Perspectives on Knowing: A Model of Nursing Knowledge

Scholarly Inquiry for Nursing Practice: An International Journal, Vol. 2, No. 2, 1988 Perspectives on Knowing: A Model of Nursing Knowledge Maeona K. Jacobs-Kramer, R.N., Ph.D. College of Nursing, University of Utah and Peggy 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. Ca per's ideas have been appreciated and commented upon extensively in the nursing literature, with little extension of her work. This article describes a model of nursing knowledge that builds from Carper's initial formulation. The model begins with an interpretation 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 with its creation; (2) expressions of the pattern; and (3) process context for assessing credibility of knowledge associated with the pattern. The position taken is that all knowledge patterns must be integrated to enable deliberate clinical choices. A failure to integrate knowledge patterns impedes choice and produces negative care outcomes. 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 widely cited, appreciated, and commented upon in nursing. Moreover, there is an increasing literature concerning the necessity for nursing knowledge other than traditional empirics (Allen et al., 1986; Benner, 1984 Benner & Tanner, 1987; Chinn, 1985). The interest in developing and using alternate knowledge forms as well as exploiting the full range of empirics is consistent with the aims and methods of a human science 1988 Springer Publishing Company 129

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 within nursing raises many questions and issues regarding the aims and purposes of nursing knowledge, as well as how it is developed, transmitted, and evaluated. Although Carper's work was significant in that it named knowledge forms in addition to empirics and set them out for debate and discussion, it remains for nurses collectively to consider how knowledge patterns other than empirics are developed and used, transmitted, evaluated, and integrated into practice. The purpose of this paper is to develop a model that constructs a perspective on the generation, transmission, and evaluation of knowledge forms other than traditional empirics and to consider the purpose for which nursing knowledge is created. It builds upon and modifies a beginning conceptualization published by us in 1987 (Chinn & Jacobs), while retaining its essential features. In this article the four knowledge patterns originally named by Carper (1978), empirical, ethical, personal, and esthetic knowledge, form the basis of the model. Each of the patterns is extended by considering how it is created, expressed, and assessed. Our interpretive overview of the knowledge patterns is followed by a discussion of the creative, expressive, and assessment dimensions of the model. OVERVIEW OF KNOWLEDGE PATTERNS Empirical knowledge the science of nursing is the pattern most closely associated with traditional science. Empirical knowledge represents knowledge that accrues from sensory experience. Empirics is classically expressed as principles, laws, and theories that have general applicability. It comprises knowledge acquired and transmitted through understanding the meanings of commonly held language symbols that which is public, verifiable, and common. Empirics rests upon assumptions of linear time and a degree of temporal stability for phenomena represented by this pattern. Ethical knowledge relates to matters of duty, rights, obligations, and moral imperatives. Ethical knowledge and reasoning processes are invoked 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, though not moral imperatives, obligations, or duties, may be good, noble, or honorable actions. Although ethical knowledge is communicable through language symbols, it is not public, verifiable, and common in the 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. It involves encountering and actualizing the self. Personal knowledge transcends objective reality, forms, and stereotypes and is not mediated by the symbols of language. That is, knowledge of self and others can be transmitted independent of written discourse. One comes to know self and others through living and lived immediate experience. Esthetic knowledge the art of nursing is knowledge by subjective acquaintance. Whereas empirical knowledge involves the abstraction of generalities, esthetic knowing requires abstracting that which is individual, particular, and unique. This knowledge pattern represents an immediate knowing that is based on comprehending specific and unique situational particulars, integrating those particulars into a balanced and unified whole, and acting in relation to projected outcomes. Our interpretation and modification of Carper's (1978) knowledge patterns form the basis for considering how each knowledge pattern is created, expressed, and assessed. EMPIRICS: CREATIVE, EXPRESSIVE, AND ASSESSMENT DIMENSIONS The creative dimension expresses the interrelationship between the processes of knowledge creation and the product created. To consider the creative dimension is to consider what the knowledge pattern is useful 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 research approaches of describing, explaining, and predicting. The product empirical knowledge is used to describe, explain, and predict, and as empirics are invoked for describing, explaining, and predicting, the process accrues information that is germane to extending and modifying it. In addition to formal research processes, clinicians in their practice may use empirically derived knowledge or data that describes, explains, or predicts features of clinical experience such as stress-coping. As clinicians apply empirical knowledge, client responses provide information about its adequacy. These responses, in turn, provide a basis for modification of that knowledge. Appreciation of processes operating within the model's creative dimension is central to understanding how the emerging product and ongoing process are expressed. The expressive dimension of the model is conceptualized as a means

132 Scholarly Inquiry for Nursing Practice to represent the form of knowledge expression associated with the pattern. That is, knowledge expression considers how patterns of knowing can 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 take forms that are rather "naturally static," since empirical knowledge is bounded, linear, and symbolically represented. Empirical knowledge related to stress-coping might be expressed as models and theories, interpretive descriptions of the meaning of stress, facts reflecting its incidence, and clinical opinions about how to manage stressful experiences. How knowledge is expressed is significant for considering processes invoked when knowledge is examined for credibility the assessment dimension. The third dimension of the model is assessment, which provides for an examination of the separate knowledge forms. Assessment of knowledge involves three aspects: First, a critical question asked of each knowledge pattern to discern the adequacy of the pattern as a pattern; second, the process context that is specific to the ongoing creation; and third, a unique credibility index that is associated with each knowledge pattern. Not only do knowledge patterns differ in how they are created and expressed, but they differ in processes and methods for assessing their value and utility. While assessment addresses the credibility of each pattern as a unique pattern, this does not equate with the evaluation of knowledge that emerges from integration of all knowledge patterns. Each knowledge pattern can be evaluated as credible in and of itself, but its ultimate value is addressed when the knowledge pattern is integrated with other forms of knowing and applied to a specific care situation. For example, it is possible to create a very "good" empirically based theory that may not result in a "good" client outcome when clinically applied. Empirical knowledge is assessed by invoking the critical questions "What does this represent?" and "How is it representative?" These questions imply an assessment of how some reality is expressed and how that expression functions as a form of human knowledge. The process and context for addressing these empirical questions is replication. In replication, the knowledge must be repeatable across similar contexts. Validity is the index of credibility. The knowledge must be demonstrated to be what it is thought to be. Assessment of stress-coping theory involves discerning what reality the theory represents and determining the adequacy of the linkages between behavioral expressions and interpretations of stress and theoretical knowledge about stress. As questions of validity and reliability are addressed, the limitations and value of stress/coping theory become

Perspectives on Knowing 133 more fully known. Engagement in this process of determining credibility is useful for continuing to develop empirical knowledge. Table 1 summarizes the features of the creative, expressive, and assessment dimensions for all knowledge patterns. Table 2 summarizes the essential elements of each dimension for empirics as discussed, as well as for ethics, personal, and esthetic knowledge, to be considered next. TABLE 1. Summary of Model's Features: Creative, Expressive, and Assessment Dimensions Dimensions Creative Expressive Assessment Features Captures how knowledge is generated and extended through its use. Implies process product interaction; implies motion. Captures how knowledge pattern is exhibited and recognized. Knowledge display with "stasis" of time. Provides for examination of knowledge by: (1) asking critical questions of knowledge form; (2) within a process context; and (3) using a pattern-specific credibility index. TABLE 2. Summary of Essential Elements: Model of Nursing Knowledge Dimension Empirics Ethics Personal Esthetics Creative Expressive Assessment Critical question Process/ context Credibility index Describing Explaining Predicting Facts Theories Models Descriptions to impart understanding What does this represent? How is it representative? Replication Validity Valuing Clarifying Advocating Codes Standards Normativeethical theories Descriptions of ethical decision making Is this right? Is this just? Dialogue Justness Encountering Focusing Realizing Self: authentic and disclosed Do I know what I do? Do I do what I know? Response and reflection Congruity Engaging Interpreting Envisioning Art-act What does this mean? Criticism Consensual meaning

134 Scholarly Inquiry for Nursing Practice ETHICS: CREATIVE, EXPRESSIVE, AND ASSESSMENT DIMENSIONS The creative dimension of ethical knowledge involves valuing, clarifying, and advocating. This pattern is both created by and extended through these processes. Individuals and groups come to hold various positions about what is right and ethical through learning and internalizing values, clarifying the emerging values, and advocacy of these values for self and others. As the process of valuing, clarifying, and advocacy proceed, ethical knowledge continues to emerge. Ethical knowledge is expressed through codes and standards, and more formally in normative ethical theories. These forms represent common patterns of ethical knowledge expression. Ethical knowledge, however, can also be expressed in descriptions of ethical decision making. Such descriptions elucidate important contextual features that determine how an ethical judgment is finally made. Descriptions can also address the reasoning processes used in reaching a course of action. Ethics also shares some characteristics with empirics in the expressive dimension. That is, ethical knowledge can be expressed as theory and, even if not in theoretical form, is linear, discursive, and mediated by language symbols. Even though ethical knowledge is expressed in a form similar to empirics, ethical forms of knowledge are assessed quite differently. It is the justness, Tightness, and responsibleness of ethical knowledge that is sought as the standard of judgment when this knowledge pattern is assessed rather than reproduction or replicability. The critical questions asked of ethical knowledge are: "Is this right?" "Is this just?" The process context involved in asking these questions is dialogue, while the credibility index is justness. With ethical knowledge it is not sufficient to logically analyze an ethical decision with reference to a normative ethical theory, professional code, or standard. Rather, dialogue is required to share understanding of contextual meaning and elucidate reasoning processes. Since in examining the credibility of ethical knowledge the reference point is not externally located empirical reality, multiple ethical positions in relation to a single situation may be justified. To illustrate, nurses can be expected to possess or have at their disposal a storehouse of ethical values, principles, and precepts that are derived, in part, from the codes of the profession, societal norms and values, and individual professional experiences. We express these values in practice by valuing, advocating, and clarifying health care options, and in so doing we contribute to the emergence of ethical patterns of knowing.

Perspectives on Knowing 135 For nurses, processes of client advocacy and clarifying the meaning of life and living have potential to alter the prevailing values of the health care system. Having experience with the predominant ethical position that life equates with physical processes, we are coming to view life and living as requiring a dimension of quality that goes beyond physical existence. The emergence of a changed value or conceptualization of life and living can then be reflected in ethical knowledge forms such as descriptive opinions about the nature of quality life and living, or professional codes related to nursing when physical life can no longer be sustained. The newly emerged knowledge forms express both what was done and what ought to be done and can be subsequently assessed through a process of dialogue with others. PERSONAL KNOWLEDGE: CREATIVE, EXPRESSIVE, AND ASSESSMENT DIMENSIONS The personal knowledge pattern expresses knowledge of self an individual in relationship with others. The creative dimension of personal knowledge involves experiencing the self encountering and focusing on self while realizing its realities and potentialities. Like other knowledge patterns, personal knowledge is conceptualized as useful for facilitating the processes of experiencing, encountering, and focusing, and these processes evolve ongoing knowledge of self. The expressive dimension of personal knowledge is the self as authentic and disclosed. Authenticity implies what the personal self actually is at any moment and is not meant to connote what finally emerges after a lifetime of work. The authentic self is known privately, while the disclosed self can be revealed to others. Unlike empirical and ethical knowledge, 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 is expressed as our selves, through the self. The assessment dimension of personal knowledge requires a focus on the self as privately known and expressed to others. Assessment of self is a process carried out by the self through a rich inner life, but not solely in the context of aloneness. Assessment involves examining the expression form the self for congruity of the authentic self with the disclosed self. The intent of this conceptualization is closely aligned with Watson's (1985) notion of "I-Me" congruity. Critical questions address the credibility index of congruity. Asking to what extent we "know what we do" and "do what we know" creates awareness of both the authentic and disclosed self. This enables personal movement toward inner

136 Scholarly Inquiry for Nursing Practice strength, genuineness, and authenticity characteristics associated with congruity. Reflection and response is the process context associated with assessment of self as a pattern of knowing. As the individual examines self, perceptions and insights are reflected and responded to by others. The reflected responses provide insight about the individual self and its congruity. In caring encounters, nurse and client participate in a sharing of their unique selves. During the encounter, what is disclosed becomes a basis for knowledge about the authenticity of self and other. The unique situation of client and nurse encounter makes possible disclosure of self, one to another. As client and nurse focus on the client's situation, heightened awareness of what each person feels or "knows" and how they act or "do" emerges in the encounter. Personal knowing grows to the extent that actions are in concert with the whole of inner experience. ESTHETICS: CREATIVE, EXPRESSIVE, AND ASSESSMENT DIMENSIONS The pattern of esthetics is a difficult pattern to comprehend because it can be conceptualized as both a separate knowledge form and a synthesis of all knowledge forms. As a separate pattern, it constitutes knowledge about artful nursing practice, knowledge that is expressed with difficulty because it is fully dependent on and integrates context. For example, expert nurses may be able to provide some insight into the esthetic knowledge they possess and use in caring for clients. Specifics of how they have used and expect to employ such knowledge, however, defy description because they do not "know" what they will do until they are in a situation, and what they "know" changes with the situation. Although the expression of esthetic knowledge is only partially describable in language, it is fully comprehensible when the whole of experience is considered. As the synthesis of knowledge patterns, esthetics can be viewed as the total knowledge spectrum integrated in practice. The creative dimension of esthetics involves engaging, interpreting, and envisioning. Esthetics requires engagement in the moment and the "all-at-once" interpretation of a situation to project an outcome and act in relation to what is envisioned. As nurses encounter clients in practice contexts, esthetic knowledge is integrated with all other forms of knowing to form and continue forming patterns of engagement, interpreting, and envisioning. New knowledge emerges in this process. Although the creative dimension of esthetics is associated with en-

Perspectives on Knowing 137 gagement, interpreting, and envisioning, its creation depends upon the artful enfoldment of all knowledge patterns. Esthetics as a separate knowledge pattern enfolds itself with empirical, ethical, and personal knowledge to bring about a harmonious and pleasing whole an artful nursing act. Esthetic knowledge finds expression in the art-act of nursing. Like personal knowledge, the expression of esthetic knowledge is not in language. We can unfold our art and retrospectively recollect and write about its features, and we can record it using electronic media, but the knowledge form itself is not what we write or record. The knowledge form is the art-act. The assessment of esthetic knowledge involves a consideration of meaning in those aspects of the art-act that can be represented. The art-act is responded to by criticism, which is the process context by which the knowledge pattern is assessed. Criticism can be thought of as an explanation of a judgment that finally reduces to the simple statement: "This means that" (Bleich, 1978). Criticism assumes that interpretation of meaning is motivated behavior and that meaning is constructed in relation to some purpose. The critical question asked of the art-act is, "What does this mean?" Criticism requires empathy and an intent to fully appreciate what the actors meant to convey. As the artact is criticized, credibility is discerned by reaching for consensus a full and rich understanding of the art-act that brings together the perspectives of a community of co-askers who construct and confer meanings. Seeking consensual meaning as motivated behavior implies a desire and need to create knowledge on one's behalf. It does not imply mere agreement or acquiescence to some meaning but connotes deep understanding of intents, a reconciliation of self with others. To summarize, as nurses encounter clinical situations, knowledge is brought to those encounters that can be conceived of as having different patterns: empirics, ethics, personal, and esthetic. Nurses possess: (1) objective, empirically based knowledge such as stress-coping theory and statistics about stress phenomena; (2) knowledge of what is ethically right and good; (3) personal knowledge of themselves and how they relate to others; and (4) knowledge about how they might esthetically approach, balance, and integrate this knowledge in differing clinical situations. To some extent, individual nurses and the profession collectively can examine these knowledge patterns separately for credibility to heighten awareness of the state of knowledge within them. As practice contexts are encountered, processes within the creative dimension of esthetics are initiated. Through the process of engagement, interpreting, and envisioning, "past" knowledge is enfolded into esthetics, and clients are uniquely cared for. As caring processes

138 Scholarly Inquiry for Nursing Practice continue, new knowledge emerges. When the nursing context is "exited," the art-act as the experience of nurse and client can be unfolded to reveal the newly emerged separate knowledge patterns. These separate knowledge patterns can be individually examined for their contributions to the total art-act, how they are altered as a result of their enfoldment during the encounter, and where the knowledge base was problematic. The total art-act, as the expression of esthetics, can also be exhibited and criticized. This exhibition of the total art-act is always imperfect, yet it can be recollected, recreated in language, and observed as it occurs in nursing situations. Both the recreation of nursing's art and its natural observation provide a means of examining practice. TOWARD A CREDIBILITY INDEX FOR NURSING PRACTICE Processes within the creative dimension of esthetics enfold the separate knowledge forms that are exhibited as an ongoing art-act. The art-act of nursing, and not separate knowledge forms, provides an avenue for examination of the credibility of nursing practice. Valid empirics, just ethics, and congruent selves are important, and critical questions within each knowledge pattern need to be asked and answered. An examination of the art-act that integrates all knowledge patterns as expressed in practice provides a comprehensive, context-sensitive means for enfolding multiple knowledge patterns. This shift toward integration of all knowledge patterns will move nursing away from a quest for structural truth and toward a search for dynamic meaning (Munhall, 1986). A focus on the art-act toward the evolution of dynamic consensual meaning is to be valued, because it promotes choice and freedom from the constraints of considering only one knowledge pattern as credible. Choice and freedom are values consistent with promotion of health. As nurses exercise the freedom to examine practice as art and analyze all patterns of knowing expressed through practice, their effectiveness as promoters of health will be enhanced. REFERENCES Allen, D., Banner, P., & Dickelmann, N. L. (1986). Three paradigms for nursing 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 nursing practice. Menlo Park, CA: Addison-Wesley.

Perspectives on Knowing 139 Benner, P., & Tanner, C. (1987). How expert nurses use intuition. American Journal of Nursing, 87( 1), 23-31. Bleich, D. (1978). Subjective criticism. Baltimore and London: Johns Hopkins University Press. Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing 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 for substance. Scholarly Inquiry for Nursing Practice, -/(I), 5-19. Munhall, P. A. (1986). Methodological issues in nursing research: Beyond a wax apple. Advances in Nursing Science, 8(3), 1-5. Watson, J. (1985). Nursing: Human science and human care. Norwalk, CT: Appleton-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.

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