Complexity and Values in Nurse Education

Dialogues on Professional Education

Martin Lipscomb

• Publisher: Routledge
• Year: 2022
• Print ISBN: 9780367672218
• eBook ISBN: 9781000590364
• Edition: 1
• Topic: Medicina
• Subtopic: Teoría y práctica de la educación

This work explores the interplay of complexity and values in nurse education from a variety of vantages.

Contributors, who come from a range of international and disciplinary backgrounds, critically engage important and problematic topics that are under-investigated elsewhere. Taking an innovative approach each chapter is followed by one or more responses and, on occasion, a reply to responses. This novel dialogic feature of the work tests, animates, and enriches the arguments being presented. Thought-provoking, challenging and occasionally rumbustious in tone, this volume has something to say to both nurse educators (who may find cherished practices questioned) and students.

Given the breadth and nature of subjects covered, the book will also appeal to anyone concerned about and interested in nursing's professional development/trajectory.

1 Pain is (or may not be) what the patient says it is — professional commitments: objects of study or sacrosanct givens?

Martin Lipscomb

DOI: 10.4324/9781003130321-2

If professional values and norms are considered inviolable the enthusiasm of educators to introduce students to arguments threatening those values/norms (and related conceptions of care) may be tempered. Where this occurs, and when the arguments perceived as hostile are ‘good’ (coherent and plausible), learning and potentially care might both be degraded.¹ Educators must then decide, ought prioritisation attend the enculturation of professional values/norms, or should student intellectual development trump other concerns?

This crude and unpolished bifurcation caricatures the issues at stake. Values and norms remain unspecified, and the threat posed to values/norms by contrarian argument is not explained. Nonetheless, complex conundrums are generated for educators when commitments or ways of acting that accompany professional values and norms are tested by argument. And with this disjuncture in mind, although it is commonly supposed that, in the academy, learning should proceed independently of external direction or restraint, this chapter discusses the possibility that university nurse educators can fail to introduce ideas to students when those ideas destabilise or offend presumptions about ‘correct’ thought and action. Correctness here references professional values and norms originating outside the academy, and if behaviour and ways of thinking sanctioned by extraneous commitments are privileged by educators to the detriment of critical investigation when investigation challenges professionally lauded notions of appropriate practice, a key feature of higher education (encouraging unfettered intellectual inquiry) is compromised.

Two background assumptions scaffold these statements. First, a real problem exists. Second, critical investigation and critical thinking about or into complex issues beneficially contribute to learning and (tangentially) care. These assumptions are accepted rather than demonstrated. Nevertheless, given this scaffolding the following question is posed: ought professional commitments and the forms of care they inform be explored in the academy in precisely the same way (i.e., critically) that other ideas/practices are handled?

Be critical (within limits)

Educators purportedly embrace and promote student criticality because, supposedly, this capacity and disposition facilitate reflection and reflection can, ultimately, augment and improve care. Augmentation might occur when reflection highlights areas of practice requiring improvement. Or, more diffusely, reflection may ‘open up’ topics for deliberation. Viewed in this light criticality has immediate concrete-practical and abstract or less visible payoffs. Yet whichever way criticality is conceptualised, educators frequently assert that they encourage students to take a critical line through all aspects of study.²

This assertion is misleading. Nursing’s rhetoric (what we tell ourselves) does not always match what we do and the possibility that, occasionally, students are discouraged from challenging established ideas is credible (Darbyshire and Thompson, 2021).

Hereafter, the commonly voiced statement ‘pain is what the patient says it is’ is considered. Variants on this proposition are introduced to preregistration/prelicence undergraduate nursing students at all institutions I am familiar with. However, while the proposition has been critiqued, and it is reasonable to suppose that educators are or should be aware of these critiques, anecdotal evidence suggests educators are hesitant to deconstruct or argue against this idea. Reluctance, in my view, stems from the potential of deconstruction to ‘cut away’ at cherished normative shibboleths. Put simply, where students are required to accept professionally sanctioned evaluative positions such as those pertaining to the care of patients experiencing pain, critique and argument are not brooked.

This chapter’s focus on pain thus highlights a problem of general concern. Following Zurn (2021), it is presumed that curiosity (critical thinking/argument) is subject to socio-cultural and political constraints. And, to restate, mindful of these constraints, critical thinking can be blocked or discouraged by nurse educators when this disposition and activity menace professional values and practices associated with those values.

Pain is what the patient says it is — discuss?

McCaffery (1968) famously stated that pain is ‘whatever the experiencing person says it is, existing whenever the experiencing person says it does’ (p. 95). The document detailing this claim is comparatively inaccessible, and nurses interested in her work will probably therefore locate Nursing Management of the Patient with Pain (McCaffery, 1972). This book reproduces the earlier definition (p. 8) whilst making it clear that patients ‘speak’ or communicate with nurses through speech and behaviour.

Our definition of pain stipulates that the patient “says” something to us about the pain. This term does not mean that the patient must verbalize. Many patients will not or cannot communicate verbally. What the patient says to us includes all voluntary and involuntary behaviors and all verbal and nonverbal behaviors.

(McCaffery, 1972, p. 9)

The nursing definition of pain has been stated as being whatever the experiencing person says it is, existing whenever he says it does. It has been stipulated that what the patient says about pain involves far more than his verbalisations. Therefore assessment will be based on a variety of observable behaviors.

(McCaffery, 1972, p. 11)

Expanding the concept of ‘saying’ or testimony to include verbal and nonverbal dimensions is now broadly agreed (see, e.g., Sonneborn and Williams, 2020).³ Yet this nuance, and a great deal of the sophistication in McCaffery’s work, is lost when educators abbreviate the message presented to students and simply state that ‘pain is what the patient says it is’. This reduced conception, at least in the academy, is close to being a nursing given. Carragher, MacLeod and Camargo-Plazas (2021) note the definition is ‘widely used today and is embedded in nursing curricula teachings’ (p. 4), and acceptance of McCaffery and McCaffery-esque like mantras tend to be demanded.⁴

Thus despite McCaffery’s (1972) own position being considerably more interesting (and sporadically more puzzling) than this abbreviation allows, and regardless of the existence of a critical or questioning literature (see, e.g., Arber, 2004; Miller, Eldredge and Dalton, 2017), McCaffery-lite propositions are frequently presented in an unproblematised manner, and assertions to the effect that ‘pain is what the patient says it is’ appear without qualification – or very little qualification – in numerous nursing and healthcare texts (see, e.g., Clarke and Iphofen, 2008; Copeland, 2020; Dubos, 2018; Jenerette et al., 2015; Jones, 2018; Malcolm, 2015; Melville and Grogan, 2019; Sonneborn and Williams, 2020; Swain et al., 2018).

Generalisation misleads and, indisputably, some educators do engage with the totality of McCaffery’s extended work. Nonetheless, in discussing McCaffery (1972), henceforth it is the bowdlerised version of her core message which is referenced. Explicitly, her assertion that ‘verification of pain by others is meaningless. [And] Pain can be verified only by the person experiencing it’ (p. 7) is, here, taken to signify ‘McCafferyism’.

Not, I hasten to add, that this condensed conception lacks merit. Asking those we care for how they feel is a sensible way of opening discussion into mood/affect and listening to patients requires no defence. However, without in any way suggesting that nurses ought not to heed patient verbal and nonverbal ‘statements’ (which would be foolish), let us ask – if we take McCaffery’s position to be encapsulated in the notion that pain can be verified only by the person experiencing it, might this proposal be introduced to students simply as a topic for discussion? That is, within the academy, can her idea be debated in a manner that allows students to query and possibly reject what is proposed? Or, given the normative weight that attaches to ‘listening to patients’, a weight undergirded by mainstream interpretations of professional values, is this option inadmissible?

To disaggregate the issues thrown out by these questions, and to explore the idea that professional values/norms and specific forms of criticality can be in tension, the assertion that pain can only be verified by the person experiencing it, and the allied assumption that nurses must accept or believe patient reports, is problematised. Problematisation is intended to highlight the complexity of ‘value choices’ confronting educators. I am not, to restate, suggesting we shouldn’t listen to patients.

Two approaches to pain

Pesut and McDonald (2007) outline two schemas for making sense of pain reports. The first of these, termed externalism, positions pain as an experience that can be misperceived by the experiencing person, and Davidson (2006 [1984]), in a related discussion, highlights a few of what might be considered its salient features.

Though there is first person authority with respect to beliefs and other propositional attitudes, error is possible; this follows from the fact that the attitudes are dispositions that manifest themselves in various ways, and over a span of time. Error is possible; so is doubt. So we do not always have indubitable or certain knowledge of our own attitudes. Nor are our claims about our own attitudes incorrigible. It is possible for the evidence available to others to overthrow self-judgements.

(Davidson, 2006, p. 243)

It may seem odd to hold that first-person testimony about experience or attitude can be in error. Surely, the beliefs we have about our own pain are necessarily correct? Yet this is the possibility externalism describes.

Error for externalists has nothing to do with deliberate dishonesty. Rather, externalism allows that individuals may be mistaken about fundamental aspects of self-understanding, and regards pain, when this phenomenon is experienced, externalists permit that experiencing subjects might misconstrue the degree, intensity, or location of experience.

The role of the doctor is to ‘treat’ or ‘handle’ the patient . .. The German word for treating a patent is behandeln, equivalent to the Latin palpare. It means, with the hand (palpus), carefully and responsively feeling the patient’s body so as to detect strains and tensions which can perhaps help to confirm or correct the patient’s own subjective localization, that is, the patient’s experience of pain . .. We all know how difficult it is . .. to locate exactly where pain is coming from. This is why pain must be ‘drawn out’.

(Gadamer, 2004, p. 108)

The need for assistance in identifying and, possibly, legitimising pain is recognised by Gadamer (2004) when he notes the role played by carers in elucidating and explicating patient experience. And to the extent that introspection is ‘an unreliable way of finding out what’s going on in one’s own mind’ (Williamson, 2020, p. 106), externalists question the idea that subjects unproblematically know what it is they feel when, for example, they note that fear or depression can cause comparatively trivial slights and injuries to appear more momentous than they ‘really’ are to the experiencing person. Moreover:

patients may be considered wrong about their perceptions of the extent of bodily damage; however, this does not imply that they are not experiencing pain. Patients can be supported in their beliefs of pain while helping them to understand that the actual bodily disturbance may be less than what they believe.

(Pesut and McDonald, 2007, p. 259)

The second approach identified by Pesut and McDonald (2007) is labelled non-representationalism. This refuses the externalist contention that experience can be ‘misread’ by experiencing individuals and, in addition, it treats pain holistically. That is, contra externalism, non-representationalism identifies pain as a phenomenon in which ‘physical and existential aspects necessarily coincide’ (p. 256), and from this perspective, misidentification is vetoed.⁵

Both approaches, Pesut and McDonald assert, require that nurses believe patient reports, and this requirement is shortly questioned. Nonetheless, vitally, contrasting forms of decision-making and action are permitted depending upon the type of assessment adopted.

For example, externalist nurses differentiate (attempt to differentiate) reports of pain from mood/affects such as angst, suffering or meaninglessness-ennui. That is, externalists judge the sense and content of what patients say (verbally and nonverbally) and, potentially, externalists will discount reports when, in their opinion, patients misapprehend experience. Nurses who take up non- representational conceptions do not, however, judge in the way externalists do. Instead, non-representationalists accept what patients say (verbally and nonverbally), and ‘the experience of pain exists if the patient says it does’ (McCaffery, 1972, p. 7). Since non-representationalists cannot conclude that patients are mistaken about their experiences, overlap exists between non-representationalism and widely peddled albeit simplified versions of McCaffery’s position.⁶

Pesut and McDonald’s (2007) paper outlines ideas that would, one imagines, be of interest to any educator involved in introducing students to thinking about pain. However, despite evidencing significant scholarly rigour, the position of this paper in nurse education could be thought problematic. Specifically, educators may be reluctant to introduce the work or the ideas it contains. Reluctance in this instance is not tied to inaccuracies or flaws in argument. Nor is it a reflection of the difficulty of argument. Instead, reluctance stems from the threat posed by externalism (and externalism’s implications) to commonly promulgated caricatures of McCaffery’s ‘line’. Thus, when educators take up non-representationalism, and assuming close links between non-representationalism and McCaffery-like dictums, engagement with Pesut and McDonald’s paper could destabilise ways of acting that are sanctioned by professional normative commitments (‘correct’ practice), and it will therefore be ignored.

The preceding claims will not be empirically demonstrated. They may be undemonstratable. Moreover, juxtaposing ‘ideas’ against ‘reluctance’ in this manner presents a staged construction. On the other hand, this is not a strawman argument and...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Table of Contents
• List of Contributors
• Foreword
• Introduction
• Chapter 1 Pain is (or may not be) what the patient says it is – professional commitments: objects of study or sacrosanct givens?
• Chapter 2 Who wants a radical nursing curriculum?
• Chapter 3 Moral Realism: Is it plausible?
• Chapter 4 No Moral Compass: A Critique of the Goals and Methods of Contemporary Nursing Ethics Education
• Chapter 5 Metaphysics and research education in nursing
• Chapter 6 Making Sense in Nursing Education
• Chapter 7 Educational Entropy in the 21st Century: A failure to adapt?
• Chapter 8 The social mandate of nursing: a mandate unfulfilled
• Chapter 9 Meillassoux, correlationism, and phenomenological transcript analysis
• Afterword
• Index