2 Knowing in nursing and nursing knowledge
Fundamentals of Nursing Models, Theories and Practice, Second Edition. Hugh P.
McKenna, Majda Pajnkihar and Fiona A. Murphy. © 2014 John Wiley & Sons, Ltd.
Published 2014 by John Wiley & Sons, Ltd. Companion
website: www.wileyfundamentalseries.com/nursingmodels
Outline of content
Knowledge and knowing are defined, by introducing defining terms and proceeding to
consider how knowledge is constructed. Rationalism, empiricism and critical thinking are
presented as means of producing knowledge. The influences of positivism, logicalpositivism, post-positivism, critical theory and constructivism on how we perceive and
construct knowledge are explored. Different categories of knowledge and different patterns
of knowing in nursing are presented. The role of reasoning and research in constructing
nursing knowledge are outlined.
Learning outcomes
At the end of this chapter you should be able to:
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1. Define ‘knowing’ and ‘knowledge’
2. Discuss three key phases in the philosophy of knowledge
3. Discuss the differences between ‘know how’, ‘know that’ and ‘know why’ knowledge, giving
examples from nursing practice
4. Discuss Carper’s (1978) ‘ways of knowing’ and Kerlinger’s (1986) ‘categories of knowledge’
and give examples from practice
5. Identify two main strategies to develop nursing knowledge
Introduction
In Chapter 1, theory and its relationship to nursing practice was introduced, as was recognising
the importance of knowledge in theory development for nursing. In this chapter we will focus
more on knowledge and the types of knowledge that nurses might use in their practice. The idea
of what counts as knowledge is complex and changes with different cultural and historical
contexts. Therefore the first section of this chapter takes us through a short history of the
philosophy of knowledge. We will:
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• touch on three key phases - rationalism, empiricism and historicism - all of which influence the
kind of knowledge that nurses use in their practice;
• look more closely at knowledge itself, in particular what types of knowledge nurses might use in
their practice and whether some types of knowledge are more valued than others;
• look at the differences between ‘know how’, ‘know that’ and ‘know why’ knowledge;
• consider the works of Carper (1978) and Kerlinger (1986);
• consider ways that nurses might produce knowledge for their practice.
Defining knowing and knowledge
As with most of the ideas presented in this book, defining knowing and knowledge is not as
straightforward as it may appear (see Key Concepts 2.1). It was Francis Bacon (1561-1626) who
said: ‘If you dissemble sometimes your knowledge of that you are thought you know, you shall
be thought, another time, to know that you know not’. He was reminding us that we should
always challenge what we know and take little for granted. However, there are distinct
differences between knowing and knowledge. According to Chinn and Kramer
(2004), knowing refers to the individual human processes of experiencing and comprehending
the self and the world in ways that can be brought to some level of conscious awareness. This
implies that because it alters with experience, knowing is always changing. Notice that it is also
about how we comprehend ourselves and the world in which we live. Therefore, as we mature
and as the world changes, our knowing also changes. There is a more esoteric view of knowing
from the Jewish Talmud (cited in Levine 1994):
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…the child in the womb of his mother looks from one end of the world to the other and knows all
the teaching, but the instant he comes in contact with the air of earth an angel strikes him on the
mouth and he forgets everything.
But not all is forgotten; we all have instincts such as blinking, sucking and retina dilatation.
These ways in which humans survive are underpinned by instinctive knowing.
Key Concepts 2.1
Knowing: individual human processes of experiencing and comprehending the self and the
world in ways that can be brought to some level of conscious awareness
Knowledge: knowing that we can share or communicate to others
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Chinn and Kramer (2004) also defined knowledge. To them it is simply the knowing that we can
share or communicate to others. This implies that there may be knowledge that we will not share
or cannot communicate to others and so, by their definition, this is not knowledge! However, if
you share or communicate your knowing with others, this ‘knowledge’ becomes part of their store
of knowing (see Reflective Exercise 2.1). Similarly, if they share knowledge with us, it becomes
part of our store of knowing. In nursing we share knowledge in many different ways, such as
through speaking, use of the written word and through our behaviour. In Chapter 1 you learned
that we experience phenomena through our five senses: hearing, seeing, touching, smelling and
tasting. Similarly we obtain knowledge through these five senses.
Reflective Exercise 2.1: Shared knowledge
Think about the nursing course you are attending at the moment. In what way is knowledge
being shared?
Philosophies of knowledge
In the main there are three philosophical views on how knowledge develops:
• rationalism
• empiricism
• historicism.
An overview of these is presented in Table 2.1.
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Table 2.1 Philosophies of knowledge.
Key concepts
Rationalism Reason
Key writers and movements
René Descartes – ‘I think, therefore I am’
Cartesian dualism
Empiricism Sensory experience John Locke – tabula rasa (blank slate)
Auguste Comte Positivism
The Vienna Circle – logical positivism
Karl Popper – principle of falsification (postpositivist empiricism)
Historicism Interpretativeconstructionist
Thomas Kuhn – paradigm shifts
The influence of phenomenology – Edmund
Husserl and Martin Heidegger
Critical science – the Frankfurt School
(enlightenment, empowerment, emancipation)
Postmodernism
Rationalism
Rationalism has its stem in ratio the Latin word for ‘reason’. Charles Darwin stated that of all the
faculties of the human mind, reason stands at the summit (Barnhart & Barnhart 1976). It is a
philosophy of science that emphasises the role that reason has to play in the development of
knowledge and the discovery of truth.
Rationalism is founded on the idea that theorists, without access to data obtained through the
senses, can generate theory through mental reasoning. They do this by formulating propositions
through theorising how one concept could be related to others. This ‘armchair theorising’ has
been ridiculed, mainly because of the absence of hard data. Nonetheless, the absence of data has
not stopped people taking such theories seriously. For example, Freud used rationalism to
develop his theories of psychoanalysis; he had very little data to support his theories on the
Oedipus complex, or the id, ego and superego (Freud 1949).
In essence, rationalists theorise without data and then experiments are set up in the real world to
see if the theory can be corroborated. This is best described as the ‘theory then research’
approach (Reynolds 1971) and can also be called deductive or a priori reasoning. In terms of
knowledge, this is seen as arising before experience or, perhaps more accurately, without the
necessity of experience. It precedes experience or the need for this. Knowledge of this form is
said to be independent of any need for supporting evidence or experience. It is self-evident.
Since Einstein presented his theory of relativity many years before the methods were available to
test it, it is perhaps the best known example of the development of such knowledge.
René Descartes
Rationalism as an approach to knowledge development can be traced to René Descartes (15961650), the 17th-century French philosopher and mathematician. He spent most of his adult life in
Holland and influenced other famous rationalists such as Antoine Arnauld (1612-1694), Benedict
de Spinoza (1632-1677) and Gottfried von Leibniz (1646-1716). Nine years before his death,
Descartes published a book entitled Meditations on First Philosophy (1641). This was to
influence the development of knowledge for the next 300 years. Perhaps the best word to signify
his contribution to rationalism is ‘doubt’ He realised that to arrive at new knowledge you must
put former opinions and experiences in doubt. When we do this we can build knowledge from
first principles (Stokes 2004).
As noted earlier, most of our knowledge comes from our senses. However, Descartes suggested
that the senses can play tricks on us. For example, we may think something looks cold but when
we touch it, it is hot, or we may believe a creaking floorboard or a branch blowing against a
window to be an intruder. Descartes considered sensory deceptions such as these and reflected
that they could be the work of a malignant being, a demon whose role is to fool us by sending us
false sensory information. Such misconceptions are often used to good effect in Hollywood films
such as The Matrix (Wachowski & Wachowski 1999).
When Descartes reasoned that all his knowledge may be false through being fooled by the
demon, he came to doubt all that he previously held to be true and to exist. He even began to
doubt his own existence. However, he realised that there was one thing that the demon could not
falsify. He reasoned that when he thinks, he must exist or else he would not be able to think.
Such reasoning led him to the one certain piece of true knowledge ‘Cogito, ergo sum’ (I think,
therefore I am). Following this, he held that by means of reason alone, knowledge and certain
universal self-evident truths could be discovered, from which the sciences could then be
deductively derived.
Cartesian dualism
Descartes was a devout Catholic and he reasoned that God created two classes of substance that
make up the whole of reality. One class comprised thinking substances, or minds, and the other
comprised extended substances, or bodies. This mind-matter split, called ‘Cartesian dualism’, is
based on the assumption that we are rational individuals with rational minds and that our minds
are divorced from our bodies and from other matter.
Rationalism as a philosophy of science was very influential and Descartes’ mind-body split
underpins much of the biomedical model referred to in Chapter 1. Physicians were often trained
to look for anatomical signs and physiological symptoms and come up with a diagnosis.
Similarly, when nurses assess patients objectively from a physical and pathological perspective
while ignoring their thoughts, emotions and feelings, they are practising Cartesian dualism. We
still hear experienced nurses referring to a coronary or a stroke being admitted! This is
reminiscent of the birthday cake analogy in Chapter 1 - by seeing only the slice, they miss the
whole cake and its meaning (see Reflective Exercise 2.2).
Reflective Exercise 2.2: Theory - Cartesian dualism in
practice
Next time you are in practice, listen to the handover. Do the nurses focus mainly on physical or
psychological aspects of the patient, or do they consider both? Do they take any account of social
factors?
Empiricism
In contrast to rationalists, empiricists believe that knowledge is derived entirely from sensory
experience. In other words if something cannot be perceived through the five senses, it does not
exist. Empiricism denies the possibility of spontaneous ideas or a priori reasoning as a
predecessor to scientific knowledge. Rather, empiricists formulate concepts and propositions that
attempt to explain the phenomena they have experienced. These propositions may be turned into
hypotheses which can be tested through experimental research. The end result is knowledge in
the form of theory. Empiricism can be described as the ‘research then theory’ approach
(Reynolds 1971) and because the theory comes last, this type of knowledge development can
also be called inductive or a posteriori reasoning, which is on the basis of observable evidence
(see Key Concepts 2.2).
Key Concepts 2.2
A priori knowledge: knowledge that arises before experience or more accurately without the
need for experience
A posteriori knowledge: sometimes called propositional knowledge, this is where knowledge
emerges from experience, and we make deductions arising from this. In this instance, it is
termed a posteriori to denote that it is derived from empirical experience which in all instances
precedes it and is its source
John Locke and empiricism
The origin of empiricism can be traced to a number of English philosophers such as John Locke
(1632-1704) and David Hume (1711-1776). Locke was the first to put forward empiricist
principles in his Essay Concerning Human Understanding. He spent 20 years writing the book
postulating on how the mind collects, organises and makes judgments based on all the data that
come to us through our senses. He had read Descartes but had rejected the rationalist philosophy
as not helping to explain human understanding. For Locke there can be no innate knowledge:
rather everything we know must be gained from experience. To him, knowledge was derived
through the outside world writing on our minds through our senses. Therefore, he envisioned the
mind at birth to be a blank slate, what he referred to as tabula rasa (Stokes 2004). As the child
develops, this slate is written on by experience.
Primary and secondary qualities
Locke distinguished between primary and secondary qualities. Primary qualities are objective
and include shape, solidity, number and motion. By contrast, secondary qualities are more
subjective and include colour, smell and taste. The reason why they are termed secondary is that
they are produced in our minds by the effect of primary qualities on our senses. To Locke,
primary qualities really exist in the world and secondary qualities exist in our minds. For
example, the primary qualities of a cancer can be observed and its size, shape and position
measured. Less important for empiricists might be pain, fear and distress that the cancer
produces in the patient. These would be labelled secondary qualities by Locke. Put very
simplistically, from an empiricist perspective, cancer biologists would mainly be concerned with
the size, position and type of cancerous growth, whereas nurses would mainly be concerned with
the secondary qualities - the effect the growth was having on the patient and his or her family.
Neither may be right, but the philosophies underpinning the education and training of different
health professionals may go some way to explaining these different perspectives.
Auguste Comte and positivism
Ninety-four years after Locke’s death, the French philosopher Auguste Comte (1798-1857), gave
empiricism a new twist. He is best remembered for being a student activist and an antiEstablishment figure and he saw science as a means of changing and possibly overthrowing
political movements. One of his many legacies is that he founded the discipline of sociology as a
means of applying the methods of science to the study of people and society.
In his six-volume work Course of Positive Philosophy (1830-42), Comte used the term ‘positive’
philosophy to differentiate it from the negative philosophy that he believed underpinned woolly
and metaphysical thinking. Adopting such a ‘positivist’ approach meant that through the use of
robust scientific methods human problems would be solved and social conditions improved. To
him, scientists should focus on ordering in a rigorous manner confirmable observations and this
alone should constitute human knowledge (see Reflective Exercise 2.3).
Reflective Exercise 2.3: Exploring knowledge
In this chapter we carry forward in more detail issues about knowledge first encountered
in Chapter 1. We now recognise that knowledge is shared and that accepted knowledge is
derived from different sources - mainly rational thinking (reasoning) and experience (formally
encountered in empirical methods).
Reflect a little further on these issues by exploring the literature. Seek definitions of knowledge,
rationalism and empiricism. Consider how rationalism and empiricism are encountered in
nursing practice.
Comte also identified a hierarchy of six sciences which had been founded on systematic
observation:
• astronomy
• biology
• chemistry
• mathematics
• physics
• sociology.
These form the ‘gold standard’ against which other disciplines would be judged. By contrast, to
Comte, subjective approaches to knowledge development were not perceived as meaningful
pursuits and so reflection and intuition as a basis for knowledge development were shunned and
denigrated by positivists.
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Throughout his life, Comte had been plagued by mental health problems and he had even
attempted suicide on occasions. In his later years his mental illness returned and with it a
softening of views regarding positivism. For instance, in some of his last writings, such as The
Catechism of Positive Religion, he stated that the intellect should be the servant of the heart!
Nonetheless, it is for his earlier work on positivism that Comte will be best remembered. Many
scientists argued that it was the only true source of knowledge. In essence, the doctrine involved
the following logic: our minds interpret the world through our senses, and because the world is
subject to the laws of science, events outside the mind can be observed, described, explained and
predicted. Therefore, to make sense of the outside world, all we had to do was to observe it and
undertake experiments to test hypotheses that were formulated from such observations.
For positivists, objective truth exists and the goal of science is to go out and discover it; to them
this forms our knowledge base.
‘The Vienna Circle’
At the turn of the 20th century, a group of philosophers, including Moritz Schlick (1882-1936)
and Ludwig Wittgenstein (1889-1951), formed an organisation called ‘The Vienna Circle’. They
built on Comte’s ideas and coined the term ‘logical positivism’, placing an even stronger
emphasis on the importance of induction and scientific verification.
For most of the first half of the 20th century, ‘respected’ scientists adopted the logical positivist
view of science. However, the philosophical force behind logical positivism dissipated just prior
to the Second World War when most of its supporters left Nazi Germany and Austria. Today, in
the first decade of the 21st century it is seen as a spent force in scientific enquiry
(McKenna 1997).
Popper: principle of falsification
Karl Popper was one of a group of philosophers known as the ‘new scientists’ and was
influenced by Descartes. Popper argued that the way to true knowledge was by conjecture
(developing theory through reason) and refutation (testing the theory through rigorous research
to see if it could be falsified). To him, the mark of a scientific theory is whether it makes
predictions that can be falsified through testing (Popper 1965).
Although initially a supporter of the Vienna Circle, he began to reject induction as a scientific
approach and replaced their emphasis on verification with his principle of falsification. In other
words, theories should not be tested to see if they can be supported; rather, they should be tested
to see if they can be falsified. If you test a theory 19 times and it holds true it may not hold true
on the 20th occasion. In Popper’s view, we can learn much more from the 20th test than from the
previous 19. The example of the paper boat was used in Chapter 1. The same principle can be
explained another way: let’s say you were to construct a kite and test it to see if it will fly. It may
fly perfectly the first 20 times you try it, but then on the next few attempts it crash lands. To
Popper this lack of reliability would be an important discovery and you would have to go back to
the drawing board to redesign the kite (see Key Concepts 2.3).
Key Concepts 2.3
Popper’s (1965) principle of falsification: theories should not be tested to see if they can be
supported; rather, they should be tested to see if they can be falsified.
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Later in his life he began to question the logical positivists’ desire to reject subjectivity as a way
of knowing. What could seem to be a ‘road to Damascus’ change, Popper admitted that there was
a place for intuition and imagination when one is using scientific empiricism!
Post-positivist empiricism
Today, thanks to philosophers like Karl Popper, logical positivism has been replaced by postpositivist empiricism, a much milder form of positivism. Gortner (1993) supported the use of this
form of empiricism in the development of nursing science. She felt it was unfortunate that it is
still being tarnished in the literature by being confused with logical positivism. Modern
empiricists accept the shortcomings of verification and recognise that the world is complex and
some behaviours and events can be reduced to their basics for study purposes and some cannot.
Empiricism is still highly regarded as a scientific approach in the physical sciences of biology,
physics and chemistry. Furthermore, all of the many experiments, quasi-experiments and
randomised controlled trials carried out within nursing and health care are clearly based upon
empiricism. In 1993, when referring to nursing theories, Gortner argued that Roy’s (1989) theory
‘reflects clearly the thinking of an empiricist scholar’ (p. 481). The same can be said of the
theories of Orem (1995), Neuman (1995) and Henderson (1966). We see the influence of
empiricism again now in the evidence-based practice movement with its emphasis on the ‘gold
standard’ of the randomised controlled trial (see Reflective Exercise 2.4).
Reflective Exercise 2.4: Nursing and empiricism
Look up a clinical care guideline or a care pathway that you are interested in. See what kind of
‘evidence’ it is based on. In particular, is the evidence obtained from randomised controlled
trials?
Historicism
So far we have dealt with knowledge that is objective and can be perceived through the senses.
Much of this knowledge can be measured. The Italian astronomer Galileo Galilei (1564-1642)
maintained that we should ‘measure what is measurable, count what is countable, and what is not
countable, make countable’. However, there are many phenomena of interest to nurses that
cannot be measured. How would you calibrate compassion, measure empathy or quantify a
presence? True rationalist or empirical principles could not be applied to these. The philosophy
of knowledge best suited to this perspective is called historicism.
Historicism recognises that we are all influenced by our different history and different
experiences, values and beliefs. From these influences, we construct our own realities and we
interpret events from this construction. Therefore, another term for this view is the interpretative-constructionist approach. In other words we interpret what is real and construct this as
knowledge (see Reflective Exercise 2.5).
Reflective Exercise 2.5: Nursing and historicism
Consider the following example. Two nurses observe an elderly patient getting out of bed but
they interpret it differently. One may believe that the patient is dependent and in danger of
falling and should not be attempting to get out of bed. The other may perceive the patient to be
gaining independence and is therefore pleased that they are getting out of bed. They see the same
thing but construct a different reality.
What would be your interpretation?
These nurses observe the same clinical phenomenon, yet past experience, reflection and intuition
lead them to understand and interpret it differently. Furthermore, each may have a personal or
internationally accepted theory that structures what they perceive. Such ‘theoretical baggage’
influences how we attempt to understand what we experience. So, to different people, reality
(and knowledge of that reality) is often a personal thing, the product of individual reflection,
perception, perspective and purpose rather than being static and objective. Realising this,
philosophers such as Kuhn (1977), Toulmin (1972) and Feyerabend (1977) challenged the
positivist view and stressed the importance of history and perception in the development of
science. They rejected the idea of there being objective truths, arguing instead that the
development of knowledge is a dynamic process and so there are no final and permanent truths.
Kuhn and scientific revolutions
Prior to Thomas Kuhn’s book The Structure of Scientific Revolutions (1977), many scientists,
particularly from the empiricist/positivist traditions, believed that different research studies built
upon one another in a progression of the science, leading eventually to ultimate truth. By
contrast, Kuhn (1922-1996) asserted that science progressed through a series of revolutionary
steps. After each revolution, there is a period of ‘normal science’ where a particular paradigm
(remember, we called this a ‘world view’ in Chapter 1) reigns supreme and scholars accept it as
a basis for knowledge and truth. Rejecting this paradigm during a period of normal science
would be frowned upon by the scientific community. However, according to Kuhn, this
paradigm is eventually questioned, leading to what he refers to as a ‘scientific revolution’. This
may be because it fails to deal adequately with some new phenomenon, or a new, more powerful
paradigm has great explanatory power. As more evidence accumulates to show that the old way
of thinking has outlived its usefulness, a ‘paradigm shift’ occurs. Kuhn maintained that paradigm
shifts are not cumulative and the new paradigm is not built on the previous paradigm. The new
paradigm becomes the focus for a new period of normal science.
One example of this would be Ptolemy’s teaching that the Sun orbited the Earth. This paradigm
held sway for centuries in what Kuhn would call ‘normal science’. However, when Copernicus
(1473-1543) challenged this with his theory that the Earth moved around the Sun, a paradigm
shift took place. Other examples includes Newton’s theory of gravity being replaced by
Einstein’s theory of relativity or the contemporary focus on community care as opposed to
institutional care for those with mental health problems. Paradigm shifts occurred because the
old paradigms were not able to explain new experiences or solve new problems. Kuhn’s views
did much to undermine the empirical/positivist view of science.
Laudan and scientific evolution
Larry Laudan (1977) challenged Kuhn’s view that knowledge development was a revolutionary
process. Rather, he believed that knowledge was developed in an evolutionary way with new
knowing being influenced by previous knowing. This evolutionary approach of Laudan is an
attractive one for nurses because it recognises a pluralistic view to knowledge development and
application. After all, the problems facing nursing are forever changing and staff must select the
theory and paradigm that are best suited to solving these problems.
More recently, Afaf Meleis (1985), the US-based Egyptian nurse metatheorist, argued that the
revolutionary and evolutionary approaches to knowledge development are too simplistic on their
own to explain nursing’s experience of knowledge development. She coined the
term ‘convolution’ to explain how nursing knowledge has developed. She maintained that
nursing as a discipline has progressed not through evolution or revolution but through a
convolutionary series of peaks, troughs, detours, backward steps and crises. This gives the
impression that knowledge development in nursing is confusing and uncoordinated. There may
be some truth in this as nursing is still a young scientific discipline, one that Kuhn (1977) might
place in a pre-paradigmatic stage of development.
The influence of phenomenology
Edmund Husserl (1859-1938) was a German philosopher and the founder of phenomenology.
Phenomenology is the study of the meaning of phenomena to a particular individual and a way of
understanding people from the way things appear to them (George 2001). In contrast to the
empiricists and positivists, Husserl believed that science involved the exploration of perceptions,
judgments, beliefs and other mental processes. He argued that, because of its refusal to count
anything other than observable entities and objective reality, positivism was not capable of
dealing with human experience. He maintained that one way to truth was to consider the essence
of things, and the best way of noting this was to explore what meaning the mind has for that
thing (Husserl 1962 trans).
The task of ‘phenomenology’ is to discover what life experiences are like for people.
Understanding their ‘lived experience’ requires the use of reflection, which is the basis of
phenomenology. While Descartes was sceptical about the external world (see earlier), Husserl
was sceptical about self-knowledge. Therefore, he recommended that phenomenologists should
‘bracket existence’. This means that when they are exploring the essence of an occurrence or
event, they should suspend previous views and influences, as these would merely distort their
true perception of it (see Key Concepts 2.4).
Key Concepts 2.4
Metatheorist: a person who studies and writes about theories. The best known metatheorists in
nursing are Afaf Meleis and Jacqueline Fawcett
Heidegger and hermeneutic phenomenology
Martin Heidegger (1889-1976) maintained that as a way of generating knowledge,
phenomenology should make manifest what is hidden in everyday taken-for-granted experience.
He argued that prior experiences and influences may be used positively in a phenomenological
study. Hermeneutics, a branch of phenomenology much influenced by Heidegger, is based upon
the idea that all texts and human activities are filled with meaning and can be subject to rigorous
interpretations. Therefore, within hermeneutics, to know is to understand through interpretation.
In Heidegger’s philosophical view, the understanding of phenomena is not about measuring,
analysing and classifying. Once more the ‘hard science’ is being softened to take account of
meaning and perception rather than detached quantification (Stokes 2004), but it is not about
being less rigorous or systematic.
Phenomenology and nursing
An example of a use of phenomenology in nursing is Patricia Benner’s (1984) work From
Novice to Expert. Excellence and Power in Clinical Nursing Practice. In this landmark
publication, Benner used a phenomenological approach to analyse experienced nurses’ accounts
of their practice. Benner then applied a ‘model of skill acquisition’, which proposed that in the
acquisition and development of skills, students pass through five levels of competency: novice,
advanced beginner, competent, proficient and expert. Novices and beginners need rules, but
experts have a huge range of experience to draw on and no longer need rules. They have an
‘intuitive grasp’ of the situation and can immediately identify and concentrate on the important
aspects (see Reflective Exercise 2.6).
Reflective Exercise 2.6: From novice to expert
(Benner 1984)
Can Benner’s ideas apply to you? Use Benner’s five levels of competency to assess yourself at
the beginning of a clinical placement and at the end. Where do you think you start from? Are you
a novice, advanced beginner, competent, proficient or expert? Did you think you progressed over
the placement from one level to another?
Critical science
We referred earlier to the Vienna Circle, which was a group that believed staunchly in logical
positivism. Contemporaneously, a rival group existed called the Frankfurt School, which was
located in the University of Frankfurt am Main in Germany and was established by Max
Horkheimer, who became its director in 1930. The Frankfurt School gathered together dissident
Marxists and was very much anti-positivist in its teachings. They saw positivism as an
inappropriate way of viewing knowledge development in the social sciences. Rather they
favoured the critical science approach.
Critical science is also a variant of phenomenology but goes further, stressing that meanings
should not be merely elicited but should be open to criticism (Habermas 1971). It is a very
political philosophy and an attractive approach for those nurses who wish to leave behind
subservience to the male-dominated health service. It has given rise to feminist research
methodologies and action research and, as such, may be perceived as a science of freedom. There
are three major concepts within critical theory:
• Enlightenment - knowledge of self in relation to the world and education of the oppressed in
terms of their potential capacity to bring about change.
• • Empowerment - social transformation through some form of educative process.
• • Emancipation - a state of reflective clarity where people have a sense of themselves and can
determine freely and collectively the directions they should take in life (Emden 1991).
Critical theory’s focus on education, enlightenment, emancipation, empowerment, critique and
change is an attractive perspective to many nurses and is supported by the increase in the number
of feminist and action research studies in nursing in recent years.
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Postmodernism
Postmodernism emerged in the later decades of the 20th century essentially as a reaction against
the unrealistic assertions of positivism and the perceived empty promises of ‘modernism’
(Lyotard 1984). The central force within postmodernism was essentially scepticism - that is, the
critical questioning of the knowledge presented by science, particularly the claims (where these
existed) for discovering or establishing irrefutable absolute truth. Aligned with this was the
notion that knowledge is relative rather than absolute, to a greater or lesser extent context-bound
or culture-specific, and often subject to multiple meanings. In relation to its central focus - the
questioning of science’s absolute and exclusive claim to ‘truth’ - the postmodern orientation
served a useful purpose. But it also carried within its orientation some fatal shortcomings:
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1. Its extreme and uncompromising rejection of all constructed knowledge. According to House
and Howe (1999), the postmodern critique of all knowledge in effect nullified all knowledge
claims. This, some might argue, was a totally preposterous position: to be sceptical
of all knowledge to the extent of rejecting it would leave us in the extreme position of believing
nothing and therefore (presumably) having no rational (knowledge) position upon which to base
our actions. By querying all knowledge claims, even its own position on ‘knowledge’, and
offering no constructive alternative way forward, postmodernism itself had nowhere to go, no
way forward. It brought the world greater scepticism, but no answers and no alternatives.
• 2. Postmodernism was to an extent already jousting with imaginary windmills. It is, of course, the
case that even today critics of science speak of its excessive positivistic shortcomings. Indeed, this
is not uncommon in nursing where the tendency to lean too much upon the natural or traditional
sciences is criticised and labelled positivism. As we discussed earlier, positivism as a movement
had long gone by the final quarter of the 20th century, and the post-positivistic position was
already taking a more balanced and reasonable position in respect of recognising the limits of
science and the need to view knowledge claims in a sceptical and critical way. Indeed, it might be
argued that, unlike postmodernism, post-positivism contained within it a balancing critique and a
viable way forward.
In this section of the chapter, we have looked at three main philosophies of knowledge:
rationalism, empiricism and historicism. All of these have influenced health care, nurses and
nursing. For example, the early nurse theorists such as Orem (1995), Roy (1980) and Neuman
(1995) were influenced by empiricism when they were developing their theories of nursing.
Later nurse theorists such as Watson (1985a) were influenced by postmodernism. Parse (1981)
and Rogers (1980) were heavily influenced by historicism. In the next section, we will look at
types of knowledge and knowing with a specific focus on how these relate to nursing knowledge.
How do nurses know?
As we saw at the beginning of the chapter, it can be a difficult task to clearly identify knowledge
and the differences between knowledge and knowing. Now we will look at particular types of
knowledge that are thought to be important in nursing; these are summarised in Table 2.2. We
will look at two key writers - Carper (1978) and Kerlinger (1986) - both of whom discussed
types of knowledge, but to begin with we will look at ‘know that’, ‘know how’ and ‘know why’
knowledge (Figure 2.1).
Figure 2.1 ‘Know that’, ‘know how’ and ‘know why’
knowledge.
Table 2.2 Types of knowledge.
1. ‘Know that’ – propositional knowledge; ‘know how’ – practical
knowledge; ‘know why’
2. Ways of knowing (Carper 1978)
Empirics
Aesthetics
Ethics
Personal
knowing
3. Categories of knowledge (Kerlinger 1986)
Empirical
Tenacity
Authority
A priorism
Know that’ or propositional knowledge
‘Know that’ knowledge is also called propositional knowledge as it is based upon reasoning and
intentional thought processes. This is best understood if we recognise that a proposition is in
essence an idea rather than a thing (some object that exists in the real world) or an action (some
practical deed). More specifically, it is an assertion that something exists or that some
relationship or other applies. Implicitly, this means that the proposer (the individual or
individuals making a proposition) believes or assumes the existence of the relationship in
question. But the assertion is still in question. That is, it still has to be shown and in this sense it
is open to question until it is adequately demonstrated. This is very different from practical
knowledge which is not an idea being asserted, but is demonstrated only in action - we know
how to do something, or we do not, as the case may be.
Propositional knowledge can be seen as emerging in two quite different ways, a priori and a
posteriori, which we touched on earlier in the chapter:
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• A priori knowledge is knowledge that arises before experience or, more accurately, without the
need for experience; think of Descartes’ rationalism.
• A posteriori knowledge, sometimes called propositional knowledge is where knowledge
emerges from experience, and we make deductions arising from this. In this instance, it is
termed a posteriorito denote that it is derived from empirical experience which in all instances
precedes it and is its source. Knowledge of this form is what people usually mean when they
speak of scientific knowledge - knowledge based on evidence that is derived through research.
Think of Hume’s empiricism.
Justified true belief
We stated earlier that the nature of knowledge derived by a priori or a posteriori means is that it
is something held to be true or acceptable. However, the conditions necessary for knowledge to
be acceptable usually involve how it meets the test of being justified true belief. This is widely
held as the test of knowledge.
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• First, we must believe something is true.
• Secondly, we must have good grounds for holding this belief: it must be justified on the basis of
rational logical thinking, as in a priori knowledge, or on the basis of observable evidence, as in a
posteriori knowledge.
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• Thirdly, it must be true. It is possible to believe something is true, to have what appears to be
strong justifications for the belief, but for the knowledge to be false rather than true. Conversely,
we may assert that something is true, have no really good grounds for justifying the belief, but yet
by good luck or chance it is true. Philosophers who study knowledge would argue that, even if the
knowledge is true by chance in the second case, in both these examples, the knowledge is not
considered to be sound knowledge. However, we must be careful of giving an impression that this
all relates to the idea that there can be absolute truth. Truth (or more properly accepted
knowledge) is a relative thing. It is very much embedded in context and culture, and is
furthermore held to be always open to critical review - indeed this is taken to be its strongest
point!
• Fourthly - defeasibility (which in this context is taken as a potential or capacity to be defeated).
That is, such knowledge is always by definition propositional, and that is exactly why we use the
term. The knowledge is conditionally true; it is the best position we have, but only until it is
disproved and this is always a possibility. Indeed, nowadays we do not usually judge knowledge
on the idea of truth at all. We judge it on the extent to which it withstands challenges. Remember
that Karl Popper argued that knowledge should be judged on the extent to which proposed
knowledge (conjecture) can withstand attempts to reject it (refutation).
‘Know how’ or practical knowledge
The process of attaining practical knowledge is perhaps more difficult to explain than
propositional knowledge. Practical (unlike propositional) knowledge is largely to do with skills
acquisition. It is, as we have noted, recognised as being fundamentally different from
propositional or ‘know that’ forms of knowledge. It is to do with manual skill and the
associated psychomotor dexterity, but also extends into something that is more cognitive and
indicates adroitness about what to do in particular circumstances, i.e. a form of practical wisdom
(Benner 1984; Benner and Wrubel 1989; McKenna 1997).
Such practical knowledge is not easily defined or described in rational language (language that is
expressed in terms of logical reasoning, such as 2 + 2 = 4). This is because it is expressed in the
doing rather than the describing. Sometimes such know-how is termed tacit knowledge because it
is more easily understood as something that resides in the individual, so that the term personal
knowing is also used (Polanyi 1958, 1967; Slevin and Kirby 2003). In essence, it is unspoken and
indeed cannot be spoken of, except obliquely. It shows itself, quite literally, in the doing.
In this form of knowledge, people can practise an activity until - no matter how complex - it
becomes easier to do it at increasingly higher levels of competence. We recognise a smoother
and more refined performance of the skills. They become ‘second nature’, in that the person can
perform them without having to think of what is being done in a rational fashion at all. Indeed,
the person performing the skill seems to be doing it almost unconsciously and, to an extent, this
is so. We start to describe this level of skill expertise (Benner 1984). However, it is important to
recognise that what is happening here is a performance.
It may seem that this is an unconscious or habitual thing, but that belies what is really going on.
Complex patterns and subtle changes are being sensed, and refinements and adjustments are
constantly being made without these being thought about in a logical step-by-step fashion.
Indeed, to do this would immediately break the rhythm, interrupt the smooth performance and
cause the expression of the ‘skill’ to deteriorate or even collapse in an instant. We might indeed
say this is all habitual and that the person is doing it unconsciously.
Just because we realise that propositional knowledge is different from know-how, and that we
cannot have propositions that directly guide know-how, does not mean we cannot reflect upon its
nature (see Reflective Exercise 2.7). We can indeed do this, and having a theory about knowhow is different from having a theory of know-how (in the sense of a theory that actually guides
it).
Reflective Exercise 2.7: ‘Know how’ and ‘know that’
The notion of know-how was introduced by the British philosopher Gilbert Ryle. His original
publication (Ryle 1949) was the first modern statement to suggest that know-how is different
from propositional knowledge, and a sophisticated form of knowing in its own right. The idea of
know-how is extremely important in nursing.
For this exercise, read further around the topic. You should not need to buy or read Ryle’s
original work as the internet is replete with descriptions of Ryle’s original arguments. Spend
some time exploring these and then proceed to write (up to a single A4 page maximum) a case
for the importance of Ryle’s concepts in nursing.
Jazz music and practical knowledge
David Sudnow is a distinguished social scientist; he is also a musician. Note the following
excerpt from his description of how his skill as a jazz musician emerged after many years of
practice. You should remember that it is in the nature of jazz music that it is an iterative and
intuitive process. While there may be (though not always) some thread in terms of a beat and/or
melody running through a performance, even the musicians do not know at the start where the
music will take them. The piece quite literally moves into new directions, exploring new spaces,
from second to second. There is, of course, a natural end to the piece, but even this is something
the musician intuitively senses. Sudnow (2001: 128-129) wrote of his jazz piano music thus:
… I now unselfconsciously follow one piece of advice - heard a long time before from jazz
musicians … Sing while you’re playing. A ‘speaking I’ is struck by the awesomeness of finding
myself singing as I play, singing right along with the movements of my fingers, reaching for next
sounds with a synchronous reach of two body parts, an achievement formerly quite impossible.
How do I know what each of these little slices of space will sound like, as a joint knowing of my
voice and fingers, going there together, not singing along with the fingers, but singing with the
fingers? How is that possible? I take my fingers to places so deeply mindful of what they will
sound like that I can sing these piano pitches at the same time, just as I make contact with the
terrain.
This is not something that is exclusive to jazz musicians. Even in the apparently highly
structured area of classical music, a notable and famous example of ‘singing along’ was the
celebrated Canadian pianist Glenn Gould. Gould died prematurely some years ago, but he is still
regarded by many as the most gifted interpreter of the music of J.S. Bach, and his two recordings
of Bach’s Goldberg Variations (made almost 30 years apart) are considered to be perhaps the
definitive piano recordings in the classical music genre. In most of his recordings, despite the
•
attempts of sound engineers to suppress it, Gould can be heard humming. He is in a world in
which voice and fingers are complementing each other, but where the artistry is directed into
sound through fingers.
What makes David Sudnow’s account so fascinating is the extent to which he approximates
something close to describing exactly what is going on in a complex skill. But it is only an
approximation. He does not really understand it himself; or, at least, he does not understand it in
rational terms that can be explained in logical language. He does of course know in certain ways.
He knows how to perform this complex skill (jazz music performance), something that we have
referred to as ‘knowing how’ or know-how.
Knowing more than we can tell
This knowing is also an awareness, and indeed a highly honed and sensitive awareness within
which the performers knows the next step (in Sudnow’s case, the next sequence of keys) without
knowing how they know this. Sudnow, who has explored this phenomenon in depth, and written
a book about it, can only speak about the ‘awesomeness’ of this, saying ‘How is that possible?’
The famous expression of Michael Polanyi (1967) that ‘we can know more than we can tell’ is
clearly at play here. Sudnow is one of the most prominent social scientists in the United States,
indeed in the whole world. He is a communicator par excellence and in his book he presented a
widely acclaimed account of such knowledge in action. Yet, at the end of the day, he like all
others can only approach that which is beyond the rational to a certain point. Rational
explanations can take us no further. It is not only that the practical knowledge being exhibited is,
by definition, complex. It is also because the language of description, which is the language of
propositional knowledge, theory and rational thinking, is not suited to uncovering what is going
on. Terms such as personal knowing, tacit awareness and intuitive responding are, in fact, almost
alien to this scientific language.
Practical knowledge as performance
Practical knowing, as noted earlier, is largely a performative knowing. That is, it is a
performance art or an expressive art form or skill, in that it exists exclusively within the act of
doing. As may be clear from the preceding discussions, it is difficult to express in words and,
when we try to do so, it is already in the past. In a sense, it is already gone and beyond our grasp.
It is possible that such know how knowledge is less valued than know that knowledge. Students
often look with astonishment at experienced nurses who are performing a highly skilled task.
The aesthetically pleasing art of the doing - almost without thinking - is perceived by the student
to be extraordinary and they think they will never be as skilled. The nurse probably thinks it
is ordinary, and one day, when qualified and experienced, the student too will perceive it as
ordinary.
However, the suggestion that at least some aspects of practice are beyond our cognitive grasp (in
terms of rational explanations) is a rather astounding realisation in respect of nursing, or indeed
in any health care profession. We are saying, in effect, that a substantial amount of nursing
activity is beyond our capacity to describe in rational or propositional terms. Furthermore,
because it can only be expressed in the doing, it is also to some extent beyond the capacity of
evidence-based health care. If the arguments presented here hold, there are important aspects of
practice that are not amenable to evidence as they cannot be addressed in evidential
(propositional) terms at all. They may be referred to as ‘practice-based evidence’ rather than
‘evidence-based practice’!
Practical knowledge as sophisticated knowledge
While the examples used earlier are from fields such as music, the principles underlying such
forms of knowing are similar in all practice knowing situations. This may seem a rather exotic
claim to be making in respect of nursing. However, some of the skills involved in nursing require
every bit as much in terms of dexterity and coordination of mind and body as does an activity
such as juggling. And in nursing we also find that our practice is every bit as creative as the jazz
performances described by David Sudnow (2001), and involve the need to respond appropriately
to often instantaneous and chaotic changes in circumstances (see Reflective Exercise 2.8).
Reflective Exercise 2.8: Tacit knowing
Picture the following scenario. During a clinical handover, a senior staff nurse asks that you pay
particular attention to Mr Smith in Bay 5. When you ask why, she is unsure but asks you to do so
nonetheless. He was admitted today for observation because he was breathless, but the diagnostic
tests have not shown any abnormalities. The ward round is over and one hour later Mr Smith has
a cardiac arrest. Thankfully he survives. When you ask the staff nurse later how she knew there
was something wrong, she is unable to tell you.
In your nursing career you will see many examples of tacit knowing, some that you yourself will
have.
Join a small group of you fellow students or friends and try to explain what is going on. You may
wish to refer to Michael Polyanyi’s (1967) work.
Gnostic and pathic touch
In an interesting paper, Max van Manen (1999) differentiated between what he
terms gnostic and pathictouch. In gnostic touch, the clinician is touching, feeling (palpating) to
obtain knowledge. In this sense he is not touching the other in a personal or relational sense. He
is in an almost mechanical sense trying to feel through, in order to gain this knowledge (is there a
swelling, what degree of tenderness exists, are the anatomical structures normally aligned?). He
is feeling through the body, not touching the person. Thus we have the term ‘diagnosis’ (from the
Greek terms dia, meaning distinguishing, looking through, to discern + gnosis meaning to know,
knowledge). The pathic touch, conversely, is a touching of or reaching out to the person. From
its Greek origins of pathos, meaning suffering or hurt, we find that pathic touch reaches out to
comfort, to relieve pain.
There is a great deal of skill involved in these touches. The diagnostic touch is only acquired
through extensive experience and a building up of expertise. There comes a time when the expert
doctor or nurse diagnostician’s powers (certainly in respect of the diagnostic touch or palpation)
appear almost magical. They are every bit as astounding and awe-inspiring as Sudnow’s jazz
riffs. This is also the case with pathic touch, which involves a reaching out, not to the physical
body, but to the person, in a healing purpose. This may involve highly developed skills of
massage or manipulation, but sometimes no less effective is the touch that conveys the way in
which the nurse is simply present, there for the person, reaching out to their pain and aloneness.
We speak here of knowing when to reach out, whether to do so in silence or with voice as well as
touch, the knowing how to listen, the knowing what to say or not, in each given moment.
Martha Rogers was a well-known American nurse theorist. Her theory was not widely used but it
did cause nurses to think differently. You will know that we as human beings are threedimensional - we have height, depth and width. Rogers (1980) believed that we had a fourth
dimension, one that was like a sixth sense or an energy field. Therefore, according to Rogers,
you can touch a person without actually touching them - their surrounding energy field means
that you can move over them without making contact and still pick up signs and symptoms of
distress or lack of wellness.
Reflective Exercise 2.9: From pathic to sympathetic
Words commonly used in clinical practice (and indeed in other areas concerning human
relations) are the terms empathy and sympathy. As you will see, these are derived from the Greek
term pathos. You may recall that this term connotes feelings or emotions, often extended to
include feelings of suffering.
The terms sympathy and empathy, while derived from the same etymology (pathos), are said to
be different modes of relating to others.
Do literature searches for these two terms. Consider how each may contribute in practice
situations. There is no further reading or writing work to be done here. However, over the few
days after reading this, attempt to identify what you feel are examples of sympathy and empathy
being acted out in your world. To what extent are these examples accompanied by what we
earlier termed pathic touch?
All these are sophisticated skills that extend beyond psychomotor actions, often requiring
responses that differ from encounter to encounter, and often even within each encounter. But
perhaps what van Manen’s work also shows is how what we have called practical knowledge and
what is termed theoretical or propositional knowledge come together in practice. In both the
gnostic and pathic touch, there are tacit dimensions of knowing of the form discussed earlier.
However, there is also a recognised need to integrate this with propositional knowledge. The
diagnostic clinician (doctor or nurse) is using a highly developed skill of palpation, but he or she
must relate this to knowledge of the anatomy, physiology and pathological processes of disease.
Similarly, behind pathic touch, and the practical knowing of how and when to use this, there is a
high level of knowledge derived from the human and social sciences, and from the humanities.
‘Know why’ knowledge
However, there is another dimension that is seldom explored and that is ‘know why’ knowledge.
This goes a stage further than ‘know how’ and ‘know that’ knowledge. For example, a nurse may
‘know how’ to position a patient who has chronic obstructive airways disease so that they are
more comfortable. The nurse may also ‘know that’ the research indicates that this is the best way
to nurse patients with this disease. But there is another dimension to this scenario; the nurse may
‘know why’ this is the case. They know that if such patients are nursed flat, their abdominal
organs will press on their diaphragm and this will increase pressure on their lungs and cause
greater difficulty with breathing. It would seem that when providing care, many nurses have
‘know how’ knowledge, fewer have ‘know that’ knowledge and fewer still have ‘know why’
knowledge.
Reflective Exercise 2.10: Different ways of knowing
• Practical knowledge is know-how, contained in the doing, tacit, intuitive, personal, complex and
performative.
• • Propositional/theoretical knowledge is know that, descriptive, explanatory, predictive,
prescriptive, contemplative, rational, justified.
These are some of the differences suggested between these two forms of knowing. Make a twocolumn table and, using library searches, make two comprehensive lists of the characteristics that
differentiate the two types of knowing. Use these lists to construct your own brief (150 word)
statement defining each type.
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While practical/know-how and theoretical/know-that knowledge forms are very different, they
share one vitally important characteristic. They are both within the practice of nursing. They both
contribute to safe and efficient treatment and care in respect of health and well-being. In
addition, they are not opposed or disruptive to each other, but of necessity complementary. We
need to know what to do (theoretical propositional knowledge), we need to know how to do it
(practical know-how) and we also need to know why we are doing it. In delivering adequate
nursing care, all of these are needed.
Categories of knowing
Carper’s ways of knowing in nursing
‘Know how’, ‘know that’ and, to a lesser extent, ‘know why’ knowledge have been recognised
as being very relevant to nursing practice. There was however a tendency to focus on ‘know that’
knowledge to the neglect of others, which is why the paper by Barbara Carper written in 1978
was so significant. In the first article in the first issue of a new US journal, Advances in Nursing
Science, Barbara Carper identified four patterns of knowing in nursing. It proved to be a seminal
paper and these four patterns of knowing were: empirics, the science of nursing; aesthetics, the
art of nursing; ethics, moral knowing, and personal knowing (Figure 2.2).
Figure 2.2 Patterns of knowing in nursing (Carper 1978).
Empirics
By now you can probably predict what type of knowing ‘empirics’ signifies. According to
Carper, empirics represents the knowing that is obtained by rigorous observation or
measurement. It provides knowledge that is verifiable, objective, factual and research-based. It
also coincides with Kerlinger’s empirical knowledge, which we will discuss later in the chapter.
Empirics is organised systematically into scientific principles, theories and laws for the purpose
of describing, explaining and predicting phenomena of special concern to nursing. The ability to
quantify empirical data allows objective measurement that yields evidence that can be replicated
by multiple observers or researchers (Carper 1992). Empirics would correspond with ‘know that’
or propositional forms of knowledge and has its roots in empiricism.
Aesthetics
As you will have gathered from previous sections, empirics is a rather narrow perspective.
Nursing practice may also be perceived as an art and Carper acknowledged this in the pattern of
knowing called ‘aesthetics’. It gives us the knowledge that focuses on the craft of nursing that
involves tacit knowledge, skill and intuition. It reflects Rhyl’s ‘know how knowledge’ and has its
roots in the philosophy of historicism. Aesthetic knowledge is subjective, individual and unique.
It enables us to go beyond that which is explained by existing laws and theories and accept that
there are phenomena that cannot be quantified, measured or calibrated. Therefore, intuition,
interpretation, understanding and valuing make up the central components of aesthetic knowing.
We could argue that, armed with this aesthetic knowing, nurses might place less emphasis on
empirics knowing. For instance, there are many research-based scales that are used to assess and
predict patients’ risk of pressure damage. Nonetheless, clinical judgment based on experience
and intuition is also used. Similarly, research evidence may provide guidance on when patients
can mobilise postoperatively, but the intuitive expertise of the nurse regarding the patient’s
ability could justifiably override this.
Ethics
Carper’s third pattern of knowing is called ‘ethics’. This type of knowing provides us with
knowledge about what is right and wrong and what is good and bad, desirable and undesirable. It
is expressed through moral codes and ethical decision making. In everyday practice, nurses often
have to make choices between competing interventions. These choices and judgments may have
an ethical dimension, and to select the most appropriate position or action requires careful
deliberation. For example, for ethical reasons, some nurses may decide not to participate in a
particular treatment even though the results of clinical trials or other studies (empirics) confirm
that it is effective for some conditions. For example, we know of nurses who will not participate
in electroconvulsive therapy or therapeutic abortions. Ethical evidence may also be used to make
decisions about the costs of treatment or whether terminally ill people should be actively
resuscitated.
Personal knowing
Like aesthetics, ‘personal knowing’ is subjective, yet is about us being aware of ourselves and
how we relate to others. It represents knowledge that focuses on self-consciousness, personal
awareness and empathy. If, as various theorists argue, caring is an interpersonal process
(Peplau 1995a) where interactions and transactions between people are central (King 1981), then
we must know our own strengths and weaknesses in order to be expert practitioners. Most nurses
do not possess an arsenal of surgical instruments: what we have is ourselves and we can use this
resource therapeutically to make a positive difference to patients. At our best we do not perceive
patients as objects, but instead have a genuine relationship with those requiring care. We can
learn as much from a caring relationship as they do and a good caring relationship will depend
on our own self-regard. Therefore, personal knowing requires self-consciousness and active
empathic participation on the part of the knower (Carper 1992). Here again, the influence of
historicism is evident.
It is possible that nurses may sometimes reject empirical evidence because of their personal
knowing. For example, consider the situation where a nurse is working with a patient or a family
member who is going through a grief reaction. Despite research findings that suggest a linear
movement through a number of grieving stages, the nurse’s personal experience of a family
bereavement may indicate that not everyone has to go through all these phases or in the order
suggested by the empirical evidence.
Experienced nurses use these four patterns of knowing interchangeably. For instance,
experienced oncology nurses will be aware of the research and theoretical basis for providing
chemotherapy (empirics) and have the skills and intuition to ensure the patient understands the
treatment and is as comfortable as possible while receiving it (aesthetics). However, the issue of
withholding chemotherapy because of the severe side-effects and sometime poor prognosis is a
moral decision to be made with the patient (ethics). Finally, knowing themselves and their inner
resources is important in the construction of an interpersonal therapeutic relationship with the
client (personal knowing) (see Reflective Exercise 2.11).
Reflective Exercise 2.11: The four ways of knowing
Construct a patient care situation in which you would use all four of Carper’s ways of knowing.
This can be in any speciality or clinical setting. Try to see how the four ways are linked and
decide which of the four is the most important for that particular scenario.
Carper revisited
Carper’s work has undergone careful analysis by many authors (see Silva et al 1995;
White 1995; Meleis 2006). White (1995), for example, added socio-political knowing to
Carper’s original four, arguing that nurses need to have knowledge of the context within which
they practice. More recently, Johns (2009) incorporated Carper’s ideas into his framework for
reflecting on practice.
As you reflect on these four patterns of knowing you will note the complexity of nursing
knowledge. The patterns are not mutually exclusive; there is overlap, interrelation and
interdependence. By recognising that there are legitimate ways of knowing, other than empirical
knowing, Carper has made a valuable contribution to the examination of knowledge
development in nursing. Further, as outlined in the preceding section, it may be possible in some
circumstances to reject empirical knowing because of the influence of one or more of the other
three ways of knowing.
Chinn and Kramer (2004) stated that:
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• empirics removed from the context of the whole of knowing produces control and manipulation;
• removing ethics produces rigid doctrine and insensitivity to the rights of others;
• removing aesthetics produces prejudices, bigotry and lack of appreciation of meaning;
• removing personal knowing produces isolation and self-distortion.
Kerlinger’s ways of knowing
Another way of thinking about knowledge is through the work of Kerlinger (1986) (Figure 2.3).
Figure 2.3 Ways of knowing (Kerlinger 1986).
• Empirical knowing is knowing something through rigorous research. This involves the
identification of variables within hypotheses and subjecting them to experimental manipulation.
Here ‘hard evidence’ is required in order to be certain that something is or is not true. You will
note that this reflects a positivist viewpoint.
• • Knowing through tenacity is knowing something because it has always been believed to be true.
• • Knowing though authority is knowing something because a respected or authoritative person
said so.
• • A priori knowing is knowing something because reason tells you it is true.
The end result of each of these ways of knowing is knowledge; what differs is how the
knowledge is acquired (see Reflective Exercise 2.12).
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Reflective Exercise 2.12: Kerlinger’s ways of knowing
From the experiences you have had on your nursing course so far, identify some examples of
Kerlinger’s four categories
To illustrate Kerlinger’s approach, consider the example of knowing that providing information
to patients preoperatively will ensure better postoperative recovery. Nurses may believe this to
be true ‘it has always been done this way’ (tenacity), because the clinical nurse manager told
them so (authority) or because it is reasonable to assume that if a person gets information they
will be less anxious (a priori).You could also have identified Kerlinger’s preferred positivist way
of obtaining knowledge; nurses provide patients with information preoperatively because this
practice was proven through the collection of empirical data or through studying the results of
well-validated empirical research into preoperative preparation (see, e.g., Boore 1978).
Like all physical scientists, Kerlinger felt comfortable building hierarchies of knowledge. In
Kerlinger’s scheme, the scientific empiricist method is supreme (see Figure 2.3) and intuitive
knowledge occupies a lowly position. For a practice discipline like nursing, this is an
inappropriate way of viewing the development of knowledge. Such hierarchies are seen in
textbooks on evidence-based practice. For example, in 1997 Muir Gray identified what he called
the hierarchy of evidence (Muir Gray 1997). This is illustrated in Figure 2.4.
Figure 2.4 Hierarchy of evidence (Muir Gray 1997).
You will notice that the top four levels are really about counting and that this has its roots in
empiricism. It is not unusual to hear the mantra that randomised controlled trials are the gold
standard, the most highly prized source of knowledge. This is a false assumption as it depends on
what knowledge you are pursuing. If we wanted to know the possible causes of diabetes, then
yes the randomised controlled trial may well be the gold standard (empiricism). However, if we
wanted to know the emotional effect a diagnosis of diabetes has on patients and their families,
then the gold standard may be a phenomenological study (historicism).
According to this hierarchy, word of mouth is not regarded as good evidence. This is not the case
in all professions. In the legal profession, such evidence is highly valued and word of mouth is
sufficient to put a person in jail for a long time, or, in some countries, be executed. By contrast,
such sources are denigrated in most textbooks and articles about evidence in nursing. It might be
more useful to propose a new hierarchy, as in Figure 2.5 (McKenna 2010).
Figure 2.5 A proposed new hierarchy of evidence.
As with the previous hierarchy, this one also has inherent problems. How can you decide
whether a patient’s preference comes above or below the experience of nurses? It depends on the
circumstances; hierarchies belong to the world of positivist quantification and the quality of
knowledge required to care should not be tied to the quality of a research design (see Reflective
Exercise 2.13).
Reflective Exercise 2.13: Frameworks for knowing
We have noted Carper’s patterns of knowing and Kerlinger’s categories of knowledge.
Consider how each might help inform our study and practice of nursing. Do you think there may
be something in one scheme that is missing in the other? If so, how might the schemes be
brought together?
Developing nursing knowledge
So far we have looked at types of knowing, we have seen the differences between ‘know how’,
‘know that’ and ‘know why’ knowledge and considered amongst others Carper’s four ways of
knowing and Kerlinger’s ways of knowing. We have also seen that in different circumstances
different types of knowing might be considered more valid and important than others. Thus
propositional, ‘know that’ knowledge might be considered more valid than ‘know how’ intuitive
practical knowledge. This final section of the chapter considers how nurses might develop
knowledge for their practice through reasoning and research (Figure 2.6).
Figure 2.6 Developing nursing knowledge.
Developing nursing knowledge through reasoning
Inductive reasoning
Every day practising nurses deal with patient phenomena. By taking note of patterns and
commonality in those phenomena that are of special interest to nursing, it is possible to build up
a body of knowledge. This is referred to as inductive reasoning and reflects moving from the
specific situation to the general. The early empiricists favoured this method when developing
theory. Qualitative research approaches from the historicist school of philosophy also use
induction to generate theory (‘know that’ knowledge) from practice (‘know how’ knowledge).
Deductive reasoning
In contrast to inductive reasoning, deductive reasoning involves moving from the general to the
specific situation. You will note elsewhere in this chapter that René Descartes favoured it as a
key component of rationalism. Deductive reasoning traditionally involves the use of three
propositions (two premises and one conclusion). In deductive reasoning, a conclusion follows
from one or more statements that are taken as true. Aristotle (384-322 BC) perfected this form of
deductive argument, calling it a syllogism (Strokes 2004). The most famous example is shown
in Key Concepts 2.5.
Key Concepts 2.5
Example of a deductive argument - a syllogism
All men are mortal
(first premise)
(axiom 1 or postulate 1)
Socrates is a man
(second premise)
(axiom 2 or postulate 2)
Therefore, Socrates is mortal
(conclusion)
(theorem)
Here the
reasoning goes from the general (all men) to the specific (Socrates). You can see that if the
premises remain the same but we changed the conclusion to read ‘Socrates is not mortal’ then the
deductive reasoning would be faulty. Similarly, if one of the premises was reversed, the
unchanged conclusion would be wrong and the reasoning would once again be faulty.
You could reverse the example and make it inductive reasoning. Here the reasoning goes from a
specific situation or example (Confucius, Socrates, Hannibal) to the general (all men). So a series
of discrete observations about phenomena are followed by a conclusion (see Key Concepts 2.6).
Key Concepts 2.6
Example of an inductive argument
Confucius is a man and is mortal
(first premise)
Socrates is a man and is mortal
(second premise)
Hannibal is a man and is mortal
(third premise)
Therefore, all men are mortal
(conclusion)
Deductive reasoning in nursing normally starts with an established theory, and this (or a
proposition from it) is tested in the real world of practice to see if it can be disproved - remember
our reference to Carl Popper’s (1965) work on refutation.
Retroductive reasoning
Whether theories should be developed deductively or inductively is seen as a false argument by
Jacox and Webster (1992). They state that some nurse theorists will use a more deductive or a
more inductive approach than others but all theory construction includes both. To them, it is not
an either/or issue. This amalgamation of induction and deduction is referred to as retroduction.
An example of this type of research would be that of Boore (1978), referred to earlier. Boore
used an experimental design to test the theory that providing information to preoperative patients
would reduce their stress levels postoperatively. Since a specific theory was being tested and
applied, the method used was deduction. However, the results of this study led to new practices
in how patients are prepared for surgery and a ‘practice theory’ of preoperative preparation was
developed. Here, Boore was also using induction where experiences within the research setting
led to the development of a new, more clinically specific, theory.
Research as a basis for knowledge development
Research is defined as ‘the attempt to derive generalisable new knowledge including studies that
aim to generate hypotheses as well as studies that aim to test them’ (National Research Ethics
Service [NRES] 2006: 2). With its emphasis on generalisation, it is possible in this terminology
to see plainly the influence of positivism. Nurses, in attempting to gain academic respect with
other more long-established professions, adopted the positivist approach over other forms of
enquiry when developing and testing theories (Suppe & Jacox 1985). Those nurses who did
pioneer other methods of enquiry, relating to understanding rather than control, were seldom
given the recognition accorded to the former. Nonetheless, the contribution of the positivistic
research approach to nursing knowledge cannot be denied and it should not be rejected
completely. Internationally there have been some very good research projects which, although
having their basis in the experimental positivist tradition, have contributed substantially to
nursing knowledge.
New methods of research do not just happen; they are the products of much philosophical
thought and discussion. One broad approach was based on what Wilhelm Dilthey (18331911) referred to as ‘human science’. Readers will note from the following that it emanates from
the historicism philosophy of science, which we discussed earlier.
Human science values subjective opinion, beliefs, personal knowledge, descriptions of
experiences and feelings, much of which are not amenable to objective verification. Human
science also recognises the effects that the researcher and the research participants/respondents
have on what is being researched. Intuition, understanding, reflection, meanings and experiences
are central components of the human science approach. Within human science, the participants’
‘lived experiences’ are the core of explanations and meanings about things, and are interpreted
by them, not by outsiders. Humans are perceived as whole people, and breaking them down into
components or parts is dehumanising. Conversations and interactions require interpretation, and
uncovering patterns in these is an appropriate goal of human science.
Human science is often referred to as the perceived view as opposed to the received view of
science. The differences can be seen in Table 2.3.
Table 2.3 Human science: the received view versus the
perceived view.
Received view
Perceived view
Objective
Subjective
Deduction
Induction
One truth
Multiple truths
Validation and replication
Trends and patterns
Justification
Discovery
Test theories
Evaluate theories
Prediction and control
Description and understanding
Particulars
Patterns
Reductionism
Holism
Generalisation
Individualism
Empirical positivism
Historicism
Chinn
and
Kramer
(2004)
accepted
the
importance of both views for the development of knowledge for nursing practice. In traditional
science, an attempt is made to study the whole through looking at its parts, while in human
science an attempt is made to study the whole as it appears. In traditional science, knowledge is
developed to describe, to explain and to predict; in human science, knowledge is developed to
understand. In traditional science, theory is developed through defining, analysing and
synthesising concepts and propositions; in human science, theory is developed through
description and interpretation. Traditional science is directed towards uncovering cause-andeffect relationships and generalisations, human science is directed towards creating knowledge
from common meanings, patterns and themes in descriptions. However, both seek empirical
honesty through methodological rigour (Smith 1994: 51).
In contrast, Susan Gadow (1990) did not think human science goes far enough in explaining how
best to develop nursing knowledge. She believed the researcher should leave the personal alone
and experience alone because there is no way to summarise (reduce) a life, a culture or any
human situation. Qualitative research is no better than quantitative here in that it treats
experience as data. She appeared to argue that quantitative researchers may be more honest
because they are ‘up front’ in calling the subject the object of their study (cited in Smith 1994).
Nonetheless, it is heartening that nurses are beginning to accept and use methods of enquiry
other than the empiricist approach to develop and test knowledge. This should have a powerful
effect on identifying a body of knowledge that has particular relevance to patient care. In this
way, ‘know that’ and ‘know why’ knowledge can enrich the ‘know how’ knowledge and vice
versa.
Conclusion
This chapter has shown that there are many ways of knowing in nursing. It has highlighted the
main philosophies of science underpinning how and why people develop knowledge. The
armchair rationalist approach to knowledge development popularised by Descartes was
influential in its day but by the mid-18th century empiricists set down the rules that were to
influence health care research from then on. Empiricism is still alive and well in nurses’ use of
randomised controlled trials, experiments and quasi-experiments. More recently, many nurse
researchers have embraced phenomenology, an approach emanating from the tradition of
historicism. Even more recently, we have seen an upsurge in nurses using a mixed-methods
approach that combines the traditions of historicism with that of empiricism.
The importance of ‘know how’, ‘know that’ and ‘know why’ knowledge was discussed and
while the strengths of each have been highlighted, the need for nurses to know why is crucial for
a practice discipline. However, Carper’s work reminds us that there are other ways of knowing
and her views are reflected in the differences between the received view and the perceived view.
There is a wealth of literature to suggest that nurses use several ways of knowing and that many
of these do not fit neatly within the empirical framework. These patterns of knowing are being
incorporated into contemporary theorising, leading to new theoretical perspectives.
In conclusion, all types of knowing and knowledge development are valuable. Placing one in a
higher position than another is not helpful; it depends on what knowledge is being sought and
what questions are being addressed.
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