Nursing Theory and the Theory-Practice Gap Explained

Introduction: Nursing Theory as Mirror, Microscope, or Telescope

A paradigm in nursing theory exists today that equates nursing theory to a mirror, a microscope, or a telescope. Meleis describes this equation in her work on theoretical nursing (2007). According to Meleis, nursing theory that is like a mirror will reflect reality but give it different shapes. Nursing theory that is like a microscope will focus in on a part of reality or magnify it, which may or may not be within the context of that reality. And nursing theory that is like a telescope will bring faraway objects and events into closer view.

When searching through the literature for articles about nursing theory, one related phrase comes up frequently: the theory-practice gap. Examples include "Tackling the theory-practice gap in mental health nursing training" (Evans, 2009); "Theoretical versus pragmatic design in qualitative research" (Smith, 2011); bridging the theory-practice gap in perioperative theatre placement in "A critical analysis of theatre as a learning environment in relation to placement duration" (Barry, 2009); bridging the theory-practice gap in "Iranian nurses' constraint for research utilization" (Salsali, 2009); and bridging the theory-practice gap through scholarship in "Scholarship in nursing: not an isolated concept" (Robert, 2011).

The theory-practice gap is what occurs when useful theories about nursing are not applied — or not applied well — in the practical, clinical setting. This gap indicates that theories may be too focused, or may scrutinize an aspect of nursing outside of its practical setting, such that the theory becomes inapplicable in reality. This presents a perspective of nursing theory that is like a microscope. Therefore, from this perspective, one way to alleviate the theory-practice gap might be to widen the scope of the theory, or to place it in context so that it more closely reflects reality.

Historical Development of Nursing and Its Theoretical Stages

Nursing has undergone several stages of development to arrive at this point in history. Meleis outlines several stages of nursing development that include: practice, education and administration, research, theory, and integration (2007). Nursing in Western cultures has its beginnings at the time of the Crimean War. It all began with Florence Nightingale, who, along with battlefield surgeons, supervised other nurses. She sought to aid the sick and enhance their health through improved hygiene by making environmental changes. Her writings were posthumously formulated into a theory. Formulating a nursing theory in this manner — by bringing a concept from the past into closer view — could be considered like a telescope.

From practice came apprenticeship as the first form of nursing education. Nursing education began as a more hands-on application within the clinical setting. Over the course of thirty years, however, curricula were developed, as were methods for training teachers, administrators, and nurse practitioners. This early focus on education and teaching may have paved the way for the development of theoretical nursing. Again, this pulling together of past and distant events from previous stages in nursing history into a nursing theory is like a telescope bringing objects and events from far away into closer view.

Nursing research was developing throughout the stages of practice and education, but became a necessity in post-war America. During this stage, more emphasis was placed on the process of research rather than its content (Kuhn, 1970). This focusing of research findings on one aspect — the process — is like the narrowing perspective of a microscope. It is no surprise that in this era of narrowing perspectives, the stage of nursing theory emerged.

Nursing theory came about at the same time that the nursing profession emerged as an autonomous science rather than an arm of medicine. Theories stem from the philosophical underpinnings of the era in which they are formulated. The early theories sought to address the nature of the human being in interactions and transactions with the healthcare system, as well as the interactions and transactions involved in problem solving and decision making for assessment and intervention. Some early recognizable theories include that of therapeutic touch (Rogers, 1970) and self-help (Henderson, 1966). These early theories seem relevant and easily applicable to practical situations — more like mirrors reflecting reality but giving it a new shape. This is unlike the current problem of the theory-practice gap.

Qualitative Research Methods and the Narrowing of Nursing Knowledge

This brings us to the twenty-first century and the era of integration in nursing's stages of development. In this era, one important aspect of integration is the revisiting of old theories and reflecting on them, like a mirror. From this new perspective — one more akin to a reflection of reality — the problem of the theory-practice gap may begin to be corrected.

The theory-practice gap can be found in abundance within the literature. In one article, Smith and colleagues argue that potentially adhering to qualitative methods because of their underpinning philosophical origins may cause research to deviate from its stated purpose (2011). They note that this is especially challenging for novice researchers because of the range and diversity of qualitative methods available. They also argue that researchers should be free to choose any qualitative method — even a general method — without criticism (Holloway, 2003).

There are three common qualitative methods used in nursing research, each with varying theoretical underpinnings: ethnography, grounded theory, and phenomenology (Sandelowski, 2000). Ethnography has its roots in anthropology and describes a social or cultural group. Grounded theory has its roots primarily in sociology and is used to develop theory. Phenomenology has its roots primarily in psychology and creates an understanding of participants' lived experiences (Smith, 2011). The authors found that when utilizing all three of these common qualitative methods, the original intent of the research was narrowed to only one aspect of the original research question. This is much like a microscope focusing in on one aspect of reality and magnifying it. The researchers suggest using a general qualitative method with no theoretical basis to alleviate this problem. However, it is possible that within the forty qualitative methods available (Tesch, 1990), the authors could find one more suited to their research questions.

Conclusion: Toward Integration and Broader Perspectives

Nursing has a long history of progression from its beginning with Florence Nightingale to today. In the practice, education, and administration of nursing that occurred in its earliest stages of development, nursing was a reflection of reality. It looked at aspects of reality and sought to give new shape — or shed new light — on the questions and issues of nursing at that time. In the era of nursing research and subsequently the stage of nursing theory, that focus became more microscopic. The problem with focusing on smaller and smaller details and specifics of nursing is that efforts to then apply those narrow findings to broad topics in healthcare are not always good reflections of reality. This has led to a gap between knowledge and its application in the practical, clinical setting — a gap that can be thought of as a theory-practice gap or, similarly, as a research-practice gap.