Nursing knowledge includes philosophies, theories, and science. All three components relate to one another in the nursing process. Research and knowledge serve as a framework within which theories and philosophies develop; theories rely on philosophical thinking, which then propels nurses to theorize (McIntyre & McDonald, 2013). Individuals decide which philosophies they will live and practice by. Butts and Rich (2011) described theory as practice, for without practice there would be no theory, no questions, and no ideals to adhere to. Nurses must understand the importance of the above three components in order to propel their practice. Throughout history, philosophy has played a major role in developing the field of nursing. Philosophy shapes nurses’ identities, belief systems, and practices. Butts and Rich (2011) described philosophy as the application of beliefs to different situations that may arise, whether familiar or unfamiliar. Nurses daily encounter both routine and emergent situations; their philosophies and experiences guide them in their professional decision making. These decisions evolve and progress based on professional growth and how individual nurses’ professional philosophies have changed over time. One philosophy of science is positivism. Empiricism and positivism have often been linked to make the claim that reality can be studied and understood through research and science (Bally, 2012). Although empiricism can describe events, it lacks the ability to explain them and describe the ” why” of situations. Positivism, though adopted relatively early by the nursing field, at that point conflicted with nursing’s ideals and goals. Positivism was critiqued for lacking subjectivity, as well as for its inability to align individuals’ social and spiritual aspects with the focus of nursing (Clark, 1998). Thomas Kuhn contributed to historicism in nursing by providing insight into knowledge development that was lacking in positivism (Butts & Rich, 2011). Kuhn argued that theories and knowledge should be understood within their historical contexts (Rodriguez & Kotarba, 2009). Historicism falls into the paradigm of perceived view. The notion of 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 science history guides scientific progress (Giuliano, Tyer-Viola, & Lopez, 2005). Yet another philosophy of science is hermeneutics. Nursing itself is hermeneutic or interpretative in nature. Hermeneutics can reveal beliefs, values, and commitments (Charalambous, 2010). Nurses can be understood as interpreters of patients’ stories; nurses can interpret vital signs and subjective clues such as body language to enable better patient care. Reading patient’s histories, which employs historicism, can also play an important role in interpreting the patient or using clinical hermeneutics. Patients are not objects waiting to be interpreted; however, including hermeneutics in nursing may prove useful in moving away from more objectified nursing theories, such as positivism (Charalambous, 2010). Another philosophy of nursing that assists in moving away from positivism’s objectivity is that of feminism and critical social theory. Critical social theory, which incorporates feminist ideals, seeks to liberate individuals from both conscious and unconscious restraints (Wilson-Thomas, 1995). . Ideals from Critical and feminist theorists have not only been to explore equality and social justice but also to identify and seek reason for today’s access to health care and analyze health issues in various populations(Kirkham &. Anderson, 2010). Healthcare providers utilize critical theory through social mandates and the development of healthcare knowledge (Doucet, Letourneau, & Stoppard, 2010). The worldviews that guide nursing typically contrast with and even oppose those in the medical system (Turkel, Ray, & Kornblatt, 2012). Nursing is not just about focusing on a disease; it is also about a person’s wellness, which includes the patient’s spirituality and culture. Three worldviews take center stage in nursing. The reciprocal worldview embraces holistic nursing, incorporating spiritual, cultural, psychological, and social aspects into nursing care (Smith, 2005). In the simultaneous worldview, the person’s inner experiences, feelings, and thoughts are of interest (Fawcett, 1996). In regard to spirituality in the simultaneous worldview, nurses share the experience with their patients and aim to be present for patients through the patients’ suffering (Smith, 2005). The reaction worldview, however, is more closely aligned with the medical model and positivism; it focuses on the promotion of physical health and curing disease, whereas the simultaneous worldview focuses on the persons’ wellbeing and quality of life (Barrett, 2002).
Development of Nursing Philosophy
Theory development in nursing occurred as early as 1859, with Florence Nightingale’s Notes on Nursing: What It Is and What It Is Not. It was nearly a hundred years before nursing theory and philosophies again took center stage 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 the declaration of independence stage, occurred in the 1950s and 1960s and involved nurses’ seeking knowledge from basic sciences, as well as 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 toward a science-based academic perspective. The American Nurses Association in 1965 declared that nurses needed to be prepared at the collegiate level; this position statement set the stage for transforming nursing into a more theoretical and scientific discipline (Kim, 2010). The second stage in Kim’s (2010) framework is the formative stage, which took place during the 1970s and 1980s. Prior to the 1980s, nursing academia lacked theory instruction, which led nurses interested in theory to apply theory from other sciences such as sociology, psychology, and other educational disciplines. During this time, researchers developed nursing’s grand theories, such as Rogers’s initial work and Newman’s models, to create uniqueness among the nursing discipline by offering divergent thinking that addressed theoretical and empirical questions regarding nurse–patient interaction (Kim, 2010). The third phase, dubbed the reformatory phase by Kim (2010), took place from the 1980s to the end of the 20th century. The reformatory phase entailed the questioning of positivism in nursing and the lack of theoretical theory in patient care. It was also during this time that nursing paradigms multiplied and multiple nursing theories were unveiled. The broad concerns of a discipline are defined in a metaparadigm, which consists of the 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 integrated into nursing theory, the evolution of nursing itself has sought to include more concepts in the metaparadigm. One example is nursing theorist Watson, who argued that the nursing concept of caring should be incorporated into the nursing metaparadigm. Caring is an essential component of nursing that should be a central concept in nursing practice. While a metaparadigm identifies common areas of concern, a paradigm is a particular way of viewing practices and believes (Welford, Murphy & Casey, 2011). No one paradigm is superior to the other and all paradigms within nursing seek to inform nursing practice. Within these paradigms, nursing knowledge is derived from philosophical 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). Four sets of paradigms have been at the forefront of nursing knowledge development. Totality paradigms present human beings as striving toward optimal health through manipulation of their environment. Health can be defined as life experiences that require continuous adjustment to environmental stressors (Defeo, 1990). The simultaneity paradigm views health as a process of becoming and understands humans as in mutual rhythmic interchange with the environment (Fawcett, 1993). One difference between the two paradigms is that totality seeks to maintain an equilibrium while staying on a horizontal imaginary line, while simultaneity seeks to move vertically or find 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 while also reaching for new possibilities and potential with the patient. The particulate-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 frequently. While this paradigm is not seen as a total holistic approach, it does values more subjective information from the patient than does the particulate-deterministic paradigm. Finally, the unitary-transformative paradigm, which deviates 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 that benefits from the paradigms mentioned above.
Knowledge Development
With the awareness of nursing paradigms’ importance, it is equally important to understand the importance of knowledge development in nursing history. Barbara Carper is one contributor to nursing’s development of knowledge that continues to stimulate nursing. Carper developed what she termed ” fundamental patterns of knowing in nursing.” Carper’s four ways of knowing—empirical, ethical, personal, and aesthetic—offer a guideline used in nursing to reflect nursing practice and process understanding in daily practice. Empirics reflects on the science of nursing, aesthetics considers the art of nursing, personal knowing gains insights into self-acceptance, and ethical knowing focuses on moral knowledge. Although these fundamental patterns accurately reflect a way for nursing to develop knowledge, a fifth principal, emancipatory knowing, was introduced. Emancipatory knowing was added to the fundamental patterns of knowing to reflect nursing’s knowledge of the social context in which individuals receive care. Such knowing recognizes the significance of social and political barriers to health and well-being (Chinn & Kramer, 2011). Nursing engages in emancipatory knowing by consistently questioning why things are the way they are and whether a particular idea or problem requires change throughout the profession. Nursing has begun to use research knowledge and evidence-based practice to guide nursing and increase patients’ quality of care. An important idea to keep in mind is that subjective and objective forms of knowledge need not oppose one another but instead should work together to engage with the complex nature of nursing (Stajduhar, Balneaves, & Thorne, 2001). It is important to recognize the significance of knowing; it is equally important to recognize and be aware of unknowing. Munhall (1993) described unknowing as an ” art.” Nurses must be aware that they do not know their patients when they first meet them; by acknowledging that awareness, the nurse becomes a more active listener for the patient. Nurses who have been in practice for a while and have gained expertise in their fields may experience habitual practice. Nurses 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 practitioners’ viewpoints on situations and thus change their practices. Therefore, reflection initiates change in nursing. As practitioners, nurses need to challenge the habitual norms they may find themselves embracing in daily practice and reflect upon aesthetics in addition to empirical knowing.
Application/Synthesis for Advanced Practice
To be honest, before I embarked on graduate school—and, in particular, this theory class—I had given theories and reflection little thought. Unknowingly, I reflected upon my practice, but that reflection was never guided or structured. I now can see myself becoming more of a reflective nurse and identifying situations differently because of this reflection. My philosophy of nursing has always focused on a holistic approach that 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; I feel that each type of knowledge discussed in this paper is essential for effective nursing care. Although I do feel that empirics is important in nursing, my main focus, as laid out above, is on holistic patient care. In my practice, I tend to put more emphasis on aesthetics and personal knowing. 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 center on recognizing the health, social, and economic challenges underlying childhood obesity for underserved populations. Questions to be asked would include ” 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 in identifying childhood obesity in pediatric patients?” The implications of these questions are important to identify and recognize so that healthcare providers can educate and provide appropriate support to both families and individuals.
Summary
In conclusion, nurses around the world need to understand and reflect upon their own personal philosophies and worldviews. In order to do that, nurses must have a basic understanding of nursing’s past contributors to the theories and philosophies that have helped shaped nursing today. By discussing knowledge development and the role that different theories have played in nursing’s history, I have been able to explain my own views and understandings of my nursing practice. I aim, through the use of reflection and knowing in my practice, to succeed as a nurse practitioner who will be able to assist underserved populations around the world.
