Health as Human Flourishing
The definition of health as human flourishing originally proposed for Careful Nursing was derived from the historical data from which Careful Nursing was constructed. Nurses and the people they cared for aimed to achieve health overall, as whole persons, despite their often gruelling living conditions and many threats to their life. Many desired to flourish according to its dictionary definition, that is, to flower as living organisms growing in a luxuriant way towards their highest being. In this sense flourishing was judged to be synonymous with health. If the common definition of health; being free in mind and body from illness and injury and having basic social needs met; could be achieved, this was seen to be encompassed in flourishing.
Interestingly, to flourish, living organisms must have nourishment and nourishing surroundings, especially if they are sick, injured or vulnerable human beings. Significantly, the word nourishing is synonymous with nursing. These associations suggest that nursing has a distinctive concern with health as human flourishing.
Health as human flourishing was initially defined as: "the person's unitary experience of personal dignity, harmony, relative autonomy, contentedness and sense of purpose in life . . . . includes the ability, or potential, to experience a personal relationship with an infinite transcendent reality through inner reflection, contemplation, meditation or prayer; and to express this experience in loving relationships with others and in seeking to fulfil a perceived purpose in life . . . . the ability to accept with equanimity influences and circumstances which are seemingly unjust but may be very difficult to alter" (Meehan, 2012, p. 2908).
Human flourishing in philosophy
As Careful Nursing was developed it was recognised that the concept of human flourishing has a rich philosophical history which is consistent with Careful Nursing. This history has its source in virtue theories where, by implication, flourishing is linked to health. Human flourishing is central to Aristotle's virtue theory (350BCE/1998). Aristotle posits that full flourishing is the highest good that we human beings seek to attain. He views it as our end state, what we might call fulfilment of our purpose in life. He proposes that we flourish thorough a lifelong process of developing "states of character" (Bk. 2, ch. 5) which will make us good and "make [us] do [our] own work well" (Bk. 2, ch. 6). This involves choosing to develop the habit of thinking and doing things with excellence. Through long practice these habits become "[our] nature in the end" (Bk. 7, ch. 10). The Greek word for such excellence, aretê, is translated in English as virtue. Aristotle describes this process as "an activity of the soul" (Bk. 1, ch. 13), that is, of our life-giving essence as human beings which is distinctively associated with reasoning.
Aquinas (1265-1274/2006), adopted Aristotle's virtue theory, including his idea of human flourishing (I, II, Q. 3, Q. 55-64), as a foundation for developing his own virtue theory. He defines virtues as natural inward capacities for excellence which, through our rational intellect and will, we express in consistently good ways, or habits, of thinking and doing things (DeYoung, et al, 2009). He adopts the intellectual and moral virtues identified by Aristotle but discusses them in much greater detail. He organizes them under four fundamental virtues; prudence, temperance, fortitude (courage), and justice. He then extends and transforms Aristotle's virtue theory by drawing on the work of other philosophers and grounding his thinking in awareness of an abundantly loving pure spiritual being (in Careful Nursing Infinite Transcendent Reality) with whom human persons have a participatory relationship. From his spiritual perspective Aquinas proposes three additional virtues; faith, hope and love.
Neither Aristotle nor Aquinas link flourishing directly to health. However, Aristotle proposes that we need to have our basic needs met in order to flourish; needs such as food, shelter, clothing, a sound body and mind, and good domestic and civil circumstances. Nonetheless, both philosophers imply persuasively that overall health for the human being as a unitary whole is the process of seeking to achieve full flourishing. A longer overview of the virtue theories of Aristotle and Aquinas can be found here
The virtue theories of Aristotle and Aquinas have been developed further by contemporary philosophers as theories of virtue ethics, notably by Alasdair MacIntyre (2007). They describe the practice of virtues as ways of functioning well, particularly doing our work well, and flourishing in the contemporary social, political, and economic context. Of particular interest for Careful Nursing is a group of papers on health and human flourishing edited by Taylor and Dell'Oro (2006) in which the definition of human beings as unitary persons is the same as for Careful Nursing. The experience of vulnerability in illness and the importance of compassionate care-giver attentiveness are discussed in detail. The virtues of faith, hope and love in the provision of health care are shown to have a central role in fostering human flourishing in both patients and care-givers.
Human flourishing in psychology
In the 1980s the idea of health as human flourishing was adopted in psychology. Initial development drew somewhat on Aristotle's virtue theory (Waterman 2008). But as the concept of flourishing has been absorbed into positive psychology, for example by Gaffney (2011), it has become a descriptive psychological term for subjective feelings of happiness related to physical and emotional health, rather than referring to Aristotle's objective state of goodness. However, more recently Niemiec (2014) has sought to re-introduce the development of character strengths, such as honesty and self-control, as part of achieving flourishing.
Human flourishing in nursing
For the most part, only passing reference to the idea of human flourishing appears in nursing literature, for example, as a nursing goal for patients from an Aristotelian perspective (Fanning, 2001), as a practice outcome related to a unitary nursing model (Cowling & Swartout, 2011), in association with healing and health in vulnerable patients (Sellman, 2005), and as a broad vision for nursing practice (MacCulloch, 2011).
However, one impressive exception is a professional practice model proposed by Barbara Jacobs (2013), developed from Carper's patterns of knowing in nursing and Aristotelian intellectual virtues, as well as moral virtues. In this model nurses' promotion of patients' flourishing as the ultimate good, in its Aristotelian meaning, is argued to be intrinsic in the essential nature of nursing practice. Nurses as virtue-guided moral agents pursue excellence in the clinical details of their practice. In their relationships with patients, they enhance patients' flourishing as well as their own flourishing. Thus, human flourishing becomes the philosophical end of professional nursing for both patients and nurses. Jacobs describes this practice model as holistic, although it does not appear to account for human beings a unitary persons and no mention is made of the spiritual dimension of human life. However, this practice model is consistent with Careful Nursing from the perspective of virtue theory and human flourishing.
Need for further development
It is evident from this limited review of health as human flourishing, that its use as a philosophical principle in Careful Nursing needs more comprehensive development and its implications for nursing practice need elaboration, for both nurses and the people they care for. The Careful Nursing definition of health as human flourishing will need to include the view that seeking health as human flourishing is a life-long process of endeavouring, through the exercise of reason and will, to choose to think and act with excellence.
Implications for practice
In Careful Nursing practice we consider health on two levels. The first level can be thought of as the desired basis for flourishing, that is, people's immediate bio-physical, psycho-spiritual and social needs for must be aimed for; needs such as food, shelter, clothing, a sound body and mind, and good domestic and civil circumstances. Although every effort is made to achieve this level it may sometimes be possible only to a limited extent, for example, for people living in a poor country or under repressive civil circumstances.
Secondly, full human flourishing is always sought. If we consider the main virtues discussed by Aristotle and Aquinas; intelligence, reason, prudence, wisdom, courage, temperance, generosity, good temper, friendliness, truthfulness, justice and Aquinas's additions of love and hope, we can easily think of ways they relate to our practice and ways that patients can draw on the practice of these virtues as they seek to cope with illness and injury and to regain their health. More about how these ideas can be applied in nursing can be found here
A virtue can be thought of as a state of character that helps us to lead a good life. For nursing, a virtue can be thought of as an attitude or activity that helps us practice well. Many virtues are thought of as being a 'golden mean', the attitude or behaviour we aim to always express. The golden mean is placed between two extremes or vices, one of deficit from the mean and the other of an excess of the mean; attitudes and behaviours we definitely do not want to express. Virtues are developed by practicing them, of developing them as habits.
It is possible to use this idea to help us develop our ability to practice well. For example, consider the two virtues illustrated here, one of gentleness and one of courage, two important nursing virtues and values. You see each with its mean and two extremes. We try to keep close to the mean which will help us practice well. But sometimes we might find ourselves falling in the direction of the virtue's deficit or excess, depending on how we are in ourselves or events happening around us. We can use these sorts of illustrations to assess ourselves and work on developing the habit of being as close to the mean as possible as often as possible.
Finally, in Careful Nursing it is recognised that ideally, health is associated with the relative absence of disease. But, health as human flourishing can still be fully experienced in states of disability, chronic illness or living under difficult socioeconomic circumstances and conflict. Healing is a natural restorative process which has its source in Infinite Transcendent Reality and in nature. Taken our human propensity for conflict on many levels, it seems necessary that health as human flourishing will also include the ability to accept with equanimity circumstances which are unjust but may be very difficult to alter.
Aquinas T (1265-1274/2006) Summa Theologiae. (ed. RJ Hennessey). Cambridge University Press, Cambridge.
Aristotle (350BCE/1998). Nicomachean Ethics. (trans. WD Ross). Oxford University Press, Oxford. http://classics.mit.edu/Aristotle/nicomachaen.html
Cowling WR & Swartout KM (2011). Wholeness and life patterning: Unitary foundations for a healing praxis. Advances in Nursing Science, 34, 51–66.
DeYoung RK, McCluskey C & Van Dyke C (2009). Aquinas's Ethics. University of Notre Dame Press, Notre Dame, IN.
Flaming D (2001). Using phronesis instead of 'research-based practice' as the guiding light for nursing practice. Nursing Philosophy, 2, 251–258.
Gaffney M (2011) Flourishing. Penguin Ireland, Dublin.
Jacobs BB (2013) An innovative professional practice model: Adaptation of Carper's patterns of knowing, patterns of research, and Aristotle's intellectual virtues. Advances in Nursing Science, 36, 271-288.
MacCulloch T (2011) Flourishing: A vision for everybody. Issues in Mental Health Nursing, 32, 335.
MacIntyre A (2007) After Virtue. (3rd ed.). Bloomsbury Publishing, London.
Meehan TC (2012) The Careful Nursing philosophy and professional practice model. Journal of Clinical Nursing, 21, 2905-2916.
Niemiec RM (2014) Mindfulness and Character Strengths: A Practical Guide to Flourishing. Hogrefe Publishing, Gottingen.
Sellman D (2005) Towards an understanding of nursing as a response to human vulnerability. Nursing Philosophy, 6, 2–10.
Taylor C R & Dell'Oro R (Eds.) (2006). Health and Human Flourishing. Georgetown University Press, Washington, DC.
Waterman AS (2008) Reconsidering happiness: A eudaimonist's perspective. The Journal of Positive Psychology, 3, 234–252.
THerese C. Meehan© September 2017