Analyze Benner’s novice to expert theory. Your analysis should include the following:Description of the theory’s background and influencing factors, including worldviewExplanation of the underlying assumptionsEvaluation of major strengths and weaknessesApplication strategies for clinical practiceCitation of case example from personal or professional life that describe the application in practice From Novice to Expert
Author(s): Patricia Benner
Source: The American Journal of Nursing, Vol. 82, No. 3 (Mar., 1982), pp. 402-407
Published by: Lippincott Williams & Wilkins
Stable URL: https://www.jstor.org/stable/3462928
Accessed: 22-06-2019 05:44 UTC
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long-term and ongoing career de- opment of a skill, one passes through
velopment. This, in turn, requires five levels of proficiency:
* novice
an understanding
Nursing in acute-care settings
hasof the differences
* advanced beginner
experienced nurse and
grown so complex that itbetween
is no the
longthe routinize,
novice.
* competent
er possible to standardize,
By Patricia Benner
The Dreyfus
and delegate much of what
theModel of Skill Ac-
nurse does.
quisition offers a useful tool for
doing this. of
This model was inducIn the past, formalization
tively derived by two University of
nursing care and interchangeability
of nursing personnel were
considCalifornia,
Berkeley, professors–
* proficient
* expert
The levels reflect changes in
two general aspects of skilled per-
formance. One is a movement from
Stuart
Dreyfus, a mathematician
ered easy answers to nurse
turnover.
and systemsof
analyst, and Hubert
The discretionary responsibility
Dreyfus, a philosopher-from
their
nursing care for patient welfare
was
reliance on abstract principles to the
lots(1,2).and repaid to providing incentives
myclinistudies, I have found
wards for long-term careersInin
thatThis
the model
be generalized to
cal nursing in hospitals.
iscan
no
nursing. It takes into account increlonger tenable.
ments of
in skilled
performance based
Increased acuity levels
patients, decreased length of
upon
hospitaliexperience as well as education. It also provides
zation, and the proliferation
ofa basis for clinical knowledge
development and
health care technology and
specialization have increased the need for
career progression in clinical nurs-
of a demand situation so that the sit-
study of was
chess players and piignored, and little attention
highly experienced nurses. The
complexity and responsibility of
use of past, concrete experience as
paradigms. The other is a change in
the perception and understanding
uation is seen less as a compilation
of equally relevant bits and more as
a complete whole in which only certain parts are relevant(2).
To evaluate the practicality of
applying the Dreyfus model to nursing and to clarify the characteristics
of nurse performance at different
stages of skill acquisition, interviews
ing.
Briefly, the Dreyfus model pos-
nursing practice today requires its that, in the acquisition and devel-
and participant observations were
conducted with 51 experienced
402 American Journal of Nursing/March 1982
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and output, temperature,
blooding graduate
clinicians,
11 new
rules legislates against successful
pulse, and other
such ob- task performance
and 5pressure,
senior
nursing
students
because no rule
tasks are
different
hospitals-two
prijectifiable, measurable
parameterscan tell a novice which
nurses,
in
six
mosttwo
relevant in a comreal situation or
vate community
of the patient’s
hospitals,
condition.
when
an
exception
to the rule is in
Novice practitioners
are also
munity teaching
hospitals,
one university medical
taught rules
center,
to guide actionand
in order. one inrespect to different
attributes. The
ner-city general
teaching
hospital.
Much
confirming
following is an example
and
of suchno
aLevel II:
disconAdvanced Beginner
context-free rule:
firming evidence
was found for use
of the Dreyfus
Skill
AcquiThe advanced
beginner is one
To Model
determine fluidof
balance,
sition
tice(3,4).
Level I: Novice
in
check the patient’snursing
morning
clinical
pracwho can demonstrate
marginally
weights and daily intake and out-
put for the past three days. Weight
gain in addition to an intake that is
consistently greater than 500 cc
Beginners have no experiencecould indicate water retention; in
with the situations in which they are
that case, fluid restriction should
be started until the cause of the
expected to perform tasks. In order
imbalance can be determined.
to give them entry to these situa-
acceptable performance. This person is one who has coped with
enough real situations to note (or to
have them pointed out by a mentor)
the recurrent meaningful situational
components, called aspects.
In the Dreyfus model, the term
“aspects” has a very specific mean-
The heart of the difficulty that ing. Unlike the measurable, contexttions, they are taught about them in
terms of objective attributes. Thesethe novice faces is the inability to free attributes of features that the
attributes are features of the task
use discretionary judgment. Since inexperienced novice uses, aspects
that can be recognized without situ- novices have no experience with the are overall, global characteristics
ational experience.
situation they face, they must usethat require prior experience in acCommon attributes accessible
these context-free rules to guide tual situations for recognition.
to the novice include weight, intake their task performance. But followFor example, assessing a pa-
American Journal of Nursing/March 1982 403
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The advanced beginner, or inindicative of pulmonary edema and
structor of the advanced beginner,those indicative of pneumonia. But
similar situations and similar teachcan formulate guidelines for actions
in practice areas, where the cliniing-learning needs. An expert clini- in terms of attributes and aspects.
cian has already attained competencian describes her assessment of a
These action guidelines integrate ascy, aspect recognition will probably
patient’s readiness to learn about his
many attributes and aspects as possibe redundant; the competent clinician will focus on the more adcontinent ileostomy this way:
ble, but they tend to ignore the difEarlier, I thought he was feel- ferential importance. In other
vanced clinical skill of judging the
relative importance of different aspects of the situation.
The major implication for both
tient’s readiness to learn depends on
experience with previous patients in
“Novices and advanced beginners
can take in little of the situation-it
is too new, too strange.”
preservice and inservice education
is that the advanced beginner needs
support in the clinical setting. Ad-
vanced beginners need help in setting priorities since they operate on
general guidelines and are only being helpless about the operation he
had just had. He looked as though
he felt crummy-physically, sort of
stressed-looking, nervous-looking.
Furthermore, he was treating the
wound physically very gingerly. He
didn’t need to be that gentle with
it. But, on this morning, it was different, he began to ask questions.
An instructor or mentor can
words, they treat all attributes and
aspects as equally important. The
ginning to perceive recurrent meaningful patterns in their clinical prac-
following comment about advanced
beginners in an intensive care nursery illustrates this.
nurses to ensure that important pa-
tice. Their patient care must be
backed up by competent level
I give very detailed and expli- tient needs do not go unattended
cit instructions to the new grad- because the advanced beginner canuate: When you come in and first not yet sort out what is most imporsee the baby, take the vital signs tant.
and make the physical examina-
provide guidelines for recognizingtion. Then, check the IV sites,
such aspects as readiness to learn; check the standby ventilator and
Level III: Competent
for example, “Notice whether or not make sure that it works, and check
the patient asks questions about the the monitors and alarms. When I
Competency, typified by the
nurse who has been on the job two
surgery or the dressing change.”say this to new graduates, they do to three years, develops when the
“Observe whether or not the patient exactly what I tell them to do, no nurse begins to see his or her actions
looks at or handles the wound.” But
matter what else is going on…. in terms of long-range goals or
the guidelines are dependent onThey can’t choose one to leave out. plans. The nurse is consciously
knowing what these aspects soundThey can’t choose which is more aware of these plans, and the goal or
like and look like in a patient careimportant…. They can’t do for plan dictates which attributes and
situation.
one baby the things that are most aspects of the current and contem-
While aspects may be made important, then go to the next baby
explicit, they cannot be made com- and do the things that are most
pletely objective. It makes a differ- important and leave out the things
ence in the way that the patient asks that can be left until later.
plated future situation are to be con-
about the surgery or the dressing
tive, and the plan is based on consid-
Novices and advanced begin-
change. You have to have some ners can take in little of the situa-
experience with prior situations be-
tion-it is too new, too strange.
Aspect recognition is dependent on
prior experience.
remembering the rules they have
fore you can use the guidelines. Besides, they have to concentrate on
PATRIC(:IA BENNER, RN. MS, has been involved in
studies to identify the competencies of new
graduates for over 10 years. When this was
prepared, Ms. Benner was director of the
Achieving Methods of Intraprofessional Con-
sensus, Assessment, and Evaluation (AMI-
CAE) Project at the University of San Francisco. This article is based on material to be
published by the National Commission on
Nursing of the American Hospital Associa-
tion in a monograph, From’ Novice to Expert:
Promoting Excellence and Career Develop-
ment in Clinical Nursing Practice. The
study reported in the monograph was sup-
ported by a Department of Health and
Human Services Division of Nursing grant.
sidered most important and which
can be ignored. For the competent
nurse, a plan establishes a perspecerable conscious, abstract, analytic
contemplation of the problem. A
preceptor describes her own evolu-
tion to the stage of competent,
been taught. As the expert clinician
planned nursing from her earlier
quoted above adds,
If I say, you have to do these
stimulus-response level of nursing:
eight things, they do those things.
They don’t stop if another baby is
I had four patients. One
needed colostomy teaching, the
others needed a lot of other things.
Instead of thinking before I went
into the room, I got caught up….
Someone’s IV would stop, and I’d
needs attention, they’re like mules
work on that. Then I’d forget to
between two piles of hay.
Much time is spent by precep- give someone their meds, and so
would have to rush around and do
tors and new graduates on aspect
that. And then someone would feel
recognition. For example, in mak-
screaming its head off. When they
do realize that the other child
ing physical assessments, aspect rec-nauseated
and I’d try to make
them feel better while they were
ognition is an appropriate learning
goal. The nurse will practice dis-sick. And then the colostomy bag
criminating between breath soundswould fall off when I wanted to
404 American Journal of Nursing/March 1982
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start teaching. And, all of a sudden
the morning was gone, and no one
had a bed bath.
Now I come out of report and
I know I have a couple of things
that I have to do. Before I go in the
room, I write down the meds I’m
supposed to give for that day, and
then walk in there and make sure
terms of aspects, and performance situation.
is
They can mean one thing
at one time and quite another at
guided by maxims.
another time. But once one has a
Experience teaches the profi-
cient nurse what typical events deep
to
understanding of the situation,
the maxim provides directions as to
expect in a given situation and how
what is important to take into conto modify plans in response to these
sideration. This is revealed in the
events. There is a web of perspectives, and as Dreyfus notes,
experienced nurse clinicians’s ac-
Except in unusual circum-count of how she weans a patient
that everybody’s IV is fine…. I stances, the performer will be expefrom a respirator:
know what I have to do, and I am
much more organized.
Competence is evidenced by
the fact that the nurse begins to see
his or her actions in terms of longrange goals or plans. The competent
nurse lacks the speed and flexibility
riencing his current situation as Well, you look at vital signs to
similar to some brain-stored, expesee if there is anything significant
there. But even here you need to do
rience-created, typical situation
little guessing. You have to decide
(complete with its saliences) due ato
recent past history of events….
if the patient is just anxious be-
cause he’s so used to the machine
Hence the person will experience
breathing for him. And if he does
of the nurse who has reached the
through a perspective, but ratherget anxious, you don’t really want
proficient level, but the competencythan consciously calculating this to medicate him, because you’re
stage is characterized by a feeling ofperspective or plan, it will simply
afraid he will quit breathing. But
mastery and the ability to cope withpresent itself to him or her(5).
on the other hand, he may really
and manage the many contingenBecause of the experience- need to calm down a bit. It just
his or her situation at all times
cies of clinical nursing. The compe- based ability to recognize whole sit-depends on the situation…. You
tent nurse’s conscious, deliberateuations, the proficient nurse canhave your groundwork from what
planning helps achieve a level of now recognize when the expectedyou have done in the past, and you
efficiency and organization. Nurses normal picture does not present know when you are going to get
at this stage can benefit from deci-itself-that is, when the normal is
sion-making games and simulations absent. The holistic understanding
that give them practice in planningof the proficient nurse improves his
and coordinating multiple, com- or her decision making. Decision
plex, patient care demands.
making is now less labored since the
The competent level is sup-nurse has a perspective about which
ported and reinforced institutional-of the many attributes and aspects
ly, and many nurses may stay at thispresent are the important ones.
level because it is perceived as the
Whereas the competent person
ideal by their supervisors. The stan-does not yet have enough experidardization and routinization of
ence to recognize a situation in
into trouble.
Proficient performers are best
taught by use of case studies where
their ability to grasp the situation is
solicited and taxed. Providing proficient performers with context-free
principles and rules will leave them
somewhat frustrated and will usually stimulate them to give examples
of situations where, clearly, the
principle or rule would be contra-
procedures, geared to manage the
terms of an overall picture or in
dicted,
high turnover in nursing, most often
terms of which aspects are most salireflect the competent level of perent and most important, the profi-
Level V: Expert
“Experience teaches the proficient
nurse what typical events to expect
in a given situation and how to modify
plans in response to these events.”
formance. Most inservice education
cient performer now considers few-
is aimed at the competent level of er options and hones in on an accuachievement; few inservice offer- rate region of the problem. Aspects
ings are aimed at the proficient or stand out to the proficient nurse as
expert level of performance.
Level IV: Proficient
With continued practice, the
competent performer moves to the
proficient stage. Characteristically,
the proficient performer perceives
situations as wholes, rather than in
being more or less important to the
situation at hand.
Maxims are used to guide the
proficient performer, but a deep
understanding of the situation is required before a maxim can be used.
At the expert level, the performer no longer relies on an analy-
tical principle (rule, guideline,
maxim) to connect her/his under-
standing of the situation to an
appropriate action. The expert
nurse, with her/his enormous background of experience, has an intuitive grasp of the situation and zeros
in on the accurate region of the
problem without wasteful consideration of a large range of unfruitful
possible problem situations.
It is very frustrating to try to
capture verbal descriptions of expert performance because the expert operates from a deep under-
standing of the situation, much like
the chess master who, when asked
Maxims reflect what would appear why he made a particularly masterto the competent or novice perform- ful move, will just say, “Because it
er as unintelligible nuances of the felt right. It looked good.”
American Journal of Nursing/March 1982 405
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The problem experts have telling all they know is evident in the
following excerpt from an interview
with an expert psychiatric nurse
clinician. She has worked in psychiatry for 15 years and is highly
respected by both nurse and physician colleagues for her clinical judgment and ability.
When I say to a doctor, “The
patient is psychotic,” I don’t always know how to legitimize that
statement. But I am never wrong
because I know psychosis from the
inside out. And I feel that, and I
know it, and I trust it.
This nurse went on to describe
a specific situation in which she
knew that a patient was being mis-
diagnosed as psychotic when the
patient was extremely angry. The
physician was convinced that the
embedded in the expert’s practice
clinical situation in the same way. It
is not that proficient nurses have
becomes visible.
This is not to say that the
internalized the rules and formulas
expert never uses analytical tools. learned during the earlier stages of
Highly skilled analytical ability is skill acquisition; they are no longer
necessary for novel or new situa- using rules and formulas to guide
tions. Analytical tools are also neces- their practice. They are now using
sary when the expert gets a wrong
take or a wrong grasp of the situation and finds that events and be-
past concrete experiences much like
the researcher uses paradigms.
haviors are not occurringaccording
the expert intended to accomplish
and what the outcomes were. Also,
it is possible to get a description
to expectations. When alternative
What can be described is what
perspectives are not available to the
experienced clinician, the only way
out of the wrong grasp of the problem is analytical problem solving.
from the patient and it is possible to
systematically observe and describe
expert practice. But it is not possible
Describing Expert Practice
to recapture from the expert in
explicit, formal steps the mental
We have much to learn from
processes or all the elements that go
into his or her expert recognitional
the expert nurse clinicians, but tocapacity in making rapid patient
describe or document expert nurseassessments. So, although you canpatient was psychotic and said,
performance, a new strategy fornot recapture elemental steps in the
“We’ll do an MMPI to see who’s
identifying and describing nursing process, you can observe and deright.” This nurse responded, “I am
competencies is needed. If, as thescribe in narrative interpretive form
sure that I am right regardless of
Dreyfus Model of Skill Acquisitionthe accomplishments and characterwhat the MMPI says.” The results
posits, the expert nurse’s perfor-istics of expert nurse performance.
mance is holistic rather than fracbacked up the nurse’s assessment,
Such a narrative, interpretive
and, based on her assessment, this
tionated, procedural, and based approach to describe expert nurse
nurse began what was a very sucupon incremental steps, then the performance is illustrated in the folcessful intervention for the patient.
strategy for describing expert nurs- lowing example which describes the
By studying proficient and exing performance must be holistic as coaching function of nursing.
pert performance, it is possible well.
to
Illness, pain, disfigurement,
obtain a rich description of the Currently, the language used
death, and even birth are, by and
kinds of goals and patient outcomes
to talk about nursing practice is too
large, segregated, isolated experiences. It makes little sense for the
that are possible in excellent nursing
simple, formal, and context-free to
practice. This knowledge of goals
capture the essence and complexity
lay person to personally prepare in
and possible outcomes can be useful
of expert nursing. At best, formal
advance for the many possible illness experiences.
Nurses, in contrast, through
their education and experience, develop and observe many ways to
“A competent nurse and a proficient
understand and cope with illness, as
nurse will not approach or solve a
well as many ways of experiencing
illness, suffering pain, death, and
clinical situation in the same way.”
birth. Nurses offer avenues of un-
derstanding, increased control, acceptance, and even triumph in the
in expanding the scope of practicemodels recognize and capture areas midst of what, for the patient, is a
of nurses who are less proficient. In
of performance typical of the nov- foreign, uncharted experience.
fact, a vision of what is possible is
ice, advanced-beginner, or compe-
Experience, in addition to
formal education preparation, is reone of the characteristics that sepa-tent nurse. But since most formal
rates competent performance frommodels focus on structure or pro-quired to develop this competency
proficient and expert performance.cess, the content and relational as-since it is impossible to learn ways of
Exemplars and descriptions of ex-pects of nursing practice in even thebeing and coping with an illness
solely by concept or theorem. A
cellence from expert nurse clini-beginning levels go undescribed.
It is important to underline the deep understanding of the situation
cians can raise the sights of the
competent nurse, and perhaps facil-claim of the Dreyfus model that is required before one acquires a
itate his or her movement to the
there is a transformation, a qualita-repertoire of ways of being and copproficient stage. By assisting the ex- tive leap, from the competent toing with a particular illness experipert to describe clinical situations proficient levels of performance. A ence. Often, these ways of being
where his or her interventions made competent nurse and a proficientand ways of coping are transmitted
a difference, some of the knowledge nurse will not approach or solve anonverbally by demonstration, by
406 American Journal of Nursing/March 1982
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attitudes, and by reactions as in the
a little smoother for those who had realities than can be captured by
to travel it. With that, he hugged theory alone. Theory, however,
me, said thank you, and turned guides clinicians and enables them
young man close to her own age away nodding his head, with tears to ask the right questions.
following example. A nurse clini-
cian described an encounter with a
Theory and research are generwho was visiting his father who was in his eyes. There were tears in my
ated from the practical world, from
dying. There was a rather sudden eyes too.
deterioration in the father, and the
In translating for the son how the practices of the experts in a
family was extremely distraught. the culturally avoided had become field. Only from the assumptions
and expectations of the clinical
practice of experts are questions
. *. . experience is not the mere
passage of time or longevity . . ”
The son stopped the nurse in the
understandable and approachable
to her, the nurse widened this young
hall and asked how long his father
would live. The nurse answered that
man’s perspective and acceptance.
she really didn’t know, that it could
be minutes, hours, days, or weeks.
There was no way to tell. He then
asked if there were other patients
dying on the floor. The nurse re-
This is what is meant by the coaching function of nursing, nurses who
have come to grips with the cultur-
ally avoided or uncharted and can
open ways of being and ways of
sponded, “Yes.” Then, as she re- coping for the patient and the
counts the incident, there was a long
pause, followed by a barrage of
questions:
How could I work here? How
family.
I have collected many examples of this particular skilled prac-
generated for scientific testing and
theory building.
Recognition, reward, and retention of the experienced nurse in
positions of direct clinical practice-along with the documention
and adequate description of their
practice-are the first steps in improving the quality of patient care.
The Dreyfus Model of Skill Acquisi-
tion, applied to nursing and combined with an interpretive approach
to describing nursing practices, of-
fers guidelines for career and for
knowledge development in clinical
nursing practice.
It also indicates the importance
of career ladders within clinical
nursing practice and adds to our
can I go home and sleep at night? case the nurse did not offer the
understanding of the need for and
How could I do what I do?
patient precepts or platitudes that
acceptance of the emergence of
No one had ever been so direct might sound like, “Even in the
clinicians and clinical specialists in
tice and am impressed that in each
with such questions as these before, midst of great handicap and impos-the patient-care setting.
and their bluntness threw me off sibility, I think it is possible to make
balance. But he was sincere and
the most of it.” This would be an
was waiting for my answer, and soexample of inflexible teaching by
I told him how I had resolved theseprecept.
same questions within myself. It
Nurses, in their practice, by the
was not quite a monologue, but forway they approach a wound or the
10 plus minutes he listened intent-way they talk about recovery from a
ly as I described to him my feelsurgery, offer ways of understand-
ings. I told him my philosophy
ing and avenues of acceptance.
about life and about dying and
Through the nurse’s own ability to
about nursing.
face and cope with the problem,
I told him how gradually I hadsuch as a difficult, draining wound,
settled into the medical floor inthe patient can come to sense that
stead of using it as a stepping stone
the problem is approachable and
to a surgical floor-which was my
manageable.
first intention. I told him how it Experience, as it is understood
was difficult, and how it was emo-and used in the acquisition of expertionally draining, and how it some-tise, has a particular definition that
should be clarified. As it is described
times was difficult to sleep at
night.
I told him how there was great
satisfaction in helping a patient
through the particular passage
known as death and how I felt I
was able to help the family also
through the pain of that passage. I
told him the gratification, the
in this model, experience is not the
mere passage of time or longevity; it
is the refinement of preconceived
notions and theory by encountering
many actual practical situations that
add nuances or shades of differences to theory(6,7).
Theory offers what can be
thing that kept me here, was in
knowing that maybe somehow, I
made explicit and formalized, but
had made this particular rocky road
complex and presents many more
clinical practice is always more
References
1. Dreyfus, H. L. What Computers Can’t Do: A
Critique of Artificial Reason. New York, Harp-
er & Row. 1972. (Paperback edition, 1979)
2. Dreyfus, Stuart, and Dreyfus, Hubert. A FiveStage Model of the Mental Activities Involved
in Directed Skill Acquisition. (Supported by
the U.S. Air Force, Office of Scientific Research (AFSC) under contract F49620-C-0063
with the University of California) Berkeley,
February, 1980. (Unpublished study)
3. Benner, Patricia, and Benner, R. V. The New
Nurse’s Work Entry: A Troubled Sponsorship.
New York, Tiresias Press, 1979.
4. Benner, P., and others. From Novice to Expert:
A Community View of Preparing for and
Rewarding Excellence in Clinical Nursing
Practice. (AMICAE Project Grant # 7 D20NU
29104) San Francisco, University of San Francisco, 1981. (Unpublished study)
5. Dreyfus, Stuart. Formal Models vs. Human
Situational Understanding: Inherent Limitations on the Modeling of Business Expertise.
(Supported by the U.S. Air Force, Office of
Scientific Research (AFSC), under contract
F49620-79-C-006x with the University of Cali-
fornia) Berkeley, Feb. 1981, p. 19. (Unpub-
lished report. Copies, for $5 each to cover the
cost of duplicating and mailing, are available
from Stuart Dreyfus, Director of Operations
Research Center, Univ. of Calif., Berkeley, Calif. 94720).
6. Cadamer, H.G. Truth and Method. London,
Sheet and Ward, 1970.
7. Benner, Patricia, and Wrubel, Judith. Clinical
knowledge development: a neglected staff development and clinical function. (Submitted for
publication to Nurse Educ 1981)
American Journal of Nursing/March 1982 407
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3 Theory from practice and practice from theory Fundamentals of Nursing Models, Theories and
Practice, Second Edition. Hugh P. McKenna, Majda Pajnkihar and Fiona A. Murphy. © 2014 John Wiley &
Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd. Companion website:
www.wileyfundamentalseries.com/nursingmodels
Outline of content The relationship between theory and practice is explored in depth. The idea that
practice is based upon or guided by theory and the extent to which practice influences the development
of theory are considered. Building upon definitions of theory in the first chapter, different forms of
theory are considered. In so far as theory is linked to science, the discussion is extended into the
relationship between science and practice. Learning outcomes At the end of this chapter you should be
able to: 1. Review definitions of theory and nursing theory 2. Discuss how theories may be classified in
terms of both their sophistication and their abstraction 3. Discuss Dickoff and James’ (1968) four levels
of theory and provide an example of each 4. Discuss the differences between practice theory, mid-range
theory, grand theory and meta-theory, giving examples of each 5. Appraise the argument that nursing
cannot have theories 6. Discuss at least three possible explanations for the theory-practice gap 7.
Evaluate the contribution of science to nursing and society Introduction In Chapter 1, we proposed that
theory is a statement about a piece of knowledge, and in Chapter 2, we looked at different categories
and types of knowledge that nurses might use in their practice. In this chapter we turn our attention
back to theory, looking at the relationship between theory and practice. We will explore: • the early
developments of theory in nursing; • what levels of theory might be appropriate for nursing; • the
relationship between theory and practice, in particular the theory-practice gap; • the science-practice
gap (as theory is associated with science and the early nurse theorists wanted to develop nursing
‘science’) and consider some of the strengths and limitations of science for nursing and the wider
society. First steps – reflecting on theory In Chapter 1 we aimed to convince you of the importance of
theory for nursing. Given that purpose, the case for having theory in nursing was presented in the form
of a logical argument. Hopefully, we persuaded you and you are reading on as a consequence. In this
chapter, we move to a different level of discourse. There are still logical arguments in respect of theory,
but here, to a far greater extent, we are asking you to be more introspective and to reflect upon certain
theoretical and practical issues. In the following quotation, Thomas Merton (1969: 53), in his book My
Argument with the Gestapo, is alluding to assumptions we may make about things: Some things are too
clear to be understood, and what you think is your understanding of them is only a kind of charm, a kind
of incantation in your mind concerning that thing. This is not understanding, it is something you
remember … We always have to go back to the beginning and make over all the definitions for ourselves
again. However, when we reflect upon these things, they are not always as transparent and as
irrefutable as they first appeared. We have just taken them for granted. In Chapter 1 we defined theory
as ‘statements that link (by propositions) ideas (concepts) about the world as experienced through our
senses, thus creating knowledge’. However, within this notion are assumptions about the composite
terms: ideas, concepts, propositions, knowledge. Therefore, when we say theory is to do with concepts
and the propositions that link them, in a process of extending knowledge about the world, we are
making assumptions about a number of things. We make suppositions about what concepts and
propositions are. We make assertions about knowledge, but what we mean by knowledge and knowing
may be problematic, as we have discovered in Chapter 2. This is relevant to you personally. You do, as
Merton says, need to go back (or at least go into a reflective mode), so that you can make over (review,
refine, confirm) your understanding of issues that are vital to your understanding of theory and its
relation to your practice. However, the success of this project depends on the vital notes you also make,
whether these are actual physical written notes, or mental notes that provide you with the grounding to
proceed with the issues subsequently addressed. We claim that the relationship between theory and
practice is vitally important in nursing. But within this apparently straightforward statement there lurks
a number of potential pitfalls. Not only about what theory actually is and what we mean when we say
‘practice’, but also about the terms that lie hidden within theory and practice: knowledge, knowing,
concepts, propositions, skill, praxis, wisdom, and so on. This is why we are identifying the essentially
reflective nature of this chapter at its beginning. It is a call to reflect back to previous positions in respect
of theory, knowledge and practice, not only as presented in Chapters 1 and 2 but also what you may
have learned about theory previously. It is also a call to reflect inwards about your own assumptions and
understandings. However, it may be useful to undertake the activity in Reflective Exercise 3.1 first.
Reflective Exercise 3.1: Retrospective Before you proceed, it may be useful to briefly review what we
have covered in respect of theory and its relevance to nursing. Then, using your internet connection or
one in your university/college, go to the Wikipedia website (you can find it very easily via your search
page). Using the search box in Wikipedia, look up the terms ‘theory’ and ‘nursing theory’. (Remember
that Wikipedia is an open source internet encyclopaedia that readers can contribute to themselves, so
the quality is only as good as the contributors, whose expertise may vary widely.) Review the statements
on the nature of theory in Chapter 1 and compare how theory is defined in Chapter 1 with what is said
about theory (and nursing theory) in Wikipedia. Write out your reflections (in no more than 400 words),
and, if possible, discuss with your peers/fellow students and/or teacher. The questions begged Our
chapter title (‘Theory from practice or practice from theory?’) begs some fundamental questions: • Does
theory go beyond describing, explaining or predicting our practice? • If so, does it inform, advise, guide
or even direct or prescribe our practice? • Does practice itself provide the most appropriate source of
theory for nursing? • If theory does emerge from practice, what do we do with it after it is mined from
the practice situation? • Can we assume a reflexive and cyclical relationship between theory and
practice, wherein practice is the source of theory, and theory in turn informs practice? • If practice is in
some way faulty, what does this mean for the theory derived from it? And, in any case, might it be
argued that theory derived from practice in one set of circumstances may not apply well to practice
under different circumstances? • Apart from theory derived from nursing practice, does theory from
other sources (including non-practice sources of theory), or sources that are not theoretical at all,
inform nursing practice? We might go on with such questions, and undoubtedly enter into detailed
debate arising from them. Common to all such situations, the questions lead to yet more questions. As
we found with our discussion of the opening quotation from Thomas Merton (1969), when we attend to
something, we find progress hindered because of lack of clarity in respect of things we had taken for
granted. All of the questions in the preceding list depend upon (among other things) how we define
‘practice’ and how we define ‘theory’ (see Reflective Exercise 3.2). Reflective Exercise 3.2: Defining
‘practice’ In this and previous chapters we have started to define theory. In this chapter we are looking
at the relationship between theory and practice. As you will have several practice placements on your
course, make a note of your understandings of what ‘practice’ means. Developing nursing theory It is
important to understand how the historical and cultural contexts shaped the development of nursing
theory. As you saw in Chapter 1, much of the significant early theorising in nursing arose in the United
States in the late 1950s and early 1960s. Nurses in the US wanted to clearly identify what the differences
were, if any, between nursing and medicine and to do this they had to try to begin to define nursing.
Thus some important and influential definitions of nursing were published at that time, which included
Henderson’s landmark definition in 1966 (see Reflective Exercise 3.3). Reflective Exercise 3.3: Defining
nursing Look up Virginia Henderson’s (Henderson 1966) definition of nursing. Do you think this
definition still has relevance for nursing today? Additionally, nurses at that time wished to try and
develop nursing as a profession. The major professions, such as law and medicine, commanded a great
deal of respect, authority and autonomy with a characteristic of a profession being that it had a unique
body of knowledge. However, it was clear that nursing did not appear to have that but used knowledge
from other disciplines, in particular medicine. To achieve professional status and to clearly demarcate
nursing from medicine, nursing needed to try to develop itself as a discipline and to do so it had to
develop a knowledge base unique to nursing. However, nurses had to agree on a number of key things,
such as what might constitute the unique focus of the discipline of nursing. Should nursing develop its
own theories of nursing or should it just ‘borrow’ theories from other disciplines and apply them to
nursing? From Chapter 1 you will recall that what emerged from this period in the US was what were
referred to as ‘nursing models’, sometimes called ‘grand’ theories, and the authors of these became
very well known (see Reflective Exercise 3.4). Reflective Exercise 3.4: Examples of nursing
models/theories The works by Orem (1995), Roy (1980) and Roper et al. (2000) are examples of what
might be called nursing models or theories. If any of these are not familiar to you, do an internet search
to find out about the theory and in particular how the theorist defined nursing. Key Concepts 3.1 Just to
remind you, there is debate as to whether there is a difference between models and theories. Some
make a distinction between models and theories and some say that they are, in fact, all theories and
that there are just different types of theory. This will be discussed further in this and later chapters.
Theories – the building blocks of models and ‘grand’ theories These early nurse theorists tended to use
theories from other disciplines. So for example Orem (1995) drew on Maslow’s (1954) hierarchy of
needs (Maslow was a psychologist) in thinking about the person having self care deficits. Roy (1980)
used systems theory in thinking about the person as a system having to adapt. In doing so, she studied
the work of Harry Helson on how the retina of the eye adapts to its surroundings. They melded these
theories with their own ideas and experiences of nursing to develop their own nursing theories. As we
shall see, there are issues about using theories (we might term them imported theories) that do not
emanate from nursing practice, and indeed may have little support among practising nurses in their dayto-day work. There is always some risk that where attempts are made to adopt such imported
unmodified theory in its totality, it will be less amenable to the problems and issues of nursing practice
and consequently less accepted by practising nurses. This is understandable; such theories were initially
constructed for another purpose. Indeed, even attempts not simply to adopt the theory, but merely to
adapt it to nursing are not always successful: at the end of the day bicycles adapted for air travel have
always been found wanting! As already been stated in Chapter 1, there is the added danger that by
using borrowed theories, nurses will contribute more to the discipline it was borrowed from than to
nursing itself. The development of nursing models and theories were attempts to try and define nursing
and thus, by implication, identify the skills, attributes and knowledge nurses might need. It was also
hoped that they would act as a framework for delivering nursing care, and you may still see examples of
them being used in practice today. Crucially, for the purposes of this chapter, it was hoped that from
these early ‘nursing models’ nursing theories would develop that could be tested by nursing research to
develop nursing knowledge and nursing science (see Reflective Exercise 3.5). Reflective Exercise 3.5:
Models and theories Try typing in ‘Orem’s theory generation and testing’ into an internet search engine.
Look to see if any of the theories that emerged from Orem’s self-care model have been tested for use in
practice. Levels of theory Along with recognising the need to formally identify types of knowledge used
by nurses, there was also much debate about what kinds of theories might be useful for nurses and
nursing. However, as we will outline in Chapter 5, how theories might be named and categorised is quite
a confusing area of the literature. In this chapter, we will look at the categorisation of theory in two
main ways (Figure 3.1): Figure 3.1 Categorisations of theory. • levels of sophistication of the theory •
levels of abstraction of the theory Levels of theory – sophistication To illustrate theory in terms of levels
of sophistication, we will draw on a landmark paper, written in 1968 by two philosophers, James Dickoff
and Patricia James. As we discussed earlier, a key issue in the 1960s was whether nursing could develop
‘nursing’ knowledge and what kind of theory was best suited to and most appropriate for a practice
discipline such as nursing. The paper by Dickoff and James (they also wrote another paper in the same
year with Ernestine Wiedenbach who was a nurse) was influential because they said that as nursing was
a practice discipline, it therefore needed particular types of theory. Consequently they identified four
levels of theory for nursing: • Factor-isolating theory, which describes and names concepts. • Factorrelating theory, which relates concepts to one another and explains. • Situation-relating theory, which is
the interrelationship among concepts or propositions and can predict. • Situation-producing theory
which prescribes actions to reach certain outcomes; They also proposed two crucial arguments: 1. In
ascending order each of these levels builds on previous levels, so factor-isolating theory is a precursor of
factor-relating theory and so on (Figure 3.2). 2. A practice discipline like nursing requires situationproducing theory so that nurses could, with a degree of certainty, prescribe interventions that lead to
desired outcomes for patients. Figure 3.2 Levels of theory (Dickoff & James 1968). Thus we must
adequately describe the concepts within a situation before we can explain how these are linked by
propositions. Then, in turn, we can only suggest cause-effect or predictive relationships when we have
such explanations available. Finally, we cannot actually take the risk of advocating or prescribing actions
or interventions until we have firm grounds for claiming predictive relationships. Thus, prescriptive
theory is the most sophisticated level of theory that emerges from the development of the three
preceding levels. For a practical discipline like nursing, prescriptive theory is the best that can be had.
Nonetheless, compared with established disciplines like medicine, law and divinity, this kind of theory in
nursing is relatively new. This means that we do not have a large number of prescriptive theories.
However, we have an increasing number of descriptive and explanatory theories and, in due course,
these will be developed to become predictive and prescriptive theories (Figure 3.3). In Figure 3.3, it can
be seen that at the two lower levels, theory simply demonstrates that something is so, and why it is so
in terms of propositions that link the defining concepts. At the two higher levels, one particular way in
which concepts are linked (the cause-effect form of linkage or relationship) is the essential factor. Figure
3.3 The utility of theory in nursing. Predictive and prescriptive theory Sometimes, the difference
between predictive and prescriptive theory can be unclear. Indeed, sometimes authors seem to say
nothing more than that strong predictions will inform practice and in this context are prescriptive
theories. On such an argument, prescriptive theory is really no different from predictive theory (other
than that we are stating that only well tested or ‘strong’ predictive theory should inform our actions). In
one sense, this is exactly what prescriptive theory is. Rather than saying (as does predictive theory) the
following: if such an action is taken in these circumstances, then this will be the outcome… the
prescriptive theory is saying something like: in order that this outcome will be achieved you must do the
following… However, to be accepted as having such prescriptive power, prescriptive theory must have
gone beyond us merely establishing the cause-effect relationship. We must have considered the
evidence for the cause-effect relationship. We must have considered the ‘expected utility’ of one or
some actions as opposed to others. And we will have taken account of the context. In the example
within the ‘prescriptive theory’ box in Figure 3.3, only the decision (give the patient aspirin) is presented.
But behind this, there are a number of other things that have taken place, e.g.: • The strong evidence
that aspirin does reduces temperature is confirmed. • There is recognition that paracetamol would also
reduce temperature, but that in some circumstances it may be more toxic. • The fact that while both
aspirin and paracetamol will relieve pain equally well (as strong empirical evidence has shown, there is
no significant difference), aspirin also has anti-inflammatory properties and this person has joint
inflammation as well. • Although aspirin may be contraindicated in some cases (young children, people
with bleeding disorders), there is no evidence to exclude its use with this particular person – the theory
is taking account of context and the individual case. • The evidence clearly shows that immersion in
chilled water will also reduce temperature (but in this case would be distressing to and uncomfortable
for the person). • There is clear evidence that other methods to reduce temperature, such as tepid
sponging or using electric fans, are not effective. Behind a prescriptive theory, as indicated earlier, there
is a large body of supporting evidence (obtained through research and a systematic review of research
findings), and a strong foundation of decision-making that has taken account of context and expected
utility. Importantly, the theory is stated in prescriptive terms. In real-world situations, it is presented
within treatment protocols or care guidelines and this is the link to evidence-based practice and the
hierarchy of evidence that we discussed in Chapter 2. To be so placed, it must, by definition, be tested
theory, and very well tested indeed. Theory-testing is a matter we address later in this book. For now we
note that a cause-effect theory that is still not well tested can still be termed a predictive theory.
However, where there is a prescriptive theory, there is an assumption that one of the essential
attributes is that it has already been well tested. Therefore, such theories are not just predicting, they
also aim to operate on the world and do things in it; they are thus termed ‘situation-producing theories’
(Dickoff & James 1968; McKenna 1997; Slevin 2003b). Application to practice Clinical nurses will analyse
practice situations so that their practice is more effective. They do try to think about (or describe) the
nature of nursing situations, they further attempt to make sense of (or explain) what is happening in
these situations, and on this basis try to forecast (or predict) what would be the outcome of actions they
undertake. Based on such predictions they may even stipulate (or prescribe) nursing actions. In doing so,
clinicians are to some extent mirroring the more substantial theory construction of their nurse scientist
and nurse theorist colleagues. However, the ways in which clinical nurses theorise from moment to
moment throughout their day, making predictions and prescribing actions, particularly where there is no
other theoretical guidance available, is different from formal construction of theory. This does not mean
it is unimportant or insignificant. When we think of theory as being of the different types outlined
earlier, we see that – whether on a smaller scale during clinicians’ practice, or in more formal theoryconstruction situations – they are in fact of increasing degrees of sophistication, as indicated in Figure
3.3 (see Reflective Exercise 3.6). Reflective Exercise 3.6: Does theory have a use? We have referred to
how, in theorising, nurses are describing, explaining, predicting and perhaps even prescribing. In an
important seminal paper, the authors Dickoff and James (1968) described these different theoretical
positions (we might see them as theory types) as follows: • factor-isolating theory, which describes; •
factor-relating theory, which explains; • situation-relating theory, which predicts; • situation-producing
theory, which prescribes. Furthermore, they see these as progressively more sophisticated theoretical
positions. It is not possible to prescribe unless you can predict. It is not possible to predict unless you
can explain. Before you explain, you must first describe. Taking it from the opposite direction, unless the
basic ideas or building blocks of a theory (remember in Chapter 1 we called them concepts) are sound, it
will be difficult to explain relationships between them and proceed from this to prediction of causal
relationships and prescribing actions. Undertake a brief literature review on the idea of a situationproducing theory and the influence of Dickoff and James’s seminal work. Write a brief report of your
review. You may find it useful to share and discuss this with your peers/fellow students. Levels of
theory: abstraction (Figure 3.4) Figure 3.4 Levels of theory. The paper by Dickoff and James was very
important in suggesting what level of theory nurses might need to develop based on the assumption
that nursing is a practice discipline. These levels were expressed in the form of their sophistication, with
one building on the other. We have seen before that theories consist of concepts that are linked
together as propositions or statements, which are then linked together to form a theory. Some of these
statements might be very focused with a clear identification of the ideas within them. However, some
theory statements might be quite unclear, abstract and have a very wide focus rather than a narrow
one. The understanding of this led to different ways of classifying theories within nursing based on how
abstract the theory is. Within this way of thinking about theory there are four main categories (Figure
3.5): Figure 3.5 Levels of theory-abstraction. Meta-theory This is about theory, rather than being itself a
form of theory and is at the most abstract level (above grand theory) (McEwen & Wills 2007). Nurses
may also think about theory and its importance to nursing and nursing practice, which might be seen as
theories of or about theories. A theory of theories suggests that we take some position on the nature of
theories, their purpose and how we might make practical use of them. Such theorising about theory is
sometimes termed ‘meta-theory’, a term that usually means a critical appraisal or evaluation of theory.
Thus, we might say that the outcome of such a critique would be some understanding (as suggested
earlier, we might term this a theory) about theory. This is itself a highly complex critical activity
(McKenna 1997; McEwen & Wills 2007). Clearly, if we are to promote theory, and if it is to be used to
inform our practice, it must be evaluated. We return to this topic in some detail later in the book. In
Chapter 1 and 2 you learned that two of the best-known nursing meta-theorists were the Egyptian Afaf
Meleis (Meleis 2012) and the American Jacqueline Fawcett (Fawcett 2004). They have written some very
important texts in which they provide an overview of the development of nursing theory and also
provide detailed critical analysis and evaluation of some of the best-known models and theories. Nurses
who think critically about theory in nursing tend to be those working in academic or research positions,
rather than in clinical practice. But clinical nurses may also, on occasion, reflect upon whether theory is
relevant to their practice, and, if so, what types of theory might be best suited to that purpose and this
is done from a position of considerable experience and wisdom. Nurses can make astute judgments
about the appropriateness of a theory for informing their practice. In so doing, they are often drawing
from years of experience and from a deep understanding of the health care context. Grand theories
These are also referred to by some authors as conceptual models. They often cover issues at a level of
abstraction not easily amenable to research testing. Thus, theories about nursing (as a profession) are
not intended to be reducible to testable hypotheses. They are intended to provide world views, to help
us map out our discipline’s areas of activity, give general future direction, and so on. Such theory is too
abstract to be restated and/or tested in empirical terms. However, while the theory as a whole may be
untestable, one or more of its concepts or propositions could be tested. For example, Roper, Tierney
and Logan’s (grand) theory is very broad and abstract (Roper et al. 2000). However, two of the 12
activities of daily living are ‘maintaining a safe environment’ and ‘mobilising’. You could imagine a
situation where researchers tested the relationship between these two concepts to uncover new
knowledge of use to clinical nursing. Here the researcher is not testing the grand theory; rather they are
testing concepts and propositions from the theory. The same principle can apply to other grand theories
(see Reflective Exercise 3.7). Reflective Exercise 3.7: Researching parts of grand theories As with the
description in the preceding paragraph, take other concepts from Roper et al.’s theory and outline
relationships between them that could be researched. Also do this with another grand theory such as
those of Orem, Roy or Peplau. When we think of nursing theory, we tend to think of ‘models of nursing’
and, as you can see, these are referred to as ‘grand theories’ (Figure 3.6). Meleis (2012), as a metatheorist, saw that these early nursing grand theories may be categorised into four schools of thought:
Figure 3.6 Classification and examples of ‘grand’ theories (Meleis 2012). • Needs theorists (Orem 1959;
Abdellah 1960; Henderson 1966; Roper et al. 1983) • Interaction theorists (Peplau 1952; Orlando 1961;
Wiedenbach 1964; Travelbee 1966; King 1968; Paterson and Zderad 1976) • Outcome theorists (Levine
1966; Rogers 1970; Roy 1970) • Caring/becoming theorists (Watson 1979; Parse 1981). Such grand
theories offer a broad framework to guide nursing practice, research and education. Because they were
so broad, they did not fit well into every aspect of nursing practice and were sometimes considered too
complicated and jargonistic to be useful for practising nurses. This may have had a lot to do with their
American origin, a country that has a different health care system and a different nurse education
system from those in Europe. Crucially as well, they were considered too abstract to enable them to be
tested by research to identify and develop more usable nursing theories from them. Mid-range theories
These are theories that are still expressed in terms that are sufficiently linked to the specific setting so as
to at least allow for testable hypotheses or research goals to be stated. Such theories are broad enough
to retain a view of the discipline and its general progression, yet specific enough to identify the empirical
work that could provide evidence for practice. In the 1990s and in early years of the 21st century there
appeared to be a move away from the ‘grand theories’ to ‘mid-range’ theories (Figure 3.7). As suggested
earlier, grand theories are broad and abstract and do not easily lend themselves to application or
testing. By contrast, mid-range theories are moderately abstract and inclusive but are composed of
concepts and propositions that are measurable. At their best, mid-range theories balance the need for
precision with the need to be sufficiently abstract (Merton 1968). They have fewer concepts and
propositions within their structure, are presented in a more testable form, have a more limited scope
and have a stronger relationship with research and practice. Mid-range theory tends to focus on
concepts of interest to nurses. As well as pain, these include empathy, grief, self-esteem, hope, comfort,
dignity and quality of life. They help to close both the theory-practice and the research-practice gaps
and provide knowledge that is more readily applicable in direct care situations. As was seen from the
Roper, Logan and Tierney example in the section on ‘grand theories’, some mid-range theories might
have their basis in grand theories. For example, the mid-range theory of ‘self-care deficit’ grew out of
Orem’s (1980) grand theory of ‘self-care’. This supports Smith’s (1994) assertion that a major function of
grand theories is to act as a source for mid-range theory. However, other mid-range theories emerge
from practice. For example, Swanson’s (1991) mid-range theory of ‘caring in perinatal nursing’ was
inductively developed from studies in three perinatal settings. Similarly, Mishel (1990) developed a midrange theory of ‘uncertainty’ among patients. Meleis, in conjunction with other authors, has developed
a mid-range theory of transitions as applied to nursing. This developed from a concept analysis
(Schumacher and Meleis 1994), the development of a model (Schumacher and Meleis 1994) through to
a mid-range theory (Meleis et al. 2000). Figure 3.7 Examples of mid-range theories. Practice theory
Practice theory is sometimes called micro-theory, and refers to theory that is expressed in concrete and
researchable terms and is very specific to a knowledge issue. Practice theories are very specific in their
clinical focus, are narrower in scope than mid-range theory and more concrete in their level of
abstraction. Jacox (1974: 10) defined ‘practice theory’ as ‘a theory that says – given this nursing goal
(producing some desired change or effect in the patient’s condition), these are the actions the nurse
must take to meet the goal (produce the change)’. In terms of sophistication, practice theories relates to
Dickoff and James’s (1968) highest level of theory – situation-producing theory. There has been much
recent interest in focusing on nurses’ practice to realise that nurses, as well as using different types of
knowledge in their practice, are also theorising and using different types of theory (Reed 2006; Rolfe
2006). You will recall from Chapter 1 that nurses in their practice are constantly theorising and they
draw on their knowledge of practice to make clinical decisions as to what might be the best course of
action to help the patient. As well as ‘formal’ theories, it is important to recognise the informal theories
that nurses use every day. This recognition that practitioners constantly theorise and think about their
practice is an important component in quality improvement (1000 Lives Plus 2011). A framework for this
is the ‘plan, do, study, and act’ model based on the work of Langley et al. (1996). In order to make
improvements in practice, practitioners have to think about their own practice, recognise what might
need changing and how they might bring about such changes. An important component of this activity is
the ability to theorise. Using theories in practice: an example Let’s consider an example from practice to
illustrate these levels of theory. A nurse working on a gynaecological ward cares for women who suffer
early miscarriages (loss of the foetus in the early stages of pregnancy). On the ward, the nursing care is
framed by the work of Orem (1995) and her grand theory of self-care. Orem’s ideas have been called a
‘model’ or a grand theory, in that the ideas are quite abstract and cannot be tested by research. Orem
was one of the early nurse theorists writing in the early 1970s. She felt that individuals had, to varying
degrees, the capacity to look after themselves – to self-care. Sometimes, because of illness, they could
do not do this, in which case the nurses’ role was to compensate for the person’s self-care deficits until
they could be independent and once again self-care. The nurse working on the gynaecological ward
within this grand theory focuses on getting the woman safely through the operative procedure, until she
can be self-caring again, and then works with her to plan a safe discharge home. However, a grand
theory such as Orem’s would not be specific enough to guide the nurse in caring for women after
miscarriage. Therefore, in addition to the grand theory, the nurse might be guided by a mid-range
theory such as that of Swanson (1991). This theory is much more focused on the psychological needs of
women experiencing miscarriage in that its primary focus is on the women’s emotions. The theory
guides the nurse specifically to focus on caring for the women’s emotional needs in listening to and
attending to the woman and offering interventions such as counselling. Swanson’s mid-range theory has
a narrower focus than Orem’s grand theory and can therefore be tested by research. It might be argued
that Swanson’s theory, although it places much welcome emphasis on the need for emotional care,
makes an assumption that all women need that kind of emotional care. However that might be
inappropriate, as individual women are likely to react very differently to their miscarriage. Additionally,
the focus on emotions might neglect other aspects of care such as the physical pre- and postoperative
care required. Thus experienced gynaecological nurses may also draw on their own practice theory
developed through years of experience in caring for women after miscarriage. This might involve the
tacit knowledge referred to in Chapter 2. The nurse might recognise through experience that not all
women feel the same after miscarriage and so carefully assesses the woman as an individual to judge
the best way to approach her. So, in addition to using Orem’s grand theory and Swanson’s mid-range
theory, the nurse will also draw on practice theory similar to ‘theories in use’ (Argyris and Schön 1974)
to care for the woman. Thus the nurse might recognise the emotional needs of that particular woman
and her partner, judge what is likely to be the best intervention and also recognise the importance of
helping the woman efficiently and safely though the operative procedure. The nurse is theorising and
drawing on theories. Some of these theories would be at different levels of abstraction and
sophistication, as we have discussed earlier. However, the aim was to produce nursing knowledge and
nursing theory that informed practice. So for the scenario described, the aim would be the development
of prescriptive theory, which would identify the optimum nursing intervention for women experiencing
miscarriages. Summary – categorising theory So far in this chapter we have looked at levels of theory and
have identified two broad ways of thinking about levels of theory: sophistication and abstraction (see
Key Concepts 3.2). Key Concepts 3.2 Categorising theory In this chapter we have categorised theories: 1.
In terms of their sophistication where we drew on the work of Dickoff and James (1968) and identified
four levels: factor-isolating, factor-producing, situation-relating and situation-producing 2. In terms of
their level of abstraction, where again we identified four types: meta-theory, grand theory, mid-range
theory and practice theory) However, others speak of just two theory types – grand theory and midrange theory (Fawcett 2005a). According to Fawcett (2005a), mid-range theories are specific enough to
allow empirical indicators to be drawn from them. These empirical indicators (later renamed empirical
research methods) are, by definition, concrete and specific, which allow data to be collected and tested
to validate the mid-range theory. Fawcett does not see these indicators as theories, but they fill that
space containing what others define as practice theory or micro-theory. You may find all this a little
confusing: after all, we speak of theory as being of different levels of sophistication (descriptive,
explanatory, predictive, prescriptive) and also of different levels of abstraction (practice, mid-range
theory, grand theory, meta-theory). But Fawcett (2005a), as illustrated in Figure 3.8, perhaps presented
an easier way of thinking about theory: • Grand theory provides broad direction to the discipline. • Midrange theory provides testable hypotheses for operational practice. For another alternative, see
Reflective Exercise 3.8. Figure 3.8 Propositional theory: from conception to application. Reflective
Exercise 3.8: Nursing cannot have theories! In an interesting editorial, Edwards and Liaschenko (2003)
presented the following argument (not as their own position, but as one advanced by others): (a)
Nursing requires practical knowledge. (b) Practical knowledge is distinct from propositional knowledge.
(c) Theories are set out in propositions. (d) Therefore, there cannot be a theory of nursing. We found in
previous chapters that theory is indeed about propositional knowledge: theory was defined as concepts
linked by propositions. But is the argument outlined above convincing? Are practical and propositional
types of knowledge different, and if so, is propositional (theoretical) knowledge to be excluded from
nursing? Using literature on nursing theory, seek out three points in favour of and three against the
latter position. The relationship between theory and practice In Chapter 1, we attempted to present a
case for theory not just being important in nursing, but being indispensable. In this chapter so far, we
have reviewed what theory is and identified different levels of theory. In carrying this argument
forward, there is some value in reflecting upon the relationship between theory and practice, the idea of
a theory-practice gap, and the linked issue of the relationship between science and practice. Practice
and theory may be related in various ways. Figure 3.9 illustrates some possible configurations, and in
the remainder of this chapter, the relationship is explored further. We can note that the idea is as
follows: the theory that will be most useful and appropriate is that which emerges from the situation
being studied (as opposed to theory imported from other situations). In effect, data are not being
collected from the situation to test a previously posited theory – the usual approach in research. Instead,
by analysing the data, it is claimed that theory will emerge from it. However, in Figure 3.9, practice is
shown to be informed by theory that is practice-grounded or by theory from other sources. Importantly,
it is also illustrated that practice may be informed from other non-theory sources. It would be easy to
assume from Figure 3.9 that such other ‘non-theory’ sources play a minor role in this matter. We speak
here of knowledge derived from sources such as the arts – literature, painting, poetry – or ethics, all of
which differs from the propositional knowledge characteristic of theory. Figure 3.9 The theory–practice
relationship. The theory–practice gap The idea of praxis, discussed in Chapter 1, allows for no separation
and indeed no distinction between theory and practice. The argument was that practice is by definition
informed by some theory, that indeed praxis is a form of practice we might term ‘living theory’: good
practice is good theory in action. However, some do see practice and theory as separate and discrete
entities and some view the two concepts as not only separate but also discordant ideas. Even in those
instances where it is argued that theory and practice are in fact complementary, it is recognised that
there is a challenge to be faced in bringing theory and practice together. This separation – between
theory and practice – is a matter frequently debated in nursing and other professional contexts (Rolfe
1996; Slevin 2003b). So much so, that the term theory-practice gap has become almost shorthand for
referring to the whole debate surrounding theory and the difficulties people have experienced in
bringing theory into practice. For some, this is not a matter for concern: the two terms are not only
separate, but desirably so. This, it may be recalled, is a view sometimes expressed by those who see
nursing as practical and not involving theory. It is also a view held by those who see theory as largely
conjecture and not a valid aspect of science, arguing instead that practice must be based upon the best
scientific empirical evidence. However, for others, theory is viewed as essential. It is the basis of science,
and theory tested through research is seen to be the basis of best practice. Here, any separation of
practice from theory is seen as problematic. Explaining the theory-practice gap As noted in Chapter 1,
there are a number of explanations about why the gap occurs and why theory may not be used in
practice. We noted, for example: • a failure on the part of educators to adequately convince practising
nurses of the value of theory and/or to adequately prepare them for using such theory; • ineffective
change management infrastructures and strategies for introducing innovations, including theory; • an
agreement and resignation among clinical nurses, that they should concentrate on practical issues and
leave intellectual pursuits to others; • recognition by practitioners that theory being promoted from
above is sometimes inappropriate and ineffective – as adopted (unchanged) theory borrowed from other
sources, or as adapted (changed or refined) theory. This raises an additional and perhaps more serious
reason for the gap: given that theory as propositional knowledge and practice knowledge are entirely
different forms of knowing, there will always be a gap. It is as inappropriate to try mixing them together
as it is to try mixing oil and water. Of course, as we suggested earlier, this is not to say that the two
forms cannot and do not complement each other. Indeed, it was suggested in Chapter 2, and is now
emphasised once again: we need to know what to do, why we do it and how to do it, and one without
the other will not do. The important issue in all of this is as follows. As far as theory does to some extent
enhance practice, and as far as the practice situation is a testing field for theory, wherein it can be both
tried and refined, any gap between the two is potentially problematic. While we can accept that
practical knowledge (or know-how) is different from theoretical (or know that) forms of knowledge, we
must also accept that the latter has a part to play in guiding our rational actions. Finally, in explaining
the theory-practice gap, there may be issues in respect of how science is linked to the real or practical
world, particularly where theory is seen as a part of science. A possible gap between science and
practice will be considered now. Science-practice gaps Science and reality An interesting extension of
the theory-practice gap theme is as follows: the activity of producing propositional knowledge (i.e.
scientific knowledge) is sometimes also viewed as having no necessary link with the real world.
Therefore, insofar as theory is a part of this scientific enterprise, it, too, is held to be dissociated from
reality. Such thinking rests on the assumption that theory is essentially an element of science. The image
of science as divorced from the real world or reality conjures up the fictional images of the unworldly
scientist, the person who lives in a world of ideas rather than in reality. While such caricatures may not
exist, there is an element of truth to the suggestion that scientists may become separated from the real
world, to the extent that they cease to take an interest in anything outside the laboratory. The
unworldly researcher, the ‘mad scientist’, the absent-minded professor, and the unreal and dreamy
world of academia within its ivory towers are all well-known images. It is possible that such images
might sometimes lead some nurses to discount science, and theory, as being of little relevance to the
real world. Noumenon and phenomenon Of course, this depends on what we mean by ‘the real world’.
In a narrow or technical sense, reality, as a psychological or philosophical concept, brings into question
the actual existence and nature of an object as opposed to the appearance (to us) of the phenomenon.
As illustrated in Figure 3.10, how an object appears to us may approximate reality to some extent, but it
never actually equates to it. The thing that exists out there (the noumenon) is different from how we
experience it through our senses (the phenomenon). Figure 3.10 The thing observed. Idealism and
realism These ideas, when taken to their extreme, can be found in the orientations within philosophy
known as idealism and realism. The term idealism has been used to describe the position that reality
does not exist outside of ideas. Taken to its extreme, it is some elaborate mental construction and there
is in fact no physical world out there at all. In other words, we and our total world are thoughts and
ideas in the mind of some being (the nature of which may be God or some other cosmic being).
Remember René Descartes’ views in Chapter 2. The alternative view, entitled realism, argues that there
is indeed a real physical world out there. According to this argument, the fact that different individuals
perceive the same thing confirms that it must exist. The counter-argument of the idealists is that even
the people who are doing the perceiving are part of the ideational construction! Such rather abstract
deliberations may be of little interest to you at this stage in your studies. However, you should
nevertheless take seriously the need to be sceptical about the information presented to you. While it
may be unreasonable (or at least unprofitable) to question seriously the existence of the world we are
observing, we should nevertheless be guarded in assuming that what we are observing is reality exactly
as it is. It is something of a paradox that, on the one hand, science (and scientists as researchers and
theorists) is devalued because its proponents are not in touch with the real world, when in fact that socalled ‘real world’ is itself open to question. This situation is even more astonishing when we realise that
we need this very same science to help us view the world critically and objectively. Science (and theory)
divorced from concerns about the use of science and technology If science is seen as having nothing to
do with everyday life or what happens in the real world (i.e. it is concerned with knowledge
construction, not its practical application), we are creating yet more distance between theory and
practice. In the past, scientists took the position that they were in the business of discovering
knowledge, of establishing what was true in respect of things or phenomena observed in the world.
What people did with this knowledge, so the argument ran, had nothing to do with science. For
example, splitting the atom was a great scientific achievement; the fact that it led to the creation of
better bombs and many deaths may be considered as not the fault of scientists. In effect, scientists
recognised only a moral or ethical responsibility in respect of the authenticity of their work, not any
consequences emerging from it. That is, they accepted responsibility to adhere only to certain principles
of research ethics. In this respect, the dominant moral obligation recognised was that of absolute
truthfulness in conducting research and reporting findings. Other ethical principles recognised in science
today (e.g. as derived from the biomedical ethics of Beauchamp and Childress 2001) relate to ethical
principles such as beneficence (doing good), non-maleficence (doing no harm), autonomy (respecting
the right to choose or give informed consent) and justice (equality and fairness – other than that aspect
of justice pertaining to truthfulness). These were often largely ignored, even in respect of issues such as
seeking full informed consent from subjects being studied. Indeed, in some instances, the well-being of
subjects being researched (humans as well as animals) was sometimes ignored or compromised (see
Reflective Exercise 3.9). Reflective Exercise 3.9: Science in the clinic In the sections on ‘Idealism and
realism’ and ‘Science (and theory) divorced from concerns about the use of science and technology’, we
considered how science may not be fully attuned to the real or practical world within which we live, and
also how science may not recognise a moral obligation in respect of this world. It was even suggested
that science might blatantly further its own interest at the expense of others. We do need research to
provide the knowledge required to advance medicine and combat disease. This, so it is argued, makes it
necessary to trial treatments and drugs, on animals and eventually on people. There are risks that, in
such activities, there may be inadequate attention given to the welfare of those involved. This is
increasingly recognised within the National Health Service and research institutions, particularly where
responsibilities in respect of ‘research governance’ are addressed. Look up the terms ‘research
governance’ and ‘clinical trial’. Consider how these areas may impact upon nurses’ responsibilities in
respect of the safety and care of their patients. You may elect to make some notes, but you are only
being asked to reflect on these issues. Science (and theory) failing – or saving – the world The limited
concern of science for moral issues really changed with the advent of nuclear physics, particularly at the
end of World War II, when this extended into the development of nuclear armaments. Scientists
increasingly acknowledged that they had a responsibility to be mindful of the consequences of their
work. Indeed, some of the scientists involved in the Manhattan Project at Los Alamos in the USA never
recovered from their intense distress and guilt at the devastation wreaked when the two atomic bombs
they had invented were dropped on Hiroshima and Nagasaki. Therefore, it might be suggested that from
the end of World War II in the mid-20th century, science acquired a conscience. The emergence of an
ethics of science certainly goes back earlier than the 1950s, but from that period it reached a new level
of importance. Not only did science acknowledge its impact upon the world (and upon humanity) but it
also (to greater or lesser extent) embraced a moral obligation to attend to that possibility. Of course, it
must be recognised that there are variations not only in terms of ‘degrees’ of moral obligation but also
in terms of the nature of that obligation. To some extent, the modern scientific community has become
polarised into two camps. On one side, a largely green and populist grouping is concerned with ensuring
that science does not harm our environment and that its ‘discoveries’ are geared towards ecological
protection and the benefit of society in general. On the other side, a largely opportunist and capitalist
grouping is concerned with acquiring profit for the few (sometimes even to the extent that others are
harmed). Thus some science is seen as supporting for-profit industry and technology that increases
hothouse gases, and deliberately facilitates technology that underpins unethical practices such as the
sale of high-tar tobacco products in the developing world. Conversely, other science is seen as
supporting such beneficial technologies as the development of largely harmless wind turbine energy and
facilitating the development of safe technology, including the development of pharmaceuticals by
ethically acceptable research. One danger in the emergence of a moral conscience and the
establishment of ethical positions is that one might end up taking ‘the moral high ground’, not only
claiming but also believing that one knows best. If the belief that ‘science’ knows best in a moral sense
comes together with an equally strong belief that science is the only real source of knowledge and,
furthermore, that it is capable of uncovering knowledge to solve most, if not all, of our problems, the
claims being made are not only extreme but dangerous. This is because, allied to the belief that science
knows best – indeed, that only science really knows at all – is an almost blind faith in its capabilities and
an equally blind rejection of alternatives (as presented in religion, law or other forms of non-scientific
thought) (see Reflective Exercise 3.10). This may be viewed as a naïve and misguided position at best or
as an arrogant and deceptive position at worst. Reflective Exercise 3.10: From science to Utopia There is
a view that science can solve all the problems of humankind – that, as we advance our sciences and our
technologies, we will eradicate disease and need, construct ideal living environments, and create a
perfect and harmonious world for living. However, such faith in science may be naive. The term
scientism is used to describe this. Scientism is the view that the natural sciences are the only valid
sources of factual knowledge about the world (Williams 1983). There is an almost blind faith in what is
viewed as hard science. Science will solve all our problems, leading us into a new and better world. For
now, draw upon your own experience to date in clinical settings. Do you feel that there is too much faith
being placed in the technologies of science? Is this more characteristic of some groups than others? In
particular, compare medical and nursing staff – do they differ in their alignment to the scientific
orientation, and if so, why? Science (and theory) disappointing the world It is important to remember
that, particularly from the middle to latter part of the 20th century, doubts in respect of science
extended beyond moral concerns. Within science the movement known as positivism (discussed in
Chapter 2) had exerted an influence well beyond the bounds of the laboratory and the academy. The
fundamental ‘positivist’ position saw science as a quest for real or genuine true knowledge. This could
only be achieved by observing – i.e. through sensing and experiencing – how things were and how things
worked in the world. In effect, the only genuine knowledge was that procured through empirical
(experiential) means, by the objective identification and measurement of phenomena. The positivists’
claims for absolute truth were persuasive. They fitted well with significant scientific discoveries that did
greatly benefit humanity. Furthermore, the devaluing of other forms of knowledge in comparison to this
persuasive position was also in turn compelling. Society, having previously placed its faith in religion and
law, now saw science as the route to a new Utopia. Science would eradicate poverty and disease; it
would allow us to develop new technologies that would make life a veritable heaven upon earth.
Consider the labour-saving devices that we have in our homes or that we carry on our person.
Unfortunately, while science led to the invention of penicillin (a life-saving antibiotic) and electricity, it
also led to the invention of thalidomide (a highly toxic medicine for unborn infants) and the
aforementioned nuclear weapons. Science, it was discovered, could not lead to absolute truth or the
total harnessing of nature to our advantage, and indeed its products might sometimes harm us. It is not
that the advantages brought by science (and its fellow-traveller, technology) were being discounted.
These advantages were and are vitally important to the well-being of people and indeed all living things
and the environment in which they dwell. The impact of past inventions such as antibiotics and
electricity is at least matched by advancing modern-day technologies such as the internet (and its
application in such endeavours as distance education and telemedicine). But what is different now is the
increasing realisation that the product of science and technology may be harmful, and possibly even
destructive, on a global scale. It might be suggested on the basis of the latter arguments that the
relationship between science and practice is a complex one. Science, we have seen, does lead to
technological advances that have a direct impact upon practice. Intercontinental air travel, modern
antibiotics, high-technology food processing, laser technology and automobile travel have all had
profound practical implications for how we live today. But the relationship is complicated and not
without its negative aspects. In a sense we are deceived into the false security of a brave and bright new
world. But this is an illusion. The costs of modern super-antibiotics are the ravages of super bugs and
methicillin-resistant Staphylococcus aureus (MRSA) infection. The costs of increasingly available air
travel are massive increases in hothouse gases and global warming. And the cost of much technology
that relieves us of burdens of activity (such as physical toil) includes the consequences of sedentary
living: obesity, hypertension, cardiac disease and cancers. It is important to recognise that by the latter
half of the 20th century, a more reasoned and realistic outlook on the limits of science had emerged. As
discussed in Chapter 2, this still broadly positivistic perspective, known as post-positivism, adopted the
more balanced view that scientific evidence can only be viewed as the best available knowledge until
and if or when it is refuted. This perspective in a sense reinforced the link between theory (making
conjectures) and practice (seeking refutations through actions based on testing those theories – i.e.
research). Such outlooks are definitive of the post-positivistic orientation. Science and nursing theory
With the benefit of hindsight, it was apparent that some of the early nurse theorists writing in the
1950s, 1960s and 1970s were very much influenced by the perspective on science outlined in the
preceding sections. The early goal was to develop nursing theories that could be tested or refuted by
research. However, this goal was not fully achieved and there were concerns that grand nursing theories
were not the best way to achieve this; hence the call to focus on mid-range theories that could be
tested. Additionally, critiques of propositional knowledge by influential writers such as Donald Schön in
his book The Reflective Practitioner (Schon 1983) were also of importance. He argued that such
propositional knowledge (which he called technical-rational knowledge) has l imitations in professional
practice. In the swampy lowlands of practice (Schon 1983), practitioners reflect in and on action and use
espoused theories and theories in action depending on the situation before them. Reflection in and on
action also has limitations. What may be required is a movement from a position of reflection on what is
(or was in the past) knowable, to a more reflexive orientation to dynamic changing processes. As the
argument runs here, such is the dynamic and changing nature of the world that our past knowledge and
previous experiences are of limited value in addressing new and previously unencountered phenomena
and the problems they present. We must therefore develop reflexive approaches – wherein the nature
of what we encounter challenges us to respond appropriately. The questions begged – some answers We
have concerned ourselves in this chapter with how practice and theory are related and posed a number
of questions at the beginning of the chapter. The fundamental questions (by definition binary in nature),
which are even contained within our chapter title, are as follows: • Does our practice derive from
theory? • Does our theory derive from our practice? The questions are not simple to answer and we can
return to our opening quotation from Thomas Merton (1969). Once we start to explore the issues, we
become aware of inconsistencies and lack of clarity. This chapter has demonstrated that the simple
questions raised are complex and multifaceted, and if it has made you more sceptical and critical about
superficial statements on the relationship between theory and practice, it has achieved a lot and, in
reality, so have you. Furthermore, later in the book, and particularly in Chapter 6, we do take up this
issue again (e.g. in Chapter 6 we extend the argument by considering the relationships among research,
theory and practice). Fortunately, from this chapter we can add some comments about the relationship
between theory and practice, as follows: 1. We must recognise the close complementary relationship
between theory and practice, including the knowledge of practical doing that we term know-how. We
must know what is the best thing to do in practice situations (through knowledge derived from tested
theory), and we must know how to do it (through the development of practical know-how). 2. We
recognise different levels of theory in terms of sophistication and abstraction. 3. There are different
sources of theoretical knowledge and these can be seen as emerging from other disciplines through
being adopted or adapted to the nursing purpose; or emerging from the nursing field itself as theory
derived from practice; or indeed from all these sources (e.g. where the practice context helps us to
adapt non-nursing theory to the nursing context). 4. Knowledge used in practice must be thoroughly
tested and presented as the best information or evidence available, as in evidence-based practice.
Theory, even where it is constructed from such reliable evidence, must also be tested for its fitness for
purpose. 5. We recognise the distinction between theory and theorising, and also the case for
recognising that we all theorise (attempt to make sense of our environment), as a fundamental
characteristic of being human. 6. Given that nurses themselves theorise about their practice, we
recognise that there is no such thing as practice without theory. We therefore recognise the need to
ensure that this valuable, context-bound theory is also nurtured and, where possible, explicated and
tested. 7. Insofar as nurses do themselves theorise, and are also presented with theory that may inform
their practice, there is a need to develop within nursing practice a sceptical and critical approach to
theory, particularly where it has not or cannot be adequately tested. 8. We have demonstrated that
theory is derived from science and in turn contributes to science. To the extent that theory is indeed
sometimes recognised as part of science (the conjectural, creative part that relates to and indeed guides
the doing or research part), there is a need to view critically what has been and what can be achieved by
science and theory. 9. There is the particular need to recognise the risks that have emerged from
science, some of a global nature, and the ways in which these risks impact upon our practice. 10. There
is a need to look to the future that is unfurling, and how we might respond indicates the importance of
embracing nursing theories that were perhaps rejected previously, for it is these that are designed to
look towards our horizons and the new ways forward. Conclusion The relationship between theory and
practice has been explored in detail. The definitional statements of theory were extended into
classifying theory in terms of increasing sophistication (as in descriptive, explanatory, predictive and
prescriptive theory) and increasingly abstract properties (as in meta-theory, grand theory, mid-range
theory and practice theory). The relationship was further explored in terms of how theory may inform
practice and how, in turn, practice may inform theory and contribute to theory construction. This
discussion was carried forward into the issue of the relationship between science and practice, given
that theory is most often recognised as a part of science.
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$8Free title page
$8Free formatting
$8How Our Dissertation Writing Service Works
First, you will need to complete an order form. It's not difficult but, if anything is unclear, you may always chat with us so that we can guide you through it. On the order form, you will need to include some basic information concerning your order: subject, topic, number of pages, etc. We also encourage our clients to upload any relevant information or sources that will help.
Complete the order form
Once we have all the information and instructions that we need, we select the most suitable writer for your assignment. While everything seems to be clear, the writer, who has complete knowledge of the subject, may need clarification from you. It is at that point that you would receive a call or email from us.
Writer’s assignment
As soon as the writer has finished, it will be delivered both to the website and to your email address so that you will not miss it. If your deadline is close at hand, we will place a call to you to make sure that you receive the paper on time.
Completing the order and download