CREDENTIALS AND BACKGROUND OF THE THEORIST

Kari Marie Martinsen, a nurse and philosopher, was born in Oslo, the capital of Norway, in 1943, during the WW II German occupation of Norway. Her parents were both engaged in the Resistance Movement. After the war, moral and sociopolitical discussions dominated home life, a home that consisted of three generations: a younger sister, parents, and a grandmother. Both parents were economists who were educated at the University of Oslo. Her mother worked all of her adult life outside the home.

After high school, Martinsen began her studies at Ullevål College of Nursing in Oslo, graduating in 1964. She worked in clinical practice at Ullevål hospital for 1 year, while doing preparatory studies for university entry. Before embarking upon a university degree, she specialized as a psychiatric nurse in 1966 and worked for 2 years at Dikemark Psychiatric Hospital near Oslo, where she also was engaged for several years in psychiatric care of outpatients.

While practicing as a nurse, she became concerned about social inequalities in general and in the health service in particular. Health, illness, care, and treatment were obviously distributed unequally. She also became disturbed over perceived discrepancies between healthcare theories, ideals, and goals on the one hand, and practical results of nursing, medicine, and the health service on the other. She began to pose questions about how a society and a profession must be constituted to support and aid the ill and the unemployed. One particularly poignant question was, How the nursing profession must operate if it is not to let down its weakest patients and those that need care the most. The obvious follow-up question was how the nurse might be able to care for the patient when medical science first and foremost relates to patient’s diseases? In other words, Martinsen wanted to know how we who represent the health services provide adequate nursing for the subjects of our care, when we are so closely allied with a science that objectifies the patient. She posed questions about whether that same objectification will increase with the emphasis on a scientific base for the discipline of nursing.

These fundamental questions urged Martinsen to take up additional studies, this time for a bachelor’s degree in psychology at the University of Oslo in 1968, with the goal of obtaining a master’s degree in psychology. As a prerequisite, she needed an intermediate examination in physiology and another free credit at the intermediate level; here she chose philosophy. This encounter with philosophy and phenomenology changed her plans drastically. She realized that philosophy rather than psychology might better illuminate the existential questions with which she was concerned. The study of phenomenology attracted her to the University of Bergen, Norway’s second largest city.

From 1972 to 1974, she attended the Department of Philosophy at the University of Bergen. In her work for the graduate degree in philosophy (Magister artium), Martinsen grappled philosophically with questions that had disturbed her as a citizen, a professional, and a healthcare worker. The dissertation Philosophy and Nursing: A Marxist and Phenomenological Contribution (Martinsen, 1975) created an instant debate and received much critical attention. The dissertation directed a critical gaze toward the nursing profession for its refusal to take up or take seriously the consequences of the nursing discipline uncritically adopting the characteristics of a profession, and uncritically embracing only a scientific basis for nursing. Such a development might contribute to distancing nurses from the patients who need them most. This dissertation, the first written by a nurse in Norway, analyzed the discipline of nursing from a critical philosophical and social perspective.

During the mid-1970s, Norway experienced a marked shortage of nursing teachers. The rectors of three nursing colleges in Bergen took the initiative to establish a temporary nursing teacher–training course to address this problem. The course was established jointly by the University of Bergen, the county authorities, and three nursing colleges. A nurse with university level qualifications was needed to head the program. Martinsen was asked to be Dean of the Faculty of Nursing Teachers’ Training in Bergen, which she accepted from 1976 to 1977.

Through her philosophical studies and the sociological issues she encountered in practical nursing and in nursing education, Martinsen developed an interest in nursing history. How did education of nurses in Norway begin, who was responsible for its inception, and what did they wish to achieve? In order to look more closely at some of these issues, Martinsen applied for and received a grant from the Norwegian Nurses’ Association in 1976. She was affiliated with the Department of Hygiene and Social Medicine at the University of Bergen, where she lectured not only to her students in the nursing teachers’ training program but also to medical students in social medicine.

At that time, an intense debate over nursing education was raging in Norway. A public commission proposed retention of the traditional 3-year degree but eventually agreed to alter this to a system of stage-based qualification. This meant that after completion of 1 year, a student became a qualified care assistant, and after 2 additional years, a qualified nurse. This implied the end of the principle of a comprehensive 3-year degree. Nurses throughout the country, with the Norwegian Nurses’ Association at the forefront, marched in protest to save the 3-year nursing degree. Sides in this debate remained rigidly opposed, and the tone of the political discourse on the issue of nursing education was heated. Martinsen threw herself into this debate. She suggested that nursing education be changed to a 4-year program, but she also gave her approval to the principle of stage-based education. She sketched an educational model in which one is qualified as a care assistant after 2 years and as a nurse after 4 years (Martinsen, 1976). With the comprehensive 3-year degree as the stated goal for the nursing association, her suggestion was viewed as a provocation.

In 1978, she received a grant from Norway’s General Science Research Council. At this time, she was attached to the History Department at the University of Oslo, where she worked on her new project on the social history of nursing, while lecturing master’s degree students in sociopolitical history. From 1981 to 1985, she was a scientific assistant at the History Department at the University of Bergen. In addition to conducting her own research, Martinsen lectured and supervised master’s degree students in feminist history and developed a database of Norwegian feminist history.

The period from 1976 to 1986 can be described as a historical phase in Martinsen’s work (Kirkevold, 2000). She published several historical articles (Martinsen, 1977, 1978, 1979a, 1979b). Close collaborators during this phase were Anne Lise Seip, professor of social history, Ida Blom, professor of feminist history, and Kari Wærness, professor of sociology. In 1979, Martinsen and Wærness published a “lit torch” of a book with the provocative title, Caring Without Care? (Martinsen & Wærness, 1979). In this book, the authors raised important questions about whether nurses were “moving away” from the sickbed, whether caring for the ill and infirm was disappearing with the advent of increasingly technical care and treatment, and whether nurses were becoming administrators and researchers who increasingly relinquished the concrete execution of care to other occupational groups.

Aiding ill and care-dependent people was considered women’s work, and this view has long historical roots. However, the existence of the professionally trained nurse is not very old in Norway, originating in the late 1800s. The deaconesses (Christian lay sisters), who were educated at different deaconess houses in Germany, were the first trained health workers in Norway. Martinsen described how these first trained nurses built up a nursing education in Norway, and how they expanded and wrote textbooks and practiced nursing both in institutions and in homes. They were the forerunners of Norway’s public health system. This pioneer period was described by Martinsen in her book, Nursing History: Frank and Engaged Deaconesses: A Caring Profession Emerges 1860-1905 (Martinsen, 1984). Based on this work, Martinsen attained the doctor of philosophy degree from the University of Bergen in 1984.

In defense of her dissertation, Martinsen had to prepare two lectures: “Health Policy Problems and Health Policy Thinking behind the Hospital Law of 1969” (Martinsen, 1989a), and “The Doctors’ Interest in Pregnancy—Part of Perinatal Care: The Period ca. 1890-1940” (Martinsen, 1989b). This work emerged from her 10-year historical phase, beginning in the mid-70s, when she wrote about nursing’s social history and feminist history, as well as on the social history of medicine.

From 1986, Martinsen worked for 2 years as Associate Professor at the Department of Health and Social Medicine at the University of Bergen. She lectured and supervised master’s degree students, in addition to writing a series of philosophical and historical papers, published in 1989 under the title Caring, Nursing and Medicine: Historical-Philosophical Essays (Martinsen, 1989c). With this book, the threads of Martinsen’s historical phase were drawn together, marking the beginning of a more philosophical period (Kirkevold, 2000). The book has several editions, and the 2003 publication includes a lengthy interview with the author (Karlsson & Martinsen, 2003). Fundamental problems in caring and interpretations of the meaning of discernment are what preoccupied Martinsen from 1985 to 1990. In a Danish anthology published in 1990, she contributed a paper entitled “Moral Practice and Documentation in Practical Nursing.” Here she writes:

In 1990, Martinsen moved to Denmark for a 5-year period. She was employed at the University of Århus to establish master’s degree and PhD programs in nursing. Her philosophical foundation was further developed during these years mainly through encounters with Danish life philosophy (Martinsen, 2002a) and theological tradition. In Caring, Nursing and Medicine: Historical-Philosophical Essays, Martinsen (1989c, 2003b) had connected the concept of caring to the German philosopher Martin Heidegger (1889-1976). While she was living in Denmark, Heidegger’s role as a Nazi sympathizer during WW II became public knowledge. At that time, a series of academic articles were published, which proved that Heidegger was a member of the national Socialist Party in Germany, and that he had betrayed his Jewish colleagues and friends such as Edmund Husserl (1859-1938) and Hannah Arendt (1906-1975). Heidegger was banned from teaching for several years after the war because of his involvement with the Nazis (Lubcke, 1983).

Martinsen confronted Heidegger and her own thinking about his philosophy in From Marx to Løgstrup: On Morality, Social Criticism and Sensuousness in Nursing (Martinsen, 1993b). Precisely because life and learning cannot be separated, it became important for Martinsen to go to sources other than Heidegger to illustrate the fundamental aspects of caring. Knud E. Løgstrup (1905-1981) was the Danish theologian and philosopher who became her alternative source, although the two never met. Martinsen knew him through his books and via his wife Rosemarie Løgstrup, who was originally German. She met her husband in Germany, where both were studying philosophy. She later translated his books into German.

While Martinsen lived and worked in Denmark, she met with Patricia Benner on several occasions for public dialogues in Norway and Denmark, and again in 1996 in California. One of these dialogues was later published with the title, “Ethics and Vocation, Culture and the Body” (Martinsen, 1997b); it took place at a conference at the University of Tromsø.

Martinsen also had important dialogues with Katie Eriksson, the Finnish professor of nursing. They met in Norway, Denmark, Sweden, and Finland. In the beginning, their discussions were tense and strained, but over time, they developed into fruitful and enlightening conversations that later were published as Phenomenology and Caring: Three Dialogues (Martinsen, 1996). Martinsen’s first chapter in this book is titled “Caring and Metaphysics—Has Nursing Science Got Room for This?” the second, “The Body and Spirit in Practical Nursing,” and the third, “The Phenomenology of Creation—Ethics and Power: Løgstrup’s Philosophy of Religion Meets Nursing Practice.” These headings employ impressive language, similar to that of the dialogues that Martinsen conducted with Benner; in her preface to the book, she elaborates:

While Martinsen was teaching in Århus, she became Adjunct Professor at the Department of Nursing Science at the University of Tromsø in 1994. In 1997, she moved north and become a full-time professor. However, needing more time for her research and writings, she left after only 1 year in this position to become a freelancer in 1998.

The period from 1990 is characterized by philosophical research. Fundamental philosophical and ontological questions and their meaning for nursing dominated Martinsen’s thought. During this period, in addition to her own books, she worked on a variety of projects and published in several journals and anthologies. Books from this period have already been mentioned (Martinsen, 1993b, 1996). In 2000, The Eye and the Call (Martinsen, 2000b) was published. The titles of the chapters in this book ring more poetically than before: “To See with the Eye of the Heart,” “Ethics, Culture and the Vulnerability of the Flesh,” “The Calling—Can We Be Without It?” and “The Act of Love and the Call.”

Martinsen also worked with ideas about space and architecture. According to her, space and architecture can influence human dignity. She first wrote about this idea in an article with the poetic title, “The House and the Song, the Tears and the Shame: Space and Architecture as Caretakers of Human Dignity” (Martinsen, 2001). In 2004, she was working on a book project about space and architecture within the health service. This has been interrupted because of her engagement in discussions about the role of evidence-based medicine in nursing practice (Martinsen 2005, 2008).

Martinsen has held positions at two nursing colleges. From 1989 to 1990, she was employed as researcher at Bergen Deaconess University College, Bergen. From 1999 to 2004, she was adjunct Professor at Lovisenberg Deaconess University College, Oslo. Ideas and academic ventures sprouted and flourished easily around her, and she drew others into academic projects. She edited a collection of articles which several nursing college teachers contributed to, called The Thoughtful Nurse (Martinsen, 1993a). Lovisenberg Deaconess University College in Oslo, with Martinsen’s assistance, took the initiative to publish a new edition of the first Norwegian nursing textbook, which was originally published in 1877 (Nissen, 2000). In this edition, Martinsen (2000a) wrote an Afterword, placing the text within a context of academic nursing. Together with a colleague in Oslo, Martinsen edited another collection of articles. In addition to the editors, college lecturers again contributed articles to the book, published as Ethics, Discipline, and Refinement: Elizabeth Hagemann’s Ethics Book—New Readings (Martinsen & Wyller, 2003). This book provides an analysis of a text on ethics for nurses published in 1930 and used as a textbook right up to 1965. When the ethics text was republished in 2003, it was interpreted in the light of two French philosophers, Pierre Bourdieu (1930-2002) and Michel Foucault (1926-1984), as well as the German sociologist Max Weber (1864-1920).

With these last publications, Martinsen returned to her roots in history. Historical and philosophical threads seem to merge. Both are present in different phases of her thought, but they color her work differently during the different periods.

In 2002, Martinsen made her way back to the University of Bergen as professor at the Department of Public Health and Primary Health Care section for nursing science. Teaching master’s and doctoral students was central. She arranged doctoral courses and was much in demand in the Nordic countries as supervisor and lecturer. Again, she experienced a lack of time for her research. Therefore, she became a part-time professor at Bergen Deaconess University College in 2006, and from 2007, a full-time professor at Harstad University College, in northern Norway.

THEORETICAL SOURCES

What is Martinsen’s theoretical background? In her analysis of the profession of nursing in the early 1970s, Martinsen looked to three philosophers in particular: Karl Marx (1818-1883), the German philosopher, politician, and social theorist; Edmund Husserl (1859-1938), the German philosopher and founder of phenomenology; and Merleau-Ponty (1908-1961), the French philosopher and phenomenologist of the body. Later, she broadened her theoretical sources to include other philosophers, theologians, and sociologists.

Paul Ricoeur: The Bridge-Builder

Ricoeur (1913-2005) is a French philosopher. His position is often designated as critical hermeneutics or hermeneutic phenomenology. He seeks to build a bridge between natural science and human science, between phenomenology and structuralism and other opposing positions. He focuses on topics such as time and narrative, language and history, discernment and science. Ricoeur is concerned with human communication, on what it is to understand one another. He points to everyday language and its many meanings, in contrast to the language of science. Martinsen states:

The culture of medicine is dominated by an abstract conceptual language in which words are embedded in different classifications, and in which they are not always in accordance with actual practical and concrete situations…. In everyday language of the caring tradition on the other hand, words are followed by the manner in which they unfold in different contexts of meaning within concrete caring—in the company of the patient and the professional community. When spoken in everyday language, the words are distinguished by their power of expression. They strike a tone (Martinsen, 1996, p. 103).

Martinsen referred to several parallels in the philosophy of language of Løgstrup and Ricoeur.

MAJOR CONCEPTS & DEFINITIONS

Martinsen is reluctant to provide definitions of terms, since definitions have a tendency to close off concepts. Rather, she maintains, the content of concepts should be presented. It is important to circumscribe the meaningful content of a term, explain what the term means, but avoid having terms locked up in definitions.

CARE

Care “forms not only the value base of nursing, but is a fundamental precondition for our lives. Care is the positive development of the person through the Good” (Martinsen, 1990, p. 60). Care is a trinity: relational, practical, and moral simultaneously (Alvsvåg, 2003; Martinsen, 2003b). Caring is directed outward toward the situation of the other. In professional contexts, caring requires education and training. “Without professional knowledge, concern for the patient becomes mere sentimentality” (Martinsen, 1990, p. 63). She is clear that guardianship negligence or sentimentality are not expressions of care.

PROFESSIONAL JUDGMENT AND DISCERNMENT

These qualities are linked to the concrete. It is through the exercise of professional judgment in practical, living contexts that we learn clinical observation. It is “training not only to see, listen and touch clinically, but to see, listen and touch clinically in a good way” (Martinsen, 1993b, p. 147). The patient makes an impression on us, we are moved bodily, and the impression is sensuous. “Because perception has an analogue character, it evokes variation and context in the situation” (Martinsen, 1993b, p. 146). One thing is reminiscent of another, and this recollection creates a connection between the impressions in the situation, professional knowledge, and previous experience. Discretion expresses professional knowledge through the natural senses and everyday language (Martinsen, 2005, 2006).

MORAL PRACTICE IS FOUNDED ON CARE

“Moral practice is when empathy and reflection work together in such a way that caring can be expressed in nursing” (Martinsen, 1990, p. 60). Morality is present in concrete situations and must be accounted for. Our actions need to be accounted for; they are learned and justified through the objectivity of empathy, which consists of empathy and reflection. This means in concrete terms to discover how the other will best be helped, and the basic conditions are recognition and empathy. Sincerity and judgment enter into moral practice (Martinsen, 1990).

PERSON-ORIENTED PROFESSIONALISM

Person-oriented professionalism is “to demand professional knowledge which affords the view of the patient as a suffering person, and which protects his integrity. It challenges professional competence and humanity in a benevolent reciprocation, gathered in a communal basic experience of the protection and care for life…It demands an engagement in what we do, so that one wants to invest something of oneself in encounters with the other, and so that one is obligated to do one’s best for the person one is to care for, watch over or nurse. It is about having an understanding of one’s position within a life context that demands something from us, and about placing the other at the centre, about the caring encounter’s orientation toward the other” (Martinsen, 2000b, pp. 12, 14).

SOVEREIGN LIFE UTTERANCES

Sovereign life utterances are phenomena that accompany the Creation itself. They exist as precultural phenomena in all societies; they are present as potentials. They are beyond human control and influence, and are therefore sovereign. Sovereign life utterances are openness, mercy, trust, hope, and love. These are phenomena that we are given in the same way that we are given time, space, air, water, and food (Alvsvåg, 2003). Unless we receive them, life disintegrates. Life is self-preservation through reception (Martinsen, 2000b). Sovereign life utterances are preconditions for care, simultaneously as caring actions are necessary conditions for the realization of sovereign life utterances in the concrete life. We can act in such a way that openness, trust, hope, mercy, and love are realized through our interactions, or we can shut them out. Without their presence in our actions, caring cannot be realized. At the same time, caring actions clear the way for the realization of sovereign life utterances in our personal and our professional lives. Care can bring the patient to experience the meaning of love and mercy; caring can light hope or give it sustenance, and caring can be that which makes trust and openness foremost in relations with the nurse. In the same way, lack of care can block the other’s experience of mercy; it can create mistrust and an attitude of restraint in relation to the health service.

THE UNTOUCHABLE ZONE

This term refers to a zone that we must not interfere with in encounters with the other and encounters with nature. It refers to boundaries for which we must have respect. The untouchable zone creates a certain protective distance in the relation; it ensures impartiality and demands argumentation, theory, and professionalism. In caring, the untouchable zone is united with its opposite, which is openness, in which closeness, vulnerability, and motive have their correct place. Openness and the untouchable zone constitute a unifying contradiction in caring (Martinsen, 1990, 2006).

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