Tuesday, November 30, 2010

Developing a Personal Nursing Philosophy

Formulating and Presenting My Personal Philosophy of Nursing

When contemplating a philosophical viewpoint within a particular discipline it is essential to understand its relationship to current issues in the field (DeKeyser & Medoff-Cooper, 2009; Schlotfeldt, 2006). Articulation of a personal nursing philosophy involves contemplation of one’s beliefs, principles and values which direct practice (p. 65, Uys & Smit, 1994 as cited in DeKeyser & Medoff-Cooper, 2009). My personal nursing philosophy began with attempting to answer the questions, “what does nursing mean to me” and “what is guiding my practice”? My philosophy is based on personal reflections, values and beliefs and is connected to the current body of nursing literature; it incorporates my understanding of the traditional nursing metaparadigm that includes person, environment, nursing and health (Monti & Tingen, 2006) and the concept of social justice proposed by Schim, Benkert, Bell, Walker and Danford (2006). My personal philosophy characterizes the discipline of nursing using four distinct attributes: (1) the person, (2) society, (3) health and (4) nursing (Northup, Tschanz, Olynyk, Makaroff, Szabo & Biasio, 2009). The goal of this paper is to discuss each of these attributes in relation to each other, how this philosophy developed, how I have encountered each attribute in my own practice, and how some of these attributes shape my contribution to the current body of nursing knowledge. My discussion begins with the person.

The Person

Nursing is first and foremost about people. Human beings are central to the articulation of my personal nursing philosophy because the profession of nursing is person-centred: care involves the whole client, and not just a single illness or health concern treated in isolation from the whole (Cody, 2006; DeKeyser & Medoff-Cooper, 2009; Monti & Tingen, 2006). Nursing is personal and unique, and contrasts with illness-focused medical models, because holistic perspectives consider all facets of a client’s life, and facilitate optimum quality of life rather than care based on generalizations (Fawcett, 2006).

Within my own nursing practice in acute mental health, there has traditionally been a medical model. This model focuses specifically on a particular diagnosis or set of symptoms observed and reported by the client. I have found that this narrow focus on a diagnosis misses the bigger picture – that of life beyond the acute care setting, and creates stigma while ignoring the importance of the client’s lived experience. Person-centred principles also extend into the relationship of nursing practice within the professional nursing community. For example, social feminist perspectives outline the importance of subjective, lived-experiences of nurses, and formulate models for the development of nursing knowledge with the express purpose of advancing the discipline (Wuest, 2006). Developing my own ability to perceive clients as unique, and providing holistic care while being reflexive of this subjective experience has resulted in the enhancement of my personal understanding of how individuals fit into the larger community or population (i.e. society).

Society

While human beings are central to nursing it is also necessary to look beyond the individual to the society in which an individual lives. Society is an integral component of nursing because all individuals are members of a larger community – a community with distinct features, environments and characteristics that influence the health of individuals and populations. Traditionally, nursing has involved treating a physical concern in a strictly one-to-one relationship. This tenet, which has been central to development of nursing theories in the discipline, isolates the illness being treated from the multitude of external factors that shape behaviours contributing to the client’s health (Butterfield, 2006; DeKeyser & Medoff-Cooper, 2009; Schim et. al, 2006).

The conceptualization of society necessarily involves consideration of both internal and external patient environments. Society includes environmental forces that impact individual’s external, physical, health experience, and also includes psychosocial aspects (Schim et. al, 2006). My conceptions are in-line with those proposed by DeKeyser & Medoff-Cooper (2009) in which both the person and health care community are connected to their environment. My definition extends beyond static constraints of an acute or community setting because, as I have seen in my practice, client situations (environments) change based on their social position prior to, during and after interaction with the health care system. For example, I may encounter a client experiencing their first psychotic break. This break may have led them to lose their current job and, after a lengthy stay in the hospital, they may have now lost their housing as well. Personal and community health experiences are often influenced by uncontrollable factors. Within my definition of the environment I must also recognize that sometimes individuals do not have a free choice in altering the impact of the environment on health.

Furthermore, I believe that equal emphasis should be placed on societal factors that impact individual and population health. My personal philosophy incorporates the multi-centred approach proposed by Schim et. al (2006). This approach involves the inclusion of health initiatives focused on entire populations, providing optimal care for all, rather than individuals. In order to achieve this I believe nursing ideally should emphasize determining those societal factors inextricably linked with the environment. I believe nursing incorporates acknowledging that socioeconomic status, ethnicity, gender and geographic location contribute to health. I have observed this approach demonstrated in the acute withdrawal setting, where energy is focused on modifying the social precursors that lead to poor health in the population such as lack of housing and mental health issues. This type of long-term approach is termed upstream thinking (Butterfield, 2006). My use of upstream thinking helps me challenge short-sighted, individually based interventions highlighting the importance of viewing health from a broader perspective that includes changing the system as more powerful than blaming individuals for poor health.

Health

I believe that nursing encompasses optimization of health in terms of both individuals and populations. Health is defined as a dynamic state, existing on a continuum from wellness to illness, shifting in response to environmental factors (Butterfield, 2006; DeKeyser & Medoff-Cooper, 2009; Schim, 2006). My belief is similar to that proposed by DeKeyser & Medoff-Cooper (2006) that health is more about quality of life, varying based on perception guided by upstream perspective discussed by Butterfield (2006) in which the social, political and economic factors shape the health of a society. This connects person and societal factors by looking beyond the health problems of the individual, exploring what can be changed to optimize the client’s personal definitions of health.

The population that I work with in addictions is diverse. I routinely encounter clients that have experienced trauma in their live; some clients experience beginning stages of their addiction while there are also clients that have battled addiction chronically. I encounter clients that suffer from multiple chronic and acute physical and mental health conditions. Individually, I have found it necessary to understand each client’s perception of health, considering their personal goals in order to establish successful care plans because personal definitions of health may vary greatly. In my experience nursing care of addiction requires both concrete, empirically based knowledge about managing acute withdrawal symptoms while also utilizing critical thinking skills and being in the moment with the complex clients. Optimal care in these situations requires both scientific and artful practice of nursing.

Nursing: Conceptualizing Care as both an Art and a Science

It is essential to recognize that the profession of nursing is deeply bound to the notion of nurturance and women’s traditional role of mother and caregiver within the private sphere (Wuest, 2006). Nursing is a science in the sense that it is an organized body of knowledge that draws on the strengths abstract thinking in order to develop an empirically based body of knowledge specific to the discipline (Carper, 2006; Kikuchi, 2009; Phillips, 2006). However, it is also essential to acknowledge that nursing is an art because it requires embodying the creation of holistic health plans that involve caring, establishing meaningful relationships, competence, morality, advocacy and empowerment (Johnson, 2006).

Nursing as a Science

Philips (2006) defines science as, “an original body of knowledge concerning human beings and their world,” (p.43). The science of nursing is multifaceted, based on nursing knowledge, but also drawing on the theory of behavioural and natural sciences, to embody skills and professional values that are applied in a caring manner (Newman, 2009; Phillips, 2006). I believe that the science of nursing successfully incorporates empirically based means and methods of pursuing knowledge in cases where it is appropriate. For example, in addictions and mental health nursing the role of pharmacotherapy is often essential to providing good patient care. The efficacy and therapeutic value of medication is obtained through empirically means. It is the nurse’s role to be familiar with clinically established guidelines of medication use and obtain objective data about effectiveness for the purpose of assessing progress of treatment. The scientific method is in isolation insufficient for addressing all nursing questions because nursing is a human science that involves intangible components of the external and internal environment, for example love (Kikuchi, 2009).

Nursing as an Art

I believe that although the characteristic of caring is essential to being a nurse it is not unique to the profession of nursing, a notion discussed by DeKeyser & Medoff-Cooper (2009). I agree with Johnson (2006) that science alone is not able to solve all of the problems presented in nursing. The process of nursing is not black and white, artful aspects of nursing help to address the various shades of gray (Kikuchi, 2009). Conceptualizing nursing as an art is a longstanding idea that many nursing scholars have written about (Johnson, 2006; Kikuchi, 2009; Phillips, 2006). When examining current literature of nursing as an art Johnson (2006) identified five distinct descriptions. My own conceptualization of nursing care includes emphasis on three interrelated concepts, (1) engaging in meaningful relationships with patients, (2) skill competence and (3) ability to morally conduct one’s nursing practice to create health care plan (p.133).

Engaging in Meaningful Relationships

Nursing involves being with individual clients or communities and also being engaged in the moment, making meaning as a component of providing care. Each day a practicing nurse encounters diverse situations that require ability to make meaning of a client’s situation (Johnson, 2006). The task of making meaning involves subjective interaction with clients, attaching significance to those things that can be felt, observed, heard, touched, tasted, smelled, or imagined, including emotions, objects, gestures, and sounds (Johnson, 2006).

The concept of being engaged in meaningful relationships requires that the nurse be actively involved. For example, in addictions the nurse’s role could be limited to simply collecting objective data like signs and administering medication to alleviate observed symptom but making meaning involves going beyond concrete observation and using reflection and reasoning beyond the five senses for the purpose optimizing client care. In this sense there is a creative aspect of nursing which places emphasis on the unique situation of clients and communities. These are artful aspects of nursing practice that involve using personal experience and expertise to focus on a particular patient situation. My belief is that artful practice can be learned and further developed over time; nurses can learn to listen to and trust their inner experiences (p. 134, Johnson, 2006). This occurs in a holistic capacity taking into account the complete situation of a client rather than focusing on a piece, such as a particular illness.

Meaningful relationships also occur between members of the professional nursing community. Bunker (2006) highlights the importance of community for nurses, because no nurses work in isolation. It is important to recognize that the purpose of nursing is to establish relationships with others, meaning work happens with clients as well as with other nurses and members of other health care disciplines. For example, I believe that engaging in a mentorship relationships, as discussed by Cody (2006), is a good way in which I can immediately impact the development of nursing knowledge. Creation of a knowledge community may be regularly utilized to teach those new students and professionals (Cody, 2006).

Skill Competence

Intellectual ability is critical to performing any nursing activity. This connects to conceptions of nursing as a science, involving the ability to be reflective in decision making and utilizing critical thinking skills to put nursing knowledge into action appropriately (Birx, 2006). I believe that nursing epitomizes the ability to rationally design and implement care plans (Johnson, 2006). The key to successfully engaging in this process is recognition that nursing is practice focused, meaning there is a purpose which ideally optimizes health situations (Johnson, 2006; Northup et. al, 2009; Schlotfeldt, 2006). I believe nurses develop problem solving abilities, guided by intellect in which knowledge and other types of information are selected based on the expertise and intended outcome (p.138, Johnson, 2006).

Ability to Morally Conduct Nursing Practice

Lastly, I believe that artful practice involves developing the ability to practice nursing morally; the nurse is obligated to practice in a way that seeks to avoid doing harm, benefitting clients and communities (p.129, Johnson, 2006). Nurses act in a moral way, which is defined by Johnson (2006) as, “that which is good, or desirable, for human beings,” even in the face of adversity (p.139). Central to this is the concept of caring which has helped to increase the nurse’s awareness of which interventions are successful (Johnson, 2006). There is deep interconnection between skill competence and moral action (Johnson, 2006). Nurses demonstrate skill competence and knowledgeable but without moral decision making it is not artful practice. I believe that nursing provides a voice against unjust and unmoral actions.

Advocacy is an important component of moral nursing practice. The discipline of nursing has faced many challenges being with the health care system building roots as a hierarchical system where nurses were traditionally at the bottom (Wuest, 2006). A handful of women nurses worked hard to progress the status of women and challenge the dominant social order (Wuest, 2006). I believe that nurses embody the ability to do what is fair, placing the greater good ahead of the good of the individual. Health is one way to help people be able to attain a good quality of life (Butterfield, 2006; Schim et. al, 2006 ). Schim et. al (2006) discuss a population focused perspective that emphasizes the importance of including a social justice component into the traditional metaparadigm of nursing. The intent is to look beyond the health and wellness of the individual at entire population in order to achieve a culture of healthcare. I share this belief because nurses, having such a large number of professions, have the power to influence change in marginalized groups of people (Schim et. al, 2006).

Bunker (2006) discusses that there is great importance given to the idea of social justice, a similar sentiment to that offered by Schim, et al. (2006). Bunker (2006) notes that social justice is a theme that has consistently been a part of nursing since the time of Florence Nightingale. This indicates that being an advocate is an important component of nursing even in the face of critical judgement, from those outside of the profession, but also those within as highlighted by Wuest (2006). I believe that nurses have the power and responsibility to challenge the status quo both for the advancement of those in nursing and for the pursuit of public health for all.

Within my practice I have experienced the ability to exercise power for the purpose of advocating for clients suffering from addictions to be included in health programs that exclude based on stigma attached to their health situations. I have developed the belief that it is my moral responsibility to advocate for this marginalized group. This is in line with Schim et. al (2006) viewpoint that nursing requires development of a population consciousness. This enables nurses to see the community and global aspects of health care beyond the immediate situation. This perception of nursing requires critical analysis of the status quo in health care and the larger society, exposing oneself to the larger societal issues that form the upstream precursors to urban health disparities (Butterfield, 2006; Schim et. al, 2006).

Conclusion

As nursing progresses into the 21st century there is some suggestion that survival and advancement of the discipline requires increase engagement of practicing nurses in utilizing and developing specifically nursing knowledge (Cody, 2006; Fawcett, 2006; Silva, 2006). Perhaps a beginning point may be developing a personal nursing philosophy that focuses on areas distinct to nursing as this enables reflection on understanding relationships between personal philosophical thought as related to current issues in the field (DeKeyser & Medoff-Cooper, 2009; Schlotfeldt, 2006). The goal of this paper was to discuss each component of my personal nursing philosophy in relation, how I arrived at my belief, how I encountered each in my practice and how each may facilitate my personal contribution to the current body of nursing knowledge. My personal philosophy of nursing incorporates components of the traditional nursing metaparadigm (Monti & Tingen, 2006) while also incorporating the concept of social justice proposed by Schim, Benkert, Bell, Walker and Danford (2006). I believe that nursing is a discipline that encompasses four integral attributes (1) the person, (2) society, (3) health and (4) nursing which I have discussed in relation to current literature on nursing, using examples from my own nursing experience, including explanation of how some have allowed me to contribute to the development of nursing knowledge.


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