Original article
doi: 10.1111/nup.12028
Contemporary nursing wisdom in the UK and ethical knowing: difficulties in conceptualising the ethics of nursing Roger Newham* DMedEth RN, Joan Curzio† PhD RN, Graham Carr† MSc RNT RN and Louise Terry† PhD LLB (Hons) FIBMS *Faculty of Society and Health, Buckinghamshire New University, Uxbridge, and †Faculty of Health and Social Care, London South Bank University, London, UK
Abstract
This paper’s philosophical ideas are developed from a General Nursing Council for England and Wales Trust-funded study to explore nursing knowledge and wisdom and ways in which these can be translated into clinical practice and fostered in junior nurses. Participants using Carper’s (1978) ways of knowing as a framework experienced difficulty conceptualizing a link between the empirics and ethics of nursing. The philosophical problem is how to understand praxis as a moral entity with intrinsic value when so much of value seems to be technical and extrinsic depending on desired ends. Using the Aristotelian terms poesis and praxis can articulate the concerns that the participants as well as Carper (1978) and Dreyfus (in Flyvbjerg, 1991) among others share that certain actions or ways of knowing important for nursing are being devalued and deformed by the importance placed on quantitative data and measurable outcomes.The sense of praxis is a moralized one and most of what nurses do is plausibly on any account of normative ethics a morally good thing; the articulation of the idea of praxis can go some way in showing how it is a part of the discipline of nursing. Nursing’s acts as poesis can be a part of how practitioners come to have praxis as phronesis or practical wisdom. So to be a wise nurse, one needs be a wise person. Keywords: praxis, epistemology, nursing.
The relationship between nursing and praxis Correspondence: Dr Roger Alan Newham, Senior Lecturer, Faculty of Society and Health, Buckinghamshire New University, 106 Oxford Road, Uxbridge, Middx UB8 1NA, UK. Tel.: +44 (0) 149 452 2141 ext 4431; fax: + 44 (0) 149 460 3179; e-mail: [email protected]
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This paper’s philosophical ideas developed from a General Nursing Council for England and Wales Trust-funded study (the study) to explore nursing knowledge and wisdom and ways in which these can be translated into clinical practice and fostered in
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 50–56
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junior nurses (Curzio et al., 2012). Participants, who were nurses with at least five years clinical experience, used Carper’s (1978) ways of knowing as a framework for discussion. They experienced difficulty conceptualizing a link between the empirics and ethics of nursing. The philosophical problem seems to be how to understand praxis as a moral entity with intrinsic value when so much of value is technical and extrinsic depending on desired ends. With obvious debt to Oded Balaban, using the Aristotelian terms poesis and praxis can articulate the concerns that the participants as well as Carper (1978) and Dreyfus (in Flyvbjerg, 1991) among others share that certain actions or ways of knowing important for nursing are being devalued and deformed by the importance placed on quantitative data and measurable outcomes. The sense of praxis is a moralised one; most of what nurses do is plausibly on any account of normative ethics a morally good thing and the articulation of the idea of praxis and how it can be taught and learnt can assist in showing how it is a part of the discipline of nursing. Nursing’s acts as poesis can be a part of how practitioners come to have praxis as phronesis or practical wisdom (Benner, 2000). So to be a wise nurse, one needs be a wise person. Poesis and praxis are both distinguished by Aristotle from theoria as sophia by being practical human activity. Nursing is claimed to be a practice discipline; it uses theory for a purpose. To anticipate the rest of the paper, the very claim of using theory for a purpose, though generally understood and useful for technical skills (albeit not without problems), becomes problematic in recent (and some Ancient) moral philosophy. The data from the study suggest that the experienced nurse participants (though they do not use these terms explicitly) think that nursing is a skilled technè as poesis as well as a moral praxis. They frequently commented that to be a ‘competent’ nurse they need to have certain practical skills but to be a ‘good’ nurse more was necessary. The implicit claim seemed to be that what was needed to bridge the gap was ethics, hence the idea postulated in this paper is that nurses in the study interpreted nursing as both poesis and praxis. But the two concepts poesis and praxis are distinct (Balaban, 1989). The former is means end technical reasoning where the end is
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 50–56
known and given, for example, poesis has to do with making, taking the means of achieving a given end such as replacing an empty bag of intravenous fluid or inserting an intravenous line; praxis has to do, with the way the activity is carried out, the means is, in a sense, the end. In other words, in praxis the ends and means are identical and thus are related to phronesis and ethics and/as politics (Balaban, 1989). Praxis as a moral concern has no end, or rather the activity is what matters (Balaban, 1989). On this account of ethics, good action is the end. . . . action and making are different kinds of thing, since making aims at an end distinct from the act of making, whereas in doing, the end cannot be other than the act itself. Doing well is itself the end.
(Aristotle, 1999, Nicomachean
Ethics 1140 b 1–5)
These two distinct concepts, poesis and praxis, can provide an account of the participants’ verbal responses in the discussion as to what nurses know and the underlying problem with such articulation. They struggled to express in what sense the moral aspect of nursing could be distinct from the technical. It is plausible to suggest that they wanted the moral aspect to be distinct from the technical in order to say how it was a morality of nursing (a morality distinctive of nursing) or at least a morality in nursing (morality applied to nursing). As a minimum, they wanted to be able to articulate just how nursing knowledge was related to ethics; that nursing was something more than just being able to carry out evidence-based technical tasks effectively using empirical knowledge and measurable outcomes. In moral philosophy a similar problem of articulation or explanation of what this moral sense of praxis as intrinsic value actually is, has been acknowledged (Zimmerman, 2001; Crisp, 2006). Plausibly then it is little wonder that nurses in the study also struggled to explain in what sense nursing knowledge was more than and distinct from technical knowledge. A key theme from the study was that nursing knowledge has been reduced to Carper’s (1978) empirical knowing by the focus on quantitative data and measurable outcomes which can be made a goal to achieve and also done within a certain time frame.
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Efficiency can then be judged (by some) according to how quickly one can achieve the goal and at what cost. I’m getting more frustrated because the job I was trained to do has been limited by external forces . . . everything seems finance driven now.
It is important however not to assume that the solution is to be inefficient. Rather, the concern is that nursing knowledge is being reduced to the empirical, because it can be measured and easily articulated; but this comes at the expense of ethical aspects. But it is difficult to articulate and explain exactly what this ethical aspect amounts to (Crisp, 2006). Most of the responses in the study recognize explicitly the need for nurses to have good clinical skills; that is, to have a given end such as the need for a peripheral intravenous cannula and to take the means to insert one. Perhaps there is a much more general end for nursing, e.g. health. Aristotle, contrary to some authors’ interpretations (Pellegrino & Thomasma, 1981, 1988), claimed that medicine was a poeitic activity having an end other than its activity; in this case, health and the nursing literature also claim that nursing has an end (McCabe, 2007). More recently, this has been contested (Newham, 2012). However, as an end it can be distinct from the means and persons carrying out the means. Frequently the participants in the study recognized the limitations of poesis for what they think nursing is or should be, claiming that anybody could (at least in theory) do the task or skill with practice and technical education there being nothing distinctive of nursing. This is reflected in actual healthcare practice in the UK and many other countries in that people with a different role such as phlebotomists, healthcare assistants, and doctors can and do often perform skills which nurses perform. We cannot think of any form of poesis that is exclusive or even distinctive to nursing. Rather, it seems to be, as one of the researchers of the project stated in one of the interviews, ‘nurses do what nurses do’ – a sort of practice positivism whereby whatever nurses are currently doing just is nursing (Applbaum, 1999). In trying to articulate what it is that allows the prefix ‘nurse’ or ‘nursing’ to poesis to make it ‘nursing knowledge’, the participants began to articulate that it
must be the way poesis is done as not just focusing on the one task in hand such as peripheral intravenous cannulation but observing the ‘whole’ patient for signs and symptoms of other needs while one is there to perform the cannulation and to be able to prioritize which ends or goals are the most important. So, for instance, one may be there initially with the aim of achieving the goal or end of inserting a cannula but realize that the patient’s catheter bag is full of urine and needs to be measured and emptied, or that it was now 10 am and the morning medications need to be given to the patient. Although some awareness of the situation is necessary, the focus is on the observing of a set of goals that need be achieved. This is really just an extension of poesis as a singular task to multiple tasks and fails to account for much perhaps most of the participants’ responses about what nurses know; though, sadly, many responses suggested that junior nurses often could not manage to, or struggled to, have this ability of seeing the whole patient’s physical needs at that particular time. So, although there remains the problem as to just what makes poesis distinctly nursing, the fact that most of the participants’ responses were focused not just on clinical skills but on the actual doing of nursing or the way nursing was done which is also in the nursing literature (Whelton, 2002; Manley et al., 2005), makes room for an entry into the idea of praxis. This idea of the doing of nursing and the way it is carried out is a focus of the revival of neo-Aristotelian virtue ethics (Hursthouse, 1999) and its application to nursing (Armstrong, 2010; Sellman, 2011), as well as a focus on a distinct way of understanding ethics (McDowell, 1998; Wiggins, 2006) that blurs boundaries between moral and so-called non-moral ways of being and doing. One of the main points of this paper is that it is very difficult to ascertain in what sense the general idea of the ‘way’ a nurse acts or behaves is meant to be understood in order to distinguish between ways of acting as praxis and ways of acting as poesis. Three examples can show how making the distinction within nursing is actually quite difficult because of the very nature of the work. These will support the idea to be given later that nursing’s poesis is a type of practice positivism in the sense that there is no distinct boundary to its knowledge as a discipline
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but it is applied in an ethical way, thus helping to develop individual’s praxis. The first example is doing a technical skill; the second incorporates moral or at least value-laden concepts; and the last shows how an imposed action perhaps meant to ‘evidence’ praxis can turn it into poesis. Taking a patient’s temperature is an essential skill to be mastered by all nurses. There is a correct way to do this that is evidenced based on measurable data. So one could take the temperature without any thought about the patient himself; an accurate result can be measured and recorded and the poesis completed. A complication for the relationship between nursing and praxis is that no one doing this task ought to do it in just this manner or way. This is not because one is a nurse but the fact that one is dealing directly with another human being. But focusing on the nurse, this example can show a distinction between poesis and praxis in that it may be (ought to be) felt that just doing the poetic activity of temperature taking by itself is not sufficient to being a good nurse. The second example concerns deception. For instance, deception may be taken to be a good thing in art (Balaban, 1989) or in nursing as poesis but, as praxis, not so. This example is arguably more difficult to separate into poesis and praxis because it is value laden at the outset. So it is much contested as to whether deceiving a patient in order to either allow one to finish work on time or even to get a patient to take his/her medication is simply poesis because deception by its nature could be claimed to be directly a moral issue. This would apply to anyone able to do these things, but the point would be that deceiving with an end in view makes it poesis because there is a goal and, once achieved, it ends and could be done in principle by anyone, without it mattering who was doing the deceiving. But, as praxis, this separation in time and the irrelevancy of the agent cannot be the case (see below for an expansion of this point about praxis). The third example follows from the frequent participant’s responses in the study of the importance of interacting with the patient. It is sometimes not clear from the comments what the interaction amounted to, whether it was in order to achieve an end or goal poesis or if it were interacting without a specific end
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 50–56
or where the way of interaction mattered and did so in itself praxis. Intentional rounding as routinely entering a bay of patients to ask them how they are may seem to be a way to ‘evidence’ nursing praxis but it in fact turns it into poesis. There is a given end, to enter patients’ bays and ask them how they were and as long as someone did so it did not matter who. However, there is also the non-end-related idea that interacting with patients is good as non-goal or endorientated but simply in itself, so there can be a contradiction in the same activity between poesis and praxis (Balaban, 1993). Hence, there can be difficulty in articulating with any sort of explanation just what makes it praxis but, as praxis, there is nothing that makes it nursing praxis. Rather, it is better understood as skills nurses carry out that are applied in an ethical way. Here, then, is where the trouble lies for both participants in the Nursing Wisdom Project and in moral philosophy more generally with articulating and explaining how knowledge is more than technical knowledge or poesis. What is it to be praxis? And there is a further related problem of scope both for the Nursing Wisdom Project and for moral philosophy of saying how such knowledge remains nursing knowledge for the former and ethical knowledge for the latter? If praxis is to be understood as for the sake of an end, which is poesis, praxis is open to being ‘rationalised’ as action for the sake of X and taken over by technology. H. Dreyfus (in Flyvbjerg, 1991) comments on this replacement of aspects of marginalized practices such as nursing by rationalized technological accounts especially efficiency as an outcome for poesis. The non-rationalized aspects of marginalized practices then get devalued which arguably explains Carper’s (1978) attempt to bring back other ‘ways of knowing’ that are non-propositional and almost inarticulate as important and important to nursing. So one distinction might be to claim that poesis remains propositional knowledge and can easily be articulated. This idea was raised by one of the researchers in the project who was not a nurse in response to one participant’s struggle to express what was missing from a student nurse’s knowledge when compared with a good nurse/expert nurse, that the student nurse is limited to propositional knowledge whereas the
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good or expert nurse is not. But praxis as a moral notion done for itself praxis as phronesis, need neither be completely non-rationalized or completely inarticulate; in fact, Aristotle says that phronesis is linked with reason and can be learnt from example and by doing.
Poesis, praxis, and phronesis: implications for teaching what nurses know Phronesis is an intellectual virtue related to praxis; it uses reason and can be taught but, and this is crucial, the agent is a necessary part unlike action as poesis which can also be taught but the person as an individual nurse working towards the given end is separable from any other person or role as long as the end is achieved. Poesis needs an end, and successful or ‘good’ action is achieving the specified end. Two problems arise. One is that in relation to the study we need to know what nursing is in order to know its subject matter and thus its general end; this is in order to know how the specific ends relate to the general end, hence the need for an examination of nursing ontology before its epistemology. Unfortunately, Carper’s epistemological focus fails to do this. Knowing the end of nursing is extremely problematic, even if one thinks there is some focal (in Aristotle’s sense of focal) account of nursing’s end based on the human body and illness and disease. Nursing seems torn between knowledge of the body as organism and knowledge of the body as whole living human being with a place in society/culture in order to distinguish itself from medicine and other healthcare roles. The other problem is that there seems to be no distinction between novice and competent or even proficient nurse. Some of the data collected spoke of expert nurses’ frustration with qualified junior nurses and student nurses’ inability to move beyond being told what to do, Benner’s (1984) novice stage. But even the competent stage is based upon knowing the end in advance as well as some efficiency in carrying out the task at hand as efficient application of the rule. Poesis makes efficiency the standard because it is a goal separated from an end in time or relying on time to separate them (Balaban, 1989). Praxis is directly linked with the intellectual virtue of phronesis (prac-
tical wisdom), but some accounts of praxis as phronesis in the nursing and medical literature turn it into efficient application of rules and so poesis. The connection between praxis and phronesis automatically rules out interpretations of phronesis as means end reasoning which would make phronesis more like poesis and plausibly a non-moral concept. One would not need to be practically wise but clever. Perhaps expert nurses are clever nurses? Pellegrino & Thomasma (1993), for instance, imply that phronesis is the virtue that enables one to apply a principle or rule to a particular situation correctly given an end; as does one interpretation of the study’s mention of the term praxis. This returns nursing knowledge to poesis as what early commentators classed as nursing science and Carper (1978) classed as empirics, and says little about the telos or end of the patient understood as more than biological function; a reason Carper (1978) wrote about four fundamental patterns of knowing in nursing. The data from the study follow at least part of a structure by Dreyfus & Dreyfus (1986) and Benner (1984) by distinguishing between nurses who are novice and above from nurses who are expert. Nonexpert nurses initially conform to rules and then follow rules which allow for some correction and justification according to the rules, while the expert seems to do without rules; their knowledge being uncodifiable. The data also suggest that the expert nurse is meant to be one who does not need to give explicit knowledge claims for what he does. Hence another reason for Carper’s (1978) three other ways of knowing for nurses which are in some sense inexplicit or implicit. But it is doubtful in the extreme whether knowledge can be completely inarticulate or implicit and whether rules can be totally dispensed with for knowing what to do. Even with this in mind we seem to be heading to Benner’s interpretation of a proficient nurse rather than expert nurse. The expert nurse has a different ability. The expert nurse, rather than his knowledge being in some sense non-propositional and uncodifiable in rules and principles, has a limited codifiability (Little, 2001) and crucially an ability for situational appreciation (aisthesis) which is intentional acting based upon some type of non-conceptual knowledge as a content of
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shared experience in practice and develops new concepts via a range of attentional skills. The mentor helps the nurse to ‘see’ and catch on. It is likely that emotion or attitudes are important in guiding the attention. The pre-conceptual skills are the province of the expert. And ‘the novice has quite literally stopped learning’ (Luntley, 2009). So the expert nurse as mentor teaches by giving the right tips and nudges in practice, enabling the novice to catch on to what it is nurses do and how they should be. Nursing, by its very nature of dealing with people who are often more vulnerable than most and frequently suffering in a complex and shifting environment, has a lot more to see and attend to than most (Luntley, 2009), but this should not be extended to a different type or way of knowing (Luntley, 2011). And such learning is not helped by student nurses’ competency-based assessment outcomes as the sole method of assessment; even the focus of assessment of practice values looks to some forms of measurable outcomes such as arriving at work on time. The focus on outcomes or ends brings it back to poesis. Although there is a necessity for poesis in nursing, and poesis as technè may involve reflection, when the drivers are empiricism, nurses with less maturity and skill of aisthesis as situational appreciation will remain struggling with poesis. Rather than good action being the end, certain given outcomes will be the end, and as such can be driven by efficiency. Good action, however, is the end so cannot be primarily driven by outcomes or efficiency. So, will the notion of praxis and phronesis help with understanding how nursing knowledge is taught? Will understanding these notions help nurses combat the impact of quantitative data and measurable outcomes which have overridden the ethics of nursing? We think it can help articulate how any applied and practical issues are learnt and taught and help explicate difficulties for nursing in a multicultural society. Praxis as practical wisdom (phronesis) is a moral notion about leading a good life and hence is much broader than the category of nurse (Wiggins, 1980). On being asked if the research participants thought of themselves as wise, the response was positive but then they restricted themselves to being wise in nursing, not outside of nursing. However, this shows either
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 50–56
modesty on their part or else expertise, not wisdom. Perhaps the prefix ‘nursing’ is problematic because there is unlikely to be something called ‘nursing wisdom’, though some people may be perhaps practically wise as persons. Phronesis with the Aristotelian notion of living well as eudaimonia looks to leading a good life not a certain practice. This idea was also brought out in a few places in the data from the study, particularly in discussions about whether older students are more likely to express wisdom or whether age is less of a major factor than moral maturity and a good upbringing . Knowledge of practical wisdom is more than knowledge of the expert, being about how to live a good life in general, but knowing ‘the why?’ is still important (Little, 2001) and the phronimos could, if required, articulate it to at least some extent. Also, the range of things there are to be seen and catch onto requires, as Aristotle thought, experience of life but, if the student or new nurse’s life experience is dominated by empiricism in service delivery, their practice, not just their praxis or phronesis, is likely to be impaired. In a sense the organizational environment of nursing practice and the students’ assessment criteria to be a nurse are not likely to help develop ‘good’ practitioners. But trying to explain to others the idea of praxis and its relationship to nursing practice and nursing knowledge will be difficult just as trying to explain the boundaries of the ethical and praxis in moral philosophy is difficult especially in a multicultural, and morally pluralistic society and also to people who do not want to know.
Conclusion The use of Aristotelian notions of poesis and praxis helps to explain the difficulties participants in the Nursing Wisdom Project experienced in exploring what nursing wisdom is, its relation to an expert nurse, and how it can be taught. The data were divided between nursing as a technical skill and nursing as a moral activity. Part of the problem of articulating what it is nurses know is part of the more general problem of any practice that must go beyond the reason based on rules alone. This becomes even more
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problematic when the claims move from nursing as poesis to nursing as a moral discipline in part because there is debate within moral philosophy as to the bounds of ethics. Finally, the challenge is, how can the drive for technology and efficiency be reconciled with nursing or rather practical wisdom and how can ways be found to promote the viewpoint that nursing is not, or ought not to be, merely technè and poesis to the managers and politicians whose perspectives dominate healthcare provision (at least within the UK)?
References Applbaum A. (1999) Ethics for Adversaries: The Morality of Roles in Personal and Public Life. Princeton University Press, Princeton, NJ. Aristotle (1999) Nicomachean Ethics, Translated by H. Rackham, Loeb Classical Library. Harvard University Press, Cambridge, MA. Armstrong A. (2010) Nursing Ethics: A Virtue Based Approach. Palgrave Macmillan, London. Balaban O. (1989) Poesis and praxis in Aristotle’s practical philosophy. The Journal of Value Enquiry, 24, 185–198. Balaban O. (1993) The torn human activity, a response to Alfred Guy’s ‘The role of Aristotle’s praxis today’. The Journal of Value Enquiry, 27, 231–234. Benner P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison Wesley, London. Benner P. (2000) The roles of embodiment, emotion and lifeworld for rationality and agency in nursing practice. Nursing Philosophy, 1, 5–19. Burnyeat M. (1980) Aristotle on Learning to be Good. In: Essays on Aristotle’s Ethics (ed. O.A. Rorty), pp. 69–92. University of California Press, Berkley, CA. Carper B. (1978) Fundamental patters of knowing in nursing. Advances in Nursing Science, 1(1), 13–23. Crisp R. (2006) Reasons and the Good. Oxford University Press, Oxford. Curzio J., Terry L. & Carr G. (2012) Nursing Wisdom: An Exploration of Nursing Wisdom and Ways in Which This Can Be Translated into Clinical Practice and Fostered in Junior Nurses. Final Report for the General Nursing Council for England and Wales Trust. London South Bank University, London. Dreyfus H. & Dreyfus S. (1986) Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer. Blackwell, Oxford.
Flyvbjerg B. (1991) Sustaining non rationalized practices: body-mind, power and situational ethics. Praxis International, 1, 92–113. Hursthouse R. (1999) On Virtue Ethics. Oxford University Press, Oxford. Little M. (2001) On the Knowing Why. Particularism and Moral Theory, Hastings Centre Report, 31(4), 32–40. Luntley M. (2009) Understanding expertise. Journal of Applied Philosophy, 26(4), 356–370. Luntley M. (2011) What do nurses know? Nursing Philosophy, 12, 22–33. Manley K., Hardy S., Titchen A., Garbett R. & McCormack B. (2005) Changing Patients’ Worlds through Nursing Practice Expertise. Royal College of Nursing Institute, London. McCabe H. (2007) Nursing involvement in euthanasia: a ‘nursing-as-healing-praxis’ approach. Nursing Philosophy, 8, 176–186. McDowell J. (1996) Deliberation and moral development in Aristotle’s Ethics. In: Aristotle, Kant and the Stoics: Rethinking Happiness and Duty (eds S. Engstrom & J. Whiting), pp. 19–35. Cambridge University Press, Cambridge. McDowell J. (1998) Virtue and reason. In: Mind, Value and Reality (ed. J. McDowell), pp. 50–73. Harvard University Press, Cambridge, MA. Newham R. (2012) Is there unity in the discipline? Nursing Philosophy, 13, 214–223. Pellegrino E. & Thomasma D. (1981) A Philosophical Basis of Medical Practice. Oxford University Press, New York. Pellegrino E. & Thomasma D. (1988) For The Patient’s Good: The Restoration of Beneficence in Healthcare. Oxford University Press, Oxford. Pellegrino E. & Thomasma D. (1993) The Virtues in Medical Practice. Oxford University Press, Oxford. Sellman D. (2011) What Makes A Good Nurse: Why the Virtues Are Important for Nursing. Jessica Kingsley Publishers, London. Whelton B. (2002) The multifaceted structure of nursing: an Aristotelian analysis. Nursing Philosophy, 3, 193–204. Wiggins D. (1980) Deliberation and practical reason. In: Essays on Aristotle’s Ethics (ed. A.O. Rorty), pp. 221–240. University of California Press, Berkley, CA. Wiggins D. (2006) Ethics: Twelve Lectures on the Philosophy of Morality. Penguin, London. Zimmerman M. (2001) The Nature of Intrinsic Value. Rowman and Littlefield Publishers, Oxford.
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doi: 10.1111/nup.12028
Contemporary nursing wisdom in the UK and ethical knowing: difficulties in conceptualising the ethics of nursing Roger Newham* DMedEth RN, Joan Curzio† PhD RN, Graham Carr† MSc RNT RN and Louise Terry† PhD LLB (Hons) FIBMS *Faculty of Society and Health, Buckinghamshire New University, Uxbridge, and †Faculty of Health and Social Care, London South Bank University, London, UK
Abstract
This paper’s philosophical ideas are developed from a General Nursing Council for England and Wales Trust-funded study to explore nursing knowledge and wisdom and ways in which these can be translated into clinical practice and fostered in junior nurses. Participants using Carper’s (1978) ways of knowing as a framework experienced difficulty conceptualizing a link between the empirics and ethics of nursing. The philosophical problem is how to understand praxis as a moral entity with intrinsic value when so much of value seems to be technical and extrinsic depending on desired ends. Using the Aristotelian terms poesis and praxis can articulate the concerns that the participants as well as Carper (1978) and Dreyfus (in Flyvbjerg, 1991) among others share that certain actions or ways of knowing important for nursing are being devalued and deformed by the importance placed on quantitative data and measurable outcomes.The sense of praxis is a moralized one and most of what nurses do is plausibly on any account of normative ethics a morally good thing; the articulation of the idea of praxis can go some way in showing how it is a part of the discipline of nursing. Nursing’s acts as poesis can be a part of how practitioners come to have praxis as phronesis or practical wisdom. So to be a wise nurse, one needs be a wise person. Keywords: praxis, epistemology, nursing.
The relationship between nursing and praxis Correspondence: Dr Roger Alan Newham, Senior Lecturer, Faculty of Society and Health, Buckinghamshire New University, 106 Oxford Road, Uxbridge, Middx UB8 1NA, UK. Tel.: +44 (0) 149 452 2141 ext 4431; fax: + 44 (0) 149 460 3179; e-mail: [email protected]
50
This paper’s philosophical ideas developed from a General Nursing Council for England and Wales Trust-funded study (the study) to explore nursing knowledge and wisdom and ways in which these can be translated into clinical practice and fostered in
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 50–56
Nursing Wisdom and Praxix
junior nurses (Curzio et al., 2012). Participants, who were nurses with at least five years clinical experience, used Carper’s (1978) ways of knowing as a framework for discussion. They experienced difficulty conceptualizing a link between the empirics and ethics of nursing. The philosophical problem seems to be how to understand praxis as a moral entity with intrinsic value when so much of value is technical and extrinsic depending on desired ends. With obvious debt to Oded Balaban, using the Aristotelian terms poesis and praxis can articulate the concerns that the participants as well as Carper (1978) and Dreyfus (in Flyvbjerg, 1991) among others share that certain actions or ways of knowing important for nursing are being devalued and deformed by the importance placed on quantitative data and measurable outcomes. The sense of praxis is a moralised one; most of what nurses do is plausibly on any account of normative ethics a morally good thing and the articulation of the idea of praxis and how it can be taught and learnt can assist in showing how it is a part of the discipline of nursing. Nursing’s acts as poesis can be a part of how practitioners come to have praxis as phronesis or practical wisdom (Benner, 2000). So to be a wise nurse, one needs be a wise person. Poesis and praxis are both distinguished by Aristotle from theoria as sophia by being practical human activity. Nursing is claimed to be a practice discipline; it uses theory for a purpose. To anticipate the rest of the paper, the very claim of using theory for a purpose, though generally understood and useful for technical skills (albeit not without problems), becomes problematic in recent (and some Ancient) moral philosophy. The data from the study suggest that the experienced nurse participants (though they do not use these terms explicitly) think that nursing is a skilled technè as poesis as well as a moral praxis. They frequently commented that to be a ‘competent’ nurse they need to have certain practical skills but to be a ‘good’ nurse more was necessary. The implicit claim seemed to be that what was needed to bridge the gap was ethics, hence the idea postulated in this paper is that nurses in the study interpreted nursing as both poesis and praxis. But the two concepts poesis and praxis are distinct (Balaban, 1989). The former is means end technical reasoning where the end is
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 50–56
known and given, for example, poesis has to do with making, taking the means of achieving a given end such as replacing an empty bag of intravenous fluid or inserting an intravenous line; praxis has to do, with the way the activity is carried out, the means is, in a sense, the end. In other words, in praxis the ends and means are identical and thus are related to phronesis and ethics and/as politics (Balaban, 1989). Praxis as a moral concern has no end, or rather the activity is what matters (Balaban, 1989). On this account of ethics, good action is the end. . . . action and making are different kinds of thing, since making aims at an end distinct from the act of making, whereas in doing, the end cannot be other than the act itself. Doing well is itself the end.
(Aristotle, 1999, Nicomachean
Ethics 1140 b 1–5)
These two distinct concepts, poesis and praxis, can provide an account of the participants’ verbal responses in the discussion as to what nurses know and the underlying problem with such articulation. They struggled to express in what sense the moral aspect of nursing could be distinct from the technical. It is plausible to suggest that they wanted the moral aspect to be distinct from the technical in order to say how it was a morality of nursing (a morality distinctive of nursing) or at least a morality in nursing (morality applied to nursing). As a minimum, they wanted to be able to articulate just how nursing knowledge was related to ethics; that nursing was something more than just being able to carry out evidence-based technical tasks effectively using empirical knowledge and measurable outcomes. In moral philosophy a similar problem of articulation or explanation of what this moral sense of praxis as intrinsic value actually is, has been acknowledged (Zimmerman, 2001; Crisp, 2006). Plausibly then it is little wonder that nurses in the study also struggled to explain in what sense nursing knowledge was more than and distinct from technical knowledge. A key theme from the study was that nursing knowledge has been reduced to Carper’s (1978) empirical knowing by the focus on quantitative data and measurable outcomes which can be made a goal to achieve and also done within a certain time frame.
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Efficiency can then be judged (by some) according to how quickly one can achieve the goal and at what cost. I’m getting more frustrated because the job I was trained to do has been limited by external forces . . . everything seems finance driven now.
It is important however not to assume that the solution is to be inefficient. Rather, the concern is that nursing knowledge is being reduced to the empirical, because it can be measured and easily articulated; but this comes at the expense of ethical aspects. But it is difficult to articulate and explain exactly what this ethical aspect amounts to (Crisp, 2006). Most of the responses in the study recognize explicitly the need for nurses to have good clinical skills; that is, to have a given end such as the need for a peripheral intravenous cannula and to take the means to insert one. Perhaps there is a much more general end for nursing, e.g. health. Aristotle, contrary to some authors’ interpretations (Pellegrino & Thomasma, 1981, 1988), claimed that medicine was a poeitic activity having an end other than its activity; in this case, health and the nursing literature also claim that nursing has an end (McCabe, 2007). More recently, this has been contested (Newham, 2012). However, as an end it can be distinct from the means and persons carrying out the means. Frequently the participants in the study recognized the limitations of poesis for what they think nursing is or should be, claiming that anybody could (at least in theory) do the task or skill with practice and technical education there being nothing distinctive of nursing. This is reflected in actual healthcare practice in the UK and many other countries in that people with a different role such as phlebotomists, healthcare assistants, and doctors can and do often perform skills which nurses perform. We cannot think of any form of poesis that is exclusive or even distinctive to nursing. Rather, it seems to be, as one of the researchers of the project stated in one of the interviews, ‘nurses do what nurses do’ – a sort of practice positivism whereby whatever nurses are currently doing just is nursing (Applbaum, 1999). In trying to articulate what it is that allows the prefix ‘nurse’ or ‘nursing’ to poesis to make it ‘nursing knowledge’, the participants began to articulate that it
must be the way poesis is done as not just focusing on the one task in hand such as peripheral intravenous cannulation but observing the ‘whole’ patient for signs and symptoms of other needs while one is there to perform the cannulation and to be able to prioritize which ends or goals are the most important. So, for instance, one may be there initially with the aim of achieving the goal or end of inserting a cannula but realize that the patient’s catheter bag is full of urine and needs to be measured and emptied, or that it was now 10 am and the morning medications need to be given to the patient. Although some awareness of the situation is necessary, the focus is on the observing of a set of goals that need be achieved. This is really just an extension of poesis as a singular task to multiple tasks and fails to account for much perhaps most of the participants’ responses about what nurses know; though, sadly, many responses suggested that junior nurses often could not manage to, or struggled to, have this ability of seeing the whole patient’s physical needs at that particular time. So, although there remains the problem as to just what makes poesis distinctly nursing, the fact that most of the participants’ responses were focused not just on clinical skills but on the actual doing of nursing or the way nursing was done which is also in the nursing literature (Whelton, 2002; Manley et al., 2005), makes room for an entry into the idea of praxis. This idea of the doing of nursing and the way it is carried out is a focus of the revival of neo-Aristotelian virtue ethics (Hursthouse, 1999) and its application to nursing (Armstrong, 2010; Sellman, 2011), as well as a focus on a distinct way of understanding ethics (McDowell, 1998; Wiggins, 2006) that blurs boundaries between moral and so-called non-moral ways of being and doing. One of the main points of this paper is that it is very difficult to ascertain in what sense the general idea of the ‘way’ a nurse acts or behaves is meant to be understood in order to distinguish between ways of acting as praxis and ways of acting as poesis. Three examples can show how making the distinction within nursing is actually quite difficult because of the very nature of the work. These will support the idea to be given later that nursing’s poesis is a type of practice positivism in the sense that there is no distinct boundary to its knowledge as a discipline
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but it is applied in an ethical way, thus helping to develop individual’s praxis. The first example is doing a technical skill; the second incorporates moral or at least value-laden concepts; and the last shows how an imposed action perhaps meant to ‘evidence’ praxis can turn it into poesis. Taking a patient’s temperature is an essential skill to be mastered by all nurses. There is a correct way to do this that is evidenced based on measurable data. So one could take the temperature without any thought about the patient himself; an accurate result can be measured and recorded and the poesis completed. A complication for the relationship between nursing and praxis is that no one doing this task ought to do it in just this manner or way. This is not because one is a nurse but the fact that one is dealing directly with another human being. But focusing on the nurse, this example can show a distinction between poesis and praxis in that it may be (ought to be) felt that just doing the poetic activity of temperature taking by itself is not sufficient to being a good nurse. The second example concerns deception. For instance, deception may be taken to be a good thing in art (Balaban, 1989) or in nursing as poesis but, as praxis, not so. This example is arguably more difficult to separate into poesis and praxis because it is value laden at the outset. So it is much contested as to whether deceiving a patient in order to either allow one to finish work on time or even to get a patient to take his/her medication is simply poesis because deception by its nature could be claimed to be directly a moral issue. This would apply to anyone able to do these things, but the point would be that deceiving with an end in view makes it poesis because there is a goal and, once achieved, it ends and could be done in principle by anyone, without it mattering who was doing the deceiving. But, as praxis, this separation in time and the irrelevancy of the agent cannot be the case (see below for an expansion of this point about praxis). The third example follows from the frequent participant’s responses in the study of the importance of interacting with the patient. It is sometimes not clear from the comments what the interaction amounted to, whether it was in order to achieve an end or goal poesis or if it were interacting without a specific end
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or where the way of interaction mattered and did so in itself praxis. Intentional rounding as routinely entering a bay of patients to ask them how they are may seem to be a way to ‘evidence’ nursing praxis but it in fact turns it into poesis. There is a given end, to enter patients’ bays and ask them how they were and as long as someone did so it did not matter who. However, there is also the non-end-related idea that interacting with patients is good as non-goal or endorientated but simply in itself, so there can be a contradiction in the same activity between poesis and praxis (Balaban, 1993). Hence, there can be difficulty in articulating with any sort of explanation just what makes it praxis but, as praxis, there is nothing that makes it nursing praxis. Rather, it is better understood as skills nurses carry out that are applied in an ethical way. Here, then, is where the trouble lies for both participants in the Nursing Wisdom Project and in moral philosophy more generally with articulating and explaining how knowledge is more than technical knowledge or poesis. What is it to be praxis? And there is a further related problem of scope both for the Nursing Wisdom Project and for moral philosophy of saying how such knowledge remains nursing knowledge for the former and ethical knowledge for the latter? If praxis is to be understood as for the sake of an end, which is poesis, praxis is open to being ‘rationalised’ as action for the sake of X and taken over by technology. H. Dreyfus (in Flyvbjerg, 1991) comments on this replacement of aspects of marginalized practices such as nursing by rationalized technological accounts especially efficiency as an outcome for poesis. The non-rationalized aspects of marginalized practices then get devalued which arguably explains Carper’s (1978) attempt to bring back other ‘ways of knowing’ that are non-propositional and almost inarticulate as important and important to nursing. So one distinction might be to claim that poesis remains propositional knowledge and can easily be articulated. This idea was raised by one of the researchers in the project who was not a nurse in response to one participant’s struggle to express what was missing from a student nurse’s knowledge when compared with a good nurse/expert nurse, that the student nurse is limited to propositional knowledge whereas the
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good or expert nurse is not. But praxis as a moral notion done for itself praxis as phronesis, need neither be completely non-rationalized or completely inarticulate; in fact, Aristotle says that phronesis is linked with reason and can be learnt from example and by doing.
Poesis, praxis, and phronesis: implications for teaching what nurses know Phronesis is an intellectual virtue related to praxis; it uses reason and can be taught but, and this is crucial, the agent is a necessary part unlike action as poesis which can also be taught but the person as an individual nurse working towards the given end is separable from any other person or role as long as the end is achieved. Poesis needs an end, and successful or ‘good’ action is achieving the specified end. Two problems arise. One is that in relation to the study we need to know what nursing is in order to know its subject matter and thus its general end; this is in order to know how the specific ends relate to the general end, hence the need for an examination of nursing ontology before its epistemology. Unfortunately, Carper’s epistemological focus fails to do this. Knowing the end of nursing is extremely problematic, even if one thinks there is some focal (in Aristotle’s sense of focal) account of nursing’s end based on the human body and illness and disease. Nursing seems torn between knowledge of the body as organism and knowledge of the body as whole living human being with a place in society/culture in order to distinguish itself from medicine and other healthcare roles. The other problem is that there seems to be no distinction between novice and competent or even proficient nurse. Some of the data collected spoke of expert nurses’ frustration with qualified junior nurses and student nurses’ inability to move beyond being told what to do, Benner’s (1984) novice stage. But even the competent stage is based upon knowing the end in advance as well as some efficiency in carrying out the task at hand as efficient application of the rule. Poesis makes efficiency the standard because it is a goal separated from an end in time or relying on time to separate them (Balaban, 1989). Praxis is directly linked with the intellectual virtue of phronesis (prac-
tical wisdom), but some accounts of praxis as phronesis in the nursing and medical literature turn it into efficient application of rules and so poesis. The connection between praxis and phronesis automatically rules out interpretations of phronesis as means end reasoning which would make phronesis more like poesis and plausibly a non-moral concept. One would not need to be practically wise but clever. Perhaps expert nurses are clever nurses? Pellegrino & Thomasma (1993), for instance, imply that phronesis is the virtue that enables one to apply a principle or rule to a particular situation correctly given an end; as does one interpretation of the study’s mention of the term praxis. This returns nursing knowledge to poesis as what early commentators classed as nursing science and Carper (1978) classed as empirics, and says little about the telos or end of the patient understood as more than biological function; a reason Carper (1978) wrote about four fundamental patterns of knowing in nursing. The data from the study follow at least part of a structure by Dreyfus & Dreyfus (1986) and Benner (1984) by distinguishing between nurses who are novice and above from nurses who are expert. Nonexpert nurses initially conform to rules and then follow rules which allow for some correction and justification according to the rules, while the expert seems to do without rules; their knowledge being uncodifiable. The data also suggest that the expert nurse is meant to be one who does not need to give explicit knowledge claims for what he does. Hence another reason for Carper’s (1978) three other ways of knowing for nurses which are in some sense inexplicit or implicit. But it is doubtful in the extreme whether knowledge can be completely inarticulate or implicit and whether rules can be totally dispensed with for knowing what to do. Even with this in mind we seem to be heading to Benner’s interpretation of a proficient nurse rather than expert nurse. The expert nurse has a different ability. The expert nurse, rather than his knowledge being in some sense non-propositional and uncodifiable in rules and principles, has a limited codifiability (Little, 2001) and crucially an ability for situational appreciation (aisthesis) which is intentional acting based upon some type of non-conceptual knowledge as a content of
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shared experience in practice and develops new concepts via a range of attentional skills. The mentor helps the nurse to ‘see’ and catch on. It is likely that emotion or attitudes are important in guiding the attention. The pre-conceptual skills are the province of the expert. And ‘the novice has quite literally stopped learning’ (Luntley, 2009). So the expert nurse as mentor teaches by giving the right tips and nudges in practice, enabling the novice to catch on to what it is nurses do and how they should be. Nursing, by its very nature of dealing with people who are often more vulnerable than most and frequently suffering in a complex and shifting environment, has a lot more to see and attend to than most (Luntley, 2009), but this should not be extended to a different type or way of knowing (Luntley, 2011). And such learning is not helped by student nurses’ competency-based assessment outcomes as the sole method of assessment; even the focus of assessment of practice values looks to some forms of measurable outcomes such as arriving at work on time. The focus on outcomes or ends brings it back to poesis. Although there is a necessity for poesis in nursing, and poesis as technè may involve reflection, when the drivers are empiricism, nurses with less maturity and skill of aisthesis as situational appreciation will remain struggling with poesis. Rather than good action being the end, certain given outcomes will be the end, and as such can be driven by efficiency. Good action, however, is the end so cannot be primarily driven by outcomes or efficiency. So, will the notion of praxis and phronesis help with understanding how nursing knowledge is taught? Will understanding these notions help nurses combat the impact of quantitative data and measurable outcomes which have overridden the ethics of nursing? We think it can help articulate how any applied and practical issues are learnt and taught and help explicate difficulties for nursing in a multicultural society. Praxis as practical wisdom (phronesis) is a moral notion about leading a good life and hence is much broader than the category of nurse (Wiggins, 1980). On being asked if the research participants thought of themselves as wise, the response was positive but then they restricted themselves to being wise in nursing, not outside of nursing. However, this shows either
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modesty on their part or else expertise, not wisdom. Perhaps the prefix ‘nursing’ is problematic because there is unlikely to be something called ‘nursing wisdom’, though some people may be perhaps practically wise as persons. Phronesis with the Aristotelian notion of living well as eudaimonia looks to leading a good life not a certain practice. This idea was also brought out in a few places in the data from the study, particularly in discussions about whether older students are more likely to express wisdom or whether age is less of a major factor than moral maturity and a good upbringing . Knowledge of practical wisdom is more than knowledge of the expert, being about how to live a good life in general, but knowing ‘the why?’ is still important (Little, 2001) and the phronimos could, if required, articulate it to at least some extent. Also, the range of things there are to be seen and catch onto requires, as Aristotle thought, experience of life but, if the student or new nurse’s life experience is dominated by empiricism in service delivery, their practice, not just their praxis or phronesis, is likely to be impaired. In a sense the organizational environment of nursing practice and the students’ assessment criteria to be a nurse are not likely to help develop ‘good’ practitioners. But trying to explain to others the idea of praxis and its relationship to nursing practice and nursing knowledge will be difficult just as trying to explain the boundaries of the ethical and praxis in moral philosophy is difficult especially in a multicultural, and morally pluralistic society and also to people who do not want to know.
Conclusion The use of Aristotelian notions of poesis and praxis helps to explain the difficulties participants in the Nursing Wisdom Project experienced in exploring what nursing wisdom is, its relation to an expert nurse, and how it can be taught. The data were divided between nursing as a technical skill and nursing as a moral activity. Part of the problem of articulating what it is nurses know is part of the more general problem of any practice that must go beyond the reason based on rules alone. This becomes even more
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problematic when the claims move from nursing as poesis to nursing as a moral discipline in part because there is debate within moral philosophy as to the bounds of ethics. Finally, the challenge is, how can the drive for technology and efficiency be reconciled with nursing or rather practical wisdom and how can ways be found to promote the viewpoint that nursing is not, or ought not to be, merely technè and poesis to the managers and politicians whose perspectives dominate healthcare provision (at least within the UK)?
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