CJNR Guest Editorial Vol. 37, No. 2, June 2005
Knowing Is Not Enough: We Must Do
Susan McClement and Lesley F. Degner
It is a simple fact that every person will die. What is less of a given
is the extent to which those with life-limiting illnesses will receive
the type of care encapsulated in the World Health Organization (2002)
definition of palliative care:
An approach that improves the quality of life of individuals and their
families facing the problems associated with life-threatening illness,
through the prevention and relief of suffering by means of early identification
and impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual. (p. 1)
Though there are many ways of "knowing" in nursing (Silva,
Sorrell, & Sorrell, 1995), achievement of the "deliverables"
embedded within this definition is contingent, in large measure, upon
the generation of a sound body of empirical knowledge to guide practice.
A major component of palliative care research is nursing research, the
ultimate goal of which is to improve patient care (Ferrell & Grant,
2001). As in all areas of nursing, a solid research base will inform
and enhance palliative nursing practice and the appropriate standards
to be adhered to within it.
The pioneering nurse researcher Jeanne Quint Benoliel observed that,
historically, palliative nursing care depended on "the good will
and personal skills of individualized nurses; yet what they offered
was invisible, unrecognized, and unrewarded" (Quint, 1967, p. ix).
Good will and personal skill still hold currency in the provision of
palliative nursing care. It is only in concert with sustained research
efforts, however, that the full potential and promise of palliative
nursing can be made visible, recognized, and celebrated.
The German dramatist, novelist, poet, and scientist Johann Wolfgang
von Goethe (1749-1832) understood well the reciprocal relationship between
knowledge and practice. Goethe asserted: "Knowing is not enough;
we must apply. Understanding is not enough; we must do. Knowing and
understanding in action make for honor. And honor is the heart of wisdom."
(http://www.p-mmm.com/sayings.htm) This issue of the Journal contains
papers reflective of knowing, understanding, application, and wisdom
as regards palliative care research.
The concept analysis paper by Marie Bakitas speaks to the importance
of conceptual clarity in conducting empirical work, and the need to
both understand and attend to the ways in which historical, legal, bioethical,
and clinical influences shape our understanding of concepts and affect
our ability to integrate them into programs of palliative care research.
The integrative review by Dr. Joan Bottorff and colleagues of methodological
issues in researching palliative care nursing practice illuminates our
understanding of the ways in which nursing knowledge has been generated,
and sensitizes us to the importance of keeping the efficacy of nursing
interventions front and centre in the research agenda, particularly
in the context of interdisciplinary work. The grounded theory study
by Drs. Duggleby and Wright of how palliative care patients live with
hope enables us to better understand this dynamic process, and illustrates
the coalescence between the facets of knowing, understanding, and application
that ideally characterize the research enterprise.
This issue of CJNR is augmented by several invited papers. In her Discourse,
Dr. Linda Kristjanson speaks to the wisdom and importance of distinguishing
between the different types of palliative care that patients and families
receive in order to construct contextually appropriate and meaningful
research questions. She offers a sound argument against reliance on
prognostication as the defining index by which palliative care services
are made available, and she challenges us to develop innovate research
approaches that will inform the development of models of palliative
care nursing for those with diseases other than cancer.
In the Designer's Corner, Dr. Julia Addington-Hall provides readers
with a clear statement of the benefits of palliative care research and
stresses the need for health-services research, particularly as it relates
to funding sustainability for palliative care. She thoughtfully outlines
the multitude of ethical considerations and tensions inherent in conducting
palliative care research and provides cogent guidance for ways of responding
to them. Dr. Addington-Hall reminds us of the need for academics to
partner with clinicians and service users in order to ensure research
excellence.
In Translating Research, Dr. Lesley Degner takes a lesson from the history
books to remind us that successful implementation of a change in evidence-based
practice must be nested solidly within a theoretical framework that
takes into account elements of professional and organizational behavioural
change. She provides an overview of four theories that may prove instructive
to those seeking to initiate knowledge-translation projects in palliative
care settings. The relevance and timeliness of Dr. Degner's contribution
is underscored by the brisk evolution of evidence-based practice as
a means of improving patient care and closing the chasm between optimal
end-of-life care and that which exists (Rutledge, 2005).
In the Happenings section of the Journal, Dr. Doris Howell outlines
several recent initiatives that have the potential to significantly
advance research in palliative and end-of-life care. These include the
commitment of funds by the Canadian Institutes of Health Research to
support interdisciplinary research on a variety of topics salient to
end-of-life care, and the establishment of an endowed research Chair
in Cancer Nursing at the University Health Network and the University
of Toronto's Faculty of Nursing. Dr. Howell has been awarded that prestigious
Chair, and as part of her mandate will develop a patient-focused outcomes
research program focusing on the effectiveness of health-care delivery
and nursing intervention research in symptom assessment and management.
Dr. Susan McClement describes the development and future directions
of a recently funded interdisciplinary unit in Manitoba dedicated to
psychosocial research in end-of-life care for patients with a variety
of life-limiting illnesses.
Finally, graduate nursing student Annemarie Hoffmann critiques for us
the feature documentary film The Man Who Learned to Fall. Her characterization
of the vivid and realistic way in which this documentary captures the
experiences, challenges, joys, and sorrows of a person living with amyotrophic
lateral sclerosis and his family reminds us of the reasons why we strive
for excellence in palliative care nursing and research in the first
place.
While dying is part of the human condition, dying poorly certainly ought
not to be (Chochinov, 2004). Goethe was right: knowing and understanding
are not enough; we must do.
References
Chochinov, H. M. (2004). Palliative care: An opportunity for mental
health professionals. Guest editorial. Canadian Journal of Psychiatry,
49(6), 347-349.
Ferrell, B. R., & Grant, M. (2001). Nursing research. In B. R. Ferrell
& N. Coyle (Eds.), Textbook of palliative nursing (pp. 701-709).
Oxford: Oxford University Press.
Quint, J. C. (1967). The nurse and the dying patient. New York: Macmillan.
Rutledge, D. N. (2005). Evidence-based interventions. In K. K. Kuebler,
M. P. Davis, & C. D. Moore (Eds.), Palliative practices: An interdisciplinary
approach. St. Louis: Elsevier.
Silva, M. C., Sorrell, J. M., & Sorrell, C. D. (1995). From Carper's
patterns of knowing to ways of being: An ontological philosophical shift
in nursing. Advances in Nursing Science, 18(1), 1-13.
World Health Organization. (2002). National cancer control programmes:
Policies and managerial guidelines, 2nd ed. Geneva: Author. Available
online: www.who. int/cancer/palliative/definition/en/
Susan McClement, RN, PhD, is Assistant Professor, Faculty of Nursing,
University of Manitoba, Winnipeg, Canada. Lesley F. Degner, RN, PhD,
is Professor, Faculty of Nursing, University of Manitoba, and Consultant
in Evidence-Based Practice, Health Sciences Centre, Winnipeg.
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