• Truth from correspondence to integrative view of truth
KNOWING FROM THE RECEIVED VIEW TO POSTMODERNISM VIEW
Knowing is not static, but dynamic and changeable, and patterns of knowing in a discipline are not discrete; they reflect the progress and maturity of the discipline as well as the agents of knowing
CHAPTER 8 Our Syntax: An Epistemological Analysis 137 in a discipline. Patterns of knowing in a discipline are constantly evolving, multidimensional, and may be transformed and transforming. They reflect societal trends in defining acceptable patterns, and these definitions may change over time. We still remember when knowing in nursing emanated only from traditions, history, and experiences, when all alternative complementary the- ories were completely ignored and rejected, and when only scientific methods were the methods of choice. We also saw new concepts such as practice theories, personal knowing, expert knowing, and interpretive knowing become mainstream in the knowledge development arenas. To under- stand and appreciate the framework for our most contemporary syntax in nursing, one that is likely to endure long into the future, I will present it within the context of our history. In many ways, that history has shaped our current level of tolerance of the epistemic diversity we are expe- riencing and in the different ways by which we claim “to know” in our discipline.
Knowing includes knowledge based on observations, research findings, clinical manifesta- tions, and scientific approaches. Although knowing has been viewed to be more dependent on sense data, it also includes other types of data. To understand is to connect bits of knowledge in a relational form to other broader statements. For example, we know that women who work outside the household tend to work a double shift: one shift outside their home, and the other taking care of their home. We also know that women who work outside the home tend to have better mental health than do women who work only inside the home. On the basis of this knowledge, inferences could be made about the types of support and health care resources that women who work inside the home may need. Housework is an activity that was not acknowledged as work or leisure, an activity with no set hours, wages, rewards, or retirement benefits (Harding, 1988, p. 87). Consid- ering the findings within this context of meanings may prompt a consideration of the forces and constraints in using resources that are developed especially for the promotion of health in women who are engaged primarily in housework. Similarly, we have always known that menopause was a
“deficiency disease” from a biomedical perspective until feminist scholars enhanced our knowl- edge by demonstrating its transformation from a disease to a normal process that is experienced differently in different cultures (Andrist and McPherson, 2001). These examples illustrate the need for developing understanding beyond sense data. Understanding, therefore, includes putting the experiences and situations of women within historical, gender, and social contexts. It includes a consideration of the norms, values, and the meanings of housework and the barriers that soci- eties impose on women and their work. That, then, requires epistemological diversity.
Knowing results from careful systematic research or from repeated experiences in clinical practice. Reflecting on that knowledge and interpreting the meanings of relationships, as seen and experienced by all parties concerned, and putting that which is known within a context of feelings, values, and different perspectives, is what brings us closer to an understanding of that which is known. One pattern of knowing by itself will not uncover all the knowledge needed for a human and practice-oriented science.
In a classical analysis that represented a turning point in our epistemological past, Carper (1978) identified four patterns of knowing in nursing:
1. Empirical (the science of nursing)
2. Personal knowledge (concerned with the quality of interpersonal contacts, promoting therapeutic relationships, and individualized care)
3. Aesthetic (the art of nursing) 4. Ethics (moral component of nursing)
These patterns, which transcend time, but are neither complete nor static (Fry, 1988), received a great deal of attention and were instrumental in alerting nurses that science alone will not answer the significant questions in our discipline (Johnson, 1994). Jacobs-Kramer and Chinn (1988) extended knowledge about the four patterns by developing a model that includes five dimensions: creative, expressive, assessment questions, process-context, and credibility index to describe and explain the four patterns developed by Carper. They further extended this model and refined it, illustrating how each pattern contributed to a more complete knowing (Chinn and Kramer, 2003).
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The first pattern developed by Carper (1978) and used to guide the development of nursing knowledge is the empirics, requiring scientific competence leading to explanations and structure, requiring replication and validation, and resulting in theories and models. The second pattern is personal knowing, requiring therapeutic use of self, which requires openness and centering and can be achieved through the use of stories and genuine use of the self. These are organized as responses and reflections. The third pattern of knowing is the aesthetic, manifested in critical analysis of works of art that result in transformative expressions of art or acts. The fourth pattern is ethics, knowing manifested in principles and codes that could evolve through processes of dia- logues and justification. These could be developed by valuing and clarifying discourses and acts of caring (Chinn and Kramer, 2003). White (1995) supported the four patterns but added a fifth one, sociopolitical knowing, which is considered an essential pattern for the understanding that may evolve from all other patterns of knowing. This pattern focuses on the broader context for the caring process; it allows and drives inquiry to critically question the status quo of the participants in the caring process. It includes organizational, cultural, and political processes that influence the person, the nurse, and other health care providers; the profession; and other structures involved in the caring process. This pattern of knowing allows for the construction of alternative structures of reality and is expressed through critiques and transformations. It is a pattern predicated on collab- oration and on a movement toward more equity in knowledge development.
There are many ways to organize epistemic diversity, which is shaping the next phase of knowledge development in nursing. I chose to build on previous classifications (Carper, 1978;
Chinn and Kramer, 2003; Allen, Benner, and Dickelman, 1986; Stevenson and Woods, 1986;
Mantzoukas and Jasper, 2008) by presenting here four views of knowing:
• The received view
• The perceived view
• The interpretive view
• The postmodernism, poststructuralism, and postcolonialism views
The Received View
Several philosophers in nursing have been concerned that nurses may have adopted a limited view of science that directly contradicts nursing’s philosophy, heritage, and goals. Their view could be summarized under the rubric of “the received view,” which others may call the scientific method (Suppe, 1977). The received view is philosophically old and outdated, but its effects lin- gered longer in nursing than in the field of philosophy of science (Suppe and Jacox, 1985).
The received view in any discipline usually denotes a set of ideas that are not to be chal- lenged––the philosophical equivalent of being engraved in stone. It is the same premise that declares that holy books were received and therefore should not be challenged. The received view is also a label given to “empirical positivism” or “logical positivism,” a 19th-century philosophi- cal movement closely aligned with Rudolph Carnap and rooted in the celebrated Vienna circle of philosophers. This circle advocated an amalgamation of logic, with the goals of empiricism in the development of scientific theories (Runggaldier, 1984). Eventually, the concept of “positivism”
was dropped from “logical positivism” and replaced with “empiricism” to avoid the connection with Auguste Comte, whose ideas were coming into disfavor at that time. When Carnap joined The University of Chicago in 1936, he introduced logical empiricism to the United States (White, 1955, pp. 203–225).
The following are the tenets of logical empiricism:
1. Theoretical statements that cannot be confirmed by sensory data, and sensory experiences are not considered worthy of pursuit. As a result, they are disqualified as common sense statements. Predictive statements that have no corroboration from sensory data are not sci- entific. A direct relationship has to exist between experience and a meaningful theory.
2. True statements are only those that are a posteriori. That is, they are based on experience and known from experience.
CHAPTER 8 Our Syntax: An Epistemological Analysis 139 3. Positivists regard most traditional metaphysics and ethical considerations as meaningless.
They regard such questions as possessing “emotive” meaning and as being “cognitively meaningless” (White, 1955).
4. Analyses of theories are based on analyses of completed theories, and completed theories are based on empirical data (Suppe, 1977, p. 125). The context of justification––that is, the verification and falsification of complete theory propositions––is the only significant context for consideration by scientists and philosophers alike. Conversely, the contexts of discovery, such as conceptual ideas, contexts within which theories are developed, logic in theory development, and usefulness, should be within the province of the sociologists of knowledge: the psychologist and historian (Reichenback, 1968).
5. Because the received view considers theories to reflect the a posteriori depiction of real- ity, documented by sensory experiences, it therefore follows that propositions of theories are presented symbolically, formally, and axiomatically. There is room for a priori analy- sis, although it is only mathematical in nature.
6. Science is value-free, and there is only one method for science, which is the scientific method.
The “ghost of the received view” loomed over nursing in its quest for a scientific base, according to Webster, Jacox, and Baldwin (1981). Others, such as Watson (1981) and Winstead- Fry (1980), also blamed nursing’s slow scientific progress on the insistence of its leaders to using the outdated scientific method as its model and to strive for one scientific method.
The scientific method that they were speaking of is one based on the received view, one that espouses “reductionism, quantifiability, objectivity, and operationalization” (Watson, 1981, p. 414). As a result, the critics maintained that significant holistic problems in nursing have been ignored because they are not reducible, quantifiable, or objective. The scientific method adopted by nursing reduced a problem to its smallest unit or its most significant form and stripped it of the rich context from which it emanated (Newman, 1981). The scientific method, oriented toward quantitative methods, and highly accepted and respected, could not address theory and developing theory; therefore, it has not helped nursing to develop meaningful theories, nor has it advanced nursing to its projected goal of a scientific discipline.
Historically, some justification existed in blaming the received view for nursing’s slow progress and development. Many examples support the view that an outmoded and ineffective philosophical view of science has somewhat disillusioned nurses (Newman, 1994). One example is the many theoretically disconnected but methodologically immaculate research projects that nurses have produced, a view that is shared by Batey (1977). Nevertheless, more evidence than we have been led to believe supports the view that nursing has, in fact, considered and followed a sci- entific path broader in scope and more integrative in approach than the received view.
Logical empiricism succeeded from logical positivism, and it is how the received view is expressed. After many transformations, it has come to be accepted as an essential approach to knowing; it is not, however, the only approach. Although there are variations to how empiricism may be utilized, it has some common properties.
A theory for empiricists is a product of research findings that is used as a framework for fur- ther research. The empiricists’ observations are not contextual and usually focus on single behav- iors, events, or situations. Theorizing for empiricists is based on inductive logic, sense data supported by a set of value-free assumptions. Empiricists develop theories by providing precise, well-defined, operationalized concepts––measurable variables. Empiricists are objective, sepa- rated, and distanced from their theories; they treat theories as objects and are reluctant to share insights related to findings or evolving ideas with their clients or research subjects. The language they use is research-specific and their approach is inductive. Statistical model building is a signif- icant tool for empiricist theory development.
Empirical theories are based on careful and methodologically impeccable research studies geared to finding relationships between different variables and finding support for a multitude of statements––all geared to answering a set of well-defined questions, hypotheses, and null
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hypotheses that produce prediction and verification (Table 8-1). Empiricists’ theories are well understood by colleagues from other disciplines, and when theory development is discussed, it is more likely to be understood in relationship to the development of empirical theories (Dzurec, 2003). The discourse about evidence-based practice emanates and reflects a focus on a limited view of empiricism (Porter, 2010). Many narrow interpretations of evidence may exist; however, the prevailing, dominant interpretation is one that is most limited in focus. (Fawcett, Watson, Neuman, Hinton-Walker, and Fitzpatrick, 2001; Chinn and Kramer, 2003) (Table 8-1).
The Perceived View
Knowing through the more subjective view of those who are experiencing the situation and those agents who are uncovering the situation reflects another view of knowing. Knowing is not only based on sense data. Proponents of the perceived view of knowing discuss different patterns and dimensions.
Nursing theorists who have worked diligently to give us their conception of the discipline have not followed a received view approach. They have offered several conceptualizations that encompass the whole of nursing––a perceived view––based on their experiences and theory- incorporated ideas that are subjective, intuitive, humanistic, integrative, and, in many instances, not based on sense-oriented data. (See Chapter 20 for citations reflecting this statement.)
TABLE 8-1 COMPARISON OF THE RECEIVED, PERCEIVED, INTERPRETIVE, AND POSTMODERN VIEWS OF SCIENCE*
Postmodernism, Poststructuralism, &
Received View Perceived View Interpretive View Postcolonialism Objectivity Subjectivity Analysis within context Narration
Finding meaning
Deduction Induction Contextual analysis Political and structural analysis
One truth Multiple truths Patterns Different views
Themes
Validation and Trends and Authenticity Uncovering opposing views
replication patterns
Justification Discovery Uncovering meaning Uncovering inequity
Marginalization Prediction and control Description and Narrative descriptions Metanarrative analysis
understanding
Particulars Patterns Patterns within a structure Stories
and history
Reductionism Holism Uncover weakness Macro-relationship with micro
and flaws structures
Generalization Individuation Knowing about context Knowing about structures
Logical positivism Historicism Historicism Macro-analysis
Logical empiricism Structure
*Based on Meleis, A.I. (1985). Theoretical nursing., Philadelphia: Lippincott; and Stevenson, J.S. and Woods, N.F. (1986). Nursing science and contemporary science: Emerging paradigms. In G. Sorenson (Ed.), Setting the agenda for the year 2000: Knowledge development in nursing.
Kansas City, MO: American Academy of Nursing.
CHAPTER 8 Our Syntax: An Epistemological Analysis 141 The discovery of field concepts, theory development, and processes of theorizing in nursing has not been based on the received view or on a structured and strictly scientific approach. Tradi- tionally, the context of discovery for these ideas has been case studies, personal anecdotes, and group insights. The acceptance of those visions then emanating from our nurse theorists has been slow because some have branded the theories as unscientific. Therein lies the problem.
To generalize, saying that nursing has followed a positivistic path is akin to saying that physics has followed an intuitive one. The theoreticians in nursing, those who have developed conceptualizations encompassing the field as a whole, have used the perceived view, which com- bines the phenomenological and philosophical approaches as alternate methods of theory devel- opment. The scholars in the field who believe that knowledge emanates from the context of justification may have helped to orient nursing toward considering concepts such as sensory data, verification, and falsification as ways to accept or reject nursing conceptualizations. These schol- ars have therefore precipitated the early mass rejection of nursing theory, as well as the continuous rejection by many in the field who are skeptical about the use or effectiveness of nursing theories.
In the perceived view, patterns of knowing include both theoretical and practical knowing.
Sarvimaki (1994) makes a distinction between theoretical and practical knowledge, although she acknowledges their equal significance. Theoretical knowledge includes and reflects the basic val- ues, guiding principles, elements, and phases of a conception of nursing. Its goals are to drive and promote thinking and understanding of that which is the nursing discipline. Its base is intellectual, and it is organized into assumptions, concepts, propositions, and models. Practical knowledge, however, does not have to be organized in the same way because many parts of this knowledge are not yet articulated and because the artistic side of practice may not be amenable to total articula- tion. The channel of communication for theoretical knowledge may be theories and science, whereas the channel of communication for practical knowledge may be tradition, according to Sarvimaki (1994). Practical knowledge may be achieved through personal and collective means and reflections (Winstead-Fry, 1979) and through integrating and blending evidence with clinical judgment (Paley, 2006). Personal knowing, which may be arrived at through one’s own practice, reflection, synthesis, and integration of artistic, scientific, and practice components is, according to Moch (1990), essential to the development of nursing knowledge. She identifies three components in personal knowing: experiential, interpersonal, and intuitive knowing. Experiential knowing is achieved through being part of the world of nursing and becoming increasingly aware of the expe- riences inherent in this participation. (See powerful examples of one aspect of personal knowing through an illness experience [Hall, 2003].) Interpersonal knowing results from enhanced aware- ness about situations resulting from extensive, in-depth interactions with others. These interactions are another source of knowing, and they promote the development of knowledge.
When a person knows without the explicit use of scientifically accepted forms of reasoning, it is said that the person achieved the knowing through intuition. It is knowing a whole without resorting to linear reasoning (Polanyi, 1962). It is knowing without knowing how (Benner and Wrubel, 1982; Rew, 1988; Rew and Barrow, 1987). When nurses use intuition to know, they open themselves up to allow sensing and understanding of the patient’s responses and situations to occur, which leads to a better knowledge of the patient’s situation (Agan, 1987; Paul and Heaslip, 1995). Intuitive knowing was a neglected pattern of knowing, but it has been gaining more atten- tion as a component in “clinical knowing,” as essential in a more holistic understanding of clinical situations, and as significant in making more effective therapeutic decisions, as evidenced from the many descriptive studies that affirm its significance (Rew, 1990; Rew and Barrow, 2007).
Intuition by experts is based on rapidly perceiving a whole situation without having to pause to construct the different processes or steps (Benner, Tanner, and Chesla, 1996). Many discourses in nursing have established intuition as a source of knowing to be carefully explored, and different theories about intuitive learning also should be explored (Gobet and Chassy, 2008).
Knowing a patient through perception or intuition, as well as through forms of knowing, allows for more particular and individualistic approaches that may be based on more general knowledge related to that patient’s situations. Knowing the patient leads to more appropriately selecting nursing therapeutics, based on knowing the patient’s resources, readiness, and current
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