Contextual Action Theory in Nursing

Nursing is a professional field with a very broad scope of areas of responsibility. Nurses are confronted during their professional life with many tasks and situations often also addressed by other disciplines, such as medicine, psychology, social work, management and many other ¹. In addition, practice, research and theorizing are equally a part of the package. Consequently, the theorizing in nursing, whether it is understood as a reflective system of a professional discipline or a practice-leading set of rules for the members of the profession, it is required to encompass a very large area of knowledge. Can we expect nursing to cover a great part of medicine, of psychology, of social work, of management among others ²? Can we expect an individual nurse to be competent, possessing knowledge and exercising skills, in all these areas ³? No, these expectations are not realistic, even if, while stressing the complexity of the profession, they are maintained. It is frequently suggested that a way out of over-stretching the discipline lies in stressing the practice focus of nursing ^{4, 5}. Indeed, nurses, unlike philosophers, for instance, are required to provide help on a daily basis through their practical engagement with other people.

While the development of nursing practices is a well-established system of procedures providing and achieving a continuous adaptation to new problems, resources, technologies and tasks, the nursing theorizing is often, and has historically been seen, as a source of substantial scrutinizing and controversial discussions ⁶. The stance that nursing does not require the same amount of theorizing as other professional disciplines ⁷ is an attitude from the past and the belief that nursing should improve theory competencies has often been expressed ⁸. There is a broad range of aims connected with theory building. Some propose the necessity of a meta-theory ⁹, others stress the need for a theory as a profession-legitimizing canon of knowledge ¹⁰, yet others expect a theory as a normative prescription for nursing practices ¹¹. The ongoing publication activity on nursing theories and theories in nursing ^{12, 13, 14, 15} indicates a need and interest in theorizing within the nursing profession. Alligood ¹⁶ suggested that the 21st century is an era of application of theory in nursing. She also stresses that the continued theory development is essential for the progress of nursing as a profession and as a discipline. Thus, theoretical considerations in nursing should cover certain issues such as their application in nursing practice.

It is beyond the possible scope of this text to address all theoretical contributions to nursing and do them justice but we would like to propose a conceptualization, a view which other theories in nursing do not provide to such an extent and which might prove helpful in nursing practice, particularly considering the current emphasis on evidence based practice and quality outcome ¹⁷. In seeking an appropriate nursing theory many attempts were proposed: the psychological approach to person ¹⁸, the interactive or communicative approach ¹⁹, the humanistic ²⁰, value or ethic driven approach, a number of medical approaches ²¹, systems theory approach ²², phenomenology ^{23, 24} and many others.

We would like to turn the reader’s attention to some postulates of nursing and specific features which might help in pointing out the requirements for an appropriate nursing theory – a theory, without being a meta theory ⁹ or a theory of everything, but a theory which would allow a nurse and the nursing profession to focus their view on the nursing topic and integrate all the necessary knowledge needed for dealing with specific questions posed by everyday nursing tasks.

One of the most important specifications of nursing is its practical stance. Gone are the times when the practical orientation of nursing was used to formulate skepticism towards theoretical foundation of nursing. Today the necessity of theoretical anchoring of the nursing profession is well recognized ²⁵. But how should one deal with the postulate of practice in theorizing? Some see the solution in mid-rage theories as opposed to grand theories ²⁶, others suggest phenomenology linked to common sense ²⁷, yet others propose to bridge this gap by nursing education ²⁸. To have a theory accounting for the practice stance of nursing is not just ‚nice to have’ as it might impact the nursing ability of evidence-based practice ²⁹.

We would like to argue that practice relevant conceptualization is closely connected to action conceptualization, as practice is defined as an action or process of performing or doing something pursuing a goal. Thus, an action theory could be the focus nursing could consider as its topic of its professional activities. Individual or joint action is the unit of inquiry, the unit of practical consideration in nursing. Burks ³⁰ suggested that intentional action is a relevant concept for nurses. Burks proposed that further inquiry should include exploration of the effect of self-efficacy, motivation, self-esteem, managed care and reduced health care resources on intention and subsequent action; as well as the efficacy of nursing interventions designed to influence health behaviour such as health promotion education and treatment counselling. Some action concepts, such as goals, are regularly studied in nursing and other health disciplines ^{31, 32}. Participating in developing the conceptualization and in the research discussed by Burks ^{30, 33} the author would like to provide an update on this thinking.

With this conceptual framework we can study action processes for research or evaluation purposes, we can outline or plan professional and private action processes and we can also perform the target action processes. Thus, action theory can be used by nurses utilizing its research methods for research purposes. It can also be used for devising and evaluating nursing processes, and be used as a blueprint in everyday professional activities while performing nursing tasks. In addition, the action theoretical perspective provides an important view of the conceptualization of evidence-based nursing and of the quality management in nursing ^{36, 37}.

Using action theory in nursing research implies several issues. However, applying action theory the researcher in nursing has to define the units of inquiry. Consider suicide. If we want to study social phenomena such as suicide rates ³⁸ we will employ a different approach. The causal approach to changes in suicide rates is appropriate here. Considering a suicide as an action we can then utilize the action approach. This is first of all the case if we study ongoing processes in such a way that the results of these inquiries will help us prevent a suicide action ³⁹. Deciding that we study action processes, the most obvious step is applying the research method devised within the contextual action theory. As indicated above, action theory assumes that the target phenomena consist of social meaning, subjective processes and manifest behavior. Thus, empirical research methods addressing these processes must be used. The social meaning, the common sense understanding of the ongoing processes, is best reflected in everyday naïve descriptions – less so in naïve explanation. The manifest processes are best addressed in the systematic observation following the professional rules of reliable inquiry. The subjective processes can be targeted by the self-confrontation interview – a video supported recall of ongoing action ⁴⁰.

Another important issue following on from applying the action theory informed view in nursing research is the action theoretical conceptualization of the target processes. Thus, the phenomena to study will be defined in terms of goal-directed processes of action, project and career, in individual and joint forms and with the above described systemic hierarchical organization of three different levels. Thus, any joint processes with the patient, client, colleagues, superiors or clients’ relatives can be seen as goal-directed actions or projects. Equally, any auxiliary or technical equipment in these interactions will be included and described in these terms ⁴¹.

Consequently, the problems occurring in these processes and the optimal functioning of these processes could be defined in the terms of action processes. In so doing we can find easily the path from the problem to the improvement. E.g., a colleague seems to respond in a hurried and superfluous way to my inquiry. In recognizing my behavior or required actions, in terms of action conceptualization, such as addressing the emotional and identity goals actualized but not respected in this joint action, helps me revise and improve my action in these terms. Thus, before inquiring I have to make sure that the emotional state of the colleague is recognized and their identity goals addressed. Equally, problems in dealing with certain technical equipment seen in action terms will help in developing manageable actions and facilitative emotional energizing and monitoring ⁴². In addition, seeing this encounter in terms of joint action and asking myself what we intended to achieve as a dyad will disclose my action or action step as not appropriate or not functional to the dyad’s goal – if there was any. This view provides the suggestion that I must try to establish a common goal toward which my contribution could fit.

As far as research is concerned this conceptualization will also help us in formulating appropriate research questions better equipped to address practical problems. One of the most important changes would be that we would see the ongoing phenomena as processes and not as dispositional structures causing these processes. Thus, as a result of our research we will be able to change these processes and not rely on the hope that they will be different when some structural changes are attempted. Additional gain in applying the action perspective results from seeing human activities as prospective ventures, thus understanding humans as agents, a view which often is undervalued in medical treatment. We suggested to study health processes as joint health promotion projects in several segments of life ^{43, 44, 45}. Equally, the destructive processes should be conceptualized as active prospective processes as this allows us to assess the clients and patient participation in these processes, such as suicide ^{46, 39} or substance addiction ⁴⁷ and help them change their destructive project into constructive and life enhancing processes ⁴⁸.

Using the action theoretical conceptualization enables us also to describe nursing activities in these terms. This is not alien to nursing, as many descriptions of nursing procedures and activities are anchored in an everyday action theory ⁴⁹. The contextual action theory also integrates everyday action theories but in a reflected manner as it integrates naïve observation, which, however, does not replace systematic observation and does not undermine the reliability and validity of the action-project research method. The Standard Operation Procedures (SOPs) used in health services required by the Quality Assurance or Quality Management are based on similar assumptions and the action theoretical conceptualization can improve the SOPs tools. In clearly stipulating the hierarchy of tasks, the task goals defining the required actions, the hierarchy of action steps and the characteristics and features of the action elements provided in structural and metric terms help in organizing and structuring the process and operation descriptions ⁵⁰ with the appropriate consequences for teaching these skills ⁵¹. However, as contextual action theory encompasses more than instrumental processes and conceptualizes not only subjective steering and control, but also processes of energizing, monitoring and regulation, often linked to emotional processes, it can provide a comprehensive description of human encounter and activities.

The use of an action theory informed approach to nursing quality management goes far beyond understanding and developing SOPs in a psychologically relevant way. It also helps us in understanding other processes in quality management and in complementing the required standards of evidence-based procedures and of the outcome control. In understanding the nursing process in action terms, we realize that the ongoing action of nurses and nursing teams execute a number of functions and processes, among them monitoring and evaluation. However, these processes have to be focused on and optimized. It cannot be more efficient to eliminate these processes as too subjective and unreliable. The standard research procedure of double-blind placebo control studies, in which the evaluative processes of the participants are eliminated, cannot provide the only roots of knowledge generating procedure in nursing. Equally, the outcome studies cannot represent the only data for assessing the quality of nursing. Thus, the quality management must understand human individual and joint action and project processes and help in optimizing them. This also implies that we try to improve monitoring and evaluation processes in actions and their integration in feedback and feed-forward processes in nursing. This could be more effective than outsourcing the evaluative processes from the nursing actions and projects.