The Role of Theory in Clinical Nursing Practice

Transcription

1 16 Klinisk Sygepleje 26. årgang nr TEORETISK ARTIKEL The Role of Theory in Clinical Nursing Practice uu The role of theory in clinical nursing practice is an issue at the core of how knowledge is used in clinical practice. The role of theory in clinical nursing practice is viewed from the perspective of knowledge-use in practice, and is examined in the context of the nature of nursing practice and the structure of nursing knowledge. The role of theory in clinical nursing practice is at two levels: a general, un-specified level and a particularistic, situation-specific level. At the general, un-specified level, the theory s role is to establish orientations and commitments to nursing perspectives and the philosophies of practice to be embedded in all instances of nursing practice. On the other hand, at the particularistic, situation-specific level, the theory s role is to provide theoretical rationales to guide the ways specific nursing actions are produced in clinical situations. Nursing practice becomes knowledge-based by integrating these two levels of theory-use in clinical situations. Hesook Suzie Kim Introduction The role of theory in clinical nursing practice is an issue at the core of how knowledge is used in clinical practice. In modern times, theory as a type of knowledge has been considered critical in (a) improving human conditions and affairs in general by directing us to better ways of handling problems we encounter in our lives, and (b) in managing human practice in particular by grounding our practice in specialized knowledge. Nursing practice as a human service practice has a specific goal of improving human health, and has to be guided by a system of nursing knowledge that includes various sorts of theory. The role of theory in clinical nursing practice viewed from the perspective of knowledge-use then needs to be considered from what the nature of nursing practice is and how nursing knowledge is structured. The presentation in this paper regarding the role of theory in clinical nursing practice is based on a set of basic assumptions: Theories have different utilities in clinical nursing practice. Theories are used in clinical nursing practice in two different ways: (a) theories are used to formulate orientations, attitudes, and commitments to the fundamental features of nursing practice, which influence the way nursing is practiced in all clinical situations. (b) Theories are used selectively to address each clinical situation to understand and explain it, to arrive at nursing approaches responding to the requirements of the clinical situation, and to carry out nursing care. Therefore, the first is a general, un-specified role of theory in clinical practice, while the second is a particularistic, situation-specific role of theory in practice. In the particularistic role, some theories are used to: understand what exists and what does not exist, what are good/bad, working/not working, and desirable/problematic of what exists in clinical situations. On the other hand, some theories are used to explain what exists, while others play a role in designing and carrying out clinical actions in specific clinical situations. Nursing practice cannot be based on a single theory. Clinical nursing practice requires

2 Klinisk Sygepleje 26. årgang nr multiple theories at different levels and for different purposes. Theories by themselves, singularly or in combinations, cannot tell us exactly what to do in clinical situations. They inform practitioners to best or correct things that can be done in practice within the limit of what is known, but at the same time this has to be re-examined in the context of unique characteristics of each clinical situation. Theories are divided into different types according to their scope: Grand, meso, middle-range, and micro theories. Furthermore, theories are divided into different types according to their epistemological goals: Descriptive, explanatory, predictive, and prescriptive theories. Given these assumptions, the role of theory in clinical nursing practice will be examined in the perspectives that delineate the nature of nursing practice, the nature of nursing knowledge, and the concept of knowledge-based practice. The Nature of Nursing Practice While there is a general consensus in nursing about the nature of nursing practice, it is necessary to extract out the fundamental features of nursing practice that guide the consideration of the role of theory in practice. Nurses are in practice in order to produce the best outcomes in their clients with the general understanding that nursing practice is: a goal-directed, deliberative, actionoriented, and coordinated work for and with people for enhancing healthful living or peaceful dying, in which both patients and nurses embody the ontological realities of human features and life, and of human agency. Nursing practice is an intentionally coordinated process consisting of scientific, technological problem solving, human-tohuman engagement, and services to people with specific needs. It occurs in social situations of health-care in which nurses assume particular sorts of responsibilities. (1, 48-49). Nursing practice is goal-directed, meaning it is oriented to helping clients to deal with problems and issues pertaining to their health both in times of health and illness. This goal is socially and legally mandated, as nurses are licensed to practice in accordance with the law that specifies what the practice must entail. The goal is related to enhancing clients abilities to gain or sustain healthful living or peaceful dying. Nursing practice is deliberative in that it is designed and intended to address the goals for clients. It requires nurses to know how to mobilize their own resources, both instrumental and cultural (such as knowledge, skills, techniques, attitudes, and values), and resources in clients and the environment deliberatively and intentionally. In practice nurses need to be aware of and take into consideration the consequences of their actions in clients through their deliberations, as deliberation means making choices. Nursing practice is action oriented, as it is doing that eventually counts in practice. Practice occurs as nurses are engaged in actions such as assessing clients, observing, carrying out treatments, caring, communicating, teaching, or counseling. Such doings require doing them correctly and skillfully, doing them at the right moments, doing them in concert with other things happening at the same time, doing them with foresights, and doing them valuing clients identities, worth, wants, and humanness. Nursing practice as doing is praxis in the sense that it is originally articulated by Aristotle as doing and acting guided by a moral disposition to act truly and rightly with a commitment to human well being (2,3). Nursing practice is a coordinated work for and with clients. Nurses are responsible for coordi-

3 18 Klinisk Sygepleje 26. årgang nr nating various sectors and players in the healthcare system in order to bring about the goals for clients. Nurses coordinate with clients and their families so that clients needs, wants, and resources are brought into client-care. Nursing practice is primarily working with clients and not upon clients, as clients are not receptacles of care provided by nurses but are co-participants in the process of care. As co-participants in the process of care, clients are involved in transforming their lives and actualizing their potentials for healthful living in concert with nurses. Nursing in general also is not practiced in an isolated, separated, solo format, but is practiced in concert with others engaged together within a same time period or connected in a network of relationships. Nursing practice involves clients and nurses, both of which embody the ontological realities of human features and life. This means that nursing practice as a form of life needs to be understood to involve both clients and nurses as humans, embodying strengths and weaknesses of humanness, such as: (a) bounded physicality and consciousness, (b) unbounded imagination and creativity, (c) discursiveness, (d) social, cultural, and historical situatedness, (e) interpersonal dependence, and (f) solitary, independent existence. Humans are complex beings ontologically, encompassing various forms of paradoxes. Humans use language and other symbols to communicate with each other, and engage in thoughts and activities that are based on imagination and creativity. Each nursing practice occasion is a meeting of at least two human beings with their complexities, similarities and differences, and sharedness and uniqueness. In this sense, nursing practice is a part of life, that of both the client and the nurse. Nursing practice involves clients and nurses as human agents. Human agency is a term that refers to human autonomy, freedom, and responsibility in relation to one s own actions. Human agency requires making choices and acting based on moral and ethical responsibility, and making a fine balance between self-interest and communal interests in social life. Nursing practice viewed in terms of human agency refers to the participation of nurses and clients in the care as agents of autonomy, freedom, and responsibility. For our purpose, human agency is conceived to be both free and constrained in dialectic relations to each other for the control of human actions and in the pursuit of coordinated life. Hence, in nursing practice from the human agency perspective, it is neither the nurse nor the client who wields final choices, but both as engaged agents. Because of this feature, nurses are called upon to act as moral agents in upholding human agency of clients [4], at the same time being responsible moral agents themselves. Nursing practice encompasses an aspect of scientific, technological problem solving. Nursing within the current scientific, technological culture and economic efficacy and accountability has been entrusted with the responsibility of providing solutions for a set of human problems of health and illness. Hence, nursing is responsible for providing solutions to problems presented by clients from the nursing perspective, utilizing scientific knowledge and technological instrumentation. Outcomes of nursing practice are measured in the context of expected results of certain treatments, strategies, and interventions applied to solving clients problems. Solving clients problems in a practice situation is a complex process where the problems need to be contextualized and interpreted, and often managed or attended to rather than solved or removed. The notion of scientific problemsolving in nursing does not necessarily mean applying standardized solutions A client s problem can be approached as an individual, unique one requiring an application of general theories and techniques fashioned for such uniqueness and individuality. Nursing practice involves human-to-human engagement. Nursing practice occurs among people, nurses and clients being the major players. It is a relational practice as Gadow (5) and

4 Klinisk Sygepleje 26. årgang nr Bishop and Scudder (6) suggest, in which nurses and clients are engaged with each other as humans, interacting and sharing. Nursing practice is a service to clients with specific needs. Nursing practice is a form of human service aimed at helping clients with specific needs related to their health and illness. As a form of human service it is guided by a set of ethical and moral principles and standards that shape the normative basis for the practice. Nursing practice occurs in social situations of health-care in which nurses assume particular sorts of responsibilities. Nursing practice is assumed by nurses who are social actors with the knowledge of their specific role obligations and expectations. This makes nursing practice social practice, contextualized both within each individual social situation and within the continuing structure of practice situations. Giddens (7) suggests that social practice is founded upon knowledgeability as practical consciousness of social actors regarding the conditions and consequences of their conduct, and that such knowledge provides for the generalized capa city to respond to and influence an indeterminate range of social circumstances (7, p. 22). This makes nursing practice a form of social practice that is bound both to specific time-space and to contiguous time-space contexts. These key characteristics and elements together illustrate nursing practice in the contemporary world. Each characteristic by itself does not depict nursing practice, but all of these as a complex set of characteristics are present in nursing practice. Nursing, whether practiced in a neighborhood health clinic or in a highly critical tertiary care unit, involves an intricate weaving and putting-together of these elements for each occasion of practice and for each client so that the goal of improving clients living in the context of health and illness is attained. For such weaving to occur successfully, efficiently, and Nursing Perspective Nursing Knowledge Nursing Perspective Philosophy of Care Scientific Dimension Technical Dimension Ethical Dimension Deliberation PROCESSES Enactment Existential Dimension Aesthetic Dimension Philosophy of Theory Nursing Perspective Philosophy of Professional Work Nursing Knowledge Nursing Perspective Figur 1. A model of nursing practice.

5 20 Klinisk Sygepleje 26. årgang nr finely (or beautifully) it is necessary that such weavings be guided by a model, a stencil, or signposts. For this general definition of nursing practice, I have developed a model of nursing practice that is structured about five components (frame, knowledge, philosophy, dimension, and process) reflecting the essence of nursing practice revised from an earlier version (This is a revision of the model presented by Kim (1)). This model of nursing practice is a normative model rather than a descriptive one, specifying how and what nursing practice ought to be, rather than what it is (figure 1). The structure of frame (i.e., nursing perspective) is the foundational base that incorporates the nursing-specific way of seeing the world, and is the base that establishes the nursing frame of reference for practice. This frame is constituted by a two-dimensional perspective for nursing practice: (a) a perspective of viewing humans, and (b) a perspective of doing in nursing. The nursing perspective focuses on clients with their related clinical situations and on what nursing should do in clinical situations. The focus on client and clinical situation in the nursing perspective is the foreground perspective as it determines the way the reality of clinical situation is grasped in a nursing specific way. The focus on what is expected as nursing responses is the background perspective as it determines the direction with which nursing has to move forward in response to clinical situations. The structure of knowledge refers to nursing knowledge that informs and designs nursing practice that is knowledge-based, responsible, and goal-oriented. The content of this structure specifically for nursing is determined by all of the structures that constitute the nature of nursing practice. The structure of philosophy provides the philosophical underpinnings for how nursing practice is to be carried out, and consists of three philosophical orientations: the philosophies of care, therapy, and professional work. Nursing practice is an integrated set of human actions which are enacted both in direct contacts with clients as well as away from clients in order to address goals established for clients in the situation of nursing practice. This idea points to three modes of attending in nursing practice as: (a) attending to clients as persons, (b) attending to clients in terms of clinical problems, and (c) attending as work. Nursing practice is configured by these three modes of attending, which need to be guided by specific philosophies of practice. Goals of nursing practice are determined by its responsibilities primarily to clients and their problems. Nursing practice requires its attention to clients in two ways: clients as persons with individuality and vulnerability, and clients with clinical problems. Nursing practice involves attending to clients as persons via caring, i.e., helping, and attending to clients clinical problems by instituting nursing therapeutics and approaches. This means that nursing practice must coordinate these two aspects guided by two philosophies of practice related to its attendance to clients: the philosophy of care, focusing on clients as human persons in their totality, and the philosophy of therapy, focusing on clients problems for resolution or improvement. At the same time, because nursing practice is a form of professional work, it is also guided by the norms regarding how nurses work as professional, social agents of healthcare provision to individuals and groups in healthcare organizations. This requires then the philosophy of professional work as the third set of philosophy of nursing practice. It is critical to accept that nursing practice is NOT caring, therapy, or professional work at different times or different situations separately, but consists of actions (in a broad sense) coordinated, integrated to reflect and guided by the philosophies of care, therapy, and professional work in totality at all times and in all situations. The structure of dimension refers to the characteristics that make up the nature of nursing practice and is based on five organizing rationalities to characterize nursing practice. It is consti-

6 Klinisk Sygepleje 26. årgang nr tuted by the scientific, technical, ethical, aesthetic, and existential dimensions. The five different dimensions represent the characteristics of nursing practice as a whole, because nursing practice is viewed to be a special type of human action guided by the perspective and the philosophies, and also because it is believed that a system of human actions for goal-orientation is shaped by rationalities that determine how knowledge, value systems, and special modus operandi are applied in practice. The dimensions refer to the specific characteristic orientations of nursing practice not in order to separate out nursing practice into five types, but to show how five different sets of characteristics make up for nursing practice. Each dimension specifies the characteristics influenced by how a specific rationality is infused in practice. The specific rationalities for these five dimensions are: scientific rationality for the scientific dimension, technical rationa lity for the technical dimension, moral rationality for the ethical dimension, aesthetic rationality for the aesthetic dimension, and practical rationality for the existential dimension. Nursing prac tice involves a synthesis of all five types of rationa lity, which are oriented to produce the best possible outcomes in clients. The structure of process encompasses how nursing practice is actualized, specifying human processes that produce actual contents and modes of nursing practice. It is composed of two processes: deliberation and enactment. These two processes that depict the ways nurses actually engage in their practice are integrative, seamless, and non-linear, meaning that two processes as different processes are only analytically possible. The process of deliberation is a mental process and a forward process which always occurs with a view to the future. The end points of deliberation are mental pictures (idea formation, concept formation, and need identification) and action choices (what is to be done with the mental pictures and which actions are to be selected). On the other hand, enactment is doing and includes sensory doing, behavioral doing, communicative doing, relational doing, and technical doing in practice. Since these structures of nursing practice depict the nature of nursing practice, and since all responsible actions for professional practice must be informed and guided by knowledge, it is critical that knowledge for nursing practice be determined by these structures of nursing practice. Fundamentally at the basic level, nursing knowledge is determined by the nursing perspective that frames the way of seeing clients of nursing and what nursing must do for clients. Knowledge for nursing practice therefore needs to be determined by (a) knowledge type and (b) knowledge content. Knowledge type for nursing is considered in terms of nursing epistemology, and knowledge content for nursing is considered in terms of knowledge domains (1). Nursing Knowledge The role of theory in nursing practice needs to be considered under the general ideas regarding the role of knowledge in nursing practice. Generally speaking the role of knowledge in nursing practice is to guide nursing practice. The assumption is that nursing practice as a human service practice needs to be based on knowledge rather than just intuition, sensitivity, experience, and wisdom which are critical for practice but need to be coalesced with knowledge. Nursing knowledge for practice is circumscribed by the nursing perspective for its boundary driven by the three philosophies of nursing practice for its content the grounds for determining the characteristics of the five dimensions of practice the basic foundation upon which the processes of nursing practice must occur. This means that knowledge for nursing practice is arising from these structures of nursing prac-

7 22 Klinisk Sygepleje 26. årgang nr tice and is influencing the characteristic variations in these structures as nursing is practiced by individual nurses and in specific clinical situations. Nursing knowledge in the context of nursing practice is constituted by knowledge type and knowledge content. The type of knowledge for nursing practice is considered as nursing epistemology, and the content of knowledge for nursing practice is considered in terms of the knowledge domains for nursing. Nursing Epistemology A nursing epistemology (See Kim (1, p ) for a detailed description of the model) was proposed as a way of specifying the types of knowledge necessary for nursing practice. The knowledge types for nursing practice are delineated by five specific cognitive needs based on a set of ontological commitments necessary for nursing practice regarding human nature, human living, human agency, and nursing practice. The inferential cognitive need which is grounded in the ontology of human nature is based on the assumptions that (a) some aspects of reality for humans exist in patterned ways (i.e., regularities and systematic differences), (b) it is possible to develop theories that explain how such patterns exist, and (c) it is possible to understand, explain, or predict (not factually but theoretically) individual occurrences by drawing inferences from theories (1, p ). The referential cognitive need is based on the ontology of human living, which is entrenched in uniqueness, situatedness, meanings, and contextuality. The referential cognitive need is for deep understanding of human living through knowing about similarities, differences, commonalities, and uniqueness in human living experiences posed against various backgrounds (1, p. 53). The transformative cognitive need is grounded in the ontology of human agency which is unshakably intertwined with the socially coordinated nature of living. It is for acknowledging, understanding, and developing transformations of constraints, distortions, dominations, and misunderstandings in social life in order to attain mutuality with freedom. The normative cognitive need is grounded in the ontological commitment regarding what constitutes human practice in general and nursing practice in particular. It refers to the need to know what is expected and required in making right and good choices in nursing practice. The desiderative cognitive need is grounded in the ontology of practice as a form of self-presentation and self-expression. It refers to the need to know what is desirable in the form of nursing practice. These five types of cognitive needs for nursing practice designate five types of knowledge spheres for nursing: the generalized knowledge sphere for the inferential cognitive need, the situated hermeneutic knowledge sphere for the referential cognitive need, the critical hermeneutic knowledge sphere for the transformative cognitive need, the ethical knowledge sphere for the normative cognitive needs, and the aesthetic knowledge sphere for the desiderative cognitive need. These five spheres of nursing knowledge by different knowledge types are subject to develop different types of theories: the generalized knowledge sphere for inferential theories of description, explanation, prediction, and prescription, the situated hermeneutic knowledge sphere for theories of heuristic (understanding), the critical hermeneutic knowledge sphere for theories of interpretation, critique, transformation and change, and the ethical and aesthetic knowledge spheres for normative theories (1, p. 269). Nursing s Substantive Knowledge Domains While the model of nursing epistemology provides a way of organizing a set of cognitive needs that points to five types of knowledge necessary for nursing practice, nursing knowledge also has to be specified in terms of content. I believe that the substantive characteristics of nursing knowledge are oriented to four different domains, each of the domains having specific locational focus. The four domains specified in my model of nursing domains (See Kim (1, p ) for

8 Klinisk Sygepleje 26. årgang nr a detailed description of the framework) are the client domain, the client-nurse domain, the practice domain, and the environment domain. The knowledge in the client domain is for understanding, describing, explaining, and/or predicting phenomena in the client. The knowledge in the client-nurse domain is for understanding, describing, explaining, and/or predicting phenomena that exist or can exist when a nurse and a client (or clients, clients and families) are together as experiencing humans. On the other hand, the knowledge in the practice domain is for understanding, describing, explaining, and/ or predicting phenomena of nursing practice. The knowledge of the environment domain is for specific environmental phenomena relevant to health-care and nursing. Nursing epistemology and the nursing knowledge domains together provide a configuration of nursing knowledge specifying types of knowledge for each of the substantive domains (1, p ). Hence, there are generalized, situated hermeneutic, critical hermeneutic, ethical, and aesthetic knowledge types for phenomena of the client domain, the client-nurse domain, the practice domain, and the environment domain. This means that nurses have to seek out knowledge from all of these sectors to apply in clinical practice. Knowledge-based Practice The idea that there is a role for theory in clinical nursing practice has to be examined from a broader perspective of knowledge-based nursing practice. The concept of knowledge-based nursing practice is a much broader and more generic perspective, regarding how nursing should be practiced, than the currently espoused idea of evidence-based nursing practice (8). This shifting from evidence-based to knowledgebased nursing practice is necessary for nursing in order to move away from a specific type of knowledge, that is, evidence-based knowledge as the primary type of knowledge for nursing practice. Nursing practice cannot be based solely on the evidence-based knowledge type, but has to rely on a more general, comprehensive view of knowledge to meet its mandate. The model of knowledge-based nursing is based on four key assumptions: (a) knowledge for nursing practice refers to a body of specialized knowledge that is multidimensional, complex in its configuration, and derived from multiple sources; (b) knowledge-use in nursing practice involves two inter-linked but different foci - the first on the client s status as an experiential one involving the practice of assessment, and the second on the client s status as requiring nursing approaches and interventions involving the practice of care, therapy, and professional work; (c) the processes by which individual practitioners use or apply knowledge in practice are contextspecific, situated and individualistic in the sense that each practice instance is unique in its presentation of a client s conditions, problems, trajectory, history, and context; and (d) the practitioner is the user of knowledge who must adopt certain cognitive, strategic, and action processes (8). The five cognitive needs identified for the nursing epistemology fulfill how knowledgebased nursing practice can be produced in a comprehensive manner, and refer to five different types of knowledge necessary for informed, responsible practice. The five types of knowledge for nursing practice are to be coalesced and synthesized in situation-specific instances of nursing practice, drawing from theories developed for phenomena in four different domains. However, the knowledge used in practice is the knowledge in the private domain, and for the knowledge in the public domain to be actually used in practice, it must first be integrated, transferred, transmitted, or incorporated into the private knowledge domain by what I term as knowledge synthesis. Public knowledge is the knowledge that belongs to a discipline (or a field of study) as a shared, validated and/or accepted

9 24 Klinisk Sygepleje 26. årgang nr knowledge as opposed to private knowledge that belongs to individuals. When we talk about public knowledge of a practice discipline, there is an assumption that such knowledge is to be used/ applied in practice by practitioners of the discipline. Thus, knowledge-based practice involves a process of linking the private knowledge of practitioners and the public knowledge of the discipline (8,9). Knowledge-practice linkages in a general sense must be examined in relation to two interrelated but distinct processes knowledge synthesis and knowledge use. Knowledge synthesis deals with how knowledge in the public domain comes to be incorporated, assimilated or transferred to the private domain, and knowledge use addresses how knowledge in the private domain, that is, the knowledge acquired, stored, and cumulated by individuals comes to be used in actual practice (8). The Role of Theory in Clinical Nursing Practice Knowledge-based nursing practice in the context of these comprehensive characterizations of nursing practice and nursing knowledge is rather complex. The term, knowledge, in this presentation refers to many different forms including theories. Since theories in general refer to abstract statements regarding classes of phenomena rather than singular phenomena, it can be assumed that the large chunk of a disciplinary knowledge (such as nursing knowledge as a system) is constituted by theories. Thus, knowledge-based nursing practice, specifically in reference to theories, involves what theories are to base practice and how theories are to be used in practice. The role of theory in clinical practice is relevant in addressing what theories are to base clinical nursing practice. As presented earlier, theories play two distinct roles in clinical nursing practice: (a) a general, un-specified role to shape and undergird how nursing is practiced in general regardless of clinical situations, and (b) a particularistic, situation-specific role to respond to requirements of specific clinical situations for nursing practice. These two roles can be understood as two levels of theory-use in practice the general, un-specified role as the base level providing the basic orientations, attitudes, and commitments, and the particularistic, situation-specific role as the second level, providing specific ways of nursing practice to fit to unique requirements of specific clinical situations. Clinical nursing practice in specific clinical situations thus involves integrating these two roles of theory. These two roles are discussed by juxtaposing to the model of nursing practice presented. The discipline of nursing has been involved in developing theories since the middle of the 20th century. This means that there is a collection of so-called nursing theories which are developed to address phenomena theoretically from the nursing perspective. There are in addition theories which are developed in other disciplines that have the utility for nursing practice. Thus, theories for nursing practice in general can be distinguished as (a) nursing theories and (b) applied theories for nursing. Although these two sorts of theories for nursing practice have different utilities for application, the role of theory in clinical nursing practice is considered in this paper by encompassing both sorts of theories together. The discussions in the literature and among nursing scholars and practitioners regarding the role of theory for nursing practice are intrinsically tied to the trajectory with which theories in nursing have been developed during the past several decades. During the first part of this period, the term, nursing theory, has connoted the so-called grand theories of nursing, because during the past forty some years of nursing theory development, the most significant signpost was marked by the development of the grand theories of nursing. These theories include Roger s science of unitary humans, Roy s adaptation model, Orem s self-care model, and Neuman s systems

10 Klinisk Sygepleje 26. årgang nr model, which were developed in the 1970s. They also include Parse s human becoming theory and Watson s theory of human care, which were both developed in the 1980s in the US. Following this initial theoretical development, nursing has been engaged in developing many meso-level and middle range nursing theories, especially during the past two decades to describe, explain, and predict phenomena of interest to nursing (1). Many of these address human problems from a nursing perspective, or propose nursing approaches to deal with human health problems (See Kim (1, p ) for a list of middle-range theories in nursing). Some are general while others are narrowly circumscribed to specific contexts or situations. Some of these theories have specific nursing origins while others are reconstructions of theories developed in other disciplines such as biology, psychology, sociology, and anthropology. Among these theories there are intervention theories which are specifically developed to propose nursing therapeutics and nursing approaches to address people s health problems defined from the nursing perspective, while many theories are descriptive or explanatory rather than prescriptive. To a great degree, the role of theory in nursing practice has become institutionalized in response to this background of nursing s theory development. As the development of the grand nursing theories was mostly stimulated and energized by nursing s effort to move away from medical influence for its practice and knowledge development, these grand nursing theories played a crucial role in determining nursing perspectives. From the 1970s, especially with the recommendations made by the National League for Nursing in the US to identify a specific theoretical orientation for nursing curriculum, many educational programs and health-care institutions (hospitals and community health agencies) adopted a specific grand theory of nursing to be a guide or a framework for nursing practice. The attendant development of assessment frameworks based on these grand nursing theories also provided an added impetus to incorporate these grand theories as the frameworks for nursing practice, especially for client assessment. On the other hand, the development of middle-range theories has influenced application of specific theories in nursing care, such as the early application of the work of Jean Johnson and colleagues on sensory and cognitive pain experiences to design a pre-operative sensory preparation protocol. In addition, the institutionalization of practice guidelines both for medicine and nursing has provided an impetus to delineate specific theories embedded in practice guidelines as a way of showing how theories can be used in practice. Level Role of Theory Structural Orientation within the Model of Nursing Practice Theory Type Level I: The General, Un-specified Role Role for establishing general orientations and commitments in nursing practice The structure of frame (Nursing Perspectives) The structure of philosophy (Philosophies of Care, Therapy, and Professional work) Grand nursing theories and conceptual frameworks General nursing theories of care, therapy, and professional work Level II: The Particularistic, Situation-specific Role Role for providing rationales for specific nursing actions The structure of dimension (Scientific, Technical, Ethical, Aesthetic, and Existential) The structure of process (Deliberation and Enactment) Meso, middle range, and micro theories in client, client-nurse, practice, and environment domains; Normative theories; Theories of heuristic Figure 2. The role of theory in relation to the model of nursing practice.

11 26 Klinisk Sygepleje 26. årgang nr However, the application of theory in clinical practice remains a non-systematic, haphazard practice, with a view that all theories might play the same role in clinical practice. The delineation of two roles of theory in clinical practice is to systematize the way theory is used in clinical practice by integrating the model of nursing practice presented in this paper (Figure 2). The rationale for this proposal is in my belief that nursing theories with varying scope (grand, meso, middle-range, & micro) and of different types (generalized, heuristic, transformative, ethical, & aesthetic types) have two roles to play in clinical practice, that is, one a general, and the other particularistic. The first level corresponds to the two outer structures of nursing practice (the structures of frame and philosophy), while the second level corresponds to the two inner structures of nursing practice (the structures of dimension and process), and each level embraces specific scopes/types of theories to represent the structural characteristics for nursing practice. The General, Un-specified Role of Theory At the first level, the knowledge for the structures of frame and philosophy has to provide the basis for understanding humans and practice from a nursing perspective, and to establish the philosophical commitment necessary for nursing practice. Therefore, theoretical or conceptual frameworks (that is, the so-called grand theories) of nursing which are oriented to delineate the foundational characteristics of humans and human health problems in general ways would be most appropriate for the first level in establishing nursing perspectives. Therefore, the role played by theories for the structure of frame is to establish nursing perspectives that orient nurses to view and understand humans, human problems for nursing, and nursing practice in a discipline specific way. Grand theories or frameworks of nursing (Needs theories, Rogers science of unitary humans, Roy s adaptation model, Orem s self-care framework, Neuman s systems model, Parse s human becoming theory, and the activities of living model of Roper, Logan, & Tierney) play this role of specifying nursing perspectives. Whether or not nursing can eventually agree on a unified nursing perspective, a unified grand theory of nursing, is a question that will continue to be raised. For example, the attempt in the 1980s by NANDA to establish a unified nursing framework by coalescing many of the grand theories of nursing has failed to be embraced by the discipline. As the second component of the base layer, the knowledge for the structure of philosophy, which encompasses the philosophies of care, therapy, and professional work, specifies the normative elements that configure these three philosophies in detail for nursing practice. Theories that delineate theoretical characteristics of these three philosophies of nursing practice are the basis with which nurses establish commitments and attitudes for the philosophies of care, therapy, and professional work, so that these philosophical commitments are upheld in clinical nursing practice in general. I consider Watson s theory of human care and other caring philosophies and theories developed in nursing to play this role. We do not have theories dealing with the philosophy of therapy and the philosophy of professional work specifically from the nursing perspective. I believe there is a need to develop such theories to establish a theoretical basis for these philosophies for nursing practice. The role of theory at this level is general in the sense that theories for this role are to be used in all situations of nursing practice characterizing nurses general perspectives and philosophies in their practice. The Particularistic, Situation-Specific Role of Theory At the second level, theories are selectively applied to address problems and requirements specific in clinical nursing situations. It is possible to conceptualize clinical nursing situations at varying degrees of specificity, such as a broadly defined nursing care situation of Mr. Smith who

12 Klinisk Sygepleje 26. årgang nr is hospitalized with a stroke to a narrowly defined nursing care situation of Mrs. Jones postoperative pain. However, at this level, the role of theory is specific to the situation of nursing practice. One assumption is that the characteristics of nursing practice in such situations are determined primarily by the first level use of nursing theories providing the generalized ways of practice, and more specifically by the second level use of specific nursing theories. The role of theory at the second level is related to the structures of dimension (scientific, technical, ethical, aesthetic, and existential) and process (deliberation and enactment). The knowledge in general, as well as theory in particular for the structures of dimension and process, is the basis by which specific nursing actions are determined, exhi biting the scientific, technical, ethical, aesthetic, and existential characteristics. Theories at this level are the basis of nursing actions processed through deliberation and enactment, and re presented by the five dimensional characteristics integrated together. Specific theories and knowledge become interwoven in the processes of deliberation and enactment in practice to reveal the dimensional characteristics. The scientific dimension of nursing actions is represented by selection and application of scientific theories that provide answers to clinical questions of a specific situation. The sorts of answers sought through scientific theories are in general meant to satisfy inferential and transformative cognitive needs in practice. This dimension relies on scientific rationality governed by the principles of logic, explanatory power, and experiential base in selecting and applying scientific theories for nursing actions. There are many scientific theories that have been developed to provide answers to clinical questions, some are broadly generalized theories while others are situation-specific theories. Some are oriented to provide understandings and explanations while others are oriented to solving/addressing clinical problems. Because a given clinical situation, however narrowly defined, encompasses multiple phenomena that have to be viewed as interconnected, the role of theory at this level is to gain as comprehensive answers as possible to the clinical questions in the situation. It thus involves multiple theories to play this role. The technical dimension of nursing action is represented by the manner with which techniques in nursing actions are delivered in clinical situations. The general principles of technical rationality applied in nursing practice are optimization, coordination, contextualization, and flexibility. These principles of technical rationality are oriented to efficiency and effectiveness of technical delivery. Technical rationality based on these principles makes it possible for nursing practice to be efficiently and effectively delivered to solve clients problems and attend to their needs. The role of theory for this dimension is to provide guidelines regarding these principles (optimization, coordination, contextualization, and flexibility) so that techniques of nursing practice are delivered to unique clients in unique situations. The sorts of theory that play a role for this dimension are those necessary for designing techniques of practice, and are mostly applied theories. The ethical dimension of nursing actions is governed by moral rationality upon which choices and actions in nursing practice are made for and in behalf of the other (i.e., the client) and for client-singularity. The general principles of moral rationality applied in nursing practice are holistic understanding, truthfulness, consistency, and compassion. The role of theory for this dimension is to provide a normative base addressing nursing s service obligation to clients and client s vulnerability. The epistemological focus is the normative cognitive need in nursing practice, and the type of theories applied for this dimension is normative. The aesthetic dimension of nursing action is governed by aesthetic rationality for expression-based characteristics in practice. The general principles of aesthetic rationality applied in nursing practice are harmony, fittingness, and

13 28 Klinisk Sygepleje 26. årgang nr finesse. In order for nursing actions to reveal aesthetic rationality it is necessary to apply the knowledge of creativity and design in nursing practice. The role of theory for this dimension is thus to make nursing actions individualistic, creative, and harmonious within a given clinical situation. The epistemological focus is the desiderative cognitive need in nursing practice. The existential dimension of nursing action is governed by practical rationality for experience-based characteristics in practice. The general principles of practical rationality applied in nursing practice are contextualization, individuality, and insightfulness. In order for nursing actions to be represented by practical rationality it is necessary to apply phronesis and theories of heuristic. Theories of heuristic are developed to address the referential cognitive need and provide enriched understanding of uniqueness and variability in human affairs. The role of theory for this dimension is to provide referential bases to circumscribe on-going experiences in clinical nursing practice. The referential bases are constituted by nurses past experiences that culminate in phronesis as well as by theories of heuristic. The role of theory for these five dimensions to characterize nursing actions in clinical practice is multidimensional but oriented to application in specific clinical situations. The role of theory for these dimensions interwoven with the processes of nursing actions is to provide epistemic rationale for specific nursing actions in practice. Conclusion In this model, nursing practice is configured to be based on theories at general and particularistic levels. It means that at the general level clinical nursing practice needs to be holistically configured by general theories that determine nursing perspectives and specify the contents for the philosophies of care, therapy, and professional work. Clinical nursing practice at the fundamental level is guided by nursing perspectives and the philosophies of practice for which theories play the role of establishing orientations and commitments. At the same time, clinical nursing practice is configured by specific theories to address clinical questions of given clinical situations. Clinical nursing practice is characterized by what theories are applied to meet the rationalities for the scientific, technical, ethical, aesthetic, and existential dimensions, and how theories are applied in the processes of practice in addressing clinical questions. Nurses in clinical practice are required to synthesize various sorts of theories in order to arrive at the fullest possible answers regarding clinical situations, to design specific nursing approaches to address the requirements of specific clinical situations, and to deliver nursing actions that reveal the best possible characteristics in the scientific, technical, ethical, aesthetic, and existential dimensions. There are three contingencies that are required for this to occur well: (a) theoretical knowledge for all five cognitive needs in nursing practice be well-developed, (b) practicing nurses continue to be up-to-date in nursing knowledge development, and (c) practicing nurses be committed to intentional, goal-oriented use of knowledge in practice. PhD, RN, Professor Emerita Hesook Suzie Kim University of Rhode Island College of Nursing Kingston, RI and Project Director for Research Programs Buskerud University College Faculty of Health Science Norway

14 Klinisk Sygepleje 26. årgang nr REFERENCES 1. Kim HS. The nature of theoretical thinking in nursing. 3rd ed. New York: Springer Publishing, Aristotle. The Nicomachean ethics (trans. by D. Ross). Oxford, UK: Oxford University Press, Book VI, Chapter IV. 3. Lobkowicz N. Theory and practice: A History of a concept from Aristotle to Marx. Notre Dame, IN: University of Notre Dame Press, 1967: Liaschenko J. Ethics in the work of acting for clients. ANS Adv Nurs Sci 1995;18(2): Gadow S. Relational narrative: The postmodern turn in nursing ethics. Sch Inq Nurs Pract 1999;13(1): Bishop AH, Scudder JR, Jr. Gadow s contribution to our philosophical interpretation of nursing. Nurs. Philos 2003;4(2): Giddens A. The constitution of society: Outline of the theory of structuration. Berkeley, CA: University of California Press, Kim HS. Knowledge synthesis and use in practice Debunking evidence-based. Klinisk Sygepleje 2006;20(2): Kim HS. Putting theory into practice: Problems and prospects. J Adv Nurs 1993;18: