Nursing Metaparadigms and Practice-Specific Concepts Since Florence Nightingale, there have been a number of so-called grand theories of nursing advanced, and these grand theories have been used by other nursing theorists to conceptualize metaparadigms of practice that continue to influence clinical practice today. In addition, the central concepts of nursing are person, nursing, environment and health have formed the basis for other nursing theorists such as Jean Watson's Philosophy and Science of Caring and Madeleine Leininger and her Cultural Diversity and Universality Theory. This paper provides a review of the relevant literature concerning these issues, followed by a summary of the research and important findings concerning nursing metaparadigms and practice-specific concepts in the conclusion.

Review and Discussion

Nursing Autobiography

My background in nursing is in long-term and home care. In these capacities, I have had a number of opportunities to apply the four metaparadigms of nursing as discussed further below.

The Four Metaparadigms

While authors differ with respect to specifics, a useful definition provided by Masters (2012) states that, "A metaparadigm is the most global perspective of a discipline and acts as an encapsulating unit, or framework, within which the more restricted ... structures develop" (p. 42). The conceptualization of a metaparadigm involves the identification of phenomena of interest to each discipline that are addressed in a fashion that is unique to each (Master, 2012). There is some nebulosity to metaparadigms, though, that transcend mere protocols or perspectives. In this regard, Masters emphasizes that, "The concepts and propositions that identify and interrelate these phenomena are even more abstract than those in the conceptual models. These are the concepts that comprise the metaparadigm of the discipline" (2012, p. 42).

The conceptual models that link and define the four metaparadigms of nursing concepts differ, but all four metaparadigm concepts are components of each of the models (Masters, 2012). In sum, Masters notes that, "The central concepts of the discipline of nursing are person, environment, health and nursing" (p. 48). While each of the four metaparadigms is unique in some fashion depending on the discipline that is involved, with respect to nursing, Masters advises that these four concepts of the metaparadigm of nursing are: "The person receiving the nursing, the environment within which the person exits, the health -- illness continuum within which the person falls at the time of the interaction with the nurse, and, finally, nursing actions themselves" (p. 48).

It is important to note, though, that even the most thoughtful and insightful formal model of care based on the four paradigms is not an end-all in the development of professional standards of care. For instance, according to Ondrejka and Barnard (2011), "By itself, a formal model of care is not likely to produce improvement on the nursing report card, unless there is a continuous move for nurses to own their practice and integrate a model of care that agrees with their values and is patient centered" (p. 142). In fact, the pressing need for patient-centered and evidence-based practice is made evident in the two practice-specific concepts discussed further below.

Two Practice-Specific Concepts

Jean Watson's Philosophy and Science of Caring. Watson's theory holds that the overarching goal of the nursing profession is to facilitate the attainment of a higher level of harmony within the mind -- body -- spirit triad (Masters, 2012). The theory also maintains that by attaining this goal, it is possible to potentiate healing and health (see Table 1 below). In order to achieve the Watsonian goal, nurses employ transpersonal care that is guided by carative factors and associated caristas processes. In fact, Watson's theory for nursing practice is founded on 10 fundamental carative factors. According to Masters, "As Watson's work evolved, she renamed these carative factors into what she termed clinical caritas processes. Caritas means to cherish, to appreciate, and to give special attention. It conveys the concept of love" (2012, p. 52).

The 10 caritas processes conceptualized by Watson are as follows:

1. Practice of loving kindness and equanimity for oneself and other;

2. Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and the one being cared for;

3. Cultivating one's own spiritual practices; going beyond the ego self; deepening of self-awareness;

4. Developing and sustaining a helping -- trusting, authentic caring relationship;

5. Being present to, and supportive of, the expression of positive and negative feelings as a connection with a deeper spirit of oneself and the one being cared for;

6. Creatively using oneself and all ways of knowing as part of the caring process and engagement in artistry of caring -- healing practices;

7. Engaging in a genuine teaching -- learning experience within the context of a caring relationship, while attending to the whole person and subjective meaning; attempting to stay within the other's frame of reference;

8. Creating a healing environment at all levels, subtle environment of energy and consciousness whereby wholeness, beauty, comfort, dignity,...

Assisting with basic needs, with an intentional caring consciousness; administering human care essentials, which potentiate alignment of the mind -- body -- spirit, wholeness, and unity of being in all aspects of care; attending to both embodied spirit and evolving emergence;
10. Opening and attending to spiritual, mysterious, and unknown existential dimensions of life, death, suffering; "allowing for a miracle" (Masters, 2012, pp. 52-53).

In addition, Watson describes the underlying clinical caritas processes as being the "core" of nursing that has its foundation in the art of caring as well as philosophy and science (Masters, 2012). An interesting aspect of Watson's theory is her distinction between the foregoing core of nursing practice with so-called "trim," which is used to describe the "practice setting, procedures, functional tasks, clinical disease focus, technology, and techniques of nursing. The trim, Watson explains, is not expendable, but it cannot be the center of professional nursing practice" (Masters, 2012, p. 53).

The metaparadigm concepts defined in Watson's philosophy and science of caring are set forth in Table 1 below.

Table 1

Metaparadigm Concepts as Defined in Watson's Philosophy and Science of Caring

Metaparadigm Concept

Description

Person (human)

This term is used by Watson to describe a unity of mind-body-spirit/nature; embodied spirit.

Nursing

Reciprocal transpersonal relationship in caring moments guided by carative factors and caristas processes.

Healing space and environment

A nonphysical energetic environment; a vibrational field integral with the person where the nurse is not only in the environment but the nurse IS the environment (Watson, 2008, p. 26).

Health (healing)

Harmony, wholeness and comfort.

Source: Constructed from figure in Masters, 2012, p. 52

Another prominent nursing theorist whose work has been influential in shaping nursing practice in recent years is Madeleine Leininger and her Cultural Diversity and Universality Theory which are discussed further below.

Madeleine Leininger's Cultural Diversity and Universality Theory. The primary features of the Cultural Diversity and Universality Theory developed by Leininger are as follows: Transcultural nursing is a substantive area of study and practice focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people face unfavorable human conditions, illness, or death in culturally meaningful ways. (p. 58)

The definition of the metaparadigm of concepts of nursing defined by Leininger specifically included the need for the nurse to take the delivery of competent nursing care into account as set forth in Table 2 below.

Table 2

Metaparadigm Concepts as Defined in Leininger's Theory

Metaparadigm Concept

Description

Person

Human being, family, group, community or institution

Nursing

Activities directed toward assisting, supporting, or enabling with needs in ways that are congruent with the cultural values, beliefs, and lifeways of the recipient of care.

Environment

This term means the totality of an event, situation, or experience that gives meaning in human expressions, interpretations, and social interactions in physical, ecological, sociopolitical and/or cultural settings.

Health

A state of well-being that is culturally defined, valued and practiced.

Source: Constructed from figure in Masters, 2012, p. 67

According to Leininger, there are three basic modalities that serve to guide nursing judgments, decisions, and actions that can facilitate the delivery of nursing services that are satisfying, meaningful and beneficial to recipients (Masters, 2012). These three modes are as follows:

1. Cultural care preservation or maintenance. This term is used to describe supportive, assistive, facilitative, or enabling professional interventions that facilitate improved clinical outcomes in cross-cultural settings. In addition, this term is used to refer to actions and decisions that help people (a) maintain meaningful care values for their well-being, (b) recover from illness, or (c) deal with a disability or death (Masters, 2012).

2. Cultural care accommodation or negotiation. This term refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a specific culture or subculture adapt to or negotiate with others for meaningful, beneficial, and congruent health outcomes.

3. Cultural care repatterning or restructuring. This term refers to the assistive, supportive, facilitative, or enabling professional actions and decisions that help patients reorder, change, or modify their lifeways for new, different, and beneficial health outcomes (Masters, 2012).

The argument can be made that all of the foregoing modes involve developing an effective therapeutic relationship and that the better the relationship the better the clinical outcomes.…