Interpretive Phenomenology: Embodiment, Caring, and Ethics in Health and Illness

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Edited by: Patricia Benner

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    This book is dedicated to Richard Benner, who has participated in, inspired, and supported every stage of this book.

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    Preface

    Hubert L.Dreyfus

    The authors in this collection of essays and studies collectively demonstrate the power of Heideggerian or Interpretive phenomenology for areas of study related to lifeworld, meanings, skilled know-how, clinical knowledge and everyday skillful ethical comportment. The background of this work and its philosophical underpinnings are described in Part I. Part II demonstrates how the powers of understanding and the skills, of allowing the text and the transitions in thinking that naturally occur when questioning and interpreting texts, shape the studies. The authors use Interpretive Phenomenology to study these everyday aspects of the world and give new access and vision to interpretive human studies. While each of the interpretive studies has a family resemblance, they are uniquely shaped by the questions asked and responses given by the participants. The family resemblance is not based on uniformly trying to get structures, processes, or functions of human capacities explained or described in the same ways. The similarities come from a shared understanding of what it means to be an embodied human-being that is self-interpreting and that takes a stand on being a particular finite human being in particular communities at a particular time in history.

    These authors reverse the usual hierarchical relationship between theory and practice. The relation between theory and practice and between reason and intuition has concerned our culture since our Western way of being human was first defined in ancient Greece. To understand the complicated relation between theory and practice and between reason and intuition illustrated in these studies, we have to go back to the time when Hippocrates was trying to move medicine from folk wisdom to a scientific art of healing, while, at the same time, Socrates, born 9 years after Hippocrates in 469 B.C., was trying to understand this new intellectual achievement, of which medicine was only one example. Around 400 B.C., physics, astronomy, and geometry had taken off from everyday, practical, measuring and counting and thinkers were asking: What is special about these new disciplines? The answer proposed by Socrates and refined by the philosophical tradition was that these new disciplines were based on theory.

    Descartes and Kant completed the Socratic account of theory by insisting that theory must be stated in terms of context-free elements, which we now call features, factors, attributes, data points, cues, and so on—isolable elements which make no reference to human interests, traditions, institutions, and so on. A theory must be a new whole in which decontextualized elements are related to each other by rules or laws. Plato clairvoyantly expressed all five characteristics in the myth of the cave: The theorist must remove his object of knowledge from the everyday, perceptual, social world in order to see the universal relations between the explicit and abstract elements, in this case the ideas. Freed from all context, the elements form a system of their own—all ideas are organized by the idea of the Good. Plato saw that while everyday understanding is implicit, concrete, local, holistic, and partial, theories, by contrast, are explicit, abstract, universal, and range over elements organized into a new total whole.

    What the authors in this book have done is revisit this monolithic assumption about the primacy of theory as being the source of knowledge and a meaningful human world and examine actual meanings and patterns of everyday, skilled, ethical comportment. For example, Socrates assumes in his dialogue, Euthyphro, that Euthyphro, a religious prophet, is an expert at recognizing piety, and so asks Euthyphro for his piety recognizing rule:

    “I want to know what is characteristic of piety … to use as a standard whereby to judge your actions and those of other men”(6e3–6). He wanted a principle that would ground piety in theory and so make it knowledge.

    A generation after Plato, Aristotle already suspected that something crucial had been left out of Plato's theory-based model of knowledge. Rather than being able to give reasons for their actions as the test of expertise, Aristotle sees, precisely, the immediate, unreasoned, intuitive response as characteristic of an expert craftsman. “Art (techne) does not deliberate” he says in Physics, Bk. II, Moreover, Aristotle was clear that even if there were universal principles based on a theory, intuitive skill was needed to see how the principles applied in each particular case. He (Thomson, 1953) derives an illustration from ethics, which Plato thought must be based on universal rules:

    [I]t is not easy to find a formula by which we may determine how far and up to what point a man may go wrong before he incurs blame. [Aristotle notes, and then adds:] But this difficulty of definition is inherent in every object of perception: such questions of degree are bound up with the circumstances of the individual case, where our only criterion is the perceptions.(p. 75)

    The same would, of course, apply to thinking about disease, health, and illness. Disease is a dysfunction of the body, a physical object governed by physical laws, so it should come as no surprise that Hippocrates' vision of the physician as scientist is finally being achieved. But it would be a mistake characteristic of our rationalistic culture to think that the success of medicine in any way suggests that there can be a theory of nursing as a caring practice. Caring, in the context of illness, consists in keeping open the possibilities that can be saved in the world of the sick person, while aiding the person in letting go of possibilities that are no longer realistic. If human beings were simply rational animals, as the Greeks thought, then it might be possible to reduce the world to theories about having a world and how to keep it. But as the existential thought of Soren Kierkegaard, points out human beings cannot be understood as some combination of body and mind. Human beings, Martin Heidegger, the most famous philosopher in existential phenomenology points out, are defined by their self-understandings and the stand they take upon themselves, which in turn sets up the range of possibilities open to them. On this view, human being is a unique way of being in that human experience and actions follow from their self-interpretation. The meaning of a whole life is basic and determines what possibilities show up and how they make sense to a person. Moreover, we are not objective, theoretical spectators of our lives and of the world, but involved participants. Things show up as mattering to us. Heidegger's project is to demonstrate that human being does not have fixed properties, like an object or animal, but that the basic human way of being is care. These papers show that care is a way of being that must be understood, preserved and enhanced in health care in general and by nursing as a caring practice.

    There can be no abstract, analytical theory of the human way of being in all its cultural and historical diversity and because it is holistic skilled practice, there can be no abstract, analytical theory of it. Caring is what one might call an existential skill. It is, indeed, what Socrates would have called a knack, but because, unlike cooking, it is a matter of life and death and involves the whole person, that term hardly seems appropriate. It shows the power of a tradition based on the theory of disease that the existential skills of caring have no traditional name that does honor to their importance and uniqueness, and we seem to have no appropriate word for them in our vocabulary. The best I can come up with is that caring, as a way of helping people by entering their world, is a higher kind of knowledge, which we can call understanding and the potential for what Aristotle called practical wisdom. Individually and collectively, the studies in this volume demonstrate the power of understanding for revealing human concerns.

    These studies show that much can be said about the tact involved in world preserving. They describe the general structure of human being, the way care consists of mattering, possibilities and inhabiting a shared world. This is what Heidegger calls an existential account of human being. They also describe in detail how specific cultures, families, and individuals structure their worlds. Because meanings are shared, one can also select and describe paradigm cases, laying out what matters and what possibilities are opened and closed in typical situations. One can then make qualitative distinctions between more and less successful interventions. They also examine the knowledge and skills residing in caring practices, growth and healing. Experts in caring know that they cannot be guided by principles or any pseudo-sciences of the psyche but must enter into the situation of the patient and be guided by participation and intuition.

    In this domain there can be no clinical knowledge as Plato would define it, but there can and must be clinical understanding. Thus in caring, as in the case of the application of medical theory, one finds a practice requiring involvement for which there can be no theory. But there is an important difference between the treatment of disease and the care of illness. Those engaged in caring must be able to take on the perspective of the patient and make his or her peace with the situation and its suffering in order to be touched by the situation of a fellow human being. They must have the tact to enable that person to face, surmount or weather his or her illness. Only by combining both technological and existential skills can we approach healing the embodied person.

    For the past 18 years, nurses have come to my courses in Kierkegaard, Heidegger, and interpretive methodology for the human sciences and they seem to have found there a language for the concerns, meanings, and practices of nursing. Few have had the usual philosophical background for taking existential phenomenology, but because of the concerns that are central to their practice they have contributed to class discussion and shown that they have found new ways of thinking about and articulating what they know in their practice. Typically they discover a new way of describing and understanding what it means to be human being, who is finite and always situated in a world with a history and concerns. In exchange, I have come to see that nursing draws on a mixture of natural and medical sciences and that in addition to the human sciences nurses need a way to criticize the Cartesian view of the person as a private subject standing up against an objective world. They need to be able to describe and legitimize the person in relation with others for coherence in their own self understanding as nurses engaged in caring practices. Finally, studying Heideggerian phenomenology seems to enable them to understand human beings in their physical and cultural diversity and not only as private, autonomous Cartesian selves.

    References
    Euthyphro, 6e3–6.
    ThomasJ. A. K. (trans.). (1953). Aristotle, Nicomachean Ethics as The Ethics of Aristotle (p. 75). New York: Penguin.

    Introduction

    PatriciaBenner

    Most agree in this postpositivistic era that significant distinctions between the natural and human sciences exist, but debate continues about over where and what the distinctions are (Hiley, Bohman, & Shusterman, 1991). Some argue that the physical sciences are far closer to the human sciences in their holism, whereas others argue for distinctions between the holism of the physical sciences and the human sciences. Dreyfus (1991) argues for scientific realism, attributing the particular kind of holism that exists in the natural sciences to an inability to account for the background habits, practices, and skills that create the science. For Dreyfus, holism in the human sciences is different in that it stems from not being able to account adequately for the malleability of human “nature” and embodiment shaped by cultural understandings, habits, skills, practices, and environment. The atom and the quark do not change their physical properties or responses because the physical scientist introduces a new description and interpretation of them. The authors in this book hold that the particular methodological assumptions of logical positivism and the preference for disengaged criteria-based reasoning (Taylor, 1993) in the human sciences cause a systematic bias for the study of breakdown and a systematic blindness to embodied, lived experience in learning, health, illness, and any human transformation that includes transitions and experiential learning.

    The chapters in this book reflect the work of a scholarly community who have worked out what interpretive phenomenology has to offer nursing science, nursing practice, the lived experience of health and illness, and health care ethics and policy. It was not possible to include all those who have participated in this dialogue, and where possible references to these works are made to extend the dialogue (see Appendix for a list of dissertations using interpretive phenomenology). Throughout the work, the teachings of Hubert L. Dreyfus (1979, 1991; Dreyfus & Rubin, 1991), Jane Rubin (1984), and Charles Taylor (1985, 1989, 1991, 1993) are evident. Each has sustained a conversation with nurses doing interpretive phenomenology over the past 11 years, teaching courses, giving lectures, and commenting on manuscripts. Because the chapters come from a community of scholars engaged in an ongoing project of developing interpretive phenomenology, the careful reader will sense the family resemblances and even the conversations between the contributors. The goal of this collection is to illustrate how this research tradition is worked out by different researchers with different lines of inquiry.

    The book has three aims: (a) to offer a philosophical introduction to interpretive phenomenology, (b) to guide the reader in understanding the strategies and processes of this approach to human science, and (c) to provide a wide range of high-quality interpretive studies so that the reader can see the family resemblance in the method while examining the variance created by the phenomenon being studied. The terms interpretive and hermeneutical are used interchangeably, though admittedly the term interpretive is more accessible. Part 1 presents theoretical and philosophical foundations as well as practical guidance for conducting interpretive phenomenological studies. Part 2 presents excellent examples of interpretive phenomenological studies that address a diverse range of questions.

    This work stands in the hermeneutical tradition found in the study of biblical texts, jurisprudence, historical studies, literary criticism, and anthropology (Geertz, 1973, 1983), but it is also shaped by the existential phenomenology of Kierkegaard (1843/1985), Heidegger (1975), Merleau-Ponty (1962), Wittgenstein (1980), Dreyfus (1979, 1991), and Taylor (1964, 1985, 1989, 1991) and thus goes beyond the strictly rationalist tradition in early hermeneutical methods. The commentary and articulation of interpretive phenomenology are similar to the kind of reasoning in transitions that occurs in particular practices such as nursing, medicine, practical moral reasoning, and law (see Thomasma, chapter 5 of this book; Taylor, 1993). By engaging in the interpretive process, the researcher seeks to understand the world of concerns, habits, and skills presented by participants' narratives and situated actions. These understandings are then used to contrast similarities to and differences from other participants' narratives and situated actions. Understanding human concerns, meanings, experiential learning, and practical everyday skillful comportment, when they are functioning smoothly or are in breakdown, is the goal as opposed to explanation or prediction through causal laws and formal theoretical propositions. It is posited that understanding is more powerful than explanation for prediction in the human sciences because it stands more fully in the human world of self-understandings, meanings, skills, and tradition. Prediction is possible only in limited ways for human beings who are self-interpreting and subject to change by the very interpretations offered by research. Prediction in the human sciences resists single-factor theories and explanations because human action and world always contain incomplete and multiple levels of meanings. The understanding sought in interpretive phenomenology considers historical change, transformations, gains, losses, temporality, and context. As in any human science, predictions are offered with qualifiers such as “all things being equal” or “barring no major changes in self-understandings and context, this is what may be expected” (see Plager, chapter 4 of this book; Dreyfus, 1991).

    The reader is challenged to consider the power of understanding for becoming more effectively, skillfully, or humanely engaged in practice. The ethos embedded in existential phenomenology is respect for the social and cultural nature of being human. Human practices, skills, habits, meanings, and, in particular, recognition practices allow for the other to be encountered and made visible (MacIntyre, 1981; Taylor, 1992). When unarticulated, taken-for-granted practices and meanings fade from our social ecology and the social fabric of our lives, and we lose what they enable us to see, create, and represent. This constitutive role of background meanings, practices, and skills is, according to Dreyfus (1991), the distinction between the physical and human sciences:

    Not just any cultural interpretation will disclose entities. If, instead of encountering heroes or saints, a culture begins to develop practices for encountering aliens that are round and give off beams of light, it may well be that nothing will show up at all. But there are no clear limits as to what kinds of cultural entities can be encountered [in the human sciences]. In physical science, however, there seems to be one right answer as far as physical causality is concerned. Radically different theories than those proposed by modern science presumably would not reveal physical causal powers. (1991, p. 38)

    The ethical issues of our understanding of a good life and what we consider to be an equal opportunity for the freedom to pursue health and happiness are central to whether our human science practices allow us to reveal, critique, and preserve a range of diversity in a pluralistic society. If our human science is monolithically patterned on the physical sciences, it will allow only decontextualized, elemental, rational, atomistic agents or overdetermined, radically unfree objects to be revealed. Aspects of being human related to being constituted by membership, participation, relationship, and human concerns will be covered over by the methods of the physical sciences. In the study of health and illness, we run the risk of medicalizing more and more spheres of human existence if our science allows us to study only disease, cellular processes, biochemistry, and treatments. We also exclude the possibility of studying health and smooth functioning.

    The works in this book struggle to uncover and restore to visibility and credibility of marginalized practices and other voices encountered in everyday skillful comportment. All chapters share a deep respect for the primacy of practice and the primacy of caring (Benner & Wrubel, 1989). Charles Taylor (1991) points out that what the works of Martin Heidegger (1927/1962), Maurice Merleau-Ponty (1962), and Ludwig Wittgenstein (1980) have in common is that

    they see the agent, not primarily as the locus of representations, but as engaged in practices, as a being who acts in and on a world….

    To situate our understanding in practices is to see it as implicit in our activity, and hence as going well beyond what we manage to frame representations of. We do frame representations: We explicitly formulate what our world is like, what we aim at, what we are doing. But much of our intelligent action in the world, sensitive as it usually is to our situation and goals, is carried on unformulated. It flows from an understanding that is largely inarticulate.

    This understanding is more fundamental in two ways: (1) it is always there, whereas we sometimes frame representations and sometimes do not, and (2) the representations we do make are comprehensible only against the background provided by this inarticulate understanding. It provides the context within which alone they make the sense they do. Rather than representations being the primary locus of understanding, they are just islands in the sea of our unformulated grasp of the world….

    This puts the role of the body in a new light. Our body is not just the executant of the goals we frame, nor just the locus of causal factors shaping our representations. Our understanding is itself embodied. That is, our bodily know how, and the way we act and move, can encode components of our understanding of self and world. I know my way around a familiar environment in being able to get from any place to any place with ease and assurance. I may be at a loss when asked to draw a map, or even give explicit directions to a stranger. I know how to manipulate and use the familiar instruments in my world, usually in the same inarticulate fashion.

    But it is not only my grasp on the inanimate environment which is thus embodied. My sense of myself, of the footing I am on with others, are in large part also. The deference I owe you is carried in the distance I stand from you, in the way I fall silent when you start to speak, in the way I hold myself in your presence. Or alternatively, the sense I have of my own importance is carried in the way I swagger. Indeed, some of the most pervasive features of my attitude to the world and to others is encoded in the way I carry myself and project in public space, whether I am “macho,” or timid, or eager to please, or calm and unflappable, (pp. 308–309)

    I have cited this long passage to allow the reader to trace the influence of Taylor's project of articulation in the tradition of philosophers who have studied the primacy of practices, world, and the relationship between body and world (see also Dreyfus, 1991). Social meanings and their embodied social postures, stances, habits, skills, and practices are relevant for recovery and rehabilitation, for nursing practice, and for skillful ethical comportment in caring for the ill (see especially SmithBattle, Chapter 8, and Doolittle, Chapter 11). Nurses deal with not only normality and pathophysiology but also with the lived social and skilled body in promoting health, growth, and development and in caring for the sick and dying. However, we have focused more on the mind than on the body and have not developed adequate language for the experience of skilled, responsive psychosocial bodies because of our “representational” Cartesian bias. Our medical metaphors have more to do with repairing and treating failed bodies than with promoting health or nurturing and facilitating the recovery of socially engaged, skilled bodies.

    Interpretive phenomenology cannot be reduced to a set of procedures and techniques, but it nevertheless has a stringent set of disciplines in a scholarly tradition associated with giving the best possible account of the text presented. The interpretation must be auditable and plausible, must offer increased understanding, and must articulate the practices, meanings, concerns, and practical knowledge of the world it interprets. Good interpretation is guided by an ethic of understanding and responsiveness. One must not read into the text what is not there. Self-knowledge is required to limit the interpreter's projection of his or her own world onto the text. The extremes of idealizing and villainizing are to be avoided. As with interpretive studies in literary criticism, readers can judge the fidelity, clarity, insightfulness, and comprehensiveness of the interpretation of the text (MacIntyre, 1993). The reader plays an active role in critically reading the interpretive work, judging the textual evidence presented by the author, and judging the interpretation against the reader's own knowledge of the subject and text, including aesthetic appreciation. The lines of inquiry of any particular study, plus the discoveries and dialogue within data collection, interpretive analysis, and writing, comprise the ongoing evolution and design of the study. The dialogue with the participants and situation must make claims on the researcher's understanding and shape the dialogue. A controlled, completely predesigned study is not a dialogue in which the study design is altered as new lines of inquiry develop from the text. The interpretive researcher is constrained by the demands of the text—carefully listening, hearing the voices and concerns inherent in the text, giving the fullest possible account. The interpretive account should illuminate the world of the participants, articulating taken-for-granted meanings, practices, habits, skills, and concerns. Thus, as Dreyfus (1991) points out in his lectures on human science methods, the validity of an interpretation is demonstrated when participants say, “You have put into words what I have always known, but did not have the words to express.”

    Although the interpretation may be critical, the interpretive tradition presented here is not a hermeneutics of suspicion that offers a particular theoretical framework to reveal a reality behind or beyond the text such as a psychoanalytic or Marxist reading of the text—though once an interpretation of a text is developed, one may engage in a comparison of that interpretation with any other level of theoretical or cultural discourse offering critical reflection and comparison with the interpretive commentary. Each interpreter enters the interpretive circle by examining preunderstandings and confronting otherness, silence, similarities, and commonalities from his or her own particular historical, cultural, and personal stance. Though the interpreter begins to set up the inquiry with as much reflection and clarity as is available to him or her, the actual study is required to make visible and to challenge aspects of the researcher's preunderstanding that are not noticed prior to engaging in a dialogue with the text. The researcher must enter study with the intent and practices of staying open to the text and expecting that the text will reveal blind spots, mysteries, and otherness. Participants (where possible), research colleagues, a community of scholars, and eventually readers of the research must serve as enriching and corrective voices to augment the interpreter's finite and perspectival grasp. In working with dissertation students, I always read some raw data, both cases that are highly informative and accessible to the doctoral researcher and cases that are puzzling or troubling or that create resistance, rejection, or even moral outrage. This gives me access to the students' strategies of inclusion and exclusion, powers of understanding, and even resistances and blind spots. Multiple dialogues with dissertation advisers and research colleagues help reveal the stance of the researcher and the text over time. The discipline and intent is to avoid projecting one's own world onto the world of another. Though the horizon and similarities from one's own world provide the necessary positive bias that projects questions and provides access to the text, the text must also confront and expose these projections, questions, and access (Gadamer, 1960/1975). The interpretive researcher's questions (like those of all researchers) inadvertently shape and foretell the possible answers to the question (Dreyfus, 1991). The questions raised before and during the study become a source of reflection for the interpretive project. Why these questions and not others? The other's world is encountered through dialogue based upon shared and distinct horizons of meaning (Gadamer, 1960/1975): that is, taken-for-granted common and divergent meanings, habits, skills, and practices. Common and distinct taken-for-granted meanings are accessible through embodiment, strong situations, shared cultural and linguistic heritage, dialogue, and translation that allow differences and controversies to show up (Kesselring, 1990). But this gets ahead of the story and depends upon a philosophical critique of the Cartesian understanding of the person as a private subject, radically separate from an objective world, a topic taken up in Chapters 1 and 3 and illustrated in all the interpretive research presented.

    Methodological rigor is based upon the rationality of articulation (Taylor, 1985, 1989, 1991) and a strong perspective on what it is to be a human being skillfully embodied and dwelling in a world that is constituted by taken-for-granted background meanings, concerns, practices, habits, relationships, and understandings of self and other (see Leonard, Chapter 3 of this book; Benner, 1984; Dreyfus, 1991; Heidegger, 1962). The issue of rigor is taken up in chapter 6 and in various ways by each of the chapters.

    A growing concern with social engineering and human sciences designed to shape social policy is that they overlook life world, meanings, practical knowledge (skilled know-how), transition, and experiential learning. The strategies of objectification are strategies designed to decontextualize social and psychological data so that generalizations can be made across a range of situations without regard for context, temporality, transitions, and multiple meanings. As Bellah (1982) has pointed out, social engineering fails to consider communities and the constitutive meanings that shape social reality, particular communities, and social action. For example, in health care, the goal is to design a health care system based upon systems analysis and economic incentives and patterns. Consequently the system is designed and controlled based upon treatments and procedures that can be easily counted and priced. Caring practices, healing relationships, and attentiveness that prevent illness and complications are not easily counted and tend to get marginalized as the focus intensifies on treatment techniques and procedures. What shows up in the system is what can be paid for fairly equally. But this economism is parasitical on the skillful ethical comportment of health care practitioners with notions of good about what is required to adequately care for particular patients. The bureaucratic controls, economic planning, and costing are dependent on a background of practices by health care providers and participants that lend concern and attentiveness to the health care situation. Without these the system would become so adversarial and mistrusting that even basic interactions would become bogged down. (Taylor, 1992). Interpretive phenomenology offers an alternative to quantitative social science studies geared toward social engineering because it is concerned with life world, human concerns, habits, skills, practices, experiential learning, and notions of the good that fuel health care practices, help seeking, and receiving.

    The interpretive studies in Part 2 offer understandings of life worlds that open new ways of community development, public policy design, and clinical practice based upon dialogue, recognition of differences, articulation, understanding, and extending of situated possibility, as opposed to the control and identification of pathologies evident in breakdown (see particularly SmithBattle, Chapter 8; Doolittle, Chapter 11; and Stuhlmiller, Chapter 15). In a democracy that wants to honor pluralism and limit domination and coercion, methods that seek understanding and recognition of others' desires, aspirations, and concerns are basic requirements (Taylor, 1992). And social policy strategies must be linked up to these studies in ways that further these projects and do not unduly limit the freedoms of others. Though we cannot do without procedural justice and negotiations based upon the rights of generalized others, we need public strategies that allow for coordinating notions of the good life, community, and particularity (“positive freedoms to”) while protecting from coercion and oppression (“negative freedoms from”).

    In Chapter 1, Ragnar Fjelland and Eva Gjengedal discuss the constitutive relationships between theory and practice—theory being derived and constituted by practice, and practice being altered and guided by theory. They provide a condensed intellectual history of the development of hermeneutics and phenomenology without tracing the interpretive turn in phenomenology by Heidegger and Merleau-Ponty. As they point out, the limitation of traditional hermeneutics was that it assumed that actions and language were rational until proven otherwise. However, theories of rationality, particularly scientific rationality, and rational calculation (a cost-benefit analysis of two or more choices) exclude many aspects of the human world that are based upon meanings, commitments, and concerns that cannot be reduced to simple rational calculations about advantages that maximize pleasure or utility. Phenomenology, as developed by Husserl (1964, 1936/1970), offered a vision of the life world, the world of practical reasoning, human concerns, and meanings. Heidegger, a student of Husserl, offered a critique of the Cartesian understanding of the subjective and objective distinctions that traditionally separated the traditions of the physical and human sciences, or explanation and understanding. Fjelland, a philosopher from Norway, and Gjengedal, a nurse ethicist who is also from Norway, provide a provocative introduction to the current philosophy of science, mind-body philosophy, and the relationships between practice and theory. They make an argument for a science of the particular (prudence or phronesis) as a basis for nursing theory and practice.

    In Chapter 2, Margaret J. Dunlop takes up a feminist perspective on science, asking whether it is possible to have a science of caring. She proposes a broadening of our notions of science to include caring practices, life world, and interpretation. She too argues for including serious study of the care of the body and the embodiment of health and illness. Rather than blunting or distorting the knowledge and voice of caring—practices traditionally relegated to women's work and therefore privatized—she argues for developing a language and science capable of making this knowledge and skill visible without sentimentalizing or trivializing these practices.

    In the third chapter, Victoria W. Leonard examines views of the person embedded in rational empiricism and endemic in the Cartesian view of the person. She extends the critique of traditional theory/method distinctions raised in the first two chapters and the discussion of the links between ontological concerns—that is, what it means to be a person or a thing and how these assumptions are inextricably linked to methods and ways of knowing (epistemology). Linkages between hermeneutics and phenomenology in the work of Heidegger are drawn. Leonard points to a way to get beyond a fruitless oppositional debate between “subjective” and “objective” framing of research methods in terms of choosing between quantitative and qualitative research methods. She expands the discussion of world, care, embodiment, and temporality.

    In Chapter 4, Karen A. Plager introduces the use of interpretive phenomenology in studying the family (or any natural grouping and community). Drawing on Heidegger's notion of “the clearing”—the possibilities and concerns that are made accessible by shared history, practices, and meanings—she describes focal and local clearings created by rituals, celebrations, and human events. She outlines the modes of engagement for interpretive phenomenology, explicating an approach to studying smoothly functioning social practices and human excellence, not just breakdown. She raises the problem with theory that “present-at-hand” accounts tend to be accounts of breakdown and emphasizes the danger of constructing smooth functioning or health from studying situations of breakdown. Her concern is to understand health promotion, illness prevention, and primary health care as they are practiced in families. She extends the previous discussions of rigor in evaluating interpretive phenomenological studies.

    In Chapter 5, David C. Thomasma points to the similarity between clinical reasoning and practical moral reasoning as a ground for developing a nursing ethic that is true to the caring and healing practices of nurses. Thomasma gives a brief historical overview of the development of biomedical ethics and suggests ways that nursing ethics might diverge from bioethics.

    Chapter 6 by Patricia Benner shifts the discussion to practical considerations and guidelines for designing and carrying out interpretive phenomenological studies. Benner explores the ethics of conducting interpretive studies and the role of narrative and participant observation for uncovering and articulating taken-for-granted concerns, meanings, and notions of the good. She also explores sources of text and strategies for data collection and interpretation.

    Benner's practical discussion is extended in Chapter 7 by Diekelmann, Schuster, and Lam, who present a computer program designed to aid in the formation and writing of interpretive studies. This computer program was piloted by many of the authors in this text, and their commentary shaped some of the design. Though it is still in the developing stages, it has the marked advantages of allowing others to follow the interpreter's reasoning, patterns, and associations so that joint work on a large text and consensual validation are facilitated. The program is discovery oriented, and the retrieval is based upon the text itself. A search of interpretive terms is possible and the interpreter never has to retype a portion of text, a decided advantage of this program.

    Part 2 of the book comprises actual interpretive studies. These studies were selected to demonstrate a range of interpretive investigations. In chapter 8, Lee SmithBattle brilliantly illustrates the power of the use of narrative to allow marginalized others to be heard and seen in their own terms. Lee SmithBattle is an expert community health nurse, and her own expert practice in community development and community health promotion allows her to be in diverse situations in nonintrusive, attentive ways. Her interviews and observations of teenage mothers and their significant others take place in the community where suspicion of outsiders is reasonable. She argues for a new form of health and social services and offers a critique of normalizing science that identifies deficits without examining the strengths, possibilities, and learning inherent in most experiential transitions. Interpretive talent and an ethic of responsiveness are evident in her ability to allow us to hear the voice of a teenage mother and her family.

    In Chapter 9, Catherine A. Chesla examines and describes four major patterns of care constituted by parental caregiving concerns of parents with schizophrenic offspring. She uses these patterns of care to critically reflect on the existing theories of family caregiving in families with schizophrenic members. Chesla then raises her level of commentary to consider the ways in which these caregiving patterns reflect dominant societal concerns about parenting. This study demonstrates the critical powers that can be gained from in depth studies of actual practices. The Enlightenment tradition contains a bias that only theory liberates and creates innovation and that theoretical reflection is the primary source of critique and cultural design. Chesla's work powerfully demonstrates that the influence goes in both directions and that practice is richer and more varied than decontextualized theories can describe. Her work raises new challenges for thinking about caregiving practices for all parents.

    In chapter 10, Philip Darbyshire reflects with candor upon his developing understanding of the distinctions between grounded theory (Glaser & Strauss, 1967) and interpretive phenomenology as he proceeded in his research project of studying parents' participation and involvement in the care of their hospitalized child. He gains a critical and reflective perspective by comparing dissonance between parental practices and understandings, public policy understandings, and nurses' practices and understandings of parental involvement. In each case, he uses narratives and observations of practice.

    In Chapter 11, Nancy Doolittle presents an excellent example of clinical ethnography, an anthropological form of interpretive phenomenology that allows for a “thick description” (Geertz, 1973) of the lived experience of an illness, a phenomenological account of the social and embodied experience of the illness and manifestations of the disease, and a descriptive account of the transitions encountered during recovery. Doolittle presents paradigm cases to illustrate the meanings of recovery and the evolution of embodied skilled know-how throughout recovery. One gains an appreciation of the experiential learning and practical knowledge of the person recovering from a stroke. Reading such a work, the clinician is forced to confront the patient's perspective and possibilities in other than medical and nursing terms. Such work provides new understandings and access to compassionate responses on the part of the clinician as well as providing direction for the development of new rehabilitation therapies. Doolittle's interpretation of nursing's project recalls Thomasma's comment (Chapter 5) that “the theory underlying nursing practice suggests that the proper ethics be a relational ethic, one that targets the problems patients have with their disease, with family, with disruptions in their social and work structure, and in relation to their values, including their ultimate values.” This chapter and Chapter 12 illustrate an approach to exploring these multiple levels of interpretation within one study.

    In Chapter 12, Benner, Janson-Bjerklie, Ferketich, and Becker explore the moral dimensions of illness through narrative self-understandings and identity in relation to having asthma as a chronic illness. A thematic analysis of interviews yielded four different self-described relationships to the illness: an extremely adversarial relationship to the disease, rejection of the illness, a transition in self-understanding, and acceptance of the illness as a part of one's identity. The taken-for-granted projects of autonomy and mind over matter go hand in hand to create systems of responsibility, shame, blame, and guilt for causing and recovering from an illness. Acceptance and nonacceptance ways of relating to an illness are explored with their attendant tacit assumptions about responsibility, guilt, and shame. The self-described relationship to the illness is mirrored in social relationships. This is a large study that combined qualitative and quantitative strategies (Janson-Bjerklie, Ferketich, & Benner, 1993; Janson-Bjerklie, Ferketich, Benner, & Becker, 1992). The interpretive portion of the study for such a large number of participants (N = 95) was made possible by federal funding for a team of qualitative researchers who developed the thematic analysis of interviews obtained from the study participants.

    In Chapter 13, Peggy L. Wros examines the ethics embedded in the care of particular patients. Her study includes the observation of the nursing care of dying patients and families in critical care units and the interviewing of nurses and families. She presents a paradigm case that encompasses many of the ethical concerns discovered in the study and describes “(a) characteristics of an ethic of care, (b) the role of judicial ethics in decision making, and (c) specific moral concerns expressed by nurses.” Wros's chapter illustrates the philosophical directions recommended by Thomasma in Chapter 5 and exemplifies clinical and practical moral reasoning from an engaged stance and within a transition. It provides an excellent example of articulating moral concerns and notions of the good embedded in expert nursing practice.

    In Chapter 14, Deborah R. Gordon describes the cultural practices and experiences that shape the health care practices of telling and not telling the diagnosis of cancer. Gordon constructs the local background of this tradition in Florence, Italy. Currently local, national, and international background forces are pushing for change. But as Gordon shows, changes toward clear communication of a cancer diagnosis and prognosis, based on the “right” of informed consent, confront many background practices concerning relationships to authority; relationships between couples and family members; gender relationships; taboos on sex, death, and emotion; and many self-understandings that remain at odds with “informed consent.” These background practices and meanings create difficulty and uncertainty for people, even people seeking to change their practices and self-understandings.

    Gordon constructs a story by tacking back and forth between general and local practices and particular medical practices. As an American anthropologist living in Florence, Italy, she engages in dialogue between her distinctly American practices and Italian practices. Very strong in the Italian “not telling, not knowing” practice is a way of being fundamentally social that makes not telling and not knowing show up as the kindest thing to do and the kindest way to behave. Gordon finds a conflict between universal language about what is right to do and the Italian sense of a good way to be. The Italian way of experiencing the present highlights North American and Italian differences in temporality and the dramatic individualistic self-understanding prevalent in the North American practices of telling and knowing. This chapter sheds light on the North American experience of illness and death described in chapters 12 and 13.

    In Chapter 15, Cynthia Stuhlmiller presents and interprets the narratives of two groups of emergency workers—paratroopers and firefighters—who rescued survivors trapped in the collapsed Cypress Freeway following the 1989 Loma Prieta earthquake, articulates the common meanings and sustaining narratives used by these two distinct groups of rescue workers who were exposed to life-threatening conditions. In the narratives of both groups she uncovers shared cultural meanings related to “personal commitment, dedication to saving human lives, avoiding suffering, facing death, and comforting families and friends.” The data sources for her study of the lived experience of the rescue workers included participant observation, document analysis, and interpretive analysis of semistructured interviews. Her study provides a contrast and point of critique for post-traumatic stress disorder theory, the predominant perspective guiding disaster studies.

    Taken together, these studies present a lively account of a relatively new research tradition within nursing, nursing ethics, health, and illness. Parts 1 and 2 illustrate an interpretive turn in research related to human concerns, practical knowledge, reasoning in transitions, embodiment, and ethics. Interpretive phenomenology seeks to preserve the participant's engaged action in the world and to understand human actions in everyday skillful comportment and in breakdown. These studies offer new directions in health care ethics and policy and offer a critique of human sciences modeled on the natural sciences. They show promise for recovering a discourse on healing arts and practices that can create new therapies and enrich the increasingly highly technical, cure-oriented, commodified discourse on health and illness.

    References
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    Dreyfus, H. L.(1979). What computers can't do: The limits of artificial intelligence (rev. ed.). New York: Harper & Row.
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    Gadamer, H. J.(1975). Truth and method (G.Barden & J.Cumming, Trans.). New York: Seabury. (Original work published 1960)
    Geertz, C.(1973). The interpretation of cultures. New York: Basic Books. http://dx.doi.org/10.1177/002096438303700305
    Geertz, C.(1983). Local knowledge. New York: Basic Books.
    Glaser, B. G., & Strauss, A.(1967). The discovery of grounded theory: Strategies for qualitative research. Chicago: Aldine. http://dx.doi.org/10.1097/00006199-196807000-00014
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    Heidegger, M.(1975). The basic problems of phenomenology (A.Hofstadter, Trans.). Bloomington: University of Indiana Press.
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    Husserl, E.(1970). The crisis of European sciences (D.Carr, Trans.). Evanston, IL: Northwestern University Press. (Original work published 1936) http://dx.doi.org/10.1002/9780470755501.ch9
    Janson-Bjerklie, S., Ferketich, S, & Benner, P.(1993). Predicting the outcomes of living with asthma. Research in Nursing and Health, 16, 241–250. http://dx.doi.org/10.1002/nur.4770160403
    Janson-Bjerklie, S., Ferketich, S., Benner, P., & Becker, G.(1992). Clinical markers of asthma severity and risk: Importance of subjective as well as objective factors. Heart and Lung, 21(3), 265–272.
    Kesselring, A.(1990). The experienced body: When taken-for-grantedness fails. Unpublished dissertation, University of California, San Francisco
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  • Appendix

    Doctoral Dissertations Using Interpretive Phenomenology

    Brykczynski, K. (1985). Exploring the clinical practice of nurse practitioners. Unpublished doctoral dissertation, University of California, San Francisco.

    Chesla, C. (1988). Parents' caring practices and coping with schizophrenic offspring, an interpretive study. Unpublished doctoral dissertation, University of California, San Francisco.

    Darbyshire, P. (1992). Parenting in public: A study of the experiences of parents who live-in with their hospitalized child, and of their relationship with paediatric nurses. Unpublished doctoral dissertation, University of Edinburgh, Edinburgh, Scotland.

    Doolittle, N. D. (1992). Life after stroke: Survivors' bodily and practical knowledge of coping during recovery. Unpublished doctoral dissertation, University of California, San Francisco.

    Dunlop, M. (1990). A phenomenological investigation of clinical knowledge evident in university curricula in Australia. Unpublished doctoral dissertation, University of California, San Francisco.

    Haberman-Little, B. (1993). The experience of Parkinson's disease in middle life: An interpretive account. Unpublished doctoral dissertation. University of California, San Francisco.

    Hartfield, M. (1986). Coping with anger in normotensive and hypertensive samples. Unpublished doctoral dissertation, University of California, San Francisco.

    Kesselring, A. (1990). The experienced body, when taken-for-grantedness falters: A phenomenological study of living with breast cancer. Unpublished doctoral dissertation, University of California, San Francisco.

    Leonard, V. (1993). Stress and coping in the transition to parenthood of first-time mothers with career commitments: An interpretive study. Unpublished doctoral dissertation, University of California, San Francisco.

    MacIntyre, R. (1993). Sex, power, death and symbolic meanings of T-cell counts in HIV+ gay men. Unpublished doctoral dissertation, University of California, San Francisco.

    MacLeod, M. L. P. (1990). Experience in everyday nursing practice: A study of “experienced” ward sisters. Unpublished doctoral dissertation, University of Edinburgh, Scotland.

    Madjar, I. (1991). Pain as embodied experience: A phenomenological study of clinically inflicted pain in adult patients. Unpublished doctoral dissertation, Massey University, Palmerston North, New Zealand.

    McKeever, L. (1988). Menopause: An uncertain passage. Unpublished doctoral dissertation, University of California, San Francisco.

    Popell, C. L. (1983). An interpretive study of stress and coping among parents of school-age developmentally disabled children. Unpublished doctoral dissertation, Wright Institute Graduate School of Psychology, Berkeley, California.

    Schilder, E. J. (1986). The use of physical restraints in an acute care medical ward. Unpublished doctoral dissertation, University of California, San Francisco.

    SmithBattle, L. (1992). Caring for teenage mothers and their children: Narratives of self and ethics of intergenerational caregiving. Unpublished doctoral dissertation, University of California, San Francisco.

    Stainton, C. (1985). Culture and cue sensitivity: A phenomenological study of mothering. Unpublished doctoral dissertation, University of California, San Francisco.

    Stuhlmiller, C. M. (1991). An interpretive study of appraisal and coping of rescue workers in an earthquake disaster: The Cypress collapse. Unpublished doctoral dissertation, University of California, San Francisco.

    Warnian, L. (1987). A hermeneutical study of group psychotherapy. Unpublished doctoral dissertation, University of California, San Francisco.

    Wnos, P. L. (1993). Behind the curtain: Nursing care of dying patients in critical care. Oregon: Oregon Health Science University.

    Wrubel, J. W. (1985). Personal meanings and coping processes: A hermeneutical study of personal background meanings and interpersonal concerns and their relation to stress appraisals and coping. Unpublished doctoral dissertation, University of California, San Francisco.

    Name Index

    About the Contributors

    Gay Becker, Ph.D., a medical anthropologist, is Professor in Residence, Social and Behavioral Sciences and Medical Anthropology, University of California, San Francisco. The primary theme in her research is the process by which individuals acquire and live with health conditions that create unforeseen paths in the course of life. Her particular emphasis is on the experience of illness. In addition to her work on asthma with Janson-Bjerklie, Benner, and Ferketich, she has conducted research on aging and the life span; chronic and disabling conditions, including life after a stroke; reproductive health problems, including the experience of infertility; and chronic health problems as they are experienced by ethnic minorities. She is the author of three books and numerous papers in social science journals.

    Patricia Benner is a Professor in the Department of Physiological Nursing, University of California, School of Nursing, San Francisco, California. Her current research examines expert ethical comportment of nurses and focuses on engaged clinical and moral reasoning. She has conducted research in stress and coping in persons with a chronic illness. She is the author of From Novice to Expert: Excellence and Power in Clinical Nursing Practice (1989) and, with Judith Wrubel, The Primacy of Caring: Stress and Coping in Health and Illness (1984).

    Catherine A. Chesla, R. N., D. N. Sc, is Assistant Professor at the Department of Family Health Care Nursing, University of California, San Francisco. She teaches family theory and family intervention to graduate family nurse practitioner students. In her research she examines family responses over time to the chronic illness of a member, using a hermeneutic approach. To date she has examined family patterns of response to schizophrenia and Alzheimer's disease. She additionally worked with Drs. Benner and Tanner in a hermeneutic investigation of clinical judgment and skill development in nursing practice. A study of Pilipino-American family responses to the care of a member with schizophrenia is in progress. Next, she plans to conduct, with a multidisciplinary research team, a combined hermeneutic and model-testing investigation of family processes and coping with the diagnosis of diabetes in a primary care population. She has recently published in such journals as Family Relations, Journal of Community Health Nursing, and Image.

    Philip Darbyshire is Lecturer in Health and Nursing Studies at Glasgow Caledonian University. His clinical background is in learning disability and pediatric nursing. He holds a master's in nursing from the University of Glasgow and a doctorate from the University of Edinburgh. He is a frequent contributor to a range of nursing books and journals, and has most recently published in Nurse Education Today and Journal of Advanced Nursing, where he serves on their editorial boards. He also writes a regular review column called “Media Watch” for Nursing Times and is the Consulting Editor for their regular “Telling Stories” series of nurses' narratives. As an educator he is committed to promoting interpretive and narrative approaches within undergraduate and postgraduate education. His current research interests involve an interpretive appraisal of a new course called “Understanding Caring Through Arts and Humanities,” which he cocreated and teaches, and an interpretive study that looks at the process of becoming a nurse teacher. He is a frequent presenter at nursing conferences and forums in the United Kingdom and abroad and has recently presented his work in Canada, the United States, Australia, and New Zealand. In 1994 he will be returning to the University of Wisconsin-Madison for a second term as a Visiting Scientist.

    Nancy L. Diekelmann, R.N., Ph.D., F.A.A.N., is a Helen Denne Schulte Professor at the University of Wisconsin-Madison School of Nursing, a Fellow in the American Academy of Nursing, and a past president of the Society for Research in Nursing Education. A noted authority for her work in nursing education and primary health care, she received two Book of the Year awards from the American Journal of Nursing for her textbook Primary Health Care of the Well Adult. In addition, and as the coeditor of Transforming RN Education: Dialogue and Debate. Her current research uses Heideggerian hermeneutics to explicate the narratives of teachers, students, and clinicians. Dr. Diekelmann has described an alternative approach for nursing education in her educational program Narrative Pedagogy: Caring, Dialogue and Practice.

    Nancy D. Doolittle, R.N., M.S., Ph.D., received her master's degree and doctorate in nursing from the University of California, San Francisco. Her primary research interest is qualitative study of living with neurologic illness. The focus of her doctoral dissertation was the bodily experience of recovery following stroke. Her contribution to this book is based on the dissertation findings. Publications related to this work can be found in the Journal of Neuroscience Nursing (1991) and Rehabilitation Nursing (1992). She is currently a research nurse in the Department of Physiological Nursing, University of California, San Francisco. She serves on the editorial boards of Journal of Stroke and Cerebrovascular Diseases and Rehabilitation Nursing Research. She has presented her research findings on recovery after stroke to national and international audiences.

    Margaret J. Dunlop is Foundation Professor and Head of Australia's newest school of nursing at Griffith University in Queensland. She is preparing a monograph that critically evaluates the relationship between nursing and hermeneutics and is also involved in a major funded research study on nursing specialty education in universities in Australia. Her research interests are in structuring of nursing knowledge, women and health care, midwifery, nursing history, and nursing education. She has recently published Shaping Nursing Knowledge: An Interpretive Analysis of Curriculum Documents from NSW Australia (1992) and has contributed a chapter to D. Gaunt's A Global Agenda for Caring (1993).

    Sandra Ferketich, Ph.D., R.N., F.A.A.N., earned a B.S.N, and a B.A. in Fine Arts from the University of New Mexico, a master's degree from Indiana University, and a Ph.D. in Nursing with a minor in Statistics from the University of Arizona. She is Professor and Project Director for the Institutional NRSA program in instrumentation (funded by National Institute of Nursing Research) at the College of Nursing, University of Arizona. She has numerous publications, which focus on measurement issues in nursing research. She edits the column “Focus on Psychometrics” in Research in Nursing and Health. In addition, she publishes and speaks extensively on model respecification, with a particular emphasis on the use of graphic residual analysis. Dr. Ferketich has a sustained publication record on the effect of antepartum stress on families. Her current research funding centers on the evaluation of community-based nursing intervention studies. She is funded by the Agency for Health Care Policy and Research to study the effectiveness of a comprehensive multi-level practice model for rural Hispanics and by the National Institute of Nursing Research to examine the effectiveness of an aggressive nursing contact intervention for homeless on prophylactic medication for Mycobacterium Tuberculosis.

    Ragnar Fjelland is Professor of Philosophy of Science at the Center for the Study of the Sciences and the Humanities, University of Bergen, as well as Director of the Center. In 1990, he was a Visiting Scholar at the University of California, Berkeley. His current topics of interest include the relation between science and technology, the possibility of an “alternative science,” philosophical implications of chaos theory and fractal geometery, and philosophical problems of quantum mechanics. He is a member of the National Research Ethics Committee for Natural Science and Technology and has written several books on philosophy of science, technology, and human values in Norwegian.

    Eva Gjengedal is Assistant Professor at the Center for Continuing Education, the University of Bergen. She received her master's degree in nursing from the University of Oslo in 1987 and has just finished the work on her doctoral dissertation. Included among her recent publications is an article in the Scandinavian Journal of Caring Science. Her main interests are methodological and theoretical problems in nursing science, in particular phenomenology as a justification for the uses of qualitative methods in empirical research.

    Deborah R. Gordon is Research Consultant in Medical Anthropology at the Center for the Study and Prevention of Cancer in Florence, Italy, and International Affiliate with the Center for the Study of Medicine and Culture, Harvard Medical School, Boston. She holds a Ph.D. in Medical Anthropology from the University of California, San Francisco/Berkeley. Her recent ethnographic research in Tuscany, Italy, has focused on communication around cancer and the local cultures of cancer prevention, death and dying, home care, and bioethics, as well as on Italian women's experience with breast cancer. Her research interests include cultural—particularly cultural phenomenological—studies of biomedicine, bioethics, technology, illness, and distress, with special attention to spiritual/religious dimensions of Western medicines and cultures.

    Susan Janson-Bjerklie, D.N.Sc, A.N.P., F.A.A.N., received the B.S.N. and M.S. degrees in nursing from the University of Michigan and her doctoral degree from the University of California, San Francisco. She is a Professor in the Department of Physiological Nursing and an Adjunct Professor in the Department of Medicine at the University of California, San Francisco. She is the Director of the Pulmonary Graduate Nursing Program. Dr. Janson-Bjerklie is a pulmonary clinical nurse specialist and certified nurse practitioner and a nationally known expert in care of people with asthma. She was a member of the Expert Panel on Diagnosis and Management of Asthma, National Asthma Education Program, NIH-National Heart, Lung, and Blood Institute. Her current research is focused on the biobehavioral markers of airway inflammation in asthma and the impact of patient education. She maintains a faculty practice in the Division of Pulmonary Medicine, specializing in care of adult patients with asthma.

    Sui-Lun Lam is an Information Processing Consultant for the Alice Simonds Center for Instruction and Research in Nursing, School of Nursing, University of Wisconsin-Madison. He specializes in computer networks and in the development of software for research applications. He has degrees in mathematics and in engineering with a focus on robotics and computer applications.

    Victoria W. Leonard recently completed her doctoral work at the University of California, San Francisco. Her doctoral work focused on stress and coping of first-time mothers with career commitments in the transition to parenthood.

    Karen A. Plager is a master's-prepared family nurse practitioner and doctoral candidate in nursing science currently completing her dissertation research at the University of California, School of Nursing, San Francisco. She specializes in family primary care nursing and family health promotion.

    Robert Schuster is the Director of the Alice Simonds Center for Instruction and Research in Nursing, School of Nursing, University of Wisconsin-Madison. He has developed several hundred instructional programs, has authored numerous corporate films, and has coauthored Natural Landscaping: Designing With Native Plant Communities. His graduate work was in American literature, with a focus on the American transcendentalists.

    Lee SmithBattle, R.N., D.N.Sc, is Assistant Professor at Saint Louis University School of Nursing, in St. Louis, Missouri, where she teaches community health nursing. Her research interest in teenage mothering as shaped by family and community contexts and ethics of care has drawn upon extensive community health nursing experience. Her current study examines the life course and caregiving practices of former teenage mothers and their family members.

    Cynthia M. Stuhlmiller, R.N., M.S., D.N.Sc, is affiliated with the University of San Francisco, Department of Veterans Affairs, Palo Alto, California, and the American Red Cross, Palo Alto, disaster action team. She is a private consultant and lecturer and has worked as a clinical nurse specialist with Vietnam Veterans with PTSD at the National Center for Post Traumatic Stress Disorder Clinical Laboratory and Education Division (formerly the Vietnam Veterans Inpatient Treatment Program). Her experiences in those 10 years have generated her concern for the pathologizing of psychological responses to trauma. In her participant observation and ongoing research on rescue and emergency workers, she seeks to uncover the salutary aspects of extreme experiences and incorporate them into treatment.

    David C. Thomasma, Ph.D., is the Michael I. English Professor of Medical Ethics and Director of the Medical Humanities Program at Loyola University, Chicago Medical Center, and also Chief of the Ethics Consult Service and a member of the Hospital Ethics Committee. He has served on the Technical Advisory Panel for Biomedical Ethics of the American Hospital Association, and the Theology and Ethics Advisory Committee for the Catholic Health Association. He is Editor-in-Chief of Theoretical Medicine, Coeditor of Cambridge Quarterly for Healthcare Ethics, and Section Editor of The Journal of the American Geriatrics Society, has written an Ethics Column for Healthcare Executive, and is on the editorial boards of four other journals. He has published more than 200 articles and 15 books. His most recent books are Human Life in the Balance (1990); with Edmund Pellegrino, The Virtues in Medical Practice (1993) and For the Patient's Good (1988); with Glenn Graber, Theory and Practice in Medical Ethics (1989) and Euthanasia: Toward an Ethical Social Policy (1990); and with John Monagle, Medical Ethics: Policies, Protocols, Guidelines, and Programs (1992). In 1992 he was named Director of the International Bioethics Institute.

    Peggy L. Wros is Assistant Professor of Nursing at Linfield College, School of Nursing, in Portland, Oregon. She obtained her B.S.N, from the University of Wisconsin-Madison, and her M.S.N, from Marquette University, Milwaukee, Wisconsin. She recently completed her Ph.D. in nursing at Oregon Health Sciences University. Her dissertation work focused on nursing care of dying patients in critical care, and continuing research interests include bedside nursing ethics and phenomenological methods. She is also interested in the implementation and evaluation of new paradigm curriculum change and teaching strategies in nursing education. She is currently involved in the ongoing phenomenological analysis of an existing data set concerning the development of clinical judgment in critical care nurses (Drs. Patricia Benner and Christine Tanner, Co-Investigators). The present analysis is focused on learning from clinical practice and on the relevance for nursing education.


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