Interpretive Phenomenology

Embodiment, Caring, and Ethics in Health and Illness

Patricia Ellen Benner

• Publisher: SAGE Publications, Inc
• Year: 1994
• ISBN:
  9781452237329
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Patricia Benner's introduction to phenomenology develops the reader's understanding of the strategies and processes involved in this innovative approach to nursing.

The author discusses the relationship between theory and practice, considers the possibility of a science of caring from a feminist perspective, introduces interpretive phenomenology to the study of natural groups such as families, and suggests a basis for developing nursing ethics that is true to the caring and healing practices of the nursing profession.

Part I

Interpretive Phenomenology:
Theory and Practice

1

A Theoretical Foundation for Nursing as a Science

RAGNAR FJELLAND

EVA GJENGEDAL

The Aim of a Science of Nursing

During the last three decades theoretical disciplines have grown out of several professional activities that were once regarded as mainly practical. The aim of the theoretical efforts has been to lay a theoretical foundation for the practical activity. One of these activities is nursing. In the United States nursing has for years been taught at the university level, and several theories of nursing have been developed. But does nursing, which is basically a practical activity, really need these theories? One justification for the development of theories and research is that they are necessary components in a professional education. On the other hand, it is sometimes argued that theories may create a gap between those engaged in practical nursing and those working with theories.

Hence one might be tempted to ask, Is science good? However, this question, asked in a rather general and imprecise way, has no simple and unambiguous answer. We cannot assume that science is simple and unambiguous, and in particular we should not assume that science has just one function. It is therefore a better starting point to assume that some science is good for some purposes. What works well, what does not work so well, and what may even turn out to be harmful must be investigated in each particular case. In evaluating the result, the scientist cannot claim to be specially competent. The general public, which both pays for research and is often affected by it, should also have something to say.

As far as the usefulness of a science of nursing is concerned, there seems to be a simple procedure for deciding the issue. A starting point that all involved parties might accept is that a science of nursing is good if it produces better practical nursing. Hence we will formulate the following aim for a science of nursing: The aim of a science of nursing is to contribute to better practical nursing.

The question of whether theory can improve practice is not new. It has been raised on several occasions in the history of science. For example, around 1386 the city council of Milano decided to build a cathedral that was bigger than all existing cathedrals to symbolize the prosperity and power of the city. In the Gothic tradition rules for the construction of churches had been developed. One such rule said that the height of the church should equal its width (quadratic cross section). However, the city council decided not to use a Gothic construction because it did not fit into the Roman style. They decided to build a cathedral for which the relation between the height and width would correspond to the height and width of an equilateral triangle.

But the decision to deviate from the Gothic construction, which was the best developed at that time, caused several problems. The first problem was that the architects of Milano were not able to calculate the height of an equilateral triangle. The city council had to engage a mathematician from outside the city to solve the problem. But then they faced two problems of statics. Once they had decided to deviate from the Gothic construction, the Gothic principles of support by beams had to be abandoned. The architects of Milano had experience only with smaller Gothic churches, and so no one knew whether the cathedral was constructed well enough not to collapse. A collapsed cathedral would not have been a good symbol of the prosperity and power of Milano.

Experts from abroad were called to Milano. One of these was the Frenchman Jean Mignon, who asserted that the construction was not sufficiently solid. He argued that the architects of Milano were not competent to carry out the project because they lacked the required theoretical knowledge, and concluded, “Ars sine scientia nihil est” (“Art without science is worthless”). But the architects and engineers of Milano used the opposite argument in their defense: “Scientia sine arte nihil est” (“Science without art is worthless”). They prevailed, and the cathedral of Milano was constructed according to their instructions.

As we know, the cathedral still stands and might be used to support the view that practical experience should be preferred to theory. But it is not that simple. The cathedral stands out of sheer luck. Statics in the Middle Ages generally gave too large dimensions to constructions, leaving a rather generous margin of error. Hence the construction was reliable, but the justification was not (Böhme, Daele, & Krohn, 1978, pp. 341-344).

Building cathedrals and nursing are similar in the sense that both, with or without theory, are basically practical disciplines. In this sense they are arts. In the arts we have criteria for what is good and bad independently of theories. Hence we can distinguish between good and bad practice. For instance, when a cathedral collapses, we may conclude that either the construction was defective or the work was not properly done. Of course, it may not always be easy to judge if professional performance is good or bad, but in principle the distinction is clear enough.

The same applies to nursing. Normally it is fairly easy to see the difference between good and bad nursing. Even patients who are hospitalized for the first time will often be able to recognize a novice nurse. They may notice that the performance is hesitant and unsteady, that the bandage is too loose, or that the information given does not inspire confidence.

But normally it is not easy to determine if the lack of competence is due to lack of theory or the lack of practical experience. The relation between theoretical knowledge, knowledge obtained by experience, and the achieved end product is complicated. In the case of the cathedral of Milano practical skills seemed to triumph, but that turned out to be a coincidence. To determine the contributions of theoretical knowledge versus practical experience in achieving a special goal, one has to demonstrate in detail how the goal is achieved. Investigating these matters in more detail raises several theoretical problems. In itself this is an argument in favor of theory.

However, nursing faces a more fundamental problem. The builders of cathedrals work in stone and wood, but nurses “work on” people. The question of good nursing is not exclusively a technical problem, like the building of cathedrals. What is good nursing also depends on what is morally right. Nursing may be technically perfect, but it is not good nursing if it is morally unacceptable. Hence what is good nursing is itself a problem. It is a theoretical problem, if “theory” is taken in a broad sense, including ethics.

It is not sufficient to say that the aim of a science of nursing is to contribute to better nursing practice. The question of what constitutes good nursing is in itself a theoretical and ethical question. The aim of a science of nursing should consequently be expanded to comprise (a) contributing to better practical nursing and (b) exploring what good nursing is.

Good Nursing Practice as a Basis for the Science of Nursing

If the aim of nursing theory is improved practical nursing, the idea that practical nursing must be its starting point as well immediately suggests itself. This point is stressed by Patricia Benner and Judith Wrubel in their book The Primacy of Caring: “A theory is needed that describes, interprets, and explains not an imagined ideal of nursing, but actual expert nursing as it is practiced day to day” (Benner & Wrubel, 1989, p. 5).

Benner and Wrubel do not try to construct a theory of nursing on the model of natural science. They build their theory on another ideal, one inspired by S0ren Kierkegaard, Martin Heidegger, and Maurice Merleau-Ponty.

Even if this is a good starting point, we face at least one problem. The aim of a theory of nursing is to tell what good nursing is. But if the starting point is good practical nursing, must we not already know what good nursing is? How can we, in the first place, distinguish between good and not good nursing? One solution to the problem is that we take as our starting point what is agreed upon by nurses as good nursing and try to describe the knowledge involved in the actual performance. But if the only aim of a theory of nursing is to articulate as exactly as possible what is already taken for granted in good practical nursing, then we do not need a theory of nursing because it does not produce any new knowledge. However, we shall restrict ourselves to pointing out that good practical nursing is only the starting point for the theory. Hence our first aim is to demonstrate how a theory can take the essential attributes of good practical nursing into consideration. The second aim is to demonstrate how such a theory can improve the practice of nursing. We shall start with the first task.

The Unity of Science and Scientism

It is sometimes argued that the distinguishing mark of science is the application of a special method, which is therefore the scientific method. This implies that there is one method common to all sciences, from physics to literary science. The assertion that there is such a method is often called the thesis of the unity of science, and it was maintained by the logical empiricists, who held this to be an inductive method. Others, especially Karl Popper, argued that it was the hypothetico-deductive method. Still others spoke of “the problem-solving method.” But because Popper argued that the hypothetico-deductive method was nothing but the method of trial and error (or, to be more specific, the method of trial and elimination of error) applied to theoretical problems, the hypothetico-deductive method and the problem-solving method may be regarded as identical.

The thesis of the unity of science has been criticized, especially during what has been known as “the positivist struggle.” The critics argued that there is no one scientific method, but that on the contrary each field must develop its own method. In particular they argued against the application of “the method of natural science” to the social sciences and the humanities. Some of the critics argued that the hypothetico-deductive method may be adequate to the natural sciences, but that it cannot—and in particular should not—be applied as the only method in the social sciences and the humanities.

Advocates of the thesis of the unity of science have argued that the hypothetico-deductive method does not make any presuppositions, in particular any presuppositions that restrict its validity to the natural sciences. If the method is nothing but the systematic use of trial and error applied to theoretical problems, this view is obviously correct. The method of trial and error is used in all activities. But then it can be argued that if the scientific method is nothing more than this, there is really no general scientific method.

However, the proponents of the thesis of the unity of science often have more in mind. During the last two decades there has been a tendency among nursing theorists to attempt to construct a science of nursing on the model of natural science. The development of different instruments for measuring the quality of nursing care is one illustration of this tendency. By the scientific method theorists mean the method developed in the natural sciences, characterized by the use of measurements, mathematics, and experiments. Hence a discipline becomes a science by applying the same method. We shall call this view scientism. It is normally related to a mechanistic world view and can be traced back to two of the founders of modern science, Galileo and Descartes.

It is a popular view that modern science is characterized by being observational and experimental. This is in general correct, but it should be understood correctly. If by observation one means the observation of simple sense perception, most natural science is not based on observation. The investigation of nature presupposes the language in which the questions are to be posed and the answers interpreted. This is the language of mathematics, or rather the language of geometry. But this language, or the decision to use it, cannot be the outcome of observation or experiments. It is rather a result of “a change of metaphysical attitude” (Koyré, 1978, p. 2).

It is a historical fact that the emergence of modern science is intimately connected with a mechanistic world view. When Galileo founded a mathematical science, he argued that only that which can be described mathematically has an objective existence. According to Galileo, the world of science is a world of mathematical bodies.

Descartes, who was fundamentally influenced by Galileo, maintained that the only property that remains as objectively existing is the extension of things. All material things are res extensa, and extension is their essential property. When he had already presupposed a world solely consisting of mathematical bodies, Descartes also had to regard the human body as a material body, which like other material bodies is governed by the laws of mechanics. However, he was aware that human beings have a consciousness. Indeed, this fact was the very starting point of his philosophy. The only thing he kept outside the material realm was consciousness, that is, the human soul. But he had to pay a rather high price, for he had to divide our existence into two parts, material body and soul, which are essentially different. Material bodies are res extensa, pure matter, and consciousness is res cogitans, pure consciousness.

The advocates of scientism normally argue in favor of quantification, the use of mathematics and experiments where possible. They accept a discipline as a science only if it satisfies the requirements of the natural sciences. Hence the humanities should not be accepted as science unless they satisfy these requirements. In this paper we are not going to criticize scientism. Rather, we want to present an alternative way of thinking that we think may provide a useful foundation for nursing theory.

The Humanistic Tradition

Another tradition claims the same cognitive status for the humanities as for the natural sciences. It states that the distinguishing features of the humanities must be considered and that the humanities are essentially different from the natural sciences. This view goes back to Aristotle, who argued that a method of investigation must take into consideration the nature of the objects to be investigated. Later this view was maintained by Giambattista Vico. Vico was 16 years younger than Newton. Accordingly, he lived at a time when modern natural science rode the crest of the wave. In his main work, Scienza nuova, he outlined the principles of a new science of the humanities. Basically he made a distinction between human-made things and nature, which is not human-made. Human beings can understand only what is human-made, such as language, institutions, and works of art—in short, everything that belongs to human history has been made by human beings and can in principle be understood by human beings.

To see what difference this makes we can use Galileo’s experiments with freely falling bodies as an illustration. Galileo wanted to discover the law governing falling bodies. He measured distance and time and found a mathematical relationship between the two magnitudes. But let us imagine that instead of investigating falling bodies, Galileo wants to find out how the clouds move. One day when he is out watching the motions of the clouds, he suddenly observes some smoke from a bonfire. The formations of the smoke look like clouds, and their motions may be worth studying. Galileo observes that the “smoke clouds” appear at different intervals, so he measures the time of those intervals and tries to find some mathematical law. The task of finding such mathematical relations corresponds to the task of finding the law of freely falling bodies. But if he suddenly realizes that the clouds of smoke ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface
• Introduction
• Part I Interpretive Phenomenology: Theory and Practice
• Part II Interpretive Phenomenological Studies
• Appendix
• Name Index
• Subject Index
• About the Contributors