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More considerations concerning the application of nursing models to curricula: a reply to lorraine smith
Nurse Edwatvm Tcday (1988) 8, 187-190 @ Longman GroupUK Ltd 1988
More considerations concerning the application of nursing models to curricula: a reply to Lorraine Smith J Greenwood
This paper attempts to explicate the distinction between formal and intuitive models of nursing, their relationship to nursing process, and the implications of this relationship for nursing practice. It is argued, firstly, that without the intelligent application of nursing models into practice nursing process will necessarily remain problematic and, secondly, that the function of formal nursing models is to improve practice by facilitating the articulation and critical appraisal of informal or intuitive models.
point
INTRODUCTION In Lorraine Smith’s illuminating paper published in this journal (1987) three fundamentally
important
introduction curricula, nursing
questions
of nursing and
practice
their
concerning
models
into
application
in
were posed. These
the
nursing clinical
were:
Why bother with nursing models when nursing process still remains problematic? What do nursing
models
offer
words, what is the motivation
planning
highlighted
and delivery of care?
The paper suggests that, if answers to these questions cannot be provided, there seems little
represents
1
The original explicate
and
utilise
satisfactorily
an endeavour
article (Smith
the crucial
in this
1987) does not
distinction
between
formal models of nursing intuitive models
and informal
Nursing
or intuitive,
models,
formal
or
are
necessary in order to put nursing process to work (or, without the intelligently critical application of nursing models into practice and education nursing process will necessarily remain
3. The function Jennie Greenwood RNT DipEd MEd Director of Nurse Education, North and East Hem DHAs, Chestnut House, Hitchin Hospital, Hitchin, Herts SG5 2LH Manuscript accepted March 1988
develop
My theses are simple:
2 to the
to
they are not answered
and this paper direction.
or the incen-
models contribute
attempting
models.
However, although the centrality of these questions to nursing practice and education is
- in other
tive for using models of nursing? What do nursing
in
nursing
problematic) of formal
nursing
models is
to improve nursing practice and education (other things being equal) and to do this by challenging informal or intuitive models. 187
188
NURSE EDUCATION TODAY
FORMAL AND INFORMAL OF NURSING
MODELS
Nursing practice and education are undertaken in the pursuit of aims or goals and are, therefore, necessarily reflective of internal models. These models may be consciously or unconsciously held, may or may not be verbally expressible by the subject and therefore, by implication, may or may not be internally consistent or readily modified. Moreover, such models are a function of the interaction between a subject’s existing cognitive structure (the ‘what’ and ‘how’ of what she knows) and incoming stimulation and, as such, constitute her basis for making sense of reality. To put it more simply: all human thought and action, irrespective of whether its purpose is to bring something about or to express something of its author, or both, (Harre 1979) reflects some internal model. A person cannot think about nothing at all and action, if it is to be appropriate to the purposes of its author, demands on the part of that author some internal model of the present context, what is required in it etc. A banal example that of opening a door will serve to clarify the point. Normal adult persons can open doors, they do it many times each day, and, generally speaking, they do it ‘without thinking’, that is without being aware of doing it. And yet in order to open doors handles must be recognised, grasped, turned and pushed or pulled; all these operations are required in order to open doors. Adult persons, therefore, possess some internal model of opening doors and the operations of which it is comprised, although most of them are unaware that they do possess them. Nursing thought and action is essentially the same; whatever a nurse does as a nurse, is reflective of her own internal models. Given this, why is the distinction between formal and informal models so crucial? Firstly, because formal models, by definition are explicit and systematised (Tomlinson 1981); their authors construct them carefully to ensure coherence and self-consistency. Secondly, and this point follows from the first,
by virtue of their expliciteness they can be examined critically to see how far and in what respects they do justice to the experiences they purport to explain, Any limitations thus exposed can then be addressed. Thirdly, internal models are constructed by the individual person; it is the subject, who represents their own cognitions the objects of experience and experience of objects. This is not to suggest, however, that models are ‘profoundly unique’ (Polanyi 1958) for if they were normal social intercourse would be impossible; each individual shares with others of their culture similar internal models by virtue of sharing life experiences. Fourthly, there is now ample evidence to suggest that the construction of these models begins before children learn to speak (Eysenck 1984) and also that some forms of internal model may not, in principle, lend themselves to verbal expression (Polanyi 1958). It is hardly surprising, therefore, that many people are unable to explicate the models which underpin their activities. Fifthly, many of the more mundane models are constructed, as much of mundane realities are experienced, without the subject’s awareness. They are ‘caught’ during everyday activities rther than ‘taught’ deliberately. What all this means is that even when nurses cannot describe their own models of nursing, and even when they are more or less unaware of their existence, they are still using them to inform their activities; their personal constructions of patient, nursing context, health and nursing work will issue in their mundane nursing practice. The implications of this are obvious; for if a nurse has only a tenuous grasp of the models underpinning his/her activities, she/he will find it difficult to say what they are and their criticial examination will be almost impossible. This in turn implies that they could be fragmentary and incoherent and it is at least arguable that such models issue in the activities of those nurses who still ‘do the obs’ for all their allocated patients although they claim to organise care on an individual basis. In addition, and this point is important, they
NURSE EDUCATION
may not adequately or accurately represent realities they seek to describe or explain. If this is accepted,
the
that is that informal
or
What this means
is that nursing
introduced
complete
concerning
the focus
of nursing
seems sufficient to have masked, least, its essential emptiness.
possess them to discover what they are, let alone make appropriate modifications?
burgeoning
To begin with nurses own practices
need to examine
and, by implication,
their
the models
underpinning them (and they may well require tutorial and peer support to do this); further-
189
process
was
with its own assumptions
intuitive models may be variously unsatisfactory and difficult to articulate, how are nurses who
of
TODAY
literature
on
care and this temporarily The
at
recent
formal
nursing
models testifies to the sterility of such notions as ‘whole’ persons, communities and so on in the real
world
of
practice;
for
precisely
which
aspects of whole persons or communities the caring
process be focused
should
on?
more, they will require something to examine their models against, or in the light of, and
‘ . . . it exhorts
formal nursing This is not
little about what to assess. It encourages planning, but says little about how to plan. It asks
uncritical
models can provide this. to suggest, however, that
and unintelligent
models is to be advocated; tions
can
and
any
espousal
of formal
theoretical
construc-
should
highlight
imperfection
but the converse
true. Perhaps
we are inclined
practical
should
nurses
to assess, but tells them
nurses to intervene,
but fails to say in what ways. It advocates evaluation, but does not specify when or how’. (Aggleton & Chalmers 1986).
also be
to forget
this.
It is nursing
models,
formal
and/or intuitive
which flesh out these details. planned,
NURSING PROCESS AND NURSING MODELS Nursing
process
1987; Pearson
is not a nursing
& Vaughan
model, as previously representation which
the
model
(Smith
is an ‘. . .abstract
of reality . . . a tool or device by activity
. . . can
be
studied.
(Chapman 1985). In contrast, a process is a continuous operation
or a series
operations
(Shorter
More precisely,
of regular
Oxford nursing
action or
actions
process
of regular
operations;
ment,
planning,
implementing
that).
and evaluating
this
by nursing
was process
repeatedly reflective
not
explicitly
advocates
at
is a func-
models
and
in our clinical areas to
on nursing
care
of the relatively
plans
of nursing
was the
fashionable
bandwagon
are already
sufficient
to be
model of
that was incorporated
into early conceptualisations process
seem
meaningless
the person or community
process.
profession’s
most
of the 1970s and there pointers
to suggest
that
nursing models will be the bandwagon of the 1980s. It is salutary to remember, however, that the uncritical resulted persists
of
care (but none the less valuable for
Unfortunately
acknowledged
in a
are assess-
nursing care (Kratz 1979; Smith 1982). That is all nursing process is; it is a method systematising
and
1984).
consists
these
. .’
internal
support this. The relatively meaningless problems ‘pain’ and ‘anxiety’ which currently feature
Nursing
Dictionary
series
and evaluated
nurse’s
there are clear indications
1986; Adam 1980); a
indicated,
implemented
tion of the acting
What is assessed,
introduction
in much
of nursing
confusion,
some
process of which
to this day, and it is the poverty
of the
models of person and community it carried with it which seem implicated in this respect. This latter
point
deserves
emphasis;
for
formal
the time of its inception. There is, however, an interesting point to be noted here: nursing
nursing models also carry with them their own implicit model, namely, that of human thought and action, and it is my view that this model is
process advocates urged nurses to assess, plan, implement and evaluate care for whole indivi-
similarly simplistic. The model of thought
duals, groups,
formal nursing models characterises these operations as essentially conscious and I have
etc. (Kratz
1979) which points to
an implicit recognition that methods something to be methodical about.
require
argued
above
and action implicit
in
that this is not always the case.
190
NURSE EDUCATION
TODAY
Moreover, there is now a wealth of psychological evidence (Dixon 1981) to contest this view, and not least as this relates to the nature of human skill.
CONCLUSION The temptation to incorporate formal nursing models uncritically into practice and education should be resisted, for they may not adequately explain experienced nursing realities; nurses should not be expected, even implicitly, to keep them ‘in mind’ as they go about their mundane nursing activities for it is almost definitive of skill that this is precisely what they should not do; rather, formal nursing models should be utilised to facilitate the articulation and critical appraisal of nurses’ intuitive models. It is not models
practice;
that
the consciousness creates
opportunities
it is their adequacy.
or otherwise to
improve
of
References Adams co
E 1980 To be a nurse.
Ontario,
W B Saunders
Aggleton P, Chalmers
&
H 1986 Nursing models and the nursing process. Basingstoke, Macmillan Education Ltd Chapman C 1985 Theory of nursing - practical application. London, Harper & Row Dixon N 1981 Preconscious processing. Chichester, John Wiley & Son Eysenck M W 1984 A handbook of cognitive psychology. London, Lawrence Erlbaum Associates Harre R 1979 Social being - a theory of social psychology. Oxford, Basil Blackwell Kratz C 1979 The nursing process. London, Bailliere Tindall Pearson A, Vaughan B 1986 Nursing models for practice. London, Heinemann Medical Books Polanyi M 1958 Personal knowledge. London, Routledge and Kegan Paul Smith L 1987 Application of nursing models to a curriculum: some considerations. Nurse Education Today 7,3: 109-l 15 Smith L 1982 Models of nursing as the basis for curriculum development: some rationales and implications. Journal of Advanced Nursing 7, 2: 117IOr)
Tomlinson P 1981 Understanding teaching: interactive educational psychology. London, McGraw Hill The Shorter English Dictionary 1983 3rd Ed, London, Book Club Associates.
More considerations concerning the application of nursing models to curricula: a reply to Lorraine Smith J Greenwood
This paper attempts to explicate the distinction between formal and intuitive models of nursing, their relationship to nursing process, and the implications of this relationship for nursing practice. It is argued, firstly, that without the intelligent application of nursing models into practice nursing process will necessarily remain problematic and, secondly, that the function of formal nursing models is to improve practice by facilitating the articulation and critical appraisal of informal or intuitive models.
point
INTRODUCTION In Lorraine Smith’s illuminating paper published in this journal (1987) three fundamentally
important
introduction curricula, nursing
questions
of nursing and
practice
their
concerning
models
into
application
in
were posed. These
the
nursing clinical
were:
Why bother with nursing models when nursing process still remains problematic? What do nursing
models
offer
words, what is the motivation
planning
highlighted
and delivery of care?
The paper suggests that, if answers to these questions cannot be provided, there seems little
represents
1
The original explicate
and
utilise
satisfactorily
an endeavour
article (Smith
the crucial
in this
1987) does not
distinction
between
formal models of nursing intuitive models
and informal
Nursing
or intuitive,
models,
formal
or
are
necessary in order to put nursing process to work (or, without the intelligently critical application of nursing models into practice and education nursing process will necessarily remain
3. The function Jennie Greenwood RNT DipEd MEd Director of Nurse Education, North and East Hem DHAs, Chestnut House, Hitchin Hospital, Hitchin, Herts SG5 2LH Manuscript accepted March 1988
develop
My theses are simple:
2 to the
to
they are not answered
and this paper direction.
or the incen-
models contribute
attempting
models.
However, although the centrality of these questions to nursing practice and education is
- in other
tive for using models of nursing? What do nursing
in
nursing
problematic) of formal
nursing
models is
to improve nursing practice and education (other things being equal) and to do this by challenging informal or intuitive models. 187
188
NURSE EDUCATION TODAY
FORMAL AND INFORMAL OF NURSING
MODELS
Nursing practice and education are undertaken in the pursuit of aims or goals and are, therefore, necessarily reflective of internal models. These models may be consciously or unconsciously held, may or may not be verbally expressible by the subject and therefore, by implication, may or may not be internally consistent or readily modified. Moreover, such models are a function of the interaction between a subject’s existing cognitive structure (the ‘what’ and ‘how’ of what she knows) and incoming stimulation and, as such, constitute her basis for making sense of reality. To put it more simply: all human thought and action, irrespective of whether its purpose is to bring something about or to express something of its author, or both, (Harre 1979) reflects some internal model. A person cannot think about nothing at all and action, if it is to be appropriate to the purposes of its author, demands on the part of that author some internal model of the present context, what is required in it etc. A banal example that of opening a door will serve to clarify the point. Normal adult persons can open doors, they do it many times each day, and, generally speaking, they do it ‘without thinking’, that is without being aware of doing it. And yet in order to open doors handles must be recognised, grasped, turned and pushed or pulled; all these operations are required in order to open doors. Adult persons, therefore, possess some internal model of opening doors and the operations of which it is comprised, although most of them are unaware that they do possess them. Nursing thought and action is essentially the same; whatever a nurse does as a nurse, is reflective of her own internal models. Given this, why is the distinction between formal and informal models so crucial? Firstly, because formal models, by definition are explicit and systematised (Tomlinson 1981); their authors construct them carefully to ensure coherence and self-consistency. Secondly, and this point follows from the first,
by virtue of their expliciteness they can be examined critically to see how far and in what respects they do justice to the experiences they purport to explain, Any limitations thus exposed can then be addressed. Thirdly, internal models are constructed by the individual person; it is the subject, who represents their own cognitions the objects of experience and experience of objects. This is not to suggest, however, that models are ‘profoundly unique’ (Polanyi 1958) for if they were normal social intercourse would be impossible; each individual shares with others of their culture similar internal models by virtue of sharing life experiences. Fourthly, there is now ample evidence to suggest that the construction of these models begins before children learn to speak (Eysenck 1984) and also that some forms of internal model may not, in principle, lend themselves to verbal expression (Polanyi 1958). It is hardly surprising, therefore, that many people are unable to explicate the models which underpin their activities. Fifthly, many of the more mundane models are constructed, as much of mundane realities are experienced, without the subject’s awareness. They are ‘caught’ during everyday activities rther than ‘taught’ deliberately. What all this means is that even when nurses cannot describe their own models of nursing, and even when they are more or less unaware of their existence, they are still using them to inform their activities; their personal constructions of patient, nursing context, health and nursing work will issue in their mundane nursing practice. The implications of this are obvious; for if a nurse has only a tenuous grasp of the models underpinning his/her activities, she/he will find it difficult to say what they are and their criticial examination will be almost impossible. This in turn implies that they could be fragmentary and incoherent and it is at least arguable that such models issue in the activities of those nurses who still ‘do the obs’ for all their allocated patients although they claim to organise care on an individual basis. In addition, and this point is important, they
NURSE EDUCATION
may not adequately or accurately represent realities they seek to describe or explain. If this is accepted,
the
that is that informal
or
What this means
is that nursing
introduced
complete
concerning
the focus
of nursing
seems sufficient to have masked, least, its essential emptiness.
possess them to discover what they are, let alone make appropriate modifications?
burgeoning
To begin with nurses own practices
need to examine
and, by implication,
their
the models
underpinning them (and they may well require tutorial and peer support to do this); further-
189
process
was
with its own assumptions
intuitive models may be variously unsatisfactory and difficult to articulate, how are nurses who
of
TODAY
literature
on
care and this temporarily The
at
recent
formal
nursing
models testifies to the sterility of such notions as ‘whole’ persons, communities and so on in the real
world
of
practice;
for
precisely
which
aspects of whole persons or communities the caring
process be focused
should
on?
more, they will require something to examine their models against, or in the light of, and
‘ . . . it exhorts
formal nursing This is not
little about what to assess. It encourages planning, but says little about how to plan. It asks
uncritical
models can provide this. to suggest, however, that
and unintelligent
models is to be advocated; tions
can
and
any
espousal
of formal
theoretical
construc-
should
highlight
imperfection
but the converse
true. Perhaps
we are inclined
practical
should
nurses
to assess, but tells them
nurses to intervene,
but fails to say in what ways. It advocates evaluation, but does not specify when or how’. (Aggleton & Chalmers 1986).
also be
to forget
this.
It is nursing
models,
formal
and/or intuitive
which flesh out these details. planned,
NURSING PROCESS AND NURSING MODELS Nursing
process
1987; Pearson
is not a nursing
& Vaughan
model, as previously representation which
the
model
(Smith
is an ‘. . .abstract
of reality . . . a tool or device by activity
. . . can
be
studied.
(Chapman 1985). In contrast, a process is a continuous operation
or a series
operations
(Shorter
More precisely,
of regular
Oxford nursing
action or
actions
process
of regular
operations;
ment,
planning,
implementing
that).
and evaluating
this
by nursing
was process
repeatedly reflective
not
explicitly
advocates
at
is a func-
models
and
in our clinical areas to
on nursing
care
of the relatively
plans
of nursing
was the
fashionable
bandwagon
are already
sufficient
to be
model of
that was incorporated
into early conceptualisations process
seem
meaningless
the person or community
process.
profession’s
most
of the 1970s and there pointers
to suggest
that
nursing models will be the bandwagon of the 1980s. It is salutary to remember, however, that the uncritical resulted persists
of
care (but none the less valuable for
Unfortunately
acknowledged
in a
are assess-
nursing care (Kratz 1979; Smith 1982). That is all nursing process is; it is a method systematising
and
1984).
consists
these
. .’
internal
support this. The relatively meaningless problems ‘pain’ and ‘anxiety’ which currently feature
Nursing
Dictionary
series
and evaluated
nurse’s
there are clear indications
1986; Adam 1980); a
indicated,
implemented
tion of the acting
What is assessed,
introduction
in much
of nursing
confusion,
some
process of which
to this day, and it is the poverty
of the
models of person and community it carried with it which seem implicated in this respect. This latter
point
deserves
emphasis;
for
formal
the time of its inception. There is, however, an interesting point to be noted here: nursing
nursing models also carry with them their own implicit model, namely, that of human thought and action, and it is my view that this model is
process advocates urged nurses to assess, plan, implement and evaluate care for whole indivi-
similarly simplistic. The model of thought
duals, groups,
formal nursing models characterises these operations as essentially conscious and I have
etc. (Kratz
1979) which points to
an implicit recognition that methods something to be methodical about.
require
argued
above
and action implicit
in
that this is not always the case.
190
NURSE EDUCATION
TODAY
Moreover, there is now a wealth of psychological evidence (Dixon 1981) to contest this view, and not least as this relates to the nature of human skill.
CONCLUSION The temptation to incorporate formal nursing models uncritically into practice and education should be resisted, for they may not adequately explain experienced nursing realities; nurses should not be expected, even implicitly, to keep them ‘in mind’ as they go about their mundane nursing activities for it is almost definitive of skill that this is precisely what they should not do; rather, formal nursing models should be utilised to facilitate the articulation and critical appraisal of nurses’ intuitive models. It is not models
practice;
that
the consciousness creates
opportunities
it is their adequacy.
or otherwise to
improve
of
References Adams co
E 1980 To be a nurse.
Ontario,
W B Saunders
Aggleton P, Chalmers
&
H 1986 Nursing models and the nursing process. Basingstoke, Macmillan Education Ltd Chapman C 1985 Theory of nursing - practical application. London, Harper & Row Dixon N 1981 Preconscious processing. Chichester, John Wiley & Son Eysenck M W 1984 A handbook of cognitive psychology. London, Lawrence Erlbaum Associates Harre R 1979 Social being - a theory of social psychology. Oxford, Basil Blackwell Kratz C 1979 The nursing process. London, Bailliere Tindall Pearson A, Vaughan B 1986 Nursing models for practice. London, Heinemann Medical Books Polanyi M 1958 Personal knowledge. London, Routledge and Kegan Paul Smith L 1987 Application of nursing models to a curriculum: some considerations. Nurse Education Today 7,3: 109-l 15 Smith L 1982 Models of nursing as the basis for curriculum development: some rationales and implications. Journal of Advanced Nursing 7, 2: 117IOr)
Tomlinson P 1981 Understanding teaching: interactive educational psychology. London, McGraw Hill The Shorter English Dictionary 1983 3rd Ed, London, Book Club Associates.