perspectives on knowing: a model of nursing...

Scholarly Inquiry for Nursing Practice: An International Journal, Vol. 2, No. 2, 1988

Perspectives on Knowing: AModel of Nursing Knowledge

Maeona K. Jacobs-Kramer, R.N., Ph.D.College of Nursing, University of Utah

andPeggy L. Chinn, R.N., Ph.D., F.A.A.N.College of Nursing, State University of New York, Buffalo

In the premiere issue of Advances in Nursing Science (October, 1978),Barbara Carper detailed a typology of nursing knowledge. Caper's ideas have been appreciated and commented upon extensive-ly in the nursing literature, with little extension of her work. Thisarticle describes a model of nursing knowledge that builds fromCarper's initial formulation. The model begins with an interpreta-tion of Carper's four original knowledge patterns: empirics, ethics,esthetics, and personal. Each pattern is considered in relation to:(1) developmental processes and product outcomes associated withits creation; (2) expressions of the pattern; and (3) process contextfor assessing credibility of knowledge associated with the pattern.The position taken is that all knowledge patterns must be integrat-ed to enable deliberate clinical choices. A failure to integrateknowledge patterns impedes choice and produces negative careoutcomes.

In the premiere issue of Advances in Nursing Science, Barbara Carper(1978) set forth a typology of knowledge forms utilized in nursing.Since the appearance of this article, Carper's work has been widelycited, appreciated, and commented upon in nursing. Moreover, thereis an increasing literature concerning the necessity for nursing knowl-edge other than traditional empirics (Allen et al., 1986; Benner, 1984Benner & Tanner, 1987; Chinn, 1985). The interest in developing andusing alternate knowledge forms as well as exploiting the full range ofempirics is consistent with the aims and methods of a human science

© 1988 Springer Publishing Company 129

PC

Nota adhesiva

http://cursa.ihmc.us/rid=1P03KR1BL-MRR0T6-27KT/Jacobs-Kramer%20and%20Chinn%20-%201988%20-%20Perspectives%20on%20knowing%20A%20model%20of%20nursing%20knowle.pdf

130 Scholarly Inquiry for Nursing Practice

which is recognized as a legitimate orientation for nursing (Meleis,1987; Watson, 1985). Pursuing the tenets of human science withinnursing raises many questions and issues regarding the aims and pur-poses of nursing knowledge, as well as how it is developed, transmitted,and evaluated. Although Carper's work was significant in that it namedknowledge forms in addition to empirics and set them out for debateand discussion, it remains for nurses collectively to consider howknowledge patterns other than empirics are developed and used, trans-mitted, evaluated, and integrated into practice.

The purpose of this paper is to develop a model that constructs aperspective on the generation, transmission, and evaluation of knowl-edge forms other than traditional empirics and to consider the purposefor which nursing knowledge is created. It builds upon and modifies abeginning conceptualization published by us in 1987 (Chinn & Jacobs),while retaining its essential features. In this article the four knowledgepatterns originally named by Carper (1978), empirical, ethical, person-al, and esthetic knowledge, form the basis of the model. Each of thepatterns is extended by considering how it is created, expressed, andassessed. Our interpretive overview of the knowledge patterns is fol-lowed by a discussion of the creative, expressive, and assessment di-mensions of the model.

OVERVIEW OF KNOWLEDGE PATTERNS

Empirical knowledge — the science of nursing —is the pattern most close-ly associated with traditional science. Empirical knowledge representsknowledge that accrues from sensory experience. Empirics is classicallyexpressed as principles, laws, and theories that have general applicabili-ty. It comprises knowledge acquired and transmitted through under-standing the meanings of commonly held language symbols —thatwhich is public, verifiable, and common. Empirics rests upon assump-tions of linear time and a degree of temporal stability for phenomenarepresented by this pattern.

Ethical knowledge relates to matters of duty, rights, obligations, andmoral imperatives. Ethical knowledge and reasoning processes are in-voked when it is necessary to make a decision about a deliberate,voluntary action that is subject to the judgment "right" or "wrong."Ethical knowledge also directs judgments and actions which, thoughnot moral imperatives, obligations, or duties, may be good, noble, orhonorable actions. Although ethical knowledge is communicablethrough language symbols, it is not public, verifiable, and common inthe same sense as empirics. Legitimate disagreements can exist over

Perspectives on Knowing 131

whether or not the same course of action is "right" or "wrong," "ethical"or "unethical," "noble, honorable, and good" or not.

Personal knowledge is awareness of self and others in a relationship. Itinvolves encountering and actualizing the self. Personal knowledgetranscends objective reality, forms, and stereotypes and is not mediatedby the symbols of language. That is, knowledge of self and others canbe transmitted independent of written discourse. One comes to knowself and others through living and lived immediate experience.

Esthetic knowledge — the art of nursing —is knowledge by subjectiveacquaintance. Whereas empirical knowledge involves the abstraction ofgeneralities, esthetic knowing requires abstracting that which is indi-vidual, particular, and unique. This knowledge pattern represents animmediate knowing that is based on comprehending specific andunique situational particulars, integrating those particulars into a bal-anced and unified whole, and acting in relation to projected outcomes.Our interpretation and modification of Carper's (1978) knowledge pat-terns form the basis for considering how each knowledge pattern iscreated, expressed, and assessed.

EMPIRICS: CREATIVE, EXPRESSIVE,AND ASSESSMENT DIMENSIONS

The creative dimension expresses the interrelationship between theprocesses of knowledge creation and the product created. To considerthe creative dimension is to consider what the knowledge pattern isuseful for, and how —through use of knowledge within the pattern —knowing and knowledge are extended and modified. For empirics,processes within the creative dimension include the familiar researchapproaches of describing, explaining, and predicting. The product —empirical knowledge —is used to describe, explain, and predict, and asempirics are invoked for describing, explaining, and predicting, theprocess accrues information that is germane to extending and modify-ing it. In addition to formal research processes, clinicians in theirpractice may use empirically derived knowledge or data that describes,explains, or predicts features of clinical experience such as stress-cop-ing. As clinicians apply empirical knowledge, client responses provideinformation about its adequacy. These responses, in turn, provide abasis for modification of that knowledge. Appreciation of processesoperating within the model's creative dimension is central to un-derstanding how the emerging product and ongoing process are ex-pressed.

The expressive dimension of the model is conceptualized as a means


to represent the form of knowledge expression associated with the pat-tern. That is, knowledge expression considers how patterns of knowingcan be exhibited as knowledge. For empirics, descriptive, explanatory,and predictive knowledge can be expressed as facts, theories, models,and descriptions that impart understanding. Empirics tends to takeforms that are rather "naturally static," since empirical knowledge isbounded, linear, and symbolically represented. Empirical knowledgerelated to stress-coping might be expressed as models and theories,interpretive descriptions of the meaning of stress, facts reflecting itsincidence, and clinical opinions about how to manage stressful experi-ences. How knowledge is expressed is significant for considering pro-cesses invoked when knowledge is examined for credibility —the assess-ment dimension.

The third dimension of the model is assessment, which provides foran examination of the separate knowledge forms. Assessment of knowl-edge involves three aspects: First, a critical question asked of eachknowledge pattern to discern the adequacy of the pattern as a pattern;second, the process context that is specific to the ongoing creation; andthird, a unique credibility index that is associated with each knowledgepattern. Not only do knowledge patterns differ in how they are createdand expressed, but they differ in processes and methods for assessingtheir value and utility. While assessment addresses the credibility ofeach pattern as a unique pattern, this does not equate with the evalua-tion of knowledge that emerges from integration of all knowledge pat-terns. Each knowledge pattern can be evaluated as credible in and ofitself, but its ultimate value is addressed when the knowledge pattern isintegrated with other forms of knowing and applied to a specific caresituation. For example, it is possible to create a very "good" empiricallybased theory that may not result in a "good" client outcome whenclinically applied.

Empirical knowledge is assessed by invoking the critical questions"What does this represent?" and "How is it representative?" These ques-tions imply an assessment of how some reality is expressed and howthat expression functions as a form of human knowledge. The processand context for addressing these empirical questions is replication. Inreplication, the knowledge must be repeatable across similar contexts.Validity is the index of credibility. The knowledge must be demonstrat-ed to be what it is thought to be.

Assessment of stress-coping theory involves discerning what realitythe theory represents and determining the adequacy of the linkagesbetween behavioral expressions and interpretations of stress and theo-retical knowledge about stress. As questions of validity and reliabilityare addressed, the limitations and value of stress/coping theory become


more fully known. Engagement in this process of determining credibili-ty is useful for continuing to develop empirical knowledge. Table 1summarizes the features of the creative, expressive, and assessmentdimensions for all knowledge patterns. Table 2 summarizes the essen-tial elements of each dimension for empirics as discussed, as well as forethics, personal, and esthetic knowledge, to be considered next.

TABLE 1. Summary of Model's Features: Creative, Expressive,and Assessment Dimensions

Dimensions Features

Creative Captures how knowledge is generated and extended throughits use. Implies process product interaction; implies motion.

Expressive Captures how knowledge pattern is exhibited and recognized.Knowledge display with "stasis" of time.

Assessment Provides for examination of knowledge by: (1) asking criticalquestions of knowledge form; (2) within a process context;and (3) using a pattern-specific credibility index.

TABLE 2. Summary of Essential Elements: Model of NursingKnowledge

Dimension

Creative

Expressive

AssessmentCritical

question

Process/context

Credibilityindex

Empirics

DescribingExplainingPredicting

FactsTheoriesModelsDescriptions

to impartunderstanding

What does thisrepresent?

How is itrepresentative?

Replication

Validity

Ethics

ValuingClarifyingAdvocating

CodesStandardsNormative-

ethicaltheories

Descriptionsof ethicaldecisionmaking

Is this right?Is this just?

Dialogue

Justness

Personal

EncounteringFocusingRealizing

Self:authentic anddisclosed

Do I know whatI do?

Do I do whatI know?

Response andreflection

Congruity

Esthetics

EngagingInterpretingEnvisioning

Art-act

What doesthis mean?

Criticism

Consensualmeaning


ETHICS: CREATIVE, EXPRESSIVE,AND ASSESSMENT DIMENSIONS

The creative dimension of ethical knowledge involves valuing, clarify-ing, and advocating. This pattern is both created by and extendedthrough these processes. Individuals and groups come to hold variouspositions about what is right and ethical through learning and internal-izing values, clarifying the emerging values, and advocacy of thesevalues for self and others. As the process of valuing, clarifying, andadvocacy proceed, ethical knowledge continues to emerge.

Ethical knowledge is expressed through codes and standards, andmore formally in normative ethical theories. These forms representcommon patterns of ethical knowledge expression. Ethical knowledge,however, can also be expressed in descriptions of ethical decision mak-ing. Such descriptions elucidate important contextual features that de-termine how an ethical judgment is finally made. Descriptions can alsoaddress the reasoning processes used in reaching a course of action.Ethics also shares some characteristics with empirics in the expressivedimension. That is, ethical knowledge can be expressed as theory and,even if not in theoretical form, is linear, discursive, and mediated bylanguage symbols.

Even though ethical knowledge is expressed in a form similar toempirics, ethical forms of knowledge are assessed quite differently. It isthe justness, Tightness, and responsibleness of ethical knowledge that issought as the standard of judgment when this knowledge pattern isassessed rather than reproduction or replicability. The critical ques-tions asked of ethical knowledge are: "Is this right?" "Is this just?" Theprocess context involved in asking these questions is dialogue, while thecredibility index is justness. With ethical knowledge it is not sufficientto logically analyze an ethical decision with reference to a normativeethical theory, professional code, or standard. Rather, dialogue is re-quired to share understanding of contextual meaning and elucidatereasoning processes. Since in examining the credibility of ethicalknowledge the reference point is not externally located empirical reali-ty, multiple ethical positions in relation to a single situation may bejustified.

To illustrate, nurses can be expected to possess or have at theirdisposal a storehouse of ethical values, principles, and precepts that arederived, in part, from the codes of the profession, societal norms andvalues, and individual professional experiences. We express these val-ues in practice by valuing, advocating, and clarifying health care op-tions, and in so doing we contribute to the emergence of ethical pat-terns of knowing.


For nurses, processes of client advocacy and clarifying the meaningof life and living have potential to alter the prevailing values of thehealth care system. Having experience with the predominant ethicalposition that life equates with physical processes, we are coming to viewlife and living as requiring a dimension of quality that goes beyondphysical existence. The emergence of a changed value or conceptualiza-tion of life and living can then be reflected in ethical knowledge formssuch as descriptive opinions about the nature of quality life and living,or professional codes related to nursing when physical life can no longerbe sustained. The newly emerged knowledge forms express both whatwas done and what ought to be done and can be subsequently assessedthrough a process of dialogue with others.

PERSONAL KNOWLEDGE: CREATIVE, EXPRESSIVE,AND ASSESSMENT DIMENSIONS

The personal knowledge pattern expresses knowledge of self— an indi-vidual in relationship with others. The creative dimension of personalknowledge involves experiencing the self—encountering and focusingon self while realizing its realities and potentialities. Like other knowl-edge patterns, personal knowledge is conceptualized as useful for facili-tating the processes of experiencing, encountering, and focusing, andthese processes evolve ongoing knowledge of self.

The expressive dimension of personal knowledge is the self as au-thentic and disclosed. Authenticity implies what the personal self actu-ally is at any moment and is not meant to connote what finally emergesafter a lifetime of work. The authentic self is known privately, while thedisclosed self can be revealed to others. Unlike empirical and ethicalknowledge, this knowledge pattern is not represented in language.Though it is possible to write about the self as authentic and disclosed,it is not possible to write about or record "self." Personal knowledge isexpressed as our selves, through the self.

The assessment dimension of personal knowledge requires a focus onthe self as privately known and expressed to others. Assessment of self isa process carried out by the self through a rich inner life, but not solelyin the context of aloneness. Assessment involves examining the expres-sion form — the self— for congruity of the authentic self with the dis-closed self. The intent of this conceptualization is closely aligned withWatson's (1985) notion of "I-Me" congruity. Critical questions addressthe credibility index of congruity. Asking to what extent we "know whatwe do" and "do what we know" creates awareness of both the authenticand disclosed self. This enables personal movement toward inner


strength, genuineness, and authenticity —characteristics associatedwith congruity. Reflection and response is the process context asso-ciated with assessment of self as a pattern of knowing. As the individualexamines self, perceptions and insights are reflected and responded toby others. The reflected responses provide insight about the individualself and its congruity.

In caring encounters, nurse and client participate in a sharing oftheir unique selves. During the encounter, what is disclosed becomes abasis for knowledge about the authenticity of self and other. Theunique situation of client and nurse encounter makes possible disclo-sure of self, one to another. As client and nurse focus on the client'ssituation, heightened awareness of what each person feels or "knows"and how they act or "do" emerges in the encounter. Personal knowinggrows to the extent that actions are in concert with the whole of innerexperience.

ESTHETICS: CREATIVE, EXPRESSIVE,AND ASSESSMENT DIMENSIONS

The pattern of esthetics is a difficult pattern to comprehend because itcan be conceptualized as both a separate knowledge form and a synthe-sis of all knowledge forms. As a separate pattern, it constitutes knowl-edge about artful nursing practice, knowledge that is expressed withdifficulty because it is fully dependent on and integrates context. Forexample, expert nurses may be able to provide some insight into theesthetic knowledge they possess and use in caring for clients. Specificsof how they have used and expect to employ such knowledge, however,defy description because they do not "know" what they will do until theyare in a situation, and what they "know" changes with the situation.Although the expression of esthetic knowledge is only partially describ-able in language, it is fully comprehensible when the whole of experi-ence is considered.

As the synthesis of knowledge patterns, esthetics can be viewed as thetotal knowledge spectrum integrated in practice. The creative dimen-sion of esthetics involves engaging, interpreting, and envisioning. Es-thetics requires engagement in the moment and the "all-at-once" inter-pretation of a situation to project an outcome and act in relation towhat is envisioned. As nurses encounter clients in practice contexts,esthetic knowledge is integrated with all other forms of knowing to formand continue forming patterns of engagement, interpreting, and envi-sioning. New knowledge emerges in this process.

Although the creative dimension of esthetics is associated with en-


gagement, interpreting, and envisioning, its creation depends upon theartful enfoldment of all knowledge patterns. Esthetics as a separateknowledge pattern enfolds itself with empirical, ethical, and personalknowledge to bring about a harmonious and pleasing whole —an artfulnursing act.

Esthetic knowledge finds expression in the art-act of nursing. Likepersonal knowledge, the expression of esthetic knowledge is not inlanguage. We can unfold our art and retrospectively recollect and writeabout its features, and we can record it using electronic media, but theknowledge form itself is not what we write or record. The knowledgeform is the art-act.

The assessment of esthetic knowledge involves a consideration ofmeaning in those aspects of the art-act that can be represented. Theart-act is responded to by criticism, which is the process context bywhich the knowledge pattern is assessed. Criticism can be thought of asan explanation of a judgment that finally reduces to the simple state-ment: "This means that" (Bleich, 1978). Criticism assumes that inter-pretation of meaning is motivated behavior and that meaning is con-structed in relation to some purpose. The critical question asked of theart-act is, "What does this mean?" Criticism requires empathy and anintent to fully appreciate what the actors meant to convey. As the art-act is criticized, credibility is discerned by reaching for consensus — afull and rich understanding of the art-act that brings together the per-spectives of a community of co-askers who construct and confer mean-ings. Seeking consensual meaning as motivated behavior implies adesire and need to create knowledge on one's behalf. It does not implymere agreement or acquiescence to some meaning but connotes deepunderstanding of intents, a reconciliation of self with others.

To summarize, as nurses encounter clinical situations, knowledge isbrought to those encounters that can be conceived of as having differentpatterns: empirics, ethics, personal, and esthetic. Nurses possess: (1)objective, empirically based knowledge such as stress-coping theoryand statistics about stress phenomena; (2) knowledge of what is ethical-ly right and good; (3) personal knowledge of themselves and how theyrelate to others; and (4) knowledge about how they might estheticallyapproach, balance, and integrate this knowledge in differing clinicalsituations. To some extent, individual nurses and the profession collec-tively can examine these knowledge patterns separately for credibilityto heighten awareness of the state of knowledge within them.

As practice contexts are encountered, processes within the creativedimension of esthetics are initiated. Through the process of engage-ment, interpreting, and envisioning, "past" knowledge is enfoldedinto esthetics, and clients are uniquely cared for. As caring processes


continue, new knowledge emerges. When the nursing context is "exit-ed," the art-act as the experience of nurse and client can be unfolded toreveal the newly emerged separate knowledge patterns. These separateknowledge patterns can be individually examined for their contribu-tions to the total art-act, how they are altered as a result of theirenfoldment during the encounter, and where the knowledge base wasproblematic. The total art-act, as the expression of esthetics, can alsobe exhibited and criticized. This exhibition of the total art-act is alwaysimperfect, yet it can be recollected, recreated in language, and ob-served as it occurs in nursing situations. Both the recreation of nurs-ing's art and its natural observation provide a means of examiningpractice.

TOWARD A CREDIBILITY INDEXFOR NURSING PRACTICE

Processes within the creative dimension of esthetics enfold the separateknowledge forms that are exhibited as an ongoing art-act. The art-actof nursing, and not separate knowledge forms, provides an avenue forexamination of the credibility of nursing practice. Valid empirics, justethics, and congruent selves are important, and critical questions with-in each knowledge pattern need to be asked and answered. An exami-nation of the art-act that integrates all knowledge patterns as expressedin practice provides a comprehensive, context-sensitive means for en-folding multiple knowledge patterns. This shift toward integration of allknowledge patterns will move nursing away from a quest for structuraltruth and toward a search for dynamic meaning (Munhall, 1986).

A focus on the art-act toward the evolution of dynamic consensualmeaning is to be valued, because it promotes choice and freedom fromthe constraints of considering only one knowledge pattern as credible.Choice and freedom are values consistent with promotion of health. Asnurses exercise the freedom to examine practice as art and analyze allpatterns of knowing expressed through practice, their effectiveness aspromoters of health will be enhanced.

REFERENCES

Allen, D., Banner, P., & Dickelmann, N. L. (1986). Three paradigms fornursing research: Methodological implications. In P. L. Chinn (Ed.),Nursing research methodology (pp. 23-38). Rockville, MD: Aspen.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursingpractice. Menlo Park, CA: Addison-Wesley.


Benner, P., & Tanner, C. (1987). How expert nurses use intuition. AmericanJournal of Nursing, 87( 1), 23-31.

Bleich, D. (1978). Subjective criticism. Baltimore and London: Johns HopkinsUniversity Press.

Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances inNursing Science, ^ (1), 13-23.

Chinn, P. L. (1985). Debunking myths in nursing theory and research. Image,XVII(Z), 45-49.

Chinn, P. L., & Jacobs, M. K. (1987). Theory and nursing: A systematic approach(2nd ed.). St. Louis: C. V. Mosby.

Meleis, A. I. (1987). Revisions in knowledge development: A passion forsubstance. Scholarly Inquiry for Nursing Practice, -/(I), 5-19.

Munhall, P. A. (1986). Methodological issues in nursing research: Beyond awax apple. Advances in Nursing Science, 8(3), 1-5.

Watson, J. (1985). Nursing: Human science and human care. Norwalk, CT: Apple-ton-Century-Crofts.

Requests for reprints should be directed to Maeona K. Jacobs-Kramer, R.N., Ph.D,Professor, College of Nursing, University of Utah, Salt Lake City, UT 84112.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

perspectives on knowing: a model of nursing...

Documents