ANS987 April 25, 2015 17:4
Advances in Nursing Science
Vol. 38, No. 2, pp. 96–109
Copyright c 2015 Wolters Kluwer Health, Inc. All rights reserved.
A Practice Theory Approach to
Understanding the
Interdependency of Nursing
Practice and the Environment
Implications for Nurse-Led Care
Delivery Models
Miriam Bender, PhD, RN; Martha S. Feldman, PhD
Nursing has a rich knowledge base with which to develop care models that can transform
the ways health is promoted and valued. However, theory linking the environment domain
of the nursing metaparadigm with the real-world environments where nurses practice and
patients experience their health care is tenuous. Practice theory is used to foreground the
generative role of nursing practice in producing environments of care, providing the basis
for a metaparadigm relational proposition explicitly linking nursing practice and environment metaparadigm domains. A theoretical and empirical focus on the significance of nursing
practice dynamics in producing environments of care that promote health and healing will
strengthen present and future nursing care models. Key words: care models, nursing metaparadigm, nursing practice, nursing theory, practice environment, practice theory, work
environment
T HE NURSING profession has been challenged to address the demand for health
care quality and identify models of care
that consistently improve patients’ health and
quality of life.1,2 Nursing knowledge of the
nature of health and people’s experiences of
health and illness make the profession well
situated to develop and implement care delivery models that can fulfill the goal of health
care quality and safety.
Author Affiliations: Program in Nursing Science
(Dr Bender) and Department of Planning, Policy
and Design in the School of Social Ecology
(Dr Feldman), University of California, Irvine.
The authors have no disclosures to report.
Correspondence: Miriam Bender, PhD, RN, Program
in Nursing Science, University of California, Irvine, 252
Berk Hall, Irvine, CA 92697 (miriamb@uci.edu).
DOI: 10.1097/ANS.0000000000000068
The nursing metaparadigm—person,
health, nursing practice, and the environment—defines the nursing profession’s
disciplinary focus and forms the basis for
nursing knowledge, theory, and practice.
Effective nursing-led care delivery models
of the future must articulate the ways patients, their health, nursing practice, and
the environment interact to improve health
care quality and safety. Without an explicit
theoretical basis to guide the organization
of nursing care delivery to improve patient
health, implementation of nursing-led care
models will have varied and potentially
unpromising outcomes.
The propositions of the nursing metaparadigm explicitly link nursing practice with
patients and their health and link patients’ experience of their health with their physical
and social environment.1-3 These propositions
have been empirically tested, creating a rich
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Interdependency of Nursing Practice and the Environment 97
body of knowledge that describes how nursing practice influences patient health and
how patient’s social and physical environments influence their experiences of health.
What is not proposed, and is therefore much
less clear, is the way nursing practice is linked
to the environment. For example, the environment where patients experience their health
care is in many instances (perhaps the majority of instances) the same physical and social environment where nurses practice, and
yet there is scant theory and little empirical evidence highlighting the multiple connections and overlapping natures of this patient and nurse-filled environment of care.
Furthermore, there has been little examination of the relationship between these overlapping environments, nursing practice, and
patient care, particularly the influence of nursing practice and these overlapping environments on patient health outcomes. What are
the patterns of interactions that “make” these
overlapping environments more or less healing? What nursing practices strengthen these
patterns? What are the consequences of these
relationships and patterns of interactions? We
do not yet know the answers to these questions, yet must if we are to propose and enact
nursing-led care delivery models that consistently improve patient health.
To help answer these questions, we take
as an intellectual springboard Patricia Benner’s research on nursing practice. Patricia
Benner expanded nursing knowledge by challenging the paradigm that had previously
been defining, and limiting, nursing practice.
Benner called for an explicit articulation
of the “goods specific to nursing practice
and the skills that allows nurses to achieve
them”4(p195) and highlighted the ways an inadequate understanding of nursing practice
led to impediments in nursing knowledge and
the practice of caring for patients. She helped
redefine what it means to be a professional
nurse and provided a clear path for articulating and therefore making visible professional
nursing practice.
In this paper, we follow Benner’s lead and
challenge the current understanding of the
nursing metaparadigm, which considers nursing practice and the environment as distinct
and unlinked domains. We believe that this
artificial distinction has limited the scope of
nursing practice and diminished the nursing
profession’s capacity and authority to establish models of care that promote health and
a healing patient experience. We argue that
there is a fundamental and inseparable relationship between nursing practice and the
environment, and that the “goods specific to
nursing practice” include the constitution of
environments of care. We believe that the explicit linkage of nursing practice and environment will refine the nursing paradigm, promote new avenues for nursing knowledge,
and expand the scope of nursing practice.
It will frame inquiry toward understanding
patterns of actions that create more or less
healing environments of care and a consideration of how nursing practice can potentially
strengthen these patterns. This knowledge is
critical for developing and refining nurse-led
models of care, understanding that that nurses
engage, though their practice, in the creation
of environments of care that influence patient
health and well-being.
The organization of the paper is as follows.
We provide a brief history of the nursing
metaparadigm, focusing on the environment
domain. We describe the overlapping environments where patients experience their
health care and where nurses practice and
show how they are currently understood in
the nursing literature as independent of each
other, in line with current organizing principals of the nursing metaparadigm. We reconceptualize nursing practice and environment
as mutually constituted. This reconceptualization is based in practice theory, which
we introduce and describe. Practice theory
is used to (1) understand the duality of practice and environment and through that understanding (2) develop a proposition that
asserts the interdependency of the nursing
practice and environment metaparadigm domains. Our aim is to articulate and make
visible the interconnectivity of nursing practice and environment and shift understanding
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of environments as constituted in practice.
We explore the consequences of this shifting understanding of practice as environment, highlighting the novel connections
and inquiries this shift generates, and propose the ways “practice as environment” can
strengthen nursing care delivery models of
the future.
THE NURSING METAPARADIGM
The nursing metaparadigm expresses the
unifying focus of nursing as a professional
discipline, driving the movement toward a
shared professional understanding of the human health experience and how nursing
practice can improve these experiences.5
The nursing metaparadigm has been traditionally represented by the following 4 generally agreed upon central concepts: person, nursing/caring practice, health, and
environment.6 Person involves not just patients, but their families, caregivers, and
communities,7 and includes the embodied
person as well as personal meanings.8 The
nursing/caring practice concept has evolved
considerably over time to describe the reflexive, interpersonal, knowledgeable, and relational processes between nurses and persons
(from patients to communities) that promote
healing outcomes.9 Health, considered from a
nursing rather than medical orientation, concerns patients’ health-related quality of life as
well asthe physical and social determinants of
illness and health.8 The environment is conceptualized as the physical surroundings of
the patient to include significant others as
well as the settings where patients receive
their health and nursing care.3
The propositions of the nursing metaparadigm explicitly link nursing practice with
patients and their health and link patients’
experience of their health with their physical and social environment.3 What is not
proposed, and is therefore unclear, is the
way nursing practice is linked to the environment, especially “the settings in which nursing occur.”3(p6) Although many nurse theorists broadly declare the settings where patients receive their health care (which include the settings in which nursing occurs) to
be within the environment domain, their indepth articulation of the environment domain
focuses almost exclusively on the patient-inthe-world experiencing their health, and not
on the patient-and-nurse-in-the-health caresetting experiencing health and nursing care.
The reasons for this are not clear—the “settings in which nursing occur” would appear
to be an environment where nurses could,
through their practice, directly influence the
patient’s experience of health and therefore
be considered a vital focus of theory and practice. A history of the evolution of the environment domain helps understand this anomaly.
The environment domain of the nursing
metaparadigm
Kleffel10 describes the conceptualization
of the environment domain over time. Florence Nightingale expansively defined and directed nursing practice to improve physical,
social, political, cultural, and economic environments as a means of improving the health
of individuals. Physical nursing practice was
directed toward manipulating the immediate
physical environment so that individual patients could heal. Political and cultural nursing
practice was directed toward facilitating social and economic policiesthat enabled global
improvements in sanitation, water, food, and
housing distribution, among other elements,
to create healthful community environments.
This broad understanding of the environment domain of nursing knowledge and practice unfortunately narrowed overtime as nursing practice moved away from the public
and community setting and shifted toward
the hospital setting throughout the 1930 to
1940s, mirroring the shift in the setting for
the ill from homes to hospitals. According to
Kleffel, this “narrowing” of the setting for
nursing practice eventually resulted in a “lack
of consciousness of the broader environment”
of health, which resulted in nurses “regarding
it as outside their domain of action in practice,
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Interdependency of Nursing Practice and the Environment 99
education and research.”10(p102) The environment, in relation to nursing practice, consequently narrowed to include only the immediate situation of the patient and not the broader
settings in which nursing practice and patient
care occurred.
The patient environment
In the 1970s, Jacqueline Fawcett began the work of explicitly articulating the
4 domains of the nursing metaparadigm.
She broadly described the environment
domain as the environment in which
a person/family/community exists.11 Subsequently, others have advanced this conceptualization, focusing on theory and research expanding the environment domain to include
the interrelatedness of the physical and social
environment in creating peoples’ experiences
of health. As an example, 1 study during this
period of advancement12 revealed important
associations between patients’ experiences of
health, manifested as perceived vigor, and
their person-environment interactions. This
work strengthened the nursing metaparadigm
by expanding the theoretical and empirical associations between domains and the propositionsthat link people, their health, and the environment. However, it is important to note
that this theoretical and empirical expansion
of the environment domain did not establish
or propose linkages to nursing practice. In
fact, the vast majority of the literature examining the environment of care in relation to
nursing practice and patient health treat it as
important to nursing practice, but not a focus
of nursing practice.
The overlapping patient and nurse
environment
In a recent synthesis, Andrews et al13 articulate 3 different conceptualizations of the
environment from a nursing perspective—(1)
elements external to nursing practice, which
include patients and factors affecting their
health; (2) the interactions between internal “inside the patient” states such as mental
and physiological dispositions and the external “outside the patient” physical world; and
(3) the inseparable interrelationship between
these internal and external states. They conclude that on a basic level the environment
domain can be understood as contexts that
are important but external to nursing clinical practice. Yet on a deeper level they acknowledge that the environment can be understood as the internal features and contexts
where nurses work to include the immediate patientsurroundingssuch as physiological
and psychological state of the patient, as well
as more external features such as institutional
policies, management, and culture of the environments in which nurses practice and patients experience their health care. This is an
important advancement in the conceptualization of the environment because it explicitly
links the patient and nurse in an overlapping
environment of care.
The nurse environment
There is a growing acceptance that the environment in which nurses practice, or what
has been termed the practice or work environment, is an important factor influencing the ways nursing care is delivered and
how that care affects patient health.14,15 A
nursing-oriented concept analysis of the practice environment defines it as the environment where nursing practice takes place,
which has boundaries and structures that together shape the context for practice.16 Research on practice environments from a nursing perspective began in earnest in the 1980s
and focused on acute care practice environments. The majority of this research aimed at
better understanding elements of practice environments that make them “good places for
nurses to work.”17 This was in part because of
a looming nursing shortage and fears that hospitals would not be able to attract the nurses
they needed to care for patients.
Practice environment elements were originally identified through nursing policy and
task force directed research18,19 and include nursing participation in hospital affairs,
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nursing knowledge-oriented care delivery,
manager support, staffing, and nursephysician relationship. This work was translated into a survey instrument20 that has been
used in a plethora of studies to show the relationship between practice environment elements, nurse satisfaction, and patient health
outcomes. Although this research has identified elements important to a professional
nursing practice environment and to patient
health outcomes, it must be noted that it represents practice environments independently
of nursing practice. In fact, nurse autonomy,
or a nurse’s ability to deliver patient care
based on nursing knowledge and expertise,
did not rise to the level of a practice environment subdomain in factor analysis conducted
as part of the survey validation;20,21 nursing
practice was not conceptualized, and therefore did not load, as an integral part of the
practice environment.
Problematizing the separation of
nursing practice and environment
The practice environment is currently understood to hinder or promote the true expression of nursing practice but is not something nurses actually direct their knowledge
and practice toward. The implication of this
understanding is that nursing practice is considered something that can be thwarted by
competing environment demands (such as
organization policies, physician orders, and
technology use), and it is the job of others
(managers and leaders) to focus on ways to reduce these competing demands if nurses are
to practice to the full extent of their knowledge and abilities.
Davina Allen’s22,23 work highlights the
theoretical and practical issues the schism
between nursing practice and environment
has prompted. Allen argues for a redefinition
of the nursing mandate based on a synthesis
of field research observing nursing practice in
the environment of care. Her research found
that the overarching picture of nursing work
to emerge is that of health care mediation,
rather than current metaparadigm conceptualization of nursing practice as “emotionally
intimate, therapeutic”23(p42) patient care.
Allen found that nurses for the most part
“broker, interpret, translate and communicate
clinical, social and organizational information
that are highly consequential for patient diagnoses and outcomes.”23(p45) Allen categorizes
these health care mediation activities, accomplished in the service of patient care but
not explicitly directed at patients, to include
mediating professional boundaries, communicating information, and rationing resources,
among other activities. Allen concludes that
nursing practice as currently conceptualized
in the metaparadigm domain (reflexive,
relation-based patient care) is mostly absent
in the field evidence and argues that it is this
discrepancy between theory and practice
that results in nurses not being educated to
practice to their full professional abilities.
The assumption Allen makes visible is that
the primary nursing activities identified, engaging with the practice environment to
care for patients, are not considered nursing practice from a nursing metaparadigm
perspective. She highlights the distinction
between reflexive, interpersonal, relational
nursing practices directed at the patient (ie,
current theory of the nursing mandate) and
the majority of the things nurses are actually
doing to mediate the patient’s hospital environment in service of the patient. By doing
this, she makes visible the overlapping nature
of the practice and patient environment and
describes how nursing practice is targeted at
these overlapping environmentsto “reconcile
the requirements of healthcare organizations
with those of the patients.”23(p45) She argues
for a new definition of nursing practice that
considers the nurse’s relationship to the practice environment and suggests that the nursing profession should redirect its focus to the
“context” in which care is delivered, rather
than on the quality of individual nurse-patient
caring,22,23 to more accurately describe the
“goods specific to nursing practice and the
skills that allows nurses to achieve them.”
Bishop and Scudder also articulate a connection between nursing practice and the
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Interdependency of Nursing Practice and the Environment 101
environment of care when they state “the
nurse is in a privileged position for fostering
communal decisions that the moral sense requires. The nurse is an advocate of communal
decisions that bring together expert medical
advice and treatment, sound hospital policy
and procedure, and the realizable hopes and
aspirations of the patient into the concrete
practice of health care that fosters the wellbeing of the patient.”24(p42) In this understanding of nursing practice, the environment of
care is considered the raw materials for practice, which the nurse usesto produce the best
conditions for patient health, that is, an optimal patient environment. The environment of
care includes elements such as hospital policies that are not considered outside the scope
of nursing practice, but rather important elements the nurse needs to incorporate into
practice to accomplish the goal of producing
patient environments that improve their experience of health.
The need to reconceptualize nursing
practice and environment
As Davina Allen and others have begun to
make visible, nurses engage with the practice environment to “reconcile the requirements of healthcare organizations with those
of the patients.” However, the nursing metaparadigm does not currently account forthese
empirical observations and does not promote
conceptualization of this important body of
practice evidence. The current conceptualization of practice and environment objectifies the environment and sequestrates the
practice,25 creating 2 distinct domains of research, with discreet foci of interests, which
ultimately have led to an incomplete body of
knowledge that ignores a wide swath of actual nursing activities, the dynamics of nursing activities and the environment of care, the
consequences of those dynamics, and the implications for patient health outcomes.
In summary, the current metaparadigm
conceptualization has generated significant
blind spots in inquiry and practice. It is necessary to reorient and reinterpret the relationship between nursing metaparadigm domains
if this gap is to be addressed and nursing
knowledge promoted and expanded. In the
following sections, we introduce practice theory and show how practice theory provides
a way of reconceptualizing the link between
nursing practice and the environment to
promote more holistic inquiry and practice.
PRACTICE THEORY
Practice theory offers a new way of understanding and explaining social phenomena.
The philosophical premise of practice theory
is that the social world is brought into being
through practices. Practice theory centrally
places activities as an empirical object of consideration and source of knowledge. The focus of practice theory is on dynamics and relations, which makes it an appropriate lens
for examining nursing practice. Practice theory is a continuation of earlier philosophical
discourse by Marx, Heidegger, Wittgenstein,
and others rediscovering the consequentiality of “everydayness” in producing the world,
and action as the basis for explaining intelligibility and rationality.26 These and other
philosophers highlighted the gaps in the explanatory power of objective and subjective
oriented philosophies. Objective ontologies
of the world could not explain “the active dimension or interpretation and decision making in everyday life.”26(p53) Subjective ontologies, meanwhile, could not explain “why the
world appears both as a given field of objective meaning and as an arena of negotiation
and strategic action.”26(p54)
Practice theory emerged from more recent philosophical work in what has been
named social praxeology,27 which aims to
remove the boundary between subject and
object as distinct phenomena. Instead, practice theory acknowledges the relationship between subject and object, or structure and
practice—one does not come before the
other, but rather both exist recursively, that
is, they exist only and always in relation to
each other.28 Structures are not considered
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independent entities, but rather ongoing
constructions built and rebuilt continuously
through actions. Structure therefore cannot
be conceived without foregrounding the role
of human actions in producing it. Structures,
such as environments of care, are always being created and recreated through social activity, with the possibility for reproducing stability or producing change with every action.
This recognition of the inherent relationship between structure and action rejects the
assumption of the separation of subjective
and objective, aiming to “redefine and reintegrate concepts that have [previously] been
partitioned and polarized.”28(p1242) The rejection of dualisms means questions of causality, or “what comes first,” are replaced by
questions of relationality.26 It does not argue
that practices create ways of organizing or
vice versa, but that practices and ways of organizing are implicated in each other; they
are mutually constituting.28 Most importantly,
this continuous coproduction of practice and
environment means neither is static or stable,
butratherthey are constantly being refreshed,
adapted, or perpetuated.
Scholars studying organizations have found
practice theory to be a useful analytic tool
for understanding and explaining the dynamics of these complex and constantly changing systems.28 An important part of this analysis is moving past assumptions of structures
as discrete entities, able to be boxed up and
considered independently of their use. Take,
for example, the concept of resource. Although it has long been noted that having
more resources or the right resources is important to organizations, practice theorists
show the importance of focusing on how assets such as time, money, knowledge, and
materiality are used as resources and what
specifically they are resourcing. They argue
that the ways assets are used is what turns
them into resources—resources are notstable
entities, but rather potentialities that are enacted through the processes in which they
are used. More consequentially, resources are
only resources while they are being used—
they exist only in practice.29 This is the
essence of mutual constitution. The asset exists but only becomes a resource through
practice. The practice exists but only becomes resourceful as it enacts the asset as a
resource. The implication of this conceptualization is its explanatory power in describing
how and why resources are taken up or resisted in organizations on the basis of how
and why people actually use the resource in
practice.
LINKING NURSING PRACTICE AND THE
ENVIRONMENT
Building on practice theory, environments
of care can be understood as embedded
in the activities and practices occurring
through them, rather than a manifest structure independent of the activities occurring
within them. Nursing practices take up the
environment in ways that make it more or
less conducive to caring for patients just
as the environment constrains and enables
nursing practices (see Figure 1).
The mutual constitution of practice
and environment: an illustration
A scenario is developed here to show how
practice theory helps understand the ways
Figure 1. The duality of nursing practice and environment.
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Interdependency of Nursing Practice and the Environment 103
nursing practice constitutes environments of
care and how they condition future practice.
We hope it also illustrates the implications
of not understanding this conceptualization
of the nursing metaparadigm. Consider a scenario many nurses can identify with; missing
items needed in the service of patient care.
A nurse is in the middle of a busy day taking
care of her patients at a community hospital.
She needs gauze to change her patient’s dressings but realizes there is no gauze left in the
supply room. “Darn it, this ALWAYS happens
lately when I work towards the end of the
week,” she mutters. Thinking quickly, she
calls a nurse friend in the unit upstairs and
asks, “Do you have any gauze I can grab?”
The friend asks incredulously, “You are out
AGAIN?” “Yes, I can’t talk about it now, do
you have some or not?” The friend does,so the
nurse rushes up the stairs (the elevators are
always so slow), grabs the gauze, and rushes
back downstairs. This hastaken 25 minutestotal, and now she wonders if she will have time
to take her lunch break. After she changes
the dressings, she does have a moment to sit
in the break room and eat some lunch. Two
other nurses are in there as well. The nurse
starts a conversation—“Can you believe we
are out of gauze again, I swear somebody HAS
to start doing a better job stocking this place!”
“I know” replies another nurse, “I’ve gotten
to the point where I keep a stash in my locker:
you can borrow some when we are working
together, just let me know.” The third nurse
chimes in, “Yeah, I told a person stocking
the room about the problem a month ago,
but nothing happened.” The first nurse, now
done eating her lunch, responds as she walks
out the room, “I know, it just kills me, we are
always forced to grab our own stuff, nobody
cares, its like they just don’t want us to do our
job!” The nurse leaves the break room and everyone is left with a vague feeling that their
unit is always letting them down somehow,
making it harder and harder for them to care
for their patients every day.
In this scenario, the nurses did not experience themselves as acting on nursing knowledge and practice to affect the environment
of care. Instead, they felt frustrated by what
they saw as a lack of attention by others to
the environment to make it better for them to
care for their patients. The nurse’s narrowly
defined understanding of their nursing practice (nurse-patient interactions) created a situation where their capacity to influence the
environment of care through their practice
appears to be nonexistent. Yet these nurses
were in fact reproducing an environment that
requires heroic actions to produce mundane
resources necessary for caring for patients.
The nurses’ actions are oriented to mediating
a static environment in which gauze is not
readily available. No consideration was given
toward actions to create an environment in
which gauze is readily available for anyone
who needs it. These nurses did, in fact, create
environments in which gauze was available to
them alone. Each nurse had practices for solving the immediate issue; keeping a “stash” in a
locker, knowing individual nurses elsewhere,
etc. These practices, however, re-enact an environment that is an obstruction to the nursing practices that involve caring for patients.
These individualized actions were considered nonnursing activities that needed to
be accomplished as quickly as possible to
“get back to” nursing practice. Because these
individualized, stopgap actions were not
perceived as nursing activities, they never
rose to the level of professional nursing
practice with a patient-focused purpose.
The consequences included reinforcement of
the nurse’s short-term, individualized actions
toward distinct “environmental” problems at
hand and keeping a cycle of “we don’t have
gauze” in play. It is important to understand
how the meaning of gauze shifts when
comparing nursing practice independently
from the environment and nursing practice
as constituting environments of care. In
the latter conceptualization, gauze is not
a “thing” that by its absence signifies the
burden of an environment hostile to nursing
practice. Rather, when considering nursing
practice as constituting the environment of
care, gauze becomes an element of patient
healing and therefore an important focus
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for nursing practice. The need to focus on
gauze is not any more separated from nursing
practice than changing the patient’s gauze
dressings. Missing gauze does not prompt the
cessation of nursing practice until it is in the
hands of the nurse, but rather the initiation
of professional nursing practice to make
gauze consistently part of the conditions of
practice.
Exploring the duality of nursing
practice and environment
Practice theory makes explicit that structure is not separate from action; structure
does not exist without being enacted through
practice. Structure emerges into existence in
the interactions between people and things,
which have consequences that condition subsequent interactions. This means actions are
never meaningless; they influence further action and the conditions for future action.
Structures, such as the environment of care,
are therefore never a “given”; nurses through
their practice are always meaningfully constituting the conditions of the environment of
care along with patient and other health care
provider actions. There is no externally defined environment that nurses and patients
populate and act within, but rather the environment is embedded in their activities and
practices.
Practice theory helps us understand that
the activity of environment constitution
needs to be foregrounded and explored to
provide a more accurate understanding of
the conditions and practices of an environment of care that more or less produces
positive health outcomes. By studying the
“structuring” rather than the structure, the
environment becomes visible for what it
actually is, a continuous tangle of interrelated
practices and conditions for practice.
Practice theory helps illuminate how
nurses, the largest sector of the health care
workforce, can be considered significant
drivers of health care structures through their
practices. Making this relationship explicit is
therefore a critical starting point for understanding how to get to good environments
through practice, a rich topic for nursing
knowledge and practice. Paying explicit attention to nursing practice in action will provide a significant body of knowledge about
the full scope of nursing practice, how it is
enacted, and how it produces and conditions
environments of care that more or less promote health and healing. Attention to ways
nurses use or do not use traditionally defined infrastructures such as resources, leadership, or technology, how nurses actually
organize their care because of or despite formal care delivery models, how nurses adapt or
adopt organizational change, how nurses devise and refine workarounds, etc, will generate understanding of the conditions and consequences of nursing practice in promoting
patient health and healing.
Contrasting independence with
interdependency of nursing practice
and environment
This new understanding of the duality of
nursing practice and environment can now be
fruitfully contrasted against current conceptualizations to identify how each emphasize certain connections, inquiries, and practices over
others. Current theory and research on practice environments (mostly in the hospital setting where patients receive their acute needs
health care) focus on the “things” necessary
to create an environment that nurses can then
populate and practice within. Nursing practice is considered a mediator of patient health.
The path is for the most part linear and unidirectional, from structure to process to outcome. Bad environments make nursing practice difficult, and good environments make
nursing practice easy. Partial or thwarted
nursing practice negatively influences patient health outcomes, whereas fully engaged
nursing practice positively influences patient
health outcomes. No meaning is ascribed to
nursing practice contributing to the environment where all this occurs. In this conceptualization, nursing practice becomes in effect
powerless to shape the environment of care.
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Interdependency of Nursing Practice and the Environment 105
How does this understanding play out in
reality? It has contributed to the chasm recognized between nursing theory and practice,
where the ways the nursing profession has
conceptualized and teaches nursing practice
is not aligned with the actual experiences of
nurses in their practice.22,30 It makes invisible
the actual contributions nurses make every
day producing environments of care. The
theoretical independence of nursing practice
and environment has led conceptually and
methodologically to findings that are preconfigured and separate—because we have not
linked nursing practice to the environment
theoretically, we have not considered the
ways they ARE linked empirically and have
instead studied them in isolation from each
other. Why is this problematic? Consider that
more than 10 years of research on structures
and processes to improve patient care quality
and safety have unfortunately produced
limited evidence of structures or practices
that consistently produce better care outcomes, that scant research has focused on
mechanisms of positive patient outcomes,
and that the majority of studies have not
relied on or developed robust theory to guide
knowledge production.31
A METAPARADIGM PROPOSITION
LINKING NURSING PRACTICE AND THE
ENVIRONMENT
It is important to make explicit the theoretical link between nursing practice and the
environment that has been explored in this
paper. There are currently 4 relational propositions of the nursing metaparadigm.3 Proposition 1 links person and health. Proposition
2 links health and environment. Proposition 3
links nursing practice and person and health.
Proposition 4 links person, health, and the environment. There is currently no proposition
linking nursing practice to the environment,
and the interdependency of practice and environment has not been well articulated in
nursing science and practice. This has led
to limited understanding of the ways nursing
practice is integral to the constitution of environments of care. As Davina Allen and others
have begun to make visible, nurses engage
their environments to produce environments
of care that “reconcile the requirements of
healthcare organizations with those of the patients.” However, the nursing metaparadigm
does not currently account forthese empirical
observations and does not promote conceptualization of this important body of practice
evidence.
This paper argues for a relational metaparadigm proposition that explicitly links
nursing practice and the environment—the
discipline of nursing is concerned with nursing practices that are beneficial to the environments where people are experiencing
their health. The language of the proposition is aligned with the other metaparadigm
relational propositions and articulates the interdependency of practice and environment
and the accountability of the nursing profession to conceptualize and empirically examine thisrelationship (see Figure 2). The proposition explicitly foregrounds nursing practice as consequential to the environment—
environments of care, home and community
environments, the national policy environment, and even the socially constructed environments that influence how we perceive
“health,” “illness,” and “health care.”
Implications for education and practice
A proposition articulating the relationship
between the nursing practice and environment domains of the nursing metaparadigm
is the first step toward creating knowledge
and awareness of nurses’ critical role in
shaping environments of care through their
nursing practice. By explicitly linking nursing
practice to the environment in the nursing
metaparadigm, nurses become authorized to
target their practice to the service of creating
beneficial environments of care, as well as
focusing directly on the patient. The implications are empowering. They emphasize the
fact that nurses have stakes in the game at
all levels of care (not just the patient-nurse
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ANS987 April 25, 2015 17:4
106 ADVANCES IN NURSING SCIENCE/APRIL–JUNE 2015
Figure 2. A proposition explicating the relationship between nursing practice and the environment domains of
the nursing metaparadigm.
interaction) to ensure health care reflects a
nursing orientation to health and promotes
a positive experience of health. If nursing
practice is 1 of many actions through which
environments of care are produced, then
it becomes a professional responsibility to
educate nursing students about their critical
role in constituting the environments where
they will practice throughout their careers
and for practicing nurses to understand and
accept accountability for their practices in
creating the environment of care where
patients are experiencing their health care.
It becomes necessary to reconsider concepts
current in nursing education and practice
such as leadership, quality improvement,
and novice-to-expert practice and broaden
their scope to incorporate an explicit linkage
to the nursing profession’s environmental
production capacity. Leadership, for example, becomes more than a resource provided
by managers/leaders to nurses to promote
optimal nursing practice, or a skill that nurses
enact to promote professional standing in
the health care community. Leadership can
also be understood as a professional capacity
to engage in solving the problems that are
embedded in practice and thereby constantly
transforming the environment of care. For example, through nursing “leadership” missing
gauze becomes a focus for nursing practice
and not a thing that disables nursing practice;
leadership is of-a-piece with practice and not
an added-value skillset.
Implications for nursing-led care
delivery models
We can now extend the interdependency
and mutual constitution of practice and environment to consider the organization of
nursing practice into care models that promote patient health and healing. Instead of
asking “how can the practice environment
be modified to make it more compatible for
nursing practice,” as much the current nursing workforce research does, a more fruitful
line of inquiry becomes “how does nursing
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ANS987 April 25, 2015 17:4
Interdependency of Nursing Practice and the Environment 107
practice contribute to creating an environment of care that optimizes health and well
being?” How might answers to this question
facilitate the development of nursing-oriented
models of care that patients, nurses, and the
multi-professional health care team all consider healing and health promoting?
Nursing models of care become more
holistic when they explicitly incorporate
environment-constituting practice and acknowledge the ways nursing practice creates
the conditions for future practice and opportunities for health and well-being. New
concepts such as translational mobilization,32
in which nurses organize resources and materials through their practice to maintain
functional clinical environments for patients,
become essential to consider when developing models for health care organization
and practice. Other concepts such as “the
built environment”33 and “nursing ecological
models”34 also become useful. The built environment expands on conceptual linkages
between health, people, and the environment and encourages nursing inquiry toward
understanding pathways linking the environment to health outcomes. In nursing ecology, the environment is considered a component that needs to be included in decisions about health care structures and processes to account for its influence in health
outcomes. Both concepts begin the work of
integrating an environmental perspective into
health care structures and processes and can
be expanded to identify the ways nursing
practice is not only beneficial to uncover the
dynamics of environment, health care processes and outcomes, but the ways the environment is also inherently embedded in nursing, patient and community practices and is
refreshed or reproduced through these practices into the conditions for health and health
outcomes.
Nursing care models of the future that consider the ways nurses through their practice
create physical and social environments of
care will foreground dynamics and capacities rather than traditionally conceptualized
and distinctstructures and processes. Nursing
care models of the future will explicitly incorporate environment transformation as an inherent dynamic of practice. Concepts such as
“nurse-environment ratios” or “environmentproduction nursing” become interesting foci
for investigation and integration into models of care. They raise new ways of thinking
about the organization of nursing practice,
for example, the transportability of nursing
practice in creating dynamic environments of
care in the home, the community, the mobile clinic, or the ways technology can be enacted through nursing practice to create entirely new virtual environments of care even
when “nurses and patients no longer meet in
proximate space.”35(p64) Finally, and perhaps
most importantly, nursing care models of the
future will leverage understanding that practices constitute environments and the conditions for future practice; not just nursing
practice but medical practice, patient practice, ancillary staff practice, phlebotomy practice, finance and insurance practice, policy
practice, etc. Each of these professions has a
“recognized practice environment,”36 and it
becomes essential for nursing to fully understand how this tangle of multi-professional environments and practices interact to produce
health care and outcomes if these dynamics
are to be successfully leveraged into nursing
care models of the future. The work may be
challenging, but the rewardsinclude more dynamic and holistic environments of care, better practice and better care.
CONCLUSION
In this paper, we critically examined the
current conceptualization of the nursing
metaparadigm and identified an important
gap, the lack of a conceptual and propositional link between nursing practice and
the environment, which are notably the
only 2 metaparadigm domains not yet linked
through a relational proposition. We explored
the literature to help explain this conceptual
gap. We then used a practice theory lens to
reorient understanding of the environment
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ANS987 April 25, 2015 17:4
108 ADVANCES IN NURSING SCIENCE/APRIL–JUNE 2015
metaparadigm domain and to conceptualize
the interdependency of nursing practice
and the environment. The constitutive nature
of nursing practice in creating environments
of care was explicitly acknowledged. A
relational metaparadigm proposition that
explicitly links nursing practice and the
environment was developed. This expanded
understanding of nursing practice and environment is necessary to identify, theorize,
and promote nursing practices that are
beneficial to the environment of care as part
REFERENCES
of an explicitly proposed domain of nursing
knowledge and practice. A focus on the mutual constitution of nursing practice and the
environment will facilitate the development
of holistic models of care that better integrate
the dynamics of practice and the conditions
for health into the organization of health care
delivery. It is these nursing-oriented models
of care that will be successful in consistently
organizing care that patients, nurses, and the
multi-professional health care team consider
healing and health promoting.
1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Press NA, ed.
Washington, DC: Institute of Medicine; 2011.
2. Institute of Medicine. Future of Nursing Research
Agenda. Washington, DC: Institute of Medicine;
2011:1-9.
3. Fawcett J, Desanto-Madeya S. Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing Models and Theories. 3rd ed. F. A. Philadelphia,
PA: Davis Company; 2012.
4. Benner PE, Tanner CA, Chesla CA. Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics.
2nd ed. New York, NY: Springer Publishing Company; 2009.
5. Newman MA. Prevailing paradigms in nursing. Nurs
Outlook. 1992;40(1):10-13, 32.
6. Fawcett J, Watson J, Neuman B, Walker PH,
Fitzpatrick JJ. On nursing theories and evidence. J
Nurs Scholarsh. 2001;33(2):115-119.
7. Schultz PR. When client means more than one: extending the foundational concept of person. Adv
Nurs Sci. 1987;10(1):71-86.
8. Thorne S, Canam C, Dahinten S, Hall W, Henderson
A, Kirkham SR. Nursing’s metaparadigm concepts:
disimpacting the debates. J Adv Nurs. 1998;27(6):
1257-1268.
9. Sherwood GD. Meta-synthesis of qualitative analyses
of caring: defining a therapeutic model of nursing.
Adv Pract Nurs Q. 1997;3(1):32-42.
10. Kleffel D. The evolution of the environmental metaparadigm of nursing. In: Andrist LC, Nicholas PK,
Wolf KA, eds. A History of Nursing Ideas. Sudbury,
MA: Jones & Bartlett Publishers; 2005:97-108.
11. Fawcett J. The metaparadigm of nursing: present
status and future refinements. Image J Nurs Sch.
1984;16(3):84-87.
12. Fontana JA. The emergence of the personenvironment interaction in a descriptive study of
vigor in heart failure. Adv Nurs Sci. 1996;18(4):
70-82.
13. Andrews GJ, Moon G. Space, place, and the evidence base: part II—rereading nursing environment
through geographical research. Worldviews Evid
Based Nurs. 2005;2(3):142-156.
14. Jennings BM, Meleis AI. Nursing theory and administrative practice: agenda for the 1990s. Adv Nurs Sci.
1988;10(3):56-69.
15. Jennings BM. Research on the care environment:
celebrating signs of success, posing questions to
advance future investigations. Res Nurs Health.
2009;32(4):361-365.
16. Mccormack B, Kitson A, Harvey G, Rycroft-Malone J,
Titchen A, Seers K. Getting evidence into practice:
the meaning of “context.” J Adv Nurs. 2002;38(1):94-
104.
17. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing
care. Med Care. 1994;32(8):771-787.
18. McClure M, Poulin M, Sovie MD, Wandelt M. Magnet
Hospitals: Attraction and Retention of Professional
Nurses. American Nurses Association, ed. Kansas
City, MO: American Nurses Association.
19. American Association of Colleges of Nursing. Hallmarks of the professional nursing practice environment. J Prof Nurs. 2002;18(5):295-304.
20. Lake ET. Development of the practice environment
scale of the Nursing Work Index. Res Nurs Health.
2002;25(3):176-188.
21. Leiter MP, Spence Laschinger HK. Relationships
of work and practice environment to professional
burnout: testing a causal model. Nurs Res. 2006;
55(2):137-146.
22. Allen D. Re-reading nursing and re-writing practice:
towards an empirically based reformulation of the
nursing mandate. Nurs Inq. 2004;11(4):271-283.
23. Allen D. What do you do at work? Profession building and doing nursing. Int Nurs Rev. 2007;54(1):
41-48.
24. Bishop AH, Scudder JR. Nursing ethics in an age of
controversy. Adv Nurs Sci. 1987;9(3):34-43.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
ANS987 April 25, 2015 17:4
Interdependency of Nursing Practice and the Environment 109
25. Orlikowski WJ, Scott SV. 10 sociomateriality:
challenging the separation of technology, work
and organization. Acad Manage Ann. 2008;2(1):
433-474.
26. Nicolini D. Practice Theory, Work, and Organization. Oxford, England: Oxford University Press;
2012.
27. Wacquant L. Toward a social praxeology: the structure and logic of Bourdieu’s sociology. In: Bourdieu
P, Wacquant L, eds. An Invitation to Reflexive Sociology. Oxford, England: Blackwell; 1992:3-59.
28. Feldman MS, Orlikowski WJ. Theorizing practice and
practicing theory. Organ Sci. 2011;22(5):1240-1253.
29. Feldman MS. Resources in emerging structures and
processes of change. Organ Sci. 2004;15(3):295-309.
30. Maben J, Latter S, Clark JM. The theory-practice gap:
impact of professional-bureaucratic work conflict
on newly-qualified nurses. J Adv Nurs. 2006;55(4):
465-477.
31. Shekelle PG, Wachter RM, Pronovost PJ, et al. Making
health care safer II: an updated critical analysis of
the evidence for patient safety practices. Evid Rep
Technol Assess (Full Rep). 2013;(211):1-945.
32. Allen D, Allen D. Re-conceptualising holism in
the contemporary nursing mandate: from individual to organisational relationships. Soc Sci Med.
2014;119(C):131-138.
33. DeGuzman PB, Kulbok PA. Changing health outcomes of vulnerable populations through nursing’s
influence on neighborhood built environment: a
framework for nursing research. J Nurs Scholarship.
2012;44(4):341-348.
34. Laustsen G, Laustsen G. Environment, ecosystems,
and ecological behavior: a dialogue toward developing nursing ecological theory. Adv Nurs Sci.
2006;29(1):43.
35. Sandelowski M. Visible humans, vanishing bodies,
and virtual nursing: complications of life, presence,
place, and identity. Adv Nurs Sci. 2002;24(3):58-70.
36. Andrews GJ, Evans J. Understanding the reproduction of health care: towards geographies in health
care work. Prog Hum Geog. 2008;32(6):759-780.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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