[Scholarly Paper] What Do I Think I Know Now?

As the single largest group of regulated health care professionals in Canada, the value of nurses cannot be overstated, though it has been historically argued (Registered Nurses Association of Ontario, RNAO, 2017). In 2017, the RNAO published a report in protest to government nursing budget cuts, detailing the “tremendous value” of nurses and citing a “rich body of evidence” indicating that registered nursing care “is directly linked to positive outcomes on numerous patient, organizational and financial markers” (p. 1). Despite the fact that the profession has evolved over centuries, is regularly regarded as the most trusted, and holds itself to laudable entry-to-practice academic and professional standards, nurses seem to continually need to advocate for and prove their significance as governments, funding, and job availability cycle (Canadian Nurses Association, CNA, 2015).

In order for nurses to develop an ontological and epistemological understanding of their profession, and contribute to its evolution and preservation, it is critical for them to also understand their profession’s history and development (CNA, 2007). Over time, the scope of nursing has broadened, a scholarly body of literature has been established, the profession became self-regulated, and there has been a pursuit for a universal definition of the role. Change is an inevitable part of society, particularly in health care, which is a field that responds to inherently dynamic human conditions, environments, and social contexts. The challenge for a profession that is necessarily contextualized by change, then, is establishing a formal identity. A review of the broad collection of nursing theories suggests that being a nurse and utilizing nursing knowledge is extremely variable and dependent on individual nurse experiences, with some potentially universal themes and commonalities threading among the theories. As a nurse practicing in the emergency department, for example, my experiences differ significantly from those of a public health nurse; consequently, my definition of a nurse and the forms of knowledge that I utilize in my practice will also differ. However, given that our professional licensure, education, and scope of practice are the same, the implication is that there should be common elements between our identities and knowledge bases. It is these common elements which nurse theorists strive to elucidate and articulate into a functional, comprehensive conceptualization of nursing. Having reviewed scholarly literature and reflected on my experiences as a practicing nurse, I have developed a personal understanding of being and knowing as a nurse, and a sense of my role in the future advancement of the nursing knowledge base, all of which I will discuss in this paper.

My Personal Philosophy of Nursing

Perry articulated in her book on exemplary nursing, “An essential feature of nursing is that it is an experience between human beings, primarily between patients and nurses” (Perry, 2009, p. 26). In a sense, the role of a nurse becomes redundant without a patient to care for, meaning the patient must be, to some degree, an integral part of the ontology of nursing (Fistein & Malloy, 2014). In the CNA framework for registered nurses, each part of the definition of nurse includes the patient as a focal point, whether they be an individual, community, population, or even healthcare system as a macrocosm (2015). Kim, in her influential book on the essence of nursing, even went so far as to declare that, although nursing practice involves a variety of roles ranging from administrative work to policy development and planning, it is actually the patient-facing roles that fundamentally create meaning in and define the nursing profession (2015). While I agree with each of these sentiments as they reflect my own understanding of nursing, I hesitate to assign so much responsibility to the patient as integral to the definition of nursing. In an article on ethics and ontology of nursing, Fistein and Malloy warned of the pitfalls of basing the profession’s worth on the existence of a patient: that objectifies the patient and renders them interchangeable to the nurse’s experience (2014). In practice, no two patients are the same, and the nurse’s role must always change, adapt, and evolve to meet the unique requirements of individual patients.

Certainly, key elements of being a nurse include the license that grants nurses the responsibility to care for patients, the medical and scientific knowledge that affords nurses the ability to treat and heal patients, and the technical skills that allow nurses to physically care for and manage patients. However, each of these cannot exist in isolation from “how accurately, comprehensively, and justifiably nurses understand their clients” (Kim, 2015, p. 36). My philosophy of nursing is that, in order for nurses to achieve their ontological goal of empowering and enabling patients to meet their unique health, psychosocial, or spiritual needs – as self-identified by the patient within their specific, dynamic context – nurses must remain flexible to continually learn, adjust, and perform their actions with the establishment of a therapeutic relationship with the patient as the beginning and most important factor in the planning of care and associated interventions. The centrality of the patient to the nursing experience is one of the least argued aspects of nursing theory. In Fawcett’s four-part metaparadigm of nursing, which is often used to define nursing in entry-to-practice academia and by the CNA framework, the element of the patient is interwoven through the pillars of person, health, environment, and nursing (CNA, 2015). Despite Fawcett’s theory being heavily criticized for its rigid structure and tenuous definitions of its pillars, the importance of the patient to nursing practice remains generally uncontested (Bender, 2018). However, the patient does not exist in isolation within the healthcare system. While the patient’s unique needs validate the nurse’s role in the healthcare system within the context of their relationship, it is the nurse’s establishment of connection with the patient that facilitates and affects the patient’s experience.

In the emergency department, the distinction between utilizing the patient as a source of professional fulfillment and leveraging the professional self to fulfill the patient’s unique needs is often overlooked in favor of the former. In this fast-paced clinical setting, patients are often processed with a task-based approach, with the goals of task efficiency and speed, which is best achieved in an assembly line fashion. With this approach, nurses may view patients as interchangeable; on extremely busy days, I have found myself at times inserting IVs and drawing blood without having even spoken a complete sentence to the patient, let alone developed a therapeutic relationship with them. As Fistein and Malloy warned, this focuses on the patient as a “physical host of pathology… [so that] physical needs may be addressed but psychological ones, including dignity, may not be” (2014). However, while the physical body is undeniably a key consideration of medical treatment, “humans transcend their bodies in their existence as it has meanings stretching beyond the matters of body” (Kim, 2015, p. 7). As nurses, we must consider the human holistically in order to meet our ontological purpose. While it was not obvious to me earlier in my career, this aspect of forming a therapeutic relationship, in which my nursing identity is tied to serving patient needs in consideration of their holistic existence, is so critical to my ontological perspective of nursing that my personal satisfaction from the profession is significantly diminished when I cannot do so. Now, upon refining my perceptions of nursing practice, it is evident that the constraints of my practice environment were barriers to meeting expectations of my own practice as a nurse.

Applying Nursing Knowledge in My Practice

Early in my nursing training and career, my focus was, admittedly, on the physical aspects of care as I developed my technical skills and relied on more experienced nurses for advice on mediating patients’ psychosocial needs. The holistic picture of the patient, inclusive of the social and cultural dimensions of their contextualized healthcare experience, was almost completely elusive to me, as a novice, and even advanced beginner, nurse. It was during this early period in my career when my understanding of nursing was limited to the technical aspects of evidence-based practice and authoritative knowledge learned in school, which occupied much of my focus as I gained a mastery of the task-oriented skills required of an emergency department nurse. While these skills, such as IV insertions and medication administration, wound care and dressing changes, and physical assessments, seemed of utmost importance, my practice felt limited and comparatively lacking the nuance and perceptiveness of my more experienced colleagues. As an individual whose philosophy of life is based on lifelong learning and rising to challenges, this gap that I sensed in my practice presented itself as a point of self reflection and inspired me to seek deeper connections with my patients. Over time, I started to notice patterns and trends among varieties of symptoms or complaints with which patients presented, such as the connection between patients with addictions and their psychosocial background of trauma and mental health issues, or patients with uncontrolled hypertension and their disadvantaged socioeconomic background. In understanding these patterns and connections, my interactions with patients became adaptive to the patient’s unique circumstances, such as the provision of education in variable ways so that it could be effective for each patient or providing emotional support to the patients that needed it and silence for those that did not. Consequently, my confidence in advocating for them increased as I continued to gain experience. I felt justified in contributing to the development of and modifying my patients’ care plans according to their dynamic needs. I advocated to avoid restraint usage and, instead, I treated the anxious mental health patient with anti-anxiety medications and psychotherapy. I advocated for a docile family when noticing the signs that their care goals for their incapacitated relative were not being adequately met by the care team. My actions became supported by deeper forms of knowledge about my patients.

This development over the course of my clinical experience progressed in a subconscious manner but was substantial and followed a pathway supported by nursing theory. Benner’s Novice to Expert theory, in particular, outlines a similar progression of nursing practice based on a shift in advancement and application of knowledge. What I described as my career evolution aligns with Benner’s conceptualization of the novice and advanced beginner as relying primarily on empirical knowledge, with a gradual shift to the inclusion of aesthetic, experiential, and sociopolitical knowing in pattern recognition and establishing therapeutic relationship with patients as a competent nurse - forms of knowing which have been defined by Carper (Bonsu, 2012; Davis & Maisano, 2016). With an even greater shift away from authoritative, empirical knowledge, I became a proficient nurse as I advocated for my patients and contributed to their care plans. Eventually, the expectation is to rely almost exclusively on the latter forms of knowing as an expert nurse, the synergistic accumulation of which I believe to be the essence of the coveted intuition of an expert nurse (Davis & Maisano, 2016).

While I identified with this progression of nursing knowledge application, it remains at odds with my personal philosophy as a lifelong learner since the theoretical progress is completed at the expert level. However, with the dynamism inherent to human nature and the ever-changing society, inclusive of advancing technology and cycling politics, in which nurses practice, I am skeptical of reaching a point of expertise that will not be continually challenged by new experiences and the need for new knowledge. Despite working within the same scope and same capacity as a nurse, new and different situations will continually arise in which the expert nurse cannot apply intuition, and thus, will have to revert to authoritative or empirical knowledge in order to manage. This creates inconsistency in the applicability of the Novice to Expert theory in practice. Evidently, the universal definition of nursing is not the only endeavor evading nursing theorists; outlining the application of nursing knowledge throughout career progression and into the foreseeable future is equally challenging.

My Future Contributions to Nursing Knowledge

As a lifelong learner and scholar with higher level education, I have the training and opportunity to contribute to nursing knowledge, perhaps even to solve these existential and epistemological questions of the nursing profession. A key criticism that is made about the creation and implementation of nursing theories is the excessive use of jargon and complex terminology that is essentially meaningless to the average nurse (Murphy et al., 2010). Given my secondary profession and skillset as a writer, I envision my contribution to the nursing knowledge base to take the form of education and information dissemination through written media, in partnership with nursing scholars who are more adept at the creative conceptualization of theories. Theoretical nursing models have been criticized because they were too “idealised, lacked relevance to the reality of nursing, and, as such, increased the gap between theory and practice” (Murphy et al., 2010, p. 20). I am in an opportune mindset and position to also address this key barrier that nurses typically face in theory application, as a nurse practicing at the bedside at a proficient level, coupled with my philosophy of ongoing learning and development through my career at the bedside.

Another area of nursing knowledge that I aim to contribute to is in emphasizing the relevance of nursing’s history to its present day profession, and how that history has shaped and continues to inform our identity as nurses. This paper was introduced with the importance of nurses knowing their history in order to have a deeper understanding of their profession. After exploring the complexity of defining nursing ontologically and establishing an epistemological basis for practice, it is understandable why without appreciating how nursing became the profession we practice today, nurses cannot truly embody and connect with the profession. The CNA emphasized the importance of historical knowledge in nursing, stating that “learning from nursing history is critical to advancing the profession… and encourages different forms of critical thinking among nurses” (CNA, 2007, p. 1). It is the responsibility of nurses to “preserve history” and of nursing educators “for imparting a sense of the value of nursing history” (CNA, 2007, p. 1). As becoming a nurse educator is my future desired role in the profession, I can make a significant impact in enhancing nurses’ knowledge of their professional history through curriculum development and publications on the subject.

Conclusion

The profession of nursing has existed for over a century, with the majority of its formalization, self-regulation, and development of a unique scholarly body having been established in the recent few decades. However, the fundamental nature of nursing as a humanistic endeavor to connect with patients, heal patients on their own terms, and exhibit values of trustworthiness and morality have been enduring themes throughout nursing history and its public perception. To some extent, nursing scholars have a responsibility to continue upholding these values in their nursing models; consequently, they are also obligated to develop theories that center on or strive to contextualize and define these enduring values as they relate to nurses’ connection with the patient experience. Perhaps one of the reasons that theory is often challenging to translate into practice is nurses’ unfamiliarity with their history, which my experience suggests is becoming increasingly common among new graduate nurses. Without awareness of the profession’s history, nurses may miss a meaningful aspect of the formation of present identity and will experience challenges in advancing the future of the profession. While change is inevitable, it is up to us to influence whether it is for better or worse.

References

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