The ideal and the real: some thoughts on theoretical developments in British nursing

Two types of nursing theory are described: the realistic, whose purpose is to account for the complex reality of nursing; and the idealistic, whose purpose is to describe an idealized world of nursing as it 'ought to be'. It is argued that British nurses have overemphasized the importance of idealistic theory, and that this has retarded the development of our understanding of the real world of nursing. I recommend that the hermeneutical approach, as described by Gadamer (1989) might provide a base from which the balance might be redressed.     

Nursing diagnosis and classification systems: a position paper*

There has been little professional debate in the UK literature about nursing diagnosis and this paper explores some of the reasons why nursing diagnosis has failed to gain momentum among nurses in the United Kingdom. The nursing diagnosis movement has now reached some European countries and in the light of the International Classification of Nursing Project (ICNP) and the Strategic Advisory Group for Nursing Information Systems (SAGNIS) project commissioned by the NHS Executive (NHSE), requires a close examination by British nurses. The unsuccessful attempt by the North American Nursing Diagnosis Association (NANDA) to have its taxonomy accepted for inclusion in the World Health Organization's 10th revision of the International Classification of Diseases, an innovation which would have made the NANDA taxonomy the definitive classification of nursing, should alert British nurses to the importance of nursing diagnosis. Although nurses effectively diagnose as part of the nursing process, adoption of the concept of nursing diagnosis as a driving force for practice evades many of them. This paper reflects upon some of the logistical and conceptual difficulties including issues of culture and terminology. It is suggested that nursing diagnosis has a great deal to offer British nurses in their efforts to improve the quality of care and to provide data in this area for both practice and research.     

Policy matters: critical policy analysis and nursing

Policy is an integral part of nursing. At the organisational level, policies are constantly developed in a seemingly endless quest to provide more effective and efficient nursing services and outcomes. Such an increasing generation of policy appears to rest on the taken-for-granted assumption by nurses that policy is essential for good nursing practice. However, is it necessarily the case that the generation of policy documents advances the practice of nursing? Rather, does the apparent uncritical adoption of the role of policy by nurses actually serve to further regulate, control, and even limit the practice of nursing? This paper uses a critical perspective to explore nursing policy. In so doing it exposes the effect of policy on the construction and maintenance of everyday understandings of nursing practice.     

A social cognitive model for health education/health promotion practice

AIM: To investigate the place and validity of contemporary social cognitive models for health education practice in nursing settings and, in doing so, develop and put forward a specific model for this purpose. BACKGROUND/RATIONALE: The last decade or so has seen a marked increase in the amount of health educational/health promotional activities that nurses are expected to undertake. This has followed on from concerted calls to make health education a familiar and recognized part of nursing practice. Despite this, past and current evidence identifies that nurses have been, and continue to be, ineffective and inconsistent health education practitioners. Where health education activity does take place it tends to centre specifically on social cognitive behavioural change strategies. Subsequently, it is argued here that any failure on the part of nurses successfully to apply health educational initiatives into practice has been compounded by the lack of any nursing-specific social cognitive model process. This paper seeks to redress this imbalance by putting forward the case for such a model, developing it, and demonstrating how it can be incorporated into the practice setting. METHOD: A systematic review of the literature has been conducted and the article draws upon this in order to develop an evolving theoretical perspective for health education practice. The proposed model has evolved from this new perspective. Development of this model has drawn on contemporary social cognitive behavioural models--using them as a means to develop a further conceptual framework for nursing. CONCLUSION: Social cognitive behavioural models are valuable tools that nurses can incorporate routinely into existing frameworks of practice. The proposed model is designed to make the adoption of health-related behavioural change in clients easier and more realistic. If the current situation continues whereby social cognitive behavioural models are not adopted as a concerted and routine part of nursing practice, then nursing may well continue to fall behind other health professions in the discipline of health education.     

A critique of Fawcett's 'Conceptual models and nursing practice: the reciprocal relationship'

This paper offers a critique of Fawcett's paper 'Conceptual models and nursing practice the reciprocal relationship' published in 1992, in which it is argued that 'conceptual models inform and transform nursing practice by informing and transforming the way in which nursing is experienced and understood, and that nursing practice informs and transforms conceptual models by informing and transforming the content of the conceptual model' The critique begins by locating Fawcett's view of the relationship of nursing models to nursing practice within the intellectual tradition of positivism For the purposes of the critique, Fawcett's positivism is not taken as being problematic in itself, however, it is argued that the standards of evidence upon which some of her arguments are based are not compatible with the practice of positivist social science, with the result that the paper is internally inconsistent In particular, Fawcett's suggestion that nursing models are validated as evidence accumulates in their favour is contrasted with Popper's view that the validity of theoretical statements is established as they withstand attempts to demonstrate their falsity, and Fawcett's belief that nursing models are models in the scientific sense, which can be inferred from her adoption of the terminology of Kuhnian epistemology, is not found to be justified If, for the positivist, the validity of practice is directly proportional to the validity of the theory upon which it is based, then nursing models which lack 'scientific' validity cannot be regarded as a proper basis for nursing practice Finally, Fawcett has been criticized for failing to produce evidence of any kind to demonstrate that nursing models have a beneficial effect upon nursing outcomes     

Nursing care: professional progress

Nursing in the United Kingdom is currently taking decisions that will enable it to attain mature professional practice--or fail to. It is argued that professions are designed to serve vulnerable people competently and that competent nursing is not reliably achieved by the untrained or those in training. Competent nursing requires qualified nurses who can work in partnership with patients and help them manage their own health and an educational system which facilitates both the initial and continuing mastery of nursing knowledge and skills. Aspects of learning, including the clinical environment, are discussed. The contractual relationship between nurses and doctors is discussed and the need to develop competence in inter-professional work. Developments in clinical nursing since 1970 are reviewed including beliefs about nursing, models for practice, the organization of nursing, the development of clinical research and the demand for new knowledge and skills from qualified nurses. It is concluded that much of the essential thinking about the nature of professional nursing has been successfully achieved and that nursing in the United Kingdom should now take the decisions and actions to achieve a professional education and professional nursing practice.     

A reflective discussion: questions about globalization and multiculturalism in nursing as revealed during a student/staff exchange programme

The purpose of this paper is to present elements of a discussion on the discipline of nursing that arose from a student–faculty exchange programme, as a reflection of the experiences the students and faculty had during the 3-year exchange. It suggests that the globalization of health and the international migration of nurses might prove to be an opportunity for nurses to learn more about nursing practice. It became apparent to the participants that the phenomenon of nursing, although understood by them all, was not easy to describe, and words used in Swedish, Finnish or British or American English were often not easy to interpret or explain. These reflections were noted by the authors when the group came together to plan the programme and design experiences for the participants. We were concerned how nursing could contribute to health-care improvement globally if it wasn't universally understood within the four countries concerned.     

Feminism: a concept analysis

The purpose of this paper is to analyse the concept of feminism in order to clarify a sociological concept for its use in nursing theory and practice This analysis is earned out using the Walker & Avant (1988) model It includes a literature review, an overview of the uses of the concept drawn from the literature, the defining attributes and the justification of their choice, the cases to demonstrate the concept, and the concept criteria The concept was chosen out of an interest in developing a feminist nursing theory and desire to enhance nursing practice The literature search proved most fruitful in the sociological literature The nursing sources were fewer and concerned with practice rather than articulating any feminist nursing theory Many of these sources were sociologists and nurses The concept of feminism was denned as the concern with gender equality and the promotion of equal rights for men and woman, the expression of these concerns through theory or action, and the valuing of individuals for their contributions to society rather than their biological or sexual characteristics or roles Although the concept of feminism was defined and analysed within the model suggested by Walker & Avant, the author found that the concept became oversimplified, losing much of the richness of the literature The author felt that, for any development of theory or practice, this analysis would have to be expanded It is argued that their model is too restrictive as it is based on positivist philosophy which seeks to establish divisions where, in fact, there is a blurring of meaning Contrary to Walker & Avant, it is argued that if concepts overlap this does not necessarily diminish the potential usefulness of the concept in theory or practice     

Mediation of transcultural nursing care in clinical context: a tightrope walk

Our wish for suggestions for a line of action regarding our contact with migrants in the clinical context has led us to an increased acceptance of "Transcultural Nursing" by Madeleine Leininger. However, an uncritical adoption of this theory without theoretical and historical background information produces in practice a stereotyped image of migrants, and a cultural rating of social and individual aspects instead of mutual understanding. Hence, from the present-day perspective, Leininger's model is not suitable to establish transcultural nursing care in practice. A theory not encouraging the analysis of socio-cultural backgrounds of one's own but the sight "from without" of the so-called alien--a theory that does not make interaction its main object but culture, cannot serve as a basis for transcultural nursing care. Up-to-date transcultural nursing care does not need the introduction of a specific nursing concept for migrants but an extension of nursing by a socio-cultural and migration-specific dimension. However, nursing care does not seem to accept this challenge, what with it being far easier to add the "Leininger Culture Care Theory" to the existing curricula as an additional model. Thus nursing loses the opportunity of grappling with the adoption of certain theories and models of other disciplines. Even though Leininger is herself a nurse, she has developed her model in her capacity as a cultural anthropologist using the background of anthropological theories. But, the supplying of transcultural nursing care demands also from cultural anthropologists an analysis of the concrete context of nursing care and its approaches. Only by bearing this in mind, cultural anthropology can counter effectively the danger of being marginalized as a fringe discipline, and of being reduced to the level of providing cooking recipes.     

Development of a nursing knowledge base in the life sciences: problems and prospects

This paper reviews some of the issues concerning the role of the life sciences in nursing education. The unique contribution of the study of these sciences to the theory and practice of nursing is noted, but it is argued that progress in their application to the developing curriculum of nursing is hampered by the traditional adherence to the medical and biomedical emphasis in schools of nursing. It is suggested that the use of a new concept termed bionursing could provide a basis for the development of a distinctive link between the life sciences and their application to the practice of nursing. The author reports part of a study of the role of the life sciences in nursing which suggests that nurse educators are themselves concerned about the difficulty of linking the study of the life sciences directly to nursing theory and practice.     

Disability and oppression: some implications for nurses and nursing

Since the 1970s organizations of disabled people have defined disability as a form of oppression. However, despite nurses (along with other professionals) increasingly being viewed as part of this experience of oppression, British nursing literature has to date largely failed to conceptualize disability in these terms. In this paper the five faces of oppression identified by Young are modified to include discrimination and developed to provide a framework in which evidence of the oppression experienced by disabled people may be analysed. It is argued that if nurses and the nursing profession are to challenge and reduce oppression then this should be via a process of awareness of the nature of disability, reflection on practice and development in partnership. Accordingly, an agenda is identified which has implications for nursing practice, education and research. It is stressed that if nursing is not to be viewed as irrelevant to the needs of disabled people or as part of the process by which they are oppressed then it is vital that this agenda is heeded.     

The conceptual basis of mental health nursing

This paper traces the historical roots of mental health nursing relating these to contemporary practice in the case of people with all forms of mental illness. An attempt is made to explain the current interest in the nurse's interpersonal role with reference to specific theoreticals models and the development of care practices which emphasise social systems or social relationships. Emphasis is given to reports in the British literature, although some reference is made to North American nursing commentators. It is argued that although research evidence is weak, strong indications exist to suggest that the nurse's primary role lies in the imagination of their interpersonal relationship with the patient in an attempt to effect lasting change in the patient's capacity to live an ordinary life.     

Dissemination of Nursing Knowledge: The Application of the Model of Change

Despite the dramatic growth of nursing research and the development of nursing theory over the last 25 years, concern remains that nurses frequently fail to base their practice on the findings and recommendations of research. It is through research conducted by nurses that new knowledge can be obtained in order to implement good quality care in clinical practice. However, even when new knowledge is gained, its dissemination remains low. Several barriers to the dissemination of nursing knowledge in clinical practice have been identified. These include: lack of awareness of nursing research, lack of knowledge of the research process and the inability to understand research reports. These factors may contribute to negative attitudes among nurses regarding the use of nursing research in their clinical practice. However, research must filter down from academia to practicing nurses at all levels but it cannot make practicing nurses use research. One of the main priorities in the dissemination of nursing knowledge in clinical practice is to make research findings more “user friendly.” The use of a clinical nurse specialist or research nurse (that is a nurse with a defined role within research), combined with an action research approach, could increase the utilization of research findings in clinical nursing. The use of Journal club, research seminars, research workshops and nursing conferences are some of the enabling process in order to increase the dissemination of knowledge. The use of the model of change would enable us to understand whether nurses have the readiness to change and implement new nursing knowledge in to practice.     

A critique of Freire's perspective on critical social theory in nursing education

Nursing has been perceived as oppressed by virtue of among other things gender, occupation and class. It has been suggested that historically, nursing education perpetuated the rituals of tradition and was oppressive in terms of what was taught and how it was taught. Developments in nurse education have resulted in nurse educators seeking alternative means of educating, with the aim of emancipating nurses. Paulo Freire (1921-1997) promoted liberation through reflection and action, directed at transforming the conditions which lead to oppression. The fundamental basis of this approach is critical social theory, which is underpinned by the philosophy that social phenomena must be understood in terms of their context and history. From a critical social theory perspective, fruitful nursing education will only be possible if the history and structure of nursing are clearly understood by those involved in the educational process. We contend that the adoption of Freire's theory in nursing education may contribute towards the development of nurses who will be competent to meet the demands of contemporary healthcare practice. However, the application of this theory to nursing education can be challenging because of constraints imposed by the system in which nurse education takes place. It is therefore important that the application of critical social theory in nurse education be evaluated.     

Evidence-based nursing: a stereotyped view of quantitative and experimental research could work against professional autonomy and authority

In recent years, there have been calls within the United Kingdom's National Health Service (NHS) for evidence-based health care. These resonate with long-standing calls for nursing to become a research-based profession. Evidence-based practice could enable nurses to demonstrate their unique contribution to health care outcomes, and support their seeking greater professionalization, in terms of enhanced authority and autonomy. Nursing's professionalization project, and, within this, various practices comprising the 'new nursing', whilst sometimes not delivering all that was hoped of them, have been important in developing certain conditions conducive to developing evidence-based practice, notably a critical perspective on practice and a reluctance merely to follow physicians' orders. However, nursing has often been hesitant in its adoption of quantitative and experimental research. This hesitancy, it is argued, has been influenced by the propounding by some authors within the new nursing of a stereotyped view of quantitative/experimental methods which equates them with a number of methodological and philosophical points which are deemed, by at least some of these authors, as inimical to, or problematic within, nursing research. It is argued that, not only is the logic on which the various stereotyped views are based flawed, but further, that the wider influence of these viewpoints on nurses could lead to a greater marginalization of nurses in research and evidence-based practice initiatives, thus perhaps leading to evidence-based nursing being led by other groups. In the longer term, this might result in a form of evidence-based nursing emphasizing routinization, thus--ironically--working against strategies of professional authority and autonomy embedded in the new nursing. Nursing research should instead follow the example of nurse researchers who already embrace multiple methods. While the paper describes United Kingdom experiences and debates, points raised about the importance of questioning stereotyped views of research should have international relevance.     

Conceptual models; a power strategy with professional implications

Conceptual models and nursing theories are considered by some authors as standards that guide the thinking on how to be a nurse and practice nursing. Some authors defend that without the use of nursing models it could be difficult to improve the discipline and nursing practice, and even to transform a professional identity linked to submission, obedience and humility. The purpose of this article is not to argue about the truth or falseness, the usefulness, or not, of conceptual nursing models, but to analyse, from a post-structuralist perspective, their use as a power strategy exercised mainly by nurses since the 1970's in Spain and the unintentional professional implications of their adoption by the nursing profession. The basis of this analysis is from the results obtained in the PhD thesis of the author, in which it analysed the processes of continuity and transformation which constituted the professional identity of nurses in Spain between 1956 and 1976. Some political and social consequences are highlighted on nursing practices, on the holistic, humanist and moralist discourses transmitted by nursing models, on occasions compared with bio-pathological, technical and clinical discourses.     

Philosophy: a key to open the door to critical thinking

It has been suggested that philosophy is a bit like manure: pile it high and it rots and stinks, but spread it around and it becomes surprisingly useful. Philosophical enquiry, used sparingly, can provide a means to develop critical and analytical ability in nurses. A key principle of philosophical enquiry is the development of skills to rigorously examine and debate ideas or explanations about, for example, the nature of being human. In recent years nurses have been exhorted to critically examine or critically analyse nursing knowledge and nursing theory. It is contended that nurses have rarely been formally prepared during their education to develop the necessary critical thinking skills to examine some of the central questions about the nature of their role, and the knowledge needed to be effective in that role. This paper will discuss the development and experience of delivering a module called 'Nursing: Art and Science' within a post-registration degree programme. It is argued that philosophical enquiry offers one means of equipping nurses with the critical capacity to examine the issues which may shape the future of nursing practice.     

Continuities in the development of hospital nursing in Britain

This paper develops an argument that the choice of occupational strategy for nursing in the last century still has implications today. Nurses have retained a hierarchical principle of organization and have, albeit reluctantly, retained an in-service pattern of training. They have been concerned about recurrent shortages of nurses and this has influenced modes of development. These factors contribute to a continuity which is apparent in both 'Salmon' and 'Briggs', the two most influential reports on British nursing in recent decades. Such continuities in nursing development tend to preclude the raising of fundamental questions about the nature of nursing work and the manner in which it might be changed.     

Role of sociology within the nursing enterprise: some reflections on the unfinished debate

The present paper reviews literature on the relevance of sociology to nursing in the context of arguments presented by Cooke, Sharp and Porter. It explores some of the arguments presented for and against sociology in nursing education. On a broader perspective, sociology inter alia, is at best worthwhile for nurses and is not as positively harmful as Sharp asserts. The discussion draws attention to the relevance of social theory for nursing practice. It is argued that almost all social theories have been widely applied in nursing research. The case for sociology as applied to nursing or nursing sociology versus general sociology for nurses was examined. This paper concludes in favor of the inclusion of sociology as applied to nursing in the nursing curriculum.