The Metaparadigm of Nursing: Present Status and Future Refinements

The Metaparadigm of breast feeding Present military position and Fut ure Refinement s Jacqueline Fawcett, Ph. D. , F. A. A. N. Abstract The rudimentary concepts and themes of t he chequer of bear ar identified and formalized as nurses metaparadigm. Examples elaborate the counselor-at-law willd by the metaparadigm for theory development. Refinements of the metaparadigm through abstract illustrations and programs of nursing question are proposed. T he discipline of nursing will advance only through continuous and systematic development and test of nursing noesis.Several recent reviews of the status of nursing theory development indicate that nursing has n o established tradition of scholarship. Reviewers have pointed out that roughly work appears unfocused and uncoordinated, as each scholar moves quickly from superstar topic to another and as few scholars combine their efforts in circumscribed areas (Chinn, 1983 Feldman, 1980 Hardy, 1983 Roy, 1983 Walker, 1983). imme nse areas for theory development are, however, beginning to be recognized. Analysis of past and present writings of nurse scholars indicates that theoretic and empirical work has always centered on just a few global oncepts and has always dealt with certain ordinary themes. This paper identifies these central concepts and themes and formalizes them as nursings metaparadigm. Examples are given to illustrate the direction provided by the metaparadigm for theory development. The paper continues with a discussion o f refinements of t he metaparadigm needed at the levels of jacqueline Fawcett, Ph. D. , F. A. A. N. , i s coadjutor Professor, and Section Chairperson, Science and Role Development, School of breast feeding, University of Pennsylvania, Philadelphia. Page 84 disciplinary matrices and exemplars nd concludes with proposals for future work needed to advance to the discipline of nursing. Present view of the Metaparadigm of Nursing The metaparadigrn of any discipline i s a stat ement or group of statements identifying its relevant phenomena. These statements spell out the phenomena of interest in a most global manner. No attempt i s made to be particularised or cover at the metaparadigm level. Eckberg & Hill (1979) explained that the metaparadigm acts as an encapsulating unit, or framework, within which the more restricted . . . structures develop (p. 927).You can read also Coronary Artery Disease Nursing Care PlanThe Central Concepts of NursingEvidence supporting the public of a metaparadigm of nursing i s accumulating. A review of the literature on theory development in nursing reveals a consensus about the central concepts of the discipline-person, environment, health, and nursing (Fawcett, 1983 Flaskerud & Halloran, 1980). This consensus i s documented by the following statements O ne may. . . demarcate nursing in terms of four subsets 1 ) persons providing fretting, 2) persons with health problems receiving care, 3) the environment in which care i s given, and 4 ) an end-state, well- macrocosm. (Walker, 1971, p. 429) The major concepts identified (from an nalysis of the components, themes, topics, and threads of the conceptual frameworks of 50 baccalaureate nursing programs) were Man, Society, Health, and Nursing. (Yura &Torres, 1975, p. 22) The units person, environment, health, and nursing particularise the phenomena of interest to nursing science. (Fawcett, 1978, p. 25) Nursing studies the wholeness or health of humans, recognizing that humans are in continuous interaction with their environments. (Donaldson & Crowley, 1978, p. 119) Image The Journal of Nursing learning Nursings focus i s persons, their environments, their health and nursing itself. Bush, 1979, p. 20) Nursing elements are nursing acts, the p atient, and health. (Stevens, 1979, p. l l ) The foci of nursing are the individual in relation to health, the environment, and the change process, whether it be maturation, adaptation, or coping. (Barnard, 1980, p. 208) Nursing i s defined as the diagnosis and treatment of human repartees to actual or potential health problems. (American Nurses Association, 1980, p. 9 ) The four conceptual areas of nursing are the person receiving nursing the environment within which the person exists the health-illness continuum within which the erson falls at the duration of the interaction with the nurse and finally, nursing actions themselves. (Flaskerud, cited in Brink, 1980, p. 665) The domain of nursing has always included the nurse, the patient, the situation in which they find themselves, and the purpose of their being together, or the health of the patient. In more formalized terms, . . . the major components of the nursing metalparadigm are nursing (as an action), thickening (human being), environment (of the client and of the nurse-client), and health. ( impudentlyman, 1983, p. 388) There i s general agreement that the central oncepts of the discipline of nursing are the nature of nursing, th e individual who received nursing care, society-environment, and health. (Chinn, 1983, p. 396) These statements indicate that there i s healthy agreement among scholars as t o the concepts central to the discipline of nursing. In fact, a review of the literature revealed no contradictory statements. RecurringThemes The relationships between and among the concepts-person, environment, health, nursing-are elaborated in recurring themes found in works of nurse scholars since Nightingale (1859). These themes are listed in Table 1.Summer, 1984, Volumo XVI, blo. 3 Metaparadigm of Nursing put back 1 THEMES OF THE YETAPARAWW OF NURSING 1. The principles and laws that say the conduct-process, well-being. and optimum function of human beings, sick or well. 2. The patterning of human behavior in interaction with the environment in normal life events and critical life situations. 3. The process by which positive changes in health status are elfected. (Donaldson& Crowley, 1978, p. 113 Gortne r, 1980, p. 180) The four central concepts and three recurring themes identify the phenomena central to the discipline of nursing in an abstract, global manner.Read also Recording General Fund Operating Budget and Operating TransactionsThey represent the metaparadigm. As such, they have provided well-nigh direction for nursing theory development. As Newman (1983) explained It i s within the context of these four major components and their interrelationships that theory development in nursing has proceeded. Theoretical differences join to the emphasis placed on one or more of the components and to the way in which their relationships are viewed. (p. 388) The relationship between the concepts person and health i s considered in the first theme. Theories addressing this theme tell apart, explain, or predict individuals behavior during eriods of wellness and illness. Newmans (1979) theory of health i s one example. This theory includes the concepts of movement, time, space, and consc iousness. Newman proposes that the elaboration of consciousness i s what life, and therefore health, i s a ll about (p. 66). Another example i s Orems (1980) theory of self-care, which maintains that self-care and care of dependent family members are learned behaviors that purposely regulate human structural integrity, functioning, and human development (p. 28). S till another example i s Orerns theory of self-care deficits.This theory maintains that individuals are subject t o healthrelated or health-derived limitations that render them incapable of continuous selftare or dependent care or that result in ineffective or incomplete care (p. 2 7). The relationships among the concepts person, environment, and health are considered in the second theme. Theories addressing this theme Summer, 1B84, bulk XVI, No. 3 describe, explain, or predict individuals behavioral patterns as they are influenced by environmental factors during periods of wellness and illness. Such theories place the in dividuals ithin the context of their surrounding environment rather than considering them in isolation, as in the first theme. Roy and Roberts (1981) theory of the person as an adaptive system i s an example. This theory proposes that the person i s a system that adapts to a constantly changing environment. Adaptation i s accomplished through the action of coping mechanisms called the regulator and the cognator. The relationships among the person, health, and nursing are considered in the third theme. Environment may also be taken into account here. This heme i s addressed by theories about nursing practice. These theories describe or explain nursing processes or predict the effects of nursing actions. major powers (1981) theory of goal attainment i s one example. King explains that a paradigm, or disciplinary matrix, i s more repressive than a metaparadigm, and that i t represents the shared commitments of any disciplinary community, including exemplary generalizations, beliefs , values, and a host of other elements (p. 926). The authors went on to say, A disciplinary matrix may be seen as the special subculture of a community. It does ot refer to the beliefs of an entire discipline (e. g. biology), but more correctly t o those beliefs of a specialized community (e. g. phage workers in biology). (p. 926) Identification of the metaparadigm i s an important quality i n the evolution of a scholarly tradition for nursing. The n e x t step i s r efinement o f t h e metaparadigm concepts and themes, which occurs at the level of the paradigm or disciplinary matrix, rather than at that of the metaparadigm. The Disciplinary Matrix Eckberg and Hill (1979) explained virtually disciplines have more than one disciplinary matrix.Each one represents a typical frame of reference within which the metaparadigm phenomena are viewed. Furthermore, each disciplinary matrix reflects a particular research tradition by identifying the phenomena that are within its domain of inq uiry, the methods that are to be used to investigate these phenomena, how theories about these phenomena are to be tested, and how d ata are to be collected (Laudan, 1981, p. 151). More specifically, the research tradition of each disciplinary matrix includes six rules that encompass all phases of an investigation. The first rule identifies the specific nature f the problem to be studied, the purposes to be fulfilled by the investigation, or both. The second rule identifies the phenomena that are to be studied. The third rule identifies the research techniques that are to be employed and the research tools that are to be used. The fourth rule identifies the settings in which data are to be gathered and the subjects who are to provide the data. The fifth rule identifies the methods to be employed in reducing and analyzing the data. The sixth rule identifies the nature of contributions that the research will make to the promotion of knowledge. (Schlotfeldt, 1975, p. ) In nursing, di sciplinary matrices are most clearly exemplified by such conceptual models as Johnsons (1980) Behavioral System regulate, Kings (1981) Open Systems Model, Levines (1973) saving Model, Neumans (1982) Systems Model, Orems (1980) Self-care Model, Rogers (1980) Life Process Model, and Roys (1984) Adaptation Model. Each Image The Journal of Nursing lore Page 85 . . . nurse and client interactions are characterized by verbal and nonverbal communication, in which information i s exchanged and interpreted by transactions, in which values, of necessity, and wants of each ember of the gallus are shared by perceptions of nurse and client and the situation by self in role of client and self in role of nurse and by stressors influencing each person and the situation in time and space. (p. 144) Orems ( 1 980) theory of nursing systems is another example. This theory maintains that nursing systems are create when nurses use their abilities to prescribe, design, and provide nursing for legiti mate patients (as individuals or groups) by performing discrete actions and systems of actions (p. 29). Refinement of the Metaparadigm Metaparadigm of Nursing f these nursing models puts forth a distinctive frame of reference within which the metaparadigm phenomena are viewed. Each provides needed refinement of the metaparadigm by serving as a focus-ruling some things in as relevent, and ruling others out due to their lesser importance (Williams, 1979, p. 96). Conceptual models of nursing are beginning to make major contributions to the development of nursing theory. Theories derived directly from Kings model and from Orems model were identified earlier. A considerable amount of empirical work designed to test unique nursing theories as well as heories borrowed from other disciplines i s n ow being guided by nursing models. Some of the studies are listed in Table 2. TABLE 2 Examples of Research Derived From Conceptual Models of Nursing Oorothy Johnsons BehavioralSystem Model -An ins trument for theory and research development using the behavioral systems model for nursing The crabmeat patient. Part I (Derdiarian, 1983). -An instrument for theory and research development using the behavioral systems model for nursing The cancer patient. Part II (Derdiarian & Forsythe, 1983). -Achievement behavior in chronically ill children (Holaday, 1 974) Maternal response to their chronically ill infants attachment behavior of crying (Holaday, 1981) -Maternal conceptual set development Identifyingpatterns of maternal response to chronically ill infant crying (Holaday, 1 982) -Development of a research tool Patient indicators of nursing care (Majesky, Brester, & Nishio, 1 978) Myra Levines Conservation Model - effectuate of lifting techniques on energy expenditure A preliminary investigation (Geden, 1 982) A comparision of two bearing-downtechniques during the second stage of labor (Yeates & Roberts, 1984) Betty Neumans Systems Model Effects of information on postsurgical co ping (Ziemer. 1 983) Dorothea Orems Self-care Model -Application of Orems supposed constructs to selfcare medication behaviors in the elderly (Harper, 1984) -Development of an instrument to measure exercise of self-care agency (Kearney & Fleischer, 1 979) Martha Rogers Life Process Model -The relationship between identification and patterns of change in spouses body orbits during and after pregnancy (Fawcett, 1977) -Patients perceptions of time current research (Fitzpatrick, 1 980) -Reciprocy and helicy used t o relate mEGF and wound healing (Gill & Atwood, 1 981) Therapeutic touch as energy exchange interrogation the theory (Ouinn, 1 984) Callista Roys Adaptation Model -Needs of cesarean birth parents (Fawcett, 1981) -An exploratory study of antenatal preparation for ce- Page 86 sarean birth (Fawcett & Burritt, in press) -Clinical tool development for adult chemotherapy patients Process and content (Lewis, Firsich. & Parsell, 1 979) -Content analysis of interviews using a nurs ing model A look at parents adapting to the bear upon of childhood cancer (Smith, Garvis, & Martinson, 1 983) Despite the contributions already made by nursing models to theory development, much more work i s needed.In particular, rules addressing methodological analysis and instrumentation must be specified. Moreover, programs of research emanating from each model must be conducted to refute or validate nursing theories. Programmatic research probably i s carried out most expediently by communities of scientists. Hardy (1983) explained that each community of scientists i s . . . a g roup of persons w h o are aware of their uniqueness and the separate identity of their group. The have a special coherence which separates them from neighboring groups, and this special bond means they have a shared set of values and a common commitment which operates as hey work together t o achieve a common goal. Coordination of their activities may include interaction among the coordination of insti tutions, organizations, groups, and individuals. Such coordinated groups hold a common perspective, common values and common bonds, a nd they have common sets of activities and functions which they scarper out to achieve a common outcome. (p. 430) Each community of scientists, then, represents a distinctive subculture, or disciplinary matrix, of the parent discipline. It can be argued that communities of scientists may be formed outside the organizing framework of nursing models.However, it also can be argued that conceptual models of nursing, like the disciplinary matrices of other disciplines, are the most logical nuclei for communities of scientists. This principle i s supported by three facts. First, the curricula of most schools of nursing now are based on conceptual models. Second, most graduate programs and many an(prenominal) undergraduate programs offer courses dealing with the content and uses of nursing models. And third, clinical agencies are beginning to organize the delivery of nursing care according to the tenets of conceptual models. image The Journal of Nursing Scholarship Collectively, these facts mean that cademicians, students, clinicians, and administrators are thinking about nursing theory, nursing research, and nursing practice within the context of explicit conceptual models. It i s probable, then, that eventually the development of a ll nursing theory will be directed by nursing models. It may even by possible to categorize seemingly isolated past and current work according to conceptual models. This should provide more organization for extant nursing knowledge and should identify gaps and needed areas of inquiry more readily than is possible now. Moreover, such an endeavor should identify members of disparate ommunities of scientists to each other as w ell as t o the larger scientific community. Exemplars S till get on refinement of the metaparadigm i s needed a t the most restrictive level-that of the exemplar. Eckberg and Hill (1979) identified the function of an exemplar as permitting a way of seeing ones subject matter on a concrete level, thereby allowing puzzle solving to take place (p. 927). They went on to explain For a discipline to b e a science it must control i n puzzle-solving activity but puzzle solving can only be carried out if a community shares concrete puzzle solutions, or exemplars.It i s t he exemplar that i s i mportant, not merely the disciplinary matrix, and certainly not merely the general presuppositions of t he community i. e. , the metaparadigm. The latter may be important, but they do n ot direct ongoing, dayto-day research. (p. 927) There i s some read of exemplars in nursing. This includes but is not limited to Fitzpatricks (1980) programmatic research on time perception studies o effects of information f about a threatening procedure on a patients responses to the procedure (e. g. , Hartfied, Cason, & Cason, 1982 Johnson, Fuller, Endress, & Rice, 1978 Ziemer, 19831, and inv estigations of actors contributing to the outcomes of social support (Barnard, Brandt, Raff, & Carroll, 1984 in press). These researchers are beginning to solve some of the major puzzles of nursing. However, more work i s needed to identify other puzzles and to develop methods for their solutions. Summer, 1984, Volume XVI, No. 3 Metaparadigm of Nursing Conclusion It is time to formally accept the central concepts and themes of nursing as the metaparadigm of the discipline. It i s also time to direct efforts toward furf ther refinement o this metaparadigm by developing specific rules for the empirical work needed to generate nd test nursing theories within the context of conceptual models. The metaparadigm must be refined still further through the developing of new puzzle-solving activities that will provide answers to the most pressing problems encountered by nurse clinicians, educators, and ddministrators. Any one of these activities would in itself make a hearty contribution to t he discipline a ll three could quite possibly be the major accomplishments of the decade. As used here, theory development reft. r to generation a nd testing of theory. and encornpasiei ivory tower theorizing as well as empirical rewarch.References American Nurses As5ocialion. Nursing A social policy statement. Kansas City, Missouri ANA, 1980. Barnard, K. E. acquaintance for practice Direction5 for the future. Nursing Research, 1980. 29, 208-21 2. Barnard, K . E. , Brandt, P. , Raff. 8.. & Carroll, P. (Ed,. ). Social support and families of vulnerable infants. New York March of Dimes, 1984. Brink, P. 1. Editorial. Western Journal of Nursing Research, 1980, 2, 665-666. Buih, H . A. Models for nursing. Advances i n Nursing Science, 1979, l ( 2 ) . 13-21. Chinn, P. L. Nursing theory development Where we have been and where we are going.In N. L. Chaska (Ed. ), The nursing profession A time to speak. New York McCraw-Hill, 1983. Donaldson, S. K. , & Crowley, D. M . The discipline of nurs ing. Nursing Outlook, 1978, 26, 113-120. Eckberg, D. L .. & Hill, L. , Jr. The paradigm concept and sociology A critical review. American Sociological Review, 1979, 44,925-937. Fawcett, 1. The what of theory development. In conjecture developmenk What, why, how? (pp. 17-33). New York National League for Nursing, 1978. Fawcett, 1. (1983). Hallmarks of succeeder in nursing theory development. In P. L. Chinn, (Ed. ), Advances i n nursing theory development (pp. -17). Rockville, Maryland Aspen. Feldrnan, H. R. Nursing research in the 1980s Issues and implications. Advances in N ursing Science, 1980, 3(1)85-92. Fitzpatrick, 1. J . Patients perceptions of time Current research. International Nursing Review, 1980, 27, 148-153, 160. Flaskerud. 1. H. , & Halloran, E. J. Areas of agreement in nursing theory development. Advances in Nursing Science, 1980, 3(1), 1-7. Hardy. M. Metaparadigrnsand theory development. In N. L. Chaska (Ed. ), The nursing profession A t ime t o speak. New York McCr aw-Hill, 1983. Hartfield. M. k Cason, C. L. , & Cason, C. J . Effects of , information about a threatening procedure on patients expectations and emotional distress. Nursing Research, 1 982,31,202-206. lohnson, D. E . The behavioral system model for nursing. In J . P. Riehl & C. Roy, (Eds. ), Conceptual models for nursing practice (2nd ed. ). New York Appleton-Century-Crofts, 1980. Johnson. 1 . E. , Fuller, S . 5.. Endress, M. P . , & Rice, V S. . Altering patients responses to surgery An extension and replication. Research in Nursing and Health, 1978, 1 , 111-121. King. I. M. A theory for nursing Systems, concepts, process. New York Wiley, 1981. Neurnan, B .The Neuman systems model Application t o nursing education and practice. New York Appleton-Century-Crofts, 1982. Newrnan, M. A. Theory development in nursing. Philadelphia F. A. Davis, 1979. Newrnan, M . A. The continuing revolution A history of nursing science. I n N. L. Chaska (Ed. ), The nursing profession A time t o speak. N ew York McGrawHill, 1983. Nightingale, F. Notes on nursing What it is, a nd what it i s not. London Harrison, 1859. (Reprinted by L i p pincott, 1946) Orem, D. E. Nursing Concepts of practice (2nd ed. ). New York McCraw-Hill, 1980. Rogers, M. E . A n introduction to t he theoretical basisk f nursing. Philadelphia F. A. Davis, 1970. Roy, C. I ntroduction to nursing An adaptation model. (2nd Ed. ). Englewood Cliffs, New Jersey PrenticeHall, 1984. Roy, C. Theory development in nursing Proposal for direction. In N. L. Chaska (Ed. ), The nursing profession A time t o speak. New York McCraw-Hill, 1983. Roy, C. , & Roberts, S . L . Theory construction i n nursing An adaptation model. Englewood Cliffs, New Jersey Prentice-Hall, 1981. Schlotfeldt, R. M. The needs for a conceptual framework, In P . J. Verhonick (Ed. ), Nursing research I. Boston Little, Brown. 1975. Stevens, 8. J. N ursing theory.Analysis, application, evaluation. Boston Little, Brown, 1979. Walker, L. 0. Toward a clearer und erstanding of the concept of nursing theory. Nursing Research, 1971, 20, 428-435. Walker, L. 0. Theory and research in the development of nursing as a discipline Retrospect and prospect. In N . L. Chaska (Ed. ), The nursing profession A time to speak. New York McCraw-Hill, 1983. Williams, C. A. The nature and development of conceptual frameworks. In F. S . Downs & I . W . Fleming, (Eds. ) Issues in nursing research. New York Appleton-Century-Crofts, 1979. Ziemer, M. M. Providing patients with information rior t o surgery and the report frequency of coping behaviors and development of symptoms foll owing surgery. Unpublished doctoral dissertation, University of Pennsylvania, 1982. A Response to D r. J . Fawcetts Paper The Metaparadigm of Nursing Present Status and Fut ure Refinement s June N. Brodie, R. N. , Ph. D. D r. Fawcetts formulation of a metaparadigm for nursing represents a commendable effort to consolidate competing nursing theories and encompasses enormous potential for th e advancement of nursing knowledge, research, and practice meriting serious consideration by nursing une N . Brodie, R. N. , Ph. D . i s Associate Professor of Nursing Education, Teachers College, Columbia University. Summer, 1984, Volume XVI, No. 3 scholars. This response focuses on how she accomplished this task (what she did and how she did it as well as what she didnt do and what needs to be done). Essentially Dr. Fawcetts metaparadigm can be viewed as an evolution of a nursing metaparadigm and an organization of the growth of nursing knowledge rather than as a completed and finalized product. To be more explicit, the basis of the paper exhibits the spirit of Darwinian Evolution and ould be treated as a manifestation of Image The Journal of Nursing Scholarship a transitional phase i n the competition for the survival of the fittest (theory). The metaparadigm represents a serious and scholarly attempt to negotiate entry into a different level of the theoretical arena of nursing k nowledge. This task was accomplished by examining the concepts derived from the phenomena of the discipline and converging these concepts into a context pertinent to the domain of nursing by providing a structure (a metaparadigm) that has the potential of consolidating disparate nursing theories into Page 87