Theory
Research
Evidence
Practice
How is a Nurse to Practice?
Part Four- Interrelationships among Nursing Theory, Research and Practice
The evolution of nursing demands advanced practice nurses in need of a clear
understanding of evidence-based practice, research and nursing theory. Practice is value-based
and practitioner driven as opposed to care which is evidence-based and consumer driven. In a
professional work environment both theory-driven and evidence-based care should advance
patient health and safety. New challenges for nursing leadership, especially in hospital settings,
are how to convey the importance of integrating both evidence-based practice and theory-driven
care to make certain of patient safety and optimize patient outcomes (Cody, 2013).
Rosswurm and Larabee’s Model identifies that to translate research into practice there
must be a solid grounding in change theory and the principle of research utilization and the use
of standard classification . The theory model includes six steps that guide nurses through a
systematic process for the change to Evidence-based practice. (1) Assess the need for change in
practice, (2) link the problem with interventions and outcomes, (3) synthesize the best evidence,
(4) design a change in practice (5) implement and evaluate the practice change and (6) integrate
and maintain the practice change. The eventual goal of the mixture of theory-driven and
evidence based practice is to improve patient outcomes by optimizing the level and quality of
nursing care. (Cody, 2013).
One barrier to evidence-based practice is lack of institutional level support for nursing
research activity. Another consideration is research based practice does not take into account
clinical expertise or patient preference but evidence- based practice does. Evidence-based
practice is the conversion of evidence influencing novel practice change. The weight of
evidence-practice change should not be on one practitioner but needs to be joined with nurses
providing direct patient care and in clinical research (Drenning, 2006).
Evidence- based practice models provide opportunities for nursing staff to become
involved in change. Outcomes included in evidence-based practice are safe, cost-effective and
patient specific interventions. As a result, staff should recognize ownership of their practice and
their role in the culture of evidence-based practice (Reavy & Tavernier, 2008).
Beginning in 1999 debates discussed what constitutes evidence for theory-guided
evidence-based nursing practice. Empirical medical models threatened the foundation of
nursing’s disciplinary perspective on theory –guided practice. Up until this time many viewed
randomized clinical trial as the only legitimate source of evidence. Dialogue continued viewing
evidence-based practice as treating evidence as a theoretical entity which only widens the theory
–practice gap (Cody, 2013).
http://www.youtube.com/watch?v=m2iQeyOP8MU
*You tube –Dorthea Orum
To understand evidence for theory-guided, evidence-based nursing practice from a
narrow focus of empirics as compared to a comprehensive focus on diverse patterns of knowing.
Carper (1978) identifies four fundamental patterns of knowing in nursing that include (1)
empirical (2) ethical (3) personal and (4) aesthetic are required for nursing (Cody, 2013).
http://www.uic.edu/classes/mhpe/mhpe494dcme/Heathreflection%20&%20knowing%20in%20
Nursing.pdf
*direct link to PDF-“Reflection and Patterns of Nursing Knowing” (Understanding Carper’s
(1978- Four patterns of knowing)
Chinn and Kramer (1999) expanded Carper’s work and identified processes associated
with each pattern of knowing. These guide the analysis of nursing theory. These processes
include clarity, simplicity, generality, empirical precision, and derivable consequences. Chinn
and Kramer explain it is dangerous to use any one pattern exclusively. They explain that when
knowledge within any one pattern is not seriously examined and incorporated with the whole of
knowing, distortion instead of understanding is produced. Further, it leads to uncritical
acceptance, narrow interpretation and partial utilization of knowledge the potential for synthesis
of the whole is lost. Their term is coined “the pattern gone wild” (Cody, 2013).
http://www.elearnportal.com/courses/nursing/conceptual-approaches-to-nursing/conceptualapproaches-to-nursing-process-for-analysinc-nursing-theory *Link to the “Learn Portal” Chinn
& Kramer
Evidence-based practice critics suggest evidence should be the primary source of
knowledge stating that it obstructs the nursing process, human care and professional
accountability. Additionally, critics state evidence- based practice does indeed provide direction
for development of procedure and techniques and protocols that are performed. Secondly,
evidence may provide one more resource for clients and nurses to consider as it may be useful
for making decisions on how healthcare may be approached (Cody, 2013).
Theorist state the term evidence-based practice is being applied to the nurse-person
process. To suggest that this process can be directed by evidence is not supportable position and
inconstant with professional ethical codes and current philosophical thought (Cody, 2013).
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Co
de-of-Ethics.pdf
*ANA Code of ethics for nurses with interpretive statements
Concerning issues of theorist (1) there s no body of evidence that can justify nursing as an
applied science, (2) proponents of evidence –based practice do not sufficiently acknowledge that
all evidence is value laden and theoretically driven (3) evidence-based practice is inconsistent
with nursing’s societal mandate to serve others rather than nurses themselves (4) proponents of
evidence-based practice oversimplify and misinterpret the complexities of human relation and
the realities of multiple competing values including the client in the nurse person process (Cody,
2013).
http://us.yhs4.search.yahoo.com/yhs/search?hspart=visicom&hsimp=yhszugo&type=zg__search.startnow.com__1_0__ya__rp__rp&p=jean+watson+you+tube
*Jean Watson Theory of Caring-Nurse Blessing
Additional comments to consider about Jean Watson's Theory of Caring. Should it not be
that nurses come into nursing profession with a value of caring for the ill and vulnerable? If
evidence-based practice interrupts nurse-person relationship, we need to relearn caring with a
Theory of Caring. The questions that may be posed for today's nursing practice is can you
practice ethically with your clients combing theory and evidence.
Theorists argue that changes in practice occur through personal insight about the link
among beliefs, values, and actions and not through presentations of data. The responsibility of
nurses is to continue to integrate and develop theories that assist practitioners to be helpful and
have meaningful relationship with clients. Knowledge about how to be with others in ways that
respect client’s autonomy and direction can only be found in nursing theory because theory
directs the “how” of nursing in light of its human context. Evidence- based practice obscures the
critical links among practice, theory and the client experience of nursing. Opponents of evidence
–based practice view the ultimate goal of evidence-based practice as control (Cody, 2013).
Mitchell supports an opposing viewpoint on evidence-based practice based (EBP) on the
premise that empirical science is medical science and if nursing applies it to the nursing role, we
run the risk of losing our own identity because of the lack of incorporation of the nursing process
(Cody, 2013, p. 321). There are two circumstances deemed appropriate for the utilization of
which include protocol development (p. 321) and treatment of a disease (p. 322). Mitchell also
states that evidence helps people make care-related decisions (p. 322).
The main opposition to EBP is based on the belief that scientifically derived evidence does
not build a knowledge base for nursing practice because it removed the nursing-patient
relationship from the focus of the healing process. Mitchell believes that nursing does not need
evidence for what is obvious to nursing, such as caring, listening and relationship building.
These interventions are inherent to the nursing process and she feels the need to prove them
insults the nurse for needing to prove what is already known.
Additional barriers to her adoption of EBP include sentiments that some interventions that
nursing supports are incongruent with nursing’s values, such as behavior modification to gain
regiment compliance, assessments which cause increases in patient stress, and use of tools that
require patient to express themselves on our terms instead of their terms. The example provided
was the pain scale of 0-10. Not all patients can easily adapt their pain expression to this scale
and may provide arbitrary numbers to receive pain medication instead of expressing their
frustration with the scale.
To summarize Mitchell’s resistance to EBP, patients want therapeutic relationships, not
studies (p. 363). Research conducted via empirical methods are purposefully conducted void of
personal values. The nurse patient relationship is based on a foundation of respect and values
driven decision making. She feels that nursing care provided without values derails the heart of
nursing and places the profession at risk for become a vocation (Cody, 2013).