Perspectives: Who needs theory?

He who loves practice without theory is like the sailor who boards ship without a rudder and compass and never knows where he may cast (attributed to Leonardo de Vinci)

We currently have more access to knowledge and data than at any previous point in history, and yet we often struggle to make sense of it and to integrate it in a way that allows us to effectively plan and deliver reliable outcomes. This is particularly so for Nursing which has sometimes struggled to assert its value and its unique contribution to the healthcare team.

Nursing practice draws from several different disciplines and risks becoming a series of fragmented and discontinuous tasks without a ‘coherent group of general propositions used as principles of explanation’ (Chinn and Kramer, 2010: 177). Sharing a common set of propositions is a fundamental aspect of a profession, creating a sense of shared social identity (Haslam, 2004) and clear expectations not only for practitioners but also for managers, commissioners and the public. They are also the tools that allow practitioners to think critically and respond to the unexpected and sub-optimal conditions, as opposed to following guidelines and algorithms by rote, thereby delivering reliable outcomes.

Nursing is described in ancient Indian texts and in the Bible. In more recent history it was practised by women in religious orders and by men such as the Knights of St John in institutions such as hospices as well as in domestic settings by family members. However, for centuries the principles of nursing tacit knowledge were shared orally rather than written down.

The term ‘theory’ does not have a precise meaning. Grand theories present general concepts and propositions that bring order to knowledge and integrate apparently conflicting information. It is abstract and can be applied to very different circumstances but does not give detailed operational instruction. Mid-range theories are narrower in focus and seek to translate grand theory to practice. They guide data collection and research and are testable in a way that grand theories are not. Practice theory is grounded in experience and is limited to specific nursing situations and interventions. Nursing has paid attention to different levels of theory at different times and is not always clear which it is discussing.

The first detailed written account of the principles of nursing in English was by Florence Nightingale in 1859 (Nightingale 1992 [1859]), reflecting the social structure of Victorian England. While her work cannot be described as a ‘theory,’ others have reverse engineered her writings into an implicit theory, based on the manipulation of the environment for the benefit of the patient.

As nurse education became more formalised during the 20th century, the role of theory in making tacit knowledge explicit became more important. Post World War II there was extensive activity to develop the theory of nursing. Peplau (1952) and Henderson (Harmer and Henderson, 1955) developed theories focusing on the functional roles of nurses to meet patient needs (George, 2011). The natural progression from this was suggestion that nursing knowledge is based on a theory of nursing diagnosis that is different from medical diagnosis (Meleis, 2007). By the 1960s, the focus of theoretical thinking in nursing moved from problems/needs to the relationship between the nurse and the patient. Between the 1960s and the 1980s there was an explosion of discrete nursing theories, but this tailed off at the end of the 1980s and discussion about the theory of nursing has since waned.

Nwozichi et al. (2021) reviewed the literature on nursing theories and identified four themes: (1) ontological and epistemological issues, (2) issues with validation of nursing theories, (3) multiplicity of nursing theories that differ from practice paradigms of nursing and (4) integration of theory into professional practice. Thorne (2014) suggested that nurses should not merely borrow theories from other disciplines but should modify and adapt them to serve the disciplinary and practice purpose of nursing. However, this remains a challenge as nurse academics have yet to agree on the ontological basis of nursing. Nurses in practice can find themselves in the difficult position of trying to marry the highly positivist model of Medicine with some of the constructionist models of Nursing. And while some of the grand theories have been adapted into nursing models for practice, there has been a dearth of empirical testing and validation. This combined with the multiplicity of theories (and models) has led some to be sceptical about the idea of a unifying nursing theory and point to the lack of evidence of impact on practice in real life.

The rise in popularity of nursing theory coincided with the increase in nurse managers and the functional management of nursing reached its zenith in the United Kingdom between 1974 and 1982 (Walby et al., 1994). Senior nurses had line management responsibility for both the management of nurses and nursing practice. However, unlike medicine, senior nurses were full-time managers with no clinical caseload leading to the separation of the conceptualisation of work and its execution, as described by Braverman (1974). By the late 1980s, nursing theory was still struggling to prove its contribution when functional nurse leadership crashed head-on with New Public Management.

New Public Management

Hood (1991) noted that New Public Management was an international agenda for increased accountability across a range of publicly funded services and was adopted across OECD countries from the 1970s onwards. Concern about increasing costs of health care led to a move ‘from old public administration to new public management’ (Dunleavy and Hood, 1994). Ferlie et al. (1996) identified four tenants of New Public Management. First, achieving efficiency through the introduction of business methods into the public sector; second, de-centralising to achieve ‘leaner’ organisations together with the separation of commissioning and provision of services (thereby fracturing functional line management); third, opting for the central role of a single ‘organisational culture’ rather than professional cultures and fourth, striving for constant improvement rather than maintenance of services. In the United Kingdom, this vision was operationalised through the then Department of Health and Social Security’s response to the 1983 National Health Service (NHS) Management Review, known as the Griffiths report (Department of Health and Social Security, 1984).

The move to general management was a shock to nursing which was ill prepared and was initially squeezed out of the management top tier. Robinson and Strong (1987) found few nurses were appointed as general managers and Robinson (1992) suggested that 1985 was a low point for nursing influence in policy, calling it the ‘black hole theory’. Nursing was unable to articulate its contribution and the management of the practice of nursing moved from senior nurses to general managers. Traynor (1999) found that nurses working in services that adopted New Public Management in the first wave (by becoming quasi-independent ‘providers’ within the new market economy) felt that their managers had different priorities and values and these beliefs were expressed in a series of ‘us and them dualisms’. Similarly, Hart (1991) argued the requirement that nursing be defined by measurable tasks undermined some of its important but less opaque and removed many relevant contextual factors, a concern that remains to this day. New Public Management was at odds with the relational aspects of nursing theory and the long-term outcomes of health care.

Nursing response to New Public Management

Under New Public Management not only was nursing work being conceptualised away from those who executed it (as it had been with functional nurse management), it was also now being conceptualised by non-nurses. The profession’s response to this was divided. On one hand, Owens and Glennerster (1990) found that many senior nurses happily gave up their exclusive professional roles to embrace general management, a finding later echoed by Hennessy et al. (1993).

On the other hand, nurses retreated from management into clinical expertise, characterised by Salvage (1992) as ‘New Nursing’. Initiatives included Nursing Development Units (Pearson, 1988) which saw management hierarchies as getting in the way of the nurses’ personal accountability to the patient. A new way of preparing registered nurses, Project 2000, was instituted as an attempt by nurse educationalists to assert the independent science of Nursing (Kendrick, 1994), but there was little evidence of the oft-espoused autonomous practitioner in nursing outside specialist units.

Porter (1992) argued that professionalism is inappropriate for Nursing given its lack of autonomy and that ‘post new’ nursing should be a radical partnership with patients, not based on an exclusive knowledge base. It has been suggested that increasing technology in health care leads to post-modernist approaches associated with diversity, differentiation and fragmentation and thus the decentralisation of service. This was demonstrated not only by the independence of providers but also by further subdivision into Clinical Directorates.

Forty years after the introduction of New Public Management philosophy into the NHS, Nursing still struggles to articulate its principles and how to apply them to New Public Management. It has largely failed to reinvent itself as ‘new’ or ‘post new’ nursing. These years have seen the rise of ‘advanced practice’, defined by the UKCC (1994: 200) as ‘adjusting the boundaries for the development of future practice, pioneering and developing new roles responsive to changing needs and with advancing clinical practice, research and education enrich professional practice as a whole’. Advanced practice does not answer the philosophical questions about what nursing is and it has yet to enrich professional practice as a whole. In the United Kingdom, Advanced Practice is increasingly being seen as a new profession, rather than a level of Nursing, with a generic role proposed for candidates from different healthcare professions (Health Education England, 2017).

The future of nursing theory

Defining and defending Nursing as a discrete and valuable occupation requires a framework for describing and discussing. But this framework must be dynamic and responsive as circumstances and expectations change. It must be testable and tested to demonstrate its worth. Nursing must therefore address the themes that Nwozichi et al. (2021) identified.

First, Nursing needs to address its underlying philosophy. Much of the early theory building was purely academic and undertaken by nurses not currently in practice. Carper (1978) noted that philosophical concepts in any field of enquiry ultimately determine the kind of knowledge developed. Carper identified four ways of knowing: empirical, aesthetics, reflexivity and ethics. According to Chinn and Kramer (2010) the critical questions for empirical knowing are – what is this? and, how does it work? Aesthetics (or the art of nursing) involves the recognition of and reaction to the meaning of situations and the critical questions are – what does this mean and how is this significant? Reflexivity requires the practitioner to ask – do I know what I do and do I do what I know? Ethics critical questions are – is this right and is this responsible? Attempting to build a framework for understanding and guiding nursing practice needs to address all four ways of knowing so that it can close the gap between conception and delivery. It is the combination of all these types of knowing that creates praxis or expert practice.

Nursing badly needs a North Star, and it is time to revisit Nursing theory, not to replicate the work of the past but to learn from it and to address the shortcomings that led to its decline. That is why JRN has issued an Open Call for Papers – https://journals.sagepub.com/page/jrn/call-for-papers.

Biography

Elaine Maxwell RN PhD has worked as a clinical nurse, an Executive nurse and as a researcher. She is currently sitting on a Public Inquiry into care at an NHS hospital