A Theoretical Conceptualisation of Nursing Practice as a Reflexive Complex System

Purpose: Nursing practice is fundamental to the discipline of nursing. Documenting nursing practice through empirical research is critical to support evidence-based practice, but it is not sufficient on its own to fully contribute to its development. It is of utmost importance to establish the conceptual basis of nursing practice in order to situate the findings derived from empirical research within the field of nursing disciplinary knowledge. Here we present how a study documenting a primary care nursing practice with vulnerable populations was used to inform the development of a theory of nursing practice. The purpose of this oral presentation is to present a theoretical conceptualisation of nursing practice as a complex system.

Methods: An analysis of nursing theorists’ conceptualisations of nursing practice was conducted. A literature search was undertaken using online bibliographic databases (CINAHL, Medline, Pubmed) searching for theoretical and conceptual journal articles using the following keywords (1960-2011): nursing practice, nursing theory, nursing discipline, praxis, caring. Articles presenting a clear definition of nursing practice, a conceptualisation of nursing practice or key components of nursing practice were selected for analysis. One hundred and twenty-five articles were examined and thematically analysed. A complexity lens was used to inform the interpretive process in order to uncover the dynamic interconnections between the various components and processes of nursing practice. This analytical process led to the development of a preliminary model of nursing practice which was used as a conceptual foundation for the conduct of an empirical research project studying a primary care nursing practice with vulnerable populations.

A qualitative exploratory study of a nursing practice with vulnerable populations was carried out in three primary care organisations in the province of Quebec, Canada. Fifteen nurses participated in semi-structured interviews, followed by one year of participant observation of the nursing practice of two nurses. Informal interviews with clinical and community teams, as well as a document analysis, were conducted to further our understanding of the context within which this nursing practice is delivered. Thematic analysis was initiated during data collection and a systemic model was developed iteratively throughout the interpretive process of qualitative analysis using Le Moigne’s systemic model development methodology (Le Moigne, 2012), which was also instrumental for the representation of the study results and further theoretical elaboration.

The combination of the findings from the analysis of nursing theorists’ conceptualisations of nursing practice and those from the qualitative research led to the development of a theoretical conceptualisation of nursing practice as a complex system.

Results: Four main considerations to further theory of nursing practice were drawn from the analysis of nursing theorists’ conceptualisations of nursing practice: broaden the spectrum of theories to conceptualise nursing practice, especially those derived from social sciences; differentiate and systematically document the structural, teleological and contextual dimensions of nursing practice in order to fully appreciate its relational, strategic and political facets; identify the reflexivity mechanisms inherent to nursing practice as they are at the core of nursing practice’s ability to change and generate change; consider the environnement of nursing practice as being more than an external and influencial component, but rather as a fundamental component of its structure, therefore integral to the way nursing practice is delivered and evolves.

The qualitative findings relating to primary care nursing practice with vulnerable populations revealed four themes: 1) a goal of autonomy articulated as a social obligation for vulnerable populations; 2) relational processes carried out to interconnect vulnerable individuals with various resources in the community; 3) a practice depicted as strategic action; 4) contradictory processes contributing to a reconfiguration of nurses’ sense of professional identity. These four themes were examined from a disciplinary angle and used to further our thoughts about conceptual characteristics of nursing practice: its structure, activities, goals and aspirations, environment and transformation.

Based on the results of this empirical research and informed theoretical work, a conceptual definition of nursing practice as a complex system was developed. This definition emphasises four core characteristics: nursing practice is reflexive – it changes and generates change; nursing practice is strategic – driven by nurses’ vision, goals and interests; nursing practice is informed by humanistic values, social norms and a diversity of knowledge derived from nursing and other disciplinary fields; nursing practice is structured by a social environment represented here as a network of people, resources, knowledge and values in interaction. A model was developed to visually represent this theoretical conceptualisation of nursing practice as a complex system and represents a significant contribution to nursing knowledge.

Conclusion: This work helped in identifying fundamental dimensions of the concept of practice in addition to those of the nursing metaparadigm’s concepts. Future theoretical work and conceptualisations of nursing practice should examine the concept of health as generated within a dynamic social environment, the concept of person nuanced by those of social network and social space; and the humanistic values of nursing practice balanced by strategic interactions and social norms. Theory of nursing practice should rely on rigorous empirical research and collaborative processes with nurses, as well as a diversity of sources of knowledge from various disciplines to capture the complexity of nursing practice in a world of perpetual change.