Caring in Nursing: Theory, Practice Gap, and Bahrain

Introduction to Caring in Nursing

Over time, nursing and caring have largely been regarded as synonymous. With that in mind, it is important to note that a number of caring theories have been developed with caring as a central concept. Some of these theories include the Cultural Care theory by Leininger and the Human Caring theory by Jean Watson, both of which were developed in the 1970s. This paper is concerned with caring as a concept in nursing, and offers a detailed evaluation of the nature of the theory-practice gap, most particularly in Bahrain as it relates to nursing.

Caring behaviors in the context of nursing can be understood as those approaches and practices evidenced by nurses as they seek to care for individuals or patients in a nursing setting. There exist a number of caring behaviors — ten, to be precise — as outlined by Taber's. According to Eyles (2004), these behaviors include addressing patients by their own names, touch, respect, sensitivity, provision of relevant information so that patients can make well-founded decisions, patience, comforting, responsibility, honesty, and listening.

Defining Caring in Nursing

It can be noted that apart from nursing, other professions also have well-developed and concise caring behaviors. These professions include, but are not limited to, law enforcement — where the most evident caring behaviors include respect and honesty — and the teaching profession, where responsibility, sensitivity, active listening, and patience constitute the top caring behaviors.

Nursing is essentially founded on the key need of ensuring that a patient attains an enhanced level of harmony not only within the body but also within the soul and mind. This assertion is supported by Watson's theory. To achieve this key need, caring transactions must be invoked, and thus the relevance of caring to nursing cannot be overstated. According to Wallace and Fitzpatrick (2005), nursing is essentially a caring profession, and caring impacts positively on the well-being of a patient.

Based on literature from patients' perspectives, being a caring nurse has a significant effect on patient care. For instance, in a study on caring from the patient's perspective conducted by Brown in 1986, it was found that the nurse's ability to provide the required treatment and care, and the confidence patients had in that care, was critical to the experience of care (Nyberg, 1998). Others who have carried out similar studies include Mayer and Riemen. Mayer concerned himself with patients suffering from cancer and the perceptions their families had of nurses' caring behaviors, while Riemen undertook a phenomenological study that sought to chart patients' descriptions of caring interactions with nurses.

Some of nursing's most prominent caring theories include Jean Watson's Human Caring theory and the Cultural Care theory developed by Leininger. Caring is viewed by Watson as a science. In her own words, Watson (2008) notes that "caring encompasses a humanitarian, human science orientation to human caring processes, phenomena and experiences." It can also be noted, however, that caring as a science cannot be looked at from a purely scientific perspective, as it also encompasses humanities and arts. Therefore, it is accurate to state that today, the concept of caring in nursing is being examined from an interdisciplinary perspective, and its relevance to professionals across the health spectrum cannot be overstated.

Madeleine Leininger notes in her own words that "care in the context of nursing can be taken to be a focus that is not only unifying but also dominant and central" (Leininger, 1988). According to Leininger's theory of cultural care, it is essential to take culture into consideration when exercising caring behavior. As the only nursing theory that comprehensively addresses the issue of culture, Leininger's theory of cultural care identifies caring as largely unique and essential to nursing.

A theory is primarily a collection of related concepts whose main goal is to guide practice through action. According to Freshwater (2002), it is well recognized that gaps exist in nursing between theory and practice. When it comes to guiding nursing practice, there is insufficient systematic utilization of theories, even though the benefits of theory-informed nursing practice are considerable in terms of enhancing the level of care offered to patients. A theory-practice gap is essentially the nurses' inherent inability to utilize nursing and associated theories in clinical practice settings. This definition is also supported by Larsen and Lubkin (2006), who describe the theory-practice gap in nursing as the inability of nurses to utilize various nursing theories and related frameworks in real-world scenarios. Freshwater (2002) further notes that the disparity between theory and practice can be summarized by the fact that researchers and educators are seldom found in the practicing nurse's environment.

Though practice and theory are in some ways separate in nursing, nursing students are highly likely to encounter the theory-practice disparity. There are a number of reasons why this gap exists, beyond Freshwater's observation about the absence of researchers and educators. To begin with, nurses may fail to utilize theories because they either do not understand them or have insufficient information about them. It is also possible that some nurses do not believe in certain theories and therefore fail to apply them in practice. Additionally, the theory-practice gap is sometimes brought about by circumstances or scenarios that do not allow nurses to utilize theories and conceptual models. According to Barker (2009), the organizational or medical model of care is what professional nursing more often applies, rather than relevant nursing theories and models. It is also worth noting that some hold the opinion that theories and conceptual models cannot be applied in nursing practice due to their abstract nature — the argument being that such theories provide insufficient information to guide judgments in a nursing setting. According to Barker (2009), there are also those who consider nursing theories and conceptual models as largely incomplete and lacking in terms of refinement and adequate testing, which aligns with the view of them as thinking stimulants rather than practical guides.

Key Caring Theories: Watson and Leininger

Barker (2009) argues that measures should be designed to ensure that nursing models and theories retain their relevance in nursing practice. She notes that for theories and nursing models to produce predictable client outcomes, they should be consistent with other validated theories and should provide clear and concise rationale and consequences for nursing actions. There is also the question of whether, given that nursing is an applied science, the only appropriate theories and models are those derived from within the scope of nursing itself. A wide range of theories from other disciplines — including developmental theories, family theories, and systems theories — have been suggested for incorporation into clinical and nursing practice to enhance nurses' medical and nursing knowledge. Most nursing theories already borrow concepts from various other disciplines, and these concepts must be adapted to fit the nursing context. Barker (2009) notes that over time, a number of scholars have argued that theories and models should form the basis of nursing practice, as they align with human science from a nursing perspective. However, the introduction of theory-based practice should be handled with care, as it initially brings a real possibility of disrupting the prevailing stability of current nursing practice (Barker, 2009).

According to Kramer, new graduates consistently face a reality shock when called upon to perform in practical nursing scenarios (Chitty, 2005). This reality shock is characterized by feelings of ineffectiveness and powerlessness when confronting practical situations. Kramer's findings indicate that the psychological stresses brought about by reality shock greatly reduce new graduates' ability to cope effectively with new role demands (Chitty, 2005). In the 1970s, high nursing staff turnover was partially attributable to reality shock, as the expectations of new nurses failed to match the experiential reality of the nursing environment (Barker, 2009).

Students continue to face a reality shock once immersed in practical nursing scenarios, where their theoretical knowledge and application of nursing concepts encounters significant challenges. This is largely because no deliberate measures are taken at the training level to enhance the integration of theoretical knowledge with practical experience. This is perhaps the reason why Callara (2008) insists on the need to teach students how to apply qualitative reasoning in real-world scenarios by drawing on ideas from both their everyday living and from experts well versed in the realities of the profession.

Defining the Theory-Practice Gap

Based on analysis of available facts and evidence, a theory-practice gap exists in nursing in Bahrain. This is particularly evident in the care of schizophrenic patients. Like other parts of the world, Bahrain has shifted nursing education into Higher Education Institutions (HEIs) and has increasingly embraced androgenic principles that emphasize students becoming reflective, critical, and self-directed thinkers. This means that nursing training is becoming more focused on the "process" rather than the "product." However, in Bahrain, the situation is aggravated by an apparent overreliance on academia at the expense of practice in the training of nurses. The theory-practice mismatch in Bahrain is also informed by the conflicting underpinning philosophies of the two environments — theory and practice.

An example of an issue that illustrates the disparity between theory and practice in Bahrain's nursing is schizophrenic care. Here, it has proven inappropriate to rely solely on theoretical aspects and research when prescribing different counseling models for different patients. This is because each person is unique, and the number of variables to be considered in order to account for each patient's circumstances is significant — so much so that even a single patient can constitute an individual treatment group. Practitioners fresh from college in Bahrain have therefore encountered considerable challenges in arriving at diagnoses and determining the best treatment for individual patients, as this ability is rooted in the application of professional judgment rather than generalized research findings and theoretical frameworks.

It is important to note that compared to other disciplines, nursing appears to be most affected by the theory-practice gap. In other disciplines, the technical rationality paradigm tends to be largely efficient. For instance, in civil engineering, it is rare to encounter a significant gap between theory and practice: if a bridge is theoretically designed to withstand ten thousand tons, it will in all likelihood withstand that weight in reality. To address the existing disparity between theory and practice in nursing, deliberate measures and approaches that are both acceptable and applicable to clinical practice are needed. One advocate for closing this gap is Cody (2006), who holds that a nurse's ability to utilize theory appropriately in practice is critical for the provision of quality healthcare services. Nevertheless, some hold the opinion that it is impossible to entirely close the gap between theory and practice in nursing. McKenna (1997) is even convinced that this gap could go a long way toward stimulating innovation in the profession.

It is clear that theory-based nursing practice depends largely on two things: the knowledge nurses possess in relation to theories and concepts, and the understanding nurses have of how to apply those theories and models in practice. Theories and models in nursing represent perspectives that are unique, logical, and oriented toward patient health. Nursing theories are also highly relevant for providing a systematic approach and structure for examining client situations, interpreting nursing diagnosis data, identifying relevant information, and planning effective nursing care through critical thinking and reasoning. Closing the theory-practice gap is therefore not only critical but also necessary.

Closing the theory-practice gap calls for a number of well-considered measures. First, there is a need to ensure that theories and nursing models are consistent with other validated models. Closely related to this is the need to use a carefully considered criterion for selecting theories and models to be utilized in practice. A good example is the seven-criteria framework identified by McKenna for theory and model selection. The utilization of such criteria should be guided by questions including, but not limited to: Can the theory adequately address the health concerns and problems of a patient? How consistent are the nursing interventions suggested by the model with the patient's expectations for nursing care? It may also help if more researchers and educators involve themselves in the environment of practicing nurses, addressing Freshwater's observation that practicing nurse environments have a significant deficiency of educators and researchers.

Education is also essential for bridging the nursing theory-practice gap. The emphasis should be on enhancing education in practice, which can be achieved in a number of ways. For instance, new nursing posts could be created with a dual focus on both education and practice. If developed effectively, such posts could go a long way toward fusing students' theoretical knowledge with meaningful practical experiences. The provision of education in a work setting has proven beneficial in other disciplines — such as management — in terms of developing practical skills, and this approach can similarly be applied in nursing to help close the theory-practice gap.

Barker, A.M. (2009). Advanced Practice Nursing: Essential Knowledge for the Profession. Jones and Bartlett Learning.

Callara, L.E. (2008). Nursing Education Challenges in the 21st Century. Nova Publishers.