Characteristics of Carpers Patterns of Knowing in Nursing Pattern of Knowing
Other Views of Patterns of Knowledge in Nursing Although Carper’s work is considered classic, it is not without critics. Schultz and Meleis (1988) observed that Carper’s work did not incorporate practical knowledge into the ways of knowing in nursing. Because of this and other concerns, they described three patterns of knowledge in nursing: clinical, conceptual, and empirical.
Clinical knowledge refers to the individual nurse’s personal knowledge. It results from using multiple ways of knowing while solving problems during client care provision. Clinical knowledge is manifested in the acts of practicing nurses and results from combining personal knowledge and empirical knowledge. It may also involve intuitive and subjective knowing. Clinical knowledge is communicated retrospectively through publication in journals (Schultz & Meleis, 1988).
Conceptual knowledge is abstracted and generalized beyond personal experience. It explicates patterns revealed in multiple client experiences, which occur in multiple situations, and articulates them as models or theories. In conceptual knowledge, concepts are drafted and relational statements are formulated. Propositional statements are supported by empirical or anecdotal evidence or defended by logical reasoning.
Conceptual knowledge uses knowledge from nursing and other disciplines. It incorporates curiosity, imagination, persistence, and commitment in the accumulation of facts and reliable generalizations that pertain to the discipline of nursing. Conceptual knowledge is communicated in propositional statements (Schultz & Meleis, 1988).
Empirical knowledge results from experimental, historical, or phenomenologic research and is used to justify actions and procedures in practice. The credibility of empirical knowledge rests on the degree to which
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the researcher has followed procedures accepted by the community of researchers and on the logical, unbiased derivation of conclusions from the evidence. Empirical knowledge is evaluated through systematic review and critique of published research and conference presentations (Schultz & Meleis, 1988).
Chinn and Kramer (2015) also expanded on Carper’s patterns of knowing to include “emancipatory knowing”—what they designate as the “praxis of nursing.” In their view, emancipatory knowing refers to human’s ability to critically examine the current status quo and to determine why it currently exists. This, in turn, supports identification of inequities in social and political institutions and clarification of cultural values and beliefs to improve conditions for all. In this view, emancipatory knowledge is expressed in actions that are directed toward changing existing social structures and establishing practices that are more equitable and favorable to human health and well-being.
Summary of Ways of Knowing in Nursing For decades, the importance of the multiple ways of knowing has been recognized in the discipline of nursing. If nursing is to achieve a true integration between theory, research, and practice, theory development and research must integrate different sources of knowledge. Kidd and Morrison (1988) state that in nursing, synthesis of theories derived from different sources of knowledge will:
1. Encourage the use of different types of knowledge in practice, education, theory development, and research.
2. Encourage the use of different methodologies in practice and research. 3. Make nursing education more relevant for nurses with different educational backgrounds. 4. Accommodate nurses at different levels of clinical competence. 5. Ultimately promote high-quality client care and client satisfaction.
Research Methodology and Nursing Science Being heavily influenced by logical empiricism, as nursing began developing as a scientific discipline in the mid-1900s, quantitative methods were used almost exclusively in research. In the 1960s and 1970s, schools of nursing aligned nursing inquiry with scientific inquiry in a desire to bring respect to the academic environment, and nurse researchers and nurse educators valued quantitative research methods over other forms.
A debate over methodology began in the 1980s, however, when some nurse scholars asserted that nursing’s ontology (what nursing is) was not being adequately and sufficiently explored using quantitative methods in isolation. Subsequently, qualitative research methods began to be put into use. The assumptions were that qualitative methods showed the phenomena of nursing in ways that were naturalistic and unstructured and not misrepresented (Holzemer, 2007; Rutty, 1998).
The manner in which nursing science is conceptualized determines the priorities for nursing research and provides measures for determining the relevance of various scientific research questions. Therefore, the way in which nursing science is conceptualized also has implications for nursing practice. The philosophical issues regarding methods of research relate back to the debate over the worldviews of received versus perceived views of science versus postmodernism and whether nursing is a practice or applied science, a human science, or some combination. The notion of evidence-based practice has emerged over the last few years, largely in response to these and related concerns. Evidence-based practice as it relates to the theoretical basis of nursing will be examined in Chapter 13.
Nursing as a Practice Science In early years, the debate focused on whether nursing was a basic science or an applied science. The goal of basic science is the attainment of knowledge. In basic research, the investigator is interested in understanding the problem and produces knowledge for knowledge’s sake. It is analytical and the ultimate function is to analyze a conclusion backward to its proper principles.
Conversely, an applied science is one that uses the knowledge of basic sciences for some practical end. Engineering, architecture, and pharmacology are examples. In applied research, the investigator works toward solving problems and producing solutions for the problem. In practice sciences, research is largely clinical and
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action oriented (Moody, 1990). Thus, as an applied or practical science, nursing requires research that is applied and clinical and that generates and tests theories related to health of human beings within their environments as well as the actions and processes used by nurses in practice.
Nursing as a Human Science The term human science is traced to philosopher Wilhelm Dilthey (1833–1911). Dilthey proposed that the human sciences require concepts, methods, and theories that are fundamentally different from those of the natural sciences. Human sciences study human life by valuing the lived experience of persons and seek to understand life in its matrix of patterns of meaning and values. Some scholars believe that there is a need to approach human sciences differently from conventional empiricism and contend that human experience must be understood in context (Cody & Mitchell, 2002; Polifroni, 2015).
In human sciences, scientists hope to create new knowledge to provide understanding and interpretation of phenomena. In human sciences, knowledge takes the form of descriptive theories regarding the structures, processes, relationships, and traditions that underlie psychological, social, and cultural aspects of reality. Data are interpreted within context to derive meaning and understanding. Humanistic scientists value the subjective component of knowledge. They recognize that humans are not capable of total objectivity and embrace the idea of subjectivity (Streubert & Carpenter, 2011). The purpose of research in human science is to produce descriptions and interpretations to help understand the nature of human experience.
Nursing is sometimes referred to as a human science (Cody & Mitchell, 2002; Polifroni, 2015). Indeed, the discipline has examined issues related to behavior and culture, as well as biology and physiology, and sought to recognize associations among factors that suggest explanatory variables for human health and illness. Thus, it fits the pattern of other humanistic sciences (i.e., anthropology, sociology).
Quantitative Versus Qualitative Methodology Debate Nursing scholars accept the premise that scientific knowledge is generated from systematic study. The research methodologies and criteria used to justify the acceptance of statements or conclusions as true within the discipline result in conclusions and statements that are appropriate, valid, and reliable for the purpose of the discipline.
The two dominant forms of scientific inquiry have been identified in nursing: (1) empiricism, which objectifies and attempts to quantify experience and may test propositions or hypotheses in controlled experimentation, and (2) phenomenology and other forms of qualitative research (i.e., grounded theory, hermeneutics, historical research, ethnography), which study lived experiences and meanings of events (Gortner & Schultz, 1988; Morse, 2017; Risjord, 2010). Reviews of the scientific status of nursing knowledge usually contrast the positivist–deductive–quantitative approach with the interpretive–inductive–qualitative alternative.
Although nursing theorists and nursing scientists emphasize the importance of sociohistorical contexts and person–environment interactions, they tend to focus on “hard science” and the research process. It has been argued that there is an overvaluation of the empirical/quantitative view because it is seen as “true science” (Tinkle & Beaton, 1983). Indeed, the experimental method is held in the highest regard. A viewpoint has persisted into the 21st century in which scholars assume that descriptive or qualitative research should be performed only where there is little information available or when the science is young. Correlational research may follow and then experimental methods can be used when the two lower (“less rigid” or “less scientific”) levels have been explored.
Quantitative Methods Traditionally, within the “received” or positivistic worldview, science has been uniquely quantitative. The quantitative approach has been justified by its success in measuring, analyzing, replicating, and applying the knowledge gained (Streubert & Carpenter, 2011). According to Wolfer (1993), science should incorporate methodologic principles of objective observation/description, accurate measurement, quantification of variables, mathematical and statistical analysis, experimental methods, and verification through replication whenever possible.
Kidd and Morrison (1988) state that in their haste to prove the credibility of nursing as a profession,
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nursing scholars have emphasized reductionism and empirical validation through quantitative methodologies, emphasizing hypothesis testing. In this framework, the scientist develops a hypothesis about a phenomenon and seeks to prove or disprove it.
Qualitative Methods The tradition of using qualitative methods to study human phenomena is grounded in the social sciences. Phenomenology and other methods of qualitative research arose because aspects of human values, culture, and relationships were unable to be described fully using quantitative research methods. It is generally accepted that qualitative research findings answer questions centered on social experience and give meaning to human life. Beginning in the 1970s, nursing scientists were challenged to explain phenomena that defy quantitative measurement, and qualitative approaches, which emphasize the importance of the client’s perspective, began to be used in nursing research (Kidd & Morrison, 1988).
Repeatedly, scholars state that nursing research should incorporate means for determining interpretation of the phenomena of concern from the perspective of the client or care recipient. Contrary to the assertions of early scientists, many later nurse scientists believe that qualitative inquiry contains features of good science including theory and observation, logic, precision, clarity, and reproducibility (Monti & Tingen, 1999).
Methodologic Pluralism In many respects, nursing is still undecided about which methodologic approach (qualitative or quantitative) best demonstrates the essence and uniqueness of nursing because both methods have strengths and limitations. Beck and Harrison (2016), Risjord (2010), and Wood and Haber (2018), among others, believe that the two approaches may be considered complementary and appropriate for nursing as a research-based discipline. Indeed, it is repeatedly argued that both approaches are equally important and even essential for nursing science development.
Although basic philosophical viewpoints have guided and directed research strategies in the past, recently, scholars have called for theoretical and methodologic pluralism in nursing philosophy and nursing science as presented in the discussion on postmodernism. Pluralism of research designs is essential for reflecting the uniqueness of nursing, and multiple approaches to theory development and testing should be encouraged. Because there is no one best method of developing knowledge, it is important to recognize that valuing one standard as exclusive or superior restricts the ability to progress.
Summary Nursing is an evolving profession, an academic discipline, and a science. As nursing progresses and grows as a profession, some controversy remains on whether to emphasize a humanistic, holistic focus or an objective, scientifically derived means of comprehending reality. What is needed, and is increasingly more evident as nursing matures as a profession, is an open philosophy that ties empirical concepts that are capable of being validated through the senses with theoretical concepts of meaning and value.
It is important that future nursing leaders and novice nurse scientists possess an understanding of nursing’s philosophical foundations. The legacy of philosophical positivism continues to drive beliefs in the scientific method and research strategies, but it is time to move forward to face the challenges of the increasingly complex and volatile health care environment.
Key Points Nursing can be considered an aspiring or evolving profession. Nursing is a professional discipline that draws much of its knowledge base from other disciplines, including
psychology, sociology, physiology, and medicine. Nursing is an applied or practice science that has been influenced by several philosophical schools of
thought or worldviews, including the received view (empiricism, positivism, logical positivism), the perceived view (humanism, phenomenology, constructivism), and postmodernism.
Nursing philosophy refers to the worldview(s) of the profession and provides perspective for practice, scholarship, and research. Nursing science is the discipline-specific knowledge that focuses on the human–
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environment–health process and is articulated in nursing theories and generated through nursing research. Philosophy of science in nursing establishes the meaning of science through examination of nursing concepts, theories, and laws as they relate to nursing practice.
Nursing epistemology (ways of knowing in nursing) has focused on four predominant or “fundamental” ways of knowledge: empirical knowledge, esthetic knowledge, personal knowledge, and ethical knowledge.
As nursing science has developed, there has been a debate over what research methods to use (i.e., quantitative methods vs. qualitative methods). Increasingly, there has been a call for “methodologic pluralism” to better ensure that research findings are applicable in nursing practice.
Case Study The following is adapted from a paper written by a graduate student describing an encounter in nursing practice that highlights Carper’s (1978) ways of knowing in nursing.
In her work, Carper (1978) identified four patterns of knowing in nursing: empirical knowledge (science of nursing), esthetic knowledge (art of nursing), personal knowledge, and ethical knowledge. Each is essential and depends on the others to make the whole of nursing practice, and it is impossible to state which of the patterns of knowing is most important. If nurses focus exclusively on empirical knowledge, for example, nursing care would become more like medical care. But without an empirical base, the art of nursing is just tradition. Personal knowledge is gained from experience and requires a scientific basis, understanding, and empathy. Finally, the moral component is necessary to determine what is valuable, ethical, and compulsory. Each of these ways of knowing is illustrated in the following scenario.
Mrs. Smith was a 24-year-old primigravida who presented to our unit in early labor. Her husband, and father of her unborn child, had abandoned her 2 months prior to delivery, and she lacked close family support.
I cared for Mrs. Smith throughout her labor and assisted during her delivery. During this process, I taught breathing techniques to ease pain and improve coping. Position changes were encouraged periodically, and assistance was provided as needed. Mrs. Smith’s care included continuous fetal monitoring, intravenous hydration, analgesic administration, back rubs, coaching and encouragement, assistance while getting an epidural, straight catheterization as needed, vital sign monitoring per policy, oxytocin administration after delivery, newborn care, and breastfeeding assistance, among many others. All care was explained in detail prior to rendering.
Empirical knowledge was clearly utilized in Mrs. Smith’s care. Examples would be those practices based on the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based standards. These include guidelines for fetal heart rate monitoring and interpretation, assessment and management of Mrs. Smith while receiving her epidural analgesia, the assessment and management of side effects secondary to her regional analgesia, and even frequency for monitoring vital signs. Other examples would be assisting Mrs. Smith to an upright position during her second stage of labor to facilitate delivery and delaying nondirected pushing once she was completely dilated.
Esthetic knowledge, or the art of nursing, is displayed in obstetrical nursing daily. Rather than just responding to biologic developments or spoken requests, the whole person was valued and cues were perceived and responded to for the good of the patient. The care I gave Mrs. Smith was holistic; her social, spiritual, psychological, and physical needs were all addressed in a comprehensive and seamless fashion. The empathy conveyed to the patient took into account her unique self and situation, and the care provided was reflexively tailored to her needs. I recognized the profound experience of which I was a part and adapted my actions and attitude to honor the patient and value the larger experience.
Many aspects of personal knowledge seem intertwined with esthetics, though more emphasis seems to be on the meaningful interaction between the patient and nurse. As above, the patient was cared for as a unique individual. Though secondary to the awesome nature of birth, much of the experience revolved around the powerful interpersonal relationship established. Mrs. Smith was accepted as herself. Though efforts were made by me to manage certain aspects of the experience, Mrs. Smith was allowed control and freedom of expression and reaction. She and I were both committed to the mutual though brief relationship. This knowledge stems from my own personality and ability to accept others, willingness to connect to others, and
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desire to collaborate with the patient regarding her care and ultimate experience. The ethical knowledge of nursing is continuously utilized in nursing care to promote the health and well-
being of the patient; and in this circumstance, the unborn child as well. Every decision made must be weighed against desired goals and values, and nurses must strive to act as advocates for each patient. When caring for a patient and an unborn child, there is a constant attempt to do no harm to either, while balancing the care of both. A very common example is the administration of medications for the mother’s comfort that can cause sedation and respiratory depression in the neonate. This case involved fewer ethical considerations than many others in obstetrics. These include instances in which physicians do not respond when the nurse feels there is imminent danger and the chain of command must be utilized, or when assistance is required for the care of abortion patients or in other situations that may be in conflict with the nurses moral or religious convictions.
A close bond was formed while I cared for Mrs. Smith and her baby. Soon after admission, she was holding my hand during contractions and had shared very intimate details of her life, separation, and fears. Though she had shared her financial concerns and had a new baby to provide for, a few weeks after her delivery I received a beautiful gift basket and card. In her note she shared that I had touched her in a way she had never expected and she vowed never to forget me; I’ve not forgotten her either.
Contributed by Shelli Carter, RN, MSN
Learning Activities 1. Reflect on the previous case study. Think of a situation from personal practice in which
multiple ways of knowing were used. Write down the anecdote and share it with classmates. 2. With classmates, discuss whether nursing is a profession or an occupation. What can current
and future nurses do to enhance nursing’s standing as a profession? 3. Debate with classmates the dominant philosophical schools of thought in nursing (received
view, perceived view, postmodernism). Which worldview best encompasses the profession of nursing? Why?
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