Nursing, Theories and Philosophy of

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NURSING, THEORIES AND PHILOSOPHY OF

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Any theory or philosophy of nursing involves a quest for nursing identity. The quest that began in the last quarter of the twentieth century has been fostered by several factors, including nursing education's move from the hospital to the academy, changes within nursing itself, and the feminist movement. Although there were nursing schools in a few universities before the 1950s, the movement to place nursing education and research in universities has accelerated since then. This move required nursing to establish its place in an academic setting. Usually nursing schools were placed in the natural or applied sciences, and consequently, nursing initially attempted to establish its identity as a science. The attempt to identify nursing with natural science led to scientific studies of nursing, but these studies, while important, did not show that nursing itself was a science. Recognition that nursing was a human practical activity led to the use of the behavioral sciences to give a scientific account of nursing. In both cases, nursing itself could, at best, be called an applied science. It was hoped that scientific studies of nursing would lead to a theory of nursing and that theory would prescribe nursing practice. But attempts to use theory to prescribe nursing practice were far removed from the way nursing was practiced.

Involvement in an academic setting eventually broadened the meaning of nursing beyond that of applied science. The applied approach had been fostered by nurses taking graduate degrees in other fields and applying their methods and concepts to nursing. The development of master's and doctoral degree programs in nursing fostered a movement away from this applied approach.

Graduate study in nursing developed as nursing became more complex and required nurses to make their own decisions concerning patient care. The development of intensive care units in hospitals initiated the expansion of specialization and technical knowledge into nursing care. As this trend grew, care for patients increasingly required nurses to make decisions without specific directives from physicians. As nurses became more responsible for patient care, they began to question the traditional control of nursing care by physicians and hospital administrators. Critical examination of their dependence on others encouraged nurses to seek an independent identity for nursing.

The feminist movement enhanced the desire of nurses to be independent from control of physicians and hospital administrators. Feminist theorists pointed out that society, including healthcare institutions, undervalued care and nurturing and overvalued command, technology, and hierarchical structure. Feminists enhanced the determination of nurses to become self-directing professionals rather than workers who followed the directions of physicians and administrators.

The Primacy of Caring

As nurses articulated their own practice, they became aware that nursing was focused on care rather than on science or applied science. Beginning in 1978, a series of annual conferences turned to the task of interpreting the meaning of caring as it related to nursing. The significance of this approach to nursing is evident in the following comment by a nurse who attended one such conference: "This is the first time I have ever heard nurses talk about caring or care as related to nursing care. I had nothing like these concepts in my nursing program, and yet they make sense and seem so logical and essential to nursing. In our classes, we were taught about curing medical diseases, understanding medical diagnostic techniques, and everything but caring" (National Caring Conference, p. vi). Published regularly, the proceedings of these conferences constitute a developing interpretation of caring as the source of identity for nursing. Philosophical interpretation of caring has been fostered by the International Association for Human Caring, initiated by Madeleine M. Leininger, and the Center for Human Caring at the University of Colorado, initiated by Jean Watson.

The Phenomenology of Nursing

In her phenomenological interpretation of nursing, Patricia E. Benner articulated the meaning of nursing by drawing exemplars of excellent nursing from concrete nursing practice. In sharp contrast to using theories to prescribe the meaning of nursing, Benner disclosed the meaning of nursing excellence through descriptions of care for patients/ clients in specific situations. These exemplars of excellence were interpreted to clarify and enhance the meaning evident in nursing practice. From the study of these exemplars, she identified seven domains of nursing practice with thirty-one distinct nursing competencies. For example, one of the domains is the helping role, and two of the competencies of the helping role are: (1) providing comfort measures and preserving personhood in the face of pain and extreme breakdown; and (2) maximizing the patient's participation and control in his or her own recovery (Benner). Rather than following the tradition in nursing of using definitions of good nursing to prescribe practice, Benner conveyed the meaning of excellence through the work of excellent practitioners. Her study showed that knowledge of excellence gained from practice is essential to any adequate definition of nursing. Benner's work illustrated the use of hermeneutic phenomenological methodology in nursing in that she disclosed the meaning of nursing excellence through exemplars in actual practice and interpreted their significance for the identity of nursing.

Nursing is the practice of caring, according to Anne H. Bishop, a nurse, and John R. Scudder Jr., a philosopher. Like Benner, Bishop and Scudder employed hermeneutic phenomenology to articulate the meaning of nursing (Bishop and Scudder, 1990, 1991). Nursing is a practice in that it is a traditional way of caring for patients that fosters the patient's well-being. The moral sense of nursing inherent in the caring relationship between nurse and patient is disclosed by phenomenological interpretation.

Confused thought has been fostered in nursing by the tendency to use the term nursing to mean both care for patients and the study of that care. Bishop and Scudder called the study of nursing the "discipline" of nursing to distinguish it from the practice. They maintained that the discipline of nursing should be a human science because it studies how nurses care for patients. Furthermore, it is a practical human science because the discipline attempts to improve nursing practice as well as to study it. Practices, such as nursing, are expanded and enhanced by the realization of possibilities that are inherent in the practice.

Bishop and Scudder affirmed the tendency to find the identity of nursing in caring. Although they articulated the meaning of care primarily from nursing practice, they found the interpretations of care by feminists Carol Gilligan and Nel Noddings particularly helpful in their articulation. Gilligan's "web of connection" forms a context for an interpretation of nursing as the bringing together of patient, nurse, physician, hospital administration, and family into "wholistic care" (Bishop and Scudder, 2001). Noddings's interpretation of care as engrossment in the situation of the other and shift of concern to the well-being of the other enhances Bishop and Scudder's interpretation of nursing care as fulfillment of the moral sense of fostering the wellbeing of patients. Bishop and Scudder also argued that the integral relationship between the moral sense and nursing practice is clearly evident in Benner's description of nursing excellence (1984). Nursing practice, as they interpret it, consists of two fundamental stances: first, wholistic care that focuses on cooperative care, articulated by Bishop and Scudder; second, the stance of recognized nursing competence in which nurses are free to direct care, described by Benner. Nursing's purpose, however, is not to become autonomous, as is often stressed by nursing reformers, but instead to foster the patient's well-being. Because nursing has this fundamental moral sense, the primary purpose of ethical considerations of nursing should be to foster excellent care—a care that promotes wellness while respecting the dignity and rights of each person.

Unlike Benner and Bishop and Scudder, who seek the identity of nursing in nursing practice, Sally Gadow (1980) attempted to give nursing a new identity with her interpretation of nursing as "existential advocacy." She drew her conception of existential advocacy from the stress on authenticity that is central to existential phenomenology. "Being authentic," in existentialist phenomenology, entails choosing oneself. Because the primary meaning of being human, for the existentialist, is self-direction, it follows that nurses should become existential advocates who foster authentic human being for those facing illness, treatment, and possible death. The nurse becomes an existential advocate by "participating with the patient in determining the personal meaning which the experience of illness, suffering, or dying is to have for that individual" (Gadow, p. 97).

Nursing Ethics

Pursuit of nursing ethics began in earnest in 1979 when a series of meetings in New York and New England brought together philosophers and nurses to begin development of a specific nursing ethic. Since then, many books and articles on nursing ethics have applied philosophical understanding to the moral dilemmas faced by nurses. Most nursing ethicists have applied philosophical inquiry and/or systems to moral problems that nurses encounter, especially those originating in advances in medical science. A different approach to nursing ethics begins not with philosophical ethics but with the moral imperative inherent in nursing practice. When the moral sense of nursing is given its due, according to Benner (1984) and Bishop and Scudder (1990, 1991), the primary concern of nursing ethics becomes fulfillment of its moral sense. Hence, the primary thrust of nursing ethics becomes fulfilling the moral sense of nursing practice rather than resolving moral problems that, although arising out of practice, are treated as adjuncts to practice.

The philosophers who took part in the aforementioned conferences that brought nurses and philosophers together in search of a nursing ethic also asserted that "the longstanding concern of philosophy to assist in the process of emancipation" should be brought to bear on the "long subjugation of the nurse" by helping nursing move "away from its position of political and intellectual subordinance" (Spicker and Gadow, p. xiv). Nurses, who had long been impatient with being under the control of physicians and hospital administrators, were seeking greater individual and professional autonomy. The demand for greater autonomy was supported by feminist philosophy and by critical theory. Critical theory was used to disclose the hidden power structures in healthcare that denied nurses self-direction (Allen; Thompson).

Nurses also became interested in philosophy from their attempt to challenge the dominant scientific methodology and criteria for knowledge that prevailed when nursing first entered the academy. Recognition that nursing was primarily a human activity concerned with caring relationships between nurse and patient led nursing scholars to become involved in qualitative research and to use the methodology of the human sciences. A significant number of nurses became regular participants in the Society for Phenomenology and Human Sciences and the International Human Science Research Conference. Nursing scholars who found the stress on empirical rational science too restrictive welcomed Barbara Carper's expanded conception of knowledge. She contended that nursing knowledge should include not only scientific empirical knowledge but also three other ways of knowing in nursing—knowledge of how to make morally right choices, knowledge gained from personal experience, and knowledge of how to practice the art of nursing. Carper's patterns of knowing generated much interest among nurses who had long recognized that scientific knowledge alone was not adequate for nursing practice.

Attempts to Develop an Explicit Philosophy of Nursing

Initial interest in investigating nursing philosophically came from the quest for an independent identity for nursing and from encountering issues concerning ethics, knowledge, and justice within nursing itself. These first attempts could be called philosophical interpretations of nursing. An early attempt to foster the development of the philosophy of nursing was the establishment of the Institute for Philosophical Nursing Research at the University of Alberta, Canada. The institute invites nursing scholars with philosophical interests and talents to biannual conferences to discuss issues involved in developing a philosophy of nursing. The institute, through its conferences and publications, seeks to "establish common ground in nursing philosophy, accommodate diversity of thought in nursing philosophy, and articulate a sound philosophy of nursing" (Kikuchi and Simmons, p. 4).

Starting in the late 1990s and continuing into the early 2000s, the pace at which the philosophy of nursing was developing quickened. There is now a journal, Nursing Philosophy, that is broadening the philosophy of nursing beyond its former stress on hermeneutic and existential phenomenology to include the analytic, pragmatic, and postmodern traditions. The International Philosophy of Nursing Conference has met several times in Great Britain and Ireland, providing a forum for philosophical consideration. Discussion of the philosophy of nursing is being fostered on an Internet service called Nurse-Philosophy, which was initiated by Scottish scholars who also conduct a series of seminars on the same subject. An entire issue of Scholarly Inquiry for Nursing Practice: An International Journal has been devoted to the philosophy of nursing. Jan Reed and Ian Ground wrote an introduction to analytic philosophy, specifically for nurses, that uses nursing examples and considers nursing issues. New philosophies of nursing have expanded philosophical interpretations of nursing to include process and analytic philosophy. Janice M. Brencick and Glenn A. Webster, interpreting nursing from a process perspective, applied philosophical considerations of the universal and particular to nursing practice in their 2000 book, Philosophy of Nursing. Unfortunately, they disregarded previous studies of the philosophy of nursing with the exception of the work of Jean Watson. In contrast, Steven D. Edwards, in his 2001 book of the same name, developed an analytic philosophy of nursing in interaction with most of the extant works on the philosophy of nursing and developed a unified philosophy of nursing, thinking as an insider with degrees and standing in both nursing and philosophy.

Future Considerations

As the philosophy of nursing develops and matures, it may become a more integral part of the discipline of nursing. At present, however, many questions remain. Will the philosophy of nursing maintain its initial focus on the meaning of nursing, or will it refocus on philosophical issues and concerns? Will it bring nursing concerns into interaction with understandings, issues, and methods of philosophical traditions, or will it concentrate on philosophical issues and concerns that are to be applied to nursing? Furthermore, will philosophers of nursing become specialists who talk primarily to each other, or will the philosophy of nursing become an integral part of the development of a nursing discipline dedicated to the articulation and improvement of nursing practice?

john r. scudder, jr.

anne h. bishop (1995)

revised by authors

BIBLIOGRAPHY

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Benner, Patricia E. 1984. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.

Benner, Patricia E., and Wrubel, Judith. 1989. The Primacy of Caring: Stress and Coping in Health and Illness. Menlo Park, CA: Addison-Wesley.

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Watson, Jean. 1985. Nursing: Human Science and Human Care: A Theory of Nursing. Norwalk, CT: Appleton-Century-Crofts.