Developing a Philosophy of Nursing


Edited by: June F. Kikuchi & Helen Simmons

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  • Dedication

    To Shirley Marie Stinson


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    We deeply appreciate all those who participated in one way or another in the production of this volume. We are grateful for the generous cooperation of the contributors.

    Particularly, we thank the Alberta Foundation for Nursing Research for contributing the funds necessary to prepare the essays for publication; we hasten to add that the views expressed herein are in no way intended to convey the views of the Foundation on any of the topics. We also thank Dr. Marilynn Wood, Dean of the Faculty of Nursing at the University of Alberta as well as the faculty for their sustained support of the Institute for Philosophical Nursing Research, under the auspices of which the present volume is published.

    Our special thanks are due and granted to Vicky Dancer for her patience and expert help in typing the manuscript. Also, we thank Christine Smedley, our editor at Sage Publications, for “coming through” for us on the many occasions we needed and used her editorial advice. Finally, we renew our expression of gratitude to those graduate nursing students at the University of Alberta whose eagerness to philosophize about the nature of nursing is a standing inspiration to us.

    Prologue: Clarifying the Nature and Place of a Philosophy of Nursing

    If a study of the history of philosophical thought in nursing were to be undertaken, there would be no end of materials for nurse historians to study and analyze. Nurses have reflected upon, and continue to reflect upon, the nature of their work and they continue to put their thoughts in writing, as a “philosophy of nursing.” These philosophies have taken various forms: personal philosophy, institutional philosophy, and professional philosophy.

    The conceptualizations of nursing that have been developed and, of late, variously called “conceptual models,” “conceptual frameworks,” “theoretical frameworks,” and “nursing theories” appear to resemble professional philosophies of nursing—a professional philosophy of nursing being one in which what is thought to be true about the nature of the profession of nursing is set down, providing a basis for nursing activity. However, the opinion that these conceptualizations are not philosophies of nursing has persisted, and continues to persist, in nursing thought with only occasional questioning of the validity of this claim.

    Because these conceptualizations were generated for the purpose of directing the development of professional nursing practice and research through answering questions about such matters as what is good to do and seek in nursing and what is the nature of nursing science (philosophical questions that these conceptualizations do address), and because neither the conceptualizations nor the idea of a philosophy of nursing is new to nurses, it is curious that it is only relatively recently that the idea that these conceptualizations may indeed be philosophies of nursing has begun to be seriously entertained. Why has this change been so long in coming?

    One possible reason may be that, once again, we, in nursing, have fallen victim to the fallacy of ad hominem—we have been willing to accept as true, without critical analysis, that which has been proclaimed to be true regarding these conceptualizations by those whom we consider “experts.” For instance, have we not asked our graduate nursing students to evaluate these conceptualizations in terms of the evaluation guidelines that have been developed by “experts” for that purpose, without our first having identified the philosophical underpinnings of those guidelines particularly as they pertain to the nature of knowledge and truth? Have we not been indoctrinating our students and others into thinking that the only tests of truth applicable to these conceptualizations are those used in the evaluation guidelines? Time and again, do we not uncritically quote the “experts” on the matter of the nature of these conceptualizations? The idea that these “experts” could be in error does not seem to be entertained by us.

    In nursing knowledge development we still seem to be operating under the fallacious premise, “If nurse A, who has written or spoken prolifically on subject X, says Y is true, then Y must be true.” Operating under this premise, if we find that what nurse A says does not make sense to us, we tend to conclude almost automatically that the fault lies with us. We attribute the problem to some deficit in ourselves—our lack of knowledge, our lack of sophistication, our lack of intelligence, or some other deficit. In doing so we do not examine the claims of nurse A for possible errors. Consequently, if any errors exist, they are allowed to go unchecked. The danger inherent in this sort of behavior is clear: Whatever errors exist remain intact, to be compounded later when the false claims are used as a basis for making further claims. Examples of this compounding of error abound in the nursing literature.

    Another possible reason for our reluctance to entertain the idea that the conceptualizations of nursing, which we have been studying and using, may be professional philosophies of nursing (albeit in underdeveloped form) is not far to find. It may be that we are unclear as to what a philosophy of nursing is by nature and what it is not, and unclear, too, about the essential difference between philosophical and scientific theories, not to mention our uncertainty about even the existence of the former. If it is true that we are unclear or uncertain about these matters, then have we been making uninformed or misinformed judgments about these conceptualizations and philosophies of nursing, and, in the process, have we been erroneous in how we have conceived the development of nursing knowledge?

    Those of us who think that the conceptualizations are theories but that only scientific theories exist, and have not apprised ourselves of nor accepted the existence of philosophical theories, would not have entertained the idea that the conceptualizations may be philosophical theories of nursing, albeit incomplete ones. Further, those of us who think that the only way to develop a theory is through the use of scientific methods would not have entertained the idea that the conceptualizations are theories in that they were not developed using scientific methods. Rather, we might have judged the conceptualizations to have the form of mere opinion, fanciful imaginings conjured up by their creators as they sat and mused in an armchair. In fact this judgment has been expressed in the nursing literature. Further, some might consider all philosophical work to be nothing but mere opinion. In that case the idea that these conceptualizations may be philosophical theories of nursing, philosophies of nursing in some form arrived at through the use of legitimate philosophical research methods that entail armchair reflection and reasoning upon common-sense knowledge, would not have been entertained.

    The denial, for whatever reason, that the conceptualizations of nursing are philosophies of nursing leaves open the question of how these two kinds of entities are related one to the other, if indeed they are. This question has not been adequately addressed in the nursing literature. If nursing, as a discipline, is to develop in a way that will permit it to take its rightful place among the disciplines and make a significant societal contribution, then the confusion that currently exists in nursing thought about the nature and place of a philosophy of nursing must not be permitted to escalate. We must seek clarity on this issue without delay. We must seek common ground as to what a philosophy of nursing is. Further, the diversity of thought that exists in nursing philosophy must be accommodated, and accommodated in such a way that we avoid embracing either of two extreme positions: (a) only diversity of thought ought to be sought or (b) only unity of thought ought to be sought. Finally, we must articulate a sound philosophy of nursing—one that consists of knowledge, not mere opinion, and one adequate to guide nursing practice, education, research, and administration.

    The foregoing imperatives constitute a tall order. To meet them successfully will require that we work cooperatively for the common good of the betterment of nursing and those nursing serves. We will have to be guided by one aim—to gain a better and better grasp of the truth of the matter under consideration—rather than by such irrelevant aims as winning the argument or proselytizing. We will have to be disciplined enough to refrain from arguing prior to coming to terms with one another—until we have a common understanding of how terms are to be used and of the question to be answered. In argument, we will have to state explicitly where we sit on the issue under discussion so other parties to the controversy are not left guessing what our position might be. The more explicitly we can state what we are presupposing or assuming to be true in our claims, the more readily we will be able to get to the heart of the matter—the sources of our opposing viewpoints—and, thence, to nursing truths.

    It is with the aforementioned imperatives and the need for disciplined discussion in meeting them in mind that the Institute for Philosophical Nursing Research held an invitational conference in 1991 designed to uncover, through philosophical discussion, the sources of opposing viewpoints on matters integral to developing a sound philosophy of nursing. This collection of essays constitutes the treatises on that theme, delivered at the conference. Each essay is devoted to a topic related to the theme that, upon being subjected to discussion, holds the potential of contributing to the aim of uncovering the presuppositions and assumptions held by discussants of the topic.

    The book is divided into three parts. Part One is devoted to the topic of establishing common ground in nursing philosophy, Part Two to accommodating diversity in nursing philosophy, and Part Three to articulating a sound philosophy of nursing.

    Because one of the most difficult tasks in philosophical inquiry is that of recognizing what presuppositions or assumptions one is forced to accept as true in adopting a given position on a philosophical matter, guiding questions are included in this collection of essays. Their purpose is to assist the reader in identifying and clarifying what may lie behind the position being taken by the author (and even by the reader) of an essay. Some of the questions posed are intended to serve another purpose: to help the reader get the most out of the essays. Given these purposes, guiding questions have been placed after the introductory comments to each part of the book. None of the questions is intended to be used as a test of knowledge. They are posed primarily for the benefit of the reader in making up his or her own mind on the topics addressed in the essays.

    It is our hope, as editors, that this collection of essays will be read and discussed with a view to seeking a better understanding of what it will take to establish a sound philosophical basis for the development of nursing practice, education, research, and administration in the years to come. By no means does this collection of essays provide a ready-made or complete answer. If it succeeds in stimulating philosophical discussion about the nature, place, and articulation of a sound philosophy of nursing, then our purpose in putting forward this volume will, in large part, have been met.

  • Epilogue: Making Progress in Developing a Sound Philosophy of Nursing

    In the prologue to this volume three imperatives were set down for the nursing discipline: establish common ground in nursing philosophy, accommodate diversity of thought in nursing philosophy, and articulate a sound philosophy of nursing. The sound advancement of any discipline is dependent, in large part, on the ability of its adherents to establish common ground and to accommodate diversity of thought in philosophical matters relevant to its domain, and to articulate a sound philosophy of the discipline. Nursing is no exception.

    The progress we will be able to make, in the years to come, toward meeting the foregoing imperatives will depend on our ability and willingness to philosophize, in a sound and just manner, about relevant philosophical issues—issues such as those raised in this volume. All of us who have been party to philosophical discussions in which there has been more heat than light would agree, we think, that philosophizing in this manner is not an easy task. It requires, at least, that we be able to, and do, listen and speak in as nonbiased a manner as is humanly possible. It requires, too, that we be able to, and do, identify what is being put forward in a biased or misconstrued manner, by others or by ourselves. It requires that we be able to, and do, use appropriate epistemological standards in judging the validity of any claim that is made.

    With regard to the last requirement stated above, some elaboration is warranted. If, say, during a philosophical discussion about the nature of human beings, a scientific proposition about human beings is put forward, then scientific epistemological standards must be used to judge its validity. If a philosophical proposition is put forward, then philosophical epistemological standards must be invoked. Presupposed in all of this is that one is knowledgeable about the different modes of inquiry and about the epistemological standards and questions proper to each, and, in addition, that one is able to identify what lies within the jurisdiction of one mode of inquiry rather than another. It further presupposes that one knows and can identify the difference between mere opinion and probable truth.

    The progress that we will be able to make toward the development of a sound philosophy of nursing will, of course, depend on our affirmation of philosophical inquiry as a legitimate mode of inquiry. Furthermore, it will require that we make room for philosophical inquiry in the realm of nursing research—and in such a way that we utilize its power to best advantage. We must go beyond using philosophical inquiry only to help us clarify the meaning of words or experiences of significance in nursing, or simply to answer ethical nursing questions. We must turn to it in our attempts to answer nursing questions of an ontological nature such as those concerning the nature of nursing and of a philosophy of nursing—and epistemological nursing questions, particularly those concerning the criteria by which conceptualizations of nursing are to be assessed and the measures of truth appropriate to nursing practice.

    Finally, if we are to make progress in developing a sound philosophy of nursing, we will have to make at least one very tough decision. We will have to decide to seek agreement on some basic philosophical matters (and on the standards that we will use to do so). Here, we are thinking of such matters as the nature of reality, the nature of human beings, the nature of objective truth and of subjective truth, and the nature of knowledge. Unless we can come to some agreement about these foundational philosophical notions, it is difficult to see how we can make any progress at all in developing a sound philosophy of nursing.

    The consequences of not developing a sound philosophy of nursing to guide our research, practice, administrative, and educational endeavors seem to be clear. One need only observe what is happening, today, in and to nursing, to appreciate how urgent is the need to develop such a philosophy. How much longer can nursing afford to give full rein to our laissez-faire attitude? How much longer can nursing allow us to try to hold onto everything and not let go of anything in all that we do in nursing research, nursing practice, and nursing education? How much longer can nursing survive the tendency of nurses to hold contradictory ways of viewing nursing's central concerns?

    Today, in nursing, we are making promising strides in ensuring that the formal knowledge nurses require to nurse in an informed, reasonable, and moral manner will be developed and made available. We are preparing nurse scientists in unprecedented numbers. Given our progress, the immediate challenge before us is to prepare nurse scientists, historians, and philosophers who understand the necessity and place of a sound philosophy of nursing in the development of nursing knowledge.

    June F.Kikuchi

    About the Editors

    June F. Kikuchi, R.N., Ph.D., holds the positions of Professor and Director of the Institute for Philosophical Nursing Research (IPNR) at the University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada. She received a B.Sc.N. from the University of Toronto and an M.N. and a Ph.D. (Nursing Care of Children) from the University of Pittsburgh. Postdoctorally, she studied philosophy at the University of Toronto. She is the cofounder of the IPNR. She has published papers on philosophical nursing inquiry and knowledge, nursing knowledge development, and the quality of life of children of disabled parents. She has presented papers nationally and internationally on those topics as well as on the development of nursing research in health-care agencies. She is the co-organizer of a series of biennial invitational philosophical nursing conferences, “Philosophy in the Nurse's World.”

    Helen Simmons, Ph.D., is Associate Professor and Associate Director of the Institute for Philosophical Nursing Research (IPNR) at the University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada. She formerly held a joint appointment as Special Projects Consultant at the Edmonton Board of Health Nursing Division. She received a B.A. (Psychology and Philosophy) and an M.A. (Clinical Psychology) from the University of British Columbia, and a Ph.D. (Educational Psychology) from the University of Oregon. She has pursued studies in philosophy, postdoctorally, at the Aspen Institute for Humanistic Studies. She is the cofounder of the IPNR and the co-organizer of the “Philosophy in the Nurse's World” conference series. Her publications and presentations have focused on health, public health, philosophical nursing inquiry, and nursing knowledge development. She was awarded an honorary life membership in the Alberta Association of Registered Nurses for her contributions to the nursing profession.

    About the Contributors

    M. Patricia Donahue, R.N., Ph.D., F.A.A.N., is a Professor at The University of Iowa, College of Nursing, Iowa City, Iowa. She received a diploma (Nursing) from St. Luke's Hospital School of Nursing, a B.S.N. and an M.S. (Medical/Surgical Nursing) from The Ohio State University, and a Ph.D. (Social Foundations of Education, History, and Philosophy) from The University of Iowa. She is a Staff Nurse of the Medical Nursing Pool at The University of Iowa Hospitals and Clinics. Her areas of publication include nursing history and nursing ethics. She has received several outstanding awards including three American Journal of Nursing Book-of-the-Year Awards as author of Nursing: The Finest Art. An Illustrated History and Nursing: The Finest Art. Masterprints. She is one of the United States' most outstanding nurse historians.

    Jacqueline Laurin, R.N., D.N.Sc., is Professeure titulaire, Faculté des sciences infirmières, Université de Montréal, Montréal, Québec, Canada. She holds a B.Sc.Inf. (Nursing) from the Institut Marguerite d'Youville, Montréal, an M.N.Sc. from Wayne State University, and a D.N.Sc. from the Catholic University of America. She has produced several publications in her professional interest areas, which include evaluation of the quality of nursing care, theories and conceptualization in the health sciences, and the philosophy and science of nursing. She is known for her book Qualité des soins infirmiers: Concepts et évaluation and for her preface to the 1987 French edition of Dorothea Orem's Nursing: Concepts and Practice. She has served as a consultant in numerous settings on Orem's conceptual model of nursing. She was the first nurse to pursue doctoral study at the Institute for Philosophical Nursing Research in Edmonton, Alberta, Canada.

    Myra E. Levine, R.N., M.S.N., L.H.D. (Hon.), F.A.A.N., holds the position of Professor Emerita at the University of Illinois, College of Nursing, Chicago, Illinois. While at the University of Illinois she held an Adjunct Professorship in Humanistic Studies. She received a diploma (Nursing) from Cook County School of Nursing, a B.S. from the University of Chicago, and an M.S.N. (Medical/Surgical Nursing) from Wayne State University. She has received many honors and recognition for her outstanding scholarly contributions to nursing both in the United States and abroad (Canada and Israel). She is a Charter Fellow of the American Academy of Nursing. She has on numerous occasions served as a consultant, keynote speaker, and guest lecturer on practical and theoretical (philosophical) matters of concern in the progress of nursing knowledge development and practice. Her conceptual model for nursing has gained respect in nursing practice, education, and research.

    Marian McGee, R.N., Dr.P.H., is Professor on the Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, Ontario, Canada. She received a diploma (Nursing) at Kitchener-Waterloo Hospital, a B.N.Sc. from Queen's University, and an M.P.H. and a Dr.P.H. from The Johns Hopkins University, School of Hygiene and Public Health. Her areas of academic specialization include public health administration, community health nursing, and nursing theory development. She has served as a consultant to various organizations, at home and abroad, including the World Health Organization. She has published and presented numerous addresses on topics of international interest to the nursing and public health community.

    Ginette Pagé, R.N., Ph.D., holds the position of Professeure in the Department of Biology and Health Sciences at the University of Québec at Rimouski, Rimouski, Québec, Canada. She received a diploma (Nursing) from Maisonneuve Hospital; a diploma (Public Health Nursing), a B.N., and an M.N. (Psychiatric/Mental Health Nursing) from the University of Montréal; and a Ph.D. (Nursing) from Wayne State University. Her areas of expertise, in which she has both presented papers and published, include nursing theory development, primary health care, and Margaret Newman Science of Health. She is a Founding Fellow and Governor of the Nightingale Society. She has held nursing consultantships with the World Health Organization (French Polynesia).

    Lynn Rew, R.N., C., Ed.D., F.A. A.N., holds the positions of Associate Professor and Assistant Dean at The University of Texas at Austin, School of Nursing, Austin, Texas. She received a B.S.N. from the University of Hawaii and an M.S. (Community Health Nursing) and an Ed.D. from Northern Illinois University. Areas of expertise in which she has published and served as consultant, researcher, and invited speaker include nursing intuition, sexuality and sexual abuse, respiratory nursing care of children, and mental health nursing. She has received numerous honors and awards and has published extensively in nursing's foremost journals.

    Pamela J. Salsberry, R.N., Ph.D., is an Assistant Professor at The Ohio State University, College of Nursing, Department of Family and Community, Columbus, Ohio. She holds a B.S.N. from Case Western Reserve University, and an M.S. (Nursing) and an M.A. and Ph.D. (Philosophy) from The Ohio State University. She has served as the Administrative Assistant to the Deputy Director of the Medical Administration Department of Human Services in Columbus, Ohio. Her research and writing career has focused on scientific, philosophical, and ethical-political issues in the distribution and delivery of health-care resources and services.

    Rozella M. Schlotfeldt, R.N., Ph.D., F.A.A.N., holds the position of Professor Emeritus and Dean Emeritus at Case Western Reserve University, School of Nursing, Cleveland, Ohio. She received a B.S. (Nursing) from The University of Iowa and an M.S. (Nursing Education/Administration) and a Ph.D. (Education Curriculum Development) from the University of Chicago. She holds several honorary doctoral degrees as well as many other significant awards. She is recognized and respected nationally and internationally for her substantial contributions to the development of the nursing profession, particularly in the areas of nursing education and nursing knowledge development. Her conceptualization of nursing has gained the recognition of nurses. She has presented papers and published extensively in books and in professional nursing journals and newsletters. She has served in numerous locales as a visiting professor and has held a wide variety of prominent offices within nursing organizations.

    Marlaine C. Smith, R.N., Ph.D., is an Assistant Professor at the University of Colorado, School of Nursing. She received a B.S.N. from Duquesne University, an M.N.Ed. (Oncology Nursing-Education) and an M.P.H. from the University of Pittsburgh, and a Ph.D. (Nursing) from New York University. Her areas of expertise include consultation in, and evaluation of, the application of nursing practice models, nursing program development, nursing theory and knowledge development, qualitative research, and theory-based practice. She has presented papers at professional meetings and published extensively in her areas of expertise, most notably in Nursing Science Quarterly.

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