Empirical nursing : the art of evidence-based care [First edition.] 9781787438149, 1787438147

Table of contents :
Front Cover
Empirical Nursing: The Art of Evidence-Based Care
Copyright Page
Contents
List of Figures
List of Tables
Foreword
Preface: Using this Book
Chapter 1 Science and Nursing – Why Should I Care?
Science Under Siege
Nursing Epistemology
Science and Technology in Nursing
Science and Medicine in Contemporary Health Care
Nursing Science
Nursing Praxis
Pragmatism and its Value for Nursing
Making Sense of Nursing Theory
Summary
Key Points for Further Discussion
References
Chapter 2 The Rise of Empiricism
The Beginnings of Science
Science in the Medieval World
The Renaissance and Scientific Revolution
The Age of Enlightenment
Mathematical Probability
Rationalism
A Priori and a Posteriori Knowledge
The Rise of Empiricism
The Hypothetico-deductive Method
Inductive Reasoning
The Problem of Induction
Deductive Reasoning
Abductive Reasoning
Summary
Key Points for Further Discussion
References
Chapter 3 Modern Science and Nursing
Romanticism
Positivism
Logical Positivism
Pragmatism
Classical Pragmatism
Neo-pragmatism
Post-positivism and Karl Popper’s Critical Rationalism
Falsifiability
Popper’s Critical Rationalism
Popper’s Scientific Legacy
Thomas Kuhn: Scientific Evolution and Revolutions
The Revolution in Physics and Its Impact on Scientific Philosophy
Summary
Key Points for Further Discussion
References
Chapter 4 Scientific Determinism, Causality and Care
Scientific Determinism and Causality
The Deductive-Nomological Model
The Deductive Statistical Model
The Inductive Statistical Model (I-S Model)
The Statistical Relevance (S-R) Model
The Causal Mechanics (C-M) Model
The Pragmatic Model
Unification
Summary
Key Points for Further Discussion
References
Chapter 5 Social Science: Scientific Realism, Alternative Frameworks and the Rise of Postmodern Thought
Metaphysics and Science
Scientific Realism
Arguments Supporting Scientific Realism
Criticism of Scientific Realism
Non-Realist Empirical Frameworks
Anti-Realism (Nominalism)
Arguments for Anti-Realism
Criticism of Anti-Realism
The Mind-Body Problem Revisited
Reductionism and Holism
Reductionism
Holism
Interpretivist and Constructivist Rationales
Intentionality
Phenomenology
Hermeneutics
Critical Theory
Feminist Inquiry
Social Constructionism and Constructivism
Postmodernism
Epistemological Relativism
The Development of Postmodern Thought
Deconstruction
Neo-Pragmatism
Ways of Knowing
Trans-cultural Nursing
Reaction to Postmodernism
Post-Structuralism
Post-postmodernism
Caring and the Divine
Unitary Human Beings
Health as Human Consciousness
Human Becoming
Caring Caritas
Integral Nursing
The Appeal to Divinity
Map of the Problematique: The Limits of Postmodern Thought
Description and Explanation vs Prediction
Research Culture and Ethics in the Social Sciences
Summary
Key Points for Further Discussion
References
Chapter 6 Evidence-Based Practice and Contemporary Nursing
The Evidence-Based Practice Process
The Evidence Pyramid
Scientific Theories, Concepts, Constructs and Variables
Verification; Reliability and Validity
Reliability
Inter-Rater Reliability
Test-Retest Reliability
Parallel Forms of Reliability
Internal Consistency
Validity
Internal Validity
Construct Validity
Face value and content validity
Criterion-referenced validity
Convergent Validity
Divergent/Discriminant Validity
External Validity
Transferability and Dependability
Credibility
Research Methods for Evidence-Based Practice
Qualitative Research
Interpretive Methods
Ethnography
Grounded Theory
Phenomenology
Phenomenography
Narrative Analysis
Method Blending/Slurring
Quantitative Research
Observation and Experimentation
Descriptive and Inferential Statistics
Variables and Distributions
Standard Deviation
Variance
Skewness and Kurtosis
Sampling
Non-Probability Sampling
Probability Sampling
Sample Size
Hypothesis Testing
Statistical Significance
Clinical Significance
Absoulte Risk Reduction (RRR)
Relative Risk Reduction (RRR)
Odds Ratio (OR)
Number Needed to Treat (NNT)
Confidence Interval and Levels
Power
Criticism of Statistical Hypothesis Testing
Criticism of Evidence-Based Practice and the Semantics of Practice
Summary
Key Points for Further Discussion
References
Chapter 7 Perception and Proof
Intuitive Knowing
The Limits of Intuitive Knowing
Perception and Order
Regression to the Mean
Cognition and Memory
Falsity
Confirmation and Other Forms of Cognitive Bias
Probability
The Monty Hall Problem
Epidemiological Statistics
Bayes’ Theorem
Summary
Key Points for Further Discussion
References
Chapter 8 The Role of Science in Nursing and Contemporary Health Care
Non-science
Pseudo-science
Quasi-science
Bad Science
Errors of Logic and Reasoning Fallacies
Fallacy of Accident (Generalisation)
Argument from Adverse Consequences
Fallacy of Ad Hoc Reasoning
Fallacy of Ad Hominem
Fallacy of Ad Ignorantiam
Appeal to Authority
Begging the Question
Circular Reasoning
Appeal to Conviction
Appeal to Common Practice
Fallacy of Correlation not Causation
Denial of Causation
Fallacy of Division
Fallacy of Exception
Argument from Fallacy
False Analogy
False Continuum
Inconsistency
Moving Goalpost
Naturalistic Fallacy
No True Scotsman Fallacy
Non-sequitur
Package-dealing
Post Hoc Ergo Propter Hoc
Reductio Ad Absurdum
The Reduction of Complex Phenomena/False Dichotomy
Slippery Slope
Straw Man Argument
Tautology
Teleological Thinking
Appeal to Hypocrisy
Assigning the Unexplained to the Unexplainable
Problematic Practice
Immunisation Scares
HIV/AIDS Denialism
Faith-healing
Discriminating Practice
Regulating Practice
Summary
Key Points for Further Discussion
References
Chapter 9 An Empirical Framework for Nursing Practice
The Changing Nature of Nursing
Conventional Wisdom of the Dominant Group
Marginalizing Science in the Curriculum
Moving beyond Ways of Knowing and Being
The Impact of Technology on Nursing
Evidence-based Practice and Pragmatic Health Care
An Empirical Framework for Nursing
Nursing
Health
The Epistemological Basis for Nursing Knowledge
Client
Nursing Care
Environment
Public Healthcare Provision
Primary Health care
Secondary Health care
Tertiary Health care
A Framework for Implementing Care
Assessment
Nursing Diagnosis
Implementation Evaluation and Planning Care
New Pragmatism in Nursing
Concluding Remarks
Key Points for Further Discussion
References
Glossary
The Good Science Detection Guide
References
Index

Citation preview

EMPIRICAL NURSING

This page intentionally left blank

EMPIRICAL NURSING: THE ART OF EVIDENCE-BASED CARE

BY

BERNIE GARRETT, PhD, RN University of British Columbia School of Nursing, Vancouver, Canada

United Kingdom
North America
Japan
India
Malaysia
China

Emerald Publishing Limited Howard House, Wagon Lane, Bingley BD16 1WA, UK First edition 2018 Copyright r 2018 Bernie Garrett. Published under exclusive licence. Reprints and permissions service Contact: [email protected] No part of this book may be reproduced, stored in a retrieval system, transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without either the prior written permission of the publisher or a licence permitting restricted copying issued in the UK by The Copyright Licensing Agency and in the USA by The Copyright Clearance Center. Any opinions expressed in the chapters are those of the authors. Whilst Emerald makes every effort to ensure the quality and accuracy of its content, Emerald makes no representation implied or otherwise, as to the chapters’ suitability and application and disclaims any warranties, express or implied, to their use. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN: 978-1-78743-814-9 (Print) ISBN: 978-1-78743-813-2 (Online) ISBN: 978-1-78743-988-7 (Epub)

ISOQAR certified Management System, awarded to Emerald for adherence to Environmental standard ISO 14001:2004. Certificate Number 1985 ISO 14001

I dedicate this book to Alison, Natalie and Rachel, who provided love, support, encouragement and inspiration, but above all, excellent practical advice.

This page intentionally left blank

Contents List of Figures

ix

List of Tables

xi

Foreword

xiii

Preface: Using this Book

xvii

Chapter 1 Science and Nursing
Why Should I Care?

1

Chapter 2 The Rise of Empiricism

13

Chapter 3 Modern Science and Nursing

33

Chapter 4 Scientific Determinism, Causality and Care

55

Chapter 5 Social Science: Scientific Realism, Alternative Frameworks and the Rise of Postmodern Thought 69 Chapter 6 Evidence-Based Practice and Contemporary Nursing

131

Chapter 7 Perception and Proof

187

Chapter 8 The Role of Science in Nursing and Contemporary Health Care

207

Chapter 9 An Empirical Framework for Nursing Practice

231

Glossary

257

The Good Science Detection Guide

265

Index

271

This page intentionally left blank

List of Figures Chapter 5 Figure 1:

Reification.. . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 2:

The Hermeneutic Circle. . . . . . . . . . . . . . . . . . . . .

88 94

Chapter 6 Figure 3:

The Pyramid of Evidence for EBP. . . . . . . . . . . . . . . . 135

Figure 4:

The Cochrane Collaboration Logo. . . . . . . . . . . . . . . 136

Figure 5:

The Distribution Bell Curve and Standard Deviation. . . . . . 160

Figure 6:

H0 Probability Critical Region, α = 5%. . . . . . . . . . . . . 168

Figure 7:

Confidence Intervals Depicted on a Bar Chart with Two Results: The Red Bars. . . . . . . . . . . . . . . . . . . . . . 175

Chapter 7 Figure 8:

The Checkerboard Illusion. . . . . . . . . . . . . . . . . . . 189

Figure 9:

The Wason Selection Task.. . . . . . . . . . . . . . . . . . . 193

Figure 10: The Solomon Asch Test Example. . . . . . . . . . . . . . . . 196 Chapter 9 Figure 11: The Client. . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

This page intentionally left blank

List of Tables Chapter 2 Table 1:

Inductive, Deductive and Abductive Reasoning. . . . . . . . .

17

Classification of D-N-related Explanatory Laws. . . . . . . . .

58

Chapter 4 Table 2: Chapter 6 Table 3:

Different Models of EBP Implementation. . . . . . . . . . . . 134

Table 4:

Alternatives to Reliability and Credibility for Qualitative Work. 147

Table 5:

Key Sampling Terms. . . . . . . . . . . . . . . . . . . . . . 162

Table 6:

Non-Probability Sampling Techniques.. . . . . . . . . . . . . 162

Table 7:

Probability Sampling Techniques. . . . . . . . . . . . . . . . 164

Table 8:

Advantages and Disadvantages of Probability and Non-Probability Sampling. . . . . . . . . . . . . . . . . . . . 165

Table 9:

Key Points to Consider for Sampling. . . . . . . . . . . . . . 166

Table 10: Hypothesis Testing. . . . . . . . . . . . . . . . . . . . . . . 169 Table 11: Odds Ratio Calculation. . . . . . . . . . . . . . . . . . . . . 173 Chapter 7 Table 12: Cognitive Bias. . . . . . . . . . . . . . . . . . . . . . . . . . 198 Table 13: The Monty Hall Problem Tabulated.. . . . . . . . . . . . . . 200 Table 14: Epidemiological Malaria Test Statistics. . . . . . . . . . . . . 202 Chapter 9 Table 15: An Empirical Nursing Assessment Framework. . . . . . . . . 245 Table 16: A Care Plan Exemplar.. . . . . . . . . . . . . . . . . . . . . 250

This page intentionally left blank

Foreword I’m writing this forward on a hot summer’s day in England on what has been something of novelty for us
a two-week-long heatwave! At least, there’s no need to worry about my vitamin D levels. Isn’t it interesting how certain triggers create a certain responses in our brains? Sunshine and vitamin D, carrots and night vision, cranberry juice and urinary tract infections, gluten and allergies, MMR vaccinations and autism. I wonder what your reaction is to some of these? ‘That’s an old wives’ tale’ perhaps? Maybe ‘oh yes, my grandmother used to say that’? Or, for some, ‘Hang on! We know that isn’t true?’ In some instances, the responses can be instantaneous, as if on autopilot. What is that drives these responses? Using scientific experimentation, Kahneman and Tversky (2000) described this psychological phenomenon of the brain, introducing to us the study of cognitive biases and the idea of slow and fast thinking. They provided ways to show us this in action too. Take the following example: A bat and ball cost £11 in total and the bat costs £1.00 more than the ball. How much does the ball cost? The first time I saw this ‘£10’ also instantaneously popped into my head (the answer is £5). Being mindful of our own cognitive biases and what anchors them is the first step in understanding how they impact the way we assimilate knowledge. And no less so for professions that involve applying knowledge in the care of somebody’s health. Exploring our knowledge of what’s ‘good’ or ‘bad’ for our health inevitably takes us to advances in research and evidence-based health care. Such advances have allowed us to do away with ‘old wives’ tales’ and healthcare practices once thought to be good for us. There are examples abound: starving for a fever, cocaine for treating depression, putting babies to sleep on their fronts to prevent choking-related death, complete bed rest following surgery or giving oxygen as soon as possible after a heart attack. Practices now known, through scientific research, to cause more harm than good for most are no longer routinely advised or practiced. However, there are two sides to the coin. The misuse of science can, and does, lead to harm and we need to be ever mindful of this. For many, the words ‘Andrew Wakefield’ will trigger a very fast response. But it may not be the one you just had. I read in the news recently that there had been an outbreak of measles in the city of Bristol. And not an incidence isolated to one city in the UK. It appears at least some people have been anchored to the original ideas of Wakefield that were rapidly and widely disseminated, and recently amplified via new and all-pervading media avenues, resulting in real harm. The introduction of evidence-based medicine in the early 1990s shone a light on the way healthcare professionals made decisions. ‘That’s how we’ve always done it’, ‘It makes sense’ and mechanistic reasoning dominated. This is not to

xiv

Foreword

say that patient care and well-being weren’t at the heart of their decisions; it’s just that how these decisions were made wasn’t really questioned before. Basing them on good scientific evidence it turned out was low down the list of priorities. Its introduction also led to the need for new skills. The development of evidence-based practice has continued apace, and at its most basic represents the skill of debunking, and the art of understanding and relaying the uncertainties of scientific evidence. All health professionals should have this skill, as Paul Glasziou et al. (2008). ‘A twenty-first-century clinician who cannot critically read a study is as unprepared as one who cannot take a blood pressure or examine the cardiovascular system’. This applies to all health professionals, including nurses. In an informative and accessible way, the author explores the nature and philosophy of science and the practice of evidence-based health care. In the first chapter, he explores and expands some of the themes previously mentioned, particularly the worrying trend of public scepticism in science, driven by ‘fake news’ and celebrity-based medicine and the pivotal role nurses play in dispelling myths, both old and new, and ensuring their patients are informed by the best available scientific evidence. In Chapter 2, he provides a detailed overview of key epistemological theories; their origins, examples of their applications, discussion of relative their strengths and weakness, and the nature of science, challenging the reader to consider them in the context of their own practice and knowledge acquisition. These chapters are a crucial introduction, before the author moves on to discuss some fundamental aspects of science, including causality, its alternative approaches and the social sciences, highlighting inherent deficiencies within each and the active efforts to address them. Throughout, the ideas explored are summarised and placed in an evidence-based context, ensuring relevance and interest to all practitioners. Readers will find Chapter 6 particularly useful as this is where the knowledge and skill of evidence-based practice is introduced. In a lucid manner, the author provides excellent explanations of the key concepts that underpin health research that will be of great use to those with limited knowledge, while acting as a great reminder to those more familiar with them. The author should also be praised for discussing some of the criticisms of evidenced-based practice and how to address them. As already stressed, this knowledge is vital in modern health care and a skill that all involved in this area should have. This book will provide you with it. Bad science and ways to challenge it are the focus of the latter chapters. The rise of pseudoscience as a rational and realistic alternative is particularly prevalent in health science. As a health practitioner, there will undoubtedly be times when you will need to discuss the wishes of a patient who has inadvertently succumbed to some news story of a new, non-scientific approach. In such times, you will need to use your debunking skills, and this chapter acts as great base for developing them. He concludes with a consideration of the art of nursing practice based on science and evidence in the context of knowledge generation and effective practice.

Foreword

xv

The author leans frequently on the work of Bertrand Russell, as too will I in summary: The art of basing convictions on evidence, and of giving them only that degree of certainty which the evidence warrants, would, if it became general, cure most of the ills from which this world is suffering. This book will serve you well in your development as an artist of evidencebased practice. David Nunan, June 2018 Lecturer and Senior Research Fellow Nuffield Department of Primary Care Health Sciences University of Oxford

References Glasziou, P., Burls, A., & Gilbert, R. (2008). Evidence based medicine and the medical curriculum. British Medical Journal, 337, a1253. Kahneman, D., & Tversky, A. (Eds.) (2000). Choices, values and frames. New York, NY: Cambridge University Press.

This page intentionally left blank

Preface: Using this Book While the author would like to assume readers will ponder on every word of this book in great detail, the reality for most time-pressed nurses is that they will want to use it as a reference text to explore specific ideas at particular times, as they find necessary. Therefore, this book has been designed for use in different ways: as a textbook, a reference source, or as a concise guide and primer to scientific thinking and its application in nursing. The blend of art and science that makes up nursing is explored with the aim to emphasise the value of creative scientific thinking for practical nursing issues and understanding how to avoid the pitfalls of non-science, pseudoscience, and even bad science along the way. Even those already familiar with scientific epistemology may find some interesting arguments and challenges to their foundational beliefs. Although the book covers a wide range of philosophical approaches in nursing, it is not designed as a comprehensive philosophy text. Given the great volume of manuscripts devoted to this subject throughout the history of civilisation, it would be presumptuous to hope to do more than explore the fundamental concepts in a text of this nature. References to further readings and sources are given for the reader who wants to know more. Assume that you will encounter new ideas and terminology as you read, and you should expect the need to explore other sources. Readers who want to quickly get to grips with such terms as ontology, dialectic, nominalism, hermeneutics or gnostic can find a quick reference in a glossary of key terms included at the end of the book and an extensive index. This text together with the references supplied, and excellent sources now available on the Internet, should enable the reader to understand the key concepts and arguments. In addition, a simple “Good Science Detection Guide” is included in the appendix to aid in the identification of the good, the bad, pseudoscience and non-science in healthcare writing and research. Summary ideas for critical discussion are also presented at the end of each chapter that may be helpful for those teaching this material. Finally, it is also acknowledged that any book exploring this subject cannot be value-free, and therefore, a particular perspective on philosophy and nursing is presented here that aligns with empiricism, and contemporary science, and one that I hope readers will find compelling. Bernie Garrett June 2018

This page intentionally left blank

Chapter 1

Science and Nursing
Why Should I Care? Science alone of all the subjects contains within itself the lesson of the danger of belief in the infallibility of the greatest teachers in the preceding generation […] as a matter of fact, I can also define science another way: Science is the belief in the ignorance of experts. Richard Feynman (1918
1988)

For such a highly science-based discipline, it seems a paradox that nursing education spends so little time actually exploring the philosophy of scientific inquiry. With the current pressures on curriculum space, the same is true for most health professions. Most nurses will not have examined the basis of scientific thought much since high school, and even then, the subject is often not covered in significant depth. Although the methods of scientific inquiry are examined in undergraduate nursing programs, the underlying philosophy (the fundamental nature of knowledge) behind modern science is often only explored in very rudimentary terms, such as by contrasting positivist and humanist approaches. This can give rise to some perplexity over what is and what is not scientific inquiry. This book seeks to address this and give both practicing nurses and students a sound understanding of modern scientific thought and its origins. In this book, the key scientific concepts and principles that underpin contemporary evidence-based health care and the practical application of empirical nursing are explored. Nurses will also find rationales to make sound scientific arguments to support their practice, and to readily detect poorly structured, pseudo-scientific or unscientific arguments and practice. Readers may ask, ‘Why should I care about scientific philosophy, as I’ve got by fine without any in-depth knowledge of this so far in my career?’ In short, the answer is that in order to provide the best quality professional care, you need to be able to discriminate effectively between alternative therapeutic interventions, quickly identify illegitimate and inaccurate arguments and make decisions that support the optimum healthcare outcomes for your patients and clients. With the explosion of the information age, a growing volume of unscientific, pseudoscientific, and simply bad science has pervaded nursing and other healthcare disciplines. There has been an erosion of science in nursing education where the philosophy of science and the approaches that underpin evidence-based practice (EBP) often get limited time in the classroom today, or at least get unequal time

2

Empirical Nursing: The Art of Evidence-based Care

compared to alternative discourses. The long answer to ‘why should I care?’ is more complex, and in the book, a number of arguments are presented as to why it is important to get a good grounding in this area to be an effective nurse. In particular, this is to counter the increasing use of alternative epistemologies to explain nursing phenomena under the guise of scientific inquiry, and the growing trend in deceptive health practices that are falsely presented as science-based health care. The disciplines of science and nursing are being assailed in both contemporary socio-political structures and within academia. A good knowledge of scientific philosophy will help the reader identify bogus arguments that may impair quality care.

Science Under Siege Over the last 25 years, an interesting irony has arisen in the way science is perceived versus how much it is relied upon in our increasingly technological world. The public view of science seems to be becoming more and more negative in modern society, despite the fact that that same society has become increasingly more reliant upon it to function. Although we now live in a world that relies on the products of science to fulfil our basic and more advanced needs, postmodern academics now question the fundamental principles of science, and its value to society, and people who put belief in expert opinion or other authorities frequently reject scientific findings in favour of testimonial or dogma (Frazier, 2009; Freese, 2001). This trend is also becoming apparent in health care and in nursing practice. Naturopaths and media figures such as Jenny McCarthy tell people to ignore the scientific evidence on vaccinations and trust in their vital energy or maternal intuition in making vaccination choices for their children. Spiritually based theories, bizarre alternative therapies, health machines, traditional remedies, and nutritional supplements based on magical explanations proliferate with no substantive evidence of benefits. Many nursing academics would argue that as nurses this is as it should be, as we must consider a multiplicity of narratives and be culturally non-judgmental in such considerations. There is some merit in this as a philosophical stance, but this highlights the alignment of nursing with the methods of the humanities rather than the naturalistic sciences, which few would argue, is now well established. Nevertheless, as health professionals, there is also a duty to balance personal perspectives with evidence, the wider socio-economic implications for health care, and consider the nature of evidence itself (Thorne, 2018). This polarization of perspectives has been a significant trend in the later part of twentieth-century academia, and particularly in nursing. C. P. Snow suggested, in a famous 1959 Rede lecture (and later in his book), that there were diverging trends between the cultures of science and the humanities which he called ‘the great divide’ and that the split between the two cultures of science and the humanities was a great hindrance in solving the world’s problems (Snow, 1993). John Brockman also suggested there was a third culture of

Science and Nursing
Why Should I Care?

3

scientists communicating directly with the public about their work in media without the intervening assistance of editors (Brockman, 1995). However, today, incompetent and sensationalist reporting not to mention stereotyping by the media make it difficult for scientists to get their work understood (see Chapter 7 for examples). Advertisers make use of science and scientists to promote products (usually in iconic white lab coats), but science in the media is generally portrayed as nerdy, boring and difficult, whilst scientists are typically portrayed as either morally negligent, mad/evil villains, boffins, eccentric loonies or (perhaps more worryingly) spending their lives developing the latest cosmetic products. These popular culture images of science and scientists have impacted public trust and confidence in science-based health care. In a 2006 Harris survey of trust in various professions, only about 50% of those surveyed identified doctors and nurses as being completely trusted to give professional advice that was best for patients. In 2010, an Angus Reid Opinion Poll in Canada revealed that an increasing number of Canadians did not trust their doctors (Gillis, Belluz, & Dehaas, 2010). Another 2014 study in the USA confirmed the trend of decreased trust in public institutions and medicine. Whilst in 1966, more than 75% of Americans trusted their physicians, only 58% of people in 2014 agreed that doctors could be trusted (Blendon, Benson, & Hero, 2014). Again, in 2014, during the Ebola crisis of that year, less than one-third of Americans said they trusted public health officials to share complete and accurate information (SteelFisher, Blendon, & Lasala-Blanco, 2015). Much of the public remains scientifically illiterate due to continuing poor science education in our schools and pseudo-scientific narratives on the web. Even worse, many physicians and nurses fail to truly understand scientific methodology, often failing to discriminate effectively between a sound hypothesis and hyperbole. It is worth considering if nursing is best served by continuing down this path in the future and if scientific literacy is actually necessary for a nursing qualification. Currently, scientific illiteracy is not a major impediment to success in business, politics or in the arts; nursing could soon join their ranks in this respect.

Nursing Epistemology As professional practitioners focused on health care, nurses are concerned with the why and how questions of health care in their everyday practice. For example, ‘Why is my patient experiencing pain?’ or ‘How is this drug likely to affect my patient’s mental state?’ and so on. In order to answer these in any meaningful way, nurses need some common terms of reference, and a framework of understanding healthcare phenomena. In this, nursing is still struggling as a discipline to establish consensus as to the best way forward, although this is hardly surprising, as philosophers have been struggling with these big questions for centuries. These include such questions as ‘What are the necessary and sufficient conditions of knowledge?’ ‘What are its sources?’ ‘What is the structure of

4

Empirical Nursing: The Art of Evidence-based Care

knowledge?’ and ‘What are its limits?’ The study of the nature of knowledge and justified belief is known as epistemology, and this and its relation to nursing knowledge is one of the key areas that seem to interest nursing theorists. The academic journal Nursing Philosophy is primarily dedicated to exploring this very area. In the consideration of the epistemology of nursing knowledge, it is important to deliberate what is meant by the concept of justification itself. The more recent trend towards evidence-based health care, medicine, and nursing has resolved some of this debate for nursing, but even that has been severely criticized by some nursing academics (Holmes, Murray, Perron, & Rail, 2006). The following chapters explore why an empirical approach makes good sense for developing nursing epistemology and justifying the practice. Science itself represents a belief framework as much as any other, so before proceeding too much further perhaps, it is worth considering what science actually is?

Science and Technology in Nursing Simply put, science is a way of understanding the world. The term comes from the Latin, scientia, meaning knowledge. Science was originally synonymous with philosophy in the ancient world, and today is still used less formally to describe any systematic field of study. However, here it will be used to describe the system of acquiring knowledge through the use of explanations and predictions that can be tested. The key element of scientific inquiry is that it involves evidence and explanation of the phenomenon by observation and experimentation. In reality, the definition of science itself has come under scrutiny many times, prompting the UK Science Council to publish its latest definition in 2009, which works well here: Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence. (UK Science Council, 2018) Nursing can be considered a scientific discipline in that it represents a collective of academic scholars and practitioners that generate and add to a distinct body of knowledge. It is also an academic discipline in the sense that this knowledge is suitable for both teaching and learning (Phenix, 1962). Nursing is also often described as an applied science (and often resides within such a faculty in universities’ organizational structures) as it is concerned with the application of research into human needs, and it is notable that despite its human focus, it is heavily dependent upon technological innovation for its practice. Technology can be considered the application of tools and techniques to solve practical problems. It comes from the Greek word technologia meaning art or craft. Although frequently used in relation to science, technology involves the use of technical means derived from both science and art. Technology is often conceptualized in terms of complex electro-mechanical devices but a simple

Science and Nursing
Why Should I Care?

5

pencil and paper also represents a technology. Ever since humans first began to use tools, technological advancement has progressed. For our purposes, technology may be considered as the application of products from the findings of scientific inquiry, and in this way, nurses are heavily involved in the use of healthcare technologies in their everyday practice, from computers to stethoscopes. So why has health care become so dominated by science and technology?

Science and Medicine in Contemporary Health Care Few would argue that contemporary health care in the economically developed world remains dominated by medicine. Apart from historical gender-based and socio-cultural rationales, a major reason for this continued dominance is that the discipline has established a track record of effective practice over the last century. To date, this has been unrivalled by alternative health practitioners, and together with the legal control of medication prescription, medicine has maintained dominance in health care. This state of affairs has a relatively short history, however; and before the last century, the success of medical practitioners was not that much better than other health service providers. Even Hippocrates of Kos (460
370 BCE), who is considered the father of medicine and introduced some aspects of science advocating meticulous observation of patients, identified that more than half his patients succumbed to the diseases he was treating them for. In the seventeenth century, there were clear divisions between medicine, surgery and pharmacy, with no clear leader in terms of effective practice. Physicians held university degrees and prescribed a range of remedies, some rather dubious such as medicinal snuffs, effervescent salts and anodyne necklaces. Surgeons were apprenticed, often serving in the dual role of barber-surgeon and practiced bloodletting, whilst apothecaries undertook apprenticeships to make and sell a variety of medications, including traditional remedies with uncertain efficacy. Eventually, with the increasing success of surgery (particularly following the invention of antiseptic surgery by Joseph Lister in 1865), this distinction between medicine and surgery did not survive. Prior to 1900, there were few effective medical treatments for any of the major illnesses and maladies affecting people of the time. For example, tuberculosis, a major killer, was only identified as a bacillus in 1882, and a successfully immunized against by Bacillus of Calmette and Guérin (BCG) in 1921 in France, 18 years after the first powered aircraft had flown. Even then it was not until after World War II that that BCG received wider acceptance elsewhere in Europe and the Americas and further afield. The use of sound scientific practice by physicians was yet to develop and many doctors were prescribing dangerous treatments in the 1920s, such as chlorine gas for the common cold. There was narcotic analgesia, and insulin, but precious little else in terms of substantial effective therapies prior to 1935, but this was rapidly to change with an exponential increase in effective therapeutic interventions, becoming what has been termed a golden age of medicine (Goldacre, 2008). This golden age was heralded by the advent of a huge range of more effective medical and surgical

6

Empirical Nursing: The Art of Evidence-based Care

interventions and health knowledge including antibiotics, anaesthesia, thoracic surgery, vascular surgery, neurosurgery, solid organ transplantation, dialysis, radiotherapy, intensive care, and establishing causative links between diet, exercise, and smoking on cardiovascular and respiratory diseases. These rapid developments in effective proven therapeutic interventions were the product of huge leaps forward in scientific knowledge and technology during this time such as pharmacology, the discovery of DNA, non-invasive medical imaging and information technology. To be balanced, it is also worth recognizing that medicine also made serious blunders causing harm along the way too. For example, Dr Freeman and Watts’ lobotomy procedures in 1936, or Dr Benjamin Spock’s advice to put babies on their front to sleep in 1946. Overall, medicine has become established as a rigorously science-based discipline, requiring qualification in the naturalistic sciences (physics, chemistry and biology) for entry to training, adopting a biomedical framework and developing evidence-based medicine alongside improved ethical codes. This is one of the major reasons that medicine has maintained its status as the preeminent health profession in much of the world.

Nursing Science Nursing has also benefited from the adoption of a scientific archetype in its professional development, but Nursing now stands at rather a crossroads for its future disciplinary development. Nursing has enjoyed a collegiate and at times tempestuous relationship with our medical colleagues over the last century and a half, establishing professional self-regulation in the face of medical opposition and challenging it when questionable medical practices occurred. Florence Nightingale (1820
1910) gives a good example of the scientific practice of direct observation and hypothesis with her suggestion to an unheeding British military that most of the wounded soldiers in the Scutari were dying due to poor living conditions, rather than their injuries. She also supported the use of standardized procedural rules for the care of patients, based on the scientific knowledge of the time. Likewise, Mary Seacole, another nursing pioneer of the Crimean war, identified that poor nutrition and unsanitary conditions were a major problem for recovery of soldiers. Nightingale also suggested that ‘Evidence, which we have means to strengthen for or against a proposition, is our proper means for attaining truth’, clearly identifying support for an empirical basis for nursing care at the onset of our professional organization. Nursing’s disciplinary focus is of course, very different from medicine, in that nurses focus on patient/client care and health rather than the treatment and amelioration of illness and disease. Most nurses are motivated to enter the profession specifically with a desire to attain the knowledge, practical skills and attitudes that will allow them to help people improve their health status and maximize their quality of life, or when this is not possible to help them to die peacefully and with dignity. And here lies the most fundamental difference between nursing and medicine as distinct disciplines. Whilst medicine has identified a clear and

Science and Nursing
Why Should I Care?

7

distinct focus on preserving health by diagnosing, treating and preventing disease using a biomedical model, adopting an empirical scientific framework, nursing has adopted more behavioural models of health and struggled with a foundational philosophy, as human behaviour, care, quality of life and health are by their very nature more complex multi-faceted concepts. Historically, the development of nursing has also had a strong link with theology, particularly the ideas of giving service and aiding the sick, and this can be seen as reflected in the contemporary work of nursing academics exploring ontology, the nature of being or existence. This has become a more prevalent trend amongst nursing theorists over the last 25 years with some novel conceptual frameworks for nursing being suggested, Parse’s human becoming theory being a key example (Parse, 1992). Much of the recent development in nursing theory and research has also incorporated an increased focus on alternative post-modern and feminist philosophical approaches with the further alignment of nursing with the humanities, in the desire to develop a unique disciplinary body of knowledge. Following trends in the social sciences and arts has led to the promotion of the ethos in nursing academia that nursing science has evolved further from traditional positivist science to a broader humanistic interpretation. However, on closer inspection, this represents a rather simplistic exploration of these issues and of the current state of scientific philosophy. It has even been questioned whether contemporary nursing science as envisaged can legitimately be considered a science at all (Winters & Ballou, 2004). The nature of this argument and different viewpoints as to what actually constitutes modern scientific inquiry and nursing will be explored further in this chapter. There is a sound case to be made that nursing should be underpinned by scientific knowledge, but it is also foremost a practical profession concerned with action (or praxis) rather than theory.

Nursing Praxis The ancient Greeks identified three basic human activities: theoria (focused on knowledge leading to truth), poeisis (focused on creation and production) and praxis (focused on enacting skills and action). Both Aristotle and Plato used the word ‘praxis’ to describe the activity engaged in by people where the end goal was action. And Aristotle also identified praxis could be good (eupraxia) or bad (dyspraxia) depending on the knowledge and, of course, skill of the practitioner. This necessitates some notion of moral reasoning or phronesis, to establish what is considered good in a given situation. The nature of praxis has occupied the thoughts of many philosophers over the years from Immanuel Kant to Martin Heidegger. Karl Marx discussed it in that he suggested the purpose of his political philosophy was to understand and change the world rather than simply explain it, (Marx & Engels, 1965) whilst Paulo Freire suggested praxis required a process of reflecting upon the world followed by action to transform it (Freire, 1973). It can be argued that nursing is a form of praxis in that it is a practice-based discipline, and in that nurses are

8

Empirical Nursing: The Art of Evidence-based Care

concerned with the application of practical therapeutic techniques to maximize health and minimize suffering, and positive action rather than simply academic inquiry with a focus on theory rather than action. If the profession of nursing is a form of praxis, it follows nurses should be concerned with what knowledge is required to inform this praxis, support eupraxis and avoid dyspraxis. This in turn leads us to consider, what the nature of this knowledge should be, and from a pragmatic approach, what epistemological foundations of nursing knowledge are most likely to result in eupraxis. In other words, how should nursing knowledge be generated and used by nurses to best maximize positive health outcomes for patients or clients? This then is the central question behind our concern with the nature of nursing knowledge (nursing epistemology) and ongoing struggles within nursing academia to define nursing phenomena and knowledge and its relation to science.

Pragmatism and its Value for Nursing In exploring modern scientific thinking and its relationship to nursing, a key theme encountered is the value of a pragmatic approach. Pragmatism presents an approach that fits very well with the principles of praxis in nursing and in a contemporary scientific approach to nursing knowledge. The term is derived from the same Greek word ‘pragma’, meaning action, from which the words ‘practice’ and ‘practical’ are derived. Rather than trying to explain the nature of reality (metaphysics), a common target for philosophers, pragmatism instead tries to explain, humanly, how the relationship between the individual and their knowledge works in the practical everyday world. Pragmatism involves the idea of the theory being derived from practice and then reapplied to practice in different contexts, with the aim to support and improve it, and that theory is essential for more effective practices to develop. The origins of pragmatism are generally credited to Charles Sanders Peirce (1839
1914), who is one of the founders of modern statistics and coined the term in an article entitled, How to Make Our Ideas Clear (Peirce, 1878). In its simplest terms, pragmatism purports that something is true only insofar as it works and considers practical consequences or real effects to be vital components of both meaning and truth. Pragmatists assert that the scientific method is best suited to theoretical inquiry, but that any theory that proves itself more successful in predicting and controlling our world than others can be considered to be nearer the truth and more valuable. However, there remain very different interpretations of pragmatism; some suggesting truth is inconsistent or relative. This will be discussed further when pragmatism is explored in more detail in Chapter 4. Overall, a pragmatic approach to epistemology has value for nursing, since it is outcome focused and clearly acknowledges the changing state of human knowledge and the limitations of cognitive processes in understanding the world. These ideas reflect modern scientific philosophy very well and, it can be argued, provide a more substantive basis for nursing practice, with nursing

Science and Nursing
Why Should I Care?

9

identified as a pragmatic profession focused on action but underpinned by science as the basis for its theoretical support.

Making Sense of Nursing Theory Nursing is a unique mixture of both science and art and represents a discipline that embraces both in its practice. Nursing knowledge requires grasp of a wide range of theory in addition to practical techniques. For example, understanding of the theoretical pharmokinetics of a therapeutic medication, the behavioural psychology concerning compliance and the sociological implications for medicating the patient with this drug. Artistry can be clearly seen in skills involving psychomotor and cognitive techniques requiring the development of ability through practice, with which a degree of mastery can be obtained (Benner, 1984), for example, patient assessment and communication skills. Of course, artistry in nursing may be demonstrated in many other areas such as creativity and problem-solving. A professional nurse requires significant education and training to develop such knowledge, skills and attitudes, and the body of theoretical knowledge supporting the discipline of nursing is dynamic and rapidly changing. Given the hugely expanding knowledge base in nursing and the associated plethora of jargon readily apparent in social sciences and nursing, it is important for us to present ideas in meaningful ways. I would argue that the task of the educator is to explain complex ideas in as simple and practical terms as possible, rather than the converse; to which approach, alas, I note many modern nursing academics seem to subscribe. It is important for nursing theorists to attempt to present ideas in as plain a language as possible rather than obfuscate it with contrivance and unintelligible jargon in an attempt to appear innovative and more erudite. Using technical terminology is certainly not to be avoided, but it makes sense to use technical terms only where they readily convey an idea in a more succinct manner than other available terms or meaningfully describe a new phenomenon. Nursing academics should desist from using jargon unnecessarily or combining adjectives and verbs together that make little sense to the uninitiated (rest assured there are some first-rate examples of this later on in the book). In this approach, we are in the excellent company of Einstein who suggested that if you can’t explain an idea to a six-year-old, you probably don’t understand it that well yourself. This seems sage advice.

Summary Overall, this book presents an epistemological framework that is commensurate with modern evidence-based health care and serves as a solid foundation for nursing theory as a distinct body of knowledge within it. It presents an argument for modern, creative science as a productive way for nursing to further develop its knowledge base and for nurses to maximize their impact on society as healthcare professionals. In order to care for patients most effectively, nurses need to

10

Empirical Nursing: The Art of Evidence-based Care

adopt a pragmatic stance and not be focused on which ideas and explanations represent truth, but which approaches and arguments best describe phenomena given our current state of knowledge; or if they don’t, what other ideas or theories could explain them. This forms the basis for modern thought in clinical practice. Despite all of its problems, modern science still provides the most useful and practical approach for us to understand health phenomena and a basis for providing high-quality care. By now you will have gathered this book itself takes a particular perspective and other viewpoints are available and should also be considered by the reader. However, I hope that the arguments and ideas presented here will help inform the reader in their quest to understand nursing theory and research and help improve practice. The following chapters develop this theme and explore why nurses should consider the rich history of scientific philosophy, the value of science for nursing and consider how alternative viewpoints have influenced the profession.

Key Points for Further Discussion • How does scientific philosophy apply to nursing practice? Is nursing more art or science? • Can one be an effective nurse without using a scientific rationale for nursing action? • What are the implications of nurses not understanding of scientific philosophy for patients or clients? • Can you think of think of an example where pseudoscience or simply bad science has negatively affected patient care, and what were the reasons behind this occurrence? • What does praxis mean in nursing terms? • Is pragmatism useful for an approach to nursing? • Does the scientific paradigm best describe nursing phenomena?

References Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison Wesley. Blendon, R. J., Benson, J. M., & Hero, J. O. (2014). Public trust in physicians
U.S. medicine in international perspective. New England Journal of Medicine, 371(17), 1570
1572. Brockman, J. (1995). The third culture. New York, NY: Simon & Schuster, 1996. Frazier, K. (2009). Science under siege, defending science, exposing pseudoscience (p. 7). New York, NY: Prometheus. Freese, J. (2001). Science under siege? Interest groups and the science wars. Contemporary Sociology A Journal of Reviews, 30(3), 266
267. Freire, P. (1973). Pedagogy of the oppressed. New York, NY: Continuum. Gillis, C., Belluz, J., & Dehaas, J. (2010). Do you trust your doctor? Macleans.ca. Retrieved from http://www.macleans.ca/news/canada/do-you-trust-your-doctor/. Accessed on January 26, 2018.

Science and Nursing
Why Should I Care?

11

Goldacre, B. (2008). Bad science. London: Fourth Estate. Holmes, D., Murray, S. J., Perron, A., & Rail, G. (2006). Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. International Journal of Evidence-Based Health Care, 4(3), 180
186. Marx, K., & Engels, F. (1965). The German Ideology ad Feurbach: An appendix in Ludwig Feuerbach and the end of classical German philosophy (1888) (C. Dutt, Trans.). London: Lawrence & Wishart. Parse, R. R. (1992). Human becoming: Parse’s theory of nursing. Nursing Science Quarterly, 5(1), 35. Peirce, C. S. (1878). How to make our ideas clear. Retrieved from http://www.marxists.org/reference/subject/philosophy/works/us/peirce.htm. Accessed on January 23, 2018 Phenix, P. (1962). The use of the disciplines as curriculum content. The Educational Forum, 26(3), 273
280. Snow, C. P. (1993). The two cultures (2nd ed.). Cambridge: Cambridge University Press. Steel Fisher, G. K., Blendon, R. J., & Lasala-Blanco, N. (2015). Ebola in the United States
public reactions and implications. New England Journal of Medicine, 373(9), 789
791. Thorne, S. (2018). But is it “evidence”? Nursing Inquiry, 25(1), e12229. UK Science Council. (2009). What is science? Retrieved from http://www.sciencecouncil.org/content/what-science. Accessed on January 23, 2018. Winters, J., & Ballou, K. A. (2004). The idea of nursing science. Journal of Advanced Nursing, 45(5), 533
535.

This page intentionally left blank

Chapter 2

The Rise of Empiricism Those sciences are vain and full of error that are not born of experience, mother of all certainty. Leonardo da Vinci (1452
1519)

An understanding of the foundations of modern scientific thought is a useful precursor to any exploration of the nature of contemporary nursing, and of EBP. Whilst this movement has really only developed its formal structures over the last 30 years, its philosophical roots date back much further. Whenever humans have encountered problems, humans have always sought solutions, and compared alternatives to strive for more effective solutions. This applies not only in nursing but also in all aspects of human life from farming to genetic engineering. Practitioners have based their practice on whatever evidence they had available and, in its absence, resorted to what is next best; intuitive, traditional, cultural and religious knowledge. Our approach to nursing is more scientific now than in the past, and so has more potential to further improve health outcomes in the future. This chapter explores some of the key elements in the development of empiricism, including inductive, deductive and abductive reasoning processes.

The Beginnings of Science The exact origins of science are debatable but the term scientist is attributed to William Whewell (1794
1866). Previously, the term natural philosopher was commonly used to describe investigators of natural world, and this demarked a split of science and philosophy as separate approaches, to understanding knowledge with science denoting a focus on empirical knowledge. Most modern historians would accept the origins of modern science arising from a variety of independent influences. In ancient India, at around 3000 BCE, we have the first recorded evidence of attempts to standardise measurements with civilisations of the Indus valley. In the ancient East, Sumerian and Mesopotamian peoples are known to have started to record observations of the physical world with numerical data around 3500 BCE. Astronomical periods defined by the Mesopotamian people are still used today such as the solar year and lunar month. In most ancient cultures, intellectual thinkers were also priests, and the realm of astronomy and the cosmos was never too distant to those observing the world and struggling to associate it with a cosmological understanding (Teresi, 2003). Ancient Egyptians (3150
30 BCE) made many advances

14

Empirical Nursing: The Art of Evidence-based Care

in astronomy, mathematics and medicine. Early Babylonians (1800
600 BCE) used mathematics with a base-60 system that contributed to our modern sense of time, the understanding of which seems to have been important to ancient peoples (Teresi, 2003). An Egyptian papyrus circa 1600 BCE outlines some records of traumatic injuries, illness, treatments (some surgical) and outcomes, demonstrating some early principles in recording and analysing data (Allen, 2005). Contrary to common belief, many early innovative thinkers and the foundational elements of science arose outside of the Western world. Classical antiquity (800
500 BCE) saw the rise of Greek philosophy with the work of Thales of Miletus (624
546 BCE) who Bertrand Russell (1872
1970) described as the founder of Western philosophy. Thales’ ideas exhibit some of the earliest attempts to explain natural phenomena without reference to deities, magic or mythology. Followed by Socrates (469
399 BCE), Plato (424
423 BCE) and Aristotle (384
322 BCE), the early traditions of trying to explain the observed phenomenon by conjecture and hypothesis were developed. Socrates was reputed to be particularly concerned with ethics and had developed a systematic method of questioning (known as Socratic method) where a series of questions is asked to encourage detailed exploration and fundamental insights into a specific phenomenon. One of Socrates’ best-known arguments on the nature of knowledge is known as Meno’s paradox or the paradox of enquiry. In the Socratic dialogue Meno, written by his student Plato, a man called Meno asks Socrates ‘How could a man know that he has found which he searches, if he does not know which he searches?’ Socrates answer was that if Meno’s assumptions were true, then men could neither search for which they know (for they would already have acquired it) nor would they be able to gather something new, since they would not be able to identify this thing to be what they were looking for to start with. In other words, how do we know when we have succeeded in finding the right answer, if we don’t know what it is? Plato suggested an answer to this riddle in that, knowledge is forgotten memories and that learning consists of remembering those ideas. By this he proposed, a man could recognise the truth from the falsehood. However, the underlying premise that either you know what you’re looking for, or you don’t know what you’re looking for can be argued as a false dichotomy. It can also be argued that the pursuit of knowledge occurs in steps proceeding from limited initial knowledge of a phenomenon to increased knowledge, so the paradox is fallacious. However, the paradox embodies the notion that there could be an ultimate truth in the pursuit of knowledge towards which we are proceeding. This is an interesting point in scientific enquiry and one that is examined in more detail later in the book. Plato was profoundly influenced by the teachings of Socrates and wrote copiously on the nature of reality and being (metaphysics). He argued, in his work Theaetetus, that knowledge could be distinguished from belief by its justification (a position attributed to Socrates) and also discussed the nature of sophistry. In ancient Greece, sophists were intellectuals and private teachers who specialized in using argument and philosophy to earn money, usually by teaching wealthy statesmen’s children. Socrates himself had been described as a sophist, but Plato

The Rise of Empiricism

15

differentiated them as charlatans who used rhetoric, ambiguities of language and underhand methods in order to deceive, rather than scholars interested in exploring the nature of knowledge and truth. Largely due to the influence of Plato and Aristotle, sophistry has become seen as distinct from philosophy, and today is regarded as specious and rhetorical argument, a characteristic commonly attributed to pseudoscience. Plato also argued truth could be discovered through dialectic, the resolution of disagreement through rational discussion, using propositions and counter-propositions, and the establishment of contradictions and inconsistencies. This remains a key principle in modern scientific argument. Aristotle (Plato’s student) is another ancient Greek who had a profound influence on scientific thought. He is probably the best known of all the Greek philosophers and was an intellectual polymath. His views on the nature of the physical world and arts profoundly shaped medieval scholarship for several hundred years. He is credited with the earliest studies of formal logic and fundamental studies on the nature of matter, causality, motion, optics, biology and medicine.

Science in the Medieval World Many of the works of Plato and Aristotle were translated into Arabic around 850 and after the fall of the Roman Empire (476) and subsequent decline of intellectual innovation in early medieval Europe (500
1000), most of the development in scientific thought continued in the Islamic world. In this golden age of Islamic civilisation from 750 to 1258, Muslim culture spread across North Africa to France, from Persia to China, and south to India. The geographically central location of medieval Eurasia, in the midst of other cultures, was crucial in developing scientific practice at this time and the development of Arabic language and translations of the works of the Greek philosophers are certainly thought to have supported this process. In India, Brahmagupta (ca. 598
668) a mathematician and astronomer developed the Hindu-Arabic numerical system pioneering the use of zero as a number circa 628. This is now used as the scientific standard throughout the world. Indeed, Indian mathematics continued to flourish on the continent until the British Empire invaded in 1858 (Corbin, 1993; Teresi, 2003). Another great Islamic thinker active in the second century was Alhazan, Ibn al-Haytham (ca. 965
1040). He was a prime exponent of scientific thinking, making great contributions in the development of the scientific method and in the fields of physics, astronomy, mathematics and particularly optics. Another remarkable polymath, he led a very colourful life, at one time feigning madness to avoid the wrath of the Caliph when he failed to control the flooding of the Nile as he had predicted (Rāshid & Morelon, 1996). It has been suggested that Alhazen developed the experimental method of using controls to verify theoretical hypotheses (Gorini, 2003; Sabra, 1994), although this view is disputed as overstating his contribution by some academics (Smith, 1992). However, he

16

Empirical Nursing: The Art of Evidence-based Care

clearly developed the use of experimentation in his optical work, and also insisted upon the replication of results, and used the concept of Occam’s razor in his work (Corbin, 1993). Occam’s razor is a principle that suggests, when faced with competing hypotheses that are equal in other respects, selecting the one that makes the fewest new assumptions (i.e. is the simplest) is recommended. This maxim for scientific enquiry is (somewhat contentiously) attributed to William of Ockham (1285
1349) but Al-Haytham clearly documents evidence of this idea in his Book of Optics in 1021 (Sabra, 1994). Another great Persian thinker, Abu Hamed Al-Ghazali, known as Algezel (1058
111) described the idea of methodical doubt, proposing that we should question our beliefs and test them, an idea that was much later built upon by René Descartes (1596
1650). Unfortunately, scientific advances in this part of the world declined by the end of the end of the Middle Ages, and the reasons for this remain an area of acute historical speculation. Invasions by the Mongols, crusaders and the destruction of Islamic libraries, as well as economic and political factors are thought to have all played a part (Al-Hassan, 2002). In the West, after the collapse of the Roman Empire, Western Europe suffered significant depopulation with widespread plague and migration. The Black Death pandemic is estimated to have killed 30
60% of Europe’s population in this period (Austin Alchon, 2003). Many Greek philosophical texts were lost and few remaining Latin translations existed. The common perception is that the development of scientific thinking in Europe stalled until the Italian renaissance of the fifteenth century, a thousand years later. This is commonly described as the period of the ‘dark ages’ dominated by religious dogma and superstition. Certainly, this was a time of religious dominance of thinking in Europe, characterised by the triumph of Christianity over the paganism of antiquity. However, during the twelfth century, the Byzantine civilisation of what was the Eastern Roman Empire (based in the capital of Constantinople, now Istanbul) experienced a period of rapid intellectual and scientific development. Some historians refer to this period as the Twelfth Century Renaissance, where increased contact with the Islamic cultures to the East allowed Europeans to translate the works of antiquity that were otherwise lost to European scholars of this period, and to also become influenced by other Islamic scientific texts (Huff, 2003). Examples of important scientific advances are such innovations as the invention of eyeglasses in Italy in 1286, and the introduction of Hindu-Arabic numerals to Europe by Leonardo of Pisa (1170
1202). The first recognisable universities were also established during this time in Italy, France and England, and access to the translated texts allowed them to aid propagation of new ideas and eventually start a new infrastructure for scientific communities. The English Franciscan friar Roger Bacon (1214
1294) studied at the newly established Oxford University and advocated for the use of the inductive reasoning processes to acquire knowledge and that inductively derived conclusions (propositions based on experience and observation; see Table 1) should then be submitted to experimental testing (Clegg, 2003). This remains a fundamental idea in modern science.

The Rise of Empiricism

17

Table 1: Inductive, Deductive and Abductive Reasoning. Characteristics Inductive reasoning

Begins with observations that are specific and limited in scope and proceeds to a generalised conclusion

Ability to Guarantee a Sound Conclusion

Fitness for Purpose

Provides a conclusion that is likely, but not certain

Identifies patterns, establishes general trends for further exploration. Often used in qualitative exploratory research

Abductive Begins with an reasoning incomplete set of observations and proceeds to the likeliest possible explanation

Relies on information at hand, which often is incomplete so provides a conclusion that is likely, but not certain

Useful for creative thinking and hypothesis generation. Also, useful for explaining the acceptability of treatments and patient preferences

Deductive Starts with the reasoning assertion of some general rule and proceeds from there to deduce a specific conclusion

Excellent, if premises sound and process correctly applied, then it provides a sound conclusion

Validation of specific hypotheses. Often used in quantitative research and comparative trials

Eventually, the loss of the Byzantine lands (in the East to the Turks and in the West to Bulgaria) resulted in the fall of Byzantium in 1453. However, the resulting migration of Byzantine scholars West helped to spark the later Italian Renaissance, which was to be a time of huge change and development for the arts and for science (Huff, 2003).

The Renaissance and Scientific Revolution Generally, the consensus is that the Italian Renaissance commenced in Florence in Tuscany in the fourteenth century (kick-started by the many works commissioned by the immensely powerful Medici family), spread to the rest of Europe by the sixteenth century and lasted until the seventeenth century. The Renaissance represented a great cultural movement with a new focus on literary and historical texts and exploration facilitated by the use of the magnetic compass (including the discovery of the New World by the European Christopher Columbus in 1492). The invention of the printing press in 1436 also had a huge impact on the dissemination of ideas, and democratised learning. The new

18

Empirical Nursing: The Art of Evidence-based Care

Renaissance scholars studied the newly available classical sources enshrining both the old Aristolean and Ptolemaic views of the universe. Renaissance scholars were generally more interested in culture and art, rather than the Greek and Arabic works of natural sciences, philosophy and mathematics, and so initially, the development of scientific thinking was rather stunted until the mid-sixteenth century. Ideas such as the classical elements of earth, water, fire, air and aether making up the physical world and a geocentric universe persisted during this time. Art and scientific perspectives were also very much intertwined in the early Renaissance. Ideas of humanist theology developed, embodying the ideals of humanity in physical, psychological and spiritual terms. The best-known exponent of Renaissance ideals is probably the most famous polymath of all time, Leonardo da Vinci (1452
1519 CE). Leonardo da Vinci made incredibly accurate observational drawings of anatomy and nature using systematic medical dissection, but also devised controlled experiments in water flow, made systematic study of movement and aerodynamics and devised basic empirical research methods that led to his description by some as the ‘father of modern science’ (Capra, 2007). His view of the world was more logical than mysterious, and the empirical methods he employed (such as repeated observation, meticulous note taking and use of hypothesising and experimentation) were very unusual for his time. He is best renowned as an artist, and particularly as the painter of the famous Mona Lisa. Although Leonardo made important discoveries in anatomy and other fields, he did not publish his findings and many of his discoveries, such as his anatomical sketches, only came to light many years later, so not directly influencing the progress of science in his lifetime. Leonardo’s Vitruvian Man probably best exemplifies the blend of art and science of the Renaissance period providing the perfect example of Leonardo’s keen interest in accurate proportion, balance and the relationship of man to nature. The drawing was based on the ideas of ideal human proportions geometrically described by the ancient Roman architect Vitruvius (70 BCE
15 CE) in his book De Architecture. This is believed to be the only contemporary source on classical architecture to have survived in its entirety and was one of the classical texts now available to Leonardo and his contemporaries. This fusion of creativity, art and science and his use of both inductive and deductive processes in scientific rationale were themes that would later become more important in the development of modern scientific thinking. The great fusion of the arts and sciences developed with a slow shift away from the control of knowledge by the Roman Catholic Church, representing revolution in thinking, and challenge to authority and dogma. The practice of using new empirically based ideas to challenge established wisdom has become an established aspect of sceptical scientific enquiry today. Leonardo da Vinci wrote, ‘anyone who in discussion relies upon authority uses, not his understanding, but rather his memory’ (Nuland, 2005). Scientific scepticism of the status quo and authority is an important aspect of modern EBP. In modern science, authority isn’t really worth a jot, and concepts are presented to the world for open consideration as to their merits, for peer review and

The Rise of Empiricism

19

challenge. The key principle being that, in this way, ideas will become refined, and bad ones rejected. This remains a firm part of academic training, with PhD candidates still being required to defend their theses in robust discussion with their peers today. The peer review of scientific studies prior to publication is another modern embodiment of this principle. Interestingly, modern medicine is often criticised as being authoritarian, conspiratorial, all-controlling and closed to any alternative perspectives, prompting Ben Goldacre, a well-known UK physician to ask ‘Is mainstream medicine evil?’ (Goldacre, 2008). The argument of medical authority influencing healthcare through political influence, and legislative control maintaining the hegemony can certainly be made. However, in terms of openness to alternative therapeutic interventions, the adoption of EBP in medicine would seem to support challenges to established wisdom and presents an opportunity for change that nursing has yet to fully embrace and take advantage of. The Renaissance was also a time of great religious upheaval and division resulting in the reformation and breakup of the Roman Catholic Church. Acceptance of new ideas varied amongst church leaders and there was fierce resistance by many. Examples of this include the initial rejection of Gallileo Galliei’s (1564–1642 CE) arguments against a geocentric universe by the church, and Girolamo Savonarola’s (1452
1498 CE) bonfire of the vanities, where the Dominican friar burned books and artworks deemed offensive to pious religious thought in Florence in 1497. It is also argued by contemporary historians that many negative cultural aspects actually got far worse in this period, including religious persecution, witch hunts, censorship, wars and papal corruption (Martines, 2006). In 1543, Copernicus’s On the Revolutions of the Heavenly Spheres was published, and Andreas Vesalius’s (1514
1564 CE) On the Fabric of the Human Body, a text documenting the role of dissection, observation and a mechanistic view of human anatomy. These two empirical works openly challenged previously established doctrine, and, together with the works of Leonardo da Vinci, and later Francis Bacon (1561
1626), established what became known as the scientific revolution and furthered the development of the scientific method.

The Age of Enlightenment The end of the Renaissance set the stage for another era of profound scientific advances in seventeenth and eighteenth century Europe, known as the Age of Enlightenment (or the Age of Reason). This set in motion the development of modern science (Lindberg, 2007). The technologies developed during this time supported the industrial revolution, marking a major turning point in human history. The income and general living standards of the majority of ordinary people began to undergo sustained growth for the first time in history (Lucas, 2002). The result of this was an age characterised by a cultural movement in Europe fostering new ways of thinking and witnessed an outpouring of human knowledge in almost every field.

20

Empirical Nursing: The Art of Evidence-based Care

Enlightenment thinkers such as René Descartes (1596
1650), Benedict de Spinoza (1632
1677), Gottfried Leibniz (1646
1715), John Locke (1632
1704), George Berkley (1685
1753), Voltaire (1694
1778), David Hume (1711
1776) and Immanuel Kant (1724
1804) all examined the rational basis of beliefs and, in the process, mainly rejected the authority of church and state. Kant expressed the maxim of the Enlightenment very well with ‘aude sapere’ (dare to think). Scientific academies and societies developed as the creators of new scientific knowledge alongside the universities. After 1700, a large number of these learned societies were founded in Europe such as the Royal Society of London (1662) and the Académie Royale des Sciences in Paris (1666). The era also brought the popularisation of science forward with better social conditions and the introduction of the printing press, although women were generally excluded from the movement and not allowed membership of the academies or universities (Porter, 2003). During the Enlightenment, Johannes Keppler (1571
1630) developed and published new laws of planetary motion), and Isaac Newton (1642
1727) laid the foundations of classical mechanics with his book Philosophae Naturalis Principia Mathematica in 1687, removing the last doubts about heliocentrism. Newton was probably the most famous thinker to come out of this period, and in his monograph Philosophiae Principia Mathematica, he set out the foundations of classical mechanics describing gravity and motion that lasted for 200 years.

Mathematical Probability The discipline of mathematical probability got started at this time with the work of Pierre de Fermat (1607
1665), Blaise Pascal (1623
1662), Christian Huygens (1629
1695), Jacob Bernoulli (1654
1705) and later Pierre Laplace (1749
1827) and Thomas Bayes (1702
1761). The ideas they presented were seized on by a variety of scientific fields including medicine and have had a profound influence on modern science with very accurate methods developed to predict the likelihood of an event occurring (Salsburg, 2001). Early scientists like Newton wanted to find a more objective way to judge when a hypothesis was considered confirmed, and mathematical probability provided them with the tools to do just that. In classical probability theory arising from the work of de Fermat, Pascal, Huygens, Bernoulli and Laplace, instead of dealing with only one possible reality of how a process might develop under time, the probability of an event occurring is expressed as stochastic (random) process where there is some indeterminacy described by a probability distribution. These distributions use a ratio of the number of possible occurrences to the total possible outcomes. A 100% certain event (the sun will rise tomorrow) would get the value of one, an event we are sure will never happen (possibly a surgeon asking for a physician’s or nurse’s advice) would be ascribed the value of zero. A single roll of a normal die would give a probability of 1/6, as there are six possible outcomes and only one occurrence.

The Rise of Empiricism

21

Probability is what is known as, a priori theory, as everything can be worked out ahead of time without any reference to experience (see the following section). Classical probability can be used to calculate the possible outcomes of more complex events, using formula derived from these calculations, such as with two or more independent events, or events that influence one another. However, these calculations are not intuitive (see Chapter 6) and make the assumption of equipossibility (unbiased outcome). Classic probability works well for simple games of chance (the ideas are thought to have arisen from a dispute between de Fermat and Pascal over a game of chance). Nevertheless, for real-world problems where we cannot assume equipossibility, classic probability theory is of limited use. Typical healthcare questions are particularly complex, with multiple conditions such as for the population of patients diagnosed with stage two breast cancer, over the age of 45 years, which combination of chemotherapy, radiotherapy and surgery is likely to be most successful? Another example would be: for a patient who has had a positive prostate-specific antigen test what is the likelihood of the patient actually having prostate cancer? The need to answer more complex questions lies beyond the realms of classical probability, and this led to the development of other techniques such as central limit theorem, formulated by Abram de Moivre (1667
1754), Bayesian probability (after Thomas Bayes, 1702
1761) and later in the 1880s, the frequentist statistics from Charles Saunders Peirce, that is still used today to support statistical inference in science (Salsburg, 2001). Overall, the aim of probability theory is to make predictions of future events and support the generalisation of specific findings to the wider population. These techniques have had an enormous impact on science and healthcare and they are explored further in Chapter 5.

Rationalism René Descartes was a philosopher who made a great impact in the Age of Enlightenment and founded a philosophical movement that became known as Rationalism (or Continental Rationalism). He proposed that we should appeal to reason as our source of knowledge or justification and argued the criterion of the truth is not sensory but intellectual and deductive (e.g. his most famous quote; ‘I think, therefore, I am’). He also postulated that the body works in a mechanistic fashion, and the mind (or soul), was as a non-material entity. This idea of the mind/body dualism (Cartesian dualism) has had a significant impact on modern nursing and concepts of care and spirituality, although it is now contested by modern neuroscience. Another of his most influential ideas in science was his principle of doubt, Cartesian doubt is the systematic process of doubting the truth of one’s beliefs (scepticism), and Descartes advocated the doubting of all things that cannot be justified through logic. Cartesian doubt, the sceptical process of doubting one’s beliefs is a theme adopted in much of modern philosophy and particularly in the criticism of rationalism (see Chapter 5). Descartes suggested that the grounds of reasoning for any knowledge could be false, and we should explore

22

Empirical Nursing: The Art of Evidence-based Care

heterodoxical positions when making judgments about beliefs. Probably, his most famous example is that of Descartes demon. The argument is that if a being or demon were powerful enough to control anybody’s perception, it could create an artificial world that we may think we live in. This represents a recurrent theme for both philosophers and in dramatic narratives over the years, a notable recent incarnation of Descartes demon being the Matrix trilogy of science-fiction films between 1999 and 2003. Other proponents of rationalism, notably Spinoza and Leibniz, also asserted that, in principle, all knowledge, including scientific knowledge, could be gained through the use of reason alone, in contrast to the empiric view of the world. Rationalism is often contrasted with empiricism (although they are not actually mutually exclusive forms of thought): for example, Spinoza argued that the world was deterministic and best understood by examining nature itself. However, rationalist arguments generally support the idea that the human mind is the only source of truth, and certain innate ideas exist from birth, such as the existence of self, mutual exclusivity or god. Many empiricists, on the other hand, subscribed to the idea of the tabula rasa (first suggested by John Locke) or blank slate from birth and that all knowledge comes from experience and perception thereafter. This is a good point in the journey through the history of scientific philosophy to consider the two different ways proposed to explain the genesis of knowledge in more detail.

A Priori and a Posteriori Knowledge The terms a priori and a posteriori come from the Latin for ‘from what comes before’ and ‘from what comes after’ and are used to denote the foundations upon which a proposition is based. A proposition is knowable a priori, if it can be known independent of any experience, whereas a proposition is knowable a posteriori if it is known on the basis of experience. For example, the proposition: all ill people are not well, is a priori, and the proposition: it is snowing outside, is a posteriori. A person who knows that all ill people are not well need not have experienced the being ill, or indeed of anybody being ill to justify this proposition, as long as they can describe the concepts of illness and wellness. A priori knowledge is knowledge obtained through reasoning, where you can work something out using deduction, just by thinking about it. These terms were not new and had been used since Euclid’s (fl. 300 BCE) time, but represent one of the oldest problems in philosophy; trying to resolve whether a priori knowledge truly exists. In 1781, Immanuel Kant advocated for combining rationalist and empiricist theory proposing ‘although all our knowledge begins with experience, it does not follow that it arises from experience’. Kant suggested a framework for how this might work, proposing that the mind has innate structures (rather than innate knowledge) through which we process experience, for example, causality, plurality and unity (Kant, 1996). He rejected the rationalist notion that pure, a priori knowledge of a mind-independent world was possible and also the empiricist’s idea of the tabula rasa. Unlike the empiricists, Kant thought that a priori

The Rise of Empiricism

23

knowledge is independent of the content of experience; but, unlike the rationalists, Kant suggested that a priori knowledge, in its pure form, that is without any empirical content, is limited to the deduction of the conditions of possible experience. In his famous book The Critique of Pure Reason in 1781, he argued forms of experience and categories give phenomenal and logical structure to anything we experience empirically, structuring reason itself. Our knowledge of the world is, therefore, constructed internally and we cannot know things of themselves, only the way they appear to us. Kant’s ideas of internally structured forms of experience of phenomena gave root to the approach of phenomenology, a research technique often used in nursing research to describe a person’s lived experience in relation to the phenomenon being studied (see Chapter 5).

The Rise of Empiricism In response to the early-to-mid-seventeenth century rationalists an alternative discourse, known as British Empiricism (or Classical Empiricism) developed. John Locke, George Berkley and David Hume primarily led this movement. Whilst the rationalists held that knowledge is attained through the operations of the mind, the British empiricists argued that knowledge was based on experience and attained through human perception of the world and phenomena through sensory experience. Isaac Newton had also implicitly rejected Descartes’ emphasis on rationalism in favour of Bacon’s empirical approach. The English empiricists were highly suspicious of metaphysical schemes based on a priori propositions but held a variety of views on the perceptual nature of knowledge. Locke had outlined his tabula rasa theory, but Berkeley (an Anglican bishop) had concerns these ideas were a step towards atheism, and whilst agreeing that knowledge was based on the perception of experience, held that humans or god perceived the world and that we perceive nature as the work of god. The Scottish philosopher David Hume, on the other hand, was a confirmed atheist, and more concerned with the psychological basis of human nature. He outlined two categories of human knowledge: (1) the relationship of ideas and (2) facts. For example, a mathematical proof was seen as an example of the relationship of ideas, whilst the phases of the moon involved observations, and was, therefore, factual. Hume had developed an argument for scepticism in that he argued nothing could be conclusively established by reason, and described the problem of induction (see Inductive Reasoning, below), and also noted problems with deductive rationale. He outlined the pragmatic view that we cannot assume that the future will be like the past, but can reasonably expect it to be so, as it has previously been so; until we know otherwise. It is for this scepticism he is probably best known. Thomas Reid (1710
1796) was another important thinker in the Scottish Enlightenment at this time. A contemporary of Hume, he was a religiously trained Scottish philosopher who wrote on notions of common-sense realism (ideas later developed as naïve realism). Reid disagreed with Berkley and Hume’s position on human perception and reality, and also argued strongly

24

Empirical Nursing: The Art of Evidence-based Care

against Descartes and Locke’s concepts about the nature of human ideas. Reid argued that the human mind has a common sense of perception, claiming that the senses provide us with direct awareness of the external world. This view considered objects as real entities and that we perceive them as they really are with the innate constitution of the human mind (Yaffe & Nichols, 2009). Empiricism is a fundamental aspect of scientific thinking. In a broad sense, it is the view that knowledge is developed through sensory perception of the universe and emphasises evidence, especially as discovered through observation and experimentation (Dahnke & Dreher, 2011). The principles of empiricism were the result of the influence of many cultures throughout history, and one of the main ideas adopted by empiricists is the scientific hypothetico-deductive method.

The Hypothetico-deductive Method The development of this scientific process is attributed to Alhazan Ibn alHaytham, Leonardo da Vinci, Galileo Galelei and Francis Bacon amongst others and was first described as the hypothetico-deductive model of scientific research by William Whewell (1794
1866) and later explored further by the Austrian philosopher Karl Popper (1902
1994). Simply put, based upon experience, observation and conjecture a hypothesis is proposed to explain some phenomenon, and the consequences of that hypothesis deduced. These are then tested against experience. If the hypothesis is found to be false then we learn from the attempt, and then try and produce a better explanatory hypothesis. Hypotheses are not conclusively established until the consequences that logically follow from them are verified through repeated experiments and observations. The basic method consists of working through the following four elements, although the practical details for employing them vary (Godfrey-Smith, 2003): (1) Characterisation and observation. Define, qualify or quantify the phenomenon being investigated, using inductive reasoning (generates multiple ideas). (2) Hypotheses formation/selection. Construct hypothetical explanations of the phenomenon using inductive/abductive/deductive reasoning. (3) Prediction. Generate predictions of outcome from the hypothesis, using deductive reasoning. (4) Experimentation. Test to verify all of the above.

Inductive Reasoning The first and possibly most creative aspect of the scientific method involves inductive reasoning. Inductive reasoning originally derives from Aristotle’s classical reasoning, where he outlined three forms of inference; inductive, abductive and deductive inference. Inductive reasoning is an important part of the scientific method and involves drawing inferences from observations in order to make generalisations. Once a phenomenon has been observed and described in some way the next step is to conjecture what is happening to explain it. For example,

The Rise of Empiricism

25

if it is observed that patients who remain immobile for long periods in bed seem to develop more urinary tract infections (UTIs), we can conjecture this is a general rule and consider possible causes which could include such things as drinking less, urinary stasis, increased exposure to bacteria in bed sheets, or even the influence of evil bed spirits. This represents a process of inductive reasoning and involves the development of multiple competing explanations (propositions), all of which could potentially explain the phenomenon. It involves making generalisations in that you assume what you are observing and your explanation represents a general condition (i.e. all patients on bed rest are more likely to develop UTIs), and that your explanations are generally applicable. Some explanations can be judged more likely correct than others (unless you take a radical postmodern position and accept all are equally valid explanations, but more on that later) and to study the phenomenon further the researcher must select a proposition they feel is most likely correct to test. We could also use probability to do this. For example, if we know 75% of patients on bed rest drink less than ambulatory patients, then drinking less as a cause might seem a good candidate to explore further. The selected proposition can then be tested for confirmation or rejection with further observations. Francis Bacon wrote extensively on this process in his book Novum Organum Scientiarum in 1620 (Bacon, 1994) and felt that the inductive process was the key aspect of scientific enquiry, using four stages: (1) Observation: collect data. (2) Analysis: classify the data, identifying patterns of regularity. (3) Inference: from the patterns discovered, infer generalisations about the relations between the facts. (4) Confirmation: test the inference through further observation. For this contribution, his impact on modern science has been immense. He also suggested various techniques to categorise and list phenomenon to isolate one for testing by drawing up lists of all things in which the phenomenon you are trying to explain occurs and ranking them according to the degree in which the phenomenon occurs. Practically, these techniques proved of limited use, as they were very labour intensive, and inductive reasoning when used on its own has some significant problems. The Problem of Induction Although in essence inductive reasoning appears fairly simple (generate a list of probable explanations to explain an observed phenomenon) there are some underlying assumptions that are more problematic, and together, these are known as the Problem of Induction. These are quite complex to grasp upon first consideration. Firstly, there is the assumption of generalisation. This is a key problem, as induction requires we generalise about the properties of a set of objects based on repeated observations of particular instance. For example, it may be inferred

26

Empirical Nursing: The Art of Evidence-based Care

that all the sheep are white, based on multiple instances of observing only white sheep, but this would later be found to be false when a single black sheep is discovered. This would make any proposition derived from this generalisation equally invalid. Secondly, we have the assumption of uniformity. In inductive reasoning, it is presupposed that a sequence of events will occur in the future, just as they have in the past (e.g. the sun will rise in the East). This assumption itself requires uniformity and relies on inductive reasoning, as the only way we can predict the future is by speculation based on past experience. This is circular reasoning by deriving a conclusion from premises that presuppose the conclusion. That is, basically, saying that the future will be the same as the past because in the past the future has been the same as in the past. Causality is the third area raised in criticism of inductive reasoning. Causality is a basic assumption of science (see Chapter 4), and although we generally accept the concept of cause and effect, philosophically it is actually quite a challenging principle. Aristotle discussed ideas of deliberate (prior) and accidental causation, but David Hume (1711
1776) outlined more detailed principles suggesting three basic elements. If there is a causal link between A and B: (1) one must always precede the other (temporality); (2) the cause and effect must be in contact (spatial contiguity); and (3) there is some power in A to cause B (necessary connection). This third point is philosophically a little more problematic, in that it requires a theoretical element, ‘Something that exists in the mind, not in the objects’. (Hume, 2000). That is to say, a mental notion must be established linking the two types of object or event. Hume suggests it is our mind that makes this connection between objects or events when in reality they should be regarded as separate isolated instances. Relativity and quantum mechanics have also forced physicists to abandon their assumptions of causality, as they don’t seem to apply at the sub-atomic particle level. However, they seem to remain valid for what happens at the practical level of human experience. The final problem identified with inductive reasoning lies in the fact that to justify generalisation or causality, we use experience and inductive reasoning, creating a kind of circular logic, as we are justifying an inductive argument with more inductive reasoning. Carl Gustav Hempel (1905
1995) technically described this in logical terms with his Raven Paradox. Inductively to describe ravens one can hypothesise all ravens are black based on our observation of a subset of all ravens (as we cannot view them all). Over time, with no non-black ravens encountered, we accept this hypothesis. Therefore, he argues, by logical implication we can also state that everything that is not black is not a raven. Our hypothesis all ravens are black; therefore, it has the equivalent form that all non-black things are non-ravens, or more precisely, if an object isn’t black, then it is not a raven. Logically, if every sighting of a black raven confirms our hypothesis, then every sighting of a non-black non-raven should equally confirm

The Rise of Empiricism

27

our hypothesis. This is where the inductive logic falls down, as if I look at my car, and see it is green, and it is not a raven, this confirms my hypothesis that all ravens are black! This, of course, makes no sense at all, but by the rules of logic, if I accept inductive hypotheses and confirmation by observation, then every observation (except one that refutes my hypothesis) confirms it, even when totally irrelevant. The problem of induction is an argument frequently used by philosophers to figuratively ‘beat up’ science, by suggesting that science is no better than alternative narratives for explaining the world. However, Charles Saunders Peirce gives us a pragmatic framework that appears quite effective at generating effective outcomes, and Karl Popper (and others) have proposed a solution to the problem of induction. At worst the problem of induction represents a set of arguments that show inductive reasoning can only suggest a truthful explanation but cannot ensure it. We should certainly accept that there could well be alternative explanations for a phenomenon that has not been considered and be open to them. Pragmatically, it is also worth considering that people use inductive reasoning every day for general learning in the real world. For example, in learning to drive, we learn how to start a car engine by turning a key and generalise this technique to use in other models of cars. For science, we still rely on induction, and it is very much part of the creative (and arguably, most interesting) part of scientific enquiry. The inductive conjecture about best treatment and care options is a central part of the process. Empiricists also discovered that inductive reasoning becomes much more powerful for systematic enquiry when combined with deductive reasoning.

Deductive Reasoning Deductive reasoning, or deduction, is a process where a conclusion follows directly from a set of premises (or hypotheses) by inference. It starts with the assumption that the given hypotheses are true, and a deductive argument is valid if the conclusion necessarily follows from the premises. The classic example of a deductive argument is: (1) All men are mortal. (2) Socrates is a man. (3) Therefore, Socrates is mortal. Assuming that premises one and two are true, the conclusion, three, must follow. Deduction is used in scientific thinking to take a general scientific law and apply it to a certain case. It works from the general to the specific (the opposite of induction) and assumes that the law from which you are arguing is applicable in all cases. In evidence-based practice (EBP), we accept a general law for a particular case (such as therapy X is effective to treat problem Y) and then employ deductive experiments to demonstrate that the law holds true in many different circumstances or conduct deductive experiments that test and challenge that law.

28

Empirical Nursing: The Art of Evidence-based Care

There are two forms of deductive reasoning that may occur (also known as deductive logic laws). (1) The Law of Detachment: Detachment involves a single conditional statement being made and then a hypothesis stated. This leads to a conclusion, deduced from that statement: • A patient with no heartbeat will be unconscious. • This patient has no heartbeat. • This patient is unconscious. By the way, this law has nothing to do with the new-age ‘law of detachment’ concerning spirituality and neutrality, which you may come across elsewhere. (2) The Law of Syllogism: In syllogism, there are two propositions: a major premise and a minor premise (general rules), which lead to a conclusion (specific occurrence) formed by combining the hypothesis of one statement with the conclusion of the other. The following is an example: • A patient with no heartbeat is unconscious. • An unconscious patient cannot speak. • A patient with no heartbeat cannot speak. The all men are mortal example above is also a syllogism, and this is probably the most common type used as examples of deductive reasoning. Unfortunately, there are (as you probably guessed) also problems with deductive reasoning. David Hume also had something to say on the subject and suggested that if induction is not justified, then deduction seems to be left to rationally justify itself, an objectionable conclusion. He argued deductive reasoning alone could not increase human knowledge. It is what is described as non-ampliative, in that the conclusions yielded by deductive reasoning are tautological statements already contained in the original premises. Another problem with deductive reasoning is that it also relies on the initial assumptions to be correct for it to work. A deductive argument is only sound if the premises appear to provide complete support for the conclusion, and if that is the case and the premises are correct then it is a truth-preserving form of reasoning. It can be problematic if these are wrong then the conclusion will also be erroneous. There are many well-known fallacies where the forms of deductive reasoning are broken, and this is often seen in bad science and pseudo-scientific work. For a Summary of the most common deductive reasoning fallacies and others you may come across, see Chapter 6. Inductive or abductive reasoning (see below) is initially required to generate new knowledge. Nevertheless, deductive reasoning is useful for confirmatory processes, and as a means to provide support for a given hypothesis.

Abductive Reasoning A particular problem with deductive reasoning is that people do not really reason like that in their everyday thinking. We tend to use shortcuts in our

The Rise of Empiricism

29

thinking, described by Charles Sanders Peirce as abductive reasoning (also known as retroduction). This is really a form of educated guessing. For example, if we know we need to catch a bus at 08:00 in the morning, we generally estimate how long it will take us to walk to the bus stop, based on either prior experience or a trial and error guess, rather than deductively reasoning it through. Generally, we don’t think like Sherlock Holmes in our everyday lives. Abduction allows inferring a premise as the explanation of the conclusion. This is actually the equivalent to the logical fallacy of affirming the consequent (see Chapter 6). A simple example would be: (1) If my patient has a cold then they will sneeze. (2) My patient has sneezed. (3) My patient has a cold. Scientifically, abduction is useful for hypothesis formation and evaluation, prior to selection for further testing. For example, a researcher might have observed the phenomenon of increasing levels of headaches shown by children in their unit over the past few years. Further research discovers that this tends to occur more in societies where wireless devices are prevalent. Abductive reasoning would then lead the researcher to propose the hypothesis, that if children are exposed to wireless devices, they are more likely to have headaches. This is certainly a valid way to select a hypothesis to test, as long as the likelihood that there may be plenty of other explanations is acknowledged, as the reasoning is not truth preserving, and it might be important to consider more alternatives before proceeding. It requires the investigator to imagine the world in a new way, thus it is a highly creative process. Like any creative act, it also requires some courage. The abductive reasoning usually involves us moving away from conventional wisdom. There has also been a lot of recent interest in abductive reasoning in research into artificial intelligence, as it represents common-sense reasoning, by which we tend to operate on a day-to-day basis. An initial diagnosis is usually an application of abductive reasoning; given the signs and symptoms, what is the most likely diagnosis that would best explain them? Table 1 outlines the role of inductive, abductive and deductive reasoning in scientific enquiry, and this will be explored further, and other types of reasoning processes examined (such as semantic nets) in the following chapters.

Summary By the beginning of the nineteenth century, the scientific revolution had established empiricism as the pre-eminent method for knowledge acquisition, and a basic methodological approach, reflecting the genesis of modern science. There were still many philosophical opponents, but in society as a whole, these ideas took hold. In the next chapter, we will explore how the development of modern

30

Empirical Nursing: The Art of Evidence-based Care

science arose from this, with the influences of the romantic, positivist, pragmatist and modernist thinkers.

Key Points for Further Discussion • The traditional Western view of history holds that the Greeks founded scientific thinking, which was lost with the collapse of Greek civilisation. Their ideas were then preserved in the Arab world during the Dark Ages until they were rediscovered in the Renaissance, and enlightened Europe. What adjustments should be made to this view to yield a more accurate history of scientific enterprise? • What do you think were the causes of the decline of Islamic science, and why did the gap in modern science and technology develop between the West and East from the end of the sixteenth century? • How did the thinking of the ancient Greeks influence modern science and evidence-based practice? • What does Meno’s paradox mean for us in our search for knowledge, and how is it something of a sophistic argument? • In early civilisations, natural phenomena were often explained by magic and religion. How do these ideas differ and match those supporting nursing practice today? • How did the Renaissance rejuvenate scientific progress, and what lessons can we apply from Renaissance thinkers to modern science? • How do Descartes and Kant’s concepts of rationalism, a priori and a posteriori apply in modern scientific thinking? • Cartesian duality is widely questioned by advances in science today, yet is still widely accepted. Why is this, and how is it germane to modern nursing care? • How would you give an example of the problem of induction? • Is empiricism still relevant to modern nursing, or should we reject it? • What are the key differences between inductive, abductive and deductive reasoning, and how do we employ them in evidence-based nursing?

References Al-Hassan, A. Y. (2002). History of science and technology in Islam. Retrieved from http://www.history-science-technology.com/Articles/articles%208.htm. Accessed on April 27, 2018. Allen, J. P. (2005). The art of medicine in ancient Egypt. New York, NY: The Metropolitan Museum of Art. Austin Alchon, S. (2003). A pest in the land: New world epidemics in a global perspective. Albuquerque, NM: University of New Mexico Press. Bacon, F. (1994). Novum organum with other parts of the great instauration (volume 3, Paul Carus Student Editions) (P. Urbach and J. Gibson, Trans.). Peru, IL: Carus. Capra, F. (2007). The science of Leonardo: Inside the mind of the genius of the renaissance. New York, NY: Doubleday.

The Rise of Empiricism

31

Clegg, B. (2003). The first scientist: A life of Roger Bacon. New York, NY: Carroll & Graf. Corbin, H. (1993). History of Islamic philosophy. London: Kegan Paul International. Dahnke, E., & Dreher, M. H. (2011). Philosophy of science for nursing practice: Concepts and application. New York, NY: Springer. Godfrey-Smith, P. (2003). Theory and reality: An introduction to the philosophy of science. Chicago, IL: University of Chicago Press. Goldacre, B. (2008). Bad science. London: Fourth Estate. Gorini, R. (2003). Al-Haytham the man of experience; first steps in the science of vision. Journal of the International Society for the History of Islamic Medicine, 4(4), 53
55. Huff, T. E. (2003). The rise of early modern science (2nd ed.). New York, NY: Cambridge University Press. Hume, D. (2000). A treatise of human nature. Oxford: Oxford Philosophical Texts. Kant, E. (1996). Critique of Pure Reason (W. Pluhar, Trans.). Indianapolis, IN: Hackett. Lindberg, D. C. (2007). The beginnings of Western science: The European scientific tradition in philosophical, religious, and institutional context, prehistory to A.D. 1450 (2nd ed.). Chicago, IL: University of Chicago Press. Lucas, R. W. (2002). Lectures on economic growth. Cambridge, MA: Harvard University Press. Martines, L. (2006). Fire in the City: Savonarola and the struggle for the soul of renaissance Florence. New York, NY: Oxford University Press. Nuland, S. B. (2005). Leonardo da Vinci. New York, NY: Penguin. Porter, R. (2003). The Cambridge history of science (Vol. 4). Cambridge: Cambridge University Press. Rāshid, R., & Morelon, R. (1996). Encyclopedia of the history of Arabic science. London: Routledge. Sabra, A. I. (1994). Optics, astronomy, and logic: Studies in Arabic science and philosophy. Aldershot: Variorum. Salsburg, D. (2001). The lady tasting tea: How statistics revolutionized science in the twentieth century. New York, NY: Henry Holt. Smith, A. M. (1992). Review of A. I. Sabra, the Optics of Ibn al-Haytham. Books I, II, III: On direct vision. The British Journal for the History of Science, 25, 358
359. Teresi, D. (2003). Lost discoveries: The ancient roots of modern science. New York, NY: Simon and Schuster. Yaffe, G., & Nichols, R. (2009). Thomas Reid, in The Stanford encyclopedia of philosophy (Winter 2017 edition). Zalta, E. N. (Ed.) Retrieved from http://plato.stanford.edu/archives/win2009/entries/reid/. Accessed on November 28, 2017.

This page intentionally left blank

Chapter 3

Modern Science and Nursing I think that we shall have to get accustomed to the idea that we must not look upon science as a body of knowledge, but rather as a system of hypotheses, or as a system of guesses or anticipations that in principle cannot be justified, but with which we work, as long as they stand up to tests, and of which we are never justified in saying that we know they are true. Karl R. Popper (1902
1994)

The development of modern science arose through refinement of the ideas of empirical scientific enquiry and the hypothetico-deductive method arising in the eighteenth and nineteenth centuries. In the twentieth century, there followed even more rapid developments in scientific thinking, with markedly differing schools of thought on the epistemological basis for knowledge. Many of these arguments continue today and are frequently discussed in the development of contemporary nursing theory.

Romanticism The Scientific Revolution established science as a source for the growth of knowledge, and the romantic movement of the early nineteenth century helped reshape scientific enquiry by opening up new areas of enquiry and thought. This intellectual movement between 1800 and 1840 arose out of a rejection of realism, the enlightenment and aristocratic social and political control. Romantic thinkers spurned the enlightenment thinker’s emphasis on rational thought and deductive reasoning and their attempts to classify and control nature. The romantics argued humans should peacefully co-exist with nature, and these ideas were championed by thinkers such as Humphrey Davy (1778
1829), the man who discovered the anaesthetic action of nitrous oxide. Davy rejected scientific reductionism, arguing the whole was more important than the sum of the parts, and argued for the unity of man with nature. Although counter to many of the principles of scientific thought and attempting to link religious and scientific ideals in understanding the world, the romantic views on re-examining nature led to many major scientific breakthroughs during this time. Significant developments occurred in many fields; for example, in biology with Darwin’s theory of evolution, in physics with Ørsted (1777
1851) and Ampère’s (1775
1836) development of the theory of electromagnetism, and

34

Empirical Nursing: The Art of Evidence-based Care

Johan Wolfgang von Goethe’s (1749
1832) work on the morphology of animals and plants. John Stuart Mill (1806
1873) was a British philosopher, political economist, ardent feminist and original thinker, who also embraced romanticism. Mill recognised the problems of an inductive approach to science, particularly with confirmation bias. He rejected Kant’s a priori view of human knowledge (which he termed intuition). Mill’s view of how inductive reasoning was used in the process of enquiry was very close to what Thomas Kuhn (1922
1996) later described as the picture of ‘normal science’. What Mill referred to as laws, Kuhn called a ‘paradigm’, but the seeds of Kuhn’s later work are clearly evident in Mill’s writings. In scientific work, Mill noticed a tendency for people to gather evidence and recall information from memory selectively, especially information that confirmed their hypotheses, regardless of whether this information was true. In his well-known work A System of Logic (1843) he described the hypotheticodeductive experimental method of science and noted ways to eliminate interference in experiments and avoid confirmation bias (Robson, 1991). Mill also outlined the original principle that falsification should be a key component of the scientific method, in that a hypothesis selected for testing should be possible to be proven false to be meaningful. This idea was later much refined and further developed by Karl Popper (1902
1994). Overall, Mill is probably best known for his work on ethics and his development of the theory of utilitarianism, a theory initially proposed by Jeremy Bentham (1748
1832). Bentham argued that the measure of moral good is the maximisation of overall good; that is, a venture should be judged in its value by its impact and that the greatest happiness of the greatest number is the best measure of right and wrong. He used pleasure and pain as examples of factors influencing society, and using this principle argued for the legalisation of homosexuality and equal rights for men and women. Mill also held that this was the best way to ethically judge and that one should act so as to produce the greatest aggregate happiness among all sentient beings (within reason). Whereas Bentham treated all forms of happiness as equal, Mill argued that intellectual and moral pleasures were superior to the more physical forms of pleasure and that the goal of science should be the maximisation of utility as a moral criterion for the organisation of society. Although Mill proposed it was not possible to develop an objective scale to measure the degree of happiness or pleasure (cardinal utility), he suggested individuals could differentiate between pleasures and rank them by character, rather than a degree (ordinal utility). For example, one could not state a universal that classical music was better than folk music on a scale of pleasure, but people would certainly characterize them differently and judge their value. Mill was also concerned that the continental realist philosophy freed one from the obligation of justifying one’s beliefs and was committed to the idea that the best methods for explaining the world were through the natural sciences. He suggested anything that we could know about the human mind came from treating it as part of the causal order investigated in science, rather than as an entity that lay outside of it. Romanticism was ultimately short-lived and

Modern Science and Nursing

35

declined as the new intellectual movement of Positivism began to take hold in the mid-nineteenth century. Mill also engaged in much correspondence with Auguste Comte (1798
1857), the founder of this movement and was keenly interested in the application of scientific principles in the social sciences, a key thematic element of positivism.

Positivism Positivism was a school of thought advanced by the French philosopher Auguste Comte, often referred to as the founder of sociology. It was based on the fundamental notion that the senses, experiences and their logical and mathematical treatment were the exclusive source of all worthwhile knowledge (i.e. positive experience). Comte proposed that systematic enquiry should be the same across both the natural and social sciences, and research findings could only be proved by empirical and testable means. He is most well known for his assertion that societies advance through three distinct phases: (1) the theological stage, where the foundation of belief is faith and custom based, referring to deities for explanations and the social base of society is the family; (2) the metaphysical stage, where beliefs become based upon reason, thinking about the world, but without empirical foundation, and the state becomes the social base; and lastly, (3) the scientific stage, where belief is based upon scientific knowledge, and society turns to humanity as the social base. Positivist philosophy was further developed by Emile Durkheim (1858
1917), who rejected many details of Comte’s philosophy, but accepted the general idea that the social sciences were a logical progression of scientific enquiry into the field of human activity. Like Comte, he attempted to make sociology a science, and appropriated elements of Comte’s positivism and his scientific approach to studying societies. Durkheim originally supported the use of the hypotheticodeductive method in the social sciences and made an argument for a return to epistemological realism (or as he termed it, social realism). He argued that external social realities did exist in an objective reality independent of the individual’s perception of them. This outlook even opposed many empiricists’ views, as even thinkers such as David Hume had suggested that reality was altered by human perception, and realities were thus perceived and did not exist independently of our perceptions having no causal powers of themselves (Morrison, 2006). Whilst Comte argued social laws could be deduced from empiric work, Durkheim suggested that sociology would discover the nature of society itself. Durkheim identified many of these ideas in his influential work exploring suicide in 1897, but later (like many philosophers) revised much of this thinking. In his 1912 work Elementary Forms of the Religious Life, he explored religion as a social phenomenon. Here, he held that such social phenomenon were ‘sui generis’

36

Empirical Nursing: The Art of Evidence-based Care

(of their own kind) experiences that could only be analysed in creative and ritualistic terms, rather than as objective empirical phenomena. He argued such social occurrences were unique and irreducible to their composing parts. Overall, it can be seen these early positivist ideas are closely linked to empiricism. They strongly influenced the following development of logical positivism and pragmatism.

Logical Positivism Building on the positivist ideas of Comte and Durkheim, the logical positivists combined the empiricist’s ideas that observational evidence was indispensable for knowledge, with the rationalist ideas that mathematics, logic, linguistic constructs and deductive rationale were the only true sources of knowledge and justification of ideas. Logical positivists argued that science was the only reliable source of knowledge and that physics was the true prototype of science, and perhaps the only science (Klee, 1997)! They based much of their philosophy on the original works of the English logician Bertrand Russell (1872
1970), the Austrian philosopher Ludwig Wittgenstein (1889
1951), combined with a rejection of Georg Wilhelm Friedrich Hegel (1770
1831) and Martin Heidegger’s (1889
1976) German Idealism (which is explored in Chapter 5). Bertrand Russell was a British philosopher who had an eventful career marked by controversy. This included dismissals from Trinity College, Cambridge, and City College, New York, numerous anti-war protest activities and two spells of imprisonment. He was also awarded a Nobel Prize for literature in 1950. He was a founder of what is known as analytical philosophy, a tradition that emphasises the use of logic to clarify issues in philosophy. Russell suggested that the terminology of mathematics constituted a subset of the language of logic (an idea supported by Gottlob Fege; 1848
1925) and held that worthwhile knowledge could only be analysed in logical terms. He proposed a theory of hierarchical types, in logical language that has now become a fundamental both in logic and computer science. This was devised as a solution to contradictions Russell found in logical sets or classes (known as Russell’s paradox). The key issue he targeted was that if we divide things into sets (or classes) by some logical criteria we find that some sets seem to be members of themselves, and others not. For example, if a simple logical problem is created where there are two classes of men in a town: those who the barber shaves and those who shave themselves (and note a rule that the barber only shaves those men who don’t shave themselves), a paradox arises. This is the question; does the barber shave himself? If so, he is of the class of men who the barber shaves, but he is also of the class of men who shave themselves. If he shaves himself, this contradicts the rule that the barber only shaves men who don’t shave themselves. Logically, this is the paradox that the set of all sets that are not members of themselves cannot exist. This is logically similar to trying to determine the truth of the statement; the next sentence is true: the previous sentence is false. This observation challenged foundational mathematical theory. Russell’s solution was to create a hierarchy of types, then assigning each entity into a

Modern Science and Nursing

37

labelled type (his theory of types). Objects of a given type were built exclusively from objects of preceding types (lower in the hierarchy), therefore, preventing logical loops, for example, a top-level set of men who shave, then men who shave themselves, and then barbers would be one such hierarchy. Russell also later put forward another important contribution to the philosophy of science with his celestial/cosmic teapot theory. This idea makes the point that the burden of proof should lie with the person making a claim, rather than upon others to disprove it. In 1952, he wrote that if he claimed a teapot was orbiting the sun somewhere between the Earth and Mars, it would be ridiculous to expect others not to doubt him on the grounds they could not prove him wrong. This is another important aspect of modern scientific thinking in that we can’t easily prove a negative. It involves the notion that an absence of evidence is not the same as evidence of absence. Evidence of absence is evidence (of any kind) to suggest something is missing or that it does not exist. This is particularly hard to come by in the real world. The logician Irving Copi suggested in 1953 that: In some circumstances it can be safely assumed that if a certain event had occurred, evidence of it could be discovered by qualified investigators. In such circumstances it is perfectly reasonable to take the absence of proof of its occurrence as positive proof of its non-occurrence. (Copi, Cohen, & McMahon, 2014) However, this relies on an inductive argument that (as noted in Chapter 2) is based on a premise that as we have never observed this to happen, it will not happen. The difference between evidence that something is absent (e.g. an observation that suggests there are no dinosaurs on Earth today) and a simple absence of evidence (e.g. no careful research has been done) must be nuanced. Otherwise, it results in the argument from ignorance (Fallacy of Ad-ignorantiam: see Chapter 7). Scientists will frequently argue whether an experiment’s result should be considered evidence of absence of a phenomenon, or if it remains absence of evidence. The debate is around whether a study would have detected the phenomenon of interest, if it was there. In practical terms, there can be multiple claims within a debate, but in science, whoever makes a claim carries the burden of proof, regardless of positive or negative content in the claim. Carl Sagen refers to this when he wrote ‘Your inability to invalidate my hypothesis is not at all the same thing as proving it true’ (Sagen, 1997). Ludwig Wittgenstein was another fascinating character who influenced the logical positivist movement. He was born into a wealthy family, lost three brothers by suicide and gave away most of his fortune. He also attended the same school (the Realschule in Linz, Austria) at the same time as Adolf Hitler, and although they probably met, there is no evidence they had any relationship. Wittgenstein’s 75-page text; Tractatus Logico-Philosophicus was published in 1921. He purportedly conceived and wrote down the seminal ideas expressed in it whilst he was under fire in the trenches during his service in the Austro-Hungarian Army on the

38

Empirical Nursing: The Art of Evidence-based Care

Russian front during World War I. Tractatus explored the relationship of language and reality. The most influential idea expressed in it was that we should define the world in terms of facts that we know, rather than start with objects as the basis for reality. He argued against the theory of types, and a key idea was that language limits how well we can define reality because language is not factual truth; it is only our best attempt to state it. Our language limits our ability to understand the world. He viewed mathematics as a more truthful depiction of reality and concluded that philosophy was fairly worthless, ‘Whereof one cannot speak, thereof one must be silent’ (Wittgenstein, 1921). In other words, as philosophical propositions (i.e. conceptual statements that can be considered either true or false) merely express ideas about the world; these propositions in themselves are fairly worthless and therefore philosophical argument a waste of time. Although Tractatus was the only book published in his lifetime, Wittgenstein wrote a second book Philosophical Investigations that was published posthumously (Wittgenstein, 1953). In this he revised many of his earlier arguments, concluding that conceptual confusions surrounding language were the cause of most major philosophical problems, rather than the actual linguistic expression of them. The key proponents of logical positivism were two groups of philosophers who became known respectively as the Vienna Circle; meeting at the Café Central in Vienna and chaired by Moritz Schlick (1882
1936) and Hans Recherbach’s (1891
1953) Berlin circle, whose members included Carl Gustav Hempel (1905
1997). They sought the unification of all science and the development of a common language of science. Their beliefs rejected metaphysics and ontology as spurious constructs having no meaning. They proposed a view of science based on language involving two key principles, the Analytic-synthetic distinction and verifiability. (1) Analytic-synthetic Distinction Theory The ideas here were that propositions could be either analytic or synthetic (after Kant). Analytic sentences can be seen to be true (or false) in themselves. Examples would include the following: all ill people are unwell, or all ophthalmologists are doctors. Synthetic propositions, on the other hand, are statements that require reference to the world to demonstrate they are truthful or not. For example, all ill people have an infection or anyone with a PhD is intelligent. These synthetic statements require reference to empirical evidence to demonstrate their truth or otherwise. As explored earlier, rationalists such as René Descartes would tend to regard analytic statements as the only form of true knowledge. However, analytic statements may be considered a priori, as they require no reference to the outside world, only our conceptualization of it. That is, they are based on our symbolic interpretation of it in language. According to logical positivism, there are only two sources of knowledge: logical reasoning and empirical experience. The former is analytic and a priori, while the latter is synthetic and a posteriori. Therefore, synthetic a

Modern Science and Nursing

39

priori knowledge does not exist. The Vienna Circle of logical positivists rejected a priori analytic statements as holding no value in understanding the world and maintained that only synthetic propositions were useful for making meaningful statements. (2) Verifiability Theory This holds that the meaning of a synthetic proposition and its value as knowledge can be determined by its verification; that is, a valid statement is verifiable in that we could in principle carry out a procedure that would yield the answer that the claim in question was true or false. Essentially, a synthetic proposition was seen as meaningful only insofar of what (theoretically possible) empirical observations could verify or falsify the proposition. Verifiability is then, a theoretical position on the nature of truth. However, philosophically, it is rather a problematic construct, as what is acceptable for verification remains contentious. Generally, verifiability was interpreted by logical positivists to be that the only meaningful propositions were those that could be translated as reports of direct observation. In their attempts to produce a universal method of science, the logical positivists produced what is known as the Deductive Nomological Model (D-N model) of scientific enquiry (see Chapter 4), also known as the Covering Law Model. What this actually consists of is a set of beliefs that support the view that universal laws can be made about facts if they can be based on deductively demonstrated synthetic statements that meet the criteria of verifiability. For example, absolute affirmative statements such as all humans are warm-blooded animals. In this way, these laws are predictive and arise from deductive arguments that explain the phenomenon. Logical positivists would generally maintain that anyone constructing propositions that could not be translated as products of direct observation of the real world was simply talking nonsense! Hempel later demonstrated that the verifiability criterion was unsustainable since it really restricted empirical knowledge to the analysis of sentences and their deductive consequences. He suggested that if we consider statements about the unobservable as meaningless, then many claims about scientific laws and theories could also be considered similarly (Hempel, 1950). Following the dissolution of the Vienna and Berlin circles, due to the migration of many members with the rise of National Socialism in Germany, and the death of Schlick in 1936 at the hands of a Nazi, the logical positivists disbanded. However, logical positivism remained a leading school in the philosophy of science until the 1950s. Criticism of verifiability, and its basic tenets, especially by Karl Popper (1902
1994) and Willard Van Orman Quine (1908
2000), ultimately led to its demise. Nevertheless, the general principles underlying empirical verifiability have been refined by following thinkers, most notably by Karl Popper with his principle of falsifiability, and the idea of striving to construct meaningful hypotheses that can be demonstrated true or false. These remain an important aspect of modern healthcare science today.

40

Empirical Nursing: The Art of Evidence-based Care

Interestingly, much of the criticism of health science by contemporary nursing theorists has focused on characterizing healthcare science, the ongoing enactment of positivist thinking (Frisch & Potter, 2016, p. 112). However, this does represent something of a straw-man argument. Modern science has moved far from these early ideas, which came to their peak of influence in the 1930s and 1940s, and many of their early proponents of positivism also changed their views as time progressed.

Pragmatism Another key aspect of modern scientific thinking is pragmatism. Pragmatism was a philosophical tradition that originated in the United States around 1870 and its expressions have developed in distinctly different schools of thought, making study and use of the term complex.

Classical Pragmatism Charles Sanders Peirce (1839
1914) was an American scientist and philosopher who originally used the term pragmatism, to suggest that something is true only insofar as it works and considered practical consequences or real effects to be vital components of both meaning and truth. He asserted that the scientific method was best suited to theoretical enquiry, but that any theory that proves itself more successful in predicting and controlling our world than others should be considered to be nearer the truth and therefore more valuable. Peirce is recognised as the originator of pragmatism, arguing that any theory that proved itself more successful in predicting and controlling our world than others could be considered to be more valuable and nearer the truth (Peirce, 1878). For example, the theory of the heart as a pump in a cardio-vascular system proved more effective in treating illness, than the early Egyptian belief that the heart (rather than the brain) was the source of human wisdom. This pragmatic view focused on the outcomes of theories and empirical research as the key to their practical value as knowledge. The American physician William James (1842
1910) also identified with the notion of pragmatism as a useful framework for action, but developed a somewhat different interpretation (James, 1906, 1907). James suggested that the value of any truth was dependent upon its use to the person who held it and that an understanding of the world and experience could never be entirely objective. James saw truths emerge as being subjectively interpreted in the mind of the observer and suggested the very act of observation would affect the outcome of any empirical approach to truth, as the mind, experience and nature are inseparable. James also acknowledged the value of experimentation but suggested it could only be used as an approximate arbiter of truth. Although he acknowledged Pierce’s conceptualization, James emphasised the context of enquiry as an important influence in the conduct of scientific work and argued that the value of any truth was dependent upon its use to the person who held it (James, 1906). The appeal of Jamesian pragmatism, incorporating ideas of plurality and

Modern Science and Nursing

41

diversity, has been used to support postmodern approaches to nursing. It has even been suggested that pragmatism is incongruent with empirical science and should be adopted by nurses as it represents a more humanistic approach to enquiry, as opposed to empirical science (McCready, 2010; Rodriguez & Kotarba, 2009). This also parallels the divergence between the cultures of science and nursing. However, there remains debate as to the interpretation of James’s views on pragmatism. His writings support the ideas of a pluralistic universe, and speak of truth in relativistic terms, although he also indicated support for knowledge as existing independently of the thinker’s mind (i.e. epistemological realism). Peirce’s work indicates he believed in irrefutable truths and in the existence of infinity, as opposed to James who would argue these to be cognitive manifestations. Another view of pragmatism (and one that is probably more congruent with modern science) is that of the American philosopher, John Dewey (1859
1952). Dewey viewed knowledge as arising from an active adaptation of humans to their environment, and in a state of flux rather than fixed and immutable. He was not as pluralist or relativist in his views as James and suggested that ‘Value was not a function not of whim, nor purely of social construction’ (Dewey, 1925). Dewey held that ideas were simply instruments, or tools, that humans used to make sense of the world and also supported the importance of experimental enquiry. He argued the value of practical knowledge resulted from establishing associations between events, with experimentation by the introduction of specific variations to determine what differences occur. This is a fundamental principle in modern post-positivist science and the value of experimental enquiry is clear. For example, experimental enquiry can be used to discern how a healthy behaviour, such as non-smoking, can be promoted in relation to variations in specific interventions and for specific target groups. Dewey suggested an empirically based theory of knowledge with a pragmatic philosophy, naming this philosophy ‘instrumentalism’. This is the view that a scientific theory is a useful instrument in understanding the world and that a concept or theory should be evaluated by how effectively it explains and predicts phenomena, rather than how accurately it describes an objective reality. This pragmatic approach clearly acknowledges the changing state of human knowledge and the limitations of cognitive processes in understanding the world and would seem to give us a more substantive basis for practice and support nursing as a pragmatic profession underpinned by empirical science. Another early adopter of these ideas was Jane Addams (1860
1935), a social reformer. However, Addams’ main role in the development of pragmatism was focused on developing a social philosophy infused with a class and gender consciousness. Addams represents an early incarnation of the feminist pragmatist movement, but in terms of the generation of knowledge her conceptions were more aligned with James’ ideas in that the social setting of enquiry affected the nature of knowledge and its value to particular social groups (Elshtain, 2002). Addams rejected the possibility that a solution to a social issue could be developed by one group of people and applied to another.

42

Empirical Nursing: The Art of Evidence-based Care

These early pragmatist thinkers have become known as the classical pragmatists (Hookway, 2013). However, like many philosophers, their ideas evolved over time. Peirce remained unhappy with both his early expressions and the developments made on them by fellow pragmatists. This led him, in later life, to refine his own earlier account and rename it pragmaticism in order to distinguish it from other more relativistic versions.

Neo-pragmatism The emergence of a newer form of pragmatism arose in the 1990s, and although this neo-pragmatism has origins in the early work of James and Addams, it is more aligned with alternative epistemologies to empirical enquiry. Therefore, it is discussed in more detail in Chapter 5.

Post-positivism and Karl Popper’s Critical Rationalism Karl Popper was critical of logical positivist ideas, even though he had been a student of Hans Hahn (1879
1934), one of the founders of the Vienna Circle. Popper wanted to restate the underlying ideas of the scientific method they supported and developed a philosophical approach to science that he called ‘Critical Rationalism’. He strongly rejected Berkley, Hume and Locke’s, classical empiricism and the observational intuitivist approach. To recap, this was the approach that suggests we generate scientific knowledge by observing phenomena, and then generalising these observations into statements. A simple example of this would be: this cat has a tail, that cat has a tail, every cat I have ever seen has a tail; therefore, all cats have tails. Popper recognised the problem of induction, specifically that no number of positive instances can confirm a phenomenon to be true, only probably so. For example, one cat with no tail would disprove our earlier example and change the game. In effect, Popper noted that inductive science, like rationalism and logical positivism, suppose some form of inference based on reasoning to support propositions. Additionally, Popper questioned the validity of inductive reasoning as a useful form of scientific logical reasoning. He highlighted two problems; firstly, the psychological problem exists in that scientists tend to find what they expect to (a form of confirmation bias). Secondly, there is a logical problem in how we make the cognitive leap from our own personal experience to what we have not experienced.

Falsifiability Popper published his book Logik der Forschung (The Logic of Scientific Discovery) in 1934. In it, he argued that the Logical positivists’ criterion of verifiability was not suitable for scientific enquiry (Popper, 2003). He suggested it should instead be replaced by a criterion of falsifiability, which he saw as a practical and more deductively sound alternative. Whilst the logical positivists used

Modern Science and Nursing

43

the demarcation between science and non-science as experience and observability to verify phenomena, Popper argued this approach to verification would lead to few new discoveries and simply confirm the pre-existing beliefs of scientists. Instead, he proposed a principle of falsifiability to separate science from metaphysics. Simply put, his falsifiability principle stated that for any hypothesis to be credible, it must be inherently possible to disprove it before it can become accepted as a scientific hypothesis or theory (also known as naïve falsifiability). For example, the hypothesis that penicillin will kill streptococcal bacteria is easily testable and falsifiable, as a single incidence of the antibiotic failing to do so would make the hypothesis questionable, and it can be easily tested in deductive experiments and shown to be untrue. This is a scientific hypothesis, and an example of a hypothesis worthy of investigation in Popper’s view. However, the hypothesis intercessory prayer will speed up healing is not a scientific hypothesis in Popper’s terms, as it is impossible to falsify. There is no empirical way to ascertain if it is false. Any experiment designed to do so would be meaningless as we would have to know to which deity prayer was being directed, what sort of prayer, what sort of healing was being prayed for, who was doing the praying etc. No matter how many negative incidences there were, these could easily be ascribed to a variety of confounding factors, and no volume of negative results could ever demonstrate the hypothesis was false. Another example would be there are bio-field energies we are unable to perceive or measure controlling our health. This is not to say these propositions may not be true, but Popper argued that such forms are not hypotheses that can be tested by scientific means. Popper argued for testability and suggested falsifiability was a much better alternative because it did not present the problems inherent in verifying an inductive inference. It would also allow statements from the physical sciences that would not have satisfied the strict verification criterion, the law of thermodynamics, for example. Unlike the positivists, Popper did not claim that metaphysical statements were meaningless, but noted that a statement that was currently deemed metaphysical and unfalsifiable, could at a later date (with an identified and empirical theoretical framework, and observational technologies established) become falsifiable and thus become scientific. For example, the ancient Greeks’ notion of the atom was unfalsifiable at the time but is not so now. Identifying the cause of a phenomenon is not always possible at the time it is explored, as we may simply not know enough about it. Another example would be prehistoric people trying to explain a seizure without an understanding of neurology. Therefore, inductive generalisations based on instances may not be any help until the theoretical framework and apparatus is developed in which a hypothesis becomes testable. This notion has also been illustrated by the science fiction author, Arthur C. Clarke, who noted that ‘Any sufficiently advanced technology is indistinguishable from magic’ (Clarke, 1973), and has been identified as a criticism of Poppers falsification principle in its practical application.

44

Empirical Nursing: The Art of Evidence-based Care

Popper’s Critical Rationalism Critical rationalism is the philosophy developed by Karl Popper during the middle of the twentieth century. His approach was based on the idea that society has developed through a process of solving problems using trial and error. Popper saw the key driving force for science as the systematic development of this problem solving and that this was the definitive trait of humanity in both social and political organisation, as well as in science. It was this key insight that unified and integrated the broad spectrum of his thought (Thornton, 2009). He refined the hypothetico-deductive method to fit with his ideas and to include testability in the sequence: His scientific method may be characterised with a more iterative deductive approach and is as follows: (1) Characterisation and observation: Define, qualify or quantify the phenomenon being investigated. (2) Deduce a testable hypothesis that might explain the observations (using inductive/abductive/deductive reasoning and the principle of falsifiability). (3) Prediction: Produce a specific prediction of outcome from the hypothesis, using deductive reasoning (if A then B). (4) Perform experiments or observations to see if any of the predicted outcomes fail: • If any predicted outcomes fail, the hypothesis is demonstrated false (since deductively if A implies B, then Not B implies Not A). If so, revise the hypothesis and go back to step 2. • If the predicted outcomes are confirmed, the hypothesis is not proved, but is said to be consistent with known data. Popper’s key criticism of the scientific method was to negate the role of inductive reasoning in the process. He promoted deductive testability through inclusion of his falsifiability criteria. Most simply, he argued hypotheses could not be conclusively established as correct until the consequences that were deduced from them were verified through additional observations and experiments. He argued inferential reasoning should be used as the principle for testing and critiquing knowledge, but not for proof to verify or support it. All claims to knowledge, scientific or otherwise, should be deductively analysed and critiqued. Popper denied that science needs rely on inductive reasoning and even questioned that inductive reasoning actually existed! Nonetheless, Popper retained support of empiricism in his philosophy, and acknowledged that the scientific method does involve an appeal to experience. However, unlike the traditional empiricists, he held that experience should not determine theory. In other words, we should not argue or infer from observation to theory, but the other way around, as the former merely shows which theories are false, rather than which theories are true. Popper’s critical rationalism supported the principle of an objective reality and that knowledge is objective (and not relative) in the sense it is embodied in the world and not reducible to what individual humans know. He proposed a

Modern Science and Nursing

45

cosmology of three states of the world, firstly the physical world, secondly the world of the human mind and thirdly the body of human knowledge manifested in media (such as books and records).

Popper’s Scientific Legacy Overall, Popper’s principle of falsifiability is generally accepted as useful in the scientific community and in hypothesis formation. Although, a review of recent research journals will identify it is not extensively used amongst healthcare disciplines. This post-positivist (also described as post-empiricist) approach holds that human knowledge is not based on unchallengeable foundations or truths, but rather upon human conjecture. As human knowledge is unavoidably conjectural, the assertion of (falsifiable) conjectures is justified, but these can be adapted or withdrawn in the light of further investigation and new knowledge. However, post-positivism is not a form of relativism, and retains the notion of universals. A number of philosophers have since criticised Popper’s views on inductive reasoning and other aspects of his critical rationalism. It is now generally accepted that scientific induction can lead to worthwhile conclusions that have been established to such a degree that we can comfortably assume they are true. Stephen J. Gould (1941
2002) exemplifies this notion nicely in this quote: ‘In science, fact can only mean, confirmed to such a degree that it would be perverse to withhold provisional assent. I suppose that apples might start to rise tomorrow, but the possibility does not merit equal time in the physics classroom’ (Gould, 1981). Alan Sokal and Jean Brickmont also criticised falsification in their book Fashionable Nonsense (1998) by noting that science does not operate in this way. They noted that ‘When a theory successfully withstands an attempt at falsification, a scientist will, quite naturally, consider the theory to be partially confirmed and will accord it a greater likelihood or a higher subjective probability’. They also argued that falsifiability can’t distinguish between astrology and astronomy, as both could be used for the basis of falsifiable hypotheses to make predictions that are incorrect (even though the probability of correct predictions would likely be higher in the latter). Another important criticism is that science does not simply consider one hypothesis individually at a time and that the scientific community evaluates collections of theories together over time (sometimes is called a bundle of hypotheses), which is known as the Duhem
Quine thesis (Gillies, 1998). This proposition by Pierre Duhem and Willard Van Orman Quine suggests very convincingly that we cannot test a single hypothesis in isolation and that falsifying one has implications for others. For example, when the orbit of the planet Uranus was found not to match the predictions of Newton’s laws, the hypothesis on the number of planets in the solar system was challenged (rather than Newtonian physics), eventually leading to the discovery of the planet Neptune. Popper’s legacy for modern scientific thinking remains important. His thinking helped to overthrow the dominance of the logical positivists as the conventional

46

Empirical Nursing: The Art of Evidence-based Care

wisdom of the time, and his principle of falsification, and refinements of the hypothetico-deductive method are still used in scientific research today. Popper rejected the positivist doctrine that empirical observations were infallible, in view of the fact that they were themselves theory-laden. He sought to make the conclusions of science stronger than pseudoscience or non-science, insofar as they must survive a very vigorous selection method. Sophisticated methodological falsification was proposed as a way in which scientists ought to behave, the objective being to establish a process whereby theories become less bad. Interestingly, Popper held the view that science was an evolutionary process, as indicated by his ideas that propositions might become falsifiable in future and that as we reject falsified hypotheses we move towards new theories and move science forwards. In this way his approach to a modern philosophy of science is complementary to that of Thomas Kuhn (1922
1996), though both criticised each other’s ideas, and Popper’s work is usually presented as contradictory to Kuhn’s.

Thomas Kuhn: Scientific Evolution and Revolutions In 1962 Thomas Kuhn famously suggested that the history of science could best be described in terms of competing paradigms, or structures of knowledge based upon the state of accepted understanding of phenomenon at that time (Kuhn, 1996). Kuhn suggested science could be seen in terms of competing conceptual systems battling for supremacy in the context of the intellectual, cultural, economic and political themes of the day. In other words, science was not value free and influenced by social and cultural norms as much as any other human endeavour, scientific truth being largely determined by authority. The classic example of one of these revolutions is the changing view of our position in the universe from the Ptolemaic geocentric to Copernican heliocentric model. Ptolemy lived in Rome around 100 CE and his model of the universe was geocentric and had the Earth at the centre. This was eminently plausible given observations of the night sky and accepted as a truth. His model itself was a refinement of previous models developed by Greek astronomers, but could very accurately explain the motions of heavenly bodies, and it was not seriously challenged for over 1,300 years. At that time, astronomy was mainly a technical pursuit focused on predicting where heavenly bodies would appear in the night sky to aid navigation, and notions of the structure of the universe and our solar system were firmly in the purview of the natural philosophers such as the Greek philosopher Aristotle (384
322 BCE). To put this in context of human civilisation at the time the geocentric model was the conventionally accepted wisdom by religious and philosophical authorities, due to experience, interpretation of religious texts and the qualitative ideas of Aristotle. However, in 1543 Copernicus, a Polish mathematician and astronomer, formally suggested a model where the sun was the centre of our universe and produced better predictions of the movements of the planets. This was not only a radical idea at the time, but also unpopular with both academics and religious scholars.

Modern Science and Nursing

47

In 1587, Tycho Brahe, the Danish astronomer, also predicted an alternative to the Ptolemaic view, but like Copernicus, these ideas were generally ignored or denounced until 1610 when the Italian astronomer Galileo (1564-1642), refined the telescope and made observations that confirmed some Copernican ideas. Galileo’s work was not widely accepted either and led to controversy with theologists, astronomers and philosophers, culminating in his well-documented trial and sentencing by the Roman Inquisition in 1633 on suspicion of heresy (although unlike the popular myth, he didn’t actually go to jail). It wasn’t really until 1838 that German mathematician Fredrich Wilhelm Bessel gave an apparent proof of the heliocentric hypothesis and it became widely accepted. Interestingly, a fairly recent poll reported one third of Russians polled believe the sun revolves around the Earth (de Carbonnel, 2011) and similar results have been reported in other countries (Crabtree, 2006), so it would seem Copernicus’ work is still not finished. Initially, Kuhn’s view represented a revolutionary contrast to the previously established view of the history of science as a value-free development involving the triumph of truthful theories over falsehoods. The acceptance of his view of science evolving with leaps of knowledge and in the context of societal values, rather than progressing in a linear and continuous fashion has also been used as a basis for the criticism of science by some contemporary academics (further explored in Chapter 5). However, Kuhn was not a relativist and believed in the scientific process and value of empirical evidence. Science can be seen to proceed in an evolutionary way that is not at odds with Kuhn’s ideas of scientific revolutions. In scientific work as anomalous results build up, he believed science reaches a crisis, at which point a new paradigm of understanding results subsuming the old results and the anomalous results into one new accepted framework. This can happen gradually or suddenly with a new dominant theoretical framework gaining acceptance. This is a useful position for us to explore in the context of using best evidence to inform practice. A useful example is that of the role of Helicobacter Pylori in gastric ulceration. When the Australian scientists J. Robin Warren and Barry Marshall identified the new bacteria H. pylori as a cause of peptic ulcers in 1982, it completely transformed our understanding of the microbiology and pathology of the human stomach. Before this, the accepted medical paradigm was that stomach ulcers occurred as excess acid damaged the gastric mucosa and treatment should be aimed at reducing or neutralising that acid; with surgical techniques being most effective (Lynch, 2005). Initially, their new idea was not widely accepted and was widely criticised. I can recall, as a student nurse, asking the consultant on a surgical unit about the relevance of this new bacteria which I had just read about, only to be swiftly reprimanded for heeding such nonsense. However, as further research evidence arose from a range of repeat studies, results confirmed a link, and the role of H. pylori in peptic ulcer disease was firmly established. This revolutionized the treatment of gastric ulcers and is a good example of a revolutionary paradigm shift in medicine and illustrates the potential for EBP to influence change.

48

Empirical Nursing: The Art of Evidence-based Care

Kuhn was also a critic of Popper’s falsifiability, arguing that the methodology of falsifiability would make science impossible as no theory ever completely solves all the puzzles with which it is confronted at a specific time. This also reflected the concerns the Duhem
Quine thesis. Although a collection of theories (the theory and its background assumptions) may be falsified, the Duhem
Quine thesis and Kuhn suggest it is impossible to isolate a single hypothesis in the package to test for falsifiability. This is akin to the houseof-cards argument in that, if one hypothesis is removed the whole structure collapses; hence, falsifiability is not a viable principle for science. Imre Lakatos (1922
1974) was a student of Popper who explored this further and attempted to reconcile Kuhn’s ideas on falsification with Popper’s position, by arguing that science as a whole progress by the falsification of research programs, rather than of specific individual hypotheses of naïve falsification. Overall, Kuhn’s ideas seriously challenged the dogmatic acceptance of scientific rationale and have led to science becoming more reflexive. One of the key advantages of modern post-positivist science as a way of understanding the world is that the process is self-critical, and the conventional wisdom is consistently challenged. Modern science is pragmatic in that it presents ideas for peer review and openly invites opportunity for anyone to challenge the dominant theory if they can come up with alternative results or better explanations, supported by evidence.

The Revolution in Physics and Its Impact on Scientific Philosophy The early twentieth century brought a revolution in the science of physics. The theories of Newtonian physics that had lasted for over 200 years were demonstrated as erroneous in certain circumstances by the physicists Max Planck (1858
1957), Albert Einstein (1879
1955), Niels Bohr (1885
1962) and Luis de Broglie (1892
1987) and others. New ideas of quanta (the smallest amount of any physical entity involved in an interaction; for example, a photon is a single quantum of light) and the wave-particle duality of matter arose to explain these phenomena. In 1925, Werner Heisenberg (1901
1976) and Edwin Schrödinger (1887
1961) developed these ideas further into the new theoretical paradigm of quantum mechanics. Quantum mechanics demonstrated that Newton’s laws of motion did not work at atomic and sub-atomic scales. The mathematical principles of quantum mechanics are highly abstract and its principles counter-intuitive, invoking probabilities to explain phenomena, uncertainty in the exact state of a system at any given time, the idea that the very observation of a phenomenon can change the observed outcome and the concept of entanglement (where disparate particles can affect each other’s state). Physicists continue to make discoveries in this challenging area but have yet to reconcile all of the observed events with a theoretical framework that explains them all.

Modern Science and Nursing

49

The most widely accepted interpretation of quantum phenomena is known as the Copenhagen Interpretation (after Niels Bohr’s Institute in Copenhagen where the work was done). This posits that quantum mechanics does not yield a description of an objective reality and deals only with probabilities of observing, or measuring, various aspects of energy quanta, entities which fit neither the classical ideas of particles or waves. Indeed, as Richard Feynman noted, ‘I think I can safely say nobody understands quantum mechanics!’ (Feynman, 1967). Nevertheless, even though the exact methods of how quantum mechanics works remains unclear, the ideas have been demonstrated as correct by many experiments since they were proposed. Quantum phenomena are now practically used in technologies from ultraprecise atomic clocks, magnetic resonance imaging, lasers, computers and encryption technologies and even the USB data stick that many readers will own. Not only did the arrival of quantum mechanics upset the established Newtonian physics paradigm, but also in 1915 Einstein proposed his theory of general relativity that postulated that a fixed background of space and time (something Newtonian physics requires) did not exist, and outlined a new geometric theory of gravity. Again, the theory has stood up to all observational testing, and is used in modern applications such as global positioning system (GPS) satellites. Curiously, the theories of general relativity and quantum mechanics remain inconsistent with each other, presenting several paradoxes. The consequences of this resulting in some serious questioning of scientific philosophy. Best known is probably the Schrödinger’s cat paradox, which concerns the problems inherent in scaling up the quantum uncertainty principle. It is proposed a (theoretical) cat is put in a sealed box and its life dependent upon the state of a sub-atomic particle, which can trigger the release of a poisonous gas or not depending on its state). As the state of the cat has been entangled with the state of the particle during the experiment, Schrödinger argues that according to quantum mechanics theory the cat becomes in a super-state of being neither alive nor dead, until the box is opened up to check. Schrödinger noted, it is clearly not possible for the cat to be both alive and dead at the same time. The Copenhagen interpretation argues once the cat is observed, there is a 50% chance it will be dead, and 50% chance it will be alive. However, it does not say anything about the state of the cat before this observation. Another well-known paradox is the Einstein
Podolsky
Rosen (EPR) Paradox. Here, the entanglement principle is challenged by the theories of special (and general) relativity. Entangled particles are particles that have interacted physically and then become separated. The result is the pair of particles that have the same characteristics (momentum, spin, polarisation etc.), and their shared state is indefinite, until it is measured. The measurement of one particle affects the other particle simultaneously, even though they may be physically separated by a large distance. This behaviour has been demonstrated experimentally and is generally accepted by modern physicists. The paradox identified is that, according to general (and special) relativity, no information or entity can travel at or faster than the speed of light, and so

50

Empirical Nursing: The Art of Evidence-based Care

one particle should not be able to simultaneously influence another. Again, the Copenhagen interpretation is inconsistent with this. Many philosophers and scientists objected to the Copenhagen interpretation of quantum mechanics, arguing it is non-deterministic (see the following chapter) and that it includes undefined measurement processes that interpret probability functions as non-probabilistic measurements. These paradoxes and others have led to a fevered activity in theoretical physics seeking methods of unifying the two theories of quantum mechanics and general relativity. The latest of which includes string and superstring theory, that suggests sub-atomic particles are actually one-dimensional oscillating lines. This explanation requires acceptance of additional unobservable dimensions to the universe for this explanation. This has been more recently extended to M-theory that suggests there are 11 dimensions. Both are argued to be (currently) untestable. Although counter-intuitive, the principles of multi-dimensions have been around in mathematics for over a century and frequently used in computer science. Consider, a point in space and time can be described with four reference points a), b), c) and d), but we can easily add further reference points to describe other dimensional attributes; a), b), c), d), e), f) etc. In all, this century represented a great upheaval of established scientific thought in the field, and the era of so-called big science, requiring massive budgets and laboratories in order to test theories and move our knowledge of the physical world forward. Much of this became state sponsored, as the political advantages of big science were quickly identified (e.g. the atomic bomb). The philosophical implications of this work continue to resound through the scientific community. One of the early critics of the Copenhagen Interpretation was Albert Einstein, probably best known as the most famous physicist of the twentieth century, but he is less well known for his contributions to twentieth-century philosophy of science. The young Einstein was influenced by the writings of Hume; the physicists Ernst Mach (1838
1916), the originator of the Mach number, and Henri Poincare (1854
1912), and was a supporter of scientists exploring scientific philosophy to better understand their work. Einstein cautioned that the Copenhagen interpretation would unlikely give a solid basis for physics. He acknowledged that it was impossible to separate the real world from our sensory impression of it (Einstein, 1936). Conversely, he also didn’t like the philosophical distinctions of realism (reality exists independently) and relativism (points of view have no absolute, and all are relative) and suggested they were rather meaningless. Einstein proposed that real was a pretty empty and meaningless category ‘Whose monstrous importance lies only in the fact that I can do certain things in it but not others’ (Einstein, 1936). However, what initially seems paradoxical is, he was also an early supporter of positivism and sought to prove the real existence of atoms in his early work. Einstein identified that physics and science generally were in a state of flux and continuing to evolve and also seem to have adopted a somewhat pragmatic stance in his writings on scientific philosophy. Einstein thought the basis for the future of physical science did not lie in an inductive empirical methodology, but in the use of creativity and free-invention,

Modern Science and Nursing

51

and his position implies support for pragmatic science: ‘The justification (truth content) of the system rests in the proof of usefulness of the resulting theorems on the basis of sense experiences, where the relations of the latter to the former can only be comprehended intuitively’ (Einstein, 1936). Overall, the theoretical physicists and particularly Albert Einstein and Richard Feynman helped to legitimise the exploration of the philosophy of science by analysing and challenging conventional wisdom in their field, an area that has radically reshaped our understanding of the world and our place in it. Remarkably, the late eminent contemporary theoretical physicist, Stephen Hawking, proposed in his recent book, The Grand Design (2010) that philosophy as practised nowadays was a waste of time and philosophers a waste of space (Hawking & Mlodinow, 2010). Wittgenstein would have been in agreement! Indeed, he went as far as to suggest that philosophy is ‘dead’ since it hasn’t kept up with the latest developments in science. However, the philosophical ideas of causality and those of physical science seem to have moved closer together over the last century, but he does make a good point with regard to the postmodern trends towards relativism and alternatives to scientific thinking. These alternative approaches are explored in more detail in Chapter 5.

Summary By the end of the twentieth century, scientific progress and thinking had undergone a huge transformation. The successes of scientific thinking had led to enormous technical and social changes in every discipline and scientific thinking had evolved to reflect more pragmatic foundations. Philosophers had become characterised as (in so far as they have any influence) obstacles to progress through their interminable discussions on the nature of truth, knowledge and the problem of induction. Nevertheless, the influence of many of these ideas on modern scientific thought can be observed. Developments in social science have also acted as catalysts for change and resulted in scientific thinking that is far removed from the positivist tradition and provided a solid foundation for the EBP movement. The philosophical underpinning of scientific explanation is not value free and may not be as concrete as some might hope. But the modern scientific method is both reflexive and pragmatic, addressing new paradigms as they arise; although sometimes, admittedly, with a struggle. This contrasts with alternative epistemological stances that continue to be championed by some nursing academics, particularly in North America (Garrett, 2016) but have failed to provide a more effective way to deliver public health care. Faith-based positions on knowledge reject the opportunity for challenge by enquiry, revision of fundamental concepts and require an uncritical belief in fundamental principles; whilst relativist epistemologies (see Chapter 4) have failed to provide an effective way to discriminate bad ideas. Therefore, neither provides us with a sound basis for professional nursing in comparison to modern science.

52

Empirical Nursing: The Art of Evidence-based Care

Science has probably helped us achieve some of our most significant advances precisely by venturing beyond the furthest limits of evidential proof. In Chapter 5, we will explore some alternative epistemologies that some have argued as valid alternatives for a basis for nursing theory including more recent arguments philosophers have made about the nature of scientific explanations. However, first we will address one of scientific philosophies oldest problems, the nature of causality.

Key Points for Further Discussion • The basic question in reductionism is whether the properties, concepts, explanations, or methods from one scientific domain can be deduced from another domain of science. To what extent do you think this is true for nursing? • Do you think that Russell’s celestial teapot has relevance for modern nursing, or can an absence of evidence be used as an argument for evidence of absence? • Why do you think positivism is so-called? • What did Wittgenstein really mean by his famous quote: ‘whereof one cannot speak, thereof one must be silent?’ • Think of some examples of analytic and synthetic propositions in health science, and consider the practical implications of the difference? • How does Popper’s falsifiability differ from the logical positivist’s verifiability? • Popper and Kuhn’s ideas are often described as philosophically polarised positions. How would you summarise the similarities and differences in their thinking? • Why is scientific philosophy so entangled with physical science, and does this really have relevance for contemporary nursing? • Hawking suggests modern philosophy is a waste of time. Do you agree with him, and how far apart do you think modern science is from modern philosophy?

References Clarke, A. C. (1973). Profiles of the future: An inquiry into the limits of the possible. New York, NY: Harper & Row. Copi, I. M., Cohen, C., & McMahon, K. D. (2014). Introduction to logic. New York, NY: Routledge. Crabtree, S. (2006). New poll gauges Americans’ general knowledge levels. Retrieved from http://www.gallup.com/poll/3742/new-poll-gauges-americans-general-knowl edge-levels.aspx. Accessed on September 27, 2017. de Carbonnel, A. (2011). Third of Russians think sun spins round Earth: Poll. Reuters. Retrieved from http://uk.reuters.com/article/2011/02/11/science-us-russiapoll-education-science-idUKTRE71A5B920110211. Accessed on September 27, 2017. Dewey, J. (1925). Experience and nature. New York, NY: Dover. Durkheim, E. (1897). Suicide: A study in sociology. New York, NY: The Free Press. Durkheim, E. (1912). The elementary forms of the religious life. New York, NY: Dover.

Modern Science and Nursing

53

Einstein, A. (1936). Physics and reality. In R. Taylor (Ed.), The Einstein reader (pp. 52
99). New York, NY: Citadel, Kensington. Elshtain, J. B. (2002). The Jane Addams reader. New York, NY: Basic Books. Feynman, R. P. (1967). The character of physical law; the 1964 messenger lectures. Cambridge, MA: MIT Press. Frisch, N., & Potter, P. (2016). Nursing theory in holistic nursing practice. In B. Dossey, L. Keegan, D. Shields, M. Hemming, C. Barrere, & K. Avino (Eds.), Holistic nursing: A handbook for practice (7th ed., pp. 111–120). Burlington, MA: Jones and Bartlett. Garrett, B. M. (2016). New sophistry; self-deception in the nursing academy. Nursing Philosophy, 17(3), 182
193. Gillies, D. (1998). The Duhem thesis and the Quine thesis. In M. Curd & J. A. Cover (Eds.), Philosophy of Science: The central issues (pp. 302
319). New York, NY: Norton. Gould, S. J. (1981). Evolution as fact and theory. Discover Magazine, 2(5), 34–37. Hawking, S., & Mlodinow, L. (2010). The grand design: New answers to the ultimate questions of life. London: Bantam Press. Hempel, C. G. (1950). Problems and changes in the empiricist criterion of meaning. Revue Internationale De Philosophie, 41(11), 41
63. Hookway, C. (2013). Pragmatism. In E. N. Zalta (Ed.), The Stanford encyclopedia of Philosophy (Winter 2017 Edn). Retrieved from http://plato.stanford.edu/archives/ win2013/entries/pragmatism/. Accessed on January 23, 2018. James, W. (1906). What pragmatism means. Retrieved from http://www.marxists. org/reference/subject/philosophy/works/us/james.htm. Accessed on September 23, 2017. James, W. (1907). Pragmatism: An empirically based theory of knowledge, becoming associated with the newly emerging pragmatic philosophy. Retrieved from http:// www.gutenberg.org/cache/epub/5116/pg5116.html. Accessed on September 23, 2017. Klee, R. (1997). Introduction to the philosophy of science; cutting nature at its seams. New York, NY: Oxford University Press. Kuhn, T. (1996). The structure of scientific revolutions (3rd ed.). Chicago, IL: University of Chicago Press. Lynch, N. A. (2005). Helicobacter pylori and ulcers: A paradigm revised. Breakthroughs in Bioscience. Retrieved from http://www.faseb.org/Portals/0/ PDFs/opa/pylori.pdf. Accessed on October 29, 2017. McCready, J. S. (2010). Jamesian pragmatism: A framework for working towards unified diversity in nursing knowledge development. Nursing Philosophy, 11(3), 191
203. Morrison, K. (2006). Marx, Durkheim, Weber: Formations of modern social thought (2nd ed.). London: Sage. Peirce, C. S. (1878). How to make our ideas clear. Retrieved from: http://www.marxists.org/reference/subject/philosophy/works/us/peirce.htm. Accessed on October 29, 2017. Popper, K. R. (2003). Conjectures and refutations: The growth of scientific knowledge. London: Routledge. Robson, J. M. (Ed.). (1991). Collected works of John Stuart Mill. Toronto: University of Toronto Press. Retrieved from http://oll.libertyfund.org/?option=

54

Empirical Nursing: The Art of Evidence-based Care

com_staticxt&staticfile=show.php%3Fcollection=46&Itemid=27. Accessed on November 28, 2017. Rodriguez, T., & Kotarba, J. A. (2009). Postmodern philosophies of science: Pathways to nursing reality. Southern Online Journal of Nursing Research, 9(1). Sagen, C. (1997). The Demon-haunted World: Science as a candle in the dark. New York, NY: Ballantine Books, Random House. Sokal, A. D., & Bricmont, J. (1998). Fashionable nonsense: Postmodern intellectuals’ abuse of science. New York, NY: Picador USA. Thornton, S. (2009). Karl Popper: The Stanford encyclopedia of Philosophy (Summer 2017 edition). Zalta, E. N. (Ed.). Retrieved from http://plato.stanford. edu/entries/popper/#ImmLawConTre. Accessed on October 28, 2017. Wittgenstein, L. (1921). Tractatus logico-philosophicus. Oxford: Routledge & Keegan Paul.

Chapter 4

Scientific Determinism, Causality and Care Hitherto the principle of causality was universally accepted as an indispensable postulate of scientific research, but now we are told by some physicists that it must be thrown overboard. The fact that such an extraordinary opinion should be expressed in responsible scientific quarters is widely taken to be significant of the all-round unreliability of human knowledge. This indeed is a very serious situation. Max Planck (1858
1947)

Before moving on to look at the next phase in the nature of science and nursing theory, it is worthwhile exploring how we explain causality. This is not as straightforward as it at first might seem and remains an area of considerable debate. Somewhat surprisingly, no universally accepted scientific explanatory method of causality has arisen to date. Critics of post-positivist science frequently contest the validity of scientific enquiry, based upon arguments about scientific determinism, and the nature of causality. Therefore, a good grasp of the different explanations of causality, and problems with them can help in identifying poorly constructed arguments and in claims of evidence for the efficacy of various therapies.

Scientific Determinism and Causality In essence, there are two types of scientific knowledge. First, descriptive knowledge, explaining the respective properties that things exhibit (e.g. blood is hypertonic compared to water). Second, explanatory knowledge, explaining why phenomena occur (e.g. blood cells will lyse if placed in water as water is a hypotonic solution, and water molecules will rapidly move into the blood cells by osmosis). The important difference between these two types of knowledge is that when we have explanatory knowledge about a phenomenon, there are some fundamental aspects of it (facts) that can be used to imply what will happen in a given situation and make predictions. This is one of the key arguments of scientific determinism, a thesis that states, that for everything that happens, there are conditions such that nothing else could happen. For example, if an apple falls from a tree, it will fall downwards. Although there are many versions of this argument, determinism is usually taken to mean causal determinism. Causality seems straightforward on a common-sense level, and it is how we tend to learn and operate in our daily lives. We learn at an early age if we touch

56

Empirical Nursing: The Art of Evidence-based Care

something hot, it is painful, and generalise this to a range of hot objects. This is one of the central aspects of scientific enquiry and is why Einstein notes science is really an extension of everyday thinking. However, as we delve deeper, causality becomes more complex, and as we find out more and more about the nature of the universe with modern science, the linear link does not always work. As we saw in Chapter 2, determinism and causality remain problematic ideas for some philosophers as well. The French mathematician Pierre Simon Laplace (1749
1827) published the first articulation of scientific determinism during the enlightenment (Gillispie, 1997) and gave an interesting hypothetical argument. If we consider the possibility of an intellect large enough to know the position of every part of the universe and all of the forces that control nature, it should be possible for this entity to calculate future events completely, and nothing would be uncertain and the future would be just as transparent as the past to this being. This idea became known as Laplace’s Demon and concerns the central idea of determinism, specifically the belief that the past completely determines the future. Interestingly, this notion has many parallels with religious belief and was an idea that was extremely attractive to both scientists and philosophers alike. However, scientists now generally accept that nature is far too complex to be described in such simple deterministic ways. The second law of thermodynamics (differences in temperature, pressure, and chemical potential equilibrate over time) supports the irreversibility of events and, therefore, counters the idea of reversibility, which is needed for the demon (as it requires a relationship that works in both directions). Also, the computational power of the universe has been estimated as less than would be required for the demon to work. This, and the modern development of quantum mechanics, chaos theory and complexity theory have finally put Laplace’s Demon to rest (Cambel, 1993). Nevertheless, causality remains a fundamental requirement in scientific thinking. It involves describing and explaining things, and there have been different models proposed over the years as to how we can best do so. Hempel seems to have been the first to attempt to clearly differentiate different types of explanation and explore the complexities of statistical explanations (Salmon, 1989).

The Deductive-Nomological Model The Deductive-Nomological Model (or D-N Model) arose from work of the logical positivists. Nomological refers to the use of given laws, and this model supposes that deterministic events (events with a knowable outcome) explain phenomena. The explanation must result from the conclusion of a deductive argument, the premises of which must essentially include a law of nature (e.g. the first law of thermodynamics). In the D-N Model, a scientific explanation consists of two major elements: an explanandum (a sentence describing the phenomenon to be explained) and an explanans (sentences which account for the phenomenon), after Hempel and Oppenheim (Hempel, 1965; Hempel & Oppenheim, 1948). Hempel also discussed the nature of these scientific laws.

Scientific Determinism, Causality and Care

57

The basic idea he suggested is that with generalisation, we can distinguish between those that phenomena that are only accidentally true, and those that represent laws. For example, Hempel suggested the generalisation that all members of the Greensbury School Board are bald is accidentally true, whereas all gases expand when heated under constant pressure is a natural law. In the latter, we can use the explanans to account for the explanandum. We can explain why a certain gas expands using the law, but not so in the case of the accidentally true generalisation. We cannot explain why someone is bald, given they are a member of the Greensbury School Board. The D-N model does not apply when laws are probabilistic, but only when an outcome is certain. For probabilistic outcomes, two models closely related to the D-N model have been derived, the deductive statistical (D-S) and inductive statistical (I-S) models of explanation (Salmon, 1989).

The Deductive Statistical Model The D-S model represents a simple model for explaining indeterministic events (i.e. events that lead to uncertain outcomes) and is generally used more in the natural sciences. It involves the deduction of a statistical likelihood of an event from a more general set of premises, at least one of which involves a more generalised statistical law. As we know, not all scientific generalisations operate on an absolute universal standard, such as natural laws, and many are based on probability. An example would be the laws of probability themselves. If we roll a standard dice, we know we have a one in six chances of rolling a four. However, this is a mathematical probability, not an empiric law. Another example would be an explanation predicting the half-life of Uranium-238 based on the laws of quantum mechanics (which again are statistical). Salmon (1989) notes this example is highly theoretical and consequently not empirical. As D-S explanations also involve deduction of the explanandum from a statistical law, it conforms to the same general pattern as D-N explanations of things. An event will follow a cause (but only a certain amount of times
reflecting the known probability of the event).

The Inductive Statistical Model (I-S Model) The Inductive Statistical Model (I-S Model) is another derivative of the D-N model for explaining indeterministic events and represents the classical model of scientific enquiry originally derived from Aristotle’s thinking. It involves more complex inference, making generalisations from a number of known specifics. I-S arguments are very common in healthcare science and nursing, for example, estimating the probability of a person with a streptococcal infection being cured by taking Penicillin. This statistical law can be derived from existing empirical statistical data (from the population or experiments) and used to support clinical decision-making in specific instances. I-S model arguments rely on inductive and deductive reasoning from empirical evidence but importantly, allow that the explanandum does not always occur

58

Empirical Nursing: The Art of Evidence-based Care

in fixed ways (Hempel, 1965). This is an important point when we consider causality in healthcare science, and the likelihood of an outcome. For example, we know that not all streptococcal infections are cured by taking Penicillin. Another commonly used example is that smoking does not always lead to cancer, but there is a significantly increased likelihood of cancer for those smoking 20 cigarettes or more a day. Therefore, a statistical law, such as smoking causes cancer, is a much more complex one compared to the physical law of thermodynamics, or a general probability law, as it is not universal and has a number of supporting factors within it we must also consider. Take the following example. Consider a person taking an antimalarial drug (Proguanil) whilst visiting an area where malaria is prevalent. If it is a statistical law that the probability of contracting malaria, without taking an antimalarial drug is high, and a person has taken Proguanil and not contracted malaria during their trip to an endemic region; this information could be argued as providing an I-S explanation of our subject not contracting malaria. However, if the probability of contracting malaria were low in the area (e.g.