On Nursing Theories and Evidence

Clinical Scholarship On Nursing Theories and Evidence Jacqueline Fawcett, Jean Watson, Betty N euman, Patricia Hinton Walker, Joyce J. Fitzpatrick Purpose: To expand the understanding of what constitutes evidence for theory-guided, evidencebased nursing practice from a narrow focus on em pirics to a m ore com prehensive focus on diverse patterns of k now ing. O rganizing construct: Carper’s four fundam ental patterns of k now ing in nursing— em pirical, ethical, personal, and aesthetic— are required for nursing practice. A different m ode of inquiry is required to develop k now ledge about and evidence for each pattern. Conclusions: T heory, inquiry, and evidence are inex tricably link ed. Each pattern of k now ing can be considered a type of theory, and the m odes of inquiry appropriate to the generation and testing of each type of theory provide diverse sources of data for evidence-based nursing practice. D ifferent k inds of nursing theories provide different lenses for critiquing and interpreting the different k inds of evidence essential for theory-guided, evidence-based holistic nursing practice. JOURNAL OF NURSING SCHOLARSHIP, 2001; 33:2, 115-119. © 2001 SIGMA THETA TAU I NTERNATIONAL. [Key w ords: nursing theory, patterns of k now ing, evidence-based practice] * E vidence-based practice is in the forefront of many contemporary discussions of nursing research and nursing practice. Indeed, the term “ seems to be the up-andcoming buzzword for the decade” (Ingersoll, 2000, p. 151). The current call for evidence-based nursing practice has set t h e d eb a t e in a co n ven t io n a l, a t h eo r et ica l, m ed ica lly dominated, empirical model of evidence, which threatens the foundation of nursing’s disciplinary perspective on theorygu id ed p r a ct ice (Wa lk er & R ed m o n d , 1 9 9 9 ). M o r e specifically, as Ingersoll (2000) pointed out, almost all discussions of evidence-based practice are focused on the primacy of the randomized clinical trail as the only legitimate source of evidence. Furthermore, most discussions of evidencebased practice treat evidence as an atheoretical entity, which only widens the theory-practice gap (Upton, 1999). M oreover, although multiple patterns of knowing in nursing have been acknowledged at least since the publication of Carper’s work in 1978, nurses have ignored this disciplinary perspective and reverted to a medical perspective of evidence when discussing evidence-based nursing practice. The purpose of this paper is to invite readers to join in a dialogue about what constitutes the evidence for theoryguided, evidence-based nursing practice. We are initiating the dialogue by offering a comprehensive description of theoretical evidence that encompasses diverse patterns of knowing in nursing. We advance the argument that each pattern of knowing can be considered a type of theory and that the different forms of inquiry used to develop the diverse kinds of theories yield different kinds of evidence, all of which are needed for evidence-based nursing practice. * * On Nursing Theories Diverse patterns of knowing were identified by Carper (1978), who expanded the historical view of nursing as an art and a science in her classic paper, “ Fundamental Patterns of Knowing in N ursing.” She identified four ways or patterns of knowing in nursing: empirics, ethics, personal, and aesthetics. Carper’s work is significant in that it “ not only highlighted the centrality of empirically derived theoretical knowledge, but [also] recognized with equal importance and weight, knowledge gained through clinical practice” (Stein, Corte, Colling, & Whall, 1998, p. 43). Chinn and Kramer (1999) expanded Carper’s work by identifying processes associated with each pattern of knowing. Their work has enhanced understanding of each pattern of knowing and has brought Carper’s ideas to the attention of a wide audience of nurses. The pattern of empirical knowing (Table) encompasses publicly verifiable, factual descriptions, explanations, and Jacqueline Fawcett, PhD, FAAN, Theta Alpha, Professor, College of Nursing, University of Massachusetts-Boston; Jean Watson, PhD, FAAN, Alpha Kappa-at Large, Distinguished Professor of Nursing, School of Nursing, University of Colorado Health Sciences Center; Betty Neuman, PhD, FAAN, Delta Tau , Nurse Theorist and Health Care Consultant, Watertown, Ohio; Patricia Hinton Walker, PhD, FAAN, Alpha Kappa-at Large, Dean and Professor, School of Nursing, University of Colorado Health Sciences Center; and Joyce J. Fitzpatrick, PhD, FAAN, Alpha Mu , Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing Case Western Reserve University. Correspondence to: Dr. Fawcett, 3506 Atlantic Highway, PO Box 1156, Waldoboro, M E 04572. E-mail: jacqueline.fawcett@umb.edu Accepted for publication January 11, 2001. Journal of N ursing Scholarship Second Q uarter 2001 115 Theories and Evidence predictions based on subjective or objective group data. In other words, empirical knowing is about “ averages.” This pattern of knowing, which constitutes the science of nursing, is well established in nursing epistemology and methods. Empirical knowing is generated and tested by means of knowing is tested by means of ethical inquiries that focus on dialogue about beliefs and values and establishing justification for those beliefs and values. The pattern of personal knowing refers to the quality and authenticity of the interpersonal process between each nurse Table. Patterns of Knowing: Types of Nursing Theories, Modes of Inquiry, and Evidence Pattern of knowing: type of nursing theory Description Mode of inquiry Examples of evidence Empirics Publicly verifiable, factual descriptions, explanations, or predictions based on subjective or objective group data; the science of nursing Empirical research Scientific data Ethics Descriptions of moral obligations, moral and nonmoral values, and desired ends; the ethics of nursing Identification, analysis, and clarification of beliefs and values; dialogue about and justification of beliefs and values Standards of practice, codes of ethics, philosophies of nursing Personal Expressions of the quality and authenticity of the interpersonal process between each nurse and each patient; the interpersonal relationships of nursing Opening, centering, thinking, listening, and reflecting Autobiographical stories Aesthetics Expressions of the nurse’s perception of what is significant in an individual patient’s behavior; the art and act of nursing Envisioning possibilities, rehearsing nursing art and acts Aesthetic criticism and works of art empirical research. The next section of this paper extends the common focus on empirics as the primary focus of evidence, and offers a new lens for considering theory-guided evidence and diverse ways of knowing that can and should be integrated into nurses’ evidence-based practice initiatives. Diverse Patterns of Knowing In contrast to empirics, the other patterns of knowing are less established, but they are of increasing interest for the discipline of nursing in particular and for science in general. Ethical knowing, personal knowing, and aesthetic knowing are required for moral, humane, and personalized nursing practice (Stein et al., 1998). The pattern of ethical knowing (Table) encompasses descriptions of moral obligations, moral and nonmoral values, and desired ends. Ethical knowing, which constitutes the ethics of nursing, is generated by means of ethical inquiries that are focused on identification and analysis of the beliefs and values held by individuals and groups and the clarification of those beliefs and values. Ethical 116 Second Q uarter 2001 Journal of N ursing Scholarship and each patient (Table). This pattern is concerned with the knowing, encountering, and actualizing of the authentic self; it is focused on how nurses come to know how to be authentic in relationships with patients, and how nurses come to know how to express their concern and caring for other people. Personal knowing is not “ knowing one’s self” but rather knowing how to be authentic with others, knowing one’s own “ personal style” of “ being with” another person. Personal knowing is what is meant by “ therapeutic nursepatient relationships.” Personal knowing is developed by means of opening and centering the self to thinking about how one is or can be authentic, by listening to responses from others, and by reflecting on those thoughts and responses. The pattern of aesthetic knowing shows the nurse’s perception of what is significant in the individual patient’s behavior (Table). Thus, this pattern is focused on particulars rather than universals. Aesthetic knowing also addresses the “artful” performance of manual and technical skills. Aesthetic Theories and Evidence knowing is developed by envisioning possibilities and rehearsing the art and acts of nursing, with emphasis on developing appreciation of aesthetic meanings in practice and inspiration for developing the art of nursing. Carper (1978) and Chinn and Kramer (1999) pointed out that each pattern of knowing is an essential component of the integrated knowledge base for professional practice, and that no one pattern of knowing should be used in isolation from the others. Carper (1978) maintained that “ N ursing … depends on the scientific knowledge of human behavior in health and in illness, the aesthetic perception of significant human experiences, a personal understanding of the unique individuality of the self and the capacity to make choices within concrete situations involving particular moral judgments” (p. 22). Elaborating, Chinn and Kramer (1999) pointed out the danger of using any one pattern exclusively. They said: When knowledge within any one pattern is not critically examined and integrated with the whole of knowing, distortion instead of understanding is produced. Failure to develop knowledge integrated within all of the patterns of knowing leads to uncritical acceptance, narrow interpretation, and partial utilization of knowledge. We call this “ the patterns gone wild.” When this occurs, the patterns are used in isolation from one another, and the potential for synthesis of the whole is lost. (p. 12) The current emphasis on empirical knowing as the only basis for evidence-based nursing practice is an outstanding example of a “ pattern gone wild.” Patterns of Knowing as Theories The question arises as to whether the multiple, diverse patterns of knowing can be considered sets of theories. The answer to that question depends, in part, on one’s view of a pattern of knowing and a theory. A pattern of knowing can be thought of as a way of seeing a phenomenon. The English word “ theory” comes from the Greek word, “ theoria,” which means “ to see,” that is, to reveal phenomena previously hidden from our awareness and attention (Watson, 1999). For the purposes of this paper, a theory is defined as a way of seeing through “ a set of relatively concrete and specific concepts and the propositions that describe or link those concepts” (Fawcett, 1999, p. 4). Theories constitute much of the knowledge of a discipline. M oreover, theory and inquiry are inextricably linked. That is, theories of various phenomena are the lenses through which inquiry is conducted. The results of inquiry constitute the evidence that determines whether the theory is adequate or must be refined. Collectively, the diverse patterns of knowing constitute the ontological and epistemological foundations of the discipline of nursing. Inasmuch as both patterns of knowing and theories represent knowledge, and are generated and tested by means of congruent, yet diverse processes of inquiry (Table), we maintain that each pattern of knowing may be regarded as a type of theory. These four types of theories are subject to different types of inquiry. H enceforth, then, we will refer to the patterns of knowing as empirical theories, ethical theories, personal theories, and aesthetic theories. O ur decision to regard the patterns of knowing as types of theories is supported by Chinn and Kramer’s (1999) reference to ethical theories and Chinn’s (2001) articulation of a theory of the art of nursing. O ther global perspectives indicate the direction of diverse patterns of knowing as types of theories. For example, Scandinavian nurses view nursing within a caring science model, and they acknowledge personal knowing, personal characteristics, and moral and aesthetic knowing of caring practices as theoretical ways of knowing that elicit diverse forms of evidence (Dahlberg, 1995, Fagerstrom & Bergdom Engberg, 1998; Kyle, 1995; Snyder, Brandt, & Tseng, 2000; von Post & Eriksson, 2000). Furthermore, we, like some of our international colleagues, maintain that the content of ethical, personal, and aesthetic t h eo r ies ca n b e fo r m a lized a s set s o f co n cep t s a n d propositions, just as the content of many empirical theories has been so formalized (Fawcett, 1999; von Post & Eriksson, 2000). M oreover, regarding all four patterns of knowing as types of theories reintroduces the notions of uncertainty and tentativeness that typically are associated with empirical theories (Fagerstrom & Bergdom Engberg, 1998; M orse, 1996; Polit & H ungler, 1995). The four types of theories constitute much, if not all, of the knowledge needed for nursing practice. A potentially informative analysis, which follows from the conclusion that the patterns of knowing can be regarded as sets of theories, is the examination of extant theories to determine in which pattern of knowing each is located. That analysis is, however, beyond the scope of this paper and will not be pursued here. Rather, we are attempting to make connections between the four types of theories, representing the four patterns of knowing, and what constitutes evidence for nursing practice. On Evidence These four types of theories underlie all methodological decisions, and they are the basis for generating multiple forms of evidence. The question of what constitutes evidence depends, in part, on what one regards as the basis of the evidence. We maintain that theory is the reason for and the value of the evidence. In other words, evidence itself refers to evidence about theories. Similarly, theory determines what counts as evidence. Thus, theory and evidence become inextricably linked, just as theory and inquiry are inextricably linked. Any form of evidence has to be interpreted and critiqued by each person who is considering whether the theory can be applied in a particular practice situation. This view indicates acknowledgement of diverse forms of knowing as inherent in any global or cultural interpretation of knowledge or theory (Z oucha & Reeves, 1999). The four types of theories are diverse ontological and epistemological lenses through which evidence is both interpreted and critiqued. The current emphasis on the technical-rational model of empirical evidence denies or ignores the existence of a theory lens. In contrast, our theory-guided model of evidence requires and acknowledges interpretation and critique of diverse forms of evidence. As shown in the Table, we regard the scientific data produced by empirical research as the Journal of N ursing Scholarship Second Q uarter 2001 117 Theories and Evidence evidence for empirical theories. We count as scientific both qualitative and quantitative data and we support the call for qualitative outcome analysis (Kyle, 1995; M orse, Penrod, & H upcey, 2000; Snyder et al., 2000). The evidence for ethical theories is illustrated in formalized statements of nurses’ values, such as standards of practice, codes of ethics, and philosophies of nursing. The evidence for personal theories is found in autobiographical stories about the genuine, authentic self. The evidence for aesthetic theories is manifested or expressed as aesthetic criticism of the art and act of nursing and through works of art, such as paintings, drawings, sculpture, poetry, fiction and nonfiction, dance, and others. O ur view of the reason for evidence differs from the prevailing discussion in the literature. In current literature, typically a procedure or intervention is presented in isolation fr o m t h e t h eo r y t h a t u n d er gir d s t h a t p r o ced u r e o r intervention, and in isolation from the value of the evidence. H ence the term, “ evidence-based practice.” We maintain that the more appropriate term is “ theory-guided, evidencebased practice” (Walker & Redmond, 1999). Given the diversity of kinds of theories needed for nursing practice (See Table), evidence must extend beyond the current emphasis on empirical research and randomized clinical trials, to the kinds of evidence also generated from ethical theories, personal theories, and aesthetic theories. O ur view of the diversity of types of theories and the type of evidence needed for each type of theory addresses, at least in part, current criticisms of the evidence-based practice m o vem en t . We a gr ee w it h M it ch ell (1 9 9 9 ) t h a t t h e “ proponents of evidence-based practice have … grossly oversimplified and misrepresented the process of nursing” (p. 34). M itchell was particularly concerned that “ The notion of evidence-based practice is not only a barren possibility but also that evidence-based practice obstructs n u r sin g p r o cess, h u m a n ca r e, a n d p r o fessio n a l accountability” (p. 30). We respond to M itchell’s concern by including evidence about personal theories, which include authenticity in nurse-patient interpersonal relationships. M oreover, M itchell (1999) maintained that “ Evidence-based practice does not support the shift to patient-centered care, and it is inconsistent with the values and interests of consumers” (p. 34). H ere, we respond to M itchell’s concerns by including evidence about ethical theories, which include the values of nurses. M itchell (1999) also was concerned that “ Evidence-based practice, if taken seriously, may restrain some nurses from defining the values and theories that guide the nurse-person process” (p. 31) and relationship. This point relates to our view that the art of nursing is expressed through the nurse-person process and the evidence derived from interpretations of tests of aesthetic theories and ethical theories. Furthermore, our view of the diversity of types of theories and corresponding types of evidence needed for theoryguided, evidence-based nursing practice elaborates Ingersoll’s (2000) definition of evidence-based nursing practice. H er definition is as follows: “ Evidence-based nursing practice is the conscientious, explicit, and judicious use of theory118 Second Q uarter 2001 Journal of N ursing Scholarship derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences” (p. 152). O ur view makes explicit the multiple kinds of theories— et h ica l, p er so n a l, a est h et ic, a n d em p ir ica l—w h er ea s Ingersoll’s reference to theory could easily be construed to mean only empirical theory or, perhaps because of the reference to individual needs and preferences, to include empirical and aesthetic theories. We maintain the appropriateness of recognizing and appreciating empirical, ethical, personal, and aesthetic theories and the corresponding critique and interpretation of the evidence about each kind of theory. Such critique and interpretation of evidence is crucial for nursing practice because it is embedded in the values and phenomena located within a broad array of nursing theories. M oreover, by recognizing the four types of theories, more nurses and other health professionals may appreciate and use theories. They may agree with us that theories and values are the starting point for the critique and interpretation of any evidence needed to support clinical practices that may enhance the quality of life of the public we serve. Conclusions We invite readers to expand the dialogue about theoryguided, evidence-based practice. We urge nurses everywhere to consider the implications and consequences of the current virtually exclusive emphasis on empirical theories and empirical evidence-based nursing practice. We urge our nurse colleagues throughout the world to join us and those who have accurately pointed to the limitations of viewing nursing as a strictly empirical endeavor (Bolton, 2000; Dahlberg, 1995; Fagerstrom & Bergdom Engberg, 1998; H all, 1997; Z ocha & Reeves, 1999) to consider what might be gained by recognition and development of ethical, personal, and aesthetic theories and by formalization of those kinds of theories. Accordingly, we encourage all nurses to actualize their claim of a holistic approach to practice by adopting a more comprehensive description of evidence-based nursing p r a ct ice, a d escr ip t ive t h a t a llo w s fo r cr it iq u e a n d interpretation of evidence obtained from inquiry guided by ethical, personal, aesthetic, and empirical theories, as well as by any other kinds theories that may emerge from new understandings of nursing as a human science and a professional practice discipline. References Bolton, S.C. (2000). Who cares? O ffering emotional work as a “ gift” in the nursing labor process. Journal of Advanced N ursing, 32, 580-586. Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in N ursing Science, 1(1), 13-23. Chinn, P. L. (2001). Toward a theory of nursing art. In N . L. Chaska (Ed.), The nursing profession: Tomorrow and beyond (287-297). Thousand O aks, CA: Sage. Theories and Evidence Chinn, P. L., & Kramer, M.K. (1999). Theory and nursing: Integrated knowledge development (5 th ed.). St. Louis, M O : M osby. D ahlberg, K. (1 9 9 5 ) Q u a lit a t ive m et h o d o lo gy a s C a r in g Scien ce M ethodology. Scandinavian Journal of Caring Science, 9, 187-191. Fagerstrom, L., & Bergdom Engberg, I. (1998) M easuring the unmeasurable: A caring science perspective on patient classification. Journal of N ursing Management, 6, 165-172. Fawcett, J. (1999). The relationship of theory and research (3 rd ed.). Philadelphia: F.A. Davis. Hall, E.O.C. (1997). Four generations of nurse theorists in the U.S.: An overview of their questions and answers. Vard i N orden: N ursing Science and Research in the N ordic Countries, 17(2), 15-23. Ingersoll, G.L. (2000). Evidence-based nursing: What it is and what it isn’t. N ursing Outlook, 48, 151-152. Kyle, T. V. (1995) The concept of caring: A review of the literature. Journal of Advanced N ursing, 21, 506-514. Mitchell, G.J. (1999). 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Journal of Advanced N ursing, 29, 549-555. von Post, I., & Eriksson, K. (2000). The ideal and practice concepts of “ Professional N ursing Care.” International Journal for Human Caring, 5(3), 14-22. Walker, P.H., & Redmond, R. (1999). Theory-guided, evidence-based reflective practice. N ursing Science Quarterly, 12, 298-303. Watson, J. (1999). Postmodern nursing and beyond. N ew York: Churchill Livingstone. Zoucha, R., & Reeves, J. (1999). A view of professional caring as personal for M exican Americans. International Journal of Human Caring, 3(3), 14-20. M E M B E R M A I L B O X How do I find my membership number? Member numbers are printed on your membership card. They are also included above your name and mailing address on the mailing label of any routine correspondence FLORIDA INTERNATIONAL UNIVERSITY SCHOOL OF NURSING The School of Nursing at Florida International University seeks outstanding candidates for full-time nine-month faculty positions with responsibilities in both undergraduate and graduate programs. Successful applicants should have expertise in the following: Medical-surgical nursing Psychiatric-mental health nursing Women's health nursing Pediatric nursing Family nursing practice Candidates must hold a doctorate in nursing or related field, a master's degree in nursing and a valid registered nurse license. National certification in clinical specialty is preferred. Salary and rank will be commensurate with education and experience. Florida International University is a [young and fast-growing] university with over 30,000 students enrolled in more than 200 academic programs. Located in Miami, the gateway to the Caribbean and: Latin America, the university offers unequalled diversity among faculty and students. The School of Nursing is situated on the shore of activities and cultural opportunities. The School is NLNAC accredited and offers baccalaureate, RN completion and advanced practice master's programs in psychiatric-mental health, child, adult and family nursing. Applications will be accepted until June 2001. Please send a letter of interest, curriculum vitae, an official transcript showing your highest degree and the names, addresses and telephones numbers of four individuals willing to write a recommendation to Dr. Sandy Lobar, Chairperson, Faculty Search and Screen Committee, Florida International University, School of Nursing, 3000 NE 151 Street, ACII 230, North Miami, FL 33181-3000. Telephone: (305)919-5915. Florida International University is an Affirmative Action/Equal Access/Equal Opportunity Action Employer. 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