DOI: 10.1111/nup.

12209

ORIGINAL ARTICLE

Nursing knowledge: A middle ground exploration

Mariko Liette Sakamoto RN, MN, PhD, Student

School of Nursing, University of British

Columbia, Vancouver, BC, Canada
Correspondence
Mariko Liette Sakamoto, School of Nursing,
University of British Columbia, Vancouver,
BC, Canada.
Email: marikoliette.sakamoto@alumni.ubc.ca
Abstract
The discipline of nursing has long maintained that is has a unique contribution to
make within the health care arena. This assertion of uniqueness lies in great part in
the discipline’s claim to a distinct body of knowledge. Nursing knowledge is charac-
terized by diverse and multiple forms of knowing and underpins the work of all
nurses, regardless of field of practice. Unfortunately, it has been challenging for the
discipline to take full ownership of its epistemological diversity, largely due to factors
such as competing worldviews, and ideological and binary positioning. A philosophi-
cal middle ground stance is proposed as a way for the discipline to contemplate, dis-
cuss and develop nursing knowledge; a middle space that provides the freedom to
consider competing worldviews while still allowing for the discipline to fully express
itself in all of its epistemological diversity. In being able to enact its multiple forms of
knowledge in a creative and open space that is open to different ideas and world-
views, not only can nursing take full ownership of its practice and its unique knowl-
edge, it can also demonstrate how best to navigate an increasingly polarized world. In
a world that is increasingly fixated on binary solutions and dualistic points of view, it
is time for nursing to celebrate its epistemological diversity.

KEYWORDS
epistemology, nursing, philosophy of nursing, praxis

1 |  I NTRO D U C TI O N
The discipline of nursing has long maintained that it has a unique
contribution to make within the healthcare arena. This assertion
of uniqueness lies in great part in the discipline’s ability to stake
claim to a distinct body of knowledge (Northrup et al., 2004), es-
pecially as this relates to the discipline’s multiple forms of knowl-
edge (Tarlier, 2005, p. 126). However, world views ranging from
postpositivism to postmodernism influence how nursing’s many
forms of knowledge are considered, often to the detriment of the
discipline (Kikuchi, 2003). As world views are often seen as incom-
mensurable, this creates a tendency for dualistic or binary think-
ing, which has made it difficult for nursing to clearly articulate its
multiple forms of knowledge (Leddy, 2000). This paper proposes a
middle ground stance as a way for the discipline to contemplate,
discuss and develop nursing knowledge; a middle space that pro-
vides the freedom to consider competing world views while still
allowing for the discipline to fully express itself in all of its episte-
mological diversity.
1.1 | Nursing knowledge
The following paragraphs will discuss the development of nursing’s
epistemological underpinnings, as well as seminal conceptualiza-
tions of its diverse forms of knowledge. This sets the stage to con-
sider factors that make it challenging for the discipline to articulate
its epistemological diversity, such as the evidence-­based practice
movement, as well as the powerful influence of differing world views
and binary forms of thought.
1.2 | Nursing epistemology and ontology
The need to define nursing’s body of knowledge initially began
as a way for the discipline to distinguish itself from medicine, a

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profession nursing has long been allied with, as well as subservi-
ent to (Rolfe, 2015). Thus, attempts to explicate nursing knowl-
edge, especially in how it is distinct from medical knowledge, have
been an important step for the discipline in claiming its unique
status within the healthcare world (Nairn, 2012). As part of dis-
tinguishing itself from medicine, nursing has asserted that it is a
discipline with a holistic focus rather than one that is reductionist
in nature, and that the act of nursing is a human-­b ased interaction
concerned with the particular. As explained by Rolfe (2006), “the
essence of nursing is arguably the individual clinical encounter,
and no two encounters are ever the same” (p. 40). This description
certainly illustrates the essential nursing act: the point of contact
between nurse and patient and how each interaction is distinct in
and of itself.
However, apart from the individual clinical encounter as de-
scribed by Rolfe (2006), nursing is also able to take its dedication
to holistic and individualized care to a greater level, simply by virtue
of the fact that the nursing act is at its core a human interaction.
Spenceley (2004) expresses this idea and also situates this line of
thought in the context of nursing knowledge when she states:
…that the ultimate purpose of developing nursing knowl-
edge is to inform nursing practice, that nursing practice
occurs within the human health experience, that nursing
has something to contribute within the context of the
human health experience, and that the human health ex-
perience is simultaneously unique and universal. (p. 202)
That nursing has a contribution to make within a greater human
health context reveals the discipline’s commitment to care beyond
the individual nursing interaction. Indeed, nursing can be viewed as
having “a social mandate to contribute to the good of society through
knowledge-­based practice” (McCurry, Revell, & Roy, 2009, p. 43). By
situating nursing within both a unique and a universal caring context,
the complexity and the nature of nursing practice are revealed. Along
with this line of reasoning, as it is nursing knowledge that informs this
complex act, it makes sense that this knowledge would need to be mul-
tifaceted and certainly complex in its own right.
1.3 | Multiple forms of nursing knowledge
Thus, holistic nursing practice that transcends both the particular
and the universal requires diverse sources of knowledge or “multiple
ways of knowing” (Tarlier, 2005, p. 126). This multiplicity of knowing
refers to a broad range of nursing knowledge spanning intuitive to
empirical forms of knowledge (Schultz & Meleis, 2009). According to
Tarlier (2005), these multiple ways of knowing can be termed “epis-
temological diversity” (p. 127). This paper’s discussion hinges on the
assumption that it is vital that nursing be able to articulate that it has
diverse epistemologies that are fundamental to its practice. Further
discussion at this point would be remiss without outlining the schol-
arly work that has helped to conceptualize some of nursing’s multiple
ways of knowing.
A well-­known framework for understanding nursing’s epistemo-
logical diversity is Barbara Carper’s (2009) four fundamental pat-
terns of knowing, first described in 1978, which include empirical,
personal, ethical and aesthetic patterns of knowing. Other nurse
scholars have built upon this idea of multiple ways of knowing, in-
cluding Jacobs-­Kramer and Chinn’s work in the late 1980s (White,
1995), which further considered Carper’s model. Nursing scholar
White (1995) refined and expanded upon her predecessors’ work,
identifying a fifth pattern of knowing in nursing, that of sociopolit-
ical knowing. These conceptualizations of nursing knowledge have
provided an important basis for the discipline’s assertion that it has a
unique body of knowledge. In particular, these understandings have
attempted to capture vital facets of nursing that lie outside the realm
of the empirical.
1.4 | Challenges in articulating epistemological
diversity
Despite these important frameworks, there are concerns that at-
tempt to define the discipline’s unique body of knowledge have not
always been completely successful, particularly as this relates to the
types of nursing knowledge that are not empirically based (Nairn,
2014). At the root of this issue is the fact that nonempirical forms of
knowledge can be ineffable in nature (Nairn, 2012). In other words,
some of the claims to particular forms of knowledge that nursing
makes simply cannot be well explained or justified. This would in-
clude forms of knowledge such as aesthetic or ethical knowing that
by virtue of their somewhat impenetrable nature can “contribute
to an esoteric and unchallengeable basis for professional decision-­
making” (Nairn, 2012; p. 13). Thus, while nurses understand and
know that there is something that they do in the act of nursing that
makes a difference for patients, they often are not able to fully artic-
ulate what this esoteric element is (Tarlier, 2005). This then becomes
an issue as “a fundamental disconnect exists between knowing what
nursing is and being able to explicate the source of nursing knowl-
edge” (Tarlier, 2005, p. 126). The inability to be able to clearly lay
out what it is exactly that nursing encompasses beyond empirically
based knowledge is a significant issue in today’s healthcare world,
particular within the context of the evidence-­based practice agenda.
1.5 | Evidence-­based practice
That nursing practice be evidence-­
based has been increasingly
called for within the healthcare world. As Rycroft-­
Malone et al.
(2004) state, “evidence may well be one of the most fashionable
words in health care” (p. 82). Rycroft-­Malone et al.’s (2004) state-
ment is referring to the evidence-­based practice movement’s power-
ful agenda, whereby there is a preference in health care for evidence
that has been derived from research, in particular quantitative re-
search. There are multiple reasons for the strength of this move-
ment, which includes the ongoing influence of the biomedical care
model. Current neoliberal economic values that set great store by
principles of productivity and processes that are cost-­efficient and
SAKAMOTO
standardized also emphasize that practice be evidence-­based (Kroll
& Lavoie, 2014).
Regardless of exact influences, the issue at stake here is that a
bias for evidence that is based in empirical knowledge can preclude
other forms of evidence for practice (Rycroft-­Malone et al., 2004),
and in doing so can diminish the importance of nonempirical forms
of nursing knowledge (Avis & Freshwater, 2006). A further concern is
that nurses could become so constrained by the protocols and stan-
dards that are part of the evidence-­based reality that practice could
become more “drone-­like” and nurses would develop fewer of the
skills that are informed by other forms of knowledge (Whall, Sinclair,
& Parahoo, 2006).
The evidence-­
based practice debate in nursing is ongoing at
this time. There are some within the discipline who have advocated
for a broader definition of what constitutes evidence for practice
(Rycroft-­Malone et al., 2004), while others propose the opposite
(Scott-­
Findlay & Pollock, 2004; Thorne & Sawatzky, 2014). This
paper certainly does not refute the need for sound evidence for
decision-­making in the clinical setting. Rather, it is the fixation with
evidence of only a certain kind that is alarming. While there is dis-
agreement as to what should be considered evidence for practice,
most scholars agree that the discipline’s dedication to provide holis-
tic and contextualized care is what makes nursing unique, and that
this uniqueness is unquestionably reflected in the discipline’s mul-
tiple sources of knowledge (Rycroft-­Malone et al., 2004; Thorne &
Sawatzky, 2014).
1.6 | World views and binaries
In considering the need for nursing to be able to clearly articulate
its multiple forms of knowledge, particularly within a healthcare
environment that increasingly calls for evidence-­based practice, it
is important to take into account the influence of differing world
views. For instance, quite distinct world views exist in terms of what
counts as evidence for practice and what does not. In terms of defin-
ing the concept of world views, Kikuchi (2003) phrases it well when
she states that they are “mental constructions of reality” (p. 9). As
such, a world view can determine the reality of the discipline of nurs-
ing, and in particular, how its knowledge is viewed (Kikuchi, 2003).
Where this becomes complicated is when differing world views de-
termine different realities, which would in turn value separate forms
of knowledge.
From a Kuhnian perspective, world views or paradigms are often
seen as incommensurable (Risjord, 2010). This incommensurability
between different world views, first alluded to at the beginning of
this paper, creates a tension within a discipline such as nursing with
its many forms of knowledge. While world views provide frame-
works from which to view and understand the world, it is problem-
atic when the tensions between different frames of reference create
competition and a sense of dualism (Leddy, 2000). Thus, world views
that stand in opposition to one another establish dualistic poles of
thought or binary thinking, whereupon one way of thinking is seen as
more favourable than another. Certainly, part of the ongoing debate
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as to how nursing knowledge and evidence are understood can be
attributed to what has been termed “nursing’s problematic relation-
ship to binary argumentation” (Thorne, Henderson, McPherson, &
Pesut, 2004, p. 210) and the discipline’s tendency to dichotomize the
nursing knowledge discussion (Zanotti & Chiffi, 2016).
Dualistic or binary thinking is not unusual, and in fact, binaries
are ubiquitous in everyday life and similar to world views, commonly
help us to understand our world. This is evident in widespread ref-
erence terms that are often paired together such as right and wrong
or good and evil. Although binaries can give us a sense of familiarity
and comfort when trying to understand important concepts, they
tend to provide a simplistic way to view the world that can be quite
limiting (Thorne et al., 2004). This is likely due to the fact that bina-
ries allow for only the one and the other, options or choices that are
quite opposite in nature. When polar opposites exist, there is the
tendency for one option to be seen as more dominant than the other
(Thorne et al., 2004), and this does not allow for any less extreme
points of views or options to be expressed or enacted.
Unfortunately, many of the challenges that our world face today,
such as our numerous environmental and social problems, can
be traced to binary or dualistic thinking (Bandarage, 2013). When
Thorne et al. (2004) first wrote their article about binaries in the post-­
9/11 world, they made reference to ongoing tensions in the Middle
East and the tendency within that era’s sociopolitical climate to focus
on dualities and binary ways of thinking that tended to obscure “the
complexity of human thought and experience and [reduce] differ-
ences to ‘either you are for us or against us’” (p. 209). As we consider
our world today in 2018, binary thinking seems more prevalent than
ever. This is evident in mounting anti-­immigrant rhetoric worldwide
and in nationalistic and protectionist thought currently exhibited
around the globe. This trend has crescendoed most recently during
the United States’ presidential election, a process that has revealed
deep divisions within that country’s national identity and that has
encouraged forms of dualistic rhetoric that only serve to polarize
people further both within the United States and in other countries.
The us versus them phenomenon is closely linked to ideological
positioning. The term ideology most often refers to a set of values
and beliefs that affect one’s viewpoint of the world (Sparknotes,
2016). While ideology’s main function is to help make sense of
one’s reality, it can have negative implications when construed as
totalitarian or fanatical in nature (Mantzoukas, 2007). It is this form
of ideological thinking that this paper is concerned with, a way of
viewing the world that does not allow for other frames of reference.
World views are inherently ideological in nature and the discipline of
nursing is certainly no stranger to ideology (Kikuchi, 2003). Nursing
has discussed its forms of nursing knowledge within postpositivist
and various postmodern frames of reference. Postpositivist lean-
ings are most obvious within the evidence-­based practice debate.
Postmodernism, a philosophical world view that rejects the ratio-
nal and scientific truth of postpositivism in favour of relativism and
multiple points of view (Whall & Hicks, 2002), has in turn provided
a diverse forum for discussions of nursing knowledge. The influence
of postmodernism has allowed for new ways in which to view the
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world and has contributed to the development of social construc-
tionism, critical social theory and feminist philosophies. In recent
years, in an effort to moderate the tensions between postpositivist
and postmodern world views, other philosophical views have taken
on increased prominence. This includes such frames of reference
as neomodernism and neopragmatism (Mason, 2009; Reed, 2006;
Whall & Hicks, 2002).
While different philosophical stances allow for new and invig-
orating ways to discuss nursing issues, these multitude of ways in
which to view the world can cause confusion. As Kikuchi (2003)
explains, “when we ground conceptions of nursing in the idea of
worldviews as we have done and continue to do so, the inescapable
result is what we have today: a plurality of conceptions of nursing
based on different worldviews” (p. 9). In addition, all of these points
of view can function as manifestos from which to consider the world.
In this sense, they can become ideological and a binary when they
are presented as a form from which to best consider nursing issues,
particularly those situated around discussions of nursing knowledge.
Presenting a discussion within a world view allows for a frame of ref-
erence, but that very frame of reference can imply that other points
of view may not be as valuable.
Unfortunately, as Bandarage (2013) states, “we live in a time
of intellectual and ideological myopia” (p. 2). While world wide so-
ciopolitical issues may not at first consideration seem relevant to a
discussion of nursing knowledge, one could in fact argue for the op-
posite. By virtue of its societal mandate of caring, particularly from
a holistic frame of reference, how nursing expresses itself, particu-
larly in terms of its epistemological diversity, is very much relevant
within the context of ongoing world debates. Bandarage’s (2013) use
of the words “ideological myopia” invokes the sense of a narrowing
of vision, an inability to see the larger picture. While Bandarage, as
a sociologist, is referring to a trend for myopic vision within society,
I would like to suggest that the discipline of nursing struggles with a
similar myopic tendency.
In effect, any options that lie between ideological poles do not
have the opportunity to take form or to be fully expressed. For in-
stance, from a postpositivist point of view, the relativism of a post-
modernist stance would not be acceptable and vice versa. Within
the complexity that is nursing, would it not be possible for differing
world views to work together at the same time? Or could a particu-
lar world view work well in certain nursing situations, while others
would be equally effective in others? In their discussion of binaries,
Thorne et al. (2004) questioned whether the attraction to a binary
position in nursing thought was in part due to the fact that the dis-
cipline does not yet share a “common commitment” (p. 210) as to
what a nonbinary nursing world might look like. As stated by Thorne
et al. (2004), “we have not yet been able to visualize the creative
space that exists between the polar opposites” (p. 210). I would like
to propose that this creative space that Thorne et al. contemplate
does exist. This creative space is the winding path between com-
peting forms of thought, a middle ground where different forms of
nursing knowledge coexist. It is in the middle space where nurses
practice everyday, what many have termed nursing praxis. Praxis
occurs when nursing knowledge and experience work synergistically
together, and when the discipline’s diverse epistemologies come into
play (Duff Cloutier, Duncan, & Bailey, 2007; Tarlier, 2005). Thus, the
middle ground is where multiple forms of knowledge, while certainly
tinted by different ideologies and world views, can come together
for a common and distinct purpose: the caring act of nursing.
2 | N U R S I N G A N D TH E M I D D LE G RO U N D
2.1 | Defining the middle ground
The middle ground position creates a space apart from the over-
bearing influence of binary and dualistic points of reference. In fact,
one might be able to posit that the use of the term position should
even be avoided, as this could denote the sense of being entrenched
in yet another viewpoint. Rather, one could envision this middle
ground as a shifting fluid space, a fertile medium where ideas about
nursing and expressions of nursing knowledge can flourish beyond
the influence of what some term the “neologisms and word salads”
(Warelow, 2013, p. 39) that further confuse the issue. As Warelow
(2013) states, “there are no universally acceptable approaches, and,
perhaps the esoteric, abstract nature of many theories means that
their relevance will never be fully acceptable to many practicing and/
or academic nurses” (p. 39).
Thus, the point made earlier that the middle space is where
nurses practice everyday is germane at this juncture, as it is in prac-
tice where nursing knowledge is enacted. It is in practice that nurs-
ing’s unique knowledge is put to good use. When scholars theorize
and philosophize, they are interested in what nurses do and how
they use nursing knowledge to do this or do that. However, when
ideological positioning takes hold, it could be argued that discussions
of nursing become too far removed from the essence of practice,
that they no longer have meaning to those for whom these discus-
sions are most relevant: nurses and those they take care of.
In other words, within this middle space, nursing would be able
to make use of points of reference that suit the need of the partic-
ular moment or context of discussion. As nurses draw on different
forms of knowledge in a clinical situation in complex and change-
able ways to best meet the need of the patient, so too would a
middle ground point of reference allow nursing to express itself in
all of its diversity. This space has always existed and is manifested
everyday in the work that nurses do. Furthermore, as discussed
earlier, the discipline of nursing has long recognized that multi-
ple ways of knowing inform practice but outside of the discipline
itself has struggled to claim outright that it holds to diverse epis-
temologies (Tarlier, 2005). This paper suggests that the discipline
of nursing needs to truly make visible this middle ground, in effect
free up this space and allow for the discipline to be able to com-
fortably assert its claims to diversity in knowledge. Arguing for a
middle ground is not a novel alternative. For instance, Harbison
(2001) discussed a cognitive continuum theory as a middle ground
approach to avoid “fruitless continued theoretical debate” (p.
126). In 1994, Dawson published an article entitled In defense of
SAKAMOTO
the middle ground, where he described this space as “a vast middle
ground of compromise in which such extreme and incompatible
views begin to acknowledge that each might contain a little of the
truth” (p. 1021).
It is not the purpose of this paper to endorse a particular world
view or theory, or to even presume of conceiving a new frame of
reference altogether. Rather, the goal was to explore the possibilities
of situating discussions of nursing and its knowledge base within a
space that allows for the freedom to explore the complex reality that
is nursing without the need to either pledge enduring allegiance to
or eschew altogether a particular world view. Unlike Kikuchi (2003)
who suggests that world views have no place in the discussion of
nursing’s organized body of knowledge, it must be acknowledged
that it is likely impossible for nursing, a discipline made up of human
beings of diverse backgrounds working with other humans of varied
backgrounds, to not be influenced by world view positioning. There
are so many ways in which to be a nurse, as the field of nursing is
diverse from maternal to geriatric nursing, and thus, the possibilities
in which to view the world of nursing can be endless. However, to
not get lost in endless variations in world views and of nursing con-
ceptualizations, a middle space of existence allows nursing to focus
on the issues that matter the most: nursing practice and patient care.
2.2 | Further conceptualizing “The Middle”
It is interesting to consider the word middle itself, and its linguistic
associations. The Merriam-­Webster dictionary (Merriam-­Webster
2016) defines the middle as something that is “equally distant from
the extremes,” as well as “being at neither extreme.” Rather than pro-
pose that the middle ground is exactly between extremes, I would
prefer the second characterization noted above, of a space that ex-
ists at neither end of a polar dispute. Such a space, bound to neither
of the extremes, can be envisioned as the winding path alluded to
earlier, from which the many possibilities of nursing practice branch
out and can be explored.
It is important to note that the term middle has not always had
positive connotations. Consider the expression “stuck in the middle”
which evokes an argument that cannot be won, or an issue that can
never be resolved. It is vital that the idea of a middle ground for
nursing not be seen as the place where the discipline is stuck or sur-
rounded by world views that allow it no other place to go. Nor should
the middle ground be associated with a middling or moderate option,
as in the middle ground is the best that be expected when there is no
other recourse or resolution.
At the risk of seeming to abide by an ideological point of view,
it might be helpful to use a Buddhist description of what is termed
the Middle Path to further illustrate how nursing could envision this
middle ground. The Middle Path according to scholar-­monk Bhikku
Bodhi “is not a compromise between the extremes but a way that
rises above them, avoiding the pitfalls into which they can lead” (as
cited in Bandarage, 2013, p. 8). Thus, rather than the middle being
a compromise between disparate world views, staking out a middle
domain that rises above competing ideologies could provide a safe
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and productive space for nursing to be able to showcase, enact, dis-
cuss and create its distinct knowledge.
One could imagine this middle ground literally as a raised mass of
land with two cities at either end. This ground is high enough that the
cities do not cast a shadow, but these cities are accessible. The cities
represent different world views or paradigms of thought, and are
filled with structures that house different ideas and points of view.
The nursing world exists in the middle, and ideas, points of reference
and beliefs can be brought out of the cities for use within different
nursing contexts. This middle world is constantly changing, in fact
that is its purpose, to provide the “creative space” that Thorne et al.
(2004) referred to earlier, where multiple forms of nursing knowl-
edge can coexist and where new forms of knowledge can be created.
2.3 | Possible criticisms of a middle stance
It is likely that some would find this conceptualization of a mid-
dle space disorganized and chaotic, especially in the way that it is
ever-­changing. However, as nursing work is a “complex business
of delivering holistic nursing care to diverse individuals in the con-
text of their unique relational and sociocultural worlds” (Thorne &
Sawatzky, 2014, p. 11), one could argue that this space could not
help but be complex itself. Some may hazard to ask where the con-
cept of truth fits into a space that is constantly evolving or how
sound judgements can be made when the landscape appears to con-
stantly change? Truth as a concept related to nursing epistemology
certainly figures prominently in the ongoing ideological debate as to
what makes up nursing knowledge (Stajduhar, Balneaves, & Thorne,
2001). As there are different world views from which to view the
world and consider knowledge, so to can the concept of truth take
on varied levels of focus and importance. For instance, from a prag-
matist point of view, establishing truth is not the goal of the inquiry
process; rather the point of developing knowledge is to solve prob-
lems (Fry, 1995; Houghton, Hunter, & Meskell, 2012). While prag-
matic thought would not focus on the truth, a postpositivist frame
of reference would argue for the need to establish as close to a real-
istic approximation of the truth as possible (Guba, 1990; Houghton
et al., 2012). Thus, as disparate notions exist as to the truth, and as
all positions are open for consideration in the middle ground, the
importance of the truth then does become relative.
With this statement and the use of the word relative, one can
imagine an immediate reaction of “this sounds like an argument for
relativism!” Indeed, as part of operating from the middle ground,
a space where nursing’s epistemological diversity can be fully ex-
plored and acknowledged, the truth when contextualized within
nursing practice could in fact take various and relative forms. For
example, in a nursing situation that calls for empirically based knowl-
edge, such as understanding medication dosages or inserting a Foley
catheter, certain objective and concrete truths, such as precise med-
ication doses or the proper catheter size, are required. Similarly, sub-
jective truths are applicable in different situations, or can exist along
with those more objective in nature. For instance, a nurse may have
to choose the right type of dressing to treat a chronic leg ulcer. What
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the right choice will depend on the nurse’s objective knowledge
of vascular and healing processes and of the properties of various
wound products. This choice will also depend on subjective under-
standings of the patient’s preferences and lifestyle, factors that can
affect the success of a chosen line of treatment.
As Stajduhar et al. (2001) state, “the nature of nursing’s work
has also compelled the discipline to appreciate not only the objec-
tive physiological aspects of a disease but also recognize the actual
subjective human experience and meaning associated with that dis-
ease” (p. 75). Thus, rather than taking a stance for relativism in coun-
tenancing that the truth can have many forms, it could be argued
that a middle ground that makes explicit nursing’s multiple ways of
knowing allows for simply knowing and accepting multiple objective
and subjective truths. This is the authenticity of nursing practice,
balancing and recognizing the worth of both the objective and sub-
jective. Moreover, the middle space is where both the concrete and
ineffable, or empirical and nonempirical forms of knowledge, can co-
exist. As a caveat, it should be pointed out that all knowledge claims
may not always be relevant or applicable, and should be subjected
to criticism and consideration by those whom they will most affect
(Reed & Lawrence, 2008). While the middle ground is conceptual-
ized as an open and welcoming space that acknowledges the diver-
sity in nursing knowledge, it is not conceived as a place where ideas
that could potentially be harmful to others will be unquestionably
accepted. Nor, as certain scholars fear, should celebrating multiple
ways of knowing further fragment the discipline (Garrett, 2016).
Rather the argument for a middle space that makes visible nursing’s
epistemological diversity highlights the need to “construct places
that can sustain the conversation to explore and develop a variety of
approaches for their value in building knowledge and solving prob-
lems” (Reed & Lawrence, 2008, p. 426).
3 |  CO N C LU S I O N
The nursing knowledge debate, particularly in how knowledge in-
forms practice, has been ongoing for some time now. This paper has
discussed and examined the unique nursing knowledge that is char-
acterized by diverse and multiple forms of knowing and underpins
the work of all nurses, regardless of field of practice. Unfortunately,
it has been challenging for the discipline to take full ownership of its
epistemological diversity, largely due to factors such as competing
world views and ideological and binary positioning. This paper posits
a figurative middle ground from which to consider the complexities
of nursing and its unique body of knowledge. It suggests that the
middle ground is a space where epistemological diversity can be fully
explored. In being able to enact its multiple forms of knowledge in
a creative and open space that is open to different ideas and world
views, not only can nursing take full ownership of its practice and of
its unique knowledge, it can also demonstrate how best to navigate
an increasingly polarized world. In a world that is increasingly fixated
on binary solutions and dualistic points of view, let us celebrate what
is diverse, and continue to explore both the unique and the universal.
ORCID
Mariko Liette Sakamoto  http://orcid.org/0000-0002-1164-0324
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How to cite this article: Sakamoto ML. Nursing knowledge:
A middle ground exploration. Nurs Philos. 2018;e12209.
https://doi.org/10.1111/nup.12209