brief report
Nursing Science: The Prevailing Paradigms throughout the Centuries
Christine
Fisher MSN, RN*
School of Nursing, Oklahoma City University, Oklahoma
City, USA
*Corresponding author: Christine Fisher MSN, RN, Clinical Instructor, Kramer
School of Nursing, Oklahoma City University, 2501 N Blackwelder Ave, Oklahoma
City, OK 73106, USA. Tel: +1-4052085932; Email: cefisher@okcu.edu
Received
Date: 22 September, 2018; Accepted Date: 17 October, 2018; Published Date: 24 October, 2018
Citation: Fisher C (2018) Nursing Science: The Prevailing Paradigms throughout the Centuries. Int J Nurs Res Health Care: IJNHR-150. DOI: 10.29011/ IJNHR-150. 100050
1. Introduction
Nursing as a profession is relatively young. Although
women have been caring for ill family members, and even as wet nurses for pay
for centuries, the recognition of nursing as a profession truly began to take
shape in the 19th century. In the
early 19th century, in Europe and
North America, nurses worked primarily from the home, and nursing was not
considered a reputable position for the respected, wealthy, and educated woman.
Wars in both countries spurred changes in the delivery of nursing care from the
home to the hospital, and more intensive training for nurses became necessary
as physicians began to treat patients based on medical models rather than
spiritual models [1]. Nurses were first brought
to the hospital in order to maintain cleanliness, but just as war brought a
change in the need for improved hospital care, nursing as a profession began to
grow out of the need for reliable care of the more complex patient. Nurses
began training in values such as punctuality, sobriety and medical knowledge,
and with increased social etiquette and wages, nursing became more accepted as
a reputable profession [1]. “Entering a new
world means learning a unique language, incorporating new rules, and using new
experiences to learn how to interact effectively within that world” [2]. As the nursing profession began to grow and
change, new ideas about how to provide nursing care emerged. Additionally, the
values defining characteristics of the nursing profession also began to shift.
Nursing in the 21st century looks
quite different from its humble beginnings in the 19th century. Furthermore, changes in American
society’s values and expectations appear to be moving to shape yet another
change in the delivery of nursing care, as well as the definition of the
profession. These changes in nursing science, both historically and
futuristically speaking, can be described philosophically as paradigm shifts. This
paper aims to explore the philosophical terms “paradigm” and “paradigm shift”
as they relate to the nursing profession, discuss nursing paradigm shifts that
have occurred from the time before Florence Nightingale to the present, and
touch on recent trends in healthcare which point to an impending shift in the
current nursing paradigm.
2. Paradigm and
Paradigm Shift from a Nursing Perspective
According to the American Heritage Dictionary, the
word “Paradigm” has been present in the English language since the 1400’s, and
is commonly used presently in science to describe a theoretical framework [3]. Thomas Kuhn, author of The Structure of
Scientific Revolutions, offers
several working definitions of the concept of paradigm and paradigm shift. Kuhn
is recognized as the man who changed the way in which we view “Mankind’s most
organized attempt to understand the world” [4]. Naughton
[4] describes the idea of a paradigm, according
to Kuhn, as what is known and accepted in the scientific community. Kuhn offers
that the definition of paradigm remains the same, but the concept takes on
different meaning dependent on the context:
“On one hand, it stands for the entire constellation
of beliefs, values, techniques and so on shared by a community. On the other,
it denotes one sort of element in that constellation, the concrete
puzzle-solutions which, employed as models or examples, can replace explicit
rules as a basis for the solution of the remaining puzzles of normal science”. Kuhn
describes three contexts in which the term paradigm is appropriate: the rising
of a scientific community through paradigm, the paradigm as the language of a
scientific community, and the paradigm as the building blocks that lead to new
knowledge and understanding [5]. In the first
use, Kuhn describes a paradigm as truths adopted by a group of scientists which
had not be previously been defined, and which laid the ground work for deeper
understanding through considerable refinement by experts [5]. Florence Nightingale, a 19th century nurse known as the Mother of Modern
Nursing, found support of her notion that proper cleanliness and nutrition were
paramount in healing through early documentation of reduced wound healing time
and death of her patients. She began a nursing school, the first in England
which was based upon her scientific findings and a year later, a medical school
for the Army was also opened to educate future doctors and based on her research
findings. Nursing, as practiced today, is a community of people of science who
came together due to an acceptance of ideas that had not been used previously
and ideas that would be expanded, omitted and changed throughout time.
In the second use of the concept of a paradigm, Kuhn
described the paradigm in terms of the scientific community. A disciplinary
matrix has three parts, one, shared truths which allow for a language to be
used in a scientific community and understood by all who are part of that
community; two, shared beliefs and values of that community, and three, truths
as a basis for new knowledge [5]. In nursing,
truths are studied which allow professional practice using a common language,
belief and value system. All nurses are taught medical terms in order to
communicate effectively with other healthcare professionals. Nurses espouse the
belief that patients must be treated in a holistic manner in order to achieve
wellness, and all nurses are taught to provide care with compassion.
In the third context of a paradigm, Kuhn offers a
paradigm as the impetus for change. Inferences about phenomena based on what is
known and the experience gained lead science to set off in new directions when
the known takes on new form [5]. This use of the
word paradigm, is best used in the example of allowing family to witness
resuscitation efforts in a patient who has little possibility of regaining
quality functioning. While it can never know when a person is being called to
end his or her time on Earth, nurses use the information gathered to make
inferences about the probability of recovery when critical illness is present. Recognizing
the subtle changes that occur in resuscitation efforts that should lead the
nurse to pursue a Do Not Resuscitate (DNR) order from the family only comes
with time spent and experience gained.
Paradigm shift, conversely, is identified by Kuhn as
revolutions or breakthroughs in science that lead to significant changes in the
status quo [4]. Kuhn describes paradigms as
normal science, and when continued problems arise that cannot be solved by the
knowledge contained within the normal science, or the normal science cannot
explain the new phenomena that cannot be denied, new research and new paradigms
arise. “The proliferation of competing
articulations, the willingness to try anything, the expression of explicit
discontent, the recourse to philosophy and debate over fundamentals, all these
are symptoms of a transition from normal to extraordinary research” [6]. In nursing science, the existence of paradigm
shifts is seen throughout the centuries:
·
The emergence of
nursing science as a profession
·
The training of
the nursing professional in the 19th century
·
The shift to a
focus on developing the nursing professional’s language and education to match
physicians, as well as develop a distinct nursing language in the 20th century
·
The paradigm shifts
in the profession in the 21st century
which is leading away from the acute care and tertiary preventative model to community
and primary prevention model as the building blocks that lead to new knowledge
and understanding.
3. Nursing
Paradigm Shifts from 1800 to Present
The nursing profession has grown to be recognized as
the most trusted and ethical profession in America [7].
“The ultimate goal of nursing is an evidence-based practice that promotes
quality, cost-effective outcomes for patients, families, healthcare providers,
and the health care system” [2]. These
statements represent a significant shift in the world of nursing science both
for the practitioner and for those the profession seeks to serve. Nurses as
professionals have risen through the last three centuries from a job considered
only appropriate for uneducated laborers to respected practitioners, scholars and
leaders in the healthcare industry. Nursing as a science also has evolved
through the centuries and emerging research appears to be preparing the science
and profession for significant practice changes.
3.1. 19th Century Nursing
Early 19th
century nursing was disorganized. Home and hospital care were largely seen
through the veil of metaphysics. Illness came from an imbalance in sin and
virtue, and health was ultimately a gift from God or emerged out of well
delivered punishment of sins [1]. According to
Sir Henry Wentworth Acland, Professor of Medicine at Oxford, was quoted as
saying, in 1840 as an entering medical student with regard to health and
illness, as saying “He knew of disease only that it
was from God; that it was a remedy applied to the body to cure the disorders of
a sinning soul; a mark of chastisement; an act of love from the hand of a wise
Father” [1]. The traditionalist view of
nursing services in early 19th
century England was that of an uneducated servant. Nurses in the early 1800’s
were considered callous, dirty and immoral. This view continued until the
second half of the 19th century. As
medicine underwent the paradigm shift away from social service to medical care,
nursing as a profession began to see radical changes as well. As the doctors
were conceiving disease in a different way, nurses were being called to oversee
important aspects of patient care in the hospital settings. This change
required a change in the way nurses received training both in education and
etiquette. Florence Nightingale is known for establishing training schools for
nurses which provided education based on the premise that nursing should focus
on hospital sanitation, patient education, and effective patient care; while
nurses should be disciplined in the art and science of using observation skills
and applications of experience [8]. The nursing
profession in North America saw a similar transition in the way the nurses
received training and were received by the public they served. Hospitals in
America were considered unclean and nursing was a lower-class profession. The
Civil war was the impetus for change as hospitals were needed to care for
injured and ill soldiers, and therefore, more complex nursing care was needed
as well [9].
3.2. 20th Century Nursing
Nursing science saw great strides toward what is known
as the nursing profession today in the 20th
century. One paradigm shift which paved the way for these changes was the way
in which nurses received formal training. In 1900, schools of nursing began to
be overseen by hospital systems rather than nurses which offered greater
resources for innovation and advancement [10]. Wars
continued to be a catalyst for change in the nursing profession throughout the
20th century. The number of women who
entered the nursing profession grew exponentially in both Europe and America as
a wave of patriotism and “calling to care for our soldiers” brought many to
nursing [10]. This surge in popularity caused
governments to provide more funding for medical advancements, and as the
technological age advanced medical innovations, nursing schools began to
transition away from hospital-based training to formal university institutions
with Masters and Doctorate degrees in nursing being offered beginning in the
mid-20th century [10]. These advanced nursing degrees allowed for
another change within nursing science as nurses began to “specialize in
distinct areas and moved away from the traditional view of physician’s
assistant to performing many duties themselves including performing procedures
and prescribing medicines” [10]. Additionally,
the feminist movement provided a gateway for nursing science to move away from
a servant role in the healthcare team to a partnering or leadership role.
3.3. 21st Century Nursing
In the 21st
century, the nursing profession is preparing for the next paradigm shift. Currently,
nurses are trusted healthcare partners and are seen in the community and in the
acute care setting as leaders. Research in the nursing field has focused in
this century on providing safe and effective patient care, integration of
advancing medical technologies with compassionate care, and leaning on the
experts in the field to provide future nurses with proper training [11]. Nursing in the 21st
century is also seeing changes in the workforce. In the past centuries, nursing
was primarily a profession dominated by women, but men are now choosing the
nursing profession according to an article by the Robert Wood Johnson
Foundation [12].
“The demographics of nursing are beginning to change.
In 1980, there were 45,060 male nurses, according to the IOM report; by 2004,
that number jumped to 168,181. Today, men comprise just over 7 percent of all
RNs, and that number is projected to grow; more than 11 percent of students in
nursing baccalaureate programs in the 2010-2011 school year were men, reports
the American Association of Colleges of Nursing (section 2)”.
As more men enter this traditionally female
profession, the status quo in the profession will most certainly be challenged.
“Men provide unique perspectives and skills that are important to the
profession and society at large, according to the IOM report, called The Future of Nursing: Leading Health, Advancing Change” [12].
4. The Future of
Healthcare: An Impending Nursing Paradigm Shift
Nursing as a science and profession could be preparing
for its next paradigm shift. Since the early 1900’s nursing research and
practice has been focused on tertiary care and prevention, mainly in the acute
care setting. According to Sandy, et al. [13], the
roots of the primary care dilemma can be traced back a century and a half to
the explosion of knowledge of physiology-the scientific understanding of body
functions-which in turn led to the “biomedical model” of disease: the paradigm
that explains disease as physical-chemical alterations in the body. This new scientific paradigm facilitated the
development of specialization in medicine. The biomedical model naturally led
to conceptualizing “disease” as equivalent to “organ system dysfunction,” a
view that largely excludes the social and behavioral considerations that are
now part of our contemporary understanding of disease.
As the healthcare industry refocuses on primary and
secondary prevention strategies which will cut healthcare costs and improve the
lives of patients, significant research and changes in historical practices are
emerging. In an article in the Online Journal of Issues in Nursing, nursing
research has led to evidence-based nursing practices which highlight safe an
effective patient care. Quality improvement discussions have developed from
these results and a shift toward a refocus on prevention of chronic illness
rather than the treatment of chronic illness is laying a pathway for new
research and evidence-based practices for the future nursing practitioners [14].
5. Conclusion
The nursing profession is on the verge of a paradigm
shift. The practice of nursing which has been practiced primarily in acute care
settings and focused on tertiary care since the early 1900’s is now beginning
to consider the benefits of primary care and community-based practices.
Additionally, the nursing workforce is seeing a change as more males are
joining the profession and influencing research and practice in unique ways. The
addition of the Doctor of Nursing Practice degree in the 21st century is following the current paradigm of
diversity of the specialties available for study in the profession which began
in the 20th century. Also, as more
nursing schools continue to open to meet the growing demand for professionally
trained nursing professionals, fewer hospitals are available to train nurses,
and Universities continue to take over with more resources available for
advanced training. The nursing profession has thus far enjoyed great benefit
from the paradigm shifts from the 19th
century to today, as identified by Kuhn as, revolutions or breakthroughs in
science that lead to significant changes in the status quo. With these changes,
evidence-based research project opportunities will arise for nursing and
nursing education alike to study the needs of nursing education to include more
primary prevention strategies. This includes changes to curriculum to include
entry level nursing careers outside of the acute care setting. Practicing
nurses will find opportunities to further investigate the benefits of
preventative care measures to reduce health care risk.
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