Guest Contributor: Lacy Foster Chandler
PhD Student at Texas Women’s University
Empirical evidence has dominated science and medicine in the last century. This can also be seen in the nursing profession and nursing education. Science and empirical knowledge are the prominent, if not the only concepts being taught and tested. Carper (1978) argued this issue, the lack of esthetics, personal knowledge, and ethics in the 1970s and the problem continues today. There have been obvious advancements in these areas over the last decades but further advancements in science and technology have created a greater need for continued study of Carper’s last three patterns of knowing. A culture of science and increasing technology impacts nursing knowledge and practice, possibly in a negative manner, dehumanizing patients and changing nurse-patient relationships (Burns et. al., 2020). Increased natural science and technology may decrease patient-centered care, caring relationships, and may remove or replace ideology and nursing goals from nursing knowledge (Burns et. al., 2020). As science, technology, and medicine advance, nursing education has a responsibility to maintain the core holistic values of the discipline.
How we teach and understand complex behaviors like caring, compassion, empathy, and kindness is a philosophical issue in nursing. Carper (1978), a nurse educator and philosopher has had a significant influence on nursing knowledge development including how knowledge should be taught and how new knowledge should be evaluated. Carper (1978) discussed ways of knowing in nursing through four fundamental patterns, 1) empirics- the science, 2) esthetics-the art, 3) personal knowledge, and 4) ethics. Carper addresses a pull in empirics and other forms of knowledge by saying empirics is essential while also underlining that nursing requires an alertness to human nature that can be actualized through additional ways of knowing (Carper, 1978). She distinguished empirics and esthetics as separate entities within nursing knowledge.
Through an understanding of Carper’s philosophy of nursing knowledge, nurse scholars and educators can answer age-old questions within the nursing profession. Philosophical questions facing nurse educators include questions such as can caring behaviors be learned or cultivated, and if so, how? Are caring behaviors static and innate, unique to each person? Or can these behaviors be learned and advanced? Carper advances nursing knowledge methodologies that mimic epistemological positions through which nurse educators can answer these philosophical questions. She gives a place for all new knowledge to fit within the cardinal historical and theoretical knowledge. A deeper understanding and application of the philosophical ideas of Barbara Carper’s patterns of knowing can shed light on the importance of cultivating caring behaviors among nursing students in a new era of science.
Carper goes beyond identifying nursing as merely a science, but as a complex subject with science as only one part of contributing knowledge. Nursing has struggled and long fought to identify itself as a science but this concept could be excessively narrow (Rodgers & Yen, 2002). Science and objectivity in science can be said to know nothing of love, compassion, spirituality, morality, or ethics (Rodgers & Yen, 2002). In this context, science and nursing are not similar at all. We know there is a need for empirics in nursing, but neither can stand alone, the science and the art.
Esthetic knowledge, the art of nursing, requires abstracting that which is individual, particular, and unique (Jacobs-Kramer & Chinn, 1988). Carper (1978) describes a self-conscious reluctance in literature to use the term knowledge to include any aspects of knowing that are not empirical. We know nursing is comprised of much more than applied science including human caring, love, compassion, and empathy. Empathy, the capacity to vicariously experience another’s feelings, is an important mode in the esthetic pattern of knowing (Carper, 1978). The more skilled a nurse becomes at empathizing with others, the larger knowledge base they have for providing effective nursing care (Carper, 1978). Cultivating these skills alongside technical and scientific skills could create a more resilient, well-rounded nursing workforce that is true to the concepts that define nursing knowledge.
Personal knowledge as a fundamental pattern of nursing involves the interpersonal processes of interactions, relationships, and transactions between the nurse and patient (Carper, 1978). Carper (1978) describes this as therapeutic use of self or therapeutic relationship. A deep understanding of one’s self, beliefs, and values provides a deeper well to draw from when caring for others. This pattern of nursing knowledge may be especially problematic to new nurses or student nurses who have not had a chance to form a firm foundation of their beliefs and values within nursing practice. In personal knowledge, the nurse rejects seeing the patient as an object but instead actualizes an authentic personal relationship with the person (Carper, 1978). Personal wisdom and knowledge can be protective from negative aspects of caring for others like burnout or vicarious trauma. Personal knowledge can be broadly categorized as subjective and existential, concerned with promoting wholeness and engagement with others (Carper, 1978). Teaching and cultivating this pattern of knowing is equally if not more important than other areas of nursing knowledge but is not often seen in current education practices.
Ethics, the moral component of knowing in nursing addresses the complex context of morally right and wrong (Carper, 1978). This is the moral code that guides the ethical conduct of nurses embodied in service to people and respect for human life (Carper, 1978). Ethical issues are frequent in medical and nursing care and can be challenging to a nurse’s mind and spirit. Knowledge of morality goes beyond understanding ethics to include all voluntary actions, motives, and traits of character (Carper, 1978). The ethical pattern of knowing requires an understanding of philosophical positions in what is right and what is good (Carper, 1978). While ethics may be seen more frequently in curriculum than aesthetics or personal knowing, nursing education should incorporate ethics with a depth that mimics the real-world issues nurses face in practice.
Current literature shows the importance of curriculum and evaluation that reflect all dimensions of nursing knowledge including caring behaviors. Gorny-Wegrzyn & Perry (2021) discuss that different pedagogies and teaching strategies can make a change in student outcomes while making students kinder and more compassionate. Smith (2019) gives insight into the importance of nursing knowledge and the state of nursing education by discussing current threats that pose a direct danger to the discipline of nursing. Some examples being the lack of emphasis on the disciplinary focus in nursing education, and nursing curricula not preparing students with a full brevity of nursing knowledge (Smith, 2019). These arguments for monitoring and correcting nursing curriculum are in line with Carper’s philosophy. Current literature shows the importance of curriculum and evaluation that reflect all dimensions of nursing knowledge.
Carper’s argument for further patterns of knowing beyond empirics can be seen in current research patterns of quantitative vs. qualitative studies. Sandelowski (2004, p. 3) discussed the importance of qualitative research versus evidence based practice alone, the author stated: “Knowledge in the practice disciplines entails not just knowing that but also knowing how, when, why, whether, and for whom (Sandelowski, 2004, p. 3).
This was an important reminder that evidence-based practice or quantitative research is not better but an equal counterpart to qualitative data. Sandelowski (2004) discusses the alternative to the hierarchical ranking of data that often times leave out qualitative data is to instill an evidence- based mindset into qualitative research. This concept is in line with Carper’s desire for a greater understanding of different types of knowledge within nursing.
Carper (1978) described a philosophy for nursing knowledge that outlined four distinct patterns for nursing knowledge. The patterns of knowing for nursing knowledge are empirics, esthetics, personal knowledge, and ethics (Carper, 1978). Through these patterns, nurses can understand historical, current, and future knowledge and its value. There is a continued need to move beyond empirics as the sole form of knowledge. This can be seen in nursing education, science, and research. Teaching or practicing nursing solely on science is not just incomplete but harmful. “One doesn’t have to operate with great malice to do great harm. The absence of empathy and understanding is sufficient (Blows, 2014).” Isn’t this concept especially true when caring for another human, oftentimes in a vulnerable position? There is a continued need to cultivate caring behaviors and monitor both curriculum and evaluation methods to reflect the profound underpinnings of the nursing profession, caring, love, and kindness.
References
Blow, C. M. (2014). Fire shut up in my bones: A memoir. Houghton Mifflin Harcourt. ISBN: 978-0544228047
Burns, M., Bally, J., Burles, M., Holtslander, L., & Peacock, S. (2020). Influences of the culture of science on nursing knowledge development: Using conceptual frameworks as nursing philosophy in critical care nursing. Nursing Philosophy: An International Journal for Healthcare Professionals, 21(4), e12310. DOI: 10.1111/nup.12310
Carper, B. (1978). Fundamental patterns of knowing in nursing. ANS. Advances in Nursing Science, 1(1), 13–23. doi: 10.1097/00012272-197810000-00004.
Gorny-Wegrzyn, E., & Perry, B. (2021). Nurse educators should use pedagogies of kindness and hope to teach nursing students’ compassion. Arch Nurs Healthc, 1(1), 1-2. DOI No.: 10.46439/nursing.1.001
Jacobs-Kramer, M. K., & Chinn, P. L. (1988). Perspectives on knowing: a model of nursing knowledge. Research and Theory for Nursing Practice, 2(2), 129.
Rodgers, B. L., & Yen, W. J. (2002). Re‐thinking nursing science through the understanding of Buddhism. Nursing Philosophy, 3(3), 213-221. doi:10.1046/j.1466-769X.2002.00105.x
Sandelowski, M. (2004). Using qualitative research. Qualitative health research, 14(10), 1366-1386. doi: 10.1177/1049732304269672.
Smith, M. C. (2019). Regenerating nursing’s disciplinary perspective. Advances in Nursing Science, 42(1), 3-16. doi: 10.1097/ANS.0000000000000241
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About Lacy Foster Chandler
I am a family nurse practitioner and nurse educator. I work and teach in the community and population health setting. My passion is teaching and modeling caring to students, and providing equitable loving care to patients. I am a PhD student at Texas Women’s University and a mom to 3 sweet little boys.
Thank you so much for this excellent article that so well defines and goes beyond the empirical emphasis that has dominated our profession for decades. Because of the empirical emphasis, I felt I had to hide how I practiced, using the personal, ethical, and aesthetic ways of knowing just as much as the empirical. And this came about because I was the little nurse for my disabled brother from about age 2, on. It was unconscious until the last two years of my career when I learned about Helen Erickson’s Theory of Modeling and Role Modeling.