Theory vs. Practice in Nursing Knowledge Development

Introduction: A Profession at a Crossroads

The scope of the nursing profession has increased dramatically over the last thirty years. The demarcation between medical and nursing tasks is quickly dissolving as the nursing profession becomes increasingly multidisciplinary and complex. In 1996, nurse practitioners were mandated to obtain master's degrees to address their changing role in medical care (Nicoteri & Andrews, 2003). In this multidisciplinary and evolving healthcare environment, adaptation is paramount to providing effective patient care.

Currently, there is a controversy in nursing regarding the direction that the development of nursing knowledge should take. Many critics believe that developing new nursing theories is an effective way to promote this development. However, theories are often abstract and not readily adaptable to specific healthcare settings. The belief that the knowledge base for nursing should evolve entirely from theory has important implications for nursing as an academic discipline and, by extension, for the effective treatment of patients.

Two Models of Nursing Knowledge Development

There are two models, or ideologies, for advancing nursing knowledge: a theory approach and a practice approach. The theory-based approach develops nursing knowledge in a proactive yet untested way — it creates the theory first, and the knowledge is meant to follow. Those who support this model have argued that a clear nursing theory serves as a framework or foundation that provides direction for knowledge development (Spear, 2007).

Others find nursing theory to be an academic abstraction of no practical value. These critics point out that theory-based knowledge development creates a direction that is not necessarily grounded in what is actually applicable to the specific setting of care. They argue that it is an exercise in futility and may even misguide the development of nursing knowledge by creating conceptual confusion rather than clarity in practice (Spear, 2007). It appears that it would be more effective to adopt a reactionary knowledge development approach — one that recognizes clinical or administrative problems specific to the care setting and then conducts research to solve them, moving from practice to knowledge. This would ground the development of nursing knowledge in a more relevant and applicable footing.

Defining Nursing as a Distinct Academic Discipline

The main controversy in development, therefore, lies in the source of knowledge. Both approaches seem to have a legitimate claim and even appear to derive their ideas from the same fundamental goal. One of the main problems currently facing the nursing profession is its rapid evolution and the resulting distortion of a distinct set of fundamental objectives. Spear notes that nursing will be perceived as an indistinct discipline until it plainly defines itself in terms of science and unique knowledge — in short, by a distinct theory (2007). Northrup and colleagues support this view by emphasizing the need to develop a distinct body of nursing knowledge based on a theory that reflects the values and objectives of current practice (Northrup, Tschanz, Olynk, Szabo & Biassio, 2004). The goal of both approaches, then, is a more distinctive definition of nursing as an academic and professional discipline.

As an academic discipline, nursing would seem to benefit most from a dual approach. Relying entirely on theory would create a guide without substance. Theory-based knowledge is effective in recognizing problems and raising awareness of them, but an academic program that relies entirely on theory-derived knowledge would produce nurses who are conscientious and knowledgeable yet not necessarily skilled practitioners within the specific context of the care setting. Conversely, knowledge derived entirely from practice without any theoretical grounding lacks the guidance necessary to maintain the coherence of the nursing profession — nurses could potentially lose their understanding of their role and professional identity. The main controversy, therefore, should focus on the appropriate degree of emphasis given to each approach in the development of nursing knowledge.

Historical Development of Nursing Theory

Theorists over the past decades have attempted to present a comprehensive, rational, and systematic approach to nursing (McCrae, 2011). A number of influential models have been proposed. Hildegard Peplau is credited with developing the first recognized theory of nursing in 1952. She emphasized the nurse, rather than physical medical interventions, as the primary form of treatment (1952). Callista Roy expanded on this foundation by developing a holistic theory of nursing science based on what she described as a patient's natural tendency toward biological, psychological, and social equilibrium (1980). In Roy's framework, the nurse's role is to identify ways to promote the patient's synergy with those three aspects of well-being.

This threefold composition of physical, psychological, and social mechanisms dominates the theoretical understanding of nursing science. In a review of nursing theories, McCrae argues that a nurse responds to a patient's distress not with evidence-based research findings but rather with an intuitive, humanistic ethos rooted in professional experience (2011). This observation precisely demonstrates the difficulty of bridging the gap between theory development and nursing science and administration. It is extremely difficult to obtain empirical evidence that any one theory of nursing actually translates into superior care.

Conclusion: Toward a Balanced Approach

These findings have substantial implications for nursing as an academic discipline. They show that theories alone are insufficient in capturing the role of a nurse on the ward. An academic program that derives its knowledge base solely from theory does not fully prepare nurses; instead, it provides a set of abstract skills, care values, and ideals that are distinctly out of context. The nurse would not know how to apply the theory, which in turn undermines the ability to effectively treat patients.