Knowing in Nursing
The discipline of nursing has a unique body of knowledge that has patterns, forms, and structure. The growth of nursing knowledge since the beginning of the 21st century has increased significantly. Carper (1992, p. 73) reviewed nursing literature between 1964 and 1975 in “an effort to understand the kinds of knowledge comprising the discipline of nursing.” She published her results in a 1978 article that identified four fundamental patterns of knowing in nursing: empiricism, aesthetics, personal knowledge and ethics. It is important for members of the nursing profession to comprehend these patterns of information because it provides the type of knowledge that is most valuable to the discipline of nursing. The following is a discussion of Caper’s four fundamental patterns of knowing in nursing as well as Schultz and Meleis’ examination of nursing knowledge.
The term empirics did not emerge into nursing verbiage until the 1950s. At this point in time, it became increasingly important to nursing theorist and researchers to develop a body of knowledge in nursing based on empirics (Polifroni, 1999). The empirics of nursing are the scientific aspects of nursing, which includes the verifiable data incurred from objective information (Hood, 2006). According to Carper, “Empirical data, obtained by either direct or indirect observation and measurement . . . are formulated as scientific principles, generalizations, laws, and theories that provide explanation and prediction” (Carper, 1992, p. 76). Chinn and Kramer stated that empirical knowledge is obtained through the human senses, and that it can be substantiated by others in the profession (Chinn & Kramer, 1999). This verified and credible data is then used communicate understanding, as well as explaining and structuring the knowledge obtained (Chinn & Kramer, 1999). Empirical data is essential to the discipline of nursing because it allows professionals to communicate across multiple disciplines in a basic and generalized format. Nurses from every background are required to obtain, comprehend, and act on empirical data. This is the reason it is imperative for empirical knowledge to be understood by all members of the profession.
The esthetics of nursing is the concept of nursing as an art. The majority of literature on the development of nursing as a science is based on the factual and verifiable aspects of nursing. The concept of aesthetic knowing in nursing according to Chinn and Kramer (1999, p. 183) states, “the aspect of knowing that connects with deep meanings in a situation and calls forth inner creative resources that transform experience.”
Benner and Tanner (1987) described intuitive judgment in respect to the aesthetics of nursing. There are six aspects of intuitive judgment that should be employed by all nurses. The six aspects are:
1. Pattern recognition is the ability to recognize patterns and relationships without prior consideration of the separate components.
2. Similarity recognition is the ability to see similarities and parallels among patient situations, even when there are marked dissimilarities in objective features.
3. Common sense understanding is “a deep grasp of the culture and language, so that flexible understanding in diverse situations is possible. It is the basis for understanding the illness experience, in contrast to knowing the disease” (Benner & Tanner, 1987, p. 25). It is a way of “tuning in” to the patient and grasping the patient’s experience.
4. Skilled know-how is based on a combination of knowledge and experience that permits flexibility of actions and judgments.
5. A sense of salience makes it possible to differentiate what is particularly significant in a situation.
6. Deliberative rationality involves the use of analysis and past experience to consider alternative interpretations of a clinical situation.
The ability to adapt nursing care to meet the needs of every patient, as well as the recognition of the needs of the patient through interpreting behaviors is a part of the art of nursing. “The esthetic pattern of knowing in nursing involves the perception of abstracted particulars as distinguished from the recognition of abstracted universals. It is the knowing of a unique particular rather than an exemplary class” (Polifroni, 1999, p. 15). Caper stresses the significance of including aesthetic knowledge into the nursing process. She states that the experience of helping and caring, “must be perceived and designed as an integral component of its desired result rather than conceived separately as an independent action imposed on an independent subject” (Carper, 1978, p. 17). There is a need for nurses to allow a part of themselves to be expressed in nursing care. Through an understanding of aesthetics, and the above listed intuitive judgment, the nurse can provide clinical nursing that incorporate aesthetics.
Personal knowledge in nursing is the nurse’s individual method of obtaining, organizing, understanding and applying information. “The pattern of personal knowing refers to the quality and authenticity of the interpersonal process between each nurse and each [client]” (Fawcett et al., 2001, p. 116). The personal knowledge a nurse possesses is dynamic, and will grow constantly throughout the lifespan. The nurse must be open to new experiences, thoughts and feelings. The nurse must be honest with themselves, and explore and interpret all knowledge obtained. Once this is completed, the nurse then should apply the comprehension of the data collected individually to meet the needs of the patient. Not all of the knowledge obtained will be easily interpreted. The nurse must be able to “accept ambiguity, vagueness, and discrepancies in what is essentially a subjective and existential process” (Hood, 2006, p. 98). Every nurse draws upon personal knowledge when interacting with patients. This concept incorporates both empirical data and aesthetics, and is essential to nursing practice.
Ethics: The Moral Component
Making decisions about the care of a patient often requires the nurse to determine which actions are morally right, and morally wrong. The problems that arise in healthcare that require moral decisions are typically vague in nature, with no clear connection to the standard code of ethics that is applied in the respect of human life. Nursing is bound to moral traditions that require, “valuable and essential social service responsible for conserving life, alleviating suffering, and promoting health” (Cody, 2006, p. 24).
This pattern of knowing requires a comprehensive understanding of different philosophies of morality. The ethical dilemmas that nurses encounter must first be reflected upon as concrete situations, then with consideration of the moral results of the actions taken. Reflection of different moral and ethical codes will provide the nurse with a greater understanding of how moral choices should be made. As technology progresses and a push for socialized medicine in the United States comes closer to reality, nurses will be faced with an increased amount of ethical dilemmas dealing with end-of-life situations. A thorough understanding of ethics and morality will assist the nurse in making the decisions that will benefit the patient as well as themselves.
Other Views of Patterns in Nursing
Schultz and Meleis (1988) examined Carper’s patterns of knowing, and felt that she left out a few very important practical concepts. They decided to include the following three patterns in nursing knowledge: clinical, conceptual, and empirical. The following is a description of these patterns in nursing, which need to be appreciated as an expansion of Caper’s four fundamental patterns of nursing.
Clinical knowledge refers to the nurse’s personal knowledge. The nurse employs multiple ways of knowing while they are addressing the problems of their patients. The clinical knowledge is observable when the nurse is practicing nursing, and is created from the unity of personal knowledge and empirical knowledge (Schultz P.R. & Meleis A. I, 1988).
Conceptual knowledge is derived from the objective and subjective data collected from multiple patient interactions. These interactions occur over a span of time and in multiple settings. The nurse will recognize the patterns that evolve from these experiences while expressing them as models and theories (Schultz P. R. & Meleis A. I, 1988). Propositional statements and concepts are formed and supported by empirical or anecdotal data, as well as logical reasoning (Schultz P. R. & Meleis A. I, 1988). This knowledge draws on information from nursing, as well as multiple other disciplines including sociology, psychology, etc. According to Schultz & Meleis, conceptual knowledge, “incorporates curiosity, imagination, persistence, and commitment in the accumulation of facts and reliable generalizations that pertain to the discipline of nursing” (McEwan, 2007, p. 15).
The combination of experimental, historical, or phenomenological research is used to define the concept of empirical knowledge. This knowledge validates nursing actions and procedures. The validity of this knowledge is based upon the general acceptance by researchers within the field of nursing and the conclusions drawn from the evidence provided (McEwan, 2007). Schultz and Meleis stated that “empirical knowledge is evaluated through systematic review and critique of published research and conference presentations” (Schultz P.R. & Meleis A. I, 1988).
There is a need to recognize patterns of knowing in nursing. The recognition of these patterns will be used to validate the unique body of knowledge nursing owns. This unique body of knowledge is the justification of nursing practices. Understanding the patterns of knowing in nursing is crucial to teaching and learning nursing. The patterns of knowing will not expand nursing knowledge, but will answer the question of what it means to know, and how to identify the types of knowledge that are important to nursing. The recognition of these patterns of knowing assists to analyze the kind of knowledge that gives the discipline of nursing the meaning.
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