foumal of Advanced Nurstng,

1993,18,1651-1656

The discipline of nursing: historical roots, current perspectives, future directions

Maureen C Shaw RN MN
Climcal Nurse Spectaltst, The Arthntis Society (BC and Yukon Divtston), 895 West 10th Avenue, Vancouver, Bnttsh Columbia, W Z 717, Canada

Accepted (or publicahon 15 Febniary 1993

SHAW M C (1993) Journal of Advanced Nursing 1 8 , 1 6 5 1 - 1 6 5 6 The disapline of nursing: historical roots, current perspectives, future directions As advances m nursmg saence and research impact upon nursmg education and climcal pradice, new ways of looking at phenomena have led to a re-exammation and refmement of the traditional concepts person, environment, health and nursmg This evolving pattem of mtellectual growth holds promise for the disaplme of nursmg through the advancement of knowledge based upon saentific mquiry mto the practice of nursing This paper discusses nursmg as a disaplme by examinmg the development of a unique body of knowledge from three viewpomts histoncal past, current perspectives and future direction

HISTORICAL ROOTS The disaplme of nursing slowly evolved from the tradihonal role of women, apprenticeship, humamtanan aims, rehgious ideals, intuihon, common sense, tnal and error, theones, and research, as well as the multiple influences of mediane, technology, pobhcs, war, economics and femmism (Jacobs & Huether 1978, Keller 1979, Brooks & Kleme-Kracht 1983, Gorenberg 1983, Perry 1985, Kidd & Momson 1988, Lynaugh & Fagin 1988) The first nurse-theonst, Florence Nightmgale (1969), viewed nursmg as havmg organized concepts and social relevance distinct from mediane Later, Henderson (1965) descnbed nursing as a umque, complex service with mdependent practihoners who were authonhes on nursing care More recently, Roger's (1970) hohshc interpretations of persons have become a cntical pomt of departure in advanang theory by defining nursmg as an art and a saence and by providing a substcintive base for theory testmg In a landmark paper, Donaldson & Crowley (1978) define a disaplme as 'a umque perspechve, a dishnct way of viewmg all phenomena, which ultimately defines the limits and nature of its mquiry' Smxx the hme of Florence

Nightmgale, nurse-scholars have sought to explore, understand and explicate the concepts central to the domam of nursing person, health, environment and nursmg Themes delunitmg the boundary for nursmg practice and investigation include (a) laws and pnnaples govermng life processes and well-bemg of humans, (b) influences of the environment on human behaviour, (c) processes whereby nursmg posihvely affeds health, and (d) families and commumties as a focus of nursmg practice (Donaldson & Crowley 1978, Fawcett 1984) A recent review of the hterature suggests a consensus on the recurrent themes and commonalities central to nursing's domam of mquiry (Donaldson & Crowley 1978, Ellis 1982, Bramwell 1985, Meleis 1987)

Hallmark of success Consistency over time regarding the ldentifieation of the boundary and domam of nursmg is not orJy a strength of the discipline but also a hallmark of success m nursmg research and theory development As such, it is time to extend formal acceptance to the domain concepts and boundanes as a paradigm germane to a disaplme of nursmg 1651

MC Shaw Currently, nurse educators, scholars, dmiaans and researchers contmue to contnbute to the disaplme's comerstone by danfymg the work and role of nursmg in health care and advanang nursmg knowledge from a state of haphazard, unvenfied thoughts to a disaplme of systemahcally organized concepts (Table 1) CURRENT PERSPECTIVES Despite a growmg consensus on a nursmg paradigm, the definihon of nursmg as a disaphne remams ambiguous (Hardy 1978, Jacobs & Huether 1978, Meleis 1987, Northrup 1992) Hardy (1978) bebeves dissent is charactenstic of nursmg's preparadigmahc stage of saenhfic development where confusion and dispute over theory and research are a normal developmental stage However, Hardy's attempt to measure the performance of nursmg agamst saenhfic advances germane to medical science has resulted m a negahve, hnear estimate of nursmg as a disaplme and fculed to recognize nursing's unique contnbutions to the health care of soaety Moreover, nursing may not expenence penods of normal saence, such as those outlined by Kuhn (1970), and may conhnue to evolve indefinitely Rather than argumg the disaplinary status of nursmg, the queshon, as posed succmctly by Perry (1985), is 'Has the disaplme of nursmg developed to the stage where nurses do "think nursmg'T Numerous theones and conceptual models have been advanced smce the 1960s in order to assist nurses to systranahcally thmk nursmg To Meleis (1987) theory is a powerful, dynamic, yet focused, source of professional autonomy and dmical knowledge Rather than a saentific revolution or evoluhon, the development of nursmg knowledge is an unconvenhonal, convoluted process (Meleis 1985). It could be argued that a straight road to a convenhonal paradigm would mark nursmg's acceptance mto the saentific community However, the advancement of nursmg theory cannot be measured m the same manner as the physical, pharmacological, medical or psychological saences Smce nursing has adopted many competmg and complementary theones (Meleis 1985), the debate on the worthmess of these theones wiU conhnue to contnbute to the scholarly development of nursing as a disaplme over time Scholarsfi-omHardy (1978) to Northrup (1992) have advocated completmg theones and adophng a specific paradigm m order to bnng consensus and cohesion to the disaplme of nursmg On the other hand, recent authors (Meleis 1987, Banett 1992) propose diversity and plurality m nursmg philosophy, saence and practice From a dimcal 1652 perspective, not only is adoption of a specific perspechve unlikely m a disaphne that understands mulhdimensional, complex human behaviour, but theorehcal consensus is quite unlikely m a disaplme that values the role of percephons, uniqueness and individuality m health and illness Smce nurse-theonsts have mdividual approaches towards life, healthy differences of opmion will contmue to exist and to fuel the scholarly debate in the future regardmg nursmg's ontoiogical and epistemological aims Indeed, nursing has now tumed to philosophy for assistance with appropnate strategies congruent with nursmg's assumptions and missions (Meleis 1992) Challenge to completed-theory perspective Meleis (1987) challenges the perspechve that completed theory is the only way to achieve disaplinary status and that outcome is the sole validation of theory The endproduct 'the process of conceptualizmg a phenomenon, the process of understanding a dimcal situation and the process of going beyond the data m a research project' (Meleis 1987) is the essence of theoretical development Theones-m-process are not the mcomplete manifestahons of an unsystematic, haphazard mquiry, they connect nursing's ontological concems with the paradigm's domain concepts In knowledge development, theonzmg is not an orderly progression of thought, but a process of cnhcal thinking charged with difficulty and ambiguity Furthermore, this scholarly process has lead to the formahon of the domam concepts and ldentificahon of the boundanes of nursmg which, in tum, have further coalesced mto a paradigm that forms the base for the disaplme of nursmg as known today The recent literature on canng illustrates how nursmg scholars conhnue paradoxically to queshon the limits, yet advance the boundanes, of a disaplme of nursmg Watson (1988) developed the concept of canng as a central tenet m her nursmg model Leuunger (1981) descnbes canng as the unifymg domam for nursmg's body of knowledge and prachces, while Swanson (1991) proposes carmg as a theory of social process that is essenhal, but not unique to nursing Indeed, to many nursmg theonsts, canng provides an essenhai, unifying lmk withm the paradigm concepts (Barrett 1992) However, although carmg and health are central to nursmg, an mtegrahng statement has not been developed and the concepts cannot stand alone to meet the cntena for the focus of the disaplme (Newman et al 1991) Moreover, the addihon of carmg to the domam concepts raises questions about the artifiaal and reductionistic separahon of carmg, knowmg and domg withm nursmg's

The dtsapline of nursing

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MC Shaw totahty paradigm approach to theory development has added fuel to the debate Theonsts in the simultaneity paradigm (Rogers 1970, Parse 1981, Newman 1986) advocate the theory 'of nursing view expliatly and call for theory development that is concemed with imitary, irreducible human beings and their environments In the totality paradigm, theonsts such as Roy (1984) and Orem (1985) advance the theory 'for' nursmg view and call for the development of specialty-focused theory for dimcal populations Yet, knowledge advanced withm one An art with humanitarian aims theorehcal perspechve does not belong to a speafic paraDespite extensive literature on theoretical development digm If discovery conferred ownership, then knowledge (Meleis 1992, Mitchell 1992, Randall 1992, Ray 1992), the generated from von Bertalanfify's General Systems Theory disaplme of nursmg is a philosophy of persons and their and Selye's theory of sfress would be unavailable to the health expenences, that is, nursmg is also an art with disaplme of nursmg humamtanan aims Benner (1984) descnbes excellence m dimcal prachce based on perceptual awareness, sensihvity Practice discipline and cogmhve skills The unique synthesis of the art of canng and the empinasm of saence distmguishes nursing Despite their apparent polanty, these theorehcal perspecfrom other health professions As such, the development of hves are not m opposition if nursmg is conceptualized as a disaplme-specific perceptual and conceptual skills provides practice disaplme with a mandate from soaety to enhance one way of mamtainmg a imique nursmg focus Thus, a the health and well-being of humaruty Surely, the goal of franscending philosophical perspechve, rather than a nursmg theory is to contnbute to the wealth of knowledge specific methodology, is charadenshc of the disaplme of required for dmical practice in a vanety of settmgs When nursmg practihoners, scholars and researchers achvely engage m However, perception can contnbute towards static creatmg dynamic and workable soluhons to dmical and behefs regardmg the uneasy, sometimes dichotomous, re- empincal problems of significance to the health of soaety, lahonship between nursmg theory, prachce and research then mtegrahon of theory, research and practice may Some authors believe theory is developed from research become a reality Indeed, the upcoming era of theory based on dimcal prachce (Engsfrom 1984, Bramwell 1985), development and refinement from a nch tapestry of theorwhile others advocate the advent of pure saence without etical perspechves and research methodologies may fulfil immediate relevance to prachce (Donaldson & Crowley nursmg's quest for ldenhty and self-acceptance as a prachce 1978, Bohny 1980) disaplme This debate is made more complex and polanzed by the recent references m nursmg hterature to the purposes of FUTURE DIRECTIONS theory development Is theory 'of nursmg or 'for' nursmg? According to Barrett (I99I), the issue is whether or not In response to the challenge of humanism and the holistic nursmg is viewed pnmanly as a basic or an applied saence health care movement, nursmg research is more directed As a basic saence, theory, research and practice focus on towards enhanang the understanding of dients and their knowmg what is umque to nursmg On the other hand, as environments Genmngs 1986) Furthermore, Fawcett an applied saence, the focus of the disciplme is on the (1984) beheves that empinasm may be mcompatible with practice of nursing nursmg's humamshc and holistic aims However, queshons about knowing and doing in The nursing literature is replete with papers outhnmg nursmg are another twist to the debate regardmg theory the worth of objechve and subjechve methodologies to the development that has been simmermg in the literature for disaplme To Maturana & Varela (1988) the soluhon to the past 35 years Differences m these posihons have their this paradox is to move away from the opposihon, and to roots m the debate concemmg unique versus borrowed change the nature of the queshon m order to embrace a knowledge as the comerstone of the disaplme of nursing broader context, that is to walk the razor's edge If the (Barrett 1991) Rather than danfymg the issue, the more disapluK of nursmg is dedicated to excellence of care recent confroversy regarding the simultaneity vereus the through the advancemoit of knowledge, then to reject 1654 response to the human expenence of health Indeed, if canng is cenfral to nursing, can knowing be separated from doing withm the nurse-dient relahonship? Perfiaps the disaplme's evolving perspechve and conceptualization of the phenomena will define whether canng becomes incorporated mto the domam concepts or remams as a theory that substanhates nursmg's profound ability to assist dients to find meanmg m the expenence of health and illness

The dtsapltne of nursing

quantitahve research methods due to fear of dehumanizing patients with redudionist methods would be an epistemological error Both mduchve and deduchve methods are valid methods of furthermg nursmg knowledge Moreover, development and refinement of the substanhve body of knowledge can address dmical concems and ultimately enhance care of clients m numerous speciality areas of nursmg pradice While research is essenhal to the development of nursing knowledge, educahon of prachtioners withm a nursing perspedive is of vital importance Structuring educahon around a nursing paradigm, rather than tradihonal medical dassiAcahon of disease, would aid m the socializahon process of novices and encourage nurses to think nursmg However, nursmg m North Amenca is the only health care disaplme with diverse entry routes Smce educahonal constramts may prevent nurses from usmg theorehcal knowledge, further educahon at the baccalaureate, master's and doctoral levels may equahze some of the power struggles withm heeilth care, enhance the credibility of the disaplme of nursing, and improve the ability of practitioners to test, evaluate and utilize theoretical knowledge Society and the consumer Soaal relevance and value onentahon defme the discipline of nursing as much as empmcal knowledge (Donaldson & Crowley 1978) As such, soaety can be a powerful ally in the pursuit of nursmg knowledge Therefore, consultation with the consumer regardmg goals and diredion for nursmg research, theory development and dient-centred models of care is essential if the disaplme is to mamtam its humamtanan aims Indeed, soaety's self-help movement represents the trend towards self-care and a shift towards greater client autonomy and self-determination m health care As nursing approaches the twenty-first century, nursmg theory development must consider the changmg needs of dmical populahons Alliance with the health care consumer will ultimately benefit the disaplme of nursing by openmg up new avenues for theory development and nursing research Moreover, nursing's quest for autonomy and accountability can be synthesized with the trend towards establishmg and maintaining optimal dient outcomes m health care It is anhapated that the present emphasis on dient outcomes and programme evaluation will enhance the future development of nursing knowledge by utilizing theones and methodologies developed m nursmg and other disaphnes Nursing has become mcreasmgly explicit m defmmg the nature of its domam m a multitude of prachce areas For

example, a cnhcal appraisal of the application of theory, developed withm nursing and other disaplmes, to a vanety of settings where nursing is prachsed is now becommg evident m the nursmg administration literature (Henry et al 1989, Lutjens 1992) As such, with the increase m a substantive knowledge base and vabdation and refinement of theones through multiple modes of mquiry, a pluralism of theones is emerging (Fawcett 1984) Nursing can no longer ignore the challenge to define the disaplme m terms of knowledge based upon nursmg theory and to appraise knowledge from other disaphnes for utility withm nursmg This cannot be done from the ivory towers of academia, admimstration or pradice without consideration of the perspedive of the health care consumer Commumcahon through debate and constructive feedback is not only essential to define and refine a nursing paradigm, but also to extend the boundanes of nursmg mto the unexplored temtory of the twenty-first century

CONCLUSION
In order to chart a course mto the future, a discipline of nursmg must encompass a proachve approach to the development of theory that not only arcumnavigates the present debates, but also bridges the worlds of research, theory and practice Advanang a disaplme of nursmg is complex, convoluted and dynamic process The next century will provide nursing vnih an opportumty to think nursmg, that is, nursmg will treinscend the philosophy and knowledge of the disaplme beyond the present boundanes As Cicero (cited m Nulle 1980) wrote m 52 BC, 'reason enables us to draw inferences, to prove and disprove, to discuss and solve problems, and to come to conclusions' Surely, this Roman scholar has provided a modem mandate for a disaplme of nursmg

Acknowledgements The author wishes to thank Dr M Munro RN PhD, Dean, Faculty of Nursmg, Umversity of Pnnce Edward Island, Charlottetown, Pnnce Edward Island, and Ms Bev Hills RN MS, Manager of Nursmg and Laboratory, Arthntis Soaety (BC & Yukon Division) for their support and helpful comments on earlier drafts of this paper References
Barrett EA M (I99I) Theory of or for nursmg? Nurstng Saence Quarterly 4(2), 48-49

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Barrett E A M (1992) Response a unified perspective within Lynaugh J E & Fagin C M (1988) Nursing comes of age nursing Nursmg Sctence Qtarterly 5(4), 154155 20(4), 184-190 BffinerP (1984) From Notnce to Expert Excellence and Power in Cltntcal Mahirana HR & Varela FJ (1988) The Tree of Knowledge The Nurstng Prachce Addison-Wesley, Menlo Park, California Biohgtcal Roots of Human Understandmg (Paoluca R trans) Bohny BJ (1980) Theory development for a nursmg saence New Saence Library, Boston Nurstng Forum 19(1), 50-67 Meleis AI (1985) Theorettcal Nurstng Development and Progress BramwellL (1985) Nursing saence retrospect and prospect The Lippmcott, Philadelphia Canadian Nurse 81(3), 45-48 Meleis AI (1987) Theorehcal nursing today's challenges, Brooks JA & Kleme-Kracht A.E (1983) Evolution of a definihon tomorrow's bndges Nurstng Papers 5(2), 49-63 Meleis AI (1992) Direchons for nursing theory development in of nursing Advances in Nursing Saence 5(4), 51-63 Donaldson SK & Crowley D M (1978) The discipbne of the 21st cenhiry Nurstng Saence Quarterly 5(3), 112117 nursmg Nurstng Outlook 26(2), 113-120 Mitchell GJ (1992) Is nursing pot-bound? Nursing Saence EUis R (1982) Conceptual issues in nursir^ Nurstng Outlook 30, Qmrterly 5(4), 152-153 406-410 Newman M A (1986) Health as Expandtng Consaotdsnas C V Engstrom JL (1984) Problems in the development, use and Mosby, St Louis teshng of nursmg theory Joumal of Nursing Educatton 23(6), Newman M A , Sune A M & Corcoran-Peiry SA (1991) The focus of the disciphne of nursing Advances tn Nursing Saence 245-251 14(1), 1-6 Fawcett J (1984) Hallmarks of success in nursmg resejirch Nighhngale F (1969) Note On Nursmg What It Is and What It Is Advances in Nurstng Saence 7(1), 111 Corenberg B (1983) The research tradition of nursing an not Dover, New York Northrup D T (1992) Commentary a unified persf>echve within emergmg issue Nurstng Research 32(6), 347349 Hardy M E (1978) Perspectives on nursing theory Advances tn nursing Nursing Saence Quarterly 5(4), 154155 Nurstng Saence 1, 37-48 Nulle S H (Ed) (1980) Classics of Westem Thought The Ancient Henderson V (1965) The nature of nursmg Intemattonal Nurstng World 3rd edn vol 1 (Keyes C W hans), Harcourt Brace Revtew 12(1), 23-30 Jovanovich, San Diego, pp 269-280 Henry B, Amdt C, Vincenh M D & Mamner-Tomey A (1989) Orem D E (1985) Nursing Concepts of Practice McCraw-HiU, Dtmenstons of Nurstng Admintstratton Theory, Research, Edu- New York Parse RR (1981) Man-Ltvtng-Health A Theory of Nurstng Wiley, catton, and Practtce Blackwell Saentific, Boston New York. Jacobs M K & Huether S E (1978) Nursmg saence the theoryPerry J (1985) Has the disciplme of nursmg developed to the practice bnkage Advances tn Nursing Saence 1, 6378 Jennings B M (1986) Nursmg saence more promise than threat stage where nurses do 'thmk nursmg7 Joumal of Advanced Joumal of Advanced Nursmg 11, 505-511 Nursing 10, 31-37 Keller M C (1979) The effect of sexual stereotypmg on the Randall B P (1992) Nursmg theory the 21st century Nursing development of nursing theory Amencan Joumal of Nursing Saence Quarterly 5(4), 176-184 Ray M A (1992) Cnhcal theory as a framework to enhance 79(9), 1584-1586 KiddP & Momson EF (1988) The progression of knowledge in nursing saence Nvtrstng Saence Quarterly 5(3), 98101 Rogers M E (1970) An Introductton to the Theorettcal Basts of nursmg a search for mearung Image 20(4), 222-224 Kuhn T 5 (1970) The Structure of Saenhfic Revolutions 2nd edn Nurstng F A Davis, Philadelphia Roy C (1984) bttrodtictton to Nurstng An Adaptatton Model 2nd University of Chicago Press, Chicago edn Prenhce-Hall, Engiewood Cliffs, New Jersey Leininger M M (1981) The phenomenon of canng importance, Swanson K M (1991) Empmcal development of a middle range research queshons, and theorehcal considerahons In Canng An Essential Human Need (Lemmger M M ed), Charles B theory of canng Nurstng Research 40(3), 161-166 Watson J (1988) Nurstng Human Saence and Human Care Slack, Thorofare, New Jersey, pp 315 Lutjens L R J (1992) Denvation and teshng of tenets of a theory Nahonal League for Nursing, New York of soaal organizations as adaptive systems Nursing Saence Quarterly 5(2), 62-71

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