doi: 10.1111/nup.12042
Editorial
Nursing in the 21st century: is there a place for nursing philosophy? The 16th International Philosophy of Nursing Conference held at the University of Leeds in September 2012 addressed the meaning of nursing in the 21st century, and some of the papers presented appear in this special edition of Nursing Philosophy. The practice of nursing has changed in response to a number of external and internal drivers such as government policy, professional body requirements, the impact of globalization, and economic upheaval. Advanced practitioners with far-reaching skills are a feature of modern nursing and, in some countries, there is a substantial increase in the number of nonqualified assistant practitioners. Programmes that prepare students to become registered practitioners are mostly at undergraduate level and in some instances postgraduate level, and it is not uncommon for practicing nurses to hold master’s degrees and doctorates. The pace of change is relentless, and these and other changes are potentially challenging to what might be thought of as the traditional values of nursing such as caring, maintaining dignity, and individualized care. It is precisely these features of nursing that were found wanting in Robert Francis’s report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013). The report described numerous examples of failure to provide basic standards of care, respect, and dignity, and patients treated with callous indifference. One of the root causes of the problems at Stafford Hospital was the focus on financial pressures and achieving management targets with simultaneous understaffing of clinical areas. The delivery of nursing care takes time and is costly, but there is evidence to show that lower nurse staffing levels in hospitals are associated with poorer patient outcomes (Ball et al., 2013). However, financial concerns cannot be completely disregarded, and all international health care systems in the 21st century are likely be faced with the challenge of maintaining quality while minimizing costs. The first article by Barnes and Metzler explores a potential solution to this problem by introducing the
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 1–3
use of robots in the care of older adults. Written as a dialogue, the paper addresses merging the cultures of technology and nursing, and the concepts of consciousness and personhood. While advances in technology bring many benefits to both the patients and nurses in the equipment available for monitoring and treating people, Barnes and Metzler show that far from resolving the problems of scarce nursing resources, the use of robots raises profound psychological, philosophical, and spiritual questions for nursing practice. Continuing the theme of technological advances in nursing, the use of simulation technology in nursing education is discussed in the paper by Dunnington. Using the example of high-fidelity human patient simulation, Dunnington analyses how reality is represented in health care simulation and its impact on the learner’s experience of the reality of the human condition. The theme of nursing as a costly health care resource is also an issue in the paper by Scott et al. Set in the context of the Irish health care system and the country’s financial crisis, the nature and function of nursing are examined to understand the need for nursing in health care systems and patient care. Inevitably, such discussions lead to fundamental questions such as ‘what is a nurse’ and ‘what is nursing’, which at first sight seem rather extraordinary questions for nurses to ask. However, nursing can and has been defined in a number of ways, e.g. by stating the need for registration with a professional body, by using one of the numerous definitions published by nursing theorists such as Nightingale or Henderson, or those produced by collective bodies such as the International Council of Nursing or the Royal College of Nursing in the UK. Drawing on empirical evidence, Scott et al. investigate how nursing can be defined by examining what nurses do and suggest that a shared understanding of nursing practice consists of (at least) the concepts of safe quality care and humane, compassionate treatment. However, the term ‘nursing’ is also used in other contexts other than nursing prac-
1
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Janet Holt
tice, e.g. nursing as a profession, an academic subject, or as a practice-based discipline, and attempts to define nursing are not always meaningful across differing contexts. For example, the Royal College of Nursing’s (2003) definition of nursing talks of ‘exercising clinical judgement in the provision of care’ (p. 3), which is clearly an essential characteristic of nursing practice but is less obvious when nursing is described as a profession or an academic subject. A lecturer in nursing, if asked what they teach and/or research is unlikely to respond ‘exercising clinical judgment in the provision of care’. Furthermore, as degrees are awarded in nursing, a definition for the 21st century must have sufficient breadth and scope to explain what a student undertaking a degree in nursing would study, i.e. the epistemological basis of the discipline. The professionalization of nursing has been an important development and while even Nightingale argued for differentiation between the medical and nursing professions, nurses through the 20th century have in varying degrees been considered to be an oppressed group and subordinate to the medical profession. The complexity of the role of the nurse and physician is a feature of Risjord’s paper exploring paternalism and free will. Within the context of nursing and human freedom, the concept of autonomy is reframed to include positive and negative dimensions and consideration given to how differing roles and relationships with patients may influence the obligations of health professionals. A number of nursing theorists have argued for the articulation of a body of nursing knowledge that is distinct from other professions such as medicine or social work and how such a unique body of knowledge is important in defining nursing knowledge as a discipline in its own right. Two papers in this edition examine nursing knowledge. In the dialogue paper, June Kikuchi gives a philosophical analysis of an earlier work from Mark Risjord (2010) where he argues for a shift in the epistemology of nursing to allow it to be considered a legitimate profession. The paper sets out the key aspects of Risjord’s position for a philosophy of nursing where the discipline is developed from the nursing standpoint focusing on the values and problems of nursing practice and explores
what Kikuchi considers to be Risjord’s neglect of the idea of nursing as a practiced science. A different investigation of nursing knowledge can be found in the article by Newham. In this paper, the way in which nursing knowledge can be translated into clinical practice is explored and the problem of understanding praxis as having intrinsic value beyond that of technical expertise and measurable outcomes. Ensuring that nurses are competent to practice while at the same time having regard for traditional nursing values against a backdrop of diminishing resources may mean that there is little regard for nursing philosophy in the 21st century. A strong theme running through all the papers in this edition is the impact of changes in nursing practice on the education of future practitioners. For students, there is a substantial amount of theoretical knowledge to be imparted alongside experiential learning in the curriculum of nursing programmes, and there is a danger that nursing philosophy is not seen to be important. However, the papers in this special edition demonstrate two things: firstly, they address philosophical questions about nursing in the 21st century as yet unanswered, such as how do we define nursing, what should be its epistemological base, what is the place of technology, and how are new and existing knowledge claims to be substantiated. Irrespective of what the knowledge base is, as degrees are awarded in nursing, then it is plausible to consider it to be a distinct subject with the veracity and credibility of its knowledge claims amenable to verification. As the papers in this edition show, questions about nursing knowledge need philosophical investigation and therefore nursing philosophy must have a place in the acquisition, substantiation, and verification of at least some aspects of nursing knowledge. To argue otherwise would be to deny that ethics, e.g. is part of the body of knowledge that nurses need in order to nurse. Furthermore, exploration of concepts makes a substantial contribution to the discipline. Developing skills in critical analysis are not only expected features of graduates but useful for practice-based disciplines. This is the second important feature of the papers in this special edition: they explicitly demonstrate the skills of philosophical analysis. While this is perhaps unsurprising for papers in this journal, as Melody
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 1–3
Nursing in the 21st Century
Carter observes in her report of the conference, having space to think and question is essential for nursing practice. So reading papers such as the ones presented here gives the reader not only knowledge of the subject matter but also how to engage with the practice of nursing philosophy, both of which are essential for existing and future practitioners facing the challenges of nursing in the 21st century.
References Ball J.E., Murrells T., Rafferty A.M., Morrow E. & Griffiths P. (2013) Care left undone during nursing shifts: associa-
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 1–3
tions with workload and perceived quality of care. British Medical Journal Quality Safety. doi: 10.1136/bmjqs-2012001767. [Epub ahead of print]. Francis R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. HMSO, London. Risjord M. (2010) Nursing Knowledge: Science, Practice and Philosophy. Wiley-Blackwell, Oxford. Royal College of Nursing (2003) Defining Nursing. RCN, London.
Janet Holt University of Leeds
3
Editorial
Nursing in the 21st century: is there a place for nursing philosophy? The 16th International Philosophy of Nursing Conference held at the University of Leeds in September 2012 addressed the meaning of nursing in the 21st century, and some of the papers presented appear in this special edition of Nursing Philosophy. The practice of nursing has changed in response to a number of external and internal drivers such as government policy, professional body requirements, the impact of globalization, and economic upheaval. Advanced practitioners with far-reaching skills are a feature of modern nursing and, in some countries, there is a substantial increase in the number of nonqualified assistant practitioners. Programmes that prepare students to become registered practitioners are mostly at undergraduate level and in some instances postgraduate level, and it is not uncommon for practicing nurses to hold master’s degrees and doctorates. The pace of change is relentless, and these and other changes are potentially challenging to what might be thought of as the traditional values of nursing such as caring, maintaining dignity, and individualized care. It is precisely these features of nursing that were found wanting in Robert Francis’s report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013). The report described numerous examples of failure to provide basic standards of care, respect, and dignity, and patients treated with callous indifference. One of the root causes of the problems at Stafford Hospital was the focus on financial pressures and achieving management targets with simultaneous understaffing of clinical areas. The delivery of nursing care takes time and is costly, but there is evidence to show that lower nurse staffing levels in hospitals are associated with poorer patient outcomes (Ball et al., 2013). However, financial concerns cannot be completely disregarded, and all international health care systems in the 21st century are likely be faced with the challenge of maintaining quality while minimizing costs. The first article by Barnes and Metzler explores a potential solution to this problem by introducing the
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 1–3
use of robots in the care of older adults. Written as a dialogue, the paper addresses merging the cultures of technology and nursing, and the concepts of consciousness and personhood. While advances in technology bring many benefits to both the patients and nurses in the equipment available for monitoring and treating people, Barnes and Metzler show that far from resolving the problems of scarce nursing resources, the use of robots raises profound psychological, philosophical, and spiritual questions for nursing practice. Continuing the theme of technological advances in nursing, the use of simulation technology in nursing education is discussed in the paper by Dunnington. Using the example of high-fidelity human patient simulation, Dunnington analyses how reality is represented in health care simulation and its impact on the learner’s experience of the reality of the human condition. The theme of nursing as a costly health care resource is also an issue in the paper by Scott et al. Set in the context of the Irish health care system and the country’s financial crisis, the nature and function of nursing are examined to understand the need for nursing in health care systems and patient care. Inevitably, such discussions lead to fundamental questions such as ‘what is a nurse’ and ‘what is nursing’, which at first sight seem rather extraordinary questions for nurses to ask. However, nursing can and has been defined in a number of ways, e.g. by stating the need for registration with a professional body, by using one of the numerous definitions published by nursing theorists such as Nightingale or Henderson, or those produced by collective bodies such as the International Council of Nursing or the Royal College of Nursing in the UK. Drawing on empirical evidence, Scott et al. investigate how nursing can be defined by examining what nurses do and suggest that a shared understanding of nursing practice consists of (at least) the concepts of safe quality care and humane, compassionate treatment. However, the term ‘nursing’ is also used in other contexts other than nursing prac-
1
2
Janet Holt
tice, e.g. nursing as a profession, an academic subject, or as a practice-based discipline, and attempts to define nursing are not always meaningful across differing contexts. For example, the Royal College of Nursing’s (2003) definition of nursing talks of ‘exercising clinical judgement in the provision of care’ (p. 3), which is clearly an essential characteristic of nursing practice but is less obvious when nursing is described as a profession or an academic subject. A lecturer in nursing, if asked what they teach and/or research is unlikely to respond ‘exercising clinical judgment in the provision of care’. Furthermore, as degrees are awarded in nursing, a definition for the 21st century must have sufficient breadth and scope to explain what a student undertaking a degree in nursing would study, i.e. the epistemological basis of the discipline. The professionalization of nursing has been an important development and while even Nightingale argued for differentiation between the medical and nursing professions, nurses through the 20th century have in varying degrees been considered to be an oppressed group and subordinate to the medical profession. The complexity of the role of the nurse and physician is a feature of Risjord’s paper exploring paternalism and free will. Within the context of nursing and human freedom, the concept of autonomy is reframed to include positive and negative dimensions and consideration given to how differing roles and relationships with patients may influence the obligations of health professionals. A number of nursing theorists have argued for the articulation of a body of nursing knowledge that is distinct from other professions such as medicine or social work and how such a unique body of knowledge is important in defining nursing knowledge as a discipline in its own right. Two papers in this edition examine nursing knowledge. In the dialogue paper, June Kikuchi gives a philosophical analysis of an earlier work from Mark Risjord (2010) where he argues for a shift in the epistemology of nursing to allow it to be considered a legitimate profession. The paper sets out the key aspects of Risjord’s position for a philosophy of nursing where the discipline is developed from the nursing standpoint focusing on the values and problems of nursing practice and explores
what Kikuchi considers to be Risjord’s neglect of the idea of nursing as a practiced science. A different investigation of nursing knowledge can be found in the article by Newham. In this paper, the way in which nursing knowledge can be translated into clinical practice is explored and the problem of understanding praxis as having intrinsic value beyond that of technical expertise and measurable outcomes. Ensuring that nurses are competent to practice while at the same time having regard for traditional nursing values against a backdrop of diminishing resources may mean that there is little regard for nursing philosophy in the 21st century. A strong theme running through all the papers in this edition is the impact of changes in nursing practice on the education of future practitioners. For students, there is a substantial amount of theoretical knowledge to be imparted alongside experiential learning in the curriculum of nursing programmes, and there is a danger that nursing philosophy is not seen to be important. However, the papers in this special edition demonstrate two things: firstly, they address philosophical questions about nursing in the 21st century as yet unanswered, such as how do we define nursing, what should be its epistemological base, what is the place of technology, and how are new and existing knowledge claims to be substantiated. Irrespective of what the knowledge base is, as degrees are awarded in nursing, then it is plausible to consider it to be a distinct subject with the veracity and credibility of its knowledge claims amenable to verification. As the papers in this edition show, questions about nursing knowledge need philosophical investigation and therefore nursing philosophy must have a place in the acquisition, substantiation, and verification of at least some aspects of nursing knowledge. To argue otherwise would be to deny that ethics, e.g. is part of the body of knowledge that nurses need in order to nurse. Furthermore, exploration of concepts makes a substantial contribution to the discipline. Developing skills in critical analysis are not only expected features of graduates but useful for practice-based disciplines. This is the second important feature of the papers in this special edition: they explicitly demonstrate the skills of philosophical analysis. While this is perhaps unsurprising for papers in this journal, as Melody
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 1–3
Nursing in the 21st Century
Carter observes in her report of the conference, having space to think and question is essential for nursing practice. So reading papers such as the ones presented here gives the reader not only knowledge of the subject matter but also how to engage with the practice of nursing philosophy, both of which are essential for existing and future practitioners facing the challenges of nursing in the 21st century.
References Ball J.E., Murrells T., Rafferty A.M., Morrow E. & Griffiths P. (2013) Care left undone during nursing shifts: associa-
© 2013 John Wiley & Sons Ltd Nursing Philosophy (2014), 15, pp. 1–3
tions with workload and perceived quality of care. British Medical Journal Quality Safety. doi: 10.1136/bmjqs-2012001767. [Epub ahead of print]. Francis R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Executive Summary. HMSO, London. Risjord M. (2010) Nursing Knowledge: Science, Practice and Philosophy. Wiley-Blackwell, Oxford. Royal College of Nursing (2003) Defining Nursing. RCN, London.
Janet Holt University of Leeds
3
