The History Of Nursing Knowledge Focus Nursing Essay
McCurry et al (2009) discussed the disciplinary perspective in nursing using the individual good and social mandate of nursing. They argued that the existence of a profession is to meet the society’s need and that such need can only be met based on ‘specialised knowledge’. One example they used is the Law professionals whose knowledge is related to justice and civil order. In essence, it is critically important to treat nursing as a specialised profession guided by its own philosophy and theories. As such, nursing practice will be able to direct its knowledge towards people’s health and related need. In this assignment multiple forms of nursing knowledge critical for contemporary practice will be discussed. The integration of these forms of knowledge (epistemology) and the core philosophical aspects including the ontology in relation to theories of nursing practice such as the grand theory will be discussed in details. This assignment is divided into five major categories: firstly definition of nursing will be explored, secondly nursing knowledge is examined from scientific, practical and philosophical points of view; thirdly nursing knowledge focus is discussed in which the interdisciplinary nature of nursing practice and its interaction with other sciences is highlighted; fourthly nursing theories are detailed with particular emphasis on the application of situation-specific theory in a perioperative environment and finally standardised nursing language which distinguishes nursing from other disciplines is discussed. In conclusion, the importance of specialised and integrated knowledge (epistemology) is highlighted and outlook is presented.
Definition of Nursing
According to the American Nurses Association (2003) cited in Meleis (2012 p.107), nursing can be defined as the act of practical promotion and optimization of good heath, prevention of illness and injury, reducing suffering of patients through diagnosis and treatment and advocacy of individual, family and community care. Due to the involvement of the society in nursing, nurses are expected to constantly evaluate existing practices, review any additions and also engage in professional development through involvement in research to develop nursing. Such specialised knowledge is expected to contribute and impact positively to healthcare delivery. McIntyre and McDonald (2013) suggested that nurses can effectively reflect on their practice, understand it logically to communicate it and be able to critique nursing practice when they have the ability to theorize. They further argued that knowledge from other disciplines such as ‘social sciences or humanities’ increases the understanding of health and person concept which on the other hand influences nursing practice and nurse-patient relationship, on the other hand.
The societal involvement of nursing and the societal expectation from nurses to fulfil the individual good and the social good mandate of nursing by using a professional knowledge can be viewed through the definition of nursing by Roy cited in Meleis (2012 p.107) as ‘a health care discipline and healing profession, both an art and science, which facilitates and empowers human beings in envisioning and fulfilling health and healing in living and dying through the development, refinement and application of nursing for practice’.
In view of the above definitions, one can understand why Meleis (2012) believe that a discipline mirrors’ the definition attributed to it by its members and the society, however, McCurry et al (2009) is of the opinion that the focus of nursing knowledge as a professional discipline has been a subject of debate. Sackett et al (1996) cited in Royal College of Nursing (2003) argues that the lack of ‘organised body of knowledge’ denies nursing professionalism and application of evidence-based practice since a profession is characterised by its’ body of knowledge however, Brooker (2002) is of the opinion that nursing practice is based on professional judgement which is as a result of professional education and experience especially when it involves decision making in caring and protecting patients.
The term nursing knowledge is quite complex; this is probably because nursing is a dynamic profession which applies a wide range of knowledge including both theoretical (science and research) and practical (caring aspect of nursing based on experience) (Hall, 2005). Nonetheless, it is very important to identify what knowledge that nursing practice is anchored on as this will generally increase awareness among nurses and thus their personal and professional responsibility. Such knowledge as identified by Hall (2005) will help inform the dilemmas encountered in the nursing practice, which will consequently increase patient care. According to Carpers (1978) cited in (Meleis, 2007) nursing knowledge is guided by four aspects namely: empirical, personal, aesthetic and ethics. Broadly speaking, the knowledge could be divided into two categories – theoretical and practical; quantitative and qualitative. Empirical knowledge, which falls under the theoretical and quantitative category, is scientific, thus specific and measureable. This evidence-based aspect of nursing knowledge is necessary for laying the foundation and guiding nursing practice. Furthermore, it could be applied in the understanding and prediction of certain events in nursing practice. According to Chinn & Jacobs (1987) cited in Rutty (1998) an example of the empirical aspect of nursing knowledge is the inclusion of biological, physical and social sciences as part of the nursing curriculum. The other major category – practical and qualitative category encompasses the remaining three aspects – personal, aesthetic and ethics. The personal knowledge which is arguably the most fundamental and essential aspect of nursing knowledge should be inherent in all nurses. Rutty (1998) suggested that this aspect of nursing knowledge cannot be taught; rather it is acquired through experience and self-awareness of the uniqueness of the individual in the frontline of patient care. Aesthetical aspect of nursing knowledge could be regarded as the ‘art of nursing’. It is usually expressed through actions; for example in a clinical situation, the nurse will examine the situation and subconsciously respond with skilled action without much deliberation. In this case the nurse’s intuition and empathy is prevalent based on their skill and experience related to that particular situation. Ethical aspect of nursing knowledge could also be referred to as moral component of the nursing knowledge. It requires practical knowledge of societal values, ethical reasoning and responsible individuals. To this end, ethical codes of nursing have been developed to help confront and resolve certain conflicting values, norms and interests. Nursing knowledge however cannot be discussed without making reference to its philosophical core aspects which include ontology (overall nature of things) and epistemology (nature of knowledge itself). According to McIntyre and McDonald (2013), ontology asks the question ‘what is?’, whereas epistemology asks the question ‘how we know what we know?’ Ontological question in nursing could include ‘what does it mean to be a nurse?’ Epistemological question in nursing could include ‘what kind of knowledge is required for nursing practice?’ These philosophical questions could lead to other broader questions that may necessitate critical analysis, research, study and eventual deeper understanding of some important theories underpinning nursing practice. Subsequently, the scope (breadth and depth) of the nursing knowledge will expand.
In the light of the above discussion, Van Maanen (1990) cited in Rutty (1998) concluded that although the scientific knowledge is critically important and crucial in nursing, the personal, aesthetic and ethical aspects of nursing knowledge are equally important. Rutty (1998) further argued that they are all overlap each other, are interrelated and interdependent. It is critically important to integrate the knowledge acquired from other disciplines in other to excel and deepen our understanding of nursing practice.
Nursing knowledge focus
Willis et al (2008) observed that the dynamic nature of current healthcare-related issues requires very confident nurses who have the personal knowledge of who they are, aesthetic knowledge of what they should do, ethical knowledge of what is right and wrong, their societal mission and how to communicate it to others. Furthermore, they argued that nursing knowledge (epistemology) should be integrated with the knowledge obtained from other disciplines as this will facilitate a flourishing society with good health and well-being.
McIntyre and McDonald (2013) claim that the inclusion of multiple sources of knowledge generated from nursing discipline and other disciplines has broadened the view of nursing practice. Willis et al (2008) suggested that a central unifying focus by nurses will go a long way in sustaining nursing as a practice discipline. From their inquiry they proposed a central unifying focus for the discipline of nursing ‘facilitating humanization, meaning, choice, quality of life, healing and dying’. They suggested that this disciplinary focus would support professional identification of nurses, provide the ontological and epistemological basis for the nursing profession and at the same time strengthen the discipline as a profession.
Other scholars and theorists have proposed several other nursing disciplinary focus statements for example, Newman et al (2008) proposed ‘caring in the human health experience’ as an attempt to encompass person, health, environment and nursing as a unifying focus. Kim (2000) proposed ‘human living’ as a more unifying focus than ‘human state’ and ‘human responses’. Kim argued that human state and human responses are disjointed and does not represent a whole being. Jacobs (2001) cited in Willis et al (2008) proposed ‘human dignity’ as the main focus of concern. Willis et al (2008) is of the opinion that their proposed central unifying focus (facilitating humanization, meaning, choice, quality of life and healing in living and dying) gives nursing a logical foundation for interdisciplinary collaboration ensuring a good stance for multidisciplinary discussion. They commended scholars for their quest to propose a central unifying focus that unites nursing as a discipline. They also suggested that such distinctive knowledge will help nursing values to be visible and of practical importance for interdisciplinary collaborations which is needed for societal and healthcare reforms. Fawcett (2012) emphasized that it is important for nurses to understand the theoretical or empirical models, practice and research that govern the nursing discipline. If such an understanding was lacking, nurses will lose their professional identity and would not have the ability to engage in interdisciplinary practice. Willis et al (2008) joined forces with other scholars to criticize nursing for being narrow minded and self-protective by distancing the nursing discipline from other disciplines, in order to meet the so-called nursing goal of ‘human good’. Willis et al suggested that nursing should actually join forces with other discipline in planning and implementing societal changes needed in optimal healthcare delivery. However, Willis et al (2008) suggested that nursing disciplinary knowledge development is important as the discipline develops especially for ‘consolidating our beliefs and values’ but nursing should also use the knowledge gained from other disciplines to equip nursing for intra and interdisciplinary collaboration in health care delivery.
Willis et al (2008) on their argument for a central unifying focus for all nursing work, indicated that it serves as a ‘means of communication, uniting healthcare disciplines’ in achieving an optimal healthcare outcome especially where nursing knowledge is clear and visible.
Taking the advantages of a central unifying focus literally as outlined by Willis et al (2008), this can be mirrored in some policy documents that are used in my practice area; for example in the Operating department where I work, we use several policy documents that guide our clinical practice. One example is the ‘policy to ensure correct site, correct procedure and correct patient surgery’. The policy statement state that:
‘It is the policy of ... to ensure that all surgical procedures adhere to international standards on safe surgery in particular the prevention of wrong site, wrong procedure and wrong person surgery and applies to all areas in the organisation where surgery is performed’ (St Vincent’s University Hospital, 2013).
The main focus of this policy document is to maintain patient safety and to inform the multidisciplinary team about the hospital safety goal. The decision to start surgery (knife to skin) once the patient is prepared and draped is informed by correct use of this policy document. This policy document was developed by the theatre clinical nurse facilitator (CNF) for student nurses and registered nurses professional development. The policy serves as a framework for safe surgery which was developed based on the World Health Organisation (2011) safety initiative. The policy document serves as an effective means of communication within the multidisciplinary team and also makes visible the unique nursing contribution in achieving an optimal healthcare outcome.
According to Parker (2006 p.4), ‘a theory is a notion or idea that explains experience, interprets observation, describes relationships and project outcomes’. Parsons (1949) cited in Parker (2006) explains that theories ‘help us to know what we know and decide what we need to know’. Because theories are based on experience and the interpretation of such experience or thought, they are seen as interpretation of reflections of observation and understanding, they guide what we do, the set goals to be achieved and the result. Meleis (2012 p.29) described theory as ‘an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline and communicated as a meaningful whole’. Meleis further explained that theories are classified based on the aspects that reflect a particular discipline.
Nursing theory according to Meleis (2012) serves as a store house for results that are related to the nature of nursing or its guiding principle. Theories also serve as a tool and aid in observation and discovery, and theories have been viewed as a goal aid in description and prediction (Meleis, 2012 p.32).
Reeds (2000) is of the opinion that the wholeness of nursing profession has been destroyed despite the vast theoretical base from the ancient days of Nightingale when nursing perspective had a focus on ‘health, protection, restoration, healing and human flourishing’, and nursing characteristics were explored to appropriately guide nursing practice. Reeds further indicated that nurses who base all levels of practice on medicine have compromised the actualisation of the full potential of nursing knowledge. Nursing theories according to Smith (2008) focus its development on the holistic approach to human life and experience incorporating the processes that support relationship, integration, and transformation.
Types of theories
According to Walker and Avant (1995) cited in Smith (2008), there are four different levels of theories: the metatheory, grand theory, middle range theory and the practice theory. The metatheory is seen as the knowledge beyond the focus of nursing theory. According to Smith (2008) grand theories focus at the central phenomenon of the discipline as illustrated by Orem’s self-care deficits; middle range theories are more tangible and can be derived from a grand theory or from an observation. The practice theory is viewed as the guideline for practice.
Meleis (2012 p.33) stated that nursing discipline must have theories in other to achieve optimal healthcare outcome for individuals and the society at large. Meleis continued that the theories will describe fundamentals of the discipline, provide a framework for interventions and also predict outcomes. Meleis (2012) categorised theories based on their level of abstraction or in terms of their goals. Based on abstraction the theories were classified into three categories: grand theories, middle range theories and situation-specific theories. In addition Meleis identified descriptive and prescriptive theories based on the goal orientation basis.
Grand theories according to Meleis (2012) are very abstract with no empirical testing. They reflect a very wide scope and relate to a large number. In nursing, grand theories represent the nature, mission and goal of nursing.
According to Meleis (2012 p.411) middle- range theories deal with more specific phenomena, usually have limited number of concepts and propositions and are less abstract than grand theories. Smith (2008) observed that middle-range theories give ‘valuable organising frameworks to phenomenon being researched by interdisciplinary teams and therefore connects research to practice’.
Meleis (2012) wrote that Situation –specific theories has its focus on specific nursing experience that reflects clinical practice, targeting particular area of practice. According to Parker (2006) situation specific theories have more direct impact on nursing practice since they are developed for nursing situations.
In perioperative nursing, the guiding principles of nursing practice are effective and efficient communication, offering holistic nursing care, maintaining patient safety, dignity, confidentiality and remain the key patient advocate while working in a collaborative manner. Although that we adhere to the standards set out by the Association of Operating room Nurses, I cannot specifically mention any one grand theory that governs perioperative nursing care. However, our patient population varies so much, such that patients come into theatres from wards where certain nursing models such as Orem’s self-care model are practiced. Even though these models do not form part of our guiding theories, the level of care they receive in theatres is not comprised at all. Such a typical scenario in a perioperative care environment demonstrates the existence of certain models not presently covered by existing theories.
The situation-specific approach can be claimed to be the form of theory that is applied in perioperative nursing. Most of our daily practices are based on policy documents which are generated for a specific situation. For example, we have the: ‘Operating theatre department surgical count policy’ which is strictly adhered to for counting swabs, sharps, instrument and miscellaneous items involved in invasive surgical procedures. Another example is the: ‘Awake intubation in the Operating theatre: Patient care policy. These policies were developed by the perioperative nurses for specific patient groups in specific situations and they inform most decisions that are made by the perioperative multidisciplinary team when dealing with each specific situation.
NHS Modernisation Agency (2002) cited in Rycroft-Malone et al (2009) suggest that protocol based care standardise clinical decision making; through rationalising the protocol content, justifying it and then making informed decisions. Rycroft-Malone et al (2009) suggested that protocols and policy documents serve as communication tools between healthcare team members. However, Flynn and Sinclair (2005) argued that though policies, protocols and guidelines standardise nursing care, there is a tendency that itemised documents can make the nurse heavily dependent on them, such that they may hinder the application aesthetic aspect of nursing knowledge in challenging situations.
In the operating theatre department where I work, our policies and procedure documents are reviewed within a specific time frame and also nursing staff are involved in developing them. There is often education sessions for policy development and in some cases policies are developed from a journal club finding. Therefore the Flynn and Sinclair (2005) notion that policies and protocols might ‘take out the thinking out of nursing’ will probably not hold in our department rather the standardisation of clinical situation decision making will be timely and communication within the multidisciplinary team should be effective.
The standardised nursing language
Willis et al (2008) suggested that the use of language based mainly on nursing practice may be the unifying factor that clearly distinguishes nursing from other disciplines such as medicine, social work and physical therapy. It can be interpreted that each discipline should be identified by their language. According to Gordon (1998) nursing in the time of Nightingale used medical taxonomy to interpret nursing actions. With the evolving nursing knowledge through its identity as a professional discipline, NANDA, NIC and NOC was developed using nursing taxonomy to interpret and classify nursing care and to facilitate documentation in a systematically organised manner that is transparent to both nursing and other disciplines. The standardisation of nursing diagnoses, interventions and outcome classification also enhanced nursing autonomous practice especially in decision making (Gordon, 1998).
Nursing theories and nursing practice should interact more closely if the theories are to be understood and be applied appropriately in a clinical environment. The fact that the theorists and educators seem not to be clinically inclined, makes it more difficult for the clinical nurse to interpret and independently apply nursing theories and empirical knowledge. The application of the theories in the clinical area without the basic knowledge (epistemology) appears to be unattainable especially without the fundamental theories. As McIntyre and McDonald (2013) suggested, it will be very beneficial for the nursing professional discipline if fundamental nursing theories are included and strongly highlighted undergraduate nursing curriculum, so as to equip student nurses with the professional knowledge that is required to articulate and expand the nursing distinctive knowledge. The integration of this knowledge and in a multidisciplinary manner in relation to other disciplines, and the standardisation of nursing language will help to distinguish nursing as a professional discipline. Situation specific clinical areas can also adopt the situation-specific theories and embed the standardised nursing language in the theories to enhance clarity and efficient communication. In outlook, I propose that nursing theories should be introduced not only in the undergraduate curriculum, but also in clinical areas through seminars and workshops. And these should be reviewed regularly to ensure that they match the dynamic nature of the nursing profession. The standardisation of nursing knowledge should also be implemented swiftly in clinical areas and all healthcare environments where nursing services are needed.