Just how wide should 'wide reading' be?

doi: 10.1111/nup.12095

Original article

Just how wide should ‘wide reading’ be? Martin Lipscomb PhD RN Senior lecturer, Faculty of Health and Life Sciences, Alexandra Warehouse, University of the West of England, Gloucester Docks, Gloucestershire, UK

Abstract

Educationalists introduce students to literature search strategies that, with rare exceptions, focus chiefly on the location of primary research reports and systematic reviews of those reports. These sources are, however, unlikely to adequately address the normative and/or metaphysical questions that nurses frequently and legitimately interest themselves in.To meet these interests, non-research texts exploring normative and/or metaphysical topics might and perhaps should, in some situations, be deemed suitable search targets. This seems plausible and, moreover, students are encouraged to ‘read widely’. Yet accepting this proposition creates significant difficulties. Specifically, if non-research scholarly sources and artistic or literary (humanities) products dealing with normative/metaphysical issues were included in what are, at present, scientifically orientated searches, it is difficult to draw boundaries around what – if anything – is to be excluded. Engaging with this issue highlights problems with qualitative scholarship’s designation as ‘evidence’. Thus, absurdly, if qualitative scholarship’s findings are labelled evidence because they generate practice-relevant understanding/insight, then any literary or artistic artefact (e.g. a throwaway lifestyle magazine) that generates kindred understandings/insights is presumably also evidence? This conclusion is rejected and it is instead proposed that while artistic, literary, and qualitative inquiries can provide practitioners with powerful and stimulating non-evidential understanding, these sources are not evidence as commonly conceived. Keywords: nursing philosophy, nursing research, qualitative research, literature searching, wide reading, education.

An early draft of the ideas outlined in this paper was presented at the 18th Annual International Philosophy of Nursing conference, Nottingham University – School of Health Sciences, 2014. Correspondence: Dr Martin Lipscomb, Senior lecturer, Faculty of Health and Life Sciences, Alexandra Warehouse, University of the West of England, West Quay, Gloucester Docks, Gloucestershire GL1 2LG, UK. Tel.: 0117 328 5624; e-mail: Martin.Lipscomb@ uwe.ac.uk

© 2015 John Wiley & Sons Ltd Nursing Philosophy (2015), 16, pp. 187–202

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Introduction A final-year undergraduate discusses her dissertation with an educator. I do not mean to eavesdrop. However, we share office space and it is impossible not to overhear what is said. The student is interested in aspects of patient suffering. This is a big subject, perhaps too big. Nonetheless, suffering is something that most if not all of those we care for experience in one form or another and, importantly, nurses who ignore suffering disregard a pivotal aspect of patient experience. Given the length of the dissertation this is on the face of it a fitting place to engage with an issue of this sort. And, yet, the student is finding it difficult to collapse so broad a subject into a structure which, at my university, interprets the dissertation in a manner that focuses, through a literature review, almost exclusively on the location and appraisal of primary research evidence. To make the topic more manageable, the student has sensibly tied suffering to particular forms of end-of-life care and, in preparing for the meeting, she has printed off several quantitative and qualitative studies. However, although the student talks maturely and competently about the research in front of her, she is clearly underwhelmed by the direction in which the study findings are pushing her. The results are not quite what she thought she would be engaging with. She then says ‘Of course EastEnders [a UK TV soap drama] covered this brilliantly. They made it [a dying person’s suffering] real. That’s what attracted or interested me’. This vignette illustrates several truisms, viz. that literature searches do not always locate the material we seek, that understandings pertinent to healthcare and nursing can be garnered or obtained from multiple sources and, vitally, these sources can and do embrace more than science and its (research) products. Indeed, not only does serendipity play a role in the development of understanding but, also, fruitful sources may include or derive from – loosely – the humanities. Educators recognize this later point when they capitalize on the persuasive potency of non-academic material and employ novel texts to ‘make a point.’ To this end, I have read passages from Lean In by Sheryl

Sandberg (2013) and Nurse in Recovery by Dianne Drake (2005) to students taking a leadership module. The use of Sandberg (2013) is probably uncontentious. This conversational work anecdotally explores problems faced by women leaders in the workplace and students who are also mothers tend to react positively to Sandberg’s (2013) comments regarding the difficulties women confront in juggling home life and childcare demands alongside professional expectations. (Difficulties a male nurse may not experience to the same degree or level.) However, at the risk of overegging its naughtiness, introducing Drake’s (2005) salacious bodice ripper in an academic setting might raise sensitive eyebrows.Towards the beginning of this mildly pacey Mills and Boon medical romance, nurse Anna (frightfully attractive but dreadfully troubled) leads and manages a difficult triage situation. Students easily empathize with Anna’s predicament and with gentle prompting, they usually identify interesting ethical or normative problems within the events described (problems pertinent to nursing rather than anything else). Discussion is facilitated by the accessibility of the prose and, in case you are wondering, Anna eventually, if predictably, finds love with masterful but ‘burned out’ doctor Mitch Durant. On the other hand, while the utility of nonacademic sources in aiding or stimulating debate and hence understanding is readily granted in classroom situations, when it comes to formal literature searching, educators invariably direct students to locate and make sense of very particular types of literature – namely, primary research reports and a limited range of scholarly works. However, problematically, primary research reports are not always adequate, helpful, or useful. For example, primary reports can be inadequate or misleading when nurses interest themselves in subjects that include or may be associated with normative and/or metaphysical features. Core nursing concerns such as the nature of suffering, or the meaning of care, or compassionate practice, or the maintenance of hope, or the preservation of dignity, or justice, or empathy, or the nature of professionalism (this list could easily be extended) are both normative (they prompt evaluative or value-laden examinations about what should or should not occur) and metaphysical insofar as they deal with abstract


Just How Wide Should ‘Wide Reading’ Be?

principles or the nature of what is. Because of this, importantly, questions linked with these concerns cannot be conclusively answered simply by inspecting research study findings. A great deal of empiric work is done into or around these topics and this work may determine that various percentages of nurses or patients/clients hold or do not hold certain views, or act in certain ways, etcetera. However, because each descriptor (suffering, care, compassion, hope, dignity, justice, empathy, professionalism) encompasses or brings into view normative and metaphysical issues, while research findings can inform understanding and debate, empiric investigation cannot on its own decide or settle these issues. None of this is controversial or new. Nevertheless, current search strategies – i.e. the sorts of strategy outlined in undergraduate or pre-registration (prelicensure) student texts, the sorts of strategy taught in the classroom – mostly ignore this limitation and, moreover, this deficiency or lacuna is not always remedied in post-registration or higher degree teaching/ education. Thus, although educators reasonably and properly introduce students to search strategies that enable the location of primary research reports, because nurses are legitimately interested in topics and subjects that are inherently normative and/or metaphysical, it seems entirely sensible that nonresearch sources dealing with these issues should also be sought out. However, as I hope to show, taking this step quickly raises sticky questions. Students and nurses are frequently encouraged to ‘read widely’ and this injunction, variously phrased, normally (I presume) allows that non-research texts may be pursued. However, while weighty and ponderous scholarly papers can be valid target texts in a search on, for example, suffering, here are two difficult questions. First, could C S Lewis’ A Grief Observed [2013 (1961)] or Albert Camus’s The Myth of Sisyphus [2005 (1942 French, 1955 English translation)] be valid sources for nurses conducting a search into suffering and, second, should these sorts of text be deliberately sourced? More generally, can and ought artistic, literary, or cultural products develop and/or underpin practice-relevant understandings? Can these sources sensibly facilitate practice decisions/actions? Clearly, a lot depends here upon


what we mean by ‘facilitate’. However, if ‘yes’, then a myriad of interpretive and other problems ensue. If ‘no’, on what grounds are these types of text/product being excluded? Exploring this issue has value because it forces us to think through what it is we are attempting to accomplish in a search and, also, it provides an entry point into problematizing the evidential status of qualitative research.

The reduction inherent in currently promoted search strategies Let us grant that nursing texts that outline search strategies for students close down the range of sources that are accessed. That is, strategies largely limit themselves to the identification of primary research evidence and reviews of that evidence. This reduction in turn collapses the questions that students are directed or lead towards and this closing down, this direction, may be significant. We might not want to follow Kittler (1999) in claiming that (simply put) technologies create us rather than the other way around. Nonetheless, it is probably reasonable to suggest that different sources embody or illuminate particular ways of thinking (technologies or ideologies) that in large or small measure steer understanding and, in consequence, behaviour. Further, search strategies are often introduced to students in modules or courses that are associated with research or evidence-based practice (EBP) and while the evidential status of, for example, qualitative research continues to be contested, most introductory and advanced texts outwardly embrace all forms of research (i.e. quantitative, qualitative, and mixed). Little credence is given to commentaries or expert opinion in EBP (albeit that clinical expertise is valorized) and, arguably, particular ways of conceptualizing and engaging with problems and particular forms of solution are normalized and made acceptable by this stance. That said, empiric quantitative sources carry significantly more weight than qualitative sources in EBP (Brown et al., 2003) and, in response, nursing texts often devote greater space and energy to the description of quantitative rather than other research forms. Some nurses and some researchers instinctively feel this emphasis is correct. Others are less sanguine.

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The claim may be disputed or, alternatively, the honoured status accorded to quantitative research has been challenged and, of course, a huge amount of nursing research is qualitative in nature. Few nurse researchers today exalt quantification in the unabashed manner famously expounded by Lord Kelvin.1 However, evidence-based medicine unreservedly privileges comparative clinical studies and, generally speaking, randomized controlled trials and (even better) systematic reviews of randomized controlled trials ‘outrank’ observational studies even within this restricted pallet of evidence sources (see Howick, 2011). In nursing, despite the publication of a great quantity of qualitative research, when we look at where the big grant money is spent, and when we look at where kudos and professorial titles reside, it is difficult not to conclude that numbers count. To recap, core nursing interests encompass subjects with significant normative and metaphysical elements. Scientific research texts cannot on their own answer or resolve questions associated with these interests because normative and metaphysical questions cannot be answered empirically – indeed, in key respects, they may be unanswerable. Search strategies taught to students emphasize skills associated with the location of primary research reports and within these accounts, more attention is frequently devoted to quantitative rather than qualitative research forms. Qualitative scholarship is, however, recognized by many (if not all) nurses as a legitimate and appropriate source and – a new point – the legitimacy of qualitative studies resides in or derives from their use value. More specifically, use value rests on the ability of qualitative work to generate or provide practicerelevant insights with or understandings to readers. (I assume here that the value of qualitatively derived insight differs from the value of generalized truth claims of the sort ideally supplied by quantitative 1

The quotation, worth repeating, is as follows: ‘when you can

measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science’ (Thomson 1889).

studies.) If this is the case, if legitimacy rests upon use value and if use value derives from the generation of practice-relevant insight or understanding then, presumably, discursive scholarly and artistic, literary, or cultural products can be deemed valid sources when they produce practice-relevant insight or understanding. Research texts, scholarly works, and artistic or literary products differ in form and function. Nonetheless, non-research texts can arguably stimulate insights and understandings that are at least as profound or rich as those associated with qualitative interpretative inquiry and, if this is accepted, the gulf separating currently favoured search strategies from the need to meet nursing interests with strong normative and metaphysical elements might be bridged. That is, some non-research sources engage productively with aspects of nursing that are underdeveloped or underexplored in research sources. The move made here is if qualitative study findings are legitimate target sources in nursing literature searches because those findings enable or engender clinically relevant insight/understanding (so it is ‘use value’ that makes something a legitimate source), then non-research texts (e.g. scholarly and artistic or literary products) are also valid target sources if or when they stimulate insights/understandings similar or equal in value to those delivered by research findings. Broadening the range of legitimate search objects in this way could prove helpful in addressing the normative and metaphysical aspects of nursing that are underserved by solely focusing on primary research evidence. On the face of it, this plausible argument favours expanding the range of sources sought or allowed in search strategies – and I would like this to happen. However, in important ways, this expansion edges nursing towards a preposterous and absurd position and, also, it raises questions about the status of qualitative scholarship.

Two types of knowledge Following Annas (2000, 2009), hereafter a twofold distinction of Greek origin is employed. First, knowledge describes or comes from the procurement and articulation of individual skills, facts, and units or monads of data. For example, I may know that Mrs



Smith is rapidly losing weight. This is a known fact about Mrs Smith. Second, knowledge is a component of practical reasoning or wisdom and, while this latter term may appear strange to modern readers, wisdom here denotes the manner in which virtuous persons assemble knowledge in intelligible fields of understanding that link together and give meaning to otherwise disparate skills, facts, etcetera (Roberts & Wood, 2007). Knowledge in this second sense involves amassing and making sense of facts. Thus, Mrs Smith is not only losing weight. She is also newly bereaved. She gives every indication of having loved her husband dearly and she is, contrary to her normal euthymic disposition, withdrawn and listless. Putting these facts together allows us to form, provisionally at least, an understanding of Mrs Smith as someone who is suffering emotionally and physically consequent to her husband’s death. This conception of knowledge has a long lineage or pedigree. It can be located within Platonist, Neo-Platonist, and indeed radically alternative and contrasting philosophies and, vis-à-vis Mrs Smith, this type of understanding is important insofar as it potentially allows carers to sympathize with and practically assist sufferers. Further, the capacity to offer empathetic and helpful care may in part rest upon grasping forms of understanding that derive from reflection on and engagement with normative or metaphysical concerns (e.g. suffering). Search strategies that presume that knowledge sufficient for action (clinical decisions) can be based solely or largely on isolated research findings/data (knowledge in the first sense) run the risk of ignoring relevant ‘other’ considerations. Alternatively, where the object of wide reading is the development of broad subject comprehension, homage continues to be paid to knowledge in the second sense. Divisions between these knowledges should not be overblown and it might be objected that just as all observation is theory laden, so individual items of knowledge cannot be realized without the ambit of a theoretical framework. Equally or conversely, fields of understanding do not exist apart from the information that constitutes them. (These claims need not be antithetical to realist conceptions of knowledge/the world – see, e.g. Weissman, 1993). Nevertheless, the distinction between knowledges outlined here is expedient and,


henceforth, it is assumed that these ideas are in key respects opposed.

Example problems Students and nurses are interested in subjects that lend themselves to interpretative and/or phenomenological investigation (e.g. Mrs Smith’s suffering) and, unsurprisingly, search strategies that prioritize research will, in addressing these subjects, locate phenomenological studies (e.g. see Rehnsfeldt & Arman, 2008; Gudmannsdottir & Halldorsdottir, 2009; Rydahl-Hansen & Eriksen, 2009; Nay & Fetherstonhaugh, 2012). Phenomenological researchers believe their studies offer action-guiding or action-informing if not generalizable knowledgeevidence. However, if the truthfulness or correctness of knowledge contained in or derived from phenomenological studies rests on the theoretical validity and robustness of the research methodology and methods employed (and if it does not, on what does it rest?), assessments of this approach to understanding which undermine validity/robustness demand acknowledgment. Recognition is necessary because, when critical assessments are accurate or well aimed, the truth content of phenomenological findings must be questioned and, presumably, questionable findings of any sort should not generally inform practice. Or, if this is disputed, such findings at least require very careful handling. Prudence is required as we here expose the link between qualitative research claims (i.e. claims about what is or might be) and the use value of insights generated by those claims and, however we define insight, it would be odd if practice-informing insights were knowingly based on research claims that were in significant ways indefensible and/or unjustified (albeit that, irrespective of the accuracy or truthfulness of the stimulus, insight can be roused or sparked by any source). John Paley’s (2014) vigorous examination and critique of nurse researchers’ interpretation of phenomenological ideas is one such assessment. Paley (2014) proposes that there is a mismatch between the type of studies carried out by Heideggerian or hermeneutic phenomenologists and their affiliation with Heidegger. Heidegger’s work does not, however, imply or

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sanction the use to which it is put in these inquiries. Indeed, where this mismatch occurs, it is feasible that because nurse researchers make errors in the way they conceptualize and conduct their inquiries, those results or outputs are unsound. These studies do not provide evidence for action in any straightforward sense (Petrovskaya, 2014). Alternatively, Paul Snelling’s (2013) work on ‘rounding’ (planned/structured regular nurse–patient contacts) addresses an aspect of patient experience that many nurses and nurse managers are currently interested in. Research appears to support a variety of startlingly daring claims regarding the benefits of rounding and students and registered nurses who access individual empiric descriptive studies on this topic may conclude that rounding is of established worth. However, Snelling’s (2013) evaluation of research on this subject challenges (to put it politely) simplistic readings of the research. If nursing’s instructional literature on search strategy performance downplays or marginalizes the importance of locating discursive or scholarly nonresearch papers, it thereby does a disservice to student and nurse searchers. Searchers who focus primarily on locating primary research evidence will overlook documents that, if read, problematize less informed readings. Paley (2014) unpicks the philosophic assumptions (including metaphysical assumptions) upon which many nursing phenomenological research methods and practices claim to rest. Snelling (2013) provides a cutting and in part normative deconstruction of existing research literature. Both scholars could be mistaken in their analysis. However, the point made here is that where clinical nursing decisions/actions are informed by a reading of only primary research, those decisions/actions run the risk of being misguided or, at the very least, they could be decisions/actions taken on the basis of an indefensible or contestable evidence base. The work of both example authors would have been overlooked by a search fixated on locating only primary research and knowledge of the second (contextualizing) sort would therefore have been unavailable to readers. Reading beyond primary research data does not guarantee that error will be avoided and it may even

exacerbate error. Nonetheless, regarding the illustrative examples, literature reviewers would, having looked only at primary research, not be able to fit the knowledge gained from those studies into epistemically satisfactory frameworks of wider understanding – which may include rejection of the ideas of Paley (2014) and/or Snelling (2013). And, in both instances, acknowledging these broader frameworks is necessary in order that the findings of primary research are not misconstrued. Numerous similar examples could be cited. When nurses address questions other than treatment comparisons (e.g. is this dressing more absorbent than that dressing?) and when nurses interest themselves in evidence interpretation or application and the normative, metaphysical, social, cultural, psychological, and political issues that interpretation or application generates, ideas about searching that prioritize only the location of primary research may be found wanting. This, it must be stressed, is not an abstract problem where ‘abstract’ denotes something irrelevant to concrete real-world practice. Search strategies that fail to fit research findings within the wider literature potentially permit clinical decisions to be made on the basis of partial or suspect understanding and, when this occurs, patient safety and comfort may suffer. On the other hand, if in certain situations non-research sources are deemed legitimate targets for investigators (because these sources offer reviewers the possibility of obtaining insights not found in the research literature), where will the boundary to what counts as an acceptable source be set? As will be seen, expanding the range of materials deemed legitimate results in or prompts problematic conclusions.

Read widely – ‘okay but’ The above examples cited non-research but scholarly articles that would be overlooked by a search focused simply on identifying research and, it was claimed, not locating these sorts of paper could potentially lead to sourced research being misunderstood. I now turn to look at problems associated with reading widely and, thereafter, how we might interpret literary and other products.



The good reader loves knowledge and understands that knowledge is not just a collection of facts; he critically insists on good reasons for affirming what he affirms and denying what he denies. He does not just seek support for his prejudices but is open to learning, willing to take a critical look at his own preexisting views. But these dispositions are all virtues: love of knowledge, love of truth, an open willingness to hear another side. Insofar as tutoring can teach these things in the course of a curriculum of reading, it is not just skill purveyance, but an education, a nurturing in the intellectual virtues.

Roberts and Wood

(2007, p. 123)

Suggesting that nurses ought to read more widely than is currently the case is problematic insofar as it posits nursing as a singular object and, perhaps more realistically, we must allow that a variety of nursing practices and therefore nursings (plural) exist. Alternatively, if group coherence or collective intentionality is being claimed on behalf of nurses, then the contentious and underdetermined nature of these concepts should be acknowledged and argued for (see, e.g. Tuomela, 2013 or Chant et al., 2014). However, this aside, calling for wide reading is, as per Roberts & Wood (2007), to seek an expanded form of critical and reflective engagement and this raises at least seven distinct albeit tightly interlinked categories of challenge. First, the phrase ‘the literature’ easily assumes the existence of a homogenous and self-contained entity. Thus, when we are told that ‘the literature’ was searched or when we learn that a review of ‘the literature’ is being presented, this may imply that ‘the literature’ is a singular thing. Is it? At the risk of excessive bowdlerization, Plato’s Sophist [1993 (360 BCE)] is identified with the idea that knowledge is a unitary or universal object while Aristotle‘s On the Heavens [1922 (350 BCE)] is associated with the notion that knowledges or disciplines rather than knowledge or singular science exist. Clearly, these respective positions are more complex than is here allowed and, for example, Aristotle is associated with a conception of knowledge that is highly constraining. (Namely, that warranted knowledge claims require possession of necessary and universal truths attained via valid demonstration).


My preference is to suppose that a range of discrete literatures (plural) exist and, in consequence, I presume interests and the ontological substance of study objects divide and delineate disciplines. Allowing diverse knowledges explains one element of the difficulty of reading across disciplines/sciences. Alternatively, if knowledge is a unitary object, then professional claims to status grounded on the ownership of distinct knowledge bases ought to be rejected. That is, there can be no specific nursing knowledge if by this we mean something unique to nursing (as if nursing was a homogenous entity). And, importantly, if ‘truth cannot contradict truth’, Aristotelian knowledges do not necessarily refute the idea that knowledge exists potentially in or as coherent fields of understanding. This position is thus compatible with knowledge of the second contextualizing sought (outlined above). Second, arguments in favour of wide reading are ambiguous (what exactly does this entail?) and platitudinous (who would disagree?). However, adapting Loughlin et al. (2012), ‘when we try to spell out precisely what we mean by these terms [here wide reading], in a way that could enable us to recognize and develop these qualities [behaviours] in real situations, any initial appearance of general accord soon evaporates’ (p.929). These comments were made in relation to clinical reasoning. Nonetheless, the sentiment conveyed is apropos. No one would presumably argue against wide reading just as no one would argue against critical and reflective engagement with ‘the literature’ (hereafter I revert to literature rather than literatures). Yet in any particular instance, dispute may occur over how much and what sort of literature should be accessed as well as the manner in which decision choices around these questions might be defended/justified and, unfortunately, there is no easy resolution to these sorts of question. Aveyard (2014) illustrates the difficulties generated by language use here when she asserts that literature searchers should seek to obtain a ‘comprehensive’ overview of published work on the subject under review. Yet comprehensiveness is a slippery term that, in nursing, easily collapses to ‘relevance’ and, in turn, relevance can become (in texts about searching) ‘generalizable research’. Moreover, does being com-

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prehensive necessitate, for example, the location of primary sources? Thus, when nursing research reports claim or state that they model their analysis on a philosophic or methodological theory or tradition, do reviewers need to ‘check out’ the sources being cited to ensure that they are being used credibly or can the researchers’ word be taken at face value? Here it is probably worth noting that Paley (2014) critiques phenomenological studies that misconstrue the philosophic ideas that are invoked to justify the methods used and, I suggest, misconstrual often occurs because, in part, nurse researchers rely upon secondary rather than primary sources when engaging with theory. By analogy, reviewers should presumably seek out primary sources and references whenever this is realistically feasible (alternatively, see Strawson, 1992). That aside, if we allow that the questions nurses ask and the topics they are interested in are not simply or always ‘technical problems’ (Traynor, 2013, p. 88), research from within and without a discipline field, as well as non-research sources, can potentially ‘speak to’ the question or topic at issue. This much is easy to agree upon. However, reading unfamiliar material is difficult and setting boundaries or parameters to reading is even more contentious. Greenhalgh (2012) notes that one of the reasons why ‘we find research papers outside our own paradigm so impenetrable is that scientists consider their core assumptions to be self-evident and so don’t make them explicit’ (p. 93). Specialist training or enculturation may therefore be required if we are to make sense of alien literature (scientific or otherwise) and, depending on context, this training/enculturation might need to be extensive and deep. Further, if we reject all boundaries to reading (so wide reading potentially includes all and any sources), the unconstrained nature and scope of comprehensive reviews might imply that an end point to reading can never be achieved or known if achieved. From an academic vantage, this may be tolerable or even welcome. However, the conclusion is clearly unsatisfactory to busy clinicians who must take important decisions, often on the basis of limited information, under great pressure, in real time. Therefore, third, recognizing the fundamentally instrumental nature of professionally driven litera-

ture searches, pragmatic limits to reading, or engagement with the literature will be required or dictated in some or many circumstances. But where should limits be set? The location of up-to-date scientific or research outputs generally involves limiting – sometimes quite severely – the dates within which searches take place. However, restrictions of this sort make little or no sense when metaphysical and normative questions are being pursued since the work of long dead scholars can potentially be more pertinent to these questions than recently written texts. Students and nurses engaged with such topics therefore confront awkward dilemmas around what is, and is not, to be included/excluded. This crucial or bedrock problem does not need to be resolved if by resolved we mean closed and, instead, case by case, reviewers might perhaps explain and justify search strategies. How would this work? Search strategies aimed at locating scientific and research only material should be pursued when we are interested in clarifying the evidence around, for example, specific treatment options (e.g. ceteris paribus – is this medication more/less likely than that medication to relieve this sort of pain in this patient group?). In such instances, it is both reasonable and legitimate to focus solely on those forms of evidence currently advantaged (i.e. generalizable research evidence and the propositional truth claims this provides). Alternatively, in privileged situations (e.g. academic student assignments and ex post facto reflection on clinical practice), constraints weigh less heavily and, in certain circumstances – i.e. when topics with a normative and/or metaphysical component are explored – humanities as well as scientific/research sources can and should be accessed and appraised. In almost every instance, only a small fraction of available and possibly appropriate sources will be reviewed and, therefore, we mostly fail to read comprehensively (however defined). This failure is inevitable/implicit but inadequately acknowledged in the current literature. Nonetheless, its explicit recognition places UK nurses in an uncomfortable situation since regulatory requirements demand that practitioners must deliver care ‘on the basis of the best evidence available and best practice’ (NMC, 2015, p. 7). Yet if only a subset of the literature is



accessed, nurses cannot know and should not therefore assert that best evidence/practice is being used or achieved. Further, acknowledging the partial or incomplete nature of reviews reminds us that understanding is fallible and capable of revision – i.e. this is what we know now and, at a later date, we may revise our current understanding as new information is gleaned. New information here can mean new to the reviewer (e.g. information overlooked or ignored in prior searches) or newly created information (i.e. new findings). The options outlined above leave a great deal unresolved and they do not, for example, address the resource- and time-limited nature of search options available to nurses in practice. Nevertheless, justifying search criteria on a case-by-case basis potentially allows a wider spectrum of sources to be taken into consideration (occasionally at least) and, I propose, this offers a significant improvement on the more formulaic procedures that are presently advanced. Further, even amid the clatter of clinical practice, framing search strategies within a discourse of open inquiry and dialogue [Thorne’s (2014) ‘conversation’] leaves the door ajar to wider reading at another time and allowing a greater range of sources to contribute to decision making, even fitfully, shows humility in the face of uncertainty. Fourth, returning to the second conception of knowledge (knowledge as understanding), if knowledge is a part of wisdom, and if wisdom requires or involves interpretation, art, and craft, then wisdom is perforce personal and subjective. It is an aspect of character and, as Roberts & Wood (2007) note, knowledge for the virtuous knower is more than ‘a collection of facts’ (p. 123). Knowledge in this sense is not something that can easily be modularized, broken down into parts, reassembled, and assessed. Educators may figuratively gesture towards frameworks or understandings in which knowledge becomes meaningful. However, the frameworks identified – like critical thinking more generally (for those who are uncomfortable with terms such as wisdom or virtue) – must be grasped ‘in the round’ by individuals who are able and ready to make the connections demanded. Metrics that seek to fastidiously grade and rank student knowledge sit awkwardly alongside concep-


tions of knowledge that rely upon the subjective or personal nous of students and educators. Knowledge in this sense is not developed through fixed or predetermined processes (i.e. a ‘correct’ search strategy) and it generates no one answer or set of responses. This is, as stated, potentially problematic for professionals and professions who need (or believe they need) to sift and classify the intellectual outputs of students against procedurally standardized assessment criteria. It is also a problem for practitioners who in clinical practice confront issues that are in key respects irresolvable (i.e. cannot simply be affirmed or denied). Knowledge here may stimulate thinking, reflection, and debate. However, discursive endeavours are of little comfort to nurses who need to make decisions in ‘the now’. It is also a problem for those who (like me) privilege reliabilist epistemological truth-generating processes in evaluating the internal validity of research outputs because reliabilism predominantly rests on external criteria and these criteria are not met by knowledge reliant on subjective comprehension. Externalism and internalism are complicated ideas and these descriptors carry different meanings depending on the type of assertions that are being discussed. Nonetheless, for normative/evaluative questions, I am prepared to countenance normative internalism (see, e.g. Goldman, 2009) and where our reasons for acting derive from internal values and concerns rather than externally situated values that reason prompts us to accept, this cannot but add to educator, practitioner, and professional complexity. Subjectivity is recognized by Hutchison & Rogers (2012) when they note that evidence-based medicine (and I suggest, by implication, evidence-based nursing or practice) illegitimately assumes that knowers (i.e. individuals who consume or read, in this instance, research papers) are substitutable. That is, the knower’s situation (prior personal beliefs/understandings) is deemed irrelevant to the manner in which external evidence imprints itself upon them. Reliabilism notwithstanding, subjectivity in interpretation cannot, however, be sidestepped. Knowers (people) are not substitutable and subjectivity is not a ‘shameful secret. Experience is what we start from and what every demand for verification must come back to.

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And since empiricism itself means “belief in experience” empiricists [researchers] are supposed to take this first-person activity seriously’ (Midgley, 2014, p. 56 – italicization in original). Fifth, following on from point four above, individuals do not and need not approach the literature on any subject in a state of dispassionate apatheia. People are emotional, engaged, and excitable. They go to the literature because they are interested in a subject (even if only to pass an assignment) and because they are in part intrinsically motivated (Freshwater, 2004) it is fallacious to imagine that interests do not colour search strategies or reading. This does not mean reviewers are dupes. Rationality and rational discernment, basic critical faculties, need not be abandoned simply because the topic being investigated is, for the reviewer, emotionally charged and educationalists should not assume that students conduct searches oblivious to the findings they expect to locate. Crude assumptions regarding the otherworldly objectivity of researchers were long ago shattered by philosophers of science and social scientists. Yet we continue to expect that students and nurses will find and weigh up ‘the literature’ as if they had no personal stake in what is concluded. This is silly. A more realistic approach would be to ‘out’ subjectivity head on. To this end, just as educationalists introduce students to the idea that ostensively value-free scientific practices and assumptions are frequently value laden, educationalists might also invite students to examine more fully their personal reasons for exploring a subject (question/topic) and, as part of reflection, students could be encouraged to recognize how their own value-informed reasons influence aspects of the review process. This does not commit to the claim that values direct or determine what is considered true and reflection of this sort does not guarantee that interest directing reasons will, in all cases, be identified for, as Sosa (2010) recognized, ‘The idea that we can always or even often spot our operative “evidence” for examination is a myth’ (p. 290). Moreover, as Williams (2006) claimed, ‘reflection can destroy knowledge’ (see also Moore, 1991). Thus, not only are the reasons why we hold beliefs/knowledge often inaccessible to reflection – i.e. we cannot reflectively

reason our way back through the layers of reasons and understanding to uncover some bedrock knowledge/belief – it is also as likely that reflection will undermine or extinguish beliefs/knowledge as it is that reflection will ground or illuminate beliefs/ knowledge. Nonetheless, let us grant that thinking through personally held motivations for focusing on a review topic or clinical issue may beneficially alert searchers to the potential for skewed or prejudiced reading. Sixth, the types of literature that are here being promoted – i.e. literature other than scientific research reports – often rest upon or deploy rational argument rather than descriptions of empiric observation. Rational argument can be difficult to assess and, reintroducing the Greek theme initially outlined earlier, Allen (2008), contrasting rationalism against empiricism, warns that arguments based on rational criteria are peculiarly vulnerable to an overreliance on rhetoric. [T]he plausibility, likelihood, or reasonableness attaching to conjectural conclusions can be represented in a favourable light, as providing the best available reasons for the conclusion in question, or unfavourably, as mere plausibility or apparent reasonableness. Exploiting the pejorative implications of ‘conjecture’, Cicero argues . . . that plausible divinatory conjectures for different and conflicting interpretations of the same event can be constructed on the basis of the same evidence, just as they can in forensic oratory. He means to imply that the credibility of an interpretive conjecture in divination has little to do with the force of the evidence and a great deal to do with the cleverness and persuasive skill of the diviner who proposes it.

Allen (2008, p. 167)

The place and significance of rhetoric in persuasion have yet to receive adequate attention in the nursing literature and, while it is in principle possible to distinguish between the logical and rhetorical aspects of argument in some if not all instances, in practice this is almost always difficult to do. Rhetoric is not ineludibly problematic and, for example, the persuasive force of papers such as those by Paley (2014) and Snelling (2013) – or anyone – is or can be enhanced by various linguistic devices. It is thus important to emphasize that rhetoric forms an element in most discourse (speech and writing). It is a necessary part



of communication. And, moreover, rhetoric aids and enhances as much as it obfuscates explanation. Nonetheless, more needs to be done around this subject as readers may locate work that is written from particular perspectives and, when this occurs, rhetoric and logic can become unhelpfully entangled. For example, Whyte (2013) discusses alcohol pricing (and other issues) and health policy in an Institute of Economic Affairs (IEA) publication titled Quack Policy: Abusing Science in the Cause of Paternalism. The IEA is a right of centre think tank/ educational charity and its outputs promote what might crudely be termed a classical or neo-liberal economic agenda. IEA publications include or utilize politically populist argumentative devices and anyone reading Whyte (2013) who is not aware of this bias (sophistry) could find their opinions swayed in a manner that may not otherwise have occurred. That said, the critique of health policy and alcohol pricing that Whyte (2013) advances is of relevance/interest to healthcare professionals and it is a critique that I bring to the attention of students. (This does not mean I necessarily want students to accept the critique.) The position advanced by Whyte (2013) is plausible. However, even if rejected (and I suspect most nurses will reject it), Whyte’s (2013) argument is one that nurses ought perhaps to be aware of. That said, from the perspective of an educator steering students towards materials that challenge credulous orthodoxies, significant problems surround the positioning of student reading for works of this sort – i.e. publications infused with persuasive (here political) rhetoric. Finally, seventh, the issue outlined above, the difficulty for literature reviewers in assessing the actionguiding value of arguments that incorporate both conspicuous and/or less overt forms of persuasive rhetoric is heightened or exacerbated if, by wide reading, we actively include or allow artistic and literary products to inform search processes. Here, the focus of difficulty centres on the balance that must be struck in forming understandings that comingle reason alongside emotion, sentiment, and understanding grounded upon imaginative construction. Rolfe (2014) argues that ‘What is lacking [in nurse education] is not training and not the ability to perform technical skills, but the empathy and imagi-


nation that a broad and well-rounded education provides’ (p. 1459).To enable this roundedness in relation to an appreciation of suffering, Rolfe (2014), invoking Rorty’s concept of solidarity, states that: Solidarity with those we care for can . . . be increased through the study of the humanities (history, social geography, the classics), through anthropology and through philosophy (hermeneutics, phenomenology, existential ethics). The study of these subjects is not a distraction from the business of learning to be a nurse, but a real and genuine attempt to understand the suffering of others and to place ourselves in their position.

Rolfe, (2014, pp. 1459–1460)

I am sympathetic to aspects of this position and, yet, let us be clear about what is proposed here. Accepting Rolfe’s (2014) argument might suggest that a literature search about suffering (perhaps related to the experiences of patients receiving palliative or end-of-life care) might not only include healthrelated commentaries and secondary sources, it could also seek out materials from the humanities. Indeed, any source that productively develops the understanding of the person conducting a search might be deemed legitimate and, if this is allowed, imaginative and thoughtful narratives such as C S Lewis‘ A Grief Observed (2013), or Albert Camus‘s The Myth of Sisyphus (2005), or the Book of Job (King James Bible), or Primo Levi‘s The Drowned and the Saved (2013) are not merely acceptable (‘okay, if you must’) but, rather, seeking out these sorts of texts could be desirable (‘this is what we want and expect to see’). Students and clinicians would possibly falter at such a suggestion. However, pragmatics aside, opening up searches in this way radically problematizes current epistemic norms of argumentative acceptability and adequacy.

Absurd outcomes Can artistic or literary texts inform practice-relevant understanding? The Book of Job (King James Bible) and The Drowned and the Saved (Levi, 2013) both engage important, vital, aspects of the human condition. Job describes the response of an individual to suffering and the oft posed question ‘why me?’ Levi (2013) details a personal response to pain and death

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and horror. These works are about many things. However, they both speak to understandings of suffering. Further, A Grief Observed (Lewis, 2013) and The Myth of Sisyphus (Camus, 2005) are, for me, profoundly insightful works that elide reasoned argument with emotive and inventive, almost poetic, oratory. Indeed, for me, these works say more about suffering’s nature, scope, and remit than any research study I recall (this ‘insight’ does not require that I agree with everything said in these texts). Surely then, were I seeking out literature to develop thinking about suffering, texts of this sort would be relevant. However, mindful of the fourth point (above), my personal reaction to Lewis and Camus need and will not be shared by all. Variation in interpretation occurs because, obviously, while my reading is correct for me (and by ‘correct’ I mean that I find these works movingly or persuasively insightful), there can be no uniform or consensus reaction to these texts and, in consequence, educators would struggle to assess student interpretations of these types of work. Difficulty surrounds the ability of educationalists to judge student assertions derived from literary sources for if student x says the work was insightful for her and student y says that she was unmoved by the work, we clearly cannot conclude that one student was right and the other wrong. We can assess the ability of students x and y to support, explain, and argue for their reactions/interpretations. However, this might lead to both students receiving the same grade despite coming to diametrically opposed conclusions. This is not in itself problematic albeit that I suspect some nurse educationalists would feel profoundly uncomfortable with such an outcome. Further, difficulty also stems from the avowedly Christian perspective of Lewis and the defiant nature of Camus’s somewhat bleak existentialism. Thus, in Lewis, we encounter a writer whose work can be appreciated but not fully understood without acknowledging a standpoint (Christianity) that sits awkwardly alongside aspects of modern UK healthcare practice. Lewis (2013) introspects in A Grief Observed upon his spiritual and psychological reaction to loss. The work ferociously analyses one man’s suffering in bereavement and I interpret Lewis’ experience in the light of other bereavements I witnessed

while working in palliative care. As a non-believer, I recognize and value the insights he offers. Yet my reading is coloured by the spiritual distance that separates us and, further, insofar as modern UK healthcare is secular or non-theist in practice, it would be foolish to imagine that a singular or general ‘healthrelated’ reading of the work is possible. Alternatively, in The Myth of Sisyphus, Camus (2005) upturns and questions taken-for-granted conventions about, for example, suicide and life’s meaning and, while I find this text thought-provoking, many nurses (individually) and nursing bodies (collectively) would in all likelihood be reluctant to endorse or sanction the views expressed. Both works are, to recap, insightful for me. Moreover, they are about suffering and possible reactions to suffering. On the face of it then, they are potentially relevant sources for me if I was exploring this territory and that exploration was not limited to the evaluation of research outputs. (By implication then, they are also similarly potentially relevant to other students/nurses).Yet neither work references or relies on the exposition of descriptive studies (point five above) and, although many nurse scholars are favourably disposed towards the arts and, a different but partially allied topic, the artistry of nursing (e.g. Tami, 2011; Wikström, 2011; Chan, 2014), anyone wishing to include these texts in, for example, a dissertation, will have to tread carefully. Educators who wish to bring ideas contained in these and other literary works to the attention of students may, as a protective mechanism, to avoid controversy, seek to distance themselves from those ideas (as I did above). And, if students took Lewis’ or Camus’s ideas seriously but did not perform similar ‘distancing manoeuvres’ in their writing, educators might well fault that writing. Thus, many, if not all, students who took up Lewis may want to recognize but then sidestep his Christian vantage and, also, students who engaged with Camus would be well advised to note that he decidedly does not demonstrate ‘nursing values’ as normally understood. The perceived need for cautious engagement of this sort is not confined to artistic or literary texts. However, the deliberate use of ambiguity and controversy in these works heightens interpretative prob-



lems. Unsurprisingly, it is easier for students and educators if we – nurses – collectively only access texts with safe, predetermined, and agreed outcomes. Though whether this self-censorious attitude necessarily or always benefits patients is less clear. Moreover, allowing – indeed encouraging – literary or artistic products into the mix of sources that students and nurses can legitimately employ in academic and other activities that have as their end point or telos practice improvement/decision making means the search process is now unbounded and, at this point, expanding the range of legitimate search objects teeters on the brink of absurdity. By this I mean that, while educators may be willing to countenance high art products in student search strategies (and Rolfe, 2014, for example, recognizes ‘the classics’, p. 1459), if the rationale for countenance rests on the insights that such products provide or potentially provide, then no obvious reason exists to exclude lowbrow artistic products. It will here be recalled that this paper began by noting that a TV soap drama ‘made sense’ of or captured something important about suffering for one student and, in addition, romantic or saucy ‘chick lit’ was used as a teaching aid. At a more exalted level, the philosopher John (2014) uses artistic works by Melville [1969 (1853)], Paley [1994 (1959)], and O’Connor [2000 (1947)] to illuminate and explore aspects of disagreement. Faulkner (2014) examined trust through a reading of Dostoyevsky’s (2003) The Brothers Karamazov and other examples could easily be listed. Artistic sources clearly provide useful material for scholars working across various disciplines and, definitional problems notwithstanding, high and lowbrow artistic and cultural products can generate rewarding insights for those who consume them. Thus, if insights relevant to nursing practice can be garnered from or stimulated by any source – so insights are essentially source irrelevant – then all sources have a potentially legitimate albeit differentially weighted place in developing thinking/ understanding. Indeed, insofar as relevance is an attribute or function of individual psychology, high and lowbrow artistic and cultural products may provide insights germane to practice and, depending upon the subject or topic being investigated, sources


such as these could be deliberately pursued by literature searchers and/or opportune exposure to any stimulus that sparks a ‘good idea’ should not be ignored. Except that this is preposterous. It surely cannot be the case that an episode of Family Guy or The Archers, or a steamy summer pulp bestseller, or a cosmetic advert can provide insights pertinent to practice and, even if an obscure or mundane or trashy source did prompt a student or nurse to think about care in a newly productive or creative way, we presumably do not want these products cited in academic work or, worse, we do not want practice decisions to be justified by reference to them. This would hold up nursing to ridicule, scorn, and mockery. And, yet, depending on the topic or issue being addressed, artistic and literary and other products probably can and on occasion do generate good or even better (more profound) insights than, for example, research reports. Of course, even the most optimistic of searchers would be unlikely to seek out cosmetic adverts on the off chance that meaningful health-related insights would thereby be obtained. However, Blackwell’s (2014) work on narcissism was inspired or stimulated in part by the L’Oréal advertising strapline ‘Because you’re worth it’, and a cursory glance of the social science databases will unearth a wealth of kindred examples (i.e. examples of seemingly trivial artistic, literary, and cultural products motivating perceptive scholarship/understanding). Therefore, unless educationalists are prepared to privilege as action-guiding claims derived exclusively by external reliabilist processes – and many or most qualitative studies probably fail this requirement – research findings do not necessarily trump artistic, literary, or other nonresearch sources in ‘use value’ for questions or issues that are primarily evaluative, normative, or metaphysical (and, as repeatedly stated, these sorts of question/issue infuse a great deal of nursing). In part, I am here simply reiterating or reintroducing the problematic status of qualitative research. However, I also pose a dilemma. A reasonable case can be made for expanding the range of sources that students and nurses should access when topics with strong normative and metaphysical components are

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addressed. On the other hand, escalating legitimacy leads to apparent silliness. Artistic or literary texts can and do inform our understanding. But allowing these products a place in search strategies could be a step too far and, corrigendum, it may be telling that this paper does not ‘follow through’ on the proposition that artistic/literary products can substitute for traditional scholarship. Thus, while Annas (2000, 2009), a respected Greek scholar, was cited to support the claim that (broadly speaking) two contrasting conceptions of knowledge exist, Alan Bennett’s The History Boys (2004) would equally have sufficed. In this play, Hector applauds an appreciation of knowledge for its own sake and in context (knowledge as understanding) while Irwin cynically deploys facts for affect (knowledge collapses to factoids of information). Artistic and literary works can present ideas more imaginatively and vividly than academic sources and, when this occurs, these sources carry greater psychological or persuasive impact. Distinctions between imaginative and factual narratives can be overdrawn (see, e.g. Matravers, 2014) and the relation between truth and value is complex and disputed (Weissman, 1993). Nonetheless, the use of artistic and literary sources in academic and/or professional works of this sort remains comparatively unusual and, by not introducing Bennett earlier, this paper reproduces rather than challenges existing mores.

Conclusion Almost everyone would allow that non-research scholarly texts can provide or stimulate ideas that have a bearing on practice and, depending upon circumstance, depending upon the question or problem being addressed, we could permit highbrow artistic and literary products to be similarly classified as insight or understanding generating. If this is granted, scholarly and high status artistic/literary products presumably are legitimate target sources in nursing searches that deal with, for example, normative and metaphysical issues. However, if highbrow art products can be legitimate sources in some searches, then why not lowbrow products? What is to prevent this slide?

Perceptive readers might learn much about the human condition from Boëthius, Montaigne, Shakespeare, Eliot, Brecht, or any number of esteemed and earnest writers. Indeed, it is because these and kindred authors possess a knowledge of humanity that is profound, deep, and lasting that we read and value them. Yet – and here’s the rub – we presumably do not want nurses basing practice on insights gleaned from Vanity Fair, Vogue, or last night’s TV soap. However, if we permit scholarly and high status artistic/literary texts to be sourced in searches because they arouse or generate insight and understanding in certain situations (e.g. situations involving normative/metaphysical considerations), have we not opened the proverbial floodgates? For if a cheap or ephemeral lowbrow artistic or literary product allows me insight or understanding into an aspect of human experience that I had hitherto been unaware of, then that insight/understanding is valuable for me. Further, if that insight/understanding informs my actions in a practice setting, it directly impacts patient care. That something can be valuable or informative ‘for me’ does not commit us to particular theories of truth, varieties of solipsism, or anything else. Nonetheless, while we might claim that the source of insight/ understanding is in key respects irrelevant – since what is important is that I now comprehend something previously unrealized, and what generated the insight/understanding is neither here nor there – nurses can hardly defend their decisions and actions to patients or colleagues by saying that a story in a throwaway magazine or a TV drama enabled them to realize something pertinent to practice. That could be thought absurd and, for nurses, this form of justification – if articulated – might lead quite quickly to reprimand, censure, and even dismissal. Thus, while good arguments can be marshalled in favour of broadening search strategies so that currently overlooked texts will be picked up by searchers, expanding the range of sources judged legitimate in developing thinking/understanding could allow into consideration material that prudent people would not countenance. In this way, a reasonable and unobjectionable argument prompts or ends in an incongruous conclusion. Further, if we are unsure about or need to problematize some artistic/cultural and non-research



literary sources because their ‘use value’ in generating understanding leaves us uneasy – what shall we say about qualitative scholarship – a form of inquiry that claims the status of ‘evidence’ on these very grounds? Thorne (2016) argues that, while the products of qualitative research can describe or be valuable nonevidential forms of knowledge, qualitative research is not ‘evidence’ as commonly understood and, perhaps, the same might be said of non-research scholarly and high or lowbrow artistic, literary, and cultural products. We should value ideas regardless of where they come from, regardless of the sources that stimulate them. However, we cannot accord these sources the title evidence. This does not downplay their importance. It does warn us, as Thorne (2016) counsels, against overexpanding the descriptor evidence. But, problematically, we are left with the dilemma posed by the potential of cheap or ephemeral artistic, literary, and cultural products to spark insight and understanding. Even if the influence of these sources on understanding was referenced or acknowledged in a review or academic work, how, if at all, these materials – as opposed to the ideas they generate – might support practice-based decisions/actions remains unresolved.

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