We have to live today by what truth we can get, and be ready tomorrow to call it falsehood.”
William James
Pragmatism as set out by authors such as William James and Charles Peirce and interpreted for the post modern age by writers like Richard Rorty and John Dewey7, has many common factors with the concept of childhood. In both childhood and pragmatism we understand that time, space and place are important. The quote above is an early statement indicating that the pragmatist recognises that our understanding about the world changes, just as our view of children as people changes as they move through childhood. Pragmatists like Richard Rorty recognise that the ideas held at one time in a certain place may have been useful to the people at that time 8, but just as our behaviours towards a 3 year old would not be appropriate demonstrated towards a 13 year old, ideas and people change, and our understanding changes too. This is then a rejection of much of Western European thought which, based on Plato ideas of schema, holds that there is a universal truth, one we might not have found yet but which is awaiting discovery.
In Pragmatic Children’s Nursing there is no “right way” to do children’s nursing. Instead we have to attend to the doubts or meanings which are raised in clinical practice. In the figure below I use the example of whether children’s carers can report on the subjective experience of pain. Doubt is an uncomfortable condition so as humans we tend to want to resolve doubt into beliefs or to find meaning in the situation. By reading various research studies we can understand that children’s carers can not accurately report what a child experiences9.The belief then leads to actions or intentions to act and behaviours. In this case, realising children are the only ones who can comment on their pain would lead to introducing a self-report scale. John Dewey and his fellow pragmatist Quine considered the effects of language. What they concluded was that language only has meaning in groups who share the same understanding of the language. The rather complex overlapping circles in the diagram below attempt to show the potential groups who share meanings via language and interaction in the triad between child-carer-nurse. Thus, to return to our example, introducing and using a self report scale for pain in children on a ward would require the parties to share beliefs or meanings. Such a tool would not work if one party, let’s say children themselves, did not believe that it was acceptable or useful. Thus the doubts raised and the meanings or beliefs associated with these doubts might be seen differently by these groups A-G but could share aspects. More often than not, the resolution of meaning or belief results in raising more doubts – What about nonverbal children? What about children who lack capacity?
Thankfully Pragmatism allows us to limit our questions or doubts by insisting that we only attend to the questions which will have an effect on the phenomena.
So much for some of the basic philosophy (for more in depth discussion please see chapter 2 in the book 1) now for perhaps the more practical element of the theory. Below is a flow diagram setting out the main elements of the theory. Underpinning or running through the theory is John Dewey’s ideas on education- that to learn is to grow and to be alive one has to grow and change. Because Pragmatism demands that one captures all elements of the phenomena7, we have to account for the acutely unwell child in PICU, the child living with long term conditions, and the dying child, as all of these are part of children’s nursing.
The elements of the theory can then be grouped into those associated more perhaps with the acutely unwell child and those where time and cognitive states allow the development of relationships and nursing practices.
The internal environment in the first box relates to promoting, restoring and stabilising (when possible) such factors as blood pressure, renal output, or cerebral spinal pressure. All the elements relate to how children access or live a childhood. So children whose physical or mental health is unstable or deteriorating cannot socialise with their peers and find it difficult to play or learn.
The second box places the child in an environment. Here we recognise that a child’s health status might not remain stable for long if he is in a burning building. Learning can also be difficult if you are in a noisy, hot environment with poor light. So the child’s internal and external environments are related and both need to be attended to, to promote, restore and stabilise the child’s health and wellbeing.
Once the internal and external environments have been stabilised (or at least some measure of equilibrium restored) then we can attend to the child’s longer term needs. The related next two boxes set out the negotiation between children, their carers and nurses as to who has the locus of control. Who directs and shapes care? Where possible nurses should promote children’s self care, but at certain stages of childhood and with certain conditions care might be directed by the child’s carer or by nurses (see chapter 3 for more detailed discussion1). In the book I set out in more detail how such negotiations might be guided by Urban Walker’s ideas on feminist expressive collaborative morality10. What is important to realise here is that care and the objectives of care are negotiated not just between children, their cares and healthcare professionals, but also by communities and wider society. The last box indicates that the previous 4 boxes are set in a context of the ideas about children, the diseases and conditions that affect children and the social, cultural and political responses to children living with illness in communities.