Does Nursing Need Theory?

=Do nurses need theory? A question that can be considered on many different levels. If one considers the evolution of nursing over time, one can observe that the nurse of antiquity was arguably as dependent on the prevalent theories of the day as the current nurse. Theory determines practice and theory justifies practice (Einstein paraphrased in Kuhse & Singer 2001). The nurse who changed the blood letting bowls of antiquity was as dependent upon the theories of imbalances in the humors for her practice as were the nurses in the wards of Ignaz Semmelweis (Semmelweis IP. 1861) who may well have found the idiosyncratic insistence on hand washing to remove the presence of the unseen agents of infection completely bizarre until the evidence base of reduction in puerperal infection could be clearly established.

In this latter comment we can find one of the major dilemmas facing the nursing theorists of today. The plethora of nursing theories have been subsumed into a goal (albeit defined by the theorists themselves) of finding a unified nursing theory. One that will define the human condition and also medical science’s response to the management of the various conditions of pathophysiology that can befall it. The stumbling block of many theories is the difficulty in establishing a credible evidence base to support it. (Brechin A et al. 2000). To revisit the Einstein quotation cited earlier, one can have a theory that may determine practice, but it is only with the demonstration of an evidence base that the theory can actually be used to justify practice.

One of the luminaries of nursing theory and practice was Martha Rogers, the late Dean of Nursing at New York University. To illustrate the point, Rogers published many nursing theories in her working life. Some (the Unitary theory) have gained a degree of general acceptance others have faded in the mists of time. It was her stated goal to define a unified theory of nursing. (Meleis, A 1997). The Rogerian approach appeared to have little room for establishment of evidence bases and we would suggest that this approach is essentially flawed. (Halpern S D 2005).

To consider an extrapolation into other scientific disciplines by way of analogy, we note that it has not been possible to define a unified theory of biological science. Biology is essentially a study of life in general. It does not seek to be a theory of life. Although theories may be postulated in the explanations of the various phenomenon encountered in the field, such as natural selection or the function of the genome, these are used to test the various hypotheses underpinning practical observations, laboratory work and in some cases, mathematical models. There is no all-encompassing biological theory. At a more fundamental level we can observe that biology is based on chemistry which, in turn, is ultimately based on principles of physics. Again we can observe that there is no unified theory encompassing the entire field. (after Green J et al. 1998). This analogy is applicable to nursing theory if one considers the huge range of skills and requirements needed by the modern professional nurse. The spectrum of tasks required and expected of the nurse in a variety of situations is legion. To be effective the nurse must understand the human condition from the viewpoint of the pathophysiology, the psychology, the human dynamic and socio-economic elements of the patient’s presentation and disease trajectory. (Yura H et al. 1998). Much of our understanding of these elements is encapsulated into various concepts or theories which are perhaps best regarded as dynamic and fluid or in a process of evolution. (Wadensten et al. 2003).

A practical consideration would suggest that the nurse is responsible for giving medication, undertaking procedures of medical intervention as well as caring for the general physical well-being of the patient, they record various parameters of their patient’s progress. They can be the patient’s advocate in terms of their dealings with other healthcare professionals, organisations or even commercial concerns. (Hogston, R et al. 2002). In order to carry out these ( and many other) functions efficiently. The nurse needs to be competent in a huge number of areas with skills in interpersonal relationships, organisational, technical and clerical areas. It follows that these skills are derived from a large number of disparate areas such as anatomy, physiology, therapeutics, psychology, management theory, bookkeeping and tabulation. (Mason T et al. 2003)

The point being made here is that, in the light of these comments, it seems inappropriate to consider that there should be, in Rogerian terms, a unified theory of nursing (Rogers, M E 1970). The overall goal would undoubtedly be that the professional nurse should seek to improve the overall well-being of their patients. This target is the accumulative result of any number of different and disparate processes and skills form many differing academic and human disciplines. We would suggest that it is not amenable to the reductionist philosophy of Rogers.

Despite the notable article by Christensen (P et al. 1994) which criticises authors who have applied such strategies to both extrapolate from and to expand implications of Rogerian theory, reductionist strategies are not totally inappropriate. In a further scientific analogy, we can point to a classic case of reductionism which contributed greatly to our understanding of the natural world. When Newton made his mathematical models linking orbiting planets, projectiles and falling apples, he produced one of the most dramatically valid reductions in scientific literature. Reductionism per se. is not an inappropriate process.

Herein lies a frequently perpetuated fallacy that permeates the field of literature on nursing theory. The term “Reduction“, in a nursing context, can have two distinct connotations. It can be observed that some nursing theorists apply the term to the tendency of some healthcare professionals to visualise and regard the patient as a number, a set of symptoms or a demonstration of a particular element of pathophysiology rather than as an individual in their own specific socio-economic, cultural and psychological setting. (Alcock P, 2003). Although this is a completely appropriate and specific use of the term, it is distinctly different from the implications of “Reductionism” in the scientific and analytical sense. Some nursing theorists (viz. Christensen) use the term in a derogatory or disparaging form that does not appreciate or even acknowledge the positive aspects of the technique. (Hott, J R et al. 1999).

We would suggest that such confusion in the terminology has led to some nursing theory being discredited. If we expand this theme by staying with Rogerian theory as an illustration of the point, we can suggest that in the broader context of medicine generally, scientific reduction has enabled progress in medical science by allowing the accurate identification of causal agents of disease and thereby allowing the development of appropriate strategies to combat and eliminate them. Nursing theorists should embrace this aspect of the concept of reductionism while combating any suggestion of a reduction of the status of the patient from that of an autonomous human being (Mill JS 1982).

To consider the situation as Christensen does and to decry the use of reductionism and to treat events as essentially causal, does no favours for the analytical process that is central to any theoretical process. It effectively takes nursing theory out of the realms of science which, almost by definition, considers processes as cause and effect. (Polit, D F et al. 1997). Even if we consider processes that are essentially acausal such as the spontaneous degradation of atomic nuclei, one can point to the fact that these processes are still quite capable of being considered reliable processes because they can be detected, demonstrated, quantifiable, repeatable and amenable to statistical analysis. If we contrast this to the nursing theorists in general, and perhaps Rogers in particular, we can show that their writing and reasoning is largely devoid of causal argument and subsequent reasoning. (Barnum, B J. S. 1998).

The reasons for this are clearly a matter of speculation. The less charitable analyst might be tempted to conclude that some of the theories propounded do not meet common sense standards. Few of the theories meet the criteria that would satisfy a reputable evidence base as they appear to avoid rigorous testing. To take a specific example, the theory of therapeutic touch is certainly complete enough to permit a degree of submission to testing. Much of the literature cited by Rogers is however, very subjective, done by unblinded clinicians and very speculative. Some is purely in the form of no more than reported anecdotes (Rosa, L et al. 1998).

This trend has done little to increase the confidence of the analytically minded investigator in the usefulness and relevance of nursing theory. To a casual observer, who considered only these elements of nursing theory, it might appear that the theorists had allowed themselves to become detached from the scientific rigour of logical deduction or experimental validation and thereby effectively deprived the field of any degree of precision of predictive possibility (which any useful theory should have). To support this view, one can cite Rogers herself (cited in Meleis 1997). “Reality does not exist but appears to exist as expressed by human beings”.

In this respect, we can put forward a coherent argument that nursing does not need theory.

Having presented this argument, we can also examine the opposing view put forward by Prof Margaret Rosenthal (Rosenthal 2000) in her thought provoking book “Changing Practice in Health and Social Care“. The book itself is primarily about accountability in healthcare, but in its discussion it considers the relevance of the nursing theorists in general. The author puts forward the view that the public have experienced a decline in the trust and standards of the healthcare professionals. She cites the media as being one of the major contributors to this erosion, rather than the actual reality of the situation and suggests that the way forward is to submit all types of clinical practice to the scrutiny of its evidence base. She suggests rejecting practices that do not have a secure evidence base in favour of those that do so that “at every level so that the public in general and the patients in particular, are able to feel confident in every therapeutic manoeuvre that they are offered“. (quote from McNicol M et al 1993 Pg 219). As an overview the author suggests that all dealings, whether they are practical or theoretical, should have “accountability as their watchword”.

In some respects, this is a simple conceptual extension of the comments advanced by Florence Nightingale a century and a half earlier, that the ultimate objective of working in a healthcare environment as a healthcare professional is to provide the best form of support, treatment and care for the patient. (Nightingale F 1859). We would both concur and expand the sentiments expressed by adding that this may be best achieved by considering that the best form of treatment is the one that has the strongest evidence base for its use.

Having made these comments, it is appropriate to consider the more positive aspects of nursing theory. If we accept Wadenstein’s view (Wadenstein B et al. 2003) that it is an important purpose of theories to challenge practice, create new approaches to practice and remodel the structures of rules and principles, then we could usefully progress this argument by considering some of those theories which help to explain patient behaviour and thereby modify the nursing approach.

The basic nursing process is traditionally based on assessment, planning, implementation and evaluation. The particular theories that we shall consider here, together with the models that they support, all basically follow the same pattern, but each analyses the patient situation from a different aspect or in different terms. (Fawcett J 2005)

The Roper Logan Tierney model (Roper, Logan and Tierney 2000) is primarily concerned with the activities of daily living. It requires identification of the problems and then dealing with them on a problem solving basis. This type of model has been extensively reported, evaluated and is one of the most generally accepted models of the nursing process. (Holland K et al. 2003). This type of approach is very useful for problems which are mainly or primarily based on a physical or disability orientated disease process. Its major shortcomings revolve around the fact that it is not very useful in describing strategies that cope with patient responses that are overtly manipulative or psychological in nature. The theories that underpin this model have largely withstood the test of time and clinical practice and have accumulated a large evidence base in the literature. (Holland K et al. 2003).

For patients who fall into the category of manipulation or functional symptomatology as a result of an adaptation process for coping with their illness the Roy adaptation model (Roy 1991) is useful in describing the abilities of a patient to adapt (or maladapt) to the evolving pattern of their illness. This model allows for changing perceptions and adaptation mechanisms on the part of the patient and can be used to explain the various behaviour patterns exhibited by various patients as their disease trajectory unfolds. It allows for the major patterns of illness adaptation but has the major shortcoming that it does not allow for the behaviour patterns that are consistent with denial of the underlying diagnosis. The patient who has a diagnosis of terminal cancer but copes with a total refusal to accept it and continues as if all is well, is not described in this particular approach. The model dismisses this as a degree of cognitive distortion rather than a coping mechanism. It can be seen as possibly choosing to ignore the reality of the situation and changing the theory to make it more coherent. It would categorise the patient as not adapting to the situation by choosing to ignore it. (Steiger, N. J. et al. 1995)

This particular situation is better dealt with by the application of the theories associated with the Johnson Behavioural System ( in Wilkerson et al 1996). This model can be considered useful in describing the situation of denial considered above but it too has shortcomings insofar as most experienced clinicians would note that a patient in denial of a terminal illness almost always is forced into acceptance by the progressive nature of the illness itself. (Johnson, D. E. 1990) The majority therefore have to accept their terminal status as they are overtaken by progressive physical manifestations of the disease process and other symptoms.

This element of the argument is presented as showing that the basis of some nursing theories is valid and useful but also even the most accepted theories have their shortcomings and limitations. (Tomey A M, Alligood M R 2005). To paraphrase the comment of Wadensten (et al 2003), one can observe that the nursing models and theories all have their place, but one has to add the caveat that there is not one satisfactory theory or model which can account for all aspects of care and all eventualities.

The thrust of this essay is directed at the preposition that some nursing theories are indeed useful and some are not. Even a brief consideration of the literature on the subject will reveal a plethora of opinions. (Powers, B. A 1995). It is vital to consider each theory or model in isolation and make a critical judgement relating to its ability to inform the nurse and to predict practice for the overall benefit of the patient. Those, such as the ones discussed in the early part of this essay, which rely heavily on intuition and anecdote and also have a marked lack of independent validation, are clearly less likely to be of value to the practical nurse and, in the worst analysis, in the opinion of Prof. Rosenthal, may contribute to the reduction of public confidence in the healthcare professions in general terms. By contrast, the more accepted, reproducible and statistically valid theories which have predictive value and are amenable to independent validation are much more likely to be considered of value to the profession in general terms.

In direct consideration of the title of this essay “Does nursing need theory?” the considered answer must be a qualified “Yes” but within the limitations that we have outlined here.

References

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