NURSE THEORIST

Consensus Statement on

Emerging Nursing Knowledge

A Value-Based Position Paper Linking Nursing Knowledge and Practice Outcomes

USA Nursing Knowledge Consensus Conference, 1998

Boston, Massachusetts

(Draft October 1999)

Introduction: A series of conferences was held in the Northeastern area of the USA during the 1980s and 1990s and were well attended by nurses from throughout the USA and representatives of other countries. This series was followed by the historic convening of Knowledge Consensus Conference 1998 in Boston, Massachusetts from October 22-24, 1998. The focus of the conference was to build on previous presentations and perspectives on developments within nursing science using a participatory process. The goal for the 140 conference participants, consensus builders, and facilitators was to discuss and synthesize various perspectives on knowledge development related to (1) the nature of the human person, (2) the nature of nursing, (3) the role of nursing theory, and (4) the links of each of these understandings to nursing practice. This document summarizes the key assumptions, scientific principles, and values for each issue that had the greatest amount of consensus.

I. Ontology of the Person

A. Assumption: Understanding the human person, as individuals, families, communities, and groups, is the focal point of knowledge development in nursing.

B. Scientific Principles and Values:

1. The person is characterized by wholeness, complexity, and consciousness. Person-hood can be considered on individual, family and community levels. The person is sentient with multiple dimensions including individuality and embodiment. A human being is evolving, in process, fluid, and changing. Each person or social group has purpose, promise, and potential for continuing transformations. The social and cultural environment for the person, family, or community reflects multiple values and social-political perspectives. Nurses recognize both the commonalities and differences of people. Humankind is moving from an ethnocentric to global perspective.

2. The person is capable of choice and has free will tempered by the context of one’s past, present, and future. The individual is inherently good, has rights, and is self-directed. At the same time, each person recognizes the rights of others and works toward increasing freedom and emancipation for self and other persons. Conflicting rights are to be resolved, resulting in balancing and harmony. Such balance and harmony are sought at all levels for individuals and groups, from electrolytes to the cosmos.

3. The person is interdependent and lives in reciprocity, connection, affiliation, and relationship. Through dialogue and exchange, together with self-reflection, the person makes meaning. Through such meaning, the person understands self, and other persons, particularly within family and community, as well as the larger world. Personal meanings and knowledge are shared through distributed cognition.

4. The person in both Eastern and Western traditions has a yearning beyond the human. This characteristic has been termed spirituality and involves seeking a common destiny. Spiritual beliefs may be spoken or unspoken, and are particularly rooted in family and social traditions. For some, the soul of the person is viewed as the energy of the universe, and an existential reality.

II. Ontology of Nursing

A. Assumption: Nursing is a human practice discipline that facilitates well-being using a scientific knowledge base and values in a caring relationship.

B. Scientific Principles and Values:

1. The essence of nursing lies in modes of being, including the nurse’s true presence of his or her whole self. The nurse uses the mode of being with and being for, in the process of human to human engagement. Other terms used to describe this fundamental aspect of nursing include interaction, mutuality, and encounter. The engagement is mutual, an iterative process that includes giving and receiving and being humble. Nursing provides a presence with others derived from the soul or spirit of the nurse that interfaces with the soul and spirit of the other. This relationship includes respect and acceptance of where the person is and the nurse’s openness to another person’s reality. The nurse appreciates the patient and the space between the nurse and the patient. An empathetic presence requires reflection by the nurse and engaging persons in the process of their journey. It also includes intimacy, trust, and authenticity. Further, commitment, responsibility, and accountability are terms used to characterize the nature of nursing. Caring is described as including presence, feeling empathy, and nurturing that is oriented to promotion of health and well being. Caring takes place within the context of a therapeutic relationship and is considered a moral imperative of nursing. Caring relationships occur with individuals, family, communities, and societies as a whole.

2. Nursing by its nature brings intentionality to the therapeutic process. In addition to being for the other, the nurse acts for the other. Actions of the nurse focus on health. Health involves fulfilling human potential and enabling well being for individuals, families, communities, and groups. Some nurses refer to the goal of nursing action as movement on the health-illness continuum. For the nurse, the human encounter is purposeful and focuses on building and bridging human possibilities. The nurse uses both philosophic and scientific knowledge to empower others. Nursing knowledge is based on understandings and values related to the nature of persons. The science of nursing involves complex ways of knowing, including clinical wisdom. Nurses strive to be competent and recognize their limitations. Nurses' work is with humans and includes the role of raising consciousness about the sacredness of human beings. Helping people to make healthy choices requires knowledge, integrity, and accountability. Nurses are responsible for their actions and put the patient, family, or community first. Ethical and moral principles are used in respecting the autonomy of persons.

3. Cultural competence is a core element of nursing. Caring by the nurse is transcultural. To be transcultural is more than a value; it is a demand for action. Cultural competence and scientific competence are not hierarchical, but integrated in nursing action. Nurses have a special accountability to transcend ethnocentrism. A nurse cannot be effective if he or she is confined in the narrowness of one's own culture. The knowledge base of nursing is meaningful to the patient and the patient's needs and to the needs of the family and community. Such needs occur within a given social context. Nurses value cultural differences and strive to individualize knowledge for care. Nurses recognize the real and strive for the ideal. At the same time, nurses acknowledge the complexity in the world. They question how privilege may blind the nurse to the wisdom of ordinary people and thus, how the needs of some people may not be recognized by nursing.

4. As a discipline with a social mandate, nurses take responsibility for social transformation. Political activism is one form of valuing and acting within the discipline. Nurses are altruistic and strive to do what is morally right in the service of human beings and society. Nurses are proactive in engaging in health promotion and prevention of ill health. They advocate for others and work to provide access to health care for all. Nurses examine the constraints of modern organizations and work to create systemic change that is more responsive to the needs of the global population. Nurses strive to return the face of humanity to health care systems. Nurses are open to change, anticipate change, and respond to the challenge of change. Current challenges include changes in economic and technologic realities at national and international levels. A goal for nursing knowledge and action is to empower communities. Commitment to empowerment of others requires a fierce compassion from nurses.

III. Nursing Theory

A. Assumption: Nursing theory expresses the values and beliefs of the discipline, helps to frame the human experience, and guides the caring process.

B. Scientific Principles and Values

1. Nursing theory is the vehicle used to operationalize a disciplinary perspective. It embraces a wholistic view of what it means to be human and helps frame the nurse/patient experience. Theory is respective of personal meaning, human diversity, the uniqueness of the individual and spiritual expression. It provides the context from which nurses come to understand personal responses to a dynamic and changing health care environment.

2. In nursing theory, the discipline articulates core beliefs and common assumptions. Guided by these universal philosophical links, multiple epistemologic views emerge to help understand the complex, dynamic, interactive and transforming caring experience that occurs between the nurse and patient, family, community or other social group. The result is knowledge (content and language) that depicts how nurses think and what they think about. Nursing theory creates a way to link the disciplinary ontology with a unique perspective about the dynamic person/environment interaction. It is useful in providing an approach to guide nursing practice, education and research.

3. Theory creates a way to organize knowledge. It allows for the integration of knowledge from other disciplines that can inform and expand the sphere of understanding from a nursing perspective. Theory is not static. Rather, it is iterative, dynamic and evolving. It must be continually updated and informed by practice and research. Theory helps to clarify existing knowledge and direct new discoveries. Through synthesis and reflection, nurses are able to develop the content of the discipline and create the bridge between theory and practice.

4. Theory helps to illuminate practice. It creates the disciplinary knowledge needed to guide clinical judgments, actions and articulate clinical outcomes that acknowledge a disciplinary contribution to global health. Theory should reflect reality. It is only then that it is clinically useful. Theory directs the nurse to uncover new knowledge about the human experience in a unique way. The testing and refinement of theory helps to generate information that can be used to fill the existing knowledge gaps needed to describe and explain the human experience of individuals, families, communities and groups.

IV. Linking the nature of Person, the nature of nursing, and nursing theory to Nursing Practice.

A. Assumption: The essence of nursing practice is the nurse-patient relationship that embodies beliefs about the nature of person and the nature of nursing.

B. Scientific Principles and Values

1. Nursing practice manifests a unique understanding of the person from a disciplinary perspective.

The connection between the nurse and the patient fosters human health and supports self-discovery. The nurse uses problem solving and process skills, such as reflection, to come to know the person, family, community, or social group. This knowing results in actions that guide patients and groups in making choices and decisions that promote personal and group growth. Knowledge and creative artistry are used to tailor nursing care to an individual or group’s unique responses and/ behaviors across the health care experience.

2. The nurse-patient relationship is a dynamic, evolving and transforming partnership, grounded in trust and truth. It flourishes in an environment that is sensitive to the uniqueness of the person or group and includes attention to biophysical, cultural, and spiritual dimensions of both. The intentional presence of the nurse is essential for coming to know and understand what it means to be human and humans in relationship. This knowledge provides the basis for the mutual selection of interventions that can promote health and self-determination.

3. Nursing practice occurs within a socio-political environment. As a discipline, nursing continues to make visible the role it plays in problem solving and decision making. Nursing demonstrates the effectiveness for the health of a society of a practice that achieves outcomes of personal growth for individuals and groups, promotion and evaluation of change, self-knowing, and personal and social transformation. It is essential that the contributions of nursing be described within the framework of quality and cost effectiveness. Nurses use language that has collaborative acceptance in order to justify contributions to care that are recognized by sources of funding for health care. Nursing knowledge, both theory and research, are used to inform health care policy and provide the basis for nurses’ voice for change and social reform.

4. Nursing practice uses knowledge, both theory and research based, to guide care and promote change.

The patient, as individuals, families, communities, and groups, is the central focus of nursing care. Nursing education, practice, and research assist in optimizing the patient experience within a caring environment. Nursing education reflects the reality of practice while providing students with the knowledge needed to reform and direct health care across settings. Nurse mentors are essential to professional development and optimal patient care. Nursing theory provides a framework for understanding the nurse-patient interaction and helps direct patient care. The continued preparation of nurses who can define the discipline to the public and other health care providers is critical to the advancement of the discipline. Nursing practice creates environments that optimize and differentiate the unique contributions of nurses to patient care and the health of the society.