Original article
doi: 10.1111/nup.12077
On to the ‘rough ground’: introducing doctoral students to philosophical perspectives on knowledge Ellen Rehg* PhD and Lee SmithBattle† RN PhD *Adjunct Assistant Professor and †Professor of Nursing, School of Nursing, Saint Louis University, St. Louis, MO, USA
Abstract
Doctoral programmes in nursing are charged with developing the next generation of nurse scholars, scientists, and healthcare leaders. The American Association of Colleges of Nursing (AACN) endorses the inclusion of philosophy of science content in research-focused doctoral programmes. Because a philosophy course circumscribed to the natural or social sciences does not address the broad forms of knowledge that are relevant to nursing practice, we have developed and co-taught a course on the philosophy of knowledge that introduces students to competing claims regarding the nature of knowledge, truth, and rationality. In addressing broad themes related to science and knowledge of the body, health and illness, and ethics, the course equips students to tread the rough and shifting ground of nursing scholarship and practice. Providing doctoral students with this philosophical footing is intended to give future scholars, researchers, and healthcare leaders the intellectual skills to critically reflect on knowledge claims, to challenge the hegemony of science, and to recognize the disciplinary forms of knowledge that are left out or trivialized. Our pedagogical approach to knowledge development does not denigrate scientific knowledge, but elevates forms of inquiry and notions of clinical knowledge that are too often marginalized in doctoral education and the academy in general. Keywords: knowledge, nursing inquiry, nursing research, philosophy of science, praxis.
Introduction We have got on to slippery ice where there is no friction and so in a certain sense the conditions are ideal, but also, just Correspondence: Dr Lee SmithBattle, Professor of Nursing, School of Nursing, Saint Louis University, 3525 Caroline Avenue, St. Louis, MO 63104, USA. Tel.: 3149778980; fax: 314977-8819; e-mail: [email protected]
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because of that, we are unable to walk. We want to walk: so we need friction. Back to the rough ground! (Wittgenstein, 1958/1968, p. 46).
Doctoral programmes in nursing are charged with developing the next generation of nurse scholars, researchers, and healthcare leaders. The American Association of Colleges of Nursing (AACN) has endorsed the inclusion of philosophy of science
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content in research-focused doctoral programmes since at least 1993. More recently, the AACN (2010) recommended including ‘ways of knowing and habits of mind’ (p. 5) and ‘practice knowledge’ (p. 5) as core curricular content. We welcome this apparent nod to broad forms of knowledge, and agree with many nursing scholars that the quest to equate knowledge with science, based on the natural science paradigm, has been deeply problematic for advancing the nursing discipline (Canam, 2008; Ayres, 2013; Thorne & Sawatsky, 2014). Like all forms of knowledge, the Cartesian view that lurks in the background of scientific inquiry disregards its own blindspots and assumptions regarding the nature of truth, knowledge, and reality. Because these biases are generally hidden to healthcare professionals and researchers, we agree with Thorne (2009) that philosophy offers rich resources for deepening our understanding of the forms of knowledge needed to advance nursing practice: The alignment between scientific advancement and improvements in the health of societies has been so close as to seem patently obvious. And yet those of us who embrace the ethos of a practice discipline are continually reminded of how disparate are the enthusiastic claims of science when set against the realities of human misery and suffering. By contrast, philosophy orients us towards work in the world of what is and what ought to be. It steers us towards careful examination of what we consider to be the values by which we operate, and to account for how they pertain to our notions of truth.Thus, the philosophical enterprise in nursing inevitably bumps us up against the conventional knowledge generation and translation enterprise that has become the familiar backdrop of all that we do in health care and nursing. (p. 150)
The growing recognition for diverse forms of knowledge occurs in the wake of nursing research showing that clinical judgment, at its very best, melds scientific evidence with knowledge of the specific patient and with clinical understanding of the meanings and trajectories of illness in concrete situations (James et al., 2010; Benner et al., 2011; Thorne & Sawatsky, 2014). Because science does not exhaust the ways that clinicians act and know, as implied in the AACN document and described in nursing research, a
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philosophy of science course, even one that introduces students to philosophies of science and social science, cannot provide sufficient ground for discovering, testing, and translating nursing’s disciplinary knowledge into practice. Assuming that scientific knowledge is but one form of knowledge that supports excellent nursing care, students need to be familiar with the competing claims regarding knowledge and truth, and understand how clinicians meld scientific evidence and practical and relational knowledge with appropriate technology and the core values of the discipline for the good of specific patients, families, and communities. In this paper, we argue for and describe a philosophy of knowledge course for research-focused doctoral programmes that include, but is not limited to, philosophy of science. In exploring philosophical perspectives on knowledge, we introduce students to competing claims regarding the nature of knowledge, truth, and rationality; and by addressing the broad themes of the body, health, illness, and ethics, in relation to technology and power dynamics, we prepare doctoral students to tread the rough and shifting ground of nursing science, scholarship, and practice. Providing doctoral students with this philosophical footing is intended to give future scholars, researchers, and healthcare leaders the intellectual skills to critically reflect on knowledge claims, to challenge the hegemony of science, and to recognize all that is passed over or trivialized: human agency, embodiment, the life-world. Our pedagogical approach to knowledge development does not denigrate scientific knowledge, but elevates forms of philosophical inquiry and notions of clinical knowledge that are too often marginalized in doctoral education and the academy in general.
Background To determine how other PhD programmes address philosophical issues related to science and knowledge development, we conducted a survey of PhD programmes listed on the AACN website (http:// www.aacn.nche.edu/research-data/DOC.pdf). From this list, we downloaded the curricula and course descriptions, when available, from the websites of each
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School of Nursing offering a PhD programme. Of the 100 PhD programmes that were surveyed in 2010, the majority (n = 62) did not offer a philosophy course of any kind. Judging by the titles, the majority of the 26 philosophy courses that were offered in these programmes appeared to be straightforward philosophy of science courses. The content of the remaining 25 courses was difficult to discern from titles such as ‘Knowledge Development in Nursing’. Only 8 of the 100 programmes appeared to offer a course similar to ours. Because the majority of programmes do not offer a stand-alone philosophy course of any kind in their curriculum, we were not surprised to find only one relevant published article (Butts & Lundy, 2003). These authors are to be applauded for describing how they introduce nursing doctoral students who have had little philosophical background to the relevance and limits of philosophy of science and social science for developing nursing knowledge. Beyond philosophy of science We assume that programmes offering a philosophy of science course aim to provide nurse scholars with a more sophisticated understanding of science than that of the lay person. In a philosophy of science course, students typically investigate the rational underpinnings of science and are introduced to concepts such as induction, deduction, empiricism, rationalism, and theories of truth. Questions that are examined include: What differentiates science from nonscience? Is scientific knowledge cumulative? Is science ‘proven’ knowledge? What is the nature of causation? What is the problem of induction? These questions should lead the nurse scholar towards a more sophisticated understanding of exactly what kind of knowledge science can and cannot yield. The student should come to see that science itself is probable knowledge; that findings are tentative; and that no research is ever completely objective or value free. However, even with this more chastened, contemporary, ‘post-empiricist’ understanding of the nature of science, we still might ask whether these questions alone provide enough ‘friction’ for a nurse scholar to journey through the diverse terrain of disciplinary knowledge related to human health and illness. Wittgenstein’s quote at the beginning of our paper refers
to his initial quest to render language, and hence our grasp of the world, completely in accord with logic. Only then would the world be a rational one, capable of human comprehension. Wittgenstein ultimately determined that language cannot be reduced to logic, and the world cannot be reduced to language; human experience is simply much richer, complex, and meaningful to be fully systematized into logical propositions. We would extend Wittgenstein’s observation to say that knowledge itself, and nursing knowledge in particular, is much more uneven and contingent on specific situations to be fully abstracted into scientific theories and causal explanations. Even if we learn to design research so that it yields rational, scientific knowledge, the evidence privileged by the evidencebased movement, have we captured all there is to nursing knowledge? While scientific knowledge is crucial for clinical care, does it exhaust the philosophical notions of ‘ways of knowing’, ‘practical knowledge’, and reasoning through specific clinical cases that ultimately furthers positive patient outcomes? Can it yield the kind of knowledge generated in human interactions with others, which is uncertain, concrete, and replete with meaning? How do we capture nursing’s pursuit of the ‘rough ground’, that is, the melding of complex kinds of knowledge that escapes abstraction and cannot be formulated into universal principles? And if we do capture the complexity and contingency of clinical judgment that spills over conventional scientific evidence, what would it mean to claim that this knowledge also qualifies as evidence? Although our argument might appear to echo the work of Barbara Carper (1978), in her seminal article on ‘ways of knowing’, there are important differences between her work and a philosophical approach to knowledge. Carper’s article remains on the level of nursing theory, rather than philosophy itself. As such, she does not provide philosophical foundations or justifications for her claims that nursing contains these different ways of knowing. In our course, we investigate the meta-level of ways of knowing, through the philosophical work of continental philosophers, including Martin Heidegger, MerleauPonty, Levinas, and others. These philosophers’
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insights recover aspects of human experience (including clinical judgment and the meanings and practice of living with health and illness) that elude traditional science, and provide the philosophical framework to show how other kinds of systematic investigations also generate disciplinary knowledge. The question might be raised whether such forms of knowing count as evidence. Indeed, what difference would it make, in terms of evidence-based nursing, that there are multiple ways of knowing that can be systematically investigated, if only scientific knowledge counts as evidence? Thorne and Sawatzky (2014) argue that non-science-based types of knowing are of a ‘fundamentally different nature’ (p. 8) than scientific knowledge understood as justified true beliefs. They write: In that [personal, spiritual, or esthetic knowing are] grounded in sources such as personal experience, intuition, or revelation, subjectively derived knowledge cannot be objective and generalizable in terms of the patterns of phenomena to which a particular evidentiary claim applies. Thus, although it may have a role to play in the praxis process, it is not in and of itself a shared form of knowledge that can be confirmed and argued as an evidential basis for nursing practice.
(p. 9)
Although much of what these authors argue is consistent with our argument, we depart from the view that knowledge not derived from traditional methods of verification is necessarily subjective, and hence, a poor candidate for evidence-based care. This view is based on a philosophy which divides subject/object and person/world into separate categories with unassailable boundaries. In contrast, a philosophical approach nurtured by the contemporary thinkers listed above can provide the resources to overcome these boundaries. Heidegger’s (1962) ontology provides a description of being-in-the-world that highlights how human engagements provide our most primordial way of knowing and acting which, Benner (1984) adapted (following Dreyfus) to explain how nurses evolve from novice to experts. The embodied skills which nurses absorb from their practice are not merely personal or subjective phenomena as they are a hallmark of excellent nursing care that are easily recognized and verified by others. Even the practical
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and relational knowledge that is derived from knowing specific patients (e.g. meanings of illness, patients’ concerns, preferences, and ways of embodying an illness) is not totally subjective or idiosyncratic, at least when patients share a similar cultural background. Because this knowledge can be shared, it is open to verification and validation. Using another example, the ‘docile body’ described by Foucault (1979) should not be construed as a purely subjective phenomenon as it is widely adopted by patients and reinforced by healthcare providers. These examples challenge the claim that only the empirical sciences generate ‘objective’ evidence. Thorne and Sawatzky (2014) also assume that the kinds of methodically justified propositions derived or inferred from empirical experimentation are somehow privileged forms of evidence, because they are ‘based on established premises of empirical verification and philosophical argumentation’ (p. 9). Such a position overlooks the perspectival nature of all empirical science and the social elements that enter into scientific knowledge construction (Kuhn, 1970; Chalmers, 1999). Beyond philosophy of social science One way to introduce students to a broader view of knowledge is to include content related to the philosophy of social science along with philosophy of science. As shown above, courses which do this may be less common than those which are straightforward philosophy of science courses. This approach is exemplified in a recently published textbook for nursing doctoral students which expands the notion of science to include a science of human actions (Dahnke & Dreher, 2011). The philosophy of social science has traditionally rested upon the distinction between the ‘natural’ or ‘hard’ sciences, like physics, chemistry, biology and the like, and the social or ‘human’ sciences, such as psychology, economics, and sociology. Part of the goal of the philosophy of social science is to broaden the base of what counts as rigorous knowledge. This approach argues that human actions, while considerably different from objects in the natural world, can also be studied empirically and used to provide a solid basis for knowledge. From this vantage point, knowledge is
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not the province of the empirical sciences alone, but disciplines such as psychology can be made rigorous enough to ground knowledge claims, with objective procedures imported from the natural sciences. The philosophy of social science initially relied on the natural sciences as the paradigm for what counts as trustworthy knowledge: the ability to make universal, law-like claims which can serve as both an explanation of a physical event and a prediction of when that event will next occur. For a number of decades, the philosophy of social science had as its primary task the effort to make the philosophy of human actions conform to this model. The ground-breaking work of Kuhn (1970) casts doubt on the model of the natural sciences as the ‘gold standard’ for knowledge, and on the possibility of objectivity and value-neutrality even in the natural sciences. This freed the philosophy of social science to broaden its focus to one of analysing the nature of interpretation, and how it could provide a basis for epistemological claims. However, the question regarding the relationship between the social and the natural sciences has not been entirely abandoned, and is an enduring one in this field (Dahnke & Dreher, 2011). With the move towards interpretation, the social sciences adopted the twin goals of both explaining social phenomena and also understanding them. One of its many questions has to do with the type of knowledge that the human sciences can generate, and along those lines, whether and to what extent this knowledge can be objective, or value free.As valuable as this approach is, we believe that there are drawbacks to adding the philosophy of social science into the philosophy of science as a way to broaden the view of knowledge for a practice discipline like nursing. One of the drawbacks is that much of this philosophy remains within the dualist tradition initiated by Rene Descartes and the hard and fast separation between subject and object, mind and body, and person and world (Guignon, 1983; Leder, 1990). Its ‘building blocks’ are the mechanical body and the intentional acts of human beings. These intentional acts are described as phenomena that have an underlying ‘mental state’, such as a person’s beliefs or desires. Intentionality in this context refers to a con-
scious mind that causes an action. Such a philosophy seeks to study this kind of intentionality in a way analogous to the natural sciences’ methodic investigation of natural objects. The fundamental assumption of a dualist ontology circumscribes the social sciences to a particular epistemological tradition that eliminates other possibilities within the full richness and scope of philosophy. Relying on the philosophy of social science as a framework retains the divisions between subject– object, mind–body and person–world that consigns and miscategorizes so-called ‘subjective’ knowledge to mere personal opinion or belief. Thus, our bodies, relationships, and practices are ultimately reduced to objectively defined, one-dimensional categories stripped of our experience. The questions pursued by the philosophy of social science within this tradition remain limited. Hence, this approach can provide a partial solution to broadening knowledge generation, but may not go far enough. Other approaches, such as the ‘new’ philosophy of social science, go further and challenge this view of knowledge by developing the historical aspects of scientific and social scientific knowledge (Bohman, 1991). An investigation of the historical and indeterminate nature of knowledge ends up blurring the line between subject and object, or nature and culture. Personal experience is not something set apart from the ‘objective’, the social, and the interpersonal world. This perspective on knowledge starts from the postempiricist viewpoint ushered in by the work of Kuhn (1970). Ultimately, we believe that the point of studying philosophy in a doctoral programme for nurses goes beyond deepening students’ understanding of science and the methods that may ground their research. We agree with Thorne (2014) that philosophical thought can deepen their understanding of core disciplinary knowledge. Studying philosophy opens up a wealth of insights and questions. Our course examines how different philosophical and scientific approaches reveal or marginalize aspects of the body and what these approaches disclose or conceal about illness. We look at how they bring to light power dynamics in caring relationships and healthcare systems, and whether they uncover the technological and systemic impera-
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tives which drive healthcare decisions, and colonize the lifeworld (Habermas, 1981/1984). Fruitful questions also include what counts as evidence and how forms of evidence shape (or obfuscate) nursing science and clinical practices. Rather than focusing on the philosophical foundations of science, we introduce students to the philosophical foundations of knowledge for the purpose of understanding and investigating nursing phenomena. This approach encourages a healthy skepticism towards forms of knowledge that are privileged in evidence-based practice. We seek to prepare doctoral students with the skills for walking the ‘rough ground’, capable of pursuing questions, critiquing hallowed assumptions, and developing knowledge that nurses routinely integrate in their care – including, but not limited to. scientific knowledge, relational knowledge, ethical knowledge, and practical know-how. These multiple forms of knowledge cohere with our core disciplinary knowledge. They require deep philosophical thought and diverse methodologies to advance clinical practice, promote healing and recovery, and relieve suffering. With the advent of an increasingly technologically mediated healthcare system, we believe that it is even more imperative to hold on to this ‘rougher’, more human dimension of nursing and the multiple forms of knowledge that safeguard patients and the core ethos of the discipline. Ultimately, the study of philosophy sets up a tension in which the search for answers competes with the discipline of philosophy’s inherent iconoclastic challenge contained in the practice of questioning. This is the ultimate ‘rough ground’. Once philosophy is introduced into a discipline, the notions of clarity and system building are always accompanied by their opposite – the entangled web of ongoing and competing discourses about the questions. Science fundamentally seeks answers; philosophy fundamentally questions and challenges the ‘received’ answers. Along the way, the answers and the questions improve as the spiraling process enlightens both. To continue to question in this way is to remain faithful to the deepest roots of our humanity, and to preserve a space for our humanity in the practice of nursing.
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Description of the course For more than a decade, we have developed and co-taught a course which is aligned with this more expansive view of knowledge. As the title of our course, ‘Nursing knowledge development: Philosophical perspectives’, suggests, we eschew a narrow focus on philosophy of science or social science, believing that a broad understanding of knowledge encompasses the ‘rough ground’ of human experiences of health, illness, and clinical encounters. While our course addresses the history and philosophy of science, we refer to our course as a philosophy of knowledge course, not a philosophy of science course. This shift is consequential for the organization and content of the course, and is apparent in the course description, objectives, and units (see Table 1). Because nurses necessarily rely on many forms of evidence for making ethically sound and astute clinical judgments (Nortvedt, 2001; Benner & Leonard, 2005; James et al., 2010; Thorne & Sawatsky, 2014), our course problematizes a naïve or outmoded view of science. We challenge students to rethink their assumptions about science, knowledge, and truth, especially in relation to health and illness phenomena, and invite them to critically reflect on the limits and strengths of various modes of inquiry. Thus, the broad questions animating the course include the following: What is knowledge and truth? What kinds of knowledge are needed to examine embodiment (of the patient and nurse), ethical knowledge, relational knowledge, theoretical/empirical knowledge, and practical know-how in the day-to-day realities of the practice world? What forms of knowledge are privileged or marginalized by various stakeholders, including universities, research funders, textbook publishers, journals, and healthcare corporations? To this end, we examine different conceptions of truth, knowledge, rationality, and personhood from the philosophical perspectives of empiricism, rationalism, hermeneutics, critical theory, feminism, and postmodernism. Our broad themes include the body, illness, health and ethics, and nursing as a practice in the context of relationships, technology, and power. By the end of the course, we expect students to appreciate that all forms of knowledge are perspectival, even those ame-
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Table 1. Overview of course Course description
Course objectives
Course units
Class sessions
This course will examine the development of nursing knowledge from diverse philosophical perspectives and traditions. Different conceptions of truth, knowledge, rationality, personhood, the body, and the moral good will be examined as a foundation for understanding and investigating nursing phenomena. 1. Examine notions of truth, knowledge, rationality, and the stance of the nurse scientist from the philosophical perspectives of empiricism, rationalism, hermeneutics, critical theory, and postmodernism. 2. Distinguish between various forms of inquiry as the basis for understanding and studying the natural world and the human world. 3. Examine how philosophical perspectives (re: truth, rationality, and origins of knowledge) shape nursing practice, ethics, and science. 4. Describe the implications of different philosophical perspectives and traditions for studying discrete nursing phenomena. 5. Critique different philosophical perspectives for studying the body and the person. • Historical development of scientific knowledge, focusing on the development of modern science: Descartes’ dualism and mechanistic philosophy • Contemporary influences on nursing knowledge development (e.g. hermeneutics, critical theory, postmodernism) • Conceptions of the person and the body (e.g. Descartes, Merleau-Ponty); how the person is studied as an isolate (methodological individualism) or is considered to be social through and through • Relationships between truth, knowledge, rationality, and power and technology (e.g. Foucault, Heidegger, critical theorists) • Nursing perspectives on knowledge development Introduction: History of the Natural Sciences The Body as Machine What is Scientific Knowledge? Kuhn Introduction to Heidegger: Overcoming the Cartesian Legacy Being-in-the-world Merleau-Ponty and the Lived Body Foucault and Biopower Critical Theory: The Challenge to Power Feminist Perspectives on Science Science and Technology Ethical Knowledge, Nursing, and Relationship Nursing Knowledge Development: Phronesis vs Techne? Evidence-Based Practice Social and Political Forces in the Construction of Knowledge
nable to precise measurement, and that attempts to find a neutral starting point, in line with Cartesian assumptions, contribute to an illusion that ‘true’ knowledge is ‘scientific’ and should therefore be privileged over forms of knowledge that are less amenable to scientific measurement and scrutiny. While the course includes content on traditional conceptions of science, assigning science a privileged position denigrates the complexity of clinical judgment and undermines nursing’s social mandate. Treading the rough ground implies that students gain a healthy respect for alternative forms of inquiry and that they will draw on philosophical resources to become better educators, practitioners, and scholars. We fully acknowledge and discuss the tension that students
will inevitably face as scientific knowledge is upheld as the gold standard in future coursework and over their careers. The course is offered in the PhD programme at the School of Nursing at Saint Louis University, a Jesuit university located in the Midwest of the United States. The doctoral programme has existed since 1990. When the doctoral programme began, students were required to take two philosophy courses, an epistemology and a philosophy of science course, both of which were offered by the Philosophy Department. The current course was developed a few years later by a task force led by the second author in response to a curricular change in the doctoral programme. The new course was approved by the
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doctoral faculty to replace the two philosophy courses, along with the recommendation that the course be co-taught by a philosopher and nurse. The course was first offered in 2002 and has always been co-taught by a philosopher whose background includes the history of philosophy and applied philosophy, and a nurse who brings nursing issues and a background in contemporary philosophy to the course. Local and distance students take the class together via web-based video conferencing technology, typically in the first semester of their programme, along with a course on Nursing Theory. Most students are nurse educators and are enrolled in the programme part time; full-time students are typically international students and local students. Students from Health Ethics have also enrolled in the course. We appreciate our good fortune in co-teaching this course. We are also fortunate to supplement required readings with video presentations of distinguished scholars and philosophers which were produced with funding from the US Department of Health and Human Resources (HRSA) in 2004. This award made it possible for the School of Nursing to invite nationally recognized scholars to present on their area of expertise. We refer to the scholars and the films included in the course below. The course is based on the seminar method with readings for discussion; faculty and students also make presentations. Course progression: from slippery ice to the rough ground The course begins with an overview of the history of science, from the focal point of the modern scientific revolution. Beginning with the earth-centred view of the universe, we discuss how this model was overthrown with the advent of the new theories of Copernicus, the experimentation of Galileo, and the culminating work of Isaac Newton. The point of this historical analysis is to show how the development of modern science ushered in mechanistic and materialistic explanations of phenomena, which enabled scientists to measure the material world. Therein lies the brilliance and success of much of modern science. Having introduced students to the scientific revolution, we highlight the philosophy of Descartes (1641/1993), whose work marks the beginning of
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modern philosophy, and who, as a scientist, wrote ground-breaking works on human physiology. We show how his dualistic approach laid the groundwork for modern scientific medical thought, allowing the body to be treated as a material object, with the mind conceived of as an entirely separate substance. This dualism enabled subsequent medical approaches to focus solely on the body as an object and to ignore those aspects of persons which cannot be measured. By way of contrast, we introduce the ‘lived body’, as articulated in the phenomenology of Merleau-Ponty, and interpreted by physician and philosopher Leder (1990, 1998). The lived body perspective introduces students to a more holistic and inclusive view of embodiment and personhood, which we return to later in the course. Having established this fundamental tension in how the body is understood and studied, we proceed to outline the trajectory of 20th century philosophy of science, beginning with theories like logical positivism and Karl Popper’s falsificationism (Chalmers, 1999), and culminating in the revolutionary work of Kuhn’s (1970), The Structure of Scientific Revolutions, which the students are assigned to read. The purpose of this section is to show students that naïve views of science, which typically take the form of a positivist view, are no longer rationally tenable, given the work of Kuhn and others. Because students unknowingly accept something like a positivist view of science, the revelation that their view is outmoded prepares them to seek better, more inclusive models of knowledge which are to come in the course. The course then takes a hermeneutic turn by introducing students to the early philosophy of Heidegger, as interpreted by Dreyfus (1991), an internationally renowned expert on Heidegger and continental philosophy. Heidegger broke away from the projects of modern philosophy in which questions concerning what it means to know predominated.We read Heidegger’s critique of Descartes’ dualism with secondary sources (Guignon, 1983; Magee, 1987), and watch a video presentation by Dr. Dreyfus. His presentation focuses on early Heidegger’s challenge to Cartesian assumptions and the separation of subject from object, mind from body, and person from world. Heidegger’s focus on ontology prior to epistemology
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and his hermeneutics of being-in-the-world revealed new dimensions of knowing that included noncognitive, more embodied perspectives for researching human experience that are passed over by scientific practices of generalizing and unitizing (Guignon). Heidegger’s notions of the ‘ready to hand’ and ‘the unready to hand’ reveal ways of knowing embedded in everyday human practices and skills that are traditionally overlooked by scientists trained to investigate phenomenon in terms of ‘present to hand’ entities that are shorn free from any human context or activity. In drawing attention to the tacit ways of knowing that are formed through our practical engagements in the world, students are encouraged to see and value aspects of their clinical work, which a scientistic view of knowledge traditionally overlooks. In spite of the difficulty of Heidegger’s language and thought, everyday examples from students’ clinical experiences, and (Benner’s, 1994; Benner et al., 2011) research on nursing practice, substantiate how these forms of knowing are central to good patient outcomes, even though they elude conventional forms of scientific research. The course then turns to some of the rich philosophical developments that mushroomed in response to Heidegger’s thought. Each subsequent philosopher we study builds on Heidegger’s hermeneutics by flushing out aspects of ‘being-in-the-world’ that were not taken up as directly in his work. For example, we return to Merleau-Ponty’s (1945/1962) ‘lived body’, and discuss how our embodiment during health and illness is addressed or obscured in science and contemporary health care. Baron’s (1985) classic article, with the ironic title ‘I Can’t Hear You While I’m Listening’, reveals how a machine body approach to clinical care dehumanizes patients and prevents practitioners from attending to their concerns and perspectives. Leder’s (1998) video presentation on Merleau-Ponty introduces students to the way the Cartesian body is treated as a ‘living corpse’ or bioengineerable machine. This mechanical body is composed of cells, tissues, organs, and complex neuroendocrine and immunologic interactions that are mapped and measured so that disease is diagnosed and treated. Leder (1990, 1998) contrasts this Cartesian body with Merleau-Ponty’s description of the
lived body, which is skilled, sentient, taken for granted in health, but foregrounded in illness because of pain, fatigue, intrusive symptoms, and an uncooperative body. The image of the ‘panopticon’, a design for prisons in which prisoners are seen but cannot see their jailers, provides a metaphor for Foucault’s (1979) crucial notion of ‘bio-power’, which we take up next. Through his historical analyses of modern and contemporary social sciences, in particular his study of medicine in ‘The Birth of the Clinic’, Foucault (1973) shows how modern systems seek to manage large populations through the control and subjugation of their bodies. Students have noted the likeness of the panopticon to many modern institutions, including intensive care units (ICUs). Required research articles provide further evidence of clinical practices that reinforce a docile body. We view the film, Wit (Nichols, 2001), of a woman dying of ovarian cancer through the lens of bio-power and the docile body, an exercise which powerfully reveals how these concepts organize knowledge in everyday healthcare practices. We then study Habermas’ (1981/1984) theory of communicative rationality. Bro. William Rehg, a philosopher at Saint Louis University, introduces students via video presentation to the major concepts of critical theory. The concepts of lifeworld and system help us to view health care from a social and political level, one that includes the effects of our economic system on the daily work of nurses. Readings by feminist philosophers challenge the notion of objectivity as emotionally neutral or impartial. Franklin’s (2001) lovely piece, ‘Science is Knowing and Loving the World’, shows how a feminist approach appreciates science’s relational and emotional aspects. We watch Moyers (1994) interview Evelyn Fox Keller where she describes our culture’s tendency to connect science with masculinity and objective forms of knowledge. With Barbara McClintock as an example of a scientist who challenged traditional conceptions of objectivity, Fox Keller argues that ‘feeling’ is just as important as impartial reasoning in conducting rigorous scientific research. Moving to the topic of technology, we explore the relationship between science, technology, and nursing practice. Because of their clinical practice, students
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have a great deal to say about the technological imperative in shaping knowledge, patient experiences, and nursing practice. Published studies on the experience of being a patient in an ICU (Almerud et al., 2007) or having an implantable defibrillator (Kaufman et al., 2011) highlight vexing issues related to the technological understanding in health care that call for nursing investigation. Although ethical issues and concerns have arisen in earlier class sessions, we turn to Emmanuel Lévinas’ (1989) phenomenology of the personal encounter, the ‘face-to-face’ interaction, as the basis for an ethical knowledge that is prior to all other kinds of knowledge. The implications of Lévinas’ thought for nursing science and practice are described in a video presentation by Dr Michael Barber, also a philosopher at Saint Louis University, and are further flushed out in assigned readings. Nortvedt (2001), for example, draws on Lévinas’ thought to describe the inseparability of ethical sensitivity and clinical nursing knowledge. Papers by Naef (2006), Wynn (2002), and SmithBattle (2009) shed further light on the ethical responsibilities that are grounded in first knowing the person. We examine the development of evidence-based practice, and its underlying premises, as we return to issues that have been raised over the entire course, including what counts as evidence and truth and how truth claims are negotiated and constructed, and for what purpose. This content invites students to address the question that now emerges from the much richer view of knowledge that the course has afforded them: whether nursing is more properly understood as a practice discipline, a scientific discipline, or a human science. Students read the work of scholars who have addressed this issue (Bishop & Scudder, 1997; Flaming, 2001; Thorne & Sawatsky, 2014). We also encourage students to consider the relationship between science and practice by examining Aristotelian categories of ‘phronesis’ and ‘techne’ as discussed by several nurse authors (Flaming, 2001; Benner & Leonard, 2005; Kinsella, 2007). At this point, students are somewhat familiar with the difference between knowing-how (clinical knowledge developed in practice) versus knowing-that (theoretical knowledge developed by scientists). Although many students
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have previously seen the video (Benner et al., 1992) From Novice to Expert, they watch it again with new interest and are typically surprised to see how nursing knowledge based on pattern recognition, clinical reasoning, and knowing the person, while essential to quality care, is considered too contingent and situated to count as evidence. This tension between the particular and the general contributes to the slippery ground that nurses walk with patients. Challenges of the course include the fact that students with little prior philosophical background are introduced to new ways of thinking about knowledge. The breadth and scope of the course also place limits on reading primary sources, although readings by Descartes, Kuhn, Merleau-Ponty, Levinas, and Foucault are assigned. These limitations are offset by video presentations from distinguished scholars and many excellent nursing articles. While students are stretched to understand philosophical thought in a short space of time, course evaluations have been universally positive. Students report that they find the course to be very meaningful and that they see and value their teaching and clinical practice knowledge with new eyes. They recognize a richer spectrum of nursing knowledge that awaits further investigation and translation into practice. In conclusion, nursing’s quest for knowledge remains a central imperative in doctoral education. Because this quest has been constrained by an epistemological focus on knowledge generation, we introduce doctoral students to a philosophy of knowledge course that is not confined to philosophy of science and social science. Rather, we introduce students to a broad understanding of knowledge that encompasses the ‘rough ground’ of the human experience of health and illness, laying the groundwork for examining the many forms of knowledge (scientific, ethical, relational, and practical ways of knowing) that nurses routinely integrate in their practice. In highlighting how different philosophical approaches simultaneously reveal and marginalize aspects of the body and the experiences of illness and health, the course prepares students to consider studying various dimensions of nursing phenomena and translating diverse forms of evidence to the rough ground of practice. This approach also safeguards tensions regarding
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knowledge and evidence that inevitably arise in a profession entrusted with the care of individuals, families, and communities.
Acknowledgements We gratefully acknowledge the research assistance of Ann Pierce, RN, MSN, FNP, and the helpful review by William Rehg, S.J., Dean of Arts and Letters, Saint Louis University.
References AACN. (2010). The research-focused doctoral program in nursing: pathways to excellence. Almerud S., Alapack R.J., Fridlund B. & Ekebergh M. (2007) Of vigilance and invisibility – being a patient in technologically intense environments. Nursing in Critical Care, 12, 151–158. doi: 10.1111/j.1478-5153.2007.00216.x. Ayres L. (2013) Practice makes perfect. Research in Nursing and Health, 36, 325–327. doi: 10.1002/nur.21552. Baron R.J. (1985) An introduction to medical phenomenology: I can’t hear you while I’m listening. Annals of Internal Medicine, 103, 606–611. Benner P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Redwood City, CA. Benner P. (1994) The role of articulation in understanding practice and experience as sources of knowledge in clinical nursing. In: Philosophy in a Time of Pluralism: Perspectives on the Philosophy of Charles Taylor (eds J. Tully & D.M. Weinstock), pp. 136–155. Cambridge University Press, Cambridge, England. Benner P. & Leonard V.W. (2005) Patient concerns, choices, and clinical judgment in evidence-based practice. In: Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice (eds B.M. Melnyk & E. Fineout-Overhold), pp. 163–182. Lippincott Williams & Wilkins, Philadelphia, PA. Benner P., Tanner C. & Chesla K. (1992) From beginner to expert: clinical knowledge in critical care nursing. In: S.T. Productions (Producer), Fuld Institute for Technology in Nursing Education. Benner P., Hooper-Kyriakidis P. & Stannard D. (2011) Clinical Wisdom and Interventions in Acute and Critical Care: A Thinking-in-Action Approach, 2nd edn. Springer, New York. Bishop A.H. & Scudder J.R. (1997) Nursing as a practice rather than an art or science. Nursing Outlook, 45, 82–85. doi: 10.1016/S0029-6554(97)90085-3. Bohman J. (1991) New Philosophy of Social Science. MIT, Cambridge, MA.
Butts J.B. & Lundy K.S. (2003) Teaching philosophy of science in nursing doctoral education. Journal of Nursing Scholarship, 35, 87–91. doi: 10.1111/j.1547-5069.2003 .00087.x. Canam C.J. (2008) The link between nursing discourses adn nurses’ silence: implications for a knowledge-based discourse for nursing practice. Advances in Nursing Science, 31(4), 296–307. Carper B.A. (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–24. Chalmers A.F. (1999) What is this Thing Called Science?, 3rd edn. Hackett Publishing, Cambridge, MA. Dahnke M.D. & Dreher H.M. (2011) Philosophy of Science for Nursing Practice: Concepts and Application. Springer Publishing Company, LLC, New York. Descartes R. (1641/1993) Meditations on First Philosophy. Translated by D. A. Cress, 3rd edn. Hackett, Indianapolis, IN. Dreyfus H.L. (1991) Being-in-the-World: A Commentary on Heidegger’s Being and Time, Division I. MIT Press, Cambridge, MA. Flaming D. (2001) Using phronesis instead of ‘researchbased practice’ as the guiding light for nursing practice. Nursing Philosophy, 2, 251–258. doi: 10.1046/j.1466769X.2000.00066.x. Foucault M. (1973) The Birth of the Clinic: An Archaeology of Medical Perception. Random House, New York. Foucault M. (1979) Discipline and Punish: The Birth of the Prison. Random House, New York. Franklin B.S. (2001) Science is knowing and loving the world: a memoir of a feminist critique of science. Woman’s Studies Quarterly, 2, 208–215. Guignon C.B. (1983) Heidegger and the Problem of Knowledge. Hackett, Indianapolis, IN. Habermas J. (1981/1984) The Theory of Communicative Action: Vol 1: Reason and the Rationalization of Society. Beacon, Boston. Heidegger M. (1962) Being and Time. Translated by J. Macquarrie and E. Robinson. Harper & Row, New York, NY. Original work published 1935. James I., Andershed B., Gustavsson B. & Ternestedt B.-M. (2010) Knowledge constructions in nursing practice: understanding and integrating different forms of knowledge. Qualitative Health Research, 20, 1500–1518. doi: 10.1177/1049732310374042. Kaufman S.R., Mueller P.S., Ottenberg A.L. & Koenig B.A. (2011) Ironic technology: old age and the implantable cardioverter defibrillator in US health care. Social Science and Medicine, 72, 6–14. doi: 10.1016/j.socscimed .2010.09.052. Kinsella E.A. (2007) Technical rationality in Schön’s reflective practice: dichotomous or non-dualistic epistemological position. Nursing Philosophy, 8, 102–113. doi: 10.1111/ j.1466-769X.2007.00304.x.
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Kuhn T.S. (1970) The Structure of Scientific Revolutions, 2nd edn. University of Chicago Press, Chicago. Lévinas E. (1989) Ethics as first philosophy. In: The Levinas Reader (ed. S. Hand), pp. 75–87. Blackwell, Madden, MA. Leder D. (1990) The Absent Body. University of Chicago, Chicago, IL. Leder D. (1998) A tale of two bodies: the Cartesian corpse and the ‘lived body’. In: Body and Flesh: A Philosophical Reader (ed. D. Welton), pp. 117–130. Blackwell, Oxford. Magee B. (1987) Husserl, Heidegger and modern existentialism: dialogue with Hubert Dreyfus. In: The Great Philosophers:An Introduction to Western Philosophy, pp. 254–277. Oxford University Press, Oxford. Merleau-Ponty M. (1945/1962) Phenomenology of Perception. Translated by C. Smith. Routledge & Kegan Paul, London, England. Moyers B. (1994) Science and Gender: Evelyn Fox Keller, The Moyers Collection: A World of Ideas. U.S.: Films for the Humanities & Sciences. Naef R. (2006) Bearing witness: a moral way of engaging in the nurse-person relationship. Nursing Philosophy, 7, 146– 156. doi: 10.1111/j.1466-769X.2006.00271.x.
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Nichols M. (2001). Wit [Motion picture]. U.S.: HBO Films. Nortvedt P. (2001) Clinical sensitivity: the inseparability of ethical perceptiveness and clinical knowledge. Scholarly Inquiry for Nursing Practice, 15, 25–43. SmithBattle L. (2009) Pregnant with possibilities: drawing on hermeneutic thought to reframe home-visiting programs for young mothers. Nursing Inquiry, 16, 191–200. doi: 10.1111/j.1440-1800.2009.00457.x. Thorne S. (2009) Ideas and action in a terrain of complexity. Nursing Philosophy, 10, 149–151. doi: 10.1111/j.1466769X.2009.00411.x. Thorne S. (2014) What constitutes core disciplinary knowledge? Nursing Inquiry, 21, 1–2. doi: 10.1111/nin.12062. Thorne S. & Sawatzky R. (2014) Particularizing the general: sustaining theoretical integrity in the context of an evidence-based practice agenda. Advances in Nursing Science, 37(1), 5–18. doi: 10.1097/ANS.0000000000000011. Wittgenstein L. (1958/1968) Philosophical Investigations. Translated by G. E. M. Anscombe. Macmillan, New York. Wynn F. (2002) Nursing and the concept of life: towards an ethics of testimony. Nursing Philosophy, 3, 120–132. doi: 10.1046/j.1466-769X.2002.00097.x.
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doi: 10.1111/nup.12077
On to the ‘rough ground’: introducing doctoral students to philosophical perspectives on knowledge Ellen Rehg* PhD and Lee SmithBattle† RN PhD *Adjunct Assistant Professor and †Professor of Nursing, School of Nursing, Saint Louis University, St. Louis, MO, USA
Abstract
Doctoral programmes in nursing are charged with developing the next generation of nurse scholars, scientists, and healthcare leaders. The American Association of Colleges of Nursing (AACN) endorses the inclusion of philosophy of science content in research-focused doctoral programmes. Because a philosophy course circumscribed to the natural or social sciences does not address the broad forms of knowledge that are relevant to nursing practice, we have developed and co-taught a course on the philosophy of knowledge that introduces students to competing claims regarding the nature of knowledge, truth, and rationality. In addressing broad themes related to science and knowledge of the body, health and illness, and ethics, the course equips students to tread the rough and shifting ground of nursing scholarship and practice. Providing doctoral students with this philosophical footing is intended to give future scholars, researchers, and healthcare leaders the intellectual skills to critically reflect on knowledge claims, to challenge the hegemony of science, and to recognize the disciplinary forms of knowledge that are left out or trivialized. Our pedagogical approach to knowledge development does not denigrate scientific knowledge, but elevates forms of inquiry and notions of clinical knowledge that are too often marginalized in doctoral education and the academy in general. Keywords: knowledge, nursing inquiry, nursing research, philosophy of science, praxis.
Introduction We have got on to slippery ice where there is no friction and so in a certain sense the conditions are ideal, but also, just Correspondence: Dr Lee SmithBattle, Professor of Nursing, School of Nursing, Saint Louis University, 3525 Caroline Avenue, St. Louis, MO 63104, USA. Tel.: 3149778980; fax: 314977-8819; e-mail: [email protected]
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because of that, we are unable to walk. We want to walk: so we need friction. Back to the rough ground! (Wittgenstein, 1958/1968, p. 46).
Doctoral programmes in nursing are charged with developing the next generation of nurse scholars, researchers, and healthcare leaders. The American Association of Colleges of Nursing (AACN) has endorsed the inclusion of philosophy of science
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content in research-focused doctoral programmes since at least 1993. More recently, the AACN (2010) recommended including ‘ways of knowing and habits of mind’ (p. 5) and ‘practice knowledge’ (p. 5) as core curricular content. We welcome this apparent nod to broad forms of knowledge, and agree with many nursing scholars that the quest to equate knowledge with science, based on the natural science paradigm, has been deeply problematic for advancing the nursing discipline (Canam, 2008; Ayres, 2013; Thorne & Sawatsky, 2014). Like all forms of knowledge, the Cartesian view that lurks in the background of scientific inquiry disregards its own blindspots and assumptions regarding the nature of truth, knowledge, and reality. Because these biases are generally hidden to healthcare professionals and researchers, we agree with Thorne (2009) that philosophy offers rich resources for deepening our understanding of the forms of knowledge needed to advance nursing practice: The alignment between scientific advancement and improvements in the health of societies has been so close as to seem patently obvious. And yet those of us who embrace the ethos of a practice discipline are continually reminded of how disparate are the enthusiastic claims of science when set against the realities of human misery and suffering. By contrast, philosophy orients us towards work in the world of what is and what ought to be. It steers us towards careful examination of what we consider to be the values by which we operate, and to account for how they pertain to our notions of truth.Thus, the philosophical enterprise in nursing inevitably bumps us up against the conventional knowledge generation and translation enterprise that has become the familiar backdrop of all that we do in health care and nursing. (p. 150)
The growing recognition for diverse forms of knowledge occurs in the wake of nursing research showing that clinical judgment, at its very best, melds scientific evidence with knowledge of the specific patient and with clinical understanding of the meanings and trajectories of illness in concrete situations (James et al., 2010; Benner et al., 2011; Thorne & Sawatsky, 2014). Because science does not exhaust the ways that clinicians act and know, as implied in the AACN document and described in nursing research, a
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philosophy of science course, even one that introduces students to philosophies of science and social science, cannot provide sufficient ground for discovering, testing, and translating nursing’s disciplinary knowledge into practice. Assuming that scientific knowledge is but one form of knowledge that supports excellent nursing care, students need to be familiar with the competing claims regarding knowledge and truth, and understand how clinicians meld scientific evidence and practical and relational knowledge with appropriate technology and the core values of the discipline for the good of specific patients, families, and communities. In this paper, we argue for and describe a philosophy of knowledge course for research-focused doctoral programmes that include, but is not limited to, philosophy of science. In exploring philosophical perspectives on knowledge, we introduce students to competing claims regarding the nature of knowledge, truth, and rationality; and by addressing the broad themes of the body, health, illness, and ethics, in relation to technology and power dynamics, we prepare doctoral students to tread the rough and shifting ground of nursing science, scholarship, and practice. Providing doctoral students with this philosophical footing is intended to give future scholars, researchers, and healthcare leaders the intellectual skills to critically reflect on knowledge claims, to challenge the hegemony of science, and to recognize all that is passed over or trivialized: human agency, embodiment, the life-world. Our pedagogical approach to knowledge development does not denigrate scientific knowledge, but elevates forms of philosophical inquiry and notions of clinical knowledge that are too often marginalized in doctoral education and the academy in general.
Background To determine how other PhD programmes address philosophical issues related to science and knowledge development, we conducted a survey of PhD programmes listed on the AACN website (http:// www.aacn.nche.edu/research-data/DOC.pdf). From this list, we downloaded the curricula and course descriptions, when available, from the websites of each
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School of Nursing offering a PhD programme. Of the 100 PhD programmes that were surveyed in 2010, the majority (n = 62) did not offer a philosophy course of any kind. Judging by the titles, the majority of the 26 philosophy courses that were offered in these programmes appeared to be straightforward philosophy of science courses. The content of the remaining 25 courses was difficult to discern from titles such as ‘Knowledge Development in Nursing’. Only 8 of the 100 programmes appeared to offer a course similar to ours. Because the majority of programmes do not offer a stand-alone philosophy course of any kind in their curriculum, we were not surprised to find only one relevant published article (Butts & Lundy, 2003). These authors are to be applauded for describing how they introduce nursing doctoral students who have had little philosophical background to the relevance and limits of philosophy of science and social science for developing nursing knowledge. Beyond philosophy of science We assume that programmes offering a philosophy of science course aim to provide nurse scholars with a more sophisticated understanding of science than that of the lay person. In a philosophy of science course, students typically investigate the rational underpinnings of science and are introduced to concepts such as induction, deduction, empiricism, rationalism, and theories of truth. Questions that are examined include: What differentiates science from nonscience? Is scientific knowledge cumulative? Is science ‘proven’ knowledge? What is the nature of causation? What is the problem of induction? These questions should lead the nurse scholar towards a more sophisticated understanding of exactly what kind of knowledge science can and cannot yield. The student should come to see that science itself is probable knowledge; that findings are tentative; and that no research is ever completely objective or value free. However, even with this more chastened, contemporary, ‘post-empiricist’ understanding of the nature of science, we still might ask whether these questions alone provide enough ‘friction’ for a nurse scholar to journey through the diverse terrain of disciplinary knowledge related to human health and illness. Wittgenstein’s quote at the beginning of our paper refers
to his initial quest to render language, and hence our grasp of the world, completely in accord with logic. Only then would the world be a rational one, capable of human comprehension. Wittgenstein ultimately determined that language cannot be reduced to logic, and the world cannot be reduced to language; human experience is simply much richer, complex, and meaningful to be fully systematized into logical propositions. We would extend Wittgenstein’s observation to say that knowledge itself, and nursing knowledge in particular, is much more uneven and contingent on specific situations to be fully abstracted into scientific theories and causal explanations. Even if we learn to design research so that it yields rational, scientific knowledge, the evidence privileged by the evidencebased movement, have we captured all there is to nursing knowledge? While scientific knowledge is crucial for clinical care, does it exhaust the philosophical notions of ‘ways of knowing’, ‘practical knowledge’, and reasoning through specific clinical cases that ultimately furthers positive patient outcomes? Can it yield the kind of knowledge generated in human interactions with others, which is uncertain, concrete, and replete with meaning? How do we capture nursing’s pursuit of the ‘rough ground’, that is, the melding of complex kinds of knowledge that escapes abstraction and cannot be formulated into universal principles? And if we do capture the complexity and contingency of clinical judgment that spills over conventional scientific evidence, what would it mean to claim that this knowledge also qualifies as evidence? Although our argument might appear to echo the work of Barbara Carper (1978), in her seminal article on ‘ways of knowing’, there are important differences between her work and a philosophical approach to knowledge. Carper’s article remains on the level of nursing theory, rather than philosophy itself. As such, she does not provide philosophical foundations or justifications for her claims that nursing contains these different ways of knowing. In our course, we investigate the meta-level of ways of knowing, through the philosophical work of continental philosophers, including Martin Heidegger, MerleauPonty, Levinas, and others. These philosophers’
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insights recover aspects of human experience (including clinical judgment and the meanings and practice of living with health and illness) that elude traditional science, and provide the philosophical framework to show how other kinds of systematic investigations also generate disciplinary knowledge. The question might be raised whether such forms of knowing count as evidence. Indeed, what difference would it make, in terms of evidence-based nursing, that there are multiple ways of knowing that can be systematically investigated, if only scientific knowledge counts as evidence? Thorne and Sawatzky (2014) argue that non-science-based types of knowing are of a ‘fundamentally different nature’ (p. 8) than scientific knowledge understood as justified true beliefs. They write: In that [personal, spiritual, or esthetic knowing are] grounded in sources such as personal experience, intuition, or revelation, subjectively derived knowledge cannot be objective and generalizable in terms of the patterns of phenomena to which a particular evidentiary claim applies. Thus, although it may have a role to play in the praxis process, it is not in and of itself a shared form of knowledge that can be confirmed and argued as an evidential basis for nursing practice.
(p. 9)
Although much of what these authors argue is consistent with our argument, we depart from the view that knowledge not derived from traditional methods of verification is necessarily subjective, and hence, a poor candidate for evidence-based care. This view is based on a philosophy which divides subject/object and person/world into separate categories with unassailable boundaries. In contrast, a philosophical approach nurtured by the contemporary thinkers listed above can provide the resources to overcome these boundaries. Heidegger’s (1962) ontology provides a description of being-in-the-world that highlights how human engagements provide our most primordial way of knowing and acting which, Benner (1984) adapted (following Dreyfus) to explain how nurses evolve from novice to experts. The embodied skills which nurses absorb from their practice are not merely personal or subjective phenomena as they are a hallmark of excellent nursing care that are easily recognized and verified by others. Even the practical
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and relational knowledge that is derived from knowing specific patients (e.g. meanings of illness, patients’ concerns, preferences, and ways of embodying an illness) is not totally subjective or idiosyncratic, at least when patients share a similar cultural background. Because this knowledge can be shared, it is open to verification and validation. Using another example, the ‘docile body’ described by Foucault (1979) should not be construed as a purely subjective phenomenon as it is widely adopted by patients and reinforced by healthcare providers. These examples challenge the claim that only the empirical sciences generate ‘objective’ evidence. Thorne and Sawatzky (2014) also assume that the kinds of methodically justified propositions derived or inferred from empirical experimentation are somehow privileged forms of evidence, because they are ‘based on established premises of empirical verification and philosophical argumentation’ (p. 9). Such a position overlooks the perspectival nature of all empirical science and the social elements that enter into scientific knowledge construction (Kuhn, 1970; Chalmers, 1999). Beyond philosophy of social science One way to introduce students to a broader view of knowledge is to include content related to the philosophy of social science along with philosophy of science. As shown above, courses which do this may be less common than those which are straightforward philosophy of science courses. This approach is exemplified in a recently published textbook for nursing doctoral students which expands the notion of science to include a science of human actions (Dahnke & Dreher, 2011). The philosophy of social science has traditionally rested upon the distinction between the ‘natural’ or ‘hard’ sciences, like physics, chemistry, biology and the like, and the social or ‘human’ sciences, such as psychology, economics, and sociology. Part of the goal of the philosophy of social science is to broaden the base of what counts as rigorous knowledge. This approach argues that human actions, while considerably different from objects in the natural world, can also be studied empirically and used to provide a solid basis for knowledge. From this vantage point, knowledge is
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not the province of the empirical sciences alone, but disciplines such as psychology can be made rigorous enough to ground knowledge claims, with objective procedures imported from the natural sciences. The philosophy of social science initially relied on the natural sciences as the paradigm for what counts as trustworthy knowledge: the ability to make universal, law-like claims which can serve as both an explanation of a physical event and a prediction of when that event will next occur. For a number of decades, the philosophy of social science had as its primary task the effort to make the philosophy of human actions conform to this model. The ground-breaking work of Kuhn (1970) casts doubt on the model of the natural sciences as the ‘gold standard’ for knowledge, and on the possibility of objectivity and value-neutrality even in the natural sciences. This freed the philosophy of social science to broaden its focus to one of analysing the nature of interpretation, and how it could provide a basis for epistemological claims. However, the question regarding the relationship between the social and the natural sciences has not been entirely abandoned, and is an enduring one in this field (Dahnke & Dreher, 2011). With the move towards interpretation, the social sciences adopted the twin goals of both explaining social phenomena and also understanding them. One of its many questions has to do with the type of knowledge that the human sciences can generate, and along those lines, whether and to what extent this knowledge can be objective, or value free.As valuable as this approach is, we believe that there are drawbacks to adding the philosophy of social science into the philosophy of science as a way to broaden the view of knowledge for a practice discipline like nursing. One of the drawbacks is that much of this philosophy remains within the dualist tradition initiated by Rene Descartes and the hard and fast separation between subject and object, mind and body, and person and world (Guignon, 1983; Leder, 1990). Its ‘building blocks’ are the mechanical body and the intentional acts of human beings. These intentional acts are described as phenomena that have an underlying ‘mental state’, such as a person’s beliefs or desires. Intentionality in this context refers to a con-
scious mind that causes an action. Such a philosophy seeks to study this kind of intentionality in a way analogous to the natural sciences’ methodic investigation of natural objects. The fundamental assumption of a dualist ontology circumscribes the social sciences to a particular epistemological tradition that eliminates other possibilities within the full richness and scope of philosophy. Relying on the philosophy of social science as a framework retains the divisions between subject– object, mind–body and person–world that consigns and miscategorizes so-called ‘subjective’ knowledge to mere personal opinion or belief. Thus, our bodies, relationships, and practices are ultimately reduced to objectively defined, one-dimensional categories stripped of our experience. The questions pursued by the philosophy of social science within this tradition remain limited. Hence, this approach can provide a partial solution to broadening knowledge generation, but may not go far enough. Other approaches, such as the ‘new’ philosophy of social science, go further and challenge this view of knowledge by developing the historical aspects of scientific and social scientific knowledge (Bohman, 1991). An investigation of the historical and indeterminate nature of knowledge ends up blurring the line between subject and object, or nature and culture. Personal experience is not something set apart from the ‘objective’, the social, and the interpersonal world. This perspective on knowledge starts from the postempiricist viewpoint ushered in by the work of Kuhn (1970). Ultimately, we believe that the point of studying philosophy in a doctoral programme for nurses goes beyond deepening students’ understanding of science and the methods that may ground their research. We agree with Thorne (2014) that philosophical thought can deepen their understanding of core disciplinary knowledge. Studying philosophy opens up a wealth of insights and questions. Our course examines how different philosophical and scientific approaches reveal or marginalize aspects of the body and what these approaches disclose or conceal about illness. We look at how they bring to light power dynamics in caring relationships and healthcare systems, and whether they uncover the technological and systemic impera-
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tives which drive healthcare decisions, and colonize the lifeworld (Habermas, 1981/1984). Fruitful questions also include what counts as evidence and how forms of evidence shape (or obfuscate) nursing science and clinical practices. Rather than focusing on the philosophical foundations of science, we introduce students to the philosophical foundations of knowledge for the purpose of understanding and investigating nursing phenomena. This approach encourages a healthy skepticism towards forms of knowledge that are privileged in evidence-based practice. We seek to prepare doctoral students with the skills for walking the ‘rough ground’, capable of pursuing questions, critiquing hallowed assumptions, and developing knowledge that nurses routinely integrate in their care – including, but not limited to. scientific knowledge, relational knowledge, ethical knowledge, and practical know-how. These multiple forms of knowledge cohere with our core disciplinary knowledge. They require deep philosophical thought and diverse methodologies to advance clinical practice, promote healing and recovery, and relieve suffering. With the advent of an increasingly technologically mediated healthcare system, we believe that it is even more imperative to hold on to this ‘rougher’, more human dimension of nursing and the multiple forms of knowledge that safeguard patients and the core ethos of the discipline. Ultimately, the study of philosophy sets up a tension in which the search for answers competes with the discipline of philosophy’s inherent iconoclastic challenge contained in the practice of questioning. This is the ultimate ‘rough ground’. Once philosophy is introduced into a discipline, the notions of clarity and system building are always accompanied by their opposite – the entangled web of ongoing and competing discourses about the questions. Science fundamentally seeks answers; philosophy fundamentally questions and challenges the ‘received’ answers. Along the way, the answers and the questions improve as the spiraling process enlightens both. To continue to question in this way is to remain faithful to the deepest roots of our humanity, and to preserve a space for our humanity in the practice of nursing.
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Description of the course For more than a decade, we have developed and co-taught a course which is aligned with this more expansive view of knowledge. As the title of our course, ‘Nursing knowledge development: Philosophical perspectives’, suggests, we eschew a narrow focus on philosophy of science or social science, believing that a broad understanding of knowledge encompasses the ‘rough ground’ of human experiences of health, illness, and clinical encounters. While our course addresses the history and philosophy of science, we refer to our course as a philosophy of knowledge course, not a philosophy of science course. This shift is consequential for the organization and content of the course, and is apparent in the course description, objectives, and units (see Table 1). Because nurses necessarily rely on many forms of evidence for making ethically sound and astute clinical judgments (Nortvedt, 2001; Benner & Leonard, 2005; James et al., 2010; Thorne & Sawatsky, 2014), our course problematizes a naïve or outmoded view of science. We challenge students to rethink their assumptions about science, knowledge, and truth, especially in relation to health and illness phenomena, and invite them to critically reflect on the limits and strengths of various modes of inquiry. Thus, the broad questions animating the course include the following: What is knowledge and truth? What kinds of knowledge are needed to examine embodiment (of the patient and nurse), ethical knowledge, relational knowledge, theoretical/empirical knowledge, and practical know-how in the day-to-day realities of the practice world? What forms of knowledge are privileged or marginalized by various stakeholders, including universities, research funders, textbook publishers, journals, and healthcare corporations? To this end, we examine different conceptions of truth, knowledge, rationality, and personhood from the philosophical perspectives of empiricism, rationalism, hermeneutics, critical theory, feminism, and postmodernism. Our broad themes include the body, illness, health and ethics, and nursing as a practice in the context of relationships, technology, and power. By the end of the course, we expect students to appreciate that all forms of knowledge are perspectival, even those ame-
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Table 1. Overview of course Course description
Course objectives
Course units
Class sessions
This course will examine the development of nursing knowledge from diverse philosophical perspectives and traditions. Different conceptions of truth, knowledge, rationality, personhood, the body, and the moral good will be examined as a foundation for understanding and investigating nursing phenomena. 1. Examine notions of truth, knowledge, rationality, and the stance of the nurse scientist from the philosophical perspectives of empiricism, rationalism, hermeneutics, critical theory, and postmodernism. 2. Distinguish between various forms of inquiry as the basis for understanding and studying the natural world and the human world. 3. Examine how philosophical perspectives (re: truth, rationality, and origins of knowledge) shape nursing practice, ethics, and science. 4. Describe the implications of different philosophical perspectives and traditions for studying discrete nursing phenomena. 5. Critique different philosophical perspectives for studying the body and the person. • Historical development of scientific knowledge, focusing on the development of modern science: Descartes’ dualism and mechanistic philosophy • Contemporary influences on nursing knowledge development (e.g. hermeneutics, critical theory, postmodernism) • Conceptions of the person and the body (e.g. Descartes, Merleau-Ponty); how the person is studied as an isolate (methodological individualism) or is considered to be social through and through • Relationships between truth, knowledge, rationality, and power and technology (e.g. Foucault, Heidegger, critical theorists) • Nursing perspectives on knowledge development Introduction: History of the Natural Sciences The Body as Machine What is Scientific Knowledge? Kuhn Introduction to Heidegger: Overcoming the Cartesian Legacy Being-in-the-world Merleau-Ponty and the Lived Body Foucault and Biopower Critical Theory: The Challenge to Power Feminist Perspectives on Science Science and Technology Ethical Knowledge, Nursing, and Relationship Nursing Knowledge Development: Phronesis vs Techne? Evidence-Based Practice Social and Political Forces in the Construction of Knowledge
nable to precise measurement, and that attempts to find a neutral starting point, in line with Cartesian assumptions, contribute to an illusion that ‘true’ knowledge is ‘scientific’ and should therefore be privileged over forms of knowledge that are less amenable to scientific measurement and scrutiny. While the course includes content on traditional conceptions of science, assigning science a privileged position denigrates the complexity of clinical judgment and undermines nursing’s social mandate. Treading the rough ground implies that students gain a healthy respect for alternative forms of inquiry and that they will draw on philosophical resources to become better educators, practitioners, and scholars. We fully acknowledge and discuss the tension that students
will inevitably face as scientific knowledge is upheld as the gold standard in future coursework and over their careers. The course is offered in the PhD programme at the School of Nursing at Saint Louis University, a Jesuit university located in the Midwest of the United States. The doctoral programme has existed since 1990. When the doctoral programme began, students were required to take two philosophy courses, an epistemology and a philosophy of science course, both of which were offered by the Philosophy Department. The current course was developed a few years later by a task force led by the second author in response to a curricular change in the doctoral programme. The new course was approved by the
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doctoral faculty to replace the two philosophy courses, along with the recommendation that the course be co-taught by a philosopher and nurse. The course was first offered in 2002 and has always been co-taught by a philosopher whose background includes the history of philosophy and applied philosophy, and a nurse who brings nursing issues and a background in contemporary philosophy to the course. Local and distance students take the class together via web-based video conferencing technology, typically in the first semester of their programme, along with a course on Nursing Theory. Most students are nurse educators and are enrolled in the programme part time; full-time students are typically international students and local students. Students from Health Ethics have also enrolled in the course. We appreciate our good fortune in co-teaching this course. We are also fortunate to supplement required readings with video presentations of distinguished scholars and philosophers which were produced with funding from the US Department of Health and Human Resources (HRSA) in 2004. This award made it possible for the School of Nursing to invite nationally recognized scholars to present on their area of expertise. We refer to the scholars and the films included in the course below. The course is based on the seminar method with readings for discussion; faculty and students also make presentations. Course progression: from slippery ice to the rough ground The course begins with an overview of the history of science, from the focal point of the modern scientific revolution. Beginning with the earth-centred view of the universe, we discuss how this model was overthrown with the advent of the new theories of Copernicus, the experimentation of Galileo, and the culminating work of Isaac Newton. The point of this historical analysis is to show how the development of modern science ushered in mechanistic and materialistic explanations of phenomena, which enabled scientists to measure the material world. Therein lies the brilliance and success of much of modern science. Having introduced students to the scientific revolution, we highlight the philosophy of Descartes (1641/1993), whose work marks the beginning of
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modern philosophy, and who, as a scientist, wrote ground-breaking works on human physiology. We show how his dualistic approach laid the groundwork for modern scientific medical thought, allowing the body to be treated as a material object, with the mind conceived of as an entirely separate substance. This dualism enabled subsequent medical approaches to focus solely on the body as an object and to ignore those aspects of persons which cannot be measured. By way of contrast, we introduce the ‘lived body’, as articulated in the phenomenology of Merleau-Ponty, and interpreted by physician and philosopher Leder (1990, 1998). The lived body perspective introduces students to a more holistic and inclusive view of embodiment and personhood, which we return to later in the course. Having established this fundamental tension in how the body is understood and studied, we proceed to outline the trajectory of 20th century philosophy of science, beginning with theories like logical positivism and Karl Popper’s falsificationism (Chalmers, 1999), and culminating in the revolutionary work of Kuhn’s (1970), The Structure of Scientific Revolutions, which the students are assigned to read. The purpose of this section is to show students that naïve views of science, which typically take the form of a positivist view, are no longer rationally tenable, given the work of Kuhn and others. Because students unknowingly accept something like a positivist view of science, the revelation that their view is outmoded prepares them to seek better, more inclusive models of knowledge which are to come in the course. The course then takes a hermeneutic turn by introducing students to the early philosophy of Heidegger, as interpreted by Dreyfus (1991), an internationally renowned expert on Heidegger and continental philosophy. Heidegger broke away from the projects of modern philosophy in which questions concerning what it means to know predominated.We read Heidegger’s critique of Descartes’ dualism with secondary sources (Guignon, 1983; Magee, 1987), and watch a video presentation by Dr. Dreyfus. His presentation focuses on early Heidegger’s challenge to Cartesian assumptions and the separation of subject from object, mind from body, and person from world. Heidegger’s focus on ontology prior to epistemology
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and his hermeneutics of being-in-the-world revealed new dimensions of knowing that included noncognitive, more embodied perspectives for researching human experience that are passed over by scientific practices of generalizing and unitizing (Guignon). Heidegger’s notions of the ‘ready to hand’ and ‘the unready to hand’ reveal ways of knowing embedded in everyday human practices and skills that are traditionally overlooked by scientists trained to investigate phenomenon in terms of ‘present to hand’ entities that are shorn free from any human context or activity. In drawing attention to the tacit ways of knowing that are formed through our practical engagements in the world, students are encouraged to see and value aspects of their clinical work, which a scientistic view of knowledge traditionally overlooks. In spite of the difficulty of Heidegger’s language and thought, everyday examples from students’ clinical experiences, and (Benner’s, 1994; Benner et al., 2011) research on nursing practice, substantiate how these forms of knowing are central to good patient outcomes, even though they elude conventional forms of scientific research. The course then turns to some of the rich philosophical developments that mushroomed in response to Heidegger’s thought. Each subsequent philosopher we study builds on Heidegger’s hermeneutics by flushing out aspects of ‘being-in-the-world’ that were not taken up as directly in his work. For example, we return to Merleau-Ponty’s (1945/1962) ‘lived body’, and discuss how our embodiment during health and illness is addressed or obscured in science and contemporary health care. Baron’s (1985) classic article, with the ironic title ‘I Can’t Hear You While I’m Listening’, reveals how a machine body approach to clinical care dehumanizes patients and prevents practitioners from attending to their concerns and perspectives. Leder’s (1998) video presentation on Merleau-Ponty introduces students to the way the Cartesian body is treated as a ‘living corpse’ or bioengineerable machine. This mechanical body is composed of cells, tissues, organs, and complex neuroendocrine and immunologic interactions that are mapped and measured so that disease is diagnosed and treated. Leder (1990, 1998) contrasts this Cartesian body with Merleau-Ponty’s description of the
lived body, which is skilled, sentient, taken for granted in health, but foregrounded in illness because of pain, fatigue, intrusive symptoms, and an uncooperative body. The image of the ‘panopticon’, a design for prisons in which prisoners are seen but cannot see their jailers, provides a metaphor for Foucault’s (1979) crucial notion of ‘bio-power’, which we take up next. Through his historical analyses of modern and contemporary social sciences, in particular his study of medicine in ‘The Birth of the Clinic’, Foucault (1973) shows how modern systems seek to manage large populations through the control and subjugation of their bodies. Students have noted the likeness of the panopticon to many modern institutions, including intensive care units (ICUs). Required research articles provide further evidence of clinical practices that reinforce a docile body. We view the film, Wit (Nichols, 2001), of a woman dying of ovarian cancer through the lens of bio-power and the docile body, an exercise which powerfully reveals how these concepts organize knowledge in everyday healthcare practices. We then study Habermas’ (1981/1984) theory of communicative rationality. Bro. William Rehg, a philosopher at Saint Louis University, introduces students via video presentation to the major concepts of critical theory. The concepts of lifeworld and system help us to view health care from a social and political level, one that includes the effects of our economic system on the daily work of nurses. Readings by feminist philosophers challenge the notion of objectivity as emotionally neutral or impartial. Franklin’s (2001) lovely piece, ‘Science is Knowing and Loving the World’, shows how a feminist approach appreciates science’s relational and emotional aspects. We watch Moyers (1994) interview Evelyn Fox Keller where she describes our culture’s tendency to connect science with masculinity and objective forms of knowledge. With Barbara McClintock as an example of a scientist who challenged traditional conceptions of objectivity, Fox Keller argues that ‘feeling’ is just as important as impartial reasoning in conducting rigorous scientific research. Moving to the topic of technology, we explore the relationship between science, technology, and nursing practice. Because of their clinical practice, students
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have a great deal to say about the technological imperative in shaping knowledge, patient experiences, and nursing practice. Published studies on the experience of being a patient in an ICU (Almerud et al., 2007) or having an implantable defibrillator (Kaufman et al., 2011) highlight vexing issues related to the technological understanding in health care that call for nursing investigation. Although ethical issues and concerns have arisen in earlier class sessions, we turn to Emmanuel Lévinas’ (1989) phenomenology of the personal encounter, the ‘face-to-face’ interaction, as the basis for an ethical knowledge that is prior to all other kinds of knowledge. The implications of Lévinas’ thought for nursing science and practice are described in a video presentation by Dr Michael Barber, also a philosopher at Saint Louis University, and are further flushed out in assigned readings. Nortvedt (2001), for example, draws on Lévinas’ thought to describe the inseparability of ethical sensitivity and clinical nursing knowledge. Papers by Naef (2006), Wynn (2002), and SmithBattle (2009) shed further light on the ethical responsibilities that are grounded in first knowing the person. We examine the development of evidence-based practice, and its underlying premises, as we return to issues that have been raised over the entire course, including what counts as evidence and truth and how truth claims are negotiated and constructed, and for what purpose. This content invites students to address the question that now emerges from the much richer view of knowledge that the course has afforded them: whether nursing is more properly understood as a practice discipline, a scientific discipline, or a human science. Students read the work of scholars who have addressed this issue (Bishop & Scudder, 1997; Flaming, 2001; Thorne & Sawatsky, 2014). We also encourage students to consider the relationship between science and practice by examining Aristotelian categories of ‘phronesis’ and ‘techne’ as discussed by several nurse authors (Flaming, 2001; Benner & Leonard, 2005; Kinsella, 2007). At this point, students are somewhat familiar with the difference between knowing-how (clinical knowledge developed in practice) versus knowing-that (theoretical knowledge developed by scientists). Although many students
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have previously seen the video (Benner et al., 1992) From Novice to Expert, they watch it again with new interest and are typically surprised to see how nursing knowledge based on pattern recognition, clinical reasoning, and knowing the person, while essential to quality care, is considered too contingent and situated to count as evidence. This tension between the particular and the general contributes to the slippery ground that nurses walk with patients. Challenges of the course include the fact that students with little prior philosophical background are introduced to new ways of thinking about knowledge. The breadth and scope of the course also place limits on reading primary sources, although readings by Descartes, Kuhn, Merleau-Ponty, Levinas, and Foucault are assigned. These limitations are offset by video presentations from distinguished scholars and many excellent nursing articles. While students are stretched to understand philosophical thought in a short space of time, course evaluations have been universally positive. Students report that they find the course to be very meaningful and that they see and value their teaching and clinical practice knowledge with new eyes. They recognize a richer spectrum of nursing knowledge that awaits further investigation and translation into practice. In conclusion, nursing’s quest for knowledge remains a central imperative in doctoral education. Because this quest has been constrained by an epistemological focus on knowledge generation, we introduce doctoral students to a philosophy of knowledge course that is not confined to philosophy of science and social science. Rather, we introduce students to a broad understanding of knowledge that encompasses the ‘rough ground’ of the human experience of health and illness, laying the groundwork for examining the many forms of knowledge (scientific, ethical, relational, and practical ways of knowing) that nurses routinely integrate in their practice. In highlighting how different philosophical approaches simultaneously reveal and marginalize aspects of the body and the experiences of illness and health, the course prepares students to consider studying various dimensions of nursing phenomena and translating diverse forms of evidence to the rough ground of practice. This approach also safeguards tensions regarding
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knowledge and evidence that inevitably arise in a profession entrusted with the care of individuals, families, and communities.
Acknowledgements We gratefully acknowledge the research assistance of Ann Pierce, RN, MSN, FNP, and the helpful review by William Rehg, S.J., Dean of Arts and Letters, Saint Louis University.
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