Present Status and Future Refinements

Present Status and Fut ure Refinement s Jacqueline Fawcett, Ph. D. , F. A. A. N. Abstract The central concepts and themes of t he discipline of nursing are identified and formalized as nursing’s metaparadigm. Examples illustrate the direction provided by the metaparadigm for theory development. Refinements of the metaparadigm through conceptual models and programs of nursing research are proposed. T he discipline of nursing will advance only through continuous and systematic development and testing of nursing knowledge.

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 most work appears unfocused and uncoordinated, as each scholar moves quickly from one topic to another and as few scholars combine their efforts in circumscribed areas (Chinn, 1983; Feldman, 1980; Hardy, 1983; Roy, 1983; Walker, 1983). Broad 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 general themes. This paper identifies these central concepts and themes and formalizes them as nursing’s 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 Associate Professor, and Section Chairperson, Science and Role Development, School of Nursing, 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 Status of the Metaparadigm of Nursing The metaparadigrn of any discipline i s a statement 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 specific or concrete 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). The Central Concepts of Nursing

Evidence supporting the existence 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 care, 2) persons with health problems receiving care, 3) the environment in which care i s given, and 4 ) an end-state, well-being. (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 specify 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 Scholarship Nursing’s 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 responses 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 time 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), client (human being), environment (of the client and of the nurse-client), and health. (Newman, 1983, p. 388) There i s general agreement that the central oncepts of the discipline of nursing are the nature of nursing, the individual who received nursing care, society-environment, and health. (Chinn, 1983, p. 396) These statements indicate that there i s considerable 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 TABLE 1 THEMES OF THE YETAPARAWW OF NURSING 1. The principles and laws that govern the life-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; Gortner, 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.

They represent the metaparadigm. As such, they have provided some 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 relate 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 describe, explain, or predict individuals‘ behavior during eriods of wellness and illness. Newman’s (1979) theory of health i s one example. This theory includes the concepts of movement, time, space, and consciousness. Newman proposes that “the expansion of consciousness i s what life, and therefore health, i s a ll about” (p. 66). Another example i s Orem’s (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 Orern’s 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, Volume 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 individuals 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. King‘s (1981) theory of goal attainment i s one example. King explains: that a paradigm, or disciplinary matrix, i s more restrictive than a metaparadigm, and that i t “represents the shared commitments of any disciplinary community, including symbolic 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 step 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 Most disciplines have more than one disciplinary matrix.

Each one represents a distinctive 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 inquiry, 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 precise 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 advancement of knowledge. (Schlotfeldt, 1975, p. ) In nursing, disciplinary matrices are most clearly exemplified by such conceptual models as Johnson‘s (1980) Behavioral System Model, King’s (1981) Open Systems Model, Levine’s (1973) Conservation Model, Neuman’s (1982) Systems Model, Orem’s (1980) Self-care Model, Rogers’ (1980) Life Process Model, and Roy’s (1984) Adaptation Model. Each Image: The Journal of Nursing Scholarship 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, needs, and wants of each ember of the dyad 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) Orem’s ( 1 980) theory of nursing systems is another example. This theory maintains that ”nursing systems are formed when nurses use their abilities to prescribe, design, and provide nursing for legitimate 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 King’s model and from Orem’s 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 Johnson’s BehavioralSystem Model -An instrument for theory and research development using the behavioral systems model for nursing: The cancer 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 Levine’s Conservation Model -Effects 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 Neuman’s Systems Model Effects of information on postsurgical coping (Ziemer. 1 983) Dorothea Orem’s Self-care Model -Application of Orem’s theoretical 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 Roger’s Life Process Model -The relationship between identification and patterns of change in spouses’ body images 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: Testing the theory (Ouinn, 1 984) Callista Roy’s 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 nursing model: A look at parents adapting to the impact 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 methodology 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 institutions, 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 carry 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 argument 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 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 different ommunities of scientists to each other as w ell as t o the larger scientific community. Exemplars S till further 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 one’s 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 engage 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 evidence of exemplars in nursing. This includes but is not limited to Fitzpatrick’s (1980) programmatic research on time perception; studies o effects of information f about a threatening procedure on a patient’s responses to the procedure (e. g. , Hartfied, Cason, & Cason, 1982; Johnson, Fuller, Endress, & Rice, 1978; Ziemer, 19831, and investigations 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 significant contribution to the 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. Knowledge 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 nursing. 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 Theory developmenk What, why, how? (pp. 17-33). New York: National League for Nursing, 1978. Fawcett, 1. (1983). Hallmarks of success 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: McCraw-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. New 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 understanding 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 reported frequency of coping behaviors and development of symptoms foll owing surgery. Unpublished doctoral dissertation, University of Pennsylvania, 1982. A Response to D r. J . Fawcett’s Paper: “The Metaparadigm of Nursing: Present Status and Fut ure Refinement s” June N. Brodie, R. N. , Ph. D. D r. Fawcett’s formulation of a metaparadigm for nursing represents a commendable effort to consolidate competing nursing theories and encompasses enormous potential for the 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 didn’t do and what needs to be done). Essentially Dr. Fawcett’s 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 knowledge. 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