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Table of Contents
CONCEPTS AND ISSUES
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 3-9

Exploring issues in theory development in nursing: Insights from literature


1 Lecturer, Department of Adult Health Nursing, Babcock University School of Nursing, Ilishan Remo, Ogun, Nigeria
2 Lecturer, Department of Adult Health Nursing, Federal University Oye-Ekiti, Ekiti, Nigeria
3 Nursing Officer, Department of Nursing, Babcock University Teaching Hospital, Ilishan Remo, Ogun, Nigeria

Date of Submission26-Sep-2020
Date of Decision01-Mar-2021
Date of Acceptance11-Apr-2021
Date of Web Publication07-Jul-2021

Correspondence Address:
Dr. Chinomso Ugochukwu Nwozichi
Babcock University School of Nursing, Ilishan Remo, Ogun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_100_20

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  Abstract 


Theory development in nursing profession continues to raise more debates about critical issues. The present study aimed to explore the critical and contemporary issues and concerns about theory viewed from both the discipline- and professional-related perspectives. This narrative literature review was done in 2020. English articles in the electronic databases of Medline, Scopus, PubMed, CINAHL and Google Scholar were searched using the keywords: concerns, issues, nursing theory development, nursing theory construction, nursing discipline and nursing profession, and literature was retrieved and screened for eligibility. The date limit considered in the literature search was from 2010 to 2019. In the initial search, a total of 179 studies were retrieved and assessed for eligibility; 163 studies were eliminated due to not meeting the exact criteria set, leaving only 16 studies that were finally included in the content analysis. Content analysis method was used to extract our findings. Four themes (issues) emerged and were grouped into two overarching categories of discipline-related issues/concerns and profession-related issues/concerns. The four themes were (1) philosophical issues, (2) issues with validation of nursing theories, (3) multiplicity of nursing theories and divergent practice paradigms of nursing and (4) integration of theory into professional practice. This paper offers a promising premise to reconcile various concerns arising from nurses' attempts to develop, use and test theories. Identification and discussion of these issues should inform the nursing profession to plan activities to resolve or reduce them systematically.

Keywords: Discipline-related, literature review, nursing, profession-related, theory development, validation


How to cite this article:
Nwozichi CU, Olorunfemi O, Madu AM. Exploring issues in theory development in nursing: Insights from literature. Indian J Cont Nsg Edn 2021;22:3-9

How to cite this URL:
Nwozichi CU, Olorunfemi O, Madu AM. Exploring issues in theory development in nursing: Insights from literature. Indian J Cont Nsg Edn [serial online] 2021 [cited 2021 Dec 1];22:3-9. Available from: https://www.ijcne.org/text.asp?2021/22/1/3/320829




  Introduction Top


Nursing is a professional discipline centred on the study of human health and healing through caring, and nursing practice is based on the knowledge of nursing, which consists of its philosophies, theories, concepts, principles, research findings and practice wisdom.[1] Generally, the knowledge base of any profession is expressed in the form of concepts, propositions and theories.[2] Nursing has currently reached this level of theoretical evolution. Nursing, over the years, has been keenly aware of the need to justify its existence as a distinct profession, one which stands apart and is unique from both the social sciences and the other healthcare disciplines.[3] Nursing has realised that to accomplish this goal, it must develop a body of knowledge and theories that are unique to nursing and nursing practice.[4],[5]

Cody holds the belief that 'nursing cannot survive as a discipline without a specified body of knowledge of its own, being fragmented and discontinuous, a discipline with many major stakeholders within it who have no real commitment to higher education in nursing and commitment to the philosophies, theories or methods specific to nursing' (p. 229).[6] The visibility of nursing theory in knowledge development is evident in the literature of the past 15 years globally.[7] To some nursing scholars, the development of theory was considered to be the most critical task facing the profession in the past, because, once nursing theory is adequately articulated, a body of nursing knowledge can be developed systematically through the conduct of research that is guided by this theoretical framework.[8],[9],[10]

Theory development has significantly influenced evolution of nursing into a scientific discipline and professional practice.[5] Theory by itself defines nursing's body of knowledge and direction to research and practice in nursing. Therefore, theory development has a directly proportional relationship in building the body of knowledge in nursing. Today, theories are part of the structure of the knowledge base of nursing and expressions of disciplinary roots for guiding practice and research.[11]

According to Roy, the science of nursing is at a critical time with rapid development in society, healthcare, technology and basic science representing differing priorities.[7] There are constant arguments surrounding nursing theory and what constitutes nursing knowledge. These arguments revolve around philosophical/paradigmatic, conceptual, empirical and theory–practice gap issues that were previously seen as critical in developing core disciplinary knowledge for professional practice in nursing.[7],[11] Many of these concerns have always been present since the early years of theoretical foundations of nursing.[8],[9],[10],[12] More recently, Grace et al. have described the situation as 'a profession at the crossroads' (p. 61), characterised by contradictory, divergent and confusing point of views that often lead to probing questions about the nature of nursing theory.[13] Interestingly, however, Engstrom had posited that the confusions, ambiguities and dissatisfaction with state of the art in theory development constitute a normal phenomenon in the growth of any discipline.[8] Therefore, an analysis of issues and concerns in nursing theory development and application is necessitated to engender a classical view of providing direction for nursing as a discipline and as a profession of practice.

This paper aims to explore the critical and contemporary issues and concerns about theory viewed from both the discipline-related and professional perspectives. Furthermore, it aims to accentuate the understanding of how some suggested pathways can be applied to foster the reconciliation of the identified issues and generate a recommendation for discipline-related and professional advancements in nursing, as Roy clearly stated, 'having a coherent plan for the future of nursing knowledge development is critical for the survival of the profession and thus for the health of individuals and society' (p. 88).[7]


  Methods Top


Design

This paper adopted a narrative literature review design with content analysis and discussion.

Search methods

The data for this discussion paper are from published studies. Electronic databases of Medline, Scopus, PubMed, CINAHL and Google Scholar were searched using the keywords: concerns, issues, nursing theory development, nursing theory construction, nursing discipline and nursing profession, and literature was retrieved and screened for eligibility. The researcher noted that issues and debates have often surrounded discourses about nursing theory development since the beginning of professional evolution of nursing. Therefore, the date limit considered in the literature search was from 2010 to 2019 to identify only the contemporary issues and concerns. The author defined the topic of interest and what he was looking for. Then, he broke it down into its individual concepts and decided on the words/phrases to describe his research interest. Finally, the author searched for each concept as a separate set and used different subject headings for literature search. The data analysis for this study was achieved through content analysis. The goal was to identify and organise various themes that address disciplinary- and profession-related issues with regard to theory development and construction in nursing.

Search outcomes

In the initial search, a total of 179 studies were retrieved and assessed for eligibility; 159 studies were eliminated from the initial assessment for not meeting the eligibility criteria. Further analysis resulted in the exclusion of four more studies due to not meeting the exact criteria set, leaving only 16 studies that were finally included in the content analysis [Table 1].
Table 1: List of literature reviewed

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Quality appraisal

After the initial search, a preliminary review of all titles/abstracts was conducted to determine which studies are potentially eligible, and an additional, more in-depth review of the full text was done to determine final eligibility for the review. Articles were screened based on their year of publication, focus and credibility of the publisher. Only articles that discussed contemporary issues related to theory development and construction in nursing within the time frame were included.


  Results Top


Four themes (issues) emerged and were grouped into two overarching categories of discipline-related issues/concerns and profession-related issues/concerns [Table 2].
Table 2: Discipline-related and profession-related issues in nursing theory development and construction

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Discipline-related issues

The discipline-related issues identified in the literature are philosophical issues and issues related to the empirical testing of nursing theories.

Philosophical issues

The philosophical issues identified are those related to both ontology and epistemology concerns.[3] Nursing discipline is firmly rooted in a variety of philosophical traditions, and the nature of nursing theory development and its focus on emergent problems have warranted deep philosophical thinking.[3] The question remains: what philosophy guides theory development and construction in nursing? Contemporary scholars view nursing as a discipline whose theoretical backings are grounded in various nursing paradigms influenced by philosophical viewpoints of empiricism and historicism.[3],[14],[15] Within empiricism is positivism that subscribes to the aspects of knowledge that are generated particularly from deliberate experimental manipulations and scientific laws,[3],[14] while historicism offers a perspective that knowledge is constructed in context as it is not only influenced by the past but also the present circumstances.[15] In addition, the use of mechanism in nursing theories conflicts with the holistic philosophy adhered to by nurse practitioners.[3],[16] These divergent philosophical positions have contributed to some confusion,[14] and there seems to be little philosophical coherence in theory development and its use in nursing,[7],[13] and as such, the unique focus of the nursing discipline has continued to be debated with no universal consensus yet reached.[15],[16] There is also a concern about the overemphasis of empirics compared to philosophical and theoretical dimensions in improving professional practice in higher educational programmes of nursing.[13]

Issues with validation/evaluation of nursing theories

Another primary issue/concern about theory development is the lack of empirical testing/validation.[3] While there is evidence that nursing theories are being used to guide practice,[16] there is a pressing need for enhanced evidence of use in practice.[11] Colley emphasised that it is hazardous to develop a nursing theory without the empirical validation of proposed relationships.[17] In addition, if nursing theories have not been validated in reality, the proposed relationships of the theories may not withstand the test of clinical practice.[11],[18] While it is true that one method of validating theory consists of using it in clinical practice,[7] if nurses are aware that the theory has not been validated by research, they may become frustrated when they find that the theory is difficult to use.[11],[17] In addition, knowledge derived through research can demonstrate the adequacy or weakness of a theory and form the basis for enhancement endeavours.[16],[18]

Profession-related issues

The multiplicity of nursing theories and divergent practice paradigms of nursing

Explication of knowledge relevant to caring in the human health experience is affected by the paradigmatic perspective. Ever since the time nursing theory started evolving, a sense of disagreement and omission has typified the discourse involving multiple theories and the unifying focus of nursing.[13],[14] This has contributed to increased confusion among nurse practitioners.[11] Roy addressed the issue of whether having one encompassing theory was better than having a choice of many theories.[7] It was pointed out that the pluralism of nursing theories was needed for practice.[7],[16],[17],[19] However, the debate about one theory or many theories has left practicing nurses out of the conversation and side-lined the role they could have played in developing a nursing theory that could advance practice.[4],[18]

Another concern is what constitutes the focus of nursing.[14] Over the years, some concepts have been identified as central to the study of nursing, such as the frequently cited paradigm of person, environment, nursing and health.[4] While narrowing these concepts to the focus of nursing, a need to identify a concept that reflects the explicit connectedness and social relevance of nursing's field of study emerged.[13],[20] The concept of caring has since occupied a prominent position as the essence of nursing.[15] Contemporary nursing is facing pluralism of nursing paradigm.[16],[19],[21] Hence, no universal consensus has been reached about the adoption of a unified nursing model and the unique focus of nursing.[7] Two nurses are likely to subscribe to the same standard and yet endorse opposing viewpoints.

Integration of theory into professional practice: Addressing the theory–practice gap

Despite theory and practice being viewed as inseparable concepts, a theory–practice gap still exists in nursing.[17],[19] The integration of nursing theories into professional practice is another critical issue identified in this review. Roy identified the fundamental concern of contemporary nursing as that which relates to how nurses can use theoretical knowledge to advance practice.[7] According to her, 'the development of theory-based knowledge presents members of a practice discipline with obligations to evaluate the effectiveness of those theories for meeting practice purpose' (p. 85).[7] There is currently a massive gap between theoretical knowledge and clinical nursing practice that needs to be bridged. The disparity between the language used to define practice and the language used in theory accounts for this gap[11] and needs to be unravelled.[17] Nurse scholars have also emphasised on nursing meta-theories and frameworks to be taught and used in research and practice.[21]

In addition, the use of technical terminologies can be cumbersome to practicing nurses, not only because of the need to be familiar with the terminology but also because the terms are defined in imprecise and sometimes contradictory ways.[17] In fact, Theodoridis posited that some areas of nursing theory and nursing research are not relevant to nursing practitioners and need to be addressed.[19] As a practice discipline, it is logical that nursing theory is inextricably linked to practice. In fact, Saleh advocates that theory should begin and end in clinical practice.[5] While theory originates from and is used in practice,[5] many nurse researchers and theorists are detached from clinical practice.[19] Since nursing practice entails collaboration with other members of the health-care team, it should be clear how nursing theories will foster interdisciplinary practice including the responsible use of technology to advance knowing and caring[4],[22] and in nursing education.[5],[23] Classroom teachers as well as clinical instructors play a vital role in bridging the theory–practice gap.[23]


  Discussion Top


It is clear that discourses about the place of theory in the discipline and profession of nursing will continue to raise more debates about critical issues. The issues identified in this study represent the evolving nature of nursing as a discipline and a profession of practice. Philosophically, various ontological and epistemological tenets determine the goals and boundaries of nursing and its organisation of knowledge founded on paradigmatic ways of articulating expertise and discipline-specific views.[24] Some nurse philosophers have argued for non-positivist philosophical approach to nursing theory development.[14],[20] Although multiple perspectives are appropriate for knowledge development and have contributed to the advancement of nursing to its present state, Thomas cautioned that a multitude of paradigms within one discipline is the mark of an immature science.[25] This remark means a lot to nursing, given its current reliance on and utilisation of diverse philosophical viewpoints. As rightly pointed out by Cody and Mitchell, the need for nurses to articulate a coherent philosophical foundation for their practice has never been greater.[26]

The importance of validating nursing theories empirically cannot be over-emphasised. Unfortunately, Fawcet posited that existing nursing theories are challenging to validate because they are too unspecific and broad.[27] It is therefore imperative that nurses should develop some theories that are clear and specific enough to allow deduction of testable hypothesis. During empirical validation, the discovery of limitations and inconsistencies of a theory is what stimulates theorists to re-evaluate the theory, leading to possible modification of existing theory or development of new ones, as Kritek opined, 'theory construction is, by nature, a self-perpetuating process. Each developmental step reveals both new deficiencies and new alternatives' (p. 33).[28]

Concerning the multiplicity of nursing theories and divergent focus/paradigm of nursing, Johnson (1968, 1990)[29],[30] in the earlier periods of theory development had persuasively argued that we would always have multiple theories and use knowledge from other disciplines that are useful to understand people in health and illness and that nurses would test and extend theories in the basic science. Johnson's position was the existence of parallel development of knowledge unique to nursing practice.[29],[30] Currently, there is broad recognition that nurses use knowledge from other disciplines and transform this knowledge to answer questions in nursing.[7] Examples of such instances as presented by Henly et al.[31] and Parse[14] include the omics, patient-reported outcomes, symptom science, biological and behavioural sciences, big data, quantitative science, translation science and health economics (p. 405). In this connection, Thorne in 2014 suggested that nurses should not merely borrow theories from other disciplines but modify and adapt them to serve the disciplinary and practice purpose of nursing.[32] The suggestion is to revise/expand the definitions of the nursing meta-paradigms (health, person, environment and nursing) based on the current concepts such as precision science, big data and e-science.[4]

Although agreement exists that nursing theory should inform practice, the theory–practice gap remains.[7] Risjord in 2010 called this a 'relevance gap' (p. 20) arising from different philosophical orientations to theory development.[33] Risjord in 2010 also described the situation as 'the demise of practice theory' (p. 31).[33] He, therefore, advocated that theory development should start from practice and use multiple approaches to nursing inquiry to support the central role of nursing practice. In this issue, Roy in 2018 has questioned the type of knowledge required for effective practice and the theories necessary to address the social mandate of nursing.[7] Her question highlights nursing's current challenges in integrating person-centred care and precision health-care approaches. To bridge the gap, Risjord in 2010 suggested that the nursing discipline needs to adopt a standpoint epistemology conjoined with a post-positivist conception of scientific theory.[33] In this sense, a legitimate brand of nursing science may emerge and the theory–practice gaps may be overcome.

Limitations

Citations for this review were derived from electronic databases and limited to original studies published in English. Although the literature search was systematic, it is possible that valuable sources may have gone undetected.


  Conclusion Top


This paper has identified and described two discipline-related and two profession-related issues with theory development and construction in nursing. Perhaps, it is time that the profession redirects its efforts and attempts to identify the specific difficulties encountered by nurses when they endeavour to develop the use and test theories. Once these issues that hamper the proper theoretical orientation of nursing are clarified, then the profession can systematically plan activities to resolve or reduce them.

Acknowledgements

The author would like to appreciate the administration of Babcock University, Ilishan, Nigeria, for providing full sponsorship to the first author for a PhD in nursing program that produced this article. Further, the authors express their appreciation to Dr. Rozzano C. Locsin for his invaluable contributions and mentorship

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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