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Nursing in Relation to Knowing and the Metaparadigms

Ibtihal Haib

Athabasca University

Nursing in Relation to knowing and the Metaparadigms

Nursing has evolved throughout the years to become an identified practice discipline.

Through the development of theory, philosophy and knowledge, the field of nursing has built

its distinctive discipline. Nurses used to be viewed as direct patient care providers and task

oriented in clinical settings (Graham, 2010). However, nursing scope of practice has expanded

beyond patient care to include research, education, policy making and administrative work.

According to Cody, the expansion of nursing roles can positively influence the development of

nursing practice. The direct involvement of nurses in different roles enables them to be part

of constructing policies and strategies to meet the needs of the discipline (2013, p. 63). In

addition, nursing scholars and theorists have created ontological and philosophical

dimensions that make nursing different from other disciplines such as the ways of knowing

by Carper, 1978. However, the discipline of nursing requires continuous progress by all

different roles to face limitations and barriers that can halt its progress as professional, practice

and academic discipline.

Historically, nursing was practiced based on the biomedical model that focuses on

disease, diagnosis and treatment where nurses focused on performing set of tasks typically

ordered by doctors. Nursing practice expanded beyond the biomedical model and beyond the

focus on the patient as an object. Nursing become a profession that provides holistic care

including psychological, social, physical and spiritual aspects of the person. Throughout the

years, nurses began to realize that these are essential elements of the individuals that are

also interactive in affecting health and wellness. The field of nursing progressed to

acknowledge and focus on the human experience with regard the physical concerns (Thorne,

Canam, Dahinten, Hall, Henderson & Kirkham,1998). The Authors also explain the
importance of this evolution where nursing care become more than just treating a disease

but works towards health promotion and disease prevention (1998).

Knowledge in Nursing

Nursing practice is based on knowledge, science, critical thinking and problem solving to

promote healing and restoration of physical well being. Zander (2007) identifies two types of

knowledge, tacit and explicit. Tacit is the knowledge gained with experience that can vary

from one person to another which is also dynamic. Werease explicit is the knowledge

learned through writing and reading words, maps and symbols and is more factual

knowledge. In nursing, this type of knowledge is based on practice setting, speciality and

population the nurse works with. Tacit knowledge on the other hand is affected by changes

in health care, social, political and cultural aspects such as cultural diversity. As these

factors change constantly, knowledge based on experience is reconstructed and continues

to change throughout the years.

Four ways of knowing were identified by Carper (1978) in the discipline of nursing.

These include, 1) empirics; the science of knowing, 2) esthetics; the art of knowing, 3)

personal knowing and 4) ethics; the moral aspect. The four ways of knowing are

fundamental key concepts for nursing practice. Through these patterns of knowing nursing

epistemology was advanced from a science based, to include moral obligations, caring,

empathy, and nurse-patient relationship. It also assisted nursing to build its autonomous

discipline. According to Hoeck & Delmar (2018) without the transition in nursing research

and theory to a humanistic, caring and nurse-patient relationship, nursing would have

remained a task oriented with the focus on evidence based biomedical knowledge. This
epistemological shift in nursing has aided in making nursing different from other


Each one of the four patterns of knowing is unique for nursing practice. However,

personal knowing is the pattern that supports patient centred care theories. Through

personal knowing, nurses find what health means and how its defined by the patient

through interactive and therapeutic relationship between the nurse and the patient. Carper

describes this pattern on knowing as therapeutic use of self where the nurse strives to

know the patient as a self and not as an object (1978). Through nurse-patient relationship,

nurses can learn different aspect of the individual's life that can affect their health. This may

include health practices, values, beliefs, access to health care and more. This patient centred

care has driven nursing away from a task oriented profession to a larger body of knowledge

discipline. According to Graham, nursing knowledge is achieved through critical thinking and

problem solving to promote health and well being which requires the use of the four ways of

knowing (2010). The ways of knowing by Carper (1978) was credited by other scholars for

broadening nursing epistemology from a science based to a more complex and diverse field

that helped in understanding the professional aspect of nursing (Zander, 2007).

The Metaparadigms of Nursing

Fawcett, (1978) identified four fundamental elements of nursing; the metaparadigms

of nursing. Fawcett describes, that each discipline has a matrix, and the metaparadigms are

the result of nursing disciplinary matrix. In nursing, the matrices defined as conceptual

models which are the result of studying a phenomena such as Orem’s self care model

(Fawcett, 1984). The four metaparadigm include nurse, person, environment and health

became the fundamentals in the field nursing. The metaparadigms of nursing are integrated
concepts and affect one another. However, scholars have further elaborated on the need to

refine, edit or expand the metaparadigms. Literature has diverse views and definitions of

the metaparadigms.

The first concept, the person; according to Thorne et al., (1998), there are diverse

definitions of the person as a concept, some literature describes the person within the

community and others define the person as the main focus of nursing care. The person was

defined as the patient, who is also the recipient of nursing care. Subsequently the concept was

expanded to include family, caregiver and other individuals considered valuable by the patient.

It describes the person within a society and not as an isolated patient. Schim, Benkert, Bell,

Walker & Danford, 2017 argue that the concept of the person should represents the

diversity of individuals within communities and institutions. This would further expand the

definition of the person to consider cultural, ethnic, and language diversity within nursing

care. This suggestion shows refinement of the concept in order to meet the changes within


The second concept, nursing; according to Bender & Feldman (2015), nursing and

nursing care refer to “reflexive, interpersonal, knowledgeable processes”. This definition

describes nurse-patient relationship as an integral part of nursing care. Nurses provide care for

patients in a variety of settings including acute care, long term care, community, in patient

homes and others. In all different settings and levels of acuity, the patient is the focus of

nursing care and the goal is to restore health and quality of life or to assist in coping with an

illness. Kim, (2015) describes nursing care as situational and person specific that varies

from patient to patient. Every person is a unique individual that has different experiences,

living conditions, educational, ethnic, and cultural backgrounds. Therefore, nurses need to
consider all different aspects of the persons within nursing care. Also, caring was described

as the defining term and building block of nursing. Smith, (2007) states, without caring,

nursing does not exist. In contrary, Salem press encyclopedia of health defines nursing care

as guided by professional knowledge, tasks and technical skills (2016). These different

views and definitions show the diversity in nursing literature in defining nursing.

The third concept, the environment; was earlier defined as the the physical

surrounding were nursing care is provided including identified significant others by the patient.

However, Thorne et al suggest that environment is “fluid, changeable and

constructed”(1998) . The authors also discuss the limitations in nursing literature to

examine the person-environment relationship within the social and political contexts

(1998). On the other hand, the environment from the nurses’ perspective can also be valuable

in influencing the care delivered (Bender & Feldman, 2015). The authors further discuss the

importance of the settings were nursing care is provided that are influenced by workplace

policies, management and other factors which can impact the quality of nursing care.

The fourth concept, health; according to Thorne et al., (1998), health was historically

defined by Nightingale as the physical state of well being and the ability of the person to use

every power he or she has. The authors on the other had argue that health and quality of life are

integrated within social and political contexts. Therefore, nursing should be involved in

addressing factors that can negatively impact the person’s’ quality of life (1998). The social and

political aspects that can affect the human health and quality of life may include social

disparities, education, poverty, access to health care and more.

Roy and Robert describe the individual as an adaptive system that adapts to the

constantly changing environment through coping mechanisms (as cited in Fawcett, 1984). A
constantly changing environment involves social, political and health care issues which can also

influence the person’s adaptive skills and quality of life. Moreover, Schim, Benkert, Bell,

Walker & Danford found that social justice is a crucial element affecting people’s health

(2017). The authors found limitations in nurses’ knowledge regarding racial and ethnic

backgrounds in the persons of colors those who are foreign or immigrants. Therefore,

(Schim et al., 2017) adopted social justice as the fifth concept of urban health

metaparadigms to address the gap in nursing knowledge and meet the need of minorities

within societies.

In conclusion, nursing has evolved throughout the years to create its own ontological

and philosophical dimensions which elevated the academic quality of the field of nursing.

Nursing was successful in expanding its’ professional role to include research, education,

management and policy making. In addition, patient care roles were advanced and

expanded. Roles such as clinical nurse specialist, nurse practitioner, nurse midwife and

others. However, in order for nursing to continue developing as a theoretical, philosophical and

empirical discipline, it requires continuous adaptation to the changes affecting health, quality of

life and nursing. Hoeck & Delmark, (2018) argue that nursing has social and professional

obligations, therefore nursing ontology and epistemology need to continue be re-evaluated

and developed to meet the needs of the society and the changes in knowledge and science.

Idditionally, Hoeck & Winther, (2012) discussed the implications of the societal changes on

the nursing theory (as cited in Hoeck & Delmark, 2018, p.). These changes may require the

creation of new theories and or refinements of existing ones.


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