these many concepts together is less likely to produce a unitary theory of nursing than a range of theories. Concepts like helping, assisting, caring, the nature of man, wellness, health, protection, oxygenation, homeostasis, homeodynamics, adaptation, body image, hopelessness, territoriality, and many more are concepts identified by individuals and groups of nurses as being inherent in their practice.
Theory of theories It is helpful to consider the Theory of theories postulated by Dickoff & James (1968). They say 'A theory is a set of elements in interrelation. All elements ofa theory are at the conceptual level but theories vary according to the number of elements, the complexity and relationship between elements'. They indicate four levels or phases of theories in a practice discipline: I Factor-isolating theories. These include two activities: a Naming or labelling. b Classifying or categorizing. This would seem to me to be the basic level of conceptualization.
264
/ . K. McFarlane
2 Factor-relating theories. Again there are two activities: a Depicting or describing. b Relating factors. i.e. How a single named factor relates to another single factor (e.g. how fluid intake relates to hydration). 3 Situation-relating theories. These are: a Predictive—if a occurs b will occur. b Promoting or inhibiting—under what circumstances and with what speed and effort things will occur. One ofthe essential ingredients in this level of theory is a causal connecting statement which enables predictions to be made. Hence, their importance in developing realistic alternatives for action in nursing care. Perhaps an example is Norton's (1962) pressure area tool. 4 Situation producing theories. These are prescriptive and enable us to prescribe nursing care. Dickoff & James (1968) describe five necessary aspects ofa prescriptive theory: a The goal to be achieved. b Survey alternatives to achieve the goal. c Choosing among alternatives. d Prescriptions of activities necessary to achieve the goal, e Implementing choice. I suggest that theory at this level has the status of a law or principle.
THE R E L A T I O N OF N U R S I N G T H E O R Y T O P R A C T I C E Ntorsing is a practice discipline and therefore any theory of nursing must be intimately related to this practice. Theory grows out of practice. One observes, names and classifies nursing experience and develops nursing concepts. We must all have been impressed at some time in our professional lives by the wisdom of experienced ward sisters (head nurses). If we could only catch their wisdom and write it down we would have a rich feast of concepts of nursing practice. This is one of the reasons why more emphasis should be placed on recording nursing practice so that we can classify and categorize from their records. This level of theory making is more consciously undertaken by researchers using the grounded theory approach of Glaser & Strauss (1967), although this differs little from the rigorous recording and classifying that scientists have used since the time of Archimedes. In attempting to relate concepts or to demonstrate causal relationships as predictive or prescriptive we are again thrown back on practice. Any theory must be tested. The purpose of a practice theory is to be able to make a prescription for practice where, after all, nursing begins and ends. Hence, I am often a little sceptical of theories of nursing which seem to bear no relationship to any practice I have ever seen. But I also ask myself if it could be that the theory seems unrelated
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to reality because ofthe way in which I have looked at reality? Dickoff & James (1975) say 'These views about first level and fourth level theory lead us to propose that theory begins and ends in practice'.
Introduction and deduction My emphasis so far has been on the inductive method of developing theory from practice, but I suggest that in the process of identifying concepts we become aware that we share concepts, theories and laws with other practitioners and other disciplines. Theories of interaction are no less valid because the interaction occurs between a patient and a nurse; nor is the physiology of stress invalidated because it occurs in a nursing situation. By deductive means one applies concepts, theories and principles from other disciplines. Valuable studies (Hartnett 1968, Rohweder 1975) have been made of the literature in relevant disciplines (behavioural and biological sciences) and the derived concepts applied to nursing. In teaching health visitor students, for instance, we use Erikson's (1965) eight stages of human development, the works of Piaget (see Beard 1969) and Bowlby (1951). We make use of learning theory in teaching patients, relatives and students. It is noteworthy, however, that theorists who apply theories from different disciplines may reach very different conclusions about some ofthe concepts basic to nursing. Schlotfeldt (1975), for instance, reviews the differences in the concepts of pain and death as viewed by behavioural and biological scientists. It is, however, the application which makes these concepts uniquely part of nursing theory and their articulation together in the practice of nursing. This is where a degree in nursing for nurses may have some advantage over a degree in a related subject— there is opportunity to articulate or integrate theories from other disciplines in a unique amalgam.
The nursing process One way of looking at the unique amalgam, which makes nursing theory, is to look at the nursing process. Bevis (1973) suggests that there are in any process three characteristics: purpose; internal organization; and infinite creativity or innovation. If the practice of nursing is regarded as a process Bevis suggests that there are six subprocesses within that process: 1 The stress adaptation process. 2 The decision-making process. 3 The communication process. 4 The learning process. 5 The human development process. 6 The change process. She suggests that these many subprocesses come together to make nursing activity. Hence the 'innovation' as they come together. 'That which is uniquely
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nursing is the "one" (nursing) act or intervention that is novel or different and the result of uniting the many.' We are, however, looking at a highly rational and scientific approach to nursing and a search for a theory which can be the basis of rational description. Murphy (1971) draws attention to the fact that the body of knowledge we have in nursing derives from transmission of superstition, speculation and the accumulation of unrationalized experiences. It is a sobering thought that many of the nursing texts for students are prescriptive about nursing practice without any scientific validity other than the sanctification of ritual. Nursing procedure books do not always allow the student to apply theoretical considerations based on the nature of man and his needs and the process of nursing, which individualizes care. This leads us into the implication of theory for education. Suffice it to say that unless nursing practice grows from an adequate theoretical basis then the care given is likely to be inadequate and of poor quality. Work such as Orem's (1971) in which she has analysed nursing practice and gave some categories of selfcaring activities, methods of assisting, systems which delineate variations in the respective roles of patient and nurse and categories ofnursing acts, provide a basis of theory which has more to do with the practice of nursing than the previous obsession with medical diagnoses.
THE R E L A T I O N OF N U R S I N G T H E O R Y T O E D U C A T I O N Nursing is a practice discipline and the primary objective of education in the profession is education for practice. If as Reilly (1975) claims ' . . . professionals go to the theory base of their discipline to obtain the basis for curriculum and programme development. . . ' it is necessary that nurse educators should be aware of the state of development in theories of nursing. Those theories emanate from practice, are tested in practice situations at the highest level, and are prescriptive of practice. The theoretical basis of nursing can, therefore, only be learned in intimate association with the practice situation. Nursing students from the outset must be encouraged to conceptualize from their own practice and before they are conditioned to unthinking responses. They must be encouraged to use the deductive method and apply the concepts, theories and principles from other discipplines to their own. They must also learn to question our professional wisdom and test the validity of our hypotheses about care. They must be taught the discipline of meticulous observation and description, and the bearing of the theories of perception on what they observe. They must be able to analyse, to classify, and to hypothesize about the outcomes of different nursing activities and their use in achieving nursing goals or objectives. Furthermore, these cognitive skills must be matched by manual dexterity and human relations' skills. This should influence the kinds of educational methods used as this kind of learning will not take place in a classroom in a didactic situation. More than that, the close relationship of theory to practice has many pertinent things to say to educators about their attempts to correlate theory and practice.
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Bendall (1975) and Hunt (1974) have demonstrated the well-known divorce. Dodd (1973) has indicated that the school and the nurse teacher are regarded as irrelevancies to the student who values the ward as the real situation. Our learning strategies are managed in such a way that relatively few students achieve any degree of correlation between theory and practice. We are often teaching a theory which is no part of the theory of nursing because it is patently unrelated to practice and taught in such a way and in such a context that it is seen to be irrelevant to practice. It is as if what God has joined together, we have put asunder. An immense range Some may draw the conclusion that nursing students are being taught 'too much theory', others say that nursing is essentially a practical craft and can best be learned in an apprenticeship situation. Both of these points of view fall short ofthe truth. The truth is rather that there is an immense range of concepts, theories and principles to be learned in an activity as complex as the practice of nursing, but the cognitive skills and content can only be acquired by repeated analysis of nursing situations using, for example, the nursing process. The skills and knowledge required to carry out the nursing process need repeated practice until they become part ofthe nurse's approach and repertoire. The data collection on which the nurse bases an assessment of patient needs can only be made if she is skilled at observation and interviewing, and if she can apply and synthesize knowledge from a wide range of physical, biological, behavioural and medical sciences. This kind of learned behaviour cannot be acquired by rote, only by a careful analysis of real situations and the application of relevant knowledge. Bevis (1973) makes the point that an apprentice system limits learning to an intuitive level. The nature of theory in a practice discipline demands that learning takes place in the practice area but that the theoretical basis of practice is constantly reinforced. So far as learning is concerned Bevis (1973) makes an interesting comparison of the levels of theories outlined by Dickoff & James (1968) and the sequential varieties of learning outlined by Gagne (1965) starting with stimulusresponse connections, then verbal associations, and moving up to concepts, principles and problem-solving. It is also possible to apply Bloom's (1956) taxonomy of educational objectives in the cognitive domain in a similar way.
Cognitive skill in nursing In the acquisition and development of different levels of theory in nursing, the student will require different types of cognitive skill ranging through knowledge, comprehension, application, analysis, synthesis and evaluation. The learning experiences will need to take in these and objectives in the affective domain if there is to be an adequate grasp of theory. Educators tend to go to the theoretical base of their discipline in planning the cognitive content of their curriculum. What does this mean for us as nurse educators? What theoretical content should be taught? There are relatively few
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concepts ofnursing practice which British nurses have identified with any sense of assurance. There are fewer articulated theories which have been hypothesized or tested. The cupboard is pretty bare for curriculum building. We talk about the principles of nursing (an examination is set in this subject at Manchester) and the principles of health visiting. But to what laws ofnursing or health visiting can we point? It is clear that our curricula are built from the conventional wisdom of generations of nurses which is for the most part untested. Conventional wisdom can be a euphemism for ritual, superstition, speculation, unsystematized experience. Only slowly are we beginning to identify concepts, which are born ofnursing rather than medical practice, and to subject them to testing. But the nursing profession is not alone. Only recently it was pointed out to me that the vast body of medical treatment is carried out on a placebo basis. It works, but no-one knows how it works. Sometimes, when defending access to higher education for nurses, I talk about the desirability of placing the practice ofnursing on a scientific basis and I have had medical colleagues say 'I wish someone would do that for medicine'!
THE R E L A T I O N B E T W E E N N U R S I N G T H E O R Y A N D RESEARCH In the discussion ofthe relation ofnursing theory to practice and to education, the importance of research in establishing theory will, hopefully, have been apparent. Whilst theory building may not always be a conscious effort logically undertaken step by step, this can be a fruitful approach and is undertaken by a few. Researchers are increasingly using the inductive method and slowly identifying concepts ofnursing practice (see Stockwell 1972, Towell 1975, Harrisson 1975). The form of literature research which has analysed concepts in other disciplines and their relevance to nursing has already been discussed. The complementary aspect of the relationship of theory to research is in the importance ofthe theoretical basis ofany research undertaken. Thus King (1971) in developing a theory for nursing constructs a model ofthe types of variables in nursing situations. This is a framework linking nurse variables, patient variables, situational variables, nurse behaviour and criteria of effectiveness. Treece & Treece (1973) discuss the relationship between theory and method. They conclude that it is necessary to have theories to guide research, but it is also necessary to do research to produce theories. Schlotfeldt (1975) states that the development of a conceptual or theoretical framework is the fundamental process required before conducting actual research. She states that 'the conceptual framework selected for a research problem influences the nature of the problem studied, the phenomena studied, the techniques and tools employed, the setting in which data are gathered, the methods of analysis and the use made of findings'. Thus the conceptual perspective influences each stage ofthe research process. There is a call to systematize the practice ofnursing and to record and analyse it (i.e. there is a need to document the nursing process). What kinds of data are required for an adequate nursing assessment? What kind of decisions are the
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assessment of nursing problems based on? What relationships exist between nursing actions and their outcomes? It is in research which records and analyses nursing practice that testable relationships and alternative routes to nursing objectives will be detected. This is a form of research to which every nursing practitioner can contribute and only the practitioner can identify the cognitive process by which she arrived at certain actions. It will not be easy to persuade the nursing profession to do so. There is already evidence that nurses regard a systematized approach to caring antithetical to their caring philosophy.
The alpha and omega of nursing It is helpful to quote Dickoff & James (1975) once again. They say: 'We need to ask "What's the use of theory? Why bother to theorize and to research?" Our contention is that nursing practice is the alpha and omega of nursing theorizing and nursing research. The impetus for nursing theorizing and researching must arise from practice, since nursing is a practice.' And 'In so far as the practitioner brings existing practice to conceptual awareness, she is theorizing. The nurse who, immersed in the reality of doing, records conceptually the awareness got in practice, engages in rudimentary theorizing. The nurse as theorist or researcher must exploit; that is, midwife, the nurse as practitioner for that awareness of nursing obtainable only by doing. Undoubtedly it is unrealistic to suppose that one and the same person will simultaneously have as goals—giving service, producing theory and engaging in explicit research. More realistically in practice disciplines, there is a triad of "speculators": the practitioner, the theory builder and the theory tester or researcher.'
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RINES A. & MONTAG M . (1976) Nursing Concepts and Nursing Care. Wiley, New York & London. ROBERTS S.L. (1976) Behavioural Concepts and the Critically III Patient. Prentice Hall, New Jersey ROGERS M.E. (1970) An Introduction to the Theoretical Basis of Nursing. Davis, Philadelphia. RoHWEDER N. (1975) Scientific Foundations of Nursing. Lippincott, Philadelphia. ScHLOXFELDT R.M. (1975) The Conceptual Framework of Nursing Research. The Need for a Conceptua Framework. In: Nursing Research. Ed. P.J. Verhonick. Little, Brown, Boston. STOCKWELL F. (1972) The Unpopular Patient. Royal College of Nursing, London. TOWELL D . (1975) Understanding Psychiatric Nursing. Royal College of Nursing, London. TREECE F . W . & TREECE J.W. (1973) Elements of Research in Nursing. C. V. Mosby, St. Louis.
