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Ongoing development of nursing science requires attention to the philosophical and theoretical basis upon which the science is built. A feminist theoretical perspective offers a useful lens for understanding the needs of both nurses and their clients. Adolescent and young adult women are an underserved and understudied population for whom nursing care can be especially beneficial. Considering the needs of this population from a philosophical perspective, through a feminist lens, is one effective means of developing nursing science approaches that contribute to and ultimately improve care for adolescent and young adult women.
The greatest potential for successful provision of healthcare relies in part on formulating and delivering care that acknowledges and incorporates an individual's experiences, knowledge and expectations of health. Such efforts are often the specific province of nursing, which has been described as the art of combining empirical knowledge of physical processes with intuitive and acquired knowledge of the individual client. The philosophical questions of what constitutes each type of knowledge and how it is applied are critically important, if somewhat elusive, underpinnings of the art and the science of nursing. The process by which nurses progressively integrate clinical skills and knowledge and professional judgment has long been of interest to nurse researchers and educators because of the associated potential to enhance how nursing knowledge is acquired, applied, and shared.1 Some scholars have also sought to determine what the responsibilities of nursing science are to nurses and how best to ensure that these are fulfilled,2 and note that nursing theory and nursing science must rely on the practice experiences of nurses to be applicable to the profession's advancement.2,3 Efforts of this type could perhaps be described as the provision of nursing care to nursing: seeking to apply principles that shape the practice of nursing to the ongoing development of the professional science of nursing, its ontology and epistemology.
A parallel can be drawn between this “nursing of nursing” and the efforts entailed in developing care for special populations and the individual members thereof. The existence of such similarity is indicative of the fundamental need for nursing's contributions in the mutable structure of modern healthcare. Nurses must often seek to understand the individual's ways of relating to health, and to determine what ongoing cognitive and behavioral processes may augment or hinder the ability to participate in care. This is of special importance in assessing and meeting the needs of underserved or understudied groups, where different factors may influence the giving and receiving of care. It is thus incumbent on development of both the practice discipline and the larger profession and science of nursing to incorporate efforts that advance understanding of health-related experiences in underserved or vulnerable groups.
One population notably often absent from the nursing research literature is that of adolescent and young adult women. Examination of this population has historically been frustrated by suppositions that adolescents are most similar to children and must mainly be protected from risk, or that young adults possess the same psychosocial stability as other adults and can therefore be treated as such.4 Paradoxically, adolescents—particularly girls—have been popularly viewed as overly emotional and difficult to work with, and thus with limited ability to make healthy decisions or to participate in healthcare.5-7 Since the late 1990s, however, care providers working with these groups have questioned such presumptions and suggested that young people can well make effective contributions to their own healthcare.5,8-10 As dedicated care for this population is needed in multiple contexts, and as preventive healthcare becomes a greater priority globally, it is useful to consider the ways in which the evolving pursuit of nursing knowledge can inform the development of such care.11,12 In both areas, the nature of knowledge and its applications are at stake—as nurses pursue development of the science that shapes our professional lives, adolescents and young adults often seek greater understanding of the events that shape their daily lives.7 Much as nursing research has sought to make the voices of nurses evident in its literature, efforts to develop care strategies for young people must incorporate the voices of adolescents and young adults.13,14 Both enterprises seek to illuminate some aspect of lived experience, whether personal or professional, that has been “previously unexamined [or] misunderstood,” and therefore a feminist perspective is likely to be effective in developing the knowledge sought15(p135).
Philosophical examination—specifically via a philosophy of science approach—has been and continues to be both vital to and effective in the development of nursing science. Described as efforts to make sense of and to extrapolate explanations from observation, philosophies of science seek to elucidate how the work of practitioners of science shapes the field.16,17 In addition, a philosophy of science may examine how knowledge is created and maintained in the practice of scientific exploration.18 Nursing science has, however, been described as distinct from other types of science, owing to its specific and ongoing combination of applied theory and practice within the act of providing or “doing” nursing.19 For both nursing generally and the care of adolescent and young adult women specifically, philosophical questions about the nature of knowledge bear special relevance. The goal of this paper is therefore to examine how a feminist standpoint on the philosophical development of nursing science can support the improvement of care for adolescent and young adult women.
Philosophy of science is a constantly evolving field, seeking to illuminate the ways in which knowledge is acquired and utilized for inquiry or in this case, to enhance and support practice 16,19. As such, disagreements about what constitutes inquiry, knowledge, and even science itself persist. In both nursing generally and the care of adolescent and young adult women specifically, the development of a philosophical framework for studying the population of interest requires examination of the ways in which discernment and integration function both for the provider and within the population. Adolescents' perceptions of personal health and beliefs about health more broadly are of particular relevance to health care providers, since they may influence risk-taking behaviors, relationships, and other important aspects of development.7,12,20-23 Likewise, individual nurses' perceptions of nursing as a whole and of nursing care-provision are necessary parts of a developing professional science, since they influence when and how that science is applied.3,24 For girls and young women, health beliefs and behaviors may be informed by the centrality of the desire for good relationships—romantic and otherwise—which is one way by which these populations self-locate socially, or sociolocate.25 This refers to the act of evaluating self-worth by the timbre of one's relationships with others: the more positive relationships the individual has, the better or more worthy she must be. Nursing as a profession has also struggled with the centrality of forming relationships, whether with colleagues in other disciplines, among nurses with different expertise or levels of experience, or with clients in the caregiving process.26,27 Historically, the valuation of relationships has been viewed as emotional and therefore unscientific, feminine in nature, or anti-intellectual, and this has been used both to dismiss the needs of adolescent and young adult women and to deny the agency of nursing as a science.28
Far from being detrimental, disagreements about what constitutes science are fundamental to philosophy—as Rosenberg17 notes, “Philosophy deals with two sets of questions: First, questions that science…cannot answer now and perhaps may never be able to answer. Second, the questions about why the sciences cannot answer the first lot of questions.” (p. 4) Efforts to generate philosophies of science in new and divergent contexts are therefore vital to the continued existence of the field. Although only a modicum of work in the philosophy of science has yet specifically focused on nursing, there are myriad ways in which it informs the discipline. Meleis3 and others29 have described “borrowing” and synthesis in order to generate nursing-specific perspectives on existing phenomena.19 Walker and Avant30 have also described a process of theory derivation by which existing theoretical constructs can be selectively and purposively applied in order that they become more relevant to nursing. Since many nursing scholars have already touched on the consequences of nursing's history being heavily influenced by the fact that it was long a mainly female-populated profession,28,31 feminist theory offers a useful lens for the examination of nursing and its interactions with adolescent and young adult women's health.
An important tenet of feminist theory is that women's contributions to professional arenas have at times been either ignored or devalued in large part because they originate with women.7,28,32 For nursing especially, this is an important point of consideration not only because nurses have historically been predominantly women, but also because the work of nursing has been characterized as somehow feminine in nature. An early instance of the confluence of nursing and the constructs of femininity is found in Florence Nightingale's Notes on Nursing: What it is and what it is not, considered by many to represent the beginnings of professional nursing.22 According to its author, the purpose of the original text was to “give hints…to women who have personal charge of the health of others.”(p. 3) Interestingly, this demonstrates both that the author sees the provision of health-related care as a female activity and that she does not necessarily consider it something that is a profession. In the same passage, she notes that her writings are not intended to prepare nurses for nursing, adding that the responsibilities of care-giving are really those of women at large.22 This is characteristic of the first wave of the feminist movement, in which women sought “social and political equality while honoring the ideal moral, intuitive and nurturing” qualities then attributed mainly to the female gender.32(p. 342)
Problems with this construction of femininity in feminism in part drove what has been called second wave feminism, when perceptions of women as embodying these caring qualities came to be seen as creating artificial and restrictive divisions that devalued women and their work.32 As one of these activities, nursing was associated with women's domestic roles—an extension of the caretaking seen as the role of wife and mother, largely carried out in the private, rather than the public, sphere.28,32 Despite the fact that professional nursing care necessarily occurs in the public sphere, its association with private-sphere, home-related roles of women has been seen as detrimental to the advancement of the profession and its science.28
This stance, too, has become problematic with the post-modern increase in scholarly efforts to expand on Nightingale's original thoughts about the definition of nursing. Post-modernism, specifically in regard to scientific development and rigor, allows for the use of multiple means of discovery in the generation of new knowledge.3,29 Along the same continuum of broadening knowledge is poststructuralism, in which power dynamics and accepted social “structure” are also factored into how knowledge is both developed and acknowledged by a scientific community.3,33 As already discussed, in nursing some attempts in this area have been complicated by lack of clarity about how the intellectual component of nursing practice occurs. One effort to remedy this is seen in the work of some nursing theorists to assess the role of moral reasoning in nursing, and to develop frameworks that account for the role of this reasoning in practice. Some of these works have utilized an ethical construct known as the ethics of care, which emphasizes centrality of relationships, trust, and emotional connection in healthcare.34-36 This construct originates in Gilligan's work on the ways in which bias—specifically binary gender bias and the subsequent assignment or expectation of gendered behaviors—conflicts with the potential for women and girls to be agent, both morally and socially.37 In the ethics of care, relationships and interactions become as fundamental as any other factor in overall health and successful development of the individual, and serve to disrupt the predominance of hierarchical structures such gender binarism, heteronormativity, and scientific positivism.38,39 This is decidedly both a feminist and specifically poststructuralist approach.
Obviously, this conflicts to some extent with the efforts of second-wave feminism to eradicate emphasis on caring and relationship development from the social construction of women's roles. There is, however, room for it in third-wave feminist theory, which incorporates the poststructuralist perspective and emphasizes the value of difference, multiple perspectives, and intersectionality in social discourse.32,39 Feminist standpoint theory, which emerged in part from efforts to combat the tendency toward reductionist absolutism at the intersection of these social and scientific discourses, incorporates emphasis on multiplicity and heterogeneity in both approach and valuation within scientific exploration.38 The concept of intersectionality, which specifically resists the essentializing of populations into singular social descriptors such as age or race, suggests the myriad dimensions in which an individual exists in any social interaction—including accessing health care. Both have great significance for nursing care of adolescent and young adult women. In planning for the care of anyone who has needs ranging beyond acute intervention, the application of multiple perspectives to a given situation may be the most effective means of promoting overall health.39 It is at this point in the application of feminist analysis to nursing that exploration of adolescent and young adult women's healthcare becomes extremely relevant.
The historic bias recorded by feminist scholars in the development and professionalization of health sciences parallels a demonstrable bias against adolescent and young adult women. Adolescence and young adulthood have been acknowledged as periods of heightened risk for health-related problems, but this risk has historically been viewed as behavioral in nature—most aptly demonstrated by the perception of adolescence as a de facto time of “storm and stress” and risk-taking behaviors.6,8 Related issues include social perceptions and characterizations of young women as emotionally dramatic, duplicitous, and otherwise difficult to work with, as well as the idea that models of adolescent and young adult health needs can be easily derived from otherwise adult or pediatric models5,6,40. These biases are harmful to care providers as well as to adolescent and young adult women because they can proscribe therapeutic interaction—even when providers are receptive to the needs of young clients, the expectation of devaluation or rejection of their input can cause young women to forego care5,8,12,40,41. Encapsulating the complexities of this situation, Reimer-Kirkham and Anderson42 argue for the role of a feminist dialectic between the provision of care and the need for advocacy by nurses for themselves as well as for their patients. The establishment of working care models for adolescent and young adult women thus depends on the ability of providers to account for and manage multiple factors in the lives of these women.
Adolescent and young adult health has recently emerged as an important focus area for providers. This is at least partially due to the fact that some adult health problems have been linked to prior life events, including those of adolescence. It is worth noting that in many studies suggesting such a link, the inceptive event was of a traumatic nature—either physical or psychological—and that for adolescent and young adult women, the impact of relationship- or gender-based trauma has its own set of problematic implications.25,43,44 This suggests that there are missed opportunities for prevention as well as intervention with this population. In considering such oversights, questions arise of how best to assess and respond to the needs of young women, how to encourage their participation in health-related activities, and how to integrate the appropriate care frameworks into existing systems 5,21,44. Answers to these questions may depend largely on what adolescent and young adult women know about and want from their personal health—much as the development of nursing science depends on what nurses know about and want from their profession. In order to move toward the elucidation of these answers, a strong philosophy of science for and within nursing is crucial.
The work of nursing has been described as science, as art, and a combination of both.24,28,45,46 Within the profession there has been considerable emphasis on establishing nursing as a scientific discipline, on using scientific methodology to establish an empirical practice framework, and on the necessity of applying technology in professional nursing—yet conceptualization of and references to nursing as an art persist, implying that the conjunction of art and science is somehow fundamental to the profession28. This suggests the importance to nursing of something other than strictly concrete or positivistic epistemology and its application—something that is connected to individual nurses as well as to the overall profession. This has been described in terms of development and self-identification as a nurse,32 patterns of knowledge application in nursing,24 experiential knowledge acquisition and recollection of “information alerting,”1 direct integration of science and social support in a holistic manner,3 and the combination of individual wisdom with practice activity.45 These descriptions evoke a particular understanding of practice unique among nurses—an understanding acquired through participation in the work of nursing and associated learning processes that rely on both evaluative observation and reflexive evaluation.
Evaluation—both through direct observation, as when working with a client; and reflexive, as when considering the actions of self in retrospect—and the effort to derive or interpret the meaning of occurrences are clearly important nursing activities. Both kinds of evaluation activity allow nurses to develop personal ways of formulating responses to practice situations, ways not always easily conveyed to others.1 Efforts to do so often rely on instructions for skill acquisition or task performance, but leave out necessary linkages made through professional judgment, clinical forethought, or other insight that an experienced nurse may not even consciously recognize.1,18,24 Polanyi describes the spontaneous making of this connection between the directly observed and the determined meaning as the application of tacit knowledge, an idea echoed in the words of nurses who in striving to share their knowledge and experience have explained that they “just knew” something about a client.1,18 Describing these phenomena and gaining access to the vast amount of knowledge accrued as well as transmitted this way are among the main challenges facing the development of the omnibus nursing science.
Similarly, efforts to develop useful models of care for adolescent and young adult women are complicated because these populations are not easily aggregated, and have broad, divergent cognitive, developmental and physical health needs.47,48 The many life transitions occurring at this time create a complex psychosocial experience, rendering difficult the application of universal or even linear developmental models to care planning.9 In addition, the complexity and extremity of psychosocial change in this population can increase both relational and physical risks, which can include both social and bodily injury risk, cumulatively creating significant short- and long-term implications for individual health.9,49 While existing in this state of flux, it may be difficult for adolescent and young adult women to fully recognize and communicate health-related needs.47,48,50 Nonetheless, it has been shown that young women do engage in behaviors to enhance and improve their health and wellbeing.20,23,25 This evidence of self-caring suggests that like nurses, young women may know more about themselves and their needs than they readily verbalize.
Adolescent and young adult women's lack of direct health need articulation is compounded by the fact that little is well understood about younger populations' preferences for access to healthcare and health information—a situation not unlike that facing nursing scholars attempting to create effective education and advocacy models for nursing.5,14,32 For both groups, the transference of knowledge is at issue, but the composition of that knowledge and its implications for care-provision remain somewhat ambiguous—obscured perhaps by the emotional and lived experience that itself creates the knowledge. These felt or experienced emotional ways of knowing are the focus of aesthetic inquiry, which has been applied to developing understanding of nurses' knowledge.45,46,51 Although aesthetic inquiry could logically benefit the study of adolescent and young adult women's health, it has been little used—which may again proceed from certain social structures and perceptions of what young women are like emotionally and socially. For adolescent and young adult women, this is especially relevant to population-level risks because it means that health-related issues may be overlooked by parents, providers and other support persons.21,41,50 Without standard care models or even adequate theoretical frameworks upon which to draw, care providers may be less able to anticipate the needs of young women and miss opportunities for therapeutic interaction, prevention, or education.41,47 Failure to take advantage of such opportunities may be part of the reason that much of adolescent and young adult healthcare has involved intervention in, rather than prevention of, health problems.
Although some of the focus in adolescent and young adult healthcare has already shifted from intervention to prevention, little data is available to shape collaborative care strategies for young woman and their providers.52 While much discussion of negative influences on young women's health and self-concept has emerged in health care and other social sciences, only modest effort has been made to examine the ways in which this population actually develops understanding and personal perceptions of health.13,23,44 The present shortage of specialized care strategies for adolescent and young adult women, despite evidence of the need for such care, suggests that this group remains distinctly underserved.52 Ensuring adequate care of underserved populations is a crucial part of maintaining overall community and public health standards, and is addressed as a key responsibility for care providers in various professional ethics resources.34,53 As nurse scientists and scholars seek to shape the future of the profession, it is thus undeniably important that care of adolescent and young adult women be considered an area worthy of knowledge development in nursing.
There are numerous questions related to the creation of care models for adolescent and young adult women that are unresolved. Among them are what the nature of health knowledge among this population is and how care providers can best contribute to and foster the expansion of that knowledge.20,54 These questions address a combination of philosophical and practical issues that are key to formulating a nursing response to the needs of young women. Though the development of care models for this population must necessarily be complex, nurses are in an ideal position to influence the health of young women and therefore to shape the development of their healthcare as a field.9 This is so for a variety of reasons, among them the fact that nursing as a profession has already sought to examine some of the intricacies of knowledge acquisition related to health in its efforts to establish and elaborate the science of nursing. Applying analogous strategies to the creation of improved care systems for young women may provide insights into this practice area as well as the overall profession.
A variety of techniques, already proven successful in nursing inquiry, are available to obtain information about the ways in which adolescents and young adults conceive of and participate in personal health. Among these, in addition to the potential for aesthetically-based inquiry already noted, are reflective journaling, generation of personal narratives, communication evaluation, peer interviewing, and participatory and/or transformative inquiry33. Common to most of these techniques is an emphasis on relationship—either between the client and the nurse, between clients, or between the client and another source of support. This commonality is no accident: it reflects both the centrality of relationships to nursing and the high premium many young women place on relationships in their lives 9,23. These relationships are an important point entrée in care of this population, in part because they have not always been acknowledged or validated. The nursing profession has had a similar problem, wherein nurses' perspectives on diagnoses, care planning and treatments have at times been devalued as non-scientific because nurses are viewed as being heavily influenced by their relationships with clients.35 Therefore, nursing science that integrates both aesthetic and feminist perspectives is likely to produce care structures that are more effective for both nurses and the young women in our care.
The use of the term “feminist” has been problematic in the social sciences because for some it connotes a specific interest in gender-related experiences, even though feminist standpoints often explore many types of disempowering social constructs.3,34 Among these are constructs that have been seen to prescribe the roles of certain social groups in the absence of input from those groups. Fundamental to the current feminist philosophical stance on developing science is the idea that any science intended to affect the lived experiences of a population must incorporate and set in a place of value the individual voices within that population.12,32,33 This idea is not uniquely feminist, however, as the practice of nursing has also been shown to require special focus on the needs and abilities of individuals. Although little literature exists on a specifically feminist conceptualization of nursing, there is clearly a shared focus on empowerment and validation of individual experiences33,55. This congruency suggests that feminism and nursing—or some synthesis thereof—have considerable relevance to the development of care for underserved populations.
With regard to adolescent and young adult women's healthcare, the combination of feminist and nursing principles is especially and in fact necessarily useful. Reflection and observation, already important to both the practice and scientific development of nursing, are valuable tools for working with young women in that they afford nurses the opportunity to consider both personal and professional responses to needs. Addition of a feminist emphasis to nursing activities could help spotlight the ways in which adolescent and young adult women also practice reflection and observation as they navigate the changes and transitions inherent in their lives. Many young women demonstrably prioritize relationships, and place considerable personal focus on the maintenance of those relationships5,9. Nurses, for whom the formation and utilization of relationships is often an important aspect of practice, are therefore uniquely situated to generate care options appropriate to this population. By drawing the feminist perspective within nursing, nurses and nurse scientists may be able to establish effective models of care delivery to young women, as well as further elucidate the structure and function of nursing science and praxis.
The present dearth of specifically nursing-generated literature on the care of young women is easily demonstrated through examination of the reference section of this paper. As this area garners more attention from care providers in a variety of disciplines, it is imperative that nursing be among those contributing to the development of care strategies. This is so for several reasons, not least among them the potential contribution of exploration in this area to an expanding science of nursing. Because the structure of our science is still somewhat nascent, as well as controversial among its scholars, it seems important to consider how it can be applied in a variety of contexts—especially those not yet fully expounded by other disciplines. Efforts to involve nursing in the development of care systems and structures for young women will allow the formulation of nursing-driven and nursing-specific responses to the needs of these women—a vital aspect of differentiation for the profession. In addition, such work shifts focus to theoretical and structural work within nursing, illustrating both the diversity of the profession and its potential to integrate the abstract with the practical work that are both fundamental to nursing. It has been argued that such integration is particularly necessary to legitimize nursing science and to counter the perception of nursing as a solely derivative field 3,24,32. With a feminist philosophical approach, it is possible to develop nursing science interdisciplinarily without losing scientific autonomy.
As the profession of nursing seeks knowledge of both nurses and their clients, opportunities to foster exploration in both populations simultaneously are of singular value. By applying the techniques already in use by nurse researchers to gain knowledge of nurses and their practices to adolescent and young adult women's perceptions of and involvement with health, nursing scholars may make considerable contributions to care for this population. At the same time, nuances of technique and its application not previously evident may emerge—a process similar to that which occurs as individual nurses observe, reflect on, and practice nursing. This use of nursing principles to guide professional and disciplinary growth, the idea of nursing care for nursing, is perhaps the best way to ensure that nursing retains its practice identity while developing as a science. The process is thus valuable to both nursing and to young women, making it an ideal opportunity for nursing knowledge development.
Dr. Burton received funding from the National Institutes of Health National Institute of Nursing Research (T-32 #2 T32 NR07088-10) and the Robert Wood Johnson Foundation Nurse Faculty Scholars Program (Grant ID: 71242) during the development of this manuscript.