Tuesday, 7 April 2015

Nursing knowledge

Here is a draft chapter co-written with David Crepaz-Keay, Head of Empowerment and Social Inclusion Mental Health Foundation Foundation for People with Learning Disabilities, Sebastian Birth, student mental health nurse and Jan Verhaegh, board member of both ENUSP and Autism Europe. 

I suspect it will never be published in this more relaxed and lengthy form. (PS: I was right. I have been told to cut it by 40%)

Nursing knowledge: Its nature and generation.
Key points
1.       Knowledge is more than merely true belief. It is grounded. The traditional view, that it is justified true belief, highlights how knowledge cannot depend on luck though could not be used to teach the word ‘knowledge’.
2.       Explaining natural events by deriving them from laws of nature and understanding mental events by making sense of them seem distinct. On one view, explanation concerns what typically happens and understanding what should happen. Nurses need to know both.
3.       Knowledge of facts and knowledge of values depend on distinct approaches and forms of justification. On some views, value judgements are merely subjective. On others they are objective but uncodifiable.
4.       There is reason to think that explicit knowledge depends on a bedrock of tacit knowledge.
5.       Nursing practice draws on a potentially unlimited set of other disciplines to inform patient care. This places a heavy burden on knowledge-based practice.
6.       The co-production of knowledge suggests a more equal role for patients and service users, a richer source of knowledge but also some challenges.
7.       Because clinical judgement has to select from a body of knowledge to match a particular patient’s needs, it may be that nursing is better thought of as an art than a science.

What kind of knowledge underpins good nursing practice? Is it a unified field? And if not, what are the appropriate methods for arriving at new knowledge? In this chapter, we will consider three important distinctions which divide up forms of knowledge and argue that, in each case, nursing knowledge is distributed across both sides. Nurses must be able to understand their patients / service users as well as explain the course of their of illnesses. They must know about facts and about values. And they must have tacit knowledge as well as explicit knowledge of their profession.
This suggests that nursing knowledge is not a single unified field but rather draws on a range of different disciplines. Given the requirements on the nature of knowledge itself, this suggests that a range of quite different approaches are necessary to generate new knowledge. The challenges are increased especially in mental healthcare by the aim of co-producing knowledge with patients or service users. Finally, we will suggest that that this places the skill of identifying the right pieces of knowledge appropriate for each particular patient or service user at the heart of nursing. Although underpinned by scientific knowledge, this ability to judge what is relevant can helpfully be interpreted as an art.
This chapter concerns some deep questions about the kind of knowledge nurses need to have. It is a chapter about the philosophy of nursing and asks hard questions about what knowledge is and whether all knowledge is of the same sort. But our contention is that knowledge of a variety of different kinds lies at the heart of good nursing care. Dealing with this is the key – practical and philosophical – challenge of modern nursing.

The value of knowledge
Reflection point: Why should nurses aim to have knowledge of their subject? What is the value of knowledge? 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 definition nor that hearing the formal definition will teach the meaning of sticky since it raises further questions such as what the word ‘adhere’ means.
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 Staff Nurse Robin knows that, because it is 5pm, Service User/Patient Terry is due for medication. If so, Robin must hold, 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 Robin does know that Terry is due for medication, then Terry must really be due for medication. If Robin has knowledge, what she believes must be true.
Third, Robin’s belief cannot merely be accidentally true. Neither a reckless guess nor an ungrounded hunch can support knowledge even if they turn out to be true. They might, too easily, not have been true. But knowledge can be undermined even when one does one’s best. Suppose Robin believes that it is time for Terry’s medication because she knows that he takes medication every day at 5pm and she believes, by looking at the ward clock, that it is now 5pm. But supposethat the normally reliable ward clock which has, in fact, stopped the day before. By lucky chance, however, it is now nearly 5pm. If so, although Robin has a true belief that it is time for Terry’s medication she does not know it. Her belief is merely true by luck. If she had looked at the clock an hour earlier she would have formed the false belief that it was 5pm and so time for his medication. 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 Robin and the stopped ward clock, does that work?
Reflection point: Think about this question for a moment. Does the traditional analysis give the correct account of Robin? Here is a clue: ask whether Robin 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?
We will return to this question shortly.
As well as trying to rule out merely lucky true beliefs, justification also plays a second role which is helpful 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 right, but quite another to work out how to avoid being wrong.
Suppose a 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 instruction 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 or grounds. 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 Robin and the stopped clock illustrates, Robin 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 Robin has justified, true belief but she does not have knowledge, she is merely lucky). But a better response is to argue that what the example really shows is that Robin 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 or grounds.
If so, nursing knowledge has to have the right kind of justification or grounding. 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 for nurses to aim at truth. 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 [Craig 1987].
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 also 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.

Explanation and understanding
In the first section we asked what knowledge was and considered the definition: ‘justified, true belief’. The question, and the discussion which followed, may suggest that knowledge is a single unified sort of state. In fact, however, what is called ‘knowledge’ can be subdivided. Now one way to divide up knowledge would be to divide it very finely by subject matter.
For example, knowledge of human physiology subdivides into knowledge of the skeletal system, the muscular system, the immune system, the renal system etc. And knowledge of the skeletal system divides between itself subdivides into the ribs, vertebrae, cranium etc. But whilst the facts concerning the skeletal system differ from those of muscular system, there is no reason to think that the form of knowledge differs in these cases, any more than that knowledge of the location of one train station differs in kind from another. What one knows differs but the nature of knowledge itself does not.
Some divisions, however, do seem to concern not just what is known – the facts – but the way it is known. Consider these two examples of patient history.
Mr Smith is a 65 year old man who has recently visited his GP because he has found in recent weeks that he needs to pass urine more frequently and is having difficulty when he needs to. Mr Smith’s GP finds out from a case history that Mr Smith’s grandfather died of prostate cancer. Owing to his age and his family history, the GP gains permission to perform a digital rectal examination of Mr Smith’s prostate, and finds that it is ever so slightly ridged. The GP requests an oncology appointment in order to perform a prostate-specific antigen test which tests for a specific antigen produced by the prostate whose levels are raised if there are cancerous cells in the prostate, as well as to run an ultrasound in order to determine the size of the prostate and potentially perform a biopsy of the prostate. From these diagnostic tests the different doctors involved are able to look at Mr Smith’s medical records and see the results of his tests. From these test results they can determine the stage and grade of the cancer in Mr Smith’s prostate, monitor the progress of the disease and adjust treatment accordingly.
Miss Singh is a 23 year old who has gone to visit her GP because she has recently had very strong feelings and ideas to end her life. Miss Singh’s GP refers her to a community mental health team where she is seen by a nurse. The nurse gains permission to ask Miss Singh some questions about her current suicidal ideations as well as her mental state now and historically. Throughout the course of the assessment the nurse finds out that Miss Singh has been finding it hard to fall asleep, that she struggles to get out of bed and her appetite has dropped considerably in the past few months. Miss Singh tells the nurse that she has been feeling worthless and inconsequential ever since she can remember but now these feelings are worse and she cannot plan for or see any happiness in her future. The nurse thinks that these could be some symptoms of depression and wants to find out more about Miss Singh’s past to see if there are any psychosocial triggers to how Miss Singh is feeling now. Miss Singh tell the nurse that her mother passed away a few years and this event left her depressed. After some further questions the nurse discovers that it is approaching the date of Miss Singh’s mother’s death.
Reflection point: what are the typical indicators that one is on the right track top have grasped the biological course of a disease? And what for the development of a patient or service user’s attitude to their diagnosis? Are they the same?
In both cases, GPs and nurses aim at knowledge: a truthful account backed up by reasons. In one case, the justification flows from a process of looking at medical records and in the other of asking questions and recording answers or having a conversation. Nevertheless, despite sharing the aim of knowledge, these two accounts appear to have different structures. One accords with a structure of biological processes described by physiological laws of nature. The other has a psychological structure of thinking, feeling and acting for reasons. The former sort of knowledge depends on a theoretical inference about how (biological) events are governed by natural laws. The latter depends on a more general pattern of what makes sense to the speaker and listener.
The idea that there really is a difference of kind between these two apparently different forms of knowledge dates back to debates about psychology in the late nineteenth century called, in German, the Methodenstreit. It concerned whether the human sciences should try to emulate their far more successful cousins the natural sciences or whether they should follow a distinct logic or method.
The philosopher and psychiatrist Karl Jaspers is of particular relevance to mental health nursing. Like now, at the start of the twentieth century, German psychiatry was dominated by neuroscience and the assumption that mental illnesses were brain illnesses. Jaspers thought 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 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 approaches which focus on individual people or individual processes such as history which he called ‘idiographic’.
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 (EBM) 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 (RCTs), person centred care stresses the importance of a focus on individual patients.
Intuitive though the distinction between nomothetic and idiographic seems, however, there are some problems in grasping exactly what it means. After all, it cannot just be the difference between a focus on repeated versus unique events since nomothetic sciences such as cosmology may study, and attempt to explain, unique events such as the Big Bang. Further, there is a challenge which arises from the worry that a truly idiographic form of understanding could never amount to knowledge. As we argued in the first section, knowledge can never be true by 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 more general skill. It would be impossible, for example, to practice such a skill since practicising on other cases – eg learning to understand other people or at other times – would not count. So even if a truly idiographic judgement were correct, that would be a matter of luck and hence not knowledge.
The more promising distinction seems to be a distinction 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. The distinction between explanation and understanding can be thought of as the difference between deriving events from general scientific natural laws versus fitting them into normative patterns of good reasons, what should happen. Whilst explanation concerns what typically happens, what is statistically likely, understanding concerns what should happen: having good reasons for thinking, saying or even feeling what one does.
With this distinction in place, in order to care for patients and service users nurses need knowledge that 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. This is knowledge of central importance for healthcare.
How then is it possible to generate new nursing knowledge on both sides of this conceptual divide? New explanatory knowledge – that is knowledge based on natural scientific laws – is the focus of Evidence Based Medicine hose main approach is the randomised control trial (RCT) or, even better, the meta-analysis of randomised control trials. Such knowledge is underpinned by research that seeks out larger and larger study groups in order to avoid the potential errors and biases introduced by small populations and particular researchers.
New knowledge from the other side, the understanding rather than explanation side, of the distinction calls for a different approach. Now there are some general science-based results that are relevant to understanding individual patients. For example, it is increasingly recognised that patients often take in and recall very little information that is given to them when they receive a serious and worrying diagnosis and hence measures need to be taken to compensate for this [Jedlicka-Köhler et al 1996]. Further, there are some general communication skills that can be formally taught and ongoing psychological research is likely to have an impact on this. But the most obvious way to generate relevant new knowledge of this sort is to continue to listen to the changing beliefs, wishes and feelings of patients recognising that listening is a skill that can be practiced and developed. By contrast with the ever more general perspective of explanation, looking away from the individual to the general population-based research of EBM, the key focus for understanding is away from the general and towards the individual patient.

Knowledge of facts and values
In the previous section, we 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 ways that make intuitive sense. 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 be 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 as a reminder of another key 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- but also about values based-practice. This prompts the following question: is knowledge of values a distinct kind of knowledge from knowledge of facts?
Let us take an example. Mrs Jones is a 29 year old mother of one, who lives with her husband and is currently working part time as a teaching assistant. Mrs Jones also has a diagnosis of bi-polar affective disorder, which is successfully managed by Sodium Valproate. She and her partner are planning to try for another child. This poses two risks, firstly that of neural tube damage in the potential child, birth defects and developmental delay. A second factor is the risk of Mrs Jones developing post-partum psychosis. Mrs Jones has many choices to make in the preparation for her pregnancy, all of which are intertwined with her own values, the values of her partner, society’s values and healthcare professionals. Mrs Jones may well wish to continue taking Sodium Valproate, with a full understanding of the risks to her child. This may very well clash with the current evidence base for best practice, however her values must be acknowledged. For it could be the case that Mrs Jones has been on other mood stabilising medication in the past and has found the side effects unbearable and the effect they have on her mood unnoticeable. A further issue could be that Mr and Mrs Jones express a desire that, if Mrs Jones were to become psychotic after childbirth, she be treated at home rather than a mother and child unit. This again contravenes best practice. But there could be reasons why Mr and Mrs Jones would wish for treatment at home. It is the role of the nurse to merge the worlds of scientific fact, evidence based medicine and best practise with that of the lived human experience, with its values, emotions and desires.
As we stressed at the start, nursing is a practical discipline. It aims to change the world as well as understand it. So a case like this prompts the question: what is the right course of action? An informed answer will include the best medical evidence for the likely prognoses of interventions. But knowledge of the bio-medical facts is only part of the story. Another part might concern relevant economic facts concerning treatments permitted by NICE. But another will concern the values relevant to a decision. These will include those values encapsulated in mental health law concerning capacity. They will include a range of ethical factors some of which will command wide agreement whilst others will be contentious. Yet others concern the wishes, hopes, fears of, primarily, the patient or service user.
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 is no equivalent of RCTs to decide how we ought to act. The closest equivalent, in the case of medical ethical values, might be 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 natural 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, thinks that values are subjective. They lie merely in the eyes of the beholder. As Hamlet says: there is nothing either good or bad, but thinking makes it so. Fulford thus argues that successful values based practice in mental healthcare does not aim at a correct judgement but to follow a good process [Fulford 2005]. It is a matter of following the appropriate deliberative process, exercising good communication skills, and seeing what view emerges rather than aiming to get the values in a particular situation objectively right.
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 truth, that value judgements are objective [Thornton 2011]. On this latter view, whilst knowledge of values is not reducible to, or codified in, general principles it is still a form of knowledge of the values inherent in the clinical situation.
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. Nurses need both, however.
Is it possible to generate new knowledge of values relevant for nursing practice? (We considered new knowledge of explanatory facts relevant for nursing practice in the previous section.)
Reflection point: think for a moment about the kind of skills that might be involved in values based practice. Do they depend on knowledge of values? If so, how does one acquire such knowledge?
This is a difficult question for which there is no clear cut answer. To begin, it depends on the view of values one takes. If one thinks that value judgements are subjective then there are no new truths about values to be discovered, because there are no truths about values, merely new truths about what people, as a matter of fact, like or dislike. But, even so, there may be new approaches to values based practice in the way that Fulford’s or the ‘Four Principles’ approaches were both new developments in their day.
If on the other hand, one thinks that values are real or objective features of the world, then the possibility of new general knowledge of values will hang on the possibility of a kind of moral – and other value – progress. On this view, the present day rejection of the historical claim that plantation slaves who had a compulsion to run away suffered a form of mental illness, ‘drapetomania’, is a piece of moral progress and hence new knowledge of the values that underpin mental health and illness. It is a piece of knowledge, on this view, because more can be said to justify the claim that there was something wrong with thinking of such behaviour as pathological. Reasons can be given. But exploring such reasons is as much developing a kind of sensitivity to other people as it is learning anything general.
The debate between these overall views is, however, ongoing. And hence one possibility for new moral knowledge would be a justified view of their relative merits. Whatever the future outcome of this debate, however, the nature of new knowledge in this area will be of a distinct form from that of new knowledge of the value-free facts underpinning nursing. We will return to the significance of this difference at the end.

Tacit and explicit knowledge
The characterisation of evidence based medicine from Sackett et al above also highlights a further distinction of kind within what nurses need to know. Sackett defines 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 we set out in the first section, on the standard model of knowledge, this content is a belief (eg. that Terryis due for medication). But if so, why can this not be put into words?
Reflection point: What kind of thing could be known but not be put into words? Do we use ‘knowledge’ about anything other than knowing facts, knowing that something?
Polanyi himself suggests a clue to this riddle:
I may ride a bicycle and say nothing, or pick out my macintosh among twenty others and say nothing. Though I cannot say clearly how I ride a bicycle nor how I recognise my macintosh (for I don’t know it clearly), yet this will not prevent me from saying that I know how to ride a bicycle and how to recognise my macintosh. [Polanyi 1962: 88]
Polanyi suggests that we call ‘tacit’ any knowledge of how to do something – practical knowledge – where the skilled practitioner, nevertheless, does not know, in some sense, how she does it. Just as the skilled cyclist may be unable to explain her skill or the owner of a raincoat may not be able to describe the features by which he can recognise it in a pile of similar coats so nursing, being a practical discipline, contains its fair share of practical, tacit knowledge. This includes knowledge of how to do things: basic clinical skills but also recognitional skills summarised by Sackett et al. These are the kind of recognitional and other practical skills which Benner describes using Dreyfus’ five stage hierarchy connecting novice to expert practitioner. [Benner 2004; Dreyfus and Dreyfus 1986]. The idea is that whilst a beginner learns a skill by following – consciously and explicitly – some general rules, the skilled practioner first internalises the rules but then learns how interpret them and deviate from them when the context demands.
For example, take Motivational Interviewing, a complex skill used by mental health nurses to help clients to motivate and change their own negative health behaviours. The skill involves addressing the ambivalence some clients might have to change. Motivational interviewing presents a skill which is different from standard methods of clinical and non-clinical conversation. There are steps to learn the skill. It may be strange for the nurse taking part in Motivational Interviewing at first to restrain from dispensing advice on how or why a client should change their behaviours. However, when the necessary skills are practised, they become internalised and the nurse will no longer have to look at the ‘manual’ to utilise Motivational Interviewing, but will instead be able to work from a more intuitive grasp of the process.
There is, however, another 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.
For the last fifty years, both of the main diagnostic manuals for mental illness (the World Health Organisation’s International Classification of Diseases (ICD) and the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM)) have adopted an ‘operationalist’ approach. Syndromes are described and characterised in terms of lists of observable or expressible symptoms 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 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 and plays up explicit knowledge.
Nevertheless, there remains a key role for tacit knowledge. The main diagnostic manuals set out or define the syndromes using symptoms but they do not describe the symptoms at length. Other books do just that [eg Sims 1988]. But there remains a gap between even a very thorough description of a symptom and its expression by a particular patient or service user at a particular time. The skilled practioner learns to see that the words set out on the page apply to the lived experience before them. This skill is not itself a matter for explicit knowledge since sooner or later, whatever is written down in general terms has to be applied on the ward. It is a practical skill in recognition.
Criticising the ability of the DSM criteria to capture the nature of schizophrenia, the President of the World Psychiatric Association Mario Maj 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]
Maj suggests that either the DSM does not capture the full nature of schizophrenia or schizophrenia is a myth. In fact, he 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). Clinicians know more than is codified in the DSM. There is, nevertheless, no particular danger in the use of DSM criteria by already skilled, expert clinicians for whom it serves merely as a reminder of a more complex underlying tacit 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 rest on a bedrock of tacit knowledge.
We suggested in the first section that knowledge cannot rest merely on luck and still count as knowledge. Although Robin had a true belief that it was time for Terry’s medication, she did not know it.
Reflection point: Does that restriction apply to tacit knowledge? Stop reading and think what might be the equivalent for practical or tacit knowledge of justification for explicit knowledge? How does practical or tacit knowledge avoid resting on mere luck?
The clue is in the idea that tacit knowledge is a form of practical knowledge (even if by practical knowledge we mean being merely being able to recognise a macintosh coat or a mental illness symptom) and practical knowledge is a skill. So the equivalent of justification for tacit knowledge is having developed a general ability through practice, repetition and criticism. This suggests the route to new practical or tacit knowledge for nurses: the arduous work of moving through Dreyfus’ five stage hierarchy connecting novice to expert practitioner.

Is there such a thing as nursing knowledge?
In the previous three sections, we have examined three distinctions that apply to the knowledge that underpins nursing care. Knowledge can concern explanation (using laws of nature) or understanding (making sense though reasons); facts or values and be explicit or tacit. In each case, we have argued that nursing straddles the divide. That is, nursing practice should be based on knowledge from both sides. This suggests that the way to learn and to generate new knowledge, both individually and as a discipline, varies.
In this section we wish to raise a more provocative question: is there such a thing as ‘nursing knowledge’? This is not the same as asking whether nursing should be based on knowledge and whether nurses should keep up to date with new developments and findings. Of course it, and they, should. But is there a characteristic unified field of knowledge that could helpfully be called ‘nursing knowledge’ and can it help 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]. We think that the answer to both questions is ‘no’ and that this places a particular burden or duty on nurses.
Consider the contrast between those professional roles or disciplines whose related 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, belong to the former category. What unifies the role or discipline of practitioners is the nature of the knowledge they have. Thus mathematicians could be identified as those possessors of mathematical knowledge where mathematics can be defined without mentioning mathematicians. Mathematics as a subject is defined in some way such as the abstract study of quantity and shape.
On the other side of the distinction, there might be professional roles such as restaurant proprietorship for which what has to be known is not intrinsically unified. That role gathers together diverse areas of subsidiary knowledge. It might include some of what is involved in cookery, customer relations, tax law etc. To identify ‘restaurant-proprietor-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 tax lawyers.
Given this contrast, on which side does nursing lie? We have argued 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 a simple unified kind at all but instead comprises different kinds or sorts all of which are necessary for the practice of nursing.
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 all important and that all kinds of knowledge. They are but they are gathered together to underpin the nature and role of the profession of nursing: 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.
This places a heavy burden on nursing as a profession and individual nurses in maintaining their knowledge base. It is impossible to put limits in advance on the areas of human inquiry which might provide knowledge relevant for improving patient care. Even now, nursing education draws on the biological sciences and chemistry, psychology, communication, management science and moral philosophy. The duty for the future is to keep an open mind to developments from any other discipline that might have a bearing.

Can nursing knowledge be co-produced?
Much of the discussion of nursing knowledge focuses on the nurse as acquiring and having knowledge. But it is also important to consider the role of the patient or service user and in particular to consider their role as co-producer of knowledge.
Historically, the role of the patient has been a passive one. The patient was thought of as the ‘problem’ needing to be explained or understood and solved. That patients may themselves have knowledge or opinion has been regarded as a mixed blessing, with the role of nurse (and other clinical professionals) being to extract the ‘wheat’ of knowledge from the ‘chaff’ of patients’ descriptions of their experience. This process was rendered more difficult in mental health nursing where there may be a concern that the patient lacks insight and whose testimony may therefore be unreliable. As well as making the generation of knowledge more difficult, this observer/object relationship can lead to therapeutic conflicts.
Modern nursing has seen the development of service user /patient involvement, expert patients, self-management and peer support. These developments have changed the role of the patient from passive recipient of nursing to active player in a partnership. The term ‘co-production’ is being applied to these (and other) partnerships. It is most commonly applied to service development, but it is also being applied to a range of activities (like care planning) and even more abstract concepts like reality and meaning. Co-production typically involves both professionals and service users (and often informal carers) bringing their skills and experience to a joint process that creates something new. This collaborative approach can be applied to the process of generating knowledge, both at the individual case level, and at a more widespread level in developing research and practice.
Reflection point: consider the idea of nurses and patients co-producing knowledge. What are the challenges? What are the benefits?
Some of the challenges will depend on the nature of knowledge. If, for example, we consider the definition ‘justified true belief’ then we need to consider whether both ‘justification’ and ‘truth’ can have common meaning to nurse and patient. Nurses are trained to assess information in a particular way; patients are not. Patients are living the condition, and living with the consequences of the condition; nurses are not. We also need to consider the power differences that exist as a result of the respective roles of nurse and patient. In most nursing situations, this power relationship is based on perceptions, but in the case of mental health nursing there are also legal powers that may affect the relationship.
While these may be challenges, the differences in perspective, experience and even perception also offer potential benefits. This chapter has highlighted the diversity of forms of knowledge needed for nursing care. If we ensure that knowledge is co-produced, this broadens the experience and values that contribute to knowledge.
There may well be conflicts during the process of co-producing knowledge: these conflicts may be the result of, among other things, differences in existing knowledge and training, differences in perception or differences in values. These conflicts may be resolvable, and should help to test the truth and justification of all contributors’ beliefs. Where the knowledge being co-produced is at the level of an individual therapeutic relationship, the conflicts will need to be resolved. Where the knowledge is being co-produced for broader understanding, it may be appropriate to maintain and highlight the differences, where this may indicate further research is required. There will be a range of tools and approaches available to help achieve consensus, but it is also important to recognise that some tools and approaches associated with knowledge creation and in particular with evidence based practice, may introduce a bias towards a particular type of knowledge. Genuine co-production suggests that such assumptions should be approached critically to see what is relevant in particular cases.

We began this chapter by asking the very general question: Why should nurses aim to have knowledge of their subject? What is the value of knowledge? One way to address that is to consider the nature of knowledge itself. On a traditional view dating back to Plato, knowledge is a state that fuses belief, truth and justification. Although it now seems that the traditional view cannot serve as a non-question-begging explanation of knowledge because one already needs to know what knowledge is before one can understand what justification is and also vice versa, it does highlight the intimate connections between knowledge, truth and justification. Given this, nurses should aim at knowledge because, among other things, knowledge supports successful action and nursing is a practical discipline.
Despite this general argument for the importance of knowledge for nursing, subsequent sections have highlighted the different kinds of knowledge that underpin nursing care, calling for quite different ways of acquiring new knowledge. And thus it seems that there is not a single unified field that nurses should aim to know. In the previous section, we put this deliberately provocatively by arguing that there is no such thing as ‘nursing knowledge’. The point of putting the point that way is to highlight the ongoing duty for nursing as a discipline to look outwards for fresh sources of knowledge to improve patient care.
We will end the chapter with a final open-ended but illustrative question. As a knowledge-driven practical discipline is nursing an art or science? This is not to question whether nursing should draw on science (of course it should). But, at heart, is nursing itself an art of science? There are a number of different ways in which one might address this question and you should compare your own approaches with ours. (One different approach would be to think of the roles of art and science in caring relationships.)
Let us start from the ongoing duty for nursing to look for fresh sources of knowledge to improve patient care. If this is the case, it suggests a central task for the nurses as experts in diverse forms of knowledge. In the presence of a particular patient, or mental health service user, nurses 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 what the philosopher Immanuel Kant calls ‘determinate’ and ‘reflective’ judgement suggested 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]
In a determinate judgement, one already knows the general concept that is relevant to a particular instance, and deduces from it something that follows from that. For example, if one knows that Mrs Jones is suffering from mild depression and one knows that those who are mildly depressed are likely to respond well to CBT then one knows that Mrs Jones is likely to respond well to CBT. A determinate judgement seems to require no great imagination: just the simple unpacking of deductive consequences of a concept one already knows applies.
The case of a reflective judgement is different. It corresponds to the case of meeting a particular patient or service user (for example, Mrs Smith) and seeking out the general concepts that fit her, for example, that she is suffering from depression. Unlike determinate judgement, it seems that this cannot be an unimaginative rule governed judgement. Reflective judgement faces a principled problem of 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 or recognition 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 essentially an imaginative ability and he suggests that it calls on the very same abilities and responses that are drawn on in the appreciation 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]. In appreciating art, we balance imagination and understanding and this balance is the source of pleasure. This is the ‘art of judgement’.
This connection between what he calls ‘reflective’ judgement and art suggests a final characterisation of nursing. Because nursing has to draw on an open ended list of other subjects to match knowledge to the particular needs of patients, that very fact puts a key intellectual skill at the heart of nursing, a key piece of know-how or tacit knowledge or good judgement. Good patient-focused nursing requires the exercise of judgement which seeks out, rather than presupposing, the right piece of general knowledge. And thus, 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: the art of nursing.

Commentary by Jan Verhaegh, board member of European Network of (ex-)Users and Survivors of Psychiatry (ENUSP) and Autism Europe
Health problems are always problems of the whole person. That means that they have a biological, psychological and social dimension. In the Netherlands we have physicians who treat mainly the physical dimension, psychotherapists who treat mainly the psychological dimensions and nurses who take care of both the physical and psychological dimensions. In some institutions nurses, who have the greatest contact with patients, are called ‘socio-therapists’ because of their focus on the social dimension. They need, practically, to be trained in such knowledge and skills for example to empower their patients. But they also need broader knowledge of their patients’ social worlds such as what it means to live in a patriarchal unequal world which can lead to violence, abuse, mistreatment and so on and thus in turn to mental and physical health problems.
For example, recent research links the intelligence of people with Asperger’s syndrome to the experience social stress because of bullying, social conflicts and exclusion which can in turn lead to psychosis [Selten et al 2015]. The most intelligent young people suffering from Asperger’s are18 times more likely to develop psychosis than a neurotypical child. To take care of such people, nurses need knowledge of the biological, psychological and social dimensions of health and illness.

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Learning outcomes
Readers will be able to:
·         List some fundamental distinctions between kinds of knowledge: understanding versus explanation, tacit versus explicit, facts versus values.
·         Articulate some of the key properties of knowledge in general
·         Differentiate between explanation and understanding.
·         Compare different views of the subjectivity or objectivity of value judgements.
·         List examples of tacit knowledge.
·         Outline the advantages of and challenges to the co-production of knowledge

Further reading
For an introduction to philosophical accounts of knowledge in general
Pritchard, D. (2006) What is this thing called knowledge London: Routledge
For a general book on philosophy for nursing
Reed, J. and Ground, I. (1996) Philosophy for nursing, CRC Press
For an account of nursing ethics
Armstrong, A. (2010) Nursing ethics: a virtue-based approach, Palgrave
For a wide ranging discussion of tacit knowledge knowledge
Gascoigne, N and Thornton, T. (2013) Tacit Knowledge Durham: Acumen
For a discussion of Dreyfus’ hierarchy of skills applied to nursing
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
For discussion of the subjectivity or objectivity of values based practice
Loughlin, M. (ed) Debates in Values-based Practice: arguments for and against, Cambridge: Cambridge University Press

Web resources
Values based practice