Abstract
A theme of this article is the theory-research link and its essential role in advancing nursing science and practice. Concern is expressed over the current status of nursing theory relative to the advances in research and practice. Soon-to-be and current theoreticians and scientists are encouraged to champion not just nursing theory proper but scientific nursing theories that have explanatory power. The role of the precision health movement in facilitating development of scientific theory is explored.
What is especially satisfying about theories, and indeed about science, is when theories provide not just descriptions or even predictions of things but explanations of those things. Theories are pivotal in knowledge development and advancing our science and profession. However, I admit to having some concern and frustration over the current status of nursing theory, especially in comparison to the happenings in research and practice. Nursing students and professors, practicing nurses and patients, and the discipline and society in general benefit from advances in nursing theory as a carrier of scientific knowledge. This process is facilitated when theory is linked to research in the integral manner depicted by Fawcett’s (1978) classic double-helix model of knowledge development.
I offer this article, then, to encourage soon-to-be and current theoreticians and scientists to champion not just nursing theory proper but scientific nursing theories that have explanatory power. For purposes here, I am defining explanatory power from a primarily pragmatic view in which the relevant phenomena are explained by describing the patterns, processes, or mechanisms theorized to be producing or influencing them in significant ways (French, 2016). It involves making rational connections between theoretical ideas and empirical evidence with respect to relevant contextual factors, background assumptions, and scientific knowledge. Further, it is explanatory power of theory as judged within the context of both the epistemic and social values that influence theory development and evaluation (see Longino, 2002).
Decades ago, philosophers of science outlined criteria for judging the adequacy and acceptability of scientific theories. These criteria, referred to as cognitive or epistemic values, are familiar as they are often listed, with minor variations, in many nursing theory textbooks: accuracy, parsimony, consistency, generality, and fruitfulness (Kuhn, 1977). However, feminist postpositivist philosopher of science Helen Longino (2002) and other scholars found several of these standard theory criteria lacking and challenged the status quo for a reinterpretation from a contemporary perspective of science as a social practice. Her insights are appropriate for nursing science as well, given our disciplinary perspectives about health and human-environment interactions and emancipatory nursing practice.
Longino, for example, reformulated accuracy into the more liberal criterion of empirical adequacy regarding the agreement between a theory’s concepts, relationships, and empirical results of research; and parsimony into ontological heterogeneity to better account for the complexity in the phenomena (see Reed, 2018b). Importantly, Longino refuted the 20th-century science dichotomy between epistemic and social values and developed a philosophical system (critical constructive empiricism) to engage both types of values in the context and practices of scientific communities. Two additional epistemic values endorsed by Longino and other feminists are novelty (rather than the traditional value for consistency) in theoretical principles to avoid perpetuating biases or oppression in explanations of phenomena, and applicability to current human needs (see Longino cited in Reed, 2018b).
Pythagoras and Nightingale
The inextricable link between theory and empirical research has existed since antiquity and is demonstrated in the works of both Pythagoras and Nightingale. What Pythagoras was to music, Nightingale was to nursing. Each brought scientific discovery and theory to a field of study and practice.
Pythagoras, of early 6th-century B.C. Greece, is credited with the invention of music theory and music therapy (Anderson, 1983). He was a philosopher, scientist, and mathematicus, described as a “curious blend” of religiousness and scientific achievement (Anderson, 1983, p. 48). Through observations of his environment, systematic experiments, and creative reasoning, he discovered connections between numerical properties and the musical tones and scaling. He developed his theory of musical intervals and their associations using ratios of integers. Pythagoras’ theory about the mathematical dimensions of music marked the shift from music as magical to music as scientific while retaining its aesthetic value in society (Gioia, 2019). Pythagoreans went on to “cultivate the practice of music for its therapeutic value” (Gioia, 2019, p. 54). But they, like Nightingale, lacked the scientific tools needed to delve into explanations of underlying social, biological, and chemical processes of person-music interactions that generated well-being.
Nightingale’s scholarship and practice transformed nursing into a scientific discipline and respected profession. Her empirical generalizations about the influence of environmental factors on human health and well-being, outlined in her Notes on Nursing (Nightingale, 1859/1969), represented a historically significant nursing theory. She too lacked the scientific means to explain how, for example, colorful flowers promoted a sense of well-being or rustling dresses and chattering visitors distressed patients or why dust and dank air were harmful. Nevertheless, Nightingale applied her keen observations and reasoning in positing connections between environment and health to promote healing and well-being of the sick. The explanatory power of her theory and its documented effectiveness in promoting human health was reflective of and limited by the status of 19th-century science.
Rubbery Concepts
In contrast to Pythagoras’ or Nightingale’s eras, science today offers a substantial repertoire of methods and tools to use for generating theories that have explanatory power. However, advances in research have not always been matched by a parallel rise in status and activity surrounding nursing theory. Instead, nursing theory may call to mind structures of concepts that are very abstract, broad in scope, and sometimes moralistic, metaphysical, or mystical—concepts incompatible with scientific engagement.
In a review article, Goldstein (2015) critiqued Christensen’s (1997) theoretical concept of disruption, suggesting that it was a rubbery concept that had been stretched far beyond its boundaries of meaningfulness and accuracy. He summarized results of a recent study by Dartmouth business school professor Andrew A. King and University of British Columbia graduate student Baljir Baatartogtokh, who found very little empirical evidence to support disruption as the mechanism for innovation, despite its theoretical claims and global popularity. Goldstein also cited from a new book, Disruption Dilemma, the fact that scholars overall have selected what they liked about the theory and failed to delve deeply into the phenomenon. He closed his review with the observation that, lacking the precision afforded by the pruning of empirical testing, the concept of disruption has grown like a weed “filling any void.”
Lest we in nursing promote theoretical concepts that are popular though rubbery and empirically inadequate, I suggest that we consider doing the following: First, in our writings, communications, and teaching, more deliberately distinguish between our scientific and philosophical theories of nursing to avoid the “slippage” in referencing philosophical frameworks as nursing theory “meant in the scientific, or evidential, sense” (Thorne & Sawatzky, 2014, p. 16). Second, shift our scholarly focus from philosophy to precision in regard to our work with any conceptual structure we signify as nursing theory. The idea here is to invest more of our efforts in producing or in supporting others in the production of scientific nursing theories.
This suggestion is not in any way intended to diminish the critical roles of philosophical theories in nursing and the nonscientific ways of knowing in knowledge development and practice. These conceptual resources provide essential inspiration and ontological and ethical foundations about human beings and nursing practice, and epistemological guidance for the practice of nursing science.
Further, the idea of precision in scientific concepts still allows for creativity and even metaphor as beneficial attributes of scientific theorizing. Greenwood and Bonner (2008) argued that metaphorical concepts are not simply heuristic devices in theory development but may represent entities that “resist literal expression.” These concepts provide epistemic access to phenomena that are not easily observed but are nonetheless real to nursing (Greenwood & Bonner, 2008, p. 166), entities I suggest are a natural kind in nursing. In sum, then, we can employ creative concepts in our theories to refer to dynamic, complex, difficult-to-describe human-environment phenomena while still holding a critical, realist perspective of science that supports empirical investigation.
Science and Theory in the Precision Health Movement
The precision health movement, which has developed especially over the past two decades, can facilitate investigation of nursing phenomena and achievement of greater precision in nursing theory. Nurses who aim for explanatory power in their theories may employ precision health perspectives. The precision health/precision nursing movement in science, distinct from precision medicine that focuses on mechanisms of pathology, entails study of dynamic and complex phenomena by integrative research methods and an extended epistemology. These research methods integrate data about “about lifestyle and preferences, health status and behaviors, genomics, other physiological measures of health, and environment to design and deliver targeted, personalized interventions to assist individuals [in achieving and maintaining] optimal health and well-being” (Moore et al., 2019, p. 127). Extended epistemology incorporates but extends beyond standard scientific ways of knowing, including those assisted by technology, to omics, electronic sensors, and geospatial data among other methods to assess a fuller range of human health experiences (Corwin, Redeker, Richmond, Docherty, & Pickler, 2019). To these I add the patient-nurse interaction as a key source of data for precision health. This patient-centered element in development of scientific knowledge is championed in intermodernism (Reed, 2018a) and in Green’s (2018) clinical intimacy.
Nursing science is not limited to traditional disciplinary boundaries between social, biological, behavioral, nursing and human sciences; knowledge and methods from all of these areas can be used to more fully inform nurses about human experiences. Advances in research methods enable new forms of scientific inquiry that draw from many patterns of knowing. Researchers engage not only in describing the phenomenological or existential health experiences but also in explaining processes underlying those health-related experiences. Theoretical concepts such as stress, health risk, adaptation, self-management, and advanced care planning have personal and social meaning but may also have biological bases for their therapeutic value.
Examples of Theoretical Concepts in Precision Health Research
Theory can take us only so far, to where we then need to explore theoretical concepts more precisely and empirically through practice-relevant research. The following brief examples of precision health research across various health experiences show how this is done.
Stress
Precision nursing research by Corwin and Ferranti (2016) into family caregiver stress involved biomarkers for both objective and subjective health factors for a more comprehensive theoretical model of stress and related illness in family caregivers.
Risk
Founds, Tsigas, Ren, and Barmada (2018) precision healthcare research included work toward understanding associations between genotype and phenotype, characterizing symptom phenotype to achieve “holistic phenotyping” of women during pregnancy and women at risk for preeclampsia to optimize the health and well-being of mother and her offspring.
Self-Management
Nursing and medical frameworks for self-management in chronic conditions typically focus on cognitive behavior only. But Moore and colleagues (2019) extended this theoretical focus using the theory of opposing domains hypothesis (Friedman, Jack, Rochford, & Boyatzis, 2015 cited in Moore et al., 2019). The investigators wanted to obtain a deeper understanding of the brain to increase knowledge of how chronically ill individuals process and respond to self-management information. A long-term goal was to develop brain signatures—“brain-based phenotypes of self-management to assist clinicians in tailoring interventions” (Moore et al., 2019, p. 128). They measured brain signature using three biomarkers: magnitudes of task differentiation in each of two neural networks in the brain (analytic and emotion/empathy) and a third brain marker (activation of the ventromedial prefrontal cortex [vmPFC]) considered to be an indicator of the person’s valuation process such as how the individual evaluates benefits and barriers for behavior change. The vmPFC ratings were theorized to be high in response to emotional information and significantly lower in response to analytic information.
Preliminary research results supported the theory (with a negative correlation between task differentiation scores of the analytic network and both the empathy network and vmPFC ratings, and a positive correlation between the empathy network activity and the vmPFC ratings). Results also showed good interindividual variability in scores using those biomeasures and, importantly, supported the feasibility of measuring these brain biomarkers in human beings. Moreover, investigators gained knowledge about a crucial individual factor—that is, how individuals process information for nurses to apply in designing the information and personalized coaching to connect to the person (Moore et al., 2019).
Advanced Care Planning
Sullivan (2019) incorporated a precision health perspective into her derivation of a nursing theoretical framework to guide person-centered advance care planning. Her theory included personal values and goals, social marketing concepts, behavior change, and community engagement to foster an improved rate of completion of advanced care plans in the community, compared to previous efforts.
Action Points for Linking Precision Research and Theory
The following list of actions, based in part on commentary by Dorsey and colleagues (2019), summarizes considerations for linking theory and research in the precision health era. These considerations also reflect both epistemic and social values for theory, for example, by their attention to empirical adequacy in representing the many relevant aspects of a health experience; by embracing the complexity of factors and their interactions influencing a health situation; by employing a wide variety of measures to access and assess data at various levels of analysis from the cell to the personal, social, and environmental; and by fostering a collegial community of scientists and theoreticians for inquiry.
Account for updated definitions of race, ethnicity, sex, and gender from a postgenomic perspective.
Attend to the interactions between biological (including molecular omics [genomics, proteomics, metabolomics, microbiomics]) and social and environmental influences on health.
Use a disease-agnostic manner to identify theoretical concepts that represent patterns shared across specific diseases or medical diagnoses.
Select theoretical concepts that facilitate discovery of human patterns (biological or otherwise). For example, pain is a concept that incorporates all three types of pain (nociceptive, neuropathic, and inflammatory) that may share an underlying mechanism.
Focus on gene expression and epigenetic studies that generate data relevant to patients’ clinical symptoms and experiences.
Use theoretical models that incorporate complex elements to frame not only biology and behavior but the broader living environment, while still achieving adequate specificity for targeting the particular problem.
Extend epistemic access through a diversity of data “from molecular pathways, biological processes, and behavioral models” (Dorsey et al., 2019, p. 90).
Practice team science for both theory development and research.
Precision Nursing Theory
Precision nursing theory, to coin a term here, requires an integrative approach that brings together diverse research data that range across health status and physiological indicators, social and environmental factors, lifestyle, and epigenetics to improve understanding and ability to facilitate health and well-being. Given the challenges of precision health for nursing theorizing, Jairath, Peden-McAlpine, Sullivan, Vessey, and Henley (2018) called for a “new social order” where scientists not only “partner with theorists and practitioners but also create theoretical infrastructures”(p. 193) to cultivate meaningful links between data and theory.
Exploring, creating, testing, and refining nursing theories through scientific practices in the laboratory, clinic, and community will advance human health and nursing science for 21st-century nursing practice. Since Fawcett’s 1978 paper, when broad conceptual frameworks dominated our theory landscape, nursing has achieved considerable philosophical clarity about its disciplinary perspective. It seems now is the time, during this Year of the Nurse celebrating Nightingale’s 200th birthday and all nurses, to turn more deliberately toward the empirical to achieve greater theoretical clarity and precision. Nightingale would have liked this.
