Clinical outcomes research and Rogerian science: strange or emergent bedfellows?
The purpose of this paper is to describe and reconcile conceptual inconsistencies between clinical outcomes research and the ontological assumptions of the SUHB. Specifically, the authors address a clinical trial examining outcomes of touch therapies framed within Rogerian science. They raise the question of whether the clinical trial is inherently incompatible with the SUHB, or if through reconceptualization, it can be an emergent way of interpreting and developing research methods within the conceptual system. The paper contains an overview of the study, the ontological and epistemological assumptions that underpin experimental design, conflicts between these assumptions and the assumptions of SUHB, perspectives within the literature on issues of ontological-methodological congruency within Rogerian Science, and paths to reconciliation of the conflicts presented. The discussion of reconciliation calls attention to the nature of scientific inquiry, developing knowledge within the Rogerian research tradition, Bohm's holographic theory, body-field relationships, linking theory to outcomes in the SUHB, complexity science, and reconceptualing through metaphor.
Key Words Rogers Science of Unitary Human Beings, clinical trials, nursing epistemology, touch therapies
Introduction and Background
The study of practice outcomes is receiving considerable emphasis in all of the health care professions. In this era of managed care and professional accountability, there is increasing pressure to document the differences that we make in the lives of patients. This emphasis on outcomes is a double-edged sword. On the one hand, there is danger that the value of a practice or a therapy may be determined by a discernible statistical difference on a variable identified by the dominant medical community as significant. For example, if we identify healing solely by variables that reflect curing within the bio-medical model, then perhaps significant outcomes related to quality of life Key Words and subjective experience will be submerged or ignored. On the other hand, in resisting outcomes research because of these pitfalls, we may miss the opportunity to document the differences that nurses potentiate with our practices. Evaluating models of care and nursing therapeutics that are based in nursing science offers profound possibilities for advancing our discipline. And the public are seeking therapeutics that are consistent with nursing models and are asking for away to discern their value. Even within nursing's scientific community, there are calls to identify nurse-sensitive outcomes as the focus of our research.
Qualitative methods have been used for evaluating models of care. They do provide us with rich and substantive de scriptions about how patients, families and care providers perceive and experience certain processes or models of care, but they do not seek to answer the critical questions asked by many clients, payers and providers: What confidence can we have that the use of this therapy, process or practice model can make a difference in a particular outcome? It is through the traditional scientific method that consumers and others in professional communities most frequently discern this confidence.
While seeking to study "outcomes" of touch therapies (Therapeutic Touch and massage) that were framed within the SUHB, we confronted a dilemma that grew from: 1) An awareness of the inconsistencies of the scientific method within the ontological assumptions of the SUHB; 2) a desire to engage in research that advanced the integration of nursing therapeutics framed within the SUHB into mainstream health care; and 3) a commitment to nursing science and the freedom of creative scientific inquiry. Out of this dilemma our struggle was born. Would the partnership of a clinical trial outcomes study framed within the ontological assumptions of the SUHB be "strange bedfellows," coexisting in an awkward and uncomfortable conceptual marriage? Or could they be "emergent bedfellows," unfamiliar partners that through conceptual reconciliation manifest a creative leap in our vision of the possibilities for understanding methods and practice within the SUHB?
Another piece of the picture surrounding our decision to pursue this study came from the barrage of criticism levied against the practice of Therapeutic Touch within the University of Colorado School of Nursing. In 1993 the Rocky Mountain Skeptics challenged practitioners and faculty at the University of Colorado School of Nursing. This watchdog group, with a mission of uncovering health care quackery, mistakenly contended that there was no scientific research supporting the practice of Therapeutic Touch. Because of this, they reasoned that state revenues should not support the teaching of this practice, nor should the practice be allowed within the definitions of the state Nurse Practice Act. The Chancellor of the Health Sciences Center at the University of Colorado appointed a panel to study this question. Members were drawn from all the schools within the Health Sciences Center. Three nationally-recognized nurse researchers from outside the School of Nursing were appointed to review the evidence and contribute opinions to the panel. The panel received testimony and open hearings were held. The final decision supported by the research evidence and the tenets of academic freedom, upheld the faculty's right to teach and practice Therapeutic Touch (Clamen, 1994). While faculty had been engaged in phenomenological research related to Therapeutic Touch, a major recommendation related to research was delivered by the Panel. They stated that the faculty teaching and practicing Therapeutic Touch should be engaging in research regarding the outcomes of the practice.
While this provided some additional motivation for a research project on the outcomes of touch therapies, our purpose for pursuing the inquiry was founded on a commitment to nursing science-based practice, a valuing of the unitary world view and a sense of the potentiality of integrative therapies framed within the SUHB. Both Therapeutic Touch and massage have in common caring intention and rhythmic movement within the continuous mutual patterning process of nurse and client. This focused intent to care is communicated through the hands, potentiating changing field patterning. This foundation within the SUHB is important for the advancement of science-based practice.
The burgeoning interest in integrative healing modalities is encouraging. This groundswell of interest generated by the public, was reported in the now classic study by Eisenberg, et. al (1993) which revealed that about a third of Americans were already using integrative healing modalities; massage was one of the most sought-after among them. The establishment of the Office of Alternative Medicine with subsequent increases in funding of research, creation of the several journals focusing on publishing research in integrative modalities, the establishment of educational programs specializing in teaching these modalities to practitioners, and the popularity of certain books such as Weil's (1983; 1995) Health and Healing and Spontaneous Healing and Moyers' (1993) Healing and the Mind were bellwether signs that the climate was prime for the acceptance of these modalities into mainstream health care.
One could argue that medicine's relatively recent embrace of integrative modalities has led to their new-found legitimacy. Some of these therapeutics had been an integral part of nursing practice for a century, and "nurses began developing literature in the holistic arena at the same time as their physician and lay counterparts in the late 1970s and early 1980s" (Dossey, 1988, p. 69). Touch therapies are examples. Massage, in the form of the backrub, was taught as a fundamental of nursing practice. Therapeutic Touch emerged within nursing science and practice, and along with other "holistic" modalities, has been framed within nursing's SUHB (Krieger, 1981; Quinn, 1984; Rogers, 1986). It is important to claim nursing's scientific heritage and future in these therapeutic practices. This can happen through the specification of how these integrative modalities are linked to nursing knowledge and practice.
So, with all this as a background to our process, we needed to reconcile the following questions: Does the movement of clinical outcomes research fit with the ontological assumptions of the SUHB? Can the clinical trial or experimental design be consistent with the assumptions of the SUHB? Can "physiological" measures be congruent outcome variables for research framed within the SUHB? Can healing, as we defined it, be manifest through these physiological indicators? Can we use both physiological indicators and subjective descriptions to arrive at a more complete understanding of patterning in the healing process? The purpose of this paper is to describe our current thinking on the reconciliation of conceptual inconsistencies between methodology, epistemology and ontology in the development of a clinical trial focusing on outcomes of touch therapies for patients during bone marrow transplant with the SUHB as the theoretical framework.
An Overview Of The Current Research Study As Context
While the issues discussed in this paper transcend any particular study, the study that we are currently conducting, "Clinical Outcomes of Touch Therapies during Bone Marrow Transplant" led to the exploration of these issues. For this reason, a brief overview of the study is provided. The purpose of the study is to discern differences in selected outcomes for patients undergoing bone marrow transplant (BMT) who receive massage, Therapeutic Touch, a placebo called a friendly visit, and routine care. The touch therapies are defined as approximately 30 minutes of massage and Therapeutic Touch using standard practice protocols. The friendly visit is 30 minutes of social conversation with a volunteer. The control group consists of a random sample of patients who had received routine care on the same BMT unit in the year prior to initiation of the study. The subjects are patients admitted to the BMT unit who agree to participate in the study, are English-speaking and between the ages of 18-65. The sample is stratified to include 75% autologous BMT recipients and 25% allogeneic BMT recipients. Outcomes selected for study are period (number of days) for engraftment, number and severity of complications, and patient satisfaction with care. Patients keep a log of their experiences throughout their stay on the BMT unit and practitioners log their reflections and observations. Patients are randomly assigned to one of the 3 treatment groups and will receive any of the touch or placebo treatments every third day until engraftment occurs. Period of engraftment is defined as the number of days from transplant to three consecutive neutrophil counts over 500. A standard index of severity has been developed to categorize an array of complications related to bone marrow transplant. A patient satisfaction survey used on the unit has been modified for this study. Analysis will examine the differences between mean scores for each of the identified variables. A qualitative analysis of the patient logs will focus on the process of healing through examining experiences, thoughts, and perceptions of the patients during bone marrow transplant. Interpretive analysis will synthesize the findings from both sources of data.
This population and setting for the study were selected for several reasons. The outcomes identified for this study are related to healing in patients receiving BMT. The selection of these outcomes was related to their congruence with the theoretical framework and the nature of the environment of the BMT unit. In addition, the BMT unit incorporates highly technological and isolative procedures that beg for nursing therapeutics. Massage and Therapeutic Touch were already offered to patients on the unit who requested and paid for them. There was some anecdotal evidence that healing was enhanced through the use of these therapies. Finally, the controlled environment, systematic protocols on the unit, and the spirit of collaboration influenced our choice.
Within the process of theory building, the relational statements or propositions that illuminate the linkages between theory, nursing actions or therapeutics, and the selected outcome variables are clearly articulated at the level of the conceptual model, middle-range theory and empirical indicators (Fawcett & Downs, 1992). In this study, the outcome variables and the touch therapies of massage and Therapeutic Touch were framed within the SUHB. Examples of the propositions within the theoretical framework are:
1) Humans and environment are integral energy fields in continuous mutual process.
2) Any change in the environmental field may potentiate change in human-environmental field patterning.
3) Caring intention of the practitioner and rhythmic movement, essential processes of these touch therapies, are ways of participating in the dynamic flow of the human-environmental field patterning.
4) Healing is a process of human environmental field patterning toward "right relationship" (Quinn, .1990) or "symphonic integration" (Rogers, 1970) This may be reflected in multiple manifestations of patterning, from physical, even cellular changes to perceptions, images and shifts in awareness.
5) One manifestation of this coming into "right relationship" is the integration (or engraftment) of transplanted bone marrow cells. This coming together in engraftment is an index of healing in bone marrow transplant.
6) Therefore, if caring intention and rhythmic movement potentiate pattern change; and if this pattern change may be described as "synchronous" or coming into "right relationship"; and if this right relationship may be evident in multiple field manifestations, including at the cellular level; and if engraftment is a process that involves the coming into "right relationship "of newly-introduced cells to the whole; then engraftment may be enhanced through the touch therapies of massage and Therapeutic Touch during bone marrow transplant.
Ontological And Epistemological Assumptions Underpinning The Clinical Trial
Several ontological and epistemological assumptions underpin the clinical trial. The clinical trial is a true experiment used to test therapies or interventions for their effectiveness. The design calls for a control group and at least one experimental group. Subjects are assigned to these groups randomly. The clinical trial is a method emerging from the following assumptions (Suppe, 1977):
1) There is an objective reality existing independent of any observer. Science seeks to understand this objective reality. Truth in science is obtained through observation, or empirical testing, that seeks to isolate elements of this objective reality.
2) The observer's subjectivity is a source of bias which interferes with obtaining the knowledge of objective reality; there fore, all attempts are made to separate the researcher's biases from the process of observation. This may be accomplished through measurement and various controls that eliminate bias.
3) Causal relationships do exist. The goal of scientific knowledge is prediction and control. The scientific method seeks to isolate particular causes and show their effects. The clinical trial is the quintessential design to arrive at an understanding of causal relationships because it tests differences between the treatment and a control group and it seeks to remove the effects of any extraneous variables that might influence change in the dependent variable.
4) The whole can be known through reducing it to its parts. Reduction of a conceptual unit to an operational or measurable unit is a hallmark of the positivist scientific method.
5) Change is predictable and generalizable. Our system of statistical analysis is based on the assumption that changes seen in a sample may be generalized to a population, and that we can determine with what degree of certainty we can anticipate this change.
Conceptual Conflicts With Assumptions Of SUHB
Well-known conceptual conflicts exist between the assumptions presented and the assumptions of the SUHB. These conflicts have appeared in the literature and are summarized as follows:
1) In a universe of open systems there is no causality. Open systems, by their nature are dynamic, flowing and in continuous, mutual process. Manifestations of this dynamic change are unpredictable. Causality implies a linear relationship of time and a locality of cause with effect which is inconsistent with the pandimensional nature of the universe.
2) Human-environment energy fields are integral. There is no separation between observer and observed, between a subjective and objective reality. The observer is a participant in the emergent patterning process.
3) The unitary nature of the human-environmental field cannot be captured through reductionistic constructs. The whole is inherently different than any of its parts.
4) In a universe of unpredictability, it is not possible to infer truth through application of probabilistic models designed to generalize. Patterning is continuous, creative and emergent.
The conceptual inconsistencies between design of the clinical trial and Rogers' SUHB can be summarized by the following dialectic pairs: Separation-Integrality, Causality-Unpredictability; Linearity/Locality-Pandimensionality; Particularity-Patterning; and Generalizability-Creativity.
Perspectives On Issues Of Ontological-Methodological Congruency Within Rogerian Science
Disciplined discussion related to conceptual inconsistencies between particular approaches to research and the SUHB has existed since the early 1980's. This discussion provides a valuable context for the ideas presented here. Rogers, herself, spoke of the limitations of the processes of the empirical-analytic paradigm of science in studying unitary phenomena. She encouraged the selection and development of instruments that might capture the manifestations of field patterning; however, she did not support one paradigm of science over another. "One needs to look at the phenomenon under study and determine the best ways to get at it ..." (Rogers, 1994, p. 34) She was unwavering in her belief that those advancing the SUHB would do so through developing and/or testing theories that were derived from the conceptual system, and that the future scientists working within the system would discover and invent new ways of measuring, observing, experiencing, or uncovering unitary phenomena that would present closer ontological-methodological congruency. She was aware of the human science paradigm and the existence of qualitative research methods, but saw those as equally, not more promising, than quantitative methods for advancing the SUHB. Rogers anticipated an emerging sophistication in design, methods, measurement and analysis that had potential for increasing precision in understanding the human-environmental field patterning. "Certainly science is open-ended; it will never stop". (Rogers, 1994, p. 34).
Cowling's 1986 classic article of methodological issues in Rogerian science presented a clear and substantive summary of the state of ontological-methodological congruency at the time. He emphasized the importance of conceptual consistency between the variables selected for study and the Rogerian conceptual system, and questioned the value of true experimental designs for the purposes of research in the SUHB because of their inherent causal assumptions. He conceded that while experimental or quasi-experimental designs may be appropriate to monitor indices of human field pattern change in relation to introduced environmental change, caution must betaken regarding the use of such designs since they are most notably selected to reveal causal relationships. (Cowling, 1986, p. 73)
Phillips (1989) chronicled a history of research based on Rogers' conceptual system. In it, he addressed the conceptual-methodological issues that emerged from changes in the model and refinement in thinking through critique. He discussed the need for careful evaluation of measures developed in other disciplines and the movement toward using statistical analytic methods such as canonical correlation to avoid the "causal assumptions trap." He describes the movement in the science toward developing pattern profiles. These profiles encompass both "quantitative changes and the novelty ... inherent in qualitative changes in the patterning process" (p. 59). Phillips' creative conceptualizations of panoscopic vision point us to the frontiers of research in the SUHB. "Both qualitative and quantitative methods can be used ..., but new methods and instruments must be created to uncover the wholeness of these field experiences of reality". (Phillips, 1991, p. 143).
Reeder (1986) examined the congruency between Rogers' SUHB and Husserlian phenomenology. Her work stimulated interest in the use of qualitative methods for studying the phenomena central to the SUHB. Others used qualitative methods in the study of phenomena from a Rogerian perspective. Cowling (1990), Carboni (1992), and Butcher (1996) have developed qualitative approaches to understanding patterning, the healing relationship, and human experiences within the SUHB.
Carboni (1992) was critical of much of the existing body of research in Rogerian science, and presents arguments against the use of quantitative measurement.
Although her model is one of the most frequently used for research in nursing, there has been an unfortunate reliance on particularistic conceptualizations and measurements. Presently there is evidence that this dependence on three-dimensional methodology is being replaced with more coherent unitary thinking that acknowledges energy field patterns as the only reliable and valid indicators of the whole. (p. 134)
She criticizes quantitative measurement and calls for creative measurement, "a universal kind of knowing, a sense of ratio or proportion signifying wholeness or harmony ..." (Carboni, 1992, p.135) In addition, she asserts that, "In order for any construct derived from the SUHB to be unitary in nature, it must address the system in its entirety, not a portion of it. Particularistic constructs that emerge from a three-dimensional, causal world view are not consonant with Rogers' holistic, indivisible view of reality because they do not reflect the coherence that she espouses." (Carboni, 1992,p.136)
In 1996, Fawcett examined issues of incompatibility between the Rogerian world view and the research rules within the SUHB. She questions the compatibility of any quantitative designs or quantitative instruments within the Rogerian science, arguing that the use of components of variance models is a "reductionist analytic technique based on the mechanistic assumption that the whole is the sum of parts" (Fawcett, 1996, p. 9). Fawcett (1996) clearly articulates the quandary:
A seemingly simple solution to the incompatibility issue is to use only qualitative methodologies that are based on the assumption of unitary phenomena. That solution, however, raises other questions, such as how can the efficacy of SUHB-based therapeutic modalities such as imagery, Therapeutic Touch, and visualization be determined qualitatively? Furthermore, how can differences in the efficacy of therapeutic modalities be determined qualitatively? ... Or are these questions of efficacy even relevant? (p. 9)
In 1996 Barrett summarized the differing points of views on the Quantitative-qualitative debates within Rogerian science, stating that in one camp are those who believe that the ontology of the Rogerian conceptual system is inconsistent with quantitative methods, while others assert that the phenomenon being studied directs the selection of method. Barrett (1990) has been consistent in her assertion that the nature of the research question or purpose of the study suggests the research design. She has argued in favor of using both quantitative and qualitative approaches in Rogerian research, suggesting that numbers and text may be used separately in generating data that may then be combined to gain a picture of the whole. She pleads, "Let's keep the methodological doors wide open! Many undiscovered treasures may await inside as the unique Rogerian methods continue to be developed and refined. Methodology may go beyond what we now can only imagine." (Barrett, 1996, p. 51-52) Such diversity of thought points to a postmodern attitude that questions longstanding traditions of science in the face of competing worldviews.
Paths To Reconciliation
And so we are confronted with reconciling apparent opposing world views and discerning for ourselves whether the nature of the clinical trial or experimental design using physiological indicators and qualitative description is inherently at odds with Rogerian science, or, if conceptualized as an emergent, it can be a way of capturing the complexity of the patterning process of healing in its full, rich dimensions. The summary of reflections on these issues follow:
The Nature Of Scientific Inquiry
Science is open-ended, and the creative imagination and freedom of the scientist in answering questions must be pre served. Therefore, any a priori limitations placed on that process by dogmatic stances related to the correct, appropriate, or right methods should be viewed with caution if these limitations constrain the creative process of theory development within the conceptual model itself. This is not to say that "anything goes", for there is discipline and structure to scientific inquiry. Polanyi (1967) addresses this tension of originality and conformity within science. This tension is played out in the scientific community who judge the contributions of the individual scientist to science. The community's decisions of value are conferred based on criteria of: exactitude, systematic importance (correspondence with the structures in place), and intrinsic interest of its subject matter (Polanyi, 1967, p. 66). On the other hand, creative dissent is encouraged. "While science imposes an immense range of authoritative pronouncements, it not merely tolerates dissent ..., but grants its highest encouragement to creative dissent. (Polanyi, 1967, p. 68). Science is advanced within the community through the interaction of tradition or authority with creativity. "They [scientists] trust the traditions fostered by this system of mutual control ..., and at the same time claim an independent position from which they may reinterpret and possibly revolutionize this tradition" (Polanyi, 1967, p. 73). From this perspective, if the vision of Rogerian science is honored and the theories are developed, ordered and tested from the assumptions and principles of the science, then the scientist can be free to seek answers to questions through varied approaches to inquiry within the research tradition. The community of scholars will evaluate the worth of the work after its completion, not before its inception.
Developing Knowledge Within The Roqerian Research Tradition
Each conceptual model or system has both middle-range theories, practice and research traditions related to them. (Smith, 1992). The research traditions are the designs, methods, data forms and analytic processes that best help the scientist develop and test the middle-range theories emerging from the conceptual models. The research traditions are developed from a contextual web composed of three areas: 1) the phenomena to be explored within the model, 2) the foundational ontological and epistemological assumptions of the model, and 3) the research questions posed for the particular inquiry. The ontological and epistemological assumptions are one of the determinants, but not the only determinant of the design, methods, analytic processes and data forms in a study. Epistemologies, or philosophies about the nature of knowing and knowledge, do inform methodologies; however, the ontological paradigms within a discipline may be consistent with more than one epistemic paradigm. For example, Rogers' SUHB, Parse's theory of human becoming and Newman's theory of health as expanding consciousness all share some foundational ontologic perspectives that place them in the unitary-transformative (Newman, Sime, Corcoran-Perry, 1991), simultaneity (Parse, 1985) or simultaneous action paradigm (Fawcett, 1993), yet each have distinctions that are reflected by their unique research traditions. For example, in Parse's theory of human becoming, the phenomena central for study are health-related lived experiences. The research tradition, that is, the design, methods, data forms and analytic processes support the generation of qualitative descriptions of those lived experiences which are interpreted through the lens of the theory. Those scientists engaged in the exploration of Rogers' SUHB are studying the nature of human-environmental field patterning. The research tradition in Rogerian science has encompassed multiple designs, both existing and newly-developed instruments, data forms that are both qualitative and quantitative, and analytic processes that might best capture the complexities of the nature and quality of human-environmental field patterning and the research question.
The purpose of the experimental design may be framed as seeking to determine causal relationships within one ontological perspective. But, in the SUHB the purpose of this design may take on a different meaning as it is framed within the contextual web of the research tradition. The interpretation of the design and the measurements used are the product of the meanings ascribed within the conceptual system. Therefore, within the SUHB, the research tradition may encompass multiple designs, methods, data forms and analytic methods, many not yet invented to capture the nature of the pandimensional process of field patterning.
A View From The Holographic Universe
The view of reality posited by quantum, relativity and holographic models of reality can be helpful in the juxtaposition of seemingly opposite assumptions. This model reveals to us a universe characterized by: unbroken wholeness, uncertainty, and paradox. This notion of paradox is extremely important because much of our sensory experience and temporo-spatial ordering of life obscures our direct experience of unitary being-becoming. Our senses do not consistently and fully apprehend and appreciate the patterning of this pandimensional whole. Instead our senses collapse waves creating an experience of separateness and physicality.
Bohm's (1980) theory of the implicate-explicate order of reality helps us to understand this paradox. The implicate order is the ground of reality, its true nature of unbroken wholeness and patterns of energy, interconnected with all that is. We perceive the explicate order, that which is ordinarily accessible to our senses, as a reality with matter separate from energy; humans separate from environment. This seems inconsistent with the implicate order. This explicate order unfolds from the implicate in the dance of the holomovement. Through the explicate order we can get glimpses into the unitary reality. The glimpses or manifestations are like tracks in the sand, providing us with a limited, ghost-like representation of the nature of patterning.
Let's refer again to the seeming paradoxes between the assumptions underpinning the design of this study and the tenets of the SUHB which we identified as: separation-integrality; causality-unpredictability, linearity/locality-pandimensionality, and particularity-patterning. Within a dialectical relationship it is possible to conceive of separation, causality, linearity/locality and particularity as representative of the three-dimensional world, the explicate order; while integrality, unpredictability, pandimensionality and patterning are qualities of the pandimensional implicate order. In the study that we are conducting, the indices of engraftment and complications are explicate manifestations of the implicate order. Subjects and nurses will log their feelings, experiences, images, dreams, sensations and perceptions, which may give us a different set of clues about the process of healing and reflect their (both patients and nurses) integral nature and pandimensional awareness. Then, through interpretation, the researchers engage in a synthesis of the dialectic. In and of themselves, the physiological indicators are reductionistic, but interpreted within the synthesis they may become reflections, manifestations, or portholes for us to see and understand more about the nature of this patterning called healing. This is consistent with Cowling's (1986) discussion of the potential of the dialectic for knowledge development within Rogerian research.
In Rogerian research, the unitary cannot be understood through particulate physiological measurement. Phillips (1991) asserts that in human field research, "the physical body cannot be studied as an entity unto itself, but must be conceptualized within the perspective of the manifestation of the human field pattern" (p. 142). He argues that "field pattern profiles give field information better than physical measures" (p. 142). Our attempt with this research method is to synthesize a field pattern profile with the physical measures toward an understanding of their interrelationships in the field patterning of healing from a Rogerian perspective. In this way, data about complications or engraftment do not stand alone in defining healing, but are manifestations of the mosaic that compose the whole of the pattern profile.
Complexity science is another avenue to explore these contradictions. Some complexologists assert that complexity manifests at "the edge of chaos." This refers to the idea that nothing novel can emerge from systems with high degrees of order and stability or high degrees of disorder. Complexity emerges at the borders between rigid order and randomness (Horgan, 1995, p. 106). The epistemology emerging from the science of complexity recognizes that the wholeness of the universe cannot be "known", but is always an understanding-in-process. (Harmon, 1991, p. 27). This understanding is informed through multiple perspectives on the phenomenon that may manifest on the edge of conceptual or intellectual inconsistencies. In complexity science, data from the measurement of cellular activity to the descriptions of spiritual enlightenment may be included in a "comprehension nexus" related to the phenomenon. All knowledge about phenomena, no matter what source, is limited and perspectival (Suppe, 1977). In this way, complexity scientists assert that science may become less "linear" and more "poetic" (Horgan, 1995, p. 107) in the future as sources of discrepant information are woven together through interpretation. In this study, the healing process is the phenomenon for understanding. Multiple sources are used and the researchers bring these sources together, interpreting them in the process of generating knowledge related to the phenomenon.
Reconcentualizinq Throuqh Metaphor
Metaphor is a figure of speech which is used to bring two things together that do not ordinarily fit "usual states of affair". They are context-related, and therefore, require interpretation. In this study the medical metaphors are readily recognized in the physiological measures of neutrophils, toxicity scores, and platelets. These metaphors are symbolic representations of something ordinarily hidden from the naked eye, yet considered "real" and worthy of being counted as evidence. Also, in this study are narrative metaphors that are recognizable in the verbal and written expressions recorded by the patients and practitioners. These metaphors are symbolic representations of something ordinarily hidden from casual observation by a third party, yet also considered "real" to the one expressing them. They, too, count as evidence of meaningful experiences. The SUHB sets the stage for metaphoric thinking to reconcile phenomena under study ordinarily categorized in quantitative or qualitative ends of the spectrum of accountability, usually regarded as having clear scientific boundaries. Metaphoric thinking describes synthesis as a preferred way of knowing within the SUHB. In addition, metaphoric thinking is central for pattern-seeing. Metaphoric conceptualization of the variables of this study, render them recognizable within pattern; they become dynamically interrelated, manifestations of patterning.
In conclusion, we share our thinking with you for the purposes of inviting dialogue as we refine and revise these ideas. When we analyze different paradigms, it is customary to reject an opposing paradigm because of its seeming inconsistencies with our own. The open process of sciencing is essential to our advancement, and to abandon an idea because it seems inconsistent truly reflects the binding chains of ideological thinking. Free exploration and paths to understanding through the paradoxes may be possible. Emergent thinking occurs through unfettered exploration of the horizons within the landscape of the SUHB. This may happen through living with the tensions presented by seemingly opposing points of view. Through living with the tensions there is the possibility for the quantum leap!
Received February, 1998 Accepted June 1998
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Marlaine C. Smith, RN;PhD
Associate Professor and Director, Masters Program
University of Colorado School of Nursing
4200 E. Ninth Avenue
Denver, Colorado 80262
Francelyn Reeder, RN;PhD;CNM
University of Colorado School of Nursing
4200 E. Ninth Avenue
Denver, Colorado 80262
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|Author:||Smith, Marlaine C.; Reeder, Francelyn|
|Publication:||Visions: The Journal of Rogerian Nursing Science|
|Article Type:||Clinical report|
|Date:||Jan 1, 1998|
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