The purpose of this assignment is to identify and explore one of Jacqueline Fawcett’s (1984) metapardigm concepts of nursing that she identifies as being concepts central to nursing and explore how this is expressed in Judith Christensen’s (1990) Nursing Partnership Model. The following discussion seeks to analyse the metaparadigm concept of ‘person’ according to Christensen (1990).
To facilitate this, it is important to discover what is meant by metaparadigm and to further explore what a conceptual model is. This will lead to a better understanding of what Fawcett means by the four metaparadigm concepts of nursing.
Within the development of nursing theories, there is recognition of common themes and concepts. A concept of a subject is related to the way it is viewed and can be a way of classifying a theme when applied to a particular area (Pearson, Vaughan & Fitzgerald, 1997). Fawcett (1984) identifies the four main concepts or themes central to nursing as including; health, environment, person and nurse. These four concepts, the recurring themes and the inter-relationships between them are described as nursing’s metaparadigm.
Metaparadigm is the combination of two words, meta and paradigm. According to Mosby’s (1994) definition, Meta, can mean either “after or next” or “change or exchange.” Mosby’s (1994) defines Paradigm as “a pattern that may serve as a model or example. Chin & Jacobs (1987) identify paradigm as, a generally accepted world view or philosophy, a framework or structure within which theories of the discipline are organized. According to Fawcett (1984), “a metaparadigm of a discipline is a group of statements identifying its phenomena in a global rather than specific way.
” Metaparadigm is “the most global perspective of a discipline and acts as an encapsulating unit or framework, within which the more restrictive structures work” (Fawcett, 1984, p.5).
A conceptual model focuses on the main points of relevance whilst ruling others to be less important within the metaparadigm. A conceptual model has a set of concepts and statements that allow integration of them into a meaningful configuration. Mosby’s (1994, p.273) description of conceptual model (framework) as, “a group of concepts that are broadly defined and systematically organised to provide focus, rationale and a tool for the integration and interpretation of information.”
In seeking to clarify the meaning and what is meant by the four metaparadigms, Fawcett (1984) describes the ‘health’ concept as the relationship of a person’s degree of illness or wellness. The concept of ‘environment’ is and includes the surroundings or context the person moves in and interacts with e.g. home, work, roles, socio-economic status and the pattern of the person’s life in relation to these things. The concept of ‘person’ is any identity that receives health care, and may include an individual, a family (whanau) or a community (hapu or iwi). Lastly, the concept of ‘nursing’ is the giver or provider of health care and the activities the nurse undertakes that enables this giving to occur. This may include an individual or a system (Fawcett, 1984).
‘Person’ -the work of the patient.
Normal life for a person encompasses the ability to accomplish a wide range of activities, including those activities of daily living such as for caring for ones own personal needs, activities that allow social interaction and other activities which enable the person to live and grow (Pearson et al. 1997). If however, when a person becomes hospitalised and the hospital in turn becomes the person’s home, the person needs to relinquish roles and norms and put themselves in the care of hospital staff. The person leaves their familiar surroundings and subsequently withdraws from the full expression of the person’s usual social roles (Christensen, 1990).
The Beginning phase:
In reaching the point where the person finally reaches the decision to become dependent on a medical expert can be a lengthy and stressful process. Illness is not seen to begin merely when the person encounters a health professional, rather therein lies a significant period of decision making and self directed treatment in an effort by the person to control the illness, bring about symptomatic relief and leading to self healing (Morse & Johnson, 1991). The person may have lived with a period of suffering from ill health for some time because it may not have appeared to be life threatening and one just ‘coped’ with the symptoms.
Christensen (1990, p.50) quotes an example of a person with a history of childhood urinary tract infections. “I just get bad kidney infections -you know -I can hardly walk…I just know when it’s coming and when it’s gone…I used to go to the Dr. all the time…feed me some more rubbish -antibiotics and stuff…” Reaching the point were the person initiates medical help might be something they have considered and deliberated over for some time, because they known that something ‘just isn’t quite right,’ but might have put off due to a fear of the unknown.
When the person decides to engage in some form of intervention, the person becomes busy putting their life of normality on hold. They reach a point where they believe the right decision has been reached and they are ready to hand themselves over to the health experts. The person continually recounts and relays each new experience to others. This may include, friends, family or other people who are sharing similar experiences. Such information is shared many times with added information shaping and retesting issues as further information is discussed with the health care professionals. By the time the hospital admission takes place, the person has shared and thus interpreted their experience (Christensen, 1990). This does not mean that a person undergoing hospitalisation suffers no anxiety even when that person has become prepared for the event.
Taylor, Lillis & LeMone (1993), found that even from the point of admission into a health care setting, the individual experiences a range of emotions including, anxiety, confusion and concern related to unmet and unfulfilled role obligations left behind.
Settling In phase:
It takes courage and strength to trust another, for the patient this trust is often placed in a stranger, this can be a trying experience and can jeopardise emotional security. While the person may have met their doctor before, it is still a burden to place such trust in someone else’s hands. Emotional stability, trust and security are desirable and need to be met for the person’s admission into the health care setting (Taylor et al. 1993). Assisting the person to understand and identify ward routine can positively influence this. Christensen (1990, p.66) quotes a patient’s response after having been shown round a ward. “I’m finding it much easier.
I know what’s sort of going to happen…I think knowing what the routine was is quite helpful.” It becomes necessary for the person to reveal significant information of a personal nature to members of the health care team. Such disclosure becomes an accepted norm even though this may occur between the person and many strangers numerous times each day. Being able to shed privacy and attend to personal activities in front of others and submitting to intrusion, shows that the person acknowledges the legitimacy of health care workers (Christensen, 1990). The partnership developed between the person and nurse further compounds this, creating a feeling of goodwill and concern for one another (Christensen, 1990).
Negotiating the Nursing Partnership phase:
The person now looks for techniques that establish a sense of control and ensure inclusion in what is going on. The person now reaches a point whereby there is sense of trust and acquiescence, however the person may attempt to give legitimacy to the situation by trying to overcome inhibitions or lack of control by taking personal responsibility for the outcome of the intervention (Christensen, 1990). In doing so, the person becomes part of the health care team.
The person accepts submission to necessary rules and procedures of the health care environment, but it is not always passive. Christensen (1990, p.87) highlights this by quoting one of several patients. “My priorities are to make sure I do my bit to make sure this works out because the surgeon has done his bit and the nurse can put drops in. I think the main thing is my own action -not being stupid over the thing, not bending down or jerking…”
The person is required to meet many different health care workers. In doing so, the person attempts to co-operate and affiliate with these people while acquiescing to their expertise, fitting in and retaining autonomy (Christensen, 1990). Health professionals and the person must establish a partnership and involvement with one another needs to recognise multiple identities and these need to fit together and be complimentary (Beck, 1997).
However, “acquiescing may be associated with a sense of powerlessness in the presence of the expert person, particularly the surgeon.” (cited in Christensen, 1990 p.97). If a person has trust and confidence in that expert then submission is willingly given (Christensen, 1990). It could be said that the person is the real expert as they are the only one who really knows the role of the patient and context with which that experience occurs. The person has a life outside the health care setting that they will continue when they leave. The health care team in turn, will remain behind (Christensen, 2001, personal communication).
Even though a person enters into the health care setting, there can be no assumption that they are totally prepared or agreeable to intervention. New or conflicting information or coping with an unknown environment can raise doubts and that the former consent obtained was quite tenuous (Christensen, 1990). Christensen (1990, p.90) quotes one patient as saying “it came as bit of a surprise to me when I saw him hospital before the operation, the very day before, when he explained about this vision and that night I didn’t sleep to well. I thought about it quite a bit and thought am I doing the right thing?”
Additionally, communication between health care personnel and the person is of great importance, anxiety can result if there is a sense that information is being withheld. The person may adopt the ‘good patient role,’ which is then subsequently reinforced by staff (Curtis, 2000). The ‘good patient’ role is seen as being counter productive to a good recovery. If the person does not take an active role in their own care, it may lead the person to not report a change in symptoms (Curtis, 2000).
Patients may feel that by maintaining an outward sign of composure they will invoke a significant feeling of control. Endeavouring to maintain such composure underlies many behaviours of the hospitalised person, such as using humour in a frightening situation to mask nervousness (Christensen, 1990). Christensen (1990, p.92) quotes a number of patients with comments similar to the following that utilise humour. “Imagine operating all day! I certainly wouldn’t like to be at the end of the day if he was…’Oh, who’s this one? Arm? Leg?”
Additionally attending to such activities as personal grooming to the person’s usual standard can be another way of maintaining a sense of normality and composure (Christensen, 1990). Roy & Roberts (1981) theory of ‘the person as an adaptive system’ which puts forward the idea that each person is a system utilising adaptive behaviours to meet changing environmental needs by assuming coping mechanisms (cited in Fawcett, 1984, p.85).
Hardship of a temporary nature whilst the person negotiates the passage is an expectation and is generally accepted as part of the process (Christensen, 1990). Pain experienced within the health care setting is expected and tolerated, where as this might not be the case were such an event to occur within the persons home. Pitts & Phillips (1998) say there is little doubt that surgery will involve anticipation of pain for a person, due to the use of needles or knives, or other discomforts post operatively.
These things can cause stress but this combined with anxiety and coping maybe extremely hard for the patient even when expected (cited in Curtis, 2000, p.82). “if I sort of move it around, it can ache a bit. It’s got a suggestion of a little bit of stinging…certainly nothing uncomfortable that I can’t tolerate…” Christensen (1990, p.104)
Once the effects of surgery lessen, the person feels a sense of hope that all is well and the time of discharge is nearing. The person may start to feel that they are expert enough to assist in meeting the person’s needs. There is development of expertise and wisdom surrounding the person’s condition and this gives rise to being able to self-care in the future (Christensen, 1990).
Going Home phase:
Discharge from the health care setting does not always indicate a return to life as it was before admission. It maybe just a step on the road to recovery, with much work yet to be done (Christensen, 1990). A cardiac rehabilitation study by Joy Johnson (1988) identified some of the participants as “raring to go” but were mindful of the need to not “overdo it” and were aware that life would not be the same (cited in Morse & Johnson, 1991, p.43).
Travel arrangements, arranging plans for care, learning about self medication and understanding what to do and recognition of emergency signs and symptoms are all jobs the person must learn in preparation for discharge. Not all persons being discharged experience positive feelings; some negative reactions emerge when a person readies to go home (Christensen, 1990). “I think you feel as though you are in a different world. That world is going on outside and you’re in this one and it takes a little while to adjust…you miss it all…” Christensen (1990, p.152).
Solidified realisation that their own life may in fact be in their own hands can empower the person to plan, anticipate ahead improving their own outcome. Not withstanding the person is still under the influence of the health care professionals who have instructed them in ways to do this.
However, the person can decide for themselves just how much and for how long they will be compliant with the ‘doctors orders’ (Christensen, 1990). The final step is the resumption of autonomy and self-management for the person. “Torvan and Mogadon and aspirin -I was taking those and I thought it’s one of those that is giving me a headache so I’ve cut them off the last few nights.” Christensen (1990, p.155)
Fawcett (1984) identified four central themes of nursing which she described as nursing’s metaparadigm. Metaparadigm or generally regarded worldview of commonalities of nursing were identified as, including; health, environment, person and nurse. The discussion focused on Christensen’s (1990) Model of Partnership in relation to the concept of person. The reader has been taken through the persons work which has identified within it specific phases. These phases include acceptance of illness or disease, reaching a decision for action, coping with entering and passing through a period within the context of a health care setting, and finally resuming life as it was prior to the episode of contact, or life as it be following such contact.
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Beck, C. S. (1997). Partnership for Health -Building Relationships Between Women & Health Caregivers. Lawrence Erlbaum Associates, London.
Christensen, J. (1990). Partnership for Health -A Model for Nursing Practice.
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Curtis, A. J. (2000). Health Psychology.
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Fawcett, J. (1984). Analysis and Evaluation of Conceptual Models of Nursing.
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Fawcett, J. (1984). The Metaparadigm of Nursing: Present Status and Future Refinements.
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Morse, J. M. & Johnson, J. L. (1991). The Illness Experience -Dimensions of Suffering. Sage Publications, London.
Pearson, A. Vaughan, B. & Fitzgerald, M. (1996). Nursing models for practice. (2nd ed.). Butterworth-Heinemann, Oxford.
Taylor, C. Lillis, C. & LeMone, P. (1993). Fundamentals of Nursing -The Art and Science of Nursing Care. (2nd ed.). Mosby, Missouri.
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