Journal of Advanced Nursing, 1997, 25, 1089–1093

What is philosophy of nursing? Steven D. Edwards RMN BA (Hons) M Phil PhD University College Fellow, Centre for Philosophy and Health Care, University College Swansea, Swansea SA2 8PP, Wales

Accepted for publication 15 May 1996

Journal of Advanced Nursing 25, 1089–1093 What is philosophy of nursing? This paper tries to describe the nature of the subject-area known as philosophy of nursing. It is suggested that attempts to offer such a description are beset with difficulties surrounding both nurses’ and philosophers’ conception of philosophy. Nonetheless, this paper does seek to offer a description of what philosophy amounts to. Schrock’s suggestion that philosophy can be characterised partly by its methods and the distinctive nature of its questions is tentatively endorsed. Her proposal is buttressed with an account of Carnap’s distinction between internal and external questions. It is shown that this distinction helps to identify philosophical questions. Further, an attempt is made to show the importance of the distinction between a philosophy of nursing and philosophy of nursing. It is concluded that philosophy involves conceptual analysis and assessment of argument, concern with highly general metaphysical and epistemological questions, and that such questions can be regarded as ‘external’ questions. It is then shown how these three elements of philosophy also characterise philosophy of nursing.

EDWA RDS S.D. (1997)

I NTRODUCTI ON It is common to point out that nursing is essentially a practice discipline (Sarvimaki 1995). This is not to deny that theorising about nursing occurs. But any nursing theory which is developed will be evaluated in terms of its implications for nursing practice. These points are uncontroversial. But it follows from them that philosophy of nursing must, therefore, be philosophy of a practice discipline. It follows from this that philosophy of nursing, if it exists, is a branch of applied philosophy. Some philosophers appear sceptical regarding the legitimacy of applied philosophy (Warnock 1992). So if there is such a subjectarea as philosophy of nursing, such sceptical philosophers will need some persuasion. The following paper is intended to provide some such persuasion by articulating a plausible description of philosophy of nursing. Nurse theorists seem not to need convincing of the legitimacy of the idea of philosophy of nursing. But this may well be due to uncertainty or confusion regarding what philosophy is. This paper is addressed primarily to nurse theorists whether or not they are convinced of the coherence of philosophy of nursing. It is hoped that the paper will provide a clear articulation of philosophy of nursing. © 1997 Blackwell Science Ltd

This will at least have the benefit of facilitating informed debate as to the ultimate coherence of the subject. Given an adequate articulation of philosophy of nursing at least those for and against it will have a clearer idea of what it is they are arguing about; or so it is hoped.

WHAT IS PHILOSOPHY? NURSES SPEAK There seems to be some disagreement amongst nurse theorists regarding what is meant by the term philosophy. Schrock (1981a) points out that philosophy of nursing is often mistakenly construed to refer to an ideology of nursing. She construes ideology, roughly, as a set of unexamined presuppositions which influence attitudes and practices. Schrock offers the examples of views such as ‘nurses are born, not made. [And] nursing is an art based on common sense’ (Schrock 1981a p. 11). Weidenbach may commit the mistake which Schrock warns against. Apparently, for her Philosophy [is] an attitude toward life and reality that evolves from each nurse’s beliefs... (Marriner-Tomey 1994 p. 89)

If I understand Schrock, her warning is that it is not 1089

S.D. Edwards obviously the case that philosophy involves the proposal of any definite claims. Rather, she suggests that philosophy might best be characterised in terms of its methods and its problems (Schrock 1981b). As may be seen, the claims made in the present paper lend broad support to Schrock’s suggestion. More recently, Simmons has offered the following definition of philosophy By philosophy, I mean knowledge of first causes or of the highest principles of things in so far as these causes or things belong to the natural, as opposed to the supernatural, order (Simmons 1992 p. 112)

She goes on to add that this, more properly, should be understood only as a definition of metaphysics. Simmons offers no reference in support of her definition, and as it stands it seems vulnerable to some quite serious objections. First, sceptical philosophers doubt that it is possible to obtain any knowledge of anything (Ayer 1956). So a (philosophical?) claim to the effect that one could not be certain of the existence of anything would not count as philosophy by Simmons’ criterion. Hence she seems wrong to restrict philosophy to knowledge of first causes, or indeed, to knowledge of anything else. Second, her definition seems to omit large chunks of the works of Descartes and Plato. Each of these philosophers discuss extensively phenomena which lie beyond the natural world. Apart from discussing God, Descartes (1970) famously argued for the existence of a spiritual mind-stuff. Plato (1955), equally famously, posited the existence of a world of forms beyond the natural world. So it seems plausible to claim that Simmons’ definition of philosophy (or even metaphysics) is open to very serious objection.

Three components In an excellent paper, Salsberry (1994) tries to set out what is described as a philosophy of nursing. This involves, she suggests, three components. First, an ontology which informs us what the fundamental entities are that exist within the

p. 15). Given the centrality of human beings to the nursing enterprise this is evidently a plausible claim. In spite of the excellence of Salsberry’s paper, a worry remains. Why is she concerned to set out a philosophy of nursing rather than to characterise philosophy of nursing per se? The claim that one is developing a philosophy of nursing clearly implies that there are other possible philosophies of nursing. The title of Salsberry’s paper (A philosophy of nursing: what is it? what is it not?) suggests that she is out to characterize one member of a class — the class of philosophies of nursing — as opposed to setting out, more generally, the criteria for membership of the class. In other words, she deliberately omits to give an account of philosophy of nursing in favour of giving an account of one particular philosophy of nursing.

Ideology and philosophy The reasons why it matters whether Salsberry is characterising philosophy of nursing and not merely a philosophy of nursing are these. First, the expression a philosophy of nursing brings to mind the confusion to which Schrock draws attention, namely, that between an ideology of nursing and philosophy of nursing. The reason that the expression ‘a philosophy of nursing’ may lead to such a conflation stems partly from the currency of expressions such as ‘I like your philosophy’ or ‘what is your philosophy?’. These colloquial uses of the term are far removed from academic philosophy (Schrock, 1981b). Second, and perhaps more seriously, the question ‘what is a philosophy of nursing?’ neglects to address what is clearly the prior question: ‘what is philosophy of nursing?’. The priority of this second question is evident since, as noted, any one specific philosophy of nursing can only be an instance of the subject-area denoted by the expression ‘philosophy of nursing’. It seems, then, that there is some disagreement amongst nurse theorists regarding the answer to the question of just what philosophy of nursing is. It is the burden of the remainder of this paper to try to shed some light on the answer to this question.

domain of nursing (Salsberry 1994 p. 13)

Second, an epistemology which involves ‘claims about how the basic phenomena can be known’ (Salsberry 1994 p. 13). And third, an ethics: ‘statements about what one values’ (Salsberry 1994 p. ??). Salsberry suggests that these three components comprise the form of a philosophy of nursing as opposed to the substance of such a philosophy. The reason is that identification of these three components leaves open precisely how they may be completed. For example, with respect to the ontological component, the substance of that component is likely to include ‘content regarding the nature of human beings’ (Salsberry 1994 1090

WHAT IS PHILOSOPHY? PHILOSOPHERS SPEAK It was noted earlier that if applied philosophy is a part of philosophy, then philosophy of nursing must be also. An answer to the question of what philosophy of nursing is presupposes an answer to the question of what philosophy is. However, as Schrock (1981b) points out, there is disagreement amongst philosophers concerning the answer to this question. One quite narrow conception is the so-called ‘underlabourer’ view of philosophy which derives from Locke (1690). According to this view, philosophy is to be characterised in terms of the methods it

© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 1089–1093

Philosophy of nursing employs and in terms of the purposes for which its methods are employed. Roughly, the relevant methods include conceptual analysis and assessment of argument. The purpose behind the application of these methods is that of ‘removing impediments to the advance of our understanding’ (Winch 1958 p. 4). This might consist in drawing attention to inconsistencies in the claims of nurse theorists, or to conceptual unclarity in their writing. A difficulty with the underlabourer conception, raised by Winch, is this. The underlabourer view leaves philosophy without any subject matter of its own. As Winch puts it, ‘On this view philosophy is [entirely] parasitic on other disciplines’ (Winch 1958 p. 4). This is the case since on the underlabourer view the tasks of philosophy are set by claims made in other disciplines. These claims provide the subject matter of philosophy. Winch points out that the underlabourer conception cannot provide an exhaustive account of philosophy. The reason is that two of the main areas of philosophy, metaphysics and epistemology, are characterised by problems which are distinctly philosophical. For example, the concerns of metaphysics centrally include existence-questions such as: do I exist? are there other selves? are there physical objects? is there an external world? Clearly, these are not questions which figure centrally in other disciplines. Rather, it is the case that answers to such questions are presupposed in other disciplines. For example, all the sciences presuppose an answer to the question: is there an external world? And human psychology presupposes the existence of persons. So Winch’s case against the underlabourer view seems a convincing one.

draws attention. Roughly, the character of such questions can be exemplified in two ways. The first exploits a contrast between philosophical and scientific questions. For example, Bird (1972) draws attention to the following quote from Peters

Very crudely, the claim here is that scientific questions are characterised by agreement concerning what is sought and how it can be sought. So, for example, given an agreed definition of, say, schizophrenia, an epidemiologist may be able to plot the incidence of that condition in a given population. But philosophical questions focus on the concepts presupposed in such a procedure. Most obviously, these will include those of schizophrenia and illness. Less obviously, they will include the concept of a person. As Schrock indicates, it is evident that scientific questions and methods presuppose certain philosophical questions. These will include tacit agreement regarding what is to count as an instance of a particular concept (in the example just given this is schizophrenia); and also tacit agreement upon how to proceed in order to make such identifications. The former task, in philosophical terms, is an ontological task; the latter task is an epistemological one.

Substantial conception required

Internal and external questions

Evidently, a more substantial conception of philosophy than that which arises in the underlabourer view is required. The more substantial conception is one according to which underlabouring, so to speak, still constitutes philosophical activity. But it does not exhaust philosophical activity. A concern with certain highly general existence-questions of the kind given earlier remains distinctively philosophical. As does, also, a highly general concern with epistemological questions concerning, for example, the criteria for what constitutes knowledge. So a rejection of the view that the underlabourer conception provides an exhaustive account of philosophy does not imply that the tasks of conceptual analysis and assessment of argument are not fundamental to philosophy. As noted, Winch’s case suggests the need for a more substantial account of philosophy. It is one in which philosophy involves the posing of questions of a distinctive character or level, but in which conceptual analysis and assessment of argument remain central. The suggestion that philosophical questions have such a distinctive character is one to which Schrock (1981a)

A second, related, way in which the distinctive character of philosophical questions can be identified is by making use of Carnap’s (1950) distinction between internal and external questions. Roughly, Carnap develops the notion of linguistic frameworks. He suggests that all such frameworks rely upon the truth of certain propositions. For example, suppose that our ordinary discourse concerning everyday, physical objects constitutes a linguistic framework. In order for it to be true to judge that something is a table it has to be true that there are physical objects. Obviously, if there are no physical objects, one cannot truly assert of a thing that it is a physical object. Carnap proposes that internal questions are questions which presuppose the very general claims upon which discourse within a framework depends for its intelligibility. So in the example just given the question ‘is this a table or a chair?’ counts as an internal question. It is internal to the relevant linguistic framework in the sense that its intelligibility depends upon highly general framework propositions (such as: ‘There are physical objects’). External questions are those which centre on the general framework

A scientific question, for instance, is one that can in principle be answered by certain kinds of procedures in which observation and experiment play a crucial part. But the clarification and discussion of the concepts used and of how they have meaning, and of the procedures by means of which these questions are answered, is a philosophical enquiry (Peters 1966 p. 16)

© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 1089–1093

1091

S.D. Edwards propositions themselves. So in relation to our present example, the question ‘are there physical objects?’ counts as an external question. It is a question addressed at the level of the framework as a whole. Carnap (1950) proposes that such external questions are, in fact, philosophical questions, their distinctive, philosophical character derives from the fact that they are directed at very basic presuppositions; presuppositions upon which the intelligibility of discourse within the relevant linguistic framework depends.

Nursing discourse Carnap allows that linguistic frameworks need not be so general as that just discussed. And this is a view which has been developed by, for example, Wittgenstein (1979). It can be claimed that nursing discourse constitutes a linguistic framework. Its intelligibility presupposes the truth of certain general claims which can be termed framework propositions. Obvious examples of such framework propositions include: ‘There are nurses’, ‘There are patients and clients’, ‘Illness exists’; ‘Health exists’; ‘There are disease-entities’ and so on. As is implied by Salsberry’s paper, these framework propositions characterise, at least partly, the ontology of nursing. Given acceptance of the claim that nursing discourse is a linguistic framework, examples of both internal and external questions can be identified. An example of an internal question is ‘Is Smith a nurse?’ An example of an external question is ‘Are there such things as nurses?’ This question has the philosophical character which Carnap identifies in external questions. Evidently, in order to answer the external question just posed is it necessary to examine what being a nurse amounts to — to answer the question, ‘What is a nurse?’ The claim being put forward here, then, is that questions which focus on the framework propositions of linguistic frameworks are philosophical in character. This character is evidenced by the fact that they are directed at the presuppositions of the linguistic frameworks as these are set out in framework propositions. It should be added that questions regarding the understanding of the concepts which constitute framework propositions also count as philosophical questions. So, for example, in relation to nursing discourse an examination of the concept of a nurse counts as a philosophical examination. For, the concept nurse features in the framework propositions upon which nursing discourse depends for its intelligibility.

W HAT IS PHILOSOPHY OF NURSING? So far, three elements of philosophical enquiry have been identified. The first is the kind of analysis which comprises the underlabourer view. The second is the concern with particular problems traditionally regarded as philosophi1092

cal problems (e.g. those of metaphysics and epistemology). And the third element of philosophical enquiry involves the development of a criterion for the identification of philosophical questions. Such questions are those which Carnap describes as external questions. The identification of these three elements of philosophical enquiry supports the proposal that philosophy of nursing should similarly be comprised of the three elements. That is, if philosophy involves these three elements, then so too must philosophy of nursing. In this context philosophy of nursing would be said to involve the following. First, conceptual clarification and assessment of arguments. Second, consideration of traditional philosophical problems which have relevance to nursing theory and practice (clearly, this relevance would need to be made explicit). And third, in the light of our discussion of Carnap’s claims, it can be asserted that the concerns of philosophy of nursing would include a focus on the framework propositions which constitute nursing discourse and on the concepts of which those propositions are comprised. Consider, then, Salsberry’s claims regarding a philosophy of nursing in terms of this account of what philosophy of nursing amounts to. The charge made above against Salsberry is that she neglects to consider the prior, more general question of what philosophy of nursing is.

Conceptual clarification and assessment of argument It seems to me that the characterisation just offered of philosophy of nursing sits rather well with Salsberry’s description of a philosophy of nursing. For, a philosophy of nursing, if it can be formulated, must arise from application of the three elements of philosophy of nursing identified above. Evidently, formulation of a philosophy of nursing must involve conceptual clarification and assessment of argument. For example, such clarifications may focus upon the concept of a nurse, or of a patient etc., and on arguments deployed in support of particular conclusions. Further, a philosophy of nursing can be expected to take into account relevant traditional philosophical problems. For example, as Salsberry suggests, the ontological component of a philosophy of nursing must include human beings, or persons. Hence, any such component must take into account the traditional philosophical problems of personal identity and of the relationship between the mind and the body. Also, sensitivity to the distinction which Carnap raises between internal and external questions must also be present in the formulation of a philosophy of nursing. For, the propositions and concepts which comprise the linguistic framework of nursing discourse will be the focus of philosophical enquiry in nursing. And formulation of a philosophy of nursing will necessarily

© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 1089–1093

Philosophy of nursing involve the development of such framework propositions — what Salsberry describes as the substance of a philosophy of nursing as opposed to its form.

CONCLUSION At the start of this paper two possible audiences were referred to, philosophers and nurse theorists. It is hoped that the above articulation of philosophy of nursing will persuade those philosophers who are sceptical of the legitimacy of such an enterprise that it is founded upon respectable and fundamental philosophical traditions. These include the activities of conceptual analysis and assessment of argument, concern with general existence and knowledge questions; and the recruitment of Carnap’s internal/external questions distinction to aid identification of philosophical questions. Finally, it is hoped that the articulation of philosophy of nursing attempted in the paper is also of help to nurse theorists.

References Ayer A.J. (1956) The problem of knowledge. Penguin, Harmondsworth. Bird G. (1972) Philosophical tasks, Hutchinson, London. Carnap R. (1950) Empiricism, semantics and otology in Carnap R.

Meaning and Necessity, University of Chicago Press, London, pp. 205–221. Descartes R. (1970) Philosophical writings, Geach P.T. & Anscombe E. (eds), Open University Press, Hong Kong. Locke J. (1690) Essay concerning human understanding, Everyman, London. Marriner-Tomey A. (1994) Nurse theorists and their work, Mosby, London. Peters R.S. (1966) Ethics and Education. Allen and Unwin, London. Plato, (1955) The republic, Lee D. (ed), Penguin, Harmondsworth. Salsberry P.J. (1994) A philosophy of nursing: what is it? what is it not? in Kikuchi J.F. & Simmons H. (eds), Developing a philosophy of nursing, Sage, London, pp. 9–225. Sarvimaki A. (1995) Knowledge in interactive practice disciplines, Stockholm University College of Health Sciences, Stockholm. Schrock R. (1981a) Philosophical issues. in Current issues in nursing, Hockey L. (ed), Churchill Livingstone, Edinburgh, pp. 3–18. Schrock R. (1981b) Philosophical perspectives, in Nursing science in nursing practice, Smith J.P. (ed), Butterworths, London, pp. 170–184. Simmons H. (1992) Philosophic and scientific inquiry: the interface, in Kikuchi J.F. & Simmons H. (eds), Philosophic inquiry in nursing, Sage, London, pp. 9–25. Warnock M. (1992) The uses of philosophy, Basil Blackwell, Oxford, pp. 2–3. Winch P. (1958) The idea of a social science, Routledge & Kegan Paul, London. Wittgenstein L. (1979) On certainty, Basil Blackwell, Oxford.

© 1997 Blackwell Science Ltd, Journal of Advanced Nursing, 25, 1089–1093

1093