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research-article2014

NSQXXX10.1177/0894318414522665Nursing Science QuarterlyDoucet and Merlin / Practice Applications

Practice Applications Nursing Science Quarterly 2014, Vol. 27(2) 118­–125 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0894318414522665 nsq.sagepub.com

Conceptualizations of Health in Nursing Practice Thomas J. Doucet, RN; PhD1 and Marjolaine Dionne Merlin, RN; MScN2

Abstract There are many ways of living health as individuals describe it from unique perspectives. With the intent of serving others, healthcare professionals rely on a specific conceptualization of health consistent with a practice methodology. Hence, for the advancement of innovative scientific knowledge health can be viewed from distinct paradigmatic perspectives and must be founded on a congruent ontological-epistemological-methodological link in professional practice. The purpose of this column is to describe conceptualizations of health with congruent practice methodologies from three distinct nursing paradigmatic perspectives. The authors consider that these distinct paradigmatic nursing perspectives offer diverse disciplinary knowledge of social utility to nursing professional practice for the betterment of the ones being served. Keywords health, nursing paradigmatic perspectives, professional practice, theoretical frame of reference Parse (2001) defined a paradigm as a way of seeing the world based on a philosophical posture. The scientific foundation of a paradigm must present a congruent ontologicalepistemological-methodological link. According to Kuhn (1970), a change of paradigm is a new construction of fundamental scientific elements that proposes novel theoretical generalizations for innovative professional applications. Though health is not always articulated with established explicit arguments (Polanyi, 1958), a change of paradigm highlights implicit rules that allow for the abstraction of novel practice methodologies (Kuhn, 1970) in coming to know the living experiences of those served (Parse, 2012). The purpose of this column is to present one specific nursing theoretical work from three distinct paradigmatic perspectives to highlight various conceptualizations of health congruent with professional nursing practice. Indeed, theory guides practice.

perspective will identify patterns with the intent to highlight pattern recognition, while the humanbecoming nurse’s intent is to draw attention to universal human living experiences as individuals illuminate meaning, synchronize rhythms, and inspiring transcending(Parse, Personal communication, June 2013). Fawcett affirmed that the unique contribution of nursing professional practice is important because “nursing conceptual models and nursing theories are crucial to providing a rationale for what nurses do and why they do what they do” (Butts, Rich, & Fawcett, 2012, pp. 152-153). Hence, the study of a nursing theoretical work is needed to guide professional practice

The Totality Paradigm: Context as the Inescapable Variable of Health Rooted in the works of Nightingale, Parse (1987) described the totality paradigm as:

Paradigmatic Perspectives in Nursing Although several nurse scholars have conceptualized contrasting paradigmatic perspectives in nursing science (Fawcett & DeSanto-Madeya, 2013), Parse (2013) proposed the existence of the totality, simultaneity, and humanbecoming paradigms as extant perspectives of the nursing discipline. These perspectives are based on a specific differences among their ontologies, epistemologies, and methodologies. A nurse guided by a chosen nursing theoretical work from the totality perspective will identify human attributes of health and practice using steps of the nursing process, whereas the nurse guiding practice from the simultaneity

“Man [sic] is considered a bio-psycho-socio-spiritual organism whose environment can be manipulated to maintain or promote balance. Man [sic] interacts with the environment, establishes transactions, and plans toward goal attainment. Capable of selfcare, Man [sic] is an adaptive organism who may require 1

Assistant Professor, Université de Moncton, Canada Université de Moncton, Canada

2

Contributing Editor: Paula M. Karnick, RN, PhD, Director, Institute of Nursing Education, Emergency Nurses Association, Desplaines, IL. Email: [email protected]

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Doucet and Merlin / Practice Applications assistance with coping and meeting some self-care demands. Health is viewed […] as being a dynamic state and process of physical, psychological, social and spiritual well-being” (p. 32).

Newman, Sime, and Corcoran-Perry (1991) addressed this perspective as the interactive-integrative paradigm. The importance of context is viewed as multiple relations of interrelated biological, psychological, social, and spiritual data by which individuals construct the reality of subjective health experiences in an integrated whole: “To explain a phenomenon, the interrelationships of parts and the influence of context are taken into consideration” (Newman, Sime, &Corcoran-Perry, 1991, p. 4). Hence, from the totality perspective context is considered an ineluctable variable of health for which the goal of nursing is “health promotion, care and cure of the sick, and prevention of illness” (Parse, 1987, p. 32). From the totality perspective, different nursing models and theories (goal attainment, self-care, and system stability, to name a few) guide professional practice. To bring to light the congruent ontological-epistemological-methodological link of a nursing conceptual model derived from the totality paradigm, the authors here selected the work of Roy (2009). A synopsis of the Roy Adaptation Model (RAM) and its specific practice methodology are briefly discussed followed by the presentation of a care plan. Readers are encouraged to study the last edition of Roy’s (2009) book.

The Roy Adaptation Model and Practice Methodology The Roy adaptation model (RAM) (2009) postulated philosophical, scientific, and cultural assumptions. Health is defined as “a state and a process of being and becoming integrated and whole” (Roy, 2009, p. 29). According to Roy (2009), humans are adaptive systems. Adaptation is “The process and outcome whereby thinking and feeling people, as individuals or in groups, use conscious awareness and choice to create human and environmental integration” (Roy, 2009, p. 26). The goals of adaptation are “survival, growth, reproduction, mastery, and human and environment transformations” (Roy, 2009, p. 39). RAM stated that interrelationships of parts function as a whole of which stimuli provoke coping processes as ways of interacting with the internal and external environments to contribute to human adaptive systems. These processes are different for individuals and groups. Yet, these processes operate on four adaptive modes for which various adaptive levels are observable in behavior. A stimulus is that which influences behavior. They may be focal, contextual, or residual. Roy (2009) also stated that behavior, coping processes, adaptive modes, adaptive levels, or environment might act as a stimulus of one type or another. Roy (2009) defined environment as “All conditions, circumstances, and influences that surround and affect

the development and behavior of humans as adaptive systems” (p. 26). Stimuli act on innate and/or acquired coping processes. Coping processes for the individual include the regulator and the cognator subsystems. The regulator subsystem responds to stimuli to maintain homeostasis, equilibrium, and growth potential and to form perceptions, whereas the cognator subsystem pertains to “perceptual and information processing, learning, judgment, and emotion” (Roy, 2009, p. 41). These coping processes act on four adaptive modes which have specific adaptive needs. For the individual, the physiological-physical mode operates on physiological functions to maintain integrity of bodily needs and complex processes. The self-concept mode has to do with body sensation and body image (physical aspect of self-concept), self-consistency, self-ideal, and moral-ethical-spiritual self (personal aspect of self-concept). The role function mode is determined by age, sex, and developmental stages of life where role sets are linked to role expectations. Developing and taking roles associated to one’s social position in relation to other social roles is significant in order to maintain individual social integrity of this mode. The interdependence adaptive mode pertains to giving and receiving love and respect from stable significant others and support systems to maintain relational integrity. These four adaptive modes interact with one another and are observable through behavior. Roy (2009) defined behavior as “internal or external actions and reactions under specified circumstances” (p. 39). Behavior does not only refer to problems and deficiencies but also to individuals’ abilities, skills, knowledge, and commitments. A behavioral adaptive response promotes the integrity of the human system, whereas an ineffective behavioral response does not contribute to the goals of adaptation. Coping processes for a group are the stabilizer and the innovator subsystems. They are related to a social system. The stabilizer subsystem acts to maintain structures, values, and functioning of the group’s daily activities in contributing to the common purposes of society, whereas the innovator subsystem is related to changes for greater potential of the human social systems. For groups to adapt to stimuli acting on coping processes on the physiological-physical mode, adequate physical resources are needed. Group-identity mode occurs through “interpersonal relationships, group self-image, social milieu, culture, and shared responsibility” (Roy, 2009, p. 44) to maintain group identity integrity, whereas the role adaptive mode of a group needs role clarity supported by a group infrastructure to fulfill the expected tasks of its social mission. Group infrastructure is also significant for relational integrity of the adaptive interdependence mode through relational, developmental, and resource adequacy of its group members’ capability. All behaviors of the adaptive modes for both individuals and groups are observable and classified at an adaptive level—integrated, compensatory or compromised. This brief overview of the RAM shows ontology and an epistemology consistent with

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Totality paradigm

Simultaneity Paradigm

Humanbecoming Paradigm

Ontology Ontology Ontology Human-Biopsychosocialspiritual being Human-Unitary pattern Humanuniverse-indivisible,unpredictable everchanging cocreation Universe-Internal and external environment Universe-Unitary pattern in mutual process with the human Health-A state and process of well-being Health-A value; a process Living quality-Becoming visible invisible becoming of the emerging now Epistemology Epistemology Epistemology Human attributes Human patterns Universal human living experiences Methodologies (Research and practice) Methodologies (Research and practice) Methodologies (Sciencing and living the Quantitative, qualitative, mixed Quantitative, qualitative, praxis art) Qualitative Steps of the nursing process Pattern recognition True presence Illuminating meaning, synchronizing rhythms, mobilizing transcendence

Figure 1.  Paradigms of the Discipline of Nursing (Parse, 2013).

the totality paradigm. In professional practice a Roy nurse is intent in contributing to the goals of human system adaptation by following closely the steps of the nursing process. Roy (2009) stated that skills in assessing behavior and stimuli are “astute observation, sensitive intuition, accurate measurement, and perceptive interview” (Roy, 2009, p. 62), along with various competencies practiced with compassion and caring through therapeutic communication to strengthen partnership with the individual or groups. Assessment of behavior includes observable sense data and reported nonobservable behaviors. The nurse will validate observations of behavior and stimuli with the individual or groups. Establishing a nursing diagnosis is made “in statements conveying the adaptation status of the individual or group” (Roy, 2009, p. 66). Roy concurred with the NANDA diagnostic classification system and the NIC and NOC classifications. The nursing diagnosis facilitates goal setting. Setting a goal aims at reaching a desired behavioral outcome within a time frame. Determining nursing interventions consists in managing inadequate behavior related to the deficits of the coping processes in order to respond effectively to stimuli. Completing an evaluation involves the identification of effective and ineffective adaptive behaviors.

Illustration of a Care Plan Based on the RAM The following context serves as the basis of a RAM care plan. Mrs. Smith is 56 years of age and has been a school teacher for the past 34 years. She hopes to retire next year and to travel with her husband who has been faithful to her for the past 36 years. The Smiths have three children and four grand children. When she came with her husband to the oncology clinic for a follow up today, Mrs. Smith said, “Family is my source of support especially since I had breast cancer nine

months ago.” Mrs. Smith explained that since her eldest child has taken time off from work to be with her, she is able to rest a lot more and not worry about doing errands and household chores. She said, “I feel tired and out of energy since I had my left breast removed and have gone through chemo and radiation therapy.” Mrs. Smith also said that since she lost her hair, she doesn’t participate in the community exercise program and prefers staying at home because she feels embarrassed about the way she looks. Yet, she said finding sustenance visiting a community support organization—Look good, feel better—which offers workshops for woman living with breast cancer. She said, “I like it there. They show me how to take care of myself and I can share with others who have gone through the same experience. In sharing intimate feelings, we laugh and we cry together. It gives insight to look at things differently.” At this point, the oncologist arrived and announced that the most recent tests show that Mrs. Smith has metastasis to her left lung. Without batting an eyelash, Mr. Smith insisted that his wife be admitted to the hospital and that she follows prescribed treatments. After a few moment of deafening silence, Mrs. Smith ponderously said, “Dr. Reid, I understand what you say. The previous chemo and radiation treatments have been very difficult on my body and emotionally draining on me and my family. With the presence of this mass on my left lung, I do not wish to have any other treatments. That is my decision. I must prepare otherwise.” (See the plan of care in Figure 1).

The Simultaneity Paradigm: A Unitary Perspective The simultaneity paradigm offers a distinct belief system describing humans as irreducible wholes more than the sum of parts. The unitary perspective proposes that humans and environment form an integral energy field in open mutual

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Doucet and Merlin / Practice Applications process. This process is neither linear nor based on causeeffect relationships. Rogers (1970, 1991) proposed that there is open energy between humans and environment that creates distinct pattern manifestations for which each can be recognized, though both evolve together. From the simultaneity perspective, health is viewed as a value and an expression of life process. To bring to light the congruent ontologicalepistemological-methodological link of a nursing theoretical work consistent with the simultaneity paradigm, the authors selected Newman’s work. A synopsis of Newman’s theory of health as expanding consciousness (HEC) and its specific practice methodology are briefly discussed followed by the presentation of a practice example based on Mrs. Smith’s situation. Readers are encouraged to study Newman’s latest books (2000, 2008).

Newman’s Theory of Health as Expanding Consciousness and Practice Methodology Newman (2008) distinguished three basic philosophical assumptions intricately woven to HEC. “Health is an evolving unitary pattern of the whole, including patterns of disease. Consciousness is the informational capacity of the whole and is revealed in the evolving pattern. Pattern identifies the human-environmental process and is characterized by meaning” (p. 6). According to Newman (2000, 2008), health and the evolving pattern of consciousness are the same. Newman (2008) stated “expanding consciousness [is] a process of becoming more of oneself, of finding greater meaning in life, and of reaching new heights of connectedness with other people and the world” (p. 6). Newman (2000) addressed evolving stages of HEC as Human beings come from a state of potential consciousness into the world of determinate matter and have the capacity for understanding that enables them to gain insight regarding their patterns. This insight represents a turning point in evolving consciousness with concomitant gains in freedom of action (p. 43).

Consciousness is resonating with the whole (Newman, 2008). That is, a pattern of the whole is revealed and formed with information that manifests multidimensional patterns. Movement-space-time, rhythm, and diversity are dimensions of the pattern of the whole. It is a rhythmical movement that changes perception of space-time noticeable in the diversity of parts; “the capacity to comprehend differences as a unity….allows the uniqueness of each pattern to emerge” (Newman, 2008, p. 46). In other words, personal awareness of information that resonates with the integrality of particular patterns—human and environment—expands consciousness of relationships with insight into a pattern of the whole. This shift gives new meaning to situations. Newman (2008) said, “A change in the way of seeing transforms what is seen….The wholeness that we see is the meaning, not the meaning of what is seen” (pp. 44, 46). Hence, HEC is a

process of transformation to more meaningful and caring relationships with others and events by seeing the pattern of the whole. Within the unitary perspective of HEC, a Newman nurse would engage the nurse-client relationship with full presence, which is different from the observer-observed focus on the client. Full presence is unique to Newman’s practice methodology. Full presence might be defined as “unconditional love, which manifests itself in sensitivity to self, attention to others, and creativity” (Newman, 2008, p. 8). It is a partnership where the nurse interacts authentically with compassionate consciousness that transcends objective thinking. Newman (2008) emphasized the importance of feeling in this partnership and articulated that nursing intervention occurs through a relational process of “sensing into the pattern of the whole… .a continuous flow of movements and relationships that merge into each other” (Newman, 2000, p. 107). A Newman nurse guided by full presence enters the nurse-client relationship trusting that its unfolding will emerge with greater meaning through pattern recognition. Newman (2000, 2008) discussed three processes as a practice methodology: the meeting, forming shared consciousness, and moving apart. The meeting of the partnership happens when there is a mutual attraction between the nurse and client. The nurse engages in forming shared consciousness by asking the person to talk about significant persons and meaningful life events. The nurse might choose to authentically relate observations by sharing about her/himself with compassionate consciousness, by using a metaphor to convey her/his comprehension, or by drawing on therapeutic communication. Through an interpenetration of fields, there is a feeling of being “in sync” in forming shared consciousness. It is a resonating process where knowing transcends ideas, “a kind of knowing beyond intuition” (Newman, 2008, p. 55). Creating a narrative and a diagram of chronological significant persons and events deemed important to the client will reveal an evolving pattern of consciousness of the human-environment system and allow noting patterns of parts for the pattern of the whole to emerge through insight. Hence, pattern recognition pertains to the process of a more highly organized and complex pattern of relationships giving meaning to the whole as seen through the parts. The nurse does not interpret the diagram but simply “accentuates the contrasts and repetitions in relationships over time” (Newman, 2008, p. 90). Pattern recognition cannot be forced, but the stage of expanding consciousness can be noted. Moving apart occurs when the client is able to center and act on the pattern of the whole. In other words, practicing in light of HEC is a unitary unfolding. The following illustrates pattern recognition in practice with a Newman nurse meeting and interviewing Mrs. Smith (case study as described above).

Pattern Recognition in Practice According to Newman Development of a Narrative.  Mrs. Smith stated that growing up in her paternal family and raising her own children with a

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caring father and loving husband was weaved with the warmth of intimate relationships. She said that in times of challenges she didn’t feel overwhelmed but was able to take a distance sustained through sensitivity to self and others. She said, “I would find meaning and move on with different options.” As a teacher, beyond the required curricular activities, Mrs. Smith said that she deeply cared but stepped back in order for the students to make their own discovery and decisions. She said, “In fact, I didn’t try to control situations that were outside my control.” Given her current health, Mrs. Smith expressed the pang of separating from loved ones but feels profoundly concerned about their happiness and her passing. She said, “There is something peaceful and freeing in all of this.” The Diagram.  Taking a distance when feeling the Stepping back Separating when warmth of intimate relationships and caring deeply profoundly concerned

Follow-up meeting Mrs. Smith said, “The diagram shows that I am a person who cares about others by taking a step back. I can see that about myself. It is how I hope to prepare my passing”.

The Humanbecoming Paradigm: A Transformation of Health Perspective The humanbecoming paradigm arose in sciencing humanbecoming with the congruent ontological-epistemologicalmethodological link (Parse, 2013). Its ontology includes the constructs humanuniverse and living quality. Humanuniverse refers to an “indivisible, unpredictable, everchanging cocreation” (Parse, 2013, p. 112) of individuals with the whole-inmotion. It is an all-at-onceness phenomenon that permeates humans conceptualized as persons known as incarnating community all-at-once. The all-at-onceness phenomenon is the whole-in-motion where humans incarnate living quality moment-to-moment. Living quality is the “becoming visibleinvisible becoming of the emerging now” (Parse, 2013, p. 112). It is the discernible-undiscernible whatness that denotes and connotes the meaning persons give in situation while moving with the ebb and flow of circumstances. Individuals as community incarnate change by moving-initiating, anchoring-shifting, pondering-shaping with the emerging now. Parse (2013) stated, “There is only the indivisible, unpredictable, everchanging moment-to-moment movinginitiating, anchoring-shifting, and pondering-shaping, cocreating living quality as the core whatness in the emerging now of everyday situations” (p. 112). Living quality is the goal of the humanbecoming paradigm and is understood from its ontological basis, not as a permutation of the concepts health and quality of life borrowed from other paradigmatic perspectives. Hence, it follows that the epistemology of the humanbecoming paradigm is concerned about universal

human living experiences. Living the art of humanbecoming, the Parse nurse incarnates true presence as individuals describe living quality by illuminating meaning, synchronizing rhythms, inspiring transcending (Parse3013) with the emerging now. Readers are encouraged to attentively read The human becoming school of thought (Parse, 1998) and to study other major articles (Parse, 2007b, 2010, 2013).

The Humanbecoming Theory and Methodology The ontology of the humanbecoming theory is founded on assumptions, synthesized assumptions, postulates, principles, and concepts and paradoxes (see Parse, 2013). It is steeped with the ethical phenomenon of human dignity (Parse, 2010). The goal of nursing is living quality. Humanbecoming has to do with coming to understand how humans—individuals, families, communities—cocreate meaning with rhythmical patterns that arise while transcending with possibles. That is, humans live paradoxical rhythms (postulate: paradox) in affirming-not affirming (theoretical concept: powering) pattern preferences while confirmingnot confirming (theoretical concept: valuing) the cherished in attending-distancing with (theoretical concept: connectingseparating) possibles. Explicit-tacit possibles (theoretical concept: imaging) surface as humans freely choose (postulate: freedom) to disclose-not to disclose (theoretical concept: revealing-concealing) the uniqueness of personal choices (living quality), cocreating what is important (living quality). As possibles surface with unbounded knowings (postulate: illimitability) humans shapeshift (community concept: anchoring-shifting) the familiar in a different light (theoretical concept: transforming) with opportunitiesrestrictions (theoretical concept: enabling-limiting) that arise with the emerging now. This moment-to-moment unfolding in shaping-pondering (community concept) possibles emerges with mystery (postulate) as humans envisage with certainty-uncertainty (theoretical concept: originating) the meaning of the uttered-unuttered (theoretical concept: languaging) whatness that surface with penetrating silence (living quality). In moving-initiating (community concept) valued projects, humans honor (human dignity: reverence) relationships with wonder (human dignity: awe), though there is always potential for trust-mistrust (human dignity: betrayal) to surface in disregarding another’s worth (human dignity: shame). True presence is unique to the way of living the art of humanbecoming, nurse with individual(s). (Practice as a term is not consistent with the way a Parse nurse is with individual(s), as practice refers to “doing over and over again or the performance of a habit”) (Parse, Personal communication, June, 2013). True presence is a “gentling down and lifting up…[being with] the tacit-explicit knowing of the messages given and taken [all-at-once]” (Parse, 1998, p. 72). It is a “powerful humanuniverse cocreation” (Parse, 2007, p. 217). True presence arises with face-to-face discussion,

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Doucet and Merlin / Practice Applications Assessment of Behavior Refusal of treatment

Assessment of Stimuli Diagnosis of lung metastasis

Nursing Diagnosis Anticipatory grief related to impending death manifested by refusal of treatment

Goal Setting

Intervention

Mrs. Smith will identify physical problems as they surface.

Provide optimal conditions to maintain integrity of functional abilities.

Keep family informed about Mrs. Smith’s physical problems and progression of disease state. Establish advance directives with the Smith family as soon as possible.

Schedule an interdisciplinary meeting with the Smith family to discuss advance directives.

At times of family gathering, thoughts, feelings, and behaviors related to anticipatory grief will be shared among family members.

Provide a sense of trust and support by encouraging an honest and candid dialogue between Mrs. Smith and family members that express involvement, letting go, and consequences of impending death. Use therapeutic communication to facilitate mourning through expressions of thoughts, emotions and behaviors that foster the natural unfolding of grief.

At times of family gathering, Mrs. Smith will express feelings of closure related to impending death.

Evaluation Mrs. Smith is able to identify needed rest periods when feeling tired and her food preferences to maintain functional abilities. Length of family visits is agreed upon according to Mrs. Smith’s level of energy. A DNR order has been established according to Mrs. Smith’s values and her family. A written order to withhold other extraordinary measures has also been documented. Family commit to gather yearly on the eventual anniversary date of Mrs. Smith’s passing.

Mrs. Smith and family expressed that suffering in parting releases hope and dispels unimportant feud.

Figure 2.  Nursing Care Plan According to the RAM.

silent immersion, and lingering presence. The Parse nurse engages dialogue in true presence with attentive reverence to what is said and shown in face-to-face discussion. The nurse bears witness to the whatness described and/or shown about the individual(s)’ chosen cherished options. The nurse “participate[s] in the lives of others as an unknown[ing] guest” (Milton, 2005, p. 302), revering that individual(s) know the way of their unique living quality and are the expert of their life. New insights arise with silent immersion as individual(s) illuminate meaning, shift rhythms and move with possibles, while the nurse with true presence honors the individual’s living quality inextricably woven with the emerging now. A lingering presence gives life to possibles that surface with the illimitable of the indivisible, unpredictable, everchanging fabric of life. The nurse will document a

project of care with: (a) a personal description of the individual(s)’ living quality, (b) patterns that surface with paradoxical rhythms, (c) intents and priorities related to patterns of becoming from the perspective of the individuals’, and (d) description of nurse with person . In true presence with Mrs. Smith, Figure 2 illustrates a project of living the art of humanbecoming.

Conclusion A rich diversity of theoretical nursing knowledge has proven its social utility, congruence, and significance for the betterment of those being served in view of distinct practice methodologies consistent with a specific paradigmatic perspective (Fawcett & DeSanto-Madeya, 2013). Specifically, in this

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Assumptions The human with universe is coexisting while coconstituting rhythmical patterns The human is open, freely choosing meaning with situation, bearing responsibility for decisions The human is Continuously coconstituting patterns of relating The human is transcending illimitably with possibles Becoming is human [living quality] Becoming is rhythmically coconstituting humanuniverse Becoming is the human’s patterns of relating value priorities Becoming is transcending with possibles Becoming is the human’s emerging

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Synthesized assumptions Humanbecoming is structuring meaning, freely choosing with situation

Postulates

Principles

Illimitability is the knowing extended to infinity, the all-atonce rememberingprospecting with the emerging now

Humanbecoming is configuring rhythmical humanuniverse patterns

Humanbecoming is cotranscending illimitably with emerging possibles

Humanbecoming is humanuniverse cocreating a seamless symphony

Structuring meaning is the imaging and valuing of languaging

Paradox is an intricate rhythm expressed as a pattern preference

Freedom is contextually construed liberation

Configuring rhythmical patterns is the revealing-concealing and enabling-limiting of connectingseparating

Mystery is the unexplainable, that which cannot be completely known unequivocally Cotranscending with possibles is the powering and originating of transforming

Concept and Paradoxes Imaging: explicit-tacit; reflective-prereflective   Valuing: confirmingnot confirming   Languaging: speaking-being silent; moving-being still     Revealing-concealing: disclosing notdisclosing   Enabling-limiting: potentiating-restricting   ConnectingSeperating: attending-distancing     Powering: pushingresisting; affirmingnot affirming   Originating: certaintyuncertainty; conforming-not Transforming: familiarunfamiliar

   

Figure 3.  Ontology of the Humanbecoming Theory (HBT) (Parse, 2013).

Personal description of living quality

Patterns of living quality

Mrs. Smith stated feeling sadness and delight in living with metastatic cancer. She said, “I go through moments of sullen heart wrenching anguish and then again, I take pleasure being with my family. Sharing moments with those I cherish is soothing. I feel at peace though parting is difficult”. Mrs. Smith said, “Though dreams be tossed and blown, I have the opportunity to show with gentle tenderness what I live and to say what I see differently and anticipate about my passing. I move in a different way with my family.”

Intentions & priorities of the person

Description of the process nurse with person

Mrs. Smith expresses joy-sorrow while being with-moving away from family.

Mrs. Smith wants to express what she lives while being attentive to family members.

Mrs. Smith expresses and affirms living moments in a different light.

Mrs. Smith wants to affirm the moment to moment shifting view of her living experience.

In true presence, the nurse will ask Mrs. Smith to talk about what is important to her. The nurse will be vigilant about how Mrs. Smith describes and shows ways of living quality. The nurse will ask Mrs. Smith to explicate her living experience.

Figure 4.  Project of Care According to the HBT.

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Doucet and Merlin / Practice Applications paper, conceptualization of health from different nursing theoretical works has been briefly described followed by the particular way a Roy nurse, a Newman nurse, and a Parse nurse would be in light of its specific congruent practice methodology in serving others. An example of documentation has been provided to highlight how theory guides practice according to the RAM, HEC, and the HBT. The challenge that remains is to further fortify the congruent ontologicalepistemological-methodological link where theory guiding practice becomes more visible. Declaration of Conflicting Interests The author declared no potential conflicts of interest with respect to the authorship and/or publication of this column.

Funding The author received no financial support for the authorship and/or publication of this column.

References Butts, J. B., Rich, K. L., & Fawcett, J. (2012). The future of nursing: How important is discipline-specific knowledge? A conversation with Jacqueline Fawcett. Nursing Science Quarterly, 25, 151-154. Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). Philadelphia: F.A. Davis. Kuhn, T. S. The structure of scientific revolutions (3rd ed.). Chicago: University of Chicago Press.

Milton, C. (2005). The metaphor of nurse as guest with ethical implications for nursing and healthcare. Nursing Science Quarterly, 18, 301-303. Newman, M. A. (2000). Health as expanding consciousness (2nd ed.). Sudbury, MA: Jones & Bartlett. Newman, M. A. (2008). Transforming presence: The difference that nursing makes. Philadelphia: F. A. Davis. Newman, M. A., Sime, A. M., & Corcoran-Perry, S. A. (1991). The focus of the discipline of nursing. Advances in Nursing Sciences, 14(1), 1-16. Parse, R. R. (1987). Nursing science: Major paradigms, theories, and critique. Philadelphia: W. B. Saunders. Parse, R. R. (1998). The human becoming school of thought: A perspective for nurses and other health professionals. Thousand Oaks, CA: SAGE. Parse, R. R. (2001). Qualitative inquiry: The path of sciencing. Sudbury, MA: Jones and Bartlett. Parse, R. R. (2007a). A human becoming perspective on quality of life. Nursing Science Quarterly, 20, 217. Parse, R. R. (2007b). The humanbecoming school of thought in 2050. Nursing Science Quarterly, 20, 308-311. Parse, R. R. (2010). Human dignity: A humanbecoming ethical phenomenon. Nursing Science Quarterly, 23, 257-262. Parse, R. R. (2012). New Humanbecoming Conceptualizations and the Humanbecoming Community Model: Expansions with Sciencing and Living the Art. Nursing Science Quarterly, 25, 44-52. Parse, R. R. (2013). Living Quality: A Humanbecoming Phenomenon. Nursing Science Quarterly, 26, 111-115. Polanyi, M. (1958). Personal knowledge: Towards a post-critical philosophy. Chicago:University of Chicago Press. Roy, C. (2009). The Roy adaptation model (3rd. ed.). Upper Saddle River, NJ: Pearson.

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Conceptualizations of health in nursing practice.

There are many ways of living health as individuals describe it from unique perspectives. With the intent of serving others, healthcare professionals ...
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