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Chapter 5

Patterns of Knowing and Nursing Science

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Evolution of Scientific Thought

• Early humans differentiated world into two parts: me

(internal), not me (external)

– Used trial, error to discover that patterns of action led to predictable outcomes

• Nursing functioned primarily from protocols, procedures

• Disease, aches, pains assumed to be caused by gods, evil spirits

– Early medicine associated with religion or magical beliefs


The Search for Certainty

• The 1500s • Mechanistic world view

– Math

– Counting

– Philosophy of logical positivism

– Determinism

– Quantity

– Continuity

– Impersonality

• Time, space were absolute

• Humans seen as having separate psyche, soma

(Cartesian dualism)

• Principles led Galileo,

Newton to develop scientific method, based on logic


The Relative World of Process

• Scientists realized that physical world consisted of matter, forces that interact with matter:

– Gravity, magnetism, electricity

• All systems considered interrelated and interdependent, on continuum of relativity and probability, thus uncertainty

• Awareness of limitations, biases of individual perception has increased, implying that truth and meaning are not absolute but relative


Philosophy of Knowledge

• Plato

– Knowledge considered to be belief justified through reason

• Philosophy considers questions such as whether there is such a thing as truth, how one can be certain that something is true


Question

• The prior use of scientific thought prompted nursing to function using which method to guide care?

A.

Good and evil causes for aches and pains

B.

Trial and error to discover cause for illness

C.

Protocols and procedures to care for clients

D.

Logic- and reasoning-guided practice


Answer

• C. Protocols and procedures to care for clients

• Rationale: Nursing operated on a series of protocols and procedures that guided client care. Trial and error, evil spirits, and logic were all past methods of scientific inquiry or thought. These methods did not guide nursing practice.


Processes of Knowing

• Rationalism

• Empiricism

• Intuition


Approaches to Knowing

• Logical empiricism

– Body of facts, principles

– Cause-and-effect (linear) relationships

– It is necessary to control values, biases to achieve

“ objective ” knowledge

– Theoretical reduction is important scientific goal

– Whole is sum of parts


Approaches to Knowing (cont ’ d)

• Logical empiricism synonymous with logical positivism

– To predict, explain, control world events, situations, occurrences

– Nursing knowledge based on “ hard sciences ” has roots in logical empiricism



• Historicism based on these assumptions:

– “ Truth ” is dynamic, constantly changing

– Whole is more than sum of parts

– Individual or phenomenon must be studied as whole in natural setting

– Multiple research traditions desirable to explain different dimensions of same phenomenon



• Historicism based on these assumptions:

– Knowledge is related to context

– In professional nursing, historicism provides valueladen approach to nursing knowledge



• Postmodernism perspectives on knowledge development are based on

– Focuses on understanding multiple meanings, ways of knowing reality, rather than single, transcendent meaning of reality

– Multiple truths are accepted, knowledge is considered uncertain, provisional

– Statements reflect concern for context rather than universality



• Postmodernism

– Emphasis of knowledge development shifts “ from concern over the truth of one ’ s findings to concern over the practical significance of the findings ”

– Problems are not “ solved, ” but “ deconstructed ”

– Shift toward lived experience, toward “ creativity, flexibility, uniqueness, local value ”


Patterns of Nursing Knowledge

• Ways of perceiving, understanding self, world

• Gender differences have been identified in ways men and women may develop frameworks for organization of knowledge

– Linked to distribution of power, privilege in society

• Four fundamental patterns (ways) of knowing in nursing: empiricism, aesthetics, personal knowledge, ethics

(Carper)


Empirical Knowledge

• “ Encompasses publically verifiable, factual descriptions, explanations, and predictions based on subjective or objective group data ”

• Obtained through senses, can be verified, is credible, is used to impart understanding

– Explaining

– Structuring


Aesthetic Knowledge

• Aesthetic knowing in nursing:

– “ That aspect of knowing that connects with deep meanings of a situation and calls forth inner creative resources that transform experience.

”

• Rehearsing

• Envisioning

• Integrating aesthetic knowledge into nursing process is important

– Result: richness, appreciation of practice of nursing as art as well as science


Personal Knowledge

• “ Person ’ s individualized and subjective ways of learning, storing, retrieving information about the world ”

• “ Pattern of personal knowing refers to the quality and authenticity of the interpersonal process between each nurse and each [client] ”

– Experiential knowing

– Interpersonal knowing

– Intuitive knowing


Ethical Knowledge

• Obligation, “ what ought to be done ”

• Theoretical/ethical knowledge

– Intellectual conception of what is good, right

– Organized into concepts, propositions formulated into judgments, rules, principles, theories

– Moral action

– Personal moral

– Situational knowledge


Ethical Knowledge (cont ’ d)

• Biomedical ethics

– Derived from models of patient good, rights-based notions of autonomy, or social contract of medical practice

• Nursing ethics

– Should be based on ethic of caring

– Must consider nature of nurse–client relationship


Ethical Knowledge (cont ’ d)

• Three different perspectives reflecting different point of view (paradigm) of how to develop nursing knowledge:

– Particulate–deterministic perspective

– Interactive–integrative perspective

– Unitary–transformative perspective

• Different ways of knowing are not judged against one another

• Comprehensive nursing knowledge must be based on integration of all ways of knowing


The Development of Nursing Science

• Defining nursing science poses challenge

• Attaining clear definition of nursing science would provide foundation for profession ’ s unique body of knowledge

• Failure to articulate nursing ’ s exact contributions to health care delivery may place profession at risk


Concepts

• Highly abstract, general “ word[s] or phrase[s] that summarize the essential characteristics or properties of a phenomenon ”

• Four concepts accepted as central to discipline of nursing:

– Human beings

– The environment

– Health

– Nursing


Concepts (cont ’ d)

• Five conceptualizations of caring have been identified:

– Human trait

– Moral imperative

– Affect

– Interpersonal interaction

– Therapeutic intervention


Concepts (cont ’ d)

• Nursing: highly complex, has various specialty areas of practice, attaining single definition for nursing concepts is extremely difficult


Theories

• Communicate links or relationships among concepts in organized, coherent, systematic way and vary in levels of abstraction, scope

• Help nurses understand how, why phenomena of nursing are associated with one another

• Effectiveness in practice directly related to ability to understand, describe, explain, anticipate human responses concerning health


Theoretical Frameworks

• Theoretical or conceptual framework:

– “ A logical grouping of related concepts or theories ”

– Provides guidance, direction for nursing research endeavors

– Tend to address phenomena more global in nature

• Developing theoretical frameworks for nursing ensures practice that considers complex nature of professional practice


Models for Nursing

• Nursing scientists proposed individual, distinctive models about interrelationships of concepts that form nature, processes of nursing

– Based on empirical observation, intuitive insights, or deductive reasoning “ that creatively combine[s] ideas from several fields of inquiry ”


Models for Nursing (cont ’ d)

• Nursing conceptual models identify interventions that nurses use in practice while explaining four central concepts of nursing:

– Human beings

– The environment

– Health

– Nursing


Summary and Significance to Practice

• Nurses

– Use variety of methods of knowing when providing professional nursing services

– Rely on personal, ethical knowing to make effective clinical judgments, decisions

• Nursing scholars

– Have general agreement on central concepts of discipline of nursing



(cont ’ d)

• Central concepts

– Help describe phenomenon of professional nursing practice

– Guide nurses

• Clinical practice

• Research endeavors

• Educational programs


Chapter 6

Nursing Models and Theories


Models and Theories for Professional

Nursing

• Four key concepts serve as metaparadigm:

– Human beings (recipients of nursing care)

– Environment (physical, social)

– Health (process or state)

– Nursing (goals, roles, functions)


Models and Theories for Professional

Nursing (cont ’ d)

• Metaparadigm

– Greek prefix “ meta ”

• More comprehensive or transcending

– Greek word “ paradigm ”

• Overall concept accepted by most people in intellectual community

• Although nursing models, theories vary according to philosophical world views, all flow from metaparadigm of nursing


Nursing Models

• Florence Nightingale

– Primary source of nursing theory, nursing science derived principally from social, biologic, medical science theories before 1950

• Model

– Provides way to visualize reality to simplify thinking

• Conceptual model

– Gives structure to, shows how various concepts are interrelated


Nursing Theory

• Theory

– Creative, rigorous structuring of ideas that projects tentative, purposeful, systematic view of phenomena

– Professional nurses

• Apply concepts, principles, theories from many disciplines


Nursing Theory (cont ’ d)

– Professional nurses

• Borrowed theories, principles fail to capture essence of professional nursing

• Practice based on models or theories allows for hypotheses about practice, which make it possible to derive rationale for nursing actions

• Testable theories provide knowledge base for science of nursing


Categories of Nursing Models and

Theories

• Growth, stability models of change

– Two world views

• Recognizes change as continuous, desired opportunity for growth to attain maximum human potential

• Persistence, which maintains that human beings strive for stability, endurance results from synthesis of growth, stability



Theories (cont ’ d)

• Growth, stability models of change

– Stability model of change

• Natural order of things revolves around consistency



Theories (cont ’ d)

• Systems Theory

– Concerned with elements, interactions among all factors (variables) in situation

– Understanding interaction among various parts of system, rather than describing function of parts themselves

• Imogene King ’ s Systems Interaction Model

(Theory of Goal Attainment)

• Betty Neuman ’ s Health Care Systems Model


Stress/Adaptation Theory as a Framework

• Provides way to understand how balance is maintained, possible effects of disturbed equilibrium

• Used to explain, predict, control biologic (physiologic and psychological) responses of human beings, serves as traditional medical therapy

– Callista Roy ’ s Adaptation Model


The Growth Model of Change

• Focuses on helping human beings grow to realize, attain full human potential

• Uses caring theory or complexity theory as underlying framework

– Dorothea Orem ’ s Self-Care Deficit Theory

– Jean Watson ’ s Human Science and Human Care

Theory


Complexity Theory as a Framework

• Emphasizes change over time, long-term unpredictability, openness to environment with mutual simultaneous interactions

– Martha Rogers ’ Science of Unitary Human

Beings

– Rosemarie Parse ’ s

Human Becoming

Theory

• Seeks to understand patterns of phenomena as wholes within their contexts

– Margaret Newman ’ s

Theory of Health as

Expanding

Consciousness

– Susan Leddy ’ s Human

Energy Model


Nursing Models in Research and Practice

• Research

– Three kinds of research related to models of nursing are being conducted:

• Testing relationships predicted by model

• Using model as framework for descriptive analysis

• Attempting to modify nursing care through use of model



(cont ’ d)

• Practice

– Nursing models, theories provide

• Guidance to nurses engaged in practice for holistic assessments

• Rationale for various nursing interventions

• Delineation of professional nursing roles in health care delivery



(cont ’ d)

• Practice

– Nursing must demonstrate ability to articulate its important, unique contribution to client care

• New models, theories may be needed



• Four metaparadigm concepts: Human beings, environment, health, nursing

• Nursing models

– Provide variety of approaches, explanations for phenomena associated with professional nursing practice

• Future research

– To see if models provide effective description of nursing, make differences in client care outcomes


Question

• Which nursing theory framework can be used to assist clients in adapting to stressors in their environment?

A.

Caring theory

B.

Complexity theory

C.

Stability Model of Change

D.

Callista Roy ’ s Adaptation Model


Answer

• D. Callista Roy ’ s Adaptation Model

• Rationale: Roy ’ s Adaptation Model specifies that the purpose of nursing is promoting a human being ’ s adaptation, the process and outcome by which thinking and feeling human beings use conscious awareness and choice to create human and environmental integration. It integrates adaptation with stimulus and coping.


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