[Scholarly Paper] My View of the Ontological Dimension of Nursing

Ever since Florence Nightingale penned what would be the first of many defining descriptions of nursing in the 19th century, the discipline has faced a fluctuating identity crisis repeatedly solved and unraveled by theories and subsequent critiques (Kim, 2015). One of the most influential contributions to the ontology of nursing has been Fawcett’s 1984 four-domain metaparadigm consisting of person, health, environment, and nursing; a theory which was widely adopted by nursing academia, yet distinctly criticized by nursing scholars (Bender, 2018). Having been trained in an institution that adopted this metaparadigm as foundational to nursing ontology, it was one of the earliest influences on my knowledge of nursing practice. However, critical thinking was also heavily incorporated into the curriculum, leading me to reflect on and reassess my stance on being a nurse, particularly with the added perception of my clinical experience as a graduated, practicing nurse. As my experiences and views of nursing matured, certain aspects of Fawcett’s metaparadigm felt appropriate, while others I rejected as restrictive and incomplete in defining my nursing practice: a sentiment echoed by Fawcett’s critics.

Nursing as a Patient-Centered Practice

Practicing primarily in the emergency department, my perspective of being a nurse is intrinsically linked to the patient experience with their health, environment, and healthcare as a whole. In my visual conceptualization of the patient’s interactions and relations with members of the healthcare team, including nurses, the patient would be at the center of a web, and the nurse would directly encapsulate the patient so that, in essence, they are one, as shown in Figure 1. All further connecting arrows and lines to other care providers stem from the nurse as the patient’s fundamental representative and link to the rest of the healthcare system. Nursing practice, consequently, responds to the needs and demands of a patient “in a specific time and context” and is “specifically anchored on the benefit of others” (Kim, 2015, p. 4). Further, there is a collective understanding in the nursing profession that the patient is more than just their physical person; they can be an individual, group, or population whose health outcomes are affected by and dependent on their social, political, geographic, economic, and spiritual conditions. Patients are also affected by their unique perceptions and conceptions of health, and by the nature of their relationship and interactions with nurses (Kim, 2015). Pursuant to this complexity of the patient, my stance is that nursing actions and knowledge embody a suitable level of thoughtful, goal-oriented decision-making based on a scientific approach, while also being guided by a sensitive, humanistic understanding of the patient’s unique needs and circumstances. Thus, being a nurse is a nuanced combination of patient assessments, interventions, and management in the form of healthcare team coordination and liaison, with the goal of empowering and enabling patients to meet their unique needs and health outcomes.

Influence and Critique of the Four-Domain Metaparadigm

The patient-centered approach of nursing practice is supported and repeatedly reinforced in the literature. Perry iterated in her influential book on exemplary nursing that as a “therapeutic, goal-oriented process, nursing is directed at meeting patient needs” (Perry, 2009, p. 26), and Kim similarly wrote in her influential book on the essence of nursing that nursing practice “should not be equated with discrete actions [but in] how they are put together by a nurse in the context of the patient” (Kim, 2015, p. 2). The most influential part of Fawcett’s metaparadigm to my ontological approach to nursing is the person, in the broad interpretation of the patient and their context, as the core of nursing. However, Fawcett’s theory extends to include the pillars of environment, health, and nursing, which are heavily criticized, along with the person element, by nursing scholars as “unstable… having been variably conceptualized by nursing scholars, many times in very conflicting ways” (Bender, 2018, p. 4). Even more foundationally, Fawcett’s theory is criticized for forcing a scientific structure within a metaparadigm, which by its nature is meant to be a set of universal values of the profession, and simultaneously neglecting other concepts that influence nursing ontology, such as caring, social determinants of health, and the nursing perspective as unique and key aspects of nursing practice and knowledge development (Bender, 2018). While each of the four pillars of the nursing metaparadigm are valid as concerns of nursing and effectors of the patient and nurse experience of healthcare, they are not comprehensive or sufficient for defining my ontological stance of nursing, which is not as static and categorical as dictated by Fawcett’s metaparadigm.

Conclusion: Reconceptualizing the Ontological Stance

There is a collective understanding at this point in our profession that nursing is a scientific and humanistic profession aimed at enabling and empowering patients. The patient can be an individual or a group who is affected by their social, political, geographic, economic, and spiritual conditions, whose concept of health is unique and variable depending on their circumstances, and whose outcomes are affected by the nature of their relationship and interactions with nurses (Kim, 2015). From this conceptualization of nursing and the patient, it is clear that a static, categorical philosophy is not a reasonable anchor for the ontology of nursing. According to Bender, “There is no deterministic structure of nursing, no definitive theory that can be reduced to an algorithmic technology of nursing” (Bender, 2019, p. 6). Instead, Bender offers an enticing reconceptualization of nursing as a dynamic process based on the interrelated nature of person, environment, health, and nursing, as well as factoring in the significance of caring and the unique nursing perspective (Bender, 2019). I am drawn to the flexibility and broad applicability of this philosophical underpinning of scholarly exploration to define nursing; however, the question that remains is whether a universal definition of nursing practice is realistically achievable or sustainable. In a profession so dependent on responding and managing factors external to itself, is it possible to encompass the unique and diverse possibilities of nursing within one definition? Further, need this definition not adapt to technological advances and societal revolutions that have and inevitably will influence nursing practice? While outlined by a technical and legal scope, nursing practice is philosophically limitless, versatile, and everlasting; this is both its beauty and its burden in its ongoing pursuit of self-identification.

References

Bender, M. (2018). Re‐conceptualizing the nursing metaparadigm: Articulating the philosophical ontology of the nursing discipline that orients inquiry and practice. Nursing Inquiry, 25(3), 1-9. DOI: 10.1111/nin.12243.

Kim, H. S. (2015). The essence of nursing practice: Philosophy and perspective. Springer Publishing Company.

Perry, B. (2009). More moments in time: Images of exemplary nursing. Athabasca University Press.

Appendix

Figure 1

Simplified Conceptualization of Patient Relationships with Their Healthcare Team