Towards epistemic justice in nursing research in China:Time for Chinese nursing scholars to actively engage with philosophical inquiries

To the editor,

“If we were to accept that the theory era is behind us,such that we no longer see value in deep philosophical inquiry into the ideas that have shaped our discipline's evolution over its history,I believe we would be at considerable risk for creating a new generation of faculty who may be skilled research technicians with increasingly sophisticated ways of doing things but possess inadequate grounding in the reasons for which they are doing them.”

—Sally Throne [1] p.282

I am a junior nursing researcher who has been trained in both the Chinese and western nursing systems.Reflecting upon the differences in both nursing research culture in general,one of the most salient and consistent findings is that our nursing research seems to have been hazardously dominated by a post-positivist discourse,which has led to serious negative consequences to our profession.I call on Chinese nursing scholars to actively engage with philosophical inquiries to combat such dominance and maintain the core value of our discipline.

1.The dominance of post-positivism in Chinese nursing research

It is fair to say that most nursing scholars in China seldom interrogate the paradigmatic roots of nursing research.Commonly,researchers tend to classify all quantitative research as having postpositivist roots and qualitative research as having social constructivist roots.While even with the emerging trend in qualitative and mixed methods nursing research in recent years,a considerable amount of them is nothing more than a “qualitative” version of post-positivism that relies heavily on strict technical procedures and misplaced criteria on reliability and validity.

Our nursing profession has been deeply infiltrated and,to some extent,colonised by the evidence-based medicine (EBM) movement which situates itself at an extreme post-positivist tradition with the goal of finding ultimate truth and generating best practice.Extensive nursing literature bases their methodological foundation on clinical epidemiology and centres on the use of systematic reviews,trials,and different statistical models to build or uncover causal relations.But what is truth? What counts as evidence? Is there always best practice?Are causal relations essentially the constant conjunction of events? These fundamental questions are rarely interrogated or debated in nursing context,which leads to many nursing researchers blindly following the EBM trend and restricts their ability to think critically about complex issues and problems.Consequently,EBM becomes widely endorsed by nurses as the only legitimate and validated form of nursing knowledge,or as Foucault said,a “regime of truth” which tends to exclude all alternative paradigms [2,3].Our nursing profession has embarked on a dangerous route that is territorialised by post-positivism.

2.Research questions are shaped by our philosophical biases

It is our longstanding assumption that the formation of research questions often derives from either the intensive literature review or the field trip to specific healthcare settings.Both strategies can undoubtedly inspire us on the direction and focus of research,nevertheless,our research questions are shaped a priori by our philosophical biases,which are the basic and implicit beliefs in science about the nature of reality(i.e.ontology),the nature of knowledge and truth (i.e.epistemology),or how science should be practiced (i.e.norms) [4].These beliefs drive our decisions on what kind of literature to read,which (aspects of) phenomena to pay attention to and consequently,what kind of question to ask and what information to seek [5].Philosophical bias is the fundamental premise of science that is impossible to avoid.By engaging with philosophical inquires,our ingrained beliefs will be constantly challenged by alternative discourses,which will,as a result,motivate us to read,observe,and think differently.

3.Engage with alternative paradigms in philosophy of science

I argue that our nursing profession should desperately promote pluralism to resist the dominance of post-positivism.Beyond postpositivism,there are diversified paradigms that researchers can engage with to understand complex healthcare phenomena.I present a nutshell summary of some alternatives,all of which entails a wholesale or partial rejection of post-positivism.

First,social constructivism.Social constructivism rejects the notion of a singular universal truth claimed by post-positivism.Reality is relative and the collection of multiple mental constructions.Researchers holding this belief do not question the existence of the natural world but challenge the view that only one interpretation of social and cultural phenomena is valid and true.Researchers seek to understand and explain human phenomena through naturalistic inquiry.Knowledge created is often temporary,subjective,internally constructed,socially and culturally mediated.

Second,critical realism.The triumvirate of critical realism consists of ontological realism,epistemic relativism,and judgmental rationality.Ontological realism claims that reality is intransitive,meaning that the world that science investigates is independent of human perception and knowing.Reality is also stratified with three different but overlapping domains:the empirical domain(i.e.reality that can be experienced either directly or indirectly),the actual domain (i.e.reality that occurs,but may not necessarily be experienced),and the real domain (i.e.the deep structures and mechanisms that generate phenomena).According to epistemic relativism,human knowing is transitive,meaning that the knowing is finite,contextual,and fallible.Researchers build conceptual models and theories as a way of explaining social phenomena that we experience in the empirical domain.Judgmental rationality refers to a commitment to the rational evaluation of diverse and completing claims or theories about the world[6,7].Methodologically,critical realism recognizes the inherent complexity of social phenomena,and embraces a wide range of quantitative and qualitative methods [8].

Third,critical theory.Grounded in political philosophy,critical theory is an umbrella term that encompasses ontologies,epistemologies and methodologies from postmodernism,poststructuralism,feminism,critical pedagogy,and cultural studies.Ontologically,reality is shaped by structures,such as social,political,cultural,economic,ethnic,and gender constructs.These constructs interact with each other in a dynamic way to shape our social life[9].Epistemologically,Knowledge is a social and political thing that is constructed from a specific position.In fact,all scientistic endeavors are contextually situated.There is no“view from nowhere”.Critical theorists keep sensitivity towards issues of oppression and injustice;problematize what is taken for granted and challenge the status quo with an aim of producing praxis[10].Methodologically,rather than testing a hypothesis,researchers use strands of critical theory as a lens to frame inquiry and define the research question.They often use the key concepts within the critical theory to guide data interpretation and use data to refine the theory for a specific context[9].

Next,Postmodernism.Postmodernism is a set of philosophical positions that share a broadly skeptical and critical perspective on grand or totalising theories and privilege no single authority,method or paradigm.Postmodern thoughts recognize multiplicity,plurality,fragmentation,and indeterminacy when analysing any aspect of reality [11].They seek to explore the social and cultural construction of truth by analysing the relationship between power,language,and knowledge.Knowledge is never neutral.It shapes the power relations between individuals or groups and all the powerknowledge dynamics are manifested in our language,text,and discourse.Although no definitive methodologies exist for postmodernism,researchers often turn to deconstruction or discourse analysis to answer research questions [12].

4.Patterns of nursing knowing

Nowadays,many nursing research projects become grantdriven,hotspot-driven,and method-driven with the utilization of advanced techniques from other disciplines,such as artificial intelligence,machine learning and data mining.While those methods promote interdisciplinarity,they put our discipline at risk of deviation.To maintain the core value of nursing profession,an indepth understanding of the patterns of nursing knowing is very essential.It promotes us to think about what it means to know and what kinds of knowledge are considered valuable.

Carper [13] described four fundamental patterns of knowing in nursing:empirics(i.e.the science of nursing),aesthetics(i.e.the art of nursing),ethics (i.e.the moral component of nursing),and personal knowing (i.e.the self and other in nursing).White [14] reexamined the four patterns of knowing and proposed the fifth pattern:sociopolitical knowing,which focused nursing knowing on the sociopolitical context of persons and nursing.Chinn and Kramer [15] further developed the knowing and came up with emancipatory knowing with the aim to challenge and change social and political injustice or inequity.These seminal works set us free from the dominance of empirics and advanced our understanding of nursing as a discipline and as a practice.Porter[16]has suggested that to combat the hegemony of empirics,we need to insert empirics into other patterns of knowing to demonstrate their values and to make their use in practice transparent.

5.Disrupting epistemic injustice in Chinese nursing research through the active engagement with philosophy

Epistemic injustice refers to different “forms of unfair treatment that relate to issues of knowledge,understanding,and participation in communicative practices” [17] p.1.If we want to disrupt epistemic injustice and see a change in the way nursing research is conducted,we cannot leave the philosophical foundation on which they are based untouched.The change must start with challenging our ingrained beliefs about reality(i.e.ontology),truth claims and knowledge production(i.e.epistemology).Yet,it is not an easy and instant work to shake such foundations.Several practical while immature suggestions are proposed from an individual level based on my personal experience in such transition:a) researchers need to firstly understand the basic philosophical concepts before engaging with philosophical discussions;b)reflection on which paradigm resonates most after a general interrogation of different research paradigms;c) in-depth reading on one paradigm that fits with our beliefs and applying it to inform understanding of healthcare phenomena.Nevertheless,more radical changes from the system level are also indispensable.Nursing schools should play active roles in educating new generations on nursing philosophy;nursing journals should also expand their aims and scopes to welcome philosophical papers and different types of nursing knowledge.In addition,it can be considered to establish the nursing philosophy association to build a community for in-depth conversation on fundamental issues in our profession and push the nursing science forward.

It has been ten years since nursing was broken away from clinical medicine and classified as a first-level discipline.It is our duty as nursing scholars to look back and reflect critically on our gains and losses,and more importantly,look into the future to advance the nursing profession without abandoning its core values.I hope this paper can provoke more conversation on our disciplinary development.