Professional In Nursing

nursing practice involves human beings bothas patients and as nurses. it involves the interaction between those two bodies. oftentimes kim will refer to the nurse as the agent and she may refer to, in her work, the patientmay be called a target. in some ways, people consider what we do as nurses that it's amandated form of human service that for many centuries we've had someone that has alwaysbeen the caregiver in each environment throughout time. it's very much individualized basedon where people lived and at what point in history. and then there's also the componentof how do we define this nursing practice? it is something that is goal-directed, it'svery specific in terms of action, it's deliberative, and it's coordinating work for and with clientsfor the promotion of health, this is according

to kim. according to argyris and schon, whichwe'll be covering on later in the semester, practice is a sequence of actions undertakenby a person to serve others, who are considered clients. the essence of nursing practice isthat it can be scientific, technological, and it's technological problem solving. butit also involves human to human engagement, it's interactive. it also includes human serviceto clients in need of a specific service. some of the major questions in the practicedomain of nursing include process questions such as: how did you as a nurse get to knowwhat you do in a particular situation? how did you, as the nurse, do what you did inthat situation. content questions, however, are what did you do in that situation, andwhy did you do this specific action at that

point in time? and if we take the two together,what are the variations in both process and content within individual nurses and amongdifferent nurses? the phenomena do be understood would include how, such as what is the clinicalinferencing and diagnosis, the nursing descriptions, the nursing competence and expertise, whatadaptations do they do, what innovations, how are they creative, is there routinizationinvolved? and also the what and why, the caring, the empathy, using yourself as a part of yourpractice, variations in the use of nursing repertoire, advocacy vs. control over thesituation, do you advocate for the patient to have independence and freedom, choice,or do you work in the mode of trying to control the environment in thinking about safety andlimitations, what influences the strategies

that we use with our patients, is power involved,it's paradigm directed nursing practice, what paradigm exists within our particular healthcaresetting that drives how we perceive what should be done in a particular practice situation,is there a difference between working in a huge medical center with all kinds of accolades,magnet status or excellence awards with very strong motivations from medical schools vs.working in a small community hospital, does that change the paradigm or the overall wayof thinking in a particular institution? also quality is considered, is what going on isit considered good or bad, is it right, is it wrong, if what we're doing effective, isit ineffective, would you say it's appropriate, is there something about what you're doinginappropriate, is it contiguous, is it disjointed,

is what you're doing compartmentalized ordoes it feel holistic, is it creative, is it not creative at all? some of the assumptionsthat susie kim makes about nursing practice include the following. first, she has an assumptionthat human engagement and action involves an awareness of yourself and of others, ofyourself and others by the actor. she also assumes that human action is closely tiedto a human's symbolic and linguistic capabilities. susie kim also has the assumption that humanaction is logically tied to intention, choice, and free will on the part of the actor, suchas humans do not just suffer or bear the burden of life's requirements, and the actor is capableof self-monitoring to what extent what one is aware of what one is doing. other assumptionsby kim include that it's plausible to control

human actions and behaviors. and her finalassumption is human action is empirically and symbolically tied to the situation inwhich it takes place. this brings you to what are your assumptions about human beings relatedto practice, related to your nursing practice. do you believe that you are the person whoadvocates for autonomy? do you believe there needs to be a certain amount of control? doyou consider that something is with very much effected by the organization in which youwork in? are things routinized? is there a lot of flexibility? do things vary from oneunit to another? what are your assumptions about human beings related to your practice?do you have control over the situation? can you modify those human behaviors, do you think?the nature of nursing practice, for susie

kim, has several levels. one is, she callsit, the dimensions of practice. the target is your client, and that there's certain philosophiesthat we use to work with clients, or our target of care. she has two philosophies that shementions, and one philosophy that susie kim mentions is the philosophy of therapy. philosophyof therapy, when you go through her work, you'll realize has more to do with focusingon fixing problems. so philosophy of therapy would include pharmacology, or pharmacodynamics,pharmacokinetics, how do we modify things, what are we bringing in in order to changea patient outcome. there's another whole area of philosophy related to our practice andthat's a caring focus, or philosophy of care focus. and that tends to be more holisticallyfocused, such as caring theories and looking

at whole persons. philosophy of therapy onthe other hand focuses on the problem itself, identifying client problems. and with these,the nurse serves as the agent in the process of this practice. and the nurse goes throughthese two phases. the first phase the nurse will go to is the phase of deliberation, orproblem solving or decision making. and then finally, when the nurse has a chance to gothrough this deliberation, think through causes of action and bring parts of him or herselfinto the decision making, and things that you know about your client and the situationin which you work in and all of those factors. all of those come together and move a nurseinto the phase of an actmin, and an actmin is what you actually carry out what your actionis for your client. going back now to philosophy

of therapy, we had already mentioned thatit's focused on the problem. and some of the teleologic strategic orientation is for solvingand attending to the problems that patients present. in contrast, philosophy of care islooking at the client as your whole person. and here, the teleologic or strategic orientationis attending to the client as a person. this will make a difference if you use one focusvs. the other focus, or one philosophy vs. the other, as to what theories you may choosefor your practice. part of the dimension of the nurse-agent is the nurse then goes throughthe deliberation phases we mentioned, and this is your decision making process, it'syour problem solving, and that eventually moves you into the final phase of enactment,or nursing actions. when deliberations are

made by the nurse, there's five analyticallydistinct structural units in it. we'll talk about each of these in a while. the firstare the nursing goals. what do you hoping that the patient, or your client, achieves?that client is the individual, a family, a community. what are the aspects of the client?what do you know about that client, or that target? what kinds of things do you know aboutthem in terms of their age, in terms of their developmental and cognitive abilities? interms of their literacy levels? in terms of what their desires and goals are related tosurvival, or end of life care, or enjoying childhood? what are those things about theclient that you know? and then, what are your nursing means? what the nursing means arewhat do you bring to the table with you to

serve these clients? what are the aspectsof yourself, in terms of what tools do you have, what tools does the hospital have? whatkind of facility is it? are you working in a rural village or are you working in a levelone trauma center? what means do you have at your disposal? then there's the situationthat you're working in, as a nurse agent. what's that environment like? and what arethe aspects of you as a nurse agent? we talked about the aspect of the client above, whatother aspects about you, what have your experiences been in nursing? what's your expertise? howdo you deal with certain types of patients or families or end of life care? how do youwork through issues of poverty, and not knowing? so what are those things about yourself? inthe enactment phase of practice, it means

that the nurse, you as the nurse, are actingand delivering specific actions in a practice setting. you're bringing your own backgroundwith you to do this. your client is object and is responding to you, you're interactingwith each other, and then there's a situation in which all of this takes place. this isall within the enactment phase of nursing. this here is a diagram that is also in thekim 94' article. it's figure 2 in the article. and in it, it basically describes all thesepieces that we just mentioned. we talked about what do we know about the nurse in terms ofwhat are the nurses goals, where do you want to get to, what are the nursing means, whatare the aspects of the client, what are your aspects of yourself. all of those effect deliberation,or decision making, problem solving by the

nurse. all of that takes place within a particularsituation. then there's the phase of enactment. what nursing actions are you carrying out?that also depends on aspects of yourself and aspects of the client, and this also takesplace within a particular situation. and finally you move to outcome. here, i highlighted inyellow what components of this nursing practice are only related to deliberation. you cansee deliberation has all of these pieces. deliberation based on situation. what is thesituation? the situation in which you're working may be effected by noise, may be effectedby conflicting demands in the situation, may be effected by value structure in your hospitalor on your unit or by your shift, it may be effected by routinization, what's consideredokay to do within a given time period, a given

shift, a given unit. or is there some kindof institutional integration that must take place in order for you to work well in thatunit? and are there issues related to practice? staffing, related to practice? and those areall aspects of the situation that effect your deliberation. in terms of phases of deliberation,there are certain aspects of you, the nurse. and those aspects include your frame of reference,what is the personal meaning of nursing practice? where are you coming from in terms of howyou got to where you are in nursing? what is your motivation and commitment as a nurse?your motivation for action? what are your values? what are your standards guiding yourpractice? sometimes considered ethical factors that guide your practice, or ethical decisionmaking. what knowledge do you bring? is some

of it personal, from life experience and otherknowledge that you learned in school? in nursing school in particular? and then, finally, capacity.what's your personal capacity in order to practice nursing? i show this photo now becausethese are three nurses. one is a seasoned nurse, anthropologist. one is a junior innursing school and the other is a senior in nursing school. and each of these nurses bringvery different aspects of self to the situation. if we were in the acute care setting rightnow while this person is studying in the acute care setting or pediatrics or maternity, aspectsof self being, new to the content area and trying out may be beneficial. but you cansee instead that we're in the environment, we're in a rural area in the back of a truck.and we'll be providing care in an area in

the mountains across, or close to the haitianborder. and in that case, aspects of self for this nurse, who is also an anthropologist,who has worked in peru, who has worked in kenya, may be bringing the nurse aspects ofself, or aspects of the nurse agent that are going to be very beneficial for that environment.then there's aspects of the client. again, the same areas. one is their frame of reference.what do they think about illness? what do they think about hospitalization? what dothey think about nurses? what do they think about you helping them with their child? whathave been their experiences in the past that affect their confidence or their fear of beingaround healthcare providers? what's their motivation or commitment to respond to thekinds of treatments that you may want to suggest?

to stop doing certain things in life, or tostart doing certain things in life? what is their motivation? what is their commitment?what are their values and their standards? is their value to live well? live long? livehealthy? is their value to live well only in the moment? what are their values? whatknowledge do they have about their condition? how much do they understand? is literacy afactor? is cognition a factor? and what capacity do they have to change? what support systemsdo they have to guide, or to work against. then we have the nursing goals. and thesegoals are goals that we have for our clients, goals that we may have for our self, or goalsfor the nurse agent. goals for others. maybe family members, children, parents, communities,organizations. and then what are our means?

what serves our to help ours do our rolesin practice? what is our repertoire at large? our personal repertoire, or conjectured means?our repertoire at large, what means do we have in the entire unit that we're workingin that can help us? is there a person that's really good with pain management that youcan pull in to help serve your client, your patient. and you can say, you know, i knownurse x is really great at doing this particular procedure or talking to patients that justreceived this diagnosis. i'm going to pull that in, i have that as part of my means,it's a repertoire at large. it's people i can pull from. it's consultants i know thatare great in my particular facility. it's a community health worker that knows how toget water into a community. how do you pull

those in? but then there's also personal repertoire.what do you bring yourself? what do you bring to this patient care situation? to this nurse-agent,target, client interaction? what do you bring yourself that will help this patient go towardtheir goals and the goals that you've helped them to define? and then there's conjecturedmeans. what kinds of things can you pull together based on a combination of factors? what doyou think about this nurses means? what does she have, or this particular person have availableto this nurse in order to serve a patient? what does it look like these nurses here,the three of them, you can see two clients, a mom and a baby in the corner here workingwith one nurse here. an older woman here, sitting. two nurses listening to her tryingto serve her. what means do they have inside

this tent with their water bottles with theirnotebooks? what means do they have? in the process of trying to understand the dimension,the target dimension, meaning the patient dimension or the client dimension in the nurses-agentdimension of practice. so here we have the target, our focus is the client, is the target.the nurse is the agent dimension. we know that the patient, we already said is eitherproblem focused, issues, or either problem focused, theories, or whole person focus theories.the nurses- agent dimension has deliberation, problem solving, decision making, reasoning,and action, what kind of actions do they carry out? within each of these categories you cansee that there are certain theories that work well. there is another sheet of paper thati'll show you at the end, unless i can look

at it now, let's see. okay i'm gonna say itnot to stop recording. i'm going to go over here to this handout, and this handout isthe same categories, dimension of the target or the patient, dimension of nurse-agent.and in here we see all of the client problem focused theories, here, which include thenursing theories by henderson, orum, roy, newman, johnson, hall, abdellah, then a lotof the health behavior theories. the physiological theories, the pharmacotherapy theory, thepsychosocial theories. and then we have the person-focus theories under dimension of target,or dimension of patient or client. they include theories like gene watson's because it's caringtheory and ida gene, orlando, travelbee, parse, peplau, the psychosocial theories, all theway through to rogers and the unitary theory.

leininger's culture theory. habermas symbolicinteractionism. and then here on the dimensions of nurse-agents we have theories of decisionmaking, of problem solving, of pattern recognition, of clinical reasoning, it includes a theorylike pat beners theory of clinical stages, of novice to expert. and then we have theaction theories which include action science. so this is the same chart that we just lookedat on that other handout. so according to susie kim in this particular writing she saysthat this knowledge development practice domain has four philosophical positions. the firstphilosophical position is one that we call the rationalist, the causal functional explanation.some would put this in the positivist area. it's logical positivism. it's clearly doeshave a cause and effect kind of thinking to

it. the next philosophy is interpretivist.and this interpretivist position of philosophy is considered hermeneutic or intersubjectivebut what it really means is it's based on meaning. it's very much written about is georgeherbert mead's work. a third philosophical position according to kim is the mediationposition and that's where practice works as a dialectic. you're going back and forth betweennurse to nurse, nurse to physician, nurse to patient. and it moves back and forth, andit's done within a culture. and bourdieu writes about this. and then finally she talks aboutthe philosophical position of emancipation where the goal is to improve practice andthis is written about by marx. not everyone puts it into these four philosophical positionsbut this is what's mentioned by susie kim

in the 1994 article on practice theories.theories in general come from many many disciplines. nursing has borrowed from physics, from physiology,from neuroscience, from psychology, from sociology, education, and you can see that in so manyof our theories. their link is between the philosophy of practice such as the four philosophiesthat susie just mentioned, but there are others that we'll consider later in the course. andthat philosophy then must be linked to what theory you use, to your practice, and to researchingthat practice. there is a link between theory and strategies, and what problems you identify.philosophy of human beings, its about the way the world works. and in science, there'san ontology, an epistemology, and a methodology of nursing. here we talk about what ontology,epistemology, and methodology is. ontology

is the nature of reality. it's something thatwe can clearly see and touch. a realistic perspective, or is it more relative. it'ssomething that we believe is only experienced by the individual. so in terms of an ontology,you can come from a very rational perspective, a very positivist perspective that thingsare clearly what they seem to be. things are objectively measured and that there is onetruth. or, the opposite of ontology, is that things are relativistic, that things are interpretive,or hermanuetic. and in this way we say that things are really kind of anti-realty. inepistemology it means how do we study things and it follows the same kind of flow as ontology,only on the left side of continuum, where there's realists or logical positivists, onthe left side of the continuum of epistemology

we talk about being very objective. on theright side of the continuum when we talk about being relativistic or interpretivist, we saywe study things but it's more subjective, that everyone of us has our own truth. verydifferent epistemology, very different ontoligists. then in terms of methodology, if we were tostudy in one of these areas and we came all the way from the left side which was ontologyof realist, logical positivist, epistemology of objectivist. then you're methodology wouldclearly be quantitative. a the other end of the continuum, all the way to the right, ifyou're ontology is relativistic, or interpretive we believe that there is multiple truths,a truth for each person, then your epistemology is subjective and your methodology or yourresearch method would need to be qualitative.

and then in the middle we have what can bea combination of things where you'd use mixed methods, a little bit of quantitative, a littlebit of qualitative. in terms of theories this semester we'll be going through quite a fewtheories and we will be defining theories, understanding the purpose of those theories,what level is that theory, and we'll talk about evaluation of theories. these are severaldefinitions of theories. usually it's related to at least two or more concepts that worktogether. hardy would say they're testable. others would say it's a set of theoreticalstatements that show relationships between two or more classes of phenomena. and thenjackie fawcett would say theories are sets of concepts, definitions, and propositionsthat address the metaparadigms of nursing.

and the metaparadigm of nursing has four concepts:person, environment, health, nursing. the purpose of theory is to describe, explain,predict, and control. and the components of theory that you will be understanding forone theory in it's entirety will be to know what the theory is, what philosophical originsdoes it have, what are the concepts in that theory, what are the definitions for thoseconcepts, the operational or theoretical definitions, what propositions are in that theory, howdo concepts relate to each other, how do variables relate to each other, and what are the assumptions,just like we went through susie kim's assumptions about nursing practice, what are the assumptionswithin that theory? and then you'll be understanding levels of theories from very grand theorieslike symbolicinteractionism and critical social

theory, to middle range theories such as thetheory of cord clamping, or micro theories like a practice theory, an end of life carefor a child, what works well. there are several approaches to theory development. one is inductive,starting with the problem and working your way up, deductive, starting with the broadtheory and working your way down, and retroductive, moving back and forth between the two. thissemester we'll be having an entire class on evaluation of theory which will include tryingto understand how clear it is, is it consistent within itself, its it logical, is it useful,is it simple enough that things make sense, can we generalize it another floor or anotherarea of practice, what's it's fertility, does it produce more studies, do other people dosub-theories from it, and has it been tested

in research? for your analysis of theorieswe're going to have you review theories this semester and knowing their concept and definitionsand propositions, what domain is it in when it taught things about kim, what's it's level,is it midrange, is it grand theory, what are its assumptions, what's the philosophy, andyou'll be using that criteria. and for now, what i'd like you to do is use for your firstnarrative assignment these 8 areas and look at susie kim's 1994 theory of practice articleand from that article, it's called practice theories of nursing: implications for practicescience, i want you to go through these 8 areas and tell me, based on the narrativethat you already wrote, go back through your narrative and describe the aspects of yourselfas the nurse. tell me what the aspects of

your client were, or your patient. what wereyour nursing goals? what means did you have at your disposal? what deliberations did yougo through in terms of clinical reasoning, problem solving, decision making, ethicaljudgments? what actions did you take? what enactment did you take? what enactment didyou carry out? what were your nursing actions? what was the outcome of the entire process?and then what situation did this take place within? what was the situation? so addresseach of those items: 1-8. if you have any questions please feel free to contact me atthe sakai site and let me know. thanks so much.