CHAPTER VI — THEORY DEVELOPMENT AND RESEARCH
In this chapter, we will address our conception of nursing as human science and suggest directions and strategies for further development of the theory of Nursing as Caring. We initially introduced our perspective of nursing as discipline and profession in Chapter 1 and as a grounding context for the theory. As a discipline, nursing is a way of knowing, being, valuing, a way of living humanely, connected in oneness with others, living caring and growing in caring. The unity nursing offers is known in human experience through personal, empirical, ethical, and aesthetic realms.
Science has to do with knowing and that which is known. Philosophers of science are concerned with valid ways of knowing and ways of validating that which is known. Human science is described by scholars in various ways, each emphasizing particular values but all connecting to a common understanding that human science is concerned with knowing the world of human experience. A committed inquiry into human experience seems to call forth certain values related to the meaning of being human. Herein lies the fundamental difference between formal science and human science, as we perceive it. Formal science, that which is practiced in the natural sciences and other sciences that emulate them, is modeled on the structure of mathematics. Mathematics is a highly lawful science that has contributed enormous social benefits over time. However, formal science grounded in mathematics and languaged as calculus is an inappropriate approach to the study of person-as-person. A perspective that addresses the phenomenon of person-as-person is grounded in central values such as caring, freedom, and creativity. Methods to study person must be similarly grounded.
We have come to understand that valid ways of knowing nursing and legitimate warrants for nursing knowledge are discovered from within the study of nursing itself; that is, within the study of the nursing situation. The manner in which certain disciplines are conceptualized, especially those dealing in normative contexts, calls for a dialectical form of sciencing, comparing, and contrasting. However, coming to know nursing is a dialogical process—direct engagement with the "word of nursing." Nursing science must be contextual; the decontextualized methodology of formal science, while essential for certain disciplines, cannot reveal direct knowledge of nursing. Because of the nature of nursing, nursing science must permit intentionality, intimacy, mutuality, and particularity.
Human science has understanding as its goal, with the definite expectation that understanding is in the moment only (Watson, 1988; Van Manen, 1990). In addition, the nature of nursing praxis does not require knowledge for the purpose of control, but for enlightenment, moment-to-moment and reflectively. The nurse seeks knowledge neither to control one's own behavior or that of the nursed. If it were otherwise, the nurse would become his or her own prisoner, and would relate to the other as dominator rather than caring nurse. The concept of the hermeneutic circle informs our understanding of the nature of nursing as a human science. This circle of understanding, really a sphere more than a uni-dimensional circle, is a heuristic device which directs our attention. As attention pauses at any aspect of the nursing situation, we must attend to other aspects and to the whole of the nursing situation to create useful understanding. One hermeneutist has pointed out that the circle brings us further along, not the issue at hand (Droysen, 1988). This distinction points to the human science position that understanding is not constituted through analysis of facts but through dialogue with text and context. That is, what moves within the circle is the seeker, rather than that which is sought, so that many aspects are illuminated in context, and understanding grows. The hermeneutic circle requires that what we note in our inquiry remains contextualized, developing "new and ever new circles" (Boeckh, 1988). This is in contrast to normal science that requires an external referent for objects of study in order to avoid circular thinking. Heidegger (1988), for example, contrasts the vicious circle of normal science (tautology) with the circle of hermeneutic: " . . . in the circle is hidden a positive possibility of the most primordial kind of knowing" (p. 225). We would propose that valid knowing in nursing is that which is known from within the circle.
While the work of several scholars has influenced our understanding (e.g., Gadamer, 1989; Van Manen, 1990; Ray, 1994; Reeder, 1988), Macdonald's (1975) interpretation from the field of humanistic education is especially meaningful. He explains hermeneutic knowing methodologically as "circular rather than linear in that the interpretation of meaning in hermeneutic understanding depends on a reciprocal relation" (p. 286) rather than on a fixed normative reference point. The hermeneutic circle models the idea of reciprocal relation, but Macdonald goes further to call for a self-reflective science that will "transcend problems of monological and hermeneutic meaning" (p. 287). The nature of nursing as expressed in the Nursing as Caring theory is a reciprocal relation, one characterized by its grounding in person as caring, and as persons connected in oneness in caring. Sciencing in nursing from this perspective must go beyond linearity to encompass the dialogic circling involved in the nursing situation. This places the discipline of nursing among the human sciences, and calls for methods of inquiry that assure the circle or dialogue, and further, fully accommodate that which can be known of nursing.
Nursing is properly catalogued as one of the human sciences for many reasons. The most basic reason is that the discipline and the disciplined practice of nursing directly involve persons in the fullness of their humanness. From our perspective, this means person as caring. Person as caring implies person in community, connected in oneness with others and with the universe, person freely choosing the living of values which are expressions of caring. This nursing ontology requires an epistemology consonant with human science values and methods. To know of, through and with nursing necessitates methods and techniques that honor freedom, creativity, and interconnectedness.
In Chapter 4, we asserted that nursing knowledge is created and discovered within and from within the nursing situation. (Nursing situation, you may recall, is understood as a shared lived experience in which the caring between the nurse and the one nursed enhances personhood.) Therefore, because the locus of nursing inquiry is the nursing situation, the systematic study of nursing calls for a new methodology that recognizes that fact.
Certainly, we acknowledge that something useful for nursing can be learned through existing methodologies, from both natural and human science traditions. For example, an experimental design can produce information about the effectiveness of a given clinical technique within a specified range of use (e.g., placement of an oral thermometer). Such information can be important and useful to the work of the nurse and useful to the client of nursing. It tells us nothing, however, of nursing. In fact, the central tenet underlying measurement in normal science directly contradicts the central tenet of human science: created versus creating. Thus, the fullness of the nursing situation is not amenable to study by measurement techniques. Yet, aspects of the nursing situation can be abstracted and studied as variables in relation to other variables. This does not, however, yield knowledge of the nursing situation in its fullest. At best, measurement approaches can call attention to an aspect so that it can be considered within the unfolding.
Phenomenology, on the other hand, offers an example of an orientation and methodology that more closely approximates what is needed in a nursing method of inquiry. Phenomenology is an orientation toward inquiry that may be actualized through any one of a number of generic approaches, but is generally understood as the study of lived experience (e.g., Van Manen, 1990; Oiler, 1986). When the phenomenon conceptualized for study is representative of the nursing situation, nursing may be known. That is, new nursing knowledge may eventuate. New understanding of the meaning of the shared lived experience of caring between nurse and nursed enhancing personhood can be created.
Yet, for the purposes of nursing, phenomenology also has its limits. For example, when phenomena which have been abstracted from a nursing situation are selected for study (that is, when phenomena are taken out of context), results of the inquiry cannot generate knowledge of nursing proper. For example, the understanding that comes in developing a description of the essential structure of what it is like for a nurse to be called to nurse informs us about nurses, but not about nursing directly. Similarly, an exquisite phenomenological description of what it is like for a person to live grieving is helpful in understanding the person. However, it should not be mistaken for knowledge of nursing, but knowledge which illuminates the study of nursing when taken back to the full context of the nursing situation. Further, the various phenomenologies in the literature come from frames of reference that are not nursing (e.g., existential psychology or educational psychology), and thus impose a "silent" borrowed framework when used to study nursing.
Is this drawing too fine a line? And is it really important to press the issue of nursing knowledge versus knowledge of and for nurses? The answers to these questions are probably found in one's concept of nursing as a field of knowledge (discipline) and a human service (profession). It seems that nursing and nurses have suffered significantly over the years with this dilemma. Is it possible to have a sense of self as nurse without a concomitant sense of nursing as a discipline which is more than tacit and to which one is committed? Students of nursing and practitioners alike have abundant opportunities to acquire a sense of self as nurse. Yet why is it that many programs of nursing education (at all levels) do not convey a sense of nursing as a discipline? The answer may lie in those conducting the programs, who have experienced training for practice and education in disciplines other than nursing and without explicit education in the discipline of nursing.
From the perspective of Nursing as Caring, with its grounding in person as caring and nursing as discipline, the distinctions implied in this question of "does it really matter" are of central importance. Nurses in practice, education, and administration continue to address nursing primarily in terms of "what nurses do," (e.g., nursing "interventions") and most nursing research seems to derive from that perspective as well. Without a clearly articulated understanding of the focus of the discipline, it has been extremely difficult to organize and structure nursing knowledge in ways that facilitate the development of the discipline. In this book, we have offered a theory, Nursing as Caring, as one expression of that focus, languaged in terms that communicate the essence of nursing.
Nursing knowledge is knowledge of nurturing persons living caring and growing in caring within shared lived experiences in which the caring between nurse and nursed enhances personhood. Furthering nursing knowledge requires methods that can illuminate the central phenomenon of the discipline. The development of such a methodology is, as we see it, the next major effort to be undertaken in the development of the theory. In this regard, we envision a fully adequate methodology that would include a phenomenological aspect which goes beyond description to a hermeneutical process, within an action research orientation. That is, what seems to be needed is a methodology that would permit the study of nursing meaning as it is being co-created in the lived experience of the nursing situation. Supplemental methods could continue to include traditional phenomenological and hermeneutic work with texts describing particular nursing situations. Nurses who are interested in developing knowledge of techniques or modes of expressing caring would continue to use traditional methods of formal and human science for these kinds of nursing-related questions.
The development of methods of nursing inquiry appropriate to the study of the theory, Nursing as Caring, is in a formative stage. We understand to a considerable extent the limitations of existing modes of inquiry, and have a growing sense of what will be required of a new methodology. Nursing scholars are working to develop methods to illuminate the fullness of nursing. Examples of that work which has encouraged our efforts include that by Parker (1993), Swanson-Kauffman (1986), Parse (1990), and Ray (Wallace, 1992). The work of these scholars demonstrates that the development of nursing ways of inquiry is important and that a search has begun. As we have come to understand the concept of human science, our understanding of nursing has been enriched. Like most of our contemporaries in nursing, we were trained in the often-unarticulated assumptions of natural science. And we have traveled the road familiar to many nursing scholars, the road of expertise in objectification and quantification. Along that road, we began to notice the trivialization of cherished nursing ideas like presence, touch, relationship, knowing, and caring. Resisting the temptation to abandon the journey, we each persevered in a commitment to nursing as something which mattered, something involving intimate, personal, caring relationships. Discovering, inventing, and creating a new methodology is an important dream and we are committed to continuing this aspect of theory development.
Nursing as Caring is a transformational model for all arenas. Nursing practice, nursing service organization, nursing education, and nursing inquiry require a full understanding of nursing as nurturing persons living caring and growing in caring, and these underlying assumptions:
* Persons are caring by virtue of their humanness.
* Persons are caring, moment to moment.
* Persons are whole or complete in the moment.
* Personhood is a process of living grounded in caring.
* Personhood is enhanced through participating in nurturing relationships with caring others.
* Nursing is both a discipline and profession.
With these transformations, the fullness of nursing will be realized and we will grow in our understanding of self and other as caring persons connected in oneness.