The primary uses of theory are to provide insights about nursing practice situations and to guide research. Through interaction with practice, theory is shaped and guidelines for practice evolve. Research validates, refutes, and/or modifies theory as well as generates new theory. Theory then guides practice. Until empirical validation, modification, and support are completed, theory can be given support through clinical utilization and validation and can therefore be allowed to give
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tentative direction to practice. Nurses gain wisdom from their practice experiences and formulate theories that were generated from their experiences. However, until such theories are articulated and communicated, they cannot be subjected to systematic tests and, therefore, do not inform the practice of other nurses.
Theory provides nurses with the framework and the goals for assessment, diagnosis, and intervention. Nurses working as part of health care teams focus on those aspects of care that are described theoretically for a more effective judgment of patients’ situations and conditions. If the goals of the care provided are health maintenance, promotion of self-care, and enhancement of stability and integrity during the illness, then a nurse has an intellectual checklist by which the levels of health and well-being, self-care needs and abilities, and integrity and stability are assessed. Diagnosis is related to those areas in which health and wellness are compromised, self- care is problematic, or integrity of the human being is undermined. Evaluation of care and its con- sequences focus on patient care outcomes.
Theory is a tool that renders practice more efficient and more effective and helps in identify- ing outcomes. Simply by being goal-directed through a theoretical perspective, a nurse’s energies and time spent in assessing extraneous areas are minimized. If nursing goals are not articulated from a nursing perspective, a nurse’s time is used inefficiently, and the nature and quality of care are compromised. By considering areas of assessment or intervention that may be handled more efficiently and expertly by other members of the health care team, the nurse conserves her own energy, time, and talent for those areas and phenomena for which she is well prepared, such as processes of adherence to a regimen, mobilizing support, or monitoring pain. Patients and their families are more likely to seek and respond more effectively to nursing care when nursing goals driven by nursing knowledge are clearly articulated.
Theory has other uses. The language of theory provides us with common ground for commu- nicating effectively and efficiently. More effective and efficient communication can eventually lead to further theory development as concepts are refined, sharpened, extended, and validated.
Well-defined concepts with conceptual and construct validity enhance cyclical communication among practitioners, theorists, clinicians, and educators. The world of nursing can become more coherent, more goal oriented, and more effective. Building evidence depends on a common lan- guage and symbols, and using evidence is predicated on a common language. Articulating out- comes and linking these outcomes with nursing actions and interventions are enhanced by naming concepts.
Professional autonomy and accountability are supported by the use of theory in practice.
Being able to practice through the use of scientific principles allows nurses the opportunity to accurately predict those patterns of responses that are consequences of care. Articulation of actions, goals, and consequences of actions empowers nurses and enhances their accountability. If we can talk clearly about our purpose and what we hope to accomplish, perhaps other profession- als and patients will also be able to describe or articulate nursing actions and goals more accu- rately and comprehensively, and even seek and demand the type of care nurses are capable of providing. Defining the focus and the means to achieving that focus, and being able to predict consequences increase a nurse’s control of nursing practice and therefore increase a nurse’s autonomy. As stated by Fuller many decades ago (1978),
The autonomy of a profession rests more firmly on the uniqueness of its knowledge, knowl- edge gathered ever so slowly through the questioning of scientific inquiry. Nursing defined by power does not necessarily beget knowledge. But knowledge most often results in the ascrip- tion of power and is accompanied by autonomy. (p. 701)
In summary, theory helps to identify the focus, means, and goals of practice. Using com- mon theories enhances communication, thereby increasing autonomy and accountability to care. Theory helps the user gain control over subject matter (Barnum, 1998). All these in turn help bring about further refinements of theory and better relationships among theory, research, and practice. Figure 3-1 identifies the relationships among theory, research, practice, and philosophy.
CHAPTER 3 Theory: Metaphors, Symbols, Definitions 37
two opposing definitions for each and argue for what difference this particular definition makes in our practice profes- sion. Ultimately, how could developed knowledge be different, and in what ways is the practice of nursing differ- ently informed?
4. What difference do the different levels and types of theory make in advancing nursing knowledge?
REFLECTIVE QUESTIONS
1. Why does a practice-based discipline need theories?
2. Theories seem to be such esoteric notions for a profession that has functioned well for decades. Could our practice history guide our practice future without theo- ries? Why? Why not?
3. For each definition of theory compo- nents, there are different views on how the component is defined and used. Find
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Our Theoretical Heritage
THEdiscipline of nursing has established itself as a field with both a practice and a theoretical base. The process of the evolution of the discipline and its theoretical base follows a unique path, a path that may not be clearly understood by those who attempt to measure the progress and development of the discipline by the same crite- ria used to measure the progress of the physical and natural sciences. The origins of the developmental path for nursing can be traced through an analysis of both its research tradition and its theory traditions. This part, which includes Chapters 4 and 5, traces the historical development of nursing theory and theoretical nursing. Forces and constraints that nurses confronted in their quest to establish theoretical nursing are analyzed. The course of the evolution of nursing as a theoretical discipline is mapped and discussed.
Forces and barriers in the development of theory in nursing are identified.
The roles of nurses—as nurses, as predominantly women, and as nurse theorists in the development of nursing theory against many odds—are explored and discussed.
The development of the discipline of nursing is conceptualized as evolving in stages. The premise on which the discussion proceeds is that all stages preceding the most current stage made major contributions to the maturity of the discipline.
Milestones in every stage are delineated, and the influence of each milestone on nursing theory is explored. The relationships among theory, science, practice, and philosophy are also explored.
P A R T T W O
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C H A P T E R 4
From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking
The journey from the days of Florence Nightingale to scholarly nursing has been long, hard, and bumpy. Nightingale’s attempts to establish professional nursing based on nursing’s unique con- cern with the environment for the promotion of health were preempted by an illness-oriented training that depended on other professions for existence and on hospitals for training and suste- nance. Nursing has traveled from apprenticeship to education, from hospital service and training to the university, from mere implementation of doctors’ orders to accountability and autonomy, from practical to theory- and research-based applications.
The journey has included a major detour through the land of “Can’t”: a land of perceived inability to conceptualize or generalize; a land that espoused practice, concreteness, and practical relevance as antithetical to some generalizations, common propositions, and theoretical state- ments. The decades of the 1970s, 1980s, and 1990s marked our emergence from this land and, as we move into the 21st century, we are back on course to where Nightingale began. On our return journey, however, we are more experienced, more assured, and more trusting in our perceptions.
We are more accepting of the significance of patients’ and nurses’ experiences and of the varied meanings of experience in the development of nursing knowledge.
We are reminded in this journey of Immanuel Kant, a dominant 19th-century philosopher, who maintained that reality is not only a thing in and of itself but is also constructed by those who experience it. Reality in nursing history has been a synthesis of conditions that predisposed nurses to a nontheoretical existence and an a priori perception that helped to promote a lack of accept- ance of theoretical themes.
Kant aptly distinguished between perception of experience and sensation of experience. Sen- sation of experience is confounded by temporal and spatial limitations. Experience, the basis of knowledge, has, in nursing, depended on this or that procedure as performed at a certain moment, or on the knowledge of this or that patient occupying a certain space and existing at a certain moment. Although knowledge begins with experience, Kant maintained that this does not mean that all knowledge evolves from experience. To him, our experiences have two components: an a priori impression of what may be experienced, and impressions as they are actually received.
Understanding is a synthesis of both. Therefore, a human being—a knowing, active, and experi- encing subject, not a passive recipient—interprets and analyzes impression data in a certain way.
That certain way—the a priori form by which experiences are shaped—is a synthesis of some- thing that is out there and something that is constructed by the person experiencing it (Copleston, 1964).
During the journey of nurses from early to modern times, experience assumed different meanings with more profound explanations. Experience provided the impetus for describing and explaining phenomena central to nursing and perhaps was responsible for the development of new therapeutics to promote health, change environments, or control unwanted events related to health care. During this journey, some nurses were more accepting of the role of clinical experience in the development of clinical knowledge, others were reluctant to acknowledge that experience had any role in theoretical nursing, and still others preferred to rely on the experi- ences of scientists in other fields to shape their clinical knowledge. Some pioneering thinkers in nursing assumed that nurses can conceptualize, and they allowed themselves the luxury to con- sider that patients’ responses and experiences could help them, and others, better understand clients and their health care experiences. These thinkers helped the theoretical journey move forward. The journey is still in progress, and will continue to advance in a human and dynamic
CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 41 discipline such as nursing. Within the discipline of nursing, evidence suggests that this long journey will lead to more effective and useful theorizing. In order to continue to support the journey toward a more systematic development of nursing knowledge, it is necessary to value our history and envision our future.
Therefore, to enhance the development of theoretical knowledge, we must pause and ask why the journey was long and complex. Why did nursing go through such detours of seemingly non- theoretical periods and, more importantly, why did nurses appear to reject theory and theorizing during the journey, practically forcing the detour into a nontheoretical existence? Even when a small handful of nurses attempted to return, to put nursing on course by providing a theoretical view of what nursing is, it was almost two decades after the development of these conceptions that their notions and their stance began to be accepted. Why is it that some skeptics in nursing were still saying, at the end of the 20th century, that theory or theorizing in nursing is antithetical to the practice of nursing, and that nursing practice is either a practically or theoretically oriented situa- tion, but not both, and therefore choosing one standpoint leaves no room and no need for the other? And what conditions have prompted the beginning acceptance of theoretical nursing?
This chapter considers, historically, those forces that have hindered and fostered the development of nursing scholarship and more specifically nursing theory. Kant’s writing on the synthesis between reality as a separate entity and reality as constructed by the subject who is experiencing it helps us understand the dialectical meanings of these forces. Human and knowledge barriers and human and knowledge forces are two sides of the same coin. We can analyze these as both negative and positive forces in the development of nursing theory. The content may be the same (the sensation in Kant’s analysis), but the form distinguishes between forces as barriers and forces as resources. Together, con- tent and form (provided by sensation and mind) enhance the knowledge and understanding of the dynamics of the journey from no theory to theory. As we begin to perceive constraints in a new light and through a new lens, we can shift the negative power of constraint to a positive force, and we can reconstruct new realities and develop new blueprints that are more congruent with the mission of nursing and health care needs nationally and internationally. Knowing our history empowers us for a future in which we can better deal with barriers and change them into assets.