PHILOSOPHY OF SCIENCE IN A PRACTICE DISCIPLINE

Let us pose the most rudimentary, basic question here. Do professional members of any practice discipline—education, medicine, nursing, physical therapy, psychology, public health, or social work—need education in philosophy of science? To best answer this question, it is useful to understand some of the central questions that the philosophy of science poses.

As an exercise, we suggest you now take these 16 questions (which constitute the framework of philosophy of science, but by no means are exhaustive) and ask yourself: How would each question be relevant for study when pursuing a doctorate in a practice discipline, or more precisely, a health professions practice discipline? Practice inquiry³ has been proposed as a set of small-group, practice-based learning (PBL) methods designed to help internal medicine clinicians better manage clinical uncertainty using a case-based approach (Sommers, Morgan, Johnson, & Yatabe, 2007). In describing the skill set requisite for practitioners and clinicians to undertake analyses of complex patient problems, they state:

We attest that this statement applies to all practitioners involved in clinical care and certainly not just physicians. Similarly, scientific inquiry in social work practice has a rich history (Choi, Choi, & Kim, 2009; Thyer, 2010). Social work scholars have long advocated the integration of scientific thought and research into clinical social work practice (Orcutt, Flowers, & Seinfeld, 1990). It is doubtful whether there is a compelling argument that other practice disciplines should operate differently or educate their new practitioners without this emphasis. In Anderson’s (2010) article on reexamining the distinction between research and practice, he states that this attempt at distinction really misrepresents the aim of clinical inquiry. He indicates that clinical research and clinical practice “are not sharply distinct but intimately intertwined” (Anderson, 2010, p. 46). We also do not see the fine distinctions between scientific inquiry and clinical inquiry. Scientific inquiry and clinical inquiry are both analogous to critical inquiry, which has been defined as an open cycle of questioning based on empirical data and is a combination of deliberation and action (Karlik, 2010). We suggest that critical inquiry is essential to any practice discipline that seeks the best evidence, the best interventions, and the best practices.⁵ Knowledge cannot be properly evaluated or advanced without an understanding of the principles of philosophy of science that underlie this discourse and that support all types of practice-oriented decision making.

PHILOSOPHY OF SCIENCE IN THE DISCIPLINE OF NURSING

There should be no debate that philosophy of science belongs in the curricula of graduate students pursuing a PhD degree (DiBartolo, 1998).⁶ One of the curricular issues that PhD in Nursing/Nursing Science programs often face is who should teach this content. Should it be PhD-educated nurses who have an intellectual interest in philosophy of science or who have taken advanced coursework, or who are philosophers of science, trained in the analytic methods of philosophy with either specialization or competency in philosophy of science?⁷ At minimum, the research training of any graduate student in any discipline must begin with rigorous training in the scientific method. Commonly, but wrongly, attributed to Roger Bacon⁸ and other eminent 18th-century European scholars, one of the earliest records of the techniques of scientific investigation has been attributed to Al-Biruni,⁹ a Persian genius who conducted precise experiments on laws of gravitation, momentum, and motion (O’Connor, Robertson, & Edmund, 1999).¹⁰

The emergence of nursing as a discipline in the 1960s (discussed in Chapter 2) largely corresponded to the drive to develop more doctoral-prepared nurse scientists outside (with formation of the Nurse Scientist Training Program in 1961) and ultimately inside the discipline (Gortner, 2000). In 1962, Thomas Kuhn published The Structure of Scientific Revolutions, and its impact on philosophy of science and even nursing has been profound. Although for many disciplines, practically, it signaled an abrupt break with logical positivism (that predominated American philosophy of science between the two world wars), for nursing just emerging as a discipline, the influence of logical positivism persisted (Monti & Tingen, 1999; Whall, 1989). Logical positivism (to be discussed in detail in Chapter 6) had its roots in 1907 with a group of scholars who formed the “Vienna Circle.” Their approach to philosophy held in high regard facts, empirical data, and experiments as the basis of science (Rodgers, 2004). At the time of Kuhn’s book and for the decade thereafter, discussion of what was the nursing paradigm of the time became a preoccupation for nursing scholars of the day. Furthermore, part of nursing’s struggle to create a respectable disciplinary identity has been rooted in its ability to “look like the other scientific disciplines,” and we think that this has shaped nursing in both positive and negative ways. Logical positivism and later logical empiricism seem to have induced a type of rigid orthodoxy (even preoccupation) with quantitative inquiry and measurement in nursing. This has further complicated the debate about whether nursing is more science than art or practice. Empiricism, defined as both a scientific term (empirical knowledge) and a philosophical school (logical empiricism—which generally indicates that all scientific claims must be evaluated solely on their empirical evidence), has thus maintained a stranglehold on nursing knowledge development (Giuliano, 2003; Parrini, Salmon, & Salmon, 2003; Silva & Rothbart, 1984).

It has been difficult, at least in the U.S. nursing scientific community, for qualitative approaches and nursing knowledge emerging from a competing interpretive paradigm¹¹ to be regarded equally. In Figure 3.1, we have provided a diagram of this praxis of interpretive inquiry. It illustrates that praxis employs “talk” about interpretive inquiry and “doing” interpretive inquiry (Roth, 2001). According to Jun (2006) “practice may take place without an individual employing any type of critical consciousness” (p. 136). But while the bidirectional arrows indicate that praxis (and practice) imply action, praxis is more transformative (to some, even having moral significance; Joachim, 1951; Lobkowicz, 1967). Thus, the praxis of qualitative or interpretive inquiry may indeed have particular appeal to nurse investigators with a strong holistic disciplinary orientation.

FIGURE 3.1    Paradigm shift: moving from one paradigm to the next.

However, even the contemporary evidence-based research movement appears to have marginalized qualitative research findings. The prestigious Cochrane Criteria operationally minimizes the contribution made by qualitative studies to the highest levels of evidence, and this has led to criticism of its validity (Morse, 2006a, 2006b). But, how to best conduct and classify qualitative systematic reviews is controversial (Booth, 2001). A quantitative analysis of qualitative studies in clinical journals for the 2000 publishing year found that only 9% of clinical articles used qualitative methods, and most were published in nursing journals with low impact factors (McKibbon & Gadd, 2004). Sandelowski and Barasso (2003) have advocated for more classification of qualitative research findings for at least a decade, but even this effort has struggled to compete with the prestige of quantifiable classifications and their better assumed generalizability (Ludvigsen et al., 2015). And even the prolific Sandelowski (2014) is now trying to untangle (or “unmix”) the qualitative findings and implications from the popular mixed-methods research.

In 2005, Guba and Lincoln (2005), authors of the classic Naturalistic Inquiry (Lincoln & Guba, 1985), a text that fundamentally helped shepherd qualitative inquiry in the 1980s beyond the confines of mostly anthropology and sociology to nursing and other fields, declared there had been a paradigm shift toward more interpretive, postmodern, and critical theory (and away from the predominant quantitative/positivist paradigm). Although we are not so enthusiastic that this shift has occurred in the health sciences (just look at the dearth of qualitative research that is funded in the governmental and private sector or that gets published in medical/health/nursing journals), we thought we would try and depict this paradigm shift if it were to occur in Figure 3.2. The letter “A” represents the apex of the current quantitative paradigm, and any shift from our largely quantitative/positivist paradigm (A) to a qualitative/interpretive paradigm would be realized at the apex point “B.” These shifts, however, take place very slowly. Moreover, paradigm shifts do not simply indicate that one theory is out (or debunked) and a new one is in, as the shift in thinking is far greater, deeper, and wider than that. Paradigm shifts are monumental. It took a paradigm shift for Galileo’s¹² view that the Earth was not the center of the universe (heliocentrism) to take place. The Aristotelian geocentric view that the Earth was the center of the universe had persisted for centuries, and the Catholic Church was quick to prosecute anyone who openly contradicted that Copernican view, including Galileo, who spent the last 9 years of his life imprisoned on house arrest after being found “vehemently suspect of heresy” (de Santillana, 1955). In our modern day, biomedicine, particularly personalized medicine, is an example of an ongoing paradigm shift. It begins with a thesis that every individual has unique characteristics and a particular genomic profile that can predict what exact targeted pharmacotherapeutic approaches and doses would provide an individual the most optimal benefit (Laio & Tsai, 2013).

FIGURE 3.2    Praxis of interpretive inquiry. Adapted from the work of Roth (2001).

This exciting movement away from a one size (dose) fits all approach to patient care is perhaps best represented by advances in lung cancer care. Here 90% of all lung cancers occur in primary or secondary smoker populations, and 85% of those are of the non-small-cell lung cancer (NSCLC) category, which itself has three types: adenocarcinoma (the most common form of NSCLC), squamous cell carcinoma, and large-cell carcinoma. Once the human genome was sequenced in 2004 and scientists were able to identify genes, EGFR and ALK in weak spots in these types of tumor cancer cells, EGFR inhibitor drugs were then developed, which could target this specific category of lung cancer patients (Erdmann, 2014; Ladanyi & Pao, 2008). But perhaps more critically, tests to identify these specific genes in lung cancer and other types of cancers or diseases can be created that will allow for early testing (and hopefully rapid treatment) because lung cancer is often diagnosed only when it has progressed to advanced stages 3 and 4 when late treatments are less likely to be effective. Perhaps you can have a classroom discussion about other paradigms in science and health that have changed historically or that are currently underway.

It is likely, however, that as the maturation of nursing as a discipline continues, contemporary scholars (and graduate students) will further embrace the realization that some nursing phenomena simply cannot be easily measured quantitatively and that interpretive approaches are perhaps more appropriate and efficacious. Moreover, as many have suggested, attention to more rigorous methods of qualitative data analysis will be essential for this kind of research to be funded and integrated more readily into emerging discussions surrounding the nature of nursing knowledge, evidence-based practice, and practice-based evidence¹³ (Caelli, Ray, & Mill, 2003; Sandelowski, 1986; Sharts-Hopko, 2002; Thorne, 2006).

As we return to our earlier statement that there should be no debate that philosophy of science belongs in PhD curricula, there should be increasing realization that some of these questions ought to be included even in baccalaureate nursing programs. Today, all nurses are obligated to maintain currency of practice and to read and evaluate nursing research studies (at least at a basic level). The ability to advocate and articulate nursing’s need for nursing knowledge development means that philosophy of science must be acknowledged to be more than a conglomeration of esoteric concepts to which nursing students are exposed. Graduate students certainly have an even greater responsibility for the evaluation and dissemination of research findings. And if PhD graduates (or at least those educated to be nurse scientists) are going to be the primary knowledge generators of our discipline,¹⁴ then more rigor and attentiveness to philosophy of science is indeed warranted.

PHILOSOPHY OF SCIENCE IN THE DNP CURRICULUM

The central question of this chapter is whether DNP degree programs should include philosophy of science content. This point is certainly much debated by current DNP educators, as can be seen by glancing at various DNP curricula plans on websites. Our fairly comprehensive review of current national DNP curricula from published electronic material indicates that a minority of programs require a “stand-alone” course that focuses on basic philosophy of science principles. These programs are represented in Table 3.1 as Curricula A and explicitly emphasize this content.

From a review of web DNP curricula and course descriptions, a larger number of programs are represented in Table 3.1 in Curricula B. These programs appear to embed some of the basic principles of philosophy of science, but without a review of actual course syllabi, it is difficult to discern to what degree the course emphasis is on actual philosophy of science. We found an even larger number of courses (probably around 25%) where there is either a stand-alone course or a course description outlining inclusion of explicit content on nursing epistemology,¹⁵ but again this is not a nursing epistemology text (excluding Chapter 16, which introduces practice epistemology). Our suspicion, nonetheless, is that many of these doctoral courses that address nursing epistemology or nursing knowledge development must include some introductory content on philosophy of science (e.g., What is evidence? What is knowledge? What is explanation? What is deductive, inductive reasoning?). If they do not, then this is worrisome, and particularly so if the course description includes the word (or content regarding) evidence-based practice without a clear grounding (again) in “What is evidence?” It seems superficial to skip the philosophical principles of evidence and the scientific method before beginning a discussion of “What do you plan to investigate as part of your final DNP project?” practice dissertation, or whatever the final project is called (Dreher, 2009a). Packard and Polifroni (1999) at least share this concern with regard to the development of our emerging nursing epistemology and state: “The fundamental issues emanating from the philosophy of science must be fully addressed in the critique and analysis of the emerging body of knowledge [in nursing science]” (Packard & Polifroni, 1999, p. 126). The programs that appear in Curricula C are only representative of the majority of programs that do not forcefully indicate in any way that philosophy of science (in some form) is part of their normal DNP curriculum. A couple of schools even indicated that this content is in their PhD, but not in their DNP. This should not lead to the assumption that Curricula C schools (or other schools that might be classified in this category) do not teach any philosophy of science content, but that its emphasis is unknown.

But let us return to our question: How much philosophy of science should there be in a DNP degree? As the number of DNP students first surpassed PhD students in 2009 to 2010 and now hugely passed the number of PhD students in 2014 to 2015 (Fang, Li, Arietti, & Trautman, 2015; Fang, Tracy, & Bednash, 2010)¹⁶ and with PhD enrollments and graduations in such a flux over the past 15 years (Dreher, 2009b; Fang et al., 2015), we strongly predict that there is going to be a larger discussion among nursing scholars about what kind of knowledge is being generated in DNP programs. While we will wait until Chapter 16 to discuss this in more detail, it is evident from our review of DNP programs that there are many where the final project is clearly empirical in nature. In other words, the DNP graduate is not simply evaluating what is known and translating and disseminating this, but actually creating new nursing knowledge. If that is too threatening for DNP purists who honestly believe that only PhD graduates should be building new nursing knowledge, then perhaps there can be more agreement to call it practice knowledge. If DNP graduates are going to produce new practice knowledge for the discipline, then the inclusion of philosophy of science content in DNP curricula is more strongly warranted.

Except for the cited authors here, the term practice knowledge as that knowledge specifically derived by the DNP practitioner-scholar has not been widely clarified in the nursing discipline and not yet adopted widely by DNP programs (Dreher, 2011; Dreher & Rundio, 2013; Dreher & Smith Glasgow, 2010). Reed and Shearer (2011) do present a contemporary debate about knowledge development in nursing (including among DNP- and PhD-prepared nurses) in their book Nursing Knowledge and Theory Innovation: Advancing the Science of Practice. But in the chapter most explicit about the role of the DNP (graduate) in the knowledge-generating enterprise, the model, presented by Velasquez, McArthur, and Johnson (2011), proposes that the DNP as a “practitioner–theorist–researcher” will work in tandem with the PhD-prepared “scientist–theorist–researcher.” In Dreher’s conception of practice knowledge development for the DNP, it is assumed that the knowledge generated is derivative knowledge rather than purely theoretical or even abstract. Derivative knowledge as the prototype form of practice knowledge for the DNP will be discussed in more detail in Chapter 16.

Mantzoukas and Jasper (2008) describe five different types of knowledge that nurses use in nursing practice: personal practice knowledge, theoretical knowledge, procedural knowledge, ward cultural knowledge, and reflexive knowledge. Personal practice knowledge is “person-specific, acquired in a moment of interaction with each patient and developed via the dialectical relationship that is created between each patient and nurse” and “is grasped in a conscious moment of encountering and interacting with a specific patient” (Mantzoukas & Jasper, 2008, p. 321). We are describing something different from this. Estabrooks et al. (2005) also describe practice knowledge used by nurses as social interactions, experiential knowledge, documentary sources, and a priori knowledge.¹⁷ Again, this type of nursing knowledge is different as it is presented as user knowledge. We, however, do not view the DNP graduate as a mere user of practice knowledge, but as a generator of practice knowledge. Our question is who is best prepared to produce this new practice knowledge—knowledge that ultimately becomes new user knowledge for use by many different types of nurses in the profession.

Nursing scholars Rolfe and Davies (2009) indicate that in the traditional paradigm, applied science maintains a separation between the generation and application of knowledge. However, with second-generation doctorates (contemporary professional doctorates), this wall of separation is “blurred to the point of meaninglessness” (Rolfe & Davies, 2009, p. 1269). In other words, in our knowledge economy (where we need reliable data, now often mined from “big data”¹⁸ to quickly improve health care efficiency and data to indicate the best way to utilize resources to gain the maximum health care product), a “from bench to bedside” slow approach to science is no longer sufficient (Fink, 2006). Nor, we fear, can we have doctoral nursing graduates who are trained to discover and others to apply what is discovered. What we really need are knowledge-development methods and strategies that support almost real time discovery with near-immediate translation. To accomplish this, however, the investigator/practitioner will need to be literally in the field and very close to practice. Usher (2002) indicates that “the workplace becomes the site of research” (Usher, 2002, p. 150) for the professional doctorate student.¹⁹ Ten solid years into the DNP degree, this is an exciting discussion and it is one we simply must have.

Finally, in 1996, and practically a decade before the contemporary DNP movement, Reed (1996) wrote that “[Hildegard] Peplau’s theory may be one of those nursing theories that seems to lack relevance to today’s nursing practice” (p. 30). However, Reed’s analysis that Peplau was an early pioneer theorist who believed nursing knowledge development began with observations made in the context of practice is a reminder that the practice knowledge described by Peplau in 1952 may yet become fashionable again. We thus conclude that if DNP programs are going to indeed lead in the contemporary knowledge economy by producing graduates who will generate practice knowledge, then the question whether there must be more philosophy of science content in those programs committed to this mission is obvious.

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