What makes a theory or model “nursing”?

To our readers: the Nursology.net blog exists to prompt thoughtful discussion of critical issues related to the development of nursing knowledge.  We welcome your thoughts, challenges, alternative points of view, and critical questions!  Do not hesitate to comment on this or any other post at any time!  You are our “peer reviewers” and your perspectives contribute to all in our nursology.net community!

I am often asked (as are many of my colleagues):  What makes a theory or model a nursing theory or model?  This question is close to the challenge that I addressed in my keynote address in March at the Case Western Reserve Frances Payne Bolton School of Nursing Theory conference.  This question deserves serious reflection and discussion, because how each of us responds to this question is at the heart of what we envision for our discipline moving forward. In my keynote, I noted that various definitions of nursing as a discipline point to two essential matters: 1) knowledge of the human health experience, and 2) knowledge of nursing healing [well-becoming] actions.  Here I explore the issue of nursing theories and models, and propose that like the definitions, nursing theories and models are characterized by a focus on these same two essential characteristics.

One reason that questions concerning the nature of nursing theory keep surfacing is the fact that so many nurses who embarked on activities related to the development of nursology (nursing science) were educated to be scholars (researchers, theory developers) in fields outside of, but related to nursing.  There are contemporary nurses who opt to pursue their preparation for scholarship in other disciplines, influenced by the appeal of certain lines of inquiry that are already well developed in another discipline, and recognizing the significant connection between nursing’s interests and the interests of other lines of thought.  When I say “related” what I mean is that the gaze of these other disciplines is certainly pertinent to what concerns nursing, but the central concern of nursology is not actually “at the center.”  When a nurse scholar’s central focus is on the periphery, it is likely to be better placed within the scope of another discipline.

Sally Thorne (2014) has addressed this tension often in her work, most specifically in her chapter that appears in the text “Philosophies and Practices of Emancipatory Nursing.” In this chapter titled “A Case for Emancipatory Disciplinary Theorizing” (pages 79-90), Dr. Thorne pointed to the habits of “false dichotomizing” and the allure of borrowing theories from other disciplines, both of which lead to valorizing constructions from other disciplines, while neglecting the distinct focus of nursing. False dichotomizing, in the the case of social justice concerns, is the tendency to pigeon-hole a theory as either being focused on “the individual” or on “the community” (social justice), failing to recognize that from the earliest days of theorizing in nursing, scholars have explicitly embraced both the individual and the community and the  social injustices that require nursing action.  Likewise, immersion in and borrowing from the theoretical traditions of other disciplines can lead to neglect of the complex social mandate that is central to the discipline of nursing.  Unlike other disciplines, many of which focus on building knowledge as an end in itself, nursing’s mandate to act shifts the disciplinary focus so that knowledge related to a phenomena must include a focus, or point the way to “right” or “good” nursing action.  I have addressed the challenge in nursing of developing theory with this extremely complex perspective as one of the reasons for turning to theory in other disciplines, where the focus is more limited, and this complexity is typically unacknowledged and undeveloped or underdeveloped.  (see “Thoughts About Advancement of the Discipline: Dark Clouds and Bright Lights”)

From my perspective, regardless of the theorist’s background, or the origin of methodological approaches, what defines a theoretical construction as nursing arises from a clear orientation to the values and priorities of the discipline – the direction in which nursologists focus their “gaze.”  The focus of nursing must include the two elements that centrally define our discipline: knowledge of the human health experience, and knowledge of nursing actions leading to health and well-becoming.

Every discipline has the right and the responsibility to define and to conceptualize its own knowledge, domain, practice – the field which it covers. Of course people from other disciplines, and the public, have a responsibility to challenge the discipline in any way that is needed – a process that contributes to the ongoing development of the discipline. This process was prominent during the early phases of feminist thought in which feminist scholars from all disciplines developed a “gaze” focused on the rights and well-being of women, challenged the parameters, assumptions and practices of their own, and other disciplines as well. This led to vast changes for the better in all of the sciences and the humanities.

Where nursing is concerned, or more specifically nursology, disciplinary knowledge must derive from those who have been immersed in the history, philosophy, theory, and the practices of the discipline – something that is required for any discipline. Even though, for example, I do know a lot about the field of educational psychology where I earned my PhD degree and where I completed many courses in psychology and educational psychology, I do not have the background and experience to even begin to claim that I could contribute to the knowledge base of that discipline. I have used theories and insights from other disciplines in my own work contributing to the discipline of nursing, but that is quite a different kind of scholarship than would be required to contribute to the discipline of psychology (or sociology, or anthropology, etc.). My own theorizing in nursing reflects my educational psychology background, particularly the work of Brazilian educator Paulo Friere.  While the very relevant focus of Friere’s work is on human liberation from oppressive conditions, in my work the focus shifts to the health experience involved in group interactions,  conditions which influence, perhaps even threaten human health and well-being.  Health-promoting group interactions in my work draw on the methods of Friere’s  liberation theory,  but are specifically directed toward creating group actions and interactions that are life-affirming, nurturing, and support human well-becoming.

I do not think it is helpful to dwell on the simple fact of whether or not a person contributing to the knowledge of the discipline is a nurse — not all nurses are prepared to contribute to the knowledge base of the discipline, nor should they be expected to. And there are certainly nurses whose “gaze” is directed primarily on phenomena that are rooted in other disciplines.  The key to me is where a theory or model focuses the gaze – what phenomena are central, and are those central ideas consistent with the defining focus of the discipline.  I find it difficult to imagine how someone could contribute to nursing knowledge without a nursing background, or without experience in nursing healing/ well-becoming actions, as well as a background in the history and foundational knowledge of the discipline.  Beyond this essential background from which the theoretical ideas emerge, nursing theories and models are defined by the substantive focus on the phenomena of the experience of human health and well-being, and the dynamics that contribute to nursing healing and well-becoming practices.   As we have demonstrated in gathering together for this website information about the theories and models we do have, there are many more than many nurses have as yet imagined!  But the task of clearing our mental images to more fully appreciate the possibilities in the development of the knowledge of our discipline is a huge challenge, and further focusing our gaze on these possibilities and priorities is at the heart of what matters for our own discipline.

Breaking the Silence-Exploring Perceptions of Power as Freedom in the World of Nursologists

by Julianne Mazzawi, Jacqueline Fawcett and Rosanna DeMarco

In 2015, the American Nurses Association released a purpose and position statement indicating that it is an individual and shared responsibility among all nursologists and employers to promote and sustain a culture of respect that is free of incivility, bullying, and workplace violence. Such a culture reflects the ethical, moral, and legal responsibility of everyone to create a healthy and safe work environment for all members of the healthcare team, participants in healthcare (sometimes called patients), families, and communities. So why is it that nursologists and their support staff continue to show manifestations of “silencing-the-self” when instances of incivility, bullying, and even violence occur? (DeMarco, Fawcett, & Mazzawi., 2017, p. 4)?

Too often, nursologists experience sleep problems, anxiety, distress, oppression, burnout, absence from or leaving work, organizational frustration, and job dissatisfaction, and commit more errors due primarily to incivility, bullying, and violence in the workplace (Lim & Berstein, 2014; The Joint Commission, 2008; Vagharseyyedin, 2015) Obviously, it is imperative to resolve these negative outcomes for all current and future nursologists.

We conceptualized civility and incivility within the context of Neuman’s Systems Model. (See model below). Accordingly, the client system was represented by the nursologists who are the perpetrators or recipients of covert incivility (CI), defined as the “appearance of civility with negative intent” (DeMarco et al., 2018, p. 254). Stressors were represented by CI, and the reaction to stressors was represented by such manifestations as sleep problems, anxiety, oppression, burnout, and organizational frustration. The reactions were regarded as the impact of CI on nursologists who are faculty, students, and staff nurses, as well as witnesses to CI. The workplace (academic or clinical) and society also may experience reactions to CI. We identified several prevention as interventions for CI, with an emphasis on secondary and tertiary interventions; we explained that these interventions “need to be directed to existing levels of CI of all kinds that include measuring the level of ‘silencing-the-self'” (DeMarco et al., 2018, p. 256).

2018 © Jacqueline Fawcett

Of course, primary prevention as intervention also must be considered; we recommended educating all students and graduate nursologists about both overt incivility and signs of CI and creating contracts for nursologists focused on “creating a formal promise to not engage in overt of covert incivility and addressing the behavior direction at the individual, group, and systems levels” (DeMarco et al. 2018, p 257).

In this blog, we offer the specific recommendation that focus on resolution of CI through application of nursological theories of power. Resolution of CI, we are convinced, will occur when nursologists’ perceptions of power change from perceptions of others having power over them to perceptions of power as freedom to choose and peace as power.

The idea for this blog was Mazzawi’s and Fawcett’s attendance at the 2018 Society of Rogerian Scholars (https://nursology.net/2018/10/09/celebrating-30-years-the-society-of-rogerian-scholars/), at which the four nursological theories of power discussed here were presented. We began to imagine a world where nursologists perceive power as freedom to choose and peace as power rather than perceiving power as others having power over them to control them and that in this world, civility would reign, bullying and workplace violence would not happen, and only positive outcomes would occur!

Four nursological theories of power provide explanations of having power that leads to civil discourse and the conversion of negative outcomes to positive outcomes.

  • Barrett’s (2010). theory of power as knowing participation in change provides a contrast between power as freedom and power as control and encompasses awareness, choices, freedom to act intentionally, and involvement in creating change. Participating knowingly in the ongoing mutual process with ourselves, with other people, and with our immediate world creates the opportunity for not only fulfillment in one’s life but also the opportunity to create positive change. (See https://nursology.net/nurse-theorists-and-their-work/theory-of-power-as-knowing-participation-in-change/).
  • Chinn’s (2013; Chinn & Falk-Rafael, 2015) theory of peace and power provides a contrast between peace-power and power-over. The theory empathizes how “individuals and groups . . . shape their actions and interactions to promote cooperation, inclusion of all points of view in making decisions and in addressing conflicts. [Accordingly], … individuals and groups can make thoughtful choices about the ways they work together to promote healthy, growthful interactions and avoid harmful, damaging interactions.” (Retrieved from https://nursology.net/nurse-theorists-and-their-work/peace-power/)
  • Polifroni’s (2010) theory of clinical power provides a contrast between having power as the result of knowledge and hierarchical power or taking power from another person. The theory emphasizes “the belief that power is knowledge and all nurses possess that power. In this context power is a right and it is truth/knowledge. Intentionality, authenticity, ways of knowing, PEACE . . . and CARE . . . surround the awareness and relationship of the nurse who is exercising clinical power” (Retrieved from https://nursology.net/nurse-theorists-and-their-work/clinical-power/).
  • Sieloff’s (1995, 2018) theory of work team/group empowerment in organizations provides an understanding of how nursologists have power in clinical and educational organizations. The theory encompasses competency in communication and in explicating goals and outcomes, as well as the work team/group’s leader’s competency; control of environmental forces; utilization of resources; empowerment perspective; empowerment potential and actual capacity to achieve outcomes; role, that is, the “degree to which the work of an [organization] is accomplished through the efforts of [a work team/group]” (Sieloff, 1995, p. 58); and position, that is, “the centrality of [the] nursing [work team/group] within the communication network of an [organization]” (Sieloff, 1995, p. 57).

Application of the power theories as ways to enhance understanding and resolution of CI provides a nursology discipline-specific approach to practice. Readers are invited to share their experiences with application of the power theories as comments for this blog.

References

American Nurses’ Association. (2015). Incivility, bullying, and workplace violence. Retrieved from http://www.nursingworld.org/MainMenuCategories/WorkplaceSafetyHealthy-
Nurse/bullyingworkplaceviolence/Incivility-Bullying-and-Workplace-Violence.html.

Barrett, E. (2010). Power as knowing participation in change: What’s new and what’s next. Nursing Science Quarterly, 23, 47-54.

Chinn, P. L. (2013). Peace & power: New directions for building community (8th ed.). Burlington, MA: Jones and Bartlett Learning.

Chinn, P. L., & Falk-Rafael, A. R. (2015). Peace and power: A theory of emancipatory group process. Journal of Nursing Scholarship. 47, 62–69.

DeMarco, R., F., Fawcett, J., & Mazzawi, J. (2017). Covert incivility: Challenges as a challenge in the nursing academic workplace. Journal of Professional Nursing, 1-6.
doi:10.1016/j.profnurs.2017.10.001

Lim, F. A., & Berstein, I. (2014). Civility and workplace bullying: Resonance of
persona and current best practices. Nursing Forum, 49, 124-129.

Polifroni, E. C. (2010). Power right and truth: Foucault’s triangle as a model for clinical power. Nursing Science Quarterly, 238-412

Sieloff, C. L. (1995). Development of a theory of departmental power. In M. A. Frey & C. L. Sieloff (Eds.), Advancing King’s systems framework and theory of nursing (pp. 46-65). Thousand Oaks, CA: Sage.

Sieloff, C. L. (2018, October 6). Thoughts about nursing and power: Theory of work team/group empowerment. Paper presented as part of a symposium on nursological theories of power at the Society of Rogerian Scholars 30th Anniversary Conference, New York University Rory Myers College of Nursing, New York, NY.

The Joint Commission (2008). Behaviors that undermine a culture of safety. Retrieved from https://www.jointcommission.org/assets/1/18/SEA_40.PDF.

Vagharseyyedin, S.A. (2015). Workplace incivility: A concept analysis. Contemporary Nurse, 50, 115-125.

About the authors

Julianne Mazzawi

Julianne Mazzawi, RN; MS
PhD candidate, Department of Nursing
University of Massachusetts Boston

Jacqueline Fawcett, RN; PhD; ScD (hon); FAAN; ANEF
Professor, Department of Nursing
University of Massachusetts Boston

Rosanna F. DeMarco, RN; PhD;  PHNA-BC; FAAN
Professor and Chair, Department of Nursing
University of Massachusetts Boston

Jacqueline Fawcett

Rosanna DeMarco

Confronting Cultural Noise Pollution

Much earlier in my career a group of colleagues and I conducted a survey published in the American Journal of Nursing that addressed friendship in nursing*.  We were motivated to confront the message that nurses are their own worst enemies, and not friends. The results of the survey affirmed that although the message persists, and sometimes accurately describes relationships and interactions, there is ample evidence that nurses are more often than not our own best supporters and friends. I call these kinds of repeated negative messages cultural noise pollution that obscure the realities of the more accurate and complete situation – messages that obscure what is real and what is possible.

We created Nursology.net with a  similar motivation to confront the often repeated message that nursing theory is irrelevant, not necessary, or too abstract to be useful in practice.  These messages obscure the realities of the vital importance of nursing knowledge in the context of systems that serve to address the healthcare needs of our time.  They interrupt serious consideration, discussion and thought concerning who we are as nurses, what we are really all about, and why we persist in our quest to improve our practice. Failing to recognize the value of our own discipline’s knowledge, we fall prey to serving the interests of others, and neglect our own interests.

My favorite pithy definition of theory is this – theory is a vision.  Theory provides a view of concrete realities that makes it possible to mentally construct all sorts of dimensions that are not obvious to our limited perception of a situation in the moment.  It provides ways to understand how a particular “thing” comes about, what it means, what might happen next,  how the trajectory of a situation might unfold, and how human actions might change that trajectory.   In the practice of nursing, this is precisely what we are all about – we take a close look at a situation that presents a health challenge, we set about to understand what is going on beneath the surface, we examine evidence related to the situation, and we chart a course of action that might move the situation in a way that would not otherwise be possible.  People in other healthcare disciplines are doing much the same thing, but we have a nursing lens through which we as nurses view the situation.  Our  lens determines what we deem to be important in the evolution of the situation, and shapes the sensibilities we bring to the actions we take.  Our lens derives from nursology – the knowledge of the discipline.

If you take even a brief tour of Nursology.net, you will soon see that nursing theories, models and philosophies represent a coherent message focused on visions of health and well-being in the face of complex, sometimes tragic,  health challenges. You will also find a vast diversity of lenses that give a particular focus on this central message.  Some of the lenses give us a vision that is a lofty “30-thousand foot altitude” view. Some of the lenses focus in more closely on particular aspects of health challenges. There is no “right or wrong,” “better or worse.” Each lens simply brings about a different vision. Just as a camera can bring a different tone, hue or filter to see a single image in different ways, our nursing theories open possibilities and alternatives that would never be possible if we did not have the various lenses through which to view the situations we encounter. Taken together, these theories, models, philosophies form an ever-expanding nursology. Our theories, models and philosophies open possibilities for practice that can make a huge difference in the lives of real people.

We have an amazing, vast and rich heritage of nursing knowledge – and we are nowhere near done with the task!  Our vision for Nursology.net is to document and honor the serious knowledge-work that has been accomplished in the past, draw on this foundation, and inspire new directions that are yet unimagined!  We hope nurses everywhere, regardless of how or where you practice as a nurse, will join us in this journey, and add your voice to help shape what is possible! And importantly, we invite you to join us in confronting the negative, self-destructive effects of various forms of cultural noise pollution that cloud our vision!

*Friendship Study references

Chinn, P. L., Wheeler, C. E., Roy, A., Berrey, E. R., & Madsen, C. (1988). Friends on friendship. The American journal of nursing, 88, 1094–1096.

Chinn, P. L., Wheeler, C. E., Roy, A., & Mathier, E. (1987). Just between friends: AJN friendship survey. The American journal of nursing, 87, 1456–1458.