Personal Nursing Philosophy: Concept Synthesis - Essay Example

Personal Nursing Philosophy: Concept Synthesis Introduction “Metaparadigm is defined as the global concepts specific to a discipline and the global propositions that define and relate the concepts” (Fawcett, 2005, p.4). The four metaparadigms of nursing are: patient, nurse, health and environment. The metaparadigm helps to demarcate nursing’s frame of reference by delineating the boundaries. It helps to focus on the core attributes of nursing, while marginalising those characteristics which are not part of nursing. Thus, the metaparadigm allow nurse practitioners, theorists and researchers to concentrate purely on the dynamics of nursing. These concepts also provide a framework for the purpose of analysis, to compare the perspectives of different nursing theorists (Fawcett, 2000). Thesis Statement: The purpose of this paper is to identify, discuss and document the basic four domains of nursing metaparadigm: patient, nurse, health and environment. One’s own perspectives regarding two other practice-specific concepts for one’s rural emergency department setting will be identified, discussed and documented. Propositions or assumption statements that connect the concepts will be listed. Discussion Nursing philosophy explains the meaning of nursing phenomena through analysis, meaning and logical argument. Nursing philosophies provide direction for the discipline, forming a foundation for professional scholarship, leading to new theoretical understanding and professional application (Marriner-Tomey & Alligood, 2006). Most philosophies of nursing are “statements of beliefs about nursing and expressions of values in nursing that are used as bases for thinking and acting” (Chitty, 2004, p.230). Most philosophies of nursing are formulated using the concepts of people, environment, health and nursing as the main foundations. Around three decades ago began a period of major developments in nursing theory, “characterized as a transition from the pre-paradigm period to the paradigm period” (Marriner-Tomey & Alligood, 2006, p.6). Paradigms are abstract philosophical concepts which form the basic parameters and framework for organising a discipline’s knowledge. Nursing theory explains patterns and relationships found in nursing phenomena and activities. Theories are developed to describe the many aspects of nursing towards promoting a normative standard for nursing practise, through nurses’ study and evaluation of the theories (Sitzman & Eichelberger, 2004). Nursing Metaparadigm All aspects of nursing such as practice, administration, education, research and further theory development form the basis for nursing paradigms. Paradigms are discipline-specific and can be changed. On the other hand, the metaparadigm of a discipline is global, philosophically neutral, and generally cannot be changed. Metaparadigms exceed all specific philosophical or paradigmatic approaches. They are identified rather than constructed, and the identification process takes place through analysis of the recurring themes of nursing’s theories. The philosophical analysis of metaparadigm recognises the common and distinct philosophical orientation of the discipline of nursing (Peterson & Bredow, 2008). In any discipline, metaparadigms have four requirements: 1) A distinctive domain for the particular discipline. 2) Inclusion of all phenomena of interest to the discipline in a sparing manner. 3) A neutral perspective. 4) International scope and substance. The metaparadigm is composed of several domains, often referred to as a typology. In the nursing paradigm, “these domains are a classification system to identify the constructs or phenomena that are the focus of nursing” (Peterson & Bredow, 2008, p.14). There are numerous nursing metaparadigms. For example, Kim (2000) formulated the four-domain typology consisting of client, client-nurse, practice and environment. The client domian pertains only to those phenomena that relate to the client. The client-nurse domain is concerned with the phenomena that arise from interactions between client and nurse. The practice domain covers nurses’ professional work. The environment domain is composed of physical, social and symbolic components of the client’s external world, both past and present. Peterson & Bredow (2008) believe that comparing the perspectives of various nursing theorists is essential for understanding the numerous aspects of the metadimension. For instance, the concept of health was defined by Levine as wholeness (Alligood & Marriner-Tomey, 2006), whereas Johnson (Fitzpatrick & Whall, 1989) defined the concept as a moving state of equilibrium. Any discipline has only one metaparadigm. The controversy involves what the metaparadigm should be. Using the criteria of uniqueness, inclusiveness, neutrality and global reach, Fawcett (2000) stated that the paradigms suggested by authors such as Newman, Conway, Kim, King, and others excluded one or more of the required criteria of health, environment and nursing. However, the metaparadigm proposed by Fawcett (1978) was also criticised on its outdated language, orientation to a particular paradigm, inadequate perspective of the domains, and for reflecting a cultural bias (Kao et al, 2006). Malone (2005) added that the domain of environment in Fawcett’s (1978) metaparadigm was underdeveloped, and a greater focus was required on the criterion of policy environment. Kao et al (2006) define the four domains from the perspective of Chinese philosophy. For example they explain the concept of person as a social being in ethical relationships which are governed by certain rules. Fawcett’s (1978) conceptualisation of the nursing metaparadigm is believed by the author to be the final one for the discipline. However, she anticipated that “modifications in the metaparadigm concepts and propositions will be offered as the discipline of nursing evolves” (Fawcett, 1996, p.95). It is found that recent nursing literature takes the nursing metaparadigm into consideration, only to a limited extent. The Four Domains/ Concepts: Patient, Nurse, Health and Environment The metaparadigm identified by Fawcett (1978) is the four-domain typology most frequently referred to in nursing literature, which includes person/ patient, health, society/ environment, and nursing. This metaparadigm is also composed of four non-relational and four relational propositions. The non-relational propositions give the definitions of the four domains, and the relational propositions provide the associations between the domains. The non-relational propositions of metaparadigm are as follows: a) “Person refers to individuals, families, communities, and other groups involved in nursing. b) Environment refers to the person’s social network and physical surroundings, and the setting in which nursing is taking place. It also includes all local, regional, national, cultural, social, political and economic conditions that might have an impact on a person’s health. c) Health refers to a person’s state of well-being at the time of engagement with nursing. It exists on a continuum from high-level wellness to terminal illness. d) Nursing refers to the definition of the discipline, the actions taken by the nurses on behalf of and/ or with the person, and the goals or outcomes of those actions” (Fawcett, 2000, p.25). According to Thorne et al (1998), theoretical advances in nursing have become more complex because of the extreme approaches adopted towards the main metaparadigm concepts of nursing: person, health, environment and nursing. The authors argue for a less extreme and more integrated approach to nursing’s theory and practice. According to Chitty (2004), most nurses list their beliefs about nursing. However, unwritten, informal philosophies influence nursing work on a day-to-day basis. It is useful for nurses to go through the process of writing down one’s professional philosophy, and revise it from time to time. Through comparing recent and earlier versions, professional and personal growth over a duration of time, can be evaluated. Moreover, reading one’s philosophy of nursing from time to time is useful, to ensure that daily behaviors are consistent with deeply held beliefs. The key issues of person, environment, nursing and health are the core domains of the nursing metaparadigm. Nursing theorists have conceptualised their own philosophies related to the four nursing domains, some of whom are presented as follows: Florence Nightingale (1820-1910) Nightingale was one of the earliest nurse theorists. Her conceptualisation of the four domains of the metaparadigm can be summarised as follows. Nightingale believed that the health of patients was related to their surroundings. She emphasized the requirement for pure air, ventilation, sunlight, cleanliness of the patient, his surroundings, use of water, and efficient drainage (Marriner-Tomey & Alligood, 2006). A balanced diet and nurses’ responsibility to ensure that the patient’s intake was recorded, was stressed on. Though the concept of noise pollution is a contemporary issue, Nightingale had stressed on the need to ensure quiet and rest for the patient. Further, nurses had to protect patients from possible harm from well-meaning visitors, and to encourage visits from small pets. Moreover, the nurse’s responsibility to the patient continued even when she was off-duty (Chitty, 2004). Thus, nightingale’s philosophy of nursing emphasized the importance of surroundings to health or recovery from illness. Her work inherently believed that changing or improving patients’ environment, could bring about changes in their health. Nurses were responsible for patients and their environment. Virginia Henderson (1897-1996) Virginia Henderson was another early philosopher of nursing. Though her contribution to nursing has been significant throughout her career, her early work which defined nursing and specified the role of the nurse in relation to the patient is considered to be particularly relevant (Marriner-Tomey & Alligood, 2006). Henderson’s philosophy associated nursing with a list of fourteen basic patient needs which were central to nursing care. Her work described the main activities of the nurse as “a substitute for the patient, a helper to the patient, or a partner with the patient” (Chitty, 2004, p.276). The theorist’s patient needs included psychological, spiritual, emotional, sociological, physical and developmental areas, together integrating to form a holistic view of human development and health. Thus, it is clear that Henderson mainly emphasized the role and function of the nurse, that is the domain of nursing, which she combined with the other concepts of patient, health, and environment. Jean Watson (1940 - -) Watson emphasized the earlier values of the caring aspects of nursing. “Watson’s work is recognised as human science” (Chitty, 2004, p.277). She focused on the theme of caring even in her other professional accomplishments, such as setting up a center for human caring. Watson proposed ten carative factors as opposed to curative factors, to differentiate nursing from medicine. Her work addressed the philosophical question of the nature of nursing when viewed as a human-to-human relationship (Marriner-Tomey & Alligood, 2006). This new approach focused on the process of change that occurs among both patient and nurse, through transpersonal caring. Watson equated health with harmony of body, mind and soul, for which the patient is mainly responsible. Illness or disease was equated with lack of harmony experienced in internal or external environments. Nursing based on human values and interest in the welfare of others is concerned with health promotion, health restoration, and illness prevention. It is evident that Watson’s philosophy emphasized the significance of the nurse’s use of human values, the patient, and also the importance of harmony as good health. The nurse was responsible for creating an environment supporting human caring, while recognising and providing for patients’ primary human requirements (Chitty, 2004). Imogene King (1923-2007) Imogene King “focused on persons, their interpersonal relationships, and social contexts with three interacting systems: personal, interpersonal, and social” (Chitty, 2004, p.280). King’s interacting systems form a framework depicting persons in their family and social contexts. The personal system includes concepts that identify a person individually, personally and intrapersonally. These are perception, self, body image, growth and development, time and space. The interpersonal system deals with interactions and transactions between two or more persons. This includes role, interaction, communication, transaction and stress. The social system is composed of social contacts, and include organisation, power, authority, status and decision-making. King’s philosophy emphasized the role of the person, interpersonal relationships, and social contexts composed of various concepts in three different interacting systems. Two Practice-Specific Concepts for Rural Emergency Department Nursing In the context of the rural emergency department setting, the two practice-specific concepts selected are as follows: the self-reliance of rural residents, and the lack of anonymity and role diffusion of the nurse/ health care provider. Self-Reliance of Rural Residents The rural residents’ definition of health is changing from a functional concept to a more holistic view that includes “physical, mental, social and spiritual aspects” (Lee & Winters, 2005, p.24). In the emergency department setting, it is found that due to greater distances that need to be traversed by patients/ residents to reach a health care facility, most rural residents resort to self-reliant methods of treating themselves, in both non-critical and emergency conditions. Often, only when the condition of the patient is highly critical and beyond the management of the family/ carers, do they shift the patient to the emergency department. Self-reliance among rural persons in their health seeking behaviors has been supported by various authors (Thomlinson et al, 2004; Jirojwong & MacLennan, 2002; Davis & Magilvy, 2000). Jirojwong & MacLennan (2002, p.251) state that care is sought by rural residents only after “first consulting books”. It is commonly found that rural residents “try to deal with an illness themselves” (Thomlinson et al, 2002, p.10). Besides books and libraries, the media, including magazines, and the internet were frequently used. Since chronic illnesses are prevalent, older adults had information about health care providers in the neighboring areas (Roberto & Reynolds, 2001). Rural residents were found to be willing to use the health care facilities if available at a convenient distance, in order to improve their health to the desired level of independence (Niemoller et al, 2000, p.39). Further, it was found that help was sought by the caregivers through an informal rather than a formal system. Mothers living in frontier settings opted to seek advice from family, friends and neighbours, and would initiate self-care activities, if the health care situation was not considered serious. On the other hand, if the illness or injury was considered serious, professional health care was sought out (Thomlinson et al, 2004). Lack of Anonymity and Role Diffusion of Health Care Provider/ Nurse It was found that literature about health care providers in the United States of America, Australia and New Zealand support lack of anonymity and much greater role diffusion among health care providers in rural areas, as compared to suburban or urban areas. In close-knit communities, news travels fast (Lau et al, 2002), and social life in rural communities erases professional boundaries (Blue & Fitzgerald, 2002). Practice in rural communities include the social factors of privacy issues for both the health care professionals and the patients. While older women prefer receiving professional care from a familiar person (Pierce, 2001; Courtney et al, 2000), middle-aged women prefer to go to a facility where the professionals are unknown to them. However, for emergency care, they may not be selective about their options. This was specifically true for women’s health care and mental health (Lee & Winters, 2004). A study of rural nursing in America by Rosenthal (1996) and in Australia by Lau et al (2002), found that diffusion of roles was prevalent among the health care professionals. Generalist and extended practice roles were diffused in Australian rural nursing practice. Similarly, McConigly et al (2000) found role diffusion in the practice of hospice nurses in New Zealand. In rural, sparsely populated areas with few health care professionals to perform the different tasks, it becomes imperative that more tasks have to be undertaken by professional health care workers practising in these areas. Propositions/ Assumption Statements Connecting the Concepts Described In the context of a rural setting of emergency nursing care, the two practice-specific concepts of self-reliance of rural residents, and lack of anonymity along with role diffusion of nursing/ health care professional have been discussed. These two concepts are additional to the fundamental nursing paradigm consisting of health, patient, nurse and environment, all of which combine to form a functional framework for nursing care in the rural setting. A list of propositions or assumption statements connecting the concepts described above, are as follows: 1) Nursing relates to the principles that govern life processes, well-being and optimal functioning of human beings, sick or well. 2) Nursing relates to human behavioral patterns from interaction with the environment in normal life events and critical situations. 3) Nursing focuses on nursing actions or processes which bring about beneficial changes in health status. 4) Nursing is concerned with the health of humans, who are in continuous interaction with their environment (Fawcett, 2000). 5) Emergency nursing in the rural setting often deals with advanced conditions due to delay caused by self-reliant interventions by the person or patient’s family. Only when they are unable to treat the condition themselves, do they bring the patient often in a critical condition for emergency care. 6) Emergency nursing in rural areas is more frequently given for older people, adult males and young children. Due to lack of anonymity among both nurse and patient, middle-aged women often prefer to seek health care help from professionals not known to them. This is also true for patients suffering from mental health problems. Because of role diffusion caused by reduced number of staff, the nurse may need to stretch her services to medical practitioners’ role during serious emergencies. Conclusion This paper has highlighted the significance of nursing metaparadigms, and the basic four domains of nursing metaparadigm: patient, nurse, health and environment. Various nurse theorists such as Nightingale, Henderson, Watson and King’s philosophies of nursing have been presented. One’s own perspective regarding two other practice-specific concepts for one’s rural emergency department setting have been identified, examined and discussed. These concepts are patients’ self-reliance, and nurses’ and patients’ lack of anonymity and nurses’ role diffusion. Proposition or assumption statements that link the concepts have been listed, to form the concept synthesis of a personal nursing metaparadigm. This metaparadigm will prove to be useful as the basic philosophy for rural emergency nursing care practice. References Alligood, M.R. & Marriner-Tomey, A. (2006). Nursing theory: utilization and application. St. Louis, Missouri: Elsevier Health Sciences. Blue, I. & Fitzgerald, M. (2002). Interprofessional relations: Care studies of working relationships between registered nurses and general practitioners in rural Australia. Journal of Clinical Nursing, 11, 314-321. Chitty, K.K. (2004). Professional nursing: concepts and challenges. 4th Edition. 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