Nursing Metaparadigm: Insights from a Chilean ICU Nurse’s Journey

Introduction and Clinical Background

Before entering my Ph.D. studies, I was a clinical nurse for around eight years in Chile's medical-surgical intensive care unit (ICU). Early in my undergraduate studies, I was interested in critically ill patients. Still, my first face-to-face encounter was on college holidays when I worked as an ICU nursing aide. That opportunity gave me a glimpse of what ICU nurses do, but also a sense of uncertainty about if I would be able to do it, too.

Despite this fear, I started my first job as an ICU nurse in December of 2010, just two weeks before graduating.

During my clinical practice, many aspects of the ICU environment attracted me: the role of ICU nurses during life-threatening situations, the crucial role of teamwork, an atmosphere in which critical thinking was promoted, the burden of ICU family members. At the same time, I started to get more involved in research projects focused on the needs of relatives of ICU patients. During the following years, a combination of my clinical practice and research interests embodied the way I see the core nursing-related concepts in the ICU. Similarly, a philosophy embraces statements of enduring values and beliefs held by members of the discipline (Parker, 2005).

Understanding the Metaparadigm in Nursing

Specifically, the metaparadigm for nursing is a framework that sets forth the phenomena of interest and the discipline's propositions, principles, and methods. In the case of the discipline of nursing, its meta paradigm comprises the concepts of person, health, nursing, and environment (McEwen & Wills, 2014). The knowledge of the discipline's member beliefs about these critical aspects can define how its members ultimately shape their practice. This paper describes my philosophy of nursing regarding the nursing metaparadigm.

My beliefs about what constitutes a client (or person) in nursing are divided into two complementary perspectives. First, I share Betty Neumann and Virginia Henderson's view of a person that is composed of various dimensions such as the physiological, psychological, sociocultural, developmental, and spiritual (George, 2002; McEwen & Willis, 2011).

As the result of a life-threatening event, every dimension of the person is affected during and after their stay in the ICU. Research has extensively described the psychosocial burden of ICU patients related to cognitive, psychiatric, and physical disability after they stay in these units (Rawal et al., 2017). Similarly, physical functioning, quality of life, and social functioning are also affected (Hofhuis et al., 2008). This constellation of impairments has been recognized under "Post Intensive Care Unit Syndrome" and can lead to increased fragility and dependence from family members, especially after hospital discharge (Davidson et al., 2012).

Person: Beyond the Individual

Even though most nursing models state that the person is the center of the nursing profession, some theorists have extended this view to families or communities (Thorne et al., 1998). For instance, Leininger's conceptualization of a person includes human beings, families, groups, communities, or institutions (Leininger, 1991). Currently, the definition of family is no longer tied to only blood-related persons. According to the Society of Critical Care Medicine, family is defined by the patient, can be related or unrelated to the patient, provide support, and with whom the patient has a significant relationship (Davidson, 2010).

Family members in the ICU are not just visitors since they experience the care process with their loved ones (Stricker et al., 2009; van Beusekom et al., 2016). Under this perspective, family-centered care is an approach that recognizes the needs and role of patients' family members and embraces the belief that patients are part of a larger 'whole' (Hennenman & Cardin, 2002).

In tune with my multidimensional concept of the person, I adhere to Orem's vision of the environment, which consists of diverse contexts such as the physical, chemical, biological, and social within which the person exists (Orem, 1985).

Environment: A Holistic View in ICU

In the ICU, a holistic view of the environment can help understand the additional burden that family members must face daily when visiting their loved ones. Social aspects of the environment, such as the interactions with the ICU team or organizational barriers like intransigent visiting hours, can negatively synergistically affect the psychological outcomes of family members (Fassier & Azoulay, 2010). That environment is everything that surrounds the stay of a patient and their family in an ICU, and it is intimately connected with the rest of the components of the nursing metaparadigm.

It could be considered the ultimate goal of the nursing practice to achieve a positive health status for its clients. However, after reviewing several definitions of the term among the classic nursing theorists, many need to clearly state what health could be or use the same word (health) in their descriptions. In this scenario, Orem defines health as "a state characterized by soundness or wholeness of developed human structures and of bodily and mental functioning" (Orem, 1995, p. 101). It is more meaningful to me because it involves terms related to well-being and integrity. Even with health generally conceptualized as a positive and desired outcome for ICU patients and families, it could not be as important as surviving a life-threatening episode.

Moreover, the well-established burden associated with ICU survivorship for family members can make mortality a nonfunctional outcome for those whose loved one survives (Gaudry et al., 2017). The ability of health providers to achieve the highest possible level of health and quality of life for families (and patients) must be the ultimate goal of modern ICU care (Harvey & Davidson, 2016).

Health and Nursing: Goals, Challenges, and Definitions

After more than 12 years of nursing education and clinical practice, defining what nursing is to me is still challenging. Even after three courses of nursing theories, I am not confident in providing a concise definition of nursing. Although most nurses share this problem, the lack of availability of a clear conceptualization can be related to the fact that our education as nurses has had little emphasis on the proper theoretical and disciplinary knowledge involved in clinical practice. Moreover, most of the time, we learn to be nurses just replying to what other nurses do in a mechanistic way, without being able to differentiate the nursing component of our practice from the contributions of other disciplines. Despite this issue, I think that one of the most exciting definitions of nursing that I have read comes from the American Nurses Association (ANA):

Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. (ANA, 2010a, p. 10)

While this holistic and sound definition lacks parsimony, its plain language and comprehensiveness could be complementary to understanding classical definitions provided by nursing theorists. The ANA definition strongly emphasizes the advocacy role of nurses and illuminates the focus of the nursing profession: the diagnosis and treatment of the human response.

Just as different nurses shaped my clinical practice, my view of each component of the nursing metaparadigm has been nurtured by different sources. My nursing philosophy is still in development, especially after the beginning of my doctoral studies. The exercise of reflexing on the nursing's metaparadigm could assist clinical and research nurses to clarify the differences and similarities in their worldviews to effectively collaborate with other disciplines without losing their identity.

References

1. American Nurses Association (ANA). (2010a). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Nursesbooks.org.
2. Davidson, J. E. (2010). Facilitated sensemaking a strategy and new middle-range theory to support families of intensive care unit patients. Critical Care Nurse, 30(6), 28–39. https://doi.org/10.4037/ccn2010410
3. Davidson, J. E., Jones, C., & Bienvenu, O. J. (2012). Family response to critical illness. Critical Care Medicine, 40(2), 618–624. https://doi.org/10.1097/CCM.0b013e318236ebf9
4. Fassier, T., & Azoulay, E. (2010). Conflicts and communication gaps in the intensive care unit. Current Opinion in Critical Care, 16(6), 654–665. https://doi.org/10.1097/MCC.0b013e32834044f0
5. Gaudry, S., Messika, J., Ricard, J.-D., Guillo, S., Pasquet, B., Dubief, E., … Tubach, F. (2017). Patient-important outcomes in randomized controlled trials in critically ill patients: a systematic review. Annals of Intensive Care, 7(1), 28. https://doi.org/10.1186/s13613-017-0243-z
6. George, J. B. (2002). Nursing theories: The base for professional nursing practice. (5th ed.). Upper Saddle River, NJ: Prentice Hall.
7. Harvey, M. A., & Davidson, J. E. (2016). Postintensive Care Syndrome: Right Care, Right Now…and Later. Critical Care Medicine, 44(2), 381–385. https://doi.org/10.1097/CCM.0000000000001531
8. Henneman, E. A., & Cardin, S. (2002). Family-centered critical care: a practical approach to making it happen. Critical Care Nurse, 22(6), 12–19. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12518563

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