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Theory, nurse decision-making, and practice

What's all the fuss?

Waters, Virginia Lynn PhD, MBA, MSN, RN, NEA-BC

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Nursing Management (Springhouse): February 2020 - Volume 51 - Issue 2 - p 22-28
doi: 10.1097/01.NUMA.0000605164.72940.25
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It's well established that theory contributes to research, which eventually culminates into best practice and is demonstrated within effective relationships and practice. There's a vast amount of discussion in the literature surrounding the integration of theory into practice. However, theory isn't often given much thought by nurses, as well as nurse leaders. Many authors agree that the art of integrating and bridging theory into practice is extremely challenging, but it can be rewarding.1-4 If professional practice is separated from theory, then practice will ultimately not be affiliated with evidence.5 And if theory becomes separate from reality in practice, then practice will be far from what's deemed to be reality.6 Theory can be regarded as part of a threefold approach to practice, with theory, research, and practice working in concert.7 This literature review explores the application of theory to practice, with a close look at contingency theory and generational identity. See Selected nursing theories for examples of how the theories discussed in this article interact with nursing practice.

Application of theory to practice

You may have staff members ask you, “What's the big deal about nursing theory?” The concept of theory and practice is extremely significant in healthcare where nurses are expected to practice under the guidance of current, relevant theory. Theory and practice are tightly woven into most decisions that nurses make, and the impact of those decisions becomes very important when patient outcomes are involved. Theory guides and informs practice, and is most prevalent and influential in decision-making that's the result of critical thinking in care delivery.

Reflecting on theory in terms of promoting best practice is a topic frequently discussed in the literature.1,3,4,6,8 Scheel, Pedersen, and Rosenkrands described theory interrelated with nursing as interactional nursing.6 These authors believed that the science of nursing is interpretive, founded on the integration of theory with the natural, human, and social sciences and then the application of that theory to practice. Payne focused on intuitive decision-making, describing it as a nonconscious event that's orchestrated by the mind.9 Analytical decision-making requires the nurse to perform a conscious, logical, and sequential thought process. Staempfi, Junz, and Tov's model provides a process whereby the nurse first approaches a critical situation, then reflects on personal knowledge, applies knowledge and skills, and implements appropriate action.4

Theory is utilized to guide practice in most professional disciplines, and it's especially critical in nursing education and practice. Jefford, Fahy, and Sundin discussed several theories related to making clinical decisions and how those theories can be readily applied to practice in a study examining clinical decision-making surrounding healthcare concerns, specifically decisions made by nurse midwives.10 The authors believed the outcomes of decisions made by nurses are definitively based on their ability to apply theory to practice.

One theory of significance is the hypothetico-deductive model, which utilizes a scientific approach to decision-making and implies the concurrent use of rationality with empirical evidence.10 This underlies the concept of nurses' clinical decision-making in many healthcare situations and outlines the process whereby a healthcare worker presented with a patient or situation must make immediate, critical, and sometimes life-threatening decisions. The nurse is expected to quickly and thoroughly assess a given situation, analyze, synthesize, and critically interpret information based on previous knowledge; decide on a course of action; and ultimately implement the action. This process of critical thinking is crucial to bridging theory to practice and demonstrates integration of knowledge obtained through research, skill, process, and intuitive reflection.

Another theory of note is the intuitive-humanistic decision-making model, which implies that decisions made by healthcare workers are generally quick, spontaneous, and supported with profound understanding and rationality.10 If decisions are made with a lack of understanding, knowledge, and information supported by research and theory, then the potential exists for adverse reactions.

Ferrara promoted evidence-based practice founded on both the use of theory and a constructivist theoretical framework.3 The process of integrating theory into practice is challenging, but using evidence combined with experience and skill provides the ultimate in learning and decision-making strength. Chavez discussed how often the parties involved separate theory from practice, which can lead to potential patient care errors.5 Chavez believed that theory or practice alone provides nothing more than a stalemate to making progress. Nutt indicated that integration of findings from the literature is challenging and limited by conceptualizations of the theory.11

Reflective thinking may be the key component to linking theory to practice; however, the concept of reflection isn't always fully understood.4 Theory and practice depend on previous knowledge and expertise, especially regarding decision-making. If theory hasn't been correctly used in the understanding of a situation, practice becomes separated from theory; reflection may be flawed; and the impact of the decisions made may be inappropriate, skewed, or perhaps devastating.

According to Annan, Bowler, Mentis, and Sommerville, when cultural values and behaviors aren't intertwined in the development of solutions to issues and predominant in behavior and attitude, digression from integrating theory into practice occurs.8 These authors discussed how frequently those involved in a situation hold onto familiar beliefs and behaviors in lieu of allowing new practices to enter their field. Nurses may tend to hold onto past practices learned many years ago and not see the need to make a change. According to Dybicz, it's crucial to have a conceptual framework that supports the nurse when bridging theory to practice.1 Nurses must take the time to focus on the patient and the environment to build a relationship and construct an identity for the patient, and then apply that identity to the patient's status. Learning how to make critical changes in patient behaviors can enable nurses to reflect on theory before taking action.

Selected nursing theories

Significance of contingency theory

Contingency theory relates and analyzes group performance contingent on the interaction of leadership styles, situations, and the effectiveness of a leader's behaviors.2 This theory is interrelated to generational identity and often used when researching organizations with respect to the behaviors of employees and their ability to make decisions, as well as initiate and implement change. Contingency theory can be readily applied to healthcare workers, especially nurses, nurse administrators, and other leaders in healthcare organizations. It's extremely applicable to nurses who are considered leaders in terms of their role and required to lead, direct, plan, evaluate, and implement patient care decisions—all of which necessitate excellent leadership skills and respective learned behaviors. Contingency theory applies directly to the behaviors and decisions of different generational and intergenerational groups in response to varying critical situations. Nurses working on a unit together and caring for a specific patient population are working as a team.

According to daCruz, Nunes, and Pinheiro, contingency theory is the application of a clear distinction between leadership style and task orientation, which is related in terms of how a group performs in any given situation.2 Jokipii empirically studied the relationship between contingency characteristics, such as strategy, size, and structure of an organization, and environmental uncertainty with internal controls and efficiencies.12 This relationship is especially relevant in healthcare organizations where the efficiency and effectiveness of activities are enhanced and adherence to governing care standards is mandatory. Danese indicated that if an organization is engaged in collaborative planning surrounding process and action, contingency theory is valuable in developing proactive approaches to actions, especially when referencing relationships and integration between situations and performance.13 Contingency theory demonstrates the relationships between leadership actions and tasks or situations.

Nurses are expected to develop strong relationships with their peers, managers, administrators, and patients. Liao, Liu, and Loi empirically studied how social relationships between leaders and their employees affect individual creativity, which ultimately affects teamwork.14 These authors discussed the importance of capitalizing on employees' creativity for an organization to remain competitive in today's environment. The quality of social exchanges between leaders and direct reports joins contingency theory with social cognitive theory. Both the leader's and direct report's position should be considered when determining the best approach to reacting to a situation contingent on the quality of the nursing team, which is determined by nurses, managers, and organizational leaders.

According to Smith and Lewis, organizational theory has close links to contingency theory.15 Organizational theory supports the implementation of shared governance and encourages nurses to evaluate their practice, research, find best practice(s), and implement those evidence-based practices to improve patient care. When applying this thinking to practice, nurses must be motivated to initiate and implement changes when necessary in just about everything they do. In today's healthcare environment, change is rampant and can occur at any given moment on any given day. All employees, especially nurses, must be ready, willing, and able to make necessary changes to care delivery to enhance practice and deliver safe, quality patient care. The concepts of change, theory, and practice are interrelated; to succeed, staff members must be empowered to make decisions that align with the organization's mission and vision. When nurses are stifled and unable to make necessary changes to their practice, patient care can and does suffer.

Nurses may be hindered by workgroup bureaucracies, organizational culture, emotions, and the influence of team behaviors, mirroring the basics of contingency theory. This in turn describes situations, emotions, behaviors, and influences as integral parts of decision-making and goal orientation. Healthcare organizations consist of a multitude of teams and interdisciplinary workgroups, often led by nurses who are responsible for making critical decisions that are potentially filled with emotion and associated behaviors. Contingency theory closely relates to both individual and team approaches to decisions and highlights the many differences that exist in various situations. For example, Battilana and Casciaro studied 68 clinical managers and discovered a theoretical link between individual employee analyses of social influences surrounding organizational roles with institutional pressures encompassing organizational actions.16 By understanding these factors, organizations can be better positioned to make necessary changes that support movement out of a status quo.

For organizations to become competitive, employees must be encouraged and enabled to be creative and stimulated in their decision-making.2 Nurses are required to make critical patient care decisions, and often those decisions are a matter of life and death. They must be able to position themselves to provide the best patient care possible, but may be hindered by patient acuity, staffing concerns, availability of resources, the environment, management, leadership, and time. Nurses are often intimated by some or all of these factors, which has an effect on how they approach patient care.

Greenwood and Miller described the heart of organizational theory as being driven by contingency theory, illustrating how contingency theory is based on the principle of being able to anticipate organizational problems and strategize and foster ways to solve those problems while concurrently holding an organization together.17 Organizational theory can be readily applied to nurses as they're expected to anticipate organizational problems, such as staffing challenges and lack of resources, and at the same time hold their unit together and deliver consistent, quality patient care. Contingency theory advocates for the use of more patient management teams to deliver diverse points of view that align with nursing care teams and patient care delivery. Hirst, Van Knippenberg, Chin-Hui, and Sacramento developed a cross-level theory built around the fact that constraints are often inflicted on individuals and creative expression is inhibited as the result of team bureaucracy.18 When an individual's creativity is decreased, there's a risk of mistake, failure, and the possibility of the individual appearing incompetent. In healthcare, nurses' creativity can be inhibited as a result of the team of nurses working the same shift and unit and/or rules and regulations, which often limit choices.

Implications of generational differences

Gentry, Griggs, Deal, Mondore, and Cox studied whether managers and staff members from different generational cohorts agree about which leadership practices are important for organizational success and to what extent managers are skilled in those practices.19 They found distinctions among intergenerational managers, but many of the distinctions were more similar than different. They discovered a gap in leadership practices, including the ability to lead others, facilitate organizational change initiatives, overcome resistance, and understand and develop relationships. These factors align with the underpinnings of contingency theory. This study supports the necessity of strategizing ways to train leaders and facilitate information sharing across an organization, as well as across generations. It also demonstrates substantial differences in the generations working within an organization and how the development strategies specific to leadership skills and practices are imperative for different generations of managers. Kowske, Rasch, and Wiley noted that the cost of tailoring interventions should be weighed against the potential benefits of considering generational differences.20

Joshi, Dencker, Franz, and Martocchio indicated that many fundamental questions remain unanswered regarding the implications of generational differences and their impact on organizational outcomes.21 They examined situations that enhance generational and intergenerational behaviors, drawing on predominant theoretical perspectives surrounding identity and identification in organizations. They argued that a facet of generational identity and its impact on intergenerational outcomes is likely contingent on organizational context. They discovered that transfer of knowledge, skills, experiences, and resources across generations may be unsuccessful under some conditions, with generational behaviors, attitudes, and biases at the root. This can readily be applied to the different generations of nurses working side-by-side in healthcare organizations who are precepting and training new nurses.

Inseparable theory and practice

This discussion demonstrates that professional practice can't be separated from theory, rather it's integrated and tightly woven with theory. Practice not founded on theory can't be considered best practice and has the potential to drive inappropriate attitudes, behaviors, decisions, and ultimately undesirable outcomes. Nurses and nurse leaders must be cognizant of the purpose and power of theory, how theory is utilized, and the reasons why and how theory is integrated into the research that drives best practice. All nurses must be alerted to the significance of theory, obtain the knowledge surrounding theory, and be diligent in applying theory to practice and practice changes. After all, understanding theory and how it interrelates with best practice is necessary for nurses to be successful in providing excellent, quality care and positive patient outcomes.


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