Nursing Theory

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

Practice Theories in Nursing and aScience 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 nursingtherapeutics is enough to make nursing practice scientific is refuted on thebasis that practice theories in nursing must encompass not only theoriesaddressing these aspects but also those dealing with practice issuespertaining to the nurse-agent in action. A comprehensive frameworkspecifying two dimensions of focus for practice theories is proposed toexamine different types of practice theories in nursing and it is furtherused to frame a science of nursing practice as a subset of nursing scienceat large. Knowledge development for a science of nursing practice is thenexamined within four possible paradigms founded on different ontologi-cal and epistemological views.

Nursing science has been somewhat preoccupied during the past two decadeswith 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 theagent of nursing work. One analysis of the research reports for the period 1985—1988 in two nursing research journals (Nursing Research and Research inNursing and Health) revealed that in 11% of the articles (24 of a total of 225the 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 thefocus of explanation (Kim, 1993a). The major focus of nursing's scientificwork was on the client domain, and only a little attention was devoted to theother three domains (the client-nurse, the practice, and the environment)specified by Kim (1987). Such emphasis is understandable and natural becausethe dominant position defining the nature of nursing science aligns with whatStevenson and Woods (1986) state: "Nursing science is a domain of knowledgeconcerned with the adaptation of individuals and groups to actual or potentialhealth problems, the environments that influence health in humans, and thetherapeutic interventions that promote health and affect the consequences ofillness" (p. 6).

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146 Scholarly Inquiry for Nursing Practice

This position focuses efforts in nursing science on the expansion of knowl-edge about clients' health problems and nursing therapeutics, neglecting othertypes of practice theories that must be developed additionally to make theknowledge-base for nursing practice comprehensive. When practice theoriesin nursing are conceptualized to include all theories that are applicable indesigning practitioners' actions in their relationships with clients and in theprovision of a specific service (i.e., nursing) to them, then they encompassmore than the theories of client problems and their solutions. Hence, practicetheories defined in this way encompass all knowledge that is applicable to theconduct of nursing practitioners. The knowledge for the practice domain, thereforeis considered within a broader framework of practice theories presented in thefollowing 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 PRACTICETHEORIES 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 thisway of thinking leads to initially.

Mr. Jones, a 67-year-old patient, admitted with a medical diagnosis of cancer ofthe larynx, had a laryngectomy performed. This is his fourth postoperative day.He is expected to receive radiation therapy beginning shortly. He has a trach tubin place that needs to be suctioned, and his incision is healing, but he is weak andis having difficulty learning to perform the special speech technique.

A nurse in practice formulates the nursing needs of Mr. Jones, selectsstrategies to be applied to meet those needs, decides on what may be needed tocarry out the selected strategies, and carries out the actions specified for thestrategies. In carrying them out, the nurse performs certain psychomotorprocedures, communicates with the patient, and may modify the actions on thespot. Theories (i.e., practice theories) that are needed (or used) by this nurse inthis situation and/or those that undergird the explanations about the situationinclude the following:

• Theories providing explanations about the patient's problems, such astheories of healing, airway patency, fatigue, and speech, and thoseproviding ideas about therapeutics for these problems, such as theoriesof suctioning, wound care, rest, and learning.

• Theories providing the nurse with ideas about how to approach thispatient, such as theories of caring, empowerment, and communication.

• Theories providing explanations and ideas about how the nurse makes orshould make decisions about what the nursing actions would be with thispatient, such as theories of clinical inferencing and clinical decision making

• Theories providing explanations about what happens in the actual deliveryof nursing actions by the nurse.

Practice Theories in Nursing 147

Practice theories in nursing therefore can be viewed as encompassing thesefour distinct sets of theories for human actions of service. A framework thatorganizes these four sets of practice theories specifies two dimensions forclassification: 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 practiceactions. The dimension of nurse-agent is differentiated into the phase ofdeliberation and the phase of enactment according to the phase in whichpractice actions are involved. Hence the dimension of target is oriented to theclient, 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 theoriesthat specify the nature of the target, both manifest and latent, for practice.Distinctions of two types within this dimension are made according to thephilosophical orientations of practice. The targets of nursing practice are bothclients presenting problems to be solved and clients themselves as humanbeings. This means that nursing practice is oriented to bringing about theoccurrence of a desired state, that is, to having a specific teleological aspect.At the same time, nursing practice is also oriented to working with andattending 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


practice encompasses two sets of human actions that are based on these twophilosophies, and each philosophy requires specific types of practice theories.

The Philosophy of Therapy Focus. The philosophy of therapy alignspractice with teleologic/strategic actions oriented to solving or attending to aspecific client's problem(s) for which the targets of practice are healthproblems. Schneider (1990) calls the same type of emphasis in clinicalpsychology "a philosophy of repair." Theories for what Habermas calls non-social and social strategic actions founded on the technical cognitive interestmay belong to this type of practice theory. Nursing science in the past twodecades 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 adesired change or effect in a patient's condition, confines the nature of practicetheories to prescription. In alignment with this orientation, Woods (1992)states that "the scope of nursing science includes an understanding of humanhealth and illness and therapies to promote health, prevent illness and disease,enhance recovery and support dignified death" (p. 1). She, however, expandsthe notion of prescriptive theories for nursing practice by including not onlythe prescriptions for nursing treatments but also the theoretical relationshipsbetween the prescription and what Dickoff and James (1968) called "the surveylists" 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 canproduce the desired change in the human condition. However, only knowingwhether this is so is not enough. Knowing the conditions under which the theorycan produce the desired change is essential to guide practice.(p. 14)

This approach suggests a rethinking of the nature of practice theories so thatthe focus of the philosophy of therapy will be context-oriented. Theoretical andscientific development for this type of practice theory adds to knowledgewithin Kim's domain of client, as it is oriented toward understanding, explain-ing, and prescribing for clients' problems (Kim, 1987).

The Philosophy of Care Focus. The philosophy of care, on the other handleads to practitioners' actions in relation to clients as human beings situated inthe service settings of nursing. The targets of practice with this orientation arehuman beings in an interactive context of nursing. Nursing practice with thisfocus is the human-to-human service with a view of clients not as clinicalevents but as experiencing, situated persons. Clients and practitioners, ashuman beings, are engaged in interactive and intertwined human activities inwhich practice is a part of continuous human engagement. Practice theorieswith this focus, then, must deal with how nursing actions performed in relationto clients influence the clients and the clients' experiences. Hence, practicetheories of this sort are "approach" theories; that is, they must deal with the


interactive nature of phenomena that occur between nurses and clients. In thefield of psychology, the movement for humanistic psychology has emphasized theneed to focus on the philosophy of care. Similarly in nursing, practice theorieswith this orientation include those developed: (1) within the humanistic nursingframework, such as the science of human care by Watson (1985); (2) within theinteractive framework, such as Travelbee's (1966) interpersonal theory of nursingand Orlando's (1961,1972) theory of nursing-disciplined process that emphasizesthe nurturing process of nursing; and (3) within the existential or phenomenologicalorientation, 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 practiceprocesses. Kim's (1993b) work in developing a theory of nursing practiceexpanding on Habermas's (1984) theory of communicative action is based onthis orientation. This theory is a generalized action theory of nursing practicein which nurses' "talk" is conceptualized as a mode of approach in practice andas means to coordinate actions so that the nursing therapeutics applied will beeffective. Four types of arguments as methods of developing consensus andunderstanding between the interacting agents as specified by Habermas areapplied as the prescriptive ways of eliciting agreement between the patient andthe nurse. Theories and knowledge development for this type of practice theoryare the knowledge in Kim's (1993b) client-nurse domain.

The practice theories with the philosophy of therapy orientation consider clientsas objects of treatment and practitioners as instruments of treatment; hence, object-actor relationship is the key aspect of this focus. The practice theories with thephilosophy of care orientation consider clients and practitioners as interactingagents; 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 practicedomain. The practice domain is conceptualized to include phenomena particu-lar to the nurse who is engaged in delivering nursing care (Kim, 1987). Whennursing practice is viewed with the focus on the nurse as an agent of action, itpresents a rather complex picture. Figure 2 shows the complex nature of practiceviewed from this dimension. The practitioner is involved in a set of actions—mentalactivities and enactment activities in a specific situation of practice encompassingaspects that pertain to: (a) the client, (b) the setting, and (c) the practitioner-self. The practice contains at least two phases: the deliberations for action andthe actual enactments. Deliberation for action by the practitioner involvesdeveloping a program of action, manifestly or latently, as analytically sepa-rated from the enactment of action. It focuses on the assessment the practitio-ner makes of the situation and the selection of a choice for action. At any giventime, such a decision may be either a simple choice for a problem at handconsidered singly or a complex set of strategies arrived at by taking on


coexisting multiple problems. For this phase, five structural units, (i.e.,nursing goals, aspects of client, nursing means, situation of nurse-agent, andaspects of nurse-agent) are analytically connected for deliberations at hand. Onthe other hand, the phase of enactment involves acting in a specific practicesituation involving the practitioner, the client as an object as well as aresponding human-other, and the situation in which the action takes place.

The Phase of Deliberations. Deliberations for practice refers to phenomenin the nurse as she or he is dealing with the practice situation in preparation foactual delivery of nursing actions. The nurse is involved in deliberating interms of the kinds of information gathered from the client and the situation, theways the nurse processes the information, the modes with which he or shedraws upon both public and personal knowledge, and the processes in whichcertain conceptual and action decisions are made by the nurse. Deliberationsinvolve five sets of structures: (a) the structure related to aspects of the clientthat becomes the focal framework upon which the goals of practice areestablished; (b) the structure pertaining to the goals of practice specifying thenature of goals in their scope and specificity; (c) the structure pertaining to themeans of practice delineating the types of available strategic repertoire; (d) thestructure related to aspects of nurse-agent, such as commitment, motivation,and capacity; and (e) the structure pertaining to the situation of nurse-agent inwhich the deliberation takes place. Deliberations ready the nurse to becomeengaged in actions. Deliberations by nurse-agent for action are thus differen-tiated into two interlinked sets, as shown in Figure 3: (a) deliberations

Figure 2. Conceptualization of Nursing Practice


regarding relationships between goals and means in the context of the clientand the nurse and (b) deliberations regarding the nature of action-situation (thefuture, where enactment takes place) in the context of the actor-situation (thepresent, wbere deliberation is taking place). The first refers to the deliberationsregarding choices for actions, and the second is concerned with deliberationslinking the future in association with the chosen present actions.

A practitioner develops a program of action or an intention to act in a certainway with a view toward fidelity of strategy, competent delivery, timeliness andrelevancy of program, and efficacy of outcomes. Although this phase appearsto involve a process that is designed and intentional, the actual practice theoriesthat explain or prescribe this process may not necessarily refer to it asprescriptive. The phase itself is Ideological in the sense that the goal is toformulate a program of action or an intention. Decision-making theories,problem-solving theories, and the theory of pattern-recognition are examplesof practice theories for this phase. Tanner and her associates' (Tanner, Padrick,Putzier, & Westfall, 1987; Westfall, Tanner, Putzier, & Padrick, 1986) work onclinical reasoning in nursing practice is an example of practice theory on thisdimension, with a focus on the deliberation phase. O'Neill's (1992) work on

Goals

Aspects

Aspects

Delib( ration

of Client

of Nurse Means

Actor-Situation(present)

Action-Situation(future)

Deliberation

NURSING ACTIONDECISIONS

(programming)

Figure 3. Nature of Deliberations in Practice


the use of cognitive processes by nurses tests the theory of representativenessheuristic by Tversky and Kahneman (1982) and can be considered an attemptto develop a practice theory with this focus.

The Phase of Enactment. The phenomenon of enactment is conceptualizedin terms of "human action" being done (performed, carried out, realized) by anagent. If one considered the reality of enactment as having a direct andcomplete causal relation with intention, and intentions as the sufficient expla-nation of enactment, it would not be necessary to consider this phase separatelyfrom the phase of deliberation. For the disciplines of human-service practice,however, this position is not tenable. This is primarily because enactment inpractice invariably involves another human being (the client) who is also anenacting agent. Secondarily, it is because connections between deliberationand enactment are not uniform and can take various forms according todifferences 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 aprolonged time lag, or (3) a third-person situation, where deliberation is doneby 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 seesbut to what he fore-sees, sees in advance in the directly perceived present... Hedecides 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 ofhis team-mates, seen not as they are but in their impending positions. And hedoes 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 andreflection. He is launched into the impending future, present in the imminentmoment, and abdicating the possibility of suspending at every moment theecstasies that project him into the probable, he identifies himself with theimminent 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 presentand future at the same time but that also becomes the thing of a past instanta-neously. We also feel the immediacy of human action in the human agent'sengagement, as well as the finality once it is enacted. Action science proposedby Argyris, Putnam, and Smith (1985) and by Sch6n (1983) provides anexplanation of the reasons for practitioners' failure to achieve intendedconsequences in their practice in terms of single-loop learning. From thisapproach, Argyris and his colleagues have proposed a normative form of actionscience theory that focuses on influencing the quality of practice.

In contrast, Benner (1984), basing her analysis on the Dreyfus model of skillacquisition, suggests that clinical nurses' performances in practice reflect thenurses' movement: (a) in analytic reliance on referents from abstract to


paradigm cases, (b) in perception of the situation to increasingly holisticevaluations, and (c) in the degree of engagement from detached observers toinvolved performers. Hence, Benner's work attempts to address both thedeliberation and enactment phases of nursing practice.

This framework points up the nature of different sets of practice theoriesthat are necessary and viable for explaining and designing nursing practice.Figure 4 specifies this typology. Theories of intervention with a focus onclients' problems that are based on the philosophy of therapy are prescriptivein nature, whereas theories of approach with a focus on clients as persons,based on the philosophy of care may be descriptive/explanatory or prescrip-tive. Theories of deliberation and theories of enactment for the dimension ofnurse-agent, however, may be both descriptive/explanatory or prescriptive innature. Nursing science with a focus on practice theories, therefore, encom-passes four types of theories: they together provide a full explanation ofnursing practice and are the foundation for the effectiveness of practice.

A science of nursing practice for the practice domain is thus proposed as aspecific subset of nursing science separated from the science of nursing clientand nursing intervention. The subject matters for this science are thoseentrenched within the dimension of nurse-agent specified for the framework ofpractice theories. A science of nursing practice with a view to developingpractice theories in the dimension of nurse-agent (the practice domain) is basedon the assumption that specific subsets of knowledge in this area will guide thescientific practice of nursing. Theories in fields such as cognitive science,psychology, sociology, operations research, management, and education mayaddress the phenomena in the practice domain, but appropriate practicetheories for the phases of deliberation and enactment need to be developed for

Figure 4. Nature of Practice Theories

154 Scholarly Inquiry for Nursing Pract

the science of nursing practice that takes into consideration the specificsituational and professional nature of nursing.

PHILOSOPHICAL POSITIONS PROVIDINGFOUNDATIONS FOR THE DIMENSION

OF THE NURSE-AGENT

Four philosophical positions leading to different paradigmatic orientationsregarding the conceptualizations of human nature (encompassing both thedeliberation and enactment aspects of human action), provide the foundationupon which a science of nursing practice may develop. At one extreme is thephysicalistic, mechanistic conceptualization of action, which considers humanaction as a series of enactments or happenings that can be explained byscientific laws and causal theories. At the other extreme is the conceptualizatioof human action by analytic philosophers who emphasize the role of freedomof choice in existence and action as actualizing the individualized, creative, and

moral nature of human life. Such analytic philosophers consider human actionas purely justifiable by the circumstances in which it occurs or as richlyencompassing what Moya (1990) calls "the subjective point of view of areflective agent" (p. 168). Louch (1966) holds that explanation of human actionis moral explanation, and to the extent that human actions can be delineated anddescribed only in value terms, a science of human beings is untenable. Moya(1990) believes that as long as "intentional" human action has an "uneliminablenormative character that permeates its whole structure" (p. 168) and thisnormative character is coupled with "the human capacity for making primaryattitudes objects of reflecting thinking" (p. 168), naturalistic and scientificapproaches to human action are not viable. As this position negates the validityof a science of practice, it is not included as a possible scientific paradigm fortheory development. With deletion of this specific view, four major positionson conceptualization of human action are delineated to show different types ofpractice theories from which a science of nursing from the dimension of nurse-agent practice can emerge.

Rationalist Position. Churchland (1970) proposed that "action-explanationsare indeed of the familiar D-N (deductive-nomological) mold" (p. 214) andfurther specified a form of D-N explanation in which human acting is thefunction of the person having specific wants and a preferred action approachtoward the specific wants. This position is held by those who offer causal,teleological, or functional explanations of human action. Hence, human actionin this sense is explained: (a) as a causal phenomenon from a behavioristposition or from Davidson's (1982) causal theory of intentional action; (b) as arule-following purposive rational phenomena from the perspective of "reasonexplanation" by Peters (1960) or from the decision theory perspective; (c) as asituation-dependent phenomena from the ethogenist's perspective of Harre


(1982) or the context perspective held by Argyle and colleagues (Argyle,Farnham, & Graham, 1981); or (d) as the purely structuralist position held bysociologists regarding social action. From this perspective, then, humanactions, both deliberation and enactment, are normative in nature and rational-istic, either cognitively or socially.

Interpretivist Position, The second position calls for an explanation ofhuman action based on hermeneutic tradition, differing from both purelyrationalistic 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 Ihave called 'experiential meaning'" (p. 27). This suggests the focus ofhermeneutical sciences as human behaviors having a specific meanings insitus. Hence, this position is fundamentally based on the belief that "humanscience is largely ex post understanding" (Taylor, 1985, p. 56), and it requiresinterpretation posed hi the context of a given historical and meaning world forunderstanding. Cultural, conceptual, and linguistic innovations and transfor-mations are fundamental aspects of human action. Thus, explanation of humanaction is posed within the frames of intersubjective meanings and sharedpractices, 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 themodus operandi" (p. 52). Hence, the notion of practice presents paradoxes arepresented in the following consideration:

It is impossible to understand the logic of all the actions that are reasonablewithout being the product of a reasoned design, still less rational calculation;informed by a kind of objective finality without being consciously organized inrelation to an explicitly constituted end; intelligible and coherent withoutspringing from an intention of coherence and a deliberate decision; adjusted tothe future without being the product of a project or a plan. (pp. 50-51)

Hence, Bourdieu views practice as emerging from mediation through whathe calls habitus, which provides guidelines for representing the world in which

action is performed but also allows individuals to exercise their freedom forcreativity. Human action viewed in this way involves the adjustments andimprovisations the human agent makes in performance by mediating thestructural limits generally expected within a given social milieu, as well asone's creative adaptability in situations. The enactment aspect of nursingpractice is an appropriate subject matter for this position.

Emancipation Position. The fourth position stems from the change para-digm in which considerations of human action are ultimately tied to the needfor change to better the human lot or to bring human existence to its fullestideal. Bernstein (1971) thus suggests that Marxism, existentialism, and the


pragmatism of Dewey and Peirce focus on human activity, connecting it to theentire range of cognitive and practical life for the knowledge of not onlyinterpretation but also of change. Habermas' (1984) critical science and actionscience framework, proposed by Argyris et al. (1985) are founded on thistradition. For this position, the study of nursing actions (both deliberations andenactments) must be viewed from self-reflection with an orientation towardmovement to a more enlightened dimension of practice.

This discussion of four possible positions in conceptualizing human actionand human practice points to the possible nature of practice theories: Practicetheories for the deliberation and enactment of nursing can range from thetheory of rationalistic action to that of action science. A science of nursingpractice thus addresses questions related to: (a) the deliberative processesinvolved in the ways (modus operandi) nurses arrive at different programs ofnursing care such as nursing diagnoses, nursing care plans, creativity, routin-ized practice, and utilization of innovation, and (b) the enactment or performativephenomena in nursing practice (opus operatum), focusing on such issues aswhy there are variations in the actions of caring and empathy by the samenurses with different patients and in different situations, why nurses do notcarry out nursing actions that they intended in their planning, or why whatnurses think they did for their patients is different from what they actually did.The four philosophical paradigms discussed above point to a variety ofpossible theories and knowledge that provides understanding and explanationsabout these and other relevant phenomena in the practice domain.

A science of nursing practice is, therefore, aimed at providing knowledgeabout what nurses do in their practice, how they get to do what they do inpractice, and what is affected by what nurses do in their practice. By focusingon what von Wright (1971) called the result of action, it is also possible toaddress concomitant variations in what he called the consequences of actionThis 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 outcomesas the consequences of nursing practice. Furthermore, knowledge in thescience of nursing practice will eventually provide guidance to nurses in theireffort to enact "appropriate" practice behaviors that respond not only to thehere-and-now needs of clinical situations but also to the reflected and antici-pated needs of future clinical situations.

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Acknowledgment. Revised and expanded version of the paper presented at the SecondSymposium on Knowledge Development: Examining the Linkages: Philosophies of HumaBeings and Nursing Practice—Practice Theories in Nursing, sponsored by the University oRhode Island College of Nursing, Newport, Rhode Island, September 26-28, 1991.

Offprints. Request for offprints should be sent to, Hesook Suzie Kim, Ph.D., R.N.,College of Nursing, White Hall, University of Rhode Island, Kingston, RI 02881 -0814.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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