Philosophical Perspectives and Nursing Practice In order to understand a nurse’s practice, it is important to appreciate a nurse’s philosophical outlook. This outlook includes paradigms and theories, which reflect a nurse’s values, and exert significant influence over nursing practice. There are three major paradigms within the nursing profession: empiricism, interpretive, and critical social theory. Each has unique tenets, and contributes to the profession and discipline of nursing in a different way. Each paradigm also informs the development and implementation of nursing theories, which connect nursing theory and practice. In addition to the three major paradigms, pragmatism is also an important philosophical consideration. Pragmatism furthers the discussion about the best approach to take in nursing practice. The purpose of this article is to describe each major nursing paradigm, demonstrate the connection between nursing paradigms and nursing theory, and use case examples to illuminate the contributions of pragmatism to nursing practice. Paradigms and Theories in Nursing Definition of Terms This discussion is facilitated by the definition of the following terms: 1. Paradigm: a pattern of beliefs and practices; its identification explicates researchers’ philosophical assumptions about their subject matter (Weaver & Olson, 2006). A paradigm directs what research topics are investigated, how research is conducted, and how theories are derived within nursing (Monti & Tingen, 1999). A paradigm is not directly testable through research. 2. Theory: creation of a relationship between concepts to form a specific view of a phenomenon (Higgins & Moore, 2012). A theory may be explanatory or predictive, and its concepts are defined in such a way that its premise may be tested through research. In nursing, theory is generally categorized into three levels: grand, which addresses the identity and boundaries of the discipline; middle-range, which addresses nursing practice concerns, but is also broad enough to cross practice areas; and situational-specific, which addresses a specific population or phenomenon of nursing practice. A full discourse on the levels of theory is beyond the scope of this paper; however, classification using the aforementioned terms is applied in this paper, in order to facilitate comparison. Also of note, the term client, as used in this paper, reflects the recipient(s) of NURSING PARADIGMS AND THEORIES 4 nursing care within a given practice setting, however defined. This may include individuals, families, or larger populations. Empirical Paradigm Content and contributions. The empirical paradigm is rooted in the assumption that there is one reality, which can be verified through the senses (Monti & Tingen, 1999). Within this paradigm, knowledge is established by controlling the circumstances around variables, in order to determine their relationship (Monti & Tingen, 1999). This paradigm was one of the first to be embraced by nursing researchers, as it aligned with the paradigm used in the natural sciences, and thus helped to establish the legitimacy of nursing research (Weaver & Olson, 2006). The empirical paradigm has several incarnations, including positivism and postpositivism. Positivism was rooted in a values-free scientific approach, with the aim of establishing absolute truths, which is now recognized as unreasonable and has fallen out of favor (Monti & Tingen, 1999). The current manifestation of the empirical paradigm in nursing is postpositivism, which recognizes that absolute truth cannot be ascertained, and contextual factors are important in understanding relationships between variables (Monti & Tingen, 1999). These considerations make modern empiricism, or post-positivism, applicable to nursing research and practice. Research. The empirical paradigm contributes to nursing research as it facilitates the development and testing of hypotheses, comparison of interventions, and the establishment of relationships between variables (Monti & Tingen, 1999). Adherents of the empirical paradigm often use quantitative methods when conducting research (Gillis & Jackson, 2002). Research methodologies commonly employed in empirical paradigm include experiments, surveys, and the evaluation of secondary-source data (Gillis & Jackson, 2002). Confirmation of research findings is sought through replication, which allows comparison across research settings or timeframes (Weaver & Olson, 2006). While absolute truth cannot be established, it is possible to illustrate the relationship among variables. All of these considerations make the empirical paradigm relevant in nursing research. Disadvantages. The empirical paradigm also has several disadvantages, including limited application for aspects of nursing that are not conducive to quantitative measurement (Gillis & Jackson, 2002). Themes like the experience of receiving a terminal diagnosis are not NURSING PARADIGMS AND THEORIES 5 easily quantified; thus, the empirical paradigm is of limited use to investigate these topics. The empirical paradigm also minimizes the fact that each person has unique life experiences, and that an individual may perceive an event differently from another person (Gillis & Jackson, 2002). While it is possible to identify trends with research, there is no guarantee that what holds true for one person will also apply to another. There is also the belief that empirical findings support evidence-based practice, but statistical significance does not always mean clinical significance (Cody, 2012a; Monti & Tingen, 1999). The empirical paradigm contributes greatly to nursing practice, but also has limitations. Theoretical development. It is possible to predict the type of theories that can be developed from each nursing paradigm, based on the worldview that each paradigm presents. The empirical paradigm gives rise to a variety of theories within nursing. Orem’s (2001) SelfCare Deficit Nursing Theory (SCDNT) is a prime example. This grand theory states that nursing is required when persons’ needs for self-care exceed their ability to provide self-care. Relatively linear relationships link factors such as the ability to provide self-care, self-care that is required, and any subsequent deficit. It is assumed that all persons require similar basic needs to be met in order to achieve their full potential. Variables addressed in this theory are named, described, and quantified. The empirical paradigm was used by Orem (2001) to create the SCDNT, a theory with wide applications for nursing practice. Case study. The various nursing paradigms are evident in an example from nursing practice in the intensive care unit (ICU). A young woman was admitted to ICU from the operating room, because her anesthetist had vague concerns about her ”not doing well” intraoperatively. At the time of arrival, Laura’s? vital signs were relatively stable and she did not have any obvious deficits. She was an active young woman, who had a minor surgery to remove pre-cancerous polyps in her bowel. She had no significant medical history, and this surgery was an elective, routine procedure. Within an hour of her arrival, Laura was in fulminant shock, and required massive ventilation assistance, and vasopressors to maintain her blood pressure. She ultimately survived her stay in ICU, but required weeks of intensive management, followed by months of rehabilitation. Laura’s nursing care was based strongly in an empirical paradigm. For example, as her illness progressed, her blood pressure dropped. Using Orem’s (2001) SCDNT, a nurse would ? Name changed NURSING PARADIGMS AND THEORIES 6 identify that the patient is not able to meet her own needs; therefore, nursing intervention is required. Nursing intervention was to administer fluids and vasopressor medications. When this did not raise her blood pressure as expected, the physician was contacted to address this concern. For each of her body systems, there was an expected level of functioning, which had been established through empirical research methods (for instance, blood pressure should normally be maintained to reach a minimum mean arterial pressure of 65 mmHg). Nurses recognized when Laura deviated from these normative standards, and anticipated the associated nursing interventions. When these interventions were implemented, without effect, the nurses recognized that the expected relationship between variables was not manifesting and that further intervention was required. Nurses also recognized the implications of nursing care for Laura and adjusted the plan accordingly. For example, turning a patient helps to prevent skin breakdown, but also increases metabolic demand. Normally, maintaining skin integrity is a nursing priority, but in this instance, Laura could not tolerate turning. The establishment of priorities and evaluation of nursing interventions rooted Laura’s in the empirical paradigm. This example demonstrates that an abstract paradigm has concrete implications for nursing practice.
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