Inr. 1. .?.urs. Stud., Vol. 27. No. 3. pp. ~4%:56. Pnntrd tn Great Brirain.
M)2&7489/90 53.00 + 0.00 C 1990 Pergamon Press plc
Nursing models and the idea of nursing .
KEITH CASH, B.A.(Hons),
Assistant Professor, School of Nursing, Memorial University, St. John’s, Newfoundland. Canada
Abstract-The Wittgensteinian idea of family resemblances and meaning is explained. The idea of nursing is examined from this standpoint as are the knowledge claims of several influential nursing models. It is argued that the task of building a general model of nursing is theoretically impossible. The political and educational implications of the above argument are developed.
Introduction This paper is philosophical in nature but aimed at a very practical series of questions. On many wards nurses are looking at or trying to implement models of nursing. Models are now an explicit part of some curricula: for example that for Registered Mental Nurses. The success or otherwise of these attempts will have complex results on the attitudes of nurses towards theoretical questions and the relevance of theory, as well as presumably on the quality of care delivered. The second thrust of the paper is towards the political, in its broadest sense, implications for nursing and nurse education. If the argument that I am going to present, that nursing is not a unitary concept, that crudely, nursing is what nursing does, then the current problems in the definition of nursing or the attempted reduction to the concepts of, for example, caring or adaptation is theoretically misguided. The problem stated
The current fashion in nursing models seems to raise the question of what nursing is. Nursing models are predicated on the assumption that such a thing exists. Patently it does. But if so why is it so difficult to define the word? This paper looks at the definitional problems involved, offers some philosophical resolution of them and considers the implications of this approach for the theories of and the politics of, nursing. 249
When we think of ‘Nursing’ it seems immediately obvious that nursing is what nurses do. Nurses tend to think that they know what they do; some non-nurses seem to think that they know what nurses do (Griffin, 1980, 1983; Baldwin, 1983). The nursing theorists create entities such as a Theory of Nursing, ‘Conceptual Nursing Models’, etc., all of which seem to be predicated on this thing that is nursing. Here I propose a philosophical digression: there is a long standing debate in academic philosophy about the nature of terms such as ‘nursing’. The argument is about whether there are general terms that refer to an element that is constant, such that there is something that is common across all instances of the use of the term. The common element is called a universal and every member of the class referred to by a general term is a member of that class because of the possession of a particular property shared by all members of that class. We can further distinguish between universal terms in the world of language and real universals in the non-linguistic world, where the latter are objective properties. The general term is correctly applied when it refers to something which possesses the objective, universal property.
The Family Resemblance
and its Relevance to Nursing
Of course, the definitional problem is not exclusively confined to nursing and its associated concepts. Wittgenstein (1953: para.65) argued that words get their meaning in use, rather than by having some inner meaning that is hooked into them, and dissoluble from them. He used the example of the general term ‘game’, where no common element of all games can be found. For example, Olympic games, ball games and card games differ in terms of the number of players, the element of competition, the materials used etc., but we would agree that they are all games. Wittgenstein talks of family resemblances where the interrelationships are like the strands of a thread where no single fibre runs the whole length of the thread but there is a constant overlapping of successive fibres (1953: para 67). We can move from game to game and agree that they are games but, from the first to the last game discussed, we will find nothing in common. “We see a complicated network of similarities overlapping and crisscrossing: sometimes overall similarities, sometimes similarities of detail” (1953: para 66). Bambrough (1960) gives a more formal example. Suppose that we have five objects that we wish to classify: and we want the classification to be based on whether, or not, the features ABCDE are present or absent. It happens that the five objects edcba each have four of the properties but lack the fifth, and that the missing factor is different in each case. e
As Bambrough (1960: p.189) puts it, “Here we can see already how natural and how proper it might be to apply the same word to number of objects between which there is no common feature.” A more accessible argument is another of Bambrough’s (1960: p.190) using the ‘Churchill face’ as a literal family resemblance. We suppose that there is a striking family resemblance such that, if we had a family photograph with the members present, we would have no difficulty in seeing that they all belong to the same family. Now, further suppose that there are ten features by which we can describe the family face, for example, dark hair, ruddy
NURSING MODELS AND THE IDEA OF NURSING
complexion etc. “It is obvious that the unmistakable presence of the family face in each single one of the ten members of the family is compatible with the absence from each of the ten members of the family of one of the ten constituent features of the family face” (Bambrough 1960: p.190). I intend to argue that this is precisely the situation in nursing and that therefore to talk of a general theory of Nursing is as wrong as talking of a theory of games; if, that is, a theory of games presupposes that all games have something in common in virtue of which they are games. (There is a thing called Games Theory but this is different. It can be seen as the principles of poker applied to similar situations of competition with imperfect knowledge). The argument will be presented in two stages. The first is the examination of the idea of nursing. The second, the examination of the idea of caring, which some have seen as central to nursing. (Griffin, 1983; Orem, 1985). There are multiple definitions of ‘nursing’ in existence. There is an understandable drive in constructing nursing theories to attempt to include some definition of the subject matter. Suppose we take the definitions of eight theorists and writers of influential texts (Peplau, 1952; Henderson, 1964; Hargreaves, 1979; Johnson, 1980; Luckman and Sorensen, 1980; Neuman, 1980; Roy, 1980; Stuart and Sundeen, 1983) and attempt to analyse them structurally, i.e. counting word frequencies we then get the following result. There is no universally common term but, rather, we get a series of related but separate terms. If we cluster these terms we can find terms that seem to have a family resemblance. The first family is that of independence with associated terms such as ‘self-care’, ‘normal activities’, ‘patterns of daily life’, ‘activities contributing to health’ and ‘recovery’. The next grouping is that of dependence, with terms such as ‘direct assistance’, ‘comfort’, ‘helping’, ‘support’, ‘cannot do for himself’, ‘assist’ and ‘sick’. The third cluster is the family of technical terms, such as ‘promoting adaptation’, ‘response to stressors’, ‘therapeutic’, ‘maturing forces’, and so on. We can see from this elementary analysis some of the main theories current in England that no absolutely clear definition or semantic pattern arises but that the terms nevertheless seem to have something in common with each other. I intend to argue, following Wittgenstein, that this does not mean some common element underlies these terms that we can call the essence of nursing in the sense that the realist would hold (Staniland, 1972: p. 75). Rather there is a family resemblance between most of what these terms refer to which does not imply the existence of some common core that we can call nursing. We could introduce the idea of higher and lower order terms whose specificity is related to the clustering of the various meanings as defined by usage. For example, a lower order term has greater clustering, greater intercorrelations between terms, a more distinct family resemblance. In this sense ‘nursing’ is a high order term. Theoretical positions can relate to lower order terms as explanatory mechanisms. With higher order terms it becomes more problematic-the theoretical scheme necessarily has to exclude a great deal of the various uses of the term. In this process a general theory of nursing ceases to be general and so, in this sense, to talk of one theoretical position being generally applicable is inappropriate. In this context it will be instructive to examine in detail the nature of nursing as envisaged in two of the major general theories in current use. Orem (1985) specifically states that hers is a “general theory of nursing” (1985: p, 33). It is predicated on the theory of self-care deficits. These are related to eight self-care requirements that are seen as universal. These include categories such as maintaining sufficient intake of air, sufficient intake of water etc. (1985: pp. 90-91) Self-care is seen
as “. . . care that is performed by oneself for oneself when one has reached a state of maturity that is enabling for consistent, controlled, effective and purposeful action.” (1985: p. 39) Nursing then is the substitution for this self-care agency in the presence of a self-care deficit. The above summary raises some important points about Orem’s view and about the theoretical foundation of nursing. The universal self-care needs and their fulfilment do not seem to be exclusively the province of the nurse. Medical staff have an intimate relationship with these needs and, it can be argued, have the legal right to prescribe or prohibit the specific care for each one. Ancillary professions such as physiotherapy or psychology also claim some areas as their legitimate sphere of activity. The aiding of these self-care needs might therefore be necessary for nursing but not sufficient to define it. It could be argued that the situation with regard to the universal self-care needs is more precise the more the need is related to medical practice. By this I mean that the more the universal self-care need is related to immediate survival then the clearer is the nature of the intervention required. For example, if a person is on a ventilator to assist breathing because of some dysfunction of the breathing mechanism, then the nurses’ role can be seen to be directly related to supporting the breathing until the patient’s own ability to do so has been restored. The argument against this limiting case however is as follows. The decision to place the patient on the ventilator is a medical decision. What the nurse does following this is not unique to nursing. For example, the physiotherapist could be involved in a variety of tasks that are related to the breathing, suction for example, and even in some hospitals the management of pressure areas. In other words the self-care model does not provide an exclusive definition of what nursing is. It could be argued that in this situation nursing is still needed to help people who are in this position and cannot help themselves. This misses the point of my argument. If selfcare substitution is seen as the-constant, the universal throughout nursing practice, then if that universal is found in other professions then it is meaningless to speak of a general theory of nursing. In that case we have provided something that a// caring professions have in common, and we have not delineated what is exclusive to nursing. We should rather, in the case of the.example above of the patient on the ventilator, be trying to develop some theory of, say, intensive care nursing that could distinguish the nurses’ contribution from the physiotherapists’. Roy’s model (Riehl and Roy, 1980) provides a different focus in general theory construction as the categories of the model are glued together by the principles of systems theory. The “goal of nursing” (1980: p. 183) is the “person’s adaptation” in the four modes that are associated with her theory and “nursing is unique because it focuses on the patient as a person adapting to those stimuli present as a result of his position on the health illness continuum” (1980: p. 183). This latter statement seems to be simply wrong. As has been demonstrated above, other professions also share elements of this interest. The use of the concept of adaptation, using systems approach as the theoretical matrix is shared with Johnson’s model (Johnson 1980). The idea that nursing is indissoluble is present in this approach. By this I mean that the various elements that comprise nursing must be in some way constant elements if they are to be joined by the process of adaptation. In other words the theoretical structure requires nursing to contain elements that are constant and therefore universal. This procedure seems simply to assume what has to be established, i.e. that the general terms used invoke properties that are general. If my use of Wittgenstein’s family resemblance argument is correct, then the term ‘nursing’ does not refer to these universal properties. A theoretical foundation such as adaptation is therefore inappropriate.
AND THE IDEA OF NURSING
We have seen now two sorts of general theory, one where a concept is seen as central to the theory and the other where the concepts are placed in an imported theoretical matrix. In both cases the same difficulty of finding an exclusive universal is found. It could be argued that one way round the problem is to look at what is usually seen as the paradigm case-general nursing, that is medical, surgical and obstetric nursingand focus on its exclusive categories. It is undoubtedly true that numerically it is the most important in terms of staffing. However, to argue that therefore the definitional problem is solved is rather like arguing that because numerically 22 people play football there are no difficulties in relating that concept of a game to a solo game such as solitaire. Clearly the interesting philosophical points are where we reach the areas further from the centre, from the paradigm case. For example, we have psychiatric nursing, health visiting, school nursing, mental handicap nursing and health education. Within each of those areas we can have differing specialities; in psychiatric nursing we have behavioural therapists, psychotherapists and nurses caring for the elderly mentally ill. If we relate the work of the behavioural therapist with the psychogeriatric nurse under the concepts extracted above we can see that whilst there are some areas of similarity there are considerable areas of difference. If we try to look at the family resemblance between say the psychotherapist and the psychogeriatric nurse we can perhaps see the wide difference between them. However if we compare the behaviour modification nurse with the psychotherapist there is a closer resemblance. When we move to comparing the surgical nurse with the health visitor we can again find some relationships, but whether these are exclusively Nursing relationships is problematic.
The Idea of Caring
The point can be more completely developed if we look at a concept that has been seen as central to nursing, that of caring. Applying the family resemblance argument we can see again that the meaning of the concept is use-specific. In behavioural therapy an attempt is made to alter some behavioural characteristic of the client. What does caring mean in this context? Applying Griffin’s (1983) criteria of the activity of the ‘activity’ and ‘attitudinal’ elements of caring we can see that the therapist can be seen to care. But looking also at the general practitioner writing out a prescription we can see that he also can be said to care in a very similar way. We argue therefore that this concept of caring as central to nursing has the following problem. If an attempt is made to abstract the term from the many usages and referents into a single concept, then the result is so general that it does not particularise Nursing but, rather, is applicable to a wide variety of other occupations. Dunlop (1986) uses a similar argument where as Nursing becomes more and more divorced from the physical aspects of care it becomes more similar to other professions. It might be useful at this point to look at two of the more extensive analyses of the concept of caring. Griffin (1983) argues that there is a multiplicity of meanings of caring but that merely listing the usages is of limited use and that one needs to examine not the words but “. . . the coherence of the ideas underlying them” (1983: p. 290). The difficulty with this approach is that this ignores the precise point made by Wittgenstein, and immediately assumes what has not been demonstrated-that there is something that can be described as a universal feature of caring, rather than us having a family resemblance of terms. Austin (1979) gives the warning of “. . . how essential it is to have a thorough knowledge of the
different reasons for which we call different things by the same name before we can confidently embark on an enquiry.” For example Griffin gives the activities of caring as assisting, serving and helping. This merely postpones the problem until one has examined these three elements to see if they have universal features in common that can provide the universalising strands that her argument requires. A simple case-a nurse refuses to do something for a patient; must this necessarily be construed as not caring? Clearly not, so the family resemblance argument will be relevant to the triad of caring characteristics. The politically relevant question also arises as this mesh of meanings within the context of nurses’ activities overlap with the use of terms by other occupational groups apart from nursing. The implication if these categories are unique is that we can really talk in the realist sense of nursing having some common core and therefore perhaps being a unique profession; if they are not unique then the general models that have the assumption that nursing is defined by these terms are wrong in a fundamental sense. They are wrong because they call themselves models of nursing, but if nursing has no common core one can only talk of models of, say, dialysis nursing, of behaviour modification nursing etc. Dunlop (1986) in her examination of whether a science of caring is possible provides the useful distinction between a ‘science for caring’ and a ‘science of caring’. In the former case we have the multiple applications of other disciplines to clarify and improve the process of caring: in the latter case we have caring itself as the central subject matter. She points out the historical, societal, and linguistic determinations of the term ‘caring’. Following Benner (1984) she seems to support a hermeneutical, Husserlian approach to the attempts to grasp the underlying knowledge of nursing/caring; this expression being used to limit the construction of caring within the nursing domain. What constitutes caring will be explicated by situational paradigms rather than generally acceptable rules. “This is extremely useful in elucidating nursing/caring . . . But it does not provide us with any universal truth about caring in general or nursing/caring in particular” (1983: p. 688). This argument can be extended to include the one that I have constructed above: if the use of the term ‘caring’ is context specific even within nursing then the meaning of the term will be of the family resemblance type. However, in the case of Dunlop it is difficult to see how the expression ‘science of caring’ can be useful. Science as usually meant would seem to require precisely what we don’t have here-some universal with which we could build causal networks. In that sense Dunlop seems to beg the question by presuming the existence of nursing/caring before the hermeneutical investigation to discover it. Arguments that Nursing is in some way pre-paradigmatic in a Kuhnian (1962) sense would also seem to be in error. The paradigm assumes the possibility of a dominant explanatory conceptual or theoretical scheme. If my argument is correct then there is no such possibility for nursing and the search for such a scheme should be removed from the agenda of nurse thinkers. What we have is nursing being so generally defined that it loses its identity. Barristers can care, nurses cannot conduct a court case, doctors can care, nurses cannot transplant a heart, social workers can care, nurses cannot take a child into care. Here, of course, we start to get the overlapping between occupational groups that is significant in reducing the specific clarity of professional aspirations. So, for example, clinical psychologists can find themselves in the position of working in a team with more experience in specific psychological therapies than themselves: nurses can work with occupational therapists in a similar position to the clinical psychologists.
The situation is interesting because if it is not possible to strictly, and philosophically, delineate the core of some professions then the only way to do so is by legislation. For example, clinical psychologists are in the process of being chartered (British Psychological Society, 1988) in an attempt to protect their interest areas from outside incursions. Job descriptions for them can be such as ‘responsible for the psychological care on the unit.’ Such statements immediately imply a territorial dispute with nursing. Politically therefore the growth in general models of nursing, if my analysis is correct, seems to have effects that bear little relation to their original intention. Rather than pointing to the distinctiveness of nursing they show that nursing potentially encompasses precisely what nurses want and are capable of encompassing. If, for example, the profession decided that special training was needed and that it would be provided, then the role of, say, the clinical psychologist, physiotherapist, occupational therapist, radiographer and so on and so forth would have been considerably limited. We have the situation therefore where there is no central core that can distinguish nursing theoretically from a number of other occupational activities. To talk of a general theory of nursing is therefore as much of a solecism as talking of a general theory of psychology or a general theory of social work. One feels intuitively that in the latter two cases the statement would be taken to mean one particular theory of psychology, e.g. behaviourism, or one particular area of interest to social work, such as social deprivation. McFarlane (1976) argues that there is no possibility of a unitary theory of nursing, at least it is as unlikely as a unitary theory of sociology or medicine. However, what are possible are theories related to concepts such as self-care, agency, continence and so on (1976: p. 450). If what I have argued above is true then this is not an obtainable goal either. The reason is that once again the idea of-say-continence is not a unitary thing but rather multiplicit in the variety of its meanings. We can therefore have a variety of theories applied to continence but not a theory of continence. This is the science for caring mentioned by Dunlop (1986). Conclusions
Let us see where the argument has lead us so far. We established, following Wittgenstein, that terms are given their meaning through their use. And, looking at the meaning of the word ‘nursing’ and the (in the literature) associated word ‘caring’ that there were no features that were exclusive to nursing or caring. Therefore it was argued that a general theory of nursing, or a general model of nursing were not possibilities. Looking at two of the major established general theories it was shown that they do not answer the above case but rather showed the result of not accepting this theoretical conclusion. The implication for practising nurses is therefore that implementing an established nursing model in a practice setting will lead to some difficult problems because of this fundamental theoretical error. These problems will be related both to the degree of the possible implementation of the model, the perceptions of the practising nurses, and the quality and nature of the nursing care delivered. References Austin, J. L. (1979). Philosophical Pupers. Oxford University Press. Oxford. Baldwin, S. (1983). Nursing models in special hospital settings. J. Adv. Nun. 8, 473-476. Bambrough, R. (1960). Universals and family resemblance. Proc. Arisroleun Sot. LXI, 207-222.
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(Received 23 March 1989; accepted for publication 2 January 1990)