Miriam Bender

ABSTRACT At the start of academic nursing in the United States, nurses philosophized. And they did it grandly. So grandly in fact that this entire period (beginning in the mid 1900s) has been called the era of grand nursing theory. Grand nursing theory attempted to express the conceptual side of nursing but struggled, not least in confusing philosophy with theory. Nevertheless, grand nursing theories are still actively promoted in nursing education, practice, and research, suggesting there is something to them that continues to resonate with nursing. This resonating something can be made more consistent when connected to the philosophy of Gilles Deleuze. For Deleuze philosophy is not a tracing of the actual in terms of theory. Rather, every actuality involves a ‘shadowy and secret part,’ which is its conceptuality, and which is the work of philosophy to construct. It is this conceptuality that speaks the shadowy part of an actuality, and which Deleuze calls an event. An analysis of a 2008 paper by grand nursing theorist Margaret Newman and colleagues demonstrates that they were trying to speak an event of nursing through creative gestures such as ‘rhythmic fluctuations’ and ‘oscillating possibilities’ and ‘experiencing the infinite,’ but were using outdated theory structures to formalize them, which made for distortions and denaturing effects. Reconsidering their creative gestures through a Deleuzian philosophy premised on movement and variation (rather than stasis and standardization) a concept of liquid perception is developed to express how nursing can be conceived as bearing witness to an event and counter‐actualizing its emerging possibilities in the context of healthcare. It involves gaining a capacity to bear affects and thereby pass to different and more expansive thresholds of perception, which Deleuze defines as becoming subjected to an action, and affirms Newman and colleagues claim that ‘relationship … emerge[s] as the central focus of the discipline.’ Liquid perception expresses this relationality in terms of a practice of making actionable more and other things across more and other dimensions, thus expanding the very scope of what can become related, thus expanding the very potentiality of nursing. Importantly, liquid perception has nothing to do with putting forth a new grand theoretical truth of nursing. It constitutes a dynamic conceptualization that makes nursing visible without making prescriptions. Liquid perception is not a fact about nursing—it is a speaking of what remains shadowy and secret in nursing, which involves nursing's unique efficacy, and becoming worthy of its event.

Theories and models are not equivalent. I argue that an orientation towards models as a primary carrier of nursing knowledge overcomes many ongoing challenges in philosophy of nursing science, including the theory–practice divide and the paradoxical pursuit of predictive theories in a discipline that is defined by process and a commitment to the non‐reducibility of the health/care experience. Scientific models describe and explain the dynamics of specific phenomenon. This is distinct from theory, which is traditionally defined as propositions that explain and/or predict the world. The philosophical case has been made against theoretical universalism, showing that a theory can be true in its domain, but that no domain is universal. Subsequently, philosophers focused on scientific models argued that they do the work of defining the boundary conditions—the domain(s)—of a theory. Further analysis has shown the ways models can be constructed and function independent of theory, meaning models can comprise distinct, autonomous “carriers of scientific knowledge.” Models are viewed as representations of the active dynamics, or mechanisms, of a phenomenon. Mechanisms are entities and activities organized such that they are productive of regular changes. Importantly, mechanisms are by definition not static: change may alter the mechanism and thereby alter or create entirely new phenomena. Orienting away from theory, and towards models, focuses scholarly activity on dynamics and change. This makes models arguably critical to nursing science, enabling the production of actionable knowledge about the dynamics of process and change in health/care. I briefly explore the implications for nursing—and health/care—knowledge and practice.

At the start of academic nursing in the United States, nurses philosophized. And they did it grandly. So grandly in fact that this entire period (beginning in the mid 1900s) has been called the era of grand nursing theory. Grand nursing theory attempted to express the conceptual side of nursing but struggled, not least in confusing philosophy with theory. Nevertheless, grand nursing theories are still actively promoted in nursing education, practice, and research, suggesting there is something to them that continues to resonate with nursing. This resonating something can be made more consistent when connected to the philosophy of Gilles Deleuze. For Deleuze philosophy is not a tracing of the actual in terms of theory. Rather, every actuality involves a ‘shadowy and secret part,’ which is its conceptuality, and which is the work of philosophy to construct. It is this conceptuality that speaks the shadowy part of an actuality, and which Deleuze calls an event. An analysis of a 2008 paper by grand nursing theorist Margaret Newman and colleagues demonstrates that they were trying to speak an event of nursing through creative gestures such as ‘rhythmic fluctuations’ and ‘oscillating possibilities’ and ‘experiencing the infinite,’ but were using outdated theory structures to formalize them, which made for distortions and denaturing effects. Reconsidering their creative gestures through a Deleuzian philosophy premised on movement and variation (rather than stasis and standardization) a concept of liquid perception is developed to express how nursing can be conceived as bearing witness to an event and counter‐actualizing its emerging possibilities in the context of healthcare. It involves gaining a capacity to bear affects and thereby pass to different and more expansive thresholds of perception, which Deleuze defines as becoming subjected to an action, and affirms Newman and colleagues claim that ‘relationship … emerge[s] as the central focus of the discipline.’ Liquid perception expresses this relationality in terms of a practice of making actionable more and other things across more and other dimensions, thus expanding the very scope of what can become related, thus expanding the very potentiality of nursing. Importantly, liquid perception has nothing to do with putting forth a new grand theoretical truth of nursing. It constitutes a dynamic conceptualization that makes nursing visible without making prescriptions. Liquid perception is not a fact about nursing—it is a speaking of what remains shadowy and secret in nursing, which involves nursing's unique efficacy, and becoming worthy of its event.

In this paper I summarize a talk I was invited to give by the International Philosophy of Nursing Society (IPONS) as the Steven Edwards Memorial Lecture at the 2024 international nursing philosophy conference in association with IPONS. This occurred in the absolutely sublime setting of the restored outdoor Dodona Theatre, home to the ancient Greek oracle Dodona, mentioned in both the Iliad and the Odyssey, and which lies a few miles outside Ioannina, Greece, which was the site of the conference. In this magical setting I described a long tradition of rich diversity in terms of how nursing has engaged philosophy to produce, refine, and critique ideas, concepts, and arguments relevant to nursing. I then interrogated some of these relations and wondered about some future potentials for nursing and philosophy.

As a practicing clinical nurse, a phenomenon I experienced at times was the sudden acute sense that something was going wrong with a person in care at the sub‐critical unit in the hospital where I worked. In fact, many hospital nurses have their story of “something's not right” in relation to a person they were caring for/with, in that the day started with them on a coherent path to healing and then suddenly the nurse feels something is going very wrong, and yet there is nothing observable that would justify such a feeling. This feeling would be called “intuition” by many nurses, a concept most notably theorized in nursing by Patricia Benner in her extensive program of scholarship. Benner defines intuition as “understanding without rationale.” Benner opposes embodied intuition and rational abstract reasoning and creates criteria for the use of each by nursing depending on whether the clinical situation is familiar or novel. The philosophical idea is that the new must be reasoned with a different mode of thought than the familiar. Charles Sanders Peirce was a philosopher of reasoning. He defined logic as the theory of reasoning, which by the end of his career he was declaring was only another name for semiotic. Peirce argued that all reasoning/semiosis is done through signs, or more accurately sign‐activity. Semiotic is the philosophical schema providing the concepts and methods by which semiosis ‐ reasoning ‐ happens. Importantly, semiotic does not oppose different modes of thought, and conceptualizes reasoning as a process that functions in familiar as well as novel situations. In this paper I describe Peirce's philosophy of semiotic. I then provide an example relevant to nursing by conducting a semiosis of the nursing scenario above to show how nursing “works chance,” or novelty, in a way that doesn't need to resort to rational abstract reasoning and yet is different than Benner's notion of intuition.

My purpose in this short response to Clinton's interesting article On Bender's orientation to models: Towards a philosophical debate on covering laws, theory, emergence and mechanisms in nursing science, which is published in this issue, is not to provide any counterargument to Clinton's interpretation of my own argument; readers are welcome to interrogate both articles at their leisure and make their own conclusions. What I will do instead is provide a brief critical assessment of my own (il)logic re bringing in the notion of mechanism as conceived by Machamer, Darden and Craver into an argument for models versus theories as a carrier of nursing knowledge.

This article summarizes a virtual live‐streamed panel event that occurred in August 2020 and was cosponsored by the International Philosophy of Nursing Society (IPONS) and the University of California, Irvine's Center for Nursing Philosophy. The event consisted of a series of three self‐contained panel discussions focusing on the past, present and future of IPONS and was moderated by the current Chair of IPONS, Catherine Green. The first panel discussion explored the history of IPONS and the journal Nursing Philosophy. The second panel involved a reflection on the challenges of doing nursing philosophy in a research‐intensive context of a Canadian university and the history and current movements in nursing philosophy in the Nordic countries. The final panel involved presentations on the future potential for philosophy in/and for nursing, the critical connections between nursing philosophy and nursing theory, dismantling racism in nursing and the potential for process philosophy to help explore nursing's unique efficacy in creating possibilities for health. The panels were followed by a lively Q&A session with participants, of which there were 252 registrants from across the globe. The event underscored the wide and diverse interests of nurses in philosophical discussion and the need for more virtual events and other connective modalities bringing nurses together to discuss and analyze the value and potential of philosophy to better understand and advance nursing theory and practice.

Nursing claims a significant history of engaging philosophical inquiry. To better understand the rationale for this engagement, and what nursing understands itself to achieve through philosophical inquiry, we conducted an interpretive synthesis of the recent nursing literature to identify what nurses are doing when they say they are doing philosophy. The overarching finding was that while vanishingly few articles articulated any definition of philosophy, the synthesis showed how nursing considers philosophical engagement a generative mode for asking and answering questions in/for nursing. Whatever aspects of nursing were focused on in these articles, and they were myriad, philosophy was invoked as an appropriate modality to work through that aspect rigorously, critically, and with an expectation that something “knowledgeable” would result from the effort. Based on the synthesis, we conclude that nursing philosophy could be considered a specific modality of nursing practice by which nursing is both done and delineated, a discursive practice in which we continually assess and explore and adapt and advance our understanding of the discipline in service to advancing our unique efficacy. This definition of “nursing philosophy” provides an opening for further inquiry helping to illuminate its functionalities and potentialities for outputs that can facilitate rigorous practice, education, and scholarship.

Jacqueline Fawcett's nursing metaparadigm—the domains of person, health, environment, and nursing—remains popular in nursing curricula, despite having been repeatedly challenged as a logical philosophy of nursing. Fawcett appropriated the word “metaparadigm” (indirectly) from Margaret Masterman and Thomas Kuhn as adevisethat allowed her to organize then‐current areas of nursing interest into a philosophical “hierarchy of knowledge,” and thereby claim nursing inquiry and practice as rigorously “scientific.” Scholars have consistently rejected the logic of Fawcett's metaparadigm, but have not yet proposed a substantially agreed‐upon alternative. Through an analysis of articles introducing and critiquing Fawcett's metaparadigm, I argue for a re‐conceptualized metaparadigm that articulates nursing's ontology.What exists for the nursing discipline are not already‐demarcated metaparadigm domains, but rather interdependent, dynamic relations that constitute people, including nurses, in their health/environment circumstance. The nursing discipline aims to skillfully access this dynamic relationality as the basis for action and reflection to produce both positive health trajectories and knowledge that facilitates future action and reflection. Further inquiry into the onto‐epistemology of nursing will produce a more robust understanding of nursing practice, science, and philosophy, and clarify its unique contribution to health and healthcare.

There is an enduring debate in nursing regarding the art–science dualism, involving an articulation of two distinct ‘kinds’ of disciplinary knowledge: objective/scientific and subjective/artistic. Nursing identifies both as necessary, yet unbridgeable, which creates problems in constructing a coherent disciplinary knowledge base. We describe how this problem arises based on an ontological assumption of two different kinds of ‘stuff’ in the world: that with essential determinate properties and that without essential properties. We experiment with a solution by ontologically understanding the world as made from a single kind: That the most irreducible element of the world is process, in that reality is a continuous construction whereby subject and object are products, not independent constituents, of reality. Process philosophy overcomes nursing's ontological bifurcation and enables nursing's art–science dualism to be re‐conceptualized as a cohesive logic of skilled reality production. An unavoidable implication of a process turn in nursing philosophy is that the disciplinary goal no longer becomes a privileged ‘body of knowledge’ that authorizes, which has always been a defining challenge in nursing. Rather, and more productively perhaps, the aim is for greater sophistication and plurality in its ongoing commitment to attuning to reality in ways that shape disciplinary attainment.

Theories and models are not equivalent. I argue that an orientation towards models as a primary carrier of nursing knowledge overcomes many ongoing challenges in philosophy of nursing science, including the theory–practice divide and the paradoxical pursuit of predictive theories in a discipline that is defined by process and a commitment to the non‐reducibility of the health/care experience. Scientific models describe and explain the dynamics of specific phenomenon. This is distinct from theory, which is traditionally defined as propositions that explain and/or predict the world. The philosophical case has been made against theoretical universalism, showing that a theory can be true in its domain, but that no domain is universal. Subsequently, philosophers focused on scientific models argued that they do the work of defining the boundary conditions—the domain(s)—of a theory. Further analysis has shown the ways models can be constructed and function independent of theory, meaning models can comprise distinct, autonomous “carriers of scientific knowledge.” Models are viewed as representations of the active dynamics, or mechanisms, of a phenomenon. Mechanisms are entities and activities organized such that they are productive of regular changes. Importantly, mechanisms are by definition not static: change may alter the mechanism and thereby alter or create entirely new phenomena. Orienting away from theory, and towards models, focuses scholarly activity on dynamics and change. This makes models arguably critical to nursing science, enabling the production of actionable knowledge about the dynamics of process and change in health/care. I briefly explore the implications for nursing—and health/care—knowledge and practice.