Nursing Knowledge: Practice and Practical Knowing

Introduction

In 1893 Florence Nightingale wrote of nursing in a manner that has become eerily contemporary in its tenor. In sick nursing and health nursing Nightingale wrote of the fact that, until convinced of the error in its thinking, society would focus on sickness and disease as the mission of healthcare. However she predicted that soon enough the error of this approach would be apparent and the true focus for nursing as health nursing would be realised (1893). As we have entered the second decade of the 21^st century her words have a prophetic ring. Internationally it is recognised that health systems need to be funded and focused differently to service the population. Concentrating efforts on disease management with little effective attention to living well and the promotion of health is metaphorically like chasing one’s tail. As the affluence of society has increased as a result of technological advance the incidence of ill health related to lifestyle factors has also risen.

Nightingale spoke of the ongoing and steady evolution of nursing as a profession underpinned of necessity by the continued development of nursing knowing. She referred to this steady evolution as a ‘march’. Whilst nursing as a profession in the west is young, with a history spanning a couple of hundred of years, nursing as a concept has been written about as early as 1900-1500 years ago in Indian and Buddhist literature. Historically the advancement of nursing knowing would appear to be anything but a forward and direct march into the future: there have been periods of rapid forward momentum followed by periods of inertia where no evolution occurred. The march has occurred at different rates and in different trajectories in different cultures, but nonetheless it could be argued that overall there has been global forward movement in nursing knowing. The evolution of nursing practice into a profession that exists in complex relations with other professions has provided opportunities to critically reflect on and refine what we understand of nursing knowing. Reflection has been enabled in and on a broad range of developed nursing practice. The organisational structures traditionally based on command lines and subservience, and now on the structures of managerialism and bureaucratisation has obscured significant features of nursing knowing, as we hope to show.

In this chapter, we will discuss dimensions of nursing knowledge and ways of knowing. Our aim is not to provide a taxonomy or descriptive review of various kinds of knowledge and ways of knowing, but to offer reflection on what these things reveal about nursing practice. More specifically, we want to show that familiar binary contrasts such as ‘theory/practice’ are distortions of the reality of nursing because the primacy of practice is a more satisfactory characterisation of that reality. However, we will show that ‘practice’ names something complex and profound: it is both a way of knowing and a kind of knowledge, and it both grounds abstract theoretical knowledge and is informed by that knowledge. Practice is thus a kind of praxis. So understood, practice necessarily involves practitioners with certain skills and demeanour. Fundamental here are the capability for informed situational judgment, and an habitual receptivity and self-awareness best described as ‘mindfulness’. Our discussion aims to show that the ‘primacy of practice’ thesis is a persuasive account of nursing knowing, and to suggest some implications of this thesis for the profession’s current situation.

While knowing can be investigated within any number of disciplines, we will focus mainly on philosophical contributions to the inquiry. We will provide a brief overview of selected moments in the history of Western epistemology in the modern era in order to make clear the present context of debate regarding knowledge in nursing practice. Our discussion of the ‘primacy of practice’ thesis will also be philosophically oriented. We believe this emphasis makes clearest our claims for nursing knowing.