The four patterns of knowing as identify by Carper, are empirics, esthetics, personal knowledge and ethics. More recently, Chin & Kramer (2008) added the fifth, emancipatory knowing (Jackson, 2009). As stated by Carper (1978), these patterns represented the complex phenomenon of knowing that nurses use when caring for their patients. Chin & Kramer added emancipatory knowing to address the issue of equality, justice, and transformation in all areas of practice to include nursing leadership. The five patterns of knowing when used together are beneficial to nursing leadership theory, specifically because they were developed by nurses and for nurses.
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Empirics: According to Carper (1978); Fawcett et al (2001), empirics leadership knowing is based on the science of nursing and includes a body of empirical knowledge that is based on research and systematically organized. They noted that empirical knowing is factual, objective and can be verified by “outcome measures” (Jackson, 2009). The postpositivist and interpretive paradigms have attained a welcoming approach in nursing as paradigms for guiding knowledge development (Alligood & Tomey, 2010). For Carper (1978), empirical knowing is how we came to understand the science of nursing and other disciplines that are used in the practice of nursing (Jackson, 2009).
Esthetics: Carper (1978), defines the esthetic knowing as the art of nursing. It is the creative and imaginative use of nursing knowledge in practice as stated in Jackson (2009). This pattern of knowing encompasses non-verbal expressions, therapeutic actions, unconditional presence, and empathy. As stated by Parker & Smith (2010), each nurse is an artist, expressing and interpreting the guiding theory uniquely in his or her practice. One needs to reflect on the experience of nursing to enhance the understanding of esthetic knowing. Only through such reflection, the nurse understands that each instance of nursing is unique, and that outcomes of nursing cannot be precisely predicted (Parker & Smith, 2010). Esthetic knowing gives meaning to the wholeness of experience.
Ethical Knowing: As stated by Parker (2010), ethical knowing is increasingly important to the discipline and practice of nursing today. According to Carper (1978), ethics in nursing is the moral component providing guidance for choices within the complex structure of health care. Ethical knowing guides and direct nurses in doing what’s right, doing what’s ask of them, and what a prudent nurse should or most under any circumstances. Ethical nursing plays a pivotal role in every action taken by the nurse in his/her daily undertaking. Nurses are expected to maintain a high level of professionalism and to maintain their ethical standards at all times. Respect for human dignity, right to self-determination, relationships with peers, accountability and responsibility for own actions, self-respect, influence of environment on nurses, advancement of the profession and assertion of values are all included in the code of nursing ethics (Jackson, 2009).
Personal Knowing: Carper (1978), describes personal knowing as striving to know the self and to actualize authentic relationship between the nurse and the one nursed. By applying this pattern of knowing in nursing, the nurse sees the patient as a person heading toward attainment of potential, rather than viewing the individual as an object (Jackson, 2009). As stated by Jackson (2009), personal knowing encompasses consistency between what one knows and what he/she does. Reflecting on a person as a client and a person as a nurse in the nursing situation can foster understanding of nursing practice and can centrality of relationships in nursing.
Emancipator: The fifth and most recently devised pattern is emancipatory knowing. According Jackson (2009), emancipatory knowing is a combination of both a traditional social idea and a developing dimension of nursing knowledge (Chinn & Kramer, 2008). This pattern of knowing elevate nurse leaders to the next step, and have actively changed the work place environment, and have positively impacted outcomes for both patients and nurses. Contrary to other patterns, introducing and implementing the emancipatory way of thinking/knowing may require months or perhaps years. This pattern is significantly important because it provide organizational level playing field for nurse leaders with a vision of the future in health care systems.
2A. Historical /Chronological aspects of theory development
The theoretical journey has taken the discipline of nursing through various stages and milestones. According to Marrs & Lowry (2006), Nightingale in the beginning placed emphasis on care of patient and hygiene to foster healing, which provided nursing its mission and focus. During the early part of the 20th century, nursing practice was focused on principles and traditions via apprenticeship type of education. Emphasis shifted to that of nursing demanding a strict scientific base that was given within university settings (Marrs & Lowry, 2006). According to Alligood & Tomey (2010), Nightingale’s (1859/1969) idea of nursing has been carried out for over a century, and theory development in nursing has rapidly evolved over the past 50 years, resulting to the acknowledgement of nursing as an academic discipline with a substantive body of knowledge. As stated by Fawcett (1984); Hardy (1978), 1980s brought a period of major developments in nursing theory characterized as a transition from the pre-paradigm to paradigm period (Alligood, 2010).
B. Relationship between theory and evidence based practice.
Nursing discipline has evolved into an understanding of the relationships amongst theory, practice, and research; they are no longer separated into distinct categories. However, their complementary interrelationship has rather enhanced the growth of new understanding about practice as theory guides practice and as practice innovations encourage new middle range theories (Alligood, 2010). As stated by Alligood’s (2010), emphasis on theory is important because the development of theory in nursing is a pivotal part of nursing scholarship conducted to enhance the knowledge of the discipline. According to Taylor & Renpenning (2010), theory informs practice and practice informs theory (Alligood, 2010)).
3. Four components of metaparadigm.
Person/Human beings: Person as described by Florence Nightingale is the individual receiving nursing care. Her main perception is that the patient of nursing is a human being, although this perception expanded with the development of nurse visitors, who deal with the welfare of the family unit (Selanders, 2010). Alligood (2010), stated that nurses performed tasks to and for patient and had control over the patient’s environment to foster recovery. However, the nurse was given instructions to inquire about the patient’s choices, which reveals the belief that Nightingale viewed each patient as a human being. Her writings show that she had respect for persons from different backgrounds and was non-judgmental social worth, and her beliefs about the need for secular nurses show her reverence for persons. (Alligood, 2010).
Environment: According to Selanders (2010), environment is the umbrella in the Nightingale’s theory of nursing. It was Nightingale’s belief that the environment could be modified in such a way as to improve conditions so that the natural laws will provide suitable conditions for healing to take place. This idea stemmed from her empirical observation that a poor and challenging environment contributed to poor health and disease (Selanders, 2010). Selanders (2010),defines environment as anything that when manipulated, puts the individual in the best possible situation for nature to act.
Health: Health as stated by Nightingale (1893/1946b), is “not only to be well, but to be able to use well every power we have”. This definition is in line with the current perception of health, which is characterized as a relative state, with ultimate health being the best you can be at any given point. A person does not need to be free from diseases to be healthy; rather, one must simply maximize optimal potential to be in a healthy state Selanders, 2010). According to Alligood (2010), Nightingale’s vision on heath maintenance is through disease prevention via environmental controls and social responsibility. Her vision resulted to public health nursing and more recent concept of health promotion, which has been adopted my many institutions and departments in the United States (Alligood, 2010).
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Nursing: King (1971, P.125), describes nursing as an observable behavior found in the healthcare system in society. The main aim of nursing is to assist the patient to attain the best possible condition for nature to act, and this can be accomplished via the modification of the environment in a manner that reinforce natural laws (Selanders,2010). Nightingale assert that nursing can take place in any setting in which people exist, and as a result she personally invested her time and effort to develop nurse midwifery, public health nursing, occupational, hospice nursing, as well as nursing in the acute care setting (Selanders, 2010). According to Nightingale’s model, nursing contributes to the ability of persons to restore and maintain health, directly or indirectly through managing the environment (Parker & Smith, 2010).
4. Watson’s theory of transpersonal caring:
The main focus of this theory is that humans should not be treated as objects or separated from self. According to Alligood (2010), caring is the ethical principle by which healing interventions are measured (Watson, 1999). Watson’s theory places emphasis on the caregiver and individual receiving care. As stated in Alligood (2010), the theory of transpersonal caring embodies caring for the whole person and also describes transpersonal caring as essence of theory. Transpersonal caring is a relationship between person to person. Watson’s ten carative factors are based on theory for nursing practice. As stated by Alligood (2010), Watson believes that thinking skills and personal growth can be improved by studying humanities. She asserts that utilization of nursing process brings a scientific problem solving approach, and that the encouragement of interpersonal teaching/learning is an integral concept for nursing because it delineates caring from curing (Alligood, 2010).
How each has been applied to nursing practice and research.
Watson’s theory of transpersonal caring has been applied to the nursing practice through the use of philosophy of caring practice which brings wholeness to dissonancy situation (Alligood, 2010). Subjectively, the nurse has intent to heal by developing an environment that is compassionate. According to Parker (2010), transpersonal caring theory afforded the opportunity in October 2002 for seventeen interdisciplinary health care personnel at a children hospital in Denver Colorado to part take in a trial study aimed at exploring what happens if caring theory is integrated into comprehensive pain management. Her theory has profoundly impacted the nursing profession by introducing a new way of thinking as relate to patient care.
Florence Nightingale’s original theory for nursing practice.
As stated in Alligood (2010), Nightingale’s theory focused on the environment. According to Selanders (2010), Nightingale beliefs that nursing can be achieve through modification of the environment. Nightingale realized the imminent impact of the environment on the patient and patient wellbeing thereby enhancing a symbiotic relationship between patient and environment (Selander, 2010). This stems from her empirical observation that a poor or challenging environment resulted to poor health and disease and that a healthy environment was essential to nursing care. A good example of her assessment came from the Crimean experience; lack of cleanliness, poor nutrition, lack of clean water, and inadequate sewage disposal methods resulted to outcomes in which the number of British soldiers that died in the hospital from infections, where disproportionately higher than the number that were killed in battle (Alligood,2010).
As described in Parker (2010), Nightingale viewed nursing as separate from medicine. Her goal of nursing is to assist the patient to return to a state of being able to care for self or meet his or her needs, hence, placing the patient in the best condition for nature to act upon. Nightingale believed that that modification of the environment can enhance patient’s healing. The goal of nursing as described by Nightingale is assisting the patient in his or her retention of “vital powers” by meeting his or her needs, and thus, putting patient in the best condition for nature to act upon (Parker, 2010).
Applied to nursing practice and research
The principle of environmental alteration has played a pivotal role in nursing research studies. According to Selanders (2010), a classical example of a qualitative study that highlighted the continuing utility of Nightingale’s model was carried out by Dennis and Prescott (1985). Other studies closely related to environmental alteration have been completed in practice settings including labor and delivery, and in the treatment of sleep disorder by advanced practice nurses (Parker, 2010). Some examples such noise reduction, music therapy and hand hygiene are still very popular and widely used by hospitals and health care settings worldwide. Her concept of clean environment and good hand hygiene is the standard of practice used by health care facilities to help reduce the spread of nosocomial infections.
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