Contributors:
Emma Crocker, DNP, RN
Patrick McMurray, BSN, RN
Shelley Mitchell, BA, BSN, MS, RN
Elizabeth Mizerek, MSN, RN, FN-CSA, CEN, CPEN,
CNE, FAEN, PhD Candidate
Timothy Joseph Sowicz, Ph.D., NP-C
Authors’ Disclosure:
The authors would like to note that all members
put in equal amounts of work in this project.
Nursing theory is the foundation of our practice, the way we differentiate nursing from other professions and disciplines. As readers of the Nursology blog, we assume that we do not need to discuss why nursing theory is essential to our practice. We would instead like to call your attention to a concerning trend – the lack of nursing theory in associate degree nursing programs. Please note that we are making generalizations based on our experience of graduating from and/or working in associate degree programs. There is a paucity of current research surrounding theory in associate degree programs.
According to the National Council of State Boards of Nursing (NCSBN), in 2019 50% licensure applicants were graduates from ADN and diploma schools of nursing; this number has historically been even higher. In other words, half of our newly practicing nurses may not have foundational knowledge of nursing theory to apply to their practice, further widening the theory practice gap. If theory content is not being integrated into the initial nursing education for half of our profession, how can we convince them it is important, let alone essential to their praxis?
We suspect that several factors contribute to the lack of theory in some ADN programs. Many nursing education programs are externally accredited by agencies such as the Accreditation Commission on Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE). Previous accreditation standards required nursing education programs to explicitly name the nursing theorists that guide the curriculum. This emphasis has been removed from current standards, allowing nursing education programs to use general educational theorists such as Knowles Adult Learning Theory.
Another critical point is that ADN programs do not usually require doctoral-level preparation for nurse faculty. According to the 2018-2019 National League of Nursing’s annual survey of nursing schools, 74% of schools replied that it was “somewhat difficult” or “challenging” to hire new faculty. The primary reasons cited were an inability to offer competitive salaries and a lack of qualified candidates. ADN programs usually have fewer financial resources and do not have research missions. Therefore, they have difficulty attracting and retaining faculty with research-focused doctorates and higher educational credentials. This may result in ADN faculty who do not have the knowledge and/or experience with integrating theory into pre-licensure education.
Without the requirements of accreditation and with faculty who are not supported and enabled to the inclusion of nursing theory, it is our anecdotal observation that many ADN programs have dropped the emphasis on nursing theory. We have personally worked in nursing education programs where theory is either given cursory attention or not included in the curriculum at all. This has resulted in removing or deemphasizing nursing theory from a large portion of the nursing professional population.
Nursing theory is currently situated in a place where it feels like it only belongs to some nurses, those embedded in academia or research, never practice. This has created a culture where most nurses and students cringe at the thought of theory-based content, with some complaining it has very little to do with “real-world” nursing practice. Nursing theory has not been made relevant to the modern nurse.
Many nurse scholars might use this conversation as yet another reason why the entry level of nursing practice should be raised. Students seeking nursing education in the U.S. encounter many barriers, such as socioeconomic status, geography, structural racism, and more. Many of these students choose to attend ADN programs rather than seek a BSN, especially as their entry to practice. If we want to continue to grow the practice of nursing in the US, we need to support and encourage ADN programs, especially in the integration of nursing theory in practice.
The authors of this blog post greatly value the contributions of ADN programs, ADN graduates, and ADN educators. We would like to challenge all educators, scholars, and researchers to consider how we might restore nursing theory to its rightful place in all levels of nursing education. Nursing theory belongs to all nurses – not just those in higher education.
Nursologists, what do you think?
About the contributors:
Emma Crocker, DNP, RN – CHIPS Health and Wellness Center, St, Louis, Missouri. Emma is a equity driven, population health quality improvement doctorate and advocate, devoted to ensuring the implementation of constituent-centered health policies, enabling communities to thrive located in St. Louis, Missouri. Twitter: @EmmaCrockerDNP.
Patrick McMurray, BSN, RN – Adjunct nursing faculty, Robeson Community College, Lumberton, North Carolina. Patrick is a Adjunct Nursing Faculty at Robeson Community College, in N.C. Patrick is patient about community college nursing education and championing social change via equitable access to nursing education. Twitter: @nursePatMacRN.
Shelley Mitchell, BA, BSN, MS, RN – Professor of Nursing, Austin Community College, Austin, Texas. Shelley contains multitudes. She teaches full-time in Austin Community College’s Professional Nursing Program, which has been voted as the best in the region for three years in a row, and she is deeply involved in the college’s equity and inclusion work. She has a BA in English from Oberlin College in addition to her nursing education, and she reads comics and writes queer romance in her spare time. Twitter: @ProfShelleyRN
Elizabeth Mizerek, MSN, RN, FN-CSA, CEN, CPEN, CNE, FAEN, PhD Candidate – Director of Nursing Education, Mercer County Community College, West Windsor, New Jersey. Elizabeth is the Director of Nursing Education at Mercer County Community College in New Jersey. She is currently a PhD candidate at Widener University in Chester, Pennsylvania pursuing a doctoral degree in Nursing Science. Her research interests include nursing education, patient safety, and emergency preparedness.
Timothy Joseph Sowicz, Ph.D., NP-C – Assistant Professor, UNC Greensboro, Greensboro, NC. Tim is an assistant professor at UNC Greensboro. His research is concerned with aspects of living with heroin and opioid use disorders, especially following an overdose.
I work at a school with PN, ADN, and BSN programs and we do not discuss nursing theory or have a nurse theorist. This has given me a lot to think about.
Thank you for this compelling commentary. I applaud your efforts to make several valid points on the topic including faculty preparation and accreditation. Nurse educators must illuminate, integrate, and apply theory at every opportunity in their practice – nursing theory.
One observation I have in my role as educator, with quantitative data as evidence, is that theory, is at times, a weakness in graduate nursing student learning outcomes. I also observe that faculty, even at the graduate level, hold varying degrees of appreciation for, and use of theory in educational strategies. Many may have not used a nursing theory in their doctoral work at all.
If we are going to advance our discipline we must support the use of nursing theory in our work, and the work of our students, at every opportunity we have – and at every level of nursing education. The background of nursing knowledge has transitioned from a receptive phase wherein nursing knowledge was attained from other disciplines, to a self-generative phase wherein knowledge focused on nursing itself, and then on to a transformative phase wherein nursing knowledge has the capacity to influence nursing practice and disciplines other than nursing (Newman, Smith, Dexheimer, Pharris, & Jones, 2008).
The majority of researchers that have cited my study about anti-Muslim discrimination (Martin, 2015), guided by Ray’s (2016) Transcultural Caring Dynamics in Nursing and Health Care Model, are from disciplines other than nursing. The time is now for all nurses to enact this transformative phase, as we possess a definitive body of knowledge derived from both nursing and the social sciences including anthropology, psychology, and political science. Embrace the opportunity!
References
Martin, M.B. (2015). Perceived discrimination of Muslims in health care in the United States. Journal of Muslim Mental Health, 9(2). https://quod.lib.umich.edu/cgi/p/pod/dod-idx/perceived-discrimination-of-muslims-in-health-care.pdf?c=jmmh;idno=10381607.0009.203;format=pdf
Newman, M., Smith, M., Dexheimer Pharris, M., & Jones, D. (2008). The focus of the discipline revisited. Advances in Nursing Science, 31(1), E16-E27.
doi:10.1097/01.ANS.0000311533.65941.f1
Ray, M. (2016). Transcultural caring dynamics in nursing and health care. F.A. Davis.
I am a supporter and advocate for nursing theory, but it is sometimes not appropriate for doctoral work. For example, try as I may, when I set about to create a pn instrument to measure shared governance 30 yrs ago at Penn, where I was schooled in nursing theory by no less than Jackie Fawcett, I could not find a theory that would be foundational for my work. I had to essentially borrow and create my own from other discipline’s theories. I anticipated that I would eventually land in other professions’ spaces where a nursing theory would serve well. My point is that we keep our minds open to many potentials.
I agree that sometimes we can borrow and create theories from other disciplines. I would also like other disciplines to borrow and create from us! I have a dream of someday co-writing a piece on using the nursing process to analyze literature with a friend who is ABD in English. Let’s work with educational theory, with literary theory, with sociology, and more. We already use scientific theory, after all. But we can work with those other theories (and hey, how about some critical race theory, huh? We could really stand to do a lot more with that!) and create a blend that is both open and unique.
A beautiful example of this is the piece that Jess Dillard-Wright, Jane Hopkins-Walsh, and Brandon Blaine Brown (all of our own NTC!) did, “We Have Never Been Nurses: Nursing in the Anthropocene, Undoing the Capitalocene” (https://journals.lww.com/advancesinnursingscience/Fulltext/2020/04000/We_Have_Never_Been_Nurses__Nursing_in_the.4.aspx).
Hi Robert!
I appreciate your post, but I do respectfully disagree. What you actually did is what we need in nursing, the development of NEW theory. Just because we have historical theories, doesn’t mean they answer all of our questions (and rightly so!). One purpose of science in itself to develop a deeper understanding of a specific area of interest – if we constantly focus on the knowledge we have how we will do that?
I, like you, in my doctoral work found no fitting theory for my problem of interest. Luckily, I was encouraged by my advisor to develop my own thinking – a conceptual or theoretical framework that is, for what I thought explained my ideas. Before we had our grand theorists and those we refer to as our theoreticians in our discipline, they didn’t have any frameworks to follow either. Therefore, it’s time we as nurses grab our epistemic authority and get to work if we do not see a “fitting” theory – theory is not prescriptive, it is a tool in which we can explain what we see in the world. Thank you for theorizing in your doctoral work in an innovative way!
With gratitude,
Chloe
Yes, I had to build my own theory, based in reality.
I deeply appreciate your thoughtful essay and I share your concerns. To add to the urgency of the issue, the new essentials documents from AACN that guide pre-licensure and post-licensure education for many schools further diminish the attention paid to nursing theory.
I realize I’m probably speaking to the choir but I’ll say it anyway. I challenge you to find 10 BSN programs that genuinely teach nursing theory as a foundation for nursing practice…or 5 MSN programs…or 3 PhD programs…or 2 DNP programs. Wouldn’t it be ironic if a re-valuing of nursing education actually grounded in nursing theory were to emerge from associate degree nursing programs! Thank you for this wake up call. Now let’s work on getting it out of the choir loft and into the nave and beyond. One way to begin to do that is to make sure every single nursing paper you publish is explicitly grounded in nursing theory. Further, that every single nursing education assignment requires an explicit framework of nursing theory.
I’ve had the privilege of teaching in one (RN to BSN) program that emphasized the school’s commitment to nursing theory. They relied on Erickson’s Modeling and Role-Modeling Theory and built a required course that I was invited to teach. It proved pivotal in helping adult, mid-career, learners understand how theory can be a foundation for practice.
I am now retired from nursing and practicing as a Health & Wellness Coach, but in my every-day life I continue to embrace Margaret Neuman’s theory of Health as Expanding Consciousness. It informs my own choices as a healthcare consumer and my conversations with clients whose lives are filled with self-defeating belief systems. Grounding my practice in Newman’s work continues to expand how I rely on nursing even as I work as a coach.
great content! plus it included reliable sources too