Abstract
Paradigms and theories in nursing provides a nurse’s philosophical view and provides a significant influence over nursing practice. There are three nursing paradigms and they are empiricism, interpretive, and critical social theory. The pragmatic perspective is also discussed as it offers the best approach to take in a specific nursing situation. This paper aims to discuss the advantage and disadvantage of each perspective and to provide a specific case review to demonstrate the connections between nursing paradigms, theory, and the author’s nursing practice. It is concluded that a multipragmatic approach is best used as it allows both nursing theorist and practicing nurse to think outside the box; as focusing on one paradigm limits one’s worldview as if wearing blinders. There is a danger of having a nurse become more of a problem solver with the pragmatic approach, as it does not seem to contribute to theory development.
Keywords: nursing paradigm, nursing theory, pragmatic perspective, empiricism, interpretive, critical social theory
Paradigms and Theories in Nursing
Weaver and Olson (2006) defined paradigm as “patterns of beliefs and practices that regulate inquiry within a discipline by providing lenses, frames, and processes through which investigation is accomplished”. Nursing paradigm is the lens that we use to perceive and interpret our world. Bohm (as cited in Leddy, 2000) supports this by suggesting that “one’s perspective shapes the experience of reality”. A paradigm provides a guiding framework for resolving problems, conducting research, and deriving theories and laws (Monti and Tinge, 1999). Theory, as defined by Bohm (as cited in Leddy, 2000), is primarily a way of looking at the world as a whole (worldview) and is not an “absolutely true knowledge” of how things are. This paper aims to discuss the three paradigms of nursing: Empirical, interpretive, and critical social theory. The pragmatic approach will also be explored and the strength and weakness of all four approaches to nursing practice. Concrete examples from my nursing practice will be provided to illustrate the difference between all four perspectives.
Empirical
Content and Contribution
Empiricism is highly influenced by the medical model and is based on the assumption that what is known can be verified through the senses. The ontological assumption of empiricism and is that there is only one reality, which is out there somewhere (Monti and Tingen, 1999). The methodology associated with empiricism is the scientific method. This method focuses on experiment, control, objectivity, precise measurement, quantification of date, and description of results in statistic terms (Monti and Tingen, 1999).
Advantage. The value of the empirical approach to knowledge development lies in its ability to test hypotheses, compare interventions, produce generalizations, and generate confidence intervals that uncover influences. Generalizability is an important goal of empirical research, as it allows relationships to be extrapolated to a larger population or different situation, a factor that is advantageous in nursing practice (Monti and Tingen, 1999).
Disadvantage. Aspects of empiricism such as objectivity and control provides strength to theory development, as it eliminates extraneous factors making examination of relationships easier and clearer. However, objectivity and control also serve as a disadvantage with the study of humans, as excessive control produces an artificial situation that bears no resemblance to reality and thus decrease generalizability. As Monti and Tingen (1999) stated, the traditional experimental method treats people like machines that responds to the environment, rather than interacting with the environment. This paradigm may be strong in reducing concepts to measurable and quantifiable information, but it completely disregards concepts that are not measurable or predictable such as human experience. It completely disregards other ways of knowing such as ethics, esthetics, and personal knowledge. Another criticism of empiricism is that it does not reflect the values and beliefs of nursing and the discipline’s focus on holism, person-centered care, and understanding of the human experience (Monti and Tingen, 1999).
Case Study. I received a referral for Mrs. A.N. who is going to be discharged one afternoon and required medication assistance, as this client has a history of non-compliance with her medications. It was believed that her cardiovascular accident/stroke was due to a thrombus that originated from her heart as she had atrial fibrillation, and this could have been prevented if she had filled her prescription for warfarin (anticoagulant). She also required wound care as she fractured her right hip due to a fall and unfortunately required a hemiarthroplasty. As a nurse I completed a medication reconciliation and medication risk screen. I knew that some medications have nursing considerations that I needed to check, before I could delegate medication assistance to a health care aide (HCA). For example: Her alendronate (Fosamax), a bisphosphonates needed to be taken on an empty stomach and 30 minutes prior to a meal as food, as medications and other vitamins can interfere with its absorption; and that the she needed to drink a full glass of water and be sitting upright, as alendronate can cause chemical irritation of the esophagus (Merck Sharp & Dohme Limited, 2016). I also had to assess the wound on her right hip and followed home care regional guidelines and used my knowledge of the wound healing process to select appropriate wound care products and delegate the wound care to the HCA. It is clear how empiricism is greatly influenced by the medical model in this case scenario. Having some knowledge in pharmacology and pathophysiology (wound healing), I was able to choose appropriate nursing actions based on clinical facts that have already been tested and trialed (ie. research and development of Fosamax and wound care products).
Interpretative
Content and Contribution
The interpretative paradigm is quite a contrast from the empirical paradigm. The interpretative paradigm acknowledges that there are multiple meanings and knowledge that can be derived other than the senses. The interpretative paradigm emphasizes the understanding of the meaning individuals ascribe to their actions and the reactions of others (Weaver and Olson, 2006) The research methodology used in the interpretative paradigm is broadly grouped as qualitative research, as the general goal of the interpretative paradigm is to understand and derive meaning from human experience, as well as instrumentation and conceptualization (Monti and Tingen, 1999).
Advantage. The interpretative paradigm covers what the empirical paradigm could not. Reality and human experience are variable, thus multiple ways of knowing such as esthetics, ethical, and personal knowledge are valued in uncovering human experience (Fawcett, 1984). The researcher and participant have a mutual interaction and the setting selected is in a natural setting. Another strength of the interpretative paradigm is that it offers new perspectives and methodologies for answering the questions of the discipline (Monti and Tingen, 1999). Qualitative methods are used to identify patterns and relationships, which can be used for the development of new theories.
Disadvantage. While the interpretative paradigm emphasizes humanistic approaches, it ignores the reality of physiological problems that are part of the discipline that deals with health and disease (Monti and Tingen, 1999). Gortner (1993) has made it clear that nursing is a practice-based discipline and is not only a social science, it is a discipline grounded in the physiological realities of the human body and patterns of human behavior (as cited in Stajduhar, Balneaves, and Thorne, 2001). Downs (as cited in Monti and Tinge, 1999) state that the results of qualitative studies have been characterized as a “…set of interesting stories” that result in isolated findings that do not advance the discipline as they do not form the basis for further work. Weaver and Olson (2006) adds that loss of objectivity and the focus on subjectivity can actually lead to limited theorizing.
Case Study. Leininger’s (2008) Theory of Culture Care Diversity and Universality is the prime example of a nursing theory that is focused on qualitative nursing research that aims to describe, explain, and interpret an informant’s worldview. As Leininger explains, “caring is held as the action mode to help people of diverse cultures while care is the phenomenon to be understood and to guide actions and decisions. Culture and care together are predicted to be powerful theoretical constructs essential to human health, wellbeing, and survival”. Mrs. A.N. is Vietnamese and is 78 years old. Using an interpreter and teleconferencing with her family from Vancouver (daughter-in-law), select members of her acute care team, and herself; we identified that Mrs. A.N. was actually unaware of what was going on and was just saying “yes” to procedures and questions. The nurse practitioner provided Mrs. A.N. and her family an overview of what lead to her hospital admission, interventions provided, and presented the plan to be discharged home with home care. The family informed us that the client disliked pills and only took her herbal medications. Her family helped me explain to the client that she does indeed need to take her medications, if she did not want to have another stroke and return to the hospital. It was also discovered that mental illness is highly stigmatized in Vietnamese culture, and Mrs. A.N. believed that her medications were only for her schizophrenia. The acute care team and I had to normalize schizophrenia and the pharmacist provided additional medication teaching, to make the client more receptive to care and mental health follow-up in the community. Mrs. A.N.’s daughter-in-law reassured us that client’s son will be coming over next week to reinforce the need to take her medications and to stay at home for the scheduled home care visits, as Mr. A.N. would often disregard hospital suggestions (as evidenced by frequent hospitalizations) and is more likely to follow hospital suggestions if it was coming from her eldest son.
Critical Paradigm
Content and Contribution
Butterfield (2013) mentions that nursing needs conceptual foundations that enable its practitioners to understand health problems manifested in the community, national, and international levels, as well as those at the individual and family levels (p. 146). Hence, within the critical social theory paradigm, research is aimed at taking action and explaining how things can be, as it recognizes that realities are shaped by social, political, cultural, gender, and economic factors. The elimination of oppression in society is a paramount goal of the critical paradigm (Weaver & Olson, 2006). Wuest (2012) states that knowledge cannot be value-free, and is shaped by the society from which it emerges.
Advantage. Butterfield (2013) states that an understanding of the complex social, political, and economic forces that shape people’s lives, is necessary for nurses to promote health of individuals and groups. Critical paradigm encourages nurses to take an upstream approach rather that a downstream approach. McKinlay (as cited in Butterfield, 2013) uses the analogy of a swift flowing river to represent illness. Medical professionals are so focused on saving patients downstream with individual-based interventions (that are often short-term), instead of focusing endeavors on finding out who is pushing patients into the river. Root-cause analysis should be utilized and modifying economic, political, and environmental factors that are precursors to poor health (that have long term effects) should be the focus. Evidence have shown that an upstream approach to health (that addresses people’s determinants of health), benefits everyone and should be the focus of society as a collective (National Collaborating Centre for Determinants of Health, 2014).
Disadvantage. The critical theory paradigm has been criticized for valuing the collective above the individual, and that individuals face the high expectation of changing social structures that oppresses them (Weaver and Olson, 2006). Researchers of the critical paradigm have been reported to be bias as they impose their values upon research participants and researchers accept some truths as more legitimate than others, if it conforms to their paradigm (Weaver and Olson, 2006).
Case Study. In the case of Mrs. A.N., I did take a look at her social determinants of health and looked upstream for the reason for her admission. Mrs. A.N. has poor health literacy, as she only finished grade 4. She is an immigrant, who migrated to Canada in 1988 and worked most of her years as a housekeeper in a hotel. She speaks only Vietnamese and only understands a bit of English. Most of her family are in Vancouver and her only support is her next door neighbor, who is also Vietnamese. Mrs. A.N. does not drive and has difficulties leaving the apartment because it has stairs, and with her recent arthroplasty, she requires one person to assist her up and down the stairs. I have made a referral to a social worker who was able to help with her applying to additional funding sources such as Alberta Senior’s Benefit. With her inability to drive and with her recent arthroplasty, I had agreed to pick-up her medications and brought it to her during my home visit and I had arranged with her pharmacy to have her future dispensed medications to be delivered to her. I ensured that she was connected with Community Geriatric Psychiatry who were able to provide her with Independent Living Service Workers who were able to driver her to her appointments. I acted as her bridge as I handed her case to her psychiatric nurse in the community to ensure continuity of care and to ensure that she is able to trust this new person that is coming into her life. I tried to set her up with services and resources, in an attempt to address her barriers to health care and determinants of health.
Pragmatic Perspective
Content and Contribution
As a pragmatic profession, nurses must choose the best method that works best to provide the critical services that clients require (Monti and Tingen, 1999). Pragmatism is a method of evaluating philosophical problems by tracing the practical consequences of each question (Warms and Schroeder, 2012). The focus of a pragmatic perspective is to solve a significant clinical problem by incorporating new knowledge to expand the explanatory power of the framework (Leddy, 2000). As explored above, different paradigms have different strength and weaknesses. Leddy (2000) has emphasized that the fragmentation of nursing science can be related to the dominant way of thinking of worldviews as competing dualities. Monti and Tingen (1999) agree and uses this analogy that theoretical unification, or having only one universal worldview, is just like focusing on one plane such as a microscope; while having multiple paradigms expand vision like a wide angle-lens, as multiple paradigms encourages creativity as it examines a problem or question through different point of views. Pragmatism bridges that gap through inquiry that is continually reweaving different versions of the truth: One that incorporates new ideas and better explanation in the context of human encounters and activities (Warms and Shroeder, 2012).
Advantage. Weaver and Olson (2006) believe that a pragmatic approach can move nursing beyond the boundaries and restriction of having a single paradigm towards theory construction to fit a particular situation. A pragmatic perspective allows theories to be designed and tested in practice, as well as provide the opportunity to stimulate inquiry that complements one paradigm with another (Weaver and Olson, 2006). Warms and Schroeder (2012) highlight pragmatism’s collaborative and inclusive nature, which assists nurses in serving clients with justice and fairness.
Disadvantage. Monti and Tingen (1999) state that having multiple paradigms can also be disadvantageous as practitioners may become confused and divided over the conflicting claims of different viewpoints. Nowell (2015) states pragmatism has been criticized for focusing on practical results and ignoring philosophy and theory, and not engaging in meta-theoretical debates. Criticism of pragmatism is that it tends to be “anti-intellectualist” and uses theories as instruments and not answers to enigmas (Warms and Schroeder, 2012). We have to realize that paradigms are used to guide and develop nursing practice, and is not just a tool for problem solving. Cody (2013) was very clear that nursing theory-guided practice is based on theory that is specific to the discipline of nursing, explicitly rooted in a philosophy of nursing, and intended solely to guide nursing practice and research.
Case Study. It is clear from the above case studies that I wouldn’t have been able to provide my client, Mrs. A.N., a comprehensive and focused nursing care if I did not consider the empirical, interpretative, and critical paradigm in her care. If one of those paradigms were missing then I wouldn’t be able to describe my nursing practice as holistic. Pragmatics would be in agreement when I say that I was able to practice pragmatism when I highlighted priorities and worked in collaboration with other disciplines to ensure that her needs were met and addressed.
Conclusion
This paper has provided some concrete examples of the multiple paradigms in nursing and how significant each and every one of these paradigms are in contributing to the knowledge and practice of nursing. Each paradigm is a specific worldview, which has its own unique strength and weakness. Hence a multiparadigm approach is necessary to allow researchers to think outside of the box and to use alternative thinking and research methods. The paradigmatic approach utilizes various paradigms and theories to provide better nursing care as it addresses specific nursing dilemmas, however, it does not contribute much to theory development as that is not its focus.
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