Saturday, November 7, 2009

Florence Nightingale taught us that nursing theories describe and explain what is and what is not nursing (Nightingale, 1859/1992). Today knowledge development in nursing is taking place on several fronts, with a variety of scholarly approaches contributing to advances in the discipline. 
Nursing practice increasingly takes place in interdisciplinary community settings, and the form of nursing in acute care settings is rapidly changing. Various paradigms and value systems that express perspectives held by several Groups within the discipline ground the knowledge and practice of nursing. Because the language of nursing is continually being formed and distinguished, it often seems confusing, as does any language that is new to the ears and eyes. Nurses, who have active commitments to the work of the discipline, whether in nursing practice, research, education, or administration, are essential for the continuing development of nursing theory. This chapter offers an approach to understanding nursing theory within three contexts: nursing knowledge, nursing as a discipline, and nursing as a professional practice. 

Definitions of Nursing Theory
Nursing theory is a conceptualization of some aspect of reality (invented or discovered) that pertains to nursing. The conceptualization is articulated for the purpose of describing, explaining, predicting or prescribing nursing care. (Meleis, 1997). Nursing theory is an inductively and/or deductively derived collage of coherent, creative, and focused nursing phenomena that frame, give meaning to, and help explain specific and selective aspects of nursing research and practice. (Silva, 1997) 

Barnum (1998) divides theories into those that describe and those that explain nursing phenomena. Types of nursing theories generally include grand theory, middle-range theory, and practice theory. These will be described below:

Grand Nursing Theory 
Grand theories have the broadest scope and present general concepts and propositions. Theories at this level may both reflect and provide insights useful for practice but are not designed for empirical testing. This limits the use of grand theories for directing, explaining, and predicting nursing in particular situations. Theories at this level are intended to be pertinent to all instances of nursing. Although there is debate about which nursing theories are grand in scope, the following are usually considered to be at this level: Leininger’s Theory of Culture Care Diversity and Universality, Newman’s Theory of Health as Expanding Consciousness, Rogers’ Science of Unitary Human Beings, Orem’s Self-Care Deficit Nursing Theory, and Parse’s Theory of Human Becoming. 

Middle range Nursing Theory
Nursing scholars proposed using this level of theory because of the difficulty in testing grand theory (Jacox, 1974). Middle-range theories are narrower in scope than grand theories and offer an effective bridge between grand theories and nursing practice. They present concepts and propositions at a lower level of abstraction and hold great promise for increasing theory-based research and nursing practice strategies. The methods used for developing middle range theories are many and represent some of the most exciting work being published in nursing today. Many of these new theories are built on content of related disciplines and brought into nursing practice and research (Lenz, Suppe, Gift, Pugh, & Milligan, 1995; Polk, 1997; Eakes, Burke, & Hainsworth, 1998). The literature also offers middle-range nursing theories that are directly related to grand theories of nursing (Olson & Hanchett, 1997; Ducharme, Ricard, Duquette, Levesque, & Lachance, 1998). Reports of nursing theory developed at this level include implications for instrument development, theory testing through research, and nursing practice strategies. 

Nursing Practice Theory 
Nursing practice theory has the most limited scope and level of abstraction and is developed for use within a specific range of nursing situations. Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice. At the same time, nursing questions, actions, and procedures may be described or developed as nursing practice theories. Benner (1984) demonstrated that dialogue with expert nurses in practice is fruitful for discovery and development of practice theory. Research findings on various nursing problems offer data to develop nursing practice theories as nursing engages in research-based development of theory and practice. Nursing practice theory has been articulated using multiple ways of knowing through reflective practice (Johns & Freshwater, 1998). The process includes quiet reflection on practice, remembering and noting features of nursing situations, attending to one’s own feelings, reevaluating the experience, and integrating new knowing with other experience (Gray & Forsstrom, 1991). 

Nursing Is a Professional Practice 
The major reason for structuring and advancing nursing knowledge is for the sake of nursing practice. The primary purpose of nursing theories is to further the development and understanding of nursing practice. Theory-based research is needed in order to explain and predict nursing outcomes essential to the delivery of nursing care that is both humane and cost-effective (Gioiella, 1996). Because nursing theory exists to improve practice, the test of nursing theory is a test of its usefulness in professional practice (Fitzpatrick, 1997). From the viewpoint of practice, Gray and Forsstrom (1991) suggest that through use of theory, nurses find different ways of looking at and assessing phenomena, have rationale for their practice and criteria for evaluating outcomes. Development of nursing knowledge is a result of theory-based nursing inquiry. The circle continues as data, conclusions, and recommendations of nursing research are evaluated and developed for use in practice. Nursing theory must be seen as practical and useful to practice and the insights of practice must in turn continue to enrich nursing theory.

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