Foreword

I’m writing this foreword on one of those clear spring mornings in England when you realise that it’s a good time to be alive. In fact, for me, it is the best of times to be alive, for if I had been born just a hundred years earlier, the chances of surviving into my adulthood would not have been good. It is rather sobering to know that I would have died as a result of the complications associated with the appendicitis that I suffered at the age of sixteen. That is supposing, of course, that I’d survived birth and infancy and any number of infectious diseases in childhood.

Being born in the latter half of the 20^th century means that my chances of survival to adulthood increased significantly. Indeed, for those of us fortunate to live in high-income countries, we have seen more than a doubling in life expectancy in a few hundred years. To ask the question “To what do we owe such longevity?” inevitably takes us to advances in biomedicine, the science of public health and improvements in healthcare and practice. Not only has this combination of science and healthcare allowed me to live past the age of 16, but also the staggering improvements in life expectancy have provided our generation with what nearly equates to an extra lifetime.

Of course other advances that we have made through the use of science are no less spectacular and have been so rapid that now the science fiction of my youth has long since become the science fact of my adulthood. Today, the products (both physical and metaphysical) of nothing less than a scientific revolution surround us. The hardware of new technologies has influenced the ways in which we live, behave and even how we perceive the world. Advances in science have affected us all.

Yet given how science pervades our lives in such profound ways, it seems curious then that many seem to misunderstand its nature. For those working in front line health care services understanding something of the scientific process is essential. You will be working with people who are worried and vulnerable and there may well be times when you will need to clearly explain how a piece of equipment works and what the results may (or may not) show, explain to people why a certain procedure needs to be carried out, why a new drug that has yet to be trialled cannot be prescribed quite yet. There will undoubtedly be times when you will need to be interpreters of science and scientific procedures. When that time comes, you will need a sound understanding of the scientific process yourself, and herein lies the importance of this book.

In a clear and approachable way the author explores the nature, philosophy and practice of science, in a form specifically designed and written for health care professionals. In the first chapter he explores and expands some of the themes previously mentioned, in relation to why a good understanding of science is so important to nursing and healthcare practice, and moves on in Chapter Two to discuss how the process of science underpins modern nursing practice. Those two chapters are a crucial introduction, before he moves on to discuss some fundamental aspects of science, including causality, and how in recent years alternative approaches, whilst important, seem to have enjoyed prominence over scientific approaches in nursing. This is explored with examples of the key issues, conflicts and problems that this shift has produced. These ideas are explored through a methodical discussion of evidence-based practice that should be of great interest to all practitioners. In this context, the author provides an excellent explanation of statistical treatments of data, and its limits, with clear examples of what statistical analyses can (and cannot) show. The lucidity and sense-making language will be of great use to those with limited knowledge of statistical probability, but will also be of great interest to those who are more familiar with such analysis. Understanding what statistics show (or don’t show) is vital in modern healthcare and again a real skill that all involved in this area should have. This book will provide you with it.

In the latter stages of the book the author turns to what is widely known as bad science and ways to challenge it. Unfortunately health science seems particularly susceptible to it, probably due to the high stakes and complexity involved. Yet, through these last few chapters he allows the reader to fully appreciate what is meant by bad science and pseudoscience and explores and explains the idea of proof and how we arrive at it in practical way that will allow the reader to clearly challenge non-scientific approaches. He concludes with a consideration of the future of nursing practice in the context of change.

We live in uncertain times, and it is during such periods of indefinite change that people may be tempted to reject the empirical and rational and look for quick fixes, simplistic explanations or the elusory promises of faith. Yet it is at times like these that scientific creativity is needed more than ever and that health professionals need to have the knowledge and understanding science to provide that synergy of care and practice, that not only saved my life, but also continues to save the lives of millions of others. This book is not only timely, but is a vital contribution to the furtherance of good practice.

Chapter I: Science: Why Should I Care?

Edwin Howard Armstrong (1890-1954)

For such a highly science-based health discipline it seems a paradox that most nurse’s knowledge of scientific philosophy (the fundamental nature of knowledge) remains fairly limited. Indeed, the same is true of most health professions, and many nurses will not have explored some of the basic principles of science since primary/elementary school, as they are often not covered in any depth in modern secondary school curricula, and rarely in modern university undergraduate nursing programs. Although the methods of scientific inquiry are examined in nursing curricula, the underlying philosophy behind modern science is often only explored in very basic terms (such as by contrasting positivist and humanist approaches). This can give rise to some confusion over what is, and what is not scientific inquiry. This book seeks to address this and give both practicing nurses and students a sound understanding of modern scientific thought and its origins. Readers will also find the tools to consider and make sound scientific arguments to support practice, and readily detect poorly constructed, pseudo-scientific or simply bad scientific practice. In this book we will consider key scientific concepts and principles that underpin contemporary evidence-based health care and explore the practical application of the philosophy of science for nursing.

You may ask, “why should I care about scientific philosophy, as I’ve got by fine without any in-depth knowledge of this so far?” In short, the answer is that in order to provide the best quality professional care, you need to be able to discriminate effectively between alternative therapeutic interventions, quickly identify illegitimate and inaccurate arguments, and make decisions that support the optimum health care outcomes for your patients and clients.  With the explosion of the information age we have a growing volume of unscientific, pseudo-scientific and simply bad science in nursing and other health care disciplines. There seems to have been an erosion of science in nursing education where the philosophy of science and the approaches that underpin evidence-based practice (EBP) often get limited time in the classroom today, or at least unequal time compared to alternative discourses. The long answer to “why should I care?” is more complex, and in the book I will argue a number of reasons why it is essential to get a firm grounding in this area to be an effective contemporary nurse, and in particular to counter the growing trend in questionable health practices that are presented as scientifically based health care, and the increasing popularity in seeking alternative frameworks of understanding to explain nursing phenomena under the guise of scientific inquiry. The disciplines of science and nursing are being assailed in both contemporary socio-political structures and within academia. A good knowledge of scientific philosophy will help you identify bogus arguments that may erode the quality of nursing care.  Let us explore why nurses should become better acquainted with the philosophy of science to inform and improve their practice.

This polarization of perspectives has been a significant trend in latter 20th century academia, and particularly in nursing. C.P. Snow suggested in a famous 1959 Rede lecture, (and later in his book) that there were diverging trends between the cultures of science and the humanities which he called “the great divide” and that the split between the two cultures of science and the humanities was a great hindrance in solving the world’s problems (Snow, 1993). John Brockman also suggested there was a third culture, of scientists communicating directly with the public about their work in media without the intervening assistance of editors (Brockman, 1995). However, today, incompetent and sensationalist reporting not to mention stereotyping by the media make it difficult for scientists to get their work understood (see Chapter Seven for a number of examples). Advertisers make use of science and scientists to promote products (usually in iconic white lab coats), but science in the media is generally portrayed as nerdy, boring and difficult, whilst scientists are typically portrayed as either morally negligent, mad/evil villains, boffins, eccentric loonies, or (perhaps more worryingly) spending their lives developing the latest cosmetic products. These popular culture images of science and scientists have impacted public trust and confidence in science-based health care. In a 2006 Harris survey of trust in various professions only about 50% of those surveyed identified doctors and nurses as being completely trusted to give professional advice that was best for patients.

Much of the public remains scientifically illiterate due to continuing poor science education in our schools, and even worse, many physicians and nurses fail to truly understand scientific methodology, often failing to discriminate effectively between a sound hypothesis and hyperbole. We should consider whether or not we want to continue down this path for the future development of nursing, and if scientific literacy is actually necessary for a nursing qualification. Currently, scientific illiteracy is not a major impediment to success in business, politics or in the arts; nursing could soon join their ranks in this respect.

In our consideration of the epistemology of nursing knowledge we must also consider what we mean by the concept of justification itself. We can argue that the more recent trend towards evidence based health care, medicine and nursing has resolved some of this debate for nursing, but even that has been severely criticized by several nursing academics (Holmes, Murray, Perron, & Rail, 2006). In the following chapters we will see why a scientific approach makes good sense for developing our nursing epistemology and justifying our practice. Indeed, science itself represents a belief framework as much as any other, so before we go too much further perhaps we should consider what science actually is?

(UK Science Council, 2009).

Nursing can be considered a scientific discipline in that it represents a collective of academic scholars and practitioners that generate and add to a distinct body of knowledge. It is also an academic discipline in the sense that this knowledge is suitable for both teaching and learning  (Phenix, 1962) Nursing is also often described as an applied science (and often resides within such a faculty in universities organizational structures) as it is concerned with the application of research into human needs, and we should also note that despite its human focus is heavily dependent upon technological innovation for its practice.

Technology can be considered the application of tools and techniques to solve practical problems. It comes from the Greek word technologia meaning art or craft. Although frequently used in relationship to science, technology involves the use of technical means derived from both science and art. Technology is often conceptualized in terms of complex electro-mechanical devices but we should also remember a simple pencil and paper represents a technology and ever since humans first began to use tools technological advancement has progressed. For our purposes here we can consider technology as the application of products from the findings of scientific inquiry, and in this way nurses are heavily involved in the use of health care technologies in their everyday practice, from computers to stethoscopes. So why has health care become so dominated by science and technology in the economically developed modern world?

Science and Medicine in Contemporary Health Care

Few would argue that contemporary health care in the economically developed world remains dominated by medicine as the most publicly sought source of professional health care. A major reason for this continued dominance is that the discipline has established a track record of effective practice over the last century, which to date has been unrivalled by alternative health practitioners. This together with the legal control of medication prescription has maintained the medical dominance in health care. This state of affairs has a relatively short history however, and before the last century the success of medical practitioners was not that much better than other health service providers. Even Hippocrates of Kos (460-370 BCE) who is considered the father of medicine, and introduced some aspects of science advocating meticulous observation of patients, identified that more than half his patients succumbed to the diseases he was treating them for.  In the 17^th Century there were clear divisions between medicine, surgery and pharmacy, with no clear leader in terms of effective practice. Physicians held university degrees and prescribed a range of remedies, some rather dubious such as medicinal snuffs, effervescent salts, and anodyne necklaces. Surgeons were apprenticed, often serving in the dual role of barber-surgeon and practiced bloodletting, whilst apothecaries undertook apprenticeships to make and sell a variety of medications, including traditional remedies with uncertain efficacy. Eventually with the increasing success of surgery (particularly following the invention of antiseptic surgery by Joseph Lister in 1865) this distinction between medicine and surgery did not survive. 

Prior to 1900 we had few effective medical treatments for any of the major illnesses and maladies affecting people of the time. For example tuberculosis, a major killer, was only identified as a bacillus in 1882, and a successfully immunized against by Bacillus of Calmette and Guérin (BCG) in 1921 in France, eighteen years after the first powered aircraft had flown. Even then it was not until after World War II that that BCG received wider acceptance elsewhere in Europe and the Americas and further afield. The use of sound scientific practice by physicians was yet to develop and many doctors were prescribing dangerous treatments into the 1920s, such as chlorine gas for the common cold. We had narcotic analgesia, and insulin but precious little else in terms of substantial effective therapies prior to 1935, but this was rapidly to change with an exponential increase in effective therapeutic interventions, becoming what has been termed a golden age of medicine (Goldacre, 2008). This golden age was heralded by the advent of a huge range of more effective medical and surgical interventions and health knowledge including antibiotics, anesthesia, thoracic surgery, vascular surgery, neurosurgery, solid organ transplantation, dialysis, radiotherapy, intensive care, and establishing causative links between diet, exercise and smoking on cardiovascular and respiratory diseases. These rapid developments in effective proven therapeutic interventions were the product of huge leaps forward in scientific knowledge and technology during this time such as pharmacology, the discovery of DNA, non-invasive medical imaging and information technology. To be balanced we should recognize that medicine also made serious blunders causing harm along the way too. For example, Dr. Freeman and Watts lobotomy procedures in 1936, or Dr. Benjamin Spock’s advice to put babies on their front to sleep in 1946. Overall, medicine has established itself as a rigorously science based discipline, requiring a base qualifications in the naturalistic sciences (e.g., physics, chemistry and biology) for entry to training, adopting a biomedical framework and EBP alongside improved ethical codes. This has resulted in medicine maintaining its status as the preeminent health profession in much of the modern world.

Florence Nightingale (1820-1910) gives a good example of the scientific practice of direct observation and hypothesis with her suggestion to an unheeding British military that most of the wounded soldiers in the Scutari were dying due to poor living conditions, rather than their injuries.  She also supported the use of standardized procedural rules for the care of patients, based on the scientific knowledge of the time. Likewise, Mary Seacole, another nursing pioneer of the Crimean war, identified that poor nutrition and unsanitary conditions were a major problem for recovery of soldiers. Nightingale also suggested that “evidence, which we have means to strengthen for or against a proposition, is our proper means for attaining truth” clearly identifying her support for an empirical basis for nursing care at the onset of our professional organization.

Nursing’s disciplinary focus is of course, very different from medicine, in that as nurses we focus on patient/client care and health rather than the treatment and amelioration of illness and disease. Indeed most nurses are motivated to enter the profession specifically with a desire to attain the knowledge, practical skills and attitudes that will allow them to help people improve their health status and maximize their quality of life, or when this is not possible to help them to die peacefully and with dignity. And here lies the most fundamental difference between nursing and medicine as distinct disciplines. 

Whilst medicine has identified a clear and distinct focus on preserving health by diagnosing, treating and preventing disease using a biomedical model, adopting an empirical scientific framework; nursing has adopted more behavioural models of health and struggled with a foundational philosophy, as human behaviour, care, quality of life and health are by their very nature more complex multi-faceted concepts. Historically, the development of nursing has also had a strong link with theology, particularly the ideas of giving service and aiding the sick and we can also see this reflected in the contemporary work of nursing academics exploring ontology; the nature of being or existence. This has become a more prevalent trend amongst nursing theorists over the last twenty-five years with some novel conceptual frameworks for nursing being suggested; Parse’s Human Becoming theory being a key example (Parse, 1992). Much of the recent development in nursing theory and research has also incorporated an increased focus on alternative post-modern and feminist philosophical approaches with the further alignment of nursing with the humanities, in the desire to develop a unique disciplinary body of knowledge. Following trends in the social sciences and arts has led to the promotion of the ethos in nursing academia that nursing science has evolved further from traditional positivist science to a broader humanistic interpretation. However, on closer inspection we find this is rather a simplification of the issues, and of the current state of scientific philosophy. It has even been questioned whether contemporary nursing science as envisaged can legitimately be considered a science at all (Winters & Ballou, 2004). The nature of this argument and different viewpoints as to what actually constitutes modern scientific inquiry will be explored further in this text as we proceed. There is a sound case to be made that nursing should be underpinned by scientific knowledge, but it is also foremost a practical profession concerned with action or praxis, rather than theory.

The nature of Praxis has occupied the thoughts of many philosophers over the years from Immanuel Kant, to Martin Heidegger. Karl Marx discussed it in that he suggested the purpose of his political philosophy was to understand and change the world rather than simply explain it, (Marx & Engels, 1965) whilst Paulo Freire suggested praxis required a process of reflecting upon the world followed by action to transform it (Freire, 1973). It can be argued that nursing is a form of praxis in that it is a practice-based discipline, and in that we are concerned with the application of practical therapeutic techniques to maximize health and minimize suffering, and positive action rather than simply academic inquiry with a focus on theory rather than action.

If we accept that the profession of nursing is a form of praxis, it follows we should be concerned with what knowledge is required to inform this praxis, support eupraxis, and avoid dyspraxis. This in turn leads us to consider, what the nature of this knowledge should be, and from a pragmatic approach, what epistemological foundations of nursing knowledge are most likely to result in eupraxis. In other words, how should nursing knowledge be generated and used by nurses to best maximize positive health outcomes for patients or clients? This then, is the central question behind our concern with the nature of nursing knowledge (nursing epistemology) and ongoing struggles within nursing academia to define nursing phenomena and knowledge, and its relationship to science.

Key Points for Further Discussion

Brockman, J. (1995). The third culture. New York: Simon & Schuster, 1996.

Dahnke, E., & Dreher, M. H. (2011). Philosophy of science for nursing practice: concepts and application. New York: Springer Publishing Company.

Frazier, K. (2009). Science under siege, defending science, exposing pseudoscience. New York: Prometheus. 7

Freese, J. (2001). Science under siege? Interest groups and the science wars. Contemporary Sociology - a Journal of Reviews, 30(3), 266-267.

Freire, P. (1973). Pedagogy of the oppressed. New York: Continuum.

Holmes, D., Murray, S. J., Perron, A., & Rail, G. (2006). Deconstructing the evidence-based discourse in health sciences: Truth, power and fascism. International Journal of Evidence-Based Health Care, 4(3), 180-186.

Marx, K., & Engels, F. (1965). The German ideology ad Feurbach; An appendix in Ludwig Feuerbach and the end of classical German philosophy (1888)] (C. Dutt Trans.). London: Lawrence & Wishart.

Parse, R. R. (1992). Human becoming: Parse's theory of nursing. Nursing Science Quarterly, 5(1), 35

Phenix, P. (1962). The use of the disciplines as curriculum content. The Educational Forum, 26(3), 273-280.

Peirce, C. S. (1878). How to make our ideas clear Retrieved 8/23/2011, 2011, from http://www.marxists.org/reference/subject/philosophy/works/us/peirce.htm

Snow, C. P. (1993). The two cultures (Second Ed.). Cambridge: University Press.

UK Science Council. (2009). What is science? | www.sciencecouncil.org Retrieved 8/25/2011, 2011, from http://www.sciencecouncil.org/content/what-science

Winters, J., & Ballou, K. A. (2004). The idea of nursing science. Journal of Advanced Nursing, 45(5), 533-535.