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ontology

Plain Talk:  Thinking of health as mind-body-spirit, while useful, in its own right, leaves out the importance of meaning and purpose that we know we are made for.  We have to include this when we think of health.

The Details:
No nurse (at least in the western world) sees nursing as “just” caring for the sick, the babies, and the old people.  Heaven forbid.  Hopefully, we’ve come much farther than that.  But we have much farther to go, in my opinion.

If I asked you to tell me how nursing is different than medicine, you’d probably offer that medicine is disease-focused, and nursing is holistic, and by that you would mean that nursing considers the “whole” person.  You would describe to me that people are not just bodies, but also made of a unity of body, mind, and spirit.  Nurse scholars have offered similar concepts.  McEwen &Wills (2007) put it this way:  “Person refers to a being composed of physical, intellectual, biochemical, and psychosocial needs; a human energy field; a holistic being in the world; an open system; an integrated whole; an adaptive system; and a being who is greater than the sum of his parts.” (p. 43).

We’ll come back to this.

Next, consider the objectives of the nursing profession:  care of the sick, care of the well, assisting self-care activities, helping people attain their human health potential.  McEwen &Wills (2007) continue:  “The purposes of nursing care include placing the client in the best condition for nature to restore health, promoting the adaptation of the individual, facilitating the development of an interaction between the nurse and the client in which jointly set goals are met, and promoting harmony between the individual and the environment.  Furthermore, nursing practice facilitates, supports, and assists individuals, families, communities, and societies to enhance, maintain, and recover health and to reduce and ameliorate the effects of illness.” (p. 43).

I hoped you picked up on the common bond between these well-accepted explanations of person and of the purpose of nursing.  The commonality is that of a systems framework.  When man is conceptualized as a system, then any nursing interventions will necessarily be systems-oriented, if nursing is to be at all congruent with their philosophical foundations.  But for reasons I’ll discuss below, I think this is a thoroughly short-sighted framework that has squelched the work of nursing, at least theoretically speaking. 

At the risk of sounding disrespectful, one can pretty easily substitute “dog” (especially a smart dog like mine) in the above definitions and have coherent statements.  I’m not saying nurse scholars through the ages think of humans as mere systems.  It’s obvious they don’t think that. I definitely appreciate the great difficulty that arises in finding adequate language to describe the nature of man.  That’s been the plague of philosophy for ages, after all.

But is there a more robust conceptualization of man and by extension, nursing, that will take us beyond this constrictive framework of “mind-body-spirit”?  I believe there is.  Indeed, nurse researchers have come close to it in their studies on hope. 

What I am proposing is a re-conceptualization of man within nursing philosophy that places the focus on vision, passion, and purpose of the individual.  This new paradigm more rightly aligns “health” with the true nature of man.  Health is not a repair schedule in which “systems” are fixed and fiddled.  Health, true health, is when people possess a passion for the purpose of enriching the lives of others and themselves by virtue of a higher vision for a meaningful life that reaches outside themselves to others in goodness.  This is the only explanation offered by say, a patient with terminal cancer, who is consumed not by cancer, but is consumed with life purpose.  This vision and passion I speak of is akin to hope but not the same as hope.  I think passion is much deeper than hope and I think it is more representative of how we would describe true health.  It is a passion fueled by virtue.

As nurses, if our calling is to direct patients towards true health, then our focus cannot solely be on a systems orientation.  The absence of physical (system) illness is not true health. The absence of mental (system) illness is not true health.  The absence of emotional (system) illness is not true health.  The absence of spiritual (system) distress is not true health.  A “working” systems paradigm cannot constitute true health, because we are not, fundamentally speaking, a set of systems. 

We must look far beyond the confines of systems paradigms.  Is it possible to instill a sense of vision, passion, and purpose in our patients?  Of course it is. The opportunities are immense.  This is a huge field ripe for some creative and scholarly research focused on optimizing the individual to live a life of importance, of service, of love.

Lack of purpose robs.  Lack of passion starves.  Lack of vision kills.  We were not made for ourselves only…such thinking is destructive to our souls and bodies.  Think how much “healthier” we would all be if we just had a megadose of vision, passion, and purpose to benefit others and truly impact our world.

The new metaparadigm for true health:
Perceive the vision.
Possess the passion.
Pursue the purpose.

 
See.
Feel.
Live.

Stay tuned.  More to come as we flesh this out little by little and see how it fits within the Perspectival Evidentialism model.  Let me know your thoughts.

McEwen, M. and Wills, E. M. (2007).  Theoretical Basis for Nursing. 2nd ed. (Philadelphia: Lippincott Williams & Wilkins.

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.

(Satellite photo of the world at night)

Perspectival Evidentialism ©.
Kind of a mouthful, isn’t it?

Plain Talk:  These ideas demonstrate how we might picture human nature a bit differently compared to body-mind-spirit yet still accounting for body-mind-spirit.  A perspectival view accounts not only for the patient, but also the nurse, social networks, values, and environmental aspects and how all these impact the person as a whole.

The Details:
How about a preview?
This is the name I’ve chosen (for now, anyway) for my philosophy of nursing. I think “perspectival evidentialism” is a good fit because the term itself embraces the simultaneous elegance of reality’s simplicity and complexity while permitting evidential evaluation of the whole of man’s well-being. This is the backdrop against which nursing epistemology and, by logical extension, nursing science rests. In a definite but more general sense, it is a philosophy of nursing based on human ontology of ethic, being, and doing. The beauty of this is that both client and nurse stand together in a holistic interchange. In other words, because of the perspectival reality we all live in that is comprised of ethics (which reflect our beliefs about truth), personal relationships (even including society as a whole), and our own existential being, both nurse and client are always interdependent.

I offer here a very simplistic overview of Perspectival Evidentialism:
Envision a 3-D triangle.

The perspectival component entails three perspectives (the angles of the triangle) of human ontology…three lenses, if you will, through which we develop nursing science: Normative (i.e., truth, beauty and ethic), Existential (the self, I, me), and the Situational (relationships, environmental factors, anything outside of “me”).*

Each perspective is just that: a view of the problem or situation from one perspective, but it is a view of the WHOLE in its entirety. The model is inseparable, non-linear, non-hierarchical. It is an integrative whole.  It is NOT like that old parable about 3 blind men’s interpretations of what an elephant is like, because in that parable each interpretation is actually an interpretation of a PART, which is more of a “systems” framework.

The evidential aspect refers to the “evidence” revealed by each perspective, such as a particular ethical or truth problem, a situational problem (relational, social justice, environmental, economic), or an existential problem (self-identity, self-purpose, personal desires, lack of knowledge).

I want you to think about this evidential aspect. Consider:

1. If you are a nurse, you stand in the middle of these triangulated perspectives (normative, existential, and situational) as a perspectival interpreter: to the client, to the profession of nursing, and to society, with the ultimate purpose to maximize the holistic health of mankind based on a knowledge of biobehavioral motivations.

2. It is the nurse who assists the client existentially in interpreting the knowledge (scientific or ethical or relational) available at the given moment and who upon proper assessment of the interplay of the perspectives, offers a plan of care to optimize the holistic fulfillment of the client in keeping with truth (scientific, ethical, relational).

3. It is the nurse who stands in the public arena of social justice to destroy barriers that enable disparity. These barriers are seen as roadblocks to holistic health because we interpret them as unethical, whether we are talking about laws, medical access, or economics. We are constantly measuring issues relative to the perspectival model, whether we realize it or not. We adjudicate on the basis of our understanding of truth, the reality of man, and the nature of man’s relationships. In the end it all boils down to a battle of truth. That doesn’t mean, however, that truth is always easily discerned.

4. It is the nurse who takes notice of the biobehavioral responses of the client (the existential) relative to his situation (environmental and relational) and relative to truth (scientific and ethical). Nursing research/science is thus borne from these biobehavioral observations.

Perspectival Evidentialism is broad enough for transglobal application yet readily adaptable to the narrowest client problem conceivable. I believe its success as a nursing philosophy is rooted in its description of human desire and its constant quest for balance of ethics (truth and beauty) and relationships (interpersonal and environmental relationships). The willful choices of man relative to his desires are the “evidence” of his holistic state (at any given time) and “evidence” of the influence of the related perspectives. Think about that. We constantly interpret our world within these perspectives, and then act on our strongest desire at that moment.

“Evidence-based practice” just took on a greater meaning. Do you see that?  Perspectival Evidentialism forces us to analyze the evidence of man’s self and his desires; the evidence of truth, ethic, and beauty; the evidence of relationships. The nurse as interpreter of “evidence” then refines and hones the nursing knowledge (“evidence”) discovered through nursing research/science, then stands again as interpreter (translator, disseminator) of evidence to the client.

I believe the Perspectival Evidential model holds promise for framing nursing science within a truly holistic sense at the most fundamental ontological level of personal desire, intention, and purpose. I believe it will enable us to speak more cogently, concisely, and coherently about holistic health within the current catch-phrase of “evidence-based practice”. The beauty of Perspectival Evidentialism is that evidence-based practice can now encompass holism without the sacrifice of empiricism, rationalism, or subjectivism. Indeed, holism requires all these and then some.

Perspectival Evidentialism © is a model of revelation (of what we know or believe to be true) whereby examination and research that is guided by a truthful ethic, facilitates nurses to intervene therapeutically for clients (whatever form that might take: physical, emotional, intellectual, spiritual). Kind of like a holistic GPS. 🙂

*(I had envisioned this model in rudimentary form about three years ago. Much to my delight, John M. Frame had created and exposited this same perspectival model. His book, The Doctrine of the Knowledge of God (1987, P&R Publishing), is a philosophical and theological argument for the model. I am indebted to Dr. Frame for allowing me to adapt this model for nursing philosophy. E-mail correspondence 01-23-08.)

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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