Original article

doi: 10.1111/nup.12077

On to the rough ground: introducing doctoral students

to philosophical perspectives on knowledge
Ellen Rehg* PhD and Lee SmithBattle RN PhD
*Adjunct Assistant Professor and Professor of Nursing, School of Nursing, Saint Louis University, St. Louis, MO, USA

Abstract

Doctoral programmes in nursing are charged with developing the next

generation of nurse scholars, scientists, and healthcare leaders. The
American Association of Colleges of Nursing (AACN) endorses the
inclusion of philosophy of science content in research-focused doctoral
programmes. Because a philosophy course circumscribed to the natural
or social sciences does not address the broad forms of knowledge that
are relevant to nursing practice, we have developed and co-taught a
course on the philosophy of knowledge that introduces students to competing claims regarding the nature of knowledge, truth, and rationality.
In addressing broad themes related to science and knowledge of the
body, health and illness, and ethics, the course equips students to tread
the rough and shifting ground of nursing scholarship and practice. Providing doctoral students with this philosophical footing is intended to
give future scholars, researchers, and healthcare leaders the intellectual
skills to critically reflect on knowledge claims, to challenge the hegemony of science, and to recognize the disciplinary forms of knowledge
that are left out or trivialized. Our pedagogical approach to knowledge
development does not denigrate scientific knowledge, but elevates forms
of inquiry and notions of clinical knowledge that are too often marginalized in doctoral education and the academy in general.
Keywords: knowledge, nursing inquiry, nursing research, philosophy of
science, praxis.

Introduction
We have got on to slippery ice where there is no friction and
so in a certain sense the conditions are ideal, but also, just
Correspondence: Dr Lee SmithBattle, Professor of Nursing,
School of Nursing, Saint Louis University, 3525 Caroline
Avenue, St. Louis, MO 63104, USA. Tel.: 3149778980; fax: 314977-8819; e-mail: smithli@slu.edu

98

because of that, we are unable to walk. We want to walk: so

we need friction. Back to the rough ground! (Wittgenstein,
1958/1968, p. 46).

Doctoral programmes in nursing are charged with

developing the next generation of nurse scholars,
researchers, and healthcare leaders. The American
Association of Colleges of Nursing (AACN) has
endorsed the inclusion of philosophy of science

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On to the Rough Ground

content in research-focused doctoral programmes

since at least 1993. More recently, the AACN (2010)
recommended including ways of knowing and habits
of mind (p. 5) and practice knowledge (p. 5) as core
curricular content. We welcome this apparent nod to
broad forms of knowledge, and agree with many
nursing scholars that the quest to equate knowledge
with science, based on the natural science paradigm,
has been deeply problematic for advancing the
nursing discipline (Canam, 2008; Ayres, 2013; Thorne
& Sawatsky, 2014). Like all forms of knowledge, the
Cartesian view that lurks in the background of scientific inquiry disregards its own blindspots and assumptions regarding the nature of truth, knowledge, and
reality. Because these biases are generally hidden to
healthcare professionals and researchers, we agree
with Thorne (2009) that philosophy offers rich
resources for deepening our understanding of the
forms of knowledge needed to advance nursing
practice:
The alignment between scientific advancement and improvements in the health of societies has been so close as to seem
patently obvious. And yet those of us who embrace the ethos
of a practice discipline are continually reminded of how
disparate are the enthusiastic claims of science when set
against the realities of human misery and suffering. By contrast, philosophy orients us towards work in the world of
what is and what ought to be. It steers us towards careful
examination of what we consider to be the values by which
we operate, and to account for how they pertain to our
notions of truth.Thus, the philosophical enterprise in nursing
inevitably bumps us up against the conventional knowledge
generation and translation enterprise that has become the
familiar backdrop of all that we do in health care and nursing.
(p. 150)

The growing recognition for diverse forms of

knowledge occurs in the wake of nursing research
showing that clinical judgment, at its very best, melds
scientific evidence with knowledge of the specific
patient and with clinical understanding of the meanings and trajectories of illness in concrete situations
(James et al., 2010; Benner et al., 2011; Thorne &
Sawatsky, 2014). Because science does not exhaust
the ways that clinicians act and know, as implied in the
AACN document and described in nursing research, a

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philosophy of science course, even one that introduces students to philosophies of science and social
science, cannot provide sufficient ground for discovering, testing, and translating nursings disciplinary
knowledge into practice. Assuming that scientific
knowledge is but one form of knowledge that supports excellent nursing care, students need to be
familiar with the competing claims regarding knowledge and truth, and understand how clinicians meld
scientific evidence and practical and relational knowledge with appropriate technology and the core values
of the discipline for the good of specific patients, families, and communities.
In this paper, we argue for and describe a philosophy of knowledge course for research-focused doctoral programmes that include, but is not limited to,
philosophy of science. In exploring philosophical perspectives on knowledge, we introduce students to
competing claims regarding the nature of knowledge,
truth, and rationality; and by addressing the broad
themes of the body, health, illness, and ethics, in relation to technology and power dynamics, we prepare
doctoral students to tread the rough and shifting
ground of nursing science, scholarship, and practice.
Providing doctoral students with this philosophical
footing is intended to give future scholars, researchers, and healthcare leaders the intellectual skills to
critically reflect on knowledge claims, to challenge the
hegemony of science, and to recognize all that is
passed over or trivialized: human agency, embodiment, the life-world. Our pedagogical approach to
knowledge development does not denigrate scientific
knowledge, but elevates forms of philosophical
inquiry and notions of clinical knowledge that are too
often marginalized in doctoral education and the
academy in general.

Background
To determine how other PhD programmes address
philosophical issues related to science and knowledge
development, we conducted a survey of PhD programmes listed on the AACN website (http://
www.aacn.nche.edu/research-data/DOC.pdf). From
this list, we downloaded the curricula and course
descriptions, when available, from the websites of each

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Ellen Rehg and Lee SmithBattle

School of Nursing offering a PhD programme. Of the

100 PhD programmes that were surveyed in 2010, the
majority (n = 62) did not offer a philosophy course of
any kind. Judging by the titles, the majority of the 26
philosophy courses that were offered in these programmes appeared to be straightforward philosophy
of science courses. The content of the remaining 25
courses was difficult to discern from titles such as
Knowledge Development in Nursing. Only 8 of the
100 programmes appeared to offer a course similar to
ours. Because the majority of programmes do not
offer a stand-alone philosophy course of any kind in
their curriculum, we were not surprised to find only
one relevant published article (Butts & Lundy, 2003).
These authors are to be applauded for describing how
they introduce nursing doctoral students who have
had little philosophical background to the relevance
and limits of philosophy of science and social science
for developing nursing knowledge.
Beyond philosophy of science
We assume that programmes offering a philosophy of
science course aim to provide nurse scholars with a
more sophisticated understanding of science than that
of the lay person. In a philosophy of science course,
students typically investigate the rational underpinnings of science and are introduced to concepts such
as induction, deduction, empiricism, rationalism, and
theories of truth. Questions that are examined
include: What differentiates science from nonscience? Is scientific knowledge cumulative? Is
science proven knowledge? What is the nature of
causation? What is the problem of induction? These
questions should lead the nurse scholar towards a
more sophisticated understanding of exactly what
kind of knowledge science can and cannot yield. The
student should come to see that science itself is probable knowledge; that findings are tentative; and that
no research is ever completely objective or value free.
However, even with this more chastened, contemporary, post-empiricist understanding of the nature
of science, we still might ask whether these questions
alone provide enough friction for a nurse scholar to
journey through the diverse terrain of disciplinary
knowledge related to human health and illness. Wittgensteins quote at the beginning of our paper refers

to his initial quest to render language, and hence our

grasp of the world, completely in accord with logic.
Only then would the world be a rational one, capable
of human comprehension. Wittgenstein ultimately
determined that language cannot be reduced to logic,
and the world cannot be reduced to language; human
experience is simply much richer, complex, and
meaningful to be fully systematized into logical
propositions.
We would extend Wittgensteins observation to say
that knowledge itself, and nursing knowledge in particular, is much more uneven and contingent on specific situations to be fully abstracted into scientific
theories and causal explanations. Even if we learn to
design research so that it yields rational, scientific
knowledge, the evidence privileged by the evidencebased movement, have we captured all there is to
nursing knowledge? While scientific knowledge is
crucial for clinical care, does it exhaust the philosophical notions of ways of knowing, practical knowledge, and reasoning through specific clinical cases
that ultimately furthers positive patient outcomes?
Can it yield the kind of knowledge generated in
human interactions with others, which is uncertain,
concrete, and replete with meaning? How do we
capture nursings pursuit of the rough ground, that is,
the melding of complex kinds of knowledge that
escapes abstraction and cannot be formulated into
universal principles? And if we do capture the complexity and contingency of clinical judgment that
spills over conventional scientific evidence, what
would it mean to claim that this knowledge also qualifies as evidence?
Although our argument might appear to echo the
work of Barbara Carper (1978), in her seminal article
on ways of knowing, there are important differences
between her work and a philosophical approach to
knowledge. Carpers article remains on the level of
nursing theory, rather than philosophy itself. As such,
she does not provide philosophical foundations or
justifications for her claims that nursing contains
these different ways of knowing. In our course, we
investigate the meta-level of ways of knowing,
through the philosophical work of continental philosophers, including Martin Heidegger, MerleauPonty, Levinas, and others. These philosophers

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insights recover aspects of human experience (including clinical judgment and the meanings and practice
of living with health and illness) that elude traditional
science, and provide the philosophical framework to
show how other kinds of systematic investigations
also generate disciplinary knowledge.
The question might be raised whether such forms
of knowing count as evidence. Indeed, what difference would it make, in terms of evidence-based
nursing, that there are multiple ways of knowing that
can be systematically investigated, if only scientific
knowledge counts as evidence? Thorne and Sawatzky
(2014) argue that non-science-based types of knowing
are of a fundamentally different nature (p. 8) than
scientific knowledge understood as justified true
beliefs. They write:
In that [personal, spiritual, or esthetic knowing are]
grounded in sources such as personal experience, intuition,
or revelation, subjectively derived knowledge cannot be
objective and generalizable in terms of the patterns of phenomena to which a particular evidentiary claim applies.
Thus, although it may have a role to play in the praxis
process, it is not in and of itself a shared form of knowledge
that can be confirmed and argued as an evidential basis for
nursing practice.

(p. 9)

Although much of what these authors argue is consistent with our argument, we depart from the view
that knowledge not derived from traditional methods
of verification is necessarily subjective, and hence, a
poor candidate for evidence-based care. This view is
based on a philosophy which divides subject/object
and person/world into separate categories with unassailable boundaries. In contrast, a philosophical
approach nurtured by the contemporary thinkers
listed above can provide the resources to overcome
these boundaries. Heideggers (1962) ontology provides a description of being-in-the-world that highlights how human engagements provide our most
primordial way of knowing and acting which, Benner
(1984) adapted (following Dreyfus) to explain how
nurses evolve from novice to experts. The embodied
skills which nurses absorb from their practice are not
merely personal or subjective phenomena as they are
a hallmark of excellent nursing care that are easily
recognized and verified by others. Even the practical

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and relational knowledge that is derived from

knowing specific patients (e.g. meanings of illness,
patients concerns, preferences, and ways of embodying an illness) is not totally subjective or idiosyncratic,
at least when patients share a similar cultural background. Because this knowledge can be shared, it is
open to verification and validation. Using another
example, the docile body described by Foucault
(1979) should not be construed as a purely subjective
phenomenon as it is widely adopted by patients and
reinforced by healthcare providers. These examples
challenge the claim that only the empirical sciences
generate objective evidence.
Thorne and Sawatzky (2014) also assume that the
kinds of methodically justified propositions derived
or inferred from empirical experimentation are
somehow privileged forms of evidence, because they
are based on established premises of empirical verification and philosophical argumentation (p. 9). Such
a position overlooks the perspectival nature of all
empirical science and the social elements that enter
into scientific knowledge construction (Kuhn, 1970;
Chalmers, 1999).
Beyond philosophy of social science
One way to introduce students to a broader view of
knowledge is to include content related to the philosophy of social science along with philosophy of
science. As shown above, courses which do this may
be less common than those which are straightforward
philosophy of science courses. This approach is exemplified in a recently published textbook for nursing
doctoral students which expands the notion of science
to include a science of human actions (Dahnke &
Dreher, 2011).
The philosophy of social science has traditionally
rested upon the distinction between the natural or
hard sciences, like physics, chemistry, biology and the
like, and the social or human sciences, such as psychology, economics, and sociology. Part of the goal of
the philosophy of social science is to broaden the base
of what counts as rigorous knowledge. This approach
argues that human actions, while considerably different from objects in the natural world, can also be
studied empirically and used to provide a solid basis
for knowledge. From this vantage point, knowledge is

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not the province of the empirical sciences alone, but

disciplines such as psychology can be made rigorous
enough to ground knowledge claims, with objective
procedures imported from the natural sciences.
The philosophy of social science initially relied on
the natural sciences as the paradigm for what counts
as trustworthy knowledge: the ability to make universal, law-like claims which can serve as both an explanation of a physical event and a prediction of when
that event will next occur. For a number of decades,
the philosophy of social science had as its primary
task the effort to make the philosophy of human
actions conform to this model.
The ground-breaking work of Kuhn (1970) casts
doubt on the model of the natural sciences as the
gold standard for knowledge, and on the possibility
of objectivity and value-neutrality even in the natural
sciences. This freed the philosophy of social science to
broaden its focus to one of analysing the nature of
interpretation, and how it could provide a basis
for epistemological claims. However, the question
regarding the relationship between the social and the
natural sciences has not been entirely abandoned, and
is an enduring one in this field (Dahnke & Dreher,
2011).
With the move towards interpretation, the social
sciences adopted the twin goals of both explaining
social phenomena and also understanding them. One
of its many questions has to do with the type of
knowledge that the human sciences can generate, and
along those lines, whether and to what extent this
knowledge can be objective, or value free.As valuable
as this approach is, we believe that there are drawbacks to adding the philosophy of social science into
the philosophy of science as a way to broaden the
view of knowledge for a practice discipline like
nursing. One of the drawbacks is that much of this
philosophy remains within the dualist tradition initiated by Rene Descartes and the hard and fast separation between subject and object, mind and body,
and person and world (Guignon, 1983; Leder, 1990).
Its building blocks are the mechanical body and the
intentional acts of human beings. These intentional
acts are described as phenomena that have an underlying mental state, such as a persons beliefs or
desires. Intentionality in this context refers to a con-

scious mind that causes an action. Such a philosophy

seeks to study this kind of intentionality in a way
analogous to the natural sciences methodic investigation of natural objects.
The fundamental assumption of a dualist ontology
circumscribes the social sciences to a particular epistemological tradition that eliminates other possibilities within the full richness and scope of philosophy.
Relying on the philosophy of social science as a
framework retains the divisions between subject
object, mindbody and personworld that consigns
and miscategorizes so-called subjective knowledge
to mere personal opinion or belief. Thus, our bodies,
relationships, and practices are ultimately reduced
to objectively defined, one-dimensional categories
stripped of our experience. The questions pursued by
the philosophy of social science within this tradition
remain limited. Hence, this approach can provide a
partial solution to broadening knowledge generation,
but may not go far enough.
Other approaches, such as the new philosophy of
social science, go further and challenge this view of
knowledge by developing the historical aspects of scientific and social scientific knowledge (Bohman,
1991). An investigation of the historical and indeterminate nature of knowledge ends up blurring the line
between subject and object, or nature and culture.
Personal experience is not something set apart from
the objective, the social, and the interpersonal world.
This perspective on knowledge starts from the postempiricist viewpoint ushered in by the work of Kuhn
(1970).
Ultimately, we believe that the point of studying
philosophy in a doctoral programme for nurses goes
beyond deepening students understanding of science
and the methods that may ground their research. We
agree with Thorne (2014) that philosophical thought
can deepen their understanding of core disciplinary
knowledge. Studying philosophy opens up a wealth of
insights and questions. Our course examines how different philosophical and scientific approaches reveal
or marginalize aspects of the body and what these
approaches disclose or conceal about illness. We look
at how they bring to light power dynamics in caring
relationships and healthcare systems, and whether
they uncover the technological and systemic impera-

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tives which drive healthcare decisions, and colonize

the lifeworld (Habermas, 1981/1984). Fruitful questions also include what counts as evidence and how
forms of evidence shape (or obfuscate) nursing
science and clinical practices.
Rather than focusing on the philosophical foundations of science, we introduce students to the philosophical foundations of knowledge for the purpose
of understanding and investigating nursing phenomena. This approach encourages a healthy skepticism
towards forms of knowledge that are privileged in
evidence-based practice. We seek to prepare doctoral
students with the skills for walking the rough
ground, capable of pursuing questions, critiquing
hallowed assumptions, and developing knowledge
that nurses routinely integrate in their care including, but not limited to. scientific knowledge, relational knowledge, ethical knowledge, and practical
know-how. These multiple forms of knowledge
cohere with our core disciplinary knowledge. They
require deep philosophical thought and diverse
methodologies to advance clinical practice, promote
healing and recovery, and relieve suffering. With the
advent of an increasingly technologically mediated
healthcare system, we believe that it is even more
imperative to hold on to this rougher, more human
dimension of nursing and the multiple forms of
knowledge that safeguard patients and the core
ethos of the discipline.
Ultimately, the study of philosophy sets up a
tension in which the search for answers competes
with the discipline of philosophys inherent iconoclastic challenge contained in the practice of questioning. This is the ultimate rough ground. Once
philosophy is introduced into a discipline, the notions
of clarity and system building are always accompanied by their opposite the entangled web of
ongoing and competing discourses about the questions. Science fundamentally seeks answers; philosophy fundamentally questions and challenges the
received answers. Along the way, the answers and
the questions improve as the spiraling process
enlightens both. To continue to question in this way is
to remain faithful to the deepest roots of our humanity, and to preserve a space for our humanity in the
practice of nursing.

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Description of the course

For more than a decade, we have developed and
co-taught a course which is aligned with this more
expansive view of knowledge. As the title of our
course, Nursing knowledge development: Philosophical perspectives, suggests, we eschew a narrow focus
on philosophy of science or social science, believing
that a broad understanding of knowledge encompasses the rough ground of human experiences of
health, illness, and clinical encounters. While our
course addresses the history and philosophy of
science, we refer to our course as a philosophy of
knowledge course, not a philosophy of science course.
This shift is consequential for the organization and
content of the course, and is apparent in the course
description, objectives, and units (see Table 1).
Because nurses necessarily rely on many forms of
evidence for making ethically sound and astute clinical judgments (Nortvedt, 2001; Benner & Leonard,
2005; James et al., 2010; Thorne & Sawatsky, 2014),
our course problematizes a nave or outmoded view
of science. We challenge students to rethink their
assumptions about science, knowledge, and truth,
especially in relation to health and illness phenomena, and invite them to critically reflect on the limits
and strengths of various modes of inquiry. Thus, the
broad questions animating the course include the following: What is knowledge and truth? What kinds of
knowledge are needed to examine embodiment (of
the patient and nurse), ethical knowledge, relational
knowledge, theoretical/empirical knowledge, and
practical know-how in the day-to-day realities of the
practice world? What forms of knowledge are privileged or marginalized by various stakeholders, including universities, research funders, textbook publishers,
journals, and healthcare corporations? To this end, we
examine different conceptions of truth, knowledge,
rationality, and personhood from the philosophical
perspectives of empiricism, rationalism, hermeneutics, critical theory, feminism, and postmodernism.
Our broad themes include the body, illness, health and
ethics, and nursing as a practice in the context of
relationships, technology, and power. By the end of
the course, we expect students to appreciate that all
forms of knowledge are perspectival, even those ame-

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Table 1. Overview of course

Course description

Course objectives

Course units

Class sessions

This course will examine the development of nursing knowledge from diverse philosophical perspectives and
traditions. Different conceptions of truth, knowledge, rationality, personhood, the body, and the moral good will be
examined as a foundation for understanding and investigating nursing phenomena.
1. Examine notions of truth, knowledge, rationality, and the stance of the nurse scientist from the philosophical
perspectives of empiricism, rationalism, hermeneutics, critical theory, and postmodernism.
2. Distinguish between various forms of inquiry as the basis for understanding and studying the natural world and
the human world.
3. Examine how philosophical perspectives (re: truth, rationality, and origins of knowledge) shape nursing practice,
ethics, and science.
4. Describe the implications of different philosophical perspectives and traditions for studying discrete nursing
phenomena.
5. Critique different philosophical perspectives for studying the body and the person.
Historical development of scientific knowledge, focusing on the development of modern science: Descartes
dualism and mechanistic philosophy
Contemporary influences on nursing knowledge development (e.g. hermeneutics, critical theory, postmodernism)
Conceptions of the person and the body (e.g. Descartes, Merleau-Ponty); how the person is studied as an isolate
(methodological individualism) or is considered to be social through and through
Relationships between truth, knowledge, rationality, and power and technology (e.g. Foucault, Heidegger, critical
theorists)
Nursing perspectives on knowledge development
Introduction: History of the Natural Sciences
The Body as Machine
What is Scientific Knowledge?
Kuhn
Introduction to Heidegger: Overcoming the Cartesian Legacy
Being-in-the-world
Merleau-Ponty and the Lived Body
Foucault and Biopower
Critical Theory: The Challenge to Power
Feminist Perspectives on Science
Science and Technology
Ethical Knowledge, Nursing, and Relationship
Nursing Knowledge Development: Phronesis vs Techne?
Evidence-Based Practice
Social and Political Forces in the Construction of Knowledge

nable to precise measurement, and that attempts to

find a neutral starting point, in line with Cartesian
assumptions, contribute to an illusion that true
knowledge is scientific and should therefore be privileged over forms of knowledge that are less amenable
to scientific measurement and scrutiny. While the
course includes content on traditional conceptions of
science, assigning science a privileged position denigrates the complexity of clinical judgment and undermines nursings social mandate. Treading the rough
ground implies that students gain a healthy respect
for alternative forms of inquiry and that they will
draw on philosophical resources to become better
educators, practitioners, and scholars. We fully
acknowledge and discuss the tension that students

will inevitably face as scientific knowledge is upheld

as the gold standard in future coursework and over
their careers.
The course is offered in the PhD programme at the
School of Nursing at Saint Louis University, a Jesuit
university located in the Midwest of the United
States. The doctoral programme has existed since
1990. When the doctoral programme began, students
were required to take two philosophy courses, an
epistemology and a philosophy of science course,
both of which were offered by the Philosophy Department. The current course was developed a few years
later by a task force led by the second author in
response to a curricular change in the doctoral
programme. The new course was approved by the

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doctoral faculty to replace the two philosophy

courses, along with the recommendation that the
course be co-taught by a philosopher and nurse. The
course was first offered in 2002 and has always been
co-taught by a philosopher whose background
includes the history of philosophy and applied philosophy, and a nurse who brings nursing issues and a
background in contemporary philosophy to the
course. Local and distance students take the class
together via web-based video conferencing technology, typically in the first semester of their programme,
along with a course on Nursing Theory. Most students
are nurse educators and are enrolled in the programme part time; full-time students are typically
international students and local students. Students
from Health Ethics have also enrolled in the course.
We appreciate our good fortune in co-teaching this
course. We are also fortunate to supplement required
readings with video presentations of distinguished
scholars and philosophers which were produced with
funding from the US Department of Health and
Human Resources (HRSA) in 2004. This award made
it possible for the School of Nursing to invite nationally recognized scholars to present on their area of
expertise. We refer to the scholars and the films
included in the course below. The course is based on
the seminar method with readings for discussion;
faculty and students also make presentations.
Course progression: from slippery ice to
the rough ground
The course begins with an overview of the history of
science, from the focal point of the modern scientific
revolution. Beginning with the earth-centred view of
the universe, we discuss how this model was overthrown with the advent of the new theories of Copernicus, the experimentation of Galileo, and the
culminating work of Isaac Newton. The point of this
historical analysis is to show how the development of
modern science ushered in mechanistic and materialistic explanations of phenomena, which enabled scientists to measure the material world. Therein lies the
brilliance and success of much of modern science.
Having introduced students to the scientific revolution, we highlight the philosophy of Descartes
(1641/1993), whose work marks the beginning of

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modern philosophy, and who, as a scientist, wrote

ground-breaking works on human physiology. We
show how his dualistic approach laid the groundwork
for modern scientific medical thought, allowing the
body to be treated as a material object, with the mind
conceived of as an entirely separate substance. This
dualism enabled subsequent medical approaches to
focus solely on the body as an object and to ignore
those aspects of persons which cannot be measured.
By way of contrast, we introduce the lived body, as
articulated in the phenomenology of Merleau-Ponty,
and interpreted by physician and philosopher Leder
(1990, 1998). The lived body perspective introduces
students to a more holistic and inclusive view of
embodiment and personhood, which we return to
later in the course.
Having established this fundamental tension in
how the body is understood and studied, we proceed
to outline the trajectory of 20th century philosophy of
science, beginning with theories like logical positivism
and Karl Poppers falsificationism (Chalmers, 1999),
and culminating in the revolutionary work of Kuhns
(1970), The Structure of Scientific Revolutions, which
the students are assigned to read. The purpose of this
section is to show students that nave views of science,
which typically take the form of a positivist view, are
no longer rationally tenable, given the work of Kuhn
and others. Because students unknowingly accept
something like a positivist view of science, the revelation that their view is outmoded prepares them to
seek better, more inclusive models of knowledge
which are to come in the course.
The course then takes a hermeneutic turn by introducing students to the early philosophy of Heidegger,
as interpreted by Dreyfus (1991), an internationally
renowned expert on Heidegger and continental philosophy. Heidegger broke away from the projects of
modern philosophy in which questions concerning
what it means to know predominated.We read Heideggers critique of Descartes dualism with secondary
sources (Guignon, 1983; Magee, 1987), and watch a
video presentation by Dr. Dreyfus. His presentation
focuses on early Heideggers challenge to Cartesian
assumptions and the separation of subject from
object, mind from body, and person from world.
Heideggers focus on ontology prior to epistemology

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and his hermeneutics of being-in-the-world revealed

new dimensions of knowing that included noncognitive, more embodied perspectives for researching human experience that are passed over by
scientific practices of generalizing and unitizing
(Guignon). Heideggers notions of the ready to hand
and the unready to hand reveal ways of knowing
embedded in everyday human practices and skills
that are traditionally overlooked by scientists trained
to investigate phenomenon in terms of present to
hand entities that are shorn free from any human
context or activity. In drawing attention to the tacit
ways of knowing that are formed through our practical engagements in the world, students are encouraged to see and value aspects of their clinical work,
which a scientistic view of knowledge traditionally
overlooks. In spite of the difficulty of Heideggers
language and thought, everyday examples from students clinical experiences, and (Benners, 1994;
Benner et al., 2011) research on nursing practice, substantiate how these forms of knowing are central to
good patient outcomes, even though they elude conventional forms of scientific research.
The course then turns to some of the rich philosophical developments that mushroomed in response
to Heideggers thought. Each subsequent philosopher
we study builds on Heideggers hermeneutics by
flushing out aspects of being-in-the-world that were
not taken up as directly in his work. For example, we
return to Merleau-Pontys (1945/1962) lived body,
and discuss how our embodiment during health and
illness is addressed or obscured in science and contemporary health care. Barons (1985) classic article,
with the ironic title I Cant Hear You While Im Listening, reveals how a machine body approach to
clinical care dehumanizes patients and prevents practitioners from attending to their concerns and perspectives. Leders (1998) video presentation on
Merleau-Ponty introduces students to the way the
Cartesian body is treated as a living corpse or
bioengineerable machine. This mechanical body is
composed of cells, tissues, organs, and complex neuroendocrine and immunologic interactions that are
mapped and measured so that disease is diagnosed
and treated. Leder (1990, 1998) contrasts this Cartesian body with Merleau-Pontys description of the

lived body, which is skilled, sentient, taken for granted

in health, but foregrounded in illness because of pain,
fatigue, intrusive symptoms, and an uncooperative
body.
The image of the panopticon, a design for prisons
in which prisoners are seen but cannot see their
jailers, provides a metaphor for Foucaults (1979)
crucial notion of bio-power, which we take up next.
Through his historical analyses of modern and contemporary social sciences, in particular his study of
medicine in The Birth of the Clinic, Foucault (1973)
shows how modern systems seek to manage large
populations through the control and subjugation of
their bodies. Students have noted the likeness of the
panopticon to many modern institutions, including
intensive care units (ICUs). Required research
articles provide further evidence of clinical practices
that reinforce a docile body. We view the film, Wit
(Nichols, 2001), of a woman dying of ovarian cancer
through the lens of bio-power and the docile body, an
exercise which powerfully reveals how these concepts
organize knowledge in everyday healthcare practices.
We then study Habermas (1981/1984) theory of
communicative rationality. Bro. William Rehg, a philosopher at Saint Louis University, introduces students via video presentation to the major concepts of
critical theory. The concepts of lifeworld and system
help us to view health care from a social and political
level, one that includes the effects of our economic
system on the daily work of nurses. Readings by feminist philosophers challenge the notion of objectivity
as emotionally neutral or impartial. Franklins (2001)
lovely piece, Science is Knowing and Loving the
World, shows how a feminist approach appreciates
sciences relational and emotional aspects. We watch
Moyers (1994) interview Evelyn Fox Keller where she
describes our cultures tendency to connect science
with masculinity and objective forms of knowledge.
With Barbara McClintock as an example of a scientist
who challenged traditional conceptions of objectivity,
Fox Keller argues that feeling is just as important as
impartial reasoning in conducting rigorous scientific
research.
Moving to the topic of technology, we explore the
relationship between science, technology, and nursing
practice. Because of their clinical practice, students

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On to the Rough Ground

have a great deal to say about the technological

imperative in shaping knowledge, patient experiences, and nursing practice. Published studies on the
experience of being a patient in an ICU (Almerud
et al., 2007) or having an implantable defibrillator
(Kaufman et al., 2011) highlight vexing issues related
to the technological understanding in health care that
call for nursing investigation.
Although ethical issues and concerns have arisen in
earlier class sessions, we turn to Emmanuel Lvinas
(1989) phenomenology of the personal encounter, the
face-to-face interaction, as the basis for an ethical
knowledge that is prior to all other kinds of knowledge. The implications of Lvinas thought for nursing
science and practice are described in a video presentation by Dr Michael Barber, also a philosopher at
Saint Louis University, and are further flushed out in
assigned readings. Nortvedt (2001), for example,
draws on Lvinas thought to describe the inseparability of ethical sensitivity and clinical nursing knowledge. Papers by Naef (2006), Wynn (2002), and
SmithBattle (2009) shed further light on the ethical
responsibilities that are grounded in first knowing the
person.
We examine the development of evidence-based
practice, and its underlying premises, as we return to
issues that have been raised over the entire course,
including what counts as evidence and truth and how
truth claims are negotiated and constructed, and for
what purpose. This content invites students to address
the question that now emerges from the much richer
view of knowledge that the course has afforded them:
whether nursing is more properly understood as a
practice discipline, a scientific discipline, or a human
science. Students read the work of scholars who have
addressed this issue (Bishop & Scudder, 1997;
Flaming, 2001; Thorne & Sawatsky, 2014). We also
encourage students to consider the relationship
between science and practice by examining Aristotelian categories of phronesis and techne as discussed
by several nurse authors (Flaming, 2001; Benner &
Leonard, 2005; Kinsella, 2007). At this point, students
are somewhat familiar with the difference between
knowing-how (clinical knowledge developed in practice) versus knowing-that (theoretical knowledge
developed by scientists). Although many students

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Nursing Philosophy (2015), 16, pp. 98109

have previously seen the video (Benner et al., 1992)

From Novice to Expert, they watch it again with new
interest and are typically surprised to see how nursing
knowledge based on pattern recognition, clinical reasoning, and knowing the person, while essential to
quality care, is considered too contingent and situated
to count as evidence. This tension between the particular and the general contributes to the slippery
ground that nurses walk with patients.
Challenges of the course include the fact that students with little prior philosophical background are
introduced to new ways of thinking about knowledge.
The breadth and scope of the course also place limits
on reading primary sources, although readings by
Descartes, Kuhn, Merleau-Ponty, Levinas, and Foucault are assigned. These limitations are offset by
video presentations from distinguished scholars and
many excellent nursing articles. While students are
stretched to understand philosophical thought in a
short space of time, course evaluations have been universally positive. Students report that they find the
course to be very meaningful and that they see and
value their teaching and clinical practice knowledge
with new eyes. They recognize a richer spectrum of
nursing knowledge that awaits further investigation
and translation into practice.
In conclusion, nursings quest for knowledge
remains a central imperative in doctoral education.
Because this quest has been constrained by an epistemological focus on knowledge generation, we introduce doctoral students to a philosophy of knowledge
course that is not confined to philosophy of science
and social science. Rather, we introduce students to a
broad understanding of knowledge that encompasses
the rough ground of the human experience of health
and illness, laying the groundwork for examining the
many forms of knowledge (scientific, ethical, relational, and practical ways of knowing) that nurses
routinely integrate in their practice. In highlighting
how different philosophical approaches simultaneously reveal and marginalize aspects of the body and
the experiences of illness and health, the course prepares students to consider studying various dimensions of nursing phenomena and translating diverse
forms of evidence to the rough ground of practice.
This approach also safeguards tensions regarding

107

108

Ellen Rehg and Lee SmithBattle

knowledge and evidence that inevitably arise in a

profession entrusted with the care of individuals,
families, and communities.

Acknowledgements
We gratefully acknowledge the research assistance of
Ann Pierce, RN, MSN, FNP, and the helpful review by
William Rehg, S.J., Dean of Arts and Letters, Saint
Louis University.

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