Philosophy has played a major role in the development of nursing throughout history. Philosophy shapes who we are as nurses, what we believe and how we practice. Butts & Rich (2011) describe philosophy as an application of your beliefs to different situations that may arise whether known or unknown. In nursing we are faced daily with unpredictable and sometime predictable situations, it is our philosophy along with our experiences that guides us to make certain decisions in our careers. These decisions are forever evolving and progressing based on how we grow as nurses and overtime how our individual philosophies of nursing have changed.
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One philosophy of Science is Positivism. Empiricism and positivism have often been linked together describing a viewpoint that reality can be studied and understood through research and science (Bally, 2012).Although Empiricism was able to describe events it lacked being able to explain them and describe the “why” in situations. While positivism was an early paradigm that was adopted by nursing, it seemed in contrast with nursing ideals and what nursing sought to be. Critiques of Positivism indicated that it lacked the subjectivity; social and spiritual aspects of individuals which were not in align with the focus of nursing (Clark, 1998).
Thomas Kuhn was a contributor to Historicism in nursing and provided insight into knowledge development which was lacking from the positivism philosophy (Butts & Rich, 2011). Kuhn argued that theories and knowledge should be understood within their historical context ( Rodriguez & Kotarba, 2009). Historicism falls into the paradigm of perceived view. Perceived view is based on the belief that facts and principals are embedded in history or cultural settings (Giuliano, Tyer-Viola & Lopez, 2005). In addition, historicism argues that the influence of history of science guides scientific progress (Giuliano, Tyer-Viola & Lopez, 2005).
Yet another philosophy of science is hermeneutics. Nursing itself is hermeneutic or interpretative in nature. Through hermeneutics, beliefs, values and commitments can become known (Charalambous,2010). The nurse can be seen as an interrupter of the patient’s story. Vital signs and subjective clues such as body language can be interpreted by the nurse to better care for the patient. Reading patient’s histories which draws into effect the historicism philosophy can also play an importance in interpreting the patient or using clinical hermeneutics. Patients are not objects waiting to be interpreted, however including hermeneutics into nursing may prove to be useful to move away from more objectified theories in nursing such as positivism (Charalambous,2010).
Another philosophy of nursing that sways away from the objectivity of positivism is that of feminism and critical social theory. Critical social theory which incorporates feministic ideals seeks to liberate individuals from conscious and unconscious restraints (Wilson-Thomas, 1995). Critical theorists seek to understand and study society along with critiquing and changing society. Health care providers utilize critical theory through social mandate and the development of health care knowledge (Doucet, Letourneau & Stoppard, 2010).
Worldviews that guide nursing are typically opposite to those in the medical system (Turkel, Ray & Kornblatt, 2012). That being said, nursing is not just about focusing on a disease but also about a person’s wellness which includes the patient’s spirituality and culture. Three worldviews are at the center stage of nursing. Reciprocal worldview embraces holistic nursing incorporating spirituality, cultural, psychological and social aspects into nursing care (Smith 2005). In simultaneous worldview the person’s inner experiences, feelings and thoughts are of interest (Fawcett, 1996). In regards to spirituality in simultaneous worldview the nurse would be sharing the experience with the patient and aim to be present for them through their suffering (Smith, 2005).The reaction worldview however is more align with the medical model and positivism philosophy; by focusing on the promotion and health of the disease whereas simultaneous focus on the wellbeing of the person and quality of life ( Barrett, 2002).
Development of nursing philosophy
Theory development was introduced as early as 1859 with the writings of Florence Nightingales Notes on Nursing: What it is and What it is not. It was nearly a hundred years before nursing theory and philosophies took center stage again as an essential part of nursing.
In her book The Nature of Theoretical Thinking in Nursing Hesook Suzie Kim breaks nursing knowledge into different phases. The first phase titled declaration of independence phase is broken down from the 1950’s -1960’s and includes nursing seeking knowledge from basic sciences and were borrowing concepts and philosophies from other disciplines ( Rutty, 1998). It was also during this time that Positivism had its greatest influence on nursing. Nursing was shifting towards a science base academia. The American Nurses Association in 1965 declared that nurses need to be prepared at the collegiate level , this position statement set the stage for moving nursing into a more theoretical and scientific discipline ( Kim, 2010). The second stage in Kims (2010) framework is the formative stage which takes place during the 1970’s-1980’s. Prior to the 1980’s nursing academia lacked theory instruction which led to nurses interested in theory to apply theory from other sciences such as sociology, psychology and other education disciplines. It was during this time that nursing grand theories such as Rogers’s initial work and Newman’s models sought to create uniqueness among the nursing discipline by offering divergent thinking by addressing theoretical and empirical questions regarding patient client interaction (Kim, 2010). The third phase titled the reformatory phase by Kim (2010) took place during the 1980’s to the end of the 20th century. The reformatory phase entailed questioning of positivism in nursing and the lack of theoretical theory in patient care. It was also during this time that nursing was full of paradigms and multiple nursing theories were being unveiled.
The broad concerns of a discipline are defined in a metaparadigm which consists of limitations and boundaries of a discipline ( Daniels, 2004). According to Fawcett (1984) a nursing theorist four major concepts create a metaparadigm in nursing. These four concepts, person, health, environment and nursing seek to define the concern for nursing during this time. While Fawcett’s metaparadigm concepts of nursing have been well accepted into nursing theory the evolution of nursing itself has sought to include more concepts into the metaparadigm. One example is nursing theorist Watson who argued that the nursing concept caring needs to be incorporated into the nursing metaparadigm. Caring is an essential component in nursing which should be a central concept in nursing practice.
While metaparadigm identifies common areas of concern, a paradigm is a particular way of viewing the area of concerns the metaparadigm has defined (Daniels,2004). Kuhn (1970) identified paradigms as a worldview of the areas of concern in a discipline. Within these paradigms nursing knowledge is derived of philosophic claims about the nature of human-environment relationships (Fawcett, 1993). How we think and reason about human experiences helps us to build paradigms in nursing ( Duff,2011).
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Four sets of paradigms have been at the forefront of nursing knowledge development. Parse (1987) discusses the characteristics of the Simultaneity and Totality paradigms. Totality paradigms are seen as human beings striving toward optimal health through manipulation of their environment. Health can be defined as life experiences which require continuous adjustment to environmental stressors (Defeo, 1990). Simultaneity is viewed as health as a process of becoming and humans are in mutual rhythmic interchange with the environment (Fawcett, 1993). A difference between the two paradigms is that totality is seeking to maintain an equilibrium stay on a horizontal imaginary line, while simultaneity seeks to move more vertical or finding new potential. It is important to note that nursing is based on both a horizontal and vertical axis (Defeo, 1990). Nursing must seek to restore the patient’s equilibrium, however reaching for new possibilities and potential with the patient as well. The Particualte-Deterministic paradigm is dominant in critical care where the focus of patient care is centered around knowledge, observation, physical environment and technology (Picard &Jones,2005). Within the Interactive-Integrative paradigm subjective information is included more often. While it is not seen as a total holistic approach it values more subjective information from the patient than the latter. Finally the unitary-transformative paradigm which derails from the former linear views of patient care, seeks to include the whole person seeing each individual as unique. Paradigms help guide frameworks for developing theories, generating research and resolving problems. Nursing is a constantly changing discipline which benefits from the paradigms mentioned above.
With the awareness of the importance of paradigms it is also equally important to understand the importance of knowledge development in nursing history. One contributor to nursing’s development of knowledge that continues to stimulate nursing is Barbara Carper. Carper developed “Fundemental Patterns of Knowing in Nursing”. Carpers four ways of knowing, empirical, ethical, personal, and aesthetic knowing prove to be a guideline used by nursing to reflect their nursing practice and to process understanding in daily practice. Empirics reflects on the science of nursing, aesthetics on the art of nursing, personal knowing gains insights into self-acceptance and ethical knowing on moral knowledge. While these fundamental patterns accurately reflect a way for nursing to develop knowledge a fifth principal of Emancipatory knowing was introduced. Emancipatory knowing was added into the fundamental patterns of knowing to reflect nursing’s knowledge on the social context in which care is given to individuals. It recognizes the importance of social and political barriers to health and well-being (Chinn & Kramer,2011). Nursing is indulged in emancipatory knowing by always questioning why things are the way they are and is this idea or problem something we need to change as a profession. Nursing began to use research knowledge and evidence based practice to guide nursing and to increase the quality of care for patients. An important idea to keep in mind is that subjective and objective forms of knowledge do not need to be in opposition to one another but instead work together to recognize the complex nature of nursing (Stajduhar, Balneaves & Thorne, 2001).
Just as it is important to recognize the importance of knowing it is equally important to recognize and be aware of unknowing. Munhall described unknowing as an art. One must be aware that they do not know the patient when they first meet them and that by acknowledging that awareness the nurse in turn is a more active listener to the patient. A nurse who has been in practice for a while and has gained expertise in her field may experience habitual practice .The nurse should use reflection to realize their habitual actions and open up room for unknowing. Reflective practice is an important tool that nurses today must possess. Using reflection can change a practitioner’s viewpoint on situations and thus change their practice. Therefore, reflection initiates change in nursing . As practitioners we need to challenge the habitual norms we may find ourselves in our daily practice and reflect upon the aesthetics instead of the empirical knowing.
Application/Synthesis for Advanced Practice
To be honest, before I embarked in graduate school and in particular this theory class I really never gave theories and reflection a thought. Unknowingly I reflected upon my practice but it was never guided or structured. I now can see myself becoming more of a reflective nurse and identifying situations in a different approach because of this reflection. My philosophy of nursing has always focused on a holistic approach which is most in line with the interpretive/hermeneutics philosophy, and the unitary-transformative paradigms. Together these frameworks guide me in my practice as a nurse to pass along holistic patient centered care to all my patients.
I do not subscribe to only one way of knowing but feel that each component is an essential necessity for effective nursing care. While I do feel we need the importance of empirics in our nursing realm, my main focus as laid out above is on holistic patient care. I tend to put more emphasis on aesthetics and personal knowing into my practice.
Focusing on holistic patient care my attention is drawn to the unprecedented levels of childhood obesity in the United States. Research questions I would pose would be centered on recognizing the health, social, and economic challenges to childhood obesity for underserved populations. Questions to be asked would be “What effect does social and economic barriers have on childhood obesity”, “What role does the family play in preventing childhood obesity” and “How effective is a nurse practitioner on identifying childhood obesity in pediatric patients”. The implications of these questions are important to identify and recognize so the health care provider can educate and provide appropriate support to the family and individual.
In conclusion, nurses around the world need to understand and reflect upon their own personal philosophies and worldviews. In order to do that it is essential to have a basic understanding of nursing’s past contributors to theories and philosophies that have helped shaped nursing today. By discussing knowledge development and the role different theories have played in nursing’s history, I have been able to explain my own personal views and understandings of my nursing practice. It is my hope and goal that throughout reflection and knowing in my practice that I will be able to succeed as a Nurse Practitioner that will be able to assist underserved populations around the world.
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