Clinical Practice Based on Theory: Reflections on Mudd et al.'s Review for Excellence in Nursing

In the Southern Denmark Region, Lillebaelt Hospital (LH) has been developing an approach to underpin personcentred care which we call ‘patient first’ (Drenkard 2022). To put the ‘patient first’, according to LH, four core values—patients should be met with results, decency, co-operation and excellence. In order to enact these goals in practice a group of clinical nurses and clinical nurse specialists supported by nurse leaders developed a framework to strive for excellence in nursing and develop a deeper understanding of what is meant by ‘excellent nursing’ (EN). The EN framework that emerged is currently being consolidated draws on European philosophies and is being established within diverse clinical departments (Stie et al. 2024; Petersen et al. 2024). The framework is constituted by seven core values: wellbeing, relational, trust, ethical, professionalism, personcentred, authentic presence (Figure 1).

In our desire to establish EN as a programme in Denmark, we read and reflected on the way the fundamentals of care (FoC) framework has approached nursing theory (Mudd et al. 2020). Our rationale is twofold: firstly to reflect on fundamentals of nursing which is a commonly used conceptual framework in Denmark and secondly to draw inspiration from Mudd et al.'s critical analysis of nursing theory. What follows is a discussion of reflections where we are in agreement with Mudd et al.'s analysis., the ‘what’ of theory and the ‘how’ of practice and challenges in application of nursing theory to practice. The EN approach is trying to close a theory practice gap, (which has been a longstanding and pernicious challenge) in a particular way. In contrast, our approach is ‘bottom up’, that is, use of theory to give us a more comprehensive and nuanced understanding of practice and primarily a more comprehensive understanding of the patient and their lived situation. We aim to understand our own practice in light of theory, in order to better grasp the patient's experience, using both guided and spontaneous reflection. We conclude with how EN may offer one distinctive approach to supporting nursing practice.

We particularly valued the authors consideration that their review provided opportunity to reflect on the FoC, that is, strengths, deficiencies and areas for further refinement and clarity about ‘gaps’ that are timely to consider in the context of developing a Framework for EN in Denmark. A supportive care context represents one of the three key dimensions within the FoC Framework, which underpins the delivery of high-quality fundamental care. The FoC Framework defines the context of care as encompassing both system-level factors—such as resources, culture, leadership, evaluation and feedback—and policy-level factors, including financial considerations, quality and safety, governance, regulation and accreditation. However, in their narrative review and synthesis of key nursing theories, Mudd and colleagues found these two levels to be overly broad with limited ability to provide meaningful insights and diminished applicability of theories to practice. Consequently, they employed an adapted classification system from the implementation science literature, which categorises context into three levels: micro (individual factors), meso (department factors) and macro (policy-level factors).

In their analysis, 22 nursing theories referred to context at the micro-level, 10 addressed both micro- and meso-levels, while only three considered all three levels of context. In one of six papers findings, with implications for nursing education and practice, Mudd and colleagues identified the concept of context as being poorly developed within both existing theories and the FoC Framework. They argue that the FoC Framework predominantly focuses on the meso-level, which represents a significant limitation. Regarding nursing theories, while context was consistently acknowledged, it was attributed various meanings; they concluded most theories concentrated on contextual factors at the micro-level, relating to the individual. Overall, the majority of nursing theories appeared to conceptualise context in a binary manner, affecting either the patient or the nurse exclusively.

Mudd and colleagues conclude that both the FoC Framework and other existing nursing theories may inadequately address context in ways that are directly applicable to nursing practice. FoC contains a number of relevant concepts (the what), but does not describe how they affect each other in clinical nursing practice (the how). We agree, and this is one of the reasons we found it necessary to identify a ‘bottom-up approach’ in EN described below. Further, nursing theories developed over time have been criticised for lack of relevance to practising nurses, but we acknowledge that theories (1960–1990s) were developed for different and distinct professional knowledge purposes.

Mudd and colleagues found, that only six recent nursing theories suggested integrating patients' physical and emotional needs. They question whether this limited focus on integration reflects a more recent shift in the ideas underpinning nursing theories, and indicate that FoC simultaneously addresses physical, psychosocial and relational needs, fronting personcentred care as a strength. However, we suggest EN can go one-step further by adding a distinctive emphasis regarding patient first and its meaning as one of the EN Framework's seven key elements. Here, the approach acknowledges patients as experts in their own lives, with their sense of wellbeing, feelings, values, plans, experiences, preferences, beliefs and rights shaping their life situation and context. Starting in this context, a highly individual perspective provides a ground to inform and guides nursing actions that are the right fit for each person and their situation, constituting an excellence in care. Further, the goal of care in EN is to support wellbeing, even within illness (Galvin and Todres 2011). This means finding pathways that support an experiential sense of wellbeing for patients to step into.

Mudd and colleagues' analysis has been inspiring for our work in comparing and contrasting with the EN framework. The EN framework helps us to have a deeper understanding of what it is like to be a patient and what is important to them, understanding from a lifeworld perspective and how being a patient impacts on, for example, patients sense of belonging, aspirations in their situation, possibilities, future expectations, if they can settle, their vulnerabilities, limitations, constraints, their sense of agency or sense of dependence on others, particularly dependence on nurses, their longing for their life, sense of support or abandonment and so on. This is an everyday life perspective, in contrast to earlier (1960–1990) nursing theories that emphasised biological and scientific influences on nursing education, subsequently practice and provided a primary delineation of nursing knowledge and professional focus in a more top-down abstract way. Through our local work with EN initiatives within the hospital, from a bottom-up perspective, starting with a more comprehensive understanding of the patient's everyday perspective, attuned to lifeworld, the experience of existential wellbeing is the goal of EN.

One can ask if the FoC describes and support ‘the why’ of nursing and leave it to the clinicians to develop the ‘how’ and ‘what’ of nursing? The FoC ambition covers an exceptionally wide view of nursing, from our point of view FoC is at risk of being too generic, too global, and a bottom-up approach among clinicians focused on each individual patient's situation in a deep way might overcome this distraction.

We acknowledge that Mudd and colleagues transparently show that the nurse–patient relationship is a central part of several theories and that the nurse–patient relationship is still a key element in FoC. We endorse their analysis that specific aspects of the relationship are not as explicitly addressed in FoC as they are in some nursing theories. However, although nurses' authentic presence, attitudes, actions and recognition of patients as persons constitute an expansive category of nursing theories, it is unclear whether Mudd and colleagues take this aspect into consideration.

In aiming to go deeper, authentic presence is a significant value in the EN framework. It involves a genuine engagement in the patient's situation, the ability to direct one's attention toward the patient and a willingness to be open to the patients suffering and possibilities for wellbeing. It is through this presence that the patient's perception of the situation becomes clear and the nurse's care for the patient emerges. Moreover, the nurses' self-awareness is highlighted as a main prerequisite in nursing theories. Evaluation of the relationship through a degree of reflection and self-awareness of nurses is also recommended in the FoC Framework, but not explicitly addressed as in nursing theories considered by Mudd et al. Acting on behalf of the patient as well as supporting or empowering patients to be in control are important aspects of the nurse–patient relationship, and according to Mudd et al. this is similar to the FoC where nurses respect patients' values and beliefs. The EN Framework suggests that respecting and supporting a person's values and beliefs is of crucial importance, but directed toward the goal of nursing is for the patient to experience well-being. Here well-being is not reduced to feeling empowered or in control but rather the experience of being able to feel at home in one's body and one's situation, with a sense of possibility, a sense of future, a vitality and zest for life, ability to handle everyday life, being present in the moment and able to let go of what is beyond one's control and come to settling and even ‘letting be’.

A programme of initiatives is underway at LH to support a further education of nurses to underpin how their specific job is to help patients experience a sense of wellbeing, no matter how limited within their situation, and this complements but is distinctive from the actions of other healthcare professions who are focused on a symptom management or curative outcomes. EN, by contrast, is focused on finding experiences of wellbeing within the illness journey.

We agree with Mudd et al. that the context for clinical nursing is important. In Scandinavia, we mainly fund our welfare state, including hospital and home care, through tax payment, so having the Patient First goal reminds us what the job is: engaging with who the patient is, what they need our help with, and how they view the solutions that are possible. Inpatients in a modern Danish hospital are often connecting with nurses for a short time. Therefore, there are two concepts that are interesting to focus on: authenticity and sensitivity. So, the question is how FoC can support a provision of nursing care that is both authentic and sensitive. The question is also whether an overarching general framework can meet that need or whether local bottom-up initiatives need to be launched to guide the nurse's approach.

At Lillebaelt Hospital, the staff deliver acute care, elective procedures and specialised cancer care. Aligned with this framework, LH established ‘Excellence’ as a core value, emphasising the importance of high quality clinical practice, leadership and continuous improvement. Clinical nurse specialists at the oncology department in collaboration with chief nurses initiated a theoretical discussion in 2017 to define and explore what EN means. A concept analysis followed and literature search revealed through the analysis seven key concepts as value-framework for EN: professionalism, wellbeing, relational, authentic presence, trust, ethical and personcentredness. Then teaching was structured for clinical staff. This bottom-up approach to excellence was shortly after adopted, reflected and lead throughout the hospital. As a tool to support the EN framework in programme, we introduced what was named the ‘ambassador education program’. The purpose of the programme is for the ambassadors to gain in-depth knowledge and skills in applying the theoretical framework that constitutes ‘Excellent Nursing’. After finalising the program, the ambassadors are able to: communicate theoretical knowledge about the seven core concepts of EN and their significance to clinical practice, facilitate reflection in clinical practice among colleagues in their own department, and plan and implement initiatives that contribute to the delivery of EN. Initially, 70 nurses have completed the programme. To provide even more opportunities for implementing EN care—also in other hospitals and municipalities—a diploma module in EN is currently ongoing in collaboration with a local University College.

In conclusion, the EN framework helps with reflection on ‘patient first’, however, the ambition is that it will help us to take positions attuned to these ideas in order to organise nursing and new structures, and develop further initiatives which use the principles of the framework and evaluate how this contributes to the sense of wellbeing experienced by the patient by holding onto the lifeworld oriented values of EN: A value based approach to developing new services, and new ways of innovating care delivery at the hospital rooted in the patient's situation.

The authors declare no conflicts of interest.