Nightingale's realist philosophy of science

Abstract This paper examines Florence Nightingale's realist philosophy of science by comparing it to the contemporaneously dominant philosophy of positivism. It starts by adumbrating the tenets of positivism and continues by assessing the degree to which Nightingale accepted or rejected those tenets. It is argued that while she accepted much of positivism, on realist grounds she opposed its belief in phenomenalism, its rejection of speculative philosophy, its separation of fact and value, and its rejection of religion. Following an examination of how Nightingale's philosophy impinged on her approach to nursing and health care, the paper concludes with a comparison of her ideas with those of modern realism and a discussion of the contemporary salience of her ideas. It is argued that while some aspects of her approach may no longer provide an appropriate basis for modern nursing, her environmental approach, her transcendental realism, and her adherence to caring values may still be of use to contemporary nurses.     

Research paradigms in medical education research

Medical Education 2010: 44 : 358–366 Context The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence. Methods This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research. Discussion This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice. Conclusions This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.     

Research paradigms and the politics of nursing knowledge: A reflective discussion

A standard view would suggest that research is a neutral apolitical activity. It neutralizes external pressures by its fidelity to robust scientific methods. However, politics is an inevitable part of human knowledge. Our knowledge of the world is always mediated by human priorities. What matters is therefore a contested and political debate rather a neutral accumulation of factual data. How researchers manage this varies. Research paradigms are one way in which research engages with knowledge. They frame knowledge within epistemological and ontological philosophies. In this paper, I will explore this view in relation to neo‐positivism, qualitative research, Foucault and critical realism. I will argue that if nursing knowledge is to be effective it needs to acknowledge the political, particularly in the context of neoliberalism. Healthcare systems are having to cope with a social world increasingly dominated by market fundamentalism, extreme levels of inequality and a rise in xenophobia. These forces are undermining the provision of ethically sound health care, misdirecting research practice and contributing to a discourse of dehumanization. These forces need to be challenged politically and I will argue that epistemologically diverse approaches, alongside a realist ontology can provide a way forward for nursing research.     

Husserl's theory of wholes and parts and the methodology of nursing research

Abstract  Whenever the name Edmund Husserl appears in the context of nursing research, what correctly comes to mind is the phenomenological approach to qualitative methodology. Husserl is not only considered the founder of phenomenology, but his broad concept development also contributed to the demise of positivism and inspired fruitful approaches to the social sciences. In this spirit of inspiration, it must be expressed that Husserl's theory of wholes and parts, and particularly his differentiation of parts into 'pieces' and 'moments', is very helpful in guiding the selection of research methods across the board in nursing science. The purpose of this paper is to highlight a frame of reference for nursing researchers to use in examining the essential nature of that which is being studied. This frame of reference is the Husserlian philosophy of 'pieces' and 'moments' in relation to the whole. 'Pieces' are independent parts of the whole that are subject to isolability in study, whereas 'moments' are nonindependent parts, which cannot be detached, presented, or studied apart from the whole. The intent is to propose this frame of reference as a philosophical base from which nursing researchers may better select among paradigms and methodological approaches in regard to the essential nature ('pieces' or 'moments') of that which they are researching.     

Critical realism in nursing: an emerging approach

Critical realism, a philosophical framework originally developed by Roy Bhaskar in the 1970s, represents a relatively new approach to research generally and to nursing research in particular. This article explores the ontological and epistemological tenets of critical realism and examines the application of critical realist principles to nursing research and practice through a review of the literature. It is evident that few published nursing research studies have, as of yet, utilized critical realism as their paradigm of choice. Both the strengths and limitations of the presentation and use of critical realism in these studies are discussed in this article. Given the varying degrees of success of the authors in explicating critical realism as a philosophical framework, the value of critical realism to the research study, and the ways in which usage of the critical realist framework influenced development of the study and interpretation of findings, it is evident that the quality of future publications espousing the use of critical realism must continue to be strengthened significantly.     

The fictionalist paradigm

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.     

Principles in practice: reflections on a 'postpositivist' approach to evaluation research

User participation is currently seen as an ethically appropriate way to proceed when researching disadvantaged groups and it is encouraged by funding agencies. However, the literature rarely discusses the methodological and practical implications for researchers attempting to incorporate user participation into evaluation studies which are informed from an epistemologically opposed (positivist) research paradigm. The paper explores this issue by drawing on the evaluation of a community-based smoking intervention to describe and reflect upon the recruitment, training and employment of local residents as survey interviewers. While the evaluation methodology adopts a quasi-experimental approach, the appointment of local residents as survey interviewers reflects an alternative (interpretive) research tradition. The combined strategy constitutes a postpositivist methodology in that it combines a data collection strategy more akin to interpretive social science while retaining a positivistic epistemological framework. The paper describes some logistics of this approach and problems encountered during the course of survey. While many of the problems described may be routinely associated (although seldom aired) with survey work, particularly in disadvantaged areas, the paper suggests they are also a function of the postpositivist research strategy which we adopted. The failure to involve interviewers in the conception and development of the evaluation meant that they lacked identification with our endeavour and this had practical implications for the survey interviewing. Although the survey was successfully executed and the employment of local residents was a valuable and worthwhile experience, the authors recognize that this narrow conception of user involvement meant that many of the potential benefits (both to the research and the participants) associated with participatory approaches were forfeited.     

Bringing critical realism to nursing practice: Roy Bhaskar's contribution

In the context of modern nursing practice that is embedded within complex social situations, critical discussions about the contribution of major philosophers are relevant and important. Whilst nurse theorists have advanced and shaped nursing as a discipline, other major philosophers can offer much to advance nursing enquiry. In this paper, we focus on philosopher Roy Bhaskar who, amongst others, developed critical realism, a philosophy for social science which connects with how many of us think about the world. Bhaskar's work focuses our attention on the interplay between structure and agency and on the search for the causative or generative mechanisms that explain the social world. Bhaskar was interested in human emancipation, and we suggest his work is of great importance to advance understanding of complex social situations. Critical realism has already been endorsed by a range of disciplines, especially in research which focuses on real problems and acknowledges the complexities of the social world. In recent evidence from healthcare literature, there has been a surge in research using realist methodology (realist evaluation and realist synthesis), which is underpinned by the philosophy of critical realism and which offers a different perspective to understanding nursing and healthcare problems through the realist lens. However, we suggest that sufficient attention is not always paid to the philosophical roots of this methodology. In this paper, we provide insight into Bhaskar's work and demonstrate how research positioned within critical realism and realist methodology can advance nursing and healthcare‐related knowledge. Through shining a light on Bhaskar, we illustrate how critical realism philosophy is a natural fit with human and health science enquiry, including nursing.     

Socioeconomic status and health: a discussion of two paradigms

Socioeconomic status and its impact on health are in the mainstream of public health thinking. This text discusses two paradigms utilized in assessing socioeconomic status in epidemiologic studies. One paradigm refers to prestige-based measurements and positive differentiation among social strata. This paradigm is characterized by classifications assessing social capital and the access to goods and services. The other paradigm refers to the classification of social deprivation and negative differentiation among social strata. The proposal of State-funded reposition to the mostly deprived social strata is acknowledged as characteristic of this paradigm. The contrast between these paradigms, and their potential interaction and debate are discussed. Fostering reflection on methodological strategies to assess socioeconomic status in epidemiologic studies can contribute to the promotion of health and social justice.     

Organizational Adaptation in the VNA

The organizational history of the visiting nurse association (VNA) is reviewed from the perspective of paradigm change. A paradigm is a behavioral and structural model that comes to characterize a field because of its compatibility with environmental conditions. The concept is applied to interpreting adaptation among the VNA's. Four distinct paradigms are identified which comprise the overlapping but sequential course of VNA adaptation to changing circumstances. These paradigms are "public health nursing," "community nursing service.," "the home health agency," and the "home care enterprise." The emergence of each is examined with emphasis on the continuity and discontinuity of elements. Particular focus is given to the durability to date of the voluntary auspice and its future prospects in light of ongoing paradigmatic change is discussed.     

Creating nursing knowledge in Brazil: research topics

The present article discusses the themes that have orientated knowledge building in nursing in Brazil. The data was collected in post-graduation programs, graduation schools, university hospitals and indexed publications in LILACS and MEDLINE's database (1990-1999). Cardoso categorized the lines and areas of research according to a document created in nursing forums of discussion. The data was analyzed through a qualitative and quantitative approach, and presented in the form of graphics. Results indicate a shift on the lines/areas of research, especially in the case of researches that are indexed. It also demonstrates a special attention of this professional area to methodological references and paradigms that relate to the object of knowledge in nursing.     

Slaves immersed in a liberal ideology

Paradigm debates have been featured in the nursing literature for over four decades. There are at least two opposing paradigms specific to nursing that have remained central in these debates. Advocates of the unitary perspective (or simultaneity paradigm) consider their theories to be more philosophically advanced and contemporary alternatives when compared to the older more traditional ideas characteristic of models they describe as originating from the totality paradigm. In the context of these debates, I focus on some theoretical positions embedded in the unitary perspective, noting their limitations with respect to integrating the individual and social mandates of nursing; nurses are responsible not only for individual health-related needs, but also for the health of the collective. I explore two hypotheses that may explain the powers of endurance of the unitary perspective. Paley, who outlines the origins of nurses' 'slave morality', inspires the first hypothesis. The second hypothesis speaks to the location of nursing knowledge development in the context of liberal ideology. In this work, I outline key conceptualizations of the unitary perspective in order to clearly illustrate the limitations of the unitary perspective for nurses' social mandate. Then, I explore how slave morality and liberal ideological assumptions might both work to sustain the unitary perspective. A paradigm for nursing must have utility in addressing both the health-related needs of individuals, and for addressing the health of the collective. To this end, I advance suggestions in three areas: first, to transform nurses' slave morality to more honest and noble aspirations; second, to examine liberal ideological premises; and third, to end paradigm debate by resituating elements of the unitary perspective to the level of mid-range theory, where it could be most effective for research and practice with specific populations.     

Philosophical Problems with Social Research on Health Inequalities

This paper offers a realist critique of socialresearch on health inequalities. A conspectus of thefield of health inequalities research identifies twomain research approaches: the positivist quantitativesurvey and the interpretivist qualitative `casestudy'. We argue that both approaches suffer fromserious philosophical limitations. We suggest that aturn to realism offers a productive `third way' bothfor the development of health inequality research inparticular and for the social scientific understandingof the complexities of the social world in general.     

Intersubjectivity and historicity: contributions of modern hermeneutics to ethnographic research

Considering the large penetration of the hermeneutic paradigm in contemporary social research, this article proposes the reflection on some of its theoretical and methodological assumptions which can be trussed under the categories "intersubjectivity" and "historicity".     

Organizational adaptation in the VNA: paradigm change in voluntary sector.

The organizational history of the visiting nurse association (VNA) is reviewed from the perspective of paradigm change. A paradigm is a behavioral and structural model that comes to characterize a field because of its compatibility with environmental conditions. The concept is applied to interpreting adaptation among the VNA's. Four distinct paradigms are identified which comprise the overlapping but sequential course of VNA adaptation to changing circumstances. These paradigms are "public health nursing," "community nursing service," "the home health agency," and the "home care enterprise." The emergence of each is examined with emphasis on the continuity and discontinuity of elements. Particular focus is given to the durability to date of the voluntary auspice and its future prospects in light of ongoing paradigmatic change is discussed.     

Mixing qualitative methods: quality assurance or qualitative quagmire?

Although the advisability of combining qualitative and quantitative approaches has been questioned on the grounds of incompatibility of epistemological assumptions that underpin the two paradigms, mixing methods within the qualitative paradigm has been viewed as a more straightforward enterprise. This article challenges this view, highlighting the existence of several qualitative traditions, each with its own distinctive set of assumptions about what constitutes appropriate research questions; theoretical frameworks; research settings; relationships with those whom we study; techniques for eliciting data; form and content of data; and approaches to analyzing, presenting, and disseminating data. Multimethod qualitative approaches can be seen to occupy a contested domain. Analytical rigor would be strengthened by acknowledging and addressing the potentially contradictory assumptions on which one draws when seeking to combine qualitative methods. As qualitative researchers, it is incumbent on us to pay attention to context--not just in terms of the data collected but in terms of our own methodological positions.     

Realism in evidence based medicine: interpreting the randomised controlled trial

Realism is emerging as a paradigm for research and explanation in the natural and social sciences. A realist framework is elaborated and applied to the four possible situations that may generate the observations of randomised, controlled trials. It is demonstrated that by using two realist concepts "mechanism" and "context" a number of misinterpretations of such trials from within the dominant empiricist paradigm may be rectified. Evidence based medicine should adopt realism to temper a misleading empiricism, this will involve relegating statistical arguments to their proper subsidiary place and adopting an adequate theory of causation.     

Nursing as concrete philosophy,Part I: Risjord on nursing knowledge

This essay addresses the problem of the essentiality of nursing knowledge and what kind of theory, if any, is essential to nursing practice. The overarching aim of the essay was to argue for the thesis that nursing may be described as a kind of philosophical activity, and, consequently, that philosophy is the kind of “theory” that is essential to nursing practice and to the nursing discipline at large. The essay consists of two papers. The present paper, Part I, is a critical examination of Mark Risjord's discussion of the problem of the theory‐practice gap in his Nursing Knowledge: Practice, Science, Philosophy, from 2010. According to Risjord, the cause of the theory‐practice gap originates in an erroneous conception of science (logical positivism) which had a decisive influence upon the way nursing scholars appropriated theoretical frameworks for the nursing discipline. This philosophical influence is considered in effect to have generated the theory–practice gap. In order to bridge the gap, Risjord suggests, the nursing discipline needs to adopt a standpoint epistemology conjoined with a postpositivist conception of scientific theory. In this way, a legitimate brand of nursing science may be developed and the theory–practice gap overcome. I will argue that neither Risjord's diagnosis of the problem, nor his recommended cure, may succeed in rescuing the nursing discipline from the theory–practice gap. Rather, the real cause of the theory–practice gap, I will claim, derives from an erroneous conception of nursing (not of science), namely the conception of nursing as a kind of science (roughly speaking). On my view, to overcome the gap, the nursing discipline needs to make salient the inherently philosophical character of nursing. In the second paper (Part II), I will continue the discussion of nursing knowledge and delineate the thesis of nursing as a kind of concrete philosophy.     

A critical realist approach to understanding and evaluating heart health programmes

Secondary prevention programmes for Coronary Heart Disease (CHD) aim to reduce cardiovascular risks and promote health in people with heart disease. Though programmes have been associated with health improvements in study populations, access to programmes remains low, and quality and effectiveness is highly variable. Current guidelines propose significant modifications to programmes, but existing research provides little insight into why programme effectiveness varies so much. Drawing on a critical realist approach, this article argues that current research has been based on an impoverished ontology, which has elements of positivism, does not explore the social determinants of health or the effects on outcomes of salient contextual factors, and thereby fails to account for programme variations. Alternative constructivist approaches are also weak and lacking in clinical credibility. An alternative critical realist approach is proposed that draws on the merits of subjectivist and objectivist approaches but also reflects the complex interplay between individual, programme-related, socio-cultural and organizational factors that influence health outcomes in open systems. This approach embraces measurement of objective effectiveness but also examines the mechanisms, organizational and contextual-related factors causing these outcomes. Finally, a practical example of how a critical realist approach can guide research into secondary prevention programmes is provided.     

Realism and nursing

Abstract It is argued that philosophical realism is well suited to serve as a perspective from which to understand nursing, and that it should be considered as an alternative to positivist, interpretivist, hermeneutical and phenomenological approaches. However, existing forms of realism, including theory and entity realism are shown to be faced with serious problems. In response, an alternative form 'constraint realism' is outlined, and shown to be apposite for illuminating the rule or convention governed behaviour characteristic of human beings. A brief sketch is offered of its application to the social practice of nursing.