The evolving nature of nursing ideas

Nursing is a discipline defined by its unique and particular relationship to ideas. It accepts as its societal mandate the experiential domain of health and illness, arguably the most complex and messy of phenomena in the human universe. It deals with people as wholes, as entities within a broader context, and also as constituent parts, depending on the mindset called upon by each client encounter. It attends to, reasons through, reflects upon and integrates general knowledge of various varieties into elements applicable to the unique particularities at hand. It funnels that infinite knowledge into the strategic bundle most likely to be of use to a distinct sentient being caught in what may be the most complex and difficult point in his or her lifespan. The intrinsic complexity of the task facing every nurse on a daily basis becomes the driver for the nursing philosophy and science striving to find intellectual tools to make this unbelievably complex function as manageable and effective as possible. This challenge has attracted generations of disciplinary thinkers to try to define nursing’s essential nature by way of the ideas that make sense of the complexities and have impact on the world of applied practice. Although ideas have always been prominent in the writings of great nurses, the discipline has long suffered what Traynor (1999) has called an inherent disjuncture between the science and the practice of the discipline. This has occurred, at least in part, because the conventional scientific theorizing available to early thinkers was of a form that inadequately represented the complexity that is human health experience. Before the advent of complexity science, which entered the field only a few decades ago, justifying a shifting emphasis from causal relationships to dynamic, adaptive systems (Gleick 1987; Wilson and Holt 2001), there were few theoretical options from which to draw an understanding of the ontological and epistemological underpinnings of the discipline. Thus, nursing tried to conceptualize itself as a scientific entity, focusing its attention on theoretical knowing as its driver. The kinds of ideas we might now more usefully consider philosophizing were expressed in a language and form that implied empirical advancement, and our different philosophical perspectives were positioned as distinct ‘nursing theories’. From the late 1960s and through the 1970s and 1980s, when our theorizing era took flight, nursing science began to separate itself into perspectival camps. Initially, it thought of those distinctions structurally, with different groups of theorists approaching their claims on thought within the discipline as most usefully organized through general systems, adaptive systems, interpersonal relationships or developmental approaches. Each group of theorists represented attempts to devise a conceptual framework that would optimally account for the dynamic complexities that inherently characterize the thinking underlying excellent nursing practice. Later, the theorizing was reconfigured into two paradigmatic camps – simultaneity versus totality. The ideological battles that erupted in relation to these paradigmatic debates prompted a general distancing from formal theorizing within the discipline (Thorne, Reimer Kirkham and Henderson 1999), eventually opening up a space into which nursing philosophizing came to the fore. Distinguishing her approach from what was mainstream theorizing in the discipline at the time, Carper (1978) shifted the conversation into considerations of what she called Fundamental Patterns of Knowing in the discipline. Although this typology clearly acknowledged empiricism as a source of nursing knowledge, it added ethical, aesthetic and personal knowing to the lexicon. Later, expansions along this direction featured sociopolitical knowing (White 1995) and emancipatory knowing (Chinn and Kramer 2008), acknowledging the unique character of knowledge as it evolved iteratively within a situated practice disciplinary context. Although it took some time for nurses to confidently claim philosophizing as what they were doing (Kikuchi and Simmons 1992; Salsberry 1994; Edwards 1997), by the start of the new millennium the journal Nursing Philosophy (Wiley-Blackwell) had been launched, and a proliferation of explicitly philosophical writings began to appear. Many of the exciting new conceptualizations of importance to how nurses think about what they are doing, and what their discipline’s unique contribution is to the wider global health context, have emerged from the increasingly sophisticated body of philosophical thinking within the discipline. In parallel to these theoretical transitions, understandings of the empirical science underlying professional practice progressed through a variety of phases over time. The earliest authors in the tradition of nursing science were constrained by the idea that a proper science involved a series of logical propositions arising from the discipline that could be rigorously tested and proven true or false (Fry 1995). Although his work was not widely read or taken up until a decade or two later, Kuhn entered the fray in 1962 with an alternative framing of scientific advancement that discounted the orderly progression of knowledge that had been assumed within the logical positivist tradition. His notion of paradigmatic revolutions paved the way for new scientific approaches that for some decades divided the scientific nursing world into presumably incommensurate research communities, with quantitative researchers continuing to develop and strengthen instrumentation and measurement in relation to the concepts associated with human health and nursing practice, and qualitative researchers borrowing on the methodological conventions of the social sciences to generate inductively derived conceptualizations of the phenomena of concern to nursing. As nursing scholarship evolved through the methodological advancements within these competing traditions, it did so in the broader context of new tensions in health and health-care policy. In particular, the evidence-based practice movement (Sackett et al. 1996) privileged certain kinds of truth claims over others, causing considerable terminological slippage and conceptual confusion within the discipline (Tarlier 2005). Within this context, new conversations began to emerge in relation to methodological approaches that might bring together elements of the qualitative and quantitative options in new configurations, including triangulated and mixed-method studies and blended programmatic research (Sandelowski 2000), methods deriving from emerging philosophical developments such as critical realism (Nairn 2012; Parlour and McCormack 2012), and methods that explicitly oriented methodology towards the evidence-oriented domain of applied practice (Thorne 2011). Thus, nursing science has evolved in the direction of exploiting the epistemological middle ground between the theoretically dichotomous polarities of realism and idealism, turning method towards an increasingly refined understanding of the deep nature of the disciplinary challenges for which knowledge is needed. As this interchange between philosophizing and scientific discovery moves forward, it is increasingly apparent that the question can actually determine the method rather than the other way around. As an outcome of the advancement of nursing knowledge across both traditions, concepts have been a favoured building block. The conceptual terminology we invoke conveys new and emerging meanings in relation to the fundamental ideas we have always been wrestling with. Some of the modern incarnations of older ideas include such concepts as moral agency to expand upon an earlier notion of nursing ethics and concepts such as holism or, more recently, intersectionality, to refine thinking about what might have been termed systems thinking in an earlier era. Early interpersonal theorizing has evolved into more comprehensive conceptualizations associated with relational practice, and emancipatory knowing has been transformed into an increasingly sophisticated set of ideas about such phenomena as the social determinants of health, health inequities and social justice. Thus, the language and syntax of our discipline’s conceptual progress signal important nuances in our scientific and philosophic understandings and reveals much about the manner in which nurses are working with ideas. In this special issue of Nursing Inquiry, scholars from a wide spectrum of regional and perspectival difference wrestle with ideas that they consider to have shaped and provided definition to the work of their profession and the knowledge enterprise of their discipline. Each invites us into a distinct angle of analysis on the ideas that have had a meaningful impact on who we are, what we do, how we do it and why that matters. Pesut tackles the complex and challenging theme of spirituality, an idea that has attracted so much attention among theorists in the discipline, considering why this concept has had such drawing potential over time. She proposes that, although the discipline has devoted a great deal of effort to trying to define it and work out appropriate professional engagements in light of it, it has been relatively silent on the foundational need that the idea meets for the discipline in terms its relationship to its work within an increasingly uncertain, disenchanted, globalized world. Hutchinson and Jackson examine transformational leadership as a dominant approach to theorizing solutions to the organizational challenges faced by the profession. They suggest that an uncritically held attachment to this idea has shaped a generation of ‘evidence’ and created a misleading body of studies equating it with better health outcomes. In this context, they demonstrate how recycling method has caused us to assume the weight of evidence is in favour of this particular conceptual stance and challenge us to examine this idea more critically. In the domain of qualitative nursing research, Fadyl and Nicholls reflect on overreliance on the Foucauldian interview as a mainstay of recent critical nursing scholarship. They argue that our ‘histories of the present’ fetishize what we take to mean ‘real lives’ in contrast to other forms of truth. On the basis of this argument, they suggest that we participate in the subjectification of the individual through our enactment of research methodologies that rely on interview, and challenge us to consider the advantages of detachment as a way of calling into question the self-evident that gets obscured by engagement with subjectivities. In a contrasting vein, MacDonald, Newburn-Cook, Allen and Reutter reflect on the population health framework for nursing research, explaining why it has become the primary mechanism through which nurses have been able to critically reflect on the complex political and social forces that shape health and health outcomes. Their reflections on this framework bring to our attention the complex mechanisms that allow for conceptual focus upon an intersecting array of social determinants of health on many important levels. Washington and Moxley tackle the popular theoretical concept of self-efficacy. They see it as invoking a powerful conviction within nursing that allows for supporting people, despite acknowledged social determinants of health inequities, in building the tools and capacities through which they can express their strengths and assets in meaningful ways. From their perspective, self-efficacy implies a philosophical stance that integrates social activism with a belief in the power of people – an idea that is especially potent in nursing work with vulnerable populations. O’Rourke and Ceci critically examine the notion of normal aging as an idea that has had widespread uptake and influence within nursing. From their perspective, the healthy aging concept evokes an unrealistic vision of what constitutes typical human experience, constructing a normative sense of how people ought to age. They deconstruct successful aging discourse, revealing ways in which it increasingly excludes normal aging processes and detracts from the realities of what nursing must address in its work with aging populations across a range of contexts. Gagnon, Jacob and Guta focus their reflective lens on treatment adherence. They consider treatment adherence (the phenomenon formerly known as compliance, but renamed in a failed attempt to shift discourse) as a well-intentioned and ubiquitous idea in the chronic illness world that serves to discipline the chronically ill and govern the health of entire populations who suffer from chronic conditions. Polhman, Cibulka, Palmer, Lorenz and SmithBattle further extend critical reflection into the domain of science and healing, deconstructing tensions between the biomedical world of biological science and more subjective domains of human health and healing experience. Using placebo research to unpack the ontological and epistemological foundations of our relationship to evidence in the practice world, they remind us how central nursing’s position has been in integration of these two domains, as evidenced by skilled attunement to the lived body and life world of those we serve. Finally, Bradshaw draws our attention to Gadamer’s notion of two horizons, reminding us that our lens in examining the history of ideas in the present typically ensures that the present horizon dominates, instead of allowing past and present to engage in a mutual dialogue. She takes us back to ideas like cultivating virtues as a path towards becoming good nurses, showing how we dismiss such considerations because the religiosity within which they were historically expressed no longer works in the modern secular world. In her view, history can be both revisionist and interpretive, a bridge between ‘the once and the now’. Because new insights arise when past and present come together in a fusion of horizons, Bradshaw is inviting us into imaginal empathy for the ideas of our collective disciplinary past, so that we may recognize their profound impact. Each of the authors in this special issue has something to tell us about the ideas that have influenced the evolution of nursing knowledge. And while it may be difficult to titrate the precise impact of these ideas on the basis of any known metric, the reasoned arguments presented by these authors serve to shape our understanding of the marvellous part that ideas play as provocateurs for critique and catalysts for action in the intellectual advancements of the discipline. In presenting this fascinating kaleidoscopic exploration into the nature of nursing thought, Nursing Inquiry is justifiably proud of its continuing contribution to critical developments in the ideas that shape the discipline.