CHAPTER 7. The growth of ideas and theory in nursing
Sarah Winch, Amanda Henderson and Debra Creedy
LEARNING OBJECTIVES
• define the term theory
• describe the terms modernity and postmodernity
• identify the dominant historical and societal trends within the nursing profession
• explain how these trends influence the practice of nursing and accompanying knowledge development, and
• differentiate the contribution of theory to research and research to theory.
INTRODUCING THEORY
This chapter aims to help you critically understand the relevance of theory to inform the ongoing development of nursing knowledge and contribute to the improvement of nursing practice. Clinical practice informed by theory gives nurses the necessary foundation to enlighten and restructure healthcare and improve quality of care at all practice levels. We begin with a brief overview of the philosophies, models and theories that underpin contemporary nursing theories. The next section emphasises nursing practice with a focus on knowledge utilisation, with theory and research as tools of practice.
Broadly, we can state that theory refers to any attempt to explain or represent a phenomenon, and ranges from the highly abstract and large scale, to the specific. Theories act as a lens by which to view the world. If you change the thickness of the lens and its shape, then what is being viewed is seen differently, in more or less detail, or expanded or reduced in size. Theories also act like a kaleidoscope, where turning the end of the instrument creates different patterns forming from the same small elements that are present. Theory and the application of theory to human understanding and social phenomena results in key elements (we shall call them variables and ideas) that underpin our understanding of the person and society being emphasised in different ways. Likewise, key philosophical ideas such as the nature of truth, evil and justice may be viewed differently.
When we focus on the process and practice of nursing, the central phenomena that require explanation are the nurse, the nursed and the care setting, including practices, processes and organisation. Nursing theories help us make sense of processes and practices. They explain why and when nursing takes place, provide an understanding of how the practice of nursing proceeds and also assist with practice change through critique. In this way nursing theories help us understand the practice of nursing, how we interact with the nursed and how we structure our nursing actions to provide nursing care.
NURSING AS SOCIAL PROCESS: THE ROLE OF SOCIAL THEORY IN UNDERSTANDING NURSING
Nursing can be viewed as a social and cultural product of society. That is, nursing is an interactive process that always takes place within a social context. Our common understanding of nursing involves a nurse and the nursed (the patient, consumer or client) interacting within a socially and politically constructed system (healthcare facility or provider) that directs actions and responses.
Knowledge of the role of social theory is valuable when we seek to answer the ‘how’ and ‘why’ questions about nursing and the social context from which it arises. The field of social theory is comprehensive, as it spans all of the social sciences and the humanities. In the following section we provide an overview of two major ways that social theory contributes to nursing. These are: an analysis of modernity and its contribution to the type of world we live in; and a critique of the social milieu that constructs and defines nursing.
Modernity and postmodernity: how social theory informs the way we think
Modernism, and postmodernism, are terms that hold a number of meanings in different contexts. For example, they may refer to specific styles of literature, art and architecture in the nineteenth and twentieth centuries. Or, as we explore here, they
EXAMPLES OF WELL-KNOWN NURSING THEORISTS (TOMEY & ALLIGOOD 1998)
• Faye Glenn Abdellah: 21 nursing problems
• Patricia Benner: stress and coping in illness
• Anne Boykin and Sarvina O Schoenhofer: the theory of nursing as caring
• Joyce J Fitzpatrick: rhythm model
• Dorothy Johnson: behavioural system model
• Imogene King: general system’s framework/theory of goal attainment
• Katharine Kolcaba: theory of comfort
• Madeleine Leininger: theory of cultural care, diversity and universality/transcultural nursing model
• Myra Levine: conservation model
• Ramona T Mercer: maternal role attainment
• Betty Neuman: nursing systems model
• Margaret Newman: theory of health as expanding consciousness
• Florence Nightingale: environmental adaptation theory
• Dorothea Orem: self-care framework
• Ida Jean Orlando: theory of the nursing process discipline
• Rosemarie Parse: theory of human becoming
• Josephine Paterson and Loretta Zderad: humanistic nursing theory
• Hildegard Peplau: theory of interpersonal relations
• Martha E Rogers: science of unitary human beings
• Nancy Roper, Winifred W Logan and Alison J Tierney: the elements of nursing: a model of nursing based on a model of living
• Callista Roy: adaptation model
• Jean Watson: theory of human caring
• Ernestine Wiedenbach: the helping art of clinical nursing
First, we review modernity and postmodernity as a particular set of philosophical beliefs. These provide a useful philosophical framework that we can use to analyse practice-specific theories by tracing the traditions from which they emerge. Our second understanding relates to how nursing as a social process happens within the different time frames that represent the modern and postmodern eras. This provides a broad social and historical context that explains the nature of nursing and the transformations to nursing practice that are initiated through social change. In a later section, we examine modernism and postmodernism as broad cultural configurations that influence how society is organised.
Modernity and the Enlightenment
For many theorists, modernity encompasses a large historical period that emerged in Europe dating from the Renaissance to the present. Philosophical ideas on the nature of knowledge and modern method (Rene Descartes), science as power (Frances Bacon), the state and the science of human nature (Thomas Hobbes) and modern politics and power (Niccolo Machiavelli) construct the early basis of modernity. Later, in the eighteenth century, many of these ideas had their full intellectual flowering in a time known as ‘the Enlightenment’. The goal of the Enlightenment project was to replace the ignorance, tradition and superstition present in the church-dominated societies of the Middle Ages, with knowledge that was based on science and reason. This far-reaching period of intellectual development is still prominent in much of contemporary thinking in nursing and other disciplines.
Ideas on the nature of human life that stem from the Enlightenment period reflect a particular belief about the self and the human condition. The modernist concept of ‘the self’ is a unified, rational, autonomous and essential entity. This means that ‘the self’ can be observed and studied. It is free, capable of thought and of independent action. This is a description of human beings as active agents doing things for reasons and shaping the world to their own ends. These core ideas about the nature of the self are central to many nursing theorists who see patients and nurses as autonomous beings who are able to be influenced in their behaviours to promote health and wellbeing or to address deficits caused by illness.
The Enlightenment period crystallised a belief in universal goals and human progress towards an ideal through the application of value-neutral knowledge. Knowledge derived from the empirical or natural sciences can be applied to society to increase human progress and happiness, while knowledge from the human sciences can be used to transform society into a scientific, rational culture. These ideas, which Yeatman (1991) terms ‘rational utopianism’, underpin modernist emancipatory politics (i.e. the search for truth and progress through value-free, objective knowledge).
For researchers working within this framework (and this includes most nurses), it is important to select the correct research method, as this endorses ‘truth’ and provides theory that is an objective reflection of a securely grounded world (Hollinger 1994). Society and history are seen as a whole, able to be grasped through totalising methodologies and explained by grand and comprehensive explanations (meta-narratives). In nursing these would take the form of theories of caring or grand theories of nursing.
Research methods based on modernist assumptions promote the ideas of objectivity, and most importantly value neutrality. In this way a society based on science and universal values can be assumed to be truly rational and emancipatory. As such, theory is an objective representation of social reality. Ideas from the Enlightenment period have led to positivism, scientism and an emphasis on technological reason. For example, although ideas about ageing have been present in the wider literature since ancient times, the Enlightenment constructed the idea of ‘old age’ through medicine, science and philosophy as an essential part of life. Modernity spawned practices of calculation, division and ranking of the population. It was then possible to separate older age as a distinct developmental stage (Katz 1995). As such, all human institutions and practices, including hospitals and nurses, can be analysed by science and improved. This central belief is very much a part of healthcare and service provision today.
Modernity is also about order and rationality (logical thinking underpinned by science). This order and stability are maintained in modern societies through the means of ‘grand or master narratives’. These are stories about the practices and beliefs present in a society. A ‘grand narrative’ in Australian culture may be that the family is a ‘haven’ and a ‘central building block’ of society. Generally, if we support families to function well, they will raise the next generation properly, and care for their sick and elderly. Contemporary healthcare and social policy reflects this type of grand narrative. For example, aged care policy, such as home and community care, is based on supporting families (often aged spouses) to care for their partners. Likewise, early discharge policy and short stays in acute care hospitals rely on a well-organised, functioning family to provide supportive care.
Postmodernity
The central theme of modernity is a belief in the idea of progress in human life through the application of value-free knowledge gained in an objective way (science). However, as the German philosopher Jurgen Habermas and others have established, the twentieth century experience of the Holocaust and nuclear devastation shattered confidence and faith in scientific progress (Harvey 1989). Postmodernism (which in our discussion here includes the related although not identical category of poststructuralism) presents an altogether more pessimistic view of the world in general. It seeks to critique or deconstruct grand narratives to reveal the contradictions and instabilities that are inherent in any social organisation or practice. For example, in Australia, community nurses know that the grand narrative involving the family as a source of comfort and support is not always true. Postmodernism, while rejecting grand narratives, prefers ‘mini-narratives’, or stories that explain small practices and local events, rather than large-scale universal or global concepts. These ‘mini-narratives’ are always locally based on particular situations and do not claim to be universal or generalisable to other contexts, and have great application in promoting understanding of aspects of nursing practice.
Drawn from a complex mix of ideas from theorists such as Hegel, Nietzsche and Weber, the postmodern position is associated with concepts such as irrationality, play, deconstruction, antithesis and indeterminacy (Gillan 1988). In a sense, these are the opposite of the science-based rationality that underpins modernism. Critics of the Enlightenment, such as the well-known philosopher Nietzsche, argue that truth, knowledge and rationality are not immutable and science itself may rest on faith (Hollinger 1994). Postmodernism, taken to its extreme, refutes all claims to truth and reduces theory to narrative or storytelling. Postmodernism abandons the dualism of facts and values, objectivity and subjectivity, descriptions and interpretations, and gives all methodologies a political emphasis, while contextualising all claims, methods and values. Moreover, postmodernism does not accord ‘reason’ a central and transcendental status.
From the Enlightenment onwards, the idea of the ‘subject’ has had a central place in thought about the special nature of humanity. For key Enlightenment thinkers, the autonomous subject was the central tenet of civil society. By stark contrast, many postmodern thinkers dispute the concept of the sovereign individual or subject, viewing these ideas about the subject as a form of grand narrative that requires deconstruction itself. For postmodernists, individuals are subjects, constituted through a variety of practices and knowledges or discourses in society in which they are positioned at any one point in time. The modernist, humanist concept of a unified, rational, autonomous and essential self is seen as illusory and results from regular positioning within a common, frequently used discourse (Grosz 1993).
Postmodernity has influenced several thinkers and observers of nursing practice, including Winch (2005), who argues that this type of analysis can provide a highly analytical view of nursing practice. This view links the minutiae of nursing work with formation of identity (of the subject), and the monitoring and fashioning of patient conduct within broader historical, social and political processes and institutions.
Characterising modern healthcare institutions
The second way by which we may understand modernism and postmodernism is to view them broadly as historical cultural configurations that influence how society is organised. In two to three centuries, modern industrial capitalism altered earlier farming or rural societies and set the scene for the society we know in Australia today. In line with the massive social change from the modern to the postmodern, nursing as a social process or cultural product has also been transformed.
Jameson (1984) outlines three primary phases of capitalism in Western industrialised nations that have produced particular cultural practices associated with modernism and postmodernism. These provide a framework for how we may understand healthcare and nursing. The first predates both modernism and postmodernism and is termed market capitalism. This occurred in the eighteenth through to the late nineteenth centuries in Western Europe, England and the United States. This phase is associated with particular technological developments such as the steam-driven engine. It is in this phase that nursing began to emerge as a central form of healthcare responsible for cleanliness and hygiene, with the growth of the clinic and the asylum. The work of the nursing theorist Florence Nightingale is prominent in this period.
The second phase, termed monopoly capitalism, occurred from the late nineteenth century until the mid-twentieth century, and is associated with modernism, industrialism, the growth of cities, the nuclear family, democracy and social legislation. It is in this phase that we see the growth of particular institutions such as the modern hospital, the development of the health professions and the rise of medicine as the dominant and most powerful form of healthcare.
The third phase, the one that we currently occupy, is a form of multinational or consumer capitalism, a postindustrial or postmodern society. Developing after World War II, the third phase encompasses all of the second phase but emphasises new technologies, marketing, selling and consuming commodities, and the growth of the internet. It is in this era that multinational pharmaceutical companies have grown very powerful, seeking to influence medical care and the consumption of particular drugs, ordered through medical practitioners and marketed in some countries, such as the United States, directly to the consumer. Modern managerialism has also crept into healthcare and influenced nursing work, with a focus on healthcare targets and clinical pathways. Health services are now managed as businesses, with patients as consumers.
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