Say It Ain’t So:  Graduate Students Shade Nursing Theory!

Karen J. Foli, PhD, RN, FAAN

I’d finished grading the last of the master’s-level students’ theory in nursing papers. I’d turned in final grades and then, the message came through: anonymous student course evaluations were ready for my review. I took a long sip of water and put my organic, no preservative, granola bar aside.

Steady, old girl, I said to myself. You have tenure. How bad could they be? I’d done my very best in this hybrid-structured course. The graduate students met on campus about five times throughout the semester and the rest of the “class meetings” were virtual. I liked the hybrid structure as it offered the students a sense of community; yet the online component allowed them to be self-directed as adult learners. I tried to impart a rudimentary foundation of the philosophy of science, and used discourse that included logical positivism, epistemology and ontology. The course content included a deep dive into concept analysis, nursing theorists and the major health behavior theories and – I thought – many applications of nursing theory to practice decisions and interventions. Assignments were student-personalized, asking for them to express their own philosophies of nursing care, present on nursing theorists’ work, and take a stab at concept analysis or critique a published analysis.

Yet, here I sat, wanting to avoid the dreaded student evaluations. No delaying it any longer.  I logged into the student evaluation portal and winced as I read the polarized comments. Many were very complimentary: “Course well organized. Grading was clear with helpful comments given on papers.” A continuation of gratifying comments: “Didn’t think I’d like theory, but I did. Liked the examples. Related it to real life. Dr. Foli’s passion really came through and helped make the class enjoyable.”

Then, one student’s comments made me stop. “Too many readings. I didn’t read most of them. I had to take time away from studying for patho and that’s what a nurse practitioner needs to know.”

Flinging the granola bar into the trash (it tasted like sawdust anyway), I reached for the Little Debbie Valentine cake.

What??? I had practically done summersaults trying to get the practice-to-theory connection in this class. And then I paused to reflect on my audience: students enrolled to become primary care nurse practitioners. Many continued to work at the bedside in highly stressful jobs. They all had personal responsibilities, some of which overwhelmed them (an ill child, a sick mother).

When I spoke to the class at the beginning of the semester, I asked them a question that I didn’t need a public response to: “Are you running from something in your current job or running toward a goal of being a nurse practitioner?” Upon hearing this question, I always looked for the nonverbal responses: heads slightly turned down, eyes glancing sideways. Mouths in grimaces. The ones that seemed to embrace the new career path continued to look directly at me.

So I knew from the beginning of the semester this was a tough audience. These folks were frontline, point-of-service providers who had witnessed and experienced nurse-specific trauma on an ongoing basis. Sadly, for the majority of them, nursing theory meant little.

They were here in this first semester graduate class to learn the facts, just the facts. Or as Chinn and Kramer (2015) describe it: empirical knowledge. As advanced practice nurses, they would be tasked to diagnose, prescribe, recommend a treatment plan, and manage illnesses. They’d also engage with the patients to promote wellness and encourage disease prevention. What did theory have to do with all that?

Well, as I read the students’ comments, I wondered what more I could do to ensure they saw the connection between all the ways of knowing (Chinn & Kramer, 2015), how to apply middle-range theories to their practices, and use theory as an organizing framework to track efforts. I wanted them to see patients as dynamic individuals, not merely as objects that may or may not adhere to a treatment plan.

As I put the Little Debbie wrapper in the trashcan, I felt invigorated (it could have been the sugar rush). They may have thrown some shade at theory, but I pulled out the course syllabus, reviewed it, and made note of how I could continue to refine the course so that every student would see the value of theory in primary care. I did this because it’s so important for our profession. Nursing theory gives us identity, ways to increase nursing science/nursology and patient care practices. As the Year of the Nurse and Midwife, the timing couldn’t be better!

What about you?  If you have suggestions for me on how to strengthen the theory-to-primary care advanced practice connection in a master’s level course, please forward them in the comments below.

Or, better yet, go to Nursology’s Teaching/Learning Strategies (https://nursology.net/resources/teaching-strategies/) and complete the form to submit a strategy to strengthen the link between advanced practitioners’ theory-guided knowledge and nursing practice.

Thanks in advance for your help!

24 thoughts on “Say It Ain’t So:  Graduate Students Shade Nursing Theory!

  1. Hi Dr. Foli,

    Thank you for sharing your experience in teaching advanced practice nurses. I really enjoyed your post.

    I find it concerning (but not surprising) the rebuttal from the anonymous student automatically emphasizes pathophysiology over unique nursing knowledge. I remember early in my doctoral education I often saw a ‘gap’ between theory and practice, meaning that, what I would have deemed important for the practice environment was different than the academic environment.

    Have you, or anyone for that matter, ever tried beginning coursework discussion on theory with NP//DNP students on their opinion of nursing theory, if/why they believe pathophysiology/something else is most important? I think that this may refer back to nurses’ epistemic authority, and the nurse/nurse practitioner does not believe that they have the ability to develop new knowledge (theory) when they notice a gap. Perhaps students would feel more empowered if they knew in recognition of the absence of a theory, they could actually develop one themselves?

    Thank you again for sharing!

    Liked by 1 person

    • Hi Chloe,
      Thank you for this comment! You bring up several good points — especially empowering the NP student to “own” theory on a personal/professional level. Challenging their thoughts on NP empiric knowledge might very well encourage them to be broader in their appreciation of other ways of knowing.
      Thanks again,
      Karen

      Like

    • This is my third attempt at responding, so I hope this one goes through. Like so many third drafts (where the first two are lost to me), it will likely lack the pithiness of its ancestors, but what the heck.

      Three thoughts. One, most of your students seem to have gotten it. There’s always that outlier, though, but think of this as the horseradish, not the whole roast. Don’t worry too much about changing the whole meal for a condiment, no matter how right it is.

      Second. I’ve taught undergraduates and others for years. When things start getting deep-divey, I stop and ask, “Why do we care?” Usually, this has been in the context of some arcana like sodium/water balance or acid/base regulation, but the point was to let them know how to think about how, exactly, they could use this when they were at the bedside, something students rarely grasp unless somebody hits them over the head with it.

      Consider sharing your entire post with the very first FTF meeting of your class next semester. It may be just as surprising, and confrontational (in a good way). In addition to the brilliant, “Are you running to or away from?” question (so applicable in so many contexts… I am so stealing this) asking them “Why do we care?” may also elicit some higher-level thinking on the meaning of CARE at a higher level of practice; if not, you could guide them there too.

      At very least you can think of this slight digression as a piton, a pretty small thing at the bottom of a big climb but that becomes more important the higher you go. As the class climbs, once in awhile you could point out periodically how this insignificant object became more important as an anchor that helped them get this far, and a support for what- and who– follows. “Why do we care?” may even prompt your patho geek to blink, look at things from another perspective, and integrate it in.

      And a final thought: Why do we care?

      Liked by 1 person

      • Hi Wendie,
        What a wonderful reflection on my blog post! I really like all your ideas and suggestions, but especially using this blog itself as a learning tool. I agree also that the “condiment” comment is indeed just that. But there are enough of the students (ketchup, mustard, and relish) to make me pause and want to get the whole meal on board with my message.
        Great writing and great ideas!
        Thank you,
        Karen Folli

        Like

  2. One of the reasons the students and other nurses don’t recognize the importance of nursing theory may be their lack of background in Liberal Arts and Humanities. Courses in Philosophy, Religion Logic and Epistemology provide a background for the importance and origin of knowledge. This foundation is applied life long in personal and professional roles. It can certainly highlight the necessity of theory throughout our professional lives.

    Like

    • I agree wholeheartedly. I was recently writing a book on nurse-specific trauma and brought in a passage from Cancer Ward, by Aleksandr Solzhenitsyn. I read that book over 30 years ago, yet it has stayed with me and was introduced in a liberal arts course. Great comment — thank you!

      Liked by 1 person

  3. Greetings from Canada! In my first graduate course, Theoretical Foundations of Nursing Practice, though I count myself among those who pursued an MSN, I had several colleagues in this class who were in the NP stream. I recall the readings in the first two classes really drew us all in (regardless of whether we were in the MSN or NP streams) and to this day I can remember the incredibly rich dialogue that pursued. I am here to make recommendations perhaps on some readings that can open discussion and engage the future APNs in a deep reflection of connecting the critical need for understanding theory in order to have a more unified connection with practice. These readings were:

    1) Feo, R. & Kitson, A. (2016). Promoting patient-centred fundamental care in acute healthcare systems. International Journal of Nursing Studies 57, p.1-11. http://dx.doi.org/10.1016/j.ijnurstu.2016.01.006

    2)Hatrick-Doane, G. & Varcoe, C. (2005). Toward compassionate action: Pragmatism and the inseparability of theory/practice. Advances in Nursing Science 28(1), p.81-90.

    I truly hope these are helpful to your ever growing and dynamic syllabus! I also wanted to add I agree with earlier comments about how nurses lack the ability to make these critical connections because of no Liberal Arts & Humanities exposure throughout undergraduate training, and an ongoing emphasis on these as they transition into practice too. This is especially challenging as the focus always seems to be on how fast can one gain practical skills – as can be seen in most undergraduate nursing students. Similarly, once we hit practice, there usually is no one there to promote the sense of ongoing professional development that moves beyond upgrading skills to appraising theoretical concepts that could in fact assist in providing better care and in having an increased understanding of the self as a nursing professional. I think it once again serves as opportunity to reform nursing education to meet today’s demands, but to also equip the next generation with the notion that there is no nursing practice without nursing theory.

    All the best!

    Liked by 1 person

  4. Hi Raluca,
    Thank you for these valuable readings! I will be sure to incorporate these as I add to the course design. You bring up important points about dialogue with students and the importance of being taught to think about how knowledge is created and used in our profession.
    Thanks again!
    Karen

    Like

    • So happy to contribute in any way I can! I just wrapped up my MSN and feel ever indebted to my professors and everything they taught me these last 2.5 years. I enjoyed the conversation on this topic here 🙂
      -Raluca

      Like

  5. Hi Dr Foli
    Thanks for your column and openness in describing your experiences.
    Indeed, Master Programs focus way too much on pathology, medication etc.
    If each course would focus on ADVANCED NURSING, NPs would understand and become prepared being graduated NURSES, based on nursing theories and science.
    These programs felt back into the medical model, ending in „higher fashions“ of acting as servants of medicine – instead of representing our own profession. Our research shows that using our own professional language as described in NANDA- I diagnoses, evidence-based nursing Interventions (Nursing interventions classification NIC), and outcomes (NOC) are tools to name nursing on the concrete clinical level. They allow putting nursing theories into action. The research section is in the appendix of:

    Expert report on Nurses Resonsibility,
    Nursology.net/policy-theory/nurses-accountability/

    All the best and thanks for your work!
    Maria

    Like

    • Hi Maria,
      You’ve hit on an incredibly important point — NPs are ADVANCED NURSES. This conversation is often unspoken and someone who is not an NP, I feel a bit vulnerable to jump in at times. Thank you for your post and this wonderful resource!
      Karen Foli

      Like

  6. Thank you for writing about this topic! I have always wanted to write a journal article on this exact topic. During my BSN and MSN programs, I did not appreciate the significance or the purpose of nursing theories. As a BSN student, I can remember saying to my peers, “what is the point of learning about this theory that was written by someone 50 years ago?” It was not until I was in my PhD program that I finally understood the purpose and significance of theories.

    I have now taught EBP and Research courses to undergraduate nursing students for the past 5 years and most students have the same perspective toward theory that I had as a BSN student. My experiences coupled with my students’ experiences has made me realize that the significance and importance of nursing theory is not inherent. As educators, we need to think of innovative ways to teach nursing theory to undergraduate and graduate students.

    Another piece of the puzzle is integrating nursing theory across the curriculum and making it apparent to students. The school I work for uses Jean Watson’s Caring Science theory as the foundation for our program, classes, and curriculum. It is integrated in everything we do, but still needs a lot of perfecting to help students appreciate the importance of it.

    A huge barrier is the clinical component of nursing school. I have yet to find a practicing nurse in my community that can speak of how they integrate nursing theory into their practice. In fact, I have had many students tell me about a nurse who told them that “theory is stupid” or “theory is pointless.”

    Like

    • Michael,
      I hope you write that article! Very welcomed perspectives and I am glad to learn about Watson’s Caring Science being integrated into your curriculum — a big step in helping students internalize nursing theory as part of their education.
      I agree that the clinical component is a real barrier. That also speaks to the executive leadership in industry connecting theory with practice and infusing it within their organizations.
      Thank you for these insights!
      Karen Foli

      Liked by 1 person

    • Precisely why you ask students, “Why do we care?” This also puts me in mind of when I did workers comp medical case management. I would go to an injured worker’s home for my initial assessment, and introduce myself. They would usually receive me politely, but often warily. No matter. Every time, I would settle into the chair and say, “I know what you’re thinking. Your brother-in-law or cousin or friend has said something like, ‘You’re from the insurance company, you don’t care about me, you just want to save money,’ “ (blinking and sideways glances usually ensue)
      “So let me tell you, I was a nurse for a long time before I chose this work, and it’s unethical for me to do anything I know would be harmful to you or to let something harmful happen by not doing something for you.” Then I would explore with him how comp doesn’t pay as much as the job, so if I help him get better, he gets more money and his benefits and seniority accumulation kick back in; if he gets better the employer saves money because their premium costs don’t go up because of the claim and they don’t have to pay OT or train somebody else; and of course the insurance company saves money. “So the only one that doesn’t do better when I help you get better faster is me, because I’m on salary.” By now they’re chuckling, and we get on with it.
      By the same token, when students did the dreaded care plans, I used to say, “I know that the nurses you work with tell you something like, ‘Oh, that care planning, nursing diagnosis thing is all bull, all that as-evidenced-by crap, nobody does that in the real world,’ right?” (sideways glances- she doesn’t know anything about the real world, she’s an academic) “So why are you here? I know you think it’s to finish that lab skills check off and get ‘skills.’ Shots, IVs, catheters, oooh, big stuff. Wrong-o. We can teach ‘skills’ to anybody. You are here to learn to think like a nurse.” And then I explain that I worked bedside for a lot of years (and often still was) and figured out that learning to think like a nurse is like learning to drive (more blinking).
      “When you first learn to drive, it’s confusing. You do all that crap in drivers ed classes, but who cares? You’ve been watching people drive all your life, it’s easy. And then you actually get behind the wheel. You check everything three times, you anxiously look around, you can’t have the radio on, traffic is scary, you have to remember to look at the signs, and we all know what inexperienced drivers do sometimes. But now, years later, you grab the keys, back down the driveway with your to-do list in your head and head into traffic with NPR on and the kids bickering in the back, and you’re fine. Now you’ve had a lot of practice and it’s second nature.
      “Those nurses who say they don’t use nursing dx – they do. They have a theory about why they do what they do even if they don’t use Watson’s or Orem’s language to describe it. They use it every day because somebody made them reiterate the process by which it happens. They don’t have to write the as-evidenced-by, cite Callista Roy or chart the exact NANDA language, but it’s exactly what they’re doing. You will learn to think like a nurse by practicing thinking like one doing plans for care. And so forth. Why do we care?” And then you get on with it.
      So… (and you wondered where I was rambling to get this far, eh?) you say exactly the same thing to your NP students. Tell them you know that they think they’re there for the patho and getting prescriptive authority and The credential and all. There will be blinking and sideways looks. And then … .

      Like

  7. Thank you so much for this post. While I teach a knowledge development course to PhD students with Danny Willis, I also worry that the students will not see that nursing theory is applicable and relevant, and is becoming *more* relevant as nurses develop and apply nursing theories in research and practice. I love your question about running from or to something; I hope to figure out how to incorporate that into my future teaching! Anyway, thank you for voicing what I suspect is an unstated fear of many faculty who teach these types of courses – that we will be unable to highlight the relevance of nursing theory to research and practice. I’d love to hear more about how you update your course for next year!

    Liked by 1 person

    • Hi Anne,
      Thanks for your comment! I would like to do a few things differently next fall — and I am going to use this blog as an instructional tool. They could reflect upon it in a online discussion or during our on-site meetings. I also think the recommendation to personalize theory is a good one. Using case studies that may be more empirically based is another strategy I’m considering.
      One of the aspects of being a teacher is being creative and problem solving how best to deliver content: these are what makes the role enjoyable.
      Take care,
      Karen

      Like

  8. By logging in you’ll post the following comment to Say It Ain’t So: Graduate Students Shade Nursing Theory!:
    Dr. Foli,
    After 5-7 years of doing an on-line only theory class this semester I also started a hybrid model. Our plan is to meet 8 times over the course of the semester as whole class and
    in between times there are assigned readings and slide set. The weeks we don’t meet I am available in my office from 9-10:50 for office hours. So, far so good. We had wonderful discussion today, including some new insights on Ms. Nightingale and her contemporary, Mary Seacole. Over the years there has been a bit shade thrown at theory! However, the class has been transformative for a few students and for me personally. I have had the honor of reading the practice narratives of students that I knew as undergraduates and seeing how their practice has evolved over the past decade.
    An interesting teaching strategy is to have the students to perform an artistic interpretation of a theory. I was left speechless as a group of graduate students wove excerpts from their practice narratives into a long poem that they performed as an aesthetic interpretation of Mishel’s theory of uncertainty. This year a group painted tiles, each with one of letters in NURSOLOGY. They talked about their practice and the impact of the course.
    Keep Hope Alive!

    Like

  9. What a great approach! I, too, have seen the power of aesthetic exercises and art being used to convey complex information, but not in relation to theory! Thank you!
    I also support that theory classes can be transformative for students — and instructors. My theoretical models have contributed to my research over the years and helped me make sense of phenomenon otherwise difficult to understand.
    Yes, KEEP HOPE ALIVE!
    Karen

    Like

  10. When students challenge me that theory is irrelevant I challenge them back. I explain they are already using theory but do not realize it. I then have them examine one of their own patient cases focusing on the care decisions. I ask them to think about the rationale for those decisions. They soon realize theory has shaped their perspective of the patient, the problem, and how to best resolve that problem. Students who feel theory has no place tend to be pragmatic. This exercise is a pragmatic way to gain self-reflection on their practice, and then realize there may be other ways to practice.

    Liked by 1 person

    • Brent, I agree with students’ pragmatism and will use this suggestion in the fall! A professional case study that they have been involved with is helpful — I use such a learning strategy in their first paper with a slightly different focus (having them identify the five ways of knowing outlined by Chinn and Kramer). But I will strongly consider bringing their thought processes and decision making via theory in as well!
      Thank you,
      Karen

      Like

  11. Dr. Foli,
    Theory and history receive much push back in school until people understand why it is important to study these topics If feels like busy work and the same holds true with Nursing Dx in our profession. History has the potential of keeping us from repeating choices and keeps people and populations from having to reinvent the wheel.

    As a master’s degree student I was complaining about wasting my time on theory to my academic adviser. I thought I had already taken theory in the BSN–not so because of the way nursing studies the same thing from ADN to DNP/PHD. It is difficult for the student to understand why we have to continue to repeat the same information until we realize we are NOT repeating the same information, we are delving deeper to improve understand why we are doing what we are doing. One has to understand where they came from to implement meaningful and necessary changes. How can an NP make a medical diagnosis without taking a medical history and listening to why (theory) patients do what they do.

    My adviser told me that everything we do is based on some theory even if we do not know what that theory is it is important to the job we wish to do. I’ve not forgotten that nor her. She has been one of the most influential people in my education.

    Like

    • Ann — well said! There are different points in our educational journeys when we are more open to information than others. I appreciate your emphasis on how important theory is to nurses and nursology.

      Like

  12. I love your use of “theory-practice connection” rather than “theory-practice gap.” The words we use and messages we send make a difference. If we all start emphasizing the connection between theory and practice, nurses will catch on.

    Like

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