Abstract
This paper presents that there are many paradigms of nursing science, but all share the four main metaparadigm concepts of nursing. These metaparadigm concepts are person (individual patient), health, nursing (as an action), and environment. A fifth metaparadigm, social justice, is added and introduced as it provides a focus for urban health nursing and to ensure that health resources are distributed fairly so that the marginalized can benefit and the privileged can have constraints. Nursing metaparadigm is defined and its relevance to identifying concepts that are unique to the nursing profession is pointed out. The five metaparadigms of nursing is explored by the author in relation to what it means to him and examples from his nursing practice has been provided.
Keywords: Meaning of Nursing, metaparadigms of nursing, social justice
Meaning of Nursing
There are multiple paradigms of nursing science, but there is a consensus among nursing scholars that there are four central concepts of nursing and they are: Person, environment, health, and nursing (Fawcett, 1984, p. 84; Monti and Tingen, 1999, p. 64). Schim, Benkert, Bell, Walker, and Danford (2007), faculty members coming from different nursing specialties have reviewed the four metaparadigms and add a fifth metaparadigm, which is social justice (p. 73). Nursing metaparadigm describes phenomena (values and belief) through a global perspective; highlighting what is unique to the nursing discipline, and what differentiates nursing from other disciplines (Monti and Tingen, 1999, p. 64). This paper explains what the five metaparadigm concepts mean for me and how it applies to my nursing practice.
Person
Person is defined differently by many theorists, some would even consider the family and the community as a focus, but the concept of person should always be defined as the “individual person that is the focus of nursing attention” (Thorne, Canam, Dahinten, Hall, Henderson, and Kirkham, 1999, p. 1258). As a nurse, I see my patients/clients as a “whole”. They are not merely recipients of care and their disease process does not define them. My practice can be described as aligned with the participatory paradigm, as I see my patients as “partners in care” and they are not objects or “bed blockers”. Florence Nightingale had a holistic view of a person, where she describes a person as “multidimensional, being composed of biological, psychological, social, and spiritual components” (Selanger, 2010, p. 85). In my nursing practice, I always use the P.I.E.C.E.S. assessment framework, where I assess the physical, intellectual, emotional, cognitive, environmental, and spiritual/social aspects of my patient. I see my patient as multidimensional. The only way that I will be privileged enough to get to know my patient more, is if I develop a therapeutic relationship with my patient. Although my focus is my client, I always consider and involve my client’s family and support system, as this provides me helpful collateral information, especially if my client have signs and symptoms of dementia, or has poor insight into their situation.
Environment
Fawcett (1984) described environment as “the context of an individual’s surrounding environment and how it influences individual’s behaviors” (p. 85). Chopoorian (as cited in Schim et al., 2006) expands this definition and includes the political and economic structures in the context of environment that affects the individual (p. 75). Nightingale was a strong proponent of how altering the environment could lead to good health outcomes and would allow “healing to occur” (p. 83). This resonates strongly in my practice. As a system case manager with Home Living (Home Care), a client’s geographical location dictates the quality and quantity of services that they receive. Clients in the rural parts of the Edmonton Zone will receive less visits in a day as health care aides are not willing to drive long distances, as compared to the urban parts of Edmonton where services can be guaranteed as there is a high number of workers available in the city. The socioeconomic aspect of a client’s neighborhood can also affect the number of visits that they will receive. Health care aides tend to refuse to work in the evening for neighborhoods deemed unsafe and they will not enter homes that are unsanitary and are in disrepair. Even hospitals have different services available to patients, as determined by geography. Patients who have substance abuse issues can only receive extensive follow-up by a specialized team who focus on harm reduction and community follow-up, in hospitals in the inner city. If a patient goes to any other hospital, abstinence is always the approach or the issue is not addressed at all. As a practitioner that deals with home safety assessments and accessibility, one barrier to a safe discharge home are stairs if a person is wheelchair bound and the lack of other equipment. The environment and my ability to authorize services for a postal code, is an important determinant if a client should be placed in a higher level of care or barrier-free home.
Health
The concept of health is dynamic and can be best described as an individual or personal process (Schim et al., 2007, p. 75). Health is not the absence of disease, but rather a state of ultimate and optimal health at any given point in time (Selanders, 2010, p. 85). In my undergraduate studies, I have been taught that health is subjective and the definition is unique to everyone and that health is relative and not an absolute. Parse (as cited in Thorne et al., 1998) supports this and states that “quality of life cannot be separated from the person’s lived experience and thus can only be described, at the moment, by the person living the life” (p. 1261). I have encountered many individuals who definitely had very different views of health from myself. I once had a client who refused to be placed in supportive living, despite her being qualified and having the finances to do so. She is medically frail and had end-stage chronic obstructive pulmonary disease. She is on oxygen supplementation and continues to smoke cigarettes and drink alcohol. She knows that she needs the help and needs to move somewhere more supportive but she refuses to do so as she does not want to part with her pet cat. For her, this is her optimum level of health, being at home and not being in hospital or a care facility. She believes that moving to a different environment “would be the end of her” as she wouldn’t be with her pet that she considers her family as she has no one else in her life.
Nursing
Nursing here is used as a verb, it is the act of nursing. Fawcett (1984) affirms that the theories in this metaparadigm attempts to describe or explain nursing process or predict the effects of nursing action (p. 85). Nightingale adds that “the goal of nursing is to place the patient in the best possible condition for nature to act” (as cited in Selanders, 2010, p. 86). As I previously mentioned under the metaparadigm of person, Rogers (as cited in Reed, 2013) describe “nursing is a participatory process that transcends the boundary between patient and nurse, and derives from a human’s systems’ inherent propensity for innovation and creative change” (p. 75). This metaparadigm is meaningful to my nursing practice as all my interventions are evidence-based and are purposeful. My nursing education, training, and experience plays a big role in my ability to provide safe, competent, care. I always involve the patient in discharge planning to ensure that I am able to respect their autonomy to make decisions and so that I can focus my interventions in meeting mutually set goals. As an example, for the lady with COPD that lives with her cat that I discussed above, I will not focus on encouraging her to move to supportive living and rehoming her cat. I will focus on actually getting to know her and work together in accomplishing her goal of being at home with her cat, as long as possible. I will advocate for her to receive all the appropriate services, equipment, and funding that she will need in order for her to be successful at home. I value and respect an individual’s right of choice and self-determination, especially if they are their own decision maker. We all have unique views, and often what is insignificant to us, is what keeps someone motivated to keep on living.
Social Justice
Social justice in nursing should viewed from a population vantage point and is connected with all the four nursing metaparadigms (Schim et al., 2006, p. 74-75). The focus of this metaparadigm is protecting the rights of all people and to have equal access to the benefits and health resources (p. 78). In my practice, I am a gatekeeper of resources and only allocate finite resources to individuals who needs it the most, if they even qualify or need those resources. A good example would be prioritizing a visit. Should I be visiting someone who have good family supports, where family can help bridge support, or should I prioritize to see someone who lives alone and requires the services the most? The focus is shifted from an individual, to the whole community. In my practice, I take into consideration the 12 social determinants of health (Public Health Canada, 2013) and how they affect my client. I am well aware that income is the most important determinant of health. As Schim et al. (2007) suggested, there should be a paradigm shift for nurses to promote primary and secondary prevention through political action (p. 77). I have not written my Member of Legislative Assembly in terms of making changes, but I am in a great position to facilitate change as I belong to the process development team with Home Living, therefore ensuring that my suggestions and concerns are voiced is important to ensure that change can be facilitated. Patient advocacy is another big role that I have, as I often need to speak with a manager or attend a case review to authorize services that a client really need, but I am not allowed to authorize without a manager’s approval, such as housekeeping for a client who lives alone and have functional impairments and is unable to complete Instrumental Activities of Daily Living like housekeeping, laundry, and cooking.
Conclusion
There are a multitude of nursing theories and knowledge, however, they all share the same 5 distinct concepts of person, environment, health, nursing, and social justice. When the literature review was being conducted and as this paper was being written, it was noted that some metaparadigms are interrelated and that it can be best described in a relationship such as a dyad (or even triad), as the interaction between these concepts affects a patient’s health status and outcome. It is important to note that my nursing practice have these nursing metaparadigms as key areas of focus. The discussion provided here is limited, and can definitely be expounded.
References
Fawcett, J. (1984). The metaparadigm of nursing: Present status and future refinements. Journal of Nursing Scholarship, 16(3), 84-87. doi:10.1111/j.1547-5069.1984.tb01393.x
Monti, E., & Tingen, M. (1999). Multiple paradigms of nursing science. Advances in Nursing
Science, 21(4), 64-80. Retrieved from http://journals.lww.com/advancesinnursingscience/pages/default.aspx
Public Health Canada (2013, January 15). What Makes Canadians Healthy or Unhealthy?
Retrieved October 04, 2017, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health/what-makes-canadians-healthy-unhealthy.html#defining
Reed, P. (2013). Nursing: The ontology of the discipline. In W. Cody (Ed.), Philosophical and
theoretical perspectives for advanced nursing practice (5th ed., pp. 73-80). Burlington, MA: Jones & Bartlett.
Selanders, L. (2010). The power of environmental adaptation: Florence Nightingale's original
theory for nursing practice. Journal of Holistic Nursing, 28(1), 81-88. doi:10.1177/0898010109360257
Schim, S., Benkert, R., Bell, S., Walker, D., & Danford, C. (2007). Social justice: Added
metaparadigm concept for urban health nursing. Public Health Nursing, 24(1), 73-80. doi:10.1111/j.1525-1446.2006.00610.x
Thorne, S., Canam, C., Dahinten, S., Hall, W., Henderson, A., & Kirkham, S. R. (1998).
Nursing's metaparadigm concepts: Disimpacting the debates. Journal of Advanced Nursing, 27(6), 1257-1268. doi:10.1046/j.1365-2648.1998.00623.x
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