understanding nursing: the usefulness of a philosophical perspective

Understanding nursing: the usefulness of a philosophical perspective*

Semiramis M. M. Rocha1, Regina A. G. Lima2 and Marina Peduzzi21Professor, School of Nursing, and 2Professor, Ribeirão Preto School of Nursing, University of São Paulo, Brazil

designed to foster health, prevent illness, and supportrecovery and rehabilitation, and to do so working inteams. In this work, nursing is responsible for har-bouring and comforting patients, promoting theirwell-being, supporting patient autonomy throughhealth education, and co-ordinating with other disci-plines so as to provide assistance whether throughdirect care or by managing care. For approximatelythe last 50 years, the knowledge and practice ofnursing has received much attention and many theo-ries and intervention models have been constructed.Despite differences among them, every theory refersto the environment and its impact on human beings,the person, individual, family, group, or communityreceiving care, and the concepts of health and illness.Nursing is described as a process capable of harmo-

Abstract The work of nursing involves both treatment orientated action and careorientated action, but there exists a ‘treatment–care’ dichotomy that isstructured by social factors and views of knowledge that privilege sci-entific, instrumental rationality. It is a claim of this paper that there is aneed to establish connections between ‘treatment’ and ‘care’. The studyof work processes in the healthcare field make it possible for nursing torecognize the technical and social separation of work, the separationbetween manual and intellectual work, the dominance of medicineamong healthcare professionals, and other relations of power withininstitutions. The authors believe that Habermas’ theory of communica-tive action offers an alternative view, one suitable for transforminghealthcare practices and helping nurses build new responses to health-care needs.

Introduction

Nursing is one of the healthcare professions whosework is to look after human beings, individually,within a family or a community, to carry out actions

50 © Blackwell Science Ltd 2000 Nursing Philosophy, 1, pp. 50–56

Correspondence: Professor Semiramis Melani Melo Rocha,

University of São Paulo – School of Nursing, Av. Bandeirantes,

3900, CEP 14049-902 Ribeirão Preto-SP, Brazil. Tel.: (016)

602 3391/3426; fax: (016) 633 3271; e-mail: smmrocha@glete.

eerp.usp.br

* Integrated project: “Nursing and integrated assistance to chil-

dren’s and adolescents’ health”, sponsored by Conselho

Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

and Fundação de Amparo à Pesquisa do Estado de São Paulo

(FAPESP).

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Understanding Nursing 51

© Blackwell Science Ltd 2000 Nursing Philosophy, 1, pp. 50–56

niously integrating the relation between these components.

In nursing, the search for qualitative methodologiesstarted in the 1970s, and was apparently related to anincreasing interest in nurses’ everyday experiences.This reorientation occurred simultaneously with thecriticism of the positivistic approach by the social sci-ences throughout the world. The results of investiga-tions in the 1980s and 1990s opened new horizons,making possible the current surpassing of biologicalmodels through the proposal that nursing careexpand beyond technique, quantification, and themere observation of signs and symptoms. These newmodels permit nurses to have an interdisciplinaryacademic dialogue, to understand their position in thehealth care work process, and to understand the con-sequences of power relations, domination, and sub-ordination that are inherent to societies split intosocial classes. Regarding the users of health services,studies have approached their biopsychosocial needsas differentiated according to their living conditionsand as affected by their position in the modes of pro-duction (Boemer & Rocha, 1996).

The purpose of this paper is to examine the workof nursing and how it is connected to historical trans-formation from a philosophical point of view.

Work processes in the healthcare field

In Brazil, authors such as Donnangelo (1975),Donnangelo & Pereira (1979),and Mendes Gonçalves(1979, 1994),among others, introduced the category ofwork as a means of understanding the health–illnessprocess and practices in Brazilian society. Theirresearch viewed medicine as a form of work and theystudied how medicine functioned as a mode of pro-duction in relation to society at large, the State, theindustries producing goods and services, and socialpolicies. Nursing has also been studied as the specificsocial practice of work by several researchers includ-ing Germano (1983), Almeida & Rocha (1986), Silva(1986), Rocha (1987), and Lima (1995). Viewingnursing as work has led to substantial theoretical pro-duction of scholarship among Brazilian graduatenursing students, a recent study indicates that 40 post-

graduate theses using this framework were completedbetween 1983 and 1998 (Almeida et al., 1999).

The most abstract determinations of the workprocess in the economy of capitalistic social forma-tions are expressed in the work of Karl Marx(1818–1883). This theory, reorganized by MendesGonçalves (1979, 1994), shows the work processes inhealth care and its technological organization in oursociety.

In the concept of the technological organization ofwork in health care, technology refers to the linksestablished within the labour process between theoperating activity and the objects of work in accord-ance with the objectives and aims of each particularprocess. These processes are determined by the socialrelations of production. The operating activity iscarried out using instruments that are considered ina broad sense, with knowledge being the maininstrument because it guides the entire process.Therefore, we are not using the term technology in itsmost common meaning, that is, as a set of materialworking tools often associated with higher efficiencyand productivity. Instead we look to the meaning oftechnology in a particular type of production, in thiscase health care services, which is concerned with theinteraction between agents, aims, and the economicnecessities of production.

Within health care the recent developments inequipment are transforming the work process, includ-ing both the activities carried out by professionals andscientific rationality itself which governs the process.When knowledge, equipment, and their forms of inte-gration within the work process are considered interms of an overall perspective, technology is nolonger merely an option among several possible ones(Mendes Gonçalves, 1994). Rather, a given technol-ogy proves to be an aspect that is already given in theessence of a particular work process. Therefore, theuse of a given technology is not only an option but isalso a rational selection for the attainment of certaingoals. In the health care services, all the equipment is planned for interventions with the anatomical-biological body, by trying to maintain or restore thephysiological conditions of functioning.

The techno-scientific revolution that started in the20th century has the conscious and intentional

52 Semiramis M. M. Rocha et al.


purpose of becoming part of the production methodas it continually feeds the social processes of produc-tion of goods and services with technological possi-bilities. Science is no longer a spontaneous activity ofdiscovery and invention but has become a buying andselling commodity and, as all commodities, is articu-lated in the capital and work relations. On this basis,changes always occur in the direction of higher productivity. A working process is created that is governed by science and machines to which theworker is added as an executor, fragmenting the unityof thinking and action, idea and performance. Thesubjective factor of the working process is transferredto a place among its inanimate objective factors(Braverman, 1974).

The study of work processes in the healthcare fieldmade it possible for nursing to recognize the techni-cal and social separation of work, the separationbetween manual and intellectual work, the domi-nance of medicine among healthcare professionals,and other relations of power within institutions.Understanding nursing as work makes it possible tomark the relation between the subject or worker andthe objective world.As such, the concept of work goesbeyond the limited technical-economic dimensioncommonly studied in political economy. Work is aspecific practice of human existence (Marcuse, 1998)and because nursing is a social practice that providesservices that fulfill specific social needs, it can bestudied as belonging to the category of work.

Treatment and care

Although the work of nursing involves both treat-ment orientated action and care orientated action,there exists a ‘treatment–care’ dichotomy that isstructured by social factors and by views of knowl-edge that privilege scientific, instrumental rationality.It is a claim of this paper that there is a need to estab-lish connections between treatment and care. Study-ing healthcare practices as work reveals the historicaland social character of the practices as well as thetechnological organization of work processes.The his-torical and social character of practices refer both tothe changes in time and space, and to the relation-ships with modes of production.

In biology, the mechanistic view of life has reducedliving organisms to machines, which has resulted inthe formulation of a rigid conceptional structure forresearch in physiology. While this has achieved greatprogress in diagnostics and therapeutics thus savingmany lives, the logic of the interaction betweenmachines and living organisms raises, at present,serious questions. Living organisms grow, and presentinternal flexibility and plasticity, following cyclic anddynamic models as open systems that are in constantexchange with the environment. In their interactionwith the environment, living organisms possess thecapacity of self-organization. In contrast, machinesare constructed with a precise definition of their com-ponents according to a logic of cause and effect in alinear structure.

When the human body is considered as a machine,disease is viewed as a malfunction of biological mech-anisms and the principal role of practical medicine inthe therapeutic process is to intervene physically orchemically in order to repair the defect. The instru-ments designed to intervene in the body are devel-oped according to the knowledge and logic of thebody as machine.

Modern scientific rationality divorces the subjectfrom the object of knowledge, splitting the objectiv-ity and subjectivity that are intrinsic to all subjectsand events. The result of this for healthcare practicesis the fragmentation of treatment and care.Treatmentis based on scientific knowledge and on scientific dis-ciplines, and is carried out through technical know-how and interventions. The knowledge on whichhealthcare practices is based consists of the clinicalknowledge of medicine, which in turn relies on thebasic sciences of anatomy, physiology, and pathology.Within this framework, the purpose of healthcare isto cure disease of the body or mind, understood as adeviation from a norm (Canguilhem, 1990). In termsof social organization, this leads to a focus on bio-logical learning and individual intervention.

On the other hand, the provision of care brings tomind a diversified range of actions that are beyondthe biological and individual scope. This results fromthe fact that the object of knowledge and interven-tion in the healthcare arena, the human being, isintrinsically complex with social, emotional, affective



and biological expressions present simultaneouslyreflecting the socio-historical and cultural conditionsof both individuals and groups. Thus, numerous activ-ities are required in attending to health whichincludes not only those activities related to treatmentbut also to those that affect the conditions of health.In this view, the objective of the provision of care isto foster health and the emancipation of subjectsunderstood as the expansion of the interdependentautonomy of social subjects.

‘To care for’ means to help human beings with theirbasic human needs and this is the universal characterof ‘care’. Nonetheless, in nursing the provision of carepresents itself in a historical and contextual way, beingconsequently variable and dependent upon the rela-tions that are established in the course of providingcare.Therefore, the human need for care in the face ofhealth alterations appears over diverse historicalmoments, yet with differing characteristics, dependingon the ruling concepts concerning such phenomena, aswell as on the learning and interventions, or work, thathave been socially legitimated.

In spite of the fact that there exists the human needfor care across a range of diverse health situations,this work has not been legitimated by the reigningsocial order and views of rationality. Instrumentallogic, through which action is directed toward a spe-cific end of controlling some particular event legiti-mates that health work based on pathophysiologyand aimed at diagnosing disease, providing treatment,and seeking cure. Certainly this rationality has pro-duced a relative measure of success if biological recu-peration is regarded as the outcome. Yet the controland structure of healthcare work by scientific knowl-edge and technical know-how has limited the devel-opment of knowledge because the human person asobject of this knowledge and, by extension, the objectof intervention is divided into segments. People areviewed and treated in a fragmented way even asattempts are made to understand their social, psy-chological, and cultural dimensions. That is to say, thehuman and social sciences have been very importantfor healthcare practices researching such issues as thehealthcare professions and practices, patient expecta-tions, and quality of care. Although this knowledgehas helped to enhance the awareness of these issues

among healthcare workers, the authors suggest thatnurses would benefit by understanding nursing froma philosophical perspective. The latter would providea means for understanding the epistemological issuesthat underlie current views on rationality, how thesemight be challenged, and the development of alter-native accounts.

For example, when one takes experience intoaccount, namely the meaning of suffering existen-tially experienced during the process of disease andtreatment, one feels obliged to confront the limits of technical-scientific intervention, the way in whichcare is or is not provided, and the relationshipbetween care and the diagnostic and therapeuticprocesses that constitute cure orientated treatment.The authors maintain that it is necessary to seek a dif-ferent approach, one that is different from the currentdichotomous characterization and capable of includ-ing the multiple dimensions of healthcare needs aswell as a connection between treatment and care. Theauthors believe that the integration of treatment andcare in the real work of action demands major trans-formations in healthcare practices and the creation of new theoretical and methodological explanatoryschemes that reflect the intersection between scienceand technology, philosophy, and ethics.

Understanding the philosophicalpoint of view

Some authors acknowledge that much of the learningrequired by nursing is acquired in the field of em-pirical reality. Therefore, one path for constructing atheory would be to observe what nurses do, havethem reflect on their practices, and using this infor-mation as a starting point, define the nature ofnursing.

The theories and intervention models constructedby nurses or about nursing, in the 20th century, havea positivistic science perspective. Many nurse theo-rists and authors proclaim the humanistic and artisticelements of nursing, but its professional credibilityhas been characterized by an alignment with scientificacademicians (Darbyshire, 1994).

Within the framework of modern scientific ratio-nality, which divorces the subject from the object of



knowledge thereby splitting the subjectivity andobjectivity that are intrinsic to all subjects and events,a process of fragmentation of the dimensions of treat-

ment and of care in healthcare takes place.Habermas (1994), following Hegel (1770–1831),

believes that both intersubjective relations andsubject–object relations are apprehended throughsymbolic representation (in which subjects namethings and proceed to interpret them), through thework process (which consists of objects, instruments,agents and activities directed at a given purpose, thatis, to meet human needs), and through interaction

(action directed at reciprocity within the family,culture, society). These three categories ‘representa-tion, the work process, and interaction’ are the dialec-tics that enable rational discussion of the constructionof knowledge, technical progress, and the social sideof existence. For Habermas (1994), there is a recipro-cal relation between work and interaction, that is, itis impossible to reduce the interaction to work or toderive work from interaction. Defining what can beregarded as a properly scientific mode of constructionof objective knowledge is no simple matter. This isparticularly the case in healthcare because the latterrequires that professionals balance, on one hand, ‘thespecificity of the case’ and, on the other, ‘the gener-ality of the norm’ (Offe, 1995). Besides the relationbetween the subject and the object of knowledge, itis also necessary to take into account the intersub-jectivity of the subjects of knowledge.

Some authors (Minayo, 1994; Ayres, 1997) believethat Habermas’ theory of communicative action(Habermas, 1988), which proposes articulating phi-losophy, science and the world of existence as a newform of dialectic relation between subject and objectin constructing knowledge, might be an alternativesuitable to counter the instrumental reason that dominates modern society. Therefore, the commu-nicative action represents an alternative vis à vis thefragmentation of the work processes and the ‘treat-ment-care’ dichotomy, which so deeply jeopardizesthe quality of healthcare practices in general, and ofnursing practices in particular.

. . . by communicative action I understand a symbolically

mediated interaction. It is guided by mandatory norms that

define reciprocal behavioural expectations, and which must

be understood and acknowledged by at least two active

agents. Social norms are strengthened by sanctions. Their

sense reflects daily linguistic communication. Whereas the

validity of technical strategies and rules depends on the

validity of empirically truthful or analytically correct state-

ments, the validity of social norms is based solely on the

intersubjectivity of agreement concerning intentions and

can only be ensured if there is general acknowledgement of

obligations (Habermas, 1994).

In the theory of communicative action, Habermas(1988) develops, as one of his core ideas, a critique of the narrowing of the concept of rationality to its cognitive-instrumental dimensions, as ethical-normative and esthetic-subjective elements are for-gotten. For society to take a quantum leap in quality, Habermas (1988) proposes the constructionof a critical philosophy based on two complementaryaxes: communicative activity and communicativereason. Philosophy would not reduce its role to amerely critical positioning vis à vis contemporarysociety, but would expand its sphere of action, becom-ing the agent of mediation between sciences. In aprocess of interdisciplinary co-operation, philosophywould become the mediator between specialists inscience, technology, and the world of daily existence.

Interdisciplinary co-operation would maintain essential

critical attitudes, on the one hand, relative to technical and

instrumental rationality, as well as technocratic ideology

and, on the other hand, as regards the attempt at the colo-

nization of the vital world by science and by sophisticated

technology, and by the ideology that justifies them

(Minayo, 1994).

The change of paradigm effects a dislocation fromthe subject as the entity that relates externally withobjects in order to get to know them, to act and todominate them, toward the subject that interacts withother subjects, all of whom are concerned with themeaning of understanding objects, people and things.

According to Minayo (1994), one of the themesthat stand out in this reflection is the issue of scien-tific validation. The principal of a hierarchy amongsciences is substituted by the principle of co-operation, enabling internal transitivity in the discus-sion of concepts and languages. Moreover, internal



validity alone cannot account for the value of knowl-edge in the way in which it has been traditionallyaddressed.All scientific discourse, in order to be valid,has certain requirements, intentions, and conditions.Scientific validation (Habermas, 1988) proceeds toencompass three aspects:

• normative validity, which comprises the aspect ofensuring that methods and development techniquesconcerning the object or the proposition are appropriate;• propositional validity, which checks on whether theobject and the proposal are relevant to science and tothe needs of the world of existence;• expressive validity/authenticity, which lendsmeaning to scientific discoveries through the pos-sibility of communications, through argument in ‘thedialogue of many voices’.

Habermas believes that the objective of interdisci-plinary co-operation between philosophy and the sciences is the critique of technical, instrumentalrationality, as well as the critique of the colonizationof the world of life. In the process of mediationbetween philosophy and the sciences, to which nohierarchies apply, the theory of rationality is woventhrough a rational understanding of a discussion ofintended validity that takes into account the co-herence between different theoretical fragments(Siebeneichler, 1989). Thus, a possible construction ofconsensus can be achieved by means of the under-standing and mutual recognition of the involved sub-jects, both within the sciences and philosophy, as wellas in the production of technologies and in the dailyexercise of work.

Final comments

Transformations in healthcare practices are deter-mined by the development of science and technology,changes in cultural standards, and changes in thematerial means of production and social relations.

Nursing definitions and models shaped on the basisof science and technology alone are incapable ofapprehending the full complexity of providing careand they are equally unable to foster the articulationof the dimensions of treatment and of the care, with

a view to providing all-around healthcare.As we havealready mentioned, the provision of care has a his-torical nature, that is, it corresponds to a social construction that expresses a certain consensus or tra-dition as to the concepts of the health–illness processand how best to attack and transform this issue so asto meet the needs of those subjects whose health fails.Within this context, it is fitting to inquire what are theconceptions, as regards to both the scope of knowl-edge and the scope of work that concern the provi-sion of nursing care. Have such conceptions been theobject of discussion and agreement between the sub-jects of this construct and practice? How should therelations between technical progress and the socialworld of existence be controlled?

We have seen that nursing care deals with a sphereof action that extends far beyond mere instrumentalaction, because it must not only respond to healthcareneeds in accordance with current scientific learning,technical knowledge and interventions regarded asappropriate, but must also build new responses toinclude the multiple dimensions of healthcare needs.This requires taking into account the vicissitudes ofprocesses by means of free and entirely uncon-strained communication. Within this line of thought,it makes sense to maintain an active posture of inter-relations, and an interdisciplinary dialogue related tothe several forms of knowledge as part of a project ofsolidarity of structure for providing healthcare.

Acknowledgements

We thank the Conselho Nacional de Desenvolvi-mento Científico e Tecnológico (CNPq) and Fun-dação de Amparo à Pesquisa do Estado de São Paulo(FAPESP) for financing this paper.

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understanding nursing: the usefulness of a philosophical perspective

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