A matter of extinction or distinction

In view of fiscal constraints and the increasingly technical environments of health care, the essential and unique contributions of all health care providers, including nurses, are being challenged. This article examines current challenges to the role of nurses and the future of nursing as a unique discipline. As the work of nurses becomes increasingly defined by the technologies of care, what will distinguish nursing from other disciplines and nurses from other care providers? Can nurses lay claim to uniqueness in their knowledge base, technical competencies, and caring behaviors? Other types of workers are increasingly rendering elements of clinical care traditionally provided by nurses. As we move into the next millennium, will nursing become extinct or distinct as a health care profession?     

Faculty mentorship: support for nurse practitioner students and staff within the rural community health setting

As pointed out in the introduction, there are certain practical concepts within our base of nursing knowledge that can only be taught through experience. Many things are easier to teach by example. As we turn back the clock in nursing, we can see how Florence Nightingale, Clara Barton, and Lillian Wald were role models to their nursing peers in their era. They taught nursing by example, by role modeling their clinical expertise. Today, this model is still effective and faculty mentoring of nurse practitioner students and CHNs in a compassionate and collegial leadership results in higher quality of health care for our nation's needy clients and their families. But greater yet are the opportunities for flexible nurse practitioner faculty practice and personal interactions on many levels for nursing faculty who wish to share their expertise. Mentorship by nurse practitioner faculty for nurse practitioner students and CHNs in a rural clinical setting has revealed many positive aspects in providing quality care for rural clients and growth for nurses. Exposure to the rural community health system helps us, as nurses, to identify the many strengths it possesses for innovative rural nursing practice.     

Exploration of personal recovery-oriented care on an acute mental health unit

BackgroundPersonal recovery should be the cornerstone of mental health nursing practice. Nursing interventions should build on consumers' strengths to provide hope, so consumers are empowered to achieve their own personal goals.AimThe aim of this study was to explore mental health nurses’ lived experience of their practice, understanding and knowledge of personal recovery-oriented care on acute mental health units.MethodVan Manen's methodology was utilised in this study. Data was gathered through semistructured conversational interviews with mental health nurses working on an acute unit.FindingsParticipants found personal recovery was difficult on an acute mental health unit. Factors that participants identified that impeded personal recovery-oriented care on acute mental health units included: the acuity of consumers in a low dependency area, lack of time to engage consumers, and loss of the therapeutic role for mental health nurses on acute units.DiscussionMental health nurses are expected to focus on the personal recovery needs of mental health consumers while managing clinical risks to consumers and others on the acute unit. This has the mental health nurse navigating a course between two worlds, and results in mental health nurses being confused between concepts of personal recovery and clinical recovery.ConclusionIf acute mental health nurses cannot define personal recovery, they will not be able to effectively implement interventions that support consumers in their personal recovery journey on acute units and will be drawn into the clinical recovery paradigm.     

Caring for the elderly: changing perceptions and attitudes.

The aging population is currently one of the main issues facing international health care systems. It is a recognized fact that with advancing age, the likelihood of developing health problems and chronic disease will increase and the demand for health care resources will escalate. This will impact hospitals and long-term care facilities. Our young nurses of the future will be faced with the challenging task of caring for this elderly population. A review of the literature revealed that nursing students have a negative attitude toward the elderly. This may be affected by personal beliefs, values, culture, experience, or observations. Their perceived attitudes toward the gerontology field will make it difficult to recruit the nurses required in this area. This article will explore these issues and examine the role of all health care professionals to help change their attitudes and develop a more positive relationship to meet the needs of this unique population.     

Recontextualizing learning in nursing education: taking an ontological turn

An ontological focus has been embedded within nursing education since its inception. There has been a strong emphasis on teaching students to become safe, competent nurses by translating knowledge into clinical action. But how would nursing education shift if we were to more intentionally orient the educative process ontologically and explicitly put epistemology at the service of ontology? We consider this question of an ontological turn in nursing education by examining what is commonly referred to in nursing curricula as interpersonal communication. With the goal of providing learning opportunities that can support students to develop confident and competent practice within the shifting, complex terrain of contemporary health care milieus, we explore the possibility of shifting the relationship between epistemology and ontology, and purposefully orienting the educative process in such a way that emphasizes and illuminates the manner in which nursing knowledge and action intersect with subjectivity and context.     

Re‐conceptualizing the nursing metaparadigm: Articulating the philosophical ontology of the nursing discipline that orients inquiry and practice

Jacqueline Fawcett's nursing metaparadigm—the domains of person, health, environment, and nursing—remains popular in nursing curricula, despite having been repeatedly challenged as a logical philosophy of nursing. Fawcett appropriated the word “metaparadigm” (indirectly) from Margaret Masterman and Thomas Kuhn as a devise that allowed her to organize then‐current areas of nursing interest into a philosophical “hierarchy of knowledge,” and thereby claim nursing inquiry and practice as rigorously “scientific.” Scholars have consistently rejected the logic of Fawcett's metaparadigm, but have not yet proposed a substantially agreed‐upon alternative. Through an analysis of articles introducing and critiquing Fawcett's metaparadigm, I argue for a re‐conceptualized metaparadigm that articulates nursing's ontology. What exists for the nursing discipline are not already‐demarcated metaparadigm domains, but rather interdependent, dynamic relations that constitute people, including nurses, in their health/environment circumstance. The nursing discipline aims to skillfully access this dynamic relationality as the basis for action and reflection to produce both positive health trajectories and knowledge that facilitates future action and reflection. Further inquiry into the onto‐epistemology of nursing will produce a more robust understanding of nursing practice, science, and philosophy, and clarify its unique contribution to health and healthcare.     

Ethical nursing practice: inquiry-in-action

Although the need to theorize ethics within the complexities of nursing practice has been identified within the nursing literature, to date the link between ethics epistemology and specific nursing actions has received limited attention. In particular, little exploration has been carried out to examine how nurses 'know' what is ethical and the knowledge they draw upon to inform their nursing actions within the complexities of their everyday practice. This study describes a participatory inquiry project that focused on developing and articulating an epistemology of ethics while in the midst of everyday nursing work. Epistemological and methodological insights are discussed in light of the challenges nurses face in contemporary healthcare contexts.     

Cultural perspectives on nursing in the 21st century.

By the year 2000, more than one fourth of the US population will consist of individuals from culturally diverse groups. Increasing numbers of international visitors and exchange students will use the US health care delivery system, and US nurses will engage in international interchanges with increasing frequency. To keep pace with these population and health care trends, US nurses will need to base their nursing care on a theoretically sound foundation that draws on knowledge from the physical, natural, and behavioral sciences, as well as on research-based theories from transcultural, cross-cultural, and international nursing. The purposes of this article are to (1) trace past, present, and future population trends among minority groups in the United States; (2) examine the ways in which transcultural nursing has provided a framework for meeting the health care needs of culturally diverse people; (3) identify current issues and trends in transcultural nursing; and (4) suggest ways in which nurses can prepare for the increasing numbers of culturally diverse individuals who are projected to need nursing care in the future.     

Starry night: using story to inform aesthetic knowing in women's health nursing

AIM OF THE PAPER: This paper describes the use of story as a vehicle to inform aesthetic knowing in nursing. Because health care demands that nurses know two distinct languages, the language of nursing science with its quantifiable outcomes as well as the experiential observations of health and illness, it is critical that nurses be fluent in each discourse. BACKGROUND: Nursing scholars have long voiced a commitment to two epistemological domains: scientifically derived knowledge (empirics) as well as the expressive, creative, intuitive application of knowledge (aesthetics). In recognition of the need for these interpretive paradigms for practice, nursing scholars have sought to identify the kinds of knowing which provide the nursing discipline with its unique perspective. DISCUSSION: Stories mould every human encounter and telling one's story in the context of a trusting relationship allows women and nurses to journey together to uncover and discover the meanings inherent in the story. Through this mutual process of unfolding the story, nurses engage the women in deep reflection and focus on what 'might be' so that possibilities for the future are illuminated. This is important in all nursing, but particularly in women's health nursing because the emergence of story suggests that contextual, phenomena-centred knowledge has found its voice in the nursing care of women as a way of knowing that focuses on personal experience and relies on methods in which woman-to-woman caring facilitates the disclosure of the human health-illness experience. CONCLUSIONS: Storytelling is a useful strategy to inform aesthetic knowing in nursing. Stories supply a foundation for nursing scholarship because truly to hear women's stories require nurses analyse information, formulate hypotheses, and seek to understand the causal relationships as expressed by women. Through this analysis and attention to detail, nurses are able to glimpse possibilities for the future, thus transforming the experience.     

A new paradigm for practice education

This paper explores the complex nature of professional practice. It suggests that educating for all practice disciplines is about to undergo a paradigm shift whereby the value of practical education and experience will be better understood, more rigorously analyzed and integrated with propositional knowledge in the construction of personal professional knowledge and identity. It relates this cross disciplinary position to the present problems of skills deficits which are evident in nurses at the point of registration and demonstrates how routinization and internalization of process and tacit knowledge can create problems for students and newly qualified staff nurses. It also suggests how this can be addressed.It discusses the present culture of 'clinical education by default', unavailability of mentors and resources, and general lack of formal collaborative structures between education and service institutions and suggests that the present system cannot sustain the complex demands, expectations and pace of the clinical context and the evolution of nursing practice. Clinical credibility is an issue as is the current heavy clinical workload of staff nurse mentors, and several collaborative clinical education models are outlined which ensure that staff nurses or resident clinical educators are available and can make clinical teaching their priority. History and the present crisis in nursing suggest that there is a case for mandatory collaborative education/service structures to ensure adequate funding and to monitor the effectiveness of selected models so that staff nurse mentors can work with lecturer colleagues to articulate and teach the complexities of clinical practice through related research.It is predicted that this collaborative approach is capable of addressing both the skills deficits and the wider intellectual challenge of developing a new paradigm of practice education and providing an integrated base for continuing professional development.     

Preventive work with families: issues facing public health nurses

This paper examines the issues that nurses experience when entering the family system to work preventively. The theoretical basis of family-centered nursing is analysed and the need for empirical work is identified in order to develop a knowledge base for this practice. Some unique characteristics of the public health nursing role are discussed with emphasis on territorial issues, power relationships and accountability problems. The need for public health nurses to function as advanced generalists across different system levels is recommended and family skills necessary for effective family nursing are examined. The authors identify the unique role of public health nurses because they have access to healthy families and families dealing with early stages of health concerns. The authors support the general structure of public health practice as of value for preventive work with families. However, clarity regarding referrals, contracting and the rights of clients is called for to facilitate collaborative family-centred nursing.     

Nigeria: the land, its people, and health care

The unique health care needs in developing countries and the responsibilities of the nursing profession in such countries place a heavy responsibility on schools of nursing involved in the education of foreign nursing students. The students in this study indicated that it was frustrating to repeat course content that was already familiar to them knowing that there are many courses that would better meet their needs. In developing countries, like Nigeria, it has been suggested that there is a need to prepare a "comprehensive nurse"--a combination bedside nurse, public health nurse, and midwife who can provide preventive and curative services in multiple settings. Such a task is awesome and illustrates the need for schools of nursing to provide an academic counselor who has some knowledge of the culture and health needs of the students' native land. When asked: "How could the school of nursing have helped you cope with your academic problems?" 43% of the students suggested a foreign student advisor or counselor. "To have a foreign student advisor who has been overseas and who will relate to the student at their level," replied one student. Only when education is relevant to the specific needs of a given country, will there be an improvement in the health of the people of that country. To educate registered nurses abroad is very costly for countries with low G.N.P. If we accept students from developing countries into our nursing programs, we have a responsibility to prepare them to be effective practitioners when they return to their homeland. The special needs of nursing students and the health care needs of the community for which they are trained must therefore be integrated into their training.     

Relational and embodied knowing: nursing ethics within the interprofessional team

In this article we attempt to situate nursing within the interprofessional care team with respect to processes of ethical practice and ethical decision making. After briefly reviewing the concept of interprofessionalism, the idea of a nursing ethic as 'unique' within the context of an interprofessional team will be explored. We suggest that nursing's distinct perspective on the moral matters of health care stem not from any privileged vantage point but rather from knowledge developed through the daily activities of nursing practice. Because of their position vis-à-vis patients and families in everyday clinical care, nurses cultivate ethical knowledge of at least two forms: (1) relational knowledge; and (2) embodied knowledge. Through the integration of these forms of knowledge, nurses develop a unique moral perspective and can make a meaningful contribution to the realm of ethics in interprofessional care.     

Processes in the creation and diffusion of nursing knowledge: an examination of the developing concept of family-centred care

The creation of a knowledge base to underpin and direct nursing practice has been the pursuit of nurse academics, educationists and practitioners over recent decades Much of this work has concerned the explication of major theories of nursing, whilst some has sought to elucidate specific areas of knowledge This paper outlines processes of creation and diffusion, considering the influence of factors from both within and without the nursing profession on the epistemology of its knowledge base An examination of the developing concept of family-centred care is utilized to illustrate the convolutionary process of knowledge creation     

Lost in the crucible of supportive clinical supervision: supervision is not therapy

Clinical supervision as a mechanism that supports both professional and personal development is a concept that has captured the imagination of nurses. Though nurses generally agree that 'supervision is not therapy', a clear distinction cannot be enunciated between these two processes when both aim at personal growth. In combining personal and professional growth, the rationale for clinical supervision is unnecessarily confused, with the unfortunate result that supervision may, unwittingly, become a form of therapy for nurses. This paper examines a model of supportive clinical supervision qua Chambers and Long's example of a facilitative therapeutic supervisory style, that reflects nurses' conceptualization of clinical supervision as enhancing personal and professional growth. However, it could be argued that this stance is in crucial respects incorrect, and needs to be rethought if clinical supervision is to be established as credible in nursing. Subsequently, it is important to remember that the utilization of certain techniques rather than their stated goals, will dictate the form that supervision, or therapy, will take. The purpose of this paper is to demonstrate the logical unacceptability in combining two processes as one, while developing a conceptual framework that differentiates supervision from therapy.     

Bringing psychiatric nursing into the twenty-first century

Psychiatric nursing stands at a crossroads, in danger of losing both its identity and standing within the larger body of nursing. Enrollment in graduate programs is at an all time low and many traditional employment opportunities for psychiatric nurses are disappearing. Many explanations have been proposed to account for the crisis in psychiatric nursing practice. Although many of the identified external forces have had real impact on psychiatric nursing, these factors have impacted all of nursing. Yet our Nurse Practitioner (NP) peers are thriving, with proliferation of NP programs with unprecedented enrollment for this nationally accepted and understood role. The psychiatric nursing crisis may be most directly related to the reality that we as a professional group have thus far failed to adequately respond to external realities that have dramatically altered the environment in which psychiatric nursing occurs. This article argues for reframing the discipline of psychiatric nursing, accomplished as a national consensus building process, and including 4 critical components: (1) reconceptualization of what constitutes the core of psychiatric nursing content and represents the epistemological heart of the profession; (2) identification of the critical clinical competencies that reflect the core content, represent the role and scope of psychiatric nursing, and that match current and anticipated practice realities; (3) identification and standardization of measurable clinical outcomes, predicated on both content and competencies, which will allow psychiatric nurses to measure, in meaningful ways, the impact of their practice on patients' health; and (4) establishment of a research agenda that will allow psychiatric nursing to expand its unique knowledge base.     

Frontiers of nursing in the 21st century: development of models and theories on the concept of nursing

In the past nursing has used a medically oriented perspective; consciously or not, nursing practice, education and research have been guided by the same conceptual frame of reference as has medicine. For nursing to justify its claim to being an independent health profession offering a particular service to society, it must adopt its own conceptual base, one that indicates those phenomena that are of concern to nursing and those health problems that nursing must try to solve. Many nurses have already chosen to base their teaching, research and nursing care on one of the existing conceptual models for nursing. The challenge for the 21st century is that all nurses adopt an explicit conceptual base. Broader than a theory, a conceptual model specifies nursing's focus of inquiry and may thus lead to the development of theories which will prove useful not only to nurses but to other health professionals as well. Since nursing exists to provide a necessary service to mankind, its conceptual base must be evaluated by using specific social criteria.     

Nursing's image on the university campus

Our study found that the faculty sampled held a different and more positive view of nursing than the one presented by the media. Nurses were perceived as educated, autonomous and compassionate individuals whose role is vital in health care. These findings might be explained by the high degree of personal contact that the sample had with nurses. It is possible that personal contact with nurses may mediate against the negative media image of nursing. As one respondent wrote, "Nursing care after recent surgery certainly erased all stereotyped notions...." The implications are tremendous for the role of the nurse in every encounter with the public. Nursing's energies might be best directed toward promoting nursing, not as it is portrayed in the media world of make-believe, but as it is lived by real nurses and their clients. Nurses must convey an image of caring, competent professionals who are capable of addressing society's health care needs. In the words of another respondent, "Unfortunately, the American public does not know the reality of professional nursing and the nurses have been treated unfairly, far from what they deserve.... I hope the American public will look on nursing as one of the most respectable professions and give the nurses credit for their efforts, devotion, and knowledge...."     

Discovery Path: a retention strategy for mid-career nurses

As health care administrators, policymakers, nursing organizations, and nurses begin to deal with the reality of a looming (and to an increasing extent, existing) serious shortage of nurses both in Canada and globally, recruitment and retention issues are again in the news. Much attention has been directed towards two responses: (a) attracting young people into the profession and helping them integrate into and identify with nursing as a lifelong career, and (b) developing sustainable retention strategies to ensure that nurses remain in nursing. One population that requires particular attention is the mid-career group of nurses. Those nurses, in their late 30s and 40s with 15 and more years of experience, have the professional memory that employers count on, the expertise that patients and clients require, and the experience and wisdom that young nurses depend on for coaching, mentoring, and support. Retention strategies targeted to these mid-career nurses require a diverse set of activities that are focused on those nurses' specific stage of personal and professional development and that recognize their unique needs. The purpose of this article is to describe a program that targets mid-career nurses, predominantly women who, having spent much of their careers and lives caring for others-children, parents, patients-are beginning to question their own futures. The goals of the program and the experiences of one group of nurses in the program, as well as the results of a two-year follow up with them, will be discussed. Recommendations for future retention strategies will also be offered.     

An exploratory study of the sources of influence on the clinical decisions of community nurses

This paper reports a small exploratory study which identifies what community nurses consider to be the scope of their practice and the sources of influence on their clinical decisions. The study was stimulated by the emergence of the nurse prescribing initiative, which is likely to bring clinical decision making to the centre of professional debate. The study was carried out over a 5-month period and data were collected from 47 community nurses in four district health authorities. A qualitative method was employed and field work involved observation of 40 home visits and five nurse-run clinics, individual interviews and group discussions with the nurses, and scrutiny of nursing records. The data were content analysed and classified, and the categories were validated by practitioners. Findings suggest that although community nurses consider that a large proportion of their work requires a scientific basis, their practice is largely founded on experiential knowledge, and on the whole they are not positively disposed to research knowledge. The findings are discussed in the context of nurse prescribing. Questions are raised about the nature of a 'professional' knowledge base and the reclassification of scientific knowledge as nursing or experiential knowledge once it has diffused into practice.