The term ‘nursing’ is today used to refer to the healthcare profession who focuses on the provision of care to individuals and families or even communities with the aim of assisting them to attain and maintain their optimal health or recover from any ill health incidence (Newman, Sime & Corcoran-Perry, 1991). Nursing is concerned in helping the individuals, families and communities attain and maintain the optimal quality of life beginning from their births to deaths. The nursing profession has today developed into several subset specialities, most of which work independently within multi-disciplinary team settings that are charged with the responsibility of assessing, planning, implementing and evaluating such healthcare services (Potter & Perry, 1992).
Nursing theories refer to concepts that offer a systematically organized way to comprehensively express assorted statements relating to nursing. Nursing theories provide nursing experts with an opportunity to predict, describe, explain and even control phenomena that are central to the practice of nursing. In their original design, theories were meant to establish a code for nursing practice as a readily recognized profession (Newman, Sime & Corcoran-Perry, 1991). Today, the nursing theories help nursing professionals to organize the manner in which they deliver the care necessary to their patients as professional practitioners (Newman, Sime & Corcoran-Perry, 1991).
It was Florence Nightingale who formulated the pioneer nursing theory. Her theory urged the nursing practitioners to manipulate their care environment inclusive of such elements as the fresh air, clean rooms etc, to assist their patient's body to recover from any illness and or injury (Newman, Sime & Corcoran-Perry, 1991). During the 1950-80 decades, most nursing theorists strongly promoted differing areas of focus for nursing. Three of these theories will be examined in this paper.
This paper thus seeks to describe the relationship that holds between the nursing research and nursing theory. It begins by an inspection of this relationship before differentiating between nursing grand theories and the nursing middle range theories. Further the paper focuses on three nursing theories to compare and contrast how these theories differ as regards the background of the theorist associated with the theory, how this background relates to theoretical framework he or she conceived, how each theory defines nursing, person, health and environment. The section also includes the relationship conceived by the theory to hold between these elements.
The paper also examines some research studies documented in the available literature that were directed by each of these theories. This helps to identify the nursing theory among these three that stands as the most congruent with the writer’s beliefs, precisely elaborating why the theory is selected based on examples experienced by the writer as a health care provider.
Nursing Research and Nursing Theory
Within the last two decades the role of nursing theory in nursing research has gained a monumental significance, with most scholars believing that the theories are the templates that inform and guide further research in this field (Newman, Sime & Corcoran-Perry, 1991). The redefinition of numerous traditional beliefs, myths and assumptions that underlie the practice of nursing have greatly contributed to the increased divergence accruing between the nursing theories and the nursing practice (Burns & Grove, 2001).
The nurses who are themselves theorists and or educationalists and the nurses who themselves engaged in the nursing practice have in the past always used different vocabularies to describe similar phenomena (Miller, 2006). They have for long held differing perceptions of core elements of nursing such as patients, health, environment etc, besides valuing different kinds of knowledge. Having considered this divergence between the nursing theory and the nursing practice, modern scholars feel that it should reconciled (Polit & Hungler, 1998)
The gap existing between nursing theory and nursing practice is largely as a result of the fact that most theories are developed my academicians in academic settings which are far removed from the direct nursing care that uses the theory at a patient’s bedside (Polit & Hungler, 1998). The practice of nursing is a science that blends the knowledge of nursing theories into practical aspects of care giving. Nursing research works to inform the practice of nursing and the available nursing knowledge most of which is borrowed from numerous other disciplines by the research (Burns & Grove, 2001). For instance, it is nursing research that borrowed psychology concepts into the concept of nursing thorough formulation of theories (Newman, Sime & Corcoran-Perry, 1991).
As such, nursing research is the practice of gathering relevant knowledge and coding it into theories that nurses can use in their actual practice (Burns & Grove, 2001). Nursing research is further conducted based on the theories already accumulated with the aim of enhancing their knowledge base, rectifying their errors, amending their short comings and or refuting their suppositions (Miller, 2006). According to the International Council of Nurses, nursing encompasses the autonomous and largely collaborative care of persons with diverse ages, families and communities both who are sick and those who are well with an aim to promote health, prevent illness and provide care for the ill, injured, disabled or dying people (Burns & Grove, 2001).
To achieve this mandate, nursing practice must utilize the nursing theories available to form the templates of their actual practice. The theories are then used in any nursing research to establish whether the theories are congruent with the practice of nursing in such a way that leads to accumulation of further knowledge (Polit & Hungler, 1998). The UK’s Royal College of Nursing defines nursing as the use of informed clinical judgement to provide care that enables people to recover, improve or maintain good health or even cope with their sustained health problems in such a way that achieves the best possible life irrespective of the disease or disability concerned until the event of death (Burns & Grove, 2001).
In this conception, nursing research works to establish the best practice and processes that can aide in the provision of such informed judgement on care (Wills & McEwen, 2002). The research findings eventually become conceptualised as nursing theories that the nurses use in their practice (Wills & McEwen, 2002). Nursing research here functions as the process through which nursing theories are born. Theories are the product of scientific research and they go on to become the guidelines on which later scientific research can be conducted (Polit & Hungler, 1998).
Florence Nightingale realised this mutual inter-reliance of nursing research and nursing theory early in her career. She used to support most of her theoretical propositions generated during practice through research and presented them as statistical data such as graphs (Burns & Grove, 2001). She then used the statistical data to arrive at tenable conclusions of the nursing practice (nursing theories) most of which depicted the resultant and desirous impact of her nursing care on the British soldier’s health (Burns & Grove, 2001).
Grand and Middle Range Nursing Theories
Nursing theories as in any other filed where theories are applicable; are usually derived from practitioners or scholars inductive and or deductive reasoning of the application of certain acquired knowledge (Boykin & Schoenhofer, 1990). There are at least four abstract kinds of nursing theories today namely the practice theories, the middle range theories, the grand theories and the metatheories. For the purposes of this paper the focus is on the grand and middle range theories.
The middle range theories have limited number of relevant variables (Miller, 2006). These variables are directly testable in a limited scope of the nursing practice. In this respect, a middle range theory is defined simply as a set of closely related ideas all of which are focused on a finite dimension of the nursing reality (Miller, 2006). Middle range theories are mostly composed of certain concepts and the suggested relationships holding between such concepts in a way that can be expressed in a model.
Most middle range theories have been developed and usually grow at the meeting point (intersection) of nursing research and nursing practice so as to provide guidance for the everyday practice and or scholarly research within the nursing discipline (Potter & Perry, 1992). Middle range theories help nurses make accurate and systematic decisions during the practice of nursing since they can determine the effect of one variable on the other. A good example of such variables is terminal illness and the provision of ongoing care, where if a patient is diagnosed as terminally ill, ongoing palliative care is settled upon but if not diagnosed as terminally ill short-term nursing care is decided upon (Potter & Perry, 1992).
The grand theories on the other hand look at the broader scope of nursing knowledge focusing on a distinct nursing perspective (Boykin & Schoenhofer, 1990). Most of these theories apply to the nursing practice in a general way that is infinite and untestable. A striking difference of grand theories and middle range theories is that grand theories are lacking in variables and mat simply comprise of a singular conception relevant to nursing such as the nursing process (Miller, 2006).
Contrastively, middle range theories focus on a particular application of knowledge to the nursing practice with the interrelation of several limited variables such as age of the patient and the process of diagnosis and or care (Miller, 2006). While grand theories conceive a particular nursing concept wholesomely and without limited variants, middle range theories focus on a particular practice and how it is affected by a set of limited variant factors (Potter & Perry, 1992).
Case Theories of Analysis
In this section of the paper, three theories are compared and contrasted based on what their proponents and what they postulate about the nursing practice. Three theorists are considered namely, Anne Boykin, Gail J. Mitchell and Janet Witucki Brown.
a) Background of the theorist
Dr. Anne Boykin is an academician besides being directly involved in the nursing practice. She is the Professor and Dean of Nursing at Florida Atlantic University’s Christine E. Lynn College of Nursing at Boca Raton. Most of her research has been conducted with Dr. Savina O. Schoenhofer the Professor of the Department of Graduate Nursing at Alcorn State University in Natchez, Mississippi (Boykin & Schoenhofer, 1990). In her encounters with patients and nursing in the actual practice of nursing, Boykin conceived the theory of nursing as caring, one of the most prominent nursing theory of contemporary times.
Professor Gail J. Mitchell is the main proponent of the client-centred
nursing care practices theory. The theory originated from her nursing research which primarily employed phenomenological and evaluation methodologies (Mitchell, 2004). Since she received her PhD degree in 1992 from the University of South Carolina, Gail Mitchell has become a world reknown nurse scientist operating form the Toronto Rehabilitation Institute, previously known as The Queen Elizabeth Hospital. She is also the Chief Nursing Officer of Sunnybrook and Women’s Health Sciences Centre. After developing the theory in 2003, Gail Mitchell began a teaching career at York to share what she had learnt in her 20 years in nursing practice (Mitchell, 2004).
Dr. Janet Witucki Brown is another academician and practitioner of nursing, currently the associate professor at the University of Tennessee’s College of Nursing. Here, she teaches the practice and theory of nursing to undergraduate, graduate through doctoral students. Her nursing research has incorporated both qualitative and quantitative research studies primarily involving senior’s populations in the community. She has written extensively on the area of continued nursing care for old people who require continued nursing care even from their homes.
Her most notable studies include three qualitative studies that focused on family, one on the nursing needs of older adults and another qualitative study focused on rural Appalachian women living alone and the kind of nursing care they need. Following her studies, Dr. Brown postulated the continuity community based nursing theory for which she is a convenor of a UTK College of Nursing grounded theory research panel and a Community of Geriatic Scholars (COGS) member.
b) Defining the Theories
According to Dr. Anne Boykin’s nursing as caring theory, nursing is conceived as both a profession and a discipline (Boykin & Schoenhofer, 2001). In this respect, nursing is the qualified practice of care (profession) and the conceptual field of care (discipline). According to Professor Gail J. Mitchell, nursing is the practice of aiding a patient (thought of as a client) to overcome a health challenge by providing the most appropriate care in respect to his or her condition (Mitchell, 2004). In this conception, the client (patient) seeks nursing care to solve an existing need that the nurse should aptly handle as part of his or her job. According to Dr. Janet Witucki Brown, nursing is the practice of continued support, guidance and care for a patient who needs that care to attain optimal quality of life regardless of being sick or not, until the event of death (Miller, 2006).
Dr. Anne Boykin conceives a person as a caring being by virtue of his or her humanness; one who lives their caring from one moment to another and one who is complete or whole in that moment of care (Boykin & Schoenhofer, 2001). To Boykin, personhood is expressed by living a life grounded in the caring of others. Personhood is greatly enhanced by participating in as many nurturing relationships while caring for others (Boykin & Schoenhofer, 2001).
Professor Gail J. Mitchell conceives a person as one seeking to attain and maintain the best circumstances for themselves and who frequently needs help to recover, attain or maintain such favorable circumstances (Mitchell, 2004). In this approach, persons are either clients (patients) or the providers (nurses) of solutions that can assist other in fulfilling their needs. This is a closer conception of a person to that of Dr. Janet Witucki Brown. Dr. Brown’s concept of a person is one who is reliant on the reassuring and thoughtful care of others and which is only fulfilled by the giving and receiving of care to those who cannot care for themselves. In all this theories, the concept of a person transverses between the nurse (care giver) and the patient (care recipient) (Marriner-Tomey & Alligood, 2006).
In the three theories, there is a general consensus of what good health entails. Good health is conceived as condition in which a person is in physically, spiritually and psychologically that enables the attainment of optimal happiness, satisfaction and functionality. Health is thus conceived as the wholesome condition in which a person is in for the proper functioning as a human being. Boykin states that health is a state and not a quality (Boykin & Schoenhofer, 1990). Dr. Janet Witucki Brown substantiates this by regarding health as the condition in which a person is in physically, spiritually and psychologically. Any variant from that optimal good health thus necessitates care, treatment and guidance towards recovery (Marriner-Tomey & Alligood, 2006).
Of the three theories, Dr. Janet Witucki Brown theory is the one most precise on environment, regarding is as the circumstances and conditions in which care is provided or in which the care giver delivers the care. Boykin borrows a concept pioneered by Florence Nightingale that environment can be manipulated by the care giver until it is most appropriate in assisting the patient recover, attain and maintain good health (Boykin & Schoenhofer, 1990). To Professor Gail J. Mitchell the care environment refers to the conditions and surroundings in which care is provided, each of which is tailored to be of assistance to the care giving process (Mitchell, 2004).
c) Theoretical Conception of the Relationship of these Elements
Dr. Anne Boykin’s conception of nursing as caring sees the process of nursing as the attainment of the core role of a person, where each individual is endowed with an innate ability and urge to care for others (Boykin & Schoenhofer, 2001). The basic premise of this theory is that every human is a caring person and that to be a human being is to live that innate caring nature overtly. Nursing to Boykin refers to the development of a person’s full potential in expressing caring, which is itself an ideal (Boykin & Schoenhofer, 1990).
The innate ability to care can however be used for functional and practical purposes such as in nursing where the nurse seeks to manipulate a patients environment in a way that promotes that patient’s health. The four elements of nursing, person, health and environment therefore inter-relate in the expression of an innate endowment to care for others, whether it is as an ideal (person) or for practical purposes in which environment is manipulated to instil good health (Marriner-Tomey & Alligood, 2006).
Professor Gail J. Mitchell conceives nursing as a practice that helps patients regain their health by using an interplay of several factors such as therapy, treatment and environment change (Marriner-Tomey & Alligood, 2006). To Mitchell, the practice of nursing is a volitional responsibility in which one is entrusted with the health of a patient (Mitchell, 2004). It is thus the responsibility of the nurse to choose which factors to adjust or apply in the process of providing the services a patient or client requires (Mitchell, 2004). Dr. Janet Witucki Brown also comes close to this understanding where nursing represents a holistic approach of life-long care provided to needy persons through the administration of clinical solutions including environment adjustment (Marriner-Tomey & Alligood, 2006).
d) Research Studies Based on Boykin Theory
Boykin has conducted many studies in the area of nursing as a natural endowment of caring ability. In Boykin, A. & Schoenhofer, S. (2001), the researchers seek to understand how nurses manipulate the care environment of patients out of their own volition with the sole aim of assisting patients optimize their health. In places where nurses are assigned particular patients, like in Boykin and Schoenhofer research, there are those nurses who initiate care giving strategies by themselves and thus acting as leaders in creating care giving environments (Boykin & Schoenhofer, 2001).
To Boykin, nursing is the expression of a person’s essence motivated by selfless need to give out care (Boykin & Schoenhofer, 1990). In most cases as the researchers concur, proper nursing accrues when such personal initiatives are not coerced or required as part of their mandate but are motivated by personal willingness to provide the best care (Boykin & Schoenhofer, 2001). Each nurse must therefore take personal initiative and become a leader to himself or herself when providing care as long as he or she remains within the accepted protocols of the facility in which such care is provided (Boykin & Schoenhofer, 2001).
The researchers thus agree that nursing is not a job that needs constant supervision since it is mainly based on the commitment of an individual nurse to give her best care to patients. The research questions used in the study included, when you realize that the patient needs to adjust their lifestyles, do you give the advice accordingly or refer the same opinion to your superiors? (Boykin & Schoenhofer, 2001). The nurses were also asked how they determine which patient needs extra care and what they do in such instances as well as the criteria they use when providing care for a particular patient is overly challenging based on the patient’s environment.
Theoretical Personal Beliefs
Theoretical nursing models are of great help in providing the knowledge that perpetually improves the nursing practice (Schoenhofer, 1989). Nursing theories are useful in guiding research and nursing curriculum since they identify those goals that a nursing practice should strive for. Being a licensed chiropractor with the close relationship and experience of numerous nurses and medical doctors in the clinics and also having done volunteer work in community health facilities, the writer is highly in favor of Dr. Anne Boykin’s theoretical conception of nursing as caring.
The writer favors Anne Boykin’s theory mainly because in practice especially during volunteer work, the writer has experienced moments in which giving care is a natural response that almost everyone is capable of. Anne Boykin’s theory of nursing as caring is itself a general theory or what was earlier described as a grand nursing theory. It is therefore very applicable as a general framework and guideline for the nursing practice.
Studying to be chiropractor requires extensive research. Yet even after the MD school, the writer still can relate with Boykin’s thinking process. A good example is one evening in which the writer had just finished a double shift and was extremely tired and desirous of going home. The two nurses in charge were totally overwhelmed with the patients admitted that day, most of who needed medication and check up.
It was a natural reaction that was motivated by no motive the writer can identify but he remained behind for an extended period of four hours aiding the nurse to check up on the patients and assist in giving medication. That was to be the beginning off similar incidences even in the clinics where the writer has been a chiropractor. The act of giving care is natural and can override any need for selfish motives such as reward and recognition (Schoenhofer, 1989). When a patient needs care, any nurse or medical practitioner almost always forgets his or her exhaustion and only feels tired after adequate care has been given (Schoenhofer, 1989). In agreement with Anne Boykin’s theory, the act of giving care absorbs one into an infinite world that is beyond the self and where the only objective is to express an innate ability.
Anne Boykin’s continued research and publications have had a great impact to the practice of nursing since in most cases, she postulates what each nurse and medical practitioner can identify with. The nursing theorist captures an essential trait of human beings, that of being selfless care givers unless that potential is suppressed by other acquired natures (Boykin & Schoenhofer, 1990). Another example is of a nurse the writer worked with in a small sub-urban clinic that almost every member of staff hated. She had a massive negative attitude, was always moody when talking to colleagues and in most cases kept to herself. Talking to her for a few minutes always left one angry and hurt since she always said something to push you away whether male or female. It was a general consensus in the office that she was highly unlikeable as a colleague.
Yet the so termed ‘unlikeable nurse’ was the most beloved nurse to the patients. Most return patients such as those coming for long-term care and consultation always asked for her specifically. She was always receiving a bunch of flowers from one patient or the other a rare gesture among the other four nurses. The most tenable explanation to this phenomenon is that during her care giving moments, the natural potential of caring emerged and this is what most patients saw or experienced. But once she was through with caring, such as when in the lodge with colleagues, her personality changed dramatically.
Anne Boykin conceives a person as naturally caring by virtue of being human such that each person lives distinctly each caring moment to another. While giving care, a person is whole and or complete in that moment since he or she is expressing an essential natural trait (Boykin & Schoenhofer, 2001). The essence of personhood is in giving care such as was with the so termed ‘unlikeable nurse’ who was totally different when giving care and when not giving care. Her true self was grounded in caring and the personality colleagues saw was a self imposed layer. True to Boykin’s theory, personhood is greatly enhanced when nurturing relationships through care (Boykin & Schoenhofer, 2001).