foumal of Advanced Nursing, 1995,21,184-190
Theoryfrompractice for practice: is this a
reality?
Kim Ann ToUey RGN DipN BSc(Hons) PGCEA
Nurse Lecturer, Kingston and St George's NHS Gollege of Health Studies,
100 London Road, Groydon, Surrey GR9 2BH, England
Accepted for publication 14 Apnl 1994
TOLLEY K A (1995) fouuial of Advanced Nursing 21,184-190
Theory from practice for practice: is this a reality?
Dickoff & James assert that theory comes from practice for practice This paper
will explore the reahty of this statement in nursmg today The nature of nursmg
knowledge from an historical perspective facilitates an understanding of where
nursing theory development is today The purpose of theory is debated and the
motivation for its development considered Practice theory, theory which is
developed from practice for practice, is analysed, and this is advocated as one
method to reduce the theory-practice gap m nursmg Whether practitioners are
ahle to undertake the development of practice theory is discussed and some
obstacles identified Reflection and action research have heen offered as
methods to facilitate the development of practice theory by practitioners
INTRODUCTION
Dickoff & James (1968) assert that theory comes from practice for practice, however, m reality does theory building
come from practice or should it remain with academics'
In order to consider this contentious issue, the reasons
why theory is needed for nursing will be analysed These
reasons will need to be considered m the context of their
relationship to the nature of nursmg knowledge and the
development of theory in nursing Dunng these discussions the underpinning philosophy of science and its
relationship to nursing can also be cinalysed In the light
of this, theory which comes from practice for practice can
then be defined and its development by practitioners or
academics debated
THE NATURE OF NURSING KNOWLEDGE
AND THE PHILOSOPHY OF SCIENCE
Carper (1978) identifies four pattems of knowledge Firstly
empmcs, which is linked to the science of nursmg, secondly aesthetics, which is linked to the art of nursing,
thirdly, personal knowledge, and finally moral knowledge,
which has its hnks withm ethical decision making (Carper
1978) Withm nursing all these domains of knowledge are
used (Carper 1978), but it will be seen that some have more
184
credence and value withm nursmg than others In order
to appreciate this difference m veJue, the roots of nursmg
knowledge must be examined CuU-Wilby & Pepin (1987)
review this history of nursmg knowledge or epistemology,
and through their discussion provide nurses will a clear
insight mto the recent 'sui^e m its development'
(CuU-Wilby & Pepm 1987) Peplau (1987) and Meleis
(1991) begin a historical review with the contnbution
that Florence Nightingale made to nursing knowledge
Florence Nightingale advocated that nursing had its own
knowledge base, but did nothing to stem the rapid development of a knowledge base for nursmg that bore its roots
amongst what Carper (1978) coins the logical empmcists
Logical empincism is woven in terms such as measurement, tests, scientific hypotheses and control, nurse
researchers usmg this philosophy attempt to define the
truth, usmg a reductiomst approach (CuU-Wilby & Pepm
1987) Popper (1989) and McCaugherty (1992) cnbcize this
reductiomst approach, which attempts to manipulate the
complex nature of the world into theory Vismtainer (1986)
likens theones to maps and eloquently explains the problems associated with this approach, maps mvented m the
laboratory may need adjustment when applymg them mto
the complex world of nursing practice
Theory from practice for practice
Another shift is the move towards what Reed & Procter
(1993) label as 'radical academia', m which academics
Nursing has been drawn to towards tbis paradigm m an embrace practice expenences attempting to raise the proattempt 'to appear scientific' (Robinson 1993) and this is file of this practice knowledge The populanty of Banner's
nursing's inheritance today (Gray & Pratt 1991) In today's (1984) work IS an example of this This is similar to what
health care arena nurses are developmg their practice Schon (1987) calk techmcal rationality, which is the
along the 'new nursing' pathway, encompassing a hohstic development of theones by theonsts and researchers
approach to canng (Salvage 1990) New nursii^ is m con- which IS then applied to practice However, one of the
fhct with the reductionist approach Consequently, nurs- drawbacks of techmcal rationality and radical academia is
mg IS re-explonng its boundanes (Wnght 1991) and that they are not developed by practitioners who are
moving away irora the traditions of medical science, which embedded m the practice situation and wbo therefore have
are based within emptncism, to a 'professionalizing ideol- a deeper awareness of the practice expenences But are
ogy for nursmg', which fits with this holistic and individu- they prepared to undertake this role''
alistic view (Bond 1993)
Parallel with this development is the call for nursmg to
expand its own knowledge base rather than rely on bor- WHAT IS THE PURPOSE OF THEORY?
rowed theones from other disciplines, which can be prob- A theory is 'a statement tbat purports to account for or
lematic when they are applied to nursmg (Chenitz 1984) charactenze some phenomena' (Stevens 1984) Botha
As a result of the dnve towards holism, the move to (1989) suggest that theones 'provide ways of thinking
expand nursmg knowledge, and the dissatisfaction of about and looking at tbe world around us' Moody (1990)
many nurses with this approacb, tbere was a move towards sees theory as 'the systematic abstraction of reality that
historicism or organicism (Fawcett 1984, Reed & Procter serves a goal or purpose' Tbus Botha (1989) and Moody
1993) Histoncism can be likened to Carper's (1978) pat- (1990) agree that theory should be a true reflection of the
tern of knowledge, aesthetics, which has been descnbed world around, but is this achievable''
as the art of nursmg, m contrast to empincism, which is
What IS tbe goal or purpose that Moody (1990) suggest
defined as the science of nursmg Within this paradigm, tbeory sbould have'' Draper (1990) asserts tbat the genertheory is developed durmg a process of understandmg ation of theory bas several functions, to define nursing
behaviour and considering tbe effects of this behaviour broadly, to aid curriculum design, to enhance professional
(Salvage 1990) Research approaches hased in histoncism nursmg practice, and to form the basis for a langu^e
are descriptive and phenomenological, compared to those through which nurses can communicate Moody (1990)
of empiricism, which are experimental (Draper 1990)
also explains that in the past theory was thought to
Bond (1993) feels that there is currently more support strengthen tbe autonomy of tbe nursing profession Walker
for histoncism withm nursuig Moreover, the recently pub- & Avant (1988) optimistically state tbat theones advance
lished report of the Taskforce on the Strategy for Researcb nursing practice, and indeed tbe central belief wbicb
m Nursmg, Midwifery and Health Visiting (Department of underpins theory building is that it exists to improve nursHealth 1993) states that research trammg should be ing practice by providing a rationale for nurses' actions
focused towards as qualitative as well as quantitative (Mamner 1986) Manley (1991) sums up all these
metbods Nursing m this scenario could bave a future m functions by stating tbat tbeory is one method for
generating knowledge, providing maps to guide the way
both paradigms
(Visintamer 1986)
So why do nurses want to develop these maps or theorAlternative method
ies'' To enhance patient care is the natural retort, Ingram
An alternative method for knowledge development in (1991) suggests, but then he sceptically suggests that it is
nursmg (CuU-Wilby & Pepm 1987) is cntical theory, also to satisfy nursing's desire to achieve academic
which emerged after concern was expressed about the satisfaction
This comment can be understood given the history of
shortcomings of both the positivist and interpretative
approaches to social science (Carr & Kemmis 1990) What the development of nursmg knowledge, which shows that
was missing &om these approaches was the direct link to nursuig was drawn to logical empmcism out of the need
practice, which cntical theory encompasses, and knowl- to be academically credible With these conflicts m mind
edge gamed ui this way is the 'outcome of human activity' the scope of theory development needs to be considered
(Carr & Kemmis 1990) As such this provides knowledge
which has meaning for practice Silva & Rothbart (1984)
The scope of nursing theory
discuss these trends withm the contrastmg philosophies
of science and conclude that nursing theory is currently Dickoff & James (1968) propose that there are four levels
'expenencmg shifts m its evolution'
of tbeory classified accordmg to their scope and depth
New mirsing pathway
185
KA ToUey
Firstly meta theory, which focuses on broad issues particularly related to theory in nursmg Recent examples of this
are Botha (1989) and Shaw (1993)
Secondly grand theones, which give some 'hroad perspective to the goals and structure of nursmg practice'
(Walker & Avant 1988) Grand theones mclude conceptual
models such as Orem's (1971) Ellis (1968) argues that
grand theones, as they are hroad in scope, will lead to a
greater significance for nursing However, to retum to
Vismtamer's (1986) analogy of theones as maps, maps can
leave out mformation that individuals in different contexts
may find relevant How can grand theones, with their
ahstractness and generality, lead to understanding withm
every context of nursing'
Thirdly there are middle range theones, which are
limited m scope and vanables, concept analysis is often
suggested as a method to develop middle range theones
(Walker & Avant 1988)
Finally, there is practice theory, which will be compared
with the other levels of theory
generating them These pnnciples that Walker (1971) discusses are not part of nursmg theory and are nursing practices (Walker & Avant 1988) What is missmg frtim nursmg
practices are the goal and the survey list, and it is these
elements that distinguish practice theory firom nursing
practices
However, perhaps these comments reflect nursmg's histoncai nervousness of considermg the practice of nursmg
as appropnate for theory development and are bound up
with its past leamng towards empincism Beckstrand
(1978) sums this scepticism up by status that there is no
need for practice theory, as nursing meets its needs for
knowledge from scientific knowledge and logic (cited by
Meleis 1991) Given the history of nursing knowledge,
already debated, this viewpoint can be understood
Supporters of practice theory
So why IS practice theory needed m nursmg' Supporters
of practice theory argue that it allows for cin m-depth analysis of a particular nursing practice and this narrow subject
matter increases its utility (Jacox 1974) Relevance for
nursing is increased, as opposed to grand theones which
Practice theory
have been labelled as having little direct releveince for
nursing practice
Practice theory has been defined by Jacox (1974) as
Despite this, Ellis (1968) sees grand theones as leading
theory that says given this nursing goal (producing some desired
to greater significance for nursing because of their breadth
change or effect in the patient's condition) these are the actions
Stevens (1984) continues the arguments against middle
the nurse must take to meet the goal (produce the change)
range theones, stating that if theones are developed to
These are theones which come from clmical practice, their 'create boundanes for nursmg and shared viewpomts
purpose IS to explam a specific nursmg practice (Meleis amongst nurses m diverse activities or settings', then grand
1991) Practice theory is also what Dickoff et al (1968) theones are the only type needed However, this would
define as a situation-producing theory The purpose of this result m theones that are 'so all inclusive and so abstract
situation-producing theory is to 'guide action to the pro- that m trymg to explam everythmg they explam nothing'
duction of reality' (Dickoff & James 1968) In order to guide (Miller 1985), attempting to answer all the questions of life
action, practice theory therefore must have a goal, directive Itself (Kitson 1985) Jacox (1974) concludes that nursing
for action and a survey hst (Dickoff & James 1968) In this cannot achieve its own grand theory Clarke (1986) agrees,
way practice theory is constructed to focus on a specific statmg that mid-range theones may appeal more to pracnursing problem, the examples Ramprogus (1992) uses are titioners as they can be easily applied and understood
pain and sleeplessness Others could be unnary tract infecPractice theory has only recently been used by nurses
tion or wound healing
to theonze (Pearson 1992) It has, however, been heralded
Dickoff & James (1968) and Jacox (1974) are vndely as a means to ensure the survival of nursmg, since it interegarded as the proponents of practice theory, the basis of grates theory into nursmg practice (Craig 1980)
It has been seen that the main advantage of practice
their argument focusmg on nursmg practice bemg seen as
the ideal situation for practice theory development theory is that it is based m the real world m which the
Ashworth & Longmate (1993) suggest that theonzmg from problem is identified, whereas grand theones view nursmg
practice mvolves analysing specific issues that come from in the ideal world This separation of the ideal and real m
practice and formulating theory from them with the aim nursmg theory has been suggested as one of the causes of
of understandmg them better Practice theory is mdeed the theory-practice gap (Miller 1985)
theory which comes from practice for practice (Dickoff &
James 1968)
THE THEORY-PRACTICE GAP
There is, however, some contentious debate about the
use of this term practice theory withm theory develop- One reason for the theory-practice gap is that m the 'ideal'
ment Walker (1971) explains that practice theory can be world of nursmg theory, nursmg practice is discussed as
seen as a set of pnnciples or directives for practice, and bemg performed as it 'ought to be' (Ramprogus 1992)
sees practice as having a role in testing theones but not Stevens (1984) states that this 'ideal' view of nursmg
186
Theory from practice for practice
theory has httle Televance in health care today, and will
only serve to fuel the hattle hetween theory and practice
(Miller 1985) Nursmg will contmue to he m conflict
hetween its life as a 'practice profession and its life as an
acadenuc discipline' (Visintainer 1986) If academics and
practitioners cannot reduce this divide and commumcate
their ideas, then the future of nursing is at nsk
Nursing theory and practice m this situation are viewed
as two separate nursmg activibes, with theonsts, seen as
those who wnte and teach ahout the ideal, separate from
those who implement care in reality (Lindsay 1990) Even
more depressmg is the view that theory is anything that is
taught m the classroom and practice is what is done on
the wards (McCaugherty 1991) Other authors helieve that
'theory cannot capture all that is present m practical knowhow' (McCaugherty 1992) Perhaps practice theory would
be the nearest nursmg could get to capturing this knowledge embedded in practice
Apart from the sepeiration hetween the ideal and reality
in nursing theory development, what else causes this
theory-practice gap'
PRACTITIONERS OR ACADEMICS
DEVELOPING PRACTICE THEORY?
In the past theory was thought to he 'best giuded hy memhers of its own disciplme m academic settings', mirronng
the focus on histoncism and the move towards achieving
professionalism (Moody 1990) Practitioners wanUng to
undertake this role withm theory development are therefore fighting against the history of nursing theory development, which has come mainly bom nursing theonsts and
academics and which is 'tilled with the mantle of elitism'
(Bond 1993) This mhentance has meant that practiUoners
do not see themselves as theonsts (Ramprogus 1992), they
only implement theones which they have not been
involved m developmg (Rolfe 1993)
For practitioners to see themselves as having this wealth
of knowledge embedded in practice, they need an awareness of practice theory itself and the research methods
used to develop this Practice theory needs to he sold to
practitioners, who need to see the possible benefits of it
for their clients and nursing
However, this selhng concept conflicts with the values
inherent in a nursing culture, as marketmg is often seen
Language
as unethical (Norkett 1985, Sheaff 1991) Also, there may
Miller (1985) discussed the separation hetween nursing be concerns that the promotion of practice theory is to
theory and nursing practice, and suggests that one of the develop nursing's academic standing further, as discussed,
causative factors is the language of theory, which is rather than improve nursmg care This can also he viewed
divergent from the language of practice Adams (1991) as unethical If practitioners could see themselves as theoreloquently calls this the 'language of the priesthood' If ists, would they then have the skills to develop practice
practitioners were to develop practice theory, then this theory' Indeed, can practitioners fully function withm
would not hecome an issue smce the language used would nursing today'
Pearson (1992) considers why this situation has develbe understandable to all
Practice theory would also enable practitioners to value oped, statmg that he is battlmg, as many nurses are, against
their personal and practical knowledge emd make this a nursing past which has the emphasis on doing and conknowledge available to others (Pearson 1992), as the prac- crete thinking, without attempting to be scholarly Even if
tice theonst has no illusions about what nursing actually practitioners have recognized that they have this ahility,
IS If, as Dickoff & James (1968) suggest, practice theory is they may not have been able to articulate this knowledge
the future for nursing's development of theory, then could m an acceptahle academic style (Reed & Procter 1993)
The revolution m nurse education is aiming to produce
It also help to reduce the so-called theory-practice gap by
'knowledgeahle
doers' (UKCC 1986) Will these knowldevelopmg theones based in reality and which focus on
edgeable
doers
see
things differently and have the skills
problems encoimtered by practitioners'
and
knowledge
necessary
to develop practice theory'
But if practice theory is seen to he one way of reducing
McCaugherty
(1992)
is
optimistic
and sees the knowledgethe theory-practice gap, then who should develop i f
able
doer
as
being
able
to
integrate
theory and practice in
Should the developers he the practitioners or academics'
a
balanced
way,
having
the
skills
to be able to do this
If, as it has been aigued, practitioners are m the ideal situBenner
(1984)
agrees
that
expert
nurses
have the ability to
ation to develop practice theory, smce they are closer to
develop
knowledge
and
have
a
'wealth
of
untapped knowlthe practice situation, what are the possible barners to
edge'
Stevens
(1984)
agrees
that
any
nurse
who is defined
them developmg practice theory' Indeed, could academics
become closer to chmcal practice to enable them also to as bemg 'fully functioning' has the ability to theonze from
expenences in practice
develop practice theory'
Graduate nurses
Certainly graduate nurses, who are academically prepared
to undertake the development of theory, are staying in
187
KA ToUey
practice rather then movmg into education or man^ement
(Smith 1993) and are therefore m the ideal environment
to undertake this type of theory development Given the
obvious advantages of developing practice theory, how can
practitioners who have been 'sold' the idea be facilitated
to develop this?
Reflection has been suggested as one method that can
be used by practitioners to develop their tacit knowledge
(Schan 1987, Powell 1989, Ashworth & Longmate 1993)
Polyam (1958) defines this as knowledge coming from
practice, in contrast with explicit knowledge that comes
from words or symbols Kolb's (1984) learning cycle links
the process of thinkmg and domg to achieve tacit knowledge through this process of reflection This reflection is
seen as a way to bnng the lowlands of practice towards
the high ground of research (Schdn 1987), thus reducing
the theory-practice gap
Gray & Forsstrom (1991) descnbe how they used the
process of reflection in an attempt to tap this knowledge
amd generate practice theory They conclude that they have
not yet met their aim, but demonstrate clearly the richness
of data that can be obtained from practice
This example of practice theory development is wntten
by educationalists But, are practitioners ready and able to
take on this function of developing practice theory through
reflection' Schbn (1987) states that one of the identifying
features of the expenenced practitioner is that they are
able to reflect-m-action However, m Powell's (1989) study
the opportunities for leammg from practice were not
always recogmzed by the nurses Perhaps this is due to
the ongmal argument, that practitioners do not see themselves as theorists and do not see the value of the data that
tbey are exposed to in practice itself (Ramprogus 1992)
Facilitating reOectioii
However, to undertake reflection time and a safe environment are needed (Saylor 1990) It must be asked if tbe
environment withm health care today is safe enough to
facilitate this process Farmer (1991) cautions that Benner's
(1984) work needs to be carefully implemented and hmts
that in the present political chmate the use of this
approach to theory buildmg must be carefully considered
Again perhaps this is a reflection on nursmg's mhentance
built on empmcism However, if nsks are not taken then
nursing theory and knowledge will not develop further
Jarvis (1992) agrees that the structures are not m place
yet to enable reflection to take place, consequently the
theory-practice gap has not yet been closed Jarvis (1992)
particularly emphasizes that time must be spent training
nurses to undertake reflection Jobns & Butcher (1993) and
Johns (1993) clearly demonstrate the time needed to supervise a practitioner who is usmg reflection As well as tune
It takes 'patience and diligence' to reflect, and it can be a
painful expenence (Bolt 1991) Meleis (1991) and Farmer
188
(1991) conclude that there must be the resources to
develop practice theory, mcluding tune and support
An alternative strategy for the development of practice
theory is to bnng practitioners and educationalists/
theonsts together withm the practice settmg Bnngu^
researchers and practitioners together will reduce the inaccessibility of theones to practice (Philhps 1989)
One method of bnngmg researchers and clmicians closer
together m the practice settir^ is within an action research
methodology (Gray & Pratt 1991) which is grounded m
cntical social theory (Garr & Kemmis 1990) This methodology also takes tune (Webb 1989), but joimng together
using such a collaborative approach could close the separation which Glarke (1986) identifies between tbeoretical
and practical nurses, and could enhance the development
of practice theory
WHO SHOULD DEVELOP PRACTICE
THEORY?
Practice theory bas been shown to have benefits for nursing
practice and tbe development of nursing knowledge Its
development is in its mfancy and the body of knowledge
that IS developed through pracbce theory has been likened
to a delicate plant (Reed & Procter 1993) Usmg Reed &
Procter's (1993) analogy, the plant's roots are firmly
embedded m practice and this should make it stronger to
withstand the winds and demands of the changing health
care arena
Whether practitioners are ready and able to take on the
role of developing practice theory bas been considered It
has been seen that practitioners do not often recognize the
potential for tbeory development ui practice, and uideed
do not view themselves as theonsts Again perhaps this is
the legacy of the past, with nursmg's emphasis on empmcism and 'domg' rather than undertaking scholarly
activity
Action research
If practice theory can be sold to practitioners, resources
such as time and support are needed for reflection to
develop practice theory Action research is also discussed
as a mechanism for bringing researcbers and practitioners
closer together to develop practice theory It bas been seen
that practitioners have access to a wealth of knowledge
that can be developed into practice theory through the
process of reflection However, until they are sold its benefits and have had the opportumty to develop appropnate
skills, nursing must also be sure that the 'methodologically
ngorous baby is not tbrown out witb tbe positivist
bathwater' (Bond 1993) and theory development should
be encouraged along tbe continuum (Stevens 1984)
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