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Advances in Nursing Science

Vol. 31, No. 1, pp. 7991


Copyright  c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins

A Practice Discipline Thats Here


and Now
Merian C. Litchfield, PhD, RN; Helga Jonsdottir, PhD, RN

There is a vacuum for a practice discipline of nursing that would enable nurses to articulate the
significance of what they do as an essential thread of contemporary healthcare provision. This
article is an effort to develop the meaning and possibilities of a practice discipline for nurs-
ing. Tuning into the general shift in thought about our human condition across disciplines
and nations, we consider features of a participatory paradigm, which, when refocused on the
humanness of the health circumstance, informs our approach to a practice discipline. Knowl-
edge is personal and participatory, evolving in the here-and-now of health systems. Research
integral to practice and service innovation illustrates the way of looking and talking about
a new phase in discipline development. The discipline is relational and creative in practice,
evolving in the forums for dialogue. Each one of us as nurses has responsibility in participa-
tion. Key words: dialogue, health circumstance, health experience, humanness, nursing
knowledge, nursing practice, participatory paradigm, practice discipline, relational

We cannot solve our problems with the same decades of scholarship in nursing have given
thinking that created them. us a range of theories, yet the visionand
Albert Einstein promiseof a distinct discipline of nursing is

T HE escalating problems of providing


healthcare in all nations call for new
thinking. The shortage of nurses now, as part
not reflected in the strategizing that gives di-
rection to health system reform.
In this discipline vacuum, extensive lists of
of the general workforce predicament, is in- nurse competencies have just served to por-
dication of our unsustainable systems. Work- tray nursing as a set of activities given mean-
place pressures are constraining the nurs- ing as the nurses work in the health system
ing that we as nurses know is needed. As already defined by the social relevance of
has been so throughout our history, we seek medical science. The service mission is
the freedom to nurse. Yet we continue to rooted in the prevailing health paradigm of
be hampered by our inability to articulate prevention, diagnosis, and treatment of dis-
clearly in the appropriate forums what is es- ease, its signs, symptoms, and dangers. This
sential about nursing that contributes directly obfuscates what nursing knowledge is and
to health and society and what conditions are how we could be contributing to health in
necessary for this given scarce resources. The the lives of all people and the nation. The
nursing needed as a professional practice is
obscure in health policy and system devel-
opment, while the health missions of service
Author Affiliations: Litchfield Healthcare
Associates, Wellington, New Zealand (Merian C. providers/funders define the nature of the
Litchfield); and Faculty of Nursing, University of work of nurses as employees to be managed
Iceland, Iceland (Helga Jonsdottir). as part of their pool of resources.
The authors acknowledge the funding support from Health systems are increasingly shaped by
University of Iceland Research Fund for the collabora-
tion on this project.
the drive to cost-effectiveness in our world
of expanding and extravagant possibilities for
Corresponding Author: Merian C. Litchfield, PhD,
RN, PO Box 17081, Wellington, New Zealand, 6147 the cure and control of disease and disabil-
(merian.litchfield@clear.net.nz). ity. The challenge is intensifying to articulate
79
80 ADVANCES IN NURSING SCIENCE/JANUARYMARCH 2008

our discipline in a way that influences the the differentiation of the discipline (develop-
roles and positions for nurses in the service ment of the body of knowledge) from the
configuration providing essential healthcare. activities of practitioners (the profession) to
Our (authors) respective research projects liberate nursing from its vocational status and
have brought us to the realization that we enable us to claim its social relevance. Clinical
should be vigorously pursuing the articulation practice, they said, is concerned with here-
of the discipline of nursing with the scope and-now activities, whereas a discipline gives
of research broadened to the health system knowledge of its important expansive scope
contextthe policies, strategies, service de- through past, present, and future for use in
sign, and deliveryin which nursing care is any place. They recommended lessening our
inextricably woven. We do not want to just preoccupation with the process of nursing
slot practitioners into the workforce; we do and pedagogy and placing emphasis on con-
want to see them positioned to contribute to tent as substance.2(p251)
changes and to say what needs to happen for This distinction must have been a confirma-
healthcare to be socially relevant as well as tion, perhaps a relief, to the cadre of schol-
economically sustainable. ars constructing and evaluating theories. We
We write this article with the hope for en- can now see it as a necessary phase of lay-
ergized dialogue around nursing as a prac- ing claim to a distinctly nursing knowledge.
tice discipline, across nations, not with the But, as the often cited theory-practice gap,
idea of reaching consensus of what nursing is, it created a vacuum for the kind of knowl-
which theory is right or best, or what should edge that could give identity and value to
be achieved. Rather, it is to enliven nursing nursingas a practice, in practicethat is in-
practice, research, and education in our dif- tegral to everyday healthcare, service deliv-
ferent ways in different places in the interests ery, and sector development. We see the con-
of all peoples. We have developed our thesis sequence continuing in the age-old confusion
taking account of the historical evolution of of education and training for nurses. Paradoxi-
the discipline and locate it now within con- cally, the division is accentuated in the current
temporary thought about the human condi- drive to integration of healthcare when, by
tion to articulate the significance of nursing in default, the disciplinary perspective brought
its context of healthcare and service delivery. to health assumes medical science as founda-
It is intended to contribute among the efforts tional knowledge, privileging the practice of
of many nurses to make sense of our predica- medicine. Medical knowledge has become a
ment, and as a form of response to the call to generic pool of health knowledge, practiced
conscience and action of the Nursing Man- by physicians and selectively applied as the
ifesto project inspired in the United States at work of nurses.
the turn of the millenium.1 The division was addressed directlyand
most helpfullyin a recent debate pub-
lished in Nursing Science Quarterly between
THE CALL OF THE DISCIPLINE Mitchell and Bournes3 on one side, argu-
ing that an extant theory is foundational for
We see the nursing academy divided into nurses to even start practicing, and Reed4,5
distinct camps of scholarship. In general, the and Rolfe5,6 on the other side, arguing that
efforts to develop nursing as a discipline have theorizing is rooted responsively in the prag-
been separated from the pragmatics of nurses matics of everyday activities. We (authors)
employment as the mainstay of health service could both agree and disagree with each side.
deliverythe workforce and allotted work. Neither satisfies the vacuum for a contempo-
This division seems inevitable in hindsight. In rary practice discipline.
their seminal 1978 article on the discipline We are concerned about the collapse of
of nursing, Donaldson and Crowley2 urged the vision of professional nursing into the
A Practice Discipline Thats Here and Now 81

schism between efforts to create a discipline achieve in relation to other healthcare work-
(to date) and the pragmatics of work and ers and under what conditions. We see this
workforce. We believe it is timely to juxtapose challenge illustrated in a Canadian Health Ser-
these seemingly irreconcilable points of view vices Research Foundation report written by
and camps of scholarship, and consider anew nurses working on policy and mindful of the
what is meant by a practice discipline, looking talk of multitasking and interchangeability of
to a future of globalizing, yet locally attentive healthcare workers: The question that must
healthcare. be asked is not who can do this set of tasks or
The vacuum for a nursing practice disci- activities? but rather who should and why?
pline has been recognized from outside nurs- given the context and population.8(piv) The
ing. Weinberg,7 a sociologist in the United question is complex arising in the discipline
States, set out to respond to the question vacuum.
What do nurses do? She observed the impo- Methodologies for developing nursing
tence of nurses to claim their share of scarce knowledge have derived, often adopted,
resources in a tight economic climate. She from other disciplines. They have been useful
urged the articulation of nursing in context: but found wanting in satisfying the vacuum
If nurses want to protect themselves and pa- for a distinct practice discipline. Thorne and
tient care, they cannot wait for interested ob- colleagues, among many others, explained
servers to figure out what is going on. . . . The the inadequacies of both traditional quantita-
first step is to articulate what nurses as profes- tive science and the qualitative tradition for
sionals do and why the little things are really providing the scope and depth of the study
big things.7(p43) needed for the general knowledge of the
Joining the effort toward a nursing disci- sort that enhances particularization in prac-
pline, our (authors) questions are about the tice.9(p171) Swinging to the pragmatic side,
coherence of what nursing is about, looking they argued that interpretive description of
to contemporary wise thinking about the hu- health and illness experiences would be more
man condition, life, society, and health to give appropriate to bring nursing knowledge into
relevance. In the effort to reconcile knowl- its practice context. The interpretive turn
edge and activities in the complex context was further reflected in writing about praxis
of health services and workforce, we see from the 1990s. Connor10 proposed a time
that nurses framing nursing as a practice of praxiology entering the new millennium.
practice wisdomis the task of discipline de- Doane and Varcoe11 explained the usefulness
velopment for this era. of pragmatic enquiry to attend to experience
and ultimately reshape reality. Method-
ology is left implicit in whatever the nurse
AN ERA OF PRACTICE does.
Leaving aside the efforts to develop nurs-
The political rhetoric is about changing the ing as a discipline, and with a pragmatic ori-
culture of health systems from a curative/ entation, Liaschenko and Peter found that the
reactive to a preventive/responsive orienta- current statements of ethics of nursing are
tion. Attention has turned to workforce to outdated in assuming it can be a profession
achieve it, assuming division of labor accord- with autonomy in controlling its own work:
ing to the generic health/disease outcomes. the statements are no longer adequate to
Yet, we know people need nursing not use- address the social realities and moral chal-
fully represented in either orientation. For lenges of health care work.12(p488) Alterna-
nursing to be recognized in the drive to in- tively, they argued that considering nursing
tegration through multidisciplinary projects, and medicine tooas workwould more ap-
the challenge is to be articulate about our propriately accord value in the workplaces
own discipline as practice in situ: what nurses of contemporary healthcare; it could achieve
82 ADVANCES IN NURSING SCIENCE/JANUARYMARCH 2008

the collective ethical responsibility of all environment, nursing (nurse-client process),


healthcare providers to work collaboratively person (the human being) and, for the 1980s,
and interdependently. We see this stance as health, which she saw was cumulative, giv-
important in our efforts to acknowledge the ing meaning to all the concepts.
value of everyday activities of nurses in con- Now we pick up on this historical tra-
text, but we are concerned that the social rel- jectory to add practice as the contemporary
evance of nursing would continue to be ob- integrative theme. We believe, this opens
scured within the hegemony of the current scholarship to exploration of the pragmatic
service delivery culture. vis-a-vis discipline threads. It has turned us
Thus, attention has been turning to who to the nurse-person-environment-health inter-
the nurse is and moral agency: praxiology has relationship as fundamental, and therefore to
continued to echo in procedures for reflective the process of nursing in relation to content
practice to recognize moral agency. However, and its social relevance. Our (authors) chal-
reflection on practice remains an ad hoc aca- lenge to find coherence will accord us a prac-
demic procedure if nurses (as practitioners tice discipline has brought us to a paradigm
and educators) do not have the capability of that is participatory.
articulating the nature of nursing knowledge
in relation to health that signifies the process A PARTICIPATORY PARADIGM
of a practice as part of the whole provision
of healthcare. Nursing knowledge is tacit, We refer to a participatory paradigm that
research framed within the methodologies we see is expression of the widespread shift
of other disciplines, nurse employment ex- in Western thought about how we understand
ploited, and outcomes of healthcare skewed our human condition now emerging across
and depleted of essential nursing care. nations and disciplines. The word participa-
We acknowledge the pragmatic stance of tory orients us to practice as relational; we
many nurse scholars. It turns attention to the are prompted to turn our attention to the ac-
action of nursing as relational, dynamic, and tion of nursing, elaborating beyond just the
responsive. But it is the vacuum for a dis- presence of the nurse with patients/clients,
cipline we continue to address, focusing on applied knowledge, and a set of activities she
practice as we look for coherence between or he performs. It is about the self-in-relation,
the pragmatics of nurses as workforce and the complementarity in our sense of community.
evolution of thinking about the nature of nurs- This calls for a fresh look at temporality be-
ing knowledge: a practice discipline that con- yond causality, at responsibility and ethics. We
veys our ethical foundation. see the efforts to develop a nursing discipline
In the mid 1970s, from their study of the resonating within the movement. In this sec-
theoretical frameworks for nursing curricula, tion, we refer to a selective range of authors
Torres and Yura13 identified 4 major concepts: to point to some features of a participatory
person, society, health, and nursing. With paradigm we believe are important for the ar-
some variations, these have been recognized ticulation of nursing as a practice discipline.
as the key elements of the discipline.14 As
a member of the theorist group writing at
the later end of that era, Margaret Newman15 Worldview in nursing
took a retrospective look at the trajectory of In retrospect, we can see the emergence
their emergence. She traced them as a se- of a participatory paradigm in the nursing
quential refocusing of theory development academy unfolding through the last half
to maintain the social relevance of nursing century. The theorists looked to the great
scholarship: What the theorist chose to ex- philosophers, sages, and popularizers of con-
amine reflected the needs of that particular temporary thought about our human world to
time.15(p29) She construed the trajectory as articulate an ontology of contemporary
A Practice Discipline Thats Here and Now 83

relevance for nursing, albeit mostly viewed this means for health in relation to service
through the lens of other disciplines. It was design and delivery has had little attention.
inevitable that, for a time, methodologies of Moreover, as forms of knowledge the nurse
the respective disciplines and their schools brings to what she ought to do,the theories
of thought framed the knowledge such that remain as tentative paradigms, coexisting, if
knowledge was abstract to be applied by not competing, in pockets. Their significance
nurses. The theories were used and tested, for the employing organizations mission is
mostly confirmed as guides for nurses. subtle and fragile. As the workforce, nurses
The ontologies published as grand theo- are employed to work in a causal paradigm
ries each brought coherence to knowledge in where knowledge is productthe evidence
their own frameworks. But the theorists and for discrete interventions. Activities expected
the practitioners inhabited different worlds of of nurses are rooted in the mission of the or-
scholarship. Each theory, named to empha- ganization. They continue to be subject to
size difference, had its own language for nurs- the service boundaries, resources, and condi-
ing knowledge, its own premises to frame re- tions that support healthcare within the hege-
search process and findings, and thus each at- monic medical cure and control paradigm.
tracted its own community of scholars. A frag- The vacuum for the practice discipline of
mented discipline has been no match for the nursing seeks a further turn in a participa-
coherence of medicine to inform health sec- tory paradigm to move further into the re-
tor change. lational nature of nursingbeyond packages
As a second generation from Martha of interventionsto bring the coherence of a
Rogers articulation of a unique discipline practice.
in her nursing science of unitary human Meanwhile, others have been taking an
beings, some theories haveseparately epistemological approach. Benner20 held her
intensified an orientation to the engagement focus on the activities of nurses in their
of the nurse with patients/clients. They give workplaces. She emphasized the embodied
it significance according to the particular the- moral agency of nurses in caringsocially
ory. For example, knowledge is represented embeddedand its expression in their ex-
by Parse16 as cocreated and presented in panding capability to practice knowledge-
the language of human becoming and by ably. The participatory nature of a practice is
Newman17 as life patterns recognised clear in the depiction of embodied interde-
through the intersubjectivity of nurse and pendence of nurse with patients/clients, as
patient/client and depicted as the expansion well as in practitioner communities. Doane
of consciousness of each. Newman framed and Varcoe emphasized the inventiveness of
her theory as praxis where the form that nurses to create and recreate their knowing
nursing research takes is the form of prac- in each moment of practice.11(p89)
tice18(p100) to point to knowledge asand The detour of nursing scholarship through
ofa process through which a transformative other disciplines and the separate theoreti-
change in all participating activities can be cal and pragmatist approaches emerging from
achieved. Hence, nurses have been viewed as it have been important in our consciousness
increasingly knowledgeable as engaged prac- of different paradigms of knowledge in nurs-
titioners, even if their methods and health ing. But although all the leaders of the fac-
ends have been differently construed by each tions emphasize the importance of communi-
theory. ties of scholars, trying to move between them
The theories importantly drew attention to question and articulate the nature of nurs-
to the nurse-patient function, making a dif- ing practice is fraught with misunderstanding.
ference to the experience of people when The ontological and epistemological efforts to
they are patients/clients, as well as nurses, date call forth new thinking for an inclusive
impacting on their lives.19 However, what nursing community.
84 ADVANCES IN NURSING SCIENCE/JANUARYMARCH 2008

We (authors) have been searching along- tools, and observation determine our real-
side many others for ways of developing the ity. David Bohm, US/British physicist-turned-
discipline of nursing both for and in prac- philosopher, said: World viewsits really
tice, such as Boyd,21 Connor,22 Doane and a self-world-view because it includes your-
Varcoe,11 Picard and Jones,19 Reed,4 and Roy self.27(p25)
and Jones.23 Now, as part of this movement, In biology, Chilean biologists Maturana and
we take our stand in a participative paradigm Varela28 pioneered a science of cognition,
to look beyond the divisions, while still pre- coining the term autopoiesisto convey their
serving diversity in how practitioners con- observations of a dynamic interrelationship of
tribute to health in the various places and part and whole in cellular systems. They write
times of healthcare provision. their insight as: We live our field of vision . . .
we cannot separate our history of actions
biological and socialfrom how this world
A shifting worldview appears to us.28(p23) Furthermore, it is rela-
A broad scan of literature reveals a general tional: We have only the world that we bring
shift well underway in Western societies in forth with others, and only love helps us bring
the way we understand our human condition. it forth.28(p248)
We refer to some authors to point to features Lynn Margulis, an evolutionary biologist
of a participatory paradigm that we believe from Massachusetts, writing with Dorian
are of greatest significance for the dialogue in Sagan,29 argued the inadequacy of the hege-
nursing. In particular, we see the significance monic reductionism of evolutionary theory af-
lies in how we situate ourselves in the world ter Darwin, where knowledge is framed as
we seek to understand. We are exploring linear and competitive. From another world-
the meaning this lens brings to nursing as a view, she reinterpreted observations and
discipline. drew on recent genome studies to depict evo-
Theological scholars2426 have written lution as integrative. Conveyed in the term
about a period of transition in human culture symbiogenesis, the origins of species, hu-
over the past centuries from the transethnic mans included, are explained as ecological in-
world of the great religions to this point of terrelationships at the cellular level; complex-
emergence of a global secular world in which ity increases through cooperation and new
we understand ourselves as coparticipants forms of community emerge. This realization
in the creation of lives in our shared places led the duo to address the big human question
and time, with responsibility for it. Geering What is life? to which they answer (in part)
writes: We humans are slowly coming to a question the universe poses to itself in the
realise that what each of us inhabits is a form of a human being . . . we are only a single
world of meaning, which we ourselves have theme of the orchestrated lifeform . . . our life
put together.26(p5) Cupitt25 writes about is embedded . . . in the rest of Earths sentient
be-ingto refer to our here-and-now evolving symphony (emphasis added).30(p199)
communal world. All these authors use the M. C. Escher, living and working in west-
term secular to mean attention to this world ern Europe, creatively depicted the participa-
of diverse beliefs and values of the sacred. tory thinking in 1956. Choosing to call him-
Insights from discoveries in the physi- self an artisana graphic artist with heart
cal sciences have led scientistsand many and soul,31(p8) he explored the human capa-
popularizersto write about a shift to a bility of representing 3-dimensional reality in
paradigm in which observer and observed, 2-dimensional drawings. A drawing called
knower and known, merge. Schrodingers cat Print Gallery shows a man in a gallery look-
story of the 1930s has been cited repeatedly ing at a picture in which his looking at the
to popularize the revelations from quantum picture is an integral part. He described it:
physicists: the interrelationship of observer, . . .we come to the logical conclusion that the
A Practice Discipline Thats Here and Now 85

young man himself also must be part of the entwined . . . our experience of this field is al-
print he is looking at. He actually sees himself ways relative to our situation in it.33(p40)
as a detail of the picture; reality and image are The participatory thinking has also been
one and the same.31(p67) emerging in the writing about the general or-
Historically, tracing ideas of science, theol- ganization of societies and workplaces. The
ogy, and philosophies, Skolimowski, of Polish participatory theme has been integral to the
origin, addressed directly the new order of womens movement. It shows in Wheeler
reality as the participatory mind: We are and Chinns34 reframing of group process
woven into the universe we explore.32(p88) as community represented by the acronym
The world we experience as complex con- PEACE: Praxis, Empowerment, Awareness,
tinuously evokes our efforts to simplify: The Consensus, Evolvement. Also in Margaret
patterns and configurations of the world are Wheatleys35 explanation of transformational
not there independently of mind, but are the leadership for the management of organiza-
patterns of our knowledge through which tions, linking directly to the participative na-
our minds work.32(p88) Furthermore, the ture of the universe emerging from quan-
power of creation is the power of articula- tum physics. Danah Zohars experience in
tion.32(p14) A participatory worldview is a childbirth led her to become a popularizer
new understanding of ontology and episte- of the new physics revelations with a par-
mology. The meanings of these terms require ticipatory interpretation. With psychiatrist/
us to consider them together: they elicit psychotherapist Ian Marshall, she is now
from each other what they assume in each reaching into the business worlds and cor-
other.32(p76) Knowledge is in process as com- porate culture, elaborating the relational
prehension, and to know is to constitute the theme of changing ourselves to change the
world.32(p81) world.36
A proactive ecological philosopher born In these selected but wide-ranging writ-
and based in the United States, Abram33 also ings, we can see a participatory shift. All au-
draws on great philosophical writing along thors noted the inadequacy now of our for-
with varied depictions of the worlds of indige- mer views of knowledge of past eras. These
nous oral peoples and his own experience as views have increasingly obscured the human-
a sleight-of-hand magician performing as part ness of living our livesexperience, spiritu-
of everyday life in many countries. He con- ality, sentience, and mystery. But this partic-
veys the participatory thinking inherent in the ipatory view does not negate previous ways
interrelatedness of human cognition and the of thinking, nor even transcends them. Every-
natural world. Always, he says, there is an ac- thing just looks different. Cupitt25 uses the
tive interplay between the perceiving body terms contingency, immanence, and out-
and that which it perceives: We always re- sidelessness to refer to our humanness.
tain the ability to alter or suspend any par- All authors bring coherence to their reason-
ticular instance of participation. Yet we can ing with reference to community and love.
never suspend the flux of participation it- We are participants in a creative world in the
self.33(p59) We are immersed in a sensuous moment, constantly evolving as participants
world. We make sense of this world humanly in it and together making sense of it in our
through our language: The human mind is own particular ways. Our spirituality is our
not some otherworldly essence that comes to interrelationship, as participants, in the sen-
house itself inside our physiology. Rather, it is suousness and communion of our living uni-
instilled and provoked by the sensorial field verse. We seek to understand, see patterns,
itself, induced by the tensions and participa- find order, and theorize, knowing we are our-
tions between the human body and the ani- selves inside what we write about. Temporal-
mate earth.33(p262) The common field of our ity moves beyond the linear; we live and act
lives and the other lives with which ours are in the here and now: always in the middle
86 ADVANCES IN NURSING SCIENCE/JANUARYMARCH 2008

of things, Cupitt says. 25(p64) The meaning tionary transition in worldview emerging at
of the past-future is unfolding and enfolding this historical moment.38(p1) In their intro-
in the moment of holomovement, Bohm27 duction, they too trace the roots historically
says. Hence we are brought to the realisation from the reinvention of humanism in the
of our vulnerability and our responsibility in 1950s through the cognitive and linguistic
action. turns of the postmodern era that alerted us
Expressing these features, a participatory to the relationship between power and lan-
worldview has language at its core. Geering guage, and so to the participatory worldview
explains language as evolving meaning, Lan- of today that draws on and takes us into
guage is the collective product of the powers a socially constructed world. They connect
of human imagination and creativity, where to Bohm, Abram, and Skolimowski among
words to syntax to stories construe our cul- many other contemporary sages to elaborate
tural heritage, such that by means of sto- an action science that continually enquires
ries we create the world we live in.26(p18,41) into the meaning and purpose of our prac-
Abram views language as evolving from and tice,38(p7) relational and concerned with the
expressing the participatory nature of the uni- betterment of the world and life in it. We at-
verse: The sensuous, perceptual life-world, tend to what we have come to know through
whose wild, participatory logic ramifies and an instrumental paradigm to draw on tech-
elaborates itself in language . . . a vast, living niques and knowledge of positivist science
fabric continually being woven by those who and to frame these within a human con-
speak.33(pp8384) Bohms27 physics led him to text.38(p7) They too emphasize the linguistic
focus his thinking about language on the dia- nature of things: As soon as we attempt to ar-
logic nature of our human world of unfolding ticulate (real reality) we enter a world of hu-
meaning where meaning is active, making man language and cultural expression.38(p7)
sense of things; culture construes language, They talk of knowledge as a verb rather than
and dialogue is a form of social meditation a noun in dialogue evoking attention to the
unfolding among us in what we attend to. ethical and political. Knowledge is a living,
In the academy of social sciences, John evolving process of coming to know rooted
Heron and Peter Reason37 have been elaborat- in everyday experience.38(p2) In their view,
ing their earlier work on cooperative enquiry inquiry is about the healing of the splits and
and action research, and now articulate alienation in contemporary experience.
their methods as expression of a participa- Our consciousness of the trend in thought
tory paradigm. They describe a participative about the nature of human knowledge has
paradigm: the minds conceptual articulation given us (authors) a new lens on the discipline
of the world is grounded in its experiential to see how the once-separated discipline and
participation in what is present, in what activities of nurses are one as process. After
there is.37(p277) Critical subjectivity extends Reason and Bradbury38 and Geering,26 let us
to critical intersubjectivity. To elaborate the consider the discipline of nursing as a verb
participatory nature of knowledge, they inviting the syntax to express culture and sto-
added axiology to ontology, epistemology, ries that convey nuances; it is the process of
and methodology. Axiology makes explicit practice in context and informed in dialogue.
the ethics of knowledge development in Dialogue brings nursing theoretical insights
the question: What sort of knowledge is in- and the schools of knowledge into the com-
trinsically valuable in human life?37(p277) plexity of healthcare provision.11 In nursing
Ethics is now inherent in the whole communities, our attention is drawn to the
process. language, texts, and discourses that have con-
Reason and Bradbury present their edited fused and divided us and alienated many. Our
book on participatory inquiry and practice professional responsibility is to participate in
as part of what they describe as the revolu- open, inclusive dialogue.
A Practice Discipline Thats Here and Now 87

But this meaning of discipline begs a focus social relevance of our research efforts. In a
that orients practice to the social relevance phrase, the concepts of caring and health had
of nursing: a nursing take on the common more meaning for nursing than when consid-
good to draw us into dialogue. Reason and ered separately; there is deeper meaning in
Bradbury stated their moral purpose for in- expression of culture and history.
quiry, using terms appropriated from the lit- As students, our (authors) beginning re-
erature through the ages: The flourishing of search was underway at this time. We ex-
life, the life of human persons, of human com- plored what the focus statement might mean
munities, and increasingly of the more-than- as we studied the nature of practice. This led
human world of which we are a part.38(p10) to the explication of a research-as-if-practice
We can agree with this too, but want a fo- process.4144 But separateness still bothered
cus that enables us to participate in a nursing us; a researcher is not a practitioner in the
community about nursing practice. For this, sense of having a work role and status within
we have looked to our disciplines history. the health service organization. We must be
able to state the social relevance of our prac-
THE FOCUS OF THE DISCIPLINE tice, given our paradigm of a participatory,
always-evolving-in-the-moment idea of knowl-
Each theorist proposed a focus for edge. It must have meaning for the practice
nursingthe theoryas she or he had con- of all other nurses and for health service and
ceptualized it. For other scholars it has been policy trends.
implicit. Also, there have been many threads In retrospect, we can see the 1991 focus
of nurses work and roles developing world- statement representing its era and cultural
wide, in health systems without a specifically context. The relational caring/experiential as-
nursing purpose. We see the elaboration of pect of nursing was growing as a counter-
advanced practice nursing happening within balance to the expanding challenges of tech-
specialty fields and practices, the focus nological advances and fiscally driven health
closely aligned with medical science con- service reforms. We can see the strong in-
cerning assessment-diagnosis-prescription or fluence of phenomenology, grounded theory,
defined by the mission of employing orga- and hermeneutics on nurses studies of the
nizations. As educators, we have observed lived experience of people as patients and
students searching for a nursing purpose to clients. Hence, the focus on experience priv-
anchor their theses, often reaching into other ileges these methodologies and their parent
disciplines for ideas of social relevance. disciplinesprimary attention to individuals.
Newman with Sime and Corcoran-Perry,39 Although, it acknowledges the moral rela-
in describing their framework of 3 research tional core, the phrase separates what is im-
paradigms, recognized the need for a focus portantto be attended to from the action that
statement to convey the social mandate of addresses it. It is difficult to see how it fo-
nursing. Noting the predominance of caring cuses knowledge development for much of
and health as integrative concepts in the nurs- the work of nurses in established roles and ca-
ing literature, they proposed the phrase car- reer pathways.
ing in the human health experience. New- Through our research projects in our re-
man explained: Caring designates the nature spective countries and writing together to ex-
of the nursing practice participation . . . the plore the nature of nursing practice in con-
experiential dimension characterizes the phe- text, we have sought a broader statement: a
nomenon (of human health) as something be- cohesive statement that is more inclusive of
yond the traditional objective-subjective per- the different forms of knowledge, and that re-
spective.40(p48) The phrase as a whole was solves the current splitting of the relational
the focus of the discipline. This statement has and the technical. For this, we have turned
been important in drawing attention to the our attention now to humanness.
88 ADVANCES IN NURSING SCIENCE/JANUARYMARCH 2008

This tunes us into the 1991 focus cipline. It has opened our thinking not only
statement39 and recent writing such as to an alternative form of nursing practice
the Consensus Statement on Emerging but also to the form of leadership through
Nursing Knowledge orchestrated by the which policy, service development, and man-
Boston Group.24 But, in replacing the action agement can be constructed to support the
concept (caring), we are opening to all healthcare provided by all nurses, whatever
paradigms of action, whatever the nature of the paradigms for their activities. We can
change and whatever part the nurse plays think now of an integrative people-pivotal
in change. Furthermore, while we (authors) paradigm for healthcare provision.45 The fol-
agree that attention to peoples experience lowing is a glimpse of our growing conscious-
is vital in nursing, we are now lifting our ness of the significance of nursing practice for
sights to more broadly attend to the health healthcare and possibilities for action. In this
circumstance. For us, the discipline focus is we are not proving or demonstrating our
the humanness of the health circumstance. thesis, we just want to illustrate a way of see-
With this focus, we look beyond the sep- ing and talking about nursing in context.
arateness of human beings as nurse and pa- Importantly, our research starting point
tient in engagements, to being human what- was the process of practice. We knew that
ever the health predicament, whoever is to explore the relational nature of nursing
implicated in it, and however located in time we had to be practicing. We awoke to a gen-
and place. It contrasts with, but is essentially eral trend in thinking about our humanness
complementary to, the medical discipline fo- and connected into the discourses referring
cus on the incidence of disease, differential di- to a participatory paradigm.4144 Initially
agnosis, and treatment to date framed within undertaken according to academic require-
a deterministic paradigm. ments, the research was not integral to the
The phrase expresses social relevance. The sanctioned, pressured yet seductive health
public looks to nurses for a human face in the service design, workforce, and professional
technically and fiscally oriented world; our structures. But it was as if practice; it was
understanding of health circumstance is what as close to the reality of practice as possible
enables us to advocate the humanness of peo- without being swallowed into the system.
ples experience in the strategizing for ser- The process we described was of partner-
vice development and in community devel- ship with people as patients/client (consid-
opment. It gives a common focus to research ered as collective) such that, through our
framed within the extant theoretical orien- conversations extending in time (multiple
tations, research addressing the practicalities meetings), we made sense of what was hap-
of specific activities expected of nurses, and pening for them. Holding the humanness of
research on issues of workforce and service the circumstance as our orientation, every-
management. It calls forth the examination of thing happening and talked about, place and
the ethics of nursing. time, had relevance, as far as our minds al-
lowed us: outsideless.25 There was insight
into how the predicament had come about
IN ACTION and what it meant in life ahead for family,
work, and play; meaning was actualized in
The lens of a participatory paradigm makes the statements of action that each could, and
everything look different: practice, research, would, take in the moment. In action, peo-
management, eduction, service design, and ple as families and groups with really com-
policy development. Our understanding of plex health circumstances managed tangled
the paradigm has evolved through our re- difficult times,44 accessed services discern-
search endeavors, as we sought to address ingly, made the best of healthcare available
the vacuum for a contextualized practice dis- conscious of scarce resources, and addressed
A Practice Discipline Thats Here and Now 89

health matters that would have implications practice, personally and culturally expressive
for later years or for following generations.45 and responsive within health service environ-
The insights alerted us in our practitioner ments. It was intense work, but it evoked new
role to our responsibilities around the per- vitality in its creativity and was deeply appre-
sonal predicament as well as community life, ciated by all participants. One nurse said, she
collaboration among healthcare workers to had come home to nursing.46
orchestrate healthcare, health service man- Research, practice, service development,
agement, and policy development. Hence, management, and education began to col-
action was more than a set of activities, it lapse into the dialogic process, with the
was coherence in action around whatever patient/client and nurse partnership being
was needed for everyone to get on with pivotal.45 Healthcare can become a dynamic
life as patients/clients, family and commu- collaborative endeavor. Now the new prac-
nity members, citizens, and as nurses in tice role is influencing reconfiguration in ser-
their professional world. It includedbut not vice delivery, integrative in the traditional silo
necessarilythe conventions of healthcare. structure of primary, secondary, and tertiary
Knowledge was participatory in process for sectors and specialist divisions. In a partici-
all; it was practice wisdom. As researchers, we patory paradigm, nursing practice is collec-
developed narratives that presented the hu- tive. Nurses work in different paradigms, their
manness of the health circumstance and these activities given coherence in the core dia-
were used for influence in the various forums logue centered on and reaching out from part-
where policy and funding decisions are made. nerships with patients/clients. Professional
Our interest turned to nurse roles, new forums are essential where the ethics of prac-
and traditional, and how they might be tice can take form for each nurse and stan-
complementary in contributing to the ex- dards continually examined. There is more
pected health outcomes of contracted work to be done.
services and the organizations mission. Hence, with this eversion in healthcare
Projects were funded as practice and service provision, discipline development is in prac-
innovation.44,45 Education looked different; tice, leadership comes from practice, and
roles of teacher and learner had changed. As attention primarily focused on the human-
educators-researchers, we took one step back ness of the health circumstance. Service mod-
from the practitioner roleto mentorship els are shaped by and around practice. The
with practitioners. Learning was integral to roundtable forums expand and contract to
the dialogue of practice; roundtable forums dynamically address the current issues and
were the medium. challenges. They take account of the diver-
As mentors-researchers, we came with our sity of community life, other healthcare work-
novice experience. We could see in our par- ers, service and policy developers, funders,
ticipation the expression of our own respec- health economists, and politicians. It is not
tive culturally and historically grounded edu- all easy and smooth but the possibilities are
cation and wise mentorship from our earlier open. There is even more work to be done.
professional lives that had shaped our values,
viewpoints, as well as hang-ups. The prac-
titioners took their own lead in developing CONCLUSION
their practice in relation to each other. To-
gether, we challenged our different languages, This discussion is intended as a contri-
constantly reexamining viewpoints as a pro- bution to the dialogue around the disci-
cess of theorizing, each with our own take pline, not a proposal of how to or theory.
on the task to articulate practice, what it The separation of knowledge development
achieves, and the service model to support in the academy from the activities of nurses-
it. There was work to be done to create a as-workforce has created a vacuum for a
90 ADVANCES IN NURSING SCIENCE/JANUARYMARCH 2008

practice discipline that would enable nurses cial relevance today. Turning our focus to the
to articulate the significance of nursing, so humanness of the health circumstance, our re-
essential in contemporary healthcare provi- search has brought us to an understanding of
sion. We have tuned into the trend in thought the discipline as relational and evolving in the
around the human condition represented in process of nursing practice in context. The
the emergence of a participatory paradigm, discipline is here and now, alive and creative
and explored its meaning for nursing in the in forums for dialogue. Each one of us has re-
context of health service delivery, to have so- sponsibility in participation.

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