Socrates was critical of those who lived their lives without examination (Rudebush, 2009). Within the context of practicing in a contemporary healthcare setting nursing is compelled to avoid such criticism. It is imperative that nurses reflect on and are succinct about the fundamental nature of what they do (Willis et.al, 2008) and the impact that has in the modern healthcare arena. If we cannot identify this then we will hand control of our present and our future over to others (Clarke and Lang, 1992). To enable this process we need to examine the sum of the parts that form the precepts at the very core of our existence. Present-day nursing has gone through many stages in its development. Austin (2011, p. 161) contends that in all that time nursing’s commitment to those in its care has not changed and that ‘Nursing is grounded in faithfulness, in constancy and loyalty to patients, families, communities’. The Royal College of Nursing (2014) defines nursing as ‘The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems and to achieve the best possible quality of life, whatever their disease or disability until death’.
Nursing is not practiced in a void. It has been shaped by society and in turn it has helped to shape society (Donahue, 1985). Two examples of determining factors shaping nursing today are an ageing population and the increased prevalence of chronic diseases. Frequent hospital admissions and complex treatments make chronic diseases a major issue for healthcare (O’Shea et al., 2013). The recent downturn in the global economy has resulted in a drive for cost containment. The way we provide healthcare is being changed as conformity to pre-scripted practices is favoured over clinical judgement risking the potential to inherently change the essence of the nurse-patient relationship (Austin, 2011).
We live in an era of economic polarization, armed conflicts, environmental problems, corruption, injustice and changing communication patterns (Dali Lama, 2012). The roles played by nurses and the scope of nursing practice needs to engage with these issues in a meaningful way to maintain its social mandate while at the same time maintaining the values of the profession (Risjord, 2010). The permutation of the common good and the dignity of the individual affords nursing a unique philosophical basis from which to develop its own theories and specialist knowledge enhancing its meaningful contribution to society (Mc Curry, 2009).
Nursing theories are coherent approaches to describe, explain, predict and prescript nursing care (Meleis, 2012) and it is necessary that we use them to underpin our practice (Willis et al., 2008). Early metaparadigms included the person, environment, health and nursing as central concepts to nursing (Fawcett, 1984). Theorists such as Parse (1992) contend that nursing should not be a central concept as it is in fact the whole. Intellectual discourse around nursing theory has centred on distilling the central concepts. Newman (2008) advises incorporating knowledge from other disciplines. Bohm (1980) warns against the idea of an all encompassing nursing theory and suggests the strength of nursing theory lies in their diversity. More recently a unitary- transformative approach in which the person is considered as a whole and the relationship is regarded as the central aspect of nursing theory has emerged as the imperative in the discourse around nursing theories (Newman et al., 1991).
Grace (2002, p. 67) reports that ‘Practicing according to a well-established theoretical framework generally results in more consistent and better care than does practice without such guides’. Chambers (1998) feels that nursing theories can be too aloof and may result in the exploitation of nursing. Mc Crae (2011) is concerned about theories constructed on empirical evidence only and cites Attree’s (2001) concerns about scientific methods being unsuitable to explore important nursing qualities such as sympathy and compassion. This is what Cody (2013, p. 8) refers to as the Praxis of nursing and talks about nurses using ‘reasoning relevant to their situation’. Future nursing research needs to reflect issues relevant to current practice, use a variety of research methodologies and add to how we already help patients reach their potential (Willis et al., 2008). Nursing theory should remain the construct that directs nurses in their practice with patients and is the starting point for a give-and-take relationship between nursing theories and nursing practice (Fawcett, 1992).
Nursing theories are integral when we come to talk about nursing as a professional discipline. Newman (1991, p. 1) states that ‘A discipline is distinguished by a domain of inquiry that represents a shared belief among its members regarding its reason for being’. Nursing as a discipline is inclusive of all the many purposes nurse fulfil, includes the theories developed to explain it, research findings generated by it about it and functions as an entity to promote the discipline (Meleis, 2012). Nursing as a professional discipline is bound by a code of ethics, has a registration process, has power and authority over training and education, is accountable to the public and provides a knowledgeable service to society (Bohan, 2015). Nursing as a professional discipline is defined by a number of characteristics that accumulate to afford it distinction.
Nursing now considers itself a human science with an emphasis on engaging with the human experience in health, illness and dying (Meleis, 2012). Because experiences are subjective and open to a myriad of influences nursing seeks to find out what effect they have on those under our care (Willis et al., 2008). Meleis (2012) argues that it is this exact interest that makes nursing a practice discipline. Mitchell and Coady (2002) argue that when nursing is practiced from a human science approach it can be considered both an art and a science.
It was Leininger (1978) who first described caring as a central tenant to the discipline of nursing. Newman (2008) agreed but was concerned about the lack of clarity around the concept. Authors such as Condon (1992) welcomed the introduction of the concept and felt it presented an opportunity to move away from older archaic military and religious connotations associated with the discipline. Meleis (2012) welcomes the fact that caring carries more bearing in contemporary western society and Watson (1985) argues that caring is not a means to an end but an end in its self. Further discourse around the concept has prompted nursing scholars such as Cody (2013) to suggest that the remit of caring is explained in terms of brining the humanness to any health related activity. Meleis (2012) contends that nursing has always been health orientated with nurses, through their practice, helping individuals take charge of their own health. Newman (1991) suggests a blending of the two into a defining ideology that further helps identify the discipline of nursing.
Nursing is about the doing, the actual practice of nursing care. Nurses monitor, assist and empower individuals in illness and potential illness (Bottorff, 1991). We are concerned about what we do, why we do it and when we do it (Meleis, 2012). As a practice orientated discipline we gain twenty four hour, seven days a week engagement with our clients. We are in a prime position to get to really know those in our care (Jenny and Logan, 1992). Meleis (2012, p. 91) states that nurse patient relationships ‘…are characterised by continuity, intensity, and involvement in ways that other health care professionals do not experience’. The same author is concerned that inquiry around the practical aspects of nursing is being superseded by the pursuit of more theoretical knowledge and the effect this may have on nursing as a practice discipline (Meleis, 2012).
Nursing as a discipline has a body of knowledge, a domain, which is particular to its self and which posse’s practical and theoretical considerations, too nurses (Meleis, 2012). Newman (1991) reports that concepts central to nursing have been the nurse, the patient, the situation, their purpose together and the patients health. Cowling et al., (2008) suggests adding the concepts of wholeness, consciousness and caring. Meleis (2012) uses the exaggerated scenario of space travel to reveal how the body of knowledge we consider as belonging to nursing may have to adapt to meet or client’s needs in the future – e.g. current knowledge around environment. Meleis (2012) lists seven concepts which she believes go to help define nursing’s body of knowledge. They are the nursing client, transitions, interaction, nursing process, environment, nursing therapeutics and health. Mc Namara (2011) claims that nursing has traditionally been bad at articulating its domain. Failure to do so can lead to the subordination of the discipline where nurses find themselves practicing to fill in short falls in healthcare systems (Latimer, 2000). Further delineation of nursing’s domain of knowledge will come about through research, practice, education and administration (Meleis, 2012).
Sahlsten (2008) asserts that participation with patients is present when 1) there is an established relationship between nurse and patient, 2) there is some surrendering of power or control by the nurse, 3) there is shared information and 4) there is engagement together in intellectual and /or physical activity. Newman (1991, p. E17) expands the idea further and talks of the relationship being ‘… embedded in a concept of wholeness, evolving pattern, and transformation’. On the evidence presented in the previous paragraphs this author suggests that nursing is a participatory rich practice. For maximum participation nurses need to engage without preconceived ideas (Sahlsten, 2008).
In conclusion the professional discipline of nursing can outline a very definitive practice orientated ontology. Is that ontology completed? Because of nursing’s very nature this author believes that it may not be. Nursing is and will continue to adapt to meet the needs of those in its care. If nurses can continue be clear about the disciplines ontological basis they will be afforded the privilege of engaging in practice that is rewarding for them and to the healthcare system they work in (Newman et al., 2008).