In light of recent attacks on Science Studies, it is comforting to know that some sciences still benefit from a close association with philosophers, historians, even sociologists of science. The most prominent and visible of these are the Biological Sciences which witness incredibly and uncannily close collaborations between philosophers and scientists. Traditionally less visible has been the association of Philosophy and Nursing Science. Nursing has gradually evolved into an active research discipline with its share of stimulating theoretical debates. Philosophy of science is part of its Ph.D. curriculum: philosophy provides a heightened sense of awareness of what it means to pursue Nursing as a science. Also, philosophical critiques of traditional science or of positivist methodologies have been embraced by Nursing theorists to carve out innovative avenues of research.
Dan Pesut's current research-interests owe to this give and take. He came to Nursing Science studying self-regulating pain-behaviors of patients with severe burns. For the last few years, he team-taught with members of the Philosophy Department the seminar on the Philosophy of Nursing Science. Not surprisingly, perhaps, he is currently writing a book (with JoAnne Herman) on the self-regulation of creative thought in Nursing.
According to Dan, the 'thinking routines' of nurses have to be reconceptualized as Nursing becomes increasingly science-based. Originally, nurses were taught to follow the steps of assessment, planning, implementation, and evaluation. These steps were geared toward a medical conception of 'the problem.' With nursing science coming in and claiming for itself a domain of inquiry different from that of medicine, another step was added: between 'assessment' and 'planning' comes a nursing 'diagnosis.' This newly expanded five-step nursing process required a standardization of nursing concepts, theory, and research, leading to NANDA (the North American Nursing Diagnosis Association), NIC (the Nursing Interventions Classification), and NOC (the Nursing Outcomes Classification). But whether one thinks of the nursing process in four or five linear steps, that process still remains oriented toward the medical problem rather than the nursing outcome. The scientific character of Nursing is therefore not adequately reflected even in the five-step process.
Dan's and JoAnne Hermann's research shows that the actual thought-processes of nurses are not linear or problem-oriented at all. Instead, they consist in clinical reflections and judgements that are designed to resolve tensions between a present state (for example, pain) and an outcome state (for example, comfort). The reflection on Nursing as possibly a science is thus leading to an appreciation of nurses as creative (scientific) thinkers rather than followers of routine procedures. Dan and JoAnne Herman articulated these ideas in "Metacognitive Skills in Diagnostic Reasoning: Making the Implicit Explicit" (Nursing Diagnosis, 3:4, 1992, pp. 148-154). Laura Conrad joined them to write "Using Metacognitive Skills: The Quality Audit Tool" (Nursing Diagnosis, 5:2, 1994, pp. 56-64). A third article (co-authored with L. Fowler) is in press: "Toward a Revolution in Thinking: The Opt Model of Clinical Reasoning" (in J. McCloskey and Helen H. Grace, eds., Current Issues in Nursing, 5th edition, St. Louis: Mosby).
Our discussion of Dan's contribution touched upon the politics of Nursing Science. A greater appreciation of nurses and their clinical reasoning-skills creates professional opportunities and an important line of defense for Nursing in the changing health-care environment. Indeed, the whole history of Nursing Science can be read as a history of how to confer authority and expertise to a profession that needs to move out of the shadow of medicine.
Alfred Nordmann
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