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We aimed to discuss the importance of the integration of nursing theories in advanced nursing to meet future demands.
Nursing studies reporting a lack of professional care have increased in recent years and indicate a global complex socioecological problem. The lack of a clear theoretical understanding in education, research and practice makes Advanced Practice Nursing invisible and vulnerable.
A theoretical paper was selected to stimulate vital reflexion and debate about the importance of theory integration.
The selection of nursing theories represents the position of some theorists based on our experiences with national and international research and personal leadership in a master's degree program.
For nurses to continue to make a difference in the lives of their patients, practitioners, and researchers need to practice and expand theoretical understanding within their fields. This would enable them to be visible and at the forefront of the wider changes in health care owing to their central position and connection to health organizations.
Nursing theories are essential to the continuing evolution of the discipline of nursing. Postgraduate programs in nursing and research must be encouraged to use and further develop nursing theories to facilitate the advancement of nursing care in education, research, and practice.
Keywords: Advanced Practice Nursing, master's degree programs in nursing education, nursing theoryThe rapid changes in health services and technologies require new types of expertise in nursing, namely, more nurses with specialized and advanced expertise are needed to take care of patients. To meet these challenges, postgraduate programs are evolving, which will provide systematic introductions to analytical thinking and research‐based argumentation. This will lay the foundation for evidence‐based (EB) nursing, 1 but the focus on nursing theory seems less visible.
Advanced Practice Nursing (APN) refers to enhanced and expanded health care services and interventions. The definition inherits levels of practice that require formal education beyond the preparations of the generalist nurse (master's degree). This includes an increased level of competency and capability that are measurable beyond that of a generalist nurse. The APN has acquired the ability to explain and apply the theoretical, empirical, caregiving, and professional development required to meet future demands. 2
According to Polit and Beck, 3 a theory is defined as an abstract generalization that systematically explains relationships among phenomena. Moreover, theories differ in their levels of generality and abstraction and help us understand, explain, predict, and systematize knowledge. Theories also serve as a springboard for APN knowledge and accumulation of evidence for practice. 3 Multiple theories give the profession of nursing different approaches in providing quality care. 4
Nursing theories deal with the conceptualization of specific aspects of reality that pertain to nursing. Such theories answer significant questions and help researchers and clinicians raise questions in a systematic manner. 5 Nursing theories from 1970 represent an important part of this knowledge and should be used and further developed to frame nursing thinking and actions. 6 Moreover, nursing theories are essential to the continuing evolution of the discipline of nursing. 6
However, Thorne 7 claimed that the nursing theories are not adjusted and further defined and developed in light of new research. This means that they are less capable of capturing the present reality of advanced nursing. Furthermore, she emphasized that nurses confront the challenging task to develop nursing theories further to guide nurses in performing their duties and core functions in the future. For theories to remain dynamic and useful, the discipline of nursing requires openness to new ideas and EB approaches based on reflections and insights. 6
Smith and Parker 6 noted that baccalaureate and graduate programs have few nursing theories included in their curricula. They acknowledged that for nurses to continue to make a difference in the lives of their patients, practitioners, and researchers need to collaborate and expand theoretical knowledge within their fields. If the nurses in education and clinical practice are not aware of this, the present authors fear the loss of nursing identity, lack of differentiating the role of the APN, and that practice are displaced by other disciplines.
Chinn and Falk‐Rafael 8 related unclarity in nursing education to the lack of a firm foundation in the discipline's perspectives. They admit that students' often build on perspectives based on philosophies and theories outside their discipline. This calls for innovation and courage in teaching to adjust or change the focus toward own discipline to further develop (and not reduce and replace) APN status in advanced health care.
According to Smith and Parker, 6 the use of nursing theories in research is often deficient. Outcome research appears to lack contextualization within any theoretical perspective. Moreover, theories from other disciplines are used instead of expanding their theories. Another challenge is that nursing theories must develop due to the continuous development of nursing science. However, one of the most urgent issues facing the discipline of nursing seems to be the artificial separation of theory and practice 6 making theories less visible.
Nursing studies reporting a lack of professional care have increased in recent years and indicate a global complex socioecological problem. Among these, the primary cause appears to be limited nursing resources, 9 decreased job satisfaction and the change of the nurses' main functions toward more technical procedures and checklists. 7 The nursing profession continues to face shortage due to these limitations. An unclear theoretical understanding in education makes APN invisible and vulnerable. 10 Lack of theoretical caring perspective in practice may be another contribution to poor quality of care and risk of worse outcomes. 11 , 12 , 13
Thus, it is urgent to reconsider theories covering the basic aspects or core values of the nursing discipline, which must be revitalized and clearly expressed to future generations of advanced nurses. Jones et al. 13 suggested that a more unified conceptual framework is needed to facilitate the advancement of nursing care. The starting point should be the philosophy of nursing science and new research approaches to develop theories that address unanswered questions in nursing. As described in metaparadigm theory in nursing, the theoretical understanding of man, health, and environment, is important to help nurses grasp their complex profession. 7
The present theoretical paper is based on the position of some nursing theories covering different and overlapping aspects and a common core. Among the selected theories, Meleis's theory of transitions, defined as the passage from one state to another, proposes a deeper understanding of the needs of patients during life transitions. Meleis also emphasized that the central focus in nursing deals with development and progress, and she formulated ideas about how to shape a future for nursing that is more theoretically coherent and effective. She highlights transition in relation to role insufficiency and supplementation in nursing. Transition denotes a change in the patient health status, expectations, or abilities that represent a change in the needs. Moreover, she suggested that transitions are developmental, situational, or health/illness events. 5
According to Allen, 14 nursing is a demanding profession. She estimated that the organizing work of nurses comprises 70% of the nursing role. However, lack of coordination and organization is considered the greatest threat to the quality and safety of patient care. 6 , 14 This finding is supported by Falk‐Rafael 6 who asserted that administrative pressure had narrowed the nature and scope of nursing practice. In this context, Allen 14 introduced less restrictive theoretical concepts, such as coordination and organization, to bring the organizing work of nurses to the foreground and expand nursing theories. She discusses essential parts of their work as “transitional mobilizations.” This means that nurses not only receive information but also translate it to mobilize resources directed toward further treatment and care.
Falk‐Rafael's critical caring theory 6 is described as having a practice and a research‐based focus on public health nursing and the concept of empowered nursing. As mentioned above, they affirmed that the administrative pressure had narrowed the nature and scope of nursing practice. The caritative health‐promoting process which is described contributes to the creation of a supportive and sustainable physical, social, political, and economic environment. This theory, modeled as a tree consisting of roots, trunk, and branches; the root stabilizes and nourishes the tree, while the trunk transports nourishment meaning to support praxis.
According to Locsin, 6 , 15 the purpose of knowing the patient is continuous and derived from the nurse's intention to nurse the patient as a dynamic human being. Technological advances in health care demand expertise within technology, which is often viewed as the antithesis of caring. Locsin's theory of Technological Competency as Expression of Caring in Nursing, acknowledges the harmonious coexistence of technological proficiency and caring in nursing as distinct and fundamental concepts in nursing practice.
Bureaucratic caring 6 , 16 is a holistic theory with a practical purpose. This theory facilitates and increases our understanding of the practice of nursing in complex contemporary health care environments. The practice of nursing is described as dynamic and emerging with new possibilities as people relate to each other. The organizations where nursing is practised are generally bureaucratic or systematic in nature and can be viewed as cultures. Health care and its activities are tightly interwoven into the social, political, legal, technical, and economic systems within the organizational cultures. 6 , 16 Nurses must understand bureaucratic authority and its forms and functions to be able to deal with it.
Based on the above considerations, our aim and research questions were:
To discuss the future role of integration of nursing theories in APN using five relevant theories.
Which caring aspects are important for expanding theoretical knowledge integration to guide APN in future?
What main perspectives are important to guide research and educational APN programs in future?
A theoretical paper format was selected for this review because it deals with the development of nursing knowledge and is based on our own experiences with national and international research within APN. Through long clinical experience and personal leadership of our master's and Doctor of Philosophy programs, we have experienced that a focus on the available Nursing theories to support discussions and connect theory to clinical practice is lacking. This affected our selection of theories that cover breadth and depth according to the purpose of this article. Subjective methods are used to decide which theories are included in the sample based on the aim of the study. The selected theories were systematized by identifying the central aspects as well as core and main perspectives/levels (Table 1 ) to build a meaningful discussion.
Five selected relevant nursing theories to guide future theory development within master's and postgraduate nursing programs
Middle range theory
Coordination and organization
Invisible aspects of the nursing role
Related to organizational work
Critical caring theory
Middle range theory
Theory of public health nursing rooted in caring science
Guiding nursing practice at the level of family‐, community‐ and population‐focused care
Relational way of being, knowing, selecting, and doing
Bureaucratic caring theory
Middle range theory
Holistic theory with a practical purpose, a dynamic structure of caring
Organization and society
Technological competency as caring
Middle range theory
Technological competence is an expression of caring
A review of our findings is related to five nursing theories covering different and overlapping aspects to guide further theory development. The focus is on central aspects in nursing, core, and main perspective/level, presented in Table 1 .
The aim of this theoretical paper was to discuss the future role of the integration of nursing theories in APN using five relevant theories as examples. Presently, the discipline of nursing faces formidable challenges. 7 , 8 , 9 , 10 , 11 , 12 , 13 Through experience, we have identified the following gaps within the theoretical understanding and clinical practice that must be bridged: High‐quality demands and limited economic resources, a need for continuous knowledge development and lack of academic competence, sufficient recruitment and lack of retainment, scarce economy and lack of competence, leaders without nursing competence and high demand for high‐quality nursing, more patients with comorbidities and lack of specialized nursing resources, increased use of outpatient services in a digital world, and lack of follow‐up information. These challenges call for a more unified and holistic theoretical framework in APN. Jones et al. 13 indicated that such a framework is crucial to facilitate the advancement of nursing care nationally and internationally.
Rather than emphasize one theory over another, we selected diverse middle range/descriptive nursing theories to emphasize different particular and holistic points of view. We suggest that these theories support an extended picture of the reality in nursing science and practice, and there is more than one perspective from which a phenomenon can be viewed and studied in the future. Among these perspectives, caring is related to transitions, coordination, organization, society, politics and economy, and technological competency and are essential in APN at the micro‐, meso‐, and macrolevels. Moreover, we have structured this discussion section according to the research questions.
Care is the heart of nursing and an essential part of APN 17 which must be advanced with teoretical lens. We believe that identifying different caring aspects highlight the complexity of APNs' health care services and interventions. Among these, transitions have been presented by many researchers as a central concept in nursing. 18 Multiple transitions, which are defined as the passage from one state to another, often occur simultaneously making the caring tasks of nurses even more challenging. 5 This transition theory may contribute to nursing with powerful tools that empower nurses in making a more positive impact on patients. James et al. 19 highlights the fact that health care services need guidance in delivering transition support to improve transition readiness.
Through her theoretical work, Allen 14 provided different approaches to viewing the organizing work of nurses. The caring role that nurses play is often invisible but connects different parts of the health system. This is described as more than coordination. It involves aligning services to the patients' needs across time and space to make the health system feasible in complex societal environments. Poor communication between health care systems hampers patient follow‐ups. 19
Falk‐Rafael's 6 contribution is primarily in public health nursing rooted in caring science. This theory guides nursing practice at the level of family, community, and society. At the core of this theory are relations and relational ways of being, knowing, selecting, and doing. Falk‐Rafael's theory provides the nurses a central position in health institutions to make visible the full disciplinary scope of nursing practice, with relevance to our identified gaps previously described.
Ray's bureaucratic caring theory 6 , 16 viewed nursing care as holistic, but also a part of the structural, political, economic, legal, and technological characteristics of a complex organization. This holistic theory has a practical purpose and dynamic structure of caring related to caring in organizations. The culture of the hospital is a dynamic entity illustrating caring as not only physical, ethical, spiritual, sociocultural, and educational but also a part of an organization. Informal organizational culture integrates codes of ethics and conduct encompassing commitment, identity, character, coherence, and a sense of community in social interaction and the social environment.
Locsin 15 described nursing as holistic and a dynamic unfolding of situations encompassing knowledgeable practices. He highlighted technological competence as an important expression of caring. We support that viewing technological competence and nursing care in a harmonious coexistence is crucial to theoretical knowledge integration as an extension of caring.
Identifying the micro‐, meso‐, and macrolevels in our theoretical framework appears to define movements and interactions important to the nursing specialization courses in the future. We suggest that the selected theories are well suited at most levels and different perspectives and nursing approaches are expressed. Because of advanced nursing tasks, all levels must be in focus so that APNs' can secure professional assistance whenever needed.
We agree with Meleis 5 who emphasized that theories provide the language, principles, evidence, and goals for policy recommendations. She provided a platform to guide new frameworks to advance nursing science by introducing transition theory to ensure continuity at all levels.
Allen 14 described nurses as actors in health systems through myriad processes. She highlighted and problematized the invisible aspects of the nursing role related to organizational work. In addition, Allen 14 described that the nursing work extends far beyond direct patient care (microlevel) and highlighted the nursing contribution to society (macrolevel) by focusing on the invisible aspects of the nursing role. She linked better coordination and organization with patient safety and service quality and is an important contribution to fill our identified gaps. She also discussed the importance of describing organizational work to the nurses to enable them to understand their duties better. Moreover, she emphasized translational mobilization, which deals with knowledge, articulation, and clinical competence in combination with how the organization works.
Falk‐Rafael 6 provided grounding for practitioners and made visible the full disciplinary scope of nursing practice in all levels. We believe her theory is a tool for reflective practice and providing instructions to students. She suggested expansion and integration of the critical caring theory to a broader context because of the focus on social justice and addressal of the social determinants of health. She also focused on a relational way of being in society and the nurses' central position in health institutions. Because the theory is still in an early phase, it needs to be further developed and adjusted to different settings.
Ray's theory 6 , 16 furthers the viewing of nursing and organizations as complex, dynamic, relational, integral, informational, and emergent (macrolevel). As we see it, this approach opens to new possibilities caused by the synchronicity of the interacting parts and the whole system. According to this theory, everything in the system is interconnected. The practice of nursing is dynamic. Nurses and other professionals must therefore be open to change to the dynamic unity of the human and environment. 16 Considering the health systems' goals of decreasing the length of stay and increasing staffing ratios, nurses need to be committed to establishing trust and initiating a caring relationship during their first encounter with a patient (micro‐/mesolevel). This approach to nursing practice involves viewing the patients' need for professional nursing within a complex organizational environment. Empirical studies have firmly established a link between caring and positive patient outcomes. Nurses must be encouraged to continue to not only be caring but to also respond with confidence to economic issues and deal with the political, legal, and technological questions and trials facing them at all levels. Moreover, it is time to actualize the economic value of nursing within the organization. 16
According to Locsin, the best way to achieve the intended nursing care outcomes is the appropriate and competent use of nursing technologies. Technological competency and frequent engagement in technological advancements are a part of the process of knowing persons as a whole and an expression of care in nursing. 6 , 15 His theory includes technological competence as caring in the complexity of competencies required in health care environments. In line with Locsin, 15 we suggest that the need for technological competence will increase when framing the future although the focus in nursing always is the person at the micro‐ and mesolevels.
As indicated in the Introduction, the present nursing theories are not satisfactorily adjusted and defined in light of new knowledge. 7 The discipline of nursing requires more openness to new ideas and innovative approaches. Nursing is considered a young science, which indicates that nursing theories are still in the process of being developed. 6 The present nursing theories were selected to represent useful approaches to expand this discussion. We believe that placing the present nursing situation in the context of nursing practice and research findings is a starting point to develop an awareness for theory development in advanced nursing. The discipline of nursing should be dynamic to respond to emerging and changing needs in society to fill the gap between limited nursing resources and high‐quality demands. APNs at the forefront must be encouraged to continue to not only be caring but to also respond with confidence to economic issues and deal with the political, legal, and technological questions and trials facing them.
All theorists discussed in this paper contribute APN with an extension of holistic approaches in caring within complex health care environments. In addition, they highlight the nurses' central position in health care institutions, make the full disciplinary scope of advanced nursing practice visible and represent different developmental phases important for the future. This is an important strategy to prevent the loss of nursing identity, secure differentiating the role of the APN, and that their domain may be displaced by other disciplines. 6 Our discussion and critical commentaries highlight the value of nursing theories in practice and is relevant to the international nursing community. They can also be applied to foundational nursing and postgraduate nursing programs.
Our suggestions can guide the building of theories regarding APN in different ways. APN students must be aware of their responsibility to advance the discipline of nursing, using nursing theories. This also indicates a responsibility for educators to support the integration and further development of theory into research and practice. We have highlighted the central aspects and functional levels in the development phase of theories. There is also a need to address barriers that may slow the progress, such as when the “budget‐centered care” model collides with the “patient‐centered care” model. Future theory development must deal with the integration of more research findings to develop new theories or extend those that already exist.
Moreover, APN education must encourage students to stand up for themselves through highlighting their professional identity and core values of nursing. Leaders from nursing education and practice must work together as teams to integrate nursing theories and their core values to improve care. We suggest that the selected theories should lay a firm foundation in the nursing tradition and strengthen the development of future nursing. To frame the future, APNs and researchers need to practice and expand the knowledge in their field. Clearly, APNs should work harder to communicate their contribution within healthcare to the public based on a sound theoretical framework. It is imperative that APNs demand changes in health care and develop or modify nursing theories for their practice.
To ensure credibility each theory included was considered individually and then discussed in the plenum several times. Different ideas and opinions expressed in the theories were commonly systematized in a table (Table 1 ) and helped visualize their important aspects. Through the discussion, we have highlighted theories within the competency and experiences of the authors to expand the theoretical understanding in APN. We are aware that other authors may select different theories and reach other conclusions. Because the APN courses are in continuous development, we invite international researchers to participate in an ongoing discussion to develop the future theoretical framework further.
APNs should be at the forefront and demand wider changes in health care owing to their central position in health organizations. To succeed, further development of the future theoretical framework must occur by continuous investigation of a strong disciplinary identity. The promotion of theoretical discourses in research and the use of education as a platform for clinical practice are crucial. Theoretical perspectives must be identified, acknowledged, and adjusted, to best reflect nursing views and values as a catalyst for change and a call to action. This enables APNs to meet the patients' needs in the future through reflection and lifelong learning in high‐quality patient care.
The authors declare no conflict of interest.
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Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
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