Practice as a Way of Knowing, in Its Own Right, Rather than a Mere Image of Theoretical Thinking

From Nursing Ethics, 1880s to the Present (p. 385-390)
Used by permission 2024 © Marsha Fowler
Chapter 11 Notes

In 1981, I was working with Professor Richard Lazarus at University of Berkeley, studying stress and coping in aging in the community, which was new to Professor Lazarus, whose research was primarily experimental laboratory work. We were studying mind–body relationships related to stress appraisals and coping. I sug- gested that I enroll in some mind–body philosophy classes to clarify our language and understandings, and this was life-changing for me as an experienced nurse, having worked in ICUs, emergency departments, and home health-care nursing for 18 years. I went to the UC Berkeley Philosophy Department and spent the next seven years there! Equally important is that all my doctoral students took philosophy courses from Professor Bert Dreyfus at UC Berkeley, and we would have a seminar to discuss the philosophy class in relation to nursing practices. The teaching assistants frequently commented that the most interesting research and philosophical questions came from the graduate nursing students. Bert Dreyfus waived all philosophical class prerequisites for nursing graduate students, stating, “For reasons I don’t understand, the nursing students end up with the best under- standing of Heidegger.” Students often talked about needing this new philosophical language to describe their practice of nursing.

In the Philosophy Department, I began by studying Kierkegaard, with Hubert L. Dreyfus and his brilliant TA, now Dr. Jane Rubin, friend and colleague and author of the definitive dissertation on Kierkegaard. From Kierkegaard, I now had a language and an understanding of “lifeworld” and the role of indirect discourse (first‑person‑experience narratives). Kierkegaard used letters between people liv- ing in different lifeworlds (organized by concerns, practices, habits, meanings and social relationships, and more) to convey their ways of being in the world; first‑ person accounts of the narrators’ experiences in their lifeworld, their self‑defining commitments, meanings, and how they managed the stress and anxieties and everyday coping and comportment, complete with insights, blind spots, meanings, and

more. This kind of understanding from inside a person’s lifeworld, is the coin of the realm for understanding and explaining meanings, practices, habits, skills, and re- lations within persons’ lives. For example, in Kierkegaard’s writings, the Aesthete correspondent (aesthetic sphere or existence or “lifeworld”), with Judge William in the Ethical Sphere, withdrew from his active life of seeking the maximum amount of pleasure, into a world of only reflecting and dreaming about pleasures in order to avoid the real risks of pursuing real-life pleasure that might be disappointing or elusive. “Judge William” lived in a lifeworld with self‑defining commitments to being the sole definer and arbiter of all meaning in his world. This detachment brought him a sense of control over the risks involved in being connected, related, and human, but it also caused a sense of meaninglessness when nothing outside himself could lay claim on his attention and be meaningful in its own terms.

I confronted similar meaning, stress, and coping issues in caring for persons who dwelt in different lifeworlds, in ways that shaped their suffering, anxiety, and fears related to their illnesses and recovery. Note, this came through understanding rather than explanation, but understanding is essential for understanding human beings dwelling in lifeworlds. I took Professor Dreyfus’ Kierkegaard course five times, learning and understanding more each time. His classes were so layered, nuanced, and complex, and I was learning more than I had ever learned in a psychology class on stress and coping. I now had a richer language in which to describe my nursing caring practices. I also took the courses offered by Dreyfus on Philosophy of Science, on Merleau‑Ponty’s philosophy of embodiment and critique of natural, objectifying sciences to study human beings, and courses on early Heidegger’s notions of “being in the world” and engagement and involvement as the most com- mon stance of human beings, rather than Descartes’ vision of persons as private, idiosyncratic, subjective atomistic persons, detached and standing over against an objective world. I realized that such a philosophical stance of disengagement and detachment was not a good starting point for understanding caring practices in nursing. It misrepresents human intelligence and perception. I have written in nursing and ethics literature critiquing a Cartesian representational view of the mind, which is currently not accepted as how human beings learn nor a good account of human intelligence in philosophy or the neuro-cognitive learning sciences.

Charles Taylor, a world-renowned philosopher and close friend of Bert Dreyfus, came to engage in thinking, writing, and teaching with Bert often during the next seven years. Charles Taylor was equally influential on my thinking and scholarly work in nursing and ethics. Charles Taylor’s teachings on the nature of social practices, and practical reasoning as a perfect analogue for science-using clinical reasoning, had a profound influence on my thinking and writing. Particularly in my work on clinical reasoning as a science-using form of practical reasoning, i.e., reasoning across time about the particular patient through changes in his or her clinical condition, and/or changes in the agents’ responsibility to attend to the well-being of the patient.

Charles Taylor’s writings and teachings on the interpretative nature of human sciences, in large measure, shaped my development of interpretive phenomenology as a research method for nursing, health care, and human sciences. His book Expla- nation and Understanding effectively ended the dominance of behaviorism in psy- chology, and influenced my thinking and dialogue with Professor Richard Lazarus, who had a controversial and influential research on the notion of “subception” (which I would later interpret as perceptual grasp and embodied fuzzy recognition). Lazarus’ experiment confirmed that subjects’ galvanic skin responses correlated with electrical shocks that subjects could not verbally identify.

Collectively and interactively, these philosophical teachings and readings helped articulate my understanding of the relationships between embodied skilled know‑how, “fuzzy recognition,” family resemblances, and tacit understanding, as well as relationships between practice and theory, the importance of overcoming Descartes’ representational theory of the mind with its radical mind, body, world separation and atomistic individualism. I came to realize that while theory can enrich practice, without practice, theorizing cannot sustain itself. Practice is a wellspring of knowledge and knowledge development, gained experientially in practice. The Cartesian legacy required theoretical thinking and theory for the en- actment of practice. How often do nurse educators and students cite the sacrosanct phrase “putting theory into practice” without giving thought to learning directly from practice and developing theory based upon practice? This Cartesian view im- agined that theory is stamped out on an inert, passive practice. My goal in teaching became to help students articulate their own experiential learning and new insights gained directly from experiential learning in practice. Theorizing in nursing is rela- tively underdeveloped; however, the practice of nursing is rich, practiced in many contexts, and is highly varied. Nursing knowledge is radically diminished and mis- understood without active strategies for articulating the knowledge embedded in practice, and if it is imagined that practice cannot be a self-improving, knowledge developing practice without being seen as a mere application of theory, efforts won’t be made to articulate the nature of actual nursing practice. Expert practice requires the situated use of knowledge, and this is more than mere techne (rational calculation) applying theory to practice. For example, learning to take blood pres- sure is a good example of mere application of knowledge. While interpreting blood pressures as trends and trajectories with particular clinical meaning for a patient exemplifies the situated higher‑order thinking of situated use of knowledge.

Most often nursing knowledge is described in detached, objectified “knowing about and that.” But such accounts cannot account for the situated thinking-in- action, situational awareness, and actual clinical reasoning across time through changes in the patient’s clinical condition and/or the clinician’s understanding of the patient’s clinical condition. Notably, “knowing that and about” accounts leave out “knowing how and when.” I found that first‑person‑experience narratives of nurses’ actual clinical reasoning and patient care experiences were essential to de- scribing nurses’ dynamic clinical reasoning, situational awareness, caring practices, and frontline knowledge embedded in actual practice. First-person-experience near narratives enabled me, other teachers, students, and other nurses to articulate (give a clearer descriptive language) about the knowledge embedded in practice. For example, one year in my theory class for master’s level students with about 80 students, we discovered 11 qualitatively distinct narratives on patient advocacy, e.g., “giving the silent patient her voice”; “Following the body’s lead for the pre-mature infant or the patient in a vegetative state”; “Running defense for the patient to prevent conflicting tests, therapies, or physician orders,” and more. Articulating the knowledge embedded in practice focuses students on practice as both a source of knowledge and as a moral source. In each class, reading and articulating knowledge embedded in first‑person‑experience narratives made it possible to uncover and articulate knowledge not yet well‑described in theoretical or scientific litera- ture. In this case, the narratives shed light on the rich moral tradition and practical knowledge and skilled know-how embedded in practice communities concerned with “patient advocacy.”

In studies of nursing expertise in practice, we found that the positive skills of involvement, while avoiding pathologies of helping such as over-involvement, or over‑identification, moralism, sentimentalism, and so on, were essential to becom- ing an expert nurse. By moralism, I mean focusing on one’s character virtues or flaws, and instead of once correcting character and skill problems, redirecting one’s attentions, project, issue, concern, or relationship, rather than continuing to focus one’s own moral intent and character, a continued focus on oneself (a form of in- curvature of turning emotions back on the self) instead of focusing on intents and goals embed in the situation. Sentimentalism is similar, since it is an elaboration of the feelings involved in a situation, and turning these emotions back on the self (incurvature) by feeling and acting as if what is happening in another person’s world is the same (or even equally impactful), as if it were happening in one’s own lifeworld. Excessive detachment and objectification of the patient, such as relating only to the disease and not to the human experience of illness, blocks out needed information for good clinical reasoning, and thus impedes the developing of clini- cal expertise.

In our research on skill acquisition, we also discovered that beginning in the proficient stage, in the Dreyfus and Dreyfus Model of Skill Acquisition, nurses switch to perceptually grasping similar and dissimilar whole concrete clinical cases for recognizing the nature of familiar clinical situations, rather than using text- book lists of signs and symptoms. This experience-based perceptual grasp of whole clinical situations enabled nurses to provide early warnings for clinical situations, e.g., early compensatory phases of shock, premature infants’ intolerance of patent ductus arteriosus, pulmonary embolus, and more. This kind of family resemblance or fuzzy recognition is not infallible, but it is superior to machine-based intelli- gence that is not very effective at “seeing the big picture” nor at fuzzy recognition, context or frame for particular situations. My goal has been to build in legitimacy and teaching for experience-based perceptual grasp, always staying open to dis- confirmation while continually seeking and being open to new evidence. This “real world” understanding is more nuanced, and often involves tacit memory. As the maxim of artificial intelligence (AI) states, “The real world is the best model for the real world.”

In skill acquisition research writings and teaching, I have emphasized teaching for a sense of salience, where the situation just stands out with aspects that are more or less important, higher or lower in urgency and priority. From the Novice through the Competent stages nurse educators, much like a good ethnographic guide, must fill in and point out what is most urgent and highest priority, providing the student with an understanding of the role of “salience” in clinical reasoning because they have not yet experienced sufficient clinical cases, nor sufficient “futures” of pa- tients’ clinical situations. A second emphasis, based on the Carnegie Study, is a focus on integrating the three professional apprenticeships: 1) the cognitive, the science, technology, and theory of a practice discipline; 2) the practice apprentice- ship, the skilled‑knowing how and when in the practice; 3) ethical comportment and formation. The practice-based apprenticeship focuses on practice-based ethics, and the built-in agent responsibility to the patient, family, and community in clinical reasoning.

Most of my writings and thinking are concerned with a more current vision of the embodied person engaged in the world, because I find it so relevant to nursing practice, and particularly relevant to caring practices in nursing. To that end I seek to articulate engaged, socially embedded, embodied intelligent agency and inter- subjective understandings between persons and situations. We as human beings, dwelling in lifeworlds, share common meanings, embodied understandings, and experiences. A Cartesian view of empathy imagines that we have to theoretically and mentally imagine what the other person is thinking and feeling as a separate atomistic individual, rather than considering them as a member-participant in a lifeworld that has shared, taken-for-granted meanings, and therefore, intersub- jective understandings. Empathy is possible through a shared fellow-human- embodied feeling. Empathy is not primarily or only based on intellectually figuring out the other person’s feelings and concerns. The Primacy of Caring presents caring, having something matter… have meaning and significance, for the possibility of understanding one another, and the possibility of giving and receiving help. Emotions provide one’s access to the world, and human rationality depends on emotional responses to situations, to human interactions, facial expressions, tone of voice and more.

Finally, these philosophical writings and explorations have profoundly influenced and given language to ethics in nursing care. I have sought to articulate a concern for the notions of good and qualitative distinctions in excellent nurs- ing care in my writings in both ethics and nursing literature. In keeping with the Dreyfus and Dreyfus Model of Skill Acquisition, I have never studied expertise as a trait or talent, or the possession of knowledge and skills for particular persons for all situations. Expertise, as I have studied and described in actual situations of well-managed, clinical situations, with situation awareness, early warnings, and excellent clinical grasp and sense of salience about unfolding cases can be demonstrated by direct observation or first‑person‑experience near narratives with real interventions, observations and outcomes in real time and can be assessed as expert or less than expert practice in the situation.

This nursing perspective on expert practice as a moral source, and a demonstra- tion of the notions of good and qualitative distinctions embedded in actual clinical practice contrasts to an overarching concern in biomedical ethics for rights-based ethics, and breakdown and dilemma-based ethics rather than a realization of the notions of good that guide excellence practice and ethical comportment, and clini- cal reasoning in nursing, and represent the good behind statement of human rights. It is a problem to study only “practice breakdown ethics”; ethics based only on ethical decision-making rather than excellent, above-standard clinical practice, ethical comportment, responsible care for others, relational ethics, or social ethics, and ethics that attends to the notions of good behind rights-based ethics. The Aristotelian distinction between techne and phronesis is a key ethical discourse in nursing and health care. Distinctions between techne (rational calculation) and phronesis (wisdom and skilled know-how) are central to ethical comportment, and formation and the everyday practice of the professional nurse. Techne is suited for a) producing or making things; b) can be standardized; c) outcomes can be pre- dicted; d) separating means and ends, not a problem. In phronesis (wisdom that is situated), separating means and ends can do violence (e.g., disregarding concerns for how birthing or dying processes are achieved). Situations that require phrone- sis: a) underdetermined, unfolding situations; b) ongoing experiential is involved; c) praxis, character, and skill, habits of attentiveness, thought and action involved; d) mutual influence between patient and clinician may be involved; e) outcomes cannot be reliably predicted. Clinical reasoning, a science-using form of practical reasoning, is always concerned with, in addition to accuracy and effectiveness, solving clinical problems with responsible actions toward the patient. I sat on ethics committees at two major medical centers, presented at scholarly societies on ethics and wrote many articles on this more practice-based, ethical comportment and formation. In the Carnegie Study we critiqued “socialization” as too focused on role messages from others, to fully explicate the process of ethical formation and everyday ethical comportment. Formation requires the agent (nursing student) to take up self-understandings, skills, habits, and practices that need to change in order to be a good nurse. For example, many students in their narratives, and Minnie Woods, in particular, wrote about the transformation of moving beyond their own anxiety, repulsion, concerns for skill-mastery and so on, to come to deeply understand that it is “about the patient,” and not “me” as the nurse and thus, switch their focus to the best interests of the patient. This is a common and profound trans- formation of self-involvement that occurs in most students’ self-understanding in relation to nursing practice. It is a formative change involving constituting and expressive theories of meaning, moving beyond the scientific meanings… designative and denotive theories of meanings used by physical and natural sciences.