Teresa Tarnowski Goodell, PhD,RN,TCRN,CWCN
A recent post by Karen Foli presents a perennial nurse educators’ problem: students finding nursing theory irrelevant in practice. A commenter wrote, “If I have a patient crashing, I’m not going to stand there and theorize about how to treat the patient!.” The remark illustrates the theory-practice gap perfectly; the notion that there is little practical utility in nursing theory “at the bedside.”
Nursing theory describes and differentiates us from other professional disciplines, yet many practicing nurses struggle to integrate theory into their practice, perhaps because nursing theory is not recognized by most practice settings. (I certainly didn’t see much of it in my 30 years in intensive care.)
Practicing nurses swim in the water of the medical model. Just as the fish says, “Water? What water?” when asked “How’s the water?,” nurses don’t always realize that they are swimming in the water of the medical model in their practice setting. Nurses implement both nursing and medical models, yet only the latter holds sway in many practice settings.
The electronic health record serves as an indicator of the widening theory-practice gap. Filled with checkboxes for medications, procedures, and physical exams, the EHR leaves little room for documenting nursing theory-guided practice. Built on the medical model and optimized for billing and regulatory purposes, the EHR cannot capture self-efficacy, unmet needs, living with unpleasant symptoms or helping, all concepts informed by nursing mid-range theories.
The EHR is also poor at capturing individual characteristics, such as whether someone is a night shift worker who sleeps during the day. Even when mid-range theories are in the back of a nurse’s mind, quietly informing practice, they are not visible in documentation. Because they are not seen, they become less valued by nurses and other health professionals.
The theory-practice gap affects research as well. Evidence-based practice is inhibited by a lack of research guided by nursing theory. While our colleagues in medicine rarely cite a theoretical framework, one is expected, and useful, in nursing research. Nurses acknowledge that there are many ways of viewing health and illness. Still, the medical model predominates in practice settings, inhibiting broader research implementation. Individual nurses can’t implement research based on nursing theory; nursing practice must make sense to others and must be visible in the EHR. Thus, practicing nurses who decry the pointlessness of nursing theory can’t be blamed; they practice in an environment where, for example, documenting self-efficacy for breastfeeding is irrelevant to other users of the health record. There is no checkbox for it.
My cynical side says the medical model is linked to payment and regulatory oversight, and thus will continue to prevail in clinical settings. This calls upon us to ask: how then do we acknowledge, incorporate, and communicate nursing theory within our own profession, and also outside it? How do we implement evidence-based, theory-driven nursing practice when large parts of research and practice are driven by the medical model? Nurse educators have been doing this work, but we also need drivers of change in the clinical setting.
I envision a time when nurses study pharmacology, yes, but other health professionals also study Kolcaba’s Theory of Comfort (for example.) A time when the EHR captures more than medications, procedures and physical exams. When nurse informaticists play a key role in design of clinical information systems, incorporating nursing models, interventions and observations into the EHR. Improving the presence of nursing knowledge in the EHR will not only provide practicing nurses with more complete information about the person, but it will make nursing more visible to other professionals. Changing clinical settings entrenched in the medical model will be hard. How do we develop nurse change agents to get us there?
About Teresa Goodell
Gerontology, trauma, and skin/wound care clinical nurse specialist. Now retired from clinical setting, I serve on the board of a hospice and teach trauma continuing education. I’ve been an RN for 38 years and a clinical nurse specialist for 27 years. Nurse educator in academic and continuing education settings for 26 years.
7 thoughts on “Guest Post: Mid-Range Theory: In the Gap or In The Dark?”
Great post, Teresa!
I like your statement that “Practicing nurses swim in the water of the medical model”. Indeed, nurses can and should make NURSING visible in the Electronic Health Record (EHR).
We did so in many settings by implementing Standardised, NURSING LANGUAGE (SNL) and the Advanced Nursing Process. By doing so, nurses state and document nursing diagnoses like a) Anxiety, b)Powerlessness or c) Family Caregiver Stress Overload, with research-based linked interventions, e.g. for a) Anxiety reduction, for b) Self-Efficacy Enhancement, for c) Family Coping Enhancement – to give some examples.
Evidence-based SNLs enhance individual caregiving, and are implemented into EHR systems around the world (Jones et al., 2010). Nursing informatics with a strong focus on nursing as a profession – using a nursing framework and languages – developed EHR systems (Keenan et al, 2008, 2018; Macieria et al, 2019). There is international collaboration on using SNLs (Rabelo-Silva et al, 2020).
An interesting study by Roussi et al., has shown that MDs and RNs do not speak the same professional language, because the focus and resposibily of the professions are different (Roussi et al, 2015).
New decision support systems are tested to help nurses to be visible in the EHR (Stifter et al, 2018), and we published an International Standard for Nursing Process-Decision Support Systems (Muller-Staub, 2016).
Whereas nursing theories and models are used to guide role understanding and the professions’ framework, we need operationalised concepts (in the Advanced Nursing Process) to speak and document nursing. By doing so, we can make nursing visible, documentable, and researchable.
Jones, D., Lunney, M., Keenan, G., & Moorhead, S. (2010). Standardized nursing languages: essential for the nursing workforce. Annual review of nursing research, 28, 253-294. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21639030
Keenan, G., Tschannen, D., & Wesley, M. L. (2008). Standardized nursing teminologies can transform practice. Jona, 38(3), 103-106.
Keenan, G. M., Lopez, K. D., Sousa, V. E. C., Stifter, J., Macieira, T. G. R., Boyd, A. D., . . . Wilkie, D. J. (2018). A Shovel-Ready Solution to Fill the Nursing Data Gap in the Interdisciplinary Clinical Picture. Int J Nurs Knowl, 29(1), 49-58. doi:10.1111/2047-3095.12168
Macieira, T. G. R., Chianca, T. C. M., Smith, M. B., Yao, Y., Bian, J., Wilkie, D. J., . . . Keenan, G. M. (2019). Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review. Journal of the American Medical Informatics Association : JAMIA, 26(11), 1401-1411. doi:10.1093/jamia/ocz086
Muller-Staub, M., & Paans, W. (2016). A Standard for Nursing Process – Clinical Decision Support Systems (NP-CDSS). Studies in health technology and informatics, 225, 810-811. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27332353
Peres, H. H., de Almeida Lopes Monteiro da Cruz, D., Lima, A. F., Gaidzinski, R. R., Ortiz, D. C., Mendes e Trindade, M., . . . Batista de Oliveira, N. (2010). Conceptualization of an electronic system for documentation of nursing diagnosis, outcomes, and intervention. Studies in health technology and informatics, 160(Pt 1), 279-283. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20841693
Rabelo-Silva, E. R., Monteiro Mantovani, V., Lopez Pedraza, L., Cardoso, P. C., Takao Lopes, C., & Herdman, T. H. (2020). International Collaboration and New Research Evidence on Nanda International Terminology. Int J Nurs Knowl. doi:10.1111/2047-3095.12300
Roussi, K., Soussa, V., Dunn Lopez, K., Balasubramanian, A., Keenan, G. M., Burton, M., . . . Boyd, A. D. (2015). Are we talking about the same patient? Studies in health technology and informatics, 216, 1059. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26262358
Stifter, J., Sousa, V. E. C., Febretti, A., Dunn Lopez, K., Johnson, A., Yao, Y., . . . Wilkie, D. J. (2018). Acceptability of Clinical Decision Support Interface Prototypes for a Nursing Electronic Health Record to Facilitate Supportive Care Outcomes. Int J Nurs Knowl, 29(4), 242-252. doi:10.1111/2047-3095.12178
Great to hear that you’ve been in clinical settings that are successfully implementing nursing models! I think the literature you refer to is one way of disseminating these interventions, but, again, only nurses are reading this literature. We need ways to reach out to other professions. Thank you for your remarks.
Brings memories of students before they understood that nursing theory needed to be in them. That was the gap I saw teaching nursing theory.. Once they experienced theory as a logical framework that guides their thought and action, and applied a theory in an in-class presentation there was a great ah ha by the presenter and the other students. Yes I taught theory with a lab. It was a students response in clinical as Neuman’s model guided her that I realized they need to see it help their own practice to understand. She said, “when you said it’s a model I didn’t realize you meant it was a MODEL” thank you for reminding me.
Martha, what a great story! It has to “trickle down” into the student’s mind, doesn’t it? We’ve all seen that wonderful moment when the “Aha!” occurs. That means you’re doing nursing education right, in my opinion.
Thank you for raising this issue! Nurses cannot know that nursing theory is being implemented all around them if it is not articulated. Why are there rocking chairs in nurseries? Why do parents of pediatric patients room in? Why do we have flexible visiting in hospitals? Why do we worry about patient teaching? Why are fathers welcomed into the births of their children? All of these practices were instituted because nurse researchers developed the theoretical bases for these practices back in the 1960s and 1970s. Nursing students need to be taught the historical contributions of our science the way students in other scientific disciplines are taught the chronology of their field’s development. Otherwise they cannot know it.
Great examples of how nurses have changed health care! Thank you.
Thank you for this important post! Your points about nurse informaticists and nursing theory representation in the EHR made me wonder if nursing theory is taught in graduate-level nursing informatics programs? That might be a way to move toward that change.