Nursing Knowledge E-Book

Mark Risjord

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 541

Veröffentlichungsjahr: 2011

Beschreibung

Nurses who conduct research have a longstanding interest in questions of nursing knowledge. Nursing Knowledge is a clear and well-informed exposition of the philosophical background to nursing theory and research.   Nursing Knowledge answers such fundamental questions as: How is nursing theory related to nursing practice?  What are the core elements of nursing knowledge? What makes nursing research distinctive as nursing research?  It examines the history of the philosophical debates within nursing, critiques the arguments, explains the implications and sets out to rethink the philosophical foundation of nursing science.

Nursing Knowledge begins with philosophical problems that arise within nursing science.  It then considers various solutions with the help of philosophical ideas arguingargues that nurses ought to adopt certain philosophical positions because they are the best solutions to the problems that nurses encounter. The book argues claims that the nursing standpoint has the potential to disclose a more complete understanding of human health than the common disease-and-dysfunction views. Because of the relationship to practice, nursing science may freely draw theory from other disciplines and nursing practice unifies nursing research. By redefining theory and philosophy,With a new philosophical perspective on nursing science, the so-called relevance gap between nursing theory and practice can be closed.

The final chapter of the book ‘redraws the map’, to create a new picture of nursing science based on the following principles:

• Problems of practice should guide nursing research
• Practice and theory are dynamically related
• Theory research must provide the knowledge base necessary for nurse interventions, training, patient education, etc.
• Nursing research should develop midrange theories and its results are nursing theory is strengthened when it uses theories confirmed by is integrated with other disciplines

Key features

• Clear and accessibly written
• Accurate and philosophically well-informed,
• Discusses philosophical problems in contexts familiar to nurses
• Systematically examines the philosophical issues involved in nursing research
• Examines epistemology (how we know what we know), theory development, and the philosophical foundations of scientific methodology.
• Develops a new model of nursing knowledge

Dr. Mark Risjord is Associate Professor in Philosophy at Emory University, and has a faculty appointment in the Nell Hodgson Woodruff School of Nursing. His main research areas have been in the philosophy of social science and the philosophy of medicine.  He was invited to has been teaching philosophy of science and theory development in the new PhD program in the Nell Hodgson School of Nursing at Emory University insince 1999.  He has been awarded two competitive teaching prizes: Emory Williams Distinguished Teaching Award (2004) and the Excellence in Teaching Award (1997).  He is presently serving as the Masse-Martin/NEH Distinguished Teaching Chair (2006-2010).

Leseprobe

Contents

Preface

Foreword

PART I NURSING KNOWLEDGE AND THE CHALLENGE OF RELEVANCE

Introduction to Part I

Nursing knowledge

Two kinds of theory-practice gap

Philosophy of nursing science

1 Prehistory of the problem

The domain of nursing

Professionalization and the translation gap

Nursing education reform in the United States

Nursing research begins

A philosophy of nursing

What would a nursing science look like?

Nursing theory and nursing knowledge

Conclusion: the relevance gap appears

2 Opening the relevance gap

Two conceptions of nursing science

The demise of practice theory

The consensus emerges

The relevance gap

Conclusion: the relevance gap endures

3 Toward a philosophy of nursing science

Philosophical questions about nursing

Science, value, and the nursing standpoint

Theory, science, and nursing knowledge

Conclusion: closing the gap

PART II VALUES AND THE NURSING STANDPOINT

Introduction to Part II

4 Practice values and the disciplinary knowledge base

Dickoff and James’ practice theory

Values and theory testing

Challenges to Dickoff and James’ criteria

Beckstrand’s critique

Carper’s fact-value distinction

Problems with patterns

Conclusion: fact and value in nursing knowledge

5 Models of value-laden science

The Johnson model: nursing values as guides for theory

Constitutive and contextual values

Constitutive values in science: Kuhn’s argument

Epistemic and moral/political values

Models of value-laden inquiry

Value-laden concepts in nursing inquiry

Conclusion: constitutive moral and political values in nursing inquiry

6 Standpoint epistemology and nursing knowledge

Social role and epistemic privilege

Feminist appropriation of standpoint epistemology

Generalizing standpoints

Knowledge and the division of labor in health care Nursing knowledge and nursing roles

Conclusion: nursing knowledge as an epistemic standpoint

7 The nursing standpoint

Top-down and bottom-up views of nursing

The philosophical questions revisited

Questions and concerns

Conclusion: science and standpoint

PART III NURSING THEORY AND THE PHILOSOPHY OF SCIENCE Introduction to Part III

8 Logical positivism and mid-century philosophy of science

Some history and terminology

Conceptions of theory in nursing

Theories and axiom systems Euclid and Newton

Theory structure: the received view

Explanation and confirmation

Conclusion: logical positivism and scientific knowledge

9 Echoes in nursing

Did logical positivism influence nursing?

The metaparadigm of nursing

Levels of theory

Borrowed theory

Conclusion: the relevance gap and the philosophy of science

10 Rejecting the received view

Holistic confirmation

Failure of the theory-observation distinction

Levels of theory and interdisciplinary research

Conclusion: rejecting the received view of nursing science

PART IV THE IDEA OF A NURSING SCIENCE

Introduction to Part IV

11 Postnursing theory inquiry

Passion for substance

Situation-specific theories

Postnursing theory inquiry

Research example: mastectomy

Research example: pain management

Breakthrough research and situation-specific theory

Conclusion: revisioning nursing theory

12 The structure of theory

Walls and webs

Questions and answers

Breakthrough research revisited

Borrowed theory

Conclusion: piecing the quilt

13 Models, mechanisms, and middle-range theory

What is middle-range theory?

An old, new definition of middle-range theory

The semantic conception and the received view

Middle-range theories as theoretical models

Interlevel models in nursing science

Theoretical models and explanatory coherence

Holism, reductionism, and the nursing standpoint

Conclusion: causal models and nursing science

PART V CONCEPTS AND THEORIES

Introduction to Part V

14 Consequences of contextualism

Concepts: theory-formed or theory-forming?

Public and personal concepts

The priority of theory

Contextualism and realism

Concept analysis and borrowed theory

Conclusion: philosophical foundations of multifaceted concepts

15 Conceptual models and the fate of grand theory

Models and theories

The orientation and abstraction pictures

Arguments against the abstraction picture

Advantages of the orientation picture

Rereading the early theorists

Models of nursing and models for nursing

Conceptual models as nursing philosophy

Philosophical criticism of conceptual models

Conclusion: science, practice, and philosophy

PART VI PARADIGM, THEORY, AND METHOD

Introduction to Part VI

Terminological preliminaries

16 The rise of qualitative research

Making space for qualitative methodology: Carper, Benner, and Watson

The triangulation problem

Two paradigms of nursing inquiry

Conclusion: method, theory, and paradigm

17 What is a paradigm?

Components of a paradigm

Incommensurability

Pulling paradigms apart

Against paradigms

Conclusion: nursing science without paradigms

18 Methodological separatism and reconciliation

Reality and realities

Objective and subjective

Deduction and induction

Reductionism and value-freedom

The unity of nursing knowledge

Reconciling qualitative and quantitative research

Conclusion: local methodological decision-making

PART VII CONCLUSION

19 Redrawing the map

Theory

Professional values and disciplinary knowledge

Nursing knowledge and the relevance gap

New maps, new directions

References

Index

For the nurses and scholars who have influenced me.

Constance Risjord

Norman Risjord

Arleen Winter

This edition first published 2010© 2010 by Mark Risjord

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Library of Congress Cataloging-in-Publication Data

Risjord, Mark W., 1960-Nursing knowledge : science, practice, and philosophy / Mark Risjord.p.; cm.Includes bibliographical references and index.ISBN 978-1-4051-8434-2 (pbk. : alk. paper)1. Nursing–Philosophy. 2. Nursing–Practice. I. Title.[DNLM: 1. Nursing Theory. 2. Health Knowledge, Attitudes, Practice.3. Nursing Process. 4. Philosophy, Nursing. WY 86 R595n 2010]RT84.5.R57 2010610.73–dc22

2009020260

Preface

My intellectual engagement with nursing began with a question about teaching. The Nell Hodgson Woodruff School of Nursing at Emory University had just created a PhD program, and Professors Sandra Dunbar and Margret Moloney were teaching “the theory course.” They called to ask for advice about readings in the philosophy of science. I was at a bit of a loss. Like many philosophers of science, I thought that philosophy of science should connect directly with the sciences. Only when the problems are understood from the perspective of the scientists can the important questions be asked. Since I had no understanding of nursing research, I had no clue about how to answer their simple question about a reading list.

The solution, which the Nursing School was happy to support, was to have me coteach the course. Working with PhD-level students would provide a sense of the philosophical questions that arose from nursing research. My intention was to find some philosophically and pedagogically useful readings for the course, and then return to the quiet life of a philosopher. I found, to my delight, a new world for philosophical reflection. Nurse scholars had been writing about philosophical issues for almost 40 years. While philosophers had not paid attention to them, they had been paying attention to us. The philosophical issues were clearly recognizable, and the context of nursing research and practice gave them a fresh aspect. I have taught, cotaught, or lectured in this course every year since its inception, and it remains some of the most rewarding teaching I do.

After several years of teaching the course, I began to kick around ideas for a book that would systematically treat the philosophical issues in nursing science. It was the fall semester of 2006 when a student question catalyzed the ideas. We were wrapping up our discussion of values in science. The students had worked through Longino, Harding, and other feminist philosophers of science. This is all very interesting, they said, but what does it have to do with nursing science? In the ensuing conversation, I was struck by the analogy between nursing roles and the oppressed social roles that give rise to epistemic standpoints. With the idea of a nursing standpoint, serious work on this book began.

The phrase “nursing knowledge” is ambiguous. It might plausibly refer to knowledge that individual nurses gain through their training and experience. While the topic is vitally important, this book will not be directly concerned with the knowledge that goes into the decisions or care plans of the practicing nurse. Rather, we will be concerned with the kind of knowledge on which the nursing profession is based. This knowledge is developed within the research enterprise of nursing, maintained in the academy, and transmitted through professional publications. Ultimately, of course, the two senses should join: the knowledge of individual nurses should be informed by disciplinary knowledge. When disciplinary knowledge does not support professional nursing, a theory–practice gap emerges.

This work will bring ideas and arguments from the philosophy of science to the discussion of nursing theory. The object is not to create a new nursing theory. Nor will there be sustained evaluation of, or commentary on, nursing theories. Rather, we will engage what could be called nursing “metatheory,” that is, theory about theory. Since the late 1950s, nursing has had lively debates about what forms theory should take, about the unity of the discipline, about the status of borrowed theory, and so on. These debates have been philosophical, and have drawn on philosophical writings, but they have been debates among nurse scholars. In keeping with the idea that the philosophy of science ought to be rooted in philosophical questions arising from scientific practice, this work will primarily engage with the nursing metatheoretical literature. It will elucidate the historical and contemporary nursing debates and critically evaluate the arguments. While we will develop ideas within the philosophy of science, the primary audience of this work is not philosophers, but nurse scholars.

A book with two audiences risks leaving both unsatisfied. If the technical details are passed over, philosophers may find the arguments superficial. If presented in all of their abstract glory, nurse scholars may find the arguments pedantic. This problem is partly addressed below by the chapter divisions. Some chapters (5, 8, 10, 14, and 17) are devoted mostly to philosophical positions, arguments, and counterarguments. Readers who want to understand the full philosophical background to the ideas developed in the other parts of the book will need to work through these chapters. Those who are familiar with the philosophy of science, and who are primarily interested in the ramifications of postpositivist philosophy of science for nursing, might skip them. Those readers interested in an overview of the position developed in this book might read the introduction to each Part and Chapters 3, 7, 12, and 19.

This book is the culmination of 10 years of thought about nursing science. The nurse scholars who patiently taught me about their discipline have my deep admiration and sincere appreciation: Sandra Dunbar, Margret Moloney, Kenneth Hepburn, Sue Donaldson, and every one of the nursing doctoral students who have come through Emory’s program. During this period, my thinking about theory and methodology was sharpened by some very special colleagues in the humanities and the social sciences. I hope that Ivan Karp, Cory Kratz, Martine Brownley, Kareem

Khalifa, and Robert McCauley see something of themselves reflected in this work. A number of colleagues read and commented on this book at various phases of completion. Feedback of this sort is invaluable and I am deeply grateful to Ulf Nilsson, John Paley, Emily Parker, Norman Risjord, Stephanie Solomon, Alison Wylie, and especially Beverly Whelton for their thoughtful responses. Finally, this book was entirely written during my tenure as Associate Dean of the Graduate School. It would have been impossible but for the support of Dean Lisa Tedesco. She not only helped me find the balance between research and administration, but she also made substantive contributions to my thinking about these issues.

Special appreciation must be reserved for Barbara, Andrea, and Hannah Risjord. Throughout the process of writing this book, they supported me in uncountable ways and suffered both my absences and absentmindedness.

Foreword

Nursing Knowledge is a unique and compelling contribution to the body of philosophical work in nursing. Mark Risjord offers a fresh perspective of the evolution of nursing theory, science, and practice as seen through the lens of a philosopher. Risjord comprehensively analyzes the history of the development of the professional discipline of nursing. He includes all the major threads of philosophical thought, identifying their origins, critical differences, and potential for primacy. By revealing the historical juxtaposition of competing philosophies of nursing, he retraces nursing’s tortuous path and conveys the passion of its scholars for the discipline and the practice. But this book is not a dry text; it reads as an exciting documentary that relates the development of nursing philosophy in the context of an evolving professional practice of nursing and an evolving general philosophy of science. Risjord goes beyond analysis of the writings to consider the philosophical debates in nursing in the context of societal changes in the status of women and nurses in health care along with the continuous transformation of philosophy of science into successive postpositivist forms. Each philosophical thread in nursing is addressed, treated as valid, and appropriately placed in the evolution of contemporary philosophy of nursing. But there are some surprising revelations from Risjord’s philosophical analysis.

A major advance in this book comes from Risjord’s presentation of disparate views as valuable to the evolution of nursing knowledge and science rather than as distractions. Risjord documents that while philosophers of nursing strived for consensus and adoption of a single model to unify the discipline; opposing views were key to clarifying the purpose of the discipline and developing its knowledge. A notable and valuable contribution to nursing philosophy is Risjord’s analysis of the pervasive impact of logical positivism over time, despite nursing’s rejection of this philosophy of science. One becomes aware of Risjord’s prowess as a philosopher in his analysis of the subtle and, apparently, unrecognized influence of positivism, even in recent presentations and publications of philosophers in nursing. I had not recognized this evidence and thus was surprised by his findings. It is extremely important for nursing to fully understand the philosophical underpinnings of its models for knowledge and theory generation and this book teaches by example how this is done. Risjord offers an alternate, nonpositivist, conceptual model for generating value-laden theory to assist nursing in its quest for scientific discovery that is relevant to nursing practice and to the understanding of human health in general.

Risjord captures the prevailing sense of urgency on the part of nurse scholars to articulate a unique and defining conceptual model or grand theory of nursing. Identification of a unique discipline and science of nursing was and still continues to be needed to respond to external threats to the legitimacy of nursing as a profession and as a field of PhD study. Internally, nursing scholars fiercely and legitimately debated the directionality of influence of practice and knowledge. For the beginning scholar or student in nursing, this book is an essential companion to the reading of original classic and contemporary philosophical papers in nursing because it clarifies the unique contribution and historical context of each. This book is a definitive guide to the universe of nursing knowledge and philosophy. For the seasoned scholar,Nursing Knowledge reads as a compelling documentary that recasts long-standing debates on the nature and generation of nursing knowledge in a new mode and revisits the relationship of theory to practice. Nursing Knowledge takes the reader on an historical trip that celebrates disparate views on philosophical issues as a natural part of the evolution of the discipline and its relationship to the practice of nursing. What is unexpected is the progressive philosophy of nursing that awaits the reader at journey’s end. Risjord does not disappoint; he transports the reader into a new frame of reference, a new philosophy, for advancing nursing knowledge in a manner that promises to make it more relevant to practice and theoretically coherent.

In his analysis of philosophy of nursing science, Risjord focuses on nursing’s continuing utilization of hierarchical disciplinary structures, such as meta- paradigm/paradigm and grand/middle-range/situation theory. This analysis alone makes the book required reading. He points out that while these structures serve the purpose of identifying a unique domain of nursing knowledge, they are at odds with nursing’s professed preference for postpositivist philosophical views of value-laden science, including nursing’s intent to bridge the theory-practice gap. Risjord argues that hierarchical structures isolate nursing knowledge from that of other disciplines, thus limiting the impact of nursing in advancing an enlightened view of human health across disciplines. His analysis of the separation of qualitative and quantitative research into distinct paradigms within the discipline is particularly astute; it reveals that, while intellectually convenient, this separation limits the overall support for critical theories in nursing. Perhaps the most shocking of his revelations is that hierarchical disciplinary structures in nursing emanate from the positivist viewpoint.

As an alternate, Risjord offers a radically different, nonpositivist philosophical view of knowledge structure that was first introduced by Quine ([1953] 1961). In this frame of reference, human knowledge is viewed as an integrated whole of theories from many disciplines; individual disciplines influence the whole of knowledge to the extent that their theories are coherent with those of other disciplines. Disciplines are expected to work within a unique perspective and to offer theories that reflect this perspective; but the ultimate goal is to find external support for the theories of the discipline of origin. Risjord presents this model of theory coherence in a distinctive and memorable way using the metaphors of a quilt and a spider web. Theories are depicted as nodes of a spider web that gain structural support and utility based on coherent linkages to other theories, irrespective of discipline of origin. Risjord makes a strong case for seeking coherence of theories originating in nursing across many disciplines. In the coherence model, nursing is free to link its theories to those in other fields to gain to support for them and to offer theoretical support for theories beyond nursing. The theory coherence model offers nursing a more expansive means of generating knowledge to advance the values and practice of the profession. Within a coherence framework, nursing has the potential to develop knowledge for the world as well as the practice of nursing. As a relatively young discipline, nursing is justified in considering the possibility of losing its disciplinary identity through interdisciplinary research. In Risjord’s conceptualization of theory coherence, nursing practice unifies the discipline, allowing nursing to share theory and knowledge. Supportive linkages to other disciplines can be created without losing nursing’s distinctive disciplinary perspective. In turn, nursing can use theory from other sources not for the purpose of “borrowing” but rather for establishing coherence and support for nursing theories.

Risjord makes a compelling case for restructuring nursing knowledge into a model that is theoretically coherent and practically relevant. Most importantly, he offers a new philosophy of nursing to guide its knowledge development.Nursing Knowledge is essential reading, not just to trace the evolution of nursing science and knowledge, but to frame the philosophical issues for the next round of scholarly debates and to position nursing for a transdisciplinary role in knowledge development.

Sue K. Donaldson, PhD, RN, FAANDistinguished Professor of Nursing and Interdisciplinary ScienceEmory University

Part I

Nursing Knowledge and the Challenge of Relevance

Introduction to Part I

Nursing knowledge

Nursing has two faces. To the public, nurses embody the best of modern health care. Efficient, effective, and caring, nurses are at the center of the patient’s experience. The other face is largely invisible to the patient, even though it has been a part of nursing since the time of Florence Nightingale. Nursing requires knowledge. In the first century of nursing, the intellectual dimensions of nursing remained implicit. Nurses were trained using an apprenticeship model. Long hours at the bedside were supplemented by some pearls of wisdom dispensed by physicians. By the middle of the twentieth century, it became clear that effective nursing practice required a distinctive body of knowledge. Nursing intervention had gradually become independent of the physician’s orders, and nursing required integrated knowledge of the physiological, psychological, and social dimensions of the patient. By developing programs of research, nurses asserted ownership over the knowledge required for practice. Contemporary nursing thus encompasses both the professional practice of nursing and the academic discipline of nursing.

The goal of nursing research is to develop a body of knowledge that will support and advance nursing practice. Nursing knowledge might be defined by its relevance to nurses, an idea suggested by Pamela Reed and Lisa Lawrence:

“Nursing knowledge refers to knowledge warranted as useful and significant to nurses and patients in understanding and facilitating human health processes.” (Reed & Lawrence, 2008, p. 423)

While the definition seems clear and straightforward, producing useful and significant knowledge for nurses and their clients has been challenging. The difficulties faced by nurse scholars have gone beyond the ordinary questions of method that concern all researchers. For example, nurse researchers have experimentally demonstrated that one educational intervention promotes adherence to an asthma-monitoring protocol better than another (Burkhart et al., 2007). This is knowledge that is well warranted by its experimental design, and apparently useful to nurses and their patients. However, nurse scholars have not been satisfied by contributions like these. Without deeper links to a growing body of knowledge, such studies have a limited ability to support the intellectual development of nursing. Nor do “qualitative” studies fare any better. Understanding the lived experience of the patient is certainly part of good nursing practice, but without some way of fitting the part into a larger whole, it is difficult to discern the significance of, for example, a description of the lived experience of nine pediatric liver transplant recipients (Wise, 2002). The problem is not that studies like these are poorly executed or trivial. On the contrary, they are well designed and important. The problem is that their importance has become difficult to recognize. Working nurses do not seek out the most recent research results or use nursing theories to analyze their responses to the patient. Indeed, the mention of “theory” is likely to elicit groans from a practicing nurse. Nursing theory and research are not supporting the professional practice of nursing in the way that nurses expect it to.

Two kinds of theory-practice gap

The “theory-practice gap” has been discussed in hundreds of nursing articles. This is a symptom of the dissatisfaction nurses seem to have with the research arm of their discipline. But what, exactly, is the theory-practice gap? Historically, the gap has been conceived in two fundamentally different ways. The difference turns on whether existing theory is held to be relevant or irrelevant to practice. Much writing on the relation of theory to practice assumes that there is a body of relevant intellectual knowledge that should inform nursing practices. The “gap” arises when this body of knowledge is not used as it should be. For example, nursing students often have trouble translating what they learn in the classroom into clinical practice. There is a wealth of literature on pedagogical strategies for helping nursing students bridge this gap. There are other versions of this gap too. Once in professional life, nurses need to continue to learn about new developments, and there are a number of barriers to the integration of research results into nursing practice. The crush of day-to-day work leaves little time for reading and reflection, and there may be no resources to support continuing education. Moreover, theory and research results are not always presented in a form that makes their clinical relevance obvious. These problems are all fundamentally problems of translation. They presuppose that there is a body of useful and relevant knowledge. The theory-practice gap arises when the theory is not translated into action.

The second kind of theory-practice gap is much deeper and more disconcerting. Authors in this vein question the relevance of existing theory and research. For example, in his “Preface” to the fourth edition of Philosophical and Theoretical Perspectives for Advanced Nursing Practice, William Cody wrote:

“The place of theory in nursing practice has, in reality, long been considered somewhat vague and tenuous. A situation persists today that has been referred to as the “theory-practicegap,” in which theory and practice are perceived as interacting imperfectly, infrequently, and sometimes insignificantly.” (Cody, 2006, p. ix)

In a similar vein, Peter Gallagher1 wrote:

“[M]any nurses consider it crucial for effective nursing that theory and practice must be closely related. This essentially symbiotic view of the nature of the theory-practice relationship has been embraced by many in the profession, and it is a view that has prompted both expert nurses and inexperienced student nurses to question the direct relevance of some theoretical material to the delivery of nursing care.” (Ousey & Gallagher, 2007, p. 200)

These remarks are some of the most recent in a longer tradition (Conant, 1967a, 1967b; Hardy, 1978; Jacobs & Huether, 1978; Watson, 1981; Stafford, 1982; Swanson & Chenitz, 1982; Miller, 1985; Meleis, 1987; Draper, 1990; Nolan & Grant, 1992; Whall, 1993; Good & Moore, 1996; Blegen & Tripp-Reimer, 1997; Im & Meleis, 1999 ). Unlike those authors who are trying to translate theory into practice, these authors call into question the relevance, significance, or usefulness of existing research and theory. The gap is one of relevance, and this is a disturbing situation. A primary goal—if not the rasion d’etre —of nursing research is to produce knowledge that supports practice. Since the early 1950s, dozens of journals have published thousands of pages of research reports. If some significant portion of this output supports practice only “imperfectly, infrequently, and sometimes insignificantly,” then something is wrong with the research arm of the nursing discipline.

If we follow Reed and Lawrence and define nursing knowledge as knowledge “warranted as useful and significant to nurses” (Reed & Lawrence, 2008, p. 423), then a relevance gap challenges the whole enterprise of nursing research and theory development. If nursing theory were irrelevant, then it would not be nursing knowledge at all. The relevance gap between theory and practice thus raises questions that reach to the foundations of the discipline. It challenges the philosophical conceptions of knowledge that are implicit in the nursing discussions of theory and research. The relevance gap is therefore a fundamental problem of the philosophy of nursing science.

Philosophy of nursing science

The discipline of nursing has a bountiful literature on nursing research, methodology, the character of the nursing discipline, and its substance. These topics are philosophical in the sense that they reflect on the most general and profound issues in nursing scholarship. If we permit ourselves—as we should—a generous understanding of “science,” the nursing metatheoretical literature contains substantial work in the philosophy of science. This book aims to contribute to that philosophy

of science: to map the intellectual fault lines of nurses’ thought about their discipline and to critically engage the issues.

The relevance gap arose at a specific point in the intellectual development of the nursing discipline. As Chapter 1 will show, concern that research or theory might be irrelevant to practice did not arise during the first century of the modern nursing profession. Since the time of Florence Nightingale, nurses have recognized a domain of nursing knowledge, but there was no relevance gap. A relevance gap was recognized by Lucy Conant in the late 1960s (Conant, 1967a, 1967b), but it was not the subject of widespread concern until late 1970s. Why? What caused the gap to open at that point in the history of the discipline? And why has it remained open? Chapter 2 will argue that the relevance gap emerged because of a particular constellation of philosophical ideas. In the 1950s, 1960s, and 1970s, there were debates about the character of nursing knowledge, research, and theory. Toward the end of the 1970s, a consensus about the field emerged. To be a discipline, many thought, nursing needed unique theories at a high level of abstraction. These were unified into a basic science by shared concepts and themes (the metaparadigm). The relevance gap opened because the philosophical understanding of science within nursing urged nurse researchers to develop a basic science, but nursing as basic science had little relevance to the profession.

What is done by philosophy can be undone by philosophy. To close the relevance gap we will have to think through the philosophical arguments about nursing research and theory in which nurse scholars have engaged. This will require attention on two fronts. First, nurse scholars have been influenced by ideas and arguments arising out of philosophy. These will have to be made clear and critically engaged on their own terms. The philosophy of science contains valuable resources for nursing, and several of the chapters below will be devoted to a detailed, critical discussion of issues in the philosophy of science. However, the notions of the philosophers take on a different significance when they enter the nursing context. We cannot restrict ourselves to the philosophers’ discussion. The second area of concern will therefore be the nursing literature about the character of the discipline, nursing science, and nursing knowledge. The philosophical position developed here will be intimately related to the debates within nursing. Chapter 3 is intended to be an interface between the philosophy of science and the nursing metatheoretical literature. It will distill four philosophical questions from the nursing debates canvassed in Chapters 1 and 2. It will also sketch, in a preliminary way, the debates to be engaged in this book, and the position that will be developed in subsequent chapters.

1 While this was a coauthored essay, it was presented as a debate with each author’s contribution clearly identified.

1

Prehistory of the problem

How did the discipline of nursing come to be in a position where significant parts of nursing theory and research are thought to be irrelevant to nursing practice? One might think that the relevance gap arose in the 1970s because only then was there sufficient nursing theory for there to be a theory–practice gap. It would be a mistake to begin the story there. While the development of nursing’s research program in the 1950s and 1960s was revolutionary for the profession, theory has been important to nursing since its inception. To understand how the theory–practice gap arose, and why the relevance gap emerged when it did, we have to understand how the relationship evolved between professional nursing and the theories that supported it.

The domain of nursing

Florence Nightingale is praised for her work in identifying the nurse’s role in health care, for establishing nurse training, and for her theoretical writing. All three were important for the subsequent development of nursing attitudes toward theory. Notes on Nursing: What It Is and What It Is Not (Nightingale, [1860] 1969) makes two kinds of contribution to theory. It described a domain of nursing expertise that was independent of the physician’s expertise. Specifically, the nurse was oriented toward the environment of the patients, everything from the condition of their bandages to the layout of their sickrooms. From Nightingale forward, then, one kind of theoretical writing in nursing has been to define nursing: to identify the proper scope of the nurse’s action, the kinds of nursing response to the patient’s needs, and the values that inform nursing actions. Nightingale asked the philosophical question “What is nursing?” and she gave a philosophical answer. She analyzed the nurse’s role with an eye toward the values that dictate what it should be (as opposed to the facts about what it is). Nightingale’s other theoretical contributions were more empirical. It is often forgotten that in Notes on Nursing, Nightingale rejected the germ theory of disease. The germ theory was just emerging in this period, and while it was known as a possible account of disease, it was not widely accepted. Nightingale preferred a late form of the Galenic theory of disease, and she believed that the diseased state of humans sometimes arose directly from their environment (Nightingale, [1860] 1969, pp. 32–34). While this theory of disease did not survive into the twentieth century, it was an important part of Nightingale’s justification for the nurse’s role. Physicians were to address the problems with the body that caused disease (imbalance of the humors), while nurses addressed the environmental causes. This gave nurses a domain of expertise that fell outside of the physician’s domain.

While we can recognize her empirical writings as important theoretical advances in nursing, Nightingale probably would have been reluctant to call them “theory,” or to say that nurse training required much in the way of “theory.” Indeed, she sometimes expressed a rather ambivalent attitude toward theory. In an 1881 address to the nurses at St. Thomas’s Hospital, she wrote:

“You are here trained for nurses—attendants on the wants of the sick—helpers in carrying out doctor’s orders (not medical students). Though Theory is very useful when carried out by practice, Theory without practice is ruinous to Nurses.” (Vicinus & Nergaard, 1990, p. 385)

This sentiment was echoed elsewhere in the late nineteenth century nursing literature. In the 1895 essay “Comparative Value of Theory and Practice in Training Nurses,” Brennan wrote:

“Theory in conjunction with practice is what we want, and although it is undeniable that theory has done more to elevate Nursing than any amount of clinical practice alone could have done, we still must remember that ‘too much reading tends to mental confusion.’ ” (Brennan, 1895, p. 355)

These passages warn nurses against delving too deeply into theory. This is puzzling because both authors clearly think that knowledge of theory is necessary to good nursing. This tension between the need for theory and the danger of too much theory highlights the role that theoretical knowledge played in nineteenth and early twentieth century nursing. Both authors make these remarks while discussing obedience. The role of nurses, both Nightingale and Brennan argued, is to carry out the orders of the physician. The implicit model is that the physicians are the repository of medical and scientific knowledge. To carry out the physician’s orders intelligently, nurses must know the medical terminology and enough about medical theories to understand what the physician was asking, and why he was asking for it. The sense in which nurses were enjoined not to read too much, or that theory can be “ruinous,” is the sense of “theory” that equates theory with medical knowledge.

Professionalization and the translation gap

The theory required for nursing practice could not be fully identified with medical knowledge, even in Nightingale’s time. Nightingale isolated a domain of responsibility where the nurse had expertise. There was, then, a special form of nursing knowledge to be mastered. However, through the late nineteenth and early twentieth centuries, both physicians and nurses expected women to already have this specialized knowledge, at least in part. A young woman with “good upbringing” would already know how to cook and clean, to care for a child or elderly relative, and perhaps to manage domestic help. Her knowledge of the household environment would be refined by apprenticeship in the hospital. The substantive knowledge that was specialized to nursing, contained in works such as Notes on Nursing: What It Is and Is Not (Nightingale, [1860] 1969) or Norris’s Nursing Notes: Being a Manual of Medical and Surgical Information for the Use of Hospital Nurses (Norris, 1891), was largely communicated to the student through experience in the clinic. The knowledge that was specific to nursing was embedded in practice. The pedagogical consequence was that the divide between theory and practice became a divide between knowledge taught in the classroom (or physician’s lectures) and knowledge that was acquired in the process of caring for patients. The earliest form of the theory–practice gap, then, was a translation gap. Nurse students and educators faced the challenge of translating medical knowledge into clinical practice.

Throughout the late nineteenth and early twentieth centuries, most of the literature on how theory and practice are related is concerned with pedagogy. Journals for nurses and nurse educators discuss how classroom and clinical work are to be balanced or arranged in the curriculum, and how to test whether the classroom knowledge is being used in the clinical practicum (cf. Norris, 1889, p. 23; McIsaac, 1903; Sellew, 1928). It is a bit surprising, perhaps, that during this period there is no literature complaining that theory is irrelevant or useless. Whenever the relation of theory and practice is discussed, the authors presuppose that theory—that is, models of human biology and anatomy, theories about disease etiology, etc.—is relevant to and supports nursing practice. When the theory–practice gap was not strictly pedagogical, it always involved problems of translation. For example, Hyde (1922) complained that what nurses learned in the school setting was often discarded when they entered the profession, not because it was irrelevant, but because the culture of the ward or the pressures of the job kept them from adhering to the ideals they were taught in school. During this period, theory remained relevant to practice partly because nursing stayed in a subservient role. The nurse’s job was primarily to carry out the orders of the physician, and knowledge of the physician’s theories helped her do so. The relationship between theory and practice was stable for the first hundred years of modern nursing, but its stability was maintained by a relationship of power and authority. The theory–practice relationship changed as the gender dynamics that grounded the physician–nurse relation evolved.

The drive to create a nursing profession was, perhaps, the most important motive for the rise of nursing research. Nursing was not always considered a profession by its practitioners. Nightingale thought of nursing as a vocation, not a profession, and she opposed registration and examination of nurses (Vicinus & Nergaard, 1990, p. 416). In spite of her opposition, nursing organizations pushed for professionalization. The British Nurses Association (established in 1888) and the American Society of Superintendents of Training Schools for Nurses (established in 1893) lobbied for nurses in matters of registration and licensure, educational standards, and working conditions. They initiated the first studies of nursing and established journals for the dissemination of nursing knowledge.

The conception of a profession held by nurses in the first part of the twentieth century was strongly influenced by Dr Abraham Flexner. Flexner was known at the time for his influential study of medical education, and nurse leaders tried (and failed) to get the US Bureau of Education to sponsor a similar study of nursing education (McManus, 1961, p. 77). In 1915, Flexner gave an address at the National Conference of Charities and Correction where he proposed criteria for the status of a profession. A profession, he argued, required “essentially intellectual operations with large individual responsibility” and it must derive its “raw material from science and learning” (Flexner, [1915] 2001, p. 156). Flexner’s criteria became the touchstone of nursing discussions about professionalization (cf. Covert, 1917; Roberts, 1925; Bixler & Bixler, 1945; Wolf, 1947, p. 40; Brown, 1948, p. 76). Flexner argued that nursing was not yet a profession (in 1915) because nurses were not sufficiently independent of physicians. “Her function is instrumental,” he wrote, “[I]t is the physician who observes, reflects, and decides” (Flexner, [1915] 2001, p. 158). This characterization was disputed by Emily Covert. Covert argued that “nursing is a science” (Covert, 1917, p. 108) with its own literature, that nurse education was moving away from the apprenticeship model, and that the domain of independent nursing responsibility was expanding.

The professional status of nursing was already a topic of lively debate when Flexner made his remarks, so much so that he prefaced them by saying: “I am conscious of endeavoring to pick up a live wire when I undertake to determine the status of the trained nurse” (Flexner, [1915] 2001, p. 158). The dispute about the professional status of nursing involved three related issues: nursing education, the scope of nursing responsibility, and the intellectual basis of nursing. For Flexner and subsequent authors, status as a profession depended on having a domain of independent responsibility. But responsibility alone was insufficient; the responsibility had to have an intellectual basis. Nightingale had already identified the patient’s environment as nursing’s special responsibility. If nursing was to become a profession, then, the nurse’s knowledge of that domain needed to be based on “science and learning” (Flexner, [1915] 2001, p. 156). This meant that nursing education had to move away from hospital–based apprenticeship and into the universities. It also meant that the intellectual basis of nursing action would need to be identified, and ultimately, developed through research.

Nursing education reform in the United States

The main professionalization effort in the first part of the twentieth century was directed toward reform of nursing education. The early nursing schools were affiliated with hospitals. Nurses learned their art primarily through apprenticeship, and hospitals quickly recognized that nursing students provided cheap and plentiful labor. Hospital-affiliated nursing schools thus spread quickly in the English-speaking world. However, the quality of the training varied widely. In the United States, there were many studies of nursing education, of which the Goldmark Report (Committee for the Study of Nursing Education, 1923) and the Brown Report (Brown, 1948) are the most well known. Both were critical of the quality and consistency of nursing schools, and both recommended university-based training for nurses. Brown went so far as to argue for the value of the liberal arts for nurses, in addition to courses in psychology and sociology (Brown, 1948, p. 141).

The move to affiliate nursing schools with universities was an important change. Many nursing schools were very small, and they were staffed by nurses who had been apprenticed, but had no advanced training. Affiliation with universities meant that nurse educators needed advanced degrees. In the 1920s, Teachers College at Columbia University began a masters program in nursing education. Some of these nurses were also trained in research techniques, and they became important contributors to the early study of nursing education (McManus, 1961). There were no doctorates in nursing, and this presented a problem of parity between the faculty of a nursing school and the faculty of the university with which it was affiliated. Brown argued that, if nursing education was to move into the universities, universities would have to permit nurses without PhDs to become professors and directors of nursing programs (Brown, 1948, p. 153). This did not come to pass, and as nursing education became more closely affiliated with colleges and universities, the demand for PhD-trained—and hence, research-trained—nurses increased.

As health care became a more complicated and varied social enterprise, the independence of nurses grew. Public health and private duty nurses had always operated more independently and tended to have more responsibility than their institutional counterparts (Brown, 1948, p. 141). Within hospitals, the medical advances of the early twentieth century made hospital care more elaborate. Nurses were needed to do more than monitor the patient and his or her environment. Nurses were given the responsibility for a variety of actions that were previously restricted to physicians. The domain of nursing activity thus expanded, and nurses were no longer simply carrying out the direct orders of the physician. Nurses were gaining autonomy. At the same time, women were gaining autonomy. World War II saw an influx of women into the workforce in both Great Britain and America. Nursing had helped solidify the notion that women might have a professional life (even if there was a difference between male and female professions). The idea that nursing knowledge could be a simple extension of the woman’s household role could no longer be sustained. Nursing required a specialized form of knowledge, and the leaders among nurses recognized that this knowledge needed to be developed through research and taught in a university.

While the need to develop nursing knowledge had been recognized since the early twentieth century, little research was actually carried out. The final push came when the US government began to fund nursing research. During World War II, American government agencies gathered data on the availability and need for nurses. The importance of nurses and their indispensability to modern health care had become widely acknowledged. Because of this recognition, research on nursing became a public funding priority. In 1948, the US Public Health Service created a Division of Nursing Resources, which eventually developed into the National Institute for Nursing Research. Beginning with small grants from the Division of Nursing Resources, funds gradually became available for nursing research. This began a project of research on the education of nurses, on their job satisfaction and turnover, and on nursing functions and activities (McManus, 1961; Gortner, 2000, p. 61). The journal Nursing Research was established in 1952, marking the beginning of a fullblown research enterprise.

Nursing research begins

Early nursing research fell, broadly, into three categories. During the early part of the twentieth century, research by and for nurses focused on educational and professional matters. The bulk of the work published in Nursing Research during its first decade continued the tradition of examining nurse education, roles, and job responsibilities. This literature was sociologically oriented and was strongly influenced by mid-century trends in sociology. Gradually, however, studies began to appear that either examined the effectiveness of nursing interventions or proposed a useful way of approaching nursing problems. By the early 1960s, this second kind of research had an established place in the literature.

Systematic treatises on nursing were the third kind of nursing research. Hildegard Peplau’s Interpersonal Relations in Nursing (1952), Ida Jean Orlando’s The Dynamic Nurse-Patient Relationship: Function, Process, and Principles (1961), Ernestine Wieden-bach’s Clinical Nursing: A Helping Art (1964), and Virginia Henderson’s The Nature of Nursing (1966) were among the first of these. These books had several aims. Primarily, they provided an analysis of nurse–patient (and sometimes nurse–family, nurse-nurse, etc.) interactions. They divided the process of nursing into stages and articulated the roles distinctive of nursing. The conceptual framework was intended to facilitate nursing practice and education. Conceptualizing the process was a valuable aid to making explicit nursing problems and their solution. Finally, these works tried to establish what was special, important, or essential to nursing. They aimed to provide the underlying rationale for the existence of the nursing profession.

As the resources and capacity for research grew in the 1940s and 1950s, there was some discussion about the future directions of nursing research. In the first years of its publication, Nursing Research ran a regular column asking subscribers about the research topics they thought most important for nursing. The first expression of concern about the kind of research being done in nursing was an editorial by Virginia Henderson in 1956. She pointed out that in the first 4 years of publication, most of the essays in Nursing Research had concerned nurses—their education, occupational role, working conditions, etc.—not the science that supported nursing practice (Henderson, 1956). Henderson’s generalization was supported by Hortense Hilbert, who surveyed 630 articles published in health journals between 1950 and 1958 (Hilbert, 1959). Henderson and Hilbert were both members of the editorial board for Nursing Research, and these leaders were calling for an increase in “clinical nursing research.” As they saw it, this research was to be based on the natural and social sciences. Theory was needed too, but this was not yet conceived in the terms that are now familiar to nurses. In their proposal for “An Experimental Program in Nursing Research,” Eleanor Sheldon and her colleagues wrote:

“Another aspect of nursing research is its lack of theoretical orientation and its strong emphasis on urgency and utilization However, if nursing is viewed (as medicine could be viewed also) as a process of assessment and remedial intervention, the nursing research might be conceived of as a sharpening of that assessment perspective, the products from which could yield more efficient and refined remedial intervention—for the ultimate purpose of improving the care of patients. A sharpened perspective in relation to research, however, must be drawn from a theoretical orientation or at least a body of content from which to draw and formulate researchable questions. Members of the nursing profession are not ignorant of the dire necessity for some articulated and systematic fund of knowledge on which to build both its present and future practice.” (Sheldon et al., 1959, pp. 169-170)

It is clear from the content of the proposed program that Sheldon et al. were thinking of “theory” as a systematic consolidation of natural and social scientific findings relevant to nursing practice. In the 1950s, then, the call for a new direction in research was a call to move away from educational and occupational research and toward a more systematic investigation into the kinds of theory that had traditionally supported nursing practice.

Nursing research thus developed gradually through the first half of the twentieth century. It arose out of the desire to professionalize nursing, and the belief that a profession needed a unique knowledge base to support independent action in an area of expertise. The existing theories—biological, psychological, and social—were held to be relevant and important for nursing practice. Indeed, Henderson’s critique in 1956 was aimed at increasing the engagement of nurses with these established scientific domains, not finding a new frontier for nursing science. Up through the 1950s, there was no concern that nursing research and theory was irrelevant; a relevance gap between theory and practice had yet to arise. This means that the theory–practice gap must be the result of some subsequent development. It also hints that the relevance gap between theory and practice is distinctive of the nursing discipline. It is not a general problem about how academic knowledge is related to practical know-how. If it were, the problem would have arisen during the first hundred years of modern nursing. No, the relevance problem has to do with the way nursing knowledge and the academic discipline of nursing have been conceived, and it is a product of the latter part of the twentieth century.

A philosophy of nursing

The inaugural issue of Nursing Research opened with an essay entitled “What is Nursing Research?” (Bixler, 1952). It set the direction for the new journal, articulating a conception of research that was broad and inclusive. Indeed, it was so broad as to call for research in nursing philosophy: “There is the greatest dearth at present in the area of philosophical research, in nursing even more than the literature of other professions” (Bixler, 1952). To those of us with a passion for both philosophy and nursing, this allusion is as vexing as it is exciting. Little in the nursing literature before or after Bixler’s essay would be recognized by philosophers as a contribution to their field. What could she have meant by “philosophical research?” The clue is provided by the remarks that immediately follow:

“Difficult as this kind of [philosophical] research is, it is very necessary and more of it should be produced. In times of rapid social change such as ours, it is dangerous to be charting courses by means of tradition only as a guide. On the basis of directions considered desirable by the leaders of the profession and others, and within the framework of the democratic philosophy as well as known scientific principles, systematic investigation of a projective sort must be undertaken It will include schemes for evaluation as well, another aspect of research as yet imperfectly understood and practiced within nursing.” (Bixler, 1952, p. 8)

Bixler’s talk of “rapid social change” and the need for direction from “leaders of the profession” indicate that she was referring to the rapidly changing role of nurses. At the beginning of the century, most nurses were employed in private practice. They had responsibility for the complete care of the patient. By the middle of the century, most nurses were employed in hospitals. Nurses had taken over many technical procedures that had been the sole provenance of the physician. More problematically, it also meant that many traditional nursing functions were being handed over to “nonprofessional” staff. Nurses were moving away from direct patient care and into a managerial role (Brown, 1948; Saunders, 1954; Reissman & Roher, 1957). To many nurses, this was a troubling loss. Bixler’s call for a philosophy of nursing was thus a call to define nursing, to find its heart, and thereby defend a nurse’s proper role.

Concern about the changing role of nurses led a number of mid-century authors to pursue a philosophy of nursing in Bixler’s sense. Since it was widely recognized at the time, Bixler was no doubt aware of Sister Olivia Gowan’s “definition of nursing”:

“Nursing in its broadest sense may be defined as an art and a science which involves the whole patient—body, mind, and spirit; promotes his spiritual, mental, and physical health by teaching and by example; stresses health education and health preservation, as well as ministration to the sick; involves the care of the patient’s environment—social and spiritual as well as physical; and gives health service to the family and community as well as to the individual.” (Gowan, 1946, p. 10, quotation reprinted in Nursing Outlook7 (4), 199 (1959))

This philosophy of nursing sounded all of the themes on which subsequent definitions would draw (e.g., Henderson, 1966). The other early works that fit Bixler’s conception of a philosophy of nursing were the systematic treatises on nursing by Peplau (1952), Orlando (1961), and Wiedenbach (1964). These works helped define nursing by providing an analysis of the nurse’s function that was based on an empirical study of nursing activities. Orlando characterized her work in these terms:

“The nature of the patient’s distress and his need for help are examined in order to identify professional nursing function. The nursing situation is analyzed in terms of its elements (the patient’s behavior, the nurse’s action and reaction) as they effect the process of helping the patient. From this analysis, principles of effective nursing practice are formulated.” (Orlando, 1961, p. viii)

Orlando expressed the hope that this kind of analysis would contribute to the discussion of “nurse–patient relationships, the nurse’s professional role and identity, and the development of knowledge which is distinctly nursing” (Orlando, 1961, p. viii). By the early 1960s, nurse scholars began to think that the relationship between a philosophy of nursing and the development of “distinctly nursing” knowledge was extremely important.1

What would a nursing science look like?

The connection between a philosophy of nursing and the larger research enterprise was developed in two influential papers: Dorothy Johnson’s “A philosophy of nursing” (1959a) and Rozella Schlotfeld’s “Reflections on nursing research” (1960). Both essays voice concerns about the professional role of the nurse. They took the position that nurses ought to be direct caregivers, and they were looking for intellectual grounds on which to resist change to this role. Nursing had been changed, they felt, by “social forces,” not by reflective, intentional action by nurses. Since Flexner ([1915] 2001), the intellectual expertise of a profession had been taken to be definitive of its proper domain of action. Both Johnson and Schlotfeld argued that nursing needed to develop its intellectual arm so that the proper role of the nurse could be identified and defended. Up to that point, they felt, the knowledge that supported nursing was primarily medical knowledge. In the 1940s and 1950s, nursing education had supplemented the physician’s biological knowledge with psychology and sociology. Nursing knowledge had thus grown beyond the boundaries of medical knowledge, but there was, as yet, little that nurses could call their own. Research and theory development were needed to create a knowledge base that would be unique to nursing. By calling for the development of an intellectual domain for nursing and relating it to practice, both Johnson and Schlotfeld were creating the conceptual background for the emergence of a discipline of nursing.

In these essays, Johnson and Schlotfeld also began to articulate the relationship between the discipline of nursing and the professional practice of nursing. They held that nursing research and theory development should be largely autonomous of the practical needs of nurses. The philosophical definition of nursing should set the goal for nursing practice. The knowledge required to achieve those goals would then be the intellectual domain of expertise of the professional nurse. The goals of nursing would thus determine the scope of nursing knowledge and the proper topics for research and theory (Johnson, 1959a, p. 200; Johnson, 1959b, p. 292; Schlotfeld, 1960, p. 493). Nursing research would then develop and test theories about a range of topics, including the health of the patient, the patient’s response to nursing intervention, and the nurse–patient interaction. These theories would be the knowledge on which nursing practice would be based. As Sue Donaldson and Dorothy Crowley were to later express the point, “the discipline of nursing should be governing clinical practice” (Donaldson & Crowley, 1978, p. 118, emphasis in original).

Johnson and Schlotfeld did not require that nursing theory and research directly respond to the problems of practice. As Myrtle Brown put it, nursing research should aim at “the pursuit of knowledge for the sake of knowledge; its aims should not be limited to the search for facts needed to solve a specific practical problem” (Brown, 1964, p. 111). An alternative view was articulated by a number of scholars, many of whom were associated with the Yale University School of Nursing (e.g., Wald & Leonard, 1964; Conant, 1967a; Dickoff & James, 1968; Ellis, 1969). These authors argued that nursing research needed to be directly responsive to the problems of nursing practice. Some concepts of nursing theory would be drawn from nursing practice. Practicing nurses, Ellis argued, already had substantive knowledge that was relevant to patient care. Nursing research would make some of this knowledge explicit. Established biological, psychological, or social theories would be used to illuminate and expand the practitioner’s knowledge. Then nurse researchers would subject the generalizations to clinical test. Since the theory was developed in response to problems recognized by nurses, the knowledge generated by such research would be useful to the nursing profession. Wald and Leonard called this view “practice theory” (Wald & Leonard, 1964). The focus on problem solving, rather than knowledge for knowledge’s sake, led to a different conception of the theory–practice relationship. While many writers held that the discipline must govern the practice, practice theorists held that the practice should govern the discipline: “The domain of nursing practice should delimit the domain appropriate to theory development for nursing” (Ellis, 1968, p. 222).

Nursing theory and nursing knowledge

Some nurse scholars worried that a focus on problems in nursing practice would keep nursing research from developing into a proper science. In an essay written for the 10th anniversary of Nursing Research, Loretta Heiderken argued that most nursing research up to that point had been “problem-oriented rather than knowledge- oriented” (Heiderken, 1962, p. 141). As a result:

“research in nursing is not yet scientific. Problem-solving and research are not synonymous; to be scientific problem-solving in research must proceed from a body of theory (at least a simple conceptual model) and feed back into that theory.” (Heiderken, 1962, p. 141)