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.