Nursing Educational Concept by Carper
Application of Patterns to Nursing Education
A brief history of the science of nursing education will be
presented along with a summary of selected current research and initiatives in
nursing education and how they apply to fundamental patterns of knowing in
nursing.
Carper's Ways of Knowing
Four fundamental patterns of knowing in nursing were originally
identified by Carper in 1978 from an analysis of the conceptual and syntactical
structure of nursing knowledge. The four patterns include: empirical,
aesthetic, personal, and ethical knowledge.
Empirics, the Science of Nursing
Empirics, or the science of nursing, is the pattern of knowing that is focused upon the description , classification, and explanation of phenomena that are perceptible by direct observation or experience. In other words, empirics is the factual knowledge of the discipline. It is consciously accessible and acquired by observation, inspection, and deductive reasoning (Stein, Corte, Colling, & Whall, 1998).
Empiric (or semantic) knowledge is a product of formal educational experiences like reading a professional journal or accessing a textbook (Stein et al. 1998). Empirical knowledge is based on factual descriptions of persons, places, or situations that can be verified by others. Empiric knowledge or “knowing that” is the category of knowledge that comes to mind when we think about knowledge acquired in the classroom that is derived from research in basic and nursing sciences.
In Benner's early work describing the transition from novice to expert nurse, this is the theoretical type of knowledge that drives nursing action (Benner, 1983, 1984). If empirical knowledge was sufficient to guide nursing practice, students could simply memorize procedures from a manual of nursing practice; no clinical application would be required to attain competence. As an illustration, take the example of the nurse doing a simple procedure like a catheter insertion.
The procedure
manual tells you what supplies to collect, how to proceed step-by-step, and
identifies conditions or problems that require special attention. But when the
process of inserting a Foley catheter is complicated by the real life
contingency like a patient who has benign prostatic hypertrophy, a condition
not necessarily described in the manual theoretical or empirical knowledge alone
may not be sufficient.
Aesthetics, the Art of Nursing
Aesthetics, or the art of nursing, is the type of knowledge underlying the performance of nursing practice, or “knowing how.” Aesthetic knowledge lies beneath the skillful performance of the manual and technical procedures in nursing, as well as the ability to grasp the significance of a patient's behavior immediately and respond insightfully to it. Learning the art of nursing requires students to master the ability to put together disparate facts and details about a patient's behavior into a holistic understanding of what is significant in that behavior.
Through empathy, the nurse gains understanding of the patient's felt experience and therefore has a larger repertoire of choices in designing and providing nursing care that is effective and satisfying. Because this way of knowing is not based on empirical knowledge or that which can be directly observed, the validity of this type of knowledge is only apparent once the nurse has managed to produce care that is helpful and beneficial. Aesthetic knowledge is action oriented and includes both the manual/technical skills of the profession as well as the intellectual skill necessary for grasping a situation, making a care plan, and then intervening in a clinical encounter (Stein et al. 1998).
Aesthetic knowledge is more complex than empirical knowledge and requires both motor skills and strategies and rules to make sense of information. This practical knowledge is what Benner has also described as “knowing how” and is absolutely essential for making astute judgments. Practical knowledge is gained through experience, which is not acquired through the mere passage of time, but only when one's frame of reference about what can be expected is somehow altered or challenged in an actual, real life situation (Benner, 1984).
The complex acquisition of skills sometimes escapes our capacity to describe even simple activities theoretically (Kuhn, 1970; Polanyi, 1958). As a result, some practical knowledge will not be easily reduced to step-by-step explanation. For example, when an experienced nurse encounters a crisis situation, such as a patient presenting in an emergency room with a rapidly dropping blood pressure, the knowledge needed is readily requested. To the outside observer, the nurse is able to respond almost intuitively, based on an immediate grasp of the clinical situation, and just seems to know what to do.
The beginning nurse however, will respond slowly,
trying to reason things through based on theoretical knowledge as he struggles
to figure out which particular aspect of factual knowledge applies. It is
through application that the nurse begins to develop practical knowledge that
refines and extends the theoretical base of practice. Hence, the means of acquiring
“hands on” knowledge include not only laboratory sessions and bedside
experiences, but also observation of experts' problem solving in selected
situations as in clinical rounds or seminars. Reflection on practice is key for
developing this type of practical knowledge (Tanner, 2006).
Personal Knowing in Nursing
Personal knowing in nursing assumes that gaining self-awareness is a vital aspect of professional development. Personal knowing in nursing is defined as that knowledge of self that supports a therapeutic interpersonal process between the nurse and the patient. Personal knowledge is acquired through interactions, relationships, and transactions among individuals. Personal knowledge is based on the existentialist view that people are continually evolving over time.
In the existentialist view, being cannot be made a subject of objective inquiry, it is revealed to the individual by reflection on his own unique concrete existence in time and space. Hence, each self-aware individual comes to understand their own existence in terms of their experience of themselves and their situation. The recognition of other individuals and communication with them is a criterion of authentic existence.
To be authentic, one must preserve one's own individual personal identity, while allowing others to have the freedom to make their own choices as they also constantly engage in the process of becoming. By having an authentic personal relationship with the patient, the nurse is able to help the patient achieve higher levels of individual well-being that would be impossible without this therapeutic use of self.
This form of knowledge in nursing is perhaps the most difficult to master and teach, but yet is the most essential knowledge for understanding the meaning of health for the patient. Personal knowledge is acquired gradually through interaction between the nurse and the patient and is the product of personal experience in practice (Stein et al., 1998). Writing about feelings is one way to facilitate personal knowing.
According to Higgins (1996), journal writing can be used as a mode of thinking about practice with nursing students. Capacchione's (1989) journal method is unique because it develops both sides of the brain: the rational, verbal left hemisphere and the artistic, intuitive right hemisphere. Drawing is a right brain function. With this technique, students learn to have faith and hope in themselves and can learn to inspire it in others.
Ethics, the Moral Knowledge in Nursing
Ethics or the moral knowledge in nursing is focused on making decisions on right and wrong action in the context of the care and treatment of patients. It involves the struggle to identify what should be done in situations of ambiguity or uncertainty. Knowledge of ethical codes alone will not be sufficient to provide the nurse with answers to moral questions in nursing.
Students come to the clinical situation with their own fundamental disposition toward what is good and right, and often these values remain unspoken, and unrecognized even though they may profoundly influence what students notice in a given situation, the options they may consider taking, and what they ultimately decide to do (Tanner, 2006). Allowing students to tell their stories reinforces their humanistic values. For example, Higgins (1996) had first-year students come together for a seminar, which began with introductions and asking each student to share the stories that led to them choosing nursing as a career.
The purpose of this exercise was to build upon the caring values that the students brought to nursing. Subsequent sessions built upon this work. By examining the values by which students decide what is morally right, they gain greater awareness of what is involved in making moral choices and being responsible for the choices made. Carper's model of the ways of knowing in nursing not only highlights the importance and centrality of empirical, factual, and theoretically derived knowledge, but recognizes the equally essential knowledge gained through clinical practice.
This is because both personal and aesthetic knowledge are postulated to come from experience that is more than the mastery of a list of technical skills (Stein, Corte, Colling, & Whall, 1998). Strict dedication to content coverage needs to be replaced with development of flexible skill sets that can be used across settings (Tanner, 2002, 2004). Faculty should alter what and how they teach accordingly.
The next section of this chapter will
trace the evolution of how the empirical science of nursing has been organized
and described for the novice nurse. The history of going from use of the
nursing process, to a proliferation of classification schemes, and on to
evidence-based practice developed around practice guidelines and critical
pathways will be described.
Following this description of processes, taxonomies, and evidence-based protocols, the chapter reviews current research and initiatives that communicate the contextual, interpretive, and interpersonal knowledge deemed important in Carper's ways of knowing in nursing.
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