Vol.8, No.1 April 2002
Knowledge Domains in Nursing
Linda S. Smith, DSN, RN
This article answers the question -- what should be the domains of a knowledge system for nursing -- by viewing the question based on Meleis (1991) major components of concern for nursing. These components include nursing client (as a central focus), transitions, interaction, nursing process, environment, nursing therapeutics, and health. The paper describes these domains from past and current literature. A conclusion is drawn regarding their continued importance for the promotion and advancement of our profession. Finally, the Smith Model of Nursings Knowledge Domains is illustrated (Fig. 1).
Key words: knowledge domains, discipline of nursing, nursing theory, nursing knowledge
What are, or should be, the knowledge system domains for nursing? Meleis (1991) defined a domain as the territory, or unique perspective of a discipline. Therefore, nursings domain contains the disciplines content as well as nursings established values, beliefs, concepts, phenomena, problems, and investigative methodologies (Meleis 1991, p. 12). Synthesizing beliefs of four philosophers, Meleis portrayed nursings domain with a series of inner and outer circles. "A domain informs and is informed by all outer circles of the discipline," (Meleis 1991, p. 99). Thus, nursings domain content is both stable and flexible. Within nursings knowledge domains, certain broad concepts emerge. Importantly, theory and research activities facilitate, validate, and communicate development of domain concepts and problems. Practice, education, and administration facilitate the implementation of domain goals (Meleis 1991).
This manuscript answers the question -- what should be the knowledge system domains for nursing -- by viewing the question based on Meleis (1991) and supported by Malinski (1986) major components of concern for nursing. These components include nursing client, transitions, interaction, nursing process, environment, nursing therapeutics, and health.
As leaders and educators, our obligation to science and nursing care consumers is to identify knowledge domains unique to nursing. The quest for nursing knowledge is an arduous yet revered quest, and a societal and disciplinary expectation (Cull-Wilby & Pepin 1987). We know that knowledge-seeking is evolutionary and discipline-enhancing because as the adage goes, we who know not, know not we know not, know not; and we who know not and know we know not, know a lot. If we have not yet arrived, if we are still developing our knowledge base, then the discipline of nursing knows a great deal about our special and unique approach to societal needs (McMurrey 1982). Therefore, the development of our knowledge domains continues to be a professional priority.
The nursing client, a central concept within nursings domain, receives or potentially receives our care. Nightingale wrote that clients experience a reparative process (hindered by lack of knowledge or attention) and our task was to assist in that process (1859/1969, p. 8-9). For nursing, clients may be persons, families, groups, communities, or societies. Clients are considered holistically and can be ill or well.
The holism concept separates nursing from medicine. Historically, Descartes, Cartesian philosophy founder, compared science with mathematics and promoted the idea of man as the sum of multiple parts. This perspective evolved into medical systems theory (dogma) where humans were sectioned into organs, systems, and functions (van Maanen 1990). In contrast, nursings integrated organism construct considers humans as biopsychosocial wholes, full of potential, and greater than the sum of their parts (Kiikkala & Munnukka 1994). Giger and Davidhizer further delineated clients as a culturally unique product of experiences, cultural beliefs, and cultural norms (1999).
Nurses care for clients in transition. The transition domain refers to changes requiring adjustment or adaptation. Using new knowledge, behavior, coping, self-concept, and health-illness perceptions, situational and developmental transitions occur (Kiikkala & Mannukka 1994, Meleis 1991). Nursing care focuses on clients responses to health crises and their ability to recover"...using the residual of available health (vanMaanen 1990, p. 915). Nightingales concepts sound familiar in vanMaanens (1990) description of nursing as helping clients adjust to health and illness consequences. How nursing affects and changes clients health status is nursings unique contribution (Donaldson & Crowley 1978) and refers to nursings effective management of changing situations (Fitzpatrick 1988).
Interaction, a third domain, refers to therapeutic interaction with components of sensing, perceiving, validating, and sharing relative to client needs. For nursing, interaction is considered a co-operative community-based humanistic relationship among people. When the nurse is truly present or attending, clients will "... change and unfold as they uncover insights about self, clarify plans and dreams, and move beyond the moment in their interrelationships with others and the universe," (Mitchell 1992, p. 7). Nurses and clients enter the interaction with previous ideas and skills.
Nursing process, another concept central to nursings knowledge domain, includes the nurses ability to assess, diagnose, plan, implement, organize, and evaluate client care. Importantly, nursing process concepts were carefully described by Nightingale (1859/1969) when she wrote about assessment and diagnosis. "The most practical lesson that can be given to nurses is to teach them what to observe what symptoms indicate improvement - what the reverse - which are of importance which are the evidence of neglect - and of what kind of neglect," (p. 105). Observation "is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort," (Nightingale, p. 125). Nightingale described nursing decisions [diagnosis] as follows, "Again, the question, how is your appetite? ... There may be four different causes, any one of which will produce the same result, viz., the patient slowly starving from want of nutrition:.. Yet all these are generally comprehended in the one sweeping assertion that the patient has no appetite. Surely many lives might be saved by drawing a closer distinction; for the remedies [interventions] are as diverse as the causes," (pp. 110-111).
Another pre-1961 nursing process description occurred in 1959 when Johnson wrote that astute nursing observation was the basis for conceptual speculation about the character, cause, or progress of tensions and remedial intervention. Labels are important, she wrote, because they identify nursing problems and contribute to an understanding of people (Johnson 1959, p. 294). Though criticized by some nursing theorists/scientists (Fitzpatrick 1988, Smith 1988, Taylor 1991) nurses have used nursing diagnosis to code and thus communicate nursings knowledge domain. Nursing educational curricula, literature, and certification examinations have evolved around the activities of the North American Nursing Diagnosis Association.
The fifth domain, environment, was a nursing knowledge domain since Nightingale (1859/1969) first described nurses as "... using fresh air, light, warmth, cleanliness, quiet..." and proper diet to decrease the clients expenditure of vital powers (p. 8). For Nightingale, clients experienced problems related to the environment and nurses focused on environment to facilitate health. For nursing, environment is often referred to as holistic and all encompassing, including social systems, family, culture, immediate surroundings, the nurse, and even energy fields (Meleis 1991). Because humans interact with their environment in critical life situations, environments must be supportive.
Since Nightingale, nurse theorists have described the influence of environment for clients. What are healthy environments; what social mechanisms help or hinder healthy environments; is the environment or client deterministic; and what role does health policy play in a clients environment (Flaskerud & Halloran 1980, Meleis 1991, Murphy 1985). Thus, within this knowledge domain, nursing promotes a client's/familys ability to interface with the community in order to manage health concerns. This is the thrust of the discipline of nursing during the new millennium.
Nursing intervention goals and actions are the focus of the nursing therapeutics knowledge domain. Nursing therapeutics uniquely support and enhance the nursing process (Meleis 1991). They include the nurses helping as well as teaching-coaching roles. Additionally, nurses administer and monitor therapeutics (Fitzpatrick 1988) that decrease stressors and conditions preventing optimal health (Smith et al. 1988). Practice focused outcomes research, emphasizing nursing intervention value and efficacy, will help nursing express its uniqueness (Gioiella 1996). Thus, we are accountable for identifying the most successful treatments based on these outcome studies (Peters & Hays 1995).
The last knowledge domain of nursing is health. Greater than the absense of illness, health is homeostasis and adaptation. It is awareness, empowerment, control, and self-mastery (Meleis 1991). For nursing, health is multi-dimensional, dynamic, and individualistic. Health relates to the reparative process instituted by nature (Nightingale 1859/1969). Though once lost, Nightingales ideas of equilibrium have resurfaced. In 1961, Johnson wrote of equilibrium as a stable state where the client is in harmony with self and environment.
Nursing is concerned with principles that dictate life processes, well being, and optimal functional levels (reparative processes) (Donaldson & Crowley 1978). Health promotion is the central characteristic of the health knowledge domain. Critical issues for nursing inquiry are health promotion behaviors, lifestyles, and personal health responsibilities (Hinshaw 1989). These health themes were operationalized through NINRs written Areas of Research opportunity (2001) that include chronic illnesses or conditions, behavioral changes and interventions, and compelling public health concerns.
Seven nursing knowledge domains exist within our discipline These include the nursing client, transitions, interaction, process, environment, therapeutics, and health (Meleis 1991). The discipline of nursing continues to grow in credibility by adding cutting edge information concerning each knowledge. Under these domains, education, research, and practice unite. Nursing science domains, composed of seven subsets, become whole. (See Smith Model of Nursings Knowledge Domains, Fig.1)
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