foumal of Advanced Nurstng, 1993,18,1651-1656

The discipline of nursing: historical roots,current perspectives, future directionsMaureen C Shaw RN MNClimcal Nurse Spectaltst, The Arthntis Society (BC and Yukon Divtston), 895 West 10thAvenue, Vancouver, Bnttsh Columbia, WZ 717, Canada

Accepted (or publicahon 15 Febniary 1993

SHAW M C (1993) Journal of Advanced Nursing 18 ,1651-1656

The disapline of nursing: historical roots, current perspectives, futuredirectionsAs advances m nursmg saence and research impact upon nursmg education and

climcal pradice, new ways of looking at phenomena have led to a re-exammation

and refmement of the traditional concepts person, environment, health and

nursmg This evolving pattem of mtellectual growth holds promise for the

disaplme of nursmg through the advancement of knowledge based upon

saentific mquiry mto the practice of nursing This paper discusses nursmg as a

disaplme by examinmg the development of a unique body of knowledge from

three viewpomts histoncal past, current perspectives and future direction

HISTORICAL ROOTS

The disaplme of nursing slowly evolved from thetradihonal role of women, apprenticeship, humamtananaims, rehgious ideals, intuihon, common sense, tnal anderror, theones, and research, as well as the multipleinfluences of mediane, technology, pobhcs, war, economicsand femmism (Jacobs & Huether 1978, Keller 1979, Brooks& Kleme-Kracht 1983, Gorenberg 1983, Perry 1985, Kidd& Momson 1988, Lynaugh & Fagin 1988)

The first nurse-theonst, Florence Nightmgale (1969),viewed nursmg as havmg organized concepts and socialrelevance distinct from mediane Later, Henderson (1965)descnbed nursing as a umque, complex service withmdependent practihoners who were authonhes on nursingcare

More recently, Roger's (1970) hohshc interpretationsof persons have become a cntical pomt of departure inadvanang theory by defining nursmg as an art and asaence and by providing a substcintive base for theorytestmg

In a landmark paper, Donaldson & Crowley (1978)define a disaplme as 'a umque perspechve, a dishnct wayof viewmg all phenomena, which ultimately defines thelimits and nature of its mquiry' Smxx the hme of Florence

Nightmgale, nurse-scholars have sought to explore, under-stand and explicate the concepts central to the domam ofnursing person, health, environment and nursmg Themesdelunitmg the boundary for nursmg practice and investi-gation include (a) laws and pnnaples govermng lifeprocesses and well-bemg of humans, (b) influences of theenvironment on human behaviour, (c) processes wherebynursmg posihvely affeds health, and (d) families andcommumties as a focus of nursmg practice (Donaldson &Crowley 1978, Fawcett 1984)

A recent review of the hterature suggests a consensuson the recurrent themes and commonalities central tonursing's domam of mquiry (Donaldson & Crowley 1978,Ellis 1982, Bramwell 1985, Meleis 1987)

Hallmark of success

Consistency over time regarding the ldentifieation of theboundary and domam of nursmg is not orJy a strength ofthe discipline but also a hallmark of success m nursmgresearch and theory development As such, it is time toextend formal acceptance to the domain concepts andboundanes as a paradigm germane to a disaplme ofnursmg

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Currently, nurse educators, scholars, dmiaans andresearchers contmue to contnbute to the disaplme'scomerstone by danfymg the work and role of nursmgin health care and advanang nursmg knowledge from astate of haphazard, unvenfied thoughts to a disaplme ofsystemahcally organized concepts (Table 1)

CURRENT PERSPECTIVES

Despite a growmg consensus on a nursmg paradigm, thedefinihon of nursmg as a disaphne remams ambiguous(Hardy 1978, Jacobs & Huether 1978, Meleis 1987,Northrup 1992) Hardy (1978) bebeves dissent is charac-tenstic of nursmg's preparadigmahc stage of saenhficdevelopment where confusion and dispute over theory andresearch are a normal developmental stage However,Hardy's attempt to measure the performance of nursmgagamst saenhfic advances germane to medical science hasresulted m a negahve, hnear estimate of nursmg as a disa-plme and fculed to recognize nursing's unique contnbutionsto the health care of soaety

Moreover, nursing may not expenence penods ofnormal saence, such as those outlined by Kuhn (1970), andmay conhnue to evolve indefinitely Rather than argumgthe disaplinary status of nursmg, the queshon, as posedsuccmctly by Perry (1985), is 'Has the disaplme of nursmgdeveloped to the stage where nurses do "think nursmg'T

Numerous theones and conceptual models have beenadvanced smce the 1960s in order to assist nurses to sys-tranahcally thmk nursmg To Meleis (1987) theory is apowerful, dynamic, yet focused, source of professionalautonomy and dmical knowledge Rather than a saentificrevolution or evoluhon, the development of nursmgknowledge is an unconvenhonal, convoluted process(Meleis 1985).

It could be argued that a straight road to a convenhonalparadigm would mark nursmg's acceptance mto the saen-tific community However, the advancement of nursmgtheory cannot be measured m the same manner as thephysical, pharmacological, medical or psychological sa-ences Smce nursing has adopted many competmg andcomplementary theones (Meleis 1985), the debate on theworthmess of these theones wiU conhnue to contnbute tothe scholarly development of nursing as a disaplme overtime

Scholars fi-om Hardy (1978) to Northrup (1992) haveadvocated completmg theones and adophng a specificparadigm m order to bnng consensus and cohesion to thedisaplme of nursmg On the other hand, recent authors(Meleis 1987, Banett 1992) propose diversity and pluralitym nursmg philosophy, saence and practice From a dimcal

perspective, not only is adoption of a specific perspechveunlikely m a disaphne that understands mulhdimensional,complex human behaviour, but theorehcal consensus is quiteunlikely m a disaplme that values the role of percephons,uniqueness and individuality m health and illness

Smce nurse-theonsts have mdividual approachestowards life, healthy differences of opmion will contmueto exist and to fuel the scholarly debate in the futureregardmg nursmg's ontoiogical and epistemological aimsIndeed, nursing has now tumed to philosophy for assist-ance with appropnate strategies congruent with nursmg'sassumptions and missions (Meleis 1992)

Challenge to completed-theory perspective

Meleis (1987) challenges the perspechve that completedtheory is the only way to achieve disaplinary status andthat outcome is the sole validation of theory The end-product — 'the process of conceptualizmg a phenomenon,the process of understanding a dimcal situation and theprocess of going beyond the data m a research project'(Meleis 1987) — is the essence of theoretical developmentTheones-m-process are not the mcomplete manifestahonsof an unsystematic, haphazard mquiry, they connectnursing's ontological concems with the paradigm's domainconcepts

In knowledge development, theonzmg is not an orderlyprogression of thought, but a process of cnhcal thinkingcharged with difficulty and ambiguity Furthermore, thisscholarly process has lead to the formahon of the domamconcepts and ldentificahon of the boundanes of nursmgwhich, in tum, have further coalesced mto a paradigm thatforms the base for the disaplme of nursmg as known today

The recent literature on canng illustrates how nursmgscholars conhnue paradoxically to queshon the limits, yetadvance the boundanes, of a disaplme of nursmg Watson(1988) developed the concept of canng as a central tenetm her nursmg model Leuunger (1981) descnbes canngas the unifymg domam for nursmg's body of knowledgeand prachces, while Swanson (1991) proposes carmg as atheory of social process that is essenhal, but not unique tonursing

Indeed, to many nursmg theonsts, canng provides anessenhai, unifying lmk withm the paradigm concepts(Barrett 1992) However, although carmg and health arecentral to nursmg, an mtegrahng statement has not beendeveloped and the concepts cannot stand alone to meet thecntena for the focus of the disaplme (Newman et al 1991)

Moreover, the addihon of carmg to the domam conceptsraises questions about the artifiaal and reductionisticseparahon of carmg, knowmg and domg withm nursmg's

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response to the human expenence of health Indeed, ifcanng is cenfral to nursing, can knowing be separated fromdoing withm the nurse-dient relahonship?

Perfiaps the disaplme's evolving perspechve and con-ceptualization of the phenomena will define whether canngbecomes incorporated mto the domam concepts or remamsas a theory that substanhates nursmg's profound ability toassist dients to find meanmg m the expenence of healthand illness

An art with humanitarian aims

Despite extensive literature on theoretical development(Meleis 1992, Mitchell 1992, Randall 1992, Ray 1992), thedisaplme of nursmg is a philosophy of persons and theirhealth expenences, that is, nursmg is also an art withhumamtanan aims Benner (1984) descnbes excellence mdimcal prachce based on perceptual awareness, sensihvityand cogmhve skills The unique synthesis of the art ofcanng and the empinasm of saence distmguishes nursingfrom other health professions As such, the development ofdisaplme-specific perceptual and conceptual skills providesone way of mamtainmg a imique nursmg focus Thus, afranscending philosophical perspechve, rather than aspecific methodology, is charadenshc of the disaplme ofnursmg

However, perception can contnbute towards staticbehefs regardmg the uneasy, sometimes dichotomous, re-lahonship between nursmg theory, prachce and researchSome authors believe theory is developed from researchbased on dimcal prachce (Engsfrom 1984, Bramwell 1985),while others advocate the advent of pure saence withoutimmediate relevance to prachce (Donaldson & Crowley1978, Bohny 1980)

This debate is made more complex and polanzed by therecent references m nursmg hterature to the purposes oftheory development Is theory 'of nursmg or 'for' nursmg?According to Barrett (I99I), the issue is whether or notnursmg is viewed pnmanly as a basic or an applied saenceAs a basic saence, theory, research and practice focus onknowmg what is umque to nursmg On the other hand, asan applied saence, the focus of the disciplme is on thepractice of nursing

However, queshons about knowing and doing innursmg are another twist to the debate regardmg theorydevelopment that has been simmermg in the literature forthe past 35 years Differences m these posihons have theirroots m the debate concemmg unique versus borrowedknowledge as the comerstone of the disaplme of nursing(Barrett 1991) Rather than danfymg the issue, the morerecent confroversy regarding the simultaneity vereus the

totahty paradigm approach to theory development hasadded fuel to the debate

Theonsts in the simultaneity paradigm (Rogers 1970,Parse 1981, Newman 1986) advocate the theory 'of nurs-ing view expliatly and call for theory development that isconcemed with imitary, irreducible human beings and theirenvironments

In the totality paradigm, theonsts such as Roy (1984)and Orem (1985) advance the theory 'for' nursmg view andcall for the development of specialty-focused theory fordimcal populations Yet, knowledge advanced withm onetheorehcal perspechve does not belong to a speafic para-digm If discovery conferred ownership, then knowledgegenerated from von Bertalanfify's General Systems Theoryand Selye's theory of sfress would be unavailable to thedisaplme of nursmg

Practice discipline

Despite their apparent polanty, these theorehcal perspec-hves are not m opposition if nursmg is conceptualized as apractice disaplme with a mandate from soaety to enhancethe health and well-being of humaruty Surely, the goal ofnursmg theory is to contnbute to the wealth of knowledgerequired for dmical practice in a vanety of settmgs Whenpractihoners, scholars and researchers achvely engage mcreatmg dynamic and workable soluhons to dmical andempincal problems of significance to the health of soaety,then mtegrahon of theory, research and practice maybecome a reality Indeed, the upcoming era of theorydevelopment and refinement from a nch tapestry of theor-etical perspechves and research methodologies may fulfilnursmg's quest for ldenhty and self-acceptance as a prachcedisaplme

FUTURE DIRECTIONS

In response to the challenge of humanism and the holistichealth care movement, nursmg research is more directedtowards enhanang the understanding of dients and theirenvironments Genmngs 1986) Furthermore, Fawcett(1984) beheves that empinasm may be mcompatible withnursmg's humamshc and holistic aims

The nursing literature is replete with papers outhnmgthe worth of objechve and subjechve methodologies to thedisaplme To Maturana & Varela (1988) the soluhon tothis paradox is to move away from the opposihon, and tochange the nature of the queshon m order to embrace abroader context, that is to walk the razor's edge If thedisapluK of nursmg is dedicated to excellence of carethrough the advancemoit of knowledge, then to reject

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quantitahve research methods due to fear of dehumanizingpatients with redudionist methods would be an epistemo-logical error

Both mduchve and deduchve methods are valid methodsof furthermg nursmg knowledge Moreover, developmentand refinement of the substanhve body of knowledge canaddress dmical concems and ultimately enhance care ofclients m numerous speciality areas of nursmg pradice

While research is essenhal to the development of nursingknowledge, educahon of prachtioners withm a nursingperspedive is of vital importance Structuring educahonaround a nursing paradigm, rather than tradihonal medicaldassiAcahon of disease, would aid m the socializahonprocess of novices and encourage nurses to think nursmg

However, nursmg m North Amenca is the only healthcare disaplme with diverse entry routes Smce educahonalconstramts may prevent nurses from usmg theorehcalknowledge, further educahon at the baccalaureate, master'sand doctoral levels may equahze some of the powerstruggles withm heeilth care, enhance the credibility of thedisaplme of nursing, and improve the ability of prac-titioners to test, evaluate and utilize theoretical knowledge

Society and the consumer

Soaal relevance and value onentahon defme the disciplineof nursing as much as empmcal knowledge (Donaldson &Crowley 1978) As such, soaety can be a powerful ally inthe pursuit of nursmg knowledge Therefore, consultationwith the consumer regardmg goals and diredion for nurs-mg research, theory development and dient-centred modelsof care is essential if the disaplme is to mamtam its humam-tanan aims Indeed, soaety's self-help movement representsthe trend towards self-care and a shift towards greater clientautonomy and self-determination m health care

As nursing approaches the twenty-first century, nursmgtheory development must consider the changmg needs ofdmical populahons Alliance with the health care consumerwill ultimately benefit the disaplme of nursing by openmgup new avenues for theory development and nursingresearch

Moreover, nursing's quest for autonomy and account-ability can be synthesized with the trend towards establish-mg and maintaining optimal dient outcomes m healthcare It is anhapated that the present emphasis on dientoutcomes and programme evaluation will enhance thefuture development of nursing knowledge by utilizingtheones and methodologies developed m nursmg andother disaphnes

Nursing has become mcreasmgly explicit m defmmg thenature of its domam m a multitude of prachce areas For

example, a cnhcal appraisal of the application of theory,developed withm nursing and other disaplmes, to a vanetyof settings where nursing is prachsed is now becommgevident m the nursmg administration literature (Henry et al1989, Lutjens 1992) As such, with the increase m a sub-stantive knowledge base and vabdation and refinement oftheones through multiple modes of mquiry, a pluralism oftheones is emerging (Fawcett 1984)

Nursing can no longer ignore the challenge to definethe disaplme m terms of knowledge based upon nursmgtheory and to appraise knowledge from other disaphnesfor utility withm nursmg This cannot be done from theivory towers of academia, admimstration or pradice with-out consideration of the perspedive of the health careconsumer Commumcahon through debate and construc-tive feedback is not only essential to define and refine anursing paradigm, but also to extend the boundanes ofnursmg mto the unexplored temtory of the twenty-firstcentury

CONCLUSION

In order to chart a course mto the future, a disciplineof nursmg must encompass a proachve approach to thedevelopment of theory that not only arcumnavigates thepresent debates, but also bridges the worlds of research,theory and practice

Advanang a disaplme of nursmg is complex, convolutedand dynamic process The next century will provide nursingvnih an opportumty to think nursmg, that is, nursmg willtreinscend the philosophy and knowledge of the disaplmebeyond the present boundanes

As Cicero (cited m Nulle 1980) wrote m 52 BC, 'reasonenables us to draw inferences, to prove and disprove, to

discuss and solve problems, and to come to conclusions'Surely, this Roman scholar has provided a modem mandatefor a disaplme of nursmg

Acknowledgements

The author wishes to thank Dr M Munro RN PhD, Dean,Faculty of Nursmg, Umversity of Pnnce Edward Island,Charlottetown, Pnnce Edward Island, and Ms Bev Hills RNMS, Manager of Nursmg and Laboratory, Arthntis Soaety(BC & Yukon Division) for their support and helpfulcomments on earlier drafts of this paper

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