Inr. J. Nun. Stud.. Vol. 21. No. 3. pp. Printed in Great Britain.

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002C~1489/90 $3.00 + 0.00 Pergamon Press pli

1990.

Alternatives to natural science foundations for nursing COLIN A. HOLMES, R.M.N.,

R.N.T.,

B.A.(Hons),

M.Phil.

Lecturer in Nursing, Deakin University. Geelong, Victoria 3217, Australia

Abstract-The underlying philosophical assumptions associated with the current vogue for humanistic and holistic approaches to nursing have not been subjected to systematic scrutiny, laying nursing open to the charge of being anti-scientific and even irrational. This paper outlines some of these assumptions and their origins, and proceeds to a brief survey of their impact on nursing theory, education and practice. It concludes with a call for the elucidation and consolidation of nursing practice which reflects phenomenological and humanistic alternatives to the natural science principles which have characterized traditional medical practice. In this connection I have used the term ‘positivism’ to refer to a general orientation according to which the world can only be known through observable entities, and regularities may be demonstrated and general laws verified through their measurement and quantification.

Introduction An increasingly pressing problem in nursing is the apparently contradictory demand for research-based practice, amenable to rigorous evaluative procedures, on one hand, and the adoption of broadly humanistic, person-centred approaches on the other. The former stems from the belief that nursing is comprised of activities which are appropriate objects of the scientific method-a view derived from, and validated by conventional experimental research methods. The associated ‘illness-cure’ paradigm stands in stark contrast to the ‘health-care’ paradigm to which nursing now aspires, and which is characterized by an holistic, growth-oriented perspective emphasizing respect for persons as the foundation for client-provider relationships, a commitment to an explicit philosophy of caring, and an openness to ‘unscientific’ complementary and innovative therapies (Fink, 1976; Pelletier, 1977; Podolsky, 1977; Watson, 1979; Blattner, 1980; Spicker and Gadow, 1980; Brewer, 1988; RankinBox, 1988). In summary, we may say that one approach is mechanistic, analytic and reactive, the other is dialogical, holistic and interactive; one focusses on the 187

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disease process, the other on the human process. It is from a commitment to countering the traditional dominance of the former approach that this paper is written. The sociologist Joan Busfield observes that “Medicine has a mechanistic conception of human functioning . . . as a result, the individual is rarely viewed as a whole person and a humanistic approach is made more difficult” (1986 p. 26). Certainly, nurses are feeling increasingly torn between the two paradigms, and Jean Watson refers to “. . . a junction that can lead us in two different directions. One path is that of traditional medical science with its distinctive epistemology. The other path acknowledges nursing as a human science with another epistemology” (1985 p. 16). The philosophical foundations of the second path are briefly surveyed below, and this is followed by a review of their expression in phenomenological and humanistic alternatives.

Philosophical background

The identification of an alternative to natural science approaches to understanding human behaviour and experience is rooted in the general rejection of positivism by the Neo-Kantian school of social philosophers working in Germany around the turn of the century. Throughout history, philosophers had made similar observations, but it was this group, notably Dilthey, Windelband and Rickert, who, in response to the emergent Comtean positivism of the day, first attempted an extended articulation of alternative social science foundations. Dilthey coined the term ‘Geisteswissenschuften’ to refer to all sciences concerned with the elucidation of historico-social reality, and suggested that psychology provided the basis for such enterprises. This psychology would not be the ‘scientific’, textbook variety formulated in the research laboratory, but rather a commonsense, practical one which seeks to extend our knowledge and understanding of persons in their natural, day-to-day existence. Social interactions, and we can include here what takes place between nurse and patient, are seen not simply as products of relationships between material objects, but rather as products of human consciousness-subjective, emotional, and intellectual. Understanding those interactions can thus only be achieved through an interpretative procedure grounded in what Dilthey described as ‘the imaginative recreation’ of the products of human consciousness. It was this interpretative procedure which was to constitute the method of the new psychology. Windelband also referred to a ‘psychology of daily life’ not amenable to positivist experimental methods. He made the well-known distinction between nomothetic sciences, which sought to establish general laws or theories applicable to a multiplicity of cases, and idiographic disciplines, which sought to understand, as well as explain, individual cases. Although widely discredited as a way of classifying academic disciplines, these still find a place in the literature as signifying two alternative perspectives. Whereas, for example, Midgley (1978) defends an explicitly idiographic view of the social sciences, claiming that the study of human nature is unquestionably an art which does not reduce to any single method or set of laws; Silverstein (1988) attempts a resolution of the two approaches. Certainly, persons and social events, such as nursing, health and illness, would seem to be characteristically amenable to the idiographic approach, and Sarvimaki (1988) has pointed to the difficulty in making predictions and thinking in terms of general laws in nursing practice. “Nursing”, she writes, “consists of interactions between unique individuals with unique experiences, and it always takes place in unique situations” (Sarvimaki, 1988,

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p. 465). In Kim’s (1983) theory of nursing, a distinction between idiographic and nomothetic approaches appears to underlie her reliance on two distinct modes of theoretical analysis, one which is holistic and one which is particularistic. The Neo-Kantians also coined the term ‘Verstehen’ to denote the understanding gained through empathic imagination, as opposed to objective knowledge gained through observation, and this is exactly the kind of understanding nurses are being encouraged to establish as the basis for the nurse-patient relationship. Windelband’s views were refined by Kicker?, and subsequently influenced those of Weber, who analysed ‘Verstehen’ in terms of the inaccessibility of personal meaning to the positivist method. Because the essence of social interaction lies in the individual meanings of agents, all valid social analysis must refer back to these, and Weber sought to reconcile this demand to that of natural science for causal explanation. In doing this, he distinguished several types of ‘Verstehen’, including rational, empathic, direct and explanatory understanding. He introduced the concept of motivational explanation, according to which the subjective meanings of the actor constitute the grounds for particular actions. Such grounds were to be regarded as the causal explanation of the behaviour in question, and demanded empirical testing. Of course, the view that motives may be identified with causes has remained contentious and continues to stimulate debate. The exact nature of ‘Verstehen’ in the Weberian scheme also remains problematic, although subsequent explication by Outhwaite (1974) has undoubtedly clarified the whole matter, and the Weberian position vis-a-vis natural science has received elegant exposition and critique by Keat and Urry (1975). The anti-positivist not only claims that the methods of natural science exclude individual meaning from social phenomena, but also that they exclude human subjective experience. Certainly, ‘scientific’ psychology appears to have had little to say until quite recently about normal, day-to-day existence, yet this is exactly what the efforts of psychologists are supposed to illuminate. When it does encounter or investigate issues in which personal meanings or experience are salient features, such a psychology is forced to resort to operational definitions which impose meanings amenable to measurement and manipulation. An explicit attempt to operationalize complex health and illness-related experiences forms a major methodological component of Kim’s theory of nursing, and must attract the same criticisms as far as this is concerned. Giorgi (1970) has suggested that in view of these shortcomings, traditional psychology has allowed its content to be dictated by its method, that the most distinctive feature of human psychological existence, namely experience, has been systematically eliminated, and that this has precluded any meaningful investigation of its true subject matter. In fact, many philosophers, notably P. F. Strawson (1974), have argued that conventional psychological explanations (‘P-explanations’) are inappropriate for most human behaviour, serving primarily as tools for change rather than for understanding (summary in Schliefer, 1973). Whilst Liam Hudson has argued strongly against nomothetic approaches in psychology, Strawson goes much further, claiming that the objective attitude of science toward people is directly opposed to one of personal understanding and involvement. Certainly, when science adheres rigidly to positivist principles it is forced to adopt methods of investigation in which phenomena are influenced or controlled, and this has led some to claim that all experimental research in human psychology is, therefore, in principle, unethical (Cola&i, 1978, for example). Indeed, the objective attitude does seem to preclude the full recognition of the other as a person (a claim carefully examined in Ch. 3 of Berenson, 1981), although this is vigorously denied by most behavioural psychologists (for example, in the symposium Wandersman et al., 1976).

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The positivist approach to psychology has not had it all its own way, however, and personal experiences of self and others, as well as the role of personal beliefs and meanings in the interpretation of the world and its phenomena, are increasingly important topics of research and debate. This parallels the earlier, and much more profound, effects of critiques of positivism on the development of interpretative sociologies which focussed on individual meanings and their relation to social contexts. Witness to this is the rise of cognitive psychology which, through dissonance theory and attribution theory, has focussed attention on the causal significance of individual beliefs and their role in the interpretation of human actions. Social psychology has also begun to head down a similar path, investigating the everyday experience of living from an interpersonal, rather than intrapersonal, viewpoint. Some leading psychologists, such as Rom HarrC, have sustained an overtly antipositivist theoretical and research stance over many years, and are undoubtedly key figures in the reshaping of psychological thinking (Brenner, 1980; von Cranach and HarrC, 1982; Harrt, 1979; 1983). The post-positivist thrust in social theory has burgeoned under the influence of the Frankfurt School of ‘critical theory’, notably at the hands of Habermas and Gadamer (Geuss, 1981; Bottomore, 1987; Outhwaite, 1987; Pusey 1987), and in response to the phenomenological sociologies developed by Schutz and the ethnomethodologists spearheaded by Garfinkel. Giddens (1979, 1982) presents a clear account of a social theory offered as an alternative to the two polarities of objective, positivist functionalism and subjective, critical hermeneutics, presented in this paper. The phenomenological influence The development of phenomenological approaches to the understanding of human events has origins in the ‘intentional object’ psychology of Franz Brentano, whose ideas influenced his pupil, Edmund Husserl-generally considered the founder of the phenomenological movement. Husserl’s philosophy, in turn, strongly influenced the existentialism propounded by his academic assistant, Martin Heidegger. Phenomenology developed in response to the inadequacies of the scientific method when brought to bear upon human experience. Husserl sought a means of directly exploring consciousness, and introduced the method of ‘epoche’ by which judgements about reality are held in suspension, or ‘placed in brackets’-allowing us to apprehend the true ‘essences’, or phenomena, of human existence. This is reminiscent of the method of systematic doubt adopted by Descartes, and it is significant that an important series of lectures delivered by Husserl at the University of London in 1922 was entitled ‘Cartesian Meditations’. The epoche is conspicuously missing from Heidegger’s analysis despite Husserl’s direct influence. Husserlian phenomenology provided the philosophical basis for the theory of social action developed by Alfred Schutz, widely acknowledged as the founder of phenomenological sociology. For Schutz, the epoche included the suspension of commonsense notions of the world, which he took as occluding the clear apprehension of the precariously held shared meanings which actually constitute social reality. He does not wish to resurrect the methods of the introspectionists but is concerned with intersubjective understanding in its experiential form. His ideas were utilized by Berger and Luckmann (1966) in their influential account of the sociology of knowledge, and were developed by the ethnomethodologists headed by Harold Garfinkel, whom Bilton et al. (1981, p. 741) refer to as “Schutz’s shock-troops” whose “general aim is to demonstrate the truth of his phenomenological arguments by practical experiments”. These experiments involve careful examination of the ways language is used to convey meaning, and the social scientist is viewed as unavoidably participating

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in any situation he/she seeks to understand or explain. Garfinkel sees the task of social scientists as peculiarly revelatory in the sense of “revealing the general nature of social processes, not helping actors to change the form of any particular society (op. cit. 742), and like all phenomenological sociologists, regards efforts to objectify the phenomena under consideration as futile and a manifestation of the natural scientist’s determination to dehumanize both him/herself and the subjects of his/her research. The impact of Karl Jasper’s phenomenological pychopathology on the philosophical framework of modern psychiatry has been examined by Walker (1988), and his broadening of Weber’s concept of ideal types into any cogent heuristic concept which tries to “grasp a totality”, is regarded as providing a basis for a psychiatric nosology which allows for valid comparisons without sacrificing the primacy of the individual patient’s experience. (This appears to correspond well with the ‘polythetic’ approach to diagnosis reflected in DSMIII, and discussed by Schwartz and Wiggins, 1987). The existential-phenomenoIogica1 epistemology denies the applicability of causality as it has traditionally been characterized in the natural sciences, and the experimental method insofar as this is based on causeeffect relationships. The structure of human experience replaces such relationships as the major content of psychological analysis, and “only that which is revealed or disclosed as pure phenomena is worthy of attention” (Valle and King, 1978, p. 15). This principle of acausality highlights again the view that persons are not discrete entities in the manner of objects of natural science, but rather, they act upon, and are acted upon by, their environment in ways which change their character, they are able to make themselves both subject and object of their own awareness, and in the context of social research Giddens has referred to the interactive consequences of this as “the double hermeneutic” (1982). The most explicit adoption of the acausality principle, and of the phenomenological epoche, is found in the work of the gestalt movement pioneered by Fritz Perls. Here the primary data is that of the here-and-now experiences of the self, and the causal model of human functioning is completely abandoned. The methodological implications render this quite unlike psychoanalysis, to which many adherents of critical social theory are wedded, in that it drastically reduces the importance of verbalization, preferring the exploration of subjective feelings through what gestaltists call ‘dramatization’. In contrast to the Rogerian method, which is primarily concerned with dyadic therapeutic situations, gestalt therapy is essentially a group activity.

The human influence The humanistic movement has derived much of its theoretical support from the phenomenological and existential views outlined above, serving as a counterweight to the prevailing positivist psychologies, in particular the various forms of neo-behaviourism. Interest focusses on the day-to-day experiences neglected by most traditional investigators, and the artificial experimental situation, in which the individual is decontextualized and perceived as a more-or-less responsive organism, is unequivocally despised. In short, they are strongly anti-positivist and view most ‘scientific psychology’ as trivial, irrelevant and dehumanizing. In his well-known introductory text, Schaffer sums up the characteristic features of humanistic psychology as follows: (a) it is strongly phenomenological or experiential and its starting point is conscious experience; (b) it insists on man’s essential wholeness and integrity; (c) whilst acknowledging that there are clear-cut limits inherent in human existence, it insists that human beings retain an essential freedom and autonomy;

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(d) it is anti-reductionistic; (e) it believes, with the existentialists, that human nature can never be fully defined (Schaffer 1978, pp. 10-18). The philosophical roots are seen by Schaffer to be the phenomenology of Husserl and the existentialism of Heidegger and Sartre. Exactly how these have shaped humanistic psychology is nicely illustrated by the list of human ‘meta-needs’, and corresponding ‘metapathologies’, conceived by Maslow (1971, pp. 3 18-3 19) as underpinning his concept of self-actualization, so dear to nurse educators and practitioners alike. Also writing under the clear influence of phenomenological-existential ideas, Carl Rogers formulated the student-centred approach to learning and has had a profound effect on nurse education. This parallels his client-centred therapy, which has largely shaped nursing’s approach to counselling, stressing the importance of subjective experience and the proactivity, rather than reactivity, of human behaviour.

The impact of antipositivism on nursing Nursing theory. Though not a complete theory, and ill-served by those commentators (the majority) unable to break free of their out-moded positivism, Travelbee’s (1966) approach was, at the time, a radical and far-sighted attempt to humanize both nurse and patient. It focussed attention on ‘therapeutic uses of the self’, a phrase now familiar to nurses, in the context of an holistic view of the person, and many of her ideas have, twenty years on, become commonplaces. Her dream of humanistic nursing is now substantially more of a reality. The theory developed by Jean Watson (1979, 1985) also champions a view of the person as a unity, and seeks to integrate insights drawn from the whole gamut of humanistic enquiry. Central to her theory is an elaboration of the notion of a ‘human science’, described by Amadeo Giorgi and his colleagues at Duquesne University in Pittsburgh. The main features of this human science are summarized as follows: - a philosophy of human freedom, choice and responsibility; - a biology and psychology of holism; - an epistemology that allows not only for empirics, but for advancement of aesthetics, ethical values, intuition, and process discovery; - an ontology of time and space; - a context of interhuman events, processes and relationships; - a scientific world view that is open (1985, p. 16). Watson conceives this explicitly phenomenological approach as operating alongside the materialist positivism of traditional medicine. She views the ‘human science’ of nursing, and the ‘natural science’ of medicine, not as mutually exclusive but rather as “two different ends of a continuum” (Watson, 1985, p. 21). Watson has successfully utilized the phenomenological methods developed by Giorgi (1975), Alexanderson (1981) and Marton (1981), which provide a number of methods, or ‘protocols’, for phenomenological reduction. Taking Merleau-Ponty’s (1962) account of perception as a starting-point, she substantiates case for reflection upon the essences revealed by these techniques, through an appeal to the methods of transcendental phenomenology. These centre on the experiential significance of language (Heidegger, 1971; 1975), and its poetic expression (Levin 1983). This reflects the importance given to language in hermeneutic social theory and the phenomenological sociologies, especially the ethnomethodologist’s analyses of discourse (Cicourel’s work on conversation analysis, for example; see Silverman, 1986, for a review). Unfortunately, Watson adumbrates only one case, which concerns

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experiences of grief and loss among Aboriginal people in Western Australia, and it requires a considerable leap of imagination to transpose the technique into other settings, particularly complex, urbanized ones. Nevertheless, it must be regarded as a courageous attempt to explore the phenomenological epoche as a practical tool for health care purposes, and is a powerful stimulus to innovation. Paterson and Zderad (1976) have also utilized the existential-phenomenological approach in their ‘humanistic’ theory of nursing. They identify experience as the primary initial data for theorization, and characterize nursing in terms of intersubjective transactions. Similarly, Parse (1981) has attempted to construct an existentialist theory of nursing which embodies many of the ideas articulated by post-positivist social theories. She refers, for example, to meaning as being “multidimensionally structured” and to language “cocreating reality”. She develops concepts such as becoming, imaging, situated freedom, and man-environment relatedness which have obvious antecedents in the work of Heideggerian existentialism. Unfortunately, her efforts have not had the impact on nursing that might have been hoped. Their accessibility is undermined by an obscure style, a penchant for the utterly novel use of familiar words, and a large crop of ill-explained neologisms. These problems are exacerbated if the reader is not familiar with the esoteric language and idiosyncratic conceptual tools of existential phenomenologists and American nursing theorists. Sarvimaki (1988) outlines a theory of nursing as ‘communicative action’, utilizing Habermas’ (1984) typology of action, in which he differentiates communicative from strategic and instrumental action. ‘What distinguishes this form of interaction (communicative) from the strategic form is that none of the actors has any fixed or preconceived ideas about how the other should react . . . (it) is not oriented towards success but towards reaching understanding” which, furthermore, presupposes a “special kind of attitude-the communicative attitude” (Habermas, 1984; cited in Sarvimaki, 1988, p. 464). This manifests, she says, in “striving for mutual understanding, coordination and coaction, rather than striving for control (Sarvimaki, 1988). The nursing act is unambiguously founded on the communicative attitude and is seen as helping the client to exercise control over his/her own health situation. The wishes, goals, needs and resources of the client are taken as the starting-point for all nursing activity. Changes in health status are conceived as resulting from the client’s own activity, and from his/her experiences in the interaction with caregivers (Sarvimaki, 1988, p. 465), which principle underlies Sarvimaki’s observation, alluded to above, that the formulation of general laws for nursing practice, and the prediction of outcomes, is especially difficult, since each client is a unique individual in a unique interaction with a unique nurse in a unique situation. Sarvimaki enticingly refers to a more detailed exposition of her some aspects of her theory (Sarvimaki, 1986), but this is not available in English at the present time. Sarvimaki’s work represents a unique attempt to incorporate alternative, post-positivist conceptions of the philosophy of social action into a theory of nursing. Nurses must go on to assess the developments in hermeneutics and critical social theory as they bear on the dichotomies which underlie the juxtaposition of scientistic positivist medical accounts of nursing with phenomenological and post-positivist ones. How successful are the attempts to bring the traditionally opposed camps together into a genuinely ‘post-positivist’ rapprochemenr? Can the apparently incompatible epistemologies be reconciled? Are they alternative ways of viewing the same phenomena, or are they each directed toward their own distinct phenomena? Certainly, interpretative theorists have argued that it is the objects of social enquiry which are in dispute, and we may ask what are the appropriate phenomena

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for nursing. Do the alternative methodologies represent different ways of achieving the same ends, or does each entail its own distinctive purposes? These are some of the questions which nurse theorists must address in the face of the ambiguous demands being placed upon clinicians. Can theorists assist in the consideration of whether the growing demand from controlling authorities for practice that is rational and scientifically defensible is reconcilable with the emergent belief that nursing is a human process in which the methods of measurement and quantification based on natural science epistemologies is inappropriate? The development of ‘Performance Indicators’ purporting to measure the quality of nursing care directly, provides an excellent testing ground for possible answers! Nurse education. The humanistic alternative has recently gained much ground as a basis for the restructuring and planning of nurse education internationally. In the United Kingdom a Rogerian approach to the construction of learning experiences has become widely accepted, but it is tempting to view this as a response to disaffection with previous practices rather than as a result of careful critical analysis of the strengths and weaknesses of humanistic education. There certainly appears to have been little consideration of the underlying philosophical assumptions. The style of nurse education, in the United Kingdom at least, appears to depend rather on which theorists happen to be shouting the loudest from across the Atlantic-witness the rapid moves from Gagne to Bruner to Rogers and now, perhaps more sedately, to Knowles and the androgogues. A useful review of the issues can be found in Jarvis (1980), and a more up-to-date critique focussing on the humanistic and behaviouristic approaches is provided by Tennant (1988). Certainly, the importation of phenomenology through humanistic principles into British nurse education has been fraught with problems. They stress autonomy and choice but it is difficult to reconcile these with the formal requirements imposed on statutory training programmes, characterized as they have been by unreflective ‘banking’ methods (Freire 1972), and traditional didacticism in which control and authority are vested in the tutor. They are also difficult to sustain in the face of the hierarchical system in which clinical experience is gained; all too often, mistakes are seen as totally negative events rather than as opportunities for learning or as indicators of innovation, assertion is mistaken for aggression or awkwardness, and disagreement is regarded as an unhealthy and unwelcome disruption. Furthermore, the inflexibility of some statutory training formats inhibits the creative use of individualized learning strategies, self-directed learning and self-assessment processes. Those which specify particular learning outcomes or objectives for particular learning experiences preclude the development of truly humanistic adult learning, since this stresses the freedom, openness and unpredictability of every learning experience. The temptation to opt for more controlled, and therefore less risky, pedagogical methods, is increased by the demand for the quantification of educational practice-as if this were a direct measure of the quality of the learning experience, and by implication, of their own quality as tutors. When pressed, however, I think most tutors would agree that their role is founded on their relationship with ‘the learner’, and recognize that its educative and facilitative qualities are not directly amenable to the investigative methods of positivist science which such measures embody. Burnard (1986) touches briefly on the debate as it concerns the assessment of nurse performance, and calls for a “middle path” which balances what he sees as the extremes of behaviourism and humanism. He cautions us not to “get lost in a forest of esoteric language” on one hand, nor be “forced into the dust bowl of behaviourism on the other”

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(Burnard, 1986, pp. 217-218). He insists that the two are viewing the same phenomena from different perspectives, although he does not substantiate the claim, and suggests that we need a synthesis of their respective insights (also Burnard, 1984). If, indeed, they are viewing the same phenomena from different theoretical standpoints, it is difficult to see how such a synthesis is possible without compromises over fundamental tenets of one or other theory. If we had grounds for claiming that the various approaches were actually viewing different phenomena Burnard’s claim might appear more plausible. This is where recourse to the critical social theorists and post-positivists, such as Gadamer and Habermas, and to recent philosophies of science (such as the realist theories of Roy Bhaskar, and Mary Hesse) would have provided a stimulus to more rigorous thinking. Nursing practice. Whilst the focus of this paper is nursing as a whole, it is undoubtedly in psychiatry, where alternatives to the disease-cure paradigm have proliferated and medical expertise and authority have long been contested, that dissatisfaction with the philosophy and methodology of natural science has been most explicit. It is also the arena in which the question as to whether the therapeutic components of the nurse-patient relationship are amenable to such a methodology has been most salient. Phenomenologists have argued that human behaviour demands a research approach which, unlike that of natural science, seeks to understand phenomena rather than control or dominate them, and this highlights a major problem for humanistic alternatives in psychiatric nursing. How can their philosophy of human freedom and choice be given expression in the face of psychiatry’s acknowledged, and covert, social control functions, and the ideological/cultural ethos which characterizes the bureaucracies which discharge those functions? Extending this argument to nursing generally, how can humanistic principles be reconciled to the demands of a large organization, such as a health authority, hospital or community service, in which individual needs and individualized approaches must often be subordinated to the perceived need for the smooth, efficient, systematic and regulated functioning of the organization? In psychiatry, the concept of the therapeutic community involves handing over decision-making to all participants, but only very rarely-in experimental ‘antipsychiatric’ settings for example, has control been fully relinquished by health care staff. In non-psychiatric contexts, the task of handing control back to clients has been vitalized by the care of people with HIV-related illness, but there is a real danger that it may provide, via a ‘self-care’ model of nursing, an excuse for neglect under the pressures created by inadequate resourcing. The positivist philosophy of traditional medicine is increasingly under threat, and in psychiatry this is reflected in an ever expanding repertoire of innovative therapies (Herink, 1980; Dryden, 1984; Aveline and Dryden, 1988) and, in tandem with the work of figures such as Perls, Laing, Rogers and Frankl, the germination of a truly phenomenological approach in which the client and his experience of himself and his world become the focus of therapeutic concern (Spiegelberg, 1972, gives a detailed historical survey of these developments, and Ebmeier, 1987 provides an interesting example of hermeneutics applied to psychiatry together with a brief discussion of the impact of Bhaskar and Habermas). Nursing practice is being directly influenced by these changes, and not just in psychiatry: every section of the health care disciplines is calling out for humanistic counselling skills and I detect a long-overdue desire to help clients clarify and meet their spiritual needs (often framed in terms of Frankl’s ‘will to meaning’), and to dismantle the dehumanizing aspects of in-patient care systems. Witness, too, the increasingly common inclusion of existentialphenomenological sections in nursing textbooks, and their rejection of traditional, natura1 science nosologies founded upon the classificatory systems of biological sciences in favour

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of person-centred conceptual schemes which focus attention unequivocally on the client’s experience of illness and health (cf. the development of nursing diagnoses). A challenge to nursing Nursing must not allow itself to be shaped by the interests of other disciplines, by political opportunism, the vagaries of public or media opinion, or by the passing intellectual hobbyhorses it happens to meet along the way. It must establish and pursue its own distinctive methodology in the light of developments in social theory and the philosophy of science, and it must be fiercely proactive in substantiating its chosen path. It is four years since Jean Watson challenged nursing to choose between an exclusively positivist, natural science approach which would keep it in the thrall of medicine, and a genuinely holistic, personcentred approach which could form the basis for real professional autonomy. How far have we risen to the challenge? In the United Kingdom, the reform of nurse education points the profession down the second path, and in the clinical context the Oxford Nursing Development Unit (Pearson 1988) represents one very exciting step along the path, although ‘primary nursing’ is also widely established elsewhere, especially in North America (Macdonald 1988). The opposition from medical authorities to both British enterprises, including the temporary closure of the Oxford unit, serve to remind the profession that it will not be an easy path to follow; if we are committed to a view of nursing as a human process predicated on mutual understanding and respect for individuals, however, we cannot turn back. I believe that if nursing is to successfully adopt humanistic philosophies of care and education (see Carr and Kemmis, 1986, and Grundy, 1987, for applying critical social theory in education) it will need to ‘come clean’, not only on the implicit philosophies which inform it, but also on the political, ethical and other values which have hitherto influenced its development under cover of an unhealthy, incestuous silence. The process of identifying, acknowledging, clarifying, owning and acting upon such values is surely the major challenge facing nursing today. Some progress has already been made (A.N.A., 1980; Silva, 1983; R.C.N., 1987). The Royal College of Nursing’s booklet ‘Position Statement on Nursing’ (R.C.N., 1987) identifies three core principles-equity, respect for persons, and caring, on which a “better, more excellent” system of nursing could be founded, and its explicit commitment to quality challenges nurses to face the problem of evaluating nursing care in meaningful ways. We need to explore how this can be done, given a conception of nursing as a human process and social event. Indeed, in order to construct quality assurance programmes this process of values-clarification must already be established and should enable us to deal with the ethical issues raised by ‘measurement tools’ such as quality-of-life measures, performance indicators and those claiming to measure the quality of nursing care. Nurses should be equipping themselves with the critical acumen required to successfully challenge management decisions, based on such measures, which carry a risk of jeopardizing the extent or quality of services provided. This will demand familiarity with the critiques of positivism alluded to above, and an ability to articulate alternative or post-critical methodologies. Finally, it has to be noted that the adoption of humanistic alternatives to positivism depend on the development of openness and commitment on the full range of human values, and will undoubtedly be assisted by the gradual emergence of nurses from a state of political naivety. Paulo Freire (1972) has spelt out with great force and clarity the indivisible relationship between critical social theory, social praxis and political commitment, and his words have increasing meaning for nurses as they become more aware of their role as silent

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