Nursing Knowledge

Science, Practice, and Philosophy

Mark Risjord

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781444358605
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing Skills

Nurses who conduct research have a longstanding interest in questions of nursing knowledge. Nursing Knowledge is a clear and well-informed exposition of the philosophical background to nursing theory and research. Nursing Knowledge answers such fundamental questions as: How is nursing theory related to nursing practice? What are the core elements of nursing knowledge? What makes nursing research distinctive as nursing research? It examines the history of the philosophical debates within nursing, critiques the arguments, explains the implications and sets out to rethink the philosophical foundation of nursing science. Nursing Knowledge begins with philosophical problems that arise within nursing science. It then considers various solutions with the help of philosophical ideas arguingargues that nurses ought to adopt certain philosophical positions because they are the best solutions to the problems that nurses encounter. The book argues claims that the nursing standpoint has the potential to disclose a more complete understanding of human health than the common disease-and-dysfunction views. Because of the relationship to practice, nursing science may freely draw theory from other disciplines and nursing practice unifies nursing research. By redefining theory and philosophy, With a new philosophical perspective on nursing science, the so-called relevance gap between nursing theory and practice can be closed. The final chapter of the book 'redraws the map', to create a new picture of nursing science based on the following principles:

• Problems of practice should guide nursing research
• Practice and theory are dynamically related
• Theory research must provide the knowledge base necessary for nurse interventions, training, patient education, etc.
• Nursing research should develop midrange theories and its results are nursing theory is strengthened when it uses theories confirmed by is integrated with other disciplines
  

Key features

• Clear and accessibly written
• Accurate and philosophically well-informed,
• Discusses philosophical problems in contexts familiar to nurses
• Systematically examines the philosophical issues involved in nursing research
• Examines epistemology (how we know what we know), theory development, and the philosophical foundations of scientific methodology.
• Develops a new model of nursing knowledge

Dr. Mark Risjord is Associate Professor in Philosophy at Emory University, and has a faculty appointment in the Nell Hodgson Woodruff School of Nursing. His main research areas have been in the philosophy of social science and the philosophy of medicine. He was invited to has been teaching philosophy of science and theory development in the new PhD program in the Nell Hodgson School of Nursing at Emory University insince 1999. He has been awarded two competitive teaching prizes: Emory Williams Distinguished Teaching Award (2004) and the Excellence in Teaching Award (1997). He is presently serving as the Masse-Martin/NEH Distinguished Teaching Chair (2006-2010).

Part I

Nursing Knowledge and the Challenge of Relevance

Introduction to Part I

Nursing knowledge

Nursing has two faces. To the public, nurses embody the best of modern health care. Efficient, effective, and caring, nurses are at the center of the patient’s experience. The other face is largely invisible to the patient, even though it has been a part of nursing since the time of Florence Nightingale. Nursing requires knowledge. In the first century of nursing, the intellectual dimensions of nursing remained implicit. Nurses were trained using an apprenticeship model. Long hours at the bedside were supplemented by some pearls of wisdom dispensed by physicians. By the middle of the twentieth century, it became clear that effective nursing practice required a distinctive body of knowledge. Nursing intervention had gradually become independent of the physician’s orders, and nursing required integrated knowledge of the physiological, psychological, and social dimensions of the patient. By developing programs of research, nurses asserted ownership over the knowledge required for practice. Contemporary nursing thus encompasses both the professional practice of nursing and the academic discipline of nursing.

The goal of nursing research is to develop a body of knowledge that will support and advance nursing practice. Nursing knowledge might be defined by its relevance to nurses, an idea suggested by Pamela Reed and Lisa Lawrence:

“Nursing knowledge refers to knowledge warranted as useful and significant to nurses and patients in understanding and facilitating human health processes.” (Reed & Lawrence, 2008, p. 423)

While the definition seems clear and straightforward, producing useful and significant knowledge for nurses and their clients has been challenging. The difficulties faced by nurse scholars have gone beyond the ordinary questions of method that concern all researchers. For example, nurse researchers have experimentally demonstrated that one educational intervention promotes adherence to an asthma-monitoring protocol better than another (Burkhart et al., 2007). This is knowledge that is well warranted by its experimental design, and apparently useful to nurses and their patients. However, nurse scholars have not been satisfied by contributions like these. Without deeper links to a growing body of knowledge, such studies have a limited ability to support the intellectual development of nursing. Nor do “qualitative” studies fare any better. Understanding the lived experience of the patient is certainly part of good nursing practice, but without some way of fitting the part into a larger whole, it is difficult to discern the significance of, for example, a description of the lived experience of nine pediatric liver transplant recipients (Wise, 2002). The problem is not that studies like these are poorly executed or trivial. On the contrary, they are well designed and important. The problem is that their importance has become difficult to recognize. Working nurses do not seek out the most recent research results or use nursing theories to analyze their responses to the patient. Indeed, the mention of “theory” is likely to elicit groans from a practicing nurse. Nursing theory and research are not supporting the professional practice of nursing in the way that nurses expect it to.

Two kinds of theory-practice gap

The “theory-practice gap” has been discussed in hundreds of nursing articles. This is a symptom of the dissatisfaction nurses seem to have with the research arm of their discipline. But what, exactly, is the theory-practice gap? Historically, the gap has been conceived in two fundamentally different ways. The difference turns on whether existing theory is held to be relevant or irrelevant to practice. Much writing on the relation of theory to practice assumes that there is a body of relevant intellectual knowledge that should inform nursing practices. The “gap” arises when this body of knowledge is not used as it should be. For example, nursing students often have trouble translating what they learn in the classroom into clinical practice. There is a wealth of literature on pedagogical strategies for helping nursing students bridge this gap. There are other versions of this gap too. Once in professional life, nurses need to continue to learn about new developments, and there are a number of barriers to the integration of research results into nursing practice. The crush of day-to-day work leaves little time for reading and reflection, and there may be no resources to support continuing education. Moreover, theory and research results are not always presented in a form that makes their clinical relevance obvious. These problems are all fundamentally problems of translation. They presuppose that there is a body of useful and relevant knowledge. The theory-practice gap arises when the theory is not translated into action.

The second kind of theory-practice gap is much deeper and more disconcerting. Authors in this vein question the relevance of existing theory and research. For example, in his “Preface” to the fourth edition of Philosophical and Theoretical Perspectives for Advanced Nursing Practice, William Cody wrote:

“The place of theory in nursing practice has, in reality, long been considered somewhat vague and tenuous. A situation persists today that has been referred to as the “theory-practicegap,” in which theory and practice are perceived as interacting imperfectly, infrequently, and sometimes insignificantly.” (Cody, 2006, p. ix)

In a similar vein, Peter Gallagher¹ wrote:

“[M]any nurses consider it crucial for effective nursing that theory and practice must be closely related. This essentially symbiotic view of the nature of the theory-practice relationship has been embraced by many in the profession, and it is a view that has prompted both expert nurses and inexperienced student nurses to question the direct relevance of some theoretical material to the delivery of nursing care.” (Ousey & Gallagher, 2007, p. 200)

These remarks are some of the most recent in a longer tradition (Conant, 1967a, 1967b; Hardy, 1978; Jacobs & Huether, 1978; Watson, 1981; Stafford, 1982; Swanson & Chenitz, 1982; Miller, 1985; Meleis, 1987; Draper, 1990; Nolan & Grant, 1992; Whall, 1993; Good & Moore, 1996; Blegen & Tripp-Reimer, 1997; Im & Meleis, 1999 ). Unlike those authors who are trying to translate theory into practice, these authors call into question the relevance, significance, or usefulness of existing research and theory. The gap is one of relevance, and this is a disturbing situation. A primary goal—if not the rasion d’etre —of nursing research is to produce knowledge that supports practice. Since the early 1950s, dozens of journals have published thousands of pages of research reports. If some significant portion of this output supports practice only “imperfectly, infrequently, and sometimes insignificantly,” then something is wrong with the research arm of the nursing discipline.

If we follow Reed and Lawrence and define nursing knowledge as knowledge “warranted as useful and significant to nurses” (Reed & Lawrence, 2008, p. 423), then a relevance gap challenges the whole enterprise of nursing research and theory development. If nursing theory were irrelevant, then it would not be nursing knowledge at all. The relevance gap between theory and practice thus raises questions that reach to the foundations of the discipline. It challenges the philosophical conceptions of knowledge that are implicit in the nursing discussions of theory and research. The relevance gap is therefore a fundamental problem of the philosophy of nursing science.

Philosophy of nursing science

The discipline of nursing has a bountiful literature on nursing research, methodology, the character of the nursing discipline, and its substance. These topics are philosophical in the sense that they reflect on the most general and profound issues in nursing scholarship. If we permit ourselves—as we should—a generous understanding of “science,” the nursing metatheoretical literature contains substantial work in the philosophy of science. This book aims to contribute to that philosophy

of science: to map the intellectual fault lines of nurses’ thought about their discipline and to critically engage the issues.

The relevance gap arose at a specific point in the intellectual development of the nursing discipline. As Chapter 1 will show, concern that research or theory might be irrelevant to practice did not arise during the first century of the modern nursing profession. Since the time of Florence Nightingale, nurses have recognized a domain of nursing knowledge, but there was no relevance gap. A relevance gap was recognized by Lucy Conant in the late 1960s (Conant, 1967a, 1967b), but it was not the subject of widespread concern until late 1970s. Why? What caused the gap to open at that point in the history of the discipline? And why has it remained open? Chapter 2 will argue that the relevance gap emerged because of a particular constellation of philosophical ideas. In the 1950s, 1960s, and 1970s, there were debates about the character of nursing knowledge, research, and theory. Toward the end of the 1970s, a consensus about the field emerged. To be a discipline, many thought, nursing needed unique theories at a high level of abstraction. These were unified into a basic science by shared concepts and themes (the metaparadigm). The relevance gap opened because the philosophical understanding of science within nursing urged nurse researchers to develop a basic science, but nursing as basic science had little relevance to the profession.

What is done by philosophy can be undone by philosophy. To close the relevance gap we will have to think through the philosophical arguments about nursing research and theory in which nurse scholars have engaged. This will require attention on two fronts. First, nurse scholars have been influenced by ideas and arguments arising out of philosophy. These will have to be made clear and critically engaged on their own terms. The philosophy of science contains valuable resources for nursing, and several of the chapters below will be devoted to a detailed, critical discussion of issues in the philosophy of science. However, the notions of the philosophers take on a different significance when they enter the nursing context. We cannot restrict ourselves to the philosophers’ discussion. The second area of concern will therefore be the nursing literature about the character of the discipline, nursing science, and nursing knowledge. The philosophical position developed here will be intimately related to the debates within nursing. Chapter 3 is intended to be an interface between the philosophy of science and the nursing metatheoretical literature. It will distill four philosophical questions from the nursing debates canvassed in Chapters 1 and 2. It will also sketch, in a preliminary way, the debates to be engaged in this book, and the position that will be developed in subsequent chapters.

1 While this was a coauthored essay, it was presented as a debate with each author’s contribution clearly identified.

1

Prehistory of the problem

How did the discipline of nursing come to be in a position where significant parts of nursing theory and research are thought to be irrelevant to nursing practice? One might think that the relevance gap arose in the 1970s because only then was there sufficient nursing theory for there to be a theory–practice gap. It would be a mistake to begin the story there. While the development of nursing’s research program in the 1950s and 1960s was revolutionary for the profession, theory has been important to nursing since its inception. To understand how the theory–practice gap arose, and why the relevance gap emerged when it did, we have to understand how the relationship evolved between professional nursing and the theories that supported it.

The domain of nursing

Florence Nightingale is praised for her work in identifying the nurse’s role in health care, for establishing nurse training, and for her theoretical writing. All three were important for the subsequent development of nursing attitudes toward theory. Notes on Nursing: What It Is and What It Is Not (Nightingale, [1860] 1969) makes two kinds of contribution to theory. It described a domain of nursing expertise that was independent of the physician’s expertise. Specifically, the nurse was oriented toward the environment of the patients, everything from the condition of their bandages to the layout of their sickrooms. From Nightingale forward, then, one kind of theoretical writing in nursing has been to define nursing: to identify the proper scope of the nurse’s action, the kinds of nursing response to the patient’s needs, and the values that inform nursing actions. Nightingale asked the philosophical question “What is nursing?” and she gave a philosophical answer. She analyzed the nurse’s role with an eye toward the values that dictate what it should be (as opposed to the facts about what it is). Nightingale’s other theoretical contributions were more empirical. It is often forgotten that in Notes on Nursing, Nightingale rejected the germ theory of disease. The germ theory was just emerging in this period, and while it was known as a possible account of disease, it was not widely accepted. Nightingale preferred a late form of the Galenic theory of disease, and she believed that the diseased state of humans sometimes arose directly from their environment (Nightingale, [1860] 1969, pp. 32–34). While this theory of disease did not survive into the twentieth century, it was an important part of Nightingale’s justification for the nurse’s role. Physicians were to address the problems with the body that caused disease (imbalance of the humors), while nurses addressed the environmental causes. This gave nurses a domain of expertise that fell outside of the physician’s domain.

While we can recognize her empirical writings as important theoretical advances in nursing, Nightingale probably would have been reluctant to call them “theory,” or to say that nurse training required much in the way of “theory.” Indeed, she sometimes expressed a rather ambivalent attitude toward theory. In an 1881 address to the nurses at St. Thomas’s Hospital, she wrote:

“You are here trained for nurses—attendants on the wants of the sick—helpers in carrying out doctor’s orders (not medical students). Though Theory is very useful when carried out by practice, Theory without practice is ruinous to Nurses.” (Vicinus & Nergaard, 1990, p. 385)

This sentiment was echoed elsewhere in the late nineteenth century nursing literature. In the 1895 essay “Comparative Value of Theory and Practice in Training Nurses,” Brennan wrote:

“Theory in conjunction with practice is what we want, and although it is undeniable that theory has done more to elevate Nursing than any amount of clinical practice alone could have done, we still must remember that ‘too much reading tends to mental confusion.’ ” (Brennan, 1895, p. 355)

These passages warn nurses against delving too deeply into theory. This is puzzling because both authors clearly think that knowledge of theory is necessary to good nursing. This tension between the need for theory and the danger of too much theory highlights the role that theoretical knowledge played in nineteenth and early twentieth century nursing. Both authors make these remarks while discussing obedience. The role of nurses, both Nightingale and Brennan argued, is to carry out the orders of the physician. The implicit model is that the physicians are the repository of medical and scientific knowledge. To carry out the physician’s orders intelligently, nurses must know the medical terminology and enough about medical theories to understand what the physician was asking, and why he was asking for it. The sense in which nurses were enjoined not to read too much, or that theory can be “ruinous,” is the sense of “theory” that equates theory with medical knowledge.

Professionalization and the translation gap

The theory required for nursing practice could not be fully identified with medical knowledge, even in Nightingale’s time. Nightingale isolated a domain of responsibility where the nurse had expertise. There was, then, a special form of nursing knowledge to be mastered. However, through the late nineteenth and early twentieth centuries, both physicians and nurses expected women to already have this specialized knowledge, at least in part. A young woman with “good upbringing” would already know how to cook and clean, to care for a child or elderly relative, and perhaps to manage domestic help. Her knowledge of the household environment would be refined by apprenticeship in the hospital. The substantive knowledge that was specialized to nursing, contained in works such as Notes on Nursing: What It Is and Is Not (Nightingale, [1860] 1969) or Norris’s Nursing Notes: Being a Manual of Medical and Surgical Information for the Use of Hospital Nurses (Norris, 1891), was largely communicated to the student through experience in the clinic. The knowledge that was specific to nursing was embedded in p...