Humbug: Nursing Theory

Outside Reading: Humbug: Nursing Theory

Synopsis: One of the weaknesses of the internet is its ephemeral, transient nature. Favorite articles and resources one day simply turn up missing. But if you're lucky, you can still find it on archive.org.

So it is with one of my favorite articles on the subject of nursing theory and research. Jef Raskins was a mathematician and computer scientist who wrote a fun article debunking at least one area of nursing theory and research. When he died, his website died with him, but is now preserved on archive.org and this website.

What I find so endearing about the article is that, unlike so much of nursing "scholarship", it is very readable. So, I'll let it speak for itself:
From: The Wayback Machine

Schools of nursing at major academic institutions would seem to be unlikely places to find beliefs in the paranormal and crackpot scientific theories being taught and personality cults flourishing. The author shares his surprise and alarm.

Jef Raskin

Reality does not exist but appears to exist as expressed by human beings.-–Martha Rogers

"Read this!" my wife said when she came home from the start of a new term at nursing school. The book she handed me was Martha Rogers’ "The Science of Unitary Human Beings". The more I read, the more I thought I was the butt of an elaborate joke she had somehow put together. "You’ve got to be kidding," I said.

"I’m not. This is one of the texts for our Nursing Theory course," she replied, with a tone of voice and facial expression that showed her disapproval.

It wasn’t just the book that was suspect. My wife’s Nursing Theory course itself had a number of the hallmarks of a cult indoctrination: Any serious intellectual challenge to the basic ideas was treated as troublemaking, the leader was held in reverent awe and was regarded as having knowledge beyond the current reach of science. As I did more research into the topic, I discovered that this brand of nursing theory was widespread. For example, as an alumnus of Penn State, I was not pleased to read that Sarah H. Gueldner, Director of the School of Nursing at the Pennsylvania State University believes that "Paranormal events such as precognition and clairvoyance may hold potential as evolving communication techniques of space travel and living." (Christensen, Sowell and Gueldner, 1994).

Courses in nursing theory are taught at the University of San Francisco, Penn State, Rutgers, Wayne State University, New York University, Case Western Reserve University, the University of Rochester and many other institutions. Rogerian nursing theory is also taught overseas, for example, I’ve corresponded with prominent nursing theorists and educators in England and Australia.

Martha Rogers and Her Theory

Martha Rogers (1914-1994) was dean of nursing at New York University, and published many books and articles on nursing theory. A quote from Afaf Meleis’s book, "Theoretical Nursing: Development and Progress" (1997) summarizes a number of Rogers’ teachings: "To Rogers, a unitary human being is an irreducible, indivisible energy field and a unitary one... In fact, human beings and environments do not have energy fields; they are energy fields. They are open for exchange and extend to infinity. Energy fields are identifiable through dynamic-nonstatic wave patterns and organization that changes from ‘lower frequency, longer wave pattern to high frequency shorter wave pattern’ based on the principle of resonancy. Energy fields are pandimensional, transcend time and space, and therefore may have imaginary boundaries that are unique and changeable."

To better understand what Rogers was talking about, I studied the literature and had email discussions with nursing theorists, including a number of nursing PhDs and a present and past president of the Society of Rogerian Scholars. To get started in relating Rogers work to concepts with which I am familiar, I asked each of the nursing theorists these two questions (among others): Just what are the frequencies of the energy fields? Rogers says that these frequencies increase, how did she determine this? Not one of my sources was able to answer either question.

The practice of therapeutic touch is one of the techniques that, as Meleis put it, "demonstrated the [Rogerian] theory’s principles" (see Krieger 1987). Therapeutic touch consists of moving the therapist’s hands over a patient, without physical touching. "Assessing" is done by "holding the hands 2 to 6 inches away from the individual’s energy field while moving the hands from the head to the feet in a rhythmical, symmetrical manner." Later, "treatment is accomplished by moving the hands to the areas that seem to need attention" and the hand motions are effective in "facilitating the symmetrical flow of energy through the field" according to the web page of Nurse Healers – Professional Associates International, Inc. which says that it is "the recognized professional organization for the education, practice, and research of Therapeutic Touch." How you can hold your hands 2 to 6 inches from energy fields that "extend to infinity" is not explained.

In a classic and widely-reported experiment which began as a grade-school science fair project, practitioners of therapeutic touch who had stated that they could sense human energy fields (and thus the presence of a human) with their hands discovered that they could not. (Linda Rosa et al 1998). In comparing the therapeutic touch literature from before that article appeared with that published more recently, claims of the ability to detect the hypothesized energy field as well as trauma and disease through therapeutic touch have been eliminated or are couched in terms that make the ability untestable. You now read, "some practitioners may feel..." instead of "practitioners can detect..."

Why There Can Be No Theory of Nursing

The idea of a comprehensive theory of nursing is a strange one. We could not, for example, formulate a general theory of biology, though we can state biology’s essential thrust. Biology is the study of life; it is not a theory of life. Its methods range from field observation and laboratory investigations to building mathematical models. Biology includes many theories, such as the theory of natural selection and the theory of the structure and function of DNA. There is no overarching theory of biology from which we derive biological principles. Biology, in turn, is based on chemistry and, ultimately, on physics. Similarly, there is no theory of physics, but a collection of theories about the physical world. Even if the grand unified theory now being contemplated were to be completed, the various branches of physics would not disappear. There will still be surprises from the physical world, and much work would still remain to be done even in centuries-old and well-established fields such as fluid dynamics.

The range of tasks and disciplines that nursing includes are extremely broad. An effective nurse must understand both the human and the physiological aspects of illness. A nurse administers medication and performs procedures such as vaccinations, installing intravenous catheters, and attending wounds; a nurse checks on the propriety of medicines and dosages, sees to the physical needs of patients who cannot tend for themselves, observes and records their physical and emotional status, and can serve as the effector and senses of a doctor. In practice, though not officially, nurses often suggest diagnoses and therapies to doctors. Nurses also become mediators or ombudspersons for the patient with regard to other health care professionals, organizations, governmental bureaucracies, and commercial entities such as insurance companies. This list covers but a fraction of the extraordinarily varied tasks that nurses carry out. In short, a nurse must have a disparate and broad range of interpersonal, organizational, clerical, and technical skills. The knowledge and skill base is compounded from multiple disciplines, including physiology, sociology, psychology, and bookkeeping.

Nursing educators should realize that it makes no sense to claim that there is a single theory of nursing, although the overarching goal of nurses’ professional practice – to improve the wellbeing of their patients – underlies all the other activities. Trying to impose a "scientific" theory on such a wide range of skills and techniques detracts from the credibility of the profession.

 

Nursing Theory and the Philosophy of Science

The nursing theory research literature reveals the practitioners as trying to achieve the cachet of science while at the same time distancing themselves from its methods. For example, a section of Meleis’s chapter on Rogers’ work called "Theory Testing" begins "Gill and Atwood (1981) attempted to use Rogers’ theory as the basis for a study of wound healing in animals, but were legitimately criticized by Kim (1983) for reductionism, causality, and inappropriate use of the animal model." Reduction, of course, is one of the essential contributions science makes to our understanding of the world. When Newton showed that the orbiting of the planets, the trajectory of projectiles, and the falling of objects toward the ground were all described by the same equations, and due to the same cause, he achieved a remarkable reduction, and thereby an advance in our understanding of nature.

Nursing theorists often use the word "reduction" to name the unfortunate tendency of some clinicians to regard patients as a set of symptoms and subsystems rather than as a person with cultural, social, and psychological attributes. This confusion of two meanings of the same word leads some nursing theorists to disregard the beneficial aspects of reduction (in both senses). For example, it is by isolating specific causes of diseases that medicine has been able to eliminate so many of them as threats. Nursing theory should embrace reduction where it is appropriate, while at the same time resisting any tendency toward treating individual patients as less than full human beings.

To critique an experimental study for treating events as causal again takes nursing theory out of the realm of science, which is preeminently concerned with questions of cause and effect. Even where events seem to be acausal (as in the case of the radioactive decay of atomic nuclei), the phenomena are still detectable, demonstrable, measurable, repeatable, and well described by statistical laws. Nursing theorists, by contrast, are averse to causal reasoning and criteria such as repeatability because the phenomena in which they believe, including the paranormal, do not meet with these common-sense standards. Nursing theorists also tend to avoid crucial experiments which could jeopardize the theory in the rare cases where the theory is coherent enough to permit testing; or, as noted for therapeutic touch, reinterpret the theory to make it impossible to test. The experiments that do appear in the literature usually depend on subjective judgments, rely on anecdotal reports, or are purely speculative.

For the most part, nursing theory has insulated itself from logical or experimental evaluation by avoiding precision and prediction – or even meaningfulness: for example, Rogers said (1980 p.333, quoted in Meleis, 1997), "Reality does not exist but appears to exist as expressed by human beings".

The Vested Interest

Nursing theory has an academic structure that is medieval in style. Academic titles take on great significance, and most nursing theorists display at least three sets of initials after their name. For example, an article that tells us that "From the purview of Rogerian thought, VR [computer-mediated virtual reality] is not artificial as one is already everywhere since Persons are energy fields and energy fields are infinite" lists Elizabeth Ann Manhart Barrett RN; Ph.D.; FAAN as the author. Many aspects of nursing theory are far closer in style and substance to religious beliefs than to science; Martha Rogers wrote that there is a "critical need for a body of scientific knowledge specific to nursing." [1970 p. 83]. She does not explain why the knowledge must be specific to nursing, but her desire to create some special nursing science is evident, her desire for nursing to be on an academic and intellectual par with physics is clear. Starting from Glenn Seaborg’s analogy that compared scientific research to mountain climbing, Rogers said that "To reach the upper altitudes [of nursing theory] requires the knowledge and tools implicit in doctoral study of stature." [op. cit. p. 112].

Until the advent of nursing theory, which allowed nurses to write papers of apparently vast theoretical scope, there was far less of a rationale for awarding a Ph.D. in nursing. By establishing a Ph.D. in nursing, academic institutions – which usually require their faculty to have Ph.Ds – became staffed at the highest levels with nursing theorists (in accord with the use of the word "doctoral" in Rogers’ quote). These theorists have a vested interest in not having their work questioned. Additionally, because Ph.D. nursing theorists occupy many of the higher positions in academic settings, they control who obtains Ph.Ds, and they exclude any skeptical students who would challenge their hegemony. It is a closed system, which can, to its own satisfaction, reject any attack from outside by pointing out that the critics do not have Ph.Ds. in nursing, and therefore do not properly understand nursing theory. The situation is such that many nurses do not go forward to a Ph.D. in nursing because they would have had to publicly subscribe to the absurd tenets of the theory, as has been repeatedly reported to my wife (a nurse and a nursing supervisor who moved to nursing after studying for a Ph.D. in experimental pathology).

In my correspondence with nursing theorists, I have found them to be well-meaning. Like the vast majority of nurses, their principal desire is to do what is best for their patients. They believe that they are doing so. I would expect that they would want to demonstrate that their claims are objectively true. However, as a reading of many published papers, theses, and the perusal of hundreds of abstracts of other papers, has shown me, their ranks seem devoid of people who have the necessary background to create a rational critique from within, and the system is such as to exclude those whose training allows them to see the weaknesses of nursing theory.

The Status of Nursing in the Medical Professions

As any medical intern will tell you, nurses are often the most knowledgeable people, especially with regard to patient status and treatment, in the hospital. At the same time they are undervalued, underpaid, have low social status, and are institutionally subservient to MDs and hospital management. Outside the hospital setting, their situation is not much better. This creates justifiable resentment, and, I believe, helped give rise to a strong psychological impetus to create a platform for nurses where they can publish papers, do research, feel as if they are part of the cutting edge of technology, and have outward trappings comparable to that of other disciplines. Without the real possibility of a theory of nursing comparable in scope and depth to the physical sciences or mathematics, a simulacrum or the appearance of such a theory of nursing was created.

The more you study Rogers’ work, the more you see that substance is lacking. Any competent referee outside nursing would judge the overall quality of nursing research as pathetic. Nursing theory, as we have seen, is built on undefined jargon and unfalsifyable hypotheses, it is a structure of self-perpetuating myths taken on faith by its practitioners. Nursing theory has become a home for new-age fallacies, "alternative medicine", and hyperbole. Unlike science, nursing theory has no built-in mechanisms for rejecting falsehoods, tautologies, and irrelevancies.

I believe that nursing does deserve academic status, and that there is valuable and valid nursing research to be done (two obvious examples: Studies of the causes of medication errors or the effect of the frequency of dressing changes on the rapidity of wound healing). There is justification for Ph.D. level studies in nursing, but the justification does not require a fictitious theory of nursing. Academic nursing should not be satisfied with the low standard of intellectual honesty it has set out for itself, and academic institutions should not tolerate the lack of rigor in the field. Until the Ph.D. programs in nursing are revamped, universities and colleges should look to broader qualifications for instructional positions in nursing, and downplay the importance of Ph.Ds, especially those earned in Rogerian nursing theory.

Conclusions

This article has concentrated on Rogerian nursing theory because it is the most prominent and possibly the most widespread theory in the field. There are other broad theories of nursing, such as Margaret Newman's "Health as Expanding Consciousness" or Rosemarie Parse's "Theory of Human Becoming" that I have not discussed. On the positive side, Orem’s Self-Care Model presents a direction (rather than a theory) for nursing that does not exhibit Rogerian excess. Some of the topics taught in nursing theory are not altogether nonsensical, but that there are some reasonable topics presented under the name of nursing theory does not rescue the rest or establish that there is a general theory of nursing.

I hope that this article will help academic nursing come out of the dark ages of authoritarianism and mysticism so that it legitimately can take its rightful place in academia and in medicine.

=== SIDEBAR: ROGERS, IN HER OWN WORDS ===

Analysis of quotes from Rogers, Martha E., An introduction to the theoretical basis of nursing. Philadelphia, 1970. F.A. Davis Company.

Until you read her works, it is hard to believe how confused and vague are Rogers’ theoretical writings. Where she does get precise enough to judge the validity of her thought, she is often simply wrong. For example, Rogers’ concept of negative entropy, which she calls "negentropy", is based on her misunderstanding of thermodynamics. After claiming, without examples or citations, that, "With the rise of modern science, evidence that man did not develop according to accepted physical laws became more explicit" she found that, "The second law of thermodynamics, useful in predicting the physical world, was inconsistent with the ways in which living systems behaved" because "An increase in entropy posited a trend toward degradation to homogeneity of organization in contrast to a trend towards heterogeneity and complexity." She concludes that there is a "failure of physical laws to explain the evolution of life." [all the above quotes from p. 51]. She quotes, and summarily dismisses, the correct explanation, "Rapoport endeavors to deal with this problem by stating that ‘no living system is a closed system and so the second law does not apply to it.’ " [p. 52] There is no contradiction between the laws of thermodynamics and the behavior of living systems.

Rogers confounds Darwinian evolution, which she misunderstands, and the common use of the word "evolution" to mean change over time. "Geological evolution is written in the rocks, and cosmic change is evidenced in the processes of star formation and development. The evolution of life has been traced in fossil records, in identification of growing complexity in life forms, and in discoveries of artifacts of man’s emergence." [p.56] Of course, the earth’s geology does not evolve in the Darwinian sense, and Darwinian evolution is not identified by noting growing complexity in life forms (animals, notably some parasites and cave-dwelling animals, have evolved into less-complex life forms.) Rogers still accepts the long-abandoned evolutionary hierarchy with man at the top, "life encompasses the simplest organism to the most complex in an evolutionary hierarchy... At the top of this scale man stands triumphant." [pg. 67]. All that evolution predicts is improved adaptation, which may lead to greater or lesser complexity. In no sense does the discovery of artifacts give any evidence of the evolution of life. Early human artifacts demonstrate our progress in learned skills, but give no evidence of biological evolution. It would be hard to get much more wrong in so brief a quote.

Speciation is often associated with the isolation of a portion of a population, without such isolation or a change in the environment, species tend to be stable. Rogers gets this backwards when she opines, "Heretofore isolated societies are bypassing centuries of Western World development as they are introduced to the fruits of technology. The [human] gene pools of the planet Earth are intermingling as never before and presage further evolutionary events." [p. 59]. Intermingling makes further speciation of Homo sapiens less likely.

Rogers is as fuzzy with physics as with biology. She says (getting both the scientists’ name and usual English name of the principle wrong), "Heinsenberg’s principle of indeterminacy postulates an uncertainty in all knowing." [p. 57]. This is not true: Heisenberg’s uncertainty principle casts no light at all on logical or mathematical certainty, and does not say that we cannot predict with certainty outcomes of macroscopic events. If a swiftly moving bowling ball directly strikes a bowling pin, we can predict with certainty that the pin will move, even if Heisenberg himself had launched the ball. Also, the principle was not "postulated" but derived from observation and earlier work. Rogers also tells us that "human beings are radiation bodies" [p. 113], but not what a radiation body is. "Radiation body" is not a term of art from physics or physiology, it is a phrase she has invented, and which (as is all too usual in her work) she presents without definition, leaving you to guess its meaning. Any critique you make of her conclusions can be countered by a nursing theorist saying that you have not understood the term correctly. This is coupled with a reluctance on the part of the theorist to define the term with precision.

Rogers’ theory is based on a number of what she calls "assumptions", and she is often "postulating" concepts. Assumptions and postulates are more the tools of mathematics than of science, because in science the fundamental principles are not assumed or postulated but are based on observation. Here is a typical example: "The principles of homeodynamics... are four in number, namely: principle of reciprocy, principle of synchrony, principle of helicy, and principle of resonancy. These principles postulate the way the life process is and predict the nature of its evolving." [p. 79]

Another characteristic of her writing is stating the obvious as if it is a deep insight: For example, "Man’s capacity to adapt to a wide range of environmental stresses has received considerable attention and has been proposed to be a significant factor in his survival" [p.49]. Rogers’ "second assumption on which nursing science builds may be stated thus: Man and environment are continuously exchanging matter and energy with one another." [p.54] This is no assumption, but a simple fact. She is not above window-dressing with high-sounding jargon. Her third "assumption" is: "The life process evolves irreversibly and unidirectionally along the space-time continuum." [p. 59] In plain English: "The processes of life cannot be time-reversed." When she says that "Ontogenesis and phylogenesis evidence a lengthening of conscious awareness (the waking state) through time" [p. 93], she is claiming both that during the development of an individual and during humanity’s evolutionary history, people stay awake for longer periods of time. However, some people need increasing amounts of sleep as they age, and there is no evidence at all about the sleep habits of our prehistoric ancestors.

A large part of Rogerian theory is based on the idea of an energy field. She says, without any substantiation, "An energy field is the basic unit of living things. It is this field which imposes pattern and organization on the parts." [p. 61] She mentions that the "the electrical nature of this field is well documented" [pg. 104] but gives no citations to the claimed documentation. Rogers never takes her own advice to provide the "clear unequivocal concepts" needed for "a body of scientific knowledge" [p. 81] and we are left with no guidance as to how to detect or measure this field. She does get very specific at one point and tells us that "A series of studies... were designed to investigate the relationship between electrical potential differences, as measured by the Keithley Microvoltmeter, Model 153. "[p. 104]. On what or where the potential differences were measured, a far more important piece of information, she does not report. In any case, it doesn’t matter, for she then tells us that no positive results were obtained with this device, and the matter is dropped. Why then the specific mention of the piece of apparatus used? Because, I believe, Rogers felt that it sounded impressive.

Martha Rogers was not put off by contradictions in her theory. For example, she says that "At death the human field ceases to exist." [pg. 91] and also, a few paragraphs later, that "The field projects into the future as well as into the past." She speaks of "delineating the boundary of the human field" with measuring instruments [page 113] and also that "The environment is defined as all that which is external to a given human field and is thus stated to be the environmental field." [pg. 97]. But she also has told us that the human field extends to infinity in all directions, so it has no boundary and nothing is external to it.

Mathematics and symbolic notation are not ignored. Rogers, without an explanation of what topology is likely to be able to tell us, says that "A fundamental question needing exploration concerns the topology of the human field." [p. 112]. She introduces equations such as R = f(M1 « E1) which "can be read as: ‘Reciprocy [R] is a function of the mutual interaction between the human field [M] and the environmental field [E].’ " [p. 97] The subscripts are never explained or even mentioned. No use is made of the notation except as an alternative to words: The only justification for the symbolic form that I can see is to introduce something that looks like mathematics into the book.

Lastly, Rogers accepts sources uncritically. "Further evidence of nature’s lawfulness has come about through biorhythm research, expanded recognition of the cyclical nature of physical phenomena, and significant findings pointing up interrelationships between the two." [p.62] Biorhythms were a fad at the time she was writing. She also thinks that "In recent years, scientific respectability has been granted to the study of extrasensory phenomena. The existence of paranormal occurrences is well documented." [p.72] Perhaps often discussed, but not well documented. Scientific respectability will be granted only when the phenomena can repeatably produce positive results under conditions which rule out cheating and experimenter bias, an event for which we are still waiting.

=== END OF SIDEBAR ===

Acknowledgements

I wish to thank Linda S. Blum, R.N., Aza Raskin, and Julie Ososke for their suggestions, as well as the nursing theorists who have patiently responded to my questions via email.

Author Note

Jef Raskin is a writer, interface design consultant, and cognitive psychology researcher. He created and led the Macintosh project at Apple Computer Inc. He is a contributor to the new book, Information Design (1999. Jacobson, R. ed., MIT Press) and the author of the new book, The Humane Interface, published by Addison Wesley Longman and the ACM Press.

Citation

Raskin, Jef. "Rogerian Nursing Theory: A Humbug in the Halls of Higher Learning", Skeptical Inquirer 24;5 September/October 2000 pp 30-36

References

Christensen, P., R. Sowell and S.H. Gueldner. 1994. Nursing in Space: Theoretical Foundations and Potential Practice Applications within Rogerian Science. Visions: The Journal of Rogerian Nursing Science 2.

Meleis, Afaf. 1997. Theoretical Nursing: Development and Progress, 3rd ed. Philadelphia: Lippincott, Williams & Wilkins.

Krieger, D. 1987. Living the Therapeutic Touch: Healing as a Lifestyle. New York, NY: Dodd Mead.

Rogers, Martha E. 1970. An Introduction to the Theoretical Basis of Nursing. Philadelphia: F.A. Davis Company.

Rosa, L., E. Rosa, L. Sarner and S. Barrett. 1998. "A Close Look at Therapeutic Touch". JAMA 1 April: 1005-1010.