Philosophy and theory: scholarly perspectives and frameworks

Nursing Philosophy

A Philosophy of Nursing

Like every profession, nursing is both a commonly shared calling and a very personal one. Every nurse shares certain professional standards with all of his or her colleagues, has in common a large number of experiences, has been educated and certified through similar processes. but, despite these many concurrent aspects of the lives of all nurses, the drive that each nurse feels to enter the profession and -- even more -- to stay in it decade after decade reflects very personal goals and values. This paper explores my personal nursing philosophy. This philosophy is an amalgam of my education and training, my personal ethics and values that sustain me not only within the profession but as an individual in all aspects of my life, and the wisdom of those who have come before me in this profession.

I begin this assessment of my own philosophy with an assessment of the different critical perspectives that inform nursing philosophy in general today. Some have more personal appeal to me than do others, but each one of them is important in terms of shaping the profession as it is practiced today and thus in terms of shaping me as a nursing professional. While I believe that I have thought deeply about these issues, it is important for me to note that I expect that my guiding professional philosophy will change over time, as I would expect that of any professional to do. Each day brings new opportunities to learn; this is especially true of each new patient. As I continue with my work as a nurse, I shall continue to refine my philosophy to honor what my working life allows me to learn.

Inter-relationships among philosophy, theory, and science

Those unfamiliar with nursing -- beyond the occasional contact with a nurse in an emergency room or while getting a vaccination -- may be surprised to learn that there is any theory or philosophy to the profession at all. Even to the experienced nurse, this view is understandable, for nursing is fundamental practical. Nurses are defined in large measure as the people who do not panic in any situation and know exactly what to do in any contingency. Such a practical (if expansive) basis of knowledge does not (necessarily) seem to have any theoretical basis.

Indeed it is probably true that many nurses, like many other professionals, go through their day without consciously realizing that they are tapping in to a unified (or at least mostly unified) set of precepts and values that underlie and support their behavior and the choices that they make. There is nothing at all wrong with this, of course. Indeed, the very reason that one has an integrated philosophy that informs daily behavior is that in the moment-to-moment rush of getting everything done that needs to be done one cannot continually be consulting a complex series of mental paradigms.

However, this does not mean that one should never stop to consider the ethos that informs one's professional identity. Not only does such a process help ensure that one does not stray from one's core values (sadly, something that is all-too-easy to occur in the chaos and frustrations of daily life), but it helps to ensure that one's ethical code evolves as one gains increased experience and knowledge in one's field.

Moreover, to suggest that a unified philosophy is not relevant to a profession that is as dependent on practical skills is to suggest that the airline mechanic testing the rudder of a plane does so without any understanding of or relationship to aeronautic engineering. What nurses do seems so simple and straightforward precisely because it is founded in an overall theory of how healthcare should be administered. Among the most important theories that has informed nursing since at least the 19th century is the theory or model of empiricism. In essence, empiricism is a philosophy or theory that one's actions should be based on fact, especially fact that is verified through experimentation. This is the basis of the scientific method from its inception.

Empirical Bases of Nursing

Given that nursing is in no small part a scientific field, it must at all times be informed by empiricism: The biology of the human body is based on tolerances that are known and that must be respected. However, the knowledge that arises in the laboratory -- no matter how valid or secure -- is not the only basis for nursing. One of the great challenges for all medical professionals, including nurses, is how to blend knowledge that arises in the context of basic science and knowledge that arises within the context of the practice of medicine (Meleis, 2006, p. 81).

There is, in fact, a long-running tension between the ways in which knowledge is developed and deployed in the medical field. Very few doctors and nurses are also research scientists; the reverse is also true. This is not surprising: Given the time required both to train for these different fields and to practice them very few individuals could possibly do both. But the fact that scientists who develop new medicines, new devices, and new protocols are divorced from the complexities of actual medical practice can prove to be highly problematic.

Faced with scientific, empirical facts and advice that do not seem to hold up to the immense (and even seemingly immeasurable) complexity that exists in the patient-to-patient variability of medical practice, there can be a temptation to throw out what is useful from basic science with the bathwater of experimental simplicity (Chinn & Kramer, 2010). This is highly unfortunate, given that without the rigorous protocols of science medicine would be little more than prayer.

In other words, there is more than one way to learn about the world. The medical professional must acknowledge this and not be too wedded to a single approach.

Constructivist and interpretivist models of nursing

Medicine is often described as a blend of science and art, and this is true. But even this understates the complexity of medical (including nursing) practice and theory, for science is only one of the rational ways by which humans acquire knowledge. The knowledge that is derived not through experimental means but through real-life experience under the incredibly complexity of real-life conditions (as opposed to the artificially simplified conditions of a laboratory) must be honored as well (Chinn & Kramer, 2010, pp. 217-9).

Nursing theory and epistemology -- the ways in which knowledge is created and transmitted within the profession -- must be multi-layered and multi-valent. The ways in which nurses learn from their education wedded to their own experience must be blended together in ways that honor the black-and-white nature of many important scientific findings and the ways in which experimental findings must constantly be massaged to fit the rapidly changing nature of working with a patient.

This is an essentially constructivist perspective, a theoretical model that posits that knowledge must come from as many valid sources as possible and that it is the responsibility (as well as the privilege) of each individual to construct a personal compendium of the possible ways of learning, knowing, and interpreting from all of the different ways of acquiring knowledge and skills. The fact that nurses must draw from different sources and determine for themselves what relatively weight they should give to different types of information from different sources.

This is a heavy responsibility for each nurse. It is intellectually and cognitively easier (in generally) as well as ethically less problematic to accept a set of fact or a professional philosophy in whole-cloth fashion rather than having to quilt together a personal philosophy. However, this latter approach can be much more personally satisfying (Reed & Shearer, 2007, pp. 148-9). It can also be sufficiently flexible to carry a nurse through all of the complicated situations that s/he will meet.

Historicism and hermeneutics

Another key aspect of the way in which nursing philosophy has been shaped is the idea of historicism, which is simply the idea that all knowledge bears the marks of its historical birth. Nursing knowledge and theory, in other words, is a product of each time, and the differences between one historical period in nursing and another period is not simply a question of factual knowledge and technology but also of ideas about how humans learn and understand. This idea, at least in its modern form, has its basis in the writings of Karl Marx (Reed & Shearer, 2007, p. 211).

Each of these theories of nursing, of how nurses learn to do their jobs, of how they transmit that knowledge to the next generation as well as to other medical professionals and to their patients, informs and influences other models.

One final thread in the tapestry of nursing philosophy is worth examining here in some detail, that of hermeneutics. Hermeneutics is essentially the study of how people interpret information and the world around them. Of especial interest to a hermeneutic philosophy of nursing is the idea that all ideas have assumptions buried in them and that these assumptions, these pre-conceptions, must be carefully examined to ensure that they remain relevant to current practice.

There are clear philosophical connections between the core ideas of hermeneutics and those of historicism, because each posits a potentially radical degree of relativism. Rodgers & Knafl (2005) explore this, arguing not for a return to any radical empiricism but rather to acknowledge that while knowledge and certainly medical praxis is socially constructed (and constructed along lines of socially sanctioned power hierarchies), there are fundamental empirical elements to nursing that cannot be trivialized.

Moreover, Rodgers & Knafl (2005, p. 118) argue that such a trend towards a radical sort of relativism (or, perhaps more accurately, a fully realized postmodernism) is not in keeping with the philosophical tenets and requirements of the hermeneutic writers that nurses have embraced: While knowledge is certainly socially constructed, the key to a hermeneutic reading is a focus on the social nature of the way in which knowledge is created and transmitted.

It is important to note that this is in no way an argument for a privileging of solipsism. Hermeneutics is not at any level an attempt to validate the idea that we can each make up our own reality. Indeed, to suggest anything like this is to do a great disservice to this philosophy (Rodgers & Knafl, 2005, p. 120).

A hermeneutic approach requires an individual to understand how the ideas current in a particular historical moment create complicated connections between new and old knowledge and practice. This requires nurses (in this case) to understand how they as part of an entire medical team are being influenced by past notions of how they should work.

An historical perspective

This very brief overview of some of the most important philosophical theories that have informed and continue to inform nursing practice demonstrates how much the profession has changed over the last several generations of nursing. At its inception as a profession, that is, during the Civil War, nursing relied on rationalism and empiricism as much as possible. This should hardly be a surprise for two distinct reasons. The first of these was that early leaders in the movement to professionalize nursing (for of course, nursing as a practice is as old as the human family) were women who wanted their work to be taken seriously.

In the very male world of medicine in which they were working, the first nurses had little choice but to borrow the masculine language and ideas of science as a way to validate to the rest of the world the work that they were doing. nor, it seems likely, would they have been otherwise inclined to reach outside of the scientific perspective as a way to understand and explain their own work. Nursing as a profession arose (and this is of course not entirely coincidental) during the decades in which the Industrial Revolution was bringing the practical applications of science more and more to the forefront of daily life.

The shift to a more constructivist, less empiricist view of nursing has come about since the middle of the last century, and especially since the 1970s. This was due in some significant part to the fact that as more and more nurses were educated in formal university nursing programs (rather than receiving training more on the job), they became more and more influenced by the dialogue that was going on in other areas of academia. Just as the rest of society was caught up in radical changes during the 1960s, the university too was changing, admitting theories such as historicism (all the way through the most radical forms of postmodernism) that required people in different fields to recognize that truth is often far more relative than is comfortable to acknowledge (Tomey & Alligood, 2005).

The last decade and a half have seen something of a pendulum shift back to a more empirically informed philosophy of nursing. The pendulum will never swing back as far as it once was, for there was a certain (dangerous) naivete to the original empirical writings in all of the medical fields. (Indeed, there remains in many fields of medicine a certain disingenuousness about the extent to which medical knowledge is True). However, medicine -- unlike literary criticism, for example -- can never be radically relativist. There are facts in medicine that can never be negotiated or reinterpreted.