Discipline Nursing Discuss Concepts Identified Literature Relation Thesis

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Nursing metaparadigm: Evolving views of the discipline

Ever since Florence Nightingale published her thirteen canons of nursing, nursing has striven to define itself as a unique discipline, with unique rules and protocols. The nursing metaparadigm embraced by most theorists of the nursing process today is fourfold structure encompassing patient (human being), the nursing process, health, and the wider environment. However, while the embrace of such constructs connects many of the major theorists of nursing, all theorists have slightly different notions of what constitutes 'nursing,' which affects their views of other components of the nursing process. Additionally, some writers on the topic even believe that to have a 'theory' of the practical nursing process is an oxymoron.

Those who dispute the value of having a 'theory' or larger construct with which to view nursing practice deny the value of breaking down nursing into the classic metaparadigm's four component parts. "In Meleis's (1991) view, the distinctions that some nurse theorists have made among metaparadigm, conceptual model and framework, and theory, in deciding what to call conceptualizations about nursing, are 'hair-splitting, unclear, and confusing at worst" (Kikuchi 1999). However, defenders of the metaparadigm construct regard it as a critical component of establishing nursing's unique contribution to the field of medicine. During the 1970s, "nurses began to claim that the person is more than the disease, indeed a composite of physical, psychological social and spiritual dimensions" and thus the definitions of what constituted the patient, environment, health, and by extension the nursing process began to incorporate more subjective, intangible elements (Thorne et al. 1998: 1259).

Fawcett (1995) states of a metaparadigm within any field: "(1) it must identify a discipline's domain such that it is distinct from those of other disciplines, (2) it must parsimoniously encompass all phenomena of interest to a discipline, (3) it must be neutral in perspective, and (4) it must be international in scope and substance" (Kikuchi 1999). Metaparadigms are useful in that they set disciplinary limits. This is particularly vital for nursing today, given that nurses are increasingly being called to fulfill the functions of physician's assistants, physicians, and other medical roles.

One prominent advocate of the 'metaparadigm' construct, Margaret Newman, stated that the purpose of nursing is fostering "caring in the human health experience" and nursing is designed to "help clients get in touch with the meaning of their lives by the identification of their patterns of relating" (Margaret Newman, 2009, Nursing Theories). Nurses are viewed primarily as facilitators and partners in this model. The object of nursing is not only the patient, but also includes the patient's family and community. Because of her integration of environment and person, Newman does not spend a great deal of time analyzing the environment as separate from the patient, and only notes that the environment constitutes "the larger whole, which is beyond the consciousness of the individual" patient (Margaret Newman, 2009, Nursing Theories).

Health by Newman is defined as a synthesis of "disease and non-disease:" in other words, every person manifests some degree of health or illness at every point of his or her existence (Margaret Newman, 2009, Nursing Theories). In contrast to Fawcett's determination to define nursing in a concrete fashion, Newman stresses the 'caritive' function of nursing, and the degree to which health and illness exist on a continuum, rather are distinct entities. As such, nursing is a very broadly-conceived, subjective process. Illness or health "cannot be assessed objectively," and the patient is seen as freely choosing his or her state of wellness (Thorne et al. 1998: 1259). While this can be empowering for the patient, it can also disempower the healthcare professional from seeking change, and deny the patient's environmental and cultural situation which may make achieving a state of well-being difficult (Thorne et al. 1998: 1260).

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However, despite this critique, the metaparadigm concept has proven itself useful in terms of reevaluating the various component of the nursing process with regard to patient's cultural differences. Recently, nursing has become increasingly self-conscious of the cultural biases built into previous ways of conceptualizing the patient and health. Dexheimer Pharris stresses that cultural factors will inevitably affect the patient, the patient's perceptions of what constitutes health, and the general environment of the patient. For example, prejudice can create additional health stressors, and also result in minority patients receiving less competent care. "Institutionalized racism is the reason for 'race' being highly correlated with poverty, stress, and environmental exposures, all of which lead to poor health outcomes" (Dexheimer Pharris 2009: 4). Prejudice against minority nurses can create a health profession which increasingly does not resemble the population it is ostensibly trying to serve. Dexheimer Pharris takes a more flexible view of the metaparadigm concept than Fawcett. She adheres to its basic components in her analysis of the problematic nature in which the degree to which race affects nursing and the definition of patient, health, and environment. But her disciplinary boundaries are less firmly-defined. Postmodernism, cultural studies and the acute self-consciousness of cultural criticism are all built into her analysis.

Dexheimer Pharris' approach is controversial. It has been argued that "nursing-specific conceptualizations that de-emphasize illness and embodiment limit the full participation of nursing in a health care system which currently expresses its purpose within an system which concurrently expresses its purpose within an illness/embodiment context" (Thorne et al. 1998: 1260). The degree to which definitions of 'health' seem subjective may be evident with certain individual patients, but is not an appropriate platform of advocacy for the nursing profession or the patients of nurses who usually require some form of treatment and care through conventionalized medicine, critics note. This dispute highlights one of the problems with defining nursing, which is the extent to which the phenomenon that is being studied is somewhat elusive. "The question what is the essential nature of nursing? is a philosophic nursing question, not a scientific one" (Kikuchi 1999). Is it healing a sick person nursing or is it making a person subjectively feel better in a holistic fashion the goal of nursing?

This is why naysayers to nursing theory worry that nursing runs the risk of 'defining itself out of existence. They argue that if nursing occupies itself with philosophical questions too much, it loses sight of its essential nature, which is practice, rather than theory. But to focus too much on practice, reduces nursing to a mere technical discipline, which is also not entirely accurate, either. To view nursing simply as science distills it from its human elements. "Nursing is a professional discipline (Donaldson & Crowley, 1978). Professional disciplines such as nursing, psychology, and education are different from academic disciplines such as biology, anthropology, and economics, in that they have a professional practice associated with them" (Smith 2008: 3).

One potential alternative offered by Smith (2008) to the current debate over what is the best way to conceive of nursing theory, or to know if nursing theory truly exists at all, is the notion of using middle range theories, rather than grand, over-arching theories to understand the discipline. Middle range theories focus on "expanding on specific phenomena that are related to the caring healing process. For example, the theory of self-transcendence explains how aging or vulnerability propels humans beyond self-boundaries to focus intrapersonally on life's meaning, interpersonally on connections with others and the environment, temporally to integrate past, present, and future, and transpersonally to connect with dimensions beyond the physical reality" (Smith 2008:3). Middle range theories attempt to be more useful in practice, still underline the caring functions of nursing, but also offer philosophic understanding to stretch the perspective of nurses beyond simply dealing with.....

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