¶ … Nursing Knowledge: A Controversy The scope of the nursing profession has increased dramatically over the last thirty years. The demarcation between medical and nursing tasks is quickly dissolving as the nursing profession is becoming increasingly multidisciplinary and complex. In 1996, nurse practitioners were mandated to obtain master's degrees to address their changing role in medical care (Nicoteri & Andrews, 2003). In this multidisciplinary and evolving healthcare environment, adaptation is paramount to providing effective patient care. Currently, there is a controversy in nursing regarding the direction that the development of nursing knowledge should take. There are many critics who believe that developing new nursing theories is an effective way to promote this development. However, theories are often abstract and not adaptable to specific healthcare settings. The belief that the knowledge base for nursing should evolve entirely from theory has important implications for nursing as an academic discipline and by extension the effective treatment of patients.

There are two models or ideologies for advancing nursing knowledge, namely a theory approach and a practice approach. The theory-based approach develops nursing knowledge in a proactive, yet untested way. It creates the theory first and the knowledge is meant to follow. Those who support this model have argued that a clear nursing theory serves as a framework or foundation that provides direction for knowledge development (Spear, 2007). Others find nursing theory to be an academic abstraction that is of no practical value. These critics point to the fact that theory-based knowledge developments creates a direction that is not necessarily grounded in what is actually applicable to the specific setting of care. They argue that it is an exercise in futility and may even serve to misguide the development of nursing knowledge by creating conceptual confusion rather than clarity in practice (Spear, 2007). It appears that it would be more effective to assume a reactionary knowledge development approach that recognizes clinical or administration problems specific to the setting of care and then conducts research to solve these problems -- from practice to knowledge. It would ground the development in a more relevant footing.

The main controversy in development, therefore, lies in the source of knowledge. Both seem to have a legitimate claim and even appear to derive their ideas from the same fundamental goal. Currently, one of the main problems in the nursing profession is its fast evolution and a distortion of a distinct set of fundamental objectives. Spear comments again that nursing will be perceived as an indistinct discipline until it plainly defines itself in terms of science and unique knowledge -- in short by a distinct theory (2007). Northrup and colleagues support this belief by emphasizing the need for developing a distinct body of nursing knowledge based on a theory that reflects the values and objectives of current practice (Northrup, Tschanz, Olynk, Szabo & Biassio, 2004). The goal of both approaches is a more distinctive definition of nursing as an academic and professional discipline.

As an academic discipline it seems that nursing would benefit most from a dual approach. Relying entirely on theory would create a guide without substance. Theory-based knowledge is effective in recognizing problems and achieving awareness for them. An academic approach that relies entirely on knowledge derived from theory would produce nurses that are conscientious and knowledgeable but not necessarily good practitioners in the specific context of the care setting. Conversely, knowledge that is derived entirely from practice without any theory lacks the guidance that is necessary to maintain the coherence of the nursing profession. Nurses would potentially lose the understanding of their role or professional identity. The main controversy should focus on the degree of emphasis of each approach to the development of nursing knowledge. The nursing literature is replete with opinions about the best approach for nursing as an academic discipline. It may serve useful to look at the historical developments of nursing theory and knowledge.

Theorists over the past decades have attempted to present a comprehensive, rational, and systematic approach to nursing (McCrae, 2011). A number of influential models have been proposed. Hildegard Peplau is credited with developing the first recognized theory of nursing in 1952. She emphasized the nurse, rather than the physical medical interventions, as the primary form of treatment (1952). Callista Roy expanded on this theory of nursing science by developing a holistic theory that was based on what she referred to as a patient's natural tendency towards biological, psychological and social equilibrium (1980). The nurse's role in the treatment was to identify ways to promote the patient's synergy with those three aspects of well-being.

In a review of nursing theories, McCrae argues that a nurse responds to the distress of a patient not with evidence-based research findings but rather with an intuitive humanistic ethos based on professional experience (2011). This idea precisely demonstrates the difficulty of bridging the gap between theory development and nursing science and administration. It is extremely difficult to obtain empirical evidence that one theory of nursing actually translates into superior care.
This problem has substantial implications for nursing as an academic discipline that relies entirely on theory. It shows that theory generally has no specific relevance to the setting or that it is difficult to prove that it does. An historical example of this problem is the emergence of the nurse practitioner. In the past three decades, a revolution in nursing theory has dramatically enhanced the administration of care. The development in nursing theories that called for a higher influence of nurses in the delivery of care contributed to the fast proliferation of nurse practitioners. An analysis of adult outpatient visits in selected hospitals between 1995 and 2001 indicated a 77% increase in nonphysician (nurse practitioners and physician assistants) visits (Burman, Hart, Conley, Brown, Sherard & Clarke, 2009).

The theory development has severely impacted the knowledge development of the nursing profession as it began to borrow heavily from the medical profession. The curriculum of current master's programs is based primarily on physical assessment, pharmacology and pathophysiology -- components of the medical profession (Burman et al., 2009). The core values of traditional nursing practice focus on health promotion and disease management using the latest theoretical developments in health behavior, behavioral sciences, exercise physiology, nutrition and medical anthropology (Burman et al., 2009). While developments in nursing theory have incorporated knowledge from other medical disciplines and thereby substantially increased the nursing knowledge, it appears that knowledge developments based on theory do not adequately prepare practitioners for the actual care setting. A national survey of 592 nurse practitioners conducted by Hart and Macnee (2007) found that many nurse practitioners felt that their formal education had inadequately prepared them for practice. The study was based on a subjective assessment of their educational experience. In response to the question, "how prepared were you for actual practice as a nurse practitioner after completing your basic nurse practitioner education [assumed master's degree]" less than 10% of the nurse practitioners responded that they were "very well prepared." Only 38.5% indicated that they were "generally well-prepared," while the same percentage of students declared that they were "somewhat prepared." In essence, the theory does not account for knowledge application in the setting of care and thus undermines the purpose of the academic discipline. Instead, the development of nursing knowledge should stem from practice.

The importance of defining the role and relationships of nursing knowledge cannot be overstated. According to Rolfe, it defines the professional status of the discipline, regulates the intellectual activities and determines the degree of emphasis that should be given to research, practice development and teaching (2007). A study was conducted to determine precisely how nursing knowledge was applied by nurses in an actual care setting (Mantzoukas & Jasper, 2008). Five discrete types of knowledge were identified that were consistently used by nurses in medical wards: personal, practice, theoretical, procedural, ward cultural and reflexive. The personal, practice and theoretical knowledge were all based on non-contextual theories of nursing while the other sources were specific to the ward setting. The study determined that all sources of knowledge become effective and applicable only as they are mediated by the ward cultural knowledge. This enabled the nurses to deal with the context of care and the unique environment in which they are working. The authors propose that the ward culture may help to explain why nursing theories consistently fail to capture the full range of nursing practice as it is lived in a ward environment (Mantzoukas & Jasper, 2008).

These findings have substantial implications for nursing as an academic discipline. They show that theories alone are insufficient in capturing the role of a nurse on the ward. An academic program that derives its knowledge base only from theory does not prepare nurses. Instead it provides a set of abstract skills, care values and ideals distinctly out of context. The nurse would not know how to apply the theory, which in essence undermines the ability to effectively treat a patient. While theory provides a foundation…