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Regenerating Nursing's Disciplinary Perspective

Smith, Marlaine C., PhD, RN, AHN-BC, HWNC-BC, FAAN

doi: 10.1097/ANS.0000000000000241
The Focus of the Discipline
Free

As we approach the 50th anniversary of the first national symposium on nursing theory development, the need to clarify nursing's disciplinary perspective is just as relevant as it was 50 years ago. The purpose of this article is to regenerate the disciplinary perspective by analyzing the literature on the focus of the discipline of nursing, synthesizing the themes and suggesting areas of knowledge development for the discipline, and imagining ways to move forward in claiming, clarifying, and strengthening the discipline. The 4 themes identified were human wholeness, health/healing/well-being, human-environment-health relationship, and caring. Nine areas of inquiry generated from the disciplinary perspective were suggested.

Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton.

Correspondence: Marlaine C. Smith, PhD, RN, AHN-BC, HWNC-BC, FAAN, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL 33431 (msmit230@health.fau.edu).

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

OVER the course of contemporary nursing's history, there has been a significant and sustained debate about the importance of identifying nursing as a professional discipline and clarifying its distinguishing features as such. As we approach the 50th anniversary of the first national symposium on nursing theory development, the need to clarify nursing's disciplinary perspective is just as relevant as it was 50 years ago. Nursing scholars of the past and present have urged us to wake up and pay attention to the critical importance of generating a clear perspective on nursing's distinctive knowledge, to be diligent about disseminating it through the education and socialization of students, and to preserve and advance it in our research and practice traditions. Listen to the voices of these nursing scholars across 5 decades:

There exists today an unprecedented need for identification of the uniqueness of nursing science and practice, lest overriding forces in contemporary society lead to disintegration of nursing as a distinct profession.1 (p160)

Failure to recognize the existence of the discipline as a body of knowledge that is separate from the activities of practitioners has contributed to the fact that nursing has been viewed as a vocation rather than a profession. In turn, this has led to confusion about whether a discipline of nursing exists.2 (p73)

... the continuing development of nursing knowledge through the further explication of extant or emerging nursing conceptual models (and theories) is essential for the growth, even survival, of the discipline of nursing as we move into the 21st century. Without it, our unique contribution to society will be marginalized or diluted.3 (p148)

Nurses are thirsting for a meaningful practice, one that is based on nursing values and knowledge, one that is relationship-centered, enabling the expression of the depth of our mission, and one that brings a much needed, missing dimension to current health care. What is missing in health care is what nursing can provide when practiced from the heart of our disciplinary perspective.4 (p25)

... without clarity on what constitutes our core disciplinary knowledge we are at risk of losing our identity.5 (p1)

The future of nursing as a discipline is at a dramatic crossroads ... Both historical developments and contemporary circumstances have helped to create a context within which the current maturation of “nursing as nursing” practice, science and knowledge development is threatened.6 (pp61-62)

Current existential threats pose a clear and present danger to the discipline of nursing and call for our vigilant and serious reflection, dialogue, and response. One potential threat is the lack of emphasis on the disciplinary focus in nursing education. Many undergraduate and graduate nursing curricula do not ground students in the breadth and depth of nursing knowledge. Educators are challenged to follow the American Association of Colleges of Nursing (AACN) Essentials, and Quality and Safety Education in Nursing, Institute of Medicine, and Interprofessional Education competencies with little attention to learning nursing theories, the research related to those theories and creating a practice guided by those theories. “Without a clear understanding of the focus of the discipline, nurse educators succumb to outside pressures of burgeoning volumes of information, demands of preparing students for licensure and certification, and efficiency in ways that benefit other interests, not the interests of nursing.”7 (p2) Grace et al6 call attention to the imbalance in PhD education in nursing, with too much emphasis placed on the empirical at the expense of philosophic and conceptual/theoretic dimensions of the discipline. Oftentimes nurse scholars have exhibited a penchant to embrace knowledge from other disciplines more than their own. Chinn refers to this as “nursogyny.”8 While it is important for nurse scientists to understand the breakthroughs in genomics, microbiology, and neuroscience, this is not nursing knowledge. Brilliant nurse scientists are conducting innovative research that contributes to discoveries in other sciences. This trend is exacerbated by the push and pull to chase whatever is fundable over advancing nursing knowledge.6 Interprofessional practice and team science have been misinterpreted, resulting in the inference that there is no longer a need for nurses to retain their own disciplinary perspective while working in teams. Team science is valuable in promoting a multiperspectival understanding of phenomena for which there are shared concerns. A deeper and more textured understanding of a phenomenon, the human response to it, and the ways it might be addressed, can only be gained if each discipline comes to the table with its own unique perspective intact. Interprofessional teams flourish when they can leverage the strengths that each profession brings to persons in their care. The nurse members of these teams must know, value, and share nursing's disciplinary knowledge and point of view, including approaches to inquiry and care, with their team members to inform discoveries and improve patient care. Finally, the growth of advanced practice nursing has created both an opportunity and a threat. Advanced practice nurses enjoy a practice structure that allows for independence and creativity. While nurse practitioners apply knowledge from the sciences and medicine, their nursing practice should be guided by a nursing perspective, a nursing qua nursing advanced practice.9 When nurse practitioners practice solely from a medical model, abandoning nursing knowledge, they risk becoming “physician extenders.”

With the awareness of these challenges, it is time for a historical analysis of nursing's disciplinary focus with the hope of regenerating a disciplinary perspective that is meaningful and inspiring for the future. Various dictionaries offered definitions of regeneration as “re-constituting, reviving, reforming and creating anew.” So I am approaching this analysis and synthesis with hope that another reflection can add something to revive our attention and interest in this dialogue and raise awareness for a new generation of nurses. The purpose of this article is to regenerate the disciplinary perspective by (1) conducting a historical analysis of the literature articulating the focus of the discipline of nursing; (2) identifying the conceptual confluence of the literature by synthesizing the emerging themes and areas of inquiry; and (3) imagining ways to move forward in claiming, clarifying, and strengthening these themes in nursing's ontology, epistemology, ethic, and praxis. The article has been organized according to these elements.

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Statement of Significance

I wrote this article as a response to the continuing existential threats to the discipline of nursing with the hope of regenerating a perspective on the discipline of nursing that, while rooted in the past, might offer some new insights and a way forward. There continues to be confusion about what distinguishes the discipline of nursing. I conducted a review of this literature on this topic and summarized the literature from a historical perspective, and then synthesized it with themes and areas of inquiry within the purview of the discipline of nursing. I think this offers a new point of view on the topic.

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HISTORICAL ANALYSIS OF THE LITERATURE ON THE FOCUS OF THE DISCIPLINE

We might begin this analysis by clarifying the definition of a discipline as a field of study, grounded in higher education, that delineates its unique phenomena of concern, the context in which they are viewed, its relevant questions and methods of inquiry.10 (p114) A professional discipline includes theories and research that inform a professional practice. It has a social relevance and a value orientation that guide knowledge development.11 (p1) As a professional discipline, nursing has the components of both an academic discipline with the added dimensions of theory and research that inform and are informed by practice.10 For the past 50 or so years, the discipline of nursing has grown, with a structure composed of philosophies (including ontology, epistemology, ethics, aesthetics, critical), conceptual models and grand theories, middle range theories, situation-specific or practice theories, and research and practice traditions grounded in these theories.12 , 13 The inquiry within the discipline expands its knowledge base. The representation of our disciplinary focus should be broad enough to encompass a diversity of views while being focused enough to provide boundaries and direction regarding lines of inquiry.12 (p50)

This historical analysis began by locating and reviewing the nursing literature that defined or described the focus, matrix of concepts, or broad phenomena of concern for the discipline of nursing, and organizing relevant sources from earliest to most recent. This historical summary appears in Table 1.

Table 1

Table 1

Florence Nightingale14 offered ideas about the nature of nursing. She identified nursing as both a science and an art, and situated the laws of health within the purview of nursing, while the laws of disease were under the purview of medicine. The whole patient (body, mind, and spirit) was at the center of her thinking about nursing as well as the influence of environmental factors on health and recovery. For Nightingale, nursing was a spiritual calling, a service to God and humanity. While she did not explicitly use the word “caring,” some scholars15–17 perceive caring as implicit in her writings. Dunphy15 (p49) asserts that that “an underlying ethos of care and commitment to others echoes in her words and, most importantly, resides in her actions and the drama of her life.”

Following Nightingale, the focus of nursing as a distinct profession was muddled and intermingled with medicine, since many nurses were educated by physicians. Beginning in the 1930s, an effort to define nursing through activities or functions emerged; however, these were not focused on nursing as a discipline, a field of study, or a sphere of distinctive knowledge. Effie Taylor wrote on the nature of nursing practice, and others such as Annie Goodrich in 1946 and Esther Lucille Brown in 1948 continued the quest to define the functions of the nurse. A 17-state study by the American Nurses Association was conducted on the nurse's function in 1950. In 1959, Ida Jean Orlando identified the nurse's prime function as meeting the patient's needs for help through the responsive relationship, and Ernestine Wiedenbach clarified the deliberative nursing process. Similarly, Virginia Henderson's classic definition of nursing as performing the activities for individuals, sick or well, that would contribute to health, recovery, and a peaceful death focused on the functions of the nurse.18 (pp13-15)

In 1970, Rogers19 defined nursing as a basic science concerned with human wholeness, and asserted that the science of nursing is directed toward understanding the unitary life process. For Rogers,20 human beings and environment are irreducible energy fields in mutual process; therefore, by definition, well-being is a manifestation of the integral human-environment relationship. She referred to nursing as a humanistic science dedicated to compassionate concern for the well-being of others.

In the early 1970s, the National League for Nursing's Council of Baccalaureate and Higher Degree Programs21 developed the criterion that nursing curricula should be based on a conceptual framework in an effort to attenuate the influence of the medical model in nursing education. In a seminal article, Yura and Torres asserted that these frameworks would accommodate the concepts within other disciplines important to nursing practice as well as “developing theory directly from the context of professional nursing practice.”22 (p.17)

... the nurse's primary concern has been and is for the person who is ill, rather than for the illness itself ... It is concern that is expressed in the attention given to patient adjustments and adaptations under the changed circumstances of illness, to coping abilities and strategies, to personalized care and patient comfort during illness, to development of lifestyles and behavior patterns conducive to a sense of physical, psychological, and social well-being ...22 (p18)

In their study of 50 nursing programs, these nurse leaders identified the major concepts of Man (sic), Society, Health, and Nursing as basic to all baccalaureate nursing frameworks. Man (sic) was viewed as whole, a “bio-psycho-social-spiritual being, holistic and unique.”22 (p.22) The concept of Society focused on environment, including family, community, and universe. Health included both wellness and illness. The concept of Nursing encompassed the nursing process and roles and functions of the nurse such as communication, decision-making, and leadership.

In their classic 1978 article, Donaldson and Crowley10 articulated the essence/core of the discipline of nursing as concern with (1) principles and laws that govern the life processes, well-being, and optimum functioning of human beings—sick or well; (2) patterning of human behavior in interaction with the environment in critical life situations; and (3) the processes by which positive changes in health status are affected. “From its perspective, nursing studies the wholeness or health of humans, recognizing that humans are in continuous interaction with their environments.”10 (p119)

Perhaps the most well-known conceptualization of the discipline is the metaparadigm developed by Fawcett23 as a way to distinguish the domain of nursing. It closely mirrors the concepts identified by Torres and Yura.22 , 24 The metaparadigm consists of 4 concepts: persons, environment, health, and nursing. Nursing is the study of the interrelationships among these 4 concepts. Similarly, Chinn and Kramer25 , 26 identified person, society-environment, and health as the concepts delineating the knowledge of nursing.

In the late 1980s, metatheorists continued to write about the constellation of concepts that defined the discipline. Meleis27 identified nursing client, transitions, interaction, nursing process, environment, nursing therapeutics, and health as the domains of the discipline. Kim's28 structure included client, client-nurse, practice, and environment, while Walker and Avant29 named health behavior and health status, stress and coping, developmental and health-related transitions, and person-environment interactions as the concepts that defined nursing.

From a unitary science perspective, Parse30 stated that nursing is the study of the human-health-universe process, and Barrett31 , 32 asserted that nursing was the study of “unitary human beings in mutual process with the environment for the purpose of well-being/well-becoming.”32 (p130) Reed33 (p78) specified the meaning of nursing as an “inherent human process of well-being manifested by complexity and integration in human systems.” From her perspective, a new term, such as nursology, could be used for the name of the discipline that studies nursing, this inherent process, as its focus.

In an attempt to find common themes evolving within nursing, Roy and Jones34 offered a consensus statement of philosophic unity in the discipline that affirmed that nursing offered a perspective on human beings characterized by wholeness, complexity, and consciousness, and that the essence of nursing is relationships exemplified by true presence in human-to-human engagement.

The authors of 8 of the sources in Table 1 have argued for the inclusion of caring within nursing's disciplinary perspective. In the late 1970s, Leininger35 and Watson36 identified human care or caring as the defining attribute of the discipline of nursing. In 1989, the American Academy of Nursing and Sigma Theta Tau convened a landmark conference where many of those in attendance asserted that “caring” should replace “nursing” in the metaparadigm, partly in response to the critique that defining nursing with the concept of nursing was tautological.37 In 1991, Newman et al published a seminal article in which they articulated the focus of the discipline of nursing as “caring in the human health experience.”11 (p3) Smith12 , 38 , 39 suggested that nursing is the study of human-environment health and healing through caring. This definition uses similar concepts but shifts the direct object in the sentence from caring to health. In this definition, “nursing knowledge focuses on the wholeness of human life and experience and the processes that support relationship, integration and transformation.”13 (p4)

In 2008, an issue of Advances in Nursing Science was devoted to the discipline of nursing. Several significant articles appeared in that issue. One was written by Newman and colleagues4 in which the focus on the discipline was revisited. These authors asserted that there was a movement within the discipline toward a unitary worldview, “from looking at parts to looking at the whole as primary, from seeking to solve a problem to seeking to know the pattern ... to realizing mutuality of the unfolding, rhythmic process ...”(pE16) Likewise, a unitary view of health is based on wholeness, evolving pattern, and transformation.(pE17) These authors identified relationship as a unifying construct for the discipline with the concepts of health, caring, consciousness, mutual process, patterning, presence, and meaning addressing the dimensions of this relationship. Another of the articles by Cowling et al40 published in that issue focused on the positioning of the concepts of wholeness, consciousness, and caring among several prominent nursing theories within a unitary worldview. The authors argued that these concepts had relevance for distinguishing nursing from other disciplines. Other concepts within the proposed disciplinary matrix were pattern, transformation and transcendence, relationship, and meaning. The authors asserted that “though a groundbreaking delineation of disciplinary boundaries for its time, the metaparadigm concepts of person, environment, health and nursing require greater clarity and specificity for a new era of knowledge development in nursing.”(pE45) Willis et al41 presented the unifying focus for the discipline as “facilitating humanization, meaning, choice, quality of life and healing in living and dying.”(pE33) They refer to human beings as unitary with the human-natural world, and that humanization is practiced “as an open-minded, caring, intentional, thoughtful and responsible, unconditional acceptance and awareness of human beings as they are.”(pE34) Finally, Litchfield and Jonsdottir42 defined the practice discipline of nursing as “humanness of the health circumstance.”(p88) They claim that the separation of knowledge development from the activities of nurses in practice “creates a vacuum for a practice discipline”; they call for the primacy of practice wisdom as the “task for disciplinary development for this era.”(p81) These scholars advance a more participatory nature of knowledge development, and offer a view that knowledge and the activities of nurses are one engaged process.

Recently, Watson43 (p64) asserted that the discipline of nursing (1) honors a whole person ontology and a relational, unitary worldview; (2) adheres to an orientation toward humanity that sustains human caring-healing-health for all; (3) asserts health as encompassing social-moral justice and whole person/system processes and outcomes; and (4) embraces human caring and eco-caring as one.

In her later writing Meleis50 identified 4 characteristics that define the nursing perspective: (1) nursing as a human science concerned with understanding the whole person, patterning, and human experience; (2) nursing as a practice-oriented discipline with a commitment to enhance the care of people through knowledge; (3) nursing as a caring discipline that embraces the ethical, spiritual, relational, and practical aspects of caring; and (4) nursing as a health-oriented discipline that includes all human health experiences through living and dying.

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CONCEPTUAL CONFLUENCE IN LITERATURE ON THE DISCIPLINE OF NURSING

Following the historical analysis, I clustered together concepts from the source documents with similar meanings. Table 2 was created to depict these themes. Some of the concepts were at varying levels of abstraction; when this occurred, the lower-level concepts were subsumed under a more abstract-level concept. Arriving at any confluence of meaning related to the discipline of nursing assumes inclusiveness of all paradigmatic, philosophic, and theoretic perspectives.

Table 2

Table 2

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Human wholeness

There is consensus within the literature that the focus of the discipline of nursing is on the study of human beings in their wholeness. One of the distinguishing features of the identified paradigms in nursing11 , 45 is that those conceptual models or theories that share the totality or integrative-interactive paradigm conceptualize human beings as whole, with integrated biologic, psychologic, sociocultural, and spiritual dimensions (bio-psycho-social-spiritual being), while those from the unitary-transformative or simultaneity paradigm espouse a unitary, irreducible view of human wholeness. In the integrative paradigm, there is a recognition that understanding the whole human being transcends the conceptual labels of biologic, psychologic, social, and spiritual. In more recent writings on the discipline, there seems to be movement toward a unitary perspective on human wholeness.4 , 11 , 34 , 40 , 43 If human wholeness characterizes our knowledge development in nursing, we would expect that those advancing nursing science would study human beings, and not animals, body systems, tissues, cells, or genetic material. While these are necessary for the study of other sciences, they cannot provide knowledge of human wholeness, the focus of knowledge development in the discipline of nursing. In the nursing conceptual models that include physiologic, psychologic, and sociocultural dimensions, biophysical, psychologic, or cultural instruments would be relevant for measuring these dimensions, but the findings would be integrated to reflect a whole person perspective. For example, in studying the impact of the stress of parent-child separation on the health of children, an indicator of stress might be plasma cortisol levels; however, this finding would be contextualized within the whole as represented by the specific nursing theory.

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Health/healing/well-being

Health/healing/well-being is conceptualized differently in nursing paradigms as well as in particular conceptual models and theories. The cluster of concepts that appear in statements related to the focus of the discipline of nursing reflects related meanings of health including: well-being, optimum functioning, health experience, health circumstance, healing, and well-becoming. Phillips46 coined the term “well-becoming” to capture the evolving nature of human health. Healing comes from the same etymology as health as “whole or sound,” and also reflects the dynamic process of flourishing. Smith47 delineated 4 different models of health as clinical, role performance, adaptive, and eudaimonistic. Within the writings about nursing from as early as Nightingale, the meaning of health is beyond the absence of disease or the clinical model. The role performance and adaptive models of health are present in conceptual models and theories of nursing; however, there is a contemporary trend to view health/healing as well-being/well-becoming, affirming the subjective, ever-changing nature of the experience and the omnipresence of health/healing throughout the life process, regardless of disease, illness, or limitations, including in the process of dying. Nursing's view of health rejects the idea that it can be externally assigned or known by diagnosis or prognosis, and acknowledges the influence of values and choice on the perception and experience of health. The discipline of nursing is embracing this more expansive view of health.

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Human-environment-health relationship

Human-environment-health relationship is the third cluster in Table 2. This is defined as the interconnectedness of human health with the multidimensional environment. Perhaps, Nightingale's14 most significant contribution is understanding the influence of the environment (ventilation, cleanliness, noise, and variety) on the process of healing. Within the literature on the discipline of nursing, the environment is represented by words such as society, human-environment/human-universe interaction. In the integrative-interactive paradigm, the process of interaction between human and environment may be characterized by responses to stimuli in the environment. The environment can be characterized by physical, social, cultural, political, economic, and metaphysical dimensions. For example, social determinants of health, such as poverty, racism, access to care, and social support, have a powerful influence on well-being. Mutual process is the nature of an integral, pandimensional person-environment relationship in the unitary-transformative paradigm. There is clear consensus that the human-environment relationship affects or relates to health; this interrelationship is central to the focus of the discipline of nursing.

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Caring

The cluster of concepts related to caring in Table 2 includes the activities or functions categorized as “Nursing” in the metaparadigm. Nursing, nursing therapeutics, nursing process, processes, practice, and client-nurse were present in 5 sources, and most of those were published in the 1970s and 1980s. On the other hand, references to caring or care as a focus of the discipline appear in 8 of the definitions with most occurring after 1990, with suggestions to replace “nursing” (representing the activities of the nurse) in the metaparadigm with “caring.” This synthesis has done this. Caring is defined as the intentions, expressions, behaviors, actions, and experiences, grounded in a moral-ethical-spiritual foundation, that nurture humanization, health, healing, and well-being. Caring has a body of substantive knowledge associated with it; it is more than the practice of compassion and kindness. Just as the meaning of human wholeness and health varies within nursing paradigms and theories, the meaning of caring can differ from the activities performed to minister to those during an illness like providing treatments, to a meaningful intersubjective nurse-person relationship, to advocating for policies that promote social justice. Caring includes the moral imperative to protect and nurture human dignity and rights. For this reason, facilitating humanization is included in this cluster. Humanization includes unconditional acceptance, promoting choice, facilitating what matters most to people, and promoting equity. With the burgeoning worldwide interest in caring science, compassion science, and the adoption of caring-based and relationship-centered frameworks as nursing models by health care organizations, it is evident that there is greater consensus around the centrality of caring in the discipline of nursing. For example, over 300 hospitals, either designated with Magnet status or on the Magnet journey, are using a caring theoretical framework as a guiding practice model, the most pervasive of all nursing models adopted.

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EXAMPLES OF AREAS OF INQUIRY

Guided by this disciplinary matrix, I have identified examples of phenomena of concern within the discipline of nursing. These examples emerge from the current theoretical and empirical work in nursing. Developing the knowledge of the discipline includes inquiry in the following areas:

  1. Promoting health, well-being, and quality of living and dying. This area of inquiry includes the research and theory development related to self-care and health promotion. Inquiry might include the study of variables that affect health-promoting lifestyles, barriers and facilitators of self-care related to living with chronic illnesses, and palliative care interventions that promote quality of life for persons with terminal cancer.
  2. Stress, coping, and adaptation throughout the life process. Research and theory development in this area relate to human-environment interactions that produce stress, and the coping and adaptive strategies that promote health, healing, and well-being. Examples include studies of resilience, hardiness, and well-being for persons experiencing life crises; the process of adaptation to chronic illness; and the identifying the most effective coping strategies when experiencing uncertainty.
  3. Transitions in the life process. This includes research related to developmental and situational transitions such as birthing and parenting as well as health-related life changes. Inquiry could include understanding the types and patterns of health-related transitions, the transition experience, and caring activities that promote health, healing, and well-being during transitions. Role development and acquisition during developmental and situational transitions are possible areas of inquiry. Specific examples include role transitions over the life cycle for mothers; caring for a spouse after the diagnosis of Alzheimer disease; and life changes accompanying retirement.
  4. Cultural care. This example includes the cultural meanings associated with health and illness and the influence of culture on perceptions of caring. Examples of studies in this area are the influence of culture on pain perception and expression; lesbian couples' responses to motherhood; and assessment of Arab-American knowledge, attitudes, and beliefs about birth control.
  5. Human-environment energy field patterning. Knowledge development in this realm includes the study of the processes and indicators of energy field patterning related to well-being/well-becoming; integrative/holistic therapies and their relationship to well-being, and changes in correlates of human development with shifts in environmental field patterns. Examples are: the relationship of power to well-being for persons experiencing heart transplants; pain for persons with osteoarthritis after therapeutic touch; and self-transcendence in women with breast cancer engaged in a spiritual practice.
  6. Consciousness and health. This sphere of inquiry is related to patterning of the life process, discovering meaning, and facing choice points when reflecting on this life patterning. Expanding consciousness or health accompanies this engagement in reflection and pattern recognition. Examples of research and theory development in this area include life patterns of persons with coronary artery disease; changes in meaning of life for older adults engaged in wellness coaching; and immigrant women's perceptions of community health.
  7. Health-related lived experiences. The study of lived experiences provides deep understanding of the vicissitudes of living and dying related to health, healing, and well-being. Examples of research include the struggle of those who are terminally ill to maintain hope; grieving a personal loss; and the experience of healthy aging.
  8. Caring relationships, processes, and practices. The study of caring relationships, processes, and practices is an example of a substantive area of knowledge development in the discipline of nursing. “Caring science within the discipline of nursing is the intentional research and theory development focused on the relationship of caring to health, healing, well-being and quality of life of the whole person within the context of the family, community, or all of humanity” (www.fau.edu/nursing). Examples of inquiry within caring science are caring communication for couples when one has dementia; patient and family satisfaction following implementation of a caring-based practice model in a bone marrow transplant unit; and patient perceptions of nurse caring in an intensive care unit.
  9. Environments that facilitate health, healing, and well-being. This is the final example of a field of inquiry within the discipline of nursing. This could include how physical, social, cultural, political, and economic environments influence health, healing, and well-being. Examples of research in this area are music listening to reduce postoperative pain; the effect of food deserts on the health of inner-city children; and the effect of discrimination on health outcomes of African American men.
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STRATEGIES FOR CLAIMING, CLARIFYING, AND STRENGTHENING THE DISCIPLINE OF NURSING

I began this article with the intention that this analysis would lead to new insights that would make a difference. The threats to the integrity of the discipline of nursing must be countered by an assertive and organized campaign of education that clarifies the discipline, illuminates the danger of undermining it, supports activities that advance nursing knowledge, and demonstrates its significance. These strategies can be assigned to nurse educators, scholars, and leaders. This is a call for action to assume responsibility for the existence of our discipline and the importance of reclaiming what nursing can offer to the world.

First, the discipline of nursing must be an integral part of all levels of nursing education. There is an urgent need to develop curricula in baccalaureate, masters, and doctoral programs that educate students about the focus of the discipline and nursing knowledge including theory-guided practice and nursing theory-based research.48 One of the earliest courses in any nursing program should introduce new students to the discipline and profession of nursing. Too frequently students begin their academic careers with courses such as health assessment, nursing skills, and pathophysiology. Without a grounding in the discipline, nursing appears to be an applied science in which nurses use the knowledge of other disciplines in the care of patients. Nursing has its own science, and this body of knowledge needs to be the foundation of the next generations' socialization into the discipline. Disciplinary knowledge must be integrated within each of the nursing courses, where students are studying the content of nursing rather than applying the fields of medicine, psychology, or public health to disease or health problems in individuals, families, or populations. Students should be guided to practice from the knowledge and values of the discipline: seeing patients through the lens of wholeness and interconnected with family and community; appreciating how the social, political, and economic environment influences health; attending to what is most important to well-being; developing a caring-healing relationship; and honoring personal dignity, choice, and meaning. This is the disciplinary perspective that transcends individual nursing theories. The knowledge of the discipline builds in graduate education, as students apply and generate nursing knowledge in their roles as advanced practice nurses or develop or test theories as researchers. To grow nursing science, PhD students need to situate their phenomena of concern within a nursing theoretical framework, and DNP students should evaluate nursing theory-guided models of care. Students often use theories from other disciplines rather than those within nursing, often because they have not studied them. Faculty develop curricula at the baccalaureate, masters, and doctoral levels using the AACN Essentials. It is time to revise the Essentials documents and go beyond them to reflect the importance of the legacy of knowledge development in the discipline.49

Scholars and researchers need to embrace the value of nursing knowledge and advance it in their work. The most compelling reason for using nursing theory is that it has the potential to improve care for the people we serve. Those hospitals on the Magnet journey identify a theory that guides the development of their practice model. Practice scholars can report in the literature about the difference that these models make to outcomes of care. Demonstrating that nursing theory can improve patient outcomes can enhance the valuing of nursing knowledge. Researchers should design theoretical frameworks for their research based on nursing theories. There are a plethora of middle-range theories that can be tested in research, and there is an opportunity to develop new ones. Reviewers and administrators of funding agencies such as the National Institute of Nursing Research can lead by encouraging the development and testing of these theories. Nurses working in interprofessional and interdisciplinary teams need to share nursing's disciplinary perspective and offer insights that arise from nursing knowledge. Often other disciplines are not familiar with nursing literature; it is our responsibility to share relevant literature that can bring new, exciting perspectives to the team.

Leaders invested in advancing the discipline have an important role to play. Like-minded nursing leaders can speak at various nursing conferences about this issue. For the most part, the topic of nursing knowledge is missing from most nursing conferences. For example, nursing leaders could hold a forum at the AACN Doctoral Program conference on the content of doctoral programs related to the focus of the discipline. It is time to submit abstracts featuring nursing theory-informed research and practice. Those who serve in leadership roles in conferences and funding agencies can advocate for requiring a nursing theoretical framework to be part of the review criteria for abstracts and grant submissions. It is time to hold nursing theory conferences once again to generate a passion for substance in the discipline.50 The conferences could feature examples of research and practice informed by nursing theory. Summits can be held with thought leaders from education and practice to generate meaningful approaches to strengthen the discipline. Standards of practice and certification examinations should reflect nursing knowledge. Finally, leaders can convene interprofessional dialogues to share nursing knowledge that has relevance for all health professionals.

The time is now for nursing to reaffirm the uniqueness of its disciplinary perspective for the good of nursing and the public. In this article, a regeneration of nursing's disciplinary perspective was offered through analyzing the past literature, examining the conceptual confluences within the literature, and synthesizing an evolutionary perspective on the discipline with possible areas for knowledge development. A call to action was issued for nurse educators, scholars, and leaders to reclaim, clarify, and strengthen the discipline of nursing.

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    Keywords:

    caring; discipline of nursing; health; holistic; human-environment relationship; knowledge development; metaparadigm; nursing knowledge; nursing theory; theory development

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