Nursing Study Guide/nursing, science and nursing science

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"What we know is tiny compared with what we don't know." says environmental science guru, David Suzuki. He was talking about the universe in general, about rocks, planets and gases and incredibly large and small measurements in time and space. Nevertheless, the same principle applies to Nursing as a new profession. Nurses have been doing research now for decades and the volume of research being used and published is rising. There are some hard facts about nursing that fit in the category of what we can safely say about nursing. Far less clear, is where this certainty fits with nurses themselves. At the same time, may nurses have opted to take a more qualitative approach to study phenomena of the nursing world and produced leading edge papers in this field as well. As you might imagine, this apparent ideological dichotomy has created a space for some brisk discourse.

There were some dark days in nursing, when early nursing disciples from various theoretical camps set out to annihilate each other's credibility in published academic forums. Nurses tried to discount the value of competitors work from approaches they disapproved. By all regards, this happens in all faculties and professions. I see no evidence that nursing is any worse. I have seen dictionary definitions of a health care genre (psychology) which specified it being characterised by marked differences of opinion.

Among the debates that continue about nursing, are the nature of nursing itself. Where should the faculty be situated on campus? Obviously nursing is not a pure science like mathematics or physics, but neither are the other health professions. Of the thirty universities teaching nursing in Australia, none share classes with medicine. Nursing tends toward being an innovative technology which combines aspects from other disciplines like psychology, but has amassed a body of it's own knowledge which does not easily fit into another library. One of the more fundamental arguments is about whether nursing should associate itself with science, since science is privileged by enterprise in our society, but the inherent positivism in this association can detract from the social aspects of nursing. Some nurses hold that nursing is an art or a craft of which science is a relatively small part. Some nursing faculties are housed as a humanity. Yet other nursing school emphasise the business aspects of nursing, or situate nursing alongside sport in combined health and wellness facilities. Rather than trying to be a branch of science, we can see why some academics believe nursing is like....well, nursing.

the nature of nursing knowledge

Epistomology is the study of knowledge, not what is contained in the knowledge, but the form of what the knowledge is. Initially this sounds very confusing so I will start explaining with an illustration.

"This sentence contains the word sentence" is a rational statement which is verifiable. This is a type of logical argument and they can become very complex and are sometimes substituted with mathematical formulae. When all the components are present to make a rational argument of this type, the knowledge is considered deductive because the arguments contain all the facts you need to make up the conclusion.

The traditional science we all think of as taking place in laboratories with Bunsen burners glass decanters and so on is nothing like that. Experimental science is called inductive because it relies on the probability that we can make the same experiment happen over and over again.This type of science is very very good at a quite specific type of experiment. The best results come from trials in which variables, like drugs, can be controlled. There are millions of experiments in which the results of pill 'A' are compared to pill 'B'. There are such thick collections of such papers that they have been drawn into over-arching studies (meta-analyses) showing the result of papers running over many years, this is most often referred to as a sound evidence base with water tight scrutiny, the best available.

Nurses who claim to be using best evidence in their practise (best practise nursing) will be able to produce randomized controlled studies where P<0.001 (the probability of producing the same result by accident is a thousand to one or less.) or better still, they will be able to show meta-analysis from a sytematic review as found in the cochrane database. The problem is , of course that there are simply not that many in nursing. The Joanna Briggs institute which prides itself in these matters has advice sheets on a few hundred topics and procedure manuals around the country are based on them. They are valuable as far as they go.

One way of making sense from all the swampy ocean of nursing theorists, is to divide them according to whether they subscribe to the unity or atomistic groups. The atomistic nursing theorists write as though the entire universe can be broken down into smaller parts and each of these studied in detail. traditional laboratory science is good at this quantitative research, but typically costs a lot of money. Pharmaceutical companies can invest large amounts on details like wound dressing material A versus B. there is not a lot of money available for nursing research which does not use any products. So, for example if you wanted to prove that certain wounds are better without any dressings at all, then the study is unlikely to attract pharmaceutical funding. Ethics committees are very good at avoiding most types of immoral investigation, but cannot produce funding where there is no interest. Theorists who belong in the atomistic camp include authors like Imogene King, Betty Neuman and Orem. Critics of the scientific approach bemoan taking client care out of context. Some warn of the militarisation or industrialisation of nursing, resulting from seeing care as mechanical.

The unity camp, on the other hand consists of writers like Jean Watson, Rosemary Risso-Parse and Barbara Rogers. Their world view incorporates a conviction about the interconnectedness of life. The unity theorists tend to be mentioned in qualitative works which investigate natural occurrences in context and reflect the subject holistic experience. These studies tend to be naturalistic and require huge volumes of text, such as transcripts of interviews. They are time intensive and produce no numbers, but wordy findings. The great strength in thee approaches is to make explorations which can't be found by other methods. The explorations often lead to focussed study by other methods and for this reason many authors speak of triangulation or cross-referencing by approaches, rather than blending or fusion between them, as there is little room for compromise on the question of methodology. Critics of the unity approach claim excessive jargon disguises similarity between theorists and the findings are too dilute to guide practise. There are not just a few papers like this, but millions. So many they inhabit journals published entirely for this style of research. The scientific camp takes themselves seriously with industrial concepts like health informatics and nursing process and so on, but clearly there are nurses who subscribe to at least two schools of thought. One might worry about the critical thinking capability of nurses if this were not the case.

A third camp was established by sociological authors like Pat Benner, who noticed that the theory practise gap may not be as big as previously thought, that Nurses may not habitually articulate, document or describe their knowledge, but it seemed to be inherent in their actions anyway. This arose from a realisation that nursing care is particular to certain nurses in given situations with specific clients. Critical observations about nursing as a community were felt to be most informative. This group are responsible for imagining the knowledge of nurses as characteristically feminine and intuitive rather than analytical. There have been calls to re-write health care history to include nurses as women. This may seem like an excuse to avoid doing any serious science, but it makes sense when you think about Hildegard Peplau (Mental Health Nursing Theorist) urging nurses to imagine all of nursing as a relationship. Behaviour has a massive semantic footprint, says Health science commentator Badacre, meaning it is hard to study social variables like feelings, thoughts and actions- Studying a relationship multiplies the difficulty by at least two.

The existence of these camps does not mean that nursing is baseless, or anything goes. Postmodernist thinkers have urged a fusion style of research called action research or participatory research. There is a danger of indulging pseudo-science in such forums. For example, If a healthcare employer provides time for staff to meet and conduct continuous improvement activity, this should be encouraged, by all means, but there is no way of bracketing the corporate interest in the proceedings. If the meetings are held in the nurses own time and the themes are recurrently emancipatory, then one cannot bracket the social activism. Conduct them and be honest when you declare the findings.

topics to cover

   quantum mechanics - uncertainty principle unexplained - no conclusions
   conclusions - critique of nursing process, alternatives to NANDA
   professional imperialism by nurse practitioners
   career structure extended at both ends