Tuesday, 3 March 2015

Why should nurses aim to have knowledge of their subject?

This is a reworked first section of a chapter for a nursing textbook. I am trying to say something general about knowledge without stumbling into an account of the last 50 years of anglo-american epistemology. This version mentions Gettier’s criticism of the traditional model of knowledge (as justified true belief) but does not draw the obvious conclusion (that the JTB analysis is false). In the context, I hope this works, is not too misleading.

The value of knowledge

Why should nurses aim to have knowledge of their subject? What is the value of knowledge?

Exercise: Think about this question before reading on. One clue might be to think about possible opposites to knowledge. If nursing practices were not based on knowledge, on what might they be based? Write down some ideas.

Answering the question of the value of knowledge is difficult. We will approach it in this section via a preliminary question: what is knowledge or what does ‘knowledge’ mean? Now there might not be a very helpful or informative answer to this question. Imagine that someone asks what stickiness is or what the word ‘sticky’ means. One might reply by offering 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. Alternatively, one might offer a more substantial explanation of the concept such as ‘a tendency of a body to adhere to another on contact’. Such an explanation 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 nor that hearing the formal paraphrase will teach the meaning of sticky since it raises further questions such as what the word ‘adhere’ means. But despite these difficulties in defining it, there is generally no difficulty in learning, understanding and teaching how to apply the word ‘sticky’. So we should approach the question of what knowledge in general is with some caution. There may not be a very helpful definition available.

Some general features of knowledge can, however, be learnt from particular examples. 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 at least believe it. (‘At least’ because we often use the word ‘believe’ when we are not sure we do know something. “Do you know that?” “Well I 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 Sandy believes that it is time for Mr Smith’s medication because she knows that he takes medication every day at 5pm and she believes that it is now 5pm. But suppose her belief about the time is based on the normally reliable ward clock which has, in fact, stopped the day before. By chance, however, it is now nearly 5pm. If so, although Sandy has a true belief about the need, now, for Mr Smith’s medication she does not know it. Her belief is merely true by luck. (Earlier in the day she would have formed the false belief that it was 5pm.) Being lucky will make no difference to how things seem to her (since she does not realise the clock has stopped) but an observer might say that she didn’t know the time, she was right only by luck.

These constraints on knowledge have motivated a definition which dates back 2,000 years to the Greek philosopher Plato: knowledge is justified, true belief. The idea is that needing a justification for a belief (for it to count as knowledge) should rule out merely lucky true beliefs. But this prompts a question: in the example of Sandy and the stopped ward clock, does that work?

Exercise: Think about this question for a moment. Does the traditional analysis give the correct account of Sandy? Here is a clue: ask whether Sandy has a justification for thinking the time is 5pm and also ask whether her true belief is lucky. If the answer to both is ‘yes’ then the traditional account does not address the problem of luck. If it does not, could some modification could be made to the definition?

As well as trying to rule out merely lucky true beliefs, justification also plays a second role which is relevant for thinking about the challenge of generating nursing knowledge. It provides a way or a method, or a route, to aim at true beliefs. It is one thing to worry that one’s beliefs about the latest medication for mental illness may not be correct, but quite another to work out how to avoid error.
Suppose some hospital authority issued an instruction that all nursing staff should replace any false beliefs they hold with true beliefs. On the face of it, this seems a good aim. But would the instruction help? Could one act on it? The problem is that ‘from the inside’ true beliefs and false beliefs seem the same. To hold a belief is to hold it to be true. (To believe that something is not true is precisely not to believe it.) Thus beliefs which are, in fact, false are not transparently so to someone who holds them. So the imagined instruction from the hospital authority is not helpful.

By contrast, the following instruction would help: replace any beliefs that one holds without a justification with beliefs that do have justifications. One can tell whether one believes something for a reason, or with a justification. And further, by aiming at having only justified beliefs, one should in general succeed in reaching true beliefs since justification is, in general, conducive to truth. (Any ‘justification’ which did not increase the chances of a belief being true would not be a justification for it after all.)

Although justification can play this second, helpful role of providing a concrete way of aiming at true beliefs it is not so successful in the first role mentioned above: ruling out being merely true by luck. As the example of Sandy and the stopped clock illustrates, Sandy does have a justification for believing that it is 5pm: she can point to the clock. Nevertheless, her belief is only true by luck because, as the narrator of the film Withnail and I says: even a stopped clock is right twice a day. So she has a justification for a belief and the belief is true but no one would say that she knows the time.
Although the definition that knowledge is justified true belief dominated philosophy for 2,000 years since Plato, the problem that one might have a justified, true belief but still not have knowledge was first pointed out in the 1960s by the philosopher Edmund Gettier using an example like this one [Gettier 1963]. What follows?

It seems at first that, as a definition of knowledge, ‘justified, true belief’ must fail (because Sandy has justified, true belief but not knowledge). But a better response is to argue that what the example really shows is that Sandy does not really have a proper justification, a good enough justification for knowledge. Knowledge can still be correctly understood as justified, true belief but not everything that one might think of as a justification (in the example, looking at the ward clock) really is a justification (because the clock has stopped). If so, it is a little like the definition of stickiness from earlier: ‘a tendency of a body to adhere to another on contact’. Just as only someone who understands the concept of stickiness will understanding the concept of adhering, so only someone who can understand the concept of knowledge can understand the kind of justification it needs. Knowledge and justification are a pair of concepts that one learns, in learning a first language, at the same time. The definition, whilst not explaining knowledge to someone who does not already understand it, highlights the essential connection between knowledge truth and justification. If so, nursing knowledge has to have the right kind of justification. The route to knowledge to underpin nursing practice will be, as suggested above, through suitable justification.

We will end this section by returning to the question we first raised. Why should nurses aim to have knowledge of their subject? What is the value of knowledge? In the light of the discussion so far part of the answer is this. Because knowledge, unlike say mere rumour or public opinion on which nursing might otherwise be based, is by definition true, aiming at knowledge is aiming at truth. Now it may seem obvious in a theoretical or contemplative discipline why one should aim at truth in one’s thinking. Cosmologists, for example, want to understand how the universe works just for the sake of understanding it. And hence they should aim at true beliefs just for their sake. But there is a further reason to aim at truth for nursing.

This is because nursing is a practical discipline. It aims not just to understand health and illness (as a merely theoretical or contemplative discipline) but, for example, to make a difference, to change people’s states of illness to health. And in general, actions – for example, medical interventions, or acts of caring – based on true beliefs are more likely to succeed than those based on false ones. So nurses should aim at having true beliefs in order that their practical interventions in the lives of their patients are more likely to be successful. But because there are no intrinsic signs or symptoms of true beliefs that mark them out from false beliefs, the route to this is via a suitable justification which forms part of the conceptually rich idea of knowledge.

In this section, we have raised a fundamental question: why should nurses aim at knowledge. By ‘unpacking’ the concept of knowledge we have suggested answers which connect to the value of truth, the role of justification as a way of aiming at truth and the practical ambitions of nursing to intervene in patients’ lives. There are further, complementary reasons we could have explored. For example, to identify someone, such as a particular member of a multiple disciplinary team, as knowing a patient’s history is to mark out what he or she says on the matter as reliable. Knowledge can be used to mark out whom to trust in cooperative disciplines like nursing.

But although we have talked about the knowledge which underpins nursing practice or ‘nursing knowledge’, there are reasons to think that the diversity of forms of knowledge that nurses need to know makes the phrase ‘nursing knowledge’ misleading. Towards the end of the chapter we will provocatively suggest that there is no such thing as ‘nursing knowledge’ and that nursing is as much an art as a science. But in the next three sections, we will discuss some broad divisions of kinds of knowledge and suggest that nursing straddles each divide. Hence in each case, the generation of new knowledge to underpin practice has to draw on distinct methods and approaches which adds to the challenge of being a modern nurse.