Earl Clarence V.

Coniconde, RN I-MAN

Dr. Eufemia F. Octaviano Nursing Theories and Conceptual Methods

NURSING THEORY AND DEVELOPMENT: RESEARCH

1. Development of Nursing Theories
Definitions: (Meleis, 1997) Philosophy is concerned with the values and beliefs of a discipline and with the values and beliefs held by members of the discipline. Philosophy focuses on providing the framework for asking both ontological and epistemological questions about central values, assumptions, concepts, propositions, and actions of the discipline. Science is a unified body of knowledge about phenomena that is supported by agreed-on evidence. Science includes disciplinary questions and provides answers to questions that are central to the discipline. Paradigm is closely associated with Kuhn (1970), who introduced the concept to members of the scientific community interested in philosophical analyses of disciplines and their development. Paradigm is defined as those aspects of a discipline that are shared by its scientific community. Domain is the perspective and the territory of the discipline. It contains the subject matter of a discipline, the main agreed-on values and beliefs, the central concepts, the phenomenon of interest, its central problems, and the methods used to provide some answers in the discipline. Phenomenon is an aspect of reality that can be consciously sensed or experienced. A phenomenon is the term, description, or label given to describe an idea about an event, a situation, a process, a group of events, or a group of situations. Phenomenon can be described from evidence that is sense based or from evidence that is is grouped together through thought connections. Assumptions are statements that describe concepts or connect two concepts that are factual, accepted as truths, and represent values, beliefs, or goals. These statements represent the thread that holds different aspects of knowledge together. When assumptions are challenged, they become propositions. Assumptions emanate from philosophy; they may or may not represent the shared beliefs of the discipline. Concept is a term used to describe a phenomenon or group of phenomena. Concept denotes some degree of classification or categorization. A concept provides us with a concise summary of thoughts related to a phenomenon; without such concise labeling. Theory is an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline that are communicated in a meaningful whole. It is a symbolic depiction of aspects of reality that are discovered or invented for describing, explaining, predicting, or prescribing responses, events, situations, conditions or relationships. Theories have concepts that are related to the disciplines phenomenon. These concepts relate to each other to form theoretical statements.

Theories are a set of interrelated concepts that give a systematic view of a phenomenon (an observable fact or event) that is explanatory & predictive in nature. Theories are composed of concepts, definitions, models, propositions & are based on assumptions.

Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior. [Robert T. Croyle (2005)]. They are derived through two principal methods; deductive reasoning and inductive reasoning. Nursing theorists use both of these methods. Theory is a creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena. A theory makes it possible to organize the relationship among the concepts to describe, explain, predict, and control practice

Nursing theory Nursing theory is defined as a conceptualization of some aspect of nursing reality communicated for the purpose of describe phenomena, explaining relationships between phenomena, predicting consequences, or prescribing nursing care. Nursing theories are reservoirs in which findings related to nursing concepts, such as comfort, healing, recovering, mobility, rest, caring, enabling, fatigue, and family care are stored. They are also reservoirs for answers related to significant nursing phenomena, such as levels of cognition after a stroke, process of recovery, refusing a rehabilitation regimen for myocardial infarction patients, and revolving admissions. Mckay (1969) logically interrelated sets of confirmed hypotheses (structure) Dickoff and James (1968) a conceptual system or framework invented for some purpose (practice goals) Barnum (1990) a statement that purports to account for or characterize some phenomenon (tentativeness) Ellis (1968) a coherent set of hypothetical, conceptual, and pragmatic principles forming a general frame of reference for a field of inquiry (research) Chinn and Jacobs (1987) - a set of concepts, definitions, and propositions that projects a systematic view of phenomena by designating specific interrelationships among concepts for purposes of describing, explaining, predicting, and/or controlling phenomena (concepts and the use of theory in practice as well as research) Fawcett (1989) are made up of concepts and propositions, they address phenomena with much greater specificity than do conceptual models, and they address the metaparadigm phenomenon of person, environment, health and nursing by specifying relationships among variables derived from these phenomena (nursing phenomena) There are many different definitions of nursing theory but according to author Cody, nursing theory is a distinct and well-articulated system of concepts and propositions rooted explicitly in a philosophy of nursing and intended solely to guide nursing practice and research (Cody, 1994, p. 144). Cody refers to this definition as the minimal criteria for any conceptual system to be called a nursing theory (p. 144). Meleis (1997) definition, however, mirrors a broader perspective when she defines nursing theory as a conceptualization of some aspect of nursing reality communicated for the purpose of describing phenomena, explaining relationships between phenomena, predicting consequences, or prescribing nursing care (p. 12). Nursing theory development many nurses have been developing their own private ideas about the practice of nursing since their first day in the field (or perhaps before) and have continued to develop private assumptions based on their readings and experiences. Nurses usually do not talk explicitly about their private theories, although these theories may influence the nursing activities they choose to implement and the manner in which they practice. If in fact all nurses are evolving private theories of nursing, why all the fuss about studying published theories? The major reason is those nurses

private conceptions of nursing may be incomplete, inconsistent, or muddled. This leads to considerable problems in using the private theory as a sound basis for practice. Further, an incomplete, inconsistent, or muddled theory may be difficult to use in studying clinical nursing situations that would advance nursing knowledge. The systematic development of scientific development has a better chance of advancing nursing and may lead to the basis for advancing nursing science. Theory Components Hage identified six components of a complete theory and specified the contribution each makes to the whole theory. These six aspects of a theory are discussed as a basis for understanding the function of each element on the theory building process. 1. Concepts - Concepts are the basic building blocks of a theory which classify the phenomena of interest. They derived their meaning from the theoretical system in which they are embedded and must not be considered separately. Concepts may be classified as abstract or concrete. Abstract concepts are independent of a specific time or place, whereas concrete concepts relate to a particular time or place. Concepts may be classified as discrete or continuous. This system of labels differentiates the concepts that specify categories of phenomena. A discrete concept identifies categories or classes of phenomena, such as patient, nurse, or environment. A continuous concept permits the classification of dimensions or gradations of a phenomenon on a continuum, such as degree of marital conflict. 2. Theoretical Statements development of theoretical statements asserting a connection between two or more concepts introduces the possibility of analysis. This can be classified into 3 categories namely: Existence statements specific concept, simply asserts that a given concept exists and is labeled with a concept name Definitions specific concept, provides descriptions of the concept Relational Statements asserts relationships between the properties of two or more concepts or variables. 3. Definitions it is crucial that the concepts are as clearly defined as possible to reduce any ambiguity in understanding the given concept or set of concepts. Both theoretical (meaning) and operational (measurement) definitions provide meaning for the concept and a basis for seeking empirical indicators. It also permits consideration of the relationship between a given concept and other theoretical ideas, but concepts must be measurable by relating concepts to observable phenomena. 4. Linkages the development of a. theoretical linkages (plausibility) offers an explanation of why the variables in the theory may be connected in some manner; that is asserting particular interrelationships. b. Operational linkages (testability) contribute the element of testability to the theory by specifying how variables are connected. The operational linkage contributes a perspective for understanding the nature of the relationship between concepts, such as whether the relationship between the concepts is negative or positive, linear or curvilinear. 5. Ordering Hage stated that complete development of the theory requires organizing statements and linkages into premises and equations. As theory evolves, concepts and theoretical statements multiply and the need to establish some logical arrangement or ordering of the theoretical components arises to bring conceptual order to the theory. This process of ordering may identify any existing overlap between concepts and definitions.

Basic processes in the development of nursing theories: Nursing theories are often based on & influenced by broadly applicable processes & theories. Following theories are basic to many nursing concepts. General System Theory It describes how to break whole things into parts & then to learn how the parts work together in systems. These concepts may be applied to different kinds of systems, e.g. Molecules in chemistry, cultures in sociology, and organs in Anatomy & Health in Nursing. Adaptation Theory It defines adaptation as the adjustment of living matter to other living things & to environmental conditions. Adaptation is a continuously occurring process that effects change & involves interaction & response. Human adaptation occurs on three levels : o The internal (self) o The social (others) & o the physical (biochemical reactions) Developmental Theory It outlines the process of growth & development of humans as orderly & predictable, beginning with conception & ending with death. The progress & behaviors of an individual within each stage are unique. The growth & development of an individual are influenced by heredity, temperament, emotional, & physical environment, life experiences & health status. Purposes of theory in practice Assist nurses to describe, explain, and predict everyday experiences. Serve to guide assessment, intervention, and evaluation of nursing care. Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. Help to establish criteria to measure the quality of nursing care Help build a common nursing terminology to use in communicating with other health professionals. Ideas are developed and words defined. Enhance autonomy (independence and self-governance) of nursing by defining its own independent functions.

PURPOSES OF NURSING THEORIES In Practice: Assist nurses to describe, explain, and predict everyday experiences. Serve to guide assessment, interventions, and evaluation of nursing care. Provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. Help to describe criteria to measure the quality of nursing care. Help build a common nursing terminology to use in communicating with other health professionals. Ideas are developed and words are defined. Enhance autonomy (independence and self-governance) of nursing through defining its own independent functions.

In Education: Provide a general focus for curriculum design Guide curricular decision making. In Research: Offer a framework for generating knowledge and new ideas. Assist in discovering knowledge gaps in the specific field of study. Offer a systematic approach to identify questions for study; select variables, interpret findings, and validate nursing interventions. Approaches to developing nursing theory Borrowing conceptual frameworks from other disciplines. Inductively looking at nursing practice to discover theories/concepts to explain phenomena. Deductively looking for the compatibility of a general nursing theory with nursing practice. Questions from practicing Nurse about using Nursing theory Classification of nursing theories A. Depending On Function (Polit et al 2001) o Descriptive-to identify the properties and workings of a discipline o Explanatory-to examine how properties relate and thus affect the discipline o Predictive-to calculate relationships between properties and how they occur o Prescriptive -to identify under which conditions relationships occur B. Depending on the Generalizability of their principles Metatheory: the theory of theory. It identifies specific phenomena through abstract concepts. Grand theory: provides a conceptual framework under which the key concepts and principles of the discipline can be identified. Middle range theory: is more precise and only analyses a particular situation with a limited number of variables. Practice theory: explores one particular situation found in nursing. It identifies explicit goals and details how these goals will be achieved. School of thoughts in Nursing Theories-1950-1970

Need theorists

Interaction Theorists

Outcome theorists

Abdellah Henderson Orem

King Orlando Peterson and Zderad Paplau Travelbee Wiedenbach

Johnson Levine Rogers Roy

C. Based on the philosophical underpinnings of the theories 1. Needs theories These theories are based around helping individuals to fulfill their physical and mental needs. Needs theories have been criticized for relying too much on the medical model of health and placing the patient in an overtly dependent position. 2. Interaction theories As described by Peplau (1988), these theories revolve around the relationships nurses form with patients. Such theories have been criticized for largely ignoring the medical model of health and not attending to basic physical needs. 3. Outcome theories Outcome theories portray the nurse as the changing force, who enables individuals to adapt to or cope with ill health. Outcome theories have been criticized as too abstract and difficult to implement in practice. 4. Humanistic Theories Humanistic theories developed in response to the psychoanalytic thought that a persons destiny was determined early in life. Humanistic theories emphasize a persons capacity for self-actualization. Humanists believe that the person contains within himself the potential for healthy & creative growth. Carl Rogers developed a person centered model of psychotherapy that emphasizes the uniqueness of the individual.The major contribution that Rogers added to nursing practice is the understandings that each client is a unique individual, so, person-centered approach now practice in nursing. Conclusion o Theory and practice are related. o A theory presents a systematic way of understanding events or situations. o It is a set of concepts, definitions, and propositions that explain or predict these events or situations by illustrating the relationships between variables. o Theories must be applicable to a broad variety of situations. They are, by nature, abstract, and dont have a specified content or topic area. Like empty coffee cups, theories have shapes and boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems. [Robert T. Croyle (2005)]

2. Evolution of Nursing Knowledge and Theories

The history of professional nursing begins with Florence Nightingale. Her central theory is to facilitate the bodys reparative processes by manipulating clients environment (1860). o H. Peplau (1952): Nursing is; therapeutic interpersonal process. o V. Henderson (1955): The needs often called Hendersons 14 basic needs o F. Abdellah (1960): The nursing theory developed by Faye Abdellah et al., emphasizes delivering nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family. o I.J. Orlando (1962): the client is an individual; with a need; that, when met, diminishes distress, increases adequacy, or enhances well-being. o D. Johnsons Theory (1968): Dorothy Johnsons theory of nursing focuses on how the client adapts to illness and how actual or potential stress can affect the ability to adapt. The goal of nursing to reduce stress so that; the client can move more easily through recovery. o M. Rogers (1970): to maintain and promote health, prevent illness, and care for and rehabilitate ill and disabled client through humanistic science of nursing o D. Orem (1971) : This is self-care deficit theory. Nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental, or social needs.

o o o o

I. King (1971): To use communication to help client reestablish positive adaptation to environment. B. Neuman (1972): Stress reduction is goal of system model of nursing practice. C. Roy (1979): This adaptation model is based on the physiological, psychological, sociological and dependence-independence adaptive modes. J. Watsons Theory (1979): Watsons philosophy of caring 1979 attempts to define the outcome of nursing activity in regard to the; humanistic aspects of life. Later in last century nursing began with a strong emphasis on practice. Following that came the curriculum era which addressed the questions about what the nursing students should study in order to achieve the required standard of nursing. As more and more nurses began to pursue higher degrees in nursing, there emerged the research era. Later graduate education and masters education was given much importance. The development of the theory era was a natural outgrowth of the research era. With an increased number of researches it became obvious that the research without theory produced isolated information; however research and theory produced the nursing sciences. Within the contemporary phase there is an emphasis on theory use and theory based nursing practice and lead to the continued development of the theories.

3. Conceptual and Theoretical Framework of Nursing 4 Essential concepts common among nursing theories:
1. Persons

Needs; Cultures; Wholeness; Development; Behavior

2. Health

Wholeness; Healing; Self-care; Wellness; Coping; Illness; Stress/crisis 3. Environment

Health care systems; Social support; Physical; Sociocultural Family 4. Nursing: Caring in the human health experience

Processes Leadership Change process Nursing process Decision making Research process Teaching and learning Collaboration Physical care Interpersonal relationships

Approaches Empowerment Reconciliation Partnership Presence Grace Justice Service Agape love Advocacy

Role Functions Practitioner Consultant Researcher Teacher Manager

Professional Responsibilities Peer support Career development Economic Organizational Legal Political Ethical Quality review

Florence Nightingales Environmental Theory

Defined Nursing: The act of utilizing the environment of the patient to assist him in his recovery. Focuses on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act. Identified 5 environmental factors: fresh cleanliness/sanitation and light/direct sunlight. air, pure water, efficient drainage,

Considered a clean, well-ventilated, quiet environment essential for recovery. Deficiencies in these 5 factors produce illness or lack of health, but with a nurturing environment, the body could repair itself.

Dorothea Orems Self-Care Theory

Defined Nursing: The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness. Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-being. Has a strong health promotion and maintenance focus. Identified 3 related concepts:

Self-care activities an Individual performs independently throughout life to promote and maintain personal well-being. Self-care deficit results when self-care agency (Individuals ability) is not adequate to meet the known selfcare needs. Nursing System nursing interventions needed when Individual is unable to perform the necessary self-care activities: Wholly compensatory nurse provides entire self-care for the client.

Example: care of a new born, care of client recovering from surgery in a post-anesthesia care unit Partial compensatory nurse and client perform care, client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently. Example: Nurse can assist post operative client to ambulate, Nurse can bring a meal tray for client who

can feed himself Supportive-educative nurses actions are to help the client develop/learn their own self-care abilities through knowledge, support and encouragement. Example: Nurse guides a mother how to breastfeed her baby, Counseling a psychiatric client on more adaptive coping strategies.

Virginia Hendersons Definition of the Unique Function of Nursing Defined Nursing: Assisting the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge. Identified 14 basic needs :

Breathing normally Eating and drinking adequately Eliminating body wastes Moving and maintaining desirable position Sleeping and resting Selecting suitable clothes Maintaining body temperature within normal range Keeping the body clean and well-groomed Avoiding dangers in the environment Communicating with others Worshipping according to ones faith Working in such a way that one feels a sense of accomplishment Playing/participating in various forms of recreation Learning, discovering or satisfying the curiosity that leads to normal development and health and using available health facilities.

Madeleine Leiningers Transcultural Care Theory and Ethnonursing

Nursing is a learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps

or death. Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-

illness caring practices, beliefs and values with the goal to provide meaningful and efficacious nursing care

services to people according to their cultural values and health-illness context. Focuses on the fact that different cultures have different caring behaviors and different health and illness values, beliefs, and patterns of behaviors. Awareness of the differences allows the nurse to design culture-specific nursing interventions.

Callista Roys Adaptation Theory

Viewed humans as Biopsychosocial beings constantly interacting with a changing environment and who cope with their environment through Biopsychosocial adaptation mechanisms. Focuses on the ability of Individuals., families, groups, communities, or societies to adapt to change. The degree of internal or external environmental change and the persons ability to cope with that change is likely to determine the persons health status. Nursing interventions are aimed at promoting physiologic, psychologic, and social functioning or adaptation.

Martha Rogers Concept of Science of Unitary Human Beings, and Principles of Homeodynamics

Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and is concerned with the nature and direction of human development. The goal of nurses is to participate in the process of change..

Nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen the wholeness of the Individual and redirect human and environmental patterns or organization to achieve maximum health.

5 basic assumptions: 1. 2. 3. 4. 5. The human being is a unified whole, possessing individual integrity and manifesting characteristics that are more than and different from the sum of parts. The individual and the environment are continuously exchanging matter and energy with each other The life processes of human beings evolve irreversibly and unidirectionally along a space-time continuum Patterns identify human being and reflect their innovative wholeness The individual is characterized by the capacity for abstraction and imagery, language and thought, sensation and emotion

Hildegard Peplaus Interpersonal Relations Theory

Defined Nursing: An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help. Nursing is a maturing force and an educative instrument

Identified 4 phases of the Nurse Patient relationship: Orientation individual/family has a felt need and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase. Identification where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which

inner strength ensues. Here happens the selection of appropriate professional assistance.

Exploitation the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services. Resolution where patients needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.

Lydia Halls Key Concepts of Three Interlocking Circles Theory

Nursing is participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team.

The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core.

Dorothy Johnsons Key Concepts of Behavioral System

Each individual has patterned, purposeful, repetitive ways of acting that comprises a behavioral system specific to that individual.

Faye Glenn Abdellahs Concept of Twenty One Nursing Problems

Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgement. Nursing is a comprehensive service that is based on the art and science and aims to help people, sick or well,

cope with their health needs. 21 Nursing Problems 1. 2. 3. 4. 5. 6. 7. 8. 9. To maintain good hygiene. To promote optimal activity; exercise, rest and sleep. To promote safety. To maintain good body mechanics To facilitate the maintenance of a supply of oxygen To facilitate maintenance of nutrition To facilitate maintenance of elimination To facilitate the maintenance of fluid and electrolyte balance To recognize the physiologic response of the body to disease conditions

10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory functions 12. To identify and accept positive and negative expressions, feelings and reactions 13. To identify and accept the interrelatedness of emotions and illness. 14. To facilitate the maintenance of effective verbal and non-verbal communication 15. To promote the development of productive interpersonal relationship 16. To facilitate progress toward achievement of personal spiritual goals 17. To create and maintain a therapeutic environment 18. To facilitate awareness of self as an individual with varying needs. 19. To accept the optimum possible goals 20. To use community resources as an aid in resolving problems arising from illness. 21. To understand the role of social problems as influencing factors Imogene Kings Goal Attainment Theory

Nursing is a process of action, reaction, and interaction whereby nurse and client share information about their perception in the nursing situation

Jean Watsons The Philosophy and Science of Caring

Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health. Nursing is a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human care transactions She defined caring as a nurturant way or responding to a valued client towards whom the nurse feels a personal sense of commitment and responsibility. It is only demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the person as what he/she may become in

a caring environment Carative Factors: 1. 2. 3. 4. 5. 6. 7. 8. 9. The promotion of a humanistic-altruistic system of values Instillation of faith-hope The cultivation of sensitivity to ones self and others The development and acceptance of the expression of positive and negative feelings. The systemic use of the scientific problem-solving method for decision making The promotion of interpersonal teaching-learning The provision for supportive, protective and corrective mental, physical, socio-cultural and spiritual environment Assistance with the gratification of human needs The allowance for existential phenomenological forces

Rosemarie Rizzo Parses Theory of Human Becoming

Nursing is a scientific discipline, the practice of which is a performing art Three assumption about Human Becoming 1. Human becoming is freely choosing personal meaning in situation in the intersubjective process of relating value priorities

2. 3.

Human becoming is co-creating rhythmic patterns or relating in mutual process in the universe Human becoming is co-transcending multidimensionally with emerging possibilities.

4. Philosophy and Theories in Health Care Delivery

There seems to be some disagreement amongst nurse theorists regarding what is meant by the term philosophy. Schrock (1981a) points out that philosophy of nursing is often mistakenly construed to refer to an ideology of nursing. She construes ideology, roughly, as a set of unexamined presuppositions which influence attitudes and practices. Schrock offers the examples of views such as nurses are born, not made. [And] nursing is an art based on common sense (Schrock 1981a p. 11). Weidenbach may commit the mistake which Schrock warns against. Apparently, for her Philosophy [is] an attitude toward life and reality that evolves from each nurses beliefs.... She suggests that philosophy might best be characterized in terms of its methods and its problems (Schrock 1981b). More recently, Simmons has offered the following definition of philosophy By philosophy, I mean knowledge of first causes or of the highest principles of things in so far as these causes or things belong to the natural, as opposed to the supernatural, order (Simmons 1992 p. 112). She goes on to add that this, more properly, should be understood only as a definition of metaphysics. Simmons offers no reference in support of her definition, and as it stands it seems vulnerable to some quite serious objections. First, skeptical philosophers doubt that it is possible to obtain any knowledge of anything (Ayer 1956). So a (philosophical?) claim to the effect that one could not be certain of the existence of anything would not count as philosophy by Simmons criterion. Hence she seems wrong to restrict philosophy to knowledge of first causes, or indeed, to knowledge of anything else. Second, her definition seems to omit large chunks of the works of Descartes and Plato. Each of these philosophers discuss extensively phenomena which lie beyond the natural world. Apart from discussing God, Descartes (1970) famously argued for the existence of a spiritual mind-stuff. Plato (1955), equally famously, posited the existence of a world of forms beyond the natural world. So it seems plausible to claim that Simmons definition of philosophy (or even metaphysics) is open to very serious objection. Salsberry (1994) tries to set out what is described as a philosophy of nursing. This involves, she suggests, three components. First, an ontology which informs us what the fundamental entities are those exists within the domain of nursing (Salsberry 1994 p. 13). Second, an epistemology which involves claims about how the basic phenomena can be known (Salsberry 1994 p. 13). And third, an ethics: statements about what one values (Salsberry 1994 p. ??). Salsberry suggests that these three components comprise the form of a philosophy of nursing as opposed to the substance of such a philosophy. In spite of the excellence of Salsberrys paper, a worry remains. Why is she concerned to set out a philosophy of nursing rather than to characterise philosophy of nursing suggestion. per se? The claim that one is developing a philosophy of nursing clearly implies that there are other possible philosophies of nursing. The title of Salsberrys paper (A philosophy of nursing: what is it? what is it not?) suggests that she is out to characterize one member of a class the class of philosophies of nursing as opposed to setting out, more generally, the criteria for membership of the class. In other words, she deliberately omits to give an account of philosophy of nursing in favor of giving an account of one particular philosophy of nursing. A way in which the distinctive character of philosophical questions can be identified is by making use of Carnaps (1950) distinction between internal and external questions. Roughly, Carnap develops the notion of linguistic frameworks. Carnap proposes that internal questions are questions which presuppose the very general claims upon which discourse within a framework depends for its intelligibility. Three elements of philosophical enquiry have been identified. The first is the kind of analysis which comprises the linguistic framework of nursing discourse the underlaborer view. The second is the concern with particular problems traditionally regarded as philosophical problems (e.g. those of

metaphysics and epistemology). And the third element of philosophical enquiry involves the development of a criterion for the identification of philosophical questions. Such questions are those which Carnap describes as external questions. The identification of these three elements of philosophical enquiry supports the proposal that philosophy of nursing similarly be comprised of the three elements. For author Olga Jarrin (2007), situated caring, as a unifying frame, provides one voice for nursing within the political world. Too often, nurses are viewed as disparate groups not knowing what the whole of nursing is all about. This tendency toward separation and distinction gets blurred when situated caring is the focus. Policy activities will be more focused and more unified with this type of approach. Likewise, as nursing researchers explore the relationship between caring and healing, the value of nursing will be translated into cost effective care and positive outcomes. An Integral approach to asking and answering research questions will generate creative research designs that will showthe value of a nurses inner state and intention, their relationship with others, and the overall value of non-measurable knowledge. Immanuel Kant, a German philosopher, maintained that reality is not only a thing in and of itself but is also constructed by those who experience it. Reality in nursing history has been a synthesis of conditions that predisposed nurses to a nontheoretical existence and an a priori perception that helped to promote a lack of acceptance of theoretical themes. Kant aptly distinguished between perception of experience and sensation of experience. Sensation of experience is confounded by temporal and spatial limitations. Experience, the basis of knowledge, has, in nursing, depended on this or that procedure as performed at a certain moment, or on the knowledge of this or that patient occupying a certain space and existing at a certain moment. Although knowledge evolves from experience, Kant maintained that this does not mean that all knowledge evolves from experience. To him, our experiences have two components: an a priori impression of what may be experienced and impressions as they are actually received. Understanding is a synthesis of both. Therefore, a human being a knowing, active, and experiencing subject, not a passive recipient interprets and analyzes impression data in a certain way the a priori form by which experiences are shaped is a synthesis of something that is out there and something that is constructed by the person experiencing it. (Copleston, 1964). Experience provided the impetus for describing and explaining phenomena central to nursing and perhaps was responsible for the development of new therapeutics to promote health, to change environment, or to control unwanted events related to health care.

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