Like disciplines, professions have unique characteristics, as defined by Flexner. Flexner (1919) initially identified as the most basic characteristic of a profession that it addresses a unique and urgent social need through techniques derived from a tested knowledge base. Professions have their historical roots in those human services that people provided for each other within existing social institutions (e.g., tribe, family, or community). Thus, each profession, including nursing, has its origins in everyday human situations and the everyday contributions people make to the welfare of others. Flexner's founding conditions for the designation profession are reiterated in the American Nursing Association's 1980 Social Policy Statement, in which the idea of a social contract is addressed.
Nursing: A Social Policy Statement was intended to provide nurses with a fresh perspective on practice while providing society with a view of nursing for the 1980s. The overall intent of this document was to call to consciousness the linkages between the profession and society. While the Social Policy Statement is considered by many (see, for example, Rodgers, 1991; Packard & Polifroni, 1991; Allen, 1987; White, 1984) to be outdated, we find the concept of the social contract to be useful when studying the relationship of nurse to nursed. As the foundation for professions, the social contract, while understood to be an "hypothetical ideal" (Silva, 1983, p. 150), is also an expression of a people recognizing (1) the presence of a basic need and (2) the existence of greater knowledge and skill available to meet that need than can be readily exercised by each member of the society. Society at large then calls for commitment by a segment of society to the acquisition and use of this knowledge and skill for the good of all. Social goods are promised in return for this commitment.
Today, the profession of nursing is moving from a social contract relationship toward a covenantal relationship between the nurse and nursed. While the social contract implies an impersonal, legalistic stance, the covenantal relationship emphasizes personal engagement and ever present freedom to choose commitments. Cooper (1988), for example, discusses her ideas on the relevance of covenantal relationships for nursing ethics. She states "the promissory nature of the covenant is contained in the willingness of individuals to enter a covenental relationship" (p. 51) and it is within this context that obligations arise. As caring persons, we "see" relationship (covenant) and honor the bond between self and other. The ultimate knowledge gained from this perspective is that we are related to one another (and to the universe) and that harmony (brotherhood and sisterhood) is present as we live out caring relationships.
Concepts of discipline and profession have been dismissed by critical theorists as oppressive, anachronistic, and paternalistic (Allen, 1985; Rodgers, 1991). In our study however, as we have explored essential meanings of these concepts, we have found that they express fundamental values congruent with cherished nursing values. Although we can agree with critical theorists that discipline and profession have been misused, perhaps too frequently, as tools of social elitism and oppression, this misuse remains inappropriate because it violates the covenantal nature of discipline and profession.
The discipline of nursing attends to the discovery, creation, structuring, testing, and refinement of knowledge needed for the practice of nursing. Concomitantly, the profession of nursing attends to the use of that knowledge in response to specific human needs. Certainly, the basic values communicated in the concepts of discipline and profession are resonate with fundamental nursing values and contribute to a fuller understanding of nursing as caring. Included among those shared values are commitment to something that matters, sense of persons being connected in oneness; expression of human imagination and creativity, realization of the unity of knowing with possibilities unfolding, and expression of choice and responsibility.
We have deliberately used the term general theory of nursing to characterize our work. The concept of a general theory is particularly useful in the context of levels of theory. Other authors have addressed what they see as three levels of nursing theory: general or grand, mid-range, and practice (Walker & Avant, 1988; Fawcett, 1989; Chinn & Jacobs, 1987: Nursing Development Conference Group, 1979). What we intend by the use of the term general theory is similar to "conceptual framework," "conceptual model," or "paradigm." That is, a general theory is a framework for understanding any and all instances of nursing, and may be used to describe or to project any given situation of nursing. It is a system of values ordered specifically to reflect a philosophy of nursing to guide knowledge generation and to inform practice.
The statement of focus of any general nursing theory offers an explicit expression of the social need that calls for and justifies the professional service of nursing. In addition, the statement of focus expresses the domain of a discipline as well as the intent of the profession, and thus directs the development of the requisite nursing knowledge. Activity to develop and use nursing knowledge has its ethical ground in the idea of the covenantal relationship as expressed in the specific focus of the profession. Fundamental values inherent in the discipline and profession of nursing derive from an understanding of the focus of nursing.
The conception of nursing that we have used in this book views nursing science as a form of human science. Nursing as caring focuses on the knowledge needed to understand the fullness of what it means to be human and on the methods to verify this knowledge. For this reason, we have not accepted the traditional notion of theory which relies on the "received" view of science, and depends on measurement as the ultimate tool for legitimate knowledge development. The human science of nursing requires the use of all ways of knowing.
Carper's (1978) fundamental patterns of knowing in nursing are useful conceptual tools for expanding our view of nursing science as human science here. These patterns provide an organizing framework for asking epistemological questions of caring in nursing. To experience knowing the whole of a nursing situation with caring as the central focus, each of these patterns comes into play. Personal knowing focuses on knowing and encountering self and other intuitively, the empirical pathway addresses the sense, ethical knowing focuses on moral knowing of what "ought to be" in nursing situations, and aesthetic knowing involves the appreciating and creating that integrates all patterns of knowing in relation to a particular situation. Through the richness of the knowledge gleaned, the nurse as artist creates the caring moment (Boykin & Schoenhofer, 1990).
Nursing, as we have come to understand our discipline, is not a normative science that stands outside a situation to evaluate current observations against empirically derived and tested normative standards. Nursing as a human science takes its value from the knowledge created within the shared lived experience of the unique nursing situation. Although empirical facts and norms do play a role in nursing knowledge, we must remember that that role is not one of unmediated application. Knowledge of nursing comes from within the situation. The nurse reaches out into a body of normative information, transforming that information as understanding is created from within the situation. The same can be said for personal and ethical knowing. Each serves as a pathway for transforming knowledge in the creation of aesthetic knowing within the nursing situation. The view we have taken unifies previously dichotomized notions of nursing as science and nursing as art and requires a new understanding of science.