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Reflections on Nursing Practice Science

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  Reflections on Nursing Practice Science: The Nature, theStructure and the Foundation of Nursing Sciences Dorothea E. Orem  Abstract: This is a retrospective examination of efforts to clarify the nature,the form and structure of nursing science. This accounting isa sample of the work done by me and my colleagues tounderstand nursing science. This sample may serve as a guideto nurses who seek to understand nursing science and thenature of work required in its development. Key words: - Nurses and Nursing Science- Kinds of Science- A Beginning Development of Nursing Sciences- A General Theory of Nursing and its Broad Conceptual Structure- Conceptual Elements and Theories- Continuing Development of Nursing Sciences Nurses and Nursing Science Professional nurses have been concerned withand have attended to the development andimprovement of nursing research includingrelationships to nursing theory. However, therelationship of nursing to nursing science has notbeen adequately addressed by the nursingprofession. The nature of nursing science and itssubject areas and content must be clarified beforethese relationships can be properly identified andunderstood. Nursing research and its results, whennot associated with nursing science, often standin isolation of the question studied. Even in thebeginning stages of development, nursing scienceidentifies its subject areas with organized contentas well as unanswered questions that researchersshould investigate in order to develop the contentof nursing science. The formalization of criteria for nurses’ selection of valid methods of assistancegiven the nature, the number, and extent of persons’self-care limitations is one example of this.In the beginning stages of our work, we sought tounderstand nursing as a practical science and setsof applied science, for example, the physiology of the universal self-care requisite for maintenance of physiologically adequate intake of air, water, and food.Research method in the early stages included naturalhistory method and hypothetical deductive method,(NDCG, p.135). Expressed premises about nursingas a discipline of knowledge and practice helped usin overcoming problems we encountered (NDCG, p. 4 156, p. 162). The chapter ‘Dynamics of ConceptDevelopment’ by Joan Backsheider, (NDCG, 1979)is a scholarly accounting of our efforts.Nurses who have or are achieving professionalstatus have responsibility for the development of nursing science. Becoming and beingprofessional requires understanding of the focus,the nature, the structure, the content, and thedomain of nursing science in relationship to thefocus of and the realities that define the domainof nursing practice. “Wallace (1996) states that“science is intellectual knowledge as opposed tosense knowledge” (p. 171). Sense knowledgeenables human beings to perceive what thingsare , for example objects such as a chair, a table,an automobile, an apple, and to know their characterizing features , such as shape, size, andcolor. Intellectual knowledge, in contrast, isconcerned with the nature of things with their meaning and content. Some scholars recognizethat intellectual knowledge is achieved throughthe human intellectual process of abstraction; thegrasping of ideas and forming concepts aboutthings that are universal, such as all apples, andthese transcend any concrete instance of whatis perceived, such as this apple on this table.See Wallace, pp. 131-135. Kinds of Science Every developed or developing science has afocus, a proper object that specifies what thescience is about, what scientists in particular fields investigate and study, and thus sets forththe domain and boundaries of the science.Wallace states that sciences are broadly groupedinto speculative science and practical sciences. Speculative sciences are pursued to increaseknowledge in particular fields. The speculativesciences that are concerned with entities foundin the world of nature are identified as physicalsciences such as chemistry and physics, lifesciences such as biology, and the humansciences of anthropology and sociology. Practical sciences are developed to describe and explainareas of knowledge necessary for use inunderstanding and achieving some practical  5 result, for example, the design of a building thathas some designated use or for designing andmaking, i.e. producing, some human healthservice. See Wallace, pp. 170-172. According to Wallace, a practical science seekscausal knowledge of what a person can do or make.To the extent that a practical science engages incausal analysis it can speculate and use analyticalprocedures similar to those of speculative sciences. A practical science aims to produce knowledge thatcan be used to produce a concrete instantiation of the subject addressed and its results sought; for example, knowledge enabling for the design andproduction of a nursing system for this person, atthis time and place that ensures that the persons’self care requisites are known and met and thepersons’ powers of self-care agency are protectedand developed. A practical science is supplemented by an art or technique that enables practitioners - e.g., nurses,physicians, engineers- to deal with singular instances of their practice. This accounts for thefrequently heard statement that nursing is both ascience and an art. See Wallace, pp. 171-172.Nurses’ mastery of the practical science knowledgeand their development of the art of nursing is namedor referred to by the term nursing agency  .Wallace gives four examples of practicalsciences.1.moral science concerned with human action2.health sciences, for example medicalsciences3.engineering sciences, concerned withmechanical and other artifacts4.political sciences concerned with humanwelfare and happiness recognizing thathuman beings are free and capable of governing themselves but are limited in self-government (Wallace, p. 188).Some philosophers and academics do not acceptthe idea of the named practical sciences but refer tosuch fields as applied sciences. This naming nodoubt is based on the need for and the practice of using facts and principles from already developedsciences in the development of specific practicalsciences each with its own proper object and itsown domain and boundaries not only for its practicefield but also for engagement in scholarly endeavor,investigations, theorizing and research. For example,facts and principles from the sciences of humananatomy and physiology, biochemistry, growth anddevelopment are used in development of varioushealth sciences.My own efforts and those of my colleagues in theformalization of nursing science were guided by aphilosophy of moderate realism and by the acceptancethat nursing science would have the form and structureof practical science with attached sets of appliedsciences. In taking the position about nursing scienceas practical science, we followed the works of Maritain, J. and Wallace, W.A. Maritain’s work of setting forth the degrees of universality and specificityof knowledge, including the practical sciences, washelpful. This included his use of the terms theoretically  practical knowledge and  practically practical knowledge .  A Beginning Development of Nursing Sciences I recognized early in my work that the mind’ssearch for knowledge, intellectual knowledge aboutnursing, proceeds without understanding of the pathbeing taken. The course followed is understoodretrospectively. One uses one’s accumulated commonsense knowledge of nursing and nursing cases, one’sunorganized intellectual knowledge about the field of nursing, as well as facts and principles from thedeveloped sciences that contribute to theunderstanding of and formalization of areas of nursingscience. Understandings of science achieved throughpursuit of the full sequence of academic courses of one or more developed speculative sciences is helpful,as well as examination of the form and structure of adeveloped practical science. For example, I washelped by my study of biology and by my explorationsof the nature, form and the proper objects of thevarious medical sciences, both the practice sciencesand the sciences foundational to the practicesciences. An essential step in the development of anyscience, speculative or practical, is the identificationand acceptance of the  proper object of the science,what the science is about, what the science describesand explains. The proper object specifies the placeof the science in the world of nature or its place in theworld of man and human affairs. Failures of nurses tounderstand and to accept the importance of nursing’sproper object is in large measure accountable for failures to formalize and validate the structure of nursingas a discipline of knowledge.My recognition of the need for understanding andstating the proper object of nursing came from worksin philosophy that differentiated between materialobjects and proper object. For example, all humanhealth services have as their object or focus, humanbeings, i.e., their material object. Each service,however, has a proper object that defines what featuresin human beings they focus their concern andattention on.  6 My expression and acceptance of nursing’s proper object occurred in my beginning and later effort to definenursing. Beginning efforts in the 1950’s were associatedwith answering the question: What is nursing? Later efforts were responsive to the critical question: Whathuman and environmental conditions exist when valid judgments can be made that individuals are in need of nursing as distinguished from other forms of healthcare?Basic to answering this question was theacceptance of two premises. The first premiseexpressed the idea that nursing is a social institutionestablished and maintained by societies for thepurpose of meeting the needs of people for thespecialized health service named nursing. The secondpremise expresses the needs of people for specifichuman health services are associated with their requirements for bringing about and maintaining or regulating specific human or environmental conditions.The identification and expression of those conditionsand their validation in concrete life situations specifiesthe proper object of the health service under consideration.The following is a 1958 adjusted expression of nursing’s proper object. Nursing’s proper object or focus is individuals insociety affected by human or environmental conditionsassociated with their states of health or their requirements for health care that result in inability toprovide continuously for themselves the amount andquality of self-care they require. With children, it isthe inability of parents or guardians to know and meetthe child self-care requirements because of the child’shealth situation (Orem, p. 20).Using the language of self-care deficit nursingtheory (SCDNT), a simple expression of nursing’sproper object is “the presence of a self-care deficit  in persons that is associated with their health statesor the nature of their health care requirements.” Aself-care deficit is expressive of a relationshipbetween person’s therapeutic self-care demands and their powers of self-care agency in whichagency is not equal to knowing and meeting their therapeutic self-care demand. The factorsassociated with the inadequacy are named self-care limitations .These statements about the proper object of nursing specifies that the proper object of nursing isthat segment of society that has legitimate needs for and can benefit from nursing. This is the populationwithin societies for which nurses design and produceindividualized systems of nursing, the population thatis the focus of their scholarly endeavors and research.It is the population that nurses study in their work asnursing scientists.The proper object of nursing is a descriptiveexplanation of why individuals require nursing. Itis not a definition of nursing. Understanding thenature and meaning of any formulation of nursing’sproper object requires understanding of the termsand concepts used to express the realities of nursing’s reason for existence. The terms used toexpress the concepts, e.g., the terms self-care andself-care agency, represent the beginningdevelopment of a nursing language.Isolation or specification of the proper objectof nursing was taken from definitions of nursing thatI formulated during the 1950s, 60s and 70s. Someof these definitions were descriptive, others weredescriptively explanatory. These definitions wereaccepted by my colleagues in the NursingDevelopment Conference Group as a starting basefor our work to understand nursing as a practicalscience, to discover its structure and its subjectmatter, both theoretical and practical.During this beginning period of study, mypersonal focus was on defining nursing and inthe formalizing and naming the concepts thatformed its conceptual structure. This led todevelopment of models to show the relationshipsamong conceptual elements. My early workculminated in development and expression of ageneral theory (or a general concept) of nursingexpressed as a word model.My colleagues and I recognized and soughtto understand the complexity of nursing. Wefound as our work progressed that a definitivedefinition or an expressed general theory of nursing were the intellectual instruments thatwere enabling for recognizing and dealing withrealities of nursing and its complexity in the worldof nurses and their patients. As my colleagues and I worked to develop,formalize and express a general theory of nursingand later to refine it, build upon it, validate itsconceptual parts and use it in nursing practice,we found it necessary to identify and seekunderstanding of the concepts of a general naturethat were the underpinnings of our work, for example, the idea of deliberate action. It is notpossible to understand the realities of self-careor nursing without a working understanding of deliberate goal seeking action including theschema of and the process components of acomplete human act (Orem, 2001, p. 61-66).Understanding of the capabilities and limitationsof people to engage in self-care conceptualizedand named self-care agency was enhanced byLouis Hartnett’s models of the physiological andpsychological features of deliberate action  7 including sociological and cultural features (NDCG,pp. 135-141).Other general concepts explored includedorganization, order, relation, process and system.We explored ways of viewing humankind and later the various meanings attached to the idea of good.These concepts in a sense were working tools thatprovided a foundation for our cognitive structuring of the subject matter of nursing. See Orem pp. 129-134 and pp. 150-157. The efforts to seek a workingunderstanding of these concepts included: a searchfor authoritative sources and study of identifiedsources; study of the nature of models and modelbuilding; development of models, or acceptance of already developed models.  A General Theory of Nursing and its Broad Conceptual Structure The general theory of nursing developed by meand my colleagues is named the self-care deficit theory of nursing  . It is a theory that expresses thedominant features of any one as well as all situationsthat are nursing practice situations. The generaltheory brings together and unifies a theory of self-care and a theory of self-care deficits with thesubsuming theory of nursing systems . According to Wallace, the term theory “has noprecise meaning that is universally accepted by thevarious branches of science” (p. 244). Theory, as theterm is used here, means an overarching explanationof conceptualized features of nursing practicesituations and relations among them that are commonto all instances of nursing. Theory formation beginswith the search for dominant features of nursingpractice situations with their isolation and search for understanding their meaning and, finally, their conceptualization and naming. Theory formation fromits beginning stages is based on premises aboutnursing that are self-evident. One such premise isthat nursing is a form or type of human assistance(NDCG, p. 156). This premise gives rise to questionsthat require answers:1.When and why do persons need nursing?2.Do people vary and how do they vary in their qualitative and quantitative requirements for assistance from nurses?3.What are valid forms of assistance given theconditions that are associated with persons’needs for nursing?4.What is the form, the structure and thecontent elements of nursing assistance?In retrospect, it can be stated the self-care deficittheory of nursing was formed from answers to thesequestions. The theories of self-care and self-caredeficits are based on answers to questions 1 and2 and the theory of nursing system is based onanswers to the questions 3 and 4.The theory of nursing systems subsumes andunifies the theory of self-care and self-caredeficits. It identifies and brings into relationshiptwo patient variables, therapeutic self-caredemands and self-care agency, and relatesthese variables to the nurse variable, nursingagency, in the nurses’ design and production of systems of nursing (care). Basic tounderstanding S-CDNT is understanding nursingas a helping service which is basic to answeringthe four stated questions (Orem, pp. 55-51). Inthe real world of nurses and their patients, thequalitative and quantitative values of each of thethree variables must be determined. This is doneby determining the conditioning effects of personal and environmental factors on the valuesof the variables. These factors have been named basic conditioning factors . Factors include thepatient’s and the nurse’s age, gender,developmental state, sociocultural orientation,family system factors, health state, health caresystem factors, patterns of living, environmentalfactors, resource availability and adequacy(Orem, pp. 325-329). For example, if oneaccepts that self-care is a human regulatoryfunction that must be performed by persons for themselves in interest of life, health andwellbeing or be performed for them, one mustknow persons’ regulatory requirements, their  self-care requisites .In the development of self-care deficit nursingtheory, we identified and classified theserequirements through study of the life sciences,human sciences, and the medical sciences(Orem, pp. 47-49). All persons, for example,must meet the self-care requisites for aphysiologically adequate intake of air, water andfood. What is physiologically adequate and themeans that are valid and reliable for meetingindividual persons’ requisites are determinedthrough use of basic conditioning factors, for example, in determining the nutritionalrequirements of infants and how infants canconsume food and water, as well as the form,the consistency of their nutritional intake andprecautions to be taken in feeding infants.Scientific theories in nursing or in any other discipline of knowledge are of value only if theyare useful. The utility of S-CDNT has beendemonstrated by nurses who understand and
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