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nursing theory

Wordle: Health Philosophy
Plain Talk:  Nursing philosophy is the reasoning behind why we do nursing the way we do.  Go deeper:  Why we do nursing the way we do is dependent upon whatever we think ‘health’ is.  Whatever we think ‘health’ is reflects our beliefs about the purpose and experience of human life.

The Tortures of Nursing Theory Class

I dreaded the required graduate nursing theory class in 1997.  Who created this mental torture chamber and charged me good money for it?  Self-preservation requires you avoid these things.  Besides,  I would never use nursing theory or philosophy, or so I thought, because, come on, that is of absolutely no use in my work as an ER/trauma nurse.  Need I say my attitude was terrible?

Aha!

Life has a way of mocking us when we reach, years later, an “aha” moment –  that moment of insight in which the past comes to bear on the present in surprise and wonder.  It was a moment when I realized that perhaps part of the reason nursing theory was so disdained by everyday nurses is that the ‘way’ we do nursing reflects our beliefs about health and human experience, and theory did not seem to capture the depth of reality we experience in practice.  Nursing practice is characterized by encounters with hearts and souls abiding in bodies, and the essence of nursing practice is grounded in how we relate to and support others through the healing process that engages skills and clinical knowledge.

Getting Down to the Real Problem

Nursing philosophy explains what nursing is and why nurses practice nursing the way they do. Nursing theory explains how nurses and patients create health and healing, by using models to describe how concepts and factors of health are related. It’s no wonder that nurses and nursing students thumb their nose at philosophy and theory, because if we don’t know, or haven’t articulated, the fundamental tenets of health in a way that is consistent with the human experience, then the disconnect from philosophy to practice will remain.

To blame nursing philosophy and theory is to make nursing the scapegoat for the bigger, more obscure problem:  the absence of a well-developed philosophy of health.  

Naivete and accepting the status quo in nursing philosophy is killing us.  We must develop philosophies of health that underpin nursing philosophy, theory, and practice.  Part of the key lies in drawing on what we intuitively know about wellness and illness, and what we know through actual experience about how patients heal.  The psychology scholars have done some marvelous work on well-being and happiness.  Tying those findings into health is OUR job, and creating those ties require a workable philosophy of health.

This is the path that led me to create the Perspectival Well-Being Model in which well-being is mediated by our sense of belonging in social relationships to others, by our sense of virtue, and the need to care for ourselves.  I posit that personal well-being is not grounded in self-centric thoughts and activities, but in being and acting in our worlds through virtue and relationship.  By focusing on the unbreakable tie between virtue, self, and others, there is plenty of room for the current understanding of health as a function of well-being and vice versa.  It is broad enough to account for a spectrum of health experiences:  from the well-being of the terminally ill or severely injured, to the ill-being of the socially isolated but physically healthy person.

Plain Talk:  Maybe we don’t have a theory-practice gap.  Instead, we may have a gap between the way we think of human nature and the questions we come up with for nursing research.  How we understand human nature will necessarily impact what we choose as nursing research topics.  We have not spent enough time in nursing developing the concept of human nature as it relates to health.

The Details:
Green, Catherine. (2009). A comprehensive theory of the human person from philosophy and nursing. Nursing Philosophy 10(4), 263-274.

Ontology: the study of what exists, what is real.

I applaud this article. Catherine Green notes that our source of knowledge of others is our observance of a person’s intentional actions. Green acknowledges the stances of two philosophers, Wallace and Sokolowski.

Wallace states that personal responsibility for choices is ingrained in our relationships with others and society.

Sokolowski asserts that personal intentionality is made known publicly by one’s actions.

If we blend Wallace and Sokolowski into one statement, it would be this: We have knowledge of other people based on their choices and these choices reflect their intentions. At this point, you might be thinking, “duh”. Keep reading.

Green uses this synthesis to suggest this might help close the theory-practice gap. But I think it’s deeper than that. To me, Green’s article reveals that the problem is not a theory-practice gap so much as it is an ontologic-research gap.

The theory-practice gap is the ‘disconnect’ that some have noted as the mismatch between theory in the classroom and real-life nursing practice. Who thinks about Roy, Orem, Nightingale, Rogers, Henderson, etc. during daily work? Some of these theoretical systems are very complex. But maybe that’s not the REAL problem.

The real problem, I think, more often lies in the ontologic, which I’ve written about before. In nursing practice, we’re not dealing with a theory, we’re working with a person. So our assumptions about the nature of man must be accurate for us to effectively intervene on their behalf. We do this instinctively. The reason theory doesn’t resonate with us may be because the theory reflects dimensions of man, rather than ontology of man. Theory recognizes domains of man as social, physical, mental, and spiritual being. But deeper than that is man’s morality and intentionality, as Wallace and Sokolowski asserted.

Ideally, philosophy informs theory which informs research which informs practice.

Skipping philosophy to focus on theory and then jumping to practice creates some potential problems. Problems like treating theory as if it were the philosophy. A poorly articulated philosophy/ontology will result in a tenuous theory, which down the road finds a disconnect to practice.

Green has it right. The ontologic notions of relationship, revelation of personal intention, and moral responsibility that Green so aptly describes is premised on the belief that nursing theory needs a more ontologically sound foundation. Indeed, an ontologic focus on man’s essential being is necessary if we are to extract pertinent research questions about the essence of man’s well-being. By defining the nature of man more thoroughly, nursing theory is built on a more solid foundation. Following suit, the research is targeted to truly pertinent questions, and practice naturally follows in accordance.

Green’s pragmatic emphasis echoes the work of Doane and Varcoe (2005) who adopted a nursing philosophy of pragmatism, which is a process to “bring knowledge, compassion, and action together to produce practical knowing – to develop knowledge in service of worthwhile human purposes” (p. 115). I assert that such practical knowing is steeped in the ontologic primarily, and in the theoretical secondarily. Green’s work is a step in the right direction.

I’m not saying my opinion is revolutionary or the be-all, end-all. I think we need to get out of the rut of always assuming there is a problem we call the theory-practice gap. Maybe it’s not that at all in some cases. Maybe it’s an ontologic-research gap.

I propose that the next step forward involves exploring this ontologic synthesis of man as a relational and intentional being.

Listen to Sokolowski: “What human nature is capable of being in its actions is shown not primarily by philosophical speculation but by good human agents. Virtuous action in concrete situations is the primary display of the possibilities of action…Virtuous agents acting are the measure of what ought to be done. There is no cognitive substitute for this original display.” (Sokolowski, 1985, p. 149).

References

Doane, G. H. (2009). Toward compassionate action: Pragmatism and the inseparability of theory/practice. In P. G. Reed, Perspectives on Nursing Theory (5th ed., pp. 111-121). Philadelphia: Lippincott, Williams, and Wilkins.

Green, C. (2009). A comprehensive theory of the human person from philosophy and nursing. Nursing Philosophy , 10 (4), 263-274.

Sokolowski, R. (1985). Moral Action: A Phenomenological Study. Bloomington IN: Indiana University Press.
Portions of this post were selected from my letter to the editor of Nursing Philosophy, publish date pending.

(This was an impromptu writing to fulfill a short assignment on metaphors for nursing theory.)

I’m sitting at my computer, gazing at my 10 year old arthritic black and tan female German Shepherd, Jala, who is sleeping three feet from me with her muzzle cradled on her right paw. A distant child’s voice from outdoors sparks her from slumber. Ears upright, a turn of the head, a quick glance towards me, and she lazily rolls onto her side. It’s only a child. No worry.

For ten years she has exercised faithful vigilance over the theoretical unknowns. New interpretive contexts fall somewhere between Jala’s creative independence and learned boundaries. Like letting babies crawl on her. Or assuming a sentry position outside doors of dreaming toddlers. Or testing new relationship constructs by “telling” me the cat need to go out. Or experimenting with new applications: Will she be allowed to take Vail’s place in bed while he is out of town?

We have not yet discovered any interpersonal environment to which she cannot adapt. Her concepts have stood the test of time. As an interdisciplinarian with Kuhnian tendencies, this 4-legged, 90 lb. holistic framework must perpetually assess the neighborhood for new evidence that might invoke a paradigm shift. The research continues to support Jala’s fundamental assumption that a healthy and safe environment is the criterion of community wellness.

Nursing theory is such a dog!


“Beauty is a very successful criterion for choosing the right theory…a beautiful or elegant theory is more likely to be right than a theory that is inelegant.”

(Murray Gell-Mann, 1969 Nobel Prize in physics, renowned for his work on elementary particles, namely quarks…which he named.)

Truth and beauty. Inseparable. One and the same.

The evidential power of beauty is in its truth, its order, in the fulfillment we experience when we perceive it. We were made to crave the ecstatic beauty of the world, of relationships, and the truth that permeates every iota of it. We desire to be astounded by an elegance that defies description…an elegance that is necessarily characterized by timeless truth and goodness.

Ultimate beauty owns truth, ethic, and order. Chaos is not an expression of beauty but its very antithesis. Ugliness is not a relative beauty, it is a violence against beauty.

Does it surprise you that physicists ascribe truth to beauty? The thrill of the profound escapes the boors who stupidly believe the age-old caricature of scientists as a group of boring intellectuals who seemingly have nothing more interesting to do than complex equations. Truth is, the boors live in a pitifully bankrupt superficiality.

There is an objective beauty that we necessarily desire and pursue to delight us, enthrall us, and enrapture us. I think physicists are a lucky lot…their profession spans the subatomic to the cosmologic…how could they ever deny the truth of beauty…they live with it daily. And so do you, if you take time to ponder. The satisfaction that only ultimate beauty and truth can fulfill is the pleasure we desire most above all else, though we often search for it in the wrong places. Man’s quest is to be consumed by a lasting and purposeful passion that brings meaningful balance and import to life. I dare you to deny you seek the same .

So what’s my point, you may ask, as it pertains to nursing philosophy. The point is this: everything. Any nursing philosophy must, without question, simultaneously possess and reflect truth and beauty, and the relentless human longing for it. If it doesn’t, well, then I’d say it’s ugly. Give it some thought. Dwell on what is beautiful, truthful, and right. Dwell deep.

“The conventional view serves to protect us from the painful job of thinking.” (John Kenneth Galbraith, economist).

The 21st century is here! Time to get out of our theoretical and philosophical ruts and get on with progress! There’s no time for idle thought, for being comfortable with the “conventional wisdom” that perceives revolutionary timekeeping as a function of watch gears. As functional and beautiful as they were in their time, their utility reached its apex long ago. No doubt it served centuries of people, but today’s time is marked by microprocessors, not watch gears.

How will nursing move into the microprocessor world? By finding more durable materials for their watch gears? By redesigning the watch casings into something more modern? Through a publicity campaign to maintain the “conventional wisdom” of watch gears?

In all these options the “conventional wisdom” is furtively retained. We are in a new era now. The time of microprocessors, of digital media, of micro-second communication, nanotechnology, quantum dynamics, and gene manipulation has arrived, which makes even Dick Tracy’s watch obsolete.

Nursing’s philosophical and theoretical progress in the future will come about not by refurbishing its antiquated watch gears, but by gently setting aside any archaic times on the shelf for safekeeping, as reminders of our beginnings, then blazing ahead into the microprocessor world. Wisdom and discretion will guide. Shall we be labeled iconoclasts in so doing? I don’t think so, and our heirs won’t think so, either.

In my opinion, nursing philosophy has failed to provide a coherent ontological basis that truly directs nursing research and knowledge development. It’s not that everyone is wrong….it’s that while many scholars intuitively have identified anthropological factors as critical to understanding man’s responses to health/illness, we haven’t quite capitalized on the core issue of the most basic element common to all people: desires.

Desire is more basic than intention, choice, or action. Man always does what he most desires at any given moment, within the context of his circumstances. The contextual milieu is critical. If you miss this, you miss my point. I am not saying that man desires being in poverty or oppressed circumstances. Not at all….but every situation involves conscious desire even when only horrible choices exist. Even suicide is expression of the desire for contentment, of satisfaction, that unfortunately is seen as only existing by self-abolishment as a measure to relieve suffering.

The context limits the choices in good and bad ways both. But a person’s response to circumstances is always based on their strongest desire at the moment. To seek relief from suffering is another way of saying that people seek satisfaction, pleasure, and contentment and thus always act on their strongest desire at any given moment within the framework of their personal ethics and values.

Desire explains why some people choose healthy lifestyles and why others choose self-abusive habits. It is pleasure we all seek after. How that is satisfied depends on our ethics and values which are shaped by a myriad of factors.

Consider: the most consistent factor among centenarians (those who live 100+yrs.) is not healthy eating, exercise, and abstinence from all vices (however you want to define those). It is optimism, and a belief that “this, too, shall pass”.

Consider: Why don’t we discipline ourselves in healthy habits?
Could it be we have other desires that are more satisfying to us than good health?

Consider: How can we separate mind, heart, and body?
Answer: We can’t. And we need a nursing philosophy that bridges all three. That concept is desire. A second related element is relationship (but we’re not ready to discuss that yet).

So what satisfies you? What are your desires? These are very complex philosophical, ethical, and theological questions that must be considered in nursing philosophy. Research should target what influences individual human desires. It is the major determinant of people’s choices regardless of race, ethnicity, economic status, sex, religion, or educational level.

Nursing research should be focused at the level of human desire within individual and population contexts. If we can labor to understand what controls desires and help patients identify these, while finding ways to modify desires into those which result in wholeness of person, then we will surely be developing nursing knowledge to truly explain what nurses do in their holistic work to attain well-being within reality’s parameters. We will also then forge a road into a new realm of holistic nursing science in understanding how desires influence mind and body.I will be proposing a triperspectival model of ethic, existential factors, and situational factors to advance nursing knowledge. A model that will, with time and research, abolish the theory-practice gap. It is a model which I believe will have global significance as the concept of desire as basic to human nature is God-given to all men. As a fundamental ontology it is applicable to all cultures. More on that later.

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