This paper examines the four central metaparadigm concepts of nursing — person, environment, health, and nursing — and explores how they underpin two influential practice-specific theories. Jean Watson's Philosophy and Science of Caring, with its ten clinical caritas processes, is analyzed alongside Madeleine Leininger's Cultural Diversity and Universality Theory and its three modes of culturally congruent care. The paper draws on Masters (2012) and Ondrejka and Barnard (2011) to demonstrate how both theorists, despite differing conceptualizations, converge on the importance of patient-centered, culturally competent practice. A set of five propositions connecting these concepts is also presented.
Since Florence Nightingale, a number of so-called grand theories of nursing have been advanced. These grand theories have been used by subsequent nursing theorists to conceptualize metaparadigms of practice that continue to influence clinical care today. The central concepts of nursing — person, nursing, environment, and health — have formed the basis for theorists such as Jean Watson, whose Philosophy and Science of Caring, and Madeleine Leininger, whose Cultural Diversity and Universality Theory, remain highly influential. This paper provides a review of the relevant literature concerning these issues, followed by a summary of key findings regarding nursing metaparadigms and practice-specific concepts.
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, addressed in a fashion that is unique to that discipline (Masters, 2012). There is some abstraction inherent in metaparadigms that transcends 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 metaparadigm concepts of nursing differ, but all four concepts are components of each model (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 metaparadigm is unique depending on the discipline involved, with respect to nursing, Masters specifies that these four concepts are: "the person receiving the nursing, the environment within which the person exists, 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, however, that even the most thoughtful formal model of care based on the four paradigms is not an endpoint in the development of professional standards of care. 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). The pressing need for patient-centered and evidence-based practice is made evident in the two practice-specific concepts discussed below.
Jean 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 attaining this goal makes it possible to potentiate healing and health (see Table 1 below). In order to achieve this goal, nurses employ transpersonal care guided by carative factors and associated caritas processes. Watson's theory for nursing practice is founded on ten 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 ten caritas processes conceptualized by Watson are as follows:
1. Practice of loving kindness and equanimity for oneself and others.
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 — a subtle environment of energy and consciousness whereby wholeness, beauty, comfort, dignity, and peace are potentiated.
9. Assisting with basic needs with an intentional caring consciousness; administering human care essentials that 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, and suffering; "allowing for a miracle" (Masters, 2012, pp. 52–53).
Watson describes the underlying clinical caritas processes as being the "core" of nursing, grounded in the art of caring as well as in philosophy and science (Masters, 2012). An interesting aspect of Watson's theory is her distinction between this core and so-called "trim," which describes 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 as defined in Watson's Philosophy and Science of Caring are presented in Table 1 below.
Table 1: Metaparadigm Concepts as Defined in Watson's Philosophy and Science of Caring
Person (human): Watson uses this term to describe a unity of mind-body-spirit/nature; an embodied spirit.
Nursing: A reciprocal transpersonal relationship in caring moments guided by carative factors and caritas 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 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 is Madeleine Leininger and her Cultural Diversity and Universality Theory. The primary features of this theory are as follows: transcultural nursing is a substantive area of study and practice focused on comparative cultural care 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 (Masters, 2012, p. 58).
The metaparadigm concepts as defined by Leininger specifically include 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
Person: A human being, family, group, community, or institution.
Nursing: Activities directed toward assisting, supporting, or enabling people with needs in ways that are congruent with their cultural values, beliefs, and lifeways.
"Three modalities for culturally congruent nursing care"
"Five assumptions linking metaparadigm concepts"
The research showed that a metaparadigm is the widest perspective available to a discipline for shaping and guiding real-world practice. The metaparadigm serves as an overall framework within which more elaborate structures develop. The research also showed that the central concepts of the nursing discipline are person, environment, health, and nursing. Two nursing theorists who developed models of care based on these metaparadigms are Jean Watson, with her Philosophy and Science of Caring, and Madeleine Leininger, with her Cultural Diversity and Universality Theory. Although these theorists differed with respect to their conceptualization of each central concept, they both agreed that patient-centered practice is an essential ingredient in informed nursing care.
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