Dr. Ruby Dunlap’s Uganda Fulbright Blog

Tell all the Truth but tell it slant—
Success in Circuit lies
Too bright for our infirm Delight
The Truth’s superb surprise
As Lightening to the Children eased
With explanation kind
The Truth must dazzle gradually
Or every man be blind—

Emily Dickinson’s (1830-1886) poetry is for me a gradual dazzle. This one came to mind as I’ve taken retrospective tours of the Ugandan nursing graduate students and my experiences with philosophy and theory over four weeks in January. Do and should nursing theories give priority to a received philosophy of science or a perceived philosophy of science? Which one fits best with a Christian worldview? What exactly is a worldview and what could be especially Christian about it? What are the logical parameters of differing worldviews? Is logic a valid criterion by which we should evaluate any worldview or theory and on what grounds do we recognize the validity of logic itself?

In fact, confidence in rational mental processes, that is, the trustworthiness of disciplined and self-correcting inferences based on observed facts and relationships, is a criterion for critical thinking according to the American critical thinking gurus, Paul and Elder. One ground for recognizing the validity of logic as a criterion for evaluating any worldview, philosophy, or theory is that our speech is so much noise otherwise. As in the parable of the fruitless fig tree, one is tempted to ask, “Why encumbereth it the ground?” (Luke 13:7, KJV) Indeed, without confidence in reason, the logic tree has no ground to encumber.

The Truth in Dickinson’s poem is objective and external, compared to lightening, public, sudden, inexorable and capable of blinding if coming at us all at once. It can also be quantifiable since she urges us to tell all of it. That is, what is told can be all or more or less depending on its relationship to the “all.” These are the assumptions of the worldview from which Dickinson wrote this poem and they are entirely consistent with the Christian worldview which holds that truth is objective and at least some of it is as self-evident as lightening. But she also urges us to tell it slant.

Truth told slant has, in our times, been slanted toward the pejorative: slanted truth is biased and, therefore, not trustworthy. Research which contains slanted truth is held to dismissive ridicule in the world of modern scholarship. This is the basis for the disclosure clauses in research publications: the investigators intend to communicate that what they are presenting has not be unduly influenced by those funding the research. “Garbage in, garbage out,” Dr. Cyndy McRae said to the students as she guided them through some SPSS demonstrations and the priority care they should take with the trustworthiness of their data. (Cyndy was here for four weeks on a short term Fulbright grant and very graciously agreed to some informal SPSS demonstrations for the students. The friendship between Cyndy and myself was instant and will be enduring.) This kind of disciplined scrutiny of data is also applied to the trustworthiness of qualitative methods and findings as it is to quantitative research. Garbage doesn’t much care about its source; truth slanted in this way is no longer truth at all. Dickinson surely meant something other than this understanding of “slant.” “Slant” in this poem is connected conceptually to “explanation kind,” terms which combine the transmission of cognitive illumination within an ethic of caring. “Explanation kind” has a particularly congenial fit with service professions.

The students were asked to present a short paragraph on whether they believed nursing should give priority to “received science” (objective, quantitative knowledge) or “perceived science” (subjective, qualitative knowledge). More than this, they were asked (by the syllabus criteria for a second short paragraph) what concerns they might have with either the received philosophy or perceived philosophy of science in relationship with a Christian worldview. They then had to challenge and defend each other’s positions with points assigned to all three activities, the initial position, the challenges and the defenses.

It proved to be a fruitful exercise with the majority of the students believing that nursing science should give priority to the perceived findings of qualitative research since these were “humanistic” and respected the right of people to define their own situations as they chose. A minority of students disagreed and said that nursing could not maintain standards of care without basing that care on received science, objective criteria by which to arrive at clinical diagnosis and treatment plans. They all agreed that nursing actually used and needed both kinds of science. In fact, the approach working nurses take is an integrative approach, one in which objective data generally is given priority in clinical decision making if they and the subjective data are contradictory. Fortunately for us nurses, we don’t get contradictory data very often. When we do, more assessment is usually required.

Many Ugandans complain of intermittent stomach discomfort and several even in my small circle have told me they have “stomach ulcers.” When I asked the students if Ugandans have a high incidence of stomach ulcers, they all agreed this was the popular perception: stomach ulcers are common among Ugandans.

One of the students, however, is an endoscopy nurse at Mulago Hospital, the national referral hospital. She has assisted in taking long, clinical looks inside many Ugandan stomachs. “Stomach ulcers are actually quite rare with Ugandans,” she said. She was basing her statement on observed facts, endoscopy findings from a significant sample of Ugandan stomachs. (She also said lab data on those stomach ulcers which were observable did not support the findings elsewhere in the world that a majority of them are caused by Helicobacter pylori. Treatment for stomach ulcers in Uganda, however, generally follows the recommendation for H. pylori eradication as part of an evidence-based therapeutic approach.) “Which evidence are you going to believe?” I asked the students, “the subjective data of Ugandan perceptions or the objective data of the endoscopy lab? They do not agree with each other. Which evidence is stronger? How will you integrate the types of evidence in your clinical practice?”

I also pointed out the problem of persons with “silent” diseases, the asymptomatic months or even years of an HIV infection, diabetes or hypertension during which those afflicted do not perceive their illness and may deny it if diagnostic data is returned positive but also during which the illness is progressing along its course with lethal effects to themselves and to others regardless of perception. Perceived science has these risks and those who give it priority over a received view of science, as my students pointed out, risk failure in delivering quality clinical services.

Objective data has its problems, too, of course. Our instruments can be faulty in their sensitivity and specificity as can we and both instrument and human fail to identify trustworthy evidence. This is why issues surrounding the quality of laboratory equipment and personnel are so critical: garbage in, garbage out applies to clinical practice as much as it does to research and the stakes can be considerably higher. No one wants an inaccurate biopsy report especially given the torture of waiting for it. Objective data can be reductionistic as can subjective data: we all know how convenient a selective telling can be at times. The issues at hand for nursing around the world are these: how best to identify and integrate types of evidence and, when the data are contradictory, which of them rise to the level of defensible grounds for our clinical decisions? And, of course, what guides us in the telling of it?

Give me the Truth, all of it, but, for my infirm Delight, give it slant in explanation kind.