Practice Theories in Nursing and a Science of Nursing Practice ...

Scholarly Inquiry for Nursing Practice: An International Journal, VoL 8, No. 2,1994

Practice Theories in Nursing and a Science of Nursing Practice Hesook Suzie Kim, Ph.D., R.N. University of Rhode Island, College of Nursing The claim that knowledge about clients, client problems, and nursing therapeutics is enough to make nursing practice scientific is refuted on the basis that practice theories in nursing must encompass not only theories addressing these aspects but also those dealing with practice issues pertaining to the nurse-agent in action. A comprehensive framework specifying two dimensions of focus for practice theories is proposed to examine different types of practice theories in nursing and it is further used to frame a science of nursing practice as a subset of nursing science at large. Knowledge development for a science of nursing practice is then examined within four possible paradigms founded on different ontological and epistemological views.

Nursing science has been somewhat preoccupied during the past two decades with developing knowledge about clients' problems and how to solve them, that is, generating knowledge about nursing diagnoses and nursing strategies, almost to the extent of ignoring scientific questions related to the nurse as the agent of nursing work. One analysis of the research reports for the period 1985— 1988 in two nursing research journals (Nursing Research and Research in Nursing and Health) revealed that in 11% of the articles (24 of a total of 225 the focus was on explaining phenomena that pertain to nurses in practice, whereas 80% of them (179 of 225) dealt with phenomena in the client as the focus of explanation (Kim, 1993a). The major focus of nursing's scientific work was on the client domain, and only a little attention was devoted to the other three domains (the client-nurse, the practice, and the environment) specified by Kim (1987). Such emphasis is understandable and natural because the dominant position defining the nature of nursing science aligns with what Stevenson and Woods (1986) state: "Nursing science is a domain of knowledge concerned with the adaptation of individuals and groups to actual or potential health problems, the environments that influence health in humans, and the therapeutic interventions that promote health and affect the consequences of illness" (p. 6). © 1994 Springer Publishing Company

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This position focuses efforts in nursing science on the expansion of knowledge about clients' health problems and nursing therapeutics, neglecting other types of practice theories that must be developed additionally to make the knowledge-base for nursing practice comprehensive. When practice theories in nursing are conceptualized to include all theories that are applicable in designing practitioners' actions in their relationships with clients and in the provision of a specific service (i.e., nursing) to them, then they encompass more than the theories of client problems and their solutions. Hence, practice theories defined in this way encompass all knowledge that is applicable to the conduct of nursing practitioners. The knowledge for the practice domain, therefore is considered within a broader framework of practice theories presented in the following sections. A science of nursing practice for the practice domain of nursing thus is delineated also as a part of this comprehensive framework. A FRAMEWORK FOR PRACTICE THEORIES IN NURSING Practice theories are those used in the actual delivery of nursing care to clients, and a scenario that depicts a nursing practice situation may reveal what this way of thinking leads to initially. Mr. Jones, a 67-year-old patient, admitted with a medical diagnosis of cancer of the larynx, had a laryngectomy performed. This is his fourth postoperative day. He is expected to receive radiation therapy beginning shortly. He has a trach tub in place that needs to be suctioned, and his incision is healing, but he is weak and is having difficulty learning to perform the special speech technique.

A nurse in practice formulates the nursing needs of Mr. Jones, selects strategies to be applied to meet those needs, decides on what may be needed to carry out the selected strategies, and carries out the actions specified for the strategies. In carrying them out, the nurse performs certain psychomotor procedures, communicates with the patient, and may modify the actions on the spot. Theories (i.e., practice theories) that are needed (or used) by this nurse in this situation and/or those that undergird the explanations about the situation include the following: • Theories providing explanations about the patient's problems, such as theories of healing, airway patency, fatigue, and speech, and those providing ideas about therapeutics for these problems, such as theories of suctioning, wound care, rest, and learning. • Theories providing the nurse with ideas about how to approach this patient, such as theories of caring, empowerment, and communication. • Theories providing explanations and ideas about how the nurse makes or should make decisions about what the nursing actions would be with this patient, such as theories of clinical inferencing and clinical decision making • Theories providing explanations about what happens in the actual delivery of nursing actions by the nurse.

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Practice theories in nursing therefore can be viewed as encompassing these four distinct sets of theories for human actions of service. A framework that organizes these four sets of practice theories specifies two dimensions for classification: the dimension of target and the dimension of nurse-agent (Figure 1). The dimension of target is differentiated into "problem" versus "person" according to the focus of attention associated with the practice actions. The dimension of nurse-agent is differentiated into the phase of deliberation and the phase of enactment according to the phase in which practice actions are involved. Hence the dimension of target is oriented to the client, whereas the dimension of nurse-agent is oriented to the practicing nurse.

The Dimension of Target The first dimension, the target dimension, is concerned with practice theories that specify the nature of the target, both manifest and latent, for practice. Distinctions of two types within this dimension are made according to the philosophical orientations of practice. The targets of nursing practice are both clients presenting problems to be solved and clients themselves as human beings. This means that nursing practice is oriented to bringing about the occurrence of a desired state, that is, to having a specific teleological aspect. At the same time, nursing practice is also oriented to working with and attending to clients as human beings situated in the context of nursing service. Therefore, nursing practice coordinates two separate philosophies of practice: philosophy of therapy and philosophy of care. For this dimension, then, nursing

Figure 1. Dimensions for Practice Theories

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practice encompasses two sets of human actions that are based on these two philosophies, and each philosophy requires specific types of practice theories. The Philosophy of Therapy Focus. The philosophy of therapy aligns practice with teleologic/strategic actions oriented to solving or attending to a specific client's problem(s) for which the targets of practice are health problems. Schneider (1990) calls the same type of emphasis in clinical psychology "a philosophy of repair." Theories for what Habermas calls nonsocial and social strategic actions founded on the technical cognitive interest may belong to this type of practice theory. Nursing science in the past two decades has been very active in developing this type of practice theory, that is, developing specific prescriptive theories for nursing clients' problems. Jacox (1974), in defining practice theory as that concerned with the production of a desired change or effect in a patient's condition, confines the nature of practice theories to prescription. In alignment with this orientation, Woods (1992) states that "the scope of nursing science includes an understanding of human health and illness and therapies to promote health, prevent illness and disease, enhance recovery and support dignified death" (p. 1). She, however, expands the notion of prescriptive theories for nursing practice by including not only the prescriptions for nursing treatments but also the theoretical relationships between the prescription and what Dickoff and James (1968) called "the survey lists" that include patiency, agency, and context. Hence, Woods (1992) states: Since the goal of prescriptive theory is to provide goal-directed (teleological) scientific base for practice, primary concern focuses on whether the theory can produce the desired change in the human condition. However, only knowing whether this is so is not enough. Knowing the conditions under which the theory can produce the desired change is essential to guide practice.(p. 14)

This approach suggests a rethinking of the nature of practice theories so that the focus of the philosophy of therapy will be context-oriented. Theoretical and scientific development for this type of practice theory adds to knowledge within Kim's domain of client, as it is oriented toward understanding, explaining, and prescribing for clients' problems (Kim, 1987). The Philosophy of Care Focus. The philosophy of care, on the other hand leads to practitioners' actions in relation to clients as human beings situated in the service settings of nursing. The targets of practice with this orientation are human beings in an interactive context of nursing. Nursing practice with this focus is the human-to-human service with a view of clients not as clinical events but as experiencing, situated persons. Clients and practitioners, as human beings, are engaged in interactive and intertwined human activities in which practice is a part of continuous human engagement. Practice theories with this focus, then, must deal with how nursing actions performed in relation to clients influence the clients and the clients' experiences. Hence, practice theories of this sort are "approach" theories; that is, they must deal with the


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interactive nature of phenomena that occur between nurses and clients. In the field of psychology, the movement for humanistic psychology has emphasized the need to focus on the philosophy of care. Similarly in nursing, practice theories with this orientation include those developed: (1) within the humanistic nursing framework, such as the science of human care by Watson (1985); (2) within the interactive framework, such as Travelbee's (1966) interpersonal theory of nursing and Orlando's (1961,1972) theory of nursing-disciplined process that emphasizes the nurturing process of nursing; and (3) within the existential or phenomenological orientation, such as the theory of man-living-health by Parse (1981). From this orientation, concepts such as empathy, empowerment, caring, control, and influence emerge as the basis for specific nursing practice processes. Kim's (1993b) work in developing a theory of nursing practice expanding on Habermas's (1984) theory of communicative action is based on this orientation. This theory is a generalized action theory of nursing practice in which nurses' "talk" is conceptualized as a mode of approach in practice and as means to coordinate actions so that the nursing therapeutics applied will be effective. Four types of arguments as methods of developing consensus and understanding between the interacting agents as specified by Habermas are applied as the prescriptive ways of eliciting agreement between the patient and the nurse. Theories and knowledge development for this type of practice theory are the knowledge in Kim's (1993b) client-nurse domain. The practice theories with the philosophy of therapy orientation consider clients as objects of treatment and practitioners as instruments of treatment; hence, objectactor relationship is the key aspect of this focus. The practice theories with the philosophy of care orientation consider clients and practitioners as interacting agents; hence, an interactive and intersubjective relationship is key to this focus.

The Dimension of Nurse-Agent: The Practice Domain This dimension refers to the domain specified by Kim (1987) as the practice domain. The practice domain is conceptualized to include phenomena particular to the nurse who is engaged in delivering nursing care (Kim, 1987). When nursing practice is viewed with the focus on the nurse as an agent of action, it presents a rather complex picture. Figure 2 shows the complex nature of practice viewed from this dimension. The practitioner is involved in a set of actions—mental activities and enactment activities in a specific situation of practice encompassing aspects that pertain to: (a) the client, (b) the setting, and (c) the practitionerself. The practice contains at least two phases: the deliberations for action and the actual enactments. Deliberation for action by the practitioner involves developing a program of action, manifestly or latently, as analytically separated from the enactment of action. It focuses on the assessment the practitioner makes of the situation and the selection of a choice for action. At any given time, such a decision may be either a simple choice for a problem at hand considered singly or a complex set of strategies arrived at by taking on

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coexisting multiple problems. For this phase, five structural units, (i.e., nursing goals, aspects of client, nursing means, situation of nurse-agent, and aspects of nurse-agent) are analytically connected for deliberations at hand. On the other hand, the phase of enactment involves acting in a specific practice situation involving the practitioner, the client as an object as well as a responding human-other, and the situation in which the action takes place. The Phase of Deliberations. Deliberations for practice refers to phenomen in the nurse as she or he is dealing with the practice situation in preparation fo actual delivery of nursing actions. The nurse is involved in deliberating in terms of the kinds of information gathered from the client and the situation, the ways the nurse processes the information, the modes with which he or she draws upon both public and personal knowledge, and the processes in which certain conceptual and action decisions are made by the nurse. Deliberations involve five sets of structures: (a) the structure related to aspects of the client that becomes the focal framework upon which the goals of practice are established; (b) the structure pertaining to the goals of practice specifying the nature of goals in their scope and specificity; (c) the structure pertaining to the means of practice delineating the types of available strategic repertoire; (d) the structure related to aspects of nurse-agent, such as commitment, motivation, and capacity; and (e) the structure pertaining to the situation of nurse-agent in which the deliberation takes place. Deliberations ready the nurse to become engaged in actions. Deliberations by nurse-agent for action are thus differentiated into two interlinked sets, as shown in Figure 3: (a) deliberations

Figure 2. Conceptualization of Nursing Practice

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regarding relationships between goals and means in the context of the client and the nurse and (b) deliberations regarding the nature of action-situation (the future, where enactment takes place) in the context of the actor-situation (the present, wbere deliberation is taking place). The first refers to the deliberations regarding choices for actions, and the second is concerned with deliberations linking the future in association with the chosen present actions. A practitioner develops a program of action or an intention to act in a certain way with a view toward fidelity of strategy, competent delivery, timeliness and relevancy of program, and efficacy of outcomes. Although this phase appears to involve a process that is designed and intentional, the actual practice theories that explain or prescribe this process may not necessarily refer to it as prescriptive. The phase itself is Ideological in the sense that the goal is to formulate a program of action or an intention. Decision-making theories, problem-solving theories, and the theory of pattern-recognition are examples of practice theories for this phase. Tanner and her associates' (Tanner, Padrick, Putzier, & Westfall, 1987; Westfall, Tanner, Putzier, & Padrick, 1986) work on clinical reasoning in nursing practice is an example of practice theory on this dimension, with a focus on the deliberation phase. O'Neill's (1992) work on

Aspects of Client Goals

Aspects of Nurse

Means

Delib( ration Action-Situation (future)

Actor-Situation (present) Deliberation

NURSING ACTION DECISIONS (programming)

Figure 3. Nature of Deliberations in Practice

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the use of cognitive processes by nurses tests the theory of representativeness heuristic by Tversky and Kahneman (1982) and can be considered an attempt to develop a practice theory with this focus. The Phase of Enactment. The phenomenon of enactment is conceptualized in terms of "human action" being done (performed, carried out, realized) by an agent. If one considered the reality of enactment as having a direct and complete causal relation with intention, and intentions as the sufficient explanation of enactment, it would not be necessary to consider this phase separately from the phase of deliberation. For the disciplines of human-service practice, however, this position is not tenable. This is primarily because enactment in practice invariably involves another human being (the client) who is also an enacting agent. Secondarily, it is because connections between deliberation and enactment are not uniform and can take various forms according to differences in the nature of the practice setting, for example, (1) a critical/ emergency situation, where on-the-spot, immediate action responses are needed (2) a delayed situation in which action is separated from deliberation by a prolonged time lag, or (3) a third-person situation, where deliberation is done by a nurse who delegates enactment to others. We are nonetheless faced with facts of enactment that are time-bound, possibly have multiple meanings, and are fleeting, as depicted by Bourdieu (1990) in describing game playing as an example of practice. A player who is involved and caught up in the game adjusts not to what he sees but to what he fore-sees, sees in advance in the directly perceived present... He decides in terms of objective probabilities, that is, in response to an overall, instantaneous assessment of the whole set of his opponents and the whole set of his team-mates, seen not as they are but in their impending positions. And he does so "on the spot," "in the twinkling of an eye," "in the heat of the moment," that is, in conditions which exclude distance, perspective, detachment and reflection. He is launched into the impending future, present in the imminent moment, and abdicating the possibility of suspending at every moment the ecstasies that project him into the probable, he identifies himself with the imminent future of the world, postulating the continuity of time. (pp. 81-82)

Here we feel the urgency of human enactment that is bound to the present and future at the same time but that also becomes the thing of a past instantaneously. We also feel the immediacy of human action in the human agent's engagement, as well as the finality once it is enacted. Action science proposed by Argyris, Putnam, and Smith (1985) and by Sch6n (1983) provides an explanation of the reasons for practitioners' failure to achieve intended consequences in their practice in terms of single-loop learning. From this approach, Argyris and his colleagues have proposed a normative form of action science theory that focuses on influencing the quality of practice. In contrast, Benner (1984), basing her analysis on the Dreyfus model of skill acquisition, suggests that clinical nurses' performances in practice reflect the nurses' movement: (a) in analytic reliance on referents from abstract to


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paradigm cases, (b) in perception of the situation to increasingly holistic evaluations, and (c) in the degree of engagement from detached observers to involved performers. Hence, Benner's work attempts to address both the deliberation and enactment phases of nursing practice. This framework points up the nature of different sets of practice theories that are necessary and viable for explaining and designing nursing practice. Figure 4 specifies this typology. Theories of intervention with a focus on clients' problems that are based on the philosophy of therapy are prescriptive in nature, whereas theories of approach with a focus on clients as persons, based on the philosophy of care may be descriptive/explanatory or prescriptive. Theories of deliberation and theories of enactment for the dimension of nurse-agent, however, may be both descriptive/explanatory or prescriptive in nature. Nursing science with a focus on practice theories, therefore, encompasses four types of theories: they together provide a full explanation of nursing practice and are the foundation for the effectiveness of practice. A science of nursing practice for the practice domain is thus proposed as a specific subset of nursing science separated from the science of nursing client and nursing intervention. The subject matters for this science are those entrenched within the dimension of nurse-agent specified for the framework of practice theories. A science of nursing practice with a view to developing practice theories in the dimension of nurse-agent (the practice domain) is based on the assumption that specific subsets of knowledge in this area will guide the scientific practice of nursing. Theories in fields such as cognitive science, psychology, sociology, operations research, management, and education may address the phenomena in the practice domain, but appropriate practice theories for the phases of deliberation and enactment need to be developed for

Figure 4. Nature of Practice Theories

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the science of nursing practice that takes into consideration the specific situational and professional nature of nursing. PHILOSOPHICAL POSITIONS PROVIDING FOUNDATIONS FOR THE DIMENSION OF THE NURSE-AGENT Four philosophical positions leading to different paradigmatic orientations regarding the conceptualizations of human nature (encompassing both the deliberation and enactment aspects of human action), provide the foundation upon which a science of nursing practice may develop. At one extreme is the physicalistic, mechanistic conceptualization of action, which considers human action as a series of enactments or happenings that can be explained by scientific laws and causal theories. At the other extreme is the conceptualizatio of human action by analytic philosophers who emphasize the role of freedom of choice in existence and action as actualizing the individualized, creative, and moral nature of human life. Such analytic philosophers consider human action as purely justifiable by the circumstances in which it occurs or as richly encompassing what Moya (1990) calls "the subjective point of view of a reflective agent" (p. 168). Louch (1966) holds that explanation of human action is moral explanation, and to the extent that human actions can be delineated and described only in value terms, a science of human beings is untenable. Moya (1990) believes that as long as "intentional" human action has an "uneliminable normative character that permeates its whole structure" (p. 168) and this normative character is coupled with "the human capacity for making primary attitudes objects of reflecting thinking" (p. 168), naturalistic and scientific approaches to human action are not viable. As this position negates the validity of a science of practice, it is not included as a possible scientific paradigm for theory development. With deletion of this specific view, four major positions on conceptualization of human action are delineated to show different types of practice theories from which a science of nursing from the dimension of nurseagent practice can emerge. Rationalist Position. Churchland (1970) proposed that "action-explanations are indeed of the familiar D-N (deductive-nomological) mold" (p. 214) and further specified a form of D-N explanation in which human acting is the function of the person having specific wants and a preferred action approach toward the specific wants. This position is held by those who offer causal, teleological, or functional explanations of human action. Hence, human action in this sense is explained: (a) as a causal phenomenon from a behaviorist position or from Davidson's (1982) causal theory of intentional action; (b) as a rule-following purposive rational phenomena from the perspective of "reason explanation" by Peters (1960) or from the decision theory perspective; (c) as a situation-dependent phenomena from the ethogenist's perspective of Harre


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(1982) or the context perspective held by Argyle and colleagues (Argyle, Farnham, & Graham, 1981); or (d) as the purely structuralist position held by sociologists regarding social action. From this perspective, then, human actions, both deliberation and enactment, are normative in nature and rationalistic, either cognitively or socially. Interpretivist Position, The second position calls for an explanation of human action based on hermeneutic tradition, differing from both purely rationalistic or moral interpretations. Taylor (1985) states: "human behavior as action of agents who desire and are moved, who have goals and aspirations, necessarily offers a purchase for descriptions in terms of meaning—what I have called 'experiential meaning'" (p. 27). This suggests the focus of hermeneutical sciences as human behaviors having a specific meanings in situs. Hence, this position is fundamentally based on the belief that "human science is largely ex post understanding" (Taylor, 1985, p. 56), and it requires interpretation posed hi the context of a given historical and meaning world for understanding. Cultural, conceptual, and linguistic innovations and transformations are fundamental aspects of human action. Thus, explanation of human action is posed within the frames of intersubjective meanings and shared practices, and for this, interpretation is the key for human science. Mediation Position. From an anthropological perspective, Bourdieu (1990) considers practice as "the site of the dialectic of the opus operatum and the modus operandi" (p. 52). Hence, the notion of practice presents paradoxes a represented in the following consideration: It is impossible to understand the logic of all the actions that are reasonable without being the product of a reasoned design, still less rational calculation; informed by a kind of objective finality without being consciously organized in relation to an explicitly constituted end; intelligible and coherent without springing from an intention of coherence and a deliberate decision; adjusted to the future without being the product of a project or a plan. (pp. 50-51)

Hence, Bourdieu views practice as emerging from mediation through what he calls habitus, which provides guidelines for representing the world in which action is performed but also allows individuals to exercise their freedom for creativity. Human action viewed in this way involves the adjustments and improvisations the human agent makes in performance by mediating the structural limits generally expected within a given social milieu, as well as one's creative adaptability in situations. The enactment aspect of nursing practice is an appropriate subject matter for this position. Emancipation Position. The fourth position stems from the change paradigm in which considerations of human action are ultimately tied to the need for change to better the human lot or to bring human existence to its fullest ideal. Bernstein (1971) thus suggests that Marxism, existentialism, and the

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pragmatism of Dewey and Peirce focus on human activity, connecting it to the entire range of cognitive and practical life for the knowledge of not only interpretation but also of change. Habermas' (1984) critical science and action science framework, proposed by Argyris et al. (1985) are founded on this tradition. For this position, the study of nursing actions (both deliberations and enactments) must be viewed from self-reflection with an orientation toward movement to a more enlightened dimension of practice. This discussion of four possible positions in conceptualizing human action and human practice points to the possible nature of practice theories: Practice theories for the deliberation and enactment of nursing can range from the theory of rationalistic action to that of action science. A science of nursing practice thus addresses questions related to: (a) the deliberative processes involved in the ways (modus operandi) nurses arrive at different programs of nursing care such as nursing diagnoses, nursing care plans, creativity, routinized practice, and utilization of innovation, and (b) the enactment or performative phenomena in nursing practice (opus operatum), focusing on such issues as why there are variations in the actions of caring and empathy by the same nurses with different patients and in different situations, why nurses do not carry out nursing actions that they intended in their planning, or why what nurses think they did for their patients is different from what they actually did. The four philosophical paradigms discussed above point to a variety of possible theories and knowledge that provides understanding and explanations about these and other relevant phenomena in the practice domain. A science of nursing practice is, therefore, aimed at providing knowledge about what nurses do in their practice, how they get to do what they do in practice, and what is affected by what nurses do in their practice. By focusing on what von Wright (1971) called the result of action, it is also possible to address concomitant variations in what he called the consequences of action This means that knowledge about how nurses get to engage in certain actions (i.e., the results, in von Wright's term) in practice will explain client outcomes as the consequences of nursing practice. Furthermore, knowledge in the science of nursing practice will eventually provide guidance to nurses in their effort to enact "appropriate" practice behaviors that respond not only to the here-and-now needs of clinical situations but also to the reflected and anticipated needs of future clinical situations. REFERENCES AND BIBLIOGRAPHY Argyle, ML, Furnham, A., & Graham, J. A. (1981). Social situations. Cambridge: Cambridge University Press. Argyris, C. (1982). Reasoning, learning and action. San Francisco: Jossey-Bass. Argyris, C , Putnam, R., & Smith, D. (1985). Action science. San Francisco: Jossey-Bass. Argyris, C , & Sch6n, D. A. (1976). Theory in practice: Increasing professional effectiveness. San Francisco: Jossey-Bass.


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