Meta-Theory in Nursing

The purpose of this column is to reflect on the evolution of nursing science and examine potential futures for nursing as it moves differently into the practice environment at the doctoral level. The new Doctor of Nursing Practice (DNP) has been implemented with a clear focus on primary care practice. There is no doubt that nurse practitioners are in demand. The Affordable Care Act calls for more nurse primary care providers as essential to healthcare for the future and to insure that citizens have access to a primary provider. The Institute of Medicine’s (IOM) (2010) publication the Future of Nursing: Leading Change, Advancing Health made four key points for nursing: (a) eliminating regulations that prevent nurses from practicing to the full extent of their training and expertise, (b) expanding seamless nursing education, (c) nurses as full partners in healthcare redesign, and (d) the need for an improved information infrastructure. Certainly access to advanced practice nurses in primary care is critical for population health, and one could argue, that nursing needs to be at the same level of other practice doctorates for credibility. However, there remain questions as to whether nurse practitioners are practicing nursing as it has evolved as a science or whether nurse practitioners’ practice is more of an applied science. The answer relates to the strength of the connection with nursing science and whether practitioners can truly practice nursing without the meta-theoretical perspective and background in philosophy of science as it relates to nursing frameworks. One might wonder how graduates are expected to balance their “physician extender” role and still insure that their practice is nursing.

The Institute of Medicine IOM is pushing for still more nurse practitioners to achieve better primary care and integration of population health (IOM, 2014). The power of numbers and identity of the nursing workforce makes it key in leading change. However, in order to lead change for population health, nurses must be practicing nursing using the science developed in the discipline to achieve a clear focus on design of complex systems for individuals, families, and communities.

Nurses have struggled for identity since the early 1900’s, and the profession evolved as any new discipline might, except that the influence of medicine was a shadow that restrained independent thinking. There were years of intense debate about the definition of nursing and its ontology and epistemology. Carper (1978) and Donaldson and Crowley (1978) began to develop new ways of thinking about the discipline and gradually the scientific definition of nursing evolved and continues to evolve. Nursing theory development began in the late 1960s, and by the early 1980s, there were a number of beginning frameworks for doctoral scholars and nurse researchers to underpin their studies. Nursing’s meta-theoretical perspective offered a framework for further development of nursing models. It was a time of paradigm shift away from the applied medical practice into the depth of science grounded in nursing. As the substance of the science emerged, universities began to accept nursing doctoral (PhD) programs into the academy, recognizing the depth of scientific evolution in the discipline.

There is purportedly a great deal of confusion about the DNP by nurses as well as consumers, but educators are clearly in agreement. The American Association of Colleges of Nursing (AACN) on October, 28, 2014, released findings, which examined the progress made by nursing schools in transitioning to the practice doctorate, to meet the needs of the nation for primary care. The authors (Martsolf et al 2015) found near universal agreement among nurse educators about the value of the Doctor of Nursing Practice (DNP) degree in preparing individuals for advanced nursing practice.

Since the approval of the DNP there has been much discussion on just exactly what the education of this practitioner should be and whether there is a sufficiently strong connection to nursing science. Initially, there was the assumption that practice of nursing is based on nursing science. Early in the development of the DNP discussion, Whall (2005) questioned the difference in the programs of study and made the case that practice is not a “stand alone” phenomenon. It is one’s meta-theoretical perspective that drives one’s practice including the domains and standards of practice. Without philosophical clarity the practitioner is unable to articulate to other professionals the essence of nursing’s contribution. Recently, Clarke (2014) appraised AACN’s new position statement (Bednash, Breslin, Kirshling, & Rosseter (2014) and questioned the issue of the missing nursing science. In the side-by-side comparison table, the DNP seems to be focused on practice to the exclusion of nursing knowledge and nursing science (p. 300). Whall’s concerns almost 10 years ago are even more urgent today as the essentials appear to be clearly framed in a non-nursing perspective.

Where are we now? The DNP has been approved and is growing. The IOM’s (2010) Future of Nursing report emphasized the need for nurses to deliver primary care and for educators to produce more doctorally-prepared practitioners for the practice arena. As almost an afterthought, it also calls for more doctorally-prepared nurse faculty for teaching, science and research, presumably PhD prepared.

Nursing is also in the midst of a nurse faculty shortage that has consequences for the continued development of the nursing knowledge base and nursing education. With a decreased number of research faculties and the loss of senior investigators through retirement, the continuing development of nursing’s knowledge base may be curtailed. Almost 87% of faculty vacancies were positions that either preferred or required the doctorate (AACN, 2014), traditionally the PhD. Together with predicted retirements, the nursing faculty workforce is expected to decrease by 40% in the next 10 years.

The concerns for the future are many. Practicing advanced practice nursing without a nursing science base raises questions about what counts as evidence for practice. Practice could become so separate from the science that nursing research and practice from different paradigms fail to connect. The dialogue between practitioners and researchers is likely to be more difficult as time goes on with the potential for a loss of shared language. It’s important to continue the debate to achieve clarity and a unified picture of both practice and science.