This paper discusses compassion failure and compassion deficits in health care, using two major reports by Robert Francis in the UK as a point of reference. Francis enquired into events at the Mid Staffordshire Hospital between 2005 and 2009, events that unequivocally warrant the description ‘appalling care’. These events prompted an intense national debate, along with proposals for significant changes in the regulation of nursing and nurse education. The circumstances are specific to the UK, but the issues are international.I suggest (...) that social psychology provides numerous hints about the mechanisms that might have been involved at Mid Staffs and about the reasons why outsiders are blind to these mechanisms. However, there have been few references to social psychology in the post‐Francis debate (the Francis Report itself makes no reference to it at all). It is an enormously valuable resource, and it has been overlooked.Drawing on the social psychology literature, I express scepticism about the idea that there was a compassion deficit among the Mid Staff nurses – the assumption that the appalling care had something to do with the character, attitudes, and values of nurses – and argue that the Francis Report's emphasis on a ‘culture of compassion and caring in nurse recruitment, training and education’ is misconceived. It was not a ‘failure of compassion’ that led to the events in Mid Staffs but an interlocking set of contextual factors that are known to affect social cognition. These factors cannot be corrected or compensated for by teaching ethics, empathy, and compassion to student nurses. (shrink)

The ethics of care, adopted in much of the nursing literature, is usually framed in opposition to the Kantian ethics of principle. Irrespective of whether the ethics of care is grounded in gender, as with Gilligan and Noddings, or inscribed on Heidegger's ontology, as with Benner, Kant remains the philosophical adversary, honouring reason rather than emotion, universality rather than context, and individual autonomy rather than interdependence. During the past decade, however, a great deal of Kantian scholarship – including feminist scholarship (...) – has rendered this series of oppositions questionable, challenging the view that an ethics of care and Kant's moral law are irreconcilable. This paper therefore re‐examines Kant's writings, drawing on recent scholarship, and argues both that they provide the care ethicists with everything they require, and that they offer something beyond an ethics of care, something that repairs the deficits in philosophies of caring. It concludes by suggesting that a Kantian ethics of care has significant implications for the construction of nursing knowledge. (shrink)

Phenomenology as rhetoric The literature on ‘nursing phenomenology’ is driven by a range of ontological and epistemological considerations, intended to distance it from conventionally scientific approaches. However, this paper examines a series of discrepancies between phenomenological rhetoric and phenomenological practice. The rhetoric celebrates perceptions and experience; but the concluding moment of a research report almost always makes implicit claims about reality. The rhetoric insists on uniquely personal meanings; but the practice offers blank, anonymous abstractions. The rhetoric invites us to believe (...) that knowing is subjective and involved, but at the same time it recommends a technique (bracketing) which can only represent a crude, and entirely misconceived, gesture towards objectivity. Finally, the rhetoric claims that generalisation is beside the point; but the majority of researchers generalise anyway. In quietly ignoring their own rhetoric, ‘phenomenologists’ appropriate scientific prerogatives illegitimately. For their methods do not entitle them to lay claim to anything resembling ‘objectivity’, or generalisability, or ‘reality’, or theoretical abstraction. Like other researchers, they want to talk in generalisable terms about reality; they want to be objective, they want to do theory. But they are saddled with a philosophy that is disabling, because it says they can only talk about perceptions, and meanings, and uniqueness. (shrink)

The claim that, in some nontrivial sense, nursing can be identified with caring has prompted a search for the philosophical foundations of care in the nursing literature. Although the ethics of care was initially associated with Gilligan's ‘different voice’, there has more recently been an attempt – led principally by Benner – to displace the gender perspective with a Heideggerian one, even if Kant is the figure to whom both Gilligan and Benner appear most irretrievably opposed. This paper represents the (...) first half of a double-edged project: initially, to point out that Heidegger explicitly disowns any ethical implications for his ontological thinking, and to argue that no ethical theory (including an ethics of care) can be derived from Being and Time; and then to argue that Kant's categorical imperative is not only compatible with the ethics of care but actively entails it. In this, Heideggerian, part of the argument, I consider three attempts to wrest an ethics from Being and Time– those of Benner, Olafson and Guignon – suggesting that, for different reasons, they all fail. Benner systematically confuses the ontological with the ontic, not recognizing that care, concern and solicitude have ‘deficient’ modes as well as positive ones, and that Heidegger's ontology retrieves the possibility of an ethics-in-general without at any point implying an ethics-in-particular (whether of care or justice). Olafson does recognize this, and to that extent admits his failure, but his efforts to amplify Heidegger's thought in such a way as to generate an ethical theory involve both the importing of Kantian premises, and an appeal to some rather doubtful empirical observations. Guignon resorts to Heidegger's discussion of authenticity, and the idea that authentic Dasein ‘may choose its hero’, suggesting a morally reassuring list of heroes who might fit the bill. However, there is nothing in Heidegger's account of this choice that justifies his confidence, and I conclude by proposing that we should take Heidegger at his word when he says that ontology has ‘no result, no effect’. (shrink)

Psychological research has shown that cognitive illusions, of which visual illusions are just a special case, are systematic and pervasive, raising epistemological questions about how error in all forms of research can be identified and eliminated. The quantitative sciences make use of statistical techniques for this purpose, but it is not clear what the qualitative equivalent is, particularly in view of widespread scepticism about validity and objectivity. I argue that, in the light of cognitive psychology, the ‘error question’ cannot be (...) dismissed as a positivist obsession, and that the concepts of truth and objectivity are unavoidable. However, they constitute only a ‘minimal realism’, which does not necessarily bring a commitment to ‘absolute’ truth, certainty, correspondence, causation, reductionism, or universal laws in its wake. The assumption that it does reflects a misreading of positivism and, ironically, precipitates a ‘crisis of legitimation and representation’, as described by constructivist authors. (shrink)

This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence‐based practice. Two related arguments are considered. The first suggests that standard accounts of evidence‐based practice imply an overly narrow view of ‘evidence’, and that a more inclusive concept, incorporating ‘patterns of knowing’ not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non‐problematically to individual patients in specific contexts, and points out that this (...) is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the ‘patterns of knowing’, referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence‐based practice as a template for health‐care. (shrink)

Peter Kevern believes that the cognitive science of religion (CSR) provides a justification for the idea of spiritual care in the health services. In this paper, I suggest that he is mistaken on two counts. First, CSR does not entail the conclusions Kevern wants to draw. His treatment of it consists largely of nonsequiturs. I show this by presenting an account of CSR, and then explaining why Kevern's reasons for thinking it rescues ‘spirituality’ discourse do not work. Second, the debate (...) about spirituality‐in‐health is about classification: what shall count as a ‘spiritual need’ and what shall count as ‘spiritual care’. It is about the politics of meaning, an exercise in persuasive definition. The function of ‘spirituality’ talk in health care is to change the denotation of ‘spiritual’, and attach its indelibly religious connotations to as many health‐related concepts and practices as possible. CSR, however plausible it may be as a theory of the origins and pervasiveness of religious belief, is irrelevant to this debate. (shrink)

The fictionalist paradigm is introduced, and differentiated from other paradigms, using the Lincoln & Guba template. Following an initial overview, the axioms of fictionalism are delineated by reference to standard metaphysical categories: the nature of reality, the relationship between knower and known, the possibility of generalization, the possibility of causal linkages, and the role of values in inquiry. Although a paradigm's ‘basic beliefs’ are arbitrary and can be assumed for any reason, in this paper the fictionalist axioms are supported with (...) philosophical considerations, and the key differences between fictionalism, positivism, and constructivism are briefly explained. Paradigm characteristics are then derived, focusing particularly on the methodological consequences. Towards the end of the paper, various objections and misunderstandings are discussed. (shrink)

Phenomenology as Qualitative Research: A Critical Analysis of Meaning Attribution has attracted the attention of Max van Manen, who has published a highly critical review article. Anyone reading this article, but unfamiliar with the book, will get a distorted view of what it is about, whom it is addressed to, what it tries to achieve, and how it goes about presenting its arguments. Not mildly distorted, in need of the odd correction here and there, but systematically misrepresented. One problem is (...) that van Manen appears to have an idée fixe which prevents him from recognizing that the book is not about a certain philosophical tradition (known as “phenomenology”), but about a particular type of qualitative research (also known, unfortunately and confusingly, as “phenomenology”). A second idée fixe disposes him to misread an earlier article of mine and (much more seriously) three works by Heidegger. My aim in this article is to describe these two idées fixes, and exhibit their consequences. In doing so, I will examine what van Manen has to say on four crucial topics: meaning, lived experience, empathy, and Heidegger's analysis of boredom in The Fundamental Concepts of Metaphysics. (shrink)

Several authors have commented on my reductionist account of spirituality in nursing, describing it variously as naïve, disrespectful, demeaning, paternalistic, arrogant, reifying, indicative of a closed mind, akin to positivism, a procrustean bed, a perpetuation of fraud, a matter of faith, an attempt to secure ideological power, and a perspective that puritanically forbids interesting philosophical topics. In responding to this list of felonies and misdemeanours, I try to justify my excesses by arguing that the critics have not really understood what (...) reductionism involves; that rejecting reductionism is not the same as providing arguments against it; that the ethical dilemmas allegedly associated with reductionist views are endemic to health care; that 'reifying' is what believers in the spiritual realm do; and that the closed minds belong to those who dismiss reductionist science without having studied its achievements. (shrink)

The idea of meaning plays, together with the notion of caring, a pivotal role in recent nursing theory, informing its approach to philosophy, research and practice. Unlike caring, however, it has received relatively little analytical attention – a fact that is surprising in view of the scepticism about meaning that is characteristic of much contemporary philosophy and social theory. This paper reviews the philosophical literature on meaning, highlighting sceptical currents in the Wittgensteinian corpus, neo‐behaviourism and poststructuralism. It also considers a (...) similar line of thought that has emerged in social theory, questioning the explanatory value of concepts such as ‘practice’, ‘culture’, ‘norms’, ‘tacit knowledge’, and ‘tradition’. All these perspectives suggest that there is something wrong with the common‐sense picture of a set of shared, implicit rules that account for our ability to understand and communicate; and they all point to an alternative picture which is naturalistic, materialist and causal, and which depicts ‘shared meaning’ as a rather mysterious quality, unable to explain the familiar regularities of verbal and nonverbal behaviour. In this picture, while the idea of meaning can be retained, it ceases to be something shared, and becomes something individual and idiosyncratic, a unique cluster of associations, concomitants, and other habits of thought. The paper closes with a brief interpretation of what the alternative implies for a research methodology in nursing. In particular, it proposes that certain well established approaches will have to be abandoned, and that qualitative strategies will have to be grounded in a rigorous scientific framework, rather than in techniques (such as phenomenology), which presuppose a misleading and inaccurate conception of what meaning is. (shrink)

Amedeo Giorgi has published a review article devoted to Phenomenology as Qualitative Research: A Critical Analysis of Meaning Attribution. However, anyone reading this article, but unfamiliar with the book, will get a distorted view of what it is about, whom it is addressed to, what it seeks to achieve and how it goes about presenting its arguments. Not mildly distorted, in need of the odd correction here and there, but systematically misrepresented. The article is a study in misreading. Giorgi misreads (...) the book's mise en scène; he misreads its narrative arc; he misreads individual arguments; he misreads short, simple passages; he misreads the philosophy of the science literature; he misreads his own data; he misreads the title; he misreads the blurb; he misreads the acknowledgements. In addition, there are serious failures of scholarship (ironically, he demonstrates how unacquainted he is with the relevant literature at the very moment he is accusing me of being ill‐informed). In this reply, I provide several examples of these errors, but my primary aim is to understand why Giorgi's misreading is as ubiquitous as it is. To this end, I explain his mistakes by reference to the hermetic epistemology within which he is confined. (shrink)

The idea of narrative has been widely discussed in the recent health care literature, including nursing, and has been portrayed as a resource for both clinical work and research studies. However, the use of the term 'narrative' is inconsistent, and various assumptions are made about the nature (and functions) of narrative: narrative as a naive account of events; narrative as the source of 'subjective truth'; narrative as intrinsically fictional; and narrative as a mode of explanation. All these assumptions have left (...) their mark on the nursing literature, and all of them (in our view) are misconceived. Here, we argue that a failure to distinguish between 'narrative' and 'story' is partly responsible for these misconceptions, and we offer an analysis that shows why the distinction between them is essential. In doing so, we borrow the concept of 'narrativity' from literary criticism. Narrativity is something that a text has degrees of, and our proposal is that the elements of narrativity can be 'sorted' roughly into a continuum, at the 'high narrativity' end of which we find 'story'. On our account, 'story' is an interweaving of plot and character, whose organization is designed to elicit a certain emotional response from the reader, while 'narrative' refers to the sequence of events and the (claimed) causal connections between them. We suggest that it is important not to confuse the emotional persuasiveness of the 'story' with the objective accuracy of the 'narrative', and to this end we recommend what might be called 'narrative vigilance'. There is nothing intrinsically authentic, or sacrosanct, or emancipatory, or paradigmatic about narrative itself, even though the recent health care literature has had a marked tendency to romanticize it. (shrink)

Complex adaptive systems and nursingThere have been numerous references to complexity theory and complex systems in the recent healthcare literature, including nursing. However, exaggerated claims have (in my view) been made about how they can be applied to health service delivery, and there is a widespread tendency to misunderstand some of the concepts associated with complexity thinking (usually justified by describing the misconception as a metaphor). These conceptscanbe extended to systems and structures in healthcare organisations but, at this stage in (...) the development of complexity science, only in a modest and very cautious way. In this paper I first outline some of the key ideas in the theory of complex adaptive systems, and then suggest that they have been distorted by a series of influential articles in the medical literature. I go on to present a simple case study of my own and undertake a complexity analysis of it. In the conclusion I suggest that we should beware of some outdated ideas being trotted out in the guise of complexity — an exciting and diverse area of enquiry that those old ideas do not, in fact, resemble. (shrink)

Sally Gadow's work is a sophisticated version of a familiar line of thought in nursing. She creates a chain of distinctions which is intended to differentiate cultural narratives, and particularly the ‘science narrative’, from imaginative narratives, especially poetry. Cultural narratives regulate and restrict; imaginative narratives are creative, liberating and potentially transcendent. These ideological effects are (supposedly) achieved through different structures of language. Scientific language, for example, is abstract and literal, while poetry is sensuous and metaphorical. In this paper, I argue (...) that Gadow's way of discriminating between science and poetry fails. In the first place, the ideological valence she assigns to each of them is unwarranted. Science and poetry can both be harnessed to the project of emancipation, just as both can be incorporated in a strategy of oppression. In the second place, the claim that poetry and science are distinguished by their respective linguistic features – specifically, that one is metaphorical and the other literal – cannot be sustained. I illustrate this argument, as Gadow illustrates hers, by reference to the concept of embodiment, and consider whether Gadow is correct in thinking that poetry, not science, makes it possible for individuals (especially women) to ‘reclaim the body’. I also suggest that Gadow's brand of postmodernism echoes Romanticism, whose defining characteristic was an insistent contrast between poetry and science. This is ‘flip side’ postmodernism, which merely opposes modernist values, preferring subjectivity to objectivity, feeling to rationality, and multiple realities to truth. It is less radical, and far less interesting, than ‘remix’ postmodernism, whose objective is not to reverse the polarities, but to reconfigure the entire circuit. (shrink)

The attribution of beliefs and other propositional attitudes is best understood as a form of measurement, however counter-intuitive this may seem. Measurement theory does not require that the thing measured should be a magnitude, or that the calibration of the measuring instrument should be numerical. It only requires a homomorphism between the represented domain and the representing domain. On this basis, maps measure parts of the world, usually geographical locations, and 'belief' statements measure other parts of the world, namely people's (...) aptitudes. Having outlined an argument for this view, I deal with an obvious objection to it: that self-attribution of belief cannot be an exercise in measurement, because we are all aware, from introspection, that our beliefs have an intrinsically semantic form. Subsequently, I turn to the philosophical and methodological ramifications of the measurement theoretic view. I argue, first, that it undermines at least one version of constructivism and, second, that it provides an effective alternative to the residually Cartesian philosophy that underpins much qualitative research. Like other anti-Cartesian strategies, belief-attribution-as-measurement implies that the objective world is far more knowable than the subjective one, and that reality is ontologically prior to meaning. I regard this result as both plausible and welcome. (shrink)

Peter Draper has offered a critique of concept analysis in nursing, suggesting that many concept analysis studies can be regarded as low‐grade literature reviews. Although I will argue en passant that he was right, defending Draper is not my main concern in this paper. Instead, I undertake a close reading of a single study, and identify a series of puzzles about what it says. The puzzles pertain to the distinction between concept and phenomenon; the function of definition; discriminating between the (...) concept of interest and other concepts; how defining attributes are derived; in what sense concept analysis clarifies the concept; whether concept analysis can adjudicate current debates; the role of model cases. The point is to show how a precise and detailed interrogation of this kind sets an agenda of questions which can be asked about other examples of the same genre. The approach gives rise to concerns about the politics of reading in the current academic environment, and I refer to these concerns briefly at the end. (shrink)