chapter 5 patterns of knowing and nursing science

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 5Patterns of Knowing and Nursing Science


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

– Math– Counting– Philosophy of logical

positivism • Time, space were

absolute • Humans seen as having

separate psyche, soma (Cartesian dualism)

• Mechanistic world view – Determinism– Quantity– Continuity– Impersonality

• 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 painsB. Trial and error to discover cause for illnessC. Protocols and procedures to care for clientsD. 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


Approaches to Knowing (cont’d)• 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


Approaches to Knowing (cont’d)• Historicism based on these assumptions:

– Knowledge is related to context – In professional nursing, historicism provides value-

laden approach to nursing knowledge


Approaches to Knowing (cont’d)• 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


Approaches to Knowing (cont’d)• 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


Summary and Significance to Practice (cont’d)• Central concepts

– Help describe phenomenon of professional nursing practice

– Guide nurses • Clinical practice• Research endeavors • Educational programs

Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

Chapter 4

Theoretical Foundations of Nursing Practice

33Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

The Domain of Nursing Domain

Is the perspective of a profession Provides the subject, central concepts, values and

beliefs, phenomena of interest, and central problems of a discipline

Domain of nursing provides both practical and theoretical aspects of the discipline.


Paradigm Paradigm

Links science, philosophy, and theories accepted and applied by a discipline

Nursing paradigm Links person, health, environment/situation, and

nursing


Terminology Person Health Environment/situation Nursing Nursing process: Method of applying the

theory or knowledge Integration of theory and nursing process is

the basis for professional nursing.


Theory A theory contains a set of concepts,

definitions, and assumptions or propositions that explain a phenomenon.

Theories guide the design of nursing interventions.

Nursing theory Is a conceptualization of some aspect of nursing Describes, explains, predicts, and/or prescribes

nursing care


Components of a Theory


Types of Theory Grand

Broad in scope, complex, require specification Middle-range

More limited in scope and less abstract Descriptive

Describe phenomena, speculate on why phenomena occur, and describe the consequences of phenomena.

Prescriptive Address nursing interventions for a phenomenon,

and predict the consequence of a specific nursing intervention.


Theory-Based Nursing Practice Theories

Generate nursing knowledge for use in practice Can direct how to use nursing process Are adaptable to different patients and all care

settings The goal of nursing knowledge is to explain

the practice of nursing as different and distinct from the practice of medicine, psychology, and other health care disciplines.


Interdisciplinary Theories

Explain systematic views of phenomena

specific to the discipline of inquiry:

Basic human needs

Developmental

Psychosocial

Systems


Quick Quiz!

1. Nursing theories provide nurses with perspectives from which to

A. Analyze patient data.

B. Predict phenomena.

C. Formulate legislation.

D. Link science to nursing.


Models and Theories for Professional Nursing

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


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)


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 Models in Research and Practice

Research Three kinds of research related to models

of nursing are being conducted:

• Testing relationships predicted by mode

• Using model as framework for descriptive analysis

• Attempting to modify nursing care through use of model


Nursing Models in Research and Practice (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


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

Stability model of change• Natural order of things revolves around consistency


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


Categories of Nursing Models and 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


Systems Theories


Complexity Theory as a Framework Emphasizes change

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

Seeks to understand patterns of phenomena as wholes within their contexts

Martha Rogers’ Science of Unitary Human Beings

Rosemarie Parse’s Human Becoming Theory

Margaret Newman’s Theory of Health as Expanding Consciousness

Susan Leddy’s Human Energy Model


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.


Case Study Susan is a new nurse who tutors a nursing

student, Bill, who has difficulty mastering good study habits and prioritizing school assignments. Susan is helping Bill learn the theoretical foundations of nursing practice.

After Susan and Bill review interdisciplinary theories such as Maslow’s hierarchy of needs and the developmental theories, they move on to the topic of nursing theories.


Selected Nursing Theories (cont’d) Nightingale (mid-1800s)

Environment as the focus of nursing care Descriptive theory

Peplau (1952) Focus on interpersonal relations between nurse,

patient, and patient’s family Development of nurse-patient relationship

Henderson (1955, 1966) 14 basic needs of the whole person Framing nursing care are the needs of the

individual.


Selected Nursing Theories (cont’d) Orem (2001)

Focuses on patient’s self-care needs Goal is for patient to manage his or her health

problems.

Leininger (2010) Theory of cultural care diversity and universality Considers social structure factors

Neuman (2010) Based on stress and the patient’s reaction to the

stressor Role of nursing is to stabilize the patient or

situation.


Selected Nursing Theories (cont’d) Roy (1989)

Views the patient as an adaptive system When patient cannot adapt to stressors, nursing is

needed.

Watson (1996) Defines the outcome of nursing activity with regard

to the humanistic aspects of life Purpose is to understand the interrelationships

among health, illness, and human behavior.

Benner and Wrubel (1989) Caring is central.


Case Study (cont’d) Bill reads about the concept of people’s

responses and adaptation to change. The theory that views the patient as an adaptive system is ______________.


The Link Between Theory and Knowledge Development

Nursing knowledge is theoretical and practical.

The goals of theoretical knowledge are to stimulate thinking and create a broad understanding of the “science” and practices of the nursing discipline.

Experiential knowledge, or the “art” of nursing, is based on nurses’ experiences in providing care to patients.


Quick Quiz!

2. Nursing process is central to nursing practice. Nursing practice

A. Is a theory.B. Is derived from a theory.C. Is not adaptable to all patients.D. Generates knowledge for use in practice.


Case Study (cont’d) Susan quizzes Bill about the core concept of

Benner and Wrubel’s theory. Benner and Wrubel’s theory is based on the premise that persons, events, projects, and things matter to people.

True False


The Link Between Theory and Knowledge Development

Theories provide direction for nursing research.

Nursing theory and nursing research build the knowledge base for nursing, which is then applied to practice.

Theory-generating or theory-testing research refines the knowledge base of nursing.

Nurses incorporate research-based interventions into theory-based practice.

chapter 5 patterns of knowing and nursing science

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control world events

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