Nursing Philosophy: Metaparadigms, Diversity, and Health Promotion

Nursing Autobiography

I began my career in healthcare as a patient care technician (PCT) in a large hospital. Working throughout the hospital as a float PCT, I gained experience with a diverse group of patients on every unit in the hospital. I eventually took a position in the ICU and stayed there for five years.

I enjoyed caring for patients and began taking classes toward my nursing degree. After completing the LPN program, my career in nursing became earnest and more focused by the day. Starting in a long-term skilled care rehab facility and a dialysis unit, I returned to the same hospital where I started as a PCT and worked there for seven years as a staff nurse and, later, an RN. Eventually I became team leader of the cardio unit and simultaneously completed my BSN.

Once I completed my BSN, I began working in home healthcare as a case manager for a community hospice facility. I worked in case management at a hospice and then as an ICU nurse and unit supervisor in a long-term acute care (LTAC) facility. I remained PRN for hospice for another year while I completed my orientation and training for my position at the LTAC facility.

The Four Metaparadigms of Nursing

I currently work for the LTAC facility, caring for critically ill patients in the ICU and supervising staff nurses and PCTs. I am now working toward an MSN in education, and my goal is to teach new nurses in the cardiac setting — preferably in the coronary ICU. My nursing career reflects the importance of the Dreyfus Skill Acquisition Model. Since my humble beginnings as a PCT, I now serve in a position of leadership and look forward to reaching a higher level of expertise in my career.

The four metaparadigms of nursing undergird and underpin "the entire conceptual universe of the nursing profession" (Johnson, n.d., p. 1). Useful for providing a framework for all personal nursing philosophies, the four metaparadigms include patient, nurse/nursing, health, and environment. These metaparadigms are broad and flexible enough to allow for their application and understanding within several core nursing rubrics, including community nursing. As Schim et al. (2007) point out, the metaparadigm model can also be expanded to include the "central concept of social justice," which is especially pertinent in urban nursing environments and similar settings requiring patient advocacy. The patient is reframed as a whole person, which is why the metaparadigm shifts the focus away from "patient" — a term that views the individual through the lens of illness or precipitating conditions. By viewing the individual as a whole person, the nurse is better able to provide quality care. Johnson (n.d.) points out that the person metaparadigm takes into account personal background, family, and community.

Just as the concept of "person" broadens the concept of the patient, the metaparadigm of health expands the locus of healing. Health is not defined in narrow terms, but is always understood within the framework of the person's worldview, values, goals, and beliefs. The nurse does not need to project "absolute" concepts of health; instead, the nurse works with the patient to cultivate a more personalized set of health-related goals and objectives that allow for cultural and personal specificity (Johnson, n.d.).

The metaparadigm of environment likewise expands the range of issues at stake in patient wellness. Everything from religion to addiction can be considered part of the person's environment (Johnson, n.d.). By taking into account a wide variety of variables that impact well-being, the nurse is in a better position to inspire change and healing. Finally, nursing itself is a core metaparadigm strongly linked to theories such as caring. The provision of care through evidence-based practice, combined with compassionate attitudes and behaviors, comprises the core duties of the nurse.

Two practice-specific concepts worth focusing on are diversity and health promotion. Diversity refers to cultural diversity, but also to a diversity of worldviews — especially those related to health and healing. Diversity issues can be best understood in light of Leininger's Transcultural Nursing Theory. The foundation of transcultural nursing is the universality of culture as the "broadest, most comprehensive, holistic, and universal feature of human beings and care" (Leininger & McFarland, 2006, p. 3). According to Leininger and McFarland (2006), the goal of transcultural nursing is to actively seek knowledge and information that can enhance the cultural relevance of healthcare. Until fairly recently, cultural knowledge remained "largely unknown" and discredited among healthcare workers (Leininger, 2002). Ignorance of diversity detracts from patient care and can lead to unsafe incongruences between care delivery and patient needs, expectations, and goals. Leininger (1988) therefore recognized culture as the "missing link in nursing knowledge and practice" (p. 152). When working in a diverse setting, nurses can work with their colleagues to promote cultural competency. Transcultural Nursing Theory can enhance the productivity and harmoniousness of the workplace environment, as well as improve patient outcomes (Leininger, 2002). Moreover, diversity in nursing promotes holistic care that converges with the four-pronged nursing metaparadigm by taking into account person, environment, health, and nursing care. The person is reconsidered in terms of culture, which also impacts environmental factors, attitudes toward health, and receptiveness to care.

Two Practice-Specific Concepts

The health promotion model was proposed by Nola Pender and offers a nuanced and complex method of viewing health-related behaviors and decision-making. The model comprises three main areas: individual characteristics, cognitions, and behavioral outcomes. Health promotion is a holistic concept that coincides with all four of the nursing metaparadigms: person, health, environment, and nurse/nursing. One of the underlying assumptions of health promotion is that persons "seek to create conditions of living through which they can express their unique human health potential" (Pender, 2011, p. 5). Research on adolescent populations shows that as young people develop personal responsibility for healthcare, health promotion theory becomes especially relevant for understanding the social and cognitive factors influencing health-related behaviors (Srof & Velsor-Friedrich, 2006). Families, peers, and healthcare providers become sources of influence in the adolescent's life, and these influences may "increase or decrease commitment to and engagement in health-promoting behavior" (Pender, 2011, p. 5).

Social learning takes place throughout adulthood, as well as childhood and adolescence. The nurse can play a critical role in inspiring patient self-efficacy, which is strongly correlated with positive health outcomes (Pender, 2011). Nursing actions can strongly influence health-seeking and health-promoting behaviors ("Health Promotion Model," 2012). The health promotion model has potential for long-term application and efficacy among patients, because the nurse and patient can work together to develop a comprehensive plan. Taking into account the person's background, beliefs, and prior behaviors, the plan can be constructed in ways that are meaningful to the patient and therefore more likely to inspire commitment. Pender (2011) finds that self-initiated commitment is "essential to behavior change" (p. 5).

1. Cultural background includes a composite of beliefs, many of which the patient may be unaware of, but which nevertheless shape attitudes toward health and health-related behaviors.

Rooted in Leininger's Transcultural Nursing Theory, this proposition promotes the value of cultural competence. While cultural competence is not one of the major nursing metaparadigms, it does relate to all four: person, environment, health, and nursing. Culture provides the complex of values and beliefs that inform personal identity construction, thus influencing the individual's attitudes, self-concept, and behaviors. The person cannot be understood in isolation from culture, because culture has helped form that person and his or her current state of mind-body health. Moreover, culture is a major part of the person's environment, informs the person's attitudes toward health and health goals, and shapes communication style with healthcare workers. This proposition links Health Promotion Theory and Transcultural Nursing Theory.

2. Patients are more likely to commit to health-promoting behaviors when those behaviors are normative within their cultural framework, when peers or family model those behaviors, and when those behaviors deliver rewards that are personally valuable.

Health-promoting behaviors stem from the person's value system. Basic behaviorism and cognitive-behavioral theories reveal the link between background beliefs and behaviors (Pender, 2011). Blended with Transcultural Nursing Theory, this proposition suggests that nurses better understand the cultural norms that guide health-promoting behaviors. When cultural norms clash with health promotion, the nurse is challenged to develop person-centered plans toward cognitive, emotional, and behavioral change.