Guest Contributors: Marie Gill, Laura Reed,
Keesha Roach, Janet Tucker

In 2021, the American Association of Colleges of Nursing (AACN) published The Essentials: Core Competencies for Professional Nursing Education. One of the outlined competencies addresses the integration of theory and related concepts across entry- and advanced-level nursing programs. Although many colleges and schools of nursing may already have theory and related concepts integrated in their curricula, there remains important conversations that can address the current status of theory use in clinical practice and nursing education.

Sometimes answers to nursing’s questions can be found in early literature. Rosemary Ellis was a nurse theorist, clinician, educator, and researcher who made several contributions to nursing knowledge development. In 1969, Ellis published a paper entitled “The Practitioner as Theorist” wherein she described what makes a practitioner (any practicing nurse) a theorist, how to define and build theory, and how to recognize and harness the power of nursing theory-guided practice (NTGP). In our quest to reconsider approaches to curricular integration of theory and prepare faculty to instruct students on theory-guided practice, DNP and PhD faculty colleagues at the University of Tennessee Health Science Center’s College of Nursing read Ellis’s article in search of her insight regarding the nurse as a theorist and the nature of theory-guided practice. The purpose of this blog is to examine Rosemary Ellis’s conceptualization of NTGP and the relevancy of her ideas for the 21st century. In turn, we will discuss the challenges in nursing education to teach content related to theory and NTGP. We will also offer recommendations to address these challenges based on lessons we learned from her seminal article.

A key to conceptualizing NTGP is to first understand how a practitioner becomes a theorist. According to Ellis (1969), the practitioner is a theorist because they incorporate an implicit or explicit framework to identify specific knowledge and adapt it for the delivery of nursing care. The practitioner as a theorist must understand the conditions for how to apply or not apply a theory or framework in a specific human case. Ellis used the term “practitioner” in referring to the clinical nurse. However, for this blog, we will use the term “nurse” or “nurse clinician” in place of the term “practitioner” to avoid confusion with the term of nurse practitioner. We will also use the term “bedside” to mean nursing alongside the patient in any setting. Ellis conceptualized NTGP as a translational science in which the nurse selects a theory from nursing and/or borrowed disciplines and then applies the theory to unique nursing situations.

Nursing, often considered an applied science, draws extensively from basic sciences and utilizes knowledge from disciplines such as biology, physiology, and psychology. This translation of basic science to NTGP is a vital aspect of the nurse’s role as a bedside clinician. In NTGP, the nurse employs various frameworks and theories informed by basic science to guide the delivery of patient care at the bedside. Conversely, the application of nursing theories at the bedside contributes valuable insights to bench science research. Through translational science, nurses in research, practice, and education gain a deeper understanding of disease mechanisms by being informed by real-world patient experiences. Still, there remains a gap between academic education and clinical application wherein nurses face challenges in translating theoretical knowledge into clinical practice.

Nursing theory guides nursing care; however, nurses may not consciously acknowledge or reflect on its significance. Updating nursing educational programs to include threading the use of nursing theories or borrowed theories throughout their academic trajectory will help to transform nurses’ thoughts and beliefs about nursing theory. Nurses should be educated on the influence of nursing theories on practice and how these theories guide our practice. Using the words “nursing theories” as part of caring for patients, for instance, will help facilitate the transition to formally acknowledging the role nursing theories play in the day-to-day care of patients and their families/support systems. Nurses can shift between many theories when determining their approach to a particular patient or procedure or when caring for the patient’s family/support system. For nurses to find value in nursing theory, they must understand how nursing theory guides patient care. By intentionally introducing theory throughout a prelicensure program, nursing faculty can better equip the next generation of nurses to identify and apply theory when delivering individualized, patient-centered care.

Challenges may arise in nursing education at entry and advanced levels that could impede preparing nurses to translate theoretical knowledge into clinical practice. The first education challenge is that nursing faculty may lack confidence to teach nursing theory and theory content that promotes NTGP. To address this challenge, we recommend that faculty learn how to identify the theories they are already using in their practice to strengthen their theoretical knowledge and thus increase their confidence to instruct on NTGP. From that knowledge, faculty will be more equipped to help students understand that theory drives our practice. Accordingly, faculty should introduce students to nursing theories at the beginning of their initial nursing education and reaffirm these concepts throughout their students’ nursing programs. Application of theory should not wait until graduate education. Instead, nursing educators should help students understand early on that theory provides nursing with a conceptual structure for a purpose and that purpose is practice. Moreover, integration of theory throughout their nursing program does not have to be an additional burden but can be woven throughout the nursing process. For example, in a maternal child undergraduate nursing course, Maternal Role Attainment theory along with the anticipated maternal behaviors could be introduced and included in the student’s postpartum assessment assignment. Many prelicensure nursing programs include a theory course or theory content in coursework, but we must also ask ourselves if we are demonstrating the application of theory in the clinical setting?

Similar to the challenges of teaching NTGP in prelicensure programs, graduate APRN programs face unique obstacles. The first challenge is incorporating the use of nursing theory throughout APRN educational programs and demonstrating the use of NTGP as a program outcome. To address this challenge, we must strengthen APRN faculty’s knowledge about nursing theory and the role nursing theories play in developing plans of care for patients across the lifespan. Next, faculty must understand and acknowledge the vital role nursing theory has in APRN practice and how to apply theory in their own practices. In turn, faculty can develop educational outcomes that reflect nursing theory as an influence on practice. Another challenge associated with NTGP is that APRNs use theory to drive their evidence-based practices but fail to identify the role of nursing theory in practice. To address this challenge, APRN training programs need faculty who understand and support the use of NTGP and curriculum-integrated theory throughout their students’ courses as well as demonstrate the application of NTGP through clinical opportunities. In an effort to address the challenges to integrate theory and NTGP content across curricula, we can turn to Ellis for direction in nursing education and practice.

Nurses practicing in the 21st century can learn from Ellis that theory use in nursing care is essential in advancing intelligent practice in a complex healthcare environment subject to change and chaos. Ellis introduced the term “intelligent practice” as a way to describe theory-guided practice in which the nurse moves beyond performing rote memorizations of tasks and procedures to making meaningful connections of theory to explain the “why” behind what nurses actually do in their interactions with patients. Intelligent practice moves the nurse from preconscious use of theory to intentional use of a theory or framework to guide care, thus enabling nursing to become a more science-skilled practice. Using the current vernacular, intelligent practice can be interpreted as “thinking like a nurse,” a phrase popularized by Linda Caputi’s (2017) model for clinical judgment. Because theorizing is one form of thinking, “thinking like a nurse” is an alternative naming convention for the 21st century nurse as a theorist. Today’s nurses are in the best position to determine the use of theory to guide practice because they impose the value, practicality, and relevancy of theory use in nursing. In doing so, nurses can build awareness of theory-guided practice and subsequently make theory use more explicit in nursing practice regardless of them being originators of that theory.

Finally, Ellis reminds us that the ever-changing circumstances of nursing situations require the nurse to become not only a user of theory but also an evaluator of theory to assess its value in patient care and outcomes. The challenge with using and evaluating theory is that much like nurses practicing in the late 1960s, today’s nurses are preoccupied with the “doing” of nursing rather than focusing on reflective thinking and analysis of their efforts. The goal of nursing today should be not only on the action of nursing, but rather we should focus on the analysis of our nursing actions in patient care. It is from the analysis of our actions that theory may be critically evaluated, tested, expanded, and developed for nursing practice. According to Sister Calista Roy (1984) theory development and testing of theories are nursing’s highest priorities.

References

Caputi, L. (2017). Think like a nurse: A handbook. Windy City Publishers.
Ellis, R. (1969). The practitioner as theorist. The American Journal of Nursing, 69(7), 1434-1438. https://www.jstor.org/stable/3454127
Roy, C. (1984). Introduction to nursing: An adaptation model (2nd ed.). Prentice Hall. (see https://nursology.net/nurse-theories/roys-adaptation-model/)

About the contributors

Marie Gill

Dr. Marie Gill is an Associate Professor and Director of the Margaret A. Newman Center for Nursing Theory. Prior to coming to UTHSC (University of Tennessee Health Science Center), Dr. Gill was a tenured Associate Professor and PhD Program Director for the Loewenberg College of Nursing at University of Memphis in Memphis, Tennessee.. Over 35 years as a registered nurse, Dr. Gill has practiced nursing in telemetry stepdown, cardiovascular intensive care, and cardiac rehabilitation. She has been a nurse educator for over 27 years in nursing staff development, nurse extern program management, clinical nursing education, patient education, and higher education. Dr. Gill has taught courses across the
undergraduate and graduate (PhD program) curricula and received the International Daisy Award in 2018 for her excellence in teaching. Dr Gill’s research program focuses on health literacy interventions in vulnerable populations,
especially among Drug Court Diversion Program clients to promote their sobriety and completion of the program. She expanded her program of research as Co-principal investigator of a grant-supported project to integrate Adverse Childhood Experiences (ACEs) and related concepts across undergraduate and graduate nursing curricula. Recently, her scholarship focus has transitioned to utilization of nursing theory and theory-guided practice. Dr. Gill’s publications and presentations are in her research program and scholarship areas of interest. Dr. Gill is a member of the American Nurses Association, Tennessee Nurses Association, Southern Nursing Research Society, Sigma Theta Tau International, Beta-Theta Chapter, and the Council for Advancement of Nursing Science.

Laura Reed

Dr. Reed joined the faculty of UTHSC as an Associate Professor in the FNP Concentration in July 2014. She is a graduate of the University of Tennessee Health Sciences Center (BSN, 1986 and MSN, 1990) and earned her DNP from the University of Alabama (2014). She is a nationally Certified Nurse Educator and is certified as a Family Nurse Practitioner (1990) and has practiced in a wide variety of primary care settings including end-stage renal disease, transplantation, and internal medicine. She currently sees patients at the UT Family Medicine- St. Francis clinic. Dr. Reed’s teaching responsibilities include Advanced Health Assessment, FNP didactic, and clinical courses, Advanced Role Development,as well as the DNP project courses. Her area of scholarship focuses on the management of chronic disease processes in the primary care setting and APRN education. She also incorporates telehealth and remote patient monitoring in her patient care. Dr. Reed is a member of the CON All-Faculty and DNP Faculty committees and the UTHSC Faculty Senate. She is a member of the Greater Memphis Area Advanced Practice Nurses (GMAAPN) where she is a past- president and currently a board member, Tennessee Nurses Association (TNA) , Tennessee Simulation Alliance, American Association of Nurse Practitioners (AANP), National Organization of Nurse Practitioner Faculties (NONPF), North American Menopause Society (NAMS), and Sigma Theta Tau.

Keesha Roach

Dr. Keesha Powell-Roach is an Assistant Professor at The University of Tennessee Health Science Center, where she holds a joint appointment in the College of Nursing in the department of Community and Population Health and a secondary appointment in the College of Medicine in the department of Genetics, Genomics, Informatics. She is a Robert Wood Johnson Future of Nursing Scholar alum, reflecting her dedication to advancing nursing science and healthcare. Dr. Roach demonstrates a strong commitment to unraveling the complexities of acute and chronic pain in individuals living with sickle cell disease. Her research extends beyond understanding pain itself, delving into its impact on organ systems and overall quality of life for affected patients. Her laboratory investigates the interaction between omics and biopsychosocial factors contributing to pain phenotypes in adults, notably with sickle cell disease or cancer. Dr. Roach is a primary investigator on a K01 training grant, “Contributions of Biopsychosocial Factors in Sickle Cell Disease Pain” (NHLBI) and a small research project through the Programs to Increase Diversity Among Individuals Engaged in Health-Related Research – Functional and Translational Genomics of Blood Disorders (PRIDE – FTG Program/NHLBI). Her research has been funded by the National Heart Lung and Blood Institute, National Institute on Aging, and National Human Genetics Research Institute.

Janet Tucker

Dr. Janet Tucker is an Assistant Professor for the University of Tennessee Health Science Center (UTHSC). She received her Diploma of Nursing from Methodist Hospital School of Nursing and her Bachelor of Science in Nursing Degree from Memphis State University. She completed her Master of Science of Nursing Degree focusing on Nursing Education with a concentration in Maternal-Child Health in 2010 and her Doctor of Philosophy in Nursing Science degree from the
University of Alabama at Birmingham in 2016. Dr. Tucker’s research focus has been the experience of expectant women who receive a fetal anomaly diagnosis. She has presented nationally and regionally on topics focused on the high-risk obstetric population. Dr. Tucker has extensive experience in maternal child health nursing. Dr. Tucker’s teaching responsibilities include providing clinical and didactic instruction within the BSN program. Additionally, she is currently serving on two PhD committees. She has served as a mentor in the Sigma Theta Tau Maternal Child Health Nursing Leadership Academy. Dr. Tucker is a member of the Association of Women’s Health, Obstetric, and Neonatal Nurses,
Sigma Theta Tau International Nursing Honor Society, Pregnancy Loss and Infant Death Alliance, and the Tennessee Nurses Association. She was appointed to the Tennessee Birth Defects Registry Advisory Committee in 2018. In 2023, she was the chair of the Research Advisory Committee for AWHONN.