When we consider nursing analytically, we find numerous indications that nursing is indeed a discipline with a particular perspective and a defined domain (Fig. 6-2). As you reflect on what constitutes our disciplinary domain, keep in mind that the central problems of the domain of nurs- ing may be examined by other sciences; however, the centrality of these problems to the domain is what determines primary domain affiliation. Comforting patients during intrusive procedures may be of concern to a number of health science disciplines, but comfort of clients during all life processes related to health and illness situations, as well as the ways by which comfort is enhanced, are central concerns of nurses and nursing.
The interests of some disciplines overlap others. Engineering is an example of another disci- pline that may encounter such overlap. Premises on which the discipline of engineering is built may come from physics, chemistry, economics, and behavioral sciences, but the synthesis is uniquely engineering for the purpose of describing, explaining, and predicting phenomena cen- tral to engineering (for example, the shielding of nuclear power plants). The problem of shield- ing is central to the field of nuclear engineering, but only peripheral to physics, chemistry, and other sciences.
The nursing domain does not simply encompass the results of research (i.e., nursing science), nursing theories, or nursing practice; rather it encompasses knowledge of nursing practice (New- man, 1983), which is based on philosophy, history, former practice, common sense, research find- ings, theory, and genealogy of ideas (see Fig. 6-2). The nursing domain encompasses units of analysis, congruent methodology, nursing processes, holistic approaches to assessment, and other practice and methodological procedures that are essential to knowledge development. Central components of the nursing domain are:
• Major concepts and problems of the field
• Processes for assessment, diagnosis, and intervention
• Tools to assess, diagnose, and intervene
• Research designs and methodologies that are most congruent with nursing knowledge Theoretical boundaries of the nursing domain result from an explication of the first three components listed. Research designs and methodologies evolve from acceptable philosophical
FIGURE 6-2 ◆ The domain of nursing.
CHAPTER 6 The Discipline of Nursing: Perspective and Domain 97 principles in nursing and complement knowledge development related to the discipline’s central concepts, problems, and goals. Research designs and methodologies also help identify and develop components of the domain of nursing. (Note the theory-specific research texts and methodologies that have evolved in nursing, including research texts by Rosemarie Parse and Patricia Benner, among others [references in Chapter 20].) Also note the revolutionary methodology of grounded theory that has been adopted in the discipline of nursing for its congruency with the domain of nursing (Glaser and Strauss, 1964, 1967). Nursing theories are a component of the domain of nursing, and they provide nurses with different perspectives on nursing and nursing phenomenon.
In 1975, Yura and Torres delineated and described the major concepts used in baccalaureate programs that were central to the different conceptual models and frameworks used for nursing curricula. Four focal concepts emerged: person, society, health, and nursing (Yura and Torres, 1975). The centrality of these concepts in the discipline of nursing continued to be supported through the 1980s. For example, Newman (1983) asserted that the “domain of nursing has always included the nurse, the patient, the situation in which they find themselves, and the purpose of their being together, or the health of the patient” (p. 388). Therefore, she agreed that the major components of concern to nursing are “nursing (as an action), client (human being), environment (of the client and of the nurse-client), and health” (p. 389). Others modified the list to exclude environment (Barnum, 1994), or they expanded the meaning of “person” to encompass both human being and patient (Barnum, 1994), or they redefined “client” to mean “pluralities of per- sons and internal units, such as families, groups, and communities” (Schultz, 1987, p. 71). Nurs- ing theory, it was argued by some, could include one or more of these concepts (Fawcett, 1989);
for example, client, society, health, or nursing. Or, others argued, nursing theories should include the concept of nursing as an activity, in addition to any one of the other concepts (Flaskerud and Halloran, 1980), such as any set of “commonplaces” (nursing act, patient, health, nurse–patient relationships, nursing acts and health, and patient and health). These “commonplaces” differenti- ate nursing from other disciplines (Barnum, 1994, pp. 14–15). Still others emphasized that nurs- ing theories should include health and the direction for nursing actions to facilitate the processes of health (Newman, 1983, p. 390). Although variations occurred in the recommendations of metatheorists in what, how many, and which central concepts should be included in nursing theo- ries, none objected to the inclusion of all domain concepts—if indeed a theory is able to address them all. The position adopted in this text has its own unique features also, but it falls within gen- eral patterns of agreement within the discipline (Meleis, 1986). Concepts identified as central to the domain of nursing are included in Box 6-1.
It is proposed that the nurse interacts (interaction) with a human being in a health/illness sit- uation (nursing client), who is in an integral part of his sociocultural context (environment), and who is in some sort of transition or is anticipating a transition (transition); the nurse–patient interactions are organized around some purpose (nursing process, problem solving, holistic assessment, or caring actions), and the nurse uses some actions (nursing therapeutics) to enhance, bring about, or facilitate health (health).
It is argued here that theories developed relative to any of the concepts listed in Box 6-1 are nursing theories when the ultimate goal is related to the maintenance, promotion, or facilitation of health and well-being, even though the theory may not specify nursing actions. It is also argued
BOX 6-1 CONCEPTS CENTRAL TO THE DOMAIN OF NURSING
Nursing client Nursing process Nursing therapeutics
Transitions Environment Health
Interaction
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that nursing is an encompassing concept that includes all the concepts listed in Box 6-1 and is therefore defined by them. It would be an instance of tautological conceptualizing to define nurs- ing by all its concepts and then include nursing as one of the concepts. Other disciplines may use nursing theories for different goals; as such, nursing theories lose their original goal, becoming adapted, “shared” theories (Barnum, 1994).
A conceptual definition is provided for each of the central concepts in nursing. These defini- tions, evolving from contemporary shared knowledge in nursing and from a current worldview, are provided as working definitions. The reader should use them as a springboard for further development and refinement.
The Nursing Client
The most central concept within the domain of nursing is the recipient of care or the potential recipient of care––the nursing client. Although a client is also central to a number of other disci- plines, the perspective from which that client is considered is invariably different and evolves from the domain of the discipline. Please note that the nursing client has been used to define a patient and a consumer of care. Note also that, in the United States, a definition of professional nursing has in it a return to the concept of patient rather than client or consumer (ANA, 2003).
Nurses have claimed that individuals are the focus of their actions ever since nurses began caring for patients and ever since they attempted to describe the care they provide. For example, Nightin- gale described nursing as having to “put the patient in the best condition for nature to act upon him” (Nightingale, 1946, p. 74). Others spoke of nursing in terms of helping individuals develop their self-care activities (Orem, 1988) and doing what needs to be done to help individuals adapt to their illness or environment (Roy, 1984). Newman and her colleagues defined a client as a per- son who is primarily identified by a pattern of consciousness that also incorporates a sense of recognition of how they fit within a larger system (Newman, Smith, Pharris, & Jones, 2008).
To illustrate, when a physician thinks of a person, the image is one of biologic systems with structure and function. That image may include a person’s occupation, family, socioeconomic class, or other variable; however, the central image is of a biologic system. When a sociologist thinks of a person, she thinks of the roles, status, interaction, and significant others of individuals as part of a society. When a psychologist thinks of a human being, she thinks in terms of intrapsy- chic processes. A human being to a cell biologist is made up of groups of cells.
Who the clients are and how they tend to define and interpret their patient status will drive theoretical nursing in the future. Clients have become more informed over the years, and they are vocal about what they need from their health care providers. Clients are embedded in multidimen- sional and dynamic contexts that are constantly changing (Reed, 1995). Theories that have defined clients as passive recipients of care or as human beings who are waiting for information, and those theorists who assumed that the nurse’s role is to ensure compliance are no longer con- gruent with how clients define themselves (Allen, 1987). Clients come to the health care system either with their consciousness raised about their rights for information, care, and participation in decision making, or if they do not come with such expectations, the caring encounter may then include opportunities for consciousness-raising. In either case, theories for the future must be developed to reflect changing assumptions about clients and their levels of awareness and con- sciousness, and they must also provide some strategies by which consciousness may be raised within the value and belief systems of these clients.
Nurses deal with much more diversity in clients than has been the case historically. Client diversity, with regard to gender, race, ethnicity, or religion, has always been, to a certain extent, a hallmark of health care practice; however, at the turn of the century, diversity has taken on another, more significant meaning because it comes with attached questions about the melting pot model of integration. Clients assert their identities, whether that identity is related to ethnic background or to sexual orientation. Clients are saying, “We like who we are, we do not want to assume or pre- tend otherwise, and we want to be respected and treated with sensitivity and with competence that includes our value systems and beliefs.” This assertion requires different assumptions and differ- ent propositions that must be reflected in future nursing theories.
CHAPTER 6 The Discipline of Nursing: Perspective and Domain 99 In addition, many world events are increasing transitions of people between countries and within countries through immigration and emigration. These transitions profoundly influence the health care and health outcomes of populations. The world’s population is increasingly eld- erly, and this brings with it a corresponding increase in health care needs, since the elderly require different types of expertise from nurses. Nurses are also needed to help individuals live and cope with long-term illnesses. Who the clients are, how they respond to their situations, how society has defined them, and how they define and redefine themselves are questions that can be answered only within sociocultural, economic, and political contexts. Attention to these questions and their answers could increase the power of theories to explain responses to health care.
Nursing theories claim that nursing focuses on the person whose needs are not met because of illness or the person who needs help in maintaining or enhancing wellness. Nurse theorists pro- vide us with several views of our clients. A nursing client probably is a composite of all of the con- ceptions provided by these nurse theorists, and perhaps the context determines which image is more central at any one time. Some of these conceptions are complementary, whereas others are based on conflicting value systems. The following are some examples of nurse theorist’s concep- tions of the nursing client:
• The nursing client has a set of basic human needs (Abdellah [1969]––21 problems; Hen- derson [1966]––14 daily activities; Orem [1988]––the deficit between self-care capabili- ties and self-care demands). The focus of nursing is on assisting with activities to fulfill the client’s needs.
• The nursing client is an open system, an adaptive being who changes to accommodate out- side changes.
• The nursing client is conceptualized as a person in disequilibrium or at risk of disequilib- rium due to insufficiency or incompatibility between one or more of his or her subsystems.
• The nursing client is a person who is unable, or is at risk of being unable, to be a self-care agent.
• The nursing client has a lifestyle that may render the person vulnerable or resistant to health risks.
These theories provided us with varied conceptions described in the social policy statement of the American Nurses Association (2003). These conceptions should be used as guidelines for analyses to determine their congruency with the values and mission of the discipline (Allen, 1987). A nursing client is defined in this book as a human being with needs, who is in constant interaction with the environment and has an ability to adapt to that environment but, due to illness, risk, or vulnerability to potential illness, is experiencing disequilibrium or is at risk of experienc- ing disequilibrium. Disequilibrium is manifested in unmet needs, inability to take care of oneself, and nonadaptive responses. More contemporary definitions are of “human living” (Willis, Grace, and Roy, 2008) and “human dignity” (Jacobs, 2001).
Theoretical developments of phenomena related to nursing clients encompass but are not limited to six areas.
1. Research and theories to describe philosophical principles governing views of human beings in nursing, including analyses of values and norms related to human beings and their relationships
2. Research and theories that relate to the fundamental process of responses to human and environmental conditions that are considered within normal ranges
3. Research and theories to describe, explain, and predict responses of human beings’ health and illness situations
4. Research and theories to describe human responses to nursing therapeutics
5. Research and theories to describe groups, communities, and organizational responses to health and illness and nursing therapeutics
6. Theoretical development of person models that are congruent with the disciplinary values
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The nursing client is increasingly defined by his or her experiences (McIntyre, 1995). These experiences are expressed and related to others in continuous and discontinuous ways, in isolation or within a context, and are expressed through narration and various responses, whether verbal, written, nonverbal, or through silences. Experiences can be uncovered and understood through involvement and participation in dialogues and discourses.
One of the discipline’s immediate goals is to discover and develop techniques and method- ologies to capture the holistic nature of human beings and the nature of integrated responses to the environment that are considered central to the domain of nursing. It is also to develop ways by which the nature of the lived experiences of human beings can be accessed, captured, and used as the basis for caring for people (McIntyre, 1995). Until this goal is realized, nurses may have to continue to resort to a more reductionist approach to the study of clients. However, a focus on lived experiences must include the presence of the body in the analyses. Experiences and responses to pain and illness are the embodied experiences of a person that include their physical bodies (McDonald and McIntyre, 2001). McDonald and McIntyre (2001) go even further with a warning that the body of patient and nurse included in the development of knowledge must not be objective and stripped from the synthesis of emotion and physicality. Another goal is to focus knowledge development on populations that have been marginalized, in the health care systems in particular and in society in general.
Examples of the types of theories that need to be developed are:
1. Descriptive theories (e.g., patterns of normal responses)
2. Explanatory theories (e.g., how and why different groups of clients respond in certain ways to noxious stimuli)
3. Prescriptive theories (e.g., how and in what ways nurses enhance a sense of comfort or well-being in clients)
Transitions
Nurses deal with people who are experiencing transition, anticipating transition, or completing the act of transition (Chick and Meleis, 1986; Meleis and Trangenstein, 1994). Transition denotes a change in health status, or in role relationships, expectations, or abilities. It denotes changes in needs of all human systems. Transition requires the person to incorporate new knowledge, to alter behavior, and therefore to change the definition of self in social context. Transitions are developmental, situa- tional, or health/illness events. Two significant developmental transitions may be associated with health problems (both psychosocial and biophysiologic): the transition from childhood to adoles- cence, which has the potential of being associated with ensuing problems such as substance abuse and teen pregnancies; and the transition from adulthood to mature adulthood, a period accompanied by gerontologic problems relating to identity, retirement, and chronic illness (Schumacher and Meleis, 1994). (See Chapter 17 for a comprehensive discussion of transition as a middle-range theory.)
Another transition falling within the domain of nursing is the situational transition, which includes the addition or loss of a member of the family through birth or death. Each situation requires a definition or redefinition of the roles that the client (a person or a family) is involved in.
The transition from a nonparental role to a parental one, the change from double parenting to sin- gle parenting, and the attempts of women to move from the battered role to the nonbattered role are three examples of situational transitions that affect a human being in totality, although we are concerned with them in terms of health. Nurses are also concerned with the transition from insti- tutional care to community care.
The last, but not least important, transition category is the health/illness transition. This cate- gory includes such transitions as sudden role changes that result from moving from a well state to an acute illness, from wellness to chronic illness, or from chronicity to a new wellness that encom- passes the chronicity (Tornberg, McGrath, and Benoliel, 1984). Transitions are therefore one component of the nursing domain. There is evidence that transitional care of patients who are dis- charged from hospitals and whose care requires advanced nursing practice enhances their healing and recovery (Naylor, 2002).
CHAPTER 6 The Discipline of Nursing: Perspective and Domain 101 The sociologist, psychologist, biologist, and physiologist are all interested in transitions at the micro and macro levels, and the objective of their interest is to know. Because domains are not only identified by the types of objects with which they deal but also by the questions they ask, the different domain interests can be differentiated by considering types of questions that nurses ask. Only the nurse is interested in articulating transitions that are biopsychosociocul- tural––not only to know, but ultimately to have knowledge of the utility of what we know and, in particular, to have ways to effectively use that knowledge in enhancing individuals’ healthy tran- sitions. Unlike other academic disciplines, nursing is accountable to the public; it is expected to meet the public’s needs.
An example of a multidimensional transitional interest is my own interest in the health care of immigrants, which arose from the needs of health care systems dealing with this population and the need for a broader knowledge base to support the provision of culturally competent care. It concerns immigrants in sociocultural transition, and it considers the effect of transition on clients’
biologic, psychological, sociological, and cultural needs and the effect of transitions on health behavior, illness behavior, illness episodes, and coping styles of any group of immigrants to the United States. The interest evolved from a nursing perspective, uses a sociological model, and will add to the domain of nursing.
Nursing does not deal with the transition of an individual, a family, or a community in isolation from an environment. How human beings cope with transition and how the environment affects that coping are fundamental questions for nursing. Nursing seeks to maximize clients’ strengths, assets, and potentials or to contribute to the restoration of the client to optimal levels of health, function, comfort, and self-fulfillment. Coping and adapting are multidisciplinary and interdisciplinary con- cepts. The menopausal experience, for example, is a developmental transition and a multidomain concept. Although research in nursing considers menopause from a biopsychosociocultural perspec- tive, the sociologist looks at it in terms of societal expectations, with the roles and status normatively accorded the menopausal woman. The psychologist views menopause from an intrapsychic perspec- tive; the physician views it in terms of changes in cells in the endocrine system. The nurse researcher considers the subjective meaning of the entire experience, what biopsychosociocultural variables influence that meaning, what the consequences are for the person, as well as for that person’s signif- icant others, how the person is adapting to changes, and, finally, how the nurse can help the menopausal woman cope with the experience, if indeed there is a need to do so.
Although each nurse researcher considers the nursing phenomenon according to the basic premises of the field and according to a total view of the human being, the goals of research will dic- tate the dominant model. For example, one nurse researcher conceptualizes phenomena predomi- nantly from a physiologic model, whereas another may use a sociological model. Both explicate nursing phenomena and work toward the goals of enhancing healthful living, an adaptive stance, and a higher sense of well-being. Both are adding to the nursing conceptualization of an experience.
Theories are needed to describe the nature of transitions and normal patterns of responses to transitions, to explain relationships between transitions and health, and to provide guidelines for enhancing a perception of well-being.
Relationships and Interactions
Relationships are emerging as a defining aspect of the domain of nursing or—as described by Newman, Smith, Pharris and Jones (2008)—as the central focus of the discipline of nursing, or indi- rectly as a unifying focus for the discipline (Willis, Grace, and Roy, 2008). Some theorists focused on the process of building relationships and on the tools of assessment, and, therefore, viewed nurs- ing as a relationship and an interaction process. Relationships are formed through interactions, and together they provide us with the genesis of one or more interaction theories. These theorists spoke of the properties of the nurse–patient dialogue, of therapeutic interaction, and of the components of interacting as being the sensing, perceiving, and validating of the patient’s need for help and the shar- ing of information. They explicated properties of perception, thought, and feelings during health and illness situations. Together they provided us with a framework that contains major concepts central to nursing. Theories relating these concepts could come from inside or outside nursing. They could
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