Tuesday, 8 April 2014

Is there any such thing as nursing knowledge?


‘What is nursing knowledge?’ is a complex question, the answer to which helps define nurses as a profession? [Hall 2005: 34]

Is there such a thing as ‘nursing knowledge’? What do and should we mean by that phrase? And does it help define nursing itself? It may seem that denying that there is such a thing, or unified kind, as nursing knowledge risks undermining the profession of nursing and runs counter to its new graduate status in the UK. But I will argue that on one understanding of the question, at least, it is correct to answer ‘no’ but that this is no threat to a picture of nursing as richly knowledge-based.

To do this, I will consider three important distinctions of kind and argue that, in each case, nursing knowledge is distributed across both sides. This suggests that implausible to think that it is unified. At the same time, however, I will suggest that in each case there is reason to think that what is involved is, indeed, a form of knowledge. Finally, I will suggest that there is a key intellectual skill at the heart of nursing but that this takes the form of an art rather than a science.

Knowledge and justification

But to begin, what is knowledge or what does ‘knowledge’ mean? Note that there might not be a very helpful answer to this question. Imagine someone asks what stickiness is or what the word ‘sticky’ means. One might offer a word that means more or less the same: such as ‘tacky’. But this does not help explain the concept of stickiness so much as swap one word for it for another. Or one might offer a more substantial explanation of the concept such as ‘a propensity of a body to adhere to another on contact’. This may more or less equate to the concept but it isn’t obvious that a speaker who understands the word ‘sticky’ should be able to offer such a formal paraphrase. Further, it raises further questions such as what does the word ‘adhere’ mean? So we should approach the question of what knowledge in general is with some caution. There may not be a very helpful definition available.

But some features of knowledge can be abstracted. Suppose that Sandy knows that, because it is 5pm, Mr Smith is due for medication. If so, she must hold it to be, or take it to be, true that it is time for his medication. That is, she must believe it. Second, if Sandy does know that Mr Smith is due for medication, then he must really be due for medication. If she has knowledge, what she believes must be true. Third, her belief cannot merely be accidentally true. Suppose her belief that the time is nearly 5pm is based on the ward clock but that this stopped the day before. By chance, however, it is now nearly 5pm. If so, although Sandy has a true belief about Mr Smith’s medication she does not know it.

These constraints on knowledge have motivated an account of knowledge which dates back to Plato: knowledge is justified, true belief. The justification condition is supposed to rule out cases of merely lucky true beliefs.

Justification also plays a second role. It provides a means of aiming at true beliefs. It is one thing to worry that one’s beliefs about the efficacy of rival surgical techniques may not be correct, but quite another to work out how to avoid error. It would not be helpful to be told to replace any false beliefs with true beliefs. To hold a belief is to hold it to be true. (To hold that something is not the case is not to believe it.) Thus beliefs which are, in fact, false are not be transparently so to someone who holds them. But the advice that one should ensure that one holds only beliefs that are justified is helpful. And by aiming at justified beliefs one should in general succeed in reaching true beliefs since justification is, in general, conducive of truth.

Sadly the analysis of knowledge as justified true belief faces a challenge. In the 1960s Edmund Gettier showed how to construct counter examples to the analysis in which a subject has a true belief and a justification for it but the justification only works through the intervention of luck and so, intuitively, is not a case of knowledge [Gettier 1963]. Hence the analysis must be false. One example runs as follows. Smith and Jones have applied for a job. Smith has good reason to hold that Jones will get the job (he has been told by the CEO) and that Jones has ten coins in his pocket (Smith has counted them) from which he concludes that the successful applicant has ten coins in his pocket. By chance, he himself gets the job rather than Jones and, again by chance, he himself has ten coins in his pocket. Did he know after all that the successful applicant has ten coins in his pocket? Intuitively, no because even though he believed it, had a justification and it was true, it took a stroke of luck for his belief to be true.

One possible response to Gettier’s example (and cases like it) would be to raise the standard of what we mean by ‘justification’. One might argue that Smith was not in fact justified in believing that Jones would get the job (despite being told this by the CEO) because Jones did not, after all, get the job. If so, the example is not a counter-example to the traditional analysis. But if justification has to guarantee the truth of what it justifies then justifications may be in short supply.

Or one might concede that Gettier has indeed refuted the traditional analysis and turn instead to a different third condition such as that knowledge is true belief arrived at by a reliable process. This modern view of knowledge called ‘reliabilism’. Again, the extra condition in addition to true belief is supposed to eliminate knowledge-undermining luck. Sadly if the necessary reliability of the process is anything less than 100%, Gettier style counter-examples can also be offered for reliabilism [Goldman 1976].

There is no general agreement as to how best to respond to Gettier’s challenge to accounts of knowledge. One possible approach, however, is to accept the idea of raising the bar on justification, so that to be justified is to be in a position to have knowledge, but to deny that justifications fall into general kinds that can be identified independently of the knowledge they underpin [McDowell 1982]. Thus for example, the general kind or type of justification that is being informed by a CEO who will get a job is not (always) sufficient for knowledge. But being told on a particular occasion by a particular person may be. Similar, whilst simply looking at a clock (which may have stopped) is not sufficient to know the time, looking at a particular clock on a particular day may be enough to grant Sandy, in the example mentioned above, knowledge of the time.

Such an approach has the key virtue of maintaining the knowledge’s pedigree (which is what the standard model was supposed to do). Knowledge is reliable (with a small ‘r’) and rationally commands trust. That is why it is also the rational aim as the underpinning of nursing practice. nevertheless, there is reason to think that whilst all nursing knowledge has what the status of knowledge requires that it is not more generally unified by subject matter of methodological approach. I will now examine three key distinctions across which nursing knowledge divides.

Explanation and understanding

The first distinction I wish to consider dates back to debates about psychology in the late nineteenth century, the so-called Methodenstreit. This concerned whether the human sciences (the Geisteswissenschaften) should try to emulate their far more successful cousins the natural sciences (Naturwissenschaften), or whether they should go their own methodological way. ‘Positivists’, including John Stuart Mill, in England and both Auguste Comte and Emile Durkheim in France, argued that the human sciences were no different from the natural sciences. Others argued that the human or cultural sciences were different from the natural sciences either in terms of the nature of their subject matter or their methodology or both. The latter, in Germany, included Heinrich Rickert, Wilhelm Dilthey and Wilhelm Windelband.

Of particular relevance to mental health nursing, however, was the philosopher and psychiatrist Karl Jaspers. At the start of the twentieth century, German psychiatry was dominated by academic neuroscientists working under the assumption, epitomised by the German psychiatrist Wilhelm Griesinger’s famous aphorism, that ‘Mental illnesses are brain illnesses’. But Jaspers felt that the natural science approach to psychiatry had been taken too far and needed balancing. Thus, drawing on his understanding of the Methodenstreit, he stressed the importance of understanding in addition to explanation. Whilst explanation tracked objective measurable symptoms, understanding was necessary to grasp subjective symptoms. Taking empathy to be a key aspect of understanding he said:

Objective symptoms can all be directly and convincingly demonstrated to anyone capable of sense-perception and logical thought; but subjective symptoms, if they are to be understood, must be referred to some process which, in contrast to sense perception and logical thought, is usually described by the same term ‘subjective’. Subjective symptoms cannot be perceived by the sense-organs, but have to be grasped by transferring oneself, so to say, into the other individual’s psyche; that is, by empathy. They can only become an inner reality for the observer by his participating in the other person’s experiences, not by any intellectual effort. [Jaspers 1968: 1313]

A different but similarly motivated distinction was promoted by the post-Kantian philosopher of science Wilhelm Windelband. He distinguished between scientific approaches which explained phenomena in general terms, as instances of general laws of nature, which he called ‘nomothetic’ (‘nomos’ means law in Greek) from equally scientific but nevertheless individually focussed sciences such as history which he called ‘idiographic’.

In their quest for knowledge of reality, the empirical sciences either seek the general in the form of the law of nature or the particular in the form of the historically defined structure. On the one hand, they are concerned with the form which invariably remains constant. On the other hand, they are concerned with the unique, immanently defined content of the real event. The former disciplines are nomological sciences. The latter disciplines are sciences of process or sciences of the event. The nomological sciences are concerned with what is invariably the case. The sciences of process are concerned with what was once the case. If I may be permitted to introduce some new technical terms, scientific thought is nomothetic in the former case and idiographic in the latter case. [Windelband 1980: 175-6]

These distinctions between explanation in terms of natural laws and understanding via something like empathy or an idiographic focus on the individual have an echo in the balance in contemporary mental healthcare between evidence based medicine or practice, on the one hand, and person centred care, on the other. Whilst EBM emphasises the importance of generalities by privileging evidence derived from large scale randomised control trials, person centred care stresses the importance of a focus on individual patients. This balance of demands on healthcare, resembles the balance called for by Jaspers, and is reflected, for example, in the recent call by the World Psychiatric Association for the development of a ‘comprehensive’ model of diagnosis or assessment as part of its ongoing Institutional Program for Psychiatry for the Person. A WPA workgroup charged with formulating ‘International Guidelines for Diagnostic Assessment’ (IGDA) has published a guideline called ‘Idiographic (Personalised) Diagnostic Formulation’ which recommends an idiographic component alongside criteriological diagnosis.

This comprehensive concept of diagnosis is implemented through the articulation of two diagnostic levels. The first is a standardised multi-axial diagnostic formulation, which describes the patient’s illness and clinical condition through standardised typologies and scales... The second is an idiographic diagnostic formulation, which complements the standardised formulation with a personalised and flexible statement. [IDGA Workgroup, WPA 2003: 55]

Intuitive though the distinction between nomothetic and idiographic seems, however, there are some challenges in analysing what it means. After all, it cannot just be the difference between a focus on repeated and unique events since nomothetic sciences such as cosmology may study and attempt to explain unique events such as the Big Bang. It would have to be somehow essentially individualistic. But in Windelband’s own account, the way that idiographic approaches address their subject matter is not satisfactorily explained [Thornton 2008]. Further there is a challenge which arise from the idea that a truly idiographic form of understanding could never amount to knowledge. As summarised in the first section, knowledge has a pedigree, is reliable, is not a matter of luck. But a form of judgement essentially aimed at a unique event and which carried no general connections to other possible – even if not actual – cases could not be thought of as the product of a reliable sensitivity to how things are in that particular case. Knowledge requires some sort of generality.

The more promising distinction seems to be that between explanation and understanding in which the latter refers to the ways in which sense of human subjects is made by exploring their experiences, beliefs and utterances hang together in rational patterns. Borrowing phrases from the philosophers Wilfrid Sellars and John McDowell, the distinction between explanation and understanding can be thought of as the difference between subsuming events under natural laws (thought of as descriptions of what typically happens), the ‘realm of law’, and fitting them into normative patterns of good reasons, the ‘space of reasons’.

With this distinction in place, the knowledge that nurses need in order to care for patients and service users clearly spans both sides. They need to grasp the laws that govern the workings of human physiology and which describe the course of illnesses including mental illnesses. But they also need to be able to understand mental health service users or patients: their hopes, fears, beliefs, desires and experiences. With understanding itself understood to be a matter of placing subjects into a space of reasons, however, this is still a form of knowledge even if of a different kind to that of explanation of other natural events.

Knowledge of facts and values

In the previous section, I outlined the importance of a distinction between explanation couched in lawlike generalities (‘nomological’ or ‘nomothetic’) and understanding individuals in a distinctive way by trying to fit their utterances, experiences and actions in the ‘space of reasons’. A paradigmatic instance of the former approach is the deployment of generalities inferred from randomised control trials (RCTs) or, better, the meta-analysis of RCTs which is the gold standard for evidence in Evidence Based Medicine or Evidence Based Practice.

In their influential book, Evidence-based Medicine: How to practice and teach EBM, David Sackett, Sharon Straus, Scott Richardson, William Rosenberg, and Brian Haynes define it as follows. ‘Evidence based medicine is the integration of best research evidence with clinical expertise and patient values.’ [Sackett et al 2000]. This is a surprising definition. Normally the focus of EBM is on the first element of that tripartite division: research evidence. But Sackett et al widen their definition to include two further aspects: expertise and values. They give a further brief preliminary sketch of each as follows.

By best research evidence we mean clinically relevant research… New evidence from clinical research and treatments both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious and safer.
By clinical expertise we mean the ability to use our clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations
By patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.
[ibid: 3]

This looks to a broad definition not just of EBM as such but something that should be based on it: good clinical practice, perhaps, or good medical care. But it serves a convenient reminder of another relevant distinction for nursing knowledge: that between facts and values.

Nurses need not only to know about research evidence concerning the workings of the brain and mind, or the prognoses for particular psychiatric diagnoses – the biomedical facts – but they need to know about values: those of their patients and service users but also their own and those of broader society. They need to know, in other words, not just about evidence based practice but also about values based practice.

Outlining the nature of values based practice, or the competing views of what it should involve, is beyond the scope of this chapter. But a preliminary survey suggests that knowledge of facts and values can be very different. There’s no equivalent of RCTs for the empirical determination of how we ought to act. The closest equivalent to knowledge of the empirical laws governing natural phenomena might be, in the case of medical ethical values, knowledge of ethical principles such as the Four Principles approach of respect for beneficence, non-maleficence, autonomy and justice [Beauchamp and Childress 2001]. But whereas the physical forces, for example, can be added together using the mathematics of vector addition, there is no general calculus for saying when, for example, the principle of autonomy should trump beneficence and when the other way round. Further, ethical values are merely one subset of the values, preferences, traditions that need to be taken into consideration in vales based practice and thus the prospect for codifying all the value judgements relevant for clinical decisions are dim.

Some proponents of values based practice argue for an even more dramatic difference in the nature of knowledge of facts and values. Bill Fulford, for example, argues that successful values based practice does not so much aim for a correct judgement as a good process [Fulford 2005]. It is a matter of following the appropriate deliberative process rather than aiming to get the values in a particular situation objectively right. If so, the knowledge involved is knowledge of how to follow a procedure. This contrasts with a natural view of the aims of EBM in aiming to discover the psychiatric facts. Others argue that even though there is no algorithm for forming a view of what to do in a particular situation, that does not rule out the idea that value judgements aim at correctness [Thornton 2011]. On this view, whilst knowledge of values is not reducible to or codified in general principles it is still a form of general recognitional ability to chart evaluative demands made on subjects with eyes to seen them by worldly situations.

But whatever the best view of values based practice – and it is an interesting question whether this means the most correct or the most desirable – there is no doubt that values based practice and evidence based practice call on different kinds of expertise based on a sensitivity to different features of the world: the bio-medical facts and patients’ and others’ values.

Tacit and explicit knowledge

The characterisation of evidence based medicine from Sackett et al also highlights a further distinction of kind within what nurses need to know. They define expertise as the ‘ability to use our clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations’ [Sackett et al 2000: 3].

This characterisation contains two elements already mentioned in the previous distinctions. Clinical expertise is directed towards individuals and their unique states and circumstances, picking up the understanding side of the first distinction (explanation versus understanding). It is also directed at their values and expectations, picking up the values side of the second distinction (knowledge of facts versus values). But it also suggests a practical recognitional skill is in play and that suggests a third, important, distinction: between explicit and tacit knowledge.

The idea of tacit knowledge (or ‘tacit knowing’, as he preferred) was first promoted by Michael Polanyi. In his book The Tacit Dimension he says:

I shall reconsider human knowledge by starting from the fact that we can know more than we can tell. This fact seems obvious enough; but it is not easy to say exactly what it means. Take an example. We know a person’s face, and can recognize it among a thousand, indeed among a million. Yet we usually cannot tell how we recognize a face we know. So most of this knowledge cannot be put into words. [Polanyi 1967: 4]

The suggestion is that tacit knowledge is tacit because it is ‘more than we can tell’. We cannot tell how we know things that we know tacitly. But why not? There is, however, a constraint on any plausible answer to this question which turns on an apparent tension in the very idea of tacit knowledge. To be a form of knowledge, there must be something – some content – known. As was set out in the first section, on the standard model of knowledge, this content is a belief (eg. that , Mr Smith is due for medication). But if so, why can this not be put into words? What kind of content could be known but not be put into words? Being knowledge and being tacit seem to be conflicting ideas.

A clue as to how to resolve this comes from a frequently cited example of tacit knowledge from a totally different area: the chicken industry. There is a great economic advantage to be able to determine the gender of chicks as soon as possible after they hatch. In the 1920s, Japanese scientists discovered a method by which this could be done based on subtle perceptual cues with a suitably held and gently squeezed chick. It was, nevertheless, a method that required a great deal of skill developed through practice. After four to six weeks practice, a newly qualified chick-sexer might be able to determine the sex of 200 chicks in 25 minutes with an accuracy of 95% rising with years of practice to 1,000 - 1,400 chicks per hour with an accuracy of 98% [Gellatly 1986: 4].

One reason that this is cited as an instance of tacit knowledge is that early Australian investigators were unable to determine the nature of the skill involved. Further, the story has developed that the chick-sexers themselves were unable to express the nature of their knowledge (aside from saying which were male and which female). Hence it seems that this is a form of knowledge which cannot be put into words alone.

The example suggests a resolution to the tension mentioned above. Chick sexing counts as knowledge because the content known is practical, underpinned by a general and reliable ability. The relevant content is how to tell the difference between male and female chicks through manipulation and observation. But it counts as tacit because it cannot be put into words without also a practical demonstration involving chicks. So it cannot be put into words alone. Further, as the Australian investigators reveal, such demonstrations only work for others with ‘eyes to see’ or rather the relevant practical knowledge. On this model, tacit knowledge is practical knowledge the articulation of which requires a practical demonstration in the right context. It is situation specific practical knowledge.

As a practical discipline, mental health nursing contains aspects of tacit knowledge so understood. This includes all the situation specific knowledge of how to do things: basic clinical skills but also recognitional skills summarised by Sackett et al. These are the kind of recognitional skills which Benner describes using Dreyfus’ five stage hierarchy connecting novice to expert practitioner. [Benner 2004; Dreyfus and Dreyfus 1986]. There is, however, a further argument from Polanyi which suggests that mental health nursing might involve a further key area for tacit knowledge based in an area of mental healthcare that might be thought to be paradigmatically explicit. This concerns mental illness diagnosis.

Two historic factors have encouraged an approach to diagnosis which stresses explicit knowledge. Firstly, on its foundation in 1945, the World Health Organisation set about establishing an International Classification of Diseases (ICD). Whilst the chapters of the classification dealing with physical illnesses were well received, the psychiatric section was not widely adopted and so the philosopher Carl Hempel was invited to address the American Psychological Association conference of 1959. He recommended the use of operational definitions (following Bridgman’s book The Logic of Modern Physics), although construed loosely to fit a notion of measurement appropriate for mental illness [Bridgman 1927]. This view has been influential up to the present WHO psychiatric taxonomy in ICD-10.

The second reason for the emphasis on reliability and hence operationalism was a parallel influence from within American psychiatry that shaped the writing of DSM-III. Whilst DSM-I and DSM-II had drawn heavily on psychoanalytic theoretical terms, the committee charged with drawing up DSM-III drew on the work of a group of psychiatrists from Washington University of St Louis. Responding in part to research that had revealed significant differences in diagnostic practices between different psychiatrists, the ‘St Louis group’, led by John Feighner, published operationalised criteria for psychiatric diagnosis. The DSM-III task force replaced reference to Freudian aetiological theory with more observational criteria.

This stress on operationalism has had an effect on the way that criteriological diagnosis is made explicit or codified in DSM and ICD manuals. Syndromes are described and characterised in terms of disjunctions and conjunctions of symptoms. The symptoms are described in ways influenced by operationalism and with as little aetiological theory as possible. (That they are neither strictly operationally defined nor strictly aetiologically theory free is not relevant here.) Thus one can think of such a manual as providing guidance for, or a justification of, a diagnosis offered by saying that a subject is suffering from a specific syndrome. Presented with an individual, the diagnosis of a specific syndrome is said to be justified because he or she has enough of the relevant symptoms which can be, as closely as possible, ‘read off’ from their presentation. Such an approach to psychiatric diagnosis plays down the role of individual judgement or tacit knowledge amongst clinicians.

Nevertheless, according to Polanyi, even apparently explicit knowledge such as this rests on a substrate of tacit. The reason for this is that

[I]n all applications of a formalism to experience there is an indeterminacy involved, which must be resolved by the observer on the ground of unspecified criteria. Now we may say further that the process of applying language to things is also necessarily unformalized: that it is inarticulate. Denotation, then, is an art, and whatever we say about things assumes our endorsement of our own skill in practising this art. [ibid: 81]

Consider someone who can recognise the letters of the alphabet including, for example, the letter ‘e’. Although learnt through exposure to a finite number of examples, such an ability is general and open ended. It enables the expert to recognise a potentially infinite number of letter ‘e’s. But such examples will vary across different fonts, for example, or be printed at different sizes or in different colours, or be hand written with varying degrees of irregularity or surrounded by different other letters (in different words). Polanyi’s passage suggests the following possibility. The ability to recognise all these different particular letters as instances of the same general kind (the letter ‘e’) may outrun the expert’s ability to explain or articulate just how the shape has to be for it to count as an ‘e’. It may be ‘unformalized’ or ‘inarticulate’. The expert may ‘know more than they can tell’.

If this holds for recognising a letter it holds even more obviously for the recognition of mental illness symptoms. The signs and symptoms of depression or bipolar disorder can be recognisably of the same type whilst varying in numerous ways between the people who have them.

Criticising the ability of the DSM criteria to capture the nature of schizophrenia, the President of the World Psychiatric Association Mario Maj, for example, argues that:

[W]e have come to a critical point in which it is difficult to discern whether the operational approach is disclosing the intrinsic weakness of the concept of schizophrenia (showing that the schizophrenic syndrome does not have a character and can be defined only by exclusion) or whether the case of schizophrenia is bringing to light the intrinsic limitations of the operational approach (showing that this approach is unable to convey the clinical flavour of such a complex syndrome). In other terms, there may be, beyond the individual phenomena, a ‘psychological whole’ (Jaspers, 1963) in schizophrenia, that the operational approach fails to grasp, or such a psychological whole may simply be an illusion, that the operational approach unveils. [Maj 1998: 459-60]

In fact, Maj favours the former hypothesis. He argues that the DSM criteria fail to account for aspects of a proper grasp of schizophrenia, for example, the intuitive ranking of symptoms (which have equal footing in the DSM account). He suggests that there is, nevertheless, no particular danger in the use of DSM criteria by skilled, expert clinicians for whom it serves merely as a reminder of a more complex underlying understanding. But there is problem in its use to encode the diagnosis for those without such an additional prior understanding:

If the few words composing the DSM-IV definition will probably evoke, in the mind of expert clinicians, the complex picture that they have learnt to recognise along the years, the same cannot be expected for students and residents. [ibid: 460]

Maj’s criticism that the DSM criteria do not capture a proper, expert understanding of the diagnosis of schizophrenia suggests that even aspects of mental health nursing where the greatest effort has been made to codify and make knowledge explicit still rests on a bedrock of tacit knowledge. Not everything can be put into words.

Is there such a thing as nursing knowledge?

I can now return to the question of whether there is such a thing as ‘nursing knowledge’ and whether it helps to define nursing itself? In a recent article called ‘Defining nursing knowledge’, Angela Hall says suggests that the answer to both is ‘yes’. She says ‘”What is nursing knowledge?” is a complex question, the answer to which helps define nurses as a profession’ [Hall 2005: 34].

Consider a possible contrast between those roles or disciplines whose related expertise or knowledge defines the role or discipline and those where the relationship is the other way round. One might think that theoretical physics or neurology, or mathematics, belonged to the former category. The idea is that what unifies the role or discipline of practitioners is the nature of the knowledge in question. Thus mathematicians could be identified as those possessors of mathematical knowledge which could in turn be understood directly. For this to be the case, the body of knowledge has to be in some way intrinsically unified, a natural kind.

This side of the contrast faces a challenge even in the case of the relation between mathematicians and mathematics because the extension of the concept of mathematics has, from time to time, been disputed. There was disagreement about whether Newtonian fluxions (calculus), Cantor’s ‘paradise’ of the mathematics of infinities and the computer based solution to the four colour problem counted as properly mathematical. This suggests that mathematics – and hence knowledge of mathematics – is sometimes, at least, fixed by the view taken by mathematicians rather than the other way round. But it is the other side of the contrast that matters here: disciplines whose knowledge is identified by whatever the discipline, itself picked out in some other way, requires and where there is no presupposition that what needs to be known is intrinsically unified.

On this other side of the distinction, there might be roles such as restaurant proprietorship for which what is known, or needs to be known, is not intrinsically unified. The role gathers together diverse areas of subsidiary knowledge as the knowledge proper to restaurant proprietorship. This might include some of what is involved in cookery, customer relations, tax law etc. To identify restaurant-proprietorship-knowledge, one needs to identity first the role and only then whatever is the knowledge that turns out to be necessary to carry it out successfully. Further, the knowledge so needed is not particular to this role. It involves the right mix of what is known in other roles by chefs, social psychologists and moral agents, and tax lawyers.

Given this contrast in principle in the order of determination of professional role and underpinning knowledge on which side does nursing lie? I have argued in this chapter that the knowledge nurses need to have lies on both sides of a range of significant distinctions: knowledge necessary for explanation but also for understanding; of facts but also values; and both explicit and tacit. This suggests that ‘nursing knowledge’ is not intrinsically unified but instead comprises different elements necessary for the practice of nursing.

Does this mean that there is no such thing as ‘nursing knowledge’? In a related context, the epistemologist Michael Williams suggests an analogy with Francis Bacon’s (1561–1626) discussion of the nature of heat.

Think of Bacon’s notorious natural history of heat, which brings together various things we call ‘hot’, including bodies warmed by the sun’s rays, substances undergoing exothermic reactions, and ‘hot’ oils and spices that ‘burn’ the tongue. Is there a single thing here, heat? There is no reason, in advance of theory, for supposing that there is. [Wiliams 1988: 424]

Bacon’s method is to survey all the things we call ‘hot’. Now in one sense, this is, indeed, an account of heat, all the things which have heat. But as the list implies, the sense of ‘hot’ or ‘heat’ involved varies across the cases. There is no underlying unity to them. (To achieve a unity, to advance a science of heat, would involved rejecting some of Bacon’s examples, such as ‘hot’ spices, as not instances of the revised unified concept.)

To reject the idea that there is a unified underlying concept of nursing knowledge is not to reject the idea that the different aspects highlighted in this chapter are instances of knowledge. They are but they are gathered together in virtue of a prior understanding of the nature and role of the profession of nursing: perhaps centrally what is needed for caring for patients and health service users. Nursing knowledge is whatever knowledge is needed properly to realise that aim or role.

If this is the case it suggests a related task for the nurses as experts in diverse forms of knowledge. In the presence of a particular patient of mental health service user, they have to select the knowledge appropriate to ‘each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations’ in Sackett et al’s phrase. This task fits a distinction between determinate and reflective judgement suggested by Kant in his Critique of Judgement [Kant 1987].

If the universal (the rule, principle, law) is given, then judgment, which subsumes the particular under it, is determinate... But if only the particular is given and judgment has to find the universal for it, then this power is merely reflective. [Kant 1987: 18]

The model at work here is of judgement as having two elements: a general concept and a particular subject. Judgement subsumes a particular under a general concept. The contrast between determinate and reflective judgement is then between an essentially general judgement, when the concept is already given, and a particular or singular judgement, which starts only with a particular. The former, determinate judgement, appears to be relatively mechanical and thus unproblematic. The idea that if a general principle is already given then judgements which deploy it are relatively unproblematic can be illustrated through the related case of logical deduction where a general principle is already given. If, for example, one believes that

1: All men are mortal; and
2: Socrates is a man.
Then it is rational to infer that:
3: Socrates is mortal.

One reason this can seem unproblematic is the following thought. If one has accepted premises 1 and 2 then one has, ipso facto, already accepted premiss 3. To accept that all men are mortal is to accept that Tom, Dick, Harry and Socrates are mortal. So given 1 and 2, then 3 is no step at all [though see Carroll 1895]. By contrast, for reflective judgement, there is a principled problem in how to get from the level of individuals to the level of generalities, or how to get from people and things to the general concepts that apply to them. That is not a matter of deduction because the choice of a general concept is precisely what is in question. To move from the particular to the general that applies to it is somehow to gain information not to deploy it. Reflective judgement thus cannot be a matter of mechanical derivation.

Kant suggests that the reflective judgement is an essentially imaginative ability and he connects it to aesthetic judgements or judgements of art. The key element of aesthetic judgment, he suggests, is the ‘ability to judge an object in reference to the free lawfulness of the imagination’ in which there is ‘a subjective harmony of the imagination with the understanding without an objective harmony’ [ibid: 91-92]. It is the harmony of the faculties of imagination and understanding in judgment which is both the source of pleasure that grounds aesthetic judgment. This connection between reflective judgement and art suggests a final characterisation of nursing.

Whilst there is no such thing as nursing knowledge, understood as a unified kind, that very fact puts a key selective skill at the heart of nursing, a key piece of know-how or tacit knowledge. Good patient-focused nursing requires the exercise of judgement which seeks, rather than presupposes, appropriate general knowledge. It is thus what Kant would call a reflective rather than determinate judgement. And thus, still following Kant, it is an art not a science. So the knowledge at the heart of nursing, the knowledge to select the right subsidiary knowledge called for by particular patients in particular situations, is an art not a science.

Beauchamp, T.L. and Childress, J.F. (2001) Principles of Biomedical Ethics Oxford: Oxford University Press
Benner, P. (2004) ‘Using the Dreyfus Model of Skill Acquisition to Describe and Interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education’ Bulletin of Science, Technology & Society 24: 188–19
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