Professional nursing practice grounded in the theoretical framework of the discipline: reality or utopia

Background: Supporting nursing practice on the discipline’s conceptions is currently one of the biggest challenges, which is why it is important to understand nurses’ views. Objective: Analyzing hospital nurses’ perception of the relevance of the theoretical framework for sustaining their profes-


Introduction
In the 1970s, 80s and 90s, discussions on the importance of developing nursing theory focused on theory's ability to improve practice, and on the need for a establishing a link between theory, practice and research (McEwen, 2016a). In spite of several decades of progress in nursing, theory and practice are still regarded as separate realities, which is puzzling for nurses who often believe that the theoretical framework is not very relevant for practice. Furthermore, growing economic crises, technologies, practices and medicalization policies in hospitals in the last years have shifted the nursing profession from its disciplinary grounds. The problem is that without clear disciplinary guidance and a basis for steering the development of the profession it is easy to lose track (Watson, 2017). Indeed, without a theoretical framework of nursing, the culture of nursing care focusing on the illness and anchored in the biomedical model has prevailed, with nurses being mostly responsible for managing signs and symptoms of the illness and not the patient itself (Paiva, 2016;Rodrigues, Pereira, & Amendoeira, 2015). While this applies to many health institutions, it is particularly true in hospitals, where activities are still interdependent and based on habits and routines, contrary to drawing on knowledge and beliefs in nursing. Alongside the previous remarks, the present study was triggered by the perception that nursing practice should be founded on the theoretical framework of the discipline. Integrating a broader research project conducted at the national level -"Contexts of hospital practice and nursing concepts" -the present study was drawn up to analyze the views of hospital nurses on mainland Portugal on the relevance of the theoretical framework supporting professional practice.

Background
We know that for several decades researchers tried to cover all physical, psychological and social aspects of care in nursing theories that were intended to guide practice and provide a platform for research and training, while supporting the development of professional knowledge (McCrae, 2011;McEwen, 2016a). The problem is that the global theories of the 1970s and 80s were misunderstood and ill interpreted, and were unable to fill in the existing gap between theory and practice. Consequently, at the international level, while there are contexts in which theory was applied successfully, there were also other contexts where nursing theories disappeared from the professional discourse (McCrae, 2011). In spite of many decades of development of nursing theories, currently most nurses still believe that theories are irrelevant for the development and delivery of nursing care, in addition to the difficulties faced by nurses in integrating theoretical models in their practice (Carpinteira, Sanchez, Pereira, & Castro, 2014;Zarzycka et al., 2013). In this context, supporting the view that a theoretical framework is crucial for the progress of nursing (McCrae, 2011), there is the urgent need to center professional activities on theoretical grounds that enhance the disciplinary nature of nursing and foster higher quality care (Zarzycka et al., 2013). As mentioned by Huitzi-Egilegor, Elorza-Puyadena, Urkia-Etxabe, and Asurabarrena-Iraola (2014), nursing models and theories provide the framework for understanding and giving meaning to practice, ensuring strict exercise of the profession based on scientific and philosophical assumptions provided by each theory. Proof of this is the fact that current structures, such as the Magnet Recognition Program in the international context that requires the implementation of a professional practice model, have been fostering reflection on the theoretical fundamentals of nursing, as a requirement for the quality of care (Ribeiro, Martins, & Tronchin, 2016).

Research Question
How do nurses working in Portuguese hospital institutions managed under the public corporation model (EPE) express the contribution of theoretical frameworks to supporting their professional practice?

Methodology
This is a qualitative study of an exploratory and descriptive nature, initially designed to be OLGA RIBEIRO et al. carried out in all hospitals managed under the public corporation model. At the time there were 21 Hospital Centers on mainland Portugal with this management model. Since two such institutions were not willing to take part, the study was conducted in 19 hospitals. For selecting the participants, purposeful sampling technique was used. To ensure a better understanding of the phenomenon under analysis, a nurse-manager, a nurse specialist and a nurse were chosen as informants in each hospital. Since the study was carried out in the domestic context, the three informants in each center were appointed by the chief nurse. The following were the inclusion criteria: having carried out their professional activity in a hospital for a period of no less than 6 months, working in the departments of medicine and medical specialties, surgery and surgical specialties or intensive care and emergency medicine, and openness to participate in the study. Once the potential informants were selected, their decision to take part in the study was confirmed. It was made clear to them that their participation was voluntary and that they could quit the study at any point without incurring in penalties. The collection of data was carried out through semi-structured, face-to-face interviews. The questions asked focused on the way nurses support the decisions they make when setting up and providing care. Since a nurse-manager of one hospital refused to participate, 56 nurses were named informants in total. All participants were asked to sign an informed consent form, declaring that they accepted to take part in the study and authorized the recording of the interview. The meeting with the participants was scheduled in advance via telephone, according to their availability. The interviews were conducted from August 2015 to February 2016, and lasted 60 minutes on average. To ensure the reliability of the data collected, the interviews were sound recorded. All interviews were transcribed in full and then sent to each participant by email for checking the contents. To ensure anonymity, the interviews were codified using the first letter of the word interviewee in Portuguese (E), followed by a number. Consequently, E1 to E19 were interviews done to nurses, E20 to E38 were interviews to nurse specialists and E39 to E56 were interviews to nurse-managers. The content was analyzed from the perspective of Bardin (2015) and using the software Atlas.ti. ® Version 7.5.10. It should be noted that to ensure compliance with the ethics principles inherent to the research process, prior authorization was sought from the ethics committees and boards of directors of all of the Hospital Centers involved. The study was initially approved by the Ethics Committee for Health, under opinion no. CES-98-15.

Results and discussion
Regarding the social-demographic and professional profile of the 56 participants, the majority were women (73.2%) with ages ranging between 30 and 35 years and 50 and 55 years, average age being 42.5, with a standard deviation of 9.9. Most of the interviewees were married or in a civil partnership (73.2%). In relation to their status in the profession, since this was a purposeful sample, distribution was equitable: 19 nurses (33.9%), 19 nurse specialists (33.9%) and 18 nurse-managers (32.1%). From the analysis of the content carried out, the following four categories were drawn: Relevance of the theoretical framework for nursing practice; Theoretical framework guiding the professional practice of nurses; Constraints on integrating the theoretical framework of nursing, and; Strategies for the integration of the theoretical framework of nursing.

Relevance of the theoretical framework for nursing practice
Findings concerning the relevance of the theoretical framework highlighted nurses' perception: "there can be no nursing care without a theoretical framework . . . when we don't have a theoretical assumption and a structure for organizing our care, we inevitably lose a lot in terms of quality" (E9; March, 2016). Providing a significant input to the quality of nursing care, theories are indeed a reference for the professional practice (Shah, 2015), enabling systematic and targeted action. As McEwen (2016a) specifies, nursing theories help professionals focus on the important information, versus irrelevant data. In this context, the author believes that nurses should use Professional nursing practice grounded in the theoretical framework of the discipline: reality or utopia theoretical frameworks to help them interpret the information that is important, understand how information and data relate, what can be expected from such relations, and the type of intervention that is necessary. Some (but not all) participants showed that they understood the meaning of the above stated: nursing theories are important for systematizing the way we care for our patients . . . we should know how to look at a care plan . . . practically only during interventions and understand what are the nursing problems of that patient. (E3; March, 2016) Following the above said, the availability of conceptual guidance for practice was found essential: "i think it is important to have a theoretical framework that everyone knows on which it is founded, what are the assumptions . . . so, on which to build practice" (E18; March, 2016). The possibility of bringing change to hospital institutions fostered by the approximation to theoretical framework is considered by some nurses as the opportunity for (re)orienting the development and delivery of care: "Nursing theories are like . . . a common thread of our practice, and perhaps even of our thinking . . . Therefore, I think it is important that they exist in the institution" (E23; March, 2016). Interviewees also mentioned the importance of having the institution establish the conceptual guidance for practice: "i believe that it is up to the institution to select the models, because there isn't just one model . . . because if it is just one model, it will be abstract, because the contexts are really different" (E14; March, 2016). Accordingly, as clarified: "in intensive care i am not too worried that nurses must know the transition theory, but i do want nurses in the medical wards to know it, so contexts are obviously different" (E14; March, 2016). Choosing a theoretical framework does imply analyzing the theories that support nursing practice, thinking about the concepts, the assumptions and propositions, and assessing the feasibility of implementing them in practice, considering the structure of the institution (Oliveira, Almeida, Azevedo, Almeida, & Oliveira, 2015). In the last years, some hospitals have focused on setting up conceptual guidance for practice in nursing: the institution's managers have gone in that direction . . . to bring the theories closer to the nursing models . . . It is a journey! It does not change overnight. . . we change a thing at a time. (E3; March, 2016) Although it is believed that in the hospital context the preferred model, that is, the model that must be giving greater relevance, should be established by top management, as expressed below: "someone from the top must face up and say: this is excellent, it is for everyone" (E14; March, 2016). Right now, in some institutions, we find the opposite: "it comes up in the context . . . and i don't think it's the best way . . . it must be top down" (E14; March, 2016). Alongside nurses' views on the importance of the theoretical framework, the findings also hint at the contribution of the latter to clarifying the professional role: "the theoretical framework helps clarify the target of our care . . . and we are all able to enlighten patients on our role" (E21; March, 2016 influence of other theoretical frameworks were mentioned, in particular those of Dorothea Orem, Afaf Meleis and Callista Roy: "i base myself a lot on . . . three theories which are a reference for me. Selfcare, transition and adjustment" (E38; March, 2016). As mentioned and even supported by some authors (Rocha et al., 2016;Rodrigues et al., 2015), it is possible to resort to more than one framework, as long as they are adjusted to the contexts, which has been the case: "They are three models, but they fit perfectly into the circumstances of our practice, so . . . it doesn't have to be all pure" (E41; March, 2016). The effort to draw the two (more recently-developed) models mentioned closer to the models used were found in the statements: some nurses now think of the person, they see the person as a whole, they don't focus on the patient, but there is always the patient-family dyad . . . and maybe it is largely the result of . . . the theory of transitions. (E20; March, 2016) Currently, some institutions have made an effort to improve the quality of care, to foster professional practice based on the theoretical framework: to bring in the theoretical models and promote them in the practical contexts, because the theoretical framework must be the model . . . supporting practice. . . specially since it makes us nursing technicians or nurses. (E9; March, 2016) The problem is that the use of the theoretical framework for guiding practice is not implemented by nurses in the same way: as the theoretical framework of practice . . . I can tell you that everyone internalizes and can reflect on and discuss these matters . . . most can . . . obviously not at the same level. (E40; March, 2016) Considering that some nurses received basic nursing training some years ago and did not continue to invest in this area, there may be some disparities. In this context, the institution's inherent particularities, and the fact that nurses are or are not encouraged to invest in sustaining their practice on theory, can make a difference: "what we have in our institution, I don't think it can be extended, that it can be global in nursing terms" (E40; March, 2016). In line with the mentioned above, McEwen (2016b) believes it is essential that clinical nurses be encouraged to invest in the development and consolidation of the theoretical thinking. The input of schools is paramount here, particularly since it is essential for establishing the guiding models for professional practice: "as nurse, I have my own concept of care that I internalized during my training and it guides how I think and make decisions" (E5; March, 2016).

Constraints on the integration of the theoretical frameworks of nursing
Although integrating the theoretical framework of nursing in the contexts of hospital practice is deemed important, there are clearly constraints given the diversity and complexity of such contexts: "it is tough, and if we look at our care plan, the majority of nurses are not prepared to think about some aspects" (E20; March, 2016). The statement is clarified by the participant when he mentions the process of integrating the transition theory: we focus a lot on dependence, on complications, but . . . as far as the awareness of the problem goes, the involvement in the problem, will power. . . perhaps not many nurses think about it! (E20; March, 2016) In addition to the complexity and diversity of the theoretical frameworks of nursing, there was also a clear view that they are too theoretical: we still have very theoretical, very rigid models, which in practice . . . has nurses not adapting them . . . and they all still say the same: it's all too theoretical and we cannot do it. (E49; March, 2016) Knowledge about theoretical frameworks of nursing was one of the most highlighted aspects: "colleagues may know the name of the theories, but I don't think they know the actual model, the content" (E25; March, 2016). In the study conducted in the hospital context, Morais (2012) realized that in addition to the Professional nursing practice grounded in the theoretical framework of the discipline: reality or utopia lack of nursing-specific knowledge, existing understanding of theoretical models, if any, is superficial. According to the participants in our study, the place where they were trained seems to be decisive: "It is surprising to see that even there, once again, it makes a difference where we studied (E40; March, 2016). The relationship that participants had with other nurses helped them identify some specificities of knowledge on theoretical frameworks: "some said they didn't recall . . . clearly what came up . . . we were always talking about our dear Florence Nightingale . . . We're still in that paradigm" (E40; March, 2016). The fact that the knowledge on theoretical frameworks are mostly connected with the models produced by the pioneer nursing theories can be hindering nurses' understanding. During a research work aimed at analyzing the challenges that nurses faced when implementing the theoretical models in nursing services, Carpinteira et al. (2014) remarked that the professionals lacked knowledge in nursing theories. In addition to insufficient knowledge, our study also underscored unclear views on the theoretical frameworks: "when I graduated, we still worked according to the Roper and Florence Nightingale models . . . this evolved with the ICNP . . . and it took long for the model to be implemented" (E16; March, 2016). As a consequence of the misunderstanding of the International Classification for Nursing Practice (ICNP) ® as a conceptual model, nurses have trouble understanding the contribution of conceptual models, and of the ICNP ® : the basic human needs discussed in the past were mostly linked with patient's needs . . . The ICNP model focuses much more on nursing intervention and not much on patient contact and focus. (E16; March, 2016) In spite of the progress in the past ten years, looking into the statements it is clear that nurses still have not grasped entirely the content of the ICNP ® . There is also the idea that the Support System for Nursing Practice (SAPE) contributed to downgrading the theoretical framework: "when I came to this hospital, they followed the theories of Virgínia Henderson . . . Then the SAPE was introduced, and I think the former sort of faded away" (E23; March, 2016). From the statements it is apparent that the theoretical framework is replaced, which Huitzi-Egilegor et al. (2014) had already remarked in relation to the Virginia Henderson model and the nursing assessment structures. In spite of the progress seen in the past years, the fact that there was no investment from the beginning in a theoretical framework guiding data collection, diagnoses, planning, implementation and the assessment of the results obtained, not only supports part of the confusion found in our study, but also highlights that ICNP and the SAPE, both are instrumental factors hindering the integration of the theoretical frameworks. Although Carpinteira et al. (2014) underscored the importance of theoretical models for improving the quality of care, our study found differing opinions. The idea that discussing theories is a waste of time was uttered by nurses: most of the people I know . . . think it doesn't make sense . . . It is a waste of time to talk about theories, we want practice, computerization, new technologies, this is what matters because we must keep pace with technological evolution . . . theories are over, they are history. (E30; March, 2016) In this context, McCrae (2011) recalls that for decades theorists believed that the nursing models would help professionals become more autonomous and responsible in decision-making and organizing care, while fostering the development of nursing as a discipline. The problem is that instead of bringing nursing to a level of theoretical rationale, the theories were addressed as unrealistic dogmas, up to the point of seeming useless and inapplicable. Furthermore, the replies hint at the absence of the awareness among nurses of the use of the theoretical frameworks: "we focus much more on the practice of care based on selfcare . . . than on the components of nursing theories" (E55; March, 2016). Considering the relevance of self-care in the models presented (Shah, 2015), it is clear that nurses do not always realize that they use one or more theoretical perspectives to support their practice. Assuming that nothing is atheoretical, the idea that frameworks are implemented in practice was also mentioned, although nurses do not realize it: "looking closely, they have something guiding indirectly their minds. . . But they still don't appreciate it . . . and we must help them grow in that respect" (E41; March, 2016). Although few health institutions invest in the theoretical grounds of practice, a study in Poland analyzing records found that parts of the theories are present in nursing practice (Zarzycka et al., 2013). In the research carried out in the hospital context, Morais (2012) observed that even where theoretical models are valued, they are not integrated intentionally, nor recognized formally in the context of practice. In face of such duality -importance versus integrationthe participants in the research acknowledged the need for identifying the theoretical models they use, as they support the care they deliver. An aspect that has influenced the knowledge and awareness of theoretical frameworks of nursing concerns the way the theoretical content of models was taught in the academic context: i think that nurses in the practical context are a bit detached from those theoretical models, perhaps because it is not easy for them to integrate the models, because . . . they weren't appropriately developed in the theoretical context and, especially, adapted to practice. (E9; March, 2016) The lack of integration of theory in practice, and the gap between school and the practical contexts were confirmed by other authors (Carpinteira et al., 2014). Additionally, in spite of the effort of schools, the models implemented in the practical contexts influenced negatively the integration of the theoretical references: "Although schools teach the models, recently graduated nurses always use the same models . . . their main references are always nurses in practice and not the school nurses" (E21; March, 2016). In this case, some weaknesses seem to be fundamentally related to the practice environments: then it depends on the contexts where people work, i.e. most nurses do not find and then do not create the conditions to make a difference and they use the knowledge they acquire. It is increasingly tough to find such conditions. (E21; March, 2016) In spite of the criticism at the way the work of nurses is organized in hospitals, there is often conformism, submissiveness and resignation in face of what is proposed, thus continuing the models found (Pivoto, Filho, Lunardi, & Silva, 2017;Souza, Santos, & Monteiro, 2013).

Strategies for integrating the theoretical references of nursing
In view of the issues with integrating the theoretical framework, the findings produced some strategies, of which training organized by the hospital is one example: "i think that what has helped practice evolve in that direction is actually the training we give at the institution, to nurses, it's not what they bring from school" (E41; March, 2016), and in-service training as well: "sometimes when it was also necessary, as far as in-service training is concerned . . . because, when we speak of nursing theories, we think we know everything" (E26; March, 2016). As McEwen (2016b) mentioned, it is important to encourage nurses in clinical practice to expand their knowledge by being permanently exposed to the new theoretical concepts, be it through in-service training or in the context of the programs of formal education. In part because, as the participant highlighted: "that knowledge . . . is present in daily practice, but . . . it might require greater reflection and more contextualization" (E26; March, 2016). Accordingly: that process of reflection will probably make colleagues look at patients differently and have them approach a different dimension, but we need structured things . . . that are more specific to be operationalized. (E14; March, 2016) In effect, although there is still discussion about the importance of nurses following a single theory or whether multiple theories are more appropriate, on one thing they do agree: "For a theory to be useful, it must be meaningful and relevant, and above all understood" (McEwen, 2016a, p. 25). Which was also mentioned by the interviewees: "the theoretical models have to exist, but they must be simpler . . . nurses must empathize with them, they must be implementable . . . if everything is more systematized, it will be easier and can make a difference" (E45; March, 2016). Beside streamlining, there was also mention of the need for time for nurses to understand the appropriateness of a theory-backed practice, to the detriment of a performance anchored in routines and the requirements of other professionals: nurses must stop thinking that they are only enforcers… but we can't be so presumptuous and have everyone change . . . and that they must stop thinking about Virginia Henderson and start focusing i notice it in the specialties when we sometimes discuss the theories of transition or self-care, which people even write papers about . . . but now let's take it up and bring it to our work . . . they don't transpose it. (E21; March, 2016) Participants in their statements about the contribution of schools suggest that there are gaps, insofar as training experiences have not fostered the transposal of the theoretical frameworks into practice. The fact is to reply efficiently to the population's health needs the gap between theory and practice must be closed, which requires the bridging of academic and professional contexts together. Consequently, in addition to the contribution of schools, having nurses in the team in the context of practice who, as a result of previous training procedures, are capable of fostering and facilitating change, is probably an interesting challenge. The study was carried out using a purposeful sample, and was based on what the chief-nurses knew about their staff, as the profile of the interviewees could influence the study results. However, the findings point overall at gaps in the backing of professional practice in the hospital context, which must be clarified and resolved in view of improving nursing care.

Conclusion
In spite of growing interest in using the discipline's theoretical frameworks for guiding nursing practice, the weaknesses inherent to the process have resulted in moments of progress and setback, producing results that depend on the practical contexts. The truth is there is actual consolidation of such frameworks, albeit only in some hospitals and, consequently, only in some services. And although there is currently no consensus among nurses concerning the contribution of the theoretical frameworks to nursing practice, the study shows there is room for changing course. Even assuming the constraints inherent to a purposeful sample, in spite of Virginia Henderson's inputs to the development of nursing in Portugal, some nurses have clearly sought to support their practice on the theoretical frameworks of Afaf Meleis, Dorothea Orem and Callista Roy. However, to ensure full integration into practice, the contents of the theoretical frameworks, the ICNP ® , and SAPE/Sclínico ® must be clarified. In the current stage of development of nursing, the confusion between classification systems and theoretical frameworks requires urgent clarification. Concomitant to such clarification, it is paramount that more nurses learn about and take ownership of the theories that should support their practice. Since, in spite of the significant progress achieved in theory, the consolidation of the theoretical rationale alone will enable well-grounded and streamlined practice. Accordingly, in education as well, teaching-learning strategies should be adopted to help nurses take ownership of the theoretical frameworks. Considering that we already know which theoretical frameworks are best suited to the practice of Portuguese nurses in hospitals, it would make much sense to research the integration of such frameworks in different practice settings.