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Social epistemology, gender and nursing theory
hr. J Num Stud, Vol. 34,No. 2, pp 137-143. 1997 0 1997 Elsevier Saence Ltd. All rights reserved Printed in Great Britain 002&7489197 $17.00+0 00
Pergamon PII: S002(r7489(96)00040
Social epistemology, gender and nursing theory Keith Cash School of Health and Social Care, Leeds Metropolitan University, Calverley Street, Leeds LSl 3HE, U.K. and the Leeds Community and Mental Health NHS Trust, Leeds, U.K. (Received 8 February 1993;revised 22 March 1996;accepted 6 September 1996) Abstract A major claim for nursing theory is that it contributes to the generation of a body of nursing knowledge that will be important in the definition of nursing’s boundaries. It is argued here that the epistemic authority of nursing knowledge is determined by factors such as the gender structure of nursing. This means the knowledge products of nursing will be given low epistemic status by both nurses and non-nurses. The implications of this argument, in terms of professionalisation and the project to develop nursing theory, are examined. 0 1997Elsevier ScienceLtd. Kqwords: Epistemic authority; gender structure; nursing theory.
Introduction The .rocial epistemology of nursing A major claim for formal nursing theories such as nursing models is that they will help in the drive for professionalisation by creating an explicit disciplinary boundary for nursing (Riehl and Roy, 1980). Underlying the development and use of nursing models is the idea that, in some way, this formalisation of nursing knowledge is related to power. That is either power over one’s own professional destiny, or power over other occupational groups, or, of course, both. This whole issue is related to the idea of the nature of knowledge, in other words epistemological problems. A central concern for nursing in this context is the concept of epistemological authority and how this is established for as Bourdieu (1975) puts it: Epistemological conflicts are always political conflicts: so that a survey on power in the scientific field could perfectly consist of apparently epistemological questions alone (Bourdieu, 1975,p. 21). I want to look at the arguments that apply to what can be termed the social epistemology of nursing. By this is meant the way that nursing knowledge is perceived by the community in general and particularly the status given to it. It will be argued that these factors affect not only the content of that knowledge but also the way that it is structured. The argument is made in several stages. The first is to look at the idea of social epistemology. The second is to look at the nature of professions, and more specifically for our purposes the relationship of formal knowledge to professionalisation and the third stage
is to look at the idea of gender in the context of professionalisation and the impact that it can have. These ideas will be related to the issue of nursing theory and the possible range of its impact. In brief, the argument will be that formal knowledge is a necessary but not sufficient condition for professionalisation because the epistemic authority of professions is socially rather than epistemologically determined and, because formal models of nursing ignore the issue of gender, they provide a distorted image of nursing. The issue of gender is related to the professions and it is demonstrated finally that nursing cannot become a profession without changing so fundamentally that it loses its social identity.
Epistemic authority Competence in a field and, therefore, a monopoly of that field is a result of the legitimation of that agent by society. Because this legitimacy is socially determined then the authority of the practitioner is subject to the knowledge that society has of their position in the established hierarchies and, therefore, their strength vis g vis other groups. As Bourdieu (1975) put it: The pure universe of even the purest scienceis a social field like any other, with its distribution of power and its monopolies, its struggles and strategies, interests and profits (p. 19). The monopoly here is: The monopoly of scientific competence, in the sense of a particular agent’s socially recognised capacity to 137
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speak legitimately (i.e. in an authorised and authoritative way) in scientific matters (p. 19).
Disciplinary boundaries
Nursing theories are in the style of the knowledge In the original thesis of the sociology of knowledge, claims of other sciencesalthough they operate in a that of Mannheim (1936) a knowledge claim repmatrix of uneven power relations with other disciresented the interests of particular group so that “granting epistemic warrant is a covet form of dis- plines. The status given to them will depend not on tributing power” (Fuller, 1988, p. 10). He notes that their ‘truth’ but rather the reflection of the status this thesis is most powerful when applied to disciplines given to nurses and nursing. To develop this argument such as law, medicine and the sciences,where topics further we need to examine the nature of disciplines are removed from the public domain and placed in and how this relates to nursing theory. Kohler (1982) gives a general definition of discithe domain of experts. Epistemic warrant is granted plines as to those who undertake a long period of training. Those that do not undertake the training have to defer Political institutions that demarcate areasof academic to the experts with the epistemic warrant. territory, allocate the privileges and responsibilities This model of knowledge interests can be criticised of expertise, and structure claims on resources(p. 1). because it gives the impression that interest groups This raises the question of how these disciplinary could dictate what constituted knowledge. This can further be interpreted in two ways. The first is that boundaries arise, for this is a central concern in nursthis granting of epistemic warrant is done in order to ing theories; the demarcation of nursing. Fuller says distribute power: this is a form of conspiracy theory. that a discipline’s boundary’s are defined by “its proThe second is this “granting of epistemic warrant” is cedure for adjudicating knowledge claims” (p. 191). identical to distributing power. Knowledge is, there- This is defined by “an argumentation format” whose fore, according to this theory interest laden. Fuller purpose is to restrict: (1988) proposes three categories of knowledge proword usage; ducers related to this. the permissible borrowings from other disci(a) The motivators: those putting forward a knowlplines; edgeclaim in the hopes that they might benefit. the appropriate contexts of discovery and (b) The benefitters: those who actually benefit. justification. (c) The users: those that use the claim in the preparation of other knowledge claims. A fully bounded discipline is autonomous. There are He argues that Mannheim’s theory conflates the three groups. The traditional view has been further criticised by the social constructivists (Latour and Woolgar, 1979;Knorr-Cetina, 1981)and others. They argue that the representation of knowledge in say an academic paper and, by implication, a nursing care plan does not necessarily show how that knowledge was actually produced. As Fuller (1988) puts it: Knowledge producers tend to take care in gathering evidence and testing claims only in proportion to the likelihood that the referee will check them (p. 13).
Therefore one getsuniformity in the expression and justification of claims without corresponding uniformities in the activities that lead to the formalisation of the knowledge claim. In the case of say, nursing care plans, their high visibility does not necessarily imply that the actions prescribed are undertaken in precisely the way that they are written, but rather that, like sciencein general, they provide an object for external ‘referees’, managers and other disciplines, for
example, to examine (Cash, 1992). In terms of science, Fuller propounds the thesis that “having knowledge is not a matter of possession” (Fuller, 1988, p. 30). A producer has knowledge if fellow producers either cite her work or follow up her work. Having knowledge is a “matter of credibility”. So, by inference, expertise is a also a matter of credibility rather than truth. Credibility conditions have precedence over truth conditions (Cash, 1995).
further constraints on the development of the boundary. (a) The discipline’s internal justification has to do with its control over somenatural kind or other well defined group of objects, e.g. botany, medicine. (b) The performance is itself self-justifying e.g. some pure mathematics. Fuller argues that this approach goes against the traditional Kuhnian or Popperian views becauseKuhn (1962) holds that a discipline develops through the coalescing of unrelated phenomena under some general unifying principles, whilst Fuller’s disciplines develop by “successively failing to control some other body of knowledge” (p. 192). The Popperian notion is that there is a rational progression based upon a procedure
that adjudicates knowledge claims. In the Fuller model, there is a social process rather than a logical process. The nature of boundary disputes in science have been examined by Gieryn (1983). He argues that they are a
“practical problem for scientists” (p. 781). The reason is that scientists have to create a boundary between science and non-science. They do this by using the
“stylistic resources” (Geertz, 1973, pp. 212-213) of ideologists. They do this by using a foil:
K. Cash/Social epistemology, gender and nursing theory Just as readers come to know Holmes better through contrasts to his foil Watson, so does the public better learn about ‘science’ through contrasts with ‘nonscience’ (p. 791).
He further notes three occasions when there will be recourse to these stylistic resources.
(4 In a period of expansion into the domains of
other disciplines or professions. Here the contrast between disciplines is sharpened to the ideologist’s advantage. @I In an attempt to monopolise a certain domain. Others are excluded by using labels such as ‘amateur’, ‘pseudo’ or ‘deviant’. In (cl an attempt to preserve autonomy over a domain. Scapegoatsare used to exempt members from the consequencesof their actions. What are the implications of all this for nursing? We have a sociology of knowledge that argues that truth is not the arbiter of epistemic status but rather that status is the result of past boundary disputes. Disciplinary boundaries are not rational but again the result of past battles and in a state of permanent tension. The claims of nursing theorists that they have defined the boundaries of nursing therefore has two implications. (a) That if we accept the dominance of the medical paradigm, then the theories implicitly accept or reflect existing boundaries or, (b) They are prescribing new boundaries. In the case of (a) we would expect that the use of nursing models will raise no boundary disputes with medicine despite the claims of the theorists. In the case of(b) we would expect disputes to arise but the nature of those disputes needsto be considered in the light of two other factors that are related to the above. (a) The process of professionalisation and the use of formal knowledge and, (b) The specific case of the professionalisation of nursing both historically and in terms of its gender base.
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competition as well as substantial remuneration
and higher social status (p. 41) and (b) The influential model associatedwith Freidson (1986) which sees: The machinery of professional organisations as a tool for acquiring and maintaining a privileged and autonomous position and only secondarily, if at all, as an instrument of professional self-control (p. 45).
The argument is that professional groups have power through their control of specific knowledge. This power is expressed in their terms by using concepts
such as scientific method. The usual route of accessis through a specific training and initiation procedure. This is usually characterised by a socially exclusive entry and a long training period. The social class aspect is important because working class apprenticeships in the age before deskilling were also characterised by their long duration. Formal knowledge is therefore the ideology of professional groups, and the knowledge is carefully protected through the use of jargon with obscure (to the non-classically trained, another class element) etymologies. Freidson (1986) makes the claim that encapsulates the search for professionalisation of nursing linked to the development of nursing theory: “There is a tendency for prestige and respectto be given to formal knowledge by those who lack it” (p. 4). He looks at the characterisation of formal knowledge which includes the use of esoteric terms and the exclusion of outsiders from the discourse. Those who developed modern higher knowledge addressedeach other and members of the ruling elite who shared some of their knowledge and belief in its virtues (p. 3).
This is a part of the process whereby those who have arcane knowledge are accorded high prestige. So, by implication, formal knowledge “is not part of everyday knowledge. This means that it is elite knowledge” (p. 4). This inequality in the ownership of knowledge means that its use “is of course an exercise of power, an act of domination over those who are the object” (p. 6). However, he makes the point that formal
knowledge
achieves its power by its
mediation through other power structures. He makes Professions and formal knowledge the explicit criticism of Foucault that his view of the autonomous nature of knowledge misses this point. Expansion, monopolisation and protection of autonomy are generic features of ‘professionalization’. He further develops this point when looking at how Gieryn (1983, p. 792) professions have been defined in the past. Older defiTwo sociological models of the professions have nitions stressedthe idea of expertise, later writers the concept of power. In other words, professions were to been contrasted by Rueschemeyer(1983). be characterised in terms of the power that they had, (a) The functionalist model which classifies the and the power structures that maintained them, rather professions according to characteristic traits. than more internal definitions of professions that Individually and, in association, collectively, stressedthe special nature of their knowledge base. the professions “strike a bargain with the In terms of nursing knowledge Freidson’s thesis has society” in which they exchange competence the following implications. There is no route that one and integrity against the trust of client and com- can prescribe to become a profession. The idea that munity, relative freedom from lay supervision there are once certain hurdles are cleared professional and interference, protection against unqualified status will follow is wrong. For example, one gets the
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impression from some nursing writers that if a corpus of esoteric nursing knowledge is developed then nursing can become a profession (e.g. Nyatanga, 1991). Clearly following Freidson, this is open to question. Professional status will be defined by: (a) The potentially supporting power structures. (b) By the putative profession’s relationship to existing accepted professions. The specific relations of nursing with other power structures has been examined by Katz (1969) starting from the position that “knowledge... is... a weapon for giving or depriving people of distinctive social statuses” (p. 55). Writing in the 196Os,he argues that for nursing in hospitals a bargain is made with doctors, that in return for admission to the hospital in a non-scientific caring role the nurse accepts low status. The other part of the bargain is that she assists the doctor in his scientific role and also undertakes to act as a barrier between the patient and the inadequacies and ambiguities of scientific medicine: Hospitals are, in short, under pressure to implement existing knowledge but are, at the sametime, involved in controlling knowledge (p. 57). The nurses role in terms of the organisation of knowledge occurs within a setting where, he points out, nurses are traditionally expected not to discuss doctor’s mistakes, although her own mistakes “can be openly and drastically censured” (p. 59). The nurse herself, Translates the doctors orders into discrete quanta of work, most of which sheassignsto others (Katz, 1969, p. 61). Clearly this is a boring task and Katz argues that it is a strong contributory factor to high staff turnover and wastage. In terms of the nature of the knowledge that nurses control he writes that: She has no clearly formulated body of professional knowledge that is recognised and accepted by others (P. 62). Clearly recognition of this fact has lead to the desire to create such a body of knowledge. However, despite the appropriation of knowledge from disciplines such as sociology and psychology “it is not clear to what extent nurses are actually able to put the insights into practice” (p. 63). The great distinction that he sees between medicine and nursing is in terms of the degree of universality of their relationships with patients. The nature of scientific medicine means that it is the application of general categories and solutions, therefore there is a positive disadvantage in looking for the uniqueness of each case, whereas for nursing this emphasis can be given. He locates two problems for this. (a) the technical demands of medicine reduce the amount of time that she can spend with the patient. (b) Increasing moves to professionalisation stress a management and administration focus and
therefore further removal from the bedside. As he says, the latter leads to increased social status whereas the traditional components of care do not. He locates all this within a caste system which provides ‘an unscalable wall’ between the doctor and the semi-professions. It is not a hierarchical system with possible closer approximations to the doctors status. For the nurses to achieve professional status requires, More than developing a distinct body of knowledge. It involves realisation, as Durkheim would have put it, that professionals are part of a moral community (P. 72). In other words professional status is partly the result of acceptance by legitimating groups, medicine and management in the case of nursing, who accept the knowledge claims of the aspirant group. The clear implication of Katz’s view, and little seems to have changed since the 196Os, is that any attempt to confront medicine on its own terms, that is by a scientistic approach stressing the formal knowledge of nursing, is likely to fail. For our purposes this is interesting because of the predominantly scientistic approach of most of the nursing models in use today. A criticism that can be made of his approach is that he does not draw out the implication of his use of the pronoun her for nurse and him for doctor. The gender issue is not confronted in terms of the possible epistemological and social power of a mainly female occupation. As we shall see later, science can be seen as a masculine epistemology in terms of its social organisation (Harding 1986). It can be argued from this position that nursing, therefore, stands no chance at all of professionalisation even ifit produces a coherent and impressive corpus of knowledge. Most of the above discussions have used the example of science. Allen (1985) points out that in the movement, over the last few decades, to have nursing seen as a science the concept of science has remained unproblematic. His central thesis is that empiricoanalytical science is predicated on technical control as its very nature as a theory is concerned with creating objects and postulating the dependent relationships between them. This is opposed to interpretative science which has the aim of understanding. The technical process of control can get out of hand where the means of control transcends the community’s ability to attain a rational consensus. He utilises here Habermas’s (Habermas, 1971) distinction between the technical and the practical. The former representing the means of control, the latter the elements of the community’s consensus. The issue here is that if we submit to the authority of experts, then the technocracy undermines the basis of democracy which is the free flow of information upon which rational decisions can be taken. There is, in other words, a move from civic culture to mass culture whose members uncritically submit to the authority of experts. The implication for nursing and the drive to pro-
K. Cash/Social epistemology, gender and nursing theory fessionahsation which leads to a bivalent attitude to the nurse’s relationship with patients. The first aspect is that the relationship should be direct and undistorted. The second is that it is a professional relationship. Clearly given the argument above there is a contradiction. As Habermas (1971) says, associated with the idea of control is the idea of professionalism and, The idea of professionalism itself frequently hides monopolistic, territorial prerogatives under an ideology of service and quality care (p. 63).
Gender and nursing We mentioned above the necessity of examining professions from a historical point of view and that in a number of analyses of nursing as a profession the issue of gender either not mentioned or is not seen as a central issue. Hawkesworth (1989) provides the epistemological link between general feminist theorising and the project of nurse theory when she writes “feminist theorists continue to explore theories of knowledge” (p. 533). She categorises these epistemological concerns into feminist empiricism, feminist standpoint theories and feminist postmodernism. Feminist empiricism she says is the notion that: Sexism and androcentrism are identifiable biases of individual knowers that can be eliminated by stricter application of existing methodological norms of scientific and philosophical inquiry (p, 535). This supposes the existence of neutral and genderfree procedures for evaluating knowledge claims “...it frees substantive knowledge about reality from the distorting lenses of particular observers” (p. 535). Feminist standpoint theories do not accept the above position but rather argue that knowledge, for the individual is mediated through their individual gender class and racial positions. Truth is therefore mediated through a “determinate sociopolitical formation” (p. 536). However, Hawkesworth points out that this does not mean a relativist outlook on truth, but rather that the oppressed’s privileged position creates the “core of a successor science” (p. 536). Feminist postmodernism “rejects the very possibility of a truth about reality” (p. 536). Taking the standpoint theorists implied relativity to its logical conclusion they argue that the situatedness of the individual pre-empts any privileged position that can lead to a privileged view of reality and therefore truth. Hence: Feminist postmodernists advocate a profound scepticism regarding universal (or universalizing claims about the existence, nature, and the powers of reason (p. 536).
She points out that this implies that there is not a uniform women’s view, and reinforces this argument with the appeal to the different experience of women in different cultures. However, she rejects post-
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modernism as an unsatisfactory way of analyzing the situatedness of women because it leads to a relativism that leads to passivity in the face of authoritarianism. What is constant throughout the three views above is, Hawkesworth suggests, the tendency to see one form of rationality, instrumental reason, only. They conflate all reasoning with one particular conception of rationality. Further, she argues, feminist epistemological arguments frequently resolve into functionalist discussions of epistemology. By this she means that discussion is centred on the interests that particular knowledge serves. So, “male reason promotes the interests of men as a sex-class” (p. 541). She criticises this view on the grounds that the origin of an idea might be separate from the use to which that idea is put. So the combination of instrumental reason and functionalist arguments, Sustains the appealing suggestion that the deployment of a uniquely female knowledge-a knowledge that is intuitive, emotional, engaged and caring could save humanity from the dangers of unconstrained masculinism (p. 543). As she says about this approach, intuitionism presumes “that an unmediated grasp of reality is possible but also that it is authoritative” (p. 545). The use of intuitionism is authoritarian and effectively prevents rational debate. If there is a debate between two intuitions then it cannot be resolved if the very intuition provides the truth condition. So intuitionism is both authoritarian and relativist. Knowledge then is a convention rooted in the practical judgements of a community of fallible inquirers who struggle to resolve theory dependent problems under specific historical conditions (p. 549). The social and cultural conditions provide the traditions which constitute the conceptual schemes through which the world is interpreted. She argues that this approach offers a feminist means of avoiding the pitfalls of functionalism and psychologism: Feminists can examine the specific processesby which knowledge has been constituted within determinate traditions and explore the effects of the exclusion of women from participation in those traditions (p. 551). The foundation of nursing and therefore the status of nursing knowledge occurred within a context of professionalisation where as Hearn (1987) argues that the professions “perform certain tasks formerly performed within the family” (p. 189). These include the settling of disputes and the caring for the sick, the managing of pain and the dealing with mortality. Two transfers took place with the development of professions. One was the transfer from the private to the public, the other from women to men. This results in an increase in the status of the tasks. With the growth of the semi-professions came the process whereby female activities, or activities under their control, “became... brought into public control by men, and so subject to the expertise of experts” (p. 191). This process is structured as follows: the semi-professions either:
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(4 Act as handmaidens to existing professions performing specific roles for example radiography or physiotherapy. @I Focus on specific points of reproduction, for example midwifery or, Cc) They assist in the expansion into new areas of certain professional concerns and Hearn gives here the example of psychotherapy. Because of these relationships, The male dominated professions define the limits of action and ideology and so control both reproduction and the semi-professions indirectly, almost without having to be there (p. 136). Historically, “nursing emerged as a compromise” according to Carpenter (1977, p. 165). Feminist involvement was relatively small and nursing accepted the dominant male view of women. “It was to be carried out as a service and pecuniary motives were to play no part”* (p. 166). Two other factors were important: (a) The “cloistered” separation of nurses from their clients mixed with “the espousal of religious virtues”. (b) The class differences between nurses and their clients, both factors interacting to protect the nurses from the sexual implications of their role vis a vis both male patients and doctors. “Increasing numbers of these women exchanged one rigidly authoritarian environment for another” (p. 166). The dominant model was the ‘sanitary idea’ linked to the germ theory of disease. In Carpenter’s terms this provided the demand for the potential supply of nurses. The sanitary idea was linked to the idea of hygiene, the care of patient’s needs and the keeping of the ward in a clean state. Epistemologically this idea was important because it informed all the work of the nurse down to ‘scrubbing the floors’ and meant that some contact was necessary with scientific ideas. Nightingale used the idea of the Matron as the key organisational change that as Carpenter points out gave power to the upper middle class women. As Nightingale wrote: The whole reform in nursing both at home and abroad hasconsistedin this; to take all power over the nursing out of the hands of men, and put it into the hands of one female trained head and make her responsible for everything (in Abel-Smith, 1960,p. 25). So that “what emerged was the reproduction of the Victorian class structure in the hospital” (Carpenter, 1977, p. 168). The matrons exercised power by being the symbolic wife of the doctor (Gamarnikow, 1978). In the 19.50sCarpenter (1977) articulates the changes that occurred in nursing as: (a) The increasing number of patients who became chronically ill.
(b) The increasing need for untrained nurses developed and, (c) The need to co-ordinate the other disciplines ancillary to medicine developed. The devolution of basic care to untrained nurses leads to “an increasing abandonment of traditional nursing values”. This lead to the nursing elite “to look more towards the clinical and managerial aspects of their work” (p. 174) and therefore towards professionalisation. Gamarnikow (1978) notes that the historical origin of nursing was not in terms of a debate about occupational hierarchy, that is the debate about pro and anti registration, but rather: With definitions
of nursing within an unquestioned
hierarchical model of work and authority distribution between nursing and medicine (p. 101). Nursing operated within a patriarchal system defined as one where there is domination by men qua men. This is in contradiction to the justifications of this system in terms of the relative epistemological status of nursing and medicine, a “proper division of labour resting upon work demands internal to the science” (p. 108). Rather, The occupational ideology of nursing thus genderised the division of labour: it associated science and authority with doctors, and caring-putting science into practice-with women (p. 114).
To develop as a profession therefore means that an occupation like nursing with a structure that has been historically determined on gender grounds and in a society where the knowledge products of women have been ignored, excluded or regarded as second rate (Rose, 1994; Harding, 1986) has to consider whether playing the same game as medicine or other professions will lead to that the status of profession. On the above argument the sociological identity of nursing implies that it is deeply embedded in the gendered power relations of society. The implications of this in terms of nursing can be seen as the distortion and undervaluing that occurs with any object of female thought or action. This will occur for two reasons. (a) Nursing is a mainly female occupation. (b) Nursing is a strongly contextual discipline whereas medicine can be a strongly decontextualised discipline a la science. (c) Disciplinary boundaries are the result of negotiations and struggles between interest groups using formal knowledge as their ideology. An emerging discipline therefore requires an ideology in the form of a formal knowledge structure. However, nursing is further limited in these aspirations because of the lack of status given to women’s
*This view is contradicted by Gamarnikow (1978) who argues that, on the contrary, nursing was established as a paying occupation for middle class Victorian women and that Nightingale was emphatic on this point (p. 112).
knowledge products, and because the formal knowlorientated towards scientistic based will therefore be competing in the market with higher status products such as medicine. edge is strongly products which
K. Cash/Social epistemology, gender and nursing theory (d) The consensusabout explicit form of the knowledge does not necessarily imply uniformity in terms of underlying practices.
Conclusion
The case that has been argued, therefore, is that becauseof the factors described above epistemic status will not be given to nursing knowledge becauseof any intrinsic merits that it might possess.Rather, we have a situation where that very knowledge is defined in terms of boundary disputes with other disciplines compounded by the issue of gender. To change the status of that knowledge is to redefine nursing.
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Fuller, S. (1988) Social Epistemology. Indiana University Press,Bloomington. Gamarnikow, E. (1978) Sexual division of labour: the case of nursing, In Feminism and Materialism (Kuhn, A. and Wolpe, A., Eds). Routledge and Kegan Paul, London. Geertz, C. (1973) The Interpretation of Cultures. Basic Books, New York. Gieryn, T. F. (1983) Boundary-work and the demarcation of science from non-science: strains and interests in professional ideologies of scientists. Am. Social. Rev. 48(Dec.), 781-795. Habermas, J. (1971) Towards a Rational Society. Heineman, London. Harding, S. (1986) The Science Question in Feminism. Open University Press,Milton Keynes. Hawkesworth, M. E. (1989) Knowers, knowing, known: feminist theory and claims of truth. Signs 14(31), 533-557.
References
Abel-Smith, B. (1960) A History of the Nursing Profession. Heinemann Educational Books, London. Allen, D. G. (1985) Nursing research and social control: alternative models of science that emphasize understanding and emancipation. Image: J. Nurs. Scholarship 17(Z), 58-64.
Bourdieu, P. (1975) The specificity of the scientific field and the social conditions of the progress of reason. Social Sci. Inform. 14(6), 1947. Carpenter, M. (1977) The new managerialism and professionalism in nursing. In Health and the Diuision of Labour (Stacey, M., Reid, M., Heath, C. and Dingwall, R., Eds). Croom Helm, London. Cash, K. (1990) Nursing models and the idea of nursing. Int. J. Nurs. Stud. 27(3), 249-256. Cash, K. (1992) Formal models of nursing, tacit knowledge and expertise in psychiatric nursing. Unpublished PhD Thesis, University of Manchester. Cash, K. (1995) Benner and expertise: a critique. Int. J. Nurs. Stud. 32(6), 527-534.
Foucault, M. (1972) The Archaeology of Knowledge. Routledge, London. Freidson, E. (1986). Professional Powers. University of Chicago Press,Chicago.
Hearn, J. (1987) The Gender of Oppression: Men, Masculinity and the Critique of Marxism. Wheatsheaf Books, Brighton. Katz, F. E. (1969) Nurses. In The Semi-Professions and Their Organisations. Teachers Nurses and Social Workers (Etzioni, A., Ed.). The Free Press, New
York. Kohler, R. E. (1982) From Medical Chemistry to Biochemistry. Cambridge University Press,New York. Knorr-Cetina, K. (1981) The Manufacture of Knowledge. Pergamon Press,Oxford. Kuhn, T. S. (1962) The Structure of ScientiJic Revolutions. University of Chicago Press,Chicago. Latour, B. and Woolgar, S. (1979) Laboratory Ljfe: The Social Construction of Scientific Facts. Sage, Beverley Hills. Mannheim, K. (1936). Ideology and Utopia. Routledge and Kegan Paul, London. Nyatanga, L. (1991) Nursing and the philosophy of science.Nurse Educ. Today l(Feb.), 13-18. Riehl, J. P. and Roy, C. (1980) Conceptual Nursing Models. Appleton-Century-Crofts, New York. Rose. H. (1994). Love, Power and Knowledge. Polity Press,Cambridge. Rueschemeyer,D. (1983) Professional autonomy and the social control of expertise. In The Sociology of the Professions (Dingwall, R. and Lewis, P., Eds). MacMillan PressLtd, London.
Pergamon PII: S002(r7489(96)00040
Social epistemology, gender and nursing theory Keith Cash School of Health and Social Care, Leeds Metropolitan University, Calverley Street, Leeds LSl 3HE, U.K. and the Leeds Community and Mental Health NHS Trust, Leeds, U.K. (Received 8 February 1993;revised 22 March 1996;accepted 6 September 1996) Abstract A major claim for nursing theory is that it contributes to the generation of a body of nursing knowledge that will be important in the definition of nursing’s boundaries. It is argued here that the epistemic authority of nursing knowledge is determined by factors such as the gender structure of nursing. This means the knowledge products of nursing will be given low epistemic status by both nurses and non-nurses. The implications of this argument, in terms of professionalisation and the project to develop nursing theory, are examined. 0 1997Elsevier ScienceLtd. Kqwords: Epistemic authority; gender structure; nursing theory.
Introduction The .rocial epistemology of nursing A major claim for formal nursing theories such as nursing models is that they will help in the drive for professionalisation by creating an explicit disciplinary boundary for nursing (Riehl and Roy, 1980). Underlying the development and use of nursing models is the idea that, in some way, this formalisation of nursing knowledge is related to power. That is either power over one’s own professional destiny, or power over other occupational groups, or, of course, both. This whole issue is related to the idea of the nature of knowledge, in other words epistemological problems. A central concern for nursing in this context is the concept of epistemological authority and how this is established for as Bourdieu (1975) puts it: Epistemological conflicts are always political conflicts: so that a survey on power in the scientific field could perfectly consist of apparently epistemological questions alone (Bourdieu, 1975,p. 21). I want to look at the arguments that apply to what can be termed the social epistemology of nursing. By this is meant the way that nursing knowledge is perceived by the community in general and particularly the status given to it. It will be argued that these factors affect not only the content of that knowledge but also the way that it is structured. The argument is made in several stages. The first is to look at the idea of social epistemology. The second is to look at the nature of professions, and more specifically for our purposes the relationship of formal knowledge to professionalisation and the third stage
is to look at the idea of gender in the context of professionalisation and the impact that it can have. These ideas will be related to the issue of nursing theory and the possible range of its impact. In brief, the argument will be that formal knowledge is a necessary but not sufficient condition for professionalisation because the epistemic authority of professions is socially rather than epistemologically determined and, because formal models of nursing ignore the issue of gender, they provide a distorted image of nursing. The issue of gender is related to the professions and it is demonstrated finally that nursing cannot become a profession without changing so fundamentally that it loses its social identity.
Epistemic authority Competence in a field and, therefore, a monopoly of that field is a result of the legitimation of that agent by society. Because this legitimacy is socially determined then the authority of the practitioner is subject to the knowledge that society has of their position in the established hierarchies and, therefore, their strength vis g vis other groups. As Bourdieu (1975) put it: The pure universe of even the purest scienceis a social field like any other, with its distribution of power and its monopolies, its struggles and strategies, interests and profits (p. 19). The monopoly here is: The monopoly of scientific competence, in the sense of a particular agent’s socially recognised capacity to 137
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speak legitimately (i.e. in an authorised and authoritative way) in scientific matters (p. 19).
Disciplinary boundaries
Nursing theories are in the style of the knowledge In the original thesis of the sociology of knowledge, claims of other sciencesalthough they operate in a that of Mannheim (1936) a knowledge claim repmatrix of uneven power relations with other disciresented the interests of particular group so that “granting epistemic warrant is a covet form of dis- plines. The status given to them will depend not on tributing power” (Fuller, 1988, p. 10). He notes that their ‘truth’ but rather the reflection of the status this thesis is most powerful when applied to disciplines given to nurses and nursing. To develop this argument such as law, medicine and the sciences,where topics further we need to examine the nature of disciplines are removed from the public domain and placed in and how this relates to nursing theory. Kohler (1982) gives a general definition of discithe domain of experts. Epistemic warrant is granted plines as to those who undertake a long period of training. Those that do not undertake the training have to defer Political institutions that demarcate areasof academic to the experts with the epistemic warrant. territory, allocate the privileges and responsibilities This model of knowledge interests can be criticised of expertise, and structure claims on resources(p. 1). because it gives the impression that interest groups This raises the question of how these disciplinary could dictate what constituted knowledge. This can further be interpreted in two ways. The first is that boundaries arise, for this is a central concern in nursthis granting of epistemic warrant is done in order to ing theories; the demarcation of nursing. Fuller says distribute power: this is a form of conspiracy theory. that a discipline’s boundary’s are defined by “its proThe second is this “granting of epistemic warrant” is cedure for adjudicating knowledge claims” (p. 191). identical to distributing power. Knowledge is, there- This is defined by “an argumentation format” whose fore, according to this theory interest laden. Fuller purpose is to restrict: (1988) proposes three categories of knowledge proword usage; ducers related to this. the permissible borrowings from other disci(a) The motivators: those putting forward a knowlplines; edgeclaim in the hopes that they might benefit. the appropriate contexts of discovery and (b) The benefitters: those who actually benefit. justification. (c) The users: those that use the claim in the preparation of other knowledge claims. A fully bounded discipline is autonomous. There are He argues that Mannheim’s theory conflates the three groups. The traditional view has been further criticised by the social constructivists (Latour and Woolgar, 1979;Knorr-Cetina, 1981)and others. They argue that the representation of knowledge in say an academic paper and, by implication, a nursing care plan does not necessarily show how that knowledge was actually produced. As Fuller (1988) puts it: Knowledge producers tend to take care in gathering evidence and testing claims only in proportion to the likelihood that the referee will check them (p. 13).
Therefore one getsuniformity in the expression and justification of claims without corresponding uniformities in the activities that lead to the formalisation of the knowledge claim. In the case of say, nursing care plans, their high visibility does not necessarily imply that the actions prescribed are undertaken in precisely the way that they are written, but rather that, like sciencein general, they provide an object for external ‘referees’, managers and other disciplines, for
example, to examine (Cash, 1992). In terms of science, Fuller propounds the thesis that “having knowledge is not a matter of possession” (Fuller, 1988, p. 30). A producer has knowledge if fellow producers either cite her work or follow up her work. Having knowledge is a “matter of credibility”. So, by inference, expertise is a also a matter of credibility rather than truth. Credibility conditions have precedence over truth conditions (Cash, 1995).
further constraints on the development of the boundary. (a) The discipline’s internal justification has to do with its control over somenatural kind or other well defined group of objects, e.g. botany, medicine. (b) The performance is itself self-justifying e.g. some pure mathematics. Fuller argues that this approach goes against the traditional Kuhnian or Popperian views becauseKuhn (1962) holds that a discipline develops through the coalescing of unrelated phenomena under some general unifying principles, whilst Fuller’s disciplines develop by “successively failing to control some other body of knowledge” (p. 192). The Popperian notion is that there is a rational progression based upon a procedure
that adjudicates knowledge claims. In the Fuller model, there is a social process rather than a logical process. The nature of boundary disputes in science have been examined by Gieryn (1983). He argues that they are a
“practical problem for scientists” (p. 781). The reason is that scientists have to create a boundary between science and non-science. They do this by using the
“stylistic resources” (Geertz, 1973, pp. 212-213) of ideologists. They do this by using a foil:
K. Cash/Social epistemology, gender and nursing theory Just as readers come to know Holmes better through contrasts to his foil Watson, so does the public better learn about ‘science’ through contrasts with ‘nonscience’ (p. 791).
He further notes three occasions when there will be recourse to these stylistic resources.
(4 In a period of expansion into the domains of
other disciplines or professions. Here the contrast between disciplines is sharpened to the ideologist’s advantage. @I In an attempt to monopolise a certain domain. Others are excluded by using labels such as ‘amateur’, ‘pseudo’ or ‘deviant’. In (cl an attempt to preserve autonomy over a domain. Scapegoatsare used to exempt members from the consequencesof their actions. What are the implications of all this for nursing? We have a sociology of knowledge that argues that truth is not the arbiter of epistemic status but rather that status is the result of past boundary disputes. Disciplinary boundaries are not rational but again the result of past battles and in a state of permanent tension. The claims of nursing theorists that they have defined the boundaries of nursing therefore has two implications. (a) That if we accept the dominance of the medical paradigm, then the theories implicitly accept or reflect existing boundaries or, (b) They are prescribing new boundaries. In the case of (a) we would expect that the use of nursing models will raise no boundary disputes with medicine despite the claims of the theorists. In the case of(b) we would expect disputes to arise but the nature of those disputes needsto be considered in the light of two other factors that are related to the above. (a) The process of professionalisation and the use of formal knowledge and, (b) The specific case of the professionalisation of nursing both historically and in terms of its gender base.
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competition as well as substantial remuneration
and higher social status (p. 41) and (b) The influential model associatedwith Freidson (1986) which sees: The machinery of professional organisations as a tool for acquiring and maintaining a privileged and autonomous position and only secondarily, if at all, as an instrument of professional self-control (p. 45).
The argument is that professional groups have power through their control of specific knowledge. This power is expressed in their terms by using concepts
such as scientific method. The usual route of accessis through a specific training and initiation procedure. This is usually characterised by a socially exclusive entry and a long training period. The social class aspect is important because working class apprenticeships in the age before deskilling were also characterised by their long duration. Formal knowledge is therefore the ideology of professional groups, and the knowledge is carefully protected through the use of jargon with obscure (to the non-classically trained, another class element) etymologies. Freidson (1986) makes the claim that encapsulates the search for professionalisation of nursing linked to the development of nursing theory: “There is a tendency for prestige and respectto be given to formal knowledge by those who lack it” (p. 4). He looks at the characterisation of formal knowledge which includes the use of esoteric terms and the exclusion of outsiders from the discourse. Those who developed modern higher knowledge addressedeach other and members of the ruling elite who shared some of their knowledge and belief in its virtues (p. 3).
This is a part of the process whereby those who have arcane knowledge are accorded high prestige. So, by implication, formal knowledge “is not part of everyday knowledge. This means that it is elite knowledge” (p. 4). This inequality in the ownership of knowledge means that its use “is of course an exercise of power, an act of domination over those who are the object” (p. 6). However, he makes the point that formal
knowledge
achieves its power by its
mediation through other power structures. He makes Professions and formal knowledge the explicit criticism of Foucault that his view of the autonomous nature of knowledge misses this point. Expansion, monopolisation and protection of autonomy are generic features of ‘professionalization’. He further develops this point when looking at how Gieryn (1983, p. 792) professions have been defined in the past. Older defiTwo sociological models of the professions have nitions stressedthe idea of expertise, later writers the concept of power. In other words, professions were to been contrasted by Rueschemeyer(1983). be characterised in terms of the power that they had, (a) The functionalist model which classifies the and the power structures that maintained them, rather professions according to characteristic traits. than more internal definitions of professions that Individually and, in association, collectively, stressedthe special nature of their knowledge base. the professions “strike a bargain with the In terms of nursing knowledge Freidson’s thesis has society” in which they exchange competence the following implications. There is no route that one and integrity against the trust of client and com- can prescribe to become a profession. The idea that munity, relative freedom from lay supervision there are once certain hurdles are cleared professional and interference, protection against unqualified status will follow is wrong. For example, one gets the
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impression from some nursing writers that if a corpus of esoteric nursing knowledge is developed then nursing can become a profession (e.g. Nyatanga, 1991). Clearly following Freidson, this is open to question. Professional status will be defined by: (a) The potentially supporting power structures. (b) By the putative profession’s relationship to existing accepted professions. The specific relations of nursing with other power structures has been examined by Katz (1969) starting from the position that “knowledge... is... a weapon for giving or depriving people of distinctive social statuses” (p. 55). Writing in the 196Os,he argues that for nursing in hospitals a bargain is made with doctors, that in return for admission to the hospital in a non-scientific caring role the nurse accepts low status. The other part of the bargain is that she assists the doctor in his scientific role and also undertakes to act as a barrier between the patient and the inadequacies and ambiguities of scientific medicine: Hospitals are, in short, under pressure to implement existing knowledge but are, at the sametime, involved in controlling knowledge (p. 57). The nurses role in terms of the organisation of knowledge occurs within a setting where, he points out, nurses are traditionally expected not to discuss doctor’s mistakes, although her own mistakes “can be openly and drastically censured” (p. 59). The nurse herself, Translates the doctors orders into discrete quanta of work, most of which sheassignsto others (Katz, 1969, p. 61). Clearly this is a boring task and Katz argues that it is a strong contributory factor to high staff turnover and wastage. In terms of the nature of the knowledge that nurses control he writes that: She has no clearly formulated body of professional knowledge that is recognised and accepted by others (P. 62). Clearly recognition of this fact has lead to the desire to create such a body of knowledge. However, despite the appropriation of knowledge from disciplines such as sociology and psychology “it is not clear to what extent nurses are actually able to put the insights into practice” (p. 63). The great distinction that he sees between medicine and nursing is in terms of the degree of universality of their relationships with patients. The nature of scientific medicine means that it is the application of general categories and solutions, therefore there is a positive disadvantage in looking for the uniqueness of each case, whereas for nursing this emphasis can be given. He locates two problems for this. (a) the technical demands of medicine reduce the amount of time that she can spend with the patient. (b) Increasing moves to professionalisation stress a management and administration focus and
therefore further removal from the bedside. As he says, the latter leads to increased social status whereas the traditional components of care do not. He locates all this within a caste system which provides ‘an unscalable wall’ between the doctor and the semi-professions. It is not a hierarchical system with possible closer approximations to the doctors status. For the nurses to achieve professional status requires, More than developing a distinct body of knowledge. It involves realisation, as Durkheim would have put it, that professionals are part of a moral community (P. 72). In other words professional status is partly the result of acceptance by legitimating groups, medicine and management in the case of nursing, who accept the knowledge claims of the aspirant group. The clear implication of Katz’s view, and little seems to have changed since the 196Os, is that any attempt to confront medicine on its own terms, that is by a scientistic approach stressing the formal knowledge of nursing, is likely to fail. For our purposes this is interesting because of the predominantly scientistic approach of most of the nursing models in use today. A criticism that can be made of his approach is that he does not draw out the implication of his use of the pronoun her for nurse and him for doctor. The gender issue is not confronted in terms of the possible epistemological and social power of a mainly female occupation. As we shall see later, science can be seen as a masculine epistemology in terms of its social organisation (Harding 1986). It can be argued from this position that nursing, therefore, stands no chance at all of professionalisation even ifit produces a coherent and impressive corpus of knowledge. Most of the above discussions have used the example of science. Allen (1985) points out that in the movement, over the last few decades, to have nursing seen as a science the concept of science has remained unproblematic. His central thesis is that empiricoanalytical science is predicated on technical control as its very nature as a theory is concerned with creating objects and postulating the dependent relationships between them. This is opposed to interpretative science which has the aim of understanding. The technical process of control can get out of hand where the means of control transcends the community’s ability to attain a rational consensus. He utilises here Habermas’s (Habermas, 1971) distinction between the technical and the practical. The former representing the means of control, the latter the elements of the community’s consensus. The issue here is that if we submit to the authority of experts, then the technocracy undermines the basis of democracy which is the free flow of information upon which rational decisions can be taken. There is, in other words, a move from civic culture to mass culture whose members uncritically submit to the authority of experts. The implication for nursing and the drive to pro-
K. Cash/Social epistemology, gender and nursing theory fessionahsation which leads to a bivalent attitude to the nurse’s relationship with patients. The first aspect is that the relationship should be direct and undistorted. The second is that it is a professional relationship. Clearly given the argument above there is a contradiction. As Habermas (1971) says, associated with the idea of control is the idea of professionalism and, The idea of professionalism itself frequently hides monopolistic, territorial prerogatives under an ideology of service and quality care (p. 63).
Gender and nursing We mentioned above the necessity of examining professions from a historical point of view and that in a number of analyses of nursing as a profession the issue of gender either not mentioned or is not seen as a central issue. Hawkesworth (1989) provides the epistemological link between general feminist theorising and the project of nurse theory when she writes “feminist theorists continue to explore theories of knowledge” (p. 533). She categorises these epistemological concerns into feminist empiricism, feminist standpoint theories and feminist postmodernism. Feminist empiricism she says is the notion that: Sexism and androcentrism are identifiable biases of individual knowers that can be eliminated by stricter application of existing methodological norms of scientific and philosophical inquiry (p, 535). This supposes the existence of neutral and genderfree procedures for evaluating knowledge claims “...it frees substantive knowledge about reality from the distorting lenses of particular observers” (p. 535). Feminist standpoint theories do not accept the above position but rather argue that knowledge, for the individual is mediated through their individual gender class and racial positions. Truth is therefore mediated through a “determinate sociopolitical formation” (p. 536). However, Hawkesworth points out that this does not mean a relativist outlook on truth, but rather that the oppressed’s privileged position creates the “core of a successor science” (p. 536). Feminist postmodernism “rejects the very possibility of a truth about reality” (p. 536). Taking the standpoint theorists implied relativity to its logical conclusion they argue that the situatedness of the individual pre-empts any privileged position that can lead to a privileged view of reality and therefore truth. Hence: Feminist postmodernists advocate a profound scepticism regarding universal (or universalizing claims about the existence, nature, and the powers of reason (p. 536).
She points out that this implies that there is not a uniform women’s view, and reinforces this argument with the appeal to the different experience of women in different cultures. However, she rejects post-
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modernism as an unsatisfactory way of analyzing the situatedness of women because it leads to a relativism that leads to passivity in the face of authoritarianism. What is constant throughout the three views above is, Hawkesworth suggests, the tendency to see one form of rationality, instrumental reason, only. They conflate all reasoning with one particular conception of rationality. Further, she argues, feminist epistemological arguments frequently resolve into functionalist discussions of epistemology. By this she means that discussion is centred on the interests that particular knowledge serves. So, “male reason promotes the interests of men as a sex-class” (p. 541). She criticises this view on the grounds that the origin of an idea might be separate from the use to which that idea is put. So the combination of instrumental reason and functionalist arguments, Sustains the appealing suggestion that the deployment of a uniquely female knowledge-a knowledge that is intuitive, emotional, engaged and caring could save humanity from the dangers of unconstrained masculinism (p. 543). As she says about this approach, intuitionism presumes “that an unmediated grasp of reality is possible but also that it is authoritative” (p. 545). The use of intuitionism is authoritarian and effectively prevents rational debate. If there is a debate between two intuitions then it cannot be resolved if the very intuition provides the truth condition. So intuitionism is both authoritarian and relativist. Knowledge then is a convention rooted in the practical judgements of a community of fallible inquirers who struggle to resolve theory dependent problems under specific historical conditions (p. 549). The social and cultural conditions provide the traditions which constitute the conceptual schemes through which the world is interpreted. She argues that this approach offers a feminist means of avoiding the pitfalls of functionalism and psychologism: Feminists can examine the specific processesby which knowledge has been constituted within determinate traditions and explore the effects of the exclusion of women from participation in those traditions (p. 551). The foundation of nursing and therefore the status of nursing knowledge occurred within a context of professionalisation where as Hearn (1987) argues that the professions “perform certain tasks formerly performed within the family” (p. 189). These include the settling of disputes and the caring for the sick, the managing of pain and the dealing with mortality. Two transfers took place with the development of professions. One was the transfer from the private to the public, the other from women to men. This results in an increase in the status of the tasks. With the growth of the semi-professions came the process whereby female activities, or activities under their control, “became... brought into public control by men, and so subject to the expertise of experts” (p. 191). This process is structured as follows: the semi-professions either:
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(4 Act as handmaidens to existing professions performing specific roles for example radiography or physiotherapy. @I Focus on specific points of reproduction, for example midwifery or, Cc) They assist in the expansion into new areas of certain professional concerns and Hearn gives here the example of psychotherapy. Because of these relationships, The male dominated professions define the limits of action and ideology and so control both reproduction and the semi-professions indirectly, almost without having to be there (p. 136). Historically, “nursing emerged as a compromise” according to Carpenter (1977, p. 165). Feminist involvement was relatively small and nursing accepted the dominant male view of women. “It was to be carried out as a service and pecuniary motives were to play no part”* (p. 166). Two other factors were important: (a) The “cloistered” separation of nurses from their clients mixed with “the espousal of religious virtues”. (b) The class differences between nurses and their clients, both factors interacting to protect the nurses from the sexual implications of their role vis a vis both male patients and doctors. “Increasing numbers of these women exchanged one rigidly authoritarian environment for another” (p. 166). The dominant model was the ‘sanitary idea’ linked to the germ theory of disease. In Carpenter’s terms this provided the demand for the potential supply of nurses. The sanitary idea was linked to the idea of hygiene, the care of patient’s needs and the keeping of the ward in a clean state. Epistemologically this idea was important because it informed all the work of the nurse down to ‘scrubbing the floors’ and meant that some contact was necessary with scientific ideas. Nightingale used the idea of the Matron as the key organisational change that as Carpenter points out gave power to the upper middle class women. As Nightingale wrote: The whole reform in nursing both at home and abroad hasconsistedin this; to take all power over the nursing out of the hands of men, and put it into the hands of one female trained head and make her responsible for everything (in Abel-Smith, 1960,p. 25). So that “what emerged was the reproduction of the Victorian class structure in the hospital” (Carpenter, 1977, p. 168). The matrons exercised power by being the symbolic wife of the doctor (Gamarnikow, 1978). In the 19.50sCarpenter (1977) articulates the changes that occurred in nursing as: (a) The increasing number of patients who became chronically ill.
(b) The increasing need for untrained nurses developed and, (c) The need to co-ordinate the other disciplines ancillary to medicine developed. The devolution of basic care to untrained nurses leads to “an increasing abandonment of traditional nursing values”. This lead to the nursing elite “to look more towards the clinical and managerial aspects of their work” (p. 174) and therefore towards professionalisation. Gamarnikow (1978) notes that the historical origin of nursing was not in terms of a debate about occupational hierarchy, that is the debate about pro and anti registration, but rather: With definitions
of nursing within an unquestioned
hierarchical model of work and authority distribution between nursing and medicine (p. 101). Nursing operated within a patriarchal system defined as one where there is domination by men qua men. This is in contradiction to the justifications of this system in terms of the relative epistemological status of nursing and medicine, a “proper division of labour resting upon work demands internal to the science” (p. 108). Rather, The occupational ideology of nursing thus genderised the division of labour: it associated science and authority with doctors, and caring-putting science into practice-with women (p. 114).
To develop as a profession therefore means that an occupation like nursing with a structure that has been historically determined on gender grounds and in a society where the knowledge products of women have been ignored, excluded or regarded as second rate (Rose, 1994; Harding, 1986) has to consider whether playing the same game as medicine or other professions will lead to that the status of profession. On the above argument the sociological identity of nursing implies that it is deeply embedded in the gendered power relations of society. The implications of this in terms of nursing can be seen as the distortion and undervaluing that occurs with any object of female thought or action. This will occur for two reasons. (a) Nursing is a mainly female occupation. (b) Nursing is a strongly contextual discipline whereas medicine can be a strongly decontextualised discipline a la science. (c) Disciplinary boundaries are the result of negotiations and struggles between interest groups using formal knowledge as their ideology. An emerging discipline therefore requires an ideology in the form of a formal knowledge structure. However, nursing is further limited in these aspirations because of the lack of status given to women’s
*This view is contradicted by Gamarnikow (1978) who argues that, on the contrary, nursing was established as a paying occupation for middle class Victorian women and that Nightingale was emphatic on this point (p. 112).
knowledge products, and because the formal knowlorientated towards scientistic based will therefore be competing in the market with higher status products such as medicine. edge is strongly products which
K. Cash/Social epistemology, gender and nursing theory (d) The consensusabout explicit form of the knowledge does not necessarily imply uniformity in terms of underlying practices.
Conclusion
The case that has been argued, therefore, is that becauseof the factors described above epistemic status will not be given to nursing knowledge becauseof any intrinsic merits that it might possess.Rather, we have a situation where that very knowledge is defined in terms of boundary disputes with other disciplines compounded by the issue of gender. To change the status of that knowledge is to redefine nursing.
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Fuller, S. (1988) Social Epistemology. Indiana University Press,Bloomington. Gamarnikow, E. (1978) Sexual division of labour: the case of nursing, In Feminism and Materialism (Kuhn, A. and Wolpe, A., Eds). Routledge and Kegan Paul, London. Geertz, C. (1973) The Interpretation of Cultures. Basic Books, New York. Gieryn, T. F. (1983) Boundary-work and the demarcation of science from non-science: strains and interests in professional ideologies of scientists. Am. Social. Rev. 48(Dec.), 781-795. Habermas, J. (1971) Towards a Rational Society. Heineman, London. Harding, S. (1986) The Science Question in Feminism. Open University Press,Milton Keynes. Hawkesworth, M. E. (1989) Knowers, knowing, known: feminist theory and claims of truth. Signs 14(31), 533-557.
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